Understanding the Role of the Built Environment in Safety and Quality Improvement

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Slide 1

Understanding the Role of the Built Environment in Safety and Quality Improvement

Jeff Brady, MD, MPH, AHRQ
Craig M. Zimring, Ph.D., Georgia Inst. of Tech.
James P. Steinberg, MD, Emory U.
Douglas B. Kamerow, MD, MPH, RTI

Slide 2

Welcome and Overview

Jeff Brady, MD, MPH
Agency for Healthcare Research and Quality

Slide 3

The Role of the Built Environment in Safety and Quality

Craig Zimring, PhD
Georgia Institute of Technology

Slide 4

Hospitals are Unnecessarily Dangerous, Costly and Stressful

• 48,000 to 98,000 die annually due to preventable medical errors (IOM, 2000).
• 1 in 20 patients contract infections during care; new highly antibiotic resistant pathogens, persistent problems with MRSA, C difficile (CDC, 2012).
• $750 billion of annual healthcare costs are wasted; 30% of the total (IOM, 2012.

Slide 5

Evidence-Based Design Causal Model

Image: The model shows the relationships between the following items:

• Design Strategies & Variables →
• Mediators & Process Variables →
• Patient, Family, Staff & Organizational Outcomes → (back to Design Strategies.

Moderators

• Culture.
• Care process.
• Demographics of patients & staff.
• Acuity.

Slide 6

Low visibility rooms had a 30% higher mortality rate (82.1% and 64.0%) for high acuity patients

Image: A floor plan shows the layout of the cardiac ICU at New York Presbyterian Hospital; the low-visibility rooms are highlighted.

Slide 7

Visibility

Image: A floor plan shows the layout of a hospital with distributed nursing stations; the high-, moderate-, and low-visibility rooms are highlighted in different colors.

Patient Groups by Visibility 2

• High-visibility Patient Group PT (upper half body) visible from both the corridor and the nearby nurses' station.
• Moderate-visibility Patient Group PT (upper half body) visible only from the corridor.
• Low-visibility Patient Group PT (upper half body) NOT visible from the corridor.

Low visibility rooms had a 31% higher fall rate (Choi, 2012).

Slide 8

Lighting

Sunlight Affects Length of Stay and Analgesic Use Dying in the Dark

Patients in A Cardiac Intensive Care Unit:

• Women stayed one day less in sunnier room (2.3 v 3.3 days).
• Death rate was 70% higher in dull rooms (39/335 v 21/293).

Patients exposed to 46% more natural sunlight (lux/hours):

• 22% fewer analgesics.
• Higher impact on younger patients.
• Higher impact on higher analgesic users.
• 21% lower drug costs.
• Less pain, stress.

Slide 9

Evidence-Based Design Causal Model

Design Strategies & Variables

• Placement of hand washing rubs and sinks.
• Single rooms.
• Layout.
• Provisions for family.
• Provisions for teamwork.
• Acoustic features.
• Materials.
• Reminder systems.
• Variable acuity rooms.
• Same-handed rooms.

Mediators & Process Variables

• Communication.
• Movement.
• Hand-washing compliance.
• Noise.
• Stress.
• Natural light.
• Etc.

Patient, Family, Staff & Organizational Outcomes

• Pain.
• Analgesic use.
• Errors.
• Morbidity/mortality.
• Infection rate.
• Length of stay.
• Satisfaction.
• Care coordination.
• Staff turnover/injuries.
• Costs.
• Failure to rescue.

Moderators

• Culture.
• Care process.
• Demographics of patients & staff.
• Acuity.

Slide 10

Evaluating the Current State of Evidence

• Developing a conceptual framework describing the relationship between the built environment of healthcare facilities and HAI prevention.
• Conducting an environmental scan (lit review, guideline review, and expert interviews) to document the current knowledge about HAI prevention through the use of the built environment.

Slide 11

The HAI-DESIGN Team

Kendall Hall, MD
AHRQ

RTI International
Douglas Kamerow, MD
Nancy Lefestey, MHA
Emily Richmond, MPH

Georgia Institute of Technology
Craig Zimring, PhD
Ellen Do, PhD
David Cowan, MHS
Megan Denham, MAEd
Altug Kasali, M.Arch.

Emory University School of Medicine
James P. Steinberg, MD
Jesse T. Jacob, MD
Amy Allison, MS

Slide 12

Chain Of Transmission

Image: A model shows the chain of transmission of pathogens from sources inside and outside the hospital to susceptible patients who might become infected.

Slide 13

What Does the Evidence Tell Us?

Craig M. Zimring, Ph.D.
Georgia Institute of Technology

Slide 14

More Evidence than We Expected

Images: The cover of a review of research literature on evidence-based healthcare design is shown. A photograph shows a stack of reports, papers, and manila folders on a desk.

Source: (Ulrich, Zimring et al, 2008).

Slide 15

Image: A flowchart shows the selection of articles for a study:

• 2999 articles identified through searches → Title review → 119 duplicates eliminated.
• 2880 articles reviewed for relevance → Abstract review → 1724 discarded as irrelevant within the scope of this project.
• 1156 articles meet preliminary inclusion criteria → Abstract review → 374 articles eliminated (not specific to built environment).
• 782 articles remain after second abstract review → Papers from secondary scan (Additional articles, 74 grey literature) → Full-paper review → 592 articles included in secondary sub-groups.
• 190 articles identified to be included in four primary sub-groups:
  • 57 in "air" group.
  • 45 in "contact" group.
  • 60 in "water" group.
  • 28 in "isolation" group.

Slide 16

Increasing Hand Hygiene Compliance with the Built Environment

Images: Two photographs show hand-disinfectant dispensers in the original location and after it had been moved to line-of-sight.

Moving dispensers into line-of-sight increased hand hygiene compliance from 33.6% to 60% (Source: Nevo et al 2010)

Slide 17

Technologies to Reduce Infection Risk: UVGI

• HVAC components had moderate to heavy contamination pre-eUVGI installation → All HVAC cultures negative at 6 months post.
• Surface and air samples had moderate to heavy contamination pre-eUVGI installation → All surface cultures negative at 6 months post.
• 74% of tracheal aspirates were positive for pathogens such as Pseudomonas aeruginosa and Klebsiella pneumoniae  pre-eUVGI installation  → 55% of tracheal aspirates were positive at 6 months post  → 44% of tracheal aspirates were positive at 18 months post.

Slide 18

Conclusions

• Evidence for design is different than in medicine, but as important.
• Evidence is scattered.
• The built environment matters.