The British Medical Journal recently published a ‘Head to Head’ debate between Prof Hugh Pennington and Dr Chris Isles addressing the question of: “Should hospitals provide all patients with single rooms?”
Prof Pennington made the case for 100% single rooms (see Table below), which provide infection control benefits; increased privacy, dignity and confidentiality; less noise results in sleep; intimate contact with families is easier; patients have more control over their immediate environment at a time when they have little control over what happens to them; there is better access for bed-side treatment; and bed management is improved, with less bed-blocking due to gender or infectious patients, resulting in fewer patient transfers.
Dr Isles countered with the case for a mixture of single rooms and bays (see Table below). His argument goes that ‘one room does not fit all’; patients crave company at what can be a very lonely time; patients in single rooms have less contact with healthcare workers, and patients will look out for each other when something goes wrong; and there is surprisingly poor evidence that increasing the proportion of single rooms reduces healthcare-associated infection.
Table: comparing the relative benefits of single rooms and multi-occupancy bays.
It’s interesting to note the variety in national approaches taken to advice on whether hospitals should provide single rooms for all patients. The USA and, more recently, Scotland recommend 100% single rooms, whereas England recommends 50% single rooms for newly built hospitals. There are also some ‘halfway house’ options to consider in terms of temporary or semi-permanent conversion of bays into single rooms, which may go some way to maximising the benefits of single rooms and bays.
If I had to spend time as a hospital inpatient, I’d want a single room. I appreciate that some would find social benefits from being accommodated in a four or six bed bay, but I’d like my own privacy please. And then there’s the risk of infection – healthcare workers are significantly more likely to perform hand hygiene before attending to a patient in a single room than in a bay. Plus, overall infection rates were lower in a unit composed of single rooms compared with a unit composed of a mixture of single rooms and bay. I know that I’d receive less visits from healthcare workers, and that this carries risks, but I’d still prefer a single room thank-you very much!
Article citation: Pennington H, Isles C. Should hospitals provide all patients with single rooms? BMJ 2013;347:f5695.
Other references:
- Teltsch et al. Arch Intern Med 2011; 171: 32-38.
- van de Glind et al. Health Policy 2007;84:153-161.
- Borg MA. J Hosp Infect 2003;54:316–318.
- Haill et al. J Hosp Infect 2012;82:30-35.
- King et al. Building and Environment 2013;59:436-447.
- Moore et al. J Hosp Infect 2010;76:103-107.
- Jolley S. Nursing Standard 2005;20:41–48.
- Barlas et al. Ann Emerg Med 2001;38:135–139.
- Lawson & Phiri. Health Serv J 2000;110:24–26.
- Ulrich et al. White Paper #5. The Center for Health Design. 2008.
- Maben J. Nurs Manag 2009;16:18-19.
- PricewaterhouseCoopers. The role of hospital design in the recruitment, retention and performance of NHS nurses in England. 2004.
- Stelfox et al. JAMA 2003;290:1899–1905.
- Tarzi et al. J Hosp Infect 2001;49:250-254.
- Young & Yarandipour. Health Estate 2007;61:85-86.
- Mooney H. Nursing Times 2008;104:14-16.
- UK Dept Health. Ward layouts with single rooms and space for flexibility. 2005.
Photo credit: Ward at the Royal Free Hospital, c.1908; Royal Free Archive Centre.
Reflections on Infection Prevention and Control 
So, meanwhile all the above makes sense in their own way, there is another option to that. In the Spanish health service in the early 90’s when I did my nursing training, patients where put in rooms that would accommodate for three people, four if needed. This eventually evolved to two patient’s rooms where arguably you will get the best of both worlds and easily converted in a single occupancy room.
The staffing is still 4 nurses for a 30 odd patient’s ward plus a nurse supervisor (equivalent of a sister and only in the morning shift) and two healthcare assistants for the morning and evening shifts, reduced to one nurse and one healthcare assistant for the night duty (but usually cross supported by the twin ward). So staffing remains the same.
Although infection rates in Spain seem to be higher, so they are across the Mediterranean countries and depending on pathogen. I am a strong believer that this is more due to antibiotics being sold without prescription and courses not being appropriately completed by individuals in a “I feel better” basis, rather than nosocomial acquired and due to ward design.
I think that the Spanish approach is a good compromise…and I want to be objective here :).
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Thanks Antonio, objective as ever! I remember when I worked in a hospital in Connecticut, USA, they had a mixture of single and double rooms (‘private’ and ‘semi-private’ rooms in American vernacular). They seemed to work pretty well and probably reduced the overall impact of bed-blocking. I wonder why they are not more common in the NHS?
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Private rooms sound great, it would make it easier to disinfect. The company I work for ByoPlanet Service would utilizing our exclusive catalog of proprietary products and state-of-the-art electrostatic application technology to totally clean every inch of a room. Technology is the way to get hospital rooms cleaner and safer for the patients and staff
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Agree Mike that single rooms are certainly suited to “no-touch automated room disinfection” (NTD) systems; these can be very tricky to apply in multi-occupancy bay settings due to the need to vacate the other precious bed spaces for the duration of the procedure.
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From an infection prevention it is extremely important. As has been proven, there are at least two separate “MRSA” – CA and HA, and they are clearly different organisms. To cohort these patients is similar to a cohort to CRE and MRSA.
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Hi David, that’s a useful point. I’m not aware of a single study that has evaluated acquisition of different strains of the same resistant organism while cohorted.
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Having private rooms provides many benefits: There isn’t cross contamination with other patients or their visitors, more privacy so the patient may be more active, and more open to express their needs…. like bowel, pain or emotional needs. They also make it easier for the healthcare professional to communicate with patients and their families and easier to facilitate the plan of care(dressing changes, medications etc.)
Private rooms are nice but by themselves are limited in helping prevent infections. Hand washing is overplayed unless following the WHO 5 Moments(which is not pump in and pump out). Simple things like truly cleaning rooms daily, changing the mop water between rooms, closets that can be loaded from the hallway and unloaded in the room, limiting visitors, paper dispensers that work and are located in an appropriate location, the use of the old wax coated paper bag to cover bed pans when not in use, etc…
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Thanks Barry. Single rooms, of their own accord, will do little to prevent the transmission of pathogens if basic infection prevention and control measures are lacking. However, it seems that healthcare workers going between single rooms are more likely to perform hand hygiene (http://www.ncbi.nlm.nih.gov/pubmed/20561713) and this probably underpins the reduced transmission associated with single rooms.
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The main benefit of single rooms is air isolation which is the pathway least understood by current medical research.
The alternative is to keep air ultra clean on the basis of what is not there cannot hurt patients or staff and cannot precipitate onto surfaces. Its far cheaper to achieve this than full single rooms with the additional issues of staffing and overview these bring.
Obviously in areas where isolation is required maintaining the air as ultra clean gives an additional level of safety.
From a carbon footprint view there are significant possible benefits as well as the reduction in plant leading to lowered building capital costs, a real win win which does not remove the need for conventional infection control approaches, it simply makes them significantly more robust.
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Andrew: “The main benefit of single rooms is air isolation which is the pathway least understood by current medical research.” This is certainly true of airborne isolation rooms, with HEPA filtered negative pressure. However, most single rooms that I’ve come across are not negative pressure isolation rooms and I’d say their primary benefits are providing flexibility in patient flow and reducing contact transmission of pathogens.
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Jon Otter – I think you have fallen into the trap of convention without meaning to be offensive.
Air is all around us and is the most fluid pathway. Current approaches have worried, correctly, about contact etc but when you swab a room and find c.diff or MRSA on a surface how does it get there? The assumption has been that its via contact but this is now disputed by the MRSA research, C.dff spores are shown to be air transmissible and its taken 300 years for Aspergillus to be recognised for a national centre to open up.
My meeting with the department of health in 2009 on this issue was met with the response to my “surely it must be common sense” with the response the department of health does not do common sense” – which in context scientifically is of course correct although my answer was possibly not so sensitive.
Air is ignored purely due to the complexity of proving, scientifically, that its a factor or a pathway. Despite UK research such as Leeds based Begg’s papers etc etc etc the global health care community continues to march along ignoring it by and by.
In your response regarding Negative pressure rooms the perception is amongst staff that these are safer – yet the reality is that such an area is designed to stop a graded pathogen exiting to infect others – being in such a room does not protect staff from the latest flu borne viral leukaemia ebola virus that has just surfaced and indeed PPE only works in such instances when applied and worn correctly. During the H1N1 early days we resolved situations where staff were catching it in negative pressure rooms and wearing full PPE.
The reason, in my view, is that being in a room for several hours created the physical situation of a mask being adjusted, sweat surface exposure etc and this was enough to allow transmission.
Common sense said creating an environment where it is simply not there removes the risk.
Afterwards staff ceased to contract but were only wearing barrier masks, not full PPE.
Common sense says it worked.
Science says there is no evidence that the staff were not catching it on a bus and later staff ceased to use the bus and so on.
Correct result but no proof.
To my common sense outlook, having an environment which does not contain any airborne pathogen removes any pathogen from being able to fall on surfaces or to be inspired or contacted with due to its presence.
Barriers prevent direct contact.
Cleanliness (stethoscopes etc / hand hygiene) reduce risk.
Room cleaning reduces it further.
In earlier my days in the forces I worked at the Cambridge Military Hospital in Aldershot.
It was an old TB hospital with high ceilings and lots of fresh air.
Military discipline made infection control effective and cleaning as to a high standard.
These were big well lit open wards and there was no issue, H.A.I was effectively zero outside of some minor post operative S.S.I which were quite rare.
From a patients perspective there are times when single rooms are a positive but if a patient is unconscious on life support with current staffing levels isolation can increase risk from things outside H.A.I.
Thats the problem with seeking golden bullet solutions, its only after they get fired you find the dud.
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Thank-you for this detailed information. I think the role of contaminated air in transmission is where the role of contaminated surfaces in transmission was a few years ago. Common sense says that it’s important, but the medical literature is some way behind. The work of the Leeds group and others is compelling, but convincing intervention studies are currently lacking to prove the role of contaminated air in transmission.
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Fully agree with your view in this last statement.
It would be interesting to find a client who wished to invest in investigating this further – we would certainly be prepared to supply equipment at cost if you hear of anybody.
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Single rooms have proven infection control benefits as open wards are more prone to outbreaks of c.diff and Norovirus. All hospitals will have single side rooms/isolation rooms for potentially infectious patients. However single rooms are not necessarily suitable for vulnerable patients who need to be closely monitored and observed e.g cardiac patients. I understand a hospital with wards with only single rooms has experienced difficulties – for example if a patient leaves the bed and falls. That is why I have voted no to the question should hospitals provide all patients with single rooms.
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Thanks Dan for taking the time to outline your rationale for voting against 100% single rooms. There are certainly situations where bays are preferable to single rooms. Gail Locock from Maidstone outlined some of the problems of a 100% single room hospital in her talk at the IPS 2013 conference: http://www.micro-blog.info/2013/10/infection-prevention-2013-conference-report/
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From a patient flow perspective, single rooms for all could potentially expedite movement out of the ED and transfers out of the ICU.
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Hollie yes, I agree, one of the primary advantages of single rooms is flexibility in patient flow to manage patients who require a single room for infectious or other reasons. This is especially pressing in the UK where hospitals are given hefty fines when patients stay in the ED / A&E department for more than four hours, which can happen if the hospital runs out of single rooms. Accelerated discharge from ICU due to an increase in single rooms has been demonstrated in a paper from UCLH in the UK, with a potential saving of >£40k (>$65k) per annum: http://www.ncbi.nlm.nih.gov/pubmed/20561713
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I have voted for single rooms for the following reasons:
– Privacy & Dignity
– Patients more likely to communicate more effectively with clinical staff as details not being overheard with less distractions resulting in less clinical errors
– Room only needs to have a balanced air flow to be an effective barrier against cross infection
– Friends and family more likely to stay longer during visiting times and be more pro active in discussions and care
– Can be made more dementia friendly allowing patient to easily find their room
– Easier to soundproof resulting in more calming environment
– Easier to provide access to window thus daylight and nature which has been proven to reduce LoS and reduce extent of pain relief
– no issues with mixed sex occupancy resulting in empty beds
The negatives can be isolation, lack of observation, lack of patient mobility (may just stay in bed), space requirements and cost especially increased staffing costs.
I think if you do have all single rooms there must be a communal area for patients to go and socialise if they wish.
This also encourages mobility.
We are currently designing a new private hospital in Tbilisi and this will have 40% single beds and the remainder 2 bed rooms.
This was more down to cost and feasibility rather than choice but certainly better than open bed bays.
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Thanks for sharing your justification for single rooms. Interesting perspective from Tbilisi thanks – I confess, I had to look up where it is (Georgia)!
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