Review of the Literature: Acuity-Adaptable Patient Room

Original Research: Breaking Through the Bottleneck: Acuity Adaptability in Noncritical Trauma Care

BACKGROUND

Achieving efficient throughput of patients is a challenge faced by many hospital systems. Factors that can impede efficient throughput include increased ED use, high surgical volumes, lack of available beds, and the complexities of coordinating multiple patient transfers in response to changing care needs. Traditionally, many hospital inpatient units operate via a fixed acuity model, relying on multiple intrahospital transfers to move patients along the care continuum. In contrast, the acuity-adaptable model allows care to occur in the same room despite fluctuations in clinical condition, removing the need for transfer. This model has been shown to be a safe and cost-effective approach to improving throughput in populations with predictable courses of hospitalization, but has been minimally evaluated in other populations, such as patients hospitalized for traumatic injury.

PURPOSE

This quality improvement project aimed to evaluate implementation of an acuity-adaptable model on a 20-bed noncritical trauma unit. Specifically, we sought to examine and compare the pre- and postimplementation metrics for throughput efficiency, resource utilization, and nursing quality indicators; and to determine the model's impact on patient transfers for changes in level of care.

METHODS

This was a retrospective, comparative analysis of 1,371 noncritical trauma patients admitted to a level 1 trauma center before and after the implementation of an acuity-adaptable model. Outcomes of interest included throughput efficiency, resource utilization, and quality of nursing care. Inferential statistics were used to compare patients pre- and postimplementation, and logistic regression analyses were performed to determine the impact of the acuity-adaptable model on patient transfers.

RESULTS

Postimplementation, the median ED boarding time was reduced by 6.2 hours, patients more often remained in their assigned room following a change in level of care, more progressive care patient days occurred, fall and hospital-acquired pressure injury index rates decreased respectively by 0.9 and 0.3 occurrences per 1,000 patient days, and patients were more often discharged to home. Logistic regression analyses revealed that under the new model, patients were more than nine times more likely to remain in the same room for care after a change in acuity and 81.6% less likely to change rooms after a change in acuity. An increase of over $11,000 in average daily bed charges occurred postimplementation as a result of increased progressive care-level bed capacity.

CONCLUSIONS

The implementation of an acuity-adaptable model on a dedicated noncritical trauma unit improved throughput efficiency and resource utilization without sacrificing quality of care. As hospitals continue to face increasing demand for services as well as numerous barriers to meeting such demand, leaders remain challenged to find innovative ways to optimize operational efficiency and resource utilization while ensuring delivery of high-quality care. The findings of this study demonstrate the value of the acuity-adaptable model in achieving these goals in a noncritical trauma care population.

Assessment of level of care recommendations and nursing acuity scores following an appropriateness of care intervention

BACKGROUND

As part of a multiprong intervention to eliminate waste in cost of hospital accommodations, the InterQual Level of Care (LOC) criteria was deployed by our institution to assign patients to one of three LOCs: acute care, intermediate intensive care unit (IICU) or intensive care unit (ICU). In that intervention, which sought to decrease the number of patients in a higher LOC than what was clinically necessary, patient safety balancing metrics were stable. However, nursing workload, a key balancing metric, has yet to be examined. In this study, we examine nursing workload before and after the intervention using a proprietary nursing acuity score.

METHODS

A retrospective study was conducted analysing admissions at the study institution. Patient's LOC recommendation (as determined by InterQual), assigned (actual) LOC and nursing acuity scores were collected and analysed. Average nursing acuity scores were compared across patients whose InterQual recommendation aligned with actual LOC ('Acute Match' or 'IICU Match') versus patients who were recommended to be in acute care but were receiving IICU care ('Mismatch').

RESULTS

Following the intervention, the per cent of patients in the Mismatch cohort decreased from 13% to 7%. Prior to the intervention, average nursing acuity score for the Mismatch cohort was less than the IICU Match cohort and greater than Acute Match cohort in all departments analysed. After the intervention period, average acuity score in the Mismatch cohort exceeded that of the Acute Match cohort in all eight departments, but the Mismatch cohort's scores differed from the IICU Match cohort in only one department.

CONCLUSION

Collectively, this study demonstrates that our intervention successfully decreased inappropriate use of the IICU LOC, and that the residual Mismatch cohort is a distinct entity, with nursing needs that exceed that of the Acute Match cohort. Thus, a higher LOC can be justified. This demonstrates that a nursing workload metric such as the nursing acuity score can be a valuable complement to clinical criteria such as the InterQual LOC criteria to objectively determine patient's true, necessary LOC and ensure that nursing staff feels adequately staffed to care for patients.

Physicians Leading Physicians: A Physician Engagement Intervention Decreases Inappropriate Use of IICU Level of Care Accommodations

Following the adoption of an acuity-adaptable unit model in an academic medical center, a $13M increase in cost of intermediate intensive care unit (IICU) accommodations was observed. The authors followed A3 methodology to determine the root cause of this increase and developed a 3-prong intervention centered on physician engagement, given that physicians have the ability to order a patient's level of care. This intervention consisted of: (1) identifying physician champions to promote appropriate IICU use, (2) visual changes to essential electronic medical record tools, and (3) data-driven feedback to physician champions. In the year following intervention deployment, average IICU length of stay decreased from 1.08 to 0.62 days and average IICU use decreased from 21.4% to 12.3%, corresponding to ~$5.7M cost savings with no significant change in balancing measures observed. Together, these results demonstrate that a multicomponent intervention aimed at engaging physicians reduced inappropriate IICU use with no increase in adverse events.

Burn Unit Design-The Missing Link for Quality and Safety

The relationship between infrastructure, technology, model of care, and human resources influences patient outcomes and safety, staff productivity and satisfaction, retention of personnel, and treatment and social costs. This concept underpins the need for evidence-based design and has been widely adopted to inform hospital infrastructure planning. The aim of this review is to establish evidence-based, universally applicable key features of a burn unit that support function in a comprehensive patient-centered model of care. A literature search in medical, architectural, and engineering databases was conducted. Burn associations' guidelines and relevant articles published in English, between 1990 and 2020, were included, and the available evidence is summarized in the review. Few studies have been published on burn unit design in the past 30 years. Most of them focus on the role of design in infection control and prevention and consist primarily of descriptive or observational reports, opportunistic historical cohort studies, and reviews. The evidence available in the literature is not sufficient to create a definitive infrastructure guideline to inform burn unit design, and there are considerable difficulties in creating evidence that will be widely applicable. In the absence of a strong evidence base, consensus guidelines on burn unit infrastructure should be developed, to help healthcare providers, architects, and engineers make informed decisions, when designing new or renovated facilities.

From Fable to Reality at Parkland Hospital: The Impact of Evidence-Based Design Strategies on Patient Safety, Healing, and Satisfaction in an Adult Inpatient Environment

OBJECTIVE

This research aimed to evaluate the quantitative effects of new hospital design on adult inpatient outcomes.

BACKGROUND

Tenets of evidence-based healthcare design, notably single-patient acuity-adaptable and same-handed rooms, decentralized nursing stations, onstage offstage layout, and access to nature were expected to promote patient healing and increase patient satisfaction, while decreasing adverse events.

METHODS

Patient healing was operationalized through length of stay (LOS) and patient safety through three adverse events: falls, hospital-acquired infections (HAI), and medication-related events. Standard patient surveys captured patient satisfaction. Patient records from 2013 through 2017 allowed for equivalent time periods surrounding the move to the new hospital in August 2015. Stratified by hospital division where significant, pre/post comparisons utilized proportional hazards or logistic regression models as appropriate; interrupted time series analyses afforded longitudinal interpretations.

RESULTS

Observed higher postmove LOS was due to previously increasing trends, not increases after the move. In surgical and trauma units, a constant increase in falls was unaffected by the move. Medication events decreased consistently over time; medication events with harm dropped significantly after the move. No change in HAI was found. Significant improvement on most relevant patient satisfaction items occurred after the move. Call button response decreased immediately after the move but subsequently improved.

CONCLUSION

Results did not clearly indicate a net change in adult inpatient outcomes of healing and safety due to the hospital design. There was evidence that the new hospital improved patient satisfaction outcomes related to the environment, including comfort, noise, temperature, and aesthetics.

Nurses' Participation in the Design of an Intensive Care Unit: The Use of Virtual Mock-Ups

BACKGROUND

Co-design with multiple tools is useful when end users' knowledge is important, especially when designers work with people unfamiliar with design. Many studies have highlighted the importance of nurses' participation in design, and such participation requires the development of techniques and tools to facilitate collaboration. This article analyzes how nurses participated in designing a general intensive care unit in a walk-in virtual environment (VE) and examines how their work-related knowledge can be transferred to the design process of spaces.

METHOD

In this action research study, the design process was conducted by using virtual mock-ups, which were evaluated by multi-occupational groups in a walk-in VE. Nurses were the largest occupational group. Their work processes were under modification, since existing multi-patient rooms were being redesigned as single-patient rooms. The design of single-patient rooms was performed in three iterative cycles in the walk-in VE.

RESULTS

The nurses could specify their requirements in the walk-in VE, and their suggestions were incorporated into the architectural design process. The nurses were satisfied with their role in the design process.

CONCLUSION

Co-design with virtual mock-ups in walk-in VE is appropriate when designing new healthcare facilities and when the opinions of workers are important. Virtual mock-ups in walk-in VE can be used collaboratively, facilitating simultaneous feedback from multiple users. Virtual reality (VR) technology has evolved, and changes can be made rapidly and at a lower cost. Another advantage of VR is that it allows one to design larger spaces, thus providing larger layouts of facilities for evaluation.

Developing Evidence-Based Design Guidelines for Medical/Surgical Hospital Patient Rooms That Meet the Needs of Staff, Patients, and Visitors

OBJECTIVES

This research investigated medical/surgical (Med/Surg) patient room design to accommodate the needs of hospital staff, while at the same time accommodating the needs of patients and their visitors.

BACKGROUND

Designing hospital patient rooms that provide a comfortable healing experience for patients, while at the same time meeting the needs of the hospital staff, is a challenging process. Prior research has shown that many hospital patient room designs adversely affect the ability of hospital staff to perform their tasks effectively, efficiently, and safely.

METHOD

Twenty-seven design sessions were conducted in which 104 participants, representing 24 different occupations, worked in small mixed occupational groups to design an ideal single patient Med/Surg patient room to fit their collective needs using a full-scale mock-up. During analysis, the investigators reduced the resulting 27 room designs to 5 hybrid designs that were sequentially reviewed by patients and visitors and by staff to address design conflicts.

RESULTS

This design process identified 51 desirable room design features that were incorporated into 66 evidence-based design guidelines for the different areas within the Med/Surg patient room including the entry way (16 guidelines), the patient clinical area (22 guidelines), the bathroom (17 guidelines), the family area (8 guidelines), and storage areas for patients and their visitors (3 guidelines).

CONCLUSIONS

The guidelines developed through this study identified many opportunities for improving the design of hospital Med/Surg rooms to allow staff to be more effective, efficient, and safer, while at the same time addressing the design needs of patients and their visitors.

Use of Virtual Environment and Virtual Prototypes in Co-Design: The Case of Hospital Design

Co-design is used for improving innovation, obtaining better solutions, and higher user satisfaction. In this paper we present how the use of a walk-in virtual environment and actual-size virtual prototypes support co-design. Unlike in most studies we presented the prototypes to users in an early phase of the design process. This study examines the co-design of healthcare facilities with multi-occupational groups. The practical case examines designing single-patient rooms for an intensive care unit. In this design process 238 participants of different hospital professions evaluated virtual prototypes in three iterative rounds. The participants improved the design by discussing their work practices. The virtual environment situation and actual size virtual prototypes make an easy environment for users to discuss and evaluate the design without any design knowledge. In addition to describing the co-design results we also outline some important issues and guidelines about creating the virtual prototypes and organizing the participants’ visits in a virtual environment.

A Grounded Theoretical Analysis of Room Elements Desired by Family Members and Visitors of Hospitalized Patients: Implications for Medical/Surgical Hospital Patient Room Design

Objective:

To identify family members’ and visitors’ needs with relation to the design of a hospital room.

Background:

There is a trend toward incorporating family zones in hospital patient rooms in order to improve patient satisfaction and encourage family caregivers to stay longer and overnight.

Method:

A mixed-method study was employed. Interviews of patients and family caregivers were conducted to understand opportunities to improve hospital room designs based on recent experiences. Features intended to support short-term and overnight visitors were embedded in five full-scale simulated room design concepts. Small groups of family caregivers and patients toured two room design concepts and reacted real time to room features. A grounded theory approach was employed to identify emerging themes.

Results:

A theoretical design framework is developed for the needs of family members and visitors for a range of time periods. This framework is founded upon desires to help make the patient feel more comfortable. There are various levels of helping the patient feel more comfortable, including visiting, keeping company, providing support, providing assistance, and being a caregiver. Beyond this core need, family members and visitors must take care of their own needs in order to feel comfortable in the hospital room. Activities associated with these needs include sitting, relaxing, eating, working, tending to daily needs, and resting overnight.

Conclusions:

Potential implications for architects, healthcare planners, and interior space designers are described. Design and renovation guidance for the hospital room environment in order to support the needs and expectations of families and visitors is provided.

Patient and family description of receiving care in acuity adaptable care model

AIM

To explore patient and family perspectives of hospital care in an acuity adaptable care model implemented in an urban, public safety-net hospital.

BACKGROUND

Specialty care units result in reactionary bed management. Changes in acuity generate costly, disruptive, intra-hospital patient transfers, which negatively affect clinical outcomes while increasing nurse workload. The acuity adaptable care model is a universal bed model structured to support patients in one room while providing staff, equipment and other resources across varying levels of acuity.

METHOD

Qualitative descriptive methods were used to analyse the narratives of a purposive sample of patients and family members about receiving care in an acuity adaptable care delivery model.

RESULTS

Three content areas emerged from the narratives and were categorized as feeling safe, perceiving continuity of care and valuing family, which culminated in a sense of comfort and healing while in the hospital.

CONCLUSION

By bringing care services to the patient instead of taking the patient to the services, the acuity adaptable care model facilitated a perception of a healing environment for patients and family members.

IMPLICATIONS FOR NURSING MANAGEMENT

The acuity adaptable care model should be considered when hospital facilities are undergoing major renovation or replacement.

A comparative evaluation of Swedish intensive care patient rooms

OBJECTIVE

This study investigates how design strategies in three recent intensive care units in Sweden impact patients, families, and staff. The area of focus is the patient room "module," usually consisting of a pair of patient rooms and a joint location for monitoring and documentation.

BACKGROUND

Many countries are expanding their number of intensive care beds and are also in the process of incorporating evidence-based design strategies such as single-bed patient rooms and access to daylight and nature. This situation provides a significant opportunity to review and learn from facilities leading the way in these areas.

METHODS

Three intensive care units completed since 2010 were evaluated in relation to a combination of criteria. Methods included plan drawing analysis, staff questionnaires (n = 72), staff interviews (n = 9), and systematic observation (6 hours).

RESULTS

In some patient rooms, access to daylight and/or outdoor views was excellent, while in other rooms such access was hindered by frosted glass or adjacent bushes or buildings. Single-bed rooms gave family members improved privacy and greater ability to stay in the patient room. Some patient room modules provided efficient patient observation and staff collaboration, but more noise and reduced patient privacy. Other modules provided a calm patient room environment, but caused some staff to feel isolated and have difficulty in getting assistance.

CONCLUSIONS

The evaluation of the three projects reveals variation in whether design strategies successfully achieve their desired outcomes. Varying designs of the patient room module affect users in unique ways and must balance privacy, visibility, quietness, and staff access to assistance.

KEYWORDS

Critical care/intensive care, organizational transformation, outcomes, post occupancy, work environment.

Exploring Acuity-Adaptable Care in a Rural Hospital

OBJECTIVE

The objective of this study is to assess benefits of the acuity-adaptable (AA) care model in rural hospitals.

BACKGROUND

The AA model aims to provide care in the same space from admission to discharge regardless of acuity. Evidence is lacking to support claims that AA care will improve patient safety, increase nurse productivity, and improve patient/staff satisfaction in rural hospitals.

METHODS

Patients admitted to a rural intensive care unit (ICU) were allocated to an AA group or an ICU group. Patients in the AA group remained in the ICU room through discharge. Patients in the ICU group transferred out of ICU when acuity permitted. Patient anxiety, depression, and perception of emotional care were measured. Staff responses were assessed qualitatively.

RESULTS

Acuity-adaptable patients reported significantly more anxiety and less perceived emotional care than ICU patients. Intensive care unit nurses resisted caring for less acute patients.

CONCLUSION

Disadvantages may outweigh benefits of AA care delivery in the rural ICU.

Private Rooms in Low Acuity Settings: A Systematic Review of the Literature

OBJECTIVES

Determine if the peer-reviewed evidence supports single-patient ward bedrooms in low-acuity care settings within a hospital.

BACKGROUND

New evidence exists since the 2006 Facility Guideline Institute guideline recommended single-bedded rooms (SBRs) in low-acuity care settings. Additionally, prior studies evaluated high-acuity care settings (e.g., critical care) in their recommendations on SBRs. There is a need to reevaluate the evidence.

METHODS

A systematic review of the literature was completed including electronic and hand searches of references. A data extraction form was utilized. Two reviewers evaluated the studies independently. Studies that were included examined the effect of single-patient rooms on medical surgical ward beds only. Each study was graded using accepted clinical evidence grading instruments.

RESULTS

Over 1,400 records were identified. After excluding studies, a total of 49 records were graded. The highest quality evidence identified (Center for Evidence-Based Medicine [CEBM]: 2a, 2b, and Grading of Recommendations, Assessment, Development, and Evaluation [GRADE] C) did not support the use of single-patient rooms for reducing infections, for minimizing patient falls, for reducing medication errors, or for patient satisfaction. Operational efficiencies were improved with SBRs but only addressed the maternity ward. The lowest quality evidence (CEBM: 4/5 and GRADE D) supported the use of single-patient rooms.

CONCLUSIONS

Based on CEBM and GRADE assessments, there is a lack of high-quality data supporting the use of low-acuity SBRs throughout the entire hospital. Furthermore, it is recommended that more research be conducted on the effect of SBRs, so higher quality evidence is developed.

Meeting Patient Expectations During Hospitalization: A Grounded Theoretical Analysis of Patient-Centered Room Elements

OBJECTIVES

To identify patient needs and expectations that can be utilized to inform the design or renovation of medical-surgical patient rooms in a hospital.

BACKGROUND

There is an increased interest in supportive room design to increase patient satisfaction and improve the healing process.

METHODS

Patients' and family caregivers' reactions were elicited to intentional room elements embedded in a set of five full-scale simulated room prototypes. Small groups of patients and caregivers toured two of the five rooms and provided verbal and written evaluations of room features. A grounded theory approach was employed to generate a codebook, identify the frequency of codes, and to group codes and memos into emerging themes. Insights from emergent themes were compared with findings from written surveys on the importance of various room design elements completed at the beginning of each session.

RESULTS

A theoretical design framework was generated, showing patients expect a hospital room that provides them with the core components of comfort to support healing, facilitates a strong sense of connection to people and the outside world, enables quick and independent access to the patient's things, and offers suitable levels of control to the patient throughout their hospital stay.

CONCLUSIONS

The implications for assisting architects, healthcare planners, and interior space designers are described using this framework, as well as its potential for design guidance. In addition, the connection between patient-centered room elements and relevant survey questions in publicly reported patient satisfaction scores for hospitals is discussed.

Key Spatial Factors Influencing the Perceived Privacy in Nursing Units: An Exploration Study With Eight Nursing Units in Hong Kong

Aim:

This study examined how the spatial characteristics of patient beds, which are influenced by patient room design and nursing unit configuration, affect patients’ perceptions about privacy.

Background:

In the hospital setting, most patients expect a certain degree of privacy but also understand that their caregivers need appropriate access to them in order to provide high-quality care. Even veteran healthcare designers may struggle to create just the right balance between privacy and accessibility.

Methods:

A paper-based survey was conducted with 159 participants in Hong Kong—72 (45.3%) participants had been hospitalized and 87 (54.7%) participants had not—to document their selection of high-privacy beds, given simplified plans of eight nursing units. Two types of information, comprised of six variables, were examined for each bed. These include (1) room-level variables, specifically the number of beds per room and area per bed and (2) relational variables, including walking distance, directional change, integration, and control.

Results:

The results demonstrate that when asked to identify high-privacy beds, participants selected beds in patient rooms with fewer beds per room, a larger area per bed, and a longer walking distance to the care team workstation. Interestingly, the participants having been hospitalized also chose beds with a visual connection to the care team workstation as being high in privacy.

Conclusions:

The participants with hospitalization experience may be willing to accept a bed with reduced visual privacy, perhaps out of a concern for safety.

Relational sustainability: environments for long-term critical care patients

Patients undergoing bone marrow transplant, using spinal cord services, and with traumatic brain injury represent a relatively new patient type, requiring both intense care and long-term care in the same facility. As medical advances allow these patients the opportunity to recover from their critical illnesses or injuries, designers and caregivers must give increased attention to the long-term critical care environment. Designing for this type of care requires an understanding of new technologies and the potential for the built environment to address the wide range of physical, sensory, and psychological issues long-term inpatients face. Recent work by SmithGroupJJR has provided valuable insights into the ways in which lighting, patient room and unit layouts, spatial volumes, and other design elements can contribute to the recovery of patients who must spend weeks or months in a critical care environment. This knowledge was gained through an approach that allows design professionals to immerse themselves in a health care institution's values, culture, and work processes. By mapping both operational flow and patients' experiences, project teams can develop design solutions that sustain the well-being of higher-acuity patients and their family members and caregivers.