Patient suicide ranks among the top three sentinel events, reports The Joint Commission (TJC), prompting regulators to focus heavily on ligature risks this year. If many suicide attempts are impulsive, TJC reasons, then reducing environmental risks and opportunities for self-harm is vital for curbing the suicide trend in healthcare settings.

With that in mind, surveyors are taking a hard look at ligatures: potential hanging or choking points in healthcare facilities. Patients who have been identified as potential risk to themselves or others, will use any item or ligature point within a room to accomplish harm. Additionally, some accreditation organization surveyors have gone to extremes to validate a point of view by utilizing floss, hang it over a door hinge and say, “That’s a ligature point.” Although that last example may be extreme, the fact is accreditation organizations are being extremely meticulous, which means healthcare facilities must ensure they are prepared for this type of scrutiny.

Any observable ligature risk, no matter how small, is an immediate Recommendations for Improvement (RFI) when observed in an inpatient psychiatric area, to be corrected within 45 days or less depending on the severity or the total number of issues identified. Given what’s at risk — people’s lives — ligature RFIs are never appropriate for time extensions, said the TJC at this year’s ASHE conference.

Put simply, when surveyors walk into your healthcare facility, they’ll assess:

• Has this facility identified and assessed ligature risks?
• What plans have they developed to eliminate those risks?
• What is their risk assessment process?
• Is staff aware, trained and well equipped to act on these plans and improvement processes?

In a recent alert, TJC outlined minimum expectations for ligature risk mitigation plans:

• Leadership and staff are aware of current environmental risks.
• Patient’s individual risk for suicide or self-harm is identified, followed by appropriate interventions.
• At-risk behavior is assessed on a recurring basis.
• Staff is properly trained to identify patients’ level of risk and intervene properly.
• Suicide and self-harm mitigation strategies are incorporated into the Quality Assessment/Performance Improvement (QAPI) program.
• Policies and procedures are in place, and staff knows what immediate action to take when a patient is deemed at risk for suicide.
• If equipment poses a risk but is necessary for treatment of psychiatric patients, those risks are considered in the patient’s assessments, and adequate interventions are implemented to minimize those risks.

TJC notes that psychiatric patients may pass through or spend time in non-behavioral health units like emergency rooms, so ligature risks must also be addressed in those areas. “Any physical risks not required for the treatment of the patient that can be removed, must be removed,” stated TJC, and patients should remain under surveillance if risks remain in the environment.

As you take steps to counter ligature risks, keep in mind this is so much more than a compliance issue. You wouldn’t see regulators emphasize ligatures if those risks hadn’t enabled tragedies in facilities like yours. Help ensure no patient harms him or herself under your watch.

Larry Lacombe is the vice president of Program Development and Facilities Compliance at Medxcel Facilities Management, specializing in facilities management, safety, environment of care, emergency management and compliance. Medxcel Facilities Management provides healthcare service support products and drives in-house capabilities, savings and efficiencies for healthcare organizations.

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Completed in 2013 and formally dedicated on June 3, 2014, the James Mandell Building at Boston Children’s Hospital is the latest major children’s treatment facility to showcase patient rooms outfitted for maximum comfort, especially for longer hospital stays. The 10-story urban infill building provides expansion space for the emergency department, imaging, same-day surgery, neurology, pharmacy and four floors of new inpatient beds.

Building in Boston’s Longwood medical and academic area was extremely difficult, explained Charles Weinstein, the hospital’s vice president of real estate planning and development, in an online informational video. The 116,000-square-foot space was the only “teeny, tiny plot of land,” that could accommodate the hospital’s much-needed expansion. With a curtain wall façade along Boston’s Binney Street, the building earned the nickname “Skinny Binney,” due to its footprint of just 8,900 square feet. The addition had to be squeezed in with the rest of the campus to serve as an ambulance entrance and become the main drop-off for the children’s hospital.

Boston-based architectural firm Payette needed to find a way to complete the structure without disrupting patient comfort during and after construction. The firm teamed up with Cambridge, Mass.-based Acentech to provide acoustics consultation during construction and for the building’s interior after completion.

“It’s standard practice for newly constructed hospitals and medical centers to be mindful of noise and vibration issues during construction as well as upon completion as per the newer FGI guidelines on noise in hospitals,” said Benjamin Davenny, senior consultant in acoustics at Acentech. “This project is a new building for Boston Children’s Hospital as well as the dense, urban Longwood medical area in Boston. Reducing noise emissions to neighboring buildings was a challenge, as noise sources were at the property line and there was no buffer over which noise could dissipate.”

Beyond the construction, Acentech was concerned about the noise transmission from above-grade MRIs to other locations, as well as controlling the ventilation noise emission to the outdoor courtyard. The company worked with the hospital’s mechanical engineer to incorporate sufficient noise control in the many ducted and airborne noise paths between mechanical equipment and occupied spaces. Recommendations included duct silencers, maximum airflow velocities and vibration isolation.

“The hospital and the architect wanted to make sure that the HVAC system wouldn’t be too loud inside or outside of the building. The above-grade MRIs required sound isolation to reduce noise transmission through the building,” Davenny said.

Noise transmission solutions were also recently examined in Arizona. The Phoenix Children’s Hospital studied decibel levels in the neonatal intensive care unit and found that the level of background noise was affecting the hearing of premature infants. Deb Green, RN, a nurse manager at the hospital’s cardiovascular intensive care unit, and Brent Lang, president and COO for Vocera Communications in San Jose, Calif., provided five ways to reduce noise levels in an April 2013 article published for the Healthcare Financial Management Association. They include the use of rubber flooring instead of tile, alarms that don’t buzz at the patient’s bedside, reducing the audible impact through room design, staff members reducing noise and eliminating the use of overhead pages.

Voalte, a smartphone developer based in Sarasota, Fla., that specializes in mobile communications for care teams, recently equipped the Nemours Children’s Hospital in Orlando with 100 smartphones. It revealed its case study of the hospital in June and found that by receiving nurse call alarms directly to smartphones through a text messaging system, the facility used overhead paging only in the event of an emergency and greatly reduced noise levels.

“Voalte provided a great ability to leverage our existing technologies and yet provide functionality similar to what folks use in their everyday life,” said Bernie Rice, chief information officer at Nemours Children’s Hospital, in a statement. “The use of texting has been overwhelmingly well-received by our nurses and staff.”

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The fourth annual competition included 350 hospital nominations and brought a record of nearly 170,000 votes, more than double for 2011.

HKS had many projects on the list including the Miami Children’s Hospital coming in fourth place, Health Central Hospital in Ocoee, Fla., at seventh place, the University Hospital Ahuja Medical Center in Beachwood, Ohio, in 12th place and the Phoenix Children’s Hospital placed 20th on the list.

Jeff Stouffer, principal, academic and pediatric practice leader and principle-in-charge for the Phoenix Children’s Hospital, feels that the Phoenix Children’s Hospital was designed not as a hospital, but as retreat for healing.

“The goal of the project was to create a healing oasis for the children and families in Phoenix,” said Stouffer.

The addition of the building includes a large tower with four floors of clinics and seven floors of inpatient beds. The existing hospital had used bold colors, so HKS carried that concept to the Phoenix Children’s Hospital and brought all of the colors from the desert to the hospital, whether it was from plants or animals, or the surrounding environment.

“We were designing this for children of all ages, since most children’s hospitals treat patients up to 18 and 21; and so our goal was not to be childish, but to be child-like and to respond to people of all ages,” said Stouffer.

A statement piece within the hospital is housed within the atrium, and is a LED “waterfall” on a large concrete wall. Originally a real waterfall was to go there, but due to the possibility of diseases transferred through water, HKS created a waterfall of lights.

“We decided to create the feeling of a waterfall with LED lights, so we have LED lights behind acrylic panels, and they’re full spectrum so they can be adjusted to any color. It just became what I call the ‘Theatre of Lights,’” Stouffer said.

The Arizona-based Phoenix Children’s Hospital is one of the 10 largest children’s hospitals in the county and provides specialty and sub-specialty outpatient, inpatient, emergency and trauma care. The hospital offers 40 sub-specialty fields of pediatric medicine and has focused development on medical programs to build Centers of Excellence is neurosciences, cardiac services, neonatology, hematology/oncology, orthopaedics and level 1 trauma.

Each floor has a sculpture of a different animal to help with wayfinding. Rooms are all private rooms and have space for two family members to spend the night, along with space for laptops, Wi-Fi access, storage space and private bathrooms.

Construction was completed in 30 months, opening in 2011, with the clinics opening in January and inpatient rooms in the summer. The 800,000-square-foot project was delivered $48 million under budget due to economic factors as well as the HKS team reducing the overall cost and delivering the project under budget. In addition, the hospital was completed four months ahead of schedule with a total construction cost of $275 million.

HKS Delivers More Winning Designs
Among the list of winners was the Health Central Hospital in Ocoee, Fla. The hospital began in 1952 as the West Orange Memorial Hospital in Winter Garden, Fla., and served the community’s maternity, surgical and general health care needs. In 1993, West Orange Memorial closed and re-emerged as Health Central Hospital in the new location of Ocoee, and now provides 440,000 square feet of space including a cardiac care unit, an inpatient and outpatient rehabilitation center, surgery center, pediatric care unit and more.

University Hospital Ahuja Medical Center (UHAMC) was also awarded recognition on the “Top 20” list for its design. Shannon Kraus, senior vice president at HKS Architects and lead designer for UHAMC believes that the hospital is certainly deserving of being on the prestigious list.

“We didn’t aim to be the most beautiful facility, we aimed on creating a relaxing environment that helps disarm stress when you drive on to the site; something that connects you with nature and that promotes healing. And I think it’s in that, that it became a beautiful facility,” said Kraus.

The UHAMC came to the greater Cleveland, Ohio area to provide specialized medical and surgical services to the community. UHAMC was built in response to an aging population lacking convenient access to services such as inpatient, outpatient, and emergency services in the area.

Located near wetlands, building the facility proved to be an asset to HKS, not a challenge.

“We took a site that had a fair amount of wetlands on it and worked to not only protect the wetlands but we really embraced them as part of the natural feature of the project. And so we worked to balance function with form in a way that we can connect the public throughout the hospital with nature, to bring the outside in,” said Kraus.

Overall, the project was one of great success in terms of design and construction, and the idea of patient healing was also achieved, according to Kraus.

“When you can balance function — integrating hospitality with health care — that’s when you can really create places that help with healing, that help reduce stress and help improve outcomes,” said Kraus.

The 375,000-square-foot hospital features a fertility center and specialized services in urology, orthopaedics, digital radiology, infectious disease and more. Construction lasted approximately three years and resulted in a 375,000-square-foot hospital with a 60,000-square-foot office building.

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