Sicherheit durch Design: Das sicherste Verhalten auch zum Einfachsten machen

Safety by design: making the safest behavior, the easiest behavior

Craig Zimring, Ph.D. Director, SimTigrate Design Lab Professor, Architecture Georgia Institute of Technology

Hospitals are Unnecessarily Dangerous

• Quality Chasm Reports: 48,000 to 98,000 die annually due to preventable medical errors in the US (IOM, 2000)

• Mean of estimates based on medical record review: 251,000/year in the US die due to preventable medical errors about 0.6 % of admissions (Markary & Daniel, 2016)

• 1 in 20 patients contract infections during care; new highly antibiotic resistant pathogens, persistent problems with MRSA, C difficile (CDC, 2012)

Hospitals are Unnecessarily Dangerous

• The lower end of these estimates is the equivalent of the worst air disaster in history happening three times each week, 52 weeks a year or the equivalent of all 9/11 deaths each two weeks.

583 people died when two 747s

collided in Tenerife, Canary Islands,

March 27, 1977

The Built Environment Can:

• Prevent HAI • Reduce medication errors • Reduce patient falls

Improve patient safety

• Noise reduction • Improve sleep • Reduce spatial disorientation • Reduce depression • Provide nature and positive distraction • Provide Social support • Improve communication

Reduce Stress

• Reduce length of stay • Increase patient satisfaction

Improve Overall Quality

Ulrich, Zimring et al, Health Environment Research and Design, 2008;1 (3):61-125

HCD15 | After Evidence-Based Design: Creating a Collaborative Science of Healthcare Delivery to Reduce Harm in Critical Care

Evidence-Based Design

Patient Groups by Visibility

High-visibility Patient Group

PT (upper half body) visible from

both the corridor and the nearby

nurses’ station

Source: (Choi, 2012)

Moderate-visibility Patient

Group

PT (upper half body) visible only from

the corridor

Low-visibility Patient Group

PT (upper half body) NOT visible

from the corridor

31% higher fall rate!

Measures of Visibility Predict Safety

Leaf et al, 2010, Lu et al 2014, Ossmann, 2016

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

Layout Impacts ICU Mortality

Floor plan with FOV Visibility Groups overlaid: Red = Low, Yellow = Medium, Green = High

Layout Impacts ICU Mortality

Source: Ossmann, 2016

ICU D

High visibility rooms reduce odds of death by 42%

Layout Impacts ICU Mortality

Source: Ossmann, 2016

COLONIZED

or

INFECTED

HOST

Patients

HCWs

Visitors

COLONIZED

or

INFECTED

HOST

Patients

HCWs

Visitors HAI

Human Reservoirs

Transmission Event - direct or indirect contact including

transient carriage (e.g. hands of

healthcare workers)

- airborne/droplet

Environmental sources and

reservoirs of pathogens

RESERVOIR or SOURCE

IN THE HOSPITAL

EXTERNAL SOURCE

Transmission event Transmission event

Transmission event

Barriers

Filters

Opportunities for interventions

through the built environment

Disinfect

Eliminate

Hand hygiene

Other barriers

Isolation

Hand hygiene

Isolation HERD 2013;7S;46-73

Chain of Transmission: An Intervention Model

Hand hygiene

Other barriers

Isolation

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

System 1 Fast - automatic

Line of Sight and Surveillance Increases Hand Hygiene

• Dirty • Hard to clean and

rarely cleaned • Have been linked to

transmission of pathogens (evidence relatively weak)

• What to do?

Prototype for Issues Related to Design and Infection Prevention

Curtains to Curtains?

Contamination of Hospital Curtains with MRSA, VRW, C. difficile

• Culture of lateral edge of 50 hospital curtains using 3 methods

Trillis ICHE 2008;29:1174

• Sampling of 200 fabric curtains from wards in UK – Chromogenic MRSA medium “sweep” method – MRSA recovered from 31/200 (15.5%), mean 2.5 cfu

Klakus JHI 2008;68:189

• 180 cultures obtained twice weekly from 43 vinyl curtains in ICUs & wards

• 12 of 13 (92%) new curtains showed contamination within 1 week

AJIC 2012;40:904

• 30 ICU rooms randomly assigned to get novel or standard curtain

• Curtains cultured twice weekly for 4 weeks

• Median time to contamination for antimicrobial curtains was 14 days compared to 2 days for standard curtains

• Almost all curtains contaminated by 3 weeks

ICHE 2012;33:1081-85

Pros

• Relatively inexpensive • Spatial separation • Limits direct access and

discourages movement from patient to patient

• Visual privacy • Movable • Flexible use of space

• Efficient use of space

Cons

• Aesthetics • Limited sound privacy • Cleaning/replacement

costs • Possible fomite

Curtains

Mitchell, Journal of Hospital Infection 2015;91:211-17

Risk of Organism Acquisition from Prior Room Occupants

Systematic Review and Meta-analysis

• Physical separation may reduce opportunities for direct contact with contaminated surfaces

• Other physical changes may contribute to decreased infections

– Elimination of privacy curtains – Private toilets – More frequent room cleaning – Improved sink/bed ratio; more hand rub

dispensers

• Associated with improved hand hygiene rates

– Anthropology & Medicine 2015;22:149-161

Single-patient Rooms HAI Risk

22

Single-patient Rooms

Logistical Advantages •No transfer to contact isolation •No gender matching

Facilitate exchange of sensitive information

Reduce noise/improve sleep

Allow more family presence

Incremental benefits may outweigh added construction costs

•Sadatsafavi, Journal of Critical Care 2016 ;31:193-9 •Boardman, University of British Columbia, 2007

• Translate microbiological, epidemiological, and technological discoveries into new strategies to reduce the spread of dangerous germs like Ebola.

• Rapid prototyping in simulation labs, quantifying and visualizing spatial metrics using special analytic tools, and utilizing novel technologic approaches enhancing hand hygiene adherence

Zimring, 2016

PEACH CDC Epicenter

Estimated additional first cost/room $20,000-30,000

New ICU Room with Features to Minimize Infection Risk

Materials, Simulation,

Design

Limited Field Studies

Evaluation of Operating

Designs

Design Practice

HCD15 | After Evidence-Based Design: Creating a Collaborative Science of Healthcare Delivery to Reduce Harm in Critical Care

Practice and Practice-based Research

Building a Collaborative Translational Science of Healthcare Delivery

T0 – Epidemiologic studies and basic science

T1 – Small sample studies in clinical settings or high fidelity simulation

T2 –Larger multi-site studies

T3 – Local evidence-based guidelines for practice

T4 – National guidelines and standards

Lab

Clinical Trials

Practice-Based Research

Clinical Practice

Craig Zimring http://www.simtigrate.gatech.edu https://www.healthdesign.org