Articles and Publications

Design and Role of the Intensive Care Unit

July 28, 2016 / Dochitect / Design for Critical Care

Book Chapter

Book Title: Handbook of Intensive Care Organization and Management
Book Editor: Andrew Webb
Publisher: Imperial College Press
Publication Date: July 28, 2016
Chapter Title: Design and Role of the Intensive Care Unit
Chapter Authors: Neil A. Halpern and Diana C. Anderson

Key Points

ICU-specific design is a complex process and requires a multidisciplinary team which includes both clinical and expert design-based professionals.
The layout of an ICU is arguably the most important design feature affecting all aspects of critical care services.
The core of the ICU experience is the patient room, conceptually subdivided into patient, caregiver and family/visitor zones.
Central clinical support zones within the ICU act to bind the patient rooms and other supportive areas together, with the overall goal of supporting bedside care.
Deploying advanced informatics into the modern ICU electronically integrates the patient with all aspects of care.

Link to Purchase Book:

Handbook of Intensive Care Organization and Management Book Chapter

Hearing hoofbeats: time to think zebras?

April 13, 2016 / Dochitect / Evidence-Based Design

Commentaries

Website: The SALUS Global Knowledge Exchange
Date: Published online April 13, 2016
Author: Diana Anderson, MD
View article

In medicine, the old adage goes: “when you hear hoofbeats, think of horses not zebras”.

This nugget of wisdom is attributed to Dr Theodore Woodward, professor at the University of Maryland’s School of Medicine, as he instructed his medical interns during the late 1940s on diagnosing an illness based on the presenting of symptoms.

The logic of Dr Woodward’s advice follows that since horses are common in Maryland while zebras are relatively rare, one could reason confidently that the sound of hoofbeats is more likely to derive form a horse than a zebra. Medically, this translates as doctors analysing symptoms and checking initially for common ailments, not rare conditions. By 1960, the aphorism was widely known in medical circles. Diagnosticians have noted that “zebra-type” diagnoses must nonetheless be held in mind until evidence conclusively rules them out.

But applying this adage to architecture reveals a key question: are we too often considering “horses” for our hospital designs? Can we push the boundaries of design and convert healthcare design from a reactive process to one that is proactive, planning for what is to come? I propose three disruptive design ideas in order to challenge a relatively unchanged healthcare model.

Should the patient bed be the focal point of the room design?
Can corridors become more than an eight-foot wide wayfinding path?
On-stage/off-stage – is separation of flows the answer?

Commentaries

Epidemiology of Hospital System Patient Falls: A Retrospective Analysis

April 8, 2015 / Dochitect / Evidence-Based Design

Peer-Reviewed Publication

Publication: American Journal of Medical Quality
Publication Date: Am J Med Qual. 2015 Apr 8. pii: 1062860615581199.
Authors: Diana C. Anderson, MD, MArch, Thomas S. Postler, PHD, Thuy-Tien Dam, MD

Abstract

Patient falls are the most common type of in-hospital accidents. The objective of this retrospective descriptive study was to describe the locations and characteristics of hospital-related falls. Data on patient characteristics, including locations and fall circumstances, were collected through incident reports and medical records. A total of 1822 falls were documented at a 921-bed, urban academic hospital center over a one-year period; 1767 (97.0%) of the falls occurred in the hospital setting, 55 (3.0%) in ambulatory care. The majority of falls (80.8%) occurred within inpatient units; the remainder within the greater hospital campus. In all, 73.4% of fallers had fall prevention protocols implemented prior to the fall. The youngest age group (≤49 years) had the highest percentage of fallers. This study provides novel insights into variables found to be associated with falling, including location of falls within the hospital campus, efficacy of fall prevention protocols, and age groups.

Additional Press:

Note This research was presented at Medicine Grand Rounds, Department of Internal Medicine Resident Research Day, Columbia University Medical Center, March 26, 2014:

2014 Resident Research Poster_compressed copy

Lectures, Peer-Reviewed Publications

What Will the ICU of the Future Look Like

December 11, 2014 / Dochitect / Design for Critical Care

Popular Press

Publication: Society of Critical Care Medicine, Critical Connections Newsletter
Date: December/January 2014, Volume 12, Number 6
Authors: Sandy Swoboda, RN, MS, FCCM; Diana C. Anderson, MD, March; D. Kirk Hamilton, FAIA, FACHA, EDAC; Charles D. Cadenhead, FAIA, FACHA, FCCM; Neil A. Halpern, MD, FCCM; Dan R. Thompson, MD, MA, FCCM
View Article

Demand for intensive care unit (ICU) beds is increasing as the nature of medical practice shifts to become more multi-professional and multidisciplinary. These trends likely will be reflected in both our critical care space design and working practices. Clinicians are spending more time at computers to complete documentation and more time discussing cases with the multi-professional team. Parallel to this shift toward healthcare provider teams is a growing awareness about the impact of evidence-based design principles on patient care and staff efficiency. The environment’s impact on the healing process, infection control practices and safety increasingly are studied in the context of a unit’s design and architectural layout. Hybrid professionals and interdisciplinary groups provide integrated solutions that cross disciplines in new ways.

In addition to assembling a task force to update the Guidelines for Critical Care Unit Design, members of the Society of Critical Care Medicine’s (SCCM) ICU Design Committee are champions for change and healthcare improvement. In this article, this diverse group shares their thoughts on the ICU of the future.

Click here to read more from the SCCM ICU Design Committee members about what the ICU of the future will look like.

Additional Press:

Note Dr. Anderson’s viewpoints on this topic, entitled “View from the Dochitect: Reflections of a Physician-Architect on ICU Design,” are presented as part of a panel discussion on the future of ICU design at the Society of Critical Care Medicine’s 43rd Annual Congress in San Francisco, CA; January 13, 2014.

Commentaries, Panel Discussions

Drafting Meets Doctoring: An Architect’s View of Health Design as Resident Physician

September 24, 2014 / Dochitect / The Physician-Architect Model

Book Chapter

Book Title: get better! the pursuit of better health and better healthcare design at lower costs per capita. Proceedings of the 33rd UIA/PHG International Seminar. Toronto, Canada. September 24-28, 2013
Publisher: University of Florence: TESIS Inter-University Research Center, 2014
Editor: Romano Del Nord

Chapter Title: Drafting Meets Doctoring, An Architect’s View of Health Design as Resident Physician
Chapter Author: Diana C. Anderson, MD, M.Arch.
View chapter

The architect Louis Kahn said that “once challenged, the architect will find completely new shapes and means to produce the hospital, but he cannot know what the doctor knows.” Imagine the lessons learned if the architect could know what the doctor knows. Take an inside look at the hospital environment through the eyes of a dochitect, a hybrid professional in medicine and architecture.

See health design from the perspective of an architect pursuing internal medicine residency training at a large New York City teaching hospital. A design journal was kept throughout the dochitect’s medical internship to record functional annotations for each subspecialty space and their relation to form the urban hospital. Join the dochitect through core rotations including the medical intensive care unit, emergency department, cardiac care unit, outpatient clinics, infectious diseases, general medicine, and geriatrics. Case studies highlighting the importance of space design are presented. Design anecdotes and functional analysis of hospital departments emphasize the practical importance of design qualities that impact the work environment for staff and the healing environment for patients and families.

The dochitect’s practical knowledge of environmental design qualities promotes health and well-being within the hospital environment. The clinicians will find the design perspectives useful in providing insight into their daily workspace, empowering them to return to their facilities and promote changes or become involved in renovation or new construction projects; the designers will benefit from the medical perspective and the lessons learned from an architect working within various clinical environments.

Personal anecdotes from patient case studies allow for a behind-the-scenes look and a practical understanding of the use of hospital space. The architect can know what the doctor knows.

Click here to read more dochitect diary entries detailing the design lessons learned as a medical practitioner.

Links to Purchase Book:

Standard Edition Premium Edition

Additional Press:

Note This topic, “An Architect’s View of Health Design as Resident Physician,” was presented at the International Union of Architects Public Health Group (UIA/PHG) Annual Healthcare Forum in Toronto, Canada; September 26, 2013.

Book Chapter, Conference Presentations

A View From and On the Window

July 1, 2014 / Dochitect / Design for Geriatrics

Letter to the Editors

Publication: Health Environments Research & Design Journal, Letter to the Editors
Publication Reference: 2014 Summer;7(4):135-9.
Authors: Penelope Ann Shaw, PhD, & Diana C. Anderson, MD, MRAIC, LEED AP

View article

Excerpt: One of us, Diana Anderson, is a physician and an architect whose career is aimed at bridging the gap that exists between medicine, research, and architecture in order to improve design and operational efficiency of the clinical environment. She has worked in many hospitals and healthcare environments that are not supportive of staff well-being nor sometimes even patient healing. Dr. Anderson often uses clinical anecdotes in her writing, linking them back to design in order to increase awareness of design’s impact among her clinical colleagues. A recently published piece in the Journal of the American Geriatrics Society entitled Rx: Window Bed recounted her experience with critical care unit delirium and the potential impact of windows on a patient’s physiologic response; a synopsis of this encounter is detailed below.

The other author, Penelope Ann Shaw (Penny), is a nursing home resident who has been living in a facility in a bed by a window for 11 years. She is a survivor of critical care (having spent 4 months in an ICU on life support) from an acute phase of Guillain-Barre syndrome, a rare neuromuscular disorder in which a person’s immune system damages the nerve cells, in her case causing almost total paralysis. That was followed by a year in a respiratory rehabilitation hospital. Of the 11 years in her current facility, she was mostly in bed for 3½ years with a tracheostomy and a feeding tube.

Penny reached out to Diana after reading that piece in the Journal of the American Geriatrics Society in order to relate her story of how a window changed her experience dramatically while in long-term care. They teamed up to write a piece that builds on the topic of windows and exterior views. In the following sections, they provide insight into how these architectural elements can be life changing for patients and of vital importance for staff.

Read the complete letter to the editors including Penny’s patient perspective and Diana’s physician-architect perspective.

Letters to the Editor

Rx: Window Bed

February 1, 2014 / Dochitect / Design for Geriatrics

Peer-Reviewed Publications

Publication: Journal of the American Geriatrics Society, Old Lives Tales
Publication Reference: 2014 Feb;62(2):378-9.
Authors: D. Kirk Hamilton, BArch, MSOD; Diana C. Anderson, MD, MArch

“Interns, any other ideas?” my attending asked the team as we made our daily rounds to the bedside of Ms. T, an octogenarian who had been in our ICU for just over a week. She suffered from dementia and had undergone a tracheotomy, thus limiting her ability to communicate with us. The concern of my attending that morning was due to her sustained tachycardia, the etiology of which we could not explain; she had not responded to our medical interventions.

I was only days into my internship; how could I have any medical suggestions to address this patient’s heart rate? “We could move her to another room with a window,” I said to the group instead, yielding several questionable looks. “There is evidence,” I added, as I knew physicians would consider an intervention seriously if it had been documented in prior studies.

Read the complete story of one patient’s physiologic response to an environmental intervention and the subsequent change in the clinical team’s approach to considering architectural design and the existing evidence (subscription required).

Peer-Reviewed Publications

New Medical Staffing Procedures Call For Design Solutions

October 11, 2013 / Dochitect / Design for Clinical Staff

Commentaries

Publication: Healthcare Design
Publication Date: October 11, 2013
View article

The hybrid medical professional—physician-writer, physician-researcher, physician-educator, and the physician-editor—is often mentioned in literature and popular press. As a self-labeled “dochitect,” I propose a new hybrid model, the physician-architect, with the intent of bridging the gap between architecture and medicine through the field of healthcare design.

An architect now working as a resident physician, I maintain two notebooks in my white coat pocket: one for medical facts, a common finding amongst trainees, and the other for design notes and sketches.

Click here to read about how the changing practices of medical training can impact staff space, and the subsequent needs for effective care delivery.

Commentaries

Using evidence based design to produce healthier hospital buildings

September 14, 2013 / Dochitect / Evidence-Based Design

Peer-Reviewed Publications

Publication: British Medical Journal (BMJ) Careers
Publication Date: September 14, 2013
Authors: D. Kirk Hamilton, BArch, MSOD; Diana C. Anderson, MD, MArch
View article

Excerpt: Evidence about how architecture affects staff and patients is increasingly influencing the hospital design. Diana Anderson, a qualified architect and hospital doctor and Kirk Hamilton, an architect now working in academia after 30 years of practice, provide an international perspective on the issues involved.

Diana Anderson describes the personal experiences of poor hospital design:

I am a resident physician, and a large part of my hesitation in pursuing advanced clinical training was because of what I considered an intolerable hospital setting. Staff facilities are frequently without windows or art, and I have found myself desperately anticipating the first ray of sunlight after a long shift. Working in environments with constant noise from ventilator and infusion alarms, floor polishers, telephones, pagers, and staff discussions creates an ongoing battle to work effectively, or to hold private, often life changing discussions with patients.

During my initial time working in hospitals I often wondered whether anyone asked the clinicians about their opinions on the design and function of their work environments, and whether it has been recognised that the characteristics of the physical environment can enhance or hinder productivity, and can reduce the stress associated with our work and the condition of our patients. On my obstetrics rotation as a medical student the call rooms were located several floors above the labour and delivery unit, meaning we often missed deliveries, and so we learnt not to use the suite, and we slept in chairs closer to our patients. On patient units that did not provide space for respite, I found myself retreating to the supply rooms to gain composure during overwhelming moments. As a physician, a licensed architect, and a patient, I believe that many planned spaces are ill suited to their actual use.

Click here to view the full article on evidence-based design and healthier hospital buildings.

Peer-Reviewed Publications

Guidelines for Intensive Care Unit Design

May 1, 2012 / Dochitect / Design for Critical Care

Peer-Reviewed Design Guidelines

Publication: Critical Care Medicine
Publication Reference: 2012 May;40(5):1586-600.
Authors: Dan R. Thompson, MD, MA, FACP, FCCM (Co-Chair); D. Kirk Hamilton, FAIA, FACHA (Co-Chair); Charles D. Cadenhead, FAIA, FACHA, FCCM; Sandra M. Swoboda, RN, MS, FCCM; Stephanie M. Schwindel, MArch, LEED; Diana C. Anderson, MD, MArch; et. al.
View article

Note This document was awarded the following: 2013 Society of Critical Care Medicine Section Award Winner for Published Guidelines.

Abstract

Objective: To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit.

Participants: A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal designof an intensive care unit.

Scope: The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment.

Data Sources and Synthesis: Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations.

Conclusions: Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace.

Key Words: architecture; construction; critical care medicine; design; environment; healing; intensive care unit

Click here to view the 2012 Guidelines for ICU Design.

Peer-Reviewed Design Guidelines

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