Description
Unlike outpatients, inpatients have to stay in the hospital at least overnight, and quite often for several days. Hospitalization is always a disruptive experience, forcing new roles upon the patient from the moment he or she enters the patient room. It triggers several responses that have sometimes been summarized as regression (the patient returns to a child-like existence and surrenders control to the medical staff), frustration (because it has become impossible to engage in normal, everyday life), egocentricity (enhanced by being forced into a passive role) and, obviously, fear.[109] A number of other factors contribute to the patient’s feelings of discomfort: separation from family and friends, who may visit the patient but now belong to a world the hospitalized patient is, albeit temporarily, no longer a part of; forced cohabitation with total strangers and the unpleasantness of simultaneous visits by patients’ families in multi-bed rooms that are still the norm in many countries; lack of privacy and the impossibility of creating a private realm, however limited; exposure to uncomfortable levels of noise. How can things be improved? Reducing the number of inpatients and transferring as many therapies and interventions as possible to outpatient departments undoubtedly contribute to a better patient experience. Thus, in Germany, for example, it is hoped that the number of inpatient beds will decline by at least 20 % in the years ahead.[110]
Minimizing the length of hospitalization by efficiently arranging all the steps in a care pathway is a reasonable strategy, and one that enhances the trend toward shorter stays. But what can be done to make the days and nights spent in the hospital less discomforting? Although the encounter with medical specialists and their technologies is obviously vital for hospital patients, what often has a bigger impact on the way they experience their stay is their interaction with the nursing and support staff. Since the ideals of patient-centered care gained ground in the 1970s, many initiatives have evolved for softening the cold and impersonal characteristics associated with the hospital as a medical machine. One of the best known is the ‘Planetree’ concept. Founded in San Francisco in 1978 by Angelica Thieriot, the Planetree organization emphasizes the need to take into account the patient’s subjective experiences. It asserts that direct access to the medical staff, customized information, and facilities which enable relatives and friends to offer active support are particularly important, as is the role of architecture (especially in the patient unit). Beyond noting the value of natural light and soothing colors, this approach stresses the advantages of interior decoration and furniture that resemble home. The Planetree organization even started a certification program for architectural firms.
Undoubtedly the most important trend in the last two decades has been the increasing acceptance of the single-bed room as the new standard for hospitals — although in practice multi-bed rooms are still found everywhere (in 2011 in Germany the percentage of single-bed rooms in hospitals was approximately 15 %).[111] Single-bed rooms can go a long way toward addressing many of the issues raised by multi-bed rooms, such as lack of privacy, risk of hospital-acquired infections and the experience of sharing a room with strangers, and they are especially welcomed by patients when they are spacious enough to allow family to stay overnight occasionally. Evidence-based design research supports the positive impact of single-bed rooms which also reduce the risk of medication errors (the latter is no minor problem: in Germany, the number of people dying as a consequence of accidentally receiving the wrong medication exceeds the death toll of traffic accidents).[112] Even though they occupy a lot of space and can increase the distance between the patients and nurses if the standard use of a central nursing station per ward stays unchanged (decentralized nursing solves this issue), investment in single-bed rooms is seen as profitable, since they could have a positive impact on health outcomes, increase patient satisfaction and reduce litigation. Also, patients may speak to the doctor more freely if there are no other people in the room.[113]
Martini Ziekenhuis, Groningen, the Netherlands, Burger Grunstra Architecten, 2007. Two-patient bedroom
Building spacious single-bed rooms facilitates another development: the concentration of as many medical processes in the patient room as technically and spatially feasible. The more mobile medical equipment and devices become — computers on wheels (‘
Compared to the dynamic changes in the high-tech hot floor departments in hospitals, the design of inpatient wards has been relatively stable. Ward design today still closely reflects concepts developed 30 years ago, when it was based on the per-bed per-night compensation model, which gave hospitals little incentive to reduce the length of stay.
Recent developments are just beginning to have a significant influence on ward design:
• The increasing implementation of flat-fee compensation for services (per diagnosis-related group [DRG] or outcome-based) provides incentives for length-of-stay reduction.
• Aging populations translate into ever-increasing numbers of older, multi morbid patients. Such patients need care not only for the specific medical procedure they are admitted for, but also for their other medical conditions. This could result in a shift from specialty-specific wards (cardiology, orthopedics) to multidisciplinary wards.
• Patient wards providing acute services for elderly patients (surgery, neurology, cardiology, internal medicine, etc.) increasingly need to deal with patients with dementia and gerontopsychiatric conditions, requiring modifications in the built environment.
• Early and intensive reactivation and rehabilitation after medical interventions lead to better medical outcomes and reduced lengths of stay. These inpatient rehabilitation services need to be accommodated by ward design.
• The nursing staff in inpatient wards spend more than a third of their time walking or searching for people or things, and the layout of the wards is one of the biggest reasons for this inefficiency. Injury and fatigue prevention should be achieved by an efficient, compact and intuitive layout, incorporating ‘human factors’ engineering to improve safety.
Patient rooms are usually equipped with monitoring equipment, oxygen, compressed air and suction — sufficient for relatively simple medical procedures carried out in the room. The increasing number of interventions performed in patient rooms and the trend toward dynamically scaling up and scaling down care levels in the room — instead of transferring the patient to another ward — are likely to result in additional equipment (which is stowed away when not in use). All patient rooms have a patient bed, mostly electrically powered to enable patients to adjust their position and to support ergonomic nursing at the bedside. Equally important for ergonomic nursing are mobile or ceiling-mounted patient lifts.
Proposal for a single-patient room, Perkins + Will, 2011. The room has a family zone allowing for accommodation of family members.
Deventer Ziekenhuis, Deventer, the Netherlands, De Jong Gortemaker Algra, 2008. Multi-bedroom unit with low window sill to enable a view of the outside
Many hospitals offer a personalized digital health, entertainment and services environment, with flat screens that serve as a television set but also allow patients to order meals, surf the Internet and, ideally, take a look at their health stats.
Inpatient wards are subdivided into nursing units of various sizes. Unit size depends on factors such as the severity of the medical condition of the average patient, the nursing concept and the number of beds supervised by each nurse, usually four to eight beds, quite often leading to a total of between 30 and 40 beds per nursing unit. In some countries the size of the nursing unit is considerably larger than that. One of the fundamental issues in nursing in the inpatient wards is the location of the nursing station. Whereas central nursing stations were long the norm, advances in information technology have made decentralized, mobile workstations a safe, efficient and patient-friendly alternative; indeed, research appears to show that ‘(…) significantly more time was spent on phone, computer and paper administration in each of the centralized units compared to decentralized units.’[116] Some concepts regarding reorganization of ward design in Switzerland have even abandoned the central nursing station as a spatial function altogether — a trend that can be seen in studies showing that nursing interaction with the patient in the central nursing station model is constantly in decline. Hybrid nursing stations combine bedside nursing and administration with (de)centralized workstations. Whether the hybrid model leads to an increase in the much-needed contact between nursing staff and patients remains to be seen. A typical ward also comprises facilities such as consultation and examination rooms, spaces for patients to interact with visitors and a small coffee corner for patients who are able to walk but find such facilities in the public areas to be too far away.
Design for the Centre hospitalier de l’Université de Montréal (CHUM), Montreal, Canada, Neuf architect(e)s, CannonDesign, 2018. Rendering of a single-patient bedroom with a family zone
Four zones can be distinguished in the patient room: the immediate environment of the patient; surrounding that, the area used by the caregiver; then, the space occupied by family and friends; and, finally, the zone that supports the hygienic condition in the room.[117] In the patient room itself, the location of the toilet and the bathroom has a major impact on the design. There is a clear tendency to increase the size of the rooms, allowing more bedside medical interventions, while just-in-time distribution systems are reducing the need for in-room storage. In surveys, two thirds of the inpatients prefer their room to have a residential feel.[118] Ideally, art work and some other objects from home can contribute to bridging the gap between the institution and the private domain.
Patients’ experience during their time in an inpatient ward is shaped by personal factors such as age, length of stay, multimorbidity and level of dependency, along with the architectural layout, ward size and design and care features which make the patient more comfortable. The higher intensity of care and shorter length of stay today require an increasingly intensive patient-medical staff interaction.
From the patient’s point of view it is important that the design provisions for the different types of care offer a maximum of patient safety and privacy, sufficient choice in terms of type and volume of care and an adequate level of comfort. From the perspective of economic feasibility, the challenge for ward design is to achieve a satisfactory balance among these different aspects.
If patients are bedridden, this position literally determines the perspective from which they perceive their environment, something design needs to take into account. If inpatients are mobile enough to leave the room, the patient ward should offer them at least some meaningful activities; and recovering patients should be induced to gradually expand their radius and discover new parts of the ward and, ultimately, the larger environment. Ideally, they should be able to extend their reach to patios and outside gardens as a first step on the way back home.
Aging, multimorbidity and increased dependence lead to situations where more patients require staff support to get around — to get from the bed to the toilet, for instance. As patient toilets in hospitals quite often are unable to accommodate patient lifts (ceiling-mounted or mobile), patients usually need to be lifted and transferred by a team of nursing staff. This is either inefficient, when the hospital opts for teams dedicated to transferring patients, or disruptive to normal processes, when the nursing staff have to interrupt their regular work in order to offer support for patient transfers. If not sufficiently trained and equipped for this task, the nursing staff themselves run the risk of occupational injury. Ward design therefore needs to include ergonomically acceptable (and financially feasible) solutions for patient transfers. Until now, ward design for inpatient care, on the one hand, and ward design for short-term care, such as 24-hour wards and day care wards, on the other, have been guided by significantly different approaches.[119]
As far as their position relative to other departments is concerned, individual inpatient wards are often assigned to specific medical specialties, although presently there is a trend toward accommodating all patients with a specific set of medical conditions in a multidisciplinary setting. Smaller hospitals may opt to completely abandon the traditional one-to-one relationship between inpatient wards and medical specialties.
Future ward design should provide for flexibility and aim at a basic modular design accommodating both inpatient care and ambulatory care. It should be ergonomically efficient from the perspective of the nursing staff. As good visual communication between the nursing staff and patients has been demonstrated to improve patient care, ward design may move away from the hotel room type of patient room, with the bathroom as a separating element between the patient bedroom and the ward corridor. While transparency between the ward corridor and patient rooms has become a common feature in Anglo-Saxon countries, this design option is rarely found in continental European hospitals. Since patients are, on average, older, sicker and more dependent on medical care than before, and thus need to be monitored closely, room-corridor transparency will probably become more important in future ward design. This transparency should be controlled, when possible, by the patient (with adjustable blinds). Also future ward design must contribute to further reduce the patient’s length of stay. Patient mobilization has the potential to reduce the length of stay (and cost) by one day in the ICU and 1.5 days in general inpatient care. Ward design needs to incorporate features enabling a high degree of mobilization, reactivation and rehabilitation, including features supporting the patient’s toilet visits (reducing the use of bedpans), and providing integrated physical training and therapy facilities within the ward.
• Minimum required space around the bed
• Washbasin in patient room (instead of washbasin in patient bathroom only)
• Rooming-in with a standard built-in piece of furniture or by bed-on-demand (mobile bed)
• En-suite vs. shared bathrooms
• Workstation in the patient room or mobile devices only (COWS or handhelds)
• Patient visibility from corridor (in case of glazing between patient room and corridor)
• Position of bathroom/toilet
• Size, position and direction of the door
• Privacy curtain (it should be possible to enter the room with the curtain drawn shut)
• Storage of medical equipment (leaving medical devices in plain sight contributes to a more clinical environment)
• Windows and sun screens, remotely operable by the patient
• Bedside terminal or personal tablet
• Dedicated TV or TV integrated with bedside terminal (optional)
Inpatient room with typical components: rooming-in area (green), patient area (yellow), medical staff area (brown), patient bathroom (blue)
Inpatient room layoutThe patient bed and the space around it determine the layout of the patient room; the bed in central position allows for optimal access and rapid intervention in an emergency.
Inpatient room configurations and their effect on lines of sight/staff supervision through open doors and/or glass doors and walls. Daylight access in the corridor is also different in each configuration.
• Required number of beds in the room
• Minimum required space around the beds
• Flexibility to transform multi-bed rooms into single-patient rooms in the future
• Storage of medical equipment (the options to stow away devices are more limited in multi- bed rooms than in single-bed rooms)
• Patient visibility from corridor (in case of glazing between patient room and corridor: visibility determined by position of beds vis-à-vis the corridor)
• Position of washbasins/alcohol dispensers
• Size, position and direction of the door
• Windows and sunscreens
• Less patient visibility from corridor for staff (in case of glazing between patient room and corridor)
• More privacy for the patient
• Less daylight in corridor
• Bathroom cleaning disturbs patients less
• Greater patient visibility from corridor for staff (in case of glazing between patient room and corridor)
• Surplus space which can be used for support facilities (e.g. storage)
• More daylight, reaching deeper into the building
Effect on walking distances of en-suite bathroom positions at the patient room level
A The bathroom is positioned inside the room’s structural bay, enabling a repetitive structural bay and shorter corridor lengths; counterintuitively, this results in longer walking distances for nurses.
B The bathroom is positioned in an adjacent, distinct structural bay, often leading to an irregular structural rhythm, while resulting in shorter walking distances.
Effect on walking distances of en-suite bathroom positions (at the nursing unit level)
A The bathroom is positioned inside the room’s structural bay, magnifying the effect on walking distances.
B The bathroom is positioned in an adjacent, distinct structural bay, magnifying the effect on corridor length.
For the entire inpatient ward, a layout with single-bed room and en-suite bathrooms has the following consequences:
• Bedrooms are less deep, enabling wider corridors, with more diverse configurations (space for nursing stations, coffee corners, lounge, etc.).
• Total building length can be increased.
• Potentially better organizational options for decentralized and smaller supporting functions (storage etc.)
• More visual contact between patients and staff (in case of glazing between patient room and corridor), especially in combination with decentralized nursing stations
On the other hand, a layout that positions all bathrooms adjacent to the corridor has the following consequences for the ward as a whole:
• Bathroom in front allows for more compact configuration (less façade = lower costs).
• Maintenance can be done from the corridor (instead of in or through the patient room).
A nurse is typically responsible for four to eight patients, and in a decentralized nursing concept he or she is focused mostly on processes related to those patients. Therefore, while positioning the bathroom between two single rooms results in a longer corridor, a design with the bathroom in the corner of the patient’s room could result in longer walking distances for the nursing staff.
The inpatient ward needs a number of staff and support spaces:
• Nursing station
• Centralized per ward or
• Decentralized, with multiple workstations/desks
• Control room
• Flushing and cleaning space for bedpans: one or more, depending on ward size (number of beds) and dimensions (walking distances)
• Use of regular or disposable bedpans? Regular bedpans require flushing and cleaning; disposable bedpans require additional storage space and used bedpans must be disposed of.
• Bed-linen storage (clean and used)
• Clean bed-linen storage
• Centralized storage, in-cart distribution via substations or directly to cabinets in patient rooms
• Decentralized storage
• Directly to substations located at main ward/hospital junctions
• Directly to cabinets (enough space for three to four changes/bed) in patient rooms
• Used bed-linen storage
• Decentralized substations positioned at main ward/hospital junctions, so that used bed linen can be picked up without entering the wards
• Satellite pharmacy
Effect of single-patient rooms on centralized and decentralized nursing stations (depending on the nursing intensity, the configuration can vary from two to eight patients per nursing unit; the description below is for eight patients per nursing unit)
A Centralized nursing station (top center) supervising four nursing units, each with two four-patient rooms: walking distances increase somewhat if a nursing unit is further away from the nursing station, but remain relatively short as the structural bays required for four-patient rooms are deep.
B Centralized nursing station supervising four nursing units, each with eight single-patient rooms: walking distances increase to the point of impeding the care process due to the relatively shallow structural bays; this explains the need to decentralize nursing stations when opting for single-patient rooms for improved patient privacy.
C Semi-decentralized nursing stations, each supervising two nursing units, each with eight single-patient rooms: walking distances are more manageable than in model B.
D Decentralized nursing stations, each supervising one nursing unit with eight single-patient rooms: optimal walking distances
Process flows in the inpatient department are clustered in three functional areas: patient room, patient ward and transition zone. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.
Footnotes
Robert Wischer, Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus. Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007, p. 140.
Peter Pawlik, Linus Hofrichter, ‘Die Krankenhausambulanz’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 67.
Franz Labryga, ‘Der Pflegebereich’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 84.
Franz Labryga, ‘Grundlagen und Tendenzen für Planung und Bau von Gesundheitshäusern’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 39.
Michael Kimmelman, ‘In Redesigned Room, Hospital Patients May Feel Better Already’, in The New York Times, August 22, 2014.
Elisabeth Rosenthal, ‘Is this a Hospital or a Hotel?’, in The New York Times, September 21, 2013.
Susanne Lieber, ‘Check-up mit Aussicht’, in Baumeister, B8, 2009.
Terri Zborowsky, Lou Bunker-Hellmich, Agneta Morel, ‘Centralized vs. decentralized nursing stations’, in Healthcare Design, October 3, 2010.
‘The patient care unit’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 240.
Franz Labryga, ‘Der Pflegebereich’, in Philip Meuser (ed.), Krankenhausbauten/Gesundheitsbauten. Handbuch und Planungshilfe. Band I. Allgemeinkrankenhäuser und Gesundheitszentren, Berlin: DOM Publishers, 2011, p. 80.
The ISO-TR 12296 2012, Ergonomics – Manual handling of people in the healthcare sector, outlines the spatial and technical requirements for a safer and more efficient working environment of wards. http://www.iso.org/iso/catalogue_detail.htm?csnumber=51310.
Drawings
Inpatient room with typical components: rooming-in area (green), patient area (yellow), medical staff area (brown), patient bathroom (blue)
Inpatient room layoutThe patient bed and the space around it determine the layout of the patient room; the bed in central position allows for optimal access and rapid intervention in an emergency.
Inpatient room configurations and their effect on lines of sight/staff supervision through open doors and/or glass doors and walls. Daylight access in the corridor is also different in each configuration.
Effect on walking distances of en-suite bathroom positions at the patient room level A The bathroom is positioned inside the room’s structural bay, enabling a repetitive structural bay and shorter corridor lengths; counterintuitively, this results in longer walking distances for nurses. B The bathroom is positioned in an adjacent, distinct structural bay, often leading to an irregular structural rhythm, while resulting in shorter walking distances.
Effect on walking distances of en-suite bathroom positions (at the nursing unit level) A The bathroom is positioned inside the room’s structural bay, magnifying the effect on walking distances. B The bathroom is positioned in an adjacent, distinct structural bay, magnifying the effect on corridor length.
Effect of single-patient rooms on centralized and decentralized nursing stations (depending on the nursing intensity, the configuration can vary from two to eight patients per nursing unit; the description below is for eight patients per nursing unit) A Centralized nursing station (top center) supervising four nursing units, each with two four-patient rooms: walking distances increase somewhat if a nursing unit is further away from the nursing station, but remain relatively short as the structural bays required for four-patient rooms are deep. B Centralized nursing station supervising four nursing units, each with eight single-patient rooms: walking distances increase to the point of impeding the care process due to the relatively shallow structural bays; this explains the need to decentralize nursing stations when opting for single-patient rooms for improved patient privacy. C Semi-decentralized nursing stations, each supervising two nursing units, each with eight single-patient rooms: walking distances are more manageable than in model B. D Decentralized nursing stations, each supervising one nursing unit with eight single-patient rooms: optimal walking distances
Process flows in the inpatient department are clustered in three functional areas: patient room, patient ward and transition zone. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.
Photos
Martini Ziekenhuis, Groningen, the Netherlands, Burger Grunstra Architecten, 2007. Two-patient bedroom
Proposal for a single-patient room, Perkins + Will, 2011. The room has a family zone allowing for accommodation of family members.
Deventer Ziekenhuis, Deventer, the Netherlands, De Jong Gortemaker Algra, 2008. Multi-bedroom unit with low window sill to enable a view of the outside
Design for the Centre hospitalier de l’Université de Montréal (CHUM), Montreal, Canada, Neuf architect(e)s, CannonDesign, 2018. Rendering of a single-patient bedroom with a family zone
Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.