Most healthcare providers have little experience designing and constructing an intensive care unit (ICU). These ICU Design Guidelines can make the process easier and the finished project more efficient, effective, safe, and patient centered. These ICU Design Guidelines are performance guidelines rather than prescriptive guidelines. A prescriptive guideline quantifies, as in the case of minimum square footage for a patient room, whereas a performance guideline describes functions to be accommodated. As an example, the space required for a patient room and medical equipment in a community hospital will be less than what may be required in a major tertiary care institution. In the case of a patient room, clinical protocols and equipment may evolve, rendering a prescriptive guideline obsolete. On the other hand, the prescriptive guidelines will describe things that must be done in the design of such space that may not be understood by the clinician, such as space for cleaning supplies and storage. This document proposes to describe optimum conditions rather than minimum requirements. The bibliography includes many tools that will round out the document and the process, and should be used in connection with this document.
The intent of these Guidelines is to offer a best practice approach as an alternative to the prescriptive minimum standards of The Facility Guidelines Institute (FGI) 2010 Guidelines for Design and Construction of Health Care Facilities. Other organizations, such as the National Health Service in the United Kingdom, have published guidelines to assist in the design of new ICUs, and these should be referred to in conjunction with these performance Guidelines. Optimal design ideally requires knowledge of both clinical best practice and building codes.
Due to the global nature of intensive care, these Guidelines are written with the intent to be used by healthcare organizations around the world. While the FGI provides healthcare guidelines that could be accepted globally, many of the standards set forth in the FGI Guidelines were born from policies and regulatory standards developed in the United States.
These ICU Design Guidelines are based on the concept of form follows function and that the configuration and performance of a critical care unit should be driven by the function and place it serves. As such, these ICU Guidelines must adapt to a range of facilities, from a rural or community hospital to a teaching hospital. These Guidelines are intended to apply to adult medical/surgical ICUs. Other patient populations, such as pediatric, neonatal, and subspecialty, may have additional or different requirements that may not be mentioned in these Guidelines. Some issues are changing so rapidly, such as information technology, they are referred to only briefly. During the design process, experts in information technology may be helpful along with the architects and engineer involved in construction.
Why Build a New ICU or Renovate an Old One?
Hospitals undertake ICU construction for many reasons: to adapt to changing patient demographics or disease patterns; to upgrade or add services; and to accommodate changes in the flow of information, materials, or patients. New construction may become cost effective when an older ICU requires expensive repairs or upkeep to remain viable, or simply ceases to function well.
Changes in performance standards and new issues in reimbursement and risk management may suggest alterations. Designing for infection control – by separating patients, adding isolation facilities, adding hand hygiene stations, upgrading mechanical ventilation and filtration, revising provisions for disposal of human waste, or introduction of antimicrobial materials – can lower infection rates and therefore morbidity and mortality, cost per case, and length of stay.
Changes in the model of care delivery may drive ICU design. Advances in technology have led to miniaturization of equipment, and have increased the amount of equipment needed to care for patients. Persistent shortages of skilled staff and aging of the critical care staff have added new criteria for selecting technology and for making ICU design decisions.
The Design Team
ICU design is complex and should include both clinically oriented and design-based Multi-professional team members. Each team member will bring specialized skills and knowledge to focus on the project at hand, which might be a remodeling, an expansion, or a completely new ICU. It is likely that design team members will have been involved in healthcare and ICU projects; it would be less likely for the clinical team members to have been part of such an effort. However, it is helpful for the clinical team to become familiar with the design regulations to help with interdisciplinary team communications. Learning to communicate clearly with those outside of your field may be a challenge. The ultimate ICU design – in cost, size, and details – will most likely be a compromise that balances various, sometimes competing interests.
Project team members and their primary roles will likely include: 1) hospital administration – unit sizing based on utilization, finance, and budgets; 2) the clinical team – a multidisciplinary group, including physicians, nurses, infection control specialists, pharmacists, therapists, and ancillary staff; 3) the design team – the architect, engineers (mechanical, electrical, structural), and technology planners (medical equipment, information technology, others); and 4) other hospital service representatives (materials management, environmental services, food service, others). The contractor, or construction manager, may or may not be included in the early stages of planning and design, but will be an essential team member. Environmental issues should be addressed both in the functional program and the final design. These may be relevant in the shell of the building and therefore might be addressed elsewhere in the design or in the actual design of the unit. Architects with LEED (Leadership in Energy and Environmental Design) certification may be helpful in this part of the process.
The Goal: A Healing Environment
Evidence shows that the physical environment affects the physiology, psychology, and social behaviors of those who experience it. The goal of the design process is to create a healing environment – the result of design that produces measurable improvements in the physical or psychological states of patients, staff, physicians, and visitors. Elements of a healing environment include: materials and finishes that reduce noise levels, minimize glare, and support infection control; floor plans, equipment, and other features, such as human engineering principles, may enhance efficiency and effectiveness of patient care and minimize workplace injury; stress-reducing furnishings and decor, incorporating natural light and views of nature; and thoughtful provision for the creature comforts of patients, families, and staff. Optimal ICU design can help to reduce medical errors, improve patient outcomes, reduce length of stay, and increase social support for patients, and can play a role in reducing costs.
Optimal design requires knowledge of best practices, design standards, and building codes. A design based on the functional requirements of the critical care unit and the consensus opinion of experts should enhance patient, family, and staff satisfaction, and in doing so, help to protect the institution’s bottom line. Staff satisfaction with the work environment has been shown to correlate with patient satisfaction and to improve retention and staff commitment.
One of the first pieces of work is the development of a functional (requirements) program. This should predate the actual design process and should attempt to determine what function and functions are necessary for the design to accomplish. This will include some discussion and understanding of workflow that is usually done in the unit and its environment. Developing a functional program is frequently lost in the process, but the design will of necessity be different for different functions. An example of the functional design may be: do you need isolation facilities and how often do you need them? By recognizing this need before the design process, the design can incorporate these items in the final product. Another additional task that in some way parallels the early process is the development of an Infection Control Risk Assessment. This will entail a thorough look at the risk of infection both during the construction and the utilization of the facility.
Of necessity for the healthcare team, an educational process may need to occur before the actual design, and perhaps at the same time a functional program is being prepared, and will lead into working with the process. In addition to this document, articles and reading in the bibliography may be the basis for a large part of the educational process.
Evidence-based design allows design teams to benefit from the accumulated and ever-changing experience of others, just as evidence-based medicine identifies best practices in health care. Evidence-based design is defined as “a process for the conscientious, explicit, and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project”. One pathway to best practice design is to study or visit award-winning units, such as winners of the annual design contest jointly sponsored by the Society of Critical Care Medicine, American Association of Critical Care Nurses, and American Institute of Architects. Video recordings and floor plans of these units are available in a package from the Society of Critical Care Medicine.
Design of critical care facilities has an impact on organizational performance, clinical outcomes, and cost of care delivery. Organizations involved in design and construction projects are advised to engage experienced consultants who will collaborate with the users and make key design decisions on the basis of best current evidence.
Ref: Thompson DR, Hamilton DK, Cadenhead CD, Swoboda SM, Schwindel SM, Anderson DC, Schmitz EV, St Andre AC, Axon DC, Harrell JW, Harvey MA, Howard A, Kaufman DC, Petersen C, Guidelines for intensive care unit design, Crit Care Med. 2012 May;40(5):1586-600.