Thursday, June 07, 2007

Different Continents

For a reason I can't quite figure out, different areas of my hospital have marked differences in their quality of care. The ICU's seem to be well-staffed, with a team of doctors, nurses, physical therapists, respiratory techs, case managers and social workers who collaborate to achieve fantastic results for their patients. The pediatric floors tend to have a well-working team system as well. The pedi nurses tend to be great; I've met a few who were brusque, but their interactions with the kids were good. The stroke team was an actual TEAM; we'd meet with the nurses and case managers to plan the stay and outpatient care every day, so that everyone knew patient C would be going to LTAC after PT cleared his swallow study, etc.

However, other parts of the hospital are not so nice. One floor had nurses that complained every time a patient was admitted to their care. Loudly. In the public nurses' station, where anyone could hear. Same floor, we had a patient who was supposed to be anticoagulated before discharge. His INR peaked at around 2, then began to fall again. We couldn't figure out what was going on. After three days, the resident figured out that nursing wasn't giving the anticoagulant. It was ordered, it had been given previously, but for some reason it slipped through the cracks and this guy's discharge was delayed for a week because of it. The medical and surgical floors are infamously known for "forgetting" patients--whether true or not, care does not get coordinated into large multidisciplinary teams here.

I've come to a couple of conclusions, and I feel that architecture is responsible for many of these differences.

The ICU's are generally isolated large rooms, with multiple patients inside. Nursing stations are large and arranged with clear visibility of the beds; even in an ICU with patients in separated rooms, nurses can see into the rooms--the doors are glass and often open. Patients are always visible to the nurses. The stroke unit is a separate room with only about 10 beds. The pediatric floors are arranged in "pods", with six or so rooms per small nursing station. Again, each room is visible to the nurses at all times, and the doors are often open. Each nursing station is in charge of a small number of beds.

The medical and surgical floors are in an older building than the pedi floors. A long rectangle has a nursing station at either end, two per floor. Patient rooms open off on all sides of the rectangle; some are as far as 50 feet from a nursing station and around a blind corner. The doors are usually closed. Each nursing station is in charge of about 30 patients. The design is less conducive to constant monitoring, and walls patients off in private rooms where they often feel forgotten.

It seems to me that the issue is twofold. One, each nursing station should be in view of all the patients it covers. Second, each nursing station should be in charge of fewer patients. The issue doesn't seem to be a nursing shortage, but rather a shortage of patient visibility. For whatever reason, units with better-coordinated care are isolated or have patient "pods" for more focused care.

Future Architects of America, pay attention: when designing hospitals, function follows form.


Apollo said...

Astute observation! I just took a short tour of the Clinical Center at the NIH which is currently undergoing a massive renovation project: the currently closed, older wards in the old hospital are exactly as you described the medical and surgical floors with long hallways and closed doors. The newer wards seem to keep the patient room doors open and have a higher nurse station: patient room ratio.

Midwife with a Knife said...

That is a great observation. My favorite L&D unit had the rooms arranged in a circle around a centralized nurses station. It was perfect.

health watch center said...

It's very sad to know about the behavior of nurses at the floor. Well that specific patient's discharge delayed a week but at least he recovered. But in some cases it's going to be a big issue, so the head nurses must take care about everything.

Nice observation and suggestion for new architects.

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