According to the Joint Commission, 75 percent of inpatient suicides take place in the bathroom, bedroom, or closet. While not every patient is intent on self-harm, facilities cannot afford the risk-both financial and moral-of leaving open opportunities for suicide or self-harm in the built environment, particularly in patient bathrooms. (To learn about reducing risk in patient bedrooms, see “Furnishing a high-risk area” at www.behavioral.net/designfocus1007.)
“The reality is that when patients do commit acts of self-harm, it's typically a complete surprise to staff on the unit,” says David Sine, CSP, ARM, co-author of the Design Guide for the Built Environment of Behavioral Health Facilities.“You have to design spaces that anticipate that there will be unforeseen attempts at self-harm.”
However, Sine and co-author James Hunt, AIA, caution against designing spaces that are “so institutional” that they get in the way of recovery, rather than promote it. To effectively balance the desire for a comfortable, homelike patient bathroom with patient safety needs, Sine and Hunt share strategies for inpatient design from their guide.
According to Sine and Hunt, the need for a door dividing patient bathroom and bedroom areas depends upon the number of patients sharing the space. If these spaces are designed for single-patient use, they suggest eliminating the bathroom door altogether if the location of the door does not allow direct line of sight into the patient bathroom from the corridor.
However, if the hospital feels it is necessary to have the ability to lock patients out of the bathroom, then a full door should be used. Hunt singles out the bathroom door as a “very critical element [that] deserves careful attention.” He suggests that doors come equipped with:
A continuous or piano hinge;
Recessed pulls (or handles) to reduce ligature attachment points; and
A ball latch.
Hunt also suggests equipping the door with an over-the-door alarm, a pressure-sensitive strip that alerts staff immediately should a patient attempt to attach something to the top of a door.
If the bedroom/bathroom areas are semi-private or shared, a partial door that is one of several types of commercially available doors or a standard door that has been cut off at the top and bottom may be used.
Behavioral health facilities have a variety of choices when it comes to patient toilets, although Sine and Hunt are quick to assert that urinals should not be one of those choices. “It's easier to just put a typical toilet in there,” Sine explains.
“If they are present, they should have a shape that discourages ligature attachment, and the flush valves should be recessed or covered,” Hunt adds.
For existing facilities, it may be impractical to replace an entire toilet fixture and flush valve. However, standard, wall-hung china fixtures can be easily broken and used as weapons, says Hunt. Because of this, he suggests installing a secured toilet support leg to reduce the risk of destruction. Exposed flush valve hardware, handles, and plumbing should be enclosed with stainless steel or plastic covers to reduce the opportunity for use as a ligature attachment point.
For new facilities, Sine and Hunt suggest more durable stainless steel fixtures, now available with powder-coated color finishes that reduce their institutional look. These fixtures are mounted to the floor for increased durability.
These stainless steel products also come with an integral-or built-in-seat, since standard toilet seats can be removed and used as weapons. Sine and Hunt agree that the safety and durability of these toilets may offset the look of these fixture in appropriate situations.
“It's a conversation you have to have with your designer and your clinical staff and decide where you want to go,” Sine explains. “And those [stainless steel toilets] get a little bit better looking every year.”
Regardless of the type and style of toilet fixture chosen, Sine and Hunt recommend an automatic push-button solution for the flush valve, which is preferably recessed into the wall.
Toilet paper holders may also carry risk for self-harm, since spindles attached to bathroom walls may serve as ligature attachment points. To remedy this, Sine and Hunt suggest using a stainless steel cylinder recessed into the wall that can hold a roll of toilet paper. However, this may pose an infection control issue if placed in a multi-use bathroom. In such cases, they recommend using a new holder with a foam spindle that cannot support a ligature attachment.
Sine and Hunt also suggest installing integrated lavatories in patient bathrooms. “Several manufacturers offer complete assemblies with the countertop, sink, and ligature-resistant faucet in one package,” says Hunt. “This provides a more residential appearance and function in that it gives patients some space to set toiletry items.”
The all-in-one lavatory has a push-button or automatic anti-ligature faucet that decreases the likelihood of use as an attachment point. Hunt recommends installing this product tight to a side wall to reduce the risk of the larger fixture being used as a ligature attachment point as well.
For additional space for storing toiletry items, facilities may choose to provide patients with additional shelving units. These should be open, made of stainless steel, and recessed into the wall.