Reduce the risk in the toilet for behavioral health


While every effort is made to design ligature-resistant spaces in psychiatric facilities, it is important that the designs reduce the opportunities for self-harm in the built environment. Private spaces including bathrooms, bedrooms, closets, and showers are areas of interest. In fact, up to 90 percent of hospitalized suicides occur in these spaces, according to a 2018 article in Journal of the Joint Commission on Patient Quality and Safety.

Of these spaces, depending on the patient and their level of acuity, private bathrooms can be among the most dangerous, with the patient’s risk of suicide by hanging particularly high in these spaces, according to research by National Violent Death Reporting. System (NVDRS) and Sentinel Event (SE) of the Joint Commission, which records data on hospitalized suicides in health care facilities in the United States

EYP has worked with several large maximum security forensic and psychiatric hospitals, as well as speaking with national professionals and experts about these projects to gather information and ideas. From our experience, we have identified patient safety, staff observation and patient benefit as key factors to consider when designing sanitary facilities in a behavioral healthcare facility.

Choose the right configuration

Healthcare facilities have three types or styles of bathrooms. The most typical in a hospital-type setting is a private toilet directly connected to a patient room, which allows for maximum patient privacy and comfort but reduces patient safety due to difficult staff observation. Semi-private toilets allow two adjacent patient rooms to share a common bathroom which is accessed from each patient room. This setup, however, would allow a patient to access another patient’s bedroom via the toilet, which is not ideal for psychiatric facilities. The last option is a shared bathroom accessed from the public corridor rather than from the bedrooms. While this is the least confidential and convenient from a patient’s point of view, it is the safe setup from a staff observation point of view.

The “Chapter 29 – Plumbing Systems” of the International Building Code (IBC) 2021 governs the minimum number of plumbing systems required. In the institutional classification intended for “recipients of medical care in hospitals and nursing homes”, the requirement indicates one bathroom per patient room, with the caveat that a single-user bathroom could be shared between two rooms as long as each room of the patient has direct access. In high-security psychiatric hospitals, however, staff work with mentally ill individuals, some of whom have violent and / or severe tendencies to self-harm that make individual sanitation undesirable for this population.

Alternatively, EYP partnered with code officials in multiple jurisdictions to support and receive code changes from the IBC to allow access to a single-user toilet from one public corridor for every four patients. Corridor accessible toilets with doors that can be easily observed by staff rather than hidden within a patient room are critical to patient safety.

As staff regularly walk through the housing unit to monitor patients, five minutes can mean the difference between life and death. Even in high-security settings, dignity would suggest that patients should be left alone in restrooms and yet that privacy increases the risk of suicide and self-harm. Bathrooms in sight of a nursing station improve safety because staff can see when a patient enters and how long they are in the enclosed space. If a person has been in the bathroom for too long, staff can immediately investigate and confirm the patient’s safety.

Benefits of corridor public toilets

While the goal is to provide a more normative experience in a recovery-based environment, in some cases privacy may need to be secondary to security. This does not mean that bathrooms have to be institutional in character – every effort is made to create pleasant spaces. It is also important to include multiple single-user bathrooms that are convenient for patients’ bedrooms so that patients do not have to walk through the housing unit and through public spaces to reach the bathroom.

Plus, while project budgets and square footage are always limited, fewer bathrooms mean less square footage and fewer dollars spent building and maintaining them, as well as more space and treatment funds. The average bathroom is 60 square feet. In a 28-bed housing unit this equates to 1,680 square feet for incorporating private bathrooms in each bedroom or 840 square feet for semi-private bathrooms. However, when one toilet is used for every four patients, the required space drops to 420 square feet. The remaining square footage can be applied to other areas, such as classroom space, common areas or scheduling.

Finally, the corridor accessible model allows staff to spend less time observing individual restrooms and more time interacting and therapy with the patient.

Safety first

Many positive changes have been made to the IBC over the past decade to recognize the unique requirements of psychiatric hospitals and incorporate their needs into the code. It is important to have an open dialogue with the experts and professionals who manage these facilities to help determine the needs of their patients and staff, particularly when designing treatment spaces, patient housing and restrooms, and assess the level of risk for specific design decisions. Talking to customers and code officials at the beginning of a project can help establish building blocks that enable project teams to create a healing framework that prioritizes the treatment and safety of patients and staff.

Andrea Righi, AIA, is a senior project architect and associate principal at EYP (Washington, DC). She can be contacted at [email protected]



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