Case study: design may influence use of seclusion and restraint

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.

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.

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.

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).

A design change that reduced the openness of the unit resulted in the reduction of seclusion and restraint.