Clinicians and architects share thoughts on informatics, life support systems, design trends, and use of design guidelines in renovation and new construction projects.
Life Support Systems
D. Kirk Hamilton, FAIA, FACHA, EDAC
Professor, Department of Architecture Texas A&M University
College Station, Texas, USA
The ICU of the future will require a robust life support system that organizes information (e.g., multifunction physiologic monitor), delivers medical gas utilities and electrical capacity, and allows platforms or baskets to be attached for convenience items, such as sphygmomanometers, otoscopes, or useful supplies. Today’s ICUs utilize three basic formats with some variation: headwalls, power columns, and overhead booms. In the future, these systems will be more advanced and wirelessly integrated with improved documentation and communication systems.
It is tempting to say the overhead boom offers the greatest flexibility and immediate access to the patient’s head and airway during a code situation – but it not realistic to predict that all ICUs will adopt the most flexible and elaborate system, for reasons of clinician preference, patient acuity, or cost. It is possible, however, to imagine a rational hierarchical distribution of acuity levels, similar to that used in emergency and trauma centers.
Perhaps a community hospital with the lowest expected acuity, designated as level 3, would most often utilize an improved version of the headwall life support system. Large urban and teaching hospitals might have a level 2 ICU that utilizes an advanced power column. The level 1 ICU designation might be limited to tertiary and quaternary institutions or major trauma centers, and these facilities would likely need all the flexibility an overhead boom system could provide. Life support technology selection likely will be based on acuity.
A (Slightly Provocative) Description of Architecture
Charles D. Cadenhead, FAIA, FACHA, FCCM
Senior Principal, WHR Architects Houston, Texas, USA
As an architect specializing in healthcare for 30 years, and having studied and judged entries to the ICU Design Citation for 10 years, I’ve observed trends in ICU design that I believe will become the norms of future ICU programs and designs. Not all will apply to every ICU; large academic centers are fundamentally different than small, general community hospitals. Indeed, one shoe does not fit all – but a shoe is still a shoe. Here are my predictions:
1) Larger Units – Expect more ICU beds per unit, and larger unit size per bed. Support space will increase as units become more operationally independent.
2) Patient Room – All-private rooms will remain the standard, with a stable room size of about 250 square feet. Family, toilet and possibly shower space will be added to this square footage.
3) Family Zone – Designated and meaningful family and visitor space amenities will be included in the ICU and patient rooms.
4) Technology and Life Support Systems – Ceiling-mounted life support systems will become the norm in critical care units. See Kirk Hamilton’s “Life Support Systems” for additional considerations.
5) Design for Interdisciplinary Teams – ICU teams will become more comprehensive, especially as the units become larger and include more specialties. A balance of centralized and decentralized work stations will be included.
6) Proximity to Diagnostic and Treatment Technology – More units will include diagnostic and treatment technologies, either adjacent to or within the unit. Improved mobile technology will be part of this trend.
7) Administrative and Related Spaces – Locating administrative, educational and research spaces within the ICU will be the norm.
8) Unit Geometry – ICUs will continue to adapt to surrounding conditions. Large units will be subdivided into smaller, manageable groupings of beds.
9) Unit Circulation – Segregation of public/visitor and patient/support circulations, horizontally and vertically, will be expected.
10) Access to Nature – The importance of nature to patients, families and staff is fully recognized and will be incorporated, regardless of unit size.
Neil A Halpern, MD, FCCM
Chief, Critical Care Medicine Service
Department of Anesthesiology and Critical Care Medicine
Memorial Sloan-Kettering Cancer Center
New York, New York, USA
The patient will be at the center of a vast computer system in the ICU of the future. Therefore, primary design goals will revolve around the electronic integration of the patient with all aspects of care (i.e., devices, data, supplies, caregivers, medical and administrative applications and the electronic medical record [EMR]), utilizing the data and monitoring of the ICU environment.
The first step in this process is the creation of a connectivity envelope around the patient that interfaces with ICU and hospital networks. The envelope is composed of wired and wireless data receivers, the placement of automatic identification tags on all data sources to facilitate tracking, and the attachment of adaptors/computers on the medical devices to transmit data and alarms. The second step is the installation of ICU middleware (servers and applications) on the ICU and hospital networks to perform the required tasks.
Three elements are critical to the success of advanced ICU informatics. The first is the association of all data sources and their output with the ICU patient. This is accomplished by either linking the data with the patient or with the patient’s location. The second element is synchronizing time across all bedside devices and systems to achieve a stable electronic flow sheet and medical record. The third is achieving “interoperability” among data sources, middleware and the medical record. This process converts and aligns the proprietary data output of medical devices with industry standards (www.ihe.net
), thereby allowing the middleware to recognize the data.
ICU middleware has the potential to perform many functions that advance both ICU care and management. Alarm systems capture alerts and convert them into actionable information by filtering and transmitting them to dedicated receivers and personnel. Intelligent alarm systems can even analyze raw device data and create personalized alarms. Data “sniffers” monitor ICU data and the EMR and profile patients at risk for clinical deterioration. Real-time locating systems/solutions (RTLS) can improve management and workflow by tracking or locating tagged assets, monitoring device utilization and controlling product inventory. RTLS can also be integrated with existing systems to improve personnel location, infection control and patient room management. Devices (e.g., all ventilators) can be monitored by middleware, thereby supporting global device viewing (i.e., local telemedicine), alarm transmission, report generation, and remote troubleshooting. Lastly, ICU middleware can create smart displays that merge data from bedside devices and the EMR and process these data through artificial intelligence algorithms.
Dan R. Thompson, MD, MA, FCCM
Professor of Surgery, Anesthesiology and Bioethics
Albany Medical College
Albany, New York, USA
Guidelines have a role in the design and construction of the modern ICU. Two important sources of guidelines are the medical literature and the documents created by organizations like the Facilities Guidelines Institute (FGI).(1)
The FGI Guidelines for the Design and Construction of Health Care Facilities are produced by a committee of about 120 professionals from various backgrounds, including physicians and nurses, infection control personnel, architects and designers, structural and mechanical engineers, and others with particular expertise in the design of healthcare facilities. Devised to meet minimum standards for design and construction, these guidelines are adopted throughout the United States and are used in other countries. In the United States, these are integrated into state regulations, either partially or in their entirety. The FGI guidelines also reflect and incorporate other subspecialty requirements, such as electrical, air handling, Americans with Disabilities, and Life Safety Codes. Because these are minimum standards, they can be exceeded but not reduced.
The second source, the medical literature, contains the SCCM’s Guidelines for Intensive Care Design, created from a different perspective – as optimal evidence-based design.(2) For instance, these guidelines recommend larger rooms and clearances. The combination of guideline perspectives is complimentary and will help achieve a design that fits the individual unit and the particular program, with the potential to adjust costs.
An important consideration in both the FGI and SCCM guidelines is adoption of these tools early in the design process by developing the functional program, an understanding of spaces needed to comprise the ICU. The use of design guidelines and standards enhances the finished environment, and ongoing revisions are necessary to keep pace with the changing nature of medical practice, technology and evidence-based studies. Find the SCCM guidelines at www.LearnICU.org/guidelines
1.Guidelines for Design and Construction of Health Care Facilites: The Facilities Guidelines Institute. Chicago, IL: American Society for Healthcare Engineering of the American Hospital Association; 2011.
2. Thompson DR, Hamilton DK, Cadenhead CD, et al. Guidelines for intensive care unit design. Crit Care Med. 2012;40(5):1586-600.