From left to right: Kathryn Petrovic, David Sine, Kathy Tolomeo, Sue Anderson and Tim Adams discuss the latest requirements for ligature-risk assessments in behavioral health and non-behavioral health spaces.

Photo courtesy of ASHE

Assessing health care facilities for ligature risk was the topic of discussion at this morning’s general session at the American Society for Health Care Engineering (ASHE) Annual Conference & Technical Exhibition. Tim Adams, FASHE, CHFM, CHC, director of leadership development at ASHE, led a panel of experts to help provide guidance on what’s required to create ligature-resistant environments and to dispel myths on the issue.

Adams was joined by Sue Anderson, Ph.D., CHSP, CEDP, EMTP, EMSIC, national director of emergency management, EC and safety, Medxcel Facilities Management; Kathy Tolomeo, CHEM, CHSP, director of compliance strategies safety, security and emergency management at JLL Healthcare Solutions; David Sine, DrBE, CSP, CPHRM, ARM, chief risk officer, Veterans Health Administration; and Kathryn Petrovic, MSN, RN-BC, senior associate director, Standards Interpretation, The Joint Commission.

The panel discussed the increasing emphasis placed on ligature risk by the Centers for Medicare & Medicaid Services, as well as accrediting organizations such as The Joint Commission.

Tolomeo explained that hospitals first need to identify their designated and non-designated behavioral health spaces. Designated spaces are inpatient behavioral health hospitals and behavioral health units in non-behavioral health hospitals. Non-designated spaces are areas within an acute care hospital that may service at-risk patients. Both spaces should receive the same assessment to determine self-harm risk, according to Tolomeo. However, while mitigation plans for designated spaces must follow certain design and clinical requirements, non-designated spaces must have a mitigation plan in place to modify the space for at-risk patients, such as 1-to-1 monitoring and removing items that are not needed for treatment, such as unused IV poles from a room.

The speakers stressed the need to perform risk assessments on an annual or semi-annual basis. “You have to circle back and make sure those mitigations are actually working, and if not, go back and put corrective actions in place,” Anderson said.

Tolomeo backed up that adivce. “Don’t hand in something to the surveyors that is five years old or that does not show timely corrective action.”

The panel also warned against introducing ligature-resistant solutions without assessing how the features impact other health care codes, requirements and safety procedures. For instance, removing shower curtains from a behavioral health space can eliminate a ligature risk, but could also create a fall hazard from water splashing onto the patient bathroom floor.

As hospitals continue to assess their facilities and create ligature-resistant environments, many groups are developing guidance to assist. Petrovic says the Joint Commission is revising its National Patient Safety Goal 15 within the next six to 12 months to provide extra guidance, while the Veteran’s Health Administration is partnering with The Joint Commission on an assessment tool. ASHE also is developing guidance and updated information on the issue, and Adams gave three steps the group created to assist facilities today.

  • Identify patients who are at risk for intentional harm to self or others. Skip to step 3 for psychiatric hospitals and psychiatric units in acute care hospitals that shall be ligature-resistant
  • Provide 1-to-1 monitoring with continuous observation
  • Where 1-to-1 monitoring with continuous observation is not feasible, you must mitigate all environmental safety risks.

“There is no such thing as ligature-free,” Adams says. “We will not be able to eliminate every risk. But we assess and we mitigate. And we come back and assess again, taking another look with a fresh set of eyes.”

Check out coverage from Day 1 and Day 3 of the conference.