A combination of rapidly changing medical technology and consumer demands are compelling hospitals nationwide to take another look at how their facilities accommodate patients. Many hospitals may not be aware of the design implications that are occurring in the healthcare industry and need to realize what the long-term impact may be on space and construction budget allocations. Technology and equipment, for instance, are often changing faster than project teams can build healthcare facilities.
An integral issue is size. Even though hospitals are still treating the same diseases and injuries, more space is required today than even a few years ago. This equates to larger departments and buildings, with correspondingly higher construction costs.
According to Jeff Bills, retired president and CEO of Reno, NV-based Saint Mary's Health Network, although the 1996 Health Insurance Portability and Accountability Act (HIPPA) has provided patients with a higher level of privacy, the federal regulations have resulted in hospitals having to make extensive and expensive design changes in reception areas, patient bays, waiting rooms, and exam rooms to insure privacy.
"More space is needed to help ensure confidentiality at registration areas," Bills said. "You need to make sure that when a patient talks about an illness, injury or insurance matter, that no one walking by can hear or even see anything."
Today's emergency department is undergoing a metamorphosis, noted Eileen Whalen, Vice President, Trauma, Emergency and Perioperative Services at University Medical Center (UMC). Located in Tucson, AZ, UMC is a private, non-profit hospital associated with the University of Arizona.
Whalen said emergency departments have moved away from the open ward concept to private rooms.
"The open ward concept is outdated," she said. "Pulling a curtain doesn't satisfy federal regulations and patients today are demanding greater privacy with their care."
Whalen added that physicians and nursing staff are providing more complex procedures and treatments in the emergency room, which necessitates a greater need for infection control - and more space.
"Emergency operating rooms that a few years ago were considered 'large' at 400 square feet, are now no longer adequate for many of today's revenue-generating procedures," Whalen said.
The increasing age of nurses (Whalen said the industry average is 48) necessitates that nurses take fewer steps while taking care of patients. Decentralized nursing stations, equipment and technology help make this possible, but also create design challenges to accommodate these functionalities within regulatory boundaries. At UMC, for example, electronic order entry devices are planned for each emergency department bay so nurses don't have to leave the room to do any charting. UMC is also installing centralized carts containing universal supplies so that the nurse can 'reach and pivot' in each patient's room to reduce wear and tear on nurses.
There is a recent increase in the number of bariatric patients. Increases in room size, door size, toilet room design, and equipment selection are just some of the items requiring modification for these special patients. A study of one of Kaiser Permanente's San Diego area emergency departments showed an average of one 350-pound patient visit per week. One of Kaiser Permanente's San Diego facilities has a gurney in its emergency room that can handle a 650-pound patient and a mechanized bed for someone weighing up to 1,000 pounds. Two-person 'lift' teams have also been trained to handle heavy patients statewide at Kaiser facilities - teams are on duty from 5 a.m. to 8 p.m. to help with morning weigh-ins and to make sure patients are secure for the night. The teams handle between 30 and 35 daily lifts using specially designed equipment.
According to Jim Morrison, Director of Architecture and Construction Services at Miami Children's Hospital in Miami, FL, many hospitals are promoting "family centered care."
"We're becoming more sensitive to cultural differences," Morrison said. "In Miami, which has a large Hispanic population, patients are often visited by a lot of family members. Hospitals that cater to this demographic audience will need to increase the size of patient rooms, dining room facilities, and more, to accommodate them."
Hospitals may not need as much room for hard copy storage as they transition to electronic records, but they will require increased communications and data storage for servers, cabling trays, racks and support hangars.
Other storage issues have been affected by the 2005 National Patient Safety Goals, established by the Joint Commission on Accreditation of Healthcare Organizations. The goals promote specific improvements in patient safety (the Joint Commission evaluates and accredits more than 15,000 health care organizations and programs in the United States).
According to Whalen, at UMC, many medical supplies that were previously stored in drawers now have to be locked up. Carts have been redesigned so they can be safely locked.
"Hospitals have to find innovative ways to store portable PCs, blood pressure machines, EKG units, even gurneys and wheelchairs - you can't leave them out in a hallway," said Whalen. "They could become a patient safety and/or fire hazard."
"Hospitals will have to build rooms that come with all necessary connections and hookups - you just can't build on size alone anymore," noted Bills. "The room may have to have oxygen, certain gases, even be wired to send electronic patient information around the building."
Larger patient rooms with decentralized support systems and designed more like traditional intensive care layouts will become more commonplace. Known as the 'universal room,' it allows for treatment of critical and non-critical patients, as well as labor and delivery and recovery. The room, said Bills, can be easily reconfigured from a critical care setting, rehabilitation or typical medical surgical room.
"By not designing bed configuration for a particular disease and/or acuity category, hospitals can thus achieve greater care flexibility," he said. "Universal rooms also reduce patient transfers between rooms, which helps provide a higher level and continuity of care."
With the advancement of technologies, the size of the OR has increased dramatically. Four hundred square foot rooms once thought grand are now considered hardly usable. On top of the usual suspects, the way surgeries are performed today requires space in the OR to accommodate imaging equipment, computers and robots. Providing 800 square feet per OR is often requested. It is not unheard of to have a specialized OR (such as in interventional rooms) top 1,000 square feet.
Not only are the operating rooms growing in size, but also their support space; prep and recovery rooms, waiting rooms, storage and central processing departments. The undeniable increase in outpatient procedures has directly affected the size of the patient prep and recovery rooms. Where once a patient would recover primarily in their own hospital room, outpatients must fully recover in the main recovery room, directly affecting the required square footage for efficient operations. Space for stage II recovery and 23-hour observation units are program additions to both old and new surgical departments/centers.
The importance of maintaining patient privacy, an infection free environment, control over sound and light, as well as family involvement in care has changed the open ward style Intensive Care Unit into small clusters of private rooms. Data driven design has proven the positive benefits private rooms have on high acuity patients. Patient lengths of stay decrease and stress levels for staff and families are greatly reduced. New designs for Neonatal Intensive Care Units create private patient bays within a large room. Many current codes still allow the 80 square foot per bassinet; however the newer facilities are providing rooms up to 400 square feet per patient. In addition, advancements in life sustaining technologies require more space.
Not only are departments growing, but also the space to service them. The days of 10-foot floor-to-floor heights are long over. Providing a minimum of 15 foot floor to floor assures there will be room to locate all the building support services, such as air handlers, conduits, cables, plumbing and ductwork as well as provide the necessary space to house large imaging equipment. The structural components of the buildings are also increasing to meet the requirements of stricter building codes. Inadequate floor-to-floor heights will result in cost increases for future remodels within the facility.
Hospitals must adopt a new paradigm to remain competitive and profitable, as size does matter. Some hospitals saw these trends coming and have accommodated the needs of patients and family members. Houston-based M.D. Anderson Cancer Center has a new 400-bed inpatient tower that's full every day. Bronson Methodist Hospital in Kalamazoo, MI completed a $100 million replacement facility. Both include amenities such as healing gardens, espresso coffee shops, concierge services, caf�-style restaurants, and even business centers.
Flexibility will be paramount - specialization will be brought to the patient and all this has to reflect a new way of rethinking healthcare facility design. Hospitals will increasingly be valued on how they connect to their communities.