|About this series|
This article is Part II of a three-part series on the 2006 Guidelines for Design and Construction of Health Care Facilities, also known as the “AIA Guidelines.” Part I, which appeared in the January issue, described the process by which the new edition of the guidelines was developed, along with an overview of changes in the new edition’s format and contents. This part covers major changes to the guidelines with regards to hospitals. Part III will take a look at the possible future of the guidelines.
The Guidelines for Design and Construction of Health Care Facilities, commonly referred to as the “AIA Guidelines,” provides a framework for designing environments that support the operational needs of health care facilities. The guidelines were updated last year to reflect the latest thinking in medical technology and design. This 2006 edition contains several changes regarding the design and construction of hospitals.
Patient room changes
One of the most significant changes is the specification of single-bed patient rooms in new hospital construction. Evidence concerning the benefits of single-bed rooms in medical-surgical and postpartum units has been mounting for several years. The single-bed provision was nearly included in the 2001 guidelines, missing the two-thirds majority required to change the text by a single vote.
The Dallas-based Facilities Guidelines Institute (FGI) oversees the guidelines’ development. To explore the pros and cons of private rooms, FGI funded a research project at Simon Fraser University in Canada. After reviewing data from this study and many others in the field, FGI’s Health Guidelines Revision Committee, which approves the final guidelines, fully supported the single-bed design. With an exception for hospitals that demonstrate a functional programming requirement for multiple beds in a room, the committee unanimously adopted private rooms as the standard for new hospital construction.
Patient safety was key to this decision. Properly ventilated single-bed rooms help isolate pathogens and reduce hospital-acquired infections. And patients in single-bed rooms are less likely to be given the wrong medication, therapy, surgical follow-up or meal.
By definition, private rooms also increase patient privacy. This not only allows patients to attend to bodily needs with more dignity, it affords them more control over their environment and better opportunities for rest and healing. Increased privacy also facilitates conversations between patients and their physicians, caregivers, family and clergy, which can be important to recovery as well. The confidentiality of patient information is federally mandated by the Health Insurance Portability and Accountability Act (HIPAA), making privacy an especially important consideration in design.
As hospitals continue to focus attention on the role family members play in a patient’s care, providing space for family involvement is also important. A new appendix entry (indicating advisory information) has been added to the guidelines recommending that single-occupancy rooms be used at hospitals implementing a patient and family-centered model of care.
Private rooms can also reduce the number of staff injuries that occur during patient transport by eliminating the possibility of roommate conflicts that require patients to be moved to another room.
All of these benefits provide a safer, less stressful environment for patients and staff. Studies have shown that patients in private rooms have shorter hospital stays than those in semiprivate rooms, which is clearly advantageous to patients and also reduces costs for hospitals. Hospitals can also benefit from higher occupancies with private rooms because beds do not have to remain empty due to incompatibilities in patient cases. Private rooms also make hospitals competitive with other health facilities that offer private accommodations.
Despite the many benefits of this design, the committee realized it was not appropriate for all situations. Therefore, the guidelines allow new hospitals to use a two-bed arrangement if they demonstrate a functional need to the proper licensing authority. Roommates can be therapeutic for certain patients, such as orthopedic or geriatric patients with similar afflictions. Certain facilities may not have the space to build or the resources to staff private rooms. Surge factors were also considered, allowing hospitals to plan for multibed operation in the event of a disaster.
Hospitals undergoing renovation are not required to adhere to the new standard, though they may not exceed the current number of patients per room (up to a maximum of four patients).
In another change regarding the renovation of patient rooms, the installation of waterless hand sanitation stations is now allowed if existing conditions prohibit the installation of a sink. Sinks are still required in new construction.
Special hospital units
A new section has been added to the guidelines that outlines requirements for intermediate care or step-down units. These units, for patients who require monitoring and intervention at a level between that of intensive care and regular medical-surgical units, were not covered in previous editions. The maximum room capacity of an intermediate care unit is four patients, with a minimum of 120 square feet of clear floor area per bed. For a single-bed room in an intermediate care unit, this measurement is increased to 150 square feet. Other guidelines for patient rooms in such units, including airborne infection isolation rooms, are described, as are specifications for intermediate care unit support areas.
Clearances for critical care units are now specifically stated in the guidelines. The bed clearances for adult and pediatric critical care units are a minimum of 5 feet from the foot of the bed to the wall, 5 feet on the transfer side, 4 feet on the nontransfer side and 8 feet between beds. Earlier editions of the guidelines were less prescriptive regarding the space requirements for critical care.
For neonatal intensive care units, an aisle at least 4-feet wide must be adjacent to care areas in multiple-bed rooms, with a minimum of 8 feet between beds. Single-bed rooms or fixed cubicle partitions must have an adjacent aisle at least 8-feet wide. Issues of noise control and lighting, including access to natural light, are also newly addressed in the standards for neonatal intensive care.
The guidelines also address the requirements of psychiatric nursing units, as distinct from psychiatric care provided in a medical unit. The design of psychiatric nursing units should be adaptable to the hospital’s medical and psychiatric therapy program. The guidelines for these units also make note of the special safety and security considerations for this patient population.
In-hospital skilled nursing units are included in the guidelines for the first time in the 2006 edition. Many hospitals have added these units, which are licensed hospital beds for patients who require skilled nursing care during their recovery, such as brain trauma or stroke victims undergoing rehabilitation. The requirements for in-hospital skilled nursing units are different from those of long-term skilled nursing units.
The guidelines for in-hospital skilled nursing units state that these units should be located near the physical and rehabilitation medicine departments. And, if possible, they should have access to outdoor areas that can be used for therapeutic purposes. They should also be located so that unrelated hospital traffic does not pass through the unit to reach other parts of the building.
An additional 7 square feet per bed is required in the support areas of in-hospital skilled nursing units to provide storage for wheelchairs and walking aids. Dining and recreation spaces are also required, with a minimum of 25 square feet in new construction and 14 square feet for renovations. Requirements for private spaces and grooming areas are also addressed in the guidelines as well as special construction requirements for the installation of handrails in accordance with the American with Disabilities Act and local, state and federal codes.
The space requirements for labor, delivery and recovery (LDR) rooms and labor, delivery, recovery and postpartum (LDRP) rooms are unchanged for new construction, with a minimum of 300 square feet of clear floor area per bed and a minimum dimension of 13 feet. However, an appendix entry to the 2006 guidelines recommends a minimum dimension of 15 feet to accommodate medical equipment and staff for complex deliveries. Renovations to LDR and LDRP rooms are encouraged to meet the same standard as new construction, but a minimum clear area of 200 square feet is allowed if this is not possible.
Surge capacity for the emergency department is addressed in an appendix to the emergency service section of the text. The revision cycle for the 2006 guidelines began in the wake of the 9/11 terrorist attacks; the increased threat of terrorism and bioterrorism has had a large impact on the area of emergency design. The new guidelines recommend hospitals plan for a surge of up to fourfold or tenfold increase in ED capacity for highly infectious patients. The plan should include provisions for extra space, utility upgrades and ventilation requirements. Guidance from the Department of Health & Human Services’ Office of Emergency Preparedness is advised.
For similar reasons, the design of the emergency department’s main access point, reception, security and triage areas are discussed in another appendix entry. It is recommended that these areas be designed so the hospital can maintain control of the emergency department during a disaster, terrorist event or infectious disease outbreak, to limit contamination and retain the department’s viability as a resource.
Decontamination areas for emergency departments are also newly addressed in the 2006 guidelines, as well as emergency department observation units. Observation units in the emergency department are designed to house patients up to 23 hours or until admitted to an inpatient unit. They should include bedside space for visitors, hand-washing stations, toilet rooms, showers and a nourishment area. If required by the hospital’s functional program, these units should also include a secure holding area designed to prevent injury to patients.
The requirements for freestanding emergency services, which are physically separate from the existing hospital emergency department and intended to provide comprehensive emergency service, are also outlined in the new guidelines.
Construction requirements for surgical suites now stipulate that operating room perimeter walls, ceiling and floors, including penetrations, be sealed. Monolithic ceilings are necessary to meet this requirement. A monolithic ceiling is defined in the guidelines as “a ceiling constructed with a surface free of fissures, cracks and crevices.” The glossary goes further to say that “any penetrations such as lights, diffusers, and access panels shall be sealed or gasketed. (Lay-in ceilings are not considered monolithic.)” This design, with proper ventilation, can reduce infection and help control noise.
Requirements for electrophysiology labs have been added to the guidelines for cardiac catheterization labs. These may be located within the catheterization suite or in a separate area near the cardiac care unit.
Rooms that are regularly used for fluoroscopic procedures are now required to have direct access to separate toilets with hand-washing facilities. Patients must be able to leave the toilet room without re-entering the fluoroscopic room. The use of nearby toilets is permitted for rooms that are used only occasionally for fluoroscopy.
In the area of materials management, the guidelines provide new information concerning the hospital’s receiving area and waste management collection and storage. New waste treatment and disposal requirements are also addressed.
New requirements for heating, ventilating and air-conditioning systems include those for specific locations within the hospital, such as airborne infection isolation rooms (used to isolate airborne pathogens and reduce the spread of infectious disease) and protective environment rooms (used to protect vulnerable patients from common airborne pathogens). Reversible airflow provisions for switching a room between these two functions are not allowed.
The new guidelines also call for individual temperature controls for each of the hospital’s operating and delivery rooms. When these rooms are unoccupied, the number of air changes may be reduced to save energy, as long as positive room pressure is maintained.
In patient care areas, return air must now be carried via ducted systems.
A new section on electronic surveillance systems has also been added. These systems are not required, but if they are installed, the guidelines state they should be unobtrusive, tamper-resistant and not readily observable by the general public or patients. Provision should also be made for emergency power, should normal electrical power be disrupted.
A chapter on small inpatient primary care hospitals has been added to the guidelines. These hospitals are intended to provide short-term overnight care in rural or underserved communities. As transfer, service and reciprocity agreements with general and tertiary care hospitals are prerequisites for this type of hospital, transfer support features are included in the guidelines for small inpatient primary care hospitals.
Guidelines for psychiatric hospitals are also covered in a separate chapter. These include new construction standards for doors, windows, furniture, bathroom hardware and ceilings, with special consideration for patient injury and suicide prevention.
The final chapter in the guidelines for hospitals concerns rehabilitation facilities. As in the general hospital chapter, new information on waste management and processing has been added. In another change, the guidelines state that operable windows are not required in patient rooms at rehabilitation facilities.
Advances in design
These are the major changes to the guidelines regarding hospital construction and design; and other revisions have been made to the text as well.
These new guidelines will help create hospitals that demonstrate the best of the healing, design and building arts.
Joseph G. Sprague, FAIA, FACHA, FHFI, is senior vice president/director of health facilities at HKS Inc., Dallas. He is also the chairman of the 2006 “AIA Guidelines” and president of the Facility Guidelines Institute. He can be contacted via e-mail at email@example.com.
To respond to this article, please click here.
Click here for a FREE subscription to Health Facilities Management.