Up Front: Facility and fixture design help protect suicidal patients


Consider the psychiatric patient intent on suicide. Can he strangle himself by hooking a cord to the door between his inpatient room and bathroom or hang himself from a pipe accessible via a drop ceiling? Can she jump to her death or suffocate herself with the trash can’s plastic liner?

In recent years, experts – notably The Joint Commission, federal Department of Veterans Affairs (VA) and the Facility Guidelines Institute– have developed recommendations or requirements designed to minimize the risk of suicide in the physical environment of behavioral health settings. The Joint Commission recently issued updated guidelines for complying with its existing standards. The federal Centers for Medicare & Medicaid Services expect to issue their own guidelines in mid-2018.

“Think of safety in a behavioral health unit as being on a scale,” says David Sine, DrBE, CSP, ARM, CPHRM, co-editor of the Facility Guidelines Institute’s “Design Guide for the Built Environment of Behavioral Health Facilities.” “At the far end is a prison in a concrete box. That doesn’t come close to being a therapeutic or healing environment. On the other end, we have something that looks like your home. It is full of items that a determined patient can use to harm himself. Where on that scale do we want to be? Fifteen years ago there were few specialty items to help designers and clinicians. Now there are catalogues filled with items to make behavioral health units homelike but as safe as possible.”

Guidelines for other facilities, including emergency departments and general acute inpatient units, follow similar principles to reduce patient suicide, adjusted for differences in how and where care is delivered.

Inpatient suicide data is lacking

It is difficult to find precise data on the number of inpatient suicides nationally. The Joint Commission has received sentinel event reports of approximately 85 suicides per year over the past five years. The VA, in an April 2017 brief report in the journal “Psychiatric Services,” cites a 2003 American Psychiatric Association overall U.S. estimate of about 1,500 inpatient suicides annually. It reports that its own VA inpatient suicide rate of 0.74 per 100,000 mental health admissions is down from 4.2 suicides per 100,000 admissions in the years prior to implementation of its Mental Health Environment of Care Checklist in 2007.

“That’s three or four veterans every year not dying in our facilities,” says Peter Mills, PhD, director of the VA National Center for Patient Safety Field Office in Vermont. “There are also lots of great staff. It’s not just improving the physical environment, but this has made a difference.

 “The main thing people can do is eliminate anything you can hang something on. Any protrusion. Anything on the ceiling that you could attach a lanyard or a sheet or a piece of clothing,” Mills adds. “The anchor point doesn’t have to support the weight of a human being. You can lean into it with only 10 pounds of weight. Fifty percent of hangings use anchor points that are below the head.”

Self-harm in MA hospitals

More than 200 serious reportable events (SREs) involving suicide, self-harm or attempted suicide were reported to the Massachusetts Department of Health between 2012 – 2016. The highest number of reports come from inpatient psychiatric units and emergency departments.

YEAR                             ACUTE CARE HOSPITALS        NON-ACUTE CARE HOSPITALS           TOTAL
201212315
201322729
2014352257
2015311647
2016411657
TOTAL                                          141                                                        64                                   205

Several themes emerge from the various guidelines:

  • With inpatient behavioral health treatment occurring in common areas or group settings, the places of greatest risk in psychiatric units or facilities are patients’ private rooms and bathrooms.
  • Recommendations to reduce suicide risk include:
    • using ligature- resistant hinges, handles and locks on doors connecting patient rooms and hallways;
    • removing closet doors and rods and replacing them with shelves;
    • replacing drop ceilings in patient rooms and bathrooms with solid ceilings;
    • using breathable paper trash-can liners instead of plastic; and
    • replacing towel racks with hooks capable of bearing no more weight than a bath towel.
  • In general medical units, unlike mental health units, much care occurs in the patient room, making it difficult to make these units ligature resistant. The Joint Commission’s recommendations would exempt general acute care units from removing fixtures with ligature points as long as the unit staff rigorously implements other safety procedures for patients with serious suicidal ideation. These include:
    • 1:1 monitoring;
    • removing any objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care; and
    • monitoring bathroom use and monitoring items brought into the patient’s room.

CMS is expected to include general medical settings in upcoming recommendations.

In its second set of guidelines, published in January 2018, The Joint Commission’s expert panel addressed protecting patients with serious suicidal ideation in other behavioral health care settings, such as residential treatment, partial hospitalization, intensive outpatient, and outpatient treatment programs.

“It is impossible to eliminate all ligature attachment points and other risks from the physical environment of a behavioral health unit,” says Jim Hunt, AIA, NCARB, co-editor of the “Design Guide,” which he and co-editor Sine are in the process of updating for the 19th time since it was first published in 2003.

Hunt also points out, “The goal is to reduce risks to the extent possible while creating a welcoming, comfortable setting, which will help the patients relax and be open to the only thing that will cure them, the treatment they will receive from the facility’s highly trained and talented staff.”


Hosp Room Suicide Prevent Labels Small
A patient room in the psychiatric/medical unit (for patients with a primary psychiatric diagnosis and co-existing serious medical condition) at St. Mary’s Hospital in Grand Rapids, Michigan, includes fixtures and building components designed to eliminate or minimize ligature points and hazardous materials, such as glass. The television is set behind a polycarbonate cover built into millwork (1) and security glazing is applied over the inside face of existing exterior windows (2). Jim Hunt consulted on this project. Credit: JRP Studio + Graphics
Saint Marys Pmu Bed Small 2
On the headwall, medical gas outlets and space for CPAP machines or other medical equipment are available next to the bed in a locked cabinet (1) with a polycarbonate panel (2) to allow view of gauges. The cabinet pulls (3) are ligature resistant.
Feb Psb Safety News Bathroom Revised
The patient bathroom includes a countertop-mounted sink (1) with ligature resistant faucet (2), vanity-like pipe enclosure with tamper-resistant fasteners (3), bed-pan washer recessed into under-counter enclosure (4), shatter-resistant mirror (5), recessed flush valve with no exposed piping (6), toilet fixture fits tight to wall at back, low- mounted push-button (not pull-cord) nurse alarm (7), ligature-resistant grab bar (8), and ligature-resistant toilet paper holder (not shown).
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