The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Reimaging Acute Behavioral Health Using Operational Studies to Improve Healthcare Facility Planning and Design for Behavioral Health in the Emergency Department Sabah Mohammed & Marvina Williams
University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Contents Introduction Methodology LEAN Planning Case Studies Recommendations Best Practices
University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Learner Objectives • Identify the challenges in delivering care for patients with behavioral health needs • Understand the financial impact of implementing behavioral health rooms in the ED, crisis units and EmPATH units • Describe innovative approaches in facility design and operational planning to improve the quality of care in the ED
University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Introduction Adults in the U.S. who live with a behavioral health (BH) disorder [1]
57%
70
182k Adults who died from alcohol and drug-related deaths in 2018, now termed as “deaths of despair” [3]
64.9
60 52.9 Visit rates per 1,000 people
20%
Emergency Department visit rates for adults with mental health disorders, by age group: U.S. 2017-2019
47.5
50 40
34.9
30 20 10
Adults with a BH condition who did not receive treatment [2]
0
All adults
18-44
45-64
65 and over
Age Groups Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2017–2019
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
But this is not an adult problem alone.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Adolescent BH statistics 13%
60%
Adolescents in the U.S. report having a major depressive episode, a 60% increase from 2007 [4]
Increase in suicide rates in 2018, from a stable rate between 2000-2007 [5]
Emergency department visits for self-harm by children and adolescents rose sharply over the last decade, particularly among young women
Emergency department visits for self-inflicted injuries Ages 10-19
Source: Centers for Disease Control and Prevention
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
This has caught our collective attention.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
988The Crisis Hotline
988
The 988 hotline is the national suicide prevention and mental health crisis hotline that went live on July 16th, 2022. For BH patients, this means lesser interface with law enforcement agents and higher touchpoints with mental health professionals specially trained to respond to a crisis; and mobile crisis units. For healthcare facilities, this means a higher volume of patients with high acuity in the Emergency Department (ED).
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Implications of 988 • 80% of the call volume can be resolved over the phone without dispatching mobile crisis teams, law enforcement, or emergency medical services. • The remaining 20% represents a patient population that requires extremely high acuity care. • This will overwhelm health systems, particularly Emergency Departments. Source: Adapted from Cantor, J. H., Holliday, S. B., McBain, R. K., Matthews, S., Bialas, A., Eberhart, N. K., & Breslau, J. (2022). Preparedness for 988 Throughout the United States.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Comprehensive Continuum of Care
Source: Adapted from Cantor, J. H., Holliday, S. B., McBain, R. K., Matthews, S., Bialas, A., Eberhart, N. K., & Breslau, J. (2022). Preparedness for 988 Throughout the United States.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
The ED 1 in 8
44%
ED visits are BH related issue [6]
Increase in BH related ED visits from 2018-2021 [8]
38%
17%
Increase in length of stay for BH patients [7]
Emergency physicians report a psychiatrist on call to respond to emergencies in the ED [9]
UTHealth Houston John S. Dunn Behavioral Sciences Center, Houston, Texas, Perkins&Will
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Cost
Quality
$2,265
38%
Additional cost per psychiatric ED stay [10]
BH patients in ED wait more than 7 hours to see a dedicated professional [12]
2 out of 5
$280B
65%
Psychiatric emergency patients or families who rated their ED experience as “bad” or “very bad”[14]
Spending on BH services in 2020, 5.5% of total health care spending [11]
BH patients experienced a medication error during ED stay [13]
Satisfaction scores
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
“The emergency department is the last place you want to be when you are having a panic attack. You have nowhere to go and no one to take care of you.” - ED Behavioral Health Patient
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
The role of the built environment Design is a critical leverage point for healthcare systems. Architects and facility planners play a pivotal role in destigmatizing behavioral health. Facility design can considerably impact the quality and effectiveness of BH treatment and plays a key role in recovery for many patients. Providers cannot underestimate the importance of comfortable and secure facilities in achieving population health goals. UTHealth Houston John S. Dunn Behavioral Sciences Center, Houston, Texas, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Research-Informed Design
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Methodology
65+
13
6
Literature reviews Peerreviewed journal articles & industry reports
Interviews with clinicians (6), architects (4), and BH patients (3)
Case studies of projects done by P&W (3), and externally (3)
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Understanding the constructs
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Understanding the outcomes
Impact vs Investment of Interventions Understanding the level of investment required as a function of the associated impact will guide architects and healthcare planners to meaningfully engage in client conversations.
DEGREE OF PSYCHO-SOCIAL SUPPORT Impact
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Equip ED with on-demand BH expertise
Dedicate care environments tailored to BH needs
Establish a Comprehensive Continuum of Care Continuum of care services
ED-based telepsychiatry
Designing for social support
Wrap-around clinics
Triage and stabilization
Harm reduction follow-ups
Investment CARE MANAGEMENT INTENSITY
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Healing design The five core tenets for healing design [15] Space flexibility Access to nature Calming interior design Positive distractions Clear lines of sight University ofUniversity Virginia University Hospital Emergency Source: The of Texas Health Science CenterDepartment at Houston,Expansion, Perkins&Will Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Environmental Safety-Risk Assessment
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Environmental Safety-Risk Assessment Safety
Privacy
Although there is tension between safety and privacy, there does not need to be a tradeoff. Spaces should be designed to be acuity- adaptable and adaptable for different patient populations.
Actively Suicidal Self harm not anticipated
Environmental Safety-Risk Assessment
INTENT FOR SELF -HARM (SAFETY)
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Level 2
Level 4
Level 1
Level 3
1:1 Observation
Periodic Observation
Completely alone
OPPORTUNITY FOR SELF-HARM (PRIVACY) Level 5: Special Considerations Source: Adapted from Hunt, J. M., Sine, D. M., DrBE, C. S. P., & ARM, C. (2018). Behavioral health design guide.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Lean Operational Planning in Design It brings together multidisciplinary teams in the development of processes, designing services and layouts responsive to the needs of the BH patient and staff by improving quality, safety, and delivery Designs are evaluated based on• Patient Experience • Staff Experience • Seven Flows of Healthcare • Operational Efficiencies • Flexibility • Infrastructure
Source: Duke University Medical Center, Perkins&Will
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Lean Operational Planning in Design Lean methodology can involve several steps: • • • • • • • • •
“Going to the Gemba” or place of work Create existing state process maps Evaluate the wastes Create ideal state process maps Create future state process maps focused on improving processes. Gaming Boards (Kit of Parts) Create Design Options Continuously evaluating the 7 Flows of Healthcare VR and Built Mock-ups
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Seven Flows of Healthcare FLOW OF PATIENTS FLOW OF FAMILY FLOW OF STAFF FLOW OF SUPPLIES FLOW OF MEDICATION FLOW OF INFORMATION FLOW OF EQUIPMENT
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Critical Decisions Entrances & Triage areas Central vs. dedicated BH entrance
Location of BH rooms Part of main ED vs. ED module
Privacy Open bays vs. private rooms
Type of rooms Flex vs dedicated BH rooms
Team Station Open vs Closed
Safety Locked units vs. open connectivity
University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Critical Decisions Operationalized
Duke Behavioral Health Center North Durham, Durham, North Carolina, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
De-escalation Room
Tift Regional Medical Center. Tifton, Georgia, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Flex roomGarage door
Cone Health Moses Cone Hospital North Tower, Greensboro, North Carolina, Perkins&Will
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Case Study 1
University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
“As we wrap up the night shift, and the sun begins to come up, it feels like the mood of the entire ED lightens. That window, the daylight, and the views outside bring a sense of newness to the day and everyone’s mood just picks up a little.” Dr. John Riordan, UVA Associate Professor of Emergency Medicine Vice-Chair of Clinical Operations
University of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Wellness rooms adaptable for staff needs; equipped with undercounter refrigerator for nursing mothers
Above; Medical University of South Carolina Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion, Charleston, SC, Perkins&Will
Source: Virginia, Charlottesville, Perkins&Will Far leftUniversity and above:ofUniversity of Virginia University Hospital Emergency Department Expansion, Charlottesville, NC, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Case Study 2
Northside Hospital Gwinnett, Lawrenceville, GA, Perkins&Will
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Case Study 3
Medical University of South Carolina Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion, Charleston, SC, Perkins&Will
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Communicating Planning Concepts
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The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
EmPATH Units • Stands for “Emergency Psychiatric Assessment, Treatment & Healing unit,” modeled on empathetic, rather than coercive, care. • It is a hospital-based outpatient program that accepts all medically-appropriate patients in a psychiatric crisis, including involuntary psychiatric detention. • Disposition decisions are not made until after a thorough psychiatric evaluation, treatment, and an observation period in the unit.
Outcomes 70%
25%
Reduction in LOS from 16.2 hours to 4.9 hours
Reduction in 30-day psych recidivism to ED
60%
$861k
Improved outpatient follow-up of patients from 39.4% t0 63.2%
Added to hospital’s ED bottom-line by moving psych patients that increased beds for non-psych patients.
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Recommendations & Best Practices
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Recommendations Barriers to optimal BH Care • Space constraints limit BH-specific room construction
Design Characteristics • Turn one or more patient pods into swing rooms to flex to current needs
• ED spaces are constricting and chaotic with little to no access to daylight or views
• Incorporate windows, murals, or posters to provide patients access to nature & light
• Non-BH patients feel uncomfortable in BH-outfitted rooms • Traditional ED rooms are safety hazards and make staff supervision difficult • ED spaces exacerbate BH conditions
• Use calming interior design to create BH rooms comfortable for all patients • Establish clear lines of sight with an open nursing station • Design a separate space with positive distractions to promote self de-escalation
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Best Practices • Crisis unit should be readily accessible to the ED • Clinical workflows tailored to needs of BH patients • Open design where patients can have privacy & move freely; while being safe, anti-ligature FFE • Safe, supervised environment with staff presence • Empathetic, whole person care vs. coercive care • Acuity-adaptable spaces • Minimize use of restraints; sedation; medication
Duke Medical Pavilion, Durham, North Carolina, Perkins&Will
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
The Value of Design Environmental Variables
BH Value Stream Type of Practice Payment Matrix SDOH* Clinical Use Case
Clinical Outcomes, Quality and Safety
Access to Care
Patient, Family and Caregiver Experience
Clinician Experience
Financial and Operational Impact
Care Modality Health Equity *SDOH- Social Determinants of Health Source: Adapted from Care, T. D. E. (2022). Opportunities and Challenges.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
As we move the needle on the mental health crisis, designers play a critical role in shaping the built environment and ultimately, the human experience.
The Clemson University International Nursing Conference for Excellence in Healthcare | July 2022
Thank you! Questions?
Memorial Sloan Kettering Monmouth Ambulatory Care Center, Middletown, New Jersey, Perkins&Will
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