The following is a guest blog post written by James M. Hunt, AIA, President of Behavioral Health Facility Consulting in Topeka, Kansas. He is a practicing architect and facility management professional with over 40 years of experience in behavioral healthcare projects. 

Nobody can accurately determine whether a person is on the verge of committing suicide, therefore, it is necessary to provide an environment that is as risk-free as possible for all patients.

The Number of Inpatient Suicides Continue to Increase:

There have been many studies that have determined that the currently available suicide assessment tools in use in behavioral health/psychiatric facilities are reliable.1,2,3,4,5  I am not a clinician, but an architect who has been working with these facilities for over 36 years and have been around my share of inpatient suicides.  The most apparent “evidence” is that the frequency of inpatient suicides has continued to increase according to information published by The Joint Commission6 and many other organizations.  I will leave the “why” of this to those with more expertise in clinical areas.

Some Facilities Still Rely on Trying to Predict Which Patients Are Actively Suicidal

Regardless of the overwhelming information to the contrary, the staff in many facilities still base many decisions on the assumption that they can predict which patients are actively suicidal.  These are manifested in comments like:

  • “We put our suicidal patients on 15-minute checks”7
  • “We move our suicidal patients into some specially suicide safe rooms near the nurse station”
  • “We place our suicidal patients on one-to-one observation”8

and my personal favorite

  • “Not all of our patients are suicidal, so we don’t need to include suicide resistant elements in our design”.

Law and Ethics Require Patients be Treated in the Least Restrictive Environment

The design of the architecturally least restrictive environment should be determined by deciding the most “at risk” patient that will ever be admitted to any particular unit.  Newly admitted patients, those preparing for discharge and the newly discharged all have been shown to be high risks.

A Suicide Resistant Environment Does Not Need To Look and Feel Like a Prison.

There are many suicide resistant products available and design approaches now being used that can result in creating a low risk environment with a character that helps the patient be more relaxed and comfortable.  These products and design concepts help the patients be open and receptive to the treatment that staff will provide.  This type of environment also removes a lot of pressure from staff (i.e. needing to determine which patients are the most suicidal tonight and moving them into the special rooms near the nurse station) and gives them more time to concentrate on providing treatment to the patients.

More information on these products and design concepts may be found in the Design Guide for the Built Environment of Behavioral Health Facilities9 (of which I am the co-author) that is published by the National Association of Psychiatric Health Systems and may be downloaded free of charge.

References:

  1. Tishler CI, Reiss NS. Inpatient Suicide: preventing a common sentinel event. Gen Hosp Psychiatry 2009; 31(2):103-9
  2. Milone RD. Involuntary hospitalizations, In: Wahl D, ed. Ethics Primer of the American Psychiatric Association. Washington, D.C.: APA; 2001
  3. Simon RI. Imminent suicide: the illusion of short-term prediction. Suicide Life threat Behav 2006; 36(3);296-3010
  4. Simon RI. Suicide risk assessment: is clinical experience enough? J Am Acad Psychiatric Law 2006; 34(3); 276-8
  5. Haney EM, O. M. (2012). Suicide Risk Factors and Risk Assessment Tools: A Systematic Review. Washington, DC: Department of Veterans Affairs.
  6. The Joint Commission: “SE Statistics as of 3/25/14”.
    1. Reid W. (2010). Preventing Suicide. Journal of Psychiatric Practice, 16(2), 124.
    2. Busch KA, et all: Clinical correlates of inpatient suicide. J. Clin Psychiatry 2003; 64:14
    3. Hunt JM., Sine DM., “Design Guide for the Built Environment of Behavioral Health Facilities – Edition 6.2”. [2014] National Association of Psychiatric Health Systems.  Available from Internet: www.naphs.org