HERD Health Environments Research & Design Journal

Published by SAGE

Online ISSN: 2167-5112


Print ISSN: 1937-5867


Evidence-based design
  • Article

December 2010


67 Reads


Is Evidence-Based Design a Field?
  • Article
  • Full-text available

October 2009


190 Reads


Figure 5: Mean approximate gross area per bed by construction type.
Figure 8: Mean approximate gross area per bed by unit specialty type.
Figure 9: Allocation of space by unit specialty type. A) Mean total patient room area as percentage of unit gross area. B) Mean total area for support and service functions as percentage of unit gross area. C) Mean total circulation area as percentage of unit gross area. 
Figure 11: Different types of unit layout by decade.
Figure 12: Mean approximate gross area per bed by unit layout type.
Space Allocation in the Award-Winning Adult ICUs of the Last Two Decades (1993-2012): An Exploratory Study

February 2014


1,044 Reads

Objective: This exploratory study describes space allocation among different generic categories of functions in adult intensive care units (ICUs) showing how the amount of space of any one functional category is related to that of another functional category, and how different strategic choices, such as size, construction type, specialty type, and layout type, affect space allocation in these ICUs. Background: Even though critical care practice has already undergone significant changes in the last few decades, it is still an evolving domain of medical practice. As a result, ICU design is also evolving as new regulatory standards, new technologies, and new clinical models are being introduced. A good understanding of the above issues regarding space allocation may help us better guide the evolution of ICU design. Methods: The study includes a set of 25 adult ICUs that were recognized between 1993 and 2012 by the Society of Critical Care Medicine (SCCM), the American Association of Critical Care Nurses (AACCN), and the American Institute of Architects Academy of Architecture for Health (AIA AAH) for their efforts to promote healing of the critically ill and injured patients through the design of the critical care unit environment. Results: The study finds notable differences in space allocation among different generic categories of functions between the ICUs of the first decade (1993-2002) and the second decade (2003-2012). The study also finds notable differences in space allocation among different generic categories of functions in relation to size, construction type, specialty type, and layout type. Conclusions: Despite several limitations, the study should help design better adult ICUs based on an evidence-based understanding of the relationships between space allocation and strategic choices. Keywords: Construction, critical care/intensive care, evidence-based design, planning, project management.

Book Review: Australian Healthcare Design 2000-2015: A Critical Review of the Design and Build of Infrastructure in Australia

April 2014


46 Reads

In July, 2013, the International Academy for Design & Health held the 9th World Congress in Brisbane, Australia. Australia's proposal to host the Congress evolved into the book, Australian Healthcare Design 2000-2015, which was then published to coincide with the event. Alan Dilani, Founder and CEO of the International Academy for Design & Health, states in the book's preface, "Australia's successful bid to host the event reflects the huge amount of new healthcare building that is taking place across the region, and the body of research and knowledge that has developed there as a result...this book aims to communicate to the rest of the world that the region has some of the most advanced healthcare buildings of our time" (p. 12).This richly illustrated book appeals to visually-oriented designers, but offers valuable information for scholars and healthcare administrators as well. Many compelling contemporary international healthcare projects are featured in journals and books, but rarely do we get to see so many projects collected together focused on a specific geographic region, as is done in Australian Healthcare Design 2000-2015. The book serves as both a compendium and snapshot of the latest research, practice, and design in a large and diverse country. While Australia faces some unique challenges such as the vast distances between cities and the large number of rural community facilities, most issues are those facing every country and society: rising healthcare costs, patient and worker safety, an aging population, and rapidly advancing technology.The World Health Organization defines health as "... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (1948). Most medical care, and healthcare design, in the second half of the twentieth century followed the "pathogenic" and "biomedical" model, in which mind and body were viewed as separate rather than inextricably linked, and diseases were addressed primarily with pharmaceutical drugs and/or surgery. Healthcare practice and design is now moving in the direction of care that does not just treat the sick after the fact, but instead uses a more holistic preventive care model, encouraging health and wellness in all aspects and through all stages of life. The term "salutogenesis," first coined by Aaron Antonovski in 1979, has begun to be adopted by members of the healthcare design community as an expression of this belief. This approach promotes health and well being-not just for buildings, but for all scales of design (cities, communities, landscapes). Salutogenic design and biophilic design are closely linked to concepts associated with evidence-based design.The book is organized into two sections: Essays and Projects. Following the Introduction, which includes a preface by Alan Dilani, and Forewords by the editor and the sponsors, are 15 essays by a mix of researchers and professionals, all of whom have practiced in Australia. …

Role of a Service Corridor in ICU Noise Control, Staff Stress, and Staff Satisfaction: Environmental Research of an Academic Medical Center

April 2013


55 Reads

Zhe Wang


Betsy Downs


Ashley Farell




Shimby McCreery
Objective: To investigate the role of a dedicated service corridor in intensive care unit (ICU) noise control and staff stress and satisfaction. Background: Shared corridors immediately adjacent to patient rooms are generally noisy due to a variety of activities, including service deliveries and pickups. The strategy of providing a dedicated service corridor is thought to reduce noise for patient care, but the extent to which it actually contributes to noise reduction in the patient care environment and in turn improves staff performance has not been previously documented. Methods: A before-and-after comparison was conducted in an adult cardiac ICU. The ICU was relocated from a traditional hospital environment to a new addition with a dedicated service corridor. A total of 118 nursing staff participated in the surveys regarding pre-move and post-move environmental comfort, stress, and satisfaction in the previous and new units. Acoustical measures of noise within the new ICU and a control environment of the previous unit were collected during four work days, along with on-site observations of corridor traffic. Results: Independent and paired sample t-tests of survey data showed that the perceived noise level was lower and staff reported less stress and more satisfaction in the new ICU (p < 0.01). Analyses of acoustical data confirmed that the new ICU was significantly quieter (p < 0.02). Observations revealed how the service corridor impacted patient care services and traffic. Conclusions: The addition of a dedicated service corridor works in the new unit for improving noise control and staff stress and satisfaction. Keywords: Critical care/intensive care, noise, satisfaction, staff, work environment.

Ten Trends Transforming Cancer Care and Their Effects on Space Planning for Academic Medical Centers

March 2015


72 Reads

This article aims to define the major trends currently affecting space needs for academic medical center (AMC) cancer centers. It will distinguish between the trends that promote the concentration of services with those that promote decentralization as well as identify opportunities for achieving greater effectiveness in cancer care space planning. Changes in cancer care-higher survival rates, increased clinical trials, new technology, and changing practice models-increasingly fill hospitals' and clinicians' schedules and strain clinical space resources. Conflicts among these trends are concentrating some services and dispersing others. As a result, AMCs must expand and renovate intelligently to continue providing state-of-the-art, compassionate care. Although the typical AMC cancer center can expect to utilize more space than it would have 10 years ago, a deeper understanding of the cancer center enterprise can lead to opportunities for more effectively using available facility resources. Each AMC must determine for itself the appropriate balance of patient volume, clinical activity, and services between its main hospital campus and satellite branches. As well, space allocation should be flexible, as care trends, medical technology, and the provider's own priorities shift over time. The goal isn't necessarily more space-it's better space. © The Author(s) 2015.

Table 1. Survival of MRSA on Copper Alloys Employing EPA Testing Criteria. 
Control and Mitigation of Healthcare-Acquired Infections: Designing Clinical Trials to Evaluate New Materials and Technologies

October 2011


286 Reads

Hospitals clean environmental surfaces to lower microbial contamination and reduce the likelihood of transmitting infections. Despite current cleaning and hand hygiene protocols, hospital-acquired infections (HAIs) continue to result in a significant loss of life and cost the U.S. healthcare system an estimated $45 billion annually. Stainless steel and chrome are often selected for hospital touch surfaces for their “clean appearance,” comparatively smooth finish, resistance to standard cleaners, and relative effectiveness for removing visible dirt during normal cleaning. Designers use wood surfaces for aesthetics; plastic surfaces have become increasingly endemic for their relative lower initial cost; and “antimicrobial agents” are being incorporated into a variety of surface finishes. This paper concentrates on environmental surface materials with a history of bactericidal control of infectious agents and focuses on the methods necessary to validate their effectiveness in healthcare situations. Research shows copper-based metals to have innate abilities to kill bacteria in laboratory settings, but their effectiveness in patient care environments has not been adequately investigated. This article presents a research methodology to expand the evidence base from the laboratory to the built environment. For such research to have a meaningful impact on the design/specifying community, it should assess typical levels of environmental pathogens (i.e., surface “cleanliness”) as measured by microbial burden (MB); evaluate the extent to which an intervention with copper-based materials in a randomized clinical trial affects the level of contamination; and correlate how the levels of MB affect the incidence of infections acquired during hospital stays.

Building Connections: A Clinical Operations View of Activation Planning

July 2009


15 Reads

The construction trend in healthcare remains strong compared to other construction markets due to the stability of the forces driving the growth. Constructing new healthcare facilities is challenging because of the need to collaborate continuously with the operational components of the organization. Successful planning and activation greatly enhance the outcome of any project. Working with an operational point of view throughout the building activation process, beginning with design, benefits both the construction and operational teams. The result is a more positive outcome for the institution, fewer changes during the project for the construction team, and the ability to minimize costly renovations and/or change orders. Focused and intentional communication throughout the design and construction phase is vital to the activation and success of any project. Developing a communication plan early in the project supports the development of trust and organizational participation. Activation planning must link design and operations to improve project outcomes.

Centralized and Decentralized Nurse Station Design: An Examination of Caregiver Communication, Work Activities, and Technology

October 2007


578 Reads

The healthcare construction boom requires evidence for effective design of nurse stations, including evidence supporting workflow processes, computerization, integration of technology, communication of caregivers, and optimal patient outcomes. This article describes the examination of a traditional centralized nursing station using a total patient care delivery model and minimal computerization and a highly computerized, decentralized nursing station using a team nursing model. Results specific to communication activities, time with patients, number of patient visits per registered nurse, and patient satisfaction with response time are reported.Key WordsPatient care unit design, ergonomics, healthcare workflow, medical-surgical unit, registered nurse work activities.

Acuity-Adaptable Nursing Care: Exploring Its Place in Designing the Future Patient Room

October 2011


63 Reads

To substantiate the anticipated benefits of the original acuity-adaptable care delivery model as defined by innovator Ann Hendrich. In today's conveyor belt approach to healthcare, upon admission and through discharge, patients are commonly transferred based on changing acuity needs. Wasted time and money and inefficiencies in hospital operations often result-in addition to jeopardizing patient safety. In the last decade, a handful of hospitals pioneered the implementation of the acuity-adaptable care delivery model. Built on the concept of eliminating patient transfers, the projected outcomes of acuity-adaptable units-decreased average lengths of stay, increased patient safety and satisfaction, and increased nurses' satisfaction from reduced walking distances-make a good case for a model patient room. Although some hospitals experienced the projected benefits of the acuity-adaptable care delivery model, sustaining the outcomes proved to be difficult; hence, the original definition of acuity-adaptable units has not fared well. Variations on the original concept demonstrate that eliminating patient transfers has not been completely abandoned in healthcare redesign and construction initiatives. Terms such as flex-up, flex-down, universal room, and single-stay unit have since emerged. These variations convolute the search for empirical evidence to support the anticipated benefits of the original concept. To determine the future of this concept and its variants, a significant amount of outcome data must be generated by piloting the concept in different hospital settings. As further refinements and adjustments to the concept emerge, the acuity-adaptable room may find a place in future hospitals.

Rethinking Efficiency in Acute Care Nursing Units: Analyzing Nursing Unit Layouts for Improved Spatial Flow

October 2012


847 Reads

Objective: This paper introduces a new design tool to increase efficiency in acute care settings. This visual tool facilitates matching spatial flow with caregivers' workflow to reduce waste and redundancies, as recommended by Lean thinking. Providing work environments that protect caregivers from fatigue, interruptions, and redundancies can contribute to quality patient care. Methods: By studying the Guidelines for Design and Construction of Health Care Facilities and reviewing the literature, the authors identified the main clinical spaces supporting nursing care and their important linkages. Space syntax, a diagrammatic analysis of relationships, was used to decode spatial relationships among the clinical spaces in five case studies. The movement distributions were measured and possible conflicts with focus-demanding tasks, such as noise and interruptions, were identified. The information was summarized in a visual diagram providing the "syntactic anatomy" of the most important work spaces. Results: The main clinical spaces were the following: (1) patient corridor; (2) nurses' station; (3) medication area; (4) clean room; (5) soiled room; (6) physicians' dictation area; (7) report room; (8) restricted nourishment area; (9) equipment storage; and (10) unrestricted nourishment area. The report room, nourishment area, and physician workspace showed strong linkages to the patient corridor and nurses' station, although such spaces were not clearly discussed in the design guidelines. The most caregiver movement occurs in the patient corridor and nurses' station. These areas pose the greatest possibility of interruptions by persons. The results were translated into a visual design efficiency checklist. Conclusion: Illustrating the spatial order of the support spaces-and comparing that to use patterns-enables designers to reduce the movement sequences nurses undertake when accessing resources and identify where the flow is disrupted by "displaced" functions.

An Empirical Examination of Patient Room Handedness in Acute Medical-Surgical Settings

October 2010


30 Reads

The study objective was to examine whether standardized same-handed room configurations contribute more to operational performance in comparison to standardized mirror-image room configurations. Based on a framework that physical environment standardization supports process and workflow standardization, thus contributing to safety and efficiency, the study examined the comparative effectiveness of the standardized same-handed configuration and the standardized mirror-image configuration. Patient room handedness has emerged as an important issue in inpatient unit design, with many hospitals adopting the standardized same-handed room concept at all levels of patient acuity. Although it is argued that standardized same-handed rooms offer greater levels of safety and efficiency in comparison to standardized mirror-image rooms, there is little empirical evidence either to support or refute these contentions. An experimental setting was developed where elements of the physical environment and approach to the caregiver zone were systematically manipulated. Twenty registered nurses (10 left-handed and 10 right-handed) provided three types of care to a patient-actor across nine physical design configurations, which were videotaped in 540 separate segments. Structured interviews of the subjects were conducted at the end of each individual set of simulation runs to obtain triangulation data. Video segments were coded by nursing experts. Statistical and content analyses of the data were conducted. Study data show that standardized same-handed configurations may not contribute to process and workflow standardization--hence, to safety and efficiency--any more than standardized mirror-image configurations in acute medical-surgical settings. Data suggest that a global view of the patient care environment upon entry is the most sought-after familiarization factor to reduce cognitive load.

Environmental Congruence and Work-Related Stress in Acute Care Hospital Medical/Surgical Units: A Descriptive, Correlational Study

October 2011


16 Reads

To describe the degree to which Environmental Congruence (EC) is present in sampled units and considered important/desirable by staff RNs; staff RNs' reported level of work-related stress (WRS); the perceived contribution of the physical environment to WRS; and the relationship between existing levels of EC and WRS. Few studies have focused on how the physical environment might contribute to nurses' WRS and chronic nursing shortages. The construct of EC can be used, within a Person Environment (PE)-Fit framework, to assess the fit among nurses, nursing work, the physical work environment, and WRS. EC was measured using investigator-developed, literature/criterion-based survey instruments. Staff RNs reported WRS variables by using two single-item self-report measures. The final convenience sample consisted of 471 staff RNs from 39 medical/surgical units from 12 hospitals in the upper Midwest. Data were collected over a 7-month period. The mean level of existing EC in the sample was roughly 70% percent of highest capacity and that of important/desired EC in the sample was 93%. Staff RNs' mean level of WRS was 6.7; the mean contribution of the physical environment to WRS was 5.8. Moderate negative correlations were found between EC and WRS (r = -.41, p < .05), and between physical environment contribution to WRS and EC (r = -.55, p <.001). Staff RNs in the sampled units wanted a significantly higher level of EC. They rated their WRS moderately high and the contribution of the physical environment to it as moderate. A moderately negative relationship was found between EC and WRS. EC may be a useful construct in research that attempts to improve hospital nursing work environments.

Establishing an Acute Care Nursing Bed Unit Size: Employing a Decision Matrix Framework

July 2008


33 Reads

Determining the number of patient rooms for an acute care (medical-surgical) patient unit is a challenge for both healthcare architects and hospital administrators when renovating or designing a new patient tower or wing. Discussions on unit bed size and its impact on hospital operations in healthcare design literature are isolated, and clearly there is opportunity for more extensive research. Finding the optimal solution for unit bed size involves many factors, including the dynamics of the site and existing structures. This opinion paper was developed using a "balanced scorecard" concept to provide decision makers a framework for assessing and choosing a customized solution during the early planning and conceptual design phases. The context of a healthcare balanced scorecard with the quadrants of quality, finance, provider outcomes, and patient outcomes is used to compare the impact of these variables on unit bed size.

Environmental Design in Acute Care Settings: A Case Study of a Neurological Rehabilitation Unit

October 2013


58 Reads

Objective: The purpose of this case study was to examine environmental variables that lead to staff error in acute care settings: noise; lighting; ergonomics, furniture, and equipment; and patient room design and unit layout. Background: Chaudhury, Mahmood, & Valente (2009) reviewed a number of design considerations related to reducing errors by nursing staff in acute care settings. The Neurological Rehabilitation Unit (NRU) at one hospital served to further examine the design recommendations outlined by Chaudhury et al. (2009). Methods: Based on photographs, a site tour, interviews with the NRU manager and with the son of a patient of 5 months, comparisons were made between the NRU and the acute care setting design considerations reviewed by Chaudhury et al. (2009). Results: The NRU appeared to comply with many recommendations: enforced noise reduction was facilitated through limiting both the number of patients per room and the number of patients admitted to the unit. Distinct rooms were used for various tasks that helped to contain activity-based noise. A combination of daylighting and artificial lighting was in place, but efforts to control glare and thermal comfort were not integrated into the design. The ergonomic needs of employees were incorporated in the design of the NRU, and the layouts of patient rooms and the layout of the NRU in general also were compatible with the design recommendations reviewed by Chaudhury et al. (2009). Conclusions: Many of the design attributes advocated by Chaudhury et al. (2009) were included in the NRU. Supplemental research should be undertaken, however, to objectively measure nursing error, efficiency, and staff satisfaction with respect to the comparisons and assumptions presented in this study. Keywords: Case study, design, hospital, satisfaction, staff.

Design Characteristics of Acute Care Units in China

October 2014


192 Reads

To describe the current state of design characteristics of acute care units in China's public hospitals and compare these with characteristics with acute care units in the United States. The healthcare construction industry in China is one of the fastest growing sectors in China and, arguably, in the world. Understanding the physical design of acute care units in China is of great importance because it will influence a large population. Descriptive study was performed of unit configuration, size, patient visibility, distance to nursing station and supplies, and lighting conditions in 25 units in 19 public hospitals built after 2003. Data and information were collected based on spatial and visibility analysis. The study identified major design characteristics of the recently built (from 2003 onward) acute care units in China, comparing them, where appropriate, with those in U.S. It found there are three dominant types of unit layout: single-corridor (52%), triangular (36%), and double-corridor (12%). The number of private rooms is very low (11%), compared with two- or three-bed rooms. Centralized nursing stations are the only type of nurses' working area. China also has a large unit size in terms of number of patient beds. The average number of patient beds in a unit is 40.6 in China (versus 32.9 in U.S.). The care units in China have longer walking distance from nursing station to patient bedside. The percentage of beds visible from a nursing station is lower in China than in the U.S. The access to natural light and direct sunlight in patient rooms is greater in China compared with those in U.S.-100% of patient rooms in China have natural lighting. A majority of them face south or southeast and thus receiving direct sunlight (91.4%). Because of the differences in economies and building codes, there are dramatic differences between the spatial characteristics of acute care units in China and the United States. © 2014 Vendome Group, LLC.

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