The History of Hospitals and Wards
The original facilities for the sick were most likely temples dedicated to “healing gods.” Imhotep was the Egyptian healing god while Asclepius was revered in the Greek civilization. Prayers, sacrifices, and dream interpretations played a role in their healing process, but the ancient physicians also stitched wounds, set broken bones, and used opium for pain. Plans for a 5th century BC temple in Athens dedicated to Asclepius show a large room 24 x 108 for multiple dreamer-patients.
Some believe the earliest dedicated hospitals were in Mesopotamia, while other researchers believe they were at Buddhist monasteries in India and Sri Lanka. Ancient writings indicate that the Sinhalese King Pandukabhaya had hospitals built in present day Sri Lanka in the 4th century BC. The oldest architectural evidence of a hospital appears to be at Mihintale in Sri Lanka which can be dated to the 9th century AD. The extensive ruins suggest there were patient rooms which measured 13 x 13 which is surprisingly close to the patient rooms used today. In addition to surgical instruments, archeologists found a stone “medicinal trough” approximately seven feet in length and 30 inches wide that may have been used for the first hydrotherapy with mineral water or medicinal oils.
While the Greeks were recognized as the originators of “rational” medicine, they did not have hospitals. The physicians made calls and treated patients in their homes, a practice that continued for hundreds of years. The Romans provided us with the root of the word “hospital” from the Latin word “hospes” for host or “hospitium” meaning a place to entertain. While medical schools were established in Greece in the 6th Century BC, there is general consensus that the first teaching hospital with visiting physicians and scholars from Egypt, India, and Greece was founded at Gondisapur in present day Iran in 300 AD.
Among the early, well-documented healthcare facilities were the Roman military hospitals. The plans for the one in Vindossa in present day Switzerland built in the 1st century AD shows small patient rooms with ante rooms built around courtyards. Each room was thought to hold three beds indicating the ward concept was used early in the history of hospital development. One source indicated that similar hospitals may have also been built for gladiators and slaves due their financial value, however public hospitals were not available and physicians made house calls.
As the Roman Empire turned to Christianity, the Church's role in providing for the sick became firmly established. After 400 AD, many monasteries were constructed generally including accommodations for travelers, the poor, and the sick. The monarchs of the 6th century reinforced this role with emperors, such as Charlemagne, who directed that a hospital should be attached to every cathedral that was built in his empire. Religious institutions continued to provide most of the healthcare to the poor in large, open wards, while physicians continued the practice of making house calls to the upper class. The religious influence in early healthcare is illustrated by duties of the Warden (Administrator) of St Mary's Hospital in England in 1390. He was required to not only satisfy himself of the seriousness of the medical complaint, but to also hear the confession of the patient before admission.
The wards housing multiple patients continued to be expanded and became the standard for the public hospitals for hundred of years. Often the wards were configured so the sick could see the altar to assist with their recovery. The cross-shaped plan, which is thought to have originated in Florence, Italy, in the 1400s achieved this goal with the altar in the middle and multiple wards radiating from it. The plan is similar to many hospitals today with the nurse's station rather than the altar at the center. Florence was well known for quality hospitals with good physicians and clean beds. Martin Luther, who was generally critical of all Roman Catholic institutions, even recognized the quality of the facilities during a visit in 1500.
As the wards became larger, they often became more dangerous. By the mid 1700s the Hotel-Dieu, one of the earliest and largest hospitals in Paris, had deteriorated to horrific conditions. Some wards had over 100 beds with multiple patients per bed. The wards were dark, poorly ventilated, unsanitary, and often located adjacent to other wards with infectious patients. The answer to this problem was the new “pavilion” plan, which was first implemented in the Hospital Lariboisiere built in 1854. This approach was consistent with the improvements pioneered by Florence Nightingale after seeing a mortality rate of over 42% at a military hospital in Turkey during the Crimean War. The pavilion plan provides fresh air and daylight, which improved patient recoveries and reduced infections. This plan retained the multiple patient ward approach, which was sometimes called the Nightingale Ward. The pavilion plan was used on two notable facilities-St Thomas Hospital in London and later on Johns Hopkins in Baltimore with 24 beds per ward.
As North America was explored and settled, the ward approach to hospital design was imported. The oldest hospital on the continent was built in Mexico City in 1524. The first North American Hotel-Dieu (House of God) was built in Quebec in 1639 with one 10-bed ward. In 1672, a second ward with 24 beds was added, which permitted segregation by gender. In the 13 colonies, Bellevue Hospital in New York was built in 1743 and Pennsylvania Hospital in Philadelphia received a charter from the crown in 1751.
There were exceptions to staying in a ward. One option that had been available for years was to simply pay for better accommodations. Even at the old monastic hospitals, nobles could have better housing by making donations. The approach was expanding in the late 1800s and the first “pay” hospital was opened in London in 1842 with eight single-bed rooms. At Johns Hopkins, there were two pay floors with 13 single rooms on each floor and one semiprivate room. The other option for a private room that was becoming accepted was the separation room for infectious, dirty, or hysteria cases.
With the improvements in hospital facilities and the advancements in medical practices and technology, the public and religious hospitals started to become the choice for both the upper classes as well as the poor. The perception was fading that “home was where the sick should be treated and hospitals were associated with pauperism and death”. Even though the perception of hospitals was changing, the use of multiple-bed wards continued. There were numerous attempts to improve the ward layout and to adapt the wards to multistory buildings. In 1910, the Superintendent of the Mt. Sinai Hospital in New York City developed a plan with 26-bed wards that were connected vertically on multiple floors to conserve land and help reduce travel distances related to separate pavilions. He did include quiet rooms, three of which were private. The Beaujon Hospital built in France in 1935 was one of the early multistory facilities with 13 floors. It contained 16-bed wards and private rooms as well. The need for private rooms in public hospitals was increasingly being recognized.
In spite of this recognition, the wards continued to be the predominant design approach. The number of patients per ward, however, was dramatically declining. During the rebuilding of a portion of St. Thomas Hospital in London in the 1950s, the largest ward contained four beds. The Montefiore Hospital in New York City built in 1955 has a unique layout with modules containing two- to four-bed wards and one private room sharing two toilets. Thompson and Golden's 1975 book on the history of hospitals quotes an unnamed hospital planner that said in 1962: “The semiprivate patient rooms will be as antiquated in 5 to 10 years as the four-bed wards are today”. While the planner's timing was overly optimistic, the prediction is coming true as the 2006 Guidelines for the Design and Construction of Hospitals states: “In new construction, the maximum number of beds-per-room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement”. This is clearly the trend in the United States as almost all new general hospitals are being built with private, hotel-style patient rooms even if not required by the local codes.
Private rooms are not a given in many European countries and Canada. The British National Health Services (NHS) has a Web site with an interesting description of the differences between a hospital ward and a private room. While it quickly points out that many would prefer a private room, it is not always possible unless “we are paying to go private.” The advantages of a single occupancy room are obvious and include privacy, less noise, and reduced risk of nosocomial infections. Interestingly, the disadvantages of a private room are also noted. These include:
the patient may suffer from the lack of social interaction in a private room;
it is easier to get a nurse's attention without using a buzzer; and
it is more likely that someone will notice if you fall on the way to the toilet.
Another NHS site includes a document published in June of 2009 at the Torbay Hospital in South Devon that notes the mixing of genders in wards is avoided if possible and only exceptional circumstances should lead to the mixing exceeding 24 hours. My guess is that mixed wards, even for a short time, would not be tolerated well by most Americans.
Given the disadvantages of wards, the preference for private rooms is easy to understand. The challenge before us is to find funding for all of the private rooms needed to meet the demand in U.S. hospitals. We are already spending over $7,000 per person per year on healthcare in the United States as compared to less than $4,000 per year per person in Switzerland, England, France, Canada, and other developed countries with excellent modern healthcare. Is our demand for private patient rooms contributing to the increasing healthcare costs or do private rooms actually reduce the cost of care by reducing infections and lengths of stay? This is but one of the many questions facing the healthcare industry and the design and construction community that supports them.
Hopefully, this brief history of hospitals helps illustrate the tremendous advances over the past 2,000-plus years from the temples and pauper wards to private rooms. The challenge facing us now, as in the past, is how to continue to improve the quality of the patient environment by providing cost-effective and innovative solutions. HD
Tom Gormley is Vice-President of Healthcare and Life Sciences Services at URS Corporation in San Francisco, California. Healthcare Design 2010 March;10(3):50-54