Healing in the Hospital Starts With the Architect

This article appeared in the September/October 2020 issue of Discover magazine as "Architecture of Healing." Subscribe for more stories like these.

In February 2013, the Center for Care and Discovery, a 10-story hospital in Chicago, officially opened its doors. As the first patients began to stream in, they brought their microbes with them. They shed bacteria in the lobby, sprinkled viruses around the hallways, deposited fungi in their beds. And they shared these microorganisms with their fellow patients, passing them along to subsequent occupants of their rooms.

When a patient moved into a new room, their body was “actually colonized briefly [by] some of the bacteria in the room — the previous occupant’s bacteria,” says microbial ecologist Jack Gilbert, who led a yearlong study of microbes in the new hospital. And that was true even if the room had been cleaned, he says.

After one day, however, the flow of microbes reversed, streaming from the patient’s body to the surfaces in the room. Within 24 hours, the microbes on the bedrail, the faucet and other surfaces closely resembled those that the patient had brought in with them. After the patient was discharged, the cycle would repeat itself, with the room’s new resident at first acquiring the previous patient’s microbes, and then sprinkling their own microorganisms around the space: an endless game of microbial telephone.

This microbe swapping happens in all kinds of buildings. But in hospitals, where many people harbor pathogens, it can be especially hazardous. We’ve seen this happen for months now, as the novel coronavirus SARS-CoV-2 has raced around the globe, spreading in hospitals and emergency rooms. Pathogens can persist even after the patients who deposit them are discharged; when one hospitalized patient suffers from a Clostridium difficile infection, which can cause severe diarrhea and even death, subsequent occupants of the room are at increased risk for developing the same affliction.

Many inpatients have weakened immune systems or open wounds, which leaves them vulnerable to infection. The spread of antibiotic-resistant strains of bacteria and fungi is making these hospital-acquired infections, which affect 7 to 10 percent of patients worldwide, more dangerous and difficult to treat.

These challenges have prompted health care architects to start designing with microbes in mind. And beyond the spread of microbes, researchers have assembled an overwhelming body of evidence that hospital design affects patient outcomes. The right design decision can decrease stress, alleviate pain, curb infections and speed recovery. Thousands of studies have now made it abundantly clear: Good design is powerful medicine.

When administrators at the Skåne University Hospital in Malmö, Sweden, decided to rebuild their department of infectious diseases in 2005, they tried to create a building that could operate safely in what they called the “post-antibiotic era” — an age in which effective antibiotics are disappearing and epidemics can travel around the world at lightning speed.

To keep the sharing of space to an absolute minimum, the planning team decided that every patient would have a private room, which is known to reduce the spread of infectious disease. The effect can be dramatic: When Montreal General Hospital switched from shared to single ICU rooms in 2002, the rates at which patients acquired potential pathogens, including several drug-resistant strains of bacteria, fell by more than 50 percent and the average length of stay declined by 10 percent.

But the design team went further than that — they didn’t even want patients passing one another in the hallways. So they created a circular building with balconies that wrapped all the way around the patient wards on the upper floors. Each patient room has two entrances: one primarily used by staff, and the other by patients. The former opens into a corridor facing the inside of the hospital, allowing staff to bring in clean supplies and materials; the latter allows sick patients to enter individual rooms through a set of doors facing an outdoor walkway.

“You can take patients from the outside directly to their room, so they don’t sit in waiting areas coughing and having fevers,” said Torsten Holmdahl, who was the head of the infectious diseases department and involved in the planning process. The outpatient clinic and emergency department, on the first floor, also have entrances that lead directly from the outside of the hospital into private examination rooms.

Both the interior and exterior entrances open onto small anterooms, where staff and visitors can wash and disinfect their hands and don masks and gowns, if necessary. Though the evidence is mixed, some studies suggest that providing conveniently located sinks and hand disinfectant can improve staff hand hygiene, reducing the odds that clinicians transfer bacteria from one patient to another.

The anterooms, which have airtight doors, are also pressurized, which keeps contaminated air from flowing into them. “It protects the patient from the outside and it protects the outside from the patient,” Holmdahl says. The deliberately oversized patient rooms can be transformed into double rooms in the event of an outbreak or epidemic, or converted into high-risk isolation rooms by bumping up the ventilation rate and locking the anteroom doors.

The building, which opened in 2010, has been working well overall, and disease seems to spread less readily than it did in the old facility, Holmdahl told me. Though scientists haven’t formally analyzed patient outcomes, the redesign is a harbinger of a future in which architects take microbial life seriously. And it’s fitting that it’s happening in hospitals, the birthplace of a discipline known as “evidence-based design.” It expands beyond keeping patients away from others’ germs — their recovery, as well, can be greatly affected by the design of their environments.

The roots of this relatively new school of thought can be traced back to Roger Ulrich, now a professor of architecture at Chalmers University of Technology in Sweden. Ulrich’s journey to remake the modern hospital was a long and winding road. It also began with one. As a Ph.D. student in geography at the University of Michigan, Ulrich decided to focus his studies on human spatial behavior, interviewing dozens of Ann Arbor residents about how they selected their routes when driving to a local shopping center.

His subjects all lived in the same subdivision, close to a wide expressway with a speed limit of 70 mph. If they took the expressway, they could be at the shopping center in less than six minutes. But more than half the time, they chose to take a slower route — a curving, hilly parkway lined by thick groves of trees — because it was more scenic.

The finding wasn’t shocking, but at the time, it was one of the few studies to provide hard evidence for the value that people placed on natural scenery. “There was a broad sense in the humanities — and, to some degree, the social science community — that beauty was in the eye of the beholder, something impervious to scientific inquiry,” Ulrich says.

After completing his Ph.D., Ulrich continued his research at the University of Delaware, where he dove deeper into how outdoor landscapes affected people’s moods and emotions. For a study he published in 1979, he showed a series of slides to college students who’d just taken a long exam. Half the students saw slides depicting everyday nature scenes — pictures of trees and fields, for instance — while the other half viewed images of streets, buildings, skylines and other urban environments.

Those who viewed the nature scenes felt happier and less anxious after the slideshow, whereas those who saw the urban images tended to feel worse, reporting higher levels of sadness than they had before viewing the pictures. In the years that followed, Ulrich confirmed and expanded on these findings and started to contemplate their potential application. “Is this of any use?” Ulrich wondered. “Where is a large group of people in our society who are experiencing considerable stress for a period of time? The obvious answer was hospitals.”

Ulrich knew that firsthand. He had been a sickly kid, a magnet for Streptococcus bacteria. “I had an unfortunate gift for getting strep throat all the time,” recalled Ulrich, who grew up in southeastern Michigan. Sometimes the strep triggered nephritis, an inflammation of the kidneys. As a result, he became fairly intimate with America’s health care system. “I was quite tired and had all kinds of hospital and office visits, and they were often in pretty brutal circumstances,” he said. “They were sterile and emotionally cold — often modernist and functionally efficient but emotionally unsupportive.” He much preferred recuperating in his bed at home, taking great comfort in the towering pine tree that stood outside his window.

As he thought back to that pine tree, an idea began to form: He’d find a hospital where some patients had views of the natural world and other patients didn’t and compare how they fared.

Ulrich traveled up and down the East Coast before he found a 200-bed hospital in Pennsylvania that he thought would be the perfect setting for his study. In one wing of the hospital, the patient rooms were almost identical, except for the view: Some looked out onto a small cluster of trees, while others overlooked a brick wall. “It was pretty close to being a natural experiment,” Ulrich recalls.

Ulrich analyzed the medical records of 46 patients who’d had their gallbladders removed at the hospital between 1972 and 1981. “It turned out that there was a big effect on [the patients’] pain,” Ulrich said. On average, the patients who had nature views — about half of the total sample — needed fewer doses of narcotics than those who looked out onto the brick wall. They were also discharged from the hospital about a day sooner.

At the time, health care architects relied more on instinct than evidence and rarely returned to the hospitals they’d designed to see how well they were working. “It seemed like there was an absence of rigorous research on health care environments and how they influence clinical outcomes,” Ulrich says. “The thought occurred to me, ‘No wonder hospitals are badly designed.’ ”

Ulrich’s study, which was published in Science in 1984, is frequently cited as the beginning of a new era, the birth of what became known as evidence-based design. Doctors took an oath to do no harm — shouldn’t health care architects do the same thing?

In the years since, researchers have discovered numerous ways to improve the hospital environment. Many expanded on Ulrich’s initial findings, providing even more proof of the healing power of nature. Nearly any kind of nature, they found, seems to do the trick.

In the early 1990s, Ulrich reported that heart-surgery patients who’d been randomly assigned to gaze upon nature images had less post-operative anxiety and required fewer doses of strong painkillers than those who viewed abstract art or no images at all. Other researchers found that patients who looked at a mural of a meadow and listened to nature sounds reported less pain while having bronchoscopies, and that nature videos reduced anxiety and pain in burn patients who were having their dressings changed. Indoor plants can be beneficial, too; surgical patients with plants in their rooms have lower blood pressure, report less pain and anxiety and use less pain medication than those in plant-free rooms.

But what makes nature so potent? Ulrich believes the answer lies in what’s known as the biophilia hypothesis. The hypothesis, formulated by the famed entomologist E.O. Wilson, holds that because of how we evolved — out in the rough-and-tumble of nature — we have an innate affinity for the natural world. So natural settings and images catch our eye and engage us, cheering us up and taking our minds off our pain and anxiety.

“Nature can be quite effective in distracting people in a nontaxing, nonstressful, restorative way,” Ulrich explains. And in the context of hospitals, it could mean the difference between a speedy recovery or a long, laborious one.

Excerpted from: The Great Indoors: The Surprising Science of How Buildings Shape Our Behavior, Health, and Happiness by Emily Anthes. Published by Scientific American/ Farrar, Straus and Giroux, June 2020. Copyright © 2020 by Emily Anthes. All rights reserved.