Effects of Single Versus Effects of Single Versus

MultiMulti--Bed Rooms Bed Rooms

on Outcomeson Outcomes

Welsh Health Estates and IHEEM ConferenceWelsh Health Estates and IHEEM ConferenceCardiff, March 2006 Cardiff, March 2006

Roger Ulrich, Ph.D.

Texas A&M UniversityBartlett School of Architecture, University College London

Safety (infection rates, medical errors, falls)

Stress, other medical outcomes

Satisfaction

Economic outcomes

Review research relevant to com-paring single vs. multi-bed rooms

ObjectivesObjectives

SAFETY: Single vs MultiSAFETY: Single vs Multi--Bed RoomsBed Rooms

• Increase hospital costs per patient by $40,000 in U.S.

Healthcare Associated Healthcare Associated Infections Infections (HCAI)(HCAI)

More that 145 studies were identified pertaining to infection and the hospital built environment

(Ulrich & Zimring, 2004)

• Enable proactive isolation of patients at admission

• Are far easier to decontaminate after patient is discharged

• Single-bed rooms are vastly superior to multi-bed rooms for managing air changes, pressure and maintaining clean air

SingleSingle--Bed Rooms Help to Bed Rooms Help to Reduce Infection RatesReduce Infection Rates

Surfaces commonly contaminated by MRSA(Methicillin-resistant staphylococcus aureus) R.S. Ulrich with P.A. Wilson

STUDY [by Cepeda,…Wilson et al. 2005]

RESEARCH EXAMPLE

Patients: MRSA-positive patients in multi-bed rooms in two London hospitals

Interventions: After diagnosis, patients were either (1) moved to a single room or cohort nursed or (2) not moved – that is, they remained in multi-bed rooms

Findings: Isolating patients in single rooms or cohorts did not reduce MRSA acquisition rates

STUDY [by Ben-Abraham, Keller, Szold et al., 2002]

RESEARCH EXAMPLE

Patients: children in pediatric intensive care unit

Environmental intervention: Move from open ward to private rooms

Findings: 50% decrease in infections (respiratory tract, urinary tract, catheter-associated)

Effect of Single versus Two-Bed Rooms on HCAI

Bronson Methodist Hospital, USA

Effect of Single versus Two-Bed Rooms on HCAI

Bronson Methodist Hospital, USA

Richard A. Van Enk, Ph.D.Themba L. Nyirenda, MSRichard A. Van Enk, Ph.D.Themba L. Nyirenda, MS

Pebble ProjectPebble Project

Categories of Infections in Study Categories of Infections in Study (Van Enk and Nyirenda, 2003)(Van Enk and Nyirenda, 2003)

• Urinary

• Urinary, catheter-associated

• Pneumonia

• Lower respiratory

• Reproductive

• Surgical site

• Skin

• Bloodstream, primary

• Central nervous system

• Gastrointestinal

• Cardiovascular

• Ear/nose/throat

• Bone/joint

• Systemic

The impact of the move on the CSU: t = -2.83 , p = 0.005

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Infection Rates for Cardiac Surgery Unit(Van Enk and Nyirenda, 2003)

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Move to New Building with Single Rooms

The impact of the move on the Mothers in Mother/Baby unit: t = -2.76, p = 0.006

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Infection Rates of Mothers in Infection Rates of Mothers in Mother/Baby Unit Mother/Baby Unit (Van Enk and Nyirenda, 2003)(Van Enk and Nyirenda, 2003)

Move to New Building with Single Rooms

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• Studies show that 85%-90% of the time roommates are source of stress not positive social support

Stress examples: roommate who is unfriendly or seriously ill

Roommates generate much noise

Do roommates provide stress Do roommates provide stress reducing social support?reducing social support?

American Women in Labor American Women in Labor &&

Delivery Units Rate Room NoiseDelivery Units Rate Room Noise

From Gesell and Malone (2002)Press Ganey Associates

Based on data from 152,399 female

patients in 566 hospitals across 46 statesJanuary through December, 2002

RESEARCH EXAMPLE

60

65

70

75

80

85Had roommate Single room

Pleasantness of room decor

Room cleanliness

Noise level in and around

room

Sat

isfa

ctio

nSatisfaction with Room Environment Aspects Satisfaction with Room Environment Aspects

(from Gesell and Malone, 2002)(from Gesell and Malone, 2002)

14.614.6

• Approximately 15%-20% of all

room transfers in U.S. hospitals

are caused by incompatibility

and stress among roommates

Transfers Worsen Patient Transfers Worsen Patient and Staff Safetyand Staff Safety

• Transfers cause sharp peaks in medical errors

• Increase infections

• Major cause of staff injuries

• Each transfer requires hours of staff time and paperwork

• Each transfers adds .5 day to LOS

Acuity-Adaptable, Single Coronary Critical CareMethodist Hospital, Indianapolis

Acuity-Adaptable, Single Coronary Critical CareMethodist Hospital, Indianapolis

BSA LifeStructuresBSA LifeStructures

Transfers reduced 90% compared to unit with multi-bed roomsSaves $5 million per yearMedication errors reduced 70%

Pebble ProjectPebble Project

Annual Medication Error Index Annual Medication Error Index (errors/patient days) coronary critical care(errors/patient days) coronary critical care

0

2

4

6

8

10

12

1997 1998 1999 2000 2001Med Errors

Mo

re e

rro

rs

Move to new unit Move to new unit with single, acuitywith single, acuity--adaptable roomsadaptable rooms

Source: A. Hendrich (2004). In Keeping Patients Safe: Transforming the Work Environment of Nurses. Quality Chasm Series, Institute of Medicine

Old unit with Old unit with

multimulti--bed roomsbed rooms

• Most falls occur when patients get out of bed unassisted. Design for increasing assistance for patients and thereby reducing falls includes:

Problem:Problem: FallsFalls

SAFETY: Single vs MultiSAFETY: Single vs Multi--Bed RoomsBed Rooms

Decentralized nurse stations

Single-bed rooms designed to support family presence

Acuity-Adaptable, Single Coronary Critical CareMethodist Hospital, Indianapolis

Acuity-Adaptable, Single Coronary Critical CareMethodist Hospital, Indianapolis

BSA LifeStructuresBSA LifeStructures

Pebble ProjectPebble Project

Family ZoneFamily Zone

BSA LifeStructuresBSA LifeStructures

Acuity-Adaptable, Family Centered CCUMethodist Hospital, Indianapolis

Acuity-Adaptable, Family Centered CCUMethodist Hospital, Indianapolis

FamilyFamily--centered centered single roomssingle rooms + + decentralized decentralized nurse stationsnurse stations improve observation and improve observation and assistance for patients, thereby reducing fallsassistance for patients, thereby reducing falls

Methodist Hospital Study: Patient Methodist Hospital Study: Patient Fall IndexFall Index (falls per 100 patient days)(falls per 100 patient days)

0

1

2

3

4

5

6

7

1997 1998 1999 2000 2001

Move to new unit with Move to new unit with single familysingle family--centered centered rooms and decentralized rooms and decentralized nurse stationsnurse stations

Mor

e Fa

lls

Source: A. Hendrich (2004). In Keeping Patients Safe: Transforming the Work Environment of Nurses. Quality Chasm Series, Institute of Medicine.

Old unit with Old unit with

multimulti--bed rooms, bed rooms,

centralized nurse centralized nurse

stationstation

Myth:

Single-bed rooms require much higher nurse staffing and therefore greatly increase costs

Myth:

Single-bed rooms require much higher nurse staffing and therefore greatly increase costs

Study: Staffing ImpactStudy: Staffing ImpactHendrich, Fay & Sorrells, 2004

• From two-bed to single-bed rooms• From centralized to decentralized

nurse stations• From acuity-based care model

(dependent on transfers) to acuity-adaptable without transfers

• From limited visiting times to family-centered care model

RESEARCH EXAMPLE

source: Hendrich, Fay & Sorrells, 2004

-50%

Nurse AttritionNurse AttritionNo. of Nurses EmployedNo. of Nurses Employed

Another myth: Another myth:

Single-bed rooms prevent observation of patients and therefore worsen safety

Single-bed rooms prevent observation of patients and therefore worsen safety

Visual monitor-ing window in a Canadian hospital built more than 20 years ago

Hexham HospitalNorthumbria NHSDesign: Jonathan Bailey

• Well-designed decentralizednursing stations improve visual observation of patients, thereby enhancing safety and outcomes

DecentralizedDecentralized Nurse Charting Nurse Charting

&& Observation StationsObservation Stations

Pendleton Memorial, New Orleans design: Blitch/Knevel

Decentralized charting/observationDecentralized charting/observation

Golden Jubilee National Golden Jubilee National Hospital Hospital (NHS)(NHS) GlasgowGlasgow

Single vs MultiSingle vs Multi--bed Rooms:bed Rooms:

Social Support from Family, FriendsSocial Support from Family, Friends

• Much research shows that contact with caring, emotion-ally supportive family/friends reduces patient stress and improves medical outcomes

Celebration HealthCelebration, FL Design: NBBJ

Single rooms are better for being with family, increasing social support

St. Gemma Hospice, UKDesign: Jane Darbyshire & David Kendall Ltd

Major stressor:Major stressor:

Poor staff communication Poor staff communication with patientswith patients

• Elevates patient and family anxiety and stress

• Considered by patients one of the worst stressors

• Worsens outcomes

STRESS: Single vs MultiSTRESS: Single vs Multi--Bed RoomsBed Rooms

• Patients in single rooms, com-pared to those with roommates, think staff communicate much better with them

Single vs MultiSingle vs Multi--bed Rooms:bed Rooms:

Staff Staff CommunicationCommunication

Single roomsSingle roomsimprove improve communicationcommunicationbetween clinical between clinical staff and staff and patientspatients

Evidence-Based Design to

Improve Financial Performance

Evidence-Based Design to

Improve Financial Performance

• U.S. patients are more satisfiedwith care when they are in single rooms rather than multi-bed rooms

• Vast majority of British patients likewise prefer single-bed rooms, especially if they have experience with such rooms (Lawson and Phiri, 2003)

Single Rooms and SatisfactionSingle Rooms and SatisfactionSource: Press Ganey US national data, 1999-2002

(approximately 4.5 million patients)

SingleSingle--bed vs. Multibed vs. Multi--bed Rooms bed Rooms (Ulrich, 2004)(Ulrich, 2004)

SingleSingle MultiMulti--bedbedHCAIMedical errorsFallsStaff observation of patientsStaff/patient communicationPatient confidentiality, privacyPresence of familyDeath with dignityNoiseSleep qualityPatient satisfactionPatient stress, painRoom transfers: costsManaging bed availabilityAdaptability to accommodate changeInitial construction costsWhole life costs

Example:Example:Karmanos Cancer InstituteKarmanos Cancer InstituteDetroit, Michigan, USADetroit, Michigan, USA

Previous facility: • Multi-bed rooms

• Centralized nurse stations

• Poor acoustics

$15 million renovation• 54 single-bed rooms

• Breast center

• Outpatient cancer center

Karmanos Cancer InstituteKarmanos Cancer InstituteDetroit, Michigan, USADetroit, Michigan, USA

Selected Data

• 30% reduction in errors

• 17% higher satisfaction

• Lower nurse attrition

• 16% decrease in patient use of narcotic pain drugs

• Average costs decreased >$1,000 per patient

Policy Changes Affecting Financial Policy Changes Affecting Financial Outcomes of Trusts in EnglandOutcomes of Trusts in England

• Choice

• Payment by resultsCosts of infections, falls, errors, longer stays paid to greater extent by trusts

Patients can choose where to go for care. Revenues flow with patients.

Two sources of competition: NHS and private providers

Study:Study:

Choice in the Birmingham Choice in the Birmingham

and Black Country SHAand Black Country SHA

MORI Social Research Institute, 2005

0% 10% 20% 30% 40% 50% 60%

Quality of information

Respectful care

Flexibility on visiting

Nice environment

Lower MRSA risk

Private room

Quality of food

How much do you think the How much do you think the privateprivate sector is sector is better than the NHS in these areas of activity?better than the NHS in these areas of activity?

source: 1,201 residents, MORI Birmingham SHA study, 2005

Comparing persons ‘easy to Comparing persons ‘easy to persuade’ vs ‘hard to persuade’ persuade’ vs ‘hard to persuade’

to choose private sectorto choose private sector

• Private room is important:79% of easy to persuade (EtP)47% of hard to persuade (HtP)

• Flexibility about visiting important:91% of EtP 77% of HtP

Based on the survey findings, the

independent sector could make £35

million in revenues this year from

choice in the Birmingham and Black

Country area

(source: Independent Healthcare Forum)

Kidderminster HospitalDesign: MAAP Architects

Hexham HospitalNorthumbria NHSDesign: Jonathan Bailey

Building Design and Construction

1

Maintenance

4.2

Healthcare (Business) Operations

50

Build it cheap and quick!

75-100

Healthcare Operations COSTS

Healthcare Operations REVENUES(from choice and performance)

Negative long term financial consequences

Greater risk for Greater risk for stakeholders stakeholders

After: Evans et al. 1998, Royal Academy of Engineering

Building Design and Construction

1

Maintenance

4.2

Healthcare (Business) Operations

[Revenues Minus Costs]

Build it based on evidence and spend slightly more

Healthcare Operations COSTS

Healthcare Operations REVENUES(from choice and performance)

Positive long term financial consequences

Reduced risk for NHS, taxpayer

Forecast Forecast (2010)(2010)

• Evidence-based design will become critical for improving patient safety, outcomes and trust performance

• Single-bed rooms will play pivotal role

Reference

Ulrich, R. S. and Zimring, C. (with Quan, Joseph, and Choudhary) (2004). The Role of the Physical Environment in the Hospital of the 21st Century. The Center for Health Design and the Robert Wood Johnson Foundation.

available online at www.healthdesign.org