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

Using Space Syntax Analysis to Measure Patient Aggression Risk

OBJECTIVES

The present study investigates whether space syntax offers appropriate tools for identifying risks of aggression, interventional opportunities, and environmental design strategies to reduce the risk of Type II violence in emergency departments.

BACKGROUND

Although healthcare workers are a relatively small percentage of the U.S. workforce, they sustain almost 75% of workplace assaults. Poor environmental design has been identified as an antecedent to aggression by patients and/or their companions.

METHOD

Guided by Rational Choice Theory, Lifestyle Exposure Theory, Routine Activity Theory, and Crime Prevention through Environmental Design (CPTED), the study uses five visibility graph analysis (VGA) measures: visibility, control, controllability, mean visual depth, and occlusivity. Three U.S. hospital-based emergency departments were selected. First, a VGA was performed on all three layouts. A second VGA was performed after excluding unconnected spaces, and a third was performed on key patient and staff areas. Last, a fourth VGA was conducted after performing physical modifications to the three departments.

RESULTS

Statistical analysis revealed significant differences in VGA measures not only between different layouts but also between the original and modified layouts. Specifically, small changes created by architectural features can affect visual access and exposure as measured by space syntax. Alcove-style spaces in key staff areas are also associated with limited visual control of the local environment. Typically, in smaller zones, central staff workstations afford better control of patient spaces.

CONCLUSION

This study shows that space syntax analysis is a useful tool for identifying risks of aggression in hospital spaces and for identifying interventional opportunities.

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.

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.

Designing for Effective and Safe Multidisciplinary Primary Care Teamwork: Using the Time of COVID-19 as a Case Study

Effective medical teamwork can improve the effectiveness and experience of care for staff and patients, including safety. Healthcare organizations, and especially primary care clinics, have sought to improve medical teamwork through improved layout and design, moving staff into shared multidisciplinary team rooms. While co-locating staff has been shown to increase communication, successful designs balance four teamwork needs: face-to-face communications; situational awareness; heads-down work; perception of teamness. However, precautions for COVID-19 make it more difficult to conduct face-to-face communications. In this paper we describe a model for understanding how layout affects these four teamwork needs and describe how the perception of teamwork by staff changed after COVID-19 precautions were put in place. Observations, interviews and two standard surveys were conducted in two primary care clinics before COVID-19 and again in 2021 after a year of precautions. In general, staff felt more isolated and found it more difficult to conduct brief consults, though these perceptions varied by role. RNs, who spent more time on the phone, found it convenient to work part time-from home, while medical assistants found it more difficult to find providers in the distanced clinics. These cases suggest some important considerations for future clinic designs, including greater physical transparency that also allow for physical separation and more spaces for informal communication that are distanced from workstations.

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.

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.