In psychiatric facilities, the safety of patients, especially those who are at risk of attempting suicide, receives the highest priority.

However, rules requiring inpatient psychiatric facilities to take extraordinary measures to prevent patients’ ability to hang or strangle themselves may do little to increase safety, but cost millions of dollars for institutions to comply, according to Yale New Haven Health System officials.

While some changes, such as replacing lever-type door handles, eliminate opportunities for patients to try to hang themselves, others are not as obvious. They include adding a slanted strip of wood along the tops of picture frames and card readers, even in areas where patients are never allowed to be alone.

Suicide is the 10th leading cause of death in the United States, according to the Centers for Disease Control and Prevention, accounting for 47,000 deaths per year. It’s the second-highest cause for 10- to 34-year-olds.

Suicide is “absolutely a national health crisis,” said Dr. Frank Fortunati, vice chief of psychiatry for Yale New Haven Health and medical director of Yale New Haven Psychiatric Hospital. “Being in the field for more than 25 years, we’ve always taken safety on inpatient psychiatric units very seriously. … We’ve always monitored them closely and made sure our units were as safe as they could possibly be.”

The Joint Commission, the body that accredits health care facilities in the United States, issued the requirements for “ligature resistant” areas, including patient rooms and bathrooms, corridors and common patient care areas. The commission followed policy set by the Centers for Medicare and Medicaid Services.

In addition to its standalone psychiatric hospital on Liberty Street in New Haven, Yale New Haven Health has inpatient psychiatric units at Bridgeport Hospital and Lawrence and Memorial Hospital in New London. There are also psychiatric emergency departments at all three hospitals.

After a spike in suicides in psychiatric units in 2014-15, national and state health officials grew concerned about ligature risk, the chance that a suicidal patient could use a string or shoelace — which patients are not allowed to possess — to hang or strangle themselves. There were 16 hospital inpatient suicides reported in 2014 and 30 in 2015, 34 of which were committed by psychiatric patients.

Now, psychiatric facilities previously deemed safe by the Joint Commission and the state Department of Public Health needed to replace hardware and eliminate edges that could be used to hang a ligature from, Fortunati said.

“That door hinge that was safe three years ago is no longer safe,” he said. “The distance of the toilet from the wall might be too much of a distance. … We fortunately haven’t had to change toilets. We’ve had to change a lot of other things, including our beds.”

Patient beds are simple platforms, except for those patients who require special medical beds, which only two manufacturers make. Other changes have included a plastic dome over a wall clock, ceiling tiles “clipped in a way that you can’t get up to any plumbing or anything like that,” “tamper-proof screws” on light fixtures and bathroom drains without holes that a ligature could be attached to, said Mark Sevilla, vice president for behavioral health and patient services for Yale New Haven Health.

Floor drains with holes are considered a hazard because a patient conceivably could tie a string to the drain, loop it around his neck and do a “crocodile roll” to tighten the string and strangle himself, Sevilla said.

The total cost to make the changes at the three hospitals is $6.6 million, Sevilla said. That total doesn’t include hiring 50 “environmental observation associates” who inspect patient rooms several times per hour to make sure nothing has been damaged or altered.

Fortunati said the associates are not allowed to accompany the medical staff who observe patients four times an hour when they are in their rooms, increasing the number of interruptions patients experience.

“It’s hard to argue against doing things that make things more safe,” Fortunati said. His concern, however, is about “the sense of urgency to fix things that have literally been fine for years.”

If there is little or no evidence that a change is needed, the money being spent on such safeguards could better be used on social workers or patient advocates “to help people connect with care,” Fortunati said. “That would be great, but the pie is only so big.”

He said the greater risk of suicide is in the 30 days after a patient leaves the hospital.

“Of course we want to promote safety in every way that we can,” he said. “We also have to be mindful of our fiscal responsibility to operate efficiently and provide value, and there might be greater value to … redirecting dollars to provide other treatment to help reduce suicide,” he said.

Fortunati and Sevilla said their frustration is increased because CMS, the Joint Commission and the state Department of Public Health don’t interpret the rules exactly the same way, and different inspectors may not agree with each other.

“There’s often variation in interpretation of these standards,” Sevilla said. “The Department of Health will call something acceptable. The Joint Commission will come in and say it’s not acceptable.

Because of the amount of work required to retrofit its three psychiatric units, Rush University Medical Center in Chicago closed them for three months. Nationally, complying with “ligature risk” requirements costs inpatient psychiatric units $880.4 million a year, according to the National Association for Behavioral Healthcare. But Sevilla said, “We estimate, given our own experience, that’s got to be low.”

Another of the Joint Commission’s rules, to assess each patient’s suicide risk, has long been standard procedure at Yale New Haven, Fortunati said. “We already have safety rounds to make sure everyone is safe,” he said. Any patient at risk is accompanied by a staff member throughout the day, and the most seriously ill are not allowed to be in their rooms or even the bathroom alone.

“We’re already safer than the community, nevertheless we worry about some individuals that might be at higher risk,” Fortunati said. “It does require psychiatric expertise to assign a risk level and we assign that level based on evidence-based standards and guidelines. … Most folks we’re not worried about because there’s plenty of eyes on people throughout the day.”

But, Fortunati said, staff have complained that the safety measures are “turning the hospital room into a prison cell. It’s making things so sterile it doesn’t feel like a place where people would come to get better.”

“The balance between creating a healing environment and creating a safe environment is what everyone struggles with,” Sevilla said.

Herman McKenzie, director of the Department of Engineering for the Joint Commission’s Standards Interpretation Group, said, “It’s important that we do all we can to be leaders in ensuring that the physical environment is appropriate for these patients.”

He said the commission convened “an expert panel to look at this a little bit closer and to come up with recommendations. … One of the things we came up with is organizations … need to look at all areas, all surfaces, to make sure it’s appropriate and it’s ligature resistant.”

McKenzie said everything possible should be done to reduce the risk of patients harming themselves. “I would say it it’s one of my loved ones or if it’s myself, I would want to make sure that someone is looking out for my welfare and I wouldn’t want to have a cost/benefit analysis on my life.”

The state Department of Public Health did not respond to a request for comment.

Connecticut Media Group