A Clear Path
Across the country, the population of patients who may experience mobility issues and/or are at risk for falls is increasing. For example, obesity rates continue to rise, with more than one-third of adults considered obese by U.S. national surveys. According to the 2010 U.S. Census, nearly one in every five adults may be classified as disabled, meaning a communicative, mental, and/or physical impairment necessitates assistance with one or more activities of daily living; of those, more than one-half are considered severely disabled. According to the 2010 U.S. Census, nearly one in every five adults may be classified as disabled, meaning a communicative, mental, and/or physical impairment necessitates assistance with one or more activities of daily living; of those, more than one-half are considered severely disabled.
Additionally, in 2014, 46.2 million Americans were age 65 and older, a number that’s expected to nearly double by 2045. Another changing demographic is the rising number of patients using prescription medications. In 2010, the Centers for Disease Control and Prevention published a study reporting nine out of 10 older Americans use at least one prescription drug monthly. This is significant because many common prescriptions are linked to side effects such as dizziness or vertigo, visual impairment, and sedation.
Functional limitations in muscle performance, compromised coordination and balance, and impaired cognitive function are qualities assigned to these patient populations and known to affect mobility. This means that patients entering healthcare facilities today have a higher risk of falling than ever before. Currently, inpatient hospital fall rates generally range from two to seven falls per 1,000 patient days, according to the 2001 study “Risk of Falls for Hospitalized Patients: A Predictive Model Based on Routinely Available Data,” by Patricia Halfon, Yves Eggli, Guy Van Melle, and André Vagnair. Changing patient population trends suggest this ratio will only rise.
Such shifts in patient demographics have implications on the design of healthcare facilities and how services are rendered. Architects and other project team members will need to rethink their planning and design strategies to address patients’ changing mobility requirements, minimize falls, and improve caregivers’ ability to monitor at-risk patients.
Patients with mobility issues often require equipment such as wheelchairs, lift chairs, and motorized scooters to help them move. Departments and rooms should be designed to accommodate this additional equipment and ensure necessary clearances, including around beds and toilets and in showers.
In the International Health Facility Guidelines, released in 2015 by TAHPI, an international healthcare architecture, planning, and software development firm, section “Part B—Health Facility Briefing & Design, 105 Inpatient Unit” begins to outline the unique requirements associated with bariatric design, such as key departmental adjacencies and equipment clearances. The 2014 Facility Guidelines Institute’s (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities also addresses the topic, suggesting inpatient spaces be designed to account for the proportion of the population considered bariatric and/or mobility impaired, but it doesn’t yet provide specific design directives.
It’s also important to plan how a patient with impaired mobility will circulate around the hospital, through corridors, and between floors. For example, some bariatric-sized equipment used to transport patients, such as motorized stretchers/wheelchairs and hydraulic gurneys, requires wider thresholds and turning radiuses and larger elevators. Lifts or specialty beds designed to aid in patient-handling tasks, such as lateral rotation, transportation, and bringing patients to sitting positions, should be accounted for in architectural, structural, and equipment planning. Designers should also incorporate storage in patient-accessible areas on inpatient floors for portable ambulation assistance devices and equipment.
Focus on fall prevention
Some of the conditions that make a patient most vulnerable to falls include uneven floor transitions, long corridors, and uneven lighting conditions. Most patient falls occur in the evening or at night, in the patient room, and when patients are unassisted. Bathrooms are the second most common location of falls. The most likely activity performed at the time of a fall is ambulation.
Designing to prevent falls should begin with the regulations codified in the Americans with Disabilities Act Standards for Accessible Design, which outlines specific design solutions to minimize changes in floor elevation, limit protruding objects, and ensure the correct placement of handrails.
In 2014, FGI introduced a section into its guidelines that outlines how to perform a safety risk assessment. The new section, and a Patient Handling and Movement Assessments (PHAMAs) subsection, was added to initiate hospital-specific research and implementation of both safety protocols and design strategies. FGI published a white paper outlining and explaining the PHAMA subsection, followed in June by a new white paper, “A Patient Handling and Movement Needs Assessment Toolkit,” cowritten by myself and James Harrell, senior medical planner at PDT Architects (Cincinnati). The paper was published by the American College of Healthcare Architects as a supplement to the guidelines and to provide specific instruction on how to design to mitigate patient falls. The publication includes a comprehensive list of mobility assistance equipment, reviews patient-handling procedures and policies, and provides a patient handling and mobility assessment template.
Measures to consider during design that aren’t prescribed in codes but support fall prevention efforts include:
• Improving lighting conditions to be both brighter and more evenly distributed to account for the deterioration of vision that’s common in older patients
• Minimizing transitions between floors and the depth and unevenness of flooring materials• Locating the bathroom near the patient bed to minimize travel distance
• Providing easy-to-read and obviously placed directional signs to minimize confusion and disorientation
• Ensuring corridors are clear of equipment and clutter by providing adequate storage space in each department
• Making mobility-assisting medical equipment, including walkers, canes, lifts, repositioning aids, and lateral transfer devices, more available to patients by incorporating storage directly in the patient room
• Designing wayfinding to mitigate the stress and confusion of navigating a hospital floor through the use of physical landmarks, clearly defined entryways, and shortened hallways.
Supporting caregivers’ needs
As the number of patients at risk of falling continues to rise, healthcare architects will need to consider layouts that improve clinicians’ ability to monitor patients and quickly assist whenever necessary. Proximity and visualization of at-risk patients by clinical staff is key.
Decentralized nurses’ stations or a hybrid configuration, which features a combination of decentralized satellite stations and a centralized hub for staff, are effective design options because they aim to improve clinicians’ proximity to patients and allow them to more easily respond to a patient in need of assistance.
Visualization of at-risk patients is equally critical. Designers can use transparent materials on the corridor wall of a patients’ room, such as door transoms, sidelights, and/or a storefront system (with the appropriate patient-controlled shading device for privacy, when needed), which allow clinicians to see directly into a patient room. When caregivers can see a patient, they are more likely to recognize when a patient needs help ambulating and actively mitigate the risk of falling.
The growing number of at-risk patients will impact the healthcare industry in the coming decades. As we plan future healthcare facilities, architects must examine the broader implications of these shifting patient demographics and provide design solutions that encourage safe patient mobility, decrease patients’ vulnerability to falls, and give caregivers the tools to assist patients with ambulation. Only by thoughtfully examining the changes to patient demographics can we design to better reflect future needs.
Regan Henry, PhD, AIA, LEED AP, is a research director and healthcare architect at E4H Environments for Health Architecture (Burlington, Vt.). She can be reached at firstname.lastname@example.org.