EH 2_2015

EUROPEAN HOSPITAL Vol 24 Issue 2/15 2 NEWS & MANAGEMENT Cleaning up hospital design Hospital construction and operation ‘Hygiene begins between the ears’ Keep as few buildings as possible Ernst Tabori MD has been Medical Director of the German Consulting Centre for Hospital Epidemiology and Infection Control at University Hospital Freiburg for the past 17 years. He is also a specialist in building hygiene for hospitals and out- patient healthcare facilities as well as for infection prevention and control in surgical units Copyright CalCon Deutschland AG Photo:DIMarkusPerntalerArchitektZTGmbH Report: Anja Berhringer In terms of their architectural organi- sation, few buildings need to be geared towards their occupants as much as hospitals do. This insight is not new, but medical and technical developments call for different build- ing conditions than those that might have sufficed ten years ago. The Nickl Architectural Practice, which special- ises in the new build and refurbish- ment of hospitals, introduced the term ‘healing architecture’ for this kind of design. Originating in the 19th century, the large hospital complexes in Berlin, Hamburg and Munich no longer meet the demands of modern medicine. Whilst the pavilion-type structures of the Rudolf Virchow Clinic in the grounds of Berlin’s Charité Hospital may have been considered exem- plary 150 years ago – being copied by hospitals worldwide – modern healthcare needs short distances and central treatment complexes. The Nickl Architectural Practice initially made its name with a new design for the University Hospital Hamburg- Eppendorf. Various pavilions were converted for different types of use and some of the old buildings were demolished to make way for the dominant, main new structure. However, according to Professor Christine Nickl ‘Many old hospitals are beyond a cure’ because of con- tamination with pathogens, right down in the pipework and wiring and also due to built in materials such as asbestos, at the time of construc- tion considered harmless. Her architectural practice is now also in demand abroad. The new build and redesign of Frankfurt’s University Hospital was undertaken based on the healing architecture criteria. The architects developed ten criteria, such as orientation within the building, which create trust in people; the architecture is never anonymous but always personal. There is a need for individual, one-bed rooms and the appropriate design logistics to connect these individual rooms with one other, creating adaptable spaces between them. According to Professor Nickl, this is a current issue. ‘We need the smaller spaces between rooms, which allow us to quickly react to changes in hospitals.’ She therefore advocates modular design. Modular for fast reaction to change This must not be confused with the type of modular design presented by numerous firms at the specialist meeting on Design and Operation of Hospitals, held at the Management Forum Starnberg, in University Hospital Munich. Fast increases in capacity, refurbishment of old build- ings or contingency rooms during renovations – numerous solutions are available at various levels of cost. Requirements in this field are very individual. Finding a customised solu- Report: Michael Krassnitzer Vienna is the perfect place for a sympo- sium dedicated to ‘hospital construc- tion and operation because, over the next 15 years, the Austrian capital will radically transform its hospital land- scape. In the facilities of the Municipal Hospital Association Vienna (Wiener Krankenanstaltenverband – KAV) 32,000 employees care for 400,000 in-patients annually, making KAV one of the largest hospital operators in Europe. The new hospital master plan (Wiener Spitalskonzept 2030) is indeed stunning. Currently the net- work of 15 KAV sites will be reduced to seven; one new hospital will be built, three existing hospitals are to be demolished and entirely rebuilt on their sites and the three most recent hospitals, erected in the 1970s, will be modernised and expanded. ‘The old hospitals date back to the days of the Austro-Hungarian Empire and are made up of many separate buildings – pavilions – some of them listed. Today, such a structure cannot be operated in an economically via- ble way’, explains engineer Friedrich Prem, Head of the Technical Division at KAV, during last November’s Best Practices symposium in Vienna. To operate and manage the hospitals according to present-day standards, new buildings are needed, Prem added: ‘The new buildings alone will reduce operating costs by 250 million euros annually. This means building costs are recuperated within two or three years, simply by the lower oper- ating costs.’ A point of departure in the master plan is the concept of having ‘as few buildings as possible’, which spells an end of the decentralised pavilion system in favour of one central clinical building in a large public park. In line with this new concept, for example, the hospital in the Hietzing district, currently encompassing more than 100 buildings, will be reduced to 20 percent of its present floor area, and the listed pavilions will be converted into apartments. As Prem explains, a compact central building has a number of advantages: small floor area, small frontage area and small gross floor area. After the number of buildings is reduced, how would the remaining buildings be used? ‘You separate the clinical from the non-clinical functions – that’s a major step’, Prem underlines. In Vienna, a separate administration and services building will comple- ment each clinical centre, housing tion for restoration or modernisa- tion initially requires analysis of the current building portfolio, so that appropriate investment decisions can be made. The CalCon Group, founded in 1999 as a spin-off from the Fraunhofer Institute for Building Physics, has developed software called ‘epiqr’ for portfolio assessment. The software collects just a few geometric param- eters from any building portfolio and assesses only the most important building blocks as to their condition. With the help of statistical projections the system then calculates the materi- als required and the cost of respective structural measures. An acquisition effort of only 20% achieves a data accuracy of 80%. The results are displayed in the ‘epiqr-diagram’ so that the customer can see, at a glance, where building priorities should be. The structural measures and costs database integrat- ed into the system then determines the respective costs the customer can expect once the structural measures have been selected from those stored in the database. Once the structural measures com- mence everyone’s attention should services such as pharmacy, sterile supply, kitchen, laundry, supplies, waste management, facility manage- ment and procurement. Non-clinical buildings have very different operat- ing life and functional life cycles than clinical buildings that must regularly be adapted to new functional require- be on the internal design. As the changed process logistics affect daily routines, infection prevention and control must be a priority during renovations. In the chaos that devel- ops during assumed short-term con- struction works, medical equipment has been known to have been moved out of operating theatres and stored in hallways, or sterile equipment may end up next to cleaning agents in storerooms. Building hygiene Dr Ernst Tabori, Medical Director of the German Consulting Centre for Hospital Epidemiology and Infection Control (BZH), at the University Hospital Freiburg, specialises in building hygiene in hospitals and out- patient healthcare facilities, as well as surgical units. ‘Infection Prevention and Control,’ he says, ‘is a matter of awareness and continuous educa- tion’. As far back as the 19th century, Ignaz Semmelweis was able to reduce maternal mortality rates in Vienna sig- nificantly through the simple measure of hand washing. However, these days this appears to have disappeared from our conscious- ness, as the disinfectant dispensers visible on all wards do not reduce the contamination of door handles and other surface in the hospital with germs. Says Tabori: ‘We have moved along the way a little bit but haven’t quite arrived.’ Why? Lack of time? Ignorance? Lack of staff? The hospital infection control specialist believes that, even in modern buildings, the hospital pathogens infection rate can- not be further reduced because two thirds of all these pathogens come from the patients themselves. Therefore the term ‘indirect contact infection’ is imprecise and out-dated. One solution could be for their ments. To ensure that all clinical departments can be fully operational, even during construction work, the interior layout should be as flexible as possible – for example, few primary structures and flexible interior walls. According to Prem, the clinical buildings must comply with a number general practitioners (GPs) to exam- ine patients for pathogens before hospital admission, as carried out in the Netherlands. Alternatively, new admissions could be separated from other patients until the results of their infection status are known. However, even small building-relat- ed issues can help, such as installing several, smaller wash basins in dif- ferent locations rather than central washrooms with many basins for instance. Electronic water installa- tions are susceptible to legionella, and the installation of elbow levers instead of water taps avoids contact with germs. There are many, detailed examples relating to water and air systems. Specialists at the BZH can answer all enquiries on these subjects. As so nicely put by Ernst Tabori: ‘Hygiene begins between the ears’. of strategic specifications, inter alia: •separate access areas for people and goods/emergency access •centralised people access (one entrance, one lobby) private and semi-private roomsthe highest possible degree of automation and orientation towards state-of-the-art information and communication technologies transparency and openness – with one exception: where privacy is needed it takes priority over openness. Implementing such a master plan involves decisions that go far beyond architectural and functional questions. ‘It’s crucial to separate organisational issues – for example, the transfor- mation of the existing operational structure into the new operational structure, separated from construc- tion issues, the new buildings,’ he emphasises. Dr Klaus Offner, engineer and Technical Director of the Salzburg State Hospital, totally agrees. Since 2006, his facility has been perma- nently modernised while still fully functional: ‘Such a project takes at least ten years – and in those ten years your hospital management will change and new management will introduce new ideas.’ At his hospital, Wilhelminenspital – Sub-project 1. Office and services building

EH 2_2015

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