Unobtrusive Suicide Prevention Design in Mental Health Facilities

Unobtrusive Suicide Prevention Design

in Mental Health Facilities

Name : Yeong Kam Loong

Matric Num. : SB/696/12

Supervisor : Ar. Haris Fadzilah Abdul Rahman

i

ACKNOWLEDGEMENT

First of all, I would like to express my gratitude to my supervisor, Ar. Haris Fadzilah

Abdul Rahman for his generous suggestions and advices given in preparation and

completion of this dissertation.

Furthermore, I would like to give my appreciation to Avera Behavioral Health

Center and Array Architects for uploading information of their owned/ designed

mental health facilities online. Such information is allows me to study in greater

detail terms of unobtrusive suicide prevention design and to produce more

comprehensive case studies.

Last but not least I would like to offer my gratitude to friends and family who had

helped me in completion of this report directly and indirectly in the form of moral

support and suggestions and encouragement.

Unobtrusive Suicide Prevention Design in Mental Health Facilities

ii

ABSTRACT

Suicide and suicide attempt risks in mental health facilities are high due to the

deterioration of mental state of patients as well as the affected emotion due to

involuntary hospitalisation for treatment. This is often responded with highly

institutionalised and inhumane suicide prevention designs applied in inpatient wards

which are not conducive in facilitating patients healing.

Several Western countries has noticed the importance of the balance between suicide

prevention and therapeutic environment in mental healthcare facilities and provided

design guides for architects references in design of future mental health facilities.

This dissertation will study and analyse on the pattern of suicide of mental health

patients and the existing available design guides local and abroad which will

eventually lead to a proposal of localised version of design guide to suit with the

current local context.


iii

LIST OF FIGURES

Figure 1.1: Research Methodology diagram.4

Figure 2.1: Location and percent of inpatient suicides and suicide attempts in Veteran Affairs hospital..6

Figure 2.2: Reported methods and and percent for inpatient suicide and suicide attempts in Veteran Affairs hospital8

Figure 2.3: Hanging points for inpatient suicide and suicide attempts in Veteran Affairs hospital..9

Figure 2.4: Materials used as a noose for inpatient suicide and attempted suicide by hanging in Veteran Affairs hospital..10

Figure 2.5: Suicide hazards in patients room .......................................................................11

Figure 2.6: Jumping locations for inpatient suicide and attempted suicide by jumping in Veteran Affairs hospital..11

Figure 2.7 Typical patient room..20

Figure 2.8: Types of suggested lighting fixtures21

Figure 2.9: Types of suggested diffuser and sprinkler head...22

Figure 2.10: Anti-ligature door hardware...22

Figure 2.11: Door pressure sensitive alarm solution for bathroom door23

Figure 2.12: Chamfered door top solution for bathroom door24

Figure 2.13: Recommended accesories for bathroom25

Figure 2.14: Examples of handrails and wall guards for corridor..26

Figure 2.15: Examples of furniture for communal areas27

Figure 2.16: Examples of recommended hardware for doors at inpatient unit...31

Figure 2.17: Example of recommended window for inpatient unit32


iv

Figure 2.18: Example of recommended ceiling for inpatient unit......32

Figure 2.19: Example of recommended handrail for inpatient unit.......32

Figure 2.20: Example of recommended toilet accesories for inpatient unit.......33

Figure 2.21: Example of recommended plumbing installations for inpatient unit.........33

Figure 2.22: Example of recommended ceiling mounted diffusers for inpatient unit34

Figure 2.23: Example of recommended lighting fixtures for inpatient unit...34

Figure 2.24: Example of recommended fire fighting components for inpatient unit.35

Figure 3.1: Photos of the behavioural health facility.38

Figure 3.2: Floor plan showing threecorridor circulation system......38

Figure 3.3: Floor plan showing relationship between public, patient and staff circulation39

Figure 3.4: Geriatric unit design.....40

Figure 3.5: Anti-barricade door that have two opening direction...........................41

Figure 3.6: Anti-ligature hardware used to conceal door lock............................41

Figure 3.7: Unit toilet design..42

Figure 3.8: Unit toilet design..43

Figure 3.9: Dining room and day area43

Figure 3.10: Central public courtyard corridor...............44

Figure 3.11: Central light court corridor.45

Figure 3.12: Threshold and skylight at patient room entries......46

Figure 3.13: 2-corridor system flanking patient support areas...46

Figure 3.14: Adult patient room interior.47

Figure 3.15: Details inside the adult patient room......47

Figure 3.16: Patient bathroom interior............................48

Figure 3.17: Patient common area..............................48


v

Figure 3.18: Outpatient clinic interior....49

Figure 3.19: Admission entrance interior...49

Figure 3.20: Admission outdoor area..49

Figure 3.21: Open nursing station design.......50

Figure 4.1: Diagram of fire staircase provision in 2 different layouts....68

Figure 4.2: Aesthetically chamfered doors and windows designs..............68

Figure 4.3: Diagram of 2 windows with 100mm opening..69

Figure 4.4: Suicide prevention screen design at NYU library69

Figure 4.5: Unaesthetic grilles installed at Kinta Heights low cost flat, Ipoh.70

Figure 4.6: Diagram showing buffet zone concept.70


vi

LIST OF TABLES

Table 2.1: Methods of suicide in reported cases in Malaysia...7

Table 2.2: Distribution of place of suicide act in reported cases in Malaysia..7

Table 2.3: Ligature points in menta health facilities...30

Table 4.1: Maximum suicide prevention application in mental health faciliry..60

Table 4.2: Intermediate suicide prevention application in mental health faciliry...63


vii

CONTENTS

Acknowledgement.i

Abstractii

List of Figures.iii

List of Tables..vi

CHAPTER 1 INTRODUCTION

1.0 Introduction..1

1.1 Research Issues.3

1.2 Research Objective...3

1.3 Limitations4

1.4 Research Methodology.4

CHAPTER 2 LITERATURE REVIEW

2.0 Introduction..5

2.1 Pattern of Suicides6

2.2 Design Guides Review...12

2.2.1 Mental Health Act 2001 (Act 615) and Regulations .12

2.2.1.1 Introduction12

2.2.1.2 Suicide Prevention Strategies (Summary)..12

2.2.1.3 Appraisals...12

2.2.2 Psychiatric and Mental Health Services Operational Policy..13





viii

2.2.3 Health Building Note 03-01: Adult Acute Mental Health

Units...14




2.2.4 Mental Health Facilities Design Guide..18

2.2.4.1 Introduction....18

2.2.4.2 Suicide Prevention Strategies (Summary).19


2.2.5 Patient Safety Guidelines, Materials and Systems Guidelines...29



2.3 Analysis and Reviews....35

CHAPTER 3 CASE STUDY

3.0 Introduction37

3.1 Zucker Hillside Behavioural Health Facility, Glen Oaks, New York37

3.1.1 Project Introduction37

3.1.2 Suicide Prevention Features...39

3.1.3 Appraisals...44

3.2 Avera Behavioural Health Center, Sioux Falls, South Dakota..45

3.2.1 Project Introduction45

3.2.2 Suicide Prevention Features...46

3.2.3 Appraisals...50

3.3 Overall Review...51


ix

CHAPTER 4 Proposals: Unobtrusive Suicide Prevention Design Guide For

Malaysia Mental Health Facilities

4.0 Introduction53

4.1 Proposal..53

4.1.1 Maximum Application53

4.1.2 Intermediate Application60

4.1.3 Minimal Application..64

4.2 Complimentary Requirements65

4.3 Authors Suggestions..67

CHAPTER 5 CONCLUSION

5.0 Conclusion..71

5.1 Recommendation for further study73

REFERENCES.74

1

CHAPTER 1

INTRODUCTION

1.0 Introduction

According to National Health and Morbidity Survey 2011 (Fact Sheet), 0.3

million (1.7%) of national population have General Anxiety Disorder, 0.3 million

(1.7%) have Depression while 0.2 million (1.1%) reported to have attempted suicide

in the past. Mental health illness, especially depression, affecting 350 million of

global population, is the third leading cause of global burden of disease in 2004 and

will move to the first in 2030 (WHO).

According to the National Suicide Registry Malaysia (NSRM), the overall

suicide rate at 2009 was 1.18 per 100,000 with majority were Malaysian citizens

(89% or 293/328). The age ranges from 1494 years, with a median of 37, consisting

of more men than women, with gender ratio being 2.9:1 (male:female). Mental

illness was reported in 22% (72/328) of the cases and physical illnesses in 20.4%

(67/328). Previous suicide attempts were reported in 15.5% (51/328) of cases.

History of substance abuse was present in 28.7% (83/328). Life events were positive

in 41.2% (135/328) of cases. (Ali, NH, 2012) The statistic revealed that mental

illness is among the major causes of suicide.

The rate of suicide has since increased on an alarming rate, with 425 people

committed suicide between January and august 2010, averaging 60 per month

(including undetermined deaths). Suicide rate has increased to 10 to 13 per 100,000

people which nearly equal to the US. (The Star, February 10, 2011) In response to


2

this situation, the government had decided to launch a five-year National Suicide

Prevention Strategic Action Plan starting in 2012 where part of the plan is to shift

mental health treatment from purely institutionalized in hospitals to more

community-centric and to me made available in community mental health centers.

(The Star, June 5, 2012)

This would mean the facilities will be catering for a high concentration of

potential suicidal population and the facilities must implement suicide prevention

design to avoid attempted suicide from patients during phases of treatment in the

said facilities. Occurrence of suicide in such facilities will cause distress to the

unstable emotions of patients or even provoke their urge to follow suit and commit

attempts of suicide.

Suicide prevention design strategies in mental health institutions in the past

emphasized much on the security consideration which neglected its effects on users.

The installation of screens, anti-climb barriers that are both visually imposing and

sometimes inhumane to the eye of both the patients and staff affects the overall

architectural aesthetics and mood of the premise into a prison-like setting.

Architectural critics often comment these solutions as afterthoughts where

suicide prevention design should be considered at the early stage on the drawing

board as part of architectural design. With increasing awareness of the need of

humane yet secured environment for healing, recent mental health facilities design

trend in overseas has shifted the emphasis to unobtrusive suicide prevention design

strategies and therapeutic architecture.


3

This purpose of this paper is to study the general suicide pattern of

psychiatric inpatients in mental health facilities in order to identify the high risk

areas for suicide prevention design intervention. Appraisals on current unobtrusive

suicide prevention design practices will be conducted with attempts to enhance or

modify the designs appropriate to the Malaysia context.

1.1 Research Issues

With the provision of Mental Health Act 2001 and Regulations, Psychiatric

and Mental Health Services and Operational Policy and Private Healthcare Services

and Facilities Act 1998 by the Malaysia Ministry of Health, it is anticipated more

mental health facilities will be established in the country in response to the

increasing number of mental health patients. This would mean deinstitutionalisation

of mental health services to the public from government healthcare institutions to

community setting.

However, there are inadequate design standards or guidelines for local mental

health facilities at present where the design requirements are general and not specific

enough. This situation might lead to non-uniform suicide prevention design qualities

and standards in upcoming new mental health facilities.

1.2 Research Objective

To study suicide patterns by psychiatric inpatients in mental health facilities

and identify areas for suicide prevention design.

To analyse and enhance/modify existing suicide prevention designs in mental

health facilities building practice to achieve higher level of unobtrusiveness

and appropriateness to the local context.


4

1.3 Limitations

As local design standards for mental health facilities in the country is still

insufficient for analysis currently, the dissertation will study and appraise the design

standards of guidelines established in developed countries and attempt to enhance or

modify the designs to suit the local context.

In order to compensate for the lack of detailed information from the National

Suicide Registry Malaysia in terms of the suicide patterns of psychiatric inpatients in

local mental health facilities, reference to foreign statistics where established

institutions has been conducting research in related topics is necessary.

1.4 Research Methodology

Figure 1.1: Research Methodology diagram

Selection of Research Topic

Unobtrusive Suicide Prevention

Design in Mental Health Facilities

Literature Review

Suicide patterns local and abroad

and existing design guides

Case Study

Recently completed projects

with critical analysis and

appraisals.

Proposal

Unobtrusive Suicide Prevention

Design Guide for Malaysia


5

CHAPTER 2

LITERATURE REVIEW

2.0 Introduction

Suicide (suicidium in Latin), to kill oneself is the action of intentionally

causing ones own death. It is frequently regarded as the result of a mental disorder

such as depression, bipolar disorder, schizophrenia and borderline personality

disorder (Paris, J, 2002) besides alcoholism and drug abuse (Hawton, K; van

Heeringen, K, 2009).

Mental health facilities in definition are the healthcare facilities where

mentally ill patients undergo psychiatric treatment both voluntarily and involuntarily

in order to curb or get the symptoms under control. The mental healthcare services

are often offered in both inpatient and outpatient basis, depending on the mental

stability of the patient.

The Joint Commission Journal on Quality and Patient Safety titled Inpatient

Suicide and Suicide Attempts in Veteran Affairs Hospitals prepared by the Joint

Commission on Accreditation of Healthcare Organizations in 2008 revealed that 185

inpatient suicides and suicide attempts (42 completed suicides, 143 suicide attempts)

were reported in veteran affairs hospitals in US. 52% of the events occurred in

inpatient psychiatric units.


6

Figure 2.1: Location and percent of inpatient suicides and suicide attempts in Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient Safety,

August 2008)

This chapter will analyse on the suicide patters (methods and locations) and

review on the existing suicide prevention design guides available in Malaysia and

abroad and identify areas where unobtrusive suicide prevention design can be

applied on.

2.1 Pattern of Suicides

The National Suicide Registry Malaysia 2009 report states that the three

commonly used choices of suicide methods are hanging, strangulation and

suffocation (176 cases), pesticides (43 cases) and jumping from high place (34 cases)

in 2009. It is observed that mental illness factor is has grown from 17.2% (50/290) in

2008 to 22% (72/328) in 2009 of the reported cases, showing an increase of 4.8%

over the course of one year, which the most common mental illness of suicide

victims was depression (47.2%) and schizophrenia (26.4%). Though the statistics

revealed that 32 or 9.8% of the cases happened in residential institutions, it is unclear

on the exact percentage of it happened in mental health institutions.


7

It is unable to generate the suicide pattern of mental health patients in local

mental health facilities as the NRSM report does not provide further study into that

aspect which necessitates the need to study the pattern through available statistics

abroad.

Table 2.1: Methods of suicide in reported cases in Malaysia (Source: National Suicide

Registry Malaysia 2009 Annual Report)

Table 2.2: Distribution of place of suicide act in reported cases in Malaysia (Source:

National Suicide Registry Malaysia 2009 Annual Report)

According to the Joint Commission Journal on Quality and Patient Safety

report, in 2008, hanging (31.4%), cutting with sharp objects (20.1%) and drug

overdose (18.9%) accounted for 70.4% of the total inpatient suicide and attempted


8

suicide events in VA hospitals at US. Other methods of suicide and suicide attempts

include strangulation, jumping, stabling self, asphyxiation, fire, ingestion of

chemicals and etc.

Figure 2.2: Reported methods and and percent for inpatient suicide and suicide attempts in

Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient Safety, August 2008)

It has to be noted that the inpatient suicide pattern has changed over time

after a number of strategies recommended by the Joint Commission to reduce

inpatient suicides in 1998. Prior to the recommendation in 1998, 75% of the cases

involved hanging, 20% involved jumping from roof or window. From the study, 18

of the 42 completed suicides were hangings, 15 were drug overdoses, and 4 were

jumping from high place.


9

The recommendations in 1998 include removing or replacing non-breakaway

hardware, weight testing all breakaway hardware, and blocking patient access to

sharp objects and potentially harmful items such as cleaning solvents. Consequently,

the suicide pattern was significantly changed as new kinds of methods are always

being found in response to reduction of environmental hazards which intended to

discourage suicidal behaviour.

For building infrastructure-related environmental hazards, anchor points are

identified as one of the primary environmental hazards that lead to hanging within

mental health facilities. Though door or door hardware is the most common choice

of anchor point for hanging, wardrobe cabinet as anchor point has a higher success

rate in suicide attempt.

Figure 2.3: Hanging points for inpatient suicide and suicide attempts in Veteran Affairs

hospital (Source: The Joint Commission Journal on Quality and Patient Safety, August 2008)


10

Figure 2.4: Materials used as a noose for inpatient suicide and attempted suicide by hanging in Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient

Safety, August 2008)

Patient rooms and toilets are the areas of highest risk where patients are alone

for periods of time. They are able to hang themselves from objects as close to the

floor as 18 and one study shows that 50% of non jucidal hangings were from

heights below the waist of the victim. (Hunt; Sine, 2009) This reveals the importance

of furniture and fittings to have minimal anchor points for patients to attempt

suicide.


11

Figure 2.5: Suicide hazards in patients room (Source: Pennsylvania Patient Safety Reportying System, 2007)

Inpatient suicides involving jumping are mostly occurred from balcony and

walkway, which is another building infrastructure-related environmental hazard. It is

assumed that the balcony or walkway are inadequately secured to prevent inpatients

from jumping. Though jumping is less chosen as method of suicide, injury inflicted

to inpatients from unsuccessful suicide attempt is more serious compared to hanging

which might result in head injury, broken bones or even paralyzation.

Figure 2.6: Jumping locations for inpatient suicide and attempted suicide by jumping in Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient

Safety, August 2008)


12

2.2 Design Guides Review

2.2.1 Mental Health Act 2001 (Act 615) and Regulations (Ministry of Health,

Malaysia)

2.2.1.1 Introduction

The regulation provides certain requirements and standards for private psychiatric

hospital, private psychiatric nursing home and private community health center, etc.

encompassing general requirements in terms of general spaces (reception and lobby),

specific spaces (seclusion room, electroconvulsive therapy room, treatment room and

etc.) openings, security and management of equipment. However, this report will

emphasize only on the aspects related to suicide prevention design:

2.2.1.2 Suicide Prevention Strategies (Summary)

Doors (Section 32):

All doors in patient care areas shall be made of safe and non-hazardous material and

be able to be locked and accessible by the staff in an emergency. Single outward

opening door made of study material with observation panel made of safety glass

shall be provided for seclusion room.

Windows (Section 33):

All windows in patient care areas shall have panels made of safe and non-hazardous

material with restricted degree of opening using aesthetic and non-prison like grills,

where applicable.

Lighting in patient care area (Section 36):

Recessed lights shall be provided in all patient care areas.


13

2.2.1.3 Appraisals

The guideline provided some fundamental required standards in patient care area. On

the downside, it lacks information to the detailed level such as the dimensions of

degree of restricted opening for windows, suggested type of safe and non-hazardous

materials for doors and windows, anti-ligature requirement for doors in wards and

etc.

The limitation of 100mm window opening might not comply with UBBLs Section

39(2) regarding natural ventilation in providing uninterrupted passage of air even

though the window area is not less than 10% of floor area.

2.2.2 Psychiatric and Mental Health Services Operational Policy (Ministry of

Health, Malaysia)


The document focused on standards of operational procedure in mental healthcare

services along with partial suggestions on infrastructure and facilities requirements.


High dependency ward

The ward should preferably be fully air conditioned with toileting, dining facilities

separate from patients in other wards.

Acute ward

Same as high dependency ward with exception of lockers provided for patients at a

secured place away from their beds.


14

Convalescent ward

The ward should have a sense of domesticity in terms of structure and aesthetics.

Each patient should have a locker that can be accessed at all times.

2.2.2.3 Appraisals

The reason of suggestion for fully air conditioned ward was not explained. It was

assumed to compensate with the limited window opening dimension to keep indoor

air quality at comfortable level. However, further elaboration on the application of

suicide prevention strategies for air conditioned ward is needed such as the supply

and return air grill design and location and etc.

The availability of lockers to various levels of patients differs due to their tendency

to hide and store materials of suicide and self-harm in lockers or even abuse the

locker itself for suicide attempt. No specific description on the types and design of

the lockers that should be used in terms of suicide prevention.

2.2.3 Health Building Note 03-01: Adult Acute Mental Health Units

(Department of Health, UK)


The guide covers several aspects including: scope of guidance, policy and service

context, principles of planning and design, stakeholder needs, planning

considerations, design considerations, room spaces, furniture, fixture and fittings,

building construction and components and engineering considerations.

The key consideration of suicide prevention design in the design guide is focused on

anti-ligature design and robustness through specific hardware, concealment of


15

ligature points while being as domestic in style as possible. Attention is given on

sanitary fittings, windows and doors to minimise ligature risks. Any fixture or fitting

that could provide an anchor point should safely break free under weight of patients

in a suicide attempt.


Bedroom

The layouts of rooms, fixed furniture and equipment should ensure that patients are

not able to hide themselves inside the room. Anti-ligature wardrobe, drawers or

shelves and chair should be provided and be built-in where possible.

Kitchen/ servery

All food preparation and waste disposal equipment within the kitchen/servery should

be able to be locked and isolated by staff when needed. Cupboards and drawers

should be provided in the kitchen and lockable by staffs.

If a server hatch is provided between the kitchen/servery and dining room, it should

be fire resistant and designed to be able to lock securely.

Sanitary facilities

All sanitary fittings should be of robust construction, ligature free and constituted of

materials that will withstand sustained attack. Conventionally exposed fittings such

as WC cisterns, pipework and electrical conduit are required to be concealed behind

secure panels, through boxed or set into the wall.

All shower components are required to be anti-ligature with fixed shower heads,

either wall or ceiling-mounted. Fittings such as wash basin, WC and shower

activation by pressure switch or sensor as mechanical or electrically activated water


16

supply are recommended as anti-ligature strategy besides concealed traps and anti-

ligature taps. Timed supply for shower may be needed to avoid flooding.

Windows

All windows should be ligature-free, robustly constrained to provide maximum

100mm opening to avoid patients from climbing out and secure mesh to prevent the

passage of contrabands or weapons. Windows can be opened to greater dimensions

shall the opening area protected by a secure ventilation grill.

Window frames should be constructed of steel and hardwood timber to ensure

robustness. The use of polycarbonate, toughened or laminated glass in patient care

areas is recommended. Aluminium window frames are unsuitable for opening lights

as they can be flexed or twisted out of shape.

Doors

Design of doors should minimise the opportunity for ligature risk and contraband

concealment, the means to barricade or prevent the door from being opened and

avoid parts that could be removed by patients to use as weapons. No protrusions

except security lock handle on the outside face.

Bedroom doors should have a vision panel to allow staff observation into the room

with provided means of control by staff to access the panel for viewing only when

needed in order to preserve the privacy of patients.

Doors should be equipped with override facility for staff to be able to open them

outwards if a patient barricades themselves in. The door handle for patients room

should be ligature-free. Clear opening width of 850-900mm is required.


17

Ceiling

Ceiling heights are minimum 2700mm in mental health design and 3000mm in a

secure unit so that light fittings, detectors etc. are out of reach. Grid type suspended

ceilings with removable ceiling panels should not be provided in patient-accessible

area. It should be able to withstand damage by implementing plywood backing and

the like.

Security locks

Electronic systems can be used in coordination with fire escape strategy of facility to

ensure the means of escape is controlled but no compromised.

2.2.3.3 Appraisals

It is noticed that besides surveillance and supervision, suicide prevention design in

the design guide gives a significant amount of emphasis on the use of anti-ligature

hardware, minimisation of ligature point through concealment and the use of high

tech equipment such as sensors and other electronic activation equipment to replace

conventional hardware with visible ligature points.

Though well intended and effective, the high tech solution is disputable in terms of

cost effectiveness and limitation of patients control on sanitary fittings (especially

shower with timed water supply). 100mm maximum opening for windows seemed to

be inadequate to harness natural ventilation for access to fresh air as discussed in

previous design guide. However, the installation of ventilation grille for windows

with large opening would solve the problem of inadequate ventilation but it creates a

secondary problem of higher construction cost.


18

The suggested use of override facility for doors is commendable in balancing both

patients and staffs control of access to space in response to changing situations.

The use of electronic lock for fire escape strategy could prevent escape of patients to

higher grounds of building fir jumping but the strategy has to be given exception of

UBBL requirement Section 166(2) regarding exits to be accessible at all times.

2.2.4 Mental Health Facilities Design Guide (Office of Construction and

Facilities Management, Department of Veteran Affairs, US)


This design guide is provides general operational narrative, planning and design

criteria, technical narrative and sample layouts for spaces ranging from bedrooms to

nurse station. The design guide provides comprehensive graphical reference to

communicate the strategies.

Similar to Health Building Note from UK, the design guide emphasizes on

minimizing hanging and cutting risk from patients through minimizing anchor points

and vandal-proof fixture and fittings that can be used as weapons and tools for self-

harm. More emphasis is given to inpatients bedroom and en-suite bathroom in terms

of suicide prevention strategy.

The design guide referred to The Design Guide for the Built Environment of

Behavioural Health Facilities to identify various level of risks based on the function

and level of accessibility, patients privacy of spaces with in order to determine the

zones where suicide prevention design applications is used.


19

Level 1: Staff and services area which is inaccessible by patients

Level 2: Counselling rooms, examination rooms, group therapy rooms, multi-

purpose rooms and interview rooms where patients are highly supervised and

not left unattended for periods of time

Level 3: Corridors, dayrooms and dining areas where patients are given

minimal supervision.

Level 4: Patient rooms (semi-private and private) and patient toilets where

patients are given minimal or no supervision for a longer periods of time.

Level 5: Admission rooms and seclusion rooms where staff interacts with

newly admitted patients with unknown potential risks/ in highly agitated

condition.

Level 4 & 5 spaces should have nothing in space that can be used as anchor point,

weapon, or projectile.


Bedroom

Aesthetic and safety standpoint is emphasized in the design of inpatient bedroom

with features explained through illustrations below:


20

Figure 2.7 Typical patient room (Source: Mental Health Facilities Design Guide, December

2010)

1. Use of integral blinds for exterior window (reduces hanging risk from using

conventional blinds that provide anchor points on railing) and laminated

glass on interior face ( does ont create shards that can be useds as weapon in

the event of breaking).

2. Pressure sensitive alarm at door head of bathroom door (to alert staff in event

of attempted suicide using bathroom door as anchor points for hanging),

continuous hinge and anti-ligature lever with magnetic latch. (minimize

anchor points)

3. Provide secured, non-breakable artwork, marker board and area rug as

optional elements for domestic feeling to the room without compromising

patient safety.

4. Secure trim, headboard and soothing colours to create domestic feel to the

room.


21

5. Built in desk and shelving unit for patients cloth and belonging storage.

(Avoid creating ligature points from tall wardrobe and standalone furniture,

preventing usage of furniture for barricade and vandalism purposes by

inpatients )

6. Wood grain pattern sheet vinyl flooring for aesthetic purposes.

Lighting

Recessed fluorescent lights may be used combined with high strength acrylic lens

and flush trim anchored with tamper resistant screws to prevent vandalism by

patients. Over bed lighting should be installed above the bed and be designed to

avoid creating anchor points.

Figure 2.8: Types of suggested lighting fixtures (Source: Mental Health Facilities Design

Guide , December 2010)

Air cond diffusers and sprinklers

Louvered diffusers should not be used (louvers can be used as anchor points);

perforated holes diffusers is recommended to be used in the ceiling with tamper


22

proof fasteners. Vandal-proof sprinkler head should be used with designs that do not

provide anchor points.

Figure 2.9: Types of suggested diffuser and sprinkler head

(Source: Mental Health Facilities Design Guide, December 2010)

Windows:

Heavy gauge commercial units with insulated double glazing are recommended for

exterior windows and are required to be operable for emergency ventilation. Window

openings should not exceed 4 (101.6mm)

Doors:

Patient bedroom doors should be out-swinging to prevent inpatients barricading

themselves inside the room unless corridor width is inadequate. Anti-ligature

hardware is recommended to be used for patient room doors.

Figure 2.10: Anti-ligature door hardware (Source: Mental Health Facilities Design Guide, December 2010)


23

Bathroom door has the highest probability of being used as anchor points for

hanging as patients are left unattended. The design guide offers 3 strategies to deal

with this challenge:

Option 1: Door-top pressure sensitive alarm which will signal the nurse station if

weight is exerted on the door during suicide attempt.

Figure 2.11: Door pressure sensitive alarm solution for bathroom door (Source: Mental

Health Facilities Design Guide, December 2010)

Option 2: Out-swing door with chamfered top to prevent the door being used as

anchor point with a 30 degree cut at the top of the door. However, it provides less

privacy and reduces the domestic feel of inpatients room.


24

Figure 2.12: Chamfered door top solution for bathroom door (Source: Mental Health Facilities Design Guide, December 2010)

Option 3: Sliding door deign will render hanging using door top as anchor point

impossible as the door top is fixed in the sliding track. Though the advantage of

maintaining privacy and visual appeal, the design guide concerns over the issue of

infection control with the use of track on the floor and unsuitable for patients with

weaker upper body strength.

Its not recommended to use the door without a track on the floor as it provides

opportunity for inpatients to kick the door.


25

Bathroom flooring

2x2 ceramic tile is recommended only for floor and not wall as it can be easily

dismantled and misused.

Sanitary facilities

Piping in toilets should be concealed and controls be used to prevent excessive

flushing and flooding. Push button flush actuator is recommended. All piping below

the sink should be concealed behind a panel fastened with tamper-proof screws

accessible only to maintenance staff.

Shower controls should be recessed stainless steel panels with no part able to be used

as anchor points. In case where grab bars are needed in accessible rooms, a welded

horizontal plate is needed on the bottom part to prevent it being used as anchor

points. Shower or floor traps should be screwed with security screw to prevent

removal by patients

Figure 2.13: Recommended accesories for bathroom (Source: Mental Health Facilities

Design Guide, December 2010)


26

Patient activity areas

Lighting or other ceiling mounted fixtures should be recessed. Vandal resistant

properties are needed for fixtures surface mounted to the ceiling. The space should

have no sharp wall, furniture or fixture edges that patients can be used for self-harm.

All wall mounted fixtures should be flush mounted and fastened with security screws.

Equipment used by patients under supervision such as computer and other facility

equipment should be located in lockable rooms when not in use.

Corridor spaces

Handrails should be provided along corridor for patient use and wall protection, its

design should not have anchor points. Hard edges on wall corners can be soften by

corner guards to prevent self-harm from patients. The design of both handrail and

corner guard should enhance the aesthetic image to the corridors.

Figure 2.14: Examples of handrails and wall guards for corridor (Source: Mental Health

Facilities Design Guide, December 2010)


27

Inpatient communal areas

Furniture plays a major role in suicide prevention in communal areas it can be used

as weapons. Furniture should have round edges and robust to prevent parts being

dismantled and used for self-harm. Furniture should be stain-resistant, easy to clean,

not easily thrown and able to withstand abuse including punctures while domestic in

aesthetics to avoid creating an institutional like atmosphere.

Fittings such as TV should be located within a niche with cords not exceeding 12

(304.8mm) while not accessible by patients. Furniture such as book shelf should be

built-in and have fixed shelves to prevent patients from overturning or climbing the

furniture.

Figure 2.15: Examples of furniture for communal areas (Source: Mental Health Facilities

Design Guide, December 2010)

Outdoor spaces

Outdoor spaces should be designed with landscape and hardscape features that do

not support self-harm or violence behaviour. It should be located within line of sight

from nurse stations for surveillance purposes.


28

An enclosure height of 14 feet (4.27m) is recommended and it should prevent

climbing and used as anchor point. Trees should not facilitate climbing over a wall

or fence. Landscape materials such as toxic plants, rocks, gravel, dirt planting bed or

pathway material that can be used as weapon or tools of self-harm should not be

used.

Outdoor furniture must be immovable by using heavy furniture or anchored to

concrete pads. It should not be located close to fence or wall to avoid patient escape.

Balconies or elevated outdoor porches must have all openings covered with security

railings or screenings to remove the potential of jumping.

2.2.4.3 Appraisals

It is noted that surveillance, anti-ligature furniture and fittings are among the major

strategy concerns to achieve suicide prevention in this design guide. Though

comprehensive, some of the proposals are obtrusive such as the height of enclosure

height of 4.27m in outdoor spaces is could be reduced to a more humane scale with

anti-climb designs on the top of fencing.

Architecture solutions are mainly focused on security control and surveillance while

suicide prevention solutions are focused mainly on interior hardware, furniture and

fixtures, which in a way still inevitably exert some obtrusiveness to the inpatients

such as the use of pressure sensor on door top that gives a sense of distrust,

chamfered bathroom door that compromises privacy, 101.6mm window opening that

limits the flow of air and etc.


29

The use of electronic substitutes such as control panel for shower and pressure

sensor on door top would mean higher construction cost and repair cost if subjected

to vandalism which is not uncommon in mental health facilities.

However, it is commendable that the design guide provide some options for the bath

room door case ranging from sensors to chamfered doors and to sliding doors. The

design guide can be enhanced if similar kinds of alternative suggestion are given on

other design aspects such as windows, doors and balconies.

2.2.5 Patient Safety Guidelines, Materials and Systems Guidelines (New York

State Office of Mental Health, US)


The guideline was created to provide a selection of materials, fixtures and hardware

that the office has reviewed and supports for use in mental health units. It stated the

utilisation of the listed products is not mandatory.

The guideline has identified specific anchor points within the facility for suicide

prevention application stated as below:


30

Above the waist ligature points Additional ligature points

Windows and vision panels Door hinges Sprinklers HVAC terminal devices and

covers

Thermostats Door closers Light fixtures Window treatments Shower curtains Access doors Fire alarm components Shower heads Clothes hooks Cabinetry and hardware Hanger rods Ceilings Electrical receptacles Medical gas enclosures Bulletin boards/ picture hanging

systems Toilet partitions Mirrors Fasteners

Door knobs/levers Door bumpers Cabinet hardware Lavatories Faucets Lavatory valves Shower actuators Toilet seats Toilet operator valves Plumbing traps and piping Grab bars Furniture Toilet accessories Trip strips between assemblies Sealants/ caulk Fire extinguisher and hose

cabinets

Table 2.3: Ligature points in menta health facilities (Source: Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)


The guideline categorizes the products based on evaluation on their suicide

prevention effectiveness with suggestions on areas where it is safe to install (low,

medium and high risk areas). The following are excerpts of the guideline:


31

Doors

Figure 2.16: Examples of recommended hardware for doors at inpatient unit(Source: Patient

Safety Guidelines, Materials and Systems guidelines, March 2013)


32

Windows

Figure 2.17: Example of recommended window for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

Ceiling

Figure 2.18: Example of recommended ceiling for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

Handrail

All handrails and grab bars are subjected to wedge ligature with a shoe or other

object and should be used only at places required by building code.

Figure 2.19: Example of recommended handrail for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)


33

Toilet accessories

Figure 2.20: Example of recommended toilet accesories for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

Plumbing

Detention grade stainless steel fixtures are prohibited to be used in mental health

facilities.

Figure 2.21: Example of recommended plumbing installations for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

Air cond diffusers

Avoid patient escape thru duct by providing smaller diffusers. Should be anti-

ligature.


34

Figure 2.22: Example of recommended ceiling mounted diffusers for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

Lighting fixtures

Figure 2.23: Example of recommended lighting fixtures for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)


35

Fire fighting components

Figure 2.24: Example of recommended fire fighting components for inpatient unit(Source: Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

2.3 Analysis and Reviews

Based on analysis on the suicide patterns from both local and abroad, it is observed

that hanging is the common building-related suicide method. Drug overdose in US

and pesticide exposure in Malaysia will not be discussed as they are non-building

related suicide methods.

Jumping from high place is a more common choice in Malaysia compared to the

statistics from the US. But it has to be noted that the difference of subjects between

the two report, Malaysia on general public suicide while US on inpatient suicide

which could mean the option of jumping from high place in healthcare facilities is

less compared to non-healthcare facilities with assumption of lack of access to

jumping places in an institutionalised facility.


36

Hanging on the other hand, could happen in any unsupervised places with anchor

points compared to jumping where it can happen only at high places accessible by

inpatients. This explains the emphasis of design guides abroad to focus on ligature

point reduction as the major suicide prevention strategy in mental health facilities.

However, the proposals of using anti-ligature hardware and fixtures are deemed to be

expensive as more materials are used to conceal the ligature points and increase the

robustness. Some of the solutions are inevitable such as the anti-ligature shower head

design while some could be replaced by innovation in architecture and redesigning

of the fixtures such as windows (to be further discussed in Chapter 4). It has to be

revaluated whether 100mm opening for windows could be extended to 150mm or

more in order to harness adequate natural ventilation especially in the local context

of tropical climate where relative humidity is higher.

Construction costs can be reduced by cutting down building services that can be

nullified such as sprinkler system is not needed if building height is less than 18m

(not exceeding 250sqm per floor) and 5 storeys (exceeding 250sqm) according to

10th schedule in UBBL.

In cases where fire staircase access has to be equipped with locks limited to staff

digital access only, the number of fire staircase can be reduced by providing lopped

corridor layout instead of straight corridor which means dead end limit would be

inapplicable and subsequently requires fewer staircases as long as running distance

radius is covered. Fewer fire staircases would mean fewer digital locks and reduced

construction cost.


37

CHAPTER 3

CASE STUDY

3.0 Introduction

The case study will analyse recently completed mental health facilities and other

projects related to suicide prevention design. Due to privacy, security and sensitivity

nature of mental health facilities, the author decided it would be appropriate to study

projects from available secondary data.

3.1 Zucker Hillside Behavioural Health Facility, Glen Oaks, New York

3.1.1 Project Introduction

Year of completion : January 2013

Total area : 140,000 sq ft

Architecture firm : Array Architects, Ennead Architects

The project consists of 115 beds divided into five-19 bed units (2 adult, 2 geriatric, 1

women and 1 twenty-bed adolescent unit). Patients unit are located on the ground

and first floor of the building. The rooms are designed to be able to flex from private

to semi-private. The typical 19-bed unit comprises of eight semi-private and three

private rooms. The public access to the building is located at rotunda main entrance

into a double volume lobby. The lobby serves as gathering space, reception and

security with glass stair case providing access to the second floor. Seating is

provided outside patients room as area of respite as they travel along the corridor.


38

Figure 3.1: Photos of the behavioural health facility(Source: array- architects.com)

The innovation of this project lies in its three corridor system dividing patient, visitor

and staff into three separate circulation system. Visitors and family circulation

surrounds the central courtyard with occasional seating areas provided for visitors

waiting. Patient circulation within the ward allows freedom of movement within the

ward around the activities and dining areas. Staff circulation is located at the central

core where consultation rooms, charting, medication room, soiled and clean utility

are connected by a corridor linking the nurse station with clinical and support areas.

Figure 3.2: Floor plan showing threecorridor circulation system(Source: Youtube.com)


39

Figure 3.3: Floor plan showing relationship between public, patient and staff circulation (Source: Youtube.com)

3.1.2 Suicide Prevention Features

Photo shown below is the geriatric unit of the facility are provided with anti-ligature

handrail to assist patients to go into the bath room and cubicle curtain to allow exams

be performed within the room. Recessed shelves and artwork shown in the photo are

one of the suicide prevention features of the room. The door knob is ligature proof

and can be overrided and opened outwards by staffs when needed as anti-barricade

measures. Recessed circular light seen next to the window in this photo. Lock cover

with tamper resistant screw is used to conceal door locks to prevent them to be used

as anchor points for hanging.

However, the bathroom door top does not have any suicide prevention strategy

aapplied as suggested in the VA mental health facility guide where door top pressure

sensor is used to detect potential hanging activity using door top as anchor point.

CCTV which is installed next to circular recessed light is used to monitor patients


40

activity on next to the bathroom door to compensate for the absence of door top

pressure sensor.

The application of CCTV to momitor patients acticity on bathroom door is a

compromise of patients privacy where their partial room acticity is being monitored.

Psychiatric security window used in the room is fixed window with integrated

controllable blind for sunshading purposes. Though safe and comply with standards,

fixed window would mean no user controlled natural ventilation is allowed.

Summary of suicide prevention features in rooms:

recessed ceiling light, anti ligature handrail, anti-ligature door knob, recessed shelves

and artwork.

Figure 3.4: Photo showing geriatric unit design (Source: Youtube.com)


41

Figure 3.5: Photo showing anti-barricade door that have two opening direction (Source: Youtube.com)

Figure 3.6: Photo showing anti-ligature hardware used to conceal door lock (Source: Youtube.com)

The toilet design of the units complies with universal design with anti ligature grab

bars provided that have extra plate behind to prevent looping around the bar which

which could be a ligature hazard. Recessed toilet paper holder and built-in wall shelf

are provided to store toiletries. Floor mounted WC is used rather than wall mounted

toilet as wall mounted toilets can be stepped on which will disengage and break the

WC. Anti ligature shower head is used for the shower cubicle.


42

Figure 3.7: Photo showing unit toilet design (Source: Youtube.com)

Push button nurse call system is provided with no cords to comply with maximum 6

cord length for behavioural health facilities requirement. Coat hooks have pressure

sensitive bar which the mechanism will turn down if patients try to loop on it. Every

fixtures in the toilet are fixed with tamper-resistant fasteners.

Basins are built into a niche to prevent it being used as anchor point. Shatter proof

mirror is used to prevent shards being used as weapon or tool of self harm. Sanitary

piping for basin is concealed by lockable apron panel underneath which can be

accessed for maintenance. Anti ligature soap dispenser is used to comply with

suicide prevention standards.

Summary of suicide prevention features in toilets:

Anti ligature grab bar, recessed toilet paper holde, opressure sensitive coat hook,

built in wall shelf, anti ligature shower head and soap dispenser, basin apron panel,

shatter proof mirror


43

Figure 3.8: Photo showing unit toilet design (Source: Array Architects Youtube video)

Common areas such as dining area and day room emphasises on the use of robust

and heavy furniture to prevent abuse and used as weapon or tools of self-harm. As

such common area is under supervision most of the time; the choice of ceiling type

die dining area is not the anti-ligature while the lighting fixtures at day area are not

recessed into ceiling but protected by cover. This approach of selective application

of suicide prevention measures helps in creating domestic and therapeutic

environment to facilitate patients healing. The open nurse station is design in such a

way that prevents patients from taking things from the workstation while not

obstructing line of sight of staffs supervising the surrounding space.

Figure 3.9: Photo showing dining room and day area (Source: array- architects.com)


44

As the public corridor surrounding the central courtyard is used by visitors and

family member to access the patients unit and not intended to be accessed by

patients unless escorted by staff, therefore the area is not required to be tamper proof

and anti-ligature.

Figure 3.10: Photo showing central public courtyard corridor (Source: array- architects.com)

3.1.3 Appraisals

The application of public, patient and staff zoning system allows for flexible

application of full (patients unit and bathroom), partial (patients communal area)

and zero (area accessible to public only) suicide prevention design within the facility

in a more defined approach. This allows for effective control on project cost without

having to apply suicide prevention design in most of the area within the facility.

However, the use of CCTV inside patients room to prevent suicide attempts on

bathroom door or to monitor patients bath duration is deemed to be excessive and a

violation of patients dignity. Available alternatives such as door top pressure sensor

or chamfered bathroom door should be used instead though each of the proposed

alternatives has its own setbacks.


45

3.2 Avera Behavioural Health Center, Sioux Falls, South Dakota

3.2.1 Project Introduction

Year of completion : 2006

Total area : 130,000 sq ft

Architecture firm : BWBR Architects

The project consists of 110 beds (74 private rooms, 18 semi-private rooms) for

paediatric, adolescent, adult and geriatric patients with attached outpatient

psychiatric clinics. The building design features a central two-storey light court

complimented with water feature to welcome visitors, patients and staffs. Thresholds

with integrated seating are provided at each patient room entries serving as front

doors to provide buffer space for patients to leave their rooms on their own pace.

The project is one of the pioneers in having open nursing station to enhance staff-

patient interaction, something which is not the norm in 2006. Day areas on second

floor are illuminated by natural daylight through skylight to provide therapeutic

environment.

Figure 3.11: Photo showing central light court corridor (Source: BWBR.com)


46

Figure 3.12: Photo showing threshold and skylight at patient room entries (Source: BWBR.com)

Double corridor system is used to replace traditional locked door entrance to

inpatient spaces where patient support spaces (family visitation and physician

consultation room) are located in between the corridors. This established a new type

of protocol which promotes dignity and confidentiality of patients while removing

the negative experience of passing through locked doors.

Figure 3.13: Photo showing 2-corridor system flanking patient support areas (Source: BWBR.com)

3.2.2 Suicide Prevention Features

Photo shown below is the adult unit bedroom with en suite toilet. To minimize

ligature point, chamfered wardrobe and psychiatric window with integrated blind is

used. However, not much suicide prevention strategy is applied on bathroom door

which is neither chamfered nor equipped with door top pressure sensor besides the


47

use of anti-ligature door hardware. The underside of outboard sink is covered with

apron to conceal the piping with mirror securely fixed to the wall. However, the

water tap seems to be loop able and can be used as anchor point. Radiused stainless

steel framed security mirror is used

Figure 3.14: Photo showing adult patient room interior (Source: BWBR.com)

Recessed lighting fixture with tamper resistant cover and air diffuser with small

holes are used for anti-ligature purposes. Prebuilt shower cubicle, concealed push

button toilet flush, anti-ligature grab bar and floor mounted toilet are used for

patients bathroom.

Figure 3.15 Photo showing details inside the adult patient room (Source: Avera.org)


48

Figure 3.16: Photo showing patient bathroom interior (Source: Aver.org)

Conventional type of air diffuser is used on patient common area where suicide risk

is lower. Furniture is mostly heavy and robust to prevent abuse. Curved Plexiglas

which is tamper resistant is used as partition to enclose the TV area. Recessed

lighting fixture with tamper resistant cover is used in the area which is assumed for

vandal proof purposes rather than anti ligature purposes as the area is under clear

supervision from nursing station.

Figure 3.17: Photo showing patient common area (Source: BWBR.com)

Similar approach applies to outpatient clinic and admission entrance where

conventional sprinkler head and uncovered recessed circular light is used at

admission entrance


49

Figure 3.18: Photo showing outpatient clinic interior (Source: Avera.org)

Figure 3.19: Photo showing admission entrance interior (Source: Avera.org)

The outdoor courtyard uses garden furniture which is hard to move and used as

weapon. Fencing height is less than 14 feet (4.27m) as recommended by Mental

Health Facilities Design Guide by VA office (Chapter 2.2.4.2: outdoor spaces). The

use of rocks as landscape decoration poses a risk of abuse where it can be used as

weapon or tools of self-harm.

Figure 3.20: Photo showing admission outdoor area (Source: Avera.org)


50

3.2.3 Appraisals

The application of suicide prevention measure is much loose than Zucker Hillside

Behavioural Health Facilities where anti ligature strategy is not applied to bathroom

door. A 5-year post occupancy evaluation study on the facility by the architect firm

found out that geriatric patients take advantage of the open nursing station to take

things, tip over computers and cross barrier. This is a potential hazard if sharp office

stationaries are left on the workstation.

Figure 3.21 Photo showing open nursing station design (Source: BWBR.com)

However, the evaluation does not have any reviews about patients room and

bathroom in terms of suicide prevention design deficiencies other than spatial

discomfort of having room door facing the room desk which creates insecurity to the

patients. It is safe to assumed that the patient room design has been able to prevent

suicide attempts so far.

There were several drawbacks due to the need to create anti-ligature environment in

patient rooms such as the lack of place to hang clothes while showering in bathroom

and inadequate shelving or storage for books or glasses when reading in bed.


51

3.3 Overall Review

Both of the projects have applied selective suicide prevention measures spaces based

on levels of risk and supervision which in compliance of the design guides discussed

in Chapter Two. However, having CCTV inside patient room is inappropriate for

Zucker Hillside Behavioural Health Facilities and out board basin in patient room at

Avera Behavioural Health Center is an inconvenience for patients in the local

context.

From authors observation, the application of suicide prevention measures in various

areas has various concerns other than just suicide prevention.

Full suicide prevention

measures

Partial suicide prevention

measures

Minimal suicide

prevention measures

Patient room and

bathroom

Patient common area Public area

Suicide prevention

(mostly hanging)

Prevention of violence

resulting in vandalism and

turning anything available

within the space into

weapon or tools of self-

harm.

To create welcoming

environment for both

visitors and incoming

patients

.


52

Though this report focus mainly on tangible aspects of unobtrusive suicide

prevention design within mental health facility, it has to be noted that the will for

suicide attempts among inpatients has direct relationship with the environment where

they are recovering. A therapeutic environment and caring staffs are the intangible

aspects of suicide prevention design besides active suicide prevention measures

applied within the facility.

Provision of therapeutic environment should be listed as pre requisite of any mental

health facilities design in design guides without making defined requirements on

elements that create therapeutic environment as it depends on the creativity and

common sense of architects.

Hence, it is suggested a separate research has to be done on the effects of therapeutic

environment towards the will of suicide among patients in mental health facility

which will not be discussed in this study.


53

CHAPTER 4

PROPOSAL: UNOBTRUSIVE SUICIDE PREVENTION

DESIGN GUIDE FOR MALAYSIA

MENTAL HEALTH FACILITIES

4.0 Introduction

As therapeutic environment is one of the intangible aspects in suicide prevention as

discussed in previous chapter, the proposed design guide will focus on the tangible

aspects of suicide prevention within mental health facilities. The outcome of the

proposal will be similar to the US and UK version, but appropriate to the local

context in compliance of Mental Health Regulation, UBBL and BOMBA

requirements.

4.1 Proposal

The unobtrusive suicide prevention design guide is divided into 3 categories of

suicide prevention measures application: maximum, intermediate based on the

inherited risk and level of supervision.

4.1.1 Maximum Application

Applied Spaces: Patient bedroom and bathroom, admission interview and waiting

room


54

Description Illustration examples

Patient rooms

Walls: Brick wall/concrete wall/ impact and abrasion

resistant gypsum board on metal studs in paint finishes/

impact and abrasion resistant IBS composite wall.

Painted finish is preferred.

Ceiling: No grid type suspended ceilings with

removable ceiling panels should be used. Minimum

ceiling height is 2700mm to ensure ceiling mounted

fixtures are out of reach. Provide key-lockable access

panels at location which requires services access.

Solid ceiling preferred for admission interview, waiting

room

Doors: Anti-barricade double swing door system with

staff override facility. If space is available, a separate

narrow 500mm wide door that swings to the corridor

can be used for emergency access.

Clear width of corridor leading to exit must not be

reduced to less than 1000mm by door in out swing

mode. Continuous/ concealed hinges should be used for

anti-ligature purposes.

Optional: sliding door/ pocket door/ chamfered door/

conventional door with door top pressure sensors to


55

prevent doors used as anchor points

Anti-ligature door lockset should be used for all patient

room doors. Types of recommended door locksets:

a. Lever handle

b. Crescent handle

c. Push/pull handle

*Note: for fire doors which requires wired glass to

comply with BOMBA standard, request permission

from BOMBA to install a layer of polycarbonate on

both sides of wired glass (broken wired glass yields

shards that can be used as weapons)

Windows: Limited opening of 100mm, glazing should

be made of shatter proof material (impact resistant

glass/ polycarbonate/ film)

Use of curtain track is not advisable inside patient

room. If used, it must be of anti-ligature type and

special care must be taken in installation according to

manufacturers specification to prevent creating anchor

points.

Optional: psychiatric security window with integrated

blinds


56

*Note: clerestory window should be provided to

compensate for reduced air flow in room by limited

100mm window opening in order to fulfil UBBLs

Section 39(2) requirement. Louvers should not be used

as it poses ligature risk.

Lighting fixtures: Recessed and tamper resistant, with

polycarbonate cover securely fixed in the frame with

tamper resistant screws.

No glass components should be used. Use of table

lamps is not advisable. But if used, must be firmly

anchored in place and shatter proof bulb must be used.

Fire sprinkler: Anti-ligature sprinkler

*Note: Refer to Tenth Schedule UBBL for necessity of

sprinkler system for the facility

Air cond grille: Fully recessed vandal resistant diffuser

with S-shaped air passageways recommended for wall

and ceiling mounted grilles.

Locate AC equipment outside patient room to allow for

servicing without entering patient room.


57

Furniture: Robust wood/ thermoplastic/ composite

furniture should be bolted to floor or walls whenever

possible.

Desk chair are preferred to be light weight and tamper

proof which resists breaking into sharp pieces or

heavier chair that is difficult to throw and used as

weapon.

Storage option: 1: Open shelves are recommended to

eliminate the need of wardrobe door which is a hazard.

Drawers and doors should not be provided as they can

be removed and broken to use as weapons.

Storage option 2: if drawers and wardrobe with doors

are provided, they should be lockable with keys

controlled by staff. Anti-ligature considerations must be

taken such as the pulls and wardrobe top (can be sloped

top or built into ceiling)

Wardrobe with cloth poles for hanging is discouraged

as hangers present suicide hazards.

Beds: Non-adjustable platform beds without spring or

storage drawers. It is recommended to be anchored in

place to prevent patients from barricading the door.

Openings below bed are allowed to accommodate

portable bed lifts.


58

*Note: If medical beds are necessary, special care must

be taken on anti-ligature and barricade concerns.

Others: Pull cords for nurse call button (if applicable)

should be less than 30cm and as lightweight as possible

All electrical switches and outlets should be made of

robust material such as polycarbonate and secured by

tamper resistant fasteners to avoid being broken to

access wiring or broken sharp pieces.

Cloth hooks and curtain cubicle tracks are not

recommended

TV sets should not be provided in patient rooms

Plastic trash can liners should not be used due to

suffocation risk, breathable paper liner is allowed.

Patient toilets

Floors: Ceramic tiles are acceptable as long as it is well

maintained

seamless epoxy flooring with integral cove base

sheet vinyl flooring with integral cove base (without

metal/plastic trim piece on top)

one piece floor units, Pre-built bathroom (anti-ligature)


59

Walls: Ceramic tile (small tiles are not advisable as

they can be dismantled and misused)

Gypsum board/IBS composite wall with impact

resistant with moisture and mould resistant facing

finished with epoxy paint or ceramic tile

Ceiling: Plaster ceiling with moisture resistant finishes

Mirrors: Shatter proof mirror/ radiused stainless steel

framed security mirrors

Doors: must be double swing with staff override

facility for anti-barricade purposes.

Door top should be anti-ligature and can be done in

various options: chamfered door top (only on private

bedroom)/ sliding door with tracks on top and bottom/

conventional design with door top pressure sensor (not

recommended)

Locksets should be anti-ligature (refer bedroom section

for example)

Lighting fixtures: Refer to bedroom section except for

water resistant requirement

Fire sprinklers & air cond grilles: refer to bedroom

section


60

Sanitary fixtures: Anti-ligature basin. Recommended

to be built into a niche with concealed piping below for

anti-ligature purposes. Anti-ligature water tap must be

used.

Toilet should be floor mounted with push flush button

Soap dishes should be recessed

Anti-ligature shower head and handle

Anti-ligature paper towel and liquid soap dispensers

Built-in/ recessed open shelf for item storage

Anti-ligature grab bar

Recessed/ anti-ligature toilet paper holder

Table 4.1: Maximum suicide prevention application in mental health faciliry (Source: Author)

4.1.2 Intermediate Application

Applied Spaces: Patient common area, corridors, counselling, interview and activity

rooms

Description Illustration examples

Wall: Refer to 4.1.1

Ceiling: Preferably plasterboard ceiling.

Suspended ceiling with removable acoustic tile is

allowed, if clipped-in-place ceiling tiles are used,


61

regular safety rounds should check to see that the clips

are in place.

Doors: Subject to heavy use and possibly extensive

abuse. Durable door with wood grain pattern synthetic

faces with removable end caps which can be replaced

when damaged are preferable

Painted steel door are durable and easy to maintain but

institutional looking.

Lockset recommendation refer to 4.1.1

*Note: All exit doors (including fire staircase) to be

able to lock at all times with fail safe or fail secure

configuration (only applicable when approval is given

by BOMBA on exemption of UBBL requirement

Section 166(2)

Lighting fixtures: Normal fixtures can be used as long

as it is located at height inaccessible by patients and

staff observation from nursing station is present.

For areas where fixtures are within patients reach and

staff observation is not available, refer to 4.1.1

Fire sprinklers: Refer to 4.1.1


62

Air cond grille: Standard grilles/ grilles with small

perforations secured with tamper resistant fasteners are

acceptable in these zones as long as ceiling height is

enough to be inaccessible by patients.

Windows: All operable windows should have limited

opening of 100mm

Exception: Full swing revolving windows with 100mm

opening when opened.

Others: Lockable cabinets must be provided to store

items that can be used by patients to harm themselves.

Cabinet pulls should be recessed or closed with no

protruding openings that can be used as anchor points.

Digital locks with card access can be used.

Telephones located in this zone must be securely wall

mounted with stainless steel case with and non-

removable shielded cord of 35cm maximum.

Room signs should be of material that cannot be used as

weapon if removed.

- All electrical switches refer to 4.1.1 : Others.

TV should be installed in built-in furniture and should

not be mounted on walls using brackets as it creates

ligature risks. All cords and cables length should be as


63

minimal as possible.

All fire alarm button and fire extinguisher cabinets

should be locked. All staff on duty must carry these

keys at all times

Emergency exit lights should be vandal proof and

installed tight to the ceiling with full length mounting

bracket to avoid use as anchor point. Wall mounted

installation perpendicular to wall is not recommended.

Furniture: Heavy and robust, furniture are

recommended to be anchored in place to prevent

throwing, stacking or barricading of doors

If movable seating is required for spaces like dining and

activity rooms, light weight or heavier chairs as

discussed in 4.1.1 is recommended.

Pictures and artwork: Should be protected with

polycarbonate and heavy frames screwed to walls with

minimum one tamper resistant screw per side, or fixed

recessed into wall.

Table 4.2: Intermediate suicide prevention application in mental health faciliry (Source: Author)


64

4.1.3 Minimal Application

Applied Spaces: staff working spaces, services areas and public accessible areas

(lobby, cafe)

Staff working spaces, services areas

Comply with UBBL and BOMBA requirements Unattended services areas should be

locked at all times to prevent patient entering those areas.

Anti-ligature and tamper proof consideration in these areas are optional or not

applicable depending on managements choice.

Lobby, Cafe

Furniture is recommended to be robust and heavy (optional) in lobby area in cases

when it is accessed by both patients and public upon arrival before patients are

diverted to more patient-specific areas.

Ceiling height should be high enough for ceiling mounted fixtures to be inaccessible

by visiting patients.

Special consideration should be taken on caf if it is run by patients or serving mix

of visitors and patients. A lockable cabinet/ larder must be provided to store potential

hazardous equipment (knife, boiler and etc)

Comply with UBBL and BOMBA requirements.


65

4.2 Complimentary Requirements

The requirements stated below (adopted from Design Guide for the Built

Environment of Behavioural Health Facilities by National Association of Psychiatric

Health System) is not directly related to suicide prevention design but recommended

to be applied in complimentary to enhance its efficiency.

1. The design of mental health facilities should avoid the institutional outlook

and should be designed to appear domestic, comfortable and attractive in

character as possible. This helps in creating a more healing environment to

facilitate patients recover

Unobtrusive Suicide Prevention Design in Mental Health Facilities

Documents

Transcript of Unobtrusive Suicide Prevention Design in Mental Health Facilities