Patient bathrooms present significant challenges in regard to design and patient safety. The Joint Commission and other authorities have identified patient bathrooms as being one of the highest risk locations for inpatient suicides in behavioral health facilities.
These challenges arise because patients are alone in these rooms for long periods of time and the design of many typical toilet accessories and plumbing fixtures may present potential hazards to patients. In other instances, however, typical residential finishes and products may be safe for use in behavioral health settings.
Bathroom finishes may be similar to those of residential bathrooms and utilize various tiles for floor, base and walls. Usually, larger pieces are preferred to reduce the number of joints. Care must be exercised to assure that the tiles remain in good condition and rounded outside corners should always be provided.
One piece countertop mounted lavatories are preferable to typical hospital wall hung lavatories for several reasons. They are more prevalent in residences and they provide some space to set toiletry items. This offers a significant level of convenience and reduces the need for other ligature-resistant shelves that are not considered “normal” in appearance.
It is best if the countertops for this use are made of solid surface material and the lavatory is bonded to the top to reduce the number of joints and open cracks that may occur. This is desirable not only as an infection control measure, but as an anti-tampering measure as well. The faucet and valves must not be standard units and will be discussed later in another section.
Countertops with integral lavatories also provide the opportunity to cover of all pipes below the lavatory with a modified vanity cabinet. The vanity cabinet can be normal in appearance, but openings must be securely locked or secured with tamper-resistant screws to prevent entry, concealment, or access to pipes. For wheelchair accessible rooms, a lavatory sink should be mounted on a similar wood enclosure that conforms to an ADA-required profile.
Finding a compromise
Combining safety considerations and residential appearance can be accomplished in some cases to achieve a balance between these two often competing goals. Because so much control is taken away from inpatient psychiatric patients, it is preferable to give them as much control of the water temperature and duration of flow in the lavatories as possible.
Let’s consider the options for lavatory faucets:
- Motion sensor type faucets that deliver one temperature of water may be confusing for some patients.
- Single push-button valves that deliver a single temperature of water for a predetermined amount of time can be very frustrating for patients and rate low on patient satisfaction surveys.
- Two-button systems can give some level of control of temperature, but not duration.
- There is one application that uses a ligature-resistant shower valve mounted in the countertop and a ligature-resistant faucet to provide the patients control of both duration and temperature (thermostatically limited to prevent scalding).
Showers present yet another design and safety challenge. While “safe” and ligature-resistant shower controls are available, they offer little semblance of a “typical” or “residential” appearance. Just like lavatory faucets, it is preferred to allow patients control of both water temperature (thermostatically limited to prevent scalding) and the duration of water flow.
Other factors to consider are:
- Ligature resistant handles are available that provide control similar to many residential single handle valves and are safe for use by patients, but do not meet ADA requirements.
- When handicapped accessibility is required, control valves that allow patients to choose temperature and duration are available in a touch-free controller. If handheld shower heads are provided, they should have quick-disconnect fittings and should not be left in the room when not in use. The bracket on which the head is mounted should not be provided or attached to the quick-disconnect fitting so that it is removed when the hose is disconnected. Some jurisdictions allow providing a standard institutional shower head at a lower mounting point on the wall in lieu of the handheld shower head.
- Push-button type controls (both single and two pushbutton type) that do not allow temperature control and must be pushed repeatedly to keep the water flowing are not preferred, and are neither typical nor comfortable.
- Institutional type shower heads must be used because other choices present significant hazards to patients.
When safety must prevail
Typical residential toilet fixtures that have a tank to hold the water to be flushed should never be used in behavioral health facilities because the tanks are made of china and can be easily broken to produce large, sharp objects which may be used as weapons by patients.
Therefore, the toilet fixtures in patient accessible bathrooms will be institutional in character. In remodeling projects, it may be impractical to replace the fixtures and related piping. In these cases covers may be provided which greatly improve the safety but add to the institutional appearance.
If new toilet fixtures are to be provided, consideration may be given to not using commercial fixtures made of china in lieu of fixtures made of solid surface material or powder coated stainless steel. These are more durable, but also have a more institutional appearance.
Movable toilet seats also present problems. Hinges can be used as ligature attachment points and seats themselves may be removed, potentially to be used as weapons. Many facilities feel that this is an acceptable risk since the only alternative is an integral seat fixture that can be very uncomfortable and institutional in nature. Use of integral seat fixtures sometimes results in significant patient satisfaction complaints.
Therefore, facility operators should consider carefully whether the patient population and treatment environment requires this type of safety measure.
Crossing the threshold
The door between the patient room and the patient toilet room (when the toilet room opens directly into the patient’s room as is required by the 2010 edition of Guidelines for the Design and Construction of Health Care Facilities) has been the subject of much recent discussion and deserves special consideration.
The first consideration is whether the facility feels there is ever a need to be able to lock patients out of their bathroom. If there is, then a full height, tight fitting door will probably be required. This is typically done in residences, but can present multiple hazards for these patients.
If this is done, special consideration should be given to the hinges and locking devices and an over-the-door alarm should be provided to alert the staff if a patient attempts to use the top of the door as a ligature attachment point.
If it is not necessary to have the ability to lock the door, there are a number of alternatives that may be employed, all of which are not typically residential in nature. They include:
- Removing the door from the opening of the patient toilet room in single-patient rooms. The practicality of this depends (among other things) on sight lines into the patient toilet from the corridor when the corridor door is open.
- Providing one of the specially manufactured doors that are designed to provide a higher level of safety in this environment.
- Modifying a typical door by using special hardware, cutting off the top of the door at an angle, and providing a tall opening between the bottom of the door and the floor can increase the level of safety.
Options are more limited where patient-accessible toilet rooms, shower rooms or tub rooms open directly into corridors. These may be susceptible to building or fire codes and definitely need to provide privacy. In these cases, tight fitting doors with special hardware and over-the-door alarms are needed.
Accessories and other fixtures
Toilet accessories are another example of items for which safety considerations must be the deciding factor. Advances are being made in safe designs for accessories typically found in residential bathrooms such as toilet paper holders, mirrors and towel hooks. However, none of these have a typical residential character.
Some accessories not typically found in residences, like grab bars and dispensers for paper towels or liquid soap, are frequently needed in behavioral health facilities. And the corresponding items commonly found in other parts of the hospital can provide additional avenues for self-harm.
Light fixtures and exhaust air grilles must also be vandal resistant and are unlikely to be available in typical residential-looking items. Smoke detectors are required in most cases and the currently recommended tamper-resistant heads are visually unobtrusive.
Balancing the desire for a “typically residential” appearance in patient bathrooms with very real concern for patient safety requires careful analysis of the patient population, staffing levels and many other variables.
In patient bathrooms it is necessary to give more weight to the safety concerns because the risks of suicide and other acts of self-harm are simply too great.
James M. Hunt, AIA, NCARB, is president of Behavioral Health Facility Consulting, LLC (www.bhfcllc.com) in Topeka, Kan. Hunt is the co-author of the Design Guide for the Built Environment of Behavioral Health Facilities, which is published by the National Association of Psychiatric Health Systems and available at www.naphs.org. This document may be consulted to obtain additional information on the concepts and products discussed in this article.