FGI Bulletin #3

Updated Design Guide Offers Guidance on Identifying and Addressing Patient Self-Harm Risks

Looking for information to help address the new Joint Commission emphasis on removing ligature and self-harm risks in locations where psychiatric patients will be cared for? The Design Guide for the Built Environment of Behavioral Health Facilities, co-authored by James M. Hunt, AIA, NCARB, president of Behavioral Health Facility Consulting, and HGRC-member David M. Sine, ARM, CSP, CPHRM, president of SafetyLogic Systems, can help. The Design Guide addresses the built environment for adult inpatient behavioral health care units.

While FGI’s Guidelines for Design and Construction documents provide baseline requirements, the Design Guide offers greater detail on the design of behavioral health facilities and includes best practices for protecting patients and staff. Additionally, information has been included about products found to be safer for use in behavioral health environments, recognizing that no product is entirely without risk.

The Design Guide is not intended as a replacement for regulatory requirements nor to be employed as a legal “standard of care.” Its content is provided to augment the fundamental design requirements for behavioral health facilities and to help providers and design teams develop physical environments that support safe and effective behavioral health services.

Download version 7.2 of the Design Guide, issued in March with revised text and updated product listings.

New Correction to the 2010 Guidelines re: Ducted Systems

An updated errata sheet has been posted on the FGI website that clarifies that the intent of the 2010 Guidelines is to require fully ducted returns only in patient care areas of hospitals and outpatient care facilities with required pressure relationships.

A Guidelines user found a conflict between the 2010 edition and the 2008 edition of ASHRAE 170 (Part 6 of the 2010 Guidelines): The Guidelines required fully ducted returns in all patient care areas in hospitals and outpatient facilities, while ASHRAE 170 only required fully ducted returns in spaces with pressure requirements. The Guidelines text at the beginning of Part 6 (ANSI/ASHRAE/ASHE 170) states, “In the case of a conflict between the language in Standard 170-2008 and the text of the Guidelines, the Guidelines language shall have priority.” The inquirer wanted to confirm that it was the intent of the Health Guidelines Revision Committee (HGRC) to require fully ducted returns in all patient care areas.

Because the FGI Board of Directors and the HGRC leadership have relinquished content development of ventilation requirements to ASHRAE, it was determined the resolution to the conflict was to correct a correlation error made when the 2010 Guidelines and ASHRAE 170-2008 were being prepared for publication. Therefore, the updated 2010 errata sheet removes the requirement for return air systems from Guidelines sections 2.1-8.2.4.1. and 3.1-8.2.4.1 and directs readers to ASHRAE 170, section 6.7.1, which states “Spaces listed in Table 7-1 that have required pressure relationships shall be served by fully ducted returns.”

FGI Advisory on Family and Visitor Lounge Capacity in Critical Care Units

Last month, a Guidelines user requested guidance on sizing and location options for a family waiting room in a critical care unit (CCU). The requester had concerns the 2014 requirement would result in an oversized lounge for their project, given the family-centered approach they used in designing the CCU. The FGI response to this query was informed by updates to the family and visitor lounge requirements during the 2018 revision cycle, which will enable greater flexibility in CCU waiting room design with the goal of right-sizing these spaces. The complete advisory follows:

Question: We are developing a critical care addition for an academic medical center. A challenge is the size of the family waiting room on the critical care floor. As stipulated in Section 2.2-2.6.8.1 (Family and visitor lounge), we recognize the lounge must be immediately accessible to the critical care unit and must provide seating for no fewer than 1.5 persons per patient bed. We have provided the requisite lounge and have been able to achieve the 66 seats needed to serve the 44-bed floor; however, this arrangement does not allow us to provide the family-focused environment we envision for this vital family amenity. To address this, we have been considering adding space for both families and staff on the floor above the critical care floor; in this scenario, we would provide a visitor’s lounge with a reduced seat count immediately accessible to the critical care unit and an additional family lounge on the floor above, with enhanced amenities such as family showers and consultation rooms. Does this arrangement meet the intent of Section 2.2-2.6.8.1?

Response: Since 2010, the FGI Guidelines has required hospital critical care units to provide a family and visitor waiting area/lounge with seating capacity of 1.5 guests per patient bed. Although that ratio has worked well in small facilities, it can lead to oversized waiting areas in large facilities, particularly those in which space is provided to allow family to stay by the patient’s bedside.

As hospitals have moved toward providing patient-centered care to support better patient experience and outcomes, one way that ideal has been manifested in hospital design is inclusion of family support areas in patient rooms. Nowhere has this trend been more important and impactful than in the critical care unit, where many designs today provide space in the patient room for families.

The Guidelines does not require a family support zone in any patient room; however, when hospitals choose to provide this space, appendix language recommends a larger room size as well as 30 square feet of clear floor area per family member permitted in the room at one time. The larger size of such patient rooms can result in families and visitors using the lounge only sporadically (e.g., during nurse shift changes or when eating a meal, answering a call, or taking a break), lessening the need for the seating capacity required in Section 2.2-2.6.8.1. The unintended result is that waiting areas for critical care units in these facilities can be oversized.

In the forthcoming 2018 edition of the Guidelines, the Health Guidelines Revision Committee worked to standardize the family and visitor lounge requirements across the Hospital Guidelines document, moving them to Chapter 2.1, which contains elements common to most hospitals. Thus, the family and visitor lounge in the critical care unit is covered by the common elements chapter, which reads:

2.1-2.8.1 Family and Visitor Lounge

Each patient care unit shall have access to a lounge for family and visitors.

2.1-2.8.1.1 Size

(1) The size of this lounge shall be defined in the functional program, but shall accommodate, at minimum, three chairs and one wheelchair space.

(2) In the absence of a functional program, the lounge shall be sized for at least 1.5 persons for every adult critical care bed and one person for every four general acute care beds.

2.1-2.8.1.2 This lounge shall be immediately accessible to the patient care unit(s) served.

2.1-2.8.1.3 This lounge shall be permitted to serve more than one patient care unit.

These family and visitor lounge requirements make the size of each waiting area dependent on the facility’s functional program (while providing a fall-back ratio should a facility not complete a functional program). This change gives hospitals the flexibility to size their CCU waiting areas based on census or other metrics, including the presence of a family support zone in patient rooms, rather than a strict ratio.

Guidelines Revamps Mobile Units Chapter and Introduces Telemedicine Requirements

Mobile Units

For the 2018 edition, the HGRC significantly revised the Guidelines chapter on mobile and transportable units. To better address those medical units that are intended to be mobile and/or transportable, the HGRC removed pre-fabricated structures from this chapter, as they are typically placed in service and never removed.

The second major change to this chapter is that mobile units are now designated as Class 1, Class 2, or Class 3. The types of procedures that can be performed in each unit type is determined by a new table that delineates functions for room types based on room location, use, sedation required, and patient acuity.

Other changes of note include space requirements; requirements for unit access from a health care facility site; MRI safety; radiation protection; access to a clean workroom or clean supply room and soiled workroom (need not be in unit, if co-located with host facility); and provision of support areas.

Telemedicine

As telemedicine and telehealth continue to gain wider acceptance, market share of this service is expected to increase dramatically. To address the need to develop functional telemedicine spaces within health care facilities, the 2018 Guidelines will offer a significantly expanded section on telemedicine. The new language addresses space requirements, privacy and acoustic considerations, lighting and glare reduction, interior surfaces, site identification, and support areas.

While the HGRC believes that expanding its guidance for designing a clinical telemedicine space is critically important, the bulk of the new language in the telemedicine section is explanatory—and therefore not enforceable—because this field is both expanding and evolving rapidly.

Simulation Tool to Help Users Evaluate Designs

Poorly designed health care spaces introduce hazards—to patients and health care providers alike—into the built environment. Inviting end-user participation early in the design process is essential to minimizing such problems. One way to do this is by performing simulations of activities in full-scale mock-ups of planned spaces.

To help health care organizations gather data from such efforts, the Health Quality Council of Alberta (HQCA) has created a tool that provides a framework for collecting and analyzing data from such simulations. It is available for download from the HQCA website.

FGI Participation at Conferences

Members of the Health Guidelines Revision Committee have been engaged to speak on the 2018 Guidelines at these upcoming conferences. If you plan to attend any of these conferences, please stop by to learn about the changes coming in the 2018 edition of the Guidelines.

Healthcare Facilities Symposium and Expo, Austin, Tex., September 18-20, 2017

Leading Age Annual Meeting and Expo, New Orleans, October 29-November 1, 2017

Healthcare Design Expo and Conference, Orlando, November 11-14, 2017

ASHE PDC Summit, Nashville, Tenn., March 25-28, 2018

Environments for Aging, Savannah, Ga. April 21-24, 2018

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About the Facility Guidelines Institute
Founded in 1998, the Facility Guidelines Institute is a not-for-profit corporation founded to provide leadership and continuity to the Guidelines revision process. FGI functions as the coordinating entity for development of the Guidelines series of documents using a multidisciplinary, consensus-based process and for provision of ancillary services that encourage and improve their application and use. FGI invests revenue derived from sales of the Guidelines to fund research and the activities of the next revision cycle.

About the FGI Guidelines for Design and Construction Documents
The FGI Guidelines for Design and Construction documents are updated every four years to keep pace with new concepts, capabilities, and technologies in the delivery of health care. The Guidelines documents are used by states to regulate health care facility design and construction, through adoption of the Guidelines as code, as a basis for state-written codes, as an adjunct to state codes, or for reference.

About the Health Guidelines Revision Committee
The Health Guidelines Revision Committee (HGRC) is a select multidisciplinary consensus body of about 100 clinicians, administrators, architects, engineers, and representatives from authorities having jurisdiction that is convened to revise and update the FGI Guidelines documents. As a group, HGRC members are experts on the many issues addressed in the Guidelines.