Jennifer DuBose

A Review of the Research Literature on Evidence-Based Healthcare Design

Objective: This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals. Background: It builds on a literature review conducted by researchers in 2004. Methods: Research teams conducted a new and more exhaustive search for rigorous empirical studies that link the design of hospital physical environments with healthcare outcomes. The review followed a two-step process, including an extensive search for existing literature and a screening of each identified study for the relevance and quality of evidence. Results: This review found a growing body of rigorous studies to guide healthcare design, especially with respect to reducing the frequency of hospital-acquired infections. Results are organized according to three general types of outcomes: patient safety, other patient outcomes, and staff outcomes. The findings further support the importance of improving outcomes for a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms, and improved floor layouts and work settings. Directions for future research are also identified. Conclusions: The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work.

The Business Case for Building Better Hospitals Through Evidence-Based Design

Purpose: After establishing the connection between building well-designed evidence-based facilities and improved safety and quality for patients, families, and staff, this article presents the compelling business case for doing so. It demonstrates why ongoing operating savings and initial capital costs must be analyzed and describes specific steps to ensure that design innovations are implemented effectively. Background: Hospital leaders and boards are now beginning to face a new reality: They can no longer tolerate preventable hospital-acquired conditions such as infections, falls, and injuries to staff or unnecessary intra-hospital patient transfers that can increase errors. Nor can they subject patients and families to noisy, confusing environments that increase anxiety and stress. They must effectively deploy all reasonable quality improvement techniques available. To be optimally effective, a variety of tactics must be combined and implemented in an integrated way. Hospital leadership must understand the clear connection between building well-designed healing environments and improved healthcare safety and quality for patients, families, and staff, as well as the compelling business case for doing so. Emerging pay-for-performance (P4P) methodologies that reward hospitals for quality and refuse to pay hospitals for the harm they cause (e.g., infections and falls) further strengthen this business case. Recommendations: When planning to build a new hospital or to renovate an existing facility, healthcare leaders should address a key question: Will the proposed project incorporate all relevant and proven evidence-based design innovations to optimize patient safety, quality, and satisfaction as well as workforce safety, satisfaction, productivity, and energy efficiency? When conducting a business case analysis for a new project, hospital leaders should consider ongoing operating savings and the market share impact of evidence-based design interventions as well as initial capital costs. They should consider taking the 10 steps recommended to ensure an optimal, cost-effective hospital environment. A return-on-investment (ROI) framework is put forward for the use of individual organizations.

Assessing Viral Transfer During Doffing of Ebola-Level Personal Protective Equipment in a Biocontainment Unit

Background Personal protective equipment (PPE) protects healthcare workers (HCWs) caring for patients with Ebola virus disease (EVD), and PPE doffing is a critical point for preventing viral self-contamination. We assessed contamination of skin, gloves, and scrubs after doffing Ebola-level PPE contaminated with surrogate viruses: bacteriophages MS2 and Φ6. Methods In a medical biocontainment unit, HCWs (n = 10) experienced in EVD care donned and doffed PPE following unit protocols that incorporate trained observer guidance and alcohol-based hand rub (ABHR). A mixture of Φ6 (enveloped), MS2 (nonenveloped), and fluorescent marker was applied to 4 PPE sites, approximating body fluid viral load (Φ6, 105; MS2, 106). They performed a patient care task, then doffed. Inner gloves, face, hands, and scrubs were sampled for virus, as were environmental sites with visible fluorescent marker. Results Among 10 HCWs there was no Φ6 transfer to inner gloves, hands, or face; 1 participant had Φ6 on scrubs at low levels (1.4 × 102). MS2 transfer (range, 101-106) was observed to scrubs (n = 2), hands (n = 1), and inner gloves (n = 7), where it was highest. Most (n = 8) had only 1 positive site. Environmental samples with visible fluorescent marker (n = 21) were negative. Conclusions Among experienced HCWs, structured, observed doffing using ABHR protected against hand contamination with enveloped virus. Nonenveloped virus was infrequent on hands and scrubs but common on inner gloves, suggesting that inner gloves, but not necessarily ABHR, protect against hand contamination. Optimizing doffing protocols to protect against all types of viruses may require reinforcing careful handling of scrubs and good glove/hand hygiene with effective agents.

Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination

Background Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Methods Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Results Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Conclusions Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness

OBJECTIVE To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU). DESIGN We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises. SETTING The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup.ParticipantsA total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study. RESULTS In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) and HCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCW adherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements. CONCLUSIONS Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.

Exploring the Concept of Healing Spaces

Evidence-based design (EBD) research has demonstrated the power of environmental design to support improved patient, family, and staff outcomes and to minimize or avoid harm in healthcare settings. While healthcare has primarily focused on fixing the body, there is a growing recognition that our healthcare system could do more by promoting overall wellness, and this requires expanding the focus to healing. This article explores how we can extend what we know from EBD about health impacts of spatial design to the more elusive goal of healing. By breaking the concept of healing into antecedent components (emotional, psychological, social, behavioral, and functional), this review of the literature presents the existing evidence to identify how healthcare spaces can foster healing. The environmental variables found to directly affect or facilitate one or more dimension of healing were organized into six groups of variables—homelike environment, access to views and nature, light, noise control, barrier-free environment, and room layout. While there is limited scientific research confirming design solutions for creating healing spaces, the literature search revealed relationships that provide a basis for a draft definition. Healing spaces evoke a sense of cohesion of the mind, body, and spirit. They support healing intention and foster healing relationships.

Lighting and Nurses at Medical–Surgical Units Impact of Lighting Conditions on Nurses’ Performance and Satisfaction

Objective: This study investigates the perception of nurses about their lighting environment at medical–surgical hospital units in order to understand areas of improvement for lighting at these units. Background: The bulk of the research about nurses and lighting is focused on nighttime nursing, exploring the disruptions of nurses’ circadian rhythm and maintaining alertness. The understanding of nurses’ perception about lighting and its impact on nurses’ task performance and patient examination remains imprecise. Methods: This study used an online survey to ask a set of questions about lighting in medical–surgical units at five key locations including centralized nurse stations, decentralized nurse stations (DCNS), patient bedsides, patient bathrooms, and corridors from 393 survey participants. It then explored the survey findings in more depth through conducting focus groups with eight volunteer nurses. Results: Lighting conditions at patient besides and DCNSs were significantly less desirable for nurses compared to other locations. A significant relationship between nurses’ access to lighting controls (switches and dimmers) and satisfaction about the lighting environment was found. No significant relationship was observed between the individual characteristics of nurses (such as age, years of experience, etc.) and findings of this study. Conclusions: Thoughtful design of the lighting environment can improve nurses’ satisfaction and perception about their working environment.

Healthy Health Care Settings

Health care settings represent a unique built environment because their primary function is maintaining and restoring health. In health care settings, patients, staff, visitors, and even community members may all be affected by design. Design features of health care institutions such as improved indoor air quality and natural daylighting may promote health. Some features offer direct benefits to patients, and some operate indirectly, for example, by reducing medical errors. Health care facilities are much more resource intensive than other commercial facility types, using more than twice as much energy per square foot, in part because they operate continuously. There is now a growing focus on the environmental performance of health care institutions, as a subset of green building initiatives more generally. Evidence-based design (EBD) uses systematic, empirical evidence on risks and benefits to guide design decisions. Applicable to many types of buildings, EBD has been especially well defined and applied in health care facilities. EBD can incorporate many kinds of outcomes, including health, environmental performance, cost, and aesthetic preference, although it has been most extensively applied to health impacts. Ideally, the design of health care facilities optimizes both health and environmental performance, while reducing cost.

Welcome to a Special Issue

As the United States enters one of the largest healthcare construction programs in its history-with construction projected to exceed

Improving inpatient environments to support patient sleep

70 billion a year by 2011 (Jones, 2007)-many healthcare organizations are using evidence-based design (EBD) to help guide their capital facility investment. EBD relies on a deep and broad knowledge of the relevant evidence from research and best practice. However, as Zimring, Augenbroe, Malone, & Sadler (2008) say in their paper in this issue:At the core of EBD is a fundamental shift in the way healthcare organizations think about, deliver, and manage buildings. Rather than simply being regarded as cost centers, in EBD buildings are seen as strategic tools where strategic investments can yield important benefits. Yet to achieve these benefits, buildings must be planned, designed, and operated in a new way?. [A]n EBD approach is a structured process that establishes broad agreement on the principles underlying a design, articulates goals that must be satisfied to achieve those principles, and sets measurable, expected outcomes. (pp. 7-8)This special issue focuses on four sets of key questions that illuminate the practice and science of EBD:* How does a chief executive officer actually implement EBD? All projects have ambitious goals; how can this practice actually be infused into the thousands of decisions made in a multiyear healthcare project?* What is the overall business case for EBD and how does one build a business case for individual projects?* How can physical design development be linked to development of the culture of an organization?* What is the evidence base for EBD? Where is rigorous evidence about the impact of the built environment on key healthcare outcomes to be found?These articles are based on research conducted by a diverse group of thought leaders with funding from the Robert Wood Johnson Foundation. The purpose of this grant is to provide materials and tools that will help high-level hospital decision makers effectively implement EBD in their projects. As this project, conducted jointly by Georgia Tech, The Center for Health Design, and the research partners writing in this issue, is completed, it will yield white papers, webinars, a Health- Care Design Community Portal, and other tools.This issue of HERD includes four papers:1. Implementing Healthcare Excellence: The Vital Role of the CEO in Evidence-Based Design. This paper uses lessons learned from hospital leaders and the experience of the authors to create practical guidance for CEOs who want to use EBD as a tool to transform their organizations. In addition to keys to success, the paper also discusses barriers to innovation and strategies for overcoming these barriers. This paper provides a model for EBD that CEOs can use to create a facility that increases quality, safety, patientand- family centeredness, and revenue and that reduces cost. …