it is important to remember that the
same level of concern for safety precautions is not required for all parts of a
unit. The four levels of patient safety concern identified in the patient risk
assessment matrix each have their own unique design restrictions, as described
below. In addition, a fifth level of precautions is discussed that does not
appear on the matrix because the risks are unknown.
Please
note: The precautions for each level include all of the precautions for the
previous levels as well.
Level I: Staff-Only or Direct
Supervision. These are areas where patients are not allowed or are under
constant supervision, such as staff and service areas and the nurse station or
patient laundry room. Standard commercial finishes, light fixtures, air
grilles, and so on are usually acceptable for use in these locations.
Level II: High Observation. Patients
in these areas (e.g., corridors, counseling rooms, activity rooms, and
interview rooms) are highly supervised and left alone for only very short
periods. Corridors within direct line of
sight of the nurse station that do not have alcoves or blind spots often have
accessible ceilings and standard light fixtures. However, it should be
recognized that staff may not always be present at nurse stations, especially
on third or evening shifts, when patient-to-staff ratios are usually high.
This level of precaution may be
suitable for activity rooms used only with staff present, such as activity
therapy rooms and group rooms. However, patients have been known to work
together to distract staff to one area so other patients can access hazardous
items in areas that are normally under observation.
Level III: Periodic Observation. These
are areas (e.g., lounges and day rooms) where patients may spend time with
minimal supervision. Television viewing rooms and other informal,
non-structured activity spaces may require fewer precautions than Level IV
spaces. However, the decision to apply Level III precautions to such spaces
should be carefully discussed with facility staff and any potentially hazardous
features that are included should be clearly identified and documented.
Light fixtures in spaces with Level III precautions should have substantial lenses securely anchored in place and frames secured with tamper-resistant screws. Accessible ceilings should not be used, and all fire sprinkler heads are to be as vandal-resistant as possible. Window treatments should not include curtains, drapes, or vertical blinds of any type. Mini-blinds behind security glazing without any exposed cords, chains, or wands are recommended.
Common Hazards in a Behavioral Health Patient Room
Access to all mechanical units should
be secured by locks or tamper-resistant fasteners. Air grilles should have
perforated faces with openings no larger than 3⁄16" in diameter in any
patient- accessible area needing Level III precautions.
All cabinet doors and drawers should be locked at all times and have flush pulls and recessed hinges. If the cabinets contain articles for patient use, the doors should be removed and the shelves securely anchored in place (non-adjustable). Furniture should be very sturdy and made to withstand severe abuse and, if possible, anchored in place. Table lamps should not be provided, and care should be taken with mounting of pictures or artwork.
Level IV: Minimal Observation. Areas where patients spend a great deal of time alone with minimal or no supervision, such as patient rooms (semi-private and private) and patient toilets, require Level IV precautions. In areas with minimal observation, architectural details and finishes must be used that can minimize the risk of suicide. For example, the tight fit required for corridor doors makes it possible to close the door on an article placed over it (e.g., a sheet with a knot in the end) to create a hanging device or ligature. Devices are available that will sense such activity and activate an alarm.
Door hinges may also provide attachment points for ligatures. The three butt hinges with non-rising pins and rounded “hospital tips” often used in general hospitals provide the opportunity for patients to tie something around an individual hinge while the door is open. Continuous geared hinges with tapered tops are preferred, as they cannot be used in this way.
The doorknob or door lever also may provide an attachment point. Use of standard knobs, levers, paddle-type devices, and typical pulls is strongly discouraged in psychiatric facilities. Several devices are available that attempt to address the potential hanging issues associated with these devices.
Keeping the doors of vacant patient rooms locked at all times is strongly recommended. Use of locks with a “classroom” function is preferable to help prevent a patient from being inadvertently locked in a room. If deadbolts are used, they should have a ligature-resistant turn piece on the inside that will retract the bolt but not extend it so patients cannot lock themselves in a room.
Windows and window coverings also
require special consideration. In the past, very heavy stainless steel screens
were often installed as a safety measure. Although still used in some
facilities, these screens provide a very institutional or prison-like
appearance. As well, patients have been known to use toothpaste or feces to
write obscene words in the wire mesh.
A variety of window glazing materials
that cannot be easily broken to produce sharp shards of glass and, if broken,
will stay in the frame to resist egress are appropriate for use in psychiatric
facilities. Tempered glass breaks into very small pieces that do not stay in
the frame; laminated glass will stay in the frame but yields shards.
Polycarbonate sheets satisfy both of these requirements (provided the stops are
deep enough to account for the amount of deflection in large pieces), but may
require frequent replacement if graffiti is scratched onto its surface. New
hurricane- and bomb- resistant glazing materials and films that can be applied
to increase shatter resistance are more suitable.
Patient room furniture should be anchored securely, with the possible exception of a desk chair (if provided). This is to reduce the possibility of patients using furniture to barricade themselves in a room or stacking or piling the furniture for other purposes. Patients have been known to throw furniture or use it to strike staff. Electric hospital beds present extreme hazards and have been used in successful suicides.
Cabinet doors can provide convenient hanging hazards, and many drawers can be removed or broken to yield sharp objects that can be used as weapons. For these reasons, the 2014 edition of the FGI Guidelines requires use of shelves for folded garments for patient storage rather than “arrangements for hanging garments” in new construction and major renovations. We recommend that all cabinet doors and drawers be removed from existing patient rooms as well. In addition, all shelves should be securely anchored in place.
Patient toilets are the location of
many acts of self-harm because patients are alone in them without supervision
and the rooms typically have many potentially hazardous features. It is
important that patient toilet room doors swing out of the room to reduce the
opportunity for patients to barricade themselves in these rooms and to allow
staff access in the event a patient passes out while in the toilet room. Toilet
room doors themselves can present numerous hazards. Several suitable products
are available to use instead of standard doors. Some facilities are considering
the option of leaving doors off the toilet room in single-patient rooms with no
direct line of sight into the toilet room from the corridor when the corridor
door is open.
Towel bars are a good example of the contradictory issues architects must address. If the bars can be easily removed, patients can use them as weapons to harm themselves or others. However, if the bars are securely anchored, they present a hanging risk. For these reasons, the FGI Guidelines forbid the use of towel bars. Use of towel hooks or robe hooks that collapse under weight is recommended instead.
Grab bars are not as easily avoided as
they must be provided in at least a percentage of the patient toilets to comply
with ADA and other requirements. As well, it is recommended that all patient
toilets have at least one ligature-resistant grab bar to assist patients who
are on medications that disturb their sense of equilibrium.
The most common solution to open grab bars as a hanging hazard has been to install a bar with a stainless steel plate welded to the bottom to close the opening between the bar and the wall. However, this arrangement creates an undesirable side effect where the plate meets the bottom of the bar where water can collect and create an infection control problem. Other grab bar choices are suggested in the Design Guide.
Patients have been known to “hang” themselves from objects as close to the floor as 18 inches, and one study found that 50 percent of non-judicial hangings were from heights below the waist of the victim (Frampton and Charmel 2008). In fact, patients can commit suicide by attaching a strip of torn bed sheet to a loop imbedded in the floor or under a door. At this point the danger is no longer hanging or strangulation but anoxia, which is a condition where something is tied tightly enough around the patient’s neck to cut off blood flow to the brain. The patient has to position his or her body so that tension will remain on the ligature after loss of consciousness.
After 4.5 to 5 minutes, anoxia can
result in either death or irreparable brain damage. Water supply pipes under
lavatories, sink P-traps, flush valves for toilets, faucets, and even the
lavatories themselves are potential attachment points for ligatures and should
be protected. Other known problem areas are glass mirrors, shelves, soap
dispensers, paper towel dispensers, and toilet paper holders.
Possible solutions vary depending on whether a project involves new construction, remodeling, or both. As usual, solutions for new construction are the easiest because most plumbing can be concealed in the wall and other items can be recessed to mitigate problems. A number of products have been developed specifically to assist with remodeling projects. One example is a cover with a sloped top for existing flush valves and related piping. Provision of a pushbutton- activated valve is preferable. Covers are available for the pipes under wall-mounted lavatory fixtures. These should be trimmed to fit tightly to the bottom of the fixture to avoid opportunities for patients to hide contraband such as razor blades, drugs, or other items. All mirrors should be of tempered glass with security film and be equipped with stainless steel, tamper-resistant frames; distortion should be minimal.
Hard plastic paper towel dispensers and soap dispensers can be fairly easily removed from the wall and broken to yield very sharp pieces of plastic that can be used as weapons. One manufacturer of commonly used hard plastic soap dispensers now has a lockable steel cover that fits over the standard dispenser to reduce the level of risk to these patients. Toilet paper dispensers can be hanging hazards, and springs from spring-loaded tubes that hold the paper can be removed or smashed and made into sharp objects. One solution is a stainless steel tube that is recessed into the wall to hold the entire roll. Some facilities object to this as an infection control issue because everyone using the roll has to handle it. Another option is a steel product that completely contains the roll of paper.
The lavatory faucet and valves also
provide attachment points. Wall-hung lavatories are losing favor because of
their institutional appearance and because they provide little space for patients
to set their toiletries. Solid-surface countertops with integral sinks are much
more functional and residential in nature. Pipes below the countertop can be
enclosed with a rather typical looking vanity cabinet (with recessed pulls and
securely locked doors) or ADA profile cabinets where required.
Several ligature-resistant faucet sets are on the market. Ligature-resistant valves that will give patients control of the duration of flow and temperature of the water (within limits) are preferable as these give behavioral health patients, who have so much control taken away from them, some control of their environment. In our opinion, no paper towel dispensers currently available are appropriate for use in patient areas. Shelves, either recessed or ligature-resistant surface-mounted units, can be provided to hold a few towels. Some object to this suggestion, saying patients will use the towels to clog the toilets. However, if they are so inclined, they can simply remove a quantity of paper towels from a typical dispenser, which also provides other hazards.
Patient showers and bathtubs are of
major concern. In our opinion, patients should only use bathtubs while under
direct supervision of staff. The obvious hazard of potential drowning plus the
added risks from valves and fill spout are problematic. Patients can use
showers if careful attention is given to all aspects of the design of the room,
including the following:
• Institutional-type
showerheads have been around for a number of years and work reasonably well in
this environment.
• A variety of water control valves provide ligature resistance as well as control of water temperature and duration of flow.
Some of these valves are also usable
in ADA showers. For remodeling work, assemblies that have stainless steel
panels with the head and valve already mounted are available.
• Soap
dishes should be recessed and not have grab handles.
• Grab
bars, if present, should be as discussed above.
• If
possible, shower stalls should be designed so a shower curtain is not needed.
Use of shower curtains is highly discouraged since they simultaneously provide
an attachment point and a ligature in the form of the curtain. If they must be
used, an aluminum track mounted flush to the ceiling with an absolute minimum of
breakaway fasteners could be provided. However, our experience is that the
curtain can be bunched up so the holding weight of all the fasteners can be
added together (anoxia does not require that the person’s entire body weight be
supported). The shower curtains themselves should always be made of a
breathable material such as woven fabric with applied waterproofing.
• As
elsewhere, lighting fixtures in patient toilets and showers should be a
security type with fully enclosed frames, lenses of polycarbonate or similar
material, and security fasteners.
• Air
grilles and fire sprinkler heads should be provided as discussed above.
Level V: Special Considerations. Areas
where staff interact with newly admitted patients who present unknown risks or
where patients may be in a highly agitated condition create unique issues that
fall outside the ranges described in Levels I through IV and require special
considerations for the safety of both patients and staff. Such areas include
seclusion rooms, examination rooms, and admission rooms. Seclusion rooms are
clearly defined in the FGI Guidelines and will not be elaborated on further
here.
In admissions screening rooms or intake assessment areas, staff encounter patients who are unknown to them and who may become agitated and violent when they realize they will be admitted. These rooms should have a minimum of furniture and everything possible should be securely anchored in place. Computers, telephones, and cords and cables should be kept as far from the patients as possible.
Careful attention should be given to the furniture arrangement and the location of the door. Seating for staff should always be closer to the door than the patients’ chairs. Although somewhat counter- intuitive, this arrangement is very important so that staff always have an escape route in case a patient becomes violent. Duress alarms are also highly desirable in these rooms.
Examination/treatment rooms contain multiple potentially hazardous items that are essential to the function of the room and thus cannot be removed. Therefore, it is strongly advised that two staff members always be present when a patient is in these rooms.
Solutions
Psychiatric inpatient facilities
present a unique set of challenges, and the solutions to designing safe
facilities are often completely different from what is typically done for
medical/surgical units in a general hospital. Decisions about design for
psychiatric facilities should be thoroughly discussed with facility staff
beginning during the programming phase and continuing at decision points
throughout a project. As well, the decisions made should be documented,
including the reasons behind them, before proceeding to subsequent phases of a
project.
Space does not allow detailed
discussion of solutions to all of the problems mentioned in this paper and, in
any case, answers are often very specific to a particular facility. In addition,
a product that is perfectly acceptable for one patient population may not be
acceptable for another.
Reference:FDG
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