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Intensive care unit design and mortality in trauma patients Nicholas R. Pettit, PhD,a Teresa Wood, PhD,b Mike Lieber, MS,b and Michael S. O’Mara, MD, MBA, FACSb,* a b

Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio Trauma and Acute Care Surgery, Grant Medical Center-Ohio Health, Columbus, Ohio

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Article history:

Background: The architecture of medical care facilities can affect the safety of a patient, but

Received 27 December 2013

it is unknown if the architecture affects outcomes. We hypothesized that patients in rooms

Received in revised form

who are more visible from the central nursing station would experience better outcomes

23 March 2014

than those patients in less visible rooms.

Accepted 3 April 2014

Materials and methods: A total of 773 patients admitted to the trauma intensive care service

Available online xxx

over a 12-mo period were retrospectively evaluated. Outcomes were hospital mortality and intensive care unit (ICU) length of stay (LOS). The unit is designed with a bank of high-visibility


rooms (HVRs) directly across from the nursing station and two side sections of low-visibility


rooms (LVRs). No formal triage occurs, but patients are prioritized to HVRs as available.


Results: Patients in the HVRs had a 16% mortality (52 of 320); meanwhile, the patients in the


LVRs experienced an 11% mortality (49 of 448, P ¼ 0.03). ICU mortality did not differ

ICU design

significantly when controlling for age, Charlson Comorbidity Index (CCI), Head Abbreviated

Intensive care unit

Injury Score, and the Injury Severity Score (ISS) (P ¼ 0.076). Age, CCI, Head Abbreviated Injury Score, and ISS did individually correlate with mortality (age: P ¼ 0.0008; CCI: P ¼ 0.017; and ISS: P < 0.0001). Visibility was not a predictor of ICU LOS or complications among survivors (mean ICU HVR LOS ¼ 4.8 d; mean ICU LVR LOS ¼ 4.7; P ¼ 0.88, n ¼ 661). Only ISS was a significant predictor of ICU LOS and complications (P < 0.0001). Conclusions: Trauma patient room placement within the ICU does not relate to mortality rate significantly when corrected for patient acuity. Instead, variables such as age, ISS, and CCI are associated with mortality. A policy of placing more critically ill patients in HVRs may prevent increased mortality in high-acuity patients. ª 2014 Elsevier Inc. All rights reserved.



To date, there exists a body of literature that demonstrates the various important physical design features of a modern day intensive care unit (ICU), which can influence both patient and family safety and comfort [1]. These design features include the architectural design or layout of the ICU (social isolation), views of nature, prevention of infection, single rooms, noise

restrictions, and ambient light [2,3]. Improvements in design features have resulted in improved health for patients and decreases in the acquisition of resistant bacteria [4]. Recently, many different organizational schemes have been proposed to optimize care of critically ill patients. These schemes have focused on architecture, staffing, physician coverage, physician rounding, lean processes, documentation, and many others [5,6]. The primary concern in many patient care units is

* Corresponding author. Trauma and Acute Care Surgery, Trauma Services at Grant Medical Center, 111 S Grant Ave, Columbus, OH 43215. Tel.: þ1 614 566 9021; fax: þ1 614 566 8392 E-mail address: [email protected] (M.S. O’Mara). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.04.007


j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e7

the placement of more seriously ill patients, and it is unknown if certain areas or rooms have suboptimal care or poor outcomes. Very little has been done to analyze the association between patient location and patient outcome. One study has been done in a medical ICU setting with a “racetrack” design of rooms [7]. This retrospective study revealed that a certain population of patients when placed in rooms who were not easily visible from the primary nursing station experienced worse outcomes compared with the same population of patients, who were placed in more visible rooms. The patients in low-visibility rooms (LVRs) had higher ICU and hospital mortality compared with those in the high-visibility rooms (HVRs). There are many confounding factors that have been demonstrated to affect patient outcomes in both trauma patients and in the ICU. For example, a recent publication demonstrated that within a specific population of ICU patients, factors like having windows and/or natural views were associated with reduced mortality, although ICU rooms with windows and/or natural views did not improve outcomes or reduce costs for their studied general population [8]. Other studies have further demonstrated that ICU patients may not actually be receiving much natural light, despite the presence of windows, and thus further studies and ICU optimization are warranted to obtain immune-enhancement benefits from natural light [9]. Much work has been done to improve ICU patient outcomes, as seen in the advancement and adaptation of technology within the ICU, such as computerized physician orders, smart infusion pumps, and barcode systems [10]. Furthermore, with the complexity that can be a traumatic injury and many factors that can influence outcomes, survival after trauma has improved with advancements in hemostatic resuscitation, damage control surgery, and protocol-driven management, despite increasing age and worsening injuries [11]. Although advancements have been demonstrated within certain aspects of critical care medicine, with regard to ICU design and architecture, to date, this area is still a fertile ground for research as clinicians and researchers seek to identify any and all factors that can contribute to patient care. One such fertile area is the study of patient outcomes because of room placement within an ICU. In ICUs that contain a central nursing station, there exists little data that demonstrate whether patient location in that ICU will impact their outcome [1]. No data exist among trauma patients demonstrating whether trauma patients cared for in trauma ICU beds who are poorly visualized from a central nursing station experience outcomes that differ from rooms that may be of a higher visibility toward the nursing station. The aim of this study was to assess outcomes, particularly mortality, in ICU trauma patients based on the location of their admission to the ICU. We hypothesized that patients in rooms who are more visible from the central nursing station would experience better outcomes than those in less visible rooms.


Materials and methods

In this retrospective chart review, we compared clinical outcomes among patients admitted to the trauma ICU. Patients were assigned to two categories of rooms based on the visibility from the central nursing station, with some rooms experiencing

an unimpeded view from the nursing station and other rooms experiencing poor visibility from the nursing station.


Trauma ICU description and architectural layout

Grant Medical Center is a level 1 trauma center and serves as a major site for the state of Ohio for the education of medical students, residents, and medical fellows. Furthermore, the trauma center at Grant Medical Center serves as international regional referral service, accepting all major traumas, with 4928 trauma evaluations and 4330 trauma admissions in 2012. The trauma team attending staff consists of seven boardcertified fellowship-trained trauma surgeons. The trauma nursing team work 12-h shifts and are commonly assigned to patients on a 1:2 ratio. Occasionally, critically ill patients may sometimes be staffed at a 1:1 ratio and to ensure that this happens two nurses are always on call. The ICU (trauma and surgical) and coronary care unit (CCU) (cardiac and medical) are managed in a collaborative fashion, with nurses being cross-trained and having a single manager over both units. All educational and competency requirements are the same. Nurses float only between the two units. Nighttime coverage in the CCU is provided by nurse practitioners from the trauma service, who work in collaboration with the trauma residents who cover the ICU. Daytime coverage is by separate medical and surgical critical care teams. Patients are prioritized into the trauma ICU first then into the CCU or Annex. Most of the trauma patients are placed in the ICU. This triage is done by the charge nurse. Furthermore, patient placement in the ICU is prioritized to rooms, who are thought to be closer and more visible from the nursing station, and this is also true for the ICU and the overflow rooms. There are no formal guidelines for such triaging or placement of patients to certain rooms (HVRs). Triage to HVR does occur because of a preconceived notion that being in proximity to the nursing station and providing a better line of sight to the specific bed is preferred for both the patients and for the staff. For the purposes of evaluating outcomes in this study, patients were maintained within the group of initial placement in the ICU (HVRs or LVRs). Although there was some movement within the ICU, this was minimal, and it was estimated that the room of initial placement would have the greatest effect on outcome. The number of patients who experienced an intraICU move was too small to analyze and reinforced the decision to evaluate the patients based on their room of initial ICU admission. Architecturally (Figure), the ICU at Grant Medical Center is divided into three areas: the ICU, where most of the trauma patients are admitted (rooms 301e314), the CCU, where trauma overflow patients are often admitted (rooms 320e323), and the Annex, where trauma overflow patients are occasionally admitted (rooms 335e339). Preference for trauma patient placement is in the ICU, with patients going to the CCU or Annex if ICU beds are not available. The ICU and CCU are both laid out in an arc of rooms, with a bank of HVRs directly across from the nursing station (rooms 306e311 and rooms 324e329) and the two tails of the arc, which are LVR (rooms 301e305 and 312e315 in the ICU and rooms 320e323 and 330e334 in the CCU). In the Annex, which is a straight hallway, all rooms are HVRs (rooms 335e339). Preference for patient placement in

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Figure e ICU/CCU Map: ICU, rooms 301e315. Rooms 301e305 and 312e315 were low visibility, and rooms 306e311 were high visibility. CCU, rooms 320e334. Rooms 320e323 and 330e334 were low visibility, and rooms 324e329 were high visibility. Annex, rooms 335e339. All rooms were high visibility.

rooms that were directly across from the central nursing station was done when possible. In extreme circumstances, patients may be moved within the ICU, usually from an LVR to a room across from the nursing station, to a room that is exposed to natural light, or movement from the CCU or annex to the ICU. Within this study, rooms were categorized into HVRs or LVRs because of the proximity from and the ability to visually see the patient from the central nursing station.


Study design

This retrospective chart review was approved by the Grant Medical Center Institutional Review Board. All trauma patients admitted to the ICU (including deaths) were included in this study. Room allocation was done as described in the previous section, and ICU or CCU or Annex rooms were recorded based on the patients’ first room assignment in the ICU or CCU or Annex. If a patient was moved within the ICU, the first room where the patient was assigned to was maintained (the patients stayed in the group of original assignment). Rooms are identified as one of five types: ICU high visibility, ICU low visibility, CCU high visibility, Annex high visibility, and CCU low visibility. All trauma patients, aged 16 y, who were discharged from (including deaths) the trauma service at Grant Medical Center from January 1, 2012, to December 31, 2012 who had

admission to the ICU during their initial injury admission were included in this study. Patients aged 65 y, the mortality was not different (22.2% in HVR, 18.1% in LVR, P ¼ 0.47). Logistic regression modeling was used to better assess the association between room location and hospital mortality for all patients. The clinically significant variables were considered (Table 2). Age, CCI, ISS, and Head AIS >2 were all significant on univariate analysis, so were held constant between HVRs and LVRs. ISS and Head AIS were the most significant predictors of hospital mortality, with an ISS OR of 1.09 (P < 0.0001), and Head AIS  2 OR ¼ 0.19 (P < 0.0001). Also significant predictors of hospital mortality were age (OR ¼ 1.02; P ¼ 0.0008), age >65 y (OR ¼ 2.04; P ¼ 0.0014), and CCI (OR ¼ 1.16; P ¼ 0.017).

Table 1 e Baseline demographics and comparison of HVR to LVR. Demographic Number Age (y) Female patients, n (%) Mechanism: penetrating, n (%) ISS Head AIS > 2, n (%) CCI Mechanical ventilator days Tracheostomy, n (%) Full code, n (%) DNRCC, n (%) DNRCC-A, n (%) ICU LOS (d) Complications, n (%) Mortality, n (%) Patients aged > 65 y Mortality: Patients > 65 years old, n (%) Mortality within 24 h, n (%)

All patients

HVR patients

LVR patients

773 48.0  21.1 223 (28.9) 99 (12.9) 19.2  12.9 268 (59.7) 1.1  1.9 4.1  7.5 112 (14.5) 730 (94.6) 26 (3.4) 16 (2.1) 4.7  5.7 259 (33.5) 101 (13.2) 195 (25.4) 39 (20.0) 46 (6.0)

320 49.5  21.1 90 (28.1) 39 (12.2) 19.6  13.5 112 (60.2) 1.1  1.8 4.3  7.6 47 (14.7) 301 (94.4) 10 (3.1) 8 (2.5) 4.8  5.6 105 (33.0) 52 (16.3) 90 (28.1) 20 (22.2) 23 (7.2)

448 46.8  21.0 132 (29.5) 60 (13.4) 19.1  12.5 156 (59.3) 1.1  2.0 4.0  7.5 65 (14.5) 425 (94.9) 16 (3.6) 7 (1.6) 4.7  5.8 154 (34.5) 49 (11.9) 105 (23.4) 19 (18.1) 23 (5.1)

DNRCC-A ¼ Do Not Resuscitate, Comfort Care Only in case of Arrest.

P value 0.08 0.69 0.62 0.58 0.85 0.99 0.60 0.94 0.62

0.84 0.66 0.03 0.14 0.47 0.30


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Table 2 e Logistic regression model of mortality. Predictor Unit (ICU/other) Gender (female) Penetrating mechanism Age CCI Age > 65 y ISS Head AIS  2 Visibility (HVR/LVR)

OR (95% confidence interval) 0.92 1.34 1.10 1.02 1.16 2.04 1.09 0.19 1.53

(0.51e1.64) (0.81e2.23) (0.60e2.20) (1.01e1.04) (1.03e1.32) (1.32e3.17) (1.07e1.11) (0.08e0.43) (0.96e2.45)

Table 4 e Logistic regression model of ICU LOS. P value


0.72 0.27 0.77 0.0008 0.017 0.0014 65 y, or CCI) were determined to be significant predictors of ICU LOS, and thus they were the only covariates controlled for in the ANCOVA model. As with

Table 3 e Logistic regression model of complications. Predictor Gender (female) Penetrating mechanism Age Age > 65 y CCI ISS Head AIS  2 Visibility (HVR/LVR)

OR (95% confidence interval) 0.89 1.10 1.00 0.83 1.05 1.05 0.86 1.10

(0.64e1.24) (0.70e1.69) (0.99e1.01) (0.59e1.19) (0.97e1.13) (0.54e1.37) (0.54e1.37) (0.72e1.68)

P value

0.02 0.05 0.06 0.07 0.07 0.34 0.11 0.04

0.55 0.20 0.70 0.58 0.69 2 were significant on univariate analysis, so were held constant between HVRs and LVRs. Only ISS was a predictor of complications (OR ¼ 1.05; P < 0.0001). There was no significant difference in complication rates between HVR and LVR on logistic regression analysis.


Spearman correlation coefficient

P value 0.70 0.68 0.70 0.31 0.26

Intensive care unit design and mortality in trauma patients.

The architecture of medical care facilities ca affect the safety of a patient, but it is unknown if the architecture affects outcomes. We hypothesized...
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