We shape our buildings;

thereafter they shape us.

—Winston Churchill

In the past, hospital design focused on low cost per square foot or the incorporation of new technology, and was based on models of nursing care derived from industrial settings where the transmission of infection was not a consideration. For example, placing two or more patients close to each other would seem to be more efficient for nursing care, as this would require that nurses take fewer steps between patients and would minimize square-footage requirements. In this model, the patient was considered to be like a product requiring assembly by the staff.

Newer design models incorporate the patient’s perspective and are based on medical-outcome evidence, patient satisfaction, and patient safety. One of the most important shifts in hospital design in the past few years has been to design patient-care spaces for infection control.

Treatment of patient infections comprises a significant percentage of the operational costs of any hospital. Many patients are admitted with infections or with diseases that make them more susceptible to infection, and without proper infection control, infections can spread among patients and staff. Standard hospital-cleaning procedures1 and standards for air and water systems2 have reduced the risk of infection from the hospital environment; hence, very few hospital-acquired infections come from the building’s air or water. Today, the primary source of hospital-spread infections is personnel who move from patient to patient, often carrying medical devices and equipment. Modern hospitals should be designed to reduce this risk of transfer of infection by personnel.

An important factor in the transmission of infection is proximity, and one of the most effective ways to reduce the risk of transmission is to increase the functional distance between patients. Open ward or semiprivate room designs (figure 1) make it more likely that infections can be spread among patients and staff. The private room design (figure 2) makes the spread of infection less likely because patients and visitors do not share space and equipment with other patients.

Patients carry microorganisms on their bodies, and patients with infections can shed increased numbers of infection-causing microorganisms. The items surrounding the patient (bed, furniture, equipment, etc.) become contaminated with the patient’s microorganisms after he or she spends more than a few hours in his or her room. The most common way infections are spread is by staff members touching a patient or contaminated piece of equipment with their hands, then touching another patient without washing their hands. Hand hygiene (figure 3) is the single most important way to prevent hospital infections, and the current Centers for Disease Control and Prevention hand-hygiene guidelines3 clearly mandate that all healthcare personnel decontaminate their hands as they enter a patient’s room and as they leave the room. Locating a dedicated hand-washing sink, preferably with hands-free operation, near the door of each patient room makes staff hand hygiene easier and contributes to a safer environment for patients, staff, and visitors.

Methodology

In 2000, Bronson Methodist Hospital in Kalamazoo, Michigan, replaced its older, primarily semiprivate-room hospital with a new facility (figure 4 and figure 5) incorporating private rooms. In the semiprivate room design, two patients shared the room and a bathroom, and most hospital rooms did not have a dedicated hand-washing sink for staff; staff members used the patient bathroom to wash their hands. The pediatric and adult critical care units in the old hospital featured private rooms; the semiprivate rooms were used in the noncritical care units. The Neonatal Intensive Care Unit remained a multibed design in both facilities. In the new private room design, each patient room has a bathroom and a separate hand-washing sink in a convenient location for staff use.

Bronson hypothesized that the rate of infection would be reduced in its new facility and designed a study to test that hypothesis. Bronson measured the rate of hospital-acquired infections monthly in its old, semiprivate units for two years before the opening of its new hospital and compared those rates with the two-year period following occupation of its new, private-room hospital. Bronson did not change its nursing staff or patient-care model, the number of beds and patient volume did not change significantly, and the types of patients and their diagnoses did not change significantly during this period.

Findings

The total hospital-acquired infection rate among all patient-care units in the new facility declined 11% (from 0.89 to 0.80 infections per 1,000 patient days) as measured monthly for 24 months in the old facility and the first 24 months in the new facility. Among the six patient-care units that changed from a semiprivate to a private room design, the infection rate declined by 45%, a statistically significant difference. The infection rates in the critical care units that did not change from a semiprivate to a private room design also declined, but the difference did not reach statistical significance. This reduction translated to five fewer infections or four fewer infected patients per month in the new facility. This study showed that the infection rate was reduced in the private-room facility and suggested that the reduction was because of the private room design.

The study did not measure staff hand-hygiene compliance during the comparison period, so we could not determine if the reduction in infection was because of reduced proximity or increased hand hygiene by staff. It is likely that both factors contributed to the safer environment.

Discussion and Conclusions

Because infections significantly add to the cost of medical care, reductions in infection rates significantly reduce the operational costs of the hospital and the overall costs of medical care, as well as making the hospital a safer environment for the patient. The reduction in operational costs due to a lower infection rate alone should pay for the additional construction costs of the private-room design and produce a positive return on investment in only a few years.

Private hospital rooms have many advantages, such as increased privacy (for patients, visitors, and staff), fewer medical errors, a quieter and more restful environment, and reduced stress for the patient, as well as a potential reduction in infection rates. Recent hospital design and construction guidelines4, 5 incorporate this new evidence and require a private room design for new construction and remodeling. Incorporating research findings and the contributions of infectious disease epidemiology has improved the practice of hospital design. HD

Richard A. Van Enk, PhD, CIC, is Director of Infection Control and Epidemiology at Bronson Methodist Hospital, Kalamazoo, Michigan. For more information, contact Dr. Van Enk at 269.341.6316.

References

1. Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003; 52 (No. RR-10).
2. American Society of Heating, Refrigerating and Air-Conditioning Engineers Report of the Presidential Ad Hoc Committee for Building Health and Safety under Extraordinary Incidents Washington, DC:ASHRAE, 2003.
3. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51 (No. RR-16).
4. Facilities Guidelines Institute and the AIA Academy of Architecture for Health, with assistance from the U.S. Department of Health and Human Services. Guidelines for Design and Construction of Hospitals and Health Care Facilities, 2001 edition.
5. Facilities Guidelines Institute and the AIA Academy of Architecture for Health, with assistance from the U.S. Department of Health and Human Services. Guidelines for Design and Construction of Hospitals and Health Care Facilities, 2006 edition.

Sidebar

The Pebble Report focuses on the research efforts and interests of The Center for Health Design’s Pebble Project partners, a project that began in 2000 with one provider and has grown to more than 30.