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Healthcare facilities are among the most expensive buildings to construct, maintain, and operate. How building design can best support healthcare services, staff, and patients is important to consider. In this narrative review, we outline why the healthcare environment matters and describe areas of research focus and current built environment evidence that supports healthcare in general and stroke care in particular. Ward configuration, corridor design, and staff station placements can all impact care provision, staff and patient behavior. Contrary to many new ward design approaches, single-bed rooms are neither uniformly favored, nor strongly evidence-based, for people with stroke. Green spaces are important both for staff (helping to reduce stress and errors), patients and relatives, although access to, and awareness of, these and other communal spaces is often poor. Built environment research specific to stroke is limited but increasing, and we highlight emerging collaborative multistakeholder partnerships (Living Labs) contributing to this evidence base. We believe that involving engaged and informed clinicians in design and research will help shape better hospitals of the future.
Keywords: Stroke, stroke rehabilitation, hospital design and construction, evidence-based designImagine (re-)designing the very hospital you work in. What would you design differently? What would you change, to benefit you, your patients, and their families? What evidence might help guide those design decisions?
Healthcare facilities are among the most expensive buildings to construct, maintain, and operate. 1 Once built, hospitals remain in service for decades and are difficult to modify. With stakes this high, considering how building design best supports healthcare services is important. In this narrative review, we outline why the built environment matters, with particular focus on stroke care. We also discuss challenges inherent in designing healthcare environments, undertaking research and evaluating completed architecture.
The planning and design process for new healthcare environments is incredibly complex, but, in general, it occurs in three overlapping stages: (1) the planning stage in which the healthcare provider describes the users’ needs, model of care, and clinical program in a functional brief that summarizes the requirements for the new hospital; (2) the design stage in which these requirements are interpreted by architects to develop an initial concept which is then refined to a more detailed design; and (3) the delivery stage in which the building is constructed. The extent to which hospital staff and patients are included at each stage of this process can vary significantly between projects. 2
Healthcare professionals have long advocated for design features thought to benefit health and well-being, such as natural light, ventilation, and space between patients—for example, the circular hospital design proposed by the physician Antoine Petit 3 and long “Nightingale wards” proposed by Florence Nightingale. 4 Hospital design is now informed by a process termed “evidence-based design” (EBD), in which research evidence is used alongside other considerations such as the healthcare context, budget, and architects’ experience, to inform the design of the healthcare built environment. 5,6 In this context, the “healthcare built environment” encompasses: (1) the physical construction (layout, room dimensions, doors and window placement, outdoor and community access, etc.), (2) ambient features (noise, air quality, light, temperature, etc.), and (3) interior design (furniture, signage, equipment, artwork, etc.). 7 Analogous to evidence-based clinical practice, hospitals designed following best research evidence garnered from EBD processes have better safety, patient outcomes, staff retention, and operation costs. 8,9 The Center for Health Design, established in 1993 to advance EBD, now maintains a repository of over 5,000 articles on healthcare design (https://www.healthdesign.org).
The field is growing; however, many healthcare contexts, including stroke, have a limited built environment evidence base. 10 Establishing geographically organized stroke units has been an important focus 11 ; however, these studies rarely address specifics of the built environment, and we know little about optimal stroke unit design. Stroke clinical guidelines rarely mention the built environment nor provide guidance on how the environment might best support care. There are currently no stroke care-specific building standards, nor standardized checklists to evaluate the quality of these environments. 12
Why is the built environment neglected? Clinicians may identify as knowing less about how the environment might influence patient care or staff well-being. They may also feel uninformed about the design process and how to contribute their clinical expertise to influence decision-making. To begin to address these gaps, our objectives for this review were: (1) to introduce readers to healthcare built environment research and (2) to highlight evidence that underpins acute, subacute, or rehabilitation stroke care facility design. This review is in three parts:
Overview of healthcare built environment research; Stroke care built environment evidence; and Planning and design of new healthcare environments: Challenges and opportunities.We include research from recent, relevant systematic reviews, other evidence summaries, and selected qualitative and mixed-methods research focusing on healthcare environments and design. Healthcare environments are complex and context-specific, with many interdependent variables that can rarely be isolated. This complex system does not readily lend itself to highly controlled experimental research designs in real-life settings. 13 Qualitative methods, such as case studies and pre- and post-occupancy evaluations (before and after a redesign or redevelopment), are common. With research still developing, heterogeneity exists in research designs, outcomes, environments, populations, and theoretical frameworks employed. 14 Hence, robust summary evidence derived from meta-analyses is lacking.
Research is dominated by studies conducted in acute environments such as emergency, surgery, and intensive care units (ICUs) ( Figure 1 ). 6,15,16 Older people, including those in dementia care, are frequently studied post-acute populations. 17
The volume of built environment research conducted in different healthcare settings. Circle size indicates the number of published research articles based on systematic literature review in preparation 18 and articles listed in the Centre for Healthcare Design research repository. Pink circles represent all built environment research, and the dark gray circles indicate stroke-specific research. (The aerial sketch in this image has been adapted with permission from Architectus + HDR.)
In this section, we introduce three topics relevant to most healthcare contexts: (1) design of internal spaces; (2) outdoor spaces; and (3) ambient features including light, noise, and air quality (with particular focus on infection control).
The design of internal spaces, such as ward configuration, corridor design, and nurse station placements (centralized vs. decentralized), can influence patient visibility, safety, teamwork, distances staff walk in a shift, and time spent providing direct care to patients. 10 For example, open-plan, larger convex spaces can lead to greater patient visibility, and corridor width impacts staff circulation, informal communication, and teamwork. 19 In ICU, designs with centralized nurse stations and visibility of most patient rooms from that location are increasingly being replaced with decentralized nurses’ stations, arguably without strong evidence. 19 In emergency departments, with similar critical visibility requirements for teamwork and patient monitoring, some authors argue that physically separated zones or “pods” are neither efficient nor safe. 20 Decentralized nursing stations can lead to more patient room visits by staff. 21,22 This highlights current uncertainties.
The layout of hospital spaces and line of sight influences patient and visitor orientation and their ability to find their way around (“wayfinding”). 23 Signs, information boards, and “landmarks” (artwork, furniture, views, etc.) are typical wayfinding elements. 24,25 Inadequate wayfinding leads to delays in accessing services or finding people or places, associated stress, and higher staff burden as they provide directions for lost individuals. 25 While some standards exist, wayfinding is often not optimized in healthcare. 26
The proportion of single versus multiple(two or more)-bed rooms is a prominent ward design consideration. There is evidence that single rooms can support staff/patient communication, privacy, infection control, and noise reduction, but they are also associated with patient isolation and increased falls risk. 27 This evidence is, however, of mixed quality, limited to certain populations, with neutral and/or contrary results. 27 A higher proportion of single rooms generally results in longer corridors, longer staff walking distances, perceived decrease in patient visibility due to compromised sightlines, and higher construction and cleaning costs. 28 The inherent trade-offs will be different in every healthcare context. Less controversial is location of sinks and hand sanitizers; highly visible and standardized positioning promotes more consistent use. 29,30
Hospital gardens were historically commonplace 31 ; however, less priority has been given to green space over time. Access to the outdoors and time in nature has been linked to stress reduction, improved physical symptoms, and emotional well-being in many healthcare settings. 32 Views of nature have been linked to reduced length of stay. 33 Good hospital garden design principles include creating opportunities for exercise, exploration, socialization, and to engage with and escape in nature. 32 Surprisingly, patients and visitors are often not aware of hospital gardens, and proactive approaches to increasing patient and family use of gardens have been recommended. 34 Usually conceptualized as spaces for patients and visitors, staff are often their primary users. 32 Outdoor spaces can be restorative for hospital staff, helping to reduce stress and improve attention, which may improve patient care and staff retention. 35
Ambient features, such as light and noise, can impact patient well-being and comfort, sleep, and communication with staff. 36,37 Light and noise also impact staff well-being and attention 38 and contribute to medication errors and other safety concerns. 39
Air quality is important for both comfort and infection control. Infection control is particularly prioritized in acute environments and is receiving deserved attention in the COVID-19 pandemic. A recent review of COVID-19 transmission showed that spatial configuration can affect patient density and thereby transmission. 40 Optimized systems for heating, ventilation, and air conditioning (HVAC) can filter microparticles such as viruses. Different HVAC systems also affect humidity, airflow velocities, air pressure—all important for exposure to active aerosols. Window ventilation, daylight, and electric UV light are recommended to aid disinfecting surfaces and use of surface materials that affect pathogen survival. 40
In this section, we outline how the built environment can influence important outcomes such as: (1) evidence-based stroke care, including rehabilitation; (2) efficiency of stroke care, staff processes, and communication; and (3) patient safety and well-being. The evidence-base specific to stroke care is small. 41 In Figure 2 , we summarize the design features and how they may influence a range of outcomes including patient and staff behavior. This should be considered illustrative rather than exhaustive. Where possible, we draw directly from stroke or brain injury-specific evidence, supplementing evidence from other populations where relevant.
