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September 3, 2009
Curtains for privacy? Forget it. Splendid isolation is the new model, writes Leonie Lamont.
Hands up all who have ventured into hospitals and have ever: 1) been lost trying to navigate their way around; 2) had their dignity and privacy shredded by curtains masquerading as sound barriers; 3) left sleep deprived after all the racket; and 4) picked up a hospital-acquired infection.
Keep your hand up if you feel you’ve ever won the public hospital lottery – a private room. Not so many hands waving. This is about to change with a revolution coming to hospital design.
The new generation of hospitals being built – including multibillion-dollar public hospital projects such as the Fiona Stanley Hospital in Perth, the Gold Coast University Hospital and the new Royal Adelaide Hospital – are signalling the demise of multi-bed wards. Single-bed rooms will account for 60 to 75 per cent of accommodation in these new hospitals.
The new public/private Mater Mothers’ Hospital in Brisbane, which delivers 10,000 babies a year, is already basking on the public relations map as ”the premier maternity facility in the southern hemisphere”. All 90 beds in the private section are single. In the public part, 39 per cent are singles – 61 per cent are two-bed rooms.
Australian health facility guidelines call for 30 per cent of beds to be single roomed – and the guidelines aren’t mandatory. What has tipped the balance to accepting the single room movement, despite higher construction costs, is the work of an American architecture professor, Roger Ulrich, the guru of evidence-based design.
Just as evidence-based medicine sought to analyse studies and make findings about what treatments, procedures and drugs were most effective for patients, Ulrich asked how hospital design affected medical errors, infection rates, falls, pain, stress, sleep, privacy and patient satisfaction.
His work has influenced the design of Sydney’s newest public hospital – the $145 million Auburn Hospital – and its collaborating architects, Silver Thomas Hanley and Hassell, have engaged Ulrich as a consultant on two of their projects, the $1.76 billion Fiona Stanley and the $1.5 billion Gold Coast University hospitals.
NSW could do with some good news about its hospitals. The Garling inquiry’s endorsement of our public hospitals as one of the better public health care systems in the developed world was overwhelmed by the evidence of a system in crisis.
It told of elderly women, and men, stuck in mixed-gender wards in our premier teaching hospitals. And doctors whose hand hygiene was so poor Garling wrote: ”A sizeable proportion of them trail infection around like sparks in a dry wheat field on the black soil plains at Mullaley, bringing great risk to the patients.”
Ailing infrastructure was highlighted again by the publication last month of a damning photo of a possum, and its offending poo, inside a unit at Hornsby Hospital. And even when NSW did embark on new hospitals, there were spectacular bungles. Failing to listen to clinical staff, the new $100 million Bathurst Base Hospital was riddled with construction and design failures, from operating theatres that were too small to inadequate communications and alarm systems.
Professor Guy Maddern, from the Royal Australasian College of Surgeons, says clinicians had to be involved with the planning of facilities. ”Most of us get quite frustrated because they [architects] don’t fully understand what might be coming with respect to new treatments or interventions. For example, no one built for the explosion in minimal access surgery.”
What has already arrived is the era of bringing technology to the room, rather than trolleying the patient to the technology. Studies show this reduces medical errors. Operating theatres are also changing. They need to be bigger to cater for more technology and staff, Maddern says.
”I suspect with the ageing population it is going to require more reliance on hospital-based care than we have had for the last 20 years. Although the procedures are less invasive, the patients are not as fit medically. The architects say most patients should be managed by single rooms. That greatly enhances the potential for infection control, but if people don’t wash their hands …”
In his home town, the new Royal Adelaide Hospital will be staggeringly different. ”Currently there would be 5 per cent single rooms. They are talking 60-70 per cent single.” And the redevelopment of The Queen Elizabeth Hospital in Adelaide has 40 per cent single occupancy, 40 per cent two-person, with 20 per cent given to traditional room numbers.
Associate Professor Jane Carthey, director of the Centre for Health Assets Australasia at UNSW, says Australia has some of the best and most creative health architects in the world. But she queries the wholesale adoption of Ulrich’s recommendations, as they rely substantially on overseas research. She also believes he doesn’t sufficiently emphasise other important factors such as environmental sustainability and working conditions.
In Australia, the nature of our public system means funds are limited. ”The amount we spend on health care is approximately 9.3 per cent of GDP compared with the US, which spends well over 15 per cent,” Carthey says.
When it came to single rooms, the evidence was that most patients preferred them, they were less noisy, less stressful and there was less exposure to infections. But much of the research comes from countries with higher rates of hospital-acquired infection than experienced in Australia.
”Western Australia and South Australia are both building major hospital projects and have relied on overseas evidence. In reality they have had to make judgments based on information provided by overseas experts regarding what would work for our system, which is quite different to the US system in particular,” Carthey says.
”I think we need more single rooms, but whether it’s 100 per cent or 75 per cent, or fewer, I don’t know. I don’t believe anybody knows this, as so little Australian-focused research on this issue has been done; also the issue must be considered in terms of what we can actually afford to build.”
While some architects champion technology as a way to help nurses overcome all the walking that results from single-patient rooms – by using monitors feeding information to the nurses in satellite locations – it was not a model that all nurses preferred.
Nurses, especially student nurses, often prefer to work together in a central spot where they can support each other and share expertise, Carthey says. As for remote monitoring: ”Nurses have to be visible to patients, so that the patients feel cared for. Some patients, especially older ones, feel neglected if they see nurses and other staff less often, and this seems to be the case where there are many single rooms on a ward.”
Sarita Chand, a principal of BVN Architecture and one of the country’s foremost health centre designers, says Ulrich’s research validated what many architects had been intuitively designing. But she agreed with Carthey that the Ulrich patient-focused model did not adequately address staff working conditions.
The Australian Building Code has always required natural light in overnight patients’ rooms but there’s no such code for staff, she says. ”We have staff sitting for 20 years of their life in offices without windows. Staff work areas and offices are required to have access to natural light in Europe.”
That meant hospitals needed to be designed with a thin architectural footprint, with courtyards funnelling natural light into offices and treatment and diagnostic areas – not the fat footprints seen in 1970s-era hospitals such as the old Prince of Wales at Randwick and Royal North Shore. This type of building would also address sustainable design issues for hospitals, which are huge consumers of energy.
”Hospital buildings are the most expensive buildings, the most complex buildings … they are buildings where humans are at their most vulnerable and technology is at its highest,” Chand says. She knows the pros and cons of the two camps – those comforted by visible technology; those wanting resort style ”hospitals in disguise” – but she is in no doubt that technology is crucial in managing a health system dealing with chronic staff shortages.
To her mind, hospitals have lost their status as valuable landmarks; the importance that comes with places of birth and death. ”My crusade is to get better design into hospitals, and for them to regain their status as being valued elements in the community.”
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