Invited paper

A nurse's view of i.t.u, design and equipment

Rosemary Pope

Sister in charge, Intensive Therapy Unit, Barnet Genera/Hospital, Barnet, England

Keywords--lntensive therapy unit design and equipment

The intensive therapy unit is becoming an estab- lished part of the hospital complex, providing information that would have been barely con- ceivable a decade or so ago. In time this new information has allowed advance in therapeutic techniques which have brought previously fatal conditions within salvagable reach.

The precise bias of the i.t.u.'s role has remained unsettled, so that it is still not possible to generalise the principle of its operation with great accuracy. In some hospitals it is largely concerned with respiratory pathology, in others with the care of serious medical illness including cardiac disease, and yet again in others with the immediate postoperative period; some or all of these functions may be combined. However, although precise requirements will vary from one situation to another, it ought to be possible after a decade of experience to lay down certain principles to govern the design and con- struction of intensive therapy units and their equipment.

The most cynical view sees the i.t.u, as a claustro- phobic conglomeration of flashing lights and alarm(ing) bells, in which the patient, isolated from the warmth of human contact, languishes in obscurity. I believe, however, that the nurse is still the best monitor of the patient 's condition and her care is a real aid to his recovery. The machine is one of her tools of trade. It should be designed to aid not to obstruct; to inform and not to confuse .

This complex of instructive device and personnel has grown haphazardly towards acceptability in the care of the critically ill patients. Growth has been of necessity haphazard, as the development of techni- ques has been rapid and has been stimulated by many areas of interest.

If this rather ungainly adolescent is finally to achieve the proportions of maturity, a great improve- ment in communication is required between the staff of intensive therapy units, where the problems are posed, and the men who design and build them and the equipment they contain.

These are a nurse's comments on her own terr i tory--on its strengths and weaknesses--and are, in particular, an attempt to communicate her point of view to i.t.u, architects and engineers.

Fundamental requirements An intensive therapy unit is first of all a space. It is primarily a space to house, not machines, but patients. (Frequently it was not designed for this purpose but ought to have been.) In this space along with the patients--sometimes surrounding them--are machines.

The fundamental requirement of i.t.u, design is this: that space and machine should interact to provide maximum patient observation and minimum patient interference. Unfortunately these two aims are sometimes mutually incompatible, but they must remain our ultimate goals.

In this space along with patients and machines are the staff. Their efficiency and attention are influenced by the design of both the space and the machines and designers ought to include them in their calculations.

The design of space The whole i.t.u, space should be clean, light and uncluttered. An interior construction on the lines of an operating theatre will allow frequent thorough cleaning: this is vital if a unit is to be kept free of infection. Abundant storage space must be available

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to keep the patient area clear of unwanted equipment. At the same time all equipment must be readily available and able to be moved rapidly to any part of the unit.

(a) Maximum patient observation Because of the wide variety of demands to which it is subject, the space an i.t.u, bed 'occupies' is con- siderably greater than an average ward bed. At a minimum the nursing staff must be able to work on all four sides of it. There must be room to lay out equipment around the bed, without interfering with free movement in the unit. The fittings and lighting for each bed should be mobile and effective wherever the bed is placed and trailing supply cables, which are hazardous, untidy and restricting, should be carried by telescopic limbs mounted on the walls.

Each bed position should be visible from a central area. This area, suitably equipped, becomes a nurse's station, where staff on duty will spend most of their time. Remote systems and monitoring terminals will be located here, but this should not reduce the nurse's ability or desire to observe the patients directly. Each patient must be able to communicate easily with the nursing staff by signs as well as voice.

The difficult exception to these principles is the patient who requires isolation in a separate cubicle. These patients fall into two main categories: the excitable and the infectious. The first must be protected from external interests and the second removed from the environment of other patients. The free use of glass allows observation, double glazing reduces noise transfer and a simple 'intercom' allows 1-way or 2-way transmission as appropriate. 2-way mirrors need not remain the exclusive property of the hoyden and, while expensive, would allow a more extensive use of glass without the patient feeling too exposed.

(b) Minimum patient interference It is usually assumed that the i.t.u, patient is too sick to care what happens to him but this is fre- quently untrue. He is too often stripped of privacy and dignity unnecessarily. His visitors are expected to expose themselves at their most vulnerable in a situation of curious publicity. The fact is that not only his relatives, but more often than not the patient himself, is more sensitive to his situation than is appreciated. A great deal can be done to ensure that the space a patient 'presumes' as his own is pleasant and personal; a little thought about decoration, view and individuality helps to reduce an otherwise sterile environment.

The intrusion of the cries and dilemmas of other patients is a constant reminder of his own condition. While absolute privacy is almost impossible, ade- quate screening must be available, and more thought should be given to bed layout, to reduce his exposure to the intimate details of other patient's treatment.

(c) Staff efficiency The logical site for an i.t.u, is close to the operating- theatre suite, but there are other departments to which ready access is required; e.g. the pathology department is required frequently and at all hours. Blood is often required urgently and at nighttime no-one is pleased to have to make repeated trips to a blood bank situated on the other side of the hospital complex. Similarly, unless the unit has its own X-ray plant, frequent trips for either the patient or the radiographer are called for. On the principle of a certain prophet of renown and his mountain, it may be more efficient to have small ancillary units supplying the most frequently asked for services within the unit. Kit pathology tests and small efficient machines are not expensive but these must be used and not allowed to stand idle, duplicating facilities unneccessarily.

The seemingly trivial matters of storage space and bench space only assume their correct importance when a unit has been set up without enough thought. All i.t.u.s must be virtually autonomous in matters of equipment and its storage, staff space and room for homely activities, such as coffee making.

Until recently there were probably adequate reasons for a lack of information on which a rational i.t.u, design could be formulated. However, accumulated experience should now be sufficient to map the most often trodden routes, the most frequently required equipment, the services most in demand and the techniques most often employed. A systems analysist would rapidly reduce this infor- mation into a web of principles for the design of i.t.u, location and layout, storage space and staff accommodation.

Design of machines and equipment (a) Maximum patient observation There seems no limit to the ingenuity of design engineers. Unfortunately their ingenuity is not always accompanied by clarity, simplicity, flexibility and reliability.

Clarity: It would seem fundamental to machine design that the information it offers should be readily accessible. Yet dials are still produced that are indistinct, or have indicators that are insufficiently damped, or are unduly sensitive to external vibration. The most easily read machines have digital displays. These are no longer expensive and are said to be reliable. Is it not possible to replace all dials and their trembling needles with digital-readout devices ?

There are great advantages in being able to record a measurement directly, either to convince a sceptical doctor, or to compare directly with later recordings. Tracer displays, if simple to operate, would add enormously to the value of almost any machine.

Simplicity: Nurses, as a rule, are not idiots, but neither are they machine technicians. Even if they

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were, the circumstances in which they are expected to make accurate recordings are frequently anything but conducive to a cool frame of mind. Therefore machine design should strive for simplicity of both application and operation to the point of being 'idiot proof ' . The time has surely passed when a prolonged and embarrassed fiddle in trying cir- cumstances results in a final acceptance of the unpleasant conclusion that the leads don' t fit! Machine fittings and leads must be standardised, easily and securely coupled, readily identified, and long enough to reach the patient. The custom of colour-coding leads has waited too long without standardisation and, in any event, these are easily mixed in an emergency. They should be clearly labelled in English. In contradistinction, con- nections which must not be made, i.e. gas outlet to oxygen inlet, should be shape-coded to prevent accidental connection.

Machine controls should be clearly identified in English, not machine jargon. Control layout should be rational and uniform. Step-by-step instructions for operation should be available for the occasional operator, together with an easy guide for ' trouble shooting'.

More thought is required in the design of equip- ment which has to be cleaned or sterilised. This applies to all equipment used for babies and patients with a reduced resistance to infection, and to all equipment that is introduced into the body, or is in communication with a patient's airway.

It is frequently possible to make components of a machine in these categories easily removable and disposable. Alternatively they should be entirely accessible to mechanical cleaning and constructed of material resistant to an effective method of sterilisation.

Where feasible, minor items of equipment should be disposable, although this principle must not reduce the 'functional' quality of the apparatus.

Flexibility: Modular apparatus is undoubtedly a great advance in flexibility. A patient's requirements can be built up specifically, which not only increases the efficiency with which machines are used, but avoids the use of an unnecessary component which may be required elsewhere.

At the least, machines should be mobile and require a minimum of ancillary equipment so that they can be used in an emergency wherever the patient is.

Reliability: A machine is mot urgently required when there is no time to be lost. In the stress of the moment it is liable to suffer severe injury if it doesn't work. Design engineers must realise that an i.t.u, is not a laboratory where fiddling is the spice of life: i.t.u, staff expect to turn their machines on and have them function immediately. If sophistica- tion and reliability are inversely related, on occasions

it might be better to sacrifice some sophistication for improved reliability.

An equally important fact is that few i.t.u.s have a ' tame' instrument technician, engineer or physicist to call on. The machine must go for long periods without servicing. These machines see life in the raw and are treated the same way. Therefore their construction must be rugged and injury proof. Considerable thought is required to improve these qualities in machines already in existence, as a bad reputation means reduced use-- in some cases a whole life 'on the shelf'.

Any machine that monitors a 'vital ' function should have, as well as an alarm, a 'fail-safe' device and a malfunction warning, but these should be capable of being muted to save not only the nerves of the patient, but those of the staff as well.

In many cases the reliability of the machine is a function of the adequacy of its coupling to the patient. A reappraisal is required in the field of machine-patient coupling. It must be more efficient and, if possible, more comfortable.

(b) Minimum patient interference Some machines by nature are 'invasive'. Ventilators, dialyses units and other therapeutic devices justify the discomfort they cause, but monitoring equipment should be 'noninvasive' wherever possible.

The obtrusiveness of machines may be reduced in a number of ways. Remote display panels remove the recording from the immediate vicinity of the patient and his relatives, although they encourage isolation of the patient from the nursing staff. Wall mounting of equipment saves a clutter about a patient 's bed. Looped cables from beams not only clear up the floor, but increase trolley mobility and save the odd staff injury as well. Too many machines are noisy, some unneccessarily so, like some children, they should be seen and not heard.

If an otherwise mobile patient is confined to bed for 'monitoring purposes only', there is a serious social and possibly a medical hazard as well. Secure machine-patient 'coupling' with or without intermittent 'plug-in', salvages at least some independence and mobility for him.

Attention should be directed towards minimising noise from wheels, feet, alarms and machines. It is easy to imagine the aggregate of the commotion of a busy i.t.u, day. Add to it the increased irritability of illness and the anxiety which often accompanies it and the proportions of the problems of noise begin to emerge.

(c) Staff efficiency Much of what has already been said applies here. Patients are not nursed by remote control and a computer does not prescribe, measure and administer the life-saving drugs. The patient in the long run depends on people on whom a great responsibility

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rests. I.T.U. nursing takes not only physical endurance, but mental stability as well. The staff sees a procession of seriously--often tragically-- ill patients pass through their hands. There is almost by definition a high patient mortality rate and emergencies occur with greater frequency than elsewhere. There is a growing suspicion that the machine's invasion spells the end of real nursing. I.T.U. nursing is demanding enough of energy and peace of mind without the erosion of the nurse's role as well and, in any event, nobody wants to be nursed by a machine--nor does he want to be nursed by someone who has become a rather dis- satisfied 'scope watcher'. The machine should not come between the nurse and her patient. Design modification can do a great deal to reduce the monster image it is acquiring.

Conclusion

This is a plea to consider the possibility that the time has come to pause and take stock of our present resources: have we really arrived at an integrated solution for the nursing of seriously ill patients; will further design advances provide better solutions or multiply errors; have we achieved a satisfactory relationship between the i.t.u, nurse, her space and her machine; is there enough communication bet- ween design engineers and the people who use their machines ?

In my view, anyone who is considering a new design or modification should spend enough time in an intensive therapy unit to understand its problems and its demands. They would be welcome in mine !

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