Tag: evidence-based healthcare design

By: Brooke A. Karlsen, MSN, BSN, RN, NEA-BC

Maternal care was an early clinical interest for me and this interest inspired me to pursue nursing so many years ago. As a student in the certificate program in Leadership and Innovation in Health + Design at Clemson University, I am enjoying studying the connections between healthcare policy, nursing and the design of the built environment. Last semester, I had the opportunity to undertake research on an area of public health policy and explore its connection to the built environment. I chose to study maternal mortality and morbidity and its relationship to the design of the built environment. In conducting the research, I was saddened to see the trends in the U.S. and feel called to do what I can in my new career, blending my extensive experience in healthcare with planning, design and construction to make a difference through the built environment.

I learned that the maternal mortality rate in the U.S. has risen consistently since data collection began from 7.2 deaths per 100,000 in 1987 to 17.3 in 2017. The maternal death rate exceeds that of 40 other countries and the U.S. is one of only eight countries worldwide and the only developed nation where maternal mortality has actually increased over the past three decades. Additionally, for every maternal death there are estimated to be 70 cases of severe morbidity, and many more near misses that are not quantified. With up to 60% of maternal deaths being categorized as preventable, there has been heightened interest in the clinician, patient and institutional factors that contribute to poor maternal outcomes, and to identify potential areas for intervention.

While there is a large body of literature outside of obstetrics linking care environment with patient outcomes, there is limited research on the impact of the physical environment of obstetric care on maternal morbidity and mortality. What I did learn from the limited research found on birth environments, is that there are three important built environment themes which promote normal physiological birth processes, influence the need for medical interventions, and effect cesarean section rates. The three areas that architects, clinicians and healthcare administrators should consider for design and research in birth settings are the overall aesthetics of maternal care environments, the design of the birth room as well as unit layout and design. These influences, in turn, impact maternal mortality and morbidity, both directly and indirectly.

Aesthetics

The overall aesthetics of the birth experience are important in helping to avoid triggering a fear cascade in the laboring woman, which is known to affect the birth processes by disrupting the normal physiological hormonal response in labor. The aesthetics of the space are extremely important and include all the areas the woman will encounter throughout hospitalization, and should be designed to promote relaxation. Included are the use of warm colors, textured surfaces, a homelike look for furnishings and fabrics as well as the use of soft lighting, natural light, and views of nature. Artwork, posters or symbols using the female archetype, located in strategic places in birth rooms or the unit where the laboring woman might walk, have been shown to be calming and helping to decrease stress.

Birth Room

The birth room contributes to the normal physiological processes of labor. Labor progressing naturally on its own lessens the need for medical interventions. In addition to the birth room aesthetics, birth rooms must have the essential technical equipment such as fetal monitoring capabilities and neonatal care equipment immediately available. However, for some, its’ presence might trigger anxiety or fear, so housing it in concealed cabinetry unless needed is recommended. Similarly, access to emergency supplies in the room is essential to prevent delays in necessary care, but like other technical equipment, should be concealed whenever possible. Another aspect that can trigger the fear cascade is lack of privacy. The spatial filter, which is the interface between the public corridor and the room itself, is a design element to consider. Privacy curtains, half walls, or doors angled in a way that protects the inside of the room from view from the hallway can be utilized to enhance the sense of privacy.

Features of the birth room layout contribute to the normal physical mechanisms of labor. The room’s size, shape and layout configuration should allow for flexibility to change the room for the different phases of labor and to facilitate the woman utilizing the space in a way most comfortable for her. The laboring woman needs to be able to move around and assume varied positions, so having space for optimal equipment such as birthing stools, bean bags, gym mats, wall bars, along with accessible bathrooms with showers and birthing tub is necessary. The amount of time the woman spends lying in bed impacts the progression of labor (less being better), therefore, the ability to easily move the bed out of the way should be factored into the design. Because continuous labor support is linked to successful outcomes of labor, having sufficient space in the labor room for the supporter and their belongings should be prioritized. Lighting and temperature of the rooms should be capable of being controlled by the woman and or her supporter.

Unit Layout/Design

Beyond the spaces that the laboring woman encounters during the birth process, the overall unit layout has important implications for minimizing morbidity. Because obstetric hemorrhage is a leading cause of maternal death and morbidity, managing hemorrhage requires ready access to life-saving equipment, medications and blood products. In particular, birth units should regularly reassess current practices, logistics, and locations of blood products relative to where they might be needed. At “baseline” blood storage be in the same building as the labor unit, but a “better” practice would be storage on the same floor, and “best” practice would be storage of blood product right outside the cesarean section operating room.

Additional insight into the importance of unit layout emerged from the Ariadne Lab and Mass Design Group’s exploratory study linking facility design with cesarean section rates. High cesarean rates having been identified as a key factor in the increasing maternal morbidity and mortality rates. They concluded that more deliveries per labor room, fewer labor rooms per operating room, higher ratio of overflow beds to labor rooms, longer distances between spaces, proximity of on-call rooms, and lower percent of support areas designated as collaborative spaces, were all associated with higher cesarean delivery rates. Limited unit or facility capacity, high workload, and limited accountability for decision–making all contribute to the clinical decision to perform a cesarean section. Normal vaginal delivery is both space and clinical resource-intensive, whereas a cesarean delivery requires only a few hours of clinical attention. When under pressure to make more space for incoming patients, or in times of staffing shortages, a decision point of whether to continue to attempt vaginal delivery or expedite things by performing a cesarean birth is reached. Thus, design elements can play a significant role in that decision.

Conclusion

Despite the limited number of robust studies on the built environment for labor and delivery, the research that exists supports the essential role of the built environment in promoting physiologic labor processes and reducing maternal morbidity and mortality. These initial studies provide some direction for healthcare planners and designers. However, further research is much needed! Looking to the practices and processes from other countries who have succeeded in reducing the alarming mortality and morbidity rates should also be pursued.

by Anjali Joseph

I started my work in healthcare design research more than 16 years ago as a doctoral student at Georgia Tech working with Dr. Craig Zimring on synthesizing the literature on evidence-based healthcare design. This literature review and its follow up study published in 2008 clearly showed that the built environment of healthcare settings mattered in terms of improving patient safety, healthcare quality and patient experience. However, it also highlighted the complexity involved in studying healthcare environments and the difficulty in isolating the impacts of single built environment features from other factors such as patient characteristics, staffing and organizational factors. Over the years, I have come to realize that while it is important to conduct research focused around single built environment variables (e.g. light levels, door width) and healthcare outcomes (e.g. patient falls), it is perhaps even more critical to study and design healthcare physical environments as part of a larger work system. This is particularly true in high-risk patient care environments such as patient rooms, operating rooms and exam rooms that involve complex interactions between individuals, teams, tools and technology and the space where care is provided.

Existing frameworks in the health systems and human factors world recognize the physical environment as one of the components of the healthcare work system that impact healthcare processes and outcomes. These models such as the Swiss Cheese Model and the Systems Engineering Initiative for Patient Safety (SEIPS) framework suggest that the onus for providing safe patient care does not solely rest with the clinicians that interact with the patient. Rather, well-designed work systems are critical for achieving safe patient care. The work system as described by the SEIPS framework and others includes the physical environment, the people (patient, staff, families), the tasks performed, the tools and technology used as well as the organizational policies, that dynamically interact with each other over time to shape care delivery and healthcare outcomes.

While these models recognize the built environment as a system component, the physical environment is usually considered a given, hard to change, even while recognized as a significant barrier to care. Human factors researchers often focus on studying individual and team level interventions such as tools to support communication, or device and interface design to support physical and cognitive ergonomics, improve usability and reduce error. This body of research and practice recognizes the role of the physical environment in supporting healthcare work, but the interactions between the physical environment and other elements such as technology are understudied. For example, for one of our projects at the Center for Health Facilities Design and Testing focusing on integrating computer workstations in preoperative exam rooms, we found that while there were studies and tools around the physical ergonomics of the workstation itself and computer interface design, there was a lack of information about how these workstations should be integrated into the physical space of the exam room to support workflows and communication between clinicians, patients and families. This led us to develop an ergonomic assessment tool that focused on the integration of the workstation within the physical space. Similarly, several studies have identified clutter, crowding and noise as significant environmental challenges in operating rooms. However, we found that information on how the operating room physical environment layout and design supported the work of nurses, surgeons and anesthesia teams in ORs was lacking. This led to a multi-year collaboration as part of an Agency for Healthcare Research and Quality (AHRQ) funded patient safety learning lab on safe OR design resulting in a deep understanding of the OR work system, design of a new OR prototype and Safe OR design tool and implementation of our work in two ambulatory surgery centers.

It is challenging for healthcare architects and researchers to study complex healthcare work systems – they are difficult to access and observe, with a steep learning curve involved in understanding and interpreting what is observed. In this context, simulation-based evaluation of physical mock-ups are extremely helpful in obtaining input on work system performance. These evaluations engage frontline clinicians by asking them to simulate clinical tasks in typical and high-risk patient care scenarios using different equipment and technology. This allows staff to experience proposed designs within the context of their everyday work and identify physical environment features that pose challenges. For example, as part of the design process for a new 400-bed children’s hospital, the team at Children’s Healthcare of Atlanta built out a large warehouse with physical mock-ups for 11 clinical areas and conducted three rounds of simulation-based evaluations with more than 154 clinical staff. These evaluations focused on understanding the performance of the work system, resulted in significant design changes to address the 190 workflow and patient safety challenges identified. This project also highlights the importance of collaborating with clinicians, human factors and simulation experts in healthcare facilities to study and design these complex work systems.

A poorly designed healthcare work environment will create barriers to safe care every single day, while a well-designed and flexible physical environment can support the inherent variability of healthcare work. The healthcare facility design process for new buildings or renovations can be viewed as the design of multiple interconnected work systems at different spatial scales. These work systems will shape healthcare work and patient safety for years to come. It is important that healthcare design teams approach facility design projects from a health systems perspective, actively incorporating feedback from front-line staff using approaches such as simulation-based evaluation of physical or virtual mock-ups that allow the interactions between physical space, people, tasks and technology to be understood. Similarly, it is critical that healthcare organizations commit to incorporating questions and approaches related to the physical environment into all of their patient safety initiatives. The physical environment is a critical tool in the quality improvement and patient safety toolbox that is yet to be utilized to its full potential.