sicherheit durch design: das sicherste verhalten auch zum ......sicherheit durch design: das...
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Sicherheit durch Design: Das sicherste Verhalten auch zum Einfachsten machen
Safety by design: making the safest behavior, the easiest behavior
Craig Zimring, Ph.D. Director, SimTigrate Design Lab Professor, Architecture Georgia Institute of Technology
Hospitals are Unnecessarily Dangerous
• Quality Chasm Reports: 48,000 to 98,000 die annually due to preventable medical errors in the US (IOM, 2000)
• Mean of estimates based on medical record review: 251,000/year in the US die due to preventable medical errors about 0.6 % of admissions (Markary & Daniel, 2016)
• 1 in 20 patients contract infections during care; new highly antibiotic resistant pathogens, persistent problems with MRSA, C difficile (CDC, 2012)
Hospitals are Unnecessarily Dangerous
• The lower end of these estimates is the equivalent of the worst air disaster in history happening three times each week, 52 weeks a year or the equivalent of all 9/11 deaths each two weeks.
583 people died when two 747s
collided in Tenerife, Canary Islands,
March 27, 1977
The Built Environment Can:
• Prevent HAI • Reduce medication errors • Reduce patient falls
Improve patient safety
• Noise reduction • Improve sleep • Reduce spatial disorientation • Reduce depression • Provide nature and positive distraction • Provide Social support • Improve communication
Reduce Stress
• Reduce length of stay • Increase patient satisfaction
Improve Overall Quality
Ulrich, Zimring et al, Health Environment Research and Design, 2008;1 (3):61-125
HCD15 | After Evidence-Based Design: Creating a Collaborative Science of Healthcare Delivery to Reduce Harm in Critical Care
Evidence-Based Design
Patient Groups by Visibility
High-visibility Patient Group
PT (upper half body) visible from
both the corridor and the nearby
nurses’ station
Source: (Choi, 2012)
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
31% higher fall rate!
Measures of Visibility Predict Safety
Leaf et al, 2010, Lu et al 2014, Ossmann, 2016
Low visibility rooms in a cardiac ICU had a 30% higher mortality rate (82.1% and 64.0%) for high acuity patients
Layout Impacts ICU Mortality
Floor plan with FOV Visibility Groups overlaid: Red = Low, Yellow = Medium, Green = High
Layout Impacts ICU Mortality
Source: Ossmann, 2016
ICU D
High visibility rooms reduce odds of death by 42%
Layout Impacts ICU Mortality
Source: Ossmann, 2016
COLONIZED
or
INFECTED
HOST
Patients
HCWs
Visitors
COLONIZED
or
INFECTED
HOST
Patients
HCWs
Visitors HAI
Human Reservoirs
Transmission Event - direct or indirect contact including
transient carriage (e.g. hands of
healthcare workers)
- airborne/droplet
Environmental sources and
reservoirs of pathogens
RESERVOIR or SOURCE
IN THE HOSPITAL
EXTERNAL SOURCE
Transmission event Transmission event
Transmission event
Barriers
Filters
Opportunities for interventions
through the built environment
Disinfect
Eliminate
Hand hygiene
Other barriers
Isolation
Hand hygiene
Isolation HERD 2013;7S;46-73
Chain of Transmission: An Intervention Model
Hand hygiene
Other barriers
Isolation
Moving dispensers into line-of-sight increased hand hygiene compliance from 33.6% to 60% (Source: Nevo et al 2010)
System 1 Fast - automatic
Line of Sight and Surveillance Increases Hand Hygiene
• Dirty • Hard to clean and
rarely cleaned • Have been linked to
transmission of pathogens (evidence relatively weak)
• What to do?
Prototype for Issues Related to Design and Infection Prevention
Curtains to Curtains?
Contamination of Hospital Curtains with MRSA, VRW, C. difficile
• Culture of lateral edge of 50 hospital curtains using 3 methods
Trillis ICHE 2008;29:1174
• Sampling of 200 fabric curtains from wards in UK – Chromogenic MRSA medium “sweep” method – MRSA recovered from 31/200 (15.5%), mean 2.5 cfu
Klakus JHI 2008;68:189
• 180 cultures obtained twice weekly from 43 vinyl curtains in ICUs & wards
• 12 of 13 (92%) new curtains showed contamination within 1 week
AJIC 2012;40:904
• 30 ICU rooms randomly assigned to get novel or standard curtain
• Curtains cultured twice weekly for 4 weeks
• Median time to contamination for antimicrobial curtains was 14 days compared to 2 days for standard curtains
• Almost all curtains contaminated by 3 weeks
ICHE 2012;33:1081-85
Pros
• Relatively inexpensive • Spatial separation • Limits direct access and
discourages movement from patient to patient
• Visual privacy • Movable • Flexible use of space
• Efficient use of space
Cons
• Aesthetics • Limited sound privacy • Cleaning/replacement
costs • Possible fomite
Curtains
Mitchell, Journal of Hospital Infection 2015;91:211-17
Risk of Organism Acquisition from Prior Room Occupants
Systematic Review and Meta-analysis
• Physical separation may reduce opportunities for direct contact with contaminated surfaces
• Other physical changes may contribute to decreased infections
– Elimination of privacy curtains – Private toilets – More frequent room cleaning – Improved sink/bed ratio; more hand rub
dispensers
• Associated with improved hand hygiene rates
– Anthropology & Medicine 2015;22:149-161
Single-patient Rooms HAI Risk
22
Single-patient Rooms
Logistical Advantages •No transfer to contact isolation •No gender matching
Facilitate exchange of sensitive information
Reduce noise/improve sleep
Allow more family presence
Incremental benefits may outweigh added construction costs
•Sadatsafavi, Journal of Critical Care 2016 ;31:193-9 •Boardman, University of British Columbia, 2007
• Translate microbiological, epidemiological, and technological discoveries into new strategies to reduce the spread of dangerous germs like Ebola.
• Rapid prototyping in simulation labs, quantifying and visualizing spatial metrics using special analytic tools, and utilizing novel technologic approaches enhancing hand hygiene adherence
Zimring, 2016
PEACH CDC Epicenter
Estimated additional first cost/room $20,000-30,000
New ICU Room with Features to Minimize Infection Risk
Materials, Simulation,
Design
Limited Field Studies
Evaluation of Operating
Designs
Design Practice
HCD15 | After Evidence-Based Design: Creating a Collaborative Science of Healthcare Delivery to Reduce Harm in Critical Care
Practice and Practice-based Research
Building a Collaborative Translational Science of Healthcare Delivery
T0 – Epidemiologic studies and basic science
T1 – Small sample studies in clinical settings or high fidelity simulation
T2 –Larger multi-site studies
T3 – Local evidence-based guidelines for practice
T4 – National guidelines and standards
Lab
Clinical Trials
Practice-Based Research
Clinical Practice
Craig Zimring http://www.simtigrate.gatech.edu https://www.healthdesign.org