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Understand how the built environment can affect safety and efficiency outcomes during doffing of personal protective equipment (PPE) in the context of coronavirus disease 2019 (COVID-19) patient care. We conducted (1) field observations and surveys administered to healthcare workers (HCWs) performing PPE doffing, (2) focus groups with HCWs and infection prevention experts, and (3) a with healthcare design experts. This study was conducted in 4 inpatient units treating patients with COVID-19, in 3 hospitals of a single healthcare system. The study included 24 nurses, 2 physicians, 1 respiratory therapist, and 2 infection preventionists. The doffing task sequence and the layout of doffing spaces varied considerably across sites, with field observations showing most doffing tasks occurring around the patient room door and PPE support stations. Behaviors perceived as most risky included touching contaminated items and inadequate hand hygiene. Doffing space layout and types of PPE storage and work surfaces were often associated with inadequate cleaning and improper storage of PPE. Focus groups and the design charrette provided insights on how design affording standardization, accessibility, and flexibility can support PPE doffing safety and efficiency in this context. There is a need to define, organize and standardize PPE doffing spaces in healthcare settings and to understand the environmental implications of COVID-19-specific issues related to supply shortage and staff workload. Low-effort and low-cost design adaptations of the layout and design of PPE doffing spaces may improve HCW safety and efficiency in existing healthcare facilities.

BackgroundHealthcare organizations are moving their primary care teams out of private offices into shared workspaces for many reasons, including teamwork improvement and cost reduction.ObjectiveIdentify the specific aspects of layout and design that enable two fundamental processes of high-functioning teams: communication and situation awareness.DesignThis was a multi-method study employing qualitative interviews, floor plan analysis, observations, behavior mapping, and surveys.ParticipantsTwo primary care clinics in a large, integrated healthcare system in the upper Midwest, with Clinic S in a suburban location and Clinic A in a rural setting. In the two clinics, a total of 36 staff members were interviewed, 57 (66% response rate) staff members were surveyed, and 2013 individual-points were recorded during 63 behavior mapping observations.Main MeasuresCommunication encounters, team members’ perception of the environment and teamwork, visibility, distance, functional pathways, and self-reported mode and frequency of staff communication.Key ResultsObservations, interviews, and surveys identified environmental factors that predict staff awareness and communication patterns. Visibility impacts situation awareness. Frequency of face-to-face communication increases with visibility and proximity between workstations (e.g., Clinic A nurses’ intra-role communication without workstation proximity vs inter-role communication with workstation proximity: 22.6% [11.4, 33.9] vs 77.4% [66.1, 88.6], p = 0.001) and with staff members’ functional paths. Visual exposure to patients predicts staff’s concerns about their communication (Clinic S: 2.29 ± 0.81 vs Clinic A: 3.20 ± 0.84, p < 0.001).ConclusionsDesign and layout of team spaces have important influences on the way that team members work together. The organizational goals of the healthcare system, particularly which staff members need to work together most frequently, should drive the specific design solution.

The development of non‐pharmacological treatment approaches is supported by evidence that addressing key modifiable risk factors may prevent or delay up to 45% of dementia cases. The Charlie and Harriet Shaffer Cognitive Empowerment Program (CEP) was developed to address current gaps in access to, and evidence for, interventions that reduce lifestyle risk factors and improve quality of life in individuals with mild cognitive impairment (MCI). Co‐designed with patients and families, clinicians, researchers, and industry professionals, the CEP is situated in a conceptual framework that guides assessments and interventions/supports to holistically address the experience of living with MCI. CEP comprises four cores (Therapeutic Programs, Technology, Built Environment, and Innovation Accelerator) that map to the conceptual framework. We contend that our approach provides an opportunity to contribute to the evidence base for multidomain lifestyle programs and gain a deeper understanding of MCI and how individuals can be empowered to manage it. Highlights The cognitive empowerment program (CEP) is a multidomain lifestyle program that was developed using a co‐design process and a conceptual framework that holistically addresses the experience of living with mild cognitive impairment (MCI). CEP provides comprehensive assessment and intervention/support through four cores that map to the conceptual framework: therapeutic programs, technology, built environment and research innovation. CEP's unique approach provides an opportunity to build the evidence base for multidomain lifestyle interventions and to develop and refine lifestyle biomarkers that can be used for early detection of MCI, tracking of disease progression, and objective measurement of the impact of lifestyle interventions.

Effective medical teamwork can improve the effectiveness and experience of care for staff and patients, including safety. Healthcare organizations, and especially primary care clinics, have sought to improve medical teamwork through improved layout and design, moving staff into shared multidisciplinary team rooms. While co-locating staff has been shown to increase communication, successful designs balance four teamwork needs: face-to-face communications; situational awareness; heads-down work; perception of teamness. However, precautions for COVID-19 make it more difficult to conduct face-to-face communications. In this paper we describe a model for understanding how layout affects these four teamwork needs and describe how the perception of teamwork by staff changed after COVID-19 precautions were put in place. Observations, interviews and two standard surveys were conducted in two primary care clinics before COVID-19 and again in 2021 after a year of precautions. In general, staff felt more isolated and found it more difficult to conduct brief consults, though these perceptions varied by role. RNs, who spent more time on the phone, found it convenient to work part time-from home, while medical assistants found it more difficult to find providers in the distanced clinics. These cases suggest some important considerations for future clinic designs, including greater physical transparency that also allow for physical separation and more spaces for informal communication that are distanced from workstations.

Abstract Background Few data exist to guide the physical design of biocontainment units, particularly the doffing area. This can impact the contamination risk of healthcare workers (HCWs) during doffing of personal protective equipment (PPE). Methods In phase I of our study, we analyzed simulations of a standard patient care task with 56 trained HCWs focusing on doffing of high-level PPE. In phase II, using a rapid cycle improvement approach, we tested different balance aids and redesigned doffing area layouts with 38 students. In phase III, we tested 1 redesigned layout with an additional 10 trained HCWs. We assessed the effectiveness of design changes on improving the HCW performance (measured by occurrence and number of risky behaviors) and reducing the physical and cognitive load by comparing the results from phase I and phase III. Results The physical load was highest when participants were removing their shoe covers without any balance aid; the use of a chair required the lowest physical effort, followed by horizontal and vertical grab bars. In the revised design (phase III), the overall performance of participants improved. There was a significant decrease in the number of HCW risky behaviors (P = .004); 5 risky behaviors were eliminated and 2 others increased. There was a significant decrease in physical load when removing disposable shoe covers (P = .04), and participants reported a similar workload in the redesigned doffing layout (P = .43). Conclusions Through optimizing the design and layout of the doffing space, we reduced risky behaviors of HCWs during doffing of high-level PPE. The physical design of biocontainment units impacts the contamination risk of healthcare workers (HCWs) during doffing of personal protective equipment. Through optimizing the design and layout of the doffing space, HCWs perform fewer risky behaviors and are safer.

Objective: This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals. Background: It builds on a literature review conducted by researchers in 2004. Methods: Research teams conducted a new and more exhaustive search for rigorous empirical studies that link the design of hospital physical environments with healthcare outcomes. The review followed a two-step process, including an extensive search for existing literature and a screening of each identified study for the relevance and quality of evidence. Results: This review found a growing body of rigorous studies to guide healthcare design, especially with respect to reducing the frequency of hospital-acquired infections. Results are organized according to three general types of outcomes: patient safety, other patient outcomes, and staff outcomes. The findings further support the importance of improving outcomes for a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms, and improved floor layouts and work settings. Directions for future research are also identified. Conclusions: The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work.

To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU). We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises. The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup.ParticipantsA total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study. In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) and HCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCW adherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements. Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.

Background Cancer care can negatively impact children’s subjective well-being. In this research, well-being refers to patients’ self-perception and encompasses their hospital and care delivery assessment. Playful strategies can stimulate treatment compliance and have been used to provide psychosocial support and health education; they can involve gamification, virtual reality, robotics, and healthcare environments. This study aims to identify how playfulness, whenever applicable, can be used as a strategy to improve the subjective well-being of pediatric cancer patients in the Brazilian Unified Health System. Methods Sixteen volunteers with experience in pediatric oncology participated in the study. They were physicians, psychologists, child life specialists, and design thinking professionals. They engaged in design thinking workshops to propose playful strategies to improve the well-being of pediatric cancer patients in the Brazilian Unified Health System. Data collection consisted of participatory observations. All activities were video recorded and analyzed through Thematic Analysis. The content generated by the volunteers was classified into two categories: impact of cancer care on children’s self-perception and children’s perceptions of the hospital and the care delivery. Results Volunteers developed strategies to help children deal with time at the hospital, hospital structure, and care delivery. Such strategies are not limited to using playfulness as a way of “having fun”; they privilege ludic interfaces, such as toys, to support psychosocial care and health education. They aim to address cancer and develop communication across families and staff in a humanized manner, educate families about the disease, and design children-friendly environments. Volunteers also generated strategies to help children cope with perceptions of death, pain, and their bodies. Such strategies aim to support understanding the meaning of life and death, comprehend pain beyond physicality, help re-signify cancer and children’s changing bodies, and give patients active voices during the treatment. Conclusions The paper proposes strategies that can improve the well-being of pediatric cancer patients in the Brazilian Unified Health System. Such strategies connect children’s experiences as inpatients and outpatients and may inform the implementation of similar projects in other developing countries.

Doffing personal protective equipment (PPE) after caring for patients with serious communicable diseases such as Ebola virus disease (EVD) can be both complex (ie, taking at least 10 minutes for at least 20 steps) and a major risk point of potential exposure for the healthcare worker (HCW). The 2014 Ebola outbreak revealed gaps and opportunities for PPE doffing protocols, including the role of the built environment (ie, the layout and design of spaces for care and doffing) in either supporting or detracting from safe doffing. Because most Ebola treatment centers were repurposed intensive care units or emergency department rooms and were not intentionally designed to treat serious communicable diseases, the built environment has been underappreciated until recently.1 As of this writing, a new Ebola outbreak is occurring in the Democratic Republic of Congo, and these lessons apply both to the treatment of EVD and other highly communicable diseases and to the doffing of routine PPE. The field of evidence-based design was founded in part due to healthcare-associated infections and the “quality chasm” identified by the Institute of Medicine that showed an unexpectedly high rate of errors and infections in hospitals in the United States.3 At that time, we argued that the built environment could directly reduce infection by breaking the “chain of transmission,” for example, by using materials that reduce surface contamination or by better filtering airborne pathogens. While many healthcare systems now consider safety problems as system failures rather than blaming an individual HCW,8 doffing intervention and improvement programs often focus only on improving training and improving knowledge at the individual level rather than taking a more system-based approach and leveraging the built environment to reduce the cognitive demand on the HCW.

Objective: This study analyzes 10 intensive care units (ICUs) to understand the associations between design features of space layout and nurse-to-patient visibility parameters. Background: Previous studies have explored how different hospital units vary in their visibility relations and how such varied visibility relations result in different nurse behaviors toward patients. However, more limited research has examined the specific design attributes of the layouts that determine the varied visibility relations in the unit. Changes in size, geometry, or other attributes of design elements in nursing units, which might affect patient observation opportunities, require more research. Methods: This article reviews the literature to indicate evidence for the impact of hospital unit design on nurse/patient visibility relations and to identify design parameters shown to affect visibility. It further focuses on 10 ICUs to investigate how different layouts diverge regarding their visibility relations using a set of metrics developed by other researchers. Shape geometry and corridor width, as two selected design features, are compared. Results: Corridor width and shape characteristics of ICUs are positively correlated with visibility. Results suggest that floor plans, which are repeatedly broken down into smaller convex (higher convex fragmentation values), or units, which have longer distances between their rooms or between their two opposite ends (longer relative grid distances), might have lower visibility levels across the unit. The findings of this study also suggest that wider corridors positively affect visibility of patient rooms. Conclusion: Changes in overall shape configuration and corridor width of nursing units may have important effects on patient observation and monitoring opportunities.