Several months into the pandemic a nationally recognized health system client decided to design a new acuity-adaptable inpatient unit. These rooms are larger, more capital intensive and require skilled staff to treat higher-acuity patients. The concept of universal inpatient rooms has been around for a while, but hadn't been widely adopted by many health systems. However, the pandemic has revealed the need for, and benefits of, building more capable and adaptable patient rooms.
Inpatient universal care units provide great flexibility, serving as an intensive care unit room, intermediate care, or a medical-surgical bed. This flexibility allows patients to step down in room acuity without being transferred to another unit; eliminating these transfers reduces medication errors and staff handoffs between patients.
Universal rooms typically have a full bathroom versus an ICU room with a swivvet, half bath or other less desirable toilet configuration. Additionally, they include enhanced family space. Both are key to a positive patient experience.
The client wanted to increase its capabilities to deal with surge events, such as a natural disaster or pandemic. Like many hospitals, the client made temporary modifications to existing units in response to a surge of COVID-19 patients. While functional, many of these temporary fixes were less than ideal for patients, families and caregivers.
The healthcare system had shell space originally intended to be built out as a 28-bed medical-surgical unit. However, looking at the space with a fresh eye, the team helped guide the client toward a new goal of creating a 280-bed universal care unit that could serve typical patient populations and be acuity adaptable to accommodate a diverse mix of patients and the anticipated fluctuating needs.
Getting started
Undertaking this facility conversion required a complete, integrated project team consisting of architecture, engineering, the general contractor, equipment planner and representation from several hospital departments to establish a clear understanding of the project's guiding principles and metrics for success. This inclusive approach could at times be difficult to navigate as team meetings often had upward of 50 participants. A small contingent in a conference room or mock-up space, and others joining online promoted efficiency and clarity. This format helped ease the burden of so many people participating virtually. Online surveys gathered data on needed improvements, while interdisciplinary teams did "Go and See," or GEMBA walks on multiple units and locations, followed by onsite observation, and shadowing of care team staff to validate survey comments.
Additionally, the team identified a series of metrics to use post-occupancy to determine the true impact of the design changes. These metrics will help determine the performance of design interventions and influence the health system's acceptance of acuity-adaptable inpatient units in the future.
The findings
By touring several units in the existing health system with an emphasis on positive design attributes, simple changes were uncovered that could have major impacts on treating higher-acuity patients. Keeping in mind the units were designed years prior for different acuity levels, the team identified a variety of space challenges with the potential for improvement:
> Existing nursing stations had poor acoustic performance and were not laid out to support collaboration between staff.
> Existing nursing units did not have charting stations with direct patient observation windows.
> European-style showers in patient rooms resulted in slippery floors and patient falls, wet toilet paper rolls and tripped GFI receptacles.
> Patients needing dialysis were transported out of rooms for treatment to spaces that weren't conducive to a positive patient experience.
> Although a popular feature, dual-sided nurse servers were taped shut at the bedside for pressurization and potential contamination.
The team recognized reactionary changes to a single catastrophic event, such as 9/11 or the pandemic, may not be applicable for long-term use. Therefore, a series of scenario planning sessions were facilitated to better understand the demands that could come with treating high acuity, possibly mass casualties or isolation of patients with infectious diseases.
Design changes
The team identified a series of design-related interventions to address the aforementioned items; a few key changes include:
> Nurse charting stations were included with direct visibility to the patient, alone with one-sided nurse servers.
> Technology-enabled rooms to support video patient observation for efficient staffing coverage.
> Infrastructure for EICU systems was installed in each room to allow connectivity with trauma staff and specialists from other locations.
> Equipment storage, clean supply and soiled work areas were doubled with standardized locations.
> Connections for dialysis were installed allowing patients to stay in their room for treatment.
> Show stalls were reintroduced to reduce falls, supply expenditures and cleaning, and turn times for the next patient.
> HVAC systems were designed to allow all patient rooms on the unit to switch to negative pressure.
> Medical gas systems were improved to handle higher oxygen demands.
Buy-in and next steps
Engaging a large number of stakeholders in the design stage was key to project success. As the design progressed, a series of web meetings and recordings were curated for participants. All work was presented in floorplan and 3D views and renderings were made to help judge function and aesthetics.
Full-scale mockups of the patient room and the care team collaboration space helped stakeholders judge size and scale and promote further staff interaction and understanding. These measures not only helped the team make design decisions, but also enhanced stakeholder buy-in and supported behavior changes to improve function of the newly designed spaces.
As we enter the construction stage, the team remains diligent with drawing review and coordination meetings to validate all design work. We look forward to overseeing a successful construction project and post-occupancy evaluations to prove the results of the future-focused universal care unit design interventions.
John Ford, AIA, NCARB, EDAC, LEED AP
Senior Design Architect
Medical Construction & Design