On the patient side, two new types of spaces embody this new fusion: Acuity Adaptable Care provides the full spectrum of patient care in a single room, while the Integrated Interventional Platform similarly consolidates all invasive procedures in an integrated unit. In medical education, the call for more hands-on activities, among other factors, has created the need for new learning environments, primarily for clinical skills, simulation, and surgical training.

“There is a very strong and developing connection between what’s going on in the clinical care arena and new directions in medical education, not just for doctors but pharmacists, nurses, and other allied health professionals,” observes Jonathan Kanda, senior associate with CO Architects in Los Angeles.

“On the clinical side, we’re seeing a move toward more team-based care, bringing people together to be more efficient, enhancing continuity of care, and reducing errors,” continues Scott Kelsey, managing principal at the firm. “As for training, medical schools are very interested in breaking down the silos among physicians and the allied health professions. This creates the potential for shared space and curriculum, a new consideration in this environment.”

Acuity Adaptable Care

In the traditional hospital, inpatient units are segregated according to the level of acuity, for example Critical Care, Step-Down Care, and Acute Care. The new acuity-adaptable model erases most of those distinctions, providing instead a single, uniform setting that accommodates a range of care levels. The primary rationale is reducing or eliminating the need to transfer patients from one room to another during a hospital stay, a major source of error.

“The patient stays in the same space, and the technology moves in and out based on the level of acuity,” says Stephen Yundt, also a principal at CO Architects. “The potential benefits are compelling—better continuity of care, fewer medical errors, improved operational efficiencies, and higher patient and staff satisfaction.”

Still a work in progress, the acuity-adaptable room has been adopted as the standard at the futuristic Palomar West Medical Center, an 850,000-sf, 360-bed tertiary care hospital in Escondido, Calif., slated for completion in 2011. In this iteration, the entire patient room, including the enclosed hygiene zone (toilet, shower, sink) measures approximately 340 sf. A 13' x 13' clear area accommodates the patient, staff, and all the portable equipment appropriate for ICUs. Saving steps, the bed and toilet area are close to each other, and are linked by a handrail along a common wall to minimize the chances of a patient falling. Another safety feature is the bathroom’s 4-foot wide access door, permitting a companion to enter the area with the patient, again to prevent falls. All rooms are outfitted with ceiling-mounted patient lifts for patient as well as staff safety.

A nurse work area is convenient for note-taking, while a designated supply closet keeps the most commonly used items close at hand, eliminating the need to spend time retrieving them from a centralized source. One decision that has yet to be made is whether to have in-room medication storage specific to the patient, another move that would cut down on nurses’ travel as well as the possibility for error.

Emblematic of another strong design goal—to create a soothing, healing environment—Palomar’s acuity-adaptable rooms also reflect a non-institutional aesthetic. The window wall includes a family area, with a desk and chair for writing and a built-in nook where visitors can sleep. The patient’s “second window to the world” is a large interactive screen that can be used for everything from ordering food to accessing medical records to entertainment.

Outside the room, distributed nursing space keeps staff closer to patients. Instead of a central station that aggregates space for the unit’s staff and storage needs, this approach features multiple charting stations and storage closets tucked along the corridors, allowing nurses to do paperwork while they have direct visibility into a pair of rooms.

Yundt highlights the many benefits of this approach: “Nurses and other medical staff have more time to spend caring for and monitoring the patients. There is a reduction in the amount of unnecessary walking, an important consideration for the aging nurse work force. It improves patient safety and boosts satisfaction levels for both patients and staff.”

He also points out the two major challenges to implementation: cost and culture. Designed to higher standards to suit a broader range of acuity levels, the patient rooms are larger, the equipment is more robust, and the infrastructure requirements are more stringent. Yundt figures the premium to be around $150,000 per bed compared to an acute care design.

“There is also the issue of staff training or culture,” he continues. “This model of care entails a certain degree of cross-training in knowledge and skills between acute care and critical care nursing. A formalized curriculum at schools does not yet exist, and there is a prevailing culture in the nursing ranks that is somewhat skeptical about the remixing of skill sets. Change is difficult and will take some time to be fully accepted.”

Integrated Interventional Platform

The second key planning response, the integrated interventional platform, is more attuned to the tertiary and quaternary care services offered by academic medical centers. Driven by less invasive surgery, more interventional radiology, and the growing role of image guidance, this model merges all the invasive procedures onto one level operated as an integrated unit.

“The integrated interventional platform really fosters multidisciplinary collaboration,” says Yundt, adding, “It consolidates the support spaces that are traditionally sprinkled around the facility into one location, resulting in staff savings as well as space savings. Perhaps most important, it provides some long-term flexibility, enabling institutions to adapt to changing practice models over time.”

The design of the integrated interventional platform for the Palomar West Medical Center project has procedure rooms organized into clusters of six, with a total of two OR clusters and one IR / CATH cluster. Each cluster, or pod, is supported by a consolidated pre-op/post-op space, designed “universally” to flex between pre-op in the morning and post-op as the day goes on.

A 100-foot-long truss spans the area to eliminate the need for columns, another way of adding flexibility for future equipment configurations. A robust floor load capacity and 18-foot floor-to-floor heights anticipate MRIs and other imaging modalities that may be installed later.

Like the acuity-adaptable approach, implementation challenges relate primarily to culture.  Among physicians, it’s the shift to collaboration, although some medical schools are graduating a new crop of “interventional” MDs, a yet-to-be formalized designation that combines cardiology and other vascular specialties.

The integrated interventional platform also requires some cross-training of nursing staff to accommodate the full spectrum of perioperative services, Yundt points out.

Medical Schools

Reinvented patient spaces are driving the need for curriculum change in an increasing number of medical schools. The old track—two years of basic science education, much of it via lecture, followed by two years of clinical rotations—is giving way to more problem-based learning and integration of hands-on activities earlier in the program.

According to Kelsey, the new curriculum is very “rich,” combining both traditional forms (gross anatomy labs, for example) with simulation and clinical performance. Other influences making themselves felt in medical education buildings are larger class sizes and a growing focus on student-staff amenities.

“These features create a social or cultural fabric that holds the school together and gives it an identity, through elements like food service, a wellness center, offices for student organizations, and so forth,” he explains.

The Clinical Skills Environment

The backdrop for training in standardized outpatient exams, the latest clinical skills suites impose some kind of segregation between patients and students. Each group enters the exam room from a different direction, a configuration that often entails a dual-corridor scheme. Supporting spaces such as brief/debrief and control rooms should be somewhat sequestered, again minimizing the need for patients’ and students’ paths to cross.

The exam room, which typically incorporates a write-up area for students with cameras in two corners, in most respects resembles the traditional outpatient environment, although how large the room is varies with the school program.

Kelsey used data from five of his firm’s recent medical projects to calculate benchmarks of 56 sf per student and one exam room per 10 students in the new clinical skills suite. However, these metrics are still in flux, likely to change considerably if other allied programs share the curriculum.

For example, the brand-new medical school at Texas Tech University in El Paso features 120-sf exam rooms, sized for student groups of four to six.  In contrast, the exam rooms in the new medical education building at the University of Virginia, in Charlottesville, are 180 sf, providing more space for the school’s larger classes to interact as well as for bringing in students from other campus programs, such as nursing.

Simulation

Simulation has come of age as an integral component of medical education. Technology advances have produced sophisticated full-body mannequins that allow medical students to practice a wide variety of procedures, from inserting IVs to performing tracheotomies, before working with actual patients. Today’s high-fidelity replicas can breathe, show a pulse, and respond to fluids. They can suffer from a collapsed lung or flutter their eyes coming out of anesthesia, in each state providing invaluable feedback for physicians in training.

Recognizing the importance of this hands-on activity, medical schools are now allocating dedicated space to this type of learning, which can double as the setting for drills in team-based care. Some simulation suites mirror a defined environment, like an OR or an ER, to give students a realistic sense of place. Other models are more generic, simply providing the real estate and infrastructure to support the mannequins.  Given the pace of technology change, Kanda recommends retaining some flexibility in the suite design.

In addition to the simulator room, the suite comprises several other spaces: a control room; briefing/debriefing room for introductory and follow-up discussion; a monitoring room where faculty can sit and observe; part-task rooms, abbreviated simulation rooms for small-scale procedures; and storage, which should be generous, he advises.

Data from the firm’s recent projects indicate that a simulation center can occupy between 10 and 15 percent of the overall building program. A general size guideline is approximately 44 sf per student. A suite total of 300 sf to 400 sf accommodates very large groups, such as the multidisciplinary teams involved in mock disaster training.

Surgical Training Environments

A steady stream of new surgical techniques, many of them minimally invasive, has created a parallel need for new environments for continuing medical education. According to Kelsey, the model for many of these new facilities is the French research institute IRCAD, in Strasbourg. A center of excellence ranked among the top surgical training centers in the world, IRCAD is known for its large, open (ballroom) environments that accommodate multiple technologies.

In the U.S., CO Architects is working with the Methodist Institute for Technology, Innovation, and Education in Houston to create what it describes as a “first-of-its-kind training center that will act as a new skills acquisition and retooling site for physicians and allied health workers worldwide.”

Plans call for a large procedure training suite with 15 surgical stations of about 150 sf each. Lighting and overhead equipment define each station, also outfitted with video cameras to record the sessions for later broadcast or remote viewing. An interoperative MRI allows for imaging of the animal subjects during or in between stages of a procedure. Two robotic surgery rooms offer an environment for research and development with various vendors’ equipment. The suite also includes a CT scan room, along with control rooms, part-task training areas, and brief/debrief rooms. Movable wall systems add flexibility in various areas of the training environment.

Also important is the need for breakout and casual space.

“Surgeons come to this facility for a period of time,” says Kelsey. “They need to be able to access their email, make phone calls, and break out and talk with their colleagues.

“The last issue is that technology is still changing enormously, especially with respect to simulation and clinical skills. Chances are that the decisions made today will probably be altered radically by technology in the future, so we are always striving to find a balance between short-term curriculum requirements and the need for long-term flexibility,” he concludes.

By Nicole Zaro Stahl

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