Making hospitals healthy
WITH hospital-acquired infections claiming more American lives each year than AIDS, breast cancer or automobile accidents, it seems the very facilities built to heal us have themselves become dangerous places.
Two million patients each year suffer from a hospital-acquired infection, the federal Centers for Disease Control and Prevention say, and nearly 100,000 of them die as a result. Architects believe that doesn’t have to be the case.
The right physical environment -- single-patient rooms; well-designed ventilation systems and air filters; easy-to-clean, nonporous surface materials; and plenty of sinks for washing hands -- could reduce the spread of infection, they say. They even have research supporting the concept, known as evidence-based design. Now hospitals across the country, including many in California, are using this information to reduce infections from the ground up. The Center for Health Design, a research and advocacy organization based in Concord, Calif., is currently working with 50 hospitals to design safer facilities. And some of Southern California’s largest medical center replacement projects, including Los Angeles County-USC Medical Center and UCLA Medical Center, have incorporated elements of evidence-based designs. These include private patient rooms, ubiquitous hand-washing sinks and alcohol hand-sanitizing dispensers, isolation rooms for highly infectious patients and emergency departments with negative air pressure, which pulls infectious air away from other parts of the hospital.
“Private rooms are the most important design element that reduces the spread of infection between patients,” says Richard Van Enk, director of infection control and epidemiology for Bronson Methodist Hospital in Kalamazoo, Mich. Bronson is a pioneer of evidence-based design and was among the first hospitals in the United States to build a facility with all private patient rooms.
The hospital’s new design also incorporates two sinks in each patient room, one of which is dedicated for the exclusive use of the healthcare worker. Many easily cleaned surface materials such as water-based low VOC (volatile organic chemical) paint, plastic counter coverings and linoleum floorings with antimicrobial properties were also used throughout the hospital.
Bronson measured the difference in infection rates between its old, multi-bed-room facility and new, private-room facility, which opened in December 2000, and discovered that the infection rate had dropped by approximately 11%. “The major change in that facility was the use of private rooms,” Van Enk says.
Requiring patients to share space increases the risk of airborne infections. One of the most striking examples was the outbreak of severe acute respiratory syndrome -- SARS -- in Toronto in 2003. About 75% of those SARS cases were acquired in the hospital, according to a 2003 study published in the Journal of Emergency Nursing.
Multi-bed spaces in emergency rooms and ICUs, combined with few available isolation rooms with negative airflow pressure, hindered hospital workers’ ability to treat and control the syndrome, which is spread by tiny atomized droplets from coughing individuals, much like influenza and chickenpox, said Roger Ulrich, a member of the board of directors for the Center for Health Design. “This underscored dramatically the need for single rooms, not only in intensive care units, not only in traditional wards, but in emergency departments. And the need for not only single spaces for each bed, but for appropriate ventilation and air filtration.”
Shared rooms also increase the spread of disease through contact, Ulrich said. For example, a patient in a shared room with methicillin-resistant Staphylococcus aureus, or MRSA, can, within hours, contaminate surfaces such as bed rails, tables and bathroom fixtures. In fact, a 2004 study published in the Journal of Hospital Infection showed that the contamination rates of surfaces with MRSA in surgical wards of a London teaching hospital were as high as 74% in spaces occupied by a patient with MRSA.
MRSA is resistant to many antibiotics and occurs most commonly in hospital patients or those in other healthcare facilities, such as nursing homes.
The evidence that shared hospital rooms contribute greatly to higher infection rates, as well as a host of medical errors, privacy violations and added patient stress, is so compelling that the American Institute of Architects -- in its 2006 guidelines for healthcare facilities -- called for single-patient rooms in medical/surgical and postpartum units as the standard for all newly constructed hospitals. The effect of such a change appears to be dramatic: Methodist Hospital in Indianapolis, for example, saw a 67% drop in medication errors when it changed its coronary intensive care unit to single-bed rooms.
The American Institute of Architects guidelines have now been adopted by more than 43 states, said Peter Bardwell, president of the institute’s Academy of Architecture for Health. “This was the first document to state without equivocation that unless there is some indicator of extraordinary hardship, all newly constructed patient rooms should be single occupancy.”