Although my medical training prepared me well for treating brain injuries, I learned very little about caring for the enormous emotional needs of patients in neurocritical care units and their families. Having a physical environment that encourages the participation of the patient’s family is extremely important. Not only can having loved ones nearby give great comfort to the patient, but it helps provide a critically ill patient with an identity, which affects quality of care in fundamental ways. Having an identity is an anchor for everything, ultimately influencing not only clinical care but research as well.
This article describes our experience in developing a new neurocritical care environment at Emory University Hospital over the last 10 years using an evidence-based design centered on caring for patients and their families.
STARTING POINT: A RAPIDLY GROWING PATIENT POPULATION
Emory University Hospital, part of the Emory Healthcare health system, is the largest medical center in Georgia, with 43 neuroscience floor beds, 27 dedicated neurocritical care beds, and 10 intermediate neurocritical care beds. We have experienced rapid growth, with neurocritical care admissions rising from 587 in 1999 to more than 1,400 in 2007. We treat patients with meningitis, brain aneurysms, tumors, massive strokes, Guillain-Barré syndrome, myasthenia gravis, and other severe problems.
When we proposed building a replacement neurocritical care unit, we first appealed to the bottom line: if we had more beds and could attract more patients, we would generate more revenue. The hospital’s mission stated that we had to take care of patients with neurological emergencies because no one else in town could.
The administration countered with predictable restrictions: because Emory University was at that time considering building an expensive replacement hospital, they did not want to spend a lot of money improving a single unit. They agreed only to meet the state and federal requirements so that we could quickly open up and receive additional patients.
The initial design was for a 24-bed intensive care unit (ICU) with a “track” around it: visitors would enter patient rooms from the back so as not to disrupt the central area used by the doctors and nurses. The rooms measured 200 square feet, as required by the state of Georgia, with no dedicated space for family members. This design actually duplicated the system we already had in many ways.
TRADITIONAL SYSTEM: PATIENTS SURROUNDED BY EQUIPMENT, NOT FAMILY
In our old unit, the typical patient room was so crowded with specialized equipment that it was virtually impossible to get to the patient without tripping over cords and knocking out catheters. It took some time to respond to an emergency, and maintaining sterility in such an environment was obviously difficult. During rounds, residents, fellows, and the multidisciplinary team practically fell over one another, and actually seeing the patient in the midst of all this was a challenge. In the central area, nurses were crowded around desks with charts spread all over tables, increasing the potential for mistakes in recordkeeping and medications.
Where were the families? We previously had a dark, dingy common space in the outside hallway, well away from patients. Families were prohibited from being in patient rooms during rounds for fear they should misinterpret or be alarmed by something they heard. Discussions between doctors and families took place either in the cluttered patient room or in a public area. Imagine this in situations in which a patient’s prognosis was poor and discussion was needed regarding brain death and organ donation. The new space promised little more than some new converter chair/beds in the common areas.
I did not have a clear idea of exactly what we needed, but I knew that the proposed design was not it.
EVIDENCE FOR A BETTER WAY
To convince the administration that we should pursue a completely new concept, we focused on key people: the chief executive officer of Emory Healthcare and the chief nursing officer of the neurosciences critical care unit. We told them that the current ICU was terrible for families and was inherently dangerous. The potential for medical mistakes was enormous and probably largely unrecognized. Staff burnout was also a potential issue: we reminded them of the tremendous nursing turnover, especially with our aging nursing population. We also told them that we believed there was a better way.
The medical community bases clinical decisions, such as choosing a drug to treat infection, on evidence from the literature. Shouldn’t such evidence also inform how we design hospitals and ICUs? I rapidly learned that convincing scientific evidence exists that the physical environment affects outcome.1 The literature shows that we can empower families and staff and significantly reduce cost.
We proposed a new design founded on an evidencebased approach for patient- and family-centered care. We were confident that a better design could reduce staff stress and enhance performance, and we hoped it could also reduce costs and improve effectiveness. As an academic institution, we wanted to measure such factors and continue to study this issue by building a living laboratory of a new type of family-centered ICU. We also wanted every treatment tool available while remaining flexible enough that we could continue to change in the future. Most importantly, we wanted to keep patients the center of our focus.
EMPHASIS ON FAMILY INVOLVEMENT
Our primary driver was support for families. We proposed completely eliminating all the signs restricting visitors to the ICU, such as those reading, “No visiting: Physician rounds in progress” (we were tempted to rewrite that sign as, “Physician rounds in progress: Visitor presence mandatory”). Rarely is the family actually required to participate in the care of a patient; we have no contract with the family delineating what the health care system provides and what we expect the family to do.
We planned for a family zone in the patient room, a children’s room, lockers and showers, and a family quiet room. Outcome measures would be patient/family satisfaction and provider satisfaction based on surveys, as well as the number of patient/family complaints and the number of litigation filings.
Other important drivers were the desire to support more procedures at the bedside, reduce infection, reduce medical errors, and increase patient safety. Every goal had measurable outcomes to be tracked.