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Design mistakes, part 2: More things many 'know' that 'just ain't so'

January 23, 2013
by James M. Hunt, AIA, NCARB
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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.

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