The growing (overwhelming may be a better description) challenge today in emergency departments is how to adequately and respectfully provide a safe and comfortable place for patients in crisis, experiencing mental health conditions and illnesses ranging from mood disorders (anxiety, depression, mania) to substance use disorder, PTSD, psychosis and various other conditions which can severely impact day-to-day living, self-care and possibly the ability to relate to others.
The mental health environment of care design continues to develop as an ever-changing entity in terms of determining how to provide a safe and respectful space for assessment, respite, and recovery for patients in crisis. Facility managers, clinical staff, and designers are like a three-legged stool: all three components are necessary to function safely. The commissioning process plays an important role in the testing and verification of these spaces in meeting the requirements of the design to provide fully functional spaces described below.
Mental health is evolving from its stigma to acknowledgment as a treatable/maintainable illness much like other chronic medical conditions that can be maintained with the support of various therapies, medications, and where applicable, relocation from the environment/situation that led to the condition of crisis. The emergency department is the first stop for those needing emergency treatment or stabilization for a physical condition, and this is also true for those in mental crisis, needing emergency treatment or stabilization for a mental condition.
Patients typically enter the emergency department by ambulance, police escort, or ‘walk-in’ for both physical and mental emergency care situations. The emergency department is equipped to provide emergency medical health care at various levels of acuity:
Level 1- Immediate: Life-threatening
Level 2- Emergency: Could become life-threatening Level 3-Urgent: not life-threatening
Level 4- Semi-Urgent: not life-threatening
Level 5- Non-Urgent: needs treatment when time permits.
On the other hand, many emergency departments are equipped to provide emergency mental health care on a lesser level (not so great or important as the other) regarding the availability of staff trained to treat/work with patients in mental crisis, provision of a safe physical environment, and accommodation of a patient’s longer stay while waiting for a bed in a suitable facility which could be several days. Clinical staff in the emergency department have expressed their lack of training to work with patients in mental crisis regarding maintaining their own safety when treating and working to safely de-escalate a crisis in which a patient expresses violent, unpredictable behavior.
Equally important is the provision of a therapeutic environment of care for a patient whose length of stay may exceed 23 hours. Room readiness is key when preparing an exam treatment room for a behavioral health patient who may or may not be in crisis to the level of suicidal ideation, harming others or themself via weaponization of standard items found within the exam room (including items obtained along the way to the exam room from triage). Dual training in treating the physical and mental health of patients in emergency situations would benefit clinicians working in the ED regarding their own safety, the patient’s safety with respect to mitigation of risk within their environment of care, and the patient’s perception of the care received which is often based on how they are treated or cared for and the environment in which they are placed for assessment and treatment.
Room readiness includes providing finishes and fixtures durable against impact, tampering, and weaponization for activities of self-harm and or harm to others. A review of the wall assembly construction, actual fixture attachment to walls/ ceilings, fixture-specific fasteners (screws, clips, etc), the durability of protective covers on devices (thermostats, medical gases, sink plumbing), and impact resistance (lights, fire alarm notification devices, occupancy sensors and switch- es, outlet cover plates) are a good starting point.
The placement of devices and fixtures is just as important as the selection of the device/fixture. When considering fixture/device placement, patient and staff access are the primary drivers. Patient access should be thought of in terms of the potential for the fixture to be manipulated, damaged, or destroyed. Ceiling-mounted items (lights, HVAC grilles and diffusers, smoke detectors, occupancy sensors and other devices) should be coordinated with furniture locations when possible so that furniture does not provide a way to reach the device. Smoke detectors and occupancy sensors are misidentified by patients as surveillance cameras, often damaged or disabled to maintain their privacy.
Placement of area floor drains in bathrooms is another item to be considered regarding their proximity to the toilet for overflow/flooding mitigation and the drain cover’s elevation below finished floor regarding the allowable depth of water (supporting drowning activity) should the drain become disabled. When selecting ‘behavioral health safe’ fixtures, caution should be taken with interpreting the term to mean it is free of risk regarding self-harm, and its ability to withstand impact and tampering activities.
Just as important as providing an environment of care that is safe physically, the environment of care also needs to feel safe psychologically to a patient so that it does not contribute to the escalation of the patient’s condition by being made to look sterile or institutional, and often deficient in preferred acoustic, lighting and temperature control measures.
Acoustic measures to be considered are the inclusion of sound-absorptive finish materials that can also be cleaned, higher performing wall and ceiling assemblies regarding sound transfer, reverberation and absorption like the ‘hum’ of light ballasts, HVAC duct noise from whistling air or unit issues, as well as the use of face dampers, nearby alarms of IV pumps and other monitoring devices, plus fire alarms when activated. On higher acuity or crisis units where the patient is never left alone, consideration of a silent alarm feature should be given for the various systems, in which staff are alerted via a personal notification device and able to alert the patient of an emergency when necessary, eliminating agitation from the fire alarm horn activation noise, as well as constant overhead paging and announcements. White noise is all too often the solution, which does not always have a positive effect on patients, but instead escalates their condition with the constant background static sound. A positive distraction regarding acoustic provisions is soothing sounds of nature which are available through numerous internet apps, able to be provided in the patient environment of care via Bluetooth devices.
Lighting measures to be considered include the fixture’s capability for dimming to provide lower light levels when needed, as well as the fixture’s capability to provide indirect lighting instead of direct light. Light level control is preferably located in a staff-only area to avoid nuisance or dangerous conditions created when patients have access to the controls or keyed switches in the room or directly outside of the room where a patient may have access. Lights on occupancy sensors in bathrooms should be avoided if possible to eliminate the lights ‘going out’ when a patient is still using the bathroom. An LED multi-color lighting option has been successful in support of circadian rhythms as well as patient preference for their environment. Daylighting and views of the exterior offer the patient confirmation of whether it is day or night along with other environmental awareness benefits. Blinds are to be provided within protective enclosures, sealed inside of the window unit between two pieces of glass with control provided both on the staff side via thumb turn (wheel) or keyed control.
Temperature control is another consideration regarding patient control over their immediate environment with the actual control for their room located in a staff-only area. Some patients find moving air to be a source of comfort, as facilities provide fans in a protected enclosure or within the wall where they have control of its on/off function.
Emergency Departments, when feasible, would benefit from identifying a group of rooms or ‘area’ within the ED that is designated to provide a more controlled environment of care for treatment of behavioral health patients. The designated behavioral health treatment area could be ‘swing beds,’ convertible to providing medical treatment in times of high census with the proper protective measures of medical gases, outlets, lighting, plumbing, ceiling and wall construction, as not to take away from the quantity of medical beds available. The designated behavioral health treatment area or identified group of ‘safe’ rooms would be best suited located away from trauma or high intensity treatment spaces which typically experience high levels of activity, acoustics and lighting; mitigating the behavioral health patient’s exposure to additional environmental stressors, possibly escalating their condition.
In some cases, elopement of the patient is an issue, especially if they are unwilling to volunteer or incapable of volunteering for hospitalization or treatment, requiring an emergency custody order to be issued by the magistrate when there is a substantial likelihood that the person will, in the near future, cause harm to himself or others as evidenced by recent behaviors. To assist in deterring elopement of the patient, doors would benefit from fail-secure controlled access hardware functionality, and where feasible, doors be provided in a series on an interlock function.
The interlock function for doors in a series allows only on door to open at a time, and once re-engaged with its strike, the other door is able to open. The interlock functionality is important where units are supported by dietary and housekeeping support staff, as well as clinical staff entering and exiting the unit frequently where a patient may directly walk out of the secured unit. The interlock function can be controlled by card access control devices, activated with access cards carried by staff, swiping to activate each door once the other door is closed. Or, a remote door operator control, which is operated by a staff person able to see the doorway and interact with the door user, approving their entry/exit to the unit. This, with respect to patient privacy and dignity, an exit/entrance close to the unit or designated behavioral health treatment area is recommended where feasible so that the patient’s route to the treatment area is expedited, minimizing their exposure to medical traumas in the ED, and in turn, minimizing the risk of unexpected interaction and exposure to others.
If there is opportunity to create a ‘swing’ unit to accommodate behavioral health patients, there should be multiple levels of care, ranging from a High Acuity level of care (private room) to a Moderate Acuity level of care where patients have the freedom to leave their private room and occupy an open group milieu area supervised by staff and interaction with other patients and therapeutic activities may be available to a low acuity level of care accommodating patients with open bays of seating like recliners with free interaction within the space.
Enabling the emergency department to effectively accommodate behavioral health patients is the goal, based on staff and patient safety, durability of the built environment, and preserving the dignity of the patient during their time of crisis. As designers, facility managers, and clinicians, we all have a key role in providing a suitable and supportive environment of care. Commissioning also plays an important role with a multitude of systems and equipment from lighting and lighting control, security and door interlocks, noise control, and temperature control. Commissioning not only benefits the facilities personnel by providing verification and documentation of systems and component operation, but also the users and patients within fully functional systems and components. Empathy should be equal when caring for, designing, building, and maintaining environments of care for those in both emergency medical crises and emergency mental crises.
An environment of relatability or comfort is important when establishing patient’s trust, encouraging their participation in treatment, and starting their recovery process. An environment that builds in safety through fixture selections and placement, the durability of finishes, and tamper resistance is important for risk mitigation of patient self-harm and harm to others’ activities. Such spaces have also been shown to support staff retention and recruiting efforts when they feel safe. Crisis Receiving Centers (CRCs) and Crisis Intervention and Therapeutic Assessment Centers (CITACs) continue to gain momentum in various communities, providing emergency mental health treatment as a diversion from the emergency department, intending to provide mental health focused care and allowing the emergency department to focus on providing medical health focused care. As not all communities have access to these specialty mental health treatment centers, the hospital’s emergency department will continue to be the epicenter for providing emergency medical care and mental health crisis intervention and stabilization services, while striving to provide adequate physical environments of care in which to do so.
The first step in determining each emergency department’s ‘readiness’ to support mental health care is to conduct Safety Risk Assessment (SRA) of the physical environment that the behavioral health patient will have access to. The SRA should be facility-specific, identifying the risks, known and perceived, along with the mitigation measures necessary to provide a safe and supportive treatment environment for that particular population. The SRA should be produced as a team effort, consisting of key facility management persons, key clinicians, and subject matter experts in the design and construction of the physical environment for behavioral health patient care. Upon completion of the Safety Risk Assessment, the clinical staff’s assessment of current and projected behavioral health treatment caseloads based on historical evidence and localized patterns and funding availability, the emergency department’s direction of ‘Makeover’ (renovation) or ‘Move over’ (relocate the BH specific treatment rooms out of the ED trauma area) can be determined.
