this hospital department case study analysis will be about the intensive care unit also known as icu we will begin by discussing fundamentals of critical care design starting with a brief history of patient care and how that's evolved into critical care take a quick look at uses it's not only patients and families but the caregivers as well and then we'll talk about some current influences on these environments and then after that we will cover space drivers of icu design briefly talk about regulations where it sits in the hospital some operational concepts that drive design as well as impacts of technology and equipment requirements we'll follow up all that with a handful of case studies looking at a variety of unit designs and the rooms that are in those units really a high level look at those and with some closing thoughts on future trends and where we're headed now we will start with the icu fundamentals including brief history icu users patients and their families as well as caregivers and the current influences on healthcare environments so beginning with the history i don't think any history would be complete without mentioning florence nightingale and her early explorations in the codifying of the design of a patient care unit and the design grew out of her experiences on the battlefield and she brought them to institutions this includes defining size of a unit the type of airflow that would go across it you can see in the image at the left that these were clearly based on as many patients in a room and the visibility to those patients so really complete visibility to patients and this of course informed patient care for a number of decades in a lot of the all pavilion type hospitals that we still see around architecturally today following this really was dr bjorn ibsen he is the physician that really started what we know as critical care today and it was defined by the first use of positive pressure ventilation by intubation 1952 and that was in copenhagen and so this was the first use of that ventilation this really as you'll see continues to be a definer and a space driver in critical care design this led again to the first icu established in denmark in the 50s it made its way to the united states in the 60s the first surgical icu in baltimore in 1962 we started to establish protocols for this mechanical ventilation and explorations and that equipment started too and you'll note that in 1970 a society of critical care medicine was founded and so it really began to be a specialty of its own only about 50 years ago so we've come a long way from that through sort of open bay observation of these critical patients to private patient rooms and then finally to specialty critical care units in this slide we see typical current state of the art private icu rooms in two hospitals we can see here some of the specialty icu's coronary icu where serious heart problems are treated cardio thoracic icu designed specifically for the care of post-operative cardiac and thoracic surgery patients neuro icu dealing with the brain and spinal cord surgical icu for patients that may come out of surgery and need additional support niku neonatal intensive care unit specializing in the care of ill or premature newborn infants and finally pq pediatric intensive care unit specializing in the care of critically ill infants children teenagers and young adults aged 0 to 20 so really what defines critical care unit it really starts with the patient and the image here is i think typical of what you would see in a critical care unit patients are on life support and have machines that are essentially replicating what their organs of their body would do and again the definer of this is the idea that a patient is incubated and a mechanical ventilator is doing a lot of the breathing for that patient you can see that in the image some of the care providers that you'll come across in these types of units is the intensivist and what that really is a physician that's specially trained for intensive care you'll also find that nurses are becoming more and more specialized for critical care as well as physician assistants technologists all the supporting staff really start to become specially trained for this type of care other important caregivers in the icu include respiratory therapists they are the folks that are dealing with these mechanical ventilators and understand everything going on around that and then finally i've listed the family as a caregiver as well and i think this is still evolving at a lot of institutions because in some older units the family historically has sort of been kept to the side or had their involvement limited in the critical care environment and i think that's starting to change we've certainly seen it start to change in the medical surgical unit but i think more and more the family is becoming a part of the critical care environment as well in the next slide we will watch a video talking about icu patience types and stuff patients come to the icu when they have a serious illness or injury that requires around the clock specialized and intensive care common reasons that patients are admitted to the icu include respiratory failure a surgery that requires extensive recovery such as heart surgery trauma such as a car accident stroke organ transplant surgery or possibly an overwhelming infection if your loved one is staying in the icu he or she will receive 24 7 care from a team of doctors and nurses the number and type of doctors on the team depends on the type of injury or illness together they will work with other care professionals to deliver the best possible treatment some of the care team may include a physical therapist someone who helps improve or restore movement an occupational therapist someone who helps improve or restore functions of daily living a respiratory therapist someone who evaluates and helps with breathing function dietitian an expert on nutrition pharmacist someone who prepares medicines for treatment iu health has multiple teaching facilities in which you may encounter medical students residents and fellows as part of your team an average day in the icu will include multiple visits for members of the care team in fact the icu is a very busy place so you can expect lots of lights machine noises and care members your loved one may be hooked up to many types of monitors including ones that keep track of heart rate respiratory rate blood pressure and the level of oxygen in your blood which is called pulse oximetry in addition your loved one may have other tubes placed to help deliver medicine and assist with treatment these may include the following a central line which is a long thin flexible tube used to give medicines fluids nutrients or even blood products over a long period of time through a large vein in the chest or arm an arterial line which is a thin catheter inserted into an artery a foley catheter which is a thin sterile tube inserted into the bladder to drain urine a breathing tube connected to a ventilator which is a machine that helps patients breathe when they cannot breathe on their own an og tube which is a flexible tube used to provide nutrition when a patient is unable to eat your loved one will also receive a lot of medicine in the icu including medicine to help keep him or her sedated while they are receiving so influences on these environments and this is i think really a lot of things that we've seen in the news today with the coronavirus pandemic and widespread of this infection worldwide and continue to see in the media that are affecting these environments of course i think we've all become familiar with the forecast shortage and i've said nurses here but i think it's really it spreads the gamut of care providers physicians nurses and all those sorts of things something we could see is an increased emphasis based on some of that support staff that i mentioned a moment ago the physician assistants and nursing assistants thus if we can't fill the shortage of the nurses and physicians then some of those staff may start to take a little more responsibility in these settings secondly the aging population is something we're all familiar with as well this is clearly going to increase pressure on critical care units as those populations just continue to get bigger and bigger and as they grow older thirdly really aging facilities many facilities out there have some older buildings they're providing care but again as these facilities age we'll be seeing a lot of renovation projects in addition to some of the replacement in greenfield facilities again an increase in drug resistant bacteria i think mrsa bacterium is becoming more and more of an issue what that means for us in terms of designing critical care environments is that more and more focus will be placed on a cleanable environment in one that promotes good behaviors by the staff such as encouraging hand washing and wearing precaution gowns before going into the room and a place to dispose of them after and so i think we'll see more and more focus on that infection control and also i note here is statistically the icu is the site of the most hospital acquired infections i think a lot of it may have to do with the intubation catheterization of patients and fluids running through machines answer again places the emphasis on infection control in critical care evolving technology you know i think we all get a cell phone new every six months and the monitoring technology is continuing to evolve for critical care as well as other parts of the hospital but this will always be evolving we always need to be cognizant of what's happening even though we may not know what's next around the horizon and then finally healthcare reform legislation there's a few items here that are relevant to our discussion of critical care environments one is that it's calling for no reimbursements for hospital-acquired infections and statistically the critical care units have the highest incidence of these hospital acquired infections also readmissions will not get reimbursed as at all for patients that need to come back to the hospital who have already been discharged this may affect potentially lengths of stay within an icu a lot of institutions are still just beginning to think about how to react for reform and what it's going to mean for them but these are some things that we can start to think about as designers of these environments and how that affects these places the main drivers of icu design include hospital adjacencies operations regulatory requirements equipment power and medical gases and of course technology so where does the critical care unit sit within the overall hospital in this diagram is really sort of biased toward the intensive care unit with everything spiraling around it but typically there's a strong link if you will between the intensive care unit and the perioperative or the surgical environment the idea with that is that a patient that may come out of surgery and still not be stable may need to be rushed to the intensive care unit for that level of care a lot of institutions in their ideal world would have the intensive care unit horizontally adjacent to that surgical environment so that those patients wouldn't necessarily need to go into an elevator to get to the icu a lot of times that's not possible to do and sometimes on some projects the elevators that connect the critical care unit for surgery being sized to the point that an entire team can accompany a bed into that elevator and continue the care of the patient even as they're in the elevator also good connection to an emergency department again likely via an elevator ride imaging lab pharmacy or other sort of diagnostic and treatment areas again want to be connected could be connected through a pneumatic tube in the case of a lab or maybe a pharmacy i've overlapped imaging and pharmacy because i have some examples where once a floor or a hospital gets to a certain scale it starts to make some sense for these things to be directly adjacent in at least in terms of a satellite directly adjacent to the critical care unit so for example a ct scanner may be just a few steps away from the intensive care or a satellite pharmacy may actually be embedded in the intensive care unit because the delivery of special medications to those patients is so critical and then finally the idea of respiratory therapy oftentimes respiratory therapy as a small department wants to be located next to the icu when their main charge again is taking care of the mechanical ventilators it makes a lot of sense for them to be right next to the intensive care unit so that's a very high level look at how the icu fits into the hospital overall operations are considered as a key space driver one of the first things that typically comes up in any bed unit design but particularly for critical care is what is the ratio of nursing staff to the patients that they're caring for and because critical care patients are so compromised and can tend to be very fragile the nursing ratios tend to be a nurse to every two patients and in a lot of cases it's one nurse caring for one patient on a floor so each patient would have a nurse caring for them you'll start to see how this type of ratio starts to inform some of the planning of the case studies that we'll talk about a little later even higher nursing ratios have been adopted in intensive care unit for example the use of portable heart lung machine known as ecmo increases the nursing ratio into two to one this is because a nurse is needed to care for the patient and another nurse runs the ecmo machine this becomes more than applicable in the case of coronavirus patients who critically demand the use of ecmo treatment to save their lives the idea of a centralized nursing model versus a decentralized nursing model i think when critical care units could be a lot smaller and there were not even private rooms but maybe they were just open bays of patients it was much easier for the staff to be located around a very centralized station and be able to visualize for example eight patients at once but as we've made the move to private patient rooms and as those patient rooms have gotten larger they start to spread out so it becomes very difficult to centralize the nursing staff so they can visualize a number of patients and that's when we've started to see models of decentralization start to be developed and we'll look at some case studies of that as well and again the idea of visibility or the direct monitoring of patients is always key to critical care design however technology may be changing but just a little bit and we'll talk about that infection control again i just want to reiterate the importance of understanding infection control as we design these units again very susceptible patients are in these units and then finally the idea of multidisciplinary team care i think there's a lot of people coming into the floor that are helping care for a patient and as we move into health care reform i think we'll see that's more and more focused on team care of patients with a focus on overall outcomes there will be a need to start to understand the space requirements for that type of care as well regulatory requirements i decided not to draw the diagram of what is located in the guidelines here but rather illustrate some of the forces that work to inform those guidelines again 2006 we had the aia guidelines that has since become the fgi guidelines released in 2010 and if anyone's familiar with the 2006 guidelines the 2010 guidelines have been further increased clearances around the bed a window of course is mandatory in a room the toilet however isn't necessarily mandatory in a room but access to a toilet or a soiled utility room for body waste disposal is required always good to check and make sure that states or authorities having jurisdiction may have their own set of guidelines or may have modified the fgi guidelines to suit a certain case so it's always good to check those guidelines but i mentioned the increased clearances and if you watch the diagram be changed a little bit that's really what starts to drive the clearances the clearances are looking for clear distance or length at the head wall which is to the north in the diagram b and it's also looking for a certain distance at the foot of the bed and what i just illustrated why we need the clearance of the head wall and why we need that distance at the foot of the bed is that when a patient may start to go bad what they'll always want to do you see the person behind the head of the patient they want to be able to manipulate that airway in a patient that's incubated and they need clearance to do that so if they were only a couple of feet at the foot of the bed they couldn't pull the bed out manipulate the airway at the patient's head and still get equipment and personnel around the foot of the bed to assist so this is really the driver of why these rooms tend to get very large and this access to the head of the patient you'll see that there's a variety of solutions about how the bed may be configured and how gases and power are delivered to the equipment around the head of the patient the 2018 ft i made the minimum critical care bed clearance needed is 200 square feet healthcare planner and designer needs to consider the continuous updating process of healthcare facilities guideline nationally and internationally to provide lean green efficient and updated operationally state-of-the-art healthcare facilities here we can see the major updates in the history of healthcare facilities guidelines in the united states starting with 1947 guidelines and ending with the 2018 fgi guidelines the next 2018 fgi update is expected to be on 2022 based on four year fgi continuous update cycle i think the current coronavirus pandemic should have a major influence in such update here you can see the 2018 fgi update concerning the critical care rooms by comparison to the 2014 fgi edition a design spot could be made to cover the fgi guidelines as well as other healthcare facilities guidelines such as the australasian health facility guidelines the uk hbn and htm the canadian z8 000 as well as others however the design spot of this part will be focused on the intensive care unit equipment furniture and infrastructure equipment is a huge space driver here and again this can really start to pile up at the head of the bed key of course being the mechanical ventilator assisting with breathing for the patient recently portable heart lung machine or extracorporeal membrane oxygenation system known as ecmo replacing the use of ventilators in the case of highly ill critical patients blood filtration that's the hemofiltration wall mounted patient monitor to examine continuously patients physiological parameters such as part rate ecg rhythm blood oxygen level temperature blood pressure as well as other parameters numerous iv pumps pumping nutrition or drugs or any number of things for the patient suction pumps leading to the canisters gathering of body fluids so again the machinery and the equipment are all doing a lot of the work that the organs in the patient may normally do when they were well what this all starts to add up to is typically a lot of noise and it seems like every equipment manufacturer is always trying to route to the next guy's alarm or buzzer and so acoustics start to become a concern in these types of environments clearly an alarm going off alerting that something is wrong with the patient is critical but for the patient to be able to heal and as families get more involved we need to pay some attention to acoustics but again understanding the needs of infection control in these environments and then medical gases and power here this is this always becomes a key driver of a room design which then starts to inform the unit design i'll start at the left with the most basic configuration and that's really just a head wall and what that is the gas's power any other devices that are needed are just simply mounted to the wall that the head of the bed goes against and these can be a pre-manufactured item or they could be a custom item such as shown in this image and again this is how those guidelines tend to be written as the bed is flat against a wall so this is probably where you would start to diagram a room if you were laying out a critical care room so this has evolved though based on interest in need to get better access to the patient's head for the purposes of intubation and so in the center is one step into doing that and that's a column arrangement typically these are products in this example photo is from hill rom but there's certainly other companies that manufacture these items and really what it does is take all those gases and power outlets monitors and sometimes lights and puts them onto a freestanding column in the room and so rather than have the bed pushed up against a wall the bed is really free floating in the room if you will so there's better access in terms of 360 degrees around the bed in this case this also has evolved into a boom which is at the far right and this starts to look a little bit more like what you might see in an operating room this is a pretty intense setup gases and power all from a ceiling suspended boom what this does is keep the floor area clear so staff can move around a little more easily the goal of this is to also manage a lot of the tubes and the wiring that are coming from the gases and the power outlets to the patient and to the equipment what the boom also lets you do is reconfigure the room depending on the case that you might have so i think these are all i think equally valid i don't think that the head wall necessarily at the left limits access to the patient's head i just think that the columns and booms are an effort to make it that much more easily accessible but just keep in mind that in designing a room whichever it becomes the clearances as they're defined in the guidelines tend to refer to a head wall arrangement so further study would be needed if the client selects a column or a boom arrangement technology is a space driver if you recall i talked about how we've moved from a centralized to a more decentralized nursing model as the units have gotten bigger some things that i've heard from staff is concern over how staff will be able to communicate with each other as they start to spread out on a floor and in teaching facilities questions then become well how am i going to mentor students or younger staff and teach them what they need to know if we're all separated we will watch video in the next slide about an advanced nurse calling system for lt nurse call released recently by the hill rom company such nursing platform or system will provide a solution for such concern also dealing with the visibility issue is the concept of remote monitoring and a lot of times you might hear this referred to as an eicu and much like for years radiologists have been remote and reading films and making diagnoses this is a similar thing in that telemetry and cameras broadcasting an image of the patient a sent for an intensivist that is remotely located who can help monitor that patient and keep an eye on vital signs no i don't think that this completely replaces the visualization that's needed in the unit clearly if something goes wrong with the patient the staff will need access to help the patient but this is one idea out there about providing an extra level of monitoring for patients and the third item i've listed here is switchable glass and what this is glass that's charged so that once it's turned on or off the glass can go from opaque to clear and i bring this up because it was used in a critical care renovation project where the clinician staff in doing the project decided that cubicle curtains harbored so much bacteria and were an infection control risk that they wanted to eliminate cubicle curtains from the entire unit design and so that project used the switchable glass as a solution to the maintaining some patient privacy but removing the infection control issues of cubicle curtains and i know that this certainly costs more than a typical regular glass but not quite sure how much and it may vary from manufacturer to manufacturer patients expect the highest standard of care from their hospital but care teams get bombarded by disjointed technologies it's time to connect your health system from intake to outcome and beyond from bedside to smartphone the volt platform responds to every need provide a vital lifeline between patients and caregivers workflows automated delivery steps reduced response times accelerated all to enhance safety and increased patient satisfaction bring patients into the communication loop to give them comfort in an unfamiliar environment put them in control so they can request what they need or access crucial details from an easy to navigate bedside tablet maintain the caregiver patient connection rapidly and securely no matter where you are coordinate care with direct access to meaningful patient data orders and alerts on your smartphone lessen the burden of alarm fatigue simplify your workflows around receiving and addressing alarms to get the right alert at the right time [Music] bring total context to care teams for remotely monitored patients view waveforms alarm strips vitals trends and more on the go for rapid assessment and response it's time to raise your standard elevate what you can do for your care teams and patients unite your hospital with the volt platform hilrom advancing connected care [Music] this part will cover intensive care unit design based on unit and room types then we will study four ic units case studies in terms of unit and room type so from here we'll go into some of the case studies both unit types and room types starting at the left a centralized unit and this is really based on a panoptic team station at the center of a series of rooms and the idea being that you can be in one spot and visualize any number of patients from that one spot so again this would prioritize visibility of patients over anything else in this particular case the center unit type of hive called decentralized and i think this is one that we all we see a lot of today and the idea is that between every two rooms is something like a nursing cockpit if you will so it's a computer workstation or a desk and the staff would sit there when they're working or charting and be able to observe two patients at once right at the room and this is a solution to the spreading out of the unit based on the need for larger private rooms and to the right of that diagram a little box to represent a teaming area and those don't necessarily always fall in that location but it's the idea that in addition to this decentralized nurse work area that there's also a team area where staff can gather to discuss a case and then finally at the right is one i've called a hybrid and this is really a combination of a satellite or decentralized nursing station and a central observation station or series of stations that can still visualize into patient rooms it is the recent trend adopted due to its high operational efficiency during both nursing shifts day and night and then at the lower part of the slide of the head wall or gas and power delivery types that we just talked about a few minutes ago we'll see some examples of a headwall configuration a column configuration as well as a boom configuration our first case study is really a look at the centralized nursing model in rockford illinois the swedish american heart and vascular tower again a critical care floor based around heart patients so you can see this is a very deliberate study of how to visualize eight patients at once from a central nursing station but still provide decentralized support to those nursing pods and so at the number one that's diagrammed on the plan you can see there's some shared support spaces this would be clean utility rooms soiled utility room medications room or nourishment room but set up in a way that it can open to either side so the two pods along each side of it and be a short distance from the nurses that are working in their pods one of the aims of this plan was that as a nurse is doing most of the work within that eight-bed pot the goal was to reduce the walking distance of that nurse this is something that that tends to come up a lot and as we look to make our hospitals a little more efficient and help our staff be more efficient nursing walking distances and how many steps they take to go get supplies will become more important and so this project was looking at how to minimize the nurses steps around those eight patients as well as maximize the visibility to them again the number three on the left indicates the importance of family space on these units in addition to what's provided in the room this is just because the rooms may start to get bigger and accommodate family space within them they're still especially in these intense environments need to be a space that the family can get away for a few moments of quiet an enlargement of the typical aid bed pod in this project shows the lines of visibility to the head of the bed the unique design although the room types there end up sort of differing a little bit as they go around the cluster the visibility to the patients is maintained as you can see in the photo at the right what this plan has done is really get the visibility and the clustering of these pod layouts but sort of put them on a race track that puts support within just a few steps of each of the pods so really driven by efficiency of the staff and visibility to the patients and as we look at the rooms again they are large rooms but again driven by the clearances required for intensive care for the amount of equipment that will be in the room and for the potential to pull that bed out from a head wall in this case and get access to the patient all around you'll also see that there is a toilet room here though it doesn't have a shower or a tub and typically when toilet rooms like this are provided they tend to be more for the family as a patient gets to the point where they can ambulate to the bathroom on their own they tend to be taken out of the critical care unit and may be moved to a medical surgical unit so with a little or less requirement for visibility and you'll also see that this room has a very significant family amenity space there at the window so this is one example of a critical care for really bringing the family in to be part of the care of the patient example number two is saint joseph's hospital in phoenix arizona opened within many years ago really a decentralized model and what's interesting about this floor diagram here is that it is in addition to an existing facility the small 16-bed intensive care unit is actually located horizontally adjacent to a larger medical surgical unit but as we zoom into the critical care unit i've done a little diagramming on here as well you can see i've labeled at number one some of the team areas that aren't necessarily located in a way that they could visualize six or eight rooms at once for example but that the ones closest to the entry i've got some arrows on those where located in a way that they can monitor the entries and exits to the unit so there's a level of security with where those are placed number two diagram is a typical decentralized nursing station and you can see that little notch along the plan there again this would imply a nursing ratio of two to one in this particular case i've labeled three to the top right of the plan the satellite pharmacy and this is again an example of bringing some of those functions that may be deeper into the hospital and centralized to a satellite area to serve a critical care unit this makes a lot more sense when it's located against other bed floors such as the medical surgical unit that was to the north of this critical care unit so that it can serve a number of areas from this one location but conserve the immediate needs of critical care also labeled number four and that's a blood gas lab and that tends to want to be with respiratory therapy or again directly adjacent to a critical care unit this is a lab that will take blood samples from the patient and test them to see how the blood may be absorbing oxygen or not and they can judge the patient's state based on that and those are tests that typically need a quick turnaround so that's why they want to be located here and then at number five i labeled the isolation room just to point out that the location of this on the unit is very important because our patients in these isolation rooms may be infectious and we don't want to transmit that to other patients so you'll see that number five here is located right next to the entry into the unit so when we bring a patient into that room and need to isolate them they don't have to roll past half a dozen rooms before they get to the isolation room so we can manage that in that way and again moving to the room this is an example of a column room you can see the column at number one floating in the middle of the room bed pulled away from the wall so that we can get good access to the patient all the way around the bed number two i just want to point out the idea of windows between rooms and this i don't think is a requirement but it's something that a lot of clients are interested in and again if you think about the nursing ratio of one nurse to two patients and they're staffing these two rooms the idea is that nurse can be in the room a and be able to look across into the room b and keep an eye on that patient again visualizing the patients is key to critical care nurses and then finally at number three less than what the swedish american example had but again a family zone looks to be a sleeper sofa in this area so that families do become part of the care process in this facility as well another case study to look at is rush university medical center and again this is a very large academic medical center and so we're looking at a very big floor plate here i'll point out that once we get to a floor of this size about 56 critical care beds you'll start to see some economies in scale of sharing some support space such as at number one staff lockers lounges those sorts of things but you'll also start to see in this case satellite imaging i've labeled it number two and in this case at this level of diagram i can't tell if it's a ct or mri but the idea that there's enough population here on the floor and a level of patient care needed that it makes sense in this case to bring imaging up to the floor at number three i've pointed out separate circulation and this is something i think when possible is something to strive for in a unit layout like this and the idea is that family and visitors coming up a public elevator don't cross traffic with a soiled utility cart going down to the to the basement or to the loading dock or that that would mix with food coming up on dietary cards from the kitchen and so in as much as possible it's always good in these types of units to separate that traffic flow and then finally i'll point out number four again the importance of family space i don't think we can overstate that but if you look at how the floor is broken down from the 56 beds it's a lot to manage the floor is basically bifurcated into two 28 bed units which are then split again into a 14 bed cluster now we will zoom into one of those clusters and take a look at that again a decentralized model and taking a sort of an objective analytical look at some of these plans this one looks to be based on a one-to-one nursing ratio you'll also note that the rooms here are same handed which a lot of times does complicate the idea that a central cockpit between two rooms can visualize two patients at once and so there is some support space outside of each room for a nurse to work but at the numbers one that are on the diagram there is still a team space again located in places that they can monitor entries into the units the one at the center is actually located where it can see a number of patient rooms at once and then a conferencing type space there at the end with general support for these 14 beds they're at the center again that's your clean utility or soil utility rooms medications and nourishment the basic things that is the back and forth between the patient room with materials and again i'll point out finally the isolation room at placement four again keeping that close to the doors into the unit so that we're not rolling those infectious patients past all the other patients and a look at the room this is a room based on a head wall design and i think you can see in this diagram clearance at the foot of that bed that it's been kept open i think the photo might actually be of a medical surgical room since i think these were more or less universal rooms where we see some furniture or casework at the foot but there is still a family space at item number four in this room i also pointed out here patient lifts and we see more and more of that as budgets allow even in critical care environments think this will become more and more important as we don't want to injure the patient any more than they already are again referring back to the reimbursements about hospital acquired injuries and infections we also want to keep our caregivers safe so we may see more and more integration of lifts into patient rooms such as this and then at item number three i just labeled the decentralized charting and supply areas right outside every room here and then another case study again another academic medical center with a very large floor of beds on it at ronald reagan ucla i've highlighted in the red box the critical care unit and you can see how the geometry of that differs significantly from medical surgical units on the same floor and we'll look at that in an enlarged plan and in the orange box next to that i've actually highlighted another example of a satellite imaging suite but you can see the scale of the floor here would support a satellite suite of that magnitude here so looking at the enlarged plan in terms of a diagram of this i actually couldn't decide and i thought that there were some aspects of this that were almost like a centralized model but then certainly aspects that were like a decentralized model where the numbers are placed it can certainly visualize a number of rooms but i don't think it's necessarily set up to visualize all of the rooms and that we're really relying on the decentralized stations between two rooms shown at number two for that direct observation of patients but i think that this unit is designed to be as open as possible within that center core and the support space has been put to the south side of it within the room at the right this is an example of a boom room so we can see the boom which also includes exam lighting over the bed the bed is almost completely in the center of the room and so what we're seeing here is a very intensive area of care to the point that at item number four there are even sliding breakaway doors between the rooms so that the staff can quickly get from one room to the next you can see one at the bottom right of the room photograph here and what that essentially is a piece of prefabricated plumbing slash casework that actually has a toilet attached to the door in it so when you open the door a toilet swivels out and the patient can use that toilet this known as the swivet so again if the patient is well enough to be up walking around and using a toilet they may not necessarily stay in the intensive care unit but it may be a convenience for staff dumping of a bedpan all that sort of thing in the room this part will mention some thoughts about possible trends or changes in the intensive care unit design in the future and so finally where is it going from all this i think clearly we know that we're going to have sicker patients the aging population may give us more patience factors such as the bacteria and as well as reimbursement realities will continue to increase the focus on infection control and patient safety not only from the materials that we might specify but to how we lay out a floor so again from that big idea to the detail how are we going to address these issues an increased focus on operational efficiency again it's a team outcome based reimbursement that reform may give us combining with shortages that we see coming and staffing so how can we get the staff to be more efficient potentially may see a little bit more of procedures in the room but not sure and then what might nano technology do for monitoring will a lot of this equipment at the head wall start to go away in the coming decades and be replaced by nanobots in the patient's body also the use of artificial intelligence generally and deep learning specifically could fill the gap of staff shortages robotics could also play a major role in enhancing safety and minimizing staff as well as patients injuries finally integration and interoperability among medical devices connected to a patient could lead to robust way of delivering care so those are just some closing thoughts about where we might see critical care going in the future finally thank you for watching