First-year M.Arch student.
BA Spanish BFA Fine Art: University of Georgia
Professional Experience: Disability Services
DAILY REFLECTION LOG: THOUGHTS AND SUMMARIES
8/25/10 . Thursday, Week 1 -- Professor Cowan and Dr. Ackerman give an overview of hospitals and ICUs
Fascinating! There's so much to learn about the healthcare system. I had no idea that 10=15% of Atlanta's workforce works in a hospital. Possible ways that architecture can help it out: Room Views (Patient Visibility), Interior Design, Bathrooms, Natural Light, LEED ("healthy" buildings).
8/31/10 . Tuesday, Week 2 -- Dr. Zimring gives lecture, "The State of Evidence Based Design"; Group Research Assignment given out
Take Home Messages:
- EBD is hard to implement because when hospitals do change something, they tend to change many things at once (nurses' station placement, room views, equipment arrangement, e.g.).
- EBD is a growing field.
To Do: Get up on statistical terminology and methods.
9/2/10 . Thursday, Week 2 -- Professor Cowan talks more in-depth about patient rooms, procedures, kinds of ICUs, challenges
It's wonderful to be inundated with information by several experienced professionals who are eager to answer questions and discuss these issues. I asked for details on the importance of patient visibility and was given several minutes of informative and insightful reflections that I don't think I could have gleaned as quickly from reading papers. (But we'll see about that - I start my research this weekend!)
Interesting: Visibility is important for doctors and nurses, as is physical proximity to patients. Here is why:
First and foremost, visual information comprises a large portion of the information doctors use to assess the state of a patient (Much more than I expected; medicine is apparently as much about intuition as it is about fact-checking):
- Actual physical state: Skin color, breathing, alertness, pain, etc.
- State of equipment and medications they're on. (IVs have colored tabs, e.g.)
Secondly, equipment alarms frequently go off, and good patient visibility allows nurses to see if the patient is just laughing/breathing/chewing or experiencing something more serious requiring further action.
Thirdly--and thank you to the med. student behind me for providing this answer--ICUs often contain patients who are unable to communicate verbally, so patient visibility is thusly indispensible. Question to ask next time-- Is patient visibility a factor in monitoring the state of quadriplegics, or do monitoring machines take over most of that?
9/7/10 . Tuesday, Week 3 -- Presentations of Project Phase 1: Problems and Issues - Literature Survey
Pecha Kucha waits for no one! I thought it was a good way to get an overview of the issues. I also feel like I know my classmates better, which will be helpful for future group work. Speaking with another Architecture student last night I learned that there aren't many opportunities for group design in the COA, which can make for a difficult transition to the working world. In general I find it difficult to reach the creative-brainstorm mindset while working in a group, but outside feedback often sparks new ideas.
Other interesting issues to possibly research further:
- Universal rooms and urban planning -- When a hospital reaches the end of its lifespan as such, is it normally torn down or reused as, say, an office building, hotel or loft apartments?
- Patient Beds --> Patient Chairs -- Fascinating! Lots of room for research and design here. Ergonomics would have to be taken into consideration, because according to every yoga class I've ever taken, the standard chair-seating position is NOT GOOD FOR YOU. It shortens your hip flexor muscles, allows the deterioration of core strength, and puts pressure on your lower back. We're meant to sit on the floor. Here's an article:
To look up: What does "Planned Nursing Activities" stand for? Team building? It was referenced in Group One's presentation on Noise Level Reduction, and reminds me of my own findings on the importance of reducing nurse peer-to-peer interaction on the job in order to improve patient safety. Also, how expensive are those sound-absorbing panels?
9/7/10 . Thursday, Week 3 -- Dr. Zimring discusses the nature of defining of problems
What seems easy is actually very difficult. The solution presents itself if you define the problem correctly. This is a better way to practice problem-solving than Solution-Providing, which happens often in design. Start with the real problem and you save a lot more energy and time.
Take Home Messages:
1. Models of care are changing. Things are getting both more holistic and more specialized: Families are involved in the care process more than before (providing info about the patient, i.e.) and checklists are proving to be more effective than the "right stuff" (focus, daring, courage, wits, improvisation) possessed by "audacious experts".
2. The care process itself is changing due to technology. Information is more readily available (to both families and healthcare professionals) but an enormous amount of coordination is needed to get the right information to the right person at the right time.
3. Acuity Adaptible Rooms are good.
4. The furniture of the room can have multiple functions. Thinking back to the catheter kit, this is probably a good idea for having the needed supplies, machinery, and information specific to one patient all there at once.
5. Flexibility as a concept in general is one to keep in mind. We need hospitals to be flexible in the numbers of people they can accomodate, as well as flexible past their lifespan as hospitals. Here is a great article of an architect in Japan who did something very related with his apartment: http://www.nytimes.com/2009/01/15/garden/15hongkong.html?_r=1
9/14/10 . Tuesday, Week 4 -- Guest Speaker: Joyce Bromberg, former director of Futures Research at Steelcase, Inc. on User-Centered Research
Take home message: Don't make technologies searching for a reason to exist; understand needs first.
How do you do that?
- Observe. Dress appropriately (black business attire-- don't stand out). Interview. Note "workarounds". Keep a strict boundary between what you observe and your opinion about what you observe. Keep a field notebook. Take photographs at a variety of ranges. DO NOT GET INVOLVED IN WHAT IS HAPPENING.
- Get together with team members and brainstorm observations, patterns, insights, and finally design principles. Use action verbs like "provide, allow, accommodate, fortify, offer" instead of enjoining ones like "make, force, raise, lower, etc.".
- Prototype. Test the prototype. Refine it.
Some workarounds in hospitals: Using sinks as desks, making impromptu offices in hallways. Bad for posture, concentration; increases chances of making mistakes.
Exercise on observing people working and the problems in their environment (a mini-group project): Very helpful and fun! Our group noticed that the main problems had to do with clutter, distractions, and noise. Time was spent hunting for power plugs and needed tools/machines. Coffee cups were knocked over. Client presentations were made on too-small tables with an awkward handling of presentation materials. We suggested offering more and better common areas with clear separations between work, socializing, eating, resting. We also suggested providing better storage of worker accessories like coats and handbags. A good suggestion I heard from another group was to provide a white noise machine to lessen the spill-over of conversations from area to area.
I liked this speaker a lot - very energetic, interesting, down-to-earth. After a nebulous studio class where directives like "just keep working on it" are made--presumably to keep our work original--it's very nice to be told clearly what works and what does not, while at the same time be given the freedom to improve or adapt the process. I'm looking forward to observation day. If only I could nail down my problem a bit better... I think it will have something to do with visibility, nurse concentration, and family interaction. There seems to be some sort of problem there that a well-designed floor configuration and use of glass may help with.
9/16/10 . Thursday, Week 4 -- Guest Speaker: Dr. Owen Samuels, Director of Neurointensive Care, Emory Healthcare on the redesign of the Emory NeuroICU""
Fascinating lecture on the redesign of Emory's NeuroICU, which was first considered "The Throwaway ICU" because of its temporary existence, but which has now become "The ICU" because of budgetary constraints on the new hospital construction. The Throwaway ICU was designed by Dr. Zimring and intended to be a lab for all sides of EBD, and it's done well so far.
Quotes of the day: (paraphrased)
"I knew it was bad design, but I didn't know what good design was." --Dr. Samuels, on the old ICU Thank you so much, Dr. Samuels, for just justifying my current professional endeavors! I want to make a poster of this quote and hang it in studio. What a wonderful reminder of why and how to put our talents to use, which can sometimes get lost in the bustle of the doing.
"You know you've won when you major opponent is on the cover of the magazine pointing at your project and taking credit for it!" --Dr. Samuels on working the administration. A hilarious insight into the workings of working.
"I love Emory" -- Becky, an interior design professor at Art Institute of Atlanta and successfully rehabilitated Emory Throwaway NeuroICU patient.
Thoughts: I'm very excited about the idea of transparency in the ICU, because a problem still exists with family interaction. Nurses prefer limited visiting hours and separate nurse-support areas because they get distracted by family members as well as feelng "on display" when the families there all the time. Still, care is moving towards family inclusion, so the issue is a live one. I asked Dr. Samuels as well as my med-student table-mate if families needed to interact with the nurses for any reason other than to ask questions, and they both replied no. Apparently, SEEING the nurses is beneficial and improves family and patient morale (knowledge of the process, inclusion, etc.) but that can be separated from actually having to INHABIT the space of the nurses.
One reason to not just glass off the nurses is that their satellite desks make them automatically more involved with the immediate space of the patient. SO -- how can nurses be seen without being bothered or self-conscious? That's the question.
9/21/10 . Tuesday, Week 5 -- __
9/23/10 . Tuesday, Week 5 -- __
9/28/10 . Tuesday, Week 6 -- __
9/30/10 . Tuesday, Week 6 -- __
10/5/10 . Tuesday, Week 7 -- Presentations on Site Visits from Last Week
Our group will present our findings on Piedmont and Northside ICUs on Thursday . We didn't witness many workarounds. The trip to Piedmont was quick, with us visiting the Blue, Red, and Green ICUs (Med-Surg, Open Heart, and Neuro), plus a regular hospital room for comparison. Visiting the regular room was helpful to demonstrate to our group the problems in retrofitting or renovating existing space within hospitals to become ICUs. If this topic is chosen in the final spate, I'd like to work on it. Other areas of interst include family intrusion/inclusion, and the desire expressed by Ms. Patricia Black (an upper level administrator at Piedmont and our host) for more "nursing of people, not machines". I think this speaks to the need for more efficient charting procedures and intuitive, integrated data processing.
10/7/10 . Thursday, Week 7 -- Presentations on Site Visits from Last Week, Part II
It seems we're all picking up on some major differences between Piedmont and Northside ICUs. What stuck out to Kushal and I was the non-ICU room we visited briefly for comparison to the ICU rooms. That seems to be the biggest problem at Piedmont, along with the round layout of their Green ICU preventing the efficient fitting of furniture.
10/12/10 . Tuesday, Week 8 -- __
10/14/10 . Tuesday, Week 8 -- Initial Problem Discussions
Kushal, Wanlin, Siming and I have narrowed down some ideas for potential problems we can solve:
- Though families are desired as part of the care process, they interrupt nurses. Possible solution: a device on the nurse's uniform to signal they either are or are not available to answer questions.
- Nurses desire to be more physically in-touch with the patients as part of the care process, but many older rooms converted to ICU rooms inhibit this interaction because they do not provide direct visibility. Possible solution: a display on the outside of the room with a touch-screen with a video feed of the patient's body. Nurses could tap on different areas corresponding to the charting information, heightening sense of being in touch while simultaneously performing the tasks that take them away from the bedside.
10/19/10 . Tuesday, Week 9 -- Fall Break - no class
10/21/10 . Thursday, Week 9 -- Problem Definition Part I
Kushal and I are now our own team, presented a narrowed problem set today:
- ICU renovation is desirable, but it is often difficult and expensive due to previous construction (such as embedded wiring and low floor-to-cieling ratios) as well as bad layouts (the circular ICU).
- Patient visibility is beneficial for patient health, but inbound toilets in non-ICU rooms being renovated for ICU-use prevent direct sightlines.
- Problem narrowing has proven difficult for many of us. It's very easy to jump to an invention without understanding what it is you're trying to fix. To quote Professor Zimring: "The problem isn't a lack of your solution." An example of this was a group focused on solving the problem of "A lack of integrated waste disposal systems." So the main directive from our professors has been to take a harder look at the literature and existing solutions to see exactly why certain things are not working.
- Scale is becoming an issue. Many computer science students were told that it was impossible to build something that would integrate all medical records.
- Imagination is encouraged. Professor Do said that she wanted to see the off-the-wall ideas. This makes me regret abandoning my idea for a device that nurses would wear.
10/26/10 . Tuesday, Week 10 -- Problem Definition Part II
Listened to other groups' presentations on problems. Many are focusing on data management, as many students are in CS. It's interesting to learn about how information gets handled.
10/28/10 . Thursday, Week 10 -- Meeting at HSI for the First Time
After presenting our ideas for how to provide patient visibility for non-ICU spaces being renovated for ICU use, we received three different responses:
- Dr. Do recommended we go with our "Periscope door" idea, as it was new and creative
- Dr. Zimring suggested we switch to an analytical approach, investigating the idea of renovation in general. A significant contribuition to the field would be to devise a methodology for assessing fitness for renovation of different areas of hospitals.
- Dr. Cowan suggested that we focus on the issue of visibility as it relates to monitoring in general, as nurses spend more time apart from the patient than in the room or right outside, where our interventions would have taken place. He suggested a portable device to allow remote video monitoring of the patient.
11/2/10 . Tuesday, Week 11 -- Project Realignment
We've decided to investigate the larger problem of nursing interruptions. This week will entail research into what's been done in the past to combat this.
11/4/10 . Thursday, Week 11 -- __
11/9/10 . Tuesday, Week 12 -- Onward
After a full week / weekend in the library and on the phone, we've discovered that interruptions are pretty problematic across the board in nursing practice. Through chats with a few nurse friends and other hospital administrators, I've decided that nursing is one of the most stressful jobs in existence. Not only do you walk several miles a day, counsel emotional people, and operate with little natural light and high noise levels, but people's lives depend upon you being as accurate and clear-headed as possible. Add to that a colleague shouting at you from across the ward to help them stabilize a coding patient, your pager going off to signal a new arrival, and a doctor mentioning as he's leaving that the patient just switched medications.
You're expected to count pills while this is happening? As someone who must stay plugged into her iPod if anything is to get accomplished during studio hours, I can't imagine anything worse. Luckily there is a lot of research on interruptions and best practices in other high stress environments (aviation), so we will see if something can be done in nursing.
11/11/10 . Thursday, Week 12 -- __
11/16/10 . Tuesday, Week 13 -- Nailing down
Solidifying exactly what the problem is and how we wish to solve it. I believe we're going to go with something wearable. Dr. Ackerman says he wants a beanie that lights up when he's thinking something that shouldn't be interrupted.
11/18/10 . Thursday, Week 13 -- __
11/23/10 . Tuesday, Week 14 -- Lilypad Arduino
We've decided on a mechanism that is integrated with a nursing scrub - the Lilypad Arduino. Last Thursday, Professor Zimring suggested something even simpler - a fabric mockup we could take to nurses to get their opinion. Over the weekend I sewed the fabric version we have, and Kushal is working on programming the digital one. I emailed photos of the fabric one to some friends of mine at Emory's Nursing School, and got their feedback. The only criticism was that they wanted to leave it on the (x) the whole time. Nursing reform may be beyond the purview of this course.
11/25/10 . Thursday, Week 14 -- Thanksgiving Break
11/30/10 . Tuesday, Week 15 -- Crunch Time
We've almost gotten everything together - just polishing the final report and working out the bugs in the lights. I'm making the graphics for the Open House, which is a nice break.
12/2/10 . Tuesday, Week 15 -- Final Project Due
12/7/10 . Tuesday, Week 16 -- __
12/9/10 . Tuesday, Week 16 -- VIP Open House
Fun to finally see the fruits of our labors! The high number of people in our class, combined with the easing of GA Tech's Dry-Campus Rule, meant that there was plenty to talk about. No offers from Proctor and Gamble to fund Close the Loop, but many people stopped by and expressed interest. One women did point out that we didn't interview enough nurses, which is true. Point taken for my impending thesis project...
12/14/10 . Tuesday, Week 17 -- Final Report Due (Monday)
12/16/10 . Tuesday, Week 17 -- Term End
This was a highly successful semester and I'm interested in continuing this line of work. I learned that it's best to begin a literature survey as soon as possible to test different ideas and ferret out the true gaps in research or solutions. Luckily, once you nail down a concrete problem, the solution almost presents itself. Dr. Ackerman did say he liked our project for its simplicity, obviousness, and intuitive use.