Article by Dirk Anderson, EMI USA Staff Architect
Health care ministries in the Developing World regularly balance contradictory elements in order to function within their context. Similar to challenges faced in the Global North, mission hospitals seek to adapt and compromise between optimal patient care, staff capacity, functional capability, and fiscal constraints, among other realities. EMI regularly engages in critical programming dialogue with health care ministries. The discussion is not only about facilities & function, but the organisational, economic, and philosophical priorities that underlie them.
A major topic is always inpatient care and accommodation—critical components to hospital function. Inpatient units (IPUs) present one of the highest economic burdens to the health care facility. Though outpatient and rural clinics generate the highest client-contact numbers in mission hospitals, the demand for inpatient care continues to rise. With that, there is recurring debate over the optimal IPU design.
Historically, large, open wards for multiple patients have been the norm. For centuries, wards have both functionally and economically addressed the need of extended care for the infirm. One fascinating nugget: As early as the 1400s, wards were configured so the sick could see an altar to assist with their recovery. An altar was placed in the centre of the space with multiple wards extending from it in a cross-shaped plan. Though the design philosophy has changed, the same plan idea is still in use. It is reflected today in the nurse’s station located at the centre of a ward or several wards.
Wards continue to be the predominant design approach in the majority of mission hospitals EMI interfaces with. Multi-bed ward design has a clear advantage for staff observation and efficiency, bed-space allocation and shared infrastructure. On the downside, wards often deteriorate into impersonal, loud spaces with little privacy. This is often compounded by unsanitary conditions and limited infection control. So while the efficiency is indisputable, patient care and recovery rates have been compromised.
Introduction of private, or at least smaller bed-ratio rooms is in fact a new concept. It is one that has developed only in the last 60 years or so in North America. Given the less-communal nature of European and North American cultures, single- occupancy rooms are now the standard choice of design. The obvious advantages are privacy, less noise, and reduced risk of nosocomial (hospital-acquired) infections.
However, private rooms are not without disadvantage. In cultures that highly value relational community, patients can suffer from a lack of social interaction. Social support and camaraderie often develops among neighbouring ward patients, stimulating recovery. Paediatric ward patients also thrive given the opportunity for interaction with new friends. Where staffing is limited, attracting a nurse’s attention from a private room can be difficult. This is more so when technology is limited, power is nonexistent, and doors are closed. Finally, patient accidents such as passage to the toilet, go unnoticed more frequently in a private room.
Given the common limitations on mission facilities (such as funding, staffing, and available land), multi-bed ward efficiency supersedes the disproportionate cost of privacy. However, EMI is encountering shifts at various levels and cultures away from unrestricted open wards. The trend is toward more restrained patient counts and single-bed private rooms. Patients are expressing expectations for private care and accommodation. Medical research supports the reduction in infection transmission and length of stay that private IPUs offer. The efficiency of open wards is being reconsidered and greater flexibility and thought is now demanded of in-patient design. Though it is unlikely that the ward will be abandoned, modifications can be considered.
Take a recent EMI-designed ward at ELWA Hospital for example. Located in Monrovia, Liberia, ELWA is a 45-bed hospital which began in 1965. In their existing facility, small pods of IPUs evolved into irregular spaces over their history. Patients could not be separated for isolation as needed, nor paediatrics from adults, nor maternity from well-babies. Spatial disorganization contributed to ineffectual care and cross-contamination. Staff expressed frustration as doctors made longer rounds with scattered patients. Nurses and support staff were over-extended, compromising their attention and effectiveness. Attempts to better coordinate care compromised their ability to meet the newly adopted national health care standards. EMI and ELWA had a long dialogue about their preferences and alternatives in planning for a new facility.
The outcome was a new ward model. The idea was to keep the efficiency & economy of a ward space while incorporating some of the advantages of private rooms. Though multiple IPU buildings were proposed, they were to be logically delineated. Different IPUs for gender, treatment level, medical, surgical, paediatric, and maternity also allow for staffing to become targeted. Directed circulation patterns distinguish between patients, care-givers, and staff. Grouping patient clusters around a centralized nurse station provides observational efficiency in keeping with typical 1:10 nurse/patient ratios. These clusters also afford a balance of solitude and social stimulation among patients and their care- giving family members. Partial height walls deliver moderate separation and privacy without disrupting the visual connection for the nursing staff. Toilets configured within each cluster minimize travel distance and vulnerability for accidents. Individual rooms are integrated directly off the nurse station. These double as isolation for infectious disease as well as private consultation, small procedure and/or resuscitation spaces.
The physical environment within the wards is a critical component for a healthy design. Research indicates that viewing elements of nature often promotes healing. Windows to the exterior are essential to connect the patient with the outside world. Natural or artificial plants have mental stimulation properties, though concern for allergies should be shown. Deliberate positioning and solar orientation are also essential in planning and design. At ELWA, the wards are oriented to take advantage of nearby ocean breezes and are clustered around a courtyard with vibrant vegetation. Optimal light, indirect where possible, and creative passive ventilation strategies create a more ambient interior. Fixed louvres and upper roof clerestories promote airflow while energy-efficient fans move air at slow velocities. This prevents cross-contamination and airborne infection transmission. Double-door vestibules at entrances along with mosquito screening at all openings offer insect-control — particularly important in malarial regions. Finally, hand-wash sinks at strategic transition points convenient to staff deter contact transmission of infection and disease.
These suggestions are intended to illustrate opportunities for advancement in EMI health care design. This is a continual challenge faced by designers: How to improve the quality of the patient environment within a health care delivery context that varies from country to country. In addition, the design must also provide cost-effective, sustainable, and innovative solutions to EMI’s ministry clients.