It's an exciting time for the Pebble Project's partner provider in the United Kingdom. Based in Kent, England, Maidstone and Tunbridge Wells National Health Service Trust is a large acute hospital trust that provides services on behalf of the National Health Service (NHS) in England. The Trust currently has three main hospital sites, two of which will close next year following the January 2011 opening of its new 512-bed district general hospital development at Pembury, a village in Kent, England. The contractor, Laing O'Rourke, is on schedule to hand over the hospital by December, and the Trust is planning for the transition of services in two phases in January 2011 and July 2011. The new hospital replaces existing facilities at Pembury and Tunbridge Wells (Kent & Sussex Hospital) and will become the main center for trauma and women and children's services, while Maidstone Hospital will provide elective inpatient surgery.

The new, $340-million private finance initiative hospital at Pembury was designed by Anshen + Allen to enhance patient privacy, dignity, recovery, and safety. Current guidance from the U.K. Department of Health states that the proportion of single rooms in new hospital developments should aim to be 50% and must be higher than the facilities they are replacing. The new Pembury hospital build will be the first district general hospital in England with single inpatient rooms throughout. The U.K. National Patient Safety Agency assisted the Trust with the design specification for the new hospital, which was to provide all inpatients with single rooms, each with its own clinical hand-wash basin, en suite shower, and toilet located on the bed headwall, and external windows allowing patients to benefit from natural light and views of nature. The development site overlooks a Site of Special Scientific Interest (SSSI), one of more than 4,000 SSSI in England considered important for their wildlife and geology. The innovative design of the hospital also ensures that a majority of patient rooms have views across surrounding woodland.

The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at

In contrast to the new hospital, the old facilities comprise a range of accommodation, including old Victorian and single-story buildings. Inpatient beds are currently housed mainly in large bays and Nightingale wards. A key change for the nursing workforce will be the move to single-room wards with distributed nurses' stations. The design of the new inpatient wards was conceived to ensure nurses remain in proximity to a cluster of patient rooms, thereby maximizing their availability to patients and increasing the proportion of time spent on direct patient care. For nurses moving to the new hospital, a key question is how they will communicate with each other and with patients in the single-room ward environment.

When patients push their call light or bell, it goes directly to the wireless device of their primary caregiver.

A challenge for the Trust has been the groundbreaking nature of the new hospital development and the lack of similar facilities in the United Kingdom to learn from, especially in relation to the use of mobile communications technology. Therefore, Maidstone and Tunbridge Wells NHS Trust has turned to Pebble Partner providers in the United States and Canada to find out how they have used information and communication technologies (ICT) to support communication and assure patient safety in the single-room inpatient unit environment. The Center for Health Design facilitated a series of three conference calls during which Dublin Methodist Hospital of Dublin, Ohio; Banner Estrella Medical Center of Phoenix; and Trillium Health Centre of Ontario, Canada, each shared their experiences, including issues encountered and how they were overcome.

Wireless phones with integrated nurse call systems “critical”

Dublin Methodist, Banner Estrella, and Trillium all described their wireless phones with integrated nurse call systems as an absolute requirement for all single-room units, allowing nurses to remain close to their assigned patient rooms and move between them as needed. The wireless communication devices are used for almost all internal communication, for example, locating staff, calling staff, recording messages, making group announcements, and paging.

The integration of the nurse call system was considered critical for patient safety. When patients push their call light or bell, it goes directly to the wireless device of their primary caregiver. Additional alerts from cardiac monitors or call-monitoring technology were also programmed to go through to the wireless devices. Alarm and call management software is used to roll on or escalate unanswered calls or alerts (for example, when staff are on a break or have put devices in silent or “do not disturb” mode). This programming allows caregivers to focus on their current tasks and minimizes unnecessary interruptions when working in patient rooms.

Trade-offs between different devices

There were trade-offs with each wireless phone device. Vocera badges, used at Dublin Methodist and Banner Estrella, were considered less bulky and could be worn around the neck, with voice activation facilitating completely hands-free use. The badges were said to be more difficult to lose or break in comparison with wireless phones. Initial frustrations with Vocera included poor voice recognition. However, this improved over time as staff learned Vocera's limited lexicon and became better at giving directions that Vocera would understand. Another issue was patient confidentiality, however many clinical staffs wear headsets so calls are not on speakerphone.

Trillium originally opted to use Cisco IP phones, viewing them as advantageous in terms of providing confidentiality and delivering smartphone technology, with the ability to support text-based communication. However, the small screen and numeric keypad were a limitation. Now using the Connexall integration system, Trillium is able to incorporate multiple technologies as they emerge. With the Wi-Fi-enabled BlackBerry now available and dropping in cost, a combination of BlackBerry devices and Cisco IP phones was considered to be an optimum solution.

Staff training vital

Staff members are assigned their own devices or self-allocate from a pool at the beginning of a shift, and log in to a computer to tell the system which device they have and see which rooms they are covering. Staff training is vital to ensure that everyone is able to manipulate the software and change their assignment during the course of a shift, depending on the needs of the unit. Representatives from the three U.S. Pebble facilities agreed that training incorporating different scenarios and run-throughs over a three-to-four-week period prior to opening is invaluable to helping staff become comfortable with using the devices.

Proceed with caution

All facilities advised that programming call diversions and escalations should be worked out early on to avoid later headaches, and a strong word of caution was made to resist the temptation to use the wireless phone system for more than one or two main functions, as nurses could soon become overwhelmed when working in a new environment. For example, while it is possible to integrate multiple medical device alerts, it is important to avoid alert overload for nursing staff by prioritizing the most important alerts (for example, particular types of cardiac a
lert) that will go through to nurses' badges or phones.

Finally, a thorough and systematic test of the wireless communication system was recommended, including a full site survey and room-by-room test of all devices to identify faulty units and any “dead spots” (for example, calls dropping between doorways). All facilities reported needing to install additional antennae to ensure seamless network coverage.

With new technology becoming more readily available and affordable, and with staff increasingly becoming comfortable learning and using new types of technology, these organizations are looking to implement further integrations… to further support the delivery of care.

What next?

The Trust project in Pembury, England, will include an ICT infrastructure that enables service redesign and innovation in the future, while at the same time acknowledging the need to minimize the amount of change that new technology introduces for staff during the transition phase. To support single-room working from day one, Pembury will implement the Cisco IP phone system, integrating the nurse call system. However, at Dublin Methodist, Banner Estrella, and Trillium, a wireless phone with an integrated nurse call system is viewed as just the beginning of the journey in terms of the integration of information and communication technologies. Each facility is tweaking, optimizing, and adding technology over time following the opening of their facilities, viewing the process as one of continuous evolution. With new technology becoming more readily available and affordable, and with staff increasingly becoming comfortable learning and using new types of technology, these organizations are looking to implement further integrations, such as nurses' dashboard systems, which allow staff to view patient status at a glance, to further support the delivery of care.


With thanks to: Cheryl Herbert, president, Dublin Methodist Hospital; Susie Faz-McCann, clinical director, Banner Health - Design & Construction; Susan Bisaillon, executive director of clinical operations, and Anu Tuli, director, eHealth and clinical informatics, Trillium Health Centre; Keith Swaden, ICT programme manager, new hospital development team, Maidstone and Tunbridge Wells NHS Trust; Anjali Joseph, director of research, and Ellen Taylor, research associate, The Center for Health Design.

Clarissa Penfold is a research associate at the National Nursing Research Unit, King's College London, and a member of a research team led by Jill Maben, PhD, conducting a “before-and-after” study of the impact of the move to all-single-room hospital accommodation at Pembury. The research is funded by the Health and Care Infrastructure Research and Innovation Centre, a collaborative research centre funded by the Engineering and Physical Sciences Research Council. Healthcare Design 2010 October;10(10):16-23