Suicide in the ED: Resources for a Safer Environment of Care

Erica Thibault, RN, MS, CNS, CWON

In 2015, more than 44,000 people took their own lives, making suicide the tenth leading cause of death in the U.S. It was the second leading cause of death among individuals aged 15-34. There were more than twice as many suicides (44,193) as homicides (17,793). For healthcare workers, meaning there is greater opportunity to recognize suicidal ideation as well as other behavioral health problems in the ED and the community.1 Despite growing awareness of suicide risk among hospital patients, Joint Commission-accredited facilities report about 85 suicides every year.2
In 2017, The Joint Commission (TJC), the U.S. Department of Veteran’s Affairs, and the American Society for Healthcare Risk Management (ASHRM) released information and resources to keep behavioral health patients safe during assessment and treatment.2, 5 These organizations regularly report on suicide numbers and recommend specific actions to prevent and treat suicidal ideation in the ED and inpatient units.

Sentinel Event Alert 56

In 2016, TJC released Sentinel Event Alert 56, outlining very specific actions and strategies for detecting and treating suicide ideation in healthcare settings. It reviews in detail who is at risk for suicide, which may affect certain demographics disproportionately— especially men over the age of 45 and military veterans.6
Risk factors include:

  • Mental or emotional disorders (depression, bipolar disorder, etc.)
  • Previous suicide attempts or self-inflicted injury
  • History of trauma or loss, such as abuse as a child
  • Serious illness or chronic pain
  • Alcohol and drug abuse, including prescribed medications
  • Social isolation or a pattern/history of aggressive/antisocial behavior
  • Access to lethal means
  • Discharge from inpatient psychiatric care6

Alert 56 suggests eight immediate actions for safety planning. TJC recommends using the “assessment results of the patient to inform the level of safety measures needed.”6
Those measures include:

  • Providing a safe environment for patients in acute suicidal crisis
  • Not leaving these patients alone
  • Checking patients and visitors for items that can be used to harm themselves or others
  • Eliminating anchor points or ligature points, which can be used for hanging or self-injury.6

Lethal means readily available in a hospital setting include: nurse call cords, electric cords (for IV pumps, pain pumps, etc.), sheets, long bandages, restraint belts, plastic bags, oxygen tubing, and bed frames.6
Following Alert 56, ASHRM identified several areas that may have gaps in care, specifically for ED patients with behavioral health concerns:5

  • Insufficient initial and routine assessment for patients that demonstrate high risk behaviors. The strategy includes careful screening, assessment, and reassessment. For example, perform an initial assessment upon a change in condition, change in observation level or amount of care needed, and discharge. It is worth noting that patients are at their highest risk of suicide within one week of leaving a facility.
  • Dangerous treatment setting. The typical ED may not accommodate behavioral health patients. Risk management strategies include placing patients in designated “safe rooms.” These rooms should be near the nursing station and away from doors, and designed with safety in mind—including minimizing ligature points such as those on electrical medical beds.
  • Insufficient education and training for staff. Topics for training include restraint and seclusion, monitoring and management, deescalation, and nonviolent management of aggressive behaviors.5

Design Guide for the Built Environment of Behavioral Health Facilities The Design Guide for the Built Environment of Behavioral Health Facilities addresses the environment of care for behavioral health patients. The document was first published in 2003, and is now on its seventh edition. Products found to be safe and durable are highlighted in order to help facilities select the best equipment for their patients.

A New Emphasis on Ligature Risk

In 2017, the steady trend of sentinel events caused TJC surveyors to place additional emphasis on identifying ligature risk. Each observation of a ligature or self-harm risk is documented as a requirement for improvement (RFI), with a 60- day window to achieve compliance.3 While TJC sometimes grants time extensions past the 60-day window, they will not give an extension for ligaturerelated RFIs.4
When evaluating products for the behavioral health environment, several factors must be taken into consideration: safety of the product, ease of use, and cost of ownership. There are two resources available for the behavioral health setting. TJC recommends hospitals reference the Design Guide for the Built Environment of Behavioral Health Facilities for design and ligature-resistant equipment recommendations in order to protect patients and caregivers.3 The Guide recommends creating a safe room environment with products that have:7

Definition: Ligature-resistant
The Joint Commission defines ligature-resistant as: “Without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.”11
  • Lockout features for the controls
  • Reduced-length cords
  • Tamper-resistant features
  • Electrical cords that can be secured and shortened
  • Keyed lockout switches

Another similar resource is the U.S. Department of Veterans Affairs’ Environmental Programs Service Mental Health Guide. This document rates products according to product evaluations, maintenance concerns, and infection control issues. Reviewed also is equipment such as mattresses, platform beds, and electric hospital beds in the section regarding patient bedrooms.8
The right equipment is only one piece of the puzzle. In 2017, several government organizations announced new funding to boost the number of trained healthcare workers that can assess and treat substance abuse patients, and allow hospitals and clinics to expand their mental health services. As mental health issues are brought to the forefront, more trained personnel will be needed in both the inpatient and outpatient settings.9

Suicide Statistics10

Source: National Institute of Mental Health


Hospitals have many options for promoting health and safety of the behavioral health patient seeking treatment. Treatment areas should be safe and free of hazards, such as electrical cords and ligature points. Since the ED is the main point of entry for patients with suicidal ideation, hospitals are under increased scrutiny to provide a ligature-resistant environment of care. Additionally, facilities have an increasing number of safe options available for treating behavioral health patients.

Sizewise Behavioral Health Bed

Behavioral Health Bed™

About the Author

Erica Thibault, RN, MS, CNS, CWON
Erica is the Clinical Manager at Sizewise as well as a registered nurse, a certified wound, ostomy and continence nurse (WOCN), and a clinical nurse specialist (CNS).

  1. Centers for Disease Control and Prevention. (2015). Retrieved from nchs/fastats/suicide.htm
  2. Special Report: Suicide Prevention in Health Care Settings. (2017, Oct. 25). Joint Commission Online Newsletter. Retrieved from www.jointcommission. org/issues/article.aspx?Article=GtNpk0ErgGF%2b7J9WOTTkXANZSEP Xa1%2bKH0%2f4kGHCiio%3d
  3. Now effective: Surveying, scoring of ligature, suicide, self-harm in inpatient psychiatric setting. (2017, Mar. 1). Joint Commission Online Newsletter. Retrieved from gyekSlHbR9Hi6%2fCHXVKFw2XUfze5Q3AXldxy7eEkhZM%3d
  4. Joint Commission: CMS requires ligature risk deficiencies corrected within 60 days. (2017, Aug. 15). ASHE Insider. Retrieved from actions/email_web_version.cfm?recipient_id=3135522806& message_ id=14574397&user_id=AHA%5F8&group_id=3798512&jobid=38279763
  5. Cooke, M., (2017). Getting serious about safe care of behavioral health patients in the emergency department. The American Society for Healthcare Risk Management. Retrieved from
  6. The Joint Commission. (2016). Sentinel Event Alert. Issue 56. Retrieved from www.
  7. Hunt, J.M. and Sine, D. M. (2017). Design Guide for the Built Environment of Behavioral Health Facilities (Ed. 7.2, pp. 34, 84, 113). Retrieved from www.
  8. U.S. Department of Veterans Affairs. (2014). Retrieved from www.patientsafety.
  9. U.S Department of Health and Human Services. (2017). Retrieved from www.hhs. gov/about/news/2017/06/26/hhs-announced-195-million-funding-to-expandmental-health-and-substance-abuse-service-access.html
  10. National Institute of Mental Health. (2017). Retrieved from health/statistics/suicide/index.shtml
  11. The Joint Commission’s Nov. 2017 Perspectives Preview;