The last four years have continued the hospital building boom in inpatient towers, with thousands of new patient rooms coming on-line. Only the past year's economic slump has slowed the wave of construction. With Hill Burton-era hospitals continuing to age and healthcare systems consolidating and reconfiguring, the industry will eventually revive, with more replacement of inpatient towers. Since my original series of articles, “Key Considerations in Patient Room Design, Parts 1 and 2”, ( HEALTHCARE DESIGN, April and May 2006), I have been directly involved with the design of eight such projects, all 100% private room design. Some of these projects are now completed and HOK has begun postoccupancy evaluations. Based on this experience, here is an overview and update of trends related to patient room and unit design.
Nurse servers containing frequently used patient supplies are discreetly located outside of each patient room at Soin Medical Center in Beavercreek, Ohio
Infection control strategies shape patient room design
No issue has affected the design of inpatient rooms and units more over the past few years than the increased emphasis on control of nosocomial (hospital-acquired) infections and response to recent viral epidemics such as SARS and H1N1. Since we now understand that infection is spread by physical contact more frequently than airborne transmission, there is more emphasis on hand sanitation and contact isolation for patients. It is now evidence-based practice to provide lavatories or hand sanitizers at the entries to patient rooms and in prominent locations throughout the unit. A few years ago, patient units were considered adequately equipped if they had one contact isolation supply cart per floor. This cart was usually stored away in an equipment room and brought room side. In the past few years, infection control compliance personnel are taking a greater role in facility design. Most are insisting that personal protective gear or equipment (PPG or PPE) be located outside of each patient room or small grouping of patient rooms (figure 1). This includes storage of over-gowns, masks, and several sizes of gloves. More negative pressure rooms are requested-usually two to three per a typical 28-36 bed acute care unit, though anterooms are no longer required in most states.
Since supplies and linens are considered contaminated once a patient leaves a room and it is terminally cleaned for a new patient, hospitals are now greatly reducing the amount of supplies stored in the room. Even supplies sealed in plastic wrappers can be considered contaminated by touching the wrapper. Most recent patient room designs have minimal to zero storage in the room, substituted by either supply carts or built-in nurse servers directly outside the room. Minimal storage in the room may include pillows or blankets accessible to families, and the required patient wardrobe.
Hospitals are reevaluating what needs to remain in the patient room. Even the use of cubicle curtains for patient privacy is falling out of favor, since they are touched often by passing personnel. New designs of specially treated fabrics or disposable curtains may mitigate this problem. Also the use of integral blinds, Vista or e-glass reduces the amount of cleanable surfaces of corridor windows. We are reducing the amount of horizontal surfaces in patient rooms since they harbor infection (figure 2). Manufacturers are taking a fresh look at infection-resistant computer keyboards and monitor controls for the same reason.
Likewise, hospitals are reducing the size of trash disposal and soiled linen hampers so contaminated materials do not remain for long in the patient's room. The aesthetic concealment of these hampers is falling out of favor, since it reduces compliance of personnel emptying hampers. The opening-through-the-countertop disposal method creates problems of cleanability. Leaner processes have led housekeeping to strip soiled linens and take them directly out of the room for immediate laundering. Soiled linen hampers are only used for disposal of over-gowns in contact isolation scenarios.
This Critical Care room at a major public hospital in the Midwest has no supply storage in the patient room and minimal horizontal surfaces to reduce contamination and infection
Infection control compliance personnel have also dictated that supply linen carts are separated from clean supply rooms to reduce lint infiltration. Linen carts must be covered at all times, but need to have a covering that allows easy access by staff. Linen is then par-stocked outside of each patient room.
Just-in-time distribution of supplies and medication reduces storage space and travel distances
Many health systems are instituting a just-in-time (J.I.T.) method of material delivery onto patient units to reduce the amount of inventory and to build less storage on each unit. Updated electronic tracking systems can predict utilization for levels of acuity and by diagnosis. This also includes increasingly sophisticated tracking of charges per patient through automated dispensing systems such as closed cabinet Pyxis or Omnicell, open bin PAR Excellence, and other bar-coding systems. This trend reinforces the forementioned idea of decentralizing only frequently used supplies outside each patient room, since space is limited.
Medications have been dispensed automatically in most institutions for some time. JCAHO is enforcing stricter standards for access to medications by only authorized personnel. This has led to a separation of locked medication and clean supply rooms, though they should be colocated for nursing convenience. Some hospitals are utilizing med carts or med drawers at individual nurse servers to reduce medication errors; however, this involves more intensive pharmacist involvement. Recent projects have included one medication, clean supply and linen cart per 12 to 16 private patient rooms to mitigate travel distances for nurses. The amount of linen, supplies, and contact isolation PPG outside each room varies by clinical model and space constraints.
Another emerging trend is the J.I.T. delivery of equipment to reduce inventory of frequently used items such as IV pumps and wheelchairs. In this case, clinicians need to be assured of prompt delivery from a central location off-unit when needed. This reduces the size of equipment storerooms on units and reduces upfront equipment purchase costs.
Changes make acuity adaptable rooms more practical
The creation of patient rooms that can bridge acuity levels from medical/surgical (acute) to intermediate (stepdown) to critical (intensive) care continues as a strong trend. This allows for the universal design of patient units so they can be used for multiple acuities at the same time, or cohorted and changed from one level to the next over time. As units rely on decentralized nursing and J.I.T. delivery of supplies and equipment, the core support spaces are becoming more similar at all acuity levels. The issue has been mainly one of staff training for multiple acuity levels. We continue to see a segregation of acuity levels at academic tertiary centers. But many hospitals are allowing patients to remain in their rooms when their conditions are either down or upgraded, with adjusted staffing levels. The key elements for design of acuity adaptable patient rooms continue to be:
Clearances: The Guidelines for Design and Construction of Health Care Facilities 2010 Edition recognizes the need in critical care rooms to access the patient's head by increasing the clear width of these rooms by an additional foot. So the most acuity adaptable room up to critical care standards now needs a 13-foot-wide headwall, as well as a 14-foot clear width to any cabinetwork on the footwall. Designing only to minimum medical/surgical is shortsighted because of its inflexibility; we recommend that hospitals meet intermediate care standards at minimum. Typically fully adaptable rooms are designed in the 280-300 NSF range with the toilet room in addition (figure 3, 4, and 5).
Toilet rooms: Most facilities are opting to include enclosed toilet rooms, providing showers in all patient rooms, including critical care. This allows patients to remain in their room as they gain mobility. This also allows families to remain with their loved ones in the higher acuity settings. Many state funded hospitals are enforcing 100% ADA (Americans with Disabilities Act) clearances for toilet rooms, but most private institutions are meeting the minimum requirements of 10% of patient rooms per unit as meeting ADA guidelines. There is recognition that the best toilet room clearances for staff assistance of patients are not the clearances recommended in ADA, which is geared towards those who can function in wheelchairs under their own power.
Visibility versus privacy: The debate continues regarding how much visibility is required of patients, especially in the critical care setting. All agree that there must be visualization of critical care and intermediate care patients in certain situations. This necessitates glazed windows and/or doors in all rooms, so patients do not need to be moved to be visualized. Some states still require visualization of the patient's head in critical care units. To create acuity adaptable rooms that also provide visual and acoustical privacy and light control, hospitals are rethinking the use of large sliding breakaway doors in lieu of paired swing doors with smaller glass windows. Others are continuing the use of sliding doors, but with polarized or electronically activated glass to control for light and privacy. Nurses at the new de Paul Tower at St. Joseph's Hospital in St. Paul found that they opened their window blinds in critical care approximately 10% of the time (figure 6). On their neuroscience unit, patients were rotated away from the paired door to reduce stimuli. Nurses questioned at several hospitals like to visualize two patients at a time, if patient assignments warrant. Most agree that patients with extensive monitoring need less visualization, but the paradigm of the fully glazed corridor wall in critical care is still holding at many hospitals, as well as in current guidelines.
This patient room in the University of Missouri Health Care Patient Care Tower in Columbia, Missouri, meets clearance requirements for all levels of care and includes a private family seating area
Flexible headwall configurations: New headwall products from several major manufacturers allow more flexible installation and reconfiguration of medical gases, power, and low-voltage systems than ever before. Hospitals can choose to build in utilities to meet higher acuity standards day one, or forgo additional outlets to a later day without great penalty.
Safety will remain a priority
We are now universally designing to decrease patient falls by reducing the distance between patient bed and toilet, allowing for a means of support, such as an unobstructed grab bar, along the way. Postoccupancy evaluations of completed projects have shown a reduction in falls, citing both room design and better nurse communication systems as possible positive factors.
The 287-square-foot patient room and toilet at Soin Medical Center is adaptable up to intermediate care standards. It includes minimal horizontal surfaces and supply storage only immediately outside each room
There is still no conclusive evidence that the same-handed room design reduces staff errors. Physicians and some nurses are still trained to approach the patient on the patient's right side, but this can be impeded by equipment or the patient's condition. However, clinicians have reported a preference for same-handed rooms because of the reduction of sound transmission through separating the headwalls and by separating the patient doorways. There is a growing interest in the importance of noise reduction on inpatient units to allow better staff concentration during important tasks and to allow patients to sleep better.
This 320-square-foot patient room and toilet at a major public hospital in the Midwest can house all levels of patient acuity and includes a separate seating area for families
Most agree that repetitive designs of support spaces such as medication and clean supply rooms create a better lean process, so empirically are safer.
Room designs help hospitals transition into new models of clinical care
The implementation of electronic medical record keeping has progressed far more slowly than anticipated at most hospitals. Many hospitals have been surprised to find that full realization was not met on the opening date for their new facilities, rendering them “paper-light” rather than “paper-less.” All new projects are assuming a computer workstation at every possible charting location on a unit. The major issue remaining is whether a computer workstation is located immediately adjacent to the patient bed in the room or directly outside the room; economics often dictate that both are not feasible. Some nurses prefer bedside charting, allowing them to engage with the patient, while others feel distracted by family members. It is hard to say which creates better clinical outcomes and for now, it remains based more on philosophy of care.
Nurses at St. Joseph's Hospital in St. Paul, Minnesota, found that they opened the window blinds in critical care approximately 10% of the time
This inpatient room at Soin Medical Center accommodates clinician computer charting at bedside and a desk for a family laptop
Open collaboration stations, centrally located between 12-16 beds, are in favor. These stations allow for small group meetings and private charting. Hospitals still wrestle with HIPAA compliance and noise control issues that can be mitigated by acoustical materials and electronic noise baffling systems. We are designing most of these stations in modular furniture systems to allow for future flexibility in reconfiguration.
Patient and family amenities keep pace with competition
The integration of family areas into the medical/surgical/intermediate care patient room is now a standard, making centralized family waiting rooms almost obsolete except on specialty units, such as oncology. More often, we are designing smaller niches for families to find respite. Most hospitals are also integrating family areas into critical care rooms, although with some staff resistance. Family waiting rooms in critical care are still required for additional family members and children. Consistently hospitals are including family sleeper sofas, many with blanket/pillow storage included in the patient rooms. Also additional folding chairs or ottomans are a plus, accommodating multiple visitors. Postoccupancy evaluations have shown less use for a desk surface; movable tables have far more utility for laptops and family dining. Food on demand, including increased food options for family, is a growing trend. This may necessitate more space on patient units for additional food storage or dirty trays after use.
Computer web access is increasing for patients and family. Hospitals are integrating both television and internet access into flat screen monitors for patient and family use. This can include medical education programming, movies on demand, and music services (figure 7). Will increased concern about pan-epidemics reduce family access to patients? This remains to be seen.
Even though current market conditions are reducing the cost per square foot for hospital projects, designs are striving to incorporate Lean process concepts that in turn improve clinical outcomes and operational costs while reducing building size. With economic recovery and healthcare reform as big unknowns, inpatient unit and room designs are striving to be as flexible and acuity adaptable as possible. Trends of J.I.T. supply storage and infection control considerations will continue to mean less built-in elements, allowing for more future flexibility and lower costs. HDSheila F. Cahnman, AIA, ACHA, LEED AP, is Group Vice-President and Chicago Healthcare Practice Leader for HOK. She can be reached at email@example.com. Healthcare Design 2010 August;10(8):28-39