Gina Adams noticed that her daughter's color had paled slightly as she slept in her intensive care bed surrounded by all sorts of medical devices. She glanced towards the door of the private room and could see the face of her ICU nurse peering over the PC at the charting station just outside the room. Gina's worried glance signaled concern and the nurse quickly came from her station into the room.


Photos by Richard Mandelkorn/Mandelkorn Photography

Effective communication is a critical component in today's acute care environment, networking staff, patients, and families into an efficient caregiving team. Communication at many levels can reduce patient and family anxiety, improve staff effectiveness and retention and, ultimately, accelerate healing and decrease lengths of stay. Careful architectural planning and purposeful interior design are the base elements of good communication, establishing the right physical relationships, sightlines, and visual clues to enhance interactive dynamics. Each level of patient acuity requires a delicate balance of communication and privacy—open enough for visual communication, while maintaining the appropriate patient privacy rightly desired by families and required by current HIPAA standards.

At Children's Hospital Boston, the clinical core of its 97-year-old campus has been substantially modernized, adding the 240,000-square-foot South Building and renovating the Main Building (figure 1). These two structures provide the bulk of tertiary care at Children's Boston, one of the world's leading pediatric hospitals. The central concept of the new South Building is based on communication; a lateral expansion of the Main Building creates a seamless structure of new and existing buildings, integrating functions in both buildings for improved efficiency and patient care.

The new South Building is a tight fit on Children's dense urban campus, integrating closely with the existing Main Building to form the new clinical core of this tertiary care facility. The corner stair tower becomes a beacon of light at night, communicating the hospital's around-the-clock care to the city around it

Some of the vital design concepts for enhancing communications are visibility, decentralization of staff and supplies, visual clues and wayfinding, adopting family as care partners, and adaptability. From the perspectives of patients, caregivers, and family members, these concepts enhance communications on a variety of levels.

Patients

In a truly acute care environment such as Children's Boston, the sickest patients rarely leave their beds or rooms. Communication for conscious patients is often about what they can see, hear, and feel from the limited confines of their beds. With charting stations peering through windows into each room, there is a simple visual link between patient and nurse that is not reliant on technology (figure 2). This virtual presence of staff in the room at all times gives patients comfort and security, reducing anxiety and stress. For those patients without visiting family, the constant companionship of nurses can temper feelings of loneliness and depression. Supplies and medications are decentralized from the typical central core to each of the rooms, giving staff further time at bedside in direct contact with patients.

The intensive care charting stations are decentralized, bringing staff closer visual communication with patients. Internal window blinds offer patients privacy when needed

The presence of family members at bedside adds another presence, so that patients are rarely left alone without observation or communication. The communicative presence of a parent in the room lends familiarity and comfort to what would otherwise be a completely foreign environment. The arrangement of bathrooms on the outside wall rather than on the corridor side increases the visibility of patients to and from the corridor, maximizing the potential for communication and interaction (figure 3). With a 16-foot-wide room and floor-to-ceiling translucent glass in the bathrooms, warming natural light filters into the room and the corridor beyond.

This private ICU room situates the bathroom and family space on the outside window wall, freeing the corridor wall to provide visibility through sliding and pivoting glass doors

In the ICUs, ceiling-mounted booms bring power and gasses to medical equipment which often surrounds the patient. The boom allows patients to be oriented in a variety of ways: facing the charting station by the door, facing the foot wall with a view either out the window or back to the door, or facing the outside window and parents' space, offering more direct visual communication with a parent.

Large windows in the exterior wall in the bedroom and in the bathroom bring natural light and views into the room, communicating the time of day, the weather, and the dynamics of the real world, beckoning patients to heal and experience the outside world again.

Indirect lighting coves, protected with acrylic covers for easy cleaning, surround the room, providing a gentle, calming ambient light. These lights can be adjusted to multiple levels to replicate the diurnal cycle that has been proven essential to healing. Nightlights are also located in the cove to allow staff to safely navigate the room at night without waking the patient or parent by turning on all the lights.

Caregivers

Doctors, nurses, and staff are the critical communicators in an acute care environment, particularly in the ICU where patients are faced with multiple complications and a team of specialists must collaborate on the care. The care team's communications with each other and with patients and family are critical to patients' survival and health. An intensivist once described to me his model ICU, where he could stand in one place in the middle of the unit and see every patient without moving. Naturally, with issues of privacy, infection control, and family involvement, this model is no longer valid, but the concepts of visibility and accessibility remain vital to communicating what is going on throughout the unit.

At Children's Boston, the building core of support space is rotated slightly from the patient rooms along the perimeter (figure 4). This shift in geometry opens up significant views from the nurses' stations located at each corner of the unit to each of the bedrooms along the perimeter. Our intensivist can effectively see each of his patient rooms, identifying levels of activity and possible trouble spots around the unit. Glazed sliding doors at the front of each room allow visibility to each patient without compromising noise control, an important element in maintaining quiet and privacy for patients, families, and caregivers. Alternating communicating doors and windows between adjacent rooms allow staff to spot emergencies and quickly respond to them.

The core of the ICU is rotated from the room grid to open up views from the nurses' station to the entries of all the rooms. Sliding and pivoting glass doors enhance views into each room with communicating windows and doors between alternating rooms for further visibility

Decentralized charting stations at each room place staff with their patients, not down the corridor. This face-to-face communication with the patient is ideal for the continuous monitoring of intensive care patients in private rooms. Integral blinds in the charting station windows allow for privacy when needed. These charting alcoves feature dropped soffits and special lighting to signal their location along the corridor. The alcoves offer semiprivate locations for communication between caregivers and, pooled with wider corridors in several key locations, offer interactive educational spaces for medical students and attending physicians during grand rounds.

As noted earlier, supplies and medications are decentralized in each patient room, keeping nursing staff close to patients rather than in the halls. Each ICU boom contains a card-activated medication drawer for specific patient meds, ensuring that each patient will get his or her medications and not someone else's, as can happen when communication is less direct.

Each of the intensive care floors is controlled by a single entrance through which all family and visitors must pass. These brightly colored, lighted portals welcome families while providing control to staff for access to the floor. Staffed by “greeters,” these locations assure staff that only authorized people can enter the ICU, communicating an air of safety and security to the unit.

Along the west side of the South Building is a staff corridor, highlighted by colorful wall panels along the outer wall (figure 5). This support area is for staff only, and facilitates further private communication between caregivers beyond the ears of family and visitors. The differentiated color palette and lighting clearly denotes this staff zone from the patient spaces, clarifying wayfinding for staff and for family members who have lost their way.

Staff circulation on each patient floor is highlighted by angled, colored walls, differentiating it clearly from patient corridors. Staff frequently confers in this private, transitional space beyond the ears of patients and family

One of the simplest communicating devices is in one of the most technological spaces in the hospital, the cardiac catheterization suite. The suite is loaded with high-tech imaging equipment, monitors, surgical booms, and anesthesia equipment, but communication between cardiac surgeons and technicians in the adjacent control room is provided through simple slots in the wall above the windows between the rooms. During a cardiac case, the subtle intonation of the surgeon's voice is critical to the success of the case. Only through the direct path of sound, undistorted by electronics, could ideal communication be achieved. Simplicity is often the best solution—and here the most cost-effective, as well.

Family

“Some of my patients in intensive care have their chest cavities open; you can see their little hearts beating… this is no place for parents.”

Cardiac surgeon, 2002

Fifty years ago a parent would bring a child to the hospital and hand their loved one over to a caregiver at the doorstep. “We'll let you know when your child gets better,” would be the typical comment. Over the years, however, we have learned the powerful value of families in the healing process, with their presence contributing significantly to the child's comfort and ultimate health. Only recently have family members been invited to live in with patients in intensive care units; some felt that only doctors, not parents, cure sick children, and therefore families did not belong in the ICU.

At Children's Boston, parents are welcomed and embraced in the intensive care suite, lured with places to sleep, eat, work, and assist in the care of their children. With 48 ICU beds in single rooms, parents are offered an intimate, private environment with their child, bringing some of the comforts of home to the hospital. Parents are given dedicated space in each patient room with a full bed, lockable storage for personal belongings, a data hookup for Internet access, and spectacular views of Boston from their window-side bed. Parents can pull a curtain for privacy and individually control their lighting should they want to stay up late without disrupting their child.

Usually a parent is more effective at communicating with a child than a caregiver, so their presence at the bedside is useful. The presence of family at the bedside also gives the nursing staff an extra set of eyes and ears in observing and communicating changes in the patient.

Families are given clear wayfinding clues throughout the unit to prevent them from getting lost and anxious. The two primary nursing stations are clearly located with colorful geometric forms, dropped soffits, and special lighting (figure 6). Patient and staff areas are clearly “labeled” with color and lighting to avoid confusion.

The ICU nurses' station is a memorable landmark for family with geometric casework forms, floor patterns, and a colored ceiling soffit

Life in an ICU can still be quite stressful for parents, with their child's life often on the edge. Communicating with other parents in similar situations is often the best therapy for stress and anxiety. Family lounges are located on each unit to offer parents opportunities to interact and share experiences. The living room atmosphere of these spaces is conducive to relaxation and interaction, and provides a needed escape for stressed parents. In the hematology/oncology unit at Children's Boston, “frequent-flyer” parents, independent of staff, have organized meetings in the unit lounge to discuss common challenges and issues.

Summary

Communication is a powerful healing tool in healthcare. Proper architectural planning and interior design can significantly enhance communication between patients, caregivers, and family in acute care environments. This recent example at Children's Hospital Boston has improved the healing experience for all parties involved. Shepley Bulfinch has also implemented many of these design concepts in equivalent adult healthcare facilities, where the same principles are valid. Good communication starts with good design, and ends with healthy and happy patients. HD

William Mead, AIA, ACHA, is a Principal at Shepley Bulfinch Architects in Boston. Bill is an advocate of healthcare architecture that inspires imagination, emotion, and learning.

Sidebar

Communications in the MR/OR

Good design fosters communication throughout a pediatric hospital, including the surgical suite. Children's Hospital Boston's incorporation of high-quality magnetic resonance (MR) imaging in the operating room was driven by the hospital's commitment to provide the most advanced pediatric healthcare.

The innovative design has integrated far more than technology—it has transformed the surgical suite into an environment where radiologist and surgeon work collaboratively as partners in one theatre, blurring the lines between their disciplines. Providing access to multiple high-quality MR images in the course of surgery allows the two medical teams to readily assess whether the surgery's stated objectives have been met. This not only improves patient outcomes, dramatically reducing the demand for subsequent or unnecessarily extended surgery, but also makes more efficient use of both teams' time.

Demand for the use of the MR/OR has far exceeded even the most optimistic projections. Its design has become a model now being replicated elsewhere. As more advanced technology becomes available, healthcare and design teams can continue to build on this innovative model.

—William Mead, AIA, ACHA