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A Room With a Viewpoint

and a Research Mission

Hospitals throughout the nation are looking for ways to ensure that patients are healthier and more comfortable during their stays. At one New Jersey institution, that means developing a living laboratory to study how the configuration of a hospital room can improve patient safety and comfort, health outcomes, and the efficient delivery of care. By Krystal Knapp

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Key features of the model patient room that Princeton HealthCare System is testing are designed to lessen medical errors, reduce hospital-acquired infections, and make slip-and-falls less likely. During a recent tour, Susan G. Lorenz, RN, DrNP, vice president of Patient Care Services, noted the room is divided into 3 zones: a patient zone, a visitor zone, and a caregiver zone, with technology playing a major role in each area. Patient zone: Since research indicates patient falls often occur as people move to and from the bathroom, the bed has been placed close to the bathroom, along the same wall. The bed can be lowered to 12 inches from the floor. The hospital is testing a touch-sensitive handrail that connects the bed area to the bathroom area, and lights up when patients take hold of it. The shower in the bathroom includes a long handrail along one wall; a second railing might be added. Comfort touches include soft lighting, large windows that allow lots of natural sunlight, glass doors that offer views of the hospital hallway if the patient so chooses (otherwise a curtain can be pulled to shield the door), and a homey decor. Visitor zone: A mauve couch pulls out into a bed in case a visitor wants to spend the night, and there is a small desk area where a visitor can sit and work on a laptop computer. The room will offer wireless Internet service, and include a closed storage area for luggage. Caregiver zone: Recognizing the importance of handwashing in infection control, the room includes a sink placed prominently near the entrance, next to a caregiver workspace. Hospital officials are still debating whether to include a large mirror behind the sink. Studies show staff members are more likely to wash their hands if a mirror is present, but Lorenz said staff members are also more tempted to look in the mirror and touch their hair after they wash their hands. Nurse server: Bed linens, medication, and other supplies are delivered to the room via 2-way locker-like cabinets called a nurse server that are accessed from the hallway. The intent is to reduce the risk of spreading infections and cut down on staff members entering and exiting hospital rooms multiple times, disturbing resting patients. Technology: The setup of the model room will encourage greater use of bedside computers and tablet devices that will allow doctors and nurses to conduct their charting activities in the presence of the patient, rather than at a computer terminal in a corridor or nurses station. Patients will have Internet access to watch movies and make purchases using a flat-screen monitor, and can also use the system to learn about health-related matters or communicate issues like pain levels.

rinceton HealthCare System (PHCS) has set up a model room to test what works and what does not in patient room design. Theres a pullout sofa for visitors who spend the night, a sink strategically placed to encourage hand-washing by hospital staff, and small portals that allow staff to deliver medication, bedding, and other supplies without entering the room. PHCS, which is currently building a $447 million hospital in Plainsboro, New Jersey, to replace its nearby downtown Princeton site, has created a fully functioning replica of its proposed new patient room at its existing facility in order to experiment with room design elements in preparation for the hospitals move. For 12 months, the model room at the University Medical Center at Princeton will be put to the test with actual patients. The hospital study will look at how the design of a patient room affects the rate of medication errors, hospital-acquired infections, and patient slip-andfalls. The study will also measure the satisfaction of patients, family members, hospital staff, and doctors, said Susan G. Lorenz, RN, DrNP, vice president of Patient Care Services for PHCS, who is leading the research project. Were seeking specific design solutions for common clinical problems and issues, Lorenz said in an interview with Oncology Net Guide. We are also looking for ideas and innovations that promote relaxation and healing, and make the experience of being in a hospital easier on patients and families. Results of the study will influence how rooms are built and set up in the new hospital, and the findings of the study also could have more farreaching effects on the patient room of the future, potentially influencing how patient rooms are designed nationally. The PHCS model patient room initiative is part of the Pebble Project, a program of The Center for Health Design, Concord, California, a national organization that promotes research on how the physical spaces of a hospital can contribute to patient healing and improve healthcare efficiency. About 50 hospitals across the country have participated in Pebble Project evidence-based studies since the program began about a decade ago.

Photos courtesy of Princeton HealthCare System

Targeting Errors, Infections, and Patient Falls Evidence-based healthcare design has gained more attention as hospitals across the country expand and renovate aging facilities, experts say. Despite the economic downturn, spending for healthcare-related
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Approximately 30% of hospital patient falls result in physical injury, with 4% to 6% resulting in serious injury.5 One study of falls at Barnes-Jewish Hospital in St. Louis, Missouri, published in 2005 found that a large majority of falls (82%) occurred in the patients room, while 12% occurred in the patients bathroom. Nearly half of the patients were ambulating when they fell, and 18% were getting in or out of bed. Toilet needs were a common reason for the patients activity at the time of the fall (47%). More toilet-related falls occurred overnight than nontoilet-related falls (67% at night vs 44% day). Only 17% of toilet-related falls occurred in the bathroom.6 A growing body of literature describes the link between a hospitals physical design and its key quality and safety outcomes. One study conducted by The Center for Health Design found that evidence-based design can improve hospital environments by enhancing patient safety, eliminating environmental stressors such as noise that can negatively affect health outcomes and staff performance, and reduce stress and promote healing by making hospitals more pleasant, comfortable and supportive for both patients and staff.7 Implications for Oncology Patients Overall, cancer patients are a notable segment of the inpatient hospital population. There were an estimated 1.2 million hospital discharges for people diagnosed with malignant neoplasms in 2007, or 3.4% of total inpatient care, according to a National Center for Health Statistics analysis of the latest-available data released in October.8 An analysis of 1999 hospital data from 6 states found usage was far higher, with 9% of the hospitalizations in patients aged 20 associated with a cancer diagnosis, according to the 2004 study published in Critical Care.9 Williams et al noted that cancer patients frequently contract infections that require or prolong hospital stays and can result in severe sepsis. Compared with the overall population, cancer patients are much more likely to be hospitalized (relative risk [RR], 2.77; 95% confidence interval [CI], 2.77 2.78) and to be hospitalized with severe sepsis (RR, 3.96; 95% CI, 3.943.99), the researchers said. While PHCS did not design its model University Medical Center of Princeton room specifically for at Plainsboro, oncology patients, New Jersey, under certain features will construction. help this population,
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construction has remained at high levels, exceeding $40 billion this year, according to the US Census Bureau.1 Analysts expect that amount to top $60 billion by 2013. The construction boom provides an opportunity to rethink hospital design, and to consider how improved design can help reduce staff stress and fatigue and increase effectiveness in delivering care, improve patient safety, reduce patient and family stress, and improve outcomes and overall healthcare quality. For more than a decade, healthcare policy officials have sought to address issues related to hospital care, specifically medical errors, infections, and accidents. The 1999 Institute of Medicines landmark report, To Err is Human: Building a Safer

A construction boom offers an opportunity to rethink hospital design.

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Health System, exposed the tremendous costs, both in human and financial terms, of medical errors in the US healthcare system. Two studies cited in the report indicate that between 44,000 and 98,000 people die each year in the United States as a result of medical errors.2 The national cost to the economy because of these errors is between $17 billion and $29 billion. A study of hospital infection rates published in Public Health Reports in 2007 estimated that approximately 1.7 million healthcareassociated infections occurred in US hospitals in 2002, and the infections were associated with approximately 99,000 deaths.3 Falls are the most common type of inpatient accident, accounting for up to 70% of inpatient accidents, according to a report in the British Journal of Clinical Practice.4 Falls can result in serious physical and emotional injury, poor quality of life, increased length of stay in the hospital, admission to a longterm care facility, and increased cost.

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Lorenz said. For example, all 237 patient rooms in the new hospital will be private rooms, creating not only a more relaxing environment for patients, but also improving the setting for treating infections related to cancer and reducing the risk these patients might acquire an infection in the hospital. Privacy is important for oncology patients, Lorenz said. Patients with neutropenia, for example, need to be in private rooms. Now they wont have to worry about being in a room with another patient. The age of oncology patients also makes them more vulnerable to falling in the hospital, Lorenz said. Approximately 77% of all cancers are diagnosed in persons aged 55, according to the American Cancer Society. With oncology patients more than others, the risk of falling is greater, said Lorenz. Oncology patients tend to be a little younger and think they can do things they cant do. The model room includes a video-on-demand feature that will enable greater access to patient education information, an important asset for oncology patients, Lorenz said. Model Room Is a Novel Approach While mockups of new hospital rooms have been built by hospitals in the past in order to test general patient room design features, a model built within an existing hospital, used by actual patients and studied as part of a research program, represents a new frontier in evidence-based design. Researchers like Ellen Taylor, a research associate and consultant with The Center for Health Design, are eagerly awaiting the results of the PHCS room study, which they characterize as a unique project because of the comprehensive data collection that will

Setting up a room with real patients is something new in hospital modeling.

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take place using actual patients. While many hospitals have done mockups of rooms and have tested things like equipment and finishes and modified features based on staff feedback and some patient scenarios, an actual room where data [are] collected and compared with a control group, with live patients giving feedback, is something new, Taylor said. The PHCS model patient room study is being funded by a $2.8 million research grant from the Robert Wood Johnson Foundation, Plainsboro. The mission of the foundation is to improve healthcare for all Americans, and the foundation has been involved in looking at ways to improve the quality of inpatient care for several years now. David Morse, the vice president for communications at the foundation, said the model patient room is a natural project for the foundation to support given that the study fits with the foundations mission, advances previous research in the Ellen Taylor areaisofanhospital design, and evidence-based study with measurable

results. The PHCS project also happens to be in the foundations backyard. We will literally be able to see the results, Morse said. How Study Will Be Conducted The new model room at the University Medical Center at Princeton has been constructed on a busy patient floor, side by side with traditional hospital rooms. During the course of 2011, data from patient stays in the new room and a traditional hospital patient control room will be collected and the performances of the two rooms will be compared. Patients will have to give consent before participating in any part of the research. Some patients will be assigned to the room at random, as they would to any room in the hospital, Lorenz said. At other times, well be looking for patients with certain characteristics. For example, we may select patients 65 and older who have had an orthopedic procedure or some other condition that puts them at risk of falling, and match them to Crews working on the University similar patients in Medical Center traditional rooms, of Princeton at in order to research Plainsboro. how the model room
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How Cancer Patients Use Hospitals

performs in comparison with the traditional room. In the first phase of the room design, Lorenz said foam core slabs that could easily be moved were used to identify the optimal configurations for walls, the bathroom, the bed, and other room furnishings. The room was then refined based on staff feedback. For phase II of the program, the rooms configuration was tested again through simulations and with patient volunteers. Based on patient and staff feedback from those experiences, the room will be further refined in preparation for the year-long study. Hospital officials hope that by the end of the study, close to 100 patients will have stayed in the room, providing the hospital with a solid body of data to be analyzed so that healthcare professionals have a better idea of what works in terms of patient health and satisfaction outcomes. Once the data are collected, hospital leaders will know whether placing the bathroom near the bed really does lessen falls, or whether a more prominent sink for staff members truly does increase hand-washing activity. The proof will all be in the data, Taylor said. With construction of the new hospital in Plainsboro well underway, Lorenz acknowledges that there could be design features that PHCS will not be able to incorporate into the design of its own rooms. But through our study we are contributing to a body of knowledge where really good empirical studies have been lacking, she said. There may be things we wont be able to see at our own hospital, but where others will benefit from our experience in the future.

Inpatient Care1

Outpatient Visits2

1.2 million 596,000

Patients were 65 and older

Hospital discharges for malignant neoplasms (580,000 men and 644,000 women) in 2007

2.75 million
Number of outpatient visits to nonfederal, general, and short-stay hospitals for malignant neoplasms in 2007

Emergency Room Visits3

484,000
Patients were ages 45-64

269,000

Emergency room visits to nonfederal, general, and short-stay hospitals in 2007 for malignant neoplasms

1 16,000

Patients were ages 15-44

6.5 days 210,000

Average hospital stay for patients with malignant neoplasms

Krystal Knapp is a freelance writer living in Princeton, New Jersey.

Hospital discharges for injection or infusion of cancer chemotherapeutic substances

1. Hall MJ, DeFrances CJ, Williams SN, Golosinsky A, Schwartzman A. National Hospital Discharge Survey: 2007 Summary. Hyattsville, MD: National Center for Health Statistics; 2010. National Health Statistics Reports Number 29. 2. Hing E, Hall MJ, Ashman, JJ, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Outpatient Department Summary. Hyattsville, MD: National Center for Health Statistics; 2010. National Health Statistics Reports Number 28. 3. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary. Hyattsville, MD: National Center for Health Statistics; 2010. National Health Statistics Reports Number 26.

1. US Census Bureau of the Department of Commerce. Value of construction put in place, 2010. www.census.gov/const/C30/totsa.pdf. Published November 1, 2010. Accessed November 11, 2010. 2. Institute of Medicine of the National Academies, Division of Health Care Services. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy of Sciences; 2000. 3. Klevens RM, Edwards JR, Richards CL, et al. Estimating health careassociated infections and deaths in US hospitals, 2002. Public Health Rep. 2007;122(2): 160-166. 4. Sutton JC, Standen PJ, Wallace WA. Patient accidents in hospital incidence, documentation and significance. Br J Clin Pract. 1994;48(2): 6366. 5. Ash KL, MacLeod P, Clark L. A case control study of falls in the hospital setting. J Gerontol Nurs. 1998;24(12): 715. 6. Krauss MJ, Evanoff B, Hitcho E, et al. A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med. 2005;20(2):208-209. 7. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The Center for Health Design; 2004. Designing the 21st Century Hospital Project. 8. Hall MJ, DeFrances CJ, Williams SN, Golosinsky A, Schwartzman A. National Hospital Discharge Survey: 2007 Summary. Hyattsville, MD: National Center for Health Statistics; 2010. National Health Statistics Reports Number 29. 9. Williams MD, Braun, LA, Cooper LM, et al. Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care. Crit Care. 2004;8:R291-298. doi:10.1186/cc2893.

References

Cancer Patient Visits to Health Facilities1

(2006) Estimated 24.6 million total visits 7.8% to primary care offices 23.5% to surgical specialty offices 14.2% to hospital outpatient departments 0.6% to hospital emergency departments 53.9% to medical specialty offices

1. Schappert SM, Rechtsteiner EA. Ambulatory Medical Care Utilization Estimates for 2006. Hyattsville, MD: National Center for Health Statistics; 2008. National Health Statistics Reports Number 8.

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