Introduction
There is growing evidence that the physical design of clinical spaces affects the quality, efficiency, and experience of care in intensive care units (ICUs) and other settings. These effects are complex. In some cases the design directly leads to outcomes that might have clinical significance, for example, whether improved air filtering reduces airborne pathogens. In other cases the environment contributes to noise or lighting that can increase or decrease stress for patient, families, or staff. In yet other cases, the environment contributes to staff or patient behavior that may affect care. For instance, if staff see and encounter each other informally over the course of their day, they may better coordinate care, or if they see hand hygiene sinks or rubs, they may increase their compliance with handwashing.
This chapter examines the effects of the ICU design and particularly the design of the neurocritical care unit (NCCU) on patient care. Addressed are the important areas within the ICU, key design considerations, main design guidelines, and emerging evidence on how ICU design influences patient care. The chapter ends with a case study in which the authors were involved, from the perspective of the medical director.
Evidence-Based Intensive Care Unit Design
Research in ICU environmental design is an emerging field of study, and therefore high-quality research articles are still limited in number. In addition, many confounding variables can influence the outcome of ICU design research. Therefore along with the findings of ICU design research, the authors also present expert opinions and findings of research studies in other health care settings that may be relevant to ICU design. This section reviews the primary functional and procedural issues associated with ICU design and addresses the key areas of the ICU.
Unit Layout
Unit layout defines the size and location of functional areas and their relationships within a unit. Major determinants of the layout include: (1) direct monitoring of patients by clinical staff, (2) an outside window for each patient room, and (3) reduction of cross-infection, traffic volume, and noise level, among other factors.
Monitoring
In NCCUs, patients need constant visual monitoring because their conditions may change quickly and unpredictably, and these changes need to be recognized early. NCCU patients also require frequent neurologic assessments or bedside procedures that may involve multiple members of a care team. A physical layout that supports effective face-to-face interaction in a patient’s room and within the unit is thus required. In a teaching hospital the rooms or corridors also need to support the large number of participants who make patient rounds.
Windows
U.S. law requires that ICU patients must have direct access to natural light. This same requirement also applies in several other countries (e.g., India, Saudi Arabia, and the United Arab Emirates). The number and arrangement of patient rooms consequently depend on the amount of perimeter wall available in the unit. Therefore a review of best practice examples shows that designers often select compact shapes with high area-to-perimeter ratios to accommodate the maximum number of patient rooms for any given area. They also put most support areas, including nurse work areas, in the core that do not require any outside window to reduce the walking distance between clinical support areas and patient rooms.
Limiting Infection, Traffic, and Noise
Cross-infection, traffic volume, and noise level often may help shape unit configurations, and each of these factors is of greater significance in larger hospital units. Studies suggest that patients in larger units have greater risk of hospital-acquired infection. Larger units also have more traffic and noise sources. These noise sources commonly include noises of other patients (e.g., snoring, crying), monitor alarms, telephone rings and conversations, conversations among staff, staff entering or leaving, staff wandering, sudden voices, footsteps, falling objects, noises of respirators, doors closing, and visitors talking, among others. Breaking a larger unit into smaller units, pods, or clusters may reduce infection and noise. However, pods can break down the visual and social cohesiveness of a unit, and multiple pods may make movement of supplies difficult because they create more service stops. Thus the appropriate configuration for a large ICU remains a matter of striking the right balance among various contradictory factors.
Unit Size
According to the Society of Critical Care Medicine’s Guidelines for Intensive Care Unit Design (henceforth, the Guidelines), 8 to 12 beds per unit are considered best from a functional perspective. In one survey, a group of ICU experts also suggested that the ideal number of patient beds in an ICU should be 9 or 10, and no less than 6. An NCCU with fewer than 6 beds may be inefficient to operate and manage. In contrast, in a very large unit without proper unit design and a sufficiently large nursing staff, patient monitoring and care may become difficult.
The total gross area of a unit, another indicator for unit size, is somewhat related to the number of beds in the unit—the more beds the greater the ICU gross area per bed. The amount of circulation spaces, another determinant of the gross area of a unit, is an important indicator of the square footage efficiency of an ICU. Circulation spaces within an ICU consist of internal hallways, corridors, or aisles used by all ICU users—patients, ICU staff, and visitors. Like any other facility, an ICU may be inefficient with too much or too little circulation space. Circulation spaces are sociologically important because they determine the interconnectedness of people and functions within a facility. A narrow corridor within an ICU can impede transfer of knowledge as much as it can impede the flow of goods and people. Properly designed circulation spaces in ICUs may hold a great potential to enhance the transfer of tacit knowledge through face-to-face interactions.
In the United States, the National Fire Protection Association’s Life Safety Code also affects ICU size and design. The Life Safety Code limits the size of any suite to 5000 square feet if it does not have intervening smoke partitions and fire-rated doors. The area per bed of a unit ranges from 650 to 1200 square feet or more depending on function on the unit, so most units require smoke partitions or “hold open” smoke doors. Hospitals and designers need to ensure that when any one part of an ICU larger than 5000 square feet becomes unavailable in the event of fire or smoke breakout, the other parts of the unit have the required components for patient and staff safety.
Unit Location
Important departmental relationships of the unit should be carefully considered during the site selection process. Convenient physical movement across departments may help reduce many safety risks associated with patient transfer. In general, patients are transferred from one place to another as often as three to six times during their hospital stay to receive the care that matches their level of acuity. This rate may be higher for NCCU patients. Delays, communication discontinuities, loss of information, and changes in computers and systems during patient transfer can contribute to increased medical errors and loss of staff time and productivity. Patients can get hurt, and most nurses’ back injuries occur during patient transfer (see the following text). Thus design interventions must include factors that help reduce the time and effort involved in patient transfer.
Patient Room Design
A patient’s room is the basic working unit of an ICU, and it affects patient care including safety, privacy, and comfort. For example, nurses can save multiple trips to nursing stations or storage rooms if a patient’s room includes a space for charting or storage space for supplies. A longer distance between the bed and the toilet can increase physical stress for a nurse who needs to help the patient to the toilet. If there is a well-defined area within the room for families, they can be present for patient comfort and help caregivers by providing information and assistance with care. Important design considerations of patient rooms in the NCCU, similar to other ICUs, include to: (1) create well-defined functional zones to eliminate conflicts, (2) provide enough space that is appropriate for patient care, (3) provide necessary life support systems, (4) balance visibility and privacy, (5) provide toilet facilities, (6) reduce hospital-acquired infections and psychosis among patients, and (7) reduce patient and staff injury.
Patient Room Layout
The patient room layout defines the size and location of functions and their relationships within the room. It affects how functions are performed and how patients and caregivers interface in the room. Jastremski and Harvey suggest that an ideal room should have three zones: a patient zone, a family zone, and a caregiver zone. Hamilton and Shepley defined four different zones within a patient’s room: (1) patient, (2) hygiene, (3) staff, and (4) family zones. The patient zone includes the bed, bedside, and overbed tables, and the immediate area occupied by clinicians when they provide care. The hygiene zone includes the patient’s toilet, sink, and activities associated with hygiene. The staff zone includes the area just inside or outside the entry to the patient’s room to support nursing and caregiver functions; this may include a writing surface, provisions for hand hygiene, patient information, medication, and supplies. The family zone may include seating or provisions for overnight stay, storage space, separate lighting, Internet access, and a writing surface, among others.
Defining patient room in terms of what is in a patient’s view and what is not can be important. Evidence suggests that patients lying on an ICU bed are stressed when they see medical equipment, accessories, and monitors. Therefore it is reasonable to keep these devices away from the patient’s view, and instead put family space within the patient’s view. Architectural treatment of areas within a patient’s view also can be important because it appears that “positive distractions” such as nature can reduce stress and pain and that natural light can reduce analgesic use. Soothing color and light, natural materials, and paintings of nature may be used in the area within the patient’s view to make his or her experience more comfortable.
Patient Room Size
The need for larger patient rooms is increasing in ICUs. Advocates of infection prevention recommend that each patient room should have dedicated patient care equipment to reduce cross-infection with more resistant microbial strains. Others also recommend that each room should have a dedicated family space, with amenities to improve family integration with patient care. As medical breakthroughs and advancements occur, more technology is brought into patient rooms, and this requires more space. The increasing multidisciplinary nature of patient care in the NCCU also requires patient rooms to accommodate larger medical teams. Additional space also may be needed in patient rooms to support research and the increasing number of procedural interventions that now are performed in ICUs, such as bronchoscopy, echocardiography, and placement of external ventricular drains.
The Guidelines stipulate, “Ward-type ICUs should allow at least 225 square feet of clear floor area per bed. ICUs with individual patient modules should allow at least 250 square feet per room [assuming one patient per room]. …” In a survey of the best-practice ICUs in the United States built between 1993 and 2003, the average size of a patient room was 250 square feet. However, since 2000, many best-practice ICUs have also used more than 250 square feet for patient rooms, suggesting that hospitals are aware of trends such as the demand for family spaces in patient rooms.
Privacy and Visibility in a Patient Room
Privacy is an important factor associated with individual satisfaction in many environments including hospitals and even in moments of extreme crisis, privacy may be required to preserve individual dignity. Patient and family surveys suggest hospitals with more private rooms tend to have higher patient satisfaction rates ( www.pressganey.com ). There are several advantages to private rooms. First, they provide dedicated space for individualized care without disturbing other patients and can help reduce noise, improve patient sleep quality, and support staff-patient communication. Second, hospital-acquired infection rates in ICUs with private rooms are less because of improved airflow, better ventilation, and more accessible handwashing facilities. Finally, the private room design allows for a patient care environment with more control over optimal environmental conditions. However, in private rooms patient visibility is often at a stake and patients are afraid of being left alone. From a clinical viewpoint it is easier to make a case for open patient rooms in ICUs; this permits easy visual monitoring of the patient by the clinical staff that can affect patient safety. ICU staff often prefer an open ICU to see everything that happens, to readily seek help from others in a crisis, and to act immediately in groups without the constraints of walls of a private patient room. In private patient rooms, where glass often is used for patient visibility, measures to ensure visual and acoustic privacy of patients and their families when needed also are necessary. Hospitals often prefer breakaway glass doors because they can be closed for privacy, noise reduction, and infection control and still maintain maximum visibility of patients and monitors. Breakaway glass doors also allow maximum clearance to move patients in and out of the room. In an emergency, breakaway glass doors allow the room to become more open than the other doors. However, with breakaway doors closed it may be difficult to hear patient alarms, for example, ventilator alarms.
Life Support Systems in a Patient Room
Easy access to the patient’s head and the ability to move a patient bed around during procedures are important in the NCCU. Traditional head wall systems that have been used since the 1970s to provide the life-support systems do not allow easy access to the patient’s head, nor do they allow clinicians to reorient the bed when needed. Headwall systems include power outlets and outlets for medical gases and vacuum on one or both sides of a patient bed. Some installations also include wall-mounted monitors and equipment for a patient’s vitals.
Power columns, whether rotating or static, are now used in many ICUs to provide life support systems. Equipped with medical utilities, power outlets, and monitors, these power columns allow easy access to the patient’s head and may allow clinicians to reorient the bed. Two, instead of one, power columns—one on each side of the bed—can be installed to help increase the symmetry of functions around the patient bed. However, it can be difficult to work around power columns during a procedure. Other innovations—the ceiling-mounted boom, ceiling columns, or the Draeger Ponta beam—help provide easy access and sufficient flexibility for proper patient care in NCCUs and in particular provide access to the patient’s entire body, especially to the head. These ceiling-mounted systems, however, add cost and often require additional structural support. These systems occasionally can conflict with a patient lift system in an NCCU patient room.
Toilets in a Patient Room
ICU patient rooms are not required to have toilets, but there are many good reasons to have a toilet in the room for both the patient and family. Toilets in patient rooms can be used to dump and clean bedpans, which can be a major source of aerosol contaminants and infectious organisms, and contained systems often are used to reduce aerosols. The location, use, and design of a toilet or of other devices to eliminate waste have a significant effect on ICU design. A review of current design practice shows that toilets are placed in many different locations in relation to a patient room. Inboard toilets are on the corridor side of patient rooms; outboard are on the window side. A third option is to place the toilets of two adjacent patient rooms next to each other in a wet zone. Each location has advantages and disadvantages.
Hospital-Acquired Infections
In patient room design, air quality, single-bed patient rooms, lighting conditions, noise level, and handwashing sink are important because they can help reduce infections among patients. Most studies show that (1) private patient rooms can reduce cross-infection among ICU patients; (2) single-bed patient rooms with high-quality high-efficiency particulate air (HEPA) filters and with negative- or positive-pressure ventilation are more effective in preventing airborne pathogens; and (3) multibed rooms are more difficult to decontaminate and have more surfaces that act as a reservoir for pathogens. The 2006 American Institute of Architects Guidelines for Design and Construction of Healthcare Facilities therefore has adopted the single-bed room as the standard for all new construction in the United States.
Infrequent handwashing by health care staff is associated with hospital-acquired infections. Several design factors may discourage handwashing, including: (1) poor sink location, (2) poor visibility, (3) uncomfortable sink height, and a (4) lack of redundancy and wide spatial separation of resources that are used sequentially in handwashing. There are conflicting results on how physical design influences handwashing compliance. There is, however, a consensus that a multi-strategy intervention that includes staff education, easy visual and physical access to sinks, standard sink locations in all patient rooms, comfortable sink heights, and alcohol-based dispensers can help increase handwashing compliance.
A review of current design practice shows that handwashing sinks are placed at many different locations in a patient room, including: (1) locations directly outside the room entranceway, (2) immediately after the entranceway either on the footwall or on the head wall, (3) somewhere in the middle of the footwall, and (4) at the far end of the room walls. Designers and hospitals must consider the advantages and disadvantages of each of these locations. (For a discussion on this topic, see Rashid. )
Psychosis Among Intensive Care Unit Patients
ICU patients who are confined to bed may suffer from delirium, also known as “ICU psychosis.” There is growing evidence from non-ICU settings that both natural light and outdoor views can help patients maintain sensory orientation and circadian rhythm. This in turn can reduce the likelihood of delirium. Consequently, the Guidelines recommend: “Windows are an important aspect of sensory orientation, and as many rooms as possible should have windows to reinforce day/night orientation. … If windows cannot be provided in each room, an alternate option is to allow a remote view of an outside window or skylight.” Artificial lighting conditions that mimic the variations in natural light also can help patients maintain sensory orientation and circadian rhythm. Looking at a ceiling or a wall painted in solid colors for a long period also may contribute to patient delirium. Warm colors and paintings of nature may improve the environment. Sometimes a calendar that shows the date or a digital clock that shows date and time may help patients adjust their internal physiologic rhythm. However, the monotonous clicking sound of an analog clock can cause distress in ICU patients.
ICU psychosis also may be associated with a high level of noise. Noise level in the ICU ranges from 50 to 75 dB, with peaks up to 85 dB. This is much higher than World Health Organization recommendations for noise levels in hospital patient rooms and units. Common sources of noise in hospitals include telephones, alarms, trolleys, ice machines, paging systems, nurse shift change, staff caring for other patients, doors, staff conversations, and patients crying out or coughing. Hospital noise can be improved if proper design and management measures are in place.
Reducing Patient Falls and Fall Severity
The physical environment can be a root cause for patient falls. Among specific interior design elements, flooring can contribute to the incidence of falls and the severity of injury from a fall. Patients may suffer more injuries when they fall on vinyl floors than carpeted floors. Subfloors also may influence the injury from falls; the risk of fracture is less for wooden than concrete subfloors. Several design factors can help reduce the incidence of falls including decentralized observation units next to patient rooms rather than a centralized nursing station, patient lifts and other transfer devices, and innovative acuity adaptable patient rooms.
Other Patient and Staff Injuries
Manual lifting of ICU patients poses a high risk of injury for patients, such as dislodgement of invasive tubes and lines, shoulder dislocation, fracture of fragile bones, or being dropped. Skin tears and abrasions also may occur when patients are pulled up or across beds, and manual patient handling can contribute to pain in critically ill patients. Pain experienced by these patients during turning or repositioning sometimes is greater than that experienced during tracheal suctioning, tube advancement, and wound dressing changes. Staff also are at risk for work-related injuries when moving patients. The use of ceiling lifts can help limit risks associated with manual moving to both patient and staff. If possible, lifts should extend into the toilet room. If patient volumes and staffing patterns allow, ICU rooms that can flex in acuity from super-acute to step-down also may reduce patient transfers and discontinuity in care.
Staff Work Areas and Support Spaces
ICUs can be stressful workplaces that can endanger the physical and mental health of the clinical staff. In the United States there is a shortage of critical care nursing staff, and the current staff is older and has a high turnover rate. Staff turnover rate in many institutions is greater in ICUs than other wards because of the stressful working conditions. ICU design, however, can help relieve staff stress by reducing unnecessary physical labor, by providing amenities, and by providing positive distractions for staff physical and mental recovery.
Staff Work and Support Area Location and Layout
There are three basic nursing unit configurations: (1) centralized nursing station, (2) nursing substation, and (3) nursing observation unit. In older hospital units a centralized nursing station is generally the main component of the staff work area. Along with the patients’ records room, the central monitoring station, and staff workstations for patient charting and medical recording, it serves as the hub of all unit functions. This type of nursing station usually has a centralized support and service area next to it that accommodates medical and supply storage, pharmacy, conference rooms, administrative offices, and other ancillary functions. In older units a centralized nursing station is where clinical management, staff interaction, mentoring, and socialization occur. However, centralized nursing stations may contribute to errors and inefficiency because of noise, crowding, and considerable walking distance from patient rooms.
In hospital units built in the 1990s and 2000s, the centralized nursing station often is replaced with several decentralized observation units with direct observation of one or two rooms and located either just outside or inside the patient room. Typical functions include a work surface for patient charting, a computer to record and access patient information, and telecommunication services. There may or may not be storage spaces for medication and supplies, handwashing facilities, and image retrieval systems. It is suggested that the decentralized observation units increase efficiency, but perhaps at the cost of staff “social life.” Team workstations, sometimes distributed throughout a unit, provide spaces for interdisciplinary teamwork, mentoring, clinical management, and social functions that may not be feasible in the totally decentralized observations units.
Hospitals may use different combinations of the basic nursing unit configurations in ICUs. The relation of the support or service areas to nursing units differs from unit to unit. In an exploratory study Zborowsky et al. investigated how nursing station design (i.e., centralized and decentralized nursing station layouts) affected nurses’ use of space, patient visibility, noise levels, and perceptions of the work environment. They concluded that the “hybrid” nursing design model in which decentralized nursing stations are coupled with centralized meeting rooms for consultation between staff members may strike a balance between the increase in computer duties and the ongoing need for communication and consultation that addresses the conflicting demands of technology and direct patient care. In another recent study, Hendrich et al. examined how nurses adopt distinct movement strategies based on features of unit topology and nurse assignments and observed that the spatial qualities of nurse assignments and unit layout affect nurse strategies for moving through units and affect how frequently nurses enter patient rooms and the nurse station. Therefore how various design features of nursing unit and support space configuration affect staff stress and effectiveness, staff communication, and task performance meets the needs of a particular ICU need to be considered.
Staff Stress and Effectiveness
The location of supplies and equipment and of electronic charting impact the time spent in patient care by nurses. Nurses spend a lot of time walking, which includes the time to locate and gather supplies and equipment and to find other staff members. Studies suggest that bringing staff and supplies physically and visually closer to the patient reduces the time nurses spend walking about the unit. Decentralized nurses’ stations and supplies’ servers next to patient rooms allows nurses to spend more time in direct patient care activities.
Nurses may spend between 15% and 25% of their time in charting. Computers for charting may be found at the nursing observation units next to the patient room, in the patient room, on mobile carts, and/or at the central nursing stations away from the patient room. When charting is not done at or near the bedside nurses may spend more time away from the bedside to prepare and store charts at other locations or make more mistakes in charting because of memory lapses between the time of information collection at the bedside and putting it on the chart.
Several factors contribute to staff stress in the ICU. Among them is noise that can be associated with emotional exhaustion and burnout among ICU nurses. Excessively high noise levels in healthcare settings and frequent interruptions also can interfere with work. For example, in a recent time-and-motion study that included 40 doctors for more than 210 hours, Westbrook et al. observed that interruptions led doctors to spend less time on the tasks they were working on and, in nearly a fifth of cases, to give up on the task.
Patients in NCCUs often have numerous monitoring and recording devices with alarms that may also contribute to staff stress and fatigue. Nurses may become insensitive to alarms, because every alarm may not need immediate attention. Therefore they can miss that important alarm which requires immediate attention. For example, an investigation by the Boston Globe suggested that 216 deaths from 2005 to 2010 nationwide were associated with monitor alarm problems. Device-related incidents may be underreported and it is possible that the number of adverse events associated with alarm problems is higher. According to the Globe’s investigation, the deaths listed in the U. S. Food and Drug Administration (FDA) data were linked to problems with alarms on patient monitors that track heart functions, breathing and other vital signs. The problem typically was not a broken device. Instead, most cases occurred because medical staff did not notice an alarm or react with urgency. This includes not hearing the alarm, ignoring an alarm, misprogramming complicated monitors or forgetting to turn them on.
The interface between technology and patients also can challenge NCCU staff and contribute to stress. Often, patient monitor and access lines are built up with multiple ports and, even with proper training and instructions it may difficult to sort out where to put this or that connector. ICU nurses also need to ensure that medications are compatible and so need to know how to control the stopcock. It is expected that technology innovations will help overcome some of the these interface related problems, e.g., each port can be made unique to help eliminate mixing up of lines, devices can be created to help identify incompatible drugs or integrated printers in every patient room for prescriptions may help eliminate medical errors. Together, several simple fail-safe devices may remove some of the cognitive load that contributes to stress among nurses. For example, Kobayashi et al. used simple human factors engineering principles to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues. This was associated with a significant reduction in chart binder location problems, so contributing to safe patient care delivery. Similarly Blomkvist et al., who examined the effects of changing the acoustic conditions (sound-absorbing versus sound-reflecting ceiling tiles) in a coronary ICU, observed that there were positive staff outcomes, including improved speech intelligibility and reduced perceived work demands, pressure and strain during the periods of improved acoustic conditions.
Staff Communication
Staff communication is a major variable in health care and ICU safety and several studies demonstrate that a high degree of involvement and interaction among caregivers can influence patient outcomes and length of stay. For example, Baggs et al. examined interdisciplinary collaboration and patient outcomes in a medical ICU and observed that patients had a 5% chance of death or readmission where nurses believed they had worked successfully with medical residents. The risk was tripled when the residents made decisions about patient care without adequate nurse consultation. The value of better communication is strongest in the very sick, complex patients. Research in “Magnet” hospitals also indicates that healthy collaborative relationships among caregivers are possible and appear linked to optimal patient outcome. A growing body of literature in several environmental design research areas including offices, laboratories, housing complexes, and acute care health facilities show that the physical design of an environment may affect communication, interaction, and/or or collaboration (For a review of the literature, see Ulrich et al. ; Rashid ; Elsbach and Pratt ; Rashid and Zimring. ) When designing staff areas in ICUs, the following should be considered: (1) Physical design can affect the quality and the quantity of interaction. (2) Location of people and activity and physical distance among workers may be linked to their informal communication. (3) Proximity of workspaces may predispose to the development of an informal group among compatible people as an outgrowth of the informal communication associated with proximity. (4) Spatial arrangement including the location of functions, walls, partitions, furnishings, and other barriers may affect cohesiveness and interaction among groups. (5) Visibility and accessibility play a powerful role in the way individuals perceive and use workplaces and communicate within. (6) Time spent in walking by staff may be related to time spent in patient care activities including nurse-physician interactions.
Lighting Conditions and Task Performance
There are few studies on the effects of lighting conditions on task performance among ICU staff. Studies in other work settings show that staff may make more mistakes in inappropriate lighting conditions, and performance on visual tasks gets better as light levels increase. For example, medication dispensing errors among hospital workers are more frequent when daylight hours are fewer ; these errors can be reduced at an illumination level greater than the baseline level of 45 foot candles. Studies in offices also indicate the importance of appropriate lighting levels for complex tasks that require excellent vision.
Spaces for Families
Many patients in the NCCU cannot communicate for themselves. Therefore family members have an important role as surrogate decision makers. Family members can also help patients (1) perform daily functions, (2) understand concerns about health, (3) foster a link to the environment, (4) reinforce self-esteem, and (5) enhance positive relationships by offering love and comfort. In addition, families can help busy nurses and physicians.
Location of Family Space
The location of family waiting spaces in ICUs has both practical and symbolic importance. Having family members nearby often helps to shift an ICU’s culture and make families a greater part of decision making (though sometimes this also requires clinicians to create structured ways of dealing with stressed family members). Symbolically the presence of family spaces located outside the unit may suggest that families are not integrated with patient care, whereas those provided within the patient room may indicate that families are integrated with patient care. Depending on their accessibility and comfort, family spaces provided within the unit but not in the patient room can suggest the family role is in a state of flux in the unit. These impressions can, at times, be wrong. Some units may still not allow families to play an active role in patient care even with families present in the patient room. Hospitals should consider providing family spaces at several of these locations for different functions and amenities. (For a discussion on the possible sociologic implications of different locations of family spaces in ICUs, see Rashid, 2006. )
Family Waiting Area Layout
Family waiting areas may be broken down into zones with varying degrees of privacy and control similar to a home. The number of ICU patient rooms, the availability of family space in the patient room, the average length of patient stay, and the types of amenities are some of the issues to consider to determine the size of a common waiting space. Waiting areas should be divided into sections to provide more intimate and quieter resting spaces and relatively busy and noisy activity spaces. Solid partitions, dividers, glass walls, or planters can separate each section according to the need of these spaces. Each section should contain comfortable chairs or sofas for the family, and resting and activity spaces should include private spaces or booths for telephone conversations. Activity spaces should include: (1) computers with Internet access that allow families to access these computers to stay up-to-date with patient status and the outside world and (2) study carrels with health care information for families. There should be a media room to separate the television from the rest of the waiting area, so families who wish to have quiet and solitude are not disturbed. Families with children should be given spaces separate from a “quiet zone” for adults only. A play area for children within the direct visual reach of the adult family members should be considered in the area designated for families with children. Some hospitals provide family sleep rooms with private bathrooms, kitchenettes, and laundry in their waiting areas for family members who must stay at the hospital for an extended period.
Family Space in Patient Rooms
When possible, each patient room should include a well-defined family area to allow families to be present for shift change report, teaching sessions, care-planning discussions, and daily medical rounds. A family space within a patient’s room provides families a more comfortable environment for activities, and being able to sleep in the patient’s room provides social support and reassurance for the patient and family members.
Furnishings and Finishes
Furnishings in family areas should include comfortable seating for the family and the option of a wall-mounted fold-down bed or foldout chair-bed. Flexible furniture arrangements that allow families to change furniture layout to meet their needs are preferable, because seating arrangements that cannot be changed or chairs that cannot be moved may cause frustration among families. Unnecessary sources of visual stimulation should be minimized and wall furnishings should not be of bold patterns or colors that can be misperceived as threatening objects (e.g., bugs, animals) by patients or their families. Wall coverings and colors should be soothing and relaxing. In general, the attractiveness of the physical environment in waiting areas has been shown to be significantly associated with higher perceived quality of care, less anxiety, and higher reported positive interaction with staff.
Access to Patients and Caregivers
Family spaces should provide easy visual or physical access to patient rooms so family members can see the patient. Families also should have easy access to caregivers when needed and know when caregivers are available in the unit. For patient safety it is better for families to enter the unit through a separate entry other than the one used by service and clinical staff. Designers and hospitals need to ensure that such a system of entrances does not make interfaces among families and caregivers difficult. If the ICU design restricts family-caregiver interfaces, families may gather at places where they are likely to find caregivers.
Staff-Family Communication
In ICUs, staff-family communication can provide emotional, informational, and tangible supports to family members, and can facilitate family members’ involvement in patient care. Hospitals should consider the following to help improve family-staff interactions and communication. (1) Central nursing stations and glass partitions around the staff area can limit family access to staff. (2) Decentralized nursing stations may provide more opportunities for a nurse to spend time in patient rooms. These stations also can be used during medical rounds by medical teams to retrieve patients’ records. (3) Private patient rooms and well-designed consultation rooms may provide opportunities for confidential discussions. (4) Within hallways, alcoves can provide private spaces for confidential discussions. (5) Seating that is arranged side-by-side along family space walls can discourage social interaction. (6) Private and peaceful spaces can help improve communication. (7) In dim lighting conditions and in rooms with softer floor materials, people may interact longer.
Noise Reduction in Family Space
Carpeting in corridors next to family waiting spaces can reduce the sound of footsteps, rolling carts, staff member conversations, and other common noises in ICUs, and high-performance sound-absorbing materials can be used to reduce reverberation time, sound propagation, and noise intensity levels. Storage areas, staff lounges, and utility rooms also can be located away from patient rooms and family spaces to reduce noise. Internal corridors between storage and utility rooms can help clinical and support staff members perform necessary tasks without disturbing patients or families.
Music in Family Space
Sometimes music can be used to mask distressing environmental noise that cannot otherwise be eliminated. Sounds of nature accompanied by soft music also can be used in family waiting areas to calm anxious families or visitors. However, not all music can produce a desired calming effect. Music often evokes emotions and feelings that are rooted in an individual’s past experiences and personal preferences. Thus it is essential to respect music preferences of family members and provide them choices.
Artwork in Family Space
Appropriate artwork can help reduce stress among patient families. The choice of artwork needs to be sensitive to culture, religion, the specific geographic area, and the interior design scheme. Hospitals should consider developing systems that allow artwork to be changed by the patient family as easily as changing television channels. Because art varies enormously in subject matter and style, not all artwork is suitable for high-stress health care spaces.
Lighting in Family Space
Appropriate lighting can influence mood or create a relaxed ambience. Therefore attention should be given to make natural light available in all family spaces in the unit. When the family space is within the patient room, it is necessary to make sure that the intensity of natural light is comfortable to patients. The use of slightly tinted or reflective glass can reduce glare and heat production from sunlight. Vertical blinds and other window treatments can be used to adjust light intensity as desired by the patient. For artificial light in family spaces, it is important to consider multiple lighting options that can be controlled by the family when appropriate. Where natural light is not an option (e.g., older ICUs), full-spectrum fluorescent lighting can be used for comparable benefits. A dynamic lighting solution that allows the color and temperature levels to be changed according to the time of day may be suitable for a patient room or family space.
Odors and Aromas
Pleasing aromas can help reduce blood pressure, slow the rate of respiration, lower pain perception levels, improve the immune system, and help increase a sense of well-being among family members who are under severe mental and physical stress. In contrast, odors (“negative smells”) may stimulate anxiety, fear, and stress. Hospitals, particularly ICUs, are well known for their unpleasant odors or chemical smells. If possible, strong-smelling cleaning agents should be avoided near family areas. Aroma should be used with caution in ICU family areas.
Nature, Spirituality, and Religion
Nature can have a positive effect on physical and emotional well-being; hence it is preferable to design family areas with windows to the outside. If possible these spaces need to be close to hospital gardens with plants, water, and other natural objects. When family spaces do not have a view of or access to nature, nature may be brought into the unit (e.g., potted plants, sound of nature, and nature-related artwork). Hospitals also should consider outdoor labyrinths in gardens as a focus for spirituality.
A working knowledge of common cultural and religious needs of patients and families is required to design family spaces. Sometimes a focus group with local spiritual and ethnic leaders before ICU design or redesign may help identify common design concerns of these groups. It may help families to have a community room for tai chi, yoga, and other spiritual modalities and a chapel or a sanctuary close to the ICU where religious services can take place. Sometimes these places are the only quiet refuge for families from the chaos of the hospital. Hospitals should also provide religious books, inspirational texts, and texts on grief and coping written in multiple languages in the chapel or the community room, and consider having space for common religious items used by people of different faiths (e.g., rosaries, crucifixes, and holy water for Catholic users; clean clothing, prayer rugs, and compasses for Muslim users; Sabbath kits for Jewish users) in the chapel or the community room. When building a new unit, a tile marker could be inserted in all family spaces and patient rooms to signify the direction of prayer.
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