CLINICAL SUPPORT ZONE

The quality of patient care has been shown to improve when delivered by a multidisciplinary team of clinician specialists, pharmacists, respiratory and other therapists, dieticians, social-service professionals, chaplains, and other health professionals. This document uses the term “Interdisciplinary Team Center” (ITC) to describe a central location for supporting team interaction and certain centralized activities. Additional work areas, both general and function specific (such as an imaging room, or a space for preparing and dispensing patient medications), may be placed around or near the ITC as the functional program dictates. All work areas should provide adequate, convenient storage for reference manuals, policy or procedure manuals, hospital formularies, telephone lists and other paper resource materials needed by users, as well as sufficient computer, data, and telecommunications ports.

There is perhaps no better way of monitoring a patient than by direct visualization. There is a link between poor visualization of patients by nursing staff and physicians and patient mortality. To achieve direct visualization, each patient’s face and body position should be easily seen from the main ICU corridor or from the ITC. A decentralized unit design should provide a clear view of patients from decentralized work areas. For safety reasons, each patient should be visible from more than one workstation if possible.

Centralized Monitoring. The ITC will usually house centralized monitoring devices. Designers should consider available space and the ratio of staff to patients. Space should be allocated not only for monitoring devices, but for printers and other support equipment. Monitoring functions should not infringe upon clerical functions. Monitors should be positioned to enable medical staff to easily see and hear patients from multiple vantage points. New technology, including text messaging, allows unique alarms to alert staff to changes in patient parameters, malfunctioning devices, or life-threatening situations, and the design should accommodate this technology.

Remote Monitoring (Electronic ICU). ICUs may want to send physiologic and patient trend data to specialists at remote locations in the hospital or elsewhere. To support the electronic ICU model, robust video observation, physiologic monitoring, and communications links must be provided in every patient room. Remote monitoring locations must include adequate space for video monitors, physiologic parameter monitors, computer workstations, desks, and chairs, as well as telephones and other devices to communicate with ICU staff. The lighting and environment of remote monitoring rooms should promote concentration. If the remote monitoring location is isolated, a staff toilet should be considered as part of the suite.

Clearly organized work-space for unit staff and patient care coordinators should be located in the ITC to help improve communication, facilitate ordering, and expedite care. This area should include dedicated computers, telephone, paper forms, pneumatic tube, fax machine, and digital technology used for order entry within easy reach of staff. Computer-based order entry systems are powerful emerging technologies. If such a system is not in current use, provisions should be made for its future use.

Medical rounds provide healthcare professionals with the opportunity to develop integrated care plans. In the ICU, multidisciplinary rounds often occur in various formats. Studies have documented the benefits of multidisciplinary rounds, such as reductions in cost and length of hospital stay, reduced mortality rates, and an association between multidisciplinary care teams and a lower risk of death among patients in the ICU. Staff physicians often develop a preference for either bedside or conference room rounds, implying that unit design and layout should be able to accommodate various rounding preferences and styles. Physical multidisciplinary rounding in teaching hospitals can become an event including a dozen people or more, many utilizing portable computers. The impact of a large number of people moving through the ICU influences corridor width and acoustic needs. Mobile data entry devices, such as workstations on wheels, are being increasingly used on rounds. Overall unit configurations can place limitations on how and where these devices are used and on the mobility of clinical work. Consideration should be given to types and numbers of devices used, the nature of their use, and the physical layout of the ICU.

The number of staff who may be rounding or consulting with the patient at one time should help define the amount of work surface space required for documentation and review of patient records. Areas supporting documentation and review should be located and designed to minimize distractions and potential errors.

The design of the unit must consider the pharmaceutical delivery functional process. Whether the ICU relies on the hospital pharmacy or a satellite pharmacy within or near the ICU, pharmacy services should be readily accessible, available 24/7, and provide all medications needed. Space in the unit should be designated for point-of-care pharmacist activity and may include a dedicated computer terminal and work station. Pneumatic tube systems may be used to transport pharmaceuticals to and from the main pharmacy.

Satellite pharmacies within or near the ICU can allow for immediate access to medications prepared by a pharmacist, decreasing medication delivery time. These spaces may also be sized for larger equipment. If a satellite pharmacy serves the unit, medication prep and storage may be less extensive than for units that rely on a main hospital pharmacy.

Patient Medications Receiving and organizing prescriptions prepared elsewhere can occur in a central location in the ICU, or can be decentralized closer to the patient, and in some cases may be both centralized and decentralized. For mixing IV fluids and other preparations, if done within the ICU, a location close to the ITC, or easily accessible from decentralized work stations, is recommended.

Medication delivery systems may be automated. Automated medication dispensing systems should be easily accessible in life-threatening clinical situations. Larger ICUs should consider more than one automated delivery system. Some systems may require additional electrical outlets or data port connections.

Medication Rooms. Secured medication rooms should provide adequate space for medication storage, a refrigerator restricted to pharmaceuticals, space for an automated dispensing machine or a secure lock system for controlled substances and patient-specific medications, and a hands-free hot/cold sink. Ample countertop space and disposable sharps containers should be provided. Windows should allow visualization of the patient area during medication retrieval and preparation. Medication rooms should provide computer access to medication references and electronic patient records. A telephone is beneficial for communication with the pharmacy. An intercom or other device will permit communication with patient rooms and the rest of the unit.

Wall space should be available for posting information on drug interactions or specialized instructions. Cabinets or drawers should also be available for stock supplies of one-time use vials and storage of equipment, such as syringes, alcohol pads, and needles.

Interruptions, noise, and poor lighting may negatively affect accuracy of medication dispensing. Proper illumination, including task lighting without shadows or glare, can help to minimize medication errors. The Illuminating Engineering Society of North America has published recommended illumination levels for medication dispensing areas. To control for noise and distractions, the medication room may be enclosed to assist in concentration.

The medication room should be large enough to accommodate at least two staff, a nurse and a colleague who is double checking accuracy, without disruption or interruption. It should be proximal to the ITC or easily accessible from decentralized work stations.

ICUs must have access to 24-hr clinical laboratory services. These can be provided by the central hospital laboratory or a satellite laboratory within or near the ICU. If satellite facilities are implemented, they must provide minimum chemistry and hematology testing, including arterial blood gas analysis and mixed venous blood gas analysis. Space on the unit may be allocated for point-of-care bedside testing equipment. If blood gas analysis is frequent in the unit, consideration of space for a blood gas analyzer, including cooximetry, may be included in the overall design. With the increasing prevalence of drug-resistant pathogens, care should be taken to provide for separate storage and handling of specimens from patients in isolation rooms. Pneumatic tube systems may be used for rapid transport of specimens to and from the laboratory.

Imaging services should be readily accessible to the ICU. The unit should provide adequate storage for portable imaging machines. The patient archive communication system and a reading room with film-view boxes and/or digital access with high-resolution screens should be available within or adjacent to the unit.

A respiratory therapist is frequently a part of the critical care team and respiratory equipment and supplies are constantly in use. A respiratory therapy office, department, or support space within or near the ICU provides storage for supplies and equipment, such as ventilators and oxygen tanks, including separate storage for soiled equipment.

The patient room should be designed to accommodate certain imaging or invasive procedures. Areas for specialized medical procedures may be developed adjacent to or near the ICU, such as a cardiac catheterization laboratory adjacent to a cardiac ICU. The functional requirements for the unit will dictate the need for procedure rooms. Due to equipment and staffing costs, a cost-benefit analysis should assess the probable number of cases requiring these highly specialized rooms, currently and over the lifespan of the unit.

Provisions should be made for storage and rapid retrieval of one or more “crash carts” with emergency life-support equipment and supplies containing equipment, such as “difficult airway” carts, central venous access carts, and fiber-optic bronchoscopy carts. Institutional policies governing the ratio of crash carts to patient beds will dictate how much space to allocate. Emergency carts can be located in visible alcoves along a corridor with an uninterrupted power supply to charge the equipment’s batteries. They should not be stored in a room or behind a door where they may be hard to find in a crisis. There should be sufficient storage for other emergency equipment and supplies. The design should consider space needed for an emergency oxygen tank and extension cords.

Multiple areas should be allocated for storing nonemergency equipment, such as specialty beds, stretchers, wheelchairs, isolation carts, traction devices, diagnostic equipment, bronchoscopy carts, and other specialty carts. Some ICUs may stock duplicates of equipment used daily at the patient bedside, such as Doppler machines – one for patients in isolation, and one for other patients. The unit must provide adequate – and separate – storage for such equipment.

Storage locations for electrical devices (such as transport monitors, IV pumps, and monitoring equipment) should provide adequate electrical outlets for charging. Horizontal storage (shelving) should be planned, and space allocated for other support equipment specific to the ICU, such as blanket warmers, blood transfusion refrigerators, patient cooling devices, and equipment to house products that enhance patient bathing, such as chlorhexidine- impregnated cloths. Several studies have shown the benefit of these products for infection prevention.

Hazardous Waste. Storage space for hazardous materials, such as “red bags,” sharps, and radioactive materials, should be planned. Prompt removal of these items from the bedside to a separate location reduces risk to the patient and medical staff personnel. Policies and procedures for the institution should direct disposal and storage of such items. This function can be co-located with the soiled utility space.

Dedicated spaces should provide food, drink, and ice for patients, with minimal facilities for preparation. A sink with hot and cold water must be available. Some ICUs may need to accommodate dietary carts; such carts should be stored away from clinical areas. Automated dispensers for ice, coffee, and water should be conveniently located. Facilities must be readily accessible to personnel.

Additional nourishment spaces may be provided for family or visitors – many ICUs place these facilities in or near the family/ visitor lounge. Such facilities should provide adequate refrigerator/freezer and storage space. A microwave oven may be useful. For more information, refer to the Family Care Zone section.

ICU design must consider both vertical and horizontal transport paths. Patient elevators should be deep and wide enough to accommodate patient beds, support equipment, and transportation staff. Some elevators have electrical power supplies for emergency use. Separate elevators for service traffic are recommended. Other considerations include corridor widths, door-swing directions, and timed hold-open hardware. Emergency power sources should be available in the event of medical equipment battery depletion during patient transport.