Behavioral Health Patient Boarding in the ED

Design Guidelines40

International Association of Healthcare Security and Safety recommends design guidelines for health care facilities to address the need of safe treatment environment for psychiatric patients. These patients’ presents unique challenges and risk because of their medical conditions. Design guidelines takes into account variety of health care settings which provides care to psychiatric patients. Factors impacting patient’s characteristics like diagnosis, age, gender, patient acuity and risk for themselves and others are included to develop design guideline.

Emergency Department specific security design should address the following

  1. External entrances should be equipped to restrict access to facility.
  1. Video monitoring camera at the ED walk in entrance for public viewing and awareness
  1. Queuing and screening of visitors and patients prior entering waiting areas and treatment space. Depending upon the vulnerability of the population served metal screening an also be utilized.
  1. Signage providing clear messaging for passage points for patients, visitors and staff. Clear distinction to be provided between registration/admitting desk and waiting areas. Access to the health care facility from the ED should be tightly secured.
  1. Security/police officer workstation should be visible from ED waiting area, triage area and registration.
  1. Furniture pieces should be affixed to each other, floor or the wall with no small or singular pieces.
  1. Windows in the Emergency Department should be covered to prevent internal viewing.
  1. Workstations should be strategically positioned to provide direct access to exit portals and equipped with duress alarm.
  1. Work areas and nursing stations should be protected by building high and strong compartments to prevent patients or family members from jumping over the barriers and assaulting employees.
  1. Triage and ED waiting areas should be distinct. A clear line of sight to be there between triage workstation and ED walk-in entries. Triage access should have two points of entry/exit for the staff.
  1. Authorized health care facility personnel should control access to medical treatment areas, including doors, elevators and stairwell. Doors should have communication device on the external side of the entrance with direct visual observations or video surveillance.
  1. Access to staff lockers and lounges should also be controlled by authorized healthcare facility staff.
  1. A safe room should be established within the ED that can be locked from inside to retreat in the event of an act of violence or danger. Safe room should be equipped with duress button, reinforced door with a peep hole and an external lock and key access.
  1. Patient and visitors waiting areas must be equipped with –
    • One primary access control point
    • Washrooms, vending machines, and telephones
    • Fire extinguishers
    • Security fastened wall hangings
    • Video Surveillance

If the health care facility is serving high risk patient (disruptive or aggressive patients, risk of elopement) following additional features can be implemented in the ED design –

  1. Isolating and distancing the patient from departmental exits with direct observation by room clinical staff.
  1. Locating patient in close proximity to dedicated restrooms.
  1. Patient should be remotely monitored using video surveillance with audio capacity. Monitoring location should meet patient privacy and clinical requirements.
  1. Control access in and out of the patient room.
  1. Incorporating safety measures to mitigate the potential of patient to cause harm to others and themselves.
  1. Protecting medical equipment to be placed in the room in locked cabinetry or impact resistant laminate, or hardened material.
  1. Installation of television for patients held over for extended periods of time. Television to be mounted behind protective glazing.

Emergency Departments are More Prone to Security Related Issues

Numerous factors enhance the risk of violence in Emergency Departments as compared to other hospital settings. The types of services provided coupled with the overall stressful environment increases the vulnerability15. Contributing factors include:

  1. Availability of 24-hour services at the Emergency Department
  1. Lack of adequately trained, armed, or visible security personnel
  1. Patients often arrive in pain and discomfort,
  1. High risk patients includes those with psychiatric conditions or/and under the influence of alcohol and drugs
  1. Family member are stressed due to patient’s condition and complexities related to navigating the health care system
  1. Physical hospitals factors like improper lightning conditions, building design consisting of cramped space and access to unsecured areas.
  1. Overcrowding and long wait times in ED act as a stimulant to already stressed family members of the patient
  1. Arrested individuals seeking medical clearance for alcohol and drug related problems are brought to ED before going to jail, constituting a high risk group

The hospital administrator or ED coordinator should periodically inspect the workplace and evaluate employee tasks to identify conditions and situations which might instigate an incidence of violence, and should consider a multidisciplinary group to assist them including security.15