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Adapting facilities to address needs of multiple populations

May 07, 2013

Hospital units are often designed with neat categories in mind – medical, surgical, pediatric, geriatric, adolescent, and maternity. So too are psychiatric facilities, which are often categorized by age groups – children, adolescents, adults, and geriatric. However, static categories and limited facility budgets don’t respond easily to changing, growing patient populations.

This is certainly true among behavioral health populations. “We do know that we’ve got a rapidly expanding number of patients who are likely to need both behavioral health treatment and medical treatment and it could no longer be acceptable to ship those patients off to a medical unit in many of those cases,” says James M. Hunt, AIA, NCARB, President of Behavioral Health Facility Consulting, LLC (Topeka, Kan.).

In the face of a demographic shift, Saint Mary’s Health Care (Grand Rapids, Mich.) faced a costly renovation decision. The hospital, which was equipped with one adult psych-med unit, needed not only the ability to accept adult (18 to 50) psychiatric patients, but also older geriatric patients who constituted the majority of recent new patients. Looking at demographic data, hospital officials realized they couldn’t afford separate geriatric and adult psychiatric units. So they decided on a solution: a psych-med unit that could accommodate adults, with features that catered to the geriatric population.

The design team relocated the unit to a different space within the existing hospital and did a complete renovation. Psychiatric patient capacity was maintained, while the versatility of the treatment space was improved.

Needs of geriatric-psychiatric population

Laurie N. Placinski, IIDA, LEED AP, EDAC, Interior Project Designer and Client Leader at Progressive AE, explains that the new psychiatric unit is built around a central activity area and that details of the unit were designed specifically with the geriatric-psychiatric population in mind.

Light: Describing it as a “light corridor,” Placinski explains that the central activity area has open spaces that flow together and are all visible from the main nursing station. She says that the first architectural element the design team considered was the ability of natural light to flow into the space.  From a healing perspective, it has been proven that natural light helps all ages and populations. For geriatric populations in particular, natural light helps in sustaining the circadian rhythm and identifying the time of day.

Color: Regarding the color scheme, Placinski says it was important that the finished types and tones be calming but also familiar to the older generation. “We were very careful not to make it too contemporary so they felt out of place,” she explains.

Saint Mary’s Health Care’s standard cherry door was used in the new unit because of the contrast with the light wall color in the rooms and hallways. “Whether I’m a standard psych patient that’s confused or a geriatric patient that’s confused, I would be more drawn to that contrast between materials and color tones,” she explains.

In the spaces in which patients should not go, such as the staff support area, storage, clean-utility, and soiled spaces, a very light colored wood tone was used to let it blend with the wall color. The idea is to have less contrast where patients shouldn’t need to go, and much more contrast where their eyes should be drawn near.

Orientation: The design team treated the ceiling as a “fifth wall.” A cloud mural, detailed on acrylic panels, flows across the ceiling and provides an artistic way to be engaged (if a patient happens to be spending time looking up). The chain of clouds, which extends from the activity zones to the dining space, was developed to help alleviate confusion (See figure 1). Rather than looking up and seeing a landscape, for example, the clouds provide a way for aging patients in particular to maintain their orientation within the space.

Ambulation and wayfinding: Because exercise is important, but some older patients cannot easily walk long distances, hand rails and built-in bench niches were incorporated into the unit’s corridors (See figure 2). These details enable patients to move from their rooms to the activity spaces — which is important from a physical therapy perspective — but also allow them to pause for a rest should they get winded. To ensure patient visibility and prevent hiding, the walls around each bench niche are angled so that resting patients are always clearly visible. The bench niches also benefit the nursing staff, who can pause to rest or complete tasks, yet retain complete visibility access to the activity space.

“It just encourages ambulation. Sometimes if a person needs to walk down the hall, and he or she has a spot to stop along the way, it’s not as scary and he or she may be more apt to make the journey,” Placinski illustrates.

Floors: With any elderly population, it’s crucial to keep the flooring transitions to a minimum. These patients tend to shuffle their feet and may trip easily, risking injury. Placinski says that the designers wanted a clean, durable floor that would withstand much abuse and the test of time.

They selected a sheet-type product that incorporated warm, inviting and recognizable wood tones, with a limited degree of contrast overall, since older patients may misperceive dark floor spaces as holes and attempt to walk around, rather than across them. The flooring used has tones that transition easily into one another.

Group and therapy spaces

Within the activity space, a group therapy room has full-height glass, which is carefully protected for this population. This allows light to filter into the larger central space, which is used for noisy activities such as playing cards, engaging in conversation, or overflow dining.

Also included in the activity space is a fish tank (See figure 1). While such tanks are common in hospitals and treatment centers, the team felt it was important for geriatric patients to promote engagement. The fish tank is one-sided to prevent confusion (for example, two people looking in from opposite sides) and incorporated into the architecture of one of the unit’s walls.  

“Every time I’ve gone up there they’ve pulled these heat-massage recliners that we bought over to the fish tank so they can sit with a blanket, watch the fish, and be engaged. It’s one more of those elements that is unique for this population. Someone in their 20s or 30s may not care to look at a fish, but someone that’s 65+, it’s something to help pass the time and it’s engaging but still safe,” explains Placinski.

Patient rooms and bathrooms

Psychiatric patient rooms are typically designed around a series of expectations:

  • Safety and visibility are paramount to reduce the risk of self-harm or injury to others.
  • Patients are ambulatory, able to move with reasonable ease throughout the unit or facility.
  • Patients will spend much of their day outside the room, engaged in activity and treatment areas.
  • Patients will not be treated, will not require medical procedures in their rooms.
  • All possible hazards, including medical tools, privacy curtains, movable or breakable furniture or features should be omitted or rendered tamper- or ligature-resistant by design.

However, the special demands of the Saint Mary’s Health Care renovation meant that some of these assumptions had to be reconsidered.

  • Geriatric patients tend to be weaker, more frail, and more confused. Their mobility may be limited. Thus, these patients, unlike other adult psychiatric patients, may need to spend more time in bed or in the patient room.
  • The hospital needed patient rooms that would accommodate medical examinations and procedures. Thus, medical tools, as well as appropriate features for patient privacy, were required.
  • Adjustable beds, suitable for medical treatment, were required.

Thus, the design team had to blend psychiatric, geriatric, and medical design criteria in the development of the unit’s patient rooms. For example, although cubicle curtains and their ceiling mounted tracks are typically omitted from psychiatric patient rooms due to ligature attachment concerns, the design team adopted a ligature-resistant curtain design to meet the unit’s medical and privacy needs. The team thought this privacy solution was preferable to the use of free-standing divider screens which, when brought into rooms, could be lifted up or disassembled and used as weapons.

The new unit uses a medical psychiatric bed that had been used in the previous unit. This bed is a compromise to meet medical treatment regulations since adjustable beds aren’t generally used in psychiatric facilities due to the potential for ligature attachment.

From the bed, the patient can see the bathroom (See figure 3). For a geriatric person, that’s a trigger to want to use the bathroom more and to want to ambulate. From a psychiatric perspective, instead of having a door, a ligature-resistant, releasable curtain serves the purpose. 

Instead of tile, a traditional flooring choice for patient bathrooms, the team chose a safety-type sheet flooring since, with geriatric patients in mind, it provided more slip resistance and minimized the flooring height transition. And, while toilet rooms are often equipped with railings or grab bars to help aging patients, psychiatric considerations demanded the use of products that were both ligature-resistant and tamper-resistant (to prevent removal and use as weapons).

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