In behavioral health facilities, healthcare providers care for patients who may be at risk for self-harm — up to and including suicide. That reality is a driving factor in the design of behavioral health facilities. Our goal is to reduce opportunities for patients to harm themselves. 

Plumbing engineers are responsible for some of the most crucial elements that a patient interacts with during their stay. In this particular instance, our job as plumbing engineers transcends "just designing pipes and specifying fixtures;" a well-designed behavioral health space within a hospital or clinic can prevent tragic incidents from occurring. Self-harm and suicide prevention are extremely heavy subject matters to keep in mind while designing, but the correct applications can save lives. 

Who are the key players in design?

The Facility Guidelines Institute (FGI) standards contain baseline requirements for each type of behavioral health institution (standard, pediatric, Alzheimer's/Dementia, etc.). The FGI provides additional clarity and guidelines in another document, the Behavioral Health Design Guide (BHDG).

As we design each space, an important consideration is the level of risk for self-harm in each space. Not every space presents the same level of risk for patients.

Early in design, the FGI requires the completion of a Safety Risk Assessment (SRA) for the unit, usually compiled by a team chosen by the governing body of the health care organization. The team evaluates the level of risk based on two axes: intent for self-harm and opportunity for self-harm. The higher the risk, the more stringent the design requirements.

Patient bathrooms are typically a high-risk area. The restroom offers privacy, which can create opportunities for patients contemplating self-harm and delay the staff’s ability to respond. One particular concern, which factors strongly into plumbing design, is ligatures. In a 2018 study, the Joint Commission reported that ligature-related hangings were the most common method of inpatient suicide, estimated at around 70 percent of known cases (Incidence and Method of Suicide in Hospitals in the United States, Williams). 

As plumbing engineers, a significant way that we help prevent the opportunity for harm is through “ligature-resistant” plumbing fixtures. A plumbing fixture that is ligature resistant is one that has as few points as possible where a rope or similar object can be tied and remain attached to with any sort of weight.  Of course, no object can be truly deemed "ligature free," as it is not possible to remove all such risk areas. But we can do our best to identify the hazards that might go along with fixtures and use the latest plumbing technology available to mitigate the risks.

While some manufacturers mark certain fixtures as “ligature-resistant,” no official national standards (e.g. ASME) exist for these fixtures. New York State’s Office of Mental Health frequently updates a document available online (Patient Safety Standards, Materials and Systems Guidelines) that lists approved fixtures and equipment for their state, and some owners outside of New York refer to the document for their facilities. It lists each type of room component, from door handles to coat hooks, the corresponding risks with each piece of equipment, and recommendations for each application. It even lists products that are not accepted by the state. Even if you’re not in New York, this document can be a helpful reference for selecting the appropriate fixtures for your design.

Major componentry in designing a ligature-resistant patient restroom

Psychiatric units and behavioral health spaces obviously contain many plumbing related components. Here, we will delve into the three main components of any patient restroom within these spaces: the water closet, the lavatory, and the shower. 

The Ligature-Resistant Water Closet: Wall-hung water closets are unfriendly for behavioral health spaces as they present a large ligature risk, as well as the potential for being broken off the carrier. Because of this, the BHDG recommends only floor-mounted closets with either floor or back outlets with in-wall supply designs. Do keep in mind that a ligature-resistant floor mounted water closet should not have any gaps between the toilet and the wall.  If a movable seat is too much of a risk, integral seat options are available. 

In terms of fixture materials, the BHDG notes that a downfall to utilizing a standard china toilet is that they can be broken into pieces that can be used as weapons by a patient. To bypass this risk, they suggest that facilities consider the use of a white powder-coated stainless-steel toilet. A drawback of the stainless steel option is that the owner might find it too "institutional" or prison-like in its design. I have found this to be an important issue for owners as they work through the design process. 

In cases of renovations, a hospital may already have a floor-mounted toilet, but not have an in-wall supply. In this case, it might be possible to specify a shroud that conceals the supply piping. This is an easy solution that allows the hospital to keep the existing toilet.  Most of the time, if the healthcare institution is replacing a wall-hung toilet, it is easiest to replace the flush valve as well with a push button-operated flush valve that is concealed in the wall. 

The design guides recommend foregoing sensor operated flush valves, as an unexpected flush from walking by might unsettle the patient.

The Ligature-Resistant Lavatory: As with water closets, standard lavatories present ligature risks. The BHDG recommends a solid-surface countertop with an integral sink. This style of lavatory has a much cleaner look, gives the patient more countertop space, and ultimately gives the feeling of being at home and not in a clinic. 

Much like the water closet, a sensor-operated faucet may frighten a patient if it is accidentally activated. I think one of the best options for the application is a faucet with push-button operation; some models have two buttons to allow the user to have some control in temperature. The design guide also points out that an acceptable shower valve (more later) can be used to control the temperature of the faucet, rather than having two independent buttons.

On behavioral health improvement projects, the owner or architect may request that an existing lavatory be used. On one renovation, I kept the basin but replaced the faucet to be ligature resistant. The only modification to the basin needed was the addition of an under-lavatory shroud to restrict access to the supply and waste piping and prevent contraband from being stored within. 

The Ligature-Resistant Shower: The concept of a ligature-resistant showerhead has not changed much over the past decade. The question then becomes how to create a ligature-resistant shower that also meets ADA requirements. One option from the BHDG is to provide a second showerhead beneath the primary showerhead (at about 48 inches above the basin). The other option they present, which I much prefer, is the quick-disconnect handheld shower. It allows the user to have a little bit more freedom in the shower while also allowing the provider the option of locking it away when not in use. It also gives a homier, less institutional feel to the shower. Regardless, both options must be closely coordinated with the team to determine the risk associated with the patients using the shower and so that the owner can monitor where handheld showers are located to remove when necessary. 

One of the major improvements in the ligature-resistant shower is the updates to the thermostatic mixing valve and diverter valve. The standard diverter valve is an extreme ligature risk, so designers would place it outside of the shower to be controlled by the caregiver. Today, behavioral health fixture designers have created not only ligature-resistant options, but also ADA accessible fixtures that can be located within the shower and controlled by the user. 

Be sure to specify a ligature-resistant shower drain, as there are many risks when not designed appropriately. First, similar to the lavatory shroud, the shower drain has become a place for a patient to store contraband; a specially designed shower drain will prevent this. Second, if a standard shower drain can be easily separated from the basin, it can become a tool for self-harm. Third, showers are a prime location for flooding; in some cases, owners may desire push-button activation or low flow shower heads to limit the potential flow to the drain. A trench drain might be a good option for certain applications as they are harder to clog and can prevent flooding. It is an extremely institutional measure, but some owners and stakeholders may require it.

Leveraging evolving technologies

The ultimate goal as a team of designers, manufacturers, and owners is to reduce the statistic to zero inpatient suicides. And as mental health continues to become an increasingly prominent issue in healthcare, designing these spaces with the most recent developments in behavioral health technology is vital to the safety and wellbeing of the patient. The suggestions and recommendations in the design guides and corresponding guidelines are created from experience and time; we as a plumbing community will only get better as the technology advances the environments we design.