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Taking a Closer Look at PICU Designs

New York, NY (Nov 24, 2009)

Charles L. Schleien, MD

Emerging physical models of PICUs in children's hospitals nationwide are addressing family-focused care, patient privacy, sound and infection control while, at the same time, accommodating new technologies. However, many of these changing models are raising concerns among PICU staff at children's hospitals, making it important to identify design factors that aid or hinder delivery of care. The three separate pediatric ICUs on the 9th floor of NewYork-Presbyterian Morgan Stanley Children's Hospital-each with significantly different spatial and environmental characteristics-are providing a unique and valuable opportunity to study and analyze the impact of varying PICU designs on quality of care, length of stay, and staff and patient/family satisfaction.

"From a scientific standpoint, this is an unusual and valuable situation where three separate ICUs on the same floor of a single academic children's hospital can be compared to each other without the variable of different hospitals, physicians and other factors; that's the beauty of the study," says Charles L. Schleien, MD, MBA, Executive Vice Chairman, Department of Pediatrics at Morgan Stanley Children's Hospital. "This multi-year, multi-phase PICU research study, which is employing various methodologies, will identify environmental design factors that have a positive impact on PICU settings and ultimately use these findings to guide PICU planning and design in the future."

The three units being studied are 1) North, a multidisciplinary 14-bed, older style open bay unit with two-bed pods, without walls between bed spaces, and cubicle curtains; 2) Central, a multidisciplinary 13-bed unit with glass-enclosed rooms that have sliding front and side walls; and 3) Tower, a relatively new and larger cardiac care unit for medical and surgical patients (including lung and heart transplant patients) that has 14 private rooms, each with sliding glass fronts, solid side partitions, and a built-in bed for a family member, and features decentralized room-side nursing stations, and designated family-centered space, including a lounge as well as a main waiting room outside that unit. The units are staffed with three separate teams from the same faculty and, combined, have 90% capacity and approximately 1,900 discharges annually.

During the first phase of this study, members of the study team measured, categorized, and assessed the configuration, size, space allocations, and functional relationships of each unit. They also conducted structured observations of the units to track the frequency and length of interactions among PICU caregivers, patients, and families. In addition, the team analyzed five years of patient and quality control data, including patient outcomes, self-extubation rates, infection rates, lengths of stay, medical errors, and staffing patterns; sent questionnaires to five academic children's hospital to obtain detailed information on what PICU nurses require in their visual fields while in patient rooms or at their charting stations; and distributed questionnaires to family and staff to evaluate their experiences and observations.

So far, data is indicating the three different designs do not have a major influence on quality of care. Design, for instance, does not appear to influence either adverse event reporting or the number of events. Despite the premise that the greater privacy of patients in Central and Tower possibly could lead to a higher accidental self-extubation rate, this has not shown to be so. Moreover, the acuity-adjusted length of stay in the North and Central units meets the national average; and in Tower, it is just slightly above the national average, although there is a wide standard deviation.

"We are also finding there are both advantages and disadvantages to larger units, the placement of the electronic medical record (EMR), and family-centered design amenities," notes Dr. Schleien. "However, the visibility of patient monitors is proving to be a critically important piece of PICU design."

The structured observations reveal that caregiver bedside presence and the number of visitors and their length of stay vary significantly among the units-with Central having the most caregiver bedside care presence because of in-room EMRs and Tower having the largest number of visitors at one time. Feedback from families indicates they prefer the greater privacy offered in Central and Tower, and parents in Tower particularly appreciate being able to sleep overnight on the built-in bed in their children's room. Interestingly, many family members perceive greater nursing coverage in Tower than in Central because they observe many nurses in Tower at the EMRs, which are located at the substations outside patients' rooms -although the coverage in all units is comparable.

The PICU nursing staff has expressed both positive and negative opinions about the three different designs. For example, nurses in Central have issues with storage and inventory constraints but at the same time appreciate that, compared to Tower, their unit's smaller footprint makes many things more accessible and convenient. Based on questionnaires, the research team has determined that nurses place highest design priority on the visibility of monitors and patients' alarm lights, as well as their ability to observe patients who have been intubated.

This PICU study team is continuing to gather and further quantify data. During the study's final phase, the researchers will compare the designs of the three PICUs at Morgan Stanley Children's Hospital to PICUs in several other hospitals.

Contributing faculty for this article:
Charles L. Schleien, MD, MBA, Executive Vice Chairman, Department of Pediatrics, Morgan Stanley Children's Hospital at NewYork-Presbyterian/Columbia University Medical Center, and Professor of Pediatrics and Anesthesiology, Columbia University College of Physicians and Surgeons

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