Pre-Op, PACU, and Stage 2 Recovery
There have been two major changes that affected the design of Pre-Op and Stage 2 Recovery areas. The first was the merging of these two functions into one shared suite that allows for shared staffing and a more efficient use of the space. The efficiency is largely based on the more balanced utilization of all of the bed positions. The Pre-Op area is most heavily used during the early part of the day and is relatively quiet in the afternoon, while the Stage 2 recovery area is the opposite. In order to address concerns about privacy for the patients who might be in adjoining positions, the Pre-Op and Stage 2 recovery spaces went through the other major change: they became either semiprivate, typically three-sided rooms (figure 1), or fully private, typically with ICU-type breakaway doors (figure 2). These changes started more than a decade ago and have now become standard practice. The PACU has usually remained independent of the merged Pre-Op/Level 2 Recovery suite, because of the criticality of the patients in the PACU. The PACU is often designed to be side-by-side or very close to allow for an easy movement of patients and for easy staff support.
A semiprivate, three-sided room at John Muir Medical Center, Concord Campus, in Concord, California. Courtesy of KMD Architects.
A rendering of a fully private room with ICU-type breakaway doors at Hoag Memorial Hospital Presbyterian in Newport Beach, California. Courtesy of KMD Architects.
In many open room PACUs, the central nurses' station is to one side or centrally located, and subnurse charting facilities are often located bedside, as shown in this plan from Hoag Memorial Hospital Presbyterian. Courtesy of KMD Architects.
While the organization of these areas has changed to create a more unified suite, not a lot has changed in the design of the nursing areas and the patient positions. In the PACU especially, nursing staffs still ask for an open suite, where they can see from one bed to the next throughout the unit, even when there are 20 to 30 patient positions.
Various solutions have been developed to allow this visibility to occur. Some have used columns or booms to deliver medical gases and other utilities to the patient in the open room. Other designs have used low units to house the utilities and support for the bed. In many of these open room PACUs, the central nurses' station is to one side or centrally located, and subnurse charting facilities are often located at bedside (figure 3). The trend had been to design larger bed positions, approaching the size for an ICU bed with a headwall of 11 to 12 feet despite the lack of change in the codes and guidelines. Codes have continued to refer to the minimum area for each bed being only 80 square feet. The last two updates of the AIA Guidelines for the Design and Construction of Health Care Facilities added clearances around each bed that result in an average bed position of at least 120 square feet (figure 4).
The last two updates of the AIA Guidelines for the Design and Construction of Health Care Facilities added clearances around each bed that result in an average bed position of at least 120 square feet, as shown in these renderings (A,B) from Hoag Memorial Hospital Presbyterian. Courtesy of KMD Architects.
Is the open room PACU the best environment for the recovery of the patient? If families are present in the PACU, a situation which varies among hospitals depending on policy but is increasingly common, is an environment that provides greater privacy more desirable for providing quality patient care? In addition to the concerns for the privacy of the patient and family, is nursing care best in a large open ward?
At Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, the PACU and the adjoining Pre-Op and Swing areas (areas that can be alternately used for either activity) were designed with clusters of three to four beds (figure 5). The result is a very quiet and comfortable environment when compared to many PACUs that are often busy and noisy with activity. Not only has there been positive feedback from the patients and their families, the staff has reported that they can focus more on their patients because they are not distracted by all the other activities.
Floor plan (A) and close-up (B) of the PACU cluster at Memorial Sloan-Kettering Cancer Center in New York City. Courtesy of KMD Architects
From a nurse's perspective, the request for the open PACU is often driven by the desire to be able to see every patient. From a supervisor's perspective there is a desire to see when developments are occurring anywhere in the unit. At MSKCC, however, the staff is connected via wireless communications systems that appear to have eliminated or greatly reduced the need for line of sight. The MSKCC staff state that they can easily communicate with each other on an as-needed basis.
After six months of operation, the nurses reported that patient outcomes appear to be better and staff satisfaction is up. The benefit of daylighting cannot be overlooked in the new suite as the former facility—as is the case with many PACUs—was buried inside the building with no windows, while the new suite has an abundance of natural light.