pdc_2007_intensive care design

Intensive Care Design

Wh ill b ?Where will we be?

A th St A d MD FCCMArthur St. Andre, MD FCCMWashington Hospital Center

Washington, DC

Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHAHKS Inc. Dallas, Texas

Debajyoti Pati, PhD AIIA

© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 1

Debajyoti Pati, PhD AIIAHKS Inc. Dallas, Texas

Outline

• A Day in the Life on the Unit• Critical Care Teams• Demand / SupplyDemand / Supply• Expectations Needs

E i t f C• Environment of Care• Constraining Forces • Guidelines Minimalism• Evolving Trends / Predictions / Future


Evolving Trends / Predictions / Future• The Ideal Room




Washington, DC





Shadowing Studyg y

• Washington Hospital CenterWashington Hospital Center

• Two critical care units – SICU and CCU

• Shadowing: MD Intensivist, RN, Unit Clerk

• 6-Hour Period: 7 am to 1 pm• 6-Hour Period: 7 am to 1 pm

• HKS Researchers: RN, RRT, PhD Arch

• 2-Hour shadowing rotation

• RN staffing ratios: SICU 2:1 / CCU 1:1


• RN staffing ratios: SICU-2:1 / CCU-1:1

Washington Hospitalg

CC

CCUCCU SICUSICU


1990’s11 Beds1990’s

11 Beds1970’s

14 Beds1970’s

14 Beds

MD Intensivist Time

LOCATION ACTIVITY

75%

LOCATION37% Roomside Station18% Corridor

ACTIVITY33% Consultation19% Info Gathering

83%75%18% Corridor18% Patient Bedside12% Off Unit

19% Info Gathering16% Reporting15% Document / OE

10%7% Lounge (Birthday!)3% Central Station

6% Procedures5% Break

3% Consult Room1% Conf Room

4% Patient Care1% Phone Call1% Searching


1% Searching0% Hand Washing

SICU vs CCU RN Time

LOCATION ACTIVITYSICU CCU76 -27% Patient Room8 -20% Central Station

SICU CCU34 -45% Patient Care20 -28% Documentation8 -20% Central Station

7 - 1% Med Room5 -20% Roomside Station

20 -28% Documentation13 - 5% Consultation8 - 1% Medications

2 - 5% Corridor1 -14% Patient Toilet1 11% Lounge

6 - 3% Procedures6 - 0% Reporting4 0% Phone1 -11% Lounge

0 - 2% Nourish Room4 - 0% Phone4 - 3% Searching3 - 4% Socializing


g1 - 1% Hand Washing1 -10% Eating

SICU vs CCU Unit Clerk Time

ACTIVITYLOCATION ACTIVITYSICU CCU

28 -19% Phone

LOCATIONSICU CCU

71 -69% Central Station 8 9% o e

26 -42% Documentation

21 - 6% Socializing

69% Ce t a Stat o

13 -13% Off Unit

10 -13% Break Room g

9 - 6% Consulting

9 -16% Eating

4 - 3% Corridor

1 - 0% Roomside Station

3 - 9% Search/Gathering

3 - 0% Relaxing

1 - 0% Staff Toilet

0 - 2% Nourishment Room


1 - 2% Organizing25 - 33% impacts nurses!

Posture (Ergonomic Interest)

NURSEPHYSICIAN CLERKNURSESICU CCU

0 - 3% Bending

PHYSICIAN

0% Bending

CLERKSICU CCU

0 - 0% Bending0 3% Bending

3 - 0% Squatting

0 -13% Leaning

0% Bending

0% Squatting

0% Leaning

0 0% Bending

0 - 0% Squatting

0 - 0% Leaning0 13% Leaning

0 - 0% Reaching

4 -36% Sitting

g

0% Reaching

56% Sitting

0 0% Leaning

2 - 0% Reaching

79 -77% Sittingg

92 -56% Standing

1 - 5% Walking

41% Standing

0% Walking

g

19 -23% Standing

0 - 0% Walking





Washington, DC





© HKS 2007

Rooms

Lav/ToiletCare Zone 3

16 ‘ gross

IVPumps

PhysioMonitors

Utility Boom@ Ceiling

ToiletWasteZone

DialysisMachine

OverbedTableCare

Zone21’

CareZone

1

BalloonPump

M/SSupply

Cart

HypothermiaUnit

FamilyZone

Zone2

21gross

Data Entry/Access

A320 fA320 f

SleeperChair

Data Entry/

HandWashing

Sink


320 nsf320 nsfy

Access

© HKS 2007

Rooms

Lav/ToiletCare Waste

16 ‘ gross

PhysioMonitors


ToiletZone

3

WasteZone

DialysisMachine

IVPumps Overbed

TableCareZone

1Care21’

BalloonPump

M/SSupply

Cart

Data Entry/Access

HypothermiaUnitFamily

Zone

CareZone

2

21gross

BBSleeperChair

HandWashing

Sink

Data Entry/


320 nsf320 nsfy

Access

Rooms

Lav/ToiletC Waste

18’ gross

ToiletCareZone

1Care

WasteZone

BalloonPump

PhysioMonitors

Zone3

21’ IVUtility Boom@ Ceiling

HypothermiaUnit

OverbedTable

Data Entry/Access

FamilyZone

CareZone

2

21gross

DialysisMachine

Pumps@ Ce g

M/SSupply

Cart

CCSleeperChair

HandWashing

Sink

Data Entry/


360 nsf360 nsfy

Access

Rooms

Lav/ToiletWaste

18’ gross

Sl Toilet

CareZone

2

WasteZone

DialysisMachine

IVPumps

FamilyZone

SleeperChair

CareZone

321’


HypothermiaUnit

Pumps

OverbedTable

o e

Data Entry/Access

CareZone

21gross

BalloonPump

PhysioMonitors

M/SSupply

Cart

DDHand

WashingSink

Data Entry/

1


360 nsf360 nsfy

Access

Toward an Ideal Room Idea


BedBed

© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 16© HKS 2007

BedBed

Equipment

Pumps &Monitors

ITCart

OverbedT bl

Ventilator

BalloonPump

TableDialysisMachine

HypothermiaUnit


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Pumps &Monitors

ITCart

OverbedT bl

Ventilator

BalloonPump


Line TraysLine Trays HypothermiaUnit

Line TraysAlong

Bedsides

Line TraysAlong

Bedsides


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Circle of Access

Pumps &Monitors

16’dia

Rolling Stock for

Work SurfaceAnd Supplies

Rolling Stock for

Work SurfaceAnd Supplies

M/SSupply

Cart

ITCart

OverbedT bl

VentilatorAnd SuppliesAnd Supplies

BalloonPump


HypothermiaUnit


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Circle of Access

Staff / PhysiciansPumps &Monitors

16’dia

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

BalloonPump


HypothermiaUnit


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Circle of Access

Staff / Physicians

ImagingPumps &Monitors

16’dia

M/SSupply

CartOverbed

T bl

Ventilator

PortableX-Ray

BalloonPump

Table

HypothermiaUnit


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Circle of Access

Staff / Physicians

Imaging Pumps &Monitors

16’dia

Procedures M/S

SupplyCart

Ventilator

PortableC-Arm

Monitor

BalloonPump

HypothermiaUnit


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Pumps &Monitors

16’dia

Circle of Access

Staff / Physicians

Imaging

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

Procedures

Lines of Sight

BalloonPump


HypothermiaUnit


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Pumps &Monitors

16’dia

Circle of Access

Staff / Physicians

Imaging Toilet

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

Procedures

Lines of Sight

Work AreasBalloonPump

Data Entry/Access


Work Areas

HypothermiaUnit

Data Entry/Access


Bed ToiletBed

Equipment

Power / Linkages

ToiletDeskCloset Couch

Pumps &Monitors

Pumps &Monitors

16’dia

Circle of Access

Staff / Physicians

Imaging

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

Procedures

Lines of Sight


Data Entry/Access


Work Areas

Family Areas

HypothermiaUnit

Data Entry/Access


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Pumps &Monitors

16’dia

Circle of Access

Staff / Physicians

Imaging

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

Procedures

Lines of Sight


Data Entry/Access


Work Areas

Family Areas

Consult / EducationHypothermia

Unit

Data Entry/Access


BedBed

Equipment

Power / Linkages

Pumps &Monitors

Pumps &Monitors

16’dia

Circle of Access

Staff / Physicians

Imaging

SwingAway

Privacy

SwingAway

Privacy

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

Procedures

Lines of Sight

Work Areas

PrivacyScreenPrivacyScreen

BalloonPump

Data Entry/Access


Work Areas

Family Areas


Unit

Data Entry/Access

Room Enclosure


BedBed

Equipment

Power / Linkages AccessAccess

Pumps &Monitors

Pumps &Monitors

16’dia

Circle of Access

Staff / Physicians

Imaging

withoutmoving

Bed!

withoutmoving

Bed!

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

23’gross

Procedures

Lines of Sight


Data Entry/Access


Work Areas

Family Areas


Unit

Data Entry/Access

Room

Critical Access


18’gross© HKS 2007

BedBed

Equipment

Power / Linkages

Circle of Access

Staff / Physicians


Pumps &Monitors

16’dia

Procedures

Lines of Sight

Work Areas

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

23’gross

23’gross

Work Areas

Family Areas

Consult / Education

BalloonPump

Data Entry/Access


Room

Critical Access

Patient View

HypothermiaUnit

Data Entry/Access


18’gross

18’gross

Patient view outside via mirrors on furr-down

Patient view outside via mirrors on furr-down

© HKS 2007

BedBed

Equipment

Power / Linkages

LCD panel in ceiling projecting

LCD panel in ceiling projecting

Circle of Access

Staff / Physicians


Pumps &Monitors

p j gfamily

photos or favorite images

p j gfamily

photos or favorite images

Procedures

Lines of Sight

Work Areas

M/SSupply

Cart

ITCart

Ventilator imagesimages

Work Areas

Family Areas

Consult / Education

BalloonPump

Data Entry/Access

DialysisMachine

Room

Critical Access

Patient View

HypothermiaUnit

Data Entry/Access


Focused Imagery

© HKS 2007

ToiletDeskCloset Couch

Pumps &Monitors

Pumps &Monitors

16’dia

M/SSupply

Cart

ITCart

OverbedT bl

Ventilator

23’gross

23’gross

Ideal Room397 nsfIdeal Room397 nsf

BalloonPump

Data Entry/Access


HypothermiaUnit

Data Entry/Access


18’gross

18’gross

© HKS 2007




Washington, DC





Demographics of ICU Care 1998g p

• 6,000 Adult ICUs• 72,000 ICU beds• 55,000 ICU patients/day• 5,000,000 admissions per year• 20,000,000 patient days per year• Estimated expenditure $60-80 B/yr• 8-10% of Hospital Beds• 10-12 Avg. bed complement• Mixed Med/Surg patient populations


The Team


Critical Care Team

• Intensivists • Respiratory Therapists• Residents• PAs/NPs

• Nutritionists• Social WorkersPAs/NPs

• Bedside Nurses• Nurse aides

Social Workers• Clergy• Others -Clerk PSAs• Nurse aides

• Senior nurses -facilitator

• Others -Clerk, PSAs• Quality, Utilization and

Risk Managementfacilitator• Pharmacists

Risk Management Personnel


An Intensivist

• A physician with the training and skills to p y gassess and manage patients with or who are at risk for severe single or multi

t d f ti f di lsystem organ dysfunction from medical or surgical illnesses or injuries

• Care provided from the earliest phases of t d ti th h thacute decompensation through the

complex high risk periods of recovery


Critical Care Physicians

• Primary Specialtyy p y• Subspecialty training• Board certificationBoard certification• “Intensivist model” – Leap Frog


Models of Care Unit Typesy

Closed• Primary Attending = Critical Care Physician

Openp• Primary Attending Not Always = Critical Care• Often multi-organ system consultants without

a CC physician as the leader of a teamTransitional

• Any Primary Attending• And an Intensivist Assumes Management


No Intensivist Availability

The C’s of Critical Care

• Patient CarePatient Care

• Collaboration

• Consistency - Continuity

C di i• Coordination

• CommunicationCommunication

• With Availability and Responsiveness


Programmatic Responsibilities

Mission

g

GoalGoalMission– Effective patient care – Mandates - Throughput

CustomersDemandDemand

GoalGoal

Customers

Resources SupplySupply

Organizational Structure

O ti l F t

Chain of CommandChain of Command

Operational Factors– Mandates– Constraints Coalescence …Coalescence …


– Processes

Patients and Providers

Demand: Patients Supply: Resources– Quantity– Quality

E t ti

pp y– Providers

• Quantity – number, commitment– Expectations • Skills

• Personal expectations – Clinical equipment and– Clinical equipment and

supplies– Non clinical

accoutrementsaccoutrements – Physical Infrastructure

(i.e. built environment)


Patient Populations

• Quantity - Baby Boomers – oldest turn 60 y yin 2006 at a rate of 7918/day

• ‘Quality’y– Healthy but elderly– Chronic Co-morbid factors

Ob it f ilt– Obesity, frailty– Insults – new medical illnesses or exacerbations,

surgical procedures, trauma, complicationsg p p

• Expectations• Surges – seasonal, biological, man


Surges seasonal, biological, man induced

Patient Expectations

• Good outcome• Safe• ResponsiveResponsive • Comfortable• Information rich• Information rich• Efficient

Family convenient (time and space)• Family convenient (time and space)• Healing environment


• Minimum cost

Providers

• Youthful vs. Aged labor poolg p• Availability – professional and personal satisfaction

and commitments

• Skill set development - OJT• Expectations – personal amenities, restorativeExpectations personal amenities, restorative

and refreshment areas, communication devices, conveniences (e.g. baby care, banks, laundry, grocery)

V i t• Variety – physician and nurse ‘extenders’, patient and family services, utilization quality and risk reviewers, supply chain, device maintenance, facility


pp y ypersonnel

‘Moveable’ Objects

• Clinical activities – monitors, testing equipment, therapeutic devices, documentation and communication technology, supplies (inc. medications)

• Non clinical accoutrements implements• Non clinical accoutrements – implements related to waste, hygiene, ‘transition’ activities, environment of care


Techno Evolution - Devices• Sensor development • Devices – Monitoring

monitoring

• Communication devices• Merge monitoring and

– Plug and Play– Simplicity – set up, use,

take down• Merge monitoring and therapeutic modalities

• Electronic Medical Record

– Reliability– Light weight – small size– Wireless ?? tubelesscapture and display, task

management, transaction processing

Wireless, ?? tubeless– Voice control – Data sharing (2 way)

• Positive ID• Medication delivery

mass inventory pharmacy

• Devices – Testing– Portable (e.g. sonography)– Transportable


mass inventory pharmacy unit beside nurse (pharmacist) patient

a spo tab e

Devices Wars! (need title)


RemoDoc™

Pardon me, may I cut in?


may I cut in?

Performance Expectations

• Patient preferences p• Superior results – Quality• Efficient Use of Resources• Efficient Use of Resources

– TimelyE i l

Effectiveness– Economical– Resource conscious

(rationing)(rationing)


From Data to Orders

Recognition / Deducing / Concluding

HISTORY – TRENDSSufficient, accurate,

THINKINGKnowledge

Schooling’, Literature, TextsExperience

, ,timely data THINKING

‘Learned’ Expectations

DECISION

Clinical Conclusion - Assessment

WISDOM


ResourcesExpectations

WISDOM

For Providers

• Education and Conference rooms• Restorative atmosphere – personal / communal

• Nourishment facilitiesNourishment facilities• Personal effects – ‘uniforms’, coats, purses

• Toilet/shower• Toilet/shower• Communication devices

ADLs l d hild b ki i• ADLs – laundry, child care, grocery, banking, exercise

• Office S


• Sleep

Familyy

• Information exchange• Accommodations – waiting (inc. long and

short), nourishment, rest• Mutual support• Privacyacy• Participation in care


Patients

• Bed features• ‘Transition’ activities• Reduced tethering• Reduced tethering• Nourishment - food processing• Physical therapy • Environment

– Ceilings – Day/night cycling – eyes, ears, positioning


ay/ g t cyc g eyes, ea s, pos t o g

Infection Control

• Susceptible patients • Infection Control – ICU– Portals of entry into

patients– Antibiotic usage and

– reservoirs, contamination (structures and people)

• Aerosols and fomitesgavailability

– Immune compromise

• Aerosols and fomites– Barriers– Hand washing

• Hand cleansing• Protective barriers

• Airborne isolation– Protect other patients

P iti i l ti• Water• Surfaces

• Positive pressure isolation – Protect a single patient


Results!• 12 m Baseline average VAP rate 16.33• 12 m Project Average VAP rate 1 57 = 90% Reduction• 12 m Project Average VAP rate 1.57 = 90% Reduction • 9 out of 12 months with zero VAP

Critical Care VAP Process/ Outcome

0%

100%

ianc

e

20 0025.0030.0035.00

Rate

Started PI

0%

50%

Com

pli

0.005.0010.0015.0020.00

VAP

R

F-04

M-04

A-04

M-04

J-04

J-04

A-04

S-04

O-04

N-04

D-04

J-05

F-05

M-05

A-05

M-05

J-05

J-05

A-05

S-05

O-05

Vent Bundle Compliance 0% 0% 0% 0% 0% 0% 0% 16% 40%50% 100 100 100 100 100 96% 100 100 100 96% 100

Critical Care VAP Rate 12.6 33.518.6 25.317.5 5.055.99 16.3 5.856.25 0.000.00 0.000.00 10.8 7.140.00 0.000.00 0.000.00

VAP Cases 2 5 3 4 4 1 1 3 1 1 0 0 0 0 2 1 0 0 0 0 0

04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 05 05


VAP Cases

Equipment and Supplies

• Storage g• Accessibility• CompatibilityCompatibility


Equipment and Supplies

Increases in monitoring, pumps, and equipment requirements


Patient Rooms

• Occupants • Over bed tablesp– Patient– Family– Staff

• Restraints • Back walls– Staff

• Sitting• Documentation

• Furniture• Documentation centers• Documentation

• Circulation• Cabling

Documentation centers

• Cabling• Reaching

Comm nication


• Communication– TV, Radio, Computer


Royal Alexandra Hospital - Edmonton, Alberta WSAG Architects

Environmental Factors

• Visual • Temperature• Auditory• Tactile

p• Chemical

– including humidity• Tactile • Olfactory

• Particulate• Electromagnetic

• Gustatory• Spatial

ec o ag e c

p• Familiar – cultural, ethnic, personal• Unfamiliar psychosomatic interplay


• Unfamiliar – psychosomatic interplay

Environment of Care Continuum

EnrichingEnrichingEncouraging

HealingHealingHelpful

SoothingSoothingNeutral

Irritatingtat gNoxious

Dangerous’


gHurtful

Entrance Hallway?y


The Soda Machine?


Resource Constraints

• Labor shortage and retention – RNs, MDs, therapists, pharmacists, technicians

• EMRs – underdeveloped and installed• Physical infrastructure

• Capacity • Sq. Feet / ICU• Adjacencies

• Capital


Need Title


Constraining Forces

• Confines of real estate • Renovation projects• Capital limitationsCapital limitations• Minimum standards mind set• Ineffective Clinical/Design professional• Ineffective Clinical/Design professional

dialogue• Paucity of research and its application• Paucity of research and its application


Maslow’s Hierarchy of Needs


Title Needed

• Functional Programg– Programmatic Missions Needs ~ Acuity– Throughput – Contingency surges

Ri k ( )– Risk (e.g. age)– Physical characteristics (e.g. obesity)– Operational paradigmsOperational paradigms– Future directions

• ‘Minimum’ Standards/Guidelines– Level I– Level II

L l III


– Level III

‘Minimum’ Standards

• ‘Code’ – Guidelines for Design and Construction of Health Care Facilities, NFPA

• Resources – real estate, capitalFunctional program i i• Functional program – mission

• Patient vs./and Provider needs • Provider availability• Provider availability• Environment of Care – hierarchy of needs• Patient and provider expectations• Patient and provider expectations• Safety, longevity• Societal – environmental sensitivity


Societal environmental sensitivity• Surge

Title Needed

bil t t f t f b d


mobile system at foot of bed

CVICU, Methodist Hospital – Houston, Texas WHR Architects

Evolving Trends - Novel Ideasg

• Obesity, age, acuityy, g , y• Design to augment staff effectiveness and

retentionretention• ‘Environment of care’• Telemedicine – eICU


Evolving Trends - Novel Ideasg

• Move tests to the ICU• Laboratory - portable analyzers

? R di l i d h– ? Radiologic procedures – e. g. sonography

• EMR (Acquiring) Pattern (Recognition/Deducing/Concluding) plus electronic process management tools

• Sensitivity to our environment


Future - Predictions

• Demand/Labor Resource mismatch– Labor imperatives – professional and

personal decisionspersonal decisions

• Regionalization – ICU Certification • Team

– Composition – midlevel practitioners– ‘Model’ evolution - O/P I/P specialists -

hospitalists


p


• Expanded prescriptive authorityp p p y• Family participation• Other resources limitationsOther resources limitations

– medications, blood products• Telemetry in the ICUTelemetry in the ICU



• Marriage of monitoring and therapeuticMarriage of monitoring and therapeutic devices

• Complication prevention methodologies

• Organ based dysfunctional metabolismOrgan based dysfunctional metabolism measurements and interventions

End organ perfusion monitoring- End organ perfusion monitoring

• Genetic profiling


• Simulation

Suggestions

• More robust clinician/user participation in p pdesign planning

• Translate research into designTranslate research into design– Research into Learned Design

Evidence Based Design– Evidence Based Design• National POE database• Research• Write a proposal





Washington, DC





pdc_2007_intensive care design

Design

healthcare design

design construction

university of texas

phd aiia hks

graduate studio

texas debajyoti pati

spring semester

asheaiaaah planning