Dan Thompson, MD, FCCM
Albany Medical College
Albany, NY

Evidence-based design is receiving notice in the architectural literature and is starting to appear in the healthcare literature.^1,2 It offers a parallel to evidence-based medicine. Evidence-based designers make critical decisions, together with an informed client, on the basis of the best available information from credible research and the evaluation of completed projects.3,4 There is a growing body of research relevant to the design of healthcare environments.5,6 Basing intensive care unit (ICU) design on research findings seems particularly appropriate.

Facility design Influences organizational performance

Contemporary trends relevant to ICU design

The trend of multiprofessional teams led by intensivists in critical care implies greater interaction among the disciplines.  Physical designs need to augment the new communication patterns.9 At the same time there is growing concern that the number of qualified professionals will be limited, suggesting designs that help fewer staff accomplish more. This smaller workforce is currently disproportionately older, with the average age of critical care nurses exceeding 45 years. Design considerations must help reduce the heavy labor aspects of necessary tasks and allow for more efficient and safer use of staff to assist patients.

Advances in electronic record keeping and monitoring have moved the records from paper to electronic, allowing access from multiple points.  Single access records were one of the original reasons for a central nursing station. Records simultaneously available at multiple computer screens allow movement of caregivers back to the bedside.  Design should support record keeping near the bedside.

The JCAHO emphasized the need for quality and safety improvement, as have the Institute for Healthcare Improvement (IHI) and the SCCM.¹⁰  Good design can have a positive impact on infection control, compliance with regulations, clinical and economic outcomes. Data on infection control are one of the influences leading to an increase in all private rooms in critical care designs.⁵ Indications suggest that the 2006 edition of Guidelines for Health Facility Construction will further encourage designs featuring single rooms.¹¹

Increasing amounts of equipment and higher acuity patients require increased space in the patient room.¹²  New equipment and devices offset the modest space gained from miniaturization of some devices. At the same time there is also attention given to increasing patient room size to accommodate families.

A trend in life support systems is progressing from headwall designs, which rarely deliver intended flexibility, toward power column designs that offer increased access to the patient’s airway in a crisis and greater access to the patient’s upper body during routine care. Renovation of many older designs with smaller rooms cannot accommodate newer life support configurations, so headwalls may still be necessary. The next generation of design appears to be progressing toward pendant-mounted systems that can move for greater flexibility and offer less obstruction of the floor space.¹²

Support functions (storage and staff support spaces) are now being designed in close proximity to the work environment.¹³ At the same time, more procedures are being performed within the unit or patient room. This can include simple activities like point-of-care testing and portable imaging or more complicated activities such as line insertions, tracheotomies and even invasive imaging.  Design must take into consideration necessary movement of the patient in and out of the unit.  Proximity to the emergency room, operating room and radiology suite are some examples of important relationships.

The advent of e-ICU models utilizing remote monitoring has facility implications in design of the room and the entire unit.¹⁴  This model requires higher resolution video monitoring, remote telemetry, and sophisticated communications systems. The staffing and decision-making patterns of these remotely monitored units mandate physical adjustments in the availability of support for the local caregivers.

Planning for safety, improved patient outcomes, along with patient and family satisfaction should be fundamental to each design. Environmental research suggests that the critical care unit should be planned for a quiet, low stress setting with natural daylight and views of nature.^15,18

Acuity-adaptable designs that support combined units of critical and step-down levels of care are becoming more prevalent.¹⁷  Jointly managing these two types of units and their distinct staff members can allow staff to move in order care for the patient rather than physically moving the patient. Results from such units show reductions in length of stay, errors, falls, and dramatic reductions in transport expense.¹⁸

What will the future bring?

Changes associated with these trends are likely to result in a bigger and more costly unit.¹³  Organizations planning new units should utilize experienced teams committed to evidence-based practice in order to minimize unexpected problems and to take maximum advantage of design opportunities. Development of a functional program will facilitate important dialogue.  Clinicians and their designers should conduct benchmark tours of new units to understand current best practice models. Design of new critical care units should be based on intentional decisions about tour observations, functional plans, new trends, as well as the unit’s idealized work patterns.

Healthcare leadership recognizes the need to plan for flexibility in the face of almost continuous change. Healthcare’s economic imperative places an emphasis on design for efficiency and performance.^9,12  To reach these goals, we need to improve staff experience by attention to convenience, satisfaction and retention of a quality work force.

A new design is likely to entail extensive physical and organizational change. To offset resistance associated with learning to use a new environment, preparing the staff for inevitable culture change will be critical.¹⁹  The potential benefits make it worth the investment.