Designing a safe ED for psychiatric crises: Safe Rooms

The use of psychiatric “safe rooms” has become a de facto management tool for emergency departments over the last two decades. A safe room is a room that has been cleared of any objects a patient might use to harm themselves or others. These rooms have no items that could be used as anchor points and minimal furnishing — usually just a bed with a single blanket. The walls are typically bare to minimize stimulation and the room is arranged so that line of sight monitoring can be conducted from a distance.

Truly Safe?

While the physical safety provided by the room design is obvious, there is no empirical research to support the overall design and use of these rooms. There is anecdotal evidence and general agreement that the use of these rooms for long periods actually causes patient condition to deteriorate, increasing agitation and even inducing psychosis in previously calm and non-psychotic patients. Additionally, there is empirical research that shows patients who are in regular hospital rooms begin to show signs of agitated delirium when they have extended stays following surgery due to the lack of stimulation in the room. Other research has long established that isolation and sensory deprivation induce psychosis and cognitive decline after very short periods of time. The little empirical evidence available for the use of safe rooms suggests that these rooms provide physical safety, but cause iatrogenic psychological harm.

Relation to Boarding

In a previous post, I talked about the effect of boarding on safety in the emergency department. The longer a patient remains in a safe room setting, more likely they are to experience psychological harm and the less likely they are to benefit from or comply with any treatment. But even more importantly, the deterioration experienced by patients who are boarded in safe rooms often leads to admissions that might not otherwise have been necessary. While everyone agrees that boarding is problematic for everyone in the ED, psychiatric patients pay the biggest price. Not only is boarding in the emergency room significantly more expensive than an inpatient bed, patients generally receive no treatment and little in the way of basic human care such as human interaction, information about their situation, a way to pass time and address boredom, or access to friends and family. All of these factors lead to greater risk of elopement, suicide, agitation, psychosis and violence. Even the notion of physical safety can be called into question under these circumstances.


  1. Lighting — Ensuring a natural light spectrum and embedded in room lighting control will provide some relief from the typical glare of fluorescent lighting and some sense of control for patients.
  2. Decor — Well maintained paint, natural scenes, TVs embedded in walls, or provision of a selection of music, visible clock all help break up the monotony of long hours spent just waiting.
  3. Human Interaction — Regular interaction with friends, family, and staff helps patients feel less anxious. Staff should check on the patient’s comfort regularly. The greater the social isolation experienced by lucid patients, the more likely they are to deteriorate. Staff should use discernment and good judgement to determine what is really best for any given patient, but restricting visitors should come later in the decision tree.
  4. Observation — Line of sight observation should be human to human with close physical proximity for patients when not contra-indicated. If not in close physical proximity, the LOS staff should make regular attempts to engage the patient in brief conversation. Otherwise, the patient is likely to experience the room as an isolation environment which is known to cause severe psychological harm. ED staff should be aware of the patient’s behavior and assess for safety before initiating conversation. If a patient becomes agitated, leave immediately and allow them time to calm.
  5. Information — Unless a patient lacks the capacity to understand, keep patients informed about what is happening and discuss their condition with them as you would any other patient. Lack of information makes people anxious and increases the likelihood of agitation and violence.
  6. Patient Satisfaction — The strongest predictor of patient compliance following an encounter for psychiatric emergency is patient satisfaction. Compliance is in turn the strongest predictor of deterioration post encounter. Thus, keeping patients out of the revolving door of psychiatric emergencies requires attention to improvements in patient satisfaction.