Health Facilities Design A Look at the New 2006 Edition of the AIA Guidelines

1. Health Facilities DesignA Look at the New 2006 Editionof the AIA Guidelines David B.Uhaze, RA Chief Bureau of Construction Project Review NJ Dept. Of Community Affairs

2. Introduction The AIA Guidelines for Design and Construction of Hospital and Health Care Facilities • Established as a Federal Standard in 1947 • Published by the American Institute of Architects since 1984 • The Facilities Guidelines Institute (FGI) formed in 1998 • This is the 2nd edition to be published under the FGI

3. Significant Changes: • The document is being re-organized and number formatted similar to NFPA 101.

4. Significant Changes: • There will be 4 major Chapters: • Chapter 1 - General (formerly chapters 1, 2, 3, 4, 5 & 6) • Chapter 2 - Hospitals (formerly chapters 7, 10 & 11) • Chapter 3 - Ambulatory Care (formerly chapters 9 & 12) • Chapter 4 - Other Health Care Venues (formerly chapters 8, 13, 14 & 15)

5. Significant Changes: • Three facility sub-sections have been expanded to full standards: Adult Day Care, Assisted Living & Hospice Care. • Updated and expanded language has been added to Infection Control Risk Assessment (ICRA) in Chapter 5. • Language has been standardized where appropriate for Inpatient & Outpatient services. • Sweeping editorial changes coordinate the content of all sections

6. Chapter 1 - General • Appendix • The appendix has been expanded to provide more commentary and guidance in using the document • Glossary • Several new definitions have been added for clarity and for planning purposes. The most significant are: • Bed Size • Invasive Procedure • Monolithic Ceiling

7. Chapter 1 - General • Bed Size • For planning purposes, 40”wide x 96” long shall be used unless an actual size is given. • Invasive Procedure • Any procedure that penetrates the body’s protective surfaces (skin, mucous membranes, cornea, etc.). This does not include IV’s, catheters, gastro endoscopes, dialysis and similar procedures. • Monolithic Ceiling • A ceiling free of fissures, cracks & crevices. A lay-in ceiling is not monolithic. All penetrations of monolithic ceilings must be sealed or gasketed.

8. Chapter 1 - General • This chapter will include all of the following: • Introduction (formerly Chap.1) • Environment of Care (formerly Chap.2) • Site (formerly Chap.3) • Equipment (formerly Chap.4) • Planning, Design & Construction (formerly Chap.5) • Record Drawings & Manuals (formerly Chap.6)

9. Chapter 1 - General • Introduction (formerly Chap.1) • No significant changes • Environment of Care(formerly Chap. 2) Previously this was a single paragraph dealing with general considerations. It has been expanded to identify overall components and key elements that directly affect the health care delivery system. • This section now has several expanded parts: • Functional Program • Design Considerations • Sustainable Design • Safety & Security

10. Chapter 1 - General • Site (formerly Chap. 3) • No significant changes • Equipment (formerly Chap. 4) • A requirement for mercury elimination in new construction as well as renovation and maintenance has been added to this section

11. Chapter 1 - General • Planning, Design & Construction (formerly Chap. 5) • The section on Infection Control Risk Assessments (ICRA’s) has been expanded to include: • A wider range of areas, issues and operations that must be addressed by the ICRA for each project • Greater facility responsibility in ICRA formulation and compliance • Record Drawings & Manuals (formerly Chap.6) • No significant changes

12. Chapter 2 - Hospitals • This chapter will include all of the following: • General Hospitals(formerly Chap.7) • Small Inpatient Primary Care Hospitals(new Chap.) • Rehabilitation Hospitals(formerly Chap.10) • Psychiatric Hospitals(formerly Chap.11)

13. General Hospitals • New sections have been added to this Sub-chapter: • Intermediate Care (Stepdown Units) • In- Hospital Skilled Nursing • Free-standing Emergency Service • Some sections have been heavily revised or had language expanded: • Psychiatric Nursing • Newborn Intensive Care • Emergency Service

14. General Hospitals • Nursing Unit (Medical and Surgical) • Patient Rooms • In new construction or major renovation, the max. number of beds per room shall be one (1) • Existing rooms may remain at 2 beds per room • Nursing Unit Service Areas • Waterless, alcohol-based hand sanitation stations may be used in renovations where existing conditions prohibit an additional handsink

15. General Hospitals • Intermediate Care Units (Stepdown) • These are specialty units such as: Progressive Care, Cardiac, Surgical, Neuro, etc. • These standards apply to adult units only • These must be designated beds • Can be a separate unit or part of another unit • Maximum room capacity for these units is 4 beds • Ventilation, O2, Vac. & Med Air requirements have been added to the tables.

16. General Hospitals • Critical Care • Bed clearances have been increased to (4) 5ft on the transfer side of the bed • Language has been added to require a documentation review space at the bedsides and a designated area on the unit for staff information review • Pediatric Critical Care • The space required for parental accommodations cannot counted in or encroach on the minimum required clearances within the patient room

17. General Hospitals • Newborn Intensive Care • This section has had a number of requirements added to deal with the following: • Noise Control – background noise & transient noise • Lighting – No direct lighting of infant spaces • Daylighting – At least one source of daylight required • External windows – Must control heat loss/gain • Clearances – 4ft aisles in open areas, 8ft aisles where individual cubicles are used. • Privacy

18. General Hospitals • Psychiatric Units • The facility shall provide an appropriate therapeutic environment • Appropriate security must be provided • Adults and pediatric patients can not be mixed (They can share support spaces) • General requirements for the unit will be referenced from the Psychiatric Hospital sub-chapter, with specific exceptions

19. General Hospitals • In-Hospital Skilled Nursing • This is a new sub-section. The basic requirements for hospital nursing units must be met. In addition, the following requirements must be met: • Dining & recreation space must be provided • Grooming space must be provided • The unit must provide convenient access to the Physical Therapy and Rehab Medicine departments • The unit must be located to restrict unrelated traffic through the unit • Where possible, this unit should be located to provide outdoor activity space

20. General Hospitals • Surgical Suites • Language in this section has been coordinated with that in the Ambulatory Surgery sub-section. In addition, clarifying language has been added to the paragraphs dealing with in-hospital outpatient surgery & recovery • If outpatient & inpatient surgery are done in the same suite the Hospital section applies • If a separate outpatient surgery and recovery are provided it can meet the Ambulatory Surgery section • Where individual spaces are provided at Stage 2 Recovery, each space shall be a minimum of 100sf with handwashing • Where individual holding spaces are provided, a changing area is not required

21. General Hospitals • Obstetrical Facilities • In new construction, LDR rooms have been increased to (250) 300sf • Emergency Service • Clear floor space at exam spaces now excludes casework • You must now have 1 toilet for every 8 treatment spaces • Decontamination has been expanded to include: • Outside entry as far from other entries as possible • Interior door must be lockable, and swing into the room

22. General Hospitals • The room must be 80sf minimum • Flooring must be monolithic and be self-coving to 6in high • The room must have two (2) hand-held shower heads • The room must have a floor drain and a dedicated holding tank • Hard piped or portable oxygen and suction must be provided • Imaging Suite • Separate toilet room with direct access must be provided for each flouroscopic room • For super-conducting MRI’s, cryogen venting & exhaust must meet original mfgrs. Specs.

23. General Hospitals • Freestanding Emergency Service • This is a new sub-section covering hospital owned & operated satellite emergency services. FES’s must be physically separate from the main hospital (not located on the same campus) • They must provide the following capabilities: • Diagnostic Imaging (including radio/flouro) • Laboratory services • At least one(1) observation bed with full cardiac monitoring • Provisions for serving patient meals • Pharmacy service • Support functions (Housekeeping, laundry,etc.)

24. General Hospitals • Laboratory Suite • Handwashing must be within 25ft of each workstation • Renal Dialysis Unit (Acute & Chronic) • Ea. Treatment space shall be 80sf exclusive of circulation space • If a Stat lab is provided, it must be fully equipped (refrig, handwashing, counters, storage). Blood drawing must be adjacent and have a patient toilet with a pass-through for specimens. • Morgue • Body-holding refrig. must have temperature monitoring and alarm

25. General Hospitals • Administration & Public Areas • Waiting rooms with 15+ people must have toilet rooms • Receiving Area • Docks must be segregated to prevent noise/odors from affecting building occupants • Receiving must be convenient to elevators & corridor system • Receiving must be segregated from waste staging • Adequate space must be provided for breakdown, sorting and staging

26. General Hospitals • Waste Management • Red bag waste must be staged in enclosed & secured areas • Bio-hazardous & environmental waste (mercury, nuclear reagents, etc.) must be segregated and secured • Med waste and infectious waste storage areas must have a floor drain, cleanable floor & wall surfaces, exhaust ventilation and be refrigerated if required

27. General Hospitals • Waste Treatment & Disposal • Non-incineration waste treatment technology(ies) shall be allowed • When locating a non-incineration technology, safe transfer routes, distances from waste sources, temporary storage requirements, etc. shall be considered. • The location of the technology shall not cause traffic odor, noise, and the visual impact problems for patients, visitors or the public • Exhaust vents from the treatment technology shall be located a minimum of 25 feet from inlets to HVAC systems. • If the technology involves heat dissipation, sufficient cooling and ventilation shall be provided.

28. General Hospitals • Mechanical Standards • All return ventilation shall be via ducted systems in patient care areas • Reserve capacity for facility space heating is not required where a design dry-bulb temperature of 25ºF or more represents not less than 99 percent of the total hours in any one heating month • If system modifications affect greater than 10 % of the system capacity, designers shall utilize pre-renovation water/air flow rate measurements to verify that sufficient capacity is available and that renovations have not adversely affected flow rates in non-renovated areas.

29. General Hospitals • Relief air (air that otherwise could be re-circulated) to an air handling unit from the occupied space) is exempt from the 25 foot separation requirement. • In new construction and major renovation work, air supply for operating and delivery rooms shall be from non-aspirating diffusers with a face velocity in the range of 25 to 35 fpm, located at the ceiling above the center of the work area. • Return air in OR’s shall be permitted high on the walls, in addition to the low returns. • During unoccupied hours, operating room air change rates may be reduced, provided that the positive room pressure is maintained as required in (Table 7.2).

30. General Hospitals • Operating room ventilation systems shall operate at all times, except during maintenance and conditions requiring shutdown by the building’s fire alarm system. • When anesthesia scavenging systems are required, air supply shall be at or near the ceiling. Return or exhaust air inlets shall be near the floor level. • Humidifiers shall be connected to airflow proving switches that prevent humidification unless the required volume of airflow is present or high-limit humidistats are provided.

31. General Hospitals • Protective Environment Rooms • Protective environment rooms shall be protected with HEPA filters at 99.97 percent efficiency for a 0.3 µm sized particle • Re-circulation HEPA filters can be used to increase the equivalent room air exchanges • Constant volume airflow is required for ventilation of the protected environment • If the facility determines that airborne infection isolation is necessary for protective environment patients, an anteroom shall be provided.

32. General Hospitals • Rooms with reversible airflow provisions for the purpose of switching between protective environment and airborne infection isolation functions are not permitted • Infectious Isolation Rooms • Supplemental re-circulating devices may be used in the patient room, to increase the equivalent room air exchanges; however, such re-circulating devices do not provide the outside air requirements. • Air may be re-circulated within individual isolation rooms if HEPA filters are used.

33. General Hospitals • Rooms with reversible airflow provisions for the purpose of switching between protective environment and airborne infection isolation functions are not permitted. • Plumbing Standards • Hot-water distribution systems serving patient care areas shall be under constant recirculation • Non-re-circulated fixture branch piping shall not exceed 25 ft in length. • Dead-end piping (risers with no flow, branches with no fixture) shall not be installed. In renovation projects, dead-end piping shall be removed.

34. General Hospitals • Empty risers, mains, and branches installed for future use shall be permitted. • Copper tubing shall be provided for supply connections to ice machines. • The vacuum discharge shall be located at least 25 feet from all outside air intakes, doors, and operable windows • Electrical Standards • Field labeling of equipment and materials will be permitted only when provided by a nationally recognized testing laboratory

35. General Hospitals • Intermediate care rooms shall have at least four (4) duplex outlets per bed. The outlets shall be arranged to provide two duplex outlets on each side of the head of the bed. • LDRP rooms shall have receptacles as required for patient rooms. In addition, the bassinet shall have receptacles as required for nursery bassinets • Electronic Surveillance Systems • Electronic surveillance systems include patient elopement systems, door access/control systems, audio/video monitoring systems, etc.

36. General Hospitals • Electronic surveillance systems are not required, but if provided, devices in patient areas must be unobtrusive and tamper-resistant • Electronic surveillance system devices must to be located such that they are not readily observable by the general public or patients. • Electronic surveillance systems shall be supplied power from the emergency electrical system in the event of a disruption of normal electrical power

37. General Hospitals • Tables (Former Table 7.2) • Requirements added for Intermediate Care, Lazer Eye Room & X-Ray Room (surgical/critical care and catherization) . • In variable volume systems, the minimum outside air setting on the air-handling unit shall be calculated using the ASHRAE 62 method. • The minimum total air change requirements for (Table 7.2) shall be based on the supply air quantity in positive pressure rooms, and the exhaust air quantity in negative pressure rooms.

38. General Hospitals (Former Table 7.3) • Filter efficiencies are now expressed in MERV’s (minimum efficiency rating value). MERVs are based on ASHRAE 52.2 (Former Table 7.3) • Requirements added for Intermediate Care and for MRI’s

39. Small Inpatient Primary Care Hospital This is a new Guidelines section. • A Small Inpatient Primary Care Hospital is a facility that serves a rural area and is 50 beds or fewer in size. The small inpatient primary care hospital shall have transfer and services agreements with secondary or tertiary hospitals. • The sizes of the selected services and their clear floor areas will depend on program requirements and organization of services as required by the community needs.

40. Small Inpatient Primary Care Hospital • Some functions may be combined or shared providing the layout does not compromise safety standards and medical nursing practices. • The nursing units shall be designed to accommodate multiple patient modalities, with adequate support spaces to support the modalities in the program. • The type of surgical procedures that are to occur in these facilities shall be limited to those that can be performed and supported under an ambulatory surgical setting

41. Rehabilitation Hospitals The changes made to this chapter are editorial in nature and involve coordinating language throughout the chapter with the language in General Hospitals and in Psychiatric Hospitals

42. Psychiatric Hospitals • Environment of Care • Special design considerations for injury and suicide prevention shall be given to the following elements: • Door closer devices shall be mounted on the public side of the door rather than the patient side of the door. Ideally, the door closer should be within view of a nurse or staff workstation. • Door hinges shall be designed to minimize points for hanging for the patient. • Door lever handles shall point downward when in the latched position.

43. Psychiatric Hospitals • All hardware shall have tamper-resistant fasteners. • Clothing rods or hooks shall be designed to minimize the opportunity for residents to cause injury. • Furniture shall be constructed to withstand physical abuse. • Drawer pulls shall be recessed to eliminate the possibility of becoming a tie-off point. • Door swings for bathrooms or shower areas shall swing out to allow for staff emergency access.

44. Psychiatric Hospitals • The ceiling shall be tamper-resistive or of sufficient height to prevent patient access. Ceiling systems of a non-secured (non-clipped down) lay-in ceiling tile design are not permitted. • Any plumbing, piping, ductwork, or other potentially hazardous elements shall be concealed above a ceiling. • Air distribution devices, lighting fixtures, sprinkler heads, and other appurtenances shall be tamper-resistant.

45. Psychiatric Hospitals • Shower, bath & toilet fixtures, hardware, and accessories • ADA or ANSI-compliant grab bars are required in 10 percent of the patient toilet rooms. The remaining rooms are not required to have grab bars. • Grab bars in patient toilet rooms for fully ambulatory patients shall be removable. • Towel bars are not permitted. • Shower curtain rods are not permitted. • Showerheads shall be flush mounted to minimize hanging appendages. • Lever door handles are not permitted in patient toilet rooms for fully ambulatory patients.

46. Psychiatric Hospitals • Windows, including interior and exterior glazing • All glazing, borrowed lights, and glass mirrors shall be fabricated with laminated safety glass or shall be protected by polycarbonate, laminate, or safety screens. • Light fixtures, electrical outlets, electrical appliances, nurse call systems, and staff emergency assistance systems • Electrical receptacles in patient rooms shall not allow for unauthorized use or shall be protected with a ground fault circuit interrupter

47. Psychiatric Hospitals • Ceilings, ventilation grilles, and access panels in patient bedrooms and bathrooms • Where acoustical ceilings are permitted, they shall be of sufficient height or be secured to prevent patient access. • Ceiling access panels and light fixtures shall be secured or shall be of sufficient height to prevent patient access. • Ventilation grills shall be secured and have small perforations to eliminate their use as a tie–off point, or shall be of sufficient height to prevent patient access.

48. Psychiatric Hospitals • Fire extinguisher cabinets and fire alarm pull stations • Shall be located in staff areas or secured if in patient-accessible locations. • SeclusionTreatment Rooms • Rooms shall be at least 60 square feet with a min. wall length of 7 ft and a max. wall length of 11 ft. Where restraint beds are required, 80 square feet shall be required.

49. Psychiatric Hospitals • Electrical switches and receptacles are prohibited within the seclusion room. • The door to the seclusion room shall swing out. Doors shall be 3 ft 8 in wide and shall have a vision panel, maintaining patient privacy. • Minimum ceiling height shall be 9 feet. • Seclusion treatment rooms shall be accessed by an anteroom or vestibule that provides direct access to a toilet room. The doors to the anteroom and the toilet room shall be a min of 3 ft 8 in wide.

50. Psychiatric Hospitals • Child Psychiatric Unit • The total area for social activities and dining space shall be a min of 50 sq ft per patient. • If a separate dining space is provided, it shall be a min of 15 sq ft per patient. • The combined area for social activities shall be 35 sq ft per patient.