This article, based on the experience of the USA, outlines key issues that UK stakeholders should mull over while considering the change from mixed wards to single patient rooms.
With upcoming changes in the NHS policies, hospitals will begin competing for customers, perhaps like never before in UK history. As hospitals examine ways of enhancing the patient experience, single patient rooms offer an almost guaranteed avenue for improvement. However, while UK hospitals have had private rooms all along, there is no precedence of all single rooms. There is a combination of cautious optimism and reluctance among clinicians and managers in adopting the all single room concept.
In the United States, better bed utilization steered the industry towards single rooms. Over the succeeding decades, acute care facilities experienced a 118 per cent increase in gross area, according to Kurt Salmon Associates, partly from single room provision. The increase resulted in a rethinking of the appropriate unit configuration. The necessity for separating support services circulation from the public, and locating supplies proximate to caregivers found the racetrack configuration (rooms arrayed in a racetrack around a central support core), trump other configurations in new inpatient units.
To grapple with the new setting, the industry inclined towards decentralisation of documentation and support spaces, which encountered resistance from both nurses and support services. For nurses, a central station offers greater potential for mentoring and consulting. Similarly, for the support departments, stocking and inventory management in one central location on a unit demand less time and fewer personnel.
On large footprints, the centralization-decentralization issue can have considerable impact on efficiency, especially on time wasted in non-productive tasks. A 2008 HKS study comparing a centralized model with a bed/room side model on a 30-bed unit found that the difference between the two, during a 12-hour shift, is a staggering 154 minutes of reduced walking (a 68 percent decrease in wasted time). Decentralization could substantially reduce time spent in walking, queues, and hunting and gathering. The key challenge is in balancing waste reduction with opportunities for mentoring and consulting, and performance efficiency of support departments.
Since the racetrack configuration pulls the nurse activity areas into the core, window exposure to the staff is tricky. A 2006 HKS study at Children’s Healthcare of Atlanta found that duration of exposure to a window had a significant effect on both acute stress and alertness of nurses – a patient safety issue that cannot be ignored.
With single rooms, maintaining nurse-patient visibility becomes more difficult. Patient visibility is a top safety issue, as reported in a 2008 study of 20 hospitals by Stanford University and Harvard University. The importance was further reinforced in a 2010 publication from Columbia University, which found that low visibility in ICUs was associated with higher mortality for severely ill patients.
With the new configuration, maintaining visibility between staff is also tricky. Peer visibility enhances the availability of a helping hand – a safety issue. It was also one of nine design domains identified in a 2006 HKS study as a factor affecting operational flexibility and efficiency.
Addressing these multiple necessities of peer visibility, patient visibility, daylight, waste reduction, mentoring and consulting, and support departments’ performance are issues that should be addressed to reap the most benefit from single rooms.
Adopting single patient rooms
The aforementioned range of issues is not intended to deter new facilities from considering all single patient rooms. Many of these issues are inherent to large units, and probably exist to some degree on existing ones. The advantages offered by single rooms render addressing these issues worthwhile.
Single rooms offer better noise control – a major problem in hospitals around the world. Noise affects patients physiologically (blood pressure, heart rate) as well as psychologically (sleep deprivation, pain, ICU psychosis, stress and annoyance). Studies show reduced noise improves sleep quality – a key factor in improving recovery rate.
A closely associated issue is privacy. The ability to close the door when desired has a substantial influence on one’s sense of control, thus reducing stress – a known contributor to morbidity. Reduced stress means speedier recovery, reduced length of stay and, hence, reduced cost. Studies also show enhanced patient-clinician interaction with privacy.
Enabling family involvement in patient care is yet another benefit. Family presence constitutes a source of social support, which plays a crucial role in coping – a phenomenon associated with stress reduction. Anecdotes suggest that family presence could help reduce medical errors and patient falls – two major areas of concern.
Perhaps the most important advantage of single rooms is reducing hospital-acquired infection. Notably, a 2010 Canadian study shows that with each additional roommate, the risk of infection increases by 10-11 per cent. Considering the associated costs – treatment, patient satisfaction, referrals, image – infection control is a vital issue favoring single rooms.
While tapping into these advantages may appear to generate numerous operational challenges, most of the challenges can be addressed through design. Optimizing both domains, however, needs careful consideration of the operational challenges – both individually and in conjunction.
Dr Debajyoti Pati is vice president and director of research of HKS, Inc and executive director of CADRE, USA