When planning healthcare facilities, designers have much to consider – where to place caregivers’ work stations to best serve patients and allow for collaboration; how to use nature to speed healing; and what kinds of special patient needs will the hospital be required to handle, to name just a few.
The following are some key topics from the Healthcare Design Expo & Conference addressing these considerations.
Centralized vs. Decentralized Nursing: Debate Continues
Where to place nurses in relation to patient rooms to achieve the most benefit is a question hospitals face when building or renovating.
With centralized inpatient nursing, each floor has one large nurses’ station out of which all the nurses work. In decentralized layouts, smaller work stations are spread throughout the floor. Nurses work right outside of the three to four patient rooms they are responsible for.
In one case study, St. Anthony Hospital in Denver, Colo., was building a brand-new facility. They collected data in their old building, which used centralized nursing, while the new facility was being designed and built. They then collected similar data in the new hospital, which used a decentralized layout, for the first year. The study found that, while response time was improved and nurses were able to spend more time with patients, patient satisfaction surveys were unchanged. Efficiencies improved, with nurses walking less and therefore being less fatigued, but staff also felt that, because they spent less time together, their ability to collaborate and communicate suffered.
There’s no clear-cut winner of which layout is better. It really depends on the culture of the hospital which will work better for its staff and patients.
Opportunities to Incorporate Biophilic Design in U.S.
Biophilic design is based on the knowledge that there are things in nature that are naturally pleasing to us, make us feel better and heal faster. Already healthcare facilities have been moving away from sterile-looking environments toward using warmer colors, more windows and artwork. The next step in the evolution of healthcare design is bringing the healing power of nature to patients.
The main case study was Ng Teng Fong General Hospital in Singapore
that was almost completely naturally ventilated, with windows for every patient and greenery planted outside each window.
Here in the U.S., examples included a hospital in Indianapolis that has a large rooftop garden where food is grown for the hospital kitchen and patients can visit and learn about fresh produce and its importance to health. See the Sky Farm at Eskenzi Health
Located in Salem, Oregon, the Oregon State Hospital
has almost every room has a view to the outdoors, which has been beneficial for staff health as well.
Since evidence continues to mount showing the many benefits of nature on patient well-being – including reduced stress and faster healing – which also provides a financial benefit to hospitals, biophilic design will be embraced more in coming years.
Using Design to Improve Patient Survey Scores
Every year, hospitals across the United States are rated based on their HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey score. The survey provides a national standard that allows comparisons to be made between hospitals based on patients’ perspectives of care received.
Questions posed to patients cover care from nurses and doctors as well as the hospital environment:
- How often did nurses/doctors treat you with courtesy and respect?
- After you pressed the call button, how often did you get help as soon as you wanted it?
- How often did doctors listen carefully to you?
- How often were your room and bathroom kept clean?
- How often was the area around your room quiet at night?
Thoughtful design can positively affect survey scores. By placing nursing stations throughout floors (decentralized layout) and storage for supplies at point of use, nurses are able to respond to patients quicker.
Designing a hospital that is able to be cleaned – choosing materials that are easily cleanable, reducing places for dust and germs to collect – and thoughtful storage to reduce visual clutter conveys that the hospital is clean and well-organized.
Allowing patients to control their room temperature and window shades; giving them a place to display photographs and flowers; and providing access to the outdoors all help reduce pain and stress. By designing walls between patient rooms and between rooms and corridors with sound-absorbent material, you can help make patients’ rooms quieter at night.
Patients who feel safe, comfortable and valued will continue to use and recommend that hospital.
Texas Children’s Hospital Ready for Ebola Outbreak
In 2014, when the first Ebola (a deadly disease caused by an infection of the Ebola virus) case was diagnosed in the United States during a worldwide epidemic, only four medical facilities in the country were designated Ebola treatment centers by the Centers for Disease Control and Prevention (CDC).
Texas Children’s Hospital saw the need, and in 11 months was able to build an eight-bed Ebola-ready isolation unit that takes into account the special needs of children. Bright colors and large windows make the unit look friendlier and less scary in appearance. Viewing windows and special audiovisual equipment allow children and families to see and communicate with each other.
Each isolation patient room has an anteroom for donning personal protective equipment (PPE), and two patient rooms share another anteroom for doffing the PPE. Other special design considerations included durable finishes due to regular bleach wipe-downs; solid surfaces in the bathrooms (no grout); furniture that can be removed when special isolation needed; and two smoke compartments in case of a fire, since patients wouldn’t be able to leave the unit.
While the hospital has not had any Ebola patients yet, they have been able to use their specialized isolation unit to care for children with other highly infectious diseases.
Wide Halls Circle Back to Past
Debate about the layout of an inpatient unit usually sways between two main types of styles, Racetrack and X-Hall. Recently, a “new” variety of inpatient unit has gained attention that, oddly enough, grew from historical healthcare practices.
All planning models reference the collaborative spaces (nursing and clinical support spaces) either being “onstage” or “offstage.” The argument becomes, what is better, for patient and staff? Some models recommend “Off-Stage” for Outpatient Clinics and “On-Stage” for Inpatient Units. The Racetrack resembles the On-Stage model most accurately, while the X-Hall takes the collaborative space off the patient wing and into a central zone. The Wide-Hall model shakes up the plan into a hybrid version of both models, where some patient care is maximized at the patient room and other collaborative spaces are taken away from the patient wing into a central care zone.
A quick tour of each model is represented below. Images are courtesy of Healthcare Design Expo & Conference, Gaylord National Resort and Convention Center Washington, D.C., November 14-17, 2015 including the above Collaborative Space model.
Typical hospital floor plans are the “Racetrack” style, with patient rooms on the outside, patient support in the middle, and central, onstage collaboration/support area.
The “X-hall” style is more like a “T” shape and has double-loaded corridors with minimal onstage collaboration/support areas.
Harkening back to the days of Florence Nightingale, a not-so-new concept in inpatient room design is making its way back to the forefront.
A “Wide Hall” layout widens the typical eight-foot corridor to 15 to 20 feet wide! This allows for a caregiver zone to collaborate right outside of patient rooms as well as circulation. Instead of having the caregiver, family, and team walk back to a nurses’ station, they collaborate outside the patient’s room, keeping excellent patient observation and team-based approach near the patient. This model is used at the Orbis Medical Centre in the Netherlands. Families can use these Wide-Hall areas for a break, to give privacy for examinations, or to speak with the care team; instead of retreating to a family lounge, they can stay right outside their loved one’s door.
The benefit for the care team is increased collaboration and peer line of sight, visibility of patients and to family members. The peer line of sight assists with the mentoring and development of less experienced staff. The extra space gives doctors and nurses room to gather and discuss patient care “onstage,” while also keeping them in closer contact with the patients. This is also a benefit for patients as they can see their caregivers functioning as a team instead of as unrelated individuals who suddenly appear in their room.
All versions of inpatient unit planning should be considered carefully, as each model has its pros and cons. The Wide-Hall brings a historical reference into today’s requirements for collaboration and patient privacy while providing excellent team-based approach to patient care.
Covering Costly Bariatric Care
Reports are surfacing daily that obesity is becoming more and more of a health care concern, with governmental regulations and patient care trying to keep pace. In 2010, obesity was declared a “disability,” and in 2013, the American Medical Association recognized obesity as a “disease.” However, a huge disconnect has been observed by caregivers, healthcare administrators, and designers on how to manage this type of patient.
Up until the publication of the 2014 edition of the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities, there had been very little code-driven criteria established for bariatric patient care. The 2014 FGI guidelines began to address the impacts of bariatric patient care on the built environment.
However, the current Centers for Medicare & Medicaid Services (CMS) reimbursement for bariatric rooms is the same as standard rooms, even though the cost of care can be up to five times more for bariatric patient care.
The problem arises with the identification of bariatric patients. The current methodology of bariatric patient classification is simply by Body Mass Index (BMI). This index would classify The Rock (Dwayne Johnson)
as “Morbidly Obese” because of his height/weight ratio!
Obviously, there is a large gap between the classification of this disease and the reality on how to manage bariatric patient care. This inequity results in financial burdens for hospitals, which are also concerned with how to effectively treat bariatric patients with respect and dignity.
There are newer classifications being considered for bariatric patient care that would not only help guide patient care, room design, equipment and space needs but also build a new coding system for hospital reimbursement:
- Level 1 – Ambulatory; BMI 30-34, girth minimum 45”; self-sustaining patients; minimal equipment increase needed.
- Level 2 – 306-349 pounds; BMI 35-39; girth 46”-60”; not independently ambulatory; will need specialized equipment; staffing increases.
- Level 3 – 350-450 pounds; BMI 40-44; girth 61”-75”; skin sensitivities; same as Level 2 equipment needs; minimum 4 staff to treat.
- Level 4 – Morbidly obese; weight >450 pounds; BMI >45; girth >70”; skin sensitivity high; not ambulatory; very specialized equipment; very staff intensive.
Bariatric care is a healthcare concern sweeping the nation and is in need of regulatory reform in order to keep pace.
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