The Patient Room: Planning, Design, Layout 9783035617528, 9783035617498

Table of contents :
Contents
Preface
A Fundamentals
The Emergence of Hospitals: From the Monastic Hospice to the Modern Clinic
The Nursing Ward Environment: Current Care Settings and Their Challenges
Healthcare-Associated Infections
Material Applications and Material Ageing in Hospitals
B Typologies of the Patient Room
The Floor Plan of a Two-Bed Room
Qualitative Evaluation of Two-Bed Rooms
Typological Evaluation of Two-Bed Rooms
Selected Case Studies
Building Structures in German Hospitals
C Prototype of a Patient Room – the KARMIN Project
Architecture of the Patient Room
Building the Prototype
Completed Prototype and Use Scenarios
Furniture and Equipment
Conclusion
Appendix
Glossary
About the Authors
Subject Index
Index of Names, Places and Projects
Illustration Credits
Acknowledgements

Citation preview

The Patient Room

The Patient Room Planning, Design, Layout

Wolfgang Sunder Julia Moellmann Oliver Zeise Lukas Adrian Jurk

Birkhäuser Basel

Preface 7

A

Fundamentals

The Emergence of Hospitals 10 From the Monastic Hospice to the Modern Clinic The Nursing Ward Environment 15 Current Care Settings and Their Challenges Healthcare-Associated Infections 21

B

Typologies of the Patient Room

The Floor Plan of a Two-Bed Room 28 Qualitative Evaluation of Two-Bed Rooms 38 Typological Evaluation of Two-Bed Rooms 44

Rasmus Leistner

Material Applications and Material Ageing in Hospitals 24 Inka Dreßler, Katharina Schütt

Selected Case Studies General Hospitals Trillium Health Centre Mississauga, Canada  66 Zollikerberg Hospital – New West Wing Zollikerberg, Switzerland  70 Zollikerberg Hospital – Renovation of East Wing Zollikerberg, Switzerland  74 Hvidovre Hospital Hvidovre, Denmark  78 Lauf District Hospital Lauf an der Pegnitz, Germany  82 AZ Zeno Knokke-Heist, Belgium  86 Haraldsplass Hospital Bergen, Norway  90 Solothurn Public Hospital Solothurn, Switzerland  94 New North Zealand Hospital Hillerød, Denmark  100 Südspidol Esch-sur-Alzette, Luxemburg  104

C

Specialised Hospitals Jugenheim District Hospital Seeheim-Jugenheim, Germany  108 Sana Clinic Munich Munich-Sendling, Germany  112 BGU Accident and Emergency Hospital Frankfurt am Main, Germany  118 Princess Máxima Center Utrecht, the Netherlands  122 St Joseph-Stift Dresden Dresden, Germany  128 St Gallen Geriatric Clinic St Gallen, Switzerland  132 Uster Hospital Uster, Switzerland  136 University Hospitals Surgical Centre Erlangen University Hospital Erlangen, Germany  138 Crona Clinic Tübingen University Hospital Tübingen, Germany  142 Erasmus MC Rotterdam, the Netherlands  146 Oncological Centre Leuven University Hospital Leuven, Belgium  150 Paediatric Clinic Freiburg University Hospital Freiburg, Germany  154 Children’s University Hospital Zurich Zurich, Switzerland  158 Münster University Hospital Münster, Germany  161

Building Structures in German Hospitals 164

Prototype of a Patient Room – the KARMIN Project Architecture of the Patient Room  170 Planning and Design  178 Colour and Materials Concept  183 Lighting Concept  185 Building the Prototype  196 Completed Prototype and Use Scenarios  198

Furniture and Equipment 206 The Disinfectant Dispenser  210 The Patient Bedside Cabinet  224 The Bedside Terminal  230

Conclusion 237 KARMIN Project Team  239

Appendix 240 Glossary 240 About the Authors  245 Subject Index  246 Index of Names, Places and Projects  249 Illustration Credits  250 Acknowledgements 252

Preface The German healthcare system spends more money per hospital patient than most countries in the world – the public health insurance companies pay almost 70 billion euros to the hospitals annually. However, German patients receive by no means optimal care and treatment (BMG 2014). Since 1990, the number of German hospitals has gone down by about 20 % according to the Federal Statistical Office; the average length of stay in the same period has been reduced by about half to seven days. The healthcare reforms of recent years have increased the pressure on hospitals to be efficient and competitive in the marketplace. Their building infrastructure has to be highly adaptable and process flows have to be efficient. In addition, there is a strong increase in the occurrence of resistant germs in hospitals and many patients fear that they will become infected by one of these germs. Every year in Germany about 500,000 patients contract such an infection; about 10,000 to 15,000 patients die each year due to hospital-acquired infections. Many hospital infections cause not only suffering for the patients, but also lead to an extension of the length of stay in the hospital, which places an additional burden on the provision of care. Therefore, hospital-acquired infections also have a considerable economic impact. The patient room in the nursing ward has always been at the focus of hospital construction and hygiene. On the one hand, healing processes become visible here and, on the other hand, patient rooms have the largest space requirement when compared to the other hospital functions. Potential planning errors have severe consequences, as ward structures tend to be repeated. If the complex hospital system is analysed in terms of the possible spread of infections, various critical areas and situations emerge, in which the patient may be exposed to the risk of infection. The nursing wards clearly are a critical zone in this respect. In response to the increased occurrence of multi-resistant pathogens in hospitals the discussion in professional circles has been going on for years whether in future considerably more single rooms should be built or, alternatively, whether double rooms can be upgraded in a way that they can contribute to infection prevention. In Germany in 2016 the share of single rooms in normal care was 5 % (Sunder 2018). A reasonable ratio of the shares of two-bed rooms and of single rooms is insufficiently defined and requires further research. This book addresses the current challenges of the patient room within the hospital and examines which structural measures and procedural aspects are suitable to support the hygiene, to promote the recovery process and to contain the spread of infections. First of all, in chapter A, nursing care is described both historically and in its present and future challenges. The focus is on structural and functional organisation of the work processes in normal care. In two excursus contained therein, first hospital-specific infections with their sources of infection and transmission paths are explained. Secondly, it is described how the choice and sensible use of materials can improve cleaning processes and thus prevent the transmission of dangerous germs in hospitals. Thus chapter A provides the planner with knowledge of design principles. An overview of possibilities for designing a patient room is described in chapter B. The typology is presented systematically and evaluated, based on corresponding examples. In this typological consideration, both the two-bed room and the patient bathroom are analysed. A second focus of this chapter are international case studies of already

7

Preface

built patient rooms and those on the drawing board. The projects are described and documented with scaled plans and selected photographs. An overview of the current building structure of standard care units in German hospitals is given, thus demonstrating the current status quo and uncovering perspectives for action. Finally, chapter C presents the joint research project KARMIN, which was funded within the framework of InfectControl 2020. The German acronym KARMIN stands for Krankenhaus, Architektur, Mikrobiom and Infektion (hospital, architecture, microbiome and infection). The focus of this comprehensive and innovative study was the question whether the architecture of the patient room and its equipment can reduce and at best prevent infections in hospitals. Can a two-bed room in the normal care area be planned in a way that it provides an alternative to the single room? The authors of this book, based at the Institute of Construction Design, Industrial and Health Care Building (IKE) of the TU Braunschweig, have developed and built the prototype of a two-bed patient room. The project took three years and took scientific findings into account. The development also included optimised equipment like the disinfectant dispenser, the bedside table and new contents for the bedside terminal. The methodical approach, the planning phase and the result are documented in this book. The planning and realisation of future hospitals could make a significant contribution to the prevention of nosocomial germs, if hygienically robust building and room layouts were more of a focus of hospital design. After all, while the planning of a highly complex and hygienically robust hospital will remain a demanding task, the architect may not forget the most important function of health buildings, namely to treat and ideally cure patients‘ diseases. Wolfgang Sunder Julia Moellmann Oliver Zeise Lukas Adrian Jurk Braunschweig, November 2020

A

Fundamentals

The Emergence of Hospitals

From the Monastic Hospice to the Modern Clinic The history of hospitals has been shaped over many centuries by a multitude of civilisational factors: social, political and economic changes along with advances in medicine and medical knowledge have all influenced the development of a building type dedicated to care and healing to varying degrees.

1 Depiction of a hospital infirmary hall from the 16th century showing various nursing scenes

2 Plan of the Monastery of St. Gallen, around 820 AD. For several centuries this ground plan served as a model for the construction of hospitals.

3 Charité in Berlin, 1730, second floor with nursing wards

10

Fundamentals

Religious orders as providers of care In the Middle Ages, the hospitals, pest houses, almshouses and orphanages administered by Christian orders were not just institutions of religious charity but were facilities for caring for the sick and protecting other citizens against dangerous communicable infections. The importance of these institutions became particularly apparent in the 15th century when successive waves of dangerous epidemics such as leprosy or the plague swept through Europe. Isolating and treating infected persons in these buildings made it possible to contain these diseases without impacting excessively on the increasing mobility of the population. The hospitals were usually built outside the city walls or on the outskirts of a settlement to limit the spread of infections → Fig. 1. Helping and healing the sick and infirm was typically the province of religious orders acting in the spirit of Christian charity. The building complexes serving this purpose were frequently self-contained walled exclaves at the edge of settlements (Knefelkamp 1987). Their close proximity to the church reflected the Christian ideal of spiritual and religious healing of the sick. For centuries, the St. Gallen Monastery Plan of the Benedictine Order, created around 820, served as an ideal model for hospital construction → Fig. 2. The ground plan featured a rectangular cloister that provided a direct path to the church and around which the social facilities were arranged. These included not only the dormitories for the friars, pilgrims and travellers, but also nursing facilities for the sick. The status accorded to care for the sick in the Benedictine monasteries was so important that they advanced to become centres of medical knowledge. Advances in research from the 18th century onwards The Charité hospital in Berlin, completed in 1727, represents a milestone in the history of hospital design. The threat of plague epidemics and the fear of the ensuing social, economic and political consequences prompted Prussia’s King Friedrich I to build the hospital modelled on the Hôpital Saint-Louis (1607) in Paris. In addition to nursing wards for 200 patients, the Charité also had two infection wards and an obstetrics ward. The distribution of spaces was innovative for the time: the first and second floor wards had small room units with 10–12 beds, marking a departure from the hall-like infirmaries that had been common until then → Figs. 3, 4. The rooms were accessed from a corridor running along the inner wall facing the courtyard. The nursing staff supervised the daily routine and ensured that the rooms were kept clean and bed linen was changed regularly. The opening of the Charité marked the beginning of the founding of a number of other clinics in Germany from 1770 onwards dedicated to the provision of healthcare and support for poorer sections of society. The design of this first generation of hospitals attempted to find hygienic solutions for the construction of various types of buildings. The aim was to pre-

4 View of a hospital room at the Charité during a medical visit. Copperplate engraving by Daniel Chodowiecki, 1783

5 General Hospital in Vienna, 1783-1784

6 General Hospital in Vienna, view of a hospital ward

7 Charité in Berlin, 1785, second floor

11

The Emergence of Hospitals

vent patients from infecting each other in order to avoid, or at least hinder, the occurrence of hospital epidemics, a problem that was already known at that time. The period of enlightened absolutism in Central Europe marked a very significant period of hospital development. Advances in research in the natural sciences had a lasting impact on understanding medicine, and from the 18th century onwards the field of medicine grew ever better at classifying diseases and developing successful therapeutic approaches. Hospitals were especially crucial for the well-being of the less privileged classes to protect them from infirmity and disease, especially as increasing industrialisation during the Age of Enlighten­ ment led to a perilous deterioration of the living conditions of the working classes. It was during this period of major upheaval that a large hospital was built in Vienna, which at that time had 250,000 inhabitants. Completed in 1780 to the plans of the physician Joseph von Quarin and the architect Matthias Gerl, it aimed to centralise and rationalise care of the sick for an entire region. The buildings had three storeys, each with two wards that were combined into one unit. Each hospital room had 20 beds, which were placed along the two longitudinal walls below the windows. As such, there was no corridor along the side and the rooms were entered from the ends → Figs. 5, 6. In 1785, Prussia’s King Friedrich II commissioned the construction of a new Charité hospital in Berlin. The new building was to have three wings, each with four storeys. A central axis divided the building into two sections: the rooms to the left of the entrance hall were reserved for women, those on the right for men. On the ground floor were the surgical and the internal medical wards. The nursing wards were located on the floors above → Fig. 7. Smaller hospital rooms were arranged in the side wings, while the middle wing of the building, facing the street, contained wards for 16 patients each. Between each pair of wards was a sanitary zone and toilet. The building structure of the Charité also reflected the ongoing expansion and differentiation of medical disciplines since the beginning of the 19th century, and there were already eight independent clinics on the site at that time. Pavilion layout providing patients with light and air The period up to the foundation of the German Reich in 1871 is considered a transitional period in the history of hospital development. Hospital structures and equipment were changing constantly, and hygiene was increasingly becoming the focus of attention. Sanitary facilities were expanded, and washhouses were constructed, such as the one for the Charité in 1848 → Fig. 8. At the same time, scientists began to address hygienically relevant topics such as the proper disposal of general and medical waste or the concerted cleaning of sanitary facilities, floors and surfaces. Hospitals were built that offered a high degree of spatial variability, making it possible to separate patients according to type of illness, sex and age, as well as to improve the quality of nursing care. In the period between 1870 and 1918 the number of hospitals in Germany grew rapidly. Between 1876 and 1900 alone, the number of hospitals more than doubled from 3000 to 6300 and the number of beds rose from 150,000 to 370,000 (Murken 1995). At the same time, a surprising variety of hospital types emerged. One of the most important aspects of the new wave of hospital construction activity was the prevention of the transmission of hospital pathogens, resulting in so-called nosocomial infections. In addition, many hospital operators strove to offer patients better-quality care during their stay in hospital, for example with respect to bed comfort, sanitary facilities and

8 Steam laundry of the Berlin Charité. Woodcut from ca. 1868

9 Municipal Hospital in Hamburg-­Eppendorf, 1885–1888

10 Municipal Hospital in Hamburg-­Eppendorf. Floor plan and longitudinal section of a hospital pavilion

12

Fundamentals

nutrition. This also led to a reorganisation of the design of hospitals. Instead of the corridor-type hospitals that had previously been built, freestanding pavilions were built on open ground. Small, low-rise buildings with patient wards were loosely distributed over a large area, their architecture more reminiscent of resorts and hotels than hospitals. Patients lay in wards with large windows, wide verandas or terraces. Priority was given to ensuring hospital beds had fresh air and sunlight and to maintaining a supply of clean air to the rooms. These structural changes to the design of hospitals were accompanied by advances in the fields of hygiene and bacteriology. One of the largest pavilion complexes of this period is the Städtisches Allgemeines Krankenhaus (Municipal Hospital) in the Hamburg district of Eppendorf, which opened in 1888 → Figs. 9, 10. However, by the end of the 19th century the pavilion structure was increasingly abandoned in favour of more densely-built, multi-storey constructions. Wards were arranged around corridors and hospitals were structured in smaller sections and spread across more storeys, resulting once again in taller buildings such as the Municipal Hospital in Düsseldorf → Figs. 11, 12. The principle of access to fresh air was, however, maintained and almost all of the wards opened to the south and were equipped with a large south-facing balcony. This type of hospital, known as terrace hospitals, was common throughout Germany until the Second World War (Murken 1995). The changing hospital landscape after 1945 After the end of the Second World War, hospital construction in Germany began to develop in different directions. A common priority, irrespective of size of the hospital or clinic operator, was to increase efficiency through rationalisation. From the mid-1960s onwards, high-rise construction began to displace low-rise hospital building. An important basis for these structural changes were the scientific advances made after about 1950 in the field of antibiotics research to combat infectious diseases. The resulting continual decline in infections led to a reduction in the number of patient rooms needed, and the combination of a shortage of skilled nursing staff and successful advances in medicine (e.g. artificial dialysis, heart-lung machines) meant that centralisation and automation now determined the direction of hospital design. Business management aspects began to play a more significant role. At the beginning of the 1960s, an efficient hospital would ideally have 200 beds or more, while an optimal nursing ward comprised between 25 and 35 beds. Centralisation also meant that workplaces were merged where similar or sequential tasks had to be performed. The progressive rationalisation of the German hospital system in turn led to a standardisation of individual hospitals according to capacity and number of beds, and since the 1970s, four categories have dominated the hospital landscape: hospitals with 200 beds provide a basic level of care services, those with 300–400 beds a standard level of services, with 600 beds central care services and those with 1200 beds or more maximum care provision. For the nursing sector, a double-corridor configuration was increasingly adopted, greatly improving functional flexibility. Inward-facing rooms, located between two parallel corridors, were partially lit and ventilated by inner courtyards within the building. The double-corridor system also made it possible to separate the circulation of visitors and patients. The shift from a humanistic-holistic healthcare focus to a high-tech system is best seen in the so-called university clinics that were established in Germany from the 1960s onwards. The very high requirements

11 Municipal Hospital in Düsseldorf, 1904–1907

12 Municipal Hospital in Düsseldorf, site plan

13 Münster University Hospital, 1975–1982, model

14 Münster University Hospital, floor plan of a nursing ward

13

The Emergence of Hospitals

in terms of economy, care, hygiene and medical technology that they had to fulfil resulted in highly technical hospital buildings. This development also paved the way for intensive care provision, which was centrally located in separate intensive care units. These technically elaborate rooms were used to treat seriously ill and newly operated patients, who were constantly monitored and supervised by a variety of measuring and other equipment. The university clinics with their three pillars – teaching, research and healthcare – very quickly became the most important source of innovation in clinical medicine, where new research results could be put directly into practice. The rapid expansion of the university clinics came in response to a recommendation by the German Council of Science and Humanities in 1960 to increase the number of beds in the 18 medical faculties in Germany from 16,500 to 25,700. A notable example is the vertical solution developed by the architects Benno Schachner, Peter Brand and Wolfgang Weber in 1973 for Münster University Hospital. Their solution is based on the by then already common model of a broad three-storey base for central diagnostics and treatment that connects vertically to two ten-storey towers with nursing wards, and horizontally to the teaching building and the care centre → Fig. 13. The towers with the patient rooms are cylindrical in form and are arranged so that two circular wards connect to a square central area. The circular ward configuration made it easier to keep an eye on patients and minimised travel distances for the nursing staff. Glazed sections in the patient room doors also afford visual contact between the patient and the nurses’ station in the middle. Each floor comprises two circular wards with 28 beds each, divided into two- and four-bed rooms. Each patient room has its own sanitary unit with toilet, shower and washbasin on the outside wall and between two patient rooms → Fig. 14. New challenges Since the early 1990s, the German hospital system has faced several new challenges. Since 1993, the length of stay in hospitals has been shortened by a third as a result of the introduction of the DRG (Diagnosis Related Groups) system, a flat-rate billing procedure based on the classification of similar hospital treatments and diagnoses. In addition, both privatisation and specialisation have advanced significantly, and the proportion of privately funded hospitals is steadily increasing. Accordingly, the share of public hospital operators had fallen to below 30 % in 2008 (Ernst & Young 2010). While shorter hospital stays and fewer patients due to improvements in medicine have freed up hospital capacities, hospitals are increasingly competing for patients. The design of hospitals has had to adapt accordingly, particularly with regard to flexibility, adaptability and speed of reaction as the basis for long-term economic success. Modern hospital buildings need to be flexible and sustainable. A further response to changes in society and healthcare that has been the subject of discussion for some years now is the concept of “Healing Hospitals” in which the architecture contributes positively to the patient’s recovery process (Meuser, Schirmer 2006). The hospital is gradually evolving into a place of convalescence with recuperative and recreational components more commonly seen in leisure facilities. We are seeing a gradual convergence of the building types of the hospital and the hotel. One example of this is the district hospital in Agatharied, Bavaria, planned by the architects Nickl & Partner. It provides contemporary medical healthcare in an attractive architectural context situated in an idyllic landscape, and its atmosphere is more akin to a comfortable hotel than a hospital → Figs. 15–17.

Looking back over the centuries of hospital development, one becomes aware that few building types have had to adapt so consistently to changing social and medical conditions. Numerous factors, be they advances in medicine and hygiene, shifts in politics and society or the need to train doctors, have given rise to changes that were hard to foresee. New hospitals can take many years to build and thus run the risk of being functionally outdated by the time they are completed. As such, the design of hospitals must increasingly focus on creating a high-quality environment for both patients and its highly specialised staff that is also capable of responding and adapting to the diverse changes it will encounter in its lifetime.

References Bundesministerium für Gesundheit (BMG), Einnahmen und Ausgaben der gesetzlichen Krankenversicherung, KJ I Statistik, as per 27 May 2014 Ernst & Young, Krankenhauslandschaft im Umbruch, Stuttgart: Ernst & Young, 2010, p. 9 Ulrich Knefelkamp, “Die Heilig-Geist-Spitäler in den Reichsstädten”, in: Rainer A. Müller (Ed.), Reichsstädte in Franken, Munich: Haus der Bayerischen Geschichte, 1987 Philipp Meuser and Christoph Schirmer, New Hospital Buildings in Germany: General Hospitals and Health Centres, Vol. 1, Berlin: DOM Publishers, 2006, p. 18 Axel Hinrich Murken, Vom Armenhospital zum Großklinikum: Die Geschichte des Krankenhauses vom 18. Jahrhundert bis zur Gegenwart, Cologne: DuMont, 1995, p. 217 Statistisches Bundesamt (2019), https://www.destatis. de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/ Krankenhaeuser/Tabellen/gd-krankenhaeuser-jahre. html;jsessionid=997DF721D500EE17D682B76A9F210B9F. internet732. Last accessed 18 February 2020 15, 16 Agatharied District Hospital, 1994–1998,   exterior view with conservatories

17 Agatharied District Hospital, partial floor plan of the nursing area

14

Fundamentals

Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier, Andrea Haselbeck and Inka Dreßler, Bauliche Hygiene im Klinikbau. Planungsempfehlungen für die bauliche Infektionsprävention in den Bereichen der Operation, Notfall und Intensivmedizin (Zukunft Bauen – Forschung für die Praxis, Band 13), Bonn: Bundesinstitut für Bau-, Stadt- und Raumforschung, 2018

The Nursing Ward Environment

Current Care Settings and Their Challenges The design of healthcare environments is constantly changing in response to developments in medicine, changing social requirements and advances in architecture and building technology. Before we examine the spatial characteristics, functional areas and work processes of standard care wards, as well as the specific building-related hygiene measures available, we should first consider the challenges that the field of nursing has been confronted with over the past decades and the last ten years in particular.

Resistant germs (%) 18

4

60

18

50

15

40

12

30

9

20

6

10

3

1980

1985

1990

1995

2000

2005

MRSA

FQRP

VRE

Number of approved antibiotics

1 The number of companies capable of developing antibiotics to marketability. Number of antibiotics approved versus the increase in multi-resistant bacterial strains

Men

Age 100

Women

90 80 70 60 50 40 30 20 10

500 thous.

300

2000

0

300

500 thous.

2050

2 Demographic development in Germany

15

The Nursing Ward Environment

2010

An increase in nosocomial infections and multi-resistant germs It is expected that the number of seriously ill patients suffering from infectious or nosocomial infectious diseases in hospitals will increase, with intensive care units being particularly vulnerable due to the numerous invasive procedures they involve. Parallel to this, recent years have seen a dramatic increase in MRSA and nosocomial infectious agents that may potentially spread considerably (Kramer et al. 2012). At the same time, the number of antibiotics available to doctors will be significantly limited in the foreseeable future because the number of companies capable of independently developing antibiotics through all clinical phases for active use in medical practice has fallen from 18 in 1990 to just four in 2011 → Fig. 1. Meanwhile, antibiotics, and reserve antibiotics in particular, are being increasingly prescribed in large quantities, not least because many patients expect their doctors to prescribe antibiotics when they have a fever and other symptoms of infection. New pathogens The risk of new pathogens appearing is high. New bacteria, viruses, fungi and parasites are regularly being identified that have the potential to cause infections in humans. The most recent influenza epidemics, SARS, Ebola or the outbreak of Covid 19 are examples that are as well-known as they are worrying. The emergence of new pathogens is particularly critical if they are able to spread rapidly. Routine medical care is not prepared for the diagnosis of new pathogens, as most methods are based on the detection of known pathogens. The situation is further aggravated by the fact that general nursing wards and especially intensive care areas have insufficient isolation facilities for infected patients. Demographic change Since 1972, the death rate in Germany has exceeded the birth rate → Fig. 2, so that the total population has been falling. At the same time, higher life expectancy means that the proportion of older people is rising in relation to the proportion of younger people. Parallel to this, more and more older people up to the age of about 80 have few or no chronic diseases or disabilities. A major challenge regarding this population group is, however, the significantly higher number of immunosuppressed patients with concomitant diseases and their corresponding appropriate accommodation in nursing wards. As the immune system of this group of patients is weakened by an underlying chronic disease or by the administration of certain drugs, they need particular protection against infections in hospitals. In addition, the nursing sector has faced a series of further shifts within the healthcare sector that have implications for the design of healthcare environments.

%

A decline in the number of hospitals and an increase in bed occupancy Increasing competition among German clinics, the Hospital Financing Act (KHG 1991, 2019) and the German flat-rate billing procedure (DRG for short), introduced in 2004, have led to a continuing reduction in the number of hospitals in Germany as well as in the length of stay for inpatient treatment. At the same time, there has been an increase in the number of inpatients treated per hospital bed → Fig. 3.

100

95

90

Year

85 2001

2003

2005

2007

2009

2011

2013

2015

2017

Hospitals Bed occupancy 3 The number of hospitals and bed occupancy in Germany between 2000 and 2017

Employees in thousands

450 400 350 300 250 200 150 100 50 Year 2001

2003

2005

2007

2009

2011

2013

2015

2017

Nursing staff

Auxiliary staff

Medical-technical staff

Hospital service staff

4 The number of full-time staff employed in German hospitals between 2000 and 2017

An increased need for medical staff Costs in the German hospital sector have been rising continuously for years by an average of about 3 % per year over the past ten years. The overall increase between 2000 and 2008 was 21 %. In 2008, the costs amounted to 62 billion euros (Ernst & Young 2010), with personnel costs alone accounting for around 60 % of the overall costs. Changing patient expectations and the services provided to them have led to a sharp increase in medical staff (doctors, nurses and administration combined) in recent decades. The rise in personnel costs, in turn, is primarily due to a significant increase in medical procedures and services, while the cost of nursing care has risen only moderately. Nursing staffing levels have, however, increased steadily, especially in the last ten years → Fig. 4. On the other hand, there is an acute shortage of skilled staff: there is already a lack of skilled workers in all nursing professions. While official figures on the number of unfilled positions in the nursing professions are not available, an indication of existing bottlenecks can be obtained from the Federal Employment Agency’s analysis of the shortage of skilled personnel. In 2018, there were only 29 unemployed persons for every 100 vacant positions for qualified geriatric nursing staff and specialists (outside temporary employment) and only 48 unemployed persons for every 100 vacant positions for qualified nurses → Fig. 5. Innovations in medical technology and new forms of treatment With the development of new diagnostic and therapeutic procedures, examination and treatment facilities were separated from the nursing wards. At the same time, hospitals have become more efficient at treating each individual patient. In recent years, new hybrid forms of treatment have also been established, such as partial inpatient treatment or pre- and post-operative care, which are increasingly replacing the traditional form of nursing care. In addition, there has been a sharp rise in the number of intensive care beds in both university hospitals and general hospitals: between 1991 and today, the number of intensive care beds throughout Germany rose from 20,000 to 27,000 (Wischer, Riethmüller 2007; GBE Bund 2016). Changing patient demands In Germany’s modern industrial society, there has been a shift in recent decades from a previously largely universal set of common values to a plurality of quite different values for different subgroups of society. As individualisation, fragmentalisation and diversity increase, the forces of social integration are diminishing. Likewise, as traditional family structures change, the amount of care and support provided within the family is declining, in turn increasing the demand for care services outside the home. Individualisation has also led to an increase in personal services. In the nursing care sector, care providers are increasingly expanding their service spectrum to include a range of non-medical services for patients. Hospitals have also had to adjust to a growing proportion of foreign patients and staff in recent decades, in particular in urban areas. This

16

Fundamentals

places increased demands on communication amongst staff members and between staff and patients and also requires tolerance of different norms and practices.

Unemployed per 100 job vacancies

90 80

An increase in patients with dementia Alongside the steadily increasing number of older patients, the risk of developing dementia will also increase → Fig. 6. In total, some 1 million people aged 65 and over are currently affected by dementia in Germany, which corresponds to about 7 % of this age group. The number of new cases is increasing by about 300,000 people every year and is set to reach up to 2.8 million people by 2050 (Deutsche Alzheimer Gesellschaft 2018). This will lead to a higher level of nursing care and a greater demand for nursing staff, since the possibilities of automation in this area are limited.

70 60 50 40 30 20 10 Year 2011

2012

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Hospital nursing staff Geriatric nursing staff 5 Skilled labour shortages in nursing, unemployment to job ratio

Mill.

25

20

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5

Year 2010

2016

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Estimated number of over 65-year-olds Estimated number of sick people 6 Predicted development of the number of dementia patients compared to over 65-year-olds in Germany from 2010 to 2060 in millions

17

The Nursing Ward Environment

2060

Prognosis The developments over the past decades show clearly that the hospital nursing care sector will need to continue to respond to further changes in the future, and in the process will have to consider a multitude of structural, technical, material science and organisational aspects. Research and development into innovative spatial configurations in hygiene-critical areas of nursing wards with a view to preventing infection will be increasingly important. The number of beds per hospital will continue to decrease in future, as will the average length of stay. The absolute number of inpatients per bed, on the other hand, will increase. As a consequence, we can expect to see a shift towards building structures with uniform and standardised care areas. For non-intensive care and observation phases, more economical care structures will be needed such as admission and observation wards. Future developments in nursing forms at hospitals will make it necessary to increase intensive care capacities, and even smaller hospitals are now being equipped with these personnel- and technology-intensive care facilities. The costs of investment in medical technology, personnel and equipment are extremely high though the economic returns are also quite attractive. It is difficult to make precise predictions of the numbers that future nursing care areas will need to accommodate in future. We can expect, on the one hand, to see structural changes such as the increasing splitting off of individual medical fields, new focal areas of patient care and a transition to semi-inpatient or outpatient care. At the same time, it is hard to accurately predict how future financing systems in Germany will affect the size of hospital wards. Every hospital and every area of nursing care will need adapt in response to these developments.

Nursing Wards Location in the hospital

Examination and treatment area (blue) in a high-rise. Two-storey nursing ward (orange) next to examination area

Multi-storey nursing ward (orange) next to two-storey examination and treatment area (blue)

Multi-storey nursing ward (orange) above two-storey examination and treatment area (blue)

The location of nursing wards within the structure of a hospital is largely determined by their optimal relationship to the examination and treatment areas. Since the 1960s, four typical organisational concepts have emerged in Germany → Fig. 7. The first two are horizontal and vertical building types in which the nursing wards are located on several floors next to or above the examination and treatment areas. Another concept is a single-storey nursing ward arranged either next to or above the examination and treatment areas. A fourth, less common variant is the integration of the nursing ward into the overall hospital structure. Here, the nursing wards are not grouped in a spatially and functionally independent unit but instead adjoin the respective treatment and examination zones of the individual disciplines. The primary criterion for the location of nursing wards is their optimal connection to other relevant functional areas in the hospital. Travel distances between the nursing wards and the surgical, medical examination and specialist departments should be kept as short as possible. Close proximity to intensive care and IMC (Intermediate Care) is also desirable as many logistical and staffing processes overlap with those of normal care wards. For patients and visitors, proximity to services located at the entrances, access to outdoor areas and to other care facilities is also important.

Spatial-functional layout

Single-storey nursing ward (orange) above two-storey examination and treatment area (blue)

Examination and treatment areas (blue) with nursing ward (orange) mixed in one overall complex

7 Typical locations of nursing wards (orange) in hospitals. Depending on the concept, the nursing wards lie next to or above the examination and treatment areas.

8 Typical arrangement of a double-corridor nursing ward layout

The profitability of a nursing ward is based on a nursing organisational standard, which should be in the order of 28–41 beds. Despite the differences between individual medical disciplines with respect to the nursing needs of patients, which are quite different, for example, for trauma surgery than they are for transplant surgery, it is still expedient to have a common denominator for the size of normal care wards for both constructional and organisational reasons → Fig. 8. Nursing groups with different numbers of beds or inconsistent room sizes make it hard to standardise operational processes and result in less efficient staffing organisation. For this reason, a uniform standard for nursing wards in a nursing group should be established. The spatial-functional arrangement of a nursing ward is divided into core services and nursing areas. The core services of a nursing ward are grouped together spatially and are solely for use by the doctors and nurses. They include preparatory facilities for delivering care services as well as staff and rest areas for internal use and consultation among colleagues. The core services typically comprise a nurses’ station, staff rooms, examination rooms, supplies, storage and disposal rooms. The nursing areas include the ward corridor and patient rooms. Nurses’ station The nurses’ station is the central point of every ward and should be easy for patients and visitors to find and reach. It is the contact point for patients and visitors as well as for staff, and the place where all process cycles and information in the ward converge. As a rule, it adjoins the medication store, where further work processes can be carried out. Staff rooms This group of rooms includes a common room for the nursing staff, with a kitchenette and workstations for the nursing staff along with sanitary facilities and staff changing rooms.

18

Fundamentals

Doctors’ consultation rooms Consultation rooms within wards are often only equipped to the extent necessary for ward operations, for example for doctor/patient consultations or for dealing with administrative procedures related to the inpatient stay of patients. Examination rooms The examination and treatment of patients does not usually take place in the patient room, especially not in shared rooms. All general care wards have one examination and treatment room for standard examinations, which can be equipped differently depending on the respective ward’s discipline. Supplies, storage and disposal rooms The logistics in general care wards can differ with regard to the degree of centralisation of supply and disposal rooms and their relation to the patient rooms. In many cases, the nurses’ station, nursing workroom and unclean storage room are grouped in a connected series of rooms. Unclean storage rooms, which should always be equipped with bedpan washer-disinfectors, are usually set apart from the patient rooms. It makes sense to locate both supplies and disposal rooms close to goods transport lifts. Ward corridor The ward corridor is the central axis of the nursing ward and should accordingly be of a sufficient size and clear structure. As a rule, patient rooms are arranged on both sides of the corridor, and it must therefore be wide enough to ensure that two patient beds can be pushed past each other. For patients, staff and visitors, the nursing corridor is both a working and meeting area. Preparatory and follow-up care work for treating patients outside of the examination rooms often takes place in front of the patient’s room. Small niches in the corridors can hold necessary materials, storage space or disposal containers for use by the nursing and medical staff. This arrangement also helps facilitate the care and treatment of patients with different diseases. The ward corridor is also a place of social encounters and exchanges, where patients from often quite different social and cultural backgrounds meet in a variety of ways. Patient rooms There are various different solutions for the functional layout and design of patient rooms with respect to their size, arrangement and placement of wet cells and ancillary rooms. A uniform structural wall or column spacing is sensible, both for economic reasons and standardisation as well as to flexibly accommodate future changes of use. The originally widespread six-bed and four-bed room constellations are increasingly being abandoned in favour of two-bed rooms. In 2012, single-bed rooms accounted for between 5 and 10 % of all beds in Germany, which compared to other European countries lies in the middle range (ECDC 2015). So far, shared rooms are the rule, single rooms the exception. The higher proportion of two-bed and single-bed rooms requires more space but also makes it possible to use the nursing areas more intensively, as patients can be distributed to smaller room units according to their illness and nursing needs. Single-bed rooms can be designed in such a way that they can also be used as two-bed rooms in the event of peak occupancy (Wischer, Riethmüller 2007). Special room configurations can apply in particular ward departments such as paediatrics, obstetrics and psychiatry. They may deviate

19

The Nursing Ward Environment

from the pattern of general care wards due to the specific additional functions they need, and their space requirements are generally greater. The patient room is an important cellular unit and base spatial component of a hospital. Its design must be considered in exacting detail as it has significant implications through its replication on the overall structure of the hospital. A patient room includes a sanitary cell, possibly with a separate toilet, the patient bed and wardrobe, a cloakroom for visitors and a seating area → Fig. 9. Architects have continually striven to develop and improve the patient rooms, focusing on and accentuating certain aspects.

Processes

9 Conventional two-bed room

The workflows in normal care wards comprise for the most part standardised processes. Logistical processes, such as the direct supply of laundry, consumables and pharmaceuticals, are designed around modern supply principles. Care and treatment routines undertaken as part of ward operations by medical and nursing staff, including the doctors’ rounds or administering of medication, are carried out either in a circulatory sequence within a ward group or directly for individual patients. These routines are usually preparatory or post-operative measures accompanying medical procedures where specific materials need to be provided or disposed of. Depending on the type of procedure and its hygienic requirements, nursing or medical activities are carried out either at the bedside or in the ward’s examination room. For simple patient examinations, the necessary utensils, for example a syringe or dressing, can be brought from the nurses’ workroom to the patients on a work trolley. After completion of the procedure, this trolley is taken to the unclean disposal room. For more complex or extensive patient procedures, the trolleys in the nurses’ workroom may be equipped with medicines, infusions, instruments, dressing materials, fresh laundry and so on. After completion, the trolley with dirty laundry is stored in the unclean disposal room and replaced once a day.

References H. Bickel, “Demenzsyndrom und Alzheimer Krankheit. Eine Schätzung des Krankenbestandes und der jährlichen Neuerkrankungen in Deutschland”, Gesundheitswesen, 2000, 62 (4): pp. 211–218 Deutsche Alzheimer Gesellschaft e. V., Informationsblatt 1: “Die Häufigkeit von Demenzerkrankungen”, Berlin, 2018 ECDC (2015) European Center for Disease Prevention and Control (ECDC), Healthcare-associated infections, www. ecdc.europa.eu/en/healthtopics/healthcare-associated­­ _­infections/database/pages/hai-pps-database-indicators-­ maps.aspx. Last accessed 4 February 2020 Ernst & Young (2010), Krankenhauslandschaft im Umbruch, Stuttgart: Ernst & Young, 2010, p. 9 Gesundheitsberichterstattung des Bundes (GBE Bund), Intensivmedizinische Versorgung in Krankenhäusern, Anzahl Betten, http://www.gbe-bund.de/oowa921. Last accessed 7 April 2016 A. Kramer, O. Assadian and M. Exner, Krankenhaus- und Praxishygiene, 2nd edition, Munich: Urban Fischer Verlag, 2012, pp. 1–7 Gesetz zur wirtschaftlichen Sicherung der Krankenhäuser und zur Regelung der Krankenhauspflegesätze (Krankenhausfinanzierungsgesetz – KHG). Originally issued 1972, reinstated 1991, last revised 2019 Robert Wischer and Hans-Ulrich Riethmüller, Zukunftsoffenes Krankenhaus – Ein Dialog zwischen Medizin und Architektur, Vienna: Springer, 2007

20

Fundamentals

Excursus 1

Healthcare-associated infections or nosocomial (derived from Greek nósos, illness, and komein, care) infections are infections that only occur after the patient has been admitted to hospital. This means the patient is not infected at the time of admission to hospital, although they may be colonised with various microorganisms, which in itself is a natural condition. To differentiate between regular and nosocomial infections in everyday practice, a simplified definition is used: infections that manifest themselves after the third day of hospitalisation are very likely acquired there and are therefore considered nosocomial while infections that arise within the first three days are considered as not having been acquired in hospital, i.e. were either brought in or acquired on an outpatient basis. What, then, are the possible sources and transmission pathways of nosocomial infections and how can they be addressed through hygiene measures in hospitals?

HealthcareAssociated Infections Rasmus Leistner

Endogenous and exogenous infections The human body is populated with an average bacteria mass of 200 g (approx. 3 × 1013 bacterial cells). As most bacteria are much smaller than human cells, that means that our body contains about the same number of microorganisms as human cells (Sender 2016). The totality of these microorganisms is called human microbiome. Most bacteria are found in the gastrointestinal tract and fulfil a central function in the digestion and production of important metabolic products. Many bacteria are also naturally found on the skin and mucous membrane of the body. The intact skin, and also the intact intestinal mucosa, protects our body against penetration by microorganisms. Invasive medical procedures pierce this natural barrier and thus open up a channel for pathogens to enter otherwise non-microbial areas of the body. If the number of path-

Number of deaths per year 35,000

30,000 Pneumonia 25,000

Primary bloodstream infection

20,000 Surgical site infection 15,000 Urinary tract infection

10,000 Clostridium difficile infection 5,000

Neonatal sepsis 200,000

400,000

600,000

800,000

1,000,000 Number of cases per year

Burden of healthcare-associated infections in Europe Six healthcare-associated infections according to their number of cases per year (x-axis), number of deaths per year (y-axis) and DALYs per year (width of bubble) in Europe for the years 2011 and 2012. DALYs (Disability Adjusted Life Years) are the years of potential life lost due to premature mortality and of productive life lost due to disability. 1 Frequency of nosocomial infections and the associated mortality and disease burden (morbidity)

21

Healthcare-Associated Infections

5

1

2

3

4

5

Development of a biofilm in five steps. Stage 1: Initial adhesion of cells on the surface. Step 2: Production of firmly adherent extracellular polymeric substances. Step 3: Early development of biofilm architecture. Stage 4: Maturation of biofilm architecture. Stage 5: Separation of single cells from the biofilm. Prävalenz noskomialer Infektionen (Patienten mit nosokomialer Infektion in Prozent, links), und Verteilung der verschiedenen nosokomialen Infektionen 2 Phases of biofilm formation on plastic surfaces Prävalenz noskomialer Infektionen (Patienten mit nosokomialer Infektion in pro Fachdisziplin. Aus ECDC Punktprävalnezstudie 2011-2012 Prozent, links), und Verteilung der verschiedenen nosokomialen Infektionen pro Fachdisziplin. Aus ECDC Punktprävalnezstudie 2011-2012 Surgery Internal medicine Surgery Paediatrics Internal medicine Intensive care Paediatrics Gynaecology/obstetrics Intensive care Geriatrics Gynaecology/obstetrics Psychiatry Geriatrics Rehabiliation/other Psychiatry Rehabiliation/other

0

5

0

5

10

15

20

Patients with HAI (%) 10 15 20 Patients with HAI (%)

Surgery Internal medicine Surgery Paediatrics Internal medicine Intensive care Paediatrics Gynaecology/obstetrics Intensive care Geriatrics Gynaecology/obstetrics Psychiatry Geriatrics Rehabiliation/other Psychiatry Rehabiliation/other

0 0

20

40

20

Percentage of HAIs 40 60 80 100

60

80 100

Percentage of HAIs Lower respiratory tract Gastrointestinal Urinary tract Systemic infection Lower respiratory tract Gastrointestinal Surgical site Skin/soft tissue Urinary tract Systemic infection Bloodstream Other Surgical site Skin/soft tissue Bloodstream Other (HAI: Healthcare-associated infection) (HAI: Healthcare-associated infection) 3 Frequency and distribution of nosocomial infections in different disciplines and hospital departments

Abb 004: Häufigkeit und Verteilung nosokomialer Infektionen in verschiedenen Fachdisziplinen und KrankenhausbeAbb 004: Häufigkeit und Verteilung nosokomialer Infektioreichen. nen in verschiedenen Fachdisziplinen und Krankenhausbereichen.

22

Fundamentals

ogens that make it into the body exceeds a critical quantity, the body’s own defence mechanisms are unable to contain them, or at least can only partially do so, resulting in an infection. In addition, bacteria can settle very effectively, especially on plastic surfaces, and once settled produce a slimy substance (the so-called biofilm) that protects them and promotes their unhindered reproduction → Fig. 2. Common medical procedures in hospitals where this route of infection applies are surgical procedures, urinary tract catheterisation, artificial respiration by tracheal intubation, intravenous access, and so on. Most hospital infections are therefore endogenous in nature. This means that the infectious pathogens mostly stem from the patient’s own flora. In industrial nations, an estimated 85 % of all infections are assumed to be endogenous. Consequently, invasive procedures must be used very sparingly in order to minimise the risk of infection. Some hospital-acquired infections are caused by pathogens that enter the patient from outside, from the surrounding environment. This so-called exogenous acquisition of infection is suspected to account for about 15 % of hospital infections. Most of these pathogens are transmitted directly, for example from the hands of hospital staff, or indirectly, through medical devices (e.g. a stethoscope or endoscope). Droplet, airborne or hospital water-borne transmission usually plays a secondary role in the genesis of nosocomial infections. Through appropriate built measures, it is largely possible to reduce the proportion of exogenous infections. By creating a built environment that facilitates uncomplicated workflows and by creating positive incentives (so-called “nudging”), such as encouraging hand disinfection, it is also possible to reduce the risk of endogenous infections. In addition, an environment in which the patient feels comfortable and less exposed to supplementary stress factors can have a protective effect. To begin with, one can prevent the transmission of airborne infections using built means, for example single-bed rooms with and without an airlock. The assumption is that single-bed patient rooms reduce the possibility of contact transmission of infectious pathogens. A separate room may offer a further incentive to remind people to disinfect their hands regularly. Single rooms are also presumed to be advantageous in preventing infection transmission resulting from the shared use of sanitary facilities. The risk of hospital-acquired infections correlates to hospital size (number of beds), i.e. the proportion of patients with hospital-acquired infections increases with hospital size. This can be explained by the fact that hospitals at the end of the treatment chain generally admit more patients with more serious underlying health conditions. These hospitals are usually maximum care facilities with a large number of beds and a wider range of highly specialised disciplines. The risk of infection also varies within the hospital depending on the respective department and discipline → Fig. 3. They are most prevalent in departments that frequently require invasive procedures such as intensive care units or after major operations, e.g. abdominal surgery. Other high-risk areas are those with patients whose immune systems are particularly weakened, such as oncology wards or wards with transplant patients. For this reason, infection prevention in these areas is especially important. Hospital-acquired infections occur relatively constantly throughout the year. Seasonal fluctuations only occur for individual types of infection and pathogens. For example, post-operative wound infections are more frequently observed in summer. Viral gastroenteritis such as norovirus infection occurs more frequently in winter.

Patient zone

Healthcare area

1

Before touching a patient

3

2

Before clean/ aseptic procedure

4

After body fluid exposure risk

5

After touching a patient

After touching patient surroundings

4 The five moments for hand hygiene defined by the WHO

Contaminated catheter hub e.g. from endogenous flora of patient or extrinsic from hands of staff

Skin organisms e.g. from endogenous skin flora of patient or extrinsic from hands of staff or contaminated disinfectant

Contaminated infusate

Skin

Fibrin sheath, thrombus

Vein Hematogenous dissemination from distant infection

5 The pathogenesis of catheter-related bloodstream Abb 003: Pathogenese der Infektion eines Gefäßkatheters. infection

Horizontal and vertical prevention measures In hospitals, a distinction is made between horizontal and vertical prevention measures. Horizontal measures are implemented equally for all patients. The most important example is hand disinfection with alcohol-based handrub by all patients and by all hospital staff in patient care. According to the scheme established by the World Health Organization (WHO 2009), hand disinfection is carried out before touching a patient, before clean/aseptic procedures, after body fluid exposure risk, after touching a patient and after touching patient surroundings → Fig. 4. Cleaning and disinfection are also part of the horizontal measures, as is the focused and sparing use of antimicrobial drugs. The latter is also controlled at hospital level as part of a so-called antibiotic stewardship programme (Leitlinie "Strategien" 2019). Antibiotic stewardship programmes are hospital-wide projects that regulate the prescription practice of antibiotics. This is often implemented by in-house teams (e.g. infectiologists), who implement a sort of quality management system for the entire hospital. Vertical prevention measures are those that are only carried out with certain patients to prevent a specific pathogen or infection. For example, typical vertical prevention measures include screening for multi-­resistant bacteria such as MRSA (methicillin-resistant staphylococcus aureus) and placing patients with MRSA bacteremia in a single room. In order to plan and implement the appropriate preventive measures individually for each hospital, hospitals employ medical and nursing hygiene specialists. Almost all hospitals employ nursing staff with appropriate specialist training (so-called hygiene specialists) and larger hospitals also employ medical staff trained as hospital hygienists. The main requirements for infection prevention in Germany are specified in the Protection against Infection Act and the respective federal state’s hygiene regulations. The Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI) is an expert committee that develops and publishes national recommendations for the prevention of healthcare-associated infections based on current publications and expert knowledge. Because certain vital medical products such as vascular catheters → Fig. 5, urinary tract catheters, intubation tubes represent such a major potential source of infection, most of the KRINKO recommendations deal with the infection-preventive handling of these aids. Other recommendations focus on measures to prevent the spread of certain pathogens. Due to the small number of systematic studies of the influence of hospital design and planning on hygiene, these feature only rarely in the KRINKO recommendations.

References Ron Sender, Shai Fuchs and Ron Milo, “Revised Estimates for the Number of Human and Bacteria Cells in the Body“, in: PLoS Biology 14 (8), 2016 WHO, “My 5 Moments for Hand Hygiene“, WHO Guidelines on Hand Hygiene in Health Care, 2009, https:// www.who.int/infection-prevention/campaigns/ clean-hands/5moments/en. Last accessed 5 March 2020 Leitlinie “Strategien zur Sicherung rationaler Antibiotika-­ Anwendung im Krankenhaus“, 2019, https://www.awmf. org/leitlinien/detail/ll/092-001.html. Last accessed 5 March 2020

23

Healthcare-Associated Infections

Excursus 2

The causes of infectious hospitalisation, that is the infection of hospital patients, staff or visitors by germs, include a lack of hygiene and higher levels of residual contamination on surfaces with which patients come into direct or indirect contact in healthcare facilities (Knoll 2000). By taking appropriate measures it is possible to reduce the frequency of nosocomial infections – infections that occur during a hospital stay – by about one third (RKI 2000). To identify such appropriate measures, one must consider all the conceivable chains of transmission of pathogens (Boyce 2007). Contaminated or insufficiently clean surfaces can serve as a reservoir for microorganisms and therefore represent a potential path of transmission for nosocomial infections due to the long residence time of many pathogens. To counteract this, hygiene-safe solid surfaces should be used in hospitals. Solid surfaces are classed as being hygienesafe when they can be easily and effectively cleaned over their entire lifetime. To assess this, one must consider the mechanical, chemical and physical effects acting on a material in the intended area of application. This article discusses the testing of different material surfaces over their product lifecycle to ascertain how their properties change as they age. Through an appropriate choice of materials, the risk of infection emanating from inanimate solid surfaces can be permanently reduced. This is a key hygiene measure alongside a suitable cleaning strategy, physical barriers and the implementation of an appropriate hand hygiene infrastructure.

Material Applications and Material Ageing in Hospitals Inka Dreßler, Katharina Schütt

Initial condition of the test specimen

Material ageing The property of a material changes over its lifetime. In most cases, material ageing means a change in the material’s chemical composition and physical structure (Pongratz 2005). These chemical, physical and also mechanical ageing processes can be caused by various internal and external factors. The internal influencing factors are specific to the material and include its chemical composition or physical structure as well as possible additives. Each material thus reacts differently to the external influencing factors acting on it in the context of a healthcare environment to cause ageing. These external influencing factors are essentially: — chemical influencing factors (e.g. body fluids, disinfectants/cleaning agents, gases), — physical factors (UV radiation, temperature), and — mechanical factors (static and dynamic surface pressure, for example caused by rolling beds and trolleys). Through the use of a specially developed artificial ageing programme, the key influencing factors can be simulated to determine the impact of material ageing on the cleanability of solid surfaces. To begin with, the initial conditions of the samples were first recorded before they were exposed to an artificial ageing programme that simulates the extreme boundary conditions found in hospitals in a time-lapse manner → Fig. 1. Firstly, the mechanical stresses caused by low or high mechanical abrasion were simulated. This was followed by artificial weathering, whereby UV radiation, temperature fluctuation and liquid acted on the material surfaces. Finally, the materials were chemically stressed by exposing them to low- or high-concentration disinfectant baths.

Artificial ageing

Mechanical factors

Low/high mechanical abrasion

Physical factors

UV radiation, fluids, temperature fluctuations

Chemical factors

Low/high concentrations of disinfectant

Condition of the test specimen 1 Artificial ageing programme for materials

b 0.3 µm < d ≤ 0.5 µm

b 0.5 µm < d ≤ 1 µm

b 1 µm < d ≤ 3 µm

Rª [µm]

5.0120

2.5161

1.4622

γs [mN/m]

0.2300

0.1390

0.1123

− 0.1291

− 0.0440

− 0.0111

Rª γs [µm mN/m]

2 Coefficients b for the system behaviour during cleaning for different-sized contaminants in the range of 0.3 µm to 3 µm

24

Fundamentals

Methods Cleanability refers to the ability of a solid surface to facilitate the removal of (particulate) contamination. Cleanability depends essentially on two surface properties: the shape deviation from an ideally smooth surface (roughness, Ra [µm]) and the wetting properties (surface free energy, γs [mN/m]). These parameters have the greatest influence on the interaction between contamination and a surface and thus the cleanability of a surface. The cleanability of surfaces can be described

by the quantity of residual particle deposits P [-] after a defined soiling and cleaning process as follows P = exp [ bi Rª + bj γs + bij Rª γs ] – k0

3 Exemplary depiction of a micro-structured surface with the recorded surface profile (left) and contact angle measurement (right)

Test group

Description of material

K

Rubber flooring with post-crosslinked surface (factory-applied)

H

HPL board with melamine formaldehyde resin treated surface

P

PVC flooring with polyurethane surface coating

Material Elastic floor coverings made of rubber or polyvinyl chloride (PVC) as well as high-pressure laminates (HPL boards) were investigated → Fig. 4, all of which are commonly used for many surfaces in various areas in hospitals. Since they are used as flooring, laboratory worktops or the surfaces of patient headboards and furniture, patients, staff and visitors come into direct or indirect contact with them. Alongside the material’s composition, the nature of its surface is also important, as this is directly exposed to external factors and consequently influences the durability of the polymer. An overview of the roughness and surface free energy properties of all the material samples prior to artificial ageing is given in → Fig. 5. The various material groups exhibit different degrees of roughness with sample H5 exhibiting the highest and sample P1 the lowest roughness. This can be attributed to variations in the profile of the material surfaces. In general, all the tested material samples have a low surface energy compared to glass or metals and can therefore be described as low surface energy materials.

4 Overview of the investigated material samples

Sample

Roughness Rª [µm]

Surface free energy Ys [mN/m]

K1

1.16

33.56

H1

1.20

30.42

H2

1.32

28.62

H3

0.91

29.04

H4

0.95

33.18

H5

1.49

28.87

P1

0.87

30.98

5 Key surface properties of the samples prior to ageing

Normalised line roughness [%] 200 150 100 50

K1 (low)

K1 (high)

H1-5 (low)

H1-5 (high)

P1 (low)

P1 (high)

Intensity of mechanical abrasion (low/high) Before artificial ageing After artificial ageing with disinfectant bath A After artificial ageing with disinfectant bath B 6 Change in line roughness after artificial ageing of the examined materials (normalised)

25

where b [-] is a system-specific coefficient b [-] and k0 = 0.1 is a constant. The higher the value of P, the more difficult it is to clean the surface. Different coefficients → Fig. 2 result for different sizes of particulate contaminants and have a significant influence on cleanability (Dreßler 2018). This means that both an increase in roughness and an increase in surface free energy impair the cleanability of a surface. An increase in roughness in particular leads to a surface being less easy to clean effectively. The solid surfaces tested were examined with a digital 3D laser scanning microscope to determine the surface profile or line roughness → Fig. 3 left. To determine the surface free energy, the progressive contact angle → Fig. 3 right of three liquids on the samples is determined from which the surface free energy is calculated.

Applications and Material Ageing in Hospitals

Results The artificial ageing programme was employed to investigate the influence of material ageing on the cleanability of solid surfaces in the case of particulate contamination and the results were evaluated using the equation shown earlier. Physical factors (UV radiation, temperature fluctuations, liquid influence) caused the greatest changes in the surface properties, whereas hardly any changes resulted from mechanical abrasion. Chemical exposure to disinfectants – especially with long exposure times – intensified the ageing phenomena already present. The artificial ageing programme was applied with exposure to different degrees of mechanical abrasion (high and low) and physical factors and immersion in a low-concentration and a high-concentration disinfectant bath. The resulting changes in line roughness and surface free energy of the sample surfaces before and after the artificial ageing programme are shown in → Figs. 6, 7. The changes of the respective property were normalised to be relative to the initial value. Since the material changes can be attributed to multifactorial influences, the changes in the parameters roughness and surface free energy caused by the artificial ageing programme are described using the example of the rubber sample K1.

The roughness of the rubber sample K1 decreases, which can be attributed to an oxidative ageing process, which manifests itself for example in chalking or microcracks. The removal of the chalking pigments through cleaning processes during the measurements led to a reduction in roughness. The oxidative ageing process also causes an increase in the surface free energy and thus the wettability of K1. The low-concentration disinfectant bath also appears to have a greater effect on the surface free energy of K1 compared to the high-concentration disinfectant bath.

Normalised surface free energy [%] 200 150 100 50

K1 (low)

K1 (high)

H1-5 (low)

H1-5 (high)

P1 (low)

P1 (high)

Intensity of mechanical abrasion (low/high) Before artificial ageing After artificial ageing with disinfectant bath A After artificial ageing with disinfectant bath B 7 Change in surface free energy after artificial ageing of the investigated materials (normalised)

Residual particle quantity [-] 1200 1000 800 600 400 200

K1

H1

H2

Before artificial ageing

H3

H4

H5

P1

After artificial ageing

8 Mean change in the quantity of residual particles after artificial ageing of the test materials (absolute)

Residual particle quantity and cleanability ˆ of the individual samples before and The residual particle quantity P after the artificial ageing programme is shown in → Fig. 8 for the particle size group 0.5 < d ≤ 1.0 µm. In this case the before and after results are shown without the individual effects of the mechanical abrasion and the different disinfectants. On average, the residual particle quantity of all material groups increases, which means the materials are more difficult to clean than before artificial ageing. The samples H1 and H2, in particular, exhibit a significant increase in the quantity of residual particles and are therefore the most difficult to clean in comparison. Samples P1 and H4 have the best cleanability in comparison despite the increase in the quantity of residual particles. Conclusion The test showed that the mechanical, chemical and physical influences common in healthcare facilities do affect the (surface) properties of materials, resulting in a change in their cleanability properties and in turn in the risk of possible infection caused by surface contamination. Depending on the combination of influences, this need not necessarily mean a deterioration of the properties. Each hospital operator must decide what they deem to be an acceptable measure of change. Where possible, hospitals should select materials that change as little as possible in the expected conditions they are exposed to. In this study, those materials were PVC or HPL boards with a corresponding supplementary surface coating.

References J . M. Boyce, "Environmental contamination makes an important contribution to hospital infection", Journal of Hospital Infection, 65, 2007, pp. 50–54 Inka Dreßler, Hygienesichere Oberflächen im nicht-­ immergierten System, PhD thesis, Technische Universität Braunschweig, 2018 arl Heinz Knoll, Hygiene in Gesundheitseinrichtungen. K Planung – Anlage – Bau – Ausstattung – Betrieb, Stuttgart: Wissenschaftliche Verlagsgesellschaft, 2000 obert Koch Institut (RKI) and Statistisches Bundesamt, R 2000, Nosokomiale Infektionen – Gesundheitsbericht­ erstattung des Bundes. Vol. 8, 2000 Sonja Pongratz, Die Alterung von Thermoplasten, post-doctoral thesis, Friedrich-Alexander Universität Erlangen-Nürnberg, 2005

26

Fundamentals

B

Typologies of the Patient Room

The Floor Plan of a Two-Bed Room

8 m² 1.2 m

8 m²

1 Mindestanforderung Minimum standard

28

Typologies

1.2 m

barrierearm/-frei 2 Barrier-free/low-barrier

The design of patient rooms is a particularly demanding task that generations of architects, hospital planners and interior designers have grappled with. The challenge is to accommodate a wide range of specific needs and users’ interests in a room of limited size. Despite its small floor area, the patient room is the most frequently reproduced unit in a hospital and can quickly become the primary determinant for a hospital design. The repetition of the rooms in a ward is not only legible from outside on the building’s façade; it can also define the typology, for example in the case of a “bed tower block” through vertical repetition where the upper floors are typically exclusively patient wards. The patient room is therefore a central element of the planning of a hospital. This section discusses the planning principles for designing a two-bed room and examines its constituent structural elements. First and foremost, the design of a patient room is always a specific, individual response to the existing needs and prevailing contextual conditions. Whether the design is for a new building, for an extension to an existing building or for the renovation and upgrading of existing facilities, the context and the available budget are key determining factors for the room design. Likewise, regulations and guidelines have a direct impact on room planning and floor plan design and can sometimes be very constraining by defining minimum distances and optimised care provision pro­ cedures that must be ensured without exceeding a certain room size or financial parameters. While this may create the impression that there is little remaining scope for design, a wide range of different patient room designs have been created over the past few decades. Architects and hospital planners have succeeded in developing and implementing various original concepts, especially for two-bed rooms, often in the context of clinical studies. A study of these room types reveals the entire spectrum of design possibilities. Two-bed rooms are a particularly interesting typology to study. This chapter examines the different options in the design of a patient room and the design principles that guide them. It details the design possibilities available to the planner when designing a patient room and presents them in a scheme with the aid of a corresponding example. This study takes the floor plan as its basis and therefore describes only those aspects that actually manifest themselves in or influence the floor plan, and that can be seen as design principles. Likewise, it also considers the essential fittings and equipment that influence the room layout. A key aspect that has a decisive impact on the floor plan design of two-bed patient rooms is the wet cell – the patient’s bathroom within the room. It determines the remaining layout of the patient room and often also the placement of other key fittings within the room. To understand how the different elements in the room interact, it is instructive to look at each part of a room configuration and identify how these can be grouped according to recognisable interdependencies or principles.

The Patient Room The patient room is divided into an area for the patient and the corresponding patient bathroom.

Floor area requirements Minimum standard While the hospital building regulations of many German federal states prescribe only 8 m² per bed place, the State Office for Health and Social Affairs in Mecklenburg-Vorpommern states that a two-bed room should have an area of at least 21 m². In either case, the minimum distances must be observed → Fig. 1.

3 Standard floor plan Regelgrundriss

Barrier-free/low-barrier standard In the context of the floor plan, accessibility considerations primarily concern spaces of free movement. At least one area of 120 × 120 cm must be available for turning and swivelling, and walking and mobility aids must be available in the room and additionally along one long side of the bed (DIN 18040-2). As not all accessibility requirements can be evaluated based on the floor plan, we use the term “low-barrier” to denote the minimising of barriers → Fig. 2.

4 Floor plan combination Kombinationsgrundriss

Floor plan types on a ward Standard floor plan The standard room layout is the most frequently found room type on a ward → Fig. 3. 5 Floor plan variation 6 Specific floor plan Variationsgrundriss

Sondergrundriss

Floor plan combination/variation Different floor plan types can be combined, e.g. single and two-bed rooms. In such cases a two-bed room may be a combination of two types or a modified variant of a floor plan layout → Figs. 4, 5. Specific floor plan Particular situations may require a specific, atypical floor plan arrangement, such as in the case of corner rooms or rooms that connect to other functional spaces. Where these are a response to structural constraints in the building plan, they typically recur at the same position on each floor → Fig. 6.

Additive principles for patient rooms

7 Same-handed Same-handed

The most common additive principle is a repeating row of patient rooms along a ward corridor. Different repetition patterns are possible: Same-handed The same-handed configuration is the simplest form of the additive repetition of rooms along a hospital corridor. Each room is identical in its orientation and fittings. The name derives from the underlying principle that carers can always tend to patients from the same preferred side → Fig. 7.

8 Mirrored floor plan Grundrissspiegelung

29

Floor Plan

Mirrored floor plan Each patient room and the orientation of fittings and equipment is mirrored along the dividing wall. This configuration is popular because it allows a common vertical duct to serve two adjacent wet rooms, effectively halving the amount of plumbing and supply lines, saving materials and costs. The repetition principle is like that of the samehanded configuration, except that each repeated unit comprises two rooms with mirrored layouts → Fig. 8.

9 Floor plan combination

Floor plan combination or variation With this configuration, a room layout may be combined with another typological variation of the same floor plan, or alternatively a completely different floor plan type. This pairing is then repeated as often as needed → Figs. 9, 10.

Grundrisskombination

Unsystematic arrangement In some cases, the additive principle follows no clear pattern. The position of necessary functional rooms, or the unique structural configuration of a building may hinder the application of a clear repeating arrangement. In such cases, varying room layouts are typically used → Fig. 11.

1 0 Floor plan variation Grundrissvariation

Room depth The room depths given here are defined in terms of the bed placement principle rather than a precise dimension. There are two main arrangements for two-bed rooms: One bed deep The room depth is defined by the placement of one bed arranged parallel, orthogonal or rotated at an angle to the ward corridor → Figs. 12, 13. 1 1 Unsystematic arrangement

Two beds deep The depth of the room must accommodate two beds placed along the crosswall, positioned parallel, orthogonal or rotated at an angle to the ward corridor → Figs. 14, 15.

Unsystematische Anordnung

Room geometry

1 2

Ein-Bett-Tiefe 1

12, 13 One bed deep  room

2

4, 15 Two beds deep 1 Zwei-Bett-Tiefe Zwei-Bett-Tiefe  room

Any number of room geometries are conceivable for patient rooms, but not all are practical or realisable. The key determining factors are their potential for useful repetition and their contribution to forming a ward. Rectangular floor plans are therefore predestined, but various hospitals show that other, more complex floor plan configurations are also possible. This results in two typical types of room geometry:



Compact spatial geometry (rectangular) A rectangular floor plan is compact and simplifies the arrangement of fittings and equipment in the room → Fig. 16.

Ein-Bett-Tiefe

Complex spatial geometry (polygonal) A polygonal or non-rectangular floor plan figure can be applied for specific situations, for example to ensure optimum visibility of the bed area from the ward corridor. As most standardised fittings and objects, such as patient cabinets and tables, are rectangular, their placement is more complex. In some cases, custom-made fittings may be necessary → Fig. 17. Kompakt 6 Compact spatial 1 geometry (rectangular)

30

Komplex 7 Complex spatial 1 geometry (polygonal)

Typologies

Zoning

18 Three-zone  room Drei Zonen

19 Three-zone Drei-Zonen-Plus  plus room

Three-zone room The three-zone floor plan is the classic arrangement of a two-bed room. It comprises a movement area for the staff, a patient and patient care zone and a general activity zone for patients and visitors → Fig. 18.

20 Three-zone  plus room Drei-Zonen-Plus

2 1 Two-zone  room Zwei Zonen

2 3 Two entrances 2 2 Single entrance Eine Tür

The zoning of a room designates the respective areas of the patient room in which the different users of the room remain, move around in or which they use actively. A room’s users include the hospital staff, the patient and their visitors. For two-bed patient rooms, there are three necessary zones: — Movement zone and transport, — Patient and patient care zone, and — General activities and visitors’ zone. While these zones may overlap, they should not fall completely within the scope of another zone. Given the small area of a two-bed room, the placement of furniture and standard room fittings often determines the zoning. Three typical zoning options are outlined below. The diagrams provide an abstract indication of the zoning principles without showing the movement spaces of each user group.

Zwei Türen

Three-zone plus room Where there are more than three zones, one speaks of a three-zone plus room layout. Additional zones can include, for example, a balcony for the patients → Fig. 19. A special variant of the three-zone plus room layout occurs when one of the three zones, for example the patient zone, is subdivided into two → Fig. 20. Two-zone room Given the limited space for movement in two-bed rooms, there is inevitably some overlap of the different users’ zones. But when the visitor zone, for example, falls entirely within the staff movement areas (see the example), a three-zone arrangement no longer applies → Fig. 21.

Room entry Room entry denotes the means of entrance from the ward corridor, typically through one or two doors. Most two-bed rooms have a single entrance → Fig. 22; however, some room layouts may have a separate entrance for each patient. This also provides a better view of the patient from the corridor → Fig. 23.

Ward corridor

24 Patient room flush with the ward corridor Flurbereich bündig mit Patientenzimmer

The floor plan of the patient room can influence the form of the ward corridor and thus also defines the nature of the threshold between the hospital and patient room, and between everyday hospital operations and the patient. While the precise articulation can vary, there are two main variants: Patient room flush with the ward corridor The serial repetition of patient rooms produces a flush wall along the ward corridor → Fig. 24.

31

Floor Plan

Ward corridor with alcove in front of patient room By setting back part of the patient room, or the wet cell, in the floor plan, an alcove in front of the room can be created that acts as a buffer space to the ward corridor → Fig. 25.

Flexibility Patient room floor plans are often so spatially optimised that the room zones and elements can seem rigidly defined. However, a degree of flexibility is often beneficial for use and positive for the room’s atmosphere. The following measures can contribute to a room’s flexibility: 25 Ward corridor with alcove in front of patient room Vorbereich vor Patientenzimmer

2 7, 28 Retrofittable airlock 26 Bedside trolley positionable Nachttisch beidseitig positionierbar on both sides of bed

Eingang schleusentauglich Eingang schleusentauglich

Bedside trolley positionable on both sides The bedside trolley can be positioned on either side of the bed without obstructing access to nearby cupboards → Fig. 26. Retrofittable airlock Even in standard care wards, there may be a need to isolate patients with contagious pathogens. In most cases, however, improvised ISO rooms do not meet the requirements to function effectively as a means of infection prevention: many entrance areas that are retrofitted to act as an airlock zone or anteroom are too small to be divided into separate clean and unclean zones. In addition, the airlock may block access to the patient bathroom from within the room. Even though airlocks are not a requirement of standard care wards, provisions for temporarily retrofitting a patient room with an airlock can still be made in the room design → Figs. 27, 28.

Fittings While it is not possible to exhaustively list all the fittings in a patient room, certain aspects and elements are common to nearly all patient rooms. All of them can exist alongside one another in a room. Standard fittings In addition to the patient beds, the standard fittings include a bedside table or trolley, lockers or cupboards for patients’ belongings and a table and at least two chairs for receiving visitors → Fig. 29.

29 Standard fittings Standardausstattung

3 0 Staff workplace in patient room Arbeitsbereich für Personal

Staff workplace in patient room A washbasin or other worktop for all activities relating to care, preparation and documentation of the patient may be provided for use by nursing staff. This can also include a cupboard or storage area specifically for storing medical supplies and aids. A glove box and disinfectant dispenser, as well as additional storage space is often also part of the staff work area → Fig. 30. Washbasin in patient room In addition to hand disinfection, clinical practice may require staff to wash their hands to remove coarse dirt. In the past, fitted washbasins in patient rooms unfortunately contributed to the spread of pathogens and nosocomial outbreaks. We list them nevertheless as they are still planned for patient rooms in new buildings → Fig. 31.

32

Typologies

Privacy screen between patients A movable privacy screen in the form of a curtain or partition can screen patients from their neighbours, for example when examinations need to be undertaken in the room → Fig. 31. Patient desk A separate desk for patients – ideally one per patient – can add another personal space for the patient(s) in the room, sometimes obviating the need for a desk for receiving visitors → Fig. 32.

32 Patient desk 3 1 Washbasin in patient room and privacy screen between patients & Waschbecken Sichtschutz

Schreibtisch für Patienten

Guest accommodation This typically takes the form of furniture designed to allow next of kin to stay the night in the patient’s room. Fold-out furniture, for example, can serve as seating during the day and as a bed for relatives at night. This is most commonly found in children’s wards → Fig. 33.

Openings in the façade The façade is the interface between the patient and the outside world. It allows light into the room, creates a visual connection to the world outdoors and can serve as a spatial extension of the patient room. Room with window and standard sill A conventional window with one opening casement → Fig. 34. Room and bathroom with window and standard sill An outboard bathroom (placed on the exterior wall) may have its own additional window → Fig. 35. Room with window and seat-level sill A window with a lower sill height can be used as seating through the insertion of a bench into the window reveal. In most cases the window sections are fixed, or only certain sections can be opened → Fig. 36.

3 3 Guest accommodation Gästeunterbringung

Internal façade extension Indentations or projections in the façade can be used to create bay windows or conservatories that provide an internal transitional space between the rooms and the world outdoors → Fig. 37.

3 4 Window with standard sill Fenster mit Standardbrüstung

36 Window with seat-level sill Fenster mit Brüstung als Sitzbereich Bad mit Fenster 3 5 Bathroom with window

3 7 Internal façade interne Fassadenerweiterung externe 3 8 Fassadenerweiterung External façade extension extension

33

Floor Plan

External façade extension External extensions to the façade are outdoor fresh-air areas such as balconies, terraces and loggias → Fig. 38.

Bed positions Bed positions describe the spatial relationship between the beds. Parallel The beds are positioned next to each other in a parallel arrangement, creating a two beds deep room → Fig. 39.

40 Opposite one another

39 Parallel

gegenüber

nebeneinander

Opposite one another The beds are placed facing each other directly opposite one another in a one bed deep room → Fig. 40. Staggered opposite one another The beds are placed facing each other but offset in a staggered arrangement → Fig. 41.

41 Orthogonal

orthogonal

Orthogonal The beds are arranged at right angles to each other, irrespective of the depth of the room → Fig. 42.

42 Staggered opposite one another gegenüber versetzt

Turned towards each other The beds can also be turned to face each other at an angle, again irrespective of the depth of the room → Fig. 43. Facing apart The head ends of the beds can be turned to face away from each other, so that neither sees the other. This can be further reinforced by a headwall separating the two → Fig. 44.

4 4 Facing apart ohne Blickbezug 3 Turned towards 4 each other zueinander gedreht

Views in and out of the room Two visual connections play a key role in the spatial configuration of patient rooms: Patients’ view outside This denotes the view the patient has of the window and in turn of the world outdoors. The room design should ensure that both patients have an equally good view → Figs. 45–47.

45 Equal view 4 6 Relatively equal view relativ gleichwertig

gleichwertig

4 7 Unequal view nicht gleichwertig

50 Neither patient Beide Patienten verdeckt visible for staff 48 Patienten Both patients Beide sichtbar visible for staff

34

Ein4 sichtbar 9 One patient Patienten visible for staff

Typologies

Staff’s view of the patient Ideally, the placement of the beds should ensure that patients are immediately visible from the doorway when the door is opened. In some cases, however, only one patient can be seen clearly while a view of the second is restricted. In some countries it is common to see glazed sections in the room doors of standard care wards so that staff in the corridor have a clear view of the patients in bed → Figs. 48–50.

1.2 m

Patient Bathroom Floor area of wet cells

51 Minimum standard Mindestanforderung

5 2 Barrier-free/low-barrier Barrierearm/-frei

The floor area of wet cells is determined largely by requirements for freedom of movement and minimum distances within the patient bathroom. In this study, we classify them into two groups: Minimum standard The bathroom complies with the prescribed minimum distances between the individual bathroom components and the passage width of the door, but this does not guarantee barrier-free access → Fig. 51.

innenliegend 53 Inboard

außenliegend 5 4 Outboard

Barrier-free/low-barrier standard In terms of the floor plan, the focal consideration is the provision of sufficient freedom of movement. An area of at least 120 × 120 cm must be provided in front of sanitaryware such as the toilet bowl, wash­ basin, bathtub and shower area (DIN 18040-2). As not all accessibility requirements can be evaluated using the floor plan, we use the term “low- barrier” to denote the minimising of barriers → Fig. 52.

Position of wet cells In this study, we only evaluate two-bed rooms that comprise a wet room. Within these units, the position of the wet room is of central importance as it determines the remaining disposition of the floor plan. Four basic configurations are commonly used: 5 Alternating inboard/outboard 5 innen- und außenliegend im Wechsel

Inboard An inboard wet room is placed next to the room entrance adjoining the corridor and is the standard and therefore most common arrangement seen in hospitals → Fig. 53. Outboard An outboard wet room is located along the exterior wall. This much less common arrangement reduces the size of the window opening of the two-bed room, and thus limits the degree of light entering the room but has the advantage of being able to naturally ventilate and illuminate the bathroom → Fig. 54.

56 Nested nested

Alternating inboard/outboard Inboard and outboard wet cells can be employed alternately in a row of rooms with the room constellation switching. Alternatively, one room can have two bathrooms → Fig. 55. Nested In the nested arrangement, two bathrooms are placed between two patient rooms. This has the advantage of allowing the patient rooms to be open and rectangular. A minimum planning unit therefore comprises two patient rooms and two intermediate wet cells → Fig. 56.

35

Floor Plan

Additive principles for wet cells

57 Same-handed Same-handed

Additive principles apply equally to the serial repetition of wet cells as they do to the patient rooms. Although the bathroom arrangement is linked to that of the patient rooms, it is not identical and therefore warrants its own consideration. The following patterns of repetition apply to patient bathrooms and echo those of the patient rooms described earlier. Same-handed The size, orientation and fittings of the wet rooms are identical throughout the ward. Because of the identical layout, carers can always approach patients from the same side → Fig. 57.

58 Mirrored floor plan Spiegelung

59 Floor plan combination Kombination

Mirrored floor plan The wet cell and the orientation of fittings and equipment within it are mirrored along the dividing wall. As previously mentioned, this configuration is encountered frequently because it allows a common vertical duct to serve two adjacent wet cells, effectively halving the amount of plumbing and supply lines, saving materials and costs. The repetition principle is like that of the same-handed configuration, except that each repeated unit comprises two cells with mirrored layouts → Fig. 58. Floor plan combination or variation With this configuration, two different wet room configurations are used in combination within a row. Alternatively, variations of a single type of bathroom are also possible, for example when additional requirements need to be met or the size or equipment is adapted to meet a specific need (e.g. rooms for obese patients) or where modifications are necessary for design reasons → Figs. 59, 60.

Use of wet cells

60 Floor plan variation Variation

Bathrooms may be used by patients in different ways. One bathroom for shared use A two-bed room usually has a single shared bathroom, which is about 3–4 m² in size → Fig. 61. Two bathrooms for shared use Two bathrooms in a patient room can be equipped differently to serve two different purposes. They are used by both patients → Fig. 62.

61 One bathroom for shared use Eine Nasszelle - Gemeinsame Nutzung

62 Two bathrooms for shared use Zwei Nasszellen - Gemeinsame Nutzung

36

Typologies

Two identical bathrooms for separate use In this configuration, two identical bathrooms are created, one for each patient → Fig. 63.

Fittings in wet cells Fittings are all essential components and equipment in a patient bathroom that influence the layout. Standard fittings with shower Wet cells with a washbasin, toilet and shower are now standard fittings in general care wards in German hospitals, but that is a relatively recent development. Patient toilets are still often located in the corridor and collective shower rooms or a ward bathroom are still permissible → Fig. 64.

63 Two identical bathrooms for separate use Zwei Nasszellen - Getrennte Nutzung

Second washbasin In addition to the standard fittings, an additional washbasin is provided so that each patient has their own place to wash → Fig. 65.

64 Standard fittings with shower Standardeinrichtung

66 Sliding door Schiebetür

37

Floor Plan

65 Second washbasin Zwei Waschbecken

Second WC In such configurations, each patient has their own WC, regardless of the number of bathrooms. Sliding door A sliding door as access to the bathroom can be employed in floor plan arrangements where conventional hinged doors would lead to overlaps in the use of space → Fig. 66.

Qualitative Evaluation of Two-Bed Rooms

In this section, we examine the various options for the floor plan design and its constituent elements and evaluate each in turn with respect to their characteristics and possible impact. As part of the KARMIN research project, presented in detail in Part C of this book, we undertook a series of surveys and workshops to ascertain the significance of the individual design options in everyday hospital practice. Our assessment is therefore based on interviews with experts, observing staff in hospitals, research and relevant literature. The interviews were conducted with professionals and staff at all levels: doctors, nurses and nursing managers, cleaning staff, architects and designers, hygiene specialists and employees of hospital product manufacturers. To include the patients’ perspective, we also talked to people not professionally involved in the health sector, such as senior citizens. The statements and insight gained from our survey are grouped into six main categories: 1. 2. 3. 4. 5. 6.

Structural complexity Infection prevention potential Workplace quality and safety Spatial qualities Patient safety Patient satisfaction and privacy

These six categories describe important criteria or qualities that must always be taken into account when planning a patient room and that are therefore particularly relevant, not least because they impact on the interests of all the users and people involved in a patient room. We shall examine each of these six qualities in turn and identify which of the above design options contribute to them and why. Those design options not mentioned under a particular quality are accordingly of no consequence for that quality.

1. Structural complexity Structural complexity concerns all principles and floor plan features that in practice give rise to additional construction and/or design requirements. The respective floor plan is compared against a solution that has been optimised in its construction and economic efficiency. If one or more of the design options make its design or construction more difficult or even disadvantageous, the floor plan is regarded as being structurally complex. Barrier-free/low-barrier interior design In principle, barrier-free accessibility should be the norm. However, due to their larger space requirements for movement and spacing distances, barrier-free rooms are larger, and fewer can be realised on one floor. Unfortunately, many designs therefore only observe minimum spacing distances. The additional requirements for barrier-free room design add to the complexity of the design task. Additive principle: floor plan combination/variation The coupling of at least two different floor plan types in an additive sequence of rooms is often employed in the context of an overall façade concept. The need to plan at least two room types with fittings and furnishings in different orientations increases the duration and complexity of the design task.

38

Typologies

Additive principle: unsystematic arrangement of rooms Where the constraints of the planning context hinder the use of a regular arrangement of rooms, for example as a result of predefined functional rooms or specific building forms, designers need to develop custom room variants. This requires more planning time and results in a lower degree of prefabrication of individual room elements. Complex room geometry (polygonal) Non-rectangular building elements are more complex to design and manufacture than rectangular forms. It is likewise harder to incorporate standardised rectangular furniture into room layouts with complex spatial geometries. Irregular room shapes therefore typically entail custom-designed fittings and furnishings co-developed by architects and other planners, increasing the complexity of the design task. Two room entrances A single point of entry is suitable for all room layouts while a patient room with two entrances introduces additional spatial constraints that impact on the rest of the room configuration. Two entrances also require more circulation space and result in additional costs for the door opening, the door and its associated fittings. Alcove in front of patient room Alcoves in front of the patient rooms result in greater floor areas for circulation and additional wall surfaces compared to straight, flush corridor walls. The result is higher costs for materials and production. Retrofittable airlock Designing a floor plan to accommodate retrofitting with an airlock adds functional flexibility but introduces constraints at a structural level as the entrance area must be planned to be convertible into an anteroom. Internal or external façade extension Providing the patient room with an additional area inside or outside the façade, such as a winter garden, bay window or balcony, is a fundamental design decision that affects the entire building design. Compared with a regular outside wall with windows, it requires additional planning work and entails higher costs. Bathroom with window Placing the bathroom on the external wall with an outside window increases the number of openings in the façade to be planned, constructed and installed, and with it the cost of construction. Where prefabricated wet cell modules are used, the opening in the module must be coordinated with the façade design, entailing increased planning work. Two identical wet cells for separate use The positioning of two wet cells in a two-bed room determines much of the zoning of the rest of the patient room and their production inevitably involves higher manufacturing costs.

2. Infection prevention potential This criterion describes the potential of the various built measures to prevent or limit the transmission of infection between patients or between staff and patients. Built measures can also promote compliance among hospital staff. The following design options have the potential to prevent the transmission of infection.

39

Qualitative Evaluation

Barrier-free/low-barrier interior design Dimensioning rooms to afford barrier-free or low-barrier accessibility allows patients with mobility impairments to move around independently, reducing the degree of assistance required and in turn the degree of direct, unrestricted contact between staff and patients. Same-handed room configuration When rooms are identical in their arrangement, staff and patients do not need to adjust and reorient when switching rooms. Care provision procedures are more predictable in their choreography and can be optimised accordingly. Errors resulting from changing situations can be avoided, improving compliance with regulations among nursing staff. Three-zone room/three-zone plus room When each user has their own, clearly legible zone, physical contact between users (e.g. at pinch points) can be minimised. Alcove in front of patient room An alcove in front of the entrance to the patient room creates more distance between the patient and the ward corridor for isolated patients. Additional protective equipment can be placed outside the room and further disinfectant dispensers can be attached without causing obstruction or injury. Similarly, disposed material is kept away from the corridor. Retrofittable airlock The ability to retrofit or temporarily create an airlock in the case of a nosocomial outbreak can be an effective built means to reduce the transmission of infection. Staff workplace in patient room If supplies and equipment for nurses and nursing care are located within the room instead of being brought in on a supplies trolley, staff can care for the patients more directly and work processes can be planned and optimised. External façade extension A balcony or loggia makes it easier for patients to go outside. Fresh air can help reduce the patients’ germ load. Bathroom with window A naturally ventilated bathroom adjoining the building’s façade can contribute to a better room climate and counteract the spread of germs. Beds not placed next to each other Placing the beds further apart reduces the potential of infection transmission between patients in a two-bed room. It likewise promotes staff compliance with regulations by reducing the risk of staff tending to each patient in turn without disinfecting their hands. Beds clearly visible to staff If a patient is clearly visible to staff from the door, they are able to monitor patients better and respond quickly in the case of an emergency. It likewise deters patients and visitors from activities detrimental to their recovery.

Barrier-free/low-barrier bathroom Bathrooms dimensioned for barrier-free or low-barrier accessibility allow patients with mobility impairments to use the bathroom independently and conduct their own personal hygiene. Where necessary, staff can assist in the room rather than transporting high-risk patients to a ward bathroom. Same-handed wet cell configuration The identical arrangement of objects in a patient bathroom means that staff and patients do not need to adjust and reorient when switching rooms. The choreography of hygienic care and assistance can be planned and optimised accordingly. Procedural errors resulting from changing situations can be avoided. Two identical wet rooms for separate use Where each patient has a patient bathroom of their own, the risk of infection transmission through jointly used sanitaryware can be minimised. In addition, contamination in one sanitary cell does not necessarily transfer to the other cell. Second washbasin The installation of a second washbasin reduces the risk of infection transmission via the surfaces of the washbasin or tap. Second WC The installation of a second WC reduces the risk of infection transmission via the surfaces of the toilet or flush button.

Retrofittable airlock Floor plans that accommodate retrofitting with an airlock already anticipate the need for an anteroom where additional personal protective equipment can be accommodated. In addition, preventing door swings from clashing in room entrances reduces the risk of accidental injury. Staff workplace in patient room A workplace for staff in the room with all necessary supplies and equipment to hand avoids the need to transport necessary aids from room to room in the ward on a supplies trolley. Washbasin in patient room In addition to hand disinfection, a washbasin in the room allows staff to also wash their hands to remove dirt. Beds not placed next to each other When beds are placed further apart, staff caring for a patient cannot unintentionally come into uncontrolled contact with the neighbouring patient. This also helps minimise the risk of infection transmission. Beds clearly visible to staff If patients can be seen clearly from the entrance to the room, staff can monitor patients without having to walk fully into the room, saving time and energy. Barrier-free/low-barrier bathroom If a patient bathroom and WC is sufficiently accessible for patients, staff no longer need to transport patients to a suitable bathroom on the ward.

3. Workplace quality and safety All aspects that improve the working conditions and work processes of hospital staff (e.g. doctors and nurses) contribute to workplace quality. Workplace safety is improved by preventing the risk of injury and reducing avoidable contact situations between staff and patients or visitors. Barrier-free/low-barrier interior design Accessible patient rooms allow people with limited mobility to be as independent as possible in their room, reducing the degree of assistance required and the physical strain and stress on care staff. Same-handed room configuration When patient beds and fittings are always in the same place in every room, staff can act immediately without needing to adjust to changing room configurations.

Same-handed wet cell configuration When bathroom fittings are identically placed in each room, staff do not need to readjust from room to room, saving time and making care procedures easier. Standard fittings with shower When a patient can wash and conduct personal hygiene in their own bathroom, staff do not need to transport or accompany them to showers or a bathroom on the ward. Bathroom with sliding door A sliding door to the bathroom reduces the risk of injury caused by doors slamming open or shut. Sliding doors also make it easier to simultaneously assist a patient and operate the door.

4. Spatial qualities One bed deep room In one bed deep rooms, patients are closer to the door so that staff have shorter distances to walk. Removing or bringing a bed is likewise easier as the beds are both near the entrance. Three-zone room/three-zone plus room Where room zones for each user are clear and legible, physical contact when moving about the room can be avoided, for example during bed transport. Staff can move independently of other room users. Bedside cabinet positionable on both sides The ability to move the bedside trolley to the other side of the bed makes it easier to carry out medical care procedures.

40

Typologies

This describes all the spatial qualities of a patient room that can be deduced from the floor plan and covers all aspects that contribute to a room’s potential spatial quality. Compliance with design standards and the room proportions can provide a sense of the space, even when the actual spatial effect cannot be described by the floor plan alone. Barrier-free/low-barrier interior design A room in which the individual items of furniture are placed further apart for better barrier-free access will also appear more spacious and less cramped.

One bed deep room Rooms that are only one bed deep have more balanced proportions. Less deep rooms are generally better illuminated and therefore feel lighter and brighter. Three-zone room/three-zone plus room Clear zoning lends rooms a sense of clarity and legibility and suggests immediately how they might be used. Alcove in front of patient room Ward corridors are divided into areas with different functions. Alcove areas in front of the patient rooms provide a more sheltered buffer to the sometimes hectic activities in the ward and also give each room its own “address”. Bedside cabinet positionable on both sides The ability to position the bedside trolley on either side of the bed affords the room greater flexibility. Conversely, a room where everything has a fixed position appears more static. Room with window and seat-level sill Locating a seating area in the depth of the window opening or next to it makes optimum use of the window as a threshold to the world outdoors, while also minimising the spatial impact on the room. The lower sill height also means the window is larger so that patients lying in bed have a better view of the world outside. Internal and external façade extension Every external area or projection of the façade represents an extension of the space of the room for the patients’ and visitors’ use. The traditional notion of the hospital as rows of rooms behind windows is broken down by the façade extensions, which add elements familiar from domestic environments. Bathroom with window A daylit bathroom has a positive effect on the atmosphere of the room. View outside For patients who spend most of the day lying in bed, the view outside is their primary means of contact with the outside world during their stay. It is therefore especially important that both patients have an equally good view from their respective beds out of the window. Barrier-free/low-barrier bathroom More generous spacing between the elements of a bathroom improves its sense of space and and makes it appear less cramped. A floor-flush shower tray heightens this effect, visually enlarging the room. Nested wet room configuration When the wet cells are grouped together and arranged between the rooms, the rooms themselves appear more spacious. The bathroom does not obstruct the view out or of the entrance area. Bathroom with sliding door Eliminating door swings creates more room for movement and fewer obstructions for all the room’s users.

41

Qualitative Evaluation

5. Patient safety This encompasses all measures aimed at maintaining patients’ physical safety by avoiding the risk of injury and restricting unnecessary exposure to other user groups. These illustrate how design decisions, room fittings and the layout of the patient room can impact on patient safety. Barrier-free/low-barrier interior design As rooms designed for barrier-free or low-barrier accessibility facilitate freer movement, the risk of injury from bumping into things or falling is reduced. Same-handed room configuration A same-handed room layout across a ward allows patients to find their orientation quickly should they be moved to another room for medical reasons. Conversely, changing room configurations can confuse patients with dementia or other impairments, leading to the risk of injuries or falls. One bed deep room The incidence of accidents or falls is particularly high between the bed and the bathroom. The distance to the bathroom is typically shorter and thus safer in rooms that accommodate the depth of one bed than those with two beds arranged behind one another. Three-zone room/three-zone plus room Clearly legible zones for the room’s different users minimises collisions between patients and other room users. Two room entrances Two room entrances lessen the probability of injuries arising through doors unexpectedly opening. Alcove in front of patient room An alcove can be used to hold additional protective equipment or other protective precautions for patients in isolation and also acts as a buffer between the room and the corridor and other patients. On leaving the room, a patient can first safely find their bearings and assess the situation before embarking down the ward corridor and is not forced to suddenly evade unexpected oncoming traffic. Retrofittable airlock Rooms that can be retrofitted with an airlock must ensure that the bathroom is accessible from the patient room and that the entrance area can be divided off. The separate placement of the doors therefore avoids collisions between opening doors and is safer for patients. Staff workplace in patient room A staff work area within the room with essential supplies and equipment to prevent the transmission of infections contributes to patient safety. Beds not placed next to each other, but in sight of one another Placing beds further apart within a room reduces the risk of infection transmission between patients. However, if they also remain within sight of one another, both patients benefit from the ability of the other to call for help in the event of an emergency.

Beds clearly visible for staff If patients can be seen clearly from the door, staff are able to monitor patients more easily and can react quickly if needed. Barrier-free/low-barrier bathroom The greater room for movement in a barrier-free bathroom as well as the additional grab rails help patients use the bathroom more safely. Same-handed wet cell configuration As with same-handed room layouts, a consistent bathroom layout allows patients to find their bearings easily should they need to move to another room for medical reasons. Patients with dementia or other impairments can find a new situation challenging and disorientating, increasing the risk of collisions or falls.

Three-zone room/three-zone plus room Clear zoning within the room makes non-intrusive movement in the room easier and avoids different zones having to overlap. As a result, each patient has a degree of personal space. Two entrances A separate entrance for each patient means that patients do not need to feel obliged to respond to everyone who enters. This can potentially reduce stress levels. Alcove in front of patient room As a spatial buffer between the patient room and the corridor, an alcove adds a layer distancing the public activities on the hospital ward from the comparative privacy of the patient room.

Two identical bathrooms for separate use Separate bathrooms for each patient reduce the risk of infection transmission via common contact surfaces or mix-ups between the patients’ items such as towels.

Bedside cabinet positionable on both sides The ability to freely position the bedside trolley on either side of the bed allows patients to determine their immediate surroundings according to their preferences, for example if they are left- or right-handed.

Standard fittings with shower The ability of a patient at risk of infection or who is themselves infectious to wash in their own room avoids the need for them to be exposed to hospital operations or use a ward bathroom used by other patients.

Staff workplace in patient room A place where staff can prepare care procedures in the room avoids the need for a supplies trolley to be wheeled right up to the bed. The staff workplace also ensures that distance is maintained quite naturally between the staff and the patients.

Second washbasin/WC Two washbasins or toilets reduce the risk of infection transmission between two patients via jointly used sanitaryware that tends to have a high bacterial load.

Privacy screen between patients A movable privacy screen such as a curtain or a partition offers a patient the possibility to screen themselves from their fellow patients or other visitors when privacy is required.

6. Patient satisfaction and privacy This criterion encompasses all design measures that contribute to the patients’ well-being and satisfaction. Means of improving privacy are particularly important as this study assumes that to feel comfortable each patient in a two-bed room requires a sense of relative privacy. Barrier-free/low-barrier interior design Barrier-free or low-barrier patient rooms enable patients with mobility impairments to move around without needing the assistance of staff, contributing to their sense of independence and self-assurance. Same-handed room configuration In contrast to the mirrored floor plan, the head ends of the beds in two same-handed adjacent rooms do not adjoin the same dividing wall. As supply lines and connections are not situated on both sides of the same wall, noise transmission through the wall is avoided. And because the distance between the beds in neighbouring rooms is greater, the noise level is also lower. As noise is known to be a major stress factor for patients, reducing the impact of noise contributes significantly to patient well-being. One bed deep room By positioning the beds on a separate wall surface of a one bed deep room, each patient has their own corner of the room, contributing to the patients’ sense of privacy.

42

Typologies

Patient desk A separate desk enhances the sense of having personal space and can encourage patients to engage in cognitive activities such as crossword puzzles, reading newspapers or writing letters. Guest accommodation The possibility for relatives to stay overnight in the hospital room can contribute immeasurably to a patient’s well-being. Room with window and seat-level sill A dedicated seating area adjoining the window can offer a personal corner to sit set apart from the bed. A bench-level sill height also means the window is larger so that patients lying in bed have a better view of the world outside. Internal and external façade extension For patients with impaired mobility, access to an outdoor area can be an important substitute when they are unable to go outdoors in the fresh air. In addition, conservatories, bay windows and balconies are elements that lend a homely character to a patient room. Bathroom with window A daylit bathroom and the ability to naturally ventilate the room likewise lends a patient bathroom a more homely character.

Beds not placed next to or opposite each other Placing the beds as far apart as possible, for example positioning each along a separate wall, creates a separate area of the room for each patient. View outside from the bed A view of the window that does not encroach on the privacy of the fellow patient allows both patients to retain a sense of privacy and prevents one or the other from feeling as if they are at a disadvantage. Barrier-free/low-barrier bathroom A barrier-free bathroom can enable a patient to wash independently without additional assistance from nursing staff, allowing them to maintain a sense of personal privacy. Inboard wet cell configuration The inboard arrangement of the bathroom along the corridor wall means that the beds are further away from the entrance. Patients feel less exposed when staff or visitors enter the room and are also further away from the noises of the ward corridor beyond. Same-handed wet cell configuration As with the room itself, the fact that with a same-handed configuration two bathrooms in adjacent rooms do not lie either side of the same wall reduces noise transmission and contributes to a sense of patient satisfaction. Two identical bathrooms for separate use Separate bathrooms allow each patient to have a place of retreat where they can feel undisturbed. Standard fittings with shower A shower in the room means that patients do not need to use ward bathrooms or collective showers. Second washbasin/WC A sense of relative privacy can be heightened when each patient has a separate washbasin or a separate toilet.

A note on the evaluation and assessment of qualities In clinical practice, other dependencies and causal relationships will no doubt arise that do not correspond entirely with our evaluation in this study. In cases where there are good reasons for or against a certain classification, we have either taken a specific standpoint or refrained from making any classification. Similarly, factors that could be included but do not impact directly on the ground plan have been excluded. In all of the evaluation categories described, we start from the assumption that measures, usage and procedures comply with regulations, that necessary cleaning is undertaken and that each of the users act sensibly within the scope of their health and mental capabilities. Worst-case scenarios, negative examples or grossly negligent actions by the users are therefore not considered here.

References DIN 18040-2:2011-09 Barrierefreies Bauen – Planungs­ grundlagen – Teil 2: Wohnungen (Construction of accessible buildings – Design principles – Part 2: Dwellings), Berlin: Beuth, 2011. (The DIN standard for housing applies as there is not a separate DIN for barrier-free patient rooms). Landesamt für Gesundheit und Soziales in Mecklenburg-Vorpommern (State Office for Health and Social Affairs in Mecklenburg-Vorpommern), Bauanforderungen und funktionelle Empfehlungen aus der Sicht der Hygiene für den Neubau- und die Sanierung von Krankenhäusern und Universitätskliniken in M-V. Anforderungen zur Konzessionierung von Krankenanstalten § 30 Gewerbeordnung, Allgemeine Pflegestation, as of 2 November 2018

43

Qualitative Evaluation

Typological Evaluation of Two-Bed Rooms

44

Typologies

In a patient's room the bed position and the position of the wet room already have a decisive influence on the further configuration of the floor plan. Especially for two-bed rooms this results in a wide range of possibilities. In the following, examples of 18 very different two-bed room floor plans are shown. The most effective way to compare and evaluate the respective qualities of different floor plan layouts would be to study how they are used in everyday clinical practice, but this is not practical, neither in the context of this study nor in reality. Nevertheless, this typological study instead analyses and evaluates the configuration of various two-bed rooms using their floor plans. By considering each aspect of the room’s design individually in terms of its potential qualities, we can build up a qualitative profile for each type of floor plan. The evaluation matrix on the right details each of the spatial design aspects along with their respective qualitative characteristics already introduced → Qualitative Evaluation of Two-Bed Rooms, pp. 38–43. Each of the 18 different floor plans is briefly introduced. Then the plans are analysed using this matrix to identify their respective features and corresponding qualitative characteristics. Using a points system, an overall evaluation of the floor plan can be obtained. Mutually exclusive qualities are not added together – e.g. a standard room plan cannot also be a special case solution – and where certain characteristics are not present throughout – for example for only one of the two beds – only half a point is added. Adding the points together produces a maximum rating for each qualitative characteristic. The points are then used to generate diagrams that show a graphical representation of the qualitative evaluation of the respective floor plan layout. Each graphic provides a visual indication of the qualitative characteristics of the respective floor plan typology. The intention here is not to propose model floor plan types for twobed patient rooms, because, as discussed earlier in the introduction, each patient room design is an individual response to the prevailing context and specific needs of the respective clinic. While the configurations shown here illustrate room layout principles, they cannot serve as a universally applicable solution for every case. Instead they show the relationship between optimised operational and constructional solutions and their potential qualities in use. As such, they reveal the complexity of the design task of two-bed patient rooms. One should also note that achieving a “maximum score” in all aspects is neither practicable nor feasible in the actual context of a real clinic. A “maximum” variant would have two entrances and two nested wet cells for a one bed deep room, guest accommodation, a balcony etc. Instead, this qualitative study aims to illustrate the relationships between built, process-related and emotional factors.

Patient room Floor area Floor plan types Additive principles Room depth Room geometry Zoning Room entry Ward corridor Flexibility Fittings Openings in the façade Bed positions Views in and out

Overview of the individual design aspects of a patient room and the corresponding potential qualities they have in the patient room.

Minimum standard Barrier-free/low-barrier standard

● ● ● ● ● ●

Standard floor plan Floor plan combination/variation Specific floor plan

● ●

Same-handed

● ●

● ●

Mirrored floor plan Floor plan combination/variation Unsystematic arrangement

● ● ● ●

One bed deep Two beds deep Compact Complex

●

Two-zone room

● ● ● ● ● ● ● ● ● ●

Three-zone room Three-zone plus room Single entrance Two entrances

●

● ●

Entrances flush with corridor Alcove in front of room Bedside cabinet positionable on both sides Retrofittable airlock

● ●

● ● ● ● ● ● ● ● ● ● ●

Standard fittings Staff workplace Washbasin

● ● ●

● ● ● ● ●

Privacy screen between patients Patient desk Guest accommodation Window with standard sill Bathroom with window

● ●

● ● ● ●

Room with window and seat-level sill Internal façade extension External façade extension

● ● ●

● ● ● ●

Beds side by side Beds opposite Beds staggered opposite one another Beds at right angles Beds turned towards each other Beds facing apart Patient’s view outdoors Staff’s view of the patient

● ● ● ● ●

● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ●

Patient bathroom Floor area Position Additive principles Use Fittings

45

Minimum standard Barrier-free/low-barrier standard Inboard

● ● ● ● ● ●

Outboard



Alternating inboard/outboard Nested Same-handed

● ●

●

● ●

Mirrored floor plan Floor plan combination/variation One bathroom for shared use Two bathrooms for shared use Two bathrooms for separate use

● ●

Standard fittings with shower Second washbasin Second WC Sliding door

Typological Evaluation

● ●

● ● ●

● ● ● ●

● ● ● ●

● Structural complexity ● Infection prevention potential ● Workplace quality and safety ● Spatial qualities ● Patient safety ● Patient satisfaction and privacy

Complex room layout with balcony

The angled, polygonal floor plan is particularly suitable in a same-handed arrangement of the rooms. In the example shown here also the patient in the rear bed has an unimpeded visual relationship with the outside. In addition to the seating area in the room, the balcony offers another place to sit.

Patient room

Structural complexity Infection prevention potential

Minimum standard

Workplace quality and safety

Standard floor plan

● ●

Same-handed

● ●

Two beds deep Complex Three-zone plus room





●

● ● ● ● ●



Spatial qualities Patient safety



Patient satisfaction and privacy



Single entrance Alcove in front of room



Bedside cabinet positionable on both sides Retrofittable airlock



● ●

● ● ● ● ● ● ● ● ● ● ●



Standard fittings Staff workplace Washbasin



● ● ●

● ●

Window with standard sill External façade extension Beds turned towards each other



Patient's view outdoors (2 beds) Staff's view of the patient (1 bed)

● ● ● ● ● ● ● ● ● ● ● ● ●











Patient bathroom





Minimum standard Inboard Same-handed

● ●



● ● ●

One bathroom for shared use



Standard fittings with shower Sliding door

46

Typologies

● ● ● ● ●



Layout with outboard bathroom with window

An outboard bathroom positioned on the outer wall has the advantage that it can be supplied with daylight through a window. In addition, the view of the patients is unobstructed when staff enter the room. At the same time, however, the bathroom limits the window area and the bed positions move further into the room.

Patient room

Structural complexity Infection prevention potential

Minimum standard

Workplace quality and safety

Standard floor plan

Spatial qualities

Mirrored floor plan Two beds deep

Patient safety

Compact

Patient satisfaction and privacy

Three-zone room



● ● ● ● ●

Single entrance Entrances flush with corridor

●

Patient desk



Window with standard sill Bathroom with window



● ●

●

●

Beds side by side



Patient's view outdoors (1 bed) Staff's view of the patient (2 beds)



● ●

●

●

●

Patient bathroom



Minimum standard

Outboard



Mirrored floor plan One bathroom for shared use Standard fittings with shower

47

Typological Evaluation

●

● ●

Layout with private lounge area per patient by the window

As in the floor plan with one entrance area per patient → Fig. p. 52, this layout is characterised by a symmetrical room division. In this example, this room division allows for a separate lounge area at the window and even a separate desk for each patient fits in here. An optimal spatial separation of patient care and patient privacy is achieved.

Patient room Barrier-free/low-barrier standard

Structural complexity Infection prevention potential

● ● ● ● ● ●

Workplace quality and safety

Standard floor plan Same-handed One bed deep

● ● ● ● ● ● ● ●

Compact

Three-zone plus room



● ● ● ● ●



Spatial qualities Patient safety



Patient satisfaction and privacy



Single entrance





Entrances flush with corridor



Bedside cabinet positionable on both sides

● ●

Patient desk



● ●





Window with standard sill Bathroom with window Beds opposite



Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

● ● ● ● ● ● ● ● ● ● ● ●





Patient bathroom Barrier-free/low-barrier standard

● ● ● ● ●

Outboard Same-handed





● ●



● ●



One bathroom for shared use



Standard fittings with shower

Sliding door

48

Typologies

● ● ● ● ●







Square floor plan with inboard and outboard wet room

Each patient has their own wet room. The position of the bathrooms in the corners of the room creates a separate area for each patient. However, while one patient is hidden from sight by a wet room when staff enter the room, the other wet room restricts the second patient's view to the outside.

Patient room

Structural complexity Infection prevention potential



Minimum standard

Workplace quality and safety

Standard floor plan

Spatial qualities

Mirrored floor plan

Patient safety

Two beds deep Compact Three-zone plus room



● ● ● ● ●



Single entrance Entrances flush with corridor

● ●

Bedside cabinet positionable on both sides

●

Standard fittings



Window with standard sill Beds staggered opposite one another



● ●

Patient's view outdoors (1 bed) Staff's view of the patient (1 bed)



● ●

●

● ● ● ●

Patient bathroom Minimum standard

●

Inboard Outboard



Mirrored floor plan Two bathrooms for separate use

● ●

Standard fittings with shower Second washbasin Second WC

49

Typological Evaluation

● ●

●

● ● ● ●

● ● ● ●



Patient satisfaction and privacy

Layout combination of single and two-bed rooms

In this spatial sequence, double rooms are combined with single rooms, whose floor plan varies slightly in each case. The double rooms have their own separate patient area thanks to the wet rooms in between. The façade projection offers each patient a "dedicated" window for the view to the outside.

Patient room

Structural complexity Infection prevention potential

Minimum standard Floor plan combination/variation

Workplace quality and safety

●

Spatial qualities

Two beds deep

Patient safety

Compact

● ● ● ● ●

Three-zone plus room



● ●

● ● ●

● ● ●

Washbasin





● ●



Window with standard sill Internal façade extension Beds staggered opposite one another



Patient's view outdoors (2 beds) Staff's view of the patient (1 bed)

●

● ● ● ● ● ● ● ● ● ●

●





Patient bathroom



Minimum standard

●

Nested





Standard fittings Staff workplace



Patient satisfaction and privacy

Single entrance Alcove in front of room





Floor plan combination/variation



One bathroom for shared use



Standard fittings with shower

Sliding door

50

Typologies

● ● ● ● ●







Specific floor plan with beds without visual connection

The two-bed room (right) in question is a special layout → Fig. 6, p. 29, which is not intended for additive arrangement. The patients are visually separated from each other by a screen. Each patient is assigned an additional bed for the accommodation of relatives. The two wet cells are equipped differently and must therefore be used by both patients → Fig. 62, p. 36, Two bathrooms for shared use.

Patient room

Structural complexity



Minimum standard Specific floor plan

●

Unsystematic arrangement

● ● ● ●

One bed deep Compact Three-zone plus room



● ● ● ● ●

Single entrance

Retrofittable airlock Staff workplace Privacy screen between patients Guest accommodation





● ● ● ● ● ● ● ● ● ● ● ● ●

Window with standard sill Beds facing apart



● ●

Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)



● ●

●

●

● ●

Patient bathroom

Minimum standard

●

Inboard



Two bathrooms for shared use Standard fittings with shower Second washbasin

51

Typological Evaluation

●

●

● ● ● ●

Workplace quality and safety Spatial qualities Patient safety



Entrances flush with corridor Bedside cabinet positionable on both sides

Infection prevention potential



Patient satisfaction and privacy

Floor plan with one entrance area per patient

The two entrance doors to the patient's room allow for an equal division of the patient's space and there is even room for a staff workplace per patient. The patient is directly visible to the staff from the door area and has an unobstructed view of the outside area even in a lying position. The central position of the wet room means that the bathroom door is visible from both beds and the distance to it can be easily assessed by the patient. The distance to the bathroom is also short for both patients.

Patient room Barrier-free/low-barrier standard

Structural complexity Infection prevention potential

● ● ● ● ● ●

Workplace quality and safety

Standard floor plan Same-handed One bed deep

● ● ● ● ● ● ● ●

Compact

Three-zone plus room Two entrances

Alcove in front of room Retrofittable airlock



● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ●

Spatial qualities Patient safety



● ●

Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

● ●

● ●

● ●



●



Patient bathroom Barrier-free/low-barrier standard Inboard Same-handed



● ● ● ● ● ● ● ● ● ●



One bathroom for shared use



Standard fittings with shower

Sliding door





● ● ●





Window with standard sill Beds opposite



Patient satisfaction and privacy



Standard fittings Staff workplace



● ● ● ● ●







52

Typologies

Floor plan with two identical bathrooms

The beds are slightly turned towards the outer wall and window, in favour of a better view to the outside. The floor plan is divided into two equal halves and each patient has their own bathroom. The room proportions allow generous window openings and also the accommodation of separate seating areas at the window for the patients and their visitors.

Patient room Barrier-free/low-barrier standard

Structural complexity Infection prevention potential

● ● ● ● ● ●

Workplace quality and safety

Standard floor plan Same-handed One bed deep

Spatial qualities

● ● ● ● ● ● ● ●

Patient safety Patient satisfaction and privacy

Compact Three-zone plus room



● ● ● ● ●

Single entrance Alcove in front of room Bedside cabinet positionable on both sides Retrofittable airlock Staff workplace Washbasin Patient desk



● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Window with standard sill Beds turned towards each other



Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

● ●

● ● ● ● ● ● ●







Patient bathroom

Barrier-free/low-barrier standard Inboard

● ● ● ● ● ●



Mirrored floor plan Two bathrooms for separate use

● ●

Standard fittings with shower Second washbasin Second WC

53

Typological Evaluation

● ●

●

● ● ● ●

● ● ● ●



Mirrored floor plan with parallel bed position

This room layout can be referred to as the "standard floor plan”. Beds side by side, inboard wet cells in a mirrored floor plan constitute a patient room type used very often in hospitals → Fig. 58, p. 36, Mirrored floor plan.

Patient room

Structural complexity



Minimum standard Standard floor plan

Workplace quality and safety

Mirrored floor plan

Spatial qualities

Two beds deep

Patient safety

Compact

Patient satisfaction and privacy





Two-zone room



Infection prevention potential



Single entrance Alcove in front of room



● ●

● ● ●



Standard fittings





Window with standard sill Beds side by side



Patient's view outdoors (1 bed) Staff's view of the patient (1 bed)



● ●

●

●

●



Patient bathroom



Minimum standard

●

Inboard Mirrored floor plan One bathroom for shared use



Standard fittings with shower

54

Typologies

●

● ●



Floor plan with orthogonal bed position

The layout is characterised by the orthogonal bed position. Each patient has their own corner of the room, but one patient is not immediately visible to the staff when entering the room. The provision of areas of movement towards a low-barrier standard leads to larger spacing in the bathroom and patient room.

Patient room Barrier-free/low-barrier standard

Structural complexity

● ● ● ● ● ●

Standard floor plan Same-handed

● ●

● ●

Two beds deep Three-zone plus room

Single entrance Entrances flush with corridor

● ● ● ● ●

Standard fittings Staff workplace

● ●

● ●

Window with standard sill Beds at right angles



Patient's view outdoors (2 beds) Staff's view of the patient (1 bed)

● ●

● ●

●

● ● ● ●

Patient bathroom

Barrier-free/low-barrier standard Inboard Same-handed

● ● ● ● ● ● ● ● ● ●

One bathroom for shared use Standard fittings with shower

55

Workplace quality and safety Spatial qualities Patient safety Patient satisfaction and privacy

Compact



Infection prevention potential

Typological Evaluation

●

● ●

Low-barrier patient room with nested position of the wet cells

The nested position of the bathrooms → Fig. 56, p. 35, Nested, results in a rectangular room layout that is quite flexible. The visual relationship – both between patient and outside and between staff and patient – is neither restricted towards the entrance area nor towards the window. The spacious, barrier-free wet cells allow each patient to have their own washbasin.

Patient room Barrier-free/low-barrier standard

Structural complexity

● ● ● ● ● ●

Standard floor plan Mirrored floor plan

Infection prevention potential



Two beds deep Compact

Three-zone room



● ● ● ● ●



Workplace quality and safety Spatial qualities Patient safety Patient satisfaction and privacy



Entrances flush with corridor





Standard fittings Staff workplace Washbasin

● ● ●

● ●



●



●



Privacy screen between patients





Window with standard sill



Beds side by side



Patient's view outdoors (1 bed) Staff's view of the patient (2 beds)



● ●

●

●



Patient bathroom Barrier-free/low-barrier standard Nested Same-handed

● ● ● ● ● ● ● ● ● ●







One bathroom for shared use



Standard fittings with shower Second washbasin Sliding door

56

Typologies

●

● ● ●

● ● ● ●



Complex floor plan with bay window

A bay window allows for even larger window areas and creates new visual relationships with the outside. Here, the beds are also rotated so that every patient can look directly outside without having to turn the head. The remaining space behind the beds, which results from the bed rotation, can be used to store personal belongings. The barrier-­ free movement areas enlarge the room proportions in the patient room and bathroom.

Patient room Barrier-free/low-barrier standard

Structural complexity

● ● ● ● ● ●

Standard floor plan Mirrored floor plan Two beds deep

●

Complex Three-zone plus room



● ● ● ● ●

Infection prevention potential



Single entrance Entrances flush with corridor Retrofittable airlock

● ● ●

● ●

● ● ●

● ●



Standard fittings Staff workplace Washbasin



●



● ● ● ● ● ●



Window with standard sill Internal façade extension Beds turned towards each other



Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

●

● ● ● ● ● ● ● ● ● ●

Patient bathroom Barrier-free/low-barrier standard Inboard Mirrored floor plan One bathroom for shared use Standard fittings with shower

57

Typological Evaluation

●

● ●

Workplace quality and safety Spatial qualities Patient safety Patient satisfaction and privacy

Alternating inboard/outboard bathrooms in floor plan variation

A floor plan is combined with another, slightly varied floor plan and then repeated → Fig. 10, p. 30, Floor plan variation. The bathrooms are alternately positioned along the corridor or the exterior wall. Both patient room and bathroom floor plan vary. The room shown here is barrier-free and offers patients their own desk.

Patient room Barrier-free/low-barrier standard Floor plan combination/variation

Structural complexity

● ● ● ● ● ● ●

Two beds deep Three-zone plus room

● ● ● ● ●

Single entrance Alcove in front of room



Bedside cabinet positionable on both sides Staff workplace Washbasin Patient desk



Window with standard sill Beds staggered opposite one another



Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Patient bathroom

Workplace quality and safety



Spatial qualities Patient safety

Compact







Infection prevention potential

Patient satisfaction and privacy





Minimum standard





Floor plan combination/variation



One bathroom for shared use Standard fittings with shower

●

● ●



58

Typologies







Alternating inboard/outboard





Low-barrier rooms in same-handed arrangement with parallel beds

The barrier-free movement areas in the patient room and bathroom and the beds side by side result in a deep room floor plan. The patient who is closer to the entrance will not only be concealed to the staff by the inboard wet room – the other patient is also in his field of vision when looking towards the window.

Patient room Barrier-free/low-barrier standard

Structural complexity

● ● ● ● ● ●

Standard floor plan Same-handed

● ●

Compact

Patient satisfaction and privacy

Alcove in front of room Retrofittable airlock

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Standard fittings

●

Privacy screen between patients Window with standard sill Beds side by side



Spatial qualities Patient safety

Single entrance



Workplace quality and safety

Two beds deep Three-zone plus room



● ●

Infection prevention potential

Patient's view outdoors (1 bed) Staff's view of the patient (1 bed)



● ●

●

●

●

Patient bathroom Barrier-free/low-barrier standard Inboard Same-handed

● ● ● ● ● ● ● ● ● ●

One bathroom for shared use Standard fittings with shower Sliding door

59

Typological Evaluation

● ● ● ● ●

Floor plan with inboard and outboard bathroom

Like in the square floor plan with inboard and outboard wet room → Fig. p. 49, there is a bathroom for every patient, one positioned towards the corridor and one on the exterior wall. The beds are positioned staggered and opposite one another. This creates a deep room layout and the addition of rooms follows the same-handed principle.

Patient room

Structural complexity Infection prevention potential

Minimum standard

Workplace quality and safety

Standard floor plan Same-handed

● ●

Spatial qualities

● ●

Patient safety

Two beds deep Compact

Three-zone room





● ● ● ● ●



Patient satisfaction and privacy



Single entrance





Entrances flush with corridor



Standard fittings



Room with window and seat-level sill Beds staggered opposite one another



Patient's view outdoors (1 bed) Staff's view of the patient (1 bed)

●

● ● ● ● ● ● ● ● ● ●







Patient bathroom Minimum standard Outboard Same-handed



Two bathrooms for separate use

Second washbasin Second WC

60









●

Inboard

Typologies



● ● ● ● ● ●



● ● ● ●

● ● ● ●





Radial building plan with outdoor areas and nested bathrooms

The spatial organisation of a two-bed room in a radial building floor plan is a particular challenge, as room widths taper towards the building core. This results in this example in the combination of two different types of bathrooms. While the nested position of the wet cells has advantages for the visual connection to the outside, the rooms also benefit from a balcony, which is located between two rooms.

Patient room

Structural complexity Infection prevention potential

Minimum standard



Standard floor plan Mirrored floor plan

●

Three-zone room



● ● ● ● ●



Single entrance Entrances flush with corridor Standard fittings

●

Washbasin



Window with standard sill External façade extension



● ●

●

●

Beds side by side



Patient's view outdoors (1 bed) Staff's view of the patient (2 beds)



● ●

●

●

●

Patient bathroom

Minimum standard

●

Nested Floor plan combination/variation One bathroom for shared use Standard fittings with shower Sliding door

61

Typological Evaluation

Spatial qualities Patient safety

Two beds deep Complex

Workplace quality and safety

● ● ● ● ●



Patient satisfaction and privacy

Layout in same-handed arrangement with staggered bed positions and anteroom

The rooms are arranged according to the same-handed principle along the hospital corridor and their alignment and fittings are identical → Fig. 7, p. 29, Same-handed. The inboard wet cells are spatially slightly offset and thus enable a central entrance with an unobstructed sightline towards the patients as well as an anteroom in front of the patient rooms.

Patient room

Structural complexity Infection prevention potential



Minimum standard

Workplace quality and safety

Standard floor plan Same-handed

● ●

Spatial qualities

● ●

Two beds deep





Patient safety

Compact

Three-zone plus room



Patient satisfaction and privacy



● ● ● ● ●



Single entrance



Alcove in front of room



● ●

● ● ●



Standard fittings Staff workplace



● ●

● ●



Window with standard sill Beds staggered opposite one another



Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

● ●

● ● ● ● ● ● ●





Patient bathroom

Minimum standard Inboard Same-handed

● ●



● ● ●



One bathroom for shared use



Standard fittings with shower

62

Typologies

●

● ●





Floor plan combination of different two-bed rooms with same-handed wet rooms

Two different types of double rooms are combined with each other. The orientation of the fittings in the same-handed patient bathrooms remains identical. In the table, the floor plan with the opposite and staggered beds was evaluated.

Patient room

Structural complexity



Minimum standard Floor plan combination/variation

●

Patient safety

Compact Three-zone plus room

● ● ● ● ●

Single entrance Entrances flush with corridor Standard fittings Staff workplace



● ●

● ●

Window with standard sill Beds staggered opposite one another



Patient's view outdoors (2 beds) Staff's view of the patient (2 beds)

● ●

● ●

●

● ● ● ●

Patient bathroom Barrier-free/low-barrier standard Inboard Same-handed

● ● ● ● ● ● ● ● ● ●

One bathroom for shared use Standard fittings with shower Sliding door

63

Workplace quality and safety Spatial qualities

Two beds deep



Infection prevention potential

Typological Evaluation

● ● ● ● ●

Patient satisfaction and privacy

Selected Case Studies

General Hospitals Trillium Health Centre Mississauga, Canada  66 Zollikerberg Hospital – New West Wing Zollikerberg, Switzerland  70 Zollikerberg Hospital – Renovation of East Wing Zollikerberg, Switzerland  74 Hvidovre Hospital Hvidovre, Denmark  78 Lauf District Hospital Lauf an der Pegnitz, Germany  82 AZ Zeno Knokke-Heist, Belgium  86 Haraldsplass Hospital Bergen, Norway  90 Solothurn Public Hospital Solothurn, Switzerland  94 New North Zealand Hospital Hillerød, Denmark  100 Südspidol Esch-sur-Alzette, Luxemburg  104

p. 70  Zollikerberg Hospital – New West Wing

p. 154  Paediatric Clinic, Freiburg University Hospital

p. 74  Zollikerberg Hospital – Renovation of East Wing

64

Typologies

Specialised Hospitals

University Hospitals

Jugenheim District Hospital Seeheim-Jugenheim, Germany  108

Surgical Centre Erlangen University Hospital Erlangen, Germany  138

Sana Clinic Munich Munich-Sendling, Germany  112 BGU Accident and Emergency Hospital Frankfurt am Main, Germany  118 Princess Máxima Center Utrecht, the Netherlands  122 St Joseph-Stift Dresden Dresden, Germany  128 St Gallen Geriatric Clinic St Gallen, Switzerland  132 Uster Hospital Uster, Switzerland  136

Crona Clinic Tübingen University Hospital Tübingen, Germany  142 Erasmus MC Rotterdam, the Netherlands  146 Oncological Centre Leuven University Hospital Leuven, Belgium  150 Paediatric Clinic Freiburg University Hospital Freiburg, Germany  154 Children’s University Hospital Zurich Zurich, Switzerland  158 Münster University Hospital Münster, Germany  161

p. 158  Children's University Hospital Zurich

p. 132  St Gallen Geriatric Clinic

p. 150  Oncological Centre, Leuven University Hospital

65

Case Studies

Trillium Health Centre New extension

This interesting approach addresses both the functional requirements and the patients‘ needs. It led to a new interpretation of a frequently used room layout that has a privileged and a less attractive area. The layout at Trillium with two equal halves and a separate entrance for each patient creates a high degree of privacy in a two-bed room; at the same time the social isolation of a single occupancy is avoided.

Architects Perkins Eastman Black Client Trillium Health Partners

Mississauga is a growing city in Ontario, on the outskirts of Toronto. This project for Trillium Health Centre required the addition of 135 beds and a learning centre on the Mississauga Hospital campus. The extension was to incorporate novel intensive acute-care models, including the provision of procedures right at the bedside. Designed as a prototype within the 17,000 m² building, the unit includes 36 beds, subdivided into 12-bed clusters. Each cluster is served by a decentralised team station. The unit comprises both one- or two-bed rooms, to reflect varied insurance coverage restrictions. The two-bed patient room exudes spaciousness and provides privacy like a single room – along with unobstructed views from the angled bed location to a replanted treed zone outdoors. Families have space to relax and visit, and staff have bedside work space while enjoying shortened walking distances from satellite team stations. The room, perhaps due to the angled bed position, does not feel institutional. The vestibule proved a valuable addition. It facilitates bed and stretcher movement as well as access to each bed. This has decreased staff injury and the care team can easily view the patient’s face as they walk past. Although the three-piece washroom is shared by two patients, it can be accessed by them individually. Several one-bed rooms exist as well. Two two-bed rooms can be coupled together as well as divided by a glass slider, thus providing both privacy and flexibility in urgent situations.

Location Mississauga, Ontario, Canada Completion 2008 Beds per floor 36 Net area, two-bed room 36.73 m² + 5.42 m² bathroom

1

1 Site plan, 1 : 20,000 2 South façade and entrance to inpatient tower with learning centre on lower level 3 Tea kitchen and social space 4 Ward floor plan, 1 : 500

66

Typologies

3

2

4

67

Case Studies

1:500

5

6

7

8

68

Typologies

9

5 Satellite team station in corridor 6 Wayfinding light art in corridor, rehabilitation space beyond 7 Reception and family room on patient levels with seamless flooring inlay 'Magic Carpet' in front of elevators 8 Floor plan of the patient rooms, 1 : 100 9 Two-bed room with seating 10 One side of the two-bed room with bedside terminal and view outside

69

Trillium Health Centre

10

Zollikerberg Hospital New west wing

The patient rooms of the new wing, with their modern furnishings, indented glazed balconies and adjoining light-filled seating areas, evoke a sense of comfort more commonly associated with hotel rooms. The flush surfaces in the rooms and corridors, the choice of materials and the transparent sculptural quality of the façade make the new west wing one of the most elegant and aesthetically attractive hospital wings to have been built in recent years.

Architects Silvia Gmür Reto Gmür Architekten Client Stiftung Diakoniewerk Neumünster – Swiss Nursing School Location Zollikerberg, Switzerland Completion 2011





Beds per floor 45 Net area, two-bed room 31.9 m² + 3.5 m² bathroom

1

70

Typologies

Neumünster Hospital, built between 1931 and 1933 by the Zurich architects Otto and Werner Pfister, lies on the Zollikerberg in Zollikon near Zurich and includes a hospital, nurses’ accommodation, staff and training rooms and a chapel. All the hospital wings have a double-loaded arrangement with a clear functional division: the patient rooms and main rooms are oriented towards the park while the ancillary spaces are located on the north side. While some wings were to be upgraded → p. 74–77, the original west wing was deemed no longer able to meet modern hospital requirements and was replaced with a new building on the same site. The four-storey replacement wing faces the park and houses three wards and a floor of treatment rooms including a therapy pool. The wards retain the original south-facing orientation of the patient rooms with ancillary nursing rooms to the north. The patient rooms are spacious and have a balcony and view of the park. Open lounge areas break down the length of the ward corridor and allow daylight to suffuse the circulation zones. The floor plan of the two-bed rooms creates a progression from the entrance area to the patient zone to a sitting area and outdoor space. By arranging the beds at right angles to one other, both patients have a direct view outside. The two bed positions are of equal status, but not identical, and are far enough apart to have their own space, with movable curtains for additional visual privacy when needed. The seating area is designed as a bay with glazing on two sides that looks onto the park and the adjoining balcony-veranda, which provides a sheltered outdoor space. Ample distance between the table and the beds, as well as between the two beds, affords greater privacy as well as space for visitors, and a glazed strip that runs from floor to ceiling allows natural light to permeate into the inboard patient bathroom. The open views, natural surroundings and the bright, daylit interiors contribute, along with the fittings and furnishings, to the pleasant atmosphere of the rooms. Dark parquet flooring, curtains of varying translucency, upholstered chairs and indirect lighting create a sense of comfort that is further heightened by the coordinated colour scheme and high-quality bed linen. The materials used in the new building, as well as in the renovated wings, establish a coherent overall impression that harmonises with the original materials of the existing building. High-quality materials in the rooms and ward corridors lend the new wing a sense of sophistication and warmth that reflects the elegant character of the entire hospital complex and its park.

2

3

1 Site plan, 1 : 20,000 2 The patient rooms seen from outside 3 North elevation 4 Ward floor plan, 1 : 500

71

Case Studies

4

5

6

7

72

Typologies

8

9

5 South elevation 6 The ward corridor with room entrances 7 Floor plan of the patient rooms, 1 : 100 8 Patient room with curtains for privacy 9 Patient room

73

Zollikerberg Hospital

Zollikerberg Hospital Renovation of east wing

The renovated patient rooms in the east wing of Zollikerberg Hospital show that necessary upgrading measures can be successfully incorporated into existing buildings. The new fixtures accommodate all the necessary functions and storage areas in the patient rooms and their distinctive colours contrast refreshingly with the white hospital interiors. Through their integrative design and reductive formal language, they allow the character of the existing rooms to prevail, and free up more space for unimpeded movement in the room and around the bed.

Architects Metron Architecture AG, Brugg Client Stiftung Diakoniewerk Neumünster – Swiss Nursing School Location Zollikerberg, Switzerland Completion 2015





The renovation of the east wing of Zollikerberg Hospital in Zollikon near Zurich, built in 1933, enabled the hospital to provide single rooms for patients of all health insurance classes. Thanks to the good quality of the existing building, only specific, moderate interventions were needed to fulfil modern, efficient operational standards. The façade of the building remained unchanged. Each of the new rooms features a custom-fabricated full-height cupboard that acts as a partition to the bathroom. Through a serially producible modular design, clever detailing and intelligent variation and optimisation, the joiner was able to cost-effectively manufacture the fitted elements for 90 rooms while responding to irregularities in the existing building, fitting them exactly to each room. Unsurprisingly, this entailed careful coordination between the architect and joiner and the joiner and the specialist planner. The new red, orange or pale green insertions – each ward has a signature colour – incorporate the technical installations and risers and serve as a two-sided cupboard and storage unit for the room and the bathroom. Their matt varnished surfaces and planar fronts also make them easy to wipe clean. Clearly visible niches hold disinfectant dispensers within easy reach for patients and staff. Despite their small size, the single rooms are pleasant, bright and airy. The slightly rotated position of the bed faces the window, offering a direct view of the quiet open parkland outside. In addition to single rooms, each floor has several larger two-bed rooms, some of which can be used as mother and child rooms. The new insertions serve and incorporate multiple functions while simultaneously affording ample space for wheelchair users and freedom of movement for staff despite the tight room proportions. Their reductive design creates an orderly impression while retaining the character of the existing building, both in the patient rooms and the ward corridors.

Beds per floor 36 Net area, single room 14.1 m² + 3.1 m² bathroom Net area, two-bed room 33 m² + 4 m² bathroom

1

1 Site plan, 1 : 20,000 2 View of the east wing 3 Ward floor plan, 1 : 750

74

Typologies

1:750

2

3

75

Case Studies

4

6

5

7

76

Typologies

8

9

4 Patient bathroom 5 Ward with nursing station 6 Entrances to the patient rooms 7 Floor plan of the patient rooms, 1 : 100 8 Patient room with cupboard partitioning off the bathroom 9 Patient room in the maternity ward

77

Zollikerberg Hospital

Hvidovre Hospital Conversion of the wards

As part of the modernisation of Hvidovre Hospital, the existing four-bed rooms were to be turned into two-bed rooms. The architects, however, went a step further and developed a flexible, functional room type that works for both single and double occupancy. In view of the projected decline in demand for inpatient treatment, a trend towards single-­ bed rooms is emerging, but hospitals still need to be prepared for high occupancy scenarios. In this case, the hospital is well equipped for both situations.

Architects C. F. Møller Architects Client Regionhovedstaden v. Amager og Hvidovre Hospitaler Location Hvidovre, Denmark Completion 2016





Beds per floor 55 Net area, two-bed room 24 m² + 4.3 m² bathroom

Hvidovre Hospital near Copenhagen is one of the largest hospitals in Denmark, catering for more than 40,000 patients annually. When it opened in 1976, it represented a departure from the typical bed skyscraper as its four main buildings are only three storeys high. As part of the reconstruction of the nursing wards, C. F. Møller Architects were asked to renew the patient rooms within the existing structure to make them more user-friendly in various ways. One of the main tasks was to convert the existing four-bed rooms into single and two-bed rooms. The new flexible room type is designed as a single room in which relatives can also stay overnight. For this purpose, a bench that can be folded out into a bed is provided in the same room as the patient. Each room also has a second set of supply lines and connections to accommodate an additional patient as required. As such, Hvidovre Hospital can respond flexibly to a possible rise in the number of patients. The design of all the rooms is determined by the outboard placement of the bathrooms along the façade. This has the advantage that the beds are easily visible for the staff from the entrance area, and even from the corridor thanks to an additional glazed strip next to the entrance. When more privacy is required, the glass can be made opaque at the touch of a button, obscuring the view into the room from the corridor. A pull-out screen between the beds can provide additional privacy where necessary when one room is occupied by two patients. At the entrance to each room is a supply point with a washbasin and glove dispenser as well as storage space for necessary materials for the patient, and a ceiling-mounted patient lift system helps nursing staff raise and move patients more easily. As part of the modernisation, the patient bathrooms were optimised and redesigned to be barrier-free. Additional handrails around the oval-shaped washbasin can be used as a grip and handhold and, together with height-adjustable WCs, enable older or mobility-impaired patients to be more independent. Wooden surfaces and wood decor on the walls and floor lend the rooms a homely atmosphere, as does the dark upholstered bench next to the window.

1

1 Site plan, 1 : 20,000 2 View of the patient terrace from outside 3 Nurses’ station with a view along the corridor to the patient rooms 4 Ward floor plan, 1 : 500

78

Typologies

2

3

4

79

Case Studies

5

6

7

8

80

Typologies

9

10

5 Upholstered seating area next to the window 6 Fold-down section for use as a bed for guests 7 Single occupancy for mother and child 8 Floor plan of the patient rooms, 1 : 100 9 View towards the entrance with the glazed window to the corridor 10 Double occupancy of the patient room

81

Hvidovre Hospital

Lauf District Hospital New ward block and intensive care unit

Instead of an extension with budget-­ friendly standard rooms and a single bathroom per room, Lauf Hospital and their architects elected to design a new edition of the original layout with two wet cells per room. Building on a tried and tested solution from the past, the new design provides added comfort for patients in two-bed rooms and offers potential as a model for better hygiene.

Architects ATP HAID architekten ingenieure (Integral planning; Design: Prof. Hans Peter Haid) Client Krankenhäuser Nürnberger Land GmbH Location Lauf an der Pegnitz, Germany Completion 2017





Beds per floor 92 Net area, two-bed room 20.5 m² + 1.87 m² bathroom

Lauf District Hospital was built in the 1960s and 1970s and has been extended and converted several times over the years. Trend forecasts for the sector, however, pointed to the need for a longer-term plan for a flexible operational model. The original design concept for the district hospital already served as a solid typological basis: a main corridor runs from east to west and acts as the functional backbone with a bed block facing south. This structural arrangement presented a number of qualities that the extension was able to build on. Alongside additions and improvements to the existing facilities, the construction project encompassed the addition of two new standard care wards with 32 beds each and a three-bed extension to the intensive care unit. The new three-storey wing was built as a compact block at the rear, northern edge of the hospital and the western patio building was extended. The new building has two wards on the first and second floors, with administrative facilities above, while a connecting section links the new facilities to the existing building. On the upper floors, the wards connect at both ends to the existing hospital, creating a circulation ring that makes it possible for several nursing wards to be flexibly organised on one level. To ensure a uniform room standard across the entire hospital, the design team adopted the basic room floor plan of the existing patio building and adapted it to modern requirements. The hospital’s existing patient rooms have two wet cells per room, and the new ward block continues this pattern with a wet cell per patient located to the left and right of the entrance to the two-bed rooms. Showers for all patients are located on the ward corridors. The new arrangement sacrifices a shower in the room in favour of a separate bathroom (toilet and washbasin) for each patient. In the single-bed rooms, the second cell contains a shower room. For maximum safety and hygiene, the bathrooms are fitted with slip-resistant floor tiles and additional grips and handrails. The patient rooms have the same generous glazing as the existing building and look out over the surrounding landscape. Each window is set into a deep wooden surround that frames the view and serves as a window seat at sill level. Wood is also used for the bed headwalls and integral patient cupboards to add a more homely feel. Made of chipboard and faced with HPL, they are easy to wipe clean. The interior design eschews cold metallic materials in favour of wooden surfaces and warm, earthy yellow and orange colour highlights, for example in the curtains, upholstery, coloured wall surfaces and bathroom tiles. Contrasting dark grey frames are used to mark room and door entrances, providing orientation in the rooms and ward corridors.

1

1 Site plan, 1 : 20,000 2 Inner courtyard with a view of the walkway connecting the existing and new buildings 3 Façade of the new ward block 4 Ward floor plan, 1 : 750

82

Typologies

2

3

4

83

Case Studies

5

6

7

8

84

Typologies

9

10

5 Common room and lounge in the ward 6 Patient bathroom (left) and shower room (right) in single-bed room 7 Room entrances (left) in the ward corridor 8 Floor plan of the patient rooms, 1 : 100 9 Two-bed room with entrance to the bathroom 10 Two-bed room

85

Lauf District Hospital

AZ Zeno New hospital

Despite its considerable size, the design concept for the AZ Zeno in Knokke-Heist is applied consistently at all scales, from the building to the patient rooms to every last detail of the fittings. The architects have achieved a good balance between modern appearance and the impression of clinical cleanliness.

Architects AAPROG Boeckx B2Ai Interior designers B2Ai Client AZ ZENO Location Knokke-Heist, Belgium Completion 2018 Beds per floor 80 Net area, single room 20.62 m² + 3.5 m² bathroom Net area, two-bed room 28.62 m² + 3.5 m² bathroom

The new building for the AZ Zeno (AZ is the abbreviation for algemeen ziekenhuis, or general hospital) with its organic building form is the product of a collaboration between three Belgian architectural offices – AAPROG, Boeckx and B2Ai – who together won the competition for its design in 2007. Opened in 2018, the new hospital building comprises a rehabilitation centre, nursing wards with a total of 270 beds, an outpatient clinic, lecture halls, event areas and a helicopter landing pad. The building’s design needed to meet the requirements of a modern, sustainable, forward-looking hospital while respecting the rural character of its surroundings. Raised off the ground and enveloped in a curved exterior, the three-storey and four-wing volume has the futuristic appearance of a floating object that has alighted nimbly on the existing landscape. Three of the wings house patient rooms with views out over the dunes while the fourth facing the road and parking areas contains the medical facilities. A 600 m² roof garden on the second floor can be reached from the cafeteria. All transitions between inside and outside and between the wards and public areas within the building are fluid. Warm colours, bright daylight and art in the interiors create a homely environment for the patients. The design of the patients’ rooms is simple and restrained. In addition to a regular door, a movable panel in the single rooms can be slid to one side to provide direct access to the patient bathroom. It also acts as a room divider, closing off the entrance area from the room when more privacy is required. The split two-panel door – with separate upper and lower opening sections – was especially conceived for the geriatric wards to allow patients to feel connected and in contact with people in the ward corridor when in their room. A particularly space-saving solution is the fold-out bed for relatives to stay overnight incorporated into the fitted wall cupboards. Instead of the desk in the single rooms, the two-bed rooms have two rounded shelves for placing pictures and greeting cards as well as a shared table. In the bathroom, all components, including the polycarbonate swinging shower partitions, are wall-mounted to avoid contact with the floor, preventing colonisation with germs and making it easier to clean the floors. The bathroom flooring in bright colours such as green or violet contrasts with the otherwise white rooms. The bathrooms in the two-bed rooms have two washbasins, one for each patient. The solid oak window frames harmonise with the wood-effect flooring in the rooms and some surfaces, such as the sliding door panels, are printed with photographic motifs. The interior design aims to create a calm and comfortable atmosphere for the patients so that the clinical functions recede into the background.

1

1 Site plan, 1 : 20,000 2 The building façade with the roof terrace adjoining the cafeteria 3 The mass of the building is raised off the ground. 4 Ward floor plan, 1 : 1000

86

Typologies

3

2

2

4

87

Case Studies

5

6

7

88

Typologies

8

9

10

5 Bathroom 6 Nurses’ station with waiting area 7 Floor plans of single and two-bed rooms, 1 : 100 8 Single room looking towards the split-leaf entrance door 9 The sliding bathroom door panel can act as a room divider. 10 Room in the mother and child ward with nurses’ work area

89

AZ Zeno

Haraldsplass Hospital New extension

The abundant use of wood and views inside and out create a calm but stimulating environment for patients at Haraldsplass Hospital. Oriel windows facing onto the atria provide a sheltered place to observe the hustle and bustle of daily clinic routine, relieving boredom during long hospital days. Floor-to-ceiling windows in the patient rooms afford a view over the city in the valley or out onto the countryside, encouraging a swifter recovery.

Architects C. F. Møller Architects Client Haraldsplass Diakonale Stiftelse Location Bergen, Norway Completion 2018





Beds per floor 35

The new extension to Haraldsplass Hospital, built at the foot of Mount Ulriken in 1940, extends the hospital’s accident and emergency capacity by providing 170 additional beds. The five-storey building has a wood frontage with a kink that follows the course of the Møllendalselven river beneath the hospital, and the comparatively low proportion of glazed surfaces ensures a good energy balance. Almost all the patient rooms overlook the city of Bergen and its port, and have a view across the valley, which patients can enjoy from their beds thanks to fixed floorto-ceiling window sections. The rooms to the rear enjoy a view of the wooded hillside of the mountain. In contrast to many hospitals, there are no long corridors. Instead, the various functions are distributed around two open atria at the heart of the pentagonal building, which ensures efficient logistics, flexibility and proximity between caregivers and patients. The wards are arranged in a ring around these covered atria, which allow daylight to spill into the heart of the building and serve as communal areas for communication and orientation. Small oriel windows project from the atria walkways as “boxes”, creating sheltered seating areas with views into the atria and across to other levels of the hospital. While single rooms predominate, a smaller number of two-bed and three-bed rooms are also provided. The bathrooms are typically arranged in pairs between the rooms, leaving the rooms open and unobstructed. Both the rooms and the bathrooms are barrier-free. The striking wooden framework of the façade hints at the abundance of wood in the interior. The atria are clad entirely in wood, as are the windows in the patient rooms. The flooring likewise has a wood decor. Wall-mounted cabinets for the patients’ belongings add a colourful accent in the rooms and make it easier to clean the floors. Low-maintenance materials are used throughout to ensure maximum longevity.

Net area, two-bed room 16 m² + 5 m² bathroom

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1 Site plan, 1 : 20,000 2 View of the wood façade of the patient rooms 3 Haraldsplass Hospital at the foot of Mount Ulriken 4 The second atrium 5 Ward floor plan, 1 : 500

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6 Atrium with projecting oriel boxes 7 Seating niche with a view into the atrium 8 A ward corridor 9 Floor plans of single and two-bed rooms, 1 : 100 10 Full-height window in a standard room 11 Wall cabinet for patients’ belongings 12 A patient room with two beds

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Haraldsplass Hospital

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Solothurn Public Hospital New building

The design of Solothurn’s new public hospital is centred around the patient. The placement of the beds at right angles creates two different bed locations of equal status, and the angular twist in the floor plan reinforces this, marking out a space for each person and creating a corner mid-room into which the patient cupboards have been fitted. High-quality materials, such as wooden parquet flooring, and the harmonious colour concept contribute to the impression of a healing environment rather than a hospital.

Architects Silvia Gmür Reto Gmür Architekten Client Canton of Solothurn, Public Building Authority Location Solothurn, Switzerland Completion 2020 Beds per floor 76 Net area, two-bed room 31.4 m² + 3.7 m² bathroom

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Typologies

The new building for Solothurn Public Hospital is the product of an international competition for a new hospital with 327 beds and surgery, obstetrics, intensive care, outpatient and emergency units. Built on the grounds of the existing hospital, which had to remain fully operational during the construction period, the new complex takes the form of an L-shaped structure inserted around the existing buildings. The new building consists of a two-storey base of exposed concrete for the public zones and examination and treatment areas, on top of which the wards are placed. Separating the two is a glazed recessed floor. The wards are fronted by striking, sculptural brise-soleils made of white concrete that cover the exterior of the cuboid bed block. Two inner courtyards, reaching below grade, provide additional lighting in the interior. The floor plan of the main floors is divided into two functionally separate access areas, one for the patients, the other for staff, beds and materials. Straight paths parallel to the outer walls – leading towards a daylit point – ensure easy orientation in the building. As patients walk along the bright corridors with a view of the park, they pass various departments without crossing paths with staff or the supply and disposal systems. Each patient room has two separate zones, one for each patient: the beds are placed at right angles and a twist in the floor plan produces a step in the cross walls that demarcates the foot of one bed area and creates a niche for the head end of the other bed. The patients’ cupboards are fitted into these corners so that they do not stand in the room where they might obstruct the view or movement in the room. The angled placement of the beds means the beds stand further apart, affording each patient more personal space. Compared with a conventional side-by-side arrangement, the rearward bed has a much better, unobstructed view out of the window. Each patient, therefore, has their own view but can screen themselves off by drawing a curtain as desired. Nursing staff were consulted for the design of the patient bathrooms, and especially the arrangement of the elements and the choice of materials and colours. The bathroom core is a prefabricated rectangular concrete cell with seamless polyurethane wall and floor coatings. The flush-fitted shelves and glove dispenser in the wall next to the wide acrylic stone washbasin are likewise designed for optimal hygiene and ease of cleaning. Yellow or pink highlights enliven the grey base colour, adding more vibrant moments of colour. For the façade, a system of fixed brise-soleils was developed that in addition to protecting against glare and overheating ensures unobstructed views outside and adequate natural illumination. It shields partially against views in from outside while allowing for solar gain in the winter. A curtain designed by the artist Gido Wiederkehr can be drawn across the window. The materials and furnishings are restrained, with wood parquet flooring and a wooden shelf-strip above the bed, shaping the rooms' character. The shelf-strip incorporates the necessary medical connections and an indirect light source so that the impression of a comfortable room predominates without restricting medical necessities.

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1 Site plan, 1 : 20,000 2 View of the façade and brise-soleils 3 Ward floor plan, 1 : 500

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4 View of the inner courtyards and the green roofs 5 Inner courtyard of the two-storey base with brise-soleils 6 Corridor on the nursing floor (7th storey) 7 Patient bath

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Solothurn Public Hospital

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8 Corridors on the nursing floor with entrances to the patient rooms 9 Floor plan of the patient rooms, 1 : 100 10 Patient room with artist-designed curtains 11 View of a patient bed

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Solothurn Public Hospital

New North Zealand Hospital New hospital

The considerable size of this new hospital is effectively enabled by the addition of standardised bed units. However, the organic shape of the building emphasises the human scale, with each patient room becoming an individual part of an organic ribbon. An interesting spatial feature is an alcove as a calm place for rest and seclusion within the patient rooms.

Architects Herzog & de Meuron Client New North Zealand Hospital Location Hillerød, Denmark Completion 2024





Beds per floor 228 Net area, single room 23 m² + 6.3 m² bathroom

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Typologies

Located on the outskirts of the town of Hillerød in the northeast corner of the Danish island of Zealand, New North Zealand Hospital is woven into the broad Danish landscape. The new acute care hospital is not only completely surrounded by nature but also encloses it within the winding ribbon of its star-shaped form. The new facility serves a catchment area of around 310,000 inhabitants, a task previously served by three smaller hospitals. With 570 beds spread across a total area of approx. 120,000 m², it consolidates and improves the emergency and intensive care services for the region. The examination and treatment rooms are accommodated in a total of 20 departments on the two lower floors. Circular inner courtyards are cut into the plinth in a repeating pattern so that daylight can permeate the lower levels of the hospital, and four circular courtyards illuminate a central hall at the heart of the complex. The roof of the plinth becomes an open-air park landscape. The two upper floors rest on the plinth and follow its outline as an undulating ribbon. Contrasting with the plinth, these floors are articulated visually with a more delicate façade, exuding privacy and a personal scale. The neonatology and paediatric patient rooms are equipped with an alcove that serves as a seating niche for greater privacy and moments of peace and seclusion and where the parents can spend the night. The bathrooms are placed between the rooms and are polygonal in shape to accommodate the changing curvature of the ribbon. From the rooms, patients have an expansive view into the treetops of the surroundings or the garden landscape in the interior of the hospital. From outside, the hospital looks like a two-storey complex. Bright colours and light wood in the corridors and rooms of the upper patient floors create a pleasant and friendly atmosphere. In the corridors and rooms of the ward floors, the use of wood as the dominating design element creates a friendly atmosphere. In those areas of the hospital that are accessible for patients, the ceilings consist of an industrially manufactured system of wooden slats fixed on mineral wool panels. This simple, additive feature is a cost-effective solution that enhances the quality of the interior at the same time.

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1 Site plan, 1 : 20,000 2 New North Zealand Hospital seen from a distance 3 Roof garden in the inner courtyard of the hospital 4 Ward floor plan, 1 : 1500

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5 Nurses’ station 6 Ward corridor 7 Floor plans of the patient rooms, 1 : 100 8 Patient room with alcove 9 Patient room with balcony 10 Seating niche near the window and bathroom

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New North Zealand Hospital

Südspidol New campus hospital

While the Südspidol employs a repeating same-handed room module arranged in rows to form a large structure, it interlocks them in such a way that each room is individually legible. This floor plan principle is a first hint of the importance accorded to the wellbeing of each patient in the design of the patient rooms.

Architects ARGE Health Team Vienna Albert Wimmer ZT GmbH Architects Collective GmbH Client Centre Hospitalier Emile Mayrisch Location Esch-sur-Alzette, Luxembourg Completion 2026



Beds per floor 90 Net area, single room 20.5 m² + 4.3 m² bathroom

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The Südspidol Hospital in Esch-sur-Alzette in Luxembourg is designed as a new health campus. The architects responded to the need for a central facility with optimised medical processes and minimised travel distances with a series of distinct, individually differentiated building structures. Their design aims to address both the needs of the patient as well as facilitate the complex medical processes within a high-efficiency hospital. The signature elements of the 59,380 m² hospital complex are three triangular buildings with gently curving rounded edges that through their appearance soften the hard precision of clinical processes. Although the three buildings are interconnected, each building has its own patient rooms and can therefore function as an independent unit. Instead of confronting staff, patients and visitors with a megastructure, the design aims to be relatable at a human scale. Rather than endless ward corridors, the curved building shape allows the creation of more legible circulation spaces. The entrances and nurses’ stations at the nodal points divide the wards into more manageable sections and serve as open and pleasant waiting and meeting areas for staff and visitors alike. The approx. 550 patient rooms (of which about 80 % are single-­ bed rooms) are arranged along the façades. Their floor plan with the bathroom offset to one side enables them to interlock with one another to form broad sweeping rows around the perimeter of each building and tighter rings around the almost circular inner courtyard. The geometry of the floor plan was developed according to the principles of Evidence-based Design and focuses on the safety and wellbeing of the patient. On the one hand, nursing staff have an unimpeded view of the patient from the door, and on the other hand, patients have a good view of the world outside without having to turn their head. The bathroom is located immediately to the right of the bed, the short distance minimising the risk of falls, especially for elderly patients and patients with multiple clinical conditions. At the same time, the large sliding bathroom door maximises autonomy and accessibility. Additional fixed fittings in the room have been avoided to minimise obstructions and improve ergonomics for caregivers when caring for the patient. The use of a same-handed modular room design, i.e. with an identical floor plan, makes it possible to improve the efficiency of care processes and standardise procedures so that fewer errors can occur. A large multimedia screen on the wall opposite the bed can be used to watch TV or surf on the internet but also as a monitor for discussing treatments and diagnoses with one’s doctor during visits. The three buildings will be embedded in a park-like landscape and complemented by green inner courtyards and green roofs.

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1 Site plan, 1 : 20,000 2 View of the complex embedded in the surrounding landscape 3 Ward floor plan, 1 : 750

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4 Waiting area near the nurses’ station 5 Floor plan of the patient rooms, 1 : 100 6 Patient room 7 Inner courtyard with communal areas

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Südspidol

Jugenheim District Hospital Renovation of the wards

The original ward with polygonal, diagonally arranged rooms at Jugenheim District Hospital near Darmstadt is still one of the most interesting and most well-known ward layouts in Germany. Its sustainable design qualities reveal themselves in the ability to accommodate changes and new design ­concepts. As such, the ward renovation was able to retain its original structure.

Architects LSK-Architekten (renovation) Junghans+Formhals Client District hospital board of Darmstadt-Dieburg Location Seeheim-Jugenheim, Germany Completion 2014





Beds per floor 38 Net area, two-bed room 23.7 m² und 3.7 m² bathroom

The wards at Jugenheim District Hospital were originally designed by the architects Junghans+Formhals in the 1990s. The wards were modernised as part of the long-term, comprehensive redevelopment of the hospital as a regional centre for orthopaedics. The conversion had to be undertaken without interrupting ongoing operation of the hospital and no changes were made to the façade or the loadbearing structure. As a result, the renovation of the wards with a total of 80 beds as well as the diagnostics and treatment facilities were carried out floor by floor and interventions to the existing room structure were kept to a minimum. The original room layout with its diagonal floor plan that allows the beds to be arranged opposite each other was retained. The interior conversion was particular challenging due to the angled and cramped geometry of the three-storey building and the additional technical equipment required in the upgraded wards. All surfaces were renewed and coordinated to create a harmonious interior: flooring in a warm strip wood decor, walls smooth plastered in white, and the ceilings in perforated acoustic plasterboard with integral lighting. The fittings in the existing patient rooms were redesigned for better comfort: sections of the wall surface were clad in wood-effect panelling into which the medical connections, lighting, patient cupboards and mirrors were integrated. To provide additional seating for visitors, the radiators were fronted by benches made of a similar material. Fitted cupboards were incorporated into the two-bed rooms, which also have a dining table and chairs, a desk, fridge and bedside units with TV. From an armchair near the window, patients can see the hills of the Bergstrasse region. In the single-bed rooms, a larger desk and an armchair with side table take the place of the second bed. To soften the restless angularity of the corridors in the new orthopaedic ward, LSK Architekten proposed introducing calm, rounded forms in the core zone. The counter of the nurses’ station curves around at the heart of the ward and looks onto a round atrium planted with tall bamboo to create a “green atrium”. Benches have been also been set into the corridors, the walls of which have been decorated throughout with works of art by Joan Sofron. A central patient lounge with kitchen provides a space to meet and talk for patients and visitors.

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1 Site plan, 1 : 20,000 2 The patient rooms seen from outside 3 Ward floor plan, 1 : 500

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4 View of the ward corridor from the nurses’ station 5 Lounge and kitchen for patients and visitors 6 Corridor 7 Floor plan of the patient rooms, 1 : 100 8 Two-bed room 9 Single-bed room with desk

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Jugenheim District Hospital

Sana Clinic Munich New regional medical centre

Fixed screens between two beds are an uncommon fixture and even here in the Sana Clinic in Munich are only found in the rooms for private healthcare patients. The spacious rooms show the kind of privacy and comfort possible in a two-bed room when there is sufficient space and budget.

Architects wörner traxler richter Client Sana Kliniken Solln Sendling GmbH Location Munich-Sendling, Germany Completion 2017





Beds per floor 67 Net area, two-bed room (standard) 22.1 m² + 3.2 m² bathroom Net area, two-bed room (private patients) 37.3 m² + 4.3 m² bathroom

The Sana Kliniken Solln Sendling GmbH originally operated orthopaedic clinics at two locations, which were merged in May 2017 to form the Sana Health Campus at Munich-Sendling. Designed as a district-level hospital, it includes facilities for diagnostics, surgery and intensive care along with the corresponding nursing wards. The compact, five-storey building wraps around the perimeter of an urban block and sits alongside a listed building. Its upper floors look onto an open inner courtyard and house two wards per floor with a total of 173 beds. The clinic with a gross floor area of 6600 m² treats more than 8000 patients per year. The ward corridors are spacious and offer a range of different seating areas to provide motivational stopover and rest points for patients with locomotive impairments, for example after hip or knee operations. To make it easier for patients to stand up after sitting, the seat height of the chairs and armchairs has been slightly raised from the normal height of 45 cm to 48 or 50 cm. The standard two-bed patient rooms face onto the inner courtyard with a projecting bay window at the end that provides better illumination and serves as a niche for a window-side table for writing or dining. The low sill height maximises the window size and allows patients lying in bed to see out of the window. The fittings and furnishings in both the standard and private healthcare patient rooms aim to create an atmosphere more akin to a hotel than a hospital. The brightly lit rooms with their tastefully painted white and beige walls are complemented by black and white photographs of well-known squares and sights in Munich, either elegantly framed in the standard rooms or as wall-size photographs in the private healthcare patient rooms. In addition to the beige wall tones, private healthcare patients can enjoy white fitted furniture and black armchairs and the bed headwalls with medical connections are finished with a dark wood decor, as are the floors. The spacious entrance lounge area of the twobed rooms for private healthcare patients is the product of combining two single-bed room layouts. A central partition in the middle ensures each patient has their own space, each with a separate window. The low, deep-set window sill can be used as a bench, creating an attractive visitor zone for each patient. For optimal cleaning and hygiene, the surfaces have been made as seamless as possible, both around the walls and on the floors. The PVC flooring has upturned coved skirting to avoid corners and hairline seams which are particularly susceptible to germ contamination. Where joints were necessary, they were made large enough to receive proper grouting. Each floor has one or two quarantine rooms with an airlock for isolating individual patients with viral or bacterial infections.

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1 Site plan, 1 : 20,000 2 The clinic building 3 Ward floor plan, 1 : 500

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4 Seating area in one of the corridors 5 Ward corridor with nurses’ station 6 Entrance to a standard two-bed room 7 Standard two-bed room with low window sill 8 Standard room floor plan, 1 : 100

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Sana Clinic Munich

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9 Two-bed room for private healthcare patients with fixed partition 10 Private healthcare room floor plan, 1 : 100 11 Two-bed room for private healthcare patients 12 Bathroom in private healthcare room

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Sana Clinic Munich

BGU Accident and Emergency Hospital New ward building

Modern-day patient rooms have to be much more than a place for patients to stay and recuperate. Different clinical symptoms place varying requirements on the design of patient rooms and their fittings. This spinal cord unit shows how the design of the patient rooms incorporates specific technical equipment and helps address the challenges facing paraplegia patients.

Architects Dewan Friedenberger Architekten GmbH Client Berufsgenossenschaftliche Unfallklinik Frankfurt a. M. gGmbH Location Frankfurt am Main, Germany Completion 2017





Beds per floor 17 Net area, two-bed room 30.6 m² + 6.7 m² bathroom

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The BGU Accident and Emergency Hospital in Frankfurt am Main is not only a supra-regional trauma centre for accidents and emergencies but also a university hospital for the Goethe University in Frankfurt am Main. The new extension to the intensive care medical centre consists of three buildings, including a ward building to the south, and is reached via the main corridor from the new entrance hall. It links directly to the renovated and restructured treatment building in which the operating theatres are located. The rectangular building, with its white render façades and ribbon windows interspersed by orange and yellow vent boxes, is the first of the three sections. It contains an intensive care unit with intermediate care areas, general care wards and wards for specific medical conditions, including a spinal cord unit, with a total of 72 beds. As a trauma centre, the BGU Accident and Emergency Hospital treats and cares for patients with paraplegia resulting from an accident or illness. The specialist department for spinal cord injuries can accommodate 17 patients and is located on the second floor. It has nine barrier-free patient rooms, of which five two-bed rooms and one isolation room are wheelchair-accessible. The architects devoted particular attention to these rooms. Their wider structural spans of 5.20 m and large floor areas of almost 31 m² provide sufficient space to arrange beds offset to and opposite each other and to park a wheelchair next to the bed. The furnishings, design and atmosphere of the rooms are geared towards longer-duration inpatient stays and the degree of injury that patients may have: all furnishings were planned with special consideration of hygiene factors and access for people with disabilities. A media panel next to each bed allows patients to control lighting levels, sun shading, to watch or listen to media and to call a nurse. Additional control devices are available for patients with tetraplegia, a form of paralysis below the neck. An overhead lift allows nursing staff to help patients in and out of bed with the help of lifting sheets – for example into a wheelchair or a mobile commode chair. A disinfectant dispenser near the door is incorporated into the fitted furnishings, reminding patients and visitors to disinfect their hands when entering and leaving the room. Each of the rooms has its own disabled-access bathroom, some of which are specially designed for patients with obesity. The bathrooms are large enough to be accessed with a shower trolley and have an overtoilet-compatible WC as well as – for hygienic reasons – a wall-mounted bedpan washer. The placement of the beds opposite each other has hygienic advantages while also enabling better communication between patients. A desk, larger cupboard storage, a refrigerator as well as wood-decor flooring contribute to the high quality of the interior. The interplay of lighting and ventilation openings as well as the choice of calming colours, the well-thought-out furnishings and generous room size create a positive atmosphere for long-stay patients.

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1 Site plan, 1 : 20,000 2 Façade with coloured vent boxes 3 View of the main corridor connecting the separate buildings 4 Ward floor plan, 1 : 500

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5 Bathroom in the spinal cord unit 6 Vent box 7 Corridor in the spinal cord unit 8 Nurses’ station 9 Floor plan of the patient rooms, 1 : 100 10 Two-bed room in the spinal cord unit 11 Two-bed room in the spinal cord unit with media panel

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BGU Accident and Emergency Hospital

Princess Máxima Center New clinic for paediatric oncology

The compelling design concept for the Princess Máxima Center with its numerous communal areas and play corners in the patient rooms aims not just to make the young patients’ stay as pleasant and free from anxiety as possible. It also includes a specially developed area for parents with a separate bathroom – an interesting variation on the idea of rooming-in that will for sure become even more relevant in future.

Architects LIAG architects Interior designers Mmek Client Board Princess Máxima Center, Utrecht NL Location Utrecht, the Netherlands Completion 2018





Beds per floor 40 Net area, single room 16.08 m² + 4.41 m² bathroom Net area, guest room 11.21 m² + 2.39 m² bathroom

The Princess Máxima Center is a centre for healthcare and research in one that focuses on treating children with cancer. At a size of 45,000 m², it is the largest paediatric oncology centre in Europe. Developed in cooperation with Kopvol, an architecture practice specialising in psycho­ logical aspects of architecture, the spatial concept aims to create a place where young patients feel safe and can spend time with their parents and relatives with primary focus on their recovery. The wards consist exclusively of single rooms, to which a guest room is connected. A sliding door connects the two areas of the room and creates a visual link between the two sleeping areas, but two bathrooms and separate entrances from the ward corridor mean that they can also be used independently and flexibly. Pergola-like balconies, most of which are arranged around the inner courtyards, provide a connection with outdoors from each room and are reached through the parents’ room so that children cannot go outside unattended. There are also specially designed communal areas for different age groups that address the different interests and needs of the children and promote social interaction between them. In addition, spaces are provided for cooking and socialising at the dining table and for playing together with visiting grandparents. These facilities contribute to the homely atmosphere of the Princess Máxima Center. Each patient room has a nurses’ workplace with a washbasin and adequate storage for materials, and the bathrooms for the patients are barrier-free with sliding doors. In addition to parental supervision from the neighbouring space, a glass door and an additional window ensure optimal visibility of the bed area from the corridor. Nurses can oversee the patient from the workstation next to the entrance to each room. From here they can record patient data without needing to return to a central nurses’ station, avoiding the risk of potential mix-ups. By making it possible to access the digital patient record right next to the patient room, no unnecessary equipment need be brought into the room. The parents’ area is understandably more simply equipped, but an integral refrigerator offers a level of comfort appropriate for longer stays. The low window sills are articulated as benches with storage boxes beneath in which toys can be stowed. Patients have a good view of the courtyards and outdoor areas, whose playfully designed playgrounds are intended to encourage children to romp in the fresh air.

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1 Site plan, 1 : 20,000 2 View of the clinic 3 Ward floor plan, 1 : 1000

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4 View of the balconies from the courtyard 5 Outdoor area in an inner courtyard 6 View of atrium 7 A communal play area 8 A workstation for nursing staff in the corridor

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Princess Máxima Center

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9 View of the entrances and bathrooms in both halves of the room 10 Patient room with the adjacent parent area 11 Floor plan of the patient rooms, 1 : 100 12 Patient room with view of the balconies

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Princess Máxima Center

St Joseph-Stift Dresden New acute geriatric care unit and central outpatient clinic

The majority of patients treated in hospitals are over 65 years of age and dementia is in many cases a secondary diagnosis alongside the primary clinical condition. The design of the patient rooms of the geriatric unit at the St Joseph-Stift in Dresden shows how one can address the challenges of dementia and impaired mobility with the help of a coherent overall concept.

Architects wörner traxler richter Client Krankenhaus St. Joseph-Stift Dresden GmbH Location Dresden, Germany Completion 2018





Beds per floor 26 Net area, two-bed room 25.2 m² + 6.2 m² bathroom

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Typologies

The new, three-storey west wing of the St Joseph-Stift comprises a 1200 m² large acute geriatric care unit with capacity for about 400 patients annually as well as a central outpatient clinic on the ground floor that brings together all the outpatient consultation facilities in one place. Its 720 m² accommodate 18 treatment rooms and extensive waiting areas. From the outside, the brick and render façade with its striking grouped window strips is more reminiscent of a residential building than a clinic. Inside, the floor plans have been kept very clear. Patients of an advanced age and especially those with dementia often find admission to hospital a highly confusing experience. To help them find their bearings in unfamiliar surroundings, the design deliberately conveys a calm, non-challenging atmosphere. The simple floor plan arrangement assists in providing effective orientation, with straight corridors leading in clear directions and direct visual relationships between patients and staff. It allows patients to move freely around the ward while simultaneously preventing them from “walking off”. The system of double corridors with a central transparent nurses’ station is well-suited to this purpose. Alongside providing acute therapy, acute geriatric treatment aims to enable patients to maintain or regain the ability to care for themselves independently. As such, the patient rooms are not just a place for the patients to stay but also a therapy room. Due to the greater need for assistive aids, the rooms are 20 % larger than the usual hospital rooms so that there is ample room for patients using walking frames, rollators or wheelchairs. The patient bathrooms are also designed to be accessible to people with handicaps and are twice as large as those normally found in patient rooms. They include wall-hung washbasins for easy wheelchair access, sufficient turning space for wheelchair users, hooks and controls that are easy to reach while seated, and low-mounted mirrors. As many patients are predominantly sedentary, the sill height of the windows is lower to afford a better view and the sills often double as a bench seat. Curtains provide greater privacy – a common preference among older people – while also allowing daylight into the room along with a glimpse of the sky. A helpful detail brought over from the hotel sector is the use of orientation lighting close to the floor that helps patients find their way to the toilet at night without being dazzled by the bright light of the room or disturbing another patient in the room. A large mirror with additional handrails near the entrance to the room is useful for postural training after a stroke. Another key element is the so-called “Memoboard” with a therapy calendar, television and a large, clearly legible wall clock. Staff can attach personal treatment reminders and use it for memory training with the patients. There are also “empty” picture frames for patients to insert personal mementos and family photos. In the patient rooms and accompanying bathrooms, blue and orange colour accents have been used to assist patients with dementia and those with poor sight to locate and recognise key parts of their environment. The colour code is used for distinguishing the respective patient’s cupboards, shelves in the bathrooms and also the towels. Special attention was also given to the choice of colours and materials to ensure sufficient light/ dark contrast between different surfaces. Clear differentiation between the bed and the floor, the chair and the floor, the wall and the floor, and the handrail and the wall help reduce the risk of accidents and falls. A continuous, non-reflective and pattern-free floor covering was chosen to avoid the risk of floor markings being mistaken for steps or gaps, causing unintentional stumbling or missteps. Only where such visual barriers are useful – for example in front of the ward exits to discourage patients from wandering out of the ward – has this principle been used very specifically.

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1 Site plan, 1 : 20,000 2 The acute geriatric care unit at the St Joseph-Stift 3 Ward floor plan, 1 : 500

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4 Mirror with handrail and “Memoboard” 5 Bathroom 6 Floor plan of the patient rooms, 1 : 100 7 Patient room showing the colour-coded patient cabinets 8 Patient room

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St Joseph-Stift Dresden

St Gallen Geriatric Clinic Renovation and extension

This room type with two beds placed at right angles to the façade is comparatively rare due to the large room width it entails. It is, however, particularly beneficial for patients who are confined to their bed for most of their stay. Both patients benefit from the same outlook towards the window, the same proximity to the door and more favourable lighting thanks to the room’s advantageous proportions.

Architects Silvia Gmür Reto Gmür Architekten Client Geriatrische Klinik St. Gallen AG Location St Gallen, Switzerland Completion 2020





Beds per floor 28 Net area, two-bed room 30 m² + 2.3 m² bathroom

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Typologies

The existing building of the Geriatric Clinic was built in 1980 by Bärlocher & Unger as an addition to St Gallen’s Bürgerspital, a public hospital complex from the 19th and 20th century. The site comprises three buildings that together constitute the Kompetenzzentrum Gesundheit und Alter (competence centre health and age) in St Gallen. To ensure the continued operation of the Geriatric Clinic during the renovation and extension works, a temporary structure was built that is to be dismantled later. The extension adds a new layer of rooms along the entire north face of the building, maintaining the urban figure of the building as well as the linear building line of the Bürgerspital ensemble. The result is a rational arrangement of three parallel spatial layers in which the new rooms augment the existing operational organisation of the building. The façade of the new north wing picks up aspects of the existing building, incorporating the horizontal strip windows and concrete cladding of the south side. At the same time, sheet metal profiles were inserted between the concrete bands and glazing on both the north and south façades, which along with slender window frames, gives the whole a sleek, modern appearance. The geriatric ward treats elderly patients who frequently suffer from multiple conditions and need special support. The intention of the treatment is to enable patients to lead a largely independent life after their stay in hospital. With advancing old age, many people are unsettled by changes to their life situation. The design of the patient rooms, including the arrangement of the beds and the equipment, therefore strives to create a calm and peaceful environment for the patients. The ancillary spaces and nurses’ stations are accessible from two sides, on the one hand ensuring the shortest direct path from carer to patient, and on the other forming a ring that allows patients with an urge to move to circulate within the ward. The patient rooms in the newly added layer of rooms are comparatively wide and shallow in depth. The windows run along the entire breadth of the room, heightening its sense of spaciousness, while the back of the room behind the beds is lined with cupboards that conceal and incorporate technical equipment and provide storage for use by the patients and nurses. The entrance is located in the middle of the cupboards, dividing the room into two patient areas. The generous distance between the patients allows the space between to serve as a communal area and it can also be used as a dining area. The arrangement of the beds at right angles to the corridor and window, along with the low sill height, affords patients an expansive view of the surroundings from their beds over the entire width of the room. The bathroom is likewise of a generous size and is reached via a transitional zone that has daylighting and a washbasin. Patients can use this sheltered space, which is separated from the rest of the room, to wash and dress out of direct sight but not within the bathroom. The warm tone of the oak windows and wall units, the dark red of the linoleum floor and the light colours of the walls aim to create a welcoming, restful character in which the presence of indispensable medical equipment recedes into the background.

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1:500

1 Site plan, 1 : 20,000 2 View of the new north wing of the hospital 3 Ward floor plan, 1 : 500

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Case Studies

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Typologies

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4 View of patient room circulation area 5 Alcove in front of bathroom with washbasin 6 Patient room with a generous view 7 Patient bed with bedside terminal 8 Floor plan of the patient rooms, 1 : 100

135

St Gallen Geriatric Clinic

Uster Hospital

The design of the new rehabilitation centre and ward building at Uster Hospital draws on the typology of the historical sanatorium buildings from the 1930s and takes it a step further to develop its own solution for the new extension. By turning the rooms slightly out of the axis of the new building, they pick up the orientation of the existing building and divide the large building mass into individually articulated units – the architects’ answer to expressing the aspect of human scale in a large clinic building. The façade is therefore an expression of the underlying design idea. All the rooms face south and have floor-to-ceiling glazing providing generous views of the surrounding park and mountainous landscape and ensuring optimal illumination with natural light. Each room is fronted by a walk-on balcony, with slats screening patients in neighbouring rooms from prying eyes. The horizontal screen in front of the balcony provides shade, obstructs the direct view downwards and focusses attention on the snow-capped mountains beyond. The patient rooms are barrier-free and wheelchair-accessible in all areas, not just in the bathrooms but also in the common zones, and a floor-flush threshold provides direct access to the wood-covered balcony via a sliding glazed door. The position of the beds can be varied so that both beds can be placed lengthwise along the wall without any restrictions. Their diagonal placement eliminates the disadvantage of the rear bed, allowing the patient almost the same view as from the front bed, even when the privacy curtain between the beds is drawn. The patients’ common area with table and chairs fits perfectly into the bay window of the façade with its panoramic glazing. The wall dividing the room from the bathroom is a custom-made fitting that includes a barrier-free shower, toilet and washbasin and has multifunctional niches and cupboards that can be used from either side of the wall by the patients and nursing staff. The wooden headboard wall behind the patient beds incorporates and conceals the medical fittings and lighting in order to emphasise the atmospheric qualities of the room as a living area over its medical function.

New rehabilitation centre

By arranging the same-handed rooms at a slight angle, each room benefits from a southerly orientation. The resulting triangular indentations in the façade become balconies and a twist in the room plan allows for moving the bed into a second position. The project shows how small deviations from conventional floor plans can create new possibilities and improve the quality of the patient’s stay.

Architects Metron Architektur AG, Brugg Client Zweckverband Spital Uster Location Uster, Switzerland Completion 2025





Beds per floor 30 Net area, two-bed room 30.3 m² + 4.6 m² bathroom

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136

Typologies

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1 Site plan, 1 : 20,000 2 The patient room units seen from outside 3 Patient room 4 Ward floor plan, 1 : 500 5 Floor plan of the patient rooms, 1 : 200

137

Case Studies

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Surgical Centre Erlangen University Hospital New ward block

For the patient rooms at the Surgical Centre in Erlangen, the architects experimented with different surface qualities: smooth and reflective in the entrance area and for impact protection, and glass wall surfaces in the bathroom, which are usually reserved for private healthcare patient rooms. Together with the use of wood decor and selected colours, they have created a tasteful and inviting overall interior that complements the design quality of the entire clinic building.

Architects Tiemann-Petri Koch Planungsgesellschaft Client Free State of Bavaria Erlangen-Nuremberg State Building Authority Location Erlangen, Germany Completion 2013





Beds per floor 68 Net area, two-bed room 22.56 m² + 3.08 m² wet room

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138

Typologies

Founded in 1815, Erlangen University Hospital has a total capacity of 1394 beds and is a central healthcare facility of the city as well as a training institute for the medical faculty of the Friedrich-Alexander University Erlangen-Nuremberg. Most of the buildings are located near the Schlossgarten in Erlangen. The new ward block building provides 328 beds and is the first construction phase for the new Surgical Centre (OPZ) on the main site on the edge of the historical city centre. The building follows the course of the listed city wall and is divided into two sections by an entrance courtyard. Coarse render with natural stone inlay and striking window elements contrast with delicate, delineated metal façades, expressing the tension between the historical surroundings and the requirements of a modern hospital. Each floor of the building is divided into two wards with 34 beds, each arranged around a greened inner courtyard. Patients and visitors enter a ward, either from the respective main stairs and lift or from the adjacent medical building, arriving at a central point near the nurses’ station and patient waiting area. Views into the inner courtyard or onto the street help provide orientation within the wards. The patient rooms are arranged along one side overlooking the street, and between the two wards a large balcony allows patients to step outdoors and look onto the entrance courtyard. Each ward has various types of patient rooms: two-bed and single rooms are supplemented by a four-bed supervision room, a disabled-access patient room and a room with airlock. The headboards in the patient rooms are equipped with a high degree of technical fittings for treating patients after surgery, but they do not dominate the room. Ample wood, a seating area at the window with an overhead pendant lamp and the wall opposite free of equipment and installations create a calm environment for the patients. Cupboards for supplies and for patients’ belongings are located in the entrance area to the room next to the bathroom so that the area around the bed can be kept free for therapy and treatment. The same-handed layout of the rooms and the flush-fitted cupboards also ease handling of the beds in transport. The cupboards have mobile cupboard inserts for holding patient belongings so that they can be relocated along with the bed should a patient change rooms. A washstand spanning the width of the bathroom along with generous shelf space and a large mirror helps impart the impression of spaciousness. The mirror height and washstand are designed to be usable by patients in wheelchairs. Within the rooms, simple but high-quality materials have been used. The double-leaf entrance doors are articulated as room-high elements within solid oak frames, which are likewise used for the window surrounds. By contrast, the glossy white cabinet surfaces and jointfree glass walls in the bathroom combine easy-clean functionality with smooth modern aesthetics. The patient rooms on the ground floor that face directly on the historic city wall are glazed from floor to ceiling and look onto their own semi-private green courtyard with a view of the city wall behind as a historical backdrop.

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1 Site plan, 1 : 20,000 2 Inner courtyard

1:750

3 The east façade and the historical city wall 4 View of green courtyard in front of ground floor patient room 5 Ward floor plan, 1 : 750

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Case Studies

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Typologies

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6 Patient balcony 7 Ward corridor with entrances to the rooms 8 Ground floor patient room with floor-to-ceiling windows 9 Mobile patient wardrobe 10 Patient bathroom (standard) with glass walls 11 Floor plan of the patient rooms, 1 : 100 12 Patient room with seating area and wood window surrounds 13 Entrance area within the patient rooms

141

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Surgical Centre, Erlangen University Hospital

Crona Clinic Tübingen University Hospital Renovation and fire safety improvements

In recent years, patient rooms have increasingly been equipped with a supply point providing gloves and disinfectant dispensers for clinic and nursing staff. These can take up more or less space, depending on requirements. The patient rooms at the University Hospital in Tübingen employ a particularly slimline integral solution that is immediately visible to staff entering the room but remains out of sight to patients lying in bed.

Architects a|sh sander.hofrichter architekten GmbH Client Vermögen und Bau Baden-Württemberg, Tübingen Council Location Tübingen, Germany Completion 2016 Beds per floor 44 Net area, two-bed room 26.11 m² + 4 m² bathroom

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142

Typologies

Since 2002, a|sh architekten have successively realised various building projects on the site of the University Hospital in Tübingen. For the renovation of the Crona Clinic, which first opened in 1988 and derives its name from the German words for surgery, radiology, orthopaedics, neurology and anaesthesia, they took a holistic approach that aimed to give the clinic a contemporary, more patient-friendly focus. For the renovation of the “Wards of the Future” section of the building, which was completed in 2015, incorporated fire safety improvements and equipped the wards to meet future needs. After the ward building was gutted, only the loadbearing walls and columns, the floor slabs, ceilings and the façades remained. The new floor plan for the star-shaped building incorporates more views of the outside world to assist orientation within the wards. Two wards were created, a standard care ward and a private healthcare patients’ ward, with a total of 44 beds, four of which are in single rooms. The nurses’ station is located at the centre, creating a link between the two wards. Its open design facilitates better communication between visitors, patients and staff. A restrained colour scheme ensures a contemporary appearance. Different tones of blue create accents in the corridors and wall panelling, creating a sense of greater space. In the patient rooms, the shades of blue are complemented by warmer tones and wood decor, and abstract motifs of the city of Tübingen serve as graphical references to the location of the clinic. Before renovation the bathrooms had a threshold, making barrier-free access impossible. The cupboard walls were also used to pass bed linen through to the ward corridor. Fire safety regulations made it necessary to revise this arrangement. Some slight changes and a redesigned bathroom created more space in the rooms. The new fitted furniture incorporates storage usable from the bathroom and from the room, creating a cleaner, tidier overall impression. Instead of a separate workplace for staff near the entrance to the room, the glove dispenser, waste bin and disinfectant dispenser have been incorporated in a vertical slot in the wall that staff see as soon as they enter the room but is concealed by the wall from patients lying in bed. The low sill height of the windows also allows patients to enjoy the view out of the window from their beds. The private healthcare patient rooms feature glass headboard panels behind the beds as well as other high-quality materials that further enhance the comfort and quality of the interiors.

2

1 Site plan, 1 : 20,000 2 View of the building 3 Ward floor plan, 1 : 750

143

Case Studies

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Typologies

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4 Nurses’ station 5 Seating area for patients and visitors 6 Ward corridor 7 Graphical motifs refer to the clinic’s location in Tübingen

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8 Patient bathroom in a standard room 9 Floor plan of the patient rooms (standard care ward), 1 : 100 10 Two-bed room (standard care ward) with a view of the supply point 11 Single-bed room (private healthcare ward) with glass headboard panel behind the beds

145

Crona Clinic, Tübingen University Hospital

Erasmus MC New university hospital

The floor plan of the patient rooms at the Erasmus MC University Hospital in Rotterdam is particularly flexible. Based on the layout of the standard room, three additional room types for more demanding use cases were developed through minor interventions. The convertible seating adds a rooming-in option to the patient rooms and testifies to the demand for maximum functionality combined with the high level of planning standardisation that is inevitable in projects of this size.

Architects EGM architects, EGM interiors Client Erasmus MC Location Rotterdam, the Netherlands Completion 2017 Beds per floor 122 Net area, single room 18.94 m² + 3.97 m² bathroom

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146

Typologies

Erasmus Medical Center (MC) in the heart of Rotterdam is the largest university medical centre in the Netherlands. On the site of an existing hospital, a new complex was built where healthcare, research and education all come together. The new building comprises 522 medium-care patient rooms, 38 intensive care units, 18 ICCU rooms (intensive cardiac care units) as well as 94 day-patient treatment places. The nursing wards are located on the 8th to the 12th floor, thus far away from the bustle of the public areas and the city. This complex transforms the university medical centre from a cluster of separate buildings into a small medical city for 13,500 staff, 4500 students and thousands of patients. There are four types of patient rooms, depending on care requirements: standard rooms, extra-large rooms, pressurised and isolation rooms for haematology care. All of those 522 rooms have direct daylight with views towards the city, the port or the roof garden. Patients can open their window by themselves, unusual in a hospital, thus encouraging activity and bringing in fresh air. The wooden window frames, together with the carefully chosen colour palette and specially designed window covering, generate a warm domestic atmosphere. All fixed and freestanding elements in the room are kept at a low height, which makes the room appear spacious and ensures uninterrupted views from the bed to the outside and to the door. In the pressurised alcove a ceiling-high glass corner provides a direct and undisturbed sightline towards the patient upon entering. Every room has its own bathroom which is wheelchair-accessible. The room is equipped with a toilet, shower and a tailor-made washbasin. The toilet is positioned in line with the door, enabling easy access for an overtoilet wheelchair. Rounded corners in the shower area ensure less soap and dirt accumulation and easy cleaning, while the shower faucet is mounted close-by for easy access by the nursing staff without getting wet. By the window, a specially designed canape provides an attractive place to sit. At night, it can be folded out to become an extra bed for visitors. All rooms have an electric ceiling hoist to facilitate moving patients. In addition, plenty of attention has been given to self-sufficiency and self-control. The latest technologies have been installed for supplying meals, administering medication and monitoring the patients. Patients can watch TV, use the internet, or call a nurse from anywhere in the room using a tablet. There is an alarm button attached to the bed, and the nursing staff can also call for help using the wall-mounted alarm display unit. Mobile patients wear a wristband so that they can alert the nursing staff if necessary while outside their bed, even when in the outside roof garden. But not everything is fully automated. A conscious decision was made, for instance, not to provide a remote control for closing the curtains; the nurse will always come to the room at the end of the day for a final check and personal contact. Erasmus MC opted exclusively for single rooms in the new hospital but for years, this was a subject for debate. Feedback, however, showed that almost all patients prefer peace and quiet to social contact. For socialising, patients can meet in the lounge or in the bed-accessible 3000 m² roof garden located on the 8th floor. It provides an oasis of calm, relaxation and diversion for patients, who sometimes remain in hospital for extended periods of time.

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1 Site plan, 1 : 20,000 2 View of the roof garden 3 Erasmus MC with main entrance 4 Ward floor plan, 1 : 1000

147

Case Studies

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Typologies

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5 Seating area with family room in the nursing ward 6 Patient bathroom 7 Pressurised room with bathroom 8 The ceiling-high glass corner of the alcove allows a view into the patient room. 9 Floor plan of the patient rooms, 1 : 100 10 Patient room with tailor-made rooming-in furniture 11 Entrance with nursing workplace in standard room

149

Erasmus MC

11

Oncological Centre Leuven University Hospital New hospital

The nested position of wet cells between the patient rooms results in a rectangular floor plan and therefore in very good conditions for flexible use of space. This solution also works to the advantage of the patient rooms in the new Oncology Centre in Leuven. Guide rails behind the beds allow for different positions for the bed and thus create options for individual seating areas, enabling new room layouts in a two-bed room.

Architects Wiegerinck LOW Architects Client Universitair Ziekenhuis Leuven Location Leuven, Belgium Completion 2023





Beds per floor 40 Net area, two-bed room 32 m² + 5 m² bathroom

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150

Typologies

The new Oncological Centre at UZ Leuven, located on Gasthuisberg, consolidates and upgrades existing oncology facilities at Leuven University Hospital, Belgium’s largest hospital. A single multidisciplinary unit on 23,000 m² will diagnose and treat up to 35,000 patients from across the country. The centre will be located at the crossroads of care, education, research and medical-social facilities on the campus, thus reflecting the multidisciplinary nature of oncology. The new centre will provide room for outpatient clinics, clinical trials, radiotherapy and nursing wards. In addition, the building will form one of the main entrances to UZ Leuven. Incorporation into the campus, building height, daylighting, orientation and connection with the hospital are leading factors in modelling the building volume. The centre’s appearance is characterised by a modest but distinctive architecture. A pure orthogonal mass is underscored by freely designed spacious patios. The fact that the centre very conveniently faces southwest, combined with the large voids on the lower storeys, ensures that daylight can reach all essential areas. All design decisions are based on the ambition to create spaces that are user-friendly to a range of users. Through trials with hospital staff, design decisions are to be checked during the planning phase and can be optimised. A balanced ratio of single and two-bed rooms was striven for, so that each floor has 14 double and 12 single rooms. The patient rooms are equipped with a system which enables the beds to shift along a guide rail. By altering the bed’s position, various options for seating are enabled. Thus, each patient in a two-bed room should be designated their own, clearly defined zone, with their own seating area. This serves as a visitor zone for relatives or as a place for relaxing activities such as reading. The bathrooms are situated between the patient rooms in order to have a fairly flexible corridor wall where a window is placed to optimise visual contact between patients and medical staff. The awareness of medical professionals close-by affects the patient in a positive way; this can shorten the process of recovery.

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1 Site plan, 1 : 20,000 2 Oncology Centre with entrance for UZ Leuven 3 Ward floor plan, 1 : 500

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Case Studies

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Typologies

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4 Entrance and window between corridor and room 5 Bathroom

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6 Floor plan of the patient rooms, 1 : 100 7 Two-bed room 8 View from patient bed towards bathroom and nursing workplace

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Oncological Centre, Leuven University Hospital

Paediatric Clinic Freiburg University Hospital New clinic building

Little attention is devoted to the space opposite a bed and all too often patients are left to look at a blank wall. Not so in the Paediatric Clinic in Freiburg where seating and play areas have been created in the patient rooms. This seemingly self-­evident solution is an ice-breaker when rooming-in and also an incentive for patients to get out of bed.

Architects ARGE Health Team Vienna Albert Wimmer ZT GmbH Architects Collective GmbH Client State of Baden-Württemberg Location Freiburg, Germany Completion 2023





Beds per floor 69 Net area, single room 20.5 m² + 4 m² bathroom Net area, two-bed room 26.5 m² + 4 m² bathroom

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154

Typologies

The new clinic for children and adolescents is situated in the grounds of Freiburg’s University Hospital and unites the paediatric facilities and institutes that were previously dispersed across different buildings. The placement and figure of the building allows the landscape to flow around the building and into the five green inner courtyards. New gardens and adventure zones will be created in the existing park to meet the different needs of children and young people. The design of the patient rooms elevates patient well-being to its central principle, creating a safe and welcoming environment tailored to the specific requirements of the “parent-and-child patient”. This term reflects the importance of the family for the recovery of the young patients, and the concept therefore also considers the health of the parents. As such, the need for close personal interaction between the children and their parents influences the spatial design of the patient rooms. The patient rooms have one or two beds and are clearly zoned into different areas. The seating area near the window creates space for sitting and communication while the permanent rooming-in area is designed as a niche in which the young patients can play together with relatives and visitors. In the two-bed rooms, this area extends across the entire wall opposite the beds so that the patients always have an interesting view from their beds. Immediately behind the entrance door is a work area for nursing that picks up the diagonal of the bathroom wall and directs incoming people straight towards the patient as soon as they enter the room. The entrances to the rooms are offset in niches from the ward corridor, creating a small buffer zone and “address” for each room. The colour scheme and materials as well as the choice of motifs take into account the wide age range of the patients from young children to young adults. A series of different images were developed that pick up and adapt motifs from the local Black Forest region, which are used to denote the different rooms. Particular attention was given to ways in which patients can person­ alise their rooms to create a family-friendly environment and promote recovery. Various magnetic and writeable surfaces can be used by the patients to make the room their own. In addition, communal play areas in the wards encourage mobility and personal development and promote interaction between the patients, helping them to make new friends.

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1 Site plan, 1 : 20,000 2 The paediatric clinic and its outdoor areas 3 Ward floor plan, 1 : 750

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Case Studies

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Typologies

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4 Nurses’ station with a view of the room entrances (left) 5 Library 6 Main corridor along the inner courtyards 7 Floor plans of the patient rooms, 1 : 100 8 Two-bed room 9 Single room with writing desk

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Paediatric Clinic, Freiburg University Hospital

Children’s University Hospital Zurich New acute care hospital

To create a sense that each patient room at the Children’s University Hospital in Zurich is an individual entity, the design emphasises a frequently neglected aspect of patient rooms: the ceiling. The symbolic notion of a roof over one’s head imparts a sense of shelter and being looked after in the unsettling situation of being ill and in hospital.

Architects Herzog & de Meuron Client Kinderspital Zürich – Eleonorenstiftung Zürich, Switzerland Location Zurich, Switzerland Completion 2022





Beds per floor 114

An international competition for the design of a new building for the Children’s University Hospital in Zurich was launched in 2011, and subsequently won by the architects Herzog & de Meuron. With 200 beds, including 51 intensive care and neonatal beds, it is the largest hospital for the inpatient and outpatient treatment of children and young people in Switzerland. In addition to treating a range of highly specialised medical conditions, it also incorporates spaces for research, teaching and the promotion of young academics in the field of paediatrics. These two facilities – an acute care hospital and a research and teaching unit – are housed in two buildings. The Akutspital on the south site is a three-storey, strongly horizontal building located opposite the existing “Burghölzli”, the Psychiatric University Hospital in Zurich. The main entrance to the new building, a large opening, is exactly opposite the historical portal of the existing building and the concave gesture of the entrance façade creates a large joint forecourt for both institutions. Inside, the Akutspital is designed like a gridded city with streets, intersections and squares. Each floor has a main street and the functional facilities are their quarters. A large number of planted inner courtyards of different sizes illuminate the interior and punctuate the orthogonally organised interior space. Some of the courtyards are more conspicuous due to their round shape and are arranged along the main street near the entrances to the most important functional areas. The wards are located on the top, the most private level of the Akutspital. Designed as quadrants, they contain a total of 114 rooms arranged in a ring and oriented outwards. Both single and two-bed rooms are equipped with sofas that can be converted into sleeping accommodation for parents and relatives. They also have a work area for the nursing staff. Each individual patient room is designed as a small house with its own roof, ensuring privacy for the young patients and their relatives in combination with an expansive view. By staggering the arrangement of the rooms and varying the roof incline, each individual room is legible as a separate unit: this elementary, immediately comprehensible form expresses the individuality of each patient within the larger complex of the hospital.

Net area, single room 20 m² + 4 m² bathroom Net area, two-bed room 30 m² + 4 m² bathroom

1

1 Site plan, 1 : 20,000 2 View of the entrance area 3 Inner courtyard 4 Ward floor plan, 1 : 1000

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Typologies

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Case Studies

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5 Two-bed patient room 6 Floor plan of the patient rooms, 1 : 100

160

Typologies

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Münster University Hospital Renovation of the ward towers

Fitting two-bed rooms into a radial floor plan is particularly challenging because the tapered room shape makes it hard to create two equally good bed places. At the Universitäts­klinikum Münster, two nested bathrooms have been arranged spaced apart between the rooms, creating a niche for the bed closest to the door, or for a comfortable sofa area in the single rooms.

Architects wörner traxler richter Client Universitätsklinikum Münster Location Münster, Germany Completion 2025





Beds per floor 38 Net area, two-bed room 26.3 m² + 4.3 m² bathroom

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161

Case Studies

The renovation and restructuring of the patient rooms in the east and west towers housing the wards of Münster University Hospital (UKM) are part of the “University Medicine 2025” project, which is the culmination of a study begun in 2014 by the UKM and the Medical Faculty of the University of Münster, aimed at developing robust sustainable strategies for hospitals. While the façades of the so-called bed towers have already been renovated, the renovation and restructuring of the wards within is ongoing. The new plan will accommodate either 38 beds in two-bed rooms or 19 beds in single rooms, depending on the occupancy concept. The rooms are watched over from a nurses’ station at the centre of each floor with the ancillary functional spaces. Patient rooms can be allocated to one or the other nurses’ station according to the “floating principle” so that the hospital can react flexibly to changing patient occupancy levels. The creation of care groups spanning different clinical treatment areas is also planned. The interiors of the patient rooms will change significantly. The structure of the new façade has been hung in front of the existing concrete parapet elements, making it possible to incorporate the previous escape balconies into an enlarged room design. To provide fresh air to the room, a vent casement can be opened. The façade construction with internal window elements and external skin optimises thermal insulation in winter and prevents overheating in summer thanks to solar shading elements arranged between the layers. The room enlargement makes it possible to position the bathrooms along the partition wall between two patient rooms, and in turn to stagger the position of the beds in a two-bed room, avoiding the problem of there being a “window-bed” and “corridor-bed” as commonly seen in parallel bed arrangements. Here, each position has its own qualities and an unobstructed view through the large window, as well as a spacious zone around each bed for greater privacy and receiving visitors. Arranging beds in opposite directions also facilitates better interaction between room occupants. In the single rooms, typically for patients with private health insurance, the niche can be used for a seating area instead of a second bed. The placement of the bathrooms between the rooms also ensures that staff have a good view of both patients, as does the radial structure which gives the hospital building its iconic, recognisable form.

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1 Site plan, 1 : 20,000 2 View of the two bed towers 3 Single room with sofa niche 4 Ward floor plan, 1 : 500 5 Two-bed room

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6 Floor plan of the patient rooms, 1 : 100

1:500 162

Typologies

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Münster University Hospital

Building Structures in German Hospitals

References Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier, Andrea Haselbeck and Inka Dreßler, Bauliche Hygiene im Klinikbau. Planungsempfehlungen für die bauliche Infektionsprävention in den Bereichen der Operation, Notfallund Intensivmedizin. (Zukunft Bauen – Forschung für die Praxis, Vol, 13), Bonn: Bundesinstitut für Bau-, Stadt- und Raumforschung, 2018

164

Typologies

In 2015, a survey of the condition of building structures in German hospitals was undertaken for the first time with the help of the Hospital Infection Surveillance System (Krankenhaus-Infektions-Surveillance-System – KISS) of the German National Reference Center for Surveillance of Nosocomial Infections (NRZ), which has been recording nosocomial infection rates and multi-resistant pathogens throughout Germany since 1997. The National Reference Center is run by the Institute for Hygiene and Environmental Medicine at Charité – Universitätsmedizin Berlin. The survey was conducted within the framework of the research project “HYBAU+” by an interdisciplinary research team of experts from the fields of building construction (Institute of Construction Design, Industrial and Health Care Building, Technical University of Braunschweig), material sciences (Institute of Building Materials, Concrete Construction and Fire Safety, TU Braunschweig) and hygiene (Institute for Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin) who investigated how structural and functional processes in hospitals can be optimised for better hygiene, how hygienic materials can be used more optimally and how new building structures can be designed efficiently and sustainably. The project was funded by the Federal Office for Building and Regional Planning (BBR) as part of the research initiative Zukunft Bau (Ref. No. SWD-10.08.18.7-14.04). The results were published in 2018 in Bauliche Hygiene im Klinikbau, volume 13 of the publication series “Zukunft Bauen”. The survey was sent as an online questionnaire to the staff responsible for KISS in the respective clinics, usually the hospital hygienists and hygiene specialists. The survey of all hospitals participating in KISS was conducted between March and June 2015 and invitations were sent to 1357 of the nearly 2000 hospitals in Germany. It comprised one questionnaire for the entire hospital and one short questionnaire for each intensive care unit and neonatology unit. 621 hospitals took part in the survey, corresponding to a response rate of 46 %. The questionnaire for intensive care units was answered by 534 units from 368 hospitals. Of the 246 hospitals asked, 127 neonatological wards provided data on their building structures. The survey examined the current state of the building structure of hospitals in Germany and covered everything from the location of the hospital (e.g. urban or rural), to the cubature of the building, the geometric layout of the functional areas right down to details such as whether the rooms are equipped with hand disinfectant dispensers. The survey collected a broad range of data, ranging from the year of construction of the hospital and periods of later structural alterations to information on the building structures of the hospital building and selective departments. Other aspects surveyed included the number of single, double and multi-bed rooms, the room sizes and the distance between the nurses’ station and the furthest patient room. The Institute of Construction Design, Industrial and Health Care Building at the TU Braunschweig developed pictograms for the different building structures for use in the questionnaire. The results of the survey made it possible to obtain an initial assessment of the actual condition of building structures in hospitals and how they compare to the corresponding guidelines for hospital hygiene and infection prevention. From this, the discrepancy between actual and desired conditions could be identified to determine the corresponding need for action in specific areas.

Where is the hospital located?

When was the hospital built? Before 1900 1901–1945

17.7 %

16.9 %

16 % 23 %

1946–1960

11 %

1961–1990

35 % 8%

1991–2000

28.7 % 36.7 %

After 2001

7%

City up to 100,000 inhabitants City up to 500,000 inhabitants City over 500,000 inhabitants Rural area

When were building measures undertaken?

When were building measures undertaken?

1901–1945

Intensive care ward

1946–1960

7% 9%

1961–1990

29 %

1991–2000

12 %

1991–2000 71 %

10 %

58 %

Normal care ward 2%

1961–1990

20 %

1991–2000

20 %

After 2001

Building Structures in German Hospitals

28 %

After 2001

1946–1960

165

2%

1961–1990 40 %

After 2001 No intervention

1946–1960

58 %

What level of care does the hospital have?

Which building structure has the hospital? Grown structure

Freestanding building

50 %

12 %

18 % 34 %

17 %

18 % 19 % Organically grown structure, i.e. the individual buildings evolved over time, no coherent style

Freestanding, compact building volume

Normal care

Comb structure

Specialised care

Plinth

Basic care

16.4 %

8.3 %

Specialised hospital Maximum care

Are there patient rooms without a toilet?

Comb structure, i.e. the individual wings of the buildings are connected by a central spine

Base building with superstructure

Mat

Cluster 4.2 %

28 %

3.1 % 72 %

Normal care ward Yes No Mat structure, several courtyards, expandable

166

Typologies

Cluster structure, i.e. individual pavilions; the freestanding volumes are not connected but have a consistent style

Spatial organisation

Number of beds

Normal care ward

Intensive care ward

36

13

Structure normal care ward

Structure intensive care ward

30.9 %

29.6 %

Dead end corridors with centre access, e.g. in a high-rise slab

19.5 % Room size + Beds in single rooms

17.2 m² 5.6 %

18.2 m² 23.1 %

Room size + Beds in double-bed rooms

22.7 m² 50.0 %

28.5 m² 61.5 %

19.5 %

Dead end corridor, e.g. in comb structures and extensions

13.2 % Room size + Beds in multi-bed rooms (Overall number of beds = 100 %)

Openable window in patient room

31.4 m² 44.4 %

n. a.

Maximum distance between nurses’ station and furthest patient room

30.6 %

n. a. 15.4 %

L-shaped dead end corridor, e.g. in comb structures and extensions

69.5 %

Dead end corridor, e.g. in comb structures and extensions

10.3 %

69.4 %

L-shaped dead end corridor, e.g. in comb structures and extensions

L-shaped dead end corridor

31.2 m

15.8 m 10.1 %

8.6 %

Double corridor with centre access, e.g. in a high-rise

167

Perimeter corridor, e.g. in comb structures and extensions

17.0 %

10.3 %

Hand disinfectant dispenser at patient bed

Dead end corridor with centre access, e.g. in a high-rise slab

Building Structures in German Hospitals

Double corridor with centre access, e.g. in a high-rise

C

Prototype of a Patient Room – the KARMIN Project

Architecture of the Patient Room

170

Prototype

Should hospitals in future have more single or more two-bed rooms? Can the design of hospitals and patient rooms contribute to preventing infection transmission in hospitals? What are the challenges of designing patient rooms today and in future, especially with regard to hygiene? These and other questions were the focus of the KARMIN research project discussed in this book, which investigated possible responses to preventing the spread of multi-resistant pathogens: should hospitals be converted to have more single-bed rooms or can the design of two-bed rooms be improved so that they are a viable alternative with respect to infection control. KARMIN stands for “Krankenhaus, Architektur, Mikrobiom und Infection” (Hospitals, Architecture, Microbiome and Infection) and is a research project funded by the German Federal Ministry of Education and Research (BMBF) from 2016 to 2020 under the “Zwanzig20” funding programme as part of the InfectControl 2020 research network. The project was undertaken as a partnership of the TU Braunschweig (co­ordination: Institute of Construction Design, Industrial and Health Care Building), the Charité – Universitätsmedizin Berlin (Institute for Hygiene and Environmental Medicine), the Jena University Hospital (Septomics Research Group) and the company Röhl GmbH from Waldbüttelbrunn near Würzburg. National and international guidelines have for some time been calling for patients with multi-resistant pathogens to be isolated in single rooms. However, the rising number of MRSA pathogens makes such a demand increasingly difficult to implement. In addition, the exclusive use of single rooms has several disadvantages and higher costs. In Germany, these consequences have not yet been scientifically evaluated to provide hard data for decision making. Most multi-resistant pathogens are transmitted primarily through contact. By implementing appropriate design means to minimise contact, it should therefore be possible to safely care for patients with such pathogens in two-bed rooms. Studies on alternative multi-bed scenarios – such as equipping two-bed rooms with two wet cells, or alternatively two toilets, or with self-disinfecting sanitary facilities – are currently lacking. Likewise, there have as yet been no studies on how new hospital buildings are colonised by microorganisms, and the factors that influence this. In the KARMIN project, a team of architects, designers, medical practitioners and molecular biologists identified and evaluated interdisciplinary risk factors for infection transmission in patient rooms, the accompanying wet cells and adjacent functional areas on the basis of their structure and design as well as the procedures and activities that take place within them. From this, they elaborated planning recommendations for breaking the chains of possible infection transmission and developed a prototype for a two-bed room with wet cells designed to minimise infection transmission. This also included optimised equipment such as a disinfectant dispenser, bedside trolley and a concept for a bedside terminal with corresponding advisory content. Seventeen competent and innovative industrial partners were involved in the planning and implementation process. This chapter presents the analytical study and methodology used, including, among other things, expert workshops with planners, care staff, cleaning personnel and hygienists as well as comprehensive studies on lighting and colour design. From this, designs and then detailed construction plans were developed in ongoing consultation with the project partners for both the room and selected fittings and furnishings. This process and the resulting final design variant are documented here. A second focal area of the KARMIN research project was the study of how hospital microbiome develops. For this, the first occupancy of

the newly renovated Charité high-rise bed building was studied. The Charité – Universitätsmedizin Berlin (Institute for Hygiene and Environmental Medicine) and the Jena University Hospital with the Septomics Research Group jointly investigated how architectural conditions (e.g. multi-bed and single rooms) influence the development and diversity of the microbiome and the emergence of multi-resistant bacteria. Furthermore, different cleaning regimes (e.g. surface disinfection vs. surface cleaning) were also evaluated. While the latter is beyond the scope of this book, the results are available on request from the project partners.

Work Process and the Project Team The KARMIN project, under the leadership of the Institute of Construction Design, Industrial and Health Care Building (IKE) at the Technical University of Braunschweig, brings together architects, medical practitioners, hygienists and product manufacturers in an interdisciplinary work group for the first time. The research team for the design and realisation of the patient room thus unites partners from the realms of science, medicine and industry. The participating university institutes have undertaken joint research in various areas of health and infection prevention for many years and are well-known and established research institutions. In addition, 17 partners from industry were involved from the outset in the development of the concept for an infection-prevention optimised patient room. Both the university institutes and the industrial partners consulted regularly over the course of the project, with meetings in person at least every three months as a means of ensuring successful collaboration.

time, the Institute of Hygiene is a National Reference Center (NRZ) for the surveillance of nosocomial infections, i.e. infections acquired in hospital. The Institute is therefore home to the Krankenhaus-Infektions-Surveillance-System (KISS), in which about 75 % of German hospitals currently participate. KISS is a benchmarking tool with which hospitals can objectively measure their infection rates and adapt their prevention measures accordingly. The Institute also organises nationwide hygiene projects such as the “Clean Hands Campaign”, which is supported by the Federal Ministry of Health, among others, and currently seven national and EU-funded third-party projects on infection prevention issues. Research conducted at the Institute of Hygiene and Environmental Medicine focuses on the surveillance of nosocomial infections and multi-­ resistant pathogens, evidence-based infection prevention measures and their implementation, molecular biological investigations to identify infection chains, and technical investigations into hospital hygiene. Röhl GmbH Sheet Metal Processing Röhl is an association partner for the project and a family-run mediumsized company with more than 40 years of experience of producing healthcare products. Alongside sheet metal processing, the main focus of its production is composite elements. It has undertaken numerous projects in the prefabricated bathroom sector for hospitals and care facilities such as the Traunstein District Clinic, Braunschweig and Halle Municipal Clinics, Hannover Region Clinic, SRH-Holding Heidelberg, the Surgical Centre Erlangen, Aachen Medical Centre and Alsterdorf Protestant Hospital in Hamburg. It has also produced prefabricated bathroom systems for nursing homes and homes for the elderly, such as those at Bad Neuenahr-Ahrweiler, the Leonhard Center Nuremberg, the St Martinus Wevelinghoven or the DRK Memory Zentrum Neuss. Röhl has an extensive network of suppliers and decades of experience in the hospital and healthcare construction sector.

Research phases Institute of Construction Design, Industrial and Health Care Building (IKE), TU Braunschweig The Institute of Construction Design, Industrial and Health Care Building, which acted as project coordinator, has developed over the past ten years into a leading centre for teaching and research into healthcare building design in Germany. With its interdisciplinary research team of experts from the fields of architecture, process design and hygiene, it addresses the complex challenges of sustainable hospital construction. A focal area is the planning of infrastructural requirements for optimal patient care and the process-optimisation of staff workflows. A specialisation in the field of healthcare building is the prevention of infection transmission through building design. This encompasses both construction and design aspects, for example the choice of materials or the design of junctions between components and built elements. Ways of optimising processes within hospitals using design means is a further aspect, for example through the organisation of the ward floor plan or operational processes in the hospital or patient room. The Institute takes an interdisciplinary approach, working together with other research institutes at the TU Braunschweig and with other nationally and internationally recognised institutions. Institute for Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin The Institute for Hygiene and Environmental Medicine is a further association partner and concentrates on the aspect of infection prevention among patients at the Charité – Universitätsmedizin Berlin. At the same

171

Architecture of the Patient Room

The research objectives were divided into five research phases → Fig. 1 in which all the project partners were involved: Phase 1: research and investigation Using a variety of different methods, the research team investigated the topic of infection prevention through design in the patient room. To this end, they visited clinics, observed activities in hospitals, and researched and analysed relevant literature and existing studies. They consulted experts as well as the various different users of patient rooms, asking them specific questions and documenting their findings. Phase 2: concept and design Based on the findings of the first phase, the team drew up a catalogue of requirements that should serve as the basis for the design of a two-bed patient room with wet cell designed to minimise infection transmission. From this, a design was elaborated for the patient room in ongoing consultation with all the project partners. The design also considered optimised designs for items in the room including a disinfectant dispenser, the bedside trolley and a concept for a bedside terminal with corresponding advisory content. Partners from industry were likewise consulted from an early stage to incorporate their expertise and recommendations, for example, on the choice of suitable materials and surfaces.

Phase 3: planning and construction Detailed working drawings for the construction of a prototype were developed in close cooperation with the project partners and partners from industry. As part of the process, various products, fittings and furnishings in the room were either optimised or developed further to improve their ability to control the spread of infection and to meet a demand for innovative equipment. A prototype patient room equipped with all the necessary supply lines was completed in January 2020 on the premises of the company Röhl in Waldbüttelbrunn. Phase 4: optimisation The optimisation phase was used to fine-tune decisions on colours and materials and to investigate ways to optimise the design details and the junctions between elements. The prototype was examined several times by the project team and the research and industry partners, and each planning decision was jointly evaluated. An important aspect was to evaluate how products that had been developed individually worked in the context of the room in order to optimise their handling. It was also possible to examine the construction process with a view to avoiding weak points arising through the installation process. Phase 5: evaluation The findings and experience gained from the prototype up to this point will be documented for future improvements to the prototype and for presentation to a wider specialist audience at the Charité site and as part of the World Health Summit (25–27 October 2020) in Berlin. Selected experts as well as relevant user groups from everyday clinical practice will also have the opportunity to assess the KARMIN patient room at the facility in terms of its suitability for use and infection prevention. Their responses will also feed into the evaluation of the newly created two-bed patient room with two wet cells and should provide useful insight into transferring the findings of the project into the practice of modern patient room planning and design.

1 The five research phases of the KARMIN project

1 RESEARCH + INVESTIGATION

172

Prototype

2 CONCEPT + DESIGN

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173

Architecture of the Patient Room

For the development as well as the detailed construction of the prototype for a two-bed room with wet cells designed to minimise infection transmission, the project team collaborated with experienced, motivated and innovative partners from industry. To be able to develop the best possible solutions for the project, 17 companies and manufacturers were selected according to various criteria based on the components in the patient room. The criteria ranged from the size of the product portfolio, the degree of experience in the healthcare sector and whether the company had their own research department. Each industry partner represents one of the components of the patient room and/or wet cell: — Windows — Doors — Door and window fittings — Walls/ceiling — Floor — Lighting/illumination — IT/communications — Furniture/furnishings/equipment — Patient bed/bedside cabinet — Disinfectant dispenser — Tap fittings — Sanitary objects — Bathroom equipment In contrast to traditional planning processes (as outlined in the architects' specification of works and fee structure) where companies bid for a tender based on a specification of works, the industry partners were involved in an ongoing basis in the concept development and design phases as well as in the detailed construction design planning. Involving the industry partners from such an early stage made it possible to draw on their respective expertise in each sub-area and to discuss and develop the best solutions in each case. In order to structure the work process in a meaningful way, four working groups were defined: Room, Furnishings, Bathroom and Objects → Fig. 2. Project partners and companies could work together to discuss interfaces between components and develop appropriate joint solutions, also in meetings with all working groups. Together with the research team from the TU Braunschweig, the company Röhl coordinated the realisation of the prototype at the Röhl site.

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(Abb. 12): „Expertenworkshop – Auswertung Defizitabfrage“

174

Prototype

Requirements for a Patient Room and Its Fittings A number of different methods were employed as part of the analytical study to identify relevant information, findings and evaluations of existing approaches to infection control in patient rooms. A first avenue of exploration was to examine relevant literature and existing scientific studies to obtain an overview of the complexities of designing a patient room. Aside from desk research, a period spent observing clinical practice at Braunschweig Hospital also provided first-hand insight into the intricacies of this design task. By accompanying hospital staff on site, we could observe care processes, study cleaning behaviour and identify the daily challenges facing the different user groups in a patient room. Following on from this, two workshops with various experts and users were conducted in March and April 2017 to define the most important focal points in the planning context. A typological examination of the floor plans of two-bed rooms studied the extent to which the design of the floor plan can positively influence factors supporting infection prevention in a patient room. Selected floor plan types were also critically assessed in practice as part of the clinic visits and their respective performance was discussed with operators and architects. The various findings and information derived from these different methods were then compiled as a catalogue of requirements that served as a basis for the concept and design phase as well as for the detailed design and construction planning → Fig. 3. Literature research on planning principles As part of the analytical study, the relevant norms and standards for infection prevention in the context of building design were collated and structured according to their importance in legislative norms, ordinances and guidelines produced by independent organisations. The German Infection Protection Act (IfSG) has been in force since 1 January 2001 and sets out regulations for the prevention and control of infectious diseases in humans. Its key areas of focus are measures for preventing the transmission of diseases to humans, the rapid detection of infections and the prevention of the spread of infections. The IfSG also provides the legal basis for the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI). The KRINKO publishes recommendations on hygiene-relevant topics such as the cleaning and disinfection of surfaces, best practices for handling patients with multi-resistant pathogens or the operational organisation of functional areas. These also include recommendations for the structural and functional design of hospitals such as minimum space requirements, the size of rooms and the location of hygienerelevant rooms, as well as the quality of materials. In terms of ordinances, the building regulations (for example the KhBetrVO), the hospital ordinances of various federal states and the drinking water ordinance are among the most important for the design of buildings. In addition to the general building regulations, six federal states (Brandenburg, Berlin, North Rhine-Westphalia, Saarland, Saxony-Anhalt, Schleswig-Holstein) have issued ordinances that deal specifically with requirements for hospitals.

Many of these regulations are based on the model hospital building regulations (KhBauVO) issued in 1976, which lay down guidelines for fire protection, hygiene, ventilation, lighting, room size and room layout. As the requirements for the construction and operation of healthcare buildings have changed over the decades, these regulations are no longer up to date and are in urgent need of revision, but they do still provide general orientation for hospital planners in Germany. Alongside norms and regulations, there are a large number of guidelines and recommendations issued by privately-run independent organisations, which have been drawn up by expert committees and provide specific instructions for action in the field of hygiene. Design services provided by architects are regulated by the latest version of the German HOAI (Official Scale of Fees for Services by Architects and Engineers), dated 17 July 2013. It defines architectural services for new buildings and conversion projects, along with the corresponding remuneration rates, and divides them into nine work phases that cover the various stages of a project’s design and realisation, from basic evaluation and planning permission to construction supervision and documentation. This breakdown assists hospital planners in de­termining at what points in the process building hygiene measures need to be considered. In terms of the design of hospitals, DIN 13080 specifies the division of the hospital into different functional areas and locations and the structuring of the respective floor areas according to their clinical purposes. Another norm relevant to hospital design is DIN 1946-4, which concerns air conditioning systems in buildings and rooms in the healthcare sector. The Association of German Engineers has published the VDI Guideline 6023 “Hygiene in drinking-water installations” and VDI Guideline 6022 “Ventilation and indoor-air quality” that likewise contain recommendations for hospital design and hygiene. Since 2013, an expert committee for sustainability in the construction and operation of hospitals has existed that also deals with the topic of hygiene, as well as a VDI expert committee for the “Management of hygiene-relevant surfaces in medical or care facilities”. The Association of the Scientific Medical Societies (AWMF) serves as an umbrella organisation for a total of 168 member societies, and issues recommendations for the respective fields. These are divided into four levels of relevance. Classification S1 (recommendations for action by expert groups) is of lower relevance and classification S3 (evidence- and consensus-based guidelines) is of highest relevance. The recommendations of the working group “Hygiene in Hospitals and Doctors’ Practices” are of relevance to the design and function of healthcare facilities. On-site observation in clinic environments In order to gain insight into the processes on a normal care ward, the KARMIN project team accompanied nursing staff during their daily routine of caring for patients as well as cleaning staff on two wards of the nephrology department over a two-day period at Braunschweig Hospital. Conversations and interviews conducted on site aimed to identify hygiene-critical areas from the perspective of hospital staff and from these to derive measures relevant for planning. Input from the staff served, among other things, as a basis for defining the criteria by which to conduct the typological evaluation of patient rooms. These were also discussed in two workshops with a broad range of experts, not least to verify their transferability to other contexts.

175

Architecture of the Patient Room

Typological evaluation of two-bed floor plans As presented in detail in the section → Typological Evaluation, p. 44–63, the team undertook a systematic examination of different patient room floor plans of two-bed rooms in general care hospitals in national and international institutions. The study looked at numerous design aspects evaluated according to different categories, including structural complexity, infection-prevention potential, workplace quality and safety, spatial quality, patient safety, patient satisfaction and privacy. The result was an overview of two-bed patient room floor plans and their spatial dependencies, which influence the corresponding qualities. Some of these floor plans were then selected as the basis for the survey conducted with experts. Workshops with experts Two workshops with experts were held at the TU Braunschweig. The two workshops, which both followed the same pattern, served as a platform for interdisciplinary exchange with the aim of identifying hygiene-­critical areas in the patient room and wet cell and discussing appropriate design strategies for infection prevention in hospital environments. A total of 23 experts from different disciplines – hospital planners, nursing staff, cleaning staff, hygienists and “patients”, the latter represented by students and university staff – were selected and invited to contribute their views. Among others, staff from Braunschweig Hospital, Hanover Medical School and the University Hospital in Göttingen took part. Deficits analysis The first part of the workshop constituted a deficits analysis in which participants were invited to note their answers to the question “Where do you see the greatest deficits in hygiene in patient rooms and wet rooms in terms of construction, process, regulations, etc.?” on a defined number of cards. The answers were then collected, clustered and assigned to topic headings. In addition, all participants could use adhesive dots to indicate the relevance of the respective issue to the topic of infection prevention → Fig. 5. Evaluating the results → Fig. 4 identified two key subject areas of most relevance to hygiene deficits in the patient room: the spatial arrangement, and fittings and equipment in the patient room and wet cell. Other major challenges cited were the processes in nursing care, insufficient information for patients and visitors, the often inappropriate positioning of the disinfectant dispenser, supplies and waste disposal, standards of cleaning and disinfection and the shared use of the bathroom. Topics of lesser importance that were also raised included the arrangement of the ward, a lack of automation for contactless operation of items such as WC flushing, and the planning process. Aspects pertaining to the arrangement of the room included the placement of beds next to each other, excessively small patient rooms and wet cells, no clearly separated zones, and insufficient space between the beds and other furniture and furnishings. In terms of fittings and equipment, factors such as contact surfaces of the equipment, room textiles such as curtains, surfaces that are not easy to clean and insufficient storage and work surfaces for nursing staff were also identified. These deficits provide an indication of possible relevant hygiene-critical factors.

5 Evaluation of subject areas as part of the workshop with experts

1

2

6 A survey of different floor plan types (1 : 200) for twobed patient rooms. A common aspect of the three most favoured floor plans (1, 2, 3) is the arrangement of the Abb.: 13 „Grundrissvarianten Zweibettzimmer – Auswertung Abfrage Grundrisstypen“ beds opposite, at an angle or offset opposite each other.

176

Prototype

3

Evaluation of floor plan types In the second part of the workshop, the participants were asked to select three favourites from a selection of eleven two-bed patient room floor plans. The selection of the eleven floor plan types represents different possible spatial configurations of the patient room and wet cell → Fig. 6. The floor plans differ, among other things, in their room geometry, the position of the beds in relation to each other, the alignment of the beds to the façade and the entrance, and the number of wet rooms and their equipment and possible uses. The aim was to obtain an expert assessment on which spatial floor plan configurations or aspects thereof can have a positive effect on the prevention of infection transmission. The floor plan that was rated most positively → Fig. 6, No. 1 has the beds placed not next to each other, two wet cells and an equal relationship between the bed areas and the façade and entrance. The three most frequently mentioned floor plans all have the beds arranged opposite, orthogonally or offset to each other.

these individual methods, five main categories were defined: structural complexity, infection prevention potential, workplace quality and safety, spatial quality, and patient safety, patient satisfaction and privacy. The findings obtained through the various methods were then assigned to these categories. To determine the relevance of the respective findings, three further hierarchical evaluation categories were used. — Category I – “must” — Category II – “shall” — Category III – “may” Category I corresponds to high-level legislation and building regulations that must be implemented in the planning. Category II describes, among other things, planning recommendations set out by independent organisations such as DIN standards. Category III includes, for example, recommendations by experts. The resulting catalogue of requirements in the different categories was then used as a basis for deriving design principles.

Ideal floor plan patient room In the final assignment of the workshop, we asked the experts to sketch an “ideal floor plan” of a two-bed patient room. The floor plan could include furnishings and fittings that they considered ideal and they were free to add relevant details in writing. To this end, mixed groups of experts were formed to bring in different expert opinions. A series of idealised proposals were developed, presented and then discussed among the group in the workshop.

Material testing as a basis for planning

Survey 65 + In the workshop with experts, the patient user group was represented by students and university staff. To obtain a better picture of the majority of patients in everyday hospital situations, a survey was also conducted with people over 65 years of age. Of particular interest was to identify deficits and evaluate different floor plans. These results augmented the evaluation of the workshops with experts. Hospital visits Based on the results of the typological study and the workshops with experts, three clinics in Germany were selected that feature patient rooms and nursing wards with specific hygiene-relevant aspects, both in their layout and design, and in their hospital processes. The team examined these aspects as part of visits to the clinics and spoke with clinic staff and planners. One of the clinic wards features two-bed patient rooms with two identical wet cells, one for each patient. In on-site conversations with hygiene specialists, the planning department and caregivers, the team were able to discuss the relative advantages and disadvantages of this structural solution. Another clinic featured identical two-bed patient rooms with a same-handed arrangement. Here, too, the respective factors favouring this arrangement were discussed with the architecture office responsible for the hospital design.

Catalogue of requirements for the patient room and wet cell A catalogue of requirements was developed to assimilate and give order to all the information acquired in the analytical study, with the aim of deriving concrete planning-relevant requirements for the concept and design phase. In a first step, all the investigative methods such as the workshops with experts and on-site observation of everyday clinical practice → Fig. 3 were listed. To structure the information gathered through

177

Architecture of the Patient Room

Suitable surfaces and products were researched for each of the areas and aspects of the room prototype – the walls, floors, patient bed, fittings and equipment, doors, and door and window hardware. The project’s industry partners were asked to test at least five material samples for cleanability in their respective area of responsibility within the patient room or wet cell. The assumption is that the surface properties and the type of soiling or contamination influence the ease of cleaning. The tests were carried out by the Institute of Building Materials, Concrete Construction and Fire Safety at the Technical University of Braunschweig. The sequence for the test setup for simulating cleaning was as follows: a. Defined degree of contamination, b. Cleaning with a linear wiping simulator, c. Quantification of residual contamination using a particle counter with surface sensor. The testing procedure also included measuring roughness, surface free energy and cleanability for each material sample. The results of the material tests fed into the selection of materials, surfaces and decors in the subsequent phases of the design process. Often, several product ranges by a single manufacturer exhibited comparable results so that the designers were typically able to choose from between one and three products for each sub-aspect. Further information on material applications and material ageing can be found in the section on → Material applications, pp. 24–26.

Planning and Design Design concept

J

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D: Gleichwertige Bettplätze; E: Einsehbarkeit auf beide Patienten vom 7gegenüber; The key requirements for the room concept Eingangsbereich inkl. Übersichtlichkeit des Zimmers; F: Arbeits- und Lagerfläche Personal im Eingangsbereich; G: Fenster für optimale natürliche Belüftung; H: Zwei Nasszellen inkl. Dusche und barrierefrei; I: Optimierte Zonierung für Pflegeabläufe; J: Desinfektionsmittelspender sichtbar und in Nähe zum Patientenbett

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Prototype

The results of the analytical study were compiled, evaluated and hierarchically organised as a catalogue of requirements. From these, design principles were identified that could form the basis for the concept and design phase of the patient room. The requirements for the room relate directly to the floor plan configuration, while the requirements for fittings and equipment will be considered in a later planning phase. In design terms, the challenge was to configure a patient room that has a high spatial quality for the patient and the staff, facilitates optimal care provision and cleaning processes and embodies new approaches to infection prevention that are feasible for implementation in practice. In close cooperation with the research partners, the team defined the following structural, hygienic and procedural requirements → Fig. 7: — A. Patient rooms in additive arrangement — B. Compact design — C. Beds placed opposite one another — D. Equal-status bed positions — E. Both patients can be seen from the entrance area; clear room arrangement — F. Work and storage area for staff near the entrance — G. Windows for optimal natural ventilation — H. Two barrier-free bathrooms with showers — I. Optimised zoning for care processes — J. Clearly visible disinfectant dispenser close to the patient bed The following requirements were defined for fittings and equipment: — The formal design should facilitate optimal cleaning — Flush, integral fittings with few construction joints — Surface characteristics should be optimised for cleaning Three levels of consideration were defined for the subsequent design phase – “Room and layout”, “Components and joining” and “Surfaces and materials”. The design team, along with the project partners, used these as a means of approaching the design development over the following six months. Several variants were developed for each level of consideration and then discussed, evaluated and prioritised. For the first of these, “Room and layout”, three room concept proposals were elaborated, all of which meet the previously defined requirements → Figs. 9–11. In a subsequent project meeting, the project partners and industry partners were asked to select which of the variants they viewed as the most sensible and to justify their decision. Working in small groups, the participants presented their results using sketches and maps. From the ensuing evaluation, variant 1 was selected as the basis for further development → Fig. 9. In a second step, the participants also defined additional requirements for the next design phase: — Clear zoning and allocation of work areas to staff and the bathroom, and of cupboards to patients — One nurses’ work area per patient including disinfectant dispenser and storage/shelf space for staff — The disinfectant dispenser should be next to the nurses’ work area, positioned in the direction of the patient and visible from all parts of the patient room. — The bedside cabinet should be placeable on both sides of the patient bed.

8 Working model during the design process

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Architecture of the Patient Room

— A permanently installed bench at the window as seating for patients and visitors — The bathroom should be able to accommodate a sliding door to reduce risk of injury and improve clarity of the entrance situation. — A possibility for staff to store materials in the patient bathroom — Built-in storage in the wall zone between the bathroom and patient room — Bathrooms with different fittings Three concept proposals were likewise developed for the aspect of “Components and joining” and presented for discussion. These were based on layout variant 1 and the additional requirements identified. The overall room layout is therefore the same for the different variants with respect to the position of the bathrooms, the patient beds and the large window front. Here the means of accessing the wet rooms, the position and size of the nurses’ work area and the patient cupboards varied → Figs. 12–14. The three new room variants were again discussed as part of a project meeting to which, alongside the project partners, an interior designer and hospital planner were invited. The aim was to identify possible deficits in the concepts and to invite suggestions for improvements in the detailed design planning. Smaller group meetings were also held with the partners from industry, each concentrating on a specific aspect: the room, bathroom, fittings and objects. The objective was to identify crossover points and dependencies between the respective trades and to discuss possible detailed solutions and complicated junctions, joints or material transitions. Relevant products or product ranges were likewise discussed among the partners, as well as how existing products could be adapted or developed to meet the defined project requirements. Following the design meeting and smaller group meetings, variant 3 was selected for further development → Fig. 14. A new set of requirements was likewise elaborated for the equipment in the patient room: — Patient cupboard with clothes rail, fixed shelves and a lockable compartment, as well as push-to-open cupboard hinges for easier cleaning — Patient table surface slightly angled so that the patient’s sitting position is slightly rotated to improve the angle of view into the room and facilitate communication with visitors and the other patient. The table must be large enough to put down a food tray. — Visitor bench with wipable edges and removable, easy-to-clean cushions — One waste bin per patient located near to the nurses’ work area — A compartment for stowing suitcases — Patient bed (bed length 2.21 m) with maximum extension length of 2.51 m. It should be accessible from both sides without needing to move the bed or creating an impractical room depth. Space limitations should be addressed by controlling room occupancy, e.g. by pairing a long bed (2.51 m) with an average bed (2.21 m). For the bathroom position and equipment, the following requirements were proposed for the final design: — Sliding door arranged in front of the wall — Wall-mounted WC and waste bin for easier cleaning — Tiled floor and walls — Infrared mirrors — Folding support rails — Shelves for patient use — Waste bin — Placement of disinfectant dispenser not at the wash basin, but in a cupboard niche to avoid confusion between soap and disinfectant

10 Consideration “Room and layout” – Variant 2, 1 : 100

— Symmetrical arrangement

— Diagonal arrangement

— Bed placement opposite and at an angle

— Bed placement offset opposite each other

— Wet cells “inboard”

— Wet cells “inboard” and “outboard”

- Grundriss Patientenzimmer und Nasszellen nebeneinander - Bettposition gegenüber versetzt - Nasszelle innen- und außenliegend

- Grundriss verwinkelt - Bettposition gegenüber versetzt - Nasszelle innen- und außenliegend

- Grundriss symmetrisch - Bettposition gegenüber gedreht - Nasszellen innenliegend 9 Consideration “Room and layout” – Variant 1, 1 : 100

11 Consideration “Room and layout” – Variant 3, 1 : 100 — Patient room and wet cells next to  each other — Bed placement offset opposite each other — Wet cells “inboard” and “outboard”

- Pflegearbeitsbereich in der Erschließungszone - Nasszellenzugang von der Patientenbettseite - Pflegearbeitsbereich in Nähe zum Patientenbett und schräg angeschnitten - Patientenschrank neben Patiententisch an der Fassade 2 Consideration “Components and joining” – 13 Consideration “Components and joining” – - 1Nasszellenzugang seitlich vom Eingangsbereich Variant 1, 1 : 100 Variant 2, 1 : 100 - Patientenschrank neben Pflegearbeitsbereich — Nurses’ work area facing patient bed, — Nurses’ work area in the entrance area diagonal wall — Access to wet cells from the patient bed — Access to wet cells from the entrance area — Patient cupboard next to the nurses’ work  area

180

Prototype

— Patient cupboard next to patient desk near the window

- Pflegearbeitsbereich in Nähe zum Patientenbett 4 Consideration “Components and joining” – - 1Nasszellenzugang seitlich vom Eingangsbereich Variant 3, 1 : 100 - Patientenschrank neben Patiententisch an der Fassade — Nurses’ work area facing patient bed — Access to wet cells from the entrance area — Patient cupboard next to patient desk near the window

Patientenraum Same-handed

15 Patient room with wet cells in a same-handed arrangement

Final design

Regelgrundriss

Drei-Zonen-Plus

16 Standard floor plan

17 Three-zone plus room

Betten gegen-

18 Beds arranged opposite

Beide Patienten für Personal sichtbar

Bettplätze gleichwer-

19 Equal-status bed positions

20 Design principle: both patients visible to staff

Nasszellen innenlie-

21 Inboard wet cells

Zwei identische Nasszellen

22 Two identical wet cells

181

A design concept was also developed for the aspect “Surfaces and materials” based on the previously agreed design variant and other requirements → Colour and materials concept → pp. 183, 184. The results of the materials testing conducted at the iBMB (Institute of Building Materials, Concrete Construction and Fire Safety) at the Technical University of Braunschweig were also considered in the selection of materials and surfaces → Material applications, pp. 24–26.

Architecture of the Patient Room

Based on the analytical study and cross-partner evaluation and development of interdisciplinary approaches, an innovative design for an infection-prevention optimised patient room and accompanying wet cells was developed. The resulting prototypical concept takes numerous aspects into consideration including the structural layout, functional processes and pathways, detailed solutions, materiality and surfaces. Room layout and process The final floor plan is designed for additive repetition to create wards of identical patient rooms. The resulting treatment, nursing care and cleaning processes are therefore predictable and can be optimised in their choreography. Errors and omissions resulting from the need to adjust to new room configurations can therefore be avoided → Figs. 15, 16. The division of the patient room into three zones also promotes good hygiene practices: the so-called nursing zone is the area around the patient bed and next to the nurses’ work area that staff move around in; the patient zone is the patient bed and its immediate surroundings; and the lounge area for patients and visitors is on the outer wall alongside the window front with the patients’ wardrobes, desks and bench → Fig. 17. The floor plan is directly informed by the design principles discussed earlier: for example, the beds are arranged opposite each other, the bed positions are of equal status, and staff have good visibility of both patients. The room layout is symmetrical, so that each patient has half of the room with an identical arrangement of fittings and equipment. The principle of arranging the beds opposite each other marks a departure from the conventional layout of two beds arranged parallel next to each other → Fig. 18. This arrangement ensures that both patients have an equally good view of their surroundings → Fig. 19 and that staff can see both patients from the door area of the room and are able to monitor patients and react more quickly in the case of an emergency → Fig. 20. The position of the beds is intended to encourage hospital staff to more consciously disinfect their hands when caring for the patients. In addition, the head ends of the beds are further apart, reducing the risk of infection transmission between patients through physical proximity. The symmetrical division of the room and separate set of fittings per patient ensures that it is clear which items belong to which patient, thus avoiding unnecessary contact transmission. The same principle applies through the provision of two wet cells → Figs. 21, 22. A separate, wheelchair-accessible nurses’ work area for each patient with its own storage is likewise not just a help for the staff but encourages compliance with hand disinfection guidelines. Disinfectant dispensers are also located at the foot of each bed so that staff always have the opportunity to disinfect their hands as they walk past – either when entering the room or when switching from one patient to the other.

M1:100)

Innovative solutions in the final design A. Entrance area The entrance area widens towards the patient beds, making it simpler for nursing staff to glance inside and have an unobstructed view of the patient. On the right, a control panel allows staff to select different lighting scenarios to suit the situation. These simplify work processes for the staff. B. Care and work area A work area for nursing staff is located close to each bed. It incorporates storage and thus direct access to new medical materials and gloves, a disinfectant dispenser and safe waste disposal, grouping typical work processes in one place. 23 Floor plan of Grundriss the final design, 1 : 100 Finaler Entwurf (M1:100)

C. Wet cell Two wet cells, one for each patient, prevent usage scenarios where cross-contamination can potentially occur through shared contact surfaces. D. Visitor zone The visitor zone is a separate area combining the window bench, the patient desk and chair. The bench is raised on a plinth, the front side of which rises up from the floor to beneath the bench in a single smooth surface for easier cleaning. E. Bedside cabinet The new design of the KARMIN bedside trolley → pp. 224–229 facilitates better cleaning due to its seamless construction. It provides more stowage space without being larger than a conventional unit, with clearly defined areas for better organisation, and can be used from either side so that it can be positioned flexibly.

Finaler Entwurf Ansichten (M1:100)

F. Disinfectant dispenser The dispensers are placed along the routes of work processes and close to the respective patient bed. The newly developed KARMIN dispenser → pp. 210–223 can record usage levels and attribute these to specific user groups, making it possible for staff to assess compliance with hand hygiene guidelines in team meetings by evaluating usage statistics. G. Bedside terminal The bedside terminal → pp. 230–236 is the primary means of providing informative content to educate patients on hygiene behaviour so that they may actively contribute to infection prevention.

Finaler Entwurf Ansichten (M1:100)

24 Interior elevations of the final design, 1 : 100

182

Prototype

Colour and materials concept

25 Colour and material selection

The colour and design concept of a patient room contributes significantly to the quality of a stay in hospital and thus also to the patient’s well-­ being during their period of treatment. The interior design of healthcare environments has undergone a shift towards improving patient comfort by creating a more hotel-like atmosphere. Other factors such as the quality of the air and of light, as well as a visual connection to the world outdoors, have also been given increased attention in recent years. The approach of Healing Architecture considers how the design of the environment affects physical and mental well-being. Factors that contribute to a positive environment can be conducive to the recovery of patients, and at the same time contribute to staff satisfaction in the workplace. For the KARMIN project, the team needed to develop a design concept that is uniform and appealing but also compatible with the principles of infection prevention. An essential aspect in this respect is the good cleanability of surfaces. As such, colours were needed that make it easy to see coarse soiling or to detect when a surface has not been sufficiently wiped clean. Colours can therefore contribute indirectly to promoting compliance with cleaning procedures in patient rooms. The planned fittings have the advantage that one can match colour surfaces to one another more easily than with mass-produced furniture where only selected designs and decors are usually available. Surfaces that are intensively used or touched frequently should not have uneven textures and should have solid colours to make it easier to detect contamination. The use of comparatively inexpensive materials also means that these benefit all patients, and not just those in better-equipped private health insurance rooms. Three potential colour schemes were developed for the final design of the patient room, each with a different theme. As numerous different combinations are possible within each theme, a 3D model was built to simulate colour and material combinations. The following variants illustrate an example for each of the key themes. “Clean” theme with a contrasting colour The “clean” theme presents a neat and tidy overall impression comprised predominantly of light colours, especially white and grey tones along with a contrasting accent colour on selected surfaces. The colour accents not only lifts the mood of the room but can be used to demarcate areas of the floor, for example to aid movement and orientation, which is helpful for the mobility of older patients in particular → Fig. 26. “Two colour zone” theme In this variant, two different colours are used to denote how room zones, fittings and equipment are allocated to each of the two bed locations, and thus the patients. Two contrasting colours are proposed to ensure they can be told apart, especially for patients with sight impairments. A central aspect of this theme is to aid older patients and/or patients with dementia in recognising their own room zone and associated areas and items in the room. Colour coding can also reduce the frequency with which surfaces are touched by both patients or confusion between items in the rooms, which can also apply to younger or sedated patients, both of which help to reduce the incidence of contact infection transmissions → Fig. 27. “Atmospheric” theme This theme employs colours and decors that are harmonious and, in their combination, lend the patient room a pleasant and inviting atmosphere for patients and their visitors → Fig. 28.

183

Architecture of the Patient Room

26 Rendering of the patient room: “Clean” theme with a contrasting colour

27 Rendering of the patient room with two colour zones

The final colour scheme Although the 3D model was helpful as a tool for simulating different colour schemes, examining actual colour and material samples was essential when determining the colour concept. Samples were obtained for all surfaces, from the flooring to the sides of the patient bed to bathroom tiles. The final colour concept is a combination of the “Clean” and “Atmospheric” themes shown in → Fig. 29. As infection prevention is the primary focus of the project, the colour choices must create an impression of cleanliness expected of a clinic environment. For this reason, the proportionally largest surfaces of the room – ceiling and walls – have been painted white. The nurses’ work area, including the worktop and push-to-open cupboards, are likewise white to ensure contamination is immediately visible. A cool blue is used as the contrasting colour. To address the aspect of patient well-being – a parallel aim of the design concept – warm colour accents in the form of brown tones and wood decor were chosen for the patient and visitor zone. In combination with warm grey tones, the overall result is a colour-coordinated and harmonious colour concept → Fig. 25. Surfaces in the patient room For the majority of surfaces in the patient room, high-pressure laminate (HPL) was used: it is easy to wipe clean and tests conducted in advance showed that it is resistant to erosion through disinfectants. HPL is used for all cupboard and work surfaces, for the impact protection wall cladding and the window benches. For the room design, this also made it possible to coordinate colours and decors more easily rather than having to select colours from different product catalogues. Similarly, the colour concept for the KARMIN patient room can be varied as needed by selecting from the broad range of colours available for HPL surfaces. A rubber flooring was chosen for the floor as it is a natural product that requires no chemical sealing and is thus emission-free. Fittings in the patient bathroom The decision to include two identical but independent wet cells in the KARMIN patient room made it possible to trial different surfaces in the prototype. While one bathroom is completely tiled, the other is clad with HPL panels. As the cleaning tests revealed that both surfaces are equally suitable, the prototype can be used to compare them directly in practice. The same principle was used to test differing degrees of automation in the patient bathroom: one bathroom has an elbow-operable single lever mixer tap while the other is equipped with an automatic motion sensor tap.

28 Rendering of the patient room: “Atmospheric” theme

184

Prototype

Lighting concept

29 Rendering of the patient room with the final design and colour concept

The importance of light Light is a vital part of human life. The changing light conditions determine the rhythm of the day and seasons, influence our hormonal balance and contribute to the formation of important vitamins. Light has an effect on our physical and mental health and thus on the process of recovery. Good lighting is also essential for nursing care procedures, for example to correctly place a needle for an injection or to recognise a clinical picture based on how the patient looks. Sufficient lighting is also needed for cleaning to ensure contamination can be seen, which is essential for the prevention of infection. By the same token, inadequate lighting can lead to people feeling downcast or to blunders. Lighting in normal care wards should support a general impression of cleanliness but also be pleasant enough to feel homely and thus positively connotated. Bright and colourful room interiors elevate the patients’ sense of well-being in the sometimes rather dreary daily routine of being in hospital. Natural light is preferable to artificial light. The arrangement of fittings, windows and ultimately the shape of the floor plan should therefore be coordinated with the type, positioning and number of lamps during the planning stage. While the designer is largely able to use their discretion, lighting design must also comply with certain standards. A “smart” patient room can employ sensors to automatically create lighting situations that react to specific circumstances. For example, the bed used in the KARMIN patient room triggers underbed lighting when it detects a shift in weight. Manual controls, on the other hand, when used by many people, bear the risk of cross-contamination as a shared contact surface. As such, any lighting scheme must reflect the importance of light for well-being and the usage scenarios and needs of the different groups of people within a patient room. In addition, it should be as contactless and individually controllable as possible. Requirements To do justice to the importance of light, a multitude of requirements must be met. These are both determined by existing standards and the individual situation of the room to be designed. In general, a pleasant atmosphere can be achieved using indirect lighting providing light levels of at least 100 lux and warm white light (DIN 5035-3). Changing requirements at different times of day To determine the specific lighting requirements, it is useful to define usage scenarios and lighting situations. The changing incidence of natural light and the various activities of the different groups of people within a patient room, along with their varying frequency of use, result in a large number of different possible lighting scenarios over the course of the day. The following activities should be considered: — Daily cleaning — Room cleaning between patient occupancies — Nursing care at the bedside — Preparatory work at the nurses’ work area — Accessing the nurses’ cupboard — Doctors’ rounds and examination — Visitors — Reading — Personal hygiene — Toilet use — Rest and recuperation — Dressing/undressing at the patient cupboard

185

Architecture of the Patient Room

— Eating — Sleeping — Night-time orientation These scenarios relate to specific zones in the room and in the wet cells and require lighting of varying intensity and orientation. In some cases, the situations mentioned above are already covered by existing standards.

1000 mm 800 mm

75° Reading height Examination height 1100 mm 850 mm

30 Norm dimensions for reading and examination heights

6

4

5

7

9

8 4

5 7

2

3 20

21

12

2 10

13

11

1

19

17 15

14 1

31 Position of the light sources (blue) and control units (orange) 1 Overall lighting control panel 2, 3 Switch for lighting strip above the worktops 4, 5 Bedside terminal with interface for patient’s selection of lighting scenario 6, 7 Switch for reading light above the patient’s tables 1–3 Large, flat tunable white LEDs 4, 5 Reading light above the patient’s table 6, 7 Reading light above the patient’s bed 8, 9 Continuous lighting strip providing indirect lighting 10, 11 Concealed lighting strip above the worktop 12, 13 Lighting strip in skirting rail for orientation at night 14, 15 Light above the WC 16, 17 Central ceiling light bathroom 18, 19 Vertical lighting strip by the mirrors 20, 21 Lighting beneath the bed

Prototype

3 18

16

186

6

Standards DIN 5035-3 and DIN EN 12464-1 are the relevant norms governing lighting. They set out suitable lighting situations not just for patients but also for the occupational health and safety of staff, and address some of the scenarios mentioned above. For example, bedridden patients must not be exposed to constant direct glare by limiting the average luminance of the luminaires visible from the bed to 1000 candelas per square metre. Similarly, indirect lighting illuminating a ceiling should not cause the ceiling to exceed a brightness of 500 candelas per square metre. Each patient bed should be provided with a reading lamp providing a localised brightness of at least 300 lux at reading height. They should be individually switchable to avoid disturbing the room neighbour in a multi-bed room → Fig. 30. At night, however, the requirements are completely different. Both nurses and patients need a sufficient level of light to be able to find their way in the dark. At the same time, such light should not wake any other patients in the room. To provide orientation, concealed LED lighting with a wide beam can be mounted to illuminate the floor beneath the bed and near the door so that other sleeping patients are not exposed to the light source. A certain level of night lighting is also required to assure nursing staff can quickly appraise the room and conduct any necessary simple tasks. A light level of 5 lux at a height of 0.85 m above the floor is sufficient. During the day, the examination height and the nurses’ work area should be illuminated as evenly as possible at a light intensity of at least 300 lux. Brighter levels of at least 1000 lux are only required in the case of emergencies, or detailed examinations and treatments. Variances in the uniformity of illumination should not exceed a minimum ratio of 1 : 2 between the highest and average illuminance (Licht.Wissen 07, 2013). Additional requirements Alongside norms and standards, the various light scenarios described above have additional requirements. The principle of Human Centric Lighting (HCL) can be applied to create a pleasant, healing environment in which lighting is specially tailored to supporting people and their sense of well-being. Humans, as biological beings, are used to daylight in its different forms and to the diurnal rhythm of day and night. The biological effect of light on our body clock and psyche is fundamental: the melanopic, non-visual effect of light can have an activating effect and strengthen recovery and general well-being. By contrast, the visual, atmospheric effect can evoke emotions ranging from discomfort to a sense of security or confidence. As room neighbours may have different needs at the same time, the lighting design should also be able to accommodate conflicting lighting requirements. It should, for example, be possible to darken one half of the room while allowing a second patient to switch on a reading light at the same time without causing glare. Targeted lighting can also help demented or fatigued patients find their way around but also discourage them from undertaking un­­ desirable activities. Good lighting is also vital for hospital staff to ensure they can carry out their work correctly without making errors due to poor visibility.

Sufficient illumination is essential for diagnostics and nursing care, and care staff need to be able to see the colour of the patient’s skin without it being falsified by low light levels or coloured reflections from the walls. Green hospital walls are inadvisable, and warm-white lighting should be avoided during the doctors’ rounds. Dazzling caused by reflections from screens should be avoided as it can lead to premature tiredness. Various measures can help reduce reflected glare: — Dimmable lighting — Correct arrangement of the screens in relation to lamps and windows — Shading option for windows and skylights — Use of glare-free lamps — Luminaires with large luminous surfaces but low luminance — Non-reflective surface finishes (matt surfaces) for underlays and work surfaces, etc. — Careful alignment of lamps in relation to the direction of vision — Similarly, the corners of rooms or inaccessible or covered areas must also be well lit to ensure they are properly cleaned. Lighting controls Lighting controls should allow patients and staff to quickly and intuitively activate the appropriate lighting profile for their needs. They need to consider that staff may have their hands full or a patient may be too exhausted or physically impaired to operate a light switch. Similarly, having to press a switch, and thus a contact surface, in the middle of a work process makes it hard to comply with the five moments for hand disinfection. Light switches should be touched by as few people as possible, and for this reason sensors can be a good alternative. By placing switches near the patient and near the entrance to the room, different users can set the desired lighting mode directly and joint use of the same switch is avoided. Lighting controls equipped with mid-range RFID readers can also respond to staff or patients wearing an appropriate RFID chip, changing the lighting profile when people arrive at or leave the room. Lighting operation To operate the lights, the two primary user groups, the nursing staff and the patients, are each assigned a respective lighting control point at the room entrance and at the patient bed that allow them to select specific lighting scenarios. At the entrance, staff can switch on the ceiling light and the light above the worktop of the nurses’ work area. To assist patients at night in unfamiliar surroundings, sensors are used so that patients do not have to search for a switch or a menu item on a touch panel: a weight sensor at the bed automatically activates orientation lighting. The programming logic of lighting scenarios has to be considered carefully to avoid lighting scenarios switching in mid-activity, leaving patients in the dark at night or interrupting nursing procedures. Automatic control systems have advantages for motor-impaired patients but are less adaptable to specific situations, as sensor technology is not able to interpret the actual situation in the room. Consequently, the lighting in the KARMIN patient room must be switched off manually. Lighting concept and implementation in the KARMIN patient room The lighting of the KARMIN patient room is designed to accommodate the diverse needs of the different user groups. To begin with, the large windows of the room provide as much natural light as possible along with views outside, both of which are beneficial to patient recovery by relating them physically to the world outside and time of day. The

187

Architecture of the Patient Room

inboard arrangement of the wet cells and the placement of the beds parallel to the façade also maximises the incidence of natural light on the beds. The lighting concept also reinforces the zoning of the room, accentuating and delimiting the patient area, the nurses’ work area, the visitors’ zone and the two wet cells. In certain situations, such as for nighttime orientation, the concept shifts so that the light guides patients to the wet cell and back, bridging rather than delimiting the zones. Positioning and selection of light sources Altogether, 21 different light sources and several control units have been installed in the KARMIN patient room → Fig. 31. The three large, flat surface lamps → Fig. 31, Nos. 1–3 are useful for extensive illumination during the doctors’ rounds and during cleaning. The white balance of the LEDs is tunable, making it possible to simulate the colour temperatures of daylight, which are important for Human Centric Lighting, and to promote the patient’s sleep rhythm → Figs. 32–36. They can be individually controlled and radiate directly and indirectly through a broad flat panel and an outer, offset RGB colour ring. These three lights also zone the room into an entrance area and two patient areas. The three ceiling lights change the mood of the room over the course of the day from morning to night when orientation lighting takes over. During the day, the luminaires are switched on by default but can also be switched off if desired. Each patient area is also indirectly illuminated by a long, continuous lighting strip → Fig. 31, Nos. 8, 9 in the wall panel at the head end of the bed that both visually underlines the depth of the room and delimits the extent of the patient zone. Two reading lights above each of the patient beds provide the requisite illumination at the reading plane­ → Fig. 31, Nos. 6, 7, and a further reading light is installed above each of the patients’ desks → Fig. 31, Nos. 4, 5 next to the window → Fig. 37. Below the nurses’ work area, a light-deflecting aluminium skirting rail has been installed that illuminates the floor along the wall → Fig. 31, Nos. 12, 13. A sensor detects when a patient gets up from the bed and automatically activates the lighting strip at night → Fig. 31, Nos. 20, 21, which shines from the skirting rail onto the floor, illuminating the path to the bathroom where the light is on but dimmed. As both the under-bed and skirting light are at a very low level, they disturb the neighbouring patient as little as possible. Its warm-white colour avoids stimulating the patient too much, so that they can get back to sleep after visiting the toilet → Fig. 38. A second dimmed lighting strip above the nurses’ work surface provides even illumination of the worktop for the nursing staff to carry out their work → Fig. 31, Nos. 10, 11. A central ceiling light → Fig. 31, Nos. 16, 17 and a light above the respective WC → Fig. 31, Nos. 14, 15 illuminate each bathroom and vertical lighting strips illuminate the mirrors → Fig. 31, Nos. 18, 19. The matt-white surface of the HPL panels lining the wet rooms disperses light evenly without dazzling. The mirrored arrangement of the lighting on both sides of the room means that each patient or work area can be illuminated individually without affecting the other patient. This makes the room better able to respond to the needs and well-being of the individual patients and improves the quality of a multi-bed room. Control panel, bedside terminal, switches and sensors In normal use, the room lighting follows the course of the day. For specific application situations and visual tasks, different scenarios have been developed → Fig. 39. The settings for all luminaires can be saved in

32 Morning lighting scheme

33 Lighting scheme for doctors’ rounds

34 Midday lighting scheme

35 Evening lighting scheme

36 Night-time lighting scheme

37 The patient area with ceiling and reading light above the bed and patient desk, as well as a light strip in the head panel

188

Prototype

preset scenarios that govern which areas are illuminated at what level of intensity and colour temperature. While the scenarios switch multiple luminaires at once, specific lamps can still be switched on individually. The lighting scenarios can be selected from a control panel at the room entrance and the patient’s bedside terminal: the control panel at the entrance includes scenarios for nursing and medical staff, cleaning staff as well as visitors and patients, while the bedside terminal provides only patient-specific scenarios. For ease of use, the scenarios have been named in the control panel and are also shown with additional pictograms on the bedside terminal. The reading lights above the two patient desks next to the window can be switched on and off manually via a switch, as can the light above the respective nurses’ work area. A motion detector activates the light in the bathroom. The exact settings, including which lights are switched on at which level of intensity and colour temperature, are shown in the table in → Fig. 39. The lighting of the KARMIN patient room conforms to the norms and ensures that specific groups of users have the necessary lighting, whether temporarily or in general. It supports staff in their activities and ensures patients have a pleasant room environment over the course of the day.

38 The bed sensor triggers the night-time orientation light.

189

Architecture of the Patient Room

39 The different light scenarios of the KARMIN patient room. The intensity is the percentage dimming level of the ­maximum luminous intensity of the lamp, i.e. 100 % stands for full brightness.

Scenario

Lamp

Intensity

Colour temperature

Rounds

1|2|3

100 %

5000 K

10 | 11

100 %

5000 K

8|9

50 %

1|2|3

100 %

4000 K

4|5

100 %

4000 K

14 | 15 | 16 | 17 | 18 | 19

100 %

4000 K

General daytime lighting (HCL function)

2 | 3 (only inner panel)

100 %

variable

8|9

100 %

variable

1

60 %

variable

Night-lighting right patient

1

40 %

3000 K

11

40 %

individually settable

6

40 %

separately settable via bedside terminal

1

40 %

3000 K

10

40 %

individually settable

7

40 %

separately settable via bedside terminal

13 socket

10 %

2700 K

21 bed

100 %

14

10 %

2700 K

12 socket

10 %

2700 K

20 bed

100 %

15

10 %

6|8

individually

1|3|5|8

settable

Cleaning

Night-lighting left patient

Night bed sensor right patient

Night bed sensor left patient

Bedside terminal right patient

2700 K

3000 K

60 % Bedside terminal left patient

7|9

individually

1|2|4|9

settable

3000 K

60 % Bathroom motion sensor right patient

14 | 18

100 %

17

separate switch

Bathroom motion sensor left patient

15 | 19

100 %

16

separate switch

190

Prototype

3000 K

3000 K

Detailed planning The detailed design planning took the final design concept as its basis and incorporates not only the high-level requirements for the room fittings and equipment → Requirements, pp. 174–177, but also relevant planning requirements derived from practical experience. This stage of the planning process strove to find solutions to construction details that ensure a high quality of design → Fig. 40 and minimise component joints for optimal cleaning. The work was undertaken in close cooperation with all the partners involved and across the disciplines → Work Process and the Project Team, pp. 171–173.

40 View of one patient area of the room

Design requirements A design vocabulary was developed for the fittings and equipment that focussed in detail on optimising the ease of cleaning the items. The furnishings are designed to be as flush as possible with minimum construction joints. The materials and surfaces were selected based on the preceding material investigations → Material testing, p. 177 to facilitate and support easy cleaning in the long term. Surfaces with coatings more prone to wear and tear were deliberately avoided to avert the incidence of room closures for maintenance and upkeep. Planning requirements The design of the floor plan adheres to planning recommendations and DIN standards relevant to the design of hospitals and patient rooms, for example with respect to required distances between items in the room, or freedom of movement in barrier-free bathrooms. The resulting patient room has two wet cells each observing the required minimum dimensions for patient room bathrooms.

41 The nurses’ work area provides space for preparing treatments.

Sizes, distances and dimensional dependencies The patient room has 25.2 m² and the two wet rooms are each 3.7 m² in size. The lateral distance between the patient beds and furniture or fittings (bed to patient wardrobe and bed to nurses’ cupboard) is 90 cm. The distance between the patient beds was defined according to two occupancy scenarios: — A. Occupancy with two average-sized patients – bed length 2.21 m, with a passage width between them of 1.20 m. — B. Occupancy of one average and one above-average sized patient – bed lengths 2.21 m and 2.51 m, with a passage width of 90 cm. The width of the passage between the beds must be measured as the distance between the disinfectant dispensers mounted at the foot end of each bed. The room layout ensures a minimum width of 90 cm, as required for doors, for example, with one above-average sized patient. The wet cells are designed for barrier-free access in accordance with DIN 18040-2. For this, an area of free movement of 1.20 m in diameter is required in front of the various sanitaryware in the bathroom. The washbasin, the storage compartments and the shower rails are installed at a height of 85 cm. The nurses’ work area The challenge when designing the nurses’ work area next to each patient bed was to provide all the necessary facilities for nurses and medical staff to prepare necessary treatments while affording the patients the maximum possible sense of space. The nurses’ work area is a single spatial unit comprising a fitted cupboard and worktop. A disinfectant dispenser is mounted on the wall above the work surface and faces into the room → Fig. 41. The nurses’ cupboard includes compartments for storing necessary medical materials, a glove dispenser and a waste bin for disposing of used

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Architecture of the Patient Room

192 cm

1 292 cm

2 3

4 44 Nurses‘ cupboard

90 cm

5

10 cm

6

7

8

42 Section through the nurses’ work area and wall to the bathroom, 1 : 20 Schnitt Arbeitsfläche Maßstab 1:20cupboard: chipboard 19.6 mm – HPL surface 1 Nurses’ 2 Workplace lighting: aluminium profile with LED strip

1 Pflegeschrank: Spanplatte 19,6 mm - HPL Oberfläche Reach-through slot for Aluminiumprofil disposable gloves 2 3 Arbeitsplatzbeleuchtung: mit LED-Band Worktop: 38.6 mm – HPL surface fürchipboard Einmalhandschuhe 3 4 Durchgriff 4 5 Arbeitsfläche: mm– -HPL HPL-Oberfläche Back panel: Spanplatte chipboard 38,6 24 mm surface 5 6Rückwand: Spanplatte 24 mm - HPL-Oberfläche Wall covering – bathroom 1: tiles, 9 mm – bathroom 2: HPL board, waterproof 6 Wandbelag Bad 1: Fliese 9 mm, Bad 2: Spa-Styling-Board Skirting lighting: aluminium profile rail with LED strip Aluminiumprofilschiene mit LED-Band 7 7Sockelbeleuchtung: Concave skirting board: rubber, 8 8Hohlkehlsockelleiste: Kautschuk, h= height 100 mm100 mm 9 Korpus Pflegematerial 10 Patientenablage: HPL-Kompaktplatte 8mm 11 Korpus Boxen Einmalhandschuhe 12 Abwurfklappe Entsorgung: HPL-Kompaktplatte 8 mm 13 Abwurfführung: Edelstahlblech gekantet 14 Korpus Entsorgung, Öffnung elektromechanisch 5 6 15 Mülleimer

7 8

43 Detail of skirting lighting, 1 : 5

Detail Sockelbeleuchtung Maßstab 1:5

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Prototype

45 Waste bin integrated into nurses‘ cupboard and accessible from patient room and bathroom

items. The glove dispensers are accessible from slots on the cupboard sidewall adjoining the worktop. Push-to-open cupboard fittings have been used throughout to create an even visual appearance and a smooth surface for cleaning as there are no protruding knobs or recesses in or around which dirt can gather → Fig. 44. The cupboard is integrated into the bathroom wall and its depth is designed so that the reverse side serves as recessed shelving for the patient in the bathroom → Fig. 55. A disinfectant dispenser and waste flap are integrated into the recess on the bathroom side → Fig. 47. The waste bin in the nurses’ cupboard is accessed via a push-to-open fitting. Waste from the patient room and from the bathroom is deposited in the same bin. The position of the disinfectant dispenser to one side in the bathroom recess avoids it being confused with the soap dispenser. The edge of the work surface follows the splayed line of the bathroom wall and has a rounded corner to prevent any risk of injury. A flush-mounted recessed wall luminaire is mounted above the worktop with a concealed, downward-facing LED lighting strip to illuminate the work area in accordance with statutory requirements → Fig. 42, No. 2. In addition, a similar recessed aluminium profile with an LED lighting strip is flush-mounted at the base of the wall and serves as night-time orientation lighting → Fig. 43, No. 7. The rubber flooring is turned up at the edges with a curved floor-to-wall junction rising 10 cm above the floor. In places where fittings project forward, such as between the cupboard and floor or the bench and floor, the floor turns up to meet a plinth construction, resulting in a seamless transition from floor to wall for easier cleaning → Figs. 42, 43, No. 8. The visitor and patient area The visitor and patient area encompasses the window bench, a desk for the patient and a wardrobe for the patient’s belonging. Arranged alongside the window front, and mirrored on both sides of the room, it offers a direct view of the world outside → Fig. 48. It has to accommodate different dimensions in a single spatial unit – the seating and table heights and the table and wardrobe widths and depths – while also maintaining a sensible distance to the beds. The windows also need to be openable for natural ventilation, but people should not be able to fall out of the window. The chair is the only movable element in this area, a conscious decision so that as little as possible needs moving to clean the room. The window bench, the patient desks and the patient wardrobes form a single fitted unit with the wardrobes placed at either end in front of the external wall and the seating below the large window to ensure maximum natural illumination and an unobstructed view of the world outside. The window is divided into fixed glazed sections behind the visitors’ bench and opening casements in front of the desks. To protect against people falling out of the window, two variants were chosen for patient use: the first is a side-hung window with an opening limiter decouplable by means of a handle, the second a “tilt and turn” window with an assistive handle to ensure the window is operable by people with reduced strength. In both variants, patients cannot open the window completely. This is only possible with an appropriate key. The bench has a total width of 2.57 m. The base of the bench is approx. 40 mm thick and is covered by an upholstered seat cushion. It transitions into the construction of the side and then tabletop of the desk. The front edge of the desk is cut away at an angle so that the patient’s sitting position is turned slightly into the room. The patient wardrobe has a width of 77.5 cm with a standard depth of 60 cm and contains different compartments of various sizes for clothing and personal items. Alongside the regular compartments, there is a space for stowing a suitcase and a lockable compartment for valuables.

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Architecture of the Patient Room

All the partitioning dividers are firmly attached to the body of the cupboard to avoid the need for supports or fasteners that could obstruct cleaning. The cupboard doors and dividers are arranged asymmetrically for large and smaller items. The narrower cupboard door opens into the room while the wider door to the compartment for hanging clothes opens onto the wall so that the patient’s movement is not constrained by the door when the cupboard is open. The floor-to-wall junction is the same as in the nurses’ work area with an upturned rounded skirting rising to a height of 10 cm for easy cleaning. A small recess affords a degree of tolerance for the items mounted above → Figs. 49–51.

30 cm 45 cm

192 cm

30 cm

9

30 cm

292 cm

10

35.3 cm

11

12

90 cm

14

47 Bathroom shelves for patients with integral disinfectant dispenser and waste disposal flap

13

10 cm

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85 cm

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8

4 6 Section through the nurses’ cupboard and bathroom shelving, 1 : 20 chipboard 1 Pflegeschrank/ Nurses’ cupboard: Schnitt Ablage Bad 19.6 mm – HPL surface Maßstab 1:20 lighting: aluminium profile with LED strip 2 Workplace 3 Reach-through slot for disposable gloves 4 Worktop: chipboard 38.6 mm – HPL surface 5 Back panel: chipboard 24 mm – HPL surface 6 Wall covering bathroom 1: tiles, 9 mm bathroom 2: HPL board, waterproof 7 Skirting lighting: aluminium profile rail with LED strip 8 Concave skirting board: rubber, height 100 mm 9 Storage unit for nursing materials 10 Shelves for patients: HPL compact board, 8 mm 11 Storage boxes for disposable gloves 12 Waste disposal flap: HPL compact board, 8 mm 13 Waste disposal chute: stainless steel sheet, folded 14 Waste disposal unit, electromechanical opening mechanism 15 Waste bin 48 Visitor and patient area

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Prototype

62 cm 130 cm

1

50 Base of the window bench with concave skirting for easier cleaning

2

3 26 cm

4

8

2 Patient cupboard: chipboard 19.6 mm – HPL surface 3 Impact protection: HPL compact board, 8 mm 4 Light switch for ceiling light above the desk, electrical socket 5 Patient desk: chipboard 38.6 mm – HPL surface 6 Bench upholstery, back: artificial leather with foam core 7 Bench upholstery, seat: artificial leather with foam core

10 cm

9 10

1 Patient lighting strip: aluminium profile with LED strip

100 cm

7

49 Section through window bench, 1 : 20

49 cm

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25 cm

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8 Bench base: chipboard 38.6 mm – HPL surface 9 Supporting structure and fascia: chipboard 38.6 mm – HPL surface 10 Concave skirting board: rubber, height 100 mm

Schnittansicht Sitzbank Maßstab 1:20

55 cm

1 Patientenbeleuchtung: Aluminiumprofil mit LED-Band 2 Pflegeschrank: Spanplatte 19,6 mm - HPL Oberfläche 3 Rammschutz: HPL-Kompaktplatte 8mm 4 Taster für Deckenleuchte über Tischplatte, Steckdose 5 Patiententisch: Spanplatte 38,6 mm - HPL-Oberfläche 6 Rückenpolster: Kunstleder mit Schaumstoffkern 7 Sitzpolster: Kunstleder mit Schaumstofffüllung 8 Tragplatte Sitzbank: Spanplatte 38,6 mm - HPL-Oberfläche 9 Blende und Tragkonstruktion: Spanplatte 38,6 mm - HPL-Oberfläche 10 Hohlkehlsockelleiste: Kautschuk, h= 100 mm

5

2.1 Ablagefächer und abschließbares Wertfach 2.2 Fach für hängende Kleidung 8

7

2

30 cm 8

116.5 cm

8

91 cm

41.6 cm 77.5 cm 2.5

51 Horizontal section and plan of the bench, table and cupboard area, 1 : 20

Grundrissausschnitt Sitzbank, Patiententisch- und schrank Maßstab 1:20

195

Architecture of the Patient Room

Building the Prototype

1 The KARMIN prototype was built in a works hall of the association partner Röhl.

2 The room’s walls were first erected as sandwich panels with integral ducts and supply lines.

196

Prototype

3 View of the shell of the room looking towards the entrance

4 View through the steel structure of the interior of the room. The walls and ceilings were clad and electrical cables laid.

5 The coloured impact protection wall panels were installed at the head ends of the beds. Cut-outs were left in the HPL panels for supply connections.

6 Final surface finishes and painting of the ceilings and walls

7 The construction for the window bench and patient desks was built prior to inserting the window. The bathroom fittings were installed and connected to the water supply and drains.

8 One of the wet cells with HPL wall cladding and tiled floor before installation of the ceiling

197

Building the Prototype

Completed Prototype and Use Scenarios

9 View of the patient room with the “doctor’s rounds” lighting scenario showing the patient area, the associated bathroom and the nurses’ work area

198

Prototype

10 The patient area during the doctor’s visit. The patient’s wardrobe can be seen in the background. The staff use their own mobile device so that they do not need to touch the patient’s bedside terminal.

12 The nurse has direct access to any necessary materials stored in the cupboard next to the nurses’ work area.

199

Completed Prototype

11 The doctor explains the medication plan displayed on the patient’s bedside terminal.

13 A nurse helps a patient to the bathroom.

14 View of the patient room from the entrance with the regular lighting scenario which changes subtly over the course of the day

200

Prototype

15 View of the bathroom. For easy access, the door slides to one side in front of the wall.

16 A member of the cleaning staff mops the floor. The large window with the seat in front allows ample natural light to enter the room and provides a good view of the world outside. The floor beneath the bench is also easy to reach with the mop. On either side of the window seat is a patient desk illuminated by a ceiling-mounted reading lamp.

17 A member of the cleaning staff cleans the nurses’ worktop.

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Completed Prototype

18 The rounded corners of the washbasin are wiped dry after cleaning.

19 Changing a patient’s dressing. The necessary materials can be placed within easy reach on the worktop of the nurses’ work area.

20 The wet cell with HPL wall panelling. The soap dispenser and ­disinfectant dispenser are placed apart and look different to avoid confusing them. The HPL panelling reduces the number of construction joints for more effective cleaning.

202

Prototype

21 The wet cell with wall tiling

22 View from the window towards the entrance. The mirrored, symmetrical layout of the room is clearly visible as are the positions of the newly developed KARMIN disinfectant dispensers above the nurses’ work areas.

23 The KARMIN bedside cabinet with seamless drawer unit and top tray has been designed for optimum effective cleaning.

203

Completed Prototype

24 The KARMIN disinfectant dispenser has been designed to improve compliance with hand ­hygiene guidelines and to simplify its installation and cleanability.

25 The recessed shelving in the bathroom includes a waste disposal flap that discharges into the waste bin in the cupboard of the nurses’ work area, from where it can be emptied.

26 Close-up of the waste disposal flap in the bathroom

27 The nurses’ work area comprises a cupboard for nursing materials and the adjoining worktop.

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Prototype

28 The rubber flooring has a rounded concave skirting that turns up at the base of the wall. This enables easier cleaning of the room corners and prevents the build-up of micro­ organisms at the junctions and corners of the room.

29 The window seat defines a zone for visitors in the patient room. On the left, one can see the open patient wardrobe with a lockable compartment for valuables.

205

Completed Prototype

Furniture and Equipment

1 Typical fittings and equipment in the immediate vicinity of a patient

206

Prototype

With technological advances and increasingly intensive patient care, the modern patient room has become a room filled with numerous objects and items of equipment. These, in turn, are used in a large number of different work processes. The typologies of these objects range from medical equipment to fittings, furniture, decor, patient beds, bedside cabinets and mobile devices → Fig. 1. Each of them has different surfaces, functions and shapes, which are more or less favourable in terms of infection prevention. In general, every object is colonised with microorganisms, but they are touched, moved, removed from the room and brought back again by different user groups at different frequencies depending on their function. People and objects carrying pathogens in and out of a room are the main transmitters in infection chains. Contact surfaces that are frequently touched typically pose a higher risk of transmission than rarely used items. For example, almost everyone touches the door handle, but the bedside drawer is used primarily by the patient and only occasionally by staff or visitors. The construction of the various objects in the room – some of which are classified as medical equipment – is governed by various standards and norms, which contribute to its potential to prevent infection transmission. The positive or negative influence of an object on the infection prevention potential is hard to measure purely in objective categories. Objects such as a disinfectant dispensers or infusion stands are essential items of medical equipment but a bunch of flowers, while unimportant from a medical perspective, and perhaps even harmful as a source of infection, is beneficial to the patient emotionally and may indirectly help speed the process

2 Four approaches to infection control among patients: cohorting, isolating, separating infection chains within a room or no measures at all despite different infections and clinical pictures (from left to right)

of recovery. Likewise, functional objects, such as seating for visitors, are necessary but entirely irrelevant to medical procedures. As these various objects are involved to different degrees in cycles of use and work processes, they are also cleaned and disinfected at different intervals. For combating the transmission of multi-resistant pathogens, this presents several challenges in the design of patient rooms. Which objects can limit or prevent the incidence of nosocomial infections? How can items be incorporated into work processes to encourage safe disinfection procedures, and how can they be designed for easy cleaning? Can (mobile) devices encourage good hygiene practices among patients through digital information and advice? And in general, how can the design of the environment of the patient help break the transmission chain of pathogens?

The infection prevention potential of key objects in a patient room There are numerous strategies for controlling the spread of infection that act at almost as many different levels. Cleaning surfaces and washing hands are essential for removing coarse dirt that can be a breeding ground for microorganisms – but they do not kill pathogens. Disinfecting surfaces and hands immediately after washing further minimises the risk of infection by killing pathogens that have not developed a corresponding resistance. Probiotic cleaning methods using biocidal agents are increasingly being tested as they do not eradicate microorganisms that are harmless to humans and cause less chemical damage to surfaces than aggressive cleaning and disinfecting agents. Surfaces that are chemically cleaned over a long period eventually become porous and can harbour dirt and germs more easily. As such, objects in patient rooms must be designed so that they need less frequent disinfection to prevent the development of resistance. In addition to cleaning, other methods of infection prevention include isolating patients, pathogens and objects, though these are costly and require space and time. They also do not prevent micro­ organisms being transported by nursing staff, unfiltered air or rubbish. One principle among patients is cohorting → Fig. 2 in which people with the same pathogens are isolated together. Other strategies can also be employed to reduce the risk of cross-contamination between patients in a room, for example by ensuring patients do not mistakenly use each other’s personal hygiene products and by clearly distinguishing between disinfectant and soap dispensers. In addition, separating both work processes as well as patient-specific items can help prevent pathogen transmission by droplets and contribute to infection control. Staff can, for example, wear a face mask and avoid physical contact, while suitable design measures that take into account the radius of action of patients, can employ design means to prevent patients with dementia from accidentally reaching for or misidentifying the personal hygiene items of their neighbour. RFID chip technology can be used to permit and restrict access to certain items, and motion detectors can avoid the need to touch switches, minimising contact infections. As part of the KARMIN project, the “Furniture and Equipment Design” sub-project investigated which additional strategies can be developed for preventing infections through equipment, work processes and behaviour, and which existing approaches can be optimised.

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Furniture and Equipment

3 The three radii of action and their overlaps from patient outwards: gripping radius, droplet radius and mobility radius (the entire circle)

Prevention All user groups

Cleaning Care staff – Patient – Visitor

Information Patient

4 The primary themes of the newly developed equipment

208

Prototype

Future scenarios Alongside existing norms for equipment that reflect the current level of knowledge on infection prevention, future scenarios must be considered so that one can derive insights from them and implement solutions accordingly. By appraising the existing situation and extrapolating from it, existing norms and established processes can be critically examined and new research findings in the field of infection control can feed back into the design of equipment and fittings for hospital rooms. In this respect, digitalisation and innovation in medical technology and treatments on the one hand and demographic change on the other play an important role. Longer life expectancies and a proportional shift towards older patients will lead to a change in clinical pictures and in the composition of patients in hospitals. Patient rooms will need different fittings, work processes will have a different focus and patients will be less mobile. In addition, the proportion of elderly patients with dementia will increase, placing new demands on the ward environment. The changing patient demography also has implications for the ergonomics of equipment, which will need to meet the needs of people with physical and cognitive limitations. More intensive patient education is also imperative. At the same time, new types of digital and networked devices enable the contactless transmission of information about the physical condition of patients and of work processes. Digital patient records, for example, eliminate the need to carry paper-based files in and out of the room, reducing the risk of transmitting pathogens. Care must be taken, however, that all these technical means do not result in an overly distanced, impersonal atmosphere. Physical experience is a fundamental sensory sensation that stimulates cognitive response and is better at transporting and also expressing emotions. Haptic experiences are essential to the emotional well-being and recovery of patients. Similarly, patients must be actively involved in infection prevention, rather than relying on passive and/or purely technological solutions. Economic aspects will also have an impact on patient rooms in the future. Shorter durations in hospital and fewer nursing staff will increase the frequency with which beds need preparing for new patients and shorten the time that nursing staff have for their everyday activities. A supportive environment must be developed that provides physical, emotional and also procedural support. Future developments do not necessarily imply a decline in infection prevention. Instead opportunities and potential for improvement must be sought, such as the digital patient records. Methodology and relevant objects The research group began by drawing up a tabular list of all the objects always present or potentially found in a patient room, and analysing each according to a series of aspects: the object’s inherent prevention potential, the degree to which its surfaces and contact surfaces are colonisable with MRSA/VRE, its frequency of use, its potential for contamination by the relevant user group(s) and its position relative to the radius of action of the patient and hospital staff. To help assess how colonisation develops over longer periods of time, two further evaluation factors – usage and cleaning cycles – were examined and classified as either constant, hourly, daily, weekly and after/before patient discharge. Finally, the patient’s radius of action was classified as being either within gripping distance, droplet radius or mobility radius → Fig. 3. These categories provide an indication of the likelihood of surface contamination of an object through contact by or droplets from a patient or caregiver. In addition, the group studied the degree to which the objects are used consecutively between each hand disinfection.

Expert workshops with planners, patients, hygienists, doctors, architects, nursing staff and experts from the private sector as well as visits to clinics and work placements provided additional insight into which objects need redesigning and further development. The methodology used is described in → Catalogue of requirements for the patient room and wet cell, p. 177. From the long list of objects in a patient room, the research group selected three relevant objects for in-depth design analysis with a view to optimising and adapting their design, or where necessary rethinking their design. The objects were chosen based on the degree of colonisation of the objects, the frequency with which users come into contact with them, and their respective prevention potential. The first object is the disinfectant dispenser as it is the central, preventive object in everyday hospital life; the second is the bedside table and cabinet as a frequently used object in the immediate vicinity of the patient that is also encountered by nurses during their work; and the third is the bedside terminal as a frequently touched surface that can also serve as an educational and informational tool. Three objects in focus As patient care becomes increasingly centred around the immediate area of the patient’s bed as a consequence of demographic change, we can expect to see an increase in the frequency and duration of use of the bedside table and cabinet and the bedside terminal. All three objects have been re-examined with a view to optimising infection prevention, not just in terms of their appearance and construction but also in the way they are used or invite people to use them. While the disinfectant dispenser and the bedside cabinet are already familiar objects in patient rooms, the bedside terminal is comparatively new and offers new informational possibilities for improving good hygiene practices. In terms of their physical functionality, the first two cases are far more complex objects but still have room for improvement in the way they support work processes, in how easy they are to clean and through digitalisation. Research conducted as part of hospital visits and in conversation with experts during workshops also revealed that existing standards and guidelines were not always heeded due to economic constraints or time pressure in hectic work situations. The objective of a redesign should therefore be to encourage certain patterns of use and inhibit unfavourable actions through the object’s design. The primary themes of the re-examination of these objects are their potential for infection prevention, ease of cleaning and their informational-educational potential → Fig. 4. In this context, the researchers also reviewed the existing patterns of information provision and work processes in two-bed patient rooms with a view to identifying opportunities for optimisation. Pathways As part of the analysis of the work processes, the researchers identified the various points within a room that users visit, the order in which they are visited and how they might be better positioned. The patient bathroom, for example, has a major effect on the work steps and pathways within the room. Depending on its position, it can lengthen the path from the door to the patient, restrict the field of vision and obstruct accessibility. The arrangement of fittings and equipment within a patient room should facilitate direct paths between them and support work processes. When patients are located crosswise and opposite each other, walking distances are made unnecessarily longer, causing staff to potentially omit work and disinfection steps. One idea discussed in this context is the extent to which lighting can encourage staff as well as patients to follow certain paths. Spotlights and correct lighting sce-

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Furniture and Equipment

narios can promote a smooth working process. The aim was to create a coherent environment in which the objects and architecture support both patients and staff. Cross-contamination Failure to disinfect hands between work steps and failure to clean and disinfect contact surfaces used by many different people can lead to cross-contamination. Optimising the placement of disinfectant dispensers can help increase compliance, while the use of contactless sensor technology can reduce contamination. This is described in more detail, along with an overview of infectious diseases, their occurrence and transmission paths, in the section → Healthcare-Associated Infections, pp. 21–23. Methodological approach to determining requirements The research served as a basis for deriving the requirements the objects need to serve. For each of the selected objects – the disinfectant dispenser, bedside terminal and patient bedside table – the requirements were systematically categorised and then prioritised according to the labels “could have”, “should have” and “must have”, based on the findings of the prior research. “Could have” represents qualitative, oral recommendations made by interviewees during expert workshops, work placements and hospital visits, while “should have” are a result of guidelines and standards and “must have” of laws. These requirements were then reviewed for their relevance to hygiene and infection control to prioritise them for the concept phase. As part of the conceptual design, different implementation variants were outlined and also built as a basis for discussion and evaluation by experts including partners from medicine and industry. From these, optimised prototypes were built as demonstrators for evaluation in practice. In terms of general recommendations: the surfaces and the forms of objects should be designed for easy cleaning; the respective objects should be better integrated into work processes; and digital instruments should be used to optimise and clarify processes. The following sections detail the set of requirements, the resulting concepts and the final design solutions for each of the three objects.

The Disinfectant Dispenser

The disinfectant dispenser is a central tool of horizontal infection control used in all areas of hospitals and also by all patients. It is therefore a central element of the KARMIN project. Hand disinfection can help prevent both exogenous and endogenous infections, and this applies not just to staff but also to visitors who are not traditionally encouraged to disinfect their hands. Doctors play a particularly important role as behavioural models for other user groups. Patients can, in certain situations, also reduce the risk of MRSA transmission by disinfecting their hands, but the first step for patients should always be to wash their hands properly because this suffices in many situations. Further methods of educating patients, and indirectly also visitors, on the value of hand disinfection in patient rooms are discussed in the section on the → Bedside Terminal, pp. 230–236. Disinfectant dispensers have been used for decades for infection prevention and personal protection and have evolved into a highly sophisticated device. Numerous initiatives and organisations, including the World Health Organization (WHO), have developed established and scientifically based guidelines for their placement and methods of use – such as the WHO “Five Moments for Hand Hygiene” – which have in turn influenced their design. In terms of their technical construction, ease of cleaning and how they are perceived, however, there is still potential for improving their design to minimise infection transmission. Three factors play a key role in the reasons why disinfection guidelines are not observed: memory, attention and decision-making – or in other words, forgetting, distraction and prioritising other activities. In more concrete terms, this means insufficient knowledge of or education on hand disinfection, an environmental context that is poorly designed, unclear and hinders decisive action, and a lack of time or availability of disinfectant. All these need further research, consideration and incorporation into the product’s design. But to begin with, it is useful to ask who disinfects when, where, how and why → Fig. 1, as a basis for deriving the requirements that the product must fulfil. The findings are discussed in more detail below and ultimately led to the newly developed design of the KARMIN disinfectant dispenser. However, there are also possibilities for optimisation that can be implemented with existing dispensers, for example in the positioning of the dispenser.

? ?

? ? ?

?

Who?

Where?

A

B

C1 C2 How?

When?

Why? 1 Key questions about hand disinfection

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Prototype

Requirements for a disinfectant dispenser Positioning An important factor for the aspects of memory, attention and decision-making in infection prevention is not just the design of the dispenser itself or the training of staff and the education of other potential users but also the positioning of the dispenser, i.e. the question of where. In the KARMIN project, we discuss this in the context of a two-bed room, but many aspects also apply equally to single or multi-bed patient rooms. Typically, a dispenser is positioned close to the patient room door and within the room so that the disinfectant can act on the way from the entrance to the bed. However, this means the dispenser is no longer near the path of the nurse’s subsequent work steps in a patient room with more than one bed. If it is placed too close to the door, it will be obscured by the door when it is open, where it then risks being “out of sight and out of mind”. At the same time, this protects it from collision with mobile items being wheeled in or out of the room. For the nurses, however, it is more important that the dispenser lies in easy reach for their work → Fig. 2. Instead of placing one dispenser at the entrance, two can be placed above the respective worktops and two more attached to the end rail at the foot end of each patient

bed. Two further disinfectant dispensers can also be positioned in the wet cell. This saves time between the different work steps and when switching from patient to patient because staff can disinfect their hands at the entrance, near the bed and at the washbasin in the bathroom. Positioning the dispenser above the worktop also protects it from accidental collision → Fig. 3. Alongside their positioning in the room, dispensers should also be mounted at an appropriate ergonomic height. For correct and easy operation, the pumping surface should be approx. 120 cm above floor level. Dispensers must also be accessible to users in wheelchairs, and also from the side: care should be taken that access is not blocked by other adjacent objects → Fig. 4. Disinfectant dispensers should therefore be positioned so that they tie in with the work routines of medical staff but are also accessible to other user groups in patient rooms. 2 Bad (left) and good (right) positioning of disinfectant dispensers in relation to the nurse’s work processes

3 In the KARMIN patient room the dispenser is positioned along the walking route.

ca. 120 cm

4 Mounting height and wheelchair clearance

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Disinfectant Dispenser

Five moments for hand hygiene Medical staff are trained to internalise five moments for hand disinfection. This hand hygiene strategy is designed to protect the patient and their uninfected body parts, the environment of the patient, the medical staff and the next patient against contact infections, and also details why. In outpatient medicine, one differentiates between non-invasive and invasive treatment. In inpatient medical care, invasive treatment is more common, and it becomes important to define when hand disinfection takes place. According to the five moments, hand disinfection must take place 1) before patient contact, 2) before aseptic activities, 3) after contact with potentially infectious materials, 4) after patient contact, and 5) after contact with surfaces in the immediate vicinity of the patient. A diagram of the five moments is shown in the section → Healthcare-­ Associated Infections, Fig. 4, p. 23. To ensure that these five moments are observed, disinfectant dispensers must be visible from everywhere in the patient room and mounted ergonomically within easy reach (Boog et al. 2013). Studies have shown, however, that more than three dispensers per patient does not increase compliance (Chan et al. 2013). To ensure hand disinfection between two patients, i.e. after touching the last and before touching the next patient, disinfectant dispensers can be fixed using an adaptable fixing to the end rail at the foot of the bed. A clamping mechanism makes it possible to mount the dispenser to the right or left of the rail depending on where it is most needed. Mounting the dispenser slightly away from the corner, so that it does not protrude, avoids accidental collisions when passing by the bed. Compliance Alongside observing the five moments for hand disinfection, it is also important that disinfectant is applied and rubbed in thoroughly. Measuring the frequency and quality of hand disinfection through observations on site is very time-consuming and therefore only possible on a short-term basis. It is also hard to check how well hands have been disinfected using technical means. Consequently, this is largely disregarded as a requirement for the design of the dispenser. One method suggested for checking how well staff comply with the respective guidelines is to electronically or mechanically record the pump action of the dispenser and correlate it against the respective consumption of disinfectant (Schulz-Stübner 2013, p. 217). However, this method is still inaccurate as it says little about the user group, the situation or how well the disinfectant has been rubbed in: we don’t know how many people were in a room when it was used and what activities were being carried out. An LED installed in the dispenser can light up for the duration of the minimum rubbing-in time to give users at least some direct feedback on the time required for the disinfectant to act, but it is still not possible to ascertain

5 Possible options for graphical visual cues on walls or floors to highlight the presence of dispensers

6 Positioning the soap dispenser (blue) and disinfectant dispenser (red) in a patient bathroom. Placing one by the sink and the other to one side helps separate how they are perceived by the user.

how well the disinfectant was applied to the entire hand. In addition, staff usually begin moving around the room after disinfecting their hands and rarely wait by the dispenser. In everyday hospital practice, no-one stands and waits for a signal to elapse; instead, disinfectant is applied and acts in the time between using the dispenser and before touching the patient. The proper and thorough application of disinfectant is therefore a matter of good staff training, comprehensive, repeated education of the user groups, and a conducive environment. There are, nevertheless, further means of improving compliance beyond appropriate positioning of the dispenser and sufficient education of the users. One simple method is to provide graphical visual cues on walls and the floor → Fig. 5, though these can become less effective as staff grow accustomed to the cues and begin to overlook them. Another established method is to use team meetings to give repeated targeted feedback in person to reinforce staff compliance. This can be made more effective if reliable quantitative data is available with which to analyse compliance. Disinfectant dispensers that are equipped with sensors can provide usage data that reveals at what times and what amount of hand disinfectant is used. A widely used method for monitoring compliance with standards is the current HAND-KISS principle. This calculates the consumption of hand disinfectant and the number of disinfection measures carried out per patient, per resident day or treatment case to determine conformity with guidelines for hygienic hand disinfection. HAND-KISS also compares the consumption of hand disinfectant across wards with similar patient groups (same ward types). The counting principle can also be made more precise by correlating it against the different user groups, e.g. nurses and carers, doctors, visitors and patients (Scheithauer 2018). To do this, however, existing disinfectant dispensers must be retrofitted with a technical means of data collection. Digital sensors and evaluation systems offer great potential for increasing hand hygiene and improving compliance with regulations. They provide a more exact means of monitoring usage, but care must be taken to avoid the user feeling under surveillance. From a methodological perspective, research has shown that positive motivational triggers are far more successful than admonishing users for non-adherence. An atmosphere of excessive monitoring can also give rise to the Hawthorne Effect: when people know they are being watched, they adapt their natural behaviour accordingly. In this context, this could lead to hand disinfectant being used to satisfy the monitoring system rather than to encourage correct, high-quality hand hygiene. For the design of the KARMIN disinfectant dispenser, the researchers therefore examined additional possibilities for increasing compliance through inconspicuous data collection and triggering positive emotions not seen in existing dispensers. Fill level and usage analysis As mentioned above, a constant supply of disinfectant must be ensured to comply with hand disinfection guidelines. As obvious as this may sound, it can often be a logistical problem in the everyday running of a hospital. The disinfectant dispenser’s monitoring and analysis system should therefore not only monitor usage data but also communicate the fill level and location of the dispenser to the central monitoring system so that this can be monitored constantly. Hospital staff can then replace bottles as and where needed before the disinfectant runs out and the dispenser fails to function. The dispenser must transmit this data wirelessly and a software system must record and display the data. A further requirement of this system is to eliminate multiple pumps that occur in quick succession when staff press several times on the dispenser when working. While each pump must be recorded individually to calculate

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the fill level, they should be bundled as a single operation for the usage statistics. The data acquisition system should also break down usage of the hand disinfectant dispenser by date and time of day.

and places an additional burden on the hospital’s emergency electrical supply. To this end, a self-sufficient solution was found for the KARMIN disinfectant dispenser.

Display function and prompting strategies To ensure dispensers are used at the right time by the widest possible spectrum of users, including patients and visitors, a display function can be used to animate people to use the dispenser and instruct them how. A friendly, approachable appearance likewise encourages visitors to engage with the dispenser. Surveys and conversations conducted as part of the KARMIN research project revealed that people responded negatively to the technical appearance and medical connotations of conventional dispensers. The use of animations, for example, can give character to an otherwise static piece of equipment, so that it appeals to users at an emotional level. Studies have shown that in neonatology wards, for example, staff disinfect their hands more frequently if pictures of newborn babies were placed above the dispensers. It appealed to the staff’s sense of responsibility and made them more inclined to disinfect their hands. It also strengthened the inviting character of the dispenser. Posters, flyers, films or online posts can also provide additional information on when and how to disinfect one’s hands properly. This could be sent via an app notification or information e-mail prior to the patient’s arrival. Bedside terminals likewise can be used to educate patients during their stay and to create incentives. Alongside the aspects of attention and memory, the dispenser’s display function must also aid in deciding which actions to take. To distinguish it adequately from soap dispensers, clear labelling and some form of formal or coloured differentiation can help immediately identify its purpose. Placing it at a separate location also helps and additionally prevents people disinfecting their hands prior to washing them while in haste or out of ignorance → Fig. 6. Objects in a patient room should be designed so that they meet the user’s expectations and are placed at an intuitive location.

Mechanical versus contactless dispenser A major disadvantage of electronic contactless disinfectant dispensers, aside from their considerably higher price compared to mechanical dispensers, is their dependency on an electrical supply. In the event of a power outage, they do not comply to standards as disinfectant dispensers must be functional at all times. In addition, complex electronic components require more maintenance and electronic pumps consume energy to operate. The argument that contactless dispensers avoid contact infections that arise with traditional dispensers where previous users contaminate the pump with pathogens is also not entirely true, as the user of a mechanical dispenser disinfects their hands immediately after touching the pump. Newer dispenser models therefore adopt a hybrid strategy in which a mechanical dispenser can be used that functions independently of the electronic components used for digital data acquisition and transfer.

Disinfectant supply To fulfil its function and comply with guidelines, a disinfectant dispenser must have a constant supply of disinfectant. To this end, the fill level must be visible on the exterior so that low levels of disinfectant are noticed before it runs out. Ideally, the fill level should also be transmitted to a central monitoring point so that switching out the bottles can be coordinated more easily in a timely manner. Empty bottles should be disposed of immediately to prevent improper use of any remaining liquid. Systems in which the pump head is replaced with the bottle are preferable to avoid contamination or re-use for cost reasons, where the pump head risks becoming a breeding ground for pathogens. In this case patient health is more important than waste avoidance. This can be partially mitigated by using pump heads made of recycled materials. In addition, the dispenser bottle must maintain the prescribed concentration of alcohol at a constant level for three months (Assadian et al. 2012). Hospitals can decide whether to keep supplies of replacement bottles in a central location or in each ward. Electrical supply The digital systems for the sensor systems, data acquisition and wireless communication of usage data requires electricity. As disinfectant must always be available, the dispenser must function even during a power outage. This can be achieved by connecting it to the hospital mains, which has an emergency backup system, or by means of ensuring it has a mechanical means of dispensing, even when the electronics are inoperable. The former is more complex and costly in terms of cabling

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Disinfectant dispensing function Several requirements must be met by the dispensing mechanism, first and foremost the correct concentration and dosage of disinfectants for successful hygiene measures. The German testing standard requires a disinfectant dosage of 3 ml per hand rub (DIN EN 1500). However, because staff frequently pump several times in everyday practice, various manufacturers factory-set the output to 1.5 ml, so that at least­ 3 ml of disinfectant are dispensed in total. In addition, guidelines stipulate that the pump mechanism may only fail to deliver in 1 % of cases, or in two out of 200 consecutive pump strokes (Assadian et al. 2012). Gels are not permitted as medical products, although they would be advantageous as they prevent dripping, which in the long term damages the surface of any items or the floor beneath the dispenser. Some dispenser models feature pumps that attempt to prevent dripping by sucking up the disinfectant when the pump is released. Drip protection trays help to a limited degree, because they are often not cleaned or regularly emptied so that they overflow. Similarly, one cannot prevent disinfectant dripping from the hands of the user as they move away from the dispenser. Drip protection trays must also be sufficiently far away from the dispenser outlet to allow sufficient space for a pair of hands beneath the pump head.

7 Rounded edges and avoiding joints helps to ensure clean surfaces.

Ease of cleaning In addition to hand disinfection as an essential part of infection prevention, it is also important to minimise colonisation of the surfaces and joints of the dispenser itself by germs. The design of the dispenser must be optimised for ease of cleaning through the choice of a suitable form and appropriate materials. Instead of sharp corners, the dispenser should be given clear, uninterrupted rounded edges → Fig. 7. Similarly, hard-to-clean seams and narrow joints must be avoided so that surfaces are simple to wipe clean with disinfectant. Minimising the number of components and the complexity of assembly is also advantageous as it minimises joints. Where pump heads are re-usable, they must be cleanable in an autoclave, i.e. disinfected in a machine at an A0-value of at least 60 (or 80 °C/1 min). Sterilisation at 121 °C is even better (Assadian 2012). The A0-value is a time-temperature relationship that expresses how long it takes to kill microorganisms at a specific temperature. This needs to be undertaken after each bottle change to prevent microbial contamination of the pump head. The re-use of disinfectant bottles is not permitted, and they must be properly disposed of after use, along with the disposable pump head (unless re-usable pumps are used). Materials The requirement that the dispenser can be wipe disinfected and is heat-cleanable means that the materials must be resistant to alcohol and heat. Where re-usable parts are specified by the hospital operator, it must be made of an autoclavable material. Stainless steel is recommended for this purpose but various plastics such as acrylonitrile-­ butadiene-styrene copolymer (ABS) can also be used for parts such as the housing. The material must be able to withstand the pressure applied when using the dispenser. Plastics offer greater design flexibility than curved sheet metal for the design of the housing because they can be injection-moulded. Colour, shape and character The choice of an appropriate material is not solely a matter of technical suitability but also one of associative connotations. As with the display function mentioned earlier, the colour, surface quality and shape of the dispenser should also appeal to the user and fit into the atmosphere of the room. People engage more readily with a visual form and appearance that does not have negative connotations, ultimately promoting compliance. In the expert workshops and hospital visits conducted as part of the KARMIN project, various potential user groups voiced a need for disinfectant dispensers that are perceived as “warm” and not stigmatised by being part of the medical apparatus of the hospital. On the one hand, the dispenser should evoke a sense of purity and warmth and be visually integrated into the design of the patient room, and at the same time it should be sufficiently noticeable. Slightly muted signal colours and round, soft shapes are ideal for this purpose. The cold, technical feel of materials such as polished stainless steel is less well suited than that, for example, of coloured plastics. Dispenser elements All these requirements come together in the design of the construction of the dispenser. A basic dispenser must be able to hold a dispenser bottle, provide a pump or valve that dispenses disinfectant, even when no power supply is available, and provide a means of recording how often it is used. For this, the dispenser needs an electronics system that can encourage users to use the dispenser, record and transmit usage data, display the charge and fill level and relay its location to

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a central monitoring system. The housing must have as few joints as possible, rounded rather than sharp edges, no narrow notches or gaps and be flexibly mountable, for example on a bed rail or a wall. It should be mounted with ample space above for comfortable operation, and the housing should be quick and easy to remove and replace so that untrained staff can refill it as needed. As all manner of objects are routinely stolen from hospitals, the dispenser should be mounted to prevent unauthorised removal of the bottles or of the entire dispenser. This is best achieved using a concealed fixing mechanism that is additionally covered. All these requirements need to be translated into a coherent and realistic concept. Commercially available dispensers range in price considerably from about 20€ to as much as 300€. The KARMIN disinfectant dispenser aims to have a price point of about 50€.

A concept for an intelligent disinfectant dispenser The objective for the KARMIN disinfectant dispenser is to design a smart dispenser that employs a psychological trigger to encourage use and is also generally appealing to visitors, staff and patients through its inclusive appearance. Its design should simplify cleaning and minimise colonisation with germs by reducing the number of components, and thus joints in the product. A further key requirement of its construction is the separation of the mechanical disinfectant dispensing mechanism from the electronic data collection and transfer so that each can function decoupled from the other: the dispenser should be manually operable in the event that the electronics fail. A hybrid solution is therefore necessary. To this end, the team initially set aside the classic components of current conventional disinfectant dispensers so that they could explore the horizon of possibilities for the given requirements in the concept development phase unimpeded by existing constraints. The result is a novel bottle design and housing with screen that nevertheless builds on the valuable qualities of previous models. Analysing existing dispenser models Combining all the different desired properties in a functional and compliance-enhancing design for a disinfectant dispenser that is moreover also cost-effective, is a challenging task. Previous models have therefore concentrated on the core properties and neglected secondary features. In the European market, a model of dispenser has emerged over the last decades which is sold under various trade names. Its housing consists of an anodised aluminium sheet, which is open at the bottom. It employs a purely mechanical dispensing mechanism with a simple design, but the pump system comprises many individual parts which are complex to keep clean when (re)installing the dispenser. As a consequence, they are not always properly sterilised. Furthermore, the dispenser does not offer any means of data collection and it does not look inviting, but rather technical, clinical and utilitarian. Some newer models are more attractive and also reduce the number of components but are made of less durable plastic. Aside from that, intelligent dispensers that record usage data are now also more widely available. Electronic dispensers Contactless dispensers are less common in German hospitals due to their significantly higher cost. All the currently available electronic models have different advantages and disadvantages. They differ from conventional dispensers through the type of dispensing mechanism, their ability to record information and where they can be mounted. While mechanical dispensers are considerably cheaper and easier to maintain due to

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their less complex design, many electronic dispensers offer the ability to dispense disinfectant without touching them. Electronic dispensers are permanently installed and are thus stationary dispensers usually mounted on a wall or bed. The latter can usually also be attached to the nurses’ trolleys or other objects with round profiles using a clamp but are then only semi-mobile. Permanently mounted dispensers have the advantage of being at a specific, memorisable location so that staff do not need to interrupt their work routines to find them. Gown bottles Mobile dispensers and gown bottles are, by contrast, always to hand, but not available to all user groups, for example for patients’ relatives and visitors. In addition, the smaller capacity of the bottles leads to more waste than wall-mounted dispensers. Smock bottles can, however, contribute to the perceived competence of medical professionals, and set an example. When consistently applied, only the remaining staff need be encouraged to use the available dispensers in a compliant manner. Construction differences In terms of appearance, electronic dispensers can be more aesthetically attractive and compact than mechanical models as they do not need to have a protruding lever arm. When wall-mounted, however, they cannot always be positioned optimally to lie in the working radius of staff. In addition, disinfectant can drip, over time damaging the floor through long-term exposure to disinfectant. Their greater design complexity also requires more elaborate regular cleaning and preparation than disposable (gown) bottles.

8 A data acquisition system records disinfectant consumption, time, user group membership and fill level, which are sent to a centrally controlled software for evaluation.

9 Replacing the refill bottle of the KARMIN disinfectant dispenser

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Differences in ensuring supply Further differences arise with respect to ensuring a constant supply of disinfectant. The small capacity of smock bottles means that replacements must be easy for staff to procure and that they remember to replace a nearly spent bottle in time. The logistics are more complex and the tendency to forget greater than when a smaller group of people are explicitly responsible for ensuring stationary dispensers are always functional. In addition, how much a smock bottle dispenses cannot be regulated so there is a greater danger of incorrect or excessive use. Electronic dispensers, by contrast, fail to function at all if there is a power failure and risk jeopardising the constant availability of disinfectant. The hospital may also become dependent on a single supplier when dispensers can only accept the manufacturer’s proprietary refill bottle shape. The more complex housings of electronic dispensers may require that staff need instructing in installing refills. The comparative complexity of the components may also entail more costly and time-consuming maintenance and upkeep than other models. The energy supply method can also vary: some systems are so energy-efficient that a small button cell is sufficient to supply the electronics for an extended period of time without costly, frequent replacement. Some dispenser bottles come with an integral button cell to ensure continual functionality. In other cases, a charge level indicator shows how much power remains to avoid a system shutdown. Other systems even employ the kinetic energy of the pump action to generate energy when dispensing disinfectant. When the remaining electronics draw only low power, it is then possible to dispense with a battery altogether. The various requirements discussed above are therefore complex and diverse, and occasionally also contradictory. In the expert workshops and ensuing design discussions, the decision was made to develop a concept for a stationary, wall-mounted dispenser for the KARMIN patient room. This makes it possible to combine the various requirements appropriately in a limited installation space. Increasing compliance through injunctive norms In addition to ensuring an unbroken supply of disinfectant and creating an environment that supports hand hygiene in staff work processes, staff need to know when to disinfect and be motivated to apply their knowledge of hand disinfection. To this end, ways of increasing compliance need to be developed and put into action. Alongside the existing methods – such as evaluation of usage statistics in team meetings, specific staff training and explanatory graphics near the dispensers – the design of the new KARMIN disinfectant dispenser also takes new findings into account by combining technical solutions with psychological motivators. Using “nudging methods”, the design employs emotional triggers to prompt users to make use of dispensers. Research has shown that employing such so-called injunctive norms can raise compliance by up to 40 % over the initial usage rate (Gaube et al. 2018). Injunctive norms work by appealing to the intrinsic, positive motivation of users rather than admonishing bad performance or using authoritarian dictates to increase compliance. Drawing on the same principle of hanging pictures of newborn babies above dispensers in neonatal wards, an experimental setup was trialled using a monitor mounted above the disinfectant dispenser. The monitor shows a sad-face emoticon to begin with that turns into a smiley when the pump is operated. A sensor records the number of pump strokes as well as the entry of a person into the room in order to determine the rate of use. Various motif-pairs were tested to ascertain the effect they had. Neutral, context-free motifs had little effect on the users, but compliance increased slightly when a pair of eyes was displayed: the “watching eyes” reminded users of social norms

and duties (descriptive norms). Non-punitive symbols were, however, far more effective: by appealing to injunctive norms (“I should do what is objectively right”) by means of smileys achieved a much higher increase in compliance over the test period. This method can be used alongside the analysis of quantitative data in team meetings. The “animation” of the smiley lends the dispenser a personal character without it needing to figuratively adopt the semblance of a body and face: the facial features of the on-screen smiley are effective enough without giving the dispenser a three-dimensional sculptural form (Gaube et al. 2018). Display requirements To appeal to injunctive norms using smileys, the display must be positioned so that it is immediately visible in the user’s field of view, i.e. directly above the dispenser housing. The graphic simplicity of the motif of a smiley is such that it could be displayed using a suitable array of illuminated and dimmed LEDs or other low-energy display mechanism to minimise energy consumption. Likewise, a low refresh rate and limited colour spectrum suffices, making an e-ink display a viable alternative to LCD or TFT displays. A sensor system is also needed to change the motif on display when the dispenser is used. Data acquisition To make use of injunctive norms and evaluate usage data, a dispenser needs a means of capturing and recording usage date. A sensor system causes the display to change the motif as soon as enough disinfectant has been dispensed. The dispenser then emits a signal communicating the position of the dispenser and whether it needs refilling. Various methods of data acquisition are available. To target a specific user group, an anonymised RFID chip denoting the user group can be worn on the wrist. This allows the usage data to be broken down by user group, though it does not detect whether several dispense operations were triggered or when people without an RFID chip used disinfectant. This type of sensor technology is therefore unable to relay information on the fill level. Motion, magnetic or pressure sensors, on the other hand, can detect dispenser activation more precisely, but cannot assign it to a specific user group. A combination of both approaches can, however, lead to the desired precise detection and allocation. By using only user group-specific data, no personal data is recorded, thereby adhering to data protection guidelines, and team spirit among the hospital user groups is encouraged. It also makes it possible to identify and remedy gaps in dispenser infrastructure. The data set that is transmitted contains the following information: location of the room and the exact position of the disinfectant dispenser within the room (dispenser ID), time of use and number of strokes as well as, if necessary, an RFID chip-based assignment of the user to a specific group of people. This makes it possible to determine how often the dispenser was used in a specific timeframe. In addition, the consumption of disinfectant is monitored, from which the need for refilling can be calculated based on output quantity and frequency of use. To both record and analyse the data, a hospital needs the appropriate software and IT infrastructure → Fig. 8. Power supply The electrical components in the dispenser used to increase compliance require a power supply. A self-sufficient means of power supply would be ideal to minimise maintenance. One method is to use the kinetic energy of the pump to generate electricity, but this means the electronics must be adapted to cope with the selective availability of energy. The recorded data must be bundled in packets that the wireless module can transmit when energy is available.

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Operating mechanism A further aspect is the preparation of the disinfectant dispenser, i.e. the steps needed to prepare it for operation and keep it hygienic and operational at all times. To prevent irregular and potentially inadequate upkeep, and to avoid improper re-use of the bottle and pump, the KARMIN project proposed a bottle with a valve that does not use a pump to dispense disinfectant. Both the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) and the German Society for Hospital Hygiene (DGKH) have declared that disposable pumps are advantageous (Bundesgesundheitsblatt, No. 59, 2016). Pressing the dispenser bottle itself builds up pressure within that opens a valve. For this, the bottle may not be rigid or fragile, or its shape must be designed to allow compression, for example via a concertina-type construction principle. In addition, it is important to decide whether only the hand or also an elbow can be used to activate the dispensing mechanism, as this significantly influences the ergonomics and design of the dispenser. The ease of use varies depending on whether the bottle is pressed frontally, at an angle or on top. A lever to apply pressure to the bottle was deemed undesirable as it represents an additional component that needs cleaning. Instead, the KARMIN design envisages that the pressure-applying surface is replaced automatically with the bottle, avoiding its possible colonisation by pathogens → Fig. 9. The dispenser housing must also be kept clean. Rubber coating the entire body would enable it to be machine-washable but is costly in terms of production and would require the dispenser to be removed from the wall bracket. Instead, plastic was used to be able to design an attractive shape. The outer surfaces of the KARMIN disinfectant dispenser have rounded transitions to facilitate residue-free cleaning and wipe disinfection.

10 Colour concept for the KARMIN disinfectant dispenser

Colour For the body of the dispenser, made of plastic, the team chose white to denote the idea of purity, as well as to make it easier to detect surface contamination, which is otherwise harder to see on structured or coloured surfaces. At the same time an accent colour was needed to ensure the dispenser is still noticed in more complex interiors. Signal colours are therefore used for selected components, in this case the display and the bottle → Fig. 10. After consideration, the team decided against an additional visual cue in the form of an information graphic on the floor or wall to avoid overburdening the KARMIN patient room with multiple visual sensations. Secure locking mechanism Unfortunately, objects are repeatedly stolen from hospitals, making it necessary to provide a not immediately obvious means of securing the dispenser bottle against removal. At the same time, it must be easy to handle so that it does not impede maintenance. A ring on the underside, a latch, screw mechanism or locking hook are possible solutions.

11 Renderings from the design phase

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Conceptual structure The conceptual ideas outlined so far already suggest a certain structural composition for the dispenser. For example, the electronics must be housed so that they are not exposed to liquid when the dispenser is cleaned or prepared for use. A display is also needed to show the emoticons. Ease of cleaning is a further determining factor: the surfaces should be smooth, the transitions between them rounded and the number of components minimised to reduce assembly joints between them. For example, traditionally separate pieces such as the back cover and drip tray can be a single component. This can also lead to a more pleasing and less technical shape. In an environment designed to heighten patient well-being while they are in a vulnerable state, the dispenser should not look like a foreign body. A two-part drip tray for easy removal and emptying is not necessary when it can be easily wiped clean. To reduce maintenance, power consumption and purchasing costs, no contactless pump electronics have been used, making it possible to position the sensor system differently. At the same time, conventional pump systems have also not been used. Instead, a disposable pump can be integrated into the refill bottle. The bottle and pump are purchased as a single pre-assembled one-way article, reducing the number of components and joints and effectively ruling out improper re-use of pump or bottle. All that is necessary is to insert the bottle upside down into the housing. As such, the system abandons the widely used Euronorm bottle design to achieve a new design for a combined pump-and-bottle principle. Likewise, a contactless dispenser is not necessary: the risk of smear infection from touching the dispenser is sufficiently mitigated by rubbing one’s hands with disinfectant after having pressed the bottle. A means of determining the fill level of the bottle is needed at the front of the dispenser, for example via a visual indicator or window. These various requirements and dependencies result in a concept that combines an upstream-produced bottle, top display, valve on the underside and electronics at the rear → Fig. 11.

The KARMIN disinfectant dispenser For the KARMIN patient room, two different dispensers were selected to best meet the different requirements described above. The first is the KARMIN disinfectant dispenser based on the conceptual ideas discussed here. The other is a commercially available dispenser model comprising a flexible system with a clamp holder and a small dispenser bottle with a disposable pump head. It is smaller in size and can be flexibly mounted. The newly developed KARMIN disinfectant dispenser is a stationary, wall-mounted model that combines the best features of the various existing dispenser systems with new methods to increase compliance → Fig. 12. A central distinguishing feature is the newly designed bottle with integrated dispensing mechanism. The positioning of both these dispenser types is determined by the arrangement of the room and the elements and objects within it along with the pathways of the staffs’ work processes. The intention is that they support both patients and staff in practicing hand hygiene and thus ultimately in infection prevention. Despite the higher cost of the KARMIN disinfectant dispenser, it is still cost-effective as its use can reduce the number of nosocomial infections, saving costs for longer hospital stays or patients returning with recurring infections.

12 Design sketches of the KARMIN disinfectant dispenser

13 Disinfectant dispenser above the worktop

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Disinfectant Dispenser

Positioning The correct positioning of disinfectant dispensers in the patient room is essential to increase compliance and saving nursing staff unnecessary journeys. An ideal, easily accessible location is on the wall above a workplace with supplies cabinet and worktop close to the bed. Mounted clearly visible on the open wall surface, it allows staff to quickly disinfect their hands before and after handling materials for patient care. This location was selected for the KARMIN disinfectant dispenser → Fig. 13.

14 Disinfectant dispensers mounted on the bed rail lie directly on the nurses’ path of action.

15 Positioning of the dispensers (orange) in the ­KARMIN patient room with typical workflow paths

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The position of the supplementary dispenser type is similarly optimal at the foot of the bed where the nursing staff pass it during their work. In addition, it is immediately visible when switching between patients. The nursing staff do not need to return to the worktop or the entrance to disinfect their hands, as in conventional rooms, but can reach it from either side of the bed while caring for the patient. The flexible clamp allows the dispenser bottle with vertical pump head to be mounted where desired on the tubular rail at the end of the bed. A model without extra housing was chosen for its small size so that it projects as little as possible into the room, thus minimising accidental collisions at the relatively exposed location. The combination of dispenser types ensures the transitions between the room zones within the room are equipped with hand hygiene measures → Fig. 14. A further KARMIN disinfectant dispenser is positioned in each of the wet cells, to the left of the washbasin in a shelf niche above the waste bin flap. Its different appearance and position to one side of the washbasin prevents a mix-up between the soap and disinfectant dispensers. Soap is for washing off coarse dirt before disinfecting one’s hands. The arrangement places the soap dispenser in full view when entering the room, whereas the disinfectant dispenser is slightly set back to protect it from collisions with wheelchairs or other objects on the sealed surfaces of the wet cell. The niche must be large enough to be able to mount the dispenser during installation and to easily reach the pressing surface in use. The dispenser must also be clearly visible and not obscured by elements projecting into the room. The positions of the three disinfectant dispensers – above the worktop, at the end of the bed and in the bathroom wall recess – are mirrored on the other side of the room, so that the same number of dispensers are accessible on both sides of the room → Fig. 15. For optimal accessibility, the dispensers must be not just sensibly distributed across the individual room zones but also mounted at an appropriate height. This plays a key role in increasing compliance. It is important, for example, that projecting fittings or excessively high mounting heights do not prevent smaller people or people with restricted reach such as wheelchair users from reaching the pressing surface. In the KARMIN patient room, the worktop can be driven under by a wheelchair and is not very deep so that wheelchair users can reach the dispenser. For optimal use, the dispenser should be mounted so that the pressing surface is approx. 120 cm above floor level. Display function and colour A disinfectant dispenser must be clearly visible and suitably inviting, but at the same time not visually intrusive for either staff or patients. A matt white was therefore chosen for the housing so that it contrasts with the wall colour above the worktop and with the texture of the wall niche in the bathroom. The bottle, on the other hand, has a muted red colour that signals its presence but is not overly garish. A symbol on the pressing surface additionally indicates where to press. The diagonal underside of the housing allows the valve head of the bottle to project so that it is clear to users where and in which direction the disinfectant will be dispensed. To appeal to injunctive norms, a display above the bottle shows a concerned-face smiley against a yellow background that changes when sufficient disinfectant has been dispensed. A concerned-face rather than a sad-face smiley was chosen so as to avoid overly negative connotations. By appealing to injunctive norms, it encourages use of the dispenser. The circle that usually frames a smiley was removed so that the face is framed by the display housing and perceived as belonging to the dispenser and being integral to its design → Fig. 16.

Other forms of visual or auditory feedback are not provided to avoid placing further demands on the attentions of staff and patients. Nursing and medical staff are already exposed to multiple audio-visual stimuli in the hospital environment and a dispenser should not add further sensory load.

16 Comparison of a smiling, concerned and sad smiley

RFID

RFID RFID

RFID

RFID

17 Recording user groups upon entry and use

Data acquisition To help improve compliance, the KARMIN disinfectant dispenser is equipped with various sensors for data acquisition. They ensure that the dispenser is always properly supplied with disinfectant, help appeal to injunctive norms and record usage statistics. The entrance door area as well as the four KARMIN dispensers in the room are equipped with RFID readers with different ranges that make it possible to monitor the user group of persons (also equipped with RFID readers) entering the room → Fig. 17. This can then be used in a more targeted manner to analyse ways of improving compliance. Rather than warning staff when disinfectant usage is too low, the data provides a more useful basis for constructive feedback and friendly reminders during team meetings. At the same time, a pressure sensor in the housing of the disinfectant dispenser records every press of the dispenser. This data can be used to calculate the fill level of the dispenser. When a low fill level threshold is reached, this data is transmitted as a data packet along with other usage statistics via wifi to a central server. This data packet approach means the emitting unit does not need a permanent power supply. The fill level can also always be viewed manually through the front viewing slot should the electronics not function correctly. The pressure sensor also triggers a change of the smiley motif, rewarding the user with a smiling face on the display when enough disinfectant has been discharged. After a few seconds, the display reverts back to the concerned-face smiley, so that the motif doesn’t change constantly when a user presses unnecessarily often on the bottle. Display The display of the disinfectant dispenser must be clearly visible but not intrusive. By positioning it above the dispenser slanted slightly upwards it is clearly visible to users but not in the patient’s direct field of vision, so that patients in bed are not unnecessarily burdened by the concerned-face smiley. To reduce energy supply requirements, an e-ink screen is used which has no refresh rate and only requires energy to change the motif during operation of the dispenser → Fig. 18. Power supply The KARMIN disinfectant dispenser uses the kinetic energy produced by pressing the disinfectant bottle to supply the dispenser with power. This reduces the frequency of maintenance and with it the risk of germ contamination when replacing batteries. Pressing the bottle generates energy that can then be used to change the e-ink display to show a different image.

18 The disinfectant dispenser displays a smiling face after use.

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Disinfectant Dispenser

19 Pressing the bottle to dispense the disinfectant

Pressure-operated dispenser bottle To meet the diverse requirements for ensuring a constant, reliable and hygienic supply of disinfectant, a dispenser bottle was developed that reduces the number of necessary parts, functions mechanically and also allows precise quantities to be dispensed. The flexible body of the bottle, when pressed, opens a pressure-release valve that dispenses the disinfectant. A two-chamber system in the valve head allows the dispensing charge to be regulated, i.e. the quantity of disinfectant expelled. The bottle is inserted upside down into the housing so that the convex bottom of the bottle acts as the pressing surface. This is large enough to be operated by hand or with an elbow. Pressing on the bottle creates a pressure build-up in the bottle that opens the concave valve diaphragm → Fig. 19. The valve is permanently mounted on the sealed bottle so that it cannot be refilled risking contamination. Should replacement bottles not be available due to supply difficulties, such as in a pandemic, the dispenser can also be used with regular Euronorm bottles with pump heads which are made by numerous manufacturers. Construction and materials The design of the disinfectant dispenser is determined by the requirements for the material, the mechanics, the space needed for electronic components and ergonomic considerations. The choice of a suitable material is essential to ensure easy cleaning. As the dispenser does not need to be autoclavable, and plastic offers better design possibilities in terms of form, haptics and appearance than aluminium, ABS plastic was chosen for the housing. The casing can therefore be cleaned in a dishwasher. The dispenser bottles are made of a flexible plastic through which alcohol cannot evaporate, retaining the alcohol content of the disinfectant in the long term. In addition, the material is resistant to chemicals and can withstand repeated compression by pressing on it. By dispensing with conventional bottles and pumps – made possible by incorporating several components into one unit – the number of components can be reduced, resulting in fewer joints that can be colonised by germs → Fig. 20. As the new bottle system is not yet in production, the bottle housing is dimensioned so that it can also be used with Euronorm dispenser bottles.

20 A central principle of the KARMIN disinfectant dispenser is the reduction of components. The housing comprises just three parts. The pump and the bottle are combined in a single component.

21 Hidden anti-theft protection: Pressing the drip tray holder releases a catch to remove the dispenser.

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Form The rounded housing is formally a single, closed unit, giving it a restrained, non-technical appearance that is more approachable than existing models. Due to its verticality and the curvature of its rear wall, it has a slim appearance, sits lightly on the wall and fits discreetly into its surroundings. All transitions between the different parts – for example, the bottle holder and screen surround – are curved and seamless, making it easy to wipe clean. The mechanism for opening the back plate and hanging the dispenser is concealed to discourage theft. The flat bar of the drip tray holder must be pressed to release a catch so that the body can be slid up and away from the mounting. The mounting plate and screw fitting for attaching it to the wall then becomes visible → Fig. 21. The KARMIN disinfectant dispenser thus combines new findings for increasing compliance and supports staff through its optimised, easyto-clean form. The shape and curved forms of the housing guides the hand when cleaning and wiping down with disinfectant. The dispenser's design and positioning → Figs. 22, 23 help trigger the users’ memory, draw their attention and help them take decisive action. Switching a hospital to an optimised disinfectant dispenser such as the KARMIN dispenser described here is a not inconsiderable investment that not every clinic will be able to afford, even if it reduces costs further down the line by preventing infections. Hospitals are also already

22 Front view of the KARMIN disinfectant dispenser

2 3 The position of the KARMIN disinfectant dispenser above the worktop

4 Mechanical 2 dispenser with lenticular image before pressing the lever

5 Mechanical 2 dispenser with lenticular image after pressing the lever

23°

26 The working mechanism of the lenticular image

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equipped with a large number of disinfectant dispensers. These are not necessarily optimally positioned with a view to preventing infection control but could continue to be used with some appropriate corrective measures. Aside from placing existing dispensers closer to the pathways of the staff’s work processes, other means of improving compliance are also possible. An alternative mechanical approach to appealing to injunctive norms has, therefore, also been devised that needs no power source, statistical sensors and not even a display. Instead it employs a two-phase lenticular image mounted directly on the pump lever that alternates between a concerned-face and a smiling-face. The mounting height and angle needs to be adjusted to ensure the image is seen correctly for people of average height. Depressing the lever changes the angle of the lever and with it the viewing angle of the image. Here too, the lenticular image must be designed so that a user sees a single transition from the two image phases of concerned-face and smiling-face when the lever is pressed → Fig. 26. A study of the effectiveness of such injunctive norm methods (Gaube et al. 2018) showed that the motivating effect of the image declines after about one month. One way of addressing this is to use different motifs in different delivery batches of disinfectant. The lenticular images can then be switched when bottle refills are installed, presenting a fresh image to the user. These lenticular images can be cut to fit most common dispenser models. This cost-effective principle has been tested in the context of KARMIN, using the commonly available Eurospender Safety Plus dispenser model → Figs. 24, 25; however this particular configuration is not used in the KARMIN patient room.

The Patient Bedside Cabinet

The bedside cabinet is part of the standard repertoire of a patient room and is actively used on an everyday basis. Through its location within easy reach of the patient, it is exposed to their pathogens by touch, droplets and airborne aerosols, and its surfaces are thus highly prone to colonisation with germs. Because it serves many purposes and is actively used, patients are highly likely to come into direct contact with its surfaces and with objects stored inside or on the bedside table. Avoiding contact infections is therefore a matter of carefully examining how it is used in practice and devising ways in which appropriate design can encourage safer interactions. One must examine when and where which persons touch or put down which objects. The aim in developing the KARMIN bedside cabinet was, therefore, to examine ways in which one can raise the infection prevention potential of this object while at the same time creating a patient-friendly design that reflects the many diverse requirements it must fulfil.

Potential properties of a patient bedside cabinet

1 A wide variety of objects are placed on a bedside cabinet.

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The bedside cabinet is expressly for the patient’s use for the duration of their stay in hospital. Nevertheless, nursing staff sometimes also use the surfaces and drawers to briefly store work utensils, usually due to a lack of available work surfaces near the bed, insufficient training or time pressure when working. Where workplaces in the room are not available and there is not enough space to wheel in a supplies trolley, staff often place kidney dishes on the bedside table, where they sit alongside inhalers, books, trays, smartphones, flowers, alarm clocks, medication and glasses. Other objects also placed on the table include meals, dishes, cutlery, pill boxes or drinks that are brought in by various groups of people including nursing staff, visitors and patients → Fig. 1. These are all points of contact where an undesirable and unnecessary transmission of pathogens can occur. Elderly and frail patients may also require additional support depending on the situation, and nursing staff may then unavoidably have to touch personal items. Sometimes the tabletop or bedside cabinet is so full that different user groups may need to move items out of the way to place something on it. Where space is needed around the bed, the entire cabinet may be wheeled to one side by nursing staff. How these different user groups grasp and touch the table can be partially (but not completely) directed by means of affordance, i.e. the usage characteristics that an object innately suggests. For the most part, however, its surfaces are also colonised independently of touch by patients, visitors or medical staff talking or sneezing. As such, unnecessary touching should be minimised wherever possible and cleaning made as simple as possible. The bedside cabinet is therefore a central source of possible infection in the patient room. At the same time, it must necessarily be placed close to the patient to fulfil its purpose. The best way to improve its infection prevention potential lies in simplifying cleaning and disinfection of the surfaces and reducing the incidence of contact by making it less necessary to shift around. A first step is to design a patient room to be large enough to place the cabinet close to the bed without obstructing access to other equipment. It should not block access to the patient or to necessary work-related installations such as the nurses’ equipment store or the bed headwall and its connections so as not to lose valuable time in the case of an emergency. Similarly, the bedside cabinet should not be too voluminous so that it does not collide in the vertical plane with other objects such as a bedside terminal. The tabletop should be an integral part of the cabinet as otherwise two items of furniture are required, which then both need preparation and sterilisation, often outside the room. When cleaning, staff can also ask patients to remove

their own personal objects from the bedside table so that staff do not need to touch them. For this, the patient needs access to shelves and drawers on different sides of the bedside cabinet so that they may stow away their belongings.

2 Accessibility: the areas marked in blue are most ­accessible and therefore most frequently used.

Organisation One way to counteract an excess of objects placed on the bedside table is to provide alternative usage-specific surfaces and storage spaces. Objects can then be made easier to store or be grouped according to need, while others can be stowed away so that they are harder to retrieve. A large number of objects on the bedside table is an obstacle to cleaning and can promote cross-contamination. The volume of the bedside cabinet can be divided both horizontally and vertically to create compartments of differing accessibility, which in turn affects the frequency with which patients access certain sections → Fig. 2. This can be an effective means of controlling stowage. Privacy and patient comfort Privacy is related thematically to the aspect of organisation. A patient typically lies prone and vulnerable in a patient room to which many have access. They may have valuables with them that are important to them. As such both the patient and their belongings are vulnerable and in unfamiliar surroundings. Even when a safe is available, some patients may be physically restricted and unable to use it. This influences where they place their possessions. Incorporating a lockable drawer in the bedside cabinet is therefore essential so that patients can store their wallet, smartphone or laptop within easy reach but protected against theft. The patient cabinet itself can also function as a way of marking personal space, shielding the bed area from those of other patients. Patients therefore perceive the patient cabinet as an extension of their personal realm. This aspect is particularly important for older patients and must be considered in the design. Although more slender and more open items of furniture are becoming increasingly popular, the bedside cabinet can be more opaque and solid. The lockable part should at least convey a robust and trustworthy appearance. A key or RFID chip is best for locking a drawer as patients are prone to forgetting a code, and not just when they have dementia. Similarly, a familiar design that is not overly technical or medical will be more readily accepted by patients and can have a calming effect. This is also relevant to infection prevention potential as strengthening the immune system and successful recovery contributes to the patient’s mental well-being. In short: the design of the patient bedside cabinet and table must be patient-friendly.

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Patient Bedside Cabinet

3 The patient bedside cabinet should be usable on both sides.

4 Design sketches for an opaque bedside cabinet version with tubular frame

Positioning The bedside cabinet is located in the often-congested space next to the patient’s bed. Alongside the cabinet, there may be a bedside terminal, a disinfectant dispenser, and possibly also an infusion stand, an oxygen unit or other items of medical equipment. Moving it may require care to avoid collisions with other items in the vicinity. To avoid becoming entangled with swivel arms, cables, hoses or medical supply lines, the bedside cabinet should not have protruding parts or an excessively open structure in which things can get trapped. A bedside table with an electrical supply for electrical components such as a refrigerator is less ideal. A power cord makes it less easy to move the bedside cabinet, as a plug has to be pulled when cleaning the room, and this can encourage cleaning omissions. Whether the bedside cabinet is positioned to the left or right of the bed depends largely on the room layout and the patient’s respective clinical picture, which may require more intensive care or access to the patient from a particular side of the body. This means that bedside cabinets sometimes have to be moved from one side of the bed to the other. Consequently, bedside cabinets must be flexible, usable from either side and cordless so that staff can perform their nursing procedures unobstructed and to the full extent without having to work around furniture → Fig. 3. Preparation Patient bedside cabinets are not classified as medical equipment and are therefore not subject to the same cleaning, disinfection and sterilisation requirements. Nevertheless, they bear certain parallels to the design requirements for disinfectant dispensers. The cleaning and preparation of a large number of objects is a logistical challenge for hospitals, and digitalisation can help incorporate these into existing workflows by making it possible to determine where each bedside cabinet is located, how long it has been in use and whether it is already clean. QR codes or RFID chips can be used as identifiers for locating mobile items and to document their machine processing history, providing a better means of monitoring and verifying logistical processes. This becomes increasingly essential as bed occupations become shorter and change more frequently. Alongside these organisational aspects, the construction of the bedside cabinet must be suited to machine cleaning: for example, water must be able to drain from drawers or similar enclosures without leaving any residue, and the material must be thermally suitable for the washing processes. In terms of its form, seamless surfaces and curved transitions are more suitable than sharp-edged or angular changes in surfaces. Inevitably, this may mean a reduction in the number of components, which is also advantageous in the event of spillages of food or beverages. When surfaces are unbroken, these cannot seep into joints and form a breeding ground for germs. The same applies to manual cleaning and wipe disinfection: undercuts in the form should be avoided and sufficiently large, reach-through openings help to simplify cleaning. Material Seamless forms can be produced using rotational or injection moulding processes but only with plastics, which are not always sufficient strong to withstand the weight of a person leaning on them. Polypropylene (PP), polyethylene and melamine are all suitable, and the latter is particularly scratch-resistant and therefore ideal for intensively used surfaces such as the tabletop and the top of the bedside cabinet. High-pressure laminate (HPL) is a sheet material that is exceptionally durable, smooth and easy to clean but it can only be bent in two dimensions. Bending is

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Prototype

nevertheless preferable to joints and screw-fixings. Stainless steel is very stable but has a cold surface and is heavy, making it difficult for weak patients to manoeuvre. Nursing and cleaning staff, who have to move such items regularly, likewise appreciate lightweight bedside cabinets. Requirements for a bedside cabinet The design of a bedside cabinet can aid patients in the organisation of their personal belongings by creating specifically shaped elements and compartments that determine how they are used and how easy they are to reach. For example, certain sections may only be deep enough to hold magazines or a tablet. A shoe rack can avoid the patient’s slippers from being scattered about the room, and a recess or holder for a bottle in a drawer or on the outside can avoid too many loose objects from being placed on the top surface. One must also consider how drawers and trays are to be fixed to the cabinet. To be useful to the patient, the tabletop must be ergonomically adjustable to the patient’s height and the position of the bed. It must be able to be swivelled and extended in vertical and horizontal directions. Similarly, a waste bin could be incorporated to avoid the build-up of smells but this then also needs to be emptied regularly. In the case of the KARMIN bedside cabinet this is not necessary as there is already a waste bin in the nurses’ cupboard by the worktop.

A concept for a bedside cabinet Before taking concrete steps towards designing a new bedside cabinet, it is worth looking at how existing models address these many different requirements. Benchmark A wide range of models of bedside cabinets are available on the market for intensive care units, private healthcare wards, standard care wards, geriatric healthcare and care at home situations, each of which have different requirements. Whereas in Germany, bedside cabinets are rarely made solely of plastic and have many joints where the different materials meet, manufacturers in other countries have been offering models made of injection-moulded components for some time. However, none of these are as homely as products made, for example, of imitation wood. The fittings they offer also differ: some models include a holder for a smartscreen or tablet, but this comes at the cost of restricting the mobility of the unit due to the necessary cabling and an additional projecting swivel arm. A tablet holder should therefore be avoided and instead a bedside terminal used. A terminal suspended centrally from the bed headwall is also easier to access from both sides of the bed than a tablet limited by the reach of a swivel arm attached to the bedside unit. Some concepts also offer a charging station for mobile devices. Here, too, the KARMIN bedside cabinet opts not to restrict mobility through the need for a power cord and therefore does not include an integrated charging station for mobile devices. Various solutions also exist for allowing a bedside unit to be used on both sides of the bed. Some bedside cabinets have push-through drawers openable on either side; these require a slightly wider mechanism than a conventional drawer to ensure middle and end locking in either direction. Other models allow the tabletop to be taken out and reinserted on either side without the need for tools. Another variant involves swivelling the entire body of the cabinet on its base, though this requires a relatively chunky rotating mechanism that reduces the storage space appreciably. The push-through drawer that opens in both directions was felt to be most appropriate for the KARMIN

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Patient Bedside Cabinet

bedside cabinet because very little effort is needed to switch sides in everyday use and the mechanism can be optimised for better hygiene. This benefits nursing and cleaning staff equally. Commercially available models also have different solutions for the call button, for the parking brake and in their choice of materials. For the KARMIN patient room, the call button is located on the bedside terminal rather than the bedside cabinet. The models also differ in their choice of material. Different HPL decors are used, some in plain colours, some with a wood-effect surface. In the case of plastic elements, so-called terrazzo plastic patterns are generally avoided due to the more complex production and mechanical disadvantages, but plain coloured models are offered. For the smooth rolling of the bedside unit, almost all models use double castors with an integral parking brake. They have the advantage of being more stable and better able to absorb the weight of patients supporting themselves on the furniture. Several manufacturers provide a fifth wheel beneath the dining tray to prevent tipping. Conceptual structure As the KARMIN bedside cabinet is a model for a standard care room, a fridge is not necessary. The need for a power supply and cord for the refrigerator further reduces the space available near the patient and the mobility of the unit. In this case, only shelves and compartments are needed. To aid preparation and cleaning, a system of modules inserted into a tubular metal frame is proposed. It can be easily adapted to individual patient needs and leaves sufficiently large space for easy cleaning. It also means that all areas are easy to wipe clean with disinfectant. However, this variant with its open structure is less ideal as a means of ensuring privacy. Alternatively, the volumes can be divided into different zones allowing the nurses to have lateral access to medication and care materials in a compartment not immediately accessible to the patient. In the case of the KARMIN patient room, this is not necessary as a dedicated workplace and nurse’s supplies cabinet is already available near the bed. To suggest more specific usage patterns, a cup and bottle holder can be provided on the top surface → Fig. 4. Time can be saved during cleaning by choosing an openly visible compartment structure. This is easier to clean, since, unlike closed drawers, contamination is directly visible on inner surfaces. In addition, slotted-in compartments can be easily removed to access gaps between them, which is much less laborious than screwed-on items. However, a disadvantage is that the open structure does not provide the same measure of privacy. Material When deciding between wood-effect HPL in panel form and freely-formable injection-moulded plastics, one must consider the relative benefits of reducing the number of components and construction joints for better cleaning versus a comparative lack of visual and tactile warmth. One should also consider the relative benefits of plain coloured versus patterned surfaces such as wood-effect panels. Because it is easier to detect dirt on plain surfaces, a pure white plastic material was proposed for the KARMIN bedside cabinet. The colour and feel of the cabinet should fit into the overall concept of the patient room. A coherent, coordinated concept contributes to providing a calm environment for the patient. In addition, the material is also machine-cleanable. Given the projected increase in overweight and elderly patients in future, the frame must be sufficiently sturdy to withstand the weight of a person leaning on it.

The KARMIN bedside cabinet The design of the KARMIN bedside cabinet represents a trade-off between weight optimisation, robustness, patient friendliness, manoeuvrability and ease of cleaning.

5 KARMIN bedside cabinet with objects placed on or in it. The lowered section of the edge lip makes it easier for the patient to see the top from a lying position. At the same time, it serves to contain objects within the top of the unit.

Design of the prototype In order to be able to absorb the load of transverse forces, the KARMIN model is based on a stable frame from a major manufacturer already available on the market. The base comes equipped with a fifth stabilising double castor beneath the pillar of the extendable, rotatable and inclinable tabletop. The width of the double castors reduces the risk of tipping. The frame has been optimised and modified with a view to reducing the number of components. The slot mechanisms for the sliding drawers were simplified and hard-to-clean ledges and projections removed. The top of the unit has a simple seamless raised lip around the perimeter and offers more space than many standard models on the market that subdivide the top into compartments with several webs → Fig. 5. Similarly, new seamless drawer units were developed that offer more space than conventional models. The wide handle on the side of the top panel is easy to grip for stable table movement. Its lateral placement means that nursing and cleaning staff generally grip a different part of the unit than the patient lying on their side in bed. The patient can only reach the drawers, the lower compartment and the grip of the tabletop at arm’s length. The upper drawer can be locked with an RFID lock, while the lower drawer offers ample storage space for larger objects. The wide drawer handle makes it easy for the patient to open it from different positions, and the open compartment in the middle provides quick and easy access to frequently used items. The absence of a rear panel and the dual middle and end locking of the drawer position allow it to be used from both sides and make care and cleaning procedures easier. Form, colour and atmosphere The soft, smooth shapes of the bedside table convey a sense of calm coherence. Its design is neither overly complex and fussy nor overladen with multiple different materials. Its clear structure allows the aspect of its usability to come to the fore, and in turn helps strike a balance between privacy – which is especially essential for vulnerable patients – and an open design that is easy to clean → Fig. 6.

6 Front view of the KARMIN bedside cabinet

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Prototype

7 The seamless drawer and top tray are cast with curved edges to reduce the number of components and facilitate easy cleaning of the KARMIN bedside cabinet.

8 The large, easy-­­toclean compartment with curved edging at the lateral sides of the sheet metal shelf

Cleaning The components have been optimised for easy cleaning through a largely seamless design and smooth rounded transitions → Figs. 7–9, 11. The drawers are provided with drip holes for machine cleaning and inaccessible gaps in the construction were avoided. Instead of a key-operated locking mechanism, the drawer uses an RFID lock so that no water can penetrate the keyhole during machine cleaning. The top surfaces and contact zones have been kept monochrome to make contamination easier to detect. The side walls, which are rarely touched, have been given a wood texture, lending a homely touch to the otherwise clean design of the unit. Through these simple constructive means, the bedside cabinet succeeds in raising the infection prevention potential of the object and becomes incorporated into the overall design of the patient room → Fig. 10.

9 The top tray-like ­surface is easy to clean

10 The KARMIN bedside cabinet in the context of the patient room

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1 1 The rounded edges of the tabletop help reduce the number of joints.

The Bedside Terminal

1 Digital networking of services and communication inside and outside the hospital via a server

As a consequence of economic constraints and technological advances, workflows in modern hospitals are becoming quicker and being digitalised. Examples include the collection and transfer of data on patients on admission to hospital, the use of telemedicine to consult external experts or the digital monitoring of a patient’s vital signs during a hospital stay. Processes and activities are changing, and in some cases new devices are supplementing existing work equipment. The automation of information transfer has drastically reduced the transport of patient files and made it possible to look up and print out patient data as and when needed. Apps can help prepare patients prior to arrival and allow medical staff to follow up on cases afterwards. Patients can be informed of procedures and precautions in advance while at home, as well as during their stay, and hospitals of any relevant personal information about the patient. For the aspect of hospital hygiene, these developments present both new possibilities as well as new challenges. New devices such as the bedside terminal in the patient’s room and portable monitoring devices have made inroads into everyday hospital practice. In Germany, bedside terminals are currently usually only available in rooms for private healthcare patients. Mounted on a swivel arm near the patient bed, the bedside terminal is essentially a small digital device with which patients can access the hospital’s various digital services or entertainment media, depending on the system. Often, certain content is only available if purchased privately by the patient. Staff are also increasingly being equipped with mobile devices to record and receive information directly where they are. As physical objects, these devices represent colonised contact surfaces that can be a vehicle for cross-contamination. Mobile devices carry pathogens in and out of a patient’s room; they are deposited in various places and touched by a variety of people. But digitisation also obviates the need to carry around clipboards with paper-based patient records. To entirely replace analogue patient files with digital records, the respective user groups must be equipped with devices and suitable access rights to the relevant information. The direct recording and entry of information also avoids the risk of loss of information or errors occurring with manual data transmission. Digital devices can additionally provide valuable services in infection prevention, including the ability to document the preparation and cleaning of objects for patient rooms, and patient empowerment and education. The bedside terminal is ideally suited for these last two applications, and for this reason, it was also selected as a hygiene-relevant object in the patient room for investigation as part of the KARMIN project. In addition, it makes it possible to call up required medical information and knowledge at the point of care in the event of an emergency → Fig. 1.

Patient empowerment and education

2 A patient using a bedside terminal

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Infection prevention education Patient empowerment aims to provide patients during a period of treatment with knowledge so that they can play an active role in supporting their recovery and participate in facilitating processes. Research has shown that independent, informed patients can be treated more successfully (Powers, Bendall 2008). Helping patients understand their own health condition and the treatment they are undergoing can, among other things, assist them in managing stress levels and in communicating about it. Informed patients have a better understanding of the care processes and also of restrictions, for example with regard to nutrition. Educating patients on hygiene-related aspects can also encourage better infection prevention practices during their stay (McGuckin, Govednik 2013). The question is therefore how one can best educate and

convey information to patients through digital content via the bedside terminal → Fig. 2. During treatment in hospital While patients are in hospital, the process of recovery can be assisted by encouraging movement and informing patients of the consequences of a lack of activity. This can be achieved by physical means, for example by replacing the patient’s bed with chair beds during the day and moving the patient into a more active, upright position, as well as by encouraging patients to get up and move via instructional information, videos or games presented via the bedside terminal. Activity strengthens the immune system and patients recover more quickly (Pashikanti, Von Ah 2012; Schaller et al. 2016). Shorter periods in hospital also reduce the risk of nosocomial infection. After treatment at home The concept of patient empowerment also encompasses giving the patient the opportunity to provide feedback on their stay in hospital. Many hospitals already ask patients to fill out questionnaires to gain valuable information for quality management procedures and therefore potentially also for infection prevention. In addition, doctors should provide medical recommendations for patients and how they can adjust their lifestyles to remain healthy. This can help them adhere to advice given beyond the duration of their period in hospital. For example, helping patients understand dietary recommendations can prevent future hospitalisation. Such health-promoting measures can be part of services provided via a bedside terminal. For all the above forms of communication, the bedside terminal acts as an interface for the transfer of information between patient and hospital. At present, however, digital content provided by a terminal must typically be paid for by the patient, especially in standard care wards. Hospitals must ensure that this does not hinder the communication of essential, medical or hygiene-related information; optional extras bookable by the patient should be limited to the entertainment sector.

Requirements for a bedside terminal Content A bedside terminal must address a range of topics and fulfil diverse functions. Alongside information on the daily schedule, it can provide educational information on infection prevention. It can also be used to remotely control other equipment in the room, for example enabling bedridden patients to control lights and temperature, to operate the blinds or change the backrest position. This provides a way of bundling traditionally separate, manual controls in a single interface used by one person, thus minimising situations where contact infection can occur. Video calls, making notes, telephoning and filling out feedback forms can likewise all be facilitated by a terminal, as can entertainment services such as television, radio, a newsstand and internet access. A further opportunity to engage patients is through the use of so-called “serious games” on topics related to health, and training health-promoting behaviour → Fig. 3. Many adults are increasingly open to the gamification of educational content and it is no longer solely reserved for young patients. The bedside terminal should be for the patient’s use only. Hospital staff should have their own equipment. To allow nurses or medical staff to share information during patient consultations without touching the patient’s touchscreen, an interface must exist that enables medical staff to share information from their device with the patient’s display terminal.

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Interface The full potential of a terminal for patients can only be realised if content and topics are sensibly and intuitively grouped so that patients can access it. For example, the menu system can prioritise informational content over entertainment content. Inclusive, accessible design is likewise important: content must be accessible to deaf or blind users, for example by providing information in audio as well as written form. For older patients, too, adjusting text size and contrast must be possible to ensure content can be read. Similarly, content must be available in multiple languages for patients not proficient in the dominant language used in the hospital. Tutorials on using the terminal can also be provided to help patients find their virtual bearings. Structure of the terminal Alongside the requirements for software and content, various specific hardware requirements must also be met. Since the surfaces of devices are generally colonised by pathogens, the housing of the bedside terminal must be constructed so that it is easy to clean. This includes minimising the number of components so that the housing is as seamless as possible, using materials and surfaces that can be wiped clean without being damaged by alcohol or other ingredients, and a shape that has rounded corners and edges for easy cleaning. The curvature should be ergonomically formed so that it can be comfortably wiped clean in a single movement. Since liquids are used, any vents for internal components must be watertight, or other means of heat dissipation must be found. Alongside these hygiene aspects, a bedside terminal can have a USB port and a headphone jack for charging and use with patients’ mobile devices. Wifi and Bluetooth modules make it possible to additionally synchronise content. The screen’s capacitive touch display can be supplemented by buttons or keys for basic functions so that older patients, for example, can operate essential functions via conventional means. An RFID reader can ensure that only the authorised patient can use the device. The bedside terminal should be mounted on a swivel arm that permits it to be freely and easily moved without undue resistance. The arm must be securely fixed to the wall’s surface, usually via bracket mounting on a double-planked plasterboard base. Aside from a connection to the power supply, the terminal must also be connected to the hospital’s public network infrastructure via a LAN socket or DSL connection. It should also incorporate a call button to alert staff via a light signal and an on-off switch on the swivel arm to safely disconnect the terminal from the mains where necessary. Positioning The bedside terminal must be easy for patients to grasp but should not obstruct or cover other relevant items near the bed or obstruct cleaning or care provision procedures → Fig. 4. This also applies to avoiding it casting shadows from the reading light or HCL lamp above the patient’s bed. Furthermore, the terminal should be operable from both sides of the bed: a wall-mounted swivel arm has proved more suitable than mounting it on the bed or the ceiling → Fig. 5. The swivel arm should be easy to mount and dismount and must have a radius limiter to prevent either the terminal or the arm segment from hitting the wall.

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A concept for a bedside terminal The requirements for the infection prevention potential of a bedside terminal concern not just its physical properties and ease of cleaning but also the content it provides. Its primary potential lies in providing educational information on preventing infection transmission, on encouraging active personal participation and motivating physical exercise, and on avoiding cross-contamination by providing separate touch surfaces and controls for each patient. The terminal must therefore combine content and technology from both public institutions and private companies. Use The diverse functions and content that bedside terminals provide means they are in frequent use, whether for personal communications, entertainment or as a source of information on hospital procedures and treatment. The call button is likewise increasingly incorporated into the terminal, including an option to specify the reason for the call. This can be used later to analyse care response patterns across multiple wards.

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The different possible uses result in a complex menu structure often with many sub-options. To aid immediate usability by persons of all age groups, it can be advisable to provide user interfaces adapted to different patient profiles. A patient can select their profile, for example older patients with sight impairments may be presented with larger text, audio options and simplified, less dense content choices. The interface should encourage patients to view educational content, however patients are typically more easily attracted to entertainment media. Various methods can be used to counteract this. One possibility is to first display an obligatory one-time message on educational content before other content can be accessed. This strongly instructive and restrictive approach can, however, negatively affect compliance. Another approach is using pop-ups that at regular but tolerable intervals draw attention to educational content on good hygiene practices. A further method of ensuring infection prevention information is not buried among the multitude of other information is to prioritise it in the menu hierarchy so that it is available right from the start → Fig. 6.

Format of educational information To not just present but successfully impart educational information to patients, an appropriate format must be chosen. Patients respond better to visual information and are less inclined to read textual instructions. As such, informative videos are an eminently suitable format. Another option is to train patients through instructive games.

The KARMIN Suite

4 The swing of the arm of the bedside terminal is high enough not to obstruct other movable objects on the ground or get in the way of staff.

5 A wall-mounted bedside terminal does not collide with the mounting of ceiling lights or impact significantly on lighting levels from above.

6 Different hierarchical menu models and the respective focus they place on educational content (marked in red)

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For the KARMIN patient room, a wall-mounted bedside terminal with swivel arm and integral camera and telephone function was chosen. It was important that the terminal could be attached to plasterboard walls. A hygienic housing enclosure frames a Full HD screen, and all surfaces are easy to clean and resistant to damage through disinfectants. The casing has minimal joints and is waterproof, and the ventilation slot cleanable so that the assembly meets the requirements of EN 60601-1. An extra keyboard was discounted due to their susceptibility to dirt accumulation and to reduce the number of items to clean. The display is a commercially available model that already meets the hardware requirements and comes with the underlying operating system but no more. Specific educational content, as well as software for synchronising with other hospital applications, must be added on a customer-specific basis. This enabled the KARMIN team to focus primarily on the design of the content. To implement the conceptual principles of patient empowerment and patient education, a specially developed information interface was created called the KARMIN Suite. Pathogen transmission chain As the screen is so frequently touched, it is potentially a primary transmitter of pathogens. To prevent this, its use is restricted to the patient only: hospital staff cannot enter or retrieve information and the device will only activate with the patient’s RFID bracelet. In the KARMIN patient room scenario, medical staff wear their own mobile device and can synchronise content from their device wirelessly to the bedside terminal. This allows content to be shared and displayed in parallel. By clearly separating the users so that the terminal can only be used by the patient, no pathogen transmission chain is formed → Fig. 7. One cannot, however, prevent a patient’s visitors from using the terminal, for example to view the patient’s daily schedule. This can only be prevented by educating patients and visitors accordingly.

Nudging As not every patient is motivated to inform themselves, they are “nudged” to view educational information. Pop-ups appear at intervals, based on analytical data on the frequency with which educational content is viewed, and draw the patient’s attention to further educational information on infection prevention, sensitising them to the importance of the topic. In addition, the arrangement of icons and the menu navigation prioritise the findability of educational content through their prominent placement.

7 Patient and staff use separate, synchronised terminals.

Menu structure The interface has a central display area and a top and bottom menu bar with general information and important menu items. These can also be brought up via buttons in the housing. Four options are available in the main menu: “Your stay”, “Daily exercises”, “Settings” and “Entertainment”. “Your stay” is the central information point for the patient and leads to submenus with information on meals, the daily schedule, medical information as well as communications and educational content. Private calls can be made with the telephone function. A web browser is also available via the “Entertainment” menu item. In addition to calling a nurse via the call button, patients can provide nurses with more precise information via a text field or as a spoken message. This avoids the room being entered needlessly and arbitrary items being brought into the room. It also saves staff unnecessary journeys to the patient room and allows them to plan their work in a more targeted manner. Colours and icons The associative qualities of colours and icons can strongly influence the perception of content. The KARMIN Suite picks up the colours used elsewhere in the patient room to avoid being unnecessarily jarring or intrusive to the patient. Each of the main menu items and its respective submenus is colour-coded with a signature colour. Alongside the blue tones of the impact protection rails and bathroom door, a red-orange tone that echoes the colour of the seat upholstery is used as well as a matching beige and anthracite. The colours present a harmonious but sufficiently contrasting palette to be easily distinguishable, aiding orientation within the menus. The red tone was assigned to the “Your stay” area to act as a signal directing users to the information on hygiene practices, and the blue tone to the daily exercises. The restrained beige tone is used for the settings while anthracite is the background for entertainment content → Fig. 8. The icons are white to ensure they stand out against the background of the coloured buttons and are easy to recognise. They take the form of 2D line illustrations → Fig. 10 that are simple and easy to read, and have been kept large and not too detailed so that people with visual impairments can recognise them, and people who do not speak the interface language or cannot read are still able to use the interface. Patient education Patient education has a dedicated menu with videos on the topics of hand washing and hand disinfection. A narrator guides the patient through the three questions “Why?”, “When?” and “How?”, explaining each in detail accompanied by descriptive video material or animations. This clear division into three questions begins by explaining why infection prevention measures are sensible and establishes a basis for the patient’s self-motivation. The answers to the following questions of “When?” and “How?” are equally important as not every patient is familiar with the principle or practice of good infection prevention. By

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splitting the content into three videos, each explanation is entertaining, and the patient does not need to watch a long video, which may be interrupted in the middle → Fig. 9. Various disinfectant manufacturers, as well as the Robert Koch Institute, the Clean Hands Campaign, the Patient Safety Campaign Alliance and the Federal Centre for Health Education offer relevant content, some of which is freely available. The hospitals can integrate this material into their bedside terminals. 8 Colour scheme of the KARMIN Suite

9 A patient watching an educational video on the ­bedside terminal

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Motivating mobility The consequences of increasing digitalisation, the incorporation of remote controls in the bedside terminal and the patient’s use of their own mobile devices is that patients increasingly find sufficient diversion in bed and are less often obliged to get up. Nevertheless, a stroll along the ward corridor, to the café, into the hospital grounds is advisable, depending on the severity of their illness. The problem of “bedcentricity” can have a negative impact on recovery that should not be underestimated. Muscles are not exercised, blood circulation is not stimulated and cognitive faculties such as orientation are neglected. In older patients, in particular, decubitus and muscle atrophy can occur (Rahayu Ningtyas et al. 2017). To this end, the KARMIN Suite also offers videos of simple physiotherapy exercises that can be performed without help, and also instruct patients in how to use the bed to stand up. Weakened patients can then also be encouraged to leave their bed. The KARMIN Suite motivates the patient to be more active during their stay and encourages patients to behave in a hygiene-conscious manner through informational content. The bedside terminal is therefore part of a comprehensive prevention strategy and can make a meaningful contribution to the reduction of nosocomial infections. To achieve the desired effect, all the methods mentioned above should, however, always be adapted to the specific clinical pictures of the respective patient.

10 Colour scheme and icon design for the K ­ ARMIN Suite

Welcome

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Conclusion

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Conclusion

The optimisation and redesign of central items and equipment in the patient room all contribute to preventing the spread of infection. By linking hardware and software, reconsidering the design of the objects and introducing sensor technology for statistical analysis of processes and actions, it is possible to positively influence hygiene practices and behavioural patterns as well as optimise cleaning procedures. This can be seen in the concepts for the three objects discussed in this book. These various different aspects of infection prevention should not, however, be seen in isolation but considered in the context of the spatial framework of the room, how the objects are perceived and how they interact with the staff’s work processes on an everyday basis. Here potential arises in the transfer and anchoring of knowledge, the creation of an environment that supports clear, decisive action and facilitates carrying out different activities, and in ensuring the availability of necessary materials and surfaces for infection prevention. In concrete terms, this means that objects should be designed to optimise easy cleaning. Curved transitions and minimisation of seams and joints are just as helpful in this context as choosing a suitable material, avoiding unnecessary construction gaps. Codifying objects to document cleaning cycles assists in logistical analysis: once preparatory cleansing has been done, the completed work step can be recorded using an online system by scanning a QR code. A further pillar is informing and animating people in standards-compliant hygiene. Three objects in the room were selected for optimisation and redesign in line with these requirements. The disinfectant dispensers were positioned to lie in the path of the staff’s work processes to ensure best possible accessibility, and a hybrid design concept was developed in which the benefits of electronic data acquisition through sensor technology of usage statistics was coupled with a mechanical system that ensures dispenser operation even in the event of a power outage. In addition, a novel bottle concept simplifies the cleaning of the dispenser and prevents improper re-use of bottles and pumps. A display leverages the principle of injunctive norms to increase compliance using changing motivational motifs. In addition, the bedside cabinet has been optimised structurally and design-wise in line with the aforementioned cleaning principles. Its design also promotes better organisation of the objects stored within it, and the nursing staff have been given dedicated worktops positioned near the bed including a dedicated storage area. Finally, the bedside terminal also plays a central role in the prevention of nosocomial infections: by imparting knowledge, it reinforces hygiene-relevant behaviour and helps empower patients in preventing infections. Videos and serious games provide educational guidance and involve the patient in infection prevention. These measures can be applied equally to the upgrading of existing healthcare facilities or the more purposeful design of new buildings. And many of the findings discussed can already be integrated into existing processes, as several of the resulting measures can be implemented without the need for serious structural changes. While these measures still have to be financially viable, one should also consider the long-term savings made through the reduction in costs resulting from fewer nosocomial infections. Similarly, such purely objective considerations must be weighed up against the more subjective impressions of improved everyday working conditions. These measures make it possible to successively convert existing buildings into environments that are better at preventing the transmission of infections. Where such conversions are successfully implemented, the number of nosocomial infections can be reduced and fewer serious cases of illnesses will develop, ultimately saving lives.

References O. Assadian, A. Kramer, B. Christiansen, M. Exner, H. Martiny, A. Sorger and M. Suchomel, Section Clinical Antisepsis of the German Society for Hospital Hygiene (DGKH), Disinfection Assessment Board of the Austrian Society for Hygiene, Microbiology and Preventive Medicine (ÖGHMP), “Recommendations and requirements for soap and hand rub dispensers in healthcare facilities”, in: GMS Krankenhaushygiene Interdisziplinär, 7(1), 2012, Doc 03 AWMF – Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, Arbeitskreis “Kranken­ haus- und Praxishygiene” der AWMF, Leitlinien zur Hygiene in Klinik und Praxis, in: Hyg Med, 34(7/8), 2009, pp. 287–292 Matthijs C. Boog, Vicki Erasmus, Jitske M. de Graaf, Elise van Beeck, Marijke Melles and Ed F. van Beeck, “Assessing the optimal location for alcohol-based hand rub dispensers in a patient room in an intensive care unit. Recommendations and requirements for soap and hand rub dispensers in healthcare facilities”, in: BMC Infectious Diseases, 13:510, 31 October 2013 Benjamin Chan, K. Homa and K. B. Kirkland, “Effect of Varying the Number and Location of Alcohol-Based Hand Rub Dispensers on Usage in a General Inpatient Medical Unit”, in: Infection Control and Hospital Epidemiology, 34(9), September 2013, pp. 987–989 DIN 18040-2:2011-09, Barrierefreies Bauen – Planungs­ grund­lagen – Teil 2: Wohnungen (Construction of accessible buildings – Design principles – Part 2: Dwellings), Berlin: Beuth Verlag, 2011. DIN EN 12464-1, Light and lighting – Lighting of work places – Part 1: Indoor work places, Berlin: Beuth Verlag, 2011 DIN 5035-3, Beleuchtung mit künstlichem Licht – Teil 3: Beleuchtung im Gesundheitswesen, Ausgabe 07, Berlin: Beuth Verlag, 2006 DIN EN 60601-1, Medizinische elektrische Geräte – Teil 1: Allgemeine Festlegungen fur die Sicherheit einschließlich der wesentlichen Leistungsmerkmale (Medical electrical equipment – Part 1: General requirements for basic safety and essential performance), edition 12, Berlin: Beuth Verlag, 2013 DIN 13080:2016-06, Gliederung des Krankenhauses in Funktionsbereiche und Funktionsstellen (Division of hospitals into functional areas and functional sections), Berlin: Beuth Verlag, 2016 DIN 1946-4:2008-12, Raumlufttechnische Anlagen in Gebäuden und Räumen des Gesundheitswesens (Ventilation and air conditioning – Part 4: Ventilation in buildings and rooms of health care), Berlin: Beuth Verlag, 2008 Susanne Gaube, Dimitrios Tsivrikos, Daniel Dollinger and Eva Lermer, “How a smiley protects health: A pilot intervention to improve hand hygiene in hospitals by activating injunctive norms through emoticons”, in: PLoS ONE, 13(5), 21 May 2018 “Händehygiene in Einrichtungen des Gesundheitswesens. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI)”, Bundesgesundheitsblatt, No. 59, 2016, p. 1200 HOAI. Honorarordnung für Architekten und Ingenieure, as of 10 July 2013 (BGBl. I p. 2276) IEC 60601-1:2005, Medical electrical equipment – Part 1: General requirements for basic safety and essential performance, 2005-12, Berlin: VDE Verlag 2012 Infektionsschutzgesetz, 2011. Gesetz zur Verhütung und Bekämpfung von Infektionskrankheiten beim Menschen (Infektionsschutzgesetz – IfSG). Bundesgesetzblatt 2000, p. 1045, last version as of 8 July 2011 Krankenhausbetriebs-Verordnung. Verordnung über die Errichtung und den Betrieb von Krankenhäusern, Krankenhausaufnahme, Führung von Krankengeschichten und Pflegedokumentation und Katastrophenschutz in Krankenhäusern, Berlin (KhBetrVO), 2006 Krankenhausbauverordnung. Muster einer Verordnung über den Bau und Betrieb von Krankenhäusern (KhBauV0), version December 1976

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Licht.Wissen 07 – Gesundheitsfaktor Licht, Licht im Patientenzimmer, 2013, p. 12, www.licht.de. Last accessed 16 July 2020 M. McGuckin and J. Govednik, “Patient empowerment and hand hygiene, 1997–2012”, in: The Journal of Hospital Infection, Vol. 84, No. 3, 1 July 2013, pp. 191–199 WHO, “My 5 Moments for Hand Hygiene“, WHO Guidelines on Hand Hygiene in Health Care, 2009, https://www.who.int/infection-prevention/campaignsclean-hands/5moments/en. Last accessed 5 March 2020 Ni Wayan Rahayu Ningtyas, RR Sri Endang Pujiastuti and Nina Indriyawati, “Effectiveness of progressive mobilization level 1 and 2 on hemodynamic status and decubitus ulcer risk in critically ill patients”, in: Belitung Nursing Journal, Vol. 3, No. 6, 2017, pp. 662–669 Lavanya Pashikanti and Diane Von Ah, “Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient Population: An Integrated Review of Literature”, in: Clinical Nurse Specialist, Vol. 26, No. 2, March/April 2012, pp. 87–94 Thomas L. Powers and Dawn Bendall, “Improving Health Outcomes Through Patient Empowerment”, in: Journal of Hospital Marketing & Public Relations, Vol. 15, No. 1, 2004, pp. 45–59 Stefan J. Schaller, Matthew Anstey, Manfred Blobner, Thomas Edrich, Stephanie D. Grabitz, Ilse Gradwohl-­Matis, Markus Heim, Timothy Houle, Tobias Kurth, Nicola Latronico, Jarone Lee, Matthew J. Meyer, Thomas Peponis, Daniel Talmor, George C. Velmahos, Karen Waak, J. Matthias Walz, Ross Zafonte and Matthias Eikermann, “Early, goaldirected mobilisation in the surgical intensive care unit: a randomised controlled trial”, in: The Lancet, Vol. 388, No. 10052, 1 October 2016, pp. 1377–1388 Simone Scheithauer, Johannes Bickenbach, Hans Heisel, Patrick Fehling, Gernot Marx and Sebastian Lemmen, “Do WiFi-based hand hygiene dispenser systems increase hand hygiene compliance?”, in: American Journal of Infection Control, 46(10), 2018, pp. 1192–1194 Sebastian Schulz-Stübner, Repetitorium Krankenhaus­ hygiene und hygienebeauftragter Arzt, Heidelberg: Springer 2013 VDI-Richtlinie 6023, Hygiene in Trinkwasser-Installationen – Anforderungen an Planung, Ausführung, Betrieb und Instandhaltung, Düsseldorf: VDI – Verein Deutscher ­Ingenieure e. V., 2013 VDI-Richtlinie 6022, Raumlufttechnik, Raumluftqualität – Hygieneanforderungen an raumlufttechnische Anlagen und Geräte, Düsseldorf: VDI – Verein Deutscher Ingenieure e. V., 2011 World Health Organization (WHO), 2013. www.who.int/ infection-prevention/tools/hand-hygiene/5may2013_ patient-participation/en/. Last accessed 2 April 2020

KARMIN Project Team

Sponsoring partners

Association partners Braunschweig University of Technology (coordination) Institute of Construction Design, Industrial and Health Care Building (IKE) Prof. Carsten Roth

Industrial partners Atos Information Technology GmbH, Munich (Bedside terminal)

Dr. Wolfgang Sunder (head of project) Julia Moellmann Oliver Zeise Lukas Adrian Jurk

BODE Chemie GmbH, Hamburg (Disinfectant and dispenser) Brillux GmbH & Co. KG, Münster (Walls, ceiling)

Charité – Universitätsmedizin Berlin Institute for Hygiene and Environmental Medicine Prof. Dr. med. Petra Gastmeier Dr. med. Rasmus Leistner

Continental AG, Hanover (Furnishing)

Jena University Hospital Septomics Research Group Prof. Dr. Hortense Slevogt

HEWI Heinrich Wilke GmbH, Bad Arolsen (Bathroom equipment)

Röhl GmbH Waldbüttelbrunn Dipl.-Wirt. Ing. Lars Röhl

Kusch+Co GmbH, Hallenberg (Furniture)

FSB Franz Schneider Brakel GmbH + Co KG, Brakel (Door fittings) Hansa Armaturen GmbH, Stuttgart (Bathroom fittings)

JELD-WEN Deutschland GmbH & Co. KG, Oettingen (Doors)

nora systems GmbH, Weinheim (Floor) REISS Büromöbel GmbH, Bad Liebenwerda (Furniture)

InfectControl 2020 is a consortium of commercial and academic partners who together develop solutions for the prevention and control of infections on a national and global level. It was founded within the framework of the "Zwanzig20 – Partnerschaft für Innovation" of the Federal Ministry for Education and Research (BMBF). InfectControl 2020 is a highly innovative research network dedicated to fundamentally new strategies for early detection, containment and successful control of infectious diseases and their commercial implementation. For the first time in Germany, partners from very different sectors such as agriculture, veterinary medicine, climate research, design, architecture, materials research, medicine, infection biology, psychology and public relations cooperate in this unique network.

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Project Team

Resopal GmbH, Groß-Umstadt (Interior fittings – HPL surfaces) RZB Rudolf Zimmermann, Bamberg GmbH (Lighting) Schüco International KG, Bielefeld (Windows) Villeroy & Boch AG, Mettlach (Sanitary objects) wissner-bosserhoff GmbH, Wickede (Patient bed, bedside cabinet)

Glossary Accessibility Accessibility is defined in § 4 of the German “Equality for Persons with Disabilities Act” (BGG) as: “The term accessible (barrier-free) can be applied to buildings and other structures, means of transport, technical commodities, information processing systems, acoustic and visual information sources and communication facilities, as well as other designed environments if persons with disabilities are always able to find, access and use them unaided in the usual manner and without any particular difficulty. The use of relevant disability aids is permitted.” Adherence Adherence refers to the extent to which a person’s behaviour corresponds to the recommendations agreed with the therapist, for example how regularly they take their medication or observe a dietary regime. Affordance Affordance is the quality or property of an object that defines its possible uses or makes clear how it can or should be used, for example an armchair suggests to us that we can sit on it. This signifying character can derive from its physical, material, logical or cultural character. Airlock An airlock is a transitional space between two areas whose environments should not mix, due to different air pressure, different sterility levels, different contamination degrees or different cleanliness, etc. “Aktion Saubere Hände” “Aktion Saubere Hände” (Clean Hands Campaign) is a national campaign promoting hand hygiene by several German healthcare institutions. It aims to contribute to increasing compliance with hand disinfection recommendations and thus to the reduction of hospital infections. Antibiotic An antimicrobial substance that acts against pathogens and is derived from the metabolic products of microorganisms. Aseptic Sterile, free from contamination. Automation Building automation stands for the automated control of technical building functions such as heating, ventilation or lighting. In patient rooms this can apply, for example, to the periodic controlled flushing of water pipes to prevent the build-up of germs in infrequently-used water pipes. Bacteria The smallest organism consisting of only one cell, which can give rise to decay, disease or fermentation. Bedcentricity The term refers to an organisational focus (or design focus) on the patient bed. While it has logistical advantages and the patient is easier to find, it can impede the process of recovery by making patients too passive.

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Appendix

Bedside terminal A computer tablet for the patient’s use near the bed, used for requesting information from patient, providing hospital and treatment-related information, ordering meals and TV/media entertainment. Bed tower A high-rise building predominantly containing nursing wards, especially on the upper floors. Biofilm A biofilm is a thin film of slime or fluid adhering to a solid surface that contains communities of microorganisms in a self-produced matrix. Biocide A category of disinfectants. A chemical used for room and surface disinfection. Candela A physical quantity of light and a unit of luminous intensity. Care categories Hospitals can be ranked according to the intensity of possible patient care. There are four different categories: basic care, standard care, priority care and maximum care. Care unit An alternative term for a nursing ward, often with a special purpose, such as an intensive care unit (ICU) or medium care unit (see also IMC). Chain of infection Describes the sequence and route of transmission of a pathogen. Chemotherapy Drug therapy for the treatment of cancer diseases or infections. Chronic disease Chronic diseases require constant medical treatment and monitoring. The most common chronic diseases include cancer, cardiovascular diseases, multiple sclerosis, rheumatism and epilepsy. Cleanability Cleanability describes the surface condition of a material with respect to how well it can be optimally cleaned to prevent microbial contamination. Coefficient A constant quantity placed before a variable as a multiplying factor. Cohorting An infection containment approach in which patients with the same pathogens are isolated together. Compliance The willingness of a person to actively participate in certain measures. Corona pandemic The Coronavirus pandemic (COVID-19 pandemic) is the worldwide outbreak of the new respiratory disease COVID-19 in 2019.

Cross-contamination Cross-contamination is generally defined as the direct or indirect and unintentional transfer of pathogens from a surface to an object. This can occur, for example, by touching a (contaminated) handle or the hand of another person. Degree of colonisation The degree of colonisation indicates the extent to which a surface is colonised with pathogens. Decubitus Bedsores among bedridden patients as a consequence of prolonged lying in bed in one position. Dementia Dementia is a pattern of symptoms of different diseases, the main feature of which is the deterioration of multiple mental (cognitive) abilities compared to an earlier condition. Demonstrator An alternative term for a prototype used to demonstrate the feasibility of a solution within the framework of an innovation project. Descriptive norms Descriptive norms refer to the perception of behaviours that are typically performed among a group of people. The assumption that it is normal to do the same thing everyone else is doing, e.g. to join in clapping when others start clapping.

Evaluation Proper and professional assessment. Evaluation matrix An evaluation matrix details various evaluation criteria along with their weighting and grading in a structured form. Evidence-based design (EBD) The process of making decisions about the built environment based on available or observed research. The term goes back to Roger Ulrich, who in 1984 documented the positive effects of looking out of the window on the recovery of patients. Exogenous infection An infection caused by a pathogen entering a patient’s body from their environment. Five Moments for Hand Hygiene This WHO guideline specifies when hands must be disinfected to prevent infection: 1) before patient contact, 2) before undertaking an aseptic task, 3) after contact with potentially infectious body fluid, 4) after patient contact, and 5) after contact with the patient surroundings. Functional area Hospitals in Germany are divided into seven distinct functional areas according to DIN 13080: Examination and treatment, nursing, administration, social services, supply and disposal, research and teaching, miscellaneous.

DIN norm A DIN standard or German Industrial Norm specifies requirements for products, services and/or processes. Developed under the direction of the German Institute for Standardization, their use is voluntary.

Hand hygiene compliance Hand hygiene practice in accordance with the rules.

Disinfectant dispenser Device for dispensing disinfectants. Disinfectant dispensers must be placed in the immediate vicinity wherever hand disinfection is required.

Healing Architecture In the architecture of healthcare buildings, Healing Architecture describes a planning approach that recognises architecture as a variable that contributes to the physical and mental well-being of staff, patients and visitors.

DRG Diagnosis Related Groups (DRG) is a patient classification system that standardises prospective payment to hospitals according to particular diagnostic categories, e.g. assigns cases (patients) to case groups based on medical condition.

HOAI The HOAI is the official scale of fees for services by architects and engineers in Germany.

Ebola Ebola is a rare and life-threatening infectious disease. It belongs to the viral haemorrhagic fever diseases (VHF) and is caused by the Ebola virus (EV). Emoticon A combination of different keyboard characters that can be used to convey an emotion in a written message by representing a facial expression (e.g. a smiley). Endogenous infection An infection arising from a pathogen, mostly bacteria, already present in or on the body but previously undetected.

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Glossary

Horizontal prevention measures A horizontal approach aims to prevent infections caused by a wide range of pathogens by standardised implementation of preventive measures for all patients, regardless of their degree of colonisation and infection status. Hospitalism Infection of hospital patients or staff by germs that have become resistant in the hospital. HPL HPL stands for high-pressure laminate. As a cladding material, it is suitable for indoor use – also in hygienic rooms such as laboratories and operating theatres – as well as for outdoor use.

Human Centric Lighting (HCL) HCL is the specific design of lighting that can benefit the biological, emotional, health, or well-being of people.

Lenticular image A lenticular image changes appearance or shifts when the image is viewed from different angles, i.e. when moving one’s head or the image.

Human microbiome The totality of microorganisms associated with and colonising humans.

Life cycle The life cycle of a building comprises three phases: construction, use and demolition. For a sustainable, efficient use of resources, their use over the entire life cycle of a building must be considered.

Hygiene The extent of measures aimed at promoting and improving health through the prevention and control of diseases. Inboard arrangement An “inboard” arrangement of wet cells denotes their placement next to the inner ward corridor. Induction room The term for the room in which a patient is prepared for an operation, usually through the induction of an anaesthetic. Once the anaesthetic has taken effect, the patient is then brought into the operating theatre. Infection A local or general impairment of the human organism by pathogens that have entered the human body. Infrared mirror An infrared heater whose heating surface is a mirror. Injection moulding A thermoplastic forming method by which a heated thermoplastic material is injected into a cold mould and solidifies. Injunctive norms Injunctive norms refer to the perception of behaviours that are deemed generally appropriate. The assumption is that it is right and proper, e.g. you don‘t drop litter in the street. Intermediate Care (IMC) IMC is the bridge between the intensive care unit (ICU) and its comprehensive therapy and intensive care facilities and the normal ward, where lower staffing levels prohibit the close monitoring of patients. Invasive procedure A medical measure that penetrate the body, for example the taking of samples from organs, injections or operations. KISS KISS – Krankenhaus-Infektions-Surveillance-System (Hospital Infection Surveillance System) – is a nationwide surveillance system for systematically collecting and recording hygiene-related data in medical and nursing facilities in the German healthcare system. KRINKO The Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI) in Berlin issues regularly updated guidelines that serve as a binding basis and standard for infection prevention measures in healthcare environments.

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Lux Physical quantity, unit of illuminance. Melanopsin Melanopsin is a protein found in retinal ganglion cells of the eye, where it is involved in registering ambient brightness. The melanopic effect of light therefore relates to our pattern of wakefulness and sleep (our circadian rhythm). The effect depends on the angle of incidence and the colour of light as well as the size of the light source. Meta-analysis Meta-analysis is a quantitative and statistical means of systematically assessing previous primary research studies to derive conclusions about that body of research. It serves as an evidence-based approach to aggregating and using medical information. Method A method is a more or less planned approach to reaching a goal. A method can also be understood as a path to gaining knowledge. Microorganism Microorganism is a collective term for small organisms that usually consist of only one cell, such as bacteria, yeast, fungi and algae. Microorganism entry potential The extent to which microorganisms may enter a room borne on the persons themselves or the objects they bring into a room. Movement area DIN 18025-2 sets out the free space necessary for movement in front of or beside an item of use, such as a washbasin, shower or toilet. The specified distances must be maintained. MRSA Many hospital infections are caused by methicillin-resistant staphylococcus aureus strains (MRSA). Staphylococcus aureus is a common bacterium that colonises the skin and mucous membranes in particular, while MRSA strains thereof are resistant to the antibiotic methicillin. Multiresistant pathogens Pathogens that are resistant to the mode of action of most antibiotics. Neonatology The branch of applied pediatrics concerned with newborn medicine and the care of newborns. Nested arrangement In a “nested” arrangement, the wet cells are arranged in a zone between two patient rooms.

Nosocomial infection Infections that arise during a stay or period of treatment in a hospital or healthcare facility. As so-called Hospital-Acquired Infections (HAI), they should be differentiated from infections that patients may have had, or were in the incubation phase of, prior to admission to the hospital. NRZ National Reference Centre for Surveillance of Nosocomial Infections at the Institute for Hygiene and Environmental Medicine at the Charité – Universitätsmedizin Berlin.

PVC PVC (polyvinyl chloride) is a fundamentally brittle and hard plastic, but its properties can be adapted to the respective area of application by adding plasticisers. PVC is best known as a floor covering. Reserve antibiotic Reserve antibiotics are antibiotic classes that should be reserved for the calculated antibiotic therapy of confirmed or suspected infections due to multi-resistant pathogens.

Nudging Nudging is a more or less subtle way to motivate or discourage someone from doing a specific action, either once or in general. The intention is to effect a change in behaviour.

RFID chip Radio Frequency Identification (RFID) is a technology for transmitter-­ receiver systems for the automatic and contactless identification of a carrier, which can be an object or a living being. RFID chips act as transmitters and can be identified by readers.

Oncology The study and treatment of tumours; the branch of medicine that deals with cancer.

Rotational moulding Rotational moulding is a plastic-forming method for hollow bodies in which a melt solidifies on the walls of a rotating mould.

Outboard arrangement An “outboard” arrangement of wet cells denotes their placement adjoining the external façade of the building.

Same-handed In the “same-handed” arrangement of adjacent patient rooms, the floor plan, fittings and furnishings of adjacent rooms are identical, in contrast to the mirrored arrangement where they are reversed. Its name derives from the fact that nurses always approach the patient from the same side.

Outlet valve More commonly known as a tap fitting, it can take many forms. In domestic use and in patient rooms, the most common are combined hot and cold water mixer taps operated using a single lever or two knobs. Oxidative aging process Oxidative aging is understood as the influence of thermal energy on materials and components in the presence of oxygen. This process is therefore highly temperature-dependent. Pathogenic fungus Pathogenic fungi are parasites that cause infectious diseases, the so-called mycoses. Depending on the species, they can infest animals, plants as well as humans. Patient empowerment Pro-active action and education that empowers the patient to be more independent and active in their own interests. Prevalence A figure in health and disease science that indicates how many people of a specific group of a defined size have a specific disease. Prototype In engineering terms, a prototype represents a functional, but often simplified test model of a planned product or component that is suitable for the respective purpose. Push-to-open An opening or closing mechanism that uses magnets in the hinge: applying gentle pressure is sufficient to open or close a cupboard or drawer. Its primary advantage is that no handles or knobs are required.

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Glossary

Sanitisation Sanitisation refers to the treatment and hygienic preparation of used objects for repeated use. Measures may include sterilisation, disinfection, etc. SARS Severe Acute Respiratory Syndrome (SARS) is an infectious disease caused by the SARS coronavirus (SARS-CoV), which has the clinical picture of an atypical pneumonia. Human-to-human transmission occurs mainly through the inhalation of droplets exhaled by infected persons. Indirect transmission via contaminated surfaces and materials is also possible. Screening The early detection of diseases. Sepsis Bloodstream infection, also known colloquially as blood poisoning. Serious games Serious games is a term used for gamified learning concepts not primarily or exclusively for the purposes of entertainment but to convey information and educational material in a playful way. Signifying character The stimulus emanating from a thing or an event that suggests a certain behaviour. Sterile equipment Instruments that have been sterilised for use.

Surface free energy Surface free energy is the measure of intermolecular forces at the surface of a solid versus its bulk. It influences the wettability or resistance to wetting of a surface. Surveillance The continuous, systematic collection, analysis and interpretation of health data needed for the planning, introduction and evaluation of medical measures. Systematic review Systematic review or literature survey, which employs a range of methods to collate and summarise and critically evaluate all available knowledge on a specific topic. Triage A standardised procedure for the systematic initial assessment of the urgency of treatment of patients in accident and emergency admissions. Tunable white LED Individually controllable LEDs that can adjust their light colour (temperature). Typology Building typologies or room typologies denote the classification of buildings or rooms into groups with a distinct architectural feature, function or use. Undercut An undercut is an indentation or protrusion of an injection-moulded part that can prevent the cast item from being ejected from its mould. Urinary catheterisation Catheterisation is the insertion of a catheter through the urethra (trans­ urethral) into the bladder. UV radiation Ultraviolet (UV) radiation is the most energy-rich part of the optical spectrum. UV radiation is not visible to humans and cannot be perceived with other sensory organs. Vertical prevention measures A vertical preventional approach aims to identify patients colonised or infected with a specific pathogen and to implement specific measures to prevent the spread of the pathogen in the institution (e.g. through isolation measures). VRE Vancomycin-resistant enterococci are resistant to the antibiotic vancomycin and can be pathogens for nosocomial infections. These enterococci are among the most common causes of urinary tract infections, wound infections and sepsis as well as endocarditis. Zoning Zoning denotes the division of a given realm into allocated individual sub-areas (zones). Zones can be defined for buildings and rooms but also lakes, mountains and even entire areas of land.

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Appendix

About the Authors Wolfgang Sunder studied architecture in Münster, Zurich and Berlin and earned a doctoral degree. After completing his studies in 2002, he continued his professional career with Zaha Hadid Architects in London. As head of research at the Institute of Construction Design, Industrial and Health Care Building (IKE) of the TU Braunschweig, he participated in various research projects in the field of healthcare buildings and advised hospital operators in their strategic orientation. Since 2015, he has been head of the construction section in the InfectControl research consortium. The aim here is the development of infection-preventive measures in the planning of healthcare buildings. Dr Sunder is the author of the publication Bauliche Hygiene im Klinikbau (Bundesinstitut für Bau-, Stadt- und Raumforschung, 2018). Julia Moellmann studied architecture and urban design at the Leibniz University Hanover, the Politecnico di Milano and the State University for Architecture and Civil Engineering in St Petersburg. Since 2017, she has been a research associate at the Institute of Construction Design, Industrial and Health Care Building (IKE) of the TU Braunschweig in the field of health buildings. For the KARMIN project she studied floor plan typologies of patient rooms in national and international hospitals and worked on the concept and design of the patient room demonstrator. Oliver Zeise first trained as a carpenter and then studied architecture at the University of Applied Sciences Lübeck and the TU Braunschweig. He then worked in architectural offices in Hamburg and Lüneburg. Since 2016, he has been research associate at the Institute of Construction Design, Industrial and Health Care Building (IKE) of the TU Braunschweig. In the KARMIN project he deals with structural infection prevention in the context of the patient room. The planning in detail and the realisation of the prototype with numerous industrial partners are his priorities. He is also active as a practicing architect. Lukas Adrian Jurk is a medical and speculative designer, studied industrial and car design at the University of Fine Arts Braunschweig, at the Universidad de Chile, Santiago, and social design at the Design Academy Eindhoven. Already in the context of his bachelor thesis he dealt with design in a hospital context. He is a research associate at the Institute of Construction Design, Industrial and Health Care Building (IKE) at the TU Braunschweig. Since 2020, he has also been a strategic partner in the collective The Complicity. His freelance work in the field of biodesign has been shown in international exhibitions.

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Authors

Rasmus Leistner is a specialist in hygiene and environmental medicine and infectiology. He works as a hospital hygienist at the Institute for Hygiene and Environmental Medicine and as a clinical infectiologist at the Clinic for Gastroenterology, Infectiology and Rheumatology at the Charité Berlin. He is a consultant for the National Reference Centre for the Surveillance of Nosocomial Infections. Dr Leistner is the author of numerous publications on infection prevention, epidemiology and infectiology. He is co-editor of the journal Krankenhaushygiene Up2Date. Inka Dreßler is an industrial and civil engineer. She is a senior engineer for the field of building materials at the Institute for Building Materials, Solid Construction and Fire Protection (iBMB) of the TU Braunschweig. Her research interests include structural hygiene in hospitals. Katharina Schütt has a degree in economic and civil engineering from the TU Braunschweig, the Chalmers Tekniska Högskola (Gothenburg, Sweden) and the University of Rhode Island (Kingston, RI, USA). She works as project coordinator in turnkey construction, with a focus on hospital construction. In her master thesis at the TU Braunschweig she investigated the influence of material ageing on the properties of hospital-standard solid surfaces.

Subject Index

Cupboard (patient) → also Wardrobe, patient's  82, 94, 108, 118, 128, 132, 136, 138, 178–180, 184, 185, 193, 195 Curtain  33, 42, 70, 73, 82, 94, 99, 128, 136, 146, 175

ABS 214 Additive principle  29, 30, 36, 38, 39, 45 Airlock  22, 32, 39–41, 45, 46, 51–53, 57, 59, 112, 138, 240 Alcove  32, 39, 41, 42, 45, 46, 50, 52–54, 58, 59, 62, 100, 103, 135, 146, 149 Antibiotic  12, 15, 23, 240, 242–244 Art  69, 86, 108 Aseptic procedures  23, 211, 240 Atrium  90, 93, 108, 125

Data acquisition  122, 212–217, 221, 230, 237, 242, 244 Data collection  212, 215 Daylight  41, 42, 47, 70, 86, 90, 94, 100, 128, 132, 146, 150, 186, 187 Decor  78, 90, 108, 112, 118, 138, 142, 177, 183, 184, 206, 227 Decubitus  235, 241 Dementia  17, 41, 42, 128, 183, 207, 208, 225, 241 Demographic change  15, 208, 209 Diagnosis Related Group (DRG)  13, 241 Diagnostics  13, 16, 108, 112, 187, 241 Digital sensor  212 DIN 13080  175, 241 DIN 18040-2  29, 29, 191 DIN 1946-4  175 DIN 5035-3  185, 186 DIN EN 12464-1  186 DIN norm  177, 191, 241 Disinfectant dispenser  7, 32, 39, 74, 118, 142, 164, 167, 170, 171, 173–175, 178, 179, 181, 182, 191, 193, 202, 203, 206, 209–223, 226, 237, 241 Disinfection → also Hand hygiene  23, 171, 174, 175, 207, 209, 210, 212, 217, 224, 226, 240 Disposal room  18–20 Door → also Sliding door  13, 31, 34, 35, 37, 39–42, 52, 82, 86, 89, 104, 118, 122, 132, 138, 146, 154, 161, 173, 177, 181, 186, 191, 193, 209, 210, 221, 234 Door, double-leaf  138 Double corridor  12, 18, 128, 167 Double room → Two-bed room 

Bacteria  15, 21–23, 42, 171, 240–242 Balcony  12, 31, 39, 44, 46, 61, 70, 103, 136, 138, 141 Barrier-free → also Low-barrier  28, 29, 35, 38–43, 45, 48, 52, 53, 55–59, 63, 78, 90, 118, 122, 136, 142, 178, 191, 240 Bathroom  7, 19, 20, 28, 29, 32, 33, 35–43, 45–63, 171–175, 177–182, 184, 186, 187, 189–194, 197, 198, 200, 202, 204, 209, 211, 212, 220, 234, 242, 243 Bathroom, prefabricated  39, 94, 171 Bed tower  28, 161, 162, 240 Bedcentricity 240 Bed position  34, 44, 45, 47, 54, 55, 62, 66, 70, 178, 181 Bedside cabinet  40–42, 45, 46, 48, 49, 51, 53, 58, 182, 203, 206, 209, 224–229, 237 Bedside terminal  7, 69, 135, 170, 171, 182, 186, 187, 189, 190, 199, 209, 213, 224, 226, 227, 230–237 Bedside trolley → Bedside cabinet  Biocide 240 Biofilm  22, 240 Brise-soleil  94, 95, 97 Care procedures  40, 42, 104, 174, 178, 185, 223, 230, 237 Castors, double  227, 228 Chipboard  82, 192, 194, 195 Chronic disease  15, 240 Circulation  12, 39, 70, 82, 104, 135 Clean Hands Campaign (Germany)  171, 235, 240 Cleanability  24–26, 177, 183, 203, 240 Cleaning  7, 11, 23–26, 43, 94, 112, 146, 171, 174, 175, 177–179, 181–183, 185, 187, 190, 191, 193, 195, 201–203, 205, 207–210, 214, 215, 217, 218, 222, 224–232, 237 Cleaning cycle  208, 237 Cleaning staff  38, 175, 189, 201, 227, 228 Cleaning test  184 Cluster structure  146, 166 Cohorting  207, 241 Colonisation with germs  86, 208, 209, 214, 215, 217, 224, 241 Comb structure  166, 167 Commode chair  118 Compliance  39, 40, 181–183, 203, 209, 211, 212, 214–217, 219–223, 232, 237, 240, 241 Contact surface  42, 175, 182, 185, 187, 206, 208, 209, 230 Coronavirus pandemic (COVID 19 pandemic)  241, 243 Cross-contamination  182, 207, 209, 225, 230, 232, 241 Cupboard (staff)  32, 74, 77, 86, 132, 136, 138, 184, 185, 191–194, 199, 204, 227, 243

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Ebola  13, 241 Entrance hall  11, 108 Entrance, single  31, 45–51, 53–55, 57–63 Entrances, two  31, 39, 42, 44, 45, 52 Ergonomics  104, 208, 211, 217, 222, 227, 231 Evaluation, qualitative  38–44 Evaluation, typological  44–63, 175 Evidence-based Design (EBD)  104, 241 Examination area  16, 18–20, 94, 241 Façade  33, 38, 39, 41, 42, 45, 46, 50, 57, 61, 66, 70, 74, 78, 82, 86, 90, 94, 95, 100, 104, 108, 118, 119, 128, 132, 136, 138, 139, 142, 158, 161, 177, 187, 243 Family room  69, 149 Fire safety  142–145 Fittings  28–32, 36–43, 45–63, 70, 86, 104, 108, 112, 118, 136, 138, 170, 172–175, 177–179, 181, 183–185, 191, 193, 197, 206, 208, 209, 220, 227 Five Moments for Hand Hygiene → also Hand Hygiene  23, 187, 211, 241 Flexibility  12, 13, 32, 39, 41, 45, 66, 90, 214 Floor plan, radial  61, 161 Floor plan, rectangular  30, 35, 56, 150 Floor plan, specific  29, 45, 51 Floor plan, standard  29, 45–49, 52–57, 59–62, 181 Floor plan, unsystematic  30, 39, 45, 51 Floor plan combination/variation  29, 30, 36, 38, 45, 50, 58, 61, 63 Four-bed room  13, 19, 78, 138 Freestanding building  166

Functional area (German hospitals)  15, 18, 158, 164, 170, 174, 175, 241 Fungus  15, 242, 243 Furnishings  38, 39, 70, 94, 112, 118, 170, 172, 173, 175, 177, 191, 243 Furniture  25, 31, 33, 39, 40, 112, 142, 149, 173, 175, 183, 191, 206, 224–227

Lenticular image  223, 242 Lighting  70, 94, 108, 118, 128, 132, 136, 173, 175, 182, 185–190, 192–195, 198, 200, 209, 233, 240, 242 Low-barrier → also Barrier-free  28, 29, 35, 38–43, 45, 48, 52, 53, 55–59, 63

Geriatrics  16, 17, 22, 86, 128–131, 132–135, 227 Glass headboard panel  142, 145 Glass wall  138, 141 Glove dispenser  78, 94, 142, 191, 193 Gloves, disposable  182, 192, 194 Goods transport lift  19 Grown structure (hospital)  166 Guest accommodation  33, 42, 44, 45, 51, 81 Guest room  122

Mat structure (hospital) 166 Material ageing  24, 26, 177, 245 Maximum care provision (Germany)  12, 22, 240 Medical staff  16, 19, 20, 23, 150, 189, 191, 211, 221, 224, 230, 231, 233 Medium care unit  240 Menu (bedside terminal)  232–234, 236 Microbiome  7, 21, 170, 171, 242 Microorganism  21, 24, 170, 205–207, 214, 240, 242 Minimum standard  29, 35, 45–47, 49–51, 54, 58, 60–63 Mobility  10, 154, 183, 208, 227, 235 Mirrored floor plan  29, 30, 36, 42, 45, 47, 49, 53, 54, 56, 57, 61, 203, 243 Mobility aids  29 Mobility impairment  39, 40, 42, 78, 128 Motion sensor  184, 190 Movement area  31, 57, 59, 242 MRSA  15, 23, 170, 208, 210, 242 Multi-bed room  164, 170, 171, 186, 187, 210 Multi-resistant germs  7, 15, 171

Hand hygiene → also Five Moments for Hand Hygiene  22–24, 32, 40, 181, 182, 187, 203, 208, 210–212, 214, 216, 219, 220, 234, 240, 241 Healing Architecture  183, 241 Healing environment  94, 186 Healthcare reforms (Germany)  7 High pressure laminate (HPL)  25, 26, 82, 184, 187, 192, 194, 195, 197, 202, 226, 227, 242 HOAI (Germany)  175, 241 Hospital renovation  28, 74–77, 108–111, 132–135, 142–145, 161–163 Hospitalism 242 Human Centric Lighting  186, 187, 190, 231, 242 Hygiene specialist  23, 38, 164, 177 Inboard arrangement of wet cell  35, 43, 45, 46, 49, 52–55, 57–60, 62, 63, 70, 180, 181, 187, 242 Infection chain  171, 206, 207, 240 Infection prevention, horizontal  23, 210, 241 Infection prevention, vertical  23, 244 Infection, endogenous  21–23, 210, 241 Infection, exogenous  21, 22, 210, 241 Infrared mirror  179, 242 Injection moulding  214, 216, 227, 242, 244 Intensive care unit (ICU)  13, 15, 22, 82, 118, 164, 227, 240, 242 Interface  33, 173, 186, 231–234 Interior design  38–42, 82, 86, 183 Intermediate care (IMC)  18, 118, 242 Internal medicine  22 Invasive procedure  15, 21, 22, 211, 242 Isolation room  15, 118, 146 KARMIN bedside cabinet  203, 224–229 KARMIN colour and materials concept  183, 184 KARMIN disinfectant dispenser  182, 203, 210–223 KARMIN lighting concept  185–190 KARMIN research project  7, 38, 170–172, 175, 183, 207, 210, 213, 214, 216, 230, 245 KARMIN Suite  233–236 KARMIN patient room  172, 184, 185, 187, 189, 196–205, 210, 216, 218–220, 223, 227, 233 KISS (Hospital Infection Surveillance System, Germany)  164, 171, 242 Lamp  138, 185, 187, 189, 190 LED  186, 187, 192–195, 211, 217 LED, tunable white  186, 187, 244

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Index

Neonatology  100, 158, 164, 213, 216, 243 Nested arrangement of wet cell  35, 41, 44, 45, 50, 56, 61, 150, 161, 243 Nosocomial infection  7, 11, 15, 21–24, 164, 171, 207, 219, 231, 235, 237, 243, 244 Nudging  22, 216, 234, 243 Nurses' station  13, 18, 19, 78, 89, 103, 104, 107, 108, 111, 114, 121, 122, 128, 132, 138, 142, 145, 157, 161, 164, 167 Nursing care  7, 11, 16, 17, 39, 175, 181, 185, 187 Nursing staff  10, 12, 13, 16–18, 20, 23, 32, 39, 43, 78, 94, 104, 118, 125, 136, 142, 146, 158, 175, 182, 186, 187, 207–209, 219, 220, 224, 237 Nursing ward  15–20, 78, 82, 86, 112, 146, 149, 150, 177, 240 Observation ward 17 Obstetrics  10, 19, 22, 94 Oncology  22, 122–127, 150–153, 243 One bed deep  30, 34, 40–42, 44, 45, 48, 51–53 Operating theatre  118, 242 Organic building form  86, 100 Outboard arrangement of wet cell  33, 35, 45, 47–49, 58, 60, 78, 180, 243 Paediatrics  19, 22, 100, 122–127, 154–157 Paraplegia 118 Partition  33, 42, 74, 77, 86, 112, 117, 161 Patient bed → also Bed position  19, 20, 32, 99, 135, 136, 153, 167, 173, 177–182, 184, 186, 187, 191, 206, 230, 240 Patient desk  33, 42, 45, 47, 48, 53, 58, 180, 188, 189, 193, 195, 197, 201 Patient education  208, 230, 231, 233–235 Patient empowerment  230, 231, 233, 243 Patient lift system  78, 118 Patient safety  38, 41, 45–63, 175, 177, 235 Patient satisfaction  38, 42, 43, 45–63, 175, 177 Pavilion structure (hospital)  11, 12 Plastics  214, 215, 217, 218, 222, 226, 227, 243 Plastic surface  22 Polycarbonate 86 Polymer  22, 25, 214

Polyurethane surface coating  25, 94 Plinth  100, 166, 182, 193 Power supply  214, 217, 221, 227, 231 Privacy screen  33, 42, 45, 51, 56, 59, 78 Private healthcare patients  112, 117, 138, 142, 145, 227, 230 Psychiatry  19, 22, 158 Public health insurance companies (Germany)  7 Push-to-open mechanism  179, 184, 193, 243 PVC  25, 26, 112, 243 Reading lamp  186, 201 Rehabilitation  22, 69, 86, 136, 137 Reserve antibiotic  15, 243 RFID  187, 207, 217, 221, 225, 226, 228, 229, 231, 233, 243 Risk of injury  40, 41, 104, 179, 193 Room geometry  30, 39, 45, 177 Rooming-in  122, 146, 149, 154 Rotational moulding  226, 243 Rounded corners/edges  104, 108, 146, 193, 201, 214, 215, 217, 218, 222, 229, 231 Rounded skirting  193, 205 Same-handed configuration  29, 36, 39–43, 45, 46, 48, 52–56, 59, 60, 62, 63, 104, 136, 138, 177, 181, 243 Sanitary cell → Bathroom  Sanitary facilities  11, 18, 22, 170 Sanitaryware  35, 40, 42, 173, 191 SARS  15, 243 Screening  23, 136, 243 Seat cushion  179, 193 Seating area  20, 41, 42, 46, 53, 70, 81, 90, 112, 114, 138, 141, 145, 149, 150, 154, 161 Serious games  231, 232, 237, 243 Shower  13, 35–37, 40–43, 45–63, 82, 85, 86, 118, 136, 146, 178, 191, 242 Sill, seat-level  33, 41, 42, 45, 60, 82, 112, 114, 122, 128 Sill, standard  45–59, 61–63 Single room  7, 19, 22, 23, 50, 66, 74, 78, 82, 85, 86, 89, 90, 100, 104, 108, 111, 112, 122, 138, 142, 145, 146, 150, 154, 157, 158, 161, 162, 167, 170, 171 Single-bed room → Single room  Sanatorium building  136 Sliding door  37, 40, 41, 45, 46, 48, 50, 52, 56, 59, 61, 63, 86, 89, 104, 122, 136, 179, 200 Spatial quality  40, 175, 177, 178 Staff workplace  32, 39–42, 45, 46, 50–53, 55–58, 62, 63 Staff's work processes → Care procedures  Sterilisation  214, 224, 226, 240 Storage  18, 19, 32, 74, 78, 118, 122, 132, 142, 175, 178, 179, 181, 182, 191, 194, 225, 227, 228, 237 Supplies  18, 19, 32, 39–41, 138, 174, 175, 219, 227 Supplies trolley  39, 40, 42, 224 Supply room  18, 19 Surface  11, 22, 24–26, 39, 40, 42, 70, 78, 82, 86, 90, 108, 112, 128, 138, 154, 171, 174, 175, 177–179, 181–185, 187, 191–195, 197, 206–209, 211, 213, 214, 217–220, 222, 224–227, 229–233, 237, 240–243, 245 Surface free energy  24–26, 177, 243 Surgery  18, 22, 94, 112, 138, 142

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Table  7, 32, 63, 70, 86, 108, 112, 122, 136, 179, 186, 189, 193, 195, 209, 224–226, 228 Terrace  12, 33, 78, 86 Terrace hospital  12 Three-bed room  90 Three-zone plus room  31, 39–42, 45, 46, 48–53, 55, 57–59, 62, 63, 181 Three-zone room  31, 39–42, 45, 47, 56, 60, 61 Toilet  11, 13, 20, 35–37, 40, 42, 43, 45, 49, 53, 60, 78, 82, 118, 128, 136, 146, 166, 170, 175, 179, 186, 187, 242 Touch panel  187 Transmission of pathogens  17, 11, 21–24, 39–43, 170, 171, 173, 174, 177, 181, 183, 206–210, 224, 232, 233, 237, 240, 243 Treatment area  16, 18, 94, 161 Treatment building  118 Two beds deep  30, 34, 45–47, 49, 50, 54–63 Two-bed room  7, 19, 20, 28–63, 66, 69, 70, 74, 78, 82, 85, 86, 89, 90, 93, 94, 108, 111, 112, 114, 117, 118, 121, 128, 132, 136, 138, 142, 145, 150, 153, 154, 157, 158, 161, 162, 164, 167, 170, 173–175, 210 Two-zone room  31, 45, 54 UV radiation  24, 25, 244 VDI Guideline 6022 “Ventilation and indoor-air quality”  175 VDI Guideline 6023 “Hygiene in drinking-water installations”  175 Ventilation  118, 175, 178, 193, 233, 240 Veranda  12, 70 View outdoors, patient's  34, 41, 43, 45–63, 69, 70 View of the patient, staff's  31, 34, 45–63, 104, 182 Virus  15, 22, 241, 243 Visitors  12, 18–20, 24, 25, 31–33, 39–43, 53, 70, 104, 108, 111, 112, 118, 138, 142, 145, 146, 150, 154, 161, 174, 175, 179, 181–185, 187, 189, 193, 194, 205–208, 210, 212, 213, 215, 224, 233, 241 VRE  15, 208, 244 Ward bathroom  36, 40, 42, 43 Ward corridor  30–32, 39, 41, 43, 45, 70, 73, 74, 82, 85, 86, 93, 103, 104, 111, 112, 114, 122, 141, 142, 145, 154, 235, 242 Wardrobe, patient's → also Cupboard (patient)  20, 141, 181, 191, 193, 199, 205 Washbasin  13, 32, 33, 35–37, 40, 42, 43, 45, 46, 49–51, 53, 56–58, 60, 61, 78, 82, 86, 94, 122, 128, 132, 135, 136, 146, 191, 201, 211, 220, 242 Waste bin  142, 179, 191–194, 204, 220, 227 Waste disposal  11, 19, 94, 174, 175, 182, 194, 204, 241 WC → Toilet  Wet cell → Bathroom  Wheelchair  74, 118, 128, 136, 138, 146, 181, 211, 220 Window → also Sill  11, 12, 33–35, 39, 41–43, 45–63, 74, 78, 81, 82, 86, 90, 93, 94, 103, 108, 112, 114, 118, 122, 128, 132, 136, 138, 141, 142, 146, 150, 153, 154, 161, 167, 173, 177–181, 185, 187, 189, 193, 197, 201, 203, 218, 232 Window bench → also Sill, seat-level  82, 182, 184, 193, 195, 197, 201, 205 World Health Summit  172 Zoning  31, 39, 41, 42, 45, 178, 187, 244

Index of Names, Places and Projects a|sh sander.hofrichter architekten GmbH 142 AAPROG 86 Agatharied District Hospital  14 Agatharied, Germany  14 Albert Wimmer ZT GmbH  104, 154 Architects Collective GmbH  104, 154 ARGE Health Team Vienna  104, 154 ATP HAID architekten ingenieure  82 AZ Zeno  86–89 B2Ai 86 Bärlocher & Unger  132 Bergen, Norway  90 Berlin, Germany  10, 11, 173, 174 BGU Accident and Emergency Hospital  118–121 Boeckx 86 Brand, Peter  13 Braunschweig Hospital  171, 175 C. F. Møller Architects  78, 90 Charité Berlin  11, 164, 170, 171, 239, 243 Children's University Hospital Zurich  158–160 Chodowiecki, Daniel  11 Crona Clinic, Tübingen University Hospital  142–145 Dewan Friedenberger Architekten GmbH 118 Dresden, Germany  128 Düsseldorf, Germany  12, 13 EGM architects, EGM interiors 146 Erasmus MC  146–149 Erlangen, Germany  138 Esch-sur-Alzette, Luxemburg  104 Federal Centre for Health Education 235 Federal Office for Building and Regional Planning (BBR)  164 Frankfurt am Main, Germany  118 Freiburg, Germany  154 Friedrich II  11 General Hospital Vienna 11 Gerl, Matthias  11 German Council of Science and Humanities  13 German National Reference Center for Surveillance of Nosocomial Infections  164, 171, 243 German Society for Hospital Hygiene (DGKH)  217 Haid, Hans Peter 82 Hamburg-Eppendorf, Germany  12 Hanover Medical School  175 Haraldsplass Hospital  90–93 Herzog & de Meuron  100, 158 Hillerød, Denmark  100

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Hôpital Saint-Louis, Paris  10 Hvidovre Hospital  78–81 Hvidovre, Denmark  78 HYBAU+ 164 InfectControl 2020  7, 170, 237 Institute for Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin  164, 170, 171, 239, 243, 245 Institute of Building Materials, Concrete Construction and Fire Safety (iBMB), TU Braunschweig  164, 179, 181, 245 Institute of Construction Design, Industrial and Health Care Building (IKE), TU Braunschweig  7, 164, 170, 171, 239, 243, 245 Jena University Hospital, Septomics Research Group  170, 239 Jugenheim District Hospital  108–111 Junghans+Formhals 108 KARMIN Project  7, 38, 169–237 Knokke-Heist, Belgium  86 Kopvol 122 KRINKO (Commission for Hospital Hygiene and Infection Prevention)  23, 174, 217 Lauf an der Pegnitz, Germany 82 Lauf District Hospital  82–85 Leuven, Belgium  150 LIAG architects  122 LOW Architects  150 LSK-Architekten 108 Metron Architektur AG, Brugg  74, 136 Mississauga, Ontario, Canada  66 Mmek 122 Munich-Sendling, Germany  112 Municipal Hospital Düsseldorf  12, 13 Municipal Hospital Hamburg-Eppendorf  12 Münster University Hospital  13, 161–163 Münster, Germany  13, 161 Neumünster Hospital → Zollikerberg Hospital  New North Zealand Hospital  100–103 Nickl & Partner  14 Oncological Centre, Leuven University Hospital 150–153 Paediatric Clinic, Freiburg University Hospital 154–157 Paris, France  10 Perkins Eastman Black  66 Pfister, Otto and Werner  70 Princess Máxima Center  122–127 Quarin, Joseph von 11 Robert Koch Institute (RKI)  23, 174 Röhl GmbH  170–173, 239 Rotterdam, the Netherlands  146 Sana Clinic Munich 112–117 Schachner, Benno  13

Seeheim-Jugenheim, Germany  108 Silvia Gmür Reto Gmür Architekten  70, 94, 132 Sofron, Joan  108 Solothurn Public Hospital  94–97 Solothurn, Switzerland  94 St Gallen Geriatric Clinic  132–135 St Gallen, Switzerland  10, 132 St Joseph-Stift Dresden  128–131 Südspidol 104–107 Surgical Centre, Erlangen University Hospital  138–141 Tiemann-Petri Koch Planungsgesellschaft 138 Toronto, Canada  66 Trillium Health Centre  66–69 TU Braunschweig (Technical University of Braunschweig)  7, 164, 170, 171, 173, 175, 177, 239 Tübingen, Germany  142 University Hospital Göttingen 175 Uster Hospital  136 Uster, Switzerland  136 Utrecht, the Netherlands  122 Vienna, Austria 11 Waldbüttelbrunn, Germany  170, 172, 239 Weber, Wolfgang  13 Wiederkehr, Gido  94 Wiegerinck 150 World Health Organization (WHO)  23 wörner traxler richter  114, 128, 161 Zollikerberg Hospital 70–77 Zollikerberg, Zollikon, Switzerland  70, 74 Zukunft Bau  162 Zurich, Switzerland  70, 74, 158

Illustration Credits Cover: Floor plans Julia Moellmann

A Fundamentals The Emergence of Hospitals, pp. 10–14 Figs. 1–14 From: Axel Hinrich Murken, Vom Armenhospital zum Großklinikum, Köln: DuMont, 1995; 15, 16 Stefan Müller-Naumann (photos); 17 Nickl und Partner The Nursing Ward Environment, pp. 15–20 Figs. 1–9 Institute of Construction Design, Industrial and Health Care Building (IKE), TU Braunschweig Healthcare-Associated Infections, pp. 21–23 Fig. 1 IKE, after: Alessandro Cassini, Diamantis Plachouras and Tim Eckmanns, “Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study“, in: PLOS Medicine, 18 October 2016, https://doi.org/10.1371/journal. pmed.1002150; 2 IKE, after: P. Stoodley, K. Sauer, D. G. Davies and J. W. Costerton, “Biofilms as Complex Differentiated Communities”, in: Annual Review of Microbiology, 56, 2002, pp. 187–209; 3 IKE, after: European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals, Stockholm: ECDC, 2013; 4 IKE, after: WHO, “My 5 Moments for Hand Hygiene”, WHO Guidelines on Hand Hygiene in Health Care, 2009. https://www.who.int/infection-prevention/campaigns/ clean-hands/5moments/en/; 5 IKE, after: Nasia Safdar and Dennis Maki, “The Pathogenesis of Catheter-Related Bloodstream Infection with Noncuffed Short-Term Central Venous Catheters”, in: Intensive Care Medicine, Feb. 2004, 30(1), pp. 62–67 Material Applications and Material Ageing in Hospitals, pp. 24–26 Figs. 1–8 Inka Dressler, iBMB, TU Braunschweig

B Typologies of the Patient Room The Floor Plan of a Two-Bed Room, pp. 28–37 Figs. 1–66 Julia Moellmann Typological Evaluation of Two-Bed Rooms, pp. 44–63 All drawings and diagrams: Julia Moellmann Selected Case Studies, pp. 64–163 Note on the chapter Selected Case Studies: All original planning documents have been edited and simplified for better readability and standardisation and are shown to scale. All site plans have been prepared by the author Julia Moellmann. pp. 64, 65 Floor plans, from left to right: Metron Architektur AG, Brugg; Silvia Gmür Reto Gmür Architekten; ARGE Health Team Vienna: Albert Wimmer ZT-GmbH, Architects Collective GmbH; Silvia Gmür Reto Gmür Architekten; Wiegerinck; Herzog & de Meuron Trillium Health Centre, pp. 66–69 Ben Rahn/A Frame (photos 2, 3, 5–7, 9, 10); Perkins Eastman Black (plans 4, 8)

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Zollikerberg Hospital – New West Wing, pp. 70–73 Hélène Binet (photos 2, 3, 5, 6); Silvia Gmür Reto Gmür Architekten (plans 4, 7); Reto Gmür (photos 8, 9) Zollikerberg Hospital – Renovation of East Wing, pp. 74–77 Hannes Henz (photos 2, 4–6, 8, 9); Metron Architektur AG, Brugg (plans 3, 7) Hvidovre Hospital, pp. 78–81 Thomas Hommelgaard (photos 2, 3, 5–7, 9, 10); C. F. Møller Architects (plans 4, 8) Lauf District Hospital, pp. 82–85 ATP/Wang (photos 2, 3); ATP HAID architekten ingenieure (plans 4, 8); Ralf Dieter Bischoff (photos 5–7, 9, 10) AZ Zeno, pp. 86–89 Milosz Siebert_TV AAPROG-BOECKX-B2Ai (photos 2, 5, 6, 8–10); Tim Fisher (photo 3); TV AAPROG-BOECKX-B2Ai (plans 4, 7) Haraldsplass Hospital, pp. 90–93 Jørgen True (photos 2–4, 6–8, 10–12); C. F. Møller Architects (plans 5, 9) Solothurn Public Hospital, pp. 94–99 Ralph Feiner (photo 2); Silvia Gmür Reto Gmür Architekten (plans 3, 9); Reto Gmür (photos 4–6, 8, 10); Yue Yin (photos 7, 11) New North Zealand Hospital, pp. 100–103 Herzog & de Meuron (renderings, plans 2–10) Südspidol, pp. 104–107 3D Bakery (renderings 2, 5, 6, 8–10), ARGE Health Team Vienna: Albert Wimmer ZT-GmbH, Architects Collective GmbH (plans 3, 7) Jugenheim District Hospital, pp. 108–111 Michael Lube (photos 2, 4–6, 8, 9); LSK-Architekten Lube | Schoppa | Krampitz-Mangold PartGmbH (plans 3, 7) Sana Clinic Munich, pp. 112–117 Eberhard Franke (photo 2); Christian Börner (photos 4–7, 9, 11, 12); wörner traxler richter (plans 3, 7) BGU Accident and Emergency Hospital, pp. 118–121 Rainer Mader (photos 2, 3, 8); Dewan Friedenberger Architekten GmbH (plans 4, 9); Barbara Staubach (photos 5–7, 10, 11) Princess Máxima Center, pp. 122–127 Ronald Tilleman (photos 2, 5, 7, 8, 10, 12); LIAG architects (plans 4, 11); Mart Stevens (photo 9) St Joseph-Stift Dresden, pp. 128–131 Christian Börner (photos 2, 4, 5, 7, 8), wörner traxler richter (plans 3, 6) St Gallen Geriatric Clinic, pp. 132–135 Arno Noger (photo 2); Silvia Gmür Reto Gmür Architekten (plans 3, 8); Ralph Feiner (photos 4, 5, 7); Reto Gmür (photo 6) Uster Hospital, pp. 136, 137 maaars, Zurich (renderings 2, 3); Metron Architektur AG, Brugg (plans 4, 5) Surgical Centre, Erlangen University Hospital, pp. 138–141 Albrecht Immanuel Schnabel (photos 2–4, 6–10, 12, 13); Tiemann-Petri Koch Planungsgesellschaft (plans 5, 11) Crona Clinic, Tübingen University Hospital, pp. 142–145 Markus Bachmann (photos 2, 4–8, 10, 11), a|sh sander.hofrichter architekten GmbH (plans 3, 9) Erasmus MC, pp. 146–149 Rob van Esch (photos 2, 3, 5, 7, 10, 11); Ronald Tilleman (photos 6, 8); EGM architects (plans 4, 9) Oncological Centre, Leuven University Hospital, pp. 150–153 Wiegerinck (renderings, plans 2–8) Paediatric Clinic, Freiburg University Hospital, pp. 154–157 Zoom VP.AT (renderings 2, 4–6, 8, 9), ARGE Health Team Vienna: Albert Wimmer ZT-GmbH, Architects Collective GmbH (plans 3, 7) Children’s University Hospital Zurich, pp. 158–160 Herzog & de Meuron (renderings, plans 2–7)

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Credits

Münster University Hospital, pp. 161–163 wörner traxler richter (renderings, plans 2–6) Building Structures in German Hospitals, pp. 164–167 From: Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier, Andrea Haselbeck and Inka Dreßler, Bauliche Hygiene im Klinikbau. Planungs­ empfehlungen für die bauliche Infektionsprävention in den Bereichen der Operation, Notfall- und Intensivmedizin (Zukunft Bauen – Forschung für die Praxis, Band 13), Bonn: Bundesinstitut für Bau-, Stadt- und Raumforschung, 2018

C Prototype of a Patient Room – the KARMIN Project Architecture of the Patient Room, pp. 170–193 Figs. 1–14, 23, 24 IKE TU Braunschweig; 15–22, 25 Julia Moellmann; 26–29 Kai Lorberg (renderings); 30, 31 IKE TU Braunschweig; 32–38 Tom Bauer (photos); 39 IKE TU Braunschweig; 40, 41, 44, 45 Tom Bauer (photos); 42, 43, 46, 49, 51 Oliver Zeise (drawings) Building the Prototype, pp. 196, 197 Figs. 1–8 Tom Bauer Completed Prototype and Use Scenarios, pp. 198–205 Figs. 9–29 Tom Bauer Furniture and Equipment, pp. 206–209 Fig. 1 Tom Bauer; 2, 3, 4 IKE TU Braunschweig The Disinfectant Dispenser, pp. 210–223 Figs. 1, 2, 4–8 IKE TU Braunschweig; 3, 9 Tom Bauer; 10 IKE TU Braunschweig; 11, 12 Lukas Adrian Jurk; 13, 14 Tom Bauer; 15, 17 IKE TU Braunschweig; 16 Lukas Adrian Jurk; 18–25 Tom Bauer (photos); 26 Lukas Adrian Jurk The Patient Bedside Cabinet, pp. 224–229 Figs. 1–3 IKE TU Braunschweig; 4 Lukas Adrian Jurk; 5–11 Tom Bauer (photos) The Bedside Terminal, pp. 230–236 Figs. 1, 3–5 IKE TU Braunschweig; 2, 7, 9 Tom Bauer (photos); 6, 8, 10 Lukas Adrian Jurk

Acknowledgements A large number of people have contributed to this book over several years with their professional and personal support. We can only mention some of them by name here, but all these hints were valuable and helpful. Many thanks go to Prof. Carsten Roth, the director of the Institute of Construction Design, Industrial and Health Care Building (IKE) of the TU Braunschweig, which has enabled us for many years to engage in research and teaching focused on healthcare buildings. We would like to thank our colleagues, in particular Jan Holzhausen, for their good advice. For the support in respect to graphics and illustrations we would like to thank Franziska Himmelreich, Jannik Siems and Giovanni Nobile. Many thanks to the director of the Institute for Hygiene and Environmental Medicine, Charité – Universitätsmedizin Berlin, Prof. Petra Gastmeier, and her colleagues Rasmus Leistner and Elke Lemke for their constructive advice. Special thanks are due to the doctors, nurses, hygienists and other staff of the hospitals we investigated, whose workplaces we could visit, who answered our questions and participated in workshops. Thanks are also due to several hospital planners, who provided important comments from a planning perspective. The point of departure for writing this book was the research project KARMIN within the InfectControl consortium of the Federal Ministry of Education and Research (BMBF). Our thanks goes to the association partner Röhl GmbH, with their managing directors Nicole and Lars Röhl and the entire team. We would like to thank for the constructive discussions with Prof. Hortense Slevogt from the association partner Septomics Research Group of the Jena University Hospital. Also we would like to express gratitude to Prof. Axel Brakhage, Prof. Oliver Kurzai and Hanna Heidel-Fischer from the InfectControl consortium for their support and good advice. We thank the industrial companies involved in the research project (Atos Information Technology GmbH, BODE Chemie GmbH, Brillux GmbH & Co. KG, Continental AG, FSB Franz Schneider Brakel GmbH + Co KG, Hansa Armaturen GmbH, HEWI Heinrich Wilke GmbH, JELD-WEN Germany GmbH & Co. KG, Kusch+Co GmbH, nora systems GmbH, REISS Büromöbel GmbH, Resopal GmbH, RZB Rudolf Zimmermann, Bamberg GmbH, Schüco International KG, wissner-bosserhoff GmbH, Villeroy & Boch AG) for crucial comments from the planning, construction and medical perspective, and for the provision of documents and products for the realisation of the demonstrator. A special thanks goes to our editor Ria Stein for her valuable proposals and her support throughout the entire development process of the book. We would like to thank Karen Böhme for the constructive support from the project executing agency Jülich (PtJ).

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Appendix

Colophon

Chapter authors

Graphic design, layout and typesetting: Tom Unverzagt

Overall management: Wolfgang Sunder

Translation: Julian Reisenberger

A Fundamentals The Emergence of Hospitals: Wolfgang Sunder The Nursing Ward Environment: Wolfgang Sunder Healthcare-Associated Infections: Rasmus Leistner Material Applications and Material Ageing in Hospitals: Inka Dreßler, Katharina Schütt

Copy editing and project management: Ria Stein Production: Heike Strempel Paper: 150 g/m² Condat Matt Perigord Printing: optimal media GmbH Library of Congress Control Number: 2020946436 Bibliographic information published by the German National Library The German National Library lists this publication in the Deutsche National­bibliografie; detailed bibliographic data are available on the Internet at http://dnb.dnb.de. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in databases. For any kind of use, permission of the copyright owner must be obtained. ISBN 978-3-0356-1749-8 e-ISBN (PDF) 978-3-0356-1752-8 © 2021 Birkhäuser Verlag GmbH, Basel P.O. Box 44, 4009 Basel, Switzerland Part of Walter de Gruyter GmbH, Berlin/Boston Printed on acid-free paper produced from chlorine-free pulp. TCF ∞ Printed in Germany 9 8 7 6 5 4 3 2 1

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Colophon

www.birkhauser.com

B Typologies of the Patient Room The Floor Plan of a Two-Bed Room: Julia Moellmann Qualitative Evaluation of Two-Bed Rooms: Julia Moellmann Typological Evaluation of Two-Bed Rooms: Julia Moellmann Selected Case Studies: Julia Moellmann Building Structures in German Hospitals: Wolfgang Sunder C Prototype of a Patient Room – the KARMIN Project Architecture of the Patient Room: Oliver Zeise Building the Prototype: Oliver Zeise Completed Prototype and Use Scenarios: Oliver Zeise Furniture and Equipment: Lukas Adrian Jurk Conclusion: Lukas Adrian Jurk

BODE Chemie: driving infection prevention Being one of Europe's leading manufacturers, BODE Chemie offers product solutions for hand and surface disinfection, skin care and skin antisepsis. Based in Hamburg, BODE Chemie is a subsidiary of the PAUL HARTMANN AG, Heidenheim. Jointly we offer extensive solutions for preventing infections. The highperformance hand disinfectants are only one of the highlights within the portfolio incorporating more than 400 products, which are available in more than 50 countries around the globe.

Our mission: Going further for health – by contributing relevant products and services! Knowing how (and where) to use hand disinfectants In order to protect patients against viruses and bacteria sustainably in medical wards, hand disinfectants need to be available whereever needed, namely at the point of care (PoC). Hence, as part of the KARMIN project, BODE contributed disinfectant dispensers that can be permanently installed on the wall as well as flexible PoC dispensers. This way, hand disinfectants can be easily placed on trolleys or patient beds: making them a constant, readily available companion!

Why?

When?

How?

BODE’s innovative solutions for all-round infection prevention: hand disinfectants with different efficacies for situation-specific hand disinfection, Eurodispenser Safety Plus for fixed wall installation, Eurodispenser 3 flex as a robust and flexible companion at the point of care, as well as clear educational videos for patients and visitors about the why, when and how of hand disinfection.

Empowering patients with know-how In addition to products, BODE contributed its scientific expertise to the project through the specialist departments Research & Development and the BODE SCIENCE CENTER. Both played a decisive role in the placement of the disinfectant dispensers. In order to increase patients’ and visitors’ awareness for the importance of hand hygiene, BODE also supplied motivating training videos that can be integrated into the infotainment systems at the patient bed. Each film answers an important question about hand disinfection: Why? When? And How?

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BODE Chemie GmbH Melanchthonstraße 27 | 22525 Hamburg | Germany Ph.: +49 (0)40 54006-0 | Fax: +49 (0)40 54006-200 [email protected] | www.bode-chemie.com

Brillux ..more than paint Brillux is the number one direct and full-range supplier in Germany, offering over 12,000 items in the varnish and paint sector. The family business is in its fourth generation; it is headquartered in Münster and employs over 2500 people. In addition to the Münster factory, Brillux manufactures at three other sites in Unna, Herford and Malsch. The branch network covers over 180 sites in Germany, Italy, the Netherlands, Austria, Poland and Switzerland.

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At the Brillux headquarters in Münster, Germany, research is carried out on ongoing innovations in the field of paints and coatings, with state-of-the-art technology.

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Charité Berlin Photo: Kusch+Co & Anke Müllerklein

RIU Plaza Espan˜ a Madrid

Mormor Aktivmöbel, Chair SITZ Photo: Mormor Aktivmöbel

Production plant in Weißbach

With skai®, Continental has the perfect solution for every upholstery application The surface specialists at Continental make use of the innovative power and quality commitment that skai® has stood for worldwide for over 60 years. As an upholstery surface for the furniture and contract sectors, skai® is a synonym for high-quality artificial leather. With innovative design tools, Continental consistently uses the new possibilities of individualisation and digitalisation. As a competent partner to industry, designers, planners and interior designers, Continental offers the right surface solution for every application. For

example, skai® materials with their specific properties are ideal for applications in the hospitality area, such as in hotels, restaurants and on cruise ships, and in the health sector, for outdoor use, in public areas or in mobile interiors. Among other things, skai® upholstery surfaces are characterised by their ease of cleaning and resistance to disinfectants, so that skai® Palma NF in the color inka is used for the benches and chairs of the “Patient Room of the Future” in the KARMIN project.

Continental AG Salinenstraße 1 | 74679 Weißbach | Germany Ph.: +49 (0)7947 81-8714 [email protected] www.skai.com/en/interior

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ErgoSystem® E300: angled rail in WC area

ErgoSystem® E300: drop-down support rail in WC area

ErgoSystem® E300: shower handrail combination, suspended seat, shower rail FSB 1155 lever handle, operable by hand or also with the elbow

Door handles and sanitary equipment by FSB: ergonomic, hygienic, safe FSB Franz Schneider Brakel stands for design and functional high-quality door and window fittings as well as barrier-free sanitary facilities. We are your partner of choice, when it comes to reliable, comfortable products and high-end materials. Especially in hospitals and nursing homes, where maximum hygiene and comfort are important, architects, planners and clients rely on FSB products – to be haptically experienced in the KARMIN patient room. The FSB 1155 lever handle is particularly suitable

for doors that are in frequent use. It can be operated by hand or also with the elbow. For the best possible hold, the products of our ErgoSystem® E300 used in the sanitary facilities are made of easy-care stainless steel with oval handle cross-section: the drop-down support rail and angled rail handle for the WC area, for the shower a shower rail mounted on the handrail combination (including a shower head holder with one-hand operation) as well as a suspended seat and a shower curtain rail.

Franz Schneider Brakel GmbH + Co KG Nieheimer Straße 38 | 33034 Brakel | Germany Ph.: +49 (0)5272 608-0 [email protected] | www.fsb.de

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Experts for accessibility and professional care Making life easier for people – with individually adaptable concepts that enable independence and provide security – that is what drives us. Universal Design incorporates the needs of all people. We have been living this ideal for more than 35 years with our sustainable and holistic design philosophy. Outstanding design ensues exclusively in junction with innovative technology. The combination of aesthetics, function and hygiene is firmly anchored in HEWI's DNA.

Barrier-free furnishing concepts S 900 – hygienic solution for the health sector System 900 is the answer to the complex requirements for barrier-free bathrooms. The products have been thought through down to the smallest detail – they convince through functionality, lasting quality and hygienic design. System 900 combines purist design with high functionality. Due to the unique depth of the product range and its hygienic properties, it was the appropriate solution for the patient bathroom in the KARMIN project. Increase hygiene For use in hospitals and rehabilitation clinics, hygiene is a decisive factor in sanitary solutions. For this reason, System 900 uses only materials that are insensitive to wound treatment agents and cleaning products. In the development of System 900, our product developers focused not only on design and function but also on hygiene. The result is a product line for the sanitary area in healthcare buildings with the highest demands on hygiene. Thanks to the clever design, the products are made from as few components as possible, so that there are only a very small number of joints. Precise manufacturing guarantees smooth, hygienic surfaces. The sealing element provides a quick and reliable seal between the fastening elements and the wall. The wall brackets of the support folding handles and shower seats as well as the fixing rosettes of the support handles and bar systems can be equipped with it. System 900 also includes a large number of useful accessories. For example, the soap and disinfectant dispensers are available in different versions so that they can be filled with standard care products. The touch-free sensor versions are particularly hygienic.

The functions of System 900 are designed to support patients‘ independence in the best possible way. Modularity and surface diversity reflect HEWI‘s understanding of first-class design. Due to wall unevenness, the mounting rose often does not completely close off the wall. Reliable sealing can be achieved with the System 900 sealing element.

HEWI Heinrich Wilke GmbH Prof.-Bier-Straße 1–5 | 34454 Bad Arolsen | Germany Ph.: +49 (0)5691 820 [email protected] | www.hewi.com

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nora systems – perfect hygiene made easy nora systems is the global market leader for rubber floor coverings and part of the Interface Group. With decades of experience and comprehensive know-how, nora is considered a renowned specialist in the healthcare sector. The robust and high-performance nora® rubber floor coverings “Made in Germany” are characterised by optimum hygiene, high comfort and enduring economic efficiency.

Specialist for floor systems in hospitals nora® rubber floor coverings convince through well thoughtout system solutions providing the foundation for high-quality design concepts with health- and environmentally compatible materials. They combine safety, comfort and attractive design with perfect hygienic properties. nora® floor coverings are not only easy to clean but can also be completely disinfected and are thus ideally suited for the use in risk areas. They are free of PVC, phthalate plasticizers and halogens. norament® 926 and noraplan® standard floor coverings have been awarded the German ecolabel Blue Angel (DE-UZ 120).

Clear advantages • Simple and economical cleaning • Hygienically perfect surfaces and joints • No time-consuming and costly recoating and joint sealing – usable 24/7 • Resistant to the surface disinfectants listed by VAH and RKI • Extensive range of accessories with skirtings for areas with high hygiene requirements • Recommended by renowned hospital hygienists

nora systems GmbH Höhnerweg 2–4 | 69469 Weinheim | Germany Ph.: +49 (0)6201 806040 [email protected] | www.nora.com/de

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REISS high-quality workplace solutions REISS Büromöbel GmbH, one of the leading suppliers of high-quality office furniture solutions in Germany, develops and produces furniture and accessories for performance-enhancing and health-promoting workstations that meet the highest demands of functionality and ergonomics. Driven by innovation, the company developed an office furniture programme early on that minimises the risk of germ transmission through direct contact with surfaces and thus contributes to workplace hygiene.

REISS offers a furnishing range which takes into account the increasing hygienic requirements in public spaces and the trend towards offices with rotating workplaces and co-working spaces. Desks and storage solutions from the REISS SmartClean series have special surfaces that minimise the transmission of germs by touch. Thus, the furniture offers health benefits in environments that are not subject to the intensive cleaning regulations of healthcare facilities, but do have similar conditions.

A promising approach for use in healthcare What's more, the surfaces of this furniture have excellent mechanical properties and are resistant to most chemicals. They are suitable for special cleaning in care and medical facilities and are resistant to alcohol, aldehyde and phenol-based disinfectants. Thanks to the zero-joint technology and the furniture's sophisticated design with seamless surfaces without handles, holes or other recesses, it is particularly easy to clean and allows effective hygienic cleaning in environments with high requirements, such as in hospital rooms. Characteristics of REISS SmartClean surfaces: • Resistance to chemicals, such as disinfectants, acids and alkalis or solvents • Special physical properties, such as high temperature resistance, non-reflective properties, corrosion resistance, liquid tightness, electrical dissipation capability • Excellent mechanical properties, such as shock resistance, scratch resistance and abrasion resistance • Reduction of germ transmission REISS SmartClean furnishing solutions – tables, cabinets and containers REISS Products are GS-certified. They bear the RAL-UZ 38 environmental quality seal, and meet the `Quality Office´ criteria. REISS is certified in accordance with the quality management system (DIN EN ISO 9001), the environmental management system (DIN EN ISO 14001) and the product chain certificate PEFC-CoC and EMAS III. The antibacterial effectiveness of REISS SmartClean has been tested and certified according to ISO 22196: 2011-08.

REISS Büromöbel GmbH | Südring 6 | 04924 Bad Liebenwerda | Germany Ph.: +49 (0)35341 48-360 | Fax: +49 (0)35341 48-368 [email protected] | www.reiss-bueromoebel.de

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Furniture in patient rooms © Tim Friesenhagen

Doors and impact protection panelling in hospitals

Surfaces for wet cells © Foto Studio Wiegand

Wall claddings for surgical theatre wall © DANMEDICS Medical Engineering GmbH

RESOPAL® – the brand, the company and the surface, traditional and contemporary. Resopal GmbH with approx. 600 employees in Groß-Umstadt in Hesse produces functional and decorative high-pressure laminates (HPL). The products are used for interior fittings and external façades, in hotels, hospitals, wet rooms, retail outlets and furniture. We are pioneers of laminate surfaces and continue to supply trendsetting solutions for contemporary interior design.

Resopal is a reliable partner for architects and fitters in the healthcare segment. Thanks to many years of experience and comprehensive product solutions, such as antibacterial surfaces and anti-fingerprint textures, wet room elements or customised motifs for HPL, we are an important counterpart for architectural projects in hospitals, nursing homes or laboratories. Together, we ensure that your project becomes a success.

Resopal GmbH Hans-Böckler-Straße 4 | 64823 Groß-Umstadt | Germany Ph.: +49 (0) 6078 800 | [email protected] | www.resopal.de

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Customised prefabricated bathroom

Prefabricated bathroom with cabinet system Prefabricated bathroom with wall surface made of high-quality safety glass, coated on the back

Wall protection system

WC partition wall system with HPL surface

Operation theatre panelling with PL surface

Röhl stands for individual integrated solutions in cost-efficient series production "Innovations arise from ideas but solution-oriented implementation is the key to success." The Röhl company has followed this principle for more than 75 years now. We are a family-run company with short decision paths and have been successful for more than 40 years as a system provider in the healthcare sector. Wall protection systems, OP panelling, cabinet systems, WC partition wall systems and prefabricated bathrooms form the cornerstones of our range of services.

We do not offer run-of-the-mill standard products, but rather high-quality customised solutions, adapted to the requirements of the client while remaining within budget. Due to our many years of experience, as well as the high degree of system solutions and our modular principle, adaptation is possible at very low cost – both as an all-in-one system for a new building as well as in individual components for a rapid and cost-efficient renovation.

Röhl GmbH Friedrich-Koenig-Straße 15–17 | 97297 Waldbüttelbrunn | Germany Ph.: +49 (0)931 40664-0 | Fax.: +49(0)931 40664-443 [email protected] | www.roehl.de

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RZB illuminates the "Patient Room of the Future“ In the study KARMIN, funded by the Federal Ministry of Education and Research and the Technical University of Braunschweig, the first infection-preventive patient room was presented. RZB Lighting was involved in this study from the very beginning as the partner responsible for planning and implementation of all lighting tasks. In the area of "light for health and well-being", the Bamberg-based generalist for luminaires offers a broad product portfolio of innovative and sustainable solutions.

In addition to the required provision of luminaires with hygienical and easy-to-clean surfaces, the normative lighting of the patient room meets all the necessary visual tasks and other important criteria: a high level of well-being and easy orientation both for the patients as well as for the hospital staff. Biodynamic light for more vitality and well-being Changing lighting moods, which correspond to the dynamic rhythm of daylight, can positively influence the patient's sense of well-being and vitality. Biodynamic light in the sense of human-centric lighting also minimises the loss of the natural day-night rhythm and promotes sleep. In the "patient room of the future", large-format, glare-free recessed luminaires of the "Econe" series were used. Individually preset lighting scenes e.g. during doctor’s visits (5000 K), cleaning (4000 K) or circadian daylight patterns from warm-white to cold-white can be selected via an operating panel. Guiding lights for patients Light-directing aluminium profiles with integrated LED strips, installed above the floor base, provide glare-free lighting and easy orientation and thus enable the patient to see at night when moving from the hospital bed to the bathroom. Falls due to insufficient light are avoided, but the dimmed warm-white LED bands do not disrupt the patient‘s night rhythm. The "Less is more Flex" modular system from RZB offers an extensive selection of hygienic, easy-to-clean profiles, diffusers and LED strips, including also Tunable White versions.

RZB Lighting | Highly efficient lighting solutions, progressive LED technology and excellent product quality "Made in Germany" – the summary of over 80 years of company history. The portfolio of the family business includes products from the fields of interior and exterior lighting, emergency lighting and innovative lighting management systems. RZB has already received ­several the "Top 100" seal and is therefore one of the most innovative ­companies in the German medium-sized businesses.

RZB Rudolf Zimmermann, Bamberg GmbH Rheinstraße 16 | 96052 Bamberg | Germany Ph: +49 (0)951 7909-0 | Fax +49 (0)951 7909-198 [email protected] | www.rzb.de

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Residence in Zakynthos / © Lukas Palik Fotografie / Schüco

Schüco – system solutions for windows, doors and façades Based in Bielefeld, the Schüco Group develops and sells system solutions for windows, doors and façades. With 5650 employees worldwide, the company strives to be the industry leader in terms of technology and service today and in the future. In addition to innovative products for residential and commercial buildings, the building envelope specialist offers consultation and digital solutions for all phases of a building

Schüco AWS 75 BS.HI+

project – from the initial idea through to design, fabrication and installation. 12,000 fabricators, developers, architects and investors around the world work together with Schüco. The company is active in more than 80 countries and achieved a turnover of 750 billion euros in 2019. For more information, visit www.schueco.com

Schüco International KG Karolinenstraße 1–15 | 33609 Bielefeld | Germany Ph.: +49 (0)521 783-0 | Fax: +49 (0)521 783-451 [email protected] | www.schueco.com

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