Prince Charles Hospital’s ICU of the Future Project

Traditionally, the luxury of using a blank canvas is not linked to the usual, actual available site, especially when considering retrofit solutions. Many innovative design nominations, since at least the 1990s, tend to assume a new open floor area, free of the physical constraints that hinder implementation of blue-sky ideas, often also within existing departmental boundaries.1 New and unconstrained planning tends to lead to larger bed pods and additional auxiliary adjacent spatial requisites. The latter approach may be suitable for greenfield developments, but does not address:

• the opportunity to enhance existing global ICU stock, which generally consists of smaller bed bays with finite real estate inside existing hospitals;
• disadvantages of area growth, including aggregating walking distances, stretched visual accessibility, department area, and accruing engineering plant, and
• non-first-world countries being unable to afford the growth of floor area,A nor the replacement of redundant building stock to allow the creep to area growth.

Brisbane project’s lofty aims

The ICU of the Future Project at The Prince Charles Hospital (TPCH), Brisbane, Australia had lofty aims.B However, the applied solution required a design within the tight constraints of an existing pair of old-style internal, windowless, and curtained bed bays. Consequently, the success of the design was ultimately evaluated against whether this compact design was replicable across many global contexts — limited by the local settings of existing departmental boundaries. This article reports on the outcomes of this research model, which was implemented at TPCH in December 2022 as a part of the operational ICU department.C The two upgraded bedspaces have been operating as part of the live department for more than two years since its launch, allowing the implemented solutions to be further tested by a review of the adjustments to operation by the clinical staff of the unit.

Every year, over 20 million people are admitted to an ICU globally.2 While the survival rate continues to improve, the quality of survival remains sub-optimal. As many as 70% of ICU patients will experience physical, cognitive, and/or psychological problems after their ICU admission.3 However, these problems do not only affect the patients; up to 75% of family members will also experience psychological symptoms after the ICU admission.4 These problems may be short-term, but commonly last for many years after hospital discharge.5 Therefore, the improved ICU survival rate has come with an increased burden for ICU survivors and their families.

The remedy

The Critical Care Research Group, in conjunction with the wider project team,D using a co-design approach,6 utilised information gained from interviews with patients and their family members to develop a list of patient-centred issues and subsequent solutions for incorporating into the model for the ICU of the Future.7 Solutions included reduced equipment noise (especially alarms); re-directing alerts away from the patients; active noise masking; acoustic linings; dynamic lighting to maintain circadian rhythms; distractive ceiling panels; sound attenuated barriers mitigating adjacent noises; reduced clinical aesthetic; light masking for controlling intrusion from adjacent spaces (including night light intrusion); simulated windows with scenes of nature; enhanced indoor air quality and monitoring, and improved abilities for patients to engage with family, friends, and the outside world. All are solutions aimed at promoting a quiet, peaceful, and connected environment to facilitate rather than inhibit healing, and avoid an otherwise chaotic and stressful place for the patients.

Further design responses were then focused on value, compactness, ambience, and balance against other criteria, such as infection control measures.

The designated research site consisted of a pair of existing, semi-open, adjoining bed bays, very much deep-planned in the depth of the current active ICU department. With the constricted floor areaE of an already tight floor space of the two curtained bays, the site was very much grounded into a compact solution, out of reach from utopian approaches. This part of the unit was furthest away from the other bays. The other bays had relationships to external window views; the prototype bays did not. Further, although the pair of bays was relatively close to the central staff base, they offered poor visual connectivity, or ‘sight-lines’, which are considered important by ICU clinicians. The bays had a ‘last-resort’ current usage other than being used as a storage or simulation space. In short, the site was windowless, already tight for today’s standards, in the middle of an active ICU unit, and poorly visually connected to the central staff activity.

An opportunity for clever design

Such constraints should not, however, be viewed as a hindrance to future design initiatives. They should rather be viewed as an opportunity to consider clever design, making up for, or at least testing the limitations of, the spatial and other shortfalls. This approach informs many similar global scenarios, where the predicament was of having established constraints, previously executed to older standards and expectations. It was thought that if this design could tackle the constraints, this could assist other hospitals facing developing similar scenarios. More specific design approaches included:

• Acoustic transmittance: Whether or not to not enclose the existing bed bays was briefly considered, but there was no known way of controlling stray light or sufficient blocking of externally created sound without physical barriers. The sound masking technology which was already incorporated in the design was beneficial in dampening consistent, unwanted background noise, but the technology was not ready for full cancellation of each unwanted sound wave (particularly the many short and loud noises created in the ICU — e.g. alarms). A wall and well-sealed sliding door, on the other hand, had a sound-mitigating performance. Similarly, light pollution was difficult to control without a physical barrier in the form of a wall. The design response, therefore, formed a controlled enclosure in a way that it remained accessible, selectively transparent, and versatile. A tri-arrangement of sliding glazed doors was designed to allow open-bay configurations and assist nursing staff in managing two patients simultaneously, particularly with an easy, push-open action during the more crowded emergency activities. Door openings allowed a simple bed turn for accessing and egressing the bays. To ensure equity for visitors in wheelchairs, the door arrangement was designed around a set-out for fully graspable, compliant access handles on wide leading door stiles.

• Light pollution: Because the initial research had identified that light pollution was detrimental to the nestled patient inside the cubicle, care was taken to use hospital-standard bed screen curtains as lighting barriers. Standard hospital curtains were draped from around 300 mm above the floor to a height of around 2100 mm. The glazed sliding doors were further designed to light-block the openings under and over the curtains. A double provision of curtains inside and outside the glazed cubicles was also madeF to allow the formation of a future light-lock so that night-time clinicians could come and go into the cubicle without stark changes to lighting levels.

• Reduced equipment noise: As mentioned previously, the selection of equipment searched and encouraged development of reduced alerts and alarm sounds at the patient head (‘quiet’ or ‘silent’ alarm solutions),G aiming for solutions delivering alarms directly to the caregiver. This strategy built on prior research.
   
• Other acoustic ambience: Other than minimising equipment noise and acoustic transmittance from adjacent spaces, a further aspect of design was the treatment of internally created sounds within each bedspace. The ICU environment, with its hard surfaces, has traditionally been thought to be most in alignment with good infection control practices. However, such environments’ prolonged acoustic decay times can result in unwanted ‘lingering’ and build-up of sound, contributing to occupant discomfort, while also creating an environment prone to mis-hearing verbal communications. Because the baseline research identified the criticality of quality acoustic dampening, the design team working with the Infection Control Department found a solution that met both the critical project requirement of reducing the reverberation time and improving sound absorption, balanced against key infection control criteria. This outcome ensured that the wall and ceiling surfaces were selected with preference given to acoustic criteria. A behavioural adjustment, therefore, was required in the operation of the ICU to maintain best Infection Control Practices (e.g. low hand-contact to walls).
   
• Compact design: The deficit of total available floor area was managed through compaction design techniques and a reduction in selective equipment clutter. The key spatial demands associated with each bed pod were immediate clearance around each bed — i.e. sufficient space to maintain clearance for people and equipment in a non-cluttered way, and being sufficiently flexible to facilitate instant responses such as resuscitation.

The consequence of enclosing the bed bays was that the resulting cellular spaces offer less efficiency — because shared manoeuvring space, as experienced between two adjacent curtained bays, cannot be realised. To make up the deficit, the following design techniques allowed greater functionality than would normally be possible within a more contemporary comparable floor area allocation:

• Accommodation for large items of equipment

The floor area clearance around the bed largely kept to the clear area recommended by current Australasian Health Facility Guidelines.8 This clearance allowed the flexibility for a variety of equipment around the bed, as well as maintaining space for procedures such as emergency resuscitation. An exception to this clearance zone was the lesser room, which contained an existing ‘bite’ out of its foot-end corner due to a column and recessed basin bay of an adjacent room. The intrusion was considered less than ideal, but was left for ‘value’ reasons, as well as to test actual circumstances which are common encumbrancesH around the world.

• Storage of equipment

One potential solution to fairly constricted bed bays was to increase storage capacity and storage accessibility to the whole ICU unit. Such an approach encouraged a procedural adjustment to keep unnecessary equipment out of bays. Whole-of-unit enhanced solutions were out of scope for this project, and therefore were analysed and suggested as separate projects, although none of the initiatives have been activated during the operational review period.

A second allowance was to maintain a full-length, clear universal storage zone within each bed bay. This storage accommodation was already part of the AusHFG but was in this case given the priority over other spatial allocation, such as tertiary desk space. As well as accommodating medical equipment, this bay would allow visitors’ chairs to be accessible and flexibly located as per daily requirements, or changed according to patient acuity routines.

• Control of size and quantum of fitments

Maximum flexibility is often realised when loose, mobile fitments are used in lieu of fixed ones. The number of permanent fixtures was therefore minimised. Where they still needed to be fixed (e.g. in the case of services engineering outlets), fitments were reticulated through fully articulated pendant arms for swinging out of the way.

Ambience was also considered an essential component of the design, ensuring that the bedspaces were functioning in a sterile and clinical manner while designed to look more familiar and comfortable for patients. Colours were chosen specifically to reduce pain and anxiety. Pendants were finally selected to be minimally dominating within the bedspaces, i.e. avoiding as much patient and visitor intimidation without compromising clinical efficiency, but also with the ability to periscope out of the way into ceiling voids when not needed.

• Sharing of space

As already noted, the division of cubicled dual bedspaces into two separate, cellular spaces has spatial penalties. To allow the continued use of shared space, the tri-sliding door arrangement allowed for occasions where an opening between bays is advantageous — e.g. in the case of sharing of nursing support between two adjacent patients, or where the quantum of equipment is at extreme peak demands.

• Corridor

Because the particular corridor’s context was a more likely route for daytime activity, an opportunity was structured to allow the main bedspace workstation on wheels to be nocturnally located just outside the glazing enclosure, within a second set of light barrier curtains, which partly shared space with the corridor width during quiet times.

• Opening up of rooms

The sliding door arrangement allowed a large proportion of the room perimeter to be easily accessed to an aggregate open position. Maximising the aggregate opening of the collective two bays allows flexibility — as demonstrated in an external study, which analysed the use of patient accommodation during resuscitations and other times of intense occupation. The study found that if dimensions were tightened in one direction, the actual distribution of persons and associated equipment would satisfactorily flow into other parts of the available space, such as a bleed into the connected corridor (like squeezing a balloon in one zone makes a bulge appear elsewhere).9

Post-occupancy research results for compact layouts

The findings based on the project objectives are separately published.J The aspect of compacted room sizes was worthy of a further post-occupancy study, and is discussed here. For this topic, an open-ended questionnaire was distributed, with the findings collected from volunteer clinical team members. These questions, distributed more than one year after instigation of operation, asked:

1: Did you need to adapt your practice in any way to provide clinical care within the physical bed space you are currently working in?

2: Are there procedures which remain challenging in the current bed space due to spatial limitations?

3: Did you need to communicate any information specific to the current bed space to other staff to facilitate regular clinical care?

4: Did you need to communicate any information specific to the current bed space to patients or visitors to facilitate their care and wellbeing?

5: Do you find differences in the functionality between these two bed bays that impact your routine?

Almost predictably, the smaller bedspace, with the bite out of its corner of its plan, was identified to be less than ideal for reasonable functionality. The larger bay fared better, but was noted to be limiting in manoeuvring and placing large items of equipment. Some items of equipment, such as existing mobile X-ray machines, were not comfortable to use within the available space. Similarly, large numbers of people in the room, or situations with aggressive/agitated patients, were felt as spatially constrained. A consequence of the tight room was that there needed to be a substituting of one inward item of equipment for another item to exit it.

These issues were not new, and were already extensively recognised through the design consultation period. Increasing the size of the bedspaces was out of scope for this project. There were therefore no surprises in the challenges encountered. What was unexpected in the feedback was that adaptations of operational practice were not as settled as anticipated. In addition, the aggregate sliding door openings, which allowed spatial limits to flex and extend outside the bay boundaries, were not recognised in the description of adaptive operational techniques.

Curtained bed bays

Upon analysis, the mix of having virtually all other curtained bed bays within the unit appeared to have caused a bias in comparison. The curtained bed bays allowed an instant ‘ballooning’ of one function overspilling into the next adjacent space. The expansion with the new enclosed bays was more an adjusted behaviour in using the doors. Because the curtained bay was simple and familiar behaviour, there was a temptation to not use the prototype bay for the very sick patients. Since patient comfort and wellbeing are better served by the enclosed bay, the boundary adjustment of the flexible edges ought to be a more readily accessible solution in the future.

Further observation showed that the department’s broader stock of equipment could not be modified for the context of the prototype (e.g. the existing mobile X-ray). Therefore, not all observation could demonstrate a complementary setting. In addition, wider ancillary functions, such as storage systems outside the bed bay, were not included in the scope of the prototype project — meaning that only partial conclusions can be noted in this regard.

Other, more particular comments critiqued reachability of fitments, clocks, bins, and the like. Regardless of detailed consultation having been executed over a six-month period during the design phase, there were sufficient comments during the post-occupancy stage to investigate the causes of the observations more closely.K However, since the results of these latter detailed findings do not affect the principle of applying compacted designs in future settings (i.e. those details can be adjusted within a further designs), they are not discussed in detail here. 

In applying and learning from this research into future comparable ICU upgrades, the following recommendations are made:

• Compact versions of handwash bays and fire hose reels

Many existing examples of ‘bites’ out of the corners of rooms are evident in global settings. These include, adjacent fire hose reels, handwash bays, storage alcoves, and/or columns (with particularly significant sizings in high rise or high-seismic zones). As is partly evident in this study, these ‘bites’ — which subtract amenity from rooms — can be disruptive to planning clearances, hinder room access, stifle room flexibility, and limit uniform handing, universality, or modularity.

Basin alcoves are often set out on principles of market availability. A little more careful design development reveals that a significantly more compact version can be developed without compromising the splash zone, cross-corridor traffic collisions, elbow clearances, visual encumbrance, or infection risk. This summons a call for a worthwhile design review for similar circumstances where rooms are compromised because of a ‘bite’ out of their corners.

Similarly, fire hose reels which ‘bite’ into the functional space of an adjacent room can be rationalised. In Australia, at least, they can be eliminated using performance solutions, or at least by placing the reels up at a height,L out of the functional area of a room.

•  Enhanced links to family and carers

In this study, considerations tied into extending existing hospital systems, including nurse call and food ordering. The development of technology that aids accessible and effective patient-to-carer communication is moving rapidly. Consideration should be given to the installation of an effective equipment package in a future design because it is likely to affect the basis of the layout. The twin goals of maximising integration, and giving patients and their families the option to play their own media, should not be forgotten.

• Fibre optic lighting

A window which has a visual link to a pleasant outdoor setting is preferable, i.e. not just having a window to a bay, but also having a relationship to the patient. However, reality dictates that the ideal relationship to natural views is not always possible. In the case of the ICU of the Future, daylight simulation and connection to nature scenes were electronically simulated. Future connection to the external environment into the bowels of the building can also consider a more natural fibre optic light conduit technology.

• Sliding door enhancements

In this study, the aggregate openings of the pods’ doorways were dictated by the physical limitations of existing fabric. The post-occupancy feedback demonstrated that the sliding doors appeared neither accessible enough, nor to form optimal aggregated openings to be comparable with a set of curtained bays. Enhancements could have been made to both increasing the sliding door opening widths and enhancing their ease of operation.

Although good quality manual tracks were used in the prototype, automatic doors with specially designed activation buttons on the doors themselves could be considered as a more responsive option.

• Bed bay flexibility

To augment the flexibility of each pod further, the amalgamated bed configuration is best if large clusters of beds are used. An isolated bedspace very probably has two solid partitions as its bookends (rigid elements). A pair of bedspaces will have that book-end, one to each room. A large run of rooms minimises rigid walls, and allows opening doors between cubicles. This large run of rooms in planning allows the creation of an efficient hybrid between a private room, and the expansion-capable cubicle (i.e. a hybrid between the two types of spaces: effectively a ‘roomicle’).

Conclusions

Various initiatives have been outlined in this article to demonstrate the enhanced clinical environment as per the project’s objectives, centered on improving patient outcomes. These parts of the project were published separately, and demonstrated measurable and replicable attributes which can be applied globally.

In addressing new project scenarios where similar physical constraints apply, the findings evidence successes, but are overall not entirely conclusive in all aspects. The public hospital setting appears more complex for fully integrating the compact solutions compared with the successes seen in equivalent smaller, private sector, scenarios. The latter, private sector examples had the advantage of continuous administration of an overarching vision into daily operations.

An overall departmental refurbishment would need to be further pioneered, not just a two-room prototype within an existing department. To succeed, a developed adaptation would need to be built on pre-prioritised project objectives as the integrated driving force of all design decisions, equipment procurement, operational systems, ongoing training, and future opportunity planning.

References

1 Cadenhead C, Anderson D. Critical Care Units: Trends in winning designs”. World Heal Des J 2009; 2(3): 72-77.

2 She SJ, Xu YY. (2023). Effect of CICARE communication nursing model combined with motivational psychological intervention in patients with post-intensive care unit syndrome. World J Psychiatry 2023: Sep 19;13(9):707-713.

3 Desai SV, Law TJ, Needham DM. (2011). Long-term complications of critical care. Crit Care Med 2011 Feb; 39(2):371-9.

4 Harvey MA, Davidson J.E Post-intensive care syndrome: Right care, right now… and later. Crit Care Med 2016 (44): 381-385.

5 Ramnarain D, Aupers E, den Oudsten B, Oldenbeuving A, de Vries J, Pouwels, S. (2021). Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counselling and treatment strategies. Expert Rev Neurother 2021; 10: 1159-1177.

6 Tronstad O, Flaws D, Patterson S, et al. (2023). Evaluation of the sensory environment in a large tertiary ICU. Crit Care 2023 Nov 27; 27(1):461.

 7 Tronstad O, Flaws D, Lye I, Fraser JF, Patterson S. (2021). The intensive care unit environment from the perspective of medical, allied health and nursing clinicians: A qualitative study to inform design of the ‘ideal’ bedspace. Australian Critical Care January 2021; 34(1): 15-22

8 Australian Health Infrastructure Alliance (AHUIA). (2024). Australasian Health Facility Guidelines 2024.

9 Hollander H. Bed room mock ups. A practice research paper for the Queensland Children’s Hospital 2007. Conrad Gargett Lyons, Brisbane.

Additional footnotes

A Growth of floor area is a recognised significant capital cost, with associated plant growth, additional walking distances, and addition of associated circulation area.

B They include: using design and technological solutions to optimise the ICU bedspace requirement, and reducing environmental stressors (e.g. noise, light) to reduce the incidence of delirium, improve sleep, improve patient/family experience, and ultimately improve patient outcomes.

C The two ICU of the Future bed pods operate as part of an existing 27-bed ICU.

D Led by the Critical Care Research Group, and supported by a selected team of sponsors, architects, designers, equipment suppliers, builders, consumers (patients and their families), clinicians, and researchers.

E The aggregate area of the two beds was 42.5 m2 (minus an inefficient bite out of the corner of one of the bays for an adjacent space’s basin alcove and a column). Current Australian Standards for new build call for 50 m2 for two separate rooms.8

F Not included in the prototype at this stage.

G For example: https://patents.justia.com/patent/
20170039822

H For example, columns which ‘bite’ into a part of a room.

I Greater focus on this swinging out of the way was given than would normally be executed in an ICU design.

J Publications: Doing time in an Australian ICU; the experience and environment from the perspective of patients and family members (2021); The intensive care unit environment from the perspective of medical, allied health and nursing clinicians: A qualitative study to inform design of the ‘ideal’ bedspace (2021); Evaluation of the sensory environment in a large tertiary ICU; Evaluation of the sensory environment in a large tertiary ICU (2023); Creating the ICU of the future: patient-centred design to optimise recovery; The effect of an improved ICU physical environment on outcomes and post-ICU recovery — a protocol (2024).

K For instance, is the cause due to no fully integrated mock-up being executed? Is it related to staff replacement and new expectations? Is it because the observations are contrary to normative design standards? Is it due to mixed operational modes being practised within the unit? Or is it simply that the bedspaces are ‘different’, and some staff are finding change from historical behaviours challenging?

L Current standards allow hose reels at an elevated height, providing that the hose discharge is set at an accessible level.