Point

By George Pressler, ACHA, AIA, FHFI
President, Planning Decision Resources, Inc

Two terms have been discussed over the last years as if they were interchangeable: Universal Rooms and Acuity Adaptable Rooms. Universal Room means that the environment is planned to accommodate a patient’s needs throughout their entire inpatient stay and the staffing changes based on the acuity level of the patient. The Acuity Adaptable Room is similar as far as attributes of the physical space. The change to a different level of patient care occurs as the facility requires more or less of a particular room type and then adjusts the assignment and designation of the room. This discussion Point is to address the merits of the Universal Room.

LENGTH OF STAY – Typically 40-70 percent of patients on a typical Unit are transferred each day in U.S. hospitals according to the American Journal of Critical Care. Every time a patient is moved to a different Unit, a half-day is added to the length of stay with no value added for quality of care. Each transfer may cost as much as $ 200-300 in labor and equipment. Statistically, we can demonstrate that a facility with 100 percent single-care patient rooms requires fewer total beds versus those with multi-bedded rooms. Likewise, adoption of the Universal Room model can also reduce the total of forecasted bed needs; thus, fewer beds equal a decrease of construction cost in addition to a lesser fixed and major moveable furniture and equipment budget.

PATIENT SAFETY – A significant number of medication errors are the result of patient transfers and re-assignment to a different Unit.

PATIENT SATISFACTION - The holistic patient-centric care model has proven benefits of patient and family satisfaction. The bonding of both patient and their family with the clinical staff is a tremendous factor toward a healing environment.

OPERATIONAL EFFICIENCY – Significant decrease in costs for EVS and Food Service has been documented, as well as Transport Teams. With shorter lengths of stay, the Universal Room concept focuses on bringing services to the patient, avoiding time lost in patient movement. Bed assignment, particularly from the Emergency Room is much easier to manage, eliminating unnecessary waiting in the corridors of EDs. This allows potentially earlier commencement of treatment plans as an inpatient.

100 percent Universal Rooms is NOT being recommended. The point emphasized here is consideration for those service-lines, such as Cardiology, which experience the most changes in patient acuity, requiring differing room types and clinical care. This approach allows the staffing for this Unit to include staff with various levels of experience and expertise, and still meeting the requirements of staffing ratios. Cross-training would not be a requirement, though over time this may occur. Other allied health professionals could be included within the new multi-specialty team. Ancillary services might be planned to be more proximal as well, further reducing patient movement. Following LEAN concepts, the goal and point is to eliminate waste and improve efficiency, along with enhanced quality of care.

Counterpoint

Jennie Evans RN, LEED AP,
Associate/Clinical Advisor with HKS.

The acuity adaptable nursing model, originated by Ann Hendrich in the 1990’s, is based on the concept of patients spending their entire length of stay, from admission to discharge, in the same room. To accommodate this nursing model, universal patient rooms are designed with sufficient capacity for the highest level of acuity patient.

Several potential advantages exist favoring the acuity adaptable nursing model over traditional models of care. Patient transfers, lengths of stay and medical errors are reduced and universal rooms do provide operational flexibility. If a need arises for additional high acuity beds or a patient’s acuity suddenly increases requiring additional support, the room is ready and available. Nevertheless, research suggests that pitfalls to implementing the acuity adaptable nursing model, which requires universal rooms, may outweigh these opportunities.

An exploratory study conducted by HKS and Herman Miller dialoguing with leaders from top community hospitals nationwide, found that implementing the acuity adaptable nursing model has not been easy from an operational standpoint. A perception of inadequate care, an inability to maintain intensive care nurse competencies, and lack of adequate support space are just a few of the issues raised by the nurse managers, directors and administrators interviewed.

Cross-training staff: The acuity adaptable model requires nurses who are cross-trained (or willing to be cross-trained) to address all levels of acuity. This is a challenge because nurses typically have preferences for a certain type of care environment.

Maintaining staff competency and intensive care admissions: Maintaining intensive care nursing competencies may not be practical in an acuity adaptable model. This is true especially in community hospitals, where the number of intensive care patient admissions may not be enough to maintain all of the competencies required by intensive care nurses. The hospital’s ability to admit intensive care patients may therefore be limited.

Physician’s perception: In an acuity adaptable model, intensive care patients can be located in any of the inpatient units within the hospital. However, physicians want their intensive care patients cohorted. In a dedicated intensive care unit, the physicians, especially intensivists, can readily build relationships with the intensive care nurses. Intensive care requires teamwork and there is a security in knowing that all the staff within the unit is competent and familiar with the challenges of caring for intensive patients.

Equipment cost: The acuity adaptable model requires access to critical care equipment on each unit. This entails increasing monitor capability, purchasing more IV pumps and ventilators and other pieces of equipment required to support a changing acuity. The cost of maintaining critical care equipment for all rooms that may not be used for critical care 24/7 can be prohibitive.

Physical design response: The patient room size and support space for intensive care patients requires a larger floor plate. Larger equipment rooms, supply rooms and medication space is necessary along with additional family room space to support intensive care patient families.

Change Management: In order for the acuity adaptable model to realize and maintain full implementation, the hospital must commit to an intense change management program for nursing. Changing work behavior is particularly challenging for nurses that have been in the work force for longer periods of time.

Service Lines: Service lines such as neurology, cardiology, bone marrow transplant and pediatrics may be more successful than medical-surgical service lines. However, cardiology services that have implemented the use of the acuity adaptable model are now returning to traditional models of care.

Investigation on how many facilities actually have capitalized on the flexibility of universal rooms is needed. Also, additional research and discussion must continue to involve both healthcare system planners and architects prior to committing to a full-scale design of this type.