When it comes to the safety of patients in a behavioral health facility, there is “no one-size-fits-all solution,” according to James Hunt, AIA, NCARB, an architect and consultant for the building and design of such facilities. Each population comes with its own risks and each organization must decide just how far to go to incorporate safety into design. The patient bedroom is a particularly high-risk area, since patients are unsupervised for the longest periods of time in this space. When furnishing a patient bedroom, staff should consider each item carefully. Beds . Hunt identifies “platform beds with no storage drawers or exposed wires, springs, or restraint loops” as the best choice. Facilities can minimize the institutional look and feel of these beds by selecting the bed's finish. Hunt suggests choosing a wood or wood-appearing finish, such as synthetic materials with a surface made to look like wood, as long as it is well-sealed and durable. Facilities may also choose to select plastic beds, rather than wood, as these can be more durable ( figure 1 ). “These have the advantage in that they … have no joints into which liquids can penetrate,” Hunt says. Plastic, platform beds are a safe and durable choice for facilities (mattress not shown) Photo by Norix Group, Inc. Whatever the bed choice, Hunt advises facilities that these beds be anchored firmly to the floor “to reduce the likelihood of patients using them to barricade” bedroom doors leading out into the corridor. Dressers, armoires, and closets . According to Hunt, “clothes poles and hangers have been a significant issue” for patient safety for many years. Patients have commonly used these features as ligature attachment points from which to hang themselves. To reduce this risk, the Facility Guidelines Institute eliminated space for hanging clothes as a requirement for facilities, effective this year (see FGI Guidelines for the Design and Construction of Health Care Facilities , 2010 edition). Instead, Hunt recommends a sloped, open-front cabinet with fixed, shallow shelves ( figure 2 ). The selection of this type of product: Ensures that patients cannot easily sit or climb on the top of the cabinet's sloped surface; Eliminates cabinet doors, which are “often used as an attachment point,” and reduces the risk of hanging; Reduces the risk that the secured, shallow shelves can be used for climbing or removed for use as weapons; and Eliminates drawers, which can also be broken, used as attachment points, or removed and used as weapons. Shallow shelves and a sloped top reduce climbing and hanging risks from shelving units Photo by Norix Group, Inc. Hunt insists that, like beds, these cabinets should be securely anchored to walls or floors. Nightstands, desks, and chairs . Because these furnishings are typically light in weight, Hunt says that facilities may need to eliminate the potential for patients to stack or throw nightstands, desks, and chairs. This can be done by anchoring them to the floor. The presence of drawers should also be eliminated by replacing them with open shelves. For desk chairs, Hunt suggests choosing products that are lightweight plastic, as they “are not easily broken” and “do not make good weapons.” Windows and window coverings . Windows are highly susceptible to abuse by patients, according to Hunt. Because of this, adequate selection of durable glass is essential for the patient bedroom. The FGI Guidelines refers facilities to specific American Society for Testing and Materials (ASTM) tests at http://www.astm.org for window glazing impact resistance ratings. Some facilities choose to use clear polycarbonate (Lexan) for windows in patient areas because it is very difficult to break. However, it is susceptible to being scratched. There are some mar-resistant and abrasion-resistant coatings available that will help reduce this problem. In the event that patients scratch the polycarbonate windows, Hunt suggests keeping replacement panels on hand. Window coverings pose a potentially high safety risk for patients, as blinds, draperies, curtain rods, and cords or chains for adjustment could be used for hanging. To prevent this, Hunt identifies “mini-blinds sealed between layers of the exterior window glazing” as the best selection for window coverings, provided that “the device used to adjust the position of the blind [does] not provide a ligature attachment point.” For facilities that cannot afford or use such window coverings, Hunt makes another suggestion: a flush-mounted track with break-away drapes ( figures 3 and 4 ). This track is directly mounted to the ceiling, reducing the risk that patients can hang from it. The fabric selected for the drapes should be “breathable, to reduce the risk that patients use it to suffocate themselves.” Facilities should also be sure to eliminate any and all cords, chains, and wands typically used to adjust drapes. Flush-mounted curtain tracks are secured to the ceiling (left) and lined with safety tabs for breakaway drapes (right) Photos by Imperial Fastener Company, Inc. The conical shape of Stanley Patient Safety Levers (SPSL) prevents patients from securing attachments to them Photo by Stanley Security Solutions, Inc. Doors . Hunt asserts that the selection of doors and door hardware for patient bedrooms remains “a complex issue without a clear solution at this time.” However, he does have several recommendations that he has found to be effective in his own facility design projects. His first recommendation is to select an “in-swinging” door for the bedroom. However, he notes that this could pose a potential opportunity for patients to barricade themselves in their rooms. To reduce this risk, Hunt presents several options: A “door within a door,” or “wicket.” Hunt says that this “smaller panel in the center of the primary door” should be hinged to swing outward into the hallway, but should be locked at all times, except in emergencies. An unequal pair of double egress doors. “This involves a primary door of the required width that swings into the room and an adjacent door that is approximately 18 inches wide that swings into the corridor,” Hunt says. “The narrow leaf should be locked at all times, except in emergencies.” Similarly, facilities could also choose an unequal pair of doors divided by a mullion-or vertical frame-that separates two doors. “[This] provides a more secure attachment of the smaller leaf,” Hunt says. A double-acting door with an emergency stop. “This door normally swings into the room and can be swung out if a device in the jamb is depressed to allow movement in the outward direction,” Hunt says. “This solution requires the use of center pivot hinges which present some potential hazards.” Anchored furniture, which reduces the possibility of the barricade hazard. Hinges on all door selections should be continuous (piano hinges) with sloped “hospital tips,” according to Hunt. All applicable code and regulatory officials must be consulted before deciding on any of these suggestions. Door locks may also present an opportunity for patient suicide or self-harm, as they provide attachment points from which one could hang a ligature. Because of this, Hunt says that “standard knob or lever locksets should never be used on any patient accessible door.” Instead, he suggests the following options: Anti-ligature levers with a conical rose ( figure 5 ); Push/pull locksets, also known as paddle handles, that resist downward pressure; and Crescent handle locksets, which resist upward, downward, and transverse attachment. An over-the-door alarm can alert staff if a hanging attempt is being made by a patient. These pressure-sensitive strips are avail-able from at least three companies, Hunt says. Flooring . Floors of patient bedrooms pose less of a safety risk than other components. However, patients may be inclined to damage or urinate on floors, according to Hunt. To secure flooring and prevent it from being picked or pulled loose, Hunt suggests sheet vinyl or broadloom carpet. “Both of these materials provide a minimum of seams at which patients can tamper,” he says. Solution-dyed yarn and moisture-resistant backing for carpet is also preferred. If urination is a high concern, Hunt suggests seamless, resinous flooring-which is durable, resistant to chemicals, and easy to clean-and an integral base. According to the Joint Commission, 75 percent of suicides occur by hanging in a patient bedroom or bathroom. Because of this, facilities should take as many precautions as they find necessary to protect their patients from self-harm or suicide in these environments. “Each facility must evaluate its patient population, staffing, and other issues to determine the level of risk it is willing to accept,” Hunt says. In a later article, Hunt will outline the strategies and components facilities may utilize to reduce risks in patient bathrooms. Designing a new market When James Hunt, AIA, NCARB, first began planning and designing behavioral health facilities, he says that product manufacturers wouldn't give him the time of day regarding the development of new products for the behavioral health population. After working in the industry as an architect and consultant for several decades, Hunt teamed up with long-time colleague David Sine, ARM, CSP, CPHRM, in 2003 to write the Design Guide for the Built Environment of Behavioral Health Facilities, one of the few resources for organizations on building a safe, but still visually pleasing, environment. The guide is currently in its fourth edition and available for free online at http://www.naphs.org . Hunt says that the design guide has, hopefully, helped raise awareness of hospitals, designers, and manufacturers that the behavioral health market is unique and must be designed for carefully in order to achieve a high level of safety for both patients and staff. Behavioral Healthcare 2010 July-August;30(7):32-34
Read the complete post at http://www.behavioral.net/ME2/dirmod.asp?type=Publishing&mod=Publications::Article&mid=64D490AC6A7D4FE1AEB453627F1A4A32&tier=4&id=B1341CB3785C4027BD284221C9AEA80C
Posted
Wed, Jun 30 2010 8:00 PM
by
Behavioral Healthcare Current Articles