Good design is more than providing a softer floor for healthcare workers or using different carpet colours to help patients find their way around what can be a bewildering place.
In recent years, the medical profession has been adopting “evidence-based medicine” that uses research finding to guide best practice, rather than simply accept expert opinion, the traditional and the age-old route towards clinical decisions.
The same is true in hospital design, where architects and interior designers have come to recognise that a healthcare facility is more than just its component parts. It should be a place that goes beyond mere functionality to create an environment that actually aids patient recovery.
Evidence-based design can be about recognising the importance of something as simple as natural light. For example, it’s long been known that we are all influenced by circadian rhythms that govern our performance in numerous ways – including sensitivity to drugs, hormone secretion, sleep patterns and immune responses.
Knowing that is one thing, but making natural light a key part of the architectural brief requires good medical evidence – and there is now plenty. For example, a 2005 study (1) that showed that patients in a brighter area of a hospital took 22% less analgesic medicine than patients with the same medical condition on the dark side of the hospital. Apart from the human cost, that equated to a 21% cost differential.
Good healthcare design, based on empirical evidence, aims not only to make the patient experience better but to improve patient outcomes. For architects and interior designers, it’s about building complex and expensive facilities that are designed to work to best effect, and then testing every aspect of their design.
A 2009 study in the USA (2) exemplifies how basic yet how profound evidence-based research can be and how, once bad design is built into the fabric of a building, undesigning it can be difficult if not impossible. In the study, fifty-two physicians were asked to examine a standardised patient in two hospital room settings using a replica of the proposed architectural plan. The settings differed only by the placement of the alcohol-based hand-rub dispenser.
The result was that when the dispenser was in clear view of the physicians as they observed the patient, 53.8 per cent washed their hands. When the dispenser was not in their line of sight (as it had been in the original architectural plan), only 11.5 per cent washed their hands. Based on these results, the final architectural plans were adjusted accordingly. Obvious, perhaps: but it took research.
The philosophy of patient-centric care is, of course, not a new one. It’s what hospitals are there to do: care for the sick. However, traditional hospital design has been largely about functionality. Compare that with a new private hospital opening this year in the UK. Their view is that a night in hospital costs more than a night in a 5-star hotel. So why not make the experience similar? Compellingly, the hospital aims to “give people good health, not an experience of illness.”
Good hospital design is therefore about such nonclinical issues as building in ambient light and colour, giving patients privacy – and all aimed at reducing patient stress and improving outcomes, not least by reducing the incidence of medical error. The New York Times last year reported that more than 1500 studies have been carried out into how good design can achieve those objectives.
Air quality & noise
At Desso, one of the world’s leading carpet manufacturers, we also believe in evidence-based design, because there is now overwhelming evidence that good design can start from the floor upwards. It’s more than providing a softer floor for healthcare workers or using different carpet colours to help patients find their way around what can be a bewildering place. Primarily, in terms of patient outcomes, it’s about air and noise.
Taking air quality first, the air that we breathe indoors has been named and shamed as one of the top ten health risks of the modern world, and that’s especially true in a healthcare environment dealing with the vulnerable and sick.
The World Health Organization (WHO ) estimates that indoor air pollution is the 8th most important risk factor to health and is responsible for 2.7 per cent of the global burden of disease. Asthma, in the developed and developing world, is the largest culprit.
The WHO also estimates that, in 2005 alone, some 250,000 people died from asthma worldwide. It remains the most common chronic disease in children, and its incidence is increasing. Worldwide, there are some 300 million sufferers.
As a carpet manufacturer, we’ve long recognised that carpeting can improve indoor air quality by capturing and holding allergen-causing substances tightly and, as a result, keeping them from becoming airborne, and therefore minimizing their circulation in the breathing zone.
Indoor air quality
In 2001, Dr Michael Berry wrote a report entitled Assessment of Carpet in Sensitive Environments. In it he examined the findings from a number of studies that looked at the relationship between carpet and indoor air quality (IAQ) in settings that directly affect the very young, the very old and those who are ill.
His research found that “carpet is a preferred and widely used floor covering associated with minimal complaint. Previous claims [that carpets contribute
to IAQ] are not supported in the scientific literature. Research to date, some going back over 30 years, consistently shows carpet to be a safe and healthy product.
In 1993, a study titled "Global Strategy for Asthma Management and Prevention" was published collaboratively by the US National Heart, Lung, and Blood Institute and the World Health Organization. The 2007 update to the original report states that there is no evidence that replacing carpet with hard surface flooring has a health benefit.
At Desso, recognising those potential health benefits, we’ve gone a significant step further by launching a next-generation carpet with a unique yarn structure that captures even more harmful fine dust from the air – specifically designed to meet the requirements of the health sector, and address the very real problems posed by poor indoor air quality.
Independent tests have confirmed that AirMaster® is eight times more effective in capturing and retaining fine dust than hard flooring – and four times more effective than standard carpeting (3) - and therefore able to make a very real difference, particularly in high-traffic areas where lots of feet would otherwise churn up dust and fine material from the floor.
That, however, was only half the challenge that we gave ourselves, because the other problem in a busy hospital or healthcare facility is acoustics, and noise can be distracting, intrusive – and detrimental to health.
The importance of sound in healthcare is much better understood now, although research continues to demonstrate that sound levels remain stubbornly high in many healthcare environments. A study for the Centre for Health Design (4), found that there were two primary reasons.
First, hospitals and healthcare facilities generate a range of background noises – from telephones and trolleys to staff conversations and bleepers, making sound reducing strategies inevitably complex. However, and second, the study also found that the surfaces in hospitals – floors, walls and ceilings – are usually hard and reflect sound rather than absorb it.
That conclusion is backed by recent US research by John Hopkins University and the Georgia Institute of Technology (5). They found that noise in hospitals is a significant problem that is generally getting worse, even in new construction – and that high noise levels in hospitals can potentially contribute to stress and burnout in hospital staff, reduced speed of patient wound healing. The research also found that there is legitimate concern that hospital noise can negatively affect speech communication and cause an increased number of medical errors.
The authors state that: “Conventional acoustical treatments are used sparingly in hospitals because it is believed that sound absorbing materials with pores
harbour bacteria. Instead, smooth, hard, flat surfaces are used because they are easy to clean. Consequently, these surfaces are acoustically reflective and serve to aggravate existing noise problems.”
Of course, noise can be reduced in a number of ways. A recent report in the Wall Street Journal says that, at least in the USA, there is a trend towards private patient rooms, social spaces for family members, decentralised nurses’ stations, acoustical tiles – and carpet to reduce equipment noise.
That trend is, of course, based on evidence-based research. For example, the Karmanos Cancer Institute in Detroit, Michigan, saw a 30 per cent reduction in medical errors on one unit after it installed acoustical panels and introduced decentralised nursing stations. Additionally, the Methodist Hospital in Indianapolis, Indiana, USA, attributes its lowered medical error rate on a redesign of its coronary care unit, decentralised nursing, and carpet in the hallways.
Reviewing carpet use in the US healthcare sector, the Centre for Disease Control found that carpets have been used in both public and patient areas for over
thirty years – and that carpets do not influence hospital acquired infection rates.
For many health professionals, the everyday sounds of a hospital are entirely normal. However, the experience of patients is quite different, finding themselves in unfamiliar and stressful surroundings. For patients, the evidence is that reducing sound in a healthcare environment can have significant benefits.
For example, and taking one study from many, research carried out in Stockholm (6) among coronary intensive care patients found that, when sound-reducing strategies were introduced, patients slept better, were less stressed and reported that nurses gave them better care.
Standard carpet gives impact sound reduction properties of between 20 and 30 decibels. We’ve developed a new carpet backing, specifically for environments such as healthcare facilities, that gives a further reduction, depending on the carpet type, of 10 dB or more, making it the most sound absorbent option on the market – and in many cases rendering it unnecessary to install other sound reducing strategies such as ceiling tiles.
We live in an age that has seen, and will see, huge strides forwards in healthcare, from new drug types to new treatments. Unravelling the genone and the development of stem cell research hold out the promise of medical miracles on the near horizon. But we shouldn’t forget that medicine is also holistic, and that other factors such as natural light, quietness, and air quality also have a part to play.
After all, the evidence is now there.
1. Walch JM et al
2. David J Birnbach, University of Miami Miller School of Medicine, University of Miami-Jackson Memorial Hospital Center for Patient Safety.
3. Independent tests were carried out by GUI, the German test institute, and based on AirMaster® performance against standard PVC hard flooring and standard structured loop pile carpet. GUI specialises in assessing air quality, dampness and dust particle count.
4. Ulrich and Zimring, Centre for Health Design, 2004.
5. N oise in Hospitals: Effects and Cures, 2008.
6. Blomkvist et al