Understanding the Role of the Built Environment in Safety and Quality Improvem ent Jeff Brady, MD, MPH, AHRQ Craig M. Zimring, Ph.D., Georgia Inst. of Tech. James P. Steinberg, MD, Emory U. Douglas B. Kamerow, MD, MPH, RTI

Welcome and Overview Jeff Brady, MD, MPH Agency for Healthcare Research and Quality

The Role of the Built Environment in Safety and Quality Craig Zimring, PhD Georgia Institute of Technology

Hospitals are Unnecessarily Dangerous, Costly and Stressful  48,000 to 98,000 die annually due to preventable medical errors (IOM, 2000)  1 in 20 patients contract infections during care; new highly antibiotic resistant pathogens, persistent problems with MRSA, C difficile ( CDC, 2012)  $750 billion of annual healthcare costs are wasted; 30% of the total (IOM, 2012)

Evidence-Based Design Causal Model Design Strategies & Variables Patient, Family, Staff & Organizational Outcomes Moderators  Culture  Care process  Demographics of patients & staff  Acuity Mediators & Process Variables Ulrich, Zimring et al 2008

Low visibility rooms had a 30% higher mortality rate (82.1% and 64.0%) for high acuity patients Source: (Leaf, Homel & Factor, 2010)

Visibility Patient Groups by Visibility 2 High-visibility Patient Group PT (upper half body) visible from both the corridor and the nearby nurses’ station 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 Low visibility rooms had a 31% higher fall rate (Choi, 2012)

Lighting 22% fewer analgesics Higher impact on younger patients Higher impact on higher analgesic users 21% lower drug costs Less pain, stress Source: Walch et al (2005) Patients exposed to 46% more natural sunlight (lux/hours): Sunlight Affects Length of Stay and Analgesic Use Dying in the Dark Women stayed one day less in sunnier room (2.3 v 3.3 days) Death rate was 70% higher in dull rooms (39/335 v 21/293) Patients in A Cardiac Intensive Care Unit: Source: Beauchemin & Hays (1998)

Evidence-Based Design Causal Model Design Strategies & Variables Placement of hand washing rubs and sinks Single rooms Layout Provisions for family Provisions for teamwork Acoustic features Materials Reminder systems Variable acuity rooms Same-handed rooms Patient, Family, Staff & Organizational Outcomes Pain Analgesic use Errors Morbidity/mortality Infection rate Length of stay Satisfaction Care coordination Staff turnover/injuries Costs Failure to rescue Moderators  Culture  Care process  Demographics of patients & staff  Acuity Mediators & Process Variables  Communication  Movement  Hand-washing compliance  Noise  Stress  Natural light  Etc. Ulrich, Zimring et al 2008

Evaluating the Current State of Evidence Developing a conceptual framework describing the relationship between the built environment of healthcare facilities and HAI prevention Conducting an environmental scan (lit review, guideline review, and expert interviews) to document the current knowledge about HAI prevention through the use of the built environment

The HAI-DESIGN Team Kendall Hall, MD AHRQ Georgia Institute of Technology Craig Zimring, PhD Ellen Do, PhD David Cowan, MHS Megan Denham, MAEd Altug Kasali, M.Arch. RTI International Douglas Kamerow, MD Nancy Lefestey, MHA Emily Richmond, MPH Emory University School of Medicine James P. Steinberg, MD Jesse T. Jacob, MD Amy Allison, MS

COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors CHAIN OF TRANSMISSION COLONIZED or INFECTED HOST Patients HCWs Visitors COLONIZED or INFECTED HOST Patients HCWs Visitors HAI Human elements Transmission Sources and reservoirs of pathogens RESERVOIR or SOURCE IN THE HOSPITAL RESERVOIR or SOURCE IN THE HOSPITAL EXTERNAL SOURCE

What Does the Evidence Tell Us? Craig M. Zimring, Ph.D. Georgia Institute of Technology

More Evidence than We Expected Source: (Ulrich, Zimring et al, 2008)

28 in “isolation” group 2999 articles identified through searches 2880 articles reviewed for relevance 119 duplicates eliminated 1156 articles meet preliminary inclusion criteria 1724 discarded as irrelevant within the scope of this project 782 articles remain after 2nd abstract review 374 articles eliminated (not specific to built environment) 190 articles identified to be included in four primary sub-groups 57 in “air” group 45 in “contact” group 592 articles included in secondary sub-groups (see Figure 2 for sub-group details) Title review Abstract review Full-paper review 60 in “water” group Abstract review Papers from secondary scan (Additional articles, 74 grey literature)

Moving dispensers into line-of-sight increased hand hygiene compliance from 33.6% to 60% (Source: Nevo et al 2010) Increasing Hand Hygiene Compliance with the Built Environment

Technologies to Reduce Infection Risk: UVGI HVAC components had moderate to heavy contamination pre-eUVGI installation Surface and air samples had moderate to heavy contamination pre-eUVGI installation 74% of tracheal aspirates were positive for pathogens such as Pseudomonas aeruginosa and Klebsiella pneumoniae pre-eUVGI installation 55% of tracheal aspirates were positive at 6 months post 44% of tracheal aspirates were positive at 18 months post All surface cultures negative at 6 months post All HVAC cultures negative at 6 months post Source: (Ryan et al. 2011)

Conclusions Evidence for design is different than in medicine, but as important Evidence is scattered The built environment matters