Creating a Healthcare Design and Practice That Lasts
Recent years have seen an increasing focus on the design and function of the patient room. The evolution of the all-private room concept, the design of the room to fit a specific function and, conversely, the universal room, have a rich history behind it.
In 2006, U.S. hospitals discharged 39,450,216 patients with the length of stay averaging 4.6 days, according to the United States Department of Health & Human Services' Agency for Healthcare Research and Quality. Patients who were once admitted to the hospital for treatment are now often treated as outpatients. As a result, today's hospitalized patients are generally of higher acuity across all levels of care, placing greater demands not only on the hospital staff, but also its physical facilities.
Many hospitals are burdened with older physical plans—some from the early Hill-Burton era in the 1940s and 1950s, others from the 1960s through the early 1980s. Nursing units in these facilities were planned around small, and sometimes semiprivate and double-occupancy rooms, allowing for a compact, economical plan with close nursing oversight.
In the late 1960s and early 1970s, prosperity led to an increased demand for more private patient rooms. There have always been good reasons for private rooms: infection control, patient privacy, and the ability to have families stay with the patient, among others. However, the cost and the difficulties of reconfiguring the hospital to accommodate the private patient room have always been the major obstacles to widespread adoption.
Early attempts to economically create private rooms involved making them very small and customized, with some schemes even using the same door for both the corridor and the bathroom. The organization of these small private rooms into nursing units took many shapes according to the fashion of the time; racetracks, triangles, Tees, circles, and plans that looked like flyswatters were not uncommon. Ironically, the highly customized space tended to ultimately be as expensive as larger and more universal spaces.
A few trends in the 1980s should be noted. In the early 1980s, a major reformation of healthcare services occurred with the adoption of the Diagnostic Related Group (DRG) method of medical reimbursement. The change from fee-for-service to DRGs limited the amount of money hospitals could recoup for any given patient diagnosis. The effect of this change pushed many procedures out of the hospital to an outpatient setting. Patients left in the hospital were sicker than ever, and the rooms they stayed in were proving more and more inadequate for the task of providing quality care.
Healthcare in the 1980s also saw an increasing pace of the technological revolution with the widespread deployment of CT, MRI, PET, and a number of bedside modalities. There was not enough space nor were there enough outlets in the patient room to accommodate such sophisticated medical equipment.
A third trend was also budding. The concepts of the Planetree movement—a movement to empower the patient and family in all aspects of treatment—were laying roots in the consciousness of the public and healthcare decision makers. The patient and family became the focus, and existing patient rooms and nursing units proved ill-equipped to accommodate this new consumer orientation.
In the 1980s, as now, architects were called upon to convert old semiprivate patient rooms to private, or to enlarge the all-too-small private rooms of the 1970s. Administrators often wanted to upgrade existing acute units to critical care. Of course, the odd or antiquated shapes of the existing nursing units did not lend themselves to ideal solutions.
Enter: “Universal” solutions
So what is the ideal solution? Architects, hospital planners, and administrators began to rethink the patient room, and by the early 1990s several new concepts had emerged. The private room, of course, would be the norm. The first steps included the enlargement and functional internal zoning of the patient room to create a space where families could stay that was separated from the space dedicated to caregivers and treatment. Amenities in larger rooms would also include lighting and temperature controls, private toilets and showers, and allow for easy accommodation of bedside equipment.
The next logical question was, “What would happen if we kept the patient in the same room and didn't have to move him or her from critical care to acute care as their medical condition changed?” This would save the hospital significant dollars through decreased transport costs and create a more comfortable and satisfactory situation for the patient. Thus, the concept of the “universal patient room” was born.
The universal patient room is designed for the worst case scenario, and layers on the additional requirements of an Intensive Care Unit (ICU) to the concept of internal zoning. The primary differences in the room itself include visibility from the corridor with a nursing substation outside the room to fulfill the direct observation requirements for ICU patients. The concept also includes a full complement of outlets and medical gasses, along with HVAC systems required for critical care.
Another consideration of a universal, or “variable-acuity,” unit is that of the cross-training of nurses to handle both critical and acute patients. Initial problems arising from the implementation of this concept include historical momentum: people tend to resist change, and the cross-training issue posed many problems, from accreditation to deployment. How do you staff for acute care at a nurse-patient ratio between 1:4 and 1:8 and still provide care for critical patients who require a 1:2 or even a 1:1 ratio?
Some solutions involve breaking out the truly intensive care into a separate unit and creating intermediate and monitored units that could coexist with regular acute care. There are many ongoing experiments and attempts to implement and refine such universal patient room care concepts. As data and evidence accumulate, hopefully, practical solutions to the various staffing and logistical issues will emerge.
While the staffing and management to create a single-room hospital stay for patients is still in the somewhat experimental stage, the value of creating acuity flexible patient rooms is proving to be worthwhile. The ability to reassign units from acute to intensive care while maintaining more traditional staffing and management patterns provides a hedge for the hospital against changing conditions, including changes in the mix of patient acuity, technology, and finances. A modest premium during initial construction could save the need for major renovation in a financially uncertain future.
Even when some hospitals cannot afford to build all rooms to ICU standards during initial construction, the rooms are often designed using standardized sizes and configurations. Components such as electrical and medical gas mains can be sized to allow future upgrading of individual rooms with minimal disruption.
The various highly specialized nursing unit configurations of the 1970s led to problems in changing and updating those floors to new functions and requirements. The aspect ratio of the floors (the ratio of the length to width) often impeded reuse. The older buildings were simply too narrow and some of the odd-shaped floors were too convoluted to allow efficient layouts of new functions. Often there were too many columns, too many plumbing stacks, and inadequate floor-to-floor heights.
Healthcare architects and designers have been thinking about flexibility, and many recent nursing units have been designed with simplified shapes and aspect rations that allow for other uses for the floor in the future, including conversion to diagnostic and treatment facilities or medical office functions. Longer structural spans and greater floor heights aid in this flexibility. Keeping patient toilets on the outside wall of the building not only opens up the patient room to the corridor for better nursing observation in the initial design, but locates intrusive plumbing stacks on the edges of the floor space, thus minimizing messy reconfiguration in the future.
The last decade or so has seen the growth of the Evidence-Based Design movement in healthcare facilities. Architects and designers have always innovated, but there has been little empirical evidence, aside from anecdotal experience and “common sense” that those innovations actually work for a broad spectrum of the population. What are the elements that constitute a healing environment? The movement is an attempt to impose the rigors of research-based methods upon the design of medical facilities.
Some big questions researchers are asking are: Can the hospital environment, together with appropriate procedural protocols, be designed to make patients safer? Can the environment be designed to minimize or eliminate medical and medication errors caused by environmental conditions? John Reiling, former CEO of St. Joseph's Community Hospital in West Bend, Wisconsin, thinks so and charged his architect, Gresham Smith and Partners, to implement physical concepts designed to enhance patient safety in a new nursing unit addition completed in 2004. The concepts advocated by Reiling have been much discussed in the healthcare design community and have had a great effect on the subsequent design of patient rooms.
Perhaps the most debated of the many ideas he proposed is the concept of making all the patient rooms completely identical in all details, including “handedness.” Before this, almost all patient rooms have been mirror images, or of “opposite hand,” to economize on plumbing. Toilets could be placed back-to-back around a common plumbing stack. Reiling argued that patient safety is enhanced if everything in the room is identical, so the caregiver would always know where everything is located. This is useful especially in emergency situations, but he believes that everyday errors would also be decreased. Other concepts he advocated included placing the door to the patient toilet room on the same wall as the bed, immediately accessible by the patient with as few steps as possible, thus limiting the incidence of patient falls.
Several projects by many of the nation's premier architects have been designed and are coming on-line that build on the concepts first deployed in Reiling's St. Joseph plan. A recent example of a project incorporating elements of patient safety with “universal” patient room concepts is the St. Elizabeth Hospital Boardman Campus in Youngstown, Ohio (figure 1). MoodyNolan and Strollo Architects teamed up to design a 108-bed hospital featuring 24-bed variable acuity nursing units and a 12-bed critical care unit, all with same-handed private rooms (figure 2). Controlled studies on many of these new projects will eventually provide evidence either pro or con to the efficacy of these measures in fostering patient safety.
St. Elizabeth Hospital Boardman Campus in Youngstown, Ohio
St. Elizabeth Hospital features 24-bed variable acuity nursing units and a 12-bed critical care unit, all with same-handed private rooms
“God is in the details”
Today's modern automobile has a lot in common with a Model T in basic concept. The principal difference is refinement. The same is true with the latest model patient rooms.
Organizing the caregiver zone to minimize clutter helps make the room look less clinical. Placing various dispensers and waste containers either behind doors and panels or out of direct view of the patient contributes to the quality of the environment. Location of the hand-washing sink by the room door within direct view enables the patient to make sure caregivers wash their hands. Large doors to the patient room and toilet room allow greater flexibility in assisting all patients. Portable or dedicated ceiling lifts aid with handling overweight and bariatric patients.
Patient and family spaces include, in addition to TV and other information systems, couches or special chairs for overnight stays, desks, and wireless Internet access. Like many hotels, today's hospitals often include patient safes for valuables within the rooms. Bulletin boards and flower shelves within the patient's view allow for customization of the patient experience.
Even toilet and shower rooms have been refined (figure 3). Many have large mirrors and hotel-like vanities to allow patients space for toiletries. A grab bar along the front of the vanity can provide security for unsteady patients. Floor-mounted toilets are proving to be more reliable and useful than wall-hung models, especially for bariatric patients. In some plans, not just a percentage, but all toilet rooms are totally ADA accessible.
Toilet and shower rooms at St Elizabeth Hospital have been refined. Many have large mirrors and hotel-like vanities to allow patients space for toiletries
The latest patient room and nursing unit designs build on a long history by offering a menu of unprecedented features and flexibility. The results can provide a high degree of patient comfort and safety with good caregiver access and oversight. Additionally, the studied use of universal precepts in patient room planning allows hospitals to avoid some of the short-sighted traps of the past by providing facilities that nimbly and economically meet the evolving needs of the 21st-century patient. HD