A successful project is the coming together of the Holy Trinity of Design: a smart project solution, smarter designers, and the smartest client. Clients need to be aware of their expectations… . A designer and solution will only be as good as the input they respond to.
This chapter is aimed at hospital MDs and nurses, as well as to healthcare managers, to outline what they can and should ask hospital designers regarding the best physical environment for the best outcome, and the best-value-for-money in terms of global costs.
The chapter is also for architects and engineers (“designers” in the following) to give basic hints to the needs and requests of both carers and elderly surgical patients, whose experiences can convey key knowledge for successful plans and projects.
Keeping the focus on the geriatric surgical patient, integrations and additions to adult hospitals will be analyzed here, as important knowledge and many qualified handbooks exist regarding general hospital design, but only scarce literature is found on geriatric hospitals, while no specific evidence is available regarding elderly surgical facilities.
Design for Geriatric Surgeries
Traditionally, hospital design is focused on medically managing illness states, and the environment is designed for rapid and effective care delivery; this is perfectly acceptable for adults. At the beginning of this century, light was shed on the urgency of redesigning hospitals to address the care needs of the elderly:
So, design is deemed to take into account:
the new care needs for the elderly just emphasized
the risks to which these specific patients are exposed (specific for elderly surgery and non-specific for elderly surgery, but specific for geriatric patients) (see Chapter 47)
the not-so-new concepts that:
any healthcare facility should “revolve around” patients, limiting patients’ wandering
clinical and physical pathways should cross each other as little as possible, and not at all whenever possible
The opportunities to put into service a suitable elderly surgical facility can arise from a wide range of situations:
rehabilitation of an existing hospital
dedicated elderly hospital
general hospital hosting elderly care units
different degrees of updating requested (in case of rehabilitation)
possible combinations of such cases.
If designing and building a new facility is a complex process, rehabilitation processes are even more so, because adequate performance levels have to be obtained, starting from existing, sometimes unyielding constraints. Actually, the structure of planned projects depends on policies, building culture, basic situations and resources of different countries, and of different areas in the same country.
Functions and Spaces
Spaces should be conceived, organized and equipped to deploy functions enabling:
MDs and nurses to:
implement the basic care steps and sub-steps (preoperative evaluation, preparation to surgery, intraoperative management, and postoperative care) dealt with throughout this book, fo both inpatients and outpatients
perform adequate patient surveillance
have core services available (see Figure 46.1)
have general services available
enter, move around, be cared for and rehabilitated, and finally exit the facility, as safely and comfortably as possible, managing the typical risks (delirium, falls) and discomforts (disturbing noises, scarce thermal well-being, compromised privacy) of elderly hospitalization
live the experience of hospitalization in terms of a respectful approach and not-too-frequent movement between departments.
Consequently, the following should be planned:
five functional macro-areas, organized into sub-areas:
– for inpatients (ward)
– for outpatients (day surgery)
preparation for surgery
– for inpatients (ward)
– for outpatients (day surgery)
the macro-areas should be separate, but integrated and as compact as possible, in order to:
minimize carer/patient walking, and material/meal handling times
require minimum surveillance personnel
preparation for surgery, intraoperative management and early postoperative recovery (PACU) areas should be adjacent, to optimize the work of anesthesiologists, anesthesia nurses and staff in general.
In Figure 46.1, a functional chart briefly represents the concepts above, where the overlapping areas indicate that the function is split into separate areas pertaining to inpatient and outpatient pathways.
Later in this chapter, the macro-areas above will be discussed, referring to Figures 46.1 and 46.2, in order to criss-cross and match their sub-areas with the activities specified in this book. The insertion in Figure 46.2 of cross-references to chapter numbers is also intended as a guide to navigate across the book.
Figure 46.2 Functional chart of spaces, pathways and reciprocal function interactions of a geriatric surgery facility.
No numerical values are reported in this chapter because they cannot be abstractly defined; their definition is in fact the first task of designers when developing the preliminary design of a specific project, in consultation with healthcare staff and managers, with reference to reported and future literature, and in function of boundary conditions and state-of-the-art medicine.
Defining the needs of the final users, whoever they are, is an evolving topic, depending on sensibilities, understanding and empathy in the culture of a society. In this section, a basic set is analyzed, associated with tenets aimed at satisfying the corresponding critical requirements.
The needs listed in the following should be considered as a non-exhaustive checklist, to be integrated case by case.
Chapter 47 is specifically dedicated to risk analysis from a methodological point of view; it investigates and reports on safety issues in general, and three main sources of severe inconvenience are pinpointed: falls, delirium and nosocomial infections. All in all, such issues are addressed by clinical or hygiene measures, which must be accompanied by proper design choices and provisions regarding construction, equipment, furnishing and even small supporting details, with the aim of maintaining or improving patient conditions.
The overview in Table 46.1 provides a keyword description of the foremost design cautions and provisions, and their effects on risks run by patients and carers, as well as on their comfort and attitudes.
Delirium is one of the most complex clinical issues for elderly surgical patients. In Chapters 14 and 38, predisposing and precipitating factors are examined, with evidence that this state may be triggered and/or aggravated by environmental conditions, such as loss of time/space orientation (Parke and Friesen 2015), and noise and disturbances (Chun et al. 2011, Patel et al. 2014).
Spaces and their connections, colors, furniture, complementary equipment, even if of minor importance, can prevent unnecessary risks of disorientation.
Where the function of a space is clear, people intuitively know how to behave in it; this is a primary method for both space orientation and wayfinding needs (Marquardt and Viehweger 2014).
As age increases sensory losses, any orientation cues can help to compensate for them (Jenkins et al. 2015); these may be obtained in ways usually intentionally avoided in design, e.g., singularity, oddness and asymmetry.
Solid colors on walls may be made more pleasing by placing non-repetitive, obviously different pictures, while supporting orientation and wayfinding (Marquardt and Viehweger 2014).
Different colors from space to space and room to room should be specified to help in finding the right place; similarly, to reduce unwanted use of doors, background color “camouflage” may be adopted (Lindquist et al. 2013).
Color- and image-coded directional signage should be studied and specified (Ulrich et al. 2004); color-coded tracks are useful only if accurate maintenance can be assured; standardization activities in this regard would be desirable by ISO or other institutions.
Disorientation risks should be considered whenever specifying opaque automatic doors, and opaque doors in general (Parke and Friesen 2015).
To prevent time disorientation, large-faced clocks, oversized calendars, careful, non-intrusive vocal messages or other means should be specified; any accessible space should be equipped with such orientation tools, also visible, of course, from hospital beds (see Chapters 14 and 38); LCD screens connected to computerized systems are becoming affordable solutions beneficial for their flexibility (analogic clocks can be simulated; the names of carers and family physicians can be reinforced); with the same aim, visually impaired patients should be able to receive voice messages from the same system via earplugs and/or small discreet speakers.
There is evidence that the proper music can be beneficial in delirium prevention and stress reduction in rooms, ICUs (Chaudhury et al. 2005) and delirium rooms; wifi devices (more flexible than a wired system) can be properly programmed by parents or carers.
Space and time orientation is helped by large windows with views to the outside, where possible, of identifiable features or landmarks (Reiling et al. 2008); however, care should be taken because direct natural light may be harsh, and blinding glare – “simply uncomfortable” for a person – can completely disorient a border-line delirious or demented patient, increasing the risks of delirium and falls (Lindquist et al. 2013); indirect light may have positive effects, although there is evidence of both pros and cons.
The effect of daylight and windows seems to be particularly important in intensive care units, where patients are more vulnerable and staff more susceptible to stress (Thompson et al. 2012, Caruso et al. 2014); should it be impossible to achieve this, artificial simulation of the circadian rhythm via large LCD screens or better LCD projectors has been shown to be beneficial for both patients and carers (Pechacek et al. 2008).
Fall precautions constitute the basics of patient safety, as many patients may be frail and/or suffer from loss of balance.
Tenets of Fall Prevention
Having clear functions for spaces has the overall effect of reducing wandering, and consequently the probability of injury (Marquardt and Viehweger 2014)
on both sides of stairs and walkways
wherever patient access/stay is planned (rooms, bathrooms, offices)
and even just where access is possible.
Floor surfaces should be neither too rough (no tripping) nor too smooth (no slipping); low-pile carpeting is reputedly preferable to hard surfaces (minimizes glare and noise) as far as not impeding patient and wheelchair mobility; hard surfaces should be kept clean and dry, and spills quickly removed (Chun et al. 2011); wet areas should be effectively confined, not just by signs.
Single rooms reduce the risk of falls, while meeting other requirements (see delirium prevention, privacy, communication) (Chaudhury et al. 2005)
Uncluttered hallways and spaces are a consequence of proper design and use (AHRQ 2013).
Elevated toilet seats and bariatric toilets should be always provided (ACEM 2014)
Handles and levers should (Ghatak 2016):
be smooth to the touch
have a positive action
be operated without physical exertion
move the way patients expect them to.
Patients should not be required to reach up or across, or bend down, and the height of objects they need to manipulate should be consequently assured (Lindquist et al. 2013)
Steps should be explicitly avoided, even in the toilet areas (Parke and Friesen 2015).
Seating design should consider difficulties in moving from a standing to a seated position and vice versa; good support for the seated body should be assured (Chun et al. 2011).
A different approach should be adopted when patients are to be kept under control without using “classical” restraints that might provoke worsening of delirium; seats in such cases are used as tools for “restraint without restraint,” designed to keep patients comfortably seated, while the seat shape and inclination prevents patients from getting up. This solution occurs, for instance, in delirium rooms (see below).
Detailed measures about bed falls are discussed in Chapter 47 where interactions among risks are considered.
As an example, even commodes can have a role in fall prevention; they are not acceptable (Lindquist et al. 2013) per se, but – where used – they should have soft, padded seats and, be tilted slightly backward; this will prevent patient falls as well as reducing the physical exertion of carers (Parke and Friesen 2015).
Noise and disturbance determine discomfort, can be a prelude to bad sleeping (Watson et al. 2012), and decisively favor the occurrence of delirium.
Acoustic insulation (soundproofing), acoustic absorption (low back reflection of incident sound striking a material) and low-noise equipment (AIA 2001) should be provided at levels considerably lower than suggested in hospital design manuals.
Flooring plays an important role in sound emission (impacts) and sound reflection, and the texture of flooring is also is related to fall risks and orientation (Ulrich et al. 2004).
Single rooms are often discarded for presumed cost reasons and sometimes in the name of “socialization”; however, they are evidence-based measures – in wards as well as in ICUs (Chaudhury et al. 2005) – with globally positive impacts on many relevant risks, such as:
stress and depression.
privacy and personal dignity, overcoming discomfort
communication with carers
efficiency of carers actions
exchanges with family and friends, allowing them to participate actively in the recovery process
reduction of medical and medication errors.
When single rooms are impossible to design – in rehabilitation cases with unyielding constraints – at least privacy curtains should be adopted in rooms and ICUs.
Tenet Related to Delirium Treatment: Delirium Rooms
When delirium occurs despite prevention measures (see Chapter 38), a specific space, named a “delirium room,” is proved highly beneficial (Flaherty et al. 2015). Instead of medications and physical restraints, a nurse-managed delirium room (DR) provides an environment free of physical restraints, where the T-A-DA method is applied (Tolerate, Anticipate, and Don’t Agitate) (Flaherty 2011) with the technical support of light, music and furniture to create a controlled multisensory environment (MSE). An MSE is a dedicated space designed to insulate from noise and to control space and lighting, to create an artificial environment through multisensory equipment. This induces in patients a perception of quiet and well-being, while specifically designed sofas force/accommodate persons into a fetal position favoring sleep. Flaherty reports that DRs can decrease the negative outcomes of delirium and reduce the frequency of in-hospital falls virtually to the same levels as for patients with no delirium.
Risk of Unease
Unease about devices and technology may be, at least today, but possibly not in the future, a stigma of elderly patients. Unease can lead to confusion and confusion to delirium. Tenets are:
easy-to-understand, correct positioning of switches and controls
avoid excessive redundancy (e.g., nightstand, central and wall light switches and electric curtains, etc.)
avoid hospital automation, unless really error-proof (e.g., no timer- or motion-detector-operated bathroom lights).
Continuity with domestic lifestyle and habits is an important factor in delirium prevention (see Chapter 38). Difficult as it may be to manage (organization, fair use), the adoption of family bedrooms is suggested (Thompson et al. 2012).
Surfaces like shelves, tables or supports should be accessible to hold domestic items (pictures of relatives or pets, favorite ornaments or religious items, etc.). An interesting idea is to make available to patients about to be discharged, a monitored mini-apartment, equipped with gas cooker, cooking utensils, bedroom and toilet where he/she can live and be rehabilitated to everyday life.