Tag: hospital design

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Meeting at Eye Level in Hospitals Improves Patient Experience and Outcomes

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Review of research suggests patients feel better when providers sit or crouch during bedside conversations

Photo by National Cancer Institute on Unsplash

Doctors and other healthcare workers, you may want to sit down for this news. A systematic review of studies suggests that getting at a patient’s eye level when talking with them about their diagnosis or care can really make a difference. 

Their findings, published in the Journal of General Internal Medicine, revealed that sitting or crouching at a hospitalised patient’s bedside was associated with more trust, satisfaction and even better clinical outcomes than standing, according to the review of evidence.

The study’s authors, from the University of Michigan and VA Ann Arbor Healthcare System, note that most of the studies on this topic varied with their interventions and outcomes, and were found to have high risk of bias. 

So, the researchers sat down and figured out how to study the issue as part of their own larger evaluation of how different nonverbal factors impact care, perceptions and outcomes.

Until their study ends, they say their systematic review should prompt clinicians and hospital administrators to encourage more sitting at the bedside. 

Something as simple as making folding chairs and stools available in or near patient rooms could help – and in fact, the VA Ann Arbor has installed folding chairs in many hospital rooms at the Lieutenant Colonel Charles S. Kettles VA Medical Center.

Nathan Houchens, MD, the U-M Medical School faculty member and VA hospitalist who worked with U-M medical students to review the evidence on this topic, says they focused on physician posture because of the power dynamics and hierarchy of hospital-based care. 

We hope our work will bring more recognition to the significance of sitting and the general conclusion that patients appreciate it.”

-Nathan Houchens, M.D.

An attending or resident physician can shift that relationship with a patient by getting down to eye level instead of standing over them, he notes. 

He credits the idea for the study to two former medical students, who have now graduated and gone on to further medical training elsewhere: Rita Palanjian, M.D., and Mariam Nasrallah, M.D. 

“It turns out that only 14 studies met criteria for evaluation in our systematic review of the impacts of moving to eye level, and only two of them were rigorous experiments,” said Houchens. 

“Also, the studies measured many different things, from length of the patient encounter and patient impressions of empathy and compassion, to hospitals’ overall patient evaluation scores as measured by standardised surveys like the federal HCAHPS survey.”

In general, he says, the data paint the picture that patients prefer clinicians who are sitting or at eye level, although this wasn’t universally true. 

And many studies acknowledged that even when physicians were assigned to sit with their patients, they didn’t always do so – especially if dedicated seating was not available. 

Houchens knows from supervising U-M medical students and residents at the VA that clinicians may be worried that sitting down will prolong the interaction when they have other patients and duties to get to. 

But the evidence the team reviewed suggests this is not the case. 

He notes that other factors, such as concerns about infection transmission, can also make it harder to consistently get to eye level. 

“We hope our work will bring more recognition to the significance of sitting and the general conclusion that patients appreciate it,” said Houchens. 

Making seating available, encouraging physicians to get at eye level, and senior physicians making a point to sit as role models for their students and residents, could help too. 

A recently launched VA/U-M study, funded by the Agency for Healthcare Research and Quality and called the M-Wellness Laboratory study, includes physician posture as part of a bundle of interventions aimed at making hospital environments more conducive to healing and forming bonds between patient and provider. 

In addition to encouraging providers to sit by their patients’ bedsides, the intervention also includes encouraging warm greetings as providers enter patient rooms and posing questions to patients about their priorities and backgrounds during conversations.

The researchers will look for any differences in hospital length of stay, readmissions, patient satisfaction scores, and other measures between the units where the bundle of interventions is being rolled out, and those where it is not yet.

Source: University of Michigan

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Evidence-based Design or Feng Shui in Hospital Rooms might Benefit Patients

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Image-based online study shows no benefits, however, of virtual room designs incorporating the golden ratio

In an online study, virtual hospital rooms designed according to the principles of evidence-based design or the principles of Feng Shui were associated with greater potential benefit for viewers than virtual representations of standard hospital rooms. Emma Zijlstra of Hanze University of Applied Sciences in the Netherlands and colleagues present these findings in the open-access journal PLOS ONE on June 5.

Hospital designers might consider employing specific design principles in an effort to improve patients’ experiences. Growing evidence suggests there are beneficial outcomes from an approach known as evidence-based design. For instance, exposure to more daylight in hospitals is associated with lower stress and pain. Other well-known design approaches include Feng Shui, a Chinese system based on hypothetical energy flow, and the use of proportions following the golden ratio.

Despite these well-known options, experimental evidence on their relative benefits in hospitals is lacking. To help clarify, Zijlstra and colleagues randomly assigned each of 558 study participants to view online representations and information about a virtual hospital room designed with one of four approaches: Feng Shui, the golden ratio, evidence-based design or, as a control, a standard design from a real-life hospital. Only people who had previously been hospitalized at some point in their lives were invited to participate.

After experiencing the virtual rooms, participants completed a questionnaire that included standard measures of anxiety and other outcomes. Statistical analysis of their answers showed that, compared to participants who viewed the standard rooms, those who viewed rooms with evidence-based design reported less anxiety and greater senses of control, social support, distraction from negative thoughts, and pleasantness of the room.

Feng Shui design was not directly associated with lower anxiety, but participants who viewed the Feng Shui rooms did have greater senses of social support, positive distraction, and pleasantness of the room. There was no evidence for any benefits of golden ratio-based design.

On the basis of their findings, the authors suggest that rooms designed according to the principles of evidence-based design or Feng Shui might benefit patients. They note similarities between the two approaches, such as incorporation of greenery. However, they caution, it is unclear how well these online findings might translate to real-life hospital settings.

The authors add: “To our knowledge, this is the first and largest randomized controlled trial linking design principles, partly ancient and world-renowned, directly to anxiety in hospital rooms. This study showed that both Feng Shui and Evidence-Based Design are capable in effecting anxiety and it is important that large follow-up studies are conducted to examine the effect of specific design features.”

Provided by PLOS

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Proper Handwash Basin Design and Use is Critical to Controlling AMR

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Photo by Piron Guillaume on Unsplash

Some 10 million people annually are projected to die annually from antimicrobial resistance AMR in 2050, says Briëtte Du Toit, Programme Manager and Training Coordinator at Infection Control Africa Network (ICAN). While efforts to develop new antibiotics and conserve current ones are under way, it is vitally important to limit hospital-acquired infections as this is where many resistant strains spread. One of the key ways of controlling this is through the proper use of handwash basins, which necessitates a collaboration between the medical and engineering disciplines.

Presenting at the 14th SAFHE Southern African Healthcare, Du Toit stressed the importance of proper handwashing protocol and the critical importance of handwash basin design and placement to control the spread of hospital-acquired infections amid rising antimicrobial resistance.

The simple protocol of hand washing is perhaps one of the most important in modern medicine. In the past, clinicians might perform and autopsy and then deliver a child, all without washing their hands. It was only until the mid 1800s when Hungarian doctor Ignaz Semmelweis discovered the importance of hand washing, causing infection rates to plummet after the introduction of this most simple of protocols.

In modern hospitals, handwash basin design and placement, along with inadequate water supply and inadequate knowledge on the part of staff, contributes to inadequate hand washing and therefore high infection rates, Du Toit pointed out.

The design of handwash basins may seem straightforward, but there are many factors to consider. Water may drop onto other surfaces, or splash onto HCWs’ clothes. If medical supplies are stored nearby, then stray water droplets may also land on them.

A study of handwash basins showed that only 23% of basins were used for handwashing, while the remainder were used for a variety of activities including waste disposal. Of the basins used for waste disposal, 55% were contaminated. Another study showed that, in the ICU setting, washbasins were used for handwashing a mere 4% of the time. A sluice is also needed in close proximity to patients, otherwise staff will use handwash basins for incorrect disposal of body fluids.

Having the outlet directly beneath the tap as in a traditional domestic basin increases contamination. A bowl depth less than 19cm also contributed to contamination. Without a bowl cover, 9% of gowns and 6% of hands were found to be contaminated with gram-negative bacili (GNB), versus 2% of gowns and 0% of hands when a cover was present.

Significant improvements were also seen in ‘water-free’ protocols at the point of care, which involved the extensive use of disposable wipes, bottled water and practices such as using electric shaving. The implementation of water-free protocols at one hospital saw a drop in GNB colonisations from 26.3 to 21.6 / 1 000 ICU admission days. An even greater effect was seen for long-term ICU stays, with a 3.6 fold-reduction for stay exceeding 14 days.

Du Toit concluded by stressing the importance of collaboration between the medical and engineering fields, sharing data. Engineers should also be on IPC committees. Likewise, medical personnel should be part of the project team during building and renovations.

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Greenspaces in Hospitals Calm Patients and Visitors

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It can be stressful and time-consuming for patients and visitors to become accustomed to navigating large, unfamiliar hospitals, and so an architecture researcher tested a simple remedy: to let nature in with the use of indoor greenspaces and large windows.

Research conducted by West Virginia University’s associate professor Shan Jiang showed that introducing nature into large hospitals can humanise the institutional environment and reduce the stress of patients, visitors and healthcare providers.

Prof Jiang made use of immersive virtual environments for a controlled experiment that asked participants to complete various wayfinding tasks in a simulated hospital.

Though participants saw the same layout, one group encountered large windows and nature views among the corridor walls. The control group meanwhile saw solid walls without any daylight or views of nature, more like a typical modern hospital. Participants in the greenspace group used shorter time and walked less distance to complete wayfinding tasks.

“In terms of spatial orientation and wayfinding, window views of nature and small gardens can effectively break down the tedious interiors of large hospital blocks,” Prof Jiang said, “and serve as landmarks to aid people’s wayfinding and improve their spatial experience.”

In the greenspace group, participants’ mood states, particularly anger and confusion, were also found to be “significantly relieved”.

Prof Jiang’s findings are published in the Health Environments Research and Design Journal.

Based on prior research, it’s estimated that a patient or hospital visitor must go through at least seven steps in the wayfinding process to arrive at the final destination. WVU’s Center for Health Design cites wayfinding issues as an environmental stressor and a concerning topic in healthcare design.

Prof Jiang said that she was prompted to do the study by those factors, coupled with her own personal experiences (her family members have worked in healthcare) and others’ accounts of feeling lost in hospitals.

“Large hospitals can be visually welcoming but the functionality and internal circulation are indeed complex and confusing,” she said.

Greenspaces positioned at key decision points, such as main corridors or junctions, can help improve navigation.

With a background in landscape architecture, Jiang has been interested in the immediate surroundings of people in a smaller scope, particularly the indoor-outdoor relationship and the boundaries between architecture and landscapes.

Gardens and plants also tend to have strong therapeutic effects on people, she found.

“You may explain such therapeutic effects from multiple perspectives: people’s colour/hue preferences tend to range from blue to green, nature and plants are positive distractions that could restore people’s attentional fatigue, and human beings could have developed genetic preference of greenery from evolutionary perspectives,” Prof Jiang said. “All mechanisms together contribute to the positive experience when looking at gardens and nature views.”

Prof Jiang noted that many European hospitals have successfully integrated “hospital in a park” concepts. In the United States, the Lucile Packard Children’s Hospital Stanford in California has patios and window nooks in every patient room, and most rooms have direct views of a large healing garden, she said. The Alder Hey Children’s Hospital in the UK was literally built in a park.

Source: West Virginia University