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
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
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
“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
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,”
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
“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
a step ahead, just barely
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.
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
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
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.
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
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.”
ICU today, new hospital tomorrow?
“larger project” Zimring mentions is, of course, the
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
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,”
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
“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
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.
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
Zimring is a board member of the non-profit Center for
Health Design. More information is available at the center’s