Opinion: Rethinking hospital design

Few would argue that many of our public hospitals are in dire need of an update – many of our older hospital buildings are no longer fit for purpose and major investment in refurbishing or rebuilding them is sorely needed.

Many older hospital wards are dark and cramped, with little to no space for storage or for patients, visitors and staff to move around freely. On many of our existing wards there is nowhere to keep equipment within reach of patients, inadequate storage space, limited ability to control light or temperature and no privacy to discuss concerns with staff. New builds offer an opportunity to create environments that support our ability to both provide and receive the best possible care. To do this however, we must keep in mind who it is that will be using these facilities and what they will need.

Victoria’s population, like most of the world’s, is ageing. While this has been described as one of medicine’s greatest achievements, it also means we are now faced with the prospect of living our lives with the complexity of multiple health conditions, and as a result the likelihood of more trips to hospital whether this be as an inpatient or for outpatient appointments.

The fact is that one out of every two people who find themselves in a hospital bed in Victoria for more than a night are over the age of 65 and furthermore those older than 85 are one of the fastest growing hospitalised groups. With these numbers in mind, it is becoming more and more essential that our environments are designed, and our staff are equipped, to cater for the needs of this cohort.

Hospitals were once places where a person went when acutely ill or injured, and either left having been cured, or died. As more of us live for longer with complex chronic conditions, hospitals are increasingly places we visit on multiple occasions as part of the management of these conditions, even though most of the management occurs in the community setting.

However, our hospitals are still designed with acute illness in mind – where a patient is primarily confined to bed until discharge. Our patients now need to be able to mobilise, to have spaces for families and carers to spend time, to have places to eat and drink outside of bed. We need to rethink the environment of the hospital with these factors in mind.

The Victorian Government has been instrumental in ensuring hospitals have access to evidence based resources to assist them to improve their environment for older people.

Between 2011 and 2013 the Department of Health and Human Services (DHHS) supported 32 Victorian health services to conduct environmental audits and provided funds to address the issues identified using the resource Improving the environment for older people in health services: An audit tool (2006).

The audits noted deficiencies in existing infrastructure and equipment across both acute, subacute and outpatient settings. These included appropriate seating; bathrooms; flooring; lighting; proximity to car parks; signage and wayfinding. Retrofitting these items was not only expensive, in many cases it was simply not possible.

A recent review of this audit tool, conducted by NARI for DHHS, has included an extensive consultation process. These consultations have identified that while capital projects must comply with the Australian Health Facility Guidelines and a series of other building codes, these guides do not mention older people as a vulnerable group.

The danger with this omission is that unless a member of the project planning team has an interest in designing for older people, or the facility is being designed specifically for older people, there is a significant risk that this oversight will remain just that. An omission which will ultimately impact the time our biggest patient cohort will spend in hospital, increase the risk of premature readmission and ultimately lead to poorer short and longer terms outcomes. There is also the danger that we will need to spend more money in the future to retrofit environments to the requirements of older people.

Within just two days of people over the age of 65 being admitted to their local hospital they are at risk of developing a range of issues such as reduced mobility, pain, delirium and falls.  If an older person does experience any of these conditions in hospital, they can expect to spend more time in hospital and it may ultimately impact on their ability to return to their usual way of life. These risks are not widely understood, and are largely avoidable by implementing a range of inter-related strategies, one of which is incorporating some key design elements that promote the participation of older people and their families in their care.

Elements that optimise normal routines such as sleep, access to bathrooms, regular mobilisation, cognitive stimulation and independence with regular nutrition and hydration play a major role not only in someone’s recovery but in preventing these risks.

There is a great deal of attention promoting good design when planning hospital environments for children, who like older people, benefit from a welcoming and calm place that balance the need for best care, options for privacy and social engagement, and the need to exercise control over core everyday needs and function.

Ideally you won’t need to visit a hospital either as an inpatient, outpatient or a visitor, but the next time you do, look around.  How easy is it to find your way?  Are the signs easy to read and placed just above head height?  Are there chairs of different heights, and do they have armrests? Is there adequate natural light? Is the car parking close to the site? If you work in a hospital we encourage you to use the updated audit to evaluate the environment for improvement. It will be available later this year on the Department’s online resource: www.health.vic.gov.au/older-people-in-hospital.

Designing for older people is not at the exclusion of the needs of other hospital users. In fact, when we design for the needs of older people, we enhance the usability of the environment for everyone.

Paulene Mackell

Research Stream Leader: Health Reform

Kathryn Squires

Research Officer

Frances Batchelor

Senior Research Fellow and Director Clinical Gerontology, Program Manager Melbourne Ageing Research Collaboration