Designing The Childrens Hospital of The Future The New Guidelines

New Childrens Facilities Regulations How Would
They Impact Your Projects?

Rick Majzun
St Louis Childrens Hospital
Judy Smith
Smith Hager Bajo
Laura Poltronieri, AIA
Poltronieri Tang & Associates
The International Facilities Design & Capacity Conference 2012
Learning Objectives
Become aware of forthcoming proposed design

guidelines for childrens hospitals
Review the specific requirements applicable to
childrens hospitals
Understand how these guidelines might impact the
design of childrens hospital
Agenda
What are the guidelines?

What impact will the new guidelines have on your
designs?
What impact will the new guidelines have on Owners
and Projects?
Checklist of Resources and Guidelines for the

Design of Childrens Hospitals in the US
Guidelines for the Design and Construction of
Health Care Facilities www.fgiguidelines.org
Recommended Standards for Newborn ICU
Design
www.nd.edu/~nicudes/ Just updated!
Pediatric Professional Association Guidelines
American Academy of Pediatrics
(e.g., Guidelines for Perinatal Care)
Joint Commission and DNV both reference
FGI
Recommended Standards for Newborn ICU Design
Checklist of Resources and Guidelines for the

Design of Childrens Hospitals in the US
Other Professional Association Guidelines
American Dieticians Association infant
feeding area design www.eatright.org
Society for Critical Care Medicine,
Americam College of Emergency
Medicine, Institute for Patient and
Family Centered Care
Plethora of books, articles published on
acoustics research, design experience,
resources from CHA, research journals
Websites and social media
(e.g. LinkedIn 26+ groups on hospital
design)
Other?
Intent of the New Children's Hospital

Guidelines
Consolidate minimum standards for children to one

handy chapter
Updates to reflect the distinctiveness of childrens
hospital design
Who, What, When, Where and Why
Guidelines committee structure

Guideline review process 4-year cycle
Multi-disciplinary input
Evidence/experience/consensus
Cost-benefit analysis
Access, application and interpretations
Note: While referencing and promoting the FGI, this material is not presented on
behalf of and is not associated with FGI
Where Guidelines Have Been Adopted

in the US
Starter Exercise: Where Should Childrens

Hospitals Be Designed Differently?
Key elements that
are different in
childrens
hospitals
- Scale
- Pharmacy
Education/school
- Parking, drop-off
and pick-up
- Seasonal Surges
- Patient Rooms
- Storage:
multiple beds
- Safety and
Security
- Sedation
- Play/Activity Areas
Elements
that are
different in
childrens
hospitals
- Bathrooms
- Infection
prevention
- Volunteers and gift

storage
- Exam/treatment
room
- Family
Overnight Needs
- Art &
Distractions
- Child Life
- Child bariatric
needs
- Food/Nutrition
- Emergency
Where Are We in the FGI Update Process?
Proposals accepted from public, published draft, and

public comment period began June 4, 2012
Deadline for public input 7 am CST on MONDAY,
DECEMBER 3, 2012
April 2013 vote
Late 2013 publication of 2014 Guidelines
10
2.7-1.1 Application
What is a Childrens Hospital?
(F)acilities that provide general acute pediatric

hospital care and identify and market themselves to
the general public as childrens hospitals, pediatric
health care centers, or pediatric centers of
excellence
This (does not) apply to independent specialty
hospitals with clinical specialization in areas such as
burn, psychiatric, orthopedics, rehabilitation, or
specific chronic diseases
11
Chapter 2.7 Specific Requirements for

Childrens Hospitals
Many of these requirements reference back to
corresponding relevant Sections and Chapters in the
overall code
Covers minimum design requirements for both:
New construction
and
Renovation unless impractical per Section

1.1-3
Information contained in the Appendix is advisory
only and not binding or enforceable
12
2.7-2.2 Pediatric Medical/Surgical

Nursing Unit
2.7-2.2.2.1 Capacity references 2.2-2.2.2.1
Maximum number of beds per room is 1
Unless functional program demonstrates
necessity for two-bed arrangement
Approval from licensing authority is required for
two-bed arrangement
In renovation work maximum room capacity shall
be no more than the existing capacity, with a
maximum of 4 patients
13
Medical/Surgical Nursing Unit

2.7-2.2.2.2 Patient Room Space Requirements
Patient rooms shall be constructed to meet the needs of the
functional program
Function driven
Minimum clear floor area of 120 SF per bed in both single-bed
and multi-bed rooms
Without limiting or encroaching upon the minimum
clearance requirements for staff and medical equipment
around the patients bed
In new construction, single-patient rooms should be at least
12 wide by 13 deep (or approximately 160 SF) exclusive of
toilet rooms, closets, lockers, wardrobes, alcoves, or
vestibules
[Appendix]
14

Provide a family zone at each bedside

Family zone requirements:
Space to sit
Facilities for family and visitor hygiene
Storage for family and visitor personal
belongings
15

Provide for recumbent sleep of a parent

Parent sleeping area requirements:
Preferably located within the patient room
If the parent sleeping area is separate from the
patient room, it shall be directly accessible to and
have a communication link with the patient unit
16

2.7-2.2.2.2 Patient Room Clearance Requirements
Dimensions and arrangement of rooms shall provide

minimum clear dimension of 4 feet between sides
and foot of the bed and any wall or other fixed
obstruction
. whether in single or multiple-bed rooms
17
2.7-2.2 Medical/Surgical Nursing Unit
A2.7-2.2.2.7 Patient Room Patient Bathing Facilities

Since childrens hospitals provide care for patients
from the youngest premature babies to young adults,
bathing facility design should accommodate the full
range of bathing requirements
Infants Sink-height bathing bowls
Young children Bathtubs
Adolescents/young adults Flexible showers
[Appendix]
18
Pediatric Bed Room Comparison

Current Code vs. Proposed Code
Current
Code
Proposed
Code
Max. no. of beds/room

(new construction)

(renovation)
Present capacity
up to 4
Present capacity
up to 4
Min. clear floor area

(SF/bed)
120 single / 100 multiple

(100 / 80 for renovation but
only with AHJ approval)
120
Min. bed clearances
3 all around
4 at foot of multi-bed
4
all around
Family zone
(not mentioned)
Yes
Family sleeping
(not mentioned)
Yes
Med-Surg Nursing Unit
19
Pediatric Bed Room Comparison

Proposed Adult vs. Proposed Pediatric
Proposed
Adult
Proposed
Pediatric

(new construction)

(renovation)
120
100 in renovation
120
3 all around
4 at foot of multi-bed
4
all around
No
Yes
Yes,
when allowed
Yes
Med-Surg Nursing Unit
Min. clear floor area (SF)

Min. bed clearances
Family zone
Family sleeping
20

Other Patient Room Requirements
Other requirements that are the same as for general

acute adult patient room
Windows
Patient privacy
Hand-washing stations
Patient toilet room & bathing facilities
Patient storage
21

2.7-2.2.4 Special Patient Care Rooms
2.7-2.2.4.2 Airborne Infection Isolation Room

At least one combination AII/PE (Airborne Infection
Isolation / Protective Environment) room shall be
provided for each pediatric unit
Additional AII and/or PE rooms shall be based on
an ICRA (Infection Control Risk Assessment)
All other unit requirements reference adult
hospital/unit requirements
22
A2.7-2.2.4 Palliative Care Room

Each childrens hospital should evaluate the needs and requirements for
palliative care programs and plan appropriate corresponding spaces
When childrens hospitals need this broader spectrum of supportive and
palliative care services, the following requirements should be met:
Capacity Palliative care room must be a single-bed patient room
Size Palliative care room should have a minimum clear floor area of
250 SF with a minimum clear dimension of 15 feet
[Appendix]
23
A2.7-2.2.4 Palliative Care Room
Family Area Additional area should be provided to accommodate

extended family and friends
At minimum, a recommended additional clear floor area of 30 SF per family
member
Additional area can be provided in an adjacent, preferably connected room
This area or suite can be configured so that when not required for palliative care
functions, the additional space is readily available to the general unit for
consultation space
Environment of Care Consideration should be given to locating

palliative care rooms in a low-traffic location
Providing a homelike atmosphere and furniture arrangements
Orienting the patient bed toward windows with outside views
Bereavement On-unit grieving rooms or meditation and respite

spaces should be provided
[Appendix]
24

2.7-2.2.6 Support Areas References 2.1-2.6 for same requirements
Administrative center(s) or nurse station(s)
Documentation area
Nurse or supervisor office
Multipurpose room(s)
Medication safety zone
Nourishment area or room
Ice-making equipment
Clean workroom or clean supply room
Soiled workroom or soiled holding room
Environmental services room
Examination room
25

2.7-2.2.6.11 Equipment & Supply Storage Spaces
Equipment storage room or alcove, including:

Space to permit exchange of beds from cribs to
adult sizes
Storage of furnishings to accommodate parents
when furniture is not built-in
Storage space for stretchers and wheelchairs
Emergency equipment storage
Storage for toys
Storage for educational supplies
Storage for recreational equipment
26

2.7-2.2.6.14 Patient Play or Activity Area
Provided in multi-purpose or individual room(s) within or

next to areas serving pediatric and adolescent inpatients
Designed to support developmentally appropriate play,
recreation, and other functions such as dining and
education
Provide access and equipment for patients with physical
restrictions
Special design considerations
Constructed of surfaces and materials that are easy to
clean and durable (nonporous and smooth)
Minimize the transmission of impact noise through
floor, walls, and ceiling
27

2.7-2.2.8 Support Areas for Patients, Families & Visitors
2.7-2.2.8.1 Family and visitor lounge
Size shall be based upon the number of beds served
Location shall be immediately accessible to the nursing
unit(s) served
May serve more than one nursing unit when it is centrally
located on the same floor as the units served
Provided with private area for communication, e.g. cell
phones, computers, wireless Internet access, patient-family
information stations
2.7-2.2.8.2 Toilet room(s) readily accessible to the lounge
shall include space for a built-in diaper-changing station
2.7-2.2.8.3 Consultation room (if required by the functional
program)
Provided for confidential parent/family comfort, consultation,
and teaching
28
2.7-2.3 Pediatric Oncology Nursing Unit
2.7-2.3.5.1 Patient play area

Patient play or activity areas shall be provided in
multi-purpose or individual room(s) that are
within or next to the unit
29
2.7-2.6 Pediatric Critical Care Unit

Applies to all types of critical care units, including Pediatric
Cardiac Critical Care Unit
Patient Care Rooms
2.7-2.6.2.2 Space requirements Same as adult unit, but
must also include space for recumbent sleep of a parent
2.7-2.6.6.11 Equipment and supply storage Provisions for
formula and human milk storage
2.7-2.6.8.1 Family and visitor lounge Same as adult unit, but
must also provide seating capacity of no fewer than 1.5
seats per patient bed
2.7-2.6.8.3 Consultation/demonstration room provided
within or readily accessible (to the unit) for private
discussions
30
2.7-2.6 Pediatric Critical Care Unit
Other requirements that are the same as for adult

critical care units
Windows
Patient privacy
Toilet room or soiled utility room
Nurse call system
31
2.7-2.16 Bariatric Care Unit
A2.7-2.16
The need for care of the extremely obese patient,
including children, is growing in the US
These patients require facilities with more space
and clearances, as well as staff with greater
strength to carry heavier loads
They also have a variety of special health care
needs from climate control requirements to the
need for specialty bathing fixtures
[Appendix]
32
2.7-3.1 Emergency Services
2.2-3.1.3.6 (2) single-bed treatment rooms (100 NSF) shall apply

in lieu of
2.2-3.1.3.6 (4) pediatric treatment rooms (120 NSF)
2.7-3.1.6.13 Patient play area
Provided in multi-purpose or individual room(s) within or next to

areas serving pediatric and adolescent inpatients
Designed to support developmentally appropriate play, recreation,

and other functions such as dining and education
Provide access and equipment for patients with physical restrictions
Special design considerations

Constructed of surfaces and materials that are easy to clean and durable
(nonporous and smooth)
Minimize the transmission of impact noise through floor, walls, and ceiling
33
2.7-3.2 Observation Unit
2.7-3.2.2 Space Requirements

Each patient bed area shall have space at
bedside for families and visitors
34
2.7-3.3 Surgical Services
2.7-3.3.3.2 Pre-operative patient care area

Sedation room shall be provided outside the
operating or procedure room where sedation is
required
May be combined with pre-operative or recovery
spaces
Quantity and size shall be dictated by the
functional program
35
2.7-3.4 Imaging Services

Magnetic Resonance Imaging (MRI)
2.7-3.4.4.2 Design configuration Suites shall
conform with the American College of Radiologys
Guidance Document for safe MR Practices, including
section on Pediatric MR Safety Concerns
Support Areas for Diagnostic Imaging Services
2.7-3.4.6.16 Sedation room
Where sedation is required (by the functional program),
sedation room shall be provided outside the imaging
procedure room
May be combined with pre-operative or recovery spaces
Quantity and size as required by the functional
program
36
2.7-3.8 Respiratory Therapy Services
2.7-3.8.3 Outpatient Testing and Demonstration

Services
Respiratory services (if offered) shall also provide
rooms where children can practice activities of
daily living with related storage
in addition to the other (i.e. adult respiratory
therapy) requirements
37
2.7-3.9 Renal Dialysis Service
Support Areas for Renal Dialysis Service Facilities

A2.7-3.9.6.18 Laboratory Space
Blood draw for children should be done in an enclosed
room with consideration of noise and privacy
Blood draw area should be next to a patient toilet
room
[Appendix]
38
2.7-5 General Support Services

and Facilities
2.7-5.2.3.1 Special (On-site) Laundry Facilities
Provide space for a washing machine/dryer and
dishwasher for laundering and/or washing plush
toys and hard plastic toys respectively
Provide washing machine dryer accessible to
families for the purpose of laundering their personal
clothing when they are staying with their children
during extended hospitalizations
[Appendix]
2.7-5.3.3 General Stores

Additional storage for donated toys, educational
supplies, and recreational equipment
Off-site location for this storage permitted
39
2.7-6.1 Public Areas

2.7-6.1.2 Public Toilet Rooms Requires toilet rooms
with diaper changing facilities throughout
A2.7-2.3.1 Drop-off / pick-up area at building entrance
Adequate curbside space for handling strollers, baby
carriers and toys
Additional vehicle queuing space to compensate for
increased time necessary for load/unload
Provision of safe zone area for children during
loading/unloading activity duration
[Appendix]
40
Case Study:
How the New Guidelines Impact
St. Louis Children's Hospital
Overall Impact of Guidelines
Most of the guidelines are already being followed in

new construction projects.
This will be more expensive, and it will be better for
patients and families.
The guidelines will help you educate your funders.
42
Case Study St. Louis Childrens Hospital
250-bed free-standing childrens

hospital affiliated with Washington
University School of Medicine
110 private bed inpatient expansion
63 beds for growth, 47 for
decompression to privates
Shelled space for additional 32
private bed unit
43
Case Study St. Louis Childrens Hospital
Expansion/reorganization of
outpatient services, amenities
and support services, including:
Additional outpatient space
Shell space for operating
rooms and radiology
Reorientation of emergency
room services
New family zone
44
Goals for the SLCH project
Offer a private room

experience
Minimize capital spend
and depreciation
burden
Maintain as much
future flexibility as
possible
45
SLCH Guiding Principles

Be Child and Family Focused*
Express Our Commitment to Patient- & Family-Focused
Care Through Our Facilities
Be Visionary
Be Leaders in Pediatric Healthcare & Consistently
Reflect That Leadership Through Our Buildings
Be Functional
Ensure That Form Follows Function Throughout All
Projects & Facilities
Be Healthy and Safe*

Provide a protective and comforting environment for
patients, families, and staff
Be Accountable*
Doing what is right for children in a responsible and
sustainable way
* = impacted by new guidelines

46
SLCH Facilities Objectives
1. Move to private room model*

2. Consolidate Diagnostic and Treatment Services
3. Separate low-intensity OP services from IP services; place
high-intensity OP services with IP services
4. Consolidate Family Support Services to increase
visibility/accessibility*
5. Separate (and make invisible) soiled/clean Materials
Management functions*
6. Further develop existing off-site outreach programs
7. Allow for future growth and flexibility
47
Educating Your Stakeholders
Funders
Board
System
Hospital leaders
Physicians
Staff
Private rooms are a

good thing
When you treat a child,
you treat a family and
families need more
space
This will be more
expensive, but worth it
48
Private Rooms Are a Good Thing
Private Rooms Are a Clinical and Service

Imperative
They are safer: The higher prevalence of respiratory
disease in a childrens hospital presents a higher risk
of cross infection in semi-private rooms
They eliminate co-horting: Toddler + teenager =
lousy sleep + two unhappy families = increased
recovery times
They improve medical education: A lack of privacy
interferes with the effectiveness and confidentiality
of family-centered rounds
50
Private Rooms Are Operationally

Efficient
15% of patients undergo co-horting-related
transfers, wasting hundreds of hours of nurse time
Effective occupancy of 90% can be reached if rooms
are 100% private (which means fewer rooms needed)
Note: running higher than 90% increases risk of not
being able to receive outside transfers, excess ED
boarding, and slower OR/procedural throughput.
51
When You Treat a Child, You Treat a Family

and Families Need More Space
Private Rooms Meet the Needs of

Families
At a critical point, families travel much greater
distances and need more space
A pediatric admission is a very rare occurrence
and a significant family stressor, not a commonly
accepted part of aging:
4 % of kids, 39% of seniors
Average parent travels 43 miles

Welcome to your new home: private space to
live, comfort, entertain, eat, work, host visitors,
live, sleep, and store your things
53
Families and Visitors Need Space

Outside the Room as Well
Increase square footage in family and visitor lounges
on each floor even as we make patient rooms bigger
and create a separate family zone
54
Create and Expand Support Areas for

Patients, Families & Visitors
Will expand spaces like our sibling playroom
55
Create a Family Zone

All Services Co-Located
Family Resource Center
Admitting
Child Life
Gift Shop
Volunteers
Chapel
Laundry
Outpatient Pharmacy
56
This Will Be More Expensive, But Worth It
Costs Will Be Higher
Increased square footage =

increased cost
Be prepared to justify cost
differentials over past projects
Is square foot premium
balanced by improving
operating efficiency, quality
and safety?
58
Dont Underbuild or Overbuild

Our Goal: New private medical/surgical beds, at least
80% of admissions fully private, at 90% occupancy
Total recommended (med/surg)
% of calendar days fully private
% of calendar days with
semi-privates
Days with 1-10 patients (semi-private)
Days with >30 patients (semi-private)
166
79%
21%
170
87%
13%
174
92%
8%
30
20
13
12
23
9
10
7
8
12
7
1
59
Making the Case for Bigger Rooms

Medical/Surgical
A minimum of 900 DGSF per medical/surgical bed
Meet guidelines for patient room size and
clearances
Accommodate 24-hour family presence
Offer teaching space (in room/out of room)
Support family centered rounding
Provide play/child life space on floors
Appropriate equipment/supply storage on floors
Accommodate research activities
60
Making the case for bigger rooms

NICU
700 DGSF as the standard we are using
Space for the extensive medical equipment
needed for critically ill neonates
Space for bedside surgeries
Parent sleeping should not be inadequate at the
most critical time in a familys life
Storage space for families: living at the hospital
for 30 days is very challenging
61
A Few Closing Things to Think About .
Questions Were Struggling With

(and How They Relate to the Guidelines)
Do we build more
Acuity adjustable rooms?*
Psych-capable rooms or a unit of psych rooms?*
Shell space to accommodate future IT solutions?
How will we balance:
Adjacency with efficiency (e.g. anesthesiology, radiology)?
On stage/off stage space?
Integration of research and education space on floorsT
The need for common space for multi-disciplinary care as
well as private think space?*
63
Questions Were Struggling With

(and How They Relate to the Guidelines)
How will we utilize converted yet formerly semi-private rooms
at times of surge?*
How will we leverage design to counter infectious disease
(e.g. air flow, materials, staff practices)?
How will we integrate lean thinking into our physical and
operational design?
How can we efficiently provide adequate recumbent sleep
room space for physicians, trainees and families?*
64
Q&A
65

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New Childrens Facilities Regulations How Would

They Impact Your Projects?

The International Facilities Design & Capacity Conference 2012

Become aware of forthcoming proposed design

The International Facilities Design & Capacity Conference 2012

What are the guidelines?

The International Facilities Design & Capacity Conference 2012

Checklist of Resources and Guidelines for the

The International Facilities Design & Capacity Conference 2012

Checklist of Resources and Guidelines for the

The International Facilities Design & Capacity Conference 2012

Intent of the New Children's Hospital

Consolidate minimum standards for children to one

The International Facilities Design & Capacity Conference 2012

Who, What, When, Where and Why

Guidelines committee structure

The International Facilities Design & Capacity Conference 2012

Where Guidelines Have Been Adopted

The International Facilities Design & Capacity Conference 2012

Starter Exercise: Where Should Childrens

- Volunteers and gift

The International Facilities Design & Capacity Conference 2012

Where Are We in the FGI Update Process?

Proposals accepted from public, published draft, and

The International Facilities Design & Capacity Conference 2012

(F)acilities that provide general acute pediatric

The International Facilities Design & Capacity Conference 2012

Chapter 2.7 Specific Requirements for

Renovation unless impractical per Section

2.7-2.2 Pediatric Medical/Surgical

The International Facilities Design & Capacity Conference 2012

Medical/Surgical Nursing Unit

The International Facilities Design & Capacity Conference 2012

Medical/Surgical Nursing Unit

Provide a family zone at each bedside

The International Facilities Design & Capacity Conference 2012

Medical/Surgical Nursing Unit

Provide for recumbent sleep of a parent

The International Facilities Design & Capacity Conference 2012

Medical/Surgical Nursing Unit

Dimensions and arrangement of rooms shall provide

The International Facilities Design & Capacity Conference 2012

2.7-2.2 Medical/Surgical Nursing Unit

A2.7-2.2.2.7 Patient Room Patient Bathing Facilities

The International Facilities Design & Capacity Conference 2012

Pediatric Bed Room Comparison

Max. no. of beds/room

Max. no. of beds/room

Min. clear floor area

120 single / 100 multiple

Min. bed clearances

Med-Surg Nursing Unit

The International Facilities Design & Capacity Conference 2012

Pediatric Bed Room Comparison

Max. no. of beds/room

Max. no. of beds/room

Med-Surg Nursing Unit

Min. clear floor area (SF)

The International Facilities Design & Capacity Conference 2012

2.7-2.2 Medical/Surgical Nursing Unit

Other requirements that are the same as for general

The International Facilities Design & Capacity Conference 2012

Medical/Surgical Nursing Unit