Better Design Through Research

April 30, 2007
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For want of a properly placed sink drain. For want of a clear word. For want of a window.

Hospital patients have suffered and even died unnecessarily due to architectural design choices, said Roger Ulrich, professor of architecture at Texas A&M University. Armed with dozens of studies showing the effects of various design choices — good and bad — on patient well-being, Ulrich told the 40th annual Health Facilities Planning Seminar held in Grand Rapids recently that design based on research can impact outcomes as surely as medicines and doctors.

“Evidence-based design makes compelling economic sense,” said Ulrich. The conference, sponsored by the Michigan Department of Community Health, Bureau of Health Systems and the Michigan Architectural Foundation with AIA Michigan, drew several hundred hospital administrators, architects and construction executives to the Amway Grand Plaza.

Ulrich, a board member of the Center for Health Design in California, offered a presentation featuring four issues where research shows design can have a big impact in a hospital: noise, hospital-based infections, patient transfers and natural light.

“Evidence-based design is a deliberate attempt to base design decisions on the very best available evidence,” Ulrich said. “The goal is to create health care buildings that improve outcomes.”

While noise has been a concern in hospital design and has been researched for decades, new studies show it is a greater problem than ever. The average patient area in U.S. hospitals exceeds by 3,300 times the minimum noise standard as set by the World Health Organization, he said. Noise sources are becoming more numerous and louder, and designers tend to use hard surfaces that are easy to clean but reflect noise, he said.

Voices that reverberate too long can put a hospital at odds with privacy law, make doctors and nurses difficult to understand, and suppress patient satisfaction, Ulrich said. Research from Johns Hopkins University shows that, around the globe, daytime hospital noise increases fivefold each year, he said. In U.S. hospitals, reverberation times have been recorded as long as one second or more.

Yet effective, cost-efficient ways of mitigating noise are within reach, he said. Chief among the techniques are ultra-high-performance ceiling tiles that reduce reverberation by a half-second, according to a study in Sweden in which Ulrich was involved.

“Reverberation times can potentially be a killer in certain health care situations, because they severely hinder speech intelligibility,” Ulrich said. “Take acoustics very seriously.”

Hospital-acquired infections kill thousands of patients each year, he said. Contributing to the spread of infection at hospitals are inadequate water systems; poor air quality; too few and badly located sinks for staff hand-washing; and multi-bed rooms.

Ulrich cited research done at Bronson Methodist Hospital in Kalamazoo that tracked the dramatic decrease in hospital-acquired infections among cardiac patients when a new unit allowed a change from multi-bed to private rooms.

Just 18 months ago, he said, one hospital saw such a severe spike in pseudomonas infection in an ICU that more than a dozen patients died and even more were sickened. Much sleuthing failed to turn up the source of the germs, until two microbiologists discovered them in the drain traps of patient room sinks. Because the sink’s drain was located directly under the faucet, every time the sink was used, water would go directly into the drain trap. The pseudomonas virus harbored in the drain trap would splash up and shower the nurses and doctors washing their hands there. The staff was spreading the infection. Ulrich said the hospital has since replaced those sinks with models that have offset drains.

Still, staff hand-washing is an important method for cutting the spread of infection, Ulrich said. The traditional way to boost hand-washing rates has been training, education and making requests of staff, he said. But while that may work for a couple of weeks, hand-washing habits generally sink to prior levels. He said reported rates are in the 14 percent to 28 percent range, although following staff around shows that those self-reported rates don’t reflect the reality that puts staff hand-washing as low as 10 percent in a busy unit.

“What’s been ignored in traditional research and infection control is the role of the design of the environment,” Ulrich said. “Research suggests strongly that this is the way to go if we’re going to increase hand-washing compliance.”

He offered what he said was a well-designed hand-washing station, featuring an impervious surface that is easy to clean, a no-touch faucet with water heated to a comfortable temperature immediately, located near the patient but in the path that staff must follow to get from the door to the hospital bed. Both soap and gel dispensers are just above the sink. Ulrich said studies show that alcohol-based gel destroys a wider range of pathogens than soap, but there are some that respond better to soap.

In one study, better design pushed hand-washing rates to a “sustained and permanent” 47 percent even without education, Ulrich said.

Transfers to other departments or other rooms are a source of huge costs to hospitals, from staff time and injury to deterioration of the patient’s condition. And patients who undergo a transfer tend to have a length of stay that’s a half-day longer than average, he said. They also reduce patient satisfaction, he said.

“Transfers are costly; transfers are wasteful; transfers hurt staff because of bending and lifting issues; transfers increase cross-infection,” Ulrich said.

He said a good way to avoid those costs is to eliminate transfers altogether with rooms that can be easily adapted to accommodate the patient’s acuity level from admission to discharge, he said. So instead of moving, for example, a cardiac surgery patient from ICU to a regular medical-surgical room as healing progresses, the room itself is changed and the patient stays put. Services such as ultrasound are brought to the patient, he said.

As for the effect of natural light, Ulrich said, “Architects have always believed somehow that natural light and sun is important for health.” He cited a study showing that patients being treated for depression shorten their lengths of stay by 3.7 days by staying in rooms with morning sunlight. Ulrich described another study conducted at a hospital after an addition was built that put the east side in perpetual shadow. Comparing patients undergoing elective cervical and lumbar spinal surgery who stayed in the dark rooms that faced east with those in west-side rooms with lots of light, the study showed west-side patients used 22 percent less pain medication.    CQ

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