Beyond the universal patient room
The healthcare environment, physically and operationally, is in a constant state of transformation—learning from the “recent past” and building on the “just passed.” One significant development in the 1990s was the advent of the universal patient room, a concept that embraced the idea that a patient room could be designed to adapt to a patient's changing acuity levels.
The idea behind the original universal room concept was to allow patients to stay in a single location for the duration of their hospital stay, rather than moving them three to four times as their acuity level changed. The model, toured extensively at Celebration Health in Florida, provided rooms that were private and large enough to accommodate whatever level of care the patient required. Patient satisfaction, safety, and operational benefits were identified immediately, and the concept took hold.
But, after a decade of popular use, is the universal patient room living up to the hype? What lessons have we learned, and what's next in the evolution of “universal” design for patient care?
Although universal patient rooms have helped in many ways to advance patient care, some drawbacks also have become apparent.
For example, universal rooms did help to quickly advance a number of features now considered standard in new hospital design—flexible, adaptable layouts being among them. Technology and staff cross-training helped make adaptability possible by facilitating different levels of treatment within the same unit. However, even with cross-training, it has been a challenge for enough nurses to be sufficiently skilled in all acuities so that every hospital room can function as a true universal room.
Another example: Larger footprints, required for universal rooms, support family rooming-in features and, in turn, a more partner-supported staffing model. However, while family accommodations are now recognized as an important part of the healing environment and have become standard in today's new patient rooms, making all rooms large enough to handle all acuities has not always proven to be the best choice economically. It significantly increases square footage requirements and consequently increases the cost of the building. The fiscal challenges that many hospitals face today make this a significant potential disadvantage.
Some of these potential difficulties might be overridden by the “all-private room” movement. Most hospital owners in the United States have joined healthcare designers and caregivers in strongly encouraging the building of all-private patient rooms whenever possible. Although this is neither the set standard nor the code-mandated minimum as yet, this situation may quickly become “recent history.” During this year's revisions to the AIA/ASHE/FGI Guidelines for Healthcare Construction (new version to be released in 2006), the much-argued text concerning the mandating of all-private patient rooms was again at center stage. Not yet finalized, the section outlining the guidelines for patient unit design may change to strongly recommend only private rooms for new construction. This, in turn, will open the door to future revisions that may mandate them. If this becomes reality, combining flexible units with adaptable patient rooms will become a front-runner for maintaining good patient coverage.
More on those “flexible units” in a moment.
Designing for the Medical Staff
As the nursing shortage, combined with a growing inpatient population, continues to put pressure on the system, not only does it become critical to increase a caregiver's efficiency, but also to relieve stress and promote a healthier work environment. “Hospitality sells” is a well-known concept for attracting more patients, but amenities to increase staff recruitment and retention have become just as important.
The universal room regenerated the need for a decentralized nursing model. This system, while still preferred by most nurses for its ability to deliver more personalized care, has its disadvantages. The need for teaming, “cross-pollination,” and simple comingling of staff is critical in developing a supportive work environment. Purely decentralized models neglected this reality and tended to separate the staff. Newer models, referred to as “hybrid” or “decentralized teaming,” modify these restrictions. For the best patient units today, not only are family amenities being planned, but also spaces for caregivers to relax, conduct conversations, and basically recharge. Architectural firm RTKL Associates, Inc., refers to these areas as “nursing rest stops” and considers them as important to the success of the unit design as any other part of the plan.
Next: The Flexible Unit
There is no question that the universal room concept will give way to change—but what form will the changes take? Will the adaptable concept embrace entire patient care units? Will the growing nursing shortage be remedied in any way by the lessons learned thus far and the continually evolving model of universality?
Nursing models are changing to make better use of emerging technology. As already alluded to, COWs (computers on wheels), electronic bedside charting, and decentralized patient information are generating “decentralized team nursing” systems. A combination of decentralized stations and central team-support stations (data centers organized around six to eight rooms) is emerging as an efficient and flexible nursing model. Providing the best of both worlds, this system offers excellent patient supervision and the ability for medical staff to interact as desired. Adaptable rooms, built to accept a higher level of acuity and direct supervision, are more able to support a nursing system such as this one. This concept has been the strength behind the universal model and will remain at the center of future patient unit design.
The question is one of “thinking outside the room.” To truly develop an adaptable system, not just an adaptable room, design becomes critical to ensuring that the resources allocated to create the model are not wasted on a physical environment that simply does not support it.
The first questions to be answered with any new client considering this approach are, “What is the adaptable model?” and “What does it mean to you?” A 250-bed community hospital will have an “adaptable model” different from that of a 1,200-bed academic medical center, but both will benefit from the acuity-adaptable concept. A single-room design that accepts all types of patients, such as acute, step-down, and critical, may not always be the best allocation of space and money; the resources and real estate to create an entire hospital of critical care rooms are obviously substantial. Should we therefore be considering a new universal model that provides a series of universal care concepts under one roof? A single facility with a universal acute room, a universal critical room, and a series of specialty room layouts would still offer the benefits of the adaptable model, but possibly require fewer resources than are necessary to facilitate the traditional design.
Case in point: At Lancaster General Hospital in Pennsylvania, for which RTKL is helping to develop a future expansion plan, the discussions are centering on a universal acute concept and a universal ICU concept. The ICU room is designed around the same structural grid as the acute room so that acute rooms can be converted to ICUs in the future, if necessary (figure 1). The ICU room is shallower than a med/surg room, with a larger, more intensive nursing substation directly outside each two rooms for full observation. The toilet area is outboard for optimal visibility, and the two partner rooms have vision glass between them so that a nurse working with one patient can still observe the other patient. Each room is sized for either a 14-foot ICU headwall or a column, depending on the situation, and has a large view to the outside for optimal natural light.
Universal unit concept
System flexibility is considered in all aspects of the facility's design, from the patient room to the support core to the family zones. The units are being designed around a common module and common support core. This means that acute patients can more frequently avoid transfer and the units can be combined to support an entire floor of similar patient types. Additionally, the common structural model will allow the hospital to make relatively minor renovations in the future to swing an entire floor from acute to critical. Combine this with locating a number of higher-acuity or swing rooms on each floor, and the model finds a nice balance between universality and first-cost impact by decreasing the cost of conversion.
Planning for Optimal Efficiency
To achieve all that is expected from these models, design becomes more critical than ever. The physical layout of both the patient room and the patient unit will determine whether the space can be acuity-adaptable. For example, the largest of rooms, combined with decentralized nursing stations, will not be as effective in a traditional racetrack format as in a more circular configuration, with view lines between nurses and direct travel paths to the data centers and the unit clerks for enhanced nursing efficiency.
At the Indiana Heart Hospital in Indianapolis, RTKL used a new “hurricane” design to achieve maximum visibility and flexibility in the decentralized model (see “The Indiana Heart Hospital: The Future Starts Today,” HealthCare Design May 2003, p. 17). The name refers to the three-armed spiral shape of the patient tower (figure 2). The curved arms give caregivers sightlines to each patient, as well as other nursing teams, at all times.
Indiana Heart Hospital patient tower—“hurricane” design.
Each future patient floor design will fashion itself around the client, the nursing staff, and patient type. Although each will be unique, all should benefit from the lessons generated by past universal models.
Some aspects of the universal concept are here to stay, but in what form only time will tell. Acuity-adaptable means many different things to different operational models. Why else would the healthcare industry look at an example of flexibility, such as Celebration Health, with such differing opinions as to its success?
It only confirms the conclusion that each hospital, given changes in staffing, patient acuity, and technology, must make an executive decision about universality—what it means to that hospital, and to what degree it should be implemented there. The lessons learned from the first wave of universal patient rooms are a solid base on which to build the next generation of patient care units. As always, we must strive to advance the thinking behind healthcare design at every opportunity. HD