Design

1
Hospice Friendly Hospitals Irish Society for
Quality Safety in Healthcare
Design Dignity The case for renewing our
hospitals
Roger S. Ulrich, Ph.D.
2
Evidence Based Design

• Evidence-based design (EBD) is the deliberate
  attempt to base building decisions on the best
  available evidence with the goal of achieving the
  best possible outcomes for patients, families and
  staff

3
Evidence-Based Design (EBD) Research
Rigorous research (approx 1,500 studies to date)
links the physical environment to outcomes in
following major areas

• Improving
• Patient safety
• Other patient outcomes (such as pain, depression,
  length of stay)
• Staff outcomes (such as work satisfaction,
  retention, effectiveness)
• Overall healthcare quality
• Financial performance

4
The single most important EBD recommendation for
improving safety, dignity, and outcomes of ALL
patients

• Provide single-bed rooms for nearly all patients

• Much evidence indicates single rooms are safer,
  less stressful, and more healing for all
  categories of hospital inpatients
• Singles reduce long-term costs

5

• Widely held belief obstructing adoption of
  single-bed rooms
• Beliefs not evidence-based

Many patients (up to 50) like multi-bed rooms
and benefit from having roommates
6
UK Patient Room Preferences

• Study by Lawson and Phiri (2003)
• Surveyed 474 patients in two UK trusts
• 93 of patients in singles reported they
  preferred them over multi-bed rooms
• Those patients who had previously been in
  hospital and stayed in multi-bed rooms, and
  subsequently were hospitalized in a single room,
  shifted to preferring singles

7
Research on effects of roommates

• Studies on adult patients show that 85-90 of
  the time roommates are source of stress and
  increased infection risk
• Stress examples roommate who is unfriendly or
  seriously ill
• Roommates generate much noise
• Roommates increase risk of cross-infection

8

• Other beliefs obstructing adoption of single
  rooms
• Beliefs not evidence-based

• Single rooms prevent visual observation of
  patients, and therefore worsen safety
• Single rooms require much higher nurse staffing
  levels, greatly increasing costs

9
Visual access in a Canadian single room built
more than 25 years ago
10
Cromer Childrens Hospital Univ. of
Chicago Chicago, USA
11
Cromer Childrens Univ. of Chicago
12
Traditional vs well-designed floors Effects on
nurse activity

• Travel

• Traditional 10-18 km per day
• Well-designed 2-5 km

• Care time received by each patient

• Traditional 16-24 minutes per shift
• Well-designed 35-45 minutes

• Time spent hunting and gathering

• Traditional 40
• Well-designed 10

13
Simple linear ceiling hoist (over bed
only) Hexham Hospital, UK
Findings from Hexham post-occupancy evaluation
(Ulrich, 2007) Nearly all nurses in inpatient
units praised the ceiling hoists. Portable
hoists were disliked and used infrequently.
14
Hospital Acquired Infections

• Increase hospital costs per patient by 40,000 in
  U.S.
• Increase ICU stays by 8 days/patient, other stays
  by 14 days (Clark)

More that 200 studies were identified pertaining
to infection and the hospital built environment
(Ulrich
Zimring, 2004, 2007)
15
The future for hospitals is one of higher patient
acuity, and increasing infection risks

• Hospital patients will be sicker, more vulnerable
  and immuno-compromised
• Chronic illness patients in community also will
  be sicker, more vulnerable
• MRSA, C. difficile, other infections will be
  widespread in the community, and routinely
  brought into hospitals

16
Approx 4,000 skin scales per cubic meter
(Shiomori et al., 2002)
Surfaces commonly contaminated by MRSA
R.S. Ulrich with P.A. Wilson
17
Why Single-Bed Rooms Reduce Infection Rates

• Singles enable hospitals to separate patients
  upon admission, making it possible to prevent
  unrecognized carriers of pathogens from infecting
  others in multi-bed spaces

18
Findings effect of increased bed numbers on MRSA
transmission

• Rate of patient colonization with MRSA

• 321 higher in 5-bed wards (Kibbler et al., 1998)

Conclusion Increasing the number of beds in a
fixed area heightens MRSA cross-infection
19
Irish Community Hospital Ward 22 beds in open
room shared toilet
.3 m between beds
20
Irish Hospital Ward

• Privacy provided by curtains and low partitions

• Higher infection risk
• No privacy or dignity
• High noise, stress, sleep deprivation
• No space for family
• Risk of staff lifting injuries
• Higher costs

21
RESEARCH EXAMPLE
Effect of Single versus Two-Bed Rooms on
Infection Bronson Methodist Hospital, USA
Richard A. Van Enk, Ph.D. Themba L. Nyirenda, MS
22
Infection Rates for Cardiac Surgery Unit (Van Enk
and Nyirenda, 2003)
Move to New Building with Single Rooms
Infection Rate
23
Infection Rates of Mothers in Mother/Baby Unit
(Van Enk and Nyirenda, 2003)
Move to New Building with Single Rooms
Infection Rate
24
Unit Infection Rates of Old and New Hospital (Van
Enk and Nyirenda, 2003)
Finding infections were reduced 45 in units
that converted to single rooms
25
Problem Noise

• Hospital noise levels far higher than recommended
  values
• Noise sources are too numerous and too loud
• Surfaces are sound reflecting

More than 165 studies (Ulrich Zimring, 2007)
26

• Noise worsens patient and staff outcomes

• Elevates BP, pulse, respiration
• Worsens patient sleep
• Erodes emotional well-being
• Reduces oxygen saturation in infants
• Increases staff work pressure, strain, fatigue,
  burnout
• Erodes speech intelligibility

27

• STUDY

Hagerman, Rasmanis, Blomkvist, Ulrich, Eriksen,
and Theorell, 2005. International Journal of
Cardiology

• Patients adults (94) diagnosed with acute
  myocardial infarction in a coronary critical care
  unit in a Stockholm hospital
• Intervention Acoustics were improved by
  periodically changing ceiling tiles from
  sound-reflecting to sound-absorbing tiles

• Findings During good acoustics patients slept
  better, had less physiological stress, and a
  lower incidence of re-hospitalization

28

• Effective design measures for creating quiet
  healthcare buildings

• Single-bed patient rooms
• Install high-performance sound-absorbing ceilings
• Reduce noise sources (provide noiseless paging
  system, etc.)

29
Single rooms improve communication between
clinical staff and patients
30
St. Gemma Hospice, UK Design Jane Darbyshire
David Kendall Ltd
31
Single-bed vs. Multi-bed Rooms (Ulrich, 2004)
Single
Multi-bed
Healthcare associated infections Medical
errors Falls Staff observation of
patients Staff/patient communication Confidentiali
ty of information Presence of family Patient
privacy and dignity Avoid mixed-sex
accommodation Death with dignity Noise Sleep
quality
32
Single-bed vs. Multi-bed Rooms (Ulrich, 2004)
Single
Multi-bed
Pain Patient stress Patient satisfaction Choice St
aff satisfaction Staff work effectiveness Reducing
room transfers Adapt to handle high
acuity Patient privacy and dignity Managing bed
availability Initial construction
costs Operations and whole life costs
33
Single rooms now required in new hospitals in 40
U.S. states

• In new construction, the maximum number of beds
  per room shall be one . .
• 2006 Guidelines for Design and Construction
  of Health Care
  Facilities (section 3.1.1.1, p. 40)

Published by U.S. Department of Health and Human
Services The Facility Guidelines
Institute American Institute of Architects
34
Design to reduce stress and pain

• Provide exposure to
• Nature window views
• Calming gardens
• Art with emotionally positive subject matter
• Daylight

35
What we know about effects of viewing nature
About 50 scientific studies

• Quickly lowers psychological and physiological
  stress
• Produces clinically important pain alleviation in
  adults
• Other reduces aggression, improves satisfaction

36
Effects of nature window view on recovery from
surgery (Ulrich, 1984)
RESEARCH EXAMPLE

• Shorter stays
• Less pain
• Fewer minor complications
• Better emotional well-being

37
St. Michael's Hospital Texarkana, Texas
Architecture and Landscape Architecture Watkins
Hamilton Ross with James Burnett
38
Nortälje Hospital Sweden
39
(No Transcript)
40
Nature VR as Distraction Intervention for Women
Receiving Chemotherapy
(Schneider et al. 2003)
Pre
Pre
Chemotherapy Symptom Distress
41
Karmanos Cancer Outpatient Center Southfield,
Michigan
Evidence-Based Design Using Nature to Reduce
Stress
Infusion treatment
42
RESEARCH EXAMPLE
STUDY Natural light and depression by Benedetti
et al., 2001
EAST
WEST
Patients 602 diagnosed with severe depression
Morning 1400 lux Afternoon 3000 lux
Morning 15500 lux Afternoon 2700 lux
Findings Those with high levels of morning
sunlight (east facing rooms) had shorter stays by
3.7 days
43
Newhaven Downs House, UK Design Penoyre Prasad
44
Summary Recommendations for Improving
Experience and Outcomes for All Patients

• Provide single-bed rooms designed for good visual
  access and family presence
• Design ward layouts and nurse stations to reduce
  staff walking and fatigue, increase care time,
  and support respite from stress
• Design quiet hospitals to lessen stress, improve
  outcomes for patients and staff
• Provide exposure to daylight, nature and gardens
  to reduce stress and pain