Hospital Design

The bed cluster concept

When hospitals group patient rooms into small clusters, nurses have more time for their patients. But the design of these ‘bed clusters’ is important.

This has emerged from a new report from hospital researchers at SINTEF, a large Scandinavian independent, non-commercial research organisation. The ‘bed cluster concept’ can have different configurations, but it means that patient rooms are grouped into clusters, with workstations for the nursing staff attached to each group. Shorter walking distances make it easier for the nurses to keep an eye on patients, prevent undesirable incidents and give them more time to care for patients.

The researchers have reviewed literature and conducted interviews with nursing staff and managers at three of the hospitals using the concept. They compared and analysed existing hospitals and planned hospital projects.

Less walking time

Bed clusters are in widespread use in Norway’s newer hospitals. St Olav’s Hospital, Ringerike Hospital, Stavanger Hospital and the new Ahus have these clusters. Internationally too, the trend is towards clusters and ‘bed courtyards’, and countries like the USA, UK, Sweden, Denmark and Latvia use them extensively. The thinking behind this concept is that in the future there will be more patients and sicker patients, and that when nurses are closer to their patients, they can monitor them better.

The old ward design consisted of 20 or 30 rooms off a long corridor (or a double corridor). There was a nurses’ room in the middle, and bed linen, sluice rooms, etc. were located in a central area or distributed between the rooms.

In the bed cluster model, the rooms are grouped into a ‘courtyard’, with beds in seven to nine rooms, and the old nurses’ room has been replaced by three decentralised workstations. Shared ‘support rooms’ (sluice rooms, conference rooms) are positioned between the various bed clusters, with stores for bed linen and consumables integrated into each cluster.

The researchers have found that a decentralised configuration saves the staff from enormous amounts of unnecessary walking along corridors. The environment becomes calmer, and the role of the nursing staff changes: part of what kept the nurses so busy before was walking to and fro to patients and to fetch equipment, but now the time they save can be devoted to patient care.

Several clusters in series is best

“What all the models have in common is a decentralised nurses’ area, and bed areas divided into small groups, but their configuration and the way they are used are different. It is this effect we have been studying,” says hospital researcher Marte Lauvsnes at SINTEF Technology and Society.

“A hospital like St Olav’s in Trondheim has configured the bed clusters in the new centres in several different ways. One area has three clusters in series. Another is built in short wings that put two clusters next to each other, while a third is separate. The final configuration was dictated by building area constraints, and the solution is clearly not as good as when the clusters are arranged in series.”

No social arena

The nursing staff find that the new organisational model means that they are alone more than they used to be. Since they now each work with fewer patients, and as there are often only two or three nurses on duty in a cluster during the day, they do not come into contact with their other colleagues as much. The hospitals vary in terms of the kind of support rooms they provide for professional discussions and social interaction, and this has an impact on nurses’ job satisfaction and sense of community.

During night shifts, there may only be one nurse on duty per cluster, but if the clusters are arranged like ‘pearls on a necklace’, this still allows nurses to come into contact with each other, and to talk and work together.

“The design of the buildings must take into account the fact that individual nurses must have a sense of ownership of their ward as a whole, and not just of their small unit. Social arenas for the staff must also be considered,” says Lauvsnes.

Building with activities in mind

The hospital researchers at SINTEF conclude that if a bed cluster model is chosen, this must be decided at an early stage in the building planning process.

“The concept planning phase of a medical building has become more important than ever,” says Lauvsnes. If a site is found at an early stage, and a proposal based on that site prepared before activities and the concept have been described, this limits the options for good solutions and effective operation.

She said billions are invested in hospitals, but no money is spent on evaluating how the design of the building affects operation.

The researchers think that the traditional corridor system, with rooms designed for several patients is the worst with the future in mind. It makes poor use of capacity and space, and also makes nurses less efficient in their daily work. From a patient’s perspective, a combination of single rooms and bed clusters provides the highest quality, by increasing safety, reducing noise, minimising the risk of undesirable incidents and giving them the best access to nursing staff.

Natural gardens promote healing in hospitals

The design and landscaping of hospital green areas in accordance with the needs of patients, staff and doctors can have a health-promoting effect. These are the key findings of a study by the MedUni Vienna, led by Renata Cervinka from the Institute for Environmental Hygiene at the Centre for Public Health. Involved in the study were the representatives of three hospitals in Lower Austria, whose local hospital gardens were the subject of an environmental psychological and free space planning analysis. A further result of the study: “The more natural the garden, the greater the experience,” says Cervinka.

“The gardens and green spaces of a hospital should be regarded as a counterbalance to the hospital itself,” explains the environmental and health psychologist.

“The garden is perceived as a natural contrast to the hospital – it serves as a place of sanctuary and recuperation.” This is also confirmed by the study: green, very natural landscaped gardens came closest to the ideal hospital garden imagined by the 411 potential patients who were surveyed anonymously on the web. This result also echoes the findings of earlier studies: as far back as 1984, Roger Ulrich discovered that a view from the hospital room overlooking green spaces has more of a “healing” effect than a view of a concrete wall. Patients with a view of green space spent less time in the hospital, were generally more happy with their care and required less pain-relieving medication.

Three minutes in the garden

“Deep breathing in a green space for just three minutes can have a positive effect,” says study co-author Kathrin Rödere. “The smoking break is firmly entrenched in modern life, however the 'mental' break isn't, unfortunately.”

This break has even more impact the more the gardens and places of sanctuary are tailored to the needs of their users.

“At a general hospital, for example, where patients do not stay for very long, even a view of the appropriately-landscaped green space can have a healthpromoting effect. For other groups, such as patients undergoing orthopaedic rehabilitation, it is more important that the gardens can also be enjoyed while using walking aids, for example. Longterm patients, such as geriatric or psychiatric patients, particularly benefit from activities involving gardening.”

The authors also recommend separate green areas for hospital personnel that are private from the patients.

“The proven therapeutic effect should also counteract the trend towards regarding green spaces as purely places of rest or potential building plots,” says Cervinka. “The value of nature is incalculable. Its worth is priceless.” With this in mind, the study authors also point out how crucial it is to preserve large, old trees when carrying out extensions and conversions: “Trees have a very important role to play in recovering from stress and in mental health. They are easily felled. However they take a long time to grow.”

On the basis of the study findings, a checklist has been developed that can be used to create the ideal design for hospital gardens – with the aim of lifting the mood of their users, promoting their wellbeing and increasing the gardens’ proximity to nature.

Reference: Cervinka, R., Röderer, K., Hämmerle, I., & Hemmelmeier-Händel, B. (2012). From open and green space at hospitals to healing gardens? Transdisciplinary assessment and recommendations for (re)design. Case study presented at the 22nd IAPS Conference, June 25-29, Glasgow, UK.


Designing a healthier hospital

How do you integrate state-of-the-art medicine into the planning process of a new hospital? One key is to include people who can translate the concepts of healthcare needs into design, according to George R. Tingwald, MD, AIA, a general surgeon and director of medical planning at Stanford Hospital & Clinics in Palo Alto, California, USA. Before joining Stanford in 2007, Tingwald was director of health and science at Skidmore, Owings & Merrill LLP, one of the world’s largest architectural firms. He is one of only a handful of experts with credentials in both medicine and architecture.

Good design is not just about appearances, especially when it comes to healthcare facilities. It affects workflow and protocols, and research shows that good design influences patient outcomes, controls infection rates, and reduces medical errors. The social, psychological, and environmental aspects of a patient’s experience come from design that is both universal and flexible.

The challenge is in translating what a medical institution requires into architecture, since the two entities do not necessarily speak the same language. A nurse might say I need more storage space; the architect will make a list of every piece of inventory to calculate just how that space will need to be configured.

In planning a new hospital, since technology is changing in unpredictable ways, it’s important to focus on what doesn’t change, which is human nature. Patients and visitors form their impressions of quality very quickly – what I call surrogate evidence. They cannot really fathom or see the most complex aspects of what takes place in a hospital, so they focus on what they can understand and see.

Hospitals can learn a lot from the hospitality industry: within minutes of entering a hotel lobby a visitor gets a sense of the overall experience. If you control the quality of their first impression you set the overall standard of quality. Does it feel safe? Is it easy to get around? Good design makes areas of potential anxiety orderly and calming. Natural light, graphics, well-maintained landscaping all need to be part of the planning process.

The design must be based on a universal grid, which allows you to respond to changes in technology, traffic, and acuity. This concept of universal design applies to patient rooms as well as exam rooms and office space.

It also applies to operating and procedure rooms, what we refer to now as interventional platforms. Whether its surgery, imaging, or catheterization, the process of pre-op, operation, and post-op is the pretty much the same, so designing suites that can handle any sort of complex procedure provides flexibility for needs and demands. It makes a huge difference in how a hospital can respond to change. A modular approach – with engineering infrastructure – should allow a hospital to remain viable for the next 50 years.

Another important concept in universal design is ensuring that patient rooms are standardized but adaptable enough to accommodate different levels of acuity. Rather than moving the patient, the room converts to the patient’s needs, which saves a great deal of time. They are also designed for the family, which recognizes the powerful role a family plays as caregiver. By being part of the daily experience, the family can become the patient’s advocate and often means that the patient has fewer complications and can go home sooner.

All rooms are private, which eliminates the need to pair patients by age, gender, and medical condition, and rematch them as their acuity changes. We found that 40 percent of nurses’ time was spent in moving patients, which is when the patient is most vulnerable in terms of medical errors and falls.

We also found with private rooms we could raise our average occupancy rates from 75 80 percent to 90 95 percent: That difference makes up for the added costs of construction in a few years. In this case, what’s best for the patient is also best economically for the institution.

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 Date of upload: 20th Nov 2012


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