Designing for spinal cord injury: for the facility wanting to manage more of these cases, some environmental reminders.

Imagine that you are no longer able to move your arms and legs, and everyday tasks have become major hurdles. Individuals who have sustained spinal cord injuries face many challenges, including such medical issues as pressure wounds and infection, loss of bowel and bladder control, and requiring ventilator-aided breathing. They may also experience low self-esteem, depression, poor body image, and tension in their personal relationships and work environments.

Spinal cord injury (SCI) can result in either paraplegia (the loss of nerve control from the waist down) or quadriplegia (the loss of nerve control from the neck or shoulders down). Paraplegia accounts for about 40% of all spinal cord injuries and quadriplegia 30%. Many patients are without upper torso control, arm and hand control, and intrinsic hand articulation.

It is estimated that between 250,000 and 400,000 individuals in the United States live with SCIs. An additional 11,000 injuries occur each year, which translates to approximately 30 injuries per day. Most of these injuries are caused by traumatic events, such as auto accidents, while some are caused by chronic healthcare issues, such as infections of the spinal nerve cells. Sixty percent of SCI patients are under the age of 30, with most being men.

Designing for SCIs

The quality of life for people with a spinal cord injury can be dramatically improved with facility design that addresses their needs. SCI patients often experience long hospital or nursing home stays, and a properly designed physical environment can positively affect patient outcomes by reducing patient stress, facilitating increased independence, and ensuring patient dignity.

Mobility and accessibility are primary concerns for people with SCIs. Manufacturers continue to develop products that address mobility and accessibility constraints. An example is flooring that meets ease of roll-ability testing standards.

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Other technology promotes additional independence, such as remote control devices to adjust artificial lighting levels, window treatments that admit or filter natural daylight, and individual thermostats to control room temperature. Sip-and-puff technology--a straw-like pneumatic switch that allows the use of one's breath to perform mouse clicks--has been developed to aid individuals with quadriplegia. The signals generated from sip-and-puff are also used in conjunction with wireless transmitters that interface with various devices to control the patient environment.

Space allocation for an SCI unit should be defined early in the planning process, since it is generally much larger than that allocated for many other programs. Space allocation within facilities should meet or exceed design guidelines set forth in ADAAG (ADA Accessibility Guidelines for Buildings and Facilities) and UFAS (Uniform Federal Accessibility Standards) (figure 1). Patients confined to wheelchairs or stretchers require additional space to maneuver. Adequate clearances for corridors and doorways must be maintained. Automatic doors should also be considered.

Wall protection should be employed to reduce damage caused by wheelchairs, stretchers, and carts. A crash rail located 8" above the floor is beneficial, as well as one located at chair rail height. This upper bumper guard may be combined with a handrail to provide additional assistance to patients traveling along corridors. In areas that experience only cart traffic, the upper rail may be eliminated. Solid sheet products installed between the upper and lower crash rails can protect this area from dents and marks caused by rolling equipment and wheelchairs.

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Making It Feel Like Home

When designing for SCI facilities, the development of a homelike environment should be the primary goal, in view of the long stays involved (figure 2). Materials and finishes that suggest a residential environment may be appropriate, but care should be taken that all components are hospital-grade and easy to maintain to ensure cleanliness and durability. Materials with antimicrobial properties are ideal because patients with spinal cord injuries are at higher risk for developing infections. The introduction of color, texture, light, sound, and smell are additional tools that may be used in the design of the SCI unit. For example, a color palette that includes warm and soothing colors has been shown to have a calming effect on patients and contribute to successful patient outcomes.

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Although staff supervision is important, bedrooms must be designed to provide privacy and dignity by shielding the patient from direct view into the room. Space requirements in the bedroom for wheelchair battery charging must be considered, in addition to adequate storage space for personal possessions. Casework should be designed to meet anthropometric standards as outlined in ADAAG, UFAS, and VA guidelines to provide patients with a high level of accessibility. Outside views and adequate lighting are extremely important (figure 3), as glare is a particular consideration for patients confined to stretchers, and exterior views may be the only connection some SCI patients have with the outside environment. The color of lighting should also be considered; for visual comfort, warm white light sources are preferable to cool white ones.

Bathrooms and grooming areas must be designed to provide privacy and dignity and must include a shower area large enough to accommodate patients who rely on equipment for mobility. Facilities for bowel care, such as conveniently located handwashing sinks, should be included. Since many patients are often confined to stretchers, adequate space should be planned for staff assistance and for maneuvering stretchers in bathrooms (figure 4). Locations of accessories such as grab bars need to be designed to accommodate the SCI patient. An example is the swing-away grab bars, which accommodate various levels of patient agility.

Artwork is a design element useful for reducing stress and providing a diversion from the sometimes difficult treatment process. Studies have proven that artwork can have a positive effect on the healing process. Artwork can be hung at standard height, which is 60" to the center of the piece, so that the environment is not noticeably different from one for patients without SCI.

The location of shared spaces should be carefully considered--for example, locating dining facilities adjacent to recreation areas. Within shared spaces, special tables can be installed that electrically lower from the ceiling, eliminating table legs and providing improved access for those in wheelchairs.

Helping Patients Recover

Treatment for SCIs falls into three categories:

Intensive rehabilitation, which patients enter after initial injury. The patient is stabilized and a rehabilitation period of four to eight months begins, with the goal of enabling the individual to return to independent living.

Sustaining care, which arises when problems develop after the individual returns to independent living. Often complications arise requiring preventive or curative treatment, such as pressure wounds and infection. Ideally, upon completion of this treatment, the individual should be able to return to independent living.

Long-term care, required when an individual (typically an older patient) is unable to live outside the SCI environment because of socioeconomic reasons or lack of community/family support.

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In general, intensive rehabilitation and sustaining care patients are mostly paraplegic, while the long-term care populations are mostly quadriplegic.

To move patients from their beds to wheelchairs or stretchers, either a portable or permanently installed patient lift system can assist staff members in helping prevent injury, both to the patient and the staff member. However, a permanently installed lift system carries implications for project cost with respect to the structure of the building, ceiling heights, and electrical systems, and these considerations must be acknowledged early to ensure adequate project funding. Other types of patient lift systems can provide a path of travel from the patient bedroom to the bathroom, as well as freedom to access all areas within each space.

Exercise areas and occupational therapy are critical to the rehabilitation of people with SCIs; they teach individuals the life skills needed to live with their injuries. These areas need to be sized to adequately accommodate equipment required in the rehabilitation process, as well as added space for patient mobility. The spaces should be flexible to accommodate evolving equipment and therapy techniques. One way to accomplish this is to colocate the various therapy programs to provide the flexibility to redistribute therapy space in the future as needed.

An "activities of daily living" program may be offered to evaluate and train patients for independent living. This area resembles a home environment and provides adequate space for staff interaction and training. Typical features of this program are a training kitchen, bathroom, and laundry.

A "home environment clinic" is a transitional area for patients moving from rehabilitation therapy to independent living. Patients and their spouses live here for one to two weeks before leaving the medical facility. This clinic is outfitted with all the amenities of a small rental apartment, and it is desirable that it have its own outside entrance to replicate the challenges the patient will face in the outside world. The home environment clinic is an extension of the activities of daily living program.

As many of these patients are confined to the facility for much of their treatment, often as long as four to six months, recreation opportunities are an important part of rehabilitation and need to be incorporated in the design of outdoor spaces (figure 5). These recreational opportunities may be either passive or active. Passive recreation includes visitor areas, separate picnic areas, games facilities, and random seating areas. Active recreation includes court games such as shuffleboard, horseshoes, and basketball. Physical activity can be accomplished through an exercise station circuit that may be used by disabled as well as able-bodied persons. The landscape, in some cases a greenhouse in both passive and active exterior spaces, can provide a connection to the outside, as well as opportunities for therapeutic gardening.

Conclusion

A design that addresses the unique nature of SCI is critical to its successful treatment. Most spinal cord injuries occur suddenly, presenting patients with unexpected physical and emotional challenges. SCI facilities can offer these patients an environment that helps to reduce the stress associated with these challenges, while accommodating rehabilitation, independence, and dignity. Research has demonstrated that the physical environment can positively affect patient outcomes in this setting. By applying design considerations that are sensitive to the special needs of SCI patients, healthcare environments can be created that support the healing process and encourage positive SCI patient outcomes.

Scott Speser, RA, LEED, is an Associate and Medical Planner with Cannon Design, based in Baltimore. For further information, call [phone] or visit www.cannondesign.com. To send your comments to the author and editor, e-mail [e-mail].

BY SCOTT SPESER, RA, LEED

Resources

Department of Veterans Affairs, Office of Facilities Management 

www.va.gov/facmgt/standard/dg_clinic.asp

National Spinal Cord Injury Association

www.spinalcord.org/html/injury.php

Paralyzed Veterans of America 

www.pva.org

SpinalNet

www.spinalnet.co.uk