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The evolution of our health care system continues to present persistent and ever-growing challenges to providers and consumers alike. From any viewpoint, we are seeing a macro-trend toward interdisciplinary collaboration, as professionals from all parts of the health care field emerge from their silos to interact with other disciplines to achieve greater outcomes and improved workflows. Facility design is making particularly intense use of cross-field collaboration, bringing architects, engineers, nursing, construction firms, interior designers, IT professionals, and a host of others to create design that is ultimately best for patient outcome.


Reduced reimbursements are pressing facilities to achieve a never-before seen level of efficiency, and outcome-based reimbursements are driving actions to prevent nosocomial infection and emphasize patient safety. We are also seeing a rise in nurse involvement-with greater patient responsibility and with facility design and technology deployment. Hospitals are pressured to build environmentally sustainable facilities without compromising patient safety.


With so much to be said about nurse involvement in the design of critical care units, Critical Care Nursing Quarterly is publishing 2 back-to-back issues on the topic. The enthusiasm of our authors and the sheer volume of discussion areas are clear evidence that the industry is looking to facility design as an essential element of the patient care formula.


Mahbub Rashid begins our first issue with his retrospective analysis, "Two Decades (1993-2012) of Adult Intensive Care Unit Design: A Comparative Study of the Physical Design Features of the Best-Practice Examples," in which he reviews 20 years of ICUs that received awards from the Society of Critical Care Medicine, the American Association of Critical Care Nurses, and the American Institute of Architects/Academy of Architecture for Health and compares their physical design features. The article is arranged as a decade-over-decade comparison to demonstrate what has changed (and what has not) in what is considered "award-winning" ICU design. While some designs in both decades had features that did not reflect evidence-based design, the general trend was toward more evidence-based design. Indeed, the remainder of this issue (and our next issue as well) will prove Rashid's findings correct, as all or nearly all touch on evidence-based design as basic to the design of modern ICUs.


Debra Braun's and Kim Barnhardt's article, "Critical Thinking: Optimal Outcomes Through End User Involvement in the Design of Critical Care Areas," is a persuasive piece on using end-users in evidence-based design as a means to achieve an ICU with the highest rates of safety, outcomes, satisfaction, and efficiency. She includes nurses as end users-that goes without saying-but also the cadre of professionals that work in critical care units as well as patients themselves.


Continuing the theme of nurse involvement in design, Pamela Redden and Jennie Evans further explore the role of the nurse in design and the investment required by executive management to support this model in their article "It Takes Teamwork: The Role of Nurses in ICU Design." Redden and Evans discuss the topics of teamwork, management support, and how nurses are especially well equipped to ensure that evidence-based design forms the foundation of ICU design.


Jens Mammen and Brenna Costello take us in a new direction with their article "Relational Sustainability: Environments for Long-term Critical Care Patients." They discuss the special needs of certain ICU patients, such as those experiencing bone marrow transplant, traumatic brain injury, or spinal cord services. When patients are admitted for both intensive and long-term care, design is an even greater contributor to recovery. Lighting, room layout, and other design elements have an essential role to play when patients are hospitalized for weeks or even months.


Technology is playing an ever-growing role in health care, and Susan O'Hara addresses the value of simulation modeling in the next article "Planning Intensive Care Unit Design Using Computer Simulation Modeling: Optimizing Integration of Clinical, Operational, and Architectural Requirements." This article shows the value of computer simulation in ICU design, and how the field represents an opportunity for nurses to step into greater leadership roles.


Along the lines of simulations, Jennie Evans and Evelyn Reyers discuss the value of the mock-up room in a detailed look at design of the ICU patient room in "Patient Room Considerations in the ICU: Caregiver, Patient, Family." This article discusses how the mock-up room is an unequalled method of pre-experiencing a suggested design from the perspectives of caregiver, patient, and family.


Next, we hear from Georgeann Burns and Vicky Hogue, who present "Wellstar Paulding Hospital Intensive Care Unit Case Study: Achieving a Research-Based, Patient-Centered Design Using a Collaborative Process." This article is a case study of a recent hospital replacement project that used nurse collaboration in its ICU design process and how that impacted final design.


Jocelyn Stroupe takes on the issue of safety head-on in her article "Design for Safety in the Critical Care Environment: An Evidence-Based Approach." She tackles the issues of infection control, audial distraction, restorative space, alcoves, and others as she views designing for safety from the perspectives of the caregiver, patient, and family.


The writing team of Tim Timmers, Hans Joore, and Luke Lennen present a report on "Changes After Transformation From a Specialized Surgical Unit to a General Mixed ICU." The article analyzes 2420 consecutive admissions over a period of time during which a specialized surgical ICU was transitioned to a general-mixed ICU and reports on the influence on immediate outcome and performance data before and after the transformation.


To conclude this issue, Tim Timmers, Puck Hulstaert, and Luke Leenen report on the effects of an organizational downsizing at the University Medical Center in Utrecht, the Netherlands, which suggests that increasing workload can have a negative effect on both patient outcomes and length of stay. The report discusses a number of tactics that might have mitigated the situation.


As nurses deliver care in this time of significant change, it is clear that nurses are being asked to do more with less, and that the nursing voice will need to increase in volume-for the sake of both the nurse and the patient. As evidence-based design becomes the norm for new and renovated health care facilities, nurse input is critical. This extends to technology as well, especially as health care becomes more mobile and reaches outside the walls of the hospital. Literal and metaphorical walls are disappearing, and nurses have both the opportunity and obligation to take on greater leadership to meet the health care challenges of improved outcomes and reduced costs.


-Debbie D. Gregory, BSN, RN


Issue Editor