Innovation in the Design
of the ICU
New Trends that incorporate patient and family-centered
design
By Alex Stark
From: Minnesota Physician, May 2005
Download Magazine Article PDF: 0.6 Mb
Patient-centered design has become the hallmark of most new construction
in the health care field. This follows research that indicates that improved
design can have a significant and positive impact not only on the outcome
of the health care intervention, but on the bottom line as well (Roger
Ulrich, Healing by Design, McGill University 2000). Patients and their
families, furthermore, are asking for user-friendly environments that
have a more natural feel and look. Consequently, improved décor,
more privacy, reduced environmental stressors, natural surroundings, and
greater patient control over tasks and information are becoming commonplace.
Older hospitals are feeling this pressure as new facilities market their
user-friendly environments to a responding public.
New approaches to design
As a feng shui consultant specializing in the health care field, I am
often asked to bring a more nature-conscious and patient-centered perspective
into the design process. In fact, the very inclusion of my discipline
attests to the current effort to widen the scope of discussion in the
planning of new facilities. Often the planning team will include, in addition
to the traditional medical, nursing, management, and technology staff,
community advocates, patients, their families, and non-medical personnel
(religious, clerical, custodial, etc). Interdisciplinary focus groups,
community outreach, role playing, and mock design sessions are part of
the new designer's approach.
Nevertheless, concerns still linger over the priorities questioned by
these new demands. Nowhere is this process more evident than in the design
of the Intensive Care Unit. Here the demands of advanced technology come
head to head with the need to care for not only the patient, but the patient's
family as well. On the one hand the severity of the interventions require
the utmost in technology, methodology, and sterility. Patients and their
families, on the other hand, are experiencing some of the most traumatic
moments of their lives.
Patient's Concerns
ICU patients and family focus groups often complain about overwhelming
feelings of insecurity, disorientation, anxiety, fear and anger (Kirk
Hamilton, "Impact of the ICU 2010 Report", in Design & Health,
International Academy of Design & Health, 2003). The sheer volume
of technology, the unfamiliar, sterile surroundings, lack of privacy,
constantly revolving medical teams, incessant noise and glaring light,
and the lack of natural forms, materials, and sensory experiences all
add to this traumatic experience. As a result, the patients feel trapped
in an environment they dislike and cannot control, and their families
feel helpless. In addition, the ICU patient is often predisposed to cognitive
impairments due to their stressed conditions, psychoactive medications,
and physical trauma. The result is often dementia. A study at the Yale
School of Medicine estimates that between 50% and 80% of older patients
suffer dementia in the ICU (Pisani, Margaret, Cognitive Impairment in
the Intensive Care Unit, Yale, 2003).
Design Strategies
Many of the family's concerns can be readily addressed by allowing the
family to enjoy greater interaction with the patient and the ward. Waiting
rooms in many new facilities now include sleeping accommodations, lockers,
private phone and internet booths, playrooms for children, kitchen and
pantry facilities, soothing music, and even fish tanks, water falls and
nature views. In some cases, overnight stays in the ICU room are encouraged,
particularly in pediatric facilities. Many designers now allocate a zone
within the ICU room for this purpose. At the Woodwinds Health Campus in
St. Paul, for example, the zone closest to the window is the family's
domain and can include a sleeper sofa. A similar arrangement is used at
Clarian Methodist Hospital in Indianapolis.
Providing familiarity is another important concern. Designers are taking
cues from the hospitality industry and creating hospitals that feel much
more like traditional homes. At Woodwinds and at Clarian Methodist, for
example, a TV, VCR, and CD player are all standard in the room, as is
a special tack board for cards and notes in the step-down units. A small
shelf near the bed serves to hold personal items. Adjustable light dimmers
can be controlled by a family member. At Woodwinds a sliding wall panel,
finished in natural wood veneer, allows for the headwall delivery system
to be concealed if the situation permits.
Despite the need for round-the-clock nursing supervision and for visibility
through glass walls or large corridor windows, patient's privacy can be
enhanced by providing adjustable curtains and blinds. Low glare glass,
furthermore, is helpful in controlling night-time reflections within the
room.
Need for a more natural environment
Research demonstrates that views of nature are important in the health
care setting: patients who enjoy views of nature heal faster than control
groups that look onto blank walls (Claire Cooper Marcus, Healing Gardens,
John Wiley & Sons, 1999 and Ulrich, 2000). Although codes now require
windows in all ICU rooms, the view from these rooms should include greenery
and more distant vistas. In some cases, landscapes and nature photography
can be introduced within the room, not only as art on the walls, but also
as part of the ceiling design and on fabrics.
Wall and furniture colors can also liven up otherwise sterile ICUs. Despite
the need for seamless impermeable surfaces, advances in flooring materials
now allow for more natural looking ICU floors and for finishes that reproduce
natural wood, foliage, flowers, and even animals. In all situations a
"horizon line" should be added to the room that subliminally
mimics the natural horizon humans are accustomed to outdoors. This should
be located at waist height and should extend around the whole room. It
can be rendered through window sills, door mullions, counter tops, or
wainscoting.
Other ways of making the ICU less stressful include controlling sound
and light levels. Computerized monitoring equipment and the use of vibrating
pagers and cel phones has made it possible to eliminate overhead voice
pagers and some types of audible alarms. The modern ICU can now be a much
quieter environment, allowing for better rest for the patient. Automated
lighting controls make it possible to change the illumination patterns
within the ward, mimicking the rhythms of day and night more effectively.
In response to these trends, codes are also changing: permissible sound
levels are lower than ever before and lighting regulations now reflect
the cyclical rhythms of night and day.
Changes in technology
Despite the need for a more patient centered approach, technology still
rules most of the decisions made in ICU design and is the single most
important consideration brought up by physicians and nurses when developing
a design model. Ironically, as technology has progressed, greater versatility
has also become possible, allowing for accommodation to some of the patient's
most important concerns.
The drive towards centralized intensivist medicine, for example, has forced
many larger hospitals to cluster previously separate ICUs into one larger
ward. The financial savings in this approach are obvious. What is not
as obvious is that by doing so, ICUs have had to blur the edges between
critical, acute, and step-down rooms. In fact, at a number of new facilities,
the same room is now being adjusted to the level of care required by each
patient. This reduces stress for the patient and can avoid costly transfers
and census adjustments down the line. At Bellevue Hospital in New York
city, for example, a brand new ICU now boasts of 55 patient rooms, all
capable of instant flexing into any acuity mode. This has allowed the
designers to justify sleepers and recliners for over-night visitors in
all rooms.
A similar transformation has occurred in the composition of the care team.
Since the room now functions at varying acuity levels, the patient no
longer has to be moved as the acuity of their care fluctuates. This in
itself greatly reduces stress on the patient. In addition, the medical
staff is now being cross-trained so that any given team can step into
lesser or greater acuity mode. This has valuable patient and family appeal
because the patient can be taken care of by a single team, whose members
will follow the patient through all stages of their recovery, getting
to know them and their families in the process. This effectively addresses
one of ICU patient's most frustrating complaints: lack of familiarity
and rapport with their constantly changing medical team.
The Future
As the debate over critical care continues to unfold, better medical care
will undoubtedly be available to a more informed public. Part of this
process will have to recognize the need for a more patient-centered and
family-conscious approach that can take care of not only the physiological
needs of the patients, but their psychological and spiritual needs as
well. The ICU of the future promises to be a true place of healing in
which all dimensions of the patient's needs will be met and in which advanced
technology will accommodate the more subtle needs of the whole person.
CONCLUSION: Therapeutic Elements in the ICU ENvironment
The ICU environment should focus on these therapeutic elements:
• Windows and art that provide natural views; views of nature can
reduce stress, hasten recovery, lower blood pressure and lower pain medication
needs
• Family participation, including facilities for overnight stay
and comfortable waiting rooms
• Providing familiarity in the ICU environment through personalization,
warmer colors, natural materials, and artwork
• Providing a measure of privacy and personal control through adjustable
lighting, adjustable curtains and blinds, accessible bed controls, and
TV, VCR and CD players
• Noise reduction through computerized pagers and silent alarms
• Medical team continuity that allows one team to follow the patient
through his or her entire stay
Alex Stark is an architect and feng shui consultant who specializes
in the health care field.
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