Construction is a necessity for hospitals to accommodate newer, more efficient equipment. But noise, dust, and makeshift areas can make patients and staff uncomfortable. To ensure patient care runs smoothly during renovations, nurses are involved in the process. From providing input on new unit designs to offering patients and visitors earplugs and headsets, safety and comfort are some of their concerns.
To address some much-needed changes, St. Josephs Healthcare System in New Jersey announced the implementation of a five-year project that includes either renovation or new construction at its regional/childrens hospitals in Paterson, and its hospital in Wayne.
The first phase of the $250 million project, which began in late 2008, involved updating and expanding two ORs and the postoperative area, renovation of the preoperative area, and a face-lift and expansion of the ICU/CCU at St. Josephs Wayne (N.J.) Hospital. The nurses on the units were prepared and eager for the renovations.
The change was something the nurses had wanted for a long time, says Marie Van De Veire, RN, MSN, NEA-BC, director of nursing at the Wayne site. The rest of administration bought into it, as well.
The original space consisted of a 16-bed ICU and CCU with a wall down the middle. The idea was to remove the wall to make one large unit instead of two smaller ones. We did this to improve patient flow, and for staffing flexibility so that they would be able to assist one another both physically and professionally, says Joan Murphy, RN, nurse manager of the CCU.
Knocking down the wall increased safety and visibility of the patients from a central nursing station. The renovation reconfigured the location of the unit and the flow, Murphy says. Before it was very difficult to staff.
Before the project began, Van De Veire and Murphy met with architects, project managers, and the design team. Throughout the process, Van De Veire and Murphy worked closely together. We were joined at the hip, Van De Veire jokes.
To ensure everyone was on the same page, weekly Monday meetings were held with Van De Veire, Murphy, hospital administration, and department heads of infection control, engineering, bio-medical, IT, maintenance, distribution, environmental services, marketing, and security. The architect, construction business owner, construction manager, electrical and plumbing contractors, and others as needed also were included in the meetings, which were geared toward discussing and solving any problems or concerns.
The problem, at times, is that what looks good on paper does not necessarily look good in real life, Murphy says, so the plans need to be fluid.
To ensure patient care wasnt interrupted, the CCU renovation was completed in phases so the existing ICU/CCU didnt have to close. The active construction area was partitioned from the patient care area by temporary walls, Van De Veire says. [And] there were a few times when the planned phases needed to be adjusted or shifted based on the nursing staffs input regarding workflow and patient safety.
For example, just before starting the current phase, Murphy met with Van De Veire; Maria Brennan, RN, MSN, CPHQ, chief nursing officer, St. Josephs Healthcare System, and vice president, patient care services, St. Josephs Regional Medical Center; Dan Kline, vice president; and the construction team because she and the CCU staff believed four of the patient rooms would be too isolated. It would have been a hardship for the staff to provide patient care in those rooms, Murphy says. Everyone agreed to close those rooms during that phase even though it decreased the number of available beds.
It is very important to have a good construction manager who keeps the lines of communication open, updates you at every turn of events, and asks your permission and opinion in an ongoing basis, Murphy says.
For the most part, the renovation went smoothly. However, once construction began, a few design changes were implemented. The hospitals Patient Safe Handling Committee was evaluating best practices and equipment simultaneous to the construction project and decided that ceiling-mounted lifts would benefit patients and nursing staff, Van De Veire says.
The timing of the decision perfectly coincided with the construction of two new critical care rooms, she says. The ceiling-mounted lifts were able to be installed prior to the completion of the rooms.
Out With the OldMindy Feldman, RN, swings a sledge hammer at a half-wall in the old MICU. Feldman worked in the unit in the 1970s.
At NYU Langone Medical Center in New York City, the medical ICU underwent an entire transformation. The medical and surgical ICUs were built in the early 1960s and had received only a few minor renovations since. In 2008, the medical center began construction on a brand-new unit, according to medical ICU nurse manager Joan Barrett, RN, MS, CE-BC, and Alison Mckenzie, RN, MA, CE-BC, nurse manager of the surgical and cardiovascular ICU. The goal was to be consistent with Patient-Family Centered Care, a hospital project that was piloted in the intensive care unit, Barrett says.
Unlike St. Josephs construction, NYUs renovation would result in two separate spaces for the medical and surgical ICUs. Prior to the renovation, Susan Bowar-Ferres, RN, PhD, CEA-BC, NYUs chief nursing officer, took the idea to the Executive Nursing Council to share with architects and nurse leaders to identify evidence-based practices in designing the new space, notes Judy Dillworth, RN, MA, CCRN, NEA-BC, director of nursing for critical care/medicine/ED services at NYU.
The new unit would encompass innovations that would dramatically increase staff efficiency and increase patient satisfaction. These [units] considered the needs of an aging workforce, prevention of work-related injuries, and promoting a healthy work environment, such as identifying locations that are close to the point of care to minimize excessive time used walking, Dillworth says. It also assisted them in providing design and color that are soothing to patients, visitors, and caregivers alike.
Similar to St. Josephs ergonomic considerations, ceiling lifts and other lift devices were built into the renovation plan, as were multiple outlets within arms reach to minimize bending, as well as rubber flooring to ease foot strain, Dillworth says.
Staff was given full autonomy in the design of the bedside headwall. To get a clear picture of what the design would look like before building, a mock-up room was built and interdisciplinary staff nurses, physicians, respiratory therapists brought in equipment a typical ICU room would require.
Different types of specialty beds were brought in and out of the room to ensure the doorway would be large enough to accommodate them, Mckenzie says. The purpose was … to promote a therapeutic environment for patients and families while providing efficiency in workflow for staff.
All About the PatientFrom left, Judy Dillworth, RN; Mindy Feldman, RN; Phil Baldock, RN; Lucy Costanza, RN; Camille LaPera, RN; and Jean Forres, RN
Sometimes a renovation is about patient comfort and privacy. Through donations from a local hospice organization and private donors, the 14-bed oncology unit at Northern Westchester Hospital in Mount Kisco, N.Y., was able to renovate its space, combining two patient rooms at the end of the unit into a suite where families are able to stay with their dying loved ones for as long as they like.
When a patient is dying, they need more space, says Catherine Hartmann, RN, MPA, med/surg director at the Oncology Cancer Treatment and Wellness Center at Northern Westchester Hospital. We sat down with the nursing manager who was over the unit [at the time] to brainstorm what could be done.
Employing an architect and interior designer, they decided to take the last two rooms on the far end and break down the wall, creating a suite where the patient has his or her space, and the family has a space where they can be comfortable as well. The separating wall includes a pocket door that can be closed for patient privacy. The rooms are complete with sconces on dimmers and vinyl flooring that mimics hardwood. Sleeper chairs and sofa beds were added so families could stay with their loved ones.
While theyre in there, its their space to do whatever they want, Hartmann says. They can walk around in their pajamas if theyd like.
In addition to the patient suite, the hospice had enough funds to make more patient and family friendly changes. Hartmann suggested they take a wall between the existing solarium and a small space being used as a kitchenette, with two small bathrooms on either side. We kept one bathroom, but broke through the wall of the kitchen to make a huge room for the family that offers a computer with Internet, plasma-screen TV, a comfortable seating arrangement, and an area to sit and eat that includes an espresso coffee maker.
The entire renovation took three months, with little to no interruptions for the patients. The construction company completely encased the work area in sheetrock, which enabled them to keep dust and noise down to a bare minimum. Large posters were hung at the visitor elevators and patients and family members were given letters explaining what the renovation would entail.
Communication was key, Hartmann notes. The nurses and staff were all privy to the improvements during each phase, so they knew ahead of time what would be taking place on any given day. Managers always knew which days and for how long the drilling would go on, Hartmann says. We have a top-notch facilities management department.
Promoting Health and Harmony
Dealing with the dust and noise of a major renovation can disrupt patients comfort levels. To make care as seamless as possible, nurses found creative ways to address these issues, such as earplugs and headsets.
The temporary walls sealed out dust and pathogens and noise did not seem to be as big an issue as we anticipated, Murphy says. The noise seemed to travel up and down to floors above and below, which are not patient care areas, rather than laterally.
During the demolition phase the floor was a bit noisy, Murphy admits, but the crews were typically done by 3 p.m. We had planned on earplugs and headsets with music to mask the noise, [but] we never had a single complaint from our patients or visitors.Catherine Hartmann, RN
Throughout the renovation process at NYU, every effort was made to ensure patient care was never compromised, Dillworth says. We communicated frequently with the construction company and facilities to be sensitive to the noise and vibration and the effects on patients who are ill, she says. For example, sudden bursts of noise could lead to sleep disturbances, increased perception of pain, changes in vital signs, etc.
To alleviate construction noise, sometimes patients were relocated to different areas of the ICU where the noise was not as great. Noise reduction headphones and earplugs were provided for patients and family members, Barrett says.
Because of the additional training for new equipment and pre-occupancy survey requirements, staff was scheduled accordingly to ensure attendance at all in-service classes. When required, changes in staffing were made to ensure safe coverage for patients. Signs also were posted to ensure ongoing, consistent communication about the status of the renovation and patients and families were given daily updates.
The Hardest PartMarie Van De Veire, RN, left, and Joan Murphy, RN
Unexpected problems are likely to arise during even the simplest renovation. But with proper planning and a willingness to work cohesively, staff are able to work around most mishaps. At NYU Langone Medical Center, occasional interruptions in services, such as water shutdowns, lapses in IT service, etc., were handled quickly and with the interests of patient and staff in mind.
For example, scaffolding at the main patient transport area limited storage space and affected the ability of the staff to transfer patients to and from the unit for tests, Dillworth says. They quickly figured out how to go about their work as usual with as little inconvenience as possible to patients and staff. We coordinated with escort services, building services, and construction employees to safely transport patients to and from tests, Mckenzie says. Simple fixes such as hand carrying labs to the temporary Blood Gas Lab on another floor helped keep patient care moving along.
During the renovations at Northern Westchester, patient rooms were decreased and staff had to shift four of its patients across the unit to an area not routinely open to inpatients. We have a minimum of two staff members at all times, so we had to increase our staffing level during this time so someone was always there, Hartmann says.
For Murphy, the additional workload was a hardship, specifically, the number of decisions that needed to be made weekly, and sometimes daily. Another issue was how to utilize the space because equipment and supplies had to be moved to accommodate the area under renovation. She credits her staff for treating the major renovation as a minor inconvenience. They adjusted to anything that came their way and kept their eyes on the prize, Murphy says.