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Horseshoe, Cockpit, and Dragonfly: Nurse Movement in Headwall Patient Rooms

July 2020
The Center For Health Design
Why does this study matter?
The more we know about how care is provided in the healthcare environment, the better we can design those environments to support caregiving activities. There is a good deal of research on nurse workflow at the unit level, but we do not have much published research on how nurses navigate within the patient room. Additionally, the headwall variation of life support systems is one of the most common configurations in use in North American critical care patient rooms, and yet we have very little research-based evidence on how this layout helps or hinders critical care. Building the knowledge base in these areas is important for critical care design, to better support normal caregiving activities, and especially for events of a crisis and lifesaving activities.

How was the study done?
Hamilton spent more than 250 hours observing, shadowing and interviewing 20 experienced critical care nurses during complete day and night shifts in six ICUs across four hospitals on the East Coast of the United States. Observation focused specifically on nurse work within patient rooms featuring headwall life support systems.

So what do we learn from the study?
Analysis of behavior maps, 20 hours of recorded interviews, and photographic and floorplan data showed several consistent patterns in the patient room. With the headwall life support system, the results show the bed as a sort of “peninsula” in the room, extending from the headwall, allowing access to the patient on three sides, but blocking quick access to the head of the bed and travel to the opposite sides. When a patient is in crisis and clinicians need to get to the patient’s head and airway, clinicians must pull the bed away from the wall and step over wires and tubes extending from the headwall.

This study identified six movement patterns which are neatly named, described, and diagrammed in the article:
  1. Horseshoe Pattern. The most frequently observed pattern in this study looks like a horseshoe when viewed in plan. This semicircle is created as nurses move back and forth around the foot of the bed, working from both sides of the patient.
  2. Entry/Exit Pattern. Another common pattern observed was movement back and forth from the entrance of the room to the bed (sometimes pausing at the sink or alcohol gel dispenser on the way in or out).
  3. Major and Minor Spur Pattern. The horseshoe pattern often involved offshoot movement from around the bed to nearby objects in the room (e.g., respirator, dialysis machine, toilet).
  4. Cockpit Pattern. By positioning certain equipment close by, nurses were able to multitask while standing in one spot and pivoting/rotating around to each object.
  5. Bridge Pattern. In some of the smaller patient rooms, nurses stayed relatively stationary while reaching between two places, such as the bed and adjacent sink or overbed table during medication administration.
  6. Dragonfly Equipment Pattern. This pattern reflects the position of the equipment, rather than the nurse movement. In headwall rooms, equipment tends to be positioned on either side of the head of the bed and at the foot of the bed, appearing like a dragonfly’s shape in plan view.
The observations revealed the need for a balance between consistent fixed locations for some items and portability of other items so that every nurse can customize their own workspace. It is also clear from the patterns that there needs to be enough space for equipment so that the equipment does not impede the nurse work zone. Hamilton suggests recessed portions of the headwall adjacent to the bed for major equipment. He also proposes that duplicated utilities (such as  sharps containers) on either side of the bed might improve efficiency and save nurses steps from moving back and forth from one side of the bed to the other.

Can we say the results are definitive?
This study was conducted in four different hospitals, and focused on very common patient room layouts. However, critical care protocol varies from hospital to hospital and movement patterns are likely to vary as well. And in patient rooms with power columns or overhead booms, there are undoubtedly different movement patterns. The results are a great place to start a conversation about better ICU patient room design, and the methods lay out a great way for future studies to get at more information so that, eventually, we can start talking about generalizability.

What’s the takeaway?
While patient rooms design varies, this study is able to shed some light on one of the most common configurations in use in North American critical care patient rooms; the headwall variation of life support systems. The lovely 3D diagrams and catchy metaphoric names for these movement patterns are helpful mnemonic devices that can add value to and common understanding in conversations around patient room design.

Hamilton, D. K. (2019). Horseshoe, Cockpit, and Dragonfly: Nurse Movement in Headwall Patient Rooms. Critical Care Nursing Quarterly, 42(1), 47–52. https://doi.org/10.1097/CNQ.0000000000000237
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