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BUILDINGS FOR HEALTH CARE FACILITIES

Cesare Catanatini, Gianfranco Damiani, Giovanni Capelli

The health maintenance and enhancement, the safety and the comfort of people in health care facilities are seriously
affected if specific building requirements are not met. Health care facilities are rather unique buildings, in which
heterogeneous environments coexist. Different people, several activities in each environment and many risk factors are
involved in the pathogenesis of a broad spectrum of diseases. Functional organization criteria classify health care facility
environments as follows: nursing units, operating theatres, diagnostic facilities (radiology unit, laboratory units and so on),
outpatients’ departments, administration area (offices), dietary facilities, linen services, engineering services and
equipment areas, corridors and passages. The group of people which attends a hospital is composed of health personnel,
staff personnel, patients (long-stay inpatients, acute inpatients and outpatients) and visitors. The processes include health
care specific activities-diagnostic activities, therapeutic activities, nursing activities-and activities common to many public
buildings-office work, technological maintenance, food preparation and so on. The risk factors are physical agents
(ionizing and non-ionizing radiation, noise, lighting and microclimatic factors), chemicals (e.g., organic solvents and
disinfectants), biological agents (viruses, bacteria, fungi and so on), ergonomics (postures, lifting and so on) and
psychological and organizational factors (e.g., environmental perceptions and work hours). The illnesses related to the
above-mentioned factors range from environmental annoyance or discomfort (e.g., thermal discomfort or irritative
symptoms) to severe diseases (e.g., hospital-acquired infections and traumatic accidents). In this perspective, the risk
assessment and control require an interdisciplinary approach involving physicians, hygienists, engineers, architects,
economists and so on and fulfilment of preventive measures in the building planning, design, construction and
management tasks. Specific building requirements are extremely important among these preventive measures, and,
according to the guidelines for healthy buildings introduced by Levin (1992), they should be classified as follows:

· site planning requirements

· architectural design requirements
· requirements for building materials and furnishings
· requirements for heating, ventilation and air-conditioning systems and for microclimatic conditions.

This article focuses on general hospital buildings. Obviously, adaptations would be required for specialty hospitals (e.g.,
orthopaedic centres, eye and ear hospitals, maternity centres, psychiatric institutions, long-term care facilities and
rehabilitation institutes), for ambulatory care clinics, emergency/urgent care facilities and offices for individual and group
practices. These will be determined by the numbers and types of patients (including their physical and mental status) and
by the number of HCWs and the tasks they perform. Considerations promoting the safety and well-being of both patients
and staff that are common to all health care facilities include:

· ambience, including not only decoration, lighting and noise control but also partitioning and placement of furniture and
equipment that avoid entrapment of workers with potentially violent patients and visitors
· ventilation systems that minimize exposure to infectious agents and potentially toxic chemicals and gases
· storage facilities for clothing and effects of patients and their visitors that minimize potential contamination
· lockers, changing rooms, wash-up facilities and rest rooms for staff
· conveniently-located hand-washing facilities in each room and treatment area
· doorways, elevators and toilets that accommodate wheel chairs and stretchers
· storage and filing areas designed to minimize workers’ stooping, bending, reaching and heavy lifting
· automatic and worker-controlled communication and alarm systems
· mechanisms for collection, storage and disposition of toxic wastes, contaminated linens and clothing and so on.

Site Planning Requirements

The health care facility site must be chosen following four main criteria (Catananti and Cambieri 1990; Klein and Platt
1989; Decree of the President of Ministers Council 1986; Commission of the European Communities 1990; NHS 1991a,
1991b):

1. Environmental factors. The terrain should be as level as possible. Ramps, escalators and elevators can offset sides of
hills, but they hinder the access of elderly and handicapped people, adding both a higher cost to the project and an extra
burden to fire departments and evacuation teams. Heavy wind sites should be avoided, and the area should be far from
sources which create pollution and noise (especially factories and landfills). Radon and radon daughters levels should be
assessed, and measures to reduce exposure should be taken. In colder climates, consideration should be given to
embedding snow-melting coils in sidewalks, entrance ways and parking areas to minimize falls and other accidents.

2. Geological configuration. Earthquake-prone areas should be avoided, or at least anti-seismic construction criteria must
be followed. The site must be chosen following an hydrogeological assessment, to avoid water infiltrations into the
foundations.

3. Urbanistic factors. The site should be easily accessible to potential users, ambulances and service vehicles for goods
supply and waste disposal. Public transportation and utilities (water, gas, electricity and sewers) should be available. Fire
departments should be nearby, and fire-fighters and their apparatus should find ready access to all parts of the facility.

4. Space availability. The site should allow some scope for expansion and provision of adequate car parking.

Architectural Design

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Health care facilities architectural design usually follows several criteria:

· class of the health care facility: hospital (acute-care hospital, community hospital, rural hospital), large or small health
care centre, nursing homes (extended care facilities, skilled nursing homes, residential care homes), general medical
practice premise (NHS 1991a; NHS 1991b; Kleczkowski, Montoya-Aguilar and Nilsson 1985; ASHRAE 1987)
· catchment area dimensions
· management issues: costs, flexibility (susceptibility to adaptation)
· ventilation provided: an air-conditioned building is compact and deep with as small an amount of external walls as
possible, to reduce the heat transfer between outside and inside; a naturally ventilated building is long and thin, to
maximize exposure to breezes and to minimize internal distances from windows (Llewelyn-Davies and Wecks 1979)
· building/area ratio
· environmental quality: safety and comfort are extremely relevant targets.

The listed criteria lead health care facilities planners to choose the best building shape for each situation, ranging
essentially from an extended horizontal hospital with scattered buildings to a monolithic vertical or horizontal building
(Llewelyn-Davies and Wecks 1979). The first case (a preferable format for low-density buildings) is normally used for
hospitals up to 300 beds, because of its low costs in construction and management. It is particularly considered for small
rural hospitals and community hospitals (Llewelyn-Davies and Wecks 1979). The second case (usually preferred for high-
density buildings) becomes cost-effective for hospitals with more than 300 beds, and it is advisable for acute-care
hospitals (Llewelyn-Davies and Wecks 1979). The internal space dimensions and distribution have to cope with many
variables, among which one can consider: functions, processes, circulation and connections to other areas, equipment,
predicted workload, costs, and flexibility, convertibility and susceptibility of shared use. Compartments, exits, fire alarms,
automatic extinction systems and other fire prevention and protection measures should follow local regulations.
Furthermore, several specific requirements have been defined for each area in health care facilities:

1. Nursing units. Internal layout of nursing units usually follows one of the following three basic models (Llewelyn-Davies
and Wecks 1979): an open ward (or “Nightingale” ward)-a broad room with 20 to 30 beds, heads to the windows, ranged
along both walls; the “Rigs” layout-in this model beds were placed parallel to the windows, and, at first, they were in open
bays on either side of a central corridor (as at Rigs Hospital in Copenhagen), and in later hospitals the bays were often
enclosed, so that they became rooms with 6 to 10 beds; small rooms, with 1 to 4 beds. Four variables should lead the
planner to choose the best layout: bed need (if high, an open ward is advisable), budget (if low, an open ward is the
cheapest one), privacy needs (if considered high, small rooms are unavoidable) and intensive care level (if high, the open
ward or Rigs layout with 6 to 10 beds are advisable). The space requirements should be at least: 6 to 8 square metres
(sqm) per bed for open wards, inclusive of circulation and ancillary rooms (Llewelyn-Davies and Wecks 1979); 5 to 7
sqm/bed for multiple bedrooms and 9 sqm for single bedrooms (Decree of the President of Ministers Council 1986;
American Institute of Architects Committee on Architecture for Health 1987). In open wards, toilet facilities should be close
to patients’ beds (Llewelyn-Davies and Wecks 1979). For single and multiple bedrooms, handwashing facilities should be
provided in each room; lavatories may be omitted where a toilet room is provided to serve one single-bed room or one
two-bed room (American Institute of Architects Committee on Architecture for Health 1987). Nursing stations should be
large enough to accommodate desks and chairs for record keeping, tables and cabinets for preparation of drugs,
instruments and supplies, chairs for sit-down conferences with physicians and other staff members, a wash-up sink and
access to a staff toilet.

2. Operating theatres. Two main classes of elements should be considered: operating rooms and service areas
(American Institute of Architects Committee on Architecture for Health 1987). Operating rooms should be classified as
follows:

· general operating room, needing a minimum clear area of 33.5 sqm.

· room for orthopaedic surgery (optional), needing enclosed storage space for splints and traction equipment
· room for cardiovascular surgery (optional), needing a minimum clear area of 44 sqm. In the clear area of the surgical
suite, nearby the operating room, an additional pump room should be designed, where extracorporeal pump supplies and
accessories are stored and serviced.
· room for endoscope procedures, needing a minimum clear area of 23 sqm
· rooms for waiting patients, induction of anaesthesia and recovery from anaesthesia.

Service areas should include: sterilizing facility with high-speed autoclave, scrub facilities, medical gas storage facilities
and staff clothing change areas.

3. Diagnostic facilities: Each radiology unit should include (Llewelyn-Davies and Wecks 1979; American Institute of
Architects Committee on Architecture for Health 1987):

· appointment desk and waiting areas

· diagnostic radiographic rooms, needing 23 sqm for fluoroscopic procedures and about 16 sqm for radiographic ones,
plus a shielded control area, and rigid support structures for ceiling-mounted equipment (where necessary)
· dark room (where necessary), needing almost 5 sqm and appropriate ventilation for the developer
· contrast media preparation area, clean-up facilities, film quality control area, computer area and film storage area
· viewing area where films can be read and reports dictated.

The wall thickness in a radiology unit should be 8 to 12 cm (poured concrete) or 12 to 15 cm (cinder block or bricks). The
diagnostic activities in health care facilities may require tests in haematology, clinical chemistry, microbiology, pathology
and cytology. Each laboratory area should be provided with work areas, sample and material storage facilities
(refrigerated or not), specimen collection facilities, facilities and equipment for terminal sterilization and waste disposal,

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and a special facility for radioactive material storage (where necessary) (American Institute of Architects Committee on
Architecture for Health 1987).

4. Outpatient departments. Clinical facilities should include (American Institute of Architects Committee on Architecture for
Health 1987): general-purpose examination rooms (7.4 sqm), special-purpose examination rooms (varying with the
specific equipment needed) and treatment rooms (11 sqm). In addition, administrative facilities are needed for the
admittance of outpatients.

5. Administration area (offices). Facilities such as common office building areas are needed. These include a loading
dock and storage areas for receiving supplies and equipment and dispatching materials not disposed of by the separate
waste removal system.

6. Dietary facilities (optional). Where present, these should provide the following elements (American Institute of
Architects Committee on Architecture for Health 1987): a control station for receiving and controlling food supplies,
storage spaces (including cold storage), food preparation facilities, handwashing facilities, facility for assembling and
distributing patients’ meals, dining space, dishwashing space (located in a room or an alcove separated from the food
preparation and serving area), waste storage facilities and toilets for dietary staff.

7. Linen services (optional). Where present, these should provide the following elements: a room for receiving and
holding soiled linen, a clean-linen storage area, a clean-linen inspection and mending area and handwashing facilities
(American Institute of Architects Committee on Architecture for Health 1987).

8. Engineering services and equipment areas. Adequate areas, varying in size and characteristics for each health care
facility, have to be provided for: boiler plant (and fuel storage, if necessary), electrical supply, emergency generator,
maintenance workshops and stores, cold-water storage, plant rooms (for centralized or local ventilation) and medical
gases (NHS 1991a).

9. Corridors and passages. These have to be organized to avoid confusion for visitors and disruptions in the work of
hospital personnel; circulation of clean and dirty goods should be strictly separated. Minimum corridor width should be 2 m
(Decree of the President of Ministers Council 1986). Doorways and elevators must be large enough to allow easy passage
of stretchers and wheelchairs.

Requirements for Building Materials and Furnishings

The choice of materials in modern health care facilities is often aimed to reduce the risk in accidents and fire occurrence:
materials must be non-inflammable and must not produce noxious gases or smokes when burnt (American Institute of
Architects Committee on Architecture for Health 1987). Trends in hospital floor-covering materials have shown a shift from
stone materials and linoleum to polyvinyl chloride (PVC). In operating rooms, in particular, PVC is considered the best
choice to avoid electrostatic effects that may cause explosion of anaesthetic flammable gases. Up to some years ago,
walls were painted; today, PVC coverings and fibreglass wallpaper are the most used wall finishes. False ceilings are
today built mainly from mineral fibres instead of gypsum board; a new trend appears to be that of using stainless steel
ceilings (Catananti et al. 1993). However, a more complete approach should consider that each material and furnishing
may cause effects in the outdoor and indoor environmental systems. Accurately chosen building materials may reduce
environmental pollution and high social costs and improve the safety and comfort of building occupants. At the same time,
internal materials and finishes may influence the functional performance of the building and its management. Besides, the
choice of materials in hospitals should also consider specific criteria, such as ease of cleaning, washing and disinfecting
procedures and susceptibility to becoming a habitat for living beings. A more detailed classification of criteria to be
considered in this task, derived from the European Community Council Directive No. 89/106 (Council of the European
Communities 1988), is shown in table 97.16.

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Table 97.16 Criteria and variables to be considered in the choice of materials

Criteria Variables
Functional performance Static load, transit load, impact load, durability, construction requirements
Safety Collapse risk, fire risk (reaction to fire, fire resistance, flammability), static electric
charge (explosion risk), disperse electric power (electric shock risk), sharp surface
(wound risk), poisoning risk (hazardous chemical emission), slip risk, radioactivity
Comfort and pleasantness Acoustic comfort (features related to noise), optical and visual comfort (features
related to light), tactile comfort (consistence, surface), hygrothermal comfort
(features related to heat), aesthetics, odour emissions, indoor air quality
perception
Hygienicity Living beings habitat (insects, moulds, bacteria), susceptibility to stains,
susceptibility to dust, easiness in cleaning, washing and disinfecting, maintenance
procedures
Flexibility Susceptibility to modifications, conformational factors (tile or panel dimensions
and morphology)
Environmental impact Raw material, industrial manufacturing, waste management
Cost Material cost, installation cost, maintenance cost

Source: Catananti et al. 1994.

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On the matter of odour emissions, it should be observed that a correct ventilation after floor or wall-coverings installation
or renovation work reduces exposure of personnel and patients to indoor pollutants (especially volatile organic
compounds (VOCs)) emitted by building materials and furnishings.

Requirements for Heating, Ventilation and Air-Conditioning Systems and for Microclimatic Conditions
The control of microclimatic conditions in health care facilities areas may be carried out by heating, ventilation and/or air-
conditioning systems (Catananti and Cambieri 1990). Heating systems (e.g., radiators) permit only temperature regulation
and may be sufficient for common nursing units. Ventilation, which induces changes of air speed, may be natural (e.g., by
porous building materials), supplementary (by windows) or artificial (by mechanical systems). The artificial ventilation is
especially recommended for kitchens, laundries and engineering services. Air-conditioning systems, particularly
recommended for some health care facility areas such as operating rooms and intensive-care units, should guarantee:

· the control of all microclimatic factors (temperature, relative humidity and air speed)
· the control of air purity and concentration of micro-organisms and chemicals (e.g., anaesthetic gases, volatile solvents,
odours and so on). This target may be achieved by adequate air filtration and air changes, right pressure relationships
among adjacent areas and laminar airflow.

General requirements of air-conditioning systems include outdoor intake locations, air filter features and air supply outlets
(ASHRAE 1987). Outdoor intake locations should be far enough, at least 9.1 m, from pollution sources such as exhaust
outlets of combustion equipment stacks, medical-surgical vacuum systems, ventilation exhaust outlets from the hospital or
adjoining buildings, areas that may collect vehicular exhaust and other noxious fumes, or plumbing vent stacks. Besides,
their distance from ground level should be at least 1.8 m. Where these components are installed above the roof, their
distance from roof level should be at least 0.9 m.

Number and efficiency of filters should be adequate for the specific areas supplied by air conditioning systems. For
example, two filter beds of 25 and 90% efficiency should be used in operating rooms, intensive-care units and transplant
organ rooms. Installation and maintenance of filters follow several criteria: lack of leakage between filter segments and
between the filter bed and its supporting frame, installation of a manometer in the filter system in order to provide a
reading of the pressure so that filters can be identified as expired and provision of adequate facilities for maintenance
without introducing contamination into the air flow. Air supply outlets should be located on the ceiling with perimeter or
several exhaust inlets near the floor (ASHRAE 1987).

Ventilation rates for health care facility areas permitting air purity and comfort of occupants are listed in table 97.17.

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Table 97.17 Ventilation requirements in health care facilities areas

Areas Pressure Minimum air Minimum All air Recirculated

relationships changes of total air exhausted within room
to adjacent outdoor air changes per directly to units
areas per hour hour outdoors
supplied to supplied to
room room
Nursing units
Patient room +/- 2 2 Optional Optional
Intensive care P 2 6 Optional No
Patient corridor +/- 2 4 Optional Optional
Operating theatres
Operating room (all P 15 15 Yes* No
outdoor system)
Operating room P 5 25 Optional No*
(recirculating system)
Diagnostic facilities
X ray +/- 2 6 Optional Optional
Laboratories
Bacteriology N 2 6 Yes No
Clinical chemistry P 2 6 Optional No
Pathology N 2 6 Yes No
Serology P 2 6 Optional No
Sterilizing N Optional 10 Yes No
Glasswashing N 2 10 Yes Optional
Dietary facilities
Food preparation +/- 2 10 Yes No
centers***
Dishwashing N Optional 10 Yes No
Linen service

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Laundry (general) +/- 2 10 Yes No

Soiled linen sorting and N Optional 10 Yes No
storage
Clean linen storage P 2 (Optional) 2 Optional Optional

P = Positive. N = Negative. +/- = Continuous directional control not required.

* For operating rooms, use of 100% outside air should be limited to these cases where local codes require it, only if heat
recovery devices are used;
** recirculating room units meeting the filtering requirement for the space may be used;
*** food preparation centres shall have ventilation systems that have an excess of air supply for positive pressure when
hoods are not in operation. The number of air changes may be varied to any extent required for odour control when the
space is not in use.

Source: ASHRAE 1987.

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Specific requirements of air-conditioning systems and microclimatic conditions regarding several hospital areas are
reported as follows (ASHRAE 1987):

Nursing units. In common patient rooms a temperature (T) of and a 30% relative humidity (RH) for winter and a T of
with 50% RH for summer are recommended. In intensive-care units a variable range temperature capability of 24 to
and a RH of 30% minimum and 60% maximum with a positive air pressure are recommended. In
immunosuppressed patient units a positive pressure should be maintained between patient room and adjacent area and
HEPA filters should be used.

In full-term nursery a T of with RH from 30% minimum to 60% maximum is recommended. The same microclimatic
conditions of intensive-care units are required in special-care nursery.

Operating theatres. Variable temperature range capability of 20 to with RH of 50% minimum and 60% maximum
and positive air pressure are recommended in operating rooms. A separate air-exhaust system or special vacuum system
should be provided in order to remove anaesthetic gas traces (see “Waste anaesthetic gases” in this chapter).

Diagnostic facilities. In the radiology unit, fluoroscopic and radiographic rooms require T of 24 to and RH of 40 to
50%. Laboratory units should be supplied with adequate hood exhaust systems to remove dangerous fumes, vapours and
bioaerosols. The exhaust air from the hoods of the units of clinical chemistry, bacteriology and pathology should be
discharged to the outdoors with no recirculation. Also, the exhaust air from infectious disease and virology laboratories
requires sterilization before being exhausted to the outdoors.

Dietary facilities. These should be provided with hoods over the cooking equipment for removal of heat, odours and
vapours.

Linen services. The sorting room should be maintained at a negative pressure in relation to adjoining areas. In the laundry
processing area, washers, flatwork ironers, tumblers, and so on should have direct overhead exhaust to reduce humidity.

Engineering services and equipment areas. At work stations, the ventilation system should limit temperature to .

Conclusion
The essence of specific building requirements for health care facilities is the accommodation of external standard-based
regulations to subjective index-based guidelines. In fact, subjective indices, such as Predicted Mean Vote (PMV) (Fanger
1973) and olf, a measure of odour (Fanger 1992), are able to make predictions of the comfort levels of patients and
personnel without neglecting the differences related to their clothing, metabolism and physical status. Finally, the planners
and architects of hospitals should follow the theory of “building ecology” (Levin 1992) which describes dwellings as a
complex series of interactions among buildings, their occupants and the environment. Health facilities, accordingly, should
be planned and built focusing on the whole “system” rather than any particular partial frames of reference.

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