Understanding the Role of the Built Environment in Safety a - PowerPoint Presentation

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