Family involvement has become a major driver in improving the modern healthcare experience. Evidence-based design studies suggest that the human connection benefits the patient, the patient's loved ones, and the clinical caregiver. The healthcare industry has openly accepted the inclusion of laypersons in the healing process as a best practice. However, current Emergency Department (ED) and Intensive Care Unit (ICU) models have yet to fully achieve this human connection.

The evolution of family participation

The development of pediatric wards brought the family into the healthcare environment. Opportunities for parents to stay with their children and participate in their care improved recovery by removing the fear and anxiety that parent/child separation stirs.

The 80s brought the concept of “home” into the equation with a more comforting birthing environment. Involvement by family, and the father in particular, humanized this monumental, yet often traumatic event.

Most recently, patient rooms have undergone a redevelopment spurred on by safety (medical and physical), privacy, sustainability, and the growing shortage of traditional caregivers. Consequently, today's patient rooms are designed to encourage greater family participation.

The next phase

In the wake of extensive studies, both EDs and ICUs have adapted to the latest clinical technology and the need for future flexibility. They are safer, brighter, and roomier, and they provide a higher level of privacy. However, although they have made some strides toward family integration, the ED and ICU lag behind other areas of the hospital. An ironic truth, since the ED and the ICU share the title as the biggest generator of anxiety and emotional instability.

Shortcomings of the conventional ED and ICU model

The intensity of the ED and ICU experience pulls the patient's family and friends into the situation. Easily forgotten or overlooked are the needs of these supporters. Despite their different reactions to a healthcare circumstance, family caregivers do share two basic needs: to support the patient, and to be informed about clinical activities taking place (e.g., Who is doing what and why?, access to diagnostic information, What is coming next?). In the accepted planning model (figure 1), these two concerns often conflict with ideal unit operations, creating a thorny environment. The patient's supporters might distract the clinician in the patient zone or linger in the adjacent clinical zone as they search for information. Such interference impedes the clinician's ability to make critical decisions, which impedes clinical care. It can also aggravate neighboring patients or discount their needs for dignity and privacy.

Conventional ED/ICU conceptual diagram. Diagram courtesy of Legat Architects, Inc.

The solution to these shortcomings recognizes that not only the patient, but also the supporting family, must be at the center of all care. Recent developments in the ambulatory care environment accomplish this through separation with controlled integration. Those who plan EDs and ICUs can glean valuable insight from this model.

Rethinking the Emergency Department

The current ambulatory planning model denotes three distinct zones: the central zone (patient), and on opposite sides, the clinical staff zone and the family zone. Both clinical staff and family members have direct access to the patient, yet these caregiver entities do not disrupt each other. The model promotes privacy for all parties and controls the interface between clinical and family caregivers.

Because an ED is not a 24-hour stay, it can easily adopt the ambulatory model (figure 2). Indeed, ambulatory care facilities (e.g., urgent, immediate, or prompt care) function as a limited off-site ED.

Proposed ED conceptual diagram. Diagram courtesy of Legat Architects, Inc.

An intensive shift for the Intensive Care Unit

Although just as critical as the ED in many ways, the ICU model requires a more significant adjustment to attain a truly family-responsive environment. The inpatient room follows a completely different set of regulations. Due to the seriousness of the stay and the diversity of specialists involved, family members have a stronger need for information. Thus, family/clinical interferences are more likely to occur.

Recently, ICU's have responded to emotional support needs with family and children's areas, toilets and showers, and even sleep rooms for overnight stays. However, these spaces remain communal and disconnected from the patient room. When routed to large waiting areas, family members naturally “stake out” territories and “camp out” to meet the need for a family-based support group. Then, to access patient rooms, they have to move through highly sensitive clinical space including the nurse and physician areas.

The concept in figure 3 balances control and interface. It brings family caregivers a private, decentralized space better integrated with the patient unit. Much like the gathering room that lies just outside a bedroom, this family zone allows loved ones to be close to the patient. The clinical zone, still within the patient unit, gives clinical staff direct visual and physical access to the patient, while discouraging family members from entering the main clinical staff area. The family access corridor offers respite off the unit, connects with the rest of the hospital, and gives family caregivers 24/7 access to the patient without disrupting staff.

Proposed ICU conceptual diagram. Diagram courtesy of Legat Architects, Inc.

One challenge with this enhanced model is complying with the industry regulations for natural light in 24-hour stay arrangements. As shown in figure 3, a courtyard can bring views and natural light into both the patient unit and the clinical staff area. While a requirement for the patient, daylight also helps subdue the tension that is inherent in the staff's role as caregiver.

A win for all parties

The humanized ED/ICU environment has the ability to go beyond responding to the needs of the family caregiver. It may reduce the patient's stay through family participation. It may also provide a competitive edge in an industry with intense competition for high-quality staff. This translates to more patient and staff referrals. When all the factors mesh, the result is unanimous: a win for the patient, a win for family, a win for staff, and a win for the hospital.

Remember that the primary mission of healthcare is to provide meaningful care (both clinical and emotional) in the most effective environment with the best technological advancements. Quality of a patient's stay is paramount. After all, it is what we all want for our loved ones and for ourselves. HD

Casey Frankiewicz, AIA, LEED AP, is a principal and director of healthcare at Chicago-based Legat Architects. Douglas Ogurek, LEED AP, is a member of Legat Architects' healthcare team.

For more information, contact Frankiewicz at 847.662.3535,, or visit

Healthcare Design 2010 May;10(5):94-98