A Tale of Two Renovations
Baltimore-based CSD Architects renovated the nursing unit at Mount Washington Pediatric Hospital, Baltimore, and the NICU at St. Joseph Medical Center in Towson, Maryland, with the projects completed a month apart in July and August 2006, respectively. Despite the similar timetables, however, CSD took very different paths to solving the individual challenges posed by each facility; Mount Washington took a “town square” approach, while St. Joseph's went with a “pinwheel.” HEALTHCARE DESIGN Managing Editor Todd Hutlock sheds light on the similarities and differences though interviews with CSD's David K. Noji, AIA, Mount Washington's Robert Imhoff, III, and St. Joseph's Dr. Michael Langbaum.
Mount Washington Pediatric Hospital
Robert H. Imhoff, III, Vice-President, Mount Washington Pediatric Hospital: Our patient population, with regard to diagnoses and conditions, had changed significantly from when the nursing unit was first designed in 1989. To accommodate this new patient population, a renovation of the unit became necessary. In addition, we wanted to take advantage of technological changes and new patient safety practices, and we wanted a unit that was more patient- and family-friendly, as well as one that provided a pleasant and safe work environment for our staff.
David K. Noji, AIA, Principal, CSD Architects: The old nursing unit was built with patient rooms on the perimeter and the nursing core in the center. Over the years, the institution had essentially stolen from its patient room space. For example, one patient room was converted into a dining room area. Other than that dining room, there really wasn't too much space for children to play other than in the corridors.
In terms of the patient type, these children could have fairly significant injuries, and some of the lengths of stay could be quite long. In many ways, this is their home. In addition, the age range was diverse, ranging from toddlers up to teens which created even more design challenges for the project. The challenge for the staff, in addition to medically treating them, was to ease the adjustments patients would face when they “go back to society,” so to speak. The staff wanted to provide a normal and homelike environment for the children, which, with their existing unit, really wasn't possible. The old unit design was purely medically driven and did not adequately address the children's social needs.
Imhoff: The “town square” solution and the unit in general were the results of extensive focus group interaction with staff, patients, and families. As a result, and because of this “buy in,” there was no resistance.
Noji: As we got further into the programming discussion, the idea that replicating a social environment such as a town, started to surface. We looked at the original core space of the unit as the town center and the surrounding patient rooms as their houses. That “town square” idea became the mechanism to balance social and private spaces. The staff let us know that they really wanted to encourage the kids not to stay in their rooms. They wanted them out into the common spaces, for both the socialization aspects and for rehab. We tried to give as much space as possible for those functions so that this really became their home and operated as well as possible.
We were pressed for space so a lot of spaces had to be multifunctional. The main space in the town center allowed for dining and has a large projection screen that can drop down for movie night. Due to the diverse age groups we created a toddler room so that they could crawl around and play with age-appropriate toys while another room was for teenagers with a foosball table.
We designed with a lot of glass so that the facility would feel as open as possible, while also allowing visibility for the staff. To aid in keeping it “open,” we pushed some of the support spaces out of the unit and into an adjacent area.
The patient rooms are semiprivate, and in some ways, that has helped the hospital with population flexing. For the very young, they open up two semiprivates to create a larger room allowing a nurses' station to be brought into the room, as well as three bassinets. Under this setup, they can flex up or down in terms of the current population. When they do have older kids, they simply close off the rooms to recreate the two semiprivates.
The patient rooms were treated as their homes so the theme from the corridor—the public side—was a house with a porch; we treated it in layers of private and public. The town center was very public; the porch was a transition space. This shared space was also clinician-driven to provide for visibility into the patient rooms and also to allow for the private space. Each bed has its own “zone” reinforced by a personal frame at each bedside where patients could hang up their own artwork or stuffed toy—whatever made it their space.
Imhoff: Patient privacy has always been a strong concern of ours, even before HIPAA became law, so we have been cognizant of this issue and have been conducting business accordingly. Prior to the renovation, the unit was a very active place with communal space, albeit less than the present design. Therefore, we had addressed this issue some time ago and we were pleased to find that our practices were in compliance with the new HIPAA regulations. As a result, there were only minor changes needed, more for operational ease, when the new unit was put into service.
Noji: The solution in this case was to provide adequate private space where the clinician and patient—or clinician to clinician—can have private conversations. Some of the smaller social rooms, if they're empty, can be used. In the support area, there's an exam room and a conference/waiting room. The nurses' station also provides a glassed-in area for private conversations.
St. Joseph Medical Center, Towson, Maryland
Dr. Michael Langbaum, St. Joseph Medical Center: Our previous NICU was in a temporary space of converted patient rooms before the redesign, and it was suboptimal. Each individual bed space was not large enough, our care facilities were not large enough, and our common spaces for the staff also were not large enough. We needed a total redesign of the floor plan. We made the space we had before work, but as far as an overall state-of-the-art NICU, it was behind the times and was not ideal. It was also on a different floor from labor and delivery, making it more difficult, though we were able to safely transport babies back and forth after delivery.
I wanted something that would be comfortable for both staff and parents within the constraints of the space that we were allotted. We visited different NICUs around the country and looked at their advantages and disadvantages and basically cherry-picked off of them to take what we thought were the best parts of each design.
Noji: CSD went into this project with the assumption that we'd be doing private rooms. We had a parent focus group and were shocked because the parents were quite adamant that they actually did not want private rooms. They found great comfort in the ability to talk to their neighbors who were facing similar issues and going through the same difficult time. They felt that if they were isolated in a private room, they would lose a large part of that support environment. For them it was a healing process. They were quite vocal in saying, “No, we don't want to have private rooms,” and that's where the idea for the pinwheel design came from.
That was a big revelation for us because we were programming and budgeting based on 12 bassinets. With this change, we ended up with 16 bassinets on the core pinwheel and two private isolation rooms. We also provided a transition room that allowed for a bassinet and a parent's bed where the institution would allow a parent to sleep over for educational purposes. This way, the parents would have clinician backup right there, helping relieve some of that anxiety they would feel when they returned home with their newborn.
Langbaum: There's a lot of push now to have separate individual rooms for NICUs. That takes a lot of space, and while it has certain advantages, it has disadvantages, as well. In our NICU, parents can interact with the children, should they choose to. This is a lot more difficult if you're going into a separate room all the time. We have parents who have become life-long friends basically because their kids were in the NICU at the same time, and that helps parents get through a pretty difficult time. I think that's harder to do with the totally separate space where you just walk into a room every day. There are some parents who don't want to interact as much as others and choose not to. The pinwheel design we have gives them the opportunity to do one or the other.
Noji: The pinwheel design is a four-spoked built piece, arranged so that each quadrant would house a bassinet and also provide space for the parents. We looked at each quadrant in terms of patient and clinician space and tried to zone it just as you would a private patient room—one side is for the clinician, one side is for the family. In the pinwheel design, we grouped the clinician-type activities on one side of the bassinet, and on the other side we provided more space for the family. Each of the pinwheels has a bulletin board that family members can personalize by hanging up photos, momentos, or even a drawing that a brother or sister had drawn for the new baby.
Langbaum: The pinwheel design has its advantages and disadvantages for the staff. The old style NICU, which is basically one big square or rectangle with the beds on the walls, at the periphery, certainly makes it easier for the staff to get back and forth between beds. The pinwheel design makes it a little more difficult, but that's where technology comes in as well. We have monitors that are able to split their screens so that if a baby is in another pinwheel, a nurse can call up something on a monitor or see an alarm go off on a monitor on another baby's bedside. And so, the idea that you have to have eyes on the baby 24 hours a day—we can get around that idea. The nurse can work at an adjacent pinwheel and still see on her monitor if something is going on with another baby. That takes some staff re-education, and it was a little outside the comfort zone in the beginning. It takes a little bit of time for the nurses to come out of the mode of one big room where everybody can see everybody and go to what is really a private area for each baby.
Every baby has his own individualized bed. It's very private within the confines of that bed, but of course, because there aren't separate rooms, we still need to be careful that we're not talking too loud during rounds or divulging patient information to other families just like anywhere else in the hospital. We have to make sure that when parents want to talk to each other that it's okay with both parents. We also have individual refrigerators for every baby's breast milk, and everything is done on a single basis so that things can't get mixed up. We've done a lot to decrease medication errors.
If parents want to be next to their baby while we're rounding, that's absolutely fine. We do ask the parents to stay out when the nurses change shifts because there's just too much going on.
The pinwheels are set up as same-handed rooms. The plugs are in the same place, the lights are in the same place, the oxygen is in the same place. They are not mirror images of each other and we think that cuts down on safety errors.
Noji: We were lucky to have a very in-depth postoccupancy review with one family that was not part of the original focus group. This family actually had two children who go through the NICU—their first child was in the old NICU, and their younger son was in the new one. They strongly conveyed that having a more open design was positive. They felt that if they needed to get a nurse or doctor, they could easily do so, but that they also had more space for private bonding with their son. That was gratifying for our design team to hear. All of our hard work and planning resulted in exactly what we'd hoped for.
Langbaum: The families really like the new arrangement. We have a family room where parents can stay a night or two before they go home—overnight where they can practice taking care of the baby for a while. We have a media room with Internet access. For the parents, it's a tremendous improvement on what we had before. HD