Health Care Environment

The User's Viewpoint

William C. Beck, Ralph H. Meyer

• Publisher: CRC Press
• Year: 2019
• Print ISBN: 9780367218256, 9780367218249
• eBook ISBN: 9780429561320
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Published in 1982: This book describes the Hospital Environment from Administrative functions to patient and staff users.

Chapter 1

Introduction

W. C. Beck

TABLE OF CONTENTS

• I. The Past
• II. The Present
• III. The Future
• References

I. The Past

The first hospital recognized by modern medical historians existed in the fifth century before the birth of Christ, in Epidaurus. The Asklepieion which is now recognized to have served medical, surgical, and psychiatric patients seems to have taken the patient’s environment into consideration by providing a milieu of artistry and beauty. The patient’s communion with his fellow sufferers as well as his deities was obviously designed to be enhanced by the visual surroundings. Also the auditory senses were assuaged by the use of the sound of running water by constructing a small aqueduct over the patient’s sleeping and dreaming area.

This attention to the sensibilities of patients, and even of those who attend them within the hospital was, with the advances in both diagnosis and therapy, relegated to a secondary role. Hospital design and planning was for centuries aimed only toward providing bare shelter. This shelter was available almost entirely in the monasteries of Europe, many of which contained infirmaries. Thompson and Goldin¹ suggest that the Abbot of Cluny “faced the problems of modern administrators when they have to expand architecturally around an irreducible patient population”.

In the early Middle Ages, the sensibilities most challenging to the hospital population was the defecatory one. Necessaria or privies were constructed, often most conveniently situated and accessible from each patient’s bedside. Running water maintained a semblance of sanitation. Ventilation was achieved by the use of windows and vents in ceilings or in domes and low towers built on the roof. Convection currents were used to enhance this ventilatory system by the use of stoves or fireplaces in the center of the large wards.

The Knights Hospitallers combined the hostel for pilgrims as well as the hospital for the sick and injured. They encouraged the sisterhood to care for the sick within them. Not only did this serve to associate the religious orders with the care of the sick, but it also might be considered the initial effort of hospital planning as an entity. Moreover, we observe in this planning a conscious effort to insert a design for privacy for the upper classes, separating them from the common man who was housed in large crowded halls. To this day this social grace of privacy is a basic tenet of hospital design. In addition, the Knights of St. John added luxury to the hospital scene, particularly in food, such as white bread. They recognized the professionalism of physicians and surgeons who ate their meals with the Knights.

We find, therefore, that the environment of the hospital through the Middle Ages gave consideration to the visual milieu, the sanitation, the ventilation, and the concept of privacy to the congregation of the sick in common facilities.

To these ecologie influences, Florence Nightingale added observation and control. The so-called “Nightingale Ward” still is in use in many parts of the world, although it has been often modified by subdivision into open bays and alcoves. A partial, flexible privacy is achieved by the use of curtains — first employed in medieval hospitals.

II. The Present

The evolution of the hospital went through a variety of phases. At first it was an annex to the housing of the hospital attendants; the religious orders. Thompson and Goldin describe them as derived from monasteries, palaces, estates, prisons, or barracks. Our original hospital (The Robert Packer) was derived from the home of its original donor. Thompson and Goldin also describe the designed hospital in which an attempt was made to fashion the hospital to serve its special nursing and therapeutic function. Our original hospital in Mr. Packer’s home was partially designed by the addition of wards and a surgical suite.

About a century and a half ago, planning for function took place. Architects and medical professionals began to study the functioning organism. Research teams came into being and a scientific literature initiated. The pavilions were probably designed in France and England as responses to the great epidemics. The military hospitals particularly seemed to accommodation well to the pavilion configuration. Indeed the general hospitals of World War II were of this type of architecture. They also adapted well to the growing use of specialists and the segregation of patients by the manner of care that they required. Large hospitals, such as Cook County in Chicago and small, such as the Robert Packer, were designed and built as specialized pavilion institutions.

As early as 1905, in Chicago, Albert J. Ochsner, a prominent surgeon, foresaw the real estate problems of the growing urban hospitals and envisaged their vertical configuration. The hospital skyscraper was a product of this century. Within these confines horizontal growth gave way to vertical growth with departments waxing and moving by encroaching and replacing their neighbors.

The most significant contribution of the current era probably is the concept of progressive medical care. The movement of the patient from zone to zone within and without the hospital; from critical care, through normal, minimal, and eventually extended care has been instituted to make a maximum use of facilities, and also for economic employment of both expensive facilities and expensive manpower. The “private duty nurse” needed by both rich and poor but affordable only by the wealthy, gave way to the critical care unit; democratically dedicated to all of the very ill.

This progressive medical care has created new problems for the hospital planner and designer. The professional requirements vary as considerably as do the needs for the various tasks. Moreover, the tasks are constantly changing in response to scientific and technical progress. They are responding in geometric progression to quantum technologic advance and the continuing contributions of research.

The challenge of progressive change creates demands upon facilities with such rapidity that even flexible arrangements cannot keep pace.¹ However, the specialized units of progressive care provide modules which are most easily rearranged to suit the new demand of the diagnostic and therapeutic methods.

All of the hospital facilities may need replanning, even support services. Let us cite a few illustrations. In our hospital, additives to intravenous solutions were reoriented from a ward activity to a pharmacy locale several years ago. A clean bench was installed in the pharmacy. Within a span of only three years, with the more general acceptance of intravenous hyperalimentation, this activity now has demanded completely separate facilities with specialized personnel, three clean benches, and a centralized dedicated computer capability so that the requirements may be anticipated.

A second example is the medical library whose requirements for shelf space increases annually despite the disposition of most serials after ten years, relying upon interlibrary loans for older reference issues, and computerized telephonic searches for current title. The speed of this phenomenon is that the library of medicine will soon search the literature only for the last two years, relegating older contributions to scientific limbo.

Each modification creates a new demand upon design. An additional allocation of space means restriction for another facility. It may be achieved only by relocation of the surrendering area which, in turn, may dislocate previously carefully designed relationships. Similarly, accommodation of all of the accouterments of planning including ventilation, lighting, decor, communication, etc.

In most hospitals, who handles these considerations? It varies greatly! For major changes, the demands may become a part of a fallible long-range plan.³ Or they may be ad hoc following investigation by the administration. A variety of consultants, planners, architects, and others may create statements of need, block designs, preliminary plans, and final plans and specifications. Cooperating in this effort will be planning groups representing the ultimate users. The trustees of the hospital are responsible for adjusting all of these to the available or attainable dollars. Governmental assessment to avoid duplication follows.

Lesser modifications will be weighed and put into plans and eventual fruition by similar, but often less formal mechanisms. As change is ever present, larger hospitals may have a full-time planning team. Even middle-sized hospitals should have an organization capable of studying such changes.

Thus, the present time might be characterized by calling it the era of integrated and progressive care. Incidental to this has come the democratization with leveling the care of the economic means of all patients. These elements have reduced privacy and even segregation by sex; as one sees men and women side by side in the critical care units. Moreover, there appears, at present, an emphasis upon cure rather than care; which seems to be beginning to wane.

III. The Future

Implicit to all of this discussion is the development of master plans for the institution. Can one use the tools developed from institutional history and geographic demography. Without question these are significant and can produce useful information. But these guides are influenced in a major way by scientific progress, technical innovation, and actual changes in the disease processes.

Diseases which demanded hospital care are themselves changing. Acute appendicitis was a disease of youth and far greater in frequency two decades ago, while much less frequently represented by its dangerous complication, rupture of the inflamed organ. Infantile paralysis once occupied the major bed complement of the orthopedic section. Mastoid disease made the pediatric otology require a bed complement. Tonsillectomy was a frequent operation.

Today the orthopedic beds are populated by the patient with an inserted new artificial joint. The surgical bed is occupied by the patient with a reconstructed heart, a replaced aorta, or a patient being nourished entirely by vein. The hernia patient is no longer bed-confined for a postoperative week and a hospital stay of ten days; he returns to his home on the day following the operation.

The ancillary hospital sections from anesthetic rooms to the laboratory and the X-ray sections are all changing from the time that the plans are being created to the time of first occupancy with such rapidity that the newest hospital is antiquated when it opens.

Recently, Morss³ has called to the attention of hospital trustees problems associated with designing the structure for growth. He said “The limited vision of the master plan is almost always doomed to fail, because it is simply impossible to make concrete predictions for the future.” To this we would add that the future is constantly coming closer to the present, so that the only predictable part of a master plan is that it will constantly change. Historically, changes have been one of the most costly parts of new construction. This challenges all of those involved with new facilities or remodeling of existing ones. Obsolescence is taking place at an ever accelerating rate.

Basic design, as Morss suggests, can include flexibility. Plans can be created so that areas can be expanded or contracted as demands change. We have suggested mechanisms for flexibility which can be employed even during the construction phase.

Also we are beginning to see in our health care institutions a resurgence of the phenomenon of caring. Care does not preclude the scientific applications designed for curing. In fact, it may actually enhance recovery. The milieu for this approach within the constraints of cost should be the goal of the designer, the engineer, the architect, and the institutional provider.

The future, as we see it, is therefore one which will provide spatial, functional, and atmospheric flexibility. It should be the result of not only innovative thinking, but also of reviewing the achievements of the past and altering them to accommodate the requirements of the present, with the flexibility to adjust for the constant and ever increasing pace of future needs.

References

1. 1. Thompson, J. D. and Goldin, G...

Table of contents

• Cover
• Title Page
• Copyright Page
• Preface
• The Editors
• Dedication
• Contributor
• Contents
• The Administrative Functions
• Chapter 1 Introduction
• Chapter 2 The User and His Tasks
• Chapter 3 The Administration and Construction
• Chapter 4 The Administration and the Budget
• The Users’ Viewpoints
• Chapter 5 The Patient User
• Chapter 6 The Physician User
• Chapter 7 The Nurse User
• Chapter 8 The Environment of the Child
• Chapter 9 The Environment of the Aged
• Special Considerations
• Chapter 10 The Environment of the Visitor
• Chapter 11 Special Care Units
• Chapter 12 Noise or Sound Perception
• Chapter 13 The Air Environment
• Chapter 14 The Illumination
• Chapter 15 Odor Control
• Chapter 16 Infection Control
• Chapter 17 Housekeeping and the Environment
• The Construction and Evaluation
• Chapter 18 The Building Designer
• Chapter 19 The Interior Designer
• Chapter 20 The Evaluation
• Index
• Index