1. Greenberg, Linda A. RN, BSN


Review management considerations for structurally redesigning critical care units.


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Successful critical care unit renovation builds on patient focus and feedback.


At some point, you'll most likely participate in planning a critical care unit redesign-either the construction of an entirely new area or renovation of an existing one. Long before the first swing of a hammer, you'll spend endless hours in strategy meetings with architects and contractors. As the lead clinical member of the project team, carefully consider patient welfare and clinical efficiencies, especially during planning and implementation phases.


Your job

Get involved early; you're the liaison between your staff and other team members. To make the most of this unique opportunity, be sure to:


[white diamond suit]involve staff members. Keep the current plan on hand and encourage feedback. Consider inviting key members of your department to architectural planning sessions. Also, form a planning committee and meet regularly for feedback and plan reviews. For well-rounded representation, involve staff members from different shifts, both those who embrace change and those who resist it.


[white diamond suit]create flow charts of critical work processes. Study such issues as traffic flow and chart management to help balance current deficiencies and maintain successful operations.


[white diamond suit]visit other facilities for ideas.


[white diamond suit]bring photos of your existing space to planning meetings to help remember details. (To review the specific responsibilities of other renovation project stakeholders, see "Doing their part.")



Plans and space

Plans are produced in reduced scale, with the two most common being 1/8 inch equals 1 foot and 1/4 inch equals 1 foot. Use a scale ruler to read the plans and determine each space's actual size. Usable square footage depends on the function of the space. (To see how different shapes of the same square footage work for different functions, see "If walls could talk.")



Figure. If walls cou... - Click to enlarge in new windowFigure.

Plans become fixed and expensive to change long before they turn to bricks and mortar. Understanding the architectural process allows you to make the right decisions at the right time. Initial architectural programming includes collecting information on:


[white diamond suit] the amount of space needed, including types of rooms, common areas, and support areas.


[white diamond suit] workflow of people and materials.


[white diamond suit] necessary equipment, including telecommunications, data systems, and medical gases.



Once you've approved the final architectural drawings, subcontractors receive them for bidding. From this point forward, any changes require a change order. (For examples of construction drawings, see "Outlining details.")



Figure. Outlining de... - Click to enlarge in new windowFigure.

Demolition and construction

Unless you're able to relocate to a temporary location, construction will most likely occur in phases. Expect operational disruptions to patient care delivery and compromises to work areas. To make the most of the situation, stay as informed as possible:


[white diamond suit] Identify priorities to achieve maximum efficiency within the structural constraints.


[white diamond suit] Obtain a realistic schedule, accepting the fact that timelines change.


[white diamond suit] Keep your staff updated to minimize surprises.


[white diamond suit] Visit the construction site frequently to help visualize the plans and to recognize situations that may require your attention.


[white diamond suit] When construction is far enough along, usually after the drywall is hung, bring staff members through to begin orientation. Keep in mind that a three-dimensional space differs greatly from the flat blueprints you've viewed previously.



The transition period

Unexpected situations may impact your timeline. Include contingency options in your moving plan and don't leave planning to the last minute; consider purchasing moveable equipment in advance. For example, if you're buying new carts for supplies or specialty equipment, stock and label supplies and put them to use prior to the move.


Also, decrease your patient census a few days before the move, and then consider scheduling extra staff to transport critical patients and accompanying equipment. Lastly, schedule a thorough cleaning of the new space and equipment transportation.


Keep in mind that settling in takes time. Allow staff members several weeks to get oriented, especially regarding changes to workflow patterns. Keep a written list of things you or your staff identify for fine-tuning. This should include furnishings, equipment, and other construction issues. Shortly after taking possession of the new space, communicate this feedback to the general contractor or vendors.


Spacial considerations

Renovation of a critical care unit differs greatly from construction of an acute care department. Caring for only one or two patients creates a unique concentrated workspace at or adjacent to the bedside.


Any area a nurse is required to go to can be considered secondary, and these trips to secondary spaces are frequent and often well removed from the patients' rooms. Time and motion studies reveal that critical care nurses make countless trips during the course of a shift to secondary areas, often stopping at multiple spaces during one trip. Going for a specialty pack in the supply room may often involve a stop at the medication station and checking something in the nurses' station. Consult your architect for software packages that specifically address time and motion. To ensure a successful construction and transition, focus on both primary and secondary workspaces. (See "Defining spaces.")


For the most part, the process of renovation or new construction is challenging and fun if you're well prepared. You're key to creating a more effective, functional, and efficient clinical department that supports both staff and patient care. This is your opportunity to make a difference in this vital care environment. Remember to consult the other members of your planning team-colleagues and vendors are a wealth of information; don't hesitate to call on them.


Selected references


The American Institute of Architects Academy of Architecture for Health:Guidelines for Design and Construction of Hospital and Health Facilities, 2001.


Society of Critical Care Medicine:Critical Care Unit Design and Furnishing: A Project of the Society of Critical Care Medicine, American Association of Critical-Care Nurses, American Institute of Architects. Health Facilities Research Project, 2001.

Doing their part


In addition to collaborating with internal departments, such as infection control, information systems, and materials management, the following involved parties maintain these distinct responsibilities:


Facilities department


[white diamond suit] Interfaces with all project team members


[white diamond suit] Keeps project on schedule


[white diamond suit] Supervises in-house construction staff





[white diamond suit] Gather functional information


[white diamond suit] Determine required square footage


[white diamond suit] Design the layout of the space


[white diamond suit] Specify construction materials


[white diamond suit] Develop project budgets


[white diamond suit] Produce architectural drawings


[white diamond suit] Issue change orders (at a cost)



General contractor


[white diamond suit] Follows the architectural plans while building


[white diamond suit] Hires/supervises all subcontractors


[white diamond suit] Meets construction budgets and timelines


[white diamond suit] Implements change orders (for an additional cost)



Equipment planners


[white diamond suit] Provide an inventory list that includes existing equipment and furnishings


[white diamond suit] Assist in establishing capital equipment and other equipment budgets


[white diamond suit] Possibly coordinate or purchase equipment


Defining spaces

Primary work space (patient rooms)


The most common issue in critical care patient rooms is space: It seems there's never enough. Infection control, privacy, and security guidelines vary. Be sure to address all compliance issues. The American Institute of Architects Academy of Architecture for Health publishes Guidelines for Design and Construction of Hospital and Health Facilities. Architects, designers, and state planning regulators routinely consult this publication for minimum guidelines.


The following are the academy's recommended guidelines for space in a critical care patient room:


[white diamond suit]Square footage: In new construction, each patient space (whether separate rooms, cubicles, or multiple bed spaces) should offer a minimum of 200 square feet of clear floor area, with a minimum headwall width of 13 feet per bed, exclusive of anterooms, vestibules, toilet rooms, closets, lockers, wardrobes, and/or alcoves.


[white diamond suit]Mock-up: Create or build a mock-up of a room and furnish it. If you're considering using power columns, obtain the outside dimensions of a power column with equipment loaded and, at the very least, draw or tape this out on the floor adjacent to the bed.


[white diamond suit]Headwalls: The patient bed and the headwall area are the hub of patient care activity. Access to medical gases should be either centralized or planned for both sides of the bed with sufficient outlets. Monitors and computer terminals need to be low enough for shorter staff members. Consider the management of gloves and other small items on shelves or wall-mounted accessories.


[white diamond suit]Monitors: While improving patient care, new physiological monitoring technology, I.V. pumps, and bedside computers add to room clutter. Purchase equipment that's multifunctional and adaptable to new processes.


[white diamond suit]Handwashing: Separate handwashing sinks are necessary, preferably with hands-free controls.


[white diamond suit]Healing environment: Alternative therapies such as music and aromatherapy are used now to aid in reducing patient anxiety and to mask noises such as beeping alarms. Consider researching their merits; consult the Center for Health Design at


[white diamond suit]Seating: Invest in patient chairs that offer proper ergonomics, don't impinge on circulation, and have the capacity to recline. Casters allow you to move the chair around the room or even to another patient room. Keep visitor seating small-scale and easily cleanable. Consider armchairs for those who need support and armless ones for larger visitors.


[white diamond suit]Room supplies: How many and which supplies to store in the patient room are always difficult questions to answer, especially when trying to address patient and staff needs and regulatory/compliance issues. A common solution in critical care units includes a small mobile cart that serves as primary storage of supplies nursing has standardized for each patient room. Specialty supplies and trays are then kept in other, often large, mobile carts in the department that can be rolled to the bedside for specific procedures.


Secondary work spaces


[white diamond suit]Visibility: Closed-circuit monitors may be needed at the central station if line of sight to all patient rooms isn't possible. The ability to see other staff members is also important, especially when their help is required; wireless phones can solve much of this problem. Also ensure that signage is easy to read for visitors and staff from other departments entering the unit.


[white diamond suit]Nurses' station environment: Few facilities have a complete electronic medical record system; most use a combination of paper and computer. This keeps the central station in a state of flux. Audio and visual privacy compliance issues for HIPAA present another challenge. If you're planning new nurses' stations, provide as much clinical process information to the planners as possible. You and your staff are the only ones familiar with your chart flow and other systems. Digital radiography, electronic patient tracking systems, and documentation software take up precious desk space.


[white diamond suit]Medication rooms: The ideal med room contains I.V. solutions and related tubing sets, in addition to medications, needles/syringes, and other supplies. A handwashing sink and small medication refrigerator are required. This area requires extra space: Automated dispensing machines are large and I.V. solutions are bulky. Pay close attention to the amount of actual working counter space. A minimum of 4 feet of work counter, not including the sink, is recommended. Surfaces for posting bulletins and shelf space for reference books are needed, as well.


[white diamond suit]Clean-supply or utility room: Facilities continue to evaluate whether to use a closed system or the more traditional open system; there are advantages to both. Work closely with your materials management department and staff members who stock the supplies to make the right decisions for your unit. Evaluate your par levels and delivery frequency.


[white diamond suit]Soiled-utility room: The need for open space in a soiled-utility room has increased. This room isn't for storage of clean items, but rather the transition area for soiled linen, trash, medical waste, and instruments to be resterilized or discarded.



Source:The American Institute of Architects Academy of Architecture for Health: Guidelines for Design and Construction of Hospital and Health Facilities, 2001 edition.