Description

Intensive care unit (ICU) design is a relatively new subject. While some of the other departments, such as the wards and facility services like laundry, have a tradition reaching back to the pavilion hospitals of the 18th century and even earlier, the intensive care unit emerged only in the second half of the 20th century. The first ICU was established in 1953 in Copenhagen, Denmark in response to a polio epidemic, and the idea was subsequently adopted in the United States. However, it took some time, until the 1970s, before this innovation became more broadly accepted internationally. The initial focus of the ICU was the treatment of cardiac problems, because of the high morbidity and mortality associated with myocardial infarctions. Later on it was found that the survival rate of polytrauma patients and the treatment of multi-organ failures could be improved in the ICUs, thanks to artificial ventilation, better fluid management and more specific medication.

Intensive care will remain an area of continuous technological change in the future, with the introduction of new and improved therapies, on the one hand, and the demographic shift toward an increasingly aged and multimorbid patient population, on the other. Intensive care units have, however, acquired a bad reputation. Since they are characterized by constant and very bright artificial light, absence of daylight (and therefore a disruption of the circadian rhythm) and, above all, continuous high levels of noise, they are often seen as the least pleasant places in a hospital. ‘Intensive care’, a nurse who worked in one for a time noted, ‘is, at best, a temporary detour during which a patient’s instability is monitored, analyzed and corrected, but it is, at worst, a high-tech torture chamber, a taste of hell during a person’s last days on earth’.[127] Equally exaggerated of course, it has been said that ICUs might satisfy the criteria for torture as defined by the Geneva Convention.[128]

Even though the application of evidence-based design in the ICU is ‘just in its infancy’, it can be taken as a starting point, since ‘evidence shows that the physical environment affects the physiology, psychology and social behaviors of those who experience it’. It should also be noted that ‘pleasant surroundings for patients and staff promote increased comfort and, in some cases, improved outcomes’.[129] An ICU should have efficient noise control and avoid exposing patients to bright light 24 hours a day: what is needed is a sense of ‘calm and balance’.[130] Two aspects stand out in the effort to enhance patient experience: accommodating families in the ICU and providing natural light with views to the outside world. Family provides social support, but it can make the staff nervous if the spaces are inadequate and crowded; thus, architectural interventions are indispensable in this regard.[131] Research carried out at one particular facility ‘demonstrated that family and patient satisfaction with ICU experience increased by 6 % in the new ICU environment consisting of noise-reduced, single rooms with daylight, adapted coloring and improved family facilities.’[132] Natural light ‘is essential to the well-being of patients and staff’.[133] ‘Natural light is one of the most comforting and familiar things you can provide in a hospital. Windows must be a part of all effective ICU and CCU designs. The height of the windows should be low enough for an optimum view so that patients can see both the ground and the sky. The idea is to admit a maximum of natural light to allow patients contact and orientation with the outside world, but the light should be controllable for sleeping.’[134] Moreover, research appears to prove ‘that the design of a new facility with increased light levels and window views may have a positive impact on staff vacancy and absenteeism. Results regarding their impact on patient pain levels and staff medical errors were inconclusive; however, the data can be used as comparators for other studies on this topic.’[135]

An important trend is the renewed emphasis on infection control (triggered by an increase in hospital-acquired infections). Measures to combat this risk include single-occupancy rooms in ICUs, acuity-adaptable/scalable beds (fit to accommodate critical ‘intensive care’ patients as well as ‘medium care’ patients on their way to recovery), hand-washing fixtures, hygienic management, ventilation, risk assessment, safe use of potable water and clean surfaces. Research suggests that placing a copper alloy surface on six common, frequently touched objects in ICU rooms reduced the risk of HAI (hospital-acquired infections) by more than half at all study sites.[136]

Four zones can be distinguished in the ICU: the patient care zone, the clinical support zone, the unit support zone and the family support zone. ‘Glass partition walls to facilitate surveillance and certain medical equipment have to be installed in an intensive care unit, but designers should try to make them as homely as they can, using natural materials and colors to soften the harshness of the environment they normally provide.’[137]

Perspective of the Patient

Patients in ICUs are closely monitored at all times, drugs are administered if needed, and personnel — medical specialists and a specialized, dedicated nursing staff — are at hand to come to the rescue in case of calamities. ‘The ICU is the stage for many of life’s most extraordinary dramas’, to quote Kirk Hamilton who has researched the design of intensive care units.[138] It is, however, a misconception to think that patients do not experience their time in the ICU intensely. Swedish studies have shown that ICU patients spend on average around 60 % of their time (during daytime) in a conscious state. Design efforts in intensive care must therefore pay careful attention to the patients’ needs.

ICUs can cause a lot of unintended and unnecessary harm to patients, particularly to those staying longer than 14 days. Studies indicate that around 30 % of long-term ICU patients develop posttraumatic stress disorder (PTSD), which diminishes the patients’ ability to return to a balanced life and/or the ability to work again.[139] Design interventions can help alleviate and, more importantly, prevent such harmful effects.

Conditions with a negative impact on patient health are:

• Continuous disorientation

• Continuous illumination

• Exposure to extreme noise (frequently higher than 60 dB on average)[140]

• Sleep deprivation

• Loss of control combined with abundant alarm functions (the latter give the patient the continuous impression of being in a life-threatening situation)

Considering the goal of intensive care, namely to keep the patient alive, the design of such facilities must be significantly improved in order to prevent further collateral damage to patients. Early mobilization and reactivation while the patient is still in the ICU has been shown to have a positive effect on his or her health. Studies show that mobilization, including moving the still-ventilated patient and even mobilizing the unconscious patient, may lead to an average reduction in the length of stay for long-term patients of 1.0 days in the ICU and 1.5 days in general inpatient care. This is not only a significant cost factor but also considerably improves the patient’s quality of life by reducing the risk of loss of muscular tissue.[141] ICU design must therefore provide sufficient space and equipment to enable the early mobilization of patients.

Functional Perspective

ICU care is usually differentiated into three levels:

Level I — Intensive care surveillance (IMCU)

Patients showing signs of dysfunction in one organ system who require continuous surveillance (monitoring) and minor pharmacological or technical support. These patients are at risk of developing one organ failure or have recovered from an organ failure and require an elevated level of attention or care.

Level II — Intensive therapy (ICU)

Patients requiring intensive surveillance and/or a low level of therapy for potential failure of one organ system with life-threatening conditions, organ replacement, machine-assisted ventilation or continuous dialysis.

Level III — Intensive therapy (ICU)

Patients requiring intensive surveillance and/or a high level of therapy for two existing or potential organ system failures with immediate life-threatening conditions, organ replacement, support systems to maintain blood circulation, machine-assisted ventilation or continuous dialysis.[142]

Considering the condition of patients in ICUs, noise reduction, light management and control of alarm functions must be key parameters for ICU design. Large open-space solutions accommodating several patients in one large room represent hygienic hazards and should not be adopted.

Position Relative to Other Departments

The intensive care unit is usually adjacent to the medium care unit, offering the possibility of using the latter to scale up when the number of patients in need of intensive care exceeds the number of beds available in the ICU. It goes without saying that ICUs are best located near those departments that accommodate most patients (at risk of) needing close observation and life support after treatment. The operating block is one of these (in the case of complex surgical interventions), the emergency department another. The position next to the operating block ensures a fast transfer to an operating room in case of life-threatening complications needing surgical intervention.

In some cases, the patient can be brought into the post-anesthesia care unit (PACU) after the operation (instead of being transferred to an ICU), where he or she can be stabilized by specialized medical staff. This allows for around-the-clock supervision from multiple medical specialists, as the PACU is one of the areas nearest to the operating block. At the same time, it requires the round-the-clock presence of monitoring staff, ensuring that any change in the state of the patient is observed and, if necessary, acted upon. The optimal location of the PACU is debatable, with arguments favoring proximity/integration both to the operating block and to the ICU.

Challenges for Future Design

Due to efforts to reduce the length of stay in hospitals, the pressure to scale up the intensive care facilities will increase. Integration of continuous monitoring into general inpatient care is therefore probably unavoidable in order to reduce the burden on the limited and expensive ICU facilities. Future design could include the provision of a post-anesthesia care unit in addition to the ICU; it could serve as a pivot between the OR, OR recovery, emergency and the ICU. This will allow the ICU to focus better on its core activities.

The following criteria will be important in future ICU design:

• Patients’ quality of life

• Early mobilization facilities

• Reducing the chances of post-ICU traumatic stress disorder

• Moving from horizontal design to vertical design, with e.g. the design of ceilings above patients’ beds as an element of healing design

• PACU and more monitoring facilities in inpatient wards as pivots to reorganize ICU care

• Management of patient fear and anxiety

• Balancing health and comfort — allowing optimal supervision and monitoring with maximum comfort for the patient

• Stimulating and motivating the patient to actively participate in the healing process

The Patient Bed

The ICU bed allows for extensive customization of the position of the patient, and it is equipped with artificial ventilation, equipment necessary for life support, feeding and for monitoring of vital functions. The medical staff should be able to move freely around the patient, with rules prescribing a minimum clear area around the patient bed. This is usually 1.8 m measured from the side of the patient bed and 1.2 m measured from the foot of the bed. This area should be free of furniture, equipment and any other obstacles, with the exception of life-support equipment. The patient should have easy access from the bed to means of communication with the medical staff.

The Patient Room

The patient room is the smallest module in an ICU unit. It is recommended that patients have individual rooms and visual access to direct daylight and to an exterior view, so as to minimize the incidence and effects of disorientation. In order to support patient orientation, it is necessary to include a clock and a calendar, set to show the correct time and date, in the room. The calendar, or a whiteboard, can be used to show the timetable and names of the nurses on duty.

The patient room should allow for constant supervision. The nurse or the medical supervisor needs a workstation equipped with a computer allowing for monitoring vital signs and handling data input related to the patient’s condition. A washbasin and/or a sanitizing alcohol dispenser allows for easy hand-cleaning before and after consultation or intervention. A locker for the nurses should allow for localized storage of medical equipment, medication, folders, etc. The patient’s belongings could be stored in a locker outside the unit. The ICU patient usually is in such critical condition that movement outside the bed area is rarely possible. En-suite toilets or bathrooms are therefore not necessary. However, for situations where the patient is capable of walking (or being transported) to the bathroom or when the ICU works as a stepped-care unit, a few patient bathrooms at the cluster or unit level are advisable.

The Unit

The ICU is usually organized in clusters of six to eight patients. This facilitates short walking distances, fast access for the medical staff, close supervision and sufficient nursing backup during emergencies. The staffing levels (e.g. nurses per bed) and levels of expertise required depend on the number of patients and the level of the ICU. Limiting the number of patients per cluster and placing it under the supervision of one team also helps to reduce the risk of contamination. Each cluster usually has a supervising nurse and an intensive care specialist.

Usually one or two rooms per unit are equipped with a quarantine room with a sluice for highly infectious or very frail patients. Their position should be nearest to the elevators and transport route in order to minimize contamination risks. The sluice is meant primarily for use by medical staff members as they go in and out of the patient room; where it is also intended for use by patients, it must be wide enough to allow for the passage of the patient’s bed.

The Department

The ICU has a reception area for visitors, who are usually allowed to visit the patient in small numbers without rooming-in. In some cases, the ICU can accommodate family members wishing to spend the night in a designated area, usually immediately outside the unit. These spaces mostly have a homely living-room atmosphere. The medical staff discusses the condition of (and treatment plan for) the patient with family and provides psychological support either in these spaces, when necessary, or, when possible, in the patient’s room.

Some diagnostic imaging can be done in the patient’s room using mobile imaging equipment, but examinations requiring MRI or CT scans are conducted in the diagnostic imaging department. Other examinations and interventions such as endoscopy, psychiatric evaluation, physiotherapy and dialysis can be performed in the patient’s room.

Each unit must be equipped with a centralized washing area (next to the reception area) for medical staff and visitors. Patients are supervised by teams of nurses, who follow strict hygiene procedures when entering the ICU and who remain in the ICU during the entire shift. Therefore, staff toilets and facilities for relaxation and for deskbound work, as well as a kitchenette with a dining space, need to be part of the ICU.

Other back-office facilities required in the ICU include a sterile and non-sterile storage area, a waste storage and disposal area, a satellite pharmacy and meeting rooms. Most of the necessary instruments, medical equipment, supplies and medication are either stored at a central location in the ICU or, in case of a large ICU, at decentralized locations servicing one or more clusters. Clean bed storage is organized at the departmental level to ensure clean patient transport to, for instance, the operating block or the diagnostic imaging department.

The ICU can be configured in various ways of which five typical solutions are presented here:

The first model (A) allows the main traffic route to go through the ICU clusters. Although it provides optimal access to direct daylight, it does create a challenge for the hygiene requirements of the ICU clusters. The ICU washing area can no longer function as a filter for patient room access and, therefore, contamination risk increases due to staff moving between the ICU clusters. Hygiene protocols have to be very scrupulously followed in order to ensure patient safety.

The second model (B) distributes the IC rooms parallel to the main traffic corridor, decreasing walking distances and turnover time. In this model, however, direct daylight is unavailable for some patient rooms, although indirect daylight could be provided via the corridor (in case of glazing between patient room and corridor). However, moving shadows due to staff and visitor movements can be a source of confusion and distress for the patient. In the mirrored version of the model, access to daylight is restricted to the outward-facing rooms. Increasing the distance between the units and inserting a patio between them could allow some direct daylight into some patient rooms at the cost of longer walking distances. No matter what the solution, in this model some spaces in the ICU will be deprived of (direct) daylight.

The third model (C), in essence a variant on the second, is reminiscent of earlier hospital plans inasmuch as it allows access to natural light by dividing the ICU into separate wings with wide patios between them. A simple version of this model distributes the ICU units along a main traffic corridor, allowing support facilities to be located on the other side of the corridor. If the department requires a large number of patient beds, the ICU units can be mirrored along the main traffic axis. In this case, support facilities need to be placed on either side of the ICU units, increasing walking distances. Another disadvantage is that the wings are short, which reduces future flexibility in case there is ever a need to convert these spaces to other uses.

The fourth model (D) distributes the ICU around a central patio. Patient rooms have access to direct daylight as well as to support facilities. In the case of larger departments, the model can be mirrored along the main traffic route. However, this complex arrangement requires a judicious distribution of vertical connections to allow for fast transportation of patients. The objective should be to ensure that connections to other departments are roughly equally distant for all ICU patients.

In the fifth model (E), all the patient rooms are arranged around a large, central control room giving all of them access to daylight. The monitoring, supervision and working areas of the medical staff and other back-office functions can be organized quite efficiently, but have limited and indirect daylight. Using semi-transparent walls in patient rooms increases the amount of indirect natural light, but has the disadvantage of creating moving shadows.

The diagram below illustrates four layout options for monitoring and supervision inside the ICU, and the following two diagrams shows typical intensive care room components and layout.

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Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.