Cindy Towns, Senior Lecturer, University of Otago Wellington, University of Otago, Angela Ballantyne, Associate Professor of Bioethics, University of Otago, Matthew Kelly, Senior Clinical Lecturer, Health Sciences, University of Otago
As New Zealand agonises over its hospitals – where they are, how they should be staffed and how they should be funded – a key element in the debate is being missed: the need for single rooms in all public hospitals.
It’s currently normal for patients to stay in shared rooms with up to five other people. In some hospitals this includes accommodating men and women in the same room, despite serious safety and ethical concerns.
But it shouldn’t be this way. For a number of reasons, including infection control, privacy and cost, new hospitals and renovations need to be based on single occupancy rooms.
Our new research brings together both the clinical and ethical arguments for single rooms for all patients as the most basic standard of care.
Infection control
Many may view shared rooms as a cost saving. But one of the key arguments for individual rooms in hospitals is the cost and harm of infections and bacterial resistance.
Single rooms reduce risks by eliminating exposure to shared infection sources such as touched surfaces, unfiltered air, toilets and water systems.
They also reduce the need for room transfers within the hospital which increase the risk for infection transmission between patients.
There is strong evidence single occupancy rooms result in reduced infections in intensive care units. And further research has also found single occupancy reduces hospital transmission of COVID-19.
In New Zealand, single rooms are prioritised for patients known to be infectious. But the key word here is known. This policy fails to recognise that a large proportion of transmissible infections are unknown at the time of ward placement.
However, even when infection is known, our hospitals cannot meet basic guidelines due to the lack of single rooms. Only 30% of Wellington and Hutt hospital rooms are single occupancy, for example.
Without single occupancy as the standard in hospitals, infection control will remain compromised.
Delirium and dementia
Individual rooms are also required for older adults. New Zealand’s population is ageing; as a result, patients with delirium and dementia needing hospitalisation will increase.
Delirium affects about 25% of patients in hospital and is associated with a longer stay, more complications and an increased risk for death.
Delirium prevention and management requires a low-stimulus environment, undisrupted sleep, and control of light and noise which cannot be achieved in shared hospital rooms.
Research has shown a reduction in delirium with single rooms.
The behavioural and psychological symptoms of dementia also pose significant challenges in hospital. Symptoms include hallucinations, delusions, sleep disturbance, depression, inappropriate sexual behaviour and aggression.
These can be highly distressing for the patient and those around them and – like delirium – cannot be managed to a basic standard of care within a shared room.
Dementia prevalence will more than double by 2050. And yet New Zealand hospitals are ill-prepared to accommodate this rise in demand.
The right to security, privacy and dignity
Shared rooms in hospitals clearly undermine clinical care, but they also violate human and patient rights.
One of the most fundamental human rights is “security of person”. Nobody should have to share rooms with patients who are agitated, aggressive or sexually inappropriate due to delirium or dementia.
Unfortunately, patients frequently share with those who are unable to manage their own behaviour. While the risks to women have been highlighted, no patient should be endangered or frightened by another patient’s behaviour.
Dignity and privacy are also a fundamental patient rights, with privacy covered by by both the Health Information Privacy Code and the Health and Disability patient Code of Rights.
Hospital patients often need assistance with dressing, showering and toileting. Many admissions involve vomiting, diarrhoea or incontinence. And design that relies on curtains to maintain privacy renders this right farcical.
Research and complaints clearly show patients do not believe their privacy is adequately protected in shared spaces.
Some may argue for multi-bed rooms on the basis that some patients prefer company. However patient surveys on privacy and confidentiality are overwhelmingly in favour of single occupancy.
Factoring in cost
While there is an increase in up-front costs when building single rooms due to the larger hospital footprint, research has found there is no convincing economic evidence in favour of multi-bed rooms.
The potential savings for future pandemics – in mortality, patient transfers and disease transmission – should not be underestimated. Improved management of delirium and dementia, will also decrease length of stay and cost.
The argument for single occupancy hospital rooms on clinical, ethical and legal grounds is collectively unequivocal.
New Zealand needs to follow international best practice and introduce single occupancy rooms as a basic standard for new hospital builds and upgrades.
Not doing so would ignore the lessons learnt in the COVID-19 pandemic, fail to account for the needs of an ageing population and continue to render New Zealand’s code of patient rights a fairy tale.
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
