​Ways to mitigate behavioral health–related risk in a building environment include removing ligature points, providing tamper-resistant products, requiring high-quality, impact-resistant materials, and ensuring the proper amount of visual access and security, according to an October 4, 2018, article in Health Facilities Management. Several factors have facilities looking into redesigning behavioral health rooms in the emergency department (ED), the author said, including an increase in behavioral health case load; the Centers for Medicare and Medicaid Service's (CMS) Clarification of Ligature Risk Policy memo (see HRC Alerts, December 20, 2017: CMS Clarifies and Expands Guidance on Ligature Risks); and new Joint Commission standards (see HRC Alerts, October 3, 2018: Suicide Risk Recommendations: FAQs from Joint Commission). EDs do not need to meet the same standards as inpatient psychiatric facilities, the author said, but they should provide a safe environment. At some facilities, this means going beyond providing one-to-one observation to include design interventions. Design-related decisions will vary by facility. Modifications can range from providing one or two dedicated behavioral health rooms to dedicating a whole section of the ED to behavioral health care. Facilities should carefully consider where they place behavioral health rooms, the author said. Rooms too close to an entry or exit could make it easier for a patient to elope. Large windows make it easier for staff to see in but also allow other patients to see in. Patient safety and maintaining the dignity and privacy of patients must be balanced, the author said. The author offered several tips for reducing ligature points in rooms, such as installing smooth shower controls and automatic sinks. Rooms should be tamper resistant because items in the built environment can be used as weapons or for self-harm, the author said. Keeping ceiling height at least nine feet and having a solid and continuous celling surface can help mitigate this risk, as can using flooring material that cannot be easily peeled off.  Mirrors should be made of highly polished stainless steel and TVs should be kept behind Plexiglas. Rooms must also be designed with visual access and security in mind. One way to do this is to make sure doors swing outward so that patients cannot barricade themselves in a room. Facilities should also ensure that such rooms are safe and attractive, the author said, noting that it "will only add to the healing quality of the space."

HRC Recommends: Encountering undiagnosed psychiatric conditions, such as psychosis or bipolar disorder, is commonplace in emergency medicine. ED patients exhibiting acute behavioral health problems require careful assessment and monitoring. ED staff should consider patients experiencing acute, significant alterations in mental status to be at high risk of elopement and risk of self-harm and harm to others while in the ED. Patients being evaluated for suicidal thoughts or behaviors should not be allowed to leave the ED before a focused medical evaluation and suicide risk assessment are complete. ED policy concerning care of suicidal patients should clarify pathways for patient care and support patient safety actions, such as use of constant observation, personal searches by security staff, and appropriate use of restraints.