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eaving through the narrow hallway encircling the fifth floor ICU at Emory University Hospital, associate administrator David Pugh is careful not to disturb the small groups of families huddled outside the rooms of their loved ones.
     “You see everything. People bring food and pillows and blankets. We’ve had people try to bring pets here,” he says. “They stay here night and day. They just do not want to be separated from their family members. They will use whatever empty space is available, and there’s not much.”
     At Emory, as with other large academic medical centers throughout the country, increasing numbers of critically ill patients are requiring long hospital stays, pushing the capabilities of aging facilities to their limits and challenging providers who must adapt cutting-edge technology to small, confined spaces.
     So when administrators decided last year to expand EUH’s busy neurointensive care unit, they wanted to go beyond the usual “just add more beds” philosophy. They needed to build a model for what inpatient care in the 21st century should be.
     “We need rooms that are patient- and family-friendly and that provide an environment conducive to healing—not small, crowded spaces with blank walls, too much noise, and bright lights,” says Owen Samuels, medical director of neurocritical care, and by all accounts the human engine driving the project. “We need sufficient space to perform procedures at the bedside and not transport fragile patients across the hospital for them.”
     While the new unit will have these things and more, what makes it revolutionary, Samuels says, is not a laundry list of new features, but its inclusive, start-from-scratch design. A task force of neurologists, critical care nurses, pharmacists, social workers, family members of former patients, and health care design experts spent months discussing everything from the best use of new technology to how to position the nurses’ station. But the group’s focus was not just on satisfying different clinical demands.
     “Owen started things off by telling us a story about one of his patients,” relates Pugh. “By the end of his opening, everyone was wiping away tears. We knew we had to keep the patient in mind. Too many hospital units are built to be efficient for the providers, with the needs of the patient getting lost along the way.”
     The design of the new unit will make the patient’s perspective paramount. “There is a large body of current research that links the quality of a health care facility’s physical environment to both patient outcomes and staff efficiency,” says Samuels. The plans for the new ICU incorporate core principles of evidence-based, patient-centered design—a holistic approach that focuses on the patient’s physical environment as a tool to facilitate healing.
     It’s a philosophy that Robert Bachman, EUH’s chief operating officer, hopes will expand to all hospital services in the near future. The new neurocritical care unit is the first step in a much longer process that will ultimately result in a completely new Emory Hospital.
     “Our mission is not just treating disease but taking patients’ emotional and spiritual needs into account and providing care and support for families as well,” he says.
     This is a particularly crucial issue for EUH because of the number of critically ill patients it admits. As a teaching and research-intensive academic health center, Emory sees patients who are sicker and require longer, more acute, hospital care.
     “We had a patient here last year who was hospitalized for almost 500 days awaiting a heart transplant,” Bachman says. “EUH is what I call the hospital of last resort for lots of patients throughout Georgia and beyond. We often get patients from other hospitals that have exhausted their resources and expertise and can’t take it to the next level of care. As a result, we are seeing many patients who need to be here for months.”
Staying a step ahead, just barely  
At just over a century old, Emory Hospital has in some ways had a hard time keeping pace with its own success. When it opened in 1905 as Wesley Memorial Hospital in an antebellum mansion in downtown Atlanta, its 50 beds were largely devoted to caring for patients with pneumonia or tuberculosis—the leading causes of death at that time. In 1922, the hospital moved to its present location on the Emory campus, then on the far outskirts of the city, to serve as a learning facility for the University’s medical students.
     Since that time, it has grown into a nationally ranked medical center known for its expertise in transplant medicine, oncology, neuroscience, cardiology, and cardiac surgery. Though it is consistently listed among the top hospitals in various specialties in U.S. News & World Report’s annual “America’s Best Hospitals” issue, its physical environment has lagged behind. Much of the facility is more than 60 years old, and most is more than 30 years old, with the last major construction expansion project completed in the late 1980s.
     Nowhere is the stress of the situation more evident than in the hospital’s neurocritical care unit. One of only a handful of such units in the Southeast, it is staffed by neurointensivists (neurologists with special training in critical care) as well as a dedicated team of critical care nurse practitioners and pharmacists who specialize in neurology. This approach—offering around-the-clock monitoring and care management—has been shown to improve overall survival rates as well as long-term recovery of function and quality of life.
     “We are known as one of the best places for neurologic critical care in the region, if not the country,” says Jim Mullen, director of neurocritical nursing. “When other facilities have patients who need a higher level of care than they can provide, they send them here.”
     The hospital converted its small, seven-bed neurology and neurosurgery ICU to the more specialized neurocritical care unit in 1998, expanding it to 14 beds. Another nine beds were added in 2005. But even with the expansion, the new beds were “filled the day we opened them,” Mullen says.
Additional patients are often placed in other critical care areas, challenging the capabilities of the specialist physicians and nurses who care for them.

     “We can have more than 30 patients on many days,” says Mullen. “Can you imagine being a neurosurgeon or neurologist and you have patients to see in three completely different ICUs scattered throughout the hospital?”
     The rooms themselves are tiny; some are in a part of the hospital built in 1922 and can barely hold the patient’s bed and necessary medical equipment. There is little room for caregivers, much less visitors. Bright, fluorescent lights glow overhead.
     The new unit will add an additional 20 beds and allow centralization of services, but it will also do much more.
A high-resolution CT machine will be housed in the unit, allowing very ill patients to be scanned as they are admitted and throughout their stay, without the need to be transported to another area, as is typical in most other hospitals.
     A large waiting area, with flexible furniture arrangements and television and computer stations, will be located near the unit’s entrance. Food can be brought in and prepared or stored in an adjacent kitchenette. A second adjoining room will feature a children’s area with chalkboard walls for drawing and a variety of age-appropriate toys as well as kid-friendly computer stations.
     The patient rooms themselves will be large enough to include a separate area, partitioned off with a wall and glass block window, that will include reclining chairs or pullout sofas to allow family members to stay with the patient inside the room.
     Many of the necessary monitors and other technology will be wall- and ceiling-mounted to save space; and the patient beds can be rotated, which will permit neurosurgeons and other specialists to perform complicated procedures at the bedside.
     Although the unit will be constructed by enclosing what is now a second-floor, open-air patio, the design plans call for some of that space to be incorporated in a centralized garden area, with a variety of plant life and water features to promote healing and a sense of contact with the outside world. Windows and the use of glass brick in some places will allow natural light from the garden area into the hospital interior.

No more beige  
Mullen pulls out a copy of the design plans within seconds of being asked about the project and begins pointing out the features he likes most. A raised observation platform at the edge of the main nursing stations will allow a direct line of sight to patient rooms, he notes. And small, three-sided monitoring windows will be built into the rooms, allowing nurses to check vital signs and other readings on sleeping patients without disturbing them.
     Unlike many of the others involved in this project, Mullen has a unique perspective. Last year, he spent weeks in an ICU himself after being struck by a hit-and-run driver.
      Long hours with no diversion but a flickering television compounded the already uncomfortable environment, he says. “I just remember the beige hospital color. You’re lying there… and that’s it. I probably had a TV, but I didn’t want to watch TV. All I remember is it being loud and noisy with no positive stimulation.”
     None, that is, until Samuels charged over for a visit—a set of sketches in hand—to solicit Mullen’s support for a new neurocritical care unit.
     “He talked about how we could do something different, about how we could improve the patient experience, and I got excited about the possibilities,” Mullen says. “In all of the construction projects I’ve been a part of in 25 years, I have never seen a physician be so engaged and involved and have such passion to build something that is patient- and family-centered.”
     “This has the potential to be a landmark neuro ICU, one of the best in the country,” adds Craig Zimring, the environmental psychologist and professor of architecture at Georgia Tech who has been working with the hospital to design the unit. “What I find particularly exciting about this project is that Emory not only is seeking to create an excellent new ICU; they hope to apply evidence-based design and learn systematically from it as input into the larger project.”
New ICU today, new hospital tomorrow?  
That “larger project” Zimring mentions is, of course, the new hospital.
     The existing 579-bed physical facility has been added to, remodeled, and retrofitted extensively over the past 80 years, says Bachman. Space planners have wrung efficiency out of every last square foot, and there’s only so much more they can do.
     “With so much of the facility more than 60 years old, there are lots of issues that can’t feasibly be addressed any other way,” he says. “We have 200 rooms that are extremely difficult to cool in the summer because the HVAC system is so old. Many rooms are so small they can’t even accommodate a chair and table. The operating rooms are also not ideal, given the size of modern surgical equipment.”
     Emory University’s Board of Trustees recently gave the go-ahead to develop a plan to construct a new facility across Clifton Road from the existing hospital, though construction is not expected to begin for another three to five years.
     The long wait will give hospital leaders time to engage in the thoughtful process needed to build a facility that will not only meet the hospital’s current needs, but take it into the future. Like the new ICU, the new hospital will be better in addition to being bigger.
     “I think in the next iteration of EUH, we will look at designing our facility around service lines,” says Bachman.
As with the nearby Winship Cancer Institute, research, teaching, and patient care will take place under one roof, with translational research driving the care offered
to patients.
     “For example, we may have a whole hospital tower devoted to the research, diagnosis, and treatment of diseases of the heart and lungs,” Bachman explains. “Then, we may have three or four floors dedicated to neurology and neurosurgery, or transplant medicine, and so on. A patient in need of a transplant would be diagnosed in one area of the building, go to outpatient visits in another area, have the transplant surgery in another area, and receive follow-up care in the same building as well.”
     And more amenities will be available to support family members of patients admitted for extended hospital stays, Bachman says. Current plans include a “mall concept” for the hospital’s ground floor. The central area would feature small shops offering banking services, a dry cleaner’s, and small restaurants to be used by both family members and hospital staff. Waiting rooms on the higher floors would feature areas for computer hookups and Internet access as well as special educational kiosks where family members could learn more about their loved one’s illness and how to find supportive care.
    The hospital still faces significant challenges to building its dream home, Bachman admits. The proposed site on the east side of Clifton Road is currently occupied by the Emory Clinic A building. Those services would have to be moved and the building demolished before construction could begin. And residents of the historic neighborhood surrounding the Emory campus have in the past opposed University plans to construct buildings higher than five or six floors or expansions that would add traffic to the already congested Clifton Road corridor.
     But there are several elements working in the facility’s favor now. A new update to the University’s campus master plan includes a new hospital as a key feature that would drive both improvements to the outdated clinic buildings and expansion of University administration into the vacated 1922-era hospital building.
     Plans for an underground parking deck and expanded shuttle service will ease congestion along the busy road and offer neighborhood residents easier access to the hospital’s mall amenities and other resources on Emory’s campus.
     “We want to include the neighborhood in the planning process,” Bachman says. “It should be an asset to live next door to a nationally ranked medical center, and we want to do what we can to make sure people who live here feel that way.”
     With construction not expected to begin for a while, hospital leaders have ample time to get all stakeholders on board. And while the long wait may be frustrating, it could also be a blessing in disguise, allowing the hospital to explore new ideas and perspectives in its approach, says David Pugh.
     “That was our experience with the neurocritical care unit,” he says. “We need the beds so badly that if we’d been able to build immediately, we probably would have gone for another unit just like the other ones. But because we had to wait, it gave us an opportunity to look at things in a new way, to build something that will be an example for hospitals across the country.”

Catherine Harris is the editor of Momentum.
Extreme Makeover
You’re a patient scheduled for quadruple bypass surgery—Do you really care about room décor and floor layout? According to health care design expert Craig Zimring, professor of architecture and psychology at Georgia Tech, here are three reasons why you should.

Noise. Think you’re in for a restful recuperation? Think again. The World Health Organization recommends that hospital rooms have background noise levels no higher than 35 decibels at night and 45 decibels during the day, but the average level on most hospital floors ranges between 65 and 80 decibels, with peak levels between 85 and 90. A portable x-ray machine can generate 92 decibels of sound, the equivalent of a truck driving past you at 50 miles per hour. Newer designs provide sound buffers to noisy equipment. They use sound-absorbing ceiling tiles and lower lights and other effects to encourage physicians and other staff to speak and move quietly.

Out of sight/out of mind. Things might be quieter if you get a corner room at the end of the hall, but hospital time-motion studies show that’s bad too. Traditional hospital design features a single, central nurse’s station for an entire unit. Nursing time is consumed walking back and forth, then “hunting and gathering” needed supplies for different patients. Rooms located the farthest away from the station are hardest for them to reach. Floors are now designed with several smaller nursing stations located strategically along the hospital unit, allowing nurses to spend less time traveling and more time with patients.

Playing room roulette. Emory Hospital is ahead of the curve because all of its patient rooms are private. Research shows that no single intervention would do more to improve hospital outcomes nationwide than converting multi-patient rooms to single ones, says Zimring. Patients without roommates are less likely to acquire infections and are better able to rest without the additional disruptions of a shared room.
     But are the rooms big enough? Modern hospital rooms should be large enough to accommodate equipment that supports high-acuity patients. Patients who need mechanical ventilation or sophisticated diagnostic tests often must be moved to different areas of the hospital, and it’s during such transfers that many medical errors occur.

Zimring is a board member of the non-profit Center for Health Design. More information is available at the center’s website:


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