By Minta Ferguson, Director of Planning

We often get asked to program and design observation units for clients, whether it’s in the master planning stage or the design stage. And usually we are met with wide eyes when we start asking more about the unit’s intent and desired outcome. A common response is, “I just need an observation unit; I didn’t know it could be done so many different ways!” While some aspects of an observation unit are obvious, they’re just the tip of the iceberg with many other considerations hiding just under the surface.

To give a frame of reference, let’s review the minimum requirements. Observation units are classified under diagnostic and treatment facilities (not patient care units) within The Facility Guidelines Institute, Guidelines for Design and Construction of Hospitals, 2018 Edition. At a minimum, observation patient stations are permitted to be bays, cubicles, or private rooms, and they can be located within the emergency department. There is a minimum of three feet between the bed and fixed side and end walls/curtains, or 5 feet between beds. Additionally, it does not require private bathrooms, and some support may be shared with an adjacent clinical unit. In the big picture, or in the eyes of a patient, they aren’t in a room that is any different than the emergency department, but they may be asked to spend the night like they are in an inpatient room. This is where we must meet and manage expectations in an increasingly consumer-oriented market.

At the other end of the spectrum, a patient may be moved to an observation unit that looks like, smells like, and feels like your average medical/surgical unit, but they are receiving a level and model of care that is different. Many hospitals have a “gray area” where observation beds are mixed in with the med/surg inpatient population. It is an inpatient environment, and the staff may not be providing care any differently than they would for the 80-year-old who had a hip replacement yesterday in the room next door. It isn’t wrong; it’s just another way of managing resources and patients.

A 60-bed observation unit with rooms designed at 300 NSF, like most med/surg rooms, may not be realistic for some hospitals, nor would a unit with rooms at 150 NSF with bathrooms down the hall. So how do you know what is the right observation solution? Much of it has to do with some operational questions as well as having a good understanding of what you want your patients to experience in the process.

Below is a simple matrix of some operational and patient experience topics that affect programming and planning in different ways.

The patient experience boils down to the patient station environment. The major talking points tend to be:

  1. Private or non-private? Private rooms preferred as they create quiet and healing environments with little noise disruption and provide the most patient privacy. This decision also has a significant impact on cost.
  2. Small or large? Room size is affected by a multitude of factors, but it also has the biggest impact on the capital cost of the project as well as on annual operating costs. Larger rooms will better accommodate family and support systems.
  3. Stretcher or bed? This can come down to the ALOS of your observation patients. But if your patients spend the majority of their time in the bed, then an actual bed rather than a stretcher may provide the best results for satisfaction surveys. A minimum size room may not accommodate a patient bed.
  4. Private or shared bathrooms? Again, this can be influenced in many ways; however, patient demographics, typical diagnosis, infection control, and patient satisfaction play a large role. It also can have a significant impact on construction cost and square footage.

Some of the aforementioned key points are illustrated in two observation room scenarios below. One is an observation room that is attached to an ED, run by the ED, and is part of a 30-bed unit. The other is one that is part of a dedicated 30-bed, hospitalist-run unit with med/surg-sized rooms. Also outlined are some Rough Order of Magnitude numbers to compare the two programs, capital requirements, and continued facilities operational costs.

There are also benefits to designing the unit one way or another to be flexible in accommodating other functions in later years, such as an expansion of the ED, prep/phase II recovery unit, or converting a unit to med/surg. The bottom line is how you operate the unit, who the unit is intended to serve, and the experience you want your patients to have will collectively affect the scale and size of the observation unit.