Best Practices in the Design of Toileting and Bathing Facilities for Assisted Transfers

Types of Alternative Designs

All of the participants responded that their firms had designed facilities that incorporated bathroom designs that deviated from, or went beyond the minimum specifications in the ADA Accessibility Guidelines. Although the question was broadly posed, requesting any designs that varied from ADAAG, not only those that would promote assisted toileting and bathing, providing for caregiver assistance was the primary consideration in developing design alternatives. Moreover, the types of design solutions implemented were relatively consistent across projects.

Typical Alternatives. 
Respondents reported the following types of design alternatives:

• Water Closet: The water closet was moved further away from the sidewall (> 18+" from the sidewall to the centerline of toilet as specified in ADAAG) to provide more clearance between the sidewall and the water closet. The positioning and type of grab bars were also changed to provide more room and flexibility. Swing-away grab bars were typically located on both sides of the toilet rather than fixed grab bars on the side and rear walls as indicated in ADAAG.

• Shower: Roll-in showers were used, but sidewalls were minimized to permit access by a caregiver from outside the fixture. Built-in shower seats were typically omitted in favor of movable shower chairs or benches to provide more room and flexibility in accommodating people who required different levels of assistance.

• Bathtub: Typical residential-style bathtubs were rarely used. Whirlpool baths were generally used, although these ranged from large, institutional whirlpool tubs without grab bars for transfer to walk-in-type tubs with grab bars that were based on ADAAG.

Design Intent. 

Participants reported that each of the alternative designs was intended to provide sufficient flexibility such that both independent use and assisted use of the fixtures could be accommodated. Specific design decisions were based on a number of assumptions about the ways in which the fixtures were expected to be used. These included:

Water closet

• Increased sidewall space adjacent to toilet. Additional space between the sidewall and the water closet was intended to provide space on both sides of the fixture for a caregiver to stand alongside. This would enable caregivers to stand on either or both sides, as necessary, to provide support and assistance with transfer as well as to help with the partial removal and replacement of clothing.

• Grab bar type and positioning. With grab bars in the vertical or up position, sufficient space was provided for caregivers to stand next to the toilet on either (or both) side(s) to provide support getting on and off the toilet. In the horizontal or down position, grab bars on both sides of the toilet would permit individuals requiring assistance to maintain balance while clothing was removed or replaced. Alternatively, for individuals capable of independent transfer, grab bars on both sides would enable them to pull up to a standing position and lower down to a sitting position (Sanford and Megrew, 1996; Sanford, Echt, and Malassigné, 1999).

Shower

• Lowered sidewalls of a roll-in shower. Although not a transfer issue, lowered sidewalls were intended to facilitate assisted showering. The lowered walls would enable caregivers to reach and use a hand held shower from outside the shower to assist a care recipient. This would permit caregivers to provide assisted showering without having to get wet. Moreover, the design would work equally well for individuals who could shower independently.

Bathtub

• Grab Bars. As getting in and out of a tub is generally considered to be a falls risk for individuals, designers were not encouraged to promote independent bathing in eldercare facilities. As a result, grab bars that would permit older adults to raise and lower themselves from the bottom of the tub were not included in bathtub designs. Rather, grab bars were provided adjacent to the tub for temporary support to enable an individual to steady him/herself while a care provider assisted with removal and replacement of clothing.

• Walk-in bathtub. For individuals who had the ability to ambulate, a walk-in fixture was intended to provide a safer alternative for independent as well as assisted transfers. It was felt that assistance would be easier (and safer for both caregiver and care recipient) to provide if a care recipient was able to walk, rather than climb in and out of a tub.