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Trends in Critical Care Planning and Design

Executive Dialogue Series

Following years of downsizing, restructuring and closures, the U.S. hospital field is in the midst of a construction boom spurred by changing demographics and the need to stay competitive. Inpatient admissions are on the rise, due in part to the aging of the population and to the overall rise in acuity. The net result: a shortage of critical care beds in certain markets.

To examine trends in critical care design, Health Forum and the American College of Healthcare Architects convened a group of architects and their health care clients. The group met Oct. 24 for a closed-door dialogue in Chicago.

The Health Facilities Management Executive Dialogue Series brings you frank discussion of issues and ideas by health care executives and industry experts focused on challenges facing the industry.

MODERATOR (Alden Solovy, Health Forum): How did we get to where we are today? What changes have you witnessed in critical care over the last 20 years?

PATRICIA FULLER, R.N. (Palmetto Health Richland):

The advancement in technology has made the original room design inefficient. We're seeing a higher acuity level in the ICU patient than we saw 20 years ago. The rooms are not designed to accommodate all the technology that's available to take care of these patients.

MOLLY SCANLON (Schmidt Scanlon Gordon):

The current technology can shut people out. The big machine and the doctors can do everything--the family isn't needed. We've created these caverns between families, the patients and the people who are trying to care for them, and that's not really the solution. Families and patients don't like that separation.

It's great technology, but it's also brought on this idea that care is separate from other needs, probably because the infrastructure wasn't prepared for it. Families didn't need to be together. But that's changing. Families want to get back to something that lets them be together.

LEO BRIDEAU (Columbia St. Mary's):

We are where we are today because the ICUs were designed without much thought to what's it like to be a patient. What is it like to wake up intubated? The design should consider what it's like to be lying in a place where you can't move very much, there's a light shining in your face 24 hours a day, the noise level is out of control and you don't have access to your family.

We need to think about it from that standpoint, as well as from the standpoint of the technical stuff and the staff who have to be there.

From the patient's point of view, what should this experience be like? Not just from a patient satisfaction and public relations standpoint, or even from the standpoint of caring and humanity, but from the standpoint of better patient outcomes. What should that experience be like? We don't ask those questions enough.

One of the things we've done in planning our project is to assemble a panel of about 55 patients who weren't very happy with our services. They work with us on all of our design teams as we're designing our units.

ARTHUR ST. ANDRE, M.D. (Washington Hospital Center):

Most ICUs are encumbered by the fact that they're very old. They're not designed well for patients and families. They're not designed well for the providers. It's horrible to work in some of the ones that are modernized because the design didn't consider the functions that individuals need to perform and the creature comforts that are appropriate for anybody in that working environment.

There are many ideas that can be pursued to create a positive healing environment.

ANN HENDRICH, R.N. (Ascension Health):

Hospitals are designed the way they are, in part, because providers receive financial incentives to build more bricks and mortar, more specialization. This has created very inefficient patient flow within buildings, and that's been sustained.

KIRK HAMILTON (Watkins Hamilton Ross):

Critical care is the environment at the extreme. When you consider the patient experience--the inpatient experience--critical care has always been on the upper edge, and that upper edge has been changing faster than any of the other components. It's not just the technology.

Critical care practitioners have been advancing their processes and treatment modalities at a very fast pace. They are learning tremendously and constantly adjusting.

On the design side, we've been making trivial, incremental, minor adjustments to a dumb bed in a simple box that we called a room, and it had some stuff on the wall. The most advanced we've gotten is that we've moved the bed a little bit off the wall.

We've not attacked the question of design--we haven't gone back, started from scratch and worked in a completely different context.

I don't say that in a critical way. I've been a part of that stuff myself. I know the real constraints of everyone who has to make those decisions. Each time, it's the difference between making another incremental step versus taking that big step. But I think we're about there.

A huge component of our health care physical infrastructure dates from the Hill-Burton era. It's about time to declare it obsolete and walk away. We can prove conclusively that replacement now is less expensive than repair and renovation.

JOHN PANGRAZIO (NBBJ):

I've never designed a critical care unit without the input of nurses and doctors. I've never done it in isolation.

As far as critical care goes, we've been extremely fascinated with technology, and we've practiced, for the most part, heroic medicine. That's our basis of practicing medicine. That's where the whole dehumanization of the process came about.

We've begun thinking about designing the experience. That's where we are today, which I'm so pleased and optimistic about.

CRAIG BEALE (HKS Inc.):

When you look at the first critical care units of about 50 years ago, they were basically post-anesthesia recovery units. They were nurse stations with cubicles pulled up close to them so the nurse could see in the eyes of every one of the patients.

We've come a long way since that time. We're finally to the point where we can have ubiquitous access to information. We can put into place processes with technology that can support the care environment.

Technology really ought to be a backdrop. We tend to design critical care units from the nurse station out. That's codified by regulations in most states--that nurses must be able to see each patient. We can untether that.

PABLO VELEZ, R.N. (Sharp Chula Vista Medical Center):

We haven't done a great job with family involvement. We have not looked at care processes to make it easier for the families to have access to the patient.

Another issue is that we've added more staff for critical care patients. We already had a small unit with small rooms. Then we added staff to take care of patients. It became a very crowded environment.

I see that all of the time with our ICUs. We have a lot of staff in these small areas, and it's very chaotic.

KEN CALDWELL (KMD):

The bottom line is capital. We need to have the capital to do it right.

It's not that we don't know how to do it right. Sometimes we spend the capital on a new toy as opposed to redesigning the process or somehow reducing the patient's stay so we can afford to make more improvements in those rooms in those facilities.

MODERATOR: What are the best and worse features in critical care design today? What have you seen when you've walked into a critical care unit?

PAUL STROHM (HOK):

One best thing I've seen is the provision of family amenities that are consistent with any other med/surg unit. It used to be that families weren't allowed in the ICU, so there wasn't anything there.

I've seen new units that really provide for the family. The family has a dedicated space, and it's not just a chair. There's a refrigerator and a couch and a table within the patient room. The rooms are growing in size, and they will allow a multiplicity of functions to occur.

VELEZ: We have created an unusual feature for our patients--letting them have a family member stay overnight or at all times with them. We created bigger rooms with the amenities so the families are comfortable.

Another thing we did with the design of the ICU is include a family garden retreat area. When family members are tense or need to take a break, we bring them into that area. The area was designed with natural skylights and fountains. It's a very soothing environment for them, very quiet.

One of the things that we have observed when we have visitors going into that area is that they share their experiences. They become a support group for each other.

BRIDEAU: I can give you one of the worst examples as a way of illustrating a problem that I don't know how to solve. We haven't gotten to this point in design yet, so we still may find a solution to this.

I had a family member in the intensive care unit at a medical center on the East Coast recently. It was an older facility. If you think about ICU design, and this one was very much like it, you have the nursing station in the middle with the rooms around the periphery for better visibility.

When families come in to visit, they have to pass through the nursing station. Privacy gets severely compromised. When families pass through, they can overhear discussions about what's going on with the patients.

It's kind of like designing a restaurant and putting the kitchen in the middle of it so you have to walk through the kitchen to get to your table. The experience may be interesting, but may not be quite so great.

Is there a way for us to think about how we can keep families involved in the care, make sure that they're welcome there and they feel like it's their place, but not get them involved in everybody else's care?

HAMILTON: It's probably not legal in many states, but the ICU at Griffin Hospital, in Derby, Conn., has a corridor around the outside. The families enter the patient's room only through the outside entrance. The amenities for the families are around the perimeter.

There is daylight coming through, but it's not an operable window that some states require. They get by the requirement by using a glass block wall at eye level.

It's a very interesting model because the inner corridors are staffed corridors. They are a very quiet, calming environment with lower noise levels.

PANGRAZIO: There is another technique that I think many of us employ--having separate public and internal suite circulation. You may not avoid all the other patients, but most of them. You simply need to have a building that's wide enough.

FULLER: One thing I've seen that worked is having an elevator go from the emergency department directly to the ICU. Patients who were coming from ED came straight up to the ICU. They didn't have to go through any other corridors or hallways. It was an entrance strictly for those patients. The families were directed to another entrance.

One of the frustrating things is where the nursing stations are walled off and you cannot see the patient rooms. Patient safety is a big consideration. The most successful units I've seen are ones that have an all-glass front that's more of an oval or a round shape. The nurses' station is counter height, so you can see into all of the rooms.

Another really successful plan I've seen is where the nurses' station was taken out of the center and put immediately outside the room. Most of the front was glass and there was some counter space for a work area so the nurse can sit at the work area and see two or three patients at one time.

I don't think a centralized nursing station is needed. The nurses need to be out by the bed, out by the room.

Another thing that has frustrated me is rooms with one sink. If the patient is on dialysis, that sink is tied up. It's better to have a dialysis trough in every room on the opposite side of the bed, away from the door. If the patient codes while on dialysis, the nurse doesn't have to climb over the equipment to get to the patient.

HENDRICH: Not having sinks also keeps nurses and doctors from washing their hands.

One of the complaints I have with patient rooms is the size. I've seen new facilities with great lobbies and cafeterias. But the size of the patient room was unchanged. The clinicians were cramped into tiny working quarters. Nothing had changed with the care delivery model. It was keeping the old design in the new environment and pretending as if that would transform the care process.

HAMILTON: The toilet is the absolute, most persistent, difficult thing in design to get right. There are no good solutions yet. People are using swing-out toilets that don't work. People are dragging folks who shouldn't be moved, and they're getting injured. People are being disconnected from monitors, and it freaks them out because they think the monitor is their safety connection.

There are no good answers yet for toilets in ICUs. I have clients who say, well, if the patient can use the toilet, they shouldn't be in here, so don't give me any toilets.

On the positive side, I would say we really are getting larger units with more space allocated. Staffing in critical care is changing to a multidisciplinary team model. That's a change from when I first started in this business. It's extremely positive. The frequency with which we encounter intensivists is enormously positive.

Those changes have allowed us, along with the technology changes, to walk away from the central nursing station. In critical care, the hands-on caregiver is at the bedside, and the one you described, right outside the door, is the model for that.

What remains at the central location is the multidisciplinary team station, and it's mostly for the people like dieticians and therapists and others who don't really reside on the unit, but need a place to work while they're there. It may have a unit cleric or someone like that.

But in the old days there was one paper record, and it was kept at one place, and there was a need to see every patient from a central location. Those days are gone.

The presence of families, I think, started in the emergency departments. Clinicians realized that when a crisis is happening, it wasn't necessarily a bad thing if the family was present. The profound change in critical care that leads to understanding the families is really positive.

As long as we play on the best of those things and chip away at the worst of them, we have a chance at doing things quite a bit better if we're given the opportunity.

BEALE: Good Samaritan came up with a pretty good solution to the toilet issue. The reality is, the patient doesn't use the toilet, or the patient shouldn't be there in the first place. The reason the toilet is there is to dispose of fluids. Good Samaritan placed a little soil utility room between each pair of rooms and said that's what it's for.

STROHM: What we need to envision is a critical care room that is more flexible. While we will have patients with multisystem failure, a lot of people who are going to be in critical care are people who will need facilities. They are going to need a bathroom. There are going to be more people in critical care beds and fewer regular adult med/surg beds.

There's a need for a multiacuity room or something like that. One of the challenges is how you conceive of a room that can flex through those multiplicity of needs from a care delivery model and still be humane and environmentally correct.

BEALE: That's an issue I wanted to touch upon. You are correct, we will have really sick patients with multisystem failure who will require a certain kind of environment. But there are a lot of people who are in critical care and don't need that level of care. They are in an in-between area.

FULLER: At Palmetto Health Richland, where I work, we have some in-between areas. We call them progressive care units. It's really a step down from the ICU, and we staff three patients per one nurse.

It's very frustrating for the staff working in that area, because again, they're not as sick as they are in the ICU, but they're still sicker than they would be on the floor. The nursing care requirements are very demanding. They're at high risk for fall. You can't see them. Some of them are paired up in semiprivate rooms. It's just not very patient friendly or family friendly or staff friendly.

PANGRAZIO: That's where the process and the design come together. We need to design rooms that are flexible so we can minimize transfers. We know that errors happen whenever there are hand-offs. When you switch staff, when you switch units, that's where you make mistakes.

That's also where you create barriers in patient flow. And barriers in flow create mistakes in and of themselves.

How do you make a flexible environment from a patient standpoint, where the patient and the family don't feel bad about it? There's some celebration when a patient graduates from the ICU to a step-down unit and then to an acute unit.

Staff is a whole other issue because critical care nurses are critical care nurses. They don't want these patients who aren't quite so sick. We are wrestling with that right now. We're testing these concepts in our existing facilities before we roll them out into new facilities.

ST. ANDRE: The solutions are going to become broader, depending on the mission of the hospital in its locale. What one does at a hospital like mine, a large tertiary care facility with multiple subspecialty units, is going to be different from what is done at a small community hospital.

We also need to take the patient-need perspective. I do not believe that one room can serve the needs of all acuities throughout the hospitalization. Especially in a larger facility, we do not have the resources that can flex from one range to the next.

You can't take a critical care nurse who knows an incredible amount about that situation and flex them all the way down, or acute care nurses and flex them all the way up. You can't take a critical care physician and do that.

PANGRAZIO: One of the things that we've talked about and maybe oversimplified is this idea of a critical care room being the model for all the rooms in the hospital. We've seen that, we've heard about that. Part of the limiting factor hasn't been whether you can design it, because there are lots of ideas about that, but whether you can staff it. Is there a place for the universal room built on the critical care model?

ST. ANDRE: Currently we do need rooms to be adaptable to a more acutely ill patient population, but not a room that will have to apply the same degree of oversight, availability and therapies in every location. Acuity will always range from the not very sick, without much risk, to the very sick with incredible risk for sudden deterioration. That range will remain.

The proportion who aren't very sick, with relatively low risk, will probably be higher in quantity, even though in the last couple of decades there's been quite a bit of pressure to move that patient population out of hospitals. And we've done a reasonable job with that. We need ideas on how to recognize that they will move up and down that scale at times in a way that's very unpredictable.

VELEZ: Staffing will be a nightmare with the universal room. If you don't have a good acuity system, how will you know what patient care hours will need to be provided for this type of patient population?

We have failed to consider that our reimbursement model is not set up for universal room charges. Payers pay by the level of care. That would have to be changed. That's going to be very difficult.

FULLER: It's going to come back to patient safety. If every room is a universal room, that doesn't mean the nurse who's working beside me has the steel to take care of that higher-level acuity patient.

One of the things that makes critical care successful is the teamwork among critical care nurses. There's a lot of training required for those nurses to meet the level of acuity for those patients in that environment. It's a totally different work environment.

My biggest concern with that is the safety issue for the patient and the teamwork that's needed to deliver patient care, especially in critical care, because those nurses really help each other a lot with those patients.

BRIDEAU: The notion of an acuity-adjustable room is very attractive until you start doing it in the real world, and then it falls apart.

If you're going to minimize hand-offs, then your choices are either to have a unit that is critical care plus what has traditionally been step-down, or to have a critical care unit for the really, really sick patient and everything else goes to the acute units that are all telemetry. That's where you will adjust the acuity.

We decided that patients who require critical care and who traditionally require step-down care will be in the ICU, even though they aren't technically ICU patients. That's where we keep them.

All of the rest of the beds will be for acute care patients. That's the way we made the split. Does anybody else have suggestions as to where you would make the split?

FULLER: I would keep the step-down patients in the critical care setting. Every once in a while it's nice to have a patient who is not critically unstable. The nurses in critical care have a high burnout rate, and there's a tremendous shortage of them.

ST. ANDRE: You have to size it appropriately, based on what your future projections are for acutely ill people. You need enough beds because the tendency is to keep a patient in the ICU.

The problem in many ICUs is not admission criteria. It's good discharge criteria.

Another issue involves mixing patients who aren't particularly sick with those who are. The risk is greater for infection, and the atmosphere is not as friendly to them or to their families.

You'd have to be very sophisticated with the design to create an environment where healthier patients can simply sleep or pursue their physical rehab or more family members can be there for a longer period of time. Those are the burdens that you are left with.

CALDWELL: Is the purpose of an acuity-adaptable room for a short day-to-day flexibility, or is it the long-term flexibility? I can't see how you can put an ICU patient next to a med/surg patient.

But the ability of a facility to flex from an ICU to general acute care, or general acute care up to ICU, might be done on a three-month or six-month basis. We want to make sure we have the infrastructure to accommodate any level of acuity--then it's the staffing that has to change.

MODERATOR: If we redesign process flows by changing the shape and the design of the ICU or the ED, we essentially are influencing the unspoken set of assumptions and the unspoken contract between administration and clinicians about what their roles and responsibilities are. If we make these design changes to an acuity-flexible room, how does this impact clinicians and the way they provide care?

FULLER: The concept that a nurse is a nurse is a nurse is just as irrational as saying a pediatrician is a heart surgeon. There are specialists in nursing, just like there are in the medical field. If you told me I had to go work on pediatrics, I would quit. That is not where I would ever want to work.

HAMILTON: It's not about universality of the staff. Nobody's going to question a clinician's expertise.

Ann and her colleagues wanted to eliminate patient transfers, and they saved millions. They did enormous things that improved performance. They got great outcomes.

They didn't do it by retraining everybody in the hospital. They focused on a single service, reduced unnecessary movements, eliminated hand-offs and reduced errors.

FULLER: I like the idea of flexing up. We all have had times when critical care patients are held in the emergency room while they are recovering.

If you have some rooms where you can flex up--universal rooms--instead of relying on regular acute care rooms, that would be beneficial. When they aren't needed for critical care, they can be used for acute care.

The biggest challenge would be how to staff the rooms. But we shouldn't do this for every room in the hospital.

VELEZ: I've seen that model--they called it overflow beds. When the rooms were used for critical care purposes, the nurse-to-patient ratio was the same as in the ICU. The equipment setup was also the same.

BRIDEAU: Suppose none of the restrictions were there and suppose we took the time to retrain staff to work with patients of varying acuity. How would we design these rooms?

If you were starting from the standpoint of a provider, how would this work? If you were starting from the standpoint of the patient and the family, how would it work? But if we start from where we are and say how do we change incrementally, we will never get to where we want to be.

MODERATOR: What are the five most important assumptions we need to lay down in critical care before we get to the design stage? What is the planning horizon? Do we need to plan for something that's going to last 50 years? Do we need to look at trends for the next five years?

BEALE: You need to do both. You have to look at the trends that you can observe and project over the next five to 10 years. When you are making an investment in a facility, there has to be flexibility and adaptability.

HAMILTON: You want high performance for 10 years and flexibility for 40.

SCANLON: We need to come up with things that can be done today so we can begin moving in the right direction. I don't want us all to think too far ahead. We need to make some changes today--that's where you find the challenge and the creativity.

MODERATOR: What are the trends that we need to think about for the next 10 years for high performance?

PANGRAZIO: From a facility standpoint, building codes say we have to have long-term buildings. Even if we want a short-term building, the codes define that we're going to have 40- and 50-year buildings. Those spaces inside those buildings could change five or six times.

What we're looking for in facility design is a way of accommodating that unknown change. These buildings not only need to be adaptable, they need to be expandable and they need an exit strategy when they're no longer appropriate as a health care facility.

SCANLON: We have building regulations that require us to put in expensive systems that we don't use. That's money that could be spent on something else. I waste money putting in systems because of codes and little things in a book that are just not used. It's terrible.

HENDRICH: We need to change the reimbursement model. The way critical care is defined is now an extreme barrier to hospitals implementing acuity-adaptable rooms within specialty service lines.

HAMILTON: One trend that's being discussed a lot is the aging of the baby boomers. The boomers are more demanding than any group that has come before. They are going to alter the way we have to deliver care.

VELEZ: They have a different expectation of what the health care experience should be like.

MODERATOR: We've touched on consumerism, touched on issues in demographics, baby boomers. But we haven't touched on trends in the patient population. What will we see that will drive the ICU? We've alluded to the labor force. How can we address the shortage of labor?

BRIDEAU: The trends are pretty clear. The baby boom generation is very large and will soon reach retirement age. The cohort behind that is much smaller. That's a major issue for us: The shortages that we endure are likely to become structural as opposed to cyclical.

The other issue is what we look like in the absence of minorities in the health care workforce. There aren't enough minorities in health care. Technology's got to replace people. But it means we've got to make these places good places to work. The burnout that Pat talked about is not a function of the inherent nature of the work. It's a function of the workplaces we've created.

Critical care units that are so stressful for patients are also so stressful for staff. We've really got to take that into consideration.

One thing I wrestle with is intensivists. There aren't enough to go around. The e-ICU notion--the notion of having remote monitoring of ICU patients with TV cameras and vital signs monitors and intensivists working in a remote location but in real time, 24 hours a day--that seems very attractive, especially for hospitals that can't find intensivists.

FULLER: Considering the nursing shortage, we're looking at a 20 percent shortfall by 2020 if we continue along our current path. We keep demanding more nurses. We've not handled the problems with the workflow processes that need to be solved. Additional staffing won't be enough.

ST. ANDRE: Changes in workflow processes have led to an increase in people working in the ICU. In addition to the traditional nurses and physicians, we now have intensivists, nurse practitioners, hospitalists and physician assistants. There are also nondirect providers--quality assurance, quality control and biomedical staff--all of whom are either going to be there for a temporary basis or be housed there.

Design has to take into consideration a whole variety of new types of faces in critical care units. Whether the labor force will be able to respond to that, intensivists being the example, I'm not entirely sure.

The other thing we have to clearly keep in mind for the patients and for the labor force is that obesity is playing an incredible role for patients, families and providers.

The disease process will also change, due in part to technology. The critical care transfer and disease processes will evolve as well. Congestive heart failure will replace coronary disease in the patient population to a greater and greater extent.

The problems of infectious disease will be there and will grow, and those that sometimes get the most press will not be the ones that are most prevalent.

The simple bacterial infections, those that may be more resistant, will still be there. We've known it for a long period of time, and we're seeking ideas that will help reduce that trend.

Technology from a surgical prospective will begin to diminish the monitoring of those patient populations because they're able to be healthier more quickly. Those are the trends that will affect the ICU setting.

MODERATOR: What are the design solutions--or at least design implications--of the trends that we've been talking about?

HAMILTON: I like to design the organizational model at the same time the physical facilities are being designed. If you put the old process into the new box, it may be nice and shiny. But if you expect new results, you might think again. We need to be doing more of that, looking at what you do, how you do it, improving the process with that multidisciplinary team, led by an intensivist working in new ways. It really does mean new designs.

MODERATOR: What are some best practices in terms of design and optimizing the work space?

HAMILTON: I don't believe anybody's doing it yet. You've got to understand how the patient flows through the system, how the information flows through the system, how the supplies move through the system. You've got to integrate that while you're short-staffed and delivering superb quality care at the bedside.

SCANLON: Ethnic diversity among patients will also be an issue in design. Hispanic populations, for instance, have an unspoken requirement that all family members be present when someone's in the hospital. We have to look at the spaces and the size of spaces and how we're going to accommodate large numbers of people.

As we've had to increase the size of the spaces, we're seeing a difference. The nurses can relax. We cannot forget the diversity across our country and how it's changing, especially along our borders. It's definitely affecting health care and how it's delivered.

BRIDEAU: We talked about this a bit earlier, but I think it has workforce implications--decentralized nurse stations. Maybe we don't need the nursing station on the ICU. Instead, we can put the nurses right by the bedside where they can see two or three patients. The nurse can be there where he or she belongs.

That's attractive as a concept. But, what does it do in terms of camaraderie and teamwork? Good communication among nurses, doctors and the other providers has been demonstrated to be the one critical element in good patient outcomes.

BEALE: Some research has shown that total decentralization doesn't work. At one hospital, for instance, the nurses really didn't want to be decentralized, and they tried to cram in little, bitty nurse stations that weren't designed to house them all. We can't ignore those social factors.

VELEZ: At our facility, we have a big nurses' station as well as alcoves where the nurse sits and has a very clear view of two patients under his or her care. When they need to have interdisciplinary communication, they go to the big nurses' station. Another thing we've seen is that when physicians come to do rounds, the nurses are there. The communication level is very, very good. Because normally, when you have a big nurses' station, they tend to group where that big nurses' station is, as opposed to being at the bedside.

HAMILTON: You're absolutely right about socialization and mentorship. It's valuable; it has to happen.

I'll take the provocative position and say the central nursing station is gone. If you allow old processes to take place in the central station, you're making a mistake.

The processes need to get closer to the patient, whether it's through a handheld or right outside the door. The stuff that's needed to deliver that care--the supplies, the linens, whatever--needs to be within enough proximity that people aren't spending their time tripping up and down corridors. Design needs to foster the support for the task that has to be done, and at the same time foster the socialization.

I try to get rid of the old label and get people to talk about what they mean by interdisciplinary workstation. What is that? It launches a provocative conversation where you can discuss what it's used for and why. Isn't it possible to do that at another place that actually makes it happen better?

STROHM: At Columbia St. Mary's we're struggling with the issue of decentralization. How close do we bring the caregiver to the bedside? We think it's outside the room.

We're concerned about noise. Will having smaller, decentralized stations help the noise level? There are studies showing that if you control noise within the unit, the outcomes will be better.

Anything that can be done to reduce stress, whether it's for the patient, the caregiver, the physician, the family member--we're going to do that.

HENDRICH: The open, decentralized station is an improvement. But, nurses feel comfortable at a centralized nursing station. It's where they talk about their families, their patients. From a safety perspective, the data tells us the centralized station is contributing to errors, because of the noise level, among other things. So untangling some of that in decentralized work areas with wireless technology just makes sense.

MODERATOR: In terms of design, how do you balance the qualitative and quantitative data that's out there? How do you partner with your clients to sort of move that client along so they want to bring both of those types of things into the design?

CALDWELL: We have extensive workshops with our clients. We go over these issues. But the client we're designing for today is not likely the one who's going to occupy the building five to seven years down the line.

We have to study how to reduce obsolescence in health care facilities, because what we design today is obsolete by the time it's constructed.

We've looked at a critical care design that is somewhat of a lab approach in that we put all the amicable objects on the perimeter, the bedrooms and all the plumbing and all those types of fixtures.

We've left the core pretty much unobstructed. We know that if they want to go back to a central nursing station approach, we can provide that.

If it comes to the decentralized design, outside the rooms, we can provide that, because that zone between those patient rooms is flexible. The corridor can move anywhere in that position because we keep the underlying structure.

Anything that's immovable that penetrates through the building--any kind of an electrical, mechanical, plumbing--all those things are kept out of the zone.

ST. ANDRE: The group that has the greatest vested interest from a business perspective of getting this right is hospitals.

HAMILTON: I'll take the other point of view. The providers in the room have a relatively small number of opportunities to redesign ICUs in their career. The specialist architects do this all the time. The burden of evidence-based design lies with the architects to educate themselves, to root out the evidence, to find that knowledge base and to share it with their clients. The architect really has to challenge the client repeatedly on many of these issues.

PANGRAZIO: In the case of evidence-based design--the idea of researchers being members of the team--we as architects have the responsibility to make sure those team members are there. The aging workforce has led us to bring ergonomics and other issues to the table in terms of projects.

CALDWELL: When you start any kind of planning discussions, no matter what the project is within the hospital, whether it's ICUs, ORs or anything, there are two topics that always come up as some of the most critical things--parking and storage.

It doesn't have anything to do with patient care, necessarily, but those are always two big issues in terms of staff satisfaction and convenience for using the facilities.

FULLER: Another area as far as staff is concerned is the lack of break rooms that are available in close proximity to the ICU. We've taken a small patient room and made a break room out of it. The problem with it is in trying to do education or have a staff meeting in a space that's not conducive to that function. When you're designing the ICU, you have to consider a multipurpose room that will allow for training and education and a place where staff can take a break.

PANGRAZIO: Staff spaces now are not spaces for second-class citizens. These spaces are now being placed on the exterior for natural lighting. They are good for recruiting and good for retention and clearly for recharging your batteries. These spaces are just as celebrated in terms of design as the lobby might be because you need to protect resources in terms of the staff.

SCANLON: That is important. When Pablo opened his critical care unit, he had a special open house just for nurses in the county of San Diego. He sent them invitations and recruited that way. Some signed up for jobs as they left the open house.

MODERATOR: Let's talk about a few more practical issues, adjacencies, when you think about designing an ICU. What needs to happen around the ICU?

ST. ANDRE: Transport is a huge issue. Being close to radiologic services is incredibly important. There's high risk in transport. The patients need to be close to the MRI, the CT scan and interventional radiology. If you look at the providers, some of their space needs to be relatively close. Administrative offices, conference rooms should be different from break rooms. Sleep facilities for practitioners who are working long shifts should also be close.

The laboratory doesn't have to be that close, though the trend toward point-of-care testing, I believe, will increase as the technology improves. Some space for relatively small pieces of equipment will become a need for accommodation. Pharmacy depends on the system you use, whether it's centralized or decentralized. The pharmacist is a very valuable part of the critical care team.

PANGRAZIO: In terms of hierarchy, I don't know what needs to be immediately adjacent to the ICU. Part of it has to do with patient experience. What's the experience going to be like? It involves improving operations as much as improving the experience.

ST. ANDRE: One trend we've seen is family places growing in size, complexity and amenities. Some of them are absolutely wonderful. Some offer washing machines. Aquariums are in, by the way.

CALDWELL: What has everyone's experience been with families in the ICU? What are the policies that people are experiencing? How open is it? How many people are we talking about? We've looked into all kinds of different restrictions.

VELEZ: Traditionally, the ICUs are very restricted to the family members. A typical visit to the ICU sometimes would be 10 minutes and one or two visitors at a time.

We have a very flexible visiting policy. Any member of the family can visit the patient as long as you don't have 15 to 20 people in there and provided that you're not relinquishing control of care.

We ask the patient if the patient wants family members or not, we give the patient that choice. We also give the patient the choice of having a family member spend the night.

It was very hard for the nurses to give up control. But, we have seen that they are becoming more and more comfortable with it.

MODERATOR: Any concerns about patient privacy with the increase in the number of family members in the ICU?

VELEZ: We select a family member to be the spokesperson for the family in terms of providing information so you're not giving information to every single visitor. If they have questions, you direct them to talk to this family member.

BEALE: Does that visitation policy depend on how critical they are?

ST. ANDRE: It depends on how active it is. Ours is very acute. We have open visiting except when something's really active in the room at the time.

SCANLON: We sometimes don't give the family members credit for knowing and respecting the process. They are going to the facility and they are thankful for the privilege.

ST. ANDRE: Most units are not large enough to allow more than one or two visitors. God forbid they need a chair. If you put a chair next to a standard-height bed, they're looking at the patient's side. That all comes into play.

These families are just under incredible stress. We've had a reasonable number of acute circumstances in which a family has come in and visited. This person was still under anesthesia, still had tubes and lines coming out, and said "hi" and "goodbye," and left. It wasn't their family member.

FULLER: You've got to have a private room to take families because of HIPAA regulations. In the past, clinicians just went to the waiting room and talked with them. We can't do that any more.

HENDRICH: One of the things that we've found, when you provide adequate space inside the room, whether it's ICU or somewhere else, is that there's less need for alternative space because the private area becomes where the family member is. We've built a couple of beautiful waiting areas--one outside the elevator--to welcome folks onto the unit, and it sits empty. When you give them space in the room, that's where they stay.

MODERATOR: Let's talk about infection control. What's new, what are the hot spots, what are the areas of concern in design related to infection control?

ST. ANDRE: The greatest difficulty with infection control has to do with gram negative aerobic organisms, and to a degree gram positive organisms, which are ubiquitous. They are not the organisms that create epidemics that we all would be frightened for life and limb. There are those that contribute to infections in people who have low resistance and lots of tubes and lines in them.

By and large, prevention of infection, from a design perspective and a functional prospective, is hand washing. Hand washing, hand washing, hand washing. Soap and water and the new alcohol-based substances.

SCANLON: I'll give you a totally different twist with infection control. When we did the family garden retreat on the ICU unit, there was great debate about infection control. Fortunately, one of our physicians sat on a CDC committee and came to our meetings. We had to go through the infection group for the hospital to get a family garden retreat on the ICU.

We had to do special air handling and we had to compromise on infection control. The design team wanted to have live plants, but soil was not an acceptable material in the ICU. So we went with artificial plants. But, they don't look artificial. We were allowed to keep a water fountain as long as it was treated.

HAMILTON: At Legacy Good Samaritan in Portland, Ore., patients are taken to the garden if they're well enough to be taken outside. There are plenty of dirt and plants and squirrels and birds and everything else out there. It's part of the course of care.

At UCLA tertiary care--high-level stuff--they have pet therapy in their ICUs. So it is not an absolute that the hosed-down model of infection control will carry the day. As Arthur explained, hand washing is really where it's at.

HENDRICH: I don't know if design can change this, but moving equipment between rooms is an issue. Is there anything design can do to minimize the transport of stuff?

MODERATOR: Leo, you're the CEO at the table. When design comes to you with a plan that's 140 percent more than you think your capital budget will allow, how do you start making some of the decisions?

BRIDEAU: Each hospital's circumstance is different, so take that into consideration. The key way you pay for it is to take a look and make sure that it simply isn't a new shell, that it's not new for the sake of being new, but rather that you're redesigning the processes and getting the waste out of the system.

There is so much waste in what we do. The bottom line is that it must be good for the patient. When the patients have bad outcomes, it's not only terrible for the patient, it's costing a whole lot more money to the hospital.

There's got to be a greater return on investment. We're looking at spending extra money, and we will spend the money.

We'll be spending extra money around some of the evidence-based design findings.

Let's do some reasonable ROI so that we're not doing it all on a wing and a prayer and so the outcomes will be better. When you get better outcomes, you do save money.

HAMILTON: If you believe the typical hospital spends maybe 6 to 10 percent of its annual budget on retiring capital debt and the cost of its facilities is part of its annual deal, do you also believe that there's 10 percent savings available in the waste in the system? I do. So there's at least one plausible argument that all this design can be free if you just go about the effort with enough rigor to make sure you capture all of those wastes and get rid of them.

Whether it's tougher to talk about ROI on renovation than new construction is fascinating. The designers here would agree that new construction is cheaper than renovation.

Panelists

Craig Beale Principal and Senior Vice President HKS Inc. Dallas	Leo Brideau President and CEO Columbia St. Mary's Milwaukee
Ken Caldwell Director KMD San Francisco	Patricia Fuller, R.N. Director, Critical Care Nursing Palmetto Health Richland Columbia, S.C.
Kirk Hamilton Principal Watkins Hamilton Ross Houston	Ann Hendrich, R.N. Vice President, Clinical Excellence Operations Ascension Health St. Louis
John Pangrazio Partner NBBJ Seattle	Molly Scanlon Principal Schmidt Scanlon Gordon San Diego
Arthur St. Andre, M.D. Director, Surgical Critical Care Services Washington Hospital Center Washington, D.C.	Paul Strohm Senior Vice President HOK St. Louis
Pablo Velez, R.N. Chief Nursing Officer, Administration Sharp Chula Vista Medical Center Chula Vista, Calif.	Moderator Alden Solovy Associate Publisher Health Forum Chicago

Trends in Critical Care Planning and Design

Executive Dialogue Series

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