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Background: Frequent interruptions, inadequate privacy, and lack of collaboration are barriers to safe and efficient end-of-shift handoffs between emergency physicians. Varying levels of visibility to and from physicians can impact these outcomes. This study quantifies potential visual exposure of physicians in workstations with varying enclosure levels using isovist connectivity (IC) as a measure. Further, this study examines the association of IC with number of interruptions/hour, perceived collaboration, and privacy during handoffs. Methods: In-person observations were conducted during 60 handoffs to capture interruptions. Surveys were administered to the incoming and outgoing physicians to garner their perceptions of the extent of interruptions, collaboration, and privacy. Spatial analysis was conducted using DepthmapX. Results: Findings demonstrate significant differences in IC scores based on (a) physicians location within the workstation during; (b) handoff approach (individual or collaborative); (c) position during handoff (sitting or standing). Documented interruptions were highest in the high IC locations and lowest in the medium and low IC locations. Physicians in low IC locations perceived to have sufficient privacy to conduct handoffs. Limitations and Conclusion: It should be noted that the three pods, each housing a physician workstation with different enclosure levels, varied in number of patient rooms, patient acuity, overall size, and the location of workstations. While contextual variables were considered to the extent possible, several other factors could have resulted in differences in number of interruptions and collaboration levels. This study provides design recommendations for handoff locations and a method to test emergency physician workstation designs prior to construction.

To describe the planning, development, and implementation of a structured video-based observational method that can be used to systematically examine and model the role of the physical environment within healthcare systems.Direct observation methods are often used in healthcare to study complex healthcare systems. However, these observations often occur in real time, which predisposes the collected data to shortcomings such as time lags in recording of activities, overlooking events, or limiting the scope of information than can be collected. Video observation approaches eliminate many of these challenges and provide opportunities for researchers to understand and model the role of the physical environment.An approach to developing and implementing a structured video-based observational method to study and model complex health systems is presented.A structured observational approach can be highly effective for collecting multiple layers of data necessary for understanding interactions between the physical environment and other systems components in healthcare settings. The proposed video-based observation method is effective in settings that have clearly defined environmental boundaries, limited number of people, are complex and fast-paced such as the OR, ED trauma rooms, and ICU rooms.Video-based observation is an effective complement to the traditional observational method for in-depth study of the built environment in health systems, enabling researchers to employ quantitative approaches to data collection and analysis, in addition to qualitative interpretations.

Objective: The purpose of this study was to compare perceptions and behaviors of end users participating in simulations in a high-fidelity physical mock-up of an operating room (OR) prototype with the perceptions and behaviors of end users in the built out ORs postoccupancy. Background: Simulation-based evaluations of high-fidelity physical mock-ups of proposed layouts are increasingly being conducted during the facility design process to understand impacts on workflow and potential adverse patient safety outcomes. Nevertheless, it is unclear to what extent user experiences in these simulated healthcare spaces are similar to those in built and occupied healthcare environments. Methods: Using interviews, surveys, and observations, this study compared user evaluations in a high-fidelity physical mock-up of an OR with user evaluations of the built and occupied OR postoccupancy. Workflow disruptions were also analyzed using video recordings for a simulated pediatric surgery and five pediatric surgeries in the actual OR. Results: This study found that user perceptions and behavior in the two types of environments were mostly similar with regard to perceived support for the location of surgeon workstation, perceived space and task performance, perceived access to storage locations, boom setup, and OR cleanability. Participant’s ratings differed for supportiveness of the mobile Circulating Nurse (CN) workstation, maneuvering booms, and environmental disruptions. Conclusion: Simulation-based evaluations are extremely beneficial during the design process and can provide valuable input to design teams as well as clinical teams about workflow and safety issues that allow design issues to be addressed before construction.

Objective: The objectives of this study are to graphically depict specific clinical challenges encountered in a mirrored pediatric intensive care unit patient room and to represent potential solutions to address these challenges using a systems approach. Background: The intensive care unit (ICU) patient room is a highly complex patient care environment where the design of the room must support patient care delivery safely and efficiently. There is a lack of research examining how ICU design elements interact with other system components to impact patient care. Methods: An observational case study method utilizing a systems approach was used to observe and graphically depict clinical challenges with mirrored room configurations and to identify potential solutions. Video recordings of the three clinical scenarios were analyzed in detail in conjunction with three rounds of interviews with a clinical expert. Results: Equipment or task characteristics that require orienting to a specific side of a patient create challenges in a mirrored room. In order to deliver care safely and efficiently in the mirrored room, adaptations would be required including changing boom, equipment and team member locations, purchasing new equipment, staff training, and inventory management. Some procedures such as extracorporeal membrane oxygenation would be difficult to conduct safely in the mirrored room, even with significant adaptations. Conclusion: Solutions to the challenges presented in mirrored room configurations are multifaceted and require simultaneous and ongoing changes to multiple systems elements, while others can be addressed relatively easily, for example, purchasing new equipment.

Background: Frequent external interruptions and lack of collaboration among team members are known to be common barriers in end-of-shift handoffs between physicians in the emergency department. In spite of being the primary location for this crucial and cognitively demanding task, workstations are not designed to limit barriers and support handoffs. Objective: The purpose of this study is to examine handoff characteristics, actual and perceived interruptions, and perceived collaboration among emergency physicians performing end-of-shift handoffs in physician workstations with varying levels of enclosures—(a) open-plan workstation, (b) enclosed workstation, and (c) semi-open workstation. Method: Handoff and interruption characteristics were captured through in-person observations of 60 handoffs using an iPad-based tool. Additionally, physicians participating in the handoffs responded to a survey pertaining to their perception of interruptions and collaboration with clinicians during each phase. Other organizational and demographic data were obtained from the hospital database, surveys, and observations. Results: Physicians working in the open workstation experienced a significantly higher number of interruptions/hour (18.08 int/hr) as compared to the semi-open (13.62 int/hr) and enclosed workstations (11.41 int/hr). Most physicians perceived that they were interrupted in the semi-open and open workstations. In addition, majority of physicians in the enclosed pod perceived high collaboration with clinicians involved in and present in the workstation during handoff. Conclusion: This correlational study showed positive outcomes experienced by physician working in the enclosed workstation as compared to the open and semi-open workstations.

Purpose: This study proposes a flow mapping approach for surgical facilities that can be implemented by design teams as a component of case study tours. Background: The provision of healthcare services involves simultaneous and closely coupled flows of people, objects, and information, and the efficiency of these flows is influenced by the spatial configuration of the buildings where these services are housed. Many architecture firms conduct case study tours to inform their design process. However, these tours often lack a structured way of documenting different flows and interpreting observations. A structured approach is needed during the design process to understand the impact of spatial configuration on healthcare flows. Method: Site tours were conducted at four surgery centers to develop and test an evidence-based flow mapping approach. Idealized flows within surgical facilities were first identified from the literature, followed by the development of a data collection tool aimed at documenting these flows in each case study through a pre-assessment questionnaire, a physical assessment, and interviews with staff. Results: The flow mapping tool kit was effective in allowing the design team to systematically understand the physical configuration of surgical flows across case studies. The tool also allowed the team to identify spatial configuration characteristics acting as barriers and facilitators to idealized flows. Conclusions: The flow mapping approach was able to provide structure for conducting these short tours more effectively via observations and staff inquiry, enabling design teams to draw more meaningful conclusions from case study tours and conduct comparisons between healthcare facilities visited.

Purpose: We propose a methodological framework to use immersive virtual environments (IVEs) in head-mounted displays for environmental design research. Background: IVEs offer researchers with experimental control and realistic representations of environments with high levels of ecological validity. IVEs are also increasingly being used to visualize proposed designs. Despite these tremendous benefits, IVEs are underutilized in environmental design research. We are unaware of preexisting frameworks that synthesize the methodological decisions related to the use of IVEs to conduct environmental design research. Methods/Results: We define the concepts necessary to conduct IVE research (virtual reality [VR], IVEs, ecological validity, visual realism, behavioral realism, and contextual realism). We also summarize the available study designs (correlational studies, experimental studies, and performance evaluations) and software systems used to create IVEs. We conclude with a conceptual framework that describes how research questions and study designs inform IVE selection and ecological validity. This framework is accompanied by a workflow that operationalizes the creation and use of IVEs in research. Conclusions: VR provides a robust and innovative research strategy for environmental design research because of its high degree of experimental control, rich data collection options, and opportunities for systematic evaluation of alternative design configurations.

Aim: To assess how the adjacencies of functionally different areas within operating rooms (ORs) can influence the circulating nurse’s (CN) workflow patterns and disruptions. Background: The CN plays a significant role in promoting patient safety during surgical procedures by observing, monitoring, and managing potential threats at and around the surgical field. Their work requires constant movement to different parts of the OR to support team members. The layout of the OR and crowded and cluttered environment might impact the CN’s workflow and cause disruptions during the surgery. Method: A convenience sample of 25 surgeries were video recorded and thematically coded for CN’s activities, locations, and flow disruptions. The OR layout was categorized into transitional zones and functional zones (workstations, supply zones, support zones, and sterile areas around the surgical table). CN’s activities were classified into patient-, equipment-, material-, and information-related activities. Flow disruptions included those related to environmental hazards and layout. Results: The CN traveled through multiple zones during 91% of the activities. The CN’s workstation acted as a main hub from which the CN made frequent trips to both sides of the surgical table, the foot of the OR table, supply zones, and support zones. Transitional zones accounted for 58.3% of all flow disruption that the CN was involved in whereas 28% occurred in areas surrounding the OR bed. Conclusion: The similarity of the movement and flow disruption patterns, despite variations in OR layout, highlighted the adjacencies required between major zones that CNs regularly visit. These optimum adjacencies should be considered while designing ORs such that they are more efficient and safer.

Background: The built environment significantly affects the healthcare experiences of patients and staff. Healthcare administrators and building designers face the opportunity and challenge of improving healthcare experience and satisfaction through better environmental design. Objective: The purpose of the study was to evaluate how a novel environmental intervention for imaging rooms, which integrated multiple elements of healing environments including positive distractions and personal control over environment, affects the perceptions and satisfactions of its primary users—patients and staff. Methods: Anonymous questionnaire surveys were conducted to compare patient and staff perceptions of the physical environment, satisfaction, and stress in two types of imaging rooms: imaging rooms with the intervention installed (intervention rooms) and traditionally designed rooms without the intervention (comparison rooms). Results: Imaging technologists and patients perceived the intervention rooms to be significantly more pleasant-looking. Patients in the intervention rooms reported significantly higher levels of environmental control and were significantly more willing to recommend the intervention rooms to others. Conclusions: The environmental intervention was effective in improving certain aspects of the imaging environment: pleasantness and environmental control. Further improvement of the imaging environment is needed to address problematic areas such as noise.