• Dr John Goldstone


Q&A: Dr John Goldstone

Dr John Goldstone talks about the new intensive care unit at The London Clinic

Interview: Viel Richardson
Portrait: Alice Mann

Can you define an intensive care unit?
It is a specialised ward designed to allow us 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 while we anticipate that they are going to be okay. But the type of patients in the ICU means things do not always run smoothly.

For example their kidneys fail and they might need dialysis. But their kidney failure led to too much fluid in the body which can make it difficult to breathe. Suddenly they breathing support through a ventilator attached via face mask or a tube fed directly into their lungs, a procedure which would normally require some sedation. So in this escalating scenario which goes from simply monitoring, to single organ failure on to multiple organ failure, to a procedure which needs sedation is the type of situation which requires a specially designed unit.

So adaptability it key to a successful ICU.
Very much so. The core thing to remember is that an ICU needs the ability to deal with a wide variety of escalation situations such as the one above 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 in the ICU 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 etc. When it comes to the exact nature of the equipment you want and the orientation of the rooms these areas are not specified by regulations so vary quite a lot between ICUs.

So you can decide the priorities, within certain parameters?
Yes we can. One or our major aims was to build in the ability to precisely control the physical environment around the patient. This why 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 patient’s 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 are on external walls. It means the patient can see outside. The longest I have treated a person in intensive care has been two years, and the presence of natural light withy the patient being able to see the transition from date tonight is can be important for long stay patients.

I believe your approach to observing the patient is different here from other ICUs.
A patient may have one-to-one nursing, or something less intense where one nurse is monitoring two patients. But whatever the scenario we wanted the nursing staff have a clear view of the patient at all times, so sight lines are crucial. However the separate rooms in this unit made constructing the sight lines very difficult. If the door has a small window it's almost impossible to see the patient from the corridor. Also what happens if you're at the nurses station reading patient notes, examining some images, or typing in some data.

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 also the means patient can feel more connected to what's going on around them. In the wall separating adjoining units there is a window so a when a nurse is in one unit they can always see the bed in the other unit. 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 the privacy issues? Sometimes you won’t want the room in full view.
We have addressed this with the use of ‘smart glass’ technology. This is a very complex piece of technology which means that at the press of 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 is about creating flexibility, the ability to seal off the room when necessary but have maximum visibility at other times.

Can you tell me some other benefits of having all side rooms?
Many of the patients have infections and a key issue for any ICU is preventing infections spreading.  But what we have goes much further. The air flow systems not only the clean air but manages the pressure within each room. In a positive pressure room the air is gently pushed out of the room, which 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 we don’t want to want to leave the room, air is gently drawn into the room meaning the bacteria and viruses are contained within the space even when the doors are open. Our control systems mean we can create either set-up in all the rooms which means we can set the environment in each room depending on the needs of the individual patient.

What were the biggest challenges you to faced?
One of the big challenges was how do you future proof a ICU unit. So we had some areas which we were really concerned about addressing. One area was information technology and machine to machine connectivity which we think is going to be increasingly important. So 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 into our systems when they arrive and so we can maintain the standards we are setting.

I believe the equipment’s connectivity allows you to operate in some unique ways?
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, they can even emulate the screens of ICU equipment on a tablet or their 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 the consultant?
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 a robot which on one occasion we took to the Imperial War Museum. The curator gave an explanation of the exhibits the robot was looking at while it was being controlled by a patient from their hospital bed. We can also send it to a patient's home and transmit live images from their garden if that something they are desperately missing. It's just a way of occasionally of taking patients outside of their treatment which can have real beneficial effects.

What do you like about what you do?
It is a mix of things really. I love the intensity of the work. It very rewarding to be involved in grappling with some really difficult problems. Also with intensive care medicine you work closely with others like nurses, physiotherapists, occupational therapists, junior doctors and many others. Leading a team of people dedicated to getting the best outcome for the patient is a wonderful working environment. But the greatest satisfactions comes from the patients. In these units you are dealing with people who would definitely have died 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 genuinely world class ICU. Being part of that reminds me of my time training with the world-class clinicians who inspired me to do this work. It reminds me of units where people aspired to be really great at whatever they did, and looking around me I see the start of a really great intensive care unit here.