ent Jeff Brady MD MPH AHRQ Craig M Zimring PhD 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 ID: 416021
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Slide1
Understanding the Role of the Built Environment in Safety and Quality Improvement
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, RTISlide2
Welcome and Overview
Jeff Brady, MD, MPH
Agency for Healthcare Research
and QualitySlide3
The Role of the Built Environment in Safety and Quality
Craig Zimring, PhD
Georgia Institute of TechnologySlide4
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)Slide5
Evidence-Based Design Causal Model
Design
Strategies & Variables
Patient,
Family
,
Staff
&
Organizational Outcomes
Moderators
CultureCare processDemographics of patients & staffAcuity
Mediators & Process Variables
Ulrich, Zimring et al 2008Slide6
Low visibility rooms had a 30% higher mortality rate (82.1
% and 64.0
%) for high acuity patients
Source:
(Leaf
,
Homel
&
Factor, 2010)Slide7
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)Slide8
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 UseDying 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)
Slide9
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
MaterialsReminder systemsVariable acuity rooms
Same-handed roomsPatient, Family, Staff & Organizational OutcomesPainAnalgesic useErrors
Morbidity/mortalityInfection rateLength of staySatisfactionCare coordinationStaff turnover/injuriesCostsFailure to rescue
Moderators
Culture
Care process
Demographics of patients & staffAcuity
Mediators
&
Process Variables
Communication
Movement
Hand-washing compliance
Noise
Stress
Natural light
Etc.
Ulrich, Zimring et al 2008Slide10
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 environmentSlide11
The HAI-DESIGN Team
Kendall Hall, MD
AHRQ
Georgia Institute of Technology
Craig Zimring, PhD
Ellen Do, PhD
David
Cowan, MHS
Megan
Denham,
MAEdAltug Kasali, M.Arch.
RTI InternationalDouglas Kamerow, MDNancy Lefestey, MHAEmily Richmond, MPHEmory University School of MedicineJames
P. Steinberg, MDJesse T. Jacob, MDAmy Allison, MSSlide12
COLONIZEDor
INFECTED
HOST
Patients
HCWs
Visitors
CHAIN OF
TRANSMISSION
COLONIZED
or
INFECTED HOSTPatientsHCWsVisitors
HAIHuman elements
Transmission
Sources and reservoirs of pathogens
RESERVOIR or SOURCE
IN THE HOSPITALEXTERNAL SOURCE
Slide13
What Does the Evidence Tell Us?
Craig M. Zimring, Ph.D
.
Georgia Institute of TechnologySlide14
More Evidence than We Expected
Source: (Ulrich, Zimring et al, 2008)Slide15
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)Slide16
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 EnvironmentSlide17
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 installation55% of tracheal aspirates were positive at 6 months post
44% of tracheal aspirates were positive at 18 months postAll surface cultures negative at 6 months postAll HVAC cultures negative at 6 months post
Source: (Ryan et al. 2011)Slide18
Conclusions
Evidence for design is different than in medicine, but as important
Evidence is scattered
The built environment matters