# Presentation: 666114

##      Evidence-Based Design for Safety and Quality

**Roger S. Ulrich, Ph.D.**

- Center for Health Systems and Design
- Colleges of Architecture and Medicine
- Texas A&M University

## Many designs make hospitals riskier for patients, families & staff

**More evidence than expected: ****900+**** rigorous studies ****(Ulrich & Zimring, 2007)**
**A LOT of good evidence is available**
**Many designs make hospitals riskier for patients, families & staff**

**Full report:  www.healthdesign.org/research/reports**

## Surfaces commonly contaminated by MRSA

- (Methicillin-resistant *staphylococcus aureus*)

- R.S. Ulrich with P.A. Wilson

## Singles enable hospitals to separate patients upon admission, making it possible to prevent unrecognized carriers of pathogens from infecting others in multi-bed spaces

**Why Single-Bed Rooms Reduce Infection Rates**

## Problem: Unwashed Staff Hands

- Low hand washing compliance    has strong causal link with   contact transmission of infection

- Compliance in busy units: **14-28%**
- Education _inadequate_ and _transient_

## Design to Increase Hand Washing

**Patient Bed**

**Alcohol-based gel dispenser**

**Automatic faucet (no touch)**

**Easy-to-clean basin counter (continuous impervious surface)**

**Design to Increase Hand Washing**
- 	Conveniently   	located basin in 	single room

**Soap dispenser**

**M. D. Anderson**  Ambulatory Cancer Center
- Houston

**Handwash basins and hand rub dispensers should be close to staff movement paths, visually prominent, near care point**

## Clarian West Medical Center Indianapolis

- Clarian West Medical Center Indianapolis
- Design:  HKS

## For busy preoccupied persons, out-of-sight may be out-of-mind

## STUDY:  Effects of ICU Design on Handwashing

***RESEARCH EXAMPLE***

**Study sites:** two intensive care units (ICUs)--one older, one new--in a Texas hospital
**Three types of patient rooms:**
- Six-bed open bay
- Small single-bed rooms
- Large single-bed rooms with *decentralized* nursing stations

- (Quan and Ulrich, in submission)

- Centralized nurse stations

**Notes:**
One research study looked at the infection rate of infants before and after they were moved to private rooms.

## New Intensive Care Unit

-  Sinks and gel 	dispensers 	located close to 	staff work paths

**New Intensive Care Unit**

- gel dispenser
- sink

- St. Joseph’s Medical Center, Bryan, TX
**Design: WHR Architects**

## Handwashing rate

**0%**

**60%**

**50%**

**40%**

**30%**

**20%**

**10%**

**27**%

**38**%

**47**%

**  ****28%**** increase **

**  ****42%**** increase**

**   ****74%****              total increase**

**Handwashing rate**

**Findings**  (Quan and Ulrich, 2006)

## Infection Rates in Old vs New ICUs
source: Quan and Ulrich, 2006

**source: Quan and Ulrich, 2006**

**Reduced 44.4%**

**Move to new ICU with single rooms & better handwashing design**

**Old ICU**

## Transfers Worsen Patient and Staff Safety

- Increase infections

- Transfers cause sharp peaks in medical _errors_
- Major cause of staff injuries
- Each transfer requires hours of staff time and paperwork
- Each transfer adds .5 day to LOS

## Transfers reduced 90% compared to unit with multi-bed rooms

**Acuity-Adaptable, Single Coronary Critical Care**  Methodist Hospital, Indianapolis

- BSA LifeStructures

- Transfers reduced 90% compared to unit with multi-bed rooms
- Saves $5 million per year
- Medication errors reduced 70%

*Pebble   Project*

## Annual Medication Error Index (errors/patient days) coronary critical care 

**More errors**

- Move to new unit with single, acuity-adaptable rooms

- Source: A. Hendrich (2004). In* Keeping Patients Safe: Transforming the Work Environment of Nurses.* *Quality Chasm Series,* Institute of Medicine

- Old unit with multi-bed rooms

## Problem: Falls  

**Problem:**** ****Falls**

- Decentralized nurse stations
- Single-bed rooms designed to support family presence

## Family Zone

**Acuity-Adaptable, Single Coronary Critical Care**  Methodist Hospital, Indianapolis

- BSA LifeStructures

*Pebble   Project*

**Family Zone**

## Decentralized nurse stations improve observation of patients, safety  

- Design: BSA LifeStructures

**Acuity-Adaptable, Family Centered CCU**
**Methodist Hospital, Indianapolis**

**Decentralized nurse stations** improve observation of patients, safety

## Patient Fall Index (falls per 100 patient days)

- Move to new unit with single family-centered rooms and decentralized nurse stations

- More Falls

- Source: A. Hendrich (2004). In* Keeping Patients Safe: Transforming the Work Environment of Nurses.* *Quality Chasm Series,* Institute of Medicine.

- Old unit with multi-bed rooms, centralized nurse station

**Patient Fall Index**** **(**falls per 100 patient days**)

## Same-handed single patient roomWith evidence-based design (EBD) safety features

**Same-handed single patient room**With evidence-based design (EBD) safety features

**Large bathroom door**

**Direct path with hand assist to toilet**

**Handwashing sink with sight line**

**Dublin Methodist Hospital, Dublin Ohio**
- Design: Karlsberger with Cama

**Sound-absorbing ceiling tile**

## Same-handed single-bed rooms designed to increase patient safety

**Same-handed single-bed rooms designed to increase patient safety**
-       (UK hospital design proposal)