Hospital architects find ways to build in safety features

Designers of new hospitals want to make them look more like luxury hotels. But that can be a challenge as heightened concerns about protecting staff and patients from physical violence force designers to build in more security features.

Healthcare architects are being asked to create healing, homey environments that also keep people safe—while avoiding the use of obvious, anxiety-provoking security measures like barbed wire fences. That's particularly a challenge in designing emergency departments, which are seeing greater numbers of psychiatric patients for whom the hospital may not be able to quickly find an inpatient psych bed.

“We're getting closer to a concierge model in a hotel and high-security measures work against that,” said Dennis Kaiser, a principal in the Boston office of architecture firm Perkins & Will.

At a UnityPoint Health facility addition under construction in Rock Island, Ill., that will be part heart center and part emergency department, if an agitated patient arrives for behavioral-health stabilization or assessment, a sliding metal “garage door” can be lowered to separate the patient from equipment and supplies. Patients can also be monitored via camera and by staff in an adjacent stabilization unit which features a living room-style environment equipped with soft lights, easy chairs, a TV and a saltwater aquarium.

That's a good alternative to physically or chemically restraining patients, said Dr. Manuel Hernandez, who is leading CannonDesign's healthcare advisory services team in designing the facility. “It allows patients to be monitored without making them feel like they're being monitored. When they're actively watched, tied down or locked in a room, it only seems to escalate these patients.”

UnityPoint expects 20% of its ED patients to require a mental-health assessment. Hernandez said the project offers a unique challenge. “How do we create an environment to safely assess and stabilize these patients without creating an environment that isn't distasteful or concerning to the general population?” he said.

Design experts agree that it's possible to effectively combine aesthetics and security when security features are included in the original designs, not added on later. While bulletproof glass may be prudent in some hospitals, it can be reserved for secure areas where staff can retreat if a situation gets out of hand. Mostly, though, designers are focusing on controlling public access and improving features that prevent violent incidents from occurring. Security concerns center on four areas of hospitals—emergency departments, waiting rooms (particularly ED waiting rooms), pediatric departments and psychiatric facilities.

Tony York, chief operating officer of HSS, a Denver-based security firm with a healthcare focus, said one reason for growing hospital security concerns is the rise in patients with psychiatric problems, along with a sharp national decline in psychiatric hospital beds. According to the Arlington, Va.-based Treatment Advocacy Center, the number of state psychiatric beds fell by about 25%, from more than 50,000 in 2005 to less than 38,000 in 2011.

York, a past president of the International Healthcare Security and Safety Foundation, said data collected from news reports found that there have been at least 206 cases of gunshots being fired in a healthcare facility from 2006 to the present. A 2012 study published in the Annals of Emergency Medicine identified 154 hospital shootings between 2000 and 2011, resulting in 235 dead or injured victims; 44 of those shootings were in the ED.

An Emergency Nurses Association report found that 12.1% of respondents said they were subject to physical violence—including sexual assault, getting punched, kicked, bit or spit on, or having their hair pulled—between May 2009 and January 2011. The survey also found that 42.5% of emergency nurses were subject to verbal abuse.

“Violence in healthcare, specifically patient-generated violence, is a major concern to the healthcare delivery system,” York said. “The numbers are staggering.”

Dr. Michael Pietrzak, an emergency physician and adviser to Chicago-based HKS Architects, said security has to be built into healthcare facility designs. Too many organizations consider it an afterthought. This results in hastily planned and poorly placed guard desks or metal detectors, he said.

Pietrzak noted how earth berms and ponds can serve the same purpose as barbed wire fencing and iron gates. “You don't have to make it look like a bunker to look secure,” he said. “What you put in is not only based on threat assessment, it's also based on the local, cultural expectations of the community. Even in communities that say, 'We don't want to see any of that stuff,' you can still make it secure.”

One example of a facility where aesthetic design and high security have been successfully combined is the University of Arizona Medical Center's Behavioral Health Pavilion and Crisis Response Center in Tucson, which earned a Citation in Modern Healthcare's 2014 Design Awards. Designers created what they called a “normalized” patient environment that balanced the security requirements of a mental-health facility with the mission of healing and rehabilitation.

An innovative element of the 208,000-square-foot facility is its inclusion of a Pima County Superior Court courtroom, making patients' interactions with the justice system logistically easier, more secure and less costly. “Patients need to interact with the courts, either for short-term or long-term assessment,” said Tim Rommel, who heads CannonDesign's North American behavioral-health planning design group. “Having to move them is work for both the security and clinical staff. Also, patients can return in worse shape than when they left.

“One thing we learned long ago was that our facilities are designed to treat patients with an illness,” Rommel added. “Whether it's a surgical facility where physical medicine is involved or behavioral health, the physical environment can contribute or not contribute to the healing.”

Designers of the new Parkland Hospital in Dallas, set to open next June with 862 single-patient rooms, also paid particular attention to psychiatric patients. There will be a secure room for behavioral-health patients next to the ED. Visitors and patients will be subject to tight, airportlike screening as they enter the facility. Even patients arriving at the separate ambulance entrance will undergo this screening, unless they are in critical condition. In those critical cases, a police officer will accompany the patient and confiscate any weapons or contraband that are discovered as emergency staff puts them in a bed, said Ken Cheatle, chief of the Dallas County Hospital District Police.

Andrew Quirk, senior vice president of Skanska USA Building, said holding areas for injured patients who are in custody and are brought in by police, as well as for psychiatric patients in crisis arriving by ambulance, usually are located along an exterior wall. “That way, you minimize their contact with other patients,” he said. “You put in as much control as you can put in a place to control the uncontrollable.”

Designers increasingly are focusing on creating ED waiting rooms that are both pleasant and secure and that help defuse tensions. Potentially violent situations are not uncommon in the waiting rooms. For example, injury victims from the same traffic accident but different vehicles may be waiting together. Similarly, injured high school football players from opposing teams may be eyeing each other angrily while waiting for treatment.

Strategies to keep tensions down include providing enjoyable distractions such as free Wi-Fi access, treating patients quickly, and giving people plenty of space to spread out. Another strategy is to have two separate ED entrances—one for walk-up and drop-off traffic and another for police and paramedics. The University of Arizona facility in Tucson has separate entrances, as does the new Parkland Hospital in Dallas.

Quirk said having dedicated ED entrances for emergency personnel isn't a new concept but is only now being widely adopted. Some hospitals also are providing workstations for police to complete any required paperwork. “It's not the responsibility of a hospital to provide that space, but it's a good practice,” he said.

Temecula (Calif.) Valley Hospital, which opened in October 2013, located its security office near the ED. The new Parkland Hospital also will have a substation for the Dallas County Hospital District Police near the ED. It will be staffed by seven police officers 24 hours a day. “We will have a presence,” Cheatle said.

York cited the ED at Rocky Mountain Hospital for Children as an example of a facility where security has been done right. Elements of its ED include good visitor control, good sightlines for staff, easy access to communication with the security department, and radiology facilities inside the ED, so patients don't have to leave the secured area. Rocky Mountain officials chose not to install metal detectors for the time being. But the space was designed so that metal detectors could easily be added if needed.

Rommel said designers devote a lot of attention, especially in building EDs, to finding the right “awareness point,” giving staff maximum visibility of the operation and maximum ability to monitor who's coming and going. Hernandez added that finding the right awareness point can save on labor costs. “If you can't maintain that situational awareness, you have to add staff,” he said.

Kaiser agreed that controlling who goes where in a hospital is a key to maintaining security. He recommended that designing for safe and secure traffic flow in new facilities should be a higher priority than wrangling over where “blocks of function” are placed. One way to do this is to have separate, exclusive spaces for staff, patients and the public. The Disney Corp. is credited with originating this concept at its amusement parks, building dedicated “onstage” spaces for the public and “offstage” areas for staff and service functions.

Kaiser noted that many older facilities were built in this model but now may have haphazardly planned additions that have created crisscrossing public and staff corridors. That compromises secure areas and makes it harder to monitor visits and control access.

Department consolidation also helps. Under the traditional siloing of clinical departments, each department may have had its own entrance and waiting room. Consolidation funnels visitors to one general entrance and eliminates the need for separate waiting rooms, permitting the design of more spacious waiting areas. “Arguments can flare up in waiting rooms just because of the intensity of the experience and the perception that a person is invading another's personal space,” Kaiser said.

Kaiser worked on a project for St. Joseph's Healthcare Hamilton (Ontario) in Canada, where diagnostic imaging functions were consolidated and a waiting area was created along a wide corridor. Even though the area is in a basement, Kaiser said no one feels confined. One visitor's comment was that the waiting area “felt like we were in a spa.”

Grace Hsu, senior project manager for design and construction at Stanford Medicine, Palo Alto, Calif., said all healthcare organizations are struggling to find the right balance between security and healing aesthetics. “We err on the side of making people comfortable,” she said. “Everyone is so emotional by the time they are in our facility. So not adding to that anxiety is good.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks