Behavioral Health Brief: COVID-19 Design Lessons for Behavioral Health Facilities
By Eric M. Kern, AIA, LEED AP BD+C, and Marc Shaw, AIA
Social Work Today
Vol. 20 No. 5 P. 5

When it comes to dealing with COVID-19, residential behavioral health facilities—and their designers—are responding to a moving target. As new information emerges, practices and protocols have evolved even as the virus spreads. The impracticality of releasing or refusing patients, reducing or eliminating care, and the unique qualities of the population in care exacerbate the problem.

These facilities and their staffs provide services that are especially vital during times of crisis, when individuals may experience increased anxiety and stress and when those with preexisting mental health and substance use conditions may exhibit new or worsening symptoms.

In the wake of the pandemic, revised long-term guidelines and standards, including protocols for care and architectural and engineering responses to support that care, will undoubtedly be developed. In the short term, however, it is useful to understand some of the current ad hoc responses, the drivers behind those responses, and how those inform facilities in moving forward.

The Goal and the People
Continuing to provide quality care for a challenging and at-risk population (and, therefore, their caregivers) is the overarching goal. We must understand the populations at risk; how to best minimize exposure, infection, and transmission; how to respond to any illness that does occur; and how to support those who provide care.

Patients, care providers, support staff, administrative staff, family members, visitors, and delivery and service staff are all part of the therapeutic community. The divide rests between patients and those who provide direct care—who enter patient areas and interact with them face to face—and those who do not. While easily understood for patients and direct-care providers, it can be less clear for support and administrative staff.

Prevention
Controlling the introduction of a virus at the facility entrance is step one. Restricting access and performing ongoing testing will limit risk. Any response should include using science-based protocols such as masks, hand washing, and appropriate isolation within the hospital and in the community.
Hospitals can limit the opportunities for introduction of the virus by restricting the number and use of entries into the facility, separating entries for visitors and staff, evaluating the need for some staff to work on-site or access patient areas, and severely limiting or even eliminating visitor and vendor access.

Some administrative and legal functions typically done in person are now handled through teleconferencing and “telecourt” systems. Each change requires modifications to procedures and to staff behavior and responsibility.

Hospitals are also evaluating entry screening options. Building layout and technology that aids in this effort can include hand-held or permanently mounted temperature check devices, pulse oxygen sensors, and antibody scoring in an entry ID card access system. New entry flow procedures, such as distanced one-way traffic patterns, staggered staff arrival times, and the use of electronic self–check-in kiosks, are also available.

Response
Protocols and Space Use
Testing patients and isolating infected individuals within a behavioral health setting is a logistical and therapeutic challenge. Among U.S. facilities, the intensity of outbreaks has varied from negligible to more concerning ratios.

The need for separation exists for residents who fall into the following categories:
• untested but potentially exposed;
• tested and cleared; and
• exposed and infected.

The relative size of these populations can shift quickly. While relying heavily on guidance provided by the Centers for Disease Control and Prevention, procedural responses are often customized accordingly.

Where feasible or medically necessary, off-site isolation and treatment for small numbers of patients has been a limited solution. This approach inevitably faces the same “available capacity” challenges as for the overall population.

On-site, populations have been grouped and often relocated based on physical health or testing status. Where available, in-house infirmaries or similar medical areas have been used and appreciated. Building components have been temporarily repurposed to aid in isolation, from existing living units to classrooms, gyms, and other treatment areas converted to temporary housing. All of this occurs within the context of minimizing disruption and other risks for patients.

Within the residential, treatment, and administrative spaces, adjustments support social distancing and continued therapy. Repurposed dining spaces and conference rooms allow for activity space. Also, adding temporary partitions and spacing furniture enhances this effort.

Staff meetings often occur virtually, even within the facility. Treatment malls and other therapy spaces are being restricted to more limited use. Notably, facilities report that readily accessible outdoor areas and courtyards experience greater usage as a welcome respite for both patients and staff. These adjustments are particularly true where these spaces are associated with a small population such as a living unit.

Social distancing and reducing physical interactions while providing effective therapy remains a challenge. Responses to this have included the partial use of online communication—even for personnel within the same facility. Providing adequate infrastructure, including adequate Wi-Fi repeaters and ample charging stations, for this technology in the design is critical to its success.

Additional design considerations include spatial consideration of social distanced seating in larger group spaces, appropriate storage and staging for personal protective equipment at unit entries, and tamperproof hand sanitizers in wall units.

Mechanical Engineering
As in traditional hospitals, the use of negative and positive air pressurization is critical to limiting the spread of disease. That said, mechanical systems within a psychiatric complex are typically not designed to support invasive medical procedures or disease containment. Some hospitals are rebalancing airflow to pressurize portions of the building appropriately. Others are investigating customizing the pressurization of specific living units, building components, or individual rooms. Additional engineering solutions evaluate the adjustment of humidification levels and the potential use of ultraviolet (UV) lighting in some areas.

One potential approach is to incorporate reversible pressurization capabilities into the hospital’s programmed infirmary rooms. A lower-cost option would be to design the mechanical infrastructure of specific rooms to accommodate the use of temporary mobile pressurization equipment that could be brought in and used on an as-needed basis. While this arrangement allows for a more economical and flexible solution, some staff may believe that mobile equipment is not ideal for a behavioral health setting unless a secure place to house the units were part of the design.

Support Functions
Receiving, distributing, and removing services and materials throughout the hospital is crucial but presents risks for both virus introduction and spread. Foodservice is a good example.

Large industrial kitchens receive materials, and prepare and distribute meals throughout patient areas. While the safety and security of meal and utensil delivery have long been complex issues in behavioral health settings, building operators are now overlaying additional infection control measures to daily procedures.

Operational procedures pertaining to loading, transport, cardboard breakdown, cart cleaning, attire, and presanitizing procedures are being reviewed. In the long term, areas for investigation include antimicrobial handles, UV lighting, provisions for clean shelving, cooking surfaces, and walk-in cooler doors, and the wider use of the ServSafe curriculum for all staff.

Finally, the specification of floor, wall, and ceiling surface materials that can be pressure washed and sanitized frequently is recommended.

Materials and Cleaning
Highly durable and cleanable interior materials are crucial in behavioral health environments. Infection concerns further underscore this necessity.

During the pandemic, staff have been regular users of masks and gloves and there’s been a greater emphasis on frequent cleaning, including making cleaning products readily available. Durable and easily cleaned wall and floor finishes and coatings, such as colored concrete flooring and coated concrete masonry blocks, have been difference-makers.

Future strategies include touchless technology, hands-free controls, and propped or held-open doors. Operationally, additional cleanup support in day rooms, group rooms, and dining spaces can be beneficial.

Patient and Staff Stress
Effective therapy relies heavily on reducing anxiety and instilling a perception of calm, order, wellness, and safety. This approach is equally true for patients receiving care and for the staff providing it. Stress introduced by an ongoing pandemic, particularly combined with alarming visual cues such as interpersonal distancing, face masks, and other hesitancies toward social interaction, can harm the therapeutic environment and its effectiveness. The wellness of caregivers is a critical concern and component of a behavioral hospital’s mission.

Ideally, there should be ample opportunities for staff to decompress. Staff and scheduling changes combined with comfortable staff breakrooms and indoor and outdoor “composure spaces” show active support and appreciation for the treatment team and support staff.

Moving Forward
With increased stress, disruption to convenient access to treatment, and an understandable hesitancy to seek out additional interactions, it is likely that demand for behavioral health care will grow in light of the pandemic. Future health care events will demand a response from caregivers and the broader community. Behavioral health facilities will need to address these challenges and the evolving nature of mental health care while keeping all parties safe and providing effective, humane care.

There’s an opportunity for patients, treatment teams, and designers to be heard. Robust conversations with caregivers—and sophisticated integration of procedures, architecture, engineering, and technology—can inform the next generation of behavioral hospitals and their unique and essential mission.

Learning from the strategies developed by frontline caregivers during the COVID-19 pandemic is crucial to that effort.

— Eric M. Kern, AIA, LEED AP BD+C, is a principal and the senior project director of EYP’s behavioral health sector. He is based in the firm’s Washington, DC, office.

— Marc Shaw, AIA, is a principal with Marc Shaw, Architect, LLC in Arlington, Virginia.