Building A Better Inpatient Unit
The search for the right inpatient unit design shouldn’t just take into account size, footprint, and type of care being provided—it’s also about looking at an organization’s philosophy on patient engagement, care delivery, and technology in order to plan and build the best environment.
“There’s no right or wrong way,” says Sheila Cahnman, president of JumpGarden Consulting LLC (Wilmette, Ill.). “Each facility has its own operational ideal.”
As those ideas evolve in response to changing care models, patient expectations, and the latest research, design teams must continue looking for new ideas to find that perfect fit.
In the past, inpatient units have adapted to the shift from paper-based charts to electronic medical records (EMRs), from semiprivate to private patient rooms, and from large waiting rooms to in-room family zones with overnight accommodations.
The evolution continues as hospitals now rethink the location and layout of staff workstations, accommodate the shift to multidisciplinary care, and plan for future technologies.
Finding a middle ground
Following the first electronic charting, there was a push in healthcare to move away from the large, centralized nurses’ station and “jump whole hog into a decentralized model,” Cahnman says. The thinking was that putting small workstations around the corridor in proximity to patient rooms would increase the amount of time staff spend with patients.
The reality was that while the set-up helped improved visibility of patients, it didn’t account for employees’ social needs and made them feel disconnected.
“They don’t just want to talk about what they did over the weekend; they talk about patients, get help from each other, and ask for advice,” says Alan Black, market sector leader and principal at FKP (Houston).
Medicine has also evolved to become more team-based, which is bringing more clinicians and staff members to the inpatient unit or bedside to deliver care, including pharmacists, social workers, lab techs, and nurse practitioners, driving the need for a higher volume and variety of staff spaces.
“They all need a place to work—maybe not all eight hours in a shift, but they need a place to sit down, do some work, and then move on and see the next patient,” Black says.
As a result, the pendulum is swinging back toward the middle, where new hybrid approaches are emerging that incorporate decentralized nurses’ stations, such as alcoves or perches, with one or more centralized command centers or collaboration stations.
The MetroHealth System in Cleveland took this approach when it built a two-story addition atop its critical care pavilion to replace its existing ICU units with 85 private patient rooms for intensive care and critical patients.
The new floors, which opened in July, house nurses’ alcoves between each pair of rooms along with a variety of collaborative spaces, including a central workstation, glass-walled workrooms, and dedicated offices for some staff members.
“It’s very different,” says Walter Jones, senior vice president of campus transformation at MetroHealth. “Most of the spaces are shared and distributed around the unit to allow for the caregivers to work wherever they need.”
Going a step further, architecture firm NBBJ looked outside the industry to corporate office design to reimage the inpatient floor and staff work set-up, creating an open core nursing unit. After successfully implementing the layout in 2012 with Miami Valley Hospital Heart and Orthopedic Center (Dayton, Ohio), the firm designs double-sided unit corridors with an 8-foot clear circulation corridor that runs parallel to an additional 8-foot wide space for distributed workstations and equipment enclosures.
The layout shortens the inpatient unit length since these spaces would otherwise be embedded within a run of rooms and eliminates the cross corridors necessary for a racetrack layout, says Tim Fishking, principal at NBBJ (Columbus).
“Each of these steps reduce the overall unit square footage, driving higher efficiency and keeping caregivers closer to patients with reduced travel distances,” he says.
As more facilities test these hybrid approaches, Charlie Jorgensen, senior design manager, and Sam Burnette, senior designer and principal, at ESa (Earl Swensson Associates; Nashville, Tenn.), say they’re seeing a shift toward smaller decentralized workstations with less casework and space for only one nurse.
“That corridor wall is so competitive for the hand-wash station and wider doors to the room that it’s a luxury to have a 5- or 6-foot-wide alcove,” Burnette says. “It seems to be moving closer to a 4-foot space where someone could pull up a second chair [to sit with a coworker], but for day-to-day it’s one nurse or clinician doing some charting between rounding.”
Looking to improve efficiencies
Just as there’s no one model for nurses’ stations, there’s also no one approach to materials distribution and storage on today’s inpatient units. Some facilities choose to distribute supplies throughout the unit to put them near caregivers, with large storage rooms used for bulkier equipment located in hubs where units intersect.
“This will often drive a just-in-time supply model, which reduces space on the unit and eliminates the need for excess storage,” says NBBJ’s Fishking.
Black is seeing more facilities implementing on-stage and off-stage layouts as part of an effort to improve the patient experience by reducing noise and clutter, moving such activities as waste management, supply restocking, and staff respite to a central off-stage area in the center of a racetrack layout.
“It screens all of that activity from the patients and families,” he says.
For example, the supply and equipment rooms at Cooper University Hospital’s Roberts Pavilion are tucked into the staff passageways that run perpendicular to the racetrack layout.
“You have to take your cart off the main corridor to unload it, so when you look up and down the patient corridor you don’t see a lot of carts and such that you might typically see in other units” says Mary Frazier, principal at EwingCole (New York), the architecture firm on the project.
Healthcare organizations are still figuring out technology’s impact on the inpatient unit. The mandate for EMRs means that “computers are everywhere now,” says FKP’s Black.
While there’s no consensus on how best to support them, with some facilities preferring wall-mounted workstations in the patient rooms and corridors while others are pushing workstations on wheels from room to room or experimenting with laptops, designers are wrestling with storage and charging solutions for this ever-changing mix.
“Until it truly becomes technology that doesn’t require space, we’re not reducing the size of the units,” says ESa’s Burnette. “In some cases it may be increasing the size of the units so that we have a space to sit down in an enclave or conference room that’s wired to have telemedicine consultations with physicians hundreds of miles away.”
Cahnman says that inpatient units need flexible designs that will account for these tech upgrades as well as changing philosophies on staffing and operational needs over time.
As designers approach new projects or renovate existing units, she suggests using flexible partitions that are easier to move and putting mechanical shafts and IT and electrical rooms in places where they’re not in the way when a facility wants to rethink a layout.
“As hospitals change their processes and technologies, it’s going to continue to evolve,” she says. “The goal is to build the most effective patient unit that’s also flexible.”
Anne DiNardo is senior editor of Healthcare Design. She can be reached at firstname.lastname@example.org.