PATIENT CARE ZONE

Clear floor space is space not occupied by the patient, fixed room furnishings, and equipment. It excludes other defined spaces, such as anterooms, vestibules, toilet rooms, and closets, as well as built-in equipment, such as lockers, wardrobes, and fixed casework. Clear floor area dimensions must allow room for services that are brought to the bedside, such as portable imaging, echo-cardiology, trans-cranial Doppler examination equipment, electrocardiogram, nuclear medicine, dialysis equipment, and more.

Single-patient rooms should have an optimal clearance of not less than 4 ft at the head and foot of the bed and not less than 6 ft on each side of the standard critical care bed. This clearance does not include space needed for staff and family support functions.

The choice of system(s) for mounting and organizing electrical, medical gas, and other medical utility outlets has a major impact on patient and staff satisfaction. The design team should consider the patient type, functional plan, staff preferences, technology trends, and potential future needs. Options for mounting and configuring medical utility outlets include the flat headwall system, fixed column, suspended column, and boom configurations. Combinations or hybrids of these systems may be appropriate. The medical utility distribution system will have an impact on patient room layout and size.

Flat (or Headwall) Configuration. The flat headwall configuration is mounted on the wall at the head of the bed. This configuration is widespread. It allows outlets to be easily arranged according to patient needs. This configuration can also create problems during a crisis or “code” situation by forcing the staff member responsible for keeping the airway clear to step over a tangle of lines, tubes, and cords.

Column Configuration. The column configuration has an array of outlets on a non-movable vertical column attached to the floor and to the ceiling. The non-movable suspended column variant hangs from the structure above. Distribution of the outlets can vary depending on the needs of the purchaser.

Boom Configuration. The boom configuration consists of a movable articulated arm(s). Ceiling-mounted booms offer maximum flexibility in positioning and accessing medical gas, electrical, and data outlets. There is a wall-mounted version best suited for renovations. Accessory shelves, brackets, and poles may be mounted on these devices, allowing optimal positioning of all support devices, such as monitors, computers, communication devices, and intravenous (IV) pumps. The use of booms permits maximum flexibility in bed placement. Pendant-mounted boom configurations offer immediate and unrestricted access to the patient’s head during a crisis, but may be confusing to the patient.

Medical Gas, Vacuum, Data, and Electrical Outlets. Medical gas, vacuum, data, and electrical outlets need to be accessible from each side of the patient bed and arranged to provide enough room for multiple, simultaneous procedures. The design team should consult the minimal recommendations for gas, vacuum, data, and electrical outlets in the most current edition of the FGI Guidelines, but the unit’s functional program may require more than the prescribed minimum. It is recommended that 50% of the electrical outlets in the patient room should be connected to the hospital emergency power system.

The oxygen system must also be easy to access during intubation or extubation procedures. Face and aerosol masks should be accessible from either side of the bed. Because several devices use compressed air, including ventilators and pneumatic percussion devices, adequate space is needed for additional medical compressed air outlets.

Rooms may need at least five vacuum (suction) outlets for bronchoscopy, esophagogastroduodenoscopy, and other bedside procedures, and to accommodate patients with multiple drains (such as chest tubes and wound drains).

In an effort to embrace electronic point-of-care documentation, patient rooms may be designed to accommodate computer terminals and mobile computing solutions. If a wireless system is not provided, data ports for in-room computer terminals should be located so that clinical staff can view the patient while documenting or accessing patient information. Placement of computers should protect the confidentiality of patient data.

IV Pumps. Designers must provide adequate electrical outlets, as well as space, for pumps and IV bags for administering IV fluids and medications, as indicated by the interdisciplinary care team. Most pumps connect electronically to patient monitoring or data acquisition systems.

Medications. Medication needed on a frequent or emergency basis must be readily available either within or near patient rooms. A computer-controlled dispensing system will fulfill this requirement (See Preparing and Dispensing Patient Medications in the following section). Bedside medication storage should be secure and able to accommodate large or odd-sized articles, such as IV bags and large syringes. To reduce staff travel, consideration may be given to placing a small refrigerator in patient rooms for medications that must remain cold, or provide a central refrigerator for staff to access medications.

Supplies. In-room storage and handling of patient care supplies must minimize on-hand inventory and waste while economizing efforts of the bedside staff. Infection control is an important consideration and storage for clean and soiled items must prevent cross contamination by visitors and staff, and between the patient’s gastrointestinal and pulmonary tracts. The design should provide adequate, convenient space to handle linen during changes, a clean, dry surface (fixed or portable) for stacking clean linen, and a hamper for soiled linen. Separate storage should be provided for clean and used gloves, gowns, hair coverings, shoe covers, and eye protection.

The door system should be sized to permit rapid movement of patients, bariatric beds, equipment, and personnel into or out of patient rooms in the event of a crisis. Sliding glass doors with breakaway capacity may provide beneficial additional width as well as increased visibility to the patient.

Natural light is essential to the wellbeing of patients and staff, and is required by most codes. Each patient care space should provide visual access to the outdoors, other than skylights, with not less than one window of appropriate size per patient bed area. Window coverings should be easy to clean, in accordance with infection control guidelines.

Providing patients an outside view – preferably overlooking a garden, courtyard, or other natural setting – may help relieve anxiety and stress, improve care, enhance patients’ comfort, and improve patient orientation. In cases where a patient’s bed must face the interior of the unit to permit close observation by staff, an adjustable mirror mounted on the wall or ceiling may provide the patient a view of the outdoors.

Critical care patient rooms, at a minimum, contain the following: a hospital bed designed for the critically ill patient; one chair suitable for use by the patient and one additional chair for visitors (both with cleanable upholstery); soiled linen collection hamper or similar device; containers to collect trash and waste products; and containers to collect hazardous waste products, such as needles and syringes. The use of specialty and special-sized beds should be remembered when calculating required bed space.

To create a comfortable environment for patient healing, rooms should include a clock, a calendar, and tack boards or similar devices to permit patients and families to personalize the room. Whiteboards should also be provided to allow patients and their families to be aware of their care team. Horizontal surfaces should be provided for greeting cards, photos, and other creature comforts, and placed where patients can see them.

The unit’s functional design may allow for, or require, patient and family education. Appropriate materials should be provided to serve this purpose and to communicate general information about the institution. Each patient room may be equipped with a television and educational/ entertainment system, controllable by the patient or family, to support patient education goals and also to provide positive distraction and entertainment.

Clothing and Personal Effects. The design should include secure storage of patient and family clothing and limited personal effects.

Workflow and clear-space requirements will drive design decisions about how best to meet family needs and integrate families into patient care. Families may be accommodated in a designated Family Support Zone in or near the unit, in patient rooms, or in some combination of the two. For in-room overnight stays by family members, a variety of fold-out furniture options are available. Another option is to design hotel-type patient suites, where a family space adjoining the patient room might provide a desk, Internet and telephone access, and secure storage for a limited number of personal possessions.

Pleasant surroundings for patients and staff promote increased comfort, and in some cases, improved outcomes. Color schemes can affect mood and stress levels. Scenes of nature in greens and blues have been shown to decrease stress levels for patients and are probably helpful for families and caregivers. Pictures and artwork can be selected and placed appropriately for patients, families, and caregivers. For bed-ridden patients, the ceiling is most often what is seen. Attention early in the design process will ensure the implementation of positive distractions in addition to required ceiling-mounted medical equipment, such as a selection of images that can be incorporated into ceilings.

Critically ill patients often suffer from delirium and there is evidence that pictures and images featuring geometric designs or abstract art should be avoided. Similarly, avoid the use of bold patterns on horizontal surfaces, window coverings, and furniture upholstery.

In consultation with the care team, patients and families should be able to control patient room temperature.

Patients exposed to increased intensity of natural sunlight have been shown to experience less perceived stress, use fewer analgesics, and have improved sleep quality and quantity. Bright light, both natural and artificial, has been shown to reduce depression among patients. Artificial light for general illumination and specific tasks is essential. Consult recommendations for lighting levels developed by the Illuminating Engineers Society of North America, outlined in the Illuminating Engineers Society of North America Handbook.

A high-intensity light source for clinical procedures should be readily accessible. This light source may be portable, or wall or ceiling fixed. To prevent burns, incandescent and halogen light sources should be avoided, or if used, covered by a lens or diffuser. Flexible arms, if used with this light source, must be mechanically controlled to prevent the lamp from contacting bed linen. Each patient bed should also have a reading light that can be easily controlled by the patient.

General illumination should feature adjustable lighting levels, designed to minimize glare within the patients’ sightline. Indirect lighting is preferred. Adjustable low-level illumination should support observation and movement around the patient at night or whenever the patient requires rest. It is recommended that emergency lighting and light intensity for tasks, such as charting or data entry, comply with the Illuminating Engineers Society of North America recommendations.

If space is provided to accommodate the family, appropriate lighting should be provided. This may include a reading light source designed not to disturb a sleeping patient.

Several studies have found that work-related injuries have become a major problem on critical care units, and lifting is one of the most common causes of injury. To enhance patient and caregiver safety, mechanical lift devices can be built into the ceiling, or mobile lifts can be provided. If mobile lifts are provided, storage space must also be provided in close proximity to the patient room.

A variety of fixtures and options are available for fluid disposal, hand washing, and toilet facilities in patient rooms.

Hand Hygiene. Evidence suggests that the presence of both soap and water and alcohol gel systems are required for maximum performance and hand hygiene adherence.

Sinks. Sinks in patient rooms should be placed near the entrance and near disposal systems. Dispensers for soap should be located near the sink. A paper towel dispenser and trash receptacle should be next to the sink to minimize dripping of water onto adjacent surfaces. Sinks should enable hands-free operation. Foot-controlled devices are not recommended, since the design and mounting methods for these devices create difficult housekeeping and infection control conditions.

Alcohol gel dispensers. Alcohol gel dispensers with effective disinfectants should be located for convenience in the patient room as well as in other staff locations around the unit. In the patient room, this can include locations proximate to a hand-washing sink and near the head or foot of the bed. Placement of devices at the threshold or place of entry of each room allows for ease of access and a visual reminder for hand hygiene.

Toilets. Relatively few intensive care patients are expected to use a conventional toilet. Exceptions may include patients under observation, or before discharge. Shared toilets can be a source of cross contamination.

Toilet options for patients with limited mobility. Room design should afford privacy in the use of mobile commode chairs, or bedpans for patients who cannot get out of bed. Swing-out or fold-down commodes are not recommended because they create infection control concerns and may not be rated for bariatric patients. A fluid-disposal or bedpan flushing device should be available in each patient room or as part of an adjacent toilet. Some bedpan washers can create aerosol sprays with biological contaminants. If used, barriers that protect the staff member from exposure, or sealed models, should be part of the design. A closed macerator system in conjunction with disposable bedpans and basins or a sealed bedpan cleaner is a desirable substitute for a bedpan washer attached to a conventional toilet.

Toilets for bariatric patients. Designers should consider the needs of bariatric patients, such as providing floor-mounted fixtures that have greater bearing capacity.

Fluid Disposal. Each patient room should have direct access to a fixture for the disposal of fluids. Closed systems that do not spread aerosols are preferred. Options include macerators, bedpan washer/sterilizers, or clinical sinks placed within the room or between two rooms. A toilet (water closet) fixture may also satisfy the requirement for fluid and waste disposal. If fluid disposal is not made available in the room or in a connecting room, it should be provided in close proximity via the corridor, although this option is not optimal.

If the design requirements include bedside renal dialysis or continuous renal replacement therapy, appropriately conditioned water and drain facilities must be provided, with the capacity to deliver deionized water if necessary. Water and drain connections should be separate from hand-washing sinks and located so that dialysis equipment can be placed on either side of the patient’s bed.

Management of sharps, such as needles, blades, wires, and devices soiled with body fluids, feces, and urine, necessitates serious design consideration. Sharps containers must be placed within patient rooms where they are visible and within reach, be placed in an area free from obstruction, and in some cases, be portable. Large sharps containers allow easy and safe disposal of sharps from invasive procedures. Smaller bedside containers often cannot hold larger items, such as guide wires and catheters.

For infectious patients, formal isolation facilities must be available when the functional program dictates. Negative pressure, relative to adjacent spaces, can be used to prevent the spread of airborne pathogens from an infected patient. If an anteroom or alcove is provided, it should afford space for staff to don protective (universal precaution) garments and equipment before entering the isolation room. The number or percentage of isolation rooms in a critical care unit is dependent upon circumstances of the institution.

For patients who require protection from infection, positive pressure in the room’s air handling system ensures that airborne external contaminants will not enter the room’s environment. When determining the percentage of isolation rooms in a unit, infection control personnel should be involved to define the number of isolation rooms.

Pet visitation has been shown to be therapeutic. This may be of particular value to long-term patients. If the functional program includes pet visitation, then the unit design must accommodate it. Infection control protocols must be carefully followed.