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The End of General Hospitals


 

Where will you be in 20 years? If you’re a young hospitalist, you may work in an enormous state-of-the-art hospital complex that includes the latest technologies, the best in amenities, and a well-thought-out design that will meet your needs and those of other staff for years to come.

“There are a lot of different approaches” to designing the hospital facility of the future, says George R. Tingwald, MD, AIA, ACHA, director of healthcare design at Skidmore, Owings, and Merrill in San Francisco. “The difference depends on whether you look at it from a constructability standpoint versus a much more consumer-based focus. Though many think they have the right approach, it’s hard to say that everybody’s decided on a single solution.”

The Future Looks … Big

It’s not just the hospital facility itself that will change in the future. The number of hospitals in each community may change as well—and the hospitals will be considerably larger.

“We will probably see fewer but larger hospitals in the future,” predicts Dr. Tingwald. “We’re in an era where we’re seeing significant growth in the number of inpatients served. Because of the baby boom and increasing longevity in Americans we’re already seeing an increase, and it’s going to continue. We’ll definitely see more hospital beds in the future.”

The type of patients who fill those hospital beds will change as well.

“We’ll continue to see sicker and sicker patients in those hospital beds,” says Dr. Tingwald. “More people will be managed on an outpatient basis as more diagnostic and treatment procedures will be done as outpatients. Look at breast cancer: From initial detection to diagnosis to biopsy to lumpectomy to chemotherapy or radiation treatment, to cure, or end-of-life care, each step can now be done on an outpatient basis.”

What does this mean? “Someone can have a very significant, multiepisodic disease and never stay in the hospital—unless there are complications,” explains Dr. Tingwald. “Therefore, we’ll have only very acute patients in the hospital. The hospital will basically become an intensive care unit.”

In the past, approximately 10% of a hospital’s beds were in the ICU. That percentage is rising—an indication of things to come. That percentage is now around 20% or 30% and growing, especially in major centers. Only seriously ill people will be admitted—but even they won’t spend a lot of time in the hospital. They will die, recover to a point where they can be moved to rehabilitation or other support facility, or be sent home.

What about the prediction that there will be fewer hospitals in the future? Dr. Tingwald predicts that technology and expertise will weed out some facilities.

“We used to have a lot of what I would call general hospitals—meaning every one was the same,” he explains. “That’s changing radically. The institutions with the expertise and wherewithal to develop technical sophistication, such as university hospitals and specialty hospitals, are doing well. Those that don’t have that sophistication can’t keep up. The big centers are growing because they have the equipment and the expertise. The smaller ones are failing.”

This trend may come as a surprise to some in healthcare, in light of previous predictions. “This is different than the futurists were saying 10 or 20 years ago, when predictions were for more home-based and community-based care,” says Dr. Tingwald. “The reverse has happened. The latest equipment is not available to everyone, let alone smaller, unaffiliated hospitals. And the people that can work with that technology are few and far between.”

The addition of new technology will have some effect on the size of the hospital. “You need a lot of physical space for wiring,” admits Dr. Tingwald. “But the ‘brains’ of the technology can be offsite at a separate IT center or data center.”

Follow Regulations—or Change Them

As with other areas of healthcare, the design of hospitals and other facilities must follow specific guidelines and regulations. These very rules may hamper the rosy picture of a hospital painted in this article.

“There’s a trend toward more consistent guidelines across the country,” says Dr. Tingwald. Forty-two states use the Guidelines for Design and Construction of Hospital and Health Care Facilities developed by the American Institute of Architects Academy of Architecture for Health, the Facilities Guideline Institute, and the U.S. Department of Health and Human Services.

However, several larger states have continued to use their own codes, and all state regulatory agencies still dictate how a new hospital will be built.

“Most regulations have been prescriptive,” says Dr. Tingwald, “and will be a significant deterrent toward future design because they can’t keep up with the pace of technology and operational changes. Most states have at least five-year cycles for updating regulations and complex processes for change. This leads to significantly outdated codes that don’t accommodate operational changes. It’s getting much better than it once was, but the pace of change is making it next to impossible to keep up.

“A better way would be to make the regulations more outcomes-oriented, and not include specifics on how to get there because that’s going to change,” he advises. —JJ

Focus on Family-Centered Care

Perhaps the most noticeable differences in the hospital facility of the future will be those related to a change in services, design, and attitude toward providing amenities for patients and their families.

“Patient-centered care, or its close cousin—family-centered care—is a significant trend in healthcare design now, and that significantly impacts the design of facilities,” states Dr. Tingwald. “The most important aspect is having all private rooms. Almost no new construction includes shared patient rooms. The key element of this care is family involvement, and that includes families rooming in with patients. You can’t physically or psychologically do this in a shared room.”

He points out that this trend includes all room types: “It started in pediatrics, but has gone into general acute care settings, intensive care settings, and now neonatal intensive care units.”

What are the pros and cons of a move toward all private rooms? “It takes up room, but it’s proving not to be significantly more costly,” says Dr. Tingwald. “Private rooms are more expensive to build, but in the end they’re less expensive to operate. In an all-private room hospital you can increase your occupancy to 80% or even 90% because you’re not trying to match up patients by gender and age. Also, nursing isn’t moving patients to get the bed mixes right. Studies show that nurses spend up to 40% of their time in transfers. And finally, private rooms have increased market share considerably.”

Another aspect of family centered care is the addition of technologies and services that cater to patient comfort and even enjoyment. “Anything someone has at home or wants in a hotel, families and patients are demanding, including room service,” says Dr. Tingwald. “Patients can decide when and what they want to eat [within their prescribed diet], and families can order food. In some hospitals, patients can already order food using a plasma screen in their room. This is showing to be an economically viable alternative. There’s less food waste, and patients are much happier.”

You’ll also see patient rooms with plasma screen televisions and DVD players, equipped for movies on demand, educational content—even the ability for physicians to view X-rays and other diagnostics on screen, and for families waiting in the room to communicate with physicians in the operating room.

“These are consumer-driven things, but they’re not luxuries,” insists Dr. Tingwald. “They’re often things that save time, increase the ability for education, and significantly decrease errors.”

Another argument for adding amenities like plasma screen TVs and room service: “In healthcare you think adding this technology must be too expensive,” says Dr. Tingwald, “but if you walk into a fast-food place, the person behind the counter uses a touch screen. Everybody else has done this already. Facilities that don’t partake in these transitions are not going to survive.”

Other family-centered improvements include major changes in patient registration. “Most registration can be done from home, over the Internet,” he says. “At Northwestern Memorial Hospital [in Chicago], patients have an encoded card they swipe when they drive into the parking garage, and the receptionist knows they’re coming and gets their room ready before they arrive.”

In the future, more facilities will offer options like these to make the registration process easy and fast.

The hospital of the future will feature a friendlier environment, with landscaping and nice views from patient rooms, artwork and amenities that are important in the healing process. They will also include an emphasis on alternative treatments, says Dr. Tingwald, “from massage to aromatherapy to spaces for yoga or meditation.”

Plan for Flexibility

The key to the design of the hospital of the future will be its ability to change without building additions, remodeling, or rehabbing.

“We’re no longer planning a facility in a static way, thinking that things will not change. Flexibility and adaptability are planned from the beginning,” explains Dr. Tingwald. “You’ll see a lot more generic room types—rooms that are all a single size, but adaptable. A private patient room might be initially planned for acute care, but it can be adapted for an ICU room with minimal or no remodeling.”

This holds true for other room types as well. “In diagnostic and treatment spaces, we plan for one, or no more than two, sizes of space,” he says. “You don’t know if in the future more procedures will be surgical or non-invasive, so rooms are planned to handle both functions. Also, the kingdoms are coming down and divisions between diagnostic departments are blending.”

The Johns Hopkins Hospital (Baltimore), the University of California, Los Angeles Medical Center, and California Pacific Medical Center in San Francisco are all designing “platform floors,” where surgery, interventional imaging, cardiac catheterization, and other procedure-based services share preoperative and postoperative areas and have single access.

“These floors provide adjacency of services allowing a lot more flexibility and decreased redundancy,” explains Dr. Tingwald. “Also, there aren’t as many patient transfers, and a key to patient-centered care is less movement of the patient.”

Built-in flexibility is designed to accommodate scalability as well. “In the planning process, we anticipate higher volumes in an emergency or disaster,” he says. “We plan how to expand the emergency room, and we make rooms larger than we used to. That way, if volumes increase quickly, you could put two, three, maybe more patients in a space. Nurses hate when you say that, but we have to have timely solutions that are affordable. This approach can be considered on nursing units as well, with these ‘super singles’ able to handle a second patient during a February flu outbreak, for example. That’s better than having an entire wing of the hospital that’s only used during winter months, patients stuck in the emergency department for days, or patients in the halls.”

A Design with Built-In Patient Safety

The physical design of the hospital of the future will better address and correct issues with patient safety. “Whatever design elements can minimize errors and improve outcomes are being studied intensively right now,” says Dr. Tingwald. “For example, we used to mirror many room types so that walls could share plumbing, etc. One room would be the mirror image of the one next to it, requiring the staff to learn different layouts, which increases time of response and possible errors. Now, we try to make procedure rooms as similar as possible to reduce the potential for error.”

There are design elements that limit the possibility of hospital-borne infection, including ultraviolet light and biologic surfaces. There is also a greater emphasis on including track systems for lifts for getting patients out of bed and moving them without injury to the patient or the staff.

Consider Hospitalists and Other Staff

How will the hospital of the future accommodate hospitalists?

“We’re certainly seeing more hospitalists,” says Dr. Tingwald. “As you have sicker patients in the hospital, it’s harder for their primary care physicians to manage them, so we’re going to see even more hospitalists. This means that we have to provide space for them; both offices, because they don’t have other office space, and sleeping accommodations, which means private rooms with bath, as well as lounge space.”

Hospitals will provide appealing space for physicians because it will help them recruit hospitalists. Improving lounges and other staff spaces will be a goal of future hospital designs.

“There will be a lot more emphasis on good environments for work and for support services,” predicts Dr. Tingwald. “This will increase the attraction and retention of top staff. You’ll see things like fitness centers, and basic additions like enough parking spaces.”

As hospital facilities move toward more patient-centered care, with flexible layouts and space designed for patient safety, the working environment is certain to become more conducive to providing good care and working efficiently. It will also become more comfortable, convenient, and pleasant for hospitalists and other staff. And that is something to look forward to. TH

Writer Jane Jerrard wrote the first three installments of the “Future” series.

FLASHBACK

Cadaver Particles

Ignaz Semmelweis
My doctrine is produced in order to banish the terror from lying in hospitals, to preserve the wife to the husband, and the mother to the child.

—Ignaz Semmelweis, 1861

Death stalked the halls of the First Division of the Allegemeine Krankenhaus (Vienna General Hospital), a large teaching hospital in Austria. Healthy post-partum women suddenly become febrile and died from puerperal sepsis (childbed fever). In the mid-19th century, this problem was seen in hospitals across Europe, though rarely in home deliveries. It was a seemingly insoluble dilemma. Opinions varied on the etiology. Was it miasmas, the paint on the walls, were the beds too close, or was it clogged milk glands? Complacency and acceptance of status quo were, to some, the easiest solution.

In the mid-1800s Hungarian Physician Ignaz Semmelweis was given an appointment as an assistant in obstetrics at the Allegemeine Krankenhaus. He had adopted the Austrian paradigm of clinical and pathologic anatomy. The answer to any question lay in the autopsy. It seemed like the more autopsies they did, the more women died. The death of Semmelweis’ colleague, Jakob Kolletschka (who was initially injured when his knife slipped during an autopsy of a woman who died of puerperal fever and then died himself of symptoms similar to those that killed the woman) gave Semmelweis the vital clue.

He realized that something carried on unwashed surgeons’ hands from infected cadavers caused the disease to occur in the women. These “cadaver particles” were transmitted from the morning autopsies to the women on the wards by the unwashed hands of students and faculty. Adopting proper hygiene could save thousands of lives. Properly washed hands were the simple answer. This also explained the mystery of why the puerperal fever rate was lower on the midwife-run wards where they did not do autopsies.

Decades before Pasteur and Lister, accepting that their own hands brought death was a bitter pill for the great men of obstetrics to swallow. Unfortunately for Semmelweis and the women who continued to die, it was years before Oliver Wendell Holmes incontrovertibly published his essay, “The Contagiousness of Puerperal Fever” in 1843 in the New England Quarterly Journal of Medicine. That essay showed the source of puerperal fever. Despite his clinical success Semmelweis was unable to persuade his fellow physicians.

The nosocomial spread of infection on unwashed hands rings true to this day. We spend our days gloved, gowned, and masked in the battle against MRSA, VRE, and other pathogens. Whether soap or alcohol, when we scrub our hands we should remember that it is more than a ritual. It’s a duty to prevent the spread of disease.

—Jamie Newman, MD, FACP

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