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Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCMWashington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHAHKS Inc. Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 1ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 1
Debajyoti Pati, PhD AIIAHKS Inc. Dallas, Texas
Outline
• A Day in the Life on the Unit• Critical Care Teams• Demand / SupplyDemand / Supply• Expectations Needs
E i t f C• Environment of Care• Constraining Forces • Guidelines Minimalism• Evolving Trends / Predictions / Future
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 2ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 2
Evolving Trends / Predictions / Future• The Ideal Room
Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCMWashington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHAHKS Inc. Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 3ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 3
Debajyoti Pati, PhD AIIAHKS Inc. Dallas, Texas
Shadowing Studyg y
• Washington Hospital CenterWashington Hospital Center
• Two critical care units – SICU and CCU
• Shadowing: MD Intensivist, RN, Unit Clerk
• 6-Hour Period: 7 am to 1 pm• 6-Hour Period: 7 am to 1 pm
• HKS Researchers: RN, RRT, PhD Arch
• 2-Hour shadowing rotation
• RN staffing ratios: SICU 2:1 / CCU 1:1
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 4ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 4
• RN staffing ratios: SICU-2:1 / CCU-1:1
Washington Hospitalg
CC
CCUCCU SICUSICU
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 5ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 5
1990’s11 Beds1990’s
11 Beds1970’s
14 Beds1970’s
14 Beds
MD Intensivist Time
LOCATION ACTIVITY
75%
LOCATION37% Roomside Station18% Corridor
ACTIVITY33% Consultation19% Info Gathering
83%75%18% Corridor18% Patient Bedside12% Off Unit
19% Info Gathering16% Reporting15% Document / OE
10%7% Lounge (Birthday!)3% Central Station
6% Procedures5% Break
3% Consult Room1% Conf Room
4% Patient Care1% Phone Call1% Searching
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 6ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 6
1% Searching0% Hand Washing
SICU vs CCU RN Time
LOCATION ACTIVITYSICU CCU76 -27% Patient Room8 -20% Central Station
SICU CCU34 -45% Patient Care20 -28% Documentation8 -20% Central Station
7 - 1% Med Room5 -20% Roomside Station
20 -28% Documentation13 - 5% Consultation8 - 1% Medications
2 - 5% Corridor1 -14% Patient Toilet1 11% Lounge
6 - 3% Procedures6 - 0% Reporting4 0% Phone1 -11% Lounge
0 - 2% Nourish Room4 - 0% Phone4 - 3% Searching3 - 4% Socializing
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 7ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 7
g1 - 1% Hand Washing1 -10% Eating
SICU vs CCU Unit Clerk Time
ACTIVITYLOCATION ACTIVITYSICU CCU
28 -19% Phone
LOCATIONSICU CCU
71 -69% Central Station 8 9% o e
26 -42% Documentation
21 - 6% Socializing
69% Ce t a Stat o
13 -13% Off Unit
10 -13% Break Room g
9 - 6% Consulting
9 -16% Eating
4 - 3% Corridor
1 - 0% Roomside Station
3 - 9% Search/Gathering
3 - 0% Relaxing
1 - 0% Staff Toilet
0 - 2% Nourishment Room
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 8ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 8
1 - 2% Organizing25 - 33% impacts nurses!
Posture (Ergonomic Interest)
NURSEPHYSICIAN CLERKNURSESICU CCU
0 - 3% Bending
PHYSICIAN
0% Bending
CLERKSICU CCU
0 - 0% Bending0 3% Bending
3 - 0% Squatting
0 -13% Leaning
0% Bending
0% Squatting
0% Leaning
0 0% Bending
0 - 0% Squatting
0 - 0% Leaning0 13% Leaning
0 - 0% Reaching
4 -36% Sitting
g
0% Reaching
56% Sitting
0 0% Leaning
2 - 0% Reaching
79 -77% Sittingg
92 -56% Standing
1 - 5% Walking
41% Standing
0% Walking
g
19 -23% Standing
0 - 0% Walking
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 9ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 9
Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCMWashington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHAHKS Inc. Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 10ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 10
Debajyoti Pati, PhD AIIAHKS Inc. Dallas, Texas
© HKS 2007
Rooms
Lav/ToiletCare Zone 3
16 ‘ gross
IVPumps
PhysioMonitors
Utility Boom@ Ceiling
ToiletWasteZone
DialysisMachine
OverbedTableCare
Zone21’
CareZone
1
BalloonPump
M/SSupply
Cart
HypothermiaUnit
FamilyZone
Zone2
21gross
Data Entry/Access
A320 fA320 f
SleeperChair
Data Entry/
HandWashing
Sink
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 11ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 11
320 nsf320 nsfy
Access
© HKS 2007
Rooms
Lav/ToiletCare Waste
16 ‘ gross
PhysioMonitors
Utility Boom@ Ceiling
ToiletZone
3
WasteZone
DialysisMachine
IVPumps Overbed
TableCareZone
1Care21’
BalloonPump
M/SSupply
Cart
Data Entry/Access
HypothermiaUnitFamily
Zone
CareZone
2
21gross
BBSleeperChair
HandWashing
Sink
Data Entry/
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 12ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 12
320 nsf320 nsfy
Access
Rooms
Lav/ToiletC Waste
18’ gross
ToiletCareZone
1Care
WasteZone
BalloonPump
PhysioMonitors
Zone3
21’ IVUtility Boom@ Ceiling
HypothermiaUnit
OverbedTable
Data Entry/Access
FamilyZone
CareZone
2
21gross
DialysisMachine
Pumps@ Ce g
M/SSupply
Cart
CCSleeperChair
HandWashing
Sink
Data Entry/
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 13ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 13
360 nsf360 nsfy
Access
Rooms
Lav/ToiletWaste
18’ gross
Sl Toilet
CareZone
2
WasteZone
DialysisMachine
IVPumps
FamilyZone
SleeperChair
CareZone
321’
Utility Boom@ Ceiling
HypothermiaUnit
Pumps
OverbedTable
o e
Data Entry/Access
CareZone
21gross
BalloonPump
PhysioMonitors
M/SSupply
Cart
DDHand
WashingSink
Data Entry/
1
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 14ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 14
360 nsf360 nsfy
Access
Toward an Ideal Room Idea
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 15ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 15
BedBed
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 16ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 16© HKS 2007
BedBed
Equipment
Pumps &Monitors
ITCart
OverbedT bl
Ventilator
BalloonPump
TableDialysisMachine
HypothermiaUnit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 17ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 17© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Pumps &Monitors
ITCart
OverbedT bl
Ventilator
BalloonPump
TableDialysisMachine
Line TraysLine Trays HypothermiaUnit
Line TraysAlong
Bedsides
Line TraysAlong
Bedsides
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 18ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 18© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Circle of Access
Pumps &Monitors
16’dia
Rolling Stock for
Work SurfaceAnd Supplies
Rolling Stock for
Work SurfaceAnd Supplies
M/SSupply
Cart
ITCart
OverbedT bl
VentilatorAnd SuppliesAnd Supplies
BalloonPump
TableDialysisMachine
HypothermiaUnit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 19ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 19© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Circle of Access
Staff / PhysiciansPumps &Monitors
16’dia
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
BalloonPump
TableDialysisMachine
HypothermiaUnit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 20ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 20© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Circle of Access
Staff / Physicians
ImagingPumps &Monitors
16’dia
M/SSupply
CartOverbed
T bl
Ventilator
PortableX-Ray
BalloonPump
Table
HypothermiaUnit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 21ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 21© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Circle of Access
Staff / Physicians
Imaging Pumps &Monitors
16’dia
Procedures M/S
SupplyCart
Ventilator
PortableC-Arm
Monitor
BalloonPump
HypothermiaUnit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 22ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 22© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Pumps &Monitors
16’dia
Circle of Access
Staff / Physicians
Imaging
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
Procedures
Lines of Sight
BalloonPump
TableDialysisMachine
HypothermiaUnit
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 23ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 23© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Pumps &Monitors
16’dia
Circle of Access
Staff / Physicians
Imaging Toilet
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
Procedures
Lines of Sight
Work AreasBalloonPump
Data Entry/Access
TableDialysisMachine
Work Areas
HypothermiaUnit
Data Entry/Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 24ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 24© HKS 2007
Bed ToiletBed
Equipment
Power / Linkages
ToiletDeskCloset Couch
Pumps &Monitors
Pumps &Monitors
16’dia
Circle of Access
Staff / Physicians
Imaging
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
Procedures
Lines of Sight
Work AreasBalloonPump
Data Entry/Access
TableDialysisMachine
Work Areas
Family Areas
HypothermiaUnit
Data Entry/Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 25ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 25© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Pumps &Monitors
16’dia
Circle of Access
Staff / Physicians
Imaging
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
Procedures
Lines of Sight
Work AreasBalloonPump
Data Entry/Access
TableDialysisMachine
Work Areas
Family Areas
Consult / EducationHypothermia
Unit
Data Entry/Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 26ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 26© HKS 2007
BedBed
Equipment
Power / Linkages
Pumps &Monitors
Pumps &Monitors
16’dia
Circle of Access
Staff / Physicians
Imaging
SwingAway
Privacy
SwingAway
Privacy
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
Procedures
Lines of Sight
Work Areas
PrivacyScreenPrivacyScreen
BalloonPump
Data Entry/Access
TableDialysisMachine
Work Areas
Family Areas
Consult / EducationHypothermia
Unit
Data Entry/Access
Room Enclosure
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 27ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 27© HKS 2007
BedBed
Equipment
Power / Linkages AccessAccess
Pumps &Monitors
Pumps &Monitors
16’dia
Circle of Access
Staff / Physicians
Imaging
withoutmoving
Bed!
withoutmoving
Bed!
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
23’gross
Procedures
Lines of Sight
Work AreasBalloonPump
Data Entry/Access
TableDialysisMachine
Work Areas
Family Areas
Consult / EducationHypothermia
Unit
Data Entry/Access
Room
Critical Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 28ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 28
18’gross© HKS 2007
BedBed
Equipment
Power / Linkages
Circle of Access
Staff / Physicians
Imaging Pumps &Monitors
Pumps &Monitors
16’dia
Procedures
Lines of Sight
Work Areas
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
23’gross
23’gross
Work Areas
Family Areas
Consult / Education
BalloonPump
Data Entry/Access
TableDialysisMachine
Room
Critical Access
Patient View
HypothermiaUnit
Data Entry/Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 29ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 29
18’gross
18’gross
Patient view outside via mirrors on furr-down
Patient view outside via mirrors on furr-down
© HKS 2007
BedBed
Equipment
Power / Linkages
LCD panel in ceiling projecting
LCD panel in ceiling projecting
Circle of Access
Staff / Physicians
Imaging Pumps &Monitors
Pumps &Monitors
p j gfamily
photos or favorite images
p j gfamily
photos or favorite images
Procedures
Lines of Sight
Work Areas
M/SSupply
Cart
ITCart
Ventilator imagesimages
Work Areas
Family Areas
Consult / Education
BalloonPump
Data Entry/Access
DialysisMachine
Room
Critical Access
Patient View
HypothermiaUnit
Data Entry/Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 30ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 30
Focused Imagery
© HKS 2007
ToiletDeskCloset Couch
Pumps &Monitors
Pumps &Monitors
16’dia
M/SSupply
Cart
ITCart
OverbedT bl
Ventilator
23’gross
23’gross
Ideal Room397 nsfIdeal Room397 nsf
BalloonPump
Data Entry/Access
TableDialysisMachine
HypothermiaUnit
Data Entry/Access
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 31ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 31
18’gross
18’gross
© HKS 2007
Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCMWashington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHAHKS Inc. Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 32ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 32
Debajyoti Pati, PhD AIIAHKS Inc. Dallas, Texas
Demographics of ICU Care 1998g p
• 6,000 Adult ICUs• 72,000 ICU beds• 55,000 ICU patients/day• 5,000,000 admissions per year• 20,000,000 patient days per year• Estimated expenditure $60-80 B/yr• 8-10% of Hospital Beds• 10-12 Avg. bed complement• Mixed Med/Surg patient populations
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 33ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 33
The Team
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 34ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 34
Critical Care Team
• Intensivists • Respiratory Therapists• Residents• PAs/NPs
• Nutritionists• Social WorkersPAs/NPs
• Bedside Nurses• Nurse aides
Social Workers• Clergy• Others -Clerk PSAs• Nurse aides
• Senior nurses -facilitator
• Others -Clerk, PSAs• Quality, Utilization and
Risk Managementfacilitator• Pharmacists
Risk Management Personnel
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 35ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 35
An Intensivist
• A physician with the training and skills to p y gassess and manage patients with or who are at risk for severe single or multi
t d f ti f di lsystem organ dysfunction from medical or surgical illnesses or injuries
• Care provided from the earliest phases of t d ti th h thacute decompensation through the
complex high risk periods of recovery
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 36ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 36
Critical Care Physicians
• Primary Specialtyy p y• Subspecialty training• Board certificationBoard certification• “Intensivist model” – Leap Frog
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 37ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 37
Models of Care Unit Typesy
Closed• Primary Attending = Critical Care Physician
Openp• Primary Attending Not Always = Critical Care• Often multi-organ system consultants without
a CC physician as the leader of a teamTransitional
• Any Primary Attending• And an Intensivist Assumes Management
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 38ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 38
No Intensivist Availability
The C’s of Critical Care
• Patient CarePatient Care
• Collaboration
• Consistency - Continuity
C di i• Coordination
• CommunicationCommunication
• With Availability and Responsiveness
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 39ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 39
Programmatic Responsibilities
Mission
g
GoalGoalMission– Effective patient care – Mandates - Throughput
CustomersDemandDemand
GoalGoal
Customers
Resources SupplySupply
Organizational Structure
O ti l F t
Chain of CommandChain of Command
Operational Factors– Mandates– Constraints Coalescence …Coalescence …
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 40ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 40
– Processes
Patients and Providers
Demand: Patients Supply: Resources– Quantity– Quality
E t ti
pp y– Providers
• Quantity – number, commitment– Expectations • Skills
• Personal expectations – Clinical equipment and– Clinical equipment and
supplies– Non clinical
accoutrementsaccoutrements – Physical Infrastructure
(i.e. built environment)
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 41ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 41
Patient Populations
• Quantity - Baby Boomers – oldest turn 60 y yin 2006 at a rate of 7918/day
• ‘Quality’y– Healthy but elderly– Chronic Co-morbid factors
Ob it f ilt– Obesity, frailty– Insults – new medical illnesses or exacerbations,
surgical procedures, trauma, complicationsg p p
• Expectations• Surges – seasonal, biological, man
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 42ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 42
Surges seasonal, biological, man induced
Patient Expectations
• Good outcome• Safe• ResponsiveResponsive • Comfortable• Information rich• Information rich• Efficient
Family convenient (time and space)• Family convenient (time and space)• Healing environment
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 43ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 43
• Minimum cost
Providers
• Youthful vs. Aged labor poolg p• Availability – professional and personal satisfaction
and commitments
• Skill set development - OJT• Expectations – personal amenities, restorativeExpectations personal amenities, restorative
and refreshment areas, communication devices, conveniences (e.g. baby care, banks, laundry, grocery)
V i t• Variety – physician and nurse ‘extenders’, patient and family services, utilization quality and risk reviewers, supply chain, device maintenance, facility
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 44ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 44
pp y ypersonnel
‘Moveable’ Objects
• Clinical activities – monitors, testing equipment, therapeutic devices, documentation and communication technology, supplies (inc. medications)
• Non clinical accoutrements implements• Non clinical accoutrements – implements related to waste, hygiene, ‘transition’ activities, environment of care
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 45ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 45
Techno Evolution - Devices• Sensor development • Devices – Monitoring
monitoring
• Communication devices• Merge monitoring and
– Plug and Play– Simplicity – set up, use,
take down• Merge monitoring and therapeutic modalities
• Electronic Medical Record
– Reliability– Light weight – small size– Wireless ?? tubelesscapture and display, task
management, transaction processing
Wireless, ?? tubeless– Voice control – Data sharing (2 way)
• Positive ID• Medication delivery
mass inventory pharmacy
• Devices – Testing– Portable (e.g. sonography)– Transportable
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 46ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 46
mass inventory pharmacy unit beside nurse (pharmacist) patient
a spo tab e
Devices Wars! (need title)
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 47ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 47
RemoDoc™
Pardon me, may I cut in?
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 48ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 48
may I cut in?
Performance Expectations
• Patient preferences p• Superior results – Quality• Efficient Use of Resources• Efficient Use of Resources
– TimelyE i l
Effectiveness– Economical– Resource conscious
(rationing)(rationing)
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 49ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 49
From Data to Orders
Recognition / Deducing / Concluding
HISTORY – TRENDSSufficient, accurate,
THINKINGKnowledge
Schooling’, Literature, TextsExperience
, ,timely data THINKING
‘Learned’ Expectations
DECISION
Clinical Conclusion - Assessment
WISDOM
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 50ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 50
ResourcesExpectations
WISDOM
For Providers
• Education and Conference rooms• Restorative atmosphere – personal / communal
• Nourishment facilitiesNourishment facilities• Personal effects – ‘uniforms’, coats, purses
• Toilet/shower• Toilet/shower• Communication devices
ADLs l d hild b ki i• ADLs – laundry, child care, grocery, banking, exercise
• Office S
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 51ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 51
• Sleep
Familyy
• Information exchange• Accommodations – waiting (inc. long and
short), nourishment, rest• Mutual support• Privacyacy• Participation in care
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 52ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 52
Patients
• Bed features• ‘Transition’ activities• Reduced tethering• Reduced tethering• Nourishment - food processing• Physical therapy • Environment
– Ceilings – Day/night cycling – eyes, ears, positioning
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 53ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 53
ay/ g t cyc g eyes, ea s, pos t o g
Infection Control
• Susceptible patients • Infection Control – ICU– Portals of entry into
patients– Antibiotic usage and
– reservoirs, contamination (structures and people)
• Aerosols and fomitesgavailability
– Immune compromise
• Aerosols and fomites– Barriers– Hand washing
• Hand cleansing• Protective barriers
• Airborne isolation– Protect other patients
P iti i l ti• Water• Surfaces
• Positive pressure isolation – Protect a single patient
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 54ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 54
Results!• 12 m Baseline average VAP rate 16.33• 12 m Project Average VAP rate 1 57 = 90% Reduction• 12 m Project Average VAP rate 1.57 = 90% Reduction • 9 out of 12 months with zero VAP
Critical Care VAP Process/ Outcome
0%
100%
ianc
e
20 0025.0030.0035.00
Rate
Started PI
0%
50%
Com
pli
0.005.0010.0015.0020.00
VAP
R
F-04
M-04
A-04
M-04
J-04
J-04
A-04
S-04
O-04
N-04
D-04
J-05
F-05
M-05
A-05
M-05
J-05
J-05
A-05
S-05
O-05
Vent Bundle Compliance 0% 0% 0% 0% 0% 0% 0% 16% 40%50% 100 100 100 100 100 96% 100 100 100 96% 100
Critical Care VAP Rate 12.6 33.518.6 25.317.5 5.055.99 16.3 5.856.25 0.000.00 0.000.00 10.8 7.140.00 0.000.00 0.000.00
VAP Cases 2 5 3 4 4 1 1 3 1 1 0 0 0 0 2 1 0 0 0 0 0
04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 05 05
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 55ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 55
VAP Cases
Equipment and Supplies
• Storage g• Accessibility• CompatibilityCompatibility
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 56ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 56
Equipment and Supplies
Increases in monitoring, pumps, and equipment requirements
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 57ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 57
Patient Rooms
• Occupants • Over bed tablesp– Patient– Family– Staff
• Restraints • Back walls– Staff
• Sitting• Documentation
• Furniture• Documentation centers• Documentation
• Circulation• Cabling
Documentation centers
• Cabling• Reaching
Comm nication
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 58ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 58
• Communication– TV, Radio, Computer
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 59ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 59
Royal Alexandra Hospital - Edmonton, Alberta WSAG Architects
Environmental Factors
• Visual • Temperature• Auditory• Tactile
p• Chemical
– including humidity• Tactile • Olfactory
• Particulate• Electromagnetic
• Gustatory• Spatial
ec o ag e c
p• Familiar – cultural, ethnic, personal• Unfamiliar psychosomatic interplay
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 60ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 60
• Unfamiliar – psychosomatic interplay
Environment of Care Continuum
EnrichingEnrichingEncouraging
HealingHealingHelpful
SoothingSoothingNeutral
Irritatingtat gNoxious
Dangerous’
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 61ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 61
gHurtful
Entrance Hallway?y
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 62ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 62
The Soda Machine?
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 63ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 63
Resource Constraints
• Labor shortage and retention – RNs, MDs, therapists, pharmacists, technicians
• EMRs – underdeveloped and installed• Physical infrastructure
• Capacity • Sq. Feet / ICU• Adjacencies
• Capital
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 64ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 64
Need Title
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 65ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 65
Constraining Forces
• Confines of real estate • Renovation projects• Capital limitationsCapital limitations• Minimum standards mind set• Ineffective Clinical/Design professional• Ineffective Clinical/Design professional
dialogue• Paucity of research and its application• Paucity of research and its application
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 66ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 66
Maslow’s Hierarchy of Needs
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 67ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 67
Title Needed
• Functional Programg– Programmatic Missions Needs ~ Acuity– Throughput – Contingency surges
Ri k ( )– Risk (e.g. age)– Physical characteristics (e.g. obesity)– Operational paradigmsOperational paradigms– Future directions
• ‘Minimum’ Standards/Guidelines– Level I– Level II
L l III
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 68ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 68
– Level III
‘Minimum’ Standards
• ‘Code’ – Guidelines for Design and Construction of Health Care Facilities, NFPA
• Resources – real estate, capitalFunctional program i i• Functional program – mission
• Patient vs./and Provider needs • Provider availability• Provider availability• Environment of Care – hierarchy of needs• Patient and provider expectations• Patient and provider expectations• Safety, longevity• Societal – environmental sensitivity
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 69ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 69
Societal environmental sensitivity• Surge
Title Needed
bil t t f t f b d
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 70ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 70
mobile system at foot of bed
CVICU, Methodist Hospital – Houston, Texas WHR Architects
Evolving Trends - Novel Ideasg
• Obesity, age, acuityy, g , y• Design to augment staff effectiveness and
retentionretention• ‘Environment of care’• Telemedicine – eICU
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 71ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 71
Evolving Trends - Novel Ideasg
• Move tests to the ICU• Laboratory - portable analyzers
? R di l i d h– ? Radiologic procedures – e. g. sonography
• EMR (Acquiring) Pattern (Recognition/Deducing/Concluding) plus electronic process management tools
• Sensitivity to our environment
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 72ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 72
Future - Predictions
• Demand/Labor Resource mismatch– Labor imperatives – professional and
personal decisionspersonal decisions
• Regionalization – ICU Certification • Team
– Composition – midlevel practitioners– ‘Model’ evolution - O/P I/P specialists -
hospitalists
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 73ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 73
p
Future - Predictions
• Expanded prescriptive authorityp p p y• Family participation• Other resources limitationsOther resources limitations
– medications, blood products• Telemetry in the ICUTelemetry in the ICU
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 74ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 74
Future - Predictions
• Marriage of monitoring and therapeuticMarriage of monitoring and therapeutic devices
• Complication prevention methodologies
• Organ based dysfunctional metabolismOrgan based dysfunctional metabolism measurements and interventions
End organ perfusion monitoring- End organ perfusion monitoring
• Genetic profiling
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 75ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 75
• Simulation
Suggestions
• More robust clinician/user participation in p pdesign planning
• Translate research into designTranslate research into design– Research into Learned Design
Evidence Based Design– Evidence Based Design• National POE database• Research• Write a proposal
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 76ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 76
Intensive Care Design
Wh ill b ?Where will we be?
A th St A d MD FCCMArthur St. Andre, MD FCCMWashington Hospital Center
Washington, DC
Tom Harvey AIA MPH FACHATom Harvey, AIA MPH FACHAHKS Inc. Dallas, Texas
Debajyoti Pati, PhD AIIA
© HKS 2006 University of Texas at Arlington School of Architecture - Graduate Studio in Healthcare Design, Spring Semester 2007 Page 77ASHE/AIA-AAH Planning, Design & Construction Conference 2007 Page 77
Debajyoti Pati, PhD AIIAHKS Inc. Dallas, Texas