Intensive Care Unit Built Environments: A Comprehensive Literature Review (2005-2020)

Literature Review
Health Environments Research

& Design Journal
1-48
Intensive Care Unit ª The Author(s) 2021
Built Environments: Article reuse guidelines:

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A Comprehensive Literature DOI: 10.1177/19375867211009273
journals.sagepub.com/home/her
Review (2005–2020)
Stephen Verderber, MArch, ArchD1,2 , Seth Gray, MD3,5,8,

Shivathmikha Suresh-Kumar, MArch4, Damian Kercz, MArch4,
and Christopher Parshuram, MB.ChB, DPhil2,3,5,6,7,8
Abstract
Background: The intensive care environment in hospitals has been the subject of significant empirical
and qualitative research in the 2005–2020 period. Particular attention has been devoted to the role of
infection control, family engagement, staff performance, and the built environment ramifications of
the recent COVID-19 global pandemic. A comprehensive review of this literature is reported sum-
marizing recent advancements in this rapidly expanding body of knowledge. Purpose and Aim: This
comprehensive review conceptually structures the recent medical intensive care literature to provide
conceptual clarity and identify current priorities and future evidence-based research and design
priorities. Method and Result: Each source reviewed was classified as one of the five types—opinion
pieces/essays, cross-sectional empirical investigations, nonrandomized comparative investigations,
randomized studies, and policy review essays—and into nine content categories: nature engagement
and outdoor views; family accommodations; intensive care unit (ICU), neonatal ICU, and pediatric ICU
spatial configuration and amenity; noise considerations; artificial and natural lighting; patient safety and
infection control; portable critical care field hospitals and disaster mitigation facilities including
COVID-19; ecological sustainability; and recent planning and design trends and prognostications.
1
Centre for Design þ Health Innovation, John H. Daniels Faculty of Architecture, Landscape and Design, University of Toronto,
Ontario, Canada
2
Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario,
Canada
3
Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
4
John H. Daniels Faculty of Architecture, Landscape and Design, University of Toronto, Ontario, Canada
5
The Hospital for Sick Children, Toronto, Ontario, Canada
6
Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
7
Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
8
Center for Safety Research, Toronto, Ontario, Canada
Corresponding Author:
Stephen Verderber, MArch, ArchD, Centre for Design þ Health Innovation, John H. Daniels Faculty of Architecture, Landscape
and Design, University of Toronto, Toronto, Ontario, Canada M5S 2J9; Institute for Health Policy, Management and Evaluation,
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada M5T 3M6.
Email: sverder@daniels.utoronto.ca
2 Health Environments Research & Design Journal XX(X)
Conclusions: Among the findings embodied in the 135 literature sources reviewed, single-bed ICU
rooms have increasingly become the norm; family engagement in the ICU experience has increased;
acknowledgment of the therapeutic role of staff amenities; exposure to nature, view, and natural
daylight has increased; the importance of ecological sustainability; and pandemic concerns have
increased significantly in the wake of the coronavirus pandemic. Discussion of the results of this
comprehensive review includes topics noticeably overlooked or underinvestigated in the 2005–2020
period and priorities for future research.
Keywords
literature review, intensive care units (ICUs), infection control, inpatient hospitals, family-centered
care, evidence-based design (EBD), COVID-19 pandemic, patient-/person-centered care, staff
effectiveness
Environmental design research has evolved sig- the realm of architecture. The generation of new
nificantly over the past 50 years to be recognized knowledge on the ICU built environment can aid
as a distinct discipline centered on the transac- direct caregivers, patients, and families world-
tional relationship between the built environment, wide. This review of hospital ICUs, including
design excellence, and the improvement of the neonatal ICUs (NICU) and pediatric ICUs (PICU),
human condition. In the past 25 years, a subdisci- is focused on person–environment transactions.
pline of evidence-based research and design has These settings are conceptualized here as consti-
focused on health and the built environment. This tuting a typology, a prism of sorts, to achieve an
research is recognized as a distinct knowledge overview of current best practices and theoretical
base addressing the spectrum of healthcare build- perspectives vis-à-vis a comprehensive literature
ing types including hospitals, hospices, long-term review. This systematic review consists of
care facilities, pediatric facilities, psychiatric peer-reviewed research investigations, pertinent
and substance abuse treatment centers, and recent theoretical essays, and prognostications for
community-based outpatient clinics (Verderber, the future.
2010). Correspondingly, the published literature
has become increasingly complex and multifa- This review of hospital ICUs, including
ceted, including the role of the built environment
neonatal ICUs (NICU) and pediatric ICUs
in infection control and the prevention of adverse
(PICU), is focused on person–
medical events, furthered by the 2003 Institute of
Medicine report Crossing the Quality Chasm environment transactions. These settings
(Zimring et al., 2013). As a consequence, it has are conceptualized here as constituting a
become necessary to take stock of recent litera- typology, a prism of sorts, to achieve an
ture on the topic of the intensive care built envi- overview of current best practices and
ronment. In the medical literature, the number theoretical perspectives vis-à-vis a
and location of beds housed in intensive care units comprehensive literature review.
(ICUs) in hospitals have greatly expanded in the
past decade (Wallace et al., 2017). A review of This review directly builds upon a comprehen-
recent peer-reviewed quantitative and qualitative sive literature survey on evidence-based health-
investigations and theoretical essays on critical care design and the built environment published
care built environments can yield insight— 13 years ago (R. L. Ulrich et al., 2008). In it,
particularly now—as the world endeavors to nearly 450 peer-reviewed research publications
control and eradicate the virulent COVID-19 pan- were summarized. It addressed patient safety
demic. This pandemic fueled an acceleration of issues, patient–staff outcomes, and insights on the
new medical knowledge but has yet to fully impact interventional role of the physical environment.
Verderber et al. 3
Health status outcomes reviewed included noso- prognostications, telemedicine, and ICU planning
comial infections, medical errors, pain, sleep, and design. Fourth, referring to healthcare facility
stress, patient satisfaction, length of stay, privacy, infrastructure, that is, carbon neutral hospitals,
communication, social supports, workplace inju- sustainable design and operations, nontoxic mate-
ries, staff stress, and satisfaction. Built environ- rials, and hospital renovation and retrofitting.
ment interventions included single-bed rooms, Extensive cross-searches were then conducted
access to daylight and appropriate lighting, views using combinations of key words and phrases
of nature, dedicated family zones within the through the JSTOR and Google Scholar databases
patient room, noise reduction, workspace attri- and further searches combing multiple databases
butes, and acuity-adaptable patient rooms. ICUs including EBSCO, ScienceDirect, PsychINFO,
were but one of many in-hospital units, freestand- MEDLINE, Ovid, ProQuest, PubMed, Web of
ing building types, and user constituencies Science, Science Digest, and NIH Public Access.
addressed. Since its publication, advances in crit- This search included any study or article that
ical care medicine, ecological sustainability, ther- alluded or referred to the healthcare physical built
apeutic benefits of person–nature connectivity, environment in its title or abstract, published
and best practices with respect to the COVID-19 between January 2005 and February 2021. The
global pandemic underscore the need for a decision was made at the outset to include both
comprehensive up-to-date review. The primary empirical and qualitative research investigations,
aim of the present review is to assess the current as well as relevant theoretical and opinion essays,
state of the art and science to better inform design in order to broadly capture the scope, depth, and
choices to reduce adverse medical events, improve nuance of a rapidly evolving subject.
infection control and patient safety, better engage The initial search phase yielded 219 primary
patients and families, examine person–nature sources, subsequently reduced in the second-
interactions, and identify policies to improve stage assessment to 147 peer-reviewed sources.
caregiver work performance, satisfaction, and These met or exceeded the team’s benchmark for
well-being. rigor. In the third-stage assessment, these sources
were further examined and reduced to a compen-
dium of 135 sources (reported below). The
Method research team carefully screened three types of
The methodology consisted of a broad review of sources: (1) empirically based studies that exam-
published, peer-reviewed quantitative and quali- ine the role and impact of the built environment
tative investigations and essays. The first step or natural environment on patient, staff, and/or
consisted of a key word search to identify poten- family outcomes; (2) qualitative studies that
tially relevant peer-reviewed publications. Forty examine these same relationships; and (3) theore-
key words were used, referring to patient and staff tical essays that examine the relationship between
outcomes, that is, infection control, disease control, intensive and critical care medicine, nursing best
medical error, pain, sleep deprivation, respiratory practices, pulmonary medicine, COVID-19, and
disease, stress, privacy, and COVID-19. Second, the general planning and design of medical ICU
referring to physical environment factors, that is, built environments. Non-peer-reviewed white
hospital; therapeutic gardens; COVID-19 field hos- papers, research reports, minimum standards
pital; ICU design and layout; ICU unit layout; guidelines publications, and books on this subject
nursing station design; critical care medicine; crit- were eliminated in the first wave of the screening
ical care nursing; pulmonary medicine; ICU, process.
NICU, and PICU design and features; acuity The final compendium was then structured
adaptability; and healthcare facilities. Third, into nine content categories deemed by the
referring to related issues, that is, staff productiv- research team to best capture the current state
ity, stress, family-centered care, noise mitigation, of the art and science. The 2005–2020 period
nature, views, landscape, nature representations, witnessed numerous innovations including acuity
patient safety, the future of the ICU, theoretical adaptability, debates between patient/family
privacy versus semiprivacy in the ICU patient advancements in energy efficiency, sustainable
room, telemedicine, acknowledgment of the ther- materials of construction, and resilient facility
apeutic affordances of nature and landscape in the design and operation with direct applicability to
hospital setting, participatory planning and critical care hospital units; and recent design
design tools to meaningfully elicit ICU design trends and prognostications—essays on the pres-
input from caregiver stakeholders, and ICU built ent and future of critical care settings in hospitals,
environment impacts of the global COVID-19 including therapeutic design affordances, and
pandemic that originated in China in late 2019. performance-based trends, that is, new technolo-
gies, acuity adaptability, and the ICU of the
future.
Results Table 1 summarizes this knowledge compen-
Table 1 contains the compendium of 135 research dium vis-à-vis the nine content categories with
investigations, critical essays, and policy reviews key background information and findings sum-
presented in nine content categories: nature marized. This consists of the author(s), date of
engagement and outdoor views—studies examin- publication, topic and scope of the study/essay,
ing the influence of exposure to nature as well conceptualization of the built environment and
as representations of nature in critical care hospi- the principal study setting, research design and
tal inpatient units, with specific focus on measure sample (as applicable), outcome measures of
of stress and stress reduction outcomes; well-being, physical environment features, and
family accommodations in the ICU environment— key findings of the investigation/discussion. As
studies on the role of family involvement in the mentioned, only peer-reviewed publications are
ICU experience and the influence of family input included. These empirical investigations and qua-
in ICU design and amenities provided; ICU litative studies and essays emphasize day-to-day
spatial configuration and amenity—factors operations and the experience of frontline care-
impacting the physical layout and associated givers, patients, and family members. Early on, it
amenities, associated staff affordances, and was decided to not categorize NICU or PICU
proxemic relationships, that is, travel distances, settings separately since many issues addressed
staff–patient sight lines, single versus semiprivate in these settings were of equal relevance to the
rooms; noise considerations in ICU environ- entirety of the built environment typology as
ments—deleterious effects of excessive noise and defined above.
involuntary distractions on patient and staff
well-being, patient delirium, and the influence
Nature Engagement
of noise mitigation measures on patient out-
comes; artificial and natural lighting in ICU
and Outdoor Views
environments—adverse effects of excessive light Wilson’s biophilia hypothesis suggests that
on occupant well-being, the benefits of informa- humans possess an “innate tendency to focus on
tive views, the utility of ventilation systems, and life and life-like processes” and is often cited as a
optimal ambient light levels on patient outcomes; key consideration for using natural elements in
ICU patient safety and infection control—studies the healthcare setting (Grinde & Patil, 2009;
addressing the types and prevalence of adverse Minton & Batten, 2015). Despite U.S. Centers for
medical events in critical care settings and mea- Disease Control and Prevention guidelines sug-
sures to mitigate their occurrence and improve gesting that restriction of plants/flowers in hospi-
patient outcomes; portable field hospitals and tal settings be limited to immunocompromised
disaster mitigation including COVID-19—the patients, live plants are often uniformly prohib-
role, efficacy, and assessment of portable, critical ited in ICUs (Sehulster et al., 2004). Eight studies
care field hospitals for deployment in the after- were identified describing the integration of
math of natural disasters and pandemics with nature elements in an ICU or ancillary settings
specific focus on the global COVID-19 pan- (waiting rooms and shared outdoor gardens) and
demic; ICU ecological sustainability—recent patient (n ¼ 4), staff (n ¼ 3), and family (n ¼ 1)
Table 1. Summary of ICU Built Environment Comprehensive Literature Review—Content Areas 1–9.
Research Design, Setting, ICU Built Environment Impact

Citation and Sample Physical Environment Attributes Outcome Measures of Well-Being on Outcome(s)
1. Nature Engagement and Outdoor Views

Beukeboom Nonrandomized comparative Live plants, artwork, and murals Survey of patient room attributes, Patients exposed to real plants and
et al. (2012) study. ICU/hospital waiting with nature themes environmental stress levels posters of plants reported a lower
rooms. Single center; (State–Trait Anxiety Inventory) level of cognitive stress compared
patients. to respondents not exposed to
these conditions.
Cordoza Randomized study. ICU/ Outdoor hospital garden Staff assessment: Maslach Burnout Nurses and support staff who take
et al. (2018) hospital. Single center; Inventory, Present Functioning breaks in an outdoor garden
nursing staff. Visual Analogue Scale reported a significantly lower level
of job performance burnout.
Kohn et al. (2013) Cross-sectional observational Windowed compared to Length of stay, readmission rate, Windowed patient rooms, including
study. Adult ICU. Single windowless rooms; natural delirium occurrences, cost those affording natural views, do
center; patients. versus nonnature outdoor views implications not significantly improve patient
health status outcomes or reduce
ICU care expenditures.
Pati et al. (2008) Cross-sectional observational Duration of exposure to outdoor Stress/Arousal Adjective Checklist Nursing staff exposed to exterior
study. PICU. Multicenter; view; view informational content survey; perceived chronic stress nature views experienced
nursing staff. (nature vs. nonnature) (Perceived Stress Scale) unchanged, or increased, alertness
levels. Those whose alertness
levels deteriorated experienced
windowless or nonnature outdoor
views.
Shepley et al. (2012) Nonrandomized comparative Proximity to window, percent Patient pain levels, ICU length of stay, Lighting levels, or exterior views
study. Adult ICU. Single windowed wall area, intensity of staff errors, staff absenteeism, and alone, did not affect patients’
center; patients and staff. sunlight transmission, and view room vacancy rates perception of pain or length of
informational content hospitalization. For staff, increased
lighting levels when combined with
outdoor views were associated
with decreased staff absenteeism.
(continued)
5
6
Table 1. (continued)

Tanja-Dijkstra Randomized study. ICU/ Photographs of hospital rooms with Perceived visual attractiveness; Participants exposed to photographs
et al. (2008) hospital. Multicenter; and without plants stress level measurements of hospital rooms with indoor
student respondents. (State–Trait Anxiety Inventory) plants reported significantly lower
cognitive stress levels.
R. S. Ulrich Nonrandomized comparative Outdoor hospital garden Present Functioning Visual Analogue Cognitive stress was reduced
et al. (2020) study. Adult ICU. Single Scale stress assessment following exposure to an outdoor
center; family members. garden and indoor settings
affording exposure to the
outdoors. Breaks taken in the
garden resulted in significantly
higher satisfaction levels.
Wunsch et al. (2011) Cross-sectional observational Presence of a window in patient Neurologic disability; heating, Presence of a window in the patient
study. Adult ICU. Single room compared to windowless ventilation, and air-conditioning room did not significantly improve
center; patients. rooms (HVAC) system; command outcomes for adult patients with
response time; gastrostomy tube subdural hemorrhage admitted to
or tracheostomy procedures; the ICU.
ICU/hospital length of stay; and
mortality rate
2. Family Accommodations in the ICU Environment
Davidson Literature review. Adult ICU, Single versus multibed rooms, Visitation behavior, family Recommendations: Encourage open
et al. (2007) PICU, and NICU. directional signage, wayfinding involvement, satisfaction, and visitation policies, single-bed
Multicenter; family perceived stress rooms, navigable wayfinding
members/visitors. systems to reduce family stress
levels and foster integration in the
intensive care milieu.
Davidson Systematic literature review. Noise sources, hygiene stations, Family member engagement and Recommendations: Noise reduction
et al. (2017) ICU, PICU, and NICU. sleep amenities for families satisfaction policies, single-bed patient rooms,
Multicenter; family sleep accommodations for
members. families, and a family-centered care
accommodation checklist.
(continued)

Day et al. (2013) Cross-sectional observational Multiple locations sampled on unit Family member–visitor sleep Majority of family members of ICU
study. Adult ICU. Single where family members/visitors disturbances, anxiety level, patients reported in-hospital sleep
center; family members. sleep and fatigue disturbances; 27% reported having
slept in a waiting room.
Fridh et al. (2009) Cross-sectional observational Privacy measurements in patient Qualitative assessment of physical The ICU physical setting impacts the
study. Adult ICU. Single rooms setting obstacles encountered in ability to provide dignified
center; nurses. caring for the severely ill end-of-life care for patients and
their families. Insufficient privacy
reported as the most prevalent
obstacle encountered.
Franck et al. (2015) Cross-sectional observational Various locations where family Family self-reported sleep locations In PICUs, significant number of
study. PICU and NICU. members of ICU patient sleep and satisfaction parents sleep in child’s room,
Multicenter; family whereas most NICU parents sleep
members. at home. Hospitals with family
accommodation programs are
associated with higher parent
satisfaction level.
Huynh et al. (2020) Nonrandomized comparative Space in the patient room available Evening and overnight family–visitor The provision of dedicated space for
study. Adult ICU. Single for family/visitor use patient room usage family/visitors in the patient room
center; family members. is associated with increased
evening and overnight usage.
Jongerden Nonrandomized comparative Single-bed patient rooms, privacy, Patient and family satisfaction Key recommendations: Improve
et al. (2013) study. Adult ICU. Single outdoor views, natural daylight, noise reduction, orient bed to
center; patients and family. and noise sources provide exposure to natural
daylight, and provide family
accommodations to foster greater
patient and family involvement.
Macdonald Cross-sectional observational Noise sources, privacy Family visitation behaviors; staff Family and visitors prefer PICU
et al. (2012) study. PICU. Single center; measurement and patient assessments of policies allowing for more
family, staff, and patients. physical setting meaningful participation in the
patient hospitalization experience.
(continued)
7
8

Rashid (2010) Narrative review. Adult ICU. Physical setting amenities and Family member integration; healing The ICU physical setting is a primary
Multicenter; staff and family. appearance culture therapeutic modality in the overall
hospitalization experience of
family and visitors.
Rippin et al. (2015) Nonrandomized comparative Physical attributes of family-only Frequency, time, location, and type Increased interactions were
study. Adult ICU. Single compared to shared staff–family of nurse–family interaction identified in shared staff–family
center; nurses and family. corridors adjacent to ICU corridors, with majority initiated
by family members. Nurses report
loss of territorial workflow
control in this condition.
Peterson Nonrandomized observational Noise sources, waiting room size, Family satisfaction Quiet spaces, sufficiently large
et al. (2020) study. Adult ICU. Single private spaces, and restrooms waiting room, availability of private
center; family members. space, and proximity to restrooms
associated with higher family
satisfaction level.
Stremler Cross-sectional observational Parent sleep locations and amenity: Sleep–wake patterns and Acute sleep deprivation was
et al. study. PICU. Single center; patient room, parent room/ self-reports of fatigue and reported on more than 25% of
(2014) family members. lounge, hotel, and private sleeplessness days/evenings; long wake times
residence were reported in off-site hotels, in
on-site parent room/lounge, and
one’s private residence.
3. ICU Spatial Configuration and Amenity
Apple (2014) Nonrandomized comparative Hybrid patient room module: Staff-to-patient visibility, privacy, staff Open-view rooms increase caregiver
study. Adult ICU. Single-bed with staff monitoring collaboration, and family and family visibility but result in
Multicenter; staff and space engagement more noise and reduced privacy.
patients. Private modules assessed as
quieter, but staff feel less visually
connected to patient.
(continued)

Arenson Nonrandomized comparative Single-bed rooms with windows and Patient delirium occurrences No significant difference in delirium
et al. (2013) study. Adult ICU. Single multibed rooms without reported between private versus
center; patients. windows multibed rooms for patients
65 and older. Patients under
65 experienced highest number of
days with delirium in multibed
windowless rooms.
Bosch et al. (2012) Nonrandomized comparative Hybrid mix of single-bed and Staff assessment of workplace Nurses reported reduced job stress,
study. NICU. Single center; multibed patient rooms environmental support associated with improved level of
staff. parental privacy, as key benefits of
single-bed NICU rooms.
Cai & Zimring Nonrandomized comparative Nursing station types: Centralized, Spatial metrics, patient visibility, Each nursing station type fosters a
(2012) study. Adult ICU. Single decentralized, and hybrid team and peer proxemics, and unique staff communication
center; staff. nursing team communications pattern. Consider team-based and
peer-to-peer proxemics when
evaluating various types of ICU
workspaces.
Catrambone Cross-sectional observational Unit configuration; patient visibility, Assessment of multiple unit types Four unit types comprise the
et al. (2009) study. Adult ICUs. proxemics, single-bed rooms, and and design attributes majority of ICU types in the
Multicenter; staff and floor surface type United States, representing
patients. diverse levels of patient–staff
visibility, proxemic relationships,
design amenities, and caregiving
policies.
Caruso et al. (2014) Nonrandomized comparative Single versus multibed patient Delirium occurrences: Coma/ ICU patients admitted to single-bed
study. Adult ICU. Single rooms delirium-free days, first day in rooms experience lower
center; patients. delirium, and motoric subtypes occurrence of delirium compared
to patients in multibed rooms.
(continued)
9
10

Copeland & Nonrandomized comparative Centralized versus decentralized Job satisfaction, on-shift walking For nurses, a decentralized ICU
Chambers (2017) study. Adult ICU. Single nurses station distances, and personal energy layout contributed to reduction in
center; nursing staff. expended at work on-shift walking distances. Job
satisfaction level was higher in
decentralized versus centralized
units.
de Matos Nonrandomized comparative Single versus multibed patient Staff and family stress, staff burnout, Single-bed ICU rooms preferred by
et al. (2020) study. Adult ICU, Single rooms family satisfaction family yet yield higher staff stress
center; staff and family level, although no difference was
members. reported in staff burnout rates
between single versus multibed
rooms.
Fay et al. (2019) Systematic review. ICU/ Centralized versus decentralized Patient well-being, nursing job Decentralized nursing stations were
hospital. Multicenter; nursing station satisfaction, travel distances, and associated with higher patient
nursing staff and patients. energy expended satisfaction. Staff teamwork and
communication levels reported to
decline in decentralized nurses
stations.
Garavais et al. Nonrandomized comparative. Spatial layouts and visibility factors Team communications as a function Improved unit visibility, results in
(2018) Adult ICU. of unit visibility improved team communications
Gurses and Carayon Cross-sectional observational Noise sources, workplace spatial Staff assessment of workplace Routine work performance obstacles
(2009) study. Adult ICU. Single layout, support amenities performance obstacles/barriers identified: Excessive noise,
center; nursing staff overcrowding, insufficient space
for charting, and disorganized
work zone.
Hadi & Zimring Cross-sectional study. Adult Corridor width, length, and unit Nurse-to-patient visibility and floor Wider corridors were associated
(2016) ICU. Multicenter; nursing configuration plan/unit configuration analysis with significant increase in patient
staff. room visibility from adjacent
nursing staff workspaces.
(continued)

Hamilton et al. Policy review/essay. Adult ICU. Centralized versus decentralized Travel distances, patient visibility,
Travel distances, staff visibility of
(2018) Multicenter; nursing staff units, corridor width, and unit patients, team communication, and staff communication factors
and patients. size and patient safety were examined relative to
corridor width/type in
decentralized versus centralized
ICUs.
Leaf et al. (2010) Cross-sectional observational Room attributes, size, and location Length of stay, number of Severely ill patients experienced
study. Adult ICU. Single on unit nonventilator days, and mortality higher mortality rate when
center; patients and staff. rate admitted to patient rooms low in
visibility from nursing work core.
Lu & Zimring (2011) Cross-sectional observational Room attributes, size, and location Comparative assessment of targeted Physicians and nurses engage in
study. Adult ICU. Single on unit versus untargeted patient viewing different strategies and methods
center; staff. practices to visually monitor their patients.
Lu et al. (2014) Cross-sectional observational Patient room visibility and field of Mortality levels Among the most severely ill patients,
study. Adult ICU. Adult ICU vision from nursing station not having a direct field of view
patients. from the nearest nurses station
accounted for 33.5% of the
variance in mortality.
O’Hara et al. (2018) Cross-sectional observational Unit configuration and nursing staff Distance matrices; field-of-view ICU layout can enhance caregiver
study. PICU; staff. work zones analysis of visibility levels and team interactions and nursing staff
caregiver team interactions field of view of patients from the
work core.
Pati et al. (2015) Cross-sectional observational Centralized versus decentralized Staff assessment of work Decentralized ICU layouts foster
study. Adult ICU. nurses station productivity, on-shift travel more patient health status
Multicenter; nursing/ distances, stress, and team monitoring, medication
support staff. communications distribution, and supply room
utilization. Long walking distances
result in decreased nursing staff
team collaboration.
(continued)
11
12

Rashid et al. (2014) Nonrandomized comparative Unit configuration and physical Staff assessment of team Staff communication levels and
study. Adult ICU. attributes communications, collaboration, patterns of use/activities are
Multicenter; patients. and patterns of use impacted by ICU unit
configuration attributes and design
amenity.
Real et al. (2016) Cross-sectional observational Centralized versus decentralized Teamwork, communications, and Decentralized nurses stations were
study. ICU/hospital. Single nurses station on-shift travel distances found to be associated with a
center; nursing and support reduced level of nurse-to-nurse
staff. collaboration and
communications.
Stevens et al. (2012) Nonrandomized comparative Single-bed, multibed patient rooms Staff assessment: Noise, illumination Private patient rooms associated
study. NICU. Single center; level, enteral feeding, parent with lower nursing anxiety scores
staff and patients. satisfaction, nurse anxiety scores, due to decreased time required to
and sleep patterns perform full enteral feeding
procedure; no change in anxiety
detected in rooms rated low in
noise and illumination level.
Swanson Nonrandomized comparative Single-bed, multibed patient rooms Staff assessment: Teamwork, Nurse satisfaction scores associated
et al. (2013) study. NICU. Single center; communications, and patient with single-bed ICU rooms initially
staff and family members. safety high but decline over time. Parents
reported higher satisfaction
compared to nursing staff.
Zborowsky & Opinion essay and literature Unit configuration and patient room Patient safety and family and staff Decentralized ICUs were associated
Hellmich (2011) review. Adult ICU; staff, physical attributes satisfaction with lower frequency of
patients, and family physician–nurse communications
members. and increase in the interruption of
routine work responsibilities.
(continued)

4. Noise Considerations in ICU Environments

Brandon et al. Nonrandomized comparative Automatic towel dispensers; staff Ambient noise mitigation Introduction of new equipment:
(2007) study. NICU. Single enter; audio communication system as Automatic paper towel dispensers
nursing and support staff. noise sources and new staff audio
communications system
significantly increased ambient
noise levels in a NICU.
Carvalho Cross-sectional observational Noise source, generation, and Ambient sound measurement Ambient noise levels recorded of
et al. (2005) study. PICU. Single center; periodic data sampling 60–70 dBA (max 120 dBA). Higher
staff and patients. noise levels were recorded during
day and in admission/shift
transition. Staff conversation is the
most frequent source of noise.
Carvalho Nonrandomized comparative Noise sources, single versus Ambient noise standards Recorded noise levels were higher
et al. (2005) study. NICU. Single center; multibed patient rooms than industry-wide recommended
staff and patients. standard. Single-bed patient rooms
generate significantly lower noise
levels versus multibed rooms.
Chawla et al. (2017) Nonrandomized comparative Alarm equipment sound levels Ambient noise intervention A reduced unit-wide alarm system
study. NICU. Single center; generated during “quiet times” on ambient sound level resulted in a
staff, patients, and family unit decrease in ambient noise during
members. quiet periods in a NICU.
H. L. Chen Nonrandomized comparative Noise sources, open patient rooms Ambient sound standards In open-bed patient areas, noise
et al. (2009) study. NICU. Single center; levels generated were significantly
patients. above industry-wide
recommended maximum levels.
Christensen (2007) Cross-sectional observational Noise sources and multibed patient Ambient noise measurement The mean recorded dBA was 56
study. Adult ICU. Single rooms (max 80 dBA). Higher noise levels
center; patients were consistently recorded during
weekdays in the ICU.
(continued)
13
14

Johansson et al. Cohort observational study. Noise sources and multibed rooms Ambient sound measurement It was found the mean sound level
(2012) Adult ICU. Single center; on multiple days/times was 53 dBA (maximum
patients. 82–101 dBA). Patients recounted
sounds during ICU hospitalization
and did not report excessive noise
levels.
Kawai et al. (2019) Nonrandomized comparative Single-bed and multibed patient Ambient sound measurement It was found the mean noise level was
study. PICU. Single center; rooms 52.8 dBA (maximum 67 dBA).
patients. Louder sound levels were
routinely experienced during the
day.
Kol et al. (2015) Nonrandomized comparative Single-bed and multibed patient Ambient sound measurement Patients consistently experienced
study. PICU. Single center; rooms lower ambient noise levels in
patients. single-bed PICU rooms.
Kramer et al. (2016) Nonrandomized comparative Single-bed and multibed patient Ambient sound measurement A mean noise level of 62 dB was
study. PICU. Single center; rooms recorded (maximum 82 dBA),
patients and staff. with no significant differences
between single versus multibed
rooms. Parents and staff view
health status monitor equipment
as key noise generator.
Lasky & Williams Nonrandomized comparative Single-bed and multibed patient Ambient sound standards Documented noise level increased
(2009) study. NICU. Single center; rooms over time, averaging 56.44 dBA;
patients and staff. average ambient noise level was
within the AAP-recommended
level 50.5% of the time across
typical 24-hr period.
(continued)

Luetz et al. (2016) Nonrandomized comparative In-room equipment, finish surfaces, Ambient noise mitigation Noise-reducing headwalls,
study. Adult ICU. Single and materiality as noise sources sound-absorbing materials, and
center; patients and staff. two-door patient room–corridor
isolation reduce
average-to-maximum noise levels
and sound peaks (quieter at night
and louder during day).
Macedo et al. (2009) Cross-sectional study. Adult Two adult ICUs and one adult Ambient sound measurement Noise levels in sampled adult ICUs
ICU. Multicenter; patients cardiac ICU were found to be consistently in
and staff. excess of recommended
industry-wide standards.
Matook et al. (2010) Cross-sectional study. NICU. Multiple locations and times of day Ambient noise measurement Sound levels were found to vary
Single center; patients and sampled significantly as a function of the
staff. location sampled in the NICU. Day
shifts generate higher noise levels
than night shifts.
Ryherd et al. (2008) Cross-sectional study. Adult Multibed patient room staff survey Ambient noise and staff assessment Nurses reported perceived noise
ICU. Single center; nursing assessing perceived noise levels contributes to irritation, fatigue,
and support staff. concentration difficulty, and
headaches. Average noise
generated in direct patient care
was 53–58 dBA; for staff,
dosimeter noise generated was
65–71 dBA.
Wang et al. (2013) Nonrandomized comparative New ICU facility with a designated Ambient noise intervention Lower noise levels resulted in an ICU
study. Adult ICU. Single service corridor with an adjacent, dedicated service
center; nursing and support corridor. Staff reported their
staff. reduced stress was due to the
presence of the adjacent corridor.
(continued)
15
16

5. Artificial and Natural Lighting in ICU Environments

Kohn et al. (2013) Cross-sectional observational Windowed versus windowless Length of ICU stay, readmission rate, Patient rooms with windows
study. Adult ICU. Single rooms; nature versus nonnature delirium occurrences, and cost affording outdoor views of nature
center; patients. view informational content ramifications do not significantly improve
patient outcomes nor reduce
overall costs of ICU
hospitalization.
Lasky & Williams Cohort observational study. Single-bed and multibed patient Ambient illumination levels Illumination level reported to
(2009) NICU. Single center; rooms increase over time on shift,
patients and staff. averaging 70.56 lux; illumination
level measurements found to be
within AAP recommendations
99% of the time.
Morag & Ohlsson Systematic review. NICU. Cycled light patterns: Continuous Length of stay and growth rate in Cycled illumination strategies,
(2016) Multicenter; patients and bright light and near darkness preterm infants compared to continuous bright
staff. conditions lighting and near darkness
condition, shortened hospital
length of stays for preterm
neonates.
Rompaey et al. Nonrandomized comparative Single-bed and multibed patient Delirium occurrences The absence of visible natural
(2009) study. Adult ICU. rooms; natural daylight daylight was identified as a high
Multicenter; patients. risk factor in the occurrence of
delirium in adult ICU patients.
Shepley et al. (2012) Nonrandomized comparative Bed distance from window, Patient pain levels, length of stay, staff Neither natural daylight level nor the
study. Adult ICU. Single window–wall area ratio, sunlight medical errors, absenteeism, and presence of views of nature
center; patients and staff. intensity, and views of nature room utilization affected pain perception or length
of stay. Increased daylight level and
outdoor views were associated
with a decrease in staff
absenteeism and patient room
occupancy.
(continued)

Simons et al. (2016) Randomized study. Adult ICU. Patient room illumination Incidence of delirium; dynamic light Trial concluded prematurely due to
Single center; patients. intervention futility. Dynamic light application
method found ineffective in
recording cumulative delirium
occurrences.
Stevens et al. (2007) Nonrandomized comparative Single-bed and multibed patient Ambient illumination and physiologic Lower minimum/maximum
study. NICU. Single center; rooms parameters in neonatal patients illumination levels were identified
patients. in single-bed NICU rooms. Less
neonatal periodic breathing issues
and awake time occurred in
low-illumination conditions.
Verceles et al. Cross-sectional study. Adult Cardinal direction orientation and Nonventilator usage days; sedative, Cardinal direction room orientation
(2013) ICU. Single center; patients. ambient illumination level analgesic, and neuroleptic factors and ambient illumination
medications levels were not associated with
ICU patient outcomes.
Zores et al. (2018) Prospective observational Illumination levels Infant behaviors; sleep–awake Minor variation in illumination levels
study. NICU. Single center; patterns were found to have a disruptive
patients. impact on preterm infants’ sleep/
awake behaviors.
Zores-Koenig et al. Systematic narrative review. Illumination levels, light protection Infant sleep/awake behaviors, rate of Variations in light level should be
(2020) NICU. Multicenter; patients. device, and cycled lighting growth, and length of graduated, not abrupt. Light
protocols hospitalization protection/screening should be
utilized for infants under 32 weeks
of age; overexposure high light
levels can be harmful;
predischarge, cycled lighting is
recommended.
(continued)
17
18

6. ICU Patient Safety and Infection Control

Bloemendaal et al. Nonrandomized comparative Single-bed and multibed patient Acquisition of MRSA colonization Lower rate of MRSA acquisition
(2009) study. Adult ICU; rooms during ICU admission process reported in single-bed patient
Multicenter; patients. rooms.
Bracco et al. (2007) Nonrandomized comparative Single-bed and multibed patient Acquisition of MRSA, pseudomonas, Lower relative risk of MRSA
study. Adult ICU. Single rooms and Candida spp. during ICU infection, Pseudomonas
center; patients. admission process aeruginosa, and Candida spp.
acquisition reported in single-bed
rooms compared to multibed
patient rooms.
Carayon et al. Basic science/engineering. Human factors and ergonomics Predictors of patient safety The ICU/hospital setting can foster
(2020) General; patients/staff. patient safety through the
systematic incorporation of
human factor and ergonomics
principles in systems design
engineering models.
Cepeda et al. (2005) Nonrandomized comparative Single-bed isolation rooms and MRSA cross-infection rates Relocating MRSA-positive patients to
study. Adult ICU. multibed rooms single-bed rooms or to cohorted
Multicenter; patients. open bays does not significantly
reduce cross-infection rates.
Leaf et al. (2010) Cross-sectional observational Patient room proximity, visibility, Length of stay, ventilator-free days, Severely ill patients experienced
study. Adult ICU. Single and nurses station and mortality rate higher hospital mortality rates
center; patients. when admitted to low
staff-to-patient visibility level
patient rooms.
Levin et al. (2011) Nonrandomized comparative Single-bed and multibed patient Infection rate with Patients admitted to single-bed
study. Adult ICU. Single rooms antibiotic-resistant organisms rooms found to experience fewer
center; patients. infections caused by
antibiotic-resistant organisms.
(continued)

Malenbaum et al. Research review. ICU/hospital. Environmental stimuli: Light, nature, Patient pain level Exposure to light, nature, and virtual
(2008) General; patients. and sound reality (VR) protocols can help in
reducing pain and aid in pain
management during
hospitalization.
Pettit et al. (2014) Nonrandomized comparative High versus low staff visibility Mortality rate For trauma patients, admission to
study. Adult ICU. Single rooms; proximity to nursing patient rooms with high staff
center; patients. station visibility was not associated with
improved patient outcomes.
Reynolds et al. Experiment. ICU/hospital. Whole-room atomizer disinfection Bacterial counts as measured by Use of room atomizer disinfection
(2020) General; patents/staff. system bacterial tracers systems, in tandem with manual
cleaning protocols, was found to
be superior to manual cleaning
protocols alone.
Stiller et al. (2017) Cross-sectional study. Adult Single-bed and multibed patient Nosocomial infection rate Intercorrelations were identified
ICU. Multicenter; patients. rooms; hand sanitizer dispensers; between specific ICU design
window operability attributes and patient infection
rates; recommended HVAC and
ventilation systems and features.
Teltsch et al. (2011) Nonrandomized comparative Single-bed and multibed patient Nosocomial infection rate The conversion to all single-bed ICU
study. Adult ICU. rooms rooms was found to reduce the
Multicenter; patients. occurrence of nosocomial patient
infections.
7. Portable Field Hospitals and Disaster Mitigation Including COVID-19
Auerbach et al. Cross-sectional study. Adult Respiratory isolation unit (RIU) Personal protective equipment Best practices presented to rapidly
(2020) ICU. Multicenter; (PPE), unit retrofitting retrofit existing hospital units into
COVID-19 patients. RIUs in support of PPE
requirements in emergency care.
Blackwell & Bosse Case study/policy. Mobile ICU. Mobile critical care clinic— Staff assessment, patient well-being, MED-1 is a vehicular first response
(2007) Vehicular; patients and staff. Hurricane Katrina and mortality rate critical care facility with onboard
mobile field hospital capabilities.
(continued)
19
20

Burnweit & Stylianos Case study/policy. NICU. Field hospital installation—Haiti Staff self-assessment of stress; facility Deployment of a portable NICU
(2011) Single center; staff and occupancy and mortality rate modular field hospital was
disaster victims. effective—a strategy advocated
for postdisaster strike zones in the
future.
Capolongo et al. Cross-sectional study: United Hospital design resiliency—United Futureproofing, functional Resilient hospital design and daily
(2020) States and ICU/hospital. States, Italy, and Austria performance, user participation, operational policies can increase
Multicenter; facilities. regional networking, patient critical care delivery capacity and
safety, HVAC systems, finish contribute to positive staff and
materials, and IT patient outcomes.
L. Chen et al. (2021) Case study/policy. ICU/ Wuhan Leishenshan 1,600-bed Patient safety, mortality rate, and Rapid construction of a hospital for
hospital. Single center; COVID-19 surge hospital. staff assessment COVID-19 critical care was
patients and staff. achieved using building
information modeling and
prefabricated modular
construction methods.
Z. Chen et al. (2020) Policy review. ICU/hospital. COVID-19 mobile field hospitals— Intubated patients and infection Mobile modular field hospitals were
Multicenter; patients and China control proven effective in isolating the
staff. sickest COVID-19 patients
located in proximity to existing
medical centers.
S. Chen et al. (2020) Case study/policy. ICU/ Fangcang field hospital and Patient safety, mortality rate, staff The rapidly constructed, modular
hospital. Single center; converted sports stadium— assessment, and performance prefab Fangcang Hospital was
patients and staff. Wuhan, China demonstrated to provide effective
critical care while meeting
COVID-19 emergency care
requirements.
(continued)

des Déserts et al. Case study/policy. ICU/ 30-bed portable military field Patient well-being and staff The deployment of the EMRSSA
(2020) hospital. Single center; hospital—France assessment mobile field hospital was
patients and staff. demonstrated to be effective
without compromising patient
safety nor the well-being of direct
staff caregivers.
Doshi et al. (2020) Case study/policy. Adult ICU. Telehospital and unit configuration Health status and staff assessment Telemedicine was demonstrated to
Single center; staff and and design support patient care and aid
patients. clinicians by conserving scarce
fiscal, medical, equipment, and
ancillary staff resources.
Fang et al. (2020) Case study/policy. ICU/ Fangcang field hospital and Isolation, disease containment, A case study of the rapid adaptation
hospital. Single center; converted stadium—Wuhan, mortality rate, and staff of a large-scale public venue into a
patients and staff. China performance host facility for a modular,
portable COVID-19 critical care
unit.
Flinn et al. (2020) Case study/policy. Adult ICU. Biocontainment unit(BCU) Staff first response performance The value of BCUs was
Multicenter; patients and and disease containment demonstrated in the diagnosis and
staff. treatment of COVID-19 patients.
BCUs preposition healthcare
facilities for future pandemics and
related crises.
Fortis et al. (2014) Systematic review essay. Adult Telemedicine-based ICU versus Staff performance and patient Advocates an innovative concept
ICU. Multicenter; staff and conventional ICU—United States well-being utilizing off-the-shelf technology to
patients. unify and standardize the ICU built
environment.
Keenan (2020) Policy review. Adult ICU. ICU design and archival data Facility resiliency and adaptive The resilience and adaptive capacity
Multicenter; staff and capacity of the built environment are
patients. central components in managing
the myriad challenges associated
with critical care hospital units.
(continued)
21
22

Kreiss et al. (2010) Case study/policy. ICU/field Portable hospital—Haiti Quality control, patient well-being,Highlights the minimization of staff
hospital. Single center; and staff satisfaction fatigue/burnout, surge capacity,
disaster victims and first and critical care field hospital
response staff. facility design as major emergency
response planning determinants.
Lee et al. (2019) Policy review. Portable field Archival data, portable field Staff performance and patient health Critical care field hospitals must
hospitals. Multicenter; hospitals, and global humanitarian status support human dignity,
disaster victims and first missions organizational accountability, and
response staff. political impartiality; provide
high-quality care; and be rapidly
deployed and commissioned in
postdisaster strike zones.
Lenaghan & Case study/policy. Adult ICU/ BCU Staff assessment Meaningfully engage direct care
Schwedhelm BCU. Single center; staff. providers in selecting the facility
(2015) planning and design team and then
charge direct caregivers as key
participants in the facility planning
and design process.
Louri et al. (2020) Case study/policy. COVID-19 Portable 130-bed military field Infection control, ventilation, Recommendations for site selection,
field hospital. Single center; hospital—Bahrain transiting, commissioning, and facility design, construction,
staff. siting deployment, infection controls,
circulation, materials management,
and waste disposal.
Owens et al. (2005) Case study/policy. NICU. Deployable Rapid Assembly Shelter/ Healthcare quality control, cultural Sociocultural norms and traditions of
Single center; first response Surgical Hospital—Iran values and norms, and knowledge high priority in NICUs in
staff and disaster victims. transfer postdisaster zones; facility features
and equipment recommendations
are provided.
(continued)

Pucher et al. (2014) Nonrandomized comparative Physical and virtual facilities—UK Environmental stress and staff VR was demonstrated as effective
study. Adult ICU/hospital. assessment tool in training and pretesting of
Single center; staff. hospitals and associated
infrastructure in preparation for
mass casualty events.
Santos et al. (2020) Case study/policy. Adult ICU. COVID-19 treatment facilities Patient safety and environmental Recommended best practices are
Multicenter; patients and control systems adapted in in-hospital COVID-19
staff. ICUs with respect to design and
operation of HVAC systems.
Sonmez & Cavka Case study/policy. COVID-19 Review of nine facility surge hospital Portable prefabricated modularity Design recommendations in the
(2020) surge hospitals. Multicenter; prototypes planning, design, construction, and
facilities. operation of COVID-19 treatment
facilities.
Wosik et al. (2020) Policy review. Adult ICU. Archival data and hospital-based Virtual telehealth, staff performance, Advocates the adoption of high-tech
Multicenter; staff and telehealth care and patient outcomes virtual healthcare diagnosis and
patients. treatment capabilities in U.S.
hospitals to expand medically
underserved populations’ access
to care.
Zangrillo et al. Case study/policy. Adult ICU. Retrofitting in-hospital ICU for Staff assessment and patient safety A redesigned in-hospital resulted in
(2020) Single center; staff and COVID-19 healthcare an increase in ICU healthcare
patients. services to a community in Italy
hard-hit by COVID-19.
Zhou et al. (2020) Case study/policy. ICU/NICU/ Huoshenshan Hospital—Wuhan, Construction of 10,000-bed Modular field hospital expressly
PICU. Single center; China temporary modular COVID-19 constructed for the COVID-19
facilities. surge hospital pandemic. Mortality rates and
infection control were achieved in
this specialized pandemic
healthcare facility.
(continued)
23
24

8. ICU Ecological Sustainability

Abo & Nour (2017) Case study/policy. Adult ICU. Unit configuration; Spatial Room occupancy and prefabricated Modular floor plan templates
Single center; facilities. movement analysis—Saudi Arabia modularity increase ecological sustainability
and yield life-cycle cost benefits.
Huffling & Schenk Case study/policy. Adult ICU. Community hospitals and Ecological sustainability Staff can minimize adverse ecological
(2014) General; facilities. comparative analysis health outcomes through energy
conservation, waste reduction,
and sustainable storage and
disposal of toxic chemicals
policies.
Marshall-Baker Case study/policy. NICU. Facility management Information resource compendium Recommended design standards for
(2006) General; facilities. and ecological sustainability ecological sustainability including
the Green Guide for Health Care,
Health Care Without Harm, and
Leadership in Energy and
Environmental Design.
McGain & Naylor Cross-sectional study. Energy, water, transport, materials Construction cost analysis and Ecological sustainability remains
(2014) ICU/NICU/PICU. General; procurement, and waste facility management inadequately addressed in hospital
facilities. management planning and design.
Institution-wide benchmark
policies/metrics are outlined and
advocated.
Paterson et al. Cross-sectional study, ICU/ Facility and Supply Chain Operational and Supply Chain Toolkit administrators in 6 Candian
(2014) NICU/PICU. General; Management Management hospitals proved effective in
facilities. identifying gaps in climate change
preparedness and facility resource
allocation.
Quaglia et al. (2014) Case study/policy. Military and disaster relief housing Compactness, light weight, Modular redeployable staff housing is
ICU/hospital. General; prototypes in support of critical transiting, energy efficiency, and an effective intervention in
disaster victims. care medicine origami-inspired geometries disaster strike zones and related
emergency contexts.
(continued)

Shepley et al. (2016) Nonrandomized comparative Observational assessment; Compendium of resources and Further research is advocated on the
study. NICU. Multicenter; materiality, equipment, water, organizations and ecological impact of NICU environments on
staff and administration. waste management, and biophilia sustainability patient, family, and staff well-being
through the lens of “green”
planning, design, and operational
best practices.
White et al. (2013) Policy review. NICU. General; Materiality, equipment, energy Ecological sustainability and daily Recommended best practices in the
administration and direct conservation metrics, and operations planning and design of ecologically
caregivers. biophilia sustainable NICU built
environments.
9. Recent Design Trends and Prognostications
Brown & Gallant Policy review/essay. Adult ICU. Acuity adaptability; decentralized Patient health status and staff Acuity-adaptable rooms should be
(2006) General; administration nurses station performance incorporated in hospital ICUs as
and direct caregiver staff. effective in improving patient care
and reducing capital expenditures.
Denham et al. Randomized pilot study. NICU, single-family room (SFR), Patient health status and staff NICU environment is critical for
(2018) NICU. Single center; staff OPBY assessment short- and long-term outcomes of
and patients. babies and should be designed to
better support the needs of all
users.
Halpern et al. (2017) Policy review/essay. Adult ICU. ICU capsule system and room and Prognostications ICU “Biosphere Capsules” are an
Single center; patients. bed monitoring effective intervention. Patient care
can be provided through the use of
VR technology.
Hamilton (2013) Policy review/essay. Adult ICU. Planning, design, and unit operations Patient–family satisfaction and staff Argues for evidence-based design
General; administration, performance strategies for ICU environments
caregiver staff, patients, and with input from all key user
families. constituencies/stakeholders.
Hamilton (2020) Policy review/essay. Adult ICU. Tele-ICU, e-ICU, and off-site Patient health status and staff Planning and design
General; staff. alternatives to hospital-based performance recommendations presented on
ICU settings ICU telemedicine as an innovative
healthcare technology.
(continued)
25
26

Harris et al. (2006) Cross-sectional study. NICU. Multimethod, SFR, OPBY Staff performance and patient SFR protocols found to yield higher
General; patients, family, and family well-being patient and family privacy levels,
and staff. staff satisfaction, and staff stress
reduction; capital construction
expenditures not notably
influenced.
Huisman et al. Policy review/essay. Hospital/ Unit configuration and design: Patient–family satisfaction The use of evidence-based research
(2012) ICU. General; patients, staff, Canada and the Netherlands in the design and construction of
and families. critical care settings can have
multiple positive, long-term
impacts on occupant well-being
and staff performance.
Iyendo et al. (2016) Case study/policy. Hospital/ Unit configuration and design Patient well-being and staff Artwork, daylighting, music/ambient
ICU. General; patients and attributes—Turkey and Nigeria performance sounds, and nature can function as
direct caregiver staff. positive, therapeutic distractions
for patients and staff, contributing
to patient healthfulness.
Kesecioglu et al. Policy review/essay. Hospital/ Unit configuration and design Patient safety and staff performance Occupant-centered ICUs result in
(2012) ICU. General; patients. attributes—the Netherlands higher levels of patient safety,
functionality, innovations in care
delivery, and adaptability in
anticipation of future
requirements.
Kwan (2011) Policy review/essay. Hospital/ Acuity adaptability: flex-up/ Patient health status and staff Acuity-adaptable patient rooms
ICU. General; patients and flex-down, universal single-stay performance growing in acceptance; further
direct caregiver staff. room research is needed on patient
health status and staff impacts.
Ong et al. (2019) Nonrandomized study. Adult Unit configuration and design Patient health status VR can improve the quality of the
ICU. Single center; patients ICU experience, reducing anxiety
and direct caregiver staff. and depression without adversely
impacting pain management, sleep,
and delirium occurrences.
(continued)

Rashid (2011) Case study/policy. ICU/NICU/ Innovative technology University-based studio design Recommended planning and design
PICU. General; university proposals strategies for the medical ICU of
students. the future in medical center
contexts.
Rashid et al. (2014) Cross-sectional study. Adult Unit configuration and design Staff assessment The largest ICUs studied were rated
ICU. Multicenter; direct amenity by staff as having the most
caregiver staff. supportive, well-appointed patient
rooms, adjacent circulation, and
staff work zones.
Rubert et al. (2007) Policy review/essay. Adult ICU. Unit configuration and design Environmental stress Stress-reducing design attributes
General; staff, patients, and (nature, air quality, family
families. engagement, art, music, and
aromatherapy) were found to
improve the hospitalization
experience for patients and
families.
Rybkowski et al. Policy review. NICU. General; Unit configuration and design Patient health status and staff Target value design is an effective
(2012) planning/design team. attributes assessment method in comparatively weighing
the merits and cost implications of
NICU semi-open versus private
patient room configurations.
Sessler (2014) Policy review/essay. Adult ICU. Patient room design and robotics Patient health status and staff “Smart” ICU environments can
General; patients, staff, and performance contribute to greater patient
administration. safety, satisfaction, higher family
satisfaction, and direct caregiver
performance.
(continued)
27
28

Stevens et al. (2010) Nonrandomized study. ICU/ Unit configuration and design Patient safety, health status, and staff Staff assessments were found to be
NICU. Multicenter; staff and amenity assessment significantly higher in private
patients. rooms compared to OPBY
conditions in a NICU setting.
Stichler (2012) Policy review/essay. NICU. Private patient–family rooms Patient and family well-being SFR demonstrated as an effective
General; patients, families, evidence-based design strategy in
and staff. renovated as well as newly
constructed NICU facilities.
Sundberg et al. Case study/nonrandomized. Unit configuration and design Acoustics, views of nature, and staff A redesigned ICU patient care room
(2017) Adult ICU. Single center; amenity—Sweden assessment resulted in increased staff
staff. well-being and staff performance.
Thompson et al. Policy review/essay. ICU/ Archival data—American College of Organizational behavioral The design quality of critical care
(2012) NICU/PICU. General; Critical Care Medicine management facilities has a direct impact on
administration and unit staff. organizational performance,
clinical outcomes, and the cost of
healthcare.
Valentin & Case study/policy. Adult ICU. Unit configuration and design Patient safety, well-being, and staff ESICM was demonstrated to be an
Ferdinande Single center; patients and amenity—Austria assessment effective strategy in the ICU
(2011) staff. planning and design process.
Zborowsky & Policy review/essay. ICU/ Critical care built environment Health promotion and well-being Healthcare facility planning and
Hellmich (2011) hospital. General; facility design professionals need to
design professionals. become more adept at
incorporating evidence-based
critical care design research best
practices.
Note. ICU ¼ intensive care unit; NICU ¼ neonatal ICU; PICU ¼ pediatric ICU; MRSA ¼ methicillin-resistant Staphylococcus aureus.
Verderber et al. 29
outcomes. Interventions primarily focused on absenteeism and employment vacancy rates

the use of live plants, access to outdoor therapy (Shepley et al., 2012). Pati and colleagues
gardens, and exposure to outdoor nature views (2008) also evaluated exterior nature views expe-
(Table 1). rienced by nursing staff, reporting improved
alertness levels and a decrease in stress. These
studies suggest that while nature-content views
Plants and Gardens per se are not associated with traditional ICU
Plants and gardens are often employed in hospi- patient outcomes measures, they likely contribute
tals to facilitate nature engagement within the to an improved work environment for healthcare
healthcare environment. Patients exposed to providers.
either plants or images of plants in hospital wait-
ing rooms report greater stress reduction as
Family Accommodations
compared to controls (Beukeboom et al., 2012).
Similarly, subjects presented with photos of hos-
in the ICU Environment
pital rooms containing plants report less stress Familial presence within the ICU environment is
compared to those shown photos of rooms with- increasingly recognized as a vital component of
out plants (Tanja-Dijkstra et al., 2008). Visiting the care of critically ill patients. In a qualitative
an outdoor garden can reduce sadness and stress study examining the experiences of families of
scores in families of hospitalized patients (R. S. children hospitalized in a PICU, MacDonald and
Ulrich et al., 2020). Nursing staff have reported colleagues (2012) described a frequent discon-
less burnout, feelings of depersonalization, and nect between family-centered medicine and the
emotional exhaustion after taking breaks in out- modern medical practice of intensive care. They
door gardens (Cordoza et al., 2018). These studies described this conceptually as a conflict between
demonstrate that live plants and hospital gardens the need for the ICU room to serve as the sick
are likely of therapeutic benefit to patients, staff, child’s “bedroom” as well as a workplace for
and families. healthcare professionals, and noise, privacy poli-
cies, and visitation restrictions may affect fami-
lies and healthcare providers in opposite ways.
Nature Views The principle of a “healing environment of care”
Windows and nature views are interventions to can be utilized to facilitate the engagement of
promote positive distraction and stress reduction families in the ICU by both promoting a thera-
in the ICU. Surgical ICU patients admitted to peutic relationship between patients, caregivers,
rooms with nature views experience a slightly and families as well as highlighting environmen-
shorter ICU length of stay compared to those in tal design strategies to support healing (Rashid,
rooms with views containing industrial informa- 2010). Guidelines for family support in the ICU
tional content, although notably, there is no dif- environment have suggested that single rooms
ference in hospital and ICU mortality, ICU should be utilized to improve patient privacy and
readmission rate, or delirium occurrences (Kohn should include dedicated family space (Davidson
et al., 2013). Similarly, patients with acute brain et al., 2007). It has also been suggested that gra-
injury admitted to windowed ICU patient rooms phics and wayfinding systems be implemented
demonstrate no difference in functional status, and waiting rooms be placed close in proximity
ICU–hospital length of stay, or mortality com- to patient rooms (Davidson et al., 2007). Updated
pared to those admitted to windowless rooms guidelines have reinforced the importance of pro-
(Wunsch et al., 2011). The effect of nature views viding single-bed rooms and noise reduction
in the intensive care environment on hospital staff strategies as well as sleep surfaces for families
has also been examined. A single-center study as environmental design interventions to facili-
evaluating outcomes after moving to a new tate family integration and suggest a checklist
ICU with more windows and nature views to assess ICU readiness for family-centered care
showed a statistically significant decrease in staff (Davidson et al., 2017). However, the authors
also acknowledge the paucity of research on how sleep accommodations, and common areas
the physical setting can optimally improve family for interaction with staff may help improve
engagement in the ICU. Review of the recent family engagement at bedside in support of the
literature revealed 12 studies describing various critically ill.
environmental design interventions in support
although there have been no randomized trials,
to date. These measures have focused on improv- ICU Spatial Configuration
ing family and patient privacy, including desig- and Amenity
nation of “family” corridors adjacent to or within Despite extensive research regarding ICU config-
the ICU (Table 1). uration and ergonomics, performance obstacles
related to the physical environment continue to
Dedicated Family Spaces be frequently identified by nurses, such as room
disorganization, noisy and crowded workspaces,
Dedicated family space at bedside is associated and insufficient areas dedicated to medical docu-
with an increased proportion of visitors at night mentation (Gurses & Carayon, 2009). The review
(Hunyh et al., 2020). Family-initiated conversa- team found 22 articles, with 10 nonrandomized
tions with healthcare providers are higher in ICUs comparative studies, nine cross-sectional studies,
that utilize a shared provider–family hallway two opinion essays, and one systematic review.
space as opposed to units with separate hallways Interventions have focused on single versus mul-
for healthcare staff and families (Rippin et al., tibed room modules, nursing station typology,
2015). Critical care units that employ visibility patterns in the ICU, and workplace
noise-reduced, single-bed patient rooms that performance obstacles (Table 1).
incorporate daylight and dedicated washroom
facilities for families have been associated with
higher family satisfaction scores (Jongerden
Nurse Station Design and ICU Layout
et al., 2013). For families of patients admitted In a review of adult ICU design in the United
to a neurotrauma ICU, physical environment States, Catrambone and colleagues (2009) identi-
attributes that correlated with family satisfaction fied four predominant unit configurations, with a
included noise level, size of the waiting room, “U-shaped design” being most common, fol-
private spaces, and washroom facilities lowed by “spokes/no end station,” “parallel
(Peterson et al., 2020). Structured interviews with corridor,” and “surrounded” configuration. Spa-
nurses of dying patients in the ICU have high- tial configurations are often classified as centra-
lighted that families commonly desire spaces lized, decentralized, and hybrid based upon
allowing both privacy and togetherness and nursing station type. Unit layout affects interac-
connection with other family members (Fridh tions and communication patterns between
et al., 2009). In a multisite family satisfaction healthcare providers, with a reported lower fre-
survey evaluating family sleep location, the care- quency of physician–nurse communications and
givers of children admitted to PICUs were most social interactions in decentralized ICUs
likely to report sleeping in the child’s room, (Zborowsky & Hellmich, 2011). Layout design,
followed by their own home and then a shared visibility patterns, and accessibility were identi-
family accommodation program (Franck et al., fied in a systematic review of healthcare physical
2015). However, other studies demonstrate a sub- design attributes that impact teamwork and com-
stantial proportion of family members reporting munication (Gharaveis et al., 2018). In consider-
sleep disturbance and poor sleep quality in ICU ation of the general hospital built environment,
waiting rooms, suggesting that hospital accom- decentralized nursing stations have been associ-
modations are inadequate for quality sleep ated with improved documentation practices, less
(Day et al., 2013; Stremler et al., 2014). These steps taken, decreased energy expenditure by
studies suggest that design interventions such as healthcare providers, and better utilization of
single-bed rooms, dedicated family space, family medication and supply rooms; however, they
Verderber et al. 31
have also been associated with a decrease in patient observation, creating opportunities for
nurse-to-nurse collaborations and teamwork macrocognition and cognitive adaptation to com-
(Copeland & Chambers, 2017; Pati et al., 2015; plex situations. For severely ill patients admitted
Real et al., 2016). In a systematic review evaluat- to the ICU, one study found a significantly higher
ing decentralized nursing station design, there hospital mortality rate in patients admitted to
was a notable decline in nursing teamwork in the rooms with low visibility from the central nursing
decentralized models (Fay et al., 2019), highlight- station (Leaf et al., 2010). Lu and colleagues
ing systems-level challenges posed by the intro- (2014) further evaluated visibility patterns and
duction of the decentralized unit (Real et al., demonstrated that both the field of view of the
2016). In a theoretical essay, Hamilton and col- patient’s head and the room’s distance from the
leagues (2018) indicated that concerns regarding nursing station accounted for differences in mor-
travel distance and visibility challenges in the tality. Patient visibility can also be improved
decentralized unit may be related to corridor through the design of wider corridors; fewer
design and overall size of the ICU. Systematic small, convex spaces; and shorter travel distances
field observations have also demonstrated an (Hadi & Zimring, 2016).
association between spatial design and healthcare
worker interaction–related behaviors in adult
ICUs (Rashid et al., 2014). In this study, interac-
Single and Multibed Rooms in Intensive Care
tions that occurred while sitting tended to occur in The adoption of the all single-bed ICU unit has
areas that facilitated environmental awareness provided an opportunity to evaluate correspond-
and visibility. ing patient, staff, and family outcomes. Numer-
As a method to better understand the complex ous studies have reported higher family
interaction between ICU spatial configuration, satisfaction scores in single-bed ICU rooms as
healthcare provider interactions, and communica- compared to multibed rooms and often cite
tion patterns, Cai and colleagues proposed a enhanced privacy as a key driver of this associa-
system of spatial measures to better evaluate nur- tion (Apple, 2014; de Matos et al., 2020; Stevens
sing station typology (Cai & Zimring, 2012). In et al., 2012). Hospital staff have also reported
this approach, integration, team distance, and peer improved quality of the work environment and
distance were utilized as spatial metrics to under- enhanced patient safety in single-bed rooms
stand unit layouts, demonstrating a strong correla- (Bosch et al., 2012; Stevens et al., 2012). Conver-
tion with nurses’ physical location, awareness of sely, single-bed rooms have been associated with
colleagues, and interactions with other providers. higher staff stress (de Matos et al., 2020),
This suggests it may be useful to consider team increased travel distances, steps per nursing shift
distance and peer distance in addition to patient (Stevens et al., 2012), and feelings of staff isola-
visibility patterns when evaluating nursing station tion and difficulty with obtaining assistance from
and ICU spatial configuration. colleagues (Apple, 2014). Hybrid room designs
Visibility remains an important component of consisting of two single-patient rooms connected
ICU design with implications for both healthcare by a shared space for documentation and monitor-
provider workflow and patient outcomes. Physi- ing have been proposed as a solution to the com-
cians and nurses often differ in preferred work- peting interests between single and multibed
flow locations, with nurses proportionally rooms. Hospital staff working in hybrid ICU
favoring areas with higher targeted visibility room configurations report efficient patient obser-
toward patient beds and physicians favoring areas vation, enhanced collaboration between health-
with generic visual connectivity and large open care workers, and improved patient privacy as
spaces (Lu & Zimring, 2011). In a single-center compared to multibed rooms (Apple, 2014).
study evaluating the PICU environment, O’Hara The prevention of ICU-associated delirium
and colleagues (2018) concluded that maximiza- has gained increased focus due to its association
tion of visibility through the design of corner with length of stay, patient morbidity, and mor-
work zones can enhance team interactions and tality, with room configuration emerging as a
modifiable environmental risk factor. Adult shifts (Carvalho et al., 2005; Kawai et al., 2019;
patients admitted to multibed ICU rooms are Matook et al., 2010) and during weekdays, com-
four times more likely to develop delirium compared to weekends (Christensen, 2007). Noise
pared to those admitted to single-patient rooms levels also increase over time in the NICU setting
(Caruso et al., 2014). Age also appears to be an and appear to be attributable to age-related
important factor in understanding the relation- changes in bed type and respiratory support
ship between ICU room configuration and delir- equipment needs (Lasky & Williams, 2009).
ium. Arenson and colleagues showed that there Common sources of ambient noise include equip-
was no difference in delirium prevalence ment such as monitors and alarms, hospital staff
between single- and multibed rooms for those conversations at nurses stations, and handovers
greater than 65 years of age; however, patients between ICU and operating room teams at bed-
less than 65 years of age demonstrated a greater side (Carvalho et al., 2005). Careful consideration
proportion of delirium days when admitted to of noise pollution must occur when introducing
multibed ICU rooms compared to single-bed new equipment and technologies, as evidenced by
rooms (Arenson et al., 2013). a report describing a marked increase in noise
levels after the addition of motion-sensing motor-
ized paper towel dispensers and a new audio com-
Noise Considerations in ICU munication system (Brandon, et al., 2007).
Environments Postdischarge surveys demonstrate that patients
often recall various ICU noises and sounds
Various organizations have proposed noise-level (Johansson et al., 2012). Healthcare workers in
guidelines for the hospital setting. The World
the ICU environment also report that elevated
Health Organization has recommended hospital
noise levels contribute to feelings of fatigue, dif-
noise levels not exceed 35 decibels during the day
ficulty concentrating, and tension headaches
and 30 decibels at night, with nighttime noise
(Ryherd et al., 2008).
peaks less than 40 decibels (Berglund et al.,
1999). The American Academy of Pediatrics
(1997) has recommended noise levels not exceed
45 decibels in the NICU setting. There have been Design Interventions to Decrease Noise
15 recent studies published regarding noise levels
in the ICU environments (n ¼ 5 NICU, n ¼ 4 Multiple environmental interventions have been
PICU, n ¼ 6 adult ICU). Published studies focus evaluated as potential modifiers of ambient noise.
on the themes of measured ambient noise in the Some studies have reported that single-bed ICU
ICU versus common noise sources, the effect of rooms have lower sound levels compared to mul-
ambient noise on patients and staff, and tibed rooms (H. L. Chen et al., 2009; Kol et al.,
design-based mitigation strategies (Table 1). 2015), although others have shown no difference
(Kramer et al., 2016). Wang and colleagues (2013)
reported a decrease in average and maximum noise
Noise Levels and Stress levels in patient care areas after the addition of a
Measured ambient noise often exceeds recom- dedicated service corridor. Architectural features
mended levels in adult ICUs (Christensen, such as soundproof headwalls to separate patients
2007; Macedo et al., 2009; Ryherd et al., 2008), from medical equipment and an anteroom between
PICUs (Carvalho et al., 2005; Kawai et al., 2019), the patient room and corridor result in reduced aver-
and NICUs (H. L. Chen et al., 2009; Lasky & age and maximum sound levels in ICU rooms
Williams, 2009), with average noise levels rang- (Leutz et al., 2016). A multiphase quality improve-
ing from 48 to 70 decibels and maximum levels ment initiative in a NICU demonstrated that
ranging from 67 to 120 decibels. Temporal stud- lowering equipment alarm sounds was associated
ies of ambient noise demonstrate higher levels with an overall reduction in noise levels (Chawla
during morning shifts compared to evening/night et al., 2017).
Verderber et al. 33
Artificial and Natural Lighting light therapy involves periodic variation of ambi-
in ICU Environments ent light levels in indoor environments and has
been suggested as an intervention to decrease the
Hospital building codes emphasize that lighting incidence of ICU delirium. However, a recent
should be tailored to facilitate the diverse needs randomized control trial evaluating the effect of
of healthcare staff, with a recommended level of dynamic light application on the incidence of
30 lux for circulation areas, 300 lux for observa- delirium was concluded early due to futility and
tion and medical documentation areas, and lack of improved outcomes (Simons et al., 2016).
between 3,000 and 10,000 lux in critical exami- Adult ICU patients admitted to rooms with natu-
nation and procedural areas (Shepley et al., ral daylight experience slightly shorter length of
2012). The American Academy of Pediatrics stays compared to those with primarily artificial
(2002) has recommended a maximum light level light sources, although notably, there appears to
of 646 lux in NICU environments. Measured light be no difference in hospital and ICU mortality,
levels in the ICU often fall within guideline rec- ICU readmission rate, delirium, sedative use, and
ommendations (Lasky & Williams, 2009). A total analgesic requirement (Kohn et al., 2013;
of 10 recently published studies on lighting in the Verceles et al., 2013). Together, these data sug-
ICU were identified (n ¼ 5 NICU, n ¼ 5 adult gest further research is needed to better under-
ICU), focusing on ambient lighting levels, light stand targeted patient populations and outcomes
sources, light-mitigating interventions, and in the use of light as a therapeutic modality.
patient outcomes (Table 1).
Light Interventions in the ICU Environment ICU Patient Safety

Light source and level of illumination are fre- and Infection Control
quently identified as modifiable variables. Infants Hospital built environments have been modified
exposed to lower minimum and maximum illumi- to decrease medical errors and improve patient
nation levels in the NICU experience less peri- safety and infection control. Design interven-
odic breathing and awake time (Stevens et al., tions employed include minimizing ambient
2007). An NICU-cycled light strategy throughout noise, judicious use of lighting to facilitate task
the day versus continuous bright light, or near completion, and single-bed patient rooms. The
darkness, resulted in shortened hospital length review team identified 11 studies evaluating
of stay in premature neonates (Morag & Ohlsson, these types of environmental design interven-
2015). Subtle variations in ambient light levels tions (Table 1).
have also been associated with increased awaken-
ing in premature neonates, suggesting that design
interventions to modify abrupt changes in light-
ICU Environment Infection Control Measures
ing may affect NICU outcomes (Zores et al., Single-bed ICU rooms have been investigated as
2018). In a systematic review, it was concluded a design intervention to decrease nosocomial
that changes in light level should be gradual, light infections. In a single-site study, Levin and col-
mitigation protection should be used for infants leagues (2011) demonstrated that adult patients
less than 32 weeks corrected gestational age, and admitted to a single-bed room acquired fewer
premature infants should not be exposed continu- antibiotic-resistant infections during their stay.
ously to high light levels (Zores-Koenig et al., Bracco et al. (2007) demonstrated that patients
2020). admitted to single-bed rooms had lower relative
Light exposure has been studied as a modifi- risk of acquisition of methicillin-resistant Staphy-
able intervention. Rompaey and colleagues lococcus aureus (MRSA), Pseudomonas aerugi-
(2009) evaluated ICU environmental risk factors nosa, and Candida spp. compared to those in
and demonstrated a lack of natural light as a risk multibed rooms. Bloemendaal and colleagues
factor for delirium. The technique of dynamic (2009) also reported less acquisition of MRSA
in single-bed rooms. Similarly, Teltsch and col- Portable Field Hospitals

leagues (2011) demonstrated that conversion and Disaster Mitigation
from multibed to single-bed ICU rooms was asso- Including COVID-19
ciated with a lower nosocomial infection rate
compared to a control multibed unit. However, The rapid proliferation of the deadly coronavirus
moving adult ICU patients with documented in 2020 prompted healthcare provider organiza-
MRSA to isolation rooms or cohorted multibed tions globally to confront a major public health
rooms does not significantly reduce cross- crisis and reassess their in-house facility infra-
infection rates (Cepeda et al., 2005). Stiller and structure (Auerbach et al., 2020; S. Chen et al.,
colleagues collected data on structural design ele- 2020; Z. Chen et al., 2020; Keenan, 2020).
ments in German ICUs to examine hospital archi- COVID-19 precipitated innovative responses in
tecture in the context of nosocomial infection ICU built environments, and in telemedicine, in
occurrences. The findings demonstrated only particular. Wosik et al. (2020) examined teleme-
minor associations between architectural design dicine applications in numerous hospitals in the
factors and ICU-based infection, suggesting that context of the pandemic, specifically, ICU patient
respiratory functions, and space requirements for
design features were subordinate to more primary
ventilator equipment (Doshi et al., 2020). Fortis
drivers of infection control (Stiller et al., 2017).
et al. (2014) demonstrated that telemedicine,
Additional design interventions, such as the intro-
effectively implemented, can reduce healthcare
duction of a whole-room atomization system
costs while improving patient outcomes, enabling
for use in conjunction with standard cleaning
patients to be cared for vis-à-vis virtual bedside
practices, have been demonstrated to decrease
consultation (Table 1).
bacterial counts in vitro (Reynolds et al., 2020).
Rapid Responsiveness
Adverse Outcomes and Patient Safety In France, direct care provider involvement is
urged from the earliest facility planning stages
Healthcare environmental design has been utilized
to operationalization and staffing (des Déserts
to promote patient safety. Lighting, nature and et al., 2020). In Wuhan, China, two 10,000-bed
nature representations, and virtual reality (VR) Fangcang shelter hospitals were constructed in
interventions have correlated with improved pain March 2020 (S. Chen et al., 2020; Z. Chen
management (Malenbaum et al., 2008). For et al., 2020; Owens et al., 2005); building infor-
severely ill patients admitted to the ICU, a signif- mation modeling (BIM) technology and modular
icantly higher mortality rate occurred for those composite building finished products were uti-
admitted to rooms with low visibility from the lized to design and construct the modular Wuhan
central nursing station compared to rooms with Leishenshan Hospital in 2 weeks. All interior
higher visibility (Leaf et al., 2010). However, floors, exterior walls, and heating, ventilation,
admission to a room with high visibility was not and air-conditioning (HVAC) systems were
associated with an improved outcome for trauma designed using BIM (L. Chen et al., 2021). Best
patients (Pettit et al., 2014), indicating that visibi- practices in biocontainment unit facility planning
lity is but one factor in understanding the complex- and design have been developed (Flinn et al.,
ities of ICU patient safety. New frameworks to 2020; Lenaghan & Schwedhelm, 2015). These
facilitate incorporating human factors and ergo- facilities are reliant on preexisting technological
nomic principles into systems engineering models infrastructure, that is, site utilities, access to trans-
for improved patient safety often incorporate ele- port routes to maintain supply chain continuity,
ments of the physical environment (Carayon et al., telecommunications support, and availability of
2020), thus underscoring the need for continued installation sites ranging from community centers
research to better understand this dimension of to sports stadiums and to open fields (Fang et al.,
ICU hospitalization. 2020). Field hospital installations must be quickly
Verderber et al. 35
constructible, cost-effective, and reduce capacity of ethical, humanitarian principles in critical care
pressures on nearby conventional medical facili- emergency response contexts preserves human
ties (Keenan, 2020; Louri et al., 2020; Pucher dignity (Lee et al., 2019).
et al., 2014; Zhou et al., 2020). The Fangcang
shelter hospitals had the advantage of construct-
ability on immediately available land parcels. As ICU Ecological Sustainability
noted by both Kreiss et al. (2010) and Burnweit &
Stylianos (2011), traditional medical technolo- Sustainability and Efficiency
gies must be adaptable to emergency field hospi- The day-to-day operations of hospital ICUs con-
tal environments, specifically, negative air tribute to the depletion of the earth’s natural
filtration HVAC system design (Santos et al., resources (McGain & Naylor, 2014). The Green
2020). Ten strategies were recently outlined to Guide for Health Care program articulated
guide the design and operations of resilient hos- planning and architectural design criteria for
pital environments (Capolongo et al., 2020). Dur- sustainable best practices in hospital design, con-
ing the COVID-19 pandemic, a regional hospital struction, operation, and maintenance (Marshall-
in Italy was repurposed for cardiovascular emer- Baker, 2006). Ecologically based energy efficiency
gencies. This new role required an increase in is increasingly a baseline minimum criterion essen-
ICU bed capacity and support spaces (Zangrillo tial to achieving longer term facility operational
et al., 2020). In the United States, the MED-1 efficiency. An ICU’s physical layout impacts
mobile vehicular field hospital, first deployed in energy consumption; single-bed rooms in hospitals
the aftermath of Hurricane Katrina in New have been linked with reduced infection rates but
Orleans in 2005, has proven adaptable in diverse can contribute to higher overall energy consump-
site installation contexts (Blackwell & Bosse, tion levels (Huffling & Schenk, 2014). Trades-offs
2007; Burnweit & Stylianos, 2011) Vehicular- are necessary to balance higher initial construction
based and modular surge field hospitals must costs with reduced recurring, life-cycle operational
house advanced equipment allowing for rapid expenses. Further research is needed on this issue
reconfiguration in the field as needs evolve (Lee including the impacts of floor template size, con-
et al., 2019). A recent review was conducted of figuration, and the use of energy-star-rated equip-
nine COVID-19-inspired hospital prototypes put ment (McGain, 2014).
forth by international architectural firms. The Flexible space has been demonstrated as the
major findings include individualized patient key in achieving ecologically efficient ICU built
treatment modules, dedicated service corridors, environments. Flexible space includes spatial
and negative air pressurization filtration systems buffer zones, efficient internal circulation (with-
(Sonmez, 2020). out sacrificing spaciousness), variable ceiling
Intensive care must be adaptable to on-site heights and configurations, phased campus
determinants in humanitarian disaster relief con- design and construction, and the sensitive integra-
texts (Blackwell & Bosse, 2007; Lee et al., 2019). tion of buildings into their environmental
Organizational effectiveness, appropriate techni- contexts (Paterson et al., 2014). ICUs can benefit
cal support, and staff intercommunication are of in this regard from multifunctionality, that is,
paramount importance in effective facility oper- acuity-adaptable patient rooms, equipment, and
ations (Lee et al., 2019). First response pediatric interior amenities. Ecological efficiency in ICUs
care, including NICUs, should be available in is attainable by means of standardization and
postdisaster contexts (Burnweit & Stylianos, modularity without compromising flexibility and
2011). The provision of triage assessment is of adaptability (Abo & Nour, 2017). Ecological
utmost priority (Kreiss et al., 2010). Cross- design variables include the structural system,
cultural differences between patients, caregivers, cladding type, window/wall system,
and families must be accounted for in the delivery window-to-wall area ratio, number of treatment
of healthcare in unfamiliar postdisaster strike bays, and bay width (Valentin, A., & Ferdinande,
zones (Owens et al., 2005). The ethical integration P, 2011). Innovative geometries have been
studied in the design of ecologically efficient spe- are easily cleanable. Off-gassing of materials
cialized care units. Recent origami-inspired crit- remains a persistent concern due to the potential
ical care structures with thermally insulated rigid deleterious impact of airborne toxins, with particu-
walls include the Level Shelter Module, a system lar attention accorded infant incubators
featuring polymorphic shape optimization in the (Marshall-Baker, 2006; Shepley, 2016). Smart
attainment of life-cycle energy efficiencies lighting systems produce full-spectrum lighting—
(Quaglia et al., 2014). a health-promoting alternative to conventional
fluorescent fixtures, combined with natural day-
lighting and person–nature biophilic affordances.
Reduction of Carbon Emissions
Standards currently exist for sustainable NICU
and Biohazardous Waste design and construction, that is, floor plan layouts,
ICU environments require highly energy- materials of construction, and equipment and fur-
intensive equipment that produces significant tox- nishings (White et al., 2013). These resources
ins and as such can pose a threat to the well-being include Health Care Without Harm, Envirofacts
of building occupants (Huffling & Schenk, 2014). Master Chemical Integrator, Leadership in Energy
McGain et al. (2014) selectively studied hospital and Environmental Design, The Green Guide for
occupants’ energy consumption patterns: water Healthcare, and the sixth edition of the Recom-
consumption, materials procurement, toxic waste mended Standards for NICUs (Marshall-Baker,
generation, and closely related in-unit behaviors. 2006).
Larger scale systems including cogeneration, solar
thermal, and ground-sourced heat pumps have
also been studied recently. Research is needed to Recent Design Trends
further understand the behaviors, attitudes, and and Prognostications
organizational culture imperatives, that is, staff
ICU–NICU Spatial Configuration
dismissiveness, within ICUs to further increase
ecological sustainability quotients, with increased
(Circulation, Flow, Size, and Amenity)
collaboration between key stakeholders, including A distinct shift is underway from mixed-specialty
clinicians, engineers, architects, and equipment to single-specialty ICUs featuring innovative
specialists (McGain, 2014). Nursing staff are “racetrack” circulation typologies (Rashid,
encouraged to advocate for energy-star-rated 2014). Such wraparound circulation pathways
equipment, programmable diagnostic and moni- help to avoid bottlenecks, undue congestion, and
toring equipment, and window screens blocking promote wayfinding. In addition, along with effi-
solar gain during the day and operable at night. ciently configured circulation, patient room num-
ICU staff should routinely recycle–reuse equip- bers should be clearly marked, with systematic
ment thereby reducing overall material consump- directional signage. Currently, same-handed, sin-
tion, participate in “green teams,” and initiate gle rooms are increasingly preferred versus
commuter carpools and community outreach larger, multibed rooms (Table 1). The rationale
programs to minimize the hospital’s ecological is patient safety, although concern persists with
footprint (Huffling, 2014). regard to fitting medical equipment into these
The sustainable design movement, to date, has reduced-in-size spaces. In addition, discrete yet
had relatively little direct influence on hospital layered multiple zones are advocated, consisting
intensive care built environments. Finish wall, of patient room, family support, unit-wide sup-
flooring, and ceiling materials are often proble- port, and clinical support zones (Thompson
matic insofar as they possess substances that can et al., 2012). Sundberg et al. (2017) concluded
emit toxins into the ambient room environment. that the involvement of critical care nursing staff
In response, recent data suggest these finish surface in the design of evidence-based ICU environ-
materials are specified to be nontoxic, including all ments has a direct impact on subsequent staff
ceilings, waste management, water-efficient fix- well-being and caregiving behaviors. This was
tures, wall and floor surfaces, and furnishings that found through interviews with critical care nurses
Verderber et al. 37
combined with qualitative analysis (Sundberg templates, equipment requirements, life safety
et al., 2017). criteria, and central hospital support interdepen-
NICUs are shifting toward single-family dencies. Kesecioglu et al. (2012) examined the
rooms (SFRs) but for slightly different reasons: recent literature on ICU design in relation to
to facilitate families’ greater engagement, patient-centered care, unit functionality, infection
improve infection control, and minimize expo- control, building-related life safety issues, and
sure to adverse environmental stimuli (Denham “futureproofing.”
et al., 2018). Infant maternal bonding, noise miti- Halpern et al. (2017) examined the efficacy of
gation, improved staff satisfaction and morale, the Biosphere Capsule in capturing the essential
family zones, privacy, adequate space for routine aspects of an ICU through the application of VR
activities on the part of staff and families alike, headsets as a means to improve user participation.
and staff–family communications are of high pri- Hamilton (2020) discussed in detail the future of
ority (Harris et al., 2006; Stevens et al., 2010). the ICU in terms of its spatial configuration,
From the perspective of staff direct caregivers, equipment, furnishings, the therapeutic function
excessive noise and poor illumination are persis- of natural daylight, and increasing role of
tent hindrances in ICU built environments tele-ICU and e-ICU protocols in improving the
(Stevens et al., 2010). The utilization of VR tech- design support provided by the built environment.
nology in the planning and design process has been Using an architectural university design studio as
demonstrated to improve the ICU experience (Ong a laboratory, Rashid (2014a), Rashid et al (2014b)
et al., 2019). Also, the use of “meditative VR” has examined innovative medical and building tech-
been shown to reduce anxiety and depression nologies, and Sessler (2014) examined the poten-
among patients, although it has not yet been linked tial role of Smart ICU built environments in
with significantly improved sleep or pain manage- improving unit functionality, patient health sta-
ment outcomes (Harris et al., 2006). The ability of tus, and staff performance.
patients and families to self-regulate lighting and
temperature levels has been empirically linked
with improved well-being and satisfaction
Acuity Adaptability
(Thompson et al., 2012). The acuity-adaptable room unit model and its
Zborowsky & Hellmich (2011) discussed the manifestations in hospital intensive care have
importance for healthcare design professionals to been the subject of increasing research attention.
better understand the needs and preferences of This concept can yield enhanced individualized
patients, families, and staff and that this goal is zones for patients, families, and staff and is adap-
best achievable by means of data transparency table to ever-evolving technological innovation
and reliance on the synthesis of qualitative as well (K. K. Brown & Gallant, 2006). Its core variants—
as quantifiable health status outcomes. Nurses, flex-up, flex-down, universal room, and single-stay
ideally, can function as lead standard-bearers in units—in addition to the core original acuity-
this evidence-based research effort as they are adaptable patient room template first introduced
most directly immersed, daily, and as such can in the 1990s, are predicted to be more widely incor-
inform design professionals in understanding porated in ICUs in the coming years (Kwan, 2011).
patient safety and infection control measures,
quality improvement, and the key support role
of the built environment regarding occupant satis-
Single Family Versus Semiprivate Rooms
faction and well-being (Zborowsky, 2011). Many NICUs in North America are being trans-
Valentin & Ferdinande (2011) discussed an envi- formed from small-scale open wards to single
ronmental assessment tool (ESICM) that seeks to rooms. Rybkowski et al. (2012) presented a set
capture functional criteria in construction. This of facility planning principles defined as Target
tool records on an ICU room-by-room basis daily Value Design for application in the transition
and hourly activity-occupant needs criteria and from all semiprivate (open bay) to SFR NICUs.
recommends feasible spatial configuration In addition, the SFR model and its ramifications
for patient, nursing, and family satisfaction with pain. Their investigation, however, did not
the physical setting are described as a recent include the 2003 SARS pandemic nor general
evidence-based, applied strategy for renovating pandemic considerations in planning and design-
existing and constructing new ICUs. It is pre- ing ICU built environments—because scant
dicted that the SFR model will become more evidence-based research existed on that subject
widely advocated by clients and their commis- at the time. Since then, pandemic concerns in the
sioned design teams (Stichler, 2012). ICU milieu have dramatically risen in importance
in conventional hospitals, adjunctive surge capac-
Holistic Strategies ity isolation settings, and in postdisaster portable
field hospital contexts.
Hamilton (2013) has argued for further applica- The ICU multiuser environment, as a work-
tion of evidence-based design in the medical place for ICU professionals, a place of care for
intensive care milieu, as this will improve the patients, and a place for connection with patient
quality of care for patients, families, and yield families and other loved ones, is of enduring, cen-
more supportive work conditions for direct care- tral importance. This comprehensive review has
givers. Huisman et al. (2012) examined the phys- underscored the therapeutic importance of nature
ical environment’s fundamental, timeless effects and outdoor views, the deleterious impact of noise
on health status outcomes. This is achievable as a stress source, the increasingly important inter-
through systematic assessment of occupant ventional role of families, the acceptance of the
well-being, that is, the experience of patients, all-private-room ICU, and the continued call for
family, and staff together with systematic, itera- evidence-based research on reducing medical
tive assessment of technical support systems errors and concomitantly increasing patient safety
including materiality, space planning attributes, and infection control. Also underscored is the role
interior amenities, and relationship to central hos- of ecological sustainability in design, construction,
pital support services. Therapeutic design inter- and daily operations—and climate change–related
ventions in critical care units have been shown to disaster-responsive and pandemic architecture for
provide positive distractions for patients and their health in support of public health crises
direct caregivers. Artwork, natural and artificial (Verderber, 2021). As for the plight of direct care-
lighting, views to the exterior environment and givers, the COVID-19 pandemic has been difficult
landscape, access to gardens, noise minimization for frontline nurses and others who witnessed
on the unit, ambient music and soundscapes, ther- firsthand such widespread suffering and death
apeutic color palettes, maximizing one’s sense of (T. Brown, 2021).
personal control and privacy, the provision of social
supports, healthful air quality, cleanliness, and The ICU multiuser environment, as a
maintenance collectively contribute to a positive workplace for ICU professionals, a place
hospitalization experience (Iyendo et al., 2016). of care for patients, and a place for
In short, a reduction in physical setting–emanating connection with patient families and other
environmental stressors in the ICU can mitigate
loved ones, is of enduring, central
adverse outcomes (Rubert et al., 2007).
importance.
In Table 2, a summary of the findings of this
Summary and Conclusions comprehensive review of the literature is pre-
In 2004, R. S. Ulrich, et al. concluded that sented. The 135 source citations are categorized
evidence-based research and design had by then in two groupings: quantitative investigations and
demonstrated meaningful engagement with qualitative investigations/essays. Within each
nature and landscape is preferred during hospita- type, findings or assertions of positive outcome,
lization. Staff, family, and patient-centric built no effect, or a negative outcome are denoted. This
environment amenities have positive impacts on overview can serve as a basis for identifying areas
satisfaction, with a role in decreasing patients’ warranting further research. Research content
Table 2. ICU Built Environment Literature (2005–2020): Quantitative Investigations, Qualitative Investigations/Essays, and Associated Outcomes.
Nature Dedicated Decentralized Acuity- Virtual
Single-Bed Plants/ Views and Family Nursing Unit Natural Adaptable Reality Telemedicine Portable Field Participatory
Design Intervention Rooms Gardens Art Space Station Configuration Visibility Light Rooms Technology Capability Hospital Design
Number of studiesa 16b (6)c 4 5 (3) 5 6 4 (20) 2 3 (2) 1 (3) 3 (3) 1 (6) (14) (9)
Patient outcomes
Stress reduction (þþ) þþ (þ) (þ) þ(þþ)
Shorter ICU LOS þ (þ) þ (þ)
Reduced ICU 00 (þþþþ) þþ0 0(þ) (þþþþþþþ)
mortality
Decreased delirium þþ 0(þ) þ0 (þ)
Decreased ambient þ0 þ(þ) (þ)
noise
Decreased þþþþ00(þ) (þþ) (þ) (þþþþ)
infections
Decreased pain þ þ0 þ(þ) (þ)
Improved patient þ(þþ) (þþ) (þ) (þ) (þþþþ) (þþþþþþ) (þþ)
safety
Family outcomes
Reduced family (þ) þ
stress
Facilitate family þ þ (þ)
engagement
Improved family þþþ(þ)þ þþþþ (þ)
satisfaction
Improved þ
communication
(continued)
39
40
Nature Dedicated Decentralized Acuity- Virtual

Single-Bed Plants/ Views and Family Nursing Unit Natural Adaptable Reality Telemedicine Portable Field Participatory
Design Intervention Rooms Gardens Art Space Station Configuration Visibility Light Rooms Technology Capability Hospital Design
Number of studiesa 16b (6)c 4 5 (3) 5 6 4 (20) 2 3 (2) 1 (3) 3 (3) 1 (6) (14) (9)
Staff outcomes
Stress reduction (þ) þ (þ) (þþ) (þ)
Decreased staff þ (þ) (þ) (þþ)
burnout
Improved staff (þ) þ(þ) þ (þþþþ) (þ) (þ)
efficiency
Improved (þþ)þ (þ) (þ) (þþþ)
collaboration
Systems outcomes
Reduced energy (þ) (þþþ) (þ) (þ)
consumption
Reduced healthcare (þ) (þ) þ
costs
Design criteria (þ) (þþþþþ) (þ) (þ) (þþ) (þþþþþþ)
Note. ICU ¼ intensive care unit; LOS ¼ length of stay; quantitative investigation: þ beneficial effect observed on the studied outcome; 0 neither beneficial nor harmful effect as there is no effect or
the study sample is too small; negative effect observed on the studied outcome; qualitative investigation/essay: (þ) beneficial effect observed on the studied outcome; () negative effect
observed on the studied outcome.
a
Some literature sources are cited in more than one column. bQuantitative investigation. cQualitative investigation/essay.
Verderber et al. 41
gaps in this literature became apparent, notably hospitals constructed in response to the
the need to conduct more in-depth research on the COVID-19 global pandemic.
physical and psychological benefits of engage- – Prognostications for the future of ICU and
ment with nature, art, and multisensory stimula- related critical care built environments in
tion. Aspects of salutogenic design, and biophilia, hospital and field hospital settings are
warrant further research, perhaps within the presented.
umbrella afforded by an ecohumanist perspec-
tive—a perspective that fuses these concerns with
ecological sustainability concerns (Verderber & Declaration of Conflicting Interests
Peters, 2017). Evidence-based research is war- The author(s) declared no potential conflicts of
ranted on attention restoration theory in ICU set- interest with respect to the research, authorship,
tings, perhaps combined with the phenomena of and/or publication of this article.
nature-deficit disorder as postulated by psycholo-
gist Richard Louv (2008). Also underrepresented Funding
were studies and essays on cost containment policy The author(s) disclosed receipt of the following
and best practices, ecological/resiliency determi- financial support for the research, authorship,
nants, or the role of advanced digital technologies, and/or publication of this article: This study was
with none on robotics, and few on the subject of supported by John H. Daniels Faculty of Archi-
“Smart ICU” planning and design. tecture, Landscape, and Design, University of
Suffice to say, pandemic considerations in Toronto.
intensive care built environments will continue
to warrant research-based design attention.
ORCID iD
Cross-cultural, interdisciplinary collaborations
will be essential between health policy experts, Stephen Verderber, ArchD https://orcid.org/
direct care providers, researchers, and the many 0000-0001-8359-3144
specialists who plan and design these built envir-
onments. Architects, landscape architects, inte- References
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Intensive Care Unit Built Environments: A Comprehensive Literature Review (2005-2020)

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Intensive Care Unit Built Environments: A Comprehensive Literature Review (2005-2020)

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Literature Review

Health Environments Research

Built Environments: Article reuse guidelines:

Stephen Verderber, MArch, ArchD1,2 , Seth Gray, MD3,5,8,

Research Design, Setting, ICU Built Environment Impact

1. Nature Engagement and Outdoor Views

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

4. Noise Considerations in ICU Environments

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

5. Artificial and Natural Lighting in ICU Environments

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

6. ICU Patient Safety and Infection Control

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

8. ICU Ecological Sustainability

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

Research Design, Setting, ICU Built Environment Impact

outcomes. Interventions primarily focused on absenteeism and employment vacancy rates

Light Interventions in the ICU Environment ICU Patient Safety

in single-bed rooms. Similarly, Teltsch and col- Portable Field Hospitals

Nature Dedicated Decentralized Acuity- Virtual

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