While every effort is made to design ligature-resistant space in psychiatric facilities, it’s important for projects to reduce opportunities for self-harm in the built environment. Private spaces including bathrooms, bedrooms, closets, and showers are areas of concern. In fact, up to 90 percent of inpatient suicides occur in these spaces, according to a 2018 article in the Joint Commission Journal on Quality and Patient Safety.

Of these spaces, depending on the patient and their acuity level, private toilet rooms can be some of the most dangerous, with the risk of patient suicide by hanging being especially high in these spaces, according to research from the National Violent Death Reporting System (NVDRS) and the Joint Commission’s Sentinel Event (SE), which records data on inpatient suicides in healthcare facilities in the U.S.

EYP has worked with several large forensic and maximum-security psychiatric hospitals, as well as talked with professionals and national experts on these projects to gather insight and ideas. From our experience, we’ve identified patient safety, staff observation, and patient benefit as key factors to consider when designing toilet rooms in a behavioral health facility.

Choosing the right configuration

Healthcare facilities have three types or styles of bathrooms. The most typical in a hospital-type setting is a private toilet room directly attached to a patient room, which allows for maximum patient privacy and convenience but reduced patient safety due to difficult staff observation.  Semi-private toilet rooms allow two adjacent patient rooms to share a common toilet room accessed from each patient room. This configuration, however, would allow a patient to access another patient’s bedroom through the toilet room, which is not ideal for psychiatric facilities. The final option is a shared toilet room that’s accessed from the public corridor instead of the bedrooms. While this is the least private and convenient from a patient standpoint, it’s the safest configuration from a staff observation perspective.

“Chapter 29—Plumbing Systems” of the International Building Code (IBC) 2021 governs the minimum number of required plumbing fixtures. In the institutional classification intended for “medical care recipients in hospitals and nursing homes,” the requirement indicates one toilet room per patient room, with the caveat that a single-user toilet room could be shared between two rooms provided each patient room has direct access. In high-security psychiatric hospitals, however, staff are working with mentally ill individuals, some of whom have violent and/or serious self-harm tendencies that make individual toilet rooms for this population undesirable.

As an alternative, EYP has worked with code officials in several jurisdictions to advocate for and receive code modifications from the IBC to allow one single-user toilet room accessed from a public corridor for every four patients. Corridor-accessible toilets with doors that can be readily observed by staff instead of hidden inside a patient room are vital for patient safety.

While staff routinely walk through the living unit to monitor patients, five minutes can make the difference between life and death. Even in high-security settings, dignity would suggest that patients should be left alone in bathrooms and, yet, that privacy increases risk for suicide and self-harm. Toilet rooms in sight of a nurses’ station enhance safety because staff can see when a patient enters and how long they’re in the enclosed space. If a person has been in a toilet room too long, staff can immediately investigate and confirm the patient’s safety.

Benefits of public corridor toilet rooms

While the goal is to provide a more normative experience in a recovery-based environment, in some instances privacy may need to be secondary to safety. This doesn’t mean the toilet rooms need to be institutional in character—every effort is made to create nice spaces. It’s also important to include multiple, single-user toilet rooms that are convenient to patient bedrooms, so patients don’t have to walk across the living unit and through public spaces to get to the toilet room.

Additionally, while project budgets and square footage are always tight, fewer toilet rooms mean less square footage and fewer dollars spent building and maintaining them, as well as more space and funds for treatment. The average toilet room is 60 square feet. In a 28-bed living unit this equates to 1,680 square feet to incorporate private toilet rooms in each bedroom or 840 square feet for semi-private toilet rooms. However, when one toilet room for every four patients is used, the space requirement drops to 420 square feet.  The remaining square footage can be applied to other areas, such as space for classrooms, common areas, or programming.

Finally, the corridor-accessible model enables staff to spend less time observing individual toilet-room and more time on patient interaction and therapy.

Prioritizing safety

Many positive changes have been made to the IBC over the past decade to recognize the unique requirements of psychiatric hospitals and incorporate their needs into the code. It’s important to have an open dialogue with experts and practitioners who run these facilities to help determine the needs of their patients and staff, especially when designing treatment spaces, patient living units, and toilet rooms, and assessing the level of risk for specific design decisions. Talking with clients and code officials early on a project can help establish building blocks that allow project teams to create a healing facility that prioritizes treatment and the safety and security of patients and staff.

Andrea Righi, AIA, is a senior project architect and associate principal at EYP (Washington, D.C.).  She can be reached at arighi@eypae.com.