Description
In this essay, we examine the various options for the floor plan design and its constituent elements and evaluate each in turn with respect to their characteristics and possible impact.
As part of the KARMIN research project, presented in detail in Part C of this book, we undertook a series of surveys and workshops to ascertain the significance of the individual design options in everyday hospital practice. Our assessment is therefore based on interviews with experts, observing staff in hospitals, research and relevant literature. The interviews were conducted with professionals and staff at all levels: doctors, nurses and nursing managers, cleaning staff, architects and designers, hygiene specialists and employees of hospital product manufacturers. To include the patients’ perspective, we also talked to people not professionally involved in the health sector, such as senior citizens. The statements and insight gained from our survey are grouped into six main categories:
1. Structural complexity
2. Infection prevention potential
3. Workplace quality and safety
4. Spatial qualities
5. Patient safety
6. Patient satisfaction and privacy
These six categories describe important criteria or qualities that must always be taken into account when planning a patient room and that are therefore particularly relevant, not least because they impact on the interests of all the users and people involved in a patient room.
We shall examine each of these six qualities in turn and identify which of the above design options contribute to them and why. Those design options not mentioned under a particular quality are accordingly of no consequence for that quality.
1. Structural complexity
Structural complexity concerns all principles and floor plan features that in practice give rise to additional construction and/or design requirements. The respective floor plan is compared against a solution that has been optimised in its construction and economic efficiency. If one or more of the design options make its design or construction more difficult or even disadvantageous, the floor plan is regarded as being structurally complex.
Barrier-free/low-barrier interior design
In principle, barrier-free accessibility should be the norm. However, due to their larger space requirements for movement and spacing distances, barrier-free rooms are larger, and fewer can be realised on one floor. Unfortunately, many designs therefore only observe minimum spacing distances. The additional requirements for barrier-free room design add to the complexity of the design task.
Additive principle: floor plan combination/variation
The coupling of at least two different floor plan types in an additive sequence of rooms is often employed in the context of an overall façade concept. The need to plan at least two room types with fittings and furnishings in different orientations increases the duration and complexity of the design task.
Additive principle: unsystematic arrangement of rooms
Where the constraints of the planning context hinder the use of a regular arrangement of rooms, for example as a result of predefined functional rooms or specific building forms, designers need to develop custom room variants. This requires more planning time and results in a lower degree of prefabrication of individual room elements.
Complex room geometry (polygonal)
Non-rectangular building elements are more complex to design and manufacture than rectangular forms. It is likewise harder to incorporate standardised rectangular furniture into room layouts with complex spatial geometries. Irregular room shapes therefore typically entail custom-designed fittings and furnishings co-developed by architects and other planners, increasing the complexity of the design task.
Two room entrances
A single point of entry is suitable for all room layouts while a patient room with two entrances introduces additional spatial constraints that impact on the rest of the room configuration. Two entrances also require more circulation space and result in additional costs for the door opening, the door and its associated fittings.
Alcove in front of patient room
Alcoves in front of the patient rooms result in greater floor areas for circulation and additional wall surfaces compared to straight, flush corridor walls. The result is higher costs for materials and production.
Retrofittable airlock
Designing a floor plan to accommodate retrofitting with an airlock adds functional flexibility but introduces constraints at a structural level as the entrance area must be planned to be convertible into an anteroom.
Internal or external façade extension
Providing the patient room with an additional area inside or outside the façade, such as a winter garden, bay window or balcony, is a fundamental design decision that affects the entire building design. Compared with a regular outside wall with windows, it requires additional planning work and entails higher costs.
Bathroom with window
Placing the bathroom on the external wall with an outside window increases the number of openings in the façade to be planned, constructed and installed, and with it the cost of construction. Where prefabricated wet cell modules are used, the opening in the module must be coordinated with the façade design, entailing increased planning work.
Two identical wet cells for separate use
The positioning of two wet cells in a two-bed room determines much of the zoning of the rest of the patient room and their production inevitably involves higher manufacturing costs.
2. Infection prevention potential
This criterion describes the potential of the various built measures to prevent or limit the transmission of infection between patients or between staff and patients. Built measures can also promote compliance among hospital staff. The following design options have the potential to prevent the transmission of infection.
Barrier-free/low-barrier interior design
Dimensioning rooms to afford barrier-free or low-barrier accessibility allows patients with mobility impairments to move around independently, reducing the degree of assistance required and in turn the degree of direct, unrestricted contact between staff and patients.
Same-handed room configuration
When rooms are identical in their arrangement, staff and patients do not need to adjust and reorient when switching rooms. Care provision procedures are more predictable in their choreography and can be optimised accordingly. Errors resulting from changing situations can be avoided, improving compliance with regulations among nursing staff.
Three-zone room/three-zone plus room
When each user has their own, clearly legible zone, physical contact between users (e.g. at pinch points) can be minimised.
Alcove in front of patient room
An alcove in front of the entrance to the patient room creates more distance between the patient and the ward corridor for isolated patients. Additional protective equipment can be placed outside the room and further disinfectant dispensers can be attached without causing obstruction or injury. Similarly, disposed material is kept away from the corridor.
Retrofittable airlock
The ability to retrofit or temporarily create an airlock in the case of a nosocomial outbreak can be an effective built means to reduce the transmission of infection.
Staff workplace in patient room
If supplies and equipment for nurses and nursing care are located within the room instead of being brought in on a supplies trolley, staff can care for the patients more directly and work processes can be planned and optimised.
External façade extension
A balcony or loggia makes it easier for patients to go outside. Fresh air can help reduce the patients’ germ load.
Bathroom with window
A naturally ventilated bathroom adjoining the building’s façade can contribute to a better room climate and counteract the spread of germs.
Beds not placed next to each other
Placing the beds further apart reduces the potential of infection transmission between patients in a two-bed room. It likewise promotes staff compliance with regulations by reducing the risk of staff tending to each patient in turn without disinfecting their hands.
Beds clearly visible to staff
If a patient is clearly visible to staff from the door, they are able to monitor patients better and respond quickly in the case of an emergency. It likewise deters patients and visitors from activities detrimental to their recovery.
Barrier-free/low-barrier bathroom
Bathrooms dimensioned for barrier-free or low-barrier accessibility allow patients with mobility impairments to use the bathroom independently and conduct their own personal hygiene. Where necessary, staff can assist in the room rather than transporting high-risk patients to a ward bathroom.
Same-handed wet cell configuration
The identical arrangement of objects in a patient bathroom means that staff and patients do not need to adjust and reorient when switching rooms. The choreography of hygienic care and assistance can be planned and optimised accordingly. Procedural errors resulting from changing situations can be avoided.
Two identical wet rooms for separate use
Where each patient has a patient bathroom of their own, the risk of infection transmission through jointly used sanitaryware can be minimised. In addition, contamination in one sanitary cell does not necessarily transfer to the other cell.
Second washbasin
The installation of a second washbasin reduces the risk of infection transmission via the surfaces of the washbasin or tap.
Second WC
The installation of a second WC reduces the risk of infection transmission via the surfaces of the toilet or flush button.
3. Workplace quality and safety
All aspects that improve the working conditions and work processes of hospital staff (e.g. doctors and nurses) contribute to workplace quality. Workplace safety is improved by preventing the risk of injury and reducing avoidable contact situations between staff and patients or visitors.
Barrier-free/low-barrier interior design
Accessible patient rooms allow people with limited mobility to be as independent as possible in their room, reducing the degree of assistance required and the physical strain and stress on care staff.
Same-handed room configuration
When patient beds and fittings are always in the same place in every room, staff can act immediately without needing to adjust to changing room configurations.
One bed deep room
In one bed deep rooms, patients are closer to the door so that staff have shorter distances to walk. Removing or bringing a bed is likewise easier as the beds are both near the entrance.
Three-zone room/three-zone plus room
Where room zones for each user are clear and legible, physical contact when moving about the room can be avoided, for example during bed transport. Staff can move independently of other room users.
Bedside cabinet positionable on both sides
The ability to move the bedside trolley to the other side of the bed makes it easier to carry out medical care procedures.
Retrofittable airlock
Floor plans that accommodate retrofitting with an airlock already anticipate the need for an anteroom where additional personal protective equipment can be accommodated. In addition, preventing door swings from clashing in room entrances reduces the risk of accidental injury.
Staff workplace in patient room
A workplace for staff in the room with all necessary supplies and equipment to hand avoids the need to transport necessary aids from room to room in the ward on a supplies trolley.
Washbasin in patient room
In addition to hand disinfection, a washbasin in the room allows staff to also wash their hands to remove dirt.
Beds not placed next to each other
When beds are placed further apart, staff caring for a patient cannot unintentionally come into uncontrolled contact with the neighbouring patient. This also helps minimise the risk of infection transmission.
Beds clearly visible to staff
If patients can be seen clearly from the entrance to the room, staff can monitor patients without having to walk fully into the room, saving time and energy.
Barrier-free/low-barrier bathroom
If a patient bathroom and WC is sufficiently accessible for patients, staff no longer need to transport patients to a suitable bathroom on the ward.
Same-handed wet cell configuration
When bathroom fittings are identically placed in each room, staff do not need to readjust from room to room, saving time and making care procedures easier.
Standard fittings with shower
When a patient can wash and conduct personal hygiene in their own bathroom, staff do not need to transport or accompany them to showers or a bathroom on the ward.
Bathroom with sliding door
A sliding door to the bathroom reduces the risk of injury caused by doors slamming open or shut. Sliding doors also make it easier to simultaneously assist a patient and operate the door.
4. Spatial qualities
This describes all the spatial qualities of a patient room that can be deduced from the floor plan and covers all aspects that contribute to a room’s potential spatial quality. Compliance with design standards and the room proportions can provide a sense of the space, even when the actual spatial effect cannot be described by the floor plan alone.
Barrier-free/low-barrier interior design
A room in which the individual items of furniture are placed further apart for better barrier-free access will also appear more spacious and less cramped.
One bed deep room
Rooms that are only one bed deep have more balanced proportions. Less deep rooms are generally better illuminated and therefore feel lighter and brighter.
Three-zone room/three-zone plus room
Clear zoning lends rooms a sense of clarity and legibility and suggests immediately how they might be used.
Alcove in front of patient room
Ward corridors are divided into areas with different functions. Alcove areas in front of the patient rooms provide a more sheltered buffer to the sometimes hectic activities in the ward and also give each room its own “address”.
Bedside cabinet positionable on both sides
The ability to position the bedside trolley on either side of the bed affords the room greater flexibility. Conversely, a room where everything has a fixed position appears more static.
Room with window and seat-level sill
Locating a seating area in the depth of the window opening or next to it makes optimum use of the window as a threshold to the world outdoors, while also minimising the spatial impact on the room. The lower sill height also means the window is larger so that patients lying in bed have a better view of the world outside.
Internal and external façade extension
Every external area or projection of the façade represents an extension of the space of the room for the patients’ and visitors’ use. The traditional notion of the hospital as rows of rooms behind windows is broken down by the façade extensions, which add elements familiar from domestic environments.
Bathroom with window
A daylit bathroom has a positive effect on the atmosphere of the room.
View outside
For patients who spend most of the day lying in bed, the view outside is their primary means of contact with the outside world during their stay. It is therefore especially important that both patients have an equally good view from their respective beds out of the window.
Barrier-free/low-barrier bathroom
More generous spacing between the elements of a bathroom improves its sense of space and and makes it appear less cramped. A floor-flush shower tray heightens this effect, visually enlarging the room.
Nested wet room configuration
When the wet cells are grouped together and arranged between the rooms, the rooms themselves appear more spacious. The bathroom does not obstruct the view out or of the entrance area.
Bathroom with sliding door
Eliminating door swings creates more room for movement and fewer obstructions for all the room’s users.
5. Patient safety
This encompasses all measures aimed at maintaining patients’ physical safety by avoiding the risk of injury and restricting unnecessary exposure to other user groups. These illustrate how design decisions, room fittings and the layout of the patient room can impact on patient safety.
Barrier-free/low-barrier interior design
As rooms designed for barrier-free or low-barrier accessibility facilitate freer movement, the risk of injury from bumping into things or falling is reduced.
Same-handed room configuration
A same-handed room layout across a ward allows patients to find their orientation quickly should they be moved to another room for medical reasons. Conversely, changing room configurations can confuse patients with dementia or other impairments, leading to the risk of injuries or falls.
One bed deep room
The incidence of accidents or falls is particularly high between the bed and the bathroom. The distance to the bathroom is typically shorter and thus safer in rooms that accommodate the depth of one bed than those with two beds arranged behind one another.
Three-zone room/three-zone plus room
Clearly legible zones for the room’s different users minimises collisions between patients and other room users.
Two room entrances
Two room entrances lessen the probability of injuries arising through doors unexpectedly opening.
Alcove in front of patient room
An alcove can be used to hold additional protective equipment or other protective precautions for patients in isolation and also acts as a buffer between the room and the corridor and other patients. On leaving the room, a patient can first safely find their bearings and assess the situation before embarking down the ward corridor and is not forced to suddenly evade unexpected oncoming traffic.
Retrofittable airlock
Rooms that can be retrofitted with an airlock must ensure that the bathroom is accessible from the patient room and that the entrance area can be divided off. The separate placement of the doors therefore avoids collisions between opening doors and is safer for patients.
Staff workplace in patient room
A staff work area within the room with essential supplies and equipment to prevent the transmission of infections contributes to patient safety.
Beds not placed next to each other, but in sight of one another
Placing beds further apart within a room reduces the risk of infection transmission between patients. However, if they also remain within sight of one another, both patients benefit from the ability of the other to call for help in the event of an emergency.
Beds clearly visible for staff
If patients can be seen clearly from the door, staff are able to monitor patients more easily and can react quickly if needed.
Barrier-free/low-barrier bathroom
The greater room for movement in a barrier-free bathroom as well as the additional grab rails help patients use the bathroom more safely.
Same-handed wet cell configuration
As with same-handed room layouts, a consistent bathroom layout allows patients to find their bearings easily should they need to move to another room for medical reasons. Patients with dementia or other impairments can find a new situation challenging and disorientating, increasing the risk of collisions or falls.
Two identical bathrooms for separate use
Separate bathrooms for each patient reduce the risk of infection transmission via common contact surfaces or mix-ups between the patients’ items such as towels.
Standard fittings with shower
The ability of a patient at risk of infection or who is themselves infectious to wash in their own room avoids the need for them to be exposed to hospital operations or use a ward bathroom used by other patients.
Second washbasin/WC
Two washbasins or toilets reduce the risk of infection transmission between two patients via jointly used sanitaryware that tends to have a high bacterial load.
6. Patient satisfaction and privacy
This criterion encompasses all design measures that contribute to the patients’ well-being and satisfaction. Means of improving privacy are particularly important as this study assumes that to feel comfortable each patient in a two-bed room requires a sense of relative privacy.
Barrier-free/low-barrier interior design
Barrier-free or low-barrier patient rooms enable patients with mobility impairments to move around without needing the assistance of staff, contributing to their sense of independence and self-assurance.
Same-handed room configuration
In contrast to the mirrored floor plan, the head ends of the beds in two same-handed adjacent rooms do not adjoin the same dividing wall. As supply lines and connections are not situated on both sides of the same wall, noise transmission through the wall is avoided. And because the distance between the beds in neighbouring rooms is greater, the noise level is also lower. As noise is known to be a major stress factor for patients, reducing the impact of noise contributes significantly to patient well-being.
One bed deep room
By positioning the beds on a separate wall surface of a one bed deep room, each patient has their own corner of the room, contributing to the patients’ sense of privacy.
Three-zone room/three-zone plus room
Clear zoning within the room makes non-intrusive movement in the room easier and avoids different zones having to overlap. As a result, each patient has a degree of personal space.
Two entrances
A separate entrance for each patient means that patients do not need to feel obliged to respond to everyone who enters. This can potentially reduce stress levels.
Alcove in front of patient room
As a spatial buffer between the patient room and the corridor, an alcove adds a layer distancing the public activities on the hospital ward from the comparative privacy of the patient room.
Bedside cabinet positionable on both sides
The ability to freely position the bedside trolley on either side of the bed allows patients to determine their immediate surroundings according to their preferences, for example if they are left- or right-handed.
Staff workplace in patient room
A place where staff can prepare care procedures in the room avoids the need for a supplies trolley to be wheeled right up to the bed. The staff workplace also ensures that distance is maintained quite naturally between the staff and the patients.
Privacy screen between patients
A movable privacy screen such as a curtain or a partition offers a patient the possibility to screen themselves from their fellow patients or other visitors when privacy is required.
Patient desk
A separate desk enhances the sense of having personal space and can encourage patients to engage in cognitive activities such as crossword puzzles, reading newspapers or writing letters.
Guest accommodation
The possibility for relatives to stay overnight in the hospital room can contribute immeasurably to a patient’s well-being.
Room with window and seat-level sill
A dedicated seating area adjoining the window can offer a personal corner to sit set apart from the bed. A bench-level sill height also means the window is larger so that patients lying in bed have a better view of the world outside.
Internal and external façade extension
For patients with impaired mobility, access to an outdoor area can be an important substitute when they are unable to go outdoors in the fresh air. In addition, conservatories, bay windows and balconies are elements that lend a homely character to a patient room.
Bathroom with window
A daylit bathroom and the ability to naturally ventilate the room likewise lends a patient bathroom a more homely character.
Beds not placed next to or opposite each other
Placing the beds as far apart as possible, for example positioning each along a separate wall, creates a separate area of the room for each patient.
View outside from the bed
A view of the window that does not encroach on the privacy of the fellow patient allows both patients to retain a sense of privacy and prevents one or the other from feeling as if they are at a disadvantage.
Barrier-free/low-barrier bathroom
A barrier-free bathroom can enable a patient to wash independently without additional assistance from nursing staff, allowing them to maintain a sense of personal privacy.
Inboard wet cell configuration
The inboard arrangement of the bathroom along the corridor wall means that the beds are further away from the entrance. Patients feel less exposed when staff or visitors enter the room and are also further away from the noises of the ward corridor beyond.
Same-handed wet cell configuration
As with the room itself, the fact that with a same-handed configuration two bathrooms in adjacent rooms do not lie either side of the same wall reduces noise transmission and contributes to a sense of patient satisfaction.
Two identical bathrooms for separate use
Separate bathrooms allow each patient to have a place of retreat where they can feel undisturbed.
Standard fittings with shower
A shower in the room means that patients do not need to use ward bathrooms or collective showers.
Second washbasin/WC
A sense of relative privacy can be heightened when each patient has a separate washbasin or a separate toilet.
A note on the evaluation and assessment of qualities
In clinical practice, other dependencies and causal relationships will no doubt arise that do not correspond entirely with our evaluation in this study. In cases where there are good reasons for or against a certain classification, we have either taken a specific standpoint or refrained from making any classification. Similarly, factors that could be included but do not impact directly on the ground plan have been excluded. In all of the evaluation categories described, we start from the assumption that measures, usage and procedures comply with regulations, that necessary cleaning is undertaken and that each of the users act sensibly within the scope of their health and mental capabilities. Worst-case scenarios, negative examples or grossly negligent actions by the users are therefore not considered here.
References
DIN 18040-2:2011-09 Barrierefreies Bauen – Planungsgrundlagen – Teil 2: Wohnungen (Construction of accessible buildings – Design principles – Part 2: Dwellings), Berlin: Beuth, 2011. (The DIN standard for housing applies as there is not a separate DIN for barrier-free patient rooms).
Landesamt für Gesundheit und Soziales in Mecklenburg-Vorpommern (State Office for Health and Social Affairs in Mecklenburg-Vorpommern), Bauanforderungen und funktionelle Empfehlungen aus der Sicht der Hygiene für den Neubau- und die Sanierung von Krankenhäusern und Universitätskliniken in M-V. Anforderungen zur Konzessionierung von Krankenanstalten § 30 Gewerbeordnung, Allgemeine Pflegestation, as of 2 November 2018
Typological Evaluation of Two-Bed Rooms
In a patient’s room the bed position and the position of the wet room already have a decisive influence on the further configuration of the floor plan. Especially for two-bed rooms this results in a wide range of possibilities. In the following, examples of 18 very different two-bed room floor plans are shown. The most effective way to compare and evaluate the respective qualities of different floor plan layouts would be to study how they are used in everyday clinical practice, but this is not practical, neither in the context of this study nor in reality.
Nevertheless, this typological study instead analyses and evaluates the configuration of various two-bed rooms using their floor plans. By considering each aspect of the room’s design individually in terms of its potential qualities, we can build up a qualitative profile for each type of floor plan. The evaluation matrix on the right details each of the spatial design aspects along with their respective qualitative characteristics already introduced in the first half of this essay, Qualitative Evaluation of Two-Bed Rooms.
Each of the 18 different floor plans is briefly introduced. Then the plans are analysed using this matrix to identify their respective features and corresponding qualitative characteristics. Using a points system, an overall evaluation of the floor plan can be obtained. Mutually exclusive qualities are not added together – e.g. a standard room plan cannot also be a special case solution – and where certain characteristics are not present throughout – for example for only one of the two beds – only half a point is added. Adding the points together produces a maximum rating for each qualitative characteristic.
The points are then used to generate diagrams that show a graphical representation of the qualitative evaluation of the respective floor plan layout. Each graphic provides a visual indication of the qualitative characteristics of the respective floor plan typology.
The intention here is not to propose model floor plan types for two-bed patient rooms, because, as discussed earlier in the introduction, each patient room design is an individual response to the prevailing context and specific needs of the respective clinic. While the configurations shown here illustrate room layout principles, they cannot serve as a universally applicable solution for every case. Instead they show the relationship between optimised operational and constructional solutions and their potential qualities in use. As such, they reveal the complexity of the design task of two-bed patient rooms.
One should also note that achieving a “maximum score” in all aspects is neither practicable nor feasible in the actual context of a real clinic. A “maximum” variant would have two entrances and two nested wet cells for a one bed deep room, guest accommodation, a balcony etc. Instead, this qualitative study aims to illustrate the relationships between built, process-related and emotional factors.
Drawings
Originally published in: Wolfgang Sunder, Julia Moellmann, Oliver Zeise, Lukas Adrian Jurk, The Patient Room, Birkhäuser, 2020.