Q&A: Dr John Goldstone

What exactly is an intensive care unit?
It is a specialised ward designed to provide very intense levels of monitoring, nursing care and teamwork, and to do so in a very adaptable way. At the simplest level, a patient might just need to be monitored for a while, but the type of patients in the intensive care unit (ICU) means things do not always run smoothly. For example, a patient’s kidneys might fail and they might need dialysis. But their kidney failure could lead to too much fluid in the body, making it difficult to breathe. Suddenly they might require breathing support through a ventilator, attached via a tube fed directly into their lungs—a procedure which would normally require some sedation. So, in this escalating scenario they go from simply monitoring, to single organ failure, to multiple organ failure, to a procedure which needs sedation—it is this type of situation which requires a specially designed ICU.

So adaptability is key to a successful ICU?
Very much so. The key thing to remember is that an ICU needs the ability to deal with a wide variety of escalation situations without moving the patient. We must be able to bring all the necessary expertise and equipment to the patient’s bedside.

What do you need to consider when you design such a unit?
First, there are the legal and medical regulations. These define what facilities have to be included and the standards they must adhere to. There are also the physical requirements, such as the power, lighting and communication installations and their back-ups. When it comes to the exact nature of the equipment you want and the orientation of the rooms, these areas vary quite a lot between ICUs.

So you can decide the priorities, within certain parameters?
Yes, we can. One of our major aims was to precisely control the physical environment around the patient, so every patient is in a separate room, in which we have installed very sophisticated lighting, temperature and air flow controls. At the same time, we didn’t want the patients to get the feeling of being trapped in some technological cave, cut off from the rest of the world. This made access to natural light very important, so all of our rooms have an external wall, allowing the patient to see outside. The longest I have treated a person in intensive care has been two years, and the presence of natural light, with the patient being able to see the transition from day to night, can be really important.

With the patients all in separate rooms, how do you ensure they are being regularly observed?
We want the nursing staff to have a clear view of the patient at all times, so sight lines are crucial. However, the separate rooms made constructing sight lines very difficult. If a door just has a small window, it’s almost impossible to see the patient from the corridor. Our solution was to use lots of glass. The doors are floor-to-ceiling glass and slide right back into the walls for maximum visibility from outside the room. This allows the staff to see into the room, but it also means the patient can feel more connected to what’s going on around them. There is a window in each of the walls between adjoining units so that when a nurse is in one unit they can always see the bed in the other. We have also designed nursing stations to serve two rooms, giving the nurse access to all the information on each patient and giving them a clear view of both beds.

What about privacy?
Sometimes you won’t want the room to be in full view. We have addressed this with the use of ‘smart glass’ technology. This means that at the press of a button all the glass in a room switches from transparent to opaque. If you require total privacy in the room you can get it incredibly quickly. The design is about creating flexibility: having the ability to seal off the room when necessary but having maximum visibility at other times.

What other benefits are there to this set-up?
Many of the patients have infections and a key issue for any ICU is preventing infections spreading. But what we have goes much further than most places. The air flow systems not only clean the air but manage the pressure within each room. In a positive pressure room, the air is gently pushed out, which is useful for patients with compromised immune systems where we don’t want airborne viruses or bacteria entering the unit. In the negative pressure rooms, where the patient may have an infection, air is gently drawn into the room, meaning bacteria and viruses are contained within the space even when the doors are open. Our control systems mean we can create either set-up, so we can set the environment depending on the needs of the individual patient.

What were the biggest challenges you faced? 
One of the big challenges was: how do you future- proof an ICU unit? We had some specific areas which we were really concerned about addressing. One was information technology and machine-to-machine connectivity, which we think is going to be increasingly important. This ICU has lots of machine-to- machine connectivity built in. While we don’t know what machines will be invented in the future, they are increasingly likely to be wireless and our infrastructure means it will be much easier to integrate them when they arrive.

What does this connectivity allow you to do?
It will make a huge difference in the ways a consultant can assess and treat a patient remotely. They have access to all the information about the patient’s treatment at their fingertips and they can even emulate the screens of ICU equipment on a tablet or computer. Combined with input from staff caring for the patient, this type of set-up results in better decisions being made on remote consultations. While all of this technology has been available individually for some time, what I think is unique about this ICU is the way it has been integrated to give both the patient and the consultant the best of all possible worlds.

So the benefits are not confined to clinicians? 
The flexibility of the system means that it can be made to work for the comfort of the patient in some quite fun ways. We have used a robotic surgery camera system on one occasion for a filmed visit to the Imperial War Museum. The curator of the museum gave an explanation of the exhibits the robot was looking at while it was being controlled by a patient from their hospital bed. The patient was thrilled by this. We can also send it to a patient’s home and transmit live images from their garden if that is something they are missing. It’s just a way of occasionally taking patients outside of their treatment, which can have beneficial effects.

What do you like most about what you do?
It is a mix of things really. I love the intensity of the work — it is very rewarding to be involved in grappling with some really difficult problems. Also, with intensive care medicine you work closely with nurses, physiotherapists, occupational therapists, junior doctors and many others. Leading a team of people dedicated to getting the best outcome for the patient makes for a wonderful working environment. But the greatest satisfaction comes from the patients. In these units, you are dealing with people who could die without the care you provide. You get to follow them from being desperately ill, sometimes more likely to die than live, to seeing them leave the unit well on the way to recovery, heading back to their everyday life.

What are you proudest of now, looking around this unit?
The thing I’m most proud of is the unit’s potential — it has the potential to be a genuinely world-class ICU for years to come. Being part of that reminds me of my time training with the leading clinicians who inspired me to do this work, people who aspired to be really great at whatever they did.