Inboard, Outboard, or Nested?
Designing the ideal patient room requires resolution of many questions: Should rooms be acuity adaptable? Should they be mirrored or same-handed? Should the headwall be vertical or horizontal, with exposed or concealed services? But of all the factors involved in planning the configuration of the ideal patient room, none is more controversial or determinant than the location of the toilet room. What are the pros and cons of the most common options? Before you flush away precious capital dollars, what do you need know in order to design the ideal room for your facility? This article provides a roadmap of key decisions to be made and illustrates how the University of Minnesota Children's Hospital, Fairview, arrived at the ideal patient room for their new inpatient tower.
The American journalist Alexander Chase once quipped that “psychiatry's chief contribution to philosophy is the discovery that the toilet is the seat of the soul.” That's hard to say. What is certain, however, is that the location of the toilet room dictates the shape of the patient room and is therefore the primary driver of layout.
Before the toilet room can be located, two decisions must be made: will the room be acuity-adaptable and will it be mirrored or same-handed? Your answers to these questions will determine your options for locating the toilet room.
Decision 1: Choosing a care model
Acuity-adaptable or universal rooms have been a popular concept for the past several years. This model seeks to eliminate multiple transfers to different units as a patient's acuity level changes throughout his stay. Advantages of this room type include improved patient and family satisfaction, reduced medication and testing errors, and fewer communication hand-off errors. The disadvantages, however, are significant.
First, it costs more to build all patient rooms to have the space, gases, electrical, and monitoring capacity required of a critical care room. Acuity adaptability also requires that all nurses be trained in and maintain competencies to care for patients at all acuity levels. Such training not only is more expensive, but also ignores the reality that most nurses prefer to specialize in a particular acuity level. Many physicians also find this model unsatisfactory due to the increased rounding times required because patients aren't cohorted together. Some early adopters of this model such as the Ohio State University's Ross Heart Hospital and Clarian Health Partners are switching to a dedicated ICU and standard med/surg units or are grouping all critical care beds together.
Decision 2: Mirrored or same-handed?
In mirrored rooms, the headwall is back-to-back in every pair of rooms (figure 1). Same-handed means that all rooms are identical (figure 2). By standardizing the rooms, goes the same-handed argument, staff will know exactly where everything is located no matter which room they are in or what unit they are on. They will be able to reach automatically for the needed supply, gas, etc., without having to waste critical time. But, since no research to date proves that identical rooms reduce errors and improve efficiency, this decision is rife with controversy.
One of the main disadvantages of the same-handed model is the increased cost associated with having to provide plumbing at each toilet room rather than sharing between rooms. At $3,000-$5,000 per room, this cost can add up to as much as $500,000 for a 100-bed hospital. This is not to say that medical errors do not also carry a high cost and that they should not be factored into the equation. Some contractors have been able to keep a lid on the increased cost by taking advantage of the standardization of the rooms by prefabricating materials, which can save on the labor required for installation. An important design implication of same-handed rooms is that the increased frequency of repetition of the patient-room module can lead to a monotonous exterior and interior unless a skilled architect is engaged.
After considering the data on both sides of this issue, the University of Minnesota Children's Hospital, Fairview, has opted to build all same-handed rooms in its new inpatient tower and emergency department and will conduct studies designed to help inform future projects. The senior leadership determined that standardization was the best fit for their hospital, as the concept also supported the institution's goal of incorporating Lean principles into the design and operation of the new building. As architects for the project, Tsoi/Kobus & Associates tackled the monotony concern head on by creating a design concept that broke the floor plate into four nursing neighborhoods of six rooms each, which are separated by notches in the building that bring sunlight deep into the center of the floor plate. These notches house the children's playroom and main conference room on each floor.
Decision 3: Options for locating the toilet room
The three most common patient room layout types can be summarized as: the inboard toilet room (figure 3), the outboard toilet room (figure 4), and the nested or midboard toilet room (figure 5). According to Mike Gallivan of Turner Construction Company in Boston, approximately 50% of the rooms his company is currently building have inboard toilet rooms, while 38% have outboard toilet rooms and only 12% use nested toilet rooms.
Inboard toilet room
Outboard toilet room
Nested or mid-board toilet room
Inboard toilet room. The inboard toilet room concept draws from hospitality design by placing the toilet room at the room entry and next to the corridor as in a typical hotel room. This approach provides the most space in the family zone, allows the best views of the outdoors and the most access to daylight, and offers the most privacy and acoustic separation from corridor noise. Multiple studies using evidence-based design have shown that these amenities reduce a patient's pain, stress, depression, and length of stay. This design also clearly supports patient-/family-centered care. The primary deficit of the inboard model is that it limits staff visibility of the patient from the corridor and, therefore, is not the best choice for patients who require more vigilant monitoring. One way to address this shortcoming is to shift the toilet room to the footwall side of the patient room. But while that adjustment can improve the visibility of the patient from the corridor, a downside is the increased travel distance to the toilet room from the bed, a factor that has been linked to increased patient falls.
Outboard toilet room. The outboard toilet room locates the toilet room along the exterior wall. The main advantage of this design is that it provides maximum patient visibility from the corridor. It is therefore the obvious choice in critical care units where observation is a constant activity. But this increased visibility comes at price. The outboard approach sacrifices patient privacy and restricts family space and views to the outside. Opponents also argue that patient checks should occur at the bedside, not from the corridor. Additionally, the architect must skillfully incorporate privacy elements (such as spandrel or frosted glass) to mitigate their visual impact on the exterior expression.
Nested toilet room. The nested toilet room locates two toilet rooms between every two patient rooms, resulting in one inboard and one outboard toilet room. This layout resolves the issues of patient visibility, privacy, adequate family space, and views to the outside, but makes the building longer which in turn adds to staff travel distances and may keep the building from fitting on its site. Nested toilet rooms also cannot be made identical, prohibiting complete standardization. The nested model shares with the outboard toilet room the design challenge of how to treat the exterior since half of the toilet rooms are located along the exterior wall.
Resolving the debate: One hospital's approach
After careful consideration of all options and taking into account the preferences of representatives from the staff, the Parent Advisory Board and the Kid's Council, the leadership at the University of Minnesota Children's Hospital, Fairview, chose to build same-handed inboard toilet rooms in their new inpatient tower. The hospital concluded that the inboard model best supports their overarching principle to “create the best environment to provide and receive children's healthcare.”
To help them arrive at their decision, the leadership established the optimization of the patient and family experience through a plan and design that fosters patient- and family-centered care as an initial guiding criterion. Ultimately, they concluded that the benefits offered by the inboard toilet room best supported this principle. To address the concern some staff expressed about being able to see the patient without going into the room, Tsoi/Kobus & Associates added glazing in the door and pulled back a corner of the toilet room to improve the sight line. Cubicle curtains are provided at the door and along the family zone so privacy is achievable when desired.
So, how do you decide the best toilet room model for your facility? Start with the big picture and establish your guiding principles and operational care model. Then allow those principles to help you navigate this and all other decisions large and small, no matter how controversial. HD
For more information, visit http://www.tka-architects.com.
- Ulrich R, et. al., A Review of the Research Literature on Evidence-Based Healthcare Design. Health Environments Research & Design Journal, Spring 2008.
- Bentley F, et. al. Research Driven Design: Tracking the Evolution of Evidence-Based Health Care Architecture. The Advisory Board Company, 2008.