Acute Care Design: Designers balance hospital requirements and patient needs - Oct 2017

By Beth Miller

Hospital design continues to be impacted by the ever-changing needs of healthcare consumers, who are now playing an active role in their decision-making process. Patient satisfaction surveys no longer point to just better food, more blankets and single-occupant rooms; consumers are also requesting higher quality healthcare experiences that contribute to their overall health and wellness. One element that continues to play an integral part in the patient experience is flooring.

According to The Center for Health Design, a nonprofit organization of healthcare providers and architects focused on transforming healthcare facilities by improving their design, “A large and growing body of evidence attests to the fact that the physical environment impacts patient stress, patient and staff safety, staff effectiveness and quality of care provided in hospitals and other healthcare settings.” Rosalyn Cama, president and principal interior designer of Cama, Inc.-a health and wellness interior design studio and lab-points out that patients do not remember surgery but rather the way they felt in their room following surgery. A warm, wood-look floor reminds patients of their home. Healthcare designers must now decide how to balance patient needs and desires, stringent acute care requirements, healthcare system consolidation and service integration-and the list continues to grow. One way to sort out the various elements required of healthcare designers is through the use of evidence-based design (EBD).

The Center for Health Design defines EBD as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” Basically, this means that researchers figure out what is working and what is not, as it relates to patient outcomes. In fact, some issues can prove harmful to patients and must be ruled out in upcoming facility designs. Cama explains, The Center for Health Design performed research on patient falls, which led some facilities to move the beds closer to the bathrooms in patient rooms and provide handrails on the wall. However, this increased patient fall risk. Patients were more likely to fall because they felt they could cover the shorter distance without assistance. Some hospitals incorporate EBD into their renovations and new builds. However; according to Cama, there aren’t many who are well versed in it. Cama, who has more than 30 years experience in healthcare design, admits, “There’s lots of knowledge in the research, but designers have to make time to read it. The client has to ask for it; they have to know what they’re asking for.”

Flooring is certainly an important part of a healing environment, and it plays a role in EBD. According to The Center for Health Design, some of the EBD’s proven outcomes for flooring include reduced patient stress/anxiety, a reduced risk of contamination/infection, improved access/wayfinding and a reduction in negative health effects. Ultimately, the positive effects flooring can have, along with a myriad of other elements defined through EBD, contribute to the message that hospitals desire to promote health and wellness through a holistic approach.

KAISER PERMANENTE REDWOOD CITY MEDICAL CENTER
Kaiser Permanente is an integrated managed care consortium and the largest managed care organization in the U.S., operating in eight states and the District of Columbia. Its new Medical Center in Redwood City, California is 280,000 square feet and includes 149 private rooms. In addition to the private rooms, the seven-story facility hosts an emergency department with 24 private exam and treatment rooms, a surgery suite with ten operating rooms with a neurosurgery specialty, 24 ICU rooms, and an obstetrics department with separate labor and delivery and post-partum rooms.

The first and most crucial requirement for flooring specified for Kaiser Permanente is that it must “not add any health risks for the users of the building,” according to Donald Cremers, vice president and senior project interior designer with HOK San Francisco. He goes on to explain that flooring must “support healthy indoor air quality, be comfortable for the user, be highly durable over time and support the cleaning staff with providing a clean, infection-free environment.” HOK has designed facilities for Kaiser Permanente, ranging from clinical support facilities to medical office buildings to acute care hospitals in northern and southern California.

The Redwood City Medical Center is a new build that replaces an older facility-“in an effort to assure that all acute care facilities remain safe and functional after the occurrence of a major seismic event,” explains Cremers. Kaiser Permanente does not typically specify terrazzo for its facilities; however, it did so for this new build in the main lobby and café. Terrazzo was chosen for these high traffic areas not only for its durability but also for its aesthetics in an area where a first impression is made. According to Cremers, terrazzo was chosen for its low maintenance qualities, its lack of noise as carts and equipment roll over it, and its longevity-terrazzo will last the lifetime of the building. The neutral shades found in the terrazzo are blended with textural elements such as mother-of-pearl shells and river rock. “These natural elements reinforce the connection to the healing garden that is directly off the lobby and café,” says Cremers.

This reference to nature continues in the color palette that was inspired by Kaiser Permanente’s Total Health Environment (THE) program. The THE program was designed to align Kaiser Permanente’s healthcare environments with its branded healthcare initiative, Thrive-total health for mind, body and spirit. All hospital members, physicians and staff are encouraged to live healthier lives through the Thrive campaign. Moving forward with the project, HOK’s design team focused on THE’s guiding principles-21 key experiences, or moments, critical to the patient’s and visitor’s impression. “These principles are key to Kaiser Permanente’s promise of ‘total health’ and support their goals for ‘safe, quality care in innovative, cost effective, eco-conscious facilities,’” Cremers explains. “With that in mind, the architecture and design of the hospital defines a supportive, people-friendly environment that balances emotional and physical patient needs with expert clinical care, extending the experience throughout the unique context of the architecture and the site.”

Walking through the facility, the color palette is inspired by a walk through a redwood forest, with the colors and materials in the palette based on the THE palette. Cremers adds that the facility used additional specific and unique key materials with the “careful integration of art and local photographic images furthering the design concept, culminating in a project that eliminates any reference to institutional, sterile healthcare designs of the past.” The photos used throughout each space reference different elements of nature, ranging from moths to ferns to flowers, with the flooring echoing the various colors in the nature-inspired palette.

The neutral solid tones used in the waiting rooms and administration areas are Tandus Centiva’s Kaiser Permanente-branded carpet collection. According to Cremers, it is designed “to act as a backdrop to the furnishings and artwork throughout the spaces.”

The flooring used throughout the remainder of the facility is Nora’s Noraplan Envirocare rubber flooring, in both 2mm and 3mm thicknesses-tile and sheet format. Rubber flooring reduces foot and leg fatigue, is relatively quiet to footfall noise and comes in a wide range of colors. Nora’s tile product was used in areas that did not require a seamless, waterproof surface and cove base, reducing the overall cost of the flooring, explains Cremers. “Using a standard tile format supported the ease of installation and assembling of the complex patterns,” he says. These patterns reference the look of the terrazzo in the main lobby, though the accent colors represent a broad spectrum of hues. Of the sheet products, Cremers says, “In areas where we desired to have fluid curves, the sheet product was a perfect medium to achieve that look.” Each floor uses a specific accent color to help with identification.

EASTERN MAINE MEDICAL CENTER
Celebrating 125 years, Eastern Maine Medical Center (EMMC) in Bangor, Maine originated as Bangor General Hospital, opening its doors in 1892 with only five patient beds. This historical campus is being renovated, along with some new construction, in order to improve amenities and consolidate a number of services, as well as improve access for patients and families. This project is phase one of the multi-phase “modernization project.”

The 361,000 square-foot project had some limiting factors that played a major role in its development. The main building is situated between a state highway and railroad tracks with three additional hospital buildings immediately adjacent. With such a limited footprint, the facility is expanding vertically with construction taking place over three years. According to Joanne MacIsaac, associate partner with Environments for Health Architecture (E4H), this project sets the new standard for the remainder of the campus. MacIsaac, the lead interior designer on the EMMC project, notes that the colors EMMC is using to carry out its rebranding will continue through the remainder of the campus as renovations are made.

Evidence-based design elements were incorporated into the project, including natural light, decentralized nurses’ stations, private bathrooms, patient lifts, respite areas and interiors created to reflect Maine’s natural beauty. The new tower overlooks the Penobscot River, which is the inspiration for the flooring design in the main lobby. In addition to the lobby, the new tower hosts a café, heart and vascular care space, surgical suite, neonatal intensive care unit (NICU), two floors of private patient rooms, and a newly renovated labor and delivery center.

Terrazzo, chosen for its longevity, flows through the main lobby with wavy neutral tones, mimicking the nearby Penobscot River. Six mahogany trees were placed inside “islands” to complement the terrazzo river, buffer noise and improve air quality. Continuing through to the elevator lobby, local nature photography can be viewed in an illuminated canvas. As for the color palette, MacIsaac explains, “We wanted to put down a neutral base in terms of a color palette so that [the hospital] could go back in the future and update its image based on current trends at that time.”

From the second floor up through the remaining floors, the flooring shifts to Stone Source Q-Stone porcelain tile when exiting the elevators. The cafeteria, dining space and “servery,” also on the second floor, use porcelain tile. MacIsaac notes that the terrazzo and porcelain tiles are lifetime products, adding, “Our experience with many healthcare facilities is that you may go in and refresh a space where you may repaint it or you may put in new furniture, but very likely the floor remains.”

Continuing to represent Maine’s connection to nature, EMMC chose to use rift cut white oak with a linear grain pattern to accent the walls, ceiling, nurses’ stations, dining area and patient rooms. MacIsaac explains, “[EMMC] felt oak was the material that best reflected Maine. Not very many facilities are using oak anymore. It has a little bit of a contemporary feel because of the linear grain.” Tying back into the oak accents, Toli Mature’s 2mm sheet vinyl in a wood look was used in the patient rooms.

Just outside in the patient corridors, 2mm Nora rubber flooring is used. It is also used in the clinical corridors. EMMC went with 3mm Nora rubber in the operating rooms only to help reduce leg fatigue for the surgical staff. In addition to comfort, the rubber flooring was chosen for its ease of maintenance and acoustical properties, and because no waxing is needed.

Stonhard epoxy flooring was used in the patient bathrooms and showers. MacIsaac explains that this was purposeful to eliminate the “lip” that typically exists between where the flooring ends in the bathroom area and begins for the shower area, reducing patient fall risk.

It is worth noting that EMMC was rigorous in its approach to testing various types of flooring before settling on the ones that were approved and ultimately installed. The corridor from the parking garage to the facility-a very high-traffic area-hosted 30 different flooring materials, which were tested to see how well they held up and how well the hospital could maintain them.

ERLANGER HEALTH SYSTEM EAST HOSPITAL
The Erlanger East campus, located in Chattanooga, Tennessee, teamed up with HKS Architects out of Atlanta, Georgia to renovate its facility in order to bring about its promise to provide “world class medicine” to its patients. Erlanger envisions its East campus as a lifestyle wellness hospital, supporting staff, guests, their families and the larger community, according to Bob Farrow, principal and senior vice president with HKS. The 120,000-square-foot expansion added a 58-bed tower, increased surgical services and renovated the Women’s Services lobby.

Following through on the lifestyle and wellness vision, a 1.5-mile walking trail, edible gardens, playgrounds and a putting green were added. Erlanger East supports an active, outdoor lifestyle with mountains on all sides along with multiple rivers and lakes. Making the decision to move toward a holistic lifestyle campus-emphasizing integrated care, community and the natural elements unique to the area-Erlanger East seeks to enhance its brand identity, explains Farrow.

When a patient arrives at the newly renovated facility, complementary valet parking is offered next to the outside terrace where patients, family and staff can eat and relax. The main lobby is decorated with artwork collected from community members. Erlanger East reached out to the local photographic society asking for local photographers to submit their work for possible selection to be displayed in the main lobby area and throughout the hospital. In all, 1,500 images were submitted, and 100 were selected.

The color palette selected for the project reflects the regional elements-the mountains and the Tennessee River. According to Farrow, “The natural materials and the regional color palette create a familiar and comfortable feel, and maintain the connection with the landscape.” He adds, “Each floor contains a reclaimed wood feature wall that creates spatial hierarchy and serves as a wayfinding element.”

The flooring used in each area serves a specific function, with ease of maintenance as the top priority. In a variety of textures, the Atlas Concorde Extend series of porcelain tile was selected for the main lobby and the dining area just off the lobby. Farrow says, “By utilizing a combination of colors and textures, the floor pattern became a pattern-within-a-pattern installation that offered subtlety and sophistication.” The porcelain tile continues into a waiting area where a piano and fireplace are reminders of home, comforting family members.

Patient rooms, where infection control is critical, used Shaw Contract’s Basstones sheet vinyl. And Shaw Contract’s Jeogori LVT was used in the patient corridors where maintenance concerns were considerably higher. “The neutral tones reinforced the design concept, and the pattern inherent in the Jeogori product provides a visual texture while hiding soiling,” explains Farrow. For other areas, such as corridors where acoustics, heavy rolling loads and scuffing were of special concern, Nora’s Norament Grano rubber flooring was used.

Directly behind the main hospital lobby, the newly renovated Women’s Services lobby, reception area, elevator lobby and corridors went with an entirely different product-Terroxy terrazzo. Originally, a tile product had been installed, but it did not wear well and was torn up and replaced with terrazzo. According to Bruce Komiske, Erlanger’s vice president of new hospital design and construction, the first impression when entering a facility is the most critical.

Prior to the project build, Erlanger East hosted weekly meetings where medical staff were consulted to bring to light any issues they felt were important. Komiske says, “We developed mock-up rooms in an office building first. Then, we took one of the new rooms and built that out ahead of schedule so that people could walk through it, touch it, critique it and change it.” It is imperative that flooring be safe and durable for the sake of patients who are recovering or have some sort of impairment. Komiske explains, “You can have an incredible building and mess up on any one facet like flooring and have significant problems.”

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