High Anxiety - Dispelled by Design

By Beth Herman

Hustled by panicked family members into Washington Hospital Center’s teeming ER One, a woman complaining of intense stomach pains is triaged and soon takes a seat. It's 5 a.m. and the programmable color kinetic lighting all around her is redolent of the subtle hues of early morning, while a skylight (rediscovered during renovation) channels mild, natural light as the sun rises. Nearby, two large tropical fish tanks sparkle, and a flat screen TV with soft programming also flashes an informational display with the first four letters of the patient’s last name, and a first initial, to let her know exactly where she is in the queue. A partial wall of translucent Corian, carved into the organic shapes of grasses, reeds and willows, is backlit withmuted, evolving LED lighting to represent a restorative environment.

With wait times in metropolitan emergency rooms averaging seven to eight hours, patients’ stress and anxiety levels are exacerbated by a lack of "positive distractions." Accordingly, 21st century health care facilities have evolved to incorporate soothing elements of nature (organic design) and substantiated methods of stress reduction, manifested in design, the results of which have been called “a bridge between neuroscience and design.”

For Huelat Parimucha Ltd. Healing Design Principal Barbara Huelat, studying the emotional needs of emergency room patients and their families was all in a day’s work, so to speak, when the firm was commissioned to augment and expand the early design they’d done on Washington Hospital Center’s ER One in 2007. Employing intricate research studies, and with elements like “evidence” and “proof” no longer just linchpins of the legal system, these factors are now the domain of architects and designers whose health care clients require tangible data in making their case to vigilant boards of directors and budget arbiters. Clients are now demanding more proof that (a design choice) works,” said Huelat. “There is a direction in the industry today called ‘evidence-based design,’ which is about wanting proof that what you’re doing makes a difference.” To that end, Huelat cited decisions in the past based on best practice models with which architects and designers have worked for years, though they lacked measurable results in the form of documented data.

Embarking on a series of studies through the Pebble Project, the California-based Center for Health Design’s (which promotes improving patient outcomes in healthcare) main research initiative, MedStar Health, owner of Washington Hospital Center, sought initially to implement emergency room infection protection and bacteria mitigation throughdesign and use of materials, and also to expedite work flow processes between site nurse’s stations. In its latest study, the implementation of “positive distractions,” or design elements that serve to mitigate and redirect stress and anxiety both patients and their families may experience during interminable wait times in busy emergency centers, was the goal. But to get there, MedStar and Huelat Parimucha had to first determine what behaviors and coping mechanisms people used to navigate the ER experience.

Panacea for pacing

“The predesign emergency room was pretty awful,” Huelat said of the hospital’s inadequate 1980s space, noting there were only two ill-placed (you had to almost hunt for them), never-lit fish tanks and a television for diversion, usually tuned to inappropriate “LAPD-type” progr

ams with violence. “One of the largest ‘activities’ was hanging out at the desk,” Huelat noted, where patients would spend a lot of time trying to determine when they would be seen, or where a family member was. Among the other two most popular activities were sleeping and pacing, because there wasn’t much else todo.

Based on the “prospect - refuge” habitat theory, which states that the ability to see but not necessarily be seen is intrinsic to many of man’s survival needs and affects his comfort levels, zoned seating was created to accommodate patients.

“There were times out on the Savannah when we wanted to observe what was out there, but we wanted a sheltered area so we wouldn’t feel vulnerable,” Huelat explained. To that end, seating choices included three distinct areas: the first, being most visible to the staff (Huelat said in follow-up studies for ER One, this area has been selected the most); the second, behind a partial wall and labeled the “social interaction zone” where patients could see the TV but not feel they were in the direct view of staff; and the third zone, most isolated of the three, totally behind a wall. “This zone had the greatest view out of the windows,” Huelat said, “and was the last to fill up. If people chose to sleep, they always slept here where they felt more secluded.” Other interventions include improved acoustics and interactive video. Projected on a wall, and similarly seen in airports and shopping centers, human interaction with it (waving of hands, for instance) can scatter fish in water or balloons in the air, creating an engaging diversion, especially for children who comprise a considerable portion of emergency room populations.

A model for mental health

Based on data acquired from the Pebble Project from three perspectives: neuroscience, design, and facilities operation, MedStar’s Ella Franklin, R.N., managing director of the Center for Building Sciences at the MedStar Institute for Innovation (MI2), determined just how ER One would integrate the findings into its space. According to Franklin, for years the knowledge base for how the built environment impacts patients and caregivers was deficient.

“We were very excited to learn of the Center for Health Design and that it was starting try and aggregate knowledge into data bases – collecting stories and experiences of different hospitals and clinics,” Franklin said of MedStar’s decision to utilize the Pebble Project beginning in 2006. In fact MedStar’s own MI2 serves as a consultancy to other health systems, so that collected data is readily shared.

Among the changes gauged at ER One after December, 2010, following implementation of the positive distractions redesign, were an 80 percent reduction in pacing, patient satisfaction with perceived wait times (the information display on the TV screen factoring in), and “remarkably improved” patient performance once they left the waiting room and presented to physicians, according to Huelat.

Citing reduced mental health benefits in the District even since December, Franklin said ER One is seeing more and more patients with psychiatric needs. As such, two rooms are currently undergoing yet another redesign to achieve the right environment to care for these individuals.

“The times that we’re living in, in terms of healthcare reform and changes in delivery model…makes for an ever-changing model of what our patients need and what regulatory agencies require of us,” Franklin said, indicating ER One’s redesign is a long term, evolving challenge.

Washington DC commercial design

Take This Design and Call Me in the Morning

By Beth Herman

It is reported that what compelled preeminent psychiatrist Dr. Elisabeth Kubler-Ross to write the revolutionary On Death and Dying in 1969 were her observations of the deplorable treatment of end-of-life patients in hospitals. Prior to her own death in 2004, Dr. Kubler-Ross devoted more than 40 years to transforming people and ideas about illness and dying, cultivating hospice care centers and even founding her own holistic healing center for the terminally ill and their families in California.

For interiors principal Barbara Huelat and architectural principal Joseph Parimucha of Huelat Parimucha Healing Design in Alexandria, Va., the road to improving patient care may have emanated from a different place, but the results, even here in Washington, D.C., are still the same: to meet and exceed the physical, mental and emotional needs of patients suffering from illness and trauma, and their families, in a deeply humane environment.

"Both Joe and I were with large firms that focused on health care design prior to 1991, when we started our own firm,” Huelat said, “but the emphasis tended to be on the project deliverables, the marketing, certainly the bottom line, and we felt the patient component was really missing. We were told that we were being ‘too California’ for the client.”

First, Do No Harm

With hundreds of medical and government projects in their passbook, including emergency rooms, acute care, oncology, pediatrics and even four Veteran’s Administration hospitals on deck, Huelat Parimucha’s concepts for patient-centered design are impacting the patient experience in environments where, for so many years, the emphasis was strictly on physician pedigree, medicine, hospital policy and the administration of such. Basing their design on Planetree principles, named for Hippocrates’ famous Sycamore tree under which he taught healing and medicine, Planetree is a nonprofit partnership of healthcare facilities whose mission is described as one that provides information and education on how to achieve patient-centered care. In fact, Huelat Parimucha has become a Planetree-certified design firm, which Huelat explains differs from LEED certification, which is transaction-based rather than firm- or hospital-based (hospitals must endure a rigorous, multi-year education and results recording process to become Planetree- certified).

No Stone Unturned

For Huelat, who concedes she was disillusioned immediately following design school, discovering at that time “that design was pretty much for the wealthy and it just felt empty,” veering from a traditional course as she quickly did was probably a self-fulfilling prophecy. “I started seeing the implications of what I did,” she said, recalling a major renovation in the 1970s, among her very first projects when health care design was invariably limited to cafeterias, lobbies and public spaces, of an actual hospital endoscopy unit. “I was interviewing department users,” she said, “and I started asking about the functions, what the endoscopy process was, and what the patients saw and felt – the smells and the whole wretchedness of that experience. I just couldn’t go in with regular finishes and materials; I wanted to focus on how you help the patient relax during this very uncomfortable process.”

About 10 years later, on staff at Ellerbe Becket, a joint venture with a Japanese architectural firm to renovate the National Cancer Institute in Tokyo cast Huelat in yet another role. Because Japanese firms didn’t have interior designers in their culture (architects did everything), Huelat was renamed “patient representative,” and set about profiling seven comprehensive U.S.-based cancer centers for Ellerbe Becket’s work in Asia.

“I looked at everything from the patient’s perspective,” she said. “If we were talking about a person who was an inpatient, dying of cancer, and they still had visiting hours from 10 a.m. until 6 p.m., and the mother who’s dying also can’t have her 10-year-old daughter there, it just seemed inhumane. I brought up all of these things that had never been talked about before, and we even had other researchers to help us collect data, but I realized things like this were not in the research.” After this project, Huelat reflected, she could never look at a hospital environment the same way.

The Poetry of the Earth is Never Dead

- John Keats

With the use of hospital emergency rooms on the rise for uninsured patients, and due to private physicians’ enormous caseloads booking weeks or months in advance, the ER One project at Washington Hospital Center – D.C.’s largest trauma center – was a pivotal undertaking for Huelat Parimucha. Tantamount to designing a durable and tractable environment to withstand 21^st century catastrophes such as human fallout from emerging terrorist attacks, the firm’s goal was to create a sense of calm, respite, hope and healing in traditionally frenetic terrain, both for patients and staff.

For Parimucha, who as a member of the Air Force had spent 10 years working for the Surgeon General’s office as an architect on military installations and health care facilities, the inclusion or close replication of nature - or organic design - was a key component in health care design and especially in ER One. Incorporating “fractal design” into their plans, or what Huelat calls “nature’s geometry” - recreating the way snowflakes look and fall in a kaleidoscope pattern or the veins in a leaf resemble a tree, the firm sought to replicate these forms in floor patterns, walkways, furnishings and more in ER One. “You can see fractal design on shorelines, on beaches and in erosion,” Huelat explained. “There are no left turns at the beach; it’s very gradual curves,” as opposed to abrupt and jarring lines and colors. A former hospice volunteer, Huelat said her patients inevitably wanted to be outdoors, or if that was not possible, to have visual access. “What is it about nature?” she asked. “We’ve been living that way (since the beginning of evolution). Only the last 100 years or so have we spent more time indoors than out. We’re now in a really foreign building environment – our whole life is in buildings and we rarely get outside,” she added, noting the application of nature to health care environments greatly impacts patient well-being by reducing stress, encouraging rest and thereby promoting healing.

The VA, which traditionally adhered to standards “and just reproducing those standards,” according to Huelat, as opposed to more holistic, patient-centered care, is now implementing Planetree design at many of their facilities. With four contracts to create community-oriented living centers for young vets from the Gulf War, Huelat Parimucha’s subjects are patients their 20s and 30s with traumatic brain injuries, paralysis or multiple-amputees. “They are not in their 80s and 90s,” Huelat said, “so these are not nursing homes.” Rather they will consist of smaller households in a neighborhood concept, each with 10-15 single occupant bedrooms, combined with a kitchen, living and dining room. Nearby in more public spaces will be a post office, barbershop, activities center, computer center and more. Design of each living center will involve organic components, as do all of the firm’s projects.

“It’s a very exciting, revolutionary approach to healing,” Huelat said. “Our culture, including the aging baby boom generation now in the midst of moving into increased health care needs, is becoming a very demanding audience. In the next 20 years, we’re going to see a very dramatic change in health care delivery, more focused on the patient experience than just the medical treatment itself.”