D. Kirk Hamilton

Guidelines for intensive care unit design.

Objective: To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit. Participants: A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit. Scope: The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment. Data Sources and Synthesis: Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations. Conclusions: Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace. (Crit Care Med 2012; 40:–16)

Organizational Transformation: A Model for Joint Optimization of Culture Change and Evidence-Based Design

Healthcare organizations face continuous and accelerating external change and thus must be prepared to manage their own change initiatives proactively. Given that many believe that the U.S. healthcare system is broken and most healthcare organizations are dealing with pervasive problems, some organizations may choose to seek transformational change to achieve the six aims identified by the Institute of Medicine: healthcare that is safe, effective, patient-centered, timely, efficient, and equitable. Transformational change will almost certainly involve organizational culture. Culture change may be most effective when linked to other organizational change initiatives such as organizational strategy, structure, policies, procedures, and recruiting. Significant organizational change often requires accompanying facility change. There is an interdependent relationship between facility design and organizational culture. They affect each other and both impact organizational performance. Sociotechnical theory promotes joint optimization of the social (culture) and technical (facilities) aspects of an organization to achieve sustained positive change. To achieve organizational transformation and to sustain positive change, organizations must be prepared to adopt collaborative efforts in culture change and facility design. The authors propose a model for accomplishing joint optimization of culture change and evidence-based facility design.

The Impact of Visibility on Teamwork, Collaborative Communication, and Security in Emergency Departments: An Exploratory Study:

The aim of this study was to examine the influence of visibility on teamwork, collaborative communication, and security issues in emergency departments (EDs). This research explored whether with high visibility in EDs, teamwork and collaborative communication can be improved while the security issues will be reduced. Visibility has been regarded as a critical design consideration and can be directly and considerably impacted by ED’s physical design. Teamwork is one of the major related operational outcomes of visibility and involves nurses, support staff, and physicians. The collaborative communication in an ED is another important factor in the process of care delivery and affects efficiency and safety. Furthermore, security is a behavioral factor in ED designs, which includes all types of safety including staff safety, patient safety, and the safety of visitors and family members. This qualitative study investigated the impact of visibility on teamwork, collaborative communication, and security issues in the ED. One-on-one interviews and on-site observation sessions were conducted in a community hospital. Corresponding data analysis was implemented by using computer plan analysis, observation and interview content, and theme analyses. The findings of this exploratory study provided a framework to identify visibility as an influential factor in ED design. High levels of visibility impact productivity and efficiency of teamwork and communication and improve the chance of lowering security issues. The findings of this study also contribute to the general body of knowledge about the effect of physical design on teamwork, collaborative communication, and security.

Evidence is found in many domains.

This journal is dedicated to the concept of design based on the use of credible evidence from research. The very term evidence-based design and its fashionable currency suggest that architects and design professionals only recently may have come to use evidence in their work. Nothing could be further from the truth. Architects have certainly always applied evidence from structural and civil engineering, mathematics, geometry, physics, material science, fluid dynamics, real estate economics, and so forth. It seems to me that the current emphasis on designing with evidence is a recognition that architects are now being asked to turn to unfamiliar domains of knowledge, domains for which customarily they have no educational foundation.This issue features a much-anticipated paper that updates the important 2004 work of Roger Ulrich and his colleagues in which a meta-analysis of the research literature documented more than 600 citations linking environmental design and clinical outcomes. Ulrich and Xiaobo Quan of Texas A&M University collaborated four years ago with Craig Zimring and Anjali Joseph of the Georgia Institute of Technology to compile this important paper. It has been widely circulated and downloaded from the Robert Wood Johnson Foundation and The Center for Health Design websites many thousands of times. It seems that nearly everyone interested in evidence-based design for healthcare has encountered the original groundbreaking paper. Some irreverently have described it as the Bible for evidencebased practitioners.The editors of HERD are delighted to publish the sequel to this 2004 work by Ulrich et al. Readers will find the unusual length of the piece in this issue to be well worth the time invested in its reading. The paper was again supported by a grant from the Robert Wood Johnson Foundation through Georgia Tech. This time Ulrich, Zimring, and their new collaborators have documented more than 1,000 papers relevant to the relationship of design to outcomes, including topics such as patient safety and stress reduction for patients and staff.The study follows the basic premises of Ulrichs theory of supportive design (1997) in which he offered a summation of what was known in the literature at the time and made recommendations to designers. These suggestions addressed the concepts of stress reduction, sense of control, social support, positive distraction, and the role of nature. Many healthcare architects and designers have been influenced by this theory and actively follow the recommended model. The theory of supportive design is now well established in the mainstream canon of healthcare design best practice. …

The Impact of Environmental Design on Teamwork and Communication in Healthcare Facilities: A Systematic Literature Review.

The purpose of this systematic review is to investigate the current knowledge about the impact of healthcare facility design on teamwork and communication by exploring the relevant literature. Teamwork and communication are behavioral factors that are impacted by physical design. However, the effects of environmental factors on teamwork and communication have not been investigated extensively in healthcare design literature. There are no published systematic reviews on the current topic. Searches were conducted in PubMed and Google Scholar databases in addition to targeted design journals including Health Environmental Research & Design, Environment and Behavior, Environmental Psychology, and Applied Ergonomics. Inclusion criteria were (a) full-text English language articles related to teamwork and communication and (b) involving any healthcare built environment and space design published in peer-reviewed journals between 1984 and 2017. Studies were extracted using defined inclusion and exclusion criteria. In the first phase, 26 of the 195 articles most relevant to teamwork and 19 studies of the 147 were identified and reviewed to understand the impact of communication in healthcare facilities. The literature regarding the impact of built environment on teamwork and communication were reviewed and explored in detail. Eighteen studies were selected and succinctly summarized as the final product of this review. Environmental design, which involves nurses, support staff, and physicians, is one of the critical factors that promotes the efficiency of teamwork and collaborative communication. Layout design, visibility, and accessibility levels are the most cited aspects of design which can affect the level of communication and teamwork in healthcare facilities.

Decentralization: The Corridor Is the Problem, Not the Alcove

There is controversy today about whether decentralized intensive care unit (ICU) designs featuring alcoves and multiple sites for charting are effective. There are issues relating to travel distance, visibility of patients, visibility of staff colleagues, and communications among caregivers, along with concerns about safety risk. When these designs became possible and popular, many ICU designs moved away from the high-visibility circular, semicircular, or box-like shapes and began to feature units with more linear shapes and footprints similar to acute bed units. Critical care nurses on the new, linear units have expressed concerns. This theory and opinion article relies upon field observations in unrelated research studies and consulting engagements, along with material from the relevant literature. It leads to a challenging hypothesis that criticism of decentralized charting alcoves may be misplaced, and that the associated problem may stem from corridor design and unit size in contemporary ICU design. The authors conclude that reliable data from research investigations are needed to confirm the anecdotal reports of nurses. If problems are present in current facilities, organizations may wish to consider video monitoring, expanded responsibilities in the current buddy system, and use of greater information sharing during daily team huddles. New designs need to involve nurses and carefully consider these issues.

Evolving Roles for Practice-Based Researchers

These times are witnessing interesting changes in the practice of architecture and the evolution of a design process that depends to varying degrees on the availability of reliable, relevant evidence. As this continues to evolve, there are paths for those who seek effective ways to use the best available research in making better design decisions, and paths for those who seek to perform useful and practical research to benefit design practice. At the same time, firms have begun to hire individuals with research credentials, either as traditional young professionals who have some training in research methods or as trained researchers who intend to use their doctorates in practice rather than academia.This is quite new, because few professional design programs have had extensive exposure to rigorous literature searches, research methods, the evaluation of findings, and scholarly writing. Further, in the past, typical well-trained doctoral students had no hope of entering practice because they were ex- pected to become faculty members at universities. Some PhD graduates felt the need to conceal their credentials to get jobs in practice. This is no longer the case as more options for trained researchers are now becoming available.Highest and Best Use of a Highly Specialized ResourceWhat, then, does the firm do to make the best use of this new kind of human resource? Can this expertise be acquired through an external consultant? How should the typical firm of design professionals integrate this new type of employee? How can such people be used on project teams? Can they be introduced to the client? How will they spend their time, and is there a chance it can be profitable? What work products can be expected from someone with a PhD who may not have had design training? Can they be useful in marketing? Predesign? Functional and space programming? Budgeting? What can be expected of a designer without a PhD who has a good understanding of research? How will their work be different in this new model?Is it possible for one person to provide all that the firm or client might want or need? It seems that there will be a period of adjustment as firms adapt to the new model of an evidence-based design process. There is more than one possible role to be considered.Designers Need To Understand ResearchThe effective designer in an evidence-based or research-informed practice model must have all the skills that a designer has traditionally needed. These designers must continue to be leaders in crafting effective and creative designs for projects. To be effective in the new model, however, they will also need to develop the skills associated with finding, evaluating, and understanding serious research, and then be able to grasp the implications of the research findings for each unique project. They need to learn to take key design issues important to the client or firm and be able to develop high-quality research questions that will lead to the discovery of relevant information. Architects and designers must respect the skills of the researcher who will be collaborating with them in new and unfamiliar ways.The designer must learn to use the capabilities of the researcher to help shed light on important questions and to find useful literature sources or other helpful information. Designers need to understand at least the basics of research types, methods, and measurements to collaborate more effectively. Designers will be among those who need to provide the researcher with important questions whose answers will make a significant difference to projects and clients. The researcher may need the designers participation in developing a useful research project when the firm becomes involved in performing practical, applied research.The designer of the future must believe that working together with a researcher will improve the designs on which they collaborate. He or she must be eager for the chance to partner with a researcher. …

Evidence, Best Practice, and Intuition.

Some time ago, my commitment to an evidencebased process was challenged by a workshop participant who became a great friend. Stefan Lundin, an experienced architect from Sweden and doctoral student at the Chalmers University of Technology, was attending a program Roger Ulrich and I were teaching on the topic of evidence-based design. He was skeptical about the concept, as he had been successful without utilizing an evidence-based process. Stefan was the architect of a highly regarded psychiatric facility, which Ulrich had identified as incorporating 9 of the 10 evidence-based principles for mental health facility design; Lundin was unaware of these principles and instead attributed his success to intuition.

Qualified Researchers Bring Value to a Design Practice

A few progressive design firms have begun to offer research services as part of their commitment to design influenced by credible research and their desire to develop a convincing set of project outcomes to verify their clients’ success. More design firms are beginning to consider acquiring staff with research training and experience, as they consider making the transition to higher levels of rigor in research-informed or evidence-based models of practice. Since few design practitioners were trained in research methods as they earned traditional professional degrees, there may be a need for some guidance for those considering hiring a researcher. Design practitioners usually acquire a professional degree. Researchers usually acquire a master of science (MS) degree or a doctor of philosophy (PhD), or both, from any of several related fields.

Rx: Window Bed

“Interns, any other ideas?” my attending asked the team as we made our daily rounds to the bedside of Ms. T, an octogenarian who had been in our intensive care unit (ICU) for just over a week. She had dementia and had undergone a tracheotomy, limiting her ability to communicate with us. The concern of my attending that morning was her sustained tachycardia, the etiology of which we could not explain; she had not responded to medical interventions. I was only days into my internship; how could I have any medical suggestions to address this woman’s heart rate? “We could move her to another room with a window,” I said to the group instead, yielding several questioning looks. “There is evidence,” I added, as I knew physicians would consider an intervention seriously if it had been documented in prior studies. In fact, there is an emerging field to support my appeal on rounds for space design. Evidence-based design (EBD), an analog to evidence-based medicine, grew out of a landmark study examining the restorative effect of nature on people after surgery. Individuals with views of nature had shorter postoperative hospital stays, took fewer moderate and strong analgesic doses, and had lower scores for minor postsurgical complications than those with views of a brick wall. When considering Ms. T’s case, half of our ICU is without windows, and she had been in a windowless room for days, the overhead fluorescent lights remaining on for most of that time. My sensitivity to environmental factors comes from my training and experience as a hospital architect. As a physician and a licensed architect, I consider many hospitals to be unsupportive physical settings in which to heal. Despite the specialization of healthcare architecture, many planned spaces are ill-suited for their actual use. Through the advent of EBD and hospital architecture training programs, research supporting space design is growing, with medical planning interventions and their effect on patient care and safety now featured in medical journals. That afternoon, Ms. T was moved to the other side of the unit where windows overlooked the river. I recall looking into her room that evening and seeing the distinct light of a summer sunset streaming through her window. I noted that her cardiac monitor had stopped its incessant beeping as her heart rate normalized. The next day on rounds, my attending acknowledged that the tachycardia had resolved, “but there is likely another explanation,” she said. Although we will never know the exact mechanism for this physiological change, given that she was receiving numerous interventions in addition to the room change, I believe that the sunlight and river views may very well have had an effect; the room change had been the single most obvious adjustment to her course of care in the previous 24 hours. I called a colleague that evening to share Ms. T’s story. I knew it would interest him. “Natural light has been shown to enhance the therapeutic environment,” he said. “Your elderly patient was in a dull, low-stimulus environment with no natural light and subjected to incessant noise and constant artificial light that flickers at unnatural wavelengths.” I agreed that those were the conditions to which she was exposed. “The move put her into a setting where the window provided an important chronobiological regulator through natural light and access to the diurnal cycle. The window may have provided a view of the naturally changing sky and perhaps even human activity and the river. Even if she was not fully aware of all these things, some of it was getting in through the retina.” Again, the architect in me agreed. It is possible that some or all of these things played a role in the change she exhibited. My design perspective has enhanced my medical experience. Since that day, I include environmental interventions in my daily notes. For shared rooms on the general medicine floors, my plan will include “window bed” if I feel an elderly adult or an individual with delirium would benefit from this intervention. As often happens with the rotational structure of clinical training, I would never know Ms. T’s full course and discharge plan because I left the ICU before she was moved to another level of care. What I can say for certain is that my brief time knowing her prompted an alternative discussion of hospital care on rounds that day and for several days after her room change. Her physiological response to what they eventually attributed at least partly to the move prompted my clinical colleagues to consider architectural design and the existing evidence. Only time and more research will tell if Ms. T’s story will become the norm.