Healthcare is likely the most complex and chaotic of all industries as its standardization is difficult given the unpredictability of patient responses to therapeutic interventions. Layered on top of this are factors such as the increasing acuity of patients, an aging population being served, increasing economic constraints, and challenges
and demands on care providers that require multitasking and almost continual interruptions. Gurses et al. (5) reported that critical care nurses at seven healthcare systems found workflow, supply access, and the built environment were among several obstacles that affect their ability to provide high quality, reliable care. In addition, nurses’ work activities are interrupted at a high frequency of 10 times per hour, which illustrates the complexity of this work environment and underlies the reasons that errors are made (6,7). To ignore the needs and function of direct care providers when designing the built environment is to invite potential for adverse patient outcomes (8). In fact, studies have identified that equipment/supplies and facility issues are the two key issues that account for operational failures (9). The 2010 Facility Guidelines Institute (FGI) guidelines emphasize the involvement of personnel who work in patient-care areas during planning and design. Infection prevention aspects of the work activity can also be addressed by the inclusion of direct care providers in the Infection Control and Risk Assessment (ICRA) management process. Details of ICRA are addressed elsewhere in this text (see Chapter 83).

In the 1970s, there was intense focus on the environment as a primary reservoir of pathogens. As a result, several interventions were promulgated, including delivery of disinfectants by fogging large areas or patient-care rooms, walk-off mats to “remove” contaminants prior to entering an operating room (OR), and routine environmental microbiologic sampling of the environment. Subsequent analysis and evidence failed to support these interventions as effective and the Centers for Disease Control and Prevention stated in its 2003 environmental infection control guideline:

Fast forward to the 21st century, and one can find renewed interest and study of the role of the environment. Most of this has been driven by the ongoing challenges presented by multidrug-resistant organisms (MDROs) and the emergence of new strains of Clostridium difficile that have resulted in increasing incidence and are associated with considerable morbidity and mortality (11, 12 and 13). In addition, there have been several studies finding microorganisms persist in the environment and that admission to a room previously occupied by a patient either colonized or infected with an MDRO increases risk acquisition for the next patient (14,15,16). Coincident with studies of cross-transmission, disinfecting by use of whole-room, no-touch methods such as fogging or use of handheld ultraviolet germicidal irradiation (UVGI) devices have appeared in the literature as they undergo evaluation for efficacy and feasibility (17,18). Therefore, the design of the environment is undergoing renewed scrutiny in terms of patient safety.

The Center for Healthcare Design The Center for Healthcare Design (CHD) has coordinated a vast amount of work on defining and encouraging “evidence-based design” (EBD). The CHD defines EBD as “the deliberate attempt to base building decisions on the best available evidence with the goal of achieving the best possible outcomes for patients, families, and staff, while improving utilization of resources” (21). EBD has been developing on a path that is parallel to emerging emphasis on evidence-based practice to prevent HAIs since the 1970s and has made impressive progress in its goal to improve patient outcomes (22). The CHD, formally established in 1993, functions as a major center of research, communication, and development of a body of knowledge while it seeks to sort out the best approach to identifying EBD. In its pursuit to ensure that basic principles are incorporated by healthcare design professionals, the CHD engaged top research design professionals and developed the “Evidence-Based Design Accreditation and Certification (EDAC): Introduction to Evidence-Based Design.” The guide provides a comprehensive look at the EBD background, roots, and current developments, serving as a study guide to certify professionals in this field. Infection prevention professionals seeking to better understand many of the proposals that surface early in the ICRA design phase (e.g., patient safety based on IOM report, the Planetree and Pebble Projects, the influence of the military’s health research, and more) would find this guide an excellent overview of EBD findings and one that also addresses issues beyond the scope of this chapter.

Sustainability As is noted later, more and more professional architects, interior designers, and engineers consider sustainability as critical to design, and IPs are increasingly faced with these proposals when participating in long-term design planning. From the design professionals’ view, they are increasingly aware of the critical relationship between the environment and infection prevention and control issues, highlighting the importance of continued dialogue. Nowhere is this better demonstrated than in the consensus development work that occurs during the FGI standards review process, which includes infection prevention experts as well as an incredibly broad range of other disciplines ranging from engineering to interior design, all focused on development of the built environment to facilitate safer patient care and health outcomes.

HAI and the Environment In 2004, Ulrich et al. (23) published the results of their review of a substantial body of evidence on the impact of the environment on safety and quality. They found the environment has a significant impact on patients and others in healthcare facilities and that design that is based on solid evidence can improve safety and quality. However, studies of the efficacy of changes in the built environment in preventing HAIs remain incomplete. A systematic review of one aspect of design— single patient rooms—has reinforced that this gap continues to need more research (24).

The reasons for this include the multifactorial nature of HAIs, short lengths of stay that limit the ability to assess impact on HAIs, long incubation period between exposure and onset of infection (e.g., surgical site infection), and the need to use meaningful metrics of both processes and outcomes that are epidemiologically sound. By illustration, a well-designed study by Rupp et al. (25) involving hand hygiene and validated outcome metrics was not able to demonstrate a significant correlation between improved adherence with hand hygiene and reduction in HAIs. This need not discourage further research, but it is important that investigators use several measures of impact of environment-based interventions, assess the statistical power of their study, and avoid sole reliance on environmental microbiologic studies on which to make claims of efficacy.

A recent survey of key opinion leaders involved in design identified several critical issues going forward. These include addressing problems encountered during delivery of care, safety of care (e.g., need to prevent HAIs, medication errors, falls), patient satisfaction, and operational efficiency (26). Of note, HAI was ranked by the survey respondents as the topic of most importance in terms of the need for improving the current state.

The EHR and other devices such as wireless communication, newer methods for imaging and procedures, and wireless control of environmental conditions such as temperature control by the patient, are all elements of design in the 21st century (27). Regulatory issues may set limits for new technology since regulations frequently lag in addressing newer, more efficient design innovations. Enforcement of the National Fire Protection Association Life Safety Code comes to mind as an example of the efforts needed to modify the codes for the installations of alcohol-based hand rub (ABHR) dispensers in the corridors. CMS will frequently offer interpretations of Conditions of Participation standards to resolve conflicts for issues not anticipated decades ago. For example, wall-mounted computers in the egress corridors were recently addressed by the CMS in light of regulations governing egress corridor width (28).

Principles aimed at sustainability of the environment are also being used in over 80% of active projects based on a survey from 2008, and this is likely to continue (27). These include enhanced efficiency of heating, ventilation and airconditioning (HVAC) systems; building utilities (power and water); surface and furnishing treatments that lessen use of volatile organic compounds (VOC); the use of natural lighting; low-emission glass; and waste reclamation.

Assessment of Environmental Sustainability Leadership in Energy and Environmental Design (LEED) was developed by the U.S. Green Building Council that verifies a construction project is designed and built using environmental sustainability strategies. The certification process promotes accountability and greater attention to sustainability issues among contractors, building owners, and building occupants (29). A comparable group, Green Globes (GG), developed by the Green Building Initiative has similar goals but, until recently, was primarily used for
commercial building and is now engaged in healthcare as well (30). LEED and the GG systems are both environmental assessment methodologies that score buildings and award a ranking. These green building rating systems consist of a large set of questions relating to water efficiency, energy usage, construction materials, indoor air quality, and the building site. Details of the operational aspects have been published elsewhere (31,32,33). As noted above, as the EBD framework developed, the concept of sustainability has been incorporated as basic, and now all groups are attending more closely to environmental infection issues, as being just as critical for patient and worker safety.

Patient-centered care has emerged as the norm in acute care settings. As a result, hospitals have adapted the environment of care (EC) to accommodate increasing presence of family and other visitors, including lessening of restrictions in visiting hours.

Intensive Care Unit In light of this trend, the American College of Critical Care Medicine and the Society of Critical Medicine have published recommendations to support family involvement in the care of their critically ill loved ones (34). Many of these impact EC design and include the following:

Neonatal Units Pediatric areas have not been as thoroughly studied as neonatal intensive care units (NICUs) (30). NICUs, which have special challenges for sound and acoustic control, need to balance these with efforts aimed at infection prevention. NICUs have also undergone major transformations and, similarly, have focused on private rooms as well as space for family participation, remaining cognizant of HAI-reduction issues. Removing sources of loud noises, instituting quiet hours, educating staff and parents, putting in sound-absorbing ceiling tiles and flooring, and providing single patient rooms (as opposed to open wards) have been found to be effective in reducing noise levels, but these surfaces raise HAI-related questions. White’s recommended standards for NICUs provide valuable and detailed information on both acoustics and floor covering balanced with HAI concerns (21,35,36).

Transfers from one room to the next is disruptive to the patient, can result in hand-offs, and can increase the probability of errors or elevate the risk of HAI. Regarding the latter, frequent transfer of ventilator-dependent patients can increase the risk of ventilator-associated pneumonia (37). To address these issues, the “universal” or “scalable acuity” room—defined here as the ability of the environment to accommodate a variety of patients, including those who are critically ill—is an emerging design element (38). In addition, an emerging ICU practice involves not only emphasis on extubation from mechanical ventilation but also on early ambulation (39). This latter care intervention will have implications for design as space will need to be expanded to permit ambulation in the room, as well as the number of personnel that will be needed to assist the patient, for example, physical therapy and nursing.

Even as the trend toward the acuity-adaptable room grew, the decentralization of nursing services became another factor influencing the design of the patient-care unit to ensure the close proximity of the nurse to the patient (40). This desire for proximity of the caregiver to the patient resulted in a “racetrack” configuration—single occupancy rooms on the periphery of a common corridor with workstations (including viewing windows) in between every two rooms, increased attention to windows and use of natural lighting, and zones of space dedicated for personnel and family. Others, however, have suggested that for some units such as the ICUs, a central nursing station surrounded by private rooms permits easier visualization and response to rapid changes in patient status and should be a strong consideration for the physical design of critical care units (CCUs) (41). Another aspect related to visualization is real time, rapid communication and collaboration between personnel to respond to unexpected changes in the patient’s condition. Regardless, architectural design that enhances spatial separation of patients and facilitates communication can improve safety for patients and personnel.

The FGI research committee commissioned a study led by Chaudhury et al. to assess the benefits of single-patient rooms as a design element (42). Chaudhury found reduction in the risk of cross-infection and greater flexibility in operation. The 2006 FGI guidelines review committee reached a consensus on requiring the single room as a minimum standard. However, it made provisions for the state plan reviews, accomplished by the authority having jurisdiction (AHJ), to consider two-bedded rooms dependent on the facility’s programmatic needs. The Department of Defense independently supported the use of private rooms for its facility planning criteria at about the same time (22). More recent evidence has supported this direction in room design (4,43,44). The upfront cost of building a singlepatient room is higher compared to multi-bed rooms but benefits for the safety and comfort of the patient over the life of this room balance this initial investment. Detsky and Etchells (45) have also found this design enhances privacy/noise abatement, supports patient-centered care, results in fewer transfers, enhances flexibility with adaptable acuity, and offers spatial separation to mitigate cross-transmission of pathogens. Interestingly, some patient populations have expressed a preference for multi-bed rooms, whereas personnel favor single-patient room design (42,46). This highlights a need to involve patients in the design, if feasible.

Of note, the single-patient room has received ongoing scrutiny by others, especially in countries where multi-bed wards are more the norm. As highlighted earlier, others have called for more research on this design element (24). This design by itself is also not a panacea for infection prevention, as evidenced by the investigation by Hota et al. (2) of an outbreak described earlier in an ICU where all rooms
were single-patient occupancy. Overall, the single-patient room is likely to remain a significant design element, does provide some transmission limits, and continues to be a minimum requirement for new construction in the FGI’s 2010 guidelines (3).