Iaahq.org

REFERENCES
.plosjournals.org/archive/1549-1676/5/3/supinfo/10.1371_journal.pmed.0050067.sd001.pdf.
1. Food and Drug Administration. Developing guidance on conducting scientifi-
9. Joffe HV, Parks M, Meyer R, Jenkins J, Temple R. Rosiglitazone and the FDA.
cally sound pharmacoepidemiologic safety studies using large electronic health- N Engl J Med. 2007;357(17):1775-1776.
care data sets: public workshop: request for comments. Fed Regist. 2008;73 10. Psaty BM, Ray W. FDA guidance on off-label promotion and the state of the
literature from sponsors. JAMA. 2008;299(16):1949-1951.
2. Food and Drug Administration. The Sentinel Initiative: national strategy for moni-
11. Food and Drug Administration Amendments Act of 2007. HR 3580, enacted
toring medical product safety. http://www.fda.gov/oc/initiatives/advance/reports by the House and Senate, Pub L No. 110-85. http://frwebgate.access.gpo.gov /report0508.pdf. Accessed July 17, 2008.
/cgi-bin/getdoc.cgi?dbname=110_cong_bills&docid=f:h3580enr.txt.pdf. Ac- 3. Misbin RI. Medical office review of Avandia: application number: 021071: Cen-
ter for Drug Evaluation and Research. http://oversight.house.gov/story.asp?ID= 12. von Elm E, Altman D, Egger M, Pocock S, Götzsche P, Vandenbroucke J. STROBE
Initiative: The Strengthening the Reporting of Observational Studies in Epidemi- 4. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic dura-
ology (STROBE) statement: guidelines for reporting observational studies. Ann In- bility of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006; tern Med. 2007;147(8):573-577.
13. Rossouw JE; Writing Group for the Women’s Health Initiative. Risks and ben-
5. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of
efits of estrogen plus progestin in healthy postmenopausal women: principal re- diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a sults from the Women’s Health Initiative randomized controlled trial. JAMA. 2002; randomised controlled trial. Lancet. 2006;368(9541):1096-1105.
6. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone Evaluated for Car-
14. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research
diac Outcomes and Regulation of Glycemia in Diabetes (RECORD) Study: interim Group. Major outcomes in moderately hypercholesterolemic, hypertensive pa- findings on cardiovascular hospitalizations and deaths. N Engl J Med. 2007; tients randomized to pravastatin vs usual care: the Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). JAMA. 2002; 7. Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction
and death from cardiovascular causes. N Engl J Med. 2007;356(24):2457-2472.
15. Gerstein HC; Action to Control Cardiovascular Risk in Diabetes Study Group.
8. Vandenbroucke J. Observational research, randomised trials, and two views of
Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008; medical science. PLoS Med. 2008;5:e67; supplemental material. http://medicine Single-Patient Rooms for Safe
Patient-Centered Hospitals
and contact-related nosocomial infections.2 The evidenceis more compelling for reducing airborne infections, while some studies show no effect of single-room isolation on contact related to nosocomial methicillin-resistant Staphy- N THE 19TH CENTURY AND FIRST HALF OF THE 20TH CEN- lococcus aureus colonization.5 Single-patient rooms are tury, hospital accommodations consisted of large easier to clean and decontaminate than multi-bed rooms.
multi-bed wards with as many as 20 patients, and In addition, health care professionals may be more likely semi-private or private rooms for those who could pay.
to perform hand hygiene when moving between rooms Patients received care in these facilities for decades after rather than between beds, particularly if hand wash sta- the design had become obsolete. Almost 90 years ago, it tions are well positioned; the evidence that supports this was proposed that single-patient rooms were the ideal set- ting to provide patient care.1 In the last half of the 20th Patient transfers within the hospital can potentially lead century, new hospitals were built featuring mostly single-, to patient harm due to reduced monitoring, missed treat- double-, and 4-bed rooms. It is likely that these hospitals ments, and psychologic stress, and consume considerable may not be able to adequately provide safe patient- hospital staff resources. Single-patient rooms can reduce the centered care over the next 50 years of their life span. Most need for these transfers. For instance, once a patient is ad- modern hospitals have public value statements regarding mitted to a single-patient room, there is no need to move safety, dignity, privacy, and patient-centered care. A tan- this patient because of infection control, end-of-life care, or gible way to show commitment to these values would be administrative transfers to optimize utilization of multi- to give patients their bed with their own bathroom in a bed rooms. Acuity-adaptable rooms are single-patient rooms in which necessary medical care can be provided regard- The Benefits of Single-Patient Rooms
less of patient acuity; intensive care to palliative care can Considerable quasi-experimental and descriptive evidenceof the benefits of single-patient rooms on safety, utiliza- Author Affiliations: Division of General Internal Medicine, Patient Safety Service,
and Centre for Health Services Sciences, Sunnybrook Health Sciences Centre, Toronto,
tion, and satisfaction is available. Single-patient rooms Canada (Dr Etchells); Department of Medicine, University of Toronto, Toronto, reduce nosocomial infection rates2 provided that other basic elements of infection control are in place.3,4 A review Corresponding Author: Edward Etchells, MD, MSc, Sunnybrook Health Sciences
Centre, 2075 Bayview Ave, Room C410, Toronto, ON, Canada M4N 3M5 (edward
of 16 studies showed reductions in both airborne-related 954 JAMA, August 27, 2008—Vol 300, No. 8 (Reprinted)
2008 American Medical Association. All rights reserved.
be provided in the same setting. One before-after study Disadvantages and Considerations
of acuity-adaptable rooms showed a significant reduction With single-patient rooms, hospital staff must visit 3 rooms in reported medication errors, likely because of minimiz- to care for 3 patients, which requires additional walking and ing the confusion caused by multi-bed rooms and patient time. Other ward design features, such as wireless com- puter interfaces, satellite workstations, and accessible or- Single-patient rooms can enhance patient flow, whereas ganized supply rooms, can minimize additional excess staff shared patient rooms paradoxically limit this flow. For ex- movement and enhance efficiency. Having single-patient ample, in hospital jurisdictions that respect gender pri- rooms means the loss of roommates who can potentially sum- vacy, placing a male patient in a 3-bed room means that fe- mon help, but the increased availability of family and friends male patients cannot occupy the other 2 beds. Constrained may offset this loss. Because some patients prefer the com- access to beds in multi-bed rooms can lead to delays in pa- pany of other patients, a small number of double rooms tient flow from emergency wards, intensive care units, step- should be available. Patients isolated for infection control down units, and postsurgery recovery rooms. Accommo- have been shown to have fewer physician visits and have dating new patients in multi-bed patient rooms also leads more preventable adverse drug events.10 This apparent ne- to transfers of patients within the hospital; such transfers glect of isolated patients may be explained by the entire ar- offer no tangible benefit to patients, families, or hospital staff.
ray of infection control barriers rather than an inherent risk One estimate suggests that 85 beds in single-patient rooms can offer the same bed capacity as 100 beds in multi-bed Single-patient rooms increase new construction costs, but the incremental costs can vary widely depending on other Single-patient rooms offer greater potential for privacy, ward design features. One North American analysis found rest, and family support. Considerable attention is paid to that the cost of a new ward with exclusive single-patient the privacy of health information, yet multi-bed rooms do rooms was $182 400 per patient, whereas a ward with ex- not provide such privacy. Patients may not share sensitive clusive double rooms cost $122 550 per patient. The addi- medical history, such as sexual practices or illicit drug use, tional cost was mainly due to fewer patients accommo- in a room where strangers can listen.8 Discussions about life- dated on single-patient room wards.7 However, single- sustaining treatment or a serious diagnosis with a poor prog- patient room wards do not necessarily house fewer patients: nosis are inappropriate with other parties present when sepa- one British analysis documented that ward designs with 100% rated only by curtains. Most patients would not accept multi- single-patient rooms required the same space as those with bed birthing rooms, but end-of-life care, including cardiac 50% single-patient rooms when other space-saving design arrest care, is accepted in multi-bed rooms.
Family members can visit single-patient rooms more freely Another report found that full implementation of single- to offer support to the patient and to share information with patient room design features in new construction would the health care team. A common design feature in pediatric add 5.3% to initial construction costs, but these costs hospitals is a parent bed. A family member bed would be a would be recouped within 1 year through improved effi- welcome feature in adult hospitals with single-patient rooms.
ciencies associated with single-patient rooms.12 Informa- Increased availability of family members would improve com- tion about the costs and benefits of converting existing munication between the family and the health care team, wards to single-patient rooms does not appear to be avail- while respecting patient privacy and dignity.
able at this time; however, the expected costs and benefits Patients in single-patient rooms do not have to listen to the alarms, utterances, or conversations arising from other The increased expenditures required to achieve primar- patients’ beds. Higher noise levels have been shown to be ily single-patient rooms are capital costs rather than labor associated with increases in blood pressure, heart rate, and costs. This cost is in contrast to other efforts to improve pa- respiratory rates, all physiological findings suggestive of tient safety and satisfaction that require mostly labor costs higher stress levels.2 Reduced noise can improve sleep qual- with considerable ongoing hospital staff training and be- ity, and better sleep is associated with improved mood and havioral components to change in the culture of the hospi- better pain control, all of which may improve patient sat- tal. This distinction between capital and labor costs has 2 consequences. First, most capital costs occur at the begin- A key aesthetic and safety feature of single-patient rooms ning of the investment whereas labor costs are discounted is that each patient has his or her own bathroom. Even though because they occur over a number of years in the future.
bathrooms are not the sole source of nosocomial infec- The concept of discounting means that people who make tions, they are certainly important contributors. Most pa- investment decisions prefer to spend the same dollar amount tients would prefer not to share bathrooms with other pa- in the future instead of now. This consequence often leads tients who have an illness involving gastrointestinal decision makers to avoid current capital costs and tolerate symptoms such as vomiting, diarrhea, or gastrointestinal future labor costs, even though capital investments may ul- timately be less expensive. Second, capital costs may be more 2008 American Medical Association. All rights reserved.
(Reprinted) JAMA, August 27, 2008—Vol 300, No. 8 955
likely to produce the intended benefits, such as infection that potentially could improve safety and patient satisfac- control or patient satisfaction, than costs that require be- tion without the need for ongoing staff training, audits, or havioral or cultural changes in attitude. In other words, it reminders. Money spent on capital costs to improve pa- is easier to build a single room once than to teach thou- tient care may be more efficient than money spent on chang- sands of individuals to be attentive to patient privacy when ing hospital culture and the behavior and attitudes of health patient care is provided in multi-bed rooms.
professionals. It is not necessary to wait 50 years for exist- Hospitals currently generate income from surcharges for ing hospital structures to deteriorate before the full poten- private and semi-private rooms. Such income would disap- tial of single-patient rooms can be realized.
pear if single-patient rooms were widely available becausehospitals could not charge a premium for single-patient Financial Disclosures: None reported.
Additional Contributions: We thank Mary Vearncombe, MD (Sunnybrook Health
rooms if no multi-bed rooms were available. Moreover, any Sciences Centre, University of Toronto, Toronto, Canada), and Allan Detsky, MD hospital currently being designed with multi-bed rooms must (University of Toronto), for comments on earlier drafts of this article.
consider the likelihood that regulatory bodies will man-date single-patient rooms in the future. The same forces that REFERENCES
currently require reporting of nosocomial infection rates may 1. Bacon AS. Efficient hospitals. JAMA. 1920;74:123-126.
also one day mandate single-patient rooms. This possibil- 2. Ulrich R, Quan X, Zimring C, Joseph A, Choudhary R. The role of the physical
ity must be included in any cost analysis for future hospital environment in the 21st century: a once in a lifetime opportunity. Report to the Center for Health Design for the Designing the 21st-Century Hospital Project. 2004:10-11. http://www.healthdesign.org/research/reports/physical_environ.php. Ac- Even though the concept of single-patient rooms is in- tuitively appealing, there are gaps in the amount and qual- 3. Vietri NJ, Dooley DP, Davis CEJ, Longfield JN, Meier PA, Whelen AC. The effect
of moving to a new hospital facility on the prevalence of methicillin-resistant Staphy-
ity of existing research demonstrating potential advan- lococcus aureus. Am J Infect Control. 2004;32(5):262-267.
tages or value. Thus, studies of the important design elements, 4. Cooper BS, Stone SP, Kibbler CC, et al. Isolation measures in the hospital man-
agement of methicillin resistant Staphylococcus aureus (MRSA): systematic re-
benefits, downsides, and costs of converting existing con- view of the literature. BMJ. 2004;329(7465):533-540.
struction to single-patient rooms should be conducted.
5. Cepeda JA, Whitehouse T, Cooper B, et al. Isolation of patients in single rooms
or cohorts to reduce spread of MRSA in intensive care units: prospective two-
centre study. Lancet. 2005;365(9456):295-304.
Current Status
6. Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of
France has adopted single-patient rooms for all new hospi- patients and delivery of care. Am J Crit Care. 2004;13(1):35-45.
7. The use of single patient rooms vs. multiple occupancy rooms in acute care en-
tal construction for the past 20 years; a small number of vironments. Comparative first cost assessment of single and multiple occupancy double rooms are available for patients who prefer rooms patient rooms. Developed by Davis Langdon Adamson Construction Cost Plan-ning and Management, Submitted to Coalition for Health Environments Research with other patients. British, Dutch, and Norwegian hospi- November 20, 2003. http://www.aia.org/SiteObjects/files/06_Comparative_Fi- tals are moving toward increasing single-patient rooms as r_Assessment.pdf. Accessed May 23, 2008.
8. Barlas D, Sama AE, Ward MF, Lesser ML. Comparison of the auditory and vi-
the culture of these countries is changing to embrace single- sual privacy of emergency department treatment areas with curtains versus those patient rooms as the standard of care. Single-patient rooms with solid walls. Ann Emerg Med. 2001;38(2):135-139.
are a minimum requirement for new construction of medical/ 9. Janssen PA, Klein MC, Harris SJ, Soolsma J, Seymour LC. Single room mater-
nity care and client satisfaction. Birth. 2000;27(4):235-243.
surgical wards and obstetrical units, according to 2006 Ameri- 10. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infec-
can Institute of Architects guidelines.13 The Ward of the 21st tion control. JAMA. 2003;290(14):1899-1905.
11. Estates NHS. Ward layouts with single rooms and space for flexibility. TSO
Century in Calgary, Canada, is a multifaceted research ini- (The Stationery Office) United Kingdom, 2005. http://195.92.246.148 tiative in hospital design, with single-patient rooms as a cor- /knowledge_network/documents/Ward_layouts_20050517165909.pdf. Ac-cessed May 23, 2008.
12. Ulrich RS. Evidence-based health-care architecture. Lancet. 2006;368(suppl):
S38-S39.
13. 2006 Guidelines for Design and Construction of Health Care Facilities. The
Facility Guidelines Institute and the AIA Academy of Architecture for Health, with
Clinicians should advocate for single-patient rooms in any assistance from the U.S. Department of Health and Human Services. American new hospital construction, expansion, renovation, or rede- Institute of Architects/Facility Guidelines Institute, 2006, Washington, DC. http://www.aia.org/aah_gd_hospcons. Accessed July 10, 2008.
sign. Single-patient rooms are permanent physical features 14. Ward of the 21st century. http://www.w21c.org. Accessed May 23, 2008.
956 JAMA, August 27, 2008—Vol 300, No. 8 (Reprinted)
2008 American Medical Association. All rights reserved.

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