Patient visibility and ICU mortality: a conceptual replication

Visibility-based layout of a hospital unit - An optimization approach

A patient fall is one of the adverse events in an inpatient unit of a hospital that can lead to disability and/or mortality. The medical literature suggests that increased visibility of patients by unit nurses is essential to improve patient monitoring and, in turn, reduce falls. However, such research has been descriptive in nature and does not provide an understanding of the characteristics of an optimal inpatient unit layout from a visibility-standpoint. To fill this gap, we adopt an interdisciplinary approach that combines the human field of view with facility layout design approaches. Specifically, we propose a bi-objective optimization model that jointly determines the optimal (i) location of a nurse in a nursing station and (ii) orientation of a patient's bed in a room for a given layout. The two objectives are maximizing the total visibility of all patients across patient rooms and minimizing inequity in visibility among those patients. We consider three different layout types, L-shaped, I-shaped, and Radial; these shapes exhibit the section of an inpatient unit that a nurse oversees. To estimate visibility, we employ the ray casting algorithm to quantify the visible target in a room when viewed by the nurse from the nursing station. The algorithm considers nurses' horizontal visual field and their depth of vision. Owing to the difficulty in solving the bi-objective model, we also propose a Multi-Objective Particle Swarm Optimization (MOPSO) heuristic to find (near) optimal solutions. Our findings suggest that the Radial layout appears to outperform the other two layouts in terms of the visibility-based objectives. We found that with a Radial layout, there can be an improvement of up to 50% in equity measure compared to an I-shaped layout. Similar improvements were observed when compared to the L-shaped layout as well. Further, the position of the patient's bed plays a role in maximizing the visibility of the patient's room. Insights from our work will enable understanding and quantifying the relationship between a physical layout and the corresponding provider-to-patient visibility to reduce adverse events.

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit

BACKGROUND

Optimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU.

OBJECTIVE

To assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design-informed tools would either maintain or improve situation awareness.

DESIGN, SETTINGS, AND PARTICIPANTS

A 15-week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation.

INTERVENTION

Improved and updated communication devices and bedside mitigation plans.

MAIN OUTCOME AND MEASURES

Process metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre- and post-transition.

RESULTS

When evaluating all patients, shared situation awareness for accurate high-risk status improved from 81% pre-transition to 92% post-transition (p = .006). When assessing individual care team roles, accuracy of patient high-risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.

Measuring Potential Visual Exposure of Physicians During Shift-End Handoffs and Its Impact on Interruptions, Privacy, and Collaboration

BACKGROUND

Frequent interruptions, inadequate privacy, and lack of collaboration are barriers to safe and efficient end-of-shift handoffs between emergency physicians. Varying levels of visibility to and from physicians can impact these outcomes. This study quantifies potential visual exposure of physicians in workstations with varying enclosure levels using isovist connectivity (IC) as a measure. Further, this study examines the association of IC with number of interruptions/hour, perceived collaboration, and privacy during handoffs.

METHODS

In-person observations were conducted during 60 handoffs to capture interruptions. Surveys were administered to the incoming and outgoing physicians to garner their perceptions of the extent of interruptions, collaboration, and privacy. Spatial analysis was conducted using DepthmapX.

RESULTS

Findings demonstrate significant differences in IC scores based on (a) physicians location within the workstation during; (b) handoff approach (individual or collaborative); (c) position during handoff (sitting or standing). Documented interruptions were highest in the high IC locations and lowest in the medium and low IC locations. Physicians in low IC locations perceived to have sufficient privacy to conduct handoffs.

LIMITATIONS AND CONCLUSION

It should be noted that the three pods, each housing a physician workstation with different enclosure levels, varied in number of patient rooms, patient acuity, overall size, and the location of workstations. While contextual variables were considered to the extent possible, several other factors could have resulted in differences in number of interruptions and collaboration levels. This study provides design recommendations for handoff locations and a method to test emergency physician workstation designs prior to construction.

Systematized and efficient: organization of critical care in the future

Since the advent of critical care in the twentieth century, the core elements that are the foundation for critical care systems, namely to care for critically ill and injured patients and to save lives, have evolved enormously. The past half-century has seen dramatic advancements in diagnostic, organ support, and treatment modalities in critical care, with further improvements now needed to achieve personalized critical care of the highest quality. For critical care to be even higher quality in the future, advancements in the following areas are key: the physical ICU space; the people that care for critically ill patients; the equipment and technologies; the information systems and data; and the research systems that impact critically ill patients and families. With acutely and critically ill patients and their families as the absolute focal point, advancements across these areas will hopefully transform care and outcomes over the coming years.

Intensive Care Unit Built Environments: A Comprehensive Literature Review (2005-2020)

BACKGROUND

The intensive care environment in hospitals has been the subject of significant empirical and qualitative research in the 2005-2020 period. Particular attention has been devoted to the role of infection control, family engagement, staff performance, and the built environment ramifications of the recent COVID-19 global pandemic. A comprehensive review of this literature is reported summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent medical intensive care literature to provide conceptual clarity and identify current priorities and future evidence-based research and design priorities.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion pieces/essays, cross-sectional empirical investigations, nonrandomized comparative investigations, randomized studies, and policy review essays-and into nine content categories: nature engagement and outdoor views; family accommodations; intensive care unit (ICU), neonatal ICU, and pediatric ICU spatial configuration and amenity; noise considerations; artificial and natural lighting; patient safety and infection control; portable critical care field hospitals and disaster mitigation facilities including COVID-19; ecological sustainability; and recent planning and design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 135 literature sources reviewed, single-bed ICU rooms have increasingly become the norm; family engagement in the ICU experience has increased; acknowledgment of the therapeutic role of staff amenities; exposure to nature, view, and natural daylight has increased; the importance of ecological sustainability; and pandemic concerns have increased significantly in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review includes topics noticeably overlooked or underinvestigated in the 2005-2020 period and priorities for future research.

Impact of Inpatient Unit Design Features on Overall Patient Experience and Perceived Room-Level Call Button Response

This study explores the relationship between inpatient unit design and patient experience and how spatial features and visibility impact patients' perception of staff responsiveness. The first part of this study is a retrospective pre-post and cross-sectional study evaluating the impacts of unit design on patient experience at the unit level. This study compares patient experiences based on Press Ganey and HCAHPS surveys in two orthopedic units (existing unit in Atrium building and new unit in Tower) with differing design features at Rush University Medical Center. The chi-square test results show that when moving from the old orthopedic unit to the new unit, almost all patient survey items related to patient experience showed statistically significant improvements. The second part of this study is a room level on the new unit. The ANOVA and Pearson correlation tests revealed that the visibility measure of metric step depth had significant impacts on patients' perception of staff's "promptness in responding to call button" and "help with toileting". This study confirms that inpatient unit design plays a direct role in improvement for patient experience and should be considered as an important area of focus for future development.

Inpatient Telemedicine and New Models of Care during COVID-19: Hospital Design Strategies to Enhance Patient and Staff Safety

The challenges of the COVID-19 pandemic have led to the development of new hospital design strategies and models of care. To enhance staff safety while preserving patient safety and quality of care, hospitals have created a new model of remote inpatient care using telemedicine technologies. The design of the COVID-19 units divided the space into contaminated and clean zones and integrated a control room with audio-visual technologies to remotely supervise, communicate, and support the care being provided in the contaminated zone. The research is based on semi-structured interviews and observations of care processes that implemented a new model of inpatient telemedicine at Sheba Medical Center in Israel in different COVID-19 units, including an intensive care unit (ICU) and internal medicine unit (IMU). The study examines the impact of the diverse design layouts of the different units associated with the implementation of digital technologies for remote care on patient and staff safety. The results demonstrate the challenges and opportunities of integrating inpatient telemedicine for critical and intermediate care to enhance patient and staff safety. We contribute insights into the design of hospital units to support new models of remote care and suggest implications for Evidence-based Design (EBD), which will guide much needed future research.

Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation

OBJECTIVE

To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication.

BACKGROUND

Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes.

METHODS

This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis.

RESULTS

Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients.

CONCLUSIONS

Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

Telemedicine Implementation in COVID-19 ICU: Balancing Physical and Virtual Forms of Visibility

Objective:

This case study examines the implementation of inpatient telemedicine in COVID-19 intensive care units (ICUs) and explores the impact of shifting forms of visibility on the management of the unit, staff collaboration, and patient care.

Background:

The COVID-19 crisis drove healthcare institutions to rapidly develop new models of care based on integrating digital technologies for remote care with transformations in the hospital-built environment. The Sheba Medical Center in Israel created COVID-19 ICUs in an underground structure with an open-ward layout and telemedicine control rooms to remotely supervise, communicate, and support the operations in the contaminated zones. One unit had a physical visual connection between the control room and the contaminated zone through a window, while the other had only a virtual connection with digital technologies.

Methods:

The findings are based on semistructured interviews with Sheba medical staff, telemedicine companies, and the architectural design team and observations at the COVID-19 units during March–August 2020.

Results:

The case study illustrates the implications of virtual and physical visibility on the management of the unit, staff collaboration, and patient care. It demonstrates the correlations between patterns of visibility and the users’ sense of control, orientation in space, teamwork, safety, quality of care, and well-being.

Conclusions:

The case study demonstrates the limitations of current telemedicine technologies that were not designed for inpatient care to account for the spatial perception of the unit and the dynamic use of the space. It presents the potential of a hybrid model that balances virtual and physical forms of visibility and suggests directions for future research and development of inpatient telemedicine.

The Effects of ICU Crisis Reorganization on Outcomes in Patients Not Infected With Coronavirus Disease 2019 During the Initial Surge of the Coronavirus Disease 2019 Pandemic

To determine if ICU reorganization due to the coronavirus disease 2019 pandemic affected outcomes in critically ill patients who were not infected with coronavirus disease 2019.

DESIGN

This was a Before-After study, with coronavirus disease 2019-induced ICU reorganization as the intervention. A retrospective chart review of adult patients admitted to a reorganized ICU during the coronavirus disease 2019 surge (from March 23, 2020, to May 06, 2020: intervention group) was compared with patients admitted to the ICU prior to coronavirus disease 2019 surge (from January 10, 2020, to February 23, 2020: before group).

SETTING

High-intensity cardiac, medical, and surgical ICUs of a community hospital in metropolitan Missouri.

PATIENTS

All patients admitted to the ICU during the before and intervention period were included. Patients younger than 18 years old and those admitted after an elective procedure or surgery were excluded. Patients with coronavirus disease 2019 were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified a total of 524 eligible patients: 342 patients in the before group and 182 in the intervention group. The 28-day mortality was 25.1% (86/342) and 28.6% (52/182), respectively (p = 0.40). The ICU length of stay, ventilator length of stay, and ventilator-free days were similar in both groups. Rates of patient adverse events including falls, inadvertent endotracheal tube removal, reintubation within 48 hours of extubation, and hospital acquired pressure ulcers occurred more frequently in the study group (20 events, 11%) versus control group (12 events, 3.5%) (p = 0.001).

CONCLUSIONS

Twenty-eight-day mortality, in patients who required ICU care and were not infected with coronavirus disease 2019, was not significantly affected by ICU reorganization during a pandemic.

Viable bacterial communities on hospital window components in patient rooms

Previous studies demonstrate an exchange of bacteria between hospital room surfaces and patients, and a reduction in survival of microorganisms in dust inside buildings from sunlight exposure. While the transmission of microorganisms between humans and their local environment is a continuous exchange which generally does not raise cause for alarm, in a hospital setting with immunocompromised patients, these building-source microbial reservoirs may pose a risk. Window glass is often neglected during hospital disinfection protocols, and the microbial communities found there have not previously been examined. This pilot study examined whether living bacterial communities, and specifically the pathogens Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile (C. difficile), were present on window components of exterior-facing windows inside patient rooms, and whether relative light exposure (direct or indirect) was associated with changes in bacterial communities on those hospital surfaces. Environmental samples were collected from 30 patient rooms in a single ward at Oregon Health & Science University (OHSU) in Portland, Oregon, USA. Sampling locations within each room included the window glass surface, both sides of the window curtain, two surfaces of the window frame, and the air return grille. Viable bacterial abundances were quantified using qPCR, and community composition was assessed using Illumina MiSeq sequencing of the 16S rRNA gene V3/V4 region. Viable bacteria occupied all sampled locations, but was not associated with a specific hospital surface or relative sunlight exposure. Bacterial communities were similar between window glass and the rest of the room, but had significantly lower Shannon Diversity, theorized to be related to low nutrient density and resistance to bacterial attachment of glass compared to other surface materials. Rooms with windows that were facing west demonstrated a higher abundance of viable bacteria than those facing other directions, potentially because at the time of sampling (morning) west-facing rooms had not yet been exposed to sunlight that day. Viable C. difficile was not detected and viable MRSA was detected at very low abundance. Bacterial abundance was negatively correlated with distance from the central staff area containing the break room and nursing station. In the present study, it can be assumed that there is more human traffic in the center of the ward, and is likely responsible for the observed gradient of total abundance in rooms along the ward, as healthcare staff both deposit more bacteria during activities and affect microbial transit indoors. Overall, hospital window components possess similar microbial communities to other previously identified room locations known to act as reservoirs for microbial agents of hospital-associated infections.

Nurses' Participation in the Design of an Intensive Care Unit: The Use of Virtual Mock-Ups

BACKGROUND

Co-design with multiple tools is useful when end users' knowledge is important, especially when designers work with people unfamiliar with design. Many studies have highlighted the importance of nurses' participation in design, and such participation requires the development of techniques and tools to facilitate collaboration. This article analyzes how nurses participated in designing a general intensive care unit in a walk-in virtual environment (VE) and examines how their work-related knowledge can be transferred to the design process of spaces.

METHOD

In this action research study, the design process was conducted by using virtual mock-ups, which were evaluated by multi-occupational groups in a walk-in VE. Nurses were the largest occupational group. Their work processes were under modification, since existing multi-patient rooms were being redesigned as single-patient rooms. The design of single-patient rooms was performed in three iterative cycles in the walk-in VE.

RESULTS

The nurses could specify their requirements in the walk-in VE, and their suggestions were incorporated into the architectural design process. The nurses were satisfied with their role in the design process.

CONCLUSION

Co-design with virtual mock-ups in walk-in VE is appropriate when designing new healthcare facilities and when the opinions of workers are important. Virtual mock-ups in walk-in VE can be used collaboratively, facilitating simultaneous feedback from multiple users. Virtual reality (VR) technology has evolved, and changes can be made rapidly and at a lower cost. Another advantage of VR is that it allows one to design larger spaces, thus providing larger layouts of facilities for evaluation.

Measuring Interpersonal Visual Relationships in Healthcare Facilities: The Agent Visibility Model and SAVisualPower Tool

Visibility has a significant impact on health-related outcomes and experiences of users in healthcare settings. Built environments determine interpersonal visual relationships between users and control their ability to see (or be seen by) others. Despite this importance, metrics that fully and precisely describe these interpersonal visual relationships are lacking. In this article, we introduce the Agent Visibility Analysis Model and the SAVisualPower software, which enable person-centric visibility analysis for quantifying visual relationships both among users and between users and visual targets. The model precisely captures users' visibility by reflecting the orientation of users and by differentiating visual contents of the users-space, other users, and targets. By providing practical examples of the new model using layouts from previous studies, this article describes specific visibility metrics that can be analyzed by the new tool and how the tool can be applied to design and research in healthcare settings for improved user experiences.

Privacy and Well-Being in Aged Care Facilities with a Crowded Living Environment: Case Study of Hong Kong Care and Attention Homes

This study aims to understand the relationship between bedroom privacy and well-being of the elderly in aged care facilities with a compact living situation. A majority of studies on this topic were carried out in a low-density population context. The crowded living situation might compromise the well-being of residents. This study proposed five architectural parameters to measure bedroom privacy in aged care facilities: total open surface per unit, openness/solid ratio per bed, height of partition wall, number of people per unit, and personal control over bedroom privacy. SF-12 v.2 Health Survey was used to collect information on physical and mental health status. The study surveyed nine Care & Attention homes and their 213 residents in Hong Kong. The total open surface per unit and the openness/solid ratio per bed were positively associated with the physical health of residents. The height of partition walls was associated negatively with their physical and mental health conditions, and the number of people per unit was negatively associated with their physical health. More than half of respondents preferred a single unit with high partition walls; however, 40% of respondents preferred low partition walls. The provision of privacy for the elderly should be balanced with their needs for social interactions; total open surface per unit, openness/solid ratio per bed and height of partition wall should be taken into consideration. The study provides evidence and design guidelines for improving privacy in aged care facilities with a compact living environment.

Effects of Emergency Department Physical Design Elements on Security, Wayfinding, Visibility, Privacy, and Efficiency and Its Implications on Staff Satisfaction and Performance

OBJECTIVE

The purpose of this study was to identify the role of emergency department (ED) design on ED staff satisfaction and performance.

BACKGROUND

High patient volume, surging workloads, and violent behaviors are expected pressures for ED staff. Literature suggests the substantial role of the physical environment in the delivery of care and its role in staff and patient experiences. Nevertheless, limited studies have explored simultaneous interactions between ED physical design elements, attributes (security, wayfinding, visibility, privacy, and efficiency), and staff satisfaction or performance.

METHOD

Interviews, surveys, visibility graph analysis, and agent simulations were employed to understand the connection between ED physical design, attributes, performance, and staff satisfaction.

RESULTS

Enhanced security, effective wayfinding, team visibility, noise reduction, adequate privacy, and accessible supplies and equipment were significant predictors of staff satisfaction and performance. Unobstructed views in waiting and triage and controlled entrances were critical for improving security. To improve wayfinding, eye-level signage, reducing surveillance obstacles, and creating direct public routes were recommended. Rectangular units with multiple perpendicularly connected corridors and linear pod arrangements enhanced movement. Including team rooms and enclosed ERs were recommended for privacy improvements. Visibility was critical for team communication and improved by including short-distanced perpendicular corridors and eliminating columns. Enhancing access to supplies or equipment and reducing noise levels improved the perception of staff efficiency.

CONCLUSION

The findings contribute to the general body of knowledge on the impact of ED physical design on attributes that potentially improve staff satisfaction and work performance.

Legibility of floor plans and wayfinding satisfaction of residents in Care and Attention homes in Hong Kong

OBJECTIVE

Focusing on Hong Kong Care and Attention homes which provide residential care, meals, personal care and limited nursing care for older people, this study aimed to understand the impact of floor plans' legibility (layout and complexity) on residents' wayfinding satisfaction and self-reported health status.

METHODS

A questionnaire survey was conducted in nine Care and Attention homes. Space syntax, a well-established method, was used to evaluate the legibility of their floor plans via calculating the integration value.

RESULTS

Familiarity with Care and Attention homes did not influence the residents' satisfaction with wayfinding. The integration value had a significant impact on residents' satisfaction with wayfinding. No relationship was observed between integration value and self-reported health status.

CONCLUSION

Increasing complexity in floor plans appears to negatively affect residents' wayfinding satisfaction. These data suggest that circulation patterns should be improved for better wayfinding.

Nursing Unit Design, Nursing Staff Communication Networks, and Patient Falls: Are They Related?

Purpose:

The purpose of this research is to (1) investigate the impact of nursing unit design on nursing staff communication patterns and, ultimately, on patient falls in acute care nursing units; and (2) evaluate whether differences in fall rates, if found, were associated with the nursing unit physical structure (shape) or size.

Background:

Nursing staff communication and nursing unit design are frequently linked to patient safety outcomes, yet little is known about the impact of specific nursing unit designs on nursing communication patterns that might affect patient falls.

Method:

An exploratory longitudinal correlational design was used to measure nursing unit communication structures using social network analysis techniques. Data were collected 4 times over a 7-month period. Floor plans were used to determine nursing unit design. Fall rates were provided by hospital coordinators.

Results:

An analysis of covariance controlling for hospitals resulted in a statistically significant interaction of unit shape and size (number of beds). The interaction occurred when medium- and large-sized racetrack-shaped units intersected with medium- and large-sized cross-shaped units.

Conclusion:

The results suggest that nursing unit design shape impacts nursing communication patterns, and the interaction of shape and size may impact patient falls. How those communication patterns affect patient falls should be considered when planning hospital construction of nursing care units.

Perceptual Effects of Physical and Visual Accessibilities in Intensive Care Units: A Quasi-experimental Study

This article reports the findings of a 2-phase quasi-experimental study looking at the perceptual effects of physical and visual accessibilities on clinical staff in intensive care units (ICUs). In a previous CCNQ article by Rashid et al, the first phase of the study was reported comparing, among other things, physical and visual accessibilities and their associations with staff perception in 2 ICUs with the open-plan and racetrack-type layouts. The data for that phase of the study were collected in December 2014, which included the data on physical and visual accessibilities collected using the spatial analysis techniques of Space Syntax, and the data on staff perception collected using a questionnaire survey. Since then, the open-plan ICU has been completely redesigned using a layout composed of 4-bed pods (each dubbed as a HYPERPOD by the designer). However, the racetrack ICU has remained unchanged. In August 2016, more than years after the data for the first phase of this study were collected, the authors went back to the study sites to collect similar data using the methods of the previous study by Rashid et al. The purpose of the 2-phase study was 2-fold: (1) to see whether staff perception and their associations with physical and visual accessibilities observed in the racetrack ICU during the first phase would remain unchanged during the second phase of the study; and (2) to see whether staff perception and their associations with physical and visual accessibilities observed in the open-plan ICU during the first phase would change in the new ICU during the second phase of the study. The findings of the study comparing the racetrack ICU of the first and second phases show that while staff perception in this unit changed, its associations with the physical and visual accessibilities of the unit did not change during the period between the first and second phases of the study. In contrast, the findings of the study comparing the open-plan ICU of the first phase and the new ICU with 4-bed pods of the second phase show that staff perception as well as its associations with the physical and visual accessibilities of the unit changed in a positive direction from the open-plan ICU to the new ICU. It is concluded that staff perception is likely to change over time even in the absence of environmental changes, but any change in staff perception can be made more effective when it is associated with thoughtful environmental design changes.

Decentralization: The Corridor Is the Problem, Not the Alcove

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

Safety and Security Concerns of Nurses Working in the Intensive Care Unit: A Qualitative Study

Intensive care units (ICUs) exist to serve as a safe place for critically ill patients to receive care from skilled practitioners. In this qualitative study, ICU nurses shared their perspectives on elements that promote safety and security on their units. After obtaining institutional review board approval, participants participated in telephone interviews with a nurse researcher who has experience as a bedside ICU nurse. Five categories and 14 themes were identified and then confirmed using member checking. Results indicate that participants prefer to provide care in ICUs with no more than 12 to 14 beds and provide the following: visibility of patients and coworkers; more than 1 way to exit; and can be locked in case of emergency or threat. Nearly all respondents mentioned adequate staffing as the most important attribute of a safe, secure care environment for patients and families. More research is needed to identify design features that make the most impact on providing a safe, secure ICU environment.

Macrocognition in the Healthcare Built Environment (mHCBE): A Focused Ethnographic Study of “Neighborhoods” in a Pediatric Intensive Care Unit

Objectives:

The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the healthcare built environment (HCBE) using those constructs to explicate influences on macrocognition.

Background:

In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple healthcare settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, “macrocognition in the healthcare built environment” (mHCBE) addresses this relationship.

Method:

A focused ethnographic study was conducted including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data.

Results:

Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs).

Conclusions:

Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help increase understanding of how use of the framework of Macrocognition in the HCBE can improve design and support adaptation of interprofessional team practices, maximizing macrocognitive interaction opportunities for patient, family, and team safety and quality.

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

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

Impact of outlier status on critical care patient outcomes: Does boarding medical intensive care unit patients make a difference?

PURPOSE

To evaluate the impact of outlier status, or the practice of boarding ICU patients in distant critical care units, on clinical and utilization outcomes.

MATERIALS AND METHODS

Retrospective observational study of all consecutive admissions to the MICU service between April 1, 2014-January 3, 2016, at an urban university hospital.

RESULTS

Of 1931 patients, 117 were outliers (6.1%) for the entire duration of their ICU stay. In adjusted analyses, there was no association between outlier status and hospital (OR 1.21, 95% CI 0.72-2.05, p=0.47) or ICU mortality (OR 1.20, 95% CI 0.64-2.25, p=0.57). Outliers had shorter hospital and ICU lengths of stay (LOS) in addition to fewer ventilator days. Crossover patients who had variable outlier exposure also had no increase in hospital (OR 1.61; 95% CI 0.80-3.23; p=0.18) or ICU mortality (OR 1.05; 95% CI 0.43-2.54; p=0.92) after risk-adjustment.

CONCLUSIONS

Boarding of MICU patients in distant units during times of bed nonavailability does not negatively influence patient mortality or LOS. Increased hospital and ventilator utilization observed among non-outliers in the home unit may be attributable, at least in part, to differences in patient characteristics. Prospective investigation into the practice of ICU boarding will provide further confirmation of its safety.

Patient visibility and ICU mortality: a conceptual replication

OBJECTIVE

This study reanalyzes the data from a study by Leaf, Homel, and Factor (2010) titled "Relationship between ICU Design and Mortality" by adopting and developing objective visibility measures.

BACKGROUND

Various studies attribute healthcare outcomes (patient falls, satisfaction) to a vague notion of patient room visibility. The study by Leaf and colleagues was the first to draw an independent association between patient mortality and patient room visibility, however "visibility" remains imprecise.

METHODS

The original patient dataset was obtained from Dr. Leaf. The 664 patient sample assigned across 12 rooms at the medical ICU at Columbia University Medical Center was reanalyzed in terms of targeted visibility; the unit of analysis was the room, n = 12. Several computer-based visibility measures of patient rooms were used: patient head visibility, patient room visibility, and field of view to nursing station. Patient head visibility was defined as the percentage of area within the central nursing station from which the patient head could be seen; patient room visibility was defined as the percentage of area within the central nursing station that could see the patient room (average value of all patient room grids); field of view was defined as the maximum viewing angle from the patient head to the central nursing station.

RESULTS

Among the sickest patients (those with Acute Physiology and Chronic Health Evaluation II > 30), field of view accounted for 33.5% of the variance in ICU mortality, p = 0.049.

CONCLUSIONS

Subtle differences in patient room visibility may have important effects on clinical outcomes.

KEYWORDS

Case study, critical care/intensive care, methodology, outcomes.

Key Spatial Factors Influencing the Perceived Privacy in Nursing Units: An Exploration Study With Eight Nursing Units in Hong Kong

Aim:

This study examined how the spatial characteristics of patient beds, which are influenced by patient room design and nursing unit configuration, affect patients’ perceptions about privacy.

Background:

In the hospital setting, most patients expect a certain degree of privacy but also understand that their caregivers need appropriate access to them in order to provide high-quality care. Even veteran healthcare designers may struggle to create just the right balance between privacy and accessibility.

Methods:

A paper-based survey was conducted with 159 participants in Hong Kong—72 (45.3%) participants had been hospitalized and 87 (54.7%) participants had not—to document their selection of high-privacy beds, given simplified plans of eight nursing units. Two types of information, comprised of six variables, were examined for each bed. These include (1) room-level variables, specifically the number of beds per room and area per bed and (2) relational variables, including walking distance, directional change, integration, and control.

Results:

The results demonstrate that when asked to identify high-privacy beds, participants selected beds in patient rooms with fewer beds per room, a larger area per bed, and a longer walking distance to the care team workstation. Interestingly, the participants having been hospitalized also chose beds with a visual connection to the care team workstation as being high in privacy.

Conclusions:

The participants with hospitalization experience may be willing to accept a bed with reduced visual privacy, perhaps out of a concern for safety.

Environmental Variables That Influence Patient Satisfaction: A Review of the Literature

Patient's perception of care-referred to as patient satisfaction-is of great interest in the healthcare industry, as it becomes more directly tied to the revenue of the health system providers. The perception of care has now become important in addition to the actual health outcome of the patient. The known influencers for the patient perception of care are the patient's own characteristics as well as the quality of service received. In patient surveys, the physical environment is noted as important for being clean and quiet but is not considered a critical part of patient satisfaction or other health outcomes. Patient perception of care is currently measured as patient satisfaction, a systematic collection of perceptions of social interactions from an individual person as well as their interaction with the environment. This exploration of the literature intends to explore the rigorous, statistically tested research conducted that has a spatial predictor variable and a health or behavior outcome, with the intent to begin to further test the relationships of these variables in the future studies. This literature review uses the patient satisfaction framework of components of influence and identifies at least 10 known spatial environmental variables that have been shown to have a direct connection to the health and behavior outcome of a patient. The results show that there are certain features of the spatial layout and environmental design in hospital or work settings that influence outcomes and should be noted in the future research.

Space Syntax Analysis

Aim:

This article reviews and addresses various spatial measures that provide and facilitate accurate descriptions of different layout typologies with particular focus on healthcare facilities.

Background:

Evidence-based design is a field of study that emphasizes the importance of using credible data in order to influence the design process. It addresses whether/how the design and operation of buildings support positive health outcomes through a growing collection of solutions informed by research and practical knowledge. In order to acquire this knowledge, we must consider the environment in a very precise and measurable way, which can then be investigated quantitatively with regard to various human behaviors and cognitive processes.

Topical Headings:

Space Syntax theory and methods are concerned with understanding how spaces are arranged and connected to one another. It provides quantitative measures of individual spaces and of the entire layout, thereby achieving great accuracy. Space Syntax researchers have used graph theory to define spatial measures and have produced computer tools to quantify the relational properties of spaces and to provide numerical and display values for each. Moreover, they have developed more precise tools that can be embedded within basic Space Syntax concepts in order to augment the credibility of the acquired data.

Conclusion:

The study elaborates on the effectiveness of Space Syntax and its newly developed measures for the field of healthcare facility design and research. We present a comprehensive model that brings together these measures with their correlated behavioral and perceptual consequences, thereby providing a point of departure for further investigation and exploration.

Design to Improve Visibility: Impact of Corridor Width and Unit Shape

OBJECTIVE

This study analyzes 10 intensive care units (ICUs) to understand the associations between design features of space layout and nurse-to-patient visibility parameters.

BACKGROUND

Previous studies have explored how different hospital units vary in their visibility relations and how such varied visibility relations result in different nurse behaviors toward patients. However, more limited research has examined the specific design attributes of the layouts that determine the varied visibility relations in the unit. Changes in size, geometry, or other attributes of design elements in nursing units, which might affect patient observation opportunities, require more research.

METHODS

This article reviews the literature to indicate evidence for the impact of hospital unit design on nurse/patient visibility relations and to identify design parameters shown to affect visibility. It further focuses on 10 ICUs to investigate how different layouts diverge regarding their visibility relations using a set of metrics developed by other researchers. Shape geometry and corridor width, as two selected design features, are compared.

RESULTS

Corridor width and shape characteristics of ICUs are positively correlated with visibility. Results suggest that floor plans, which are repeatedly broken down into smaller convex (higher convex fragmentation values), or units, which have longer distances between their rooms or between their two opposite ends (longer relative grid distances), might have lower visibility levels across the unit. The findings of this study also suggest that wider corridors positively affect visibility of patient rooms.

CONCLUSION

Changes in overall shape configuration and corridor width of nursing units may have important effects on patient observation and monitoring opportunities.

Research on nursing unit layouts: an integrative review

Purpose

– This paper aims to present an integrative review of the research studies on nursing unit layouts.

Design/methodology/approach

– Studies selected for review were published between 1956 and 2014. For the purpose of this review, a framework for integrative review was developed using research orientations. The three primary dimensions – technical, psychological and social – of the designed environment and various combinations of these dimensions were used to define the research orientations of these studies.

Findings

– Of all the publications reviewed for the paper, 21 presented technical orientations, 16 psychological orientations, 3 social orientations, 20 psychotechnical orientations, 10 sociotechnical orientations, 2 psychosocial orientations and 13 presented psychosociotechnical orientations. With only a few exceptions, several issues related to nursing unit layouts were investigated no more than one time in any one category of research orientations. Several other seemingly important issues including patient and family behavior and perception, health outcomes and social and psychosocial factors in relation to unit layouts have not been studied adequately.

Research limitations/implications

– Future studies on nursing unit layouts will need to focus on patient and family behavior and perception, health outcomes and social and psychosocial factors in different units. They will also need to focus on developing theories concerning the effects of layouts on the technical, psychological and social dimensions of nursing units.

Originality/value

– Despite a long history of research on nursing unit layouts, an integrative review of these studies is still missing in the literature. This review fills in the gap using a novel framework for integrative review developed based on research orientations.

Network of spaces and interaction-related behaviors in adult intensive care units

Using three spatial network measures of “space syntax”, this correlational study describes four interaction-related behaviors among three groups of users in relation to visibility and accessibility of spaces in four adult intensive care units (ICUs) of different size, geometry, and specialty. Systematic field observations of interaction-related behaviors show significant differences in spatial distribution of interaction-related behaviors in the ICUs. Despite differences in unit characteristics and interaction-related behaviors, the study finds that when nurses and physicians “interact while sitting” they prefer spaces that help maintain a high level of environmental awareness; that when nurses “walk” and “interact while walking” they avoid spaces with better global access and visibility; and that everyone in ICUs “walk” more in spaces with higher control over neighboring spaces. It is argued that such consistent behavioral patterns occur due to the structural similarities of spatial networks over and above the more general functional similarities of ICUs.