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

Final Report

August 1, 2001

Jon A. Sanford, Project Director
Atlanta Research and Education Foundation

Prepared for:
US Access Board

The products shown in this report are only intended to serve as illustrated examples and are not intended as endorsements of the products. Other products may be available. The Access Board does not evaluate or certify products for compliance with its accessibility guidelines. Users are advised to obtain and review product specifications for compliance with the accessibility guidelines. 

Background

Although the Americans with Disabilities Act Accessibility Guidelines (ADAAG) were initially issued in 1991, many of the guidelines were based on design standards for people with disabilities that were developed almost two decades ago. In the time since the development of these early requirements, the demographics of the population of people with disabilities have changed dramatically. People are growing older and a larger number of individuals are living longer with disabilities (Bureau of the Census, 1992; Chirikos, 1986; Colvez & Blanchet, 1981, Jones & Sanford, 1996; Kunkel & Applebaum, 1992; LaPlante, Hendershot, & Moss; 1992; Zola, 1993). As a result, individuals’ functional abilities may not be served by existing design guidelines. A number of researchers, including Czaja (1984), Faletti (1984), Sanford, Echt, & Malassigné (1999), and Steinfeld & Shea (1993), have argued that accessibility standards, based primarily on the capabilities of young people, may not compensate adequately for range of comorbidities and secondary conditions that are common among older people with disabilities. In fact, adhering to accessibility codes may do more to promote excess disability among older people than to ameliorate it (Sanford, Echt & Malassigné, 1999; Sanford & Megrew, 1995). This suggests that alternative guidelines based on the needs and capabilities of elderly individuals should be established, particularly in buildings used primarily by older people (e.g., residential care facilities, senior centers and independent living facilities).

Access to toilet and bathing facilities is clearly an area in which research data suggest that a review of ADAAG specifications is needed. For example, Sanford, et al. have previously reported (1995, 1999) that the preferred ADA toilet configuration does not work as well as it should for the majority of older adults, including both those who stand to transfer, as well as those who transfer directly from wheelchair to toilet. In these studies, subjects who stood to transfer consistently reported that the preferred ADA configuration was the most difficult to use, whereas grab bars on both sides of the toilet, such as the alternative ADA configuration were easiest to use. In contrast, older respondents who were nonambulatory reported that all of the configurations (including the preferred and alternative ADA configurations) were equally difficult.

However, previous studies focused only on independent transfer, which is the underlying presumption in ADAAG. Unfortunately, many older people lack the upper body strength to pull themselves out of a wheelchair or have problems raising and lowering themselves onto a toilet even with the assistance of grab bars. Therefore, many individuals may require person-assisted transfers, regardless of the grab bar configuration.

Prior research suggests that some toilet and grab bar configurations that were the most radical departures from ADAAG (e.g., swing-away grab bars) were not only associated with greater safety and ease of independent transfer, but also potentially offered greater flexibility in facilitating assisted transfers. This suggests that alternative designs that can accommodate both individuals with disabilities as well as those who provide assistance to them need to be identified, particularly in the design of facilities that will be used mainly by older adults.

PURPOSE OF THE PROJECT

ADAAG was developed with the intention of providing greater access for individuals with disabilities. These guidelines, as most other accessibility codes, standards, and guidelines, are generally based upon the stature, strength, and abilities of younger adults. Little consideration has been given to the needs of frail individuals and those requiring assistance from caregivers. This is particularly true of the majority of users in health care and long term care facilities. Therefore, the specific objective of this project was to identify and analyze best practice exemplars of design solutions that accommodate assisted use of toilet and bathing fixtures. This information is intended to assist the Access Board to identify, understand, and evaluate key issues and features.

Methodology and Data Analysis

Data Collection
Best practices design solutions were identified from several sources including expert informants who were involved in the design or implementation of innovative solutions and archival data that documented innovations.

Expert Informants
Selection of Participants.
A comprehensive search of design and or provider organizations in the forefront of the design of residential and institutional environments for individuals who may require assistance with toileting and bathing was conducted. The search included traditional bibliographic databases to identify sources within the design and gerontological literature; online searches of designs and innovative products for people requiring assistance with transfers; interviews with major providers of eldercare facilities, including Manor Care and Sunrise Corporation; attendance at major aging conferences (i.e., AAHSA, ASA, and GSA) to solicit participation from exhibitors; recommendations from nationally-known design for aging experts (Maggie Calkins, IDEAS, Chardon, Ohio; Marc Warner, Ageless Designs, Jupiter, FL; and David Hoglund, AIA, Perkins Eastman & Partners, Pittsburgh) as well as staff at relevant organizations such as the Center on Aging, University of Wisconsin, Milwaukee; AAHASA; and the Center for Universal Design, NC State University; and recommendations for residential construction from members of the home modifications listserv sponsored by SUNY Buffalo.

Selecting potential participants was difficult. Although a large number of health and care providers as well as architectural and interior design firms specialize in Assisted Living and other Long Term Care options, most hadn’t really addressed toileting and bathing beyond the requirements in ADAAG. Nonetheless there were a few firms that were very interested and knowledgeable about the problem; and had actually done some things to accommodate assisted transfers. In addition, designs used by the major development corporations like Manor Care and Sunrise, didn’t really offer any alternatives to ADAAG either.

Individuals/firms that agreed to participate in the project included:

Senior Living (Independent, Assisted Living, & Extended Care)

• Gregory Scott - Reese, Lower, Patrick & Scott (RLPS) Architects, Lancaster, PA

• Gaius Nelson - Nelson Tremain Partnership, Minneapolis, MN

• Peter Wilson - Cochran, Stephenson, & Donkervoet Inc., Baltimore, MD (architects and interior designers)

• John Capelli - Ewing Cole Cherry Brott (ECCB), Philadelphia PA

• Robert Pfauth - O'Donnell, Wicklund, Pigozzi & Peterson (OWP&P)Inc., Chicago, IL

• Cornelia C. Hodgson - Dorsky Hodgson + Partners, Inc., Cleveland,OH

Residential (single- and multi-family)

• Alan Browne - Extended Home Living Services, Wheeling, IL

• Dick Duncan - Center for Universal Design, NCSU, Raleigh, NC

• Louis Tenenbaum - Baltimore, MD

Healthcare Facilities

• Roland Binker - Ellerbe Becket, Washington, DC

Participant Interview.
Each of the participants selected was contacted to inquire about their willingness to participate. All of those contacted agreed to participate, although not all ultimately responded. Design architects were asked to respond to a short interview to obtain detailed text and graphic information about the design solutions that each was using to accommodate assisted toileting and bathing and for whom (see Attachment A).

The information collected included the location of and approach to water closets, transfer and roll-in showers, and bathtubs; space requirements at fixtures; support and transfer devices and methods, including grab bars, lifts, shower chairs, and other hardware and devices that facilitate fixture use; assistance methods, usability with and without assistance, and such other information as may be necessary to fully describe the layout, use and rationale for the design approaches identified.

Archival Data
A comprehensive search of information sources believed to be relevant to assisted toileting and bathing was also undertaken to identify innovative architectural designs and products (e.g., tubs, showers, toilets). The search included three types of information sources: 1) electronic databases and bibliographical indices of periodicals [e.g., Avery Index of Architectural Periodicals, e-architect, Educational Resources Information Center (ERIC), and REHABDATA operated by the National Rehabilitation Information Center (NARIC)]; 2) published materials (journals, books, conference proceedings); and 3) online keyword searches of Yahoo, Netscape, Lycos, and Hotbot. These searches focused primarily on identifying featured and award-winning designs. The presumption was that these designs were considered to be exemplary according to some criteria.

Keywords used in information searches included the following:

Sources that were considered useful were those that contained information on bathroom designs and products that were not typical ADA designs. In addition, information was gathered regarding the: characteristics of those subpopulations for whom the designs were intended, how the designs were intended to be used, and the types of facilities in which they were used.

DATA ANALYSIS

Archival and interview data were analyzed to determine trends and differences in design approaches. In addition, supporting documentation of architectural and product design solutions were evaluated to determine appropriate applications for each solution and the advantages and disadvantages of each.

Results

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.

Users and Needs

Facility Types and User Profiles.  
Many of the facilities reviewed were healthcare and residential facilities specifically designed for older adults. This approach was purposeful as users of these facilities often require the assistance of caregivers and therefore may have accessibility requirements that are different from those specified in ADAAG. The potential need for alternative designs is outlined in the draft AIA Guidelines (2001) that were approved in a final committee vote. The guidelines state:

It shall be recognized, however, that the users of hospitals and health care facilities often have very different accessibility needs from the typical adult individual with disabilities addressed by the model standards and guidelines... Hospital patients, and especially nursing facility residents, due to their stature, reach, and strength characteristics, typically require the assistance of caregivers during transfer maneuvers. Many prescriptive requirements of model accessibility standards place both older persons and caregivers at greater risk of injury than do facilities that would be considered noncompliant. Flexibility may be permitted for the use of assistive configurations that provide considerations for transfer assistance.

Users of healthcare and eldercare facilities often have mobility problems, use wheelchairs and walking aids, and suffer from incontinence. Therefore, toilet and bathing fixtures in these facilities were intended to accommodate older people who had many different types of impairments and comorbidities, including limitations in reach, difficulty lifting legs, and difficulty with sit-to-stand; who used devices for assistance with ambulation; and who could transfer either independently or with assistance.

Generally, the severity of disability was expected to increase as a higher level of care was provided. For example, independent and congregate living facilities designed by OWP&P, were expected to accommodate people with mobility disabilities due to physical frailty, stroke, and arthritis. In contrast, skilled nursing facilities, such as those designed by ECCB, were expected to accommodate people who were generally frail due to arthritis and other age-related conditions, people with later stages of dementia, people aging with a disability, and subacute patients.

Meeting User Needs

The primary goals of the alternative designs were to accommodate independent transfer and use of a toilet, tub, or shower as well as assistance by as many as two care providers. Moreover, the designs were intended to prevent and/or reduce injuries to all users, both elders and care providers and to permit ease of access by individuals with many types of impairments.

Despite the expected variations in types of impairments as well as differences in severity of disability among the different levels of care, designers presumed that most older people in these facilities had the capability of supporting their own weight and pivoting on their feet during transfers. As a result, grab bars on both sides of a toilet that would support a standing transfer were provided rather than alongside and behind the toilet as would be used for a sliding transfer. Moreover, the same grab bar placement could be used to accommodate people with both right and left hemiplegia (often associated with stroke in older individuals). In fact, this alternative added sufficient flexibility to accommodate independent and assisted transfers that it also was used in non age-segregated healthcare facilities, such as Beechwood Home in Cincinnati, OH, (Dorsky Hodgson and Partners) to accommodate both younger and older adults with Multiple Sclerosis, Cerebral Palsy, and spinal cord injuries.

In facilities where people with cognitive impairments are prone to incontinence, the location, frequency, and visibility of toilet facilities were considered as important as their physical design. Toilets were often located to enable older individuals to easily see them. For example, layout of the bathroom in many of OWP&P’s projects was designed to maximize visibility of the water closet from within the sleeping room as a cueing device to encourage frequent toileting. Bathing fixtures that were familiar, non-threatening, and comfortable were selected to reduce agitation. Faucet controls were placed out of reach of the cognitively impaired individual or designed to prevent accidental injury. Finally, bathing fixtures were designed to provide ready access to all areas of the bather’s body without excess strain on the caregiver.

Design Specifications

Water Closets (ADAAG 4.16)

4.16.2 Clear Floor Space.

In order to accommodate independent wheelchair use, guidelines for clear floor space in ADAAG vary according to path of approach to the toilet. However, in accommodating assisted transfers, these guidelines were less of an issue than providing space adjacent to the water closet for caregivers and including a 5’ turning radius in the room for wheelchair maneuvering. As a result, toilet room configuration and location of the water closet were the critical design considerations in assisted transfers.

Toilet Room Configuration.

The most common practice among the innovative designs was the placement of the bathroom located in a corner of a resident room with an out-swinging bathroom door oriented at 45⁰ to the resident room. The 45⁰ angle facilitated maneuvering by eliminating the need for sharp turns in small spaces. In addition, the location of the door also permitted the toilet and lavatory in many facilities to be located at right angles to each other. This configuration provided room for a 5’ wheelchair turning radius as well as sufficient room for assistance on both sides of the toilet. Furthermore, the out-swinging door not only permitted a 5’ turning radius in the toilet room, but also facilitated entry by staff in the event of a resident fall or other incapacity inside the room that might block the door. This basic configuration was found in numerous facilities including: a nursing care addition at Pennswood Village Retirement Community, Newton, PA (Lewis and Rodgers Architects, Fort Washington, PA) (Figure 1); Bridges Medical Services, Ada, MN (Horty, Elving & Associates, Inc., Minneapolis, MN) (Figure 2); and The Heritage at Landis Homes Retirement Community, Lititz, PA, (RLPS) (Figure 3).

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Figure 2. Toilet Room Configuration at Bridges Medical Services, Ada, MN (Horty, Elving & Associates)

Figure 3. Toilet Room Configuration at The Heritage at Landis Homes Retirement Community, Lititz, PA(RLPS)

Water Closet Location. 
In contrast to ADAAG, which specifies that the centerline of the toilet shall be located 18" from a sidewall, every innovative design located the toilet further away from the sidewall in order to provide space for caregivers to stand alongside one or both sides of the toilet. However, without research data upon which to determine how much space was adequate, side clearance varied, usually dependent on the amount of space available within the overall design of the room or facility. Although 24" seemed to be the norm, the location of the toilet ranged from as little as 22" to as much as 30" from the sidewall.

For example, at two skilled nursing facilities, one for people with Multiple Sclerosis, Cerebral Palsy, and spinal cord injuires (Beechwood Home, Cincinnati, OH) and one for frail older adults (The Ledges at Rockynol, Akron, OH), Dorsky Hodgson and Partners located the toilet with the centerline 24" from the closest sidewall. In addition, at Beechwood Home where the lavatory was located adjacent to the toilet on the opposite side, the rear wall behind the toilet was pulled out so that the back of the toilet was not in the same plane as the lavatory. This effectively pulled the toilet out in front of the lavatory, thus preventing the latter from interfering with assistance on that side of the toilet (Figure 4).

Figure 4. Water Closet Location at Beechwood Home (Dorsky Hodgson and Partners)

In contrast, at Covenant Oaks at Oakwood Village, a dementia-specific assisted living facility in Madison, WI, OWP&P was only able to provide 22" from the sidewall to the centerline of the toilet (Figure 5). Although more space was preferable, it was not available in this facility. Nonetheless, this deviation from ADAAG as well as Wisconsin’s accessibility code was requested by the owner to facilitate assisted transfers and required a variance from the City of Madison.

Figure 5. Water Closet Location at Covenant Oaks at Oakwood Village, Madison, WI (OWP&P)

The general sentiment among designers was that more space was better. As a result, a number of projects (Figures 6-8) were designed to provide more than 24" of space for assisted transfer. In facilities designed by Nelson Tremain Partnership, 30" between the wall and toilet was the design goal. However, due to space limitations, that goal is difficult to achieve. At Creekview at Evergreen Retirement Community in Oshkosh, WI, 26" was available (Figure 6), while at Village Shalom, a nursing home in Overland Park, KS, only 24" was available (Figure 7). Twenty-four inches between the side wall and toilet was fairly common. For example, at Memorial Hospital of Martinsville and Henry County (Martinsville, VA), Ellerbe Becket provided 24" between the wall and the side of the toilet on each side at the request of nursing staff at the facility (Figure 8). Staff felt that 24" would provide sufficient space for them to fit on both sides of the toilet and still permit a patient to reach the wall-mounted toilet paper holder without falling off the toilet.

Figure 6. Water Closet Location atCreekview at Evergreen Retirement Community, Oshkosh, WI (Nelson Tremain Partnership)

Figure 7. Water Closet Location atVillage Shalom, Overland Park, KS (Nelson Tremain Pertnership)

Figure 8. Water Closet Location at Memorial Hospital, Martinsville, VA (Ellerbe Becket)

 The most unique concept was that of a "training toilet" developed by OWP&P based on the European model of "bathroom as shower room." Ostensibly, the idea of the training toilet was to circumvent the limitations of accessibility requirements, by designing bathroom facilities that were intended for training residents rather than for their actual use. Training toilets were either located in a separate room as a unisex toilet or combined with a bathing facility, for use by staff in retraining residents in toileting skills. Typically, these designs included swing away grab bars on both sides of the water closet and up to 3 feet of clearance on either side. As a result, the floor area needed for a "training toilet" was substantially more than for a conventional ADA-compliant toilet room. When this configuration was used at the Memory Loss Unit, a dementia care assisted living facility at C.C. Young Retirement Community in Dallas, TX (Figure 9), it was challenged by both the Dallas Building Department as well as the reviewer for compliance with the Texas Accessibility Standards (TAS). Approval was granted when it was demonstrated that other readily available toilet rooms complying with ADAAG and TAS were provided.

Figure 9. Water Closet Location at Memory Loss Unit at C.C. Young Retirement Community, Dallas, TX

4.16.3 Height.
All of the institutional designs included a raised toilet within the 17"-19" range allowed by ADAAG. Although the seat height did not differ from ADAAG specifications, the reasons for a higher seat did differ. Whereas the rationale for seat height in ADAAG is to provide a surface that is at or slightly below the wheelchair seat in order to accommodate a sliding transfer, the rationale in eldercare facilities was to minimize the distance individuals had to be lowered down or raised up. It is important to note that although designers knew that a higher seat was necessary, there was no data to suggest what the optimal seat height might be. In the absence of data, the 17"-19" range for seat height was selected to comply with ADAAG.

4.16.4 Grab Bars.
Among the various specifications for grab bars in general, including diameter, spacing, and structural strength (ADAAG 4.26) and for toilets in particular, including length and positioning, only the latter two were adjusted to accommodate assisted transfers.

Positioning. According to ADAAG, positioning is dependent on two factors, height and location of grab bars, both of which were altered by designers to better accommodate an older population.

Height. Only two firms, OWP&P and Nelson Tremain Partnership specifically addressed the issue of height. OWP&P used the high end of ADAAG (33") whereas Nelson Tremain used 10" above the seat height. Although OWP&P did not deviate from ADAAG, the intent was to account for the reduced stature of many older adults as well as to optimize their potential leverage. The maximum height in ADAAG was used because there was no other objective information available upon which to base a decision on effective height for assisted transfers.

In contrast, Nelson Tremain, in the absence of objective data, rationalized that height of toilet grab bars be based on the distance between the seat and arms of a chair. Thus, they decided to locate the bars 10" above the height of the toilet seat, whereas ADAAG permits grab bars 14"-19" above the seat. Although there is no evidence to support this rationale, common sense suggests that lower grab bars would enable caregivers to lean over the bars to provide assistance as well as permit individuals to be able to push up more effectively from the toilet.

Location. The ADAAG L-shaped grab bar configuration that includes a bar on the sidewall and one on the rear wall behind the toilet was consistently considered inadequate to meet the needs of people requiring assistance. As Gregory Scott, AIA, partner in RLPS, responded:

"…the major challenge with the implementation of ADAAG, is not with excessive space requirements or even required clearances; but more with achieving non-institutional appearances and being required to install assistive devices, such as wall-mounted grab bars at toilets, that serve no useful purpose for our age group [persons 78+ years of age]. We often end up installing redundant grab bars; one set to meet guidelines, the other set to meet the true needs of the resident. We are discovering that grab bars mounted at the recommended heights and distances from the toilet, both side and rear locations , are too far away to be effective for ‘self’ assistance. The seat mounted grab rail or fold-away models can place the ‘assistance’ where it is useful."

Subsequently, the rear grab bar behind the toilet was omitted in all configurations intended to accommodate assisted transfer. Similarly, the sidewall grab bar was often omitted. When this grab bar was used (e.g. Memorial Hospital of Iowa County, Dodgeville, WI, Nelson Tremain Partnership), it was intended to be used as a support for a standing individual during dressing and a swing away grab bar was provided on the opposite side of the toilet (Figure 10).

Figure 10. Grab Bar Location at Memorial Hospital of Iowa County, Dodgeville, WI (Nelson Tremain Partnership)

Figure 11. Location of Swing Away Grab Bars (Linido grab bars pictured here)

Rear-mounted (either floor or wall), swing away (or fold up) grab bars (e.g., Linido or Bobrick) on both sides of the toilet were the most popular configuration to accommodate one or two person-assisted transfers as well as independent toileting (Figure 11). Those designs that did not utilize these grab bars either used straddle bars (non-movable) that flanked both sides or simply applied ADAAG for compliance purposes and then added additional grab bars to meet the needs of the clients. Rob Pfauth, AIA, a design architect at OWP&P stated that:

"grab bars on both sides of water closets that either swing up or away obviously afford the ability for one or more caregivers to stand beside the resident and brace them while mounting or dismounting the toilet. Yet these grab bars, when in the extended position alongside the water closet provide superior leverage to the frail older adult, dependent on his or her waning upper body strength, in lowering or lifting themselves during independent toileting. Installing grab bars on both sides is important, particularly for stroke victims with hemiplegia, as a conventional sidewall grab bar on the "wrong" side is virtually useless for transferring."

Length. Whereas none of the respondents specifically addressed the issue of grab bar length, drawings submitted clearly indicate that many of the alternate swing away grab bars were considerably shorter (usually 24"-30") than the 42" minimum requirement for grab bars alongside the toilet (Figure 12). As these bars were used by individuals who often had unsteady gait and were at risk of falls, the shorter bars were likely to have been used to enable both older individuals and caregivers to get as close to the toilet as possible and thereby minimize ambulation.

Figure 12. Length of Grab Bars

4.16.5 Flush Controls.
None of the respondents indicated that there were any variations from ADAAG regarding flush controls.

4.16.6 Dispensers.

Few of the respondents specifically addressed the issue of dispensers, even though increasing the distance between the sidewall and the toilet would suggest that locating dispensers on the sidewall within 18" of the centerline of the toilet (as specified in ADAAG) was not possible. However, Roland Binker of Ellerbe Becket, indicated that nursing staff at Memorial Hospital of Martinsville and Henry County (Martinsville, VA), felt that 24" would provide sufficient space for staff and still permit a patient to reach a wall-mounted toilet paper holder without falling off the toilet. Alternatively, Horty Elving and Associates used a toilet paper holder at the end of each swing-away grab bar (e.g., Figure 11) at Bridges Medical Services, Ada, MN (Horty, Elving & Associates, Inc.), a facility that received a Best in Category by Design ‘99 Awards sponsored by the AIA and AAHSA. A second alternative, used at Creekview at Evergreen by Tremain Nelson Partnership, was to locate a dispenser for caregiver, rather than for user convenience. As a result, the dispenser was located 24" above the floor, 5" higher than the minimum height in ADAAG, and 42" from the rear wall (Figure 13), which would have been too high and too far in front of most older users for them to reach safely.

 Figure 13. Location of Dispenser at Creekview at Evergreen, Oshkosh, WI (Nelson Tremain Partnership)

Bathtubs (ADAAG 4.20)

ADA Accessibility Guidelines for bathtubs are predicated on the use of a conventional residential bathtub by individuals who independently transfer from a wheelchair directly to a tub seat. However, most eldercare facilities used larger whirlpool baths not conventional residential tubs. Moreover, frail older adults usually have the ability to stand. Therefore they are more likely to transfer into the tub from a standing position regardless of whether they used a wheelchair, walking aid, or no aid at all. Nonetheless, because stepping over the side of the tub as well as lowering down and raising up from the bottom of the tub is a potential safety risk for these individuals, designs were based on caregivers providing assistance and supervision during transfers and bathing. Resident lifts, which are an alternative means of safely transferring an individual into a tub, were generally discouraged, particularly among people with dementia because the experience of being lifted off the ground and lowered into a tub can be a terrifying one for them. However, for more acute populations including a lift was sometimes unavoidable.

4.20.2 Floor Space.

The amount of clear floor space in front of a bathtub required by ADAAG (30"-48" min depth depending on the direction of travel by the length of the tub including a seat at the head of the tub) is based on positioning a wheelchair along side the fixture for a sliding transfer. However, because frail older adults do not perform sliding transfers, clear floor space in eldercare facilities was needed for one or more caregivers to be able to assist with getting in and out of a tub. This not only affected the size of the space, but also where the space was needed.

Therefore, residential tubs that are only accessed from one open side, were typically designed with one end against a wall and 3 open sides from which assistance could be provided. Because wheelchair maneuverability was not an issue, less space was needed on any one side. However, more space was needed overall to accommodate caregiver access from more than one side.

4.20.3 Seat.

As tub seats are intended to keep users from being immersed, the use of tub seats defeated the purpose of providing a whirlpool bath. As a result, tub seats were not provided in conventional whirlpool bathtubs, although they were used in walk-in fixtures (see Alternative Designs below).

4.20.4 Grab Bars.

ADAAG specifications for grab bars vary slightly for bathtubs with in-tub and head of tub seats (the latter having longer bars on the sidewall and no bar on the head wall). Nonetheless, in both conditions, grab bars are located to help individuals get into the tub and then to lower and raise themselves to and from a seated position. Because these positional changes were deemed safety risks for older adults, grab bars that would permit older adults to raise and lower themselves were not included in most bathtub designs (see Alternative Designs below). Rather, in most designs, 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. In fact, in instances where local building authorities required bathing fixtures with ADAAG compliant grab bar configurations, roll-in showers were installed instead due to safety concerns, even though the former were readily available from a number of manufacturers.

4.20.5 Controls. 

None of the respondents indicated that there were any variations from ADAAG regarding controls.

4.20.6 Shower Unit. 

None of the respondents indicated that there were any variations from ADAAG regarding the shower unit.

4.20.7 Bathtub Enclosures.

None of the respondents indicated that there were any variations from ADAAG regarding the enclosure except for the walk-in fixture described below.

Alternative Designs.
One alternative design that was used by OWP&P for less frail, ambulatory individuals was the Kohler "Precedence" bathtub (Figure 14). The tub has a non-institutional appearance, a fold-down seat, and a swinging side entry door with a pressurized seal for ease of access. Similar "walk-in" units, although slightly more institutional in appearance, are made by Arjo ("Freedom" tub) and others. The walk-in capability makes this fixture suitable for either independent or assisted use by individuals with a reasonable level of mobility. In addition, the fixture is also taller than most average bathtubs (24" above the finished floor) which permits immersion in the water even when using its fold-down seat. Whereas the added height and side-entry features address the primary shortcomings of a traditional tub, they also create the two shortcomings of this tub. First, it must be drained to open the door to exit the fixture. As a result, an older individual who can only get out through the door must sit in the tub until it is drained. Second, the tub does not meet ADAAG grab bar provisions. The 24" high sides make it impossible to install the two grab bars on the back wall in the manner prescribed in ADAAG. As a result, in facilities where this fixture (Figure 15) was used, one of the back wall bars was eliminated in order to comply with the distance of 9" from the rim of the tub and 33" –36" distance from the floor to the grab bar. In addition, OWP&P placed a low wall surrounding the tub on one or more sides (usually the foot end and/or the long side opposite the entry). Although this increased the overall space requirement for the bathing room, it provided easier access by a caregiver to assist in the bathing process, enabling them to sit on the wall as well as reach over it.

Figure 14. KohlerPrecedence Bathtub

Figure 15. Bathtub Configuration at Memory Loss Unit at C.C. Young Retirement Community, Dallas, TX (OWP&P)

Shower Stalls (ADAAG 4.21)

Although ADAAG permits both transfer and a roll-in showers, roll-in showers were found in institutional facilities. As a result, design of shower stalls was intended to accommodate caregiver assistance with washing, rather than assistance with transfer into the fixture.

4.21.2 Size and Clearances.

Minimum guidelines for roll-in shower stalls are based on residential size fixtures (30" x 60" minimum or the space used by a standard residential tub/shower unit) and spaces (30" minimum depth by the length of the shower, but not less than 48"). Institutional showers exceeded the minimum stall dimensions. However, because users were not expected to independently maneuver their wheelchairs, the critical issues regarding floor space both outside and inside the shower were the amount of space available for caregivers to provide assistance. Outside, the shower space was needed for one or more caregivers to help an individual who needed a shower chair to get into and out the chair. Inside the shower, space was needed to provide assistance with showering without getting wet. To this end, several projects incorporated a half height wall to enable a caregiver using a hand held shower to stay dry while standing behind a resident seated in a shower chair.

4.21.3 Seat.

Seats are only required in transfer showers, which were not used in any of the designs reviewed. When seats were used in roll-in showers, 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.

4.21.4 Grab Bars.

ADAAG specifies grab bars on the three walls of a roll-in shower stall, 33"-36" above the floor. The plans reviewed offered little insight as to placement of grab bars in showers. In fact, information about grab bars tended to be contradictory. On the one hand, transfers are typically only made into shower chairs outside the shower and with a caregiver’s assistance. As a result, grab bars in the shower may not be necessary and their placements can be a deterrent to the required maneuvering room needed by caregivers. On the other hand, grab bars provided according to ADAAG are insufficient for independent use of the shower. As a result, more bars, particularly vertical ones, and in different configurations than specified in ADAAG were often installed. However, the location and orientation of grab bars were dependent on the type and size of shower provided.

4.21.5 Controls.

None of the respondents indicated that there were any variations from ADAAG regarding the controls.

4.20.6 Shower Unit.

None of the respondents indicated that there were any variations from ADAAG regarding the shower unit.

4.21.7 Curbs. 

All of the designs reviewed were curbless, roll-in showers.

4.21.8 Shower Enclosures.

None of the respondents indicated that there were any variations from ADAAG regarding the shower enclosure.

Alternative Designs. Bathroom as Shower Room.

The bathroom-as-shower-room is a concept adapted from the common European residential model by OWP&P as an alternative for including a shower in every resident bathroom. Due to space constraints at the Oakwood facility (Figure 16), a separate shower stall could not be accommodated in each resident toilet room. Having a shower close to the resident room was particularly important in this dementia facility to allow for impromptu clean-ups in the event of incontinent episodes without the indignity of leading residents down a corridor to a central bathing facility. As a result, each resident bathroom was designed as a shower room that permitted either independent or assisted showering. The latter is facilitated by use of a hand-held shower wand, which can be manipulated by the caregiver standing outside the area enclosed by the shower curtain. Given that this is a dementia care unit, there was a concern that residents might inadvertently douse themselves when left unattended. Thus, care providers can remove shower hoses and wands by a quick-release coupling at the outlet. When this feature was specified, it was expected that it would also cut off the flow of water even if the valve were to be opened. This turned out not to be the case, and a retrofit with an after-market in-line valve installed on the upstream side of the coupling turned out to be impractical due to the danger of backflow.

Figure 16. Shower Configuration at Covenant Oaks at Oakwood Village, Madison, WI (OWP&P)

The bathroom-as-shower design requires more space than a typical toilet room as well as special considerations for drainage, doorway design, and waterproofing of other fixtures in the space. However, it affords an enhanced opportunity for assisted showering without the caregiver getting drenched in the process as well as permitting individuals to shower independently.

Conclusions and Recommendations

Findings of this project were as discouraging as they were encouraging. On the encouraging side, most participants had a good understanding of the problems that older individuals and caregivers face with accessibility to toileting and bathing facilities. Moreover, the best practice designs reflect this understanding and are attempts to address the problems. On the discouraging side, the solutions are too few and some of those don’t go far enough. It appears that too often the solution was "when in doubt, comply with ADAAG". However, this was not because designers and facility owners did not want to push the envelope, but rather because of their limited ability to do so. The reasons for this are twofold.

First, achievement of innovation under equivalent facilitation is difficult. Too often innovation and alternative designs that will meet the needs of frail individuals, but that do not meet ADAAG specifications, are rejected by local officials who generally don’t understand the intent of the ADA as well as they do enforcement of it. As a result, even when designs (such as OWP&P’s bathroom-as-shower-room) are equivalent (or in some cases superior) for a frail, older population, ADAAG-compliant solutions are still required by local codes officials. Fortunately, innovations occur despite the system when a building owner is willing to pay for what is needed in addition to what is required. The most obvious example was found at Holy Redeemer Health System in Meadowbrook, PA (Ewing Cole Cherry Brott) where two types of toilet rooms were constructed - an ADAAG compliant toilet room to appease building code officials and a "preferred" toilet room that was not ADAAG compliant, but better met the needs of users (Figure 17).

Figure 17. Toilet Rooms at Holy Redeemer Health System, Meadowbrook, PA (Ewing Cole Cherry Brott)

Second, there is too little research information available to guide and set precedence for innovative design decisions. Even when designers intuitively believe that ADAAG specifications are not appropriate for older individuals, they don’t have data to suggest what the appropriate solutions would be. Thus, in the absence of data, designers end up using ADAAG specifications, but push its limits as much as possible (e.g., high toilets and low grab bars).

RECOMMENDATIONS

Based on the conclusions above, two avenues of attack are recommended. First, research is needed to understand the impact of design on caregivers and care recipients as well to develop design specifications for older adults. The former includes the impact of current guidelines and alternative designs on: safety and injury prevention; proper positioning of care recipients and care providers; stress reduction, especially among dementia patients; and flexibility in accommodating individuals with different abilities. The latter includes studies to determine optimum design specifications, such as: toilet height and location, grab bar height, positioning, and location; clear floor space; and size of fixtures.

Second, in the absence of any better information, it is recommended that a number of immediate changes be implemented to ADAAG to better accommodate assisted transfers in facilities used predominantly by older adults.

• Provide a minimum 24" clearance between any obstruction (e.g., sidewall) and the side of the toilet seat.

• Permit rear or floor mounted swing-away grab bars on both sides of the toilet.

• Accommodate non-standard bathtubs such as the Kohler Precedence tub by permitting a single horizontal grab bar.

• Permit swing away grab bars in and adjacent to tubs and showers to add flexibility.

• Finally, even though orientation of toilet rooms do not directly impact transfer, toilet room designs that minimize turning radii (e.g., doors on 45⁰ angles) should be encouraged to facilitate access.

References

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Czaja, S. (1984). Hand Anthropometrics. Technical paper prepared for the U.S. Architectural and Transportation Barriers Compliance Board. Washington, D.C.

Faletti, M.V. (1984). Human factors research and functional environments for the aged. In I. Altman, M.P. Lawton, and J.F. Wohlwill (Eds.), Elderly People and the Environment. New York: Plenum Press.

Jones, M.L. & Sanford, J.A. (1996). People with mobility impairments in the United States today and in 2010. Assistive Technology, 7(2).

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LaPlante, M.P., Hendershot, G.E., and Moss, A.J. (1992). Assistive technology devices and home accessibility features: Prevalence, Payment, Need, and Trends. Advance Data, No. 217. National Center for Health Statistics, Centers for Disease Control, Public Health Service, US Department of Health and Human Services.

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Sanford, J.A., Echt, K., and Malassigné, P. (1999). An E for ADAAG: The case for accessibility guidelines for the elderly based on three studies of toilet transfer. Journal of Physical and Occupational Therapy in Geriatrics16(3,4), 39-58.

Sanford, J.A. and Megrew, M.B. (1999). "Using Environmental Simulation to Measure Accessibility for Older People. In E. Steinfeld and S. Danford (Eds.), Measuring Enabling Environments, Plenum Press: 183-206.

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Attachment: Interview Questions

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

1. a) Are there any facilities that your firm has designed where you have incorporated accessible bathroom designs that you believe were alternatives to or went beyond the minimum specifications in the ADA Accessibility Guidelines?

b) If so, can you describe exactly what you did that was different than what is specified in ADAAG?

2. ADA Accessibility Guidelines for bathroom design are primarily intended for people to toilet and bathe independently. Have you done anything in the design of the bathroom to accommodate people receiving personal assistance to transfer to the:

a) Toilet?

b) Shower?

c) Bathtub?

3. Describe how you expect each of the designs to accommodate people receiving assistance to be used by older people and their caregivers (i.e., describe how the designs are better than ADAAG in facilitating getting on/off the toilet or in/out of a tub or shower):

a) Toilet?

b) Shower?

c) Bathtub?

4. For each of these design alternatives:

a) What population groups were these designs intended for (e.g., people with Arthritis, wheelchair uses, post-stroke, etc.)?

b) Do you expect these designs to be useful for people with other types of disabilities?

c)What was the rationale behind using a certain design? In other words, what problems were you trying to solve?

5. Did the designs that you used for toilet or bathing transfers create a need for a different overall design for the bathroom than you would have used if you followed ADAAG? For example:

a) Was the layout of the bathroom affected?

b) Was the amount of space required affected?

c) Was there a need for additional space for caregiver assistance or storage for wheelchairs and other mobility aids?

d) Were other changes necessary? 

6. In the facilities you have designed, have you made accommodations for lifts, lift tracks, transfer and roll-in showers, shower chairs, bathtubs, movable grab bars, and other assistive technologies (such as placement of doorways, and location of fixtures)? If so, what were they?

7. Can you identify specific facilities in which these designs have been used? Can we obtain plans/drawings of the bathrooms in these facilities?