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Environmental hazards, such as plumbing and door hinges, allow people to take their lives by ligature. This is especially concerning as suicide rates increase. With some careful planning and attention to detail, these unintentional hazards can be eliminated, or at least reduced, providing safer physical health care environments.
The Numbers Tell the Story
During the period 2000 through 2016, the average annual percentage increase in suicide rates “accelerated from approximately 1% per year from 2000 through 2006 to about 2% per year from 2006 through 2016,” according to a report by the National Center for Health Statistics, published in 2018, the data of which came from the National Vital Statistics System, Mortality.1 More specifically, the report indicates that the “age-adjusted rate of suicide among females increased by 50% from 2000 through 2016, while the rate for males increased by 21%”.1The numbers are a little different, but no less heart-wrenching in an article published in American Journal of Preventive Medicine in 2013 for a portion of the same time period. “The overall suicide rate increased from 10.4 to 12.1 per 100,000 population between 2000 and 2010, a 16% increase. The majority of the increase was attributable to suicide by hanging/suffocation (52%) ….”2 Subgroup analysis showed that “suicide by hanging/suffocation increased by 104% among those aged 45–59 years and rose steadily in all age groups except those aged ≥70 years.” 2 Data for the article came from CDC’s Web-Based Injury Statistics Query and Reporting System (WISQARS).
Let’s take a look at one more set of numbers. A 2018 study in The Joint Commission Journal on Quality and Patient Safety, “analyzed two national data sets to establish an evidence-based estimate of hospital inpatient suicides and the methods used.”3 The datasets came from National Violent Death Reporting System (NVDRS) for 2014-2015, and from hospitals reporting to The Joint Commission’s Sentinel Event (SE) Database from 2010 to 2017. Interestingly, the “study provides the first data-driven estimate of the number of inpatient suicides per year in hospitals in the United States.”3 Hopefully, there will be more.
The data revealed that “Hanging was the most common method of inpatient suicide in both … databases (71.7% and 70.3%, respectively.)”3 Additionally, “… more than 90% of suicides took place in private spaces such as the bathroom, bedroom, closet, and shower.” 3
What to Do With the Numbers?
It’s important to understand that “There are no reliable estimates of hospital inpatient suicides in the United States.”3 So, rather than a be-all, end-all, the numbers are a starting point for conversation, the topic of which is: “Understanding the rate and the methods used in suicides is important to guide prevention efforts.”3
The Joint Commission, a nonprofit organization with offices in Illinois and Washington, D.C., that accredits more than 20,000 U.S. health care organizations and programs, has started the prevention-effort conversation. In a November 2017 article, the organization, recognizing that suicide is the “10th leading cause of death in the United States,”4 convened a meeting to discuss what constitutes adequate safeguards to prevent suicide in health care settings. Out of that meeting came recommendations for inpatient psychiatric units, general acute inpatient settings, and emergency departments which, in part, included that health care organizations “focus as much on staff training and monitoring compliance with protocols as they do on detecting and correcting specific environmental hazards.”4
Product Focus: Lavatories and Faucets
There are numerous ligature resistant products on the market, from grab bars to door hinges. Complicating the design is the need to comply with Americans with Disabilities Act (ADA). The challenge comes in limiting the number of products to a reasonable amount that can be carefully evaluated for appropriateness of use in your facility.
Enter Facilities Guidelines Institute (FGI), a “not-for-profit organization dedicated to developing guidance for the planning, design, and construction of hospitals, outpatient facilities, and residential health, care, and support facilities.”5 FGI publishes Design Guide for the Built Environment of Behavioral Health Facilities, the goal of which is to share what products are working in these facilities. The guide, which is frequently updated to reflect the growing number of products available for use in adult behavioral health facilities, is available free at https://www.fgiguidelines.org/wp-content/uploads/2017/03/DesignGuideBH_7.2_1703.pdf. Regarding lavatories and faucets, the guide offers a number of recommendations, as follows:
Lavatories: “Typical commercial solid-surface countertops with integral sinks offer a much less institutional appearance. They also provide a place for patients to set their toothbrushes, etc. Specialty vanity top-type lavatories provide many of the same benefits.”5
Wall-Hung Solid-Surface Lavatories: “These make it very difficult to tie anything around them. Use of the optional filler panel is recommended to fill the space between the side of the fixture and an adjacent wall when there is one near the fixture. Stainless steel or high-impact polymer pipe covers that fit beneath the unit should also be provided. If a wall-mounted lavatory is used, a shelf (surface-mounted or recessed) that limits attachment of a ligature may be needed to hold toiletry items.”5
Lavatory and Sink Faucets and Valves: “Faucets and valves can provide attachment points for ligatures. A lavatory valve unit is now available that uses a shower valve fitted with a ligature-resistant handle to allow patients to control the temperature (thermostatically limited to prevent scalding) and duration of the water flow. This valve can be used to replace the motion sensor activation of some faucets. Faucets are available in a variety of materials and configurations that range from push-button to motion sensor activated.”5
| The ELR Series is designed for behavioral care and healthcare facilities where ligature points are a concern. The ELR combines the added safety of ligature resistance and touch-free operation with the durability of a heavy-duty, one-piece cast brass body. |
Lavatory Waste and Supply Piping: “All piping of this type must be enclosed so it is not accessible to patients. Extreme care should be taken to trim the enclosing material so it fits tightly to the underside of the lavatory fixture to prevent the patient from using this space to hide contraband.”5
Soap Dishes: “These should not have handles and should be recessed.”5
Soap Dispensers: “Many facilities now use liquid or foam soap in patient areas, but the commonly used hard-plastic soap dispensers are problematic in that they are fairly easy to pull off the wall and break into sharp shards that can be used as weapons. At least one manufacturer now offers steel covers for their standard dispensers. Another solution is a dispenser made of solid-surface material commonly used for countertops that is relatively tamper resistant. Some commercially available stainless steel dispensers are reasonably ligature-resistant.”5
While ligature resistant products are important to creating safer health care environments, it’s important to remember that they’re one of three elements—the other two being overall facility design, and well-trained and observant staff—that work together to create safe environments. As the guide reminds us, “No built environment—no matter how well designed and constructed—can be relied upon as an absolute preventive measure.”5
References
1. Hedegaard, H., Curtin, S.C., & Warner, M. (June 2018). Suicide rates in the United States continue to increase. NCHS Data Brief, no 309. Hyattsville, MD: National Center for Health Statistics. Retrieved March 29, 2019, from https://www.cdc.gov/nchs/products/databriefs/db309.htm
2. Baker, S.P., Hu, G., Wilcox, H.C., & Baker, T.D. (2013). Increase in suicide by hanging/suffocation in the U.S., 2000-2010. American Journal of Preventive Medicine, 44(2), 146–149. doi:10.1016/j.amepre.2012.10.010
3. Williams, S.C., Schmaltz, S.P., Castro, G.M., & Baker, D.W. (November, 2018). Incidence and method of suicide in hospitals in the United States. The Joint Commission Journal on Quality and Patient Safety, 44(11), 643-650. DOI:https://doi.org/10.1016/j.jcjq.2018.08.002
4. November 2017 perspectives preview: Special report: Suicide prevention in health care settings. (October 28, 2017). Accessed March 29, 2019, from https://www.jointcommission.org/issues/article.aspx?Article=GtNpk0ErgGF%2B7J9WOTTkXANZSEPXa1%2BKH0%2F4kGHCiio%3D
5. About FGI. (n.d.). Retrieved March 30, 2019, from https://www.fgiguidelines.org/about-fgi
