Intensive care unit design

According to the 2012 Society of Critical Care Medicine’s guidelines, optimal ICU design can (1) help reduce medical errors, (2) improve patient outcomes, (3) reduce length of stay, (4) increase social support for patients, and (5) play a role in reducing patient cost. Private rooms enhance the patient and family experience, and minimizing noise and disturbances can promote the healing process. On the other hand, published reports describe a correlation between lower ICU visibility and increased mortality. As such, reliable monitoring systems are crucial to patient safety and quality of care. This includes not only bedside monitoring but also remote monitoring of patients from central workstations and throughout the ICU. Several design elements can enhance situational awareness, patient surveillance, and nonverbal communication both in patient rooms and within the ICU.

In patient rooms:

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  Monitoring should be visible from the door as well as the care team’s workspace.

  
  
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  Display boards in the room can be used for daily care plans, patient and family questions, and family contact information.

  
  
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  Signage in the room can convey information to care team members, ancillary staff, and families (e.g., isolation requirements, fracture risk, fall risk, difficult airway or an open chest).

  
  
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  Boards outside the patient’s room identify the nurse, responsible physician, and contact information.

Within the ICU:

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  Remote centralized monitoring (e.g., monitors at various places in the unit itself, conference rooms, call rooms) or remote access monitoring (e.g., web-based applications) should be in place so that even when not in the vicinity of the patient, the patient’s monitoring is visible or accessible.

  
  
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  A central board near the main workstation shows the physical layout of the unit, patient location, nursing assignment, admits and transfers for the day, the care team members, and their contact information.

  
  
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  Signage denoting that a sterile procedure is in progress creates a physical barrier to encourage nonessential personnel to avoid the area and promotes situational awareness within the greater ICU team.

  
  
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  Remote access to operating room monitors and intraoperative cameras allow the ICU team to follow a patient’s progress and be prepared for patient arrival.

Medical record

Extracting useful information from the electronic medical record can be challenging. Alerts and notifications regarding code status, difficult airway status, medication allergies, or important social issues allow rapid orientation to the patient’s status and care plan. Existing monitoring and evolving prediction models take patient data (i.e., from the telemetry monitors) and identify patterns that might warn of impending clinical deterioration. Likewise, these technologies are helpful in retrospective reviews for quality improvement purposes.

Huddles

Huddles are brief gatherings that bring team members together to create a shared mental model regarding a distinct procedure or event or a status update across the entire ICU. They should include team introductions, review of planned activities, anticipation of problems that may arise, and creation of contingency plans. Huddles serve to activate teams, empowering each team member to share responsibility in the completion of the task, while encouraging openness and trust among the team, facilitating communication, and improving overall situational awareness. ^,

Keys to successful implementation of huddles in a medical setting include, but are not limited to ^{, ,} :

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  Designating a leader

  
  
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  Mandatory participation of all team members

  
  
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  Incorporation into standard work practice

  
  
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  Limiting to 10 minutes or less

  
  
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  Holding in a central location

Huddles can be used in a variety of scenarios:

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  Admission: facilitate communication to review events, create a care plan, and highlight risks/concerns.

  
  
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  Periprocedure: orient the team, define roles, and identify potential pitfalls and contingency plans.

  
  
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  ICU day/night shift: review expected procedures, admissions, transfers, discharges, and high-acuity patients

  
  
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  ICU workflow: discuss planned ICU admissions and discharges along with their impact on staffing, bed availability, and hospital census.

  
  
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  Daily check-in (a Healthcare Performance Institute initiative) : This is a focused and directed conversation to address safety/quality issues from the last 24 hours, anticipated safety/quality issues in the next 24 hours, and status reports on issues identified that day or the day before.

Checklists

Checklists have been widely adopted by the healthcare industry, with demonstrated reductions in morbidity, mortality, and preventable errors. In 2004, The Joint Commission Board of Commissioners created the Universal Protocol to address the wrong site, wrong procedure, and wrong person surgery and other procedures. ^, A 2010 survey found that greater than 90% of respondents agreed or strongly agreed that there was benefit in using the Universal Protocol in hospital units where invasive procedures are performed.

Well-constructed checklists:

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  Function as a communication tool with demonstrated benefit in routine procedures (e.g., tracheal extubation, procedural sedation, magnetic resonance imaging screening, and preoperative screening) and less frequent occurrences (e.g., extracorporeal membrane oxygenation cannulation, computer downtime).

  
  
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  Increase the reliability of care processes. Checklists performed at the end of rounds have been shown to reduce central line–associated bloodstream infections, optimize nutrition, wean sedation, and more.

  
  
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  Review daily care plans. Use of daily goals sheets have demonstrated reduction in ICU length of stay and significant reductions in mortality. ^{, ,}

  
  
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  Serve as an evaluation/audit tool.

Although creation and implementation of checklists are important, shifting the culture and behaviors of those using the checklist is what determines success. Implementing mandatory checklists with limited focus on transformation of attitudes can result in no change in outcomes. ^,

Rounds

Performance of daily rounds in a standardized format results in less variability and more consistent communication within the team. To ensure a shared mental model and optimize situational awareness, all team members (e.g., physicians, nurses, pharmacists, nutritionists, family members) should participate on rounds in preassigned roles. Structured reporting of data and presentation of information ensures that no issues are omitted and all concerns are addressed. Daily rounds conclude with review of daily safety checks and order read-back—closed-loop communication with all team members that reenforces the shared mental model. ^,

Closed-loop communication

Deficiencies in verbal communication impair the development of team structure, collaboration, and task performance. ^, Standardized methods of communication have been developed to promote safety and efficiency, thereby reducing the risk of team breakdowns. ^, A common method used in healthcare settings is closed-loop communication, which involves three steps:

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  Sender transmits a message using standardized terminology

  
  
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  Receiver accepts the message and verbally acknowledges receipt and understanding

  
  
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  Sender verifies that the message has been received and interpreted correctly

Transitions of care

Reliable communication is essential at times of transitions of care. Duty hour restrictions for physicians in training have led to increased handoffs and the potential for discontinuity in patient care. Consistent use of a handoff tool (e.g., I-PASS: illness severity, patient summary, action list, situation awareness and contingency plans, synthesis by receiver) has been associated with reductions in medical errors and preventable adverse events along with improvements in communication, without a negative effect on workflow. Another tool that has been demonstrated to improve patient safety, especially when used to structure communication over the phone, is SBAR (situation, background, assessment, recommendation). Transfers between hospitals to the ICU can be especially high risk, as they involve transport of critically ill patients, variable team members and skill sets, and resources limited by space and mobility. Transmission of clear, concise, and accurate information is imperative.

Creation of a “communication center” can facilitate this process by:

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  Use of a single phone number for all referring hospitals and providers wishing to initiate transfer of a patient

  
  
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  Recorded phone conversations to clarify information transmitted as well as quality improvement initiatives

  
  
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  Ability to conference in multiple team members

  
  
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  Prompt and reliable access to the transport team while in route

Medical training

The Accreditation Council for Graduate Medical Education requires that Pediatric Critical Care Medicine fellows are able to “demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.” Communication is also a cornerstone of effective team leadership and is a key feature of Pediatric Advanced Life Support training. Staff perceptions of teamwork and team behavior are related to the improvement of quality and safety of patient care as well as communication and teamwork that lead to safer patient care. Additionally, evaluation of a trainee’s ability to communicate is changing with the development of clinical competencies and milestones. Intentional education and assessment of communication skills is a growing expectation.

There are many ways to incorporate communication into medical training:

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  A longitudinal curriculum during undergraduate or graduate medical training

  
  
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  Strategies specific to a certain rotation or environment

  
  
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  Focus on communication as a marker for ongoing quality improvement

One effective means of teaching and evaluating communication in the ICU is through the use of simulation. Simulation scenarios focused on closed-loop communication skills—such as clarity of roles and responsibilities, order repeat-backs, clarifying questions, knowledge sharing, reevaluation and summarizing, communication with families, and mutual respect—give ICU staff the opportunity to practice in a high-fidelity, low-risk environment. Some scenarios, such as an extracorporeal life support cannulation, allow for incorporation of multiple disciplines (e.g., physicians, trainees, nurses, respiratory therapists) leading to more realistic simulation of infrequent, high-risk events that require precision teamwork. ^, Simulation is further enhanced with thorough debriefing.

Debriefing

Debriefing originated in the military (analyzing a mission after it is completed) and gained traction in critical incident reviews (mitigating stress following critical events). According to Kolb, the process of reflective observation is a cornerstone of lifelong adult learning. In medical simulation, debriefing is facilitated reflection that leads participants to analyze and learn from an event. Debriefing is also helpful after high-risk, infrequent events and after any event that team members find particularly challenging. Effective debriefing can improve skill acquisition and retention and staff satisfaction. ^,

In general, debriefing includes the following :

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  Structure: phases include description, analogy/analysis, and application. A communication tool ensures that key points are addressed and the process is standardized.

  
  
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  Content: focus can include communication, medical management processes, and logistics.

  
  
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  participation: team members should be active participants in self-reflection.

  
  
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  Action items: development of a reliable method for follow-up is essential.

Team training

The Institute of Medicine calls for interdisciplinary team training programs for critical care settings. Extensive team training curricula based on concepts central to crew resource management exist and continue to evolve. Examples include TeamSTEPPS and VA Medical Team Training.

Some common themes among these programs include :

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  Developing communication strategies that flatten hierarchy and encourage team member assertiveness

  
  
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  Cross-training to tasks, duties, and responsibilities of all team roles

  
  
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  Simulating errors and contingencies

  
  
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  Facilitated debriefings

  
  
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  Creating shared mental models and situational awareness

  
  
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  Encouraging closed-loop communication

Deliberate and continued training, evaluation, and modification are imperative to sustaining the improvement in patient safety that can be achieved when team communication is a focus of a healthcare organization.

Conclusion

ICUs are high-stakes, high-risk environments. Reliable and accurate communication is essential to optimizing patient care and safety. An ICU focused on safety is characterized by thoughtful design, reliable organizational systems of communication, and unwavering commitment to teamwork. These elements foster a shared mental model and improve situational awareness among all team members, leading to greater efficiency and safer healthcare delivery.