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Evidence-baseddesigninhospitalconstruc5on

DanishRegionsconferenceonnewhospitalconstruc4onNyborg,August31–September1,2016

RogerUlrich,PhD

CenterforHealthcareArchitectureChalmersUniversityofTechnology,Gothenburg

Evidence-baseddesign(EBD)isaprocessfortheexplicituseofcurrentbestevidencefromresearchandpracGceinmakingdecisions,togetherwithaninformedclient,aboutthedesignofeachindividualproject.

Hamilton&Watkins(2009).Evidence-BasedDesignforMul5pleBuildingTypes.NewYork:Wiley

Evidence-baseddesign(EBD)

Evidence-baseddesign(EBD)research

•  Pa5entsafety(infecGon,falls,errors)

•  Otherpa5entoutcomes(suchaspain,lengthofstay)

•  Staffoutcomes(worksaGsfacGon,retenGon,effecGveness)

•  Costsofhealthcare

Morethan2,500strongstudieslinkthehospitalphysicalenvironmenttooutcomesinfollowingmajorareas:

Best technical practice

Art of architecture

EBD

OBJECTIVE SUBJECTIVE

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Best technical practice

Art of architecture

EBD

OBJECTIVE SUBJECTIVE

AmountofEBDknowledgeisfairlysmall.Butitcarriesweightwithdecision-makersandmedicalprofessionalsbecausemostoftheknowledgerelatestopriorityissuessuchassafety,andcanbelinkedtocostsavings.

EBDresearchexample:Effectsofnoiseonoutcomesandcosts

Hospitalnoiselevelsarefarhigherthanrecommendedvalues

� Noisesourcesaretoonumerousandtooloud

� SurfacesaresoundreflecGng

Thereisgrowingevidencethatnoiseworsenspa5entandstaffoutcomes

Noiseworsensoutcomes

•  ReducesoxygensaturaGonininfants

•  Elevatesbloodpressure,respiraGon

• WorsenspaGentsleep

•  ErodesemoGonalwell-being

•  Increasesstaffworkpressure,strain,faGgue,burnout

• Worsensspeechcomprehension

Designtoreducenoisecanimproveseveraloutcomesandreducecosts

Installinghigh-performancesound-absorbingceiling5lereducedphysiologicalstressinmyocardialinfarc5onpa5ents,improvedsleep,andreducedre-hospitaliza5ons(Hagermanetal.,2005).

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Researchsummary:EffectsofNATUREinhealthfacili5es

•  Naturereducesstress

•  Reducespain

•  Lessensanger/aggression

•  Increasessa5sfac5on

Effectsofnaturewindowviewonrecoveryoutcomesfollowingsurgery(Ulrich,1984)

Number of Pain Drug Doses (days 2-5 after surgery)

Analgesic NATURE WALL Strength patients patients

Strong 0.96 2.48

Moderate 1.74 3.65

Weak 5.39 2.57

•  Less pain

•  Fewer minor complications

•  Shorter stays

Exposuretonaturallight/sunlight:

•  Lowersdepression(improvesemoGonalwell-being)

•  Reducespain

•  Increasesstaffsa5sfac5on.Mayhelpfosteralertness.

Providingaccesstodaylightimprovespa5entandstaffoutcomes

Speakingofwindows:TheimportanceofprotecGngpaGentprivacyisincreasing.

•  HealthauthoriGesindifferentcountrieshaveincreaseddesignrequirementstoensureprivacy.

•  RequirementshaveexpandedtopreventvisualintrusionsbypersonslookingintopaGents’windowsfromnearbyspaces.

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•  Spacingbetweenbuildings:15meters

• CanpersonslookintoapaGent’swindowfromanotherbuilding?

• HowmuchdaylightwillactuallyreachpaGentspacesonlowerfloors?

Spacingbetweenbuildingsaffectspa5entprivacy,daylight,andnatureexposure

•  Ifspacingbetweenbuildingsbecomesnarrow,paGentprivacyisviolatedifstrangerscanlookintheirwindowsfromnearbybuildings.

Buildingspacingandpa5entprivacy

•  PaGentswhofeeltheirprivacycanbeinvadedbypersonslookingintotheirwindowsclosetheirblinds,losingdaylightandview.

(Sherman,Varni,Ulrich&Malcarne,2005)

•  (Myopinion):architecturethatviolatespaGentprivacycannotbeconsideredgreenorsustainable.

Legacy Health Salmon Creek, Washington

Design: ZGF Architects

Visualbarriernecessarytoprotectprivacyofpa5entroomsandmeetU.S.privacyregula5ons

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•  ClientsrequirethedesignteamtoprovideacomputerrenderingorvisualizaGonthataccuratelyshowstheviewintoapaGentroomfromanearbywindoworoutsidespace.

Sugges5ontohelpensurepa5entprivacyinnewbuildings ThesinglemostimportantEBD

recommendaGonforimprovingpaGentsafetyandotheroutcomes:

Providesingle-bedrooms

Single-bedvs.mul5-bedpa5entrooms(Ulrich,2004,2014)Single Mul5-bed

Healthcare associated infections Medical errors Falls Staff observation of patients Staff/patient communication Confidentiality of information Presence of family Patient privacy and dignity Avoid mixed-sex accommodation End-of-life with dignity Low noise Sleep quality

mixed

mixed

Pain Patient stress Daylight exposure Patient satisfaction Patient choice of hospital Staff satisfaction Staff work effectiveness Reducing room transfers Adapt to handle high acuity Managing bed availability Initial construction costs Operations and whole life costs

Single-bedvs.mul5-bedpa5entrooms(Ulrich,2004,2014)Single Mul5-bed

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Singleroomsimprovestaff-pa5entcommunica5on,supportfamilypresenceandprivacy

(Kaldenburg,1999;Chaudhuryetal.,2003)St.GemmaHospice,UKDesign:JaneDarbyshire&DavidKendall

Athree-bedroominanordicchildren’shospital.Thereis5ghtspaceforparentofonechildtostayovernight.Nospaceforparentsofothertwopa5entstostayovernight.Privacycurtainblocksdaylightandviewforforegroundpa5ent.Acous5cprivacyisnon-existent.Staffcommunica5onwithpa5entsandfamilyisseriouslyhampered.

Singleroomsmakepossiblenewcareprocesses/opera5onsthatcanimproveclinicaloutcomesandreducecosts.

­  Implica4on:ahealthcareprojectshouldbeginbyrethinkingcareprocesses.

PriortorenovaGngNICUtoprovidefamily-centeredsinglerooms,thecaremodelatKarolinska(Huddinge)emphasizedfamily-centeredcarewithearlyskin-to-skincontactandbonding.

•  ButinfantswereinmulG-incubatorroomswithverylihlespaceforfamily(builtin1970s).

•  Mothers(C-secGons)wereassignedpaGentroominanotherunit.Ajerwardfamilystayedinhotel.

Example:Karolinskaneonatalintensivecare

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Level3unit

Researchslidesfrom:Lillieskold,S.&Westrup,B.(2011) Researchslidesfrom:Lillieskold,S.&Westrup,B.(2011)

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Infections (all categories) reduced 75%-80%

DocostsavingsfrombeaeroutcomesinsingleNICUroomsoutweighthehigherconstruc5onandannualopera5ngcosts?

•  Savingses5matesbasedonoutcomeimprovementsatKarolinskaHospital(Ortenstrandetal.,2010)andaU.S.children’shospital(Stevensetal.,2012).

•  Evenconserva5veanalysisshowsthattheaddedcostofsingleroomsisrepaidwithinoneyear,withsubstan5alsavingseachyearthereacer.

(source:Shepleyetal.,2014,JournalofPerinatology)

Growingandseriouschallengeforhospitalsinallcountries:

Mul5-drugresistantinfec5ons

Thepost-an5bio5ceraishere

Therearestrongreasonsforexpec5ngriskfromresistantinfec5onswillincreaseinDenmarkandother“safe”countries•  Hospitalinpa5entsaregedngsicker,morevulnerableandimmune-compromised.

•  Newresistantinfec5onsappearinothercountries.Danishci5zenstravelabroadalotandbringbackseriousinfec5ons.

Butmanyhospitalsareolder,designedbeforeresistantinfec5onsbecameproblem.Thesehavefewsingleroomswithprivatetoilets.

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Study:Conver5ngacri5calcareunittosingleroomsreducesinfec5on

•  Studysite:25-bedcriGcalcareunitbeforeandajerrenovaGonto100%singlerooms

• Mainfindings:

w  C.difficiledecreased43%

w MRSAdecreased47%

w Overallaveragelengthofstaydecreased10%(allpa5entsinintensivecare)

(Teltschetal.2011,ArchivesofInternalMedicine)

Docostsavingsfromreduc5onofinfec5onsjus5fythehighercostsofsingle-bedroomsinintensivecareunitsforadults?

•  Studycomparedreturnoninvestmentofconver5ngICUsfrommul5-bedtosingleroomsinvariedscenarios(varyingconstruc5oncosts,infec5onrisks,lengthofpa5entstay,etc.)

•  Conclusion:inallscenariossingleroomsyieldedsubstan5alcostsavings,repayingaddedcostsofconstruc5on.

(source:Sadatsafavietal.,2016,JournalofCri4calCare)

Morepa5entshaveinfec5onriskfactorsandrequiresingleroomswhenadmiaedtohospital

•  Suppressedimmunefunc5on

•  Historyofinfec5on

•  Respiratoryinfec5onsymptoms,possibleinfluenza

•  Previouslyhospitalized

•  Diarrhea

•  Recentforeigntravel

•  Admiaedfromlong-termcarefacility

Es5ma5ngnumberofhospitalbedsactuallyavailableintwoAmerican300-bedhospitals

�  Hospital A

®  300beds:100%1-bedrooms�  Hospital B (built in 1965-75)

®  300beds:10%1-bedrooms(30beds)30%2-bedrooms(90beds)60%4-bedrooms(180beds)

Hypothe4calscenario:

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Assump5ons•  Bedoccupancyratein1976:83%-87%

•  Bedoccupancyratein2016:95%-100%

•  Infectedpa5entsassignedsingleroom

•  Pa5entswithinfec4onriskfactorsshouldhavesinglerooms

•  Pa5entsduringend-of-lifecareassignedsingleroomfordignityandprivacy

•  Pa5entsassignedmul5-bedroomsarematchedbygender

1976(an5bio5cera)

2016(post-an5bio5cera)

100

200

300

Numberofbedsactuallyavailable

100%singlerooms10%singlerooms

Es5ma5ngnumberofbedsavailableintwohypothe5calU.S.300-bedhospitals

Approximately120bedsarelostbecausemul5-bedroomsmustbeusedassinglerooms.:

EBDforreducinginfec5onsinthepost-an5bio5cera

•  100%singleroomswithprivatetoilets(important!)

• Alcoholhand-rubdispenserslocatednearbedside,toilet,otheraccessibleloca5ons.

• Handwashingsinksplacedinprominentloca5onsnearstaffmovementpaths.

• Causesmanypa5entdeathsinterna5onally.

• Producessporesthatsurviveformonthsonsurfacesandequipment.

• Handwashingneeded,notalcoholhandrub.

•  Essen5altoputpa5entsinsinglerooms.

Clostridiumdifficile

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• BecauseofC.difficileoutbreaks,healthcaredesignguidelinesincreasinglys5pulatetherebetwosinksineachsinglepa5entroom.

• Onesinkforstaff,asecondsinkforthepa5ent,tohelppreventcross-contamina5onfromC.difficilespores.

Clostridiumdifficileandhandwashingsinks•  “Handhygieneshouldnotbecarriedoutatapa5entsinkasthiswillre-contaminatethehealthcareworker’shands.”(CanadianMinistryofHealthandLong-TermCare,2004,2006).

•  “Twohandwashingsta5onsshallbeprovidedineachpa5entroom:1)ahand-washingsinkshallbelocatedinthetoiletroom;and2)ahand-washingsinkinthepa5entroom.”(AmericanHospitalAssociaGon,FacilityGuidelinesInsGtute&AmericanInsGtuteofArchitects.GuidelinesforDesignandConstruc5onofHealthCareFacili5es.2006,2010,2014).

Clostridiumdifficile

Twohandwashingsinksineachsinglepa5entroomRoyalJubileeHospital,Victoria,Canada

Alcoholhandrub Alcoholhandrub

Designofthefuturemustsupportcaringforsickerpa5ents

Changeinshareofcasesbyseverityofillness(AmericanHospitalAssocia5on,2004)

Fastestinpa5entgrowthisatextremeseverityacuitylevel

1998-2000 2000-2002 Severity

ofilln

ess

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CromerChildren’sUniversityofChicago

•  SingleroomwithdirectobservaGonofpaGentfromlocalizednursestaGon.

•  Largerroomstosupporthigheracuityandfamilypresence.

•  Somewhatbeherairquality.

CromerChildren’sUniversityofChicago

Inmul5bedrooms,visualaccesstopa5entscanbeblockedbyprivacycurtains

�  AEuropeanstudyfoundthat>80%offallsinmulG-bedroomswereneitherwitnessednorreportedattheGmetheyoccurred(Schwendimann,2006).

•  Notmany.Evidenceshowsthat85%-90%oftheGmeroommatesaresourceofstressnotposiGvesocialsupport.w  Stressexamples:roommatewhoisunfriendlyorseriouslyill.

w Roommatesgeneratemuchnoiseandreduceprivacy.

w RoommateincompaGbilitycausesmanyroomtransfers.

Domanypa5entslikehavingroommates?

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100%

Preferencesforsinglevsmul5-bedrooms:TwostudiesofU.K.publichospitals

Pre

fere

nce

Single-bed

Multi-bed

Adults with little or no experience with single rooms

Patients with experience with both multi-bed and single rooms source: NHS Estates & BMRB, 2002 source: Lawson and Phiri, 2003

Study #1 Study #2

Designtodrawpa5entsoutofroomsforsocializa5onandmovementRoyalJubileeHospital,Canada

Designtoaaractpa5entsoutofroomsforsocializa5onandmovementRoyalJubileeHospital,Canada

•  Improvingbuildingdesigniscentrallyimportanttoimprovinghealthcarequality.

Muchresearchsupportsthisgeneralconclusion: