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Postgraduate Education Corner: Contemporary Reviews in Critical Care Medicine |

Innovative Designs for the Smart ICUInnovative Designs for the Smart ICU: Part 2: Part 2: The ICU FREE TO VIEW

Neil A. Halpern, MD, FCCP
Author and Funding Information

From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center; and Weill Cornell Medical College, New York, NY.

Correspondence to: Neil A. Halpern, MD, FCCP, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065; e-mail: halpernn@mskcc.org


Funding/Support: This work was funded by the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(3):646-658. doi:10.1378/chest.13-0004
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Published online

Successfully designing a new ICU requires clarity of vision and purpose and the recognition that the patient room is the core of the ICU experience for patients, staff, and visitors. The ICU can be conceptualized into three components: the patient room, central areas, and universal support services. Each patient room should be designed for single patient use and be similarly configured and equipped. The design of the room should focus upon functionality, ease of use, healing, safety, infection control, communications, and connectivity. All aspects of the room, including its infrastructure; zones for work, care, and visiting; environment, medical devices, and approaches to privacy; logistics; and waste management, are important elements in the design process. Since most medical devices used at the ICU bedside are really sophisticated computers, the ICU needs to be capable of supporting the full scope of medical informatics. The patient rooms, the central ICU areas (central stations, corridors, supply rooms, pharmacy, laboratory, staff lounge, visitor waiting room, on-call suite, conference rooms, and offices), and the universal support services (infection prevention, finishings and flooring, staff communications, signage and wayfinding, security, and fire and safety) work best when fully interwoven. This coordination helps establish efficient and safe patient throughput and care and fosters physical and social cohesiveness within the ICU. A balanced approach to centralized and decentralized monitoring and logistics also offers great flexibility. Synchronization of the universal support services in the ICU with the hospital’s existing systems maintains unity of purpose and continuity across the enterprise and avoids unnecessary duplication of efforts.

Figures in this Article

In this second of three articles on innovative design for the smart ICU, we will focus upon the essential components of the ICU, beginning with the patient room, followed by the common areas and universal support services. In part 1, we discussed the formation and management of the ICU design team and the development of the vision and plan for the new ICU.1 We also addressed the differences between designing for new construction or renovation, the expectations and ramifications that accompany ICU design, strategies for technology acquisition, and transitioning from an old ICU to a new one.1 In part 3, we will address advanced ICU informatics.2

The primary goal of this series is to familiarize critical care medicine (CCM) clinicians and practitioners, health-care architects, facility planners, interior designers, and members of future ICU design teams with innovative concepts in ICU design. These articles supplement official ICU guidelines and recommendations,3,4 and provide the reader with information and thoughts gleaned from analyses of ICU-design award winners,5,6 evidence-based approaches and reports addressing ICU design,7-10 and my experiences in designing and actualizing (renovation and new construction) three adult ICUs.11

This article is divided into three sections: the ICU patient room, central areas, and universal support services. Each is introduced by a set of core principles. As an aid to the reader, crosswalks relate the ICU terminologies used herein with descriptors from recent guidelines when describing identical ICU spaces.3,4 For example, when referring to a central station, other similar phrases, such as nursing station, administrative center, and interdisciplinary team center, follow in parentheses.

The ICU patient room (space or cubicle) is the core of the ICU patient, visitor, and staff experiences (Fig 1).3,6-8,12 Five basic principles govern modern patient-room design. First, all rooms should accommodate one patient only because single occupancy rooms best support patient privacy and infection prevention.5,10,13 Second, each room should offer a healing environment.7,14 Third, patient rooms should be similarly designed and equipped to simplify patient triage and enable staff to move seamlessly from room to room. Fourth, much of the room’s infrastructure and medical devices are informatics based. Finally, all rooms should function autonomously but, at the same time, should be fully interwoven into the ICU fabric.4

Figure Jump LinkFigure 1. ICU patient room (ultrawide angle view).Grahic Jump Location
Infrastructure

The design group must work through the room’s core infrastructure elements (electrical power [standard and emergency]; heat, ventilation, and air conditioning; plumbing; lighting; flooring; walls; ceiling; communications; video camera(s) [webcam and video EEG], and connectivity [wired and wireless access]). The design concepts and specifications for these systems are usually opaque to clinicians. Thus, the team’s clinical members need to familiarize themselves with the relevant design, architectural, and engineering issues and make sure that the end-user (patient and staff) requirements are clearly expressed to the architects. Subsequently, the design schematics should be reviewed with the entire team in simple language.

An early operational decision that guides the room’s functionality involves the selection of the medical utility distribution system. Should medical devices (eg, physiologic monitor, mechanical ventilator, and infusion pumps), utilities (eg, medical gasses and vacuum, electrical and data outlets), communication systems, and storage for select supplies be incorporated onto stationary headwalls, floor mounted, or suspended columns (fixed in position or rotating), or ceiling- or wall-mounted mobile articulating columns/arms (booms) (Fig 2)?15 The mobility of the booms offers greater flexibility, access to the patient, and enhanced bed positioning (including facing the window) than the stationary solutions. However, booms are more expensive to purchase, install, and maintain. Regardless of the utility system chosen, efficient access to the medical devices and utilities is a primary design requirement.12

Figure Jump LinkFigure 2. A-C, ICU utilities and equipment mounted on (A) a stationary headboard, (B) stationary (left side) or rotating (right side) columns, and (C) mobile articulating arms (booms) that swivel and can be moved horizontally and/or vertically. The booms can be attached to the walls or ceiling, at the head of the bed, or at all four corners.Grahic Jump Location
Core Bedside Medical Technologies

The essential medical devices and furniture for the ICU patient room include an ICU bed, physiologic monitor, mechanical ventilator, infusion and feeding pumps, pneumatic compression devices, patient lift, computers, patient and visitor chairs, over-bed tables, laboratory-specimen label printer, nurse-call station, webcam, entertainment system, storage areas, and waste disposal bins. Point-of-care testing (POCT) and ultrasonography devices are increasingly being considered as core bedside equipment because these technologies speed diagnosis, improve therapeutic decision-making, and have decreased in size, footprint, and cost.16-19

Device purchases must address the large number of options that are available per device and long-term maintenance contracts. Most ICU devices are informatics platforms; therefore, the device selection and purchase should also encompass device connectivity, middleware (network gateways, servers and applications for data and device management), and software licenses and updates. Ideally, emergency back-up systems for devices (ie, batteries and compressors for mechanical ventilators) that preserve their functionalities in the face of electrical or utility failures are included as well. Additionally, the ICU needs to own portable, battery-supported, life-support systems and devices for transport20 in the setting of an ICU evacuation (Table 1).

Table Graphic Jump Location
Table 1 —Central-Based Medical Equipment
a 

Physiologic monitor, defibrillator, ventilator, suction, and infusion pump.

Zones

ICU rooms have patient, caregiver, and family (visitor) zones (Fig 3).7 Although these zones may be physically or virtually differentiated by room layout, and furnishings and finishings, the zones must be operationally flexible to accommodate variable needs. The zones should also be efficiently located to minimize unnecessary staff and patient movements.

Figure Jump LinkFigure 3. The ICU patient room can be divided into three zones: (1) patient, (2) caregiver, and (3A) virtual or (3B) fixed family zones. Also shown are nurse server with bidirectional access, nursing work area, supply space (cabinet or cart), booms, bathroom with sanitizer (or macerator), webcam, Wi-Fi access point, and a workstation and staging area outside the room.Grahic Jump Location

The patient’s bed is the room’s focal point. Floor space should be clear of equipment to permit easy access to the patient. This is possible as most medical devices can now be attached to the medical utility distribution systems or to the bed. The caregiver zone should include work areas with sufficient surface space for preparation and administration of medications, processing of laboratory specimens, placement of materials when performing procedures, medical record charting, and storage of supplies. Comfortable chairs, wireless Internet access, and electrical and USB outlets are recommended for the family (visitor) zones (Fig 3).3,4,7 If space permits, each room should offer a long-term visiting alcove outfitted with a chair-sofa-bed, table, light, sink, locker, and refrigerator.

Room Logistics

The patient room must have storage spaces for supplies, medications, and linens. Storage systems may include a mix of secured (electronic preferred over keys) and nonsecured drawers, cabinets, and/or mobile carts. Nurse servers (cabinets with bidirectional and secure access from both outside and inside the room) should also be considered. Privacy and infection control violations are curtailed as the nurse servers can be supplied from outside the room (Figs 1, 3).21

Waste Management Systems

Current guidelines mandate that ICU patient rooms have direct access to bathrooms.3,4,7,10 Designers should consider installing sanitizers (to clean reusable bedpans) or macerators (to destroy single-use bedpans) in the bathrooms (Fig 3).22 However, these devices produce a fair amount of noise; thus, the bathroom walls should include sound-reduction barriers. Bathroom infection control is supported through frequent air exchanges and air filtering, as well negative pressure systems that limit the dispersion of aerosolized waste back to the patient room. Even with bathrooms, portable commodes are still required. Trash (standard, infectious, sharps) and soiled linens can be placed in stand-alone rolling carts or in mounted bins or containers designed into the cabinets.

Room Environment

The emotional welfare of ICU patients, staff, and visitors is greatly impacted by the room’s environment.23-25 Thus, a healing milieu that promotes serenity and encourages sleep should be developed. The essential healing elements include sound, light, temperature, time, art, and entertainment.3,7,26-29

Sound

Noise is physically minimized through the use of sound-absorbent materials on the walls and ceiling, acoustic baffling within the walls, sound-proofed windows, and sound attenuators in the heat, ventilation, and air conditioning system.27,30,31 Physical limiters of sound, however, must be accompanied by control of alarms from devices,32,33 minimization of announcements and alerts from ICU and hospital communication systems, and shifting of conversation from the front of the central stations to more distant central areas. Noise-canceling headphones and sound-masking or white-noise systems also mitigate loud noises or generate positive sounds, respectively.29,34,35

Light

ICU patient rooms are mandated to have windows.4 Natural light and a compelling view help maintain diurnal rhythms and mental stability.3,4,36,37 Beyond antiglare coating, the flow of outdoor light should also be controlled with shades (solar and black-out), glass with integral blinds, or electronic glass. Controls for these systems (mechanical or electronic) need to be available to both staff and patient. In the unusual circumstance where access to outside windows is not possible, artificial ambient light systems may be considered.

Room lighting should include direct lights for patient examinations and procedures, and indirect lighting for quiet times and night. Attention ought to be given to the fixtures, photometric properties of the light sources, and lighting direction and color, as well as the relationships among the lighting, room surfaces, and finishes. Lighting configurations are optimally managed with simple controls located both outside and inside the room.38

Temperature, Smell, and Time

Critically ill patients may have temperature dysregulation or be highly sensitive to changes in room temperature. Therefore, each patient room should have its own thermostat. Scent eliminators or generators may be used to provide fresh smells. Highly visible clocks (stand-alone, computer, or television display) with day and date help with patient orientation.

Room Controls and Environmental Sensors

Environmental controls (lights, window treatments, and thermostat) may be individualized or integrated within computer or nurse-call technologies. Continuous monitoring of the patient room by multiparameter sensors (temperature, humidity, light, sound, room pressure, and particulate matter) helps maintain the healing environment. Web-based sensor applications can transmit alerts when norms are violated.

Artwork, Entertainment, and Room Personalization

Nature-based artwork mounted on the ICU walls, embedded in privacy curtains and ceiling tiles, or electronically projected on video displays uplifts the spirits of all who enter the patient room.7 Televisions or integrated television-computers can be attached to articulating arms from the bed, walls, booms, or ceiling. Sound can be projected from the entertainment displays, nurse-call handsets, directional speakers (ceiling, wall-mounted, or bed-based), or wireless headsets.39 Entertainment may also be provided through visor-based video displays. A venue (bulletin board or electronic monitor) to display supportive cards and pictures should be in the room. Finally, a locker for patient and family belongings enhances security.

Front of ICU Room

Four issues must be addressed when designing the front of the ICU patient room. The first is the distance between the front of the room and the hallway. ICU rooms may open directly onto the hallway, be set back from the hallway, or have a hybrid design (Fig 4). Locating the front of the room directly on the hallway incorporates the maximal amount of space into the patient room. Setting the room back, however, allows for the development of a staging area. The hybrid design incorporates positive features of both prior approaches. The staging space may include a sink, handwashing dispenser, storage space (gowns, gloves, and masks), coat hangers, and an identification board (white or glass board or electronic display).

Figure Jump LinkFigure 4. A-C, The patient room may have sliding and breakaway doors that (A) open directly into the ICU hallway or (B) are set back from the hallway allowing for an open (left) or closed (right) staging area. C, Alternatively, the room may have a hybrid front wall with swinging doors and a condensed staging area. Each room has its own external WS. WS = workstation.Grahic Jump Location

The second set of concerns for the front of the room deals with privacy and control of infection, sound, and smoke. Several privacy options are available, including curtains alone, framed doors with clear glass and curtains hung behind the doors, or framed doors with integrated privacy-glass solutions (integral blinds or electronic glass [e-glass, smart glass, liquid crystal display glass or privacy glass]). E-glass instantly darkens and clears and is available in multiple colors with dimmers. The opacity levels should be monitored over time; e-glass should be purchased with long-term warranties. Privacy controls for both types of glass solutions should be located inside the patient room to enable the bedside staff to control privacy.

Curtains are less costly to install than the glass systems. However, curtains, unlike framed doors, do not provide true barriers to infection, sound, or smoke. Furthermore, curtains may also become stained or contaminated,40 thereby necessitating laundering and time-consuming curtain changes between patient admissions. Over time, as the original curtains are lost or destroyed, the replacement curtains supplied by the hospital laundry may not be compatible with the ICU motif. In contrast, the glass doors are easy to clean, but will require periodic maintenance.

Framed ICU doors are available as multipanel glass doors that slide and breakaway or as single-panel swing doors with glass inserts (Fig 4). The door opening must be large enough to permit ICU beds and personnel to pass through.4 The ICU room doors may be controlled manually or electronically. Electronic doors require the installation of presence-detection sensors to prevent the doors from inadvertently closing when the passageway is occupied.

The third issue to consider is the inclusion of a clinical workstation in the front of the room (Figs 3-5). Local work stations provide direct patient visibility and monitoring and help keep staff in close bedside proximity. Workstations may be designed as one per room or per two rooms and should be ergonomically outfitted with a desk, chair, computer, nurse-call, and a secure space for nurses’ belongings. The stations should have direct access to bedside physiologic data through a mounted slave monitor or a web-based application. An integrated display of all bedside and electronic medical record data may also be beneficial.41

Figure Jump LinkFigure 5. A-C, Decentralized WSs may be constructed outside the patient rooms as one station per two rooms (1 and 2 in A) or one station per room (1 and 2 in B), or there may be no decentralized WS (C). Room-based WSs are present in A and B; mobile WSs are used outside and inside rooms 1 and 2 in C. A, ICUs may be built with a multitiered central station with office and multipurpose conference room, (B) have a central station only, or (C) have no central station. See Figure 4 legend for expansion of abbreviation.Grahic Jump Location

The fourth item involves the incorporation of a nurse server into the room’s front (Figs 1, 3). This decision depends on the approach to ICU logistics support and physical space availability and has been discussed previously.

Central area design is governed by four tenets. First, the primary purpose of these spaces is to support bedside care. Second, the themes of healing, privacy, informatics, communication, and infection control should weave seamlessly between the patient rooms and the central areas. Third, the design of the central areas should foster a cohesive ICU environment. Lastly, the central area’s spaces should be sufficient to minimize hallway clutter (people, devices, and supplies).

Central Stations (Nursing Station, Administrative Center, Interdisciplinary Team Center)

Central stations provide areas for administrative, clinical, and uni- and interdisciplinary collaborative and social interactions.5 The layout of the central stations depends upon the physical arrangement and space availability of the ICU and the bed configurations (Figs 5, 6). One centrally located station may suffice in a small ICU, whereas multiple central stations and substations may be required in a large ICU with several bed pods.

Figure Jump LinkFigure 6. ICUs can be configured in many patterns. A, Rectangular. B, Circular. C, Triangular. D, Square. They may have differing numbers of beds and central areas.Grahic Jump Location

Ideally, central stations should have unobstructed views of the ICU beds. However, physical limitations usually preclude direct patient observation for all rooms. Technological solutions may overcome this problem through the use of bedside webcams, physiologic monitoring central stations, or applications that electronically “forward” vital signs, ventilator data, and alarms to central displays, marquees, or handheld devices.

Central stations commonly are composed of desks to greet visitors, and quiet areas for staff work, documentation, consultation, and conferencing. The stations should also include multipurpose conference rooms, CCM nursing and clinical offices, and restrooms. Central station equipment consists of nurse-call annunciator stations, telephones, grease boards, computers, high-definition image review (ie, picture-archiving and communication system) stations, multimodality printers, laboratory-specimen label printers, nourishment stations (with sound-buffered ice machines), and emergency alerts and cut-off switches for ICU utilities. Pneumatic tube stations for transport of laboratory specimens, blood products, and medications are also commonly located in the central stations.

Corridors

ICU corridors that are well coordinated with the patient rooms, central areas, and ICU exits provide efficient circulation pathways and facilitate physical and social unity, especially in large ICUs with multiple central stations and bed pods (Fig 6). The inclusion of designated hallways for transport of patients and supplies that bypass the ICU front door and waiting room augments patient privacy and helps avoid traffic jams (Fig 7).3,4 However, ideal corridor design may be difficult to achieve because of physical barriers (staircases, elevators, plumbing conduits, and electrical and network closets) and hospital hallways that are discordantly positioned.

Figure Jump LinkFigure 7. The waiting room has direct entry into the ICU (ie, on-stage) and has a reception desk, private seating areas, consultation room, computer area, social worker office, restrooms, nutrition court, and lockers and coat hangers. Long-term accommodations (beds and showers) can also be included. A bypass corridor for patient transport and staff and equipment movement circumvents the waiting room and provides privacy and prevents traffic jams (ie, off-stage).Grahic Jump Location

ICU hallways also set the emotional tone for the ICU through their finishings and artwork, sound control, and adjustable lighting. The minimum building code width for hospital hallways is 8 feet. However, hallways, especially in academic centers with large multidisciplinary ICU teams, also serve as intermediate spaces between the patient rooms and the central stations. These hallways are used to conduct rounds (with mobile computer carts), patient related consultations, family meetings, and therapeutic activities (ie, early mobility). Therefore, in such dynamic settings, design teams should consider widening the hallways past the minimum code requirement and equipping them with power outlets for the carts. Respite areas within the hallways may also be a valuable local and supportive adjunct for ICU visitors.

Fixed barriers and bumper guards or damage-resistant wall finishings should be installed along the corridor walls to protect them from dents and breakage caused by heavy rolling equipment. The installation of half-globe mirrors improves safety at ICU entrances and hallway corners. Full-time access must always be maintained along the hallways for electrical and network closets.

ICU Logistics Spaces, Supplies, and Medical Devices

Bulk supplies, medical devices, and procedure carts (Table 1) are stored in large ICU supply and storage rooms (clean workrooms or clean supply rooms) and alcoves along the hallways. These storage spaces should have access to transport or cargo elevators as well as power and data outlets for device charging and data transmission. The strategic positioning of supply rooms and alcoves minimizes travel distances from patient rooms and reduces hallway clutter.4 These efficiencies may be compromised in large ICUs with multiple pods (Fig 6) unless core facilities are easily accessible from each pod or supportive logistical spaces are duplicated in each pod. Space should also be allocated off the main corridors for storage of occasionally used large devices (ie, specialty beds) (Table 1).3

Options for supply storage include stationary or track-based shelving, closed supply cabinets, or rolling exchange carts. Ideally, these storage units are outfitted with electronic inventory management systems as part of real-time locating systems/solutions (RTLS).42 The challenge to design teams is to “right size” both the central ICU supply and bedside storage areas. This process requires accurate projections of ICU occupancy rates, supply usage, and clarity of ICU and patient-room resupply models (ie, replenishing used supplies vs discarding unused supplies or exchanging supply carts) both when the room is occupied or between patients. Regardless of the logistics plan, an emergency stockpile of vital supplies and back-up equipment for the bedside needs to be kept in the ICU (Table 1).

Central spaces maintain a host of medical devices and carts that are intermittently used at the ICU bedsides (Table 1). These devices may also supplement core bedside equipment (ie, infusion pumps) or provide emergency replacement if bedside devices fail (ie, free-standing physiologic monitor). ICU design teams must also grapple with the cost-benefit ratios of owning and storing large imaging or therapeutic devices and/or constructing permanent facilities for them in valuable ICU space.3,7 For example, should the ICU have a mobile CT scanner,43 a suite with a permanent CT scanner, or none at all? Similarly, physical therapy and early mobility can be performed both at the bedside and in the hallways using mobile devices.44-46 Would such therapies be augmented with a local rehabilitation suite?

Pharmacy

Medication management and ICU pharmacy space must be coordinated with the hospital’s primary pharmacy.47,48 If the hospital’s pharmacy system is centralized and ready-for-administration medications are regularly distributed, the design team needs to determine the minimal resources (secure and quiet medication preparation station) required for local and urgent pharmaceutical services. Alternatively, a fully equipped satellite ICU pharmacy is necessary in a hospital with a decentralized medication system. Self-contained, electronic, and secure automated medication dispensing units for readily available or emergent medications are necessary in both ICU pharmacy models. These devices should be strategically positioned and linked to the hospital’s intranet to track medication inventory, usage, and provider. Medications may also be stored in secured cabinets, with refrigeration if necessary, at the ICU bedside.

ICU Laboratory Testing and POCT

Laboratory testing performed within the ICU usually falls under the rubric of POCT and focuses primarily upon whole-blood analyses. POCT devices, available as large and small platforms, may be positioned in an ICU stat laboratory, at a central station, on mobile carts, or at each ICU bedside (Fig 8). These devices are usually connected through POCT device and data management middleware to the laboratory information system or the electronic medical record.16,49 A combination of POCT modalities, locations, and middleware may be used depending on the ICU workflow, necessary testing, and available space and resources. As POCT is never a complete replacement for the central laboratory, pneumatic tube stations are still required to transport specimens to rapid-response or central laboratories located elsewhere in the hospital.

Figure Jump LinkFigure 8. POCT paradigms. A, POCT based at every bedside. B, Mobile POCT on a cart or handheld. C, POCT based at a central station. D, POCT within a local stat (rapid response) laboratory. POCT = point-of-care testing.Grahic Jump Location
Staff Lounge

A lounge with tasteful appointments and amenities located within the ICU helps maintain the emotional and physical well-being of the staff and encourages staff members to stay in the ICU confines and socialize during breaks. Seating should accommodate the average number of ICU staff on breaks. Staff satisfaction is promoted through the provision of windows; comfortable chairs, couches, and tables; artwork; televisions; computers; a nourishment station (refrigerator, microwave, and sink); private changing areas; scrub dispensers; lockers; storage areas for heavy coats, shoes, or boots; bulletin boards; staff mailboxes; nurse nap alcoves; and bathrooms. The lounge must also have ICU communication and nurse-call systems.

Visitor Waiting Room (Family Lounge)

Placing the waiting room adjacent to the ICU allows visitors to easily access the ICU and clinicians to meet with families (Fig 7).50,51 Visitors should be greeted by a receptionist in the waiting-room area or at the ICU entrance. ICU visitors benefit from a tranquil environment with soft lighting, warm colors, nature-themed artwork (photographs, paintings, or video displays), and quiet background entertainment (wall- or ceiling-mounted televisions). If possible, the waiting room should have large windows supplemented by outdoor patio access.

Small groups of comfortable chairs, separated by dividers, allow families to sit together with relative privacy.3,24 Facility guidelines recommend a minimum of 1.5 chairs per patient bed.4 The waiting room experience is enhanced through wireless Internet access, computers, power and USB outlets to charge visitors’ phones and computers, vending machines, water fountains, bathrooms, lockers, and coat hangers. Family meetings and social support in the waiting room are promoted through the inclusion of consultation rooms and an office for the social worker, respectively. Long-term sleeping accommodations (rooms or alcoves) may also be considered if space permits and the ICU leadership is willing and capable of managing hotel-type facilities.

On-Call Suites, Conference Rooms, and Offices

The on-call suites, ICU conference and multipurpose rooms, and CCM and respiratory therapy offices are best situated within the ICU environs to facilitate staff availability for patient and family matters and meetings.4 On-call suites should be outfitted with private sleeping quarters with computers, nurse-call stations, and entertainment systems, as well as bathrooms and showers. The seating capacities of the conference rooms should be based upon predicted usage. These rooms should be furnished with computers, audiovisual systems, smartboards, ICU communications systems, wireless connectivity, nourishment stations, electronic scanners to track attendance and electronic scheduling boards outside the rooms. Dividers (mechanical or electronic) may be considered for large conference rooms to permit simultaneous meetings.

Critical-care office suites should include areas for attending physicians and clerical support staff, critical-care fellows, mid-level providers, and research personnel. Respiratory therapy suites should include offices, conference and work rooms, and storage and cleaning areas.

Two principles govern the design of universal ICU support services. First, these services must be titratable throughout the ICU to meet the varying needs of patients, visitors, staff, and space. Second, the universal services in the ICU should be synchronized with the hospital’s existing systems to maintain unity of purpose and continuity across the enterprise and to avoid unnecessary duplication of efforts.

Infection Prevention

To date, ICU infection prevention relies upon several core strategies. The first is the “behind the scenes” infrastructure that supports clean air. This includes air-cleansing systems,52 room-based air exchanges, and airborne infection isolation (positive- and negative-pressure) rooms. The second is the plumbing to provide water for sinks (inside and outside each patient room) and to eliminate waste in all patient rooms and device, supply, and garbage processing areas.53 The third is the ubiquitous installation of hand-sanitizing fluid dispensers. The fourth is the use of nonporous surface materials that resist water seepage and the subsequent adherence and growth of bacteria, viruses, or fungi.3,4,22,54 The fifth is the strategic positioning of housekeeping closets (environmental storage or service rooms) and soiled utility rooms (soiled workrooms or soiled holding rooms) to both facilitate cleaning and minimize the transit of waste and contaminated devices from patient rooms. The sixth is the placement of controllers for patient-room systems (electronics, air, and plumbing) outside, rather than inside, the patient room. This positioning allows upgrades or repairs to be effected without opening up the ceiling in the patient’s room and potentially exposing a care area to ceiling-based particulate or infectious matter.

Despite the routine application of these approaches, serious infections remain an ICU problem. The best designs will only be effective in the presence of an ICU culture that believes in infection deterrence.10,55 The use of electronic surveillance of handwashing compliance is now being advocated as an adjunctive mechanism.56 Recent reports, however, suggest that hand hygiene and surface cleaning may be less efficacious than previously thought, even when used properly.57-59

Therefore, ICU designers should additionally explore the utility of advanced infection-prevention modalities. These include the use of surfaces (countertops, bedrails, door frames and handles, drawer handles, and curtains) and technologies (sealed keyboards and computer mice) that incorporate “self-cleaning” copper or silver.60-63 ICUs should also consider the benefits of routine surface testing for bacteria, and environmental decontamination systems (ultraviolet light,64-66 high-intensity narrow-spectrum light,67 hydrogen peroxide dispersion,68 and continuous air disinfection69). The design team may even designate “super isolation” zones that facilitate the grouping of highly infectious patients and the rerouting of traffic patterns.70 Finally, the intermittent decontamination of smart phones may have to be considered; these phones have been found to be colonized with infections.71

Finishings and Flooring

Beyond being integrated within the global motif, all ICU finishings should be durable and easy to clean and maintain.3 Floors, additionally, should be comfortable to walk on, slip-resistant, and seamless.10,21,22,54 Cabinetry throughout the ICU should be solidly constructed. The walls, wall coverings, and countertops also need to be water resistant, especially near sinks and plumbing fittings.

Staff Communications

Various communication technologies including telephones, overhead speakers, nurse-call stations, pagers, and bidirectional transmitters are available.3 Landline telephones continue to play a major role in providing reliable and secure ICU communications and should be installed universally and with redundancy. Overhead speakers also remain necessary to maintain ICU participation in hospital-wide broadcasts; however, overhead announcements must be used sparingly to minimize noise. Overhead systems can be integrated with other ICU communication systems and offer zoned broadcasts and automatic adjustments to ambient sound.

Nurse-call (intercom) systems installed throughout the ICU and bidirectional transmitters (smart phones or pendants) carried or worn by staff can handle point-to-point and global communications and alarm broadcasts. Both technologies can be integrated with each other and into RTLS.42 Bidirectional transmitters and phones can convey voice, telephone, pages, alarms, and e-mail using wireless and cellular networks. Quiet communication can be maintained through ear pieces and small boom microphones.72

Signage and Wayfinding

Signs are a critical but easily underappreciated element of the design.73 Destination signs must be easily visible and clear in message. However, the text on these signs may be confusing and duplicative because building codes commonly mandate the concomitant display of official room designations in addition to the obvious purposes of the room (ie, room 1234 and bed 4).

Good directional signage guides ICU staff and visitors to their intended destinations using the most effective and appropriate pathways.24 The process of developing directional signs requires virtual ICU walkthroughs that broadly look at each corridor and destination from every direction that the sign may be viewed. Large hospitals are now also introducing kiosks that provide electronic wayfinding from the hospital’s entrance to the desired end points.

Signs also provide information about the area. The front entrance signage usually has permanent text (ie, ICU name and visiting hours). In contrast, signs at each patient room have temporary text (ie, patient name and ICU team); thus, room-based signs should include erasable whiteboards or programmable electronic displays.3,73

Security

Security and a warm setting need to be balanced within the ICU design. Electronic identification card access for staff is useful at all secure doorways. Time-limited electronic access cards may also be distributed to ICU visitors. Communications at visitor entrances are best handled by dedicated clerks; however, staffing limitations usually preclude full-time personnel. Thus, closed-circuit televisions and electronic buzzer systems should be installed at ICU entrances. Overall, the ICU is optimally monitored by a mix of hospital-based video cameras and locally based webcams.

Fire and Safety

Although there are many elements of the design that are critical to preventing and controlling fire and smoke; four deserve special mention within the design process.74,75 The first is the focus on using products and finishings that possess a low fire load and release limited quantities of heat and toxic smoke. The second is the construction of fire- and smoke-rated compartments within the ICU that keep fire and smoke within the compartment where the condition originated. This safety feature permits staff, patients, and visitors to evacuate from a danger zone to a horizontal and adjacent compartment of refuge. The third is implementation of protective technologies within the heat, ventilation, and air conditioning systems and ducts that prevent the spread of smoke and other products of combustion from one area to another. The fourth is the integration of experienced fire safety officers into the ICU design process to assure that fire codes are met in the most practical and user-friendly fashion.

Core ICU fire safety devices include smoke detectors, automated sprinklers, and a variety of fire extinguishers. The ICU must also have fire alarm pull-stations to facilitate hospital-wide notice of ICU emergencies. Conversely, the ICU needs to have sound or light alerts and overhead speakers to notify the ICU staff of local or facility-wide fire and smoke situations.

The ICU design team can optimize the experiences for patients, staff, and visitors by coordinating all aspects of the patient room, central areas, and universal support systems. This requires clarity of vision and purpose that emphasizes functionality, healing, standardization, and the thoughtful application of both existing guidelines and innovative approaches. In our third and final installment, we will focus upon advanced ICU informatics.2 We will explore the connectivity envelope around the patient, device association, interoperability, and time synchronization, ICU devices as informatics platforms, alarm and data transformation, device management, smart displays, RTLS, telemedicine, and maintaining and upgrading the smart ICU informatics systems.

Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Halpern is a consultant to Cardiopulmonary Corp; Pronia Medical Systems, LLC; and Instrumentation Laboratory. He is a member of the ICU Design Award Committee of the Society of Critical Care Medicine and The Intelligent Hospital Advisory Board of the RFID in Healthcare Consortium and is a principal of Critical Care Designs. The Memorial Sloan-Kettering Cancer Center ICU was the recipient of the 2009 ICU Design Citation award.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: The author acknowledges Elaine Ciccaroni, BA, Medical Graphics, Memorial Sloan-Kettering Cancer Center, for preparation of the figures and tables; John Letson, MBA, and Howard Venetsky, associate degree in fire science, Facilities Management, Memorial Sloan-Kettering Cancer Center for their input; and Diana C. Anderson, MD, MArch, Resident Physician, Columbia University Medical Center and Architect, Royal Architectural Institute of Canada, for manuscript review.

CCM

critical care medicine

POCT

point-of-care testing

RTLS

real-time locating systems/solutions

Halpern NA. Innovative designs for the smart ICU: part 1: from initial thoughts to occupancy. Chest. 2014;145(2):399-403. [CrossRef] [PubMed]
 
Halpern NA. Innovative designs for the smart ICU: part 3: advanced ICU informatics. Chest. In press. doi:10.1378/chest.13-0005.
 
Thompson DR, Hamilton DK, Cadenhead CD, et al. Guidelines for intensive care unit design. Crit Care Med. 2012;40(5):1586-1600. [CrossRef] [PubMed]
 
Guidelines for Design and Construction of Health Care Facilities: The Facilities Guidelines Institute. 2010 ed. Chicago, IL: ASHE (American Society for Healthcare Engineering) of the American Hospital Association; 2011.
 
Rashid M. A decade of adult intensive care unit design: a study of the physical design features of the best-practice examples. Crit Care Nurs Q. 2006;29(4):282-311. [CrossRef] [PubMed]
 
Cadenhead CD, Anderson DC. Critical care design: trends in award winning designs. WorldHealthDesign website. http://www.worldhealthdesign.com/critical-care-design-trends-in-award-winning-designs.aspx. Accessed July 17, 2013.
 
Hamilton DK, Shepley MM. Design for Critical Care: An Evidence-Based Approach. Burlington, MA: Elsevier Ltd; 2010.
 
Valentin A, Ferdinande P; ESICM Working Group on Quality Improvement. Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med. 2011;37(10):1575-1587. [CrossRef] [PubMed]
 
Kesecioglu J, Schneider MM, van der Kooi AW, Bion J. Structure and function: planning a new ICU to optimize patient care. Curr Opin Crit Care. 2012;18(6):688-692. [CrossRef] [PubMed]
 
Bartley J, Streifel AJ. Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit? Crit Care Med. 2010;38(suppl 8):S388-S398. [CrossRef] [PubMed]
 
Architectural showcase. Intensive care unit. Healthcare Design Magazine. 2007;7(7):245.
 
Nestor C. Critical conditions. A real-world look at features and technologies for the ICU. Health Facil Manage. 2005;18(8):25-29. [PubMed]
 
Teltsch DY, Hanley J, Loo V, Goldberg P, Gursahaney A, Buckeridge DL. Infection acquisition following intensive care unit room privatization. Arch Intern Med. 2011;171(1):32-38. [CrossRef] [PubMed]
 
Bazuin D, Cardon K. Creating healing intensive care unit environments: physical and psychological considerations in designing critical care areas. Crit Care Nurs Q. 2011;34(4):259-267. [CrossRef] [PubMed]
 
Pati D, Evans J, Waggener L, Harvey T. An exploratory examination of medical gas booms versus traditional headwalls in intensive care unit design. Crit Care Nurs Q. 2008;31(4):340-356. [CrossRef] [PubMed]
 
Halpern NA. Point of care diagnostics and networks. Crit Care Clin. 2000;16(4):623-639. [CrossRef] [PubMed]
 
Manno E, Navarra M, Faccio L, et al. Deep impact of ultrasound in the intensive care unit: the “ICU-sound” protocol. Anesthesiology. 2012;117(4):801-809. [CrossRef] [PubMed]
 
Field LC, Guldan GJ III, Finley AC. Echocardiography in the intensive care unit. Semin Cardiothorac Vasc Anesth. 2011;15(1-2):25-39. [CrossRef] [PubMed]
 
Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009;135(6):1416-1420. [CrossRef] [PubMed]
 
Farmer JC, Wax RS, Baldisseri MR., eds. Preparing Your ICU for Disaster Response. Mount Prospect, IL: Society of Critical Care Medicine; 2012.
 
Harvey MA. Critical-care-unit bedside design and furnishing: impact on nosocomial infections. Infect Control Hosp Epidemiol. 1998;19(8):597-601. [CrossRef] [PubMed]
 
Bartley JM, Olmsted RN, Haas J. Current views of health care design and construction: practical implications for safer, cleaner environments. Am J Infect Control. 2010;38(5)(suppl 1):S1-S12. [CrossRef] [PubMed]
 
Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002;8(4):316-320. [CrossRef] [PubMed]
 
Davidson JE, Powers K, Hedayat KM, et al; American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007;35(2):605-622. [CrossRef] [PubMed]
 
Trochelman K, Albert N, Spence J, Murray T, Slifcak E. Patients and their families weigh in on evidence-based hospital design. Crit Care Nurse. 2012;32(1):e1-e10. [CrossRef] [PubMed]
 
Petterson M. Reduced noise levels in ICU promote rest and healing. Crit Care Nurse. 2000;20(5):104.
 
Sound and vibration design guidelines for healthcare facilities. Version 2.0. Acoustic Research Council website. http://healthcareacoustics.org/. Published 2013. Accessed October 25, 2013.
 
Johansson L, Bergbom I, Lindahl B. Meanings of being critically ill in a sound-intensive ICU patient room–a phenomenological hermeneutical study. Open Nurs J. 2012;6:108-116. [CrossRef] [PubMed]
 
Hardin KA. Sleep in the ICU: potential mechanisms and clinical implications. Chest. 2009;136(1):284-294. [CrossRef] [PubMed]
 
Johansson L, Bergbom I, Waye KP, Ryherd E, Lindahl B. The sound environment in an ICU patient room—a content analysis of sound levels and patient experiences. Intensive Crit Care Nurs. 2012;28(5):269-279. [CrossRef] [PubMed]
 
Konkani A, Oakley B. Noise in hospital intensive care units—a critical review of a critical topic. J Crit Care. 2012;27(5):522e1-e9.
 
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert. 2013;;(50):1-3.
 
Görges M, Markewitz BA, Westenskow DR. Improving alarm performance in the medical intensive care unit using delays and clinical context. Anesth Analg. 2009;108(5):1546-1552. [CrossRef] [PubMed]
 
Akhtar S, Weigle CG, Cheng EY, Toohill R, Berens RJ. Use of active noise cancellation devices in caregivers in the intensive care unit. Crit Care Med. 2000;28(4):1157-1160. [CrossRef] [PubMed]
 
Xie H, Kang J, Mills GH. Clinical review: The impact of noise on patients’ sleep and the effectiveness of noise reduction strategies in intensive care units. Crit Care. 2009;13(2):208. [CrossRef] [PubMed]
 
Castro R, Angus DC, Rosengart MR. The effect of light on critical illness. Crit Care. 2011;15(2):218. [CrossRef] [PubMed]
 
Verceles AC, Liu X, Terrin ML, et al. Ambient light levels and critical care outcomes. J Crit Care. 2013;28(1):110. [PubMed]
 
Dunn H, Anderson MA, Hill PD. Nighttime lighting in intensive care units. Crit Care Nurse. 2010;30(3):31-37. [CrossRef] [PubMed]
 
Heiderscheit A, Chlan L, Donley K. Instituting a music listening intervention for critically ill patients receiving mechanical ventilation: exemplars from two patient cases. Music Med. 2011;3(4):239-246. [CrossRef] [PubMed]
 
Ohl M, Schweizer M, Graham M, Heilmann K, Boyken L, Diekema D. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. Am J Infect Control. 2012;40(10):904-906. [CrossRef] [PubMed]
 
Görges M, Kück K, Koch SH, Agutter J, Westenskow DR. A far-view intensive care unit monitoring display enables faster triage. Dimens Crit Care Nurs. 2011;30(4):206-217. [CrossRef] [PubMed]
 
Kamel Boulos MN, Berry G. Real-time locating systems (RTLS) in healthcare: a condensed primer. Int J Health Geogr. 2012;11:25. [CrossRef] [PubMed]
 
Peace K, Wilensky EM, Frangos S, et al. The use of a portable head CT scanner in the intensive care unit. J Neurosci Nurs. 2010;42(2):109-116. [CrossRef] [PubMed]
 
Hough CL. Improving physical function during and after critical care. Curr Opin Crit Care. 2013;19(5):488-495. [CrossRef] [PubMed]
 
Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review... Chest. 2013;144(5):1469-1480. [CrossRef] [PubMed]
 
Parry SM, Berney S, Koopman R, et al. Early rehabilitation in critical care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial. BMJ Open. 2012;2(5):e001891. [CrossRef] [PubMed]
 
Erstad BL. A primer on critical care pharmacy services. Ann Pharmacother. 2008;42(12):1871-1881. [CrossRef] [PubMed]
 
Maclaren R, Devlin JW, Martin SJ, Dasta JF, Rudis MI, Bond CA. Critical care pharmacy services in United States hospitals. Ann Pharmacother. 2006;40(4):612-618. [CrossRef] [PubMed]
 
Halpern NA, Brentjens T. Point of care testing informatics. The critical care-hospital interface. Crit Care Clin. 1999;15(3):577-591. [CrossRef] [PubMed]
 
Verhaeghe S, Defloor T, Van Zuuren F, Duijnstee M, Grypdonck M. The needs and experiences of family members of adult patients in an intensive care unit: a review of the literature. J Clin Nurs. 2005;14(4):501-509. [CrossRef] [PubMed]
 
Karlsson C, Tisell A, Engström A, Andershed B. Family members’ satisfaction with critical care: a pilot study. Nurs Crit Care. 2011;16(1):11-18. [CrossRef] [PubMed]
 
Ryan RM, Wilding GE, Wynn RJ, Welliver RC, Holm BA, Leach CL. Effect of enhanced ultraviolet germicidal irradiation in the heating ventilation and air conditioning system on ventilator-associated pneumonia in a neonatal intensive care unit. J Perinatol. 2011;31(9):607-614. [CrossRef] [PubMed]
 
Carling PC, Bartley JM. Evaluating hygienic cleaning in health care settings: what you do not know can harm your patients. Am J Infect Control. 2010;38(5)(suppl 1):S41-S50. [CrossRef] [PubMed]
 
O’Connell NH, Humphreys H. Intensive care unit design and environmental factors in the acquisition of infection. J Hosp Infect. 2000;45(4):255-262. [CrossRef] [PubMed]
 
Anderson J, Gosbee LL, Bessesen M, Williams L. Using human factors engineering to improve the effectiveness of infection prevention and control. Crit Care Med. 2010;38(8)(suppl):S269-S281. [CrossRef] [PubMed]
 
Levchenko AI, Boscart VM, Fernie GR. The feasibility of an automated monitoring system to improve nurses’ hand hygiene. Int J Med Inform. 2011;80(8):596-603. [CrossRef] [PubMed]
 
Sepkowitz KA. Why doesn’t hand hygiene work better? Lancet Infect Dis. 2012;12(2):96-97. [CrossRef] [PubMed]
 
Rupp ME, Fitzgerald T, Puumala S, et al. Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol. 2008;29(1):8-15. [CrossRef] [PubMed]
 
Sattar SA. Promises and pitfalls of recent advances in chemical means of preventing the spread of nosocomial infections by environmental surfaces. Am J Infect Control. 2010;38(5)(suppl 1):S34-S40. [CrossRef] [PubMed]
 
Schmidt MG, Attaway HH, Sharpe PA, et al. Sustained reduction of microbial burden on common hospital surfaces through introduction of copper. J Clin Microbiol. 2012;50(7):2217-2223. [CrossRef] [PubMed]
 
Salgado CD, Sepkowitz KA, John JF, et al. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013;34(5):479-486. [CrossRef] [PubMed]
 
Casey AL, Adams D, Karpanen TJ, et al. Role of copper in reducing hospital environment contamination. J Hosp Infect. 2010;74(1):72-77. [CrossRef] [PubMed]
 
Schweizer M, Graham M, Ohl M, Heilmann K, Boyken L, Diekema D. Novel hospital curtains with antimicrobial properties: a randomized, controlled trial. Infect Control Hosp Epidemiol. 2012;33(11):1081-1085. [CrossRef] [PubMed]
 
Memarzadeh F, Olmsted RN, Bartley JM. Applications of ultraviolet germicidal irradiation disinfection in health care facilities: effective adjunct, but not stand-alone technology. Am J Infect Control. 2010;38(5)(suppl 1):S13-S24. [CrossRef] [PubMed]
 
Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ. Evaluation of an automated ultraviolet radiation device for decontamination ofClostridium difficileand other healthcare-associated pathogens in hospital rooms. BMC Infect Dis. 2010;10:197. [CrossRef] [PubMed]
 
Anderson DJ, Gergen MF, Smathers E, et al. Decontamination of targeted pathogens from patient rooms using an automated ultraviolet-C-emitting device. Infect Control Hosp Epidemiol. 2013;34(5):466-471. [CrossRef] [PubMed]
 
Maclean M, Macgregor SJ, Anderson JG, et al. Environmental decontamination of a hospital isolation room using high-intensity narrow-spectrum light. J Hosp Infect. 2010;76(3):247-251. [CrossRef] [PubMed]
 
Falagas ME, Thomaidis PC, Kotsantis IK, Sgouros K, Samonis G, Karageorgopoulos DE. Airborne hydrogen peroxide for disinfection of the hospital environment and infection control: a systematic review. J Hosp Infect. 2011;78(3):171-177. [CrossRef] [PubMed]
 
Wong V, Staniforth K, Boswell TC. Environmental contamination and airborne microbial counts: a role for hydroxyl radical disinfection units? J Hosp Infect. 2011;78(3):194-199. [CrossRef] [PubMed]
 
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Lee YJ, Yoo CG, Lee CT, et al. Contamination rates between smart cell phones and non-smart cell phones of healthcare workers. J Hosp Med. 2013;8(3):144-147. [CrossRef] [PubMed]
 
Gamble KH. Beyond phones. With the proper infrastructure, smartphones can help improve clinician satisfaction and increase EMR use. Healthc Inform. 2009;26(8):23-24., 26.
 
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NFPA 101. Life Safety Code. 2012 ed. Quincy, MA: National Fire Protection Association; 2012.
 
NFPA 99. Standard for Health Care Facilities. 2012 ed. Quincy, MA: National Fire Protection Association; 2012.
 

Figures

Figure Jump LinkFigure 1. ICU patient room (ultrawide angle view).Grahic Jump Location
Figure Jump LinkFigure 2. A-C, ICU utilities and equipment mounted on (A) a stationary headboard, (B) stationary (left side) or rotating (right side) columns, and (C) mobile articulating arms (booms) that swivel and can be moved horizontally and/or vertically. The booms can be attached to the walls or ceiling, at the head of the bed, or at all four corners.Grahic Jump Location
Figure Jump LinkFigure 3. The ICU patient room can be divided into three zones: (1) patient, (2) caregiver, and (3A) virtual or (3B) fixed family zones. Also shown are nurse server with bidirectional access, nursing work area, supply space (cabinet or cart), booms, bathroom with sanitizer (or macerator), webcam, Wi-Fi access point, and a workstation and staging area outside the room.Grahic Jump Location
Figure Jump LinkFigure 4. A-C, The patient room may have sliding and breakaway doors that (A) open directly into the ICU hallway or (B) are set back from the hallway allowing for an open (left) or closed (right) staging area. C, Alternatively, the room may have a hybrid front wall with swinging doors and a condensed staging area. Each room has its own external WS. WS = workstation.Grahic Jump Location
Figure Jump LinkFigure 5. A-C, Decentralized WSs may be constructed outside the patient rooms as one station per two rooms (1 and 2 in A) or one station per room (1 and 2 in B), or there may be no decentralized WS (C). Room-based WSs are present in A and B; mobile WSs are used outside and inside rooms 1 and 2 in C. A, ICUs may be built with a multitiered central station with office and multipurpose conference room, (B) have a central station only, or (C) have no central station. See Figure 4 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 6. ICUs can be configured in many patterns. A, Rectangular. B, Circular. C, Triangular. D, Square. They may have differing numbers of beds and central areas.Grahic Jump Location
Figure Jump LinkFigure 7. The waiting room has direct entry into the ICU (ie, on-stage) and has a reception desk, private seating areas, consultation room, computer area, social worker office, restrooms, nutrition court, and lockers and coat hangers. Long-term accommodations (beds and showers) can also be included. A bypass corridor for patient transport and staff and equipment movement circumvents the waiting room and provides privacy and prevents traffic jams (ie, off-stage).Grahic Jump Location
Figure Jump LinkFigure 8. POCT paradigms. A, POCT based at every bedside. B, Mobile POCT on a cart or handheld. C, POCT based at a central station. D, POCT within a local stat (rapid response) laboratory. POCT = point-of-care testing.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Central-Based Medical Equipment
a 

Physiologic monitor, defibrillator, ventilator, suction, and infusion pump.

References

Halpern NA. Innovative designs for the smart ICU: part 1: from initial thoughts to occupancy. Chest. 2014;145(2):399-403. [CrossRef] [PubMed]
 
Halpern NA. Innovative designs for the smart ICU: part 3: advanced ICU informatics. Chest. In press. doi:10.1378/chest.13-0005.
 
Thompson DR, Hamilton DK, Cadenhead CD, et al. Guidelines for intensive care unit design. Crit Care Med. 2012;40(5):1586-1600. [CrossRef] [PubMed]
 
Guidelines for Design and Construction of Health Care Facilities: The Facilities Guidelines Institute. 2010 ed. Chicago, IL: ASHE (American Society for Healthcare Engineering) of the American Hospital Association; 2011.
 
Rashid M. A decade of adult intensive care unit design: a study of the physical design features of the best-practice examples. Crit Care Nurs Q. 2006;29(4):282-311. [CrossRef] [PubMed]
 
Cadenhead CD, Anderson DC. Critical care design: trends in award winning designs. WorldHealthDesign website. http://www.worldhealthdesign.com/critical-care-design-trends-in-award-winning-designs.aspx. Accessed July 17, 2013.
 
Hamilton DK, Shepley MM. Design for Critical Care: An Evidence-Based Approach. Burlington, MA: Elsevier Ltd; 2010.
 
Valentin A, Ferdinande P; ESICM Working Group on Quality Improvement. Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med. 2011;37(10):1575-1587. [CrossRef] [PubMed]
 
Kesecioglu J, Schneider MM, van der Kooi AW, Bion J. Structure and function: planning a new ICU to optimize patient care. Curr Opin Crit Care. 2012;18(6):688-692. [CrossRef] [PubMed]
 
Bartley J, Streifel AJ. Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit? Crit Care Med. 2010;38(suppl 8):S388-S398. [CrossRef] [PubMed]
 
Architectural showcase. Intensive care unit. Healthcare Design Magazine. 2007;7(7):245.
 
Nestor C. Critical conditions. A real-world look at features and technologies for the ICU. Health Facil Manage. 2005;18(8):25-29. [PubMed]
 
Teltsch DY, Hanley J, Loo V, Goldberg P, Gursahaney A, Buckeridge DL. Infection acquisition following intensive care unit room privatization. Arch Intern Med. 2011;171(1):32-38. [CrossRef] [PubMed]
 
Bazuin D, Cardon K. Creating healing intensive care unit environments: physical and psychological considerations in designing critical care areas. Crit Care Nurs Q. 2011;34(4):259-267. [CrossRef] [PubMed]
 
Pati D, Evans J, Waggener L, Harvey T. An exploratory examination of medical gas booms versus traditional headwalls in intensive care unit design. Crit Care Nurs Q. 2008;31(4):340-356. [CrossRef] [PubMed]
 
Halpern NA. Point of care diagnostics and networks. Crit Care Clin. 2000;16(4):623-639. [CrossRef] [PubMed]
 
Manno E, Navarra M, Faccio L, et al. Deep impact of ultrasound in the intensive care unit: the “ICU-sound” protocol. Anesthesiology. 2012;117(4):801-809. [CrossRef] [PubMed]
 
Field LC, Guldan GJ III, Finley AC. Echocardiography in the intensive care unit. Semin Cardiothorac Vasc Anesth. 2011;15(1-2):25-39. [CrossRef] [PubMed]
 
Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009;135(6):1416-1420. [CrossRef] [PubMed]
 
Farmer JC, Wax RS, Baldisseri MR., eds. Preparing Your ICU for Disaster Response. Mount Prospect, IL: Society of Critical Care Medicine; 2012.
 
Harvey MA. Critical-care-unit bedside design and furnishing: impact on nosocomial infections. Infect Control Hosp Epidemiol. 1998;19(8):597-601. [CrossRef] [PubMed]
 
Bartley JM, Olmsted RN, Haas J. Current views of health care design and construction: practical implications for safer, cleaner environments. Am J Infect Control. 2010;38(5)(suppl 1):S1-S12. [CrossRef] [PubMed]
 
Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care. 2002;8(4):316-320. [CrossRef] [PubMed]
 
Davidson JE, Powers K, Hedayat KM, et al; American College of Critical Care Medicine Task Force 2004-2005, Society of Critical Care Medicine. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007;35(2):605-622. [CrossRef] [PubMed]
 
Trochelman K, Albert N, Spence J, Murray T, Slifcak E. Patients and their families weigh in on evidence-based hospital design. Crit Care Nurse. 2012;32(1):e1-e10. [CrossRef] [PubMed]
 
Petterson M. Reduced noise levels in ICU promote rest and healing. Crit Care Nurse. 2000;20(5):104.
 
Sound and vibration design guidelines for healthcare facilities. Version 2.0. Acoustic Research Council website. http://healthcareacoustics.org/. Published 2013. Accessed October 25, 2013.
 
Johansson L, Bergbom I, Lindahl B. Meanings of being critically ill in a sound-intensive ICU patient room–a phenomenological hermeneutical study. Open Nurs J. 2012;6:108-116. [CrossRef] [PubMed]
 
Hardin KA. Sleep in the ICU: potential mechanisms and clinical implications. Chest. 2009;136(1):284-294. [CrossRef] [PubMed]
 
Johansson L, Bergbom I, Waye KP, Ryherd E, Lindahl B. The sound environment in an ICU patient room—a content analysis of sound levels and patient experiences. Intensive Crit Care Nurs. 2012;28(5):269-279. [CrossRef] [PubMed]
 
Konkani A, Oakley B. Noise in hospital intensive care units—a critical review of a critical topic. J Crit Care. 2012;27(5):522e1-e9.
 
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert. 2013;;(50):1-3.
 
Görges M, Markewitz BA, Westenskow DR. Improving alarm performance in the medical intensive care unit using delays and clinical context. Anesth Analg. 2009;108(5):1546-1552. [CrossRef] [PubMed]
 
Akhtar S, Weigle CG, Cheng EY, Toohill R, Berens RJ. Use of active noise cancellation devices in caregivers in the intensive care unit. Crit Care Med. 2000;28(4):1157-1160. [CrossRef] [PubMed]
 
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