Welcome to Architecture for Health Lecture Series in 2026.

We have Doctor David Pepper, psychiatrist from Harper and Institute of Living during this today.

Has been director of the Emergency Psychiatry Services for the past 18 years.

And he's also the medical director of the center right here.

And he's also very active in teaching social workers, psychologists and physician assistants and political students.

And he has more several awards, including the Institute of Living Psychiatry residency at Award for Excellence in Teaching in 2016, and the Integrated Residency in Emergency Rates.

The award is presented of Emergency Medicine Award.

2018 doctor is also a representative on the Board of Directors of the American Association for Emergency Psychiatry, and he's also the secretary of the same organization.

So please help me welcome Doctor David Pepper to the.

Thank you.

It is an honor to speak to you all today.

Had the opportunity to watch and listen to a few of the lectures from this series for the last few years, and I really am following in some some big footsteps.

So it's an honor to talk to you about my experiences in emergency Psychiatrist and Healthcare design.

Now, I'm not Altair designer or an architect is as a physician.

So I have a different set of skills, but I think we'll be able to talk about some of the key elements of design noticed and have some influence.

Our.

Our practice.

Second.

All right.

So currently I'm the medical director of an emergency psychiatric center, but also get to supervise the care of psychiatric patients in 12 different emergency departments across our health care system.

And they vary in sizes from a very rural hospital to an inner city level one trauma center.

So we have a full range of psychiatric services available throughout the system, but also different capabilities within our emergency department.

And hopefully you'll see through the lecture today that that flexibility is is one of the key elements in design for emergency psychiatric spaces.

Emergency departments are open 24 over seven.

We don't get to say no to to any patients.

We take every patient who presents and needs help.

That for us in behavioral health, could mean five patients in a row that have just overdosed on fentanyl laced with psilocybin, or five depressed patients or five patients having panic attacks.

They feel like they're dying, or five young adults or children that have had the disruptive behavior at school, or made statements of self-harm or statements of hurting others.

The most often scenario that we get is all of these patients kind of all at the same time.

So we can't design an emergency department just for those depressed patients or just for those overdose patients.

We really have to be able to accommodate all of those patients at the same time in the same environment.

So these are some numbers from emergency psychiatry.

You've probably heard some of them from past lectures, that the number of people presenting for behavioral health emergencies in emerging departments continues to climb.

There may be a bit of a plateauing happening since December of 2025.

But, you know, we'll see as the data comes in.

But when I started in emergency psychiatry, it represented about 6% of the overall visits in emergency medicine were for behavioral health concerns.

Now we're at about 12%, which roughly ends up at about 13 million patients per year.

Presenting with behavioral health concerns to emergency departments.

And unfortunately, those patients also stay for longer periods of time within the emergency department.

They require a lot more care in that department for a variety of different reasons.

It takes us longer to evaluate them, and it takes us longer to get them to the next level of care.

And this is all happening at a time where we have more opportunities than ever for patients to get into behavioral health treatment if they're feeling in crisis.

We have 988.

We have telecine services, we have crisis services available, as well as embedded emergency psychiatric services.

And that's what I'm going to talk to you about today.

That's what we have.

That's what I'm in charge of in the Hartford health care system, and that's what I have the most experience in.

But if we have questions about any of the other levels of care, certainly happy to to answer those as well.

All right.

So there's a saying in emergency psychiatry that if you've seen one emergency psychiatric space, you've seen one emergency psychiatric space, because they are all very unique.

And part of that is that we don't have a universally accepted national standard of what emergency psychiatric spaces are.

We have some federal guidelines, but they're not universally accepted.

We also need to create individualized space for these areas.

It's very purposeful that we want to design a space to incorporate the needs of that community, that hospital, the resources that that hospital has and doesn't have, and the resources beyond the hospital in the community.

What do they need?

So for behavioral health and for Hartford Health Care, we have one very rural hospital, happens to be very close to several group homes for young adults with intellectual disability.

It also happens to be very close to two therapeutic high schools.

So every day they get young adults in behavioral emergency that need they need to assess and often takes a while to do that and to get them to where they need to go.

So they've had to create a special workflow pathway and area within that emergency department to care for those patients.

Where I work, it's a level one trauma center in inner city Hartford, and we have 120 beds in that Ed, but we also happen to be 100 yards away from the only freestanding children's hospital in the state of Connecticut.

So we hardly ever get any children or adolescent to behavioral emergencies because they go to the children's hospital next door.

Similarly, with our substance use patients, we have substance use disorder patients in every one of our emergency departments.

But some areas have a higher percentage of those patients.

And those facilities really need special care, special pathways for getting those patients assessed quickly and into the treatment that they they need.

All right.

So this is Hartford Hospital.

This is the hospital that I work at.

It's in inner city Hartford.

It like most of the hospitals in the northeast seems to start seems to have been.

Dedicated after a major emergency.

There was a big manufacturing fire.

They needed to care for a large number of patients at one time.

So they started a hospital.

It was 175 years ago and it built and built it after that.

Now it's 100 and now it's a level one trauma center with a nationally recognized transplant service, cardiovascular cardiology service, a fully embedded orthopedic hospital.

Within it.

We have 800 and about 875 beds and 100, and we see about 120,000 patients through our eme But it's a bit of a hybrid, because the psychiatry department that I work for is actually the Institute of Living, which is next door to this hospital, had been a freestanding psychiatric hospital for 172 years until it merged with Hartford Hospital in 1994.

And now it's the psychiatry department for Hartford Hospital.

So there are two modern pictures here on the top and the bottom, but these are actually older pictures from the 1930s.

The Institute of Living has a fascinating history that we could talk for hours on.

It was actually founded on the principle of moral treatment.

And in the 1700s, psychiatric patients were not all treated morally, and the Institute of Living was founded on the premise that patients deserted, deserved comfort and care in their treating not just the asylums of the day, where patients were locked up to keep them away from the general public because there wasn't care, there wasn't treatment that that was possible at the time.

So the Institute of Living was really founded on that moral treatment and really developed into a nationally recognized place for those patients.

In fact, in the 1930s, it actually did have an outdoor pool that you could attend to.

It could it had a fleet of limos that would take people to Boston and New York on the weekends, had an indoor bowling alley.

Those don't exist anymore.

We've modernized over the last hundred years, and now we have 120 inpatient bed area.

But we also have multiple levels of research, outpatient programs, research programs on the campus of the Institute of Living.

What it didn't have was an emergency center.

It didn't have emergency psychiatry.

It had a waiting list.

People would call from all over the country to get a bed at the Institute of Living, and they would be able to select and integrate those patients in.

They didn't have to deal with patients in acute behavioral emergencies.

They had patients that were very sick and they needed to care for, but they didn't have to care for them in that acute phase in an emergency setting.

So since 1994, that's really been a major challenge, integrating Hartford Hospital with the Institute of Living to care for those emergency psychiatry patients.

So I don't have any fancy architectural design drawings of our emergency department, unfortunately.

So the best I have is our visitor map of our emergency department.

And you can see our layout.

We are divided into pods.

So for patient care we have blue, green and orange are our medical surgical pods.

We have a gold pod in the front that is for more urgent care type visits.

And we have red pod for traumas and medical alerts.

We also added a 20 bed observation unit a few years ago, and the purple pod is the psychiatric pod.

And we we're not really part of the original design of the emergency department, but we did have an opportunity to expand and create a new space in about 19 or sorry, 2012 to 2014, we redesigned our emergency space and created the current layout, which I do have a little bit of a design drawing from our from our expansion in 2013, where we added in this new space and redesigned our old space.

So we currently have 21 beds within this area with two transition areas, two separate nurses stations, and a quarter connecting them with a separate break area for our staff.

When we did this expansion, we had the opportunity to add some exciting features.

We added in colored lighting, LED lighting, we added in privacy glass in all of the windows and doors, and we expanded our single room capacity, which was a different trend than a lot of places we're going in and still are going.

We chose to go with single rooms very purposely because we had previously this open, just this open area with a centralized nurse's station, and none of these were walls.

It was just an open curtain area, and we had a very hard time keeping our patients safe and doing proper evaluations in that space.

And it really came to a head after we got a very poignant letter from a mother who was postpartum.

She came into that space.

She was feeling very depressed and anxious, couldn't sleep, couldn't eat, talk to her OBGYN about coming into the hospital to get some care.

And unfortunately, it was on a day where we were very busy and we were about 12 hours behind in our evaluations, so she ended up having to spend the night in that open area.

And during that night she had a gentleman who was intoxicated walk in on her and urinate on the floor.

She could hear the woman a couple curtains down, responding to internal stimuli and being very paranoid and hearing auditory hallucinations.

And she was so scared that unfortunately, she minimized her symptoms when she came.

When we finally did get to evaluate her, and we probably didn't get as good of a picture as we wanted of her because she was so motivated to leave.

She just wanted to get out of that space.

She did not want to spend another minute there.

Luckily, she was okay.

We got her to outpatient treatment.

She did well in the outpatient treatment, and she wrote a letter to our CEO.

And I had to attest that absolutely everything she said was true, and we decided that we needed a better place to really evaluate our patients and get a good assessment of them in comfort in a way that they felt comfortable talking to us very openly.

So I do want to talk more about our psychiatric assessment.

Before I do.

I want to go through just a little bit of our process, our operations in emergency psychiatry, and what happens when we have a patient present with acute behavioral emergencies.

So like all patients, they go through our triage, whether they come in by ambulance entrance or a walk in.

They see a triage nurse who gets to decide a few different things.

First, they'll look at how.

Are there any concerns for acute medical emergency, even though the patient has is presenting with a behavioral health chief complaint?

Could this be a medical cause of this behavioral chief complaint, or is there any concern for ingestion suicide attempt, self-injury?

They may require medical care.

If that's the case, they would go to one of our medical pods, and then we'd see them after they were medically screened and assessed.

And if there aren't any of those concerns, they have the opportunity to triage them directly into our purple pod.

A lot of that is dependent on space availability and their acuity level.

So we don't always have a space available within our purple pod for all the patients that are appropriate to be triage there.

So many times they're left to go to an overflow area within that medical pod where they can be observed.

They tend to be more open areas.

So we have several curtain areas within that place.

So they can have one of two observers watching a group of patients at the same time, unless they needed more individualized one on one care, their level of acuity too.

So if we have somebody who's really invisible, this control in the triage area, we get them back to a room directly and don't we don't put them in a hallway area.

Once they're seen by the nurse, they all of our patients are seen by an emergency medicine, either attending resident or advanced practitioner.

It's different than some models, some models, the psychiatry team will do that assessment and they'll come directly to them.

But in ours we're we're a consult service to emergency medicine.

So emergency medicine sees all of our patients and then refers them for psychiatric consultation with us.

And they'll decide if, if, if a medical workup is needed, if they need blood work or imaging before they see us, they'll also decide on the level of care, which is also called level of observation in some places.

So it's whether the patient needs to be checked on every 15 minutes to make sure that they're safe.

Or do they actually need one on one observation because of some level of concern for self-injury or injury to others?

Or are they so disorganized that we're worried that they're going to get up and walk away?

Or they might be a high fall risk or a high wonder risk?

So those would be on 1 to 1 level of care.

For all of those patients.

They come in with a behavioral health concerns.

We we screen them.

We have a separate area that's not labeled on that map with a screening room.

So our nurse would take them into that room, get them changed into hospital clothes and and screen them in their wanted by public safety to make sure they don't have any objects that could hurt themselves or other people.

But it's also an opportunity to orient them to the process, to the environment, to let them know what's happening, who's going to see them, and what to expect.

So after their screen, then they would go into the purple pod or back to one of these overflow areas.

If they go back to one of those overflow areas or directly to a medical surgical room, not a behavioral health space.

Our nurses are required to do what's called an environmental care checklist, to make sure that that environment is safe for this patient at this time.

And it's a pretty exhaustive list of things that they have to check to make sure that the previous occupant of that room didn't leave something lying around that could be an object that somebody could hurt themselves with or hurt other people with, or that we didn't leave something in the room that that might be able to be used as a weapon or something to injure themselves.

The.

Room that they or the area that they get assigned to obviously directly affects their their experience in the emergency department.

If they're coming into a behavioral space, it's an open area they can walk around in.

And they have we have behavioral health trained staff in that area.

If they don't, they're in a medical pod, usually with not behavioral health trained staff and usually not an opportunity to get up and walk around.

The next best scenario is a hallway area is very similar, but the patients that scare me the most as a medical director are the patients that we don't even get to those spaces because they're waiting in triage, because we haven't even seen them yet, because we're we get backed up.

We haven't even had the opportunity to to talk to them yet.

So when we don't have spaces to put people, that just adds to our patients that get stuck in the waiting room.

And it's similar for the medical side.

Those are those could be chest pain patients having heart attacks that we're very worried about in the emergency department.

So a lot of our flow and operations is to work on decreasing the amount of time that patients spend in those in the waiting rooms and in the hallways.

So now they get to us, we actually get to do our psychiatric evaluation on these patients.

And this is really the art of emergency psychiatry.

And it's not just an interview, just a conversation with a patient.

It's not just giving them a screening tool to screen for suicide or.

You know, a rating scale.

It's an in-depth one on one conversation, really looking at all of their acute behavioral concerns, talking to them about those, but also the observation of them in that interview process, but also in that area related to what they came in for.

So for a patient who came in with depression, we're looking at when they came in, how are they interacting?

Are they so scared or anxious that they didn't leave their bed, that they didn't eat or drink anything in the time that they were there?

And we have other patients who come in with a report of depression who are up and eating every turkey sandwich available and flirting with staff.

And so there's a discrepancy there.

So that's something we need to explore even more.

It's we have to look for what they're telling us.

Well, also what they're not telling us in our interview.

And unfortunately, sometimes our patients don't tell us everything and sometimes they don't tell us the truth.

So we really have to do a lot of exploring beyond that as well.

So there are some really key environmental factors to the interviewing process.

We know from the forensic science literature and the psychiatric literature, the lighting, temperature and seating arrangements are a huge influencer of patients willing or anybody's willingness to participate and give truthful information.

Lighting.

I know you guys have talked about it.

I've seen it.

I've seen some of the lectures.

Natural lighting is amazing and emergency departments, but it's really hard to.

It's really.

Coveted space and coveted areas.

So unfortunately, I think none of our emergency psychiatric centers of our 12 emergency departments have open natural lighting.

We had some in our emergency department, but unfortunately they had to break it over because we can control the temperature well enough in those rooms.

It was not a choice that I made at the time, a choice that was made up of my head, that wish we had fought harder for because it really was quite a loss for us.

But we did come away with several diving options for patients, so they don't have harsh overhead lights beating down on them.

If if we're in there talking to them, we have side lighting, we have the LED lighting that we can change the color to anything that they want.

We have individual temperature controls within that, that room.

We know some patients are cold no matter what, and some are hot no matter what.

And we want to be able to adjust it for to make them comfortable.

Seating arrangements are huge.

I'm not a small person, and if I'm standing over somebody at the bedside talk, trying to talk to them about some very delicate things, it can come off as very intimidating.

Especially they're in a hospital gown.

I'm in a white coat that can be very.

Intimidating and allow them to meet, cause them to not open up as much as as I want.

So I make it.

I'm very purposeful in sitting down and being at eye level with every single patient that I see, but that's hard.

In an emergency department, we don't have great seating options for our patients or our staff.

We have rolling chairs that I have to find and bring one into the room and make sure I take it out, but if we had had them built in, it would be much easier process and we'll get we'll talk a little bit more about that when we come to visitors.

So some other key elements that we really need to focus on in emergency psychiatry is privacy, but not for the sake of isolation.

So particularly with our staff when we do our evaluations, the interview is a major part of it.

But then we also spend a lot of time documenting.

So it's going back to a workstation, typing up notes, making phone calls.

So these are some phone calls to collateral information, friends, family, outpatient treaters of our patients gathering some some delicate information that we need to be away from the patient, that we don't want the patient to necessarily overhear these conversations.

So we have to be in a private area for that to happen.

But we don't want it to be so private that if something happens on the unit that we can't hear it, we can't respond to it.

Noise.

So that gets it annoys control that, you know, I couldn't find a good image of a noisy nurse's station on the web.

So I had AI generate a couple images for me, and this is what they came up with for a busy emergency department.

And it's pretty accurate in that you have flying papers, you have people on the phone.

If some people arguing, maybe you have a police officer in the middle who's just kind of in the way, but it gets to the chaos that can happen in the nurse's station, and we really want a more tranquil area.

Maybe not doing yoga in the nurse's station, but we always want to be able to make phone calls in a private area and be able to do our documentation without all the distraction that Nurse's station also need to be an off stage area.

I think this has come up in other discussions in your lecture series that we want our staff to be able to have a good time at work, to be able to interact with one another and enjoy the experience of being with another person who's doing the same work.

It's a very stressful environment and we try and have fun also at work, so it's not overwhelming and it's not a huge, burdensome experience.

But if we're laughing and joking in the milieu of a psychiatric unit, it can come off as very antagonistic to some patients.

It can make paranoid patients even more paranoid.

It can come across as very disrespectful to patients that you're not working hard, you're not helping me out, you're just having a good time and joking around.

So we want our staff to do that.

But in an off stage area, not in the middle of the milieu.

And obviously they can't be there all the time doing that.

There has to be a balance and that's the operation side that's on us, but we have to have the opportunity to get to that space at some point.

Then unfortunately, we have a long wait time in emergency psychiatry.

We have a problem evaluating patients in a very quick manner and also getting them to the next level of care in a timely manner.

As I was talking about the wait time for patients going into the hospital, if you need psychiatric admission, you'll wait 2 to 3 times longer than a patient waiting a medical bed, which is in some hospitals already very long.

But if you need a specialized area of the inpatient unit or specialized bed within that unit, if you need a handicapped room or you can't have roommates if you need an older adult unit or one of our child units, those can take days sometimes for us to get patients to those units.

So we manage a lot of wait time in the emergency department.

And when we designed our unit, we have embedded televisions within our room, and they're good if they help, but they're not great with any technology that you're putting into an emergency department, probably anywhere in the health care system, it has the risk of becoming obsolete before it's even opened.

We don't have smart TVs.

We don't have touch screen TVs.

We don't have on demand services on our TVs.

We don't have a way to screen music through our TVs.

So we've had to come up with alternatives for that.

Now we use iPads to provide all those things.

In addition to the TVs and iPads are another common solution and emergency departments across the country, and they can help.

But you also have to factor in their use.

They get lost, they get broken, they get stolen, they can be thrown.

And then you have to find a place to charge them and to keep them secure in the nurse's station.

And it's the same for phones.

We.

It's another controversial topic that happens in all of our emergency departments, whether our patients should be allowed to have their phone in while they're on the behavioral, the emergency psychiatric unit.

It's can be very comforting for some people.

It feels very isolating to be away from your phone, as you could probably all imagine if I asked you to lock up your phones and be away from them for several hours or days.

It can feel very disconnecting, but for others, it actually is enlightening that that phone is overwhelming.

It's a connection to a social network that is not helpful right now.

It's actually her armful, so our patients may not be able to differentiate that in the moment.

So we have to try and help them with that.

So we our policy right now is in flux.

But we don't allow phones.

But we have the ability to allow them if we feel like it could be helpful.

Visitors are another issue that that is variable across emergency psychiatric centers.

I think they're very helpful in encouraging to our patients to have somebody to help provide them support in these spaces, but we also have to allow for them to be in those spaces.

Our rooms are not big, as we'll talk about.

Room size is a major problem for us, and they have to have a place to sit or if they're a young adult, many times the family wants to stay over and sleep there, and that's usually very tight space for our patients and their families to be in.

Yeah, getting to room size.

So when we built our.

Emergency psychiatric rooms we use the minimum square footage.

I get it.

The the the larger you build, the more expensive it is, the harder it is to maintain, the more expensive it is to maintain.

So going for the minimal square footage was their choice, but it left us very hamstrung as far as when we have a dysregulated patient in the room, it can be very difficult to to work with that patient.

It didn't allow us to add in benches or anything else secured in that room, because that impedes on the square footage.

We couldn't even add in bedside tables.

Those had to be removable, which then also became broken or could be used as weapons.

So we've really struggled with that.

Seating within the room is also very troublesome.

We could not secure any seating, so we have to have seats that can come and go in those those spaces, and that means those chairs can go missing or hard to find.

I think.

So the layout of the room is also very important.

I know we've talked about natural light, that having a window in there, and this is one of the windows that we had that unfortunately they had to to brick up from the outside.

So we didn't have natural light anymore.

But orienting the bed so the patient can actually take advantage of that.

That light is very important.

But in behavioral health, we're actually lucky in that the head of the bed is not a fixed structure like it is in many of the medical units where you have medical air suction, you have outlets that you need to need to keep at the front of the bed in case there's an emergency.

And we don't use any of those.

So the head of our bed can actually be moved around.

We have a space where it's ideal for.

But all of our, our, our beds are on wheels in our space.

I know some of the other units will use platform beds that are affixed to the floor or very heavy and can't be moved, but we take advantage of the wheels are our beds and allow the patients to move the bed to where they feel most comfortable.

So some like it in the center of the room, but most like it in the corner.

They want a wall, they want they want some structure around them, especially if they don't have a window to look out of.

So we allow them to move the bed wherever they want within the room, as long as they're not blocking the doorway.

So it gives them a a bit of freedom of choice in the space that we're controlling.

We're taking away a lot of their choices already, so why not give them back a little bit of choice, a little So just some key takeaways.

We designed.

Emergency psychiatric spaces for safety.

And that's definitely what we need to do.

But we can't forget about the human being that we're trying to keep safe and allowing them to have some comfort, some care in that space that really allows for them to be more natural, more open and honest with us and us to get a better assessment of them so that we can actually get them to the right level of care.

We can do the right assessment and treat them well.

So always think about the patient needs, the volumes that you're seeing.

There's really good data that's available about patient flows and times that people come in that we use for operating our staffing models.

But when you're talking about units that can expand and contract, it's also very helpful to have that volume data for those areas as well.

As I mentioned, we have those two different areas of the purple pod that we can expand and contract based on our volumes.

But if emergency medicine is having a a surge, they may take over one of those areas and use it for medical beds.

And if they don't decompress, by the time our volume goes up, we may not have the opportunity to open that back up for our for our staff or our patients.

And then being able to manage acuity, it's really important that that all of our patients feel comfortable, and we know we're going to have some dysregulated patients in emergency psychiatrie.

And how can we keep them safe?

How can we not have that?

The the noise influence our other patients, influence our staff and their ability to do work in that setting?

So with that, any questions?

Well, thank you so much David.

It was a great presentation.

Thank you.

And it's always helpful for us as architects or healthcare design researchers to know more about clinical workflows and understand how we can design, or how the design can actually respond well to human needs in those spaces.

So again, greatly appreciate it for the presentation.

And with that, since we have we have PhD students who are focusing on this topic.

We have graduate level students who are working on the topic for the final studies, or undergrad students who again, are working on the same topic for their studio project.

Do you guys have any questions regarding what was discussed today?

Okay, Julianne.

I'm curious about the lighting.

You said that it regulates circadian rhythm, but that you don't have many big lights.

So how would that change throughout the day?

Just kind of curious about how that would work.

Yeah.

So it's really the lighting in the hallway.

So the lighting in the rooms, we allow the patients to control if they want the light on or off, they want, you know, a green light, a blue light, they can change it.

To that.

We discourage the red light.

That's generally not soothing.

We have four preset colors that patients can choose, but we have a panel that can change it to any color that they want.

So we have blue, green orange and purple.

Blue.

Green.

Blue.

Green.

Purple and white as preset.

And then they can change it to any others.

The circadian rhythm really comes into the hallway lights that can really affect their sleep or their ability.

So we don't want those bright lights right outside their room to be affecting their sleep.

If somebody needs to catch up on sleep and is there throughout the night, we don't want a bright light outside their their room affecting that.

So we have hallway lights that we can turn down or turn off in the evening and night times.

So the interactive panels that are provided in each separate room for patients.

So we have four presets that they can control at the inn in or outside their room.

And then we have two panels in the in the nurse's station that control the individual lights.

While the patients do have a choice if they want to lighting or aquamarine, I can change it, adjust the sliders to get it to something close to what they want.

Awesome.

Okay, Grace.

And then Maria touched on staff a little bit, and I would just be curious to hear a little bit more about how in these recent years, with changes you've made, how your prioritizing staff safety and comfort, you talked a little bit about allowing them to be humans off stage.

How are they, shall we say, protected while they're being those humans?

Yeah.

Good question.

Yeah.

So safety is is a huge concern.

So.

In our previous design we had panic pendants that people could wear.

They'd have to sign them in and sign them out because they would go missing and basically press it.

If you felt like you needed a staff assist when you were meeting with the patient, or you witnessed something that you felt they needed safety staff there.

With our new design, we we implemented panic alarms in the hallways and in the room.

So every eight feet in our unit, there's a panic alarm that's actually tracked more closely to public safety.

The pendant alarms was an alarm that went off for that unit.

It just told staff to come to that unit, the panic alarms.

It will tell us.

Room 36, panic alarm.

So public safety then hears that the nurse's station will hear that the nurse's station outside of Purple pod will hear that and know it's the patient in 36 that needs help, so they know who they're responding to and where that patient is.

The off stage area is also key for for staff, the space to go back and talk about a patient after you've interviewed them is key.

We hear some really, really troubling stories, really hard information to handle.

And being able to talk to somebody else about that is really key.

Our model is really based on a team philosophy that we we have clinicians and residents that see the patients usually first, then they come and talk to myself or a nurse practitioner or PA, and we come up with a disposition together.

We really talk that through.

So that gives them an opportunity to, you know, vent a little bit about what they're hearing and seeing.

And we come to a decision together and we do that in an off stage area.

I'll tell you, the break room is also a very key component to to have a place where staff can go and eat.

And, you know, they unfortunately, I missed it yesterday.

They had a chilly cook off just as a staff morale building event that we can have in an emergency departments, it's really hard to do staff events that boost morale because we have to take care of patients 24 over seven, so everybody can't leave to go to a retreat because we have to leave staff there to take care of patients.

So being able to do it in a space that's in our emergency department is really key and nice.

Thank you.

Thank you.

And Maria.

We've been talking about furniture that's ligature resistant.

I was wondering about those patient beds you were talking about.

Are those considered ligature resistance?

Yeah.

So that is something we've gotten feedback on.

And we have had to order new beds because they're they're not.

Our Department of Public Health did not consider them ligature resistant.

They were state of the art at the time.

In 2013, they were considered acceptable behavioral health beds.

Because they were lower, they didn't have.

Many of the ligature resistance, but they do have bars on them that patients can wrap things around.

And so we have new beds that are on back order that are coming in, that are a full panel that that are more ligature resistant.

So but they still have wheels.

That was the key thing we did.

We actually trialed platform beds.

And we got a lot of complaints from the patients about them that that they liked the ability to to raise the head of the bed or be able to move the bed.

And we just couldn't do that with those.

Yeah.

It doesn't allow you for that degree of flexibility.

No.

There's wedges that you can put in to elevate the the head of the bed, but they're not very comfy.

Okay.

Any other questions?

Yeah I'm gonna check the time.

I have a question myself.

We talked briefly about, well, the capacity of the facility.

And when there is a surge going on and you have a lot of patients that you cannot accommodate in the psych unit, how do you expand when that happens?

Yeah.

So it's something we plan for in the medical surgical pause that we've created some curtain areas within that area that we can use kind of as a, as a behavioral overflow area.

It's actually in the back of green pod.

So it's affectionately known as gerbil green purple that we can put patients where they can be observed by 1 or 2 staff members in a group of about 6 or 7.

So so instead of having one staff member and each room, it allows for a bit of an overflow area.

It's not a great patient experience.

It's it's it's a rough area to be a patient.

I think it's not ideal.

So our ideal is getting our patients into the purple pod in the in treatment in the right area.

But we know that surges happen.

We have to be able to accommodate for them.

Absolutely, absolutely.

Okay, Francisco.

This is regarding the patient freedom that you were talking about in the patient rooms.

What other opportunities do you give patients regarding that kind of freedom?

So the one of the best changes that we've made in emergency psychiatry since I've started is the addition of peer supports.

So we have called recovery support specialists.

So these are people with lived experience and mental health.

They have substance use disorders or psychiatric illness themselves.

And they go through our recovery academy where they they get specialized training to help other patients.

And we hire them as staff members to help our patients in the emergency department.

We have them every day of the week and on weekends into the evening hours.

And one of their main things is to to see what's helping, what's going to help this patient.

So we have other besides the iPads and TVs.

We have fidget spinners and squishy tools, squishy toys, all sorts of different things that some people may like or may help them with coloring books and crayons and word puzzles.

All, all, lots of different options for patients for what they need to help them partly manage the wait time, but also manage their symptoms, manage their anxiety, manage their their racing thoughts, you know, all sorts of different symptoms that they may have previously identified skills, but may not be able to remember them.

Now that our recovery support specialists can help them bridge that gap and really help them connect to some tools that that help them manage those those symptoms.

Patient choices.

Food is a big one.

You know, we unfortunately get generic trays delivered to our unit that are the same for everyone, but we do have the option to get an individualized diet or tray for somebody.

I think those are those are the major areas of patient choice.

So in line with that, for some of the million we've seen, some have kitchens that allow patients to grab whatever they want.

But most commonly what we see is that there is a cart and or there's a tray and the giver serve food that way.

Do you think that there is a chance that we move towards the first model with the kitchen provided in the milieu?

What what are some disadvantages with that?

So in our previous design, we had a refrigerator that was filled with sandwiches and juices that patients could grab as they wanted.

And that was really tough to manage, especially for our diabetic patients or our patients making bad choices.

But I think there are better ways to do it.

Now we have on our inpatient units, we actually have embedded juice and water dispensers that that patients can can use, and we can control access a little bit better for.

And we have other opportunities to get patients snacks that they can access on their own without having to ask a staff member for in an emergency department.

It's a harder thing to to monitor, but I think as the technology improves, the control, the dispensing of those things, I think it is possible to come up with a better, more friendly, patient friendly approach to snacks and food.

So the dispensers, how you control is that there is a badge, for example, they can scan it and they can.

So they have the ability to turn it off at the nurse's station on and off.

So very nice.

Yeah.

Same with phones actually.

So we have a unit phone in the emergency department.

If the patient doesn't have their individual phone, we have mobile phones that we can bring to them.

But we also have a unit phone that they can go and use at any time.

But sometimes they may be inappropriately using that phone or.

Calling family members and or the police or the FBI or all sorts of people that we, we don't necessarily want them to call.

So we have the ability to turn that phone off as well.

Okay.

Thank you so much, David.

My pleasure.

Thank you.