Improving hospital emergency department design for mental health presentations

Tuesday 27 August 2019 by Dr Stephanie Liddicoat, Lecturer

Stock image of emergency department

People with mental health issues are increasingly presenting to Emergency Departments, resulting in economic impacts, increasing pressure on triage processes, and poor outcomes and experiences.

In summary

  • Dr Stephanie Liddicoat is an expert in therapeutic architecture and lecturer at Swinburne’s School of Design
  • Dr Liddicoat says the design of most hospital emergency departments adds to the distress of mental health presentations
  • Her research shows how a more supportive ED can be created through architectural design focusing on privacy, visibility, psychological states, social support and autonomy.

In April this year, a woman in New Zealand was violently attacked and raped by a man who had sought help from a hospital emergency department (ED) on the country’s west coast.  It emerged that the man had presented to ED staff in a psychotic state.  He waited hours without being seen by the mental health crisis team, before leaving and making his way to the victim’s home to carry out the attack. The women later spoke out about how mental health services failed both hers and her attacker.

In situations like these, a dedicated space to address distressed patients in the ED, or increased permeability and visibility can make a huge difference.

The power of ED design

People with mental health issues are increasingly presenting to Emergency Departments, resulting in significant economic impacts, increasing pressure on triage processes, and often poor outcomes and experiences. Considered design of the built environment is an essential part of the answer. My research shows how a more supportive ED can be created through architectural design with a focus on privacy, visibility, psychological states, social support and autonomy.

When managed well, ED is an effective and reassuring doorway to the containment of an inpatient stay, supervised changes in medication or a recalibration of current outpatient treatments. However, there is evidence that ED visits are often traumatic for patients because the environment can increase anxiety and distress, particularly because those presenting are often at their most vulnerable. The architectural design of the ED environment can add to that anxiety, and negative experiences discourage patients from attending ED in the future, increasing the likelihood of poor clinical outcomes.    

The patient experience

Put yourself in the shoes of a person in mental distress, presenting to hospital ED.  Now, let’s explore five key aspects of your experience:

1) Privacy

Imagine you are approaching the ED entry, furtively looking around you to see who else is there and who might see you go in. You might be taken in by ambulance or a crisis team, perhaps accompanied by police, which makes you uncomfortable because everyone in the open waiting room turns to look as you enter. Imagine you overhear everyone else’s issues and trauma as you wait. You are already besieged by your own anxieties and listening to theirs makes you all the more distressed.

Imagine an alternative situation where you weren’t watched moving through the triage area, and you didn’t feel as though people wonder why you are there or whether you are crazy.  Imagine if you could have a private conversation with a family member who is with you, without having to shout over the din of the other voices. Imagine if you didn’t see the marks on the wall from past patients, and that you didn’t then visualize the people who have been in this cubicle before you and the suffering associated with them, all whilst trying to deal with your own worries.

The design of entry spaces, waiting areas and consultation spaces very much affects the patient chances of experiencing a calm entry into ED. The design of these areas can also affect the safety of other waiting patients and the ability to de-escalate distressed patients in a safe manner.

2) Visibility

Imagine if you could approach the ED entrance and see exactly where to go.  You would know what to expect and your fear of the unknown would be reduced. You would be able to see the staff and they would not be behind the plexiglass panels that make you feel ‘other’ and dangerous. The staff can see you as well and they can keep you safe. The staff can see each other, and you feel they are working as a team and keeping connected as they deliver care.

Designing spaces for easy wayfinding with visible directional and labelling cues in the environment can mitigate anxiety and distress in the ED environment. Appropriate signage with considered labelling of departments/functional areas can also reduce feelings of stigma and otherness. Enhanced visibility is useful to keep other waiting patients safe, and to enhance communication and connection between staff members should any incidents arise.

3) Psychological states

Imagine walking into a large and imposing hospital building that makes you feel small and insignificant. Its reflective surfaces are triggering your anxiety and you question whether you should have come. There are bright fluorescent lights and noise and voices crowding out your thoughts, and making it hard for you to navigate. You cannot see beyond the entrance area. Corridors snake away in all directions and it is not clear where they lead.  You feel as though you might be trapped, imprisoned or controlled.

Alternatively, imagine walking through a landscaped area with a clear path to the hospital entrance. The waiting area is open and you can see other spaces beyond. There are natural materials, sunlight and low ambient noise.  You feel safe and can wait, passing your time by looking out the window to a small internal courtyard, knowing that you won’t be watched or scrutinized. There is artwork you can look at and lose yourself in, which helps you to feel less anxious. This is the result of good spatial design.

4) Social support

Imagine if the ED gave you a feeling of refuge as you waited with your loved ones and ensured your conversations with your healthcare team were not overheard. If you feel a little overwhelmed, there are quiet spaces, away from the crowds and noise, to quietly sit with your loved ones in a way that is comfortable for you.

Designing quiet spaces is an essential aspect of mitigating distress for mental health presentations. Having appropriate spaces which are quiet and with fewer sensory triggers ensures these patients are more likely to receive the level of support required. This also enhances privacy for discussions between patients, family members, carers and their healthcare teams.

5) Autonomy

Imagine if the ED had private niches just for you and your carers. You have access to sensory modulation materials, which help to keep you calm. Walking helps you to relax but can disturb patients in the waiting area, but here there is space for you to pace. You can see others in the space and hear them in a muffled way, so you feel connected, without feeling crowded. You have a choice of places to sit, so you can find a space that feels just right for you and feel empowered that you have made the decision.

Research into the emotional effects of the physical space of ED is in its infancy, but has the potential to inform powerful and cost-effective architectural interventions. Evidence-based design of ED spaces will improve the experience of ED visits and encourage their use as a central component of managing the risks and distress of mental illness.

Given the increasing number of ED presentations in Victoria and across Australia, considered design of the Emergency Department is significant.  It can enhance and augment service user outcomes and experiences, and ensure the needs of those presenting in mental distress are met by their healthcare environments and services.