The concept of integrated healthcare
– treating the whole person and all of his or her diagnoses, including mental illness, in one location with one team of clinicians—has gained considerable traction in the literature (U.S. Department of Health & Human Services, n.d.). The discussion has largerly centered on outpatient treatment modalities, medical records, organizational structure, and other aspects of implementing this concept. It seems odd, given the importance of the environment to patient care, that the design of inpatient units has largely been missing in this evolving discussion of facilities where integrated treatment may be safely provided to all patients.
When designing integrated inpatient facilities, it is necessary to prepare for the possibility that mental health patients may attempt to harm themselves or others. In addition to patients with known mental health conditions, patients who are taking prescription medications for conditions such as depression but who are not identified specifically as mental health patients must also be considered. All patients will benefit from a facility that has been designed with safety in mind. Contrary to common assumptions, fixtures and design elements used in modern mental health hospitals are functional, attractive, and safer for all patients, regardless of mental health status (Figure 1).
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Figure 1. Patient Room Footwall Patient rooms designed for the safety of mentally ill patients may include features such as security glazing applied over the inside face of existing exterior windows, light fixtures with polycarbonate lenses and tamper-resistant fasteners, tamper-resistant fire sprinkler heads, medical beds that are specifically designed to be more safe for these patients, and televisions positioned behind polycarbonate cover built into millwork. (Architect: Progressive AE from Grand Rapids, Michigan. The hospital is St. Mary's Health Care in Grand Rapids. Author James Hunt consulted on this project. Credit: JRP Studio + Graphics)[/caption]
Patients with unidentified mental health issues
Studies show that the use of mental health medications varies by region, with a range from 14.6% to 23.3% of the general population (Medco Health Solutions, 2011). Therefore, it can be assumed that a significant percentage of patients being seen in integrated care treatment facilities may be using some form of prescribed mental health medication. Some of these patients may suffer from depression or suicidal ideation, which may be further exacerbated by a comorbidity, such as a serious physical condition. Therefore, it is necessary to provide an environment that is safe for them. The potential risk of self-harm by these patients within the integrated system of care must be addressed, and part of that preparation should be the safe design of the treatment unit.
Patients with known mental health issues
The earliest example of a general hospital admitting psychiatric patients was the hospital of Saint Maria della Petra Rome, founded in the 15th
century and “dedicated to the care of all sick people, including those who are mentally sick.” In the United States, Pennsylvania Hospital treated its first group of mentally ill patients, who were “admitted to the cellar,” in 1756 (Meyerson & Davis, 1983). By the early 19th
century, the design of mental health treatment facilities was based largely on a strong belief that architectural design was of “cardinal importance” and inseparable from any plan of treatment (Porter, 2002).
On a medical unit, patients spend the vast majority of their time in their rooms waiting for or receovering from specific medical interventions. The patient rooms are where they see their doctors, eat their meals, receive visitors, and, with the exception of specialty tests and treatments, receive the majority of their care. In a psychiatric facility, however, none of those activities occur in the patients’ rooms. Patients are expected to be out of their rooms participating in activities or interacting with other patients and staff during the day. These two types of facilities require completely different design approaches.
Unfortunately, patients who have both a medical as well as a mental health condition do not fit comfortably into either the traditional mental health or medical treatment systems and often fall through the cracks because neither system is equipped to take care of them. They are more likely to be found in hospitals than on inpatient psychiatric units and often present to the emergency department with injuries and serious illnesses (Bernstein, 1996).
Mental health patients who find themselves being treated on a medical unit often find ways to make their dissatisfaction felt – by escaping, committing suicide, starting a lawsuit, or simply complaining to their relatives (Tomes, 1994). In addition, it may be difficult to follow up with and provide aftercare for these patients, and they have very high rates of recidivism and readmissions for their illnesses. They tend to have multiple service needs, confounding attempts to provide a coordinated continuum of care (Bernstein, 1996). For these reasons, it is much better to treat patients presenting with mental health issues only (with no medical issues) in a unit specifically designed for mental health patients. The inpatient treatment process, and herefore the physical design of the treatment spaces, is completely different for mental health patients. They need group therapy rooms, activity rooms, day rooms, seclusion rooms, and consultation and interview rooms, all of which are typically unique to a mental health treatment unit. In addition, it is unrealistic to provide those spaces if the patient is receiving medical treatment and, therefore, not ambulatory or able to participate in group functions. Inpatient psychiatric patients who do not have a co-occurring medical condition requiring treatment will always need a separate environment.
Managing the risk of self-harm
There is inherent risk that medical equipment may be used for self-harm. The current common practice, therefore, is to assign known mental health patients in need of medical treatment to medical/surgical units and assign a sitter to observe them at all times. One recent study reported, however, that nine of the 72 suicides investigated had been successful despite one-on-one observation (Busch, Fawcett, & Jacobs, 2003). The Joint Commission reported in 1998 that in the previous two years, it had reviewed 65 inpatient suicides, 17 of which (26%) had occurred in non-psyciatric environments (The Joint Commission, 1998). In addition, competing treatment prioirites in the medical/surgical environment mean that staff members may not be familiar with, or trained to treat patients with mental illnesses. That may result in, among other things, psychotropic medications not getting the close attention they require. Potentially detrimental drug interaction may go unnoticed until undesired outcomes have occurred.
A new standard of care for all
To combat latent risks to patients in the integrated care environment, some lessons from the behavioral
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Figure 2. Patient Bathroom Patient bathrooms designed for safey may include countertop-mounted sinks with ligature-resistant faucets, vanity-like pipe enclosures with tamper-resistant fasteners, bedpan washers recessed into under-counter enclosures, shatter-resistant mirros, recessed flush valves with no exposed piping, toilet features that fit tight to the wall at back, low-mounted push button (not pull cord) nurse alarms, ligature-resistant grab bars, and ligature resistant toilet paper holder (not shown). (Architect: Progressive AE from Grand Rapids, Michigan. The hospital is St. Mary's Health Care in Grand Rapids. Author James Hunt consulted on this project. Credit: JRP Studio + Graphics[/caption]
health hospital should now also be considered the standard of care in the built environment designed for integrated care. Because bedrooms and bathrooms are the most likely location for acts of self-harm, they are good places to begin to address design opportunities, for example, by reducing ligature attachment points (Joint Commission Resources, 2007). Toilet rooms and bedrooms should have barricade-and ligature-resistant door hardware, toile accessories, and plumbing fixtures. Fittings for plumbing fixtures should be appropriate for the mental health patient in all, not just a few, treatment rooms.
Patient bedrooms and bathrooms being designed today for inpatient mental health facilities are more user-friendly, more appealing, and much safer for all patients than those currently (and historically) provided for patients in general hospitals (Figures 2 & 3
). There is no reason why these concepts cannot be used in an integrated healthcare facility. A more pleasant, functional, and safe environment for all will be the welcome result.
Guides to risk assessment and design
Another important step in this process is to perform a risk assessment that considers the patient population being served. Fortunately, the 2014 edition of the FGI Guidelines for the Design and Construction of Hospitals and Outpatient Facilities
requires that some form of safety risk assessment (SRA) be performed for all new construction and remodeling projects.
There are two known SRA approaches available in the literature. The Center for Health Design introduced its Safety Risk Assessment Toolkit
(2015) at the Planning, Design and Construction Summit on March 15, 2015, in San Antonio, Texas. It is the result of a three-year, evidence-based design consensus research project and has modules for six aspects of hospital design: falls, patient handling, psychiatric injury, security, hospital-acquired infections, and medication safety.
The second approach is found in the Design Guide for the Built Environment of Behavioral Health Facilities (Hunt & Sine, 2016). This document includes a patient safety risk assessment tool that can be used by clinicans and design professionals together to determine the appropriate level of risk tolerance for each portion of any specific project. This document is included as a reference in the Appendix of the FGI Guidelines for the Design and Construction of Hospitals and Outpatient Facilities (2014).
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Figure 3. Patient Room Headwall Inpatient bedrooms may include medical gas outlets and space for CPAP machines or other medical equipment in locked cabinets next to the bed with polycarbonate panels to allow view of gauges, ligature-resistant cabinet pulls, and other fixtures as seen in Figure 1. (Architect: Progressive AE from Grand Rapids, Michigan. the hospital is St Mary's Health Care in Grand Rapids. Author James Hunt consulted on this project. Credit: JRP Studio+Graphics).[/caption]
It is strongly suggested that some kind of formal, documented discussion of environmental risks for all of the applicable modules listed above be included in every design project. Both of these aforementioned documents can be downloaded from the Internet without charge.
Further areas of concern
Some further examples of areas of concern in medical/surgical units being used to treat mental health patients are as follows:
Doors and hardware: Barricade-resistant doors that do not create alcoves or blind spots in corridors should be provided, and all door hardware should be ligature resistant.
Medical gas systems: Providing a locked cabinet to enclose the medical gas outlets and apparatus that leaves only a small opening to allow the tubes to exit the cabinet goes a long way in reducing the risks associated with these systems. The tubes themselves are still an issue, but the level of risk can be greatly reduced by enclosing the related hardware at the headwall (Figure 4).
Electrically adjustable beds: While there are now several beds advertised as being safe for use for psychiatric patients, they still allow patients access to a wide range of small parts and open mechanisms that can be hazardous. There are at least two companies currently working on designs for beds that completely enclose the moving parts under these beds and provide a much lower level of risk. Clearly, the market has recognized the risks and is responding.
Cubicle curtains and their tracks: There is not a good solution to the use of this equipment at this time. The current trend of providing private rooms in medical/surgical units should help reduce the need for cubicle curtains going forward.
Bedpan washers: These have been provided in locked cabinets adjacent to the toilets, utilizing spray heads on flexible hoses
(Figure 5). The use of bedpan washers in all hospitals may be reduced in the future due to their role in hospital-acquired infections.
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Figure 4. Safe Storage for Medical Gas System in a Patient Bedroom (Architect: Progressive AE from Grand Rapids, Michigan. the hospital is St Mary's Health Care in Grand Rapids. Author James Hunt consulted on this project. Credit: JRP Studio+Graphics).[/caption]
Lavatories: Counters made of solid surface material with integral sinks are a significant improvement over china lavatories typically provided in the past. The countertops provide a place for patients to set their toothbrush and other items as well as having the appearance of a more residential environment. A locked cabinet can be provided below the countertop to enclose the pipes in a less obtrusive way. Providing a ligature-resistant faucet helps make the fixture safe for all, more functional, and better looking.
Toilet fixtures: Fixtures with the water supply fitting on the back (in lieu of the top) with a push-button activated flush valve recessed in the wall significantly improves safety (Figure 2).
Toilet accessories: Dispensers for soap and toilet paper, robe hooks, and grab bars should be ligature-resistant. Shatter-resistant mirrors should be provided.
Windows: All windows, both interior and exterior, should have security glazing that, when broken, stays in the frame and does not yield shards of glass that are hazardous to patients and others. An alternative glazing material is polycarbonate, which is easily scratched and may need replacement periodically. A recent project found that the security glazing is now less expensive than polycarbonate.
Window coverings: Curtains of any type are discouraged in any patient-accessible area. Miniblinds, adjustable louvers, or roller blinds located behind security glazing are recommended. The operation of these may be adjustable and controlled by the staff, patients, or both depending on the preference of the facility.
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Figure 5. Safe Storage for Bedpan Washing Equipment (Architect: Progressive AE from Grand Rapids, Michigan. the hospital is St Mary's Health Care in Grand Rapids. Author James Hunt consulted on this project. Credit: JRP Studio+Graphics).[/caption]
Lighting: The continued use of 2x4 fluorescent light fixtures is highly questionable in either general or psychiatric hospitals. Both types of facilities claim they want to provide environments that are more comforting and less institutional. Since these are not commonly used in residential construction, there is little reason to use them in medical facilities either. Recent developments in LED lighting have provided some very interesting and exciting lighting alternatives.
Ceiling material: Monolithic ceilings are required for patient bedrooms and bathrooms of facilities serving patients with possible mental illnesses. Providing typical, accessible ceilings allows patients easy access to ligature attachment points and other potentially hazardous items above the ceilings. Also, lay-in type ceilings are not frequently used in residential construction. Currently, both medical/surgical hospitals and mental health facilities are placing great emphasis on the need for a therapeutic environment, or an environment that promotes healing. The goal should be to provide spaces that are as “normal” as possible. Things that patients touch and use should be as similar as possible to items they use in other building types.
Treating the whole patient in one location with one team is a tremendous concept, one that has been lost with the high degree of specialization that has dominated the field of medicine in recent years. The basic concept of integrated healthcare provides the opportunity to rethink the way we design hospitals. It is very exciting to see the integrated healthcare trend emerging; it provides a welcome change to treating patients in silos where caregivers from different specialties seldom interact or share information.
James Hunt is president of Behavioral Health Facility Consulting in Topeka, Kansas. He may be contacted at email@example.com.
David Sine is the chief risk officer at the VA National Center for Patient Safety. He may be contacted at firstname.lastname@example.org.
The opinions in this article are those of the authors and are not intended to represent the position of the Department of Veterans Affairs or the U.S. government.
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U.S. Department of Health & Human Services. Agency for Healthcare Research and Quality. The Academy. (n.d.). What is integrated behavioral health care? Retrieved from https://integrationacademy.ahrq.gov/atlas/What%20Is%20Integrated%20Behavioral%20Health%20Care