Technology and the Future of Intensive Care Unit Design

Crit Care Nurs Q Vol. 34, No. 4, pp. 332–360 Copyright c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Technology and the Future of Intensive Care Unit Design

Mahbub Rashid, PhD, RA

Changing market demand, aging population, severity of illnesses, hospital acquired infection, clinical staff shortage, technological innovations, and environmental concerns—all are shaping the critical care practice in the United States today. However, how these will shape intensive care unit (ICU) design in the coming decade is anybody’s guess. In a graduate architecture studio of a research university, students were asked to envision the ICU of the future while responding to the changing needs of the critical care practice through innovative technological means. This article reports the ICU design solutions proposed by these students. Key words: building technology, ICU design, medical technology

HE ARTICLE DISCUSSES the changing ICU design may come too late at a high price, T needs in the critical care practice and or they may not happen at all. Designers are their implications on intensive care unit (ICU) taught to design spaces or objects for some design.Italsodiscussesmanyrecentinnova- given functions. While a thorough knowledge tions in medical and building technology that about the object of design and its functions is may help shape the future of ICU design by often desired, in spite of the best efforts the solving the problems of today’s ICUs. Finally, clinical knowledge base of a designer may not it discusses the basic features of a conceptual even begin to approach that of a professional design of an ICU of the future that incorpo- critical care provider. Therefore, it is vital that rates into the design many recent technologi- critical care providers take an active interest cal innovations. in designing their ICUs. The article does not deal with the clinical The article is broader than it is deep. It cov- practice of critical care medicine in any direct ers a lot of ground. Concerning this, the reader way, yet it hopes to reach out to critical care should note that design as an act is more syn- providers. Without their direct involvement in thetic than it is analytic. Designers often need the design of ICUs appropriate innovations in to take into account a lot of things at any one time. As a result, they cannot deal with every issue with equal importance. The presenta- Author Affiliation: University of Kansas, Lawrence, tion of this article reflects this need. It focuses Kansas. on a set of issues that appear to be important The author thanks the contributions of the following in the present context of the critical care prac- studio participants and guest critics to the article: studio tice. Even though the discussion on changing participants—Jaime Bland, Laura Boler, Andrea Long, trends in the critical care practice and innova- and Justin Rogers; guest critics—Dr Diane Boyle, School of Nursing, University of Kansas; David Hinsley, HDR tions in medical technology may not be fresh Architecture; John Kelly, TKH, Inc; Basil Sherman, WJE for critical care providers, they may find the Healthcare Architects; Steve Shogrin, HDR Architecture; implications of these trends and innovations and Frank Zilm, Frank Zilm & Associates. on the design of ICUs refreshing. They may The authors have disclosed that they have no signif- find the discussion on recent innovations in icant relationships with, or financial interest in, any commercial companies pertaining to this article. building technology as these relate to ICUs refreshing as well. Finally, the discussion on the Correspondence: Mahbub Rashid, PhD, RA, University of Kansas, 1465 Jayhawk Blvd, Lawrence, KS 66045 conceptual design of a future ICU should cer- ([email protected]). tainly be something new for them. The article DOI: 10.1097/CNQ.0b013e31822ba782 intentionally avoids references to any specific 332

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 333 products for the fear that such references can with more potential for negative patient, fam- be taken as endorsements. In this information ily, and staff outcomes. Therefore, a need to age, the willing reader should have no diffi- understand the role of environmental design culty finding the references of any products in making bigger ICUs safer for patients, fam- mentioned in the article if she so desires. ilies, and staff is indicated. It is also for safety reasons patients demand more involvement in the care they get in ICUs. CHANGING TRENDS IN CRITICAL CARE Since ICU patients are not able to communi- PRACTICE: WHAT DO THEY MEAN FOR cate for themselves in many cases, the role ICU DESIGN? of family members as surrogate decision mak- ers has become important in ICUs.2 In addi- Trends related to ICU patients tion to making decisions for patients, family In the 1960s and 1970s when critical care members can also help patients perform daily was taking its shape in the United States, functions, understand concerns about health, patients generally had very little knowledge foster a link to the environment, reinforce self- about ICUs. Today, after 50 years or so, pa- esteem, and enhance positive relationships by tients are more knowledgeable about ICUs. offering love and comfort.3 Furthermore, fam- Since critical care is not medical care as usual, ily members can help busy nurses and physi- patients and families want to know more cians become more effective.4,5 In recogni- about their ICUs. With the advent of the tion of the importance of patients and families World Wide Web, this information is available in patient care, the concept of family-centered at their fingertips. They can easily compare and patient-centered care models have been ICUs, and they are likely to choose those ICUs developed.6,7 The key elements of these mod- that are able to provide better care and ser- els are quite similar: keep patients and fami- vices. Suddenly, the marketplace has become lies informed and actively involved in med- competitive for ICUs. To attract patients, pa- ical decision making and self-management; tient and family amenities have become sig- coordinate and integrate patient care across nificantly more important in ICUs than they groups of health care providers; provide the were 2 decades back. physical comfort and emotional support for Changing patient demographics is yet an- patients and family members; understand pa- other concern for ICUs. The percentage of tients’ concepts of illness and their cultural be- older population is rising in the United States. liefs; and understand and apply principles of It is also quite common for older patients to disease prevention and behavioral change ap- have more serious illnesses. In 2004, Angus propriate for diverse populations. Therefore, stated, “One in five Americans die using ICU a need to understand the role of environmen- services. The doubling of persons over the age tal design in patient- and family-centered care of 65 years by 2030 will require a system-wide is also indicated. expansion in ICU care for dying patients un- less the health care system pursues rationing, Trends related to clinical staff and more effective advanced care planning, and practices in ICUs augmented capacity to care for dying patients More patients plus higher acuity means a in other settings.”1 Meanwhile, new, noninva- bigger demand for ICU clinical staff. Cur- sive or less invasive treatments will eliminate rently, about 90% of the US hospitals fail the need for ICU stays for all but the most com- to meet the physician staffing standards for plicated patients with extremes of age. More ICUs that have been demonstrated to achieve complicated patients probably will stay much the most positive and cost-effective out- longer in ICUs. As a result, the need for ICU comes. If those standards were implemented beds will continue to rise. Intensive care units in all non-rural hospitals, it would prevent in general will get bigger and busier arguably 54 000 deaths and save $5.4 billion annually.8

However, neither the number nor the staffing all suffer preventable adverse events.8 Thus, of ICU beds is standardized or coordinated a need to promote a culture of safety through for population needs, possibly resulting in environmental design is also indicated. inefficiencies and lack of access, especially Nosocomial infections afflict 5% to 35% of for vulnerable populations.9 As the popula- the patients admitted to ICUs, and contribute tion ages and health care costs continue to to increased mortality, length of ICU and increase, supply-demand relationships may hospital stay, and medical care costs. While worsen if not coordinated. Currently there more than 80% of NIs in ICUs are caused are only 35 000 intensivists serving more than by ventilator-associated pneumonia, catheter- 4.4 million patients.10 According to data from related bloodstream infections, surgical site the 2008 National Sample Survey of Regis- infections, and urinary catheter-related infec- tered Nurses released in September 2010 by tions, both understaffing of nurses and over- the Federal Division of Nursing, the average crowding in the ICU (both resulting in high age of the registered nurse (RN) population patient to nurse ratios) have also been shown is 47.0 years, up slightly from 46.8 in 2004. to increase NIs. Reasons for these findings in- In March 2005, the Bernard Hodes Group re- clude lower compliance with hand hygiene leased the results of a national poll of 138 and increased colonization pressure in under- health care recruiters and found that the av- staffed ICUs, crowded ICUs, or both.13 Thus, erage RN turnover rate was 13.9%, and the there is a need for ICU design to help pre- vacancy rate was 16.1%. This is important be- vent cross-contamination and to help control cause about 37% of the RNs work in critical potential sources of pathogens that could be care settings.11 Given the challenges of work- transmitted between patients and from health ing in these intense environments, it is im- care workers to patients. portant to ensure the attraction, training, and To provide high quality care to critically retention of a stable workforce. Thus, a need ill patients, ICUs must successfully integrate for environmental respite and positive distrac- the skills of all clinical staff, including physi- tion to reduce stress among ICU staff for better cians, nurses, pharmacists, respiratory ther- clinical outcomes is indicated. apists, nutritionists, and other professionals. With sicker patients and clinical staff short- Research studies now demonstrate that em- age, patient safety has become a major con- ploying a closed unit management model, cern in ICUs. The 2 primary issues related to where intensivists take over primary medi- patient safety are medical errors and noso- cal management responsibility during the pa- comial infections (NIs). The 1999 Institute tient’s ICU stay, reduces mortality and length of Medicine report12 has made it abundantly of stay up to 30%, mainly because intensivists clear that hospitals are not the safest place have specialized skills in managing critically ill that we once thought them to be, and that patients and their continuous presence on the hospitals fail patients more frequently than unit to manage these medically volatile, pro- expected. Medical errors can and do occur foundly ill patients.14 Yet most hospitals in in any part of the hospital but patients are at the United States do not employ intensivists. greater risk in ICUs given their critical condi- Dedicated intensivist staffing is currently em- tions, the intensity of their care, higher num- ployed in only 10% to 20% of US ICUs.10 In bers of prescribed medications, and the com- contrast, in an open unit the patient’s pri- plexities of multidisciplinary decision making mary physician retains medical management, by the ICU team. Together, these factors add visits the patient on the unit at least daily, and up to a higher risk for adverse events, which remains in telephonic contact with the ICU are defined as unexpected harms to patients team. Either way, the foundation of the qual- attributable to their medical care. It is then ity ICU is the multi-professional team work- no surprise that of the over 5 million patients ing in concert for the benefit of the patient. who are admitted annually to US ICUs, nearly One of the benefits of the team approach is to

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 335 create a culture that is committed to quality dures, equipment, and processes by which and that allows staff to provide independent medical care is delivered. Examples of safety and quality redundancies. Specifically, changes in technology would include new the team approach creates a climate where medical and surgical procedures (eg, angio- other ICU professionals are allowed to ques- plasty, joint replacements), new drugs (eg, bi- tion the physician team leader and to help en- ologic agents), new medical devices (eg, com- sure that patients receive the care they need. puted tomographic scanners, implantable de- Therefore, hospitals and designers must look fibrillators), and new medical support systems at all the ways environmental design can help (eg, electronic medical records and transmis- improve teamwork and face-to-face interac- sion of information, telemedicine). There is tion in ICUs. very little in the field of medicine that does The focus on quality end-of-life care is an- not use some type of medical technology and other important clinical practice trend in that has not been affected by new technol- ICUs—which are the setting for approxi- ogy. However, medical care in no other field mately one-fifth of all deaths. The national of medicine has been more impacted by medi- movement to improve care at the end of life cal technology than that in ICUs. Indeed, most originated outside of the ICU setting, primar- ICU admissions occur because the patient has ily in specialized hospice and palliative care lost the ability to self-maintain homeostasis programs. However, in the past decade or so, or sustain other vital functions, thus requires ICUs have begun paying more attention to is- technology that is available only in the ICU sues of death and dying. Although some pa- for monitoring and therapeutic purposes. Al- tients die in the ICU despite the team’s best though ventilators, monitors, and catheters efforts, their families will survive and remem- still comprise the commonly used ICU tech- ber for the rest of their lives the care given nologies, innovations in information technol- to their loved one. The priority placed on car- ogy promise to radically transform medical ingattheendoflifeinmanyICUscanbe support systems as well medical practice in seen in policies such as 24-hour open visiting ICUs everywhere. privileges and the availability of well-designed Remarkable progress in health informatics family spaces, which are used not only for the in recent years has affected several domains of conversations between families and clinical critical care including ICU administration, re- staff about treatment decisions but also for source management, medical documentation, family comfort and privacy. Families are also diagnostics and therapy, imaging, communi- encouraged by staff to observe patients and cation, and clinical support system. For exam- sometimes to help care givers. Most often, a ple, during the last 2 decades, the widespread family support team is also available to meet use of electronic health records in many ICUs with family members at the bedside to offer has enabled more reliable, consistent, and au- practical, emotional, and spiritual support for tomated collection of comprehensive patient coping with the patient’s illness. Therefore, information including laboratory and even hospitals and designers must also look at all physiologic data. Integrated data collection the ways environmental design can help im- tools and software have enabled this data to prove end-of-life care in ICUs. be stored continuously and automatically in a central data repository. Improved computer RECENT INNOVATIONS IN MEDICAL interfaces and systematized data collection AND BUILDING TECHNOLOGY: CAN have enabled appropriate therapies to be THEY HELP CHANGE ICU DESIGN? automatically identified through computer prompts. Computerized protocols and deci- Innovation in medical technology sion support tools have ensured best practices pertaining to ICUs to be standardized and correctly imple- Broadly speaking, the term “medical tech- mented. In the near future, we may see many nology” can be used to refer to the proce- other innovations in medical informatics

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 336 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2011 optimizing seemingly routine aspects of care patient room, or other supplies. These signals that require continuous observation and may identify the people or things with which feedback. they are associated. The system may also in- As the popularity and capabilities of per- clude an input device such as touch sensitive sonal digital assistants (PDAs) and wireless display, a hand pad, a keyboard, or a bar code technology grow, knowledge translation and reader to receive these identification signals. diffusion in the digital world become in- Equipped with such capabilities, the system creasingly efficient as well. In many cases, may easily be used for monitoring administra- wireless technology and PDAs enable point- tion of medication to a patient. of-care access to medical information sup- Other areas of progress in medical technol- porting clinical decision making in ICUs. ogy are related to patient monitoring, diag- Bedside computer systems currently being de- nostic, and imaging. Portable computed to- veloped, many of which can be found on the mographic scanners eliminate, in many cases, Web site of the US Patent and Trademark Of- the need to transfer critically ill patients out of fice (http://www.uspto.gov/), promise easy the ICU for imaging procedures, thereby im- access to information at the point of care from proving patient safety. Advanced or “smart” a laboratory, pharmacy, radiology, or other lo- alarms, already in use at many places, react cations where it is needed. Such systems may to patterns and trends in several physiologic include both manual and automatic data en- variables at once to help identify a patient at tryatthepointofcaretocreateanelectronic risk of deterioration earlier than is possible record. They may permit caregivers to easily with any individual vital sign. Soon, monitor- input chart data directly into the computer. In ing devices will have the capability to learn addition, these systems may be able to receive from experience with an individual patient, information automatically from various mon- and will be able to simulate “pattern recogni- itors and medical devices such as vital signs tion,” enabling prompt identification of wor- monitors, bed therapy system, IV pumps, and risome trends. Recent advances in the field of the like. Therefore, all data related to the pa- molecular biology have sparked interest in de- tientwillbecapturedatthepointofcare.Not veloping methods of monitoring the molecu- only that, the system will be designed to stay lar diagnostics of injury and repair responses, with the patient wherever the patient goes though practical applications of these tech- from admit to discharge. niques are not likely to be seen for the next It is easy to see how a bedside computer sys- several years. tem may help improve communication. Labo- More recently, “electronic ICUs” (eICUs) ratory and radiology results will be presented have been able to harness many of the tech- electronically to the ordering and consulting nological progresses in patient monitoring physicians at the point of care. The system, and medical informatics. In eICUs, doctors working as a node on a network of comput- are now able to closely track evolving vital ers, may be able to facilitate patient care by signs and other clinical early-warning indica- enabling the creation of virtual teams of care- tors for several critically ill patients at one givers who may never actually meet when car- time. These patients can be in several ICUs ing for the patient. The system may also in- in different hospitals at different locations. stantaneously capture information related to Remote-controlled devices mounted in each the patients well as to the laboratory and di- patient’s room in these ICUs also allow doc- agnostic procedures ordered for the patient. tors to see the patients and converse with It is also easy to see how a bedside computer them and staff, as needed. This concept of system may use a wireless data receiver to re- eICU opens all sorts of possibilities. It can be ceive signals from badges of the caregiver and seen as an overlay on existing ICU staffing the patient and from tags on equipment, med- and structures. It may not replace the attend- ication, medication lock box located in the ing physician’s responsibility for managing

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 337 his or her critically ill patients, but may of- taldesignofICUsthanremoteeICUsdo. fer enormous potential for maximizing scarce They make computers available through the resources, including intensivists, critical care physical environment. Inspired by sociolo- nurses, and ICU beds. This telemedicine-based gists’ work on how people interact with ordi- program can also help improve job satisfac- nary physical tools, these systems blend into tion and help prevent burnout among criti- the work environment to create more natu- cal care professionals. Eventually, it could be ral ways of using computers. Of special in- used to leverage critical care resources into terest are the efforts that have been made smaller hospitals that could not afford or at- to amplify ordinary physical tools and envi- tract intensivists for their own ICUs. However, ronments with functionality from computer what effects eICUs may have on the environ- technology.16,17 For example, a digital pen mental design of ICUs are not clear. A very has been developed with a camera that scans advanced remote eICU of the future may be paper printed with a unique pattern to capable to significantly reduce staffing need in ture pen strokes.18 A bit more avant garde use ICUs, but for a health care service that is in- of ubiquitous computing include advanced tent on providing patient and family centered biometrics (eg, facial recognition systems), care any effort to significantly reduce direct visual surveillance systems that analyze hu- staff contact with patients and families using man settings and activities, and affective in- eICUs may not be a good idea. terfaces that analyze and mimic human emo- The evolving concepts of pervasive com- tional states, all of which may have some use puting, ubiquitous computing, and/or am- in future ICUs.19–21 bient intelligence are increasingly affecting One of the devices that helps make perva- health care and medicine, and soon may elim- sive computing possible is the radio frequency inate many limitations of an eICU. These sys- identification device (RFID). They are small tems are ubiquitous in the sense of being not electronic chips that contain unique identi- bound to 1 dedicated location such as a com- fiers and can provide physical tools with Inter- puter at a workplace. As such, telemedicine- net protocol addresses. The tags can be read basedeICUscannotbeconsideredperva- from a distance by an antenna, which enables sive computing systems, though in the near the tracking of tagged objects and humans in future both may merge to define a more physical space. In an effort to reduce costs context-sensitive “intelligent” system. In sim- and improve patient safety and services, nu- ple words, a pervasive system include mobile merous hospitals and medical centers have devices (eg, laptops, PDAs, mobile phones), been piloting and deploying radio frequency wearable items (eg, computer-enhanced tex- identification technologies to track high-value tiles, accessories, or medical devices), im- assets, patients, medical records, blood prod- planted devices, and stationary devices such ucts, and beds.22 Radio frequency identifica- as sensors or other integrated communication tion devices can also be used to connect pa- technology (ICT) components embedded in per forms and folders to the electronic world. “everyday objects” or infrastructure, such as With these techniques, ordinary paper docu- buildings, furniture, etc. Many of these per- ments and folders can be activated and con- vasive systems may also have “intelligence” nected to computers and then viewed as part in the sense of context awareness or deci- of a class of physical interfaces. sion support capabilities. In addition, some In the ICU of the near future, pervasive of these systems may be capable of pro- computing may have many uses, including cessing and transferring data without human improving communication and collaboration intervention. and preventing adverse events. Many adverse Though most of the currently available per- events occur in ICUs where nurses often work vasive systems are in their prototype stage,15 under cognitive, perceptual, and physical they hold more promise for the environmen- overloads. One contributing factor to these

Figure 1. With more technologies being utilized, the patient room in ICUs can easily become crowded, complicated, and confusing. overloads is the display of treatment orders, invoked against changes in ICUs. Therefore, monitoring information, and equipment sta- innovative ways to bring life support sys- tus on numerous, spatially separated informa- tems and medical utilities in ICUs, to treat tion displays. If these separate displays were ICUs for infection control, and to dispose ICU combined into a single integrated display at wastes for environmental safety and sustain- the bedside, the display could potentially re- ability must be considered carefully to replace duce nursing workload and improve nurse many present day unsustainable practices. awareness of the patients’ treatment plans and physiological status. The biggest beneﬁts, Innovative life support systems and med- however, will come when several clinical sup- ical utilities in ICU patient rooms port systems can be combined within a pervasive computing environment to help improve Regarding life support systems and medical patient, staff, and organizational outcomes. utilities in ICU patient rooms, one important fact to note is that with more technologies Innovation in building technology being utilized, the patient room can easily be- pertaining to ICUs come crowded, complicated, and confusing Today, environmental sustainability has be- (Figure 1). Each patient will typically have one come a major driver of building practices, and or more vital signs monitors, a ventilator, mul- the desire to improve patient safety and qual- tiple intravenous pumps, and half a dozen or ity of care has overshadowed the economic so other ancillary life supporting and/or ther- considerations that have been traditionally apeutic devices. The number grows as our

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 339 understanding of medicine increases and traditional head wall systems do not allow more technologies become available. easy access to the patient’s head, nor do they As for monitors alone, it is common for a pa- allow clinicians to reorient the bed in an emer- tient to have a basic vital signs monitor plus gency (Figure 2). another 3 or 4 monitors mounted on sepa- More recently, power columns, both rotat- rate wheeled carts crowded into any given ing and static, have been used in many ICUs room. Patient temperature, blood pressure, as a way to provide the life support systems electrocardiogram, heart rate, and blood oxy- (Figure 2). Equipped with medical utilities, gen levels are routinely monitored, as well as power outlets, and monitors, these power any number of additional vital signs or condi- columns are able to provide easy access to tions that may be of particular interest with patient head. Sometimes, they also allow clini- a given patient. The overall result is a com- cians to reorient the patient bed. Two, instead plex network of wires, transducers, displays, of one, power columns—one on each side of bulky cabinets, and device carts surround the the patient bed—are also installed in patient critical care patient. rooms to help increase the symmetry of func- The need to occasionally transport a pa- tions around the patient bed. Though wires tient from one room to another further com- running between the patient and the life sup- plicates matters. When transporting, each of port equipment and monitors can often be the numerous pieces of wheeled equipment hidden within a power column, this system must simultaneously be rolled to the new loca- does not facilitate patient transfer any better tion. Moreover, since virtually all the various than a headwall system. Sometimes, it can also technologies must first be disconnected from be difficult to work around power columns their wall power for transport, they must each during a procedure or an emergency. have stand-by-power or be manually operated. Other more recent innovations such as the Many of such stand-by schemes inherently risk ceiling mounted boom, ceiling columns, or loss of data in transit. The result, too often, is the ceiling mounted beams are able to pro- to simplify matters by completely disconnect- vide easy access and sufficient flexibility for ing the equipment during transport putting proper patient care in ICUs (Figure 2). These the patient at risk. ceiling-mounted systems, however, are very Both patient safety and staff working con- costly; and often require additional structural ditions, therefore, depend on how life sup- support. These systems may also potentially port systems and medical utilities are put in conflict with a bariatric lift system in a pa- an ICU patient room. Since the 1970s, head- tient room recommended for improving pa- wall systems have been used as a ways to tient and staff safety. In addition, patients may provide these systems in the ICU. Typically, feel unsafe if a boom is allowed to hang over a headwall includes power outlets and out- them when they are lying on the bed. Further- lets for medical gasses and vacuum on one more, older nurses also find it difficult to ma- or both sides of the patient bed. Some in- neuver heavy ceiling mounted booms. Even stallations also include wall-mounted equip- with these more advanced systems, patient ment and monitors at a place and height diffi- transfer is not easy. cult to reach. In general, headwall systems do It is only during the last decade or so, patient very little to eliminate the complex network bed computer systems or patient interface sys- of wires from all the equipment and moni- tems are being considered as an option that tors commonly used in ICUs. It also does not may help solve many of the problems associ- facilitate patient transfer. In a patient room ated with patient transfer. These systems carry equipped with a traditional headwall system, all the patient information with them and stay it is simply expected that either all equipment with the patient wherever he or she goes dur- must go with the patient or they must be ing hospital stay. Some of these systems even disconnected from the patient. Furthermore, have built-in monitoring devices eliminating

Figure 2. Different types of life support systems. (A) Headwall system. (B) Ceiling mounted boom. (C) Power column.

the need of complex wiring. When they do that needs particular attention. The incidence not have built-in devices, they are able to re- of infection ICUs is one of the highest in the ceive data from monitors wirelessly (see ear- hospital. About 20% to 28% more patients lier for more). However, even with these very in critical care acquire an infection by com- high-tech patient bed computer systems, ven- parison with patients in noncritical care. In tilators, and catheters that are connected to addition to the patients’ endogenous flora, the patient must be disconnected or carried cross-transmission from health care workers with the patient as they are transferred from as well as the immediate environment and one place to another. A technologically ad- the patient’s equipment have also been im- vanced solution that would allow ventilators, plicated as sources of infection in ICUs.23–27 catheters, and other medical equipment to go Higher number of patients together with un- with patients wherever they go during hospi- derstaffing among nurses may often lead to tal stay is yet to be found. poor compliance with handwashing protocols promoting horizontal transmission of resistant strains.28 The inanimate environment Pulsed light and infection control comprising air, water, food, floors, walls, and in ICUs ceilings can contribute to the risk of acquisi- Infection control in ICUs through innovation of infection in ICUs although their actual tive environmental technology is another area role is difficult to quantify in most instances.29

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 341 A number of professional and scientific bod- to review current design recommendations ies in the United Kingdom, the United States, and environmental technology to assess how and Europe have published guidelines on the they may minimize ICU-acquired infection. design and layout of ICUs to minimize the en- One technology that could potentially be try and persistence of microorganisms into used with traditional methods of cleaning in this environment. All emphasize the impor- ICUs improving infection control significantly tance of adequate isolation facilities (at least is pulsed light (PL). It is a technique to de- 1 room for every 6 patient rooms), sufficient contaminate surfaces by killing microorgan- space in patient room and around the bed isms using short time pulses of an intense (20m2or about 225 ft2), handwashing sinks broad spectrum, rich in UV-C light. UV-C is between every other bed, High Efficiency Par- the portion of the electromagnetic spectrum ticle Arrestor filters for ventilation, positive corresponding to the band between 200 and and negative pressure ventilation for high-risk 280 nm. PL is produced using technologies patients, separate air supply to dirty utility that multiply the power manifold. Power is area to prevent air from re-circulating to other magnified by storing electricity in a capac- areas, functional and easy to clean nonporous itor over relatively long times (fractions of finishes that are able to withstand repeated a second) and releasing it in a short time cleaning with strong solutions, sufficient stor- (millionths or thousandths of a second).36 age space, separate rooms for clean utility and The technique used to produce flashes origi- dirty utility, and a separate corridor for re- nates, besides high peak power, a greater rel- moval of waste.30–33 Hospitals are also asked ative production of light with shorter bacte- to develop appropriate cleaning and disinfec- ricidal wavelengths.37 This technique has re- tion programs and to require compliance with ceived several names in the scientific litera- handwashing as imperatives to minimize in- ture:pulsedUVlight,38 high intensity broad- fection in this high-risk area. spectrum pulsed light,39 pulsed light40 and Yet, all design recommendations, barriers, pulsed white light.41 The first works on dis- and cleaning regimens often seem inadequate infection with flash lamps were performed in in preventing infections. Many antibiotic- the late 1970s in Japan,42 and the first patent resistant bacteria such as methicillin- dates from 1984.43 resistant Staphylococcus aureus, Serratia The classical UV-C treatment works in a con- marcescens, and vancomycin-resistant tinuous mode, called continuous-wave (CW) enterococci, may survive and persist in the UV light, as opposed to its modified and im- environment leading to recurrent outbreaks. proved PL version. Inactivation of microor- This is because traditional sites such as toilets, ganisms with CW-UV systems is achieved by general surfaces and sinks tend to attract using low-pressure mercury lamps designed high rates of cleaning but many hand-touch to produce energy at 254 nm (monochromatic sites, which are more likely to harbor and light), called germicidal light.44 More recently, transmit microbial pathogens, are only poorly medium-pressure UV lamps have been used cleaned.34,35 The responsibility for cleaning because of their much higher germicidal UV many hand-touch sites usually rests with power per unit length. Medium-pressure UV nurses, who are often very busy and almost lamps emit a polychromatic output, includ- permanently understaffed in many hospitals. ing germicidal wavelengths from 200 to 300 As ICU infections have a major impact on the nm.45 Another possibility for UV-C treatments patient (increased morbidity and mortality) is the use of excimer lasers, which can emit and the hospital (cost of investigations, pulsed light at 248 nm.46 PL works with xenon treatment of infections, and implementation lamps that can produce flashes several times of infection control strategies), it is important per second. to understand the propensity of certain The portable disinfection device, now com- microbes to persist in the environment and mercially available, produces pulsed xenon

UV light. The device inactivates bacteria, One disadvantage of PL treatments is the viruses, and spores without surface contact. possibility of shadowing occurring when mi- The device also deodorizes the air in the croorganisms readily absorb the rays, and are treated area. It can be used in both medical present one upon another. This makes the and public settings, including: surgical suites, organisms in the lower layers very hard to de- intensive care units, nursing homes, prisons, stroy in contrast to those in the upper layer,43 schools, public transportation, health clubs, although the use of relatively high peak pow- pharmaceutical manufacturing, food handling ers can overcome the shadowing effect. An- facilities, and in civil defense and bioterrorism other disadvantage is that in order for a PL defense applications. A trained and certified treatment to inactivate microorganisms, con- service technician wheels the device into po- tact between photons and microorganisms sition in the unoccupied room. After entering should occur. Therefore, objects between the the room variables into the control panel of light source and the microorganism that ab- the device based on the treatment plan for sorbs light will impair the disinfection pro- that specific room, the technician leaves the cess. Yet another disadvantage of PL treat- room, closes the door (with the door safety ment is that all interior surfaces should be sensor in place), and completes safety proce- flushed to achieve decontamination. There- dures before starting the treatment that lasts fore, any surface irregularities can complicate no more than few minutes. When the UV the process. Furthermore, a surface cannot be pulse treatment is finished, the device shuts decontaminated when it is in the shadow of down automatically and the room can be en- another surface. Thus, necessary precautions tered immediately. need to be taken when designing interior sur- Disinfecting treatments using a PL device faces for PL treatment. may provide some practical advantage over other cleaning devices in those situations Plasma pyrolysis and ICU wastes where rapid but better disinfection is re- American hospitals produce an average of quired. In a recent study conducted at a 2 million tons of waste per year, according large comprehensive cancer center, it was to the American Hospital Association. About found that use of pulsed xenon-UV (PX- 15% of hospital waste is classified as infec- UV) was more effective than standard man- tious. Infectious waste, known as red-bag ual room terminal cleaning in reducing the waste, includes materials considered potential room’s microbial burden and reducing levels health hazards because of possible contam- of known pathogens. Statistically significantly ination with pathogenic microorganisms.48 lower bacterial heterotrophic plate counts Therefore, its disposal is regulated. Tradi- (HPCs) and no VRE were found in rooms after tional methods of medical waste disposal PX-UV treatment, suggesting that the risk to include incineration and autoclaving, which the next occupant from environmental con- involves sterilizing the waste at high temper- tamination was correspondingly lower. The atures before it is taken to a landfill. Often study also found that the PX-UV disinfection due to insufficient temperature generated in system is quick enough to be integrated into the process chamber, incinerators produce daily hospital operations without adversely extremely toxic products like furans and diox- affecting patient throughput.47 Furthermore, ins. This can cause air pollution, or the toxic the treatment leaves no residual compounds pollutants left in the bottom ash can eventu- and chemicals behind that can cause ecologi- ally find their way into landfills. As waste reg- cal problems, are potentially harmful to hu- ulations continue to rise and environmental mans, or both. Xenon flash lamps are also standards are tightened, end disposal options more environmentally friendly because they (landfills, incinerations, etc) are thus becom- do not use mercury. ing increasingly narrow. At this time reducing

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 343 the amount of products used by hospitals is technology it is speculated that in the near fu- not a likely option, as most hospitals prefer to ture, plasma pyrolysis reactors may become use disposable products. About 90% of hos- widely accepted for on-site hospital waste pitals now use one-use disposable gowns and treatment. Therefore, the impact of an on- sterile drapes because of their potential to be site plasma pyrolysis system on the design of infectious after use.48 Therefore, focusing on waste disposal system in ICUs is indicated. other alternatives to the disposal of hospital waste, such as plasma pyrolysis, is the key to ICU OF THE FUTURE: STUDIO reducing costs and environmental impact. GUIDELINES, OBJECTIVES AND Plasma pyrolysis is a state-of-the-art technol- OUTCOMES ogy for safe disposal of medical waste.49 It is an environment friendly technology, which Studio guidelines and objectives converts organic waste into commercially use- The purpose of the design studio was to en- ful by-products. The intense heat generated vision the future of ICU design. Students of by the plasma enables it to dispose all types the studio were asked to project the needs of of waste including solid waste, biomedical a future ICU on the basis of the current trends waste, and hazardous waste in a safe and reli- in critical care practice discussed above, and able manner. Medical waste is pyrolyzed into then to design an ICU with appropriate level CO, H2, and hydrocarbons when it is exposed of technological sophistication to meet these to the plasma-arc. These gases are burned at projected needs. Students were encouraged a high temperature (around 1200◦C). In the to push the limits of current ICU design prac- plasma pyrolysis process, the hot gases are tices without losing the sight of all the impor- quenched from 500◦Cto70◦C to avoid re- tant issues pertaining to the practice of critical combination reactions of gaseous molecules care medicine. The studio guidelines required inhibiting the formation of dioxins and fu- that the underlying narratives of the proposed rans. Toxic gases found after the pyrolysis are design for a future ICU must make common well within the limit of emission standards. sense, and that the proposed design should The plasma environment also kills thermally- be something that could be built within the stable bacteria. Another advantage of plasma next 10 or 20 years. pyrolysis is the reduction in volume of organic As a part of the studio brief, students were matter, which is more than 99% (51). asked to design an ICU that would serve at A commercial plasma pyrolysis system, least 16 patients in a normal situation on which can treat waste at the rate of 25 kg/h, a given floor plate of a hospital building requires small space (∼ 15 ft × 15 ft) for currently under construction. Students were installation. On an average, 1 kW power is re- also asked not to change the geometry, size, quired to treat 1 kg waste. Consumables in this and vertical circulation systems (ie, elevators process are mainly electricity, water, and gas and stairs) of the floor plate (Figure 3). In (N2 or air). Studies show that if energy is re- addition, students were asked to assume that covered from the pyrolysed gases of medical any department that might require conve- waste, the destruction of approximately 600 nient relationships with the unit including kg waste per day for typically 50 kW is enough emergency rooms, operation rooms, imaging to break even. However, pyrolysis of plas- and testing laboratories, and pharmacy could tic (polyethylene) provides more than 90% be found on floors above or below the given combustible gases; therefore, breaking even floor and these departments could be easily can be achieved by destroying approximately reached using the vertical circulation systems 300 kg polyethylene waste per day.49 There- provided on the given floor. Furthermore, fore, the energy recovery from the waste can students were asked to design the shell and make the technology economically viable. On the infrastructure of the unit to meet their the basis of numerous advantages of plasma design objectives assuming that these would

Figure 3. Students use the floor plate shown in this figure for their ICU. They define a modular building system for the ICU using 2’X2’ vertical and horizontal grids. somehow be integrated with the rest of the prove bedside care, patient mobility and building. safety, and bedside access to information. Students were given the first few weeks of • Design ICU spaces and surfaces for PL and a semester to learn the current ICU trends and continuous-wave UV light (CW-UV) treat- to identify the design objectives for a future ments for better infection control. ICU. During the next several weeks, students • Design the ICU waste disposal system for designed the unit to meet these objectives plasma pyrolysis to reduce negative envi- under the direction of the author and other ronmental impact. experts in the field. Students identified the • Provide environmental respite and positive following design objectives for a future ICU: distractions to reduce stress for all in the • Envision a flexible architecture, where plug ICU. and play devices allow for easy modifica- • Overall, promote a more efficient model for tions, upgrades, and replacements of the health care practice and a better environ- ICU to meet the changing needs of critical ment for healing people. care practice. • Use appropriate space planning strategies Studio outcomes to avoid conflicts in movements of people and goods, to improve patient visibil- Built-in flexibility ity while maintaining an appropriate level To create a flexible ICU, students propose a of privacy, and to reduce the number and flexible, modular building system. The system length of trips made by nurses. uses plug-and-play devices for easy modifica- • Use recent developments in pervasive com- tions, upgrades, and replacements of the computing and medical informatics to facili- ponents, subsystems, and systems of the ICU tate communication and collaboration, data to meet the changing needs of critical care management, and patient safety. practice. The system uses 2’x2’ vertical and • Use innovative bedside technology, such as horizontal grids (Figures 3 and 4). Students the “smart” patient bed, the patient bed use this particular module for the grid because computer system, and/or the patient in- many building materials and components cur- terface system, to reduce bedside clutter rently available in the market can easily be fit- and overcrowding of technology and to im- ted onto this grid. Students also create a kit of

Figure 4. The reflected ceiling plan of the ICU showing different utility hubs. parts made up of framing units and panel units devices that typically spread germs may be of 2’X2’ module (Figure 5). These pieces can self-illuminated with CW-UV and thus become be mixed and matched manually because of self-disinfecting. their convenient size. Therefore, the unit can In circumstances where a high level of disin- be easily reconfigured when needed. Most of- fection is needed, PL is utilized. In lieu of mo- ten, the reconfiguration process may involve bile units currently available in the market, in making minor changes to walls and ceilings. future it may be beneficial to incorporate such On rare occasions, this may involve changing lighting into building infrastructure. Such in- the configuration of the unit altogether to ac- corporation may allow the system to com- commodate the surge in patient population pletely clean a space between occupations. because of a man-made or a natural disaster. By automating disinfection practices, many of Wall units of the system are pre-plumbed for the germ spreading practices or simply staff utility and can be plugged into the medical malpractices may be eliminated. gas hubs located in the ceiling. As soon as the Because the CW-UV and PL disinfect by wall units make contact with the 2’x2’ elec- way of lighting surfaces, space geometry and trical grid located in the ceiling (Figure 4), it surface smoothness become essential. Thus, automatically brings power down through the students use curvilinear shaped crown and wall conduit into the space. As a result, this base moldings along with semi-reflective sur- building system makes it possible to place a faces to ensure that each type of disinfecting wall anywhere on the grid and still gain access light reaches every corner of the patient room to medical gases and electricity. (Figure 6). In addition to CW-UV and PL, students also CW-UV lighting and PL for infection use a low-pressure plasma disinfector, a tech- control nology that may soon be available in the mar- Students incorporate a combination of CW- ket, at the patient room entrance. These units UV and PL for disinfecting patient rooms. are equipped with a motion sensor and a CW-UV will continuously disinfect individual prompt. If a person passes by a disinfector spaces within the ICU. While systems built without using it, the device notifies the per- in walls may primarily emit such light, work son that she needs to disinfect her hands be- surfaces, instrument panels, and interface fore entering the room (Figure 7).

Figure 5. The kit of parts of the ICU. These pieces can be mixed and matched manually because of their convenient size. Therefore, the unit can be easily reconﬁgured when needed.

bright task lighting is needed for procedures; soft and indirect lighting is needed for patient and family comfort; and natural light or broad-spectrum artiﬁcial light is needed for the patient’s circadian rhythm. In contrast, in staff work area, task lighting is primarily needed. After developing matrices showing lighting needs for different spaces in the ICU (Figure 8), students propose an intelligent digital lighting management system that would allow users to choose among various Figure 6. Students use curvilinear shaped crown “scenes” on the basis of their current mood and base mouldings along with semi-reﬂective sur- or task need (Figures 9 and 10). In addition, faces in the patient room ensuring that each type of they envision that data bands worn by the pa- disinfecting light reaches every corner of the room. tient may be used to send signals to the lighting module to inform it of sleeping schedules Intelligent lighting systems for different and other scenarios that may be encountered. functions The interface of such an intelligent digital Spaces within an ICU have different light- lighting management system can be mounted ing needs. For example, in patient rooms at multiple places in the patient room and,

Figure 7. In the staff zone of the patient room, which is located in and around the entrance doorway, students include a low-pressure plasma hand disinfector with a motion sensor and a warning device. They use smart surface for a part of the glass sliding door to display the patient’s name and status, the name and picture of the attending nurse, and the name and picture of the family member. Immediately inside, students put the digital environment control interface, the inlets for the pneumatic waste collection system (not shown in this ﬁgure), and 1 RFID-enabled supply storage. Next to the storage a smart surface can be seen. if necessary, can be engaged with various (for details see earlier). Such systems have mobile devices as well. Students propose to been in use for some years now in Roo- use light emitting diode panels composed of sevelt Island, New York and Walt Disney numerous light emitting diodes for different World, Orlando. The collection points of the types of lighting scenarios within a space pneumatic systems can be located in the pa- (Figure 11). Such light emitting panels may tient room, at some common locations within be incorporated into the grid of the build- the unit, or both. When located within the pa- ing system in any orientation, including walls, tient room, these collection points may elim- ceilings, and ﬂoors (Figure 12). inate the need to carry any waste out of the patient room, thus eliminating the risk of con- Waste disposal system tamination. In its simplest form, there can Students use pneumatic waste collection be only 1 pneumatic collection system that systems for transporting waste from the unit takes all ICU wastes to the treatment unit. In to an on-site plasma pyrolysis treatment unit its more complex form, there can be more

Figure 8. The matrices in this ﬁgure show the lighting needs for different spaces in the ICU. It also shows the primary and secondary users of these spaces, and the color and directionality of lighting needed for these users.

Figure 9. The conceptual and integrated intelligent digital lighting management interfaces.

Figure 10. Different lighting scenarios. (A) Lighting for procedures. (B) Lighting for routine work. (C) Lighting for sleep time.

than 1 collection system for hazardous medical wastes, recyclable wastes, and laundry. In this particular instance, students choose 2 separate collection systems—one for hazardous medical wastes and the other for laundry (Figure 13). Wastes are sorted and put in appropriate bags in the patient room, and are deposited into appropriate inlets located in the room. The pneumatic systems take hazardous wastes directly to where it needs to. These inlets can be color coded for safety (Figure 14). Automatic prompts can also be used to notify the kind of wastes an inlet takes as its lid is opened for a waste deposit. In ad- Figure 11. A light emitting diode (LED) panel may dition, student uses CW-UV lighting at these be composed of numerous LEDs for different types inlets to make sure the surfaces around them of lighting scenarios within a space. are kept free of germs.

Figure 12. Different types of lighting panels. (A) Basic illumination panel. (B) Recessed light strip. (C) Extruded wall washer. (D) Direct spot. (E) Horizontal surface lighting.

Figure 13. Pneumatic waste collection systems. (A) The medical waste is taken out of the building to a remote plasma pyrolysis treatment plant. (B) The medical waste is taken to a on-site plasma pyrolysis treatment plant.

“Smart” surfaces tient information can be pulled up on any one Students use “smart” surfaces for multi- of these surfaces within the facility with ap- ple functions within an ICU. These surfaces propriate access code. The medical staff can are enhanced with computer capabilities and carry a PDA that is in continuous communi- wireless communication devices. In addition cation with these smart surfaces to have all to the computers located on carts, in patient the patient information at their ﬁngertips. All rooms, nurse workstations, or ofﬁces, smart of the smart surfaces within the medical facil- surfaces can also work as computers. An ar- ity also constantly share data with each other. chitectural surface, a countertop, or a bedside For example, as the vitals and other measure- table could potentially become a smart sur- ments are being taken periodically on a pa- face to be used by the medical staff as well as tient, that data are automatically stored and patients and families. All these smart surfaces can be pulled up on any smart surface in the are treated as nodes in a network, and pa- facility. This also means that when a patient

Figure 14. The smart surface at the integrated headwall system in its idle state, and the waste collection inlets in the patient room. is being transported from one department to consider as well. These surfaces need to be another the patient’s chart will be available strategically placed, and privacy filters can be not only in the unit but also in any other de- used on portions of the surface to insure ap- partment within the building. propriate privacy and security needs. The smart surfaces within the patient rooms This concept of smart surface can be com- can be put on the integrated head wall sys- parable to what we find in an airport to- tem to display patient data (Figure 14). They day, where information display panels are dis- can also be put on the footwall for use by tributed everywhere to be seen by all. How- clinicians to explain clinical care related is- ever, it is assumed that smart surfaces in an sues to the patient and family, or for use by ICU or a hospital can be only accessed by the patient and family to gain access to enter- authorized personnel or people on demand. tainment (Figure 15). Because everyone can Otherwise, they would display general infor- use these surfaces, security needs to be con- mation for all. sidered. Advanced biometrics can be used to determine the level of access for someone to Smart patient bed protect patient information and to insure that Students equip the smart patient bed with a someone without proper identification is not computer system. As in any other patient bed able to view private medical information. The computer systems currently being developed placement of these surfaces is important to by manufacturers, this computer system stays

Figure 15. The smart surface on the footwall of the patient room can be used as a communication and collaboration tool for the patient, family, and staff. It can also be used as a form of entertainment for the patient and family. with the patient as he or she is moved from pacemaker, mechanical ventilator, deﬁbrilla- one place to another. It carries the patient’s in- tor, and the dialysis equipment. In addition, it formation with it. It also has built-in monitor- includes a rechargeable battery with enough ing devices eliminating the need of complex power to run these systems when transfer- wiring. Furthermore, it is able to receive data ring the patient from one location to another. from other monitors wirelessly. The bed has These systems are stored in drawers in the 2 interface panels—one located on the side lower part of the bed, and can be pulled out rail for the patient and the other on the foot- if needed (Figure 17). board for the clinician. The footboard of the The modular wall system in the patient board is also equipped with a smart surface to room serves as an integrated headwall sys- access the patient’s information (Figure 16). tem when equipped with a smart surface. The The footboard can be pulled up when the clin- headwall is also used as the docking station ician needs to use the smart surface. for smart patient beds. Housed within these Students also equip the smart patient bed walls are electrical and data connections, as with the most frequently used life support sys- well as medical gas connections (Figure 18). tems including medical gas storage, external When the patient bed is docked, it acts like a

Figure 16. The smart patient bed. (A) The patient information interface in its regular position. (B) The patient information interface in its pulled out position.

Figure 17. The smart patient bed equipment layout. normal patient bed, with the patient’s infor- the bed serves as an independent unit, ca- mation accessible from the smart headwalls. pable of storing and displaying patient infor- It is during its docking position the batteries mation and housing necessary medical equip- for the life support systems housed within the ment (Figure 19). bed are also recharged. Even in this docking Students hope that the smart patient bed position, the bed can be rotated as needed be- would help eliminate the clutter caused by all cause of the swivel, extendible arm that con- the wires running from the life support sys- nects the bed to the wall. When undocked, tems and monitors to the patient. It would

Figure 18. Details of the docking interface for the smart patient bed at the integrated headwall system.

Figure 19. Different positions of the smart patient bed. also help save space in the patient room by students anticipate that their smart patient eliminating the need to use medical equip- bed may signiﬁcantly transform the medical ment on wheels or carts. This space may be- care at the bedside. come very important during a lifesaving procedure. In addition, it would make charting, ordering, and accessing the patient’s informa- Patient room design tion easier. By providing patient information With all the components, subsystems, and at the bedside, it would also help improve systems in place, students now conceive the collaboration and communication among patient room of the future to have 3 zones. patients, families, and clinicians. Further- In the staff zone, which is located in and more, when equipped with a barcode reader around the entrance doorway, they include it could help reduce errors and streamline a low-pressure plasma hand disinfector with billing processes through monitoring any a motion sensor and a warning device. They supplies delivered to the patient. In short, use smart surface for a part of the glass

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Technology and the Future of ICU Design 355 sliding door to display the patient’s name and In the family area, students provide a soft status, the name and picture of the attend- pullout seating, dimmable exterior glazing for ing nurse, and the name and picture of the heat gain and glare control, a hand disinfector, family member. Immediately inside, students and a toilet equipped with the CW-UV and PL put the digital environment control interface, treatment systems. the inlets for the pneumatic waste collection system, and 1 RFID-enabled supply storage Unit layout options (Figure 7). Students divide their ICU into 3 zones: In the patient area, students include a digital the clinical zone with patient beds/rooms headboard on the integrated headwall system, and clinical support functions; the staff area and a smart patient bed. On the footwall, they with staff lounge, lockers, ofﬁces, conference include a smart surface that always show the spaces, and storage spaces; and the family date and time for the patient and others. When area with toilets and an information center not in use by the clinician to explain care equipped with smart surfaces. Since the unit related issues to the patient and family, the is designed using plug and play devices, stu- surface may display a soothing video of nature dents are able to conﬁgure the clinical area (Figures 20 and 21). When the patient is fast of the unit for different scenarios. In the asleep, the surface may be used by the family normal scenario, the unit has 16 private pa- for recreation. tient rooms with individual toilets and fam-

Figure 20. A view of a private patient room.

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 356 CRITICAL CARE NURSING QUARTERLY/OCTOBER–DECEMBER 2011 ily spaces, 1 centralized nurse station, and 1 patient rooms to be operated as step-down observation unit for every 2 rooms (Figures units. In this conﬁguration, the unit may be 20 and 22). This layout allows direct visibility able to accommodate unusual surge in patient of the patient from the nurse station and ob- population (Figures 21 and 23). In the third servation units. In another, students change scenario, students reconﬁgure the unit as an some of the private patient rooms to 2-bed openbedunitwithasmanyas40bedsby

Figure 21. A view of a semiprivate room.

Figure 22. The ICU layout with 16 private patient rooms.

Figure 23. The ICU layout with private and semi-private patient rooms.

Figure 24. The ICU with open ward layout. removing the panels for emergency mass crit- at the core of this progress. However, the ical care. In this conﬁguration, they still keep design of ICUs has not been able to keep the toilets and the disinfectant devices within up with this rapid pace of progress of the the unit (Figures 24 and 25). It may be worth practice of critical care medicine. As more noting here that in all these scenarios, the lo- technologies become available to practice cations of plumbing and waste collection in- critical care medicine, ICUs become increas- lets remain unchanged. ingly crowded, complicated, and confusing. The design of ICUs in general fails to sup- CONCLUSION port effective interdisciplinary communica- tions and collaborations and easy handoffs be- The practice of critical care medicine has tween providers. Information technology and made signiﬁcant progress during the last 50 medical informatics promise to bring patient years or so. No doubt, innovations in med- information closer to caregivers, but ICUs can- ical and information technology have been not support effective use of this information

Figure 25. A view of the open ward ICU. because of environmental design limitations. To overcome this, they must accept the idea Better technologies are available for disin- that technology has the ability to shape archi- fecting ICUs, but they cannot be used in tecture in a way that promotes a more efﬁ- ICUs for environmental design limitations as cient health care practice and a better envi- well. The design of ICUs in general does not ronment for healing people. As the practice provide user-friendly human-technology inter- of critical care medicine rapidly advances, it faces, thus causing stress among clinicians is necessary to take a new approach to inte- with negative outcomes. The list of environ- grate innovations made in practice with ICU mental design limitations get bigger as the design. Traditional building systems, subsys- technology for the practice of critical care tems, and components do not allow ICUs to medicine gets better. As a result, in spite of all become ﬂexible enough to accommodate in- medical and technological innovations critical novations as they occur. Therefore, there is an care patients are still unsafe, and the quality of urgent need to reconsider these building sys- critical care still has much room for improve- tems, subsystems, and components in a new ment. way. The students of this studio take this bold As students of this design studio correctly step. They take what is already available and pointout,onereasonwhyICUdesignfails simply suggest new ways to integrate them to keep pace with the developments in for a better ICU of the future. Such integra- critical care medicine is that hospitals and de- tion may work only if all the stakeholders join signers simply use technology as an additive force to harness the power of innovations in element, in which devices are placed into a ICUs in a way that supports everyday practice space as an afterthought to the architecture. of critical care medicine.

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