Innovation in the Design of the ICU

Innovation in the Design of the ICU

Patient-centered design has become the hallmark of most new con­struction in the health care field. This follows research that indicates that improved design can have a significant and positive impact not only on the out­come of the health care intervention, but on the bottom line as well. Patients and their families, fur­thermore, are asking for user-friendly environments that have a more natural feel and look. Consequently, improved décor, more privacy, reduced environ­mental stressors, natural surroundings, and greater patient control over tasks and information are becoming commonplace. Older hospitals are feeling this pressure as new facilities market their user-friend­ly environments to a responding public.

New approaches to design

As a feng shui consultant specializing in the health care field, I am often asked to bring a more nature-conscious and patient-centered perspective into the design process. In fact, the very inclusion of my discipline attests to the current effort to widen the scope of discussion in the planning of new facilities. Often the planning team will include, in addition to the traditional medical, nursing, manage­ment, and technology staff, community advocates, patients, their families, and non-medical personnel (religious, cleri­cal, custodial, etc). Interdisciplinary focus groups, community outreach, role play­ing, and mock design sessions are part of the new designer’s approach.

Nevertheless, concerns still linger over the priorities questioned by these new demands. Nowhere is this process more evident than in the design of the Intensive Care Unit. Here the demands of advanced technology come head to head with the need to care for not only the patient, but the patient’s family as well. On the one hand the severity of the interventions require the utmost in technology, methodology, and sterility. Patients and their families, on the other hand, are experiencing some of the most traumatic moments of their lives.

Patient’s Concerns

ICU patients and family focus groups often complain about overwhelming feel­ings of insecurity, disorientation, anxiety, fear and anger. The sheer volume of technology, the unfamiliar, sterile sur­roundings, lack of privacy, constantly revolving medical teams, incessant noise and glaring light, and the lack of natural forms, materials, and sensory experiences all add to this traumatic experience. As a result, the patients feel trapped in an envi­ronment they dislike and cannot control, and their families feel helpless. In addi­tion, the ICU patient is often predisposed to cognitive impairments due to their stressed conditions, psychoactive medica­tions, and physical trauma. The result is often dementia. A study at the Yale School of Medicine estimates that between 50% and 80% of older patients suffer dementia in the ICU.

Design Strategies

Many of the family’s concerns can be readily addressed by allowing the fam­ily to enjoy greater interaction with the patient and the ward. Waiting rooms in many new facilities now include sleep­ing accommodations, lockers, private phone and internet booths, playrooms for children, kitchen and pantry facili­ties, soothing music, and even fish tanks, waterfalls and nature views. In some cases, overnight stays in the ICU room are encouraged, particularly in pediatric facilities. Many designers now allocate a zone within the ICU room for this pur­pose. At the Woodwinds Health Campus in St. Paul, for example, the zone clos­est to the window is the family’s domain and can include a sleeper sofa. A similar arrangement is used at Clarian Methodist Hospital in Indianapolis.

Providing familiarity is another impor­tant concern. Designers are taking cues from the hospitality industry and creat­ing hospitals that feel much more like traditional homes. At Woodwinds and at Clarian Methodist, for example, a TV, VCR, and CD player are all standard in the room, as is a special tack board for cards and notes in the step-down units. A small shelf near the bed serves to hold personal items. Adjustable light dimmers can be controlled by a family member. At Woodwinds a sliding wall panel, finished in natural wood veneer, allows for the headwall delivery system to be concealed if the situation permits.

Despite the need for round-the-clock nursing supervision and for visibility through glass walls or large corridor win­dows, patient’s privacy can be enhanced by providing adjustable curtains and blinds. Low glare glass, furthermore, is helpful in controlling night-time reflec­tions within the room.

Need for a more natural environment

Research demonstrates that views of nature are important in the health care setting: patients who enjoy views of nature heal faster than control groups that look onto blank walls. Although codes now require windows in all ICU rooms, the view from these rooms should include greenery and more distant vis­tas. In some cases, landscapes and nature photography can be introduced within the room, not only as art on the walls, but also as part of the ceiling design and on fabrics.

Wall and furniture colors can also liven up otherwise sterile ICUs. Despite the need for seamless impermeable surfaces, advances in flooring materials now allow for more natural looking ICU floors and for finishes that reproduce nat­ural wood, foliage, flowers, and even animals. In all situations a “horizon line” should be added to the room that subliminally mimics the natural horizon humans are accustomed to out­doors. This should be located at waist height and should extend around the whole room. It can be rendered through window sills, door mullions, counter tops, or wainscoting.

Other ways of making the ICU less stressful include controlling sound and light levels. Computerized moni­toring equipment and the use of vibrating pagers and cel phones has made it possible to eliminate overhead voice pag­ers and some types of audible alarms. The modern ICU can now be a much quieter envi­ronment, allowing for better rest for the patient. Automated lighting controls make it pos­sible to change the illumina­tion patterns within the ward, mimicking the rhythms of day and night more effectively. In response to these trends, codes are also changing: permissible sound levels are lower than ever before and lighting regula­tions now reflect the cyclical rhythms of night and day.

Changes in technology

Despite the need for a more patient centered approach, technology still rules most of the decisions made in ICU design and is the single most important consideration brought up by physicians and nurses when developing a design model. Ironically, as technology has progressed, greater versatility has also become possible, allowing for accommodation to some of the patient’s most important concerns.

The drive towards central­ized intensivist medicine, for example, has forced many larger hospitals to cluster previously separate ICUs into one larger ward. The financial savings in this approach are obvious. What is not as obvious is that by doing so, ICUs have had to blur the edges between critical, acute, and step-down rooms. In fact, at a number of new facilities, the same room is now being adjusted to the level of care required by each patient. This reduces stress for the patient and can avoid costly transfers and census adjustments down the line. At Bellevue Hospital in New York City, for example, a brand new ICU now boasts of 55 patient rooms, all capable of instant flexing into any acuity mode. This has allowed the designers to justify sleepers and reclin­ers for over-night visitors in all rooms.

A similar transformation has occurred in the composi­tion of the care team. Since the room now functions at varying acuity levels, the patient no longer has to be moved as the acuity of their care fluctuates. This in itself greatly reduces stress on the patient. In addi­tion, the medical staff is now being cross-trained so that any given team can step into lesser or greater acuity mode. This has valuable patient and fam­ily appeal because the patient can be taken care of by a single team, whose members will follow the patient through all stages of their recovery, getting to know them and their fami­lies in the process. This effec­tively addresses one of ICU patient’s most frustrating com­plaints: lack of familiarity and rapport with their constantly changing medical team.

The Future

As the debate over critical care continues to unfold, better medical care will undoubtedly be available to a more informed public. Part of this process will have to recognize the need for a more patient-centered and family-conscious approach that can take care of not only the physiological needs of the patients, but their psychologi­cal and spiritual needs as well. The ICU of the future promises to be a true place of healing in which all dimensions of the patient’s needs will be met and in which advanced technology will accommodate the more subtle needs of the whole per­son.

Ref: Alex Stark, Innovation in the Design of the ICU