Bathrooms balance comfort, safety

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.

Bathroom doors

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.

Toilets

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.

Lavatories

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.

Sine and Hunt point out that under-the-sink cabinet space and medicine cabinets-which can be used to conceal dangerous or contraband items-should never be present in patient bathrooms. If cabinet spaces are already available in an existing lavatory, Hunt recommends securing them shut with tamper-resistant screws. In place of medicine cabinets, they recommend providing patients with mirrors made of shatter-resistant, tempered safety glass that are enclosed in stainless steel frames.

“The tempered safety glass is probably the most popular because it doesn't distort and it can't be damaged by scratching, but with enough force it can be destroyed,” says Sine.

“I strongly suggest that facilities obtain full-size samples of materials to determine the balance of durability and distortion they feel is appropriate,” adds Hunt.

Shower spaces and fixtures

For patient shower spaces, Sine says that there are “not a lot of good solutions” available for reducing risk of self-harm. “The thing we know for sure is that shower curtains should not be part of the equation,” he says. “It's extremely difficult to hang a shower curtain in a manner that cannot be defeated by a patient who's intent on self-harm.”

To eliminate the need for a shower enclosure, Sine and Hunt suggest an innovative design strategy that has become the norm in European bathrooms: treating the entire room as the shower basin. This approach requires treating the toilet and shower spaces as separate but open areas, distinguished by different floor tiles or by placement of wall segments that provide a semi-enclosed shower space within the layout.

“You've got to get the shower enclosure big enough and locate the showerhead itself so that water is not spraying out into the middle of the bathroom,” Sine says. “There's a drain in the middle and no curb between the shower and the rest of the bathroom.” Drains must be secured to the floor with tamper-resistant screws.

Shower fixtures provide another potential ligature attachment point in patient bathrooms. “The simplest solution is a single-push button which gives a preset temperature of water for a predetermined time,” says Hunt. “But many facilities feel that it is preferable to give patients control of the water temperature in the shower and let them determine the length of time they want the water to stay on.”

For new or renovating facilities, anti-ligature showerheads and water temperature valves are available to give patients the ability to control the temperature and duration of their shower without increasing risk for self-harm.