Case study: design may influence use of seclusion and restraint.
OBJECTIVE
The psychiatric emergency room is a dynamic and sometimes volatile environment. Its design may be an important variable in patient care, but most design decisions are based on models of thought and treatment with a minimal evidence base.


BACKGROUND
The concept of open design, increasing access of patients to nursing staff, for inpatient psychiatric units has recently gained widespread acceptance, despite a dearth of empirical data.


METHODS
We examined rates of seclusion and restraint before and after a design change that reduced the openness of the unit in a dedicated emergency psychiatric service in a general university hospital. Quality assurance data regarding the census, occurrence of assaults, and the use of seclusion and restraint were queried. Two independent analyses utilizing a test of proportional data were performed to replicate the findings.


RESULTS
After placement of a door to restrict patients' access to the waiting area of the unit, the rate of the use of seclusion and restraint went from 0.03 (44/777) to 0.0185 (27/1,514; z = 2.02, p < .04). Replication over a separate time period saw reduction from 0.029 (67/2,277) to 0.018 (44/2,431), z = 2.44, p < .02).


CONCLUSIONS
A design change that reduced the openness of the unit resulted in the reduction of seclusion and restraint.
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
John M
JM
McCurdy
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
James R
JR
Haliburton
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Hardik C
HC
Yadav
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Allison M
AM
Yoder
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Lindsey R
LR
Norton
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Josef A
JA
Froehlich
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Harpreet
H
Kaur
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Nicholas F
NF
Kramer
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Ayesha
A
Silman
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Brian J
BJ
Quinn
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Sharon
S
Pudlo
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA.
Christina Butler
CB
Terrell
Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA rselma01@louisville.edu.
Rif S
RS
El-Mallakh
D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006272:Health Facility Environment / Q000458:organization & administration; D006749:Hospital Design and Construction / Q000379:methods*; D006778:Hospitals, Psychiatric / Q000458:organization & administration*; D006785:Hospitals, University / Q000458:organization & administration; D006801:Humans; D010356:Patient Isolation / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care; D012149:Restraint, Physical / Q000706:statistics & numerical data*; D014754:Violence
assault; psychiatric unit design; restraint; seclusion