Jacqui Close is a consultant in Orthogeriatrics at the Prince of Wales Hospital in Sydney, Director of the Falls and Injury Prevention Group at Neuroscience Research Australia and President of the Australian and New Zealand Society for Geriatric Medicine. Her research interests range from injury epidemiology, to intervention studies and implementation research.
The days of the Nightingale ward are thankfully gone. No longer do we see two long neat rows of beds with starched sheets. Whilst the occupants of the bed were rarely encouraged to roam freely, the close proximity of the beds allowed for easy spread of highly mobile viruses and bacteria. Even in the absence of an understanding of infection risk, many complained about the lack of dignity and privacy resulting from this ward design.
Time has moved on and there is recognition of the multiple benefits of single rooms for all patients including older people. Single rooms allow for the delivery of health care which minimizes infection risk, respects privacy, promotes dignity and on the whole reflects with wishes of those people unfortunate enough to require a period in hospital. But is a single room right for everyone and can we be flexible in the way we deliver care?
The recent report by Singh et al. in Age and Ageing demonstrates the potential consequences of a move to 100% single rooms for a hospital and its staff. This opportunistic before and after study looked at the rate of falls when moving from an older hospital with shared rooms to a new hospital with all single rooms. The rate of falls increased with the move to the new hospital, almost certainly reflecting the challenges for staff who need to adequately supervise patients needing help with basic activities. Of course the solution may not be to dismiss the other advantages of single rooms and return to shared rooms, but to look at staffing ratios and the mix of patients to ensure that care can be delivered safely and effectively.
The reality is that those most likely to come to harm in hospital are those who are cognitively impaired. This is an important population whose needs are not always optimally met. A fall in an older person with dementia can reflect a failure to take into account brain function when developing and implementing care plans – a patient with delirium may not remember to push a buzzer to seek assistance in going to the bathroom. Enhanced supervision, as well as proactive rather than reactive care, may minimize risk of harm for this population.
Not all patients want a single room, as is evidenced by recent UK surveys; if we are to be “patient-centred” in our approach to care then we must be able to offer choice. For some, loneliness and isolation in a single room can result in low mood, depression and poor dietary intake – which doesn’t result in a therapeutic environment. Company and camaraderie can improve motivation and the desire to do well.
So yes, single rooms are to be broadly supported across the NHS but let’s remember the importance of a therapeutic environment to promote recovery as well as the need to provide enhanced supervision and care to some of the frailer members of society – single rooms may not deliver for all.