Images courtesy of Hellmuth, Obata + Kassabaum, Inc. (HOK)

Images courtesy of Hellmuth, Obata + Kassabaum, Inc. (HOK)

In last month's article I summarized the basic models for inpatient room design, as determined by the toilet room location: midboard, inboard, and outboard. I also discussed how same-handed rooms, some with canted walls, have entered recent design practice to address safety concerns. These rooms reflect evidence indicating that repetitive actions and standardization cause fewer errors in the hospital environment.

This month I will explore how Hellmuth, Obata + Kassabaum, Inc. (HOK), in designing hospitals, is interpreting the concept of same-handed rooms to create designs that meet each hospital's operational and philosophical goals. A working rule is that no two hospitals are alike—there are no cookie-cutter solutions, as these case studies will show.

Same-Handed Room: Outboard Toilet

St. Joseph's Hospital, St. Paul, Minnesota

St. Joseph's Hospital is the oldest institution in St. Paul, Minnesota, even predating the city itself. When it was threatened with closure a few years ago, an involved and active community rallied to support this center-city hospital. The HealthEast system pledged to reinvigorate the facility by locating centers of excellence within its cardiovascular and neuroscience services. The system's concept included an inpatient continuum of care to allow patients ranging from critical care to medical/surgical to remain on one floor—and perhaps in one room—for their entire length of stay.

Each floor—one for cardiovascular and one for neuroscience patients—contains 45 beds and is configured to maximize exposure to light and views of the urban setting. The design sizes patient rooms to handle all levels of care. Approximately one-third of beds received additional medical gas and power outlets and corridor-view windows to meet critical care standards on each floor. The floor shape allows more support space to be provided near the more acute beds. Each program's therapy and rehab services, as well as family amenities, are located on their respective floors to decrease patient movement.

In planning meetings, the nursing staff set the patient room priorities: patient visibility and safety. Based on their experience in other hospitals in the system, staff were predisposed to outboard toilet rooms, which allow complete visibility from the corridor. (One of the biggest debates involved how many rooms should be completely visible and the importance of patient privacy versus patient safety.) The staff felt proximity of the patient toilet room door to the patient was an important consideration. However, in most outboard settings the door is located across from the bed. The designers were concerned that the usual outboard toilet configuration would reduce patient access to the captivating views of two of St. Paul's most prominent landmarks: the State Capitol and the Cathedral of St. Paul.

The solution was a same-handed patient room, with the headwall canted toward the corridor view window (figures 1-3). This unique geometry splayed the room walls to allow for a more open family area by the window while allowing clear views for the patient. The toilet room door is directly to the side of the bed, with a grab bar leading to the toilet. There is a 12-foot-clearance headwall for each room, which meets critical care width requirements. A linear headwall is incorporated for consistency throughout but is dual-tiered in critical care rooms. The toilet room size is slightly under national and state ADA requirements to allow for this length, but the required 10% of toilet rooms do meet ADA criteria.

The patient room headwall at St. Joseph's Hospital, St. Paul, Minnesota, is canted toward the corridor for better visibility of patients

A typical patient room at St. Joseph's Hospital

The unusual geometry of the rooms at St. Joseph's Hospital allows for both visibility by staff and open views to the exterior

Cabinetwork includes a counter and sink with minimal nursing supply storage; the hospital wanted to centralize inventory as much as possible to reduce par stocking and minimize waste. Patient and family amenities include a small desk, flower shelves, and a wardrobe.

The hospital decided to floor-mount the patient toilet in view of safety concerns for overweight patients. Four patient rooms per floor are equipped with bariatric ceiling lifts and reinforced toilets and grab bars. All critical care rooms have reverse-osmosis water outlets for dialysis patients.

St. Joseph's Hospital assumes that once it is open, decentralized charting will be done on computers on wheels (COWs) or handheld computers. Multiple nursing core workstations allow for nurse seating near patient rooms. The critical care rooms are designed for a more typical centrally located “ring” nurse, to allow for continuous observation.

A full-size patient room mock-up helped refine the room shape and features and convinced staff of the design's uniquely helpful properties. Construction for the patient tower will be complete in 2008.

Same-Handed Room: Inboard Toilet

The Miriam Hospital, Lifespan Health System, Providence, R.I.

HOK and the S/L/A/M Collaborative developed the design for the Patient Services Building, which is Phase I of the Miriam Hospital master plan. The project includes one floor of 36 new acuity-adaptable beds, along with surgery and imaging facilities. The beds will serve as swing beds while two more phases are accomplished, totaling 108 new private rooms. Scheduled for completion later this year, this project engaged the hospital community in a consensus-building process that would ensure acceptance of new design directions for a campus that, until now, has had almost all semiprivate rooms.

The floor plan organizes the 36 beds in linear groupings of six rooms across from a nursing station. The patient room is a same-handed, canted room (figure 4) on a 30′6″ grid module. The headwall is canted toward the outside wall for increased patient views (figure 5). The patient toilet door on the headwall adjacent to the patient bed reduces steps from bed to toilet, a key safety issue. The “throat” into the patient room widens to create an ample clinical work space clear of the door swing; this can be closed off by a cubicle curtain. A pass-through nurse server cabinet allows access for staff from the corridor to replenish supplies and linen and to remove soiled linen.

The plan for the Miriam Hospital in Providence, Rhode Island, has an inboard toilet with convenient access for both patients and staff. Rendering by HOK and the S/L/A/M Collaborative

In the Miriam Hospital plan, the outward-canted headwall opens up more views to the exterior and provides a larger seating area at the window

The room is acuity-adaptable in that it is designed for medical/ surgical-to-stepdown (intermediate care) requirements. The 12-foot room headwall length and room size will allow this room to be upgraded to critical care standards in the future, if so desired. The project judiciously uses wood-look laminate to create a hospitality-friendly environment (figure 6). The footwall is composed of asymmetrical shelving, art, a flat-screen television, and a desk. All clinical items, such as glove dispensers and sharps disposals, are stored over the nursing counter out of the patient's direct view. The headwall consists of vertical, premanufactured, full-height millwork panels.

Judicious use of millwork integrates all elements of the patient rooms in the Miriam Hospital. Rendering by HOK and the S/L/A/M Collaborative

Same-Handed Rooms in Renovation

UCSF Long Hospital, San Francisco, California

The limitations of an existing 23-foot column grid did not deter UCSF from its goal of same-handed patient rooms within a 32-room 13th floor medical/surgical unit renovation project (figure 7). The original hospital design from the 1960s had already incorporated same-handed rooms. The typical room size of 224 net square feet required every element to be placed just so. In this case, a slight cant to the headwall allows the room to maintain minimal four-foot clearance to the footwall (figure 8). The patient toilet rooms were inboard to the corridor in order to open views to the magnificent San Francisco skyline. The hospital standard was sinks outside the patient toilet room, which allowed the patient toilet to be smaller (figure 9). ADA-compliant and bariatric rooms are located at the end of the floor plate where there is more room depth. A reclining sleeper chair further conserves space in the patient room.

At UCSF Long Hospital, San Francisco, the patient room maximizes limited space and is still same-handed

A slight cant to the headwall allows the rooms at UCSF Long Hospital to maintain minimal four-foot clearance to the footwall

A separate sink unit outside the toilet room at UCSF Long Hospital creates more circulation space at the room entry

Structural sheer walls that ran parallel along the corridor across from the patient rooms presented a formidable challenge, allowing only minimal access to core support functions, such as clean and soiled holding areas. Extensive hoteling stations—workstations designed to be used by all clinical and ancillary support personnel, as needed—maximize use of this compromised space.

Conclusion

Evidence already exists that acuity-adaptable rooms, whether built to stepdown or critical care standards, positively affect outcomes by reducing patient moves, especially during shorter average lengths of stay. Likewise, the importance of proximity of the toilet to the bed in these room designs is becoming established. As more same-handed rooms are built and analyzed, the resulting evidence will validate how much safer identical rooms really are in clinical practice.

One challenge to same-handed room design is that it represents a construction cost premium, since plumbing chases are not being shared as in the back-to-back model. Some construction managers estimate the additional plumbing costs at approximately $3,000 per room. However, other analysis has shown that exact repetition of millwork and other prefabricated elements, such as headwalls, can help offset this additional cost per room. Also, creating room mock-ups to develop the constructability technique can reduce labor costs by allowing all subcontractors to “rehearse” their construction on a single room type.

There is also the value of experience. No doubt, the next generation of patient room design will build on the knowledge acquired for same-handed room design and create an even better, more cost-efficient staff and patient environment. HD

Sheila F. Cahnman, AIA, ACHA, is Group Vice-President of Hellmuth, Obata + Kassabaum, Inc. (HOK). For further information, please e-mail sheila.cahnman@hok.com.

To send comments to the author and editors, e-mail cahnman0506@hcdmagazine.com.

Healthcare Design 2006 May;6(3):25-30