Should hospitals provide all patients with single rooms?

Pro single rooms:
1. Reduced infection rates (probably).
2. Privacy,
3. You are not disturbed by other patients, their care, their TV and their visitors, so more able to sleep at night and rest by day.
4. Your visitors will not disturb other people.

Cons of single rooms:
1. Cost of new or rebuilt facilities (Can single room facilities still be called wards?)
2. More nurses required to monitor patients in single rooms, and we don't have enough nurses as it is.
3. Boredom – at least the buzz of activity provides distraction.
4. Other patients can provide valuable companionship and support.
5. Isolation from the watchful eyes not only of staff but also from those of other patients, so risk that a collapse or other sudden and dangerous change in condition is not attended to in time.

There is a place for single rooms, but making single rooms an NHS policy seems both undesirable and unrealistic.

It is with great interest that I read the recent head-to-head about the availability of single room accommodation. Having unfortunately been hospitalized on multiple occasions and for prolonged admissions, I can agree with both sides of the argument.

There is a lot to be said for companionship for patients. The days for a patient are long, and being cooped up in a side room hour after hour and day after day is surely going to cause mental health issues such as depression, anxiety and withdrawal. The only interaction you get in such situations is with the domestic staff, healthcare assistants and nursing staff. As a patient who was clinically stable, self-caring and independent these encounters were minimized further. And even on the occasions that nursing staff are performing observations or 'intentional rounding' it is clear that they do not have the time for anything more than a quick exchange of niceties, not a full blown conversation. It is simply not possible for ward staff to fit such things into their already busy day. Some may say such things are the role of visitors – friends and family. But as a young patient, who finds himself far from home due to the vagaries of the medical profession, family visits cannot be daily or even weekly while friends are generally fellow medics or professionals who work long hours. It can be lonely enough without then confining patients to single rooms as a rule.

On the other hand, sleep is vital for good physical recovery and health, as well as mental well-being. Anyone who has spent one night on a ward will know that sleep is not easily obtained. Nursing rounds can go late into the night, with ward lighting not being dimmed until after midnight on many occasions during the week. Not to mention the inevitable event that another patient in the bay will need medical or nursing intervention in the night. For someone who is afflicted by being a light sleeper you can imagine that constant interruptions in the night leads very quickly to sleep deprivation. New York may be the city that never sleeps, but hospital wards need to be recognised also as places that never sleep. Whether it be a door that accidentally slams shut, a fellow patients loud snoring, or that sick patient who is being reviewed by the doctor (can all juniors please wear soft soled shoes overnight?) there is never a night where you can get a full nights rest. A single room certainly allows the door to be shut, thereby shutting out the bulk of noise from a ward.

The way ahead is surely to use common sense (a free but undervalued aspect of organising heath-care provision). The aspects I highlight are from my own experiences. Clearly the needs of differing groups of patients will be different. Nursing care on a elderly care ward will be different to an elective surgery ward. Staffing on wards needs to reflect this, as well as the accommodation provided.

One thing from the article does strike me. Both sides suggest that proof either way is not going to be easily obtained. Yes, a controlled trial is not going to happen – what would the outcome measures be? But retrospective or concurrent surveying using the Hospital Anxiety and Depression Scale (HADS)(1), or other such scoring systems, could identify patient groups that would benefit from single rooms and those that would not. It is interesting that the Scottish Government commissioned a survey that asked non-patients their views should they be admitted(2). Asking people to make presumptions without any experience of the situation. A 'one size fits all' approach cannot be accepted and hospitals should reflect the needs of the patients, not the assumed wishes of those lucky enough not to have spent time as an in-patient.

1 Zigmond, AS; Snaith, RP (1983). "The hospital anxiety and depression scale".Acta Psychiatrica Scandinavica 67(6): 361–370
2 Scottish Government. Single room provision steering group report. 2008.

The overwhelming trend in new hospital design is for single bed rooms. As Hugh Pennington rightly points out, single bed rooms increase privacy and allow for better sleep, as well as being an effective tool in the fight against infections. However, single rooms may also lead to isolation and necessitate different practices or systems for monitoring safety. Whether we choose single or multi-bed rooms in our hospitals, what appears to be missing in current design and care models is serious consideration of how we can encourage patients to be more active to promote faster recovery.

Overwhelming evidence shows that bed rest is not an effective treatment for most conditions.1

We’ve studied where stroke patients go within a hospital ward, how active they are during the day, and how they interact with staff. Using direct observation (behavioural mapping) our group and collaborators have studied over 800 patients in 7 countries over the last 10 years. We consistently find that stroke patients are ‘inactive and alone’ for the majority of the day2,3 during a critical phase of care when the brain is primed for recovery and restoration of function. Another striking finding of our work is that patients rarely move from in or beside their bed.2 Since activity is a major driver of recovery, and the built environment is likely to significantly influence our movement patterns and behaviours, it’s important that the impact of the environment on patient and staff behaviour is a focus of research for proponents of evidence based health care design.

As we move forward building more hospitals with single beds, let’s not lose sight of the importance of making sure that patients and families, particularly the long stayers, have access to spaces that draw them out of their rooms and the staff, policies and culture that make it possible to be active participants in their care.

References
1. Allen C, Glasziou, P., & Del Mar, C. Bed rest: A potentially harmful treatment needing more careful evaluation. The Lancet. 1999;354:1229-33.

2. Bernhardt J, Dewey H, Thrift A, Donnan G. Inactive and alone: physical activity within the first 14 days of acute stroke unit care. Stroke. 2004;35:1005-9.

3. Wellwood, I., et al., An observational study of acute stroke care in four countries: The European registers of stroke study. Cerebrovascular Diseases, 2009. 28: p. 171-176.

The question is: can the NHS afford single beds and what is practicable? Dr Nussbaum's response is quite right: Nurse numbers must be considered first and above everything else. But also what number of cleaners? And what kit should each room have? Missing completely from the debate is the winter admission beds crises. All hospitals need bigger footprints if single rooms are planned. There must be rooms which can be opened up or areas that can be re-partitioned easily in a crisis, an epidemic or a coach crash. Mother and child rooms, learning-disabled-friendly rooms and adaptable toilets for severely disabled need to be planned for, and requirements for each specialty may be different. Sluices and hoists should be easily available for every room and perhaps windows between rooms can be one-way, mirrored or black-out adaptable.

Let's assume that the next generation of hospital patients are all elderly confused immobile and requiring both multi-specialty input and special sensory input. Does the single room allow nurses to see the patient when they fall out of bed, to accommodate dialysis and resusc equipment, to not only sound-proof adequately from neighbouring rooms but also allow patients to talk to others for company in the long hours without stimulation?

I read the next door article on "What went wrong with the quality and safety agenda?" (BMJ 2013;347:f5800). Doctors still have "bunker mentality" and most complaints are due to lack of care and attention and repeating the same old futile cycles without advancing up the chain of command. The clear benefit of the likes of Atul Gawande and his surgical checklist before operations must be applied to the single room problem. It is "time out" to consider the very best way to plan for single rooms in an NHS hospital before the predictable complaints of "being left in a single room" come rolling in.