Sheila Cahnman, AIA, ACHA, Frank Zilm., D.Arch, FAIA
he single major characteristic that differentiates a hospital from other healthcare settings is the ability to care for patients for overnight stays over 24 hours within the facility. The inpatient acute care unit is the largest component of this capability in most hospitals and frequently has a major influence on the overall building design, usually as a tower element. We will focus on the acute inpatient unit in this section, often referred to as a Medical / Surgical Unit. A key characteristic of this area is the management of acute healthcare needs resulting in length of stays typically falling in the range of 1 to 14 days. Other areas that provide overnight care include intensive care, rehabilitation, and skilled nursing units.
The patient rooms are a key repetitive element in the design of an inpatient acute care unit. Other space and functional elements that come into play in design include the staff work areas, storage / distribution / removal of materials, movement and circulation through the unit, and management of special patient conditions and needs.
As discussed in the history section, one the seminal developments in the evolution of healthcare design was the sanitarian movement in England and the influence of Florence Nightingale. In addition to emphasizing cleanliness and air ventilation, Nightingale incorporated nursing management concepts into design. She recommended the ideal nursing unit at 32 beds, determined by the maximum sphere of influence of nursing management. Minimal built in components were advocated to maintain a clean environment. The pavilion unit design was the major hospital design driver from the late 1800's through the 1920's.
Most nursing units designed during this period were "open ward" units, with all patients housed in one large room. Although this model can still be seen in many developing countries, over the past fifty years is the trend has been to subdivide beds into smaller units - four bed wards, two bed "double occupancy" or “semi-private” rooms, and single, private patient rooms. In the United States a common model in the 60's and 70's was to have a mix of double occupancy rooms and single rooms. Most insurance plans covered the costs of stay in a double occupancy room. Patients requesting a single occupancy room frequently paid an out-of-pocket additional charge.
Towards the end of the century the all private room nursing unit emerged from a variety of influences. One operational issue was the desire to maintain high bed occupancies: patient mismatch (male and female patients in the same room) and social incompatibilities caused unnecessary patient reassignment and lower levels of semi-private room utilization. Greater recognition of infection control, family involvement and privacy of patients were further influences. As capital costs became a smaller part of the overall hospital budget in the United States, more hospitals set a goal of providing all private bed hospitals, which has become a market standard in the US and has begun to gain traction abroad. The 2010 edition of the Facilities Guideline Institute Guidelines established the private patient room as the preferred model.
The space implications of a single room model are significant. The DGSF per bed in acute care units with a mix of single and double occupancy beds is typically in the range of 550 to 650 square feet. A contemporary all private room unit will have 700 to 850 square feet per bed.
The Patient Room
The exam room is the key space driver for ambulatory design. For acute care units the patient room is the most important design element. Functional requirements of the room which are frequently described as spacial zones include:
- Patient care - this zone includes the bed and surrounding space for floor based equipment and the headwall behind the patient for medical gases, electrical outlets, monitoring, suction and communications.
- Staff work zone- this includes supply storage, counters with handwashing sinks for staff to prepare for patient treatment, computers to chart and record results, and places to safely dispose of soiled material. Since supplies and linens are considered contaminated once a patient leaves a room and it is terminally cleaned for a new patient, hospitals are now greatly reducing the amount of supplies stored in the room.
- Family area - with the increasing acceptance of the family as key patient support, the provision of appropriate space to allow for comfortable family accommodations, including overnight stays, has become a significant element in the room.
A fundamental code requirement for over 23 hour stays is that all patient rooms have an exterior window. Studies conducted by Roger Ulrich and others, have supported the importance of views to the outside and natural daylight in supporting patient's mental acuity and in reducing stress. As a result of these factors, the orientation of the patient bed is typically parallel to the exterior wall; ideally to provide a direct view to the outside from the bed. The window requirement for all rooms dictates the basic geometry of nursing unit, placing a premium on exterior wall space. Every foot of exterior is important to maximizing the number of beds that can be provided on a unit.
The other key driver in the patient room layout is the location of the toilet/shower. Three fundamental layout options have emerged:
- "Inboard" - with the toilet located on the interior corridor. This provides maximum opportunities for windows and a family zone area. Conversely, it limits staff visibility into the rooms and may require extra walking to access patients.
- "Outboard" - places the patient toilet on the outside wall. This model maximizes staff visibility into the room for the adjacent corridor, and minimizes staff travel distances to the patient. There is typically less window space and the toilet area may interfere with family zone.
- “Nested" - this model places toilets for two rooms together between the rooms, allowing an open room with both large window areas and visibility from the adjacent corridor. The major drawback of this model is the exterior wall / corridor space generated by the toilets. The length of space required for a resulting patient room and toilet is longer than with the other two models, either limiting the number of beds that can be provided in a fixed unit size, or requiring a longer corridor and increased building area to accommodate a target number of beds.
A major issue for hospitals is the risk of patient falls. Disoriented, incapacitated patients are at risk of falling, particularly while accessing the toilet. This represents both a health risk to the patient (fractures, contusions, etc.), and liability to the hospital for additional care and legal risks. One design solution to this issue is the location of the patient toilets on the same wall as the headwall of the bed, sometimes including handrails to help patient access the toilet.
Another variation of these three models has emerged - the "same handed" room. The hypothesis is that by locating all staff supplies, monitors, and other equipment in the same space for all rooms there will be a reduced risk of errors in treatment and increased staff efficiency, though there is still no conclusive evidence yet in research studies. Many physicians and nurses are still trained to approach the patient on the patient’s right side, but this can be impeded by equipment or the patient’s condition. Same handed rooms reduce sound transmission through separating the headwalls and by separating the patient doorways. There is a growing interest in the importance of noise reduction on inpatient units to allow better staff concentration during important tasks and to allow patients to sleep better.
Design solutions to these requirements have resulted in some innovative solutions, with both inboard and outboard toilet configurations. One model is the "canted" rooms, as illustrated in the above diagram and offset toilet rooms (see below) to allow for more access and visibility both into the room and of exterior views..
Wishard Health / Eshkenazi Medical Center
Perhaps as important as the patient room is the design of the associated toilet area. Studies of hospital falls identify the bathroom as the most dangerous space in a hospital. Current Americans withDisability regulations require at least ten percent of the toilets to comply with ADAaccess standards. Ironically this can conflict with the efficient design of a toilet are
a for staff to access both sides of a patient to assist in seating and lifting. Another critical requirement is the accommodation of bariatric patients (people over 100 pounds overweight). Toilets to accommodate these patients need to be floor mounted to prevent collapsing from weight.
Patient toilets, Aliber "Safety Zone", Health Facilities Management, September 2012
Staff safety, particularly related to back injuries associated with lifting patients, must also be considered in the room design. Inclusion of ceiling mounted patient lifts is a concept some hospital are incorporating into new units. The alternative to this system include mobile lift systems, or “lift teams” of staff to assist a nurse. Lifts are now mandatory in some states.
The Acute Care Unit
An acute care unit is the organization of patient rooms into a manageable configuration of operational and physical systems. The size and configuration of a unit is the function of multiple factors:
- Nurse staffing ratios – the daytime staffing ratio of nurses to acute care patients in the US typically falls in a range of 4 patients per nurse to 6 patients. The exact mix depends upon the nursing model of care, the level of patient need (sometimes referred to as the acuity), and the other support staff assigned to the nursing unit.
- Management model – Florence Nightingale originally recommended that an ideal nursing unit should be no larger than 32 patients based on the nursing leadership supervision required. It is interesting that the current recommended range for nursing units falls in the 24-36 bed range.
- Travel distances – The current Facilities Guideline recommendations is for single patient bed rooms. With a patient room width of 14-16 feet, the size of a nursing unit can quickly become very large, requiring significant travel time for families, staff, and patient transport.
- Site and building configuration – Nursing units are a major design driver and form-giver for hospitals. As discussed in the master planning section of this Guide, vertical versus horizontal organizational models contribute to the configuration and size of nursing units. Additions to existing hospitals in urban or site constrained settings can present a major challenge to the achievable size.
Components that are provided in a nursing unit are determined by the programming process, the standards established by the state Authority Having Jurisdiction, the Joint Commission and other review agencies. The Facilities Guidelines Institute recommendations are a recognized baseline and code in most States. In addition to the patient bedroom and toilets, elements that are required on an acute care unit include:
- Staff charting and workstations – when medical records were paper based, access to a patient chart was a major management issue. Centralized charting areas, monitored by a unit clerk, were the common design solution. Implementation of electronic medical records has opened the design of units to more decentralized charting locations, in and outside the patient room. This is particularly useful for reducing staff travel distances. This has however not reduced the need for multi-disciplinary collaboration areas. Conferencing and education space may also be required on units especially in teaching hospitals.
- Medications- This is a frequently accessed space that is usually coupled with the Clean Storage room to reduce nurse travel. Specific requirements for this will depend upon state requirements and the method of storing and distributing medications. Many hospitals have placed frequently used medications into automated dispensing units (Pixus or Omnicell units). This area is usually locked. Sometimes medications are decentralized in locked cabinets in or just outside the patient room.
- Clean Storage/Soiled Holding– the costs associated with medical supplies makes management a major administrative responsibility. Disposable supplies frequently used in patient care should be located in or near the patient room. Back-up or costly supplies, and less frequently used items are stored in a clean supply room. Clean linens are held usually on movable carts adjacent to this room. A variation of this model is a system called a “nurse server,” a supply cabinet directly outside the patient room storing stat supplies and items used for protection from infection (gloves, masks etc.) and sometime a locked pharmacy cabinet.” One concept, developed by Gordon Friesen, provides a pass-through closet between each patient room and the adjacent corridor so it can be stocked without entering the room. Typically there is one medication, clean supply and linen cart per 12 to 16 private patient rooms to mitigate travel distances for nurses.
- Nourishment – serving meals, providing snacks and other nourishment is an important service. We will discuss overall strategies for the dietary service later in this course. A staging area for serving meals, holding soiled trays, and floor based food storage are common elements.
- Equipment storage – The FGI guidelines require at least 10 nsf per bed for general equipment storage. There is usually at least one equipment storage room per unit as well as alcoves for frequently used movable equipment.
- Family support – As hospitals move to private patient rooms with appropriate family areas, the size of the unit family waiting area is typically reduced. Outside of the patient room, there remains a need to accommodate waiting for children, overflow families, to provide a respite area, and to accommodate special family needs. Supporting functions to family waiting include toileting, family consultation, and nourishment.
- Staff lounge, break areas, administrative – Provision of support space is crucial to maintaining staff moral and efficiency. Administrative space for the nurse manager and possibly nurse educator may also be required. If two nursing units are located adjacent to each other these areas may be combined. Staff lockers are important for coats and purses but changing areas are not usually required.
- Environmental Services – including storage of supplies and equipment for cleaning rooms.
- Diagnostics / Therapy- Depending upon the patient population on units, some specialized diagnostic and physical therapy services may be provided.
Specialty units, such as pediatric care, bone marrow transplant, and epilepsy care will have additional space and equipment requirements.
Management of high risk infectious patients presents an increasingly important issue as hospital struggle with nosocomial (hospital acquired) infections, such as C-Dif, and MERSA. Isolation of infectious patients requires special, negative pressure, isolation rooms and may also require anterooms for staff to gown in protective clothing that is discarded after seeing a patient. Some patients, particularly those with immunosuppressed conditions, such as burn patients, may require protective isolation, requiring positive air pressurization in the room relative to the adjacent areas. Usually two to three negative pressure isolation rooms are required per a typical 28 – 36 bed acute care unit, though anterooms are no longer required in most states.
How do we evaluate a design? Alternative methods have been proposed over the past century. For example, in the late 1950’s John Thompson and other researchers at Yale University developed an index based on the amount of walking a nurse experienced during a shift. Different nursing unit configurations were evaluated to identify the most efficient design.
Today we recognize that there are other important criteria in addition to walking that should be included in the assessment. These include patient safety, staff visualization, staff communication capabilities and gross area per bed. In addition to evaluation of the functionality for the anticipated patient population, the long term adaptability of the unit should be factored into the design assessment.
Is bigger better?
Over the past two decades the gross area per bed on a nursing unit has grown dramatically, in large part due to the shift from semi-private rooms to private. Another factor that influences room size is the market-driven model of care, where design could be used to help differentiate a consumer’s perception of a hospital. Additional research may be required to develop methods to determine the optimal room size for a hospital based on the previously suggested criteria and on pressure to reduce capital costs.
Lean Process Improvement
New pressures for cost efficiency are driving a trend toward lean process improvement in hospitals that ultimately reduce operational and capital costs. Under the Affordable Care Act, Accountable Care Organizations, HMO’s and other care models could reduce patient choice as a site for inpatient care. Significant research has been conducted on the inpatient room environment to increase efficiency. Some lean operational changes are affecting unit design:
The Just–in-time (J.I.T.) method of material delivery onto patient units reduces the amount of inventory and requires less storage on each unit. Updated electronic tracking systems can predict utilization for levels of acuity and by diagnosis. This also includes increasingly sophisticated tracking of charges per patient through automated dispensing systems, open bin “PAR Excellence” and other bar-coding systems.
Just-in-time delivery of equipment reduces inventory of frequently used items such as IV pumps and wheelchairs. In this case, clinicians need to be assured of prompt delivery from a central location off-unit when needed. This reduces the size of equipment storerooms on units and reduces upfront equipment purchase costs.
The trend of lean planning pulls more services to the patient, instead of moving the patient to services. This includes clinical charting at the bedside, and more diagnostics in the patient room such as imaging (ultrasound and mobile X-Ray ) and lab testing.
Acuity Adaptable Patient Rooms
The creation of patient rooms that can bridge acuity levels from medical/surgical (acute) to intermediate (stepdown) to sometimes critical (intensive) care allows for the universal design of patient units so they can be used for multiple acuities at the same time, or cohorted and changed from one level to the next over time. As units rely on decentralized nursing and just-in-time delivery of supplies and equipment, the core support spaces are becoming more similar at all acuity levels. The difficulty has been staff training for multiple acuity levels. There continues to be a segregation of acuity levels at higher acuity academic tertiary centers, but community hospitals are embracing this concept, that allows patients to remain in their rooms when their conditions are either down or upgraded, with adjusted staffing levels. The key elements for design of acuity adaptable patient rooms continue to be:
The “Guidelines for Design and Construction of Health Care Facilities 2010 Edition” recognizes the need in critical care rooms to access the patient’s head by increasing the clear width of these rooms by an additional foot. So the most acuity adaptable room up to critical care standards now needs a 13 foot wide headwall as well as a 14 foot clear width to any cabinetwork on the footwall Most hospitals meet intermediate care standards at minimum. (see image below). Typically fully adaptable rooms are designed in the 280-300 NSF range with the toilet room . Kettering Soin Medical Center
Kettering Soin Medical Center
Flexible Headwall Configurations:
New headwall products from several major manufacturers allow more flexible installation and reconfiguration of medical gases, power and low voltage systems than ever before. Hospitals can choose to build in utilities to meet higher acuity standards day one, or forgo additional outlets to a later day without great penalty.
New Models of Clinical Care
The implementation of electronic medical record keeping has progressed far more slowly than anticipated at most hospitals. Many hospitals have been surprised to find that full realization not met the opening date for their new facilities, rendering them “paper-light” rather than “paper-less”. All new projects are assuming a computer workstation at every possible charting location on a unit. The major issue remaining is whether a computer workstation is located immediately adjacent to the patient bed in the room or directly outside the room; economics often dictate that both are not feasible. Some nurses prefer bedside charting, allowing them to engage with the patient, while others feel distracted by family members. It is hard to say which creates better clinical outcomes and for now, it remains based more on philosophy of care. In the future hand-held devices may replace fixed computer locations.
Open collaboration stations, centrally located between 12 -16 beds, are in favor. These stations allow for small group meetings and private charting. Hospitals still wrestle with HIPAA patient privacy compliance and noise control issues that can be mitigated by acoustical materials and electronic noise baffling systems. Many of these stations are in modular furniture systems to allow for future flexibility in reconfiguration.
Sheila F. Cahnman, “Key Considerations in Patient Room Design, 2010 ”, Healthcare Design, August 2010
Sheila F. Cahnman, “Key Considerations in Patient Room Design, Part 1 & Part 2”, Healthcare Design, April & May 2006
Aliber, Jennifer,-“Safety First,” Health Facilities Management, September 2012, pages 25-30