Designing for empathic rather than coercive care

Our Evidence-Based Design (EBD) team recently led a Hot Topics event that shared the experience of the Reimagining Behavioural Emergency Environments Workshop in Scottsdale, Arizona, in December 2022.  Attendees convened in small groups that included clinicians, and/or patient/patient reps, and designers. The groups were guided through a human-centred design and process improvement. The purpose of this workshop was to change the way healthcare is delivered through simple, systematic change.

It was proposed that traditional Emergency Department design does not provide an optimal care environment for patients experiencing acute behavioural crises. Our teams explored how designers can re-imagine emergency environments to provide better mental healthcare for patients.     

The teams also considered the Facility Guidelines Institute’s white paper on Behavioral Health Crisis Unit (BHCU) design.

Emergency Departments today are under strain as never before. People seeking emergency mental or behavioural care have added to the pressure, but the often-frenetic atmosphere of the ED can be less than optimal for patients in emotional crises.

Currently, many patients experiencing a behavioural health crisis are kept in the ED for long hours, typically awaiting transfer to an inpatient bed. Research shows that 75% to 80% of patients could be discharged in less than 24 hours, if they receive prompt evaluation and treatment in a calming, therapeutic environment.

Challenges for Behavioural Care in the ED

Although mental health is now recognized as a general healthcare issue, there is still a cultural stigma attached to psychiatric crises. A one-size-fits-all approach in the ED can exacerbate the alienation of this stigma for patients.

An ED is designed to address a great number of acute traumas. Everything from lighting, layout, and acoustics undermine the needs of psychiatric patients. These patients would benefit from a space in which to decompress in a calming environment, with the support of trained psychiatric personnel.

Unfortunately, patients experiencing dangerous symptoms such as aggression, acute suicidality, addiction withdrawal, or who have other medical concerns, must be kept in the ED for safety.

Recently, healthcare facility designers have sought to re-imagine emergency environments for behavioural care.

Photo Credit: Reimagining Behavioral Emergency Environments (RBEE) Workshop, Scottsdale, AZ, 2022

EmPATH Units

“EmPATH” (Emergency Psychiatric Assessment, Treatment, and Healing) units are calm spaces designed to alleviate stress and encourage patient healing. They also have controlled access, separate from other departments at a healthcare facility.

Their primary purpose is to accommodate the safe and efficient assessment and stabilization of patients suffering from an acute behavioural health crisis.

EmPATH units were developed in response to US emergency department overcrowding as many mental health patients were waiting for hours or days until they could be transferred to an inpatient psychiatric facility.

An Empathetic Design

The design of EmPATH units aims to provide empathetic rather than coercive care.

An ED can be an agitating and frightening atmosphere at the best of times. Patients experiencing a behavioural emergency are often left waiting on gurneys in bright hallways. Their ability to move about, or pace, is usually restricted. Rather than providing care for these acute situations, the ED can exacerbate and prolong the time a patient needs to be in care.

EmPATH Units are designed as patient-centred spaces that address the unique needs of psychiatric patients requiring acute care. Patients may need a space to decompress away from the bright lights, noise, and activity happening in the regular ED. They may benefit from having some autonomy in choosing the type of space they need. Some patients need a quiet space in which to be alone, while others benefit from being able to interact with peers and family.

Photo Credit: Reimagining Behavioral Emergency Environments (RBEE) Workshop, Scottsdale, AZ, 2022

A Non-linear Design

Unlike the linear logic of an ED, the EmPATH care model is an open milieu. These open spaces allow patients to move about, or pace, to reduce anxiety. They are furnished with comfortable recliners and tables and chairs with board games and snack areas that encourage people to interact if they wish.

The nursing station is open and is designed so that staff can see all patients and provide aid when needed. This configuration also encourages interaction between healthcare staff and patients.

Re-imagining the ED for Behavioural Care

At the Reimagining Behavioural Emergency Environments Workshop in Scottsdale, Arizona, participants broke up into 7 teams to explore solutions for several challenges that a traditional ED poses for psychiatric patients.

The teams asked themselves how we might:

• Break down the one-size-fits-all experience by ensuring the right level of care and maintaining an individual’s autonomy and sense of control.
• Foster communication between peers (someone with lived experience) and patients /providers for improved outcomes and trust.
• Reduce stigma for patients, providers, and families through the design of the environment.
• Provide effective space to treat behavioural emergencies for optimal patient care.
• Design dignified care that includes the patient.
• Create flexible spaces that provide patients agency over their individualized care plan without sacrificing safety or quality.
• Provide a first impression that provides a sense of community, well-being, trust, and hope to improve potential negative experiences.
• Create a therapeutic and restorative environment while supporting staff and patient psychological and physical safety.

Photo Credit: Reimagining Behavioral Emergency Environments (RBEE) Workshop, Scottsdale, AZ, 2022

Prototype Solutions

One team consisted of four architects, an owner, a physician, and a patient partner. Together they mapped out the patient journey as it is today and then explored how they could improve it. The team proposed creating a comfortable intake space where the patient would meet with their patient navigator in advance of being triaged, and learn about what lies ahead in their patient journey.

Other teams proposed adding peer patient conversation alcoves and creating quiet zones to help de-escalate traumatized patients, including providing a decompression alcove after triage.

The spaces should allow for as much autonomy and choice as possible while also being safe for all users. Care stations need to be open and provide clear lines of sight and promote interaction between staff and patients.

Views to the outside or virtual windows along with outdoor space can help promote healing, as can access to natural daylight. Materials such as polycarbonate safety glazing provide natural views while reducing elopement opportunities or potential facility damage.

Photo Credit: Reimagining Behavioral Emergency Environments (RBEE) Workshop, Scottsdale, AZ, 2022

Conclusions

By rethinking the Emergency Department approach to behavioural healthcare delivery, designers can play a role in providing a trauma-informed space that works to treat patients with empathy and avoids re-traumatizing them. This care delivery model can reduce the time patients are in the ED and frees up beds for other crisis patients, which in the end also reduces a hospital’s operating costs.