Description

Architecture of the Patient Room

Should hospitals in future have more single or more two-bed rooms? Can the design of hospitals and patient rooms contribute to preventing infection transmission in hospitals? What are the challenges of designing patient rooms today and in future, especially with regard to hygiene?

These and other questions were the focus of the KARMIN research project discussed in this book, which investigated possible responses to preventing the spread of multi-resistant pathogens: should hospitals be converted to have more single-bed rooms or can the design of two-bed rooms be improved so that they are a viable alternative with respect to infection control.

KARMIN stands for “Krankenhaus, Architektur, Mikrobiom und Infection” (Hospitals, Architecture, Microbiome and Infection) and is a research project funded by the German Federal Ministry of Education and Research (BMBF) from 2016 to 2020 under the “Zwanzig20” funding programme as part of the InfectControl 2020 research network. The project was undertaken as a partnership of the TU Braunschweig (co­ordination: Institute of Construction Design, Industrial and Health Care Building), the Charité – Universitätsmedizin Berlin (Institute for Hygiene and Environmental Medicine), the Jena University Hospital (Septomics Research Group) and the company Röhl GmbH from Waldbüttelbrunn near Würzburg.

National and international guidelines have for some time been calling for patients with multi-resistant pathogens to be isolated in single rooms. However, the rising number of MRSA pathogens makes such a demand increasingly difficult to implement. In addition, the exclusive use of single rooms has several disadvantages and higher costs. In Germany, these consequences have not yet been scientifically evaluated to provide hard data for decision making. Most multi-resistant pathogens are transmitted primarily through contact. By implementing appropriate design means to minimise contact, it should therefore be possible to safely care for patients with such pathogens in two-bed rooms. Studies on alternative multi-bed scenarios – such as equipping two-bed rooms with two wet cells, or alternatively two toilets, or with self-disinfecting sanitary facilities – are currently lacking. Likewise, there have as yet been no studies on how new hospital buildings are colonised by microorganisms, and the factors that influence this.

In the KARMIN project, a team of architects, designers, medical practitioners and molecular biologists identified and evaluated interdisciplinary risk factors for infection transmission in patient rooms, the accompanying wet cells and adjacent functional areas on the basis of their structure and design as well as the procedures and activities that take place within them. From this, they elaborated planning recommendations for breaking the chains of possible infection transmission and developed a prototype for a two-bed room with wet cells designed to minimise infection transmission. This also included optimised equipment such as a disinfectant dispenser, bedside trolley and a concept for a bedside terminal with corresponding advisory content. Seventeen competent and innovative industrial partners were involved in the planning and implementation process.

This chapter presents the analytical study and methodology used, including, among other things, expert workshops with planners, care staff, cleaning personnel and hygienists as well as comprehensive studies on lighting and colour design. From this, designs and then detailed construction plans were developed in ongoing consultation with the project partners for both the room and selected fittings and furnishings. This process and the resulting final design variant are documented here.

A second focal area of the KARMIN research project was the study of how hospital microbiome develops. For this, the first occupancy of the newly renovated Charité high-rise bed building was studied. The Charité – Universitätsmedizin Berlin (Institute for Hygiene and Environmental Medicine) and the Jena University Hospital with the Septomics Research Group jointly investigated how architectural conditions (e.g. multi-bed and single rooms) influence the development and diversity of the microbiome and the emergence of multi-resistant bacteria. Furthermore, different cleaning regimes (e.g. surface disinfection vs. surface cleaning) were also evaluated. While the latter is beyond the scope of this book, the results are available on request from the project partners.

Work Process and the Project Team

The KARMIN project, under the leadership of the Institute of Construction Design, Industrial and Health Care Building (IKE) at the Technical University of Braunschweig, brings together architects, medical practitioners, hygienists and product manufacturers in an interdisciplinary work group for the first time.

The research team for the design and realisation of the patient room thus unites partners from the realms of science, medicine and industry. The participating university institutes have undertaken joint research in various areas of health and infection prevention for many years and are well-known and established research institutions. In addition, 17 partners from industry were involved from the outset in the development of the concept for an infection-prevention optimised patient room. Both the university institutes and the industrial partners consulted regularly over the course of the project, with meetings in person at least every three months as a means of ensuring successful collaboration.

Institute of Construction Design, Industrial and Health Care Building (IKE), TU Braunschweig

The Institute of Construction Design, Industrial and Health Care Building, which acted as project coordinator, has developed over the past ten years into a leading centre for teaching and research into healthcare building design in Germany. With its interdisciplinary research team of experts from the fields of architecture, process design and hygiene, it addresses the complex challenges of sustainable hospital construction. A focal area is the planning of infrastructural requirements for optimal patient care and the process-optimisation of staff workflows.

A specialisation in the field of healthcare building is the prevention of infection transmission through building design. This encompasses both construction and design aspects, for example the choice of materials or the design of junctions between components and built elements. Ways of optimising processes within hospitals using design means is a further aspect, for example through the organisation of the ward floor plan or operational processes in the hospital or patient room. The Institute takes an interdisciplinary approach, working together with other research institutes at the TU Braunschweig and with other nationally and internationally recognised institutions.

Institute for Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin

The Institute for Hygiene and Environmental Medicine is a further association partner and concentrates on the aspect of infection prevention among patients at the Charité – Universitätsmedizin Berlin. At the same time, the Institute of Hygiene is a National Reference Center (NRZ) for the surveillance of nosocomial infections, i.e. infections acquired in hospital. The Institute is therefore home to the Krankenhaus-Infektions-Surveillance-System (KISS), in which about 75 % of German hospitals currently participate. KISS is a benchmarking tool with which hospitals can objectively measure their infection rates and adapt their prevention measures accordingly. The Institute also organises nationwide hygiene projects such as the “Clean Hands Campaign”, which is supported by the Federal Ministry of Health, among others, and currently seven national and EU-funded third-party projects on infection prevention issues.

Research conducted at the Institute of Hygiene and Environmental Medicine focuses on the surveillance of nosocomial infections and multi-­resistant pathogens, evidence-based infection prevention measures and their implementation, molecular biological investigations to identify infection chains, and technical investigations into hospital hygiene.

Röhl GmbH Sheet Metal Processing

Röhl is an association partner for the project and a family-run medium-sized company with more than 40 years of experience of producing healthcare products. Alongside sheet metal processing, the main focus of its production is composite elements. It has undertaken numerous projects in the prefabricated bathroom sector for hospitals and care facilities such as the Traunstein District Clinic, Braunschweig and Halle Municipal Clinics, Hannover Region Clinic, SRH-Holding Heidelberg, the Surgical Centre Erlangen, Aachen Medical Centre and Alsterdorf Protestant Hospital in Hamburg. It has also produced prefabricated bathroom systems for nursing homes and homes for the elderly, such as those at Bad Neuenahr-Ahrweiler, the Leonhard Center Nuremberg, the St Martinus Wevelinghoven or the DRK Memory Zentrum Neuss. Röhl has an extensive network of suppliers and decades of experience in the hospital and healthcare construction sector.

Research phases

The research objectives were divided into five research phases (Fig. 1) in which all the project partners were involved:

Phase 1: research and investigation

Using a variety of different methods, the research team investigated the topic of infection prevention through design in the patient room. To this end, they visited clinics, observed activities in hospitals, and researched and analysed relevant literature and existing studies. They consulted experts as well as the various different users of patient rooms, asking them specific questions and documenting their findings.

Phase 2: concept and design

Based on the findings of the first phase, the team drew up a catalogue of requirements that should serve as the basis for the design of a two-bed patient room with wet cell designed to minimise infection transmission. From this, a design was elaborated for the patient room in ongoing consultation with all the project partners. The design also considered optimised designs for items in the room including a disinfectant dispenser, the bedside trolley and a concept for a bedside terminal with corresponding advisory content. Partners from industry were likewise consulted from an early stage to incorporate their expertise and recommendations, for example, on the choice of suitable materials and surfaces.

Phase 3: planning and construction

Detailed working drawings for the construction of a prototype were developed in close cooperation with the project partners and partners from industry. As part of the process, various products, fittings and furnishings in the room were either optimised or developed further to improve their ability to control the spread of infection and to meet a demand for innovative equipment. A prototype patient room equipped with all the necessary supply lines was completed in January 2020 on the premises of the company Röhl in Waldbüttelbrunn.

Phase 4: optimisation

The optimisation phase was used to fine-tune decisions on colours and materials and to investigate ways to optimise the design details and the junctions between elements. The prototype was examined several times by the project team and the research and industry partners, and each planning decision was jointly evaluated. An important aspect was to evaluate how products that had been developed individually worked in the context of the room in order to optimise their handling. It was also possible to examine the construction process with a view to avoiding weak points arising through the installation process.

Phase 5: evaluation

The findings and experience gained from the prototype up to this point will be documented for future improvements to the prototype and for presentation to a wider specialist audience at the Charité site and as part of the World Health Summit (25–27 October 2020) in Berlin. Selected experts as well as relevant user groups from everyday clinical practice will also have the opportunity to assess the KARMIN patient room at the facility in terms of its suitability for use and infection prevention. Their responses will also feed into the evaluation of the newly created two-bed patient room with two wet cells and should provide useful insight into transferring the findings of the project into the practice of modern patient room planning and design.

Collaboration with partners from industry

For the development as well as the detailed construction of the prototype for a two-bed room with wet cells designed to minimise infection transmission, the project team collaborated with experienced, motivated and innovative partners from industry. To be able to develop the best possible solutions for the project, 17 companies and manufacturers were selected according to various criteria based on the components in the patient room. The criteria ranged from the size of the product portfolio, the degree of experience in the healthcare sector and whether the company had their own research department. Each industry partner represents one of the components of the patient room and/or wet cell:

 

Windows

Doors

Door and window fittings

Walls/ceiling

Floor

Lighting/illumination

IT/communications

Furniture/furnishings/equipment

Patient bed/bedside cabinet

Disinfectant dispenser

Tap fittings

Sanitary objects

Bathroom equipment

In contrast to traditional planning processes (as outlined in the architects’ specification of works and fee structure) where companies bid for a tender based on a specification of works, the industry partners were involved in an ongoing basis in the concept development and design phases as well as in the detailed construction design planning.

Involving the industry partners from such an early stage made it possible to draw on their respective expertise in each sub-area and to discuss and develop the best solutions in each case. In order to structure the work process in a meaningful way, four working groups were defined: Room, Furnishings, Bathroom and Objects (Fig. 2). Project partners and companies could work together to discuss interfaces between components and develop appropriate joint solutions, also in meetings with all working groups. Together with the research team from the TU Braunschweig, the company Röhl coordinated the realisation of the prototype at the Röhl site.

Requirements for a Patient Room and Its Fittings

Methods

A number of different methods were employed as part of the analytical study to identify relevant information, findings and evaluations of existing approaches to infection control in patient rooms. A first avenue of exploration was to examine relevant literature and existing scientific studies to obtain an overview of the complexities of designing a patient room. Aside from desk research, a period spent observing clinical practice at Braunschweig Hospital also provided first-hand insight into the intricacies of this design task. By accompanying hospital staff on site, we could observe care processes, study cleaning behaviour and identify the daily challenges facing the different user groups in a patient room. Following on from this, two workshops with various experts and users were conducted in March and April 2017 to define the most important focal points in the planning context. A typological examination of the floor plans of two-bed rooms studied the extent to which the design of the floor plan can positively influence factors supporting infection prevention in a patient room. Selected floor plan types were also critically assessed in practice as part of the clinic visits and their respective performance was discussed with operators and architects. The various findings and information derived from these different methods were then compiled as a catalogue of requirements that served as a basis for the concept and design phase as well as for the detailed design and construction planning (Fig. 3).

Literature research on planning principles

As part of the analytical study, the relevant norms and standards for infection prevention in the context of building design were collated and structured according to their importance in legislative norms, ordinances and guidelines produced by independent organisations.

The German Infection Protection Act (IfSG) has been in force since 1 January 2001 and sets out regulations for the prevention and control of infectious diseases in humans. Its key areas of focus are measures for preventing the transmission of diseases to humans, the rapid detection of infections and the prevention of the spread of infections. The IfSG also provides the legal basis for the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI). The KRINKO publishes recommendations on hygiene-relevant topics such as the cleaning and disinfection of surfaces, best practices for handling patients with multi-resistant pathogens or the operational organisation of functional areas. These also include recommendations for the structural and functional design of hospitals such as minimum space requirements, the size of rooms and the location of hygiene-relevant rooms, as well as the quality of materials.

In terms of ordinances, the building regulations (for example the KhBetrVO), the hospital ordinances of various federal states and the drinking water ordinance are among the most important for the design of buildings. In addition to the general building regulations, six federal states (Brandenburg, Berlin, North Rhine-Westphalia, Saarland, Saxony-Anhalt, Schleswig-Holstein) have issued ordinances that deal specifically with requirements for hospitals.

Many of these regulations are based on the model hospital building regulations (KhBauVO) issued in 1976, which lay down guidelines for fire protection, hygiene, ventilation, lighting, room size and room layout. As the requirements for the construction and operation of healthcare buildings have changed over the decades, these regulations are no longer up to date and are in urgent need of revision, but they do still provide general orientation for hospital planners in Germany.

Alongside norms and regulations, there are a large number of guidelines and recommendations issued by privately-run independent organisations, which have been drawn up by expert committees and provide specific instructions for action in the field of hygiene.

Design services provided by architects are regulated by the latest version of the German HOAI (Official Scale of Fees for Services by Architects and Engineers), dated 17 July 2013. It defines architectural services for new buildings and conversion projects, along with the corresponding remuneration rates, and divides them into nine work phases that cover the various stages of a project’s design and realisation, from basic evaluation and planning permission to construction supervision and documentation. This breakdown assists hospital planners in de­termining at what points in the process building hygiene measures need to be considered.

In terms of the design of hospitals, DIN 13080 specifies the division of the hospital into different functional areas and locations and the structuring of the respective floor areas according to their clinical purposes. Another norm relevant to hospital design is DIN 1946-4, which concerns air conditioning systems in buildings and rooms in the healthcare sector.

The Association of German Engineers has published the VDI Guideline 6023 “Hygiene in drinking-water installations” and VDI Guideline 6022 “Ventilation and indoor-air quality” that likewise contain recommendations for hospital design and hygiene. Since 2013, an expert committee for sustainability in the construction and operation of hospitals has existed that also deals with the topic of hygiene, as well as a VDI expert committee for the “Management of hygiene-relevant surfaces in medical or care facilities”.

The Association of the Scientific Medical Societies (AWMF) serves as an umbrella organisation for a total of 168 member societies, and issues recommendations for the respective fields. These are divided into four levels of relevance. Classification S1 (recommendations for action by expert groups) is of lower relevance and classification S3 (evidence- and consensus-based guidelines) is of highest relevance. The recommendations of the working group “Hygiene in Hospitals and Doctors’ Practices” are of relevance to the design and function of healthcare facilities.

On-site observation in clinic environments

In order to gain insight into the processes on a normal care ward, the KARMIN project team accompanied nursing staff during their daily routine of caring for patients as well as cleaning staff on two wards of the nephrology department over a two-day period at Braunschweig Hospital. Conversations and interviews conducted on site aimed to identify hygiene-critical areas from the perspective of hospital staff and from these to derive measures relevant for planning. Input from the staff served, among other things, as a basis for defining the criteria by which to conduct the typological evaluation of patient rooms. These were also discussed in two workshops with a broad range of experts, not least to verify their transferability to other contexts.

Typological evaluation of two-bed floor plans

As presented in detail in the section Typological Evaluation, the team undertook a systematic examination of different patient room floor plans of two-bed rooms in general care hospitals in national and international institutions. The study looked at numerous design aspects evaluated according to different categories, including structural complexity, infection-prevention potential, workplace quality and safety, spatial quality, patient safety, patient satisfaction and privacy. The result was an overview of two-bed patient room floor plans and their spatial dependencies, which influence the corresponding qualities. Some of these floor plans were then selected as the basis for the survey conducted with experts.

Workshops with experts

Two workshops with experts were held at the TU Braunschweig. The two workshops, which both followed the same pattern, served as a platform for interdisciplinary exchange with the aim of identifying hygiene-­critical areas in the patient room and wet cell and discussing appropriate design strategies for infection prevention in hospital environments. A total of 23 experts from different disciplines – hospital planners, nursing staff, cleaning staff, hygienists and “patients”, the latter represented by students and university staff – were selected and invited to contribute their views. Among others, staff from Braunschweig Hospital, Hanover Medical School and the University Hospital in Göttingen took part.

Deficits analysis

The first part of the workshop constituted a deficits analysis in which participants were invited to note their answers to the question “Where do you see the greatest deficits in hygiene in patient rooms and wet rooms in terms of construction, process, regulations, etc.?” on a defined number of cards. The answers were then collected, clustered and assigned to topic headings. In addition, all participants could use adhesive dots to indicate the relevance of the respective issue to the topic of infection prevention (Fig. 5).

Evaluating the results (Fig. 4) identified two key subject areas of most relevance to hygiene deficits in the patient room: the spatial arrangement, and fittings and equipment in the patient room and wet cell.

Other major challenges cited were the processes in nursing care, insufficient information for patients and visitors, the often inappropriate positioning of the disinfectant dispenser, supplies and waste disposal, standards of cleaning and disinfection and the shared use of the bathroom. Topics of lesser importance that were also raised included the arrangement of the ward, a lack of automation for contactless operation of items such as WC flushing, and the planning process.

Aspects pertaining to the arrangement of the room included the placement of beds next to each other, excessively small patient rooms and wet cells, no clearly separated zones, and insufficient space between the beds and other furniture and furnishings. In terms of fittings and equipment, factors such as contact surfaces of the equipment, room textiles such as curtains, surfaces that are not easy to clean and insufficient storage and work surfaces for nursing staff were also identified. These deficits provide an indication of possible relevant hygiene-critical factors.

Evaluation of floor plan types

In the second part of the workshop, the participants were asked to select three favourites from a selection of eleven two-bed patient room floor plans. The selection of the eleven floor plan types represents different possible spatial configurations of the patient room and wet cell (Fig. 6). The floor plans differ, among other things, in their room geometry, the position of the beds in relation to each other, the alignment of the beds to the façade and the entrance, and the number of wet rooms and their equipment and possible uses. The aim was to obtain an expert assessment on which spatial floor plan configurations or aspects thereof can have a positive effect on the prevention of infection transmission. The floor plan that was rated most positively (Fig. 6), No. 1 has the beds placed not next to each other, two wet cells and an equal relationship between the bed areas and the façade and entrance. The three most frequently mentioned floor plans all have the beds arranged opposite, orthogonally or offset to each other.

Ideal floor plan patient room

In the final assignment of the workshop, we asked the experts to sketch an “ideal floor plan” of a two-bed patient room. The floor plan could include furnishings and fittings that they considered ideal and they were free to add relevant details in writing. To this end, mixed groups of experts were formed to bring in different expert opinions. A series of idealised proposals were developed, presented and then discussed among the group in the workshop.

Survey 65 +

In the workshop with experts, the patient user group was represented by students and university staff. To obtain a better picture of the majority of patients in everyday hospital situations, a survey was also conducted with people over 65 years of age. Of particular interest was to identify deficits and evaluate different floor plans. These results augmented the evaluation of the workshops with experts.

Hospital visits

Based on the results of the typological study and the workshops with experts, three clinics in Germany were selected that feature patient rooms and nursing wards with specific hygiene-relevant aspects, both in their layout and design, and in their hospital processes. The team examined these aspects as part of visits to the clinics and spoke with clinic staff and planners. One of the clinic wards features two-bed patient rooms with two identical wet cells, one for each patient. In on-site conversations with hygiene specialists, the planning department and caregivers, the team were able to discuss the relative advantages and disadvantages of this structural solution. Another clinic featured identical two-bed patient rooms with a same-handed arrangement. Here, too, the respective factors favouring this arrangement were discussed with the architecture office responsible for the hospital design.

Catalogue of requirements for the patient room and wet cell

A catalogue of requirements was developed to assimilate and give order to all the information acquired in the analytical study, with the aim of deriving concrete planning-relevant requirements for the concept and design phase.

In a first step, all the investigative methods such as the workshops with experts and on-site observation of everyday clinical practice (Fig. 3) were listed. To structure the information gathered through these individual methods, five main categories were defined: structural complexity, infection prevention potential, workplace quality and safety, spatial quality, and patient safety, patient satisfaction and privacy.

The findings obtained through the various methods were then assigned to these categories. To determine the relevance of the respective findings, three further hierarchical evaluation categories were used.

Category I – “must”

Category II – “shall”

Category III – “may”

Category I corresponds to high-level legislation and building regulations that must be implemented in the planning. Category II describes, among other things, planning recommendations set out by independent organisations such as DIN standards. Category III includes, for example, recommendations by experts. The resulting catalogue of requirements in the different categories was then used as a basis for deriving design principles.

Material testing as a basis for planning

Suitable surfaces and products were researched for each of the areas and aspects of the room prototype – the walls, floors, patient bed, fittings and equipment, doors, and door and window hardware. The project’s industry partners were asked to test at least five material samples for cleanability in their respective area of responsibility within the patient room or wet cell. The assumption is that the surface properties and the type of soiling or contamination influence the ease of cleaning. The tests were carried out by the Institute of Building Materials, Concrete Construction and Fire Safety at the Technical University of Braunschweig. The sequence for the test setup for simulating cleaning was as follows: a. Defined degree of contamination, b. Cleaning with a linear wiping simulator, c. Quantification of residual contamination using a particle counter with surface sensor. The testing procedure also included measuring roughness, surface free energy and cleanability for each material sample.

The results of the material tests fed into the selection of materials, surfaces and decors in the subsequent phases of the design process. Often, several product ranges by a single manufacturer exhibited comparable results so that the designers were typically able to choose from between one and three products for each sub-aspect. Further information on material applications and material ageing can be found in the section on .

Planning and Design

Design concept

The results of the analytical study were compiled, evaluated and hierarchically organised as a catalogue of requirements. From these, design principles were identified that could form the basis for the concept and design phase of the patient room. The requirements for the room relate directly to the floor plan configuration, while the requirements for fittings and equipment will be considered in a later planning phase. In design terms, the challenge was to configure a patient room that has a high spatial quality for the patient and the staff, facilitates optimal care provision and cleaning processes and embodies new approaches to infection prevention that are feasible for implementation in practice. In close cooperation with the research partners, the team defined the following structural, hygienic and procedural requirements (Fig. 7):

A. Patient rooms in additive arrangement

B. Compact design

C. Beds placed opposite one another

D. Equal-status bed positions

E. Both patients can be seen from the entrance area; clear room arrangement

F. Work and storage area for staff near the entrance

G. Windows for optimal natural ventilation

H. Two barrier-free bathrooms with showers

I. Optimised zoning for care processes

J. Clearly visible disinfectant dispenser close to the patient bed

The following requirements were defined for fittings and equipment:

The formal design should facilitate optimal cleaning

Flush, integral fittings with few construction joints

Surface characteristics should be optimised for cleaning

Three levels of consideration were defined for the subsequent design phase – “Room and layout”, “Components and joining” and “Surfaces and materials”. The design team, along with the project partners, used these as a means of approaching the design development over the following six months. Several variants were developed for each level of consideration and then discussed, evaluated and prioritised.

For the first of these, “Room and layout”, three room concept proposals were elaborated, all of which meet the previously defined requirements (Figs. 9–11).

In a subsequent project meeting, the project partners and industry partners were asked to select which of the variants they viewed as the most sensible and to justify their decision. Working in small groups, the participants presented their results using sketches and maps. From the ensuing evaluation, variant 1 was selected as the basis for further development (Fig. 9).

In a second step, the participants also defined additional requirements for the next design phase:

Clear zoning and allocation of work areas to staff and the bathroom, and of cupboards to patients

One nurses’ work area per patient including disinfectant dispenser and storage/shelf space for staff

The disinfectant dispenser should be next to the nurses’ work area, positioned in the direction of the patient and visible from all parts of the patient room.

The bedside cabinet should be placeable on both sides of the patient bed.

A permanently installed bench at the window as seating for patients and visitors

The bathroom should be able to accommodate a sliding door to reduce risk of injury and improve clarity of the entrance situation.

A possibility for staff to store materials in the patient bathroom

Built-in storage in the wall zone between the bathroom and patient room

Bathrooms with different fittings

Three concept proposals were likewise developed for the aspect of “Components and joining” and presented for discussion. These were based on layout variant 1 and the additional requirements identified. The overall room layout is therefore the same for the different variants with respect to the position of the bathrooms, the patient beds and the large window front. Here the means of accessing the wet rooms, the position and size of the nurses’ work area and the patient cupboards varied (Figs. 12–14).

The three new room variants were again discussed as part of a project meeting to which, alongside the project partners, an interior designer and hospital planner were invited. The aim was to identify possible deficits in the concepts and to invite suggestions for improvements in the detailed design planning.

Smaller group meetings were also held with the partners from industry, each concentrating on a specific aspect: the room, bathroom, fittings and objects. The objective was to identify crossover points and dependencies between the respective trades and to discuss possible detailed solutions and complicated junctions, joints or material transitions. Relevant products or product ranges were likewise discussed among the partners, as well as how existing products could be adapted or developed to meet the defined project requirements.

Following the design meeting and smaller group meetings, variant 3 was selected for further development (Fig. 14). A new set of requirements was likewise elaborated for the equipment in the patient room:

Patient cupboard with clothes rail, fixed shelves and a lockable compartment, as well as push-to-open cupboard hinges for easier cleaning

Patient table surface slightly angled so that the patient’s sitting position is slightly rotated to improve the angle of view into the room and facilitate communication with visitors and the other patient. The table must be large enough to put down a food tray.

Visitor bench with wipable edges and removable, easy-to-clean cushions

One waste bin per patient located near to the nurses’ work area

A compartment for stowing suitcases

Patient bed (bed length 2.21 m) with maximum extension length of 2.51 m. It should be accessible from both sides without needing to move the bed or creating an impractical room depth. Space limitations should be addressed by controlling room occupancy, e.g. by pairing a long bed (2.51 m) with an average bed (2.21 m).

For the bathroom position and equipment, the following requirements were proposed for the final design:

Sliding door arranged in front of the wall

Wall-mounted WC and waste bin for easier cleaning

Tiled floor and walls

Infrared mirrors

Folding support rails

Shelves for patient use

Waste bin

Placement of disinfectant dispenser not at the wash basin, but in a cupboard niche to avoid confusion between soap and disinfectant

A design concept was also developed for the aspect “Surfaces and materials” based on the previously agreed design variant and other requirements, see Colour and materials concept. The results of the materials testing conducted at the iBMB (Institute of Building Materials, Concrete Construction and Fire Safety) at the Technical University of Braunschweig were also considered in the selection of .

Final design

Based on the analytical study and cross-partner evaluation and development of interdisciplinary approaches, an innovative design for an infection-prevention optimised patient room and accompanying wet cells was developed. The resulting prototypical concept takes numerous aspects into consideration including the structural layout, functional processes and pathways, detailed solutions, materiality and surfaces.

Room layout and process

The final floor plan is designed for additive repetition to create wards of identical patient rooms. The resulting treatment, nursing care and cleaning processes are therefore predictable and can be optimised in their choreography. Errors and omissions resulting from the need to adjust to new room configurations can therefore be avoided (Figs. 15, 16). The division of the patient room into three zones also promotes good hygiene practices: the so-called nursing zone is the area around the patient bed and next to the nurses’ work area that staff move around in; the patient zone is the patient bed and its immediate surroundings; and the lounge area for patients and visitors is on the outer wall alongside the window front with the patients’ wardrobes, desks and bench (Fig. 17).

The floor plan is directly informed by the design principles discussed earlier: for example, the beds are arranged opposite each other, the bed positions are of equal status, and staff have good visibility of both patients. The room layout is symmetrical, so that each patient has half of the room with an identical arrangement of fittings and equipment. The principle of arranging the beds opposite each other marks a departure from the conventional layout of two beds arranged parallel next to each other (Fig. 18). This arrangement ensures that both patients have an equally good view of their surroundings (Fig. 19) and that staff can see both patients from the door area of the room and are able to monitor patients and react more quickly in the case of an emergency (Fig. 20).

The position of the beds is intended to encourage hospital staff to more consciously disinfect their hands when caring for the patients. In addition, the head ends of the beds are further apart, reducing the risk of infection transmission between patients through physical proximity. The symmetrical division of the room and separate set of fittings per patient ensures that it is clear which items belong to which patient, thus avoiding unnecessary contact transmission. The same principle applies through the provision of two wet cells (Figs. 21, 22). A separate, wheelchair-accessible nurses’ work area for each patient with its own storage is likewise not just a help for the staff but encourages compliance with hand disinfection guidelines. Disinfectant dispensers are also located at the foot of each bed so that staff always have the opportunity to disinfect their hands as they walk past – either when entering the room or when switching from one patient to the other.

Innovative solutions in the final design

A. Entrance area

The entrance area widens towards the patient beds, making it simpler for nursing staff to glance inside and have an unobstructed view of the patient. On the right, a control panel allows staff to select different lighting scenarios to suit the situation. These simplify work processes for the staff.

B. Care and work area

A work area for nursing staff is located close to each bed. It incorporates storage and thus direct access to new medical materials and gloves, a disinfectant dispenser and safe waste disposal, grouping typical work processes in one place.

C. Wet cell

Two wet cells, one for each patient, prevent usage scenarios where cross-contamination can potentially occur through shared contact surfaces.

D. Visitor zone

The visitor zone is a separate area combining the window bench, the patient desk and chair. The bench is raised on a plinth, the front side of which rises up from the floor to beneath the bench in a single smooth surface for easier cleaning.

E. Bedside cabinet

The new design of the KARMIN bedside trolley facilitates better cleaning due to its seamless construction. It provides more stowage space without being larger than a conventional unit, with clearly defined areas for better organisation, and can be used from either side so that it can be positioned flexibly.

F. Disinfectant dispenser

The dispensers are placed along the routes of work processes and close to the respective patient bed. The newly developed KARMIN dispenser can record usage levels and attribute these to specific user groups, making it possible for staff to assess compliance with hand hygiene guidelines in team meetings by evaluating usage statistics.

G. Bedside terminal

The bedside terminal is the primary means of providing informative content to educate patients on hygiene behaviour so that they may actively contribute to infection prevention.

Colour and materials concept

The colour and design concept of a patient room contributes significantly to the quality of a stay in hospital and thus also to the patient’s well-­being during their period of treatment. The interior design of healthcare environments has undergone a shift towards improving patient comfort by creating a more hotel-like atmosphere. Other factors such as the quality of the air and of light, as well as a visual connection to the world outdoors, have also been given increased attention in recent years. The approach of Healing Architecture considers how the design of the environment affects physical and mental well-being. Factors that contribute to a positive environment can be conducive to the recovery of patients, and at the same time contribute to staff satisfaction in the workplace.

For the KARMIN project, the team needed to develop a design concept that is uniform and appealing but also compatible with the principles of infection prevention. An essential aspect in this respect is the good cleanability of surfaces. As such, colours were needed that make it easy to see coarse soiling or to detect when a surface has not been sufficiently wiped clean. Colours can therefore contribute indirectly to promoting compliance with cleaning procedures in patient rooms. The planned fittings have the advantage that one can match colour surfaces to one another more easily than with mass-produced furniture where only selected designs and decors are usually available. Surfaces that are intensively used or touched frequently should not have uneven textures and should have solid colours to make it easier to detect contamination. The use of comparatively inexpensive materials also means that these benefit all patients, and not just those in better-equipped private health insurance rooms.

Three potential colour schemes were developed for the final design of the patient room, each with a different theme. As numerous different combinations are possible within each theme, a 3D model was built to simulate colour and material combinations. The following variants illustrate an example for each of the key themes.

“Clean” theme with a contrasting colour

The “clean” theme presents a neat and tidy overall impression comprised predominantly of light colours, especially white and grey tones along with a contrasting accent colour on selected surfaces. The colour accents not only lifts the mood of the room but can be used to demarcate areas of the floor, for example to aid movement and orientation, which is helpful for the mobility of older patients in particular (Fig. 26).

“Two colour zone” theme

In this variant, two different colours are used to denote how room zones, fittings and equipment are allocated to each of the two bed locations, and thus the patients. Two contrasting colours are proposed to ensure they can be told apart, especially for patients with sight impairments. A central aspect of this theme is to aid older patients and/or patients with dementia in recognising their own room zone and associated areas and items in the room. Colour coding can also reduce the frequency with which surfaces are touched by both patients or confusion between items in the rooms, which can also apply to younger or sedated patients, both of which help to reduce the incidence of contact infection transmissions (Fig. 27).

“Atmospheric” theme

This theme employs colours and decors that are harmonious and, in their combination, lend the patient room a pleasant and inviting atmosphere for patients and their visitors (Fig. 28).

The final colour scheme

Although the 3D model was helpful as a tool for simulating different colour schemes, examining actual colour and material samples was essential when determining the colour concept. Samples were obtained for all surfaces, from the flooring to the sides of the patient bed to bathroom tiles. The final colour concept is a combination of the “Clean” and “Atmospheric” themes shown in (Fig. 29). As infection prevention is the primary focus of the project, the colour choices must create an impression of cleanliness expected of a clinic environment. For this reason, the proportionally largest surfaces of the room – ceiling and walls – have been painted white. The nurses’ work area, including the worktop and push-to-open cupboards, are likewise white to ensure contamination is immediately visible. A cool blue is used as the contrasting colour.

To address the aspect of patient well-being – a parallel aim of the design concept – warm colour accents in the form of brown tones and wood decor were chosen for the patient and visitor zone. In combination with warm grey tones, the overall result is a colour-coordinated and harmonious colour concept (Fig. 25).

Surfaces in the patient room

For the majority of surfaces in the patient room, high-pressure laminate (HPL) was used: it is easy to wipe clean and tests conducted in advance showed that it is resistant to erosion through disinfectants. HPL is used for all cupboard and work surfaces, for the impact protection wall cladding and the window benches. For the room design, this also made it possible to coordinate colours and decors more easily rather than having to select colours from different product catalogues. Similarly, the colour concept for the KARMIN patient room can be varied as needed by selecting from the broad range of colours available for HPL surfaces. A rubber flooring was chosen for the floor as it is a natural product that requires no chemical sealing and is thus emission-free.

Fittings in the patient bathroom

The decision to include two identical but independent wet cells in the KARMIN patient room made it possible to trial different surfaces in the prototype. While one bathroom is completely tiled, the other is clad with HPL panels. As the cleaning tests revealed that both surfaces are equally suitable, the prototype can be used to compare them directly in practice. The same principle was used to test differing degrees of automation in the patient bathroom: one bathroom has an elbow-operable single lever mixer tap while the other is equipped with an automatic motion sensor tap.

Lighting concept

The importance of light

Light is a vital part of human life. The changing light conditions determine the rhythm of the day and seasons, influence our hormonal balance and contribute to the formation of important vitamins. Light has an effect on our physical and mental health and thus on the process of recovery. Good lighting is also essential for nursing care procedures, for example to correctly place a needle for an injection or to recognise a clinical picture based on how the patient looks. Sufficient lighting is also needed for cleaning to ensure contamination can be seen, which is essential for the prevention of infection. By the same token, inadequate lighting can lead to people feeling downcast or to blunders.

Lighting in normal care wards should support a general impression of cleanliness but also be pleasant enough to feel homely and thus positively connotated. Bright and colourful room interiors elevate the patients’ sense of well-being in the sometimes rather dreary daily routine of being in hospital.

Natural light is preferable to artificial light. The arrangement of fittings, windows and ultimately the shape of the floor plan should therefore be coordinated with the type, positioning and number of lamps during the planning stage. While the designer is largely able to use their discretion, lighting design must also comply with certain standards. A “smart” patient room can employ sensors to automatically create lighting situations that react to specific circumstances. For example, the bed used in the KARMIN patient room triggers underbed lighting when it detects a shift in weight. Manual controls, on the other hand, when used by many people, bear the risk of cross-contamination as a shared contact surface. As such, any lighting scheme must reflect the importance of light for well-being and the usage scenarios and needs of the different groups of people within a patient room. In addition, it should be as contactless and individually controllable as possible.

Requirements

To do justice to the importance of light, a multitude of requirements must be met. These are both determined by existing standards and the individual situation of the room to be designed. In general, a pleasant atmosphere can be achieved using indirect lighting providing light levels of at least 100 lux and warm white light (DIN 5035-3).

Changing requirements at different times of day

To determine the specific lighting requirements, it is useful to define usage scenarios and lighting situations. The changing incidence of natural light and the various activities of the different groups of people within a patient room, along with their varying frequency of use, result in a large number of different possible lighting scenarios over the course of the day. The following activities should be considered:

 

Daily cleaning

Room cleaning between patient occupancies

Nursing care at the bedside

Preparatory work at the nurses’ work area

Accessing the nurses’ cupboard

Doctors’ rounds and examination

Visitors

Reading

Personal hygiene

Toilet use

Rest and recuperation

Dressing/undressing at the patient cupboard

Eating

Sleeping

Night-time orientation

These scenarios relate to specific zones in the room and in the wet cells and require lighting of varying intensity and orientation. In some cases, the situations mentioned above are already covered by existing standards.

Standards

DIN 5035-3 and DIN EN 12464-1 are the relevant norms governing lighting. They set out suitable lighting situations not just for patients but also for the occupational health and safety of staff, and address some of the scenarios mentioned above. For example, bedridden patients must not be exposed to constant direct glare by limiting the average luminance of the luminaires visible from the bed to 1000 candelas per square metre. Similarly, indirect lighting illuminating a ceiling should not cause the ceiling to exceed a brightness of 500 candelas per square metre. Each patient bed should be provided with a reading lamp providing a localised brightness of at least 300 lux at reading height. They should be individually switchable to avoid disturbing the room neighbour in a multi-bed room (Fig. 30).

At night, however, the requirements are completely different. Both nurses and patients need a sufficient level of light to be able to find their way in the dark. At the same time, such light should not wake any other patients in the room. To provide orientation, concealed LED lighting with a wide beam can be mounted to illuminate the floor beneath the bed and near the door so that other sleeping patients are not exposed to the light source. A certain level of night lighting is also required to assure nursing staff can quickly appraise the room and conduct any necessary simple tasks. A light level of 5 lux at a height of 0.85 m above the floor is sufficient.

During the day, the examination height and the nurses’ work area should be illuminated as evenly as possible at a light intensity of at least 300 lux. Brighter levels of at least 1000 lux are only required in the case of emergencies, or detailed examinations and treatments. Variances in the uniformity of illumination should not exceed a minimum ratio of 1 : 2 between the highest and average illuminance (Licht.Wissen 07, 2013).

Additional requirements

Alongside norms and standards, the various light scenarios described above have additional requirements. The principle of Human Centric Lighting (HCL) can be applied to create a pleasant, healing environment in which lighting is specially tailored to supporting people and their sense of well-being. Humans, as biological beings, are used to daylight in its different forms and to the diurnal rhythm of day and night. The biological effect of light on our body clock and psyche is fundamental: the melanopic, non-visual effect of light can have an activating effect and strengthen recovery and general well-being. By contrast, the visual, atmospheric effect can evoke emotions ranging from discomfort to a sense of security or confidence. As room neighbours may have different needs at the same time, the lighting design should also be able to accommodate conflicting lighting requirements. It should, for example, be possible to darken one half of the room while allowing a second patient to switch on a reading light at the same time without causing glare. Targeted lighting can also help demented or fatigued patients find their way around but also discourage them from undertaking un­­desirable activities.

Good lighting is also vital for hospital staff to ensure they can carry out their work correctly without making errors due to poor visibility. Sufficient illumination is essential for diagnostics and nursing care, and care staff need to be able to see the colour of the patient’s skin without it being falsified by low light levels or coloured reflections from the walls. Green hospital walls are inadvisable, and warm-white lighting should be avoided during the doctors’ rounds.

Dazzling caused by reflections from screens should be avoided as it can lead to premature tiredness. Various measures can help reduce reflected glare:

Dimmable lighting

Correct arrangement of the screens in relation to lamps and windows

Shading option for windows and skylights

Use of glare-free lamps

Luminaires with large luminous surfaces but low luminance

Non-reflective surface finishes (matt surfaces) for underlays and work surfaces, etc.

Careful alignment of lamps in relation to the direction of vision

Similarly, the corners of rooms or inaccessible or covered areas must also be well lit to ensure they are properly cleaned.

Lighting controls

Lighting controls should allow patients and staff to quickly and intuitively activate the appropriate lighting profile for their needs. They need to consider that staff may have their hands full or a patient may be too exhausted or physically impaired to operate a light switch. Similarly, having to press a switch, and thus a contact surface, in the middle of a work process makes it hard to comply with the five moments for hand disinfection.

Light switches should be touched by as few people as possible, and for this reason sensors can be a good alternative. By placing switches near the patient and near the entrance to the room, different users can set the desired lighting mode directly and joint use of the same switch is avoided. Lighting controls equipped with mid-range RFID readers can also respond to staff or patients wearing an appropriate RFID chip, changing the lighting profile when people arrive at or leave the room.

Lighting operation

To operate the lights, the two primary user groups, the nursing staff and the patients, are each assigned a respective lighting control point at the room entrance and at the patient bed that allow them to select specific lighting scenarios. At the entrance, staff can switch on the ceiling light and the light above the worktop of the nurses’ work area. To assist patients at night in unfamiliar surroundings, sensors are used so that patients do not have to search for a switch or a menu item on a touch panel: a weight sensor at the bed automatically activates orientation lighting. The programming logic of lighting scenarios has to be considered carefully to avoid lighting scenarios switching in mid-activity, leaving patients in the dark at night or interrupting nursing procedures. Automatic control systems have advantages for motor-impaired patients but are less adaptable to specific situations, as sensor technology is not able to interpret the actual situation in the room. Consequently, the lighting in the KARMIN patient room must be switched off manually.

Lighting concept and implementation in the KARMIN patient room

The lighting of the KARMIN patient room is designed to accommodate the diverse needs of the different user groups. To begin with, the large windows of the room provide as much natural light as possible along with views outside, both of which are beneficial to patient recovery by relating them physically to the world outside and time of day. The inboard arrangement of the wet cells and the placement of the beds parallel to the façade also maximises the incidence of natural light on the beds.

The lighting concept also reinforces the zoning of the room, accentuating and delimiting the patient area, the nurses’ work area, the visitors’ zone and the two wet cells. In certain situations, such as for night-time orientation, the concept shifts so that the light guides patients to the wet cell and back, bridging rather than delimiting the zones.

Positioning and selection of light sources

Altogether, 21 different light sources and several control units have been installed in the KARMIN patient room (Fig. 31). The three large, flat surface lamps (Fig. 31), Nos. 1–3 are useful for extensive illumination during the doctors’ rounds and during cleaning. The white balance of the LEDs is tunable, making it possible to simulate the colour temperatures of daylight, which are important for Human Centric Lighting, and to promote the patient’s sleep rhythm (Figs. 32–36). They can be individually controlled and radiate directly and indirectly through a broad flat panel and an outer, offset RGB colour ring. These three lights also zone the room into an entrance area and two patient areas.

The three ceiling lights change the mood of the room over the course of the day from morning to night when orientation lighting takes over. During the day, the luminaires are switched on by default but can also be switched off if desired.

Each patient area is also indirectly illuminated by a long, continuous lighting strip → Fig. 31, Nos. 8, 9 in the wall panel at the head end of the bed that both visually underlines the depth of the room and delimits the extent of the patient zone. Two reading lights above each of the patient beds provide the requisite illumination at the reading plane (Fig. 31, Nos. 6, 7) and a further reading light is installed above each of the patients’ desks → Fig. 31, Nos. 4, 5 next to the window (Fig. 37).

Below the nurses’ work area, a light-deflecting aluminium skirting rail has been installed that illuminates the floor along the wall (Fig. 31, Nos. 12, 13). A sensor detects when a patient gets up from the bed and automatically activates the lighting strip at night (Fig. 31, Nos. 20, 21), which shines from the skirting rail onto the floor, illuminating the path to the bathroom where the light is on but dimmed. As both the under-bed and skirting light are at a very low level, they disturb the neighbouring patient as little as possible. Its warm-white colour avoids stimulating the patient too much, so that they can get back to sleep after visiting the toilet (Fig. 38).

A second dimmed lighting strip above the nurses’ work surface provides even illumination of the worktop for the nursing staff to carry out their work (Fig. 31, Nos. 10, 11).

A central ceiling light (Fig. 31, Nos. 16, 17) and a light above the respective WC (Fig. 31, Nos. 14, 15) illuminate each bathroom and vertical lighting strips illuminate the mirrors (Fig. 31, Nos. 18, 19). The matt-white surface of the HPL panels lining the wet rooms disperses light evenly without dazzling.

The mirrored arrangement of the lighting on both sides of the room means that each patient or work area can be illuminated individually without affecting the other patient. This makes the room better able to respond to the needs and well-being of the individual patients and improves the quality of a multi-bed room.

Control panel, bedside terminal, switches and sensors

In normal use, the room lighting follows the course of the day. For specific application situations and visual tasks, different scenarios have been developed (Fig. 39). The settings for all luminaires can be saved in preset scenarios that govern which areas are illuminated at what level of intensity and colour temperature. While the scenarios switch multiple luminaires at once, specific lamps can still be switched on individually. The lighting scenarios can be selected from a control panel at the room entrance and the patient’s bedside terminal: the control panel at the entrance includes scenarios for nursing and medical staff, cleaning staff as well as visitors and patients, while the bedside terminal provides only patient-specific scenarios. For ease of use, the scenarios have been named in the control panel and are also shown with additional pictograms on the bedside terminal. The reading lights above the two patient desks next to the window can be switched on and off manually via a switch, as can the light above the respective nurses’ work area. A motion detector activates the light in the bathroom.

The exact settings, including which lights are switched on at which level of intensity and colour temperature, are shown in the table in (Fig. 39).

The lighting of the KARMIN patient room conforms to the norms and ensures that specific groups of users have the necessary lighting, whether temporarily or in general. It supports staff in their activities and ensures patients have a pleasant room environment over the course of the day.

Detailed planning

The detailed design planning took the final design concept as its basis and incorporates not only the high-level requirements for the room fittings and equipment (see the section Requirements), but also relevant planning requirements derived from practical experience. This stage of the planning process strove to find solutions to construction details that ensure a high quality of design (Fig. 40) and minimise component joints for optimal cleaning. The work was undertaken in close cooperation with all the partners involved and across the disciplines (see Work Process and the Project Team).

Design requirements

A design vocabulary was developed for the fittings and equipment that focussed in detail on optimising the ease of cleaning the items. The furnishings are designed to be as flush as possible with minimum construction joints. The materials and surfaces were selected based on the preceding material investigations (see Material testing) to facilitate and support easy cleaning in the long term. Surfaces with coatings more prone to wear and tear were deliberately avoided to avert the incidence of room closures for maintenance and upkeep.

Planning requirements

The design of the floor plan adheres to planning recommendations and DIN standards relevant to the design of hospitals and patient rooms, for example with respect to required distances between items in the room, or freedom of movement in barrier-free bathrooms. The resulting patient room has two wet cells each observing the required minimum dimensions for patient room bathrooms.

Sizes, distances and dimensional dependencies

The patient room has 25.2 m² and the two wet rooms are each 3.7 m² in size. The lateral distance between the patient beds and furniture or fittings (bed to patient wardrobe and bed to nurses’ cupboard) is 90 cm. The distance between the patient beds was defined according to two occupancy scenarios:

A. Occupancy with two average-sized patients – bed length 2.21 m, with a passage width between them of 1.20 m.

B. Occupancy of one average and one above-average sized patient – bed lengths 2.21 m and 2.51 m, with a passage width of 90 cm.

The width of the passage between the beds must be measured as the distance between the disinfectant dispensers mounted at the foot end of each bed. The room layout ensures a minimum width of 90 cm, as required for doors, for example, with one above-average sized patient. The wet cells are designed for barrier-free access in accordance with DIN 18040-2. For this, an area of free movement of 1.20 m in diameter is required in front of the various sanitaryware in the bathroom. The washbasin, the storage compartments and the shower rails are installed at a height of 85 cm.

The nurses’ work area

The challenge when designing the nurses’ work area next to each patient bed was to provide all the necessary facilities for nurses and medical staff to prepare necessary treatments while affording the patients the maximum possible sense of space. The nurses’ work area is a single spatial unit comprising a fitted cupboard and worktop. A disinfectant dispenser is mounted on the wall above the work surface and faces into the room (Fig. 41).

The nurses’ cupboard includes compartments for storing necessary medical materials, a glove dispenser and a waste bin for disposing of used items. The glove dispensers are accessible from slots on the cupboard sidewall adjoining the worktop. Push-to-open cupboard fittings have been used throughout to create an even visual appearance and a smooth surface for cleaning as there are no protruding knobs or recesses in or around which dirt can gather (Fig. 44). The cupboard is integrated into the bathroom wall and its depth is designed so that the reverse side serves as recessed shelving for the patient in the bathroom → Fig. 55. A disinfectant dispenser and waste flap are integrated into the recess on the bathroom side → Fig. 47. The waste bin in the nurses’ cupboard is accessed via a push-to-open fitting. Waste from the patient room and from the bathroom is deposited in the same bin. The position of the disinfectant dispenser to one side in the bathroom recess avoids it being confused with the soap dispenser.

The edge of the work surface follows the splayed line of the bathroom wall and has a rounded corner to prevent any risk of injury. A flush-mounted recessed wall luminaire is mounted above the worktop with a concealed, downward-facing LED lighting strip to illuminate the work area in accordance with statutory requirements (Fig. 42, No. 2). In addition, a similar recessed aluminium profile with an LED lighting strip is flush-mounted at the base of the wall and serves as night-time orientation lighting (Fig. 43, No. 7). The rubber flooring is turned up at the edges with a curved floor-to-wall junction rising 10 cm above the floor. In places where fittings project forward, such as between the cupboard and floor or the bench and floor, the floor turns up to meet a plinth construction, resulting in a seamless transition from floor to wall for easier cleaning (Figs. 42, 43, No. 8).

The visitor and patient area

The visitor and patient area encompasses the window bench, a desk for the patient and a wardrobe for the patient’s belonging. Arranged alongside the window front, and mirrored on both sides of the room, it offers a direct view of the world outside (Fig. 48). It has to accommodate different dimensions in a single spatial unit – the seating and table heights and the table and wardrobe widths and depths – while also maintaining a sensible distance to the beds. The windows also need to be openable for natural ventilation, but people should not be able to fall out of the window. The chair is the only movable element in this area, a conscious decision so that as little as possible needs moving to clean the room. The window bench, the patient desks and the patient wardrobes form a single fitted unit with the wardrobes placed at either end in front of the external wall and the seating below the large window to ensure maximum natural illumination and an unobstructed view of the world outside. The window is divided into fixed glazed sections behind the visitors’ bench and opening casements in front of the desks. To protect against people falling out of the window, two variants were chosen for patient use: the first is a side-hung window with an opening limiter decouplable by means of a handle, the second a “tilt and turn” window with an assistive handle to ensure the window is operable by people with reduced strength. In both variants, patients cannot open the window completely. This is only possible with an appropriate key.

The bench has a total width of 2.57 m. The base of the bench is approx. 40 mm thick and is covered by an upholstered seat cushion. It transitions into the construction of the side and then tabletop of the desk. The front edge of the desk is cut away at an angle so that the patient’s sitting position is turned slightly into the room.

The patient wardrobe has a width of 77.5 cm with a standard depth of 60 cm and contains different compartments of various sizes for clothing and personal items. Alongside the regular compartments, there is a space for stowing a suitcase and a lockable compartment for valuables. All the partitioning dividers are firmly attached to the body of the cupboard to avoid the need for supports or fasteners that could obstruct cleaning. The cupboard doors and dividers are arranged asymmetrically for large and smaller items. The narrower cupboard door opens into the room while the wider door to the compartment for hanging clothes opens onto the wall so that the patient’s movement is not constrained by the door when the cupboard is open.

The floor-to-wall junction is the same as in the nurses’ work area with an upturned rounded skirting rising to a height of 10 cm for easy cleaning. A small recess affords a degree of tolerance for the items mounted above (Figs. 49–51).

Building the Prototype

Completed Prototype and Use Scenarios

Furniture and Equipment

With technological advances and increasingly intensive patient care, the modern patient room has become a room filled with numerous objects and items of equipment. These, in turn, are used in a large number of different work processes. The typologies of these objects range from medical equipment to fittings, furniture, decor, patient beds, bedside cabinets and mobile devices (Fig. 1). Each of them has different surfaces, functions and shapes, which are more or less favourable in terms of infection prevention. In general, every object is colonised with microorganisms, but they are touched, moved, removed from the room and brought back again by different user groups at different frequencies depending on their function. People and objects carrying pathogens in and out of a room are the main transmitters in infection chains. Contact surfaces that are frequently touched typically pose a higher risk of transmission than rarely used items. For example, almost everyone touches the door handle, but the bedside drawer is used primarily by the patient and only occasionally by staff or visitors. The construction of the various objects in the room – some of which are classified as medical equipment – is governed by various standards and norms, which contribute to its potential to prevent infection transmission. The positive or negative influence of an object on the infection prevention potential is hard to measure purely in objective categories. Objects such as a disinfectant dispensers or infusion stands are essential items of medical equipment but a bunch of flowers, while unimportant from a medical perspective, and perhaps even harmful as a source of infection, is beneficial to the patient emotionally and may indirectly help speed the process of recovery. Likewise, functional objects, such as seating for visitors, are necessary but entirely irrelevant to medical procedures.

As these various objects are involved to different degrees in cycles of use and work processes, they are also cleaned and disinfected at different intervals. For combating the transmission of multi-resistant pathogens, this presents several challenges in the design of patient rooms. Which objects can limit or prevent the incidence of nosocomial infections? How can items be incorporated into work processes to encourage safe disinfection procedures, and how can they be designed for easy cleaning? Can (mobile) devices encourage good hygiene practices among patients through digital information and advice? And in general, how can the design of the environment of the patient help break the transmission chain of pathogens?

The infection prevention potential of key objects in a patient room

There are numerous strategies for controlling the spread of infection that act at almost as many different levels. Cleaning surfaces and washing hands are essential for removing coarse dirt that can be a breeding ground for microorganisms – but they do not kill pathogens. Disinfecting surfaces and hands immediately after washing further minimises the risk of infection by killing pathogens that have not developed a corresponding resistance. Probiotic cleaning methods using biocidal agents are increasingly being tested as they do not eradicate microorganisms that are harmless to humans and cause less chemical damage to surfaces than aggressive cleaning and disinfecting agents. Surfaces that are chemically cleaned over a long period eventually become porous and can harbour dirt and germs more easily. As such, objects in patient rooms must be designed so that they need less frequent disinfection to prevent the development of resistance.

In addition to cleaning, other methods of infection prevention include isolating patients, pathogens and objects, though these are costly and require space and time. They also do not prevent micro­organisms being transported by nursing staff, unfiltered air or rubbish. One principle among patients is cohorting (Fig. 2) in which people with the same pathogens are isolated together. Other strategies can also be employed to reduce the risk of cross-contamination between patients in a room, for example by ensuring patients do not mistakenly use each other’s personal hygiene products and by clearly distinguishing between disinfectant and soap dispensers. In addition, separating both work processes as well as patient-specific items can help prevent pathogen transmission by droplets and contribute to infection control. Staff can, for example, wear a face mask and avoid physical contact, while suitable design measures that take into account the radius of action of patients, can employ design means to prevent patients with dementia from accidentally reaching for or misidentifying the personal hygiene items of their neighbour. RFID chip technology can be used to permit and restrict access to certain items, and motion detectors can avoid the need to touch switches, minimising contact infections. As part of the KARMIN project, the “Furniture and Equipment Design” sub-project investigated which additional strategies can be developed for preventing infections through equipment, work processes and behaviour, and which existing approaches can be optimised.

Future scenarios

Alongside existing norms for equipment that reflect the current level of knowledge on infection prevention, future scenarios must be considered so that one can derive insights from them and implement solutions accordingly. By appraising the existing situation and extrapolating from it, existing norms and established processes can be critically examined and new research findings in the field of infection control can feed back into the design of equipment and fittings for hospital rooms. In this respect, digitalisation and innovation in medical technology and treatments on the one hand and demographic change on the other play an important role. Longer life expectancies and a proportional shift towards older patients will lead to a change in clinical pictures and in the composition of patients in hospitals. Patient rooms will need different fittings, work processes will have a different focus and patients will be less mobile. In addition, the proportion of elderly patients with dementia will increase, placing new demands on the ward environment. The changing patient demography also has implications for the ergonomics of equipment, which will need to meet the needs of people with physical and cognitive limitations.

More intensive patient education is also imperative. At the same time, new types of digital and networked devices enable the contactless transmission of information about the physical condition of patients and of work processes. Digital patient records, for example, eliminate the need to carry paper-based files in and out of the room, reducing the risk of transmitting pathogens. Care must be taken, however, that all these technical means do not result in an overly distanced, impersonal atmosphere. Physical experience is a fundamental sensory sensation that stimulates cognitive response and is better at transporting and also expressing emotions. Haptic experiences are essential to the emotional well-being and recovery of patients. Similarly, patients must be actively involved in infection prevention, rather than relying on passive and/or purely technological solutions.

Economic aspects will also have an impact on patient rooms in the future. Shorter durations in hospital and fewer nursing staff will increase the frequency with which beds need preparing for new patients and shorten the time that nursing staff have for their everyday activities. A supportive environment must be developed that provides physical, emotional and also procedural support. Future developments do not necessarily imply a decline in infection prevention. Instead opportunities and potential for improvement must be sought, such as the digital patient records.

Methodology and relevant objects

The research group began by drawing up a tabular list of all the objects always present or potentially found in a patient room, and analysing each according to a series of aspects: the object’s inherent prevention potential, the degree to which its surfaces and contact surfaces are colonisable with MRSA/VRE, its frequency of use, its potential for contamination by the relevant user group(s) and its position relative to the radius of action of the patient and hospital staff. To help assess how colonisation develops over longer periods of time, two further evaluation factors – usage and cleaning cycles – were examined and classified as either constant, hourly, daily, weekly and after/before patient discharge. Finally, the patient’s radius of action was classified as being either within gripping distance, droplet radius or mobility radius (Fig. 3). These categories provide an indication of the likelihood of surface contamination of an object through contact by or droplets from a patient or caregiver.In addition, the group studied the degree to which the objects are used consecutively between each hand disinfection.

Expert workshops with planners, patients, hygienists, doctors, architects, nursing staff and experts from the private sector as well as visits to clinics and work placements provided additional insight into which objects need redesigning and further development. The methodology used is described in Catalogue of requirements for the patient room and wet cell.

From the long list of objects in a patient room, the research group selected three relevant objects for in-depth design analysis with a view to optimising and adapting their design, or where necessary rethinking their design. The objects were chosen based on the degree of colonisation of the objects, the frequency with which users come into contact with them, and their respective prevention potential. The first object is the disinfectant dispenser as it is the central, preventive object in everyday hospital life; the second is the bedside table and cabinet as a frequently used object in the immediate vicinity of the patient that is also encountered by nurses during their work; and the third is the bedside terminal as a frequently touched surface that can also serve as an educational and informational tool.

Three objects in focus

As patient care becomes increasingly centred around the immediate area of the patient’s bed as a consequence of demographic change, we can expect to see an increase in the frequency and duration of use of the bedside table and cabinet and the bedside terminal. All three objects have been re-examined with a view to optimising infection prevention, not just in terms of their appearance and construction but also in the way they are used or invite people to use them. While the disinfectant dispenser and the bedside cabinet are already familiar objects in patient rooms, the bedside terminal is comparatively new and offers new informational possibilities for improving good hygiene practices. In terms of their physical functionality, the first two cases are far more complex objects but still have room for improvement in the way they support work processes, in how easy they are to clean and through digitalisation. Research conducted as part of hospital visits and in conversation with experts during workshops also revealed that existing standards and guidelines were not always heeded due to economic constraints or time pressure in hectic work situations. The objective of a redesign should therefore be to encourage certain patterns of use and inhibit unfavourable actions through the object’s design. The primary themes of the re-examination of these objects are their potential for infection prevention, ease of cleaning and their informational-educational potential (Fig. 4). In this context, the researchers also reviewed the existing patterns of information provision and work processes in two-bed patient rooms with a view to identifying opportunities for optimisation.

Pathways

As part of the analysis of the work processes, the researchers identified the various points within a room that users visit, the order in which they are visited and how they might be better positioned. The patient bathroom, for example, has a major effect on the work steps and pathways within the room. Depending on its position, it can lengthen the path from the door to the patient, restrict the field of vision and obstruct accessibility. The arrangement of fittings and equipment within a patient room should facilitate direct paths between them and support work processes. When patients are located crosswise and opposite each other, walking distances are made unnecessarily longer, causing staff to potentially omit work and disinfection steps. One idea discussed in this context is the extent to which lighting can encourage staff as well as patients to follow certain paths. Spotlights and correct lighting scenarios can promote a smooth working process. The aim was to create a coherent environment in which the objects and architecture support both patients and staff.

Cross-contamination

Failure to disinfect hands between work steps and failure to clean and disinfect contact surfaces used by many different people can lead to cross-contamination. Optimising the placement of disinfectant dispensers can help increase compliance, while the use of contactless sensor technology can reduce contamination. This is described in more detail, along with an overview of infectious diseases, their occurrence and transmission paths, in the section .

Methodological approach to determining requirements

The research served as a basis for deriving the requirements the objects need to serve. For each of the selected objects – the disinfectant dispenser, bedside terminal and patient bedside table – the requirements were systematically categorised and then prioritised according to the labels “could have”, “should have” and “must have”, based on the findings of the prior research. “Could have” represents qualitative, oral recommendations made by interviewees during expert workshops, work placements and hospital visits, while “should have” are a result of guidelines and standards and “must have” of laws. These requirements were then reviewed for their relevance to hygiene and infection control to prioritise them for the concept phase. As part of the conceptual design, different implementation variants were outlined and also built as a basis for discussion and evaluation by experts including partners from medicine and industry. From these, optimised prototypes were built as demonstrators for evaluation in practice.

In terms of general recommendations: the surfaces and the forms of objects should be designed for easy cleaning; the respective objects should be better integrated into work processes; and digital instruments should be used to optimise and clarify processes. The following sections detail the set of requirements, the resulting concepts and the final design solutions for each of the three objects.

The Disinfectant Dispenser

The disinfectant dispenser is a central tool of horizontal infection control used in all areas of hospitals and also by all patients. It is therefore a central element of the KARMIN project. Hand disinfection can help prevent both exogenous and endogenous infections, and this applies not just to staff but also to visitors who are not traditionally encouraged to disinfect their hands. Doctors play a particularly important role as behavioural models for other user groups. Patients can, in certain situations, also reduce the risk of MRSA transmission by disinfecting their hands, but the first step for patients should always be to wash their hands properly because this suffices in many situations. Further methods of educating patients, and indirectly also visitors, on the value of hand disinfection in patient rooms are discussed in the section on the Bedside Terminal.

Disinfectant dispensers have been used for decades for infection prevention and personal protection and have evolved into a highly sophisticated device. Numerous initiatives and organisations, including the World Health Organization (WHO), have developed established and scientifically based guidelines for their placement and methods of use – such as the WHO “Five Moments for Hand Hygiene” – which have in turn influenced their design. In terms of their technical construction, ease of cleaning and how they are perceived, however, there is still potential for improving their design to minimise infection transmission. Three factors play a key role in the reasons why disinfection guidelines are not observed: memory, attention and decision-making – or in other words, forgetting, distraction and prioritising other activities. In more concrete terms, this means insufficient knowledge of or education on hand disinfection, an environmental context that is poorly designed, unclear and hinders decisive action, and a lack of time or availability of disinfectant. All these need further research, consideration and incorporation into the product’s design. But to begin with, it is useful to ask who disinfects when, where, how and why (Fig. 1), as a basis for deriving the requirements that the product must fulfil. The findings are discussed in more detail below and ultimately led to the newly developed design of the KARMIN disinfectant dispenser.

However, there are also possibilities for optimisation that can be implemented with existing dispensers, for example in the positioning of the dispenser.

Requirements for a disinfectant dispenser

Positioning

An important factor for the aspects of memory, attention and decision-making in infection prevention is not just the design of the dispenser itself or the training of staff and the education of other potential users but also the positioning of the dispenser, i.e. the question of where. In the KARMIN project, we discuss this in the context of a two-bed room, but many aspects also apply equally to single or multi-bed patient rooms.

Typically, a dispenser is positioned close to the patient room door and within the room so that the disinfectant can act on the way from the entrance to the bed. However, this means the dispenser is no longer near the path of the nurse’s subsequent work steps in a patient room with more than one bed. If it is placed too close to the door, it will be obscured by the door when it is open, where it then risks being “out of sight and out of mind”. At the same time, this protects it from collision with mobile items being wheeled in or out of the room. For the nurses, however, it is more important that the dispenser lies in easy reach for their work (Fig. 2). Instead of placing one dispenser at the entrance, two can be placed above the respective worktops and two more attached to the end rail at the foot end of each patient bed. Two further disinfectant dispensers can also be positioned in the wet cell. This saves time between the different work steps and when switching from patient to patient because staff can disinfect their hands at the entrance, near the bed and at the washbasin in the bathroom. Positioning the dispenser above the worktop also protects it from accidental collision (Fig. 3).

Alongside their positioning in the room, dispensers should also be mounted at an appropriate ergonomic height. For correct and easy operation, the pumping surface should be approx. 120 cm above floor level. Dispensers must also be accessible to users in wheelchairs, and also from the side: care should be taken that access is not blocked by other adjacent objects (Fig. 4). Disinfectant dispensers should therefore be positioned so that they tie in with the work routines of medical staff but are also accessible to other user groups in patient rooms.

Five moments for hand hygiene

Medical staff are trained to internalise five moments for hand disinfection. This hand hygiene strategy is designed to protect the patient and their uninfected body parts, the environment of the patient, the medical staff and the next patient against contact infections, and also details why. In outpatient medicine, one differentiates between non-invasive and invasive treatment. In inpatient medical care, invasive treatment is more common, and it becomes important to define when hand disinfection takes place. According to the five moments, hand disinfection must take place 1) before patient contact, 2) before aseptic activities, 3) after contact with potentially infectious materials, 4) after patient contact, and 5) after contact with surfaces in the immediate vicinity of the patient.

A diagram of the five moments is shown in the section . To ensure that these five moments are observed, disinfectant dispensers must be visible from everywhere in the patient room and mounted ergonomically within easy reach (Boog et al. 2013). Studies have shown, however, that more than three dispensers per patient does not increase compliance (Chan et al. 2013). To ensure hand disinfection between two patients, i.e. after touching the last and before touching the next patient, disinfectant dispensers can be fixed using an adaptable fixing to the end rail at the foot of the bed. A clamping mechanism makes it possible to mount the dispenser to the right or left of the rail depending on where it is most needed. Mounting the dispenser slightly away from the corner, so that it does not protrude, avoids accidental collisions when passing by the bed.

Compliance

Alongside observing the five moments for hand disinfection, it is also important that disinfectant is applied and rubbed in thoroughly. Measuring the frequency and quality of hand disinfection through observations on site is very time-consuming and therefore only possible on a short-term basis. It is also hard to check how well hands have been disinfected using technical means. Consequently, this is largely disregarded as a requirement for the design of the dispenser. One method suggested for checking how well staff comply with the respective guidelines is to electronically or mechanically record the pump action of the dispenser and correlate it against the respective consumption of disinfectant (Schulz-Stübner 2013, p. 217). However, this method is still inaccurate as it says little about the user group, the situation or how well the disinfectant has been rubbed in: we don’t know how many people were in a room when it was used and what activities were being carried out. An LED installed in the dispenser can light up for the duration of the minimum rubbing-in time to give users at least some direct feedback on the time required for the disinfectant to act, but it is still not possible to ascertain how well the disinfectant was applied to the entire hand. In addition, staff usually begin moving around the room after disinfecting their hands and rarely wait by the dispenser. In everyday hospital practice, no-one stands and waits for a signal to elapse; instead, disinfectant is applied and acts in the time between using the dispenser and before touching the patient. The proper and thorough application of disinfectant is therefore a matter of good staff training, comprehensive, repeated education of the user groups, and a conducive environment. There are, nevertheless, further means of improving compliance beyond appropriate positioning of the dispenser and sufficient education of the users.

One simple method is to provide graphical visual cues on walls and the floor (Fig. 5), though these can become less effective as staff grow accustomed to the cues and begin to overlook them.

Another established method is to use team meetings to give repeated targeted feedback in person to reinforce staff compliance. This can be made more effective if reliable quantitative data is available with which to analyse compliance. Disinfectant dispensers that are equipped with sensors can provide usage data that reveals at what times and what amount of hand disinfectant is used. A widely used method for monitoring compliance with standards is the current HAND-KISS principle. This calculates the consumption of hand disinfectant and the number of disinfection measures carried out per patient, per resident day or treatment case to determine conformity with guidelines for hygienic hand disinfection.

HAND-KISS also compares the consumption of hand disinfectant across wards with similar patient groups (same ward types). The counting principle can also be made more precise by correlating it against the different user groups, e.g. nurses and carers, doctors, visitors and patients (Scheithauer 2018). To do this, however, existing disinfectant dispensers must be retrofitted with a technical means of data collection. Digital sensors and evaluation systems offer great potential for increasing hand hygiene and improving compliance with regulations. They provide a more exact means of monitoring usage, but care must be taken to avoid the user feeling under surveillance. From a methodological perspective, research has shown that positive motivational triggers are far more successful than admonishing users for non-adherence. An atmosphere of excessive monitoring can also give rise to the Hawthorne Effect: when people know they are being watched, they adapt their natural behaviour accordingly. In this context, this could lead to hand disinfectant being used to satisfy the monitoring system rather than to encourage correct, high-quality hand hygiene. For the design of the KARMIN disinfectant dispenser, the researchers therefore examined additional possibilities for increasing compliance through inconspicuous data collection and triggering positive emotions not seen in existing dispensers.

Fill level and usage analysis

As mentioned above, a constant supply of disinfectant must be ensured to comply with hand disinfection guidelines. As obvious as this may sound, it can often be a logistical problem in the everyday running of a hospital. The disinfectant dispenser’s monitoring and analysis system should therefore not only monitor usage data but also communicate the fill level and location of the dispenser to the central monitoring system so that this can be monitored constantly. Hospital staff can then replace bottles as and where needed before the disinfectant runs out and the dispenser fails to function. The dispenser must transmit this data wirelessly and a software system must record and display the data. A further requirement of this system is to eliminate multiple pumps that occur in quick succession when staff press several times on the dispenser when working. While each pump must be recorded individually to calculate the fill level, they should be bundled as a single operation for the usage statistics. The data acquisition system should also break down usage of the hand disinfectant dispenser by date and time of day.

Display function and prompting strategies

To ensure dispensers are used at the right time by the widest possible spectrum of users, including patients and visitors, a display function can be used to animate people to use the dispenser and instruct them how. A friendly, approachable appearance likewise encourages visitors to engage with the dispenser. Surveys and conversations conducted as part of the KARMIN research project revealed that people responded negatively to the technical appearance and medical connotations of conventional dispensers. The use of animations, for example, can give character to an otherwise static piece of equipment, so that it appeals to users at an emotional level. Studies have shown that in neonatology wards, for example, staff disinfect their hands more frequently if pictures of newborn babies were placed above the dispensers. It appealed to the staff’s sense of responsibility and made them more inclined to disinfect their hands. It also strengthened the inviting character of the dispenser. Posters, flyers, films or online posts can also provide additional information on when and how to disinfect one’s hands properly. This could be sent via an app notification or information e-mail prior to the patient’s arrival. Bedside terminals likewise can be used to educate patients during their stay and to create incentives. Alongside the aspects of attention and memory, the dispenser’s display function must also aid in deciding which actions to take. To distinguish it adequately from soap dispensers, clear labelling and some form of formal or coloured differentiation can help immediately identify its purpose. Placing it at a separate location also helps and additionally prevents people disinfecting their hands prior to washing them while in haste or out of ignorance (Fig. 6). Objects in a patient room should be designed so that they meet the user’s expectations and are placed at an intuitive location.

Disinfectant supply

To fulfil its function and comply with guidelines, a disinfectant dispenser must have a constant supply of disinfectant. To this end, the fill level must be visible on the exterior so that low levels of disinfectant are noticed before it runs out. Ideally, the fill level should also be transmitted to a central monitoring point so that switching out the bottles can be coordinated more easily in a timely manner. Empty bottles should be disposed of immediately to prevent improper use of any remaining liquid. Systems in which the pump head is replaced with the bottle are preferable to avoid contamination or re-use for cost reasons, where the pump head risks becoming a breeding ground for pathogens. In this case patient health is more important than waste avoidance. This can be partially mitigated by using pump heads made of recycled materials. In addition, the dispenser bottle must maintain the prescribed concentration of alcohol at a constant level for three months (Assadian et al. 2012). Hospitals can decide whether to keep supplies of replacement bottles in a central location or in each ward.

Electrical supply

The digital systems for the sensor systems, data acquisition and wireless communication of usage data requires electricity. As disinfectant must always be available, the dispenser must function even during a power outage. This can be achieved by connecting it to the hospital mains, which has an emergency backup system, or by means of ensuring it has a mechanical means of dispensing, even when the electronics are inoperable. The former is more complex and costly in terms of cabling and places an additional burden on the hospital’s emergency electrical supply. To this end, a self-sufficient solution was found for the KARMIN disinfectant dispenser.

Mechanical versus contactless dispenser

A major disadvantage of electronic contactless disinfectant dispensers, aside from their considerably higher price compared to mechanical dispensers, is their dependency on an electrical supply. In the event of a power outage, they do not comply to standards as disinfectant dispensers must be functional at all times. In addition, complex electronic components require more maintenance and electronic pumps consume energy to operate. The argument that contactless dispensers avoid contact infections that arise with traditional dispensers where previous users contaminate the pump with pathogens is also not entirely true, as the user of a mechanical dispenser disinfects their hands immediately after touching the pump. Newer dispenser models therefore adopt a hybrid strategy in which a mechanical dispenser can be used that functions independently of the electronic components used for digital data acquisition and transfer.

Disinfectant dispensing function

Several requirements must be met by the dispensing mechanism, first and foremost the correct concentration and dosage of disinfectants for successful hygiene measures. The German testing standard requires a disinfectant dosage of 3 ml per hand rub (DIN EN 1500). However, because staff frequently pump several times in everyday practice, various manufacturers factory-set the output to 1.5 ml, so that at least ­ 3 ml of disinfectant are dispensed in total. In addition, guidelines stipulate that the pump mechanism may only fail to deliver in 1 % of cases, or in two out of 200 consecutive pump strokes (Assadian et al. 2012). Gels are not permitted as medical products, although they would be advantageous as they prevent dripping, which in the long term damages the surface of any items or the floor beneath the dispenser. Some dispenser models feature pumps that attempt to prevent dripping by sucking up the disinfectant when the pump is released. Drip protection trays help to a limited degree, because they are often not cleaned or regularly emptied so that they overflow. Similarly, one cannot prevent disinfectant dripping from the hands of the user as they move away from the dispenser. Drip protection trays must also be sufficiently far away from the dispenser outlet to allow sufficient space for a pair of hands beneath the pump head.

Ease of cleaning

In addition to hand disinfection as an essential part of infection prevention, it is also important to minimise colonisation of the surfaces and joints of the dispenser itself by germs. The design of the dispenser must be optimised for ease of cleaning through the choice of a suitable form and appropriate materials. Instead of sharp corners, the dispenser should be given clear, uninterrupted rounded edges (Fig. 7).

Similarly, hard-to-clean seams and narrow joints must be avoided so that surfaces are simple to wipe clean with disinfectant. Minimising the number of components and the complexity of assembly is also advantageous as it minimises joints. Where pump heads are re-usable, they must be cleanable in an autoclave, i.e. disinfected in a machine at an A0-value of at least 60 (or 80 °C/1 min). Sterilisation at 121 °C is even better (Assadian 2012). The A0-value is a time-temperature relationship that expresses how long it takes to kill microorganisms at a specific temperature. This needs to be undertaken after each bottle change to prevent microbial contamination of the pump head. The re-use of disinfectant bottles is not permitted, and they must be properly disposed of after use, along with the disposable pump head (unless re-usable pumps are used).

Materials

The requirement that the dispenser can be wipe disinfected and is heat-cleanable means that the materials must be resistant to alcohol and heat. Where re-usable parts are specified by the hospital operator, it must be made of an autoclavable material. Stainless steel is recommended for this purpose but various plastics such as acrylonitrile-­butadiene-styrene copolymer (ABS) can also be used for parts such as the housing. The material must be able to withstand the pressure applied when using the dispenser. Plastics offer greater design flexibility than curved sheet metal for the design of the housing because they can be injection-moulded.

Colour, shape and character

The choice of an appropriate material is not solely a matter of technical suitability but also one of associative connotations. As with the display function mentioned earlier, the colour, surface quality and shape of the dispenser should also appeal to the user and fit into the atmosphere of the room. People engage more readily with a visual form and appearance that does not have negative connotations, ultimately promoting compliance. In the expert workshops and hospital visits conducted as part of the KARMIN project, various potential user groups voiced a need for disinfectant dispensers that are perceived as “warm” and not stigmatised by being part of the medical apparatus of the hospital. On the one hand, the dispenser should evoke a sense of purity and warmth and be visually integrated into the design of the patient room, and at the same time it should be sufficiently noticeable. Slightly muted signal colours and round, soft shapes are ideal for this purpose. The cold, technical feel of materials such as polished stainless steel is less well suited than that, for example, of coloured plastics.

Dispenser elements

All these requirements come together in the design of the construction of the dispenser. A basic dispenser must be able to hold a dispenser bottle, provide a pump or valve that dispenses disinfectant, even when no power supply is available, and provide a means of recording how often it is used. For this, the dispenser needs an electronics system that can encourage users to use the dispenser, record and transmit usage data, display the charge and fill level and relay its location to a central monitoring system. The housing must have as few joints as possible, rounded rather than sharp edges, no narrow notches or gaps and be flexibly mountable, for example on a bed rail or a wall. It should be mounted with ample space above for comfortable operation, and the housing should be quick and easy to remove and replace so that untrained staff can refill it as needed.

As all manner of objects are routinely stolen from hospitals, the dispenser should be mounted to prevent unauthorised removal of the bottles or of the entire dispenser. This is best achieved using a concealed fixing mechanism that is additionally covered. All these requirements need to be translated into a coherent and realistic concept. Commercially available dispensers range in price considerably from about 20€ to as much as 300€. The KARMIN disinfectant dispenser aims to have a price point of about 50€.

A concept for an intelligent disinfectant dispenser

The objective for the KARMIN disinfectant dispenser is to design a smart dispenser that employs a psychological trigger to encourage use and is also generally appealing to visitors, staff and patients through its inclusive appearance. Its design should simplify cleaning and minimise colonisation with germs by reducing the number of components, and thus joints in the product. A further key requirement of its construction is the separation of the mechanical disinfectant dispensing mechanism from the electronic data collection and transfer so that each can function decoupled from the other: the dispenser should be manually operable in the event that the electronics fail. A hybrid solution is therefore necessary. To this end, the team initially set aside the classic components of current conventional disinfectant dispensers so that they could explore the horizon of possibilities for the given requirements in the concept development phase unimpeded by existing constraints. The result is a novel bottle design and housing with screen that nevertheless builds on the valuable qualities of previous models.

Analysing existing dispenser models

Combining all the different desired properties in a functional and compliance-enhancing design for a disinfectant dispenser that is moreover also cost-effective, is a challenging task. Previous models have therefore concentrated on the core properties and neglected secondary features. In the European market, a model of dispenser has emerged over the last decades which is sold under various trade names. Its housing consists of an anodised aluminium sheet, which is open at the bottom. It employs a purely mechanical dispensing mechanism with a simple design, but the pump system comprises many individual parts which are complex to keep clean when (re)installing the dispenser. As a consequence, they are not always properly sterilised. Furthermore, the dispenser does not offer any means of data collection and it does not look inviting, but rather technical, clinical and utilitarian. Some newer models are more attractive and also reduce the number of components but are made of less durable plastic. Aside from that, intelligent dispensers that record usage data are now also more widely available.

Electronic dispensers

Contactless dispensers are less common in German hospitals due to their significantly higher cost. All the currently available electronic models have different advantages and disadvantages. They differ from conventional dispensers through the type of dispensing mechanism, their ability to record information and where they can be mounted. While mechanical dispensers are considerably cheaper and easier to maintain due to their less complex design, many electronic dispensers offer the ability to dispense disinfectant without touching them. Electronic dispensers are permanently installed and are thus stationary dispensers usually mounted on a wall or bed. The latter can usually also be attached to the nurses’ trolleys or other objects with round profiles using a clamp but are then only semi-mobile. Permanently mounted dispensers have the advantage of being at a specific, memorisable location so that staff do not need to interrupt their work routines to find them.

Gown bottles

Mobile dispensers and gown bottles are, by contrast, always to hand, but not available to all user groups, for example for patients’ relatives and visitors. In addition, the smaller capacity of the bottles leads to more waste than wall-mounted dispensers. Smock bottles can, however, contribute to the perceived competence of medical professionals, and set an example. When consistently applied, only the remaining staff need be encouraged to use the available dispensers in a compliant manner.

Construction differences

In terms of appearance, electronic dispensers can be more aesthetically attractive and compact than mechanical models as they do not need to have a protruding lever arm. When wall-mounted, however, they cannot always be positioned optimally to lie in the working radius of staff. In addition, disinfectant can drip, over time damaging the floor through long-term exposure to disinfectant. Their greater design complexity also requires more elaborate regular cleaning and preparation than disposable (gown) bottles.

Differences in ensuring supply

Further differences arise with respect to ensuring a constant supply of disinfectant. The small capacity of smock bottles means that replacements must be easy for staff to procure and that they remember to replace a nearly spent bottle in time. The logistics are more complex and the tendency to forget greater than when a smaller group of people are explicitly responsible for ensuring stationary dispensers are always functional. In addition, how much a smock bottle dispenses cannot be regulated so there is a greater danger of incorrect or excessive use. Electronic dispensers, by contrast, fail to function at all if there is a power failure and risk jeopardising the constant availability of disinfectant. The hospital may also become dependent on a single supplier when dispensers can only accept the manufacturer’s proprietary refill bottle shape. The more complex housings of electronic dispensers may require that staff need instructing in installing refills. The comparative complexity of the components may also entail more costly and time-consuming maintenance and upkeep than other models. The energy supply method can also vary: some systems are so energy-efficient that a small button cell is sufficient to supply the electronics for an extended period of time without costly, frequent replacement. Some dispenser bottles come with an integral button cell to ensure continual functionality. In other cases, a charge level indicator shows how much power remains to avoid a system shutdown. Other systems even employ the kinetic energy of the pump action to generate energy when dispensing disinfectant. When the remaining electronics draw only low power, it is then possible to dispense with a battery altogether.

The various requirements discussed above are therefore complex and diverse, and occasionally also contradictory. In the expert workshops and ensuing design discussions, the decision was made to develop a concept for a stationary, wall-mounted dispenser for the KARMIN patient room. This makes it possible to combine the various requirements appropriately in a limited installation space.

Increasing compliance through injunctive norms

In addition to ensuring an unbroken supply of disinfectant and creating an environment that supports hand hygiene in staff work processes, staff need to know when to disinfect and be motivated to apply their knowledge of hand disinfection. To this end, ways of increasing compliance need to be developed and put into action. Alongside the existing methods – such as evaluation of usage statistics in team meetings, specific staff training and explanatory graphics near the dispensers – the design of the new KARMIN disinfectant dispenser also takes new findings into account by combining technical solutions with psychological motivators. Using “nudging methods”, the design employs emotional triggers to prompt users to make use of dispensers. Research has shown that employing such so-called injunctive norms can raise compliance by up to 40 % over the initial usage rate (Gaube et al. 2018). Injunctive norms work by appealing to the intrinsic, positive motivation of users rather than admonishing bad performance or using authoritarian dictates to increase compliance. Drawing on the same principle of hanging pictures of newborn babies above dispensers in neonatal wards, an experimental setup was trialled using a monitor mounted above the disinfectant dispenser. The monitor shows a sad-face emoticon to begin with that turns into a smiley when the pump is operated. A sensor records the number of pump strokes as well as the entry of a person into the room in order to determine the rate of use. Various motif-pairs were tested to ascertain the effect they had. Neutral, context-free motifs had little effect on the users, but compliance increased slightly when a pair of eyes was displayed: the “watching eyes” reminded users of social norms and duties (descriptive norms). Non-punitive symbols were, however, far more effective: by appealing to injunctive norms (“I should do what is objectively right”) by means of smileys achieved a much higher increase in compliance over the test period. This method can be used alongside the analysis of quantitative data in team meetings. The “animation” of the smiley lends the dispenser a personal character without it needing to figuratively adopt the semblance of a body and face: the facial features of the on-screen smiley are effective enough without giving the dispenser a three-dimensional sculptural form (Gaube et al. 2018).

Display requirements

To appeal to injunctive norms using smileys, the display must be positioned so that it is immediately visible in the user’s field of view, i.e. directly above the dispenser housing. The graphic simplicity of the motif of a smiley is such that it could be displayed using a suitable array of illuminated and dimmed LEDs or other low-energy display mechanism to minimise energy consumption. Likewise, a low refresh rate and limited colour spectrum suffices, making an e-ink display a viable alternative to LCD or TFT displays. A sensor system is also needed to change the motif on display when the dispenser is used.

Data acquisition

To make use of injunctive norms and evaluate usage data, a dispenser needs a means of capturing and recording usage date. A sensor system causes the display to change the motif as soon as enough disinfectant has been dispensed. The dispenser then emits a signal communicating the position of the dispenser and whether it needs refilling. Various methods of data acquisition are available. To target a specific user group, an anonymised RFID chip denoting the user group can be worn on the wrist. This allows the usage data to be broken down by user group, though it does not detect whether several dispense operations were triggered or when people without an RFID chip used disinfectant. This type of sensor technology is therefore unable to relay information on the fill level. Motion, magnetic or pressure sensors, on the other hand, can detect dispenser activation more precisely, but cannot assign it to a specific user group. A combination of both approaches can, however, lead to the desired precise detection and allocation. By using only user group-specific data, no personal data is recorded, thereby adhering to data protection guidelines, and team spirit among the hospital user groups is encouraged. It also makes it possible to identify and remedy gaps in dispenser infrastructure.

The data set that is transmitted contains the following information: location of the room and the exact position of the disinfectant dispenser within the room (dispenser ID), time of use and number of strokes as well as, if necessary, an RFID chip-based assignment of the user to a specific group of people. This makes it possible to determine how often the dispenser was used in a specific timeframe. In addition, the consumption of disinfectant is monitored, from which the need for refilling can be calculated based on output quantity and frequency of use. To both record and analyse the data, a hospital needs the appropriate software and IT infrastructure (Fig. 8).

Power supply

The electrical components in the dispenser used to increase compliance require a power supply. A self-sufficient means of power supply would be ideal to minimise maintenance. One method is to use the kinetic energy of the pump to generate electricity, but this means the electronics must be adapted to cope with the selective availability of energy. The recorded data must be bundled in packets that the wireless module can transmit when energy is available.

Operating mechanism

A further aspect is the preparation of the disinfectant dispenser, i.e. the steps needed to prepare it for operation and keep it hygienic and operational at all times. To prevent irregular and potentially inadequate upkeep, and to avoid improper re-use of the bottle and pump, the KARMIN project proposed a bottle with a valve that does not use a pump to dispense disinfectant. Both the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) and the German Society for Hospital Hygiene (DGKH) have declared that disposable pumps are advantageous (Bundesgesundheitsblatt, No. 59, 2016). Pressing the dispenser bottle itself builds up pressure within that opens a valve. For this, the bottle may not be rigid or fragile, or its shape must be designed to allow compression, for example via a concertina-type construction principle. In addition, it is important to decide whether only the hand or also an elbow can be used to activate the dispensing mechanism, as this significantly influences the ergonomics and design of the dispenser. The ease of use varies depending on whether the bottle is pressed frontally, at an angle or on top. A lever to apply pressure to the bottle was deemed undesirable as it represents an additional component that needs cleaning. Instead, the KARMIN design envisages that the pressure-applying surface is replaced automatically with the bottle, avoiding its possible colonisation by pathogens (Fig. 9).

The dispenser housing must also be kept clean. Rubber coating the entire body would enable it to be machine-washable but is costly in terms of production and would require the dispenser to be removed from the wall bracket. Instead, plastic was used to be able to design an attractive shape. The outer surfaces of the KARMIN disinfectant dispenser have rounded transitions to facilitate residue-free cleaning and wipe disinfection.

Colour

For the body of the dispenser, made of plastic, the team chose white to denote the idea of purity, as well as to make it easier to detect surface contamination, which is otherwise harder to see on structured or coloured surfaces. At the same time an accent colour was needed to ensure the dispenser is still noticed in more complex interiors. Signal colours are therefore used for selected components, in this case the display and the bottle (Fig. 10). After consideration, the team decided against an additional visual cue in the form of an information graphic on the floor or wall to avoid overburdening the KARMIN patient room with multiple visual sensations.

Secure locking mechanism

Unfortunately, objects are repeatedly stolen from hospitals, making it necessary to provide a not immediately obvious means of securing the dispenser bottle against removal. At the same time, it must be easy to handle so that it does not impede maintenance. A ring on the underside, a latch, screw mechanism or locking hook are possible solutions.

Conceptual structure

The conceptual ideas outlined so far already suggest a certain structural composition for the dispenser. For example, the electronics must be housed so that they are not exposed to liquid when the dispenser is cleaned or prepared for use. A display is also needed to show the emoticons. Ease of cleaning is a further determining factor: the surfaces should be smooth, the transitions between them rounded and the number of components minimised to reduce assembly joints between them. For example, traditionally separate pieces such as the back cover and drip tray can be a single component. This can also lead to a more pleasing and less technical shape. In an environment designed to heighten patient well-being while they are in a vulnerable state, the dispenser should not look like a foreign body. A two-part drip tray for easy removal and emptying is not necessary when it can be easily wiped clean.

To reduce maintenance, power consumption and purchasing costs, no contactless pump electronics have been used, making it possible to position the sensor system differently. At the same time, conventional pump systems have also not been used. Instead, a disposable pump can be integrated into the refill bottle. The bottle and pump are purchased as a single pre-assembled one-way article, reducing the number of components and joints and effectively ruling out improper re-use of pump or bottle. All that is necessary is to insert the bottle upside down into the housing. As such, the system abandons the widely used Euronorm bottle design to achieve a new design for a combined pump-and-bottle principle. Likewise, a contactless dispenser is not necessary: the risk of smear infection from touching the dispenser is sufficiently mitigated by rubbing one’s hands with disinfectant after having pressed the bottle.

A means of determining the fill level of the bottle is needed at the front of the dispenser, for example via a visual indicator or window. These various requirements and dependencies result in a concept that combines an upstream-produced bottle, top display, valve on the underside and electronics at the rear (Fig. 11).

The KARMIN disinfectant dispenser

For the KARMIN patient room, two different dispensers were selected to best meet the different requirements described above. The first is the KARMIN disinfectant dispenser based on the conceptual ideas discussed here. The other is a commercially available dispenser model comprising a flexible system with a clamp holder and a small dispenser bottle with a disposable pump head. It is smaller in size and can be flexibly mounted. The newly developed KARMIN disinfectant dispenser is a stationary, wall-mounted model that combines the best features of the various existing dispenser systems with new methods to increase compliance (Fig. 12). A central distinguishing feature is the newly designed bottle with integrated dispensing mechanism. The positioning of both these dispenser types is determined by the arrangement of the room and the elements and objects within it along with the pathways of the staffs’ work processes. The intention is that they support both patients and staff in practicing hand hygiene and thus ultimately in infection prevention. Despite the higher cost of the KARMIN disinfectant dispenser, it is still cost-effective as its use can reduce the number of nosocomial infections, saving costs for longer hospital stays or patients returning with recurring infections.

Positioning

The correct positioning of disinfectant dispensers in the patient room is essential to increase compliance and saving nursing staff unnecessary journeys. An ideal, easily accessible location is on the wall above a workplace with supplies cabinet and worktop close to the bed. Mounted clearly visible on the open wall surface, it allows staff to quickly disinfect their hands before and after handling materials for patient care. This location was selected for the KARMIN disinfectant dispenser (Fig. 13).

The position of the supplementary dispenser type is similarly optimal at the foot of the bed where the nursing staff pass it during their work. In addition, it is immediately visible when switching between patients. The nursing staff do not need to return to the worktop or the entrance to disinfect their hands, as in conventional rooms, but can reach it from either side of the bed while caring for the patient. The flexible clamp allows the dispenser bottle with vertical pump head to be mounted where desired on the tubular rail at the end of the bed. A model without extra housing was chosen for its small size so that it projects as little as possible into the room, thus minimising accidental collisions at the relatively exposed location. The combination of dispenser types ensures the transitions between the room zones within the room are equipped with hand hygiene measures (Fig. 14).

A further KARMIN disinfectant dispenser is positioned in each of the wet cells, to the left of the washbasin in a shelf niche above the waste bin flap. Its different appearance and position to one side of the washbasin prevents a mix-up between the soap and disinfectant dispensers. Soap is for washing off coarse dirt before disinfecting one’s hands. The arrangement places the soap dispenser in full view when entering the room, whereas the disinfectant dispenser is slightly set back to protect it from collisions with wheelchairs or other objects on the sealed surfaces of the wet cell. The niche must be large enough to be able to mount the dispenser during installation and to easily reach the pressing surface in use. The dispenser must also be clearly visible and not obscured by elements projecting into the room. The positions of the three disinfectant dispensers – above the worktop, at the end of the bed and in the bathroom wall recess – are mirrored on the other side of the room, so that the same number of dispensers are accessible on both sides of the room (Fig. 15).

For optimal accessibility, the dispensers must be not just sensibly distributed across the individual room zones but also mounted at an appropriate height. This plays a key role in increasing compliance. It is important, for example, that projecting fittings or excessively high mounting heights do not prevent smaller people or people with restricted reach such as wheelchair users from reaching the pressing surface. In the KARMIN patient room, the worktop can be driven under by a wheelchair and is not very deep so that wheelchair users can reach the dispenser. For optimal use, the dispenser should be mounted so that the pressing surface is approx. 120 cm above floor level.

Display function and colour

A disinfectant dispenser must be clearly visible and suitably inviting, but at the same time not visually intrusive for either staff or patients. A matt white was therefore chosen for the housing so that it contrasts with the wall colour above the worktop and with the texture of the wall niche in the bathroom. The bottle, on the other hand, has a muted red colour that signals its presence but is not overly garish. A symbol on the pressing surface additionally indicates where to press. The diagonal underside of the housing allows the valve head of the bottle to project so that it is clear to users where and in which direction the disinfectant will be dispensed.

To appeal to injunctive norms, a display above the bottle shows a concerned-face smiley against a yellow background that changes when sufficient disinfectant has been dispensed. A concerned-face rather than a sad-face smiley was chosen so as to avoid overly negative connotations. By appealing to injunctive norms, it encourages use of the dispenser. The circle that usually frames a smiley was removed so that the face is framed by the display housing and perceived as belonging to the dispenser and being integral to its design (Fig. 16).

Other forms of visual or auditory feedback are not provided to avoid placing further demands on the attentions of staff and patients. Nursing and medical staff are already exposed to multiple audio-visual stimuli in the hospital environment and a dispenser should not add further sensory load.

Data acquisition

To help improve compliance, the KARMIN disinfectant dispenser is equipped with various sensors for data acquisition. They ensure that the dispenser is always properly supplied with disinfectant, help appeal to injunctive norms and record usage statistics. The entrance door area as well as the four KARMIN dispensers in the room are equipped with RFID readers with different ranges that make it possible to monitor the user group of persons (also equipped with RFID readers) entering the room (Fig. 17). This can then be used in a more targeted manner to analyse ways of improving compliance. Rather than warning staff when disinfectant usage is too low, the data provides a more useful basis for constructive feedback and friendly reminders during team meetings. At the same time, a pressure sensor in the housing of the disinfectant dispenser records every press of the dispenser. This data can be used to calculate the fill level of the dispenser. When a low fill level threshold is reached, this data is transmitted as a data packet along with other usage statistics via wifi to a central server. This data packet approach means the emitting unit does not need a permanent power supply. The fill level can also always be viewed manually through the front viewing slot should the electronics not function correctly. The pressure sensor also triggers a change of the smiley motif, rewarding the user with a smiling face on the display when enough disinfectant has been discharged. After a few seconds, the display reverts back to the concerned-face smiley, so that the motif doesn’t change constantly when a user presses unnecessarily often on the bottle.

Display

The display of the disinfectant dispenser must be clearly visible but not intrusive. By positioning it above the dispenser slanted slightly upwards it is clearly visible to users but not in the patient’s direct field of vision, so that patients in bed are not unnecessarily burdened by the concerned-face smiley. To reduce energy supply requirements, an e-ink screen is used which has no refresh rate and only requires energy to change the motif during operation of the dispenser (Fig. 18).

Power supply

The KARMIN disinfectant dispenser uses the kinetic energy produced by pressing the disinfectant bottle to supply the dispenser with power. This reduces the frequency of maintenance and with it the risk of germ contamination when replacing batteries. Pressing the bottle generates energy that can then be used to change the e-ink display to show a different image.

Pressure-operated dispenser bottle

To meet the diverse requirements for ensuring a constant, reliable and hygienic supply of disinfectant, a dispenser bottle was developed that reduces the number of necessary parts, functions mechanically and also allows precise quantities to be dispensed. The flexible body of the bottle, when pressed, opens a pressure-release valve that dispenses the disinfectant. A two-chamber system in the valve head allows the dispensing charge to be regulated, i.e. the quantity of disinfectant expelled. The bottle is inserted upside down into the housing so that the convex bottom of the bottle acts as the pressing surface. This is large enough to be operated by hand or with an elbow. Pressing on the bottle creates a pressure build-up in the bottle that opens the concave valve diaphragm (Fig. 19). The valve is permanently mounted on the sealed bottle so that it cannot be refilled risking contamination. Should replacement bottles not be available due to supply difficulties, such as in a pandemic, the dispenser can also be used with regular Euronorm bottles with pump heads which are made by numerous manufacturers.

Construction and materials

The design of the disinfectant dispenser is determined by the requirements for the material, the mechanics, the space needed for electronic components and ergonomic considerations. The choice of a suitable material is essential to ensure easy cleaning. As the dispenser does not need to be autoclavable, and plastic offers better design possibilities in terms of form, haptics and appearance than aluminium, ABS plastic was chosen for the housing. The casing can therefore be cleaned in a dishwasher. The dispenser bottles are made of a flexible plastic through which alcohol cannot evaporate, retaining the alcohol content of the disinfectant in the long term. In addition, the material is resistant to chemicals and can withstand repeated compression by pressing on it. By dispensing with conventional bottles and pumps – made possible by incorporating several components into one unit – the number of components can be reduced, resulting in fewer joints that can be colonised by germs (Fig. 20). As the new bottle system is not yet in production, the bottle housing is dimensioned so that it can also be used with Euronorm dispenser bottles.

Form

The rounded housing is formally a single, closed unit, giving it a restrained, non-technical appearance that is more approachable than existing models. Due to its verticality and the curvature of its rear wall, it has a slim appearance, sits lightly on the wall and fits discreetly into its surroundings. All transitions between the different parts – for example, the bottle holder and screen surround – are curved and seamless, making it easy to wipe clean. The mechanism for opening the back plate and hanging the dispenser is concealed to discourage theft. The flat bar of the drip tray holder must be pressed to release a catch so that the body can be slid up and away from the mounting. The mounting plate and screw fitting for attaching it to the wall then becomes visible (Fig. 21).

The KARMIN disinfectant dispenser thus combines new findings for increasing compliance and supports staff through its optimised, easy-to-clean form. The shape and curved forms of the housing guides the hand when cleaning and wiping down with disinfectant. The dispenser’s design and positioning (Figs. 22, 23) help trigger the users’ memory, draw their attention and help them take decisive action.

Switching a hospital to an optimised disinfectant dispenser such as the KARMIN dispenser described here is a not inconsiderable investment that not every clinic will be able to afford, even if it reduces costs further down the line by preventing infections. Hospitals are also already equipped with a large number of disinfectant dispensers. These are not necessarily optimally positioned with a view to preventing infection control but could continue to be used with some appropriate corrective measures. Aside from placing existing dispensers closer to the pathways of the staff’s work processes, other means of improving compliance are also possible. An alternative mechanical approach to appealing to injunctive norms has, therefore, also been devised that needs no power source, statistical sensors and not even a display. Instead it employs a two-phase lenticular image mounted directly on the pump lever that alternates between a concerned-face and a smiling-face. The mounting height and angle needs to be adjusted to ensure the image is seen correctly for people of average height. Depressing the lever changes the angle of the lever and with it the viewing angle of the image. Here too, the lenticular image must be designed so that a user sees a single transition from the two image phases of concerned-face and smiling-face when the lever is pressed (Fig. 26).

A study of the effectiveness of such injunctive norm methods (Gaube et al. 2018) showed that the motivating effect of the image declines after about one month. One way of addressing this is to use different motifs in different delivery batches of disinfectant. The lenticular images can then be switched when bottle refills are installed, presenting a fresh image to the user. These lenticular images can be cut to fit most common dispenser models. This cost-effective principle has been tested in the context of KARMIN, using the commonly available Eurospender Safety Plus dispenser model (Figs. 24, 25); however this particular configuration is not used in the KARMIN patient room.

The Patient Bedside Cabinet

The bedside cabinet is part of the standard repertoire of a patient room and is actively used on an everyday basis. Through its location within easy reach of the patient, it is exposed to their pathogens by touch, droplets and airborne aerosols, and its surfaces are thus highly prone to colonisation with germs. Because it serves many purposes and is actively used, patients are highly likely to come into direct contact with its surfaces and with objects stored inside or on the bedside table. Avoiding contact infections is therefore a matter of carefully examining how it is used in practice and devising ways in which appropriate design can encourage safer interactions. One must examine when and where which persons touch or put down which objects. The aim in developing the KARMIN bedside cabinet was, therefore, to examine ways in which one can raise the infection prevention potential of this object while at the same time creating a patient-friendly design that reflects the many diverse requirements it must fulfil.

Potential properties of a patient bedside cabinet

The bedside cabinet is expressly for the patient’s use for the duration of their stay in hospital. Nevertheless, nursing staff sometimes also use the surfaces and drawers to briefly store work utensils, usually due to a lack of available work surfaces near the bed, insufficient training or time pressure when working. Where workplaces in the room are not available and there is not enough space to wheel in a supplies trolley, staff often place kidney dishes on the bedside table, where they sit alongside inhalers, books, trays, smartphones, flowers, alarm clocks, medication and glasses. Other objects also placed on the table include meals, dishes, cutlery, pill boxes or drinks that are brought in by various groups of people including nursing staff, visitors and patients (Fig. 1). These are all points of contact where an undesirable and unnecessary transmission of pathogens can occur. Elderly and frail patients may also require additional support depending on the situation, and nursing staff may then unavoidably have to touch personal items. Sometimes the tabletop or bedside cabinet is so full that different user groups may need to move items out of the way to place something on it. Where space is needed around the bed, the entire cabinet may be wheeled to one side by nursing staff. How these different user groups grasp and touch the table can be partially (but not completely) directed by means of affordance, i.e. the usage characteristics that an object innately suggests. For the most part, however, its surfaces are also colonised independently of touch by patients, visitors or medical staff talking or sneezing. As such, unnecessary touching should be minimised wherever possible and cleaning made as simple as possible.

The bedside cabinet is therefore a central source of possible infection in the patient room. At the same time, it must necessarily be placed close to the patient to fulfil its purpose. The best way to improve its infection prevention potential lies in simplifying cleaning and disinfection of the surfaces and reducing the incidence of contact by making it less necessary to shift around. A first step is to design a patient room to be large enough to place the cabinet close to the bed without obstructing access to other equipment. It should not block access to the patient or to necessary work-related installations such as the nurses’ equipment store or the bed headwall and its connections so as not to lose valuable time in the case of an emergency. Similarly, the bedside cabinet should not be too voluminous so that it does not collide in the vertical plane with other objects such as a bedside terminal. The tabletop should be an integral part of the cabinet as otherwise two items of furniture are required, which then both need preparation and sterilisation, often outside the room. When cleaning, staff can also ask patients to remove their own personal objects from the bedside table so that staff do not need to touch them. For this, the patient needs access to shelves and drawers on different sides of the bedside cabinet so that they may stow away their belongings.

Organisation

One way to counteract an excess of objects placed on the bedside table is to provide alternative usage-specific surfaces and storage spaces. Objects can then be made easier to store or be grouped according to need, while others can be stowed away so that they are harder to retrieve. A large number of objects on the bedside table is an obstacle to cleaning and can promote cross-contamination. The volume of the bedside cabinet can be divided both horizontally and vertically to create compartments of differing accessibility, which in turn affects the frequency with which patients access certain sections (Fig. 2). This can be an effective means of controlling stowage.

Privacy and patient comfort

Privacy is related thematically to the aspect of organisation. A patient typically lies prone and vulnerable in a patient room to which many have access. They may have valuables with them that are important to them. As such both the patient and their belongings are vulnerable and in unfamiliar surroundings. Even when a safe is available, some patients may be physically restricted and unable to use it. This influences where they place their possessions. Incorporating a lockable drawer in the bedside cabinet is therefore essential so that patients can store their wallet, smartphone or laptop within easy reach but protected against theft. The patient cabinet itself can also function as a way of marking personal space, shielding the bed area from those of other patients. Patients therefore perceive the patient cabinet as an extension of their personal realm. This aspect is particularly important for older patients and must be considered in the design. Although more slender and more open items of furniture are becoming increasingly popular, the bedside cabinet can be more opaque and solid. The lockable part should at least convey a robust and trustworthy appearance. A key or RFID chip is best for locking a drawer as patients are prone to forgetting a code, and not just when they have dementia. Similarly, a familiar design that is not overly technical or medical will be more readily accepted by patients and can have a calming effect. This is also relevant to infection prevention potential as strengthening the immune system and successful recovery contributes to the patient’s mental well-being. In short: the design of the patient bedside cabinet and table must be patient-friendly.

Positioning

The bedside cabinet is located in the often-congested space next to the patient’s bed. Alongside the cabinet, there may be a bedside terminal, a disinfectant dispenser, and possibly also an infusion stand, an oxygen unit or other items of medical equipment. Moving it may require care to avoid collisions with other items in the vicinity. To avoid becoming entangled with swivel arms, cables, hoses or medical supply lines, the bedside cabinet should not have protruding parts or an excessively open structure in which things can get trapped. A bedside table with an electrical supply for electrical components such as a refrigerator is less ideal. A power cord makes it less easy to move the bedside cabinet, as a plug has to be pulled when cleaning the room, and this can encourage cleaning omissions.

Whether the bedside cabinet is positioned to the left or right of the bed depends largely on the room layout and the patient’s respective clinical picture, which may require more intensive care or access to the patient from a particular side of the body. This means that bedside cabinets sometimes have to be moved from one side of the bed to the other. Consequently, bedside cabinets must be flexible, usable from either side and cordless so that staff can perform their nursing procedures unobstructed and to the full extent without having to work around furniture (Fig. 3).

Preparation

Patient bedside cabinets are not classified as medical equipment and are therefore not subject to the same cleaning, disinfection and sterilisation requirements. Nevertheless, they bear certain parallels to the design requirements for disinfectant dispensers. The cleaning and preparation of a large number of objects is a logistical challenge for hospitals, and digitalisation can help incorporate these into existing workflows by making it possible to determine where each bedside cabinet is located, how long it has been in use and whether it is already clean. QR codes or RFID chips can be used as identifiers for locating mobile items and to document their machine processing history, providing a better means of monitoring and verifying logistical processes. This becomes increasingly essential as bed occupations become shorter and change more frequently. Alongside these organisational aspects, the construction of the bedside cabinet must be suited to machine cleaning: for example, water must be able to drain from drawers or similar enclosures without leaving any residue, and the material must be thermally suitable for the washing processes. In terms of its form, seamless surfaces and curved transitions are more suitable than sharp-edged or angular changes in surfaces. Inevitably, this may mean a reduction in the number of components, which is also advantageous in the event of spillages of food or beverages. When surfaces are unbroken, these cannot seep into joints and form a breeding ground for germs. The same applies to manual cleaning and wipe disinfection: undercuts in the form should be avoided and sufficiently large, reach-through openings help to simplify cleaning.

Material

Seamless forms can be produced using rotational or injection moulding processes but only with plastics, which are not always sufficient strong to withstand the weight of a person leaning on them. Polypropylene (PP), polyethylene and melamine are all suitable, and the latter is particularly scratch-resistant and therefore ideal for intensively used surfaces such as the tabletop and the top of the bedside cabinet. High-pressure laminate (HPL) is a sheet material that is exceptionally durable, smooth and easy to clean but it can only be bent in two dimensions. Bending is nevertheless preferable to joints and screw-fixings. Stainless steel is very stable but has a cold surface and is heavy, making it difficult for weak patients to manoeuvre. Nursing and cleaning staff, who have to move such items regularly, likewise appreciate lightweight bedside cabinets.

Requirements for a bedside cabinet

The design of a bedside cabinet can aid patients in the organisation of their personal belongings by creating specifically shaped elements and compartments that determine how they are used and how easy they are to reach. For example, certain sections may only be deep enough to hold magazines or a tablet. A shoe rack can avoid the patient’s slippers from being scattered about the room, and a recess or holder for a bottle in a drawer or on the outside can avoid too many loose objects from being placed on the top surface. One must also consider how drawers and trays are to be fixed to the cabinet. To be useful to the patient, the tabletop must be ergonomically adjustable to the patient’s height and the position of the bed. It must be able to be swivelled and extended in vertical and horizontal directions. Similarly, a waste bin could be incorporated to avoid the build-up of smells but this then also needs to be emptied regularly. In the case of the KARMIN bedside cabinet this is not necessary as there is already a waste bin in the nurses’ cupboard by the worktop.

A concept for a bedside cabinet

Before taking concrete steps towards designing a new bedside cabinet, it is worth looking at how existing models address these many different requirements.

Benchmark

A wide range of models of bedside cabinets are available on the market for intensive care units, private healthcare wards, standard care wards, geriatric healthcare and care at home situations, each of which have different requirements. Whereas in Germany, bedside cabinets are rarely made solely of plastic and have many joints where the different materials meet, manufacturers in other countries have been offering models made of injection-moulded components for some time. However, none of these are as homely as products made, for example, of imitation wood. The fittings they offer also differ: some models include a holder for a smartscreen or tablet, but this comes at the cost of restricting the mobility of the unit due to the necessary cabling and an additional projecting swivel arm. A tablet holder should therefore be avoided and instead a bedside terminal used. A terminal suspended centrally from the bed headwall is also easier to access from both sides of the bed than a tablet limited by the reach of a swivel arm attached to the bedside unit.

Some concepts also offer a charging station for mobile devices. Here, too, the KARMIN bedside cabinet opts not to restrict mobility through the need for a power cord and therefore does not include an integrated charging station for mobile devices.

Various solutions also exist for allowing a bedside unit to be used on both sides of the bed. Some bedside cabinets have push-through drawers openable on either side; these require a slightly wider mechanism than a conventional drawer to ensure middle and end locking in either direction. Other models allow the tabletop to be taken out and reinserted on either side without the need for tools. Another variant involves swivelling the entire body of the cabinet on its base, though this requires a relatively chunky rotating mechanism that reduces the storage space appreciably. The push-through drawer that opens in both directions was felt to be most appropriate for the KARMIN bedside cabinet because very little effort is needed to switch sides in everyday use and the mechanism can be optimised for better hygiene. This benefits nursing and cleaning staff equally. Commercially available models also have different solutions for the call button, for the parking brake and in their choice of materials. For the KARMIN patient room, the call button is located on the bedside terminal rather than the bedside cabinet.

The models also differ in their choice of material. Different HPL decors are used, some in plain colours, some with a wood-effect surface. In the case of plastic elements, so-called terrazzo plastic patterns are generally avoided due to the more complex production and mechanical disadvantages, but plain coloured models are offered.

For the smooth rolling of the bedside unit, almost all models use double castors with an integral parking brake. They have the advantage of being more stable and better able to absorb the weight of patients supporting themselves on the furniture. Several manufacturers provide a fifth wheel beneath the dining tray to prevent tipping.

Conceptual structure

As the KARMIN bedside cabinet is a model for a standard care room, a fridge is not necessary. The need for a power supply and cord for the refrigerator further reduces the space available near the patient and the mobility of the unit. In this case, only shelves and compartments are needed.

To aid preparation and cleaning, a system of modules inserted into a tubular metal frame is proposed. It can be easily adapted to individual patient needs and leaves sufficiently large space for easy cleaning. It also means that all areas are easy to wipe clean with disinfectant. However, this variant with its open structure is less ideal as a means of ensuring privacy.

Alternatively, the volumes can be divided into different zones allowing the nurses to have lateral access to medication and care materials in a compartment not immediately accessible to the patient. In the case of the KARMIN patient room, this is not necessary as a dedicated workplace and nurse’s supplies cabinet is already available near the bed.

To suggest more specific usage patterns, a cup and bottle holder can be provided on the top surface (Fig. 4). Time can be saved during cleaning by choosing an openly visible compartment structure. This is easier to clean, since, unlike closed drawers, contamination is directly visible on inner surfaces. In addition, slotted-in compartments can be easily removed to access gaps between them, which is much less laborious than screwed-on items. However, a disadvantage is that the open structure does not provide the same measure of privacy.

Material

When deciding between wood-effect HPL in panel form and freely-formable injection-moulded plastics, one must consider the relative benefits of reducing the number of components and construction joints for better cleaning versus a comparative lack of visual and tactile warmth. One should also consider the relative benefits of plain coloured versus patterned surfaces such as wood-effect panels. Because it is easier to detect dirt on plain surfaces, a pure white plastic material was proposed for the KARMIN bedside cabinet. The colour and feel of the cabinet should fit into the overall concept of the patient room. A coherent, coordinated concept contributes to providing a calm environment for the patient. In addition, the material is also machine-cleanable. Given the projected increase in overweight and elderly patients in future, the frame must be sufficiently sturdy to withstand the weight of a person leaning on it.

The KARMIN bedside cabinet

The design of the KARMIN bedside cabinet represents a trade-off between weight optimisation, robustness, patient friendliness, manoeuvrability and ease of cleaning.

Design of the prototype

In order to be able to absorb the load of transverse forces, the KARMIN model is based on a stable frame from a major manufacturer already available on the market. The base comes equipped with a fifth stabilising double castor beneath the pillar of the extendable, rotatable and inclinable tabletop. The width of the double castors reduces the risk of tipping. The frame has been optimised and modified with a view to reducing the number of components. The slot mechanisms for the sliding drawers were simplified and hard-to-clean ledges and projections removed. The top of the unit has a simple seamless raised lip around the perimeter and offers more space than many standard models on the market that subdivide the top into compartments with several webs (Fig. 5). Similarly, new seamless drawer units were developed that offer more space than conventional models. The wide handle on the side of the top panel is easy to grip for stable table movement. Its lateral placement means that nursing and cleaning staff generally grip a different part of the unit than the patient lying on their side in bed. The patient can only reach the drawers, the lower compartment and the grip of the tabletop at arm’s length.

The upper drawer can be locked with an RFID lock, while the lower drawer offers ample storage space for larger objects. The wide drawer handle makes it easy for the patient to open it from different positions, and the open compartment in the middle provides quick and easy access to frequently used items. The absence of a rear panel and the dual middle and end locking of the drawer position allow it to be used from both sides and make care and cleaning procedures easier.

Form, colour and atmosphere

The soft, smooth shapes of the bedside table convey a sense of calm coherence. Its design is neither overly complex and fussy nor overladen with multiple different materials. Its clear structure allows the aspect of its usability to come to the fore, and in turn helps strike a balance between privacy – which is especially essential for vulnerable patients – and an open design that is easy to clean (Fig. 6).

Cleaning

The components have been optimised for easy cleaning through a largely seamless design and smooth rounded transitions (Figs. 7–9, 11). The drawers are provided with drip holes for machine cleaning and inaccessible gaps in the construction were avoided. Instead of a key-operated locking mechanism, the drawer uses an RFID lock so that no water can penetrate the keyhole during machine cleaning. The top surfaces and contact zones have been kept monochrome to make contamination easier to detect. The side walls, which are rarely touched, have been given a wood texture, lending a homely touch to the otherwise clean design of the unit.

Through these simple constructive means, the bedside cabinet succeeds in raising the infection prevention potential of the object and becomes incorporated into the overall design of the patient room (Fig. 10).

The Bedside Terminal

As a consequence of economic constraints and technological advances, workflows in modern hospitals are becoming quicker and being digitalised. Examples include the collection and transfer of data on patients on admission to hospital, the use of telemedicine to consult external experts or the digital monitoring of a patient’s vital signs during a hospital stay. Processes and activities are changing, and in some cases new devices are supplementing existing work equipment. The automation of information transfer has drastically reduced the transport of patient files and made it possible to look up and print out patient data as and when needed. Apps can help prepare patients prior to arrival and allow medical staff to follow up on cases afterwards. Patients can be informed of procedures and precautions in advance while at home, as well as during their stay, and hospitals of any relevant personal information about the patient. For the aspect of hospital hygiene, these developments present both new possibilities as well as new challenges. New devices such as the bedside terminal in the patient’s room and portable monitoring devices have made inroads into everyday hospital practice. In Germany, bedside terminals are currently usually only available in rooms for private healthcare patients. Mounted on a swivel arm near the patient bed, the bedside terminal is essentially a small digital device with which patients can access the hospital’s various digital services or entertainment media, depending on the system. Often, certain content is only available if purchased privately by the patient. Staff are also increasingly being equipped with mobile devices to record and receive information directly where they are.

As physical objects, these devices represent colonised contact surfaces that can be a vehicle for cross-contamination. Mobile devices carry pathogens in and out of a patient’s room; they are deposited in various places and touched by a variety of people. But digitisation also obviates the need to carry around clipboards with paper-based patient records. To entirely replace analogue patient files with digital records, the respective user groups must be equipped with devices and suitable access rights to the relevant information. The direct recording and entry of information also avoids the risk of loss of information or errors occurring with manual data transmission. Digital devices can additionally provide valuable services in infection prevention, including the ability to document the preparation and cleaning of objects for patient rooms, and patient empowerment and education. The bedside terminal is ideally suited for these last two applications, and for this reason, it was also selected as a hygiene-relevant object in the patient room for investigation as part of the KARMIN project. In addition, it makes it possible to call up required medical information and knowledge at the point of care in the event of an emergency (Fig. 1).

Patient empowerment and education

Infection prevention education

Patient empowerment aims to provide patients during a period of treatment with knowledge so that they can play an active role in supporting their recovery and participate in facilitating processes. Research has shown that independent, informed patients can be treated more successfully (Powers, Bendall 2008). Helping patients understand their own health condition and the treatment they are undergoing can, among other things, assist them in managing stress levels and in communicating about it. Informed patients have a better understanding of the care processes and also of restrictions, for example with regard to nutrition. Educating patients on hygiene-related aspects can also encourage better infection prevention practices during their stay (McGuckin, Govednik 2013). The question is therefore how one can best educate and convey information to patients through digital content via the bedside terminal (Fig. 2).

During treatment in hospital

While patients are in hospital, the process of recovery can be assisted by encouraging movement and informing patients of the consequences of a lack of activity. This can be achieved by physical means, for example by replacing the patient’s bed with chair beds during the day and moving the patient into a more active, upright position, as well as by encouraging patients to get up and move via instructional information, videos or games presented via the bedside terminal. Activity strengthens the immune system and patients recover more quickly (Pashikanti, Von Ah 2012; Schaller et al. 2016). Shorter periods in hospital also reduce the risk of nosocomial infection.

After treatment at home

The concept of patient empowerment also encompasses giving the patient the opportunity to provide feedback on their stay in hospital. Many hospitals already ask patients to fill out questionnaires to gain valuable information for quality management procedures and therefore potentially also for infection prevention. In addition, doctors should provide medical recommendations for patients and how they can adjust their lifestyles to remain healthy. This can help them adhere to advice given beyond the duration of their period in hospital. For example, helping patients understand dietary recommendations can prevent future hospitalisation. Such health-promoting measures can be part of services provided via a bedside terminal.

For all the above forms of communication, the bedside terminal acts as an interface for the transfer of information between patient and hospital. At present, however, digital content provided by a terminal must typically be paid for by the patient, especially in standard care wards. Hospitals must ensure that this does not hinder the communication of essential, medical or hygiene-related information; optional extras bookable by the patient should be limited to the entertainment sector.

Requirements for a bedside terminal

Content

A bedside terminal must address a range of topics and fulfil diverse functions. Alongside information on the daily schedule, it can provide educational information on infection prevention. It can also be used to remotely control other equipment in the room, for example enabling bedridden patients to control lights and temperature, to operate the blinds or change the backrest position. This provides a way of bundling traditionally separate, manual controls in a single interface used by one person, thus minimising situations where contact infection can occur. Video calls, making notes, telephoning and filling out feedback forms can likewise all be facilitated by a terminal, as can entertainment services such as television, radio, a newsstand and internet access. A further opportunity to engage patients is through the use of so-called “serious games” on topics related to health, and training health-promoting behaviour (Fig. 3). Many adults are increasingly open to the gamification of educational content and it is no longer solely reserved for young patients.

The bedside terminal should be for the patient’s use only. Hospital staff should have their own equipment. To allow nurses or medical staff to share information during patient consultations without touching the patient’s touchscreen, an interface must exist that enables medical staff to share information from their device with the patient’s display terminal.

Interface

The full potential of a terminal for patients can only be realised if content and topics are sensibly and intuitively grouped so that patients can access it. For example, the menu system can prioritise informational content over entertainment content. Inclusive, accessible design is likewise important: content must be accessible to deaf or blind users, for example by providing information in audio as well as written form. For older patients, too, adjusting text size and contrast must be possible to ensure content can be read. Similarly, content must be available in multiple languages for patients not proficient in the dominant language used in the hospital. Tutorials on using the terminal can also be provided to help patients find their virtual bearings.

Structure of the terminal

Alongside the requirements for software and content, various specific hardware requirements must also be met. Since the surfaces of devices are generally colonised by pathogens, the housing of the bedside terminal must be constructed so that it is easy to clean. This includes minimising the number of components so that the housing is as seamless as possible, using materials and surfaces that can be wiped clean without being damaged by alcohol or other ingredients, and a shape that has rounded corners and edges for easy cleaning. The curvature should be ergonomically formed so that it can be comfortably wiped clean in a single movement. Since liquids are used, any vents for internal components must be watertight, or other means of heat dissipation must be found. Alongside these hygiene aspects, a bedside terminal can have a USB port and a headphone jack for charging and use with patients’ mobile devices. Wifi and Bluetooth modules make it possible to additionally synchronise content. The screen’s capacitive touch display can be supplemented by buttons or keys for basic functions so that older patients, for example, can operate essential functions via conventional means. An RFID reader can ensure that only the authorised patient can use the device.

The bedside terminal should be mounted on a swivel arm that permits it to be freely and easily moved without undue resistance. The arm must be securely fixed to the wall’s surface, usually via bracket mounting on a double-planked plasterboard base. Aside from a connection to the power supply, the terminal must also be connected to the hospital’s public network infrastructure via a LAN socket or DSL connection. It should also incorporate a call button to alert staff via a light signal and an on-off switch on the swivel arm to safely disconnect the terminal from the mains where necessary.

Positioning

The bedside terminal must be easy for patients to grasp but should not obstruct or cover other relevant items near the bed or obstruct cleaning or care provision procedures (Fig. 4). This also applies to avoiding it casting shadows from the reading light or HCL lamp above the patient’s bed. Furthermore, the terminal should be operable from both sides of the bed: a wall-mounted swivel arm has proved more suitable than mounting it on the bed or the ceiling (Fig. 5). The swivel arm should be easy to mount and dismount and must have a radius limiter to prevent either the terminal or the arm segment from hitting the wall.

A concept for a bedside terminal

The requirements for the infection prevention potential of a bedside terminal concern not just its physical properties and ease of cleaning but also the content it provides. Its primary potential lies in providing educational information on preventing infection transmission, on encouraging active personal participation and motivating physical exercise, and on avoiding cross-contamination by providing separate touch surfaces and controls for each patient. The terminal must therefore combine content and technology from both public institutions and private companies.

Use

The diverse functions and content that bedside terminals provide means they are in frequent use, whether for personal communications, entertainment or as a source of information on hospital procedures and treatment. The call button is likewise increasingly incorporated into the terminal, including an option to specify the reason for the call. This can be used later to analyse care response patterns across multiple wards. The different possible uses result in a complex menu structure often with many sub-options.

To aid immediate usability by persons of all age groups, it can be advisable to provide user interfaces adapted to different patient profiles. A patient can select their profile, for example older patients with sight impairments may be presented with larger text, audio options and simplified, less dense content choices.

The interface should encourage patients to view educational content, however patients are typically more easily attracted to entertainment media. Various methods can be used to counteract this. One possibility is to first display an obligatory one-time message on educational content before other content can be accessed. This strongly instructive and restrictive approach can, however, negatively affect compliance. Another approach is using pop-ups that at regular but tolerable intervals draw attention to educational content on good hygiene practices. A further method of ensuring infection prevention information is not buried among the multitude of other information is to prioritise it in the menu hierarchy so that it is available right from the start (Fig. 6).

Format of educational information

To not just present but successfully impart educational information to patients, an appropriate format must be chosen. Patients respond better to visual information and are less inclined to read textual instructions. As such, informative videos are an eminently suitable format. Another option is to train patients through instructive games.

The KARMIN Suite

For the KARMIN patient room, a wall-mounted bedside terminal with swivel arm and integral camera and telephone function was chosen. It was important that the terminal could be attached to plasterboard walls. A hygienic housing enclosure frames a Full HD screen, and all surfaces are easy to clean and resistant to damage through disinfectants.

The casing has minimal joints and is waterproof, and the ventilation slot cleanable so that the assembly meets the requirements of EN 60601-1. An extra keyboard was discounted due to their susceptibility to dirt accumulation and to reduce the number of items to clean. The display is a commercially available model that already meets the hardware requirements and comes with the underlying operating system but no more. Specific educational content, as well as software for synchronising with other hospital applications, must be added on a customer-specific basis. This enabled the KARMIN team to focus primarily on the design of the content. To implement the conceptual principles of patient empowerment and patient education, a specially developed information interface was created called the KARMIN Suite.

Pathogen transmission chain

As the screen is so frequently touched, it is potentially a primary transmitter of pathogens. To prevent this, its use is restricted to the patient only: hospital staff cannot enter or retrieve information and the device will only activate with the patient’s RFID bracelet. In the KARMIN patient room scenario, medical staff wear their own mobile device and can synchronise content from their device wirelessly to the bedside terminal. This allows content to be shared and displayed in parallel. By clearly separating the users so that the terminal can only be used by the patient, no pathogen transmission chain is formed (Fig. 7). One cannot, however, prevent a patient’s visitors from using the terminal, for example to view the patient’s daily schedule. This can only be prevented by educating patients and visitors accordingly.

Nudging

As not every patient is motivated to inform themselves, they are “nudged” to view educational information. Pop-ups appear at intervals, based on analytical data on the frequency with which educational content is viewed, and draw the patient’s attention to further educational information on infection prevention, sensitising them to the importance of the topic. In addition, the arrangement of icons and the menu navigation prioritise the findability of educational content through their prominent placement.

Menu structure

The interface has a central display area and a top and bottom menu bar with general information and important menu items. These can also be brought up via buttons in the housing. Four options are available in the main menu: “Your stay”, “Daily exercises”, “Settings” and “Entertainment”. “Your stay” is the central information point for the patient and leads to submenus with information on meals, the daily schedule, medical information as well as communications and educational content. Private calls can be made with the telephone function. A web browser is also available via the “Entertainment” menu item.

In addition to calling a nurse via the call button, patients can provide nurses with more precise information via a text field or as a spoken message. This avoids the room being entered needlessly and arbitrary items being brought into the room. It also saves staff unnecessary journeys to the patient room and allows them to plan their work in a more targeted manner.

Colours and icons

The associative qualities of colours and icons can strongly influence the perception of content. The KARMIN Suite picks up the colours used elsewhere in the patient room to avoid being unnecessarily jarring or intrusive to the patient. Each of the main menu items and its respective submenus is colour-coded with a signature colour. Alongside the blue tones of the impact protection rails and bathroom door, a red-orange tone that echoes the colour of the seat upholstery is used as well as a matching beige and anthracite. The colours present a harmonious but sufficiently contrasting palette to be easily distinguishable, aiding orientation within the menus. The red tone was assigned to the “Your stay” area to act as a signal directing users to the information on hygiene practices, and the blue tone to the daily exercises. The restrained beige tone is used for the settings while anthracite is the background for entertainment content (Fig. 8).

The icons are white to ensure they stand out against the background of the coloured buttons and are easy to recognise. They take the form of 2D line illustrations (Fig. 10) that are simple and easy to read, and have been kept large and not too detailed so that people with visual impairments can recognise them, and people who do not speak the interface language or cannot read are still able to use the interface.

Patient education

Patient education has a dedicated menu with videos on the topics of hand washing and hand disinfection. A narrator guides the patient through the three questions “Why?”, “When?” and “How?”, explaining each in detail accompanied by descriptive video material or animations. This clear division into three questions begins by explaining why infection prevention measures are sensible and establishes a basis for the patient’s self-motivation. The answers to the following questions of “When?” and “How?” are equally important as not every patient is familiar with the principle or practice of good infection prevention. By splitting the content into three videos, each explanation is entertaining, and the patient does not need to watch a long video, which may be interrupted in the middle (Fig. 9).

Various disinfectant manufacturers, as well as the Robert Koch Institute, the Clean Hands Campaign, the Patient Safety Campaign Alliance and the Federal Centre for Health Education offer relevant content, some of which is freely available. The hospitals can integrate this material into their bedside terminals.

Motivating mobility

The consequences of increasing digitalisation, the incorporation of remote controls in the bedside terminal and the patient’s use of their own mobile devices is that patients increasingly find sufficient diversion in bed and are less often obliged to get up. Nevertheless, a stroll along the ward corridor, to the café, into the hospital grounds is advisable, depending on the severity of their illness. The problem of “bedcentricity” can have a negative impact on recovery that should not be underestimated. Muscles are not exercised, blood circulation is not stimulated and cognitive faculties such as orientation are neglected. In older patients, in particular, decubitus and muscle atrophy can occur (Rahayu Ningtyas et al. 2017). To this end, the KARMIN Suite also offers videos of simple physiotherapy exercises that can be performed without help, and also instruct patients in how to use the bed to stand up. Weakened patients can then also be encouraged to leave their bed.

The KARMIN Suite motivates the patient to be more active during their stay and encourages patients to behave in a hygiene-conscious manner through informational content. The bedside terminal is therefore part of a comprehensive prevention strategy and can make a meaningful contribution to the reduction of nosocomial infections. To achieve the desired effect, all the methods mentioned above should, however, always be adapted to the specific clinical pictures of the respective patient.

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Originally published in: Wolfgang Sunder, Julia Moellmann, Oliver Zeise, Lukas Adrian Jurk, The Patient Room, Birkhäuser, 2020.