Design mistakes, part 2: More things many `know` that `just ain`t so`

Editor’s Note:  In the design article in our November/December 2012 issue, consultant Jim Hunt introduced Part 1 of a discussion of common, but mistaken design and safety-related assumptions that often emerge in preliminary design meetings that precede the development or renovation of a psychiatric facility. Part 2 of his discussion, beginning with his third point, begins below.    

(3.) “15-minute checks provide sufficient observation for patients on suicide watch.” This is a widely held concept that has been around for decades. But it must be challenged, because it is not backed by evidence.  

I would suggest that a designer start a discussion with this question: “Why do you think that checking on patients at 15-minute intervals is an effective suicide deterrent?” Typical responses may note that an individual could not accomplish a suicide by strangulation or suffocation in that period of time.

But that is not the case: Medical studies verified by The Joint Commission³ establish that patients can tie something around their necks tightly enough to cause death or irreparable brain damage in as little as 4 to 5 minutes by inducing a condition called anoxia. Another study⁴ also concluded that 15-minute checks do not prevent suicides. It is clearly possible for patients to “time” suicide attempts between checks.

(4.) “Not all of our patients are suicidal, so we only need a few specially equipped rooms near the Staff Station to monitor suicidal patients.” At first, this sounds like a cost-saving suggestion, but only deeper questioning and discussion can expose its dubious underlying assumptions. Designers might ask these questions:

•    How will you know which patients are suicidal? The idea to build a few specially designed rooms places a heavy burden on staff to accurately identify all of the risks in the patients’ environments and then make appropriate adjustments.⁵  Staff must accurately decide which patients need the “safer” rooms and exactly when they need them. (See item 2 in Part 1 of the story, Nov./Dec. issue.)

•    What if you have more “suicidal” patients on the unit than your secure rooms will allow? How will you decide which patients get them? What will your defense be if the patient you moved to a less-secure room commits suicide that night?  Such questions may expose the unnecessarily high responsibility this design decision places on staff to accurately judge every patient situation. It may also lead to consideration of how disruptive—and costly in staff time—the process of moving patients can be, and whether the cost of a single misjudgment that results in an adverse outcome might more than erase any short-term savings.

(5.) “Building deficiencies can be compensated for by increasing staff.” Some facilities compensate for patient and staff safety hazards by increasing the staff-to-patient ratio and providing additional one-on-one special nursing supervision, a cost seen in increased staff or overtime pay. To get at the potentially costly long-term trade-off that added staffing involves, a designer might ask these questions:   

·•    Does the additional staff time and expense result in better patient care, or is it solely to safeguard patients against these risks?  Responses from staff members may be both positive and negative on this point.
·•    How would the one-time cost of fixing the deficiency compare to the ongoing personnel cost of your remedial practice? An evaluation of alternatives, followed by an estimate, may show that the cost of an appropriate remedy is available at a fraction of the cost of additional staffing.  

(6.) “Tight fitting doors between patient rooms and corridors pose a risk for ligature attachment, but those doors are a code requirement, so the hazard is unavoidable.”  This statement is partially true: Every facility has tight-fitting doors to patient rooms because they are required by building codes and other regulatory agencies. However, it is not true that the safety risks of such doors are unavoidable.

In this situation, the key question is this: Is it acceptable to ignore a known serious hazard just because it’s required by code and “everyone else is doing it?”  

Discussion here might center on the fact that suicides—or suicide attempts—that employ ligatures held in the seams of patient room-to-corridor doors—remain a frequent occurrence.⁶  Patients can tie a knot in almost anything—a bed sheet, a pair of trousers, a sweatshirt—place it over the top of a sturdy door, and use the other end as a ligature.

There are safety alternatives available, including pressure sensitive devices that mount on door edges, connect to a central alarm system, and sound alarms when they are compressed by the presence of an object, such as a ligature. These are available from several companies.⁷ Of course, the edge of the door is not the only ligature attachment hazard: care must also be taken when choosing the door hardware, since hinges and lockset handles can be ligature attachment points.

(7.) “The misuse of furniture to block or barricade in-swinging corridor doors is not a problem, so long as furniture is anchored in place (in patient rooms), or staff are present (in activity rooms).”
This is a bad assumption because it is always possible for a group of patients to enter any patient or activity room, with some able to block the door (even if furniture is anchored in place), while others commit harm to other patients or staff, or to the room and its furnishings.

While some might advocate the need for additional staff to prevent this situation, I would ask: How can we add or modify existing doors to mitigate this safety threat?

The first solution is to add a second doorway to the room. This can be ideal for larger rooms, such as activity rooms, particularly if the second door swings outward.

When a second door is not practical and the existing door swings inward, there are still several options⁷:

• Install or retrofit the door with double-acting continuous hinges, which allow the door to swing out into the corridor in an emergency. These doors are equipped with an emergency stop that extends the full height of the door, as well as a keyed lock to resist unauthorized use.
• Install or retrofit a door-within-a-door or “wicket” door.  These doors contain a hinged panel in the center of the door that is secured by a deadbolt lock on the corridor side. When unlocked, the movable panel swings outward into the corridor, ensuring staff entry to the room.
• Install an unequal pair of “double doors,” with the larger leaf hinged to swing inward (toward the patient or activity room) and the smaller hinged to swing outward. To maximize the width of the opening, install the doors so they are free swinging. To increase strength and reduce noise, separate the doors with a vertical frame member.

(8.) “It is not necessary to protect against ligature attachment for items less than 18 inches above the floor.”
Many years ago, the “standard of care” for preventing ligature attachment was to protect “any attachment point at or above waist level.” Then, the standard of care was reduced to 18 inches above floor height.
But in fact, there is no level below which the risk of ligature attachment and strangulation is not a concern. A ligature attachment point need not be elevated: it could be the leg of a chair or any firmly anchored item. There is no “safe zone.”⁸

Current practice requires that ligature attachment risks be mitigated throughout the environment, notably in areas where patients will be alone, such as patient or toilet rooms.⁹ But, a designer might ask: What about “non-patient areas” like staff offices, storerooms or other areas where patients are never expected to be alone?

Even these areas should be designed with safety in mind. Despite the best efforts of staff, I find on site visits that it is not unusual to find the doors to such areas unlocked, with patients inside and unknown to staff. Incorporating ligature resistant features in these rooms can reduce the pressure on staff to constantly secure such areas by locking doors or exercising extreme vigilance.   
   
(9.) “Doors of patient room wardrobes or cabinets are not strong enough to pose a problem.”
In fact, most patient room wardrobe doors are substantial enough to support suicide attempts by hanging. The slot formed between the cabinet frame, door, and the top of the hinge forms an effective ligature attachment point.  

The best approach, in my opinion, is to eliminate doors on all patient accessible wardrobes or cabinets. This dramatically reduces the ligature risk and eliminates the risk of removing a door for use as a weapon. The shelves in any patient-accessible cabinet must be securely anchored, resistant to both downward and upward force. Any cabinet doors required in patient accessible areas must be securely locked when staff is not present.

(10.) “Break-away shower and window curtains provide an adequate measure of safety.” This, I believe, is a questionable proposition. Here’s why: even when specially designed, all break-away curtain hangers hold some weight; some patients have been known to bunch these hangers together to share a bigger load. And, even when these fasteners function properly, the curtains themselves can easily be tied around the neck as ligatures, so the consideration of break-away weight alone is not sufficient to prevent hazard. One hospital recently reported that a patient was able to thread a ligature above the break-away hangers and into the ceiling-mounted track. This connection provided substantial holding force.

For these reasons, current best practice is to design all patient-accessible areas without curtains or drapes. Whenever possible, showers should be designed to contain water without the presence of a curtain or door. European type toilet rooms—rooms in which the floor space is sloped to drain (or equipped with trench-type drains) and all fixtures are designed to tolerate shower spray—are an effective alternative. Such designs require a water barrier pan beneath the entire floor area as well as slip-resistant flooring.

When shower curtains are required, they should be equipped with the minimum number of breakaway fasteners and consist of a “breathable” fabric that reduces the suffocation risk.  

Windows with integral blinds eliminate the need for curtains and drapes. The tilt of the blinds can be controlled by patients with thumbwheels, ligature-resistant knobs, or pushbuttons; or by staff with key-operated, motorized units.  

Cubicle curtains and their tracks are not required in behavioral health units¹⁰ and are strongly discouraged.

Good design requires good dialogue

Examples like those above demonstrate the potential dangers that can result when long-term facility design decisions involving the lives and safety of patients and staff are based on incorrect information and differing or untested assumptions about the real risks and costs involved. Such discussions require real effort, but are vital to project success. And, they can be aided by a design team that uses appropriately worded questions to prompt the client to explore the validity of potentially dangerous design decisions.

Throughout the design process, the client remains the decision maker. The designer’s role is to identify potential safety concerns, foster dialogue, consider and present possible solutions, and explain the positive and negative elements of each.

If, in the designer’s opinion, a client’s decision creates a potential risk of self-harm or harm to others, it may be necessary for the designer to put his or her concerns in writing, then ask the client to provide written instructions regarding the design element in question.   Hospitals are encouraged to carefully review and document the need for these elements with the help of their internal safety and risk management programs, legal counsel, and liability insurance carriers.

Should the design elements in question become the basis of legal action in the future, this review process may provide some protection for both the design team and the hospital.
 

James M. Hunt, AIA, is the president of Behavioral Health Facility Consulting, LLC in Topeka, Kansas.  Hunt is the co-author of the “Design Guide for the Built Environment of Behavioral Health Facilities” that is published by the National Association of Psychiatric Health Systems and available at www.naphs.org.

References:
    1.    American Psychiatric Association, (2003). Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. American Journal of Psychiatry, 160, 1-60. (See Part 1 of story.)
    2.    Haney EM, O. M. (2012). Suicide Risk Factors and Risk Assessment Tools: A Systematic Review. Washington, DC: Department of Veterans Affairs. (See Part 1 of story.)
    3.    The Joint Commission on Accrediation of Healthcare Organizations. (2000). Preventing Patient Suicide. Oakbrook Terrace, IL: The Joint Commission.
    4.    Reid W. (2010). Preventing Suicide. Journal of Psychiatric Practice, 16(2), 124.
    5.    The Joint Commission on Accreditation of Healthcare Organizations. (2007). The Role of Nurses in Preventing Sentinel Events, Chapter 8, Preventing Suicides. Oakbrook Terrace, IL: The Joint Commission.
    6.    Mills P, DeRocher J. (2008). Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals. Joint Commission Journal on Quality and Patient Safety, 8, 482-8
    7.    Hunt J, Sine D. (2012). Design Guide for the Built Environment of Behavioral Health Facilities Edition 5.1. Washington, DC: National Association of Psychiatric Health Systems.
    8.    Gunnell D, et al. (2005). The Epidemilogy and Prevention of Suicide: a Systemic Review. International Journal fo Epidemilolgy, 34, 433-442.
    9.    The Joint Commission. (2007). Suicide Prevention: Toolkit for Implementing National Safety Goal 15A: Joint Commission Resources.
    10.    The Facility Guidelines Institute, (2010). Guidelines for Design and Construction of Health Care Facilities. Chicago, IL. The Facility Guidelines Institute.