Close your eyes and imagine walking down a busy street. On your left, you encounter a building that you quickly identify as a hospital. Nearing its entrance, and realizing that you have access to the building, you go inside. You thoroughly explore the space, and after having examined the facility to your satisfaction, you leave. What did you see?
No two visions of what a hospital looks like (or ought to look like) will be an exact match. But I would venture to guess that the majority of you, especially those of you who work in hospitals, imagined something similar to what I did. It is a vision that I have, with only slight variation, seen over and over again in my nascent medical career.
So what did I envisage? Walking down the street, I pictured an imposing, multi-storied edifice surrounded by a cluster of smaller buildings collectively dominating a stretch of several city blocks. None are aesthetically pleasing, and they appear not to share any common architectural theme. Rather, they appeared to have been built in an ad hoc manner, probably to satisfy community demands for increased services at some indeterminate point in the past.
The interior was no better. If there was any common theme tying together the designs of every unit and every floor, it was disregard for the comfort and well-being of patients. I saw patients housed four to a room. Natural sunlight was obscured by the lack of windows, a problem insufficiently remedied by artificial light. Noise was everywhere, and the possibility of utter chaos hung over every scene. Doctors, ostensibly tasked with patient care, were housed in offices far from their patients and the nursing staff.
I am sure that my vision does not apply to every hospital in America. But over the years, working mostly on the east coast, I have seen a few examples that buck this stereotype. Many of the great hospitals here were built in a different era when design standards and priorities were far different than they are today. Rather than tearing down these outdated structures and starting over, which would require large investments and complex arrangements to ensure that patients continue to receive care at alternative facilities while new ones are constructed, many of these institutions have instead chosen to pursue incremental renovations in a half-hearted attempt to adapt to the times.
These are odd decisions because they undermine hospitals’ other major patient care initiatives. As medicine has grown increasingly complex, hospitals have rushed to bring the newest, cutting-edge technologies to their facilities, which are increasingly unsuitable to house the very patients those new innovations are intended to help. The result is paradoxical: while hospitals are able to deliver ever more technically complex acute medical interventions, they are offering increasingly subpar inpatient experiences that may be harming their patients.
Poor patient room design, for example, can have a variety of adverse effects. Rooms without windows do not allow patients to glimpse the outside world and be exposed to sunlight, which may interfere with the healing process and place acutely ill patients at higher risk of delirium and longer hospital stays. A lack of adequate circulation in these rooms allows dangerous pathogens to concentrate, which, when coupled with the fact that multiple sick patients are often housed in each room, increases the risk that infectious diseases may spread among cohabiting patients. And isolation rooms, used to house and isolate patients with particularly contagious infections, often do not have sinks located directly outside of them, increasing the risk that visitors (including medical staff) accidentally transport various illnesses throughout the hospital.
Additionally, excessive distances between patients and hospital staff can further jeopardize the safety of inpatients. The physical location of medical staff members, in my experience, is often determined by space considerations, which largely arise as a consequence of the lack of forethought by the original hospital architects. Hospitals have often accommodated growing staffs by hastily building facilities wherever they could, without any regard for the long-term consequences of their decisions on patient care. As a result, it is not uncommon to see physicians housed in facilities that are entirely separate from those that house their patients, or to see patients with particular ailments housed far away from the departments that provide the specific services they will need to get better. This arrangement carries unacceptably high risks. Long travel times between various hospital departments, such as the Intensive Care Unit and Radiology or the Emergency Department and the Cardiac Catheterization Lab, can expose unstable patients to harm during the transport process. And housing doctors in offices far away from the patients they care for puts patients at-risk of receiving delayed care during true emergencies.
Lastly, and perhaps most worrisome, hospitals are generally not designed to shield patients from the hazards of excessive noise. Crowded patient rooms, noisy healthcare equipment, and excessive alert systems generate an intolerable, nearly constant cacophony that interferes with the ability of inpatients to sleep. Depriving patients of sleep while in the hospital “has been linked to important adverse outcomes, including alteration of homeostatic functions, such as glucose metabolism, cortisol regulation, and circadian rhythmicity; difficulty weaning from mechanical ventilation; defects in cellular immunity; and increased risk of long-term sleep disorders that play a role in depression, anxiety, and posttraumatic stress disorder,” according to a recent commentary by Groton et al. in JAMA Internal Medicine. All of this directly conflicts with the core duty of hospitals to heal their patients.
Hospitals have rightly been interested in adopting cutting-edge technologies to improve the care they deliver to patients. But in their rush to bring these treatment innovations to their facilities, most have ignored reconsidering the basic structure of their facilities, a redesign of which could yield substantial benefits to patients. If hospitals are truly committed to delivering cutting-edge medical care worthy of the 21st century, a broad rethink is necessary.
Dr. Kunal Sindhu is a resident physician in New York City and a 2018-2019 Doximity Author. You can follow him on Twitter @sindhu_kunal.
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