Using evidence-based strategies to design safe, efficient, and adaptable patient rooms
The patient room is where patients spend the majority of their hospital stay and where they have the opportunity to interact with multiple caregivers. It also is the place where the potential for errors is greatest. Therefore, the design of patient rooms should be studied from the patient, staff, physician, and family perspectives. All have particular needs and desires that must be met.
It has been documented that patients want easy access, safety/security, privacy, accommodations for family, positive diversion/distraction, and the ability to see their providers. On the other hand, caregivers want the ability to see the patient and have accessible supplies/equipment. At the same time, there is pressure from families who are demanding more and better amenities as newer facilities blur the boundary between hospital and hospitality environments.
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Patients are in the hospital because they require a level of care that cannot be delivered or is not available in their home. Continued shortages of healthcare staff means creating an environment that is safest for patients and most efficient for staff is critical.
Ideally, patient room design should assure that staff members have immediate access to the patient, minimize the need for patient lifting, decrease the number of caregiver steps required to access equipment/supplies, reduce the need to transfer patients, provide workspace for all staff, and decrease physical demands on staff. There is conflicting evidence to support the design features that support these needs. Each is influenced by care processes and available technology, along with the level of involvement of the family in the care of the patient. Some of the data are supported by research and some are based on observation, opinion, or anecdotal records. A review of the various ways to organize these design features to create an efficient, patient-centered, family-friendly patient room follows and is summarized with two designs that promote safety, efficiency, and adaptability.
Patient room design strategies
Design strategies that have a positive effect on patient outcomes and family/staff satisfaction include the following: private rooms, handwashing sinks, decentralized workstations, decentralized servers, family space, acuity-adaptable rooms, and same-handed configurations. Some are supported by evidence and some by experience. All have been implemented in a variety of ways in all types of settings.
Anyone who has worked in an environment where semi-private rooms are the norm has dealt with issues caused by gender differences, incompatible roommates, and who gets the bed by the window. These issues lead to many transfers, rework, as well as dissatisfied patients, families, and caregivers. The move to private rooms has improved these inconveniences; contributed to the reduction in hospital-acquired infections; improved staff, patient, and family satisfaction; and led to fewer errors.
The placement of handwashing sinks in patient rooms and treatment areas has led to a decrease in hospital-acquired infections. However, just placing a sink in the room will not improve infection rates. The sink, in combination with staff/patient education, increases its use, thus lessening the chance for infection. In addition, technology solutions can be incorporated that remind and ensure protocols are being followed. For example, sensor technology can be used as a visual cue for the caregiver/family to wash their hands or to signal caregivers if they exit a room without washing their hands.
Users have many ideas about where the sink should be located in the room. Infection control staff suggest-and most caregivers agree-that the sink should be immediately inside the room where it is visible to all who enter and also where the patient can observe the staff washing their hands.
In a decentralized environment, caregiver workspace is dispersed throughout the patient unit. These workspaces are placed closer to (immediately outside the patient room) and sometimes within the patient room. The workspace usually has a window (controlled with blinds) that allows the nurse to observe the patient and the surroundings when necessary or that can be closed from viewing when observation is not needed.
Some practitioners believe a decentralized environment will not work without an electronic medical record. Yet, managing patient information in a paper environment is much easier when the chart resides with the patient. When all caregivers have access to the patient's chart when they need it, there is less chance of error and patient treatment occurs faster, which can lead to a decreased length of stay for the patient. Staff time spent traveling from the patient room to the centralized station to locate the chart and find the needed information is also eliminated. 1,3,8,10,11,12,15
Observations of caregivers who work in a decentralized environment have highlighted several activities that need attention. For example, to eliminate frequent trips to/from the supply and linen rooms, caregivers often will stockpile supplies and linen on an over-bed table in the hallway outside the patient room or, worse, stack them on the window ledge in the patient room. This activity leads to waste, clutter, and increased costs since often unused supplies are discarded when the patient is dismissed. A better solution is to provide cabinets near the patient room for storing a minimal level of supplies and linens.1,12,15
Most private patient rooms are designed to include space for a family member to spend the night. Some include a desk, Internet access, television, refrigerator, and locked storage. Consideration should be given to the patient and caregiver needs first when deciding where to locate this space within the room.13 Providing dedicated family space encourages participation in care and often leads to better outcomes, because family members understand how to better care for their loved one once they are dismissed to home.
Same-handed rooms (standardization)
Same-handed rooms feature an identical, repeated layout. This type of layout means the patient bed, technology, caregiver space, family space, washroom, and handwashing sink are in the same location in every patient room. The opposite of same-handed rooms are mirrored rooms. With mirrored rooms, the headwall of the patient in one room is shared with the headwall of the patient in the adjacent room. The headwall has multiple penetrations for items, such as medical gas, lights, communication equipment, data jacks, and switches. Same-handed rooms have been found to limit noise transmission between rooms (something that is measurable) because there are fewer penetrations.7
Studies are underway to evaluate the efficacy of the same-handed room. Most administrators agree standardization of rooms is important in healthcare but think there is an increased cost and no hard data so far to show a return on investment.3,6,7
Acuity-adaptable is a patient care model concept that supports the position that patients remain in the same room for the duration of their stay and the staffing level is adjusted according to their acuity. 1,2,3,4,8,9,13 Reasons for use of this room include:
Reduction in transfers of patients;
Fewer handoffs between caregiver teams;
Elimination of delays and waits;
Increased patient safety and a reduction in complications;
Decreased length of stay;
Shorter waiting time for treatment and results;
Fewer lost items; and
Fewer staff injuries from transferring patients.
Improved clinician productivity and satisfaction;
Improved operational efficiency (less cleaning due to fewer transfers);
Increased patient, family, and caregiver satisfaction;
Decreased length of stay; and
Better positioning to accommodate future care delivery and facility changes.
Designing a room for acuity adaptability has merit; however, the size and configuration of the room affects the ability to convert a medical-surgical room to an intensive care room. The placement of the toilet and the use of decentralized workstations are integral parts of achieving acuity-adaptable status.
When planning a patient room, discussion about the location of the bathroom usually gets the most attention. Should the bathroom be located on an interior (inboard) wall or an exterior (outboard) wall, or mid-board on the footwall? Should it be on the same wall as the head of the patient bed (headwall) or on the wall near the foot of the bed (footwall)? Should ICU rooms have bathrooms?
Some prefer the bathroom to be located inboard to preserve the entire outside wall for a window and maximum daylight. With this configuration, the opportunity for a decentralized caregiver workstation with a viewing window into the patient room is limited. Since the washroom and patient door take up most of the interior wall, it makes it almost impossible to create a place to house supplies, linens, and medications. In these configurations, the room door and the washroom door often interfere with each other and there is also a loss of usable floor space at the entry to the room. This forces the family space to be at the patient footwall. In the outboard variations, the family space can be adjacent to the patient at the window. Locating the bathroom on either the headwall or the footwall on the exterior wall alleviates this problem and also creates a pleasant, defined space for families near a window.
Current literature suggests that having a toilet in each ICU room improves infection control, eliminates transmission of waste to other areas, and is used by ICU patients more frequently than previously thought.5,14
Observations of toilet room locations in acuity-adaptable patient rooms
Figure 1. Inboard/headwall location. Image courtesy of HDR +Corgan; ©2011
No or minimal visibility of the patient from the hallway;
Caregiver zone next to the head of the bed is compromised;
To upgrade a room to ICU level of care, the family zone is compromised;
Non-usable space exists at the entry to the room;
Lost opportunity for a patient server; and
Opportunity for larger windows.
Figure 2. Outboard/headwall location. Image courtesy of HDR +Corgan; ©2011
Equipment, family, and bassinet may limit access to the bathroom;
Family zone is more distant from the patient;
Caregivers have immediate access to the patient upon entry to the room; and
Opportunity exists for decentralized workstation and server on the corridor wall.
Figure 3. Outboard/footwall location. Image courtesy of HDR +Corgan; ©2011
Creates family space near the patient head of bed;
Caregivers have immediate access to the patient upon entry to the room;
Opportunity for decentralized workstations;
Distinct zones for caregiver, patient, and family;
Provides an opportunity for a server on the corridor wall; and
Caregiver, patient, and family have equal access to the bathroom.
Figure 4. Inboard/footwall location. Image courtesy of HDR +Corgan; ©2011
Inefficient space at entry to the room;
Opportunity for larger windows;
Limited opportunity for visibility of the patient unless room door is open;
Room size is larger to achieve 13-foot headwall for ICU level of care; and
Family zone is compromised.
Figure 5. Mid-board location. Image courtesy of HDR +Corgan; ©2011
Extends the length of the patient unit, so caregiver travel is increased;
In critical situations when the bed is pulled away from the wall to permit staff to work, the bed and bathroom door limit movement; and
There is no opportunity for a standardized room.
Determining the right room configuration is not an easy task, but it is helpful to consider the following:
Establish guiding principles for the project;
Determine the operational care model;
Understand the dimensions of the room planned;
Read/discuss the available research;
Zone the room so family space does not interfere with caregiver workspace;
Consider flexibility for the future;
Build a mock-up room and test scenarios, such as:
What happens in a code situation? Where will people work? What equipment will be brought into the room?
What can be visualized from the patient doorway?
Where/how will fluids/waste be disposed in the ICU rooms?
How will critical patients be monitored?
Move a person on a gurney/bed into the room and transfer to the bed.
Test wheelchair accessibility into the room/bathroom.
The following project examples discuss what staff members did to decide which room configuration was best for their organization. Although the rooms are slightly different, both organizations elected to build same-handed, acuity-adaptable rooms.
The New Parkland Hospital Staff at Parkland Hospital in Dallas, Texas, decided to use a universally sized patient room for all patient rooms. They planned for same-handed rooms but were concerned if their merit outweighed any additional cost. To help them move forward with this model, a teleconference was held with users from across the country who have same-handed rooms. Participants included representatives from The Center for Health Design’s Pebble Project, Parkland Hospital, HDR’s consultants/designers, and users from Denver Health & Hospital Authority in Denver; St Mary’s North in Powell, Tennessee; New Hanover Medical Center in Wilmington, North Carolina; Wheaton Franciscan Hospital in Franklin, Wisconsin; Dublin Methodist Hospital in Dublin, Ohio; Central Washington Hospital in Wenatchee, Washington; and St. Joseph Hospital in West Bend, Wisconsin. Participants included CEOs, facility directors, and nurses. In all but one of the facilities, same-handed rooms have been in operation for at least two years. The following questions were discussed by participants:
1. What prompted the consideration of same-handed rooms?
2. What benefit was expected?
3. Were benefits realized?
4. What was the major hurdle to constructing same-handed rooms?
5. What has been the response from the patients, family, caregivers, and staff since staying/working in the same-handed environment?
6. What would you recommend? Overall, the responses to the questions were very similar. The consideration for same-handed rooms was influenced by industries where standardization led to decreased errors. All reported staff members found it easier to work in same-handed rooms. They reported that they do not need to second-guess where to find things. This is especially important during critical situations when staff from various areas converge in one place to handle the crisis. The ease of orienting float staff, residents, and medical students was also reported as a benefit. Two managers mentioned that they believed same-handed rooms were a recruiting tool because they were so easy to work in.
One of the commonly articulated reasons for not constructing same-handed rooms is the perceived first-time cost of construction. One participant indicated his organization had analyzed the cost in some detail and concluded that the premium was 75 cents per square foot compared to building mirrored rooms. Another commented the cost was less overall because it was easier and more efficient for the contractor to build due in part to the repetitious use of materials and casework.
The impact of same-handed rooms on patient outcomes was harder to quantify. All reported that falls with injury were rare, hospital-acquired infections were lowest in their system/lower than the previous environment, and patient satisfaction with noise levels was better in same-handed environment. All agreed the improvements in outcomes were due to a combination of private rooms, decentralized caregiver workstations, family space in room, and same-handed rooms, rather than to a single variable.
All who participated in the call believed standardization saved capital and operational cost, but regardless, all stated they would build and are building same-handed rooms in the future. As a result of the information gathered, Parkland staff committed to building all same-handed, acuity-adaptable patient rooms. Refer to Figure 7 for the design that Parkland is using. A decentralized caregiver workstation is located between every two patient rooms. This configuration with the toilet located outboard/footwall allows enough headwall space to convert the room to an ICU level of care. The family space is located nearest the window and away from the entrance to the room so staff members have clear access to the patient from the hallway. Caregiver space inside the room is between the doorway and the bed. This allows the caregiver to face both patient and family when discussing patient care.
Figure 6. Parkland Hospital patient room schematic. Image courtesy of HDR +Corgan; © 2011
Mock-up rooms were built during the design phase of this project. As adjustments were made in design development, the mock-up rooms were redesigned so staff could simulate different scenarios and validate the effectiveness of the final design.
Figure 7. A mock-up patient room headwall at Central Washington Hospital. Photo courtesy of HDR Architecture, Inc.; © 2011
Figure 8. A mock-up patient room footwall at Central Washington Hospital. Photo courtesy of HDR Architecture, Inc.; © 2011
Central Washington Hospital, Wenatchee, Washington
When planning for a new bed tower, staff at Central Washington Hospital (CWH) first developed a vision and guiding principles, which included:
• Convenient patient experience;
• Flexibility through acuity-adaptable rooms;
• Private rooms; and
• Support staff with appropriate technology.
To determine the room configuration that best fit the guiding principles, staff members visited several hospitals in different phases of the design process. Three hospitals had same-handed rooms but all three had standardized a different configuration. All had decentralized workstations, one had a pass-through server for each room, one had the toilet room located outboard on the headwall, and the other two had toilets located outboard on the footwall. Only one of the three had sized their rooms to be acuity-adaptable. Based on observation and discussions with staff from the three facilities they visited, staff from CWH found the following layout (See Figure 9) to best represent what they were trying to achieve.
Figure 9. Central Washington Hospital. Image courtesy of HDR Architecture, Inc.; © 2011
The decentralized workstation is located so a caregiver can observe two patients. Between this workstation and the patient room door is a server located so supplies, linens, and medications can be stocked from the corridor and used by the nurse from either the corridor or the patient room. The handwashing sink is located inside the door and visible to all who enter. The bathroom is located outboard/ footwall. This allows caregivers immediate access to the patient and preserves the patient’s view to the outside from the bed. CWH’s patient tower will open in the spring of 2011. In addition to building a mock-up room during the design phase, staff members have been improving processes, implemented an electronic patient record, and collected base-line data measuring staff travel distances. This data will be collected again in the fall of 2011 and compared to baseline data.
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