New patient rooms designed by HKS at the UW Health Burn and Wound Center in Madison, Wis., are intended to treat pediatric and adult burn patients for extended stay treatments of up to three months.

Image by Bruce Fritz

For the 2022 edition of its Guidelines for Design and Construction, the Facility Guidelines Institute (FGI) will again offer three distinct Guidelines publications for 1) hospitals; 2) outpatient facilities; and 3) residential health, care, and support facilities. 

These publications are the go-to resource for health and residential care facility planning and design and include program, space, risk assessment, infection prevention, architectural detail, and surface and building system requirements. Although the documents are called “guidelines,” they are written as fundamental standards and become enforceable when adopted by federal agencies or states or referenced in state laws, codes, rules or regulations.

Despite significant disruption during the 2022 Guidelines revision cycle caused by the COVID-19 pandemic, the Health Guidelines Revision Committee (HGRC) continued reviewing and updating the Guidelines documents. Given that approximately half the HGRC members work in health and residential care facilities, completing the four-year Guidelines revision cycle on time was an extraordinary accomplishment. Simultaneously with the Guidelines revision cycle, FGI convened a 130-person Emergency Conditions Committee separate and distinct from the HGRC to develop meaningful guidance for health and residential care facilities planning for or experiencing emergency conditions. 

The result of this effort is a white paper, “Guidance for Designing Health and Residential Care Facilities that Respond and Adapt to Emergency Conditions,” which offers design and operational guidance for health and residential care facilities and draft language for incorporation in future editions of the FGI Guidelines. The white paper with draft Guidelines text is available for free download at fgiguidelines.org.

Changes across the Guidelines documents

A common theme during the 2022 Guidelines revision cycle was person-centered care. Informed by the work of FGI topic groups on palliative care and inclusive environments, requirements and appendices have been added in the Hospital, Outpatient and Residential documents that reflect the role design plays in providing comfort to patients and residents receiving palliative and end-of-life care. 

The changes support provision of these services in hospitals and residential care settings. Likewise, requirements for inclusive environments support patients, residents, staff and visitors with low or declining vision, hearing, mobility, balance or other physical difficulty. 

The 2022 Guidelines documents also feature updated requirements for multipurpose patient care settings, lighting, nurse call systems, telecommunication systems, and ligature resistance in areas serving behavioral and mental health patients. 

Major changes in the Hospital and Outpatient Guidelines 

Design guidance in both the Hospital and Outpatient documents has been updated to encourage flexible space use. 

For example, the emergency department (ED) section in the Hospital document and free-standing emergency facility chapter in the Outpatient document now include provisions for a flexible secure treatment room, capable of serving as either a secure holding room or a single-patient treatment room. 

Although an anteroom is not required for airborne infection isolation (AII) rooms in the 2022 edition, health care organizations will be required to conduct an infection control risk assessment (ICRA) to determine whether an anteroom is necessary. The ICRA process will help an organization identify the need for and quantity and placement of anterooms. An associated appendix section offers design guidance on infection prevention considerations for storage, space for donning and doffing personal protective equipment (PPE), and PPE disposal. 

The emergency facility requirements in the Hospital document were revised to better distinguish between indoor rooms and outdoor structures for human decontamination. In both the Outpatient and Hospital documents, the size of interior decontamination rooms increased from 80 to 100 square feet; outdoor structures do not have a minimum size. 

As well, emergency facilities are now required to have video surveillance at public entrances and a duress alarm system where ED entrances may be locked. This change was proposed due to an effort in Massachusetts to pass “Laura’s Law.” Signed in January 2021, the law is named after Laura Levis, a 34-year-old woman who suffered an asthma attack and died outside an ED because she couldn’t find an unlocked entrance. (See the sidebar on this page for more on ED design changes.)

The Hospital and Outpatient Guidelines also feature new design guidance for behavioral and mental health spaces for facilities where an intensive outpatient/partial hospitalization program (IOP/PHP) will be provided. 

IOPs provide regular intense therapy sessions to support patients recovering from depression, anxiety, substance abuse, or other behavioral and mental health diagnoses. PHPs support patients who no longer need inpatient care but still require substantial step-down support and patients experiencing a relapse of symptoms. Neither program serves patients overnight. 

Major changes in the Hospital Guidelines 

The Guidelines documents encourage design flexibility and innovation as long as patient care and staff welfare will not be compromised. To support this aim, the Hospital Document Group of the HGRC adopted a strategy commonly used by authorities having jurisdiction that was successfully applied to the 2018 Outpatient Guidelines. 

Health care facilities are often at the cutting edge of practice and technology, with new spaces continually added and old spaces reconfigured. Because of this, chapters in the Guidelines don’t always align perfectly with the scope and goals of a particular project. To address this misalignment, the common elements chapter of the 2022 Hospital Guidelines now provides an alternate method of applying requirements: For hospitals of a type not addressed in chapters 2.2 through 2.8, designers are permitted and encouraged to include elements from one or more facility chapters without having to apply the entire chapter. Sections of the Guidelines that will be applied to a project to address the program and services a hospital will provide must be identified during functional programing. 

Newborn intensive care unit (NICU) room sizes have increased based on guidance from the Recommended Standards for Newborn ICU Design Consensus Committee. Multiple-infant rooms increased from 120 to 150 square feet per patient and single-infant rooms increased from 155 to 180 square feet. These enlarged space requirements are intended to accommodate families, who otherwise could be squeezed out by staff workspace and large equipment such as incubators. 

A neonatal couplet care room has been added to provide an integrated space where a hospitalized mother and NICU patient can both receive care. Other updates in the NICU section support a continued effort to reduce noise, a recognized harm to neonates, and clarify that a window to the outside isn’t required in a NICU room if daylight can be viewed through another window. 

Other changes in the 2022 Hospital document include:

• New language that encourages owners, designers and regulators to follow requirements in the critical access hospital chapter rather than the general hospital chapter when designing small and specialty hospitals with fewer than 35 beds.
• Removal of the free-standing emergency care facility chapter from the Hospital document. (For the 2022 edition, this chapter will appear only in the Outpatient Guidelines.)
• Reduction of permissible nonrecirculated fixture branch piping in hospitals from a maximum of 25 to 10 feet.
• Where pre- and post-procedure stations are combined in one care area, reduction of the minimum number of patient care stations from two to one and a half for each Class 2 and Class 3 imaging room, procedure room and operating room if volume data and procedure types verify the reduction supports efficiency.
• New requirements and recommended best practices for burn units and hospice units.
• Revisions to the critical access chapter aiming to reduce costs by improving flexibility in room use.

Major changes in the Outpatient Guidelines

The Outpatient Guidelines continues to encourage flexibility in the use of patient care spaces. Overall changes to the document include strengthened requirements for the functional program and the addition of a behavioral and mental health portion to the safety risk assessment. 

In the common elements chapter, a single-patient exam/observation room with a dual entry was added. This room must be at least 100 square feet and have a minimum clearance of 2 feet, 8 inches at the sides and foot of the exam table. While the standard exam/observation room in outpatient facilities requires 80 square feet, the additional square footage for this room type is necessary to prevent significant encroachment of the two doors into the clear floor area (CFA). 

Urgent care facilities must provide at least one single-patient exam room, and in multiple-patient exam rooms where bays or cubicles face each other, a 5-foot aisle is required outside the bay or cubicle clearances. Staff support areas have been added, and the nurses station is permitted to share space with the reception and information area. In the free-standing emergency facility chapter, the trauma/resuscitation room is now permitted to be subdivided, and use of low-acuity patient treatment stations is allowed.

This children’s dialysis bay at the Children’s Medical Center in Dallas balances requirements for space and privacy in an environment that is both calming and engaging.

Image courtesy of HKS Inc.

New provisions for renal dialysis centers, including fluid disposal sinks in hemodialysis treatment areas, support Centers for Medicare & Medicaid Services (CMS) requirements. Patient care stations in dialysis facilities no longer have a minimum CFA and require a 2-foot clearance at the foot of the chair when fully extended. The requirement for an AII room was replaced with a dedicated room to prevent contact transmission of infectious microorganisms as required by CMS. This dedicated room must be a single-patient room with a minimum CFA of 120 square feet and be designed to allow for direct observation of the patient’s face and insertion point as do other dialysis patient care stations. 

In the birth centers chapter, the size of a birthing room has been reduced from 200 to 120 square feet. This change was influenced by a national study that found 25% of existing birth center rooms are smaller than 200 square feet. 

In the dental facility chapter, the minimum 80-square-foot CFA for operatories has been removed, but the clearance of 2 feet, 8 inches on all sides of the chair remains. Dental laboratories are now required to meet the room and pressure requirements of ANSI/ASHRAE/ASHE Standard 170, Ventilation of Health Care Facilities. 

A chapter for extended stay centers was introduced in the draft Outpatient Guidelines released for public comment in 2020. This chapter was written to provide an option for overnight care for patients of outpatient surgery centers or free-standing EDs. The patients for whom this facility type is intended are stable and don’t require intensive monitoring or hospital-level care but may not be able to return home the same day due to travel distance, lack of a caregiver at home or more time needed to manage pain. 

Based on feedback received during the public comment period, the Outpatient Document Group decided too many questions remained to include this chapter in the 2022 Outpatient Guidelines. However, the group plans to prepare a white paper with revised draft requirements to encourage additional conversation. The goal is to include a chapter on extended stay centers in the 2026 edition.

Major changes in the Residential Guidelines 

The 2022 Residential Guidelines was restructured to improve usability and better align with the Hospital and Outpatient documents. As part of this effort, the content of the safety risk assessment section was thoroughly revised, a common elements chapter was created and sustainability requirements were updated to refer to existing standards where possible.

Design criteria for individuals receiving palliative care were added to the 2022 Residential document. Appendix sections to these new requirements discuss the different types of palliative care, from a service in a residential setting to care in a hospice facility. Design guidance encourages provision of restorative break spaces for caregivers, family and/or friends; home-like spaces to promote resident quality of life and living with dignity; and quiet rooms to support sensory stabilization.

Text on kitchen types and dining areas was restructured and relocated to the common elements chapter to bring clarity and consistency to requirements for these spaces. Guidance to improve acoustics in residential dining settings was also added.

In the nursing homes chapter, the exception for renovations has been revised to allow no more than four residents in multiple-resident rooms, with two permitted to share a sink or toilet. A dialysis treatment area of 80 square feet has been added to support facilities that provide training for home care dialysis.

Resident rooms in nursing homes now require a minimum CFA of 121 square feet with a minimum clear dimension of 11 feet in single-resident rooms. Multiple-resident rooms require 108 square feet per resident and a minimum clear dimension of 9 feet, 6 inches. Clearances in these rooms are required to support resident mobility and transfer. 

Likewise, all resident rooms for individuals of size require a minimum clear dimension of 13 feet, 2 inches to accommodate resident mobility and transfer. The minimum CFA required is:

• 200 square feet for single-resident rooms with a fixed overhead lift.
• 219 square feet for single-resident rooms without a fixed overhead lift.
• 197 square feet per resident for multiple-resident rooms with a fixed overhead lift.
• 216 square feet per resident for multiple-resident rooms without a fixed overhead lift.

Patient rooms in hospice facilities must now be single occupancy unless double occupancy is justified during the planning phase. The hospice patient room is required to have a minimum CFA of 153 square feet to accommodate a family support zone of 33 square feet. 

For more information

FGI is currently finalizing the 2022 edition of the Guidelines for Design and Construction. The print and electronic versions of the documents are planned for release at the same time early next year. For more information, readers can log on to fgiguidelines.org.

Changes to help improve ED efficiency and throughput

Overcrowded emergency departments (EDs) are a common problem in many hospitals, particularly those in urban areas. The 2022 Hospital and Outpatient Guidelines will introduce two clinical spaces intended to reduce crowding in EDs and free-standing emergency facilities. 

One approach the Health Guidelines Revision Committee has been considering since the beginning of the 2018 Guidelines revision cycle is the low-acuity patient treatment station. These ED spaces are intended for the “walking well” and supplement traditional treatment rooms, bays and cubicles. Evidence has shown that use of low-acuity stations reduces the average length of stay for all patients because ambulatory patients with minor injuries or conditions can be treated without waiting for a treatment room, bay or cubicle to become available. 

Although a number of health care organizations have incorporated low-acuity stations in their EDs, there previously were no fundamental requirements for these spaces. The low-acuity stations approved for the 2022 Guidelines have a 40-square-foot minimum clear floor area and provisions for clearances, medical gas outlets, electrical receptacles, nurse call devices, storage and privacy. The number of hand-washing stations required is based on the number of low-acuity patient stations in the treatment area.

The second new clinical treatment space that supports improved ED efficiency and throughput is a behavioral health crisis unit. Behavioral health visits to the ED continue to trend upward and contribute to longer than average lengths of stay. The behavioral health crisis unit is based on the EmPATH (emergency psychiatric assessment, treatment and healing unit) model and is an alternative to the ED for medically cleared patients. Patients in the unit receive care in a secure, calm and comfortable environment with large, open spaces. 

This unit is permitted to be part of the ED or located elsewhere, either on the same floor or elsewhere on campus for a hospital; or elsewhere in the building or in a separate structure for a free-standing emergency facility. 

Heather B. Livingston is chief operating officer and managing editor of the Facility Guidelines Institute. She can be reached at heather@fgiguidelines.org.