To use an evidence-based design process, you have to know what the best available evidence is. But research is published faster than anyone can read it. In this blog series, The Center for Health Design’s research team will provide insight into a few healthcare design research matters through a snapshot of 10 studies published since the 2016 Healthcare Design Expo & Conference. Serving as a sneak peek of an upcoming session at the 2017 HCD Expo, the blogs will identify why this research matters and help readers ride the waves of an ocean of research without drowning. 

The research
Falls are the result of a complex set of interactions. In this 2017 study, Dr. Debajyoti Pati and colleagues used a simulation-based approach to evaluate the biomechanics of falls to identify risk associated with physical design strategies.

Why does it matter?
As with any design problem, to optimize design solutions for performance and well-being, we need to better understand the needs, abilities, and limitations of people using the space. Past research has acknowledged the complexity of inpatient falls, which result from the interactions of organizational policies and procedures, the environment, and the people (patients and staff). This is particularly challenging for falls, as the patient is an active participant in the process. When we think about falls and patient room design, we have more evidence about tangible products (e.g., flooring, lighting) and less about how patient abilities might influence spatial layouts. The oft-asked question still prevails around bathroom location on the headwall or footwall and the use of handrails (or not) on that path. The current study helps us understand how the physical capabilities of the elderly influence specific physical environment design decisions that may contribute to falls in patient rooms.

How was the study done?
The study used an exploratory, experimental approach in two stages: developing fall scenarios representative of real-world conditions and simulating physical conditions and “potential” falls that were evaluated through motion detection software. The design variables included:
• Bathroom location (on the left or right headwall)
• Bathroom door location (facing the bed or facing the caregiver zone)
• Door swing (in or out)
• Handedness of the IV pole (whether used on the right or left arm).

Scripts representing the worst-case scenarios for falls were developed by a hospital falls committee. The researchers tested the biomechanics of 30 elders (70+ years old) of sound mind and body who were also unimpeded by medications. The motions were captured by eight infrared cameras (recording 62 reflective markers on each subject) and two camcorders at opposing angles in a physical mock-up of a patient room that included the caregiver zone (bed, IV pole, chair, over-bed table, trash bin) and bathroom (sink, toilet, toilet paper dispenser, two grab bars). About 600 test runs were conducted, 2-4 minutes each.

What was learned?
Age, gender, and bathroom location in relationship to the bed are important relative to the bathroom space, but the dominant factor for falls was posture—a result of interactions with the physical environment. The four postures significantly associated with potential falls were turning, followed by grabbing, pulling, and pushing. Turning was often associated with the other postures (e.g., pushing, pulling, grabbing), and there were often challenges in manipulating the IV pole while doing something else (e.g., moving through a door). The three most common activities in the bathroom associated with potential falls were closing the bathroom door, passing through the door, and moving to the bathroom door from inside bathroom. In the clinician zone (including walking to the bathroom door), two postures were significant: pushing and pulling. The IV pole continued to pose problems, along with restricted spaces, and layouts that forced turns. The three most common activities in the caregiver zone associated with potential falls were walking across the room, sitting on the chair, and moving the over-bed table.

The authors did not evaluate sliding doors, which have increased in popularity in new facilities, nor did they evaluate rails to the bathroom. We continue to wonder whether a rail offers any benefit, but the study outlines a clear protocol to test another set of variables.

Are the results definitive?
This research was conducted in a laboratory setting using likely scenarios acted out by elderly participants. By design, this study did not look at actual patient falls, and the further interactions of medication use or other conditions that might be encountered following hospitalization. However, the study allows us to consider whether the biomechanics of activities leading to a fall, using elderly subjects, could be generally similar to what would be found in a real-world environment. In that framework, the findings might be generalized and applied to a larger context conditions.

The takeaway
Prior research has suggested there is an increased risk of injury for the elderly when turning rather than walking straight. While the authors of the current study acknowledge completely eliminating turns is impossible, they suggest minimizing turns where possible. They acknowledge it is unclear whether a threshold in turning angle exists, beyond which the probability of falls increases.

The authors found a standard 3-inch clear opening for the bathroom door was insufficient, even for someone ambulating by themselves, let alone a condition of assisted toileting. Door swings (both away and toward the subject) added further complications to postural change: grabbing, stretching, and turning. The authors also found challenges in toilet use; in particular, the type and location of grab bars (seemingly positioned according to ADA) did not provide adequate support and the toilet flush handle promoted stretching and bending while managing the IV pole.

The IV pole was still a problem in the caregiver/patient zone, especially in configurations that forced turns. This seems to imply that bathroom doors facing the bed (a straight line) would be preferred to doors located around a corner. (Although not referenced by the authors, this type of door location would also contribute to improved visualization of the bathroom for the patient.) Consistent with many other studies, the authors observed the increased risk of falls from obstructions (the over-bed table, patient chair, etc.). In this case, however, the issue was not necessarily tripping hazards but as objects requiring postural changes to maneuver them out of the way.

Interested in the topic? Visit The Center for Health Design Knowledge Repository for more. Ellen Taylor, PhD, AIA, MBA, EDAC, is vice president for research at The Center for Health Design. She can be reached at

Summary of:
Pati, D., Valipoor, S., Cloutier, A., Yang, J., Freier, P., Harvey, T. E., & Lee, J. (2017). Physical Design Factors Contributing to Patient Falls. Journal of Patient Safety, (in press).