Thursday, September 04, 2008

Single rooms

An August 27 JAMA article by Toronto doctors Michael Detsky and Edward Etchells is entitled, "Single-Patient Rooms for Safe Patient-Centered Hospitals." Extract here. (As usual, JAMA does not allow free access to public policy articles. When will they start to do that, I wonder?)

Here's the summary:

Clinicians should advocate for single-patient rooms in any new hospital construction, expansion, renovation, or redesign. Single-patient rooms are permanent physical features that potentially could improve safety and patient satisfaction without the need for ongoing staff training, audits, or reminders. Money spent on capital costs to improve patient care may be more efficient than money spent on changing hospital culture and the behavior and attitude of health professionals. It is not necessary to wait 50 years for existing hospital structures to deteriorate before the full potential of single-patient rooms can be realized.

I do not disagree about the attributes of single-patient rooms, in terms of infection control, patient satisfaction, and optimal use of rooms for a diverse mix of patients. Also, they are strongly recommended in guidelines of the American Institute of Architects. I believe they will result in higher capital costs (and therefore higher annual carrying costs), but I do not think it likely that they will generate savings or efficiencies commensurate with those capital costs. In other words, they may not have a good rate of return, in strict financial terms, but they clearly will be the standard for new construction and renovations.

But, I think that Doctors Detsky and Etchells are off-base in their conclusion about single-patient rooms obviating the need for improved staff performance in the quality arena. The idea that increased capital investment in this arena will result in a noticeable and sustained improvement in reducing harm in hospitals -- absent ongoing and dedicated training, measurement, audits, and reminders -- seems to me to be counterintuitive.

I am not sure why the authors felt they needed to reach so far with their conclusion. It ends up sounding like they really feel that the "behavior and attitude of health professionals" is perfectly fine and that it has been the existence of multi-patient rooms that has been the source of safety and patient satisfaction problems in those rooms. This type of conclusion does harm to the quality and safety movement in that it could be used as an excuse that would distract people from investing time and effort in process improvements that are almost universally acknowledged as being long overdue.

14 comments:

Crow said...

interesting post

PJ Geraghty said...

Interesting. I had always assumed that private rooms were a patient-satisfaction decision, with perhaps some infection control as an afterthought.

I can tell you that having spent a total of about 13 days as an inpatient over the past 16 months, to the extent that I could choose a hospital, I would always choose one with single rooms, and I sold my soul (metaphorically speaking) while I was in to get one of the coveted single rooms.

I have no doubt that they're expensive, and probably a little more difficult for the staff, but in terms of patient comfort/satisfaction I think single rooms are huge.

Barry Carol said...

Paul,

How much more would single rooms cost per square foot to construct, mainly because of the extra bathrooms that would be required? Is it possible or even likely that they could produce an adequate return on investment if hospitals were paid on a capitation basis instead of fee for service? Can you envision any circumstances under which capitation could work reasonably well assuming hospitals also owned a significant base of physician practices and paid the doctors on a salary plus bonus basis?

Anonymous said...

Actually the problem of proper patient identification within double rooms has caused some fatalities. It has been very difficult to get staff to check wristbands instead of referring to "room 132, bed 1". I know it seems stupid to laymen, but it is about as stubborn as handwashing. I believe it is this or related issues to which the clinicians refer. (Not that I think single rooms will completely solve this or other issues!)

ps for interest, the fatality in my area occurred at the "best" area hospital when a phlebotomist drew blood by room and bed number - only the patients had switched beds because one liked the window. Unfortunately this led to the transfusion of the wrong blood in her subsequent surgery, and death.

nonlocal

Cindy said...

I think single rooms should be mandatory in order to comply with privacy regulations. In fact, I think patient floors should be retrofitted to all single rooms. I work at BIDMC and am constantly reminded of privacy regulations (and rightly so, patients deserve privacy). So why does privacy get blown to the wind when it might cost hospitals money?

Paul Levy said...

Folks,

Maybe I wasn't clear in this posting. EVERYONE is using the single-patient room model for future renovations and expansions. That is now the standard.

The point of this posting was that you can't use that decision as an excuse not to invest in quality and safety process improvement, too. The article I cited gave that impression.

Barry,

I don't see how the form of payment changes the underlying economics of these rooms very much. And, if it does, it is clearly a third- or fourth-order effect.

Cindy,

If you retrofitted existing doubles into singles, you would not have enough patient rooms to satisfy current demand. You would have to accompany that by building a new building and extra patient rooms. That would be a huge extra cost. Over time, we and al hospitals are acting to increase the percentage of single room, butthe key phrase is "over time", as we add new capacity.

Nonlocal,

That is an amazing and incredibly sad story, pointing out the need for double identification in such matters.

Anonymous said...

Paul;

Well, that was exactly the criticism of the hospital in the fatality - that they didn't have (readily available) systems in place to prevent this human error from occurring. In fact, they were behind our much smaller and poorer hospital.

I talked to an anesthesiologist who worked there who said the better system in question would have cost $200,000 and they didn't want to spend the $$. It cost them several times that to settle the legal case, of course - not to mention the human cost.
So you are right - investment in quality and safety are paramount. I don't think the clinicians in the article meant to say otherwise.

nonlocal

Online Dollar Man said...

Paul,

I totally agree with your single-patient room advocation, I think we should settle for noting less. This blog is truelt a blog of note.

Cheers!

Cindy said...

Okay, you got me there. My duh.
Glad to hear single rooms are being incorporated in the future.

I understand that the authors are saying that single rooms quickly add some increased safety, but I like how BIDMC is doing it - every avenue toward improved patient safety is being taken.

Paul Levy said...

Dear pj,

To confirm your point, our surveys show about a 3 percentage point higher response in terms of patient satisfaction ranking (i.e, percent of people who rank the experience as good or excellent) when people are in a private room compared to a double.

Anonymous said...

In our 350 bed hospital, every room now is a single room. As a nurse, I have tripped over more than one mechanical device, be it a stedman pump or Imed pump.. trying to get to a patient, in a crowded two bed room....and confidentiality laws as they are...is there realy patient privacy in a two bed room? I don't think so.

Zahhar said...

Clearly most of you commenting are rich people who can afford whatever medical care you require. Me, I'd be happy with just a room in a hospital should I need medical attention. And I think I'd find the presence of another human somewhat comforting over the isolation of a single room.

This is clearly an argument between rich people based on their personal tastes. People in poverty, such as myself, aren't interested in such topics. We just want access to medical care, period.

Anonymous said...

Recently visited a aunt in a four bed room of my employment and watched in utter disbielf as a physican went to each pt and asked if this was the pt. As my aunt was the only alert one in the room she directed him to the proper pt. I proceeded to leave after visiting called admitting and had her moved to a two bed room less for her to take care of!!!! Still so much to do....

Ava Mazur said...

From a saftey issue I belive single rooms to be far superior in reducing identification errors.