Patient Safety: Single-bed versus multi-bed hospital rooms
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Are multi-bed or single-bed
patient rooms safer?
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The UK’s National Patient Safety Agency and Arup have collaborated to research the relationship between patient safety and the provision of single-bed and multi-bed rooms.
Kate Fairhall, BSc (Hons), MSc; Laura Bache, BSc (Hons), MSc, MPhil; Peter Dodd, MBA, MAPM; Patricia Young
The issue of single-bed versus multibed rooms has been much debated over the last few decades. It is a debate that has been of both national and international interest and, increasingly, we are seeing a general trend towards the provision of single-bed rooms1. Consistent with this, the NHS has recently advised that, in the UK, 50-100% of all patient rooms should be single occupancy in newly-built hospitals2.
There are clearly a number of primary motivations for this change, including the need to identify the most cost-effective layout, control healthcare-associated infections (HCAIs) and meet patient expectations and legislative requirements1. Despite this clear shift towards single-bed rooms, the debate continues as to whether multi-bed or single bed hospital rooms offer more advantages for patient safety. This is a key question as it has implications for all healthcare stakeholders. Room type can impact on the cost, operations and design of the hospital environment and, ultimately, safe healthcare delivery.
The debate about the provision of room type and patient health and well-being dates back decades. Arup recently republished a paper called A Scandalous Impromptu, originally written in 1976 by Evan JR Burrough3, which is in essence a business case set in 1976 that mirrors the arguments now being posed again, over 30 years on. It provides strong views against multi-bed wards and advocates that patients who are already unwell and suffering from their existing illness, should not have to put up with noisy, crowded and impersonal environments. One quote from the paper reads: “It is the custom for a sick horse to be segregated to a loosebox, an orphaned lamb to the kitchen, a sick dog at times to the best bedroom, but our patients are put in large dormitories and obliged to adjust themselves to endure, sometimes for the very first time, an intensely public life with many discomforts, which are in now essential for the investigational treatment.”3
This quote was from Sir Rupert Vaughn Hudson who, in 1960, was calling for single rooms to combat infection but was also writing from a humanitarian point of view, to provide for everyone what only the rich or the insured could provide for themselves. The question is therefore posed as to why this debate continues today and why general opinion appears to sway in favour of single bed rooms.
Of more specific interest and relevance to this paper: what type of room is actually better for patient safety?
The research focus
In order to address these questions, the National Patient Safety Agency (NPSA) commissioned Arup to work in collaboration with it to conduct a number of research activities to both examine, and add to, the current evidence base relating to the debate over single-bed versus multi-bed rooms.
The aim of this current research was to firstly build upon a previous piece of work that was carried out by Arup4, which examined the challenges and negative assumptions around single-bed hospital rooms, but focus specifically on the implications of room type on patient safety. This research also intended to explore the existing literature and evidence base around this topic. Patient safety, for the purpose of this research, was defined as: “Incidents of patient slips, trips and falls; occurrences of medication errors made by hospital staff; cross-patient infection rates with evidence for their relationship to room occupancy type; or any other harm that arises during a patient’s hospital stay.”5,6
As well as focusing on patient safety as an outcome measure, this research aimed to consider the wider context, which is pertinent to the relationship of room type and patient safety. This was in order to provide a holistic understanding and included factors such as cost, design and construction, cleaning and maintenance. The research also endeavoured
to collect data around the issues relating to patient safety from across a number of stakeholders involved in the clinical and managerial delivery of healthcare, the design, construction and operations of healthcare facilities and patients themselves. Therefore, it included the following stakeholders: architects, designers and construction specialists; cleaning and catering specialists; clinical, managerial and operative staff within the hospital environment; and patients.
Although this list may not be exhaustive, it takes a novel approach by exploring a cross section of the stakeholders’ perspectives and enables comparisons to be drawn across these stakeholder groups.
Over a three-month period, the NPSA and Arup worked collaboratively and conducted research using a multi-method approach over three key stages (see Figure 1). Stage one consisted of a review of the literature to examine the current evidence base in relation to single-bed versus multibed rooms and patient safety. This included a review of the literature published since the 2007 Arup report to ensure inclusion of the most relevant, up-to-date literature and reduce repetition.
Stage two involved discussions with specialists in the field of hospital design and construction, and cleaning and catering, to ascertain their views on the topic and explore some of the practical issues surrounding room type and patient safety. These discussions were facilitated via a number of telephone interviews and a workshop.
Stage three comprised research conducted at an NHS foundation trust, with a good ratio of single- and multiple-occupancy bed wards, to ascertain staff and patient perceptions and obtain data from an acute healthcare context.
This stage of the research included a series of workshops with a cross section of staff, including managers, clinicians, nursing staff and estates staff, to understand the range of perspectives and differences in opinions.
This subsequently led onto the design and distribution of a staff and patient survey within the trust which explored their perspectives, opinions and personal preferences around room type and patient safety.
Background variables were also collated to enable exploration of issues relating to patient age, condition and room type preference. The views of staff and patients were compared and contrasted during analysis. Trust data was also researched to provide baseline information in order to identify whether or not there were any differences from a financial perspective in the multi-bed and single-bed facility. This included data relating to performance (length of stay, waiting times), costs (capital and operating expenditures – Capex and Opex), and patient satisfaction.
The current evidence base
Within the current evidence base, a number of key variables were highlighted, including; slips, trips and falls, HCAIs, medication errors, patient well-being and recovery. Other variables, such as patient dignity and confidentiality, were highlighted by research as having an indirect relationship with safety (both psychological and physical) within the hospital environment7. Figure 2, illustrates these variables.
Much of the evidence within the literature and professional press advocates the use of single-bed room designs within hospitals, with numerous benefits outlined for patient safety. These include reduced slips, trips and falls, due to the reduced patient movement associated with their close proximity to ensuite bathroom facilities8,9. Furthermore, medication errors have been found to be lower in single-bed rooms as they allow nurses to deal with patients individually without distractions from other patients1,10.
Cross-infection rates are often quoted as being lower in single-bed room hospitals as patients are isolated, with reduced interpatient contact. In addition, staff handwashing behaviours change, catalysed by single-bed room designs and the provision of a sink in each patient room2,7. A benefit of single-bed rooms for patient well-being is the control afforded to patients over their environment, such as the level of lighting9,11.
Despite these advantages, much of the current literature suggests that the provision of a single-bed room does not automatically assume a safe patient environment. There are also some downsides, and in-fact single bed rooms have been criticised as reducing the observation of patients, as they reduce the frequency that medical staff check on patients, as well as remove the occurrence of inter-patient observation, which may impact on slip, trip and falls occurrences12.
Another criticism of single-bed rooms is that patients may have less opportunity to participate in social interaction, which can negatively impact on their well-being.
Importantly, the evidence suggests that design features of a single-bed room can moderate the impact that this room type can have on patient safety. For example, the benefits identified for single-bed rooms on reducing slips, trips and falls can be mitigated if the room size is too small as this can increase the number of trip hazards blocking the space around the patient bed12.
While conducting the literature review a number of challenges were revealed surrounding the current evidence base. Firstly, most evidence is not empirical. Although, the current evidence base largely cites the numerous advantages of single-bed rooms, research has been criticised as lacking in rigour, with support for single-bed rooms often based upon ‘expert opinion’ or uncontrolled studies, with minimal evidence based in carefully controlled field experiments13.
In addition, there is little research based upon UK/European hospitals. Most studies around this issue are from the US, which may reduce application of their findings to the UK healthcare system. And, finally, most evidence is single-bed centric. The research evidence that is available focuses on single bed issues with minimal multi-bed-centric research1, therefore posing problems for identifying the specific advantages or disadvantages of multi-bed rooms.
These challenges and shortfalls in the literature highlight the clear need for more UK-based, empirical, controlled studies, which focus on both single-bed and multi-bed room issues to enable firm conclusions to be drawn as to which room type offers more advantages for minimising patient safety incidents.
Discussions with specialists
The majority of the design and construction specialists outlined clear advantages for single-bed rooms in terms of patient safety – reduced slips, trips falls, cross-infection rates, medication errors, enhanced patient wellbeing and recovery, as well as improvements in staff hygiene behaviours. There were some views, however, that a 100% single-bed room design may not be the best option – 100% single-bed room hospitals are difficult to design as they have a shallower and longer design. They suggest that patients should be given the choice, as some may prefer multibed rooms for the social interaction they allow.
Additionally, 100% single-bed room hospitals may offer less economical use of space than mixed-room hospital design, although the NHS Estates1 and Detsky7 argue that ward designs with 100% single-patient rooms require the same space as those with 50% single-patient rooms, as long as other space-saving design features are integrated.
Based on these design considerations, many of the design and construction specialists proposed that a mixture of rooms is best. Still, the question is posed as to what is the optimal single-bed versus multi-bed ratio.
Other key perceptions included:
- There are always going to be trade-offs with both room types; the decision should be made at a local level.
- Effective management and operations may be a key variable to consider alongside room type in improving patient safety.
- Room design needs to be flexible in order to accommodate current and future needs, however both types of rooms offer some advantages.
The discussions with cleaning and catering specialists covered a wide range of issues concerning the costs and benefits of introducing single-bed rooms into hospitals. It was suggested that any additional costs of cleaning a single room could be recompensed by a higher throughput (lower cross-infection rates and improved recovery time).
Single bed rooms may take longer to clean and may actually increase staff ‘travel time’. However, it is likely to be easier to clean a single-bed room as patients are generally not in the way and disinfectants can also be used more effectively (hydrogen peroxide vapour).
It was also suggested that single-bed rooms may exert a positive influence on patients’ perceptions, so they are perhaps more actively aware and involved in the cleaning of their room, leading to ‘occupancy pride’. It was suggested, however, that irrespective of room type, hospital design should take into account storage needs, as appropriate design could in fact lend itself to reducing slip, trip and fall occurrences and HCAIs, if hazards are stored away properly and cleaning equipment is more readily accessible. It was felt that room size was likely to be the most important factor in designing storage space, rather than the room type itself.
For catering, the direct impact of a having a single- or multi-bed room was not thought to be of very great significance, although single-bed rooms may reduce the likelihood of catering staff confusing patients, which can be particularly problematic if some patients are ‘nil by mouth’.
Another potential benefit of single-bed rooms is their ability to accommodate space for visitors; this could encourage friends and families to play a more active role in patient care by helping to feed the patient they are visiting.
NHS foundation trust research
During the workshops at the foundation trust, staff suggested a number of benefits and disadvantages for both single-bed and multibed rooms, based on a number of the patient safety variables. A common finding was that what was a disadvantage for single-bed rooms was often found to be an advantage for multi-bed rooms, and vice versa. Generally, staff advocated the use of single-bed rooms when considering patient safety, particularly when considering the potential benefits for patient well-being in single-bed rooms.
The results of these workshops went on to inform the design and structure of questions used in the survey.
The survey findings (shown in Figure 3) revealed that both staff and patient groups were found to have mixed views relating to the patient safety variable of slips, trips and falls, although the majority of staff and patients proposed that multi-bed rooms are better as they allow more observation from staff and other patients. On the other hand, some advantages of single-bed rooms on this variable were that they contain less clutter, there are fewer obstructions from equipment, the risk posed by other patients is reduced in single-bed rooms, and single rooms may be more amenable to designing in safety features, such as grab-rails.
The mixed views found from the literature review conducted by Arup in February 20095 mirror those identified in this study6. Most staff and patients reported the superiority of single-bed rooms for preventing medication errors, reasons for which included fewer distractions from other patients and less potential for confusion between the patient’s medicine in single-bed rooms. More support was also found for single-bed rooms in terms of preventing HCAIs; this was likely to be due to less contact with others, reduced sharing of equipment and facilities, easier-to-control infection outbreaks, easier deep cleaning between patient occupancies and increased confidentiality for open discussion between patients and staff.
The current evidence base does not, however, provide such strong views in favour of single-bed rooms on this patient safety variable, as it instead suggests that evidence for HCAIs is mixed. However, there was also a consistent view, consistent with Pangrazio8, who suggests that single-bed rooms may be better as they prevent direct contact between patients.
Finally, for the last patient safety variable, patient well-being, staff and patients were in disagreement as to which was the preferred room type. Staff felt that single-bed rooms were better as they increase privacy and dignity and prevent conflict from other patients, whereas patients perceived that they received more support from other patients in a multi-bed room compared to single-bed room. The current evidence base was found to provide no clear conclusion for the advantage of single-bed rooms versus multi-bed rooms on patient well-being, although there is some evidence that single-bed rooms can improve patient well-being as they offer a quiet and private environment12.
The data collated in the surveys was also examined to investigate whether staff and patient perceptions of room type and patient safety differed as a function of age and staffing position. Indeed findings did reveal differences. The views of patients under the age of 60 were mixed around the room type that was better for overall patient safety (approximately 50:50). Conversely, the majority of patients over the age of 60 perceived multi-bed rooms as being better for overall patient safety. Variations were also found for staff position, as the majority of doctors perceived that single-bed rooms were better, whereas the majority of nurses had mixed views, with a slight preference for multi-bed rooms. This highlights the strong need to consider different patients and staff when providing evidence as to room type.
Perhaps the answer is that one solution does not fit all, instead highlighting the importance of ‘patient choice’.
As part of this research the trust’s organisational data was explored to highlight whether any differences existed between single-bed rooms and multi-bed rooms in relation to performance data, including Capex, Opex and length of stay. However, data in the hospital was not collected about room type which meant that comparisons were not possible. This suggests there is a shortfall in the data that is currently collected by acute hospitals and this needs to be considered by those who administer the NHS guidelines.
Until consideration is given to data down to the level of room type, such comparisons will be difficult to explore and the issue of the best room type will not be answered.
During this exercise other practical difficulties posed by the current set-up of single-bed and multi-bed rooms in acute hospitals. For example, a patient may be transferred several times during their stay, including between single-bed and multi-bed rooms. Therefore, understanding how room types impact upon HCAI rates is almost impossible as we are unable to isolate occurrences of cross-infection to patients’ occupancy of a single-bed room or multi-bed room. This difficulty could be remedied by looking at wards which are made up of either 100% single-bed or multi-bed rooms, which means that patients who reside in that ward for the duration of their stay will have been exposed to only one room type. With this data, comparisons could then be made across the ward, providing characteristics, such as age, and patients’ conditions and severity of conditions are similar.
Conclusion
This research builds upon the current UK evidence base. The data has been collected from a UK NHS foundation trust hospital and, so, increases transferability to the UK’s National Health Service – compared to much of the data that has been collected in the US.
Furthermore, the research approach adopted has allowed the advantages and disadvantages specific to both room types to be highlighted, and so has built upon the current research base, which is currently criticised as being single-bed centric. Based upon the evidence collected, it is feasible to conclude that single-bed rooms are at least as favourable as multi-bed rooms for patient safety, and usually more so, but it does depend on the patient safety variable.
The research also provides a unique insight into the different perspectives within and between different stakeholders, and how perceptions and preferences may vary as a function of patients’ age and condition and the ward in which staff usually work.
However, there is still no conclusive answer as to what the exact ratio of single to multi-bed rooms is that a new hospital within the UK should be aiming for in its design. The current research study does, however, advocate the continued use of both room types within the acute hospital setting, with an emphasis on patient choice to allow the patient to select the best room for a speedy recovery, based upon their needs and personal preference.
The current evidence base supports the significance of patient choice in modern healthcare settings. The question is posed, however, whether it is the patients themselves who should make this choice or the staff. The research highlights the interesting finding that staff and patients seem to have quite different views about what room type is better for patient well-being. It highlights the notion that staff do not necessarily know what the patients think and raises a number of issues for consideration, including whether we need to take into account what is actually safest for patients, what patients want, how well educated patients are on patient safety issues and, if they knew more, whether their opinion may change.
This also raises the issue of what patients really want: comfort, safety or social interaction? Patient safety is only one of many variables that are important to consider in the single-bed versus multi-bed room debate.
For design and construction specialists, other variables, besides patient safety, are of key importance in this debate. They suggest that, despite their numerous advantages, 100% single-bed rooms may not be the optimal solution as they are generally harder to design. Evidence is less clear for other variables associated with the operational issues of room type, such as cost and hospital performance. Indeed, the research highlights the challenges in obtaining the information needed to draw suitable comparisons. Such data is not collected at the level of room type and the combination of room types in acute hospitals do not easily allow comparisons between room types on such issues.
The research also highlights some interesting points for consideration, relating to the complexity of the hospital environment and the moderating effects of some design factors. For example: room size, flexibility of design and positioning of nurses’ stations can all impact upon patient safety in single-bed rooms.
Phiri14 highlights the need to consider the impact of the wider hospital network, including corridors, waiting rooms and meeting rooms, in addition to bedrooms.
This paper suggests that when conducting research in any environment, there are a large number of interlinking variables to consider. These moderating factors are likely to go beyond the design of the environment and may also include operational factors, such as management, leadership, staff training and behavioural change to encourage ‘safe’ behaviours such as hand-washing. Therefore, it might not be sufficient to merely ask the question: are single-bed rooms or multi-bed rooms better in optimising patient safety?
Perhaps the answer to the debate, lies in some form of innovative hospital design which does not limit itself to room type, but somehow incorporates elements which are identified as important in promoting patient safety, such as room size, flexibility to support the patient’s personal preferences, shared social spaces and efficient ward layout.
Next steps
Key to future work in this area is the development of more rigorous research from which conclusions can be confidently drawn to inform the future design of hospitals. This should include more controlled empirical research to explore other variables to better understand the strength and direction of the relationships between patient safety variables and the hospital environment, and research conducted in other healthcare contexts, such as primary and community care, to assess the applicability of the findings to other contexts. In future research it is suggested that a multi-disciplinary approach should be adopted whereby a cohort of stakeholders are engaged. This will optimise transferability and the potential for the practical application of research findings.
A number of practical suggestions emerging from the study are also offered. Based on the existing evidence base, as well as the shift within the NHS, patient choice is clearly important. Therefore, where possible, patient choice should be accommodated and patients empowered to identify the room they believe will allow the speediest recovery.
The evidence base also suggests that within hospital environments there are moderating variables that can increase, or even mitigate, the positive impact that room type has upon patient safety. When considering room design it is therefore essential to simultaneously consider the wider hospital environment, such as decentralised nurses’ stations.
The recording of performance data should also be improved to allow for reliable comparisons across room types and for conclusions to be drawn as to which room type is preferable in terms patient safety, as well as variables such as satisfaction. There is a need for this information – to firstly add to the current evidence base and secondly to allow hospitals to make design decisions with a foundation in research.
Authors
Kate V Fairhall, BSc (Hons), MSc and Laura Bache BSc (Hons), MSc, MPhil, are managements consultant at Arup
Peter Dodd MBA, MAPM is a project manager at Arup
Pat Young is design specialist at the UK’s National Patient Safety Agency
References
1. NHS Estates. Ward layouts with single rooms and space for flexibility. London: The Stationery Office; 2005. Downloaded on 17/12/2008 from www.dh.gov.uk
2. Dowdeswell B, Erskine J,Heasman M. Hospital ward configuration determinants influencing single room provision. A Report for NHS Estates by the European Health Property Network; 2004. Downloaded on 20/11//08 from www.pcpd.scot.nhs.uk/PDFs/EUHPN_Report.pdf
3. Burrough EJR. A Scandalous Impromptu. Oxford: EJR Burrough; 1976. [reproduced in 2008 with the kind permission of the author’s son AP Burrough]
4. Arup. Challenging the negative assumptions associated with single patient rooms: a review of the evidence. 2007.
5. Arup. Single bed versus multi-bed hospital rooms: The case for patient safety [literature review]. 2009.
6. Arup. Single versus multi-bed rooms and patient safety: providing a methodology and undertaking a comparison between a multi-bed and single-bed facility in the UK. 2009
7. Detsky M, Etchells E. Single-patient rooms for safe patient-centered hospitals. JAMA 2008; 300:954-956.
8. Pangrazio JR. Room with a view: looking at the future of patient room design. Health Facilities Management 2003; 16(12):30-32.
9. Clancy C. Designing for safety: evidence-based design and hospitals. American Journal of Medical Quality 2008; 23(1):66-69.
10. Joseph A. The role of the physical and social environment in promoting health, safety, and effectiveness in the healthcare workplace. Concord CA: Center for Health Design; 2006.
11. Brown KK, Gallant D. Impacting patient outcomes through design: Acuity adaptable care/universal room design. Critical Care Nursing Quarterly 2006; 29:326-341.
12. Stichler J. Is Your hospital hospitable?: How physical environment influences patient safety. Nursing for Women’s Health 2007; 11(5):506-511.
13. Van de Glind IM, De Roode S, Goossensen MA. Do patients benefit from single rooms? A literature study. Health Policy 2007. 84(2-3):153-161.
14. Phiri, M. (2003) One patient one room – Theory and practice: An evaluation of the Leeds Nuffield Hospital. A study report for NHS Estates. Downloaded on 20/11/08 from www.sykehusplan.org
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