Accessible Healthcare It's More than Facility Access
When facility planners and designers think about healthcare accessibility, they often think about providing accessible parking spaces and restrooms; level or ramped building entrances; walkways, waiting areas and wide doorways that allow for wheelchair access; and examination rooms that provide a sufficient turning radius for wheelchair users. In other words, they think about access to the healthcare facility-which is not exactly the same as access to healthcare.
For the patient, getting to the facility, into the facility, and through the facility are only the first steps. To access healthcare, individuals must also be able to access and utilize the equipment required for care: examination tables; examination chairs; weight scales; x-ray and mammography machines; and even exercise, rehabilitation, and fitness equipment.
Unfortunately, many healthcare facilities do not provide full access to care, because they fail to provide accessible equipment. A nationwide survey of people with disabilities, conducted in 2005, found that 74.9% of those surveyed had more than a moderate degree of difficulty accessing examinations tables; similarly, 68.2% had significant problems accessing x-ray equipment; and more than 50% (for each) had difficulty accessing x-ray equipment and weight scales.
People with disabilities represent 19.3% of the population over the age of five, according to the 2000 census, and many fail to receive adequate healthcare because of accessibility issues. This is especially important because people with disabilities sometimes require more frequent healthcare services than those without disabilities. For example, those with spinal cord injuries are four times as likely to develop diabetes as the rest of the population, and people with limited mobility are more prone to low bone density and fractures. Cardiovascular diseases are also more prevalent in this population.
And it is not just people who self-identify as having a disability that lack access to healthcare equipment. The percentage of older adults is increasing rapidly as the “baby boomers” age. Older adults represented 12% of the population in 1997; they will represent 20% of the population by 2030. They are the largest group, by far, in terms of healthcare expenditures. Many of these older adults have activity limitations due to conditions such as arthritis, which affects more than 60% of those over the age of 65.
The consequences of inaccessible equipment
Inaccessible equipment impacts the quality of care and poses safety risks to patients and healthcare providers, especially nurses. When weight scales are inaccessible, it is difficult, if not impossible, to adequately monitor medical conditions such as congestive heart failure and diabetes, for which even modest weight changes can be clinically relevant. Further, medication dosages cannot be adequately adjusted for weight, based on only patient “guesstimates” of what they weigh.
Similarly, when examination tables are inaccessible, patients may receive only a cursory or incomplete physical examination. Likewise, when x-ray equipment and mammography machines are not accessible, or require extreme indignities, embarrassment or frustration to access, patients fail to have the screening examinations they need.
Some healthcare facilities compensate by providing human assistance to patients, but this not only poses additional indignities for patients, but often poses safety risks for the patient and the healthcare provider. The Bureau of Labor Statistics reported 59,000 injuries in 1999 in healthcare services, and most were strains/sprains of the back and shoulder caused by overexertion in lifting, which caused personnel to be off work for several days. Nursing has the second highest incidence of any profession in terms of nonfatal work-related injuries. In 1998 alone, 12 out of every 100 nurses in hospitals and 17.3 out of 100 in nursing homes reported work-related skeletal injuries. There have also been many cases of patient injuries caused by falls during transfers to and from medical chairs and examination tables or falling off an examination table that was poorly designed.
Designing for healthcare access
What constitutes accessibility of medical equipment in the healthcare facility? By looking at what is being required of the patient vs. what the patient can do, it is easy to see the improvements needed.
For example, the typical upright weight scale in the doctor's office requires patients to: 1) stand to be weighed; 2) step up three to five inches onto a narrow platform; and 3) maintain their balance, unsupported, for as a long as it takes the healthcare provider to weigh them. Many wheelchair users cannot stand up to be weighed. Others have balance or other mobility limitations that prevent them from safely stepping up onto the platform. In addition, many weight scales cannot accurately measure weights over 350 pounds.
An accessible weight scale is one that allows a person to be weighed while seated in a wheelchair, meaning that it has a platform large enough to allow a wheelchair user to roll onto the platform. It requires no step onto the platform and can accurately measure weights up to 800 pounds. For those being weighed while standing, the scale should have handholds so that a patient can maintain his or her balance. Such scales are available (see www.cdihp.org/briefs/brief2-weight-scales.html for further information).
When it comes to examination tables, the single biggest problem is table height. This is because the task needs of physicians are in conflict with the accessibility needs of patients. To conduct an examination, physicians generally require that the table be from 37 to 40 inches high. Many patients, however, have difficulty transferring to a fixed table of that height. In May 2010, the U.S. Department of Justice, Civil Rights Division, released a new technical assistance publication titled “Access to Medical Care for Individuals with Mobility Disabilities” (see www.ada.gov/medcare_mobility_ta/medcare_ta.htm). The guide highlights the need for accessible exam tables and chairs to lower to 17 to 19 inches from the floor, the height of a wheelchair seat. In addition, the exam table or chair should contain elements to stabilize and support a person during transfer and while on the table, such as rails, straps, or stabilization cushions.
In addition, patients can wait a significant amount of time after accessing the table before the physician arrives for the examination, which means that the patient has to sit with insufficient back and leg support for an extended period. A table adjustable to 17 to 19 inches from the floor allows people to sit comfortably while waiting, with their feet on the floor.
Once the table is accessed, the patient must maintain position while waiting for the physician and during the examination. This task can be a challenge for obese patients, those with arthritis, pregnant women, older adults, and people who have limited neuromuscular control or spasticity. The task can be made easier by providing examination tables that are wider than those typically used, and by providing adjustable side rails or hand-grabs, positioning straps, and foot and leg supports that can be adjusted and locked. Examples of tables that meet these requirements are available at www.cdihp.org/briefs/brief1-exam-tables.html.
It is also important to recognize that providing accessible equipment doesn't mean that it is, de facto, accessible. The designer must also carefully plan for where the equipment is placed in the room and how it is used in order to ensure that patients will be able to make use of its accessibility features.
Getting accessible equipment
Does designing for accessibility and obtaining accessible equipment for a healthcare facility cost money? Yes. But healthcare worker injuries and lawsuits due to lack of access cost much more. And there is huge cost to the public when lack of healthcare results in major problems for patients down the road due to delayed treatment which then requires more extensive and expensive care.
The federal government provides both tax credits and benefits for providing accessible equipment that should be attractive to small medical practices, in particular.
A practice with fewer than 30 full-time employees with gross receipts totaling less than $1 million in the preceding year can receive a credit of 50% toward the purchase price of accessible equipment, as well as an additional year-end tax benefit.
Consider providing your patients not just with access to the healthcare facility, but with true access to healthcare itself. By ensuring that your equipment is accessible, you will enable a large segment of the population to receive the healthcare they need. HD
June Isaacson Kailes, MSW, is the Associate Director of the Center for Disabilities Health Policy at Western University of Health Sciences in Pomona, California
Daryle Gardner-Bonneau, PhD, is the Principal, of Bonneau and Associates, a human factors engineering consultancy in Portage, Michigan. For further information, e-mail
firstname.lastname@example.org Healthcare Design 2010 August;10(8):70-72