The Patient Room

The Patient Room

Planning, Design, Layout

Wolfgang Sunder

Julia Moellmann

Oliver Zeise

Lukas Adrian Jurk

Birkhäuser

Basel
Preface 7

A B
Fundamentals Typologies of
The Emergence of Hospitals 10 the Patient Room
From the Monastic Hospice to the Modern Clinic
The Floor Plan of a Two-Bed Room 28
The Nursing Ward Environment 15
Current Care Settings and Their Challenges Qualitative Evaluation of Two-Bed Rooms 38

Healthcare-Associated Infections 21 Typological Evaluation of Two-Bed Rooms 44

Rasmus Leistner
Selected Case Studies
Material Applications and Material Ageing
in Hospitals 24 General Hospitals
Inka Dreßler, Katharina Schütt
Trillium Health Centre
Mississauga, Canada 66

Zollikerberg Hospital – New West Wing

Zollikerberg, Switzerland 70

Zollikerberg Hospital – Renovation of East Wing

Zollikerberg, Switzerland 74

Hvidovre Hospital
Hvidovre, Denmark 78

Lauf District Hospital

Lauf an der Pegnitz, Germany 82

AZ Zeno
Knokke-Heist, Belgium 86

Haraldsplass Hospital
Bergen, Norway 90

Solothurn Public Hospital

Solothurn, Switzerland 94

New North Zealand Hospital

Hillerød, Denmark 100

Südspidol
Esch-sur-Alzette, Luxemburg 104
 C
Specialised Hospitals
Prototype of a
Patient Room –
Jugenheim District Hospital
Seeheim-Jugenheim, Germany 108

Sana Clinic Munich

Munich-Sendling, Germany 112
the KARMIN Project
BGU Accident and Emergency Hospital Architecture of the Patient Room 170
Frankfurt am Main, Germany 118
Planning and Design 178
Princess Máxima Center Colour and Materials Concept 183
Utrecht, the Netherlands 122 Lighting Concept 185

St Joseph-Stift Dresden Building the Prototype 196

Dresden, Germany 128
Completed Prototype and Use Scenarios 198
St Gallen Geriatric Clinic
St Gallen, Switzerland 132
Furniture and Equipment 206
Uster Hospital
Uster, Switzerland 136 The Disinfectant Dispenser 210
The Patient Bedside Cabinet 224
University Hospitals The Bedside Terminal 230

Surgical Centre Conclusion 237

Erlangen University Hospital
Erlangen, Germany 138 KARMIN Project Team 239

Crona Clinic
Tübingen University Hospital
Tübingen, Germany 142 Appendix 240

Erasmus MC Glossary 240

Rotterdam, the Netherlands 146 About the Authors 245
Subject Index 246
Oncological Centre
Index of Names, Places and Projects 249
Leuven University Hospital
Illustration Credits 250
Leuven, Belgium 150
Acknowledgements 252
Paediatric Clinic
Freiburg University Hospital
Freiburg, Germany 154

Children’s University Hospital Zurich

Zurich, Switzerland 158

Münster University Hospital

Münster, Germany 161

Building Structures in
German Hospitals 164
Preface
The German healthcare system spends more money per hospital patient built patient rooms and those on the drawing board. The projects are
than most countries in the world – the public health insurance companies described and documented with scaled plans and selected photo-
pay almost 70 billion euros to the hospitals annually. graphs. An overview of the current building structure of standard care
However, German patients receive by no means optimal care and units in German hospitals is given, thus demonstrating the current status
treatment (BMG 2014). Since 1990, the number of German hospitals has quo and uncovering perspectives for action.
gone down by about 20 % according to the Federal Statistical Office; Finally, chapter C presents the joint research project KARMIN, which
the average length of stay in the same period has been reduced by was funded within the framework of InfectControl 2020. The German
about half to seven days. The healthcare reforms of recent years have acronym KARMIN stands for Krankenhaus, Architektur, Mikrobiom and
increased the pressure on hospitals to be efficient and competitive in Infektion (hospital, architecture, microbiome and infection).
the marketplace. Their building infrastructure has to be highly adaptable The focus of this comprehensive and innovative study was the ques-
and process flows have to be efficient. tion whether the architecture of the patient room and its equipment
In addition, there is a strong increase in the occurrence of resistant can reduce and at best prevent infections in hospitals. Can a two-bed
germs in hospitals and many patients fear that they will become infected room in the normal care area be planned in a way that it provides an
by one of these germs. Every year in Germany about 500,000 patients alternative to the single room? The authors of this book, based at the
contract such an infection; about 10,000 to 15,000 patients die each Institute of Construction Design, Industrial and Health Care Building (IKE)
year due to hospital-acquired infections. Many hospital infections cause of the TU Braunschweig, have developed and built the prototype of a
not only suffering for the patients, but also lead to an extension of the two-bed patient room. The project took three years and took scientific
length of stay in the hospital, which places an additional burden on the findings into account.
provision of care. Therefore, hospital-acquired infections also have a The development also included optimised equipment like the dis-
considerable economic impact. infectant dispenser, the bedside table and new contents for the bedside
The patient room in the nursing ward has always been at the focus terminal. The methodical approach, the planning phase and the result
of hospital construction and hygiene. On the one hand, healing proces- are documented in this book.
ses become visible here and, on the other hand, patient rooms have The planning and realisation of future hospitals could make a sig-
the largest space requirement when compared to the other hospital nificant contribution to the prevention of nosocomial germs, if hygieni-
functions. Potential planning errors have severe consequences, as ward cally robust building and room layouts were more of a focus of hospital
structures tend to be repeated. If the complex hospital system is analy- design. After all, while the planning of a highly complex and hygienically
sed in terms of the possible spread of infections, various critical areas robust hospital will remain a demanding task, the architect may not
and situations emerge, in which the patient may be exposed to the risk forget the most important function of health buildings, namely to treat
of infection. The nursing wards clearly are a critical zone in this respect. and ideally cure patients‘ diseases.
In response to the increased occurrence of multi-resistant patho-
gens in hospitals the discussion in professional circles has been going Wolfgang Sunder
on for years whether in future considerably more single rooms should Julia Moellmann
be built or, alternatively, whether double rooms can be upgraded in a Oliver Zeise
way that they can contribute to infection prevention. In Germany in Lukas Adrian Jurk
2016 the share of single rooms in normal care was 5 % (Sunder 2018).
A reasonable ratio of the shares of two-bed rooms and of single rooms Braunschweig, November 2020
is insufficiently defined and requires further research.
This book addresses the current challenges of the patient room
within the hospital and examines which structural measures and pro-
cedural aspects are suitable to support the hygiene, to promote the
recovery process and to contain the spread of infections.
First of all, in chapter A, nursing care is described both historically
and in its present and future challenges. The focus is on structural and
functional organisation of the work processes in normal care. In two
excursus contained therein, first hospital-specific infections with their
sources of infection and transmission paths are explained. Secondly, it
is described how the choice and sensible use of materials can improve
cleaning processes and thus prevent the transmission of dangerous
germs in hospitals. Thus chapter A provides the planner with knowledge
of design principles.
An overview of possibilities for designing a patient room is described
in chapter B. The typology is presented systematically and evaluated,
based on corresponding examples. In this typological consideration,
both the two-bed room and the patient bathroom are analysed. A
second focus of this chapter are international case studies of already

7 Preface
A
Fundamentals
The Emergence From the Monastic
Hospice to the Modern
of Hospitals Clinic
The history of hospitals has been shaped over many centuries by a mul-
titude of civilisational factors: social, political and economic changes
along with advances in medicine and medical knowledge have all influ-
enced the development of a building type dedicated to care and healing
to varying degrees.

Religious orders as providers of care

In the Middle Ages, the hospitals, pest houses, almshouses and orphan-
ages administered by Christian orders were not just institutions of reli-
gious charity but were facilities for caring for the sick and protecting
other citizens against dangerous communicable infections.
The importance of these institutions became particularly apparent
in the 15th century when successive waves of dangerous epidemics such
as leprosy or the plague swept through Europe. Isolating and treating
1 Depiction of a hospital infirmary hall from the 16th
century showing various nursing scenes infected persons in these buildings made it possible to contain these
diseases without impacting excessively on the increasing mobility of the
population. The hospitals were usually built outside the city walls or on the
outskirts of a settlement to limit the spread of infections → Fig. 1. Helping
and healing the sick and infirm was typically the province of religious
orders acting in the spirit of Christian charity. The building complexes
serving this purpose were frequently self-contained walled exclaves at
the edge of settlements (Knefelkamp 1987). Their close proximity to the
church reflected the Christian ideal of spiritual and religious healing of the
sick. For centuries, the St. Gallen Monastery Plan of the Benedictine Order,
created around 820, served as an ideal model for hospital construction
→ Fig. 2. The ground plan featured a rectangular cloister that provided
a direct path to the church and around which the social facilities were
arranged. These included not only the dormitories for the friars, pilgrims
and travellers, but also nursing facilities for the sick. The status accorded
to care for the sick in the Benedictine monasteries was so important
2 Plan of the Monastery of St. Gallen, around 820 AD. For
that they advanced to become centres of medical knowledge.
several centuries this ground plan served as a model for
the construction of hospitals.
Advances in research from the 18th century onwards
The Charité hospital in Berlin, completed in 1727, represents a milestone
in the history of hospital design. The threat of plague epidemics and
the fear of the ensuing social, economic and political consequences
prompted Prussia’s King Friedrich I to build the hospital modelled on
the Hôpital Saint-Louis (1607) in Paris. In addition to nursing wards
for 200 patients, the Charité also had two infection wards and an
obstetrics ward. The distribution of spaces was innovative for the
time: the first and second floor wards had small room units with 10–12
beds, marking a departure from the hall-like infirmaries that had been
common until then → Figs. 3, 4. The rooms were accessed from a cor-
ridor running along the inner wall facing the courtyard. The nursing
staff supervised the daily routine and ensured that the rooms were
kept clean and bed linen was changed regularly. The opening of the
Charité marked the beginning of the founding of a number of other
clinics in Germany from 1770 onwards dedicated to the provision of
healthcare and support for poorer sections of society. The design of
3 Charité in Berlin, 1730, second floor with
this first generation of hospitals attempted to find hygienic solutions
nursing wards for the construction of various types of buildings. The aim was to pre-

10 Fundamentals
 vent patients from infecting each other in order to avoid, or at least
hinder, the occurrence of hospital epidemics, a problem that was
already known at that time.
The period of enlightened absolutism in Central Europe marked a
very significant period of hospital development. Advances in research
in the natural sciences had a lasting impact on understanding medicine,
and from the 18th century onwards the field of medicine grew ever
better at classifying diseases and developing successful therapeutic
approaches. Hospitals were especially crucial for the well-being of
the less privileged classes to protect them from infirmity and disease,
especially as increasing industrialisation during the Age of Enlighten­
ment led to a perilous deterioration of the living conditions of the
4 View of a hospital room at the Charité during a medical visit.
Copperplate engraving by Daniel Chodowiecki, 1783 working classes.
It was during this period of major upheaval that a large hospital was
built in Vienna, which at that time had 250,000 inhabitants. Completed
in 1780 to the plans of the physician Joseph von Quarin and the architect
Matthias Gerl, it aimed to centralise and rationalise care of the sick for an
entire region. The buildings had three storeys, each with two wards that
were combined into one unit. Each hospital room had 20 beds, which
were placed along the two longitudinal walls below the windows. As
such, there was no corridor along the side and the rooms were entered
from the ends → Figs. 5, 6.
In 1785, Prussia’s King Friedrich II commissioned the construction
of a new Charité hospital in Berlin. The new building was to have three
wings, each with four storeys. A central axis divided the building into
two sections: the rooms to the left of the entrance hall were reserved
5 General Hospital in Vienna, 1783-1784
for women, those on the right for men. On the ground floor were the
surgical and the internal medical wards. The nursing wards were located
on the floors above → Fig. 7. Smaller hospital rooms were arranged in
the side wings, while the middle wing of the building, facing the street,
contained wards for 16 patients each. Between each pair of wards was
a sanitary zone and toilet. The building structure of the Charité also
reflected the ongoing expansion and differentiation of medical disci-
plines since the beginning of the 19th century, and there were already
eight independent clinics on the site at that time.

Pavilion layout providing patients with light and air

The period up to the foundation of the German Reich in 1871 is consid-
ered a transitional period in the history of hospital development. Hos-
pital structures and equipment were changing constantly, and hygiene
6 General Hospital in Vienna, view of a hospital ward
was increasingly becoming the focus of attention. Sanitary facilities
were expanded, and washhouses were constructed, such as the one
for the Charité in 1848 → Fig. 8. At the same time, scientists began
to address hygienically relevant topics such as the proper disposal
of general and medical waste or the concerted cleaning of sanitary
facilities, floors and surfaces. Hospitals were built that offered a high
degree of spatial variability, making it possible to separate patients
according to type of illness, sex and age, as well as to improve the
quality of nursing care.
In the period between 1870 and 1918 the number of hospitals in
Germany grew rapidly. Between 1876 and 1900 alone, the number of
hospitals more than doubled from 3000 to 6300 and the number of
beds rose from 150,000 to 370,000 (Murken 1995). At the same time, a
surprising variety of hospital types emerged. One of the most impor-
tant aspects of the new wave of hospital construction activity was
the prevention of the transmission of hospital pathogens, resulting in
so-called nosocomial infections. In addition, many hospital operators
strove to offer patients better-quality care during their stay in hospi-
7 Charité in Berlin, 1785, second floor tal, for example with respect to bed comfort, sanitary facilities and

11 The Emergence of Hospitals

 nutrition. This also led to a reorganisation of the design of hospitals.
Instead of the corridor-type hospitals that had previously been built,
freestanding pavilions were built on open ground. Small, low-rise
buildings with patient wards were loosely distributed over a large
area, their architecture more reminiscent of resorts and hotels than
hospitals. Patients lay in wards with large windows, wide verandas or
terraces. Priority was given to ensuring hospital beds had fresh air and
sunlight and to maintaining a supply of clean air to the rooms. These
structural changes to the design of hospitals were accompanied by
advances in the fields of hygiene and bacteriology. One of the larg-
est pavilion complexes of this period is the Städtisches Allgemeines
Krankenhaus (Municipal Hospital) in the Hamburg district of Eppendorf,
which opened in 1888 → Figs. 9, 10.
8 Steam laundry of the Berlin Charité. Woodcut However, by the end of the 19th century the pavilion structure was
from ca. 1868 increasingly abandoned in favour of more densely-built, multi-storey
constructions. Wards were arranged around corridors and hospitals
were structured in smaller sections and spread across more storeys,
resulting once again in taller buildings such as the Municipal Hospital
in Düsseldorf → Figs. 11, 12.
The principle of access to fresh air was, however, maintained and
almost all of the wards opened to the south and were equipped with
a large south-facing balcony. This type of hospital, known as terrace
hospitals, was common throughout Germany until the Second World
War (Murken 1995).

The changing hospital landscape after 1945

After the end of the Second World War, hospital construction in Ger-
9 Municipal Hospital in Hamburg-­Eppendorf, 1885–1888
many began to develop in different directions. A common priority,
irrespective of size of the hospital or clinic operator, was to increase
efficiency through rationalisation. From the mid-1960s onwards,
high-rise construction began to displace low-rise hospital building.
An important basis for these structural changes were the scientific
advances made after about 1950 in the field of antibiotics research to
combat infectious diseases. The resulting continual decline in infec-
tions led to a reduction in the number of patient rooms needed, and
the combination of a shortage of skilled nursing staff and successful
advances in medicine (e.g. artificial dialysis, heart-lung machines)
meant that centralisation and automation now determined the direc-
tion of hospital design. Business management aspects began to play
a more significant role. At the beginning of the 1960s, an efficient hos-
pital would ideally have 200 beds or more, while an optimal nursing
ward comprised between 25 and 35 beds. Centralisation also meant
that workplaces were merged where similar or sequential tasks had
to be performed. The progressive rationalisation of the German hos-
pital system in turn led to a standardisation of individual hospitals
10 Municipal Hospital in Hamburg-­Eppendorf. Floor plan according to capacity and number of beds, and since the 1970s, four
and longitudinal section of a hospital pavilion
categories have dominated the hospital landscape: hospitals with 200
beds provide a basic level of care services, those with 300–400 beds
a standard level of services, with 600 beds central care services and
those with 1200 beds or more maximum care provision.
For the nursing sector, a double-corridor configuration was increas-
ingly adopted, greatly improving functional flexibility. Inward-facing
rooms, located between two parallel corridors, were partially lit and
ventilated by inner courtyards within the building. The double-corridor
system also made it possible to separate the circulation of visitors and
patients.
The shift from a humanistic-holistic healthcare focus to a high-tech
system is best seen in the so-called university clinics that were estab-
lished in Germany from the 1960s onwards. The very high requirements

12 Fundamentals
 in terms of economy, care, hygiene and medical technology that they
had to fulfil resulted in highly technical hospital buildings. This devel-
opment also paved the way for intensive care provision, which was
centrally located in separate intensive care units. These technically
elaborate rooms were used to treat seriously ill and newly operated
patients, who were constantly monitored and supervised by a variety
of measuring and other equipment.
The university clinics with their three pillars – teaching, research
and healthcare – very quickly became the most important source of
11 Municipal Hospital in Düsseldorf, 1904–1907 innovation in clinical medicine, where new research results could be
put directly into practice. The rapid expansion of the university clinics
came in response to a recommendation by the German Council of Sci-
ence and Humanities in 1960 to increase the number of beds in the 18
medical faculties in Germany from 16,500 to 25,700.
A notable example is the vertical solution developed by the archi-
tects Benno Schachner, Peter Brand and Wolfgang Weber in 1973 for
Münster University Hospital. Their solution is based on the by then
already common model of a broad three-storey base for central diag-
nostics and treatment that connects vertically to two ten-storey towers
with nursing wards, and horizontally to the teaching building and the
care centre → Fig. 13. The towers with the patient rooms are cylindrical
in form and are arranged so that two circular wards connect to a square
central area. The circular ward configuration made it easier to keep an
eye on patients and minimised travel distances for the nursing staff.
12 Municipal Hospital in Düsseldorf, site plan Glazed sections in the patient room doors also afford visual contact
between the patient and the nurses’ station in the middle. Each floor
comprises two circular wards with 28 beds each, divided into two- and
four-bed rooms. Each patient room has its own sanitary unit with toilet,
shower and washbasin on the outside wall and between two patient
rooms → Fig. 14.

New challenges
Since the early 1990s, the German hospital system has faced several
new challenges. Since 1993, the length of stay in hospitals has been
shortened by a third as a result of the introduction of the DRG (Diagno-
sis Related Groups) system, a flat-rate billing procedure based on the
classification of similar hospital treatments and diagnoses. In addition,
both privatisation and specialisation have advanced significantly, and
the proportion of privately funded hospitals is steadily increasing.
13 Münster University Hospital, 1975–1982, model
Accordingly, the share of public hospital operators had fallen to below
30 % in 2008 (Ernst & Young 2010). While shorter hospital stays and
fewer patients due to improvements in medicine have freed up hospi-
tal capacities, hospitals are increasingly competing for patients. The
design of hospitals has had to adapt accordingly, particularly with
regard to flexibility, adaptability and speed of reaction as the basis
for long-term economic success. Modern hospital buildings need to
be flexible and sustainable.
A further response to changes in society and healthcare that has
been the subject of discussion for some years now is the concept of
“Healing Hospitals” in which the architecture contributes positively to
the patient’s recovery process (Meuser, Schirmer 2006). The hospital
is gradually evolving into a place of convalescence with recuperative
and recreational components more commonly seen in leisure facilities.
We are seeing a gradual convergence of the building types of the
hospital and the hotel. One example of this is the district hospital in
Agatharied, Bavaria, planned by the architects Nickl & Partner. It pro-
vides contemporary medical healthcare in an attractive architectural
14 Münster University Hospital, floor plan of a
context situated in an idyllic landscape, and its atmosphere is more akin
nursing ward to a comfortable hotel than a hospital → Figs. 15–17.

13 The Emergence of Hospitals

 Looking back over the centuries of hospital development, one
becomes aware that few building types have had to adapt so consist-
ently to changing social and medical conditions. Numerous factors, be
they advances in medicine and hygiene, shifts in politics and society
or the need to train doctors, have given rise to changes that were hard
to foresee. New hospitals can take many years to build and thus run
the risk of being functionally outdated by the time they are completed.
As such, the design of hospitals must increasingly focus on creating a
high-quality environment for both patients and its highly specialised
staff that is also capable of responding and adapting to the diverse
changes it will encounter in its lifetime.

References
Bundesministerium für Gesundheit (BMG), Einnahmen und
Ausgaben der gesetzlichen Krankenversicherung, KJ I
Statistik, as per 27 May 2014
Ernst & Young, Krankenhauslandschaft im Umbruch,
Stuttgart: Ernst & Young, 2010, p. 9
Ulrich Knefelkamp, “Die Heilig-Geist-Spitäler in den
Reichsstädten”, in: Rainer A. Müller (Ed.), Reichsstädte in
Franken, Munich: Haus der Bayerischen Geschichte, 1987
Philipp Meuser and Christoph Schirmer, New Hospital
Buildings in Germany: General Hospitals and Health
Centres, Vol. 1, Berlin: DOM Publishers, 2006, p. 18
Axel Hinrich Murken, Vom Armenhospital zum Großklinikum:
Die Geschichte des Krankenhauses vom 18. Jahrhundert
bis zur Gegenwart, Cologne: DuMont, 1995, p. 217
Statistisches Bundesamt (2019), https://www.destatis.
de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/
Krankenhaeuser/Tabellen/gd-krankenhaeuser-jahre.
html;jsessionid=997DF721D500EE17D682B76A9F210B9F.
internet732. Last accessed 18 February 2020
Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier,
15, 16 Agatharied District Hospital, 1994–1998,
Andrea Haselbeck and Inka Dreßler, Bauliche Hygiene im
exterior view with conservatories
Klinikbau. Planungsempfehlungen für die bauliche Infek-
tionsprävention in den Bereichen der Operation, Notfall
und Intensivmedizin (Zukunft Bauen – Forschung für die
Praxis, Band 13), Bonn: Bundesinstitut für Bau-, Stadt- und
Raumforschung, 2018

17 Agatharied District Hospital, partial floor plan

of the nursing area

14 Fundamentals
The Current Care Settings
and Their Challenges
Nursing Ward
Environment
The design of healthcare environments is constantly changing in
response to developments in medicine, changing social requirements
and advances in architecture and building technology. Before we exam-
ine the spatial characteristics, functional areas and work processes of
standard care wards, as well as the specific building-related hygiene
measures available, we should first consider the challenges that the
field of nursing has been confronted with over the past decades and
the last ten years in particular.

An increase in nosocomial infections and multi-resistant germs

It is expected that the number of seriously ill patients suffering from
Resistant germs (%) infectious or nosocomial infectious diseases in hospitals will increase,
18 4 with intensive care units being particularly vulnerable due to the numer-
60 18 ous invasive procedures they involve. Parallel to this, recent years have
seen a dramatic increase in MRSA and nosocomial infectious agents that
50 15
may potentially spread considerably (Kramer et al. 2012). At the same
40 12 time, the number of antibiotics available to doctors will be significantly
limited in the foreseeable future because the number of companies
30 9
capable of independently developing antibiotics through all clinical
20 6
phases for active use in medical practice has fallen from 18 in 1990 to
just four in 2011 → Fig. 1. Meanwhile, antibiotics, and reserve antibiotics
10 3 in particular, are being increasingly prescribed in large quantities, not
least because many patients expect their doctors to prescribe anti-
biotics when they have a fever and other symptoms of infection.
1980 1985 1990 1995 2000 2005 2010

MRSA FQRP New pathogens

VRE Number of approved antibiotics The risk of new pathogens appearing is high. New bacteria, viruses, fungi
and parasites are regularly being identified that have the potential to
1 The number of companies capable of developing anti-
biotics to marketability. Number of antibiotics approved cause infections in humans. The most recent influenza epidemics, SARS,
versus the increase in multi-resistant bacterial strains Ebola or the outbreak of Covid 19 are examples that are as well-known
as they are worrying. The emergence of new pathogens is particularly
critical if they are able to spread rapidly. Routine medical care is not
Men Age Women prepared for the diagnosis of new pathogens, as most methods are
100 based on the detection of known pathogens. The situation is further
90 aggravated by the fact that general nursing wards and especially inten-
sive care areas have insufficient isolation facilities for infected patients.
80

70 Demographic change
Since 1972, the death rate in Germany has exceeded the birth rate → Fig. 2,
60
so that the total population has been falling. At the same time, higher
50 life expectancy means that the proportion of older people is rising in
relation to the proportion of younger people. Parallel to this, more and
40
more older people up to the age of about 80 have few or no chronic
30 diseases or disabilities. A major challenge regarding this population
20 group is, however, the significantly higher number of immunosup-
pressed patients with concomitant diseases and their corresponding
10
appropriate accommodation in nursing wards. As the immune system of
this group of patients is weakened by an underlying chronic disease or
500 300 0 300 500 by the administration of certain drugs, they need particular protection
thous. thous. against infections in hospitals.
In addition, the nursing sector has faced a series of further shifts
2000 2050
within the healthcare sector that have implications for the design of
2 Demographic development in Germany healthcare environments.

15 The Nursing Ward Environment

 % A decline in the number of hospitals and an increase in bed
occupancy
100
Increasing competition among German clinics, the Hospital Financing
Act (KHG 1991, 2019) and the German flat-rate billing procedure (DRG
for short), introduced in 2004, have led to a continuing reduction in
the number of hospitals in Germany as well as in the length of stay for
95
inpatient treatment. At the same time, there has been an increase in the
number of inpatients treated per hospital bed → Fig. 3.

An increased need for medical staff

90 Costs in the German hospital sector have been rising continuously for
years by an average of about 3 % per year over the past ten years. The
overall increase between 2000 and 2008 was 21 %. In 2008, the costs
amounted to 62 billion euros (Ernst & Young 2010), with personnel
85 Year costs alone accounting for around 60 % of the overall costs. Changing
2001 2003 2005 2007 2009 2011 2013 2015 2017
patient expectations and the services provided to them have led to
a sharp increase in medical staff (doctors, nurses and administration
Hospitals
combined) in recent decades. The rise in personnel costs, in turn, is
Bed occupancy
primarily due to a significant increase in medical procedures and ser-
3 The number of hospitals and bed occupancy in vices, while the cost of nursing care has risen only moderately. Nursing
Germany between 2000 and 2017 staffing levels have, however, increased steadily, especially in the last
ten years → Fig. 4.
On the other hand, there is an acute shortage of skilled staff: there is
Employees in thousands
already a lack of skilled workers in all nursing professions. While official
figures on the number of unfilled positions in the nursing professions
450 are not available, an indication of existing bottlenecks can be obtained
400
from the Federal Employment Agency’s analysis of the shortage of skilled
personnel. In 2018, there were only 29 unemployed persons for every
350
100 vacant positions for qualified geriatric nursing staff and specialists
300 (outside temporary employment) and only 48 unemployed persons for
250 every 100 vacant positions for qualified nurses → Fig. 5.

200
Innovations in medical technology and new forms of treatment
150 With the development of new diagnostic and therapeutic procedures,
100 examination and treatment facilities were separated from the nurs-
ing wards. At the same time, hospitals have become more efficient at
50
treating each individual patient. In recent years, new hybrid forms of
Year treatment have also been established, such as partial inpatient treatment
2001 2003 2005 2007 2009 2011 2013 2015 2017 or pre- and post-operative care, which are increasingly replacing the
traditional form of nursing care. In addition, there has been a sharp rise
Nursing staff Auxiliary staff
in the number of intensive care beds in both university hospitals and
Medical-technical staff Hospital service staff
general hospitals: between 1991 and today, the number of intensive
4 The number of full-time staff employed in German care beds throughout Germany rose from 20,000 to 27,000 (Wischer,
hospitals between 2000 and 2017 Riethmüller 2007; GBE Bund 2016).

Changing patient demands

In Germany’s modern industrial society, there has been a shift in recent
decades from a previously largely universal set of common values to a
plurality of quite different values for different subgroups of society. As
individualisation, fragmentalisation and diversity increase, the forces
of social integration are diminishing. Likewise, as traditional family
structures change, the amount of care and support provided within
the family is declining, in turn increasing the demand for care services
outside the home.
Individualisation has also led to an increase in personal services. In
the nursing care sector, care providers are increasingly expanding their
service spectrum to include a range of non-medical services for patients.
Hospitals have also had to adjust to a growing proportion of foreign
patients and staff in recent decades, in particular in urban areas. This

16 Fundamentals
Unemployed per 100 job vacancies places increased demands on communication amongst staff members
and between staff and patients and also requires tolerance of different
90 norms and practices.

80
An increase in patients with dementia
70 Alongside the steadily increasing number of older patients, the risk of
60 developing dementia will also increase → Fig. 6. In total, some 1 million
people aged 65 and over are currently affected by dementia in Ger-
50
many, which corresponds to about 7 % of this age group. The number
40 of new cases is increasing by about 300,000 people every year and
30 is set to reach up to 2.8 million people by 2050 (Deutsche Alzheimer
Gesellschaft 2018). This will lead to a higher level of nursing care and a
20
greater demand for nursing staff, since the possibilities of automation
10 in this area are limited.
Year
2011 2012 2013 2014 2015 2016 2017 2018 Prognosis
Hospital nursing staff
The developments over the past decades show clearly that the hos-
Geriatric nursing staff
pital nursing care sector will need to continue to respond to further
5 Skilled labour shortages in nursing, unemployment to job ratio changes in the future, and in the process will have to consider a multi-
tude of structural, technical, material science and organisational aspects.
Research and development into innovative spatial configurations in
Mill.
hygiene-critical areas of nursing wards with a view to preventing infec-
tion will be increasingly important.
The number of beds per hospital will continue to decrease in future,
as will the average length of stay. The absolute number of inpatients
25
per bed, on the other hand, will increase. As a consequence, we can
expect to see a shift towards building structures with uniform and
20
standardised care areas. For non-intensive care and observation phases,
more economical care structures will be needed such as admission and
15 observation wards.
Future developments in nursing forms at hospitals will make it nec-
10 essary to increase intensive care capacities, and even smaller hospitals
are now being equipped with these personnel- and technology-intensive
5 care facilities. The costs of investment in medical technology, personnel
and equipment are extremely high though the economic returns are
also quite attractive.
Year
2010 2016 2020 2030 2040 2050 2060
It is difficult to make precise predictions of the numbers that future
nursing care areas will need to accommodate in future. We can expect,
Estimated number of over 65-year-olds on the one hand, to see structural changes such as the increasing split-
Estimated number of sick people ting off of individual medical fields, new focal areas of patient care and
a transition to semi-inpatient or outpatient care. At the same time, it
6 Predicted development of the number of dementia
patients compared to over 65-year-olds in Germany is hard to accurately predict how future financing systems in Germany
from 2010 to 2060 in millions will affect the size of hospital wards. Every hospital and every area of
nursing care will need adapt in response to these developments.

17 The Nursing Ward Environment

 Nursing Wards
Location in the hospital

The location of nursing wards within the structure of a hospital is largely

determined by their optimal relationship to the examination and treatment
Examination and treatment area (blue) in a high-rise. areas. Since the 1960s, four typical organisational concepts have emerged in
Two-storey nursing ward (orange) next to examination area
Germany → Fig. 7. The first two are horizontal and vertical building types in
which the nursing wards are located on several floors next to or above the
examination and treatment areas. Another concept is a single-storey nurs-
ing ward arranged either next to or above the examination and treatment
areas. A fourth, less common variant is the integration of the nursing ward
Multi-storey nursing ward (orange) next to two-storey
examination and treatment area (blue) into the overall hospital structure. Here, the nursing wards are not grouped
in a spatially and functionally independent unit but instead adjoin the
respective treatment and examination zones of the individual disciplines.
The primary criterion for the location of nursing wards is their opti-
mal connection to other relevant functional areas in the hospital. Travel
distances between the nursing wards and the surgical, medical exami-
nation and specialist departments should be kept as short as possible.
Close proximity to intensive care and IMC (Intermediate Care) is also
desirable as many logistical and staffing processes overlap with those
of normal care wards. For patients and visitors, proximity to services
Multi-storey nursing ward (orange) above two-storey
examination and treatment area (blue) located at the entrances, access to outdoor areas and to other care
facilities is also important.

Spatial-functional layout

The profitability of a nursing ward is based on a nursing organisational

Single-storey nursing ward (orange) above two-storey examination and
treatment area (blue)
standard, which should be in the order of 28–41 beds. Despite the
differences between individual medical disciplines with respect to the
nursing needs of patients, which are quite different, for example, for
trauma surgery than they are for transplant surgery, it is still expedient
to have a common denominator for the size of normal care wards for
both constructional and organisational reasons → Fig. 8. Nursing groups
with different numbers of beds or inconsistent room sizes make it hard
Examination and treatment areas (blue) with nursing ward (orange)
mixed in one overall complex to standardise operational processes and result in less efficient staffing
organisation. For this reason, a uniform standard for nursing wards in a
7 Typical locations of nursing wards (orange) in hospitals.
Depending on the concept, the nursing wards lie next nursing group should be established.
to or above the examination and treatment areas. The spatial-functional arrangement of a nursing ward is divided into
core services and nursing areas. The core services of a nursing ward are
grouped together spatially and are solely for use by the doctors and
nurses. They include preparatory facilities for delivering care services
as well as staff and rest areas for internal use and consultation among
colleagues. The core services typically comprise a nurses’ station, staff
rooms, examination rooms, supplies, storage and disposal rooms. The
nursing areas include the ward corridor and patient rooms.

Nurses’ station
The nurses’ station is the central point of every ward and should be easy
8 Typical arrangement of a double-corridor nursing for patients and visitors to find and reach. It is the contact point for
ward layout
patients and visitors as well as for staff, and the place where all process
cycles and information in the ward converge. As a rule, it adjoins the
medication store, where further work processes can be carried out.

Staff rooms
This group of rooms includes a common room for the nursing staff, with
a kitchenette and workstations for the nursing staff along with sanitary
facilities and staff changing rooms.

18 Fundamentals
 Doctors’ consultation rooms
Consultation rooms within wards are often only equipped to the extent
necessary for ward operations, for example for doctor/patient consul-
tations or for dealing with administrative procedures related to the
inpatient stay of patients.

Examination rooms
The examination and treatment of patients does not usually take place
in the patient room, especially not in shared rooms. All general care
wards have one examination and treatment room for standard examina-
tions, which can be equipped differently depending on the respective
ward’s discipline.

Supplies, storage and disposal rooms

The logistics in general care wards can differ with regard to the degree
of centralisation of supply and disposal rooms and their relation to the
patient rooms. In many cases, the nurses’ station, nursing workroom
and unclean storage room are grouped in a connected series of rooms.
Unclean storage rooms, which should always be equipped with bedpan
washer-disinfectors, are usually set apart from the patient rooms. It
makes sense to locate both supplies and disposal rooms close to goods
transport lifts.

Ward corridor
The ward corridor is the central axis of the nursing ward and should
accordingly be of a sufficient size and clear structure. As a rule, patient
rooms are arranged on both sides of the corridor, and it must therefore
be wide enough to ensure that two patient beds can be pushed past
each other. For patients, staff and visitors, the nursing corridor is both
a working and meeting area. Preparatory and follow-up care work for
treating patients outside of the examination rooms often takes place
in front of the patient’s room. Small niches in the corridors can hold
necessary materials, storage space or disposal containers for use by the
nursing and medical staff. This arrangement also helps facilitate the care
and treatment of patients with different diseases. The ward corridor is
also a place of social encounters and exchanges, where patients from
often quite different social and cultural backgrounds meet in a variety
of ways.

Patient rooms
There are various different solutions for the functional layout and design
of patient rooms with respect to their size, arrangement and placement
of wet cells and ancillary rooms. A uniform structural wall or column
spacing is sensible, both for economic reasons and standardisation as
well as to flexibly accommodate future changes of use.
The originally widespread six-bed and four-bed room constella-
tions are increasingly being abandoned in favour of two-bed rooms. In
2012, single-bed rooms accounted for between 5 and 10 % of all beds
in Germany, which compared to other European countries lies in the
middle range (ECDC 2015). So far, shared rooms are the rule, single
rooms the exception.
The higher proportion of two-bed and single-bed rooms requires
more space but also makes it possible to use the nursing areas more
intensively, as patients can be distributed to smaller room units accord-
ing to their illness and nursing needs. Single-bed rooms can be designed
in such a way that they can also be used as two-bed rooms in the event
of peak occupancy (Wischer, Riethmüller 2007).
Special room configurations can apply in particular ward depart-
ments such as paediatrics, obstetrics and psychiatry. They may deviate

19 The Nursing Ward Environment

 from the pattern of general care wards due to the specific additional
functions they need, and their space requirements are generally greater.
The patient room is an important cellular unit and base spatial com-
ponent of a hospital. Its design must be considered in exacting detail
as it has significant implications through its replication on the overall
structure of the hospital. A patient room includes a sanitary cell, possibly
with a separate toilet, the patient bed and wardrobe, a cloakroom for
visitors and a seating area → Fig. 9. Architects have continually striven to
develop and improve the patient rooms, focusing on and accentuating
certain aspects.

Processes

The workflows in normal care wards comprise for the most part stand-
ardised processes. Logistical processes, such as the direct supply
of laundry, consumables and pharmaceuticals, are designed around
modern supply principles. Care and treatment routines undertaken
as part of ward operations by medical and nursing staff, including the
9 Conventional two-bed room doctors’ rounds or administering of medication, are carried out either
in a circulatory sequence within a ward group or directly for individual
patients. These routines are usually preparatory or post-operative meas-
ures accompanying medical procedures where specific materials need
to be provided or disposed of. Depending on the type of procedure
and its hygienic requirements, nursing or medical activities are carried
out either at the bedside or in the ward’s examination room. For simple
patient examinations, the necessary utensils, for example a syringe or
dressing, can be brought from the nurses’ workroom to the patients on
a work trolley. After completion of the procedure, this trolley is taken
to the unclean disposal room. For more complex or extensive patient
procedures, the trolleys in the nurses’ workroom may be equipped with
medicines, infusions, instruments, dressing materials, fresh laundry and
so on. After completion, the trolley with dirty laundry is stored in the
unclean disposal room and replaced once a day.

References
H. Bickel, “Demenzsyndrom und Alzheimer Krankheit.
Eine Schätzung des Krankenbestandes und der jährlichen
Neuerkrankungen in Deutschland”, Gesundheitswesen,
2000, 62 (4): pp. 211–218
Deutsche Alzheimer Gesellschaft e. V., Informationsblatt 1:
“Die Häufigkeit von Demenzerkrankungen”, Berlin, 2018
ECDC (2015) European Center for Disease Prevention and
Control (ECDC), Healthcare-associated infections, www.
ecdc.europa.eu/en/healthtopics/healthcare-associated­­
_­infections/database/pages/hai-pps-database-indicators-­
maps.aspx. Last accessed 4 February 2020
Ernst & Young (2010), Krankenhauslandschaft im Um-
bruch, Stuttgart: Ernst & Young, 2010, p. 9
Gesundheitsberichterstattung des Bundes (GBE Bund),
Intensivmedizinische Versorgung in Krankenhäusern,
Anzahl Betten, http://www.gbe-bund.de/oowa921. Last
accessed 7 April 2016
A. Kramer, O. Assadian and M. Exner, Krankenhaus- und
Praxishygiene, 2nd edition, Munich: Urban Fischer Verlag,
2012, pp. 1–7
Gesetz zur wirtschaftlichen Sicherung der Krankenhäuser
und zur Regelung der Krankenhauspflegesätze (Kranken-
hausfinanzierungsgesetz – KHG). Originally issued 1972,
reinstated 1991, last revised 2019
Robert Wischer and Hans-Ulrich Riethmüller, Zukunfts-
offenes Krankenhaus – Ein Dialog zwischen Medizin und
Architektur, Vienna: Springer, 2007

20 Fundamentals
Excursus 1 Healthcare-associated infections or nosocomial (derived from Greek
nósos, illness, and komein, care) infections are infections that only

Healthcare- occur after the patient has been admitted to hospital. This means the
patient is not infected at the time of admission to hospital, although
they may be colonised with various microorganisms, which in itself is

Associated
a natural condition. To differentiate between regular and nosocomial
infections in everyday practice, a simplified definition is used: infec-
tions that manifest themselves after the third day of hospitalisation are

Infections
very likely acquired there and are therefore considered nosocomial
while infections that arise within the first three days are considered
as not having been acquired in hospital, i.e. were either brought in or
acquired on an outpatient basis. What, then, are the possible sources
Rasmus Leistner and transmission pathways of nosocomial infections and how can they
be addressed through hygiene measures in hospitals?

Endogenous and exogenous infections

The human body is populated with an average bacteria mass of 200 g

(approx. 3 × 1013 bacterial cells). As most bacteria are much smaller than
human cells, that means that our body contains about the same number
of microorganisms as human cells (Sender 2016). The totality of these
microorganisms is called human microbiome. Most bacteria are found
in the gastrointestinal tract and fulfil a central function in the digestion
and production of important metabolic products. Many bacteria are
also naturally found on the skin and mucous membrane of the body.
The intact skin, and also the intact intestinal mucosa, protects our body
against penetration by microorganisms. Invasive medical procedures
pierce this natural barrier and thus open up a channel for pathogens to
Number of deaths per year enter otherwise non-microbial areas of the body. If the number of path-

35,000

30,000

Pneumonia

25,000
Primary bloodstream infection

20,000

Surgical site infection

15,000
Urinary tract infection

10,000
Clostridium difficile infection

5,000

Neonatal sepsis

200,000 400,000 600,000 800,000 1,000,000

Number of cases per year

Burden of healthcare-associated infections in Europe
Six healthcare-associated infections according to their number of cases per year (x-axis), number of deaths per year (y-axis)
and DALYs per year (width of bubble) in Europe for the years 2011 and 2012. DALYs (Disability Adjusted Life Years) are the
years of potential life lost due to premature mortality and of productive life lost due to disability.

1 Frequency of nosocomial infections and the associated

mortality and disease burden (morbidity)

21 Healthcare-Associated Infections
 ogens that make it into the body exceeds a critical quantity, the body’s
own defence mechanisms are unable to contain them, or at least can
5 only partially do so, resulting in an infection. In addition, bacteria can
settle very effectively, especially on plastic surfaces, and once settled
produce a slimy substance (the so-called biofilm) that protects them
and promotes their unhindered reproduction → Fig. 2.
Common medical procedures in hospitals where this route of infec-
tion applies are surgical procedures, urinary tract catheterisation, arti-
ficial respiration by tracheal intubation, intravenous access, and so on.
1 2 3 4 5
Most hospital infections are therefore endogenous in nature. This means
Development of a biofilm in five steps. Stage 1: Initial adhesion of cells on the surface.
that the infectious pathogens mostly stem from the patient’s own flora.
Step 2: Production of firmly adherent extracellular polymeric substances. Step 3: Early In industrial nations, an estimated 85 % of all infections are assumed to
development of biofilm architecture. Stage 4: Maturation of biofilm architecture.
Stage 5: Separation of single cells from the biofilm.
be endogenous. Consequently, invasive procedures must be used very
Prävalenz noskomialer Infektionen (Patienten mit nosokomialer Infektion in
Prozent, links), und Verteilung der verschiedenen nosokomialen Infektionen
sparingly in order to minimise the risk of infection.
2 Phases
Prävalenz
pro of biofilm
noskomialer
Fachdisziplin. formation
Aus ECDC on plastic
Infektionen surfaces
(Patienten mit nosokomialer
Punktprävalnezstudie 2011-2012 Infektion in Some hospital-acquired infections are caused by pathogens that
Prozent, links), und Verteilung der verschiedenen nosokomialen Infektionen
pro Fachdisziplin. Aus ECDC Punktprävalnezstudie 2011-2012 enter the patient from outside, from the surrounding environment. This
Surgery
so-called exogenous acquisition of infection is suspected to account for
about 15 % of hospital infections. Most of these pathogens are transmit-
Internal medicine
Surgery
ted directly, for example from the hands of hospital staff, or indirectly,
Paediatrics
Internal medicine
through medical devices (e.g. a stethoscope or endoscope). Droplet,
Intensive care
Paediatrics airborne or hospital water-borne transmission usually plays a secondary
Gynaecology/obstetrics
Intensive care role in the genesis of nosocomial infections.
Geriatrics
Gynaecology/obstetrics Through appropriate built measures, it is largely possible to reduce
Psychiatry
Geriatrics the proportion of exogenous infections. By creating a built environment
Rehabiliation/other
Psychiatry that facilitates uncomplicated workflows and by creating positive incen-
Rehabiliation/other tives (so-called “nudging”), such as encouraging hand disinfection, it is
0 5 10 15 20
also possible to reduce the risk of endogenous infections. In addition,
Patients with HAI (%)
0 5 10 15 20 an environment in which the patient feels comfortable and less exposed
Patients with HAI (%) to supplementary stress factors can have a protective effect.
To begin with, one can prevent the transmission of airborne infec-
Surgery tions using built means, for example single-bed rooms with and without
Internal medicine
Surgery an airlock. The assumption is that single-bed patient rooms reduce the
Paediatrics
Internal medicine possibility of contact transmission of infectious pathogens. A separate
Intensive care
Paediatrics room may offer a further incentive to remind people to disinfect their
Gynaecology/obstetrics
Intensive care
hands regularly. Single rooms are also presumed to be advantageous
Geriatrics
in preventing infection transmission resulting from the shared use of
Gynaecology/obstetrics
sanitary facilities.
Psychiatry
Geriatrics
The risk of hospital-acquired infections correlates to hospital size
Rehabiliation/other
Psychiatry
(number of beds), i.e. the proportion of patients with hospital-acquired
Rehabiliation/other
0 20 40 60 80 100 infections increases with hospital size. This can be explained by the fact
Percentage of HAIs that hospitals at the end of the treatment chain generally admit more
0 20 40 60 80 100
Percentage of HAIs patients with more serious underlying health conditions. These hospitals
Lower respiratory tract Gastrointestinal
are usually maximum care facilities with a large number of beds and a
Urinary tract Systemic infection
Lower respiratory tract Gastrointestinal wider range of highly specialised disciplines.
Surgical site Skin/soft tissue
Urinary tract Systemic infection
Bloodstream Other The risk of infection also varies within the hospital depending on the
Surgical site Skin/soft tissue
Bloodstream Other respective department and discipline → Fig. 3. They are most prevalent
(HAI: Healthcare-associated infection)
in departments that frequently require invasive procedures such as
(HAI: Healthcare-associated infection) intensive care units or after major operations, e.g. abdominal surgery.
3 Frequency and distribution of nosocomial infections in
different disciplines and hospital departments Other high-risk areas are those with patients whose immune systems
Abb 004: Häufigkeit und Verteilung nosokomialer Infektio- are particularly weakened, such as oncology wards or wards with trans-
nen in verschiedenen Fachdisziplinen und Krankenhausbe-
Abb 004: Häufigkeit und Verteilung nosokomialer Infektio- plant patients. For this reason, infection prevention in these areas is
reichen.
nen in verschiedenen Fachdisziplinen und Krankenhausbe- especially important.
reichen.
Hospital-acquired infections occur relatively constantly throughout
the year. Seasonal fluctuations only occur for individual types of infection
and pathogens. For example, post-operative wound infections are more
frequently observed in summer. Viral gastroenteritis such as norovirus
infection occurs more frequently in winter.

22 Fundamentals
 Horizontal and vertical prevention measures
Patient Healthcare
zone area
In hospitals, a distinction is made between horizontal and vertical pre-
vention measures. Horizontal measures are implemented equally for all
Before clean/
aseptic procedure patients. The most important example is hand disinfection with alco-
hol-based handrub by all patients and by all hospital staff in patient care.

2
1
According to the scheme established by the World Health Organization
Before
touching
(WHO 2009), hand disinfection is carried out before touching a patient,
a patient before clean/aseptic procedures, after body fluid exposure risk, after

4 After
touching
a patient
touching a patient and after touching patient surroundings → Fig. 4.
Cleaning and disinfection are also part of the horizontal measures, as
is the focused and sparing use of antimicrobial drugs. The latter is also

3
controlled at hospital level as part of a so-called antibiotic steward-
ship programme (Leitlinie "Strategien" 2019). Antibiotic stewardship
After body fluid programmes are hospital-wide projects that regulate the prescription

5
exposure risk After practice of antibiotics. This is often implemented by in-house teams (e.g.
touching infectiologists), who implement a sort of quality management system
patient
surroundings for the entire hospital.
Vertical prevention measures are those that are only carried out with
certain patients to prevent a specific pathogen or infection. For example,
typical vertical prevention measures include screening for multi-­resistant
4 The five moments for hand hygiene defined by
the WHO
bacteria such as MRSA (methicillin-resistant staphylococcus aureus) and
placing patients with MRSA bacteremia in a single room.
In order to plan and implement the appropriate preventive meas-
ures individually for each hospital, hospitals employ medical and nurs-
Contaminated catheter hub ing hygiene specialists. Almost all hospitals employ nursing staff with
e.g. from endogenous flora of patient
or extrinsic from hands of staff appropriate specialist training (so-called hygiene specialists) and larger
hospitals also employ medical staff trained as hospital hygienists.
The main requirements for infection prevention in Germany are
specified in the Protection against Infection Act and the respective fed-
Skin organisms
e.g. from endogenous skin flora of patient eral state’s hygiene regulations. The Commission for Hospital Hygiene
or extrinsic from hands of staff Contaminated infusate
or contaminated disinfectant and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI) is
an expert committee that develops and publishes national recommen-
dations for the prevention of healthcare-associated infections based on
Fibrin sheath, thrombus Skin
current publications and expert knowledge.
Because certain vital medical products such as vascular catheters
Vein → Fig. 5, urinary tract catheters, intubation tubes represent such a major
Hematogenous dissemination from distant infection
potential source of infection, most of the KRINKO recommendations deal
with the infection-preventive handling of these aids. Other recommen-
5 The pathogenesis of catheter-related bloodstream
Abb 003: Pathogenese der Infektion eines Gefäßkatheters.
dations focus on measures to prevent the spread of certain pathogens.
infection
Due to the small number of systematic studies of the influence of hos-
pital design and planning on hygiene, these feature only rarely in the
KRINKO recommendations.

References
Ron Sender, Shai Fuchs and Ron Milo, “Revised Estimates
for the Number of Human and Bacteria Cells in the Body“,
in: PLoS Biology 14 (8), 2016
WHO, “My 5 Moments for Hand Hygiene“, WHO Guide-
lines on Hand Hygiene in Health Care, 2009, https://
www.who.int/infection-prevention/campaigns/
clean-hands/5moments/en. Last accessed 5 March 2020
Leitlinie “Strategien zur Sicherung rationaler Antibiotika-­
Anwendung im Krankenhaus“, 2019, https://www.awmf.
org/leitlinien/detail/ll/092-001.html. Last accessed 5
March 2020

23 Healthcare-Associated Infections
Excursus 2 The causes of infectious hospitalisation, that is the infection of hospital
patients, staff or visitors by germs, include a lack of hygiene and higher

Material levels of residual contamination on surfaces with which patients come

into direct or indirect contact in healthcare facilities (Knoll 2000). By
taking appropriate measures it is possible to reduce the frequency of

Applications
nosocomial infections – infections that occur during a hospital stay – by
about one third (RKI 2000). To identify such appropriate measures, one
must consider all the conceivable chains of transmission of pathogens

and Material
(Boyce 2007). Contaminated or insufficiently clean surfaces can serve
as a reservoir for microorganisms and therefore represent a potential
path of transmission for nosocomial infections due to the long residence

Ageing in
time of many pathogens. To counteract this, hygiene-safe solid surfaces
should be used in hospitals. Solid surfaces are classed as being hygiene-
safe when they can be easily and effectively cleaned over their entire

Hospitals
lifetime. To assess this, one must consider the mechanical, chemical
and physical effects acting on a material in the intended area of appli-
cation. This article discusses the testing of different material surfaces
over their product lifecycle to ascertain how their properties change
Inka Dreßler, Katharina Schütt as they age. Through an appropriate choice of materials, the risk of
infection emanating from inanimate solid surfaces can be permanently
reduced. This is a key hygiene measure alongside a suitable cleaning
strategy, physical barriers and the implementation of an appropriate
hand hygiene infrastructure.

Material ageing
The property of a material changes over its lifetime. In most cases, mate-
rial ageing means a change in the material’s chemical composition and
physical structure (Pongratz 2005). These chemical, physical and also
mechanical ageing processes can be caused by various internal and exter-
nal factors. The internal influencing factors are specific to the material and
include its chemical composition or physical structure as well as possible
additives. Each material thus reacts differently to the external influencing
factors acting on it in the context of a healthcare environment to cause
ageing. These external influencing factors are essentially:
— chemical influencing factors (e.g. body fluids, disinfectants/cleaning
Initial condition of
the test specimen
agents, gases),
Artificial ageing
— physical factors (UV radiation, temperature), and
Mechanical Low/high — mechanical factors (static and dynamic surface pressure, for exam-
factors mechanical abrasion ple caused by rolling beds and trolleys).
Through the use of a specially developed artificial ageing programme,
UV radiation,
Physical
fluids, the key influencing factors can be simulated to determine the impact of
factors
temperature fluctuations material ageing on the cleanability of solid surfaces. To begin with, the
initial conditions of the samples were first recorded before they were
Chemical Low/high concentrations
factors of disinfectant exposed to an artificial ageing programme that simulates the extreme
boundary conditions found in hospitals in a time-lapse manner → Fig. 1.
Condition of the Firstly, the mechanical stresses caused by low or high mechanical abra-
test specimen sion were simulated. This was followed by artificial weathering, whereby
UV radiation, temperature fluctuation and liquid acted on the material
1 Artificial ageing programme for materials
surfaces. Finally, the materials were chemically stressed by exposing
them to low- or high-concentration disinfectant baths.

b 0.3 µm < d ≤ 0.5 µm b 0.5 µm < d ≤ 1 µm b 1 µm < d ≤ 3 µm Methods

Rª [µm] 5.0120 2.5161 1.4622
Cleanability refers to the ability of a solid surface to facilitate the removal
of (particulate) contamination. Cleanability depends essentially on
γs [mN/m] 0.2300 0.1390 0.1123
two surface properties: the shape deviation from an ideally smooth
Rª γs [µm mN/m] − 0.1291 − 0.0440 − 0.0111
surface (roughness, Ra [µm]) and the wetting properties (surface free
energy, γs [mN/m]). These parameters have the greatest influence on
2 Coefficients b for the system behaviour during
cleaning for different-sized contaminants in the range
the interaction between contamination and a surface and thus the
of 0.3 µm to 3 µm cleanability of a surface. The cleanability of surfaces can be described

24 Fundamentals
 by the quantity of residual particle deposits P [-] after a defined soiling
and cleaning process as follows

P = exp [ bi Rª + bj γs + bij Rª γs ] – k0

where b [-] is a system-specific coefficient b [-] and k0 = 0.1 is a constant.

The higher the value of P, the more difficult it is to clean the surface.
Different coefficients → Fig. 2 result for different sizes of particulate
contaminants and have a significant influence on cleanability (Dreßler
2018). This means that both an increase in roughness and an increase
3 Exemplary depiction of a micro-structured surface in surface free energy impair the cleanability of a surface. An increase
with the recorded surface profile (left) and contact in roughness in particular leads to a surface being less easy to clean
angle measurement (right)
effectively.
The solid surfaces tested were examined with a digital 3D laser
scanning microscope to determine the surface profile or line roughness
Test group Description of material → Fig. 3 left. To determine the surface free energy, the progressive con-
K Rubber flooring with post-crosslinked surface (factory-applied) tact angle → Fig. 3 right of three liquids on the samples is determined
H HPL board with melamine formaldehyde resin treated surface from which the surface free energy is calculated.

P PVC flooring with polyurethane surface coating

Material
Elastic floor coverings made of rubber or polyvinyl chloride (PVC) as well
4 Overview of the investigated material samples
as high-pressure laminates (HPL boards) were investigated → Fig. 4, all of
which are commonly used for many surfaces in various areas in hospitals.
Since they are used as flooring, laboratory worktops or the surfaces of
Sample Roughness Surface free energy patient headboards and furniture, patients, staff and visitors come into
Rª [µm] Ys [mN/m]
direct or indirect contact with them.
K1 1.16 33.56
Alongside the material’s composition, the nature of its surface is
H1 1.20 30.42
also important, as this is directly exposed to external factors and con-
H2 1.32 28.62 sequently influences the durability of the polymer. An overview of the
H3 0.91 29.04 roughness and surface free energy properties of all the material samples
H4 0.95 33.18 prior to artificial ageing is given in → Fig. 5.
H5 1.49 28.87 The various material groups exhibit different degrees of roughness
P1 0.87 30.98 with sample H5 exhibiting the highest and sample P1 the lowest rough-
ness. This can be attributed to variations in the profile of the material
5 Key surface properties of the samples prior to ageing surfaces. In general, all the tested material samples have a low surface
energy compared to glass or metals and can therefore be described
as low surface energy materials.

Results
The artificial ageing programme was employed to investigate the influ-
Normalised line roughness [%]
ence of material ageing on the cleanability of solid surfaces in the case
200 of particulate contamination and the results were evaluated using the
equation shown earlier. Physical factors (UV radiation, temperature
150
fluctuations, liquid influence) caused the greatest changes in the sur-
100 face properties, whereas hardly any changes resulted from mechanical
abrasion. Chemical exposure to disinfectants – especially with long
50
exposure times – intensified the ageing phenomena already present.
The artificial ageing programme was applied with exposure to
K1 K1 H1-5 H1-5 P1 P1 different degrees of mechanical abrasion (high and low) and physical
(low) (high) (low) (high) (low) (high)
factors and immersion in a low-concentration and a high-concentration
Intensity of mechanical disinfectant bath. The resulting changes in line roughness and surface
abrasion (low/high) free energy of the sample surfaces before and after the artificial ageing
programme are shown in → Figs. 6, 7. The changes of the respective
Before artificial ageing
property were normalised to be relative to the initial value. Since the
After artificial ageing with disinfectant bath A
material changes can be attributed to multifactorial influences, the
After artificial ageing with disinfectant bath B
changes in the parameters roughness and surface free energy caused
6 Change in line roughness after artificial ageing of the
by the artificial ageing programme are described using the example of
examined materials (normalised) the rubber sample K1.

25 Applications and Material Ageing in Hospitals

Normalised surface free energy [%] The roughness of the rubber sample K1 decreases, which can be
attributed to an oxidative ageing process, which manifests itself for
200 example in chalking or microcracks. The removal of the chalking pig-
ments through cleaning processes during the measurements led to a
150
reduction in roughness. The oxidative ageing process also causes an
100 increase in the surface free energy and thus the wettability of K1. The
low-concentration disinfectant bath also appears to have a greater effect
50
on the surface free energy of K1 compared to the high-concentration
disinfectant bath.
K1 K1 H1-5 H1-5 P1 P1
(low) (high) (low) (high) (low) (high) Residual particle quantity and cleanability
The residual particle quantity P̂ of the individual samples before and
Intensity of mechanical
abrasion (low/high) after the artificial ageing programme is shown in → Fig. 8 for the particle
size group 0.5 < d ≤ 1.0 µm. In this case the before and after results are
Before artificial ageing
shown without the individual effects of the mechanical abrasion and
After artificial ageing with disinfectant bath A
the different disinfectants. On average, the residual particle quantity
After artificial ageing with disinfectant bath B of all material groups increases, which means the materials are more
difficult to clean than before artificial ageing.
7 Change in surface free energy after artificial ageing
of the investigated materials (normalised)
The samples H1 and H2, in particular, exhibit a significant increase
in the quantity of residual particles and are therefore the most difficult
to clean in comparison. Samples P1 and H4 have the best cleanability
in comparison despite the increase in the quantity of residual particles.
Residual particle quantity [-]

1200 Conclusion
The test showed that the mechanical, chemical and physical influences
1000
common in healthcare facilities do affect the (surface) properties of
800 materials, resulting in a change in their cleanability properties and in
turn in the risk of possible infection caused by surface contamination.
600
Depending on the combination of influences, this need not necessarily
400 mean a deterioration of the properties. Each hospital operator must
decide what they deem to be an acceptable measure of change. Where
200
possible, hospitals should select materials that change as little as possi-
ble in the expected conditions they are exposed to. In this study, those
K1 H1 H2 H3 H4 H5 P1 materials were PVC or HPL boards with a corresponding supplementary
surface coating.
Before artificial ageing After artificial ageing

8 Mean change in the quantity of residual particles after

artificial ageing of the test materials (absolute) References
J. M. Boyce, "Environmental contamination makes
an important contribution to hospital infection",
Journal of Hospital Infection, 65, 2007, pp. 50–54
Inka Dreßler, Hygienesichere Oberflächen im nicht-­
immergierten System, PhD thesis, Technische Universität
Braunschweig, 2018
Karl Heinz Knoll, Hygiene in Gesundheitseinrichtungen.
Planung – Anlage – Bau – Ausstattung – Betrieb, Stutt-
gart: Wissenschaftliche Verlagsgesellschaft, 2000
Robert Koch Institut (RKI) and Statistisches Bundesamt,
2000, Nosokomiale Infektionen – Gesundheitsbericht­
erstattung des Bundes. Vol. 8, 2000
Sonja Pongratz, Die Alterung von Thermoplasten,
post-doctoral thesis, Friedrich-Alexander Universität
Erlangen-Nürnberg, 2005

26 Fundamentals
B
Typologies
of the
Patient
Room
The Floor
The design of patient rooms is a particularly demanding task that gener-
ations of architects, hospital planners and interior designers have grap-
pled with. The challenge is to accommodate a wide range of specific

Plan of a
needs and users’ interests in a room of limited size. Despite its small
floor area, the patient room is the most frequently reproduced unit in a
hospital and can quickly become the primary determinant for a hospital

Two-Bed
design. The repetition of the rooms in a ward is not only legible from
outside on the building’s façade; it can also define the typology, for
example in the case of a “bed tower block” through vertical repetition

Room
where the upper floors are typically exclusively patient wards. The
patient room is therefore a central element of the planning of a hospital.
This section discusses the planning principles for designing a two-bed
room and examines its constituent structural elements.
First and foremost, the design of a patient room is always a specific,
individual response to the existing needs and prevailing contextual
conditions. Whether the design is for a new building, for an extension
to an existing building or for the renovation and upgrading of existing
facilities, the context and the available budget are key determining
factors for the room design.
Likewise, regulations and guidelines have a direct impact on room
planning and floor plan design and can sometimes be very constrain-
ing by defining minimum distances and optimised care provision pro­
cedures that must be ensured without exceeding a certain room size
or financial parameters.
While this may create the impression that there is little remaining
scope for design, a wide range of different patient room designs have
been created over the past few decades. Architects and hospital plan-
ners have succeeded in developing and implementing various original
concepts, especially for two-bed rooms, often in the context of clinical
studies. A study of these room types reveals the entire spectrum of
design possibilities.
Two-bed rooms are a particularly interesting typology to study.
This chapter examines the different options in the design of a patient
room and the design principles that guide them. It details the design
possibilities available to the planner when designing a patient room and
presents them in a scheme with the aid of a corresponding example.
This study takes the floor plan as its basis and therefore describes
only those aspects that actually manifest themselves in or influence
the floor plan, and that can be seen as design principles. Likewise, it
also considers the essential fittings and equipment that influence the
room layout.
A key aspect that has a decisive impact on the floor plan design of
two-bed patient rooms is the wet cell – the patient’s bathroom within
the room. It determines the remaining layout of the patient room and
often also the placement of other key fittings within the room. To under-
stand how the different elements in the room interact, it is instructive
to look at each part of a room configuration and identify how these can
be grouped according to recognisable interdependencies or principles.

8 m²

1.2 m

8 m²
1.2 m

1Mindestanforderung
Minimum standard
barrierearm/-frei
2 Barrier-free/low-barrier

28 Typologies
 The Patient Room
The patient room is divided into an area for the patient and the corre-
sponding patient bathroom.

Floor area requirements

Minimum standard
3 Standard floor plan
While the hospital building regulations of many German federal states
Regelgrundriss prescribe only 8 m² per bed place, the State Office for Health and Social
Affairs in Mecklenburg-Vorpommern states that a two-bed room should
have an area of at least 21 m². In either case, the minimum distances
must be observed → Fig. 1.

Barrier-free/low-barrier standard
In the context of the floor plan, accessibility considerations primarily
concern spaces of free movement. At least one area of 120 × 120 cm
must be available for turning and swivelling, and walking and mobility
aids must be available in the room and additionally along one long side
4 Floor plan combination
of the bed (DIN 18040-2). As not all accessibility requirements can be
evaluated based on the floor plan, we use the term “low-barrier” to
Kombinationsgrundriss
denote the minimising of barriers → Fig. 2.

Floor plan types on a ward

Standard floor plan

The standard room layout is the most frequently found room type on
a ward → Fig. 3.

5 Floor plan variation Floor plan combination/variation

6 Specific floor plan Different floor plan types can be combined, e.g. single and two-bed
Variationsgrundriss rooms. In such cases a two-bed room may be a combination of two
Sondergrundriss
types or a modified variant of a floor plan layout → Figs. 4, 5.

Specific floor plan

Particular situations may require a specific, atypical floor plan arrange-
ment, such as in the case of corner rooms or rooms that connect to
other functional spaces. Where these are a response to structural con-
straints in the building plan, they typically recur at the same position
on each floor → Fig. 6.

Additive principles for patient rooms

7 Same-handed
Same-handed
The most common additive principle is a repeating row of patient rooms
along a ward corridor. Different repetition patterns are possible:

Same-handed
The same-handed configuration is the simplest form of the additive
repetition of rooms along a hospital corridor. Each room is identical in
its orientation and fittings. The name derives from the underlying prin-
ciple that carers can always tend to patients from the same preferred
side → Fig. 7.

8 Mirrored floor plan

Grundrissspiegelung

29 Floor Plan
 Mirrored floor plan
Each patient room and the orientation of fittings and equipment is
mirrored along the dividing wall. This configuration is popular because
it allows a common vertical duct to serve two adjacent wet rooms,
effectively halving the amount of plumbing and supply lines, saving
materials and costs. The repetition principle is like that of the same-
handed configuration, except that each repeated unit comprises two
9 Floor plan combination rooms with mirrored layouts → Fig. 8.

Grundrisskombination Floor plan combination or variation

With this configuration, a room layout may be combined with another
typological variation of the same floor plan, or alternatively a com-
pletely different floor plan type. This pairing is then repeated as often
as needed → Figs. 9, 10.

Unsystematic arrangement
In some cases, the additive principle follows no clear pattern. The posi-
tion of necessary functional rooms, or the unique structural configuration
10 Floor plan variation
of a building may hinder the application of a clear repeating arrange-
ment. In such cases, varying room layouts are typically used → Fig. 11.
Grundrissvariation

Room depth

The room depths given here are defined in terms of the bed placement
principle rather than a precise dimension. There are two main arrange-
ments for two-bed rooms:

One bed deep

The room depth is defined by the placement of one bed arranged parallel,
orthogonal or rotated at an angle to the ward corridor → Figs. 12, 13.
11 Unsystematic arrangement
Two beds deep
The depth of the room must accommodate two beds placed along the
Unsystematische Anordnung
crosswall, positioned parallel, orthogonal or rotated at an angle to the
ward corridor → Figs. 14, 15.

1 Room geometry
2 2
Any number of room geometries are conceivable for patient rooms,
but not all are practical or realisable. The key determining factors are
their potential for useful repetition and their contribution to forming
Ein-Bett-Tiefe
1 14, 15 Two beds deep a ward. Rectangular floor plans are therefore predestined, but various
Zwei-Bett-Tiefe
room Zwei-Bett-Tiefe hospitals show that other, more complex floor plan configurations are
also possible. This results in two typical types of room geometry:
12, 13 One bed deep
room
Compact spatial geometry (rectangular)
Ein-Bett-Tiefe A rectangular floor plan is compact and simplifies the arrangement of
fittings and equipment in the room → Fig. 16.

Complex spatial geometry (polygonal)

A polygonal or non-rectangular floor plan figure can be applied for
specific situations, for example to ensure optimum visibility of the bed
area from the ward corridor. As most standardised fittings and objects,
such as patient cabinets and tables, are rectangular, their placement is
more complex. In some cases, custom-made fittings may be necessary
→ Fig. 17.

Kompakt Komplex
16 Compact spatial 17 Complex spatial
geometry (rectangular) geometry (polygonal)

30 Typologies
 Zoning

The zoning of a room designates the respective areas of the patient

room in which the different users of the room remain, move around in
or which they use actively. A room’s users include the hospital staff, the
patient and their visitors.
For two-bed patient rooms, there are three necessary zones:
— Movement zone and transport,
— Patient and patient care zone, and
— General activities and visitors’ zone.
18 Three-zone
room
Drei Zonen 19 Three-zone While these zones may overlap, they should not fall completely within
Drei-Zonen-Plus
plus room the scope of another zone. Given the small area of a two-bed room, the
placement of furniture and standard room fittings often determines the
zoning. Three typical zoning options are outlined below. The diagrams
provide an abstract indication of the zoning principles without showing
the movement spaces of each user group.

Three-zone room
The three-zone floor plan is the classic arrangement of a two-bed room.
It comprises a movement area for the staff, a patient and patient care
zone and a general activity zone for patients and visitors → Fig. 18.
20 Three-zone
plus room
Drei-Zonen-Plus 21 Two-zone Three-zone plus room
room Where there are more than three zones, one speaks of a three-zone
Zwei Zonen
plus room layout. Additional zones can include, for example, a balcony
for the patients → Fig. 19. A special variant of the three-zone plus room
layout occurs when one of the three zones, for example the patient
zone, is subdivided into two → Fig. 20.

Two-zone room
Given the limited space for movement in two-bed rooms, there is
inevitably some overlap of the different users’ zones. But when the
visitor zone, for example, falls entirely within the staff movement areas
23 Two entrances
(see the example), a three-zone arrangement no longer applies → Fig. 21.
22 Single entrance

Zwei Türen
Eine Tür Room entry

Room entry denotes the means of entrance from the ward corridor,
typically through one or two doors. Most two-bed rooms have a single
entrance → Fig. 22; however, some room layouts may have a separate
entrance for each patient. This also provides a better view of the patient
from the corridor → Fig. 23.

Ward corridor

The floor plan of the patient room can influence the form of the ward
corridor and thus also defines the nature of the threshold between the
hospital and patient room, and between everyday hospital operations
and the patient. While the precise articulation can vary, there are two
24 Patient room flush with the ward corridor main variants:
Flurbereich bündig mit Patientenzimmer

Patient room flush with the ward corridor

The serial repetition of patient rooms produces a flush wall along the
ward corridor → Fig. 24.

31 Floor Plan
 Ward corridor with alcove in front of patient room
By setting back part of the patient room, or the wet cell, in the floor
plan, an alcove in front of the room can be created that acts as a buffer
space to the ward corridor → Fig. 25.

Flexibility

Patient room floor plans are often so spatially optimised that the room
zones and elements can seem rigidly defined. However, a degree of
flexibility is often beneficial for use and positive for the room’s atmos-
phere. The following measures can contribute to a room’s flexibility:

25 Ward corridor with alcove in front of patient room Bedside trolley positionable on both sides
Vorbereich vor Patientenzimmer The bedside trolley can be positioned on either side of the bed without
obstructing access to nearby cupboards → Fig. 26.

Retrofittable airlock
Even in standard care wards, there may be a need to isolate patients
with contagious pathogens. In most cases, however, improvised ISO
rooms do not meet the requirements to function effectively as a means
of infection prevention: many entrance areas that are retrofitted to act
as an airlock zone or anteroom are too small to be divided into separate
clean and unclean zones. In addition, the airlock may block access to
the patient bathroom from within the room. Even though airlocks are
27, 28 Retrofittable airlock
not a requirement of standard care wards, provisions for temporarily
Eingang schleusentauglich
Eingang schleusentauglich retrofitting a patient room with an airlock can still be made in the room
26 Bedside trolley positionable
Nachttisch beidseitig positionierbar design → Figs. 27, 28.
on both sides of bed

Fittings

While it is not possible to exhaustively list all the fittings in a patient

room, certain aspects and elements are common to nearly all patient
rooms. All of them can exist alongside one another in a room.

Standard fittings
In addition to the patient beds, the standard fittings include a bedside
table or trolley, lockers or cupboards for patients’ belongings and a
table and at least two chairs for receiving visitors → Fig. 29.

Staff workplace in patient room

A washbasin or other worktop for all activities relating to care, prepa-
ration and documentation of the patient may be provided for use by
nursing staff. This can also include a cupboard or storage area specifi-
30 Staff workplace in
29 Standard fittings patient room cally for storing medical supplies and aids. A glove box and disinfectant
Standardausstattung Arbeitsbereich für Personal dispenser, as well as additional storage space is often also part of the
staff work area → Fig. 30.

Washbasin in patient room

In addition to hand disinfection, clinical practice may require staff to
wash their hands to remove coarse dirt. In the past, fitted washbasins
in patient rooms unfortunately contributed to the spread of pathogens
and nosocomial outbreaks. We list them nevertheless as they are still
planned for patient rooms in new buildings → Fig. 31.

32 Typologies
 Privacy screen between patients
A movable privacy screen in the form of a curtain or partition can screen
patients from their neighbours, for example when examinations need
to be undertaken in the room → Fig. 31.

Patient desk
A separate desk for patients – ideally one per patient – can add another
personal space for the patient(s) in the room, sometimes obviating the
need for a desk for receiving visitors → Fig. 32.

Guest accommodation
32 Patient desk This typically takes the form of furniture designed to allow next of kin
to stay the night in the patient’s room. Fold-out furniture, for example,
31 Washbasin in patient room
and privacy screen between Schreibtisch für Patienten
can serve as seating during the day and as a bed for relatives at night.
patients & Waschbecken
Sichtschutz This is most commonly found in children’s wards → Fig. 33.

Openings in the façade

The façade is the interface between the patient and the outside world.
It allows light into the room, creates a visual connection to the world
outdoors and can serve as a spatial extension of the patient room.

Room with window and standard sill

A conventional window with one opening casement → Fig. 34.

Room and bathroom with window and standard sill

An outboard bathroom (placed on the exterior wall) may have its own
additional window → Fig. 35.

Room with window and seat-level sill

A window with a lower sill height can be used as seating through the
33 Guest accommodation insertion of a bench into the window reveal. In most cases the window
Gästeunterbringung sections are fixed, or only certain sections can be opened → Fig. 36.

Internal façade extension

Indentations or projections in the façade can be used to create bay
windows or conservatories that provide an internal transitional space
between the rooms and the world outdoors → Fig. 37.

External façade extension

External extensions to the façade are outdoor fresh-air areas such as
34 Window with 36 Window with balconies, terraces and loggias → Fig. 38.
standard sill seat-level sill
Fenster mit Standardbrüstung Fenster mit Brüstung als Sitzbereich
35Bad
Bathroom with
mit Fenster
window

37 Internal façade
interne Fassadenerweiterung externe
38Fassadenerweiterung
External façade
extension
extension

33 Floor Plan
 Bed positions

Bed positions describe the spatial relationship between the beds.

Parallel
40 Opposite one another
The beds are positioned next to each other in a parallel arrangement,
creating a two beds deep room → Fig. 39.
39 Parallel gegenüber

nebeneinander
Opposite one another
The beds are placed facing each other directly opposite one another
in a one bed deep room → Fig. 40.

Staggered opposite one another

The beds are placed facing each other but offset in a staggered arrange-
ment → Fig. 41.
41 Orthogonal

Orthogonal
orthogonal 42 Staggered opposite
The beds are arranged at right angles to each other, irrespective of the
one another
gegenüber versetzt
depth of the room → Fig. 42.

Turned towards each other

The beds can also be turned to face each other at an angle, again irre-
spective of the depth of the room → Fig. 43.

Facing apart
44 Facing apart The head ends of the beds can be turned to face away from each
other, so that neither sees the other. This can be further reinforced by
ohne Blickbezug a headwall separating the two → Fig. 44.
43 Turned towards
each other
zueinander gedreht
Views in and out of the room

Two visual connections play a key role in the spatial configuration of

patient rooms:

Patients’ view outside

This denotes the view the patient has of the window and in turn of the
world outdoors. The room design should ensure that both patients have
45 Equal view an equally good view → Figs. 45–47.

gleichwertig 46 Relatively 47 Unequal view

equal
relativ view
gleichwertig
Staff’s view of the patient
nicht gleichwertig
Ideally, the placement of the beds should ensure that patients are imme-
diately visible from the doorway when the door is opened. In some
cases, however, only one patient can be seen clearly while a view of
the second is restricted. In some countries it is common to see glazed
sections in the room doors of standard care wards so that staff in the
corridor have a clear view of the patients in bed → Figs. 48–50.

50 Neither patient
visible
Beide for staff
Patienten verdeckt

48Patienten
Beide Both patients
sichtbar Ein49
Patienten sichtbar
One patient
visible for staff visible for staff

34 Typologies
 1.2 m
Patient Bathroom
Floor area of wet cells

The floor area of wet cells is determined largely by requirements for

51 Minimum standard
52 Barrier-free/low-barrier freedom of movement and minimum distances within the patient bath-
Mindestanforderung room. In this study, we classify them into two groups:
Barrierearm/-frei

Minimum standard
The bathroom complies with the prescribed minimum distances
between the individual bathroom components and the passage width
of the door, but this does not guarantee barrier-free access → Fig. 51.

Barrier-free/low-barrier standard
In terms of the floor plan, the focal consideration is the provision of
sufficient freedom of movement. An area of at least 120 × 120 cm must
be provided in front of sanitaryware such as the toilet bowl, wash­
basin, bathtub and shower area (DIN 18040-2). As not all accessibility
53 innenliegend
Inboard 54außenliegend
Outboard
requirements can be evaluated using the floor plan, we use the term
“low- barrier” to denote the minimising of barriers → Fig. 52.

Position of wet cells

In this study, we only evaluate two-bed rooms that comprise a wet room.
Within these units, the position of the wet room is of central importance
as it determines the remaining disposition of the floor plan. Four basic
configurations are commonly used:

55 Alternating inboard/outboard Inboard

innen- und außenliegend im Wechsel An inboard wet room is placed next to the room entrance adjoining the
corridor and is the standard and therefore most common arrangement
seen in hospitals → Fig. 53.

Outboard
An outboard wet room is located along the exterior wall. This much less
common arrangement reduces the size of the window opening of the
two-bed room, and thus limits the degree of light entering the room
but has the advantage of being able to naturally ventilate and illuminate
56 Nested the bathroom → Fig. 54.
nested
Alternating inboard/outboard
Inboard and outboard wet cells can be employed alternately in a row
of rooms with the room constellation switching. Alternatively, one room
can have two bathrooms → Fig. 55.

Nested
In the nested arrangement, two bathrooms are placed between two
patient rooms. This has the advantage of allowing the patient rooms to
be open and rectangular. A minimum planning unit therefore comprises
two patient rooms and two intermediate wet cells → Fig. 56.

35 Floor Plan
 Additive principles for wet cells

Additive principles apply equally to the serial repetition of wet cells

as they do to the patient rooms. Although the bathroom arrangement
is linked to that of the patient rooms, it is not identical and therefore
57 Same-handed
warrants its own consideration. The following patterns of repetition
apply to patient bathrooms and echo those of the patient rooms
Same-handed described earlier.

Same-handed
The size, orientation and fittings of the wet rooms are identical through-
out the ward. Because of the identical layout, carers can always approach
patients from the same side → Fig. 57.

58 Mirrored floor plan Mirrored floor plan

The wet cell and the orientation of fittings and equipment within it are
Spiegelung
mirrored along the dividing wall. As previously mentioned, this config-
uration is encountered frequently because it allows a common vertical
duct to serve two adjacent wet cells, effectively halving the amount of
plumbing and supply lines, saving materials and costs. The repetition
principle is like that of the same-handed configuration, except that
each repeated unit comprises two cells with mirrored layouts → Fig. 58.

59 Floor plan combination

Floor plan combination or variation
Kombination
With this configuration, two different wet room configurations are used
in combination within a row. Alternatively, variations of a single type
of bathroom are also possible, for example when additional require-
ments need to be met or the size or equipment is adapted to meet a
specific need (e.g. rooms for obese patients) or where modifications
are necessary for design reasons → Figs. 59, 60.

60 Floor plan variation Use of wet cells

Variation Bathrooms may be used by patients in different ways.

One bathroom for shared use

A two-bed room usually has a single shared bathroom, which is about
3–4 m² in size → Fig. 61.

Two bathrooms for shared use

Two bathrooms in a patient room can be equipped differently to serve
two different purposes. They are used by both patients → Fig. 62.
61 One bathroom for shared use
Eine Nasszelle - Gemeinsame Nutzung
Two identical bathrooms for separate use
In this configuration, two identical bathrooms are created, one for each
patient → Fig. 63.

62 Two bathrooms for shared use

Zwei Nasszellen - Gemeinsame Nutzung

36 Typologies
 Fittings in wet cells

Fittings are all essential components and equipment in a patient bath-

room that influence the layout.

Standard fittings with shower

Wet cells with a washbasin, toilet and shower are now standard fittings
in general care wards in German hospitals, but that is a relatively recent
63 Two identical bathrooms for separate use
Zwei Nasszellen - Getrennte Nutzung
development. Patient toilets are still often located in the corridor and col-
lective shower rooms or a ward bathroom are still permissible → Fig. 64.

Second washbasin
In addition to the standard fittings, an additional washbasin is provided
so that each patient has their own place to wash → Fig. 65.

Second WC
In such configurations, each patient has their own WC, regardless of
64 Standard fittings 65 Second washbasin the number of bathrooms.
with shower
Standardeinrichtung Zwei Waschbecken
Sliding door
A sliding door as access to the bathroom can be employed in floor
plan arrangements where conventional hinged doors would lead to
overlaps in the use of space → Fig. 66.

66 Sliding door

Schiebetür

37 Floor Plan
Qualitative
In this section, we examine the various options for the floor plan design
and its constituent elements and evaluate each in turn with respect to
their characteristics and possible impact.

Evaluation
As part of the KARMIN research project, presented in detail in Part C
of this book, we undertook a series of surveys and workshops to ascertain
the significance of the individual design options in everyday hospital

of Two-Bed
practice. Our assessment is therefore based on interviews with experts,
observing staff in hospitals, research and relevant literature. The inter-
views were conducted with professionals and staff at all levels: doctors,

Rooms
nurses and nursing managers, cleaning staff, architects and designers,
hygiene specialists and employees of hospital product manufacturers.
To include the patients’ perspective, we also talked to people not
professionally involved in the health sector, such as senior citizens.
The statements and insight gained from our survey are grouped into
six main categories:

1. Structural complexity
2. Infection prevention potential
3. Workplace quality and safety
4. Spatial qualities
5. Patient safety
6. Patient satisfaction and privacy

These six categories describe important criteria or qualities that must

always be taken into account when planning a patient room and that
are therefore particularly relevant, not least because they impact on
the interests of all the users and people involved in a patient room.
We shall examine each of these six qualities in turn and identify
which of the above design options contribute to them and why. Those
design options not mentioned under a particular quality are accordingly
of no consequence for that quality.

1. Structural complexity

Structural complexity concerns all principles and floor plan features that
in practice give rise to additional construction and/or design require-
ments. The respective floor plan is compared against a solution that
has been optimised in its construction and economic efficiency. If one
or more of the design options make its design or construction more
difficult or even disadvantageous, the floor plan is regarded as being
structurally complex.

Barrier-free/low-barrier interior design

In principle, barrier-free accessibility should be the norm. However, due
to their larger space requirements for movement and spacing distances,
barrier-free rooms are larger, and fewer can be realised on one floor.
Unfortunately, many designs therefore only observe minimum spacing
distances. The additional requirements for barrier-free room design add
to the complexity of the design task.

Additive principle: floor plan combination/variation

The coupling of at least two different floor plan types in an additive
sequence of rooms is often employed in the context of an overall façade
concept. The need to plan at least two room types with fittings and fur-
nishings in different orientations increases the duration and complexity
of the design task.

38 Typologies
 Additive principle: unsystematic arrangement of rooms Barrier-free/low-barrier interior design
Where the constraints of the planning context hinder the use of a regular Dimensioning rooms to afford barrier-free or low-barrier accessibility
arrangement of rooms, for example as a result of predefined functional allows patients with mobility impairments to move around independently,
rooms or specific building forms, designers need to develop custom reducing the degree of assistance required and in turn the degree of
room variants. This requires more planning time and results in a lower direct, unrestricted contact between staff and patients.
degree of prefabrication of individual room elements.
Same-handed room configuration
Complex room geometry (polygonal) When rooms are identical in their arrangement, staff and patients do
Non-rectangular building elements are more complex to design and not need to adjust and reorient when switching rooms. Care provision
manufacture than rectangular forms. It is likewise harder to incorpo- procedures are more predictable in their choreography and can be
rate standardised rectangular furniture into room layouts with complex optimised accordingly. Errors resulting from changing situations can be
spatial geometries. Irregular room shapes therefore typically entail avoided, improving compliance with regulations among nursing staff.
custom-designed fittings and furnishings co-developed by architects
and other planners, increasing the complexity of the design task. Three-zone room/three-zone plus room
When each user has their own, clearly legible zone, physical contact
Two room entrances between users (e.g. at pinch points) can be minimised.
A single point of entry is suitable for all room layouts while a patient room
with two entrances introduces additional spatial constraints that impact Alcove in front of patient room
on the rest of the room configuration. Two entrances also require more An alcove in front of the entrance to the patient room creates more dis-
circulation space and result in additional costs for the door opening, tance between the patient and the ward corridor for isolated patients.
the door and its associated fittings. Additional protective equipment can be placed outside the room and
further disinfectant dispensers can be attached without causing obstruc-
Alcove in front of patient room tion or injury. Similarly, disposed material is kept away from the corridor.
Alcoves in front of the patient rooms result in greater floor areas for
circulation and additional wall surfaces compared to straight, flush Retrofittable airlock
corridor walls. The result is higher costs for materials and production. The ability to retrofit or temporarily create an airlock in the case of a
nosocomial outbreak can be an effective built means to reduce the
Retrofittable airlock transmission of infection.
Designing a floor plan to accommodate retrofitting with an airlock adds
functional flexibility but introduces constraints at a structural level as Staff workplace in patient room
the entrance area must be planned to be convertible into an anteroom. If supplies and equipment for nurses and nursing care are located within
the room instead of being brought in on a supplies trolley, staff can care
Internal or external façade extension for the patients more directly and work processes can be planned and
Providing the patient room with an additional area inside or outside the optimised.
façade, such as a winter garden, bay window or balcony, is a fundamental
design decision that affects the entire building design. Compared with a External façade extension
regular outside wall with windows, it requires additional planning work A balcony or loggia makes it easier for patients to go outside. Fresh air
and entails higher costs. can help reduce the patients’ germ load.

Bathroom with window Bathroom with window

Placing the bathroom on the external wall with an outside window A naturally ventilated bathroom adjoining the building’s façade can
increases the number of openings in the façade to be planned, constructed contribute to a better room climate and counteract the spread of germs.
and installed, and with it the cost of construction. Where prefabricated wet
cell modules are used, the opening in the module must be coordinated Beds not placed next to each other
with the façade design, entailing increased planning work. Placing the beds further apart reduces the potential of infection trans-
mission between patients in a two-bed room. It likewise promotes staff
Two identical wet cells for separate use compliance with regulations by reducing the risk of staff tending to each
The positioning of two wet cells in a two-bed room determines much of patient in turn without disinfecting their hands.
the zoning of the rest of the patient room and their production inevitably
involves higher manufacturing costs. Beds clearly visible to staff
If a patient is clearly visible to staff from the door, they are able to mon-
2. Infection prevention potential itor patients better and respond quickly in the case of an emergency.
It likewise deters patients and visitors from activities detrimental to
This criterion describes the potential of the various built measures their recovery.
to prevent or limit the transmission of infection between patients or
between staff and patients. Built measures can also promote compliance
among hospital staff. The following design options have the potential
to prevent the transmission of infection.

39 Qualitative Evaluation
 Barrier-free/low-barrier bathroom Retrofittable airlock
Bathrooms dimensioned for barrier-free or low-barrier accessibility allow Floor plans that accommodate retrofitting with an airlock already
patients with mobility impairments to use the bathroom independently anticipate the need for an anteroom where additional personal protective
and conduct their own personal hygiene. Where necessary, staff can equipment can be accommodated. In addition, preventing door swings
assist in the room rather than transporting high-risk patients to a ward from clashing in room entrances reduces the risk of accidental injury.
bathroom.
Staff workplace in patient room
Same-handed wet cell configuration A workplace for staff in the room with all necessary supplies and equip-
The identical arrangement of objects in a patient bathroom means that ment to hand avoids the need to transport necessary aids from room
staff and patients do not need to adjust and reorient when switch- to room in the ward on a supplies trolley.
ing rooms. The choreography of hygienic care and assistance can be
planned and optimised accordingly. Procedural errors resulting from Washbasin in patient room
changing situations can be avoided. In addition to hand disinfection, a washbasin in the room allows staff to
also wash their hands to remove dirt.
Two identical wet rooms for separate use
Where each patient has a patient bathroom of their own, the risk of Beds not placed next to each other
infection transmission through jointly used sanitaryware can be mini- When beds are placed further apart, staff caring for a patient cannot
mised. In addition, contamination in one sanitary cell does not neces- unintentionally come into uncontrolled contact with the neighbouring
sarily transfer to the other cell. patient. This also helps minimise the risk of infection transmission.

Second washbasin Beds clearly visible to staff

The installation of a second washbasin reduces the risk of infection If patients can be seen clearly from the entrance to the room, staff can
transmission via the surfaces of the washbasin or tap. monitor patients without having to walk fully into the room, saving
time and energy.
Second WC
The installation of a second WC reduces the risk of infection transmission Barrier-free/low-barrier bathroom
via the surfaces of the toilet or flush button. If a patient bathroom and WC is sufficiently accessible for patients, staff
no longer need to transport patients to a suitable bathroom on the ward.
3. Workplace quality and safety
Same-handed wet cell configuration
All aspects that improve the working conditions and work processes of When bathroom fittings are identically placed in each room, staff do
hospital staff (e.g. doctors and nurses) contribute to workplace quality. not need to readjust from room to room, saving time and making care
Workplace safety is improved by preventing the risk of injury and reducing procedures easier.
avoidable contact situations between staff and patients or visitors.
Standard fittings with shower
Barrier-free/low-barrier interior design When a patient can wash and conduct personal hygiene in their own
Accessible patient rooms allow people with limited mobility to be as bathroom, staff do not need to transport or accompany them to showers
independent as possible in their room, reducing the degree of assistance or a bathroom on the ward.
required and the physical strain and stress on care staff.
Bathroom with sliding door
Same-handed room configuration A sliding door to the bathroom reduces the risk of injury caused by doors
When patient beds and fittings are always in the same place in every slamming open or shut. Sliding doors also make it easier to simultane-
room, staff can act immediately without needing to adjust to changing ously assist a patient and operate the door.
room configurations.
4. Spatial qualities
One bed deep room
In one bed deep rooms, patients are closer to the door so that staff This describes all the spatial qualities of a patient room that can be
have shorter distances to walk. Removing or bringing a bed is likewise deduced from the floor plan and covers all aspects that contribute to
easier as the beds are both near the entrance. a room’s potential spatial quality. Compliance with design standards
and the room proportions can provide a sense of the space, even when
Three-zone room/three-zone plus room the actual spatial effect cannot be described by the floor plan alone.
Where room zones for each user are clear and legible, physical contact
when moving about the room can be avoided, for example during bed Barrier-free/low-barrier interior design
transport. Staff can move independently of other room users. A room in which the individual items of furniture are placed further
apart for better barrier-free access will also appear more spacious and
Bedside cabinet positionable on both sides less cramped.
The ability to move the bedside trolley to the other side of the bed
makes it easier to carry out medical care procedures.

40 Typologies
 One bed deep room 5. Patient safety
Rooms that are only one bed deep have more balanced proportions.
Less deep rooms are generally better illuminated and therefore feel This encompasses all measures aimed at maintaining patients’ physical
lighter and brighter. safety by avoiding the risk of injury and restricting unnecessary exposure
to other user groups. These illustrate how design decisions, room
Three-zone room/three-zone plus room fittings and the layout of the patient room can impact on patient safety.
Clear zoning lends rooms a sense of clarity and legibility and suggests
immediately how they might be used. Barrier-free/low-barrier interior design
As rooms designed for barrier-free or low-barrier accessibility facilitate
Alcove in front of patient room freer movement, the risk of injury from bumping into things or falling
Ward corridors are divided into areas with different functions. Alcove is reduced.
areas in front of the patient rooms provide a more sheltered buffer to
the sometimes hectic activities in the ward and also give each room Same-handed room configuration
its own “address”. A same-handed room layout across a ward allows patients to find their
orientation quickly should they be moved to another room for medical
Bedside cabinet positionable on both sides reasons. Conversely, changing room configurations can confuse patients
The ability to position the bedside trolley on either side of the bed with dementia or other impairments, leading to the risk of injuries or falls.
affords the room greater flexibility. Conversely, a room where everything
has a fixed position appears more static. One bed deep room
The incidence of accidents or falls is particularly high between the bed
Room with window and seat-level sill and the bathroom. The distance to the bathroom is typically shorter
Locating a seating area in the depth of the window opening or next and thus safer in rooms that accommodate the depth of one bed than
to it makes optimum use of the window as a threshold to the world those with two beds arranged behind one another.
outdoors, while also minimising the spatial impact on the room. The
lower sill height also means the window is larger so that patients lying Three-zone room/three-zone plus room
in bed have a better view of the world outside. Clearly legible zones for the room’s different users minimises collisions
between patients and other room users.
Internal and external façade extension
Every external area or projection of the façade represents an exten- Two room entrances
sion of the space of the room for the patients’ and visitors’ use. The Two room entrances lessen the probability of injuries arising through
traditional notion of the hospital as rows of rooms behind windows is doors unexpectedly opening.
broken down by the façade extensions, which add elements familiar
from domestic environments. Alcove in front of patient room
An alcove can be used to hold additional protective equipment or other
Bathroom with window protective precautions for patients in isolation and also acts as a buffer
A daylit bathroom has a positive effect on the atmosphere of the room. between the room and the corridor and other patients. On leaving
the room, a patient can first safely find their bearings and assess the
View outside situation before embarking down the ward corridor and is not forced
For patients who spend most of the day lying in bed, the view outside is to suddenly evade unexpected oncoming traffic.
their primary means of contact with the outside world during their stay.
It is therefore especially important that both patients have an equally Retrofittable airlock
good view from their respective beds out of the window. Rooms that can be retrofitted with an airlock must ensure that the
bathroom is accessible from the patient room and that the entrance
Barrier-free/low-barrier bathroom area can be divided off. The separate placement of the doors therefore
More generous spacing between the elements of a bathroom improves avoids collisions between opening doors and is safer for patients.
its sense of space and and makes it appear less cramped. A floor-flush
shower tray heightens this effect, visually enlarging the room. Staff workplace in patient room
A staff work area within the room with essential supplies and equipment
Nested wet room configuration to prevent the transmission of infections contributes to patient safety.
When the wet cells are grouped together and arranged between the
rooms, the rooms themselves appear more spacious. The bathroom Beds not placed next to each other, but in sight of one another
does not obstruct the view out or of the entrance area. Placing beds further apart within a room reduces the risk of infection
transmission between patients. However, if they also remain within sight
Bathroom with sliding door of one another, both patients benefit from the ability of the other to call
Eliminating door swings creates more room for movement and fewer for help in the event of an emergency.
obstructions for all the room’s users.

41 Qualitative Evaluation
 Beds clearly visible for staff Three-zone room/three-zone plus room
If patients can be seen clearly from the door, staff are able to monitor Clear zoning within the room makes non-intrusive movement in the
patients more easily and can react quickly if needed. room easier and avoids different zones having to overlap. As a result,
each patient has a degree of personal space.
Barrier-free/low-barrier bathroom
The greater room for movement in a barrier-free bathroom as well as Two entrances
the additional grab rails help patients use the bathroom more safely. A separate entrance for each patient means that patients do not need
to feel obliged to respond to everyone who enters. This can potentially
Same-handed wet cell configuration reduce stress levels.
As with same-handed room layouts, a consistent bathroom layout
allows patients to find their bearings easily should they need to move Alcove in front of patient room
to another room for medical reasons. Patients with dementia or other As a spatial buffer between the patient room and the corridor, an alcove
impairments can find a new situation challenging and disorientating, adds a layer distancing the public activities on the hospital ward from
increasing the risk of collisions or falls. the comparative privacy of the patient room.

Two identical bathrooms for separate use Bedside cabinet positionable on both sides
Separate bathrooms for each patient reduce the risk of infection trans- The ability to freely position the bedside trolley on either side of the bed
mission via common contact surfaces or mix-ups between the patients’ allows patients to determine their immediate surroundings according
items such as towels. to their preferences, for example if they are left- or right-handed.

Standard fittings with shower Staff workplace in patient room

The ability of a patient at risk of infection or who is themselves infectious A place where staff can prepare care procedures in the room avoids
to wash in their own room avoids the need for them to be exposed to the need for a supplies trolley to be wheeled right up to the bed. The
hospital operations or use a ward bathroom used by other patients. staff workplace also ensures that distance is maintained quite naturally
between the staff and the patients.
Second washbasin/WC
Two washbasins or toilets reduce the risk of infection transmission Privacy screen between patients
between two patients via jointly used sanitaryware that tends to have A movable privacy screen such as a curtain or a partition offers a patient
a high bacterial load. the possibility to screen themselves from their fellow patients or other
visitors when privacy is required.
6. Patient satisfaction and privacy
Patient desk
This criterion encompasses all design measures that contribute to the A separate desk enhances the sense of having personal space and can
patients’ well-being and satisfaction. Means of improving privacy are encourage patients to engage in cognitive activities such as crossword
particularly important as this study assumes that to feel comfortable puzzles, reading newspapers or writing letters.
each patient in a two-bed room requires a sense of relative privacy.
Guest accommodation
Barrier-free/low-barrier interior design The possibility for relatives to stay overnight in the hospital room can
Barrier-free or low-barrier patient rooms enable patients with mobility contribute immeasurably to a patient’s well-being.
impairments to move around without needing the assistance of staff,
contributing to their sense of independence and self-assurance. Room with window and seat-level sill
A dedicated seating area adjoining the window can offer a personal
Same-handed room configuration corner to sit set apart from the bed. A bench-level sill height also means
In contrast to the mirrored floor plan, the head ends of the beds in two the window is larger so that patients lying in bed have a better view
same-handed adjacent rooms do not adjoin the same dividing wall. of the world outside.
As supply lines and connections are not situated on both sides of the
same wall, noise transmission through the wall is avoided. And because Internal and external façade extension
the distance between the beds in neighbouring rooms is greater, the For patients with impaired mobility, access to an outdoor area can be
noise level is also lower. As noise is known to be a major stress factor an important substitute when they are unable to go outdoors in the
for patients, reducing the impact of noise contributes significantly to fresh air. In addition, conservatories, bay windows and balconies are
patient well-being. elements that lend a homely character to a patient room.

One bed deep room Bathroom with window

By positioning the beds on a separate wall surface of a one bed deep A daylit bathroom and the ability to naturally ventilate the room likewise
room, each patient has their own corner of the room, contributing to lends a patient bathroom a more homely character.
the patients’ sense of privacy.

42 Typologies
 Beds not placed next to or opposite each other
Placing the beds as far apart as possible, for example positioning each
along a separate wall, creates a separate area of the room for each
patient.

View outside from the bed

A view of the window that does not encroach on the privacy of the
fellow patient allows both patients to retain a sense of privacy and
prevents one or the other from feeling as if they are at a disadvantage.

Barrier-free/low-barrier bathroom
A barrier-free bathroom can enable a patient to wash independently
without additional assistance from nursing staff, allowing them to main-
tain a sense of personal privacy.

Inboard wet cell configuration

The inboard arrangement of the bathroom along the corridor wall means
that the beds are further away from the entrance. Patients feel less
exposed when staff or visitors enter the room and are also further away
from the noises of the ward corridor beyond.

Same-handed wet cell configuration

As with the room itself, the fact that with a same-handed configuration
two bathrooms in adjacent rooms do not lie either side of the same
wall reduces noise transmission and contributes to a sense of patient
satisfaction.

Two identical bathrooms for separate use

Separate bathrooms allow each patient to have a place of retreat where
they can feel undisturbed.

Standard fittings with shower

A shower in the room means that patients do not need to use ward
bathrooms or collective showers.

Second washbasin/WC
A sense of relative privacy can be heightened when each patient has a
separate washbasin or a separate toilet.

A note on the evaluation and assessment of qualities

In clinical practice, other dependencies and causal relationships will no

doubt arise that do not correspond entirely with our evaluation in this
study. In cases where there are good reasons for or against a certain
classification, we have either taken a specific standpoint or refrained
from making any classification. Similarly, factors that could be included
but do not impact directly on the ground plan have been excluded. In
all of the evaluation categories described, we start from the assumption
References
that measures, usage and procedures comply with regulations, that
DIN 18040-2:2011-09 Barrierefreies Bauen – Planungs­
necessary cleaning is undertaken and that each of the users act sensibly grundlagen – Teil 2: Wohnungen (Construction of acces-
within the scope of their health and mental capabilities. Worst-case sible buildings – Design principles – Part 2: Dwellings),
Berlin: Beuth, 2011. (The DIN standard for housing applies
scenarios, negative examples or grossly negligent actions by the users as there is not a separate DIN for barrier-free patient
are therefore not considered here. rooms).
Landesamt für Gesundheit und Soziales in Mecklen-
burg-Vorpommern (State Office for Health and Social
Affairs in Mecklenburg-Vorpommern), Bauanforderungen
und funktionelle Empfehlungen aus der Sicht der Hygiene
für den Neubau- und die Sanierung von Krankenhäusern
und Universitätskliniken in M-V. Anforderungen zur Kon-
zessionierung von Krankenanstalten § 30 Gewerbeord-
nung, Allgemeine Pflegestation, as of 2 November 2018

43 Qualitative Evaluation
Typological
In a patient's room the bed position and the position of the wet room
already have a decisive influence on the further configuration of the
floor plan. Especially for two-bed rooms this results in a wide range

Evaluation of
of possibilities. In the following, examples of 18 very different two-bed
room floor plans are shown. The most effective way to compare and
evaluate the respective qualities of different floor plan layouts would

Two-Bed Rooms
be to study how they are used in everyday clinical practice, but this is
not practical, neither in the context of this study nor in reality.
Nevertheless, this typological study instead analyses and evaluates
the configuration of various two-bed rooms using their floor plans. By
considering each aspect of the room’s design individually in terms of its
potential qualities, we can build up a qualitative profile for each type of
floor plan. The evaluation matrix on the right details each of the spatial
design aspects along with their respective qualitative characteristics
already introduced → Qualitative Evaluation of Two-Bed Rooms, pp. 38–43.
Each of the 18 different floor plans is briefly introduced. Then the
plans are analysed using this matrix to identify their respective features
and corresponding qualitative characteristics. Using a points system, an
overall evaluation of the floor plan can be obtained. Mutually exclusive
qualities are not added together – e.g. a standard room plan cannot also
be a special case solution – and where certain characteristics are not
present throughout – for example for only one of the two beds – only
half a point is added. Adding the points together produces a maximum
rating for each qualitative characteristic.
The points are then used to generate diagrams that show a graph-
ical representation of the qualitative evaluation of the respective floor
plan layout. Each graphic provides a visual indication of the qualitative
characteristics of the respective floor plan typology.
The intention here is not to propose model floor plan types for two-
bed patient rooms, because, as discussed earlier in the introduction,
each patient room design is an individual response to the prevailing
context and specific needs of the respective clinic. While the configu-
rations shown here illustrate room layout principles, they cannot serve
as a universally applicable solution for every case. Instead they show
the relationship between optimised operational and constructional
solutions and their potential qualities in use. As such, they reveal the
complexity of the design task of two-bed patient rooms.
One should also note that achieving a “maximum score” in all
aspects is neither practicable nor feasible in the actual context of a real
clinic. A “maximum” variant would have two entrances and two nested
wet cells for a one bed deep room, guest accommodation, a balcony
etc. Instead, this qualitative study aims to illustrate the relationships
between built, process-related and emotional factors.

44 Typologies
 Patient room Overview of the individual design aspects of a
patient room and the corresponding potential
qualities they have in the patient room.
Floor area Minimum standard
Barrier-free/low-barrier standard ● ● ● ● ● ● ● Structural complexity
Floor plan types Standard floor plan ● Infection prevention potential
Floor plan combination/variation ● ● Workplace quality and safety
Specific floor plan ● ● Spatial qualities
Additive principles Same-handed ● ● ● ●
Mirrored floor plan
● Patient safety
Floor plan combination/variation ● Patient satisfaction and privacy
Unsystematic arrangement
Room depth One bed deep ● ● ● ●
Two beds deep
Room geometry Compact
Complex ●
Zoning Two-zone room
Three-zone room ● ● ● ● ●
Three-zone plus room ● ● ● ● ●
Room entry Single entrance
Two entrances ● ● ●
Ward corridor Entrances flush with corridor
Alcove in front of room ● ● ● ● ●
Flexibility Bedside cabinet positionable on both sides ● ● ●
Retrofittable airlock ● ● ● ● ●
Fittings Standard fittings
Staff workplace ● ● ● ●
Washbasin ●
Privacy screen between patients ●
Patient desk ●
Guest accommodation ●
Openings in Window with standard sill
the façade Bathroom with window ● ● ● ●
Room with window and seat-level sill ● ●
Internal façade extension ● ● ●
External façade extension ● ● ● ●
Bed positions Beds side by side
Beds opposite ● ● ●
Beds staggered opposite one another ● ● ● ●
Beds at right angles ● ● ● ●
Beds turned towards each other ● ● ● ●
Beds facing apart ● ● ●
Views in and out Patient’s view outdoors ● ●
Staff’s view of the patient ● ● ●
Patient bathroom

Floor area Minimum standard

Barrier-free/low-barrier standard ● ● ● ● ●
Position Inboard ●
Outboard
Alternating inboard/outboard
Nested ●
Additive principles Same-handed ● ● ● ●
Mirrored floor plan
Floor plan combination/variation
Use One bathroom for shared use
Two bathrooms for shared use
Two bathrooms for separate use ● ● ● ●
Fittings Standard fittings with shower ● ● ●
Second washbasin ● ● ●
Second WC ● ● ●
Sliding door ● ●

45 Typological Evaluation
 Complex room layout with balcony

The angled, polygonal floor plan is particularly suitable in a same-handed

arrangement of the rooms. In the example shown here also the patient
in the rear bed has an unimpeded visual relationship with the outside.
In addition to the seating area in the room, the balcony offers another
place to sit.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
Two beds deep Patient safety
Complex ● Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Alcove in front of room ● ● ● ● ●
Bedside cabinet positionable on both sides ● ● ●
Retrofittable airlock ● ● ● ● ●
Standard fittings
Staff workplace ● ● ● ●
Washbasin ●
Window with standard sill
External façade extension ● ● ● ●
Beds turned towards each other ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (1 bed) ● ● ●

Patient bathroom

Minimum standard
Inboard ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

46 Typologies
 Layout with outboard bathroom with window

An outboard bathroom positioned on the outer wall has the advantage

that it can be supplied with daylight through a window. In addition, the
view of the patients is unobstructed when staff enter the room. At the
same time, however, the bathroom limits the window area and the bed
positions move further into the room.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Standard floor plan
Spatial qualities
Mirrored floor plan
Two beds deep Patient safety

Compact Patient satisfaction and privacy

Three-zone room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Patient desk ●
Window with standard sill
Bathroom with window ● ● ● ●
Beds side by side
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Minimum standard
Outboard
Mirrored floor plan
One bathroom for shared use
Standard fittings with shower ● ● ●

47 Typological Evaluation
 Layout with private lounge area per patient by the window

As in the floor plan with one entrance area per patient → Fig. p. 52, this
layout is characterised by a symmetrical room division. In this example,
this room division allows for a separate lounge area at the window and
even a separate desk for each patient fits in here. An optimal spatial
separation of patient care and patient privacy is achieved.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
One bed deep ● ● ● ● Patient safety
Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Bedside cabinet positionable on both sides ● ● ●
Patient desk ●
Window with standard sill
Bathroom with window ● ● ● ●
Beds opposite ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●

Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Outboard
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

48 Typologies
 Square floor plan with inboard and outboard
wet room

Each patient has their own wet room. The position of the bathrooms
in the corners of the room creates a separate area for each patient.
However, while one patient is hidden from sight by a wet room when
staff enter the room, the other wet room restricts the second patient's
view to the outside.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Standard floor plan
Mirrored floor plan Spatial qualities

Two beds deep Patient safety

Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Bedside cabinet positionable on both sides ● ● ●
Standard fittings
Window with standard sill
Beds staggered opposite one another ● ● ● ●
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (1 bed) ● ● ●
Patient bathroom

Minimum standard
Inboard ●
Outboard
Mirrored floor plan
Two bathrooms for separate use ● ● ● ●
Standard fittings with shower ● ● ●
Second washbasin ● ● ●
Second WC ● ● ●

49 Typological Evaluation
 Layout combination of single and two-bed rooms

In this spatial sequence, double rooms are combined with single rooms,
whose floor plan varies slightly in each case. The double rooms have
their own separate patient area thanks to the wet rooms in between.
The façade projection offers each patient a "dedicated" window for
the view to the outside.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Floor plan combination/variation ●
Spatial qualities
Two beds deep
Compact Patient safety
Three-zone plus room ● ● ● ● ● Patient satisfaction and privacy
Single entrance
Alcove in front of room ● ● ● ● ●
Standard fittings
Staff workplace ● ● ● ●
Washbasin ●
Window with standard sill
Internal façade extension ● ●
●
Beds staggered opposite one another ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (1 bed) ● ● ●
Patient bathroom

Minimum standard
Nested ●
Floor plan combination/variation
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

50 Typologies
 Specific floor plan with beds without visual connection

The two-bed room (right) in question is a special layout → Fig. 6, p. 29,

which is not intended for additive arrangement. The patients are visually
separated from each other by a screen. Each patient is assigned an
additional bed for the accommodation of relatives. The two wet cells
are equipped differently and must therefore be used by both patients
→ Fig. 62, p. 36, Two bathrooms for shared use.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Specific floor plan ●
Unsystematic arrangement Spatial qualities

One bed deep ● ● ● ● Patient safety

Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Bedside cabinet positionable on both sides ● ● ●
Retrofittable airlock ● ● ● ●
Staff workplace ● ● ● ●
Privacy screen between patients ●
Guest accommodation ●
Window with standard sill
Beds facing apart ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Minimum standard
Inboard ●
Two bathrooms for shared use
Standard fittings with shower ● ● ●
Second washbasin ● ● ●

51 Typological Evaluation
 Floor plan with one entrance area per patient

The two entrance doors to the patient's room allow for an equal
division of the patient's space and there is even room for a staff work-
place per patient. The patient is directly visible to the staff from the
door area and has an unobstructed view of the outside area even in
a lying position. The central position of the wet room means that the
bathroom door is visible from both beds and the distance to it can be
easily assessed by the patient. The distance to the bathroom is also
short for both patients.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
Patient safety
One bed deep ● ● ● ●
Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Two entrances ● ● ●
Alcove in front of room ● ● ● ● ●
Retrofittable airlock ● ● ● ● ●
Standard fittings
Staff workplace ● ● ● ●
Window with standard sill
Beds opposite ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Inboard ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

52 Typologies
 Floor plan with two identical bathrooms

The beds are slightly turned towards the outer wall and window, in
favour of a better view to the outside. The floor plan is divided into
two equal halves and each patient has their own bathroom. The room
proportions allow generous window openings and also the accommo-
dation of separate seating areas at the window for the patients and
their visitors.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
One bed deep ● ● ● ● Patient safety
Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Alcove in front of room ● ● ● ● ●
Bedside cabinet positionable on both sides ● ● ●
Retrofittable airlock ● ● ● ●
Staff workplace ● ● ● ●
Washbasin ●
Patient desk ●
Window with standard sill
Beds turned towards each other ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Inboard ●
Mirrored floor plan
Two bathrooms for separate use ● ● ● ●
Standard fittings with shower ● ● ●
Second washbasin ● ● ●
Second WC ● ● ●

53 Typological Evaluation
 Mirrored floor plan with parallel bed position

This room layout can be referred to as the "standard floor plan”. Beds
side by side, inboard wet cells in a mirrored floor plan constitute a
patient room type used very often in hospitals → Fig. 58, p. 36, Mirrored
floor plan.

Patient room Structural complexity

Infection prevention potential

Minimum standard
Workplace quality and safety
Standard floor plan
Mirrored floor plan Spatial qualities

Two beds deep Patient safety

Compact Patient satisfaction and privacy
Two-zone room
Single entrance
Alcove in front of room ● ● ● ● ●
Standard fittings
Window with standard sill
Beds side by side
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (1 bed) ● ● ●
Patient bathroom

Minimum standard
Inboard ●
Mirrored floor plan
One bathroom for shared use
Standard fittings with shower ● ● ●

54 Typologies
 Floor plan with orthogonal bed position

The layout is characterised by the orthogonal bed position. Each patient

has their own corner of the room, but one patient is not immediately
visible to the staff when entering the room. The provision of areas of
movement towards a low-barrier standard leads to larger spacing in
the bathroom and patient room.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
Two beds deep Patient safety
Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Standard fittings
Staff workplace ● ● ● ●
Window with standard sill
Beds at right angles ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (1 bed) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Inboard ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●

55 Typological Evaluation
 Low-barrier patient room with nested position of
the wet cells

The nested position of the bathrooms → Fig. 56, p. 35, Nested, results in
a rectangular room layout that is quite flexible. The visual relationship
– both between patient and outside and between staff and patient – is
neither restricted towards the entrance area nor towards the window.
The spacious, barrier-free wet cells allow each patient to have their
own washbasin.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Mirrored floor plan
Patient safety
Two beds deep
Compact Patient satisfaction and privacy

Three-zone room ● ● ● ● ●
Entrances flush with corridor
Standard fittings
Staff workplace ● ● ● ●
Washbasin ●
Privacy screen between patients ●
Window with standard sill
Beds side by side
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Nested ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●
Second washbasin ● ● ●
Sliding door ● ●

56 Typologies
 Complex floor plan with bay window

A bay window allows for even larger window areas and creates new
visual relationships with the outside. Here, the beds are also rotated
so that every patient can look directly outside without having to turn
the head. The remaining space behind the beds, which results from the
bed rotation, can be used to store personal belongings. The barrier-­
free movement areas enlarge the room proportions in the patient room
and bathroom.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Mirrored floor plan
Two beds deep Patient safety

Complex ● Patient satisfaction and privacy

Three-zone plus room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Retrofittable airlock ● ● ● ● ●
Standard fittings
Staff workplace ● ● ● ●
Washbasin ●
Window with standard sill
Internal façade extension ● ●●
Beds turned towards each other ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Inboard ●
Mirrored floor plan
One bathroom for shared use
Standard fittings with shower ● ● ●

57 Typological Evaluation
 Alternating inboard/outboard bathrooms in floor plan
variation

A floor plan is combined with another, slightly varied floor plan and then
repeated → Fig. 10, p. 30, Floor plan variation. The bathrooms are alter-
nately positioned along the corridor or the exterior wall. Both patient
room and bathroom floor plan vary. The room shown here is barrier-free
and offers patients their own desk.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ●
Workplace quality and safety
Floor plan combination/variation ● Spatial qualities
Two beds deep
Compact Patient safety

Three-zone plus room ● ● ● ● ● Patient satisfaction and privacy

Single entrance
Alcove in front of room ● ● ● ● ●
Bedside cabinet positionable on both sides ● ● ●
Staff workplace ● ● ● ●
Washbasin ●
Patient desk ●
Window with standard sill ● ●
Beds staggered opposite one another ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Minimum standard
Alternating inboard/outboard
Floor plan combination/variation
One bathroom for shared use
Standard fittings with shower ● ● ●

58 Typologies
 Low-barrier rooms in same-handed arrangement with
parallel beds

The barrier-free movement areas in the patient room and bathroom and
the beds side by side result in a deep room floor plan. The patient who
is closer to the entrance will not only be concealed to the staff by the
inboard wet room – the other patient is also in his field of vision when
looking towards the window.

Patient room Structural complexity

Infection prevention potential
Barrier-free/low-barrier standard ● ● ● ● ● ● Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
Two beds deep Patient safety

Compact Patient satisfaction and privacy

Three-zone plus room ● ● ● ● ●
Single entrance
Alcove in front of room ● ● ● ● ●
Retrofittable airlock ● ● ● ● ●
Standard fittings
Privacy screen between patients ●
Window with standard sill
Beds side by side
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (1 bed) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Inboard ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

59 Typological Evaluation
 Floor plan with inboard and outboard bathroom

Like in the square floor plan with inboard and outboard wet room
→ Fig. p. 49, there is a bathroom for every patient, one positioned
towards the corridor and one on the exterior wall. The beds are
positioned staggered and opposite one another. This creates a deep
room layout and the addition of rooms follows the same-handed
principle.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
Two beds deep Patient safety

Compact Patient satisfaction and privacy

Three-zone room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Standard fittings
Room with window and seat-level sill ●
●
Beds staggered opposite one another ● ● ● ●
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (1 bed) ● ● ●
Patient bathroom

Minimum standard
Inboard ●
Outboard
Same-handed ● ● ● ●
Two bathrooms for separate use ● ● ● ●
Second washbasin ● ● ●
Second WC ● ● ●

60 Typologies
 Radial building plan with outdoor areas and nested
bathrooms

The spatial organisation of a two-bed room in a radial building floor plan

is a particular challenge, as room widths taper towards the building core.
This results in this example in the combination of two different types of
bathrooms. While the nested position of the wet cells has advantages
for the visual connection to the outside, the rooms also benefit from a
balcony, which is located between two rooms.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Standard floor plan
Spatial qualities
Mirrored floor plan
Two beds deep Patient safety
Complex ● Patient satisfaction and privacy
Three-zone room ● ● ● ● ●
Single entrance
Entrances flush with corridor
Standard fittings
Washbasin ●
Window with standard sill
External façade extension ● ● ● ●
Beds side by side
Patient's view outdoors (1 bed) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Minimum standard
Nested ●
Floor plan combination/variation
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

61 Typological Evaluation
 Layout in same-handed arrangement with staggered
bed positions and anteroom

The rooms are arranged according to the same-handed principle along

the hospital corridor and their alignment and fittings are identical
→ Fig. 7, p. 29, Same-handed. The inboard wet cells are spatially
slightly offset and thus enable a central entrance with an unobstructed
sightline towards the patients as well as an anteroom in front of the
patient rooms.

Patient room Structural complexity

Infection prevention potential

Minimum standard
Workplace quality and safety
Standard floor plan
Spatial qualities
Same-handed ● ● ● ●
Two beds deep Patient safety
Compact Patient satisfaction and privacy
Three-zone plus room ● ● ● ● ●
Single entrance
Alcove in front of room ● ● ● ● ●
Standard fittings
Staff workplace ● ● ● ●
Window with standard sill
Beds staggered opposite one another ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●

Patient bathroom

Minimum standard
Inboard ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●

62 Typologies
 Floor plan combination of different two-bed rooms
with same-handed wet rooms

Two different types of double rooms are combined with each other.
The orientation of the fittings in the same-handed patient bathrooms
remains identical. In the table, the floor plan with the opposite and
staggered beds was evaluated.

Patient room Structural complexity

Infection prevention potential
Minimum standard
Workplace quality and safety
Floor plan combination/variation ●
Spatial qualities
Two beds deep
Compact Patient safety
Three-zone plus room ● ● ● ● ● Patient satisfaction and privacy
Single entrance
Entrances flush with corridor
Standard fittings
Staff workplace ● ● ● ●
Window with standard sill
Beds staggered opposite one another ● ● ● ●
Patient's view outdoors (2 beds) ● ●
Staff's view of the patient (2 beds) ● ● ●
Patient bathroom

Barrier-free/low-barrier standard ● ● ● ● ●
Inboard ●
Same-handed ● ● ● ●
One bathroom for shared use
Standard fittings with shower ● ● ●
Sliding door ● ●

63 Typological Evaluation
Selected Case
General Hospitals

Trillium Health Centre

Studies
Mississauga, Canada 66

Zollikerberg Hospital – New West Wing

Zollikerberg, Switzerland 70

Zollikerberg Hospital – Renovation of East Wing

Zollikerberg, Switzerland 74

Hvidovre Hospital
Hvidovre, Denmark 78

Lauf District Hospital

Lauf an der Pegnitz, Germany 82

AZ Zeno
Knokke-Heist, Belgium 86

Haraldsplass Hospital
Bergen, Norway 90

Solothurn Public Hospital

Solothurn, Switzerland 94

New North Zealand Hospital

Hillerød, Denmark 100

Südspidol
Esch-sur-Alzette, Luxemburg 104

p. 70 Zollikerberg Hospital – New West Wing

p. 154 Paediatric Clinic, Freiburg University Hospital

p. 74 Zollikerberg Hospital – Renovation of East Wing

64 Typologies
Specialised Hospitals University Hospitals

Jugenheim District Hospital Surgical Centre

Seeheim-Jugenheim, Germany 108 Erlangen University Hospital
Erlangen, Germany 138
Sana Clinic Munich
Munich-Sendling, Germany 112 Crona Clinic
Tübingen University Hospital
BGU Accident and Emergency Hospital Tübingen, Germany 142
Frankfurt am Main, Germany 118
Erasmus MC
Princess Máxima Center Rotterdam, the Netherlands 146
Utrecht, the Netherlands 122
Oncological Centre
St Joseph-Stift Dresden Leuven University Hospital
Dresden, Germany 128 Leuven, Belgium 150

St Gallen Geriatric Clinic Paediatric Clinic

St Gallen, Switzerland 132 Freiburg University Hospital
Freiburg, Germany 154
Uster Hospital
Uster, Switzerland 136 Children’s University Hospital Zurich
Zurich, Switzerland 158

Münster University Hospital

Münster, Germany 161

p. 158 Children's University Hospital Zurich

p. 132 St Gallen Geriatric Clinic

p. 150 Oncological Centre, Leuven University Hospital

65 Case Studies
Trillium Health Centre
Mississauga is a growing city in Ontario, on the outskirts of Toronto. This
project for Trillium Health Centre required the addition of 135 beds and
a learning centre on the Mississauga Hospital campus. The extension
New extension was to incorporate novel intensive acute-care models, including the
provision of procedures right at the bedside. Designed as a prototype
within the 17,000 m² building, the unit includes 36 beds, subdivided into
This interesting approach addresses both 12-bed clusters. Each cluster is served by a decentralised team station.
the functional requirements and the patients‘ The unit comprises both one- or two-bed rooms, to reflect varied
needs. It led to a new interpretation of a insurance coverage restrictions. The two-bed patient room exudes
frequently used room layout that has a spaciousness and provides privacy like a single room – along with
privileged and a less attractive area. The unobstructed views from the angled bed location to a replanted treed
layout at Trillium with two equal halves and a zone outdoors. Families have space to relax and visit, and staff have
separate entrance for each patient creates a bedside work space while enjoying shortened walking distances from
high degree of privacy in a two-bed room; at satellite team stations. The room, perhaps due to the angled bed posi-
the same time the social isolation of a single tion, does not feel institutional. The vestibule proved a valuable addition.
occupancy is avoided. It facilitates bed and stretcher movement as well as access to each bed.
This has decreased staff injury and the care team can easily view the
patient’s face as they walk past. Although the three-piece washroom
Architects is shared by two patients, it can be accessed by them individually.
Perkins Eastman Black Several one-bed rooms exist as well. Two two-bed rooms can be coupled
together as well as divided by a glass slider, thus providing both privacy
Client
and flexibility in urgent situations.
Trillium Health Partners

Location
Mississauga, Ontario, Canada

Completion
2008

Beds per floor

36

Net area, two-bed room

36.73 m² + 5.42 m² bathroom

1 Site plan, 1 : 20,000

2 South façade and entrance to inpatient tower
with learning centre on lower level
3 Tea kitchen and social space
4 Ward floor plan, 1 : 500

66 Typologies
 3

67 Case Studies 1:500

 5

68 Typologies
9

5 Satellite team station in corridor

6 Wayfinding light art in corridor, rehabilitation
space beyond
7 Reception and family room on patient levels with
seamless flooring inlay 'Magic Carpet' in front of
elevators
8 Floor plan of the patient rooms, 1 : 100
9 Two-bed room with seating
10 One side of the two-bed room with bedside
terminal and view outside 10

69 Trillium Health Centre

Zollikerberg Hospital
Neumünster Hospital, built between 1931 and 1933 by the Zurich archi-
tects Otto and Werner Pfister, lies on the Zollikerberg in Zollikon near
Zurich and includes a hospital, nurses’ accommodation, staff and training
New west wing rooms and a chapel. All the hospital wings have a double-loaded arrange-
ment with a clear functional division: the patient rooms and main rooms
are oriented towards the park while the ancillary spaces are located on
The patient rooms of the new wing, with the north side. While some wings were to be upgraded → p. 74–77, the
their modern furnishings, indented glazed original west wing was deemed no longer able to meet modern hospital
balconies and adjoining light-filled seating requirements and was replaced with a new building on the same site.
areas, evoke a sense of comfort more com- The four-storey replacement wing faces the park and houses
monly associated with hotel rooms. The three wards and a floor of treatment rooms including a therapy pool.
flush surfaces in the rooms and corridors, The wards retain the original south-facing orientation of the patient
the choice of materials and the transparent rooms with ancillary nursing rooms to the north. The patient rooms
sculptural quality of the façade make the are spacious and have a balcony and view of the park. Open lounge
new west wing one of the most elegant and areas break down the length of the ward corridor and allow daylight
aesthetically attractive hospital wings to to suffuse the circulation zones.
have been built in recent years. The floor plan of the two-bed rooms creates a progression from the
entrance area to the patient zone to a sitting area and outdoor space.
By arranging the beds at right angles to one other, both patients have
Architects a direct view outside. The two bed positions are of equal status, but
Silvia Gmür Reto Gmür Architekten not identical, and are far enough apart to have their own space, with
movable curtains for additional visual privacy when needed.
Client
The seating area is designed as a bay with glazing on two sides that
Stiftung Diakoniewerk Neumünster –
looks onto the park and the adjoining balcony-veranda, which provides
Swiss Nursing School
a sheltered outdoor space. Ample distance between the table and the
Location beds, as well as between the two beds, affords greater privacy as well
Zollikerberg, Switzerland as space for visitors, and a glazed strip that runs from floor to ceiling
Completion allows natural light to permeate into the inboard patient bathroom.
2011 The open views, natural surroundings and the bright, daylit inter-
iors contribute, along with the fittings and furnishings, to the pleasant
Beds per floor atmosphere of the rooms. Dark parquet flooring, curtains of varying
45 translucency, upholstered chairs and indirect lighting create a sense of
Net area, two-bed room comfort that is further heightened by the coordinated colour scheme
31.9 m² + 3.5 m² bathroom and high-quality bed linen.
The materials used in the new building, as well as in the renovated
wings, establish a coherent overall impression that harmonises with the
original materials of the existing building. High-quality materials in the
rooms and ward corridors lend the new wing a sense of sophistication
and warmth that reflects the elegant character of the entire hospital
complex and its park.

70 Typologies
2

1 Site plan, 1 : 20,000

2 The patient rooms seen from outside
3 North elevation
4 Ward floor plan, 1 : 500 4

71 Case Studies
5 6

72 Typologies
8

5 South elevation
6 The ward corridor with room entrances
7 Floor plan of the patient rooms, 1 : 100
8 Patient room with curtains for privacy
9 Patient room

73 Zollikerberg Hospital
Zollikerberg Hospital
The renovation of the east wing of Zollikerberg Hospital in Zollikon near
Zurich, built in 1933, enabled the hospital to provide single rooms for
patients of all health insurance classes. Thanks to the good quality of the
Renovation of east wing existing building, only specific, moderate interventions were needed to
fulfil modern, efficient operational standards. The façade of the building
remained unchanged.
The renovated patient rooms in the east wing Each of the new rooms features a custom-fabricated full-height
of Zollikerberg Hospital show that necessary cupboard that acts as a partition to the bathroom. Through a serially
upgrading measures can be successfully producible modular design, clever detailing and intelligent variation
incorporated into existing buildings. The and optimisation, the joiner was able to cost-effectively manufacture
new fixtures accommodate all the necessary the fitted elements for 90 rooms while responding to irregularities in
functions and storage areas in the patient the existing building, fitting them exactly to each room. Unsurprisingly,
rooms and their distinctive colours contrast this entailed careful coordination between the architect and joiner and
refreshingly with the white hospital interiors. the joiner and the specialist planner.
Through their integrative design and reductive The new red, orange or pale green insertions – each ward has a
formal language, they allow the character signature colour – incorporate the technical installations and risers and
of the existing rooms to prevail, and free up serve as a two-sided cupboard and storage unit for the room and the
more space for unimpeded movement in the bathroom. Their matt varnished surfaces and planar fronts also make
room and around the bed. them easy to wipe clean. Clearly visible niches hold disinfectant dis-
pensers within easy reach for patients and staff.
Despite their small size, the single rooms are pleasant, bright and
Architects airy. The slightly rotated position of the bed faces the window, offering
Metron Architecture AG, Brugg a direct view of the quiet open parkland outside. In addition to single
rooms, each floor has several larger two-bed rooms, some of which can
Client
be used as mother and child rooms.
Stiftung Diakoniewerk Neumünster –
The new insertions serve and incorporate multiple functions while
Swiss Nursing School
simultaneously affording ample space for wheelchair users and freedom
Location of movement for staff despite the tight room proportions. Their reductive
Zollikerberg, Switzerland design creates an orderly impression while retaining the character of
Completion the existing building, both in the patient rooms and the ward corridors.
2015

Beds per floor

36

Net area, single room

14.1 m² + 3.1 m² bathroom

Net area, two-bed room

33 m² + 4 m² bathroom

1 Site plan, 1 : 20,000

2 View of the east wing
3 Ward floor plan, 1 : 750

74 Typologies
 1:750

75 Case Studies
4

76 Typologies
8

4 Patient bathroom
5 Ward with nursing station
6 Entrances to the patient rooms
7 Floor plan of the patient rooms, 1 : 100
8 Patient room with cupboard partitioning off
the bathroom
9 Patient room in the maternity ward

77 Zollikerberg Hospital
Hvidovre Hospital
Hvidovre Hospital near Copenhagen is one of the largest hospitals
in Denmark, catering for more than 40,000 patients annually. When
it opened in 1976, it represented a departure from the typical bed
Conversion of the wards skyscraper as its four main buildings are only three storeys high.
As part of the reconstruction of the nursing wards, C. F. Møller
Architects were asked to renew the patient rooms within the existing
As part of the modernisation of Hvidovre structure to make them more user-friendly in various ways.
Hospital, the existing four-bed rooms were to One of the main tasks was to convert the existing four-bed rooms
be turned into two-bed rooms. The architects, into single and two-bed rooms. The new flexible room type is designed
however, went a step further and developed as a single room in which relatives can also stay overnight. For this
a flexible, functional room type that works purpose, a bench that can be folded out into a bed is provided in the
for both single and double occupancy. In same room as the patient. Each room also has a second set of supply
view of the projected decline in demand for lines and connections to accommodate an additional patient as required.
inpatient treatment, a trend towards single-­ As such, Hvidovre Hospital can respond flexibly to a possible rise in the
bed rooms is emerging, but hospitals still number of patients.
need to be prepared for high occupancy The design of all the rooms is determined by the outboard place-
scenarios. In this case, the hospital is well ment of the bathrooms along the façade. This has the advantage that
equipped for both situations. the beds are easily visible for the staff from the entrance area, and
even from the corridor thanks to an additional glazed strip next to the
entrance. When more privacy is required, the glass can be made opaque
Architects at the touch of a button, obscuring the view into the room from the
C. F. Møller Architects corridor. A pull-out screen between the beds can provide additional
privacy where necessary when one room is occupied by two patients.
Client
At the entrance to each room is a supply point with a washbasin
Regionhovedstaden v. Amager og
and glove dispenser as well as storage space for necessary materials
Hvidovre Hospitaler
for the patient, and a ceiling-mounted patient lift system helps nursing
Location staff raise and move patients more easily.
Hvidovre, Denmark As part of the modernisation, the patient bathrooms were opti-
Completion mised and redesigned to be barrier-free. Additional handrails around
2016 the oval-shaped washbasin can be used as a grip and handhold and,
together with height-adjustable WCs, enable older or mobility-impaired
Beds per floor patients to be more independent.
55 Wooden surfaces and wood decor on the walls and floor lend the
Net area, two-bed room rooms a homely atmosphere, as does the dark upholstered bench next
24 m² + 4.3 m² bathroom to the window.

1 Site plan, 1 : 20,000

2 View of the patient terrace from outside
3 Nurses’ station with a view along the corridor
to the patient rooms
4 Ward floor plan, 1 : 500

78 Typologies
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79 Case Studies
5 6

80 Typologies
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10

5 Upholstered seating area next to the window

6 Fold-down section for use as a bed for guests
7 Single occupancy for mother and child
8 Floor plan of the patient rooms, 1 : 100
9 View towards the entrance with the glazed
window to the corridor
10 Double occupancy of the patient room

81 Hvidovre Hospital
Lauf District Hospital
Lauf District Hospital was built in the 1960s and 1970s and has been
extended and converted several times over the years. Trend forecasts
for the sector, however, pointed to the need for a longer-term plan for
New ward block and intensive care unit a flexible operational model.
The original design concept for the district hospital already served
as a solid typological basis: a main corridor runs from east to west
Instead of an extension with budget-­ and acts as the functional backbone with a bed block facing south.
friendly standard rooms and a single This structural arrangement presented a number of qualities that the
bathroom per room, Lauf Hospital and their extension was able to build on.
architects elected to design a new edition Alongside additions and improvements to the existing facilities, the
of the original layout with two wet cells per construction project encompassed the addition of two new standard
room. Building on a tried and tested solution care wards with 32 beds each and a three-bed extension to the intensive
from the past, the new design provides care unit. The new three-storey wing was built as a compact block at
added comfort for patients in two-bed the rear, northern edge of the hospital and the western patio building
rooms and offers potential as a model for was extended. The new building has two wards on the first and second
better hygiene. floors, with administrative facilities above, while a connecting section
links the new facilities to the existing building. On the upper floors,
the wards connect at both ends to the existing hospital, creating a
Architects circulation ring that makes it possible for several nursing wards to be
ATP HAID architekten ingenieure flexibly organised on one level.
(Integral planning; Design: Prof. Hans Peter To ensure a uniform room standard across the entire hospital, the
Haid) design team adopted the basic room floor plan of the existing patio
building and adapted it to modern requirements. The hospital’s existing
Client
patient rooms have two wet cells per room, and the new ward block
Krankenhäuser Nürnberger Land GmbH
continues this pattern with a wet cell per patient located to the left and
Location right of the entrance to the two-bed rooms. Showers for all patients are
Lauf an der Pegnitz, Germany located on the ward corridors. The new arrangement sacrifices a shower
Completion in the room in favour of a separate bathroom (toilet and washbasin) for
2017 each patient. In the single-bed rooms, the second cell contains a shower
room. For maximum safety and hygiene, the bathrooms are fitted with
Beds per floor slip-resistant floor tiles and additional grips and handrails.
92 The patient rooms have the same generous glazing as the existing
Net area, two-bed room building and look out over the surrounding landscape. Each window
20.5 m² + 1.87 m² bathroom is set into a deep wooden surround that frames the view and serves
as a window seat at sill level. Wood is also used for the bed headwalls
and integral patient cupboards to add a more homely feel. Made of
chipboard and faced with HPL, they are easy to wipe clean.
The interior design eschews cold metallic materials in favour of
wooden surfaces and warm, earthy yellow and orange colour highlights,
for example in the curtains, upholstery, coloured wall surfaces and
bathroom tiles. Contrasting dark grey frames are used to mark room and
door entrances, providing orientation in the rooms and ward corridors.

1 Site plan, 1 : 20,000

2 Inner courtyard with a view of the walkway
connecting the existing and new buildings
3 Façade of the new ward block
4 Ward floor plan, 1 : 750

82 Typologies
2

83 Case Studies
5

84 Typologies
9

10

5 Common room and lounge in the ward

6 Patient bathroom (left) and shower room
(right) in single-bed room
7 Room entrances (left) in the ward corridor
8 Floor plan of the patient rooms, 1 : 100
9 Two-bed room with entrance to the
bathroom
10 Two-bed room

85 Lauf District Hospital

AZ Zeno
The new building for the AZ Zeno (AZ is the abbreviation for algemeen
ziekenhuis, or general hospital) with its organic building form is the
product of a collaboration between three Belgian architectural offices –
New hospital AAPROG, Boeckx and B2Ai – who together won the competition for its
design in 2007. Opened in 2018, the new hospital building comprises
a rehabilitation centre, nursing wards with a total of 270 beds, an out-
Despite its considerable size, the design patient clinic, lecture halls, event areas and a helicopter landing pad.
concept for the AZ Zeno in Knokke-Heist is The building’s design needed to meet the requirements of a
applied consistently at all scales, from the modern, sustainable, forward-looking hospital while respecting the rural
building to the patient rooms to every last character of its surroundings. Raised off the ground and enveloped in a
detail of the fittings. The architects have curved exterior, the three-storey and four-wing volume has the futuristic
achieved a good balance between modern appearance of a floating object that has alighted nimbly on the existing
appearance and the impression of clinical landscape. Three of the wings house patient rooms with views out over
cleanliness. the dunes while the fourth facing the road and parking areas contains
the medical facilities. A 600 m² roof garden on the second floor can be
reached from the cafeteria.
Architects All transitions between inside and outside and between the wards
AAPROG and public areas within the building are fluid. Warm colours, bright day-
Boeckx light and art in the interiors create a homely environment for the patients.
B2Ai The design of the patients’ rooms is simple and restrained. In addi-
tion to a regular door, a movable panel in the single rooms can be slid to
Interior designers
one side to provide direct access to the patient bathroom. It also acts
B2Ai
as a room divider, closing off the entrance area from the room when
Client more privacy is required. The split two-panel door – with separate upper
AZ ZENO and lower opening sections – was especially conceived for the geriatric
Location wards to allow patients to feel connected and in contact with people
Knokke-Heist, Belgium in the ward corridor when in their room. A particularly space-saving
solution is the fold-out bed for relatives to stay overnight incorporated
Completion into the fitted wall cupboards.
2018 Instead of the desk in the single rooms, the two-bed rooms have
Beds per floor two rounded shelves for placing pictures and greeting cards as well as
80 a shared table. In the bathroom, all components, including the polycar-
bonate swinging shower partitions, are wall-mounted to avoid contact
Net area, single room with the floor, preventing colonisation with germs and making it easier
20.62 m² + 3.5 m² bathroom to clean the floors. The bathroom flooring in bright colours such as green
Net area, two-bed room or violet contrasts with the otherwise white rooms. The bathrooms in
28.62 m² + 3.5 m² bathroom the two-bed rooms have two washbasins, one for each patient.
The solid oak window frames harmonise with the wood-effect flooring
in the rooms and some surfaces, such as the sliding door panels, are
printed with photographic motifs. The interior design aims to create a
calm and comfortable atmosphere for the patients so that the clinical
functions recede into the background.

1 Site plan, 1 : 20,000

2 The building façade with the roof terrace adjoining the
cafeteria
3 The mass of the building is raised off the ground.
4 Ward floor plan, 1 : 1000

86 Typologies
 3

87 Case Studies
5

88 Typologies
8

10

5 Bathroom
6 Nurses’ station with waiting area
7 Floor plans of single and two-bed rooms, 1 : 100
8 Single room looking towards the split-leaf entrance door
9 The sliding bathroom door panel can act as a room divider.
10 Room in the mother and child ward with nurses’ work area

89 AZ Zeno
Haraldsplass Hospital
The new extension to Haraldsplass Hospital, built at the foot of Mount
Ulriken in 1940, extends the hospital’s accident and emergency capacity
by providing 170 additional beds. The five-storey building has a wood
New extension frontage with a kink that follows the course of the Møllendalselven river
beneath the hospital, and the comparatively low proportion of glazed
surfaces ensures a good energy balance. Almost all the patient rooms
The abundant use of wood and views inside and overlook the city of Bergen and its port, and have a view across the
out create a calm but stimulating environment valley, which patients can enjoy from their beds thanks to fixed floor-
for patients at Haraldsplass Hospital. Oriel win- to-ceiling window sections. The rooms to the rear enjoy a view of the
dows facing onto the atria provide a sheltered wooded hillside of the mountain.
place to observe the hustle and bustle of daily In contrast to many hospitals, there are no long corridors. Instead,
clinic routine, relieving boredom during long the various functions are distributed around two open atria at the heart
hospital days. Floor-to-ceiling windows in the of the pentagonal building, which ensures efficient logistics, flexibility
patient rooms afford a view over the city in the and proximity between caregivers and patients. The wards are arranged
valley or out onto the countryside, encouraging in a ring around these covered atria, which allow daylight to spill into the
a swifter recovery. heart of the building and serve as communal areas for communication
and orientation. Small oriel windows project from the atria walkways as
“boxes”, creating sheltered seating areas with views into the atria and
Architects across to other levels of the hospital. While single rooms predominate,
C. F. Møller Architects a smaller number of two-bed and three-bed rooms are also provided.
The bathrooms are typically arranged in pairs between the rooms,
Client
leaving the rooms open and unobstructed. Both the rooms and the
Haraldsplass Diakonale Stiftelse
bathrooms are barrier-free.
Location The striking wooden framework of the façade hints at the abun-
Bergen, Norway dance of wood in the interior. The atria are clad entirely in wood,
Completion as are the windows in the patient rooms. The flooring likewise has
2018 a wood decor. Wall-mounted cabinets for the patients’ belongings
add a colourful accent in the rooms and make it easier to clean the
Beds per floor floors. Low-maintenance materials are used throughout to ensure
35 maximum longevity.
Net area, two-bed room
16 m² + 5 m² bathroom

1 Site plan, 1 : 20,000

2 View of the wood façade of the patient rooms
3 Haraldsplass Hospital at the foot of Mount Ulriken
4 The second atrium
5 Ward floor plan, 1 : 500

90 Typologies
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2 4

91 Case Studies
 7

92 Typologies
 11

10

6 Atrium with projecting oriel boxes

7 Seating niche with a view into the atrium
8 A ward corridor
9 Floor plans of single and two-bed rooms, 1 : 100
10 Full-height window in a standard room
11 Wall cabinet for patients’ belongings
12 A patient room with two beds 12

93 Haraldsplass Hospital
Solothurn Public Hospital
The new building for Solothurn Public Hospital is the product of an
international competition for a new hospital with 327 beds and surgery,
obstetrics, intensive care, outpatient and emergency units. Built on the
New building grounds of the existing hospital, which had to remain fully operational
during the construction period, the new complex takes the form of an
L-shaped structure inserted around the existing buildings.
The design of Solothurn’s new public hospital The new building consists of a two-storey base of exposed concrete
is centred around the patient. The place- for the public zones and examination and treatment areas, on top of
ment of the beds at right angles creates two which the wards are placed. Separating the two is a glazed recessed
different bed locations of equal status, and floor. The wards are fronted by striking, sculptural brise-soleils made
the angular twist in the floor plan reinforces of white concrete that cover the exterior of the cuboid bed block. Two
this, marking out a space for each person inner courtyards, reaching below grade, provide additional lighting in
and creating a corner mid-room into which the interior.
the patient cupboards have been fitted. The floor plan of the main floors is divided into two functionally
High-quality materials, such as wooden separate access areas, one for the patients, the other for staff, beds
parquet flooring, and the harmonious colour and materials. Straight paths parallel to the outer walls – leading
concept contribute to the impression of a towards a daylit point – ensure easy orientation in the building. As
healing environment rather than a hospital. patients walk along the bright corridors with a view of the park, they
pass various departments without crossing paths with staff or the
supply and disposal systems.
Architects Each patient room has two separate zones, one for each patient:
Silvia Gmür Reto Gmür Architekten the beds are placed at right angles and a twist in the floor plan pro-
duces a step in the cross walls that demarcates the foot of one bed area
Client
and creates a niche for the head end of the other bed. The patients’
Canton of Solothurn, Public Building Authority
cupboards are fitted into these corners so that they do not stand in the
Location room where they might obstruct the view or movement in the room.
Solothurn, Switzerland The angled placement of the beds means the beds stand further apart,
Completion affording each patient more personal space. Compared with a conven-
2020 tional side-by-side arrangement, the rearward bed has a much better,
unobstructed view out of the window. Each patient, therefore, has their
Beds per floor own view but can screen themselves off by drawing a curtain as desired.
76 Nursing staff were consulted for the design of the patient bathrooms,
Net area, two-bed room and especially the arrangement of the elements and the choice of mate-
31.4 m² + 3.7 m² bathroom rials and colours. The bathroom core is a prefabricated rectangular
concrete cell with seamless polyurethane wall and floor coatings. The
flush-fitted shelves and glove dispenser in the wall next to the wide
acrylic stone washbasin are likewise designed for optimal hygiene and
ease of cleaning. Yellow or pink highlights enliven the grey base colour,
adding more vibrant moments of colour.
For the façade, a system of fixed brise-soleils was developed that in
addition to protecting against glare and overheating ensures unobstruc-
ted views outside and adequate natural illumination. It shields partially
against views in from outside while allowing for solar gain in the winter.
1 A curtain designed by the artist Gido Wiederkehr can be drawn across
the window. The materials and furnishings are restrained, with wood
parquet flooring and a wooden shelf-strip above the bed, shaping the
rooms' character. The shelf-strip incorporates the necessary medical
connections and an indirect light source so that the impression of a
comfortable room predominates without restricting medical necessities.

94 Typologies
2

1 Site plan, 1 : 20,000

2 View of the façade and brise-soleils
3 Ward floor plan, 1 : 500 3

95 Case Studies
4

96 Typologies
6

6
7

4 View of the inner courtyards and the green roofs

5 Inner courtyard of the two-storey base with brise-soleils
6 Corridor on the nursing floor (7th storey)
7 Patient bath

97 Solothurn Public Hospital

8

98 Typologies
10

11

8 Corridors on the nursing floor with entrances

to the patient rooms
9 Floor plan of the patient rooms, 1 : 100
10 Patient room with artist-designed curtains
11 View of a patient bed

99 Solothurn Public Hospital

New North Zealand
Located on the outskirts of the town of Hillerød in the northeast corner
of the Danish island of Zealand, New North Zealand Hospital is woven
into the broad Danish landscape. The new acute care hospital is not
Hospital only completely surrounded by nature but also encloses it within the
winding ribbon of its star-shaped form.
The new facility serves a catchment area of around 310,000 inha-
New hospital bitants, a task previously served by three smaller hospitals. With 570
beds spread across a total area of approx. 120,000 m², it consolidates
and improves the emergency and intensive care services for the region.
The considerable size of this new hospital The examination and treatment rooms are accommodated in a total
is effectively enabled by the addition of of 20 departments on the two lower floors. Circular inner courtyards are
standardised bed units. However, the organic cut into the plinth in a repeating pattern so that daylight can permeate
shape of the building emphasises the human the lower levels of the hospital, and four circular courtyards illuminate a
scale, with each patient room becoming central hall at the heart of the complex. The roof of the plinth becomes
an individual part of an organic ribbon. An an open-air park landscape.
interesting spatial feature is an alcove as a The two upper floors rest on the plinth and follow its outline as
calm place for rest and seclusion within the an undulating ribbon. Contrasting with the plinth, these floors are
patient rooms. articulated visually with a more delicate façade, exuding privacy and
a personal scale. The neonatology and paediatric patient rooms are
equipped with an alcove that serves as a seating niche for greater
Architects privacy and moments of peace and seclusion and where the parents
Herzog & de Meuron can spend the night. The bathrooms are placed between the rooms
and are polygonal in shape to accommodate the changing curvature of
Client
the ribbon. From the rooms, patients have an expansive view into the
New North Zealand Hospital
treetops of the surroundings or the garden landscape in the interior of
Location the hospital. From outside, the hospital looks like a two-storey complex.
Hillerød, Denmark Bright colours and light wood in the corridors and rooms of the
Completion upper patient floors create a pleasant and friendly atmosphere.
2024 In the corridors and rooms of the ward floors, the use of wood as
the dominating design element creates a friendly atmosphere. In those
Beds per floor areas of the hospital that are accessible for patients, the ceilings consist
228 of an industrially manufactured system of wooden slats fixed on mineral
Net area, single room wool panels. This simple, additive feature is a cost-effective solution that
23 m² + 6.3 m² bathroom enhances the quality of the interior at the same time.

100 Typologies
2 3

1 Site plan, 1 : 20,000

2 New North Zealand Hospital
seen from a distance
3 Roof garden in the inner courtyard
of the hospital
4 Ward floor plan, 1 : 1500

101 Case Studies

5

102 Typologies
8

10

5 Nurses’ station
6 Ward corridor
7 Floor plans of the patient rooms, 1 : 100
8 Patient room with alcove
9 Patient room with balcony
10 Seating niche near the window
and bathroom

103 New North Zealand Hospital

Südspidol
The Südspidol Hospital in Esch-sur-Alzette in Luxembourg is designed
as a new health campus. The architects responded to the need for a
central facility with optimised medical processes and minimised travel
New campus hospital distances with a series of distinct, individually differentiated building
structures. Their design aims to address both the needs of the patient
as well as facilitate the complex medical processes within a high-effi-
While the Südspidol employs a repeating ciency hospital.
same-handed room module arranged in rows The signature elements of the 59,380 m² hospital complex are three
to form a large structure, it interlocks them triangular buildings with gently curving rounded edges that through their
in such a way that each room is individually appearance soften the hard precision of clinical processes. Although the
legible. This floor plan principle is a first hint three buildings are interconnected, each building has its own patient
of the importance accorded to the well- rooms and can therefore function as an independent unit. Instead of
being of each patient in the design of the confronting staff, patients and visitors with a megastructure, the design
patient rooms. aims to be relatable at a human scale. Rather than endless ward cor-
ridors, the curved building shape allows the creation of more legible
circulation spaces. The entrances and nurses’ stations at the nodal
Architects points divide the wards into more manageable sections and serve as
ARGE Health Team Vienna open and pleasant waiting and meeting areas for staff and visitors alike.
Albert Wimmer ZT GmbH The approx. 550 patient rooms (of which about 80 % are single-­
Architects Collective GmbH bed rooms) are arranged along the façades. Their floor plan with the
bathroom offset to one side enables them to interlock with one another
Client
to form broad sweeping rows around the perimeter of each building
Centre Hospitalier Emile Mayrisch
and tighter rings around the almost circular inner courtyard.
Location The geometry of the floor plan was developed according to the
Esch-sur-Alzette, Luxembourg principles of Evidence-based Design and focuses on the safety and well-
Completion being of the patient. On the one hand, nursing staff have an unimpeded
2026 view of the patient from the door, and on the other hand, patients have
a good view of the world outside without having to turn their head.
Beds per floor The bathroom is located immediately to the right of the bed, the short
90 distance minimising the risk of falls, especially for elderly patients and
Net area, single room patients with multiple clinical conditions. At the same time, the large
20.5 m² + 4.3 m² bathroom sliding bathroom door maximises autonomy and accessibility. Additional
fixed fittings in the room have been avoided to minimise obstructions
and improve ergonomics for caregivers when caring for the patient.
The use of a same-handed modular room design, i.e. with an iden-
tical floor plan, makes it possible to improve the efficiency of care
processes and standardise procedures so that fewer errors can occur.
A large multimedia screen on the wall opposite the bed can be used
to watch TV or surf on the internet but also as a monitor for discussing
treatments and diagnoses with one’s doctor during visits. The three
buildings will be embedded in a park-like landscape and complemented
by green inner courtyards and green roofs.

104 Typologies
2

1 Site plan, 1 : 20,000

2 View of the complex embedded
in the surrounding landscape
3 Ward floor plan, 1 : 750

105 Case Studies

4

106 Typologies
6

4 Waiting area near the nurses’ station

5 Floor plan of the patient rooms, 1 : 100
6 Patient room
7 Inner courtyard with communal areas

107 Südspidol
Jugenheim District
The wards at Jugenheim District Hospital were originally designed by
the architects Junghans+Formhals in the 1990s. The wards were mod-
ernised as part of the long-term, comprehensive redevelopment of the
Hospital hospital as a regional centre for orthopaedics. The conversion had to
be undertaken without interrupting ongoing operation of the hospital
and no changes were made to the façade or the loadbearing structure.
Renovation of the wards As a result, the renovation of the wards with a total of 80 beds as
well as the diagnostics and treatment facilities were carried out floor
by floor and interventions to the existing room structure were kept to
The original ward with polygonal, diagonally a minimum. The original room layout with its diagonal floor plan that
arranged rooms at Jugenheim District allows the beds to be arranged opposite each other was retained.
Hospital near Darmstadt is still one of the The interior conversion was particular challenging due to the angled
most interesting and most well-known ward and cramped geometry of the three-storey building and the additional
layouts in Germany. Its sustainable design technical equipment required in the upgraded wards. All surfaces were
qualities reveal themselves in the ability renewed and coordinated to create a harmonious interior: flooring in a
to accommodate changes and new design warm strip wood decor, walls smooth plastered in white, and the ceilings
­concepts. As such, the ward renovation was in perforated acoustic plasterboard with integral lighting.
able to retain its original structure. The fittings in the existing patient rooms were redesigned for better
comfort: sections of the wall surface were clad in wood-effect panelling
into which the medical connections, lighting, patient cupboards and
Architects mirrors were integrated. To provide additional seating for visitors, the
LSK-Architekten (renovation) radiators were fronted by benches made of a similar material. Fitted
Junghans+Formhals cupboards were incorporated into the two-bed rooms, which also have
a dining table and chairs, a desk, fridge and bedside units with TV. From
Client
an armchair near the window, patients can see the hills of the Bergstrasse
District hospital board of Darmstadt-Dieburg
region. In the single-bed rooms, a larger desk and an armchair with side
Location table take the place of the second bed.
Seeheim-Jugenheim, Germany To soften the restless angularity of the corridors in the new ortho-
Completion paedic ward, LSK Architekten proposed introducing calm, rounded
2014 forms in the core zone. The counter of the nurses’ station curves around
at the heart of the ward and looks onto a round atrium planted with tall
Beds per floor bamboo to create a “green atrium”.
38 Benches have been also been set into the corridors, the walls of
Net area, two-bed room which have been decorated throughout with works of art by Joan Sofron.
23.7 m² und 3.7 m² bathroom A central patient lounge with kitchen provides a space to meet and talk
for patients and visitors.

1 Site plan, 1 : 20,000

2 The patient rooms seen from outside
3 Ward floor plan, 1 : 500

108 Typologies
 2

109 Case Studies

4

6
7

110 Typologies
8

4 View of the ward corridor from the nurses’ station

5 Lounge and kitchen for patients and visitors
6 Corridor
7 Floor plan of the patient rooms, 1 : 100
8 Two-bed room
9 Single-bed room with desk

111 Jugenheim District Hospital

Sana Clinic Munich
The Sana Kliniken Solln Sendling GmbH originally operated orthopaedic
clinics at two locations, which were merged in May 2017 to form the
Sana Health Campus at Munich-Sendling. Designed as a district-level
New regional medical centre hospital, it includes facilities for diagnostics, surgery and intensive care
along with the corresponding nursing wards. The compact, five-storey
building wraps around the perimeter of an urban block and sits along-
Fixed screens between two beds are an side a listed building. Its upper floors look onto an open inner courtyard
uncommon fixture and even here in the Sana and house two wards per floor with a total of 173 beds. The clinic with
Clinic in Munich are only found in the rooms a gross floor area of 6600 m² treats more than 8000 patients per year.
for private healthcare patients. The spacious The ward corridors are spacious and offer a range of different seating
rooms show the kind of privacy and comfort areas to provide motivational stopover and rest points for patients with
possible in a two-bed room when there is locomotive impairments, for example after hip or knee operations. To
sufficient space and budget. make it easier for patients to stand up after sitting, the seat height of the
chairs and armchairs has been slightly raised from the normal height of
45 cm to 48 or 50 cm. The standard two-bed patient rooms face onto
Architects the inner courtyard with a projecting bay window at the end that pro-
wörner traxler richter vides better illumination and serves as a niche for a window-side table
for writing or dining. The low sill height maximises the window size and
Client
allows patients lying in bed to see out of the window.
Sana Kliniken Solln Sendling GmbH
The fittings and furnishings in both the standard and private health-
Location care patient rooms aim to create an atmosphere more akin to a hotel
Munich-Sendling, Germany than a hospital. The brightly lit rooms with their tastefully painted white
Completion and beige walls are complemented by black and white photographs of
2017 well-known squares and sights in Munich, either elegantly framed in the
standard rooms or as wall-size photographs in the private healthcare
Beds per floor patient rooms. In addition to the beige wall tones, private healthcare
67 patients can enjoy white fitted furniture and black armchairs and the
Net area, two-bed room (standard) bed headwalls with medical connections are finished with a dark wood
22.1 m² + 3.2 m² bathroom decor, as are the floors. The spacious entrance lounge area of the two-
bed rooms for private healthcare patients is the product of combining
Net area, two-bed room (private patients) two single-bed room layouts. A central partition in the middle ensures
37.3 m² + 4.3 m² bathroom each patient has their own space, each with a separate window. The
low, deep-set window sill can be used as a bench, creating an attractive
visitor zone for each patient.
For optimal cleaning and hygiene, the surfaces have been made
as seamless as possible, both around the walls and on the floors. The
PVC flooring has upturned coved skirting to avoid corners and hairline
seams which are particularly susceptible to germ contamination. Where
joints were necessary, they were made large enough to receive proper
grouting. Each floor has one or two quarantine rooms with an airlock for
isolating individual patients with viral or bacterial infections.

1 Site plan, 1 : 20,000

2 The clinic building
3 Ward floor plan, 1 : 500

112 Typologies
2

113 Case Studies

4 5

4 Seating area in one of the corridors

5 Ward corridor with nurses’ station
6 Entrance to a standard two-bed room
7 Standard two-bed room with low window sill
8 Standard room floor plan, 1 : 100 6

114 Typologies
7

115 Sana Clinic Munich

9

10

116 Typologies
11

12

9 Two-bed room for private healthcare patients

with fixed partition
10 Private healthcare room floor plan, 1 : 100
11 Two-bed room for private healthcare patients
12 Bathroom in private healthcare room

117 Sana Clinic Munich

BGU Accident and
The BGU Accident and Emergency Hospital in Frankfurt am Main is not
only a supra-regional trauma centre for accidents and emergencies
but also a university hospital for the Goethe University in Frankfurt am
Emergency Hospital Main. The new extension to the intensive care medical centre consists of
three buildings, including a ward building to the south, and is reached
via the main corridor from the new entrance hall. It links directly to the
New ward building renovated and restructured treatment building in which the operating
theatres are located.
The rectangular building, with its white render façades and ribbon
Modern-day patient rooms have to be much windows interspersed by orange and yellow vent boxes, is the first of
more than a place for patients to stay and the three sections. It contains an intensive care unit with intermediate
recuperate. Different clinical symptoms care areas, general care wards and wards for specific medical conditions,
place varying requirements on the design including a spinal cord unit, with a total of 72 beds.
of patient rooms and their fittings. This As a trauma centre, the BGU Accident and Emergency Hospital
spinal cord unit shows how the design of the treats and cares for patients with paraplegia resulting from an acci-
patient rooms incorporates specific technical dent or illness. The specialist department for spinal cord injuries can
equipment and helps address the challenges accommodate 17 patients and is located on the second floor. It has
facing paraplegia patients. nine barrier-free patient rooms, of which five two-bed rooms and one
isolation room are wheelchair-accessible. The architects devoted par-
ticular attention to these rooms. Their wider structural spans of 5.20 m
Architects and large floor areas of almost 31 m² provide sufficient space to arrange
Dewan Friedenberger Architekten GmbH beds offset to and opposite each other and to park a wheelchair next
to the bed.
Client
The furnishings, design and atmosphere of the rooms are geared
Berufsgenossenschaftliche Unfallklinik
towards longer-duration inpatient stays and the degree of injury that
Frankfurt a. M. gGmbH
patients may have: all furnishings were planned with special considera-
Location tion of hygiene factors and access for people with disabilities. A media
Frankfurt am Main, Germany panel next to each bed allows patients to control lighting levels, sun
Completion shading, to watch or listen to media and to call a nurse. Additional cont-
2017 rol devices are available for patients with tetraplegia, a form of paralysis
below the neck. An overhead lift allows nursing staff to help patients
Beds per floor in and out of bed with the help of lifting sheets – for example into a
17 wheelchair or a mobile commode chair. A disinfectant dispenser near
Net area, two-bed room the door is incorporated into the fitted furnishings, reminding patients
30.6 m² + 6.7 m² bathroom and visitors to disinfect their hands when entering and leaving the room.
Each of the rooms has its own disabled-access bathroom, some of
which are specially designed for patients with obesity. The bathrooms
are large enough to be accessed with a shower trolley and have an over-
toilet-compatible WC as well as – for hygienic reasons – a wall-mounted
bedpan washer.
The placement of the beds opposite each other has hygienic advan-
tages while also enabling better communication between patients. A
desk, larger cupboard storage, a refrigerator as well as wood-decor
1 flooring contribute to the high quality of the interior. The interplay
of lighting and ventilation openings as well as the choice of calming
colours, the well-thought-out furnishings and generous room size create
a positive atmosphere for long-stay patients.

118 Typologies
 3

1 Site plan, 1 : 20,000

2 Façade with coloured vent boxes
3 View of the main corridor connecting
the separate buildings
4 Ward floor plan, 1 : 500

119 Case Studies

5

7 8

120 Typologies
10

11

5 Bathroom in the spinal cord unit

6 Vent box
7 Corridor in the spinal cord unit
8 Nurses’ station
9 Floor plan of the patient rooms, 1 : 100
10 Two-bed room in the spinal cord unit
11 Two-bed room in the spinal cord unit with media panel

121 BGU Accident and Emergency Hospital

Princess Máxima Center
The Princess Máxima Center is a centre for healthcare and research in one
that focuses on treating children with cancer. At a size of 45,000 m²,
it is the largest paediatric oncology centre in Europe. Developed in
New clinic for paediatric oncology cooperation with Kopvol, an architecture practice specialising in psycho­
logical aspects of architecture, the spatial concept aims to create a
place where young patients feel safe and can spend time with their
The compelling design concept for the parents and relatives with primary focus on their recovery. The wards
Princess Máxima Center with its numerous consist exclusively of single rooms, to which a guest room is connected.
communal areas and play corners in the A sliding door connects the two areas of the room and creates a visual
patient rooms aims not just to make the link between the two sleeping areas, but two bathrooms and separate
young patients’ stay as pleasant and free entrances from the ward corridor mean that they can also be used
from anxiety as possible. It also includes a independently and flexibly.
specially developed area for parents with a Pergola-like balconies, most of which are arranged around the inner
separate bathroom – an interesting varia- courtyards, provide a connection with outdoors from each room and
tion on the idea of rooming-in that will for are reached through the parents’ room so that children cannot go out-
sure become even more relevant in future. side unattended. There are also specially designed communal areas for
different age groups that address the different interests and needs of
the children and promote social interaction between them. In addition,
Architects spaces are provided for cooking and socialising at the dining table
LIAG architects and for playing together with visiting grandparents. These facilities
contribute to the homely atmosphere of the Princess Máxima Center.
Interior designers
Each patient room has a nurses’ workplace with a washbasin and
Mmek
adequate storage for materials, and the bathrooms for the patients are
Client barrier-free with sliding doors. In addition to parental supervision from
Board Princess Máxima Center, Utrecht NL the neighbouring space, a glass door and an additional window ensure
Location optimal visibility of the bed area from the corridor. Nurses can oversee
Utrecht, the Netherlands the patient from the workstation next to the entrance to each room.
From here they can record patient data without needing to return to a
Completion central nurses’ station, avoiding the risk of potential mix-ups. By making
2018 it possible to access the digital patient record right next to the patient
Beds per floor room, no unnecessary equipment need be brought into the room.
40 The parents’ area is understandably more simply equipped, but an
integral refrigerator offers a level of comfort appropriate for longer stays.
Net area, single room The low window sills are articulated as benches with storage boxes
16.08 m² + 4.41 m² bathroom beneath in which toys can be stowed. Patients have a good view of the
Net area, guest room courtyards and outdoor areas, whose playfully designed playgrounds
11.21 m² + 2.39 m² bathroom are intended to encourage children to romp in the fresh air.

1 Site plan, 1 : 20,000

2 View of the clinic
3 Ward floor plan, 1 : 1000

122 Typologies
 2

123 Case Studies

 4

124 Typologies
6

4 View of the balconies from the courtyard

5 Outdoor area in an inner courtyard
6 View of atrium
7 A communal play area
8 A workstation for nursing staff in the corridor 8

125 Princess Máxima Center

9

10

11

126 Typologies
12

9 View of the entrances and bathrooms

in both halves of the room
10 Patient room with the adjacent parent area
11 Floor plan of the patient rooms, 1 : 100
12 Patient room with view of the balconies

127 Princess Máxima Center

St Joseph-Stift Dresden
The new, three-storey west wing of the St Joseph-Stift comprises a 1200 m²
large acute geriatric care unit with capacity for about 400 patients
annually as well as a central outpatient clinic on the ground floor that
New acute geriatric care unit and brings together all the outpatient consultation facilities in one place. Its
central outpatient clinic 720 m² accommodate 18 treatment rooms and extensive waiting areas.
From the outside, the brick and render façade with its striking grouped
window strips is more reminiscent of a residential building than a clinic.
The majority of patients treated in hospitals Inside, the floor plans have been kept very clear. Patients of an
are over 65 years of age and dementia is in advanced age and especially those with dementia often find admis-
many cases a secondary diagnosis alongside sion to hospital a highly confusing experience. To help them find their
the primary clinical condition. The design of bearings in unfamiliar surroundings, the design deliberately conveys a
the patient rooms of the geriatric unit at the calm, non-challenging atmosphere. The simple floor plan arrangement
St Joseph-Stift in Dresden shows how one assists in providing effective orientation, with straight corridors leading in
can address the challenges of dementia and clear directions and direct visual relationships between patients and staff.
impaired mobility with the help of a coherent It allows patients to move freely around the ward while simultaneously
overall concept. preventing them from “walking off”. The system of double corridors
with a central transparent nurses’ station is well-suited to this purpose.
Alongside providing acute therapy, acute geriatric treatment aims
Architects to enable patients to maintain or regain the ability to care for themselves
wörner traxler richter independently. As such, the patient rooms are not just a place for the
patients to stay but also a therapy room. Due to the greater need for
Client
assistive aids, the rooms are 20 % larger than the usual hospital rooms so
Krankenhaus St. Joseph-Stift Dresden GmbH
that there is ample room for patients using walking frames, rollators or
Location wheelchairs. The patient bathrooms are also designed to be accessible
Dresden, Germany to people with handicaps and are twice as large as those normally found
Completion in patient rooms. They include wall-hung washbasins for easy wheelchair
2018 access, sufficient turning space for wheelchair users, hooks and controls
that are easy to reach while seated, and low-mounted mirrors.
Beds per floor As many patients are predominantly sedentary, the sill height of the
26 windows is lower to afford a better view and the sills often double as a
Net area, two-bed room bench seat. Curtains provide greater privacy – a common preference
25.2 m² + 6.2 m² bathroom among older people – while also allowing daylight into the room along
with a glimpse of the sky.
A helpful detail brought over from the hotel sector is the use of
orientation lighting close to the floor that helps patients find their way
to the toilet at night without being dazzled by the bright light of the
room or disturbing another patient in the room. A large mirror with
additional handrails near the entrance to the room is useful for postural
training after a stroke.
Another key element is the so-called “Memoboard” with a therapy
calendar, television and a large, clearly legible wall clock. Staff can attach
personal treatment reminders and use it for memory training with the
patients. There are also “empty” picture frames for patients to insert
1 personal mementos and family photos.
In the patient rooms and accompanying bathrooms, blue and orange
colour accents have been used to assist patients with dementia and those
with poor sight to locate and recognise key parts of their environment. The
colour code is used for distinguishing the respective patient’s cupboards,
shelves in the bathrooms and also the towels. Special attention was also
given to the choice of colours and materials to ensure sufficient light/
dark contrast between different surfaces. Clear differentiation between
the bed and the floor, the chair and the floor, the wall and the floor,
and the handrail and the wall help reduce the risk of accidents and falls.
A continuous, non-reflective and pattern-free floor covering was
chosen to avoid the risk of floor markings being mistaken for steps or
gaps, causing unintentional stumbling or missteps. Only where such
visual barriers are useful – for example in front of the ward exits to dis-
courage patients from wandering out of the ward – has this principle
been used very specifically.

128 Typologies
2

1 Site plan, 1 : 20,000 3

2 The acute geriatric care unit at the St Joseph-Stift

3 Ward floor plan, 1 : 500

129 Case Studies

4

130 Typologies
7

4 Mirror with handrail and “Memoboard”

5 Bathroom
6 Floor plan of the patient rooms, 1 : 100
7 Patient room showing the colour-coded
patient cabinets
8 Patient room

131 St Joseph-Stift Dresden

St Gallen Geriatric Clinic
The existing building of the Geriatric Clinic was built in 1980 by Bärlocher
& Unger as an addition to St Gallen’s Bürgerspital, a public hospital com-
plex from the 19th and 20th century. The site comprises three buildings
Renovation and extension that together constitute the Kompetenzzentrum Gesundheit und Alter
(competence centre health and age) in St Gallen. To ensure the contin-
ued operation of the Geriatric Clinic during the renovation and extension
This room type with two beds placed at right works, a temporary structure was built that is to be dismantled later.
angles to the façade is comparatively rare The extension adds a new layer of rooms along the entire north
due to the large room width it entails. It is, face of the building, maintaining the urban figure of the building as well
however, particularly beneficial for patients as the linear building line of the Bürgerspital ensemble. The result is a
who are confined to their bed for most of rational arrangement of three parallel spatial layers in which the new
their stay. Both patients benefit from the rooms augment the existing operational organisation of the building. The
same outlook towards the window, the same façade of the new north wing picks up aspects of the existing building,
proximity to the door and more favourable incorporating the horizontal strip windows and concrete cladding of
lighting thanks to the room’s advantageous the south side. At the same time, sheet metal profiles were inserted
proportions. between the concrete bands and glazing on both the north and south
façades, which along with slender window frames, gives the whole a
sleek, modern appearance.
Architects The geriatric ward treats elderly patients who frequently suffer from
Silvia Gmür Reto Gmür Architekten multiple conditions and need special support. The intention of the treat-
ment is to enable patients to lead a largely independent life after their
Client
stay in hospital. With advancing old age, many people are unsettled by
Geriatrische Klinik St. Gallen AG
changes to their life situation. The design of the patient rooms, including
Location the arrangement of the beds and the equipment, therefore strives to
St Gallen, Switzerland create a calm and peaceful environment for the patients. The ancillary
Completion spaces and nurses’ stations are accessible from two sides, on the one
2020 hand ensuring the shortest direct path from carer to patient, and on
the other forming a ring that allows patients with an urge to move to
Beds per floor circulate within the ward.
28 The patient rooms in the newly added layer of rooms are compa-
Net area, two-bed room ratively wide and shallow in depth. The windows run along the entire
30 m² + 2.3 m² bathroom breadth of the room, heightening its sense of spaciousness, while the
back of the room behind the beds is lined with cupboards that conceal
and incorporate technical equipment and provide storage for use by
the patients and nurses. The entrance is located in the middle of the
cupboards, dividing the room into two patient areas. The generous
distance between the patients allows the space between to serve as a
communal area and it can also be used as a dining area.
The arrangement of the beds at right angles to the corridor and
window, along with the low sill height, affords patients an expansive view
of the surroundings from their beds over the entire width of the room.
The bathroom is likewise of a generous size and is reached via a
transitional zone that has daylighting and a washbasin. Patients can
1 use this sheltered space, which is separated from the rest of the room,
to wash and dress out of direct sight but not within the bathroom.
The warm tone of the oak windows and wall units, the dark red of the
linoleum floor and the light colours of the walls aim to create a welco-
ming, restful character in which the presence of indispensable medical
equipment recedes into the background.

132 Typologies
2

1:500

1 Site plan, 1 : 20,000

2 View of the new north wing of the hospital
3 Ward floor plan, 1 : 500

133 Case Studies

 4

134 Typologies
7

4 View of patient room circulation area

5 Alcove in front of bathroom with washbasin
6 Patient room with a generous view
7 Patient bed with bedside terminal
8 Floor plan of the patient rooms, 1 : 100

135 St Gallen Geriatric Clinic

Uster Hospital
The design of the new rehabilitation centre and ward building at Uster
Hospital draws on the typology of the historical sanatorium buildings
from the 1930s and takes it a step further to develop its own solution for
New rehabilitation centre the new extension. By turning the rooms slightly out of the axis of the
new building, they pick up the orientation of the existing building and
divide the large building mass into individually articulated units – the
By arranging the same-handed rooms at architects’ answer to expressing the aspect of human scale in a large
a slight angle, each room benefits from a clinic building. The façade is therefore an expression of the underlying
southerly orientation. The resulting triangular design idea.
indentations in the façade become balconies All the rooms face south and have floor-to-ceiling glazing providing
and a twist in the room plan allows for moving generous views of the surrounding park and mountainous landscape and
the bed into a second position. The project ensuring optimal illumination with natural light. Each room is fronted by
shows how small deviations from conventional a walk-on balcony, with slats screening patients in neighbouring rooms
floor plans can create new possibilities and from prying eyes. The horizontal screen in front of the balcony provides
improve the quality of the patient’s stay. shade, obstructs the direct view downwards and focusses attention on
the snow-capped mountains beyond.
The patient rooms are barrier-free and wheelchair-accessible in all
Architects areas, not just in the bathrooms but also in the common zones, and a
Metron Architektur AG, Brugg floor-flush threshold provides direct access to the wood-covered balcony
via a sliding glazed door.
Client
The position of the beds can be varied so that both beds can be
Zweckverband Spital Uster
placed lengthwise along the wall without any restrictions. Their diagonal
Location placement eliminates the disadvantage of the rear bed, allowing the
Uster, Switzerland patient almost the same view as from the front bed, even when the
Completion privacy curtain between the beds is drawn. The patients’ common area
2025 with table and chairs fits perfectly into the bay window of the façade
with its panoramic glazing.
Beds per floor The wall dividing the room from the bathroom is a custom-made
30 fitting that includes a barrier-free shower, toilet and washbasin and has
Net area, two-bed room multifunctional niches and cupboards that can be used from either side
30.3 m² + 4.6 m² bathroom of the wall by the patients and nursing staff. The wooden headboard
wall behind the patient beds incorporates and conceals the medical
fittings and lighting in order to emphasise the atmospheric qualities of
the room as a living area over its medical function.

136 Typologies
3

1 Site plan, 1 : 20,000

2 The patient room units seen from outside
3 Patient room
4 Ward floor plan, 1 : 500
5 Floor plan of the patient rooms, 1 : 200 5

137 Case Studies

Surgical Centre
Founded in 1815, Erlangen University Hospital has a total capacity of 1394
beds and is a central healthcare facility of the city as well as a training
institute for the medical faculty of the Friedrich-Alexander University
Erlangen University Erlangen-Nuremberg. Most of the buildings are located near the Schloss-
garten in Erlangen. The new ward block building provides 328 beds and

Hospital is the first construction phase for the new Surgical Centre (OPZ) on the
main site on the edge of the historical city centre. The building follows
the course of the listed city wall and is divided into two sections by an
New ward block entrance courtyard. Coarse render with natural stone inlay and striking
window elements contrast with delicate, delineated metal façades,
expressing the tension between the historical surroundings and the
For the patient rooms at the Surgical Centre requirements of a modern hospital.
in Erlangen, the architects experimented Each floor of the building is divided into two wards with 34 beds,
with different surface qualities: each arranged around a greened inner courtyard. Patients and visitors
smooth and reflective in the entrance area enter a ward, either from the respective main stairs and lift or from the
and for impact protection, and glass wall adjacent medical building, arriving at a central point near the nurses’
surfaces in the bathroom, which are usually station and patient waiting area.
reserved for private healthcare patient Views into the inner courtyard or onto the street help provide
rooms. Together with the use of wood decor orientation within the wards. The patient rooms are arranged along one
and selected colours, they have created a side overlooking the street, and between the two wards a large balcony
tasteful and inviting overall interior that allows patients to step outdoors and look onto the entrance courtyard.
complements the design quality of the entire Each ward has various types of patient rooms: two-bed and single rooms
clinic building. are supplemented by a four-bed supervision room, a disabled-access
patient room and a room with airlock.
The headboards in the patient rooms are equipped with a high
Architects degree of technical fittings for treating patients after surgery, but they
Tiemann-Petri Koch Planungsgesellschaft do not dominate the room. Ample wood, a seating area at the window
with an overhead pendant lamp and the wall opposite free of equipment
Client
and installations create a calm environment for the patients.
Free State of Bavaria
Cupboards for supplies and for patients’ belongings are located
Erlangen-Nuremberg State Building Authority
in the entrance area to the room next to the bathroom so that the
Location area around the bed can be kept free for therapy and treatment. The
Erlangen, Germany same-handed layout of the rooms and the flush-fitted cupboards also
Completion ease handling of the beds in transport. The cupboards have mobile
2013 cupboard inserts for holding patient belongings so that they can be
relocated along with the bed should a patient change rooms.
Beds per floor A washstand spanning the width of the bathroom along with gene-
68 rous shelf space and a large mirror helps impart the impression of
Net area, two-bed room spaciousness. The mirror height and washstand are designed to be
22.56 m² + 3.08 m² wet room usable by patients in wheelchairs.
Within the rooms, simple but high-quality materials have been
used. The double-leaf entrance doors are articulated as room-high ele-
ments within solid oak frames, which are likewise used for the window
1 surrounds. By contrast, the glossy white cabinet surfaces and joint-
free glass walls in the bathroom combine easy-clean functionality with
smooth modern aesthetics.
The patient rooms on the ground floor that face directly on the
historic city wall are glazed from floor to ceiling and look onto their
own semi-private green courtyard with a view of the city wall behind
as a historical backdrop.

138 Typologies
 3

1 Site plan, 1 : 20,000

2 Inner courtyard

1:750
3 The east façade and the historical city wall
4 View of green courtyard in front of ground
floor patient room
5 Ward floor plan, 1 : 750

139 Case Studies

6

9 10

11

140 Typologies
12

6 Patient balcony
7 Ward corridor with entrances to the rooms
8 Ground floor patient room with floor-to-ceiling
windows
9 Mobile patient wardrobe
10 Patient bathroom (standard) with glass walls
11 Floor plan of the patient rooms, 1 : 100
12 Patient room with seating area and wood
window surrounds
13 Entrance area within the patient rooms 13

141 Surgical Centre, Erlangen University Hospital

Crona Clinic
Since 2002, a|sh architekten have successively realised various build-
ing projects on the site of the University Hospital in Tübingen. For the
renovation of the Crona Clinic, which first opened in 1988 and derives
Tübingen University its name from the German words for surgery, radiology, orthopaedics,
neurology and anaesthesia, they took a holistic approach that aimed

Hospital to give the clinic a contemporary, more patient-friendly focus. For the
renovation of the “Wards of the Future” section of the building, which
was completed in 2015, incorporated fire safety improvements and
Renovation and fire safety improvements equipped the wards to meet future needs.
After the ward building was gutted, only the loadbearing walls
and columns, the floor slabs, ceilings and the façades remained. The
In recent years, patient rooms have increas- new floor plan for the star-shaped building incorporates more views
ingly been equipped with a supply point of the outside world to assist orientation within the wards. Two wards
providing gloves and disinfectant dispensers were created, a standard care ward and a private healthcare patients’
for clinic and nursing staff. These can take up ward, with a total of 44 beds, four of which are in single rooms. The
more or less space, depending on require- nurses’ station is located at the centre, creating a link between the
ments. The patient rooms at the University two wards. Its open design facilitates better communication between
Hospital in Tübingen employ a particularly visitors, patients and staff.
slimline integral solution that is immediately A restrained colour scheme ensures a contemporary appearance.
visible to staff entering the room but remains Different tones of blue create accents in the corridors and wall panelling,
out of sight to patients lying in bed. creating a sense of greater space. In the patient rooms, the shades
of blue are complemented by warmer tones and wood decor, and
abstract motifs of the city of Tübingen serve as graphical references
Architects to the location of the clinic.
a|sh sander.hofrichter architekten GmbH Before renovation the bathrooms had a threshold, making barrier-free
access impossible. The cupboard walls were also used to pass bed linen
Client
through to the ward corridor. Fire safety regulations made it necessary to
Vermögen und Bau Baden-Württemberg,
revise this arrangement. Some slight changes and a redesigned bathroom
Tübingen Council
created more space in the rooms. The new fitted furniture incorporates
Location storage usable from the bathroom and from the room, creating a cleaner,
Tübingen, Germany tidier overall impression.
Completion Instead of a separate workplace for staff near the entrance to the
2016 room, the glove dispenser, waste bin and disinfectant dispenser have
been incorporated in a vertical slot in the wall that staff see as soon as
Beds per floor they enter the room but is concealed by the wall from patients lying in
44 bed. The low sill height of the windows also allows patients to enjoy
Net area, two-bed room the view out of the window from their beds.
26.11 m² + 4 m² bathroom The private healthcare patient rooms feature glass headboard
panels behind the beds as well as other high-quality materials that
further enhance the comfort and quality of the interiors.

142 Typologies
2

1 Site plan, 1 : 20,000 3

2 View of the building
3 Ward floor plan, 1 : 750

143 Case Studies

4

144 Typologies
10

4 Nurses’ station
5 Seating area for patients and visitors
6 Ward corridor
11
7 Graphical motifs refer to the clinic’s location
in Tübingen
8 Patient bathroom in a standard room
9 Floor plan of the patient rooms (standard
care ward), 1 : 100
10 Two-bed room (standard care ward) with
a view of the supply point
11 Single-bed room (private healthcare ward)
with glass headboard panel behind the beds

145 Crona Clinic, Tübingen University Hospital

Erasmus MC
Erasmus Medical Center (MC) in the heart of Rotterdam is the largest
university medical centre in the Netherlands. On the site of an existing
hospital, a new complex was built where healthcare, research and edu-
New university hospital cation all come together. The new building comprises 522 medium-care
patient rooms, 38 intensive care units, 18 ICCU rooms (intensive cardiac
care units) as well as 94 day-patient treatment places. The nursing wards
The floor plan of the patient rooms at the are located on the 8th to the 12th floor, thus far away from the bustle
Erasmus MC University Hospital in Rotterdam of the public areas and the city. This complex transforms the university
is particularly flexible. Based on the layout medical centre from a cluster of separate buildings into a small medical
of the standard room, three additional room city for 13,500 staff, 4500 students and thousands of patients.
types for more demanding use cases were There are four types of patient rooms, depending on care require-
developed through minor interventions. The ments: standard rooms, extra-large rooms, pressurised and isolation
convertible seating adds a rooming-in option rooms for haematology care.
to the patient rooms and testifies to the All of those 522 rooms have direct daylight with views towards
demand for maximum functionality combined the city, the port or the roof garden. Patients can open their window
with the high level of planning standardisation by themselves, unusual in a hospital, thus encouraging activity and
that is inevitable in projects of this size. bringing in fresh air. The wooden window frames, together with the
carefully chosen colour palette and specially designed window cover-
ing, generate a warm domestic atmosphere. All fixed and freestanding
Architects elements in the room are kept at a low height, which makes the room
EGM architects, EGM interiors appear spacious and ensures uninterrupted views from the bed to the
outside and to the door. In the pressurised alcove a ceiling-high glass
Client
corner provides a direct and undisturbed sightline towards the patient
Erasmus MC
upon entering.
Location Every room has its own bathroom which is wheelchair-accessible.
Rotterdam, the Netherlands The room is equipped with a toilet, shower and a tailor-made washbasin.
Completion The toilet is positioned in line with the door, enabling easy access for
2017 an overtoilet wheelchair. Rounded corners in the shower area ensure
less soap and dirt accumulation and easy cleaning, while the shower
Beds per floor faucet is mounted close-by for easy access by the nursing staff without
122 getting wet.
Net area, single room By the window, a specially designed canape provides an attractive
18.94 m² + 3.97 m² bathroom place to sit. At night, it can be folded out to become an extra bed for vis-
itors. All rooms have an electric ceiling hoist to facilitate moving patients.
In addition, plenty of attention has been given to self-sufficiency and
self-control. The latest technologies have been installed for supplying
meals, administering medication and monitoring the patients. Patients
can watch TV, use the internet, or call a nurse from anywhere in the
room using a tablet. There is an alarm button attached to the bed, and
the nursing staff can also call for help using the wall-mounted alarm
display unit. Mobile patients wear a wristband so that they can alert
the nursing staff if necessary while outside their bed, even when in the
outside roof garden. But not everything is fully automated. A conscious
1 decision was made, for instance, not to provide a remote control for
closing the curtains; the nurse will always come to the room at the end
of the day for a final check and personal contact.
Erasmus MC opted exclusively for single rooms in the new hospital
but for years, this was a subject for debate. Feedback, however, showed
that almost all patients prefer peace and quiet to social contact. For
socialising, patients can meet in the lounge or in the bed-accessible
3000 m² roof garden located on the 8th floor. It provides an oasis of
calm, relaxation and diversion for patients, who sometimes remain in
hospital for extended periods of time.

146 Typologies
2

1 Site plan, 1 : 20,000

2 View of the roof garden
3 Erasmus MC with main entrance
4 Ward floor plan, 1 : 1000 4

147 Case Studies

 6

148 Typologies
10

5 Seating area with family room in the

nursing ward
6 Patient bathroom
7 Pressurised room with bathroom
8 The ceiling-high glass corner of the alcove
allows a view into the patient room.
11
9 Floor plan of the patient rooms, 1 : 100
10 Patient room with tailor-made rooming-in
furniture
11 Entrance with nursing workplace in
standard room

149 Erasmus MC
Oncological Centre
The new Oncological Centre at UZ Leuven, located on Gasthuisberg,
consolidates and upgrades existing oncology facilities at Leuven Uni-
versity Hospital, Belgium’s largest hospital. A single multidisciplinary
Leuven University unit on 23,000 m² will diagnose and treat up to 35,000 patients from
across the country.

Hospital The centre will be located at the crossroads of care, education,

research and medical-social facilities on the campus, thus reflecting the
multidisciplinary nature of oncology. The new centre will provide room
New hospital for outpatient clinics, clinical trials, radiotherapy and nursing wards. In
addition, the building will form one of the main entrances to UZ Leuven.
Incorporation into the campus, building height, daylighting, orien-
The nested position of wet cells between the tation and connection with the hospital are leading factors in modelling
patient rooms results in a rectangular floor the building volume. The centre’s appearance is characterised by a
plan and therefore in very good conditions for modest but distinctive architecture. A pure orthogonal mass is under-
flexible use of space. This solution also works to scored by freely designed spacious patios. The fact that the centre
the advantage of the patient rooms in the new very conveniently faces southwest, combined with the large voids on
Oncology Centre in Leuven. Guide rails behind the lower storeys, ensures that daylight can reach all essential areas.
the beds allow for different positions for the All design decisions are based on the ambition to create spaces
bed and thus create options for individual that are user-friendly to a range of users. Through trials with hospital
seating areas, enabling new room layouts in staff, design decisions are to be checked during the planning phase
a two-bed room. and can be optimised. A balanced ratio of single and two-bed rooms
was striven for, so that each floor has 14 double and 12 single rooms.
The patient rooms are equipped with a system which enables the
Architects beds to shift along a guide rail. By altering the bed’s position, various
Wiegerinck options for seating are enabled.
LOW Architects Thus, each patient in a two-bed room should be designated their
own, clearly defined zone, with their own seating area. This serves as a
Client
visitor zone for relatives or as a place for relaxing activities such as reading.
Universitair Ziekenhuis Leuven
The bathrooms are situated between the patient rooms in order to
Location have a fairly flexible corridor wall where a window is placed to optimise
Leuven, Belgium visual contact between patients and medical staff. The awareness of
Completion medical professionals close-by affects the patient in a positive way; this
2023 can shorten the process of recovery.

Beds per floor

40

Net area, two-bed room

32 m² + 5 m² bathroom

150 Typologies
 2

1 Site plan, 1 : 20,000

2 Oncology Centre with entrance for UZ Leuven
3 Ward floor plan, 1 : 500 3

151 Case Studies

4

152 Typologies
7

4 Entrance and window between corridor

and room
5 Bathroom 8

6 Floor plan of the patient rooms, 1 : 100

7 Two-bed room
8 View from patient bed towards bathroom
and nursing workplace

153 Oncological Centre, Leuven University Hospital

Paediatric Clinic
The new clinic for children and adolescents is situated in the grounds
of Freiburg’s University Hospital and unites the paediatric facilities and
institutes that were previously dispersed across different buildings. The
Freiburg University placement and figure of the building allows the landscape to flow
around the building and into the five green inner courtyards. New

Hospital gardens and adventure zones will be created in the existing park to
meet the different needs of children and young people.
The design of the patient rooms elevates patient well-being to its
New clinic building central principle, creating a safe and welcoming environment tailored to
the specific requirements of the “parent-and-child patient”. This term ref-
lects the importance of the family for the recovery of the young patients,
Little attention is devoted to the space and the concept therefore also considers the health of the parents. As
opposite a bed and all too often patients such, the need for close personal interaction between the children and
are left to look at a blank wall. Not so in the their parents influences the spatial design of the patient rooms.
Paediatric Clinic in Freiburg where seating The patient rooms have one or two beds and are clearly zoned
and play areas have been created in the into different areas. The seating area near the window creates space
patient rooms. This seemingly self-­evident for sitting and communication while the permanent rooming-in area is
solution is an ice-breaker when rooming-in designed as a niche in which the young patients can play together with
and also an incentive for relatives and visitors. In the two-bed rooms, this area extends across
patients to get out of bed. the entire wall opposite the beds so that the patients always have an
interesting view from their beds.
Immediately behind the entrance door is a work area for nursing
Architects that picks up the diagonal of the bathroom wall and directs incoming
ARGE Health Team Vienna people straight towards the patient as soon as they enter the room.
Albert Wimmer ZT GmbH The entrances to the rooms are offset in niches from the ward corridor,
Architects Collective GmbH creating a small buffer zone and “address” for each room.
The colour scheme and materials as well as the choice of motifs take
Client
into account the wide age range of the patients from young children
State of Baden-Württemberg
to young adults. A series of different images were developed that pick
Location up and adapt motifs from the local Black Forest region, which are used
Freiburg, Germany to denote the different rooms.
Completion Particular attention was given to ways in which patients can person­
2023 alise their rooms to create a family-friendly environment and promote
recovery. Various magnetic and writeable surfaces can be used by the
Beds per floor patients to make the room their own. In addition, communal play areas in
69 the wards encourage mobility and personal development and promote
Net area, single room interaction between the patients, helping them to make new friends.
20.5 m² + 4 m² bathroom

Net area, two-bed room

26.5 m² + 4 m² bathroom

154 Typologies
2

1 Site plan, 1 : 20,000

2 The paediatric clinic and its outdoor areas
3 Ward floor plan, 1 : 750
3

155 Case Studies

 5

156 Typologies
8

4 Nurses’ station with a view of the room

entrances (left)
5 Library
6 Main corridor along the inner courtyards
7 Floor plans of the patient rooms, 1 : 100
8 Two-bed room
9 Single room with writing desk

157 Paediatric Clinic, Freiburg University Hospital

Children’s University
An international competition for the design of a new building for the
Children’s University Hospital in Zurich was launched in 2011, and sub-
sequently won by the architects Herzog & de Meuron. With 200 beds,
Hospital Zurich including 51 intensive care and neonatal beds, it is the largest hospital for
the inpatient and outpatient treatment of children and young people in
Switzerland. In addition to treating a range of highly specialised medical
New acute care hospital conditions, it also incorporates spaces for research, teaching and the
promotion of young academics in the field of paediatrics.
These two facilities – an acute care hospital and a research and
To create a sense that each patient room at teaching unit – are housed in two buildings. The Akutspital on the south
the Children’s University Hospital in Zurich is site is a three-storey, strongly horizontal building located opposite the
an individual entity, the design emphasises existing “Burghölzli”, the Psychiatric University Hospital in Zurich. The
a frequently neglected aspect of patient main entrance to the new building, a large opening, is exactly opposite
rooms: the ceiling. The symbolic notion of the historical portal of the existing building and the concave gesture of
a roof over one’s head imparts a sense of the entrance façade creates a large joint forecourt for both institutions.
shelter and being looked after in the unsett- Inside, the Akutspital is designed like a gridded city with streets,
ling situation of being ill and in hospital. intersections and squares. Each floor has a main street and the functional
facilities are their quarters. A large number of planted inner courtyards
of different sizes illuminate the interior and punctuate the orthogonally
organised interior space. Some of the courtyards are more conspicuous
due to their round shape and are arranged along the main street near
the entrances to the most important functional areas.
Architects The wards are located on the top, the most private level of the
Herzog & de Meuron Akutspital. Designed as quadrants, they contain a total of 114 rooms
arranged in a ring and oriented outwards. Both single and two-bed
Client
rooms are equipped with sofas that can be converted into sleeping
Kinderspital Zürich – Eleonorenstiftung Zürich,
accommodation for parents and relatives. They also have a work area
Switzerland
for the nursing staff. Each individual patient room is designed as a small
Location house with its own roof, ensuring privacy for the young patients and
Zurich, Switzerland their relatives in combination with an expansive view. By staggering the
Completion arrangement of the rooms and varying the roof incline, each individual
2022 room is legible as a separate unit: this elementary, immediately com-
prehensible form expresses the individuality of each patient within the
Beds per floor larger complex of the hospital.
114

Net area, single room

20 m² + 4 m² bathroom

Net area, two-bed room

30 m² + 4 m² bathroom

1 Site plan, 1 : 20,000

2 View of the entrance area
3 Inner courtyard
4 Ward floor plan, 1 : 1000

158 Typologies
2

3
4

159 Case Studies

5

5 Two-bed patient room

6 Floor plan of the patient
rooms, 1 : 100 6

160 Typologies
Münster University
The renovation and restructuring of the patient rooms in the east and
west towers housing the wards of Münster University Hospital (UKM)
are part of the “University Medicine 2025” project, which is the culmi-
Hospital nation of a study begun in 2014 by the UKM and the Medical Faculty
of the University of Münster, aimed at developing robust sustainable
strategies for hospitals.
Renovation of the ward towers While the façades of the so-called bed towers have already been
renovated, the renovation and restructuring of the wards within is ongoing.
The new plan will accommodate either 38 beds in two-bed rooms or 19
Fitting two-bed rooms into a radial floor beds in single rooms, depending on the occupancy concept. The rooms
plan is particularly challenging because are watched over from a nurses’ station at the centre of each floor with
the tapered room shape makes it hard to the ancillary functional spaces. Patient rooms can be allocated to one
create two equally good bed places. At the or the other nurses’ station according to the “floating principle” so that
Universitäts­klinikum Münster, two nested the hospital can react flexibly to changing patient occupancy levels.
bathrooms have been arranged spaced apart The creation of care groups spanning different clinical treatment areas
between the rooms, creating a niche for the is also planned.
bed closest to the door, or for a comfortable The interiors of the patient rooms will change significantly. The
sofa area in the single rooms. structure of the new façade has been hung in front of the existing con-
crete parapet elements, making it possible to incorporate the previous
escape balconies into an enlarged room design. To provide fresh air to
the room, a vent casement can be opened. The façade construction with
internal window elements and external skin optimises thermal insulation
in winter and prevents overheating in summer thanks to solar shading
elements arranged between the layers.
Architects
The room enlargement makes it possible to position the bathrooms
wörner traxler richter
along the partition wall between two patient rooms, and in turn to
Client stagger the position of the beds in a two-bed room, avoiding the pro-
Universitätsklinikum Münster blem of there being a “window-bed” and “corridor-bed” as commonly
seen in parallel bed arrangements. Here, each position has its own
Location
qualities and an unobstructed view through the large window, as well
Münster, Germany
as a spacious zone around each bed for greater privacy and receiving
Completion visitors. Arranging beds in opposite directions also facilitates better
2025 interaction between room occupants. In the single rooms, typically
Beds per floor for patients with private health insurance, the niche can be used for a
38 seating area instead of a second bed. The placement of the bathrooms
between the rooms also ensures that staff have a good view of both
Net area, two-bed room patients, as does the radial structure which gives the hospital building
26.3 m² + 4.3 m² bathroom its iconic, recognisable form.

161 Case Studies

2

1 Site plan, 1 : 20,000

2 View of the two bed towers
3 Single room with sofa niche
4 Ward floor plan, 1 : 500
4
5 Two-bed room
6 Floor plan of the patient rooms,
1 : 100

1:500
162 Typologies
5

163 Münster University Hospital

Building
In 2015, a survey of the condition of building structures in German hospitals
was undertaken for the first time with the help of the Hospital Infection
Surveillance System (Krankenhaus-Infektions-Surveillance-System – KISS)
of the German National Reference Center for Surveillance of Nosoco-

Structures mial Infections (NRZ), which has been recording nosocomial infection
rates and multi-resistant pathogens throughout Germany since 1997.
The National Reference Center is run by the Institute for Hygiene and

in German Environmental Medicine at Charité – Universitätsmedizin Berlin.

The survey was conducted within the framework of the research pro-
ject “HYBAU+” by an interdisciplinary research team of experts from the

Hospitals
fields of building construction (Institute of Construction Design, Indus-
trial and Health Care Building, Technical University of Braunschweig),
material sciences (Institute of Building Materials, Concrete Construction
and Fire Safety, TU Braunschweig) and hygiene (Institute for Hygiene
and Environmental Medicine, Charité – Universitätsmedizin Berlin) who
investigated how structural and functional processes in hospitals can
be optimised for better hygiene, how hygienic materials can be used
more optimally and how new building structures can be designed effi-
ciently and sustainably. The project was funded by the Federal Office for
Building and Regional Planning (BBR) as part of the research initiative
Zukunft Bau (Ref. No. SWD-10.08.18.7-14.04). The results were published
in 2018 in Bauliche Hygiene im Klinikbau, volume 13 of the publication
series “Zukunft Bauen”.
The survey was sent as an online questionnaire to the staff respon-
sible for KISS in the respective clinics, usually the hospital hygienists and
hygiene specialists. The survey of all hospitals participating in KISS was
conducted between March and June 2015 and invitations were sent to
1357 of the nearly 2000 hospitals in Germany. It comprised one ques-
tionnaire for the entire hospital and one short questionnaire for each
intensive care unit and neonatology unit. 621 hospitals took part in the
survey, corresponding to a response rate of 46 %. The questionnaire
for intensive care units was answered by 534 units from 368 hospitals.
Of the 246 hospitals asked, 127 neonatological wards provided data on
their building structures.
The survey examined the current state of the building structure
of hospitals in Germany and covered everything from the location of
the hospital (e.g. urban or rural), to the cubature of the building, the
geometric layout of the functional areas right down to details such as
whether the rooms are equipped with hand disinfectant dispensers.
The survey collected a broad range of data, ranging from the year
of construction of the hospital and periods of later structural alterations
to information on the building structures of the hospital building and
selective departments. Other aspects surveyed included the number
of single, double and multi-bed rooms, the room sizes and the distance
between the nurses’ station and the furthest patient room. The Institute
of Construction Design, Industrial and Health Care Building at the TU
Braunschweig developed pictograms for the different building structures
for use in the questionnaire.
The results of the survey made it possible to obtain an initial assess-
ment of the actual condition of building structures in hospitals and how
they compare to the corresponding guidelines for hospital hygiene and
infection prevention. From this, the discrepancy between actual and
desired conditions could be identified to determine the corresponding
References need for action in specific areas.
Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier,
Andrea Haselbeck and Inka Dreßler, Bauliche Hygiene im
Klinikbau. Planungsempfehlungen für die bauliche Infek-
tionsprävention in den Bereichen der Operation, Notfall-
und Intensivmedizin. (Zukunft Bauen – Forschung für die
Praxis, Vol, 13), Bonn: Bundesinstitut für Bau-, Stadt- und
Raumforschung, 2018

164 Typologies
Where is the hospital located? When was the hospital built?

Before 1900 16 %

16.9 % 17.7 % 1901–1945 23 %

1946–1960 11 %

1961–1990 35 %

1991–2000 8%
28.7 %
36.7 % After 2001 7%

City up to 100,000 inhabitants

City up to 500,000 inhabitants

City over 500,000 inhabitants

Rural area

When were building measures undertaken? When were building measures undertaken?

1901–1945 7% Intensive care ward

1946–1960 9% 1946–1960 2%

1961–1990 29 % 1961–1990 12 %

1991–2000 40 % 1991–2000 28 %

After 2001 71 % After 2001 58 %

No inter-
10 % Normal care ward
vention

1946–1960 2%

1961–1990 20 %

1991–2000 20 %

After 2001 58 %

165 Building Structures in German Hospitals

Which building structure has the hospital? What level of care does the hospital have?

Grown structure Freestanding building

50 % 18 % 12 %

34 %
17 %

18 %
19 %

Organically grown structure, i.e. the Freestanding, compact building volume

individual buildings evolved over time,
no coherent style

Normal care

Specialised care
Comb structure Plinth
Basic care
8.3 % 16.4 %
Specialised hospital
Maximum care

Are there patient rooms without a toilet?

Comb structure, i.e. the individual Base building with superstructure

wings of the buildings are connected 28 %
by a central spine

Mat Cluster

4.2 % 3.1 %
72 %

Normal care ward

Yes

No

Mat structure, several courtyards, Cluster structure, i.e. individual pavilions;

expandable the freestanding volumes are not
connected but have a consistent style

166 Typologies
Spatial organisation Structure normal care ward Structure intensive care ward

30.9 % 29.6 %

Normal Intensive
care ward care ward

Dead end corridors Dead end corridor

Number of beds 36 13 with centre access, with centre access,
e.g. in a high-rise slab e.g. in a high-rise slab

19.5 % 19.5 %

Room size
+ 17.2 m² 18.2 m²
Beds in 5.6 % 23.1 %
single rooms

Room size Dead end corridor, Perimeter corridor,

+ 22.7 m² 28.5 m² e.g. in comb structures e.g. in comb structures
and extensions and extensions
Beds in 50.0 % 61.5 %
double-bed rooms
13.2 % 17.0 %

Room size
+
Beds in 31.4 m² n. a.
multi-bed rooms 44.4 % 15.4 %
(Overall number
of beds = 100 %)

L-shaped dead end corridor, Dead end corridor,

e.g. in comb structures and e.g. in comb structures
Openable window extensions and extensions
n. a. 69.5 %
in patient room

10.3 % 10.3 %

Hand disinfectant
dispenser at 30.6 % 69.4 %
patient bed

L-shaped dead end corridor L-shaped dead end corridor,

Maximum distance e.g. in comb structures and
extensions
between nurses’
31.2 m 15.8 m
station and furthest
patient room
10.1 % 8.6 %

Double corridor with centre Double corridor with centre

access, e.g. in a high-rise access, e.g. in a high-rise

167 Building Structures in German Hospitals

C
Prototype of a
Patient Room –
the KARMIN
Project
Architecture
Should hospitals in future have more single or more two-bed rooms?
Can the design of hospitals and patient rooms contribute to preventing
infection transmission in hospitals? What are the challenges of designing

of the Patient
patient rooms today and in future, especially with regard to hygiene?
These and other questions were the focus of the KARMIN research
project discussed in this book, which investigated possible responses to

Room
preventing the spread of multi-resistant pathogens: should hospitals be
converted to have more single-bed rooms or can the design of two-bed
rooms be improved so that they are a viable alternative with respect
to infection control.
KARMIN stands for “Krankenhaus, Architektur, Mikrobiom und
Infection” (Hospitals, Architecture, Microbiome and Infection) and is a
research project funded by the German Federal Ministry of Education
and Research (BMBF) from 2016 to 2020 under the “Zwanzig20” funding
programme as part of the InfectControl 2020 research network. The
project was undertaken as a partnership of the TU Braunschweig (co­or-
dination: Institute of Construction Design, Industrial and Health Care
Building), the Charité – Universitätsmedizin Berlin (Institute for Hygiene
and Environmental Medicine), the Jena University Hospital (Septomics
Research Group) and the company Röhl GmbH from Waldbüttelbrunn
near Würzburg.
National and international guidelines have for some time been call-
ing for patients with multi-resistant pathogens to be isolated in single
rooms. However, the rising number of MRSA pathogens makes such a
demand increasingly difficult to implement. In addition, the exclusive
use of single rooms has several disadvantages and higher costs. In Ger-
many, these consequences have not yet been scientifically evaluated to
provide hard data for decision making. Most multi-resistant pathogens
are transmitted primarily through contact. By implementing appropriate
design means to minimise contact, it should therefore be possible to
safely care for patients with such pathogens in two-bed rooms. Studies
on alternative multi-bed scenarios – such as equipping two-bed rooms
with two wet cells, or alternatively two toilets, or with self-disinfecting
sanitary facilities – are currently lacking. Likewise, there have as yet been
no studies on how new hospital buildings are colonised by microorgan-
isms, and the factors that influence this.
In the KARMIN project, a team of architects, designers, medical
practitioners and molecular biologists identified and evaluated inter-
disciplinary risk factors for infection transmission in patient rooms, the
accompanying wet cells and adjacent functional areas on the basis of
their structure and design as well as the procedures and activities that
take place within them. From this, they elaborated planning recommen-
dations for breaking the chains of possible infection transmission and
developed a prototype for a two-bed room with wet cells designed to
minimise infection transmission. This also included optimised equipment
such as a disinfectant dispenser, bedside trolley and a concept for a
bedside terminal with corresponding advisory content. Seventeen com-
petent and innovative industrial partners were involved in the planning
and implementation process.
This chapter presents the analytical study and methodology used,
including, among other things, expert workshops with planners, care
staff, cleaning personnel and hygienists as well as comprehensive
studies on lighting and colour design. From this, designs and then
detailed construction plans were developed in ongoing consultation
with the project partners for both the room and selected fittings and
furnishings. This process and the resulting final design variant are
documented here.
A second focal area of the KARMIN research project was the study
of how hospital microbiome develops. For this, the first occupancy of

170 Prototype
the newly renovated Charité high-rise bed building was studied. The time, the Institute of Hygiene is a National Reference Center (NRZ) for the
Charité – Universitätsmedizin Berlin (Institute for Hygiene and Environ- surveillance of nosocomial infections, i.e. infections acquired in hospital.
mental Medicine) and the Jena University Hospital with the Septomics The Institute is therefore home to the Krankenhaus-Infektions-Surveil-
Research Group jointly investigated how architectural conditions (e.g. lance-System (KISS), in which about 75 % of German hospitals currently
multi-bed and single rooms) influence the development and diversity of participate. KISS is a benchmarking tool with which hospitals can objec-
the microbiome and the emergence of multi-resistant bacteria. Further- tively measure their infection rates and adapt their prevention measures
more, different cleaning regimes (e.g. surface disinfection vs. surface accordingly. The Institute also organises nationwide hygiene projects
cleaning) were also evaluated. While the latter is beyond the scope of such as the “Clean Hands Campaign”, which is supported by the Fed-
this book, the results are available on request from the project partners. eral Ministry of Health, among others, and currently seven national and
EU-funded third-party projects on infection prevention issues.
Research conducted at the Institute of Hygiene and Environmental
Medicine focuses on the surveillance of nosocomial infections and multi-­
Work Process and resistant pathogens, evidence-based infection prevention measures and
their implementation, molecular biological investigations to identify infec-

the Project Team tion chains, and technical investigations into hospital hygiene.

Röhl GmbH Sheet Metal Processing

The KARMIN project, under the leadership of the Institute of Construction Röhl is an association partner for the project and a family-run medium-
Design, Industrial and Health Care Building (IKE) at the Technical Univer- sized company with more than 40 years of experience of producing
sity of Braunschweig, brings together architects, medical practitioners, healthcare products. Alongside sheet metal processing, the main focus
hygienists and product manufacturers in an interdisciplinary work group of its production is composite elements. It has undertaken numerous
for the first time. projects in the prefabricated bathroom sector for hospitals and care
The research team for the design and realisation of the patient room facilities such as the Traunstein District Clinic, Braunschweig and Halle
thus unites partners from the realms of science, medicine and industry. Municipal Clinics, Hannover Region Clinic, SRH-Holding Heidelberg,
The participating university institutes have undertaken joint research in the Surgical Centre Erlangen, Aachen Medical Centre and Alsterdorf
various areas of health and infection prevention for many years and are Protestant Hospital in Hamburg. It has also produced prefabricated
well-known and established research institutions. In addition, 17 partners bathroom systems for nursing homes and homes for the elderly, such
from industry were involved from the outset in the development of the as those at Bad Neuenahr-Ahrweiler, the Leonhard Center Nuremberg,
concept for an infection-prevention optimised patient room. Both the the St Martinus Wevelinghoven or the DRK Memory Zentrum Neuss.
university institutes and the industrial partners consulted regularly over Röhl has an extensive network of suppliers and decades of experience
the course of the project, with meetings in person at least every three in the hospital and healthcare construction sector.
months as a means of ensuring successful collaboration.
Research phases
Institute of Construction Design, Industrial and Health Care
Building (IKE), TU Braunschweig The research objectives were divided into five research phases → Fig. 1
The Institute of Construction Design, Industrial and Health Care Building, in which all the project partners were involved:
which acted as project coordinator, has developed over the past ten
years into a leading centre for teaching and research into healthcare Phase 1: research and investigation
building design in Germany. With its interdisciplinary research team of Using a variety of different methods, the research team investigated the
experts from the fields of architecture, process design and hygiene, it topic of infection prevention through design in the patient room. To this
addresses the complex challenges of sustainable hospital construction. end, they visited clinics, observed activities in hospitals, and researched
A focal area is the planning of infrastructural requirements for optimal and analysed relevant literature and existing studies. They consulted
patient care and the process-optimisation of staff workflows. experts as well as the various different users of patient rooms, asking
A specialisation in the field of healthcare building is the prevention of them specific questions and documenting their findings.
infection transmission through building design. This encompasses both
construction and design aspects, for example the choice of materials Phase 2: concept and design
or the design of junctions between components and built elements. Based on the findings of the first phase, the team drew up a catalogue
Ways of optimising processes within hospitals using design means is a of requirements that should serve as the basis for the design of a
further aspect, for example through the organisation of the ward floor two-bed patient room with wet cell designed to minimise infection
plan or operational processes in the hospital or patient room. The Insti- transmission. From this, a design was elaborated for the patient room
tute takes an interdisciplinary approach, working together with other in ongoing consultation with all the project partners. The design also
research institutes at the TU Braunschweig and with other nationally considered optimised designs for items in the room including a dis-
and internationally recognised institutions. infectant dispenser, the bedside trolley and a concept for a bedside
terminal with corresponding advisory content. Partners from indus-
Institute for Hygiene and Environmental Medicine, Charité – try were likewise consulted from an early stage to incorporate their
Universitätsmedizin Berlin expertise and recommendations, for example, on the choice of suitable
The Institute for Hygiene and Environmental Medicine is a further asso- materials and surfaces.
ciation partner and concentrates on the aspect of infection prevention
among patients at the Charité – Universitätsmedizin Berlin. At the same

171 Architecture of the Patient Room

 Phase 3: planning and construction
Detailed working drawings for the construction of a prototype were
developed in close cooperation with the project partners and partners
from industry. As part of the process, various products, fittings and
furnishings in the room were either optimised or developed further to
improve their ability to control the spread of infection and to meet a
demand for innovative equipment. A prototype patient room equipped
with all the necessary supply lines was completed in January 2020 on
the premises of the company Röhl in Waldbüttelbrunn.

Phase 4: optimisation
The optimisation phase was used to fine-tune decisions on colours and
materials and to investigate ways to optimise the design details and
the junctions between elements. The prototype was examined several
times by the project team and the research and industry partners, and
each planning decision was jointly evaluated. An important aspect was
to evaluate how products that had been developed individually worked
in the context of the room in order to optimise their handling. It was also
possible to examine the construction process with a view to avoiding
weak points arising through the installation process.

Phase 5: evaluation
The findings and experience gained from the prototype up to this point
will be documented for future improvements to the prototype and for
presentation to a wider specialist audience at the Charité site and as part
of the World Health Summit (25–27 October 2020) in Berlin. Selected
experts as well as relevant user groups from everyday clinical practice
will also have the opportunity to assess the KARMIN patient room at
the facility in terms of its suitability for use and infection prevention.
Their responses will also feed into the evaluation of the newly created
two-bed patient room with two wet cells and should provide useful
insight into transferring the findings of the project into the practice of
modern patient room planning and design.

1 The five research phases of the KARMIN project

5
4
3 EVALUATION

2 OPTIMISATION

1 PLANNING +
CONSTRUCTION
RESEARCH + CONCEPT + DESIGN
INVESTIGATION

172 Prototype
 Collaboration with partners from industry

For the development as well as the detailed construction of the proto-

type for a two-bed room with wet cells designed to minimise infection
transmission, the project team collaborated with experienced, moti-
vated and innovative partners from industry. To be able to develop the
best possible solutions for the project, 17 companies and manufacturers
were selected according to various criteria based on the components
in the patient room. The criteria ranged from the size of the product
portfolio, the degree of experience in the healthcare sector and whether
the company had their own research department. Each industry partner
represents one of the components of the patient room and/or wet cell:
— Windows
— Doors
— Door and window fittings
— Walls/ceiling
ff
rho

— Floor
sse

— Lighting/illumination
bo
Hansa

er-

Vi
Atos

lle ie — IT/communications
s sn

ro m
Rö

y e
Ch — Furniture/furnishings/equipment
wi

&
hl

Bo
c Furn DE
h m itu BO — Patient bed/bedside cabinet
oo re
hr — Disinfectant dispenser
HEW ÜCO
t
Ba

I SCH — Tap fittings

IKE — Sanitary objects
Continental Institute of Construction Design, JELD-WEN
Industrial and Health Care Building
— Bathroom equipment
In contrast to traditional planning processes (as outlined in the archi-
FS B
a ce
Equ

S
REIS tects' specification of works and fee structure) where companies bid
Sp
ip

en for a tender based on a specification of works, the industry partners

m

t t Br
ep i ll u
o nc x were involved in an ongoing basis in the concept development and
-c
el design phases as well as in the detailed construction design planning.
no
al

öb
op

ra
Co

RZB

tm
s

ec Involving the industry partners from such an early stage made it

s
Re

yst
Kusch+

j
ob
e

possible to draw on their respective expertise in each sub-area and to

ms

discuss and develop the best solutions in each case. In order to struc-
2 Industry partners and the respective work groups ture the work process in a meaningful way, four working groups were
defined: Room, Furnishings, Bathroom and Objects → Fig. 2. Project
Projektbeteiligte Industriepartner / GRAFIK VERLIERT DURCH DIE ÄNDERUNG!!!
partners and companies could work together to discuss interfaces
between components and develop appropriate joint solutions, also in
meetings with all working groups. Together with the research team from
the TU Braunschweig, the company Röhl coordinated the realisation of
the prototype at the Röhl site.

173 Architecture of the Patient Room

 n
Clinic visits
Ty
po
Requirements for a
io

at Patient Room and Its

lo
rv

gi
se

ca
ob

l ass
Fittings
ite

essm
Catalogue of
On-s

requirements

ent
Patient room
Wet cell
Disinfectant dispenser Methods
L i te r

Bedside cabinet

65+
atu

A number of different methods were employed as part of the analyt-

re

ey
ical study to identify relevant information, findings and evaluations
re

rv
se

Su
ch
ar

of existing approaches to infection control in patient rooms. A first

Wo ts
avenue of exploration was to examine relevant literature and existing
rk s h o p s w it h ex p e r
scientific studies to obtain an overview of the complexities of designing
3 Methods employed in the analytical study
a patient room. Aside from desk research, a period spent observing
clinical practice at Braunschweig Hospital also provided first-hand
insight into the intricacies of this design task. By accompanying hospital
(Abb. 10): Methodik bauwissenschaftliche Untersuchung
staff on site, we could observe care processes, study cleaning behav-
Subject area
iour and identify the daily challenges facing the different user groups
Spatial arrangement in a patient room. Following on from this, two workshops with various
experts and users were conducted in March and April 2017 to define
Fittings and equipment the most important focal points in the planning context. A typological
examination of the floor plans of two-bed rooms studied the extent
Processes to which the design of the floor plan can positively influence factors
supporting infection prevention in a patient room. Selected floor plan
Patient/visitor information
types were also critically assessed in practice as part of the clinic visits
Disinfectant dispenser and their respective performance was discussed with operators and
position
architects. The various findings and information derived from these
Supplies and waste disposal different methods were then compiled as a catalogue of requirements
that served as a basis for the concept and design phase as well as for
Cleaning and disinfection the detailed design and construction planning → Fig. 3.
Joint use of a single
bathroom Literature research on planning principles
As part of the analytical study, the relevant norms and standards for
Ward arrangement
infection prevention in the context of building design were collated and
Automation structured according to their importance in legislative norms, ordinances
and guidelines produced by independent organisations.
Planning process The German Infection Protection Act (IfSG) has been in force since
1 January 2001 and sets out regulations for the prevention and control
4 Evaluation of the deficits analysis undertaken in
of infectious diseases in humans. Its key areas of focus are measures for
workshops with experts
preventing the transmission of diseases to humans, the rapid detection
(Abb. 12): „Expertenworkshop – Auswertung Defizitabfrage“ of infections and the prevention of the spread of infections. The IfSG
also provides the legal basis for the Commission for Hospital Hygiene
and Infection Prevention (KRINKO) at the Robert Koch Institute (RKI).
The KRINKO publishes recommendations on hygiene-relevant topics
such as the cleaning and disinfection of surfaces, best practices for
handling patients with multi-resistant pathogens or the operational
organisation of functional areas. These also include recommendations
for the structural and functional design of hospitals such as minimum
space requirements, the size of rooms and the location of hygiene-
relevant rooms, as well as the quality of materials.
In terms of ordinances, the building regulations (for example the
KhBetrVO), the hospital ordinances of various federal states and the
drinking water ordinance are among the most important for the design
of buildings. In addition to the general building regulations, six fed-
eral states (Brandenburg, Berlin, North Rhine-Westphalia, Saarland,
Saxony-Anhalt, Schleswig-Holstein) have issued ordinances that deal
specifically with requirements for hospitals.

174 Prototype
 Many of these regulations are based on the model hospital building Typological evaluation of two-bed floor plans
regulations (KhBauVO) issued in 1976, which lay down guidelines for fire As presented in detail in the section → Typological Evaluation, p. 44–63,
protection, hygiene, ventilation, lighting, room size and room layout. the team undertook a systematic examination of different patient room
As the requirements for the construction and operation of healthcare floor plans of two-bed rooms in general care hospitals in national
buildings have changed over the decades, these regulations are no and international institutions. The study looked at numerous design
longer up to date and are in urgent need of revision, but they do still aspects evaluated according to different categories, including struc-
provide general orientation for hospital planners in Germany. tural complexity, infection-prevention potential, workplace quality and
Alongside norms and regulations, there are a large number of safety, spatial quality, patient safety, patient satisfaction and privacy.
guidelines and recommendations issued by privately-run independent The result was an overview of two-bed patient room floor plans and
organisations, which have been drawn up by expert committees and their spatial dependencies, which influence the corresponding qualities.
provide specific instructions for action in the field of hygiene. Some of these floor plans were then selected as the basis for the survey
Design services provided by architects are regulated by the latest conducted with experts.
version of the German HOAI (Official Scale of Fees for Services by
Architects and Engineers), dated 17 July 2013. It defines architectural Workshops with experts
services for new buildings and conversion projects, along with the cor- Two workshops with experts were held at the TU Braunschweig. The two
responding remuneration rates, and divides them into nine work phases workshops, which both followed the same pattern, served as a platform
that cover the various stages of a project’s design and realisation, from for interdisciplinary exchange with the aim of identifying hygiene-­critical
basic evaluation and planning permission to construction supervision areas in the patient room and wet cell and discussing appropriate
and documentation. This breakdown assists hospital planners in de­ter- design strategies for infection prevention in hospital environments. A
mining at what points in the process building hygiene measures need total of 23 experts from different disciplines – hospital planners, nursing
to be considered. staff, cleaning staff, hygienists and “patients”, the latter represented by
In terms of the design of hospitals, DIN 13080 specifies the division students and university staff – were selected and invited to contribute
of the hospital into different functional areas and locations and the struc- their views. Among others, staff from Braunschweig Hospital, Hanover
turing of the respective floor areas according to their clinical purposes. Medical School and the University Hospital in Göttingen took part.
Another norm relevant to hospital design is DIN 1946-4, which concerns
air conditioning systems in buildings and rooms in the healthcare sector. Deficits analysis
The Association of German Engineers has published the VDI Guideline The first part of the workshop constituted a deficits analysis in which
6023 “Hygiene in drinking-water installations” and VDI Guideline 6022 participants were invited to note their answers to the question “Where
“Ventilation and indoor-air quality” that likewise contain recommenda- do you see the greatest deficits in hygiene in patient rooms and wet
tions for hospital design and hygiene. Since 2013, an expert committee rooms in terms of construction, process, regulations, etc.?” on a
for sustainability in the construction and operation of hospitals has existed defined number of cards. The answers were then collected, clustered
that also deals with the topic of hygiene, as well as a VDI expert com- and assigned to topic headings. In addition, all participants could use
mittee for the “Management of hygiene-relevant surfaces in medical or adhesive dots to indicate the relevance of the respective issue to the
care facilities”. topic of infection prevention → Fig. 5.
The Association of the Scientific Medical Societies (AWMF) serves Evaluating the results → Fig. 4 identified two key subject areas of most
as an umbrella organisation for a total of 168 member societies, and relevance to hygiene deficits in the patient room: the spatial arrangement,
issues recommendations for the respective fields. These are divided and fittings and equipment in the patient room and wet cell.
into four levels of relevance. Classification S1 (recommendations for Other major challenges cited were the processes in nursing care,
action by expert groups) is of lower relevance and classification S3 insufficient information for patients and visitors, the often inappropriate
(evidence- and consensus-based guidelines) is of highest relevance. positioning of the disinfectant dispenser, supplies and waste disposal,
The recommendations of the working group “Hygiene in Hospitals standards of cleaning and disinfection and the shared use of the bath-
and Doctors’ Practices” are of relevance to the design and function of room. Topics of lesser importance that were also raised included the
healthcare facilities. arrangement of the ward, a lack of automation for contactless operation
of items such as WC flushing, and the planning process.
On-site observation in clinic environments Aspects pertaining to the arrangement of the room included the
In order to gain insight into the processes on a normal care ward, the placement of beds next to each other, excessively small patient rooms
KARMIN project team accompanied nursing staff during their daily and wet cells, no clearly separated zones, and insufficient space between
routine of caring for patients as well as cleaning staff on two wards of the beds and other furniture and furnishings. In terms of fittings and
the nephrology department over a two-day period at Braunschweig equipment, factors such as contact surfaces of the equipment, room tex-
Hospital. Conversations and interviews conducted on site aimed to tiles such as curtains, surfaces that are not easy to clean and insufficient
identify hygiene-critical areas from the perspective of hospital staff storage and work surfaces for nursing staff were also identified. These
and from these to derive measures relevant for planning. Input from the deficits provide an indication of possible relevant hygiene-critical factors.
staff served, among other things, as a basis for defining the criteria by
which to conduct the typological evaluation of patient rooms. These
were also discussed in two workshops with a broad range of experts,
not least to verify their transferability to other contexts.

175 Architecture of the Patient Room

5 Evaluation of subject areas as part of the workshop with experts

1 2 3

6 A survey of different floor plan types (1 : 200) for two-

bed patient rooms. A common aspect of the three most
favoured floor plans (1, 2, 3) is the arrangement of the
Abb.: 13 „Grundrissvarianten Zweibettzimmer – Auswertung Abfrage Grundrisstypen“
beds opposite, at an angle or offset opposite each other.

176 Prototype
 Evaluation of floor plan types these individual methods, five main categories were defined: structural
In the second part of the workshop, the participants were asked to select complexity, infection prevention potential, workplace quality and safety,
three favourites from a selection of eleven two-bed patient room floor spatial quality, and patient safety, patient satisfaction and privacy.
plans. The selection of the eleven floor plan types represents different The findings obtained through the various methods were then
possible spatial configurations of the patient room and wet cell → Fig. 6. assigned to these categories. To determine the relevance of the respec-
The floor plans differ, among other things, in their room geometry, the tive findings, three further hierarchical evaluation categories were used.
position of the beds in relation to each other, the alignment of the beds — Category I – “must”
to the façade and the entrance, and the number of wet rooms and their — Category II – “shall”
equipment and possible uses. The aim was to obtain an expert assess- — Category III – “may”
ment on which spatial floor plan configurations or aspects thereof can Category I corresponds to high-level legislation and building regula-
have a positive effect on the prevention of infection transmission. The tions that must be implemented in the planning. Category II describes,
floor plan that was rated most positively → Fig. 6, No. 1 has the beds among other things, planning recommendations set out by independent
placed not next to each other, two wet cells and an equal relationship organisations such as DIN standards. Category III includes, for example,
between the bed areas and the façade and entrance. The three most recommendations by experts. The resulting catalogue of requirements
frequently mentioned floor plans all have the beds arranged opposite, in the different categories was then used as a basis for deriving design
orthogonally or offset to each other. principles.

Ideal floor plan patient room Material testing as a basis for planning
In the final assignment of the workshop, we asked the experts to sketch
an “ideal floor plan” of a two-bed patient room. The floor plan could Suitable surfaces and products were researched for each of the areas
include furnishings and fittings that they considered ideal and they and aspects of the room prototype – the walls, floors, patient bed,
were free to add relevant details in writing. To this end, mixed groups fittings and equipment, doors, and door and window hardware. The
of experts were formed to bring in different expert opinions. A series project’s industry partners were asked to test at least five material
of idealised proposals were developed, presented and then discussed samples for cleanability in their respective area of responsibility within
among the group in the workshop. the patient room or wet cell. The assumption is that the surface prop-
erties and the type of soiling or contamination influence the ease of
Survey 65 + cleaning. The tests were carried out by the Institute of Building Materials,
In the workshop with experts, the patient user group was represented Concrete Construction and Fire Safety at the Technical University of
by students and university staff. To obtain a better picture of the majority Braunschweig. The sequence for the test setup for simulating cleaning
of patients in everyday hospital situations, a survey was also conducted was as follows: a. Defined degree of contamination, b. Cleaning with
with people over 65 years of age. Of particular interest was to identify a linear wiping simulator, c. Quantification of residual contamination
deficits and evaluate different floor plans. These results augmented the using a particle counter with surface sensor. The testing procedure also
evaluation of the workshops with experts. included measuring roughness, surface free energy and cleanability for
each material sample.
Hospital visits The results of the material tests fed into the selection of materials,
Based on the results of the typological study and the workshops with surfaces and decors in the subsequent phases of the design process.
experts, three clinics in Germany were selected that feature patient Often, several product ranges by a single manufacturer exhibited
rooms and nursing wards with specific hygiene-relevant aspects, both comparable results so that the designers were typically able to choose
in their layout and design, and in their hospital processes. The team from between one and three products for each sub-aspect. Further
examined these aspects as part of visits to the clinics and spoke with information on material applications and material ageing can be found
clinic staff and planners. One of the clinic wards features two-bed patient in the section on → Material applications, pp. 24–26.
rooms with two identical wet cells, one for each patient. In on-site
conversations with hygiene specialists, the planning department and
caregivers, the team were able to discuss the relative advantages and
disadvantages of this structural solution. Another clinic featured identical
two-bed patient rooms with a same-handed arrangement. Here, too,
the respective factors favouring this arrangement were discussed with
the architecture office responsible for the hospital design.

Catalogue of requirements for the patient room

and wet cell

A catalogue of requirements was developed to assimilate and give order

to all the information acquired in the analytical study, with the aim of
deriving concrete planning-relevant requirements for the concept and
design phase.
In a first step, all the investigative methods such as the workshops
with experts and on-site observation of everyday clinical practice
→ Fig. 3 were listed. To structure the information gathered through

177 Architecture of the Patient Room

 Planning and Design
Design concept

The results of the analytical study were compiled, evaluated and hierar-
chically organised as a catalogue of requirements. From these, design
principles were identified that could form the basis for the concept
and design phase of the patient room. The requirements for the room
relate directly to the floor plan configuration, while the requirements for
fittings and equipment will be considered in a later planning phase. In
design terms, the challenge was to configure a patient room that has a
high spatial quality for the patient and the staff, facilitates optimal care
provision and cleaning processes and embodies new approaches to
infection prevention that are feasible for implementation in practice.
In close cooperation with the research partners, the team defined the
following structural, hygienic and procedural requirements → Fig. 7:
— A. Patient rooms in additive arrangement
A
J — B. Compact design
— C. Beds placed opposite one another
— D. Equal-status bed positions
I B — E. Both patients can be seen from the entrance area; clear room
arrangement
Requirements — F. Work and storage area for staff near the entrance
conceptual basis
— G. Windows for optimal natural ventilation
patient room
H C
— H. Two barrier-free bathrooms with showers
— I. Optimised zoning for care processes
— J. Clearly visible disinfectant dispenser close to the patient bed
The following requirements were defined for fittings and equipment:
— The formal design should facilitate optimal cleaning
G D — Flush, integral fittings with few construction joints
— Surface characteristics should be optimised for cleaning
Three levels of consideration were defined for the subsequent design
F E
phase – “Room and layout”, “Components and joining” and “Surfaces
and materials”. The design team, along with the project partners, used
A: Patientenzimmer in additiver Aufreihung; B: Kompakte Bauweise; C: Betten
these as a means of approaching the design development over the
7gegenüber; D: Gleichwertige
The key requirements Bettplätze;
for the E: Einsehbarkeit auf beide Patienten vom
room concept
Eingangsbereich inkl. Übersichtlichkeit des Zimmers; F: Arbeits- und Lagerfläche following six months. Several variants were developed for each level of
Personal im Eingangsbereich; G: Fenster für optimale natürliche Belüftung; H: Zwei
Nasszellen inkl. Dusche und barrierefrei; I: Optimierte Zonierung für Pflegeabläufe;
consideration and then discussed, evaluated and prioritised.
J: Desinfektionsmittelspender sichtbar und in Nähe zum Patientenbett For the first of these, “Room and layout”, three room concept
proposals were elaborated, all of which meet the previously defined
requirements → Figs. 9–11.
In a subsequent project meeting, the project partners and industry
partners were asked to select which of the variants they viewed as the
most sensible and to justify their decision. Working in small groups,
the participants presented their results using sketches and maps. From
the ensuing evaluation, variant 1 was selected as the basis for further
development → Fig. 9.
In a second step, the participants also defined additional require-
ments for the next design phase:
— Clear zoning and allocation of work areas to staff and the bathroom,
and of cupboards to patients
— One nurses’ work area per patient including disinfectant dispenser
and storage/shelf space for staff
— The disinfectant dispenser should be next to the nurses’ work area,
positioned in the direction of the patient and visible from all parts
of the patient room.
— The bedside cabinet should be placeable on both sides of the
patient bed.

178 Prototype
 — A permanently installed bench at the window as seating for patients
and visitors
— The bathroom should be able to accommodate a sliding door to
reduce risk of injury and improve clarity of the entrance situation.
— A possibility for staff to store materials in the patient bathroom
— Built-in storage in the wall zone between the bathroom and
patient room
— Bathrooms with different fittings
Three concept proposals were likewise developed for the aspect of
“Components and joining” and presented for discussion. These were
based on layout variant 1 and the additional requirements identified.
The overall room layout is therefore the same for the different variants
with respect to the position of the bathrooms, the patient beds and the
large window front. Here the means of accessing the wet rooms, the
position and size of the nurses’ work area and the patient cupboards
varied → Figs. 12–14.
The three new room variants were again discussed as part of a
project meeting to which, alongside the project partners, an interior
designer and hospital planner were invited. The aim was to identify
possible deficits in the concepts and to invite suggestions for improve-
ments in the detailed design planning.
Smaller group meetings were also held with the partners from
industry, each concentrating on a specific aspect: the room, bathroom,
fittings and objects. The objective was to identify crossover points and
dependencies between the respective trades and to discuss possible
detailed solutions and complicated junctions, joints or material tran-
sitions. Relevant products or product ranges were likewise discussed
among the partners, as well as how existing products could be adapted
or developed to meet the defined project requirements.
Following the design meeting and smaller group meetings, variant 3
was selected for further development → Fig. 14. A new set of require-
ments was likewise elaborated for the equipment in the patient room:
— Patient cupboard with clothes rail, fixed shelves and a lockable
8 Working model during the design process
compartment, as well as push-to-open cupboard hinges for easier
cleaning
— Patient table surface slightly angled so that the patient’s sitting posi-
tion is slightly rotated to improve the angle of view into the room
and facilitate communication with visitors and the other patient.
The table must be large enough to put down a food tray.
— Visitor bench with wipable edges and removable, easy-to-clean
cushions
— One waste bin per patient located near to the nurses’ work area
— A compartment for stowing suitcases
— Patient bed (bed length 2.21 m) with maximum extension length
of 2.51 m. It should be accessible from both sides without needing
to move the bed or creating an impractical room depth. Space
limitations should be addressed by controlling room occupancy,
e.g. by pairing a long bed (2.51 m) with an average bed (2.21 m).
For the bathroom position and equipment, the following requirements
were proposed for the final design:
— Sliding door arranged in front of the wall
— Wall-mounted WC and waste bin for easier cleaning
— Tiled floor and walls
— Infrared mirrors
— Folding support rails
— Shelves for patient use
— Waste bin
— Placement of disinfectant dispenser not at the wash basin, but in a
cupboard niche to avoid confusion between soap and disinfectant

179 Architecture of the Patient Room

 - Nasszelle innen- und außenliegend
- Bettposition gegenüber gedreht

- Bettposition gegenüber versetzt

- Nasszellen innenliegend
- Grundriss symmetrisch

- Grundriss verwinkelt

- Grundriss Patientenzimmer und Nasszellen nebeneinander

9 Consideration “Room and layout” – 10 Consideration “Room and layout” –
Variant 1, 1 : 100 Variant 2, 1 : 100
— Symmetrical arrangement — Diagonal arrangement

- Nasszelle innen- und außenliegend

— Bed placement offset opposite each other

- Bettposition gegenüber versetzt

— Bed placement opposite and at an angle
— Wet cells “inboard” — Wet cells “inboard” and “outboard”

11 Consideration “Room and layout” –

Variant 3, 1 : 100
— Patient room and wet cells next to
each other
— Bed placement offset opposite each other
— Wet cells “inboard” and “outboard”

- Pflegearbeitsbereich in der Erschließungszone

- Nasszellenzugang von der Patientenbettseite
- Pflegearbeitsbereich in Nähe zum Patientenbett und schräg angeschnitten
- Patientenschrank neben Patiententisch an der Fassade - Pflegearbeitsbereich in Nähe zum Patientenbett
-12 Consideration
Nasszellenzugang “Components
seitlich and joining” –
vom Eingangsbereich 13 Consideration “Components and joining” – -14 Consideration
Nasszellenzugang “Components
seitlich and joining” –
vom Eingangsbereich
Variant 1, 1 : 100
- Patientenschrank neben Pflegearbeitsbereich Variant 2, 1 : 100 Variant 3, 1 : 100
- Patientenschrank neben Patiententisch an der Fassade
— Nurses’ work area facing patient bed, — Nurses’ work area in the entrance area — Nurses’ work area facing patient bed
diagonal wall — Access to wet cells from the patient bed — Access to wet cells from the entrance area
— Access to wet cells from the entrance area — Patient cupboard next to patient desk near the — Patient cupboard next to patient desk near
— Patient cupboard next to the nurses’ work window the window
area

180 Prototype
Patientenraum Same-handed
A design concept was also developed for the aspect “Surfaces and mate-
rials” based on the previously agreed design variant and other require-
ments → Colour and materials concept → pp. 183, 184. The results of the
materials testing conducted at the iBMB (Institute of Building Materials,
Concrete Construction and Fire Safety) at the Technical University of
Braunschweig were also considered in the selection of materials and
surfaces → Material applications, pp. 24–26.
15 Patient room with wet cells in a
same-handed arrangement Final design

Regelgrundriss Drei-Zonen-Plus Based on the analytical study and cross-partner evaluation and devel-
opment of interdisciplinary approaches, an innovative design for an
infection-prevention optimised patient room and accompanying wet
cells was developed. The resulting prototypical concept takes numerous
aspects into consideration including the structural layout, functional
processes and pathways, detailed solutions, materiality and surfaces.

Room layout and process

16 Standard floor plan 17 Three-zone plus room The final floor plan is designed for additive repetition to create wards of
identical patient rooms. The resulting treatment, nursing care and clean-
ing processes are therefore predictable and can be optimised in their
Betten gegen- Bettplätze gleichwer-
choreography. Errors and omissions resulting from the need to adjust to
new room configurations can therefore be avoided → Figs. 15, 16. The divi-
sion of the patient room into three zones also promotes good hygiene
practices: the so-called nursing zone is the area around the patient bed
and next to the nurses’ work area that staff move around in; the patient
18 Beds arranged zone is the patient bed and its immediate surroundings; and the lounge
opposite 19 Equal-status bed
positions area for patients and visitors is on the outer wall alongside the window
Beide Patienten für Nasszellen innenlie- front with the patients’ wardrobes, desks and bench → Fig. 17.
Personal sichtbar
The floor plan is directly informed by the design principles discussed
earlier: for example, the beds are arranged opposite each other, the
bed positions are of equal status, and staff have good visibility of both
patients. The room layout is symmetrical, so that each patient has half of
the room with an identical arrangement of fittings and equipment. The
principle of arranging the beds opposite each other marks a departure
from the conventional layout of two beds arranged parallel next to each
other → Fig. 18. This arrangement ensures that both patients have an
20 Design principle: 21 Inboard wet cells
both patients visible equally good view of their surroundings → Fig. 19 and that staff can see
to staff both patients from the door area of the room and are able to monitor
patients and react more quickly in the case of an emergency → Fig. 20.
Zwei identische Nasszellen The position of the beds is intended to encourage hospital staff to
more consciously disinfect their hands when caring for the patients. In
addition, the head ends of the beds are further apart, reducing the risk
of infection transmission between patients through physical proximity.
The symmetrical division of the room and separate set of fittings per
patient ensures that it is clear which items belong to which patient, thus
avoiding unnecessary contact transmission. The same principle applies
through the provision of two wet cells → Figs. 21, 22. A separate, wheel-
chair-accessible nurses’ work area for each patient with its own storage
22 Two identical wet cells is likewise not just a help for the staff but encourages compliance with
hand disinfection guidelines. Disinfectant dispensers are also located
at the foot of each bed so that staff always have the opportunity to
disinfect their hands as they walk past – either when entering the room
or when switching from one patient to the other.

181 Architecture of the Patient Room

 Innovative solutions in the final design

A. Entrance area
The entrance area widens towards the patient beds, making it simpler
for nursing staff to glance inside and have an unobstructed view of the
patient. On the right, a control panel allows staff to select different
lighting scenarios to suit the situation. These simplify work processes
for the staff.

B. Care and work area

A work area for nursing staff is located close to each bed. It incorporates
storage and thus direct access to new medical materials and gloves, a
disinfectant dispenser and safe waste disposal, grouping typical work
processes in one place.

C. Wet cell
Finaler
23 FloorEntwurf
plan of Grundriss (M1:100)
the final design, 1 : 100
Two wet cells, one for each patient, prevent usage scenarios where
cross-contamination can potentially occur through shared contact
surfaces.

D. Visitor zone
The visitor zone is a separate area combining the window bench, the
patient desk and chair. The bench is raised on a plinth, the front side of
which rises up from the floor to beneath the bench in a single smooth
surface for easier cleaning.

E. Bedside cabinet
The new design of the KARMIN bedside trolley → pp. 224–229 facilitates
better cleaning due to its seamless construction. It provides more stow-
age space without being larger than a conventional unit, with clearly
defined areas for better organisation, and can be used from either side
so that it can be positioned flexibly.

F. Disinfectant dispenser
The dispensers are placed along the routes of work processes and close
to the respective patient bed. The newly developed KARMIN dispenser
→ pp. 210–223 can record usage levels and attribute these to specific
Finaler Entwurf Ansichten (M1:100) user groups, making it possible for staff to assess compliance with hand
hygiene guidelines in team meetings by evaluating usage statistics.

G. Bedside terminal
The bedside terminal → pp. 230–236 is the primary means of providing
informative content to educate patients on hygiene behaviour so that
they may actively contribute to infection prevention.

Finaler Entwurf Ansichten (M1:100)

M1:100) 24 Interior elevations of the final design, 1 : 100

182 Prototype
 Colour and materials concept

The colour and design concept of a patient room contributes significantly

to the quality of a stay in hospital and thus also to the patient’s well-­
being during their period of treatment. The interior design of healthcare
environments has undergone a shift towards improving patient comfort
by creating a more hotel-like atmosphere. Other factors such as the
quality of the air and of light, as well as a visual connection to the world
outdoors, have also been given increased attention in recent years. The
approach of Healing Architecture considers how the design of the envi-
ronment affects physical and mental well-being. Factors that contribute
to a positive environment can be conducive to the recovery of patients,
and at the same time contribute to staff satisfaction in the workplace.
For the KARMIN project, the team needed to develop a design
concept that is uniform and appealing but also compatible with the prin-
ciples of infection prevention. An essential aspect in this respect is the
good cleanability of surfaces. As such, colours were needed that make
it easy to see coarse soiling or to detect when a surface has not been
sufficiently wiped clean. Colours can therefore contribute indirectly to
promoting compliance with cleaning procedures in patient rooms. The
planned fittings have the advantage that one can match colour surfaces
to one another more easily than with mass-produced furniture where
only selected designs and decors are usually available. Surfaces that are
intensively used or touched frequently should not have uneven textures
and should have solid colours to make it easier to detect contamination.
The use of comparatively inexpensive materials also means that these
25 Colour and material selection
benefit all patients, and not just those in better-equipped private health
insurance rooms.
Three potential colour schemes were developed for the final design
of the patient room, each with a different theme. As numerous different
combinations are possible within each theme, a 3D model was built
to simulate colour and material combinations. The following variants
illustrate an example for each of the key themes.

“Clean” theme with a contrasting colour

The “clean” theme presents a neat and tidy overall impression com-
prised predominantly of light colours, especially white and grey tones
along with a contrasting accent colour on selected surfaces. The colour
accents not only lifts the mood of the room but can be used to demar-
cate areas of the floor, for example to aid movement and orientation,
which is helpful for the mobility of older patients in particular → Fig. 26.

“Two colour zone” theme

In this variant, two different colours are used to denote how room zones,
fittings and equipment are allocated to each of the two bed locations,
and thus the patients. Two contrasting colours are proposed to ensure
they can be told apart, especially for patients with sight impairments.
A central aspect of this theme is to aid older patients and/or patients
with dementia in recognising their own room zone and associated
areas and items in the room. Colour coding can also reduce the fre-
quency with which surfaces are touched by both patients or confusion
between items in the rooms, which can also apply to younger or sedated
patients, both of which help to reduce the incidence of contact infection
transmissions → Fig. 27.

“Atmospheric” theme
This theme employs colours and decors that are harmonious and, in their
combination, lend the patient room a pleasant and inviting atmosphere
for patients and their visitors → Fig. 28.

183 Architecture of the Patient Room

 The final colour scheme
Although the 3D model was helpful as a tool for simulating different
colour schemes, examining actual colour and material samples was
essential when determining the colour concept. Samples were obtained
for all surfaces, from the flooring to the sides of the patient bed to bath-
room tiles. The final colour concept is a combination of the “Clean” and
“Atmospheric” themes shown in → Fig. 29. As infection prevention is the
primary focus of the project, the colour choices must create an impres-
sion of cleanliness expected of a clinic environment. For this reason, the
proportionally largest surfaces of the room – ceiling and walls – have
been painted white. The nurses’ work area, including the worktop and
push-to-open cupboards, are likewise white to ensure contamination
is immediately visible. A cool blue is used as the contrasting colour.
To address the aspect of patient well-being – a parallel aim of the
26 Rendering of the patient room: “Clean” theme with a
contrasting colour design concept – warm colour accents in the form of brown tones and
wood decor were chosen for the patient and visitor zone. In combination
with warm grey tones, the overall result is a colour-coordinated and
harmonious colour concept → Fig. 25.

Surfaces in the patient room

For the majority of surfaces in the patient room, high-pressure laminate
(HPL) was used: it is easy to wipe clean and tests conducted in advance
showed that it is resistant to erosion through disinfectants. HPL is used
for all cupboard and work surfaces, for the impact protection wall clad-
ding and the window benches. For the room design, this also made
it possible to coordinate colours and decors more easily rather than
having to select colours from different product catalogues. Similarly, the
colour concept for the KARMIN patient room can be varied as needed
by selecting from the broad range of colours available for HPL surfaces.
A rubber flooring was chosen for the floor as it is a natural product that
27 Rendering of the patient room with two colour zones requires no chemical sealing and is thus emission-free.

Fittings in the patient bathroom

The decision to include two identical but independent wet cells in the
KARMIN patient room made it possible to trial different surfaces in the
prototype. While one bathroom is completely tiled, the other is clad
with HPL panels. As the cleaning tests revealed that both surfaces are
equally suitable, the prototype can be used to compare them directly in
practice. The same principle was used to test differing degrees of auto-
mation in the patient bathroom: one bathroom has an elbow-operable
single lever mixer tap while the other is equipped with an automatic
motion sensor tap.

28 Rendering of the patient room: “Atmospheric” theme

184 Prototype
 Lighting concept

The importance of light

Light is a vital part of human life. The changing light conditions deter-
mine the rhythm of the day and seasons, influence our hormonal bal-
ance and contribute to the formation of important vitamins. Light has
an effect on our physical and mental health and thus on the process of
recovery. Good lighting is also essential for nursing care procedures,
for example to correctly place a needle for an injection or to recognise
a clinical picture based on how the patient looks. Sufficient lighting is
also needed for cleaning to ensure contamination can be seen, which is
essential for the prevention of infection. By the same token, inadequate
lighting can lead to people feeling downcast or to blunders.
Lighting in normal care wards should support a general impression
29 Rendering of the patient room with the final design
and colour concept of cleanliness but also be pleasant enough to feel homely and thus
positively connotated. Bright and colourful room interiors elevate the
patients’ sense of well-being in the sometimes rather dreary daily rou-
tine of being in hospital.
Natural light is preferable to artificial light. The arrangement of fit-
tings, windows and ultimately the shape of the floor plan should there-
fore be coordinated with the type, positioning and number of lamps
during the planning stage. While the designer is largely able to use their
discretion, lighting design must also comply with certain standards.
A “smart” patient room can employ sensors to automatically create
lighting situations that react to specific circumstances. For example,
the bed used in the KARMIN patient room triggers underbed lighting
when it detects a shift in weight. Manual controls, on the other hand,
when used by many people, bear the risk of cross-contamination as a
shared contact surface. As such, any lighting scheme must reflect the
importance of light for well-being and the usage scenarios and needs
of the different groups of people within a patient room. In addition, it
should be as contactless and individually controllable as possible.

Requirements
To do justice to the importance of light, a multitude of requirements
must be met. These are both determined by existing standards and the
individual situation of the room to be designed. In general, a pleasant
atmosphere can be achieved using indirect lighting providing light levels
of at least 100 lux and warm white light (DIN 5035-3).

Changing requirements at different times of day

To determine the specific lighting requirements, it is useful to define
usage scenarios and lighting situations. The changing incidence of
natural light and the various activities of the different groups of people
within a patient room, along with their varying frequency of use, result
in a large number of different possible lighting scenarios over the course
of the day. The following activities should be considered:
— Daily cleaning
— Room cleaning between patient occupancies
— Nursing care at the bedside
— Preparatory work at the nurses’ work area
— Accessing the nurses’ cupboard
— Doctors’ rounds and examination
— Visitors
— Reading
— Personal hygiene
— Toilet use
— Rest and recuperation
— Dressing/undressing at the patient cupboard

185 Architecture of the Patient Room

 — Eating
1000 mm
— Sleeping
800 mm — Night-time orientation
These scenarios relate to specific zones in the room and in the wet
cells and require lighting of varying intensity and orientation. In some
cases, the situations mentioned above are already covered by existing
standards.
75°
Reading height
Standards
Examination height DIN 5035-3 and DIN EN 12464-1 are the relevant norms governing lighting.
They set out suitable lighting situations not just for patients but also
1100 mm for the occupational health and safety of staff, and address some of the
scenarios mentioned above. For example, bedridden patients must not
850 mm
be exposed to constant direct glare by limiting the average luminance
of the luminaires visible from the bed to 1000 candelas per square
metre. Similarly, indirect lighting illuminating a ceiling should not cause
the ceiling to exceed a brightness of 500 candelas per square metre.
30 Norm dimensions for reading and
examination heights Each patient bed should be provided with a reading lamp providing a
localised brightness of at least 300 lux at reading height. They should
be individually switchable to avoid disturbing the room neighbour in a
multi-bed room → Fig. 30.
At night, however, the requirements are completely different. Both
6 7 nurses and patients need a sufficient level of light to be able to find their
4 5 way in the dark. At the same time, such light should not wake any other
patients in the room. To provide orientation, concealed LED lighting
with a wide beam can be mounted to illuminate the floor beneath the
9 8
bed and near the door so that other sleeping patients are not exposed
4 5 to the light source. A certain level of night lighting is also required to
assure nursing staff can quickly appraise the room and conduct any
7 2 3 6
necessary simple tasks. A light level of 5 lux at a height of 0.85 m above
the floor is sufficient.
20 21 During the day, the examination height and the nurses’ work area
should be illuminated as evenly as possible at a light intensity of at least
300 lux. Brighter levels of at least 1000 lux are only required in the case
12 13 of emergencies, or detailed examinations and treatments. Variances in
2 10 11 3
the uniformity of illumination should not exceed a minimum ratio of 1 : 2
between the highest and average illuminance (Licht.Wissen 07, 2013).
19 1 18
16 17 Additional requirements
Alongside norms and standards, the various light scenarios described
15 14 above have additional requirements. The principle of Human Centric
Lighting (HCL) can be applied to create a pleasant, healing environment
1
in which lighting is specially tailored to supporting people and their
sense of well-being. Humans, as biological beings, are used to daylight
in its different forms and to the diurnal rhythm of day and night. The
31 Position of the light sources (blue) biological effect of light on our body clock and psyche is fundamental:
and control units (orange) the melanopic, non-visual effect of light can have an activating effect
1 Overall lighting control panel and strengthen recovery and general well-being. By contrast, the visual,
2, 3 Switch for lighting strip above the worktops
4, 5 Bedside terminal with interface for patient’s selection of light- atmospheric effect can evoke emotions ranging from discomfort to a
ing scenario sense of security or confidence. As room neighbours may have differ-
6, 7 Switch for reading light above the patient’s tables
1–3 Large, flat tunable white LEDs
ent needs at the same time, the lighting design should also be able to
4, 5 Reading light above the patient’s table accommodate conflicting lighting requirements. It should, for example,
6, 7 Reading light above the patient’s bed
be possible to darken one half of the room while allowing a second
8, 9 Continuous lighting strip providing indirect lighting
10, 11 Concealed lighting strip above the worktop patient to switch on a reading light at the same time without causing
12, 13 Lighting strip in skirting rail for orientation at night glare. Targeted lighting can also help demented or fatigued patients
14, 15 Light above the WC
16, 17 Central ceiling light bathroom find their way around but also discourage them from undertaking un­­
18, 19 Vertical lighting strip by the mirrors desirable activities.
20, 21 Lighting beneath the bed
Good lighting is also vital for hospital staff to ensure they can carry
out their work correctly without making errors due to poor visibility.

186 Prototype
Sufficient illumination is essential for diagnostics and nursing care, and inboard arrangement of the wet cells and the placement of the beds
care staff need to be able to see the colour of the patient’s skin without parallel to the façade also maximises the incidence of natural light on
it being falsified by low light levels or coloured reflections from the walls. the beds.
Green hospital walls are inadvisable, and warm-white lighting should The lighting concept also reinforces the zoning of the room, accen-
be avoided during the doctors’ rounds. tuating and delimiting the patient area, the nurses’ work area, the visi-
Dazzling caused by reflections from screens should be avoided as tors’ zone and the two wet cells. In certain situations, such as for night-
it can lead to premature tiredness. Various measures can help reduce time orientation, the concept shifts so that the light guides patients to
reflected glare: the wet cell and back, bridging rather than delimiting the zones.
— Dimmable lighting
— Correct arrangement of the screens in relation to lamps and Positioning and selection of light sources
windows Altogether, 21 different light sources and several control units have
— Shading option for windows and skylights been installed in the KARMIN patient room → Fig. 31. The three large,
— Use of glare-free lamps flat surface lamps → Fig. 31, Nos. 1–3 are useful for extensive illumination
— Luminaires with large luminous surfaces but low luminance during the doctors’ rounds and during cleaning. The white balance of
— Non-reflective surface finishes (matt surfaces) for underlays and the LEDs is tunable, making it possible to simulate the colour tempera-
work surfaces, etc. tures of daylight, which are important for Human Centric Lighting, and
— Careful alignment of lamps in relation to the direction of vision to promote the patient’s sleep rhythm → Figs. 32–36. They can be indi-
— Similarly, the corners of rooms or inaccessible or covered areas vidually controlled and radiate directly and indirectly through a broad
must also be well lit to ensure they are properly cleaned. flat panel and an outer, offset RGB colour ring. These three lights also
zone the room into an entrance area and two patient areas.
Lighting controls The three ceiling lights change the mood of the room over the
Lighting controls should allow patients and staff to quickly and intuitively course of the day from morning to night when orientation lighting takes
activate the appropriate lighting profile for their needs. They need to over. During the day, the luminaires are switched on by default but can
consider that staff may have their hands full or a patient may be too also be switched off if desired.
exhausted or physically impaired to operate a light switch. Similarly, Each patient area is also indirectly illuminated by a long, continuous
having to press a switch, and thus a contact surface, in the middle of a lighting strip → Fig. 31, Nos. 8, 9 in the wall panel at the head end of the
work process makes it hard to comply with the five moments for hand bed that both visually underlines the depth of the room and delimits
disinfection. the extent of the patient zone. Two reading lights above each of the
Light switches should be touched by as few people as possible, and patient beds provide the requisite illumination at the reading plane­
for this reason sensors can be a good alternative. By placing switches → Fig. 31, Nos. 6, 7, and a further reading light is installed above each
near the patient and near the entrance to the room, different users can of the patients’ desks → Fig. 31, Nos. 4, 5 next to the window → Fig. 37.
set the desired lighting mode directly and joint use of the same switch Below the nurses’ work area, a light-deflecting aluminium skirting
is avoided. Lighting controls equipped with mid-range RFID readers rail has been installed that illuminates the floor along the wall → Fig. 31,
can also respond to staff or patients wearing an appropriate RFID chip, Nos. 12, 13. A sensor detects when a patient gets up from the bed and
changing the lighting profile when people arrive at or leave the room. automatically activates the lighting strip at night → Fig. 31, Nos. 20, 21,
which shines from the skirting rail onto the floor, illuminating the path to
Lighting operation the bathroom where the light is on but dimmed. As both the under-bed
To operate the lights, the two primary user groups, the nursing staff and skirting light are at a very low level, they disturb the neighbouring
and the patients, are each assigned a respective lighting control point patient as little as possible. Its warm-white colour avoids stimulating
at the room entrance and at the patient bed that allow them to select the patient too much, so that they can get back to sleep after visiting
specific lighting scenarios. At the entrance, staff can switch on the the toilet → Fig. 38.
ceiling light and the light above the worktop of the nurses’ work area. A second dimmed lighting strip above the nurses’ work surface
To assist patients at night in unfamiliar surroundings, sensors are used provides even illumination of the worktop for the nursing staff to carry
so that patients do not have to search for a switch or a menu item on a out their work → Fig. 31, Nos. 10, 11.
touch panel: a weight sensor at the bed automatically activates orien- A central ceiling light → Fig. 31, Nos. 16, 17 and a light above the
tation lighting. The programming logic of lighting scenarios has to be respective WC → Fig. 31, Nos. 14, 15 illuminate each bathroom and vertical
considered carefully to avoid lighting scenarios switching in mid-activity, lighting strips illuminate the mirrors → Fig. 31, Nos. 18, 19. The matt-white
leaving patients in the dark at night or interrupting nursing procedures. surface of the HPL panels lining the wet rooms disperses light evenly
Automatic control systems have advantages for motor-impaired patients without dazzling.
but are less adaptable to specific situations, as sensor technology is The mirrored arrangement of the lighting on both sides of the room
not able to interpret the actual situation in the room. Consequently, means that each patient or work area can be illuminated individually
the lighting in the KARMIN patient room must be switched off manually. without affecting the other patient. This makes the room better able
to respond to the needs and well-being of the individual patients and
Lighting concept and implementation in the KARMIN patient room improves the quality of a multi-bed room.
The lighting of the KARMIN patient room is designed to accommodate
the diverse needs of the different user groups. To begin with, the large Control panel, bedside terminal, switches and sensors
windows of the room provide as much natural light as possible along In normal use, the room lighting follows the course of the day. For
with views outside, both of which are beneficial to patient recovery specific application situations and visual tasks, different scenarios have
by relating them physically to the world outside and time of day. The been developed → Fig. 39. The settings for all luminaires can be saved in

187 Architecture of the Patient Room

32 Morning lighting scheme 33 Lighting scheme for doctors’ rounds

34 Midday lighting scheme 35 Evening lighting scheme

36 Night-time lighting scheme 37 The patient area with ceiling and reading light above the bed
and patient desk, as well as a light strip in the head panel

188 Prototype
 preset scenarios that govern which areas are illuminated at what level
of intensity and colour temperature. While the scenarios switch multiple
luminaires at once, specific lamps can still be switched on individually.
The lighting scenarios can be selected from a control panel at the room
entrance and the patient’s bedside terminal: the control panel at the
entrance includes scenarios for nursing and medical staff, cleaning staff
as well as visitors and patients, while the bedside terminal provides
only patient-specific scenarios. For ease of use, the scenarios have
been named in the control panel and are also shown with additional
pictograms on the bedside terminal. The reading lights above the two
patient desks next to the window can be switched on and off manually
via a switch, as can the light above the respective nurses’ work area. A
motion detector activates the light in the bathroom.
The exact settings, including which lights are switched on at
which level of intensity and colour temperature, are shown in the table
in → Fig. 39.
The lighting of the KARMIN patient room conforms to the norms
and ensures that specific groups of users have the necessary lighting,
whether temporarily or in general. It supports staff in their activities and
ensures patients have a pleasant room environment over the course
of the day.

38 The bed sensor triggers the night-time

orientation light.

189 Architecture of the Patient Room

39 The different light scenarios of the KARMIN patient room.
The intensity is the percentage dimming level of the
­maximum luminous intensity of the lamp, i.e. 100 %
stands for full brightness.

Scenario Lamp Intensity Colour temperature

Rounds 1|2|3 100 % 5000 K

10 | 11 100 % 5000 K
8|9 50 %

Cleaning 1|2|3 100 % 4000 K

4|5 100 % 4000 K
14 | 15 | 16 | 17 | 18 | 19 100 % 4000 K

General daytime 2 | 3 (only inner panel) 100 % variable

lighting 8|9 variable
100 %
(HCL function)
1 60 % variable

Night-lighting 1 40 % 3000 K
right patient 11 40 % individually settable
6 40 % separately settable via bedside terminal

Night-lighting 1 40 % 3000 K
left patient 10 40 % individually settable
7 40 % separately settable via bedside terminal

Night bed sensor 13 socket 10 % 2700 K

right patient 21 bed 100 %
14 10 % 2700 K

Night bed sensor 12 socket 10 % 2700 K

left patient 20 bed 100 %
15 10 % 2700 K

Bedside terminal 6|8 individually

right patient 1|3|5|8 settable 3000 K
60 %

Bedside terminal 7|9 individually

left patient 1|2|4|9 settable 3000 K
60 %

Bathroom motion sensor 14 | 18 100 % 3000 K

right patient 17 separate switch

Bathroom motion sensor 15 | 19 100 % 3000 K

left patient 16 separate switch

190 Prototype
 Detailed planning

The detailed design planning took the final design concept as its basis
and incorporates not only the high-level requirements for the room
fittings and equipment → Requirements, pp. 174–177, but also relevant
planning requirements derived from practical experience. This stage
of the planning process strove to find solutions to construction details
that ensure a high quality of design → Fig. 40 and minimise component
joints for optimal cleaning. The work was undertaken in close cooper-
ation with all the partners involved and across the disciplines → Work
Process and the Project Team, pp. 171–173.

Design requirements
A design vocabulary was developed for the fittings and equipment
that focussed in detail on optimising the ease of cleaning the items.
The furnishings are designed to be as flush as possible with minimum
40 View of one patient area of the room
construction joints. The materials and surfaces were selected based on
the preceding material investigations → Material testing, p. 177 to facili-
tate and support easy cleaning in the long term. Surfaces with coatings
more prone to wear and tear were deliberately avoided to avert the
incidence of room closures for maintenance and upkeep.

Planning requirements
The design of the floor plan adheres to planning recommendations and
DIN standards relevant to the design of hospitals and patient rooms,
for example with respect to required distances between items in the
room, or freedom of movement in barrier-free bathrooms. The resulting
patient room has two wet cells each observing the required minimum
dimensions for patient room bathrooms.

Sizes, distances and dimensional dependencies

The patient room has 25.2 m² and the two wet rooms are each 3.7 m²
in size. The lateral distance between the patient beds and furniture or
fittings (bed to patient wardrobe and bed to nurses’ cupboard) is 90 cm.
The distance between the patient beds was defined according to two
occupancy scenarios:
— A. Occupancy with two average-sized patients – bed length 2.21 m,
with a passage width between them of 1.20 m.
— B. Occupancy of one average and one above-average sized patient
– bed lengths 2.21 m and 2.51 m, with a passage width of 90 cm.
The width of the passage between the beds must be measured as the
distance between the disinfectant dispensers mounted at the foot end of
41 The nurses’ work area provides space for preparing
each bed. The room layout ensures a minimum width of 90 cm, as required
treatments.
for doors, for example, with one above-average sized patient. The wet
cells are designed for barrier-free access in accordance with DIN 18040-2.
For this, an area of free movement of 1.20 m in diameter is required in front
of the various sanitaryware in the bathroom. The washbasin, the storage
compartments and the shower rails are installed at a height of 85 cm.

The nurses’ work area

The challenge when designing the nurses’ work area next to each patient
bed was to provide all the necessary facilities for nurses and medical
staff to prepare necessary treatments while affording the patients the
maximum possible sense of space. The nurses’ work area is a single
spatial unit comprising a fitted cupboard and worktop. A disinfectant
dispenser is mounted on the wall above the work surface and faces
into the room → Fig. 41.
The nurses’ cupboard includes compartments for storing necessary
medical materials, a glove dispenser and a waste bin for disposing of used

191 Architecture of the Patient Room

 192 cm

1
2
292 cm

44 Nurses‘ cupboard
5
90 cm

6
10 cm

8 7

Schnitt Arbeitsfläche
42 Section through the nurses’ work area and wall to the bathroom, 1 : 20
Maßstab
1 Nurses’1:20cupboard: chipboard 19.6 mm – HPL surface
2 Workplace lighting: aluminium profile with LED strip
1 Pflegeschrank: Spanplatte 19,6 mm - HPL Oberfläche
2 3Arbeitsplatzbeleuchtung:
Reach-through slot for Aluminiumprofil
disposable glovesmit LED-Band
3 4Durchgriff
Worktop: fürchipboard
Einmalhandschuhe
38.6 mm – HPL surface
4 5Arbeitsfläche:
Back panel: Spanplatte
chipboard 38,6 mm– -HPL
24 mm HPL-Oberfläche
surface
5 6Rückwand: Spanplatte 24 mm - HPL-Oberfläche
Wall covering – bathroom 1: tiles, 9 mm – bathroom 2: HPL board, waterproof
6 Wandbelag Bad 1: Fliese 9 mm, Bad 2: Spa-Styling-Board
7 7Sockelbeleuchtung:
Skirting lighting: aluminium profile rail with LED strip
Aluminiumprofilschiene mit LED-Band
8 8Hohlkehlsockelleiste:
Concave skirting board: rubber,
Kautschuk, h= height
100 mm100 mm 45 Waste bin integrated into nurses‘ cupboard and
accessible from patient room and bathroom
9 Korpus Pflegematerial
10 Patientenablage: HPL-Kompaktplatte 8mm
11 Korpus Boxen Einmalhandschuhe
12 Abwurfklappe Entsorgung: HPL-Kompaktplatte 8 mm
13 Abwurfführung: Edelstahlblech gekantet
14 Korpus Entsorgung, Öffnung elektromechanisch
5 6
15 Mülleimer

43 Detail of skirting lighting, 1 : 5

Detail Sockelbeleuchtung
Maßstab 1:5

192 Prototype
items. The glove dispensers are accessible from slots on the cupboard All the partitioning dividers are firmly attached to the body of the cup-
sidewall adjoining the worktop. Push-to-open cupboard fittings have board to avoid the need for supports or fasteners that could obstruct
been used throughout to create an even visual appearance and a smooth cleaning. The cupboard doors and dividers are arranged asymmetrically
surface for cleaning as there are no protruding knobs or recesses in or for large and smaller items. The narrower cupboard door opens into
around which dirt can gather → Fig. 44. The cupboard is integrated into the room while the wider door to the compartment for hanging clothes
the bathroom wall and its depth is designed so that the reverse side opens onto the wall so that the patient’s movement is not constrained
serves as recessed shelving for the patient in the bathroom → Fig. 55. by the door when the cupboard is open.
A disinfectant dispenser and waste flap are integrated into the recess The floor-to-wall junction is the same as in the nurses’ work area
on the bathroom side → Fig. 47. The waste bin in the nurses’ cupboard with an upturned rounded skirting rising to a height of 10 cm for easy
is accessed via a push-to-open fitting. Waste from the patient room cleaning. A small recess affords a degree of tolerance for the items
and from the bathroom is deposited in the same bin. The position of mounted above → Figs. 49–51.
the disinfectant dispenser to one side in the bathroom recess avoids it
being confused with the soap dispenser.
The edge of the work surface follows the splayed line of the bath-
room wall and has a rounded corner to prevent any risk of injury. A
flush-mounted recessed wall luminaire is mounted above the worktop
with a concealed, downward-facing LED lighting strip to illuminate the
work area in accordance with statutory requirements → Fig. 42, No. 2.
In addition, a similar recessed aluminium profile with an LED lighting
strip is flush-mounted at the base of the wall and serves as night-time
orientation lighting → Fig. 43, No. 7. The rubber flooring is turned up at
the edges with a curved floor-to-wall junction rising 10 cm above the
floor. In places where fittings project forward, such as between the
cupboard and floor or the bench and floor, the floor turns up to meet a
plinth construction, resulting in a seamless transition from floor to wall
for easier cleaning → Figs. 42, 43, No. 8.

The visitor and patient area

The visitor and patient area encompasses the window bench, a desk
for the patient and a wardrobe for the patient’s belonging. Arranged
alongside the window front, and mirrored on both sides of the room,
it offers a direct view of the world outside → Fig. 48. It has to accom-
modate different dimensions in a single spatial unit – the seating and
table heights and the table and wardrobe widths and depths – while
also maintaining a sensible distance to the beds. The windows also need
to be openable for natural ventilation, but people should not be able
to fall out of the window. The chair is the only movable element in this
area, a conscious decision so that as little as possible needs moving to
clean the room. The window bench, the patient desks and the patient
wardrobes form a single fitted unit with the wardrobes placed at either
end in front of the external wall and the seating below the large window
to ensure maximum natural illumination and an unobstructed view of
the world outside. The window is divided into fixed glazed sections
behind the visitors’ bench and opening casements in front of the desks.
To protect against people falling out of the window, two variants were
chosen for patient use: the first is a side-hung window with an opening
limiter decouplable by means of a handle, the second a “tilt and turn”
window with an assistive handle to ensure the window is operable by
people with reduced strength. In both variants, patients cannot open
the window completely. This is only possible with an appropriate key.
The bench has a total width of 2.57 m. The base of the bench is
approx. 40 mm thick and is covered by an upholstered seat cushion.
It transitions into the construction of the side and then tabletop of the
desk. The front edge of the desk is cut away at an angle so that the
patient’s sitting position is turned slightly into the room.
The patient wardrobe has a width of 77.5 cm with a standard depth
of 60 cm and contains different compartments of various sizes for cloth-
ing and personal items. Alongside the regular compartments, there is a
space for stowing a suitcase and a lockable compartment for valuables.

193 Architecture of the Patient Room

 30 cm
45 cm
192 cm

9
30 cm
10
292 cm

30 cm

11
35.3 cm

12
47 Bathroom shelves for patients with integral
14 13 disinfectant dispenser and waste disposal flap
90 cm

15
85 cm

6
10 cm

46 Section through the nurses’ cupboard and bathroom shelving, 1 : 20

Schnitt Nurses’ cupboard:
1 Pflegeschrank/ chipboard
Ablage Bad 19.6 mm – HPL surface
Maßstab 1:20
2 Workplace lighting: aluminium profile with LED strip
3 Reach-through slot for disposable gloves
4 Worktop: chipboard 38.6 mm – HPL surface
5 Back panel: chipboard 24 mm – HPL surface
6 Wall covering
bathroom 1: tiles, 9 mm
bathroom 2: HPL board, waterproof
7 Skirting lighting: aluminium profile rail with LED strip
8 Concave skirting board: rubber, height 100 mm
9 Storage unit for nursing materials
10 Shelves for patients: HPL compact board, 8 mm
11 Storage boxes for disposable gloves
12 Waste disposal flap: HPL compact board, 8 mm
13 Waste disposal chute: stainless steel sheet, folded
14 Waste disposal unit, electromechanical opening mechanism
15 Waste bin

48 Visitor and patient area

194 Prototype
 62 cm
1

130 cm 50 Base of the window bench with concave skirting

for easier cleaning

4
26 cm

5
49 Section through window bench, 1 : 20
1 Patient lighting strip: aluminium profile with LED strip
25 cm

6 2 Patient cupboard: chipboard 19.6 mm – HPL surface

7
100 cm

3 Impact protection: HPL compact board, 8 mm

4 Light switch for ceiling light above the desk, electrical socket
5 Patient desk: chipboard 38.6 mm – HPL surface
49 cm

8 6 Bench upholstery, back: artificial leather with foam core

9
7 Bench upholstery, seat: artificial leather with foam core
10 cm

8 Bench base: chipboard 38.6 mm – HPL surface

10 10 9 Supporting structure and fascia: chipboard 38.6 mm – HPL surface
10 Concave skirting board: rubber, height 100 mm

Schnittansicht Sitzbank
Maßstab 1:20

1 Patientenbeleuchtung: Aluminiumprofil mit LED-Band

2 Pflegeschrank: Spanplatte 19,6 mm - HPL Oberfläche
3 Rammschutz: HPL-Kompaktplatte 8mm
4 Taster für Deckenleuchte über Tischplatte, Steckdose
5 Patiententisch: Spanplatte 38,6 mm - HPL-Oberfläche
6 Rückenpolster: Kunstleder mit Schaumstoffkern
7 Sitzpolster: Kunstleder mit Schaumstofffüllung
8 Tragplatte Sitzbank: Spanplatte 38,6 mm - HPL-Oberfläche
5
55 cm

9 Blende und Tragkonstruktion: Spanplatte 38,6 mm - HPL-Oberfläche

10 Hohlkehlsockelleiste: Kautschuk, h= 100 mm

2.1 Ablagefächer und abschließbares Wertfach

2.2 Fach für hängende Kleidung

8 7 2

30 cm 41.6 cm

8 116.5 cm 8 91 cm 77.5 cm
2.5
51 Horizontal section and plan of the bench, table and cupboard area, 1 : 20
Grundrissausschnitt Sitzbank, Patiententisch- und schrank
Maßstab 1:20

195 Architecture of the Patient Room

Building the
Prototype

1 The KARMIN prototype was built in a works hall of the

association partner Röhl.

2 The room’s walls were first erected as sandwich panels

with integral ducts and supply lines.

196 Prototype
3 View of the shell of the room looking towards the entrance 4 View through the steel structure of the interior of
the room. The walls and ceilings were clad and
electrical cables laid.

5 The coloured impact protection wall panels were 6 Final surface finishes and painting of the ceilings
installed at the head ends of the beds. Cut-outs were and walls
left in the HPL panels for supply connections.

7 The construction for the window bench and patient 8 One of the wet cells with HPL wall cladding and tiled
desks was built prior to inserting the window. The floor before installation of the ceiling
bathroom fittings were installed and connected to the
water supply and drains.

197 Building the Prototype

Completed
Prototype and
Use Scenarios

9 View of the patient room with the “doctor’s rounds”

lighting scenario showing the patient area, the
associated bathroom and the nurses’ work area

198 Prototype
10 The patient area during the doctor’s visit. The patient’s 11 The doctor explains the medication plan displayed on
wardrobe can be seen in the background. The staff use their the patient’s bedside terminal.
own mobile device so that they do not need to touch the
patient’s bedside terminal.

12 The nurse has direct access to any necessary materials

stored in the cupboard next to the nurses’ work area.

199 Completed Prototype

13 A nurse helps a patient to the bathroom.

14 View of the patient room from the entrance with the 15 View of the bathroom. For easy access, the
regular lighting scenario which changes subtly over door slides to one side in front of the wall.
the course of the day

200 Prototype
16 A member of the cleaning staff mops the floor. The large
window with the seat in front allows ample natural light to
enter the room and provides a good view of the world outside.
The floor beneath the bench is also easy to reach with the mop.
On either side of the window seat is a patient desk illuminated
by a ceiling-mounted reading lamp.

17 A member of the cleaning staff cleans the 18 The rounded corners of the washbasin are wiped dry
nurses’ worktop. after cleaning.

201 Completed Prototype

19 Changing a patient’s dressing. The necessary
materials can be placed within easy reach on
the worktop of the nurses’ work area.

20 The wet cell with HPL wall panelling. The soap dispenser and 21 The wet cell with wall tiling
­disinfectant dispenser are placed apart and look different to avoid
confusing them. The HPL panelling reduces the number of con-
struction joints for more effective cleaning.

202 Prototype
22 View from the window towards the
entrance. The mirrored, symmetrical
layout of the room is clearly visible as
are the positions of the newly devel-
oped KARMIN disinfectant dispensers
above the nurses’ work areas.

23 The KARMIN bedside cabinet with seamless drawer 24 The KARMIN disinfectant dispenser has been
unit and top tray has been designed for optimum designed to improve compliance with hand
effective cleaning. ­hygiene guidelines and to simplify its installation
and cleanability.

203 Completed Prototype

25 The recessed shelving in the bathroom includes a waste 26 Close-up of the waste disposal flap in the bathroom
disposal flap that discharges into the waste bin in the
cupboard of the nurses’ work area, from where it can
be emptied.

27 The nurses’ work area comprises a cupboard for

nursing materials and the adjoining worktop.

204 Prototype
28 The rubber flooring has a rounded concave skirting that
turns up at the base of the wall. This enables easier cleaning
of the room corners and prevents the build-up of micro­
organisms at the junctions and corners of the room.

29 The window seat defines a zone for visitors in the patient

room. On the left, one can see the open patient wardrobe
with a lockable compartment for valuables.

205 Completed Prototype

Furniture and
With technological advances and increasingly intensive patient care,
the modern patient room has become a room filled with numerous
objects and items of equipment. These, in turn, are used in a large

Equipment
number of different work processes. The typologies of these objects
range from medical equipment to fittings, furniture, decor, patient
beds, bedside cabinets and mobile devices → Fig. 1. Each of them
has different surfaces, functions and shapes, which are more or less
favourable in terms of infection prevention. In general, every object
is colonised with microorganisms, but they are touched, moved,
removed from the room and brought back again by different user
groups at different frequencies depending on their function. People
and objects carrying pathogens in and out of a room are the main
transmitters in infection chains. Contact surfaces that are frequently
touched typically pose a higher risk of transmission than rarely used
items. For example, almost everyone touches the door handle, but
the bedside drawer is used primarily by the patient and only occa-
sionally by staff or visitors. The construction of the various objects in
the room – some of which are classified as medical equipment – is
governed by various standards and norms, which contribute to its
potential to prevent infection transmission. The positive or negative
influence of an object on the infection prevention potential is hard to
measure purely in objective categories. Objects such as a disinfectant
dispensers or infusion stands are essential items of medical equipment
but a bunch of flowers, while unimportant from a medical perspective,
and perhaps even harmful as a source of infection, is beneficial to
the patient emotionally and may indirectly help speed the process
1 Typical fittings and equipment in the immediate
vicinity of a patient

206 Prototype
 of recovery. Likewise, functional objects, such as seating for visitors,
are necessary but entirely irrelevant to medical procedures.
As these various objects are involved to different degrees in cycles
of use and work processes, they are also cleaned and disinfected at
different intervals. For combating the transmission of multi-resistant
pathogens, this presents several challenges in the design of patient
rooms. Which objects can limit or prevent the incidence of nosocomial
2 Four approaches to infection control among patients: infections? How can items be incorporated into work processes to
cohorting, isolating, separating infection chains within encourage safe disinfection procedures, and how can they be designed
a room or no measures at all despite different infections
and clinical pictures (from left to right) for easy cleaning? Can (mobile) devices encourage good hygiene prac-
tices among patients through digital information and advice? And in
general, how can the design of the environment of the patient help
break the transmission chain of pathogens?

The infection prevention potential of key objects in a

patient room

There are numerous strategies for controlling the spread of infection that
act at almost as many different levels. Cleaning surfaces and washing
hands are essential for removing coarse dirt that can be a breeding
ground for microorganisms – but they do not kill pathogens. Disinfect-
ing surfaces and hands immediately after washing further minimises the
risk of infection by killing pathogens that have not developed a corre-
sponding resistance. Probiotic cleaning methods using biocidal agents
are increasingly being tested as they do not eradicate microorganisms
that are harmless to humans and cause less chemical damage to sur-
faces than aggressive cleaning and disinfecting agents. Surfaces that
are chemically cleaned over a long period eventually become porous
and can harbour dirt and germs more easily. As such, objects in patient
rooms must be designed so that they need less frequent disinfection
to prevent the development of resistance.
In addition to cleaning, other methods of infection prevention
include isolating patients, pathogens and objects, though these are
costly and require space and time. They also do not prevent micro­
organisms being transported by nursing staff, unfiltered air or rubbish.
One principle among patients is cohorting → Fig. 2 in which people
with the same pathogens are isolated together. Other strategies can
also be employed to reduce the risk of cross-contamination between
patients in a room, for example by ensuring patients do not mistakenly
use each other’s personal hygiene products and by clearly distinguishing
between disinfectant and soap dispensers. In addition, separating both
work processes as well as patient-specific items can help prevent path-
ogen transmission by droplets and contribute to infection control. Staff
can, for example, wear a face mask and avoid physical contact, while
suitable design measures that take into account the radius of action of
patients, can employ design means to prevent patients with dementia
from accidentally reaching for or misidentifying the personal hygiene
items of their neighbour. RFID chip technology can be used to permit
and restrict access to certain items, and motion detectors can avoid
the need to touch switches, minimising contact infections. As part of
the KARMIN project, the “Furniture and Equipment Design” sub-project
investigated which additional strategies can be developed for prevent-
ing infections through equipment, work processes and behaviour, and
which existing approaches can be optimised.

207 Furniture and Equipment

 Future scenarios
Alongside existing norms for equipment that reflect the current level of
knowledge on infection prevention, future scenarios must be considered
so that one can derive insights from them and implement solutions
accordingly. By appraising the existing situation and extrapolating from
it, existing norms and established processes can be critically examined
and new research findings in the field of infection control can feed
back into the design of equipment and fittings for hospital rooms. In
this respect, digitalisation and innovation in medical technology and
treatments on the one hand and demographic change on the other
play an important role. Longer life expectancies and a proportional
shift towards older patients will lead to a change in clinical pictures
and in the composition of patients in hospitals. Patient rooms will need
different fittings, work processes will have a different focus and patients
will be less mobile. In addition, the proportion of elderly patients with
dementia will increase, placing new demands on the ward environment.
The changing patient demography also has implications for the ergo-
nomics of equipment, which will need to meet the needs of people with
physical and cognitive limitations.
3 The three radii of action and their overlaps from patient More intensive patient education is also imperative. At the same
outwards: gripping radius, droplet radius and mobility
radius (the entire circle) time, new types of digital and networked devices enable the contactless
transmission of information about the physical condition of patients and
of work processes. Digital patient records, for example, eliminate the
need to carry paper-based files in and out of the room, reducing the
risk of transmitting pathogens. Care must be taken, however, that all
these technical means do not result in an overly distanced, impersonal
atmosphere. Physical experience is a fundamental sensory sensation

Prevention that stimulates cognitive response and is better at transporting and also
expressing emotions. Haptic experiences are essential to the emotional
All user groups well-being and recovery of patients. Similarly, patients must be actively
involved in infection prevention, rather than relying on passive and/or
purely technological solutions.
Economic aspects will also have an impact on patient rooms in the
future. Shorter durations in hospital and fewer nursing staff will increase
the frequency with which beds need preparing for new patients and
shorten the time that nursing staff have for their everyday activities.
Cleaning Information A supportive environment must be developed that provides physical,
emotional and also procedural support. Future developments do not
Care staff – Patient necessarily imply a decline in infection prevention. Instead opportuni-
Patient – Visitor ties and potential for improvement must be sought, such as the digital
patient records.

Methodology and relevant objects

The research group began by drawing up a tabular list of all the objects
always present or potentially found in a patient room, and analysing
4 The primary themes of the newly developed equipment
each according to a series of aspects: the object’s inherent prevention
potential, the degree to which its surfaces and contact surfaces are
colonisable with MRSA/VRE, its frequency of use, its potential for con-
tamination by the relevant user group(s) and its position relative to the
radius of action of the patient and hospital staff. To help assess how
colonisation develops over longer periods of time, two further evaluation
factors – usage and cleaning cycles – were examined and classified as
either constant, hourly, daily, weekly and after/before patient discharge.
Finally, the patient’s radius of action was classified as being either within
gripping distance, droplet radius or mobility radius → Fig. 3. These cat-
egories provide an indication of the likelihood of surface contamination
of an object through contact by or droplets from a patient or caregiver.
In addition, the group studied the degree to which the objects are used
consecutively between each hand disinfection.

208 Prototype
 Expert workshops with planners, patients, hygienists, doctors, archi- narios can promote a smooth working process. The aim was to create
tects, nursing staff and experts from the private sector as well as visits a coherent environment in which the objects and architecture support
to clinics and work placements provided additional insight into which both patients and staff.
objects need redesigning and further development. The methodology
used is described in → Catalogue of requirements for the patient room Cross-contamination
and wet cell, p. 177. Failure to disinfect hands between work steps and failure to clean and
From the long list of objects in a patient room, the research group disinfect contact surfaces used by many different people can lead to
selected three relevant objects for in-depth design analysis with a view cross-contamination. Optimising the placement of disinfectant dispens-
to optimising and adapting their design, or where necessary rethinking ers can help increase compliance, while the use of contactless sensor
their design. The objects were chosen based on the degree of colonisa- technology can reduce contamination. This is described in more detail,
tion of the objects, the frequency with which users come into contact along with an overview of infectious diseases, their occurrence and
with them, and their respective prevention potential. The first object transmission paths, in the section → Healthcare-Associated Infections,
is the disinfectant dispenser as it is the central, preventive object in pp. 21–23.
everyday hospital life; the second is the bedside table and cabinet as
a frequently used object in the immediate vicinity of the patient that Methodological approach to determining requirements
is also encountered by nurses during their work; and the third is the The research served as a basis for deriving the requirements the objects
bedside terminal as a frequently touched surface that can also serve as need to serve. For each of the selected objects – the disinfectant dis-
an educational and informational tool. penser, bedside terminal and patient bedside table – the requirements
were systematically categorised and then prioritised according to
Three objects in focus the labels “could have”, “should have” and “must have”, based on the
As patient care becomes increasingly centred around the immediate findings of the prior research. “Could have” represents qualitative, oral
area of the patient’s bed as a consequence of demographic change, we recommendations made by interviewees during expert workshops,
can expect to see an increase in the frequency and duration of use of the work placements and hospital visits, while “should have” are a result of
bedside table and cabinet and the bedside terminal. All three objects guidelines and standards and “must have” of laws. These requirements
have been re-examined with a view to optimising infection prevention, were then reviewed for their relevance to hygiene and infection control
not just in terms of their appearance and construction but also in the to prioritise them for the concept phase. As part of the conceptual
way they are used or invite people to use them. While the disinfectant design, different implementation variants were outlined and also built
dispenser and the bedside cabinet are already familiar objects in patient as a basis for discussion and evaluation by experts including partners
rooms, the bedside terminal is comparatively new and offers new infor- from medicine and industry. From these, optimised prototypes were
mational possibilities for improving good hygiene practices. In terms built as demonstrators for evaluation in practice.
of their physical functionality, the first two cases are far more complex In terms of general recommendations: the surfaces and the forms
objects but still have room for improvement in the way they support of objects should be designed for easy cleaning; the respective objects
work processes, in how easy they are to clean and through digitalisa- should be better integrated into work processes; and digital instru-
tion. Research conducted as part of hospital visits and in conversation ments should be used to optimise and clarify processes. The following
with experts during workshops also revealed that existing standards sections detail the set of requirements, the resulting concepts and the
and guidelines were not always heeded due to economic constraints final design solutions for each of the three objects.
or time pressure in hectic work situations. The objective of a redesign
should therefore be to encourage certain patterns of use and inhibit
unfavourable actions through the object’s design. The primary themes
of the re-examination of these objects are their potential for infection
prevention, ease of cleaning and their informational-educational poten-
tial → Fig. 4. In this context, the researchers also reviewed the existing
patterns of information provision and work processes in two-bed patient
rooms with a view to identifying opportunities for optimisation.

Pathways
As part of the analysis of the work processes, the researchers identified
the various points within a room that users visit, the order in which they
are visited and how they might be better positioned. The patient bath-
room, for example, has a major effect on the work steps and pathways
within the room. Depending on its position, it can lengthen the path
from the door to the patient, restrict the field of vision and obstruct
accessibility. The arrangement of fittings and equipment within a patient
room should facilitate direct paths between them and support work
processes. When patients are located crosswise and opposite each
other, walking distances are made unnecessarily longer, causing staff
to potentially omit work and disinfection steps. One idea discussed in
this context is the extent to which lighting can encourage staff as well
as patients to follow certain paths. Spotlights and correct lighting sce-

209 Furniture and Equipment

The Disinfectant The disinfectant dispenser is a central tool of horizontal infection control
used in all areas of hospitals and also by all patients. It is therefore a

Dispenser
central element of the KARMIN project. Hand disinfection can help pre-
vent both exogenous and endogenous infections, and this applies not
just to staff but also to visitors who are not traditionally encouraged
to disinfect their hands. Doctors play a particularly important role
as behavioural models for other user groups. Patients can, in certain
situations, also reduce the risk of MRSA transmission by disinfecting
their hands, but the first step for patients should always be to wash
their hands properly because this suffices in many situations. Further
methods of educating patients, and indirectly also visitors, on the value
of hand disinfection in patient rooms are discussed in the section on
the → Bedside Terminal, pp. 230–236.
Disinfectant dispensers have been used for decades for infection
prevention and personal protection and have evolved into a highly
sophisticated device. Numerous initiatives and organisations, including
the World Health Organization (WHO), have developed established
and scientifically based guidelines for their placement and methods of
use – such as the WHO “Five Moments for Hand Hygiene” – which have
in turn influenced their design. In terms of their technical construction,
ease of cleaning and how they are perceived, however, there is still
potential for improving their design to minimise infection transmission.
Three factors play a key role in the reasons why disinfection guidelines
are not observed: memory, attention and decision-making – or in other
words, forgetting, distraction and prioritising other activities. In more
concrete terms, this means insufficient knowledge of or education on
hand disinfection, an environmental context that is poorly designed,
unclear and hinders decisive action, and a lack of time or availability of
disinfectant. All these need further research, consideration and incor-
poration into the product’s design. But to begin with, it is useful to ask
who disinfects when, where, how and why → Fig. 1, as a basis for deriving
the requirements that the product must fulfil. The findings are discussed
in more detail below and ultimately led to the newly developed design
of the KARMIN disinfectant dispenser.
However, there are also possibilities for optimisation that can be
implemented with existing dispensers, for example in the positioning
of the dispenser.

Requirements for a disinfectant dispenser

? ?
? ? Positioning
? ? An important factor for the aspects of memory, attention and deci-
Who? sion-making in infection prevention is not just the design of the dispenser
Where? itself or the training of staff and the education of other potential users but
also the positioning of the dispenser, i.e. the question of where. In the
KARMIN project, we discuss this in the context of a two-bed room, but
many aspects also apply equally to single or multi-bed patient rooms.
C1 Typically, a dispenser is positioned close to the patient room door
A B and within the room so that the disinfectant can act on the way from
C2 the entrance to the bed. However, this means the dispenser is no
longer near the path of the nurse’s subsequent work steps in a patient
When? How? room with more than one bed. If it is placed too close to the door,
it will be obscured by the door when it is open, where it then risks
being “out of sight and out of mind”. At the same time, this protects it
from collision with mobile items being wheeled in or out of the room.
For the nurses, however, it is more important that the dispenser lies
in easy reach for their work → Fig. 2. Instead of placing one dispenser
Why?
at the entrance, two can be placed above the respective worktops
1 Key questions about hand disinfection and two more attached to the end rail at the foot end of each patient

210 Prototype
 bed. Two further disinfectant dispensers can also be positioned in the
wet cell. This saves time between the different work steps and when
switching from patient to patient because staff can disinfect their hands
at the entrance, near the bed and at the washbasin in the bathroom.
Positioning the dispenser above the worktop also protects it from
accidental collision → Fig. 3.
Alongside their positioning in the room, dispensers should also be
mounted at an appropriate ergonomic height. For correct and easy
operation, the pumping surface should be approx. 120 cm above floor
level. Dispensers must also be accessible to users in wheelchairs, and
also from the side: care should be taken that access is not blocked by
other adjacent objects → Fig. 4. Disinfectant dispensers should therefore
be positioned so that they tie in with the work routines of medical staff
but are also accessible to other user groups in patient rooms.

2 Bad (left) and good (right) positioning of disinfectant

dispensers in relation to the nurse’s work processes Five moments for hand hygiene
Medical staff are trained to internalise five moments for hand disinfec-
tion. This hand hygiene strategy is designed to protect the patient and
their uninfected body parts, the environment of the patient, the medical
staff and the next patient against contact infections, and also details
why. In outpatient medicine, one differentiates between non-invasive
and invasive treatment. In inpatient medical care, invasive treatment is
more common, and it becomes important to define when hand disinfec-
tion takes place. According to the five moments, hand disinfection must
take place 1) before patient contact, 2) before aseptic activities, 3) after
contact with potentially infectious materials, 4) after patient contact, and
5) after contact with surfaces in the immediate vicinity of the patient.
A diagram of the five moments is shown in the section → Healthcare-­
Associated Infections, Fig. 4, p. 23. To ensure that these five moments
are observed, disinfectant dispensers must be visible from everywhere
in the patient room and mounted ergonomically within easy reach
(Boog et al. 2013). Studies have shown, however, that more than three
dispensers per patient does not increase compliance (Chan et al. 2013).
To ensure hand disinfection between two patients, i.e. after touching
3 In the KARMIN patient room the dispenser is the last and before touching the next patient, disinfectant dispensers
positioned along the walking route. can be fixed using an adaptable fixing to the end rail at the foot of the
bed. A clamping mechanism makes it possible to mount the dispenser
to the right or left of the rail depending on where it is most needed.
Mounting the dispenser slightly away from the corner, so that it does
not protrude, avoids accidental collisions when passing by the bed.

Compliance
Alongside observing the five moments for hand disinfection, it is also
important that disinfectant is applied and rubbed in thoroughly. Measuring
ca. 120 cm the frequency and quality of hand disinfection through observations on
site is very time-consuming and therefore only possible on a short-term
basis. It is also hard to check how well hands have been disinfected
using technical means. Consequently, this is largely disregarded as a
requirement for the design of the dispenser. One method suggested
for checking how well staff comply with the respective guidelines is to
4 Mounting height and wheelchair clearance electronically or mechanically record the pump action of the dispenser
and correlate it against the respective consumption of disinfectant
(Schulz-Stübner 2013, p. 217). However, this method is still inaccurate as it
says little about the user group, the situation or how well the disinfectant
has been rubbed in: we don’t know how many people were in a room
when it was used and what activities were being carried out. An LED
installed in the dispenser can light up for the duration of the minimum
rubbing-in time to give users at least some direct feedback on the time
required for the disinfectant to act, but it is still not possible to ascertain

211 Disinfectant Dispenser

 how well the disinfectant was applied to the entire hand. In addition,
staff usually begin moving around the room after disinfecting their hands
and rarely wait by the dispenser. In everyday hospital practice, no-one
stands and waits for a signal to elapse; instead, disinfectant is applied
and acts in the time between using the dispenser and before touching
the patient. The proper and thorough application of disinfectant is there-
fore a matter of good staff training, comprehensive, repeated education
of the user groups, and a conducive environment. There are, nevertheless,
further means of improving compliance beyond appropriate positioning
of the dispenser and sufficient education of the users.
One simple method is to provide graphical visual cues on walls and
5 Possible options for graphical visual cues on the floor → Fig. 5, though these can become less effective as staff grow
walls or floors to highlight the presence of accustomed to the cues and begin to overlook them.
dispensers
Another established method is to use team meetings to give
repeated targeted feedback in person to reinforce staff compliance.
This can be made more effective if reliable quantitative data is available
with which to analyse compliance. Disinfectant dispensers that are
equipped with sensors can provide usage data that reveals at what times
and what amount of hand disinfectant is used. A widely used method
for monitoring compliance with standards is the current HAND-KISS
principle. This calculates the consumption of hand disinfectant and the
number of disinfection measures carried out per patient, per resident
day or treatment case to determine conformity with guidelines for
hygienic hand disinfection.
6 Positioning the soap dispenser (blue) and
disinfectant dispenser (red) in a patient
HAND-KISS also compares the consumption of hand disinfectant
bathroom. Placing one by the sink and the across wards with similar patient groups (same ward types). The count-
other to one side helps separate how they ing principle can also be made more precise by correlating it against
are perceived by the user.
the different user groups, e.g. nurses and carers, doctors, visitors and
patients (Scheithauer 2018). To do this, however, existing disinfectant
dispensers must be retrofitted with a technical means of data collection.
Digital sensors and evaluation systems offer great potential for increasing
hand hygiene and improving compliance with regulations. They provide a
more exact means of monitoring usage, but care must be taken to avoid
the user feeling under surveillance. From a methodological perspective,
research has shown that positive motivational triggers are far more
successful than admonishing users for non-adherence. An atmosphere
of excessive monitoring can also give rise to the Hawthorne Effect: when
people know they are being watched, they adapt their natural behaviour
accordingly. In this context, this could lead to hand disinfectant being
used to satisfy the monitoring system rather than to encourage correct,
high-quality hand hygiene. For the design of the KARMIN disinfectant
dispenser, the researchers therefore examined additional possibilities
for increasing compliance through inconspicuous data collection and
triggering positive emotions not seen in existing dispensers.

Fill level and usage analysis

As mentioned above, a constant supply of disinfectant must be ensured
to comply with hand disinfection guidelines. As obvious as this may
sound, it can often be a logistical problem in the everyday running of a
hospital. The disinfectant dispenser’s monitoring and analysis system
should therefore not only monitor usage data but also communicate the
fill level and location of the dispenser to the central monitoring system
so that this can be monitored constantly. Hospital staff can then replace
bottles as and where needed before the disinfectant runs out and the
dispenser fails to function. The dispenser must transmit this data wire-
lessly and a software system must record and display the data. A further
requirement of this system is to eliminate multiple pumps that occur in
quick succession when staff press several times on the dispenser when
working. While each pump must be recorded individually to calculate

212 Prototype
the fill level, they should be bundled as a single operation for the usage and places an additional burden on the hospital’s emergency electrical
statistics. The data acquisition system should also break down usage of supply. To this end, a self-sufficient solution was found for the KARMIN
the hand disinfectant dispenser by date and time of day. disinfectant dispenser.

Display function and prompting strategies Mechanical versus contactless dispenser

To ensure dispensers are used at the right time by the widest possible A major disadvantage of electronic contactless disinfectant dispensers,
spectrum of users, including patients and visitors, a display function aside from their considerably higher price compared to mechanical
can be used to animate people to use the dispenser and instruct them dispensers, is their dependency on an electrical supply. In the event of
how. A friendly, approachable appearance likewise encourages visitors a power outage, they do not comply to standards as disinfectant dis-
to engage with the dispenser. Surveys and conversations conducted as pensers must be functional at all times. In addition, complex electronic
part of the KARMIN research project revealed that people responded components require more maintenance and electronic pumps consume
negatively to the technical appearance and medical connotations of energy to operate. The argument that contactless dispensers avoid
conventional dispensers. The use of animations, for example, can give contact infections that arise with traditional dispensers where previous
character to an otherwise static piece of equipment, so that it appeals users contaminate the pump with pathogens is also not entirely true, as
to users at an emotional level. Studies have shown that in neonatology the user of a mechanical dispenser disinfects their hands immediately
wards, for example, staff disinfect their hands more frequently if pictures after touching the pump. Newer dispenser models therefore adopt
of newborn babies were placed above the dispensers. It appealed to the a hybrid strategy in which a mechanical dispenser can be used that
staff’s sense of responsibility and made them more inclined to disinfect functions independently of the electronic components used for digital
their hands. It also strengthened the inviting character of the dispenser. data acquisition and transfer.
Posters, flyers, films or online posts can also provide additional informa-
tion on when and how to disinfect one’s hands properly. This could be Disinfectant dispensing function
sent via an app notification or information e-mail prior to the patient’s Several requirements must be met by the dispensing mechanism, first
arrival. Bedside terminals likewise can be used to educate patients and foremost the correct concentration and dosage of disinfectants
during their stay and to create incentives. Alongside the aspects of for successful hygiene measures. The German testing standard requires
attention and memory, the dispenser’s display function must also aid a disinfectant dosage of 3 ml per hand rub (DIN EN 1500). However,
in deciding which actions to take. To distinguish it adequately from because staff frequently pump several times in everyday practice, var-
soap dispensers, clear labelling and some form of formal or coloured ious manufacturers factory-set the output to 1.5 ml, so that at least­
differentiation can help immediately identify its purpose. Placing it 3 ml of disinfectant are dispensed in total. In addition, guidelines stip-
at a separate location also helps and additionally prevents people ulate that the pump mechanism may only fail to deliver in 1 % of cases,
disinfecting their hands prior to washing them while in haste or out of or in two out of 200 consecutive pump strokes (Assadian et al. 2012).
ignorance → Fig. 6. Objects in a patient room should be designed so that Gels are not permitted as medical products, although they would be
they meet the user’s expectations and are placed at an intuitive location. advantageous as they prevent dripping, which in the long term dam-
ages the surface of any items or the floor beneath the dispenser. Some
Disinfectant supply dispenser models feature pumps that attempt to prevent dripping by
To fulfil its function and comply with guidelines, a disinfectant dispenser sucking up the disinfectant when the pump is released. Drip protection
must have a constant supply of disinfectant. To this end, the fill level trays help to a limited degree, because they are often not cleaned or
must be visible on the exterior so that low levels of disinfectant are regularly emptied so that they overflow. Similarly, one cannot prevent
noticed before it runs out. Ideally, the fill level should also be transmit- disinfectant dripping from the hands of the user as they move away
ted to a central monitoring point so that switching out the bottles can from the dispenser. Drip protection trays must also be sufficiently far
be coordinated more easily in a timely manner. Empty bottles should away from the dispenser outlet to allow sufficient space for a pair of
be disposed of immediately to prevent improper use of any remaining hands beneath the pump head.
liquid. Systems in which the pump head is replaced with the bottle are
preferable to avoid contamination or re-use for cost reasons, where the
pump head risks becoming a breeding ground for pathogens. In this
case patient health is more important than waste avoidance. This can
be partially mitigated by using pump heads made of recycled materials.
In addition, the dispenser bottle must maintain the prescribed concen-
tration of alcohol at a constant level for three months (Assadian et al.
2012). Hospitals can decide whether to keep supplies of replacement
bottles in a central location or in each ward.

Electrical supply
The digital systems for the sensor systems, data acquisition and wireless
communication of usage data requires electricity. As disinfectant must
always be available, the dispenser must function even during a power
outage. This can be achieved by connecting it to the hospital mains,
which has an emergency backup system, or by means of ensuring it
has a mechanical means of dispensing, even when the electronics are
inoperable. The former is more complex and costly in terms of cabling

213 Disinfectant Dispenser

 Ease of cleaning
In addition to hand disinfection as an essential part of infection prevention,
it is also important to minimise colonisation of the surfaces and joints
of the dispenser itself by germs. The design of the dispenser must be
optimised for ease of cleaning through the choice of a suitable form and
appropriate materials. Instead of sharp corners, the dispenser should
be given clear, uninterrupted rounded edges → Fig. 7.
Similarly, hard-to-clean seams and narrow joints must be avoided
so that surfaces are simple to wipe clean with disinfectant. Minimising
the number of components and the complexity of assembly is also
advantageous as it minimises joints. Where pump heads are re-usable,
7 Rounded edges and avoiding joints helps to ensure
they must be cleanable in an autoclave, i.e. disinfected in a machine
clean surfaces. at an A0-value of at least 60 (or 80 °C/1 min). Sterilisation at 121 °C
is even better (Assadian 2012). The A0-value is a time-temperature
relationship that expresses how long it takes to kill microorganisms at
a specific temperature. This needs to be undertaken after each bottle
change to prevent microbial contamination of the pump head. The
re-use of disinfectant bottles is not permitted, and they must be prop-
erly disposed of after use, along with the disposable pump head (unless
re-usable pumps are used).

Materials
The requirement that the dispenser can be wipe disinfected and is
heat-cleanable means that the materials must be resistant to alcohol
and heat. Where re-usable parts are specified by the hospital operator,
it must be made of an autoclavable material. Stainless steel is rec-
ommended for this purpose but various plastics such as acrylonitrile-­
butadiene-styrene copolymer (ABS) can also be used for parts such as
the housing. The material must be able to withstand the pressure applied
when using the dispenser. Plastics offer greater design flexibility than
curved sheet metal for the design of the housing because they can be
injection-moulded.

Colour, shape and character

The choice of an appropriate material is not solely a matter of technical
suitability but also one of associative connotations. As with the display
function mentioned earlier, the colour, surface quality and shape of the
dispenser should also appeal to the user and fit into the atmosphere of
the room. People engage more readily with a visual form and appear-
ance that does not have negative connotations, ultimately promoting
compliance. In the expert workshops and hospital visits conducted
as part of the KARMIN project, various potential user groups voiced a
need for disinfectant dispensers that are perceived as “warm” and not
stigmatised by being part of the medical apparatus of the hospital. On
the one hand, the dispenser should evoke a sense of purity and warmth
and be visually integrated into the design of the patient room, and at
the same time it should be sufficiently noticeable. Slightly muted signal
colours and round, soft shapes are ideal for this purpose. The cold,
technical feel of materials such as polished stainless steel is less well
suited than that, for example, of coloured plastics.

Dispenser elements
All these requirements come together in the design of the construction
of the dispenser. A basic dispenser must be able to hold a dispenser
bottle, provide a pump or valve that dispenses disinfectant, even when
no power supply is available, and provide a means of recording how
often it is used. For this, the dispenser needs an electronics system
that can encourage users to use the dispenser, record and transmit
usage data, display the charge and fill level and relay its location to

214 Prototype
a central monitoring system. The housing must have as few joints as their less complex design, many electronic dispensers offer the ability
possible, rounded rather than sharp edges, no narrow notches or gaps to dispense disinfectant without touching them. Electronic dispensers
and be flexibly mountable, for example on a bed rail or a wall. It should are permanently installed and are thus stationary dispensers usually
be mounted with ample space above for comfortable operation, and mounted on a wall or bed. The latter can usually also be attached to
the housing should be quick and easy to remove and replace so that the nurses’ trolleys or other objects with round profiles using a clamp
untrained staff can refill it as needed. but are then only semi-mobile. Permanently mounted dispensers have
As all manner of objects are routinely stolen from hospitals, the the advantage of being at a specific, memorisable location so that staff
dispenser should be mounted to prevent unauthorised removal of the do not need to interrupt their work routines to find them.
bottles or of the entire dispenser. This is best achieved using a concealed
fixing mechanism that is additionally covered. All these requirements Gown bottles
need to be translated into a coherent and realistic concept. Commer- Mobile dispensers and gown bottles are, by contrast, always to hand,
cially available dispensers range in price considerably from about 20€ but not available to all user groups, for example for patients’ relatives
to as much as 300€. The KARMIN disinfectant dispenser aims to have a and visitors. In addition, the smaller capacity of the bottles leads to
price point of about 50€. more waste than wall-mounted dispensers. Smock bottles can, however,
contribute to the perceived competence of medical professionals, and
A concept for an intelligent disinfectant dispenser set an example. When consistently applied, only the remaining staff need
be encouraged to use the available dispensers in a compliant manner.
The objective for the KARMIN disinfectant dispenser is to design a smart
dispenser that employs a psychological trigger to encourage use and Construction differences
is also generally appealing to visitors, staff and patients through its In terms of appearance, electronic dispensers can be more aesthetically
inclusive appearance. Its design should simplify cleaning and minimise attractive and compact than mechanical models as they do not need to
colonisation with germs by reducing the number of components, and have a protruding lever arm. When wall-mounted, however, they cannot
thus joints in the product. A further key requirement of its construction always be positioned optimally to lie in the working radius of staff. In
is the separation of the mechanical disinfectant dispensing mechanism addition, disinfectant can drip, over time damaging the floor through
from the electronic data collection and transfer so that each can function long-term exposure to disinfectant. Their greater design complexity
decoupled from the other: the dispenser should be manually operable also requires more elaborate regular cleaning and preparation than
in the event that the electronics fail. A hybrid solution is therefore nec- disposable (gown) bottles.
essary. To this end, the team initially set aside the classic components of
current conventional disinfectant dispensers so that they could explore
the horizon of possibilities for the given requirements in the concept
development phase unimpeded by existing constraints. The result is a
novel bottle design and housing with screen that nevertheless builds
on the valuable qualities of previous models.

Analysing existing dispenser models

Combining all the different desired properties in a functional and
compliance-enhancing design for a disinfectant dispenser that is more-
over also cost-effective, is a challenging task. Previous models have
therefore concentrated on the core properties and neglected secondary
features. In the European market, a model of dispenser has emerged
over the last decades which is sold under various trade names. Its
housing consists of an anodised aluminium sheet, which is open at the
bottom. It employs a purely mechanical dispensing mechanism with a
simple design, but the pump system comprises many individual parts
which are complex to keep clean when (re)installing the dispenser. As a
consequence, they are not always properly sterilised. Furthermore, the
dispenser does not offer any means of data collection and it does not
look inviting, but rather technical, clinical and utilitarian. Some newer
models are more attractive and also reduce the number of compo-
nents but are made of less durable plastic. Aside from that, intelligent
dispensers that record usage data are now also more widely available.

Electronic dispensers
Contactless dispensers are less common in German hospitals due to their
significantly higher cost. All the currently available electronic models
have different advantages and disadvantages. They differ from conven-
tional dispensers through the type of dispensing mechanism, their ability
to record information and where they can be mounted. While mechan-
ical dispensers are considerably cheaper and easier to maintain due to

215 Disinfectant Dispenser

 Differences in ensuring supply
Further differences arise with respect to ensuring a constant supply of
disinfectant. The small capacity of smock bottles means that replace-
ments must be easy for staff to procure and that they remember to
replace a nearly spent bottle in time. The logistics are more complex
and the tendency to forget greater than when a smaller group of people
are explicitly responsible for ensuring stationary dispensers are always
functional. In addition, how much a smock bottle dispenses cannot be
regulated so there is a greater danger of incorrect or excessive use.
Electronic dispensers, by contrast, fail to function at all if there is a power
failure and risk jeopardising the constant availability of disinfectant. The
hospital may also become dependent on a single supplier when dispensers
8 A data acquisition system records disinfectant con- can only accept the manufacturer’s proprietary refill bottle shape. The
sumption, time, user group membership and fill level, more complex housings of electronic dispensers may require that staff
which are sent to a centrally controlled software for
evaluation. need instructing in installing refills. The comparative complexity of the
components may also entail more costly and time-consuming mainte-
nance and upkeep than other models. The energy supply method can
also vary: some systems are so energy-efficient that a small button cell
is sufficient to supply the electronics for an extended period of time
without costly, frequent replacement. Some dispenser bottles come
with an integral button cell to ensure continual functionality. In other
cases, a charge level indicator shows how much power remains to avoid
a system shutdown. Other systems even employ the kinetic energy of
the pump action to generate energy when dispensing disinfectant.
When the remaining electronics draw only low power, it is then possible
to dispense with a battery altogether.
The various requirements discussed above are therefore com-
plex and diverse, and occasionally also contradictory. In the expert
workshops and ensuing design discussions, the decision was made
to develop a concept for a stationary, wall-mounted dispenser for the
KARMIN patient room. This makes it possible to combine the various
requirements appropriately in a limited installation space.

Increasing compliance through injunctive norms

9 Replacing the refill bottle of the KARMIN In addition to ensuring an unbroken supply of disinfectant and creating
disinfectant dispenser
an environment that supports hand hygiene in staff work processes, staff
need to know when to disinfect and be motivated to apply their knowl-
edge of hand disinfection. To this end, ways of increasing compliance
need to be developed and put into action. Alongside the existing meth-
ods – such as evaluation of usage statistics in team meetings, specific
staff training and explanatory graphics near the dispensers – the design
of the new KARMIN disinfectant dispenser also takes new findings into
account by combining technical solutions with psychological motiva-
tors. Using “nudging methods”, the design employs emotional triggers
to prompt users to make use of dispensers. Research has shown that
employing such so-called injunctive norms can raise compliance by up
to 40 % over the initial usage rate (Gaube et al. 2018). Injunctive norms
work by appealing to the intrinsic, positive motivation of users rather
than admonishing bad performance or using authoritarian dictates to
increase compliance. Drawing on the same principle of hanging pictures
of newborn babies above dispensers in neonatal wards, an experimental
setup was trialled using a monitor mounted above the disinfectant
dispenser. The monitor shows a sad-face emoticon to begin with that
turns into a smiley when the pump is operated. A sensor records the
number of pump strokes as well as the entry of a person into the room
in order to determine the rate of use. Various motif-pairs were tested
to ascertain the effect they had. Neutral, context-free motifs had little
effect on the users, but compliance increased slightly when a pair of
eyes was displayed: the “watching eyes” reminded users of social norms

216 Prototype
and duties (descriptive norms). Non-punitive symbols were, however, far Operating mechanism
more effective: by appealing to injunctive norms (“I should do what is A further aspect is the preparation of the disinfectant dispenser, i.e.
objectively right”) by means of smileys achieved a much higher increase the steps needed to prepare it for operation and keep it hygienic and
in compliance over the test period. This method can be used alongside operational at all times. To prevent irregular and potentially inadequate
the analysis of quantitative data in team meetings. The “animation” of upkeep, and to avoid improper re-use of the bottle and pump, the
the smiley lends the dispenser a personal character without it needing KARMIN project proposed a bottle with a valve that does not use a pump
to figuratively adopt the semblance of a body and face: the facial fea- to dispense disinfectant. Both the Commission for Hospital Hygiene
tures of the on-screen smiley are effective enough without giving the and Infection Prevention at the Robert Koch Institute (KRINKO) and the
dispenser a three-dimensional sculptural form (Gaube et al. 2018). German Society for Hospital Hygiene (DGKH) have declared that dispos-
able pumps are advantageous (Bundesgesundheitsblatt, No. 59, 2016).
Display requirements Pressing the dispenser bottle itself builds up pressure within that opens
To appeal to injunctive norms using smileys, the display must be posi- a valve. For this, the bottle may not be rigid or fragile, or its shape must
tioned so that it is immediately visible in the user’s field of view, i.e. be designed to allow compression, for example via a concertina-type
directly above the dispenser housing. The graphic simplicity of the motif construction principle. In addition, it is important to decide whether
of a smiley is such that it could be displayed using a suitable array of only the hand or also an elbow can be used to activate the dispensing
illuminated and dimmed LEDs or other low-energy display mechanism to mechanism, as this significantly influences the ergonomics and design of
minimise energy consumption. Likewise, a low refresh rate and limited the dispenser. The ease of use varies depending on whether the bottle
colour spectrum suffices, making an e-ink display a viable alternative is pressed frontally, at an angle or on top. A lever to apply pressure to
to LCD or TFT displays. A sensor system is also needed to change the the bottle was deemed undesirable as it represents an additional com-
motif on display when the dispenser is used. ponent that needs cleaning. Instead, the KARMIN design envisages that
the pressure-applying surface is replaced automatically with the bottle,
Data acquisition avoiding its possible colonisation by pathogens → Fig. 9.
To make use of injunctive norms and evaluate usage data, a dispenser The dispenser housing must also be kept clean. Rubber coating
needs a means of capturing and recording usage date. A sensor system the entire body would enable it to be machine-washable but is costly
causes the display to change the motif as soon as enough disinfectant in terms of production and would require the dispenser to be removed
has been dispensed. The dispenser then emits a signal communicating from the wall bracket. Instead, plastic was used to be able to design
the position of the dispenser and whether it needs refilling. Various meth- an attractive shape. The outer surfaces of the KARMIN disinfectant dis-
ods of data acquisition are available. To target a specific user group, an penser have rounded transitions to facilitate residue-free cleaning and
anonymised RFID chip denoting the user group can be worn on the wrist. wipe disinfection.
This allows the usage data to be broken down by user group, though it
does not detect whether several dispense operations were triggered or
when people without an RFID chip used disinfectant. This type of sensor
technology is therefore unable to relay information on the fill level. Motion,
magnetic or pressure sensors, on the other hand, can detect dispenser
activation more precisely, but cannot assign it to a specific user group. A
combination of both approaches can, however, lead to the desired pre-
cise detection and allocation. By using only user group-specific data, no
personal data is recorded, thereby adhering to data protection guidelines,
and team spirit among the hospital user groups is encouraged. It also
makes it possible to identify and remedy gaps in dispenser infrastructure.
The data set that is transmitted contains the following information:
location of the room and the exact position of the disinfectant dispenser
within the room (dispenser ID), time of use and number of strokes as well
as, if necessary, an RFID chip-based assignment of the user to a specific
group of people. This makes it possible to determine how often the
dispenser was used in a specific timeframe. In addition, the consump-
tion of disinfectant is monitored, from which the need for refilling can
be calculated based on output quantity and frequency of use. To both
record and analyse the data, a hospital needs the appropriate software
and IT infrastructure → Fig. 8.

Power supply
The electrical components in the dispenser used to increase compli-
ance require a power supply. A self-sufficient means of power supply
would be ideal to minimise maintenance. One method is to use the
kinetic energy of the pump to generate electricity, but this means the
electronics must be adapted to cope with the selective availability of
energy. The recorded data must be bundled in packets that the wireless
module can transmit when energy is available.

217 Disinfectant Dispenser

 Colour
For the body of the dispenser, made of plastic, the team chose white
to denote the idea of purity, as well as to make it easier to detect sur-
face contamination, which is otherwise harder to see on structured or
coloured surfaces. At the same time an accent colour was needed to
ensure the dispenser is still noticed in more complex interiors. Signal
colours are therefore used for selected components, in this case the
display and the bottle → Fig. 10. After consideration, the team decided
against an additional visual cue in the form of an information graphic
10 Colour concept for the KARMIN disinfectant dispenser on the floor or wall to avoid overburdening the KARMIN patient room
with multiple visual sensations.

Secure locking mechanism

Unfortunately, objects are repeatedly stolen from hospitals, making it
necessary to provide a not immediately obvious means of securing the
dispenser bottle against removal. At the same time, it must be easy to
handle so that it does not impede maintenance. A ring on the under-
side, a latch, screw mechanism or locking hook are possible solutions.

Conceptual structure
The conceptual ideas outlined so far already suggest a certain structural
composition for the dispenser. For example, the electronics must be
housed so that they are not exposed to liquid when the dispenser is
cleaned or prepared for use. A display is also needed to show the emoti-
cons. Ease of cleaning is a further determining factor: the surfaces should
be smooth, the transitions between them rounded and the number of
components minimised to reduce assembly joints between them. For
example, traditionally separate pieces such as the back cover and drip
tray can be a single component. This can also lead to a more pleasing
and less technical shape. In an environment designed to heighten patient
well-being while they are in a vulnerable state, the dispenser should
11 Renderings from the design phase
not look like a foreign body. A two-part drip tray for easy removal and
emptying is not necessary when it can be easily wiped clean.
To reduce maintenance, power consumption and purchasing costs,
no contactless pump electronics have been used, making it possible to
position the sensor system differently. At the same time, conventional
pump systems have also not been used. Instead, a disposable pump can
be integrated into the refill bottle. The bottle and pump are purchased
as a single pre-assembled one-way article, reducing the number of com-
ponents and joints and effectively ruling out improper re-use of pump
or bottle. All that is necessary is to insert the bottle upside down into
the housing. As such, the system abandons the widely used Euronorm
bottle design to achieve a new design for a combined pump-and-bottle
principle. Likewise, a contactless dispenser is not necessary: the risk of
smear infection from touching the dispenser is sufficiently mitigated by
rubbing one’s hands with disinfectant after having pressed the bottle.
A means of determining the fill level of the bottle is needed at the
front of the dispenser, for example via a visual indicator or window. These
various requirements and dependencies result in a concept that com-
bines an upstream-produced bottle, top display, valve on the underside
and electronics at the rear → Fig. 11.

218 Prototype
 The KARMIN disinfectant dispenser

For the KARMIN patient room, two different dispensers were selected to
best meet the different requirements described above. The first is the
KARMIN disinfectant dispenser based on the conceptual ideas discussed
here. The other is a commercially available dispenser model comprising
a flexible system with a clamp holder and a small dispenser bottle with a
disposable pump head. It is smaller in size and can be flexibly mounted.
The newly developed KARMIN disinfectant dispenser is a stationary,
wall-mounted model that combines the best features of the various
existing dispenser systems with new methods to increase compliance
→ Fig. 12. A central distinguishing feature is the newly designed bottle
with integrated dispensing mechanism. The positioning of both these
dispenser types is determined by the arrangement of the room and the
elements and objects within it along with the pathways of the staffs’
work processes. The intention is that they support both patients and
staff in practicing hand hygiene and thus ultimately in infection pre-
vention. Despite the higher cost of the KARMIN disinfectant dispenser,
it is still cost-effective as its use can reduce the number of nosocomial
infections, saving costs for longer hospital stays or patients returning
with recurring infections.

Positioning
The correct positioning of disinfectant dispensers in the patient room
is essential to increase compliance and saving nursing staff unnecessary
journeys. An ideal, easily accessible location is on the wall above a work-
place with supplies cabinet and worktop close to the bed. Mounted
clearly visible on the open wall surface, it allows staff to quickly disinfect
their hands before and after handling materials for patient care. This
12 Design sketches of the KARMIN disinfectant dispenser location was selected for the KARMIN disinfectant dispenser → Fig. 13.

13 Disinfectant dispenser above the worktop

219 Disinfectant Dispenser

 The position of the supplementary dispenser type is similarly
optimal at the foot of the bed where the nursing staff pass it during
their work. In addition, it is immediately visible when switching between
patients. The nursing staff do not need to return to the worktop or the
entrance to disinfect their hands, as in conventional rooms, but can
reach it from either side of the bed while caring for the patient. The
flexible clamp allows the dispenser bottle with vertical pump head to be
mounted where desired on the tubular rail at the end of the bed. A model
without extra housing was chosen for its small size so that it projects
as little as possible into the room, thus minimising accidental collisions
at the relatively exposed location. The combination of dispenser types
ensures the transitions between the room zones within the room are
equipped with hand hygiene measures → Fig. 14.
A further KARMIN disinfectant dispenser is positioned in each of
the wet cells, to the left of the washbasin in a shelf niche above the
waste bin flap. Its different appearance and position to one side of
14 Disinfectant dispensers mounted on the bed rail
the washbasin prevents a mix-up between the soap and disinfectant
lie directly on the nurses’ path of action.
dispensers. Soap is for washing off coarse dirt before disinfecting one’s
hands. The arrangement places the soap dispenser in full view when
entering the room, whereas the disinfectant dispenser is slightly set
back to protect it from collisions with wheelchairs or other objects on
the sealed surfaces of the wet cell. The niche must be large enough to
be able to mount the dispenser during installation and to easily reach
the pressing surface in use. The dispenser must also be clearly visible
and not obscured by elements projecting into the room. The positions
of the three disinfectant dispensers – above the worktop, at the end of
the bed and in the bathroom wall recess – are mirrored on the other
side of the room, so that the same number of dispensers are accessible
on both sides of the room → Fig. 15.
For optimal accessibility, the dispensers must be not just sensibly
distributed across the individual room zones but also mounted at an
appropriate height. This plays a key role in increasing compliance. It
is important, for example, that projecting fittings or excessively high
mounting heights do not prevent smaller people or people with
restricted reach such as wheelchair users from reaching the pressing
surface. In the KARMIN patient room, the worktop can be driven under
by a wheelchair and is not very deep so that wheelchair users can reach
the dispenser. For optimal use, the dispenser should be mounted so that
the pressing surface is approx. 120 cm above floor level.

Display function and colour

A disinfectant dispenser must be clearly visible and suitably inviting,
but at the same time not visually intrusive for either staff or patients.
A matt white was therefore chosen for the housing so that it contrasts
15 Positioning of the dispensers (orange) in the with the wall colour above the worktop and with the texture of the wall
­KARMIN patient room with typical workflow paths
niche in the bathroom. The bottle, on the other hand, has a muted red
colour that signals its presence but is not overly garish. A symbol on
the pressing surface additionally indicates where to press. The diagonal
underside of the housing allows the valve head of the bottle to project
so that it is clear to users where and in which direction the disinfectant
will be dispensed.
To appeal to injunctive norms, a display above the bottle shows a
concerned-face smiley against a yellow background that changes when
sufficient disinfectant has been dispensed. A concerned-face rather
than a sad-face smiley was chosen so as to avoid overly negative con-
notations. By appealing to injunctive norms, it encourages use of the
dispenser. The circle that usually frames a smiley was removed so that
the face is framed by the display housing and perceived as belonging
to the dispenser and being integral to its design → Fig. 16.

220 Prototype
 Other forms of visual or auditory feedback are not provided to
avoid placing further demands on the attentions of staff and patients.
Nursing and medical staff are already exposed to multiple audio-visual
stimuli in the hospital environment and a dispenser should not add
further sensory load.

Data acquisition
To help improve compliance, the KARMIN disinfectant dispenser is
equipped with various sensors for data acquisition. They ensure that
the dispenser is always properly supplied with disinfectant, help appeal
16 Comparison of a smiling, concerned and sad smiley to injunctive norms and record usage statistics. The entrance door area
as well as the four KARMIN dispensers in the room are equipped with
RFID readers with different ranges that make it possible to monitor the
user group of persons (also equipped with RFID readers) entering the
room → Fig. 17. This can then be used in a more targeted manner to
analyse ways of improving compliance. Rather than warning staff when
disinfectant usage is too low, the data provides a more useful basis for
constructive feedback and friendly reminders during team meetings.
At the same time, a pressure sensor in the housing of the disinfectant
dispenser records every press of the dispenser. This data can be used
to calculate the fill level of the dispenser. When a low fill level threshold
is reached, this data is transmitted as a data packet along with other
usage statistics via wifi to a central server. This data packet approach
means the emitting unit does not need a permanent power supply.
The fill level can also always be viewed manually through the front
viewing slot should the electronics not function correctly. The pressure
sensor also triggers a change of the smiley motif, rewarding the user
RFID RFID with a smiling face on the display when enough disinfectant has been
discharged. After a few seconds, the display reverts back to the con-
RFID RFID
cerned-face smiley, so that the motif doesn’t change constantly when
a user presses unnecessarily often on the bottle.

Display
The display of the disinfectant dispenser must be clearly visible but
not intrusive. By positioning it above the dispenser slanted slightly
RFID
upwards it is clearly visible to users but not in the patient’s direct field
of vision, so that patients in bed are not unnecessarily burdened by the
concerned-face smiley. To reduce energy supply requirements, an e-ink
17 Recording user groups upon entry and use screen is used which has no refresh rate and only requires energy to
change the motif during operation of the dispenser → Fig. 18.

Power supply
The KARMIN disinfectant dispenser uses the kinetic energy produced
by pressing the disinfectant bottle to supply the dispenser with power.
This reduces the frequency of maintenance and with it the risk of germ
contamination when replacing batteries. Pressing the bottle generates
energy that can then be used to change the e-ink display to show a
different image.

18 The disinfectant dispenser displays a smiling face

after use.

221 Disinfectant Dispenser

 Pressure-operated dispenser bottle
To meet the diverse requirements for ensuring a constant, reliable and
hygienic supply of disinfectant, a dispenser bottle was developed that
reduces the number of necessary parts, functions mechanically and
also allows precise quantities to be dispensed. The flexible body of the
bottle, when pressed, opens a pressure-release valve that dispenses
the disinfectant. A two-chamber system in the valve head allows the
dispensing charge to be regulated, i.e. the quantity of disinfectant
expelled. The bottle is inserted upside down into the housing so that
the convex bottom of the bottle acts as the pressing surface. This is
large enough to be operated by hand or with an elbow. Pressing on the
bottle creates a pressure build-up in the bottle that opens the concave
valve diaphragm → Fig. 19. The valve is permanently mounted on the
sealed bottle so that it cannot be refilled risking contamination. Should
replacement bottles not be available due to supply difficulties, such as
in a pandemic, the dispenser can also be used with regular Euronorm
bottles with pump heads which are made by numerous manufacturers.
19 Pressing the bottle to dispense the disinfectant

Construction and materials

The design of the disinfectant dispenser is determined by the require-
ments for the material, the mechanics, the space needed for electronic
components and ergonomic considerations. The choice of a suitable
material is essential to ensure easy cleaning. As the dispenser does not
need to be autoclavable, and plastic offers better design possibilities
in terms of form, haptics and appearance than aluminium, ABS plastic
was chosen for the housing. The casing can therefore be cleaned in a
dishwasher. The dispenser bottles are made of a flexible plastic through
which alcohol cannot evaporate, retaining the alcohol content of the
disinfectant in the long term. In addition, the material is resistant to
chemicals and can withstand repeated compression by pressing on
it. By dispensing with conventional bottles and pumps – made possi-
ble by incorporating several components into one unit – the number
of components can be reduced, resulting in fewer joints that can be
colonised by germs → Fig. 20. As the new bottle system is not yet in
production, the bottle housing is dimensioned so that it can also be
used with Euronorm dispenser bottles.

Form
The rounded housing is formally a single, closed unit, giving it a
restrained, non-technical appearance that is more approachable than
existing models. Due to its verticality and the curvature of its rear wall, it
20 A central principle of the KARMIN disinfectant
dispenser is the reduction of components. The has a slim appearance, sits lightly on the wall and fits discreetly into its
housing comprises just three parts. The pump and surroundings. All transitions between the different parts – for example,
the bottle are combined in a single component.
the bottle holder and screen surround – are curved and seamless, making
it easy to wipe clean. The mechanism for opening the back plate and
hanging the dispenser is concealed to discourage theft. The flat bar of
the drip tray holder must be pressed to release a catch so that the body
can be slid up and away from the mounting. The mounting plate and
screw fitting for attaching it to the wall then becomes visible → Fig. 21.
The KARMIN disinfectant dispenser thus combines new findings for
increasing compliance and supports staff through its optimised, easy-
to-clean form. The shape and curved forms of the housing guides the
hand when cleaning and wiping down with disinfectant. The dispenser's
design and positioning → Figs. 22, 23 help trigger the users’ memory,
draw their attention and help them take decisive action.
Switching a hospital to an optimised disinfectant dispenser such as
the KARMIN dispenser described here is a not inconsiderable investment
21 Hidden anti-theft protection: Pressing the drip tray
that not every clinic will be able to afford, even if it reduces costs fur-
holder releases a catch to remove the dispenser. ther down the line by preventing infections. Hospitals are also already

222 Prototype
 equipped with a large number of disinfectant dispensers. These are not
necessarily optimally positioned with a view to preventing infection
control but could continue to be used with some appropriate corrective
measures. Aside from placing existing dispensers closer to the pathways
of the staff’s work processes, other means of improving compliance
are also possible. An alternative mechanical approach to appealing to
injunctive norms has, therefore, also been devised that needs no power
source, statistical sensors and not even a display. Instead it employs a
two-phase lenticular image mounted directly on the pump lever that
alternates between a concerned-face and a smiling-face. The mounting
height and angle needs to be adjusted to ensure the image is seen
correctly for people of average height. Depressing the lever changes
the angle of the lever and with it the viewing angle of the image. Here
too, the lenticular image must be designed so that a user sees a single
transition from the two image phases of concerned-face and smiling-face
when the lever is pressed → Fig. 26.
A study of the effectiveness of such injunctive norm methods (Gaube
22 Front view of the KARMIN 23 The position of the KARMIN disinfect-
disinfectant dispenser ant dispenser above the worktop et al. 2018) showed that the motivating effect of the image declines after
about one month. One way of addressing this is to use different motifs in
different delivery batches of disinfectant. The lenticular images can then
be switched when bottle refills are installed, presenting a fresh image
24 Mechanical to the user. These lenticular images can be cut to fit most common
dispenser with dispenser models. This cost-effective principle has been tested in the
lenticular image
before pressing context of KARMIN, using the commonly available Eurospender Safety
the lever Plus dispenser model → Figs. 24, 25; however this particular configuration
is not used in the KARMIN patient room.

25 Mechanical
dispenser with
lenticular image
after pressing
the lever

23°

26 The working mechanism of the

lenticular image

223 Disinfectant Dispenser

The Patient The bedside cabinet is part of the standard repertoire of a patient room
and is actively used on an everyday basis. Through its location within

Bedside Cabinet
easy reach of the patient, it is exposed to their pathogens by touch,
droplets and airborne aerosols, and its surfaces are thus highly prone
to colonisation with germs. Because it serves many purposes and is
actively used, patients are highly likely to come into direct contact
with its surfaces and with objects stored inside or on the bedside table.
Avoiding contact infections is therefore a matter of carefully examining
how it is used in practice and devising ways in which appropriate design
can encourage safer interactions. One must examine when and where
which persons touch or put down which objects. The aim in developing
the KARMIN bedside cabinet was, therefore, to examine ways in which
one can raise the infection prevention potential of this object while at
the same time creating a patient-friendly design that reflects the many
diverse requirements it must fulfil.

Potential properties of a patient bedside cabinet

The bedside cabinet is expressly for the patient’s use for the duration
of their stay in hospital. Nevertheless, nursing staff sometimes also use
the surfaces and drawers to briefly store work utensils, usually due to
a lack of available work surfaces near the bed, insufficient training or
time pressure when working. Where workplaces in the room are not
available and there is not enough space to wheel in a supplies trolley,
staff often place kidney dishes on the bedside table, where they sit
alongside inhalers, books, trays, smartphones, flowers, alarm clocks,
medication and glasses. Other objects also placed on the table include
meals, dishes, cutlery, pill boxes or drinks that are brought in by various
groups of people including nursing staff, visitors and patients → Fig. 1.
These are all points of contact where an undesirable and unnecessary
transmission of pathogens can occur. Elderly and frail patients may also
require additional support depending on the situation, and nursing staff
may then unavoidably have to touch personal items. Sometimes the
tabletop or bedside cabinet is so full that different user groups may
need to move items out of the way to place something on it. Where
space is needed around the bed, the entire cabinet may be wheeled
to one side by nursing staff. How these different user groups grasp
and touch the table can be partially (but not completely) directed by
means of affordance, i.e. the usage characteristics that an object innately
suggests. For the most part, however, its surfaces are also colonised
independently of touch by patients, visitors or medical staff talking or
sneezing. As such, unnecessary touching should be minimised wherever
possible and cleaning made as simple as possible.
The bedside cabinet is therefore a central source of possible infec-
tion in the patient room. At the same time, it must necessarily be placed
close to the patient to fulfil its purpose. The best way to improve its
infection prevention potential lies in simplifying cleaning and disinfection
of the surfaces and reducing the incidence of contact by making it less
necessary to shift around. A first step is to design a patient room to be
large enough to place the cabinet close to the bed without obstructing
access to other equipment. It should not block access to the patient or
to necessary work-related installations such as the nurses’ equipment
store or the bed headwall and its connections so as not to lose valuable
time in the case of an emergency. Similarly, the bedside cabinet should
not be too voluminous so that it does not collide in the vertical plane
with other objects such as a bedside terminal. The tabletop should be
an integral part of the cabinet as otherwise two items of furniture are
1 A wide variety of objects are placed
on a bedside cabinet.
required, which then both need preparation and sterilisation, often
outside the room. When cleaning, staff can also ask patients to remove

224 Prototype
 their own personal objects from the bedside table so that staff do not
need to touch them. For this, the patient needs access to shelves and
drawers on different sides of the bedside cabinet so that they may stow
away their belongings.

Organisation
One way to counteract an excess of objects placed on the bedside table
is to provide alternative usage-specific surfaces and storage spaces.
Objects can then be made easier to store or be grouped according
to need, while others can be stowed away so that they are harder to
retrieve. A large number of objects on the bedside table is an obstacle
to cleaning and can promote cross-contamination. The volume of the
bedside cabinet can be divided both horizontally and vertically to
create compartments of differing accessibility, which in turn affects the
2 Accessibility: the areas marked in blue are most
­accessible and therefore most frequently used. frequency with which patients access certain sections → Fig. 2. This can
be an effective means of controlling stowage.

Privacy and patient comfort

Privacy is related thematically to the aspect of organisation. A patient
typically lies prone and vulnerable in a patient room to which many
have access. They may have valuables with them that are important to
them. As such both the patient and their belongings are vulnerable and
in unfamiliar surroundings. Even when a safe is available, some patients
may be physically restricted and unable to use it. This influences where
they place their possessions. Incorporating a lockable drawer in the
bedside cabinet is therefore essential so that patients can store their
wallet, smartphone or laptop within easy reach but protected against
theft. The patient cabinet itself can also function as a way of marking
personal space, shielding the bed area from those of other patients.
Patients therefore perceive the patient cabinet as an extension of their
personal realm. This aspect is particularly important for older patients
and must be considered in the design. Although more slender and more
open items of furniture are becoming increasingly popular, the bedside
cabinet can be more opaque and solid. The lockable part should at
least convey a robust and trustworthy appearance. A key or RFID chip
is best for locking a drawer as patients are prone to forgetting a code,
and not just when they have dementia. Similarly, a familiar design that
is not overly technical or medical will be more readily accepted by
patients and can have a calming effect. This is also relevant to infection
prevention potential as strengthening the immune system and successful
recovery contributes to the patient’s mental well-being. In short: the
design of the patient bedside cabinet and table must be patient-friendly.

225 Patient Bedside Cabinet

 Positioning
The bedside cabinet is located in the often-congested space next to the
patient’s bed. Alongside the cabinet, there may be a bedside terminal,
a disinfectant dispenser, and possibly also an infusion stand, an oxygen
unit or other items of medical equipment. Moving it may require care
to avoid collisions with other items in the vicinity. To avoid becoming
entangled with swivel arms, cables, hoses or medical supply lines, the
bedside cabinet should not have protruding parts or an excessively
open structure in which things can get trapped. A bedside table with
an electrical supply for electrical components such as a refrigerator is
less ideal. A power cord makes it less easy to move the bedside cab-
inet, as a plug has to be pulled when cleaning the room, and this can
encourage cleaning omissions.
Whether the bedside cabinet is positioned to the left or right of the
bed depends largely on the room layout and the patient’s respective
3 The patient bedside cabinet should be usable
on both sides. clinical picture, which may require more intensive care or access to
the patient from a particular side of the body. This means that bedside
cabinets sometimes have to be moved from one side of the bed to
the other. Consequently, bedside cabinets must be flexible, usable
from either side and cordless so that staff can perform their nursing
procedures unobstructed and to the full extent without having to work
around furniture → Fig. 3.

Preparation
Patient bedside cabinets are not classified as medical equipment and are
therefore not subject to the same cleaning, disinfection and sterilisation
requirements. Nevertheless, they bear certain parallels to the design
requirements for disinfectant dispensers. The cleaning and preparation
of a large number of objects is a logistical challenge for hospitals, and
digitalisation can help incorporate these into existing workflows by
making it possible to determine where each bedside cabinet is located,
how long it has been in use and whether it is already clean. QR codes
or RFID chips can be used as identifiers for locating mobile items and to
document their machine processing history, providing a better means
of monitoring and verifying logistical processes. This becomes increas-
ingly essential as bed occupations become shorter and change more
frequently. Alongside these organisational aspects, the construction of
the bedside cabinet must be suited to machine cleaning: for example,
water must be able to drain from drawers or similar enclosures without
leaving any residue, and the material must be thermally suitable for the
washing processes. In terms of its form, seamless surfaces and curved
transitions are more suitable than sharp-edged or angular changes
in surfaces. Inevitably, this may mean a reduction in the number of
4 Design sketches for an opaque bedside cabinet components, which is also advantageous in the event of spillages of
version with tubular frame
food or beverages. When surfaces are unbroken, these cannot seep
into joints and form a breeding ground for germs. The same applies to
manual cleaning and wipe disinfection: undercuts in the form should
be avoided and sufficiently large, reach-through openings help to
simplify cleaning.

Material
Seamless forms can be produced using rotational or injection moulding
processes but only with plastics, which are not always sufficient strong
to withstand the weight of a person leaning on them. Polypropylene (PP),
polyethylene and melamine are all suitable, and the latter is particularly
scratch-resistant and therefore ideal for intensively used surfaces such
as the tabletop and the top of the bedside cabinet. High-pressure
laminate (HPL) is a sheet material that is exceptionally durable, smooth
and easy to clean but it can only be bent in two dimensions. Bending is

226 Prototype
nevertheless preferable to joints and screw-fixings. Stainless steel is very bedside cabinet because very little effort is needed to switch sides in
stable but has a cold surface and is heavy, making it difficult for weak everyday use and the mechanism can be optimised for better hygiene.
patients to manoeuvre. Nursing and cleaning staff, who have to move This benefits nursing and cleaning staff equally. Commercially avail-
such items regularly, likewise appreciate lightweight bedside cabinets. able models also have different solutions for the call button, for the
parking brake and in their choice of materials. For the KARMIN patient
Requirements for a bedside cabinet room, the call button is located on the bedside terminal rather than
The design of a bedside cabinet can aid patients in the organisation of the bedside cabinet.
their personal belongings by creating specifically shaped elements and The models also differ in their choice of material. Different HPL
compartments that determine how they are used and how easy they decors are used, some in plain colours, some with a wood-effect surface.
are to reach. For example, certain sections may only be deep enough to In the case of plastic elements, so-called terrazzo plastic patterns are
hold magazines or a tablet. A shoe rack can avoid the patient’s slippers generally avoided due to the more complex production and mechanical
from being scattered about the room, and a recess or holder for a bottle disadvantages, but plain coloured models are offered.
in a drawer or on the outside can avoid too many loose objects from For the smooth rolling of the bedside unit, almost all models use
being placed on the top surface. One must also consider how drawers double castors with an integral parking brake. They have the advantage
and trays are to be fixed to the cabinet. To be useful to the patient, the of being more stable and better able to absorb the weight of patients
tabletop must be ergonomically adjustable to the patient’s height and supporting themselves on the furniture. Several manufacturers provide
the position of the bed. It must be able to be swivelled and extended a fifth wheel beneath the dining tray to prevent tipping.
in vertical and horizontal directions. Similarly, a waste bin could be
incorporated to avoid the build-up of smells but this then also needs to Conceptual structure
be emptied regularly. In the case of the KARMIN bedside cabinet this is As the KARMIN bedside cabinet is a model for a standard care room, a
not necessary as there is already a waste bin in the nurses’ cupboard fridge is not necessary. The need for a power supply and cord for the
by the worktop. refrigerator further reduces the space available near the patient and
the mobility of the unit. In this case, only shelves and compartments
A concept for a bedside cabinet are needed.
To aid preparation and cleaning, a system of modules inserted into
Before taking concrete steps towards designing a new bedside cabinet, a tubular metal frame is proposed. It can be easily adapted to individ-
it is worth looking at how existing models address these many different ual patient needs and leaves sufficiently large space for easy cleaning.
requirements. It also means that all areas are easy to wipe clean with disinfectant.
However, this variant with its open structure is less ideal as a means of
Benchmark ensuring privacy.
A wide range of models of bedside cabinets are available on the market Alternatively, the volumes can be divided into different zones
for intensive care units, private healthcare wards, standard care wards, allowing the nurses to have lateral access to medication and care
geriatric healthcare and care at home situations, each of which have materials in a compartment not immediately accessible to the patient.
different requirements. Whereas in Germany, bedside cabinets are rarely In the case of the KARMIN patient room, this is not necessary as a
made solely of plastic and have many joints where the different materi- dedicated workplace and nurse’s supplies cabinet is already available
als meet, manufacturers in other countries have been offering models near the bed.
made of injection-moulded components for some time. However, none To suggest more specific usage patterns, a cup and bottle holder
of these are as homely as products made, for example, of imitation can be provided on the top surface → Fig. 4. Time can be saved during
wood. The fittings they offer also differ: some models include a holder cleaning by choosing an openly visible compartment structure. This is
for a smartscreen or tablet, but this comes at the cost of restricting easier to clean, since, unlike closed drawers, contamination is directly
the mobility of the unit due to the necessary cabling and an additional visible on inner surfaces. In addition, slotted-in compartments can be
projecting swivel arm. A tablet holder should therefore be avoided and easily removed to access gaps between them, which is much less labo-
instead a bedside terminal used. A terminal suspended centrally from the rious than screwed-on items. However, a disadvantage is that the open
bed headwall is also easier to access from both sides of the bed than a structure does not provide the same measure of privacy.
tablet limited by the reach of a swivel arm attached to the bedside unit.
Some concepts also offer a charging station for mobile devices. Material
Here, too, the KARMIN bedside cabinet opts not to restrict mobility When deciding between wood-effect HPL in panel form and freely-form-
through the need for a power cord and therefore does not include an able injection-moulded plastics, one must consider the relative benefits
integrated charging station for mobile devices. of reducing the number of components and construction joints for better
Various solutions also exist for allowing a bedside unit to be used cleaning versus a comparative lack of visual and tactile warmth. One
on both sides of the bed. Some bedside cabinets have push-through should also consider the relative benefits of plain coloured versus pat-
drawers openable on either side; these require a slightly wider mech- terned surfaces such as wood-effect panels. Because it is easier to detect
anism than a conventional drawer to ensure middle and end locking in dirt on plain surfaces, a pure white plastic material was proposed for the
either direction. Other models allow the tabletop to be taken out and KARMIN bedside cabinet. The colour and feel of the cabinet should fit
reinserted on either side without the need for tools. Another variant into the overall concept of the patient room. A coherent, coordinated
involves swivelling the entire body of the cabinet on its base, though concept contributes to providing a calm environment for the patient.
this requires a relatively chunky rotating mechanism that reduces In addition, the material is also machine-cleanable. Given the projected
the storage space appreciably. The push-through drawer that opens increase in overweight and elderly patients in future, the frame must
in both directions was felt to be most appropriate for the KARMIN be sufficiently sturdy to withstand the weight of a person leaning on it.

227 Patient Bedside Cabinet

 The KARMIN bedside cabinet

The design of the KARMIN bedside cabinet represents a trade-off

between weight optimisation, robustness, patient friendliness, manoeu-
vrability and ease of cleaning.

Design of the prototype

In order to be able to absorb the load of transverse forces, the KARMIN
model is based on a stable frame from a major manufacturer already
available on the market. The base comes equipped with a fifth stabilis-
ing double castor beneath the pillar of the extendable, rotatable and
inclinable tabletop. The width of the double castors reduces the risk
of tipping. The frame has been optimised and modified with a view to
reducing the number of components. The slot mechanisms for the slid-
ing drawers were simplified and hard-to-clean ledges and projections
removed. The top of the unit has a simple seamless raised lip around
the perimeter and offers more space than many standard models on
the market that subdivide the top into compartments with several
webs → Fig. 5. Similarly, new seamless drawer units were developed
that offer more space than conventional models. The wide handle on
the side of the top panel is easy to grip for stable table movement. Its
lateral placement means that nursing and cleaning staff generally grip
a different part of the unit than the patient lying on their side in bed.
The patient can only reach the drawers, the lower compartment and
the grip of the tabletop at arm’s length.
The upper drawer can be locked with an RFID lock, while the lower
drawer offers ample storage space for larger objects. The wide drawer
handle makes it easy for the patient to open it from different positions,
and the open compartment in the middle provides quick and easy
5 KARMIN bedside cabinet with objects placed on or in
access to frequently used items. The absence of a rear panel and the
it. The lowered section of the edge lip makes it easier dual middle and end locking of the drawer position allow it to be used
for the patient to see the top from a lying position. At
from both sides and make care and cleaning procedures easier.
the same time, it serves to contain objects within the
top of the unit.
Form, colour and atmosphere
The soft, smooth shapes of the bedside table convey a sense of calm
coherence. Its design is neither overly complex and fussy nor overladen
with multiple different materials. Its clear structure allows the aspect of
its usability to come to the fore, and in turn helps strike a balance between
privacy – which is especially essential for vulnerable patients – and an
open design that is easy to clean → Fig. 6.

6 Front view of the KARMIN bedside cabinet

228 Prototype
 7 The seamless drawer Cleaning
and top tray are cast
with curved edges to
The components have been optimised for easy cleaning through a largely
reduce the number seamless design and smooth rounded transitions → Figs. 7–9, 11. The
of components and
drawers are provided with drip holes for machine cleaning and inacces-
facilitate easy clean-
ing of the KARMIN sible gaps in the construction were avoided. Instead of a key-operated
bedside cabinet. locking mechanism, the drawer uses an RFID lock so that no water can
penetrate the keyhole during machine cleaning. The top surfaces and
contact zones have been kept monochrome to make contamination
easier to detect. The side walls, which are rarely touched, have been
given a wood texture, lending a homely touch to the otherwise clean
design of the unit.
Through these simple constructive means, the bedside cabinet
8 The large, easy-­­to-
succeeds in raising the infection prevention potential of the object
clean compartment and becomes incorporated into the overall design of the patient room
with curved edging → Fig. 10.
at the lateral sides of
the sheet metal shelf

9 The top tray-like

­surface is easy to
clean

10 The KARMIN bedside cabinet in the context 11 The rounded edges of the tabletop
of the patient room help reduce the number of joints.

229 Patient Bedside Cabinet

The Bedside
As a consequence of economic constraints and technological advances,
workflows in modern hospitals are becoming quicker and being digital-
ised. Examples include the collection and transfer of data on patients
Terminal on admission to hospital, the use of telemedicine to consult external
experts or the digital monitoring of a patient’s vital signs during a hos-
pital stay. Processes and activities are changing, and in some cases new
devices are supplementing existing work equipment. The automation
of information transfer has drastically reduced the transport of patient
files and made it possible to look up and print out patient data as and
when needed. Apps can help prepare patients prior to arrival and allow
medical staff to follow up on cases afterwards. Patients can be informed
of procedures and precautions in advance while at home, as well as
during their stay, and hospitals of any relevant personal information
about the patient. For the aspect of hospital hygiene, these develop-
ments present both new possibilities as well as new challenges. New
devices such as the bedside terminal in the patient’s room and portable
monitoring devices have made inroads into everyday hospital practice.
In Germany, bedside terminals are currently usually only available in
rooms for private healthcare patients. Mounted on a swivel arm near
the patient bed, the bedside terminal is essentially a small digital device
with which patients can access the hospital’s various digital services or
entertainment media, depending on the system. Often, certain content
is only available if purchased privately by the patient. Staff are also
increasingly being equipped with mobile devices to record and receive
information directly where they are.
As physical objects, these devices represent colonised contact
surfaces that can be a vehicle for cross-contamination. Mobile devices
carry pathogens in and out of a patient’s room; they are deposited in
various places and touched by a variety of people. But digitisation also
obviates the need to carry around clipboards with paper-based patient
records. To entirely replace analogue patient files with digital records,
the respective user groups must be equipped with devices and suita-
ble access rights to the relevant information. The direct recording and
entry of information also avoids the risk of loss of information or errors
occurring with manual data transmission. Digital devices can addition-
ally provide valuable services in infection prevention, including the
ability to document the preparation and cleaning of objects for patient
rooms, and patient empowerment and education. The bedside terminal
1 Digital networking of services and communication
is ideally suited for these last two applications, and for this reason, it
inside and outside the hospital via a server
was also selected as a hygiene-relevant object in the patient room for
investigation as part of the KARMIN project. In addition, it makes it
possible to call up required medical information and knowledge at the
point of care in the event of an emergency → Fig. 1.

Patient empowerment and education

Infection prevention education

Patient empowerment aims to provide patients during a period of treat-
ment with knowledge so that they can play an active role in supporting
their recovery and participate in facilitating processes. Research has
shown that independent, informed patients can be treated more suc-
cessfully (Powers, Bendall 2008). Helping patients understand their own
health condition and the treatment they are undergoing can, among
other things, assist them in managing stress levels and in communicat-
ing about it. Informed patients have a better understanding of the care
processes and also of restrictions, for example with regard to nutrition.
Educating patients on hygiene-related aspects can also encourage
better infection prevention practices during their stay (McGuckin, Gov-
2 A patient using a bedside terminal ednik 2013). The question is therefore how one can best educate and

230 Prototype
convey information to patients through digital content via the bedside Interface
terminal → Fig. 2. The full potential of a terminal for patients can only be realised if content
and topics are sensibly and intuitively grouped so that patients can
During treatment in hospital access it. For example, the menu system can prioritise informational
While patients are in hospital, the process of recovery can be assisted by content over entertainment content. Inclusive, accessible design is
encouraging movement and informing patients of the consequences of a likewise important: content must be accessible to deaf or blind users,
lack of activity. This can be achieved by physical means, for example by for example by providing information in audio as well as written form.
replacing the patient’s bed with chair beds during the day and moving For older patients, too, adjusting text size and contrast must be possible
the patient into a more active, upright position, as well as by encour- to ensure content can be read. Similarly, content must be available in
aging patients to get up and move via instructional information, videos multiple languages for patients not proficient in the dominant language
or games presented via the bedside terminal. Activity strengthens the used in the hospital. Tutorials on using the terminal can also be provided
immune system and patients recover more quickly (Pashikanti, Von Ah to help patients find their virtual bearings.
2012; Schaller et al. 2016). Shorter periods in hospital also reduce the
risk of nosocomial infection. Structure of the terminal
Alongside the requirements for software and content, various specific
After treatment at home hardware requirements must also be met. Since the surfaces of devices
The concept of patient empowerment also encompasses giving the are generally colonised by pathogens, the housing of the bedside
patient the opportunity to provide feedback on their stay in hospital. terminal must be constructed so that it is easy to clean. This includes
Many hospitals already ask patients to fill out questionnaires to gain minimising the number of components so that the housing is as seam-
valuable information for quality management procedures and therefore less as possible, using materials and surfaces that can be wiped clean
potentially also for infection prevention. In addition, doctors should without being damaged by alcohol or other ingredients, and a shape
provide medical recommendations for patients and how they can adjust that has rounded corners and edges for easy cleaning. The curvature
their lifestyles to remain healthy. This can help them adhere to advice should be ergonomically formed so that it can be comfortably wiped
given beyond the duration of their period in hospital. For example, clean in a single movement. Since liquids are used, any vents for internal
helping patients understand dietary recommendations can prevent components must be watertight, or other means of heat dissipation
future hospitalisation. Such health-promoting measures can be part of must be found. Alongside these hygiene aspects, a bedside terminal
services provided via a bedside terminal. can have a USB port and a headphone jack for charging and use with
For all the above forms of communication, the bedside terminal acts patients’ mobile devices. Wifi and Bluetooth modules make it possi-
as an interface for the transfer of information between patient and hos- ble to additionally synchronise content. The screen’s capacitive touch
pital. At present, however, digital content provided by a terminal must display can be supplemented by buttons or keys for basic functions
typically be paid for by the patient, especially in standard care wards. so that older patients, for example, can operate essential functions via
Hospitals must ensure that this does not hinder the communication conventional means. An RFID reader can ensure that only the authorised
of essential, medical or hygiene-related information; optional extras patient can use the device.
bookable by the patient should be limited to the entertainment sector. The bedside terminal should be mounted on a swivel arm that per-
mits it to be freely and easily moved without undue resistance. The arm
Requirements for a bedside terminal must be securely fixed to the wall’s surface, usually via bracket mounting
on a double-planked plasterboard base. Aside from a connection to the
Content power supply, the terminal must also be connected to the hospital’s
A bedside terminal must address a range of topics and fulfil diverse public network infrastructure via a LAN socket or DSL connection. It
functions. Alongside information on the daily schedule, it can provide should also incorporate a call button to alert staff via a light signal and
educational information on infection prevention. It can also be used to an on-off switch on the swivel arm to safely disconnect the terminal
remotely control other equipment in the room, for example enabling from the mains where necessary.
bedridden patients to control lights and temperature, to operate the
blinds or change the backrest position. This provides a way of bundling Positioning
traditionally separate, manual controls in a single interface used by The bedside terminal must be easy for patients to grasp but should not
one person, thus minimising situations where contact infection can obstruct or cover other relevant items near the bed or obstruct cleaning
occur. Video calls, making notes, telephoning and filling out feedback or care provision procedures → Fig. 4. This also applies to avoiding it
forms can likewise all be facilitated by a terminal, as can entertainment casting shadows from the reading light or HCL lamp above the patient’s
services such as television, radio, a newsstand and internet access. A bed. Furthermore, the terminal should be operable from both sides of
further opportunity to engage patients is through the use of so-called the bed: a wall-mounted swivel arm has proved more suitable than
“serious games” on topics related to health, and training health-pro- mounting it on the bed or the ceiling → Fig. 5. The swivel arm should be
moting behaviour → Fig. 3. Many adults are increasingly open to the easy to mount and dismount and must have a radius limiter to prevent
gamification of educational content and it is no longer solely reserved either the terminal or the arm segment from hitting the wall.
for young patients.
The bedside terminal should be for the patient’s use only. Hospital
staff should have their own equipment. To allow nurses or medical staff
to share information during patient consultations without touching the
patient’s touchscreen, an interface must exist that enables medical staff
to share information from their device with the patient’s display terminal.

231 Bedside Terminal

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3 Example of the menu structure and content of a bedside terminal

A concept for a bedside terminal The different possible uses result in a complex menu structure often
with many sub-options.
The requirements for the infection prevention potential of a bedside To aid immediate usability by persons of all age groups, it can be
terminal concern not just its physical properties and ease of cleaning advisable to provide user interfaces adapted to different patient pro-
but also the content it provides. Its primary potential lies in provid- files. A patient can select their profile, for example older patients with
ing educational information on preventing infection transmission, on sight impairments may be presented with larger text, audio options
encouraging active personal participation and motivating physical and simplified, less dense content choices.
exercise, and on avoiding cross-contamination by providing separate The interface should encourage patients to view educational con-
touch surfaces and controls for each patient. The terminal must there- tent, however patients are typically more easily attracted to enter-
fore combine content and technology from both public institutions tainment media. Various methods can be used to counteract this.
and private companies. One possibility is to first display an obligatory one-time message
on educational content before other content can be accessed. This
Use strongly instructive and restrictive approach can, however, negatively
The diverse functions and content that bedside terminals provide means affect compliance. Another approach is using pop-ups that at regular
they are in frequent use, whether for personal communications, enter- but tolerable intervals draw attention to educational content on good
tainment or as a source of information on hospital procedures and hygiene practices. A further method of ensuring infection prevention
treatment. The call button is likewise increasingly incorporated into the information is not buried among the multitude of other information is
terminal, including an option to specify the reason for the call. This can to prioritise it in the menu hierarchy so that it is available right from
be used later to analyse care response patterns across multiple wards. the start → Fig. 6.

232 Prototype
 Format of educational information
To not just present but successfully impart educational information to
patients, an appropriate format must be chosen. Patients respond better
to visual information and are less inclined to read textual instructions.
As such, informative videos are an eminently suitable format. Another
option is to train patients through instructive games.

The KARMIN Suite

For the KARMIN patient room, a wall-mounted bedside terminal with
swivel arm and integral camera and telephone function was chosen. It
was important that the terminal could be attached to plasterboard walls.
A hygienic housing enclosure frames a Full HD screen, and all surfaces
are easy to clean and resistant to damage through disinfectants.
The casing has minimal joints and is waterproof, and the ventilation
4 The swing of the arm of the bedside terminal is high slot cleanable so that the assembly meets the requirements of EN 60601-1.
enough not to obstruct other movable objects on the An extra keyboard was discounted due to their susceptibility to dirt
ground or get in the way of staff.
accumulation and to reduce the number of items to clean. The display
is a commercially available model that already meets the hardware
requirements and comes with the underlying operating system but no
more. Specific educational content, as well as software for synchronising
with other hospital applications, must be added on a customer-specific
basis. This enabled the KARMIN team to focus primarily on the design of
the content. To implement the conceptual principles of patient empower-
ment and patient education, a specially developed information interface
was created called the KARMIN Suite.

Pathogen transmission chain

5 A wall-mounted bedside terminal does not collide with
the mounting of ceiling lights or impact significantly on As the screen is so frequently touched, it is potentially a primary trans-
lighting levels from above. mitter of pathogens. To prevent this, its use is restricted to the patient
only: hospital staff cannot enter or retrieve information and the device
will only activate with the patient’s RFID bracelet. In the KARMIN
patient room scenario, medical staff wear their own mobile device and
can synchronise content from their device wirelessly to the bedside
terminal. This allows content to be shared and displayed in parallel.
By clearly separating the users so that the terminal can only be used
by the patient, no pathogen transmission chain is formed → Fig. 7. One
cannot, however, prevent a patient’s visitors from using the terminal, for
example to view the patient’s daily schedule. This can only be prevented
by educating patients and visitors accordingly.

6 Different hierarchical menu models and the respective

focus they place on educational content (marked in red)

233 Bedside Terminal

 Nudging
As not every patient is motivated to inform themselves, they are
“nudged” to view educational information. Pop-ups appear at intervals,
based on analytical data on the frequency with which educational con-
tent is viewed, and draw the patient’s attention to further educational
information on infection prevention, sensitising them to the importance
of the topic. In addition, the arrangement of icons and the menu nav-
igation prioritise the findability of educational content through their
prominent placement.

Menu structure
The interface has a central display area and a top and bottom menu
bar with general information and important menu items. These can also
be brought up via buttons in the housing. Four options are available in
the main menu: “Your stay”, “Daily exercises”, “Settings” and “Enter-
tainment”. “Your stay” is the central information point for the patient
7 Patient and staff use separate, synchronised terminals.
and leads to submenus with information on meals, the daily schedule,
medical information as well as communications and educational content.
Private calls can be made with the telephone function. A web browser
is also available via the “Entertainment” menu item.
In addition to calling a nurse via the call button, patients can pro-
vide nurses with more precise information via a text field or as a spoken
message. This avoids the room being entered needlessly and arbitrary
items being brought into the room. It also saves staff unnecessary jour-
neys to the patient room and allows them to plan their work in a more
targeted manner.

Colours and icons

The associative qualities of colours and icons can strongly influence
the perception of content. The KARMIN Suite picks up the colours used
elsewhere in the patient room to avoid being unnecessarily jarring or
intrusive to the patient. Each of the main menu items and its respective
submenus is colour-coded with a signature colour. Alongside the blue
tones of the impact protection rails and bathroom door, a red-orange
tone that echoes the colour of the seat upholstery is used as well as
a matching beige and anthracite. The colours present a harmonious
but sufficiently contrasting palette to be easily distinguishable, aiding
orientation within the menus. The red tone was assigned to the “Your
stay” area to act as a signal directing users to the information on hygiene
practices, and the blue tone to the daily exercises. The restrained beige
tone is used for the settings while anthracite is the background for
entertainment content → Fig. 8.
The icons are white to ensure they stand out against the background
of the coloured buttons and are easy to recognise. They take the form
of 2D line illustrations → Fig. 10 that are simple and easy to read, and
have been kept large and not too detailed so that people with visual
impairments can recognise them, and people who do not speak the
interface language or cannot read are still able to use the interface.

Patient education
Patient education has a dedicated menu with videos on the topics
of hand washing and hand disinfection. A narrator guides the patient
through the three questions “Why?”, “When?” and “How?”, explaining
each in detail accompanied by descriptive video material or anima-
tions. This clear division into three questions begins by explaining why
infection prevention measures are sensible and establishes a basis for
the patient’s self-motivation. The answers to the following questions
of “When?” and “How?” are equally important as not every patient is
familiar with the principle or practice of good infection prevention. By

234 Prototype
 splitting the content into three videos, each explanation is entertaining,
and the patient does not need to watch a long video, which may be
interrupted in the middle → Fig. 9.
Various disinfectant manufacturers, as well as the Robert Koch
Institute, the Clean Hands Campaign, the Patient Safety Campaign
Alliance and the Federal Centre for Health Education offer relevant
content, some of which is freely available. The hospitals can integrate
this material into their bedside terminals.

8 Colour scheme of the KARMIN Suite Motivating mobility

The consequences of increasing digitalisation, the incorporation of
remote controls in the bedside terminal and the patient’s use of their
own mobile devices is that patients increasingly find sufficient diversion
in bed and are less often obliged to get up. Nevertheless, a stroll along
the ward corridor, to the café, into the hospital grounds is advisable,
depending on the severity of their illness. The problem of “bedcen-
tricity” can have a negative impact on recovery that should not be
underestimated. Muscles are not exercised, blood circulation is not
stimulated and cognitive faculties such as orientation are neglected.
In older patients, in particular, decubitus and muscle atrophy can occur
(Rahayu Ningtyas et al. 2017). To this end, the KARMIN Suite also offers
videos of simple physiotherapy exercises that can be performed with-
out help, and also instruct patients in how to use the bed to stand up.
Weakened patients can then also be encouraged to leave their bed.
The KARMIN Suite motivates the patient to be more active during
their stay and encourages patients to behave in a hygiene-conscious
manner through informational content. The bedside terminal is there-
fore part of a comprehensive prevention strategy and can make a
9 A patient watching an educational video on the
meaningful contribution to the reduction of nosocomial infections. To
­bedside terminal
achieve the desired effect, all the methods mentioned above should,
however, always be adapted to the specific clinical pictures of the
respective patient.

235 Bedside Terminal

 10 Colour scheme and icon design for the
­ ARMIN Suite
K

Welcome

Your stay Daily schedule Medication plan Food menu Infection prevention When to wash hands

Why to disinfect When to disinfect How to disinfect Daily exercises Belly legs bottom Pelvis and hips

Legs Belly, legs Shoulders Back Settings Light control

Brightness Language German Englisch Settings terminal Handset volume

Ring volume Ringtones Layout My account Backrest Autocontour

Mobilisation Entertainment Internet Radio TV News

236 Prototype
Conclusion The optimisation and redesign of central items and equipment in the
patient room all contribute to preventing the spread of infection. By
linking hardware and software, reconsidering the design of the objects
and introducing sensor technology for statistical analysis of processes
and actions, it is possible to positively influence hygiene practices and
behavioural patterns as well as optimise cleaning procedures. This can
be seen in the concepts for the three objects discussed in this book.
These various different aspects of infection prevention should not,
however, be seen in isolation but considered in the context of the spatial
framework of the room, how the objects are perceived and how they
interact with the staff’s work processes on an everyday basis. Here
potential arises in the transfer and anchoring of knowledge, the creation
of an environment that supports clear, decisive action and facilitates
carrying out different activities, and in ensuring the availability of
necessary materials and surfaces for infection prevention.
In concrete terms, this means that objects should be designed to
optimise easy cleaning. Curved transitions and minimisation of seams and
joints are just as helpful in this context as choosing a suitable material,
avoiding unnecessary construction gaps. Codifying objects to document
cleaning cycles assists in logistical analysis: once preparatory cleansing
has been done, the completed work step can be recorded using an
online system by scanning a QR code. A further pillar is informing and
animating people in standards-compliant hygiene.
Three objects in the room were selected for optimisation and rede-
sign in line with these requirements. The disinfectant dispensers were
positioned to lie in the path of the staff’s work processes to ensure best
possible accessibility, and a hybrid design concept was developed in
which the benefits of electronic data acquisition through sensor tech-
nology of usage statistics was coupled with a mechanical system that
ensures dispenser operation even in the event of a power outage. In
addition, a novel bottle concept simplifies the cleaning of the dispenser
and prevents improper re-use of bottles and pumps. A display lever-
ages the principle of injunctive norms to increase compliance using
changing motivational motifs. In addition, the bedside cabinet has
been optimised structurally and design-wise in line with the aforemen-
tioned cleaning principles. Its design also promotes better organisation
of the objects stored within it, and the nursing staff have been given
dedicated worktops positioned near the bed including a dedicated
storage area. Finally, the bedside terminal also plays a central role in
the prevention of nosocomial infections: by imparting knowledge, it
reinforces hygiene-relevant behaviour and helps empower patients in
preventing infections. Videos and serious games provide educational
guidance and involve the patient in infection prevention.
These measures can be applied equally to the upgrading of existing
healthcare facilities or the more purposeful design of new buildings. And
many of the findings discussed can already be integrated into existing
processes, as several of the resulting measures can be implemented
without the need for serious structural changes. While these measures
still have to be financially viable, one should also consider the long-term
savings made through the reduction in costs resulting from fewer noso-
comial infections. Similarly, such purely objective considerations must
be weighed up against the more subjective impressions of improved
everyday working conditions.
These measures make it possible to successively convert existing
buildings into environments that are better at preventing the transmission
of infections. Where such conversions are successfully implemented, the
number of nosocomial infections can be reduced and fewer serious cases
of illnesses will develop, ultimately saving lives.

237 Conclusion
References
O. Assadian, A. Kramer, B. Christiansen, M. Exner, H. Mar- Licht.Wissen 07 – Gesundheitsfaktor Licht, Licht im
tiny, A. Sorger and M. Suchomel, Section Clinical Antisep- Patientenzimmer, 2013, p. 12, www.licht.de. Last accessed
sis of the German Society for Hospital Hygiene (DGKH), 16 July 2020
Disinfection Assessment Board of the Austrian Society
M. McGuckin and J. Govednik, “Patient empowerment
for Hygiene, Microbiology and Preventive Medicine
and hand hygiene, 1997–2012”, in: The Journal of Hospital
(ÖGHMP), “Recommendations and requirements for soap
Infection, Vol. 84, No. 3, 1 July 2013, pp. 191–199
and hand rub dispensers in healthcare facilities”, in: GMS
Krankenhaushygiene Interdisziplinär, 7(1), 2012, Doc 03 WHO, “My 5 Moments for Hand Hygiene“, WHO
Guidelines on Hand Hygiene in Health Care, 2009,
AWMF – Arbeitsgemeinschaft der Wissenschaftlichen
https://www.who.int/infection-prevention/campaigns-
Medizinischen Fachgesellschaften, Arbeitskreis “Kranken­
clean-hands/5moments/en. Last accessed 5 March 2020
haus- und Praxishygiene” der AWMF, Leitlinien zur
Hygiene in Klinik und Praxis, in: Hyg Med, 34(7/8), 2009, Ni Wayan Rahayu Ningtyas, RR Sri Endang Pujiastuti and
pp. 287–292 Nina Indriyawati, “Effectiveness of progressive mobiliza-
tion level 1 and 2 on hemodynamic status and decubitus
Matthijs C. Boog, Vicki Erasmus, Jitske M. de Graaf, Elise
ulcer risk in critically ill patients”, in: Belitung Nursing
van Beeck, Marijke Melles and Ed F. van Beeck, “Assess-
Journal, Vol. 3, No. 6, 2017, pp. 662–669
ing the optimal location for alcohol-based hand rub
dispensers in a patient room in an intensive care unit. Lavanya Pashikanti and Diane Von Ah, “Impact of Early
Recommendations and requirements for soap and hand Mobilization Protocol on the Medical-Surgical Inpatient
rub dispensers in healthcare facilities”, in: BMC Infectious Population: An Integrated Review of Literature”, in: Clinical
Diseases, 13:510, 31 October 2013 Nurse Specialist, Vol. 26, No. 2, March/April 2012, pp. 87–94
Benjamin Chan, K. Homa and K. B. Kirkland, “Effect of Thomas L. Powers and Dawn Bendall, “Improving Health
Varying the Number and Location of Alcohol-Based Hand Outcomes Through Patient Empowerment”, in: Journal
Rub Dispensers on Usage in a General Inpatient Medical of Hospital Marketing & Public Relations, Vol. 15, No. 1,
Unit”, in: Infection Control and Hospital Epidemiology, 2004, pp. 45–59
34(9), September 2013, pp. 987–989
Stefan J. Schaller, Matthew Anstey, Manfred Blobner,
DIN 18040-2:2011-09, Barrierefreies Bauen – Planungs­ Thomas Edrich, Stephanie D. Grabitz, Ilse Gradwohl-­Matis,
grund­lagen – Teil 2: Wohnungen (Construction of acces- Markus Heim, Timothy Houle, Tobias Kurth, Nicola
sible buildings – Design principles – Part 2: Dwellings), Latronico, Jarone Lee, Matthew J. Meyer, Thomas Peponis,
Berlin: Beuth Verlag, 2011. Daniel Talmor, George C. Velmahos, Karen Waak, J. Matthias
Walz, Ross Zafonte and Matthias Eikermann, “Early, goal-
DIN EN 12464-1, Light and lighting – Lighting of work places –
directed mobilisation in the surgical intensive care unit: a
Part 1: Indoor work places, Berlin: Beuth Verlag, 2011
randomised controlled trial”, in: The Lancet, Vol. 388,
DIN 5035-3, Beleuchtung mit künstlichem Licht – Teil 3: No. 10052, 1 October 2016, pp. 1377–1388
Beleuchtung im Gesundheitswesen, Ausgabe 07, Berlin:
Simone Scheithauer, Johannes Bickenbach, Hans Heisel,
Beuth Verlag, 2006
Patrick Fehling, Gernot Marx and Sebastian Lemmen, “Do
DIN EN 60601-1, Medizinische elektrische Geräte – Teil 1: WiFi-based hand hygiene dispenser systems increase
Allgemeine Festlegungen fur die Sicherheit einschließlich hand hygiene compliance?”, in: American Journal of Infec-
der wesentlichen Leistungsmerkmale (Medical electrical tion Control, 46(10), 2018, pp. 1192–1194
equipment – Part 1: General requirements for basic safety
Sebastian Schulz-Stübner, Repetitorium Krankenhaus­
and essential performance), edition 12, Berlin: Beuth
hygiene und hygienebeauftragter Arzt, Heidelberg:
Verlag, 2013
Springer 2013
DIN 13080:2016-06, Gliederung des Krankenhauses in
VDI-Richtlinie 6023, Hygiene in Trinkwasser-Installationen –
Funktionsbereiche und Funktionsstellen (Division of hospi-
Anforderungen an Planung, Ausführung, Betrieb und
tals into functional areas and functional sections), Berlin:
Instandhaltung, Düsseldorf: VDI – Verein Deutscher
Beuth Verlag, 2016
­Ingenieure e. V., 2013
DIN 1946-4:2008-12, Raumlufttechnische Anlagen in
VDI-Richtlinie 6022, Raumlufttechnik, Raumluftqualität –
Gebäuden und Räumen des Gesundheitswesens (Ventila-
Hygieneanforderungen an raumlufttechnische Anlagen
tion and air conditioning – Part 4: Ventilation in buildings
und Geräte, Düsseldorf: VDI – Verein Deutscher Inge-
and rooms of health care), Berlin: Beuth Verlag, 2008
nieure e. V., 2011
Susanne Gaube, Dimitrios Tsivrikos, Daniel Dollinger
World Health Organization (WHO), 2013. www.who.int/
and Eva Lermer, “How a smiley protects health: A pilot
infection-prevention/tools/hand-hygiene/5may2013_
intervention to improve hand hygiene in hospitals by
patient-participation/en/. Last accessed 2 April 2020
activating injunctive norms through emoticons”, in: PLoS
ONE, 13(5), 21 May 2018
“Händehygiene in Einrichtungen des Gesundheitswesens.
Empfehlung der Kommission für Krankenhaushygiene und
Infektionsprävention (KRINKO) beim Robert Koch-Institut
(RKI)”, Bundesgesundheitsblatt, No. 59, 2016, p. 1200
HOAI. Honorarordnung für Architekten und Ingenieure, as
of 10 July 2013 (BGBl. I p. 2276)
IEC 60601-1:2005, Medical electrical equipment – Part 1:
General requirements for basic safety and essential per-
formance, 2005-12, Berlin: VDE Verlag 2012
Infektionsschutzgesetz, 2011. Gesetz zur Verhütung und
Bekämpfung von Infektionskrankheiten beim Menschen
(Infektionsschutzgesetz – IfSG). Bundesgesetzblatt 2000,
p. 1045, last version as of 8 July 2011
Krankenhausbetriebs-Verordnung. Verordnung über
die Errichtung und den Betrieb von Krankenhäusern,
Krankenhausaufnahme, Führung von Krankengeschichten
und Pflegedokumentation und Katastrophenschutz in
Krankenhäusern, Berlin (KhBetrVO), 2006
Krankenhausbauverordnung. Muster einer Verordnung
über den Bau und Betrieb von Krankenhäusern (Kh-
BauV0), version December 1976

238 Prototype
KARMIN Project Team Sponsoring partners

Association partners

Braunschweig University of Technology

(coordination)

Institute of Construction Design,

Industrial and Health Care Building (IKE) Industrial partners
Prof. Carsten Roth
Atos Information Technology GmbH, Munich (Bedside terminal)
Dr. Wolfgang Sunder (head of project)
Julia Moellmann BODE Chemie GmbH, Hamburg (Disinfectant and dispenser)
Oliver Zeise
Lukas Adrian Jurk Brillux GmbH & Co. KG, Münster (Walls, ceiling)

Charité – Universitätsmedizin Berlin Continental AG, Hanover (Furnishing)

Institute for Hygiene and Environmental
Medicine FSB Franz Schneider Brakel GmbH + Co KG, Brakel (Door fittings)
Prof. Dr. med. Petra Gastmeier
Dr. med. Rasmus Leistner Hansa Armaturen GmbH, Stuttgart (Bathroom fittings)

Jena University Hospital HEWI Heinrich Wilke GmbH, Bad Arolsen (Bathroom equipment)
Septomics Research Group
Prof. Dr. Hortense Slevogt JELD-WEN Deutschland GmbH & Co. KG, Oettingen (Doors)

Röhl GmbH Kusch+Co GmbH, Hallenberg (Furniture)

Waldbüttelbrunn
Dipl.-Wirt. Ing. Lars Röhl nora systems GmbH, Weinheim (Floor)

REISS Büromöbel GmbH, Bad Liebenwerda (Furniture)

InfectControl 2020 is a consortium of Resopal GmbH, Groß-Umstadt (Interior fittings – HPL surfaces)
commercial and academic partners who
together develop solutions for the preven- RZB Rudolf Zimmermann, Bamberg GmbH (Lighting)
tion and control of infections on a national
and global level. It was founded within the framework of the "Zwan- Schüco International KG, Bielefeld (Windows)
zig20 – Partnerschaft für Innovation" of the Federal Ministry for Education
and Research (BMBF). InfectControl 2020 is a highly innovative research Villeroy & Boch AG, Mettlach (Sanitary objects)
network dedicated to fundamentally new strategies for early detection,
containment and successful control of infectious diseases and their wissner-bosserhoff GmbH, Wickede (Patient bed, bedside cabinet)
commercial implementation. For the first time in Germany, partners
from very different sectors such as agriculture, veterinary medicine,
climate research, design, architecture, materials research, medicine,
infection biology, psychology and public relations cooperate in this
unique network.

239 Project Team

Glossary
Bedside terminal
A computer tablet for the patient’s use near the bed, used for request-
ing information from patient, providing hospital and treatment-related
information, ordering meals and TV/media entertainment.
Accessibility
Accessibility is defined in § 4 of the German “Equality for Persons with Bed tower
Disabilities Act” (BGG) as: “The term accessible (barrier-free) can be A high-rise building predominantly containing nursing wards, especially
applied to buildings and other structures, means of transport, technical on the upper floors.
commodities, information processing systems, acoustic and visual infor-
mation sources and communication facilities, as well as other designed Biofilm
environments if persons with disabilities are always able to find, access A biofilm is a thin film of slime or fluid adhering to a solid surface that
and use them unaided in the usual manner and without any particular contains communities of microorganisms in a self-produced matrix.
difficulty. The use of relevant disability aids is permitted.”
Biocide
Adherence A category of disinfectants. A chemical used for room and surface dis-
Adherence refers to the extent to which a person’s behaviour corre- infection.
sponds to the recommendations agreed with the therapist, for example
how regularly they take their medication or observe a dietary regime. Candela
A physical quantity of light and a unit of luminous intensity.
Affordance
Affordance is the quality or property of an object that defines its possible Care categories
uses or makes clear how it can or should be used, for example an armchair Hospitals can be ranked according to the intensity of possible patient
suggests to us that we can sit on it. This signifying character can derive care. There are four different categories: basic care, standard care,
from its physical, material, logical or cultural character. priority care and maximum care.

Airlock Care unit

An airlock is a transitional space between two areas whose environments An alternative term for a nursing ward, often with a special purpose,
should not mix, due to different air pressure, different sterility levels, such as an intensive care unit (ICU) or medium care unit (see also IMC).
different contamination degrees or different cleanliness, etc.
Chain of infection
“Aktion Saubere Hände” Describes the sequence and route of transmission of a pathogen.
“Aktion Saubere Hände” (Clean Hands Campaign) is a national campaign
promoting hand hygiene by several German healthcare institutions. It Chemotherapy
aims to contribute to increasing compliance with hand disinfection Drug therapy for the treatment of cancer diseases or infections.
recommendations and thus to the reduction of hospital infections.
Chronic disease
Antibiotic Chronic diseases require constant medical treatment and monitoring.
An antimicrobial substance that acts against pathogens and is derived The most common chronic diseases include cancer, cardiovascular
from the metabolic products of microorganisms. diseases, multiple sclerosis, rheumatism and epilepsy.

Aseptic Cleanability
Sterile, free from contamination. Cleanability describes the surface condition of a material with respect to
how well it can be optimally cleaned to prevent microbial contamination.
Automation
Building automation stands for the automated control of technical build- Coefficient
ing functions such as heating, ventilation or lighting. In patient rooms A constant quantity placed before a variable as a multiplying factor.
this can apply, for example, to the periodic controlled flushing of water
pipes to prevent the build-up of germs in infrequently-used water pipes. Cohorting
An infection containment approach in which patients with the same
Bacteria pathogens are isolated together.
The smallest organism consisting of only one cell, which can give rise
to decay, disease or fermentation. Compliance
The willingness of a person to actively participate in certain measures.
Bedcentricity
The term refers to an organisational focus (or design focus) on the Corona pandemic
patient bed. While it has logistical advantages and the patient is easier The Coronavirus pandemic (COVID-19 pandemic) is the worldwide
to find, it can impede the process of recovery by making patients too outbreak of the new respiratory disease COVID-19 in 2019.
passive.

240 Appendix
 Cross-contamination Evaluation
Cross-contamination is generally defined as the direct or indirect and Proper and professional assessment.
unintentional transfer of pathogens from a surface to an object. This
can occur, for example, by touching a (contaminated) handle or the Evaluation matrix
hand of another person. An evaluation matrix details various evaluation criteria along with their
weighting and grading in a structured form.
Degree of colonisation
The degree of colonisation indicates the extent to which a surface is Evidence-based design (EBD)
colonised with pathogens. The process of making decisions about the built environment based on
available or observed research. The term goes back to Roger Ulrich, who
Decubitus in 1984 documented the positive effects of looking out of the window
Bedsores among bedridden patients as a consequence of prolonged on the recovery of patients.
lying in bed in one position.
Exogenous infection
Dementia An infection caused by a pathogen entering a patient’s body from their
Dementia is a pattern of symptoms of different diseases, the main environment.
feature of which is the deterioration of multiple mental (cognitive)
abilities compared to an earlier condition. Five Moments for Hand Hygiene
This WHO guideline specifies when hands must be disinfected to
Demonstrator prevent infection: 1) before patient contact, 2) before undertaking
An alternative term for a prototype used to demonstrate the feasibility an aseptic task, 3) after contact with potentially infectious body
of a solution within the framework of an innovation project. fluid, 4) after patient contact, and 5) after contact with the patient
surroundings.
Descriptive norms
Descriptive norms refer to the perception of behaviours that are typically Functional area
performed among a group of people. The assumption that it is normal Hospitals in Germany are divided into seven distinct functional areas
to do the same thing everyone else is doing, e.g. to join in clapping according to DIN 13080: Examination and treatment, nursing, admin-
when others start clapping. istration, social services, supply and disposal, research and teaching,
miscellaneous.
DIN norm
A DIN standard or German Industrial Norm specifies requirements for Hand hygiene compliance
products, services and/or processes. Developed under the direction of Hand hygiene practice in accordance with the rules.
the German Institute for Standardization, their use is voluntary.
Healing Architecture
Disinfectant dispenser In the architecture of healthcare buildings, Healing Architecture
Device for dispensing disinfectants. Disinfectant dispensers must be describes a planning approach that recognises architecture as a var-
placed in the immediate vicinity wherever hand disinfection is required. iable that contributes to the physical and mental well-being of staff,
patients and visitors.
DRG
Diagnosis Related Groups (DRG) is a patient classification system that HOAI
standardises prospective payment to hospitals according to particular The HOAI is the official scale of fees for services by architects and
diagnostic categories, e.g. assigns cases (patients) to case groups engineers in Germany.
based on medical condition.
Horizontal prevention measures
Ebola A horizontal approach aims to prevent infections caused by a wide
Ebola is a rare and life-threatening infectious disease. It belongs to the range of pathogens by standardised implementation of preventive
viral haemorrhagic fever diseases (VHF) and is caused by the Ebola measures for all patients, regardless of their degree of colonisation
virus (EV). and infection status.

Emoticon Hospitalism
A combination of different keyboard characters that can be used to Infection of hospital patients or staff by germs that have become resist-
convey an emotion in a written message by representing a facial expres- ant in the hospital.
sion (e.g. a smiley).
HPL
Endogenous infection HPL stands for high-pressure laminate. As a cladding material, it is suit-
An infection arising from a pathogen, mostly bacteria, already present able for indoor use – also in hygienic rooms such as laboratories and
in or on the body but previously undetected. operating theatres – as well as for outdoor use.

241 Glossary
 Human Centric Lighting (HCL) Lenticular image
HCL is the specific design of lighting that can benefit the biological, A lenticular image changes appearance or shifts when the image is
emotional, health, or well-being of people. viewed from different angles, i.e. when moving one’s head or the image.

Human microbiome Life cycle

The totality of microorganisms associated with and colonising humans. The life cycle of a building comprises three phases: construction, use
and demolition. For a sustainable, efficient use of resources, their use
Hygiene over the entire life cycle of a building must be considered.
The extent of measures aimed at promoting and improving health
through the prevention and control of diseases. Lux
Physical quantity, unit of illuminance.
Inboard arrangement
An “inboard” arrangement of wet cells denotes their placement next Melanopsin
to the inner ward corridor. Melanopsin is a protein found in retinal ganglion cells of the eye, where
it is involved in registering ambient brightness. The melanopic effect
Induction room of light therefore relates to our pattern of wakefulness and sleep (our
The term for the room in which a patient is prepared for an operation, circadian rhythm). The effect depends on the angle of incidence and
usually through the induction of an anaesthetic. Once the anaesthetic the colour of light as well as the size of the light source.
has taken effect, the patient is then brought into the operating theatre.
Meta-analysis
Infection Meta-analysis is a quantitative and statistical means of systematically
A local or general impairment of the human organism by pathogens that assessing previous primary research studies to derive conclusions about
have entered the human body. that body of research. It serves as an evidence-based approach to
aggregating and using medical information.
Infrared mirror
An infrared heater whose heating surface is a mirror. Method
A method is a more or less planned approach to reaching a goal. A
Injection moulding method can also be understood as a path to gaining knowledge.
A thermoplastic forming method by which a heated thermoplastic
material is injected into a cold mould and solidifies. Microorganism
Microorganism is a collective term for small organisms that usually con-
Injunctive norms sist of only one cell, such as bacteria, yeast, fungi and algae.
Injunctive norms refer to the perception of behaviours that are deemed
generally appropriate. The assumption is that it is right and proper, e.g. Microorganism entry potential
you don‘t drop litter in the street. The extent to which microorganisms may enter a room borne on the
persons themselves or the objects they bring into a room.
Intermediate Care (IMC)
IMC is the bridge between the intensive care unit (ICU) and its com- Movement area
prehensive therapy and intensive care facilities and the normal ward, DIN 18025-2 sets out the free space necessary for movement in front
where lower staffing levels prohibit the close monitoring of patients. of or beside an item of use, such as a washbasin, shower or toilet. The
specified distances must be maintained.
Invasive procedure
A medical measure that penetrate the body, for example the taking of MRSA
samples from organs, injections or operations. Many hospital infections are caused by methicillin-resistant staphy-
lococcus aureus strains (MRSA). Staphylococcus aureus is a common
KISS bacterium that colonises the skin and mucous membranes in particular,
KISS – Krankenhaus-Infektions-Surveillance-System (Hospital Infection while MRSA strains thereof are resistant to the antibiotic methicillin.
Surveillance System) – is a nationwide surveillance system for system-
atically collecting and recording hygiene-related data in medical and Multiresistant pathogens
nursing facilities in the German healthcare system. Pathogens that are resistant to the mode of action of most antibiotics.

KRINKO Neonatology
The Commission for Hospital Hygiene and Infection Prevention (KRINKO) The branch of applied pediatrics concerned with newborn medicine
at the Robert Koch Institute (RKI) in Berlin issues regularly updated and the care of newborns.
guidelines that serve as a binding basis and standard for infection
prevention measures in healthcare environments. Nested arrangement
In a “nested” arrangement, the wet cells are arranged in a zone between
two patient rooms.

242 Appendix
 Nosocomial infection PVC
Infections that arise during a stay or period of treatment in a hospital or PVC (polyvinyl chloride) is a fundamentally brittle and hard plastic, but
healthcare facility. As so-called Hospital-Acquired Infections (HAI), they its properties can be adapted to the respective area of application by
should be differentiated from infections that patients may have had, adding plasticisers. PVC is best known as a floor covering.
or were in the incubation phase of, prior to admission to the hospital.
Reserve antibiotic
NRZ Reserve antibiotics are antibiotic classes that should be reserved for
National Reference Centre for Surveillance of Nosocomial Infections at the calculated antibiotic therapy of confirmed or suspected infections
the Institute for Hygiene and Environmental Medicine at the Charité – due to multi-resistant pathogens.
Universitätsmedizin Berlin.
RFID chip
Nudging Radio Frequency Identification (RFID) is a technology for transmitter-­
Nudging is a more or less subtle way to motivate or discourage someone receiver systems for the automatic and contactless identification of
from doing a specific action, either once or in general. The intention is a carrier, which can be an object or a living being. RFID chips act as
to effect a change in behaviour. transmitters and can be identified by readers.

Oncology Rotational moulding

The study and treatment of tumours; the branch of medicine that deals Rotational moulding is a plastic-forming method for hollow bodies in
with cancer. which a melt solidifies on the walls of a rotating mould.

Outboard arrangement Same-handed

An “outboard” arrangement of wet cells denotes their placement In the “same-handed” arrangement of adjacent patient rooms, the
adjoining the external façade of the building. floor plan, fittings and furnishings of adjacent rooms are identical, in
contrast to the mirrored arrangement where they are reversed. Its
Outlet valve name derives from the fact that nurses always approach the patient
More commonly known as a tap fitting, it can take many forms. In domes- from the same side.
tic use and in patient rooms, the most common are combined hot and
cold water mixer taps operated using a single lever or two knobs. Sanitisation
Sanitisation refers to the treatment and hygienic preparation of used
Oxidative aging process objects for repeated use. Measures may include sterilisation, disin-
Oxidative aging is understood as the influence of thermal energy on fection, etc.
materials and components in the presence of oxygen. This process is
therefore highly temperature-dependent. SARS
Severe Acute Respiratory Syndrome (SARS) is an infectious disease
Pathogenic fungus caused by the SARS coronavirus (SARS-CoV), which has the clinical
Pathogenic fungi are parasites that cause infectious diseases, the picture of an atypical pneumonia. Human-to-human transmission occurs
so-called mycoses. Depending on the species, they can infest animals, mainly through the inhalation of droplets exhaled by infected persons.
plants as well as humans. Indirect transmission via contaminated surfaces and materials is also
possible.
Patient empowerment
Pro-active action and education that empowers the patient to be more Screening
independent and active in their own interests. The early detection of diseases.

Prevalence Sepsis
A figure in health and disease science that indicates how many people Bloodstream infection, also known colloquially as blood poisoning.
of a specific group of a defined size have a specific disease.
Serious games
Prototype Serious games is a term used for gamified learning concepts not pri-
In engineering terms, a prototype represents a functional, but often marily or exclusively for the purposes of entertainment but to convey
simplified test model of a planned product or component that is suitable information and educational material in a playful way.
for the respective purpose.
Signifying character
Push-to-open The stimulus emanating from a thing or an event that suggests a certain
An opening or closing mechanism that uses magnets in the hinge: behaviour.
applying gentle pressure is sufficient to open or close a cupboard or
drawer. Its primary advantage is that no handles or knobs are required. Sterile equipment
Instruments that have been sterilised for use.

243 Glossary
 Surface free energy
Surface free energy is the measure of intermolecular forces at the sur-
face of a solid versus its bulk. It influences the wettability or resistance
to wetting of a surface.

Surveillance
The continuous, systematic collection, analysis and interpretation of
health data needed for the planning, introduction and evaluation of
medical measures.

Systematic review
Systematic review or literature survey, which employs a range of meth-
ods to collate and summarise and critically evaluate all available knowl-
edge on a specific topic.

Triage
A standardised procedure for the systematic initial assessment of the
urgency of treatment of patients in accident and emergency admissions.

Tunable white LED

Individually controllable LEDs that can adjust their light colour (tem-
perature).

Typology
Building typologies or room typologies denote the classification of
buildings or rooms into groups with a distinct architectural feature,
function or use.

Undercut
An undercut is an indentation or protrusion of an injection-moulded
part that can prevent the cast item from being ejected from its mould.

Urinary catheterisation
Catheterisation is the insertion of a catheter through the urethra (trans­
urethral) into the bladder.

UV radiation
Ultraviolet (UV) radiation is the most energy-rich part of the optical
spectrum. UV radiation is not visible to humans and cannot be perceived
with other sensory organs.

Vertical prevention measures

A vertical preventional approach aims to identify patients colonised or
infected with a specific pathogen and to implement specific measures
to prevent the spread of the pathogen in the institution (e.g. through
isolation measures).

VRE
Vancomycin-resistant enterococci are resistant to the antibiotic vanco-
mycin and can be pathogens for nosocomial infections. These entero-
cocci are among the most common causes of urinary tract infections,
wound infections and sepsis as well as endocarditis.

Zoning
Zoning denotes the division of a given realm into allocated individual
sub-areas (zones). Zones can be defined for buildings and rooms but
also lakes, mountains and even entire areas of land.

244 Appendix
About the Authors
Rasmus Leistner is a specialist in hygiene and environmental medicine
and infectiology. He works as a hospital hygienist at the Institute for
Hygiene and Environmental Medicine and as a clinical infectiologist at
the Clinic for Gastroenterology, Infectiology and Rheumatology at the
Wolfgang Sunder studied architecture in Münster, Zurich and Berlin Charité Berlin. He is a consultant for the National Reference Centre for
and earned a doctoral degree. After completing his studies in 2002, he the Surveillance of Nosocomial Infections. Dr Leistner is the author of
continued his professional career with Zaha Hadid Architects in London. numerous publications on infection prevention, epidemiology and infec-
As head of research at the Institute of Construction Design, Industrial tiology. He is co-editor of the journal Krankenhaushygiene Up2Date.
and Health Care Building (IKE) of the TU Braunschweig, he participated
in various research projects in the field of healthcare buildings and Inka Dreßler is an industrial and civil engineer. She is a senior engineer
advised hospital operators in their strategic orientation. Since 2015, he for the field of building materials at the Institute for Building Materials,
has been head of the construction section in the InfectControl research Solid Construction and Fire Protection (iBMB) of the TU Braunschweig.
consortium. The aim here is the development of infection-preventive Her research interests include structural hygiene in hospitals.
measures in the planning of healthcare buildings. Dr Sunder is the author
of the publication Bauliche Hygiene im Klinikbau (Bundesinstitut für Katharina Schütt has a degree in economic and civil engineering from
Bau-, Stadt- und Raumforschung, 2018). the TU Braunschweig, the Chalmers Tekniska Högskola (Gothenburg,
Sweden) and the University of Rhode Island (Kingston, RI, USA). She
Julia Moellmann studied architecture and urban design at the Leibniz works as project coordinator in turnkey construction, with a focus on
University Hanover, the Politecnico di Milano and the State University hospital construction. In her master thesis at the TU Braunschweig she
for Architecture and Civil Engineering in St Petersburg. Since 2017, she investigated the influence of material ageing on the properties of hos-
has been a research associate at the Institute of Construction Design, pital-standard solid surfaces.
Industrial and Health Care Building (IKE) of the TU Braunschweig in the
field of health buildings. For the KARMIN project she studied floor plan
typologies of patient rooms in national and international hospitals and
worked on the concept and design of the patient room demonstrator.

Oliver Zeise first trained as a carpenter and then studied architecture

at the University of Applied Sciences Lübeck and the TU Braunschweig.
He then worked in architectural offices in Hamburg and Lüneburg. Since
2016, he has been research associate at the Institute of Construction
Design, Industrial and Health Care Building (IKE) of the TU Braunschweig.
In the KARMIN project he deals with structural infection prevention in the
context of the patient room. The planning in detail and the realisation
of the prototype with numerous industrial partners are his priorities. He
is also active as a practicing architect.

Lukas Adrian Jurk is a medical and speculative designer, studied indus-

trial and car design at the University of Fine Arts Braunschweig, at the
Universidad de Chile, Santiago, and social design at the Design Academy
Eindhoven. Already in the context of his bachelor thesis he dealt with
design in a hospital context. He is a research associate at the Institute of
Construction Design, Industrial and Health Care Building (IKE) at the TU
Braunschweig. Since 2020, he has also been a strategic partner in the
collective The Complicity. His freelance work in the field of biodesign
has been shown in international exhibitions.

245 Authors
Subject Index
Cupboard (patient) → also Wardrobe, patient's 82, 94, 108, 118, 128,
132, 136, 138, 178–180, 184, 185, 193, 195
Curtain 33, 42, 70, 73, 82, 94, 99, 128, 136, 146, 175

ABS 214 Data acquisition 122, 212–217, 221, 230, 237, 242, 244
Additive principle 29, 30, 36, 38, 39, 45 Data collection 212, 215
Airlock 22, 32, 39–41, 45, 46, 51–53, 57, 59, 112, 138, 240 Daylight 41, 42, 47, 70, 86, 90, 94, 100, 128, 132, 146, 150, 186, 187
Alcove 32, 39, 41, 42, 45, 46, 50, 52–54, 58, 59, 62, 100, 103, 135, Decor 78, 90, 108, 112, 118, 138, 142, 177, 183, 184, 206, 227
146, 149 Decubitus 235, 241
Antibiotic 12, 15, 23, 240, 242–244 Dementia 17, 41, 42, 128, 183, 207, 208, 225, 241
Art 69, 86, 108 Demographic change 15, 208, 209
Aseptic procedures 23, 211, 240 Diagnosis Related Group (DRG) 13, 241
Atrium 90, 93, 108, 125 Diagnostics 13, 16, 108, 112, 187, 241
Digital sensor 212
Bacteria 15, 21–23, 42, 171, 240–242 DIN 13080 175, 241
Balcony 12, 31, 39, 44, 46, 61, 70, 103, 136, 138, 141 DIN 18040-2 29, 29, 191
Barrier-free → also Low-barrier 28, 29, 35, 38–43, 45, 48, 52, 53, 55–59, DIN 1946-4 175
63, 78, 90, 118, 122, 136, 142, 178, 191, 240 DIN 5035-3 185, 186
Bathroom 7, 19, 20, 28, 29, 32, 33, 35–43, 45–63, 171–175, 177–182, 184, DIN EN 12464-1 186
186, 187, 189–194, 197, 198, 200, 202, 204, 209, 211, 212, 220, 234, DIN norm 177, 191, 241
242, 243 Disinfectant dispenser 7, 32, 39, 74, 118, 142, 164, 167, 170, 171, 173–175,
Bathroom, prefabricated 39, 94, 171 178, 179, 181, 182, 191, 193, 202, 203, 206, 209–223, 226, 237, 241
Bed tower 28, 161, 162, 240 Disinfection → also Hand hygiene 23, 171, 174, 175, 207, 209, 210, 212,
Bedcentricity 240 217, 224, 226, 240
Bed position 34, 44, 45, 47, 54, 55, 62, 66, 70, 178, 181 Disposal room 18–20
Bedside cabinet 40–42, 45, 46, 48, 49, 51, 53, 58, 182, 203, 206, 209, Door → also Sliding door 13, 31, 34, 35, 37, 39–42, 52, 82, 86, 89, 104,
224–229, 237 118, 122, 132, 138, 146, 154, 161, 173, 177, 181, 186, 191, 193, 209, 210,
Bedside terminal 7, 69, 135, 170, 171, 182, 186, 187, 189, 190, 199, 209, 213, 221, 234
224, 226, 227, 230–237 Door, double-leaf 138
Bedside trolley → Bedside cabinet Double corridor 12, 18, 128, 167
Biocide 240 Double room → Two-bed room
Biofilm 22, 240
Brise-soleil 94, 95, 97 Ebola 13, 241
Entrance hall 11, 108
Care procedures 40, 42, 104, 174, 178, 185, 223, 230, 237 Entrance, single 31, 45–51, 53–55, 57–63
Castors, double 227, 228 Entrances, two 31, 39, 42, 44, 45, 52
Chipboard 82, 192, 194, 195 Ergonomics 104, 208, 211, 217, 222, 227, 231
Chronic disease 15, 240 Evaluation, qualitative 38–44
Circulation 12, 39, 70, 82, 104, 135 Evaluation, typological 44–63, 175
Clean Hands Campaign (Germany) 171, 235, 240 Evidence-based Design (EBD) 104, 241
Cleanability 24–26, 177, 183, 203, 240 Examination area 16, 18–20, 94, 241
Cleaning 7, 11, 23–26, 43, 94, 112, 146, 171, 174, 175, 177–179, 181–183, 185,
187, 190, 191, 193, 195, 201–203, 205, 207–210, 214, 215, 217, 218, Façade 33, 38, 39, 41, 42, 45, 46, 50, 57, 61, 66, 70, 74, 78, 82, 86, 90,
222, 224–232, 237 94, 95, 100, 104, 108, 118, 119, 128, 132, 136, 138, 139, 142, 158, 161,
Cleaning cycle 208, 237 177, 187, 243
Cleaning staff 38, 175, 189, 201, 227, 228 Family room 69, 149
Cleaning test 184 Fire safety 142–145
Cluster structure 146, 166 Fittings 28–32, 36–43, 45–63, 70, 86, 104, 108, 112, 118, 136, 138, 170,
Cohorting 207, 241 172–175, 177–179, 181, 183–185, 191, 193, 197, 206, 208, 209, 220, 227
Colonisation with germs 86, 208, 209, 214, 215, 217, 224, 241 Five Moments for Hand Hygiene → also Hand Hygiene 23, 187, 211, 241
Comb structure 166, 167 Flexibility 12, 13, 32, 39, 41, 45, 66, 90, 214
Commode chair 118 Floor plan, radial 61, 161
Compliance 39, 40, 181–183, 203, 209, 211, 212, 214–217, 219–223, 232, Floor plan, rectangular 30, 35, 56, 150
237, 240, 241 Floor plan, specific 29, 45, 51
Contact surface 42, 175, 182, 185, 187, 206, 208, 209, 230 Floor plan, standard 29, 45–49, 52–57, 59–62, 181
Coronavirus pandemic (COVID 19 pandemic) 241, 243 Floor plan, unsystematic 30, 39, 45, 51
Cross-contamination 182, 207, 209, 225, 230, 232, 241 Floor plan combination/variation 29, 30, 36, 38, 45, 50, 58, 61, 63
Cupboard (staff) 32, 74, 77, 86, 132, 136, 138, 184, 185, 191–194, 199, Four-bed room 13, 19, 78, 138
204, 227, 243 Freestanding building 166

246 Appendix
Functional area (German hospitals) 15, 18, 158, 164, 170, 174, 175, 241 Lenticular image 223, 242
Fungus 15, 242, 243 Lighting 70, 94, 108, 118, 128, 132, 136, 173, 175, 182, 185–190, 192–195,
Furnishings 38, 39, 70, 94, 112, 118, 170, 172, 173, 175, 177, 191, 243 198, 200, 209, 233, 240, 242
Furniture 25, 31, 33, 39, 40, 112, 142, 149, 173, 175, 183, 191, 206, 224–227 Low-barrier → also Barrier-free 28, 29, 35, 38–43, 45, 48, 52, 53, 55–59, 63

Geriatrics 16, 17, 22, 86, 128–131, 132–135, 227 Mat structure (hospital) 166
Glass headboard panel 142, 145 Material ageing 24, 26, 177, 245
Glass wall 138, 141 Maximum care provision (Germany) 12, 22, 240
Glove dispenser 78, 94, 142, 191, 193 Medical staff 16, 19, 20, 23, 150, 189, 191, 211, 221, 224, 230, 231, 233
Gloves, disposable 182, 192, 194 Medium care unit 240
Goods transport lift 19 Menu (bedside terminal) 232–234, 236
Grown structure (hospital) 166 Microbiome 7, 21, 170, 171, 242
Guest accommodation 33, 42, 44, 45, 51, 81 Microorganism 21, 24, 170, 205–207, 214, 240, 242
Guest room 122 Minimum standard 29, 35, 45–47, 49–51, 54, 58, 60–63
Mobility 10, 154, 183, 208, 227, 235
Hand hygiene → also Five Moments for Hand Hygiene 22–24, 32, 40, Mirrored floor plan 29, 30, 36, 42, 45, 47, 49, 53, 54, 56, 57, 61, 203, 243
181, 182, 187, 203, 208, 210–212, 214, 216, 219, 220, 234, 240, 241 Mobility aids 29
Healing Architecture 183, 241 Mobility impairment 39, 40, 42, 78, 128
Healing environment 94, 186 Motion sensor 184, 190
Healthcare reforms (Germany) 7 Movement area 31, 57, 59, 242
High pressure laminate (HPL) 25, 26, 82, 184, 187, 192, 194, 195, 197, MRSA 15, 23, 170, 208, 210, 242
202, 226, 227, 242 Multi-bed room 164, 170, 171, 186, 187, 210
HOAI (Germany) 175, 241 Multi-resistant germs 7, 15, 171
Hospital renovation 28, 74–77, 108–111, 132–135, 142–145, 161–163
Hospitalism 242 Neonatology 100, 158, 164, 213, 216, 243
Human Centric Lighting 186, 187, 190, 231, 242 Nested arrangement of wet cell 35, 41, 44, 45, 50, 56, 61, 150, 161, 243
Hygiene specialist 23, 38, 164, 177 Nosocomial infection 7, 11, 15, 21–24, 164, 171, 207, 219, 231, 235, 237, 243, 244
Nudging 22, 216, 234, 243
Inboard arrangement of wet cell 35, 43, 45, 46, 49, 52–55, 57–60, 62, Nurses' station 13, 18, 19, 78, 89, 103, 104, 107, 108, 111, 114, 121, 122, 128,
63, 70, 180, 181, 187, 242 132, 138, 142, 145, 157, 161, 164, 167
Infection chain 171, 206, 207, 240 Nursing care 7, 11, 16, 17, 39, 175, 181, 185, 187
Infection prevention, horizontal 23, 210, 241 Nursing staff 10, 12, 13, 16–18, 20, 23, 32, 39, 43, 78, 94, 104, 118, 125,
Infection prevention, vertical 23, 244 136, 142, 146, 158, 175, 182, 186, 187, 207–209, 219, 220, 224, 237
Infection, endogenous 21–23, 210, 241 Nursing ward 15–20, 78, 82, 86, 112, 146, 149, 150, 177, 240
Infection, exogenous 21, 22, 210, 241
Infrared mirror 179, 242 Observation ward 17
Injection moulding 214, 216, 227, 242, 244 Obstetrics 10, 19, 22, 94
Intensive care unit (ICU) 13, 15, 22, 82, 118, 164, 227, 240, 242 Oncology 22, 122–127, 150–153, 243
Interface 33, 173, 186, 231–234 One bed deep 30, 34, 40–42, 44, 45, 48, 51–53
Interior design 38–42, 82, 86, 183 Operating theatre 118, 242
Intermediate care (IMC) 18, 118, 242 Organic building form 86, 100
Internal medicine 22 Outboard arrangement of wet cell 33, 35, 45, 47–49, 58, 60, 78, 180, 243
Invasive procedure 15, 21, 22, 211, 242
Isolation room 15, 118, 146 Paediatrics 19, 22, 100, 122–127, 154–157
Paraplegia 118
KARMIN bedside cabinet 203, 224–229 Partition 33, 42, 74, 77, 86, 112, 117, 161
KARMIN colour and materials concept 183, 184 Patient bed → also Bed position 19, 20, 32, 99, 135, 136, 153, 167, 173,
KARMIN disinfectant dispenser 182, 203, 210–223 177–182, 184, 186, 187, 191, 206, 230, 240
KARMIN lighting concept 185–190 Patient desk 33, 42, 45, 47, 48, 53, 58, 180, 188, 189, 193, 195, 197, 201
KARMIN research project 7, 38, 170–172, 175, 183, 207, 210, 213, 214, Patient education 208, 230, 231, 233–235
216, 230, 245 Patient empowerment 230, 231, 233, 243
KARMIN Suite 233–236 Patient lift system 78, 118
KARMIN patient room 172, 184, 185, 187, 189, 196–205, 210, 216, 218–220, Patient safety 38, 41, 45–63, 175, 177, 235
223, 227, 233 Patient satisfaction 38, 42, 43, 45–63, 175, 177
KISS (Hospital Infection Surveillance System, Germany) 164, 171, 242 Pavilion structure (hospital) 11, 12
Plastics 214, 215, 217, 218, 222, 226, 227, 243
Lamp 138, 185, 187, 189, 190 Plastic surface 22
LED 186, 187, 192–195, 211, 217 Polycarbonate 86
LED, tunable white 186, 187, 244 Polymer 22, 25, 214

247 Index
Polyurethane surface coating 25, 94 Table 7, 32, 63, 70, 86, 108, 112, 122, 136, 179, 186, 189, 193, 195, 209,
Plinth 100, 166, 182, 193 224–226, 228
Power supply 214, 217, 221, 227, 231 Terrace 12, 33, 78, 86
Privacy screen 33, 42, 45, 51, 56, 59, 78 Terrace hospital 12
Private healthcare patients 112, 117, 138, 142, 145, 227, 230 Three-bed room 90
Psychiatry 19, 22, 158 Three-zone plus room 31, 39–42, 45, 46, 48–53, 55, 57–59, 62, 63, 181
Public health insurance companies (Germany) 7 Three-zone room 31, 39–42, 45, 47, 56, 60, 61
Push-to-open mechanism 179, 184, 193, 243 Toilet 11, 13, 20, 35–37, 40, 42, 43, 45, 49, 53, 60, 78, 82, 118, 128, 136,
PVC 25, 26, 112, 243 146, 166, 170, 175, 179, 186, 187, 242
Touch panel 187
Reading lamp 186, 201 Transmission of pathogens 17, 11, 21–24, 39–43, 170, 171, 173, 174, 177,
Rehabilitation 22, 69, 86, 136, 137 181, 183, 206–210, 224, 232, 233, 237, 240, 243
Reserve antibiotic 15, 243 Treatment area 16, 18, 94, 161
RFID 187, 207, 217, 221, 225, 226, 228, 229, 231, 233, 243 Treatment building 118
Risk of injury 40, 41, 104, 179, 193 Two beds deep 30, 34, 45–47, 49, 50, 54–63
Room geometry 30, 39, 45, 177 Two-bed room 7, 19, 20, 28–63, 66, 69, 70, 74, 78, 82, 85, 86, 89, 90,
Rooming-in 122, 146, 149, 154 93, 94, 108, 111, 112, 114, 117, 118, 121, 128, 132, 136, 138, 142, 145, 150,
Rotational moulding 226, 243 153, 154, 157, 158, 161, 162, 164, 167, 170, 173–175, 210
Rounded corners/edges 104, 108, 146, 193, 201, 214, 215, 217, 218, 222, Two-zone room 31, 45, 54
229, 231
Rounded skirting 193, 205 UV radiation 24, 25, 244

Same-handed configuration 29, 36, 39–43, 45, 46, 48, 52–56, 59, 60, VDI Guideline 6022 “Ventilation and indoor-air quality” 175
62, 63, 104, 136, 138, 177, 181, 243 VDI Guideline 6023 “Hygiene in drinking-water installations” 175
Sanitary cell → Bathroom Ventilation 118, 175, 178, 193, 233, 240
Sanitary facilities 11, 18, 22, 170 Veranda 12, 70
Sanitaryware 35, 40, 42, 173, 191 View outdoors, patient's 34, 41, 43, 45–63, 69, 70
SARS 15, 243 View of the patient, staff's 31, 34, 45–63, 104, 182
Screening 23, 136, 243 Virus 15, 22, 241, 243
Seat cushion 179, 193 Visitors 12, 18–20, 24, 25, 31–33, 39–43, 53, 70, 104, 108, 111, 112, 118,
Seating area 20, 41, 42, 46, 53, 70, 81, 90, 112, 114, 138, 141, 145, 149, 138, 142, 145, 146, 150, 154, 161, 174, 175, 179, 181–185, 187, 189, 193,
150, 154, 161 194, 205–208, 210, 212, 213, 215, 224, 233, 241
Serious games 231, 232, 237, 243 VRE 15, 208, 244
Shower 13, 35–37, 40–43, 45–63, 82, 85, 86, 118, 136, 146, 178, 191, 242
Sill, seat-level 33, 41, 42, 45, 60, 82, 112, 114, 122, 128 Ward bathroom 36, 40, 42, 43
Sill, standard 45–59, 61–63 Ward corridor 30–32, 39, 41, 43, 45, 70, 73, 74, 82, 85, 86, 93, 103, 104,
Single room 7, 19, 22, 23, 50, 66, 74, 78, 82, 85, 86, 89, 90, 100, 104, 108, 111, 112, 114, 122, 141, 142, 145, 154, 235, 242
111, 112, 122, 138, 142, 145, 146, 150, 154, 157, 158, 161, 162, 167, 170, 171 Wardrobe, patient's → also Cupboard (patient) 20, 141, 181, 191, 193,
Single-bed room → Single room 199, 205
Sanatorium building 136 Washbasin 13, 32, 33, 35–37, 40, 42, 43, 45, 46, 49–51, 53, 56–58, 60,
Sliding door 37, 40, 41, 45, 46, 48, 50, 52, 56, 59, 61, 63, 86, 89, 104, 61, 78, 82, 86, 94, 122, 128, 132, 135, 136, 146, 191, 201, 211, 220, 242
122, 136, 179, 200 Waste bin 142, 179, 191–194, 204, 220, 227
Spatial quality 40, 175, 177, 178 Waste disposal 11, 19, 94, 174, 175, 182, 194, 204, 241
Staff workplace 32, 39–42, 45, 46, 50–53, 55–58, 62, 63 WC → Toilet
Staff's work processes → Care procedures Wet cell → Bathroom
Sterilisation 214, 224, 226, 240 Wheelchair 74, 118, 128, 136, 138, 146, 181, 211, 220
Storage 18, 19, 32, 74, 78, 118, 122, 132, 142, 175, 178, 179, 181, 182, 191, Window → also Sill 11, 12, 33–35, 39, 41–43, 45–63, 74, 78, 81, 82, 86,
194, 225, 227, 228, 237 90, 93, 94, 103, 108, 112, 114, 118, 122, 128, 132, 136, 138, 141, 142,
Supplies 18, 19, 32, 39–41, 138, 174, 175, 219, 227 146, 150, 153, 154, 161, 167, 173, 177–181, 185, 187, 189, 193, 197, 201,
Supplies trolley 39, 40, 42, 224 203, 218, 232
Supply room 18, 19 Window bench → also Sill, seat-level 82, 182, 184, 193, 195, 197, 201, 205
Surface 11, 22, 24–26, 39, 40, 42, 70, 78, 82, 86, 90, 108, 112, 128, 138, World Health Summit 172
154, 171, 174, 175, 177–179, 181–185, 187, 191–195, 197, 206–209, 211,
213, 214, 217–220, 222, 224–227, 229–233, 237, 240–243, 245 Zoning 31, 39, 41, 42, 45, 178, 187, 244
Surface free energy 24–26, 177, 243
Surgery 18, 22, 94, 112, 138, 142

248 Appendix
Index of Names, Places
Hôpital Saint-Louis, Paris 10
Hvidovre Hospital 78–81
Hvidovre, Denmark 78
and Projects HYBAU+ 164

InfectControl 2020 7, 170, 237

a|sh sander.hofrichter architekten GmbH 142 Institute for Hygiene and Environmental Medicine, Charité –
AAPROG 86 Universitätsmedizin Berlin 164, 170, 171, 239, 243, 245
Agatharied District Hospital 14 Institute of Building Materials, Concrete Construction and Fire Safety
Agatharied, Germany 14 (iBMB), TU Braunschweig 164, 179, 181, 245
Albert Wimmer ZT GmbH 104, 154 Institute of Construction Design, Industrial and Health Care Building
Architects Collective GmbH 104, 154 (IKE), TU Braunschweig 7, 164, 170, 171, 239, 243, 245
ARGE Health Team Vienna 104, 154
ATP HAID architekten ingenieure 82 Jena University Hospital, Septomics Research Group 170, 239
AZ Zeno 86–89 Jugenheim District Hospital 108–111
Junghans+Formhals 108
B2Ai 86
Bärlocher & Unger 132 KARMIN Project 7, 38, 169–237
Bergen, Norway 90 Knokke-Heist, Belgium 86
Berlin, Germany 10, 11, 173, 174 Kopvol 122
BGU Accident and Emergency Hospital 118–121 KRINKO (Commission for Hospital Hygiene
Boeckx 86 and Infection Prevention) 23, 174, 217
Brand, Peter 13
Braunschweig Hospital 171, 175 Lauf an der Pegnitz, Germany 82
Lauf District Hospital 82–85
C. F. Møller Architects 78, 90 Leuven, Belgium 150
Charité Berlin 11, 164, 170, 171, 239, 243 LIAG architects 122
Children's University Hospital Zurich 158–160 LOW Architects 150
Chodowiecki, Daniel 11 LSK-Architekten 108
Crona Clinic, Tübingen University Hospital 142–145
Metron Architektur AG, Brugg 74, 136
Dewan Friedenberger Architekten GmbH 118 Mississauga, Ontario, Canada 66
Dresden, Germany 128 Mmek 122
Düsseldorf, Germany 12, 13 Munich-Sendling, Germany 112
Municipal Hospital Düsseldorf 12, 13
EGM architects, EGM interiors 146 Municipal Hospital Hamburg-Eppendorf 12
Erasmus MC 146–149 Münster University Hospital 13, 161–163
Erlangen, Germany 138 Münster, Germany 13, 161
Esch-sur-Alzette, Luxemburg 104
Neumünster Hospital → Zollikerberg Hospital
Federal Centre for Health Education 235 New North Zealand Hospital 100–103
Federal Office for Building and Regional Planning (BBR) 164 Nickl & Partner 14
Frankfurt am Main, Germany 118
Freiburg, Germany 154 Oncological Centre, Leuven University Hospital 150–153
Friedrich II 11
Paediatric Clinic, Freiburg University Hospital 154–157
General Hospital Vienna 11 Paris, France 10
Gerl, Matthias 11 Perkins Eastman Black 66
German Council of Science and Humanities 13 Pfister, Otto and Werner 70
German National Reference Center for Surveillance of Nosocomial Princess Máxima Center 122–127
Infections 164, 171, 243
German Society for Hospital Hygiene (DGKH) 217 Quarin, Joseph von 11

Haid, Hans Peter 82 Robert Koch Institute (RKI) 23, 174

Hamburg-Eppendorf, Germany 12 Röhl GmbH 170–173, 239
Hanover Medical School 175 Rotterdam, the Netherlands 146
Haraldsplass Hospital 90–93
Herzog & de Meuron 100, 158 Sana Clinic Munich 112–117
Hillerød, Denmark 100 Schachner, Benno 13

249 Index
 Illustration Credits
Seeheim-Jugenheim, Germany 108
Silvia Gmür Reto Gmür Architekten 70, 94, 132
Sofron, Joan 108
Solothurn Public Hospital 94–97
Solothurn, Switzerland 94 Cover: Floor plans Julia Moellmann
St Gallen Geriatric Clinic 132–135
St Gallen, Switzerland 10, 132 A Fundamentals
St Joseph-Stift Dresden 128–131
Südspidol 104–107 The Emergence of Hospitals, pp. 10–14
Surgical Centre, Erlangen University Hospital 138–141 Figs. 1–14 From: Axel Hinrich Murken, Vom Armenhospital zum Großklinikum,
Köln: DuMont, 1995; 15, 16 Stefan Müller-Naumann (photos); 17 Nickl
Tiemann-Petri Koch Planungsgesellschaft 138 und Partner
Toronto, Canada 66
Trillium Health Centre 66–69 The Nursing Ward Environment, pp. 15–20
TU Braunschweig (Technical University of Braunschweig) Figs. 1–9 Institute of Construction Design, Industrial and Health Care
7, 164, 170, 171, 173, 175, 177, 239 Building (IKE), TU Braunschweig
Tübingen, Germany 142
Healthcare-Associated Infections, pp. 21–23
University Hospital Göttingen 175 Fig. 1 IKE, after: Alessandro Cassini, Diamantis Plachouras and Tim Eck-
Uster Hospital 136 manns, “Burden of Six Healthcare-Associated Infections on European
Uster, Switzerland 136 Population Health: Estimating Incidence-Based Disability-Adjusted
Utrecht, the Netherlands 122 Life Years through a Population Prevalence-Based Modelling Study“,
in: PLOS Medicine, 18 October 2016, https://doi.org/10.1371/journal.
Vienna, Austria 11 pmed.1002150; 2 IKE, after: P. Stoodley, K. Sauer, D. G. Davies and J. W.
Costerton, “Biofilms as Complex Differentiated Communities”, in: Annual
Waldbüttelbrunn, Germany 170, 172, 239 Review of Microbiology, 56, 2002, pp. 187–209; 3 IKE, after: European
Weber, Wolfgang 13 Centre for Disease Prevention and Control. Point prevalence survey
Wiederkehr, Gido 94 of healthcare-associated infections and antimicrobial use in European
Wiegerinck 150 acute care hospitals, Stockholm: ECDC, 2013; 4 IKE, after: WHO, “My 5
World Health Organization (WHO) 23 Moments for Hand Hygiene”, WHO Guidelines on Hand Hygiene in Health
wörner traxler richter 114, 128, 161 Care, 2009. https://www.who.int/infection-prevention/campaigns/
clean-hands/5moments/en/; 5 IKE, after: Nasia Safdar and Dennis Maki,
Zollikerberg Hospital 70–77 “The Pathogenesis of Catheter-Related Bloodstream Infection with
Zollikerberg, Zollikon, Switzerland 70, 74 Noncuffed Short-Term Central Venous Catheters”, in: Intensive Care
Zukunft Bau 162 Medicine, Feb. 2004, 30(1), pp. 62–67
Zurich, Switzerland 70, 74, 158
Material Applications and Material Ageing in Hospitals, pp. 24–26
Figs. 1–8 Inka Dressler, iBMB, TU Braunschweig

B Typologies of the Patient Room

The Floor Plan of a Two-Bed Room, pp. 28–37

Figs. 1–66 Julia Moellmann

Typological Evaluation of Two-Bed Rooms, pp. 44–63

All drawings and diagrams: Julia Moellmann

Selected Case Studies, pp. 64–163

Note on the chapter Selected Case Studies:
All original planning documents have been edited and simplified for
better readability and standardisation and are shown to scale. All site
plans have been prepared by the author Julia Moellmann.

pp. 64, 65 Floor plans, from left to right: Metron Architektur AG, Brugg;
Silvia Gmür Reto Gmür Architekten; ARGE Health Team Vienna: Albert
Wimmer ZT-GmbH, Architects Collective GmbH; Silvia Gmür Reto Gmür
Architekten; Wiegerinck; Herzog & de Meuron
Trillium Health Centre, pp. 66–69
Ben Rahn/A Frame (photos 2, 3, 5–7, 9, 10); Perkins Eastman Black (plans 4, 8)

250 Appendix
Zollikerberg Hospital – New West Wing, pp. 70–73 Münster University Hospital, pp. 161–163
Hélène Binet (photos 2, 3, 5, 6); Silvia Gmür Reto Gmür Architekten wörner traxler richter (renderings, plans 2–6)
(plans 4, 7); Reto Gmür (photos 8, 9)
Zollikerberg Hospital – Renovation of East Wing, pp. 74–77 Building Structures in German Hospitals, pp. 164–167
Hannes Henz (photos 2, 4–6, 8, 9); Metron Architektur AG, Brugg (plans 3, 7) From: Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier, Andrea
Hvidovre Hospital, pp. 78–81 Haselbeck and Inka Dreßler, Bauliche Hygiene im Klinikbau. Planungs­
Thomas Hommelgaard (photos 2, 3, 5–7, 9, 10); C. F. Møller Architects empfehlungen für die bauliche Infektionsprävention in den Bereichen
(plans 4, 8) der Operation, Notfall- und Intensivmedizin (Zukunft Bauen – Forschung
Lauf District Hospital, pp. 82–85 für die Praxis, Band 13), Bonn: Bundesinstitut für Bau-, Stadt- und Raum-
ATP/Wang (photos 2, 3); ATP HAID architekten ingenieure (plans 4, 8); forschung, 2018
Ralf Dieter Bischoff (photos 5–7, 9, 10)
AZ Zeno, pp. 86–89 C Prototype of a Patient Room – the KARMIN Project
Milosz Siebert_TV AAPROG-BOECKX-B2Ai (photos 2, 5, 6, 8–10); Tim Fisher
(photo 3); TV AAPROG-BOECKX-B2Ai (plans 4, 7) Architecture of the Patient Room, pp. 170–193
Haraldsplass Hospital, pp. 90–93 Figs. 1–14, 23, 24 IKE TU Braunschweig; 15–22, 25 Julia Moellmann; 26–29
Jørgen True (photos 2–4, 6–8, 10–12); C. F. Møller Architects (plans 5, 9) Kai Lorberg (renderings); 30, 31 IKE TU Braunschweig; 32–38 Tom Bauer
Solothurn Public Hospital, pp. 94–99 (photos); 39 IKE TU Braunschweig; 40, 41, 44, 45 Tom Bauer (photos);
Ralph Feiner (photo 2); Silvia Gmür Reto Gmür Architekten (plans 3, 9); 42, 43, 46, 49, 51 Oliver Zeise (drawings)
Reto Gmür (photos 4–6, 8, 10); Yue Yin (photos 7, 11)
New North Zealand Hospital, pp. 100–103 Building the Prototype, pp. 196, 197
Herzog & de Meuron (renderings, plans 2–10) Figs. 1–8 Tom Bauer
Südspidol, pp. 104–107
3D Bakery (renderings 2, 5, 6, 8–10), ARGE Health Team Vienna: Albert Completed Prototype and Use Scenarios, pp. 198–205
Wimmer ZT-GmbH, Architects Collective GmbH (plans 3, 7) Figs. 9–29 Tom Bauer
Jugenheim District Hospital, pp. 108–111
Michael Lube (photos 2, 4–6, 8, 9); LSK-Architekten Lube | Schoppa | Furniture and Equipment, pp. 206–209
Krampitz-Mangold PartGmbH (plans 3, 7) Fig. 1 Tom Bauer; 2, 3, 4 IKE TU Braunschweig
Sana Clinic Munich, pp. 112–117
Eberhard Franke (photo 2); Christian Börner (photos 4–7, 9, 11, 12); wörner The Disinfectant Dispenser, pp. 210–223
traxler richter (plans 3, 7) Figs. 1, 2, 4–8 IKE TU Braunschweig; 3, 9 Tom Bauer; 10 IKE TU Braun-
BGU Accident and Emergency Hospital, pp. 118–121 schweig; 11, 12 Lukas Adrian Jurk; 13, 14 Tom Bauer; 15, 17 IKE TU Braun-
Rainer Mader (photos 2, 3, 8); Dewan Friedenberger Architekten GmbH schweig; 16 Lukas Adrian Jurk; 18–25 Tom Bauer (photos); 26 Lukas
(plans 4, 9); Barbara Staubach (photos 5–7, 10, 11) Adrian Jurk
Princess Máxima Center, pp. 122–127
Ronald Tilleman (photos 2, 5, 7, 8, 10, 12); LIAG architects (plans 4, 11); The Patient Bedside Cabinet, pp. 224–229
Mart Stevens (photo 9) Figs. 1–3 IKE TU Braunschweig; 4 Lukas Adrian Jurk; 5–11 Tom Bauer
St Joseph-Stift Dresden, pp. 128–131 (photos)
Christian Börner (photos 2, 4, 5, 7, 8), wörner traxler richter (plans 3, 6)
St Gallen Geriatric Clinic, pp. 132–135 The Bedside Terminal, pp. 230–236
Arno Noger (photo 2); Silvia Gmür Reto Gmür Architekten (plans 3, 8); Figs. 1, 3–5 IKE TU Braunschweig; 2, 7, 9 Tom Bauer (photos); 6, 8, 10
Ralph Feiner (photos 4, 5, 7); Reto Gmür (photo 6) Lukas Adrian Jurk
Uster Hospital, pp. 136, 137
maaars, Zurich (renderings 2, 3); Metron Architektur AG, Brugg (plans 4, 5)
Surgical Centre, Erlangen University Hospital, pp. 138–141
Albrecht Immanuel Schnabel (photos 2–4, 6–10, 12, 13); Tiemann-Petri
Koch Planungsgesellschaft (plans 5, 11)
Crona Clinic, Tübingen University Hospital, pp. 142–145
Markus Bachmann (photos 2, 4–8, 10, 11), a|sh sander.hofrichter architek-
ten GmbH (plans 3, 9)
Erasmus MC, pp. 146–149
Rob van Esch (photos 2, 3, 5, 7, 10, 11); Ronald Tilleman (photos 6, 8);
EGM architects (plans 4, 9)
Oncological Centre, Leuven University Hospital, pp. 150–153
Wiegerinck (renderings, plans 2–8)
Paediatric Clinic, Freiburg University Hospital, pp. 154–157
Zoom VP.AT (renderings 2, 4–6, 8, 9), ARGE Health Team Vienna: Albert
Wimmer ZT-GmbH, Architects Collective GmbH (plans 3, 7)
Children’s University Hospital Zurich, pp. 158–160
Herzog & de Meuron (renderings, plans 2–7)

251 Credits
Acknowledgements
A large number of people have contributed to this book over several
years with their professional and personal support. We can only mention
some of them by name here, but all these hints were valuable and helpful.

Many thanks go to Prof. Carsten Roth, the director of the Institute of

Construction Design, Industrial and Health Care Building (IKE) of the
TU Braunschweig, which has enabled us for many years to engage in
research and teaching focused on healthcare buildings. We would like
to thank our colleagues, in particular Jan Holzhausen, for their good
advice. For the support in respect to graphics and illustrations we would
like to thank Franziska Himmelreich, Jannik Siems and Giovanni Nobile.

Many thanks to the director of the Institute for Hygiene and Environ-
mental Medicine, Charité – Universitätsmedizin Berlin, Prof. Petra Gast-
meier, and her colleagues Rasmus Leistner and Elke Lemke for their
constructive advice.

Special thanks are due to the doctors, nurses, hygienists and other staff
of the hospitals we investigated, whose workplaces we could visit, who
answered our questions and participated in workshops. Thanks are also
due to several hospital planners, who provided important comments
from a planning perspective.

The point of departure for writing this book was the research project
KARMIN within the InfectControl consortium of the Federal Ministry of
Education and Research (BMBF). Our thanks goes to the association
partner Röhl GmbH, with their managing directors Nicole and Lars
Röhl and the entire team. We would like to thank for the constructive
discussions with Prof. Hortense Slevogt from the association partner
Septomics Research Group of the Jena University Hospital. Also we
would like to express gratitude to Prof. Axel Brakhage, Prof. Oliver Kurzai
and Hanna Heidel-Fischer from the InfectControl consortium for their
support and good advice.

We thank the industrial companies involved in the research project

(Atos Information Technology GmbH, BODE Chemie GmbH, Brillux
GmbH & Co. KG, Continental AG, FSB Franz Schneider Brakel GmbH +
Co KG, Hansa Armaturen GmbH, HEWI Heinrich Wilke GmbH, JELD-WEN
Germany GmbH & Co. KG, Kusch+Co GmbH, nora systems GmbH, REISS
Büromöbel GmbH, Resopal GmbH, RZB Rudolf Zimmermann, Bamberg
GmbH, Schüco International KG, wissner-bosserhoff GmbH, Villeroy &
Boch AG) for crucial comments from the planning, construction and
medical perspective, and for the provision of documents and products
for the realisation of the demonstrator.

A special thanks goes to our editor Ria Stein for her valuable proposals
and her support throughout the entire development process of the book.
We would like to thank Karen Böhme for the constructive support from
the project executing agency Jülich (PtJ).

252 Appendix
Colophon Chapter authors

Graphic design, layout and typesetting: Tom Unverzagt Overall management: Wolfgang Sunder

Translation: Julian Reisenberger A Fundamentals

The Emergence of Hospitals: Wolfgang Sunder
Copy editing and project management: Ria Stein The Nursing Ward Environment: Wolfgang Sunder
Healthcare-Associated Infections: Rasmus Leistner
Production: Heike Strempel Material Applications and Material Ageing in Hospitals:
Inka Dreßler, Katharina Schütt
Paper: 150 g/m² Condat Matt Perigord
B Typologies of the Patient Room
Printing: optimal media GmbH The Floor Plan of a Two-Bed Room: Julia Moellmann
Qualitative Evaluation of Two-Bed Rooms: Julia Moellmann
Library of Congress Control Number: 2020946436 Typological Evaluation of Two-Bed Rooms: Julia Moellmann
Selected Case Studies: Julia Moellmann
Bibliographic information published by the German National Library Building Structures in German Hospitals: Wolfgang Sunder
The German National Library lists this publication in the Deutsche
National­bibliografie; detailed bibliographic data are available on the C Prototype of a Patient Room – the KARMIN Project
Internet at http://dnb.dnb.de. Architecture of the Patient Room: Oliver Zeise
Building the Prototype: Oliver Zeise
This work is subject to copyright. All rights are reserved, whether the Completed Prototype and Use Scenarios: Oliver Zeise
whole or part of the material is concerned, specifically the rights of Furniture and Equipment: Lukas Adrian Jurk
translation, reprinting, re-use of illustrations, recitation, broadcasting, Conclusion: Lukas Adrian Jurk
reproduction on microfilms or in other ways, and storage in databases.
For any kind of use, permission of the copyright owner must be obtained.

ISBN 978-3-0356-1749-8

e-ISBN (PDF) 978-3-0356-1752-8

© 2021 Birkhäuser Verlag GmbH, Basel

P.O. Box 44, 4009 Basel, Switzerland
Part of Walter de Gruyter GmbH, Berlin/Boston

Printed on acid-free paper produced from chlorine-free pulp. TCF ∞

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9 8 7 6 5 4 3 2 1 www.birkhauser.com

253 Colophon
 BODE Chemie: driving infection prevention
Being one of Europe's leading manufacturers, BODE Chemie offers product solutions for hand and surface
disinfection, skin care and skin antisepsis. Based in Hamburg, BODE Chemie is a subsidiary of the PAUL
HARTMANN AG, Heidenheim. Jointly we offer extensive solutions for preventing infections. The high-
performance hand disinfectants are only one of the highlights within the portfolio incorporating more than
400 products, which are available in more than 50 countries around the globe.

Our mission: Going further for health –

by contributing relevant products and services!

Knowing how (and where) to use hand disinfectants

In order to protect patients against viruses and bacteria
sustainably in medical wards, hand disinfectants need to
be available whereever needed, namely at the point of care
(PoC). Hence, as part of the KARMIN project, BODE contributed
disinfectant dispensers that can be permanently installed on
the wall as well as flexible PoC dispensers. This way, hand
disinfectants can be easily placed on trolleys or patient beds:
making them a constant, readily available companion!

Empowering patients with know-how

In addition to products, BODE contributed its scientific
expertise to the project through the specialist departments
Research & Development and the BODE SCIENCE CENTER.
Why? When? How?
Both played a decisive role in the placement of the disinfectant
dispensers. In order to increase patients’ and visitors’ awareness
for the importance of hand hygiene, BODE also supplied
motivating training videos that can be integrated into the
infotainment systems at the patient bed. Each film answers
BODE’s innovative solutions for all-round infection prevention: hand
disinfectants with different efficacies for situation-specific hand disinfection, an important question about hand disinfection: Why? When?
Eurodispenser Safety Plus for fixed wall installation, Eurodispenser 3 flex And How?
as a robust and flexible companion at the point of care, as well as clear
educational videos for patients and visitors about the why, when and how
of hand disinfection.

Offering scientific-based solutions: BODE SCIENCE CENTER

The BODE SCIENCE CENTER (BSC) is our scientific centre of excellence, dealing with current issues regarding hygiene and
infection prevention. Its focus is on evidence-based solutions for a better and up-to-date protection of healthcare workers,
consumers and patients. The BODE SCIENCE CENTER is a research and training centre and
THE contact point for all those who need qualified information.

BODE Chemie GmbH

BODE Chemie GmbH
BODE Chemie GmbH
Ein Unternehmen der Melanchthonstraße 27 | 22525 Hamburg | Germany
HARTMANN
A company GRUPPE
of the Ph.: +49 (0)40 54006-0 | Fax: +49 (0)40 54006-200
HARTMANN GROUP info@bode-chemie.de | www.bode-chemie.com

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 Brillux ..more than paint
Brillux is the number one direct and full-range supplier in Germany, offering over 12,000 items in the varnish
and paint sector. The family business is in its fourth generation; it is headquartered in Münster and employs
over 2500 people. In addition to the Münster factory, Brillux manufactures at three other sites in Unna,
Herford and Malsch. The branch network covers over 180 sites in Germany, Italy, the Netherlands, Austria,
Poland and Switzerland.

Corporate responsibility, thanks to state-of-the-art

equipment and technology

Quality and environmental protection are inseparable at Brillux:

The four factories are among the most modern in Europe in
terms of equipment, technology and energy efficiency. Environ-
mentally-friendly processes such as pigging to clean conveyor
pipes bring water consumption to a minimum. A photovoltaic
plant, combined heat and power generation system plus vari-
ous means of heat recovery contribute to ensuring that energy
consumption decreases, even in the face of increasing produc-
tion. Much of the energy used for production is channeled into
heating offices, manufacturing and storage, all through heat
recovery.

Brillux is also at the forefront when it comes to its product

range. As an example, the company established itself as the first
provider to offer a complete product range of aromatics-free
enamel paints and woodstains. When it comes to manufactur-
ing water-based paints, Brillux is always one step ahead. The
company also makes an entirely preservative-free wall coating
build-up, the Vita range.

At the Brillux headquarters in Münster, Germany, research is carried out on

ongoing innovations in the field of paints and coatings, with state-of-the-art
technology.

Brillux GmbH & Co. KG

Weseler Straße 401 | 48163 Münster | Germany
Ph.: +49 (0)251 7188-0 | Fax +49 (0)251 7188-439
info@brillux.de | www.brillux.com

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 Charité Berlin RIU Plaza España Madrid
Photo: Kusch+Co & Anke Müllerklein

Mormor Aktivmöbel, Chair SITZ

Photo: Mormor Aktivmöbel

Production plant in Weißbach

With skai®, Continental has the perfect

solution for every upholstery application
The surface specialists at Continental make use of the innovative example, skai® materials with their specific properties are
power and quality commitment that skai® has stood for ideal for applications in the hospitality area, such as in hotels,
worldwide for over 60 years. As an upholstery surface restaurants and on cruise ships, and in the health sector, for
for the furniture and contract sectors, skai® is a synonym outdoor use, in public areas or in mobile interiors. Among other
for high-quality artificial leather. With innovative design things, skai® upholstery surfaces are characterised by their
tools, Continental consistently uses the new possibilities of ease of cleaning and resistance to disinfectants, so that skai®
individualisation and digitalisation. As a competent partner to Palma NF in the color inka is used for the benches and chairs of
industry, designers, planners and interior designers, Continental the “Patient Room of the Future” in the KARMIN project.
offers the right surface solution for every application. For

Continental AG
Salinenstraße 1 | 74679 Weißbach | Germany
Ph.: +49 (0)7947 81-8714
skai.interior@continental-corporation.com
www.skai.com/en/interior

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 ErgoSystem® E300: ErgoSystem® E300:
angled rail in WC area drop-down support rail in WC area

ErgoSystem® E300:
shower handrail combination,
suspended seat, shower rail

FSB 1155 lever handle, operable by hand

or also with the elbow

Door handles and sanitary equipment by FSB:

ergonomic, hygienic, safe
FSB Franz Schneider Brakel stands for design and functional for doors that are in frequent use. It can be operated by hand or
high-quality door and window fittings as well as barrier-free also with the elbow. For the best possible hold, the products of
sanitary facilities. We are your partner of choice, when it comes our ErgoSystem® E300 used in the sanitary facilities are made
to reliable, comfortable products and high-end materials. Espe- of easy-care stainless steel with oval handle cross-section: the
cially in hospitals and nursing homes, where maximum hygiene drop-down support rail and angled rail handle for the WC area,
and comfort are important, architects, planners and clients rely for the shower a shower rail mounted on the handrail combina-
on FSB products – to be haptically experienced in the KARMIN tion (including a shower head holder with one-hand operation)
patient room. The FSB 1155 lever handle is particularly suitable as well as a suspended seat and a shower curtain rail.

Franz Schneider Brakel GmbH + Co KG

Nieheimer Straße 38 | 33034 Brakel | Germany
Ph.: +49 (0)5272 608-0
info@fsb.de | www.fsb.de

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 Experts for accessibility and professional care
Making life easier for people – with individually adaptable concepts that enable independence and provide
security – that is what drives us. Universal Design incorporates the needs of all people. We have been living
this ideal for more than 35 years with our sustainable and holistic design philosophy. Outstanding design
ensues exclusively in junction with innovative technology. The combination of aesthetics, function and
hygiene is firmly anchored in HEWI's DNA.

Barrier-free furnishing concepts

S 900 – hygienic solution for the health sector

System 900 is the answer to the complex requirements for
barrier-free bathrooms. The products have been thought
through down to the smallest detail – they convince through
functionality, lasting quality and hygienic design. System 900
combines purist design with high functionality. Due to the
unique depth of the product range and its hygienic proper-
ties, it was the appropriate solution for the patient bathroom
in the KARMIN project.

Increase hygiene
For use in hospitals and rehabilitation clinics, hygiene is a deci-
sive factor in sanitary solutions. For this reason, System 900 uses
only materials that are insensitive to wound treatment agents
and cleaning products.
In the development of System 900, our product developers
focused not only on design and function but also on hygiene. The
result is a product line for the sanitary area in healthcare buildings
with the highest demands on hygiene.
Thanks to the clever design, the products are made from
as few components as possible, so that there are only a very
small number of joints. Precise manufacturing guarantees smooth,
hygienic surfaces.
The sealing element provides a quick and reliable seal between
the fastening elements and the wall. The wall brackets of the sup-
port folding handles and shower seats as well as the fixing rosettes
of the support handles and bar systems can be equipped with it.
The functions of System 900 are designed to support patients‘ independence
System 900 also includes a large number of useful accessories. in the best possible way. Modularity and surface diversity reflect HEWI‘s un-
For example, the soap and disinfectant dispensers are available derstanding of first-class design.

in different versions so that they can be filled with standard care Due to wall unevenness, the mounting rose often does not completely close off
products. The touch-free sensor versions are particularly hygienic. the wall. Reliable sealing can be achieved with the System 900 sealing element.

HEWI Heinrich Wilke GmbH

Prof.-Bier-Straße 1–5 | 34454 Bad Arolsen | Germany
Ph.: +49 (0)5691 820
info@hewi.de | www.hewi.com

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 nora systems – perfect hygiene made easy
nora systems is the global market leader for rubber floor coverings and part of the Interface Group.
With decades of experience and comprehensive know-how, nora is considered a renowned specialist in
the healthcare sector. The robust and high-performance nora® rubber floor coverings “Made in Germany”
are characterised by optimum hygiene, high comfort and enduring economic efficiency.

Specialist for floor systems in hospitals

nora® rubber floor coverings convince through well thought-

out system solutions providing the foundation for high-quality
design concepts with health- and environmentally compatible
materials. They combine safety, comfort and attractive design
with perfect hygienic properties.

nora® floor coverings are not only easy to clean but can also
be completely disinfected and are thus ideally suited for the
use in risk areas. They are free of PVC, phthalate plasticizers
and halogens. norament® 926 and noraplan® standard floor
coverings have been awarded the German ecolabel Blue Angel
(DE-UZ 120).

Clear advantages

• Simple and economical cleaning

• Hygienically perfect surfaces and joints
• No time-consuming and costly recoating and joint sealing –
usable 24/7
• Resistant to the surface disinfectants listed by VAH and RKI
• Extensive range of accessories with skirtings for areas with
high hygiene requirements
• Recommended by renowned hospital hygienists

nora systems GmbH

Höhnerweg 2–4 | 69469 Weinheim | Germany
Ph.: +49 (0)6201 806040
info-de@nora.com | www.nora.com/de

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 REISS high-quality workplace solutions
REISS Büromöbel GmbH, one of the leading suppliers of high-quality office furniture solutions in Germany,
develops and produces furniture and accessories for performance-enhancing and health-promoting
workstations that meet the highest demands of functionality and ergonomics. Driven by innovation, the
company developed an office furniture programme early on that minimises the risk of germ transmission
through direct contact with surfaces and thus contributes to workplace hygiene.

REISS offers a furnishing range which takes into account the

increasing hygienic requirements in public spaces and the
trend towards offices with rotating workplaces and co-working
spaces. Desks and storage solutions from the REISS SmartClean
series have special surfaces that minimise the transmission of
germs by touch. Thus, the furniture offers health benefits in envi-
ronments that are not subject to the intensive cleaning regula-
tions of healthcare facilities, but do have similar conditions.

A promising approach for use in healthcare

What's more, the surfaces of this furniture have excellent
mechanical properties and are resistant to most chemicals.
They are suitable for special cleaning in care and medical facil-
ities and are resistant to alcohol, aldehyde and phenol-based
disinfectants. Thanks to the zero-joint technology and the fur-
niture's sophisticated design with seamless surfaces without
handles, holes or other recesses, it is particularly easy to clean
and allows effective hygienic cleaning in environments with
high requirements, such as in hospital rooms.

Characteristics of REISS SmartClean surfaces:

• Resistance to chemicals, such as disinfectants, acids and
alkalis or solvents
• Special physical properties, such as high temperature
resistance, non-reflective properties, corrosion resistance,
liquid tightness, electrical dissipation capability
• Excellent mechanical properties, such as shock resistance,
scratch resistance and abrasion resistance
• Reduction of germ transmission
REISS SmartClean furnishing solutions – tables, cabinets and containers
REISS Products are GS-certified. They bear the RAL-UZ 38 environmental qual-
ity seal, and meet the `Quality Office´ criteria. REISS is certified in accordance
with the quality management system (DIN EN ISO 9001), the environmental
management system (DIN EN ISO 14001) and the product chain certificate
PEFC-CoC and EMAS III. The antibacterial effectiveness of REISS SmartClean
has been tested and certified according to ISO 22196: 2011-08.

REISS Büromöbel GmbH | Südring 6 |

04924 Bad Liebenwerda | Germany
Ph.: +49 (0)35341 48-360 | Fax: +49 (0)35341 48-368
info@reiss-bueromoebel.de | www.reiss-bueromoebel.de

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 Furniture in patient rooms Doors and impact protection panelling in Surfaces for wet cells
© Tim Friesenhagen hospitals © Foto Studio Wiegand

Wall claddings for surgical theatre wall

© DANMEDICS Medical Engineering GmbH

RESOPAL® – the brand, the company and the

surface, traditional and contemporary.
Resopal GmbH with approx. 600 employees in Groß-Umstadt Resopal is a reliable partner for architects and fitters in the
in Hesse produces functional and decorative high-pressure healthcare segment. Thanks to many years of experience and
laminates (HPL). The products are used for interior fittings and comprehensive product solutions, such as antibacterial surfaces
external façades, in hotels, hospitals, wet rooms, retail outlets and anti-fingerprint textures, wet room elements or customised
and furniture. We are pioneers of laminate surfaces and conti- motifs for HPL, we are an important counterpart for architectural
nue to supply trendsetting solutions for contemporary interior projects in hospitals, nursing homes or laboratories. Together,
design. we ensure that your project becomes a success.

Resopal GmbH
Hans-Böckler-Straße 4 | 64823 Groß-Umstadt | Germany
Ph.: +49 (0) 6078 800 | info@resopal.de | www.resopal.de

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 Customised prefabricated bathroom

Prefabricated bathroom with cabinet system

Prefabricated bathroom with wall surface
made of high-quality safety glass, coated
on the back

Wall protection system WC partition wall system with HPL surface Operation theatre panelling with PL surface

Röhl stands for individual integrated solutions

in cost-efficient series production
"Innovations arise from ideas but solution-oriented implemen- We do not offer run-of-the-mill standard products, but rather
tation is the key to success." The Röhl company has followed high-quality customised solutions, adapted to the requirements of
this principle for more than 75 years now. We are a family-run the client while remaining within budget. Due to our many years of
company with short decision paths and have been successful experience, as well as the high degree of system solutions and our
for more than 40 years as a system provider in the healthcare modular principle, adaptation is possible at very low cost – both
sector. Wall protection systems, OP panelling, cabinet systems, as an all-in-one system for a new building as well as in individual
WC partition wall systems and prefabricated bathrooms form components for a rapid and cost-efficient renovation.
the cornerstones of our range of services.

Röhl GmbH
Friedrich-Koenig-Straße 15–17 | 97297 Waldbüttelbrunn | Germany
Ph.: +49 (0)931 40664-0 | Fax.: +49(0)931 40664-443
karmin@roehl.de | www.roehl.de

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 RZB illuminates the "Patient Room of the Future“
In the study KARMIN, funded by the Federal Ministry of Education and Research and the Technical University
of Braunschweig, the first infection-preventive patient room was presented. RZB Lighting was involved in this
study from the very beginning as the partner responsible for planning and implementation of all lighting tasks.
In the area of "light for health and well-being", the Bamberg-based generalist for luminaires offers a broad
product portfolio of innovative and sustainable solutions.

In addition to the required provision of luminaires with hygienical

and easy-to-clean surfaces, the normative lighting of the patient
room meets all the necessary visual tasks and other important
criteria: a high level of well-being and easy orientation both for
the patients as well as for the hospital staff.

Biodynamic light for more vitality and well-being

Changing lighting moods, which correspond to the dynamic
rhythm of daylight, can positively influence the patient's sense
of well-being and vitality. Biodynamic light in the sense of
human-centric lighting also minimises the loss of the natural
day-night rhythm and promotes sleep. In the "patient room of
the future", large-format, glare-free recessed luminaires of the
"Econe" series were used. Individually preset lighting scenes e.g.
during doctor’s visits (5000 K), cleaning (4000 K) or circadian
daylight patterns from warm-white to cold-white can be selected
via an operating panel.

Guiding lights for patients

Light-directing aluminium profiles with integrated LED strips,
installed above the floor base, provide glare-free lighting and
easy orientation and thus enable the patient to see at night
when moving from the hospital bed to the bathroom. Falls due
to insufficient light are avoided, but the dimmed warm-white
LED bands do not disrupt the patient‘s night rhythm. The "Less
is more Flex" modular system from RZB offers an extensive selec-
tion of hygienic, easy-to-clean profiles, diffusers and LED strips,
including also Tunable White versions.

RZB Lighting | Highly efficient lighting solutions, progressive LED technology

and excellent product quality "Made in Germany" – the summary of over
80 years of company history. The portfolio of the family business includes
products from the fields of interior and exterior lighting, emergency lighting
and innovative lighting management systems. RZB has already received
­several the "Top 100" seal and is therefore one of the most innovative
­companies in the German medium-sized businesses.

RZB Rudolf Zimmermann, Bamberg GmbH

Rheinstraße 16 | 96052 Bamberg | Germany
Ph: +49 (0)951 7909-0 | Fax +49 (0)951 7909-198
info@rzb-leuchten.de | www.rzb.de

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 Residence in Zakynthos / © Lukas Palik Fotografie / Schüco

Schüco AWS 75 BS.HI+

Schüco – system solutions for

windows, doors and façades
Based in Bielefeld, the Schüco Group develops and sells project – from the initial idea through to design, fabrication
system solutions for windows, doors and façades. With 5650 and installation. 12,000 fabricators, developers, architects and
employees worldwide, the company strives to be the indus- investors around the world work together with Schüco. The
try leader in terms of technology and service today and in the company is active in more than 80 countries and achieved a
future. In addition to innovative products for residential and turnover of 750 billion euros in 2019.
commercial buildings, the building envelope specialist offers
consultation and digital solutions for all phases of a building For more information, visit www.schueco.com

Schüco International KG
Karolinenstraße 1–15 | 33609 Bielefeld | Germany
Ph.: +49 (0)521 783-0 | Fax: +49 (0)521 783-451
info@schueco.com | www.schueco.com

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