Following evidence of reduced infection rates, single-person rooms are gaining popularity. Rob Wilson investigates what this means for hospital design
Hospitals today seem to have returned to a Victorian model – not, of course, in their healthcare (although you might think so from all the NHS-in-crisis stories) – but in their architectural layouts: long, skinny blocks, pulled out into loops and chains: more reminiscent of the 1860s blocks of St Thomas’ Hospital strung along the Thames, rather than its 1960s YRM-designed stacked mega-block extensions.
Indeed the factors behind the 19th-century ‘pavilion’ principle advocated by Florence Nightingale – slenderly connected blocks ensuring segregation of infectious patients and good cross-ventilation – and those driving hospitals’ architecture today aren’t so very different. Now it is evidence-based healthcare design – charting applied research methods assessing building performance against patient recovery – that is leading the way, resulting in both a reappreciation of the benefits of natural light and views out for patients, but also a seemingly relentless drive towards single-person rooms (SPRs), which have been shown to reduce infection rates.
They offer benefits regarding infection control, gender separation and patient safety, leading to reduced recovery times
This renewed emphasis on the importance of the architectural layout of new hospitals in the healing process – a factor that usually played second fiddle to new service and medical technologies in the 20th century – should be welcomed, even if it often appears to result in identikit hotel-like strings of double-banked perimeter rooms.
‘Ever-greater percentages of single-person rooms in acute hospitals have been one of the most significant changes in healthcare design in recent decades,’ says Duncan Finch, a director at Avanti Architects, whose recent projects have included the new Ulster Hospital and the Sheffield Children’s Hospital. ‘They offer practical benefits regarding infection control, gender separation and patient safety, leading to reduced recovery times. And patients prefer single rooms, due to improved privacy.’
Ulster hospital level 3
Charlotte Ruben of White Arkitekter agrees: ‘There is a clear benefit in reductions of infection and medication mix-ups,’ she says. She has been working on the New Karolinska Solna (NKS) in Stockholm, a specialist research hospital, the first phase of which has just opened. We asked her to describe its design, as the NKS is significant not only in being a 100 per cent single-person room hospital but for taking the concept further. Its patients are no longer moved to separate specialist clinics, but instead have multidisciplinary teams of clinicians come to their rooms for many simple procedures. This is enabled by each room’s generous 20m2 size and servicing by systems of robots and pneumatic tubes.
Ruben points out: ‘The move to single rooms affects the structure of the whole hospital. It becomes almost political: driving healthcare towards better, safer outcomes but also creating the demand for new ways of working and operation.’
While this trend has been seen increasingly in the UK, it has been most pronounced in Scandinavia, where the use of evidence-based design in healthcare has been used since the 1980s. Finch singles out Roger Ulrich, professor of architecture at the Centre for Healthcare Building Research at Chalmers University of Technology in Sweden (and a former adviser to the UK Department of Health) as a key figure in this. ‘He has had a profound influence internationally on how hospitals are designed,’ says Finch.
Research conducted in 2008 concluded that single rooms reduced patient observation and gave less opportunity for social interaction
But he adds that guidance in the UK is still somewhat confused. ‘For architects designing hospitals, the evidence base behind guidance such as the Health Building Note (HBN) suite of documents is not always clear. Many sources of guidance appear to be a mix of an evolving mass of standard working procedures, shaped to a certain extent by evidence-based research.’
But the trend to single-person rooms has not been uncontroversial. Research conducted by Arup with the UK’s National Patient Agency as long ago as 2008 concluded that it reduced patient observation and gave less opportunity for social interaction. As Richard Mazuch, senior director of design research and innovation at IBI Group and a long-term critic, says: ‘It results in long, leggy necklaces of rooms with staff having to travel long distances. Observation is not as good.’
Ulster hospital single bedrooms with large corridor windows rory moore photography
Source: Rory Moore Photography
Single-person room hospitals are also, with more square metres per patient, more expensive to build, to maintain – and even clean, with extra surface area and corners to cover. Indeed Mazuch even questions their advantage in terms of reducing infection: ‘I was on an MRSA working group and we found in the Netherlands much lower infection rates, despite single rooms being far less common there,’ he says.
But the loss of social interaction – ‘isolation’ as Mazuch terms it – is the most consistent criticism of single-room layouts. While the importance of engagement with natural light and views out to the world around has come back centre stage, somehow the engagement with other people as an aid to recovery has been sidelined.
The clear advantages offered by SPRs in acute specialist hospitals such as NKS become less clear-cut in longer-stay facilities. In the UK, in any case, with cuts in social care and a bed-blocking crisis, these definitions are somewhat woolly. The superficially hotel-like benefits of single-person rooms, once only available in private hospitals, appear to have become increasingly viewed as self-evidently a good thing in today’s ‘me’-orientated consumer/service provider culture. But what might seem a luxury for a day or two can rapidly become lonely for many.
Alder hey bdp
Source: David Barbour
Finch recognises this. He says: ‘The move towards 100 per cent single-person inpatient environments has not been uncontroversial. Single rooms can exacerbate loneliness and isolation.’ Of course, good design can mitigate this, as well as aid observation of patients. At Ulster Hospital, Avanti has designed clustered pairs of single-person rooms around staff bases to aid observation, while dispersed seating promotes informal social interaction. Similarly, at Sheffield Children’s Hospital, en-suites are paired between patient rooms, enabling good observation from the corridor through large glazed doors and a small ‘touch-down’ staff base position, and allowing natural light to pass to the heart of the ward. In the NKS meanwhile, the main corridor and staff bays ‘interlace’ between the ‘hygiene’ (bath)rooms, so no extra intermediate hallway is created to block views. In general too, pull-down beds in the rooms, enable relatives to spend the night with patients as required.
But research shows that many – in particular older people – prefer multi-person wards. As Mazuch says: ‘The elderly do better when recovering together, as do people with the same condition, like orthopedic groups. It accelerates recovery.’ Ruben agrees. She says: ‘100 per cent single-person rooms are definitely not relevant in all hospitals.’
The key here seems to be choice: not a one size or layout fits all. Mazuch points to his own designs for four-bed cruciform wards as another option, balancing face-to-face contact with a degree of privacy, while still offering a space that is ‘static: a room, not the transience of a big ward’.
It’s also about built-in adaptability. As Mazuch says: ‘Hospitals take a long time to build and, by the time they are complete, they are usually an anachronism.’ So with the popularity today of co-housing and co-working spaces, perhaps the radical return of the ‘co-ward’ as the default model for hospitals again is just around the corner.
Case study: University Hospital, Stockholm, by White Arkitekter
White arkitekter nks aerial credit barabilde.se copy
Our aim in designing the New Karolinska Solna (NKS), which opened this year, was to make one of the most advanced and sustainable university hospitals in Europe. With a design that is highly patient-centred, drawing on extensive research in healthcare innovation and the design of healing environments, it offers patient facilities and public spaces flooded by natural light, prioritising patient wellbeing.
The project has been inspired by evidence-based design theories and the positive impact that design strategies such as increased natural light, natural materials and views out can have on patient recovery. We’ve brought as much daylight as possible into the buildings, incorporating vistas onto the wider surroundings. The public circulation space and elevator access is housed in a glazed link between buildings, offering views over the city and parkland.
Ten years in the making, the project resulted from an international design competition won by White Arkitekter in 2006. The design was developed through a PPI procurement process led by Skanska and Tengbom and the project has been realised through the joint venture firm White Tengbom Team.
A key idea has been a strong emphasis on context. Hospitals are usually set apart from the city, which creates a psychological as well as physical barrier. We think hospitals, as important public buildings, should have an inviting civic presence. At NKS a new subway station will connect into the new entrance hall integrating the hospital into the city fabric and Stockholm’s infrastructure.
This is a single patient room hospital. The generous size of 20m2 for each room accommodates multi-disciplinary work-teams during examination and treatment, so that, instead of being wheeled around the hospital to different diagnostic departments, the clinicians come to the patient. This allows undisturbed consultation with medical staff to increase patient participation and wellbeing.
Patients’ rooms are fitted with their own en-suite bathroom and an additional bed to accommodate an overnight guest, the support and close proximity of friends and family being recognised as crucial to recovery. The light, airy rooms are designed so medical functions do not dominate. Vital technical access points are integrated into the bed-head panel and there is storage space in the support zones within the ward for mobile medical equipment.
Specialist clinicians who have traditionally worked in isolated clinics to which patients are brought, are now part of thematic diagnostic care and treatment units – for cancer, cardiovascular and neurological conditions and so on – each staffed by a full range of specialist healthcare professionals. Support functions and equipment are located inside the ward, close to small, decentralised nursing stations. Supplies can be quickly and efficiently moved around the building to and from the bedside using pneumatic tubes and remote-controlled robot carts, which have their own dedicated elevators. These efficiencies mean medical staff are able to spend the maximum time with the patient.
NKS’s design incorporates natural tactile materials, such as the light blonde ash wood for wall panelling and furniture alongside highly durable granite floors and white concrete elements to lift and lighten the atmosphere. Throughout the complex there are clear divisions between patient and public areas, and professional and service zones, minimising germ transmission.
Charlotte Ruben, architect, White Arkitekter
This essay was published in the Buildings that care issue – click here to buy a copy