Design for Critical Care

An Evidence-Based Approach

D. Kirk Hamilton, Mardelle McCuskey Shepley

• Publisher: Routledge
• Year: 2010
• Print ISBN: 9780750665308
• eBook ISBN: 9781136441196
• Edition: 1
• Topic: Architecture
• Subtopic: Architecture General

It is now widely recognized that the physical environment has an impact on the physiology,
psychology, and sociology of those who experience it. When designing a critical care unit,
the demands on the architect or designer working together with the interdisciplinary team
of clinicians are highly specialized. Good design can have a hugely positive impact in terms
of the recovery of patients and their hospital experience as a whole. Good design can also
contribute to productivity and quality of the work experience for the staff.

'Design for Critical Care' presents a thorough and insightful guide to the very best practice
in intensive care design, focusing on design that has been successful and benefi cial to both
hospital staff and hospital patients. By making the connection between research evidence and
design practice, Hamilton and Shepley present an holistic approach that outlines the future for
successful design for critical care settings.

Part One: Better Design for Better Outcomes

Evidence-based design and applied research

1

Persons associated with the world of medicine should have no trouble understanding the concept of evidence-based design. In the realm of evidence-based medicine, where physicians base best practices on the results of research studies, and in which healthcare executives have long since adopted data-driven decision-making, it is easy to understand the idea of making facility design decisions on the basis of research. Is there sufficient research about design and healthcare environments on which to base important decisions?

1.1 Hypothesis: better design will lead to better outcomes

Research findings have demonstrated the link between the design of healthcare environments and patient outcomes (Rubin, Owens, & Golden, 1998; Ulrich et al., 2004; Ulrich et al., 2008; NACHRI, 2008). It is possible to hypothesize that better design will lead to better outcomes. This can be nowhere more important than in the critical care environment, where the most ill and susceptible patients are cared for and where the difference between life and death can be attributed to any of many complicating factors associated with the intensive interventions of the caregivers.

1.2 What is evidence-based design?

Hamilton has written that evidence-based designers “make decisions, together with an informed client, on the basis of the best available information from research and project evaluations” (2003, p. 20). The belief is that in healthcare, especially in intensive care settings where the stakes are so high, one cannot consistently rely on subjective judgment to make expensive and nearly permanent design decisions. The Center for Health Design offered another definition: “Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes” (Levin, 2008, p. 8). The goal of evidence-based design is to use reliable information to support more effective design decisions and, in the case of this book, to examine the current state of that information as it applies to critical care.

Healthcare design practitioners find it comfortable to think of parallels with the evidence-based medicine familiar to their clinical clients. While the types of evidence in the two fields are not the same (Viets, 2009), there are a number of things in common. A prominent definition of evidence-based medicine comes from Sackett and his colleagues:

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

(Sackett et al., 1996, p. 71)

Hamilton admired the clarity of this definition. He first wrote the second half of his definition for evidence-based design, about critical decisions made with clients on the basis of the best available information, in 2003. He added the language of “conscientious, explicit, and judicious use” (Hamilton, 2006) after examining definitions in evidence-based medicine, and choosing to build upon David Sackett, sometimes described as the father of evidence-based medicine (Sackett et al., 1996). Defining evidence-based design as a process came last, in response to the many who expected a product—the ready-made answer to their most difficult design questions. Here is the result:

Evidence-based design is a process for the conscientious, explicit and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project.

(Hamilton & Watkins, 2009, p. 9)

There is growing interest in evidence-based design, as demonstrated by the increase in published articles and books on the topic, as well as by participation in related organizations and events (Hamilton, 2003, 2004b, 2004c, 2005; Hamilton & Watkins, 2009; Cama, 2009). The Center for Health Design (www.healthdesign.org) has for more than two decade promoted evidence-based design with an interdisciplinary audience. Its current focus is on the Pebble Project, in which healthcare organizations document patient outcomes associated with design projects (Joseph & Hamilton, 2008). The Center for Health Design has worked together with the Robert Wood Johnson Foundation (www.rwjf.org) and the Institute for Healthcare Improvement (www.ihi.org) to introduce evidence-based design to broader audiences of healthcare practitioners and executives. The Center for Health Design’s association with HealthCareDesign magazine as well as an annual interdisciplinary conference helps to spread the message.

The American Institute of Architects’ Academy of Architecture for Health (AIA/AAH), the American College of Healthcare Architects (ACHA), the American Society of Interior Designers (ASID), the International Interior Design Association (IIDA), and the American Academy of Healthcare Interior Designers (AAHID) all endorse the evidence-based process. There is now an interdisciplinary, peer-reviewed journal, Health Environments Research & Design (HERD), which publishes scholarly papers on a broad range of topics relating to design and research associated with healthcare settings.

There are an almost endless number of potential sources of information that are useful for evidence-based planning. Many of the early mentions of evidence-based design have focused on the environmental psychology aspects of the field (Malkin, 1992, 2008; Ulrich, 1991, 1997). One of the pioneering studies that brought widespread attention to the role of the environment in clinical outcomes was conducted by a behavioral scientist who demonstrated a relationship between views of nature and clinical outcomes among cholocystectomy patients (Ulrich, 1984). While these types of studies form the foundation of important theories of supportive design for health-care, it should be understood that the research that might be used by designers and their clients is not limited to one field. There is potentially relevant research from fields as varied as management, information technology, logistics, food service, and performance improvement, to name only a few.

The scientific foundation

Roger S. Ulrich, Ph.D.

“The scientific foundation for evidence-based healthcare design is already large and surprisingly strong. A joint project at Texas A&M University and the Georgia Institute of Technology in the USA indentified nearly 700 rigorous studies, most published in international medical journals, about how the architecture of acute care hospitals affects health. A collaborative of more than 30 healthcare organizations set up by the Center for Health Design has done several multi-year clinical and safety evaluations of specific design interventions and new buildings. Much credible evidence now shows that good design of a hospital’s physical environment promotes better clinical outcomes, increases safety, and reduces stress for both patients and staff” (Ulrich, 2006).

Dr. Roger Ulrich is a professor at Texas A&M University where he is a Fellow in the Center for Health Systems & Design.

Designers have used research from medicine, nursing, management, industrial design, engineering, and technology. Relevant sources also include the literature of psychology, sociology, anthropology, and economics. The journals of science may be a useful source, along with the popular press, newspapers and magazines, and documentary films and television programs. Industry data guides, guidelines from speciality boards, quality review data, infection control data, manufacturers’ testing information, association reports, and the documents of accreditation agencies and code authorities provide helpful information. Practitioners can gather new information from conference presentations, workshops, continuing education programs, and benchmarking tours of exemplary facilities. The Internet has also become a rich source of information for designers. The possible sources of relevant findings are limited only by the issues being addressed.

1.3 Therapeutic environments

While there are healing environments that have nothing to do with evidence-based design, many healing environments are the result of an evidence-based design that has demonstrated measurable improvements in the physical and/or psychological states of patients and/or staff, physicians, and visitors. If it meets these standards, a healing environment is therefore a complementary treatment modality that makes a therapeutic contribution to the course of care (van den Berg, 2005). The role played by the environment is certainly not as therapeutically effective as the role of surgery, pharmacology, medical interventions, or perhaps even the caring touch of an empathetic nurse. The therapeutic role of the physical environment is, however, absolutely real and must therefore be considered as contributing to the course of care and the patient outcome.

If the physical environment can contribute to improved clinical outcomes, then surely there is a moral obligation to provide critical care environments that are supportive of the teams of health-care professionals who work with patients and their families. Designers have a responsibility to provide environments conducive to the safety, health, therapeutic interventions, and recovery of critical care patients. Above all, the environment, like every other aspect of healthcare, should “do no harm.”

Design really matters

Maurene A. Harvey, RN, MPH, FCCM

In the first half of my 43 years in critical care nursing, I became increasingly incensed at how poorly intensive care units were designed. Having been in over 100 U.S. units and dozens in other countries, I was frequently dismayed by how poorly they met the needs of patients, families and/or caregivers, and how frequently the same general design templates were repeated even though they were inefficient, ineffective or starkly non-healing.

Many design teams tried to be more creative and open-minded, but it is difficult to see new possibilities when each team member’s experience was often limited to a few units. Hampered by each individual’s narrow perspective, teams lacked imagination and ability to develop unique or creative design solutions. They were often focused on solving problems in the existing unit using old engrained frameworks. New ground-breaking ideas that would allow the best possible patient and family care, as well as attract and retain expert staff, ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• About the authors
• Introduction
• Part One: Better Design for Better Outcomes
• 2 Facility design for critical care
• Part Two: The Physical Setting
• Part Three: Research on Persons and Environment
• Part Four: Path to a Bright Future
• Conclusion
• Appendix
• References
• Index