Over the past three decades, there has been a steady rise in the role that behavioral health takes in American health-care systems. Behavioral health has evoked many negative connotations and images in the past, but perceptions are changing with increased awareness of mental illnesses and those they affect.

Health systems have responded with better care and wider service networks for patients with these conditions. We can expect this to continue as sensitivities around mental health evolve and legislative efforts to combat poverty and homelessness, which are often rooted in untreated mental illnesses, gain ground.

While U.S. health-care systems have a renewed focus on behavioral health, there has been a much more rapid evolution of the design of facilities specializing in this area of patient care. Behavioral health is now seen by many as an equal counterpart of care for more physical conditions, and the patient environments in these facilities have evolved accordingly. 

Health-care systems now focus on senses of invitation, warmth, rehabilitation and respite in facilities that treat behavioral conditions while integrating patient safety and security into the built environment. Many plumbing elements of these facilities remain unseen, but those that are visible need to be designed with this in mind.

Designing for Patient Safety

In behavioral health facilities, many elements of the built environment become extensions of life safety systems, as many patients being treated have tendencies toward agitation, violence and suicide. However, while typical life safety systems such as fire sprinklers and medical gas systems protect patients (and staff) from outside events, behavioral health environment elements protect patients from themselves. 

It falls on the professionals designing these facilities to choose environmental designs and products that minimize the risk of patients harming themselves and their caregivers.

Making the correct choices requires knowing what this risk is in each area of the facility. Design professionals can use various resources and guidelines to establish risk levels in different areas of the facility, such as the “Facility Guidelines Institute’s (FGI) Behavioral Health Guideline” and the security zones established by the Department of Veterans Affairs. 

The former is a common guideline used by many state health departments and applied to many facilities being built today. It uses a series of increasing self-harm risk levels that design professionals assign to each space in the facility, shown in Figure 1.

• Level I: Areas where patients are not allowed and, thus, are not at risk for self-harm. These tend to be restricted, staff-only areas behind self-locking doors. These spaces are generally equipped with typical building finishes, plumbing fixtures and equipment.

• Level II: Areas behind self-closing and self-locking doors where patients are highly supervised and never left alone. Some examples include exam and counseling rooms and activity areas. There are usually no plumbing fixtures in these areas beyond occasional handwashing sinks. These sinks and their faucets usually do not need to be designed to prevent patient self-harm. 

• Level III: Areas not behind self-closing and self-locking doors where patients may spend time with minimal supervision. Lounges and day rooms where staff are not regularly present, as well as some nurse stations, fall under this level. Plumbing fixtures in these areas are usually limited to handwashing and kitchen sinks. Standard plumbing fixtures may be acceptable in these areas, but designers should coordinate with the project architect to determine if ligature-resistant fixtures are required. 

• Level IV: Areas where patients spend a lot of time left alone with minimal or no supervision. Private patient rooms and bathrooms fall under this level, and plumbing fixtures must be provided for them. Plumbing fixtures in these areas must be designed specifically for behavioral health applications with ligature-resistant and tamper-proof features.

• Level V: Areas outside the risk map where staff interact with newly admitted patients who present unknown risks or are highly agitated. These tend to encompass admissions and seclusion/restraint areas. Patient toilet rooms may be present in these areas. Plumbing fixtures in these areas need to be designed specifically for behavioral health applications with ligature-resistant and tamper-proof features.

While the facility architect ultimately determines the risk levels for given spaces, plumbing system designers should understand why they carry these risks and plan their designs to mitigate them.

Integrating Plumbing with Architectural Elements

The architectural elements in a behavioral health facility are the first line of defense in protecting patients and staff from harm. These elements and the overall design strategy often deviate from other types of health-care facilities; being familiar with both is key to designing plumbing systems for patient safety.

Plumbing designers should anticipate having even more limited interstitial space than usual in behavioral health facilities. Ceilings in these facilities are often kept high to reduce the risk of climbing injuries — 10 feet is not uncommon, even in monitored patient areas. Coordination of pipe routes with HVAC becomes more important and challenging in these areas, especially since mechanical systems are required to include ducted return air. 

Special note also needs to be paid to the ceiling materials in these areas, as they may limit or prohibit access altogether to valves and other plumbing system accessories. Ceilings tend to be either locking tamper-proof tiles in monitored areas and gypsum board in unmonitored areas. Any overhead valves or other accessories that may need to be accessed are best put above the former if possible. Putting them over gypsum board ceilings requires locking tamper-proof access panels, which still introduces a risk to patients.

Depending on architect and client preference, plumbing chases behind patient bathrooms may either be completely concealed or open to maintenance staff through an access door, such as in correctional facilities. If the latter is used, take advantage of the chase to place shut-off valves and cleanouts.

Cleanouts need to be placed generously but judiciously in behavioral health facilities. Instances of patients flushing random items down toilets are common, and sewer blockages happen frequently. Some clients are content to clear these blockages through plumbing fixtures, but a desire for dedicated cleanouts serving single or small groups of patient rooms is more common and should be considered first in early design. 

If accessible chases are used, placing cleanouts here is the best option. Otherwise, cleanouts should be placed in highly visible monitored areas and equipped with tamper-proof screws.

Seclusion rooms are Risk Level V areas where highly agitated patients are taken to and confined until they calm down. While an observation area is always adjacent to these rooms, great care must be taken to keep self-harm risks out of them. The only plumbing fixture that should be present in these rooms is a ligature-resistant floor drain in case patients soil themselves. A concealed and locked hose bibb should be placed in the observation area so the room can be washed down after use.

Clients occasionally want medical gas outlets placed in patient areas. No outlets are specifically designed for behavioral health applications, so they need to be concealed behind locked security shutters or otherwise kept away from patients.

Plumbing designers are often tasked with directing the scope of fire protection design, and that becomes critical in these facilities. Sprinkler heads are prime targets for patients prone to self-harm, and institutional-type heads that are concealed and break away with no more than eight pounds of force need to be used. These sprinklers should be placed in every area of Risk Level II or above, whether the patients in them are monitored by staff or not.

Behavioral Health Plumbing Fixtures

Plumbing fixtures for behavioral health applications are designed to be sturdy, resilient and with no ligature points that patients could use to asphyxiate themselves. Fixtures not specifically labeled for use in behavioral health environments should not be used in them. Patient bathroom fixtures are often the ones designers need to choose with the most care, as these locations are where patients may be unmonitored for extended time periods.

Patient lavatories may be made of solid surface materials or steel for resilience. They will include tamper-proof, below-deck shrouds that completely conceal the fixture trap and water supplies. Faucet controls can either be sensor or electronic push-button type. Keep in mind that sensor faucets triggering randomly can startle and agitate patients, so push-button types are often a better choice. Lavatories need to be secured either with concealed wall carriers, fastened to the floor or both.

Patient toilets should be made of steel and carry a 5,000-pound load rating. They should be fastened to both the floor and the wall with concealed bolts that are only accessible through a tamper-proof access panel on the fixture. The seat should be integral to the fixture. 

Flush valves need to be concealed in the plumbing chase and secured by a wall box with tamper-proof screws. Like faucets, flush valves can either be sensor- or push-button-activated, but the latter is often a better choice for the same reasons as noted before. Ligature-resistant grab bars should be specified by the architect.

Patient showers often have the valve concealed in the wall with a steel cover flush with it, but surface-mounted options can be concealed in steel boxes. Shower controls may be ligature-resistant dial types to allow the user to select the temperature or push-button-activated with a fixed temperature set on the valve. Fixed shower heads are the norm here, as wand showers pose a ligature risk.

Floor drains are an often overlooked risk in patient areas, but patients have used these to injure themselves. Standard drain strainers often include ligature points and should not be used. Floor drains specifically labeled for behavioral health applications should be used instead and are equipped with ligature-resistant strainers and tamper-proof screws.

Plumbing fixtures, in general, should be chosen to complement the finishes of the built environment. Psychiatric facilities were designed to look and feel like prisons in the past, but clients and architects now want calming, inviting facilities that do not carry this stigma. Fixtures with bare metal finishes should be avoided in favor of coordinating the color and texture with the interior designer.

Coordination for a Safe, Successful Project

Coordination with other disciplines, especially architecture, is key to minimizing patient and staff risk in behavioral health facilities. At a minimum, the design team should meet to discuss risk levels in each of the facility areas, expectations for fixtures in them, and who will decide what product to specify. 

Many project architects will invest in an outside behavioral health consultant to guide these decisions — if your team has not done this, it is a good idea to push for it. Use this consultant as a resource for choosing and placing plumbing elements in the built environment, and have her review your drawings and specifications. Working together with this person and your project team is the surest way to minimize risk to patients and staff in these facilities. 

Altogether, it will go a long way in producing a facility where behavioral patients can get the care they deserve. 

Aaron Bock, PE, is a senior plumbing engineer at ERDMAN and has been designing plumbing systems for the health-care industry for 15 years.