A nurse’s thoughts on safer environments for frontline patients and staff

What the National Crisis Line Means for Healthcare’s First Responders

By Marvina Williams, RN, BSN, Senior Medical Planner, and Lauren Neefe, PhD

The healthcare industry is celebrating but also bracing for the nationwide launch of 988, the three-digit code that will direct all callers to the National Suicide Prevention Lifeline. As though our first responders and frontline workers weren’t already going above and beyond to guide us through the pandemic and its impacts on behavioral health, Emergency Departments (EDs) are going to see a new surge intensify the ongoing waves of COVID-related surge.

The Duke Regional Behavioral Health Center has a variety of calm transitional environments for every point along the continuum of care. Durham, North Carolina

How our frontline spaces are designed will make all the difference in the outcomes for the courageous patients who seek help and the courageous workers who provide care for them.

Triage-minded solutions will go some of the way to improving efficiency and reducing wait times for patients and families. The impact of the hotline, however, will reach way beyond operational efficiencies and provider burnout.

For example, it is likely to exacerbate the “boarding crisis” that has been mounting in EDs over decades. A 2016 article in the Journal of the American Medical Association observed that dedicated beds for psychiatric patients decreased by 35 percent between 1998 and 2013. At the same time, psychiatry as a profession has been shifting away from inpatient care. As a result, patients searching for a precious opening in a specialized facility or even an inpatient bed at the hospital now resort to waiting out their limbo somewhere in the ED, which may or may not have a mental-health evaluator readily available to respond.

This is where design comes in—and why a nurse’s insight is invaluable on our healthcare design teams. As with triage, we have been programming and adapting our clients’ ED spaces for some time—beyond just designating a room in accordance with state-of-the-practice guidelines (see the Joint Commission on Accreditation of Healthcare Organizations and the Facilities Guidelines Institute). Having an RN at the table facilitates these collaborations between our designers and our clients, so that their healthcare environments can always deliver, no matter how fast a virus mutates, a policy changes, or a new resource becomes available.

Until EDs cease to be the only option for people not adequately covered by health insurance, we will continue to help our clients respond strategically and empathically to initiatives like the new crisis hotline. De-escalation Rooms, Flex Rooms, and Behavioral Health Modules, shown below, are a few of the ED solutions we have been innovating with consideration for the client’s budget, capacity, demand, and population.

Look out next week for more insights on the crisis hotline and healthcare design from our colleague Sabah Mohammed, who just completed her E. Todd Wheeler Health Fellowship report, “Care in the Time of Crisis: Designing for Patients with Behavioral Health Needs in the Emergency Department.”

Duke Regional intentionally chose to connect the hospital's Behavioral Health Center and Emergency Department to combine care in one location.

The De-Escalation Room in the Tift Regional Medical Center's ED minimizes sensory triggers and allows for remote monitoring. Tifton, Georgia

De-escalation Rooms

Not everyone responds immediately to talking through the acute stage of a crisis. A “de-escalation room” is a space where patients can safely stay while their behavioral-health crisis is still evolving. It is typically for patients working through severe agitation, hallucinations, or intoxication.

The absence of potential triggers is intended to preempt self-harm as well as violence misdirected at staff. Some EDs, however, recognize that these rooms can be experienced as deprivation and, contrary to the intent, escalate a patient’s symptoms and distress.

Most EDs nonetheless have some kind of de-escalation room. Evidence-based design can make sure they fulfill their intention for safety.

Flex Rooms for Behavioral Health

Hard as it is to believe right now, COVID surges are not going to last forever. The surges that come with the crisis hotline will be harder to predict.

Like triage modules, Flex Rooms offer EDs adaptable spaces that, when not in use for a behavioral-health crisis, support treatment across the spectrum of ESI acuities. They often feature a pull-down shutter, or “garage door,” which covers equipment and protects the patient from items that can inflict harm.

A recessed enclosure for oxygen, suction, and air is another option for Flex Rooms, as are specially designed door frames and heavy furniture.

The garage door in this Flex Room at the Medical University of South Carolina’s Children’s Hospital pulls down to enclose the equipment and medical gases beneath the window. Charleston, South Carolina

The Flex Room in the Cone Health Hospital ED implements a typical garage-door solution to protect equipment and the patient. Greensboro, North Carolina

To keep extended-stay patients connected to a sense of time, the ED Behavioral Health Module in the UVA University Hospital is a corridor of enclosed rooms with clerestory windows. Charlottesville, Virginia

In contrast, the Behavioral Health Module we designed for Northside Hospital Gwinnett’s ED expansion features open rooms with generous daylight. Lawrenceville, Georgia

The Behavioral Health Module we designed for Northside Hospital Gwinnett’s ED expansion features open rooms with generous daylight. Lawrenceville, Georgia

Behavioral Health Modules

There are many advantages to having a dedicated ED module for behavioral health. Patients in crisis can be monitored in a safe and healing environment. Organizing specialized staff and resources in one location creates operational efficiencies.

We design Behavioral Health Modules to support holistic treatment—that is, to meet patients’ mental-health and medical needs in addition to responding to their immediate symptoms. While there are ligature-resistant furniture and bathroom fixtures, clerestory windows provide the salutary benefits of daylight.

Some designs center on a locked module with locked team stations. Others are more open environments. Yet others establish a hybrid environment of open space and closed patient rooms. Some modules integrate courtyards to support outdoor activities.