The hospital of tomorrow: an ICU perspective
Hospitals have evolved considerably over the years from the early Greek temples of healing, asclepeia, to the large dark, cramped multiple-patient wards of the early Western hospitals, essentially for those who could not afford private care at home, and the brighter, more open smaller ward or single room hospitals of today. These changes have come about as medicine has advanced, technology has progressed and societal and patient conditions and demands have changed. It is difficult to predict how the hospital of tomorrow will look with any precision, but we can make some fairly accurate suggestions based on current trends and developments.
by Prof Jean-Louis Vincent
One key change is that intensive care unit (ICU) patients will represent an increasingly large proportion of hospital patients in the future. There are several reasons for this. First, improved disease prevention and primary care, shorter post-surgery hospital stays and facilitated home care will mean that patients who are hospitalized will be more seriously ill than at present and more likely to need intensive care. Another reason for the increased need for ICU beds is prolonged life expectancy. Improved healthcare means that the average age of the population is increasing worldwide, and older patients are more likely to have multiple comorbidities and to develop complex acute illness. In one report from the US, the number of hospital beds decreased by 2.2% while ICU beds increased by 17.8% over a 10-year period.
As such, the hospital of the future will be composed of a large number of ICU beds with relatively few hospital beds (other than daycare) for other patients (see figure). The ICU may be a physical unit at a strategic place within the hospital, or it may be a more “virtual” ICU with beds dispersed around the hospital. It is possible that in the future all hospital beds will have the potential to be an ICU bed, limiting the need for patient transfers between wards and reducing the time for key ICU interventions to be put into place when a patient is identified as deteriorating. This could also reduce any problems associated with ICU bed shortages. The potential limitations of such an approach include the need for all nursing staff to be trained in intensive care.
So, assuming that the physical ICU structure remains, at least for the near future, what will it look like? With current patient demands for privacy and problems associated with multiresistant pathogens, the ICU will almost certainly consist of multiple single rooms. These rooms will be large and spacious with easy access to the bed from all sides and room for relatives to visit and stay and for the patient to mobilize when possible. The rooms will have large interactive screens with access to patient results and monitored parameters, the ability to call and speak to healthcare staff via telemedicine, and of course standard entertainment channels. Because almost all monitoring, of hemodynamic parameters as well as laboratory values, will be non-invasive and results transmitted to the doctor’s smartphone and to central remote monitoring hubs by wireless technology, there will be much less visible equipment, cables and tubes. What equipment is still necessary will be much smaller, less cumbersome and more user-friendly than at present. Continuous monitoring, multiple feedback systems and computerized interrogation across multiple systems and disciplines will make ICUs much safer with fewer iatrogenic errors.
Visiting hours will be unrestricted throughout the hospital, including in the ICU, and family members, including children, will be welcome. This open access and greater involvement will impact positively on patients and on their families, reducing anxiety and helping to reduce post-ICU stress.
The hospital as a whole will be much more technology oriented than at present and interactive screens will be responsible for much of the routine administration with robots involved in basic services, such as delivery of food and medication, as well as patient mobilization and social stimulation. Care will be more patient-centered and personalized and the flow from home to general ward to ICU will be much more of a continuum. Indeed, some patients may be discharged directly home from the ICU, an option facilitated by continued surveillance using telemedicine. Patients and healthcare staff will have continuous and real-time access to patient medical results and data. Such data will be fed automatically into large international databases to help continuously improve patient management. This process will have become routine and current issues related to data privacy will no longer be a problem.
There will be fewer medical and nursing staff physically present on the wards as telemedicine will be more widely used, enabling remote control of drug infusions and other interventions and e-consultations at the request of the physician or patient. Although healthcare staff may therefore be seen less frequently, they will actually be able to spend more quality time talking to patients and their families.
Technological advances are changing how the world around us operates and the hospital is no exception. Future hospital and ICU design needs to provide flexibility and adaptability to continued technological developments. Healthcare workers and patients will need time to adapt to these changes and to learn how best to use them to improve care and outcomes. We must all be involved in developing the ICU of the future. As Abraham Lincoln said, “The best way to predict the future is to create it”.
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Jean-Louis Vincent, MD, PhD
Dept of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium