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Creating Safe and Homelike Facilities
05/01/2005
| Everything from patients’ beds to trees in courtyards must be considered BY RICHARD ABBOTT, AIA |
| Designing a psychiatric facility is hardly a cut-and-dried process. The days of large hospital wards are long gone; they are being replaced with more homelike and therapeutic f acilities. Yet designers must walk a fine line in balancing safety and security for patients and staff, while at the same time creating a he aling, comfortable environment. Families making the tough decision of admitting their loved ones to a psychiatric hospital will choos e a facility that has a homelike environment over one with an institutional look. Safety, however, remains an overwhelming concern. Those ch arged with designing facilities need to consider today’s patients’ higher acuity level, which creates a higher risk for staff an d patients. The increasing number of geriatric patients, as well as those with medical problems in addition to mental and behavioral health issues, creates distinctive challenges in keeping the environment safe but providing the equipment for the more medically acute patient. Because people are living longer, psychiatric facilities now need many of the same features of acute care hospitals, including hospital beds, a nurse call system, exam lights, electronic medical charting, and more; each offers diverse and interesting challenges. For example, in designing psychiatric facilities, planners with architectural firm HDR altered medical beds, making them more conducive to a secure envir onment, as well as elevating exam lights to heights inaccessible to patients. Potentially hazardous features were removed, including the bui lt-in telephone with cord and any plastic pieces that could be broken off. The bed’s electric cord was made just long enough to plug i nto the wall; patients can’t use it to hurt themselves or staff. Within the rooms, beds are situated in areas that are more visible to staff during walk-by checks or from nursing stations. Advances in Technology We live in a computer-b ased society. Acute care hospitals are going paperless; whether staff use tablets, laptops, or computers on wheels (COWs), they do virtually all charting electronically. Psychiatric hospitals, however, have not been able to keep up with this trend for many reasons, including lack of funding and reluctance to adopt technology in general. From a safety standpoint, a patient could harm him/herself with this fragile tech nology by using a cord, throwing the computer, or using a sharp fragment from a computer screen or other component as a weapon. The c hallenge has been integrating this technology into a safe setting for both staff and patients while retaining a noninstitutional look. At th e Mayo Clinic in Rochester, Minnesota, computers were built into countertops with clear shield overlays, thereby providing the technology ne eded by caregivers but also providing safety for patients and staff. HDR designs also include polycarbonate shields around nursing stations that form a partial barrier while retaining the feel of an open environment and providing unobstructed sight lines. < b>Avoiding Potential Hazards There is a push for psychiatric facilities to keep up with the latest layout and features of acut e care hospitals, such as private rooms and bathrooms. These features, however, bring a new set of problems and concerns for patients’ and caregivers’ safety. For example, staff supervision is reduced in a private bathroom. While alone, patients have access to an arra y of potentially harmful objects: the edge of ceramic tile, pieces of a broken porcelain toilet fractured by jumping on the toilet until it breaks, or the shower rod. Addressing the toilet issue, a prison-grade stainless-steel toilet would be safer, but it doesn’t fit with a homelike image. At the Mayo Clinic, designers wrestled with these concerns and ultimately decided on a porcelain toilet mounted to the flo or instead of the wall—not typically done in an institutional setting—making it less likely to break.  Water use poses problems in private bathrooms, too. Patients can clog the drain and create a flood, or they can scald themselves with hot water. To address these issues, architects at HDR use sinks and showers with temperature regulators as well as push-button controls, which allow water flow for a predetermined time length per use (the ti me is calculated on how much water can fit into a particular shower basin or sink before it overflows). Historically, psychiatric hos pital rooms tended to be dark without much natural lighting. Of course, safety of blinds and curtains were an issue, so windows were small. Newer blind designs, which place blinds between panes of glass, allow patients to control their rooms’ light level and prevent the bli nds’ components from being used as weapons (figure 1). This also eliminates the need to block sunlight with curtains, which patients c ould take down and use to harm themselves. New flooring materials provide a warm environment along with a sanitary surface. Many avai lable seamless rubber floors resemble carpeting but can be scrubbed and disinfected. These materials can withstand the extensive abuse commo n with this patient population. Onstage/Offstage Designs Psychiatric hospitals differ from general h ospitals in that patients circulate more throughout the facility. In general hospitals, patients usually stay in their rooms unless they are being moved. In psychiatric hospitals many patients are not physically impaired; they need and should have access to exercise and socializa tion areas, as well as regular visits to their physicians’ or psychiatrists’ offices. Creating a pleasant and safe image is key to a good design. One such example is an onstage/offstage approach to patient care, consisting of a system of separate circulation co rridors that keep patients, nonclinical staff, and visitors separate. A secure path of travel permits the patient to move from his/her room to other areas inside and outside the building without being exposed or exposing others to potential risks. Patients’ outdoor e nvironment, too, must be controlled with a courtyard that is enclosed on all four sides. Anything that can be moved or picked up and used to harm must be secured. With an outdoor courtyard design, the situation of trees and walkways is crucial. A high tree close to the perimeter is an invitation for a patient to climb the tree and escape or injure him/herself by jumping. Even researching which trees and plants are ed ible is important. In the case of the Mayo Clinic, because of the climate and its northern location, the courtyard was developed as an atriu m (figure 2). Patient rooms look down into this enclosed, indoor courtyard, which can be used year-round and is a gathering spot for patient s and staff.  All aspects of safety and security must be considered when de signing a psychiatric facility, from beds to computers to bathrooms to courtyards. As healthcare environments evolve, designers will continu e to be challenged to walk a fine line between creating a safe psychiatric facility while incorporating a familiar, homelike feel that comfo rts patients and their families. BHM Richard Abbott, AIA, is Vice-President and Health care Principal at HDR Architects, Inc., Alexandria, Virginia. To send comments to the author and editors, e-mail abbott0505@behavioral.net. To order reprints in quantities of 100 or more, call (866) 377-6454. |
