Texas A&M University

1. Conference ‘Ett schysst sjukrum’ Texas A&M University Design to promote health: Research and evidence-based practice from children’s hospitals Roger S. Ulrich, Ph.D.

2. Evidence Based Design Evidence-based design (EBD) is 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

3. Evidence-Based Design Research Rigorous research to date (approx 1,500 studies) links the physical environment to outcomes in following major areas: Improving • Patient safety • Other patient outcomes • Staff outcomes (such as work satisfaction, retention, effectiveness) • Overall healthcare quality • Financial performance

5. Traditional vs well-designed floors: Effects on nurse activity • Travel: • Traditional: 10-18 km per day • Well-designed: 2-5 km • Care time received by each patient: • Traditional: 16-24 minutes per shift • Well-designed: 35-45 minutes • Time spent ‘hunting and gathering’ • Traditional: 40% • Well-designed: 10%

6. Providing single rooms is vital for adapting to sicker patients in future • Combination of: • single rooms • localized nurse stations with good patient observation • good ventilation Cromer Children’s Univ. of Chicago

7. Hospital Acquired Infections • Increase hospital costs per patient by $40,000 in U.S. • Increase ICU stays by 8 days/patient, other stays by 14 days (Clark) More that 180 studies were identified pertaining to infection and the hospital built environment (Ulrich & Zimring, 2004, 2007)

8. Surfaces commonly contaminated by MRSA (Methicillin-resistant staphylococcus aureus) R.S. Ulrich with P.A. Wilson

9. Problem: Unwashed Staff Hands Low hand washing compliance has strong causal link with contact transmission of infection • Compliance in busy units: 14-28% • Education inadequate and transient

10. Design to Increase Hand Washing Conveniently located basin in single room Soap dispenser Alcohol-based gel dispenser Automatic faucet (no touch) Easy-to-clean basin counter (continuous impervious surface) Patient Bed Handwash basins and hand rub dispensers should be close to staff movement paths, visually prominent, near care point M. D. Anderson Ambulatory Cancer Center Houston

11. Problem: Noise • Hospital noise levels far higher than recommended values • Noise sources are too numerous and too loud • Surfaces are sound reflecting More than 165 studies (Ulrich & Zimring, 2007)

12. Hospital noise levels are steadily getting worse • Noise levels everywhere are rising 5 dB per decade • Much research shows noise worsens patient and staff outcomes

13. [Blomkvist, Eriksen, Theorell, Ulrich and Rasmanis, 2005. Occupational and Environmental Medicine] STUDY • Staff:nurses (36) who were specialists in cardiology and worked regularly in the coronary critical care unit • Findings:During good acoustics staff • experienced lessened work demands • increased workplace social support • improved quality of patient care • better speech intelligibility

14. [Hagerman, Rasmanis, Blomkvist, Ulrich, Eriksen, and Theorell, 2005. International Journal of Cardiology] STUDY • Patients:adults (94) diagnosed with acute myocardial infarction in a coronary critical care unitin a Stockholm hospital • Intervention:Acoustics were improved by periodically changing ceiling tiles from sound-reflecting to sound-absorbing tiles • Findings:During good acoustics patients slept better, had less physiological stress, and a lower incidence of re-hospitalization

15. Effective design measures for creating quiet healthcare buildings • Single-bed patient rooms • Install high-performance sound-absorbing ceilings • Reduce noise sources (provide noiseless paging system, etc.)

16. Do roommates provide stress-reducing social support? • Studies on adult patients show that 85%-90% of the time roommates are source of stress not positive social support • Stress examples: roommate who is unfriendly or seriously ill • Roommates generate much noise

17. Single-bed vs. Multi-bed Rooms (Ulrich, 2004) Single Multi-bed Healthcare associated infections Medical errors Falls Staff observation of patients Staff/patient communication Confidentiality of information Presence of family Patient privacy and dignity Avoid mixed-sex accommodation Death with dignity Noise Sleep quality

18. Single-bed vs. Multi-bed Rooms (Ulrich, 2004) Single Multi-bed Pain Patient stress Patient satisfaction Choice Staff satisfaction Staff work effectiveness Reducing room transfers Adapt to handle high acuity Patient privacy and dignity Managing bed availability Initial construction costs Operations and whole life costs

19. Recommendation of NACHRI:(U.S. National Association of Children’s Hospitals and Related Institutions) “Based on a converging body of evidence, it is recommended that single rooms be provided for all patients in pediatric settings.” NACHRI (2008). Transforming Children’s Health Through the Physical Environment, 8.

20. Design to Reduce Stress • Design to ensure exposure to nature, calming gardens, and natural light that reduce stress and help lower pain

21. What we know about effects of viewing nature About 40 scientific studies • Quickly lowers psychological and physiological stress • Produces clinically important pain alleviation in adults • Other: reduces aggression, improves satisfaction

22. Effects of nature window view on recovery from surgery(Ulrich, 1984) RESEARCH EXAMPLE • Shorter stays • Less pain • Fewer minor complications • Better emotional well-being

23. RESEARCH EXAMPLE “Distraction Therapy with Nature Sights and Sounds Reduces Pain During Flexible Bronchoscopy”(Diette et al., 2003) • Patients: adult patients (80) undergoing flexible bronchoscopy with conscious sedation • Intervention: Nature scene on ceiling with tape of nature sounds. Control group had no nature scene or sounds • Results: Patients with nature distraction reported significantly less pain

24. Karmanos Cancer Outpatient Center Southfield, Michigan View from chemotherapy patient chair

25. What types of art are preferred by adult patients? • Vast majority of adult patients across diverse countries prefers natureart • Public likes art that evokespositivefeelings • 77% agree “art should berelaxingto look at” • Most “want art that makes mehappy”

26. Provide Access to Daylight • Natural light/sunlight has bio-chemical and physiological effects that foster improved outcomes in many types of patients • Reduction of depression (improved emotional well-being) • Mitigation of pain

27. RESEARCH EXAMPLE STUDY: Natural light and depression by Benedetti et al., 2001 EAST WEST Patients: 602 diagnosed with severe depression Morning:1400 lux Afternoon:3000 lux Morning:15500 lux Afternoon:2700 lux Findings: Those with high levels of morning sunlight (east facing rooms) had shorter stays by 3.7 days

28. Children’s Garden Legacy Hospital Portland, Oregon

29. Children’s Garden Legacy Health Portland