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The Ten Worst Hospital Design Features: A Family Member’s Perspective

An ICU Bed False Exit Alarm

I just spent the last 8 days in the hospital, at the bedside of a loved one. Although I squirmed the whole way through a tenuous ICU course and brief stop-over in a step-down unit, it was good for me to be reminded of what it feels like to be a patient – or at least the family member of one – in the hospital. The good news is that the staff were (by and large) excellent, and no major medical errors occurred. The bad news is that the experience was fairly horrific, mostly because of preventable design and process flaws. Having worked in a number of hospitals over the years, I recognized that these flaws were commonplace. So I’ve decided to tilt at this great hospital design “windmill” on my blog – with the hope that someone somewhere will make their hospital a friendlier place because of it.

Most of these design and process flaws have one thing in common: they prevent the patient from sleeping. In some circles, sleep deprivation is an organized form of torture reserved only for the most dangerous of terrorists. In other circles, it is hospital policy. And so, without further ado, here is my top 10 list of annoying hospital design flaws:

#1: False Alarms. Every piece of hospital equipment seems to be designed to beep for a complex list of reasons, many of which are either irrelevant or unhelpful. I snapped a photo of a particularly amusing (to me anyway) alarm (see above). This was a bed alert, signaling the “patient exit” of an intubated and sedated gentleman in the ICU. Not only was the location of the alert sign curious (if you could get close enough to the alert screen to read the text, you would surely already have noticed that the patient was AWOL) but it was triggered by mattress pressure changes that occurred when the patient was repositioned every 2 hours (as per ICU pressure ulcer prevention protocol).

The I.V. drip machines are probably one of the worst noise pollution offenders, beeping aggressively when an I.V. *might* need to be changed or when the patient coughs (this triggers the backflow pressure alarm, leading it to believe that a tube is blocked). Of course, I also thoroughly enjoyed the vitals monitor that beeped every time my loved one registered atrial fibrillation on the EKG strip – a rhythm he has been in and out of for years of his life.

#2: Intercom Systems. Apparently, some hospital intercom systems are wired into every patient room and permanently set at “full volume.” This way, every resting patient can enjoy the bleating cries for housekeeping, tray pickup, incoming nurse phone calls,physician pages, and transport requests for the entire floor full of individuals undergoing the sleep deprivation protocol.

#3: The Same Questions Ad Nauseum. Over-specialization is never more apparent than in the inpatient setting. There is a different team of doctors, nurses, PAs, and techs for every organ system – and sometimes one organ can have four teams of specialists. Take the heart for example – its electrical system has the cardiac electrophysiology team, the plumbing has the cardiothoracic surgery team, the cardiologists are the “minimally invasive” plumbers, and the intensivists take care of the heart in the ICU. Not only is a patient assigned all these individual micro-managing teams, but they work in groups – where they rotate vacations and on-call coverage with one another. This virtually insures that the sleep-deprived patient will be asked the same questions relentlessly by people who are seeing him for the very first time at 20 minute intervals throughout the day.

#4: Inopportune Intrusions. There are certain bodily functions that benefit from privacy. I was beginning to suspect that the plastic urinal was attached to the staff call bell after the fifth time that someone summarily entered my loved one’s room mid-stream. Enough said.

#5: Poorly Designed Tubing. Oxygen-carrying nasal cannulas seem to be designed to maintain a slight diagonal force on the face at all times. This results in the slow slide of the prongs from the nostrils towards the eye. Since the human eye is less efficient at absorbing oxygen than the lungs, one can guess what might happen to oxygen saturation levels to the average, sleep-deprived patient, and the resulting flurry of nursing disturbance that occurs at regular intervals throughout the night (and day). My loved one particularly enjoyed the flow of air pointed directly into his left eye as he attempted to rest.

#6: The Upside Down Call Bell. In an age of wireless technology, where almost every American has a cell phone and/or a flat screen television, it is odd that the light, TV, and nurse call bell control system must be tethered to a short  cord positioned just outside of the patient’s reach. The controller is also designed so that the cord comes out of the box’s farthest point, causing it to remain upside down in the hands of anyone lucky enough to reach it from a chair or bed.

#7: Excessive Hospital Bands. In addition to multiple rotating IV access points, my loved one’s wrists and ankles were tagged with not one but four hospital band identifiers, including one neon yellow band sporting the ominous warning: “Fall risk.” If that little band is the only way that a staff member can ascertain a patient’s risk for falling down unassisted, then one is left to wonder about their powers of perception. In a moment of rare good humor, my loved one looked down at his assorted IV tubes and three plastic wrist bands and concluded, “I’m one stripe away from Admiral.”

#8: The Blank White Board. Sleep-deprivation-induced delirium can be rather disorienting. To help patients keep track of their core care team names, most hospital rooms have been outfitted with white boards. Ideally they are to be filled out each shift change so that the patient knows which activities are scheduled and the names of the staff that will be performing them. Filling out these boards is tiresome for staff members (not to mention that the dry erase markers are usually missing) and so they remain blank most of the time. This has an anxiety producing effect on patients, as the boards boldly proclaim that no nurse is taking care of them, and no activities are scheduled.  I also noted that the size of the board lettering was a fraction smaller than a person with 20/20 vision could make out from the distance of the bed.

#9: The Slightly-Too-Tight Pulse Oximeter. Because being tethered to a bed with IV tubing, telemetry cords, and a nasal cannula is not quite irritating enough, hospital staff have devised a way to keep one unhappy finger in a constant, mild vice grip. This device monitors oxygenation status and helps to trigger alarms when nasal cannulas achieve their usual peri-ocular destination every 30 minutes or so.

#10: The Ticking And Creaking IV Drip. During the few rare moments of quiet, we did not enjoy any sort of blissful silence, but rather the incessant ticking of the I.V. drip machine. My loved one remarked that he felt as if he were trapped in an endless recording loop of the first 5 seconds of the TV show “Sixty Minutes.” And so if the alarms, tethering, interruptions, PA announcements, tubing, or white boards didn’t drive you mad, the auditory reinforcement of a ticking time bomb next to your head could bring you close to tears.

And so, because of all these nuisances (not to mention the ill-fitting hospital gowns, inedible food, and floors covered with various forms of “seepage” that penetrated patient socks on hallway ambulation attempts) we had one of the most unpleasant experiences in recent memory. All this, and no dissatisfaction with the surgical team or the primary procedure performed during the hospital stay. In the end, it’s the little things that can drive you crazy – or make you well.

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12 Responses to “The Ten Worst Hospital Design Features: A Family Member’s Perspective”

  1. Beth says:

    Hi Dr Val,

    Ok admittedly some of your writing made me laugh as it was a bit tongue & cheek, but all true! When I lived in Europe I had the opportunity (ok misfortune) to be in the hospital for a few days. I was pleasantly surprised that they didn’t wake me up every 15 minutes to do vitals, nor were there alarms, intercoms etc etc going off at the same intervals. Now it could very well be the difference between the floor I was on vs telemetry or ICU; however, it could also be the difference between litigation! Malpractice suits are virtually nonexistent in the country I lived in. I’m guessing not because mistakes aren’t made, but because the government highly regulates it AND you don’t have ambulance chasers on TV hocking their wares. Just one person’s humble opinion. Hope your loved one is doing better and home in peace and quiet!

  2. Thank you, Beth. Maybe the US hospitals can learn from the Europeans in this regard? My loved one perked up like a flower after being discharged home and getting 18 hours of solid sleep! ;-)

  3. Cardionp says:

    I had major surgery at a teaching facility a few years ago and knew I’d be hospitalized at least 4 days. I brought silicone ear plugs. Helped enormously in allowing me to get better sleep (starting w the second nite).

  4. Yes Cardionp, the earplugs might have helped a bit. Maybe hospitals can offer them along with the gowns and socks? ;-)

  5. Chris says:

    When my daughter was born, our room looked out on the hospital lobby, with lights on 24 hours — and no curtains (or even a curtain rod to hang a blanket on). If there’s one time you need sleep….

    Between that and the interruptions every 2 hours (which we begged them to relent on for just a while) it was a tremendous relief when we could go home and get some sleep — not what you usually think of with a newborn.

  6. Wow, Chris. You and your baby girl were on permanent display to the entire hospital lobby (maybe it’s because she was extra cute?)! Unbelievable. Amazing how much sleep matters… My guy slept for 18 hours straight when he got home, and his body really did a 180 in terms of healing itself once he was OUT of the hospital. It doesn’t have to be this way…

  7. Jessica says:

    Noise Cancelling Headphones…nuff said.

  8. Gary Madaras, PhD says:

    Dr. Jones – Thank you for this first-hand account, especially since it is from someone that has the clinical perspective. Our hearing is the only sense that we cannot shut off. Sound affects our health every minute of every day. In most existing acute care hospitals, the auditory environment is a health risk, not just an annoyance. There is plenty of research that supports this. Some people feel that noise in a hospital is necessary and that patients are better off with multiple auditory/care intrusions every hour all night long then being left alone and monitored remotely. They just don’t get the strong relationship between relaxation, undisturbed natural sleep cycles and recovery. Recent research correlates noise as one of the three drivers of readmission rates and mortality rates. Please keep sharing this experience.

    Gary S. Madaras, Ph.D.
    Healthcare Soundscaper
    Making Hospitals Quiet

  9. Gary Madaras, PhD says:

    Dr. Jones – Thank you for this first-hand account, especially since it is from someone that has the clinical perspective. Our hearing is the only sense that we cannot shut off. Sound affects our health every minute of every day. In most existing acute care hospitals, the auditory environment is a health risk, not just an annoyance. There is plenty of research that supports this. Some people feel that noise in a hospital is necessary and that patients are better off with multiple auditory/care intrusions every hour all night long then being left alone and monitored remotely. They just don’t get the strong relationship between relaxation, undisturbed natural sleep cycles and recovery. Recent research correlates noise as one of the three drivers of readmission rates and mortality rates. Please keep sharing this experience.

    Gary S. Madaras, Ph.D.
    Healthcare Soundscaper
    Making Hospitals Quiet

  10. Jackie says:

    Dr. Jones,

    While this post is disturbing it is also not helpful. There are reasons for these alarms and precautions that are taken. Luckily your loved on had you at their bedside to help if there were any needs. Unfortunately this is not the “norm” for many many hospital patients.

    I see your frustration and also have spent time at the bedside while my father was intubated then passed away. There are things that need to be addressed in hospitals, it would be nice to see a post about what can be done and someone to purpose a solution rather than just complain.

    Fortunately there were wonderful nurses and YOU at your family members bedside to take care of the alarms and keep them comfortable. Maybe you could spend some time in the life of a nurse for a few weeks and come up with some better solutions to these problems.


  11. Thank you Dr. Jones for your perspective and voicing the noise problems in the hospital, especially the ICU setting. I was an RN in the ICU for years and worked the night shift by preference. I voiced your same complaints to our directors all in the name of patient advocacy, but it met with resistance every time. So I finally gave up and just did my best to limit the disturbances to promote sleep. I might also add that I am now CEO of Surgical Error Prevention System (SEPS). After a wrong side surgical error that changed my life, I designed,patented, manufactured and now marketing to a very resistive healthcare arena. SEPS is the only “visual and hands-on” tool designed to protect the patient, but it also protects the surgeon, nurse and facility from the surgical errors. It amazes me the reasons given for not even considering SEPS. I have made this affordable so they would buy it and start protecting everyone; the facility can even make a revenue off one of the products used in the 3 steps that is color-coded and part of the timeout process. I am not giving up because I am passionate about patient advocacy. I hope that this will inspire continued work and changes within a stubborn healthcare field. I am also glad that your loved one is recovering at home and in peace. Keep up the good work advocating for your loved one; there are not enough of you out there. And for Jackie’s comment about complaining or doing something productive, my story should be a good example of how hard it is to change systems that continue to deny that there even is a problem.

  12. Kate Riley says:

    It is understandble that alarms are annoying; there are many that keep us safe in everyday life. We seem to tolerate the incessant binging of the buckle up alarm in our cars, or the “door open” or the “something in the way” back up alarm. Why, then, the intolerance of the alarms in the hospital? It wasn’t long ago that you waited for someone to come to your room (no call light) or your IV dripped by gravity flow. Our hospital culture should be one of care but ,more importantly, of safety. Prehaps patients should hear our voices in the alarms saying “we care about you” we are keeping you safe”, “you are important, you’re being watched over”. Somethings we can modify, like interruptions or call light position, and somethings technology will modify, like call systems and overhead paging but alarms that protect you should never be modified. It’s your life we are responsible for.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

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Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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