With the COVID-19 crisis dominating our collective consciousness, many of us are imagining how this challenging experience will affect the future of healthcare design. While many great ideas and likely scenarios have been suggested, none are really applicable to psychiatric hospitals and behavioral health units.
The impact of requiring social distancing as a response to a spreading pandemic is especially complex in an environment in which socialization is a critical part of the therapeutic paradigm. As is often the case in behavioral healthcare, responses to this dilemma are widely varied.
Protecting the health and well-being of patients while preserving the benefits of socialization is second nature in behavioral health. While the impacts of COVID-19 add a new layer of safety, clinicians and staff will be rising to the challenge in ways that create lasting and positive changes.
To bring some focus to this and other pandemic-related issues in psychiatric hospitals and units, we are approaching this from three vantage points: patient bedrooms, the milieu and staff contact.
There already exists a healthy debate in the industry about single vs. double patient bedrooms. The Facility Guidelines Institute (FGI) recommends single rooms for psychiatric treatment, just as it does for all other kinds of healthcare. Many psychiatric units are designed around this principle and the evolving belief in that approach. However, many others believe strongly in the value of double rooms and the therapeutic value of a “roommate” approach. While some think this is just a cost-saving measure, significant data supports the advantages of double rooms.
Prior to the current pandemic, we were already seeing anecdotal evidence of a shift toward more of a mix of double and single rooms, allowing clinicians to put patients in the right therapeutic environment for their individual needs. Some facilities have responded to the current call for social distancing by using all of their double rooms as singles to avoid the risk of bedroom contamination. Others are taking a more moderate approach by reducing the double rooms only where the clinical staff feel strongly about the change from a therapeutic standpoint. A big part of the decision making has to do with the size of the facility and the level of resources available.
Steve Glazier, COO of the UTHealth Harris County Psychiatric Center, told us the 274-bed facility emptied one unit and designated it as a special unit for any patient showing symptoms or known to have had contact with COVID-19. That measure allowed the facility to utilize a moderate reduction in census (more on that later) while preparing to contain a spread of the virus. As of the date we spoke, HCPC had not had a single case of patient-to-patient transmission and the “special unit” has been used for patients who became symptomatic after admission to the hospital of who came to the facility after having been exposed, or after testing positive.
While there is a natural focus on the bedroom occupancy, those we spoke to felt that the real risk is in the milieu. Unlike a general hospital setting, psychiatric units are built around a socialization model. Patients do not and should not stay in their rooms. Even generously sized social spaces are not usually adequate to allow 24 patients (plus staff) to socialize effectively and follow social distancing rules. Facilities that reduced their doubles to singles found the compounding effect is a much lower census in the milieu. That allows staff to hold smaller group therapy sessions, to offer recreation in smaller groups, and to allow more space between patients and staff in the social area and during dining.
Facilities that have all single rooms or chose not to reduce the bedroom count have nonetheless reduced their census to a number they felt could be managed within their available space and staff. How much reduction varies from 10-15% reduction in census to lowering each unit to no more than 10 patients (in line with the CDC recommendation to limit groups to 10 or fewer people). At the other end of the spectrum, we heard from several facility administrators who decided that reducing census would not make any difference. They continue to operate at full capacity.
The key practice seems to be managing the population creatively within the space available. Clinical teams are using all methods at their disposal. These include:
1) Spreading out dining to use all available seats so that patients are spaced apart
2) Scheduling additional group therapy sessions so fewer patients participate in each one
3) Increasing program activities to keep patients occupied and focused in order to help staff manage social distancing.
Another key is cleaning. In addition to increased cleaning by the hospital EVS team, the unit staff is wiping down surfaces between each activity. More activities are focused on using “one-time-use” materials such as crayons, pens, paper, and other disposable materials. Facilities are installing additional secure hand sanitizer dispensers in strategic locations and encouraging patients to take responsibility for helping keep everyone safe. As one administrator told us, this habit not only helps with infection control, it also provides ADL training for the patients.
Our conversations with clients revealed that the most difficult piece of this puzzle to manage is the movement of staff. It is not reasonable nor feasible for these facilities to house all their staff to keep them effectively quarantined. As a result, while the patients are contained in a protected environment, the staff come and go. This movement introduces the risk of an employee picking up the virus from a family member, at the grocery store, or through any other contact they may have outside the facility. As we are learning, many individuals carrying the virus are asymptomatic. This adds to the infection risk.
Once a staff member picks up the virus, passing it to other staff can happen quickly. This scenario carries two risks. The facility needs to keep the infected staff from transmitting the virus to patients, of course. But also ominous is the risk of a staffing shortage. One administrator told us their biggest issue was in the admissions department, where staff members work in a small space with several cubicles in close proximity to each other. That proximity could contribute to a single individual contracting COVID-19 and consequently spreading it to the rest of that team. The administrator offered this advice, not only for psychiatric treatment space but for all healthcare environments: “Plan now for more space between people.”
Staff in some facilities are using their own creative ingenuity to create distance from one another by using COWs (Computers on Wheels) to do their work in various locations. Several individuals reported improved efficiencies in their workflow as a result of adding these devices to their toolkit. While this requires a level of care, it makes sense for more facilities to try this, especially with charting software increasingly supporting the use of tablets that staff professionals can safely carry around the unit.
Facilities are implementing a variety of measures, from screening for COVID-19 contact to more frequent temperature checks for both patients and staff. Careful screening at unit entries is often a challenge, exacerbated by entry vestibules that are either non-existent or not large enough for all the tasks now required in that space. Facilities with their screening areas close to the entry are seeing an advantage in admission and unit entry processes, especially in behavioral health units within a general hospital.
Checking staff frequently is a must in this environment. One administrator told us that a standardized questionnaire and temperature check is now required for all staff when they return from any trip outside the facility. While it may seem a little odd to ask someone if they have traveled outside the country after their lunch break, he felt the consistency and uniformity of the process helped staff take it seriously and focus on their responsibility to the health of their patients.
Another impact that is talked about because it has unique implications in behavioral health is the use of masks. Most facilities require patients and staff to wear masks. Unfortunately, the masks could present a ligature risk in various ways that are not always considered. Staff members are needing to watch carefully to make sure that this change in routine does not present an opportunity for harm to come to a patient.
Wearing a mask is a necessity that will likely continue until a vaccine is available. Most units already require masking for any patient or visitor that has not had a flu shot. They will likely implement the same policy for COVID-19. We are encouraged to see how therapists are integrating the mask change as part of the socialization process. Rather than forcing the issue, it can be managed by positive reinforcement via the whole group.
So, what does the future hold? Of course, we do not know the answer to that yet, but based on our experience and recent conversations, we offer a few likely scenarios:
- We will not see a significant change in the single vs. double debate. Clinicians and administrators on both sides of this question are entrenched in their positions, and each side has merit. We should not expect that to change any time soon, except where facilities already have all dual occupancy rooms. We can expect a shift toward more of a balance between single and dual occupancy room configurations.
- We envision a universal trend to create more space in the social, dining and treatment areas. This would create a long-overdue change regardless of pandemic health needs. But the current crisis is showing us the importance of having enough room for the people undergoing treatment. We will advocate for FGI to increase the minimum standards in this area and expect that many clients will do this anyway in preparation for future waves and to provide a more therapeutic environment.
- Accelerated adoption of and reliance on telehealth technology, benefiting both patients and their families, is certainly one of the most significant developments we see. One interesting update on this now-essential tool is its ability to connect patients and family members without the need for a physical visit to the facility. This tool will also help support and connect patients, families, and outpatient providers/agencies with inpatient treatment teams and psychiatric providers well beyond this pandemic.
- We expect to see clients more willing to dedicate sufficient space to staff, consult and admission areas. With tight budgets, it is common for staff and support spaces to get the squeeze as facilities prioritize patient spaces. The lesson learned here is that you cannot treat patients if you cannot admit them. Creating enough spacing between desks and other areas is not only a great way to treat your staff, it also might keep you operating in a crisis.
- Another critical improvement we see coming is greater access to handwashing stations in the unit. In many units today, these are located primarily in staff areas, with patients having access to hand washing sinks in the toilet rooms. Strategically locating additional stations in more visible spaces such as at the unit entry and near dining areas would help staff create a culture of hygiene. This change will not only benefit patients while in treatment, it will also build a healthy habit they can take with them when they leave
Our conversations revealed the spontaneous creativity shown by behavioral health professionals in responding to the challenges they encounter. Many of the changes that arise from this crisis will become tomorrow’s best practices, spurring behaviors that evolve not because of “we have to” motivations but because of a more positive “we want to” mindset.
How different will the future be? It will take some time before we can all answer that. Until then, we would love to hear from you on what you are seeing and what your team is doing in response to the virus threat. We look forward to continuing the conversation.
Kevin Turner, AIA, and Sherri Reyes, MA, are principals of the firm human eXperience.