The effects of the COVID-19 pandemic have pushed the U.S. healthcare system beyond all known limits. Providers were and are still challenged at several different levels, including personal protective equipment (PPE) supply shortages, changing care protocols, staff burnout, capacity demands, vaccine protocols, and facility adaptability. While COVID-19 variants and surges are still with us, it’s appropriate to begin documenting lessons learned to better understand how planning and design features can maximize a seamless response to care needs for a range of crisis events.
A forward-thinking buildout of two acute care inpatient units in the North Tower (7NT and 8NT) of Froedtert Hospital in Milwaukee, a major academic medical center affiliated with the Medical College of Wisconsin, illustrates the importance of maximizing adaptability in design to accommodate various types of acute care patient populations, including those presenting with COVID-19.
The goal of this project, completed in 2013, was to create a hospital environment for future or potential patients, not necessarily the current patients that were planned for the space. With an aging population and the move to provide care in outpatient or home settings, the acuity of patients who require hospitalization continues to increase. Recognizing that the healthcare organization was uncertain about how many ICU and acute care beds would be needed in the future, the project team sought to create an acute care environment that could be easily converted to ICU capacity. Little did they know that transition would be necessary six years later.
During predesign phases of the project, HGA Architects and Engineers (Milwaukee) partnered with leadership at Froedtert Hospital to assemble a strong interdisciplinary project team comprising of nursing staff, physicians, residents, support staff, therapists, patients, and family members, along with design researchers, engineers, architects, and construction managers.
The team engaged in several Lean exercises during user group meetings, such as space adjacency diagramming (i.e., teams organized the space according to their needs), speed dating, (i.e., teams asked one another questions about their processes), and information gathering (i.e., teams investigated topics of interest), to elicit design and operational features needed to create an adaptable patient unit and patient room design. In addition, researchers from the design team spent a week on an existing unit of the North Tower (3NT) to gather baseline data through patient and staff interviews and shadowing.
This data helped to formulate a project vision that was stated within the framework of Critical-to-Quality (CtQ) criterion—a Lean Six Sigma concept that identifies environmental or operational needs that are critical in achieving a quality process or experience outcome. For this project, quality outcome categories included patient satisfaction, patient safety, physician/staff satisfaction, family-centered care, efficiency, flow, and utilization of supplies, medications, equipment, and linens. Once CtQ metrics were established for each quality outcome, they were communicated to the project team to aid in design and operational decision making. In addition, the metrics were used to evaluate prototypes and mock-ups during the design process.
Some of the final design solutions related to the CtQ criterion included:
Patient safety: Increase patient room size to be large enough to handle equipment for higher acuity patients, patient lifts in each room, accommodations for bariatric patients, and space for caregivers to perform basic care functions. Maximize patient visibility from decentralized charting stations with a view into each patient room was also established.
Family-centered care: Include separate family space within the patient room, overnight accommodations, and a variety of family comfort zones outside room and outside unit.
Flow and utilization of supplies, medications, equipment and linens: Using a decentralized approach, access to key patient care items, including medications, supplies, linens, and PPE, would be close to the work zone in nurse servers outside each patient room. Proximity of equipment alcoves, medication rooms, and staff toilets to patient rooms was also prioritized.
Physician satisfaction: Strategies included generous spaces to handle rounding teams of 15-20 people; space within the patient room for entire team to participate in discussion; and alcoves outside the patient room to gather without blocking corridors.
Staff satisfaction: Adequate staff space on the units for collaboration, education, and respite with access to natural lighting.
Patient satisfaction: To address noise reduction, the team specified the elimination of central nurse stations, as well as the use of rubber flooring and sound-buffering artwork in the corridors.
Efficiency: Planning for flexibility, the environment would need to accommodate increasing acuity (e.g., acuity-adaptable).
Once construction of the newly design 7NT and 8NT units was complete and occupied for several months, the project team wanted to conduct a post-occupancy evaluation to understand the full impact of their design decisions. Similar qualitative and quantitative methods used to collect baseline data on 3NT during the early pre-design phases were also used to gather post-occupancy data on 8NT for comparison. As a result, the evaluation revealed significant improvement in staff efficiency as nurses traveled six percent less, which, in turn, was directly correlated to six percent more time spent inside patient rooms. Locating supply servers and charting stations outside each patient room and creating two semi-decentralized medication rooms and nourishment locations contributed to shorter distance traveled. This was an approximately 36 minute change per dayshift nurse, which equates to roughly two fulltime equivalent employees per year or $182,097 in salary costs. Another return on investment example was a 35 percent reduction in fall rates (or 5.75 fewer reported falls per year), which has resulted in estimated annual cost savings of $53,667. The reduction was attributed to nurses’ increased time spent in the room and increased visibility of patients via the decentralized charting stations positioned outside each patient room, which allowed for continuous passive monitoring of patient through an observation window.
Considering only four staff metrics—efficiency, turnover, recruitment, and staffing—there was a combined annual cost savings of $526,272 post-occupancy. Similarly, improvements in only three patient metrics—falls, pressure ulcers, and length-of-stay (LOS)—were estimated to save $371,968.00 per year. With a total annual estimated ROI of $898,240.00, it would take just seven years to recoup the one-time construction cost of $6.25 million for the newly constructed 24-bed adaptable inpatient unit. Soon after occupying the new space, the units became one of the highest performing among the 27 other units within the hospital. It was clear that the planning and design features resulted in high performing acute care units.
Strong case for adaptability
Since occupancy in 2013, both units have flexed in patient care type multiple times with minimal renovation and cost. The first transition occurred in 2019, when the original staff and acute care surgical patient population moved to another area of the hospital. This resulted in both units converting to acute care units for medical patients. The second transition occurred as COVID-19 volumes started to increase in spring 2020 in Southeast Wisconsin. At that time, approximately 40 to 50 percent of hospitalized COVID-19 patients required ICU-level care and the other 50 to 60 percent required acute care. In the months prior to the pandemic, the hospital’s average occupancy rate was already 90 to 95 percent (similar to the rest of the state), and only 17 percent of the total hospital beds were ICU level. As a result, the decision was made to transition the 8NT unit to treat COVID-19-positive acute care patients and to use the 7NT unit as a non-COVID-19 ICU unit.
Because both units were designed as highly adaptable rooms, the healthcare system could seamlessly adapt to these changing needs. For example, in the patient rooms, private bathrooms provided an infection control measure. Additionally, the 4- to 5-foot clearances around the patient bed permitted easy patient transfers to a stretcher and/or multiple large equipment pieces in the room at once. Bed clearances also allowed for two beds to be placed in the patient room in response to increased surge volumes. Two sets of medical gases on either side of the headwall made double-occupancy rooms possible, although it was not needed.
On the caregiver side, the care team was spread out to decentralized nurses’ stations (with a window view into patient rooms and recessed alcoves) closer to their assigned patient rooms instead of in a central nurses’ station. This better accommodated the Centers for Disease Control and Prevention’s recommended social distancing protocols, while also helping staff stay close to patients’ bedsides. The extra space outside of the patient rooms also allowed adequate area for patient care equipment so staff could adjust the settings without entering the room and utilizing more PPE.
Some features not originally included in the design were also either added or modified when 7NT transitioned to house ICU patients. Specifically, an equipment storage room was added to accommodate ICU equipment including additional patient monitoring equipment, ventilators and infusion pumps/modules; additional monitors were installed at each decentralized charting station to enable continuous monitoring of higher-acuity patients; and patient room doors were modified with a larger glass cutout to improve visibility of patients and monitors from the corridor. In total, the cost for the added or modified design features was approximately $40,000, allowing for a relatively quick and seamless adaptation of the design.
Despite transitioning to different levels of care and patient populations, these two units continue to perform extremely well with many improvements in patient care outcomes, including a decline in hospital-acquired infections/conditions and higher nurse-sensitive quality indicators and patient satisfaction. Furthermore, feedback from staff was that the converted ICU environment functioned well. While the lasting effects of this pandemic will be a discussion point as the industry plans and designs future hospitals and clinics, lessons learned from projects like this will help document and provide insight of how to anticipate the next crisis event
Kara Freihoefer, PhD, is Director of Research at HGA (Milwaukee). She can be reached at firstname.lastname@example.org. Sarah Cypher, DNP, RN, NE-BC, is Director of Nursing at Froedtert & Medical College of Wisconsin-Froedtert Hospital (Milwaukee). She can be reached at email@example.com.
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