Key Considerations in Patient Room Design, Part 1
Who would have imagined 10 years ago, when industry experts were predicting the downsizing of the inpatient hospital, that 2005 would bring a boom in construction of bed towers? Besides the increased need for beds in many markets, the obsolescence of the hospital chassis created during the Hill-Burton period of the late 1940s through the mid-1970s has forced many a hospital to finally build new after years of stopgap renovation. As each healthcare organization wrestles with this significant expenditure, the question is: How best to build a framework for the next 50 years? The key element in answering this is the patient room, the area repeated most in the structure. This element will, by definition, have the greatest impact on patient care delivery, patient well-being and, of course, cost.
The standard semiprivate patient room from the Hill-Burton years was a vast improvement over the open 4- to 6- to 10-bed wards first proposed by Florence Nightingale. A patient unit in the semiprivate room model could have up to 60 beds located within manageable distance of a central nursing station. Two patients per room seemed like an acceptable level of privacy for a system that allowed restricted family interaction at best. Private rooms were limited to those required for infection control or for patients of significant means. In fact, the standard of 80 square feet per patient bed with shared toilet for up to 4 beds remains legislated in many state health codes. However, semiprivate rooms built during this period have become obsolete for 21st-century medical practice because of:
operational inefficiencies and lower occupancy rates because of the transfer of male/female roommates to maintain same-sex occupancy, which increases pressure for private rooms;
proven higher risk of nosocomial infections;
lack of privacy for caregivers to discuss medical information, as mandated by HIPAA standards; and
reduced visibility of patients for nursing staff.
Indeed, all types of patient rooms and units of this period have the following significant issues:
Minimal clearances for medical equipment necessitated today by increased pa-tient acuity;
Insufficient power, data, and medical gas outlets to support increased equipment and information technology needs;
Obsolete HVAC systems that do not supply sufficient air changes or filtration to meet current standards;
Limited wheelchair accessibility around beds and into toilet rooms, with little or no room for staff assistance;
No space for visits by multiple family members or for loved ones to “room in”; and
Minimal window areas for natural light and views.
For these reasons, and others related to marketing, the standard of care has shifted to the single patient room paradigm. Private rooms increase patient and family satisfaction-in competitive markets, a key advantage. Moreover, although many hospitals have chosen to “depopulate” patient units by using semiprivate rooms as private rooms, only some of the above issues can be solved by doing so without significant capital expense, phasing, and downtime. Cost-benefit analysis has convinced many hospitals that new construction is most viable, especially since the cost of renovation can sometimes exceed the cost of new construction.
The design of an acute care patient room for today and the future cannot be a cookie-cutter solution. Each design represents the goals and operations of the healthcare facility. Here is a summary of key design questions to aid in reaching the most appropriate design solution for a particular facility:
Level of acuity. What acuity level will patients housed in the room have? Will there be multiple levels of acuity?
Specialties. Will the room/unit be flexible or designed for a specific medical specialty?
Model of clinical care. What is the nurse-to-patient ratio and how will it be implemented? Will clinical care on the unit be centralized or decentralized? What would increase staff productivity and satisfaction?
Supply distribution model. How and where will medical supplies and pharmaceuticals be distributed, stored, and tracked, and by whom?
Visibility versus privacy. How much do clinical staff need to visualize the patient? How important is patient/family privacy to the population served?
Safety. To what lengths will the rooms be designed to increase patient safety? What features can be instituted to reduce staff errors?
Patient/family amenities. What are the most attractive amenities for patients and families that will increase comfort, healing, and satisfaction?
Let's take a closer look at each of these factors.
Level of Acuity
Configuration, monitoring capability, and nursing ratio define the acuity of a typical acute care patient unit. Typically, the classifications have been medical/surgical, step-down/telemetry, and critical (intensive) care. Traditionally, each type of unit was distinct and designed to specific code requirements. Today, however, the increased acuity of inpatient populations is driving designers on most new projects to design medical/surgical units to telemetry standards, with additional patient monitoring, power, data, and medical gas outlets to decrease patient moves.
One key issue is whether critical care patients should be segregated on a unit or in adjacent units per floor, or combined with medical/surgical and telemetry beds for a continuity-of-care environment on a single unit. In this case, the design of patient rooms is either for two levels of acuity or for one type of universal room adaptable to all levels of acuity.
The universal room has many implications. If all rooms meet the highest level of acuity-critical care-that is the most costly room type. Likewise, the nursing core must be larger to accommodate critical care support requirements. On the other hand, the merits of the multiacuity or universal room include future flexibility, minimal patient movement, reduced transport costs, and reduced documentation errors. Practically speaking, this concept is most successful in specialty hospitals such as cardiovascular facilities, where length of stay is most predictable.
Many patient rooms include support for medical specialties, even outside a specialized unit, and this can transcend patient acuity. These specializations can include treated water sources for dialysis patients and ceiling lifts or floor-mounted toilets for bariatric or spinal cord patients. Most units include positive- or negative-pressure isolation rooms. The level of specialization to be incorporated into a typical unit should be determined early, since it can be costly.
Model of Clinical Care
Once the acuity level of the patient room is established, the model of nursing care must be determined. Historically, documentation revolved around the location of the paper charts. With the advent of the electronic medical record (EMR), any clinician can access charts from any location. The first wave of EMR patient unit designs enthusiastically decentralized all documentation activities to bedside computers or to charting “cockpits” outside two to four patient rooms, sometimes eliminating the central nursing station altogether. The advantage of this concept is to bring nurses closer to patients with direct visibility into patient rooms-a plus for more acute patients but a rather costly solution. Postoccupancy evaluations show that clinicians gravitate to central workstations because of a strong need to collaborate.
The question then becomes: Are decentralized stations necessary at patient rooms and, if so, how? Loyola University Medical Center in Maywood, Illinois, is using furniture instead of fixed counters in alcoves designed to accommodate stationary computers, assuming that handheld computers or computers on wheels (COWs) will become the norm in the future. Some hospitals are assuming the existence of this technology now in their designs. The number of patient care stations in the core and the distance from these stations to patient rooms are key considerations, given the aging of staff and the growing acuity of patients.
Supply Distribution Model
Another key design element is the hospital's supply distribution model; i.e., how much supply inventory control is required. The less inventory control, the more likely that supplies will be replenished continuously as they are depleted—in or just outside a patient room for easy access to most-used items. If a centralized automatic dispensing system exists, then fewer supplies are stored in the room; they are stored in centralized clean-storage rooms. Likewise, hospitals must decide whether linens will be available in patient rooms, since linens must be rotated when a new patient arrives. The more cabinetwork in a room, the greater the cost, especially since its installation is multiplied many times.
Visibility Versus Privacy
Patient acuity determines the importance of visibility versus privacy for patients. The higher the level of acuity, the more the patient needs observation by clinicians. In less acute settings, both acoustic and visual privacy for both patients and family become primary. The two needs collide in the creation of a universal room, where critical care demands visibility but medical/surgical patients and their families may crave privacy. Integral blinds in corridor windows can allow flexible privacy control, but they are costly. These considerations can also drive the decision to employ inboard toilets (more privacy) versus outboard toilets (more visibility).
Based on statistical evidence of medical errors, there is now a greater emphasis on patient safety issues and, most specifically, on reducing patient falls. Since most falls occur between the bed and the toilet, new designs try to reduce this distance, even adding grab bars along the wall. Reducing the distance from the caregiver to the bed can also increase safety. Also, the concept of repetition of key room elements has been shown in initial studies to reduce medical errors (e.g., “same-handed” rooms in which every patient room has the same orientation).
As patients and their families have more choice in the marketplace, the amenities provided become more important. For example, allowing at least one family member to “room in,” even in critical care rooms, has become standard practice. Families are no longer using family lounges except in the most acute settings because more of today's rooms are private. HD
Sheila F. Cahnman, AIA, ACHA, is Vice-President/Principal of Hellmuth, Obata + Kassabaum, Inc. (HOK)
Once you have established basic design criteria, the next step is to look at basic models of inpatient room layouts and decide which model most closely meets the hospital's goals. In a most basic sense, one determines the design of the patient room by the location of the toilet room: midboard, inboard, or outboard. Each location has its pros and cons.
Saint John Health (California).
Midboard Toilet Model (figure 1, A-C)
The midboard toilet concept locates toilets back-to-back between patient rooms. This design allows rooms to be square or rectangular, the best shape for any acuity level. The full-width wall along the corridor allows maximum visibility, while the full-width window wall allows maximum space for family seating. The bed can also be nearer to the corridor door for easy staff access. The toilet room is across from the bed footwall, a safety concern because of the distance patients must travel after getting out of bed near the headwall. The primary negative is that to allow for wheelchair-accessible or ADA-compliant toilet rooms with showers, each pair of rooms generates approximately six feet of additional corridor length. Given the increased travel distance generated by all private rooms, this additional building length can be significant. Midboard toilets also do not allow for same-handed rooms.
Methodist Willowbrook Hospital.
Inboard Toilet Model (figure 2, A-C)
This concept locates the toilet room on the corridor side, adjacent to the patient room door. This allows the toilet to be most accessible for patient assistance and housekeeping. It also allows the window wall to be open to its full width, maximizing natural light and views. This configuration provides a wide seating/sleeping area for families. By placing the toilet inboard, there is more sound attenuation from corridor noise and more privacy, which can be appealing for patients who stay longer. The in-room nursing sink counter/storage can be out of the patient's view, immediately inside the door. A drawback is that the reduced visibility from the corridor and the distance of the patient's bed from the door makes this room type less ideal for more critically ill patients. Creating windowed alcoves beside doorways can mitigate this problem and allow for decentralized nursing.
William Beaumont Hospital.
Outboard Toilet Model (figure 3, A-C)
Most multiacuity rooms designed to date have outboard toilets. This allows maximum visibility of the patient from the corridor and reduced distance from the bed to the corridor. However, there are also several negatives. In most rooms of this design, the window and family area are set back from the patient, reducing views and light and making family interaction more difficult. The patient toilet is opposite the bed, creating safety concerns because of distance, and housekeeping must traverse the room to clean the toilet room. The more successful outboard toilet configurations are on a 32-foot column grid that allows the window and toilet room adequate width. However, this adds greater building length, increasing costs.
Toronto General Hospital.
Healthcare designs are incorporating the evidence that repetitive actions and standardization cause fewer errors, a concept first applied in manufacturing. This is the impetus behind the same-handed room; i.e., creating the same room orientation throughout to reduce medical errors. No study has yet proven the effectiveness of this application; it is largely intuitive. The same-handed room can have either an inboard or outboard toilet room.
Specifically, the same-handed room locates all power and medical gas outlets, supply storage, and monitors in the same location in each room. A single rather than back-to-back headwall reduces sound transmission. Toilet rooms are no longer back-to-back, thus increasing mechanical/plumbing costs. Offsetting much of this cost, however, is the repetition of other elements. Some cost consultants have determined an additional cost of roughly $3,000 per room for the same-handed configuration.
The same-handed room model opens up other design possibilities. Canting the headwall toward the window (figure 4, B) increases the patient's views to outside. This is especially important on sites with beautiful, life-affirming views (figure 4, A). Canting the headwall toward the corridor can increase the patient's visibility to the staff (figure 4, C).
Once the patient room plan is determined, the hospital must confirm the detailed design features for the headwall, footwall, nursing support area, and family amenities.
Headwall. The wall behind and the ceiling over the patient's head are the most important spaces for incorporating clinical care elements. Provisions for medical gases, power, information systems, monitoring, and critical equipment storage are located here. A hospital must determine which mode will deliver these services: a headwall system (premanufactured or built-in), a power column, or an articulated-arm boom. Premanufactured or built-in headwalls are most common in lower-acuity and multiacuity settings and are the least expensive. The proposed highest acuity level will determine the number of each outlet type. There must also be lighting for patient examinations, patient reading, and ambient settings.
Footwall. The footwall displays those items that the patient will directly view, such as the television, clock, and tackboard/dry-erase board for information displays. It is also the ideal location for artwork. Most new hospitals are incorporating flat-screen television monitors, some with computer capabilities.
Nursing support. Depending on the decision regarding supply distribution, the nursing-support area within the patient room can consist of a simple sink and counter, or additional drawers and cabinets, and a computer. Soiled trash and linen hampers can be concealed or exposed; if they're concealed, the room environment is enhanced, but the hampers are more difficult to access. Special consideration is required for contact-isolation supplies that also can be stored in movable carts. Some hospitals prefer that these supplies be located outside rooms so that they can be shared and relatively protected from contamination.
Family amenities. Accommodations can be a built-in sleeper sofa, foldout bed, or sleeper chair. Some hospitals allow small refrigerators for family food storage and larger wardrobes for visitor coats. Computer outlets and Web access are newer amenities.
—Sheila F. Cahnman, AIA, ACHA