Scientific Papers

Creating the ICU of the future: patient-centred design to optimise recovery | Critical Care

Mixed methods were used to gather and analyse data needed to meet the project aims. The interlinked aims of the project were to assess the existing environment and impact on all end-users, to identify problems and potential solutions, and to design and implement an optimised, evidence-based ICU bedspace. The project comprised several stages and linked sub-studies as depicted in Table 1.

Table 1 summary of project stages, activities, and outcomes. dBA = A-weighted decibel; RT = Reverberation Time

Stage 1: defining the problem

To ensure the project was fit for purpose for end-users, the initial step was to complete qualitative studies with patients, family members, and staff to understand the impact of the environment on patient experience and recovery, and potential solutions to perceived problems. A full description of the methods and results of these qualitative interviews have been previously published [20, 27]; a brief synopsis is provided below.

Seventeen patients, seven family members, and thirty ICU clinicians (medical, allied health, and nursing) were interviewed individually and in focus groups (staff only). Data were analysed using a framework approach [28]. Participating patients described ICU as scary and confronting, and highlighted issues such as noise and bright lights at night preventing sleep, while reporting that the ICU bedspaces were small and cluttered negatively affecting care provision. Other issues highlighted were an inability to personalise the environment to their needs and limited access to natural light/views, cognitive stimulation, and connectivity with family and the outside world [27]. Participating staff generally supported findings from the patient interviews and acknowledged that current bedspaces were suboptimal healing environments. They reported frustrations with their inabilities to personalise the environment, and highlighted how environmental features (e.g., noise and suboptimal lighting/lack of views) negatively impacted on staff health as well as ability to provide best care [20].

Next, various methods were used to objectively measure and evaluate the physical and sensory environment in the study ICU. Studies examined factors including light, sound, acoustics, and alarm frequency [29]. In parallel, a comprehensive literature review was completed to further develop a deep understanding of current problems linked with the ICU environment, potential solutions, and impact where any had been implemented and studied.

The data collected from these interlinked sub-studies were then compiled into a draft list of patient-centred problems to be addressed for the project (Fig. 1).

Fig. 1
figure 1

Initial draft list of patient-centred problems to be addressed for the project

Stage 2: designing solutions

To address the multi-faceted problems identified in stage 1 and ensure the project continued to focus on the needs of all end-users of the bedspaces, a participatory design approach was employed to canvass and refine potential solutions. This was an iterative, interactive, and inclusive process involving all stakeholders (patients, families, staff, and industry partners) as project partners.

This phase commenced with a 2-day multidisciplinary stakeholder co-design workshop, with attendees including industry partners (builders, designers, architects, IT companies, and medical technology companies), clinicians, researchers, and former ICU patients (who shared their stories of admission to ICU and their life after ICU discharge). The workshop allowed conversations around potential solutions to commence from multiple angles. These included relevant software and IT improvements, technological innovations, and design and architectural solutions. Of interest, this was the first opportunity for any of the external collaborators to meet patients, despite having built or designed many hospitals previously.

Following the workshop, an agreed list of problems to be addressed was detailed in a draft project requirements document. This document had five streams (1: building and retrofitting, 2: materiality and acoustics, 3: clinical, 4: technology and integration, and 5: ‘other’) and outlined the requirements of an improved ICU environment (Additional file 1: Appendix 1). This document was finalised through extensive consultation and iteration, with all key stakeholders regularly meeting and engaged in suggesting and creating solutions, testing and finetuning them as relevant, before eventually agreeing on a final list of requirements to be incorporated into the proposed implementation plan. To support and guide this process, the action effect method was used to ensure all potential and suggested improvements contributed to the overall project aims (see Fig. 2 for a simplified graphical description and Additional file 2: Appendix 2 for the full diagram). This implementation and evaluation methodology uses a diagram to represent cause and effect relationships and is a commonly used framework to guide the implementation of complex quality improvement initiatives [30].

Fig. 2
figure 2

Simplified graphical description of the project action effect method diagram

Stage 3: implementation planning

After finalising requirements, a site suitable for implementation was identified. As each ICU varies regarding local context, patient population, and individual bedspace design, the solution for any given unit will always need to be individualised to the needs of that ICU and the population it serves. The project team engaged the clinical and management teams of our hospital to tailor plans for the complete upgrade of two ICU bedspaces according to the requirements identified in phases 1 and 2. This was planned to be a retrofit rebuild within a live ICU. Implementation was guided by the consolidated framework for implementation research (CFIR) innovation and implementation process domains [31].

The study ICU comprises 27 beds in three, nine-bed ‘pods’. Of these, 21 beds are open-plan and 6 are single rooms. Two internal and windowless open-plan ICU bedspaces (approximately 21 m2 each) were provided in a corner of one of the three ICU ‘pods’. Both were fully equipped ICU bedspaces, but previously used for simulation training and equipment storage (Fig. 3A and B). Following extensive consultation to ensure local context and priorities were fully understood, the two designated bedspaces were investigated, and a specific and prioritised list of recommendations for improvements produced. All recommendations were assessed against their impact on relevant patient outcomes (including impact on delirium, sleep, and experience) as defined in the requirements document and action effect diagram to ensure the main project aims were being met. The recommendations were also evaluated against the potential costs versus predicted benefit associated with implementation.

Fig. 3
figure 3

Bedspaces before (A and B) and after (C, D, E, and F) upgrade

Early architectural, design, and technological plans were then developed followed by extensive stakeholder engagement conducted over 6 months to ensure all relevant stakeholders had an opportunity to provide feedback and help shape the final plans. Stakeholders involved included former patients and their families, ICU staff, building project managers, IT departments, biomedical technology services, hospital building and engineering services, infection control, external engineering companies, and relevant companies and contractors needed to provide, install, and integrate equipment and complete the final design. Plans were presented as they were updated, with feedback incorporated. Once plans were sufficiently progressed, a full-scale prototype (Fig. 4) was built in a separate building on the hospital campus, with proposed solutions installed and/or displayed. The prototype was used to gain practical feedback from staff who were able to view and physically test the proposed solutions and location of equipment through scheduled simulation training. Feedback was also sought from former patients and their families who were invited to visit the prototype. Feedback was incorporated as able, considering constraints and unmodifiable features associated with a retrofit solution in a live ICU, including existing infrastructure and walls, size constraints, and the location of the bedspaces. Finally, interior designers were consulted to develop colour and texture schemes. Plans were then finalised in preparation for the building works in the ICU.

Fig. 4
figure 4

Prototype space built for staff consultation and simulation training

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