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19 Jun 2014
Hospitals and other healthcare facilities need not be the clinical environments to which we have all become accustomed. Building hospitals on a bedrock of evidence could improve the experience and may even have unexpected health benefits.
Everyone who has stayed in a hospital will have views on whether the environment was comforting or stressful. A good or bad physical environment – from noise levels to room layout – can even dominate the experience.
Such issues are the subject of a growing body of research that is often incorporated into the design of modern clinical care settings. Echoing the rigorous approach used to assess the effectiveness of medical care itself, this field is known as “evidence-based design”.
Some aspects of evidence-based design are highly specific and relate to the building infrastructure, such as natural lighting or views onto greenery or open landscape, all shown by multiple pieces of research to have therapeutic benefits. Other studies have shown the use of natural, rather than artificial, materials for furniture and fitments in patient rooms can induce greater comfort and wellbeing – using cotton instead of nylon, for example, or timber instead of laminates.
“Although evidence-based design in healthcare is in its infancy, there is a growing body of credible literature in the field,” says D Kirk Hamilton, Professor of Architecture and Associate Director of the Centre for Health Systems & Design at Texas A&M University and one of the world’s leading specialists in the topic.
A 2008 research literature review in the peer-reviewed, interdisciplinary Health Environments Research and Design Journal (HERD) – of which Professor Hamilton is co-editor – already included more than 1,200 study citations linking facility design to clinical outcomes. These broke down into three main areas: patient safety issues, such as infections and medical errors; other patient outcomes, such as pain and stress; and staff outcomes, such as injuries and work effectiveness.
“This does not suggest that we know nearly enough, but it confirms that the environment has an influence on human physiology, psychology, behaviour, and social interaction,” says Professor Hamilton.
Examples include the effects of artworks on patient care, he says, whether embedded in the fabric of a building or room, or temporarily applied; both inside buildings and in the grounds outside for example sculptures.
“The best projects will reserve a portion of the budget, perhaps one per cent, for artwork,” he says. “Artwork can play a significant role in stress reduction and finding your way. Art preferences and appropriateness have been studied in North America and the UK, with strong research support for representational, non-abstract pieces, especially those incorporating nature.”
A “nice” environment may be more pleasant, but deciding exactly what kind of nice environment is the best value within inevitably limited budgets is the challenge.
Professor Hamilton agrees this is an issue, but says significant improvements can always be made for relatively small amounts, or within a longer term plan.
“The cost of facilities is fairly modest and the comparison of materials on the basis of cost is sometimes a storm in a teacup,” he says. “In the US, staff costs run to about 10 times more than facilities or capital costs in a typical annual budget for a hospital and since medical equipment, mechanical systems and interest expense make up the majority of the capital cost, the decision about plastic laminate versus impervious solid material, or vinyl flooring versus terrazzo is more minor than it seems.”
A bigger problem in financing evidence-based design is a prevailing mentality among those commissioning facilities of focusing on “first cost” – and trying to reduce it – without paying enough attention to lifetime cost, Professor Hamilton says. Another problem is a standard accounting procedure that separates operating cost from capital cost, encouraging funders to cut capital cost even when a design change can be shown to save operating cost.
Ian Tempest, director of healthcare at Atkins, agrees that design costs must be looked at in as broad a way as possible and over the long term.
“This is not just about aesthetics, nor is it necessarily more expensive at any stage – you’re saving money in the long term by shortening patient stays and cutting re-admission,” Tempest says. “There is always a balance to be achieved: sometimes it is difficult to select a natural product that is going to provide the hard-wearing characteristics you need in a care environment while withstanding the necessarily aggressive cleaning regimes. Natural wood may not always be a robust enough material for surfaces, for example. It needs to be assessed case by case and weighed up against specific use.”
One major design issue for modern healthcare facilities is the balance between single-bed rooms and multi-bed ward accommodation. Here too, there is growing base of evidence to inform design decisions, showing for example that benefits of single-bed accommodation include reducing the risk of infection between patients.
“There is clear evidence that infection can be more effectively managed where patients are in single-bed accommodation,” Tempest says. “In one UK hospital where there was an outbreak of a winter vomiting virus in 2013, there were a number of four-bed rooms where there was only one patient affected, but all beds had to be deep cleaned as consequence. In all, 24 beds were taken out of service, even though there was only one patient affected in each room. Had single-bed accommodation been available, the hospital would have only lost six beds.”
Research also supports the view that patients are better cared for by clinical and nursing staff in single-bed accommodation, with fewer errors made when administering medication, for example. It has even been found that cleaning and facilities management staff take better care of single bed accommodation, because they seem to have a greater affinity with the patients occupying each room.
Official guidelines vary, even across the UK: while the Scottish Government has stipulated that all new government-funded acute healthcare facilities should provide all in-patient accommodation in single-bed rooms, NHS England has recommended only at least 50 per cent must be single-bed; and the Welsh and Northern Ireland Assemblies have expressed a preference that 80 per cent of patients are accommodated in single rooms.
This demonstrates why designers and architects should look at evidence for each decision they make, based on similar projects, as the optimal level may vary by type of facility, Tempest says.
“My view is that 80 per cent is probably about the appropriate level,” he says. “ In some circumstances, there may be some disadvantages to single beds for some patients: some elderly patients feel isolated in their own rooms and their health may deteriorate because they miss the social interaction of a multi-bed ward.
“Paediatric patients – children and young people – can also feel too isolated in single bed rooms and they similarly prefer the company of others of comparable ages. In my opinion, the optimum is about 80 per cent single-bed accommodation, with the remaining 20 per cent used primarily by younger and older patients.”
Sometimes, research findings can be surprising in terms of the effect of design on health outcomes, and show that architects must look beyond the patients themselves, says Professor Hamilton. For example, one study found that heart surgery patients who have strong social support while in hospital survive longer after they leave, than those who did not have support in hospital.
“This could mean that designers need to provide space and accommodation for family members in cardiac surgery facilities to give the patients their best opportunity for survival,” says Professor Hamilton. “Interestingly, the findings are similar to those in several other clinical specialties.”
Poor design can also have a significant impact on the effectiveness and wellbeing of staff, as well as patients – which could then also filter through to poorer patient care.
Diana Anderson, resident physician at the New York-Presbyterian Hospital, said in a 2103 BMJ Careers article co-written with Professor Hamilton that her workplace setting had almost deterred her from continuing her career: “A large part of my hesitation in pursuing advanced clinical training was because of what I considered an intolerable hospital setting. Staff facilities are frequently without windows or art, and I have found myself desperately anticipating the first ray of sunlight after a long shift.”
Overall, given the growing amount of evidence for the healthcare benefits of better design, has it become mainstream thinking in the world of healthcare architecture?
“There is a growing recognition of the evidence-based design process among the design community, especially in the healthcare industry,” says Professor Hamilton.
What can be more critical, however, is the level of awareness of these issues among the clients – hospital authorities and managers commissioning new buildings – who have rarely been provided with enough information to ensure they will properly support an evidence-based process, he says.
But even here, progress is being made. Professor Hamilton tells of one instance when an architect colleague was explaining to the chief executive of a hospital how making decisions based on the best available evidence would lead to better practice in future, to which the response came back: “Good Lord! How were you doing it before?”
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