Patients thinking of suicide are at a greater risk of harming themselves if there are convenient “ligature-risk points” in their environment. These are anything that can be used to attach a cord, rope or other material for hanging or strangulation, including ceiling pipes, shower rails and radiators.

In December, the Centers for Medicare & Medicaid Services (CMS) issued preliminary guidance for reducing ligature risk and, at press time, was expected to issue permanent guidance based on work of The Joint Commission’s panel on suicide prevention. The American Society for Healthcare Engineering (ASHE) advocacy team has been working to provide input.

“This is a tough issue, and we want to make sure it’s done right,” says Jonathan Flannery, senior associate director of advocacy for ASHE. “This has been a challenge for organizations that are providing services to patients with behavioral health concerns in areas of the hospital other than a mental health ward. For example, these individuals may show up in the emergency department (ED), but EDs are not designed for patients with those kinds of issues. There are all kinds of things in the emergency room people can hurt themselves with.”

ASHE created a checklist of potential ligature points that hospitals can use to evaluate their facilities. The list includes 39 common points that can be used as a ligature — such as light fixtures, plumbing features and door tops — with explanations about why they present a risk. This document, called “Patient Safety and Ligature Risk Checklist: Common Areas,” is available on the ASHE website at The checklist also contains guidance on patient rooms, bathrooms and EDs.

The CMS preliminary guidance notes that the ligature-risk guidance is intended for psychiatric areas of the hospital, but that patients at risk of suicide or self-harm need to be protected even in other areas of the hospital.

Specifically, the guidance states: “Psychiatric patients requiring medical care in a non-psychiatric setting (medical inpatient units, ED, intensive care unit, etc.) must be protected when demonstrating suicidal ideation or harm to others. The protection would be that of utilizing safety measures such as one-to-one monitoring with continuous visual observation, removal of sharp objects from the room/area, or removal of equipment that can be used as a weapon.”