Tuesday, January 11, 2011

Madame Necker lives on

Madame Suzanne Necker
Source: Wikimedia Commons
You are probably asking: Who is Madame Suzanne Necker? And what does she have to do with infection prevention? Well, she was the wife of a French finance minister who started a campaign in the late 1700s to limit the number of patients per hospital bed to 1. At that time, up to 8 patients shared a bed in French hospitals.

So the one patient-one bed standard came to be and has lived on. In 2006, over 200 years later, the American Institute of Architects Guidelines for Design and Construction of Health Care Facilities called for a new standard of one patient-one room. A 2008 commentary in JAMA outlined many reasons for the private room standard, including reduced potential for HAIs, reduction of patient transfers, enhanced patient throughput, and greater privacy for patients and families.

A new study in the Archives of Internal Medicine, looks at the acquisition of pathogens before and after the move from an ICU with multiple patients per room to a new ICU with all private rooms. Another hospital in the same city with the same infection control service and multi-bed rooms throughout the study period served as a comparator. The authors report that the acquisition of MRSA, VRE and C. difficile fell 54% after the move to the all private-room ICU. I think the study has a number of problems, which I won't belabor here, but will point out one curious finding that somewhat undermines the authors' conclusions--although the rate of MRSA acquisition fell after the move, the rate of MSSA acquisition did not.

Two years ago, all the ICUs at my hospital except one moved to a new tower with all private rooms, including our NICU. Clearly, it's easier to practice good infection prevention with patients separated nicely, though one downside that we noticed immediately was that it became much more difficult for our hand hygiene observers to collect as many hand hygiene observations from any single point of observation.

Bottom line: I think that private rooms probably do have an impact on reducing infections, though I don't think we have proven that yet. And whatever gains can be made by better design can probably be undone by poor compliance with hand hygiene.

1 comment:

  1. Excellent post! A lot of attention has been given to cleaning between patients (ie at discharge before a new admission). However, little is done to clean rooms during a patient's stay. It may be that private rooms lower transmission for that reason. If there were efforts to clean rooms during the stay or technological advances that continuously decontaminate rooms (eg antibacterial surfaces), might the incremental benefit of private rooms be reduced?

    Outside of ICUs, I have always felt that roommates provided conversation and could even alert staff to a decompensating roommate. Perhaps there are downsides to private rooms outside of ICUs?

    I agree with your MRSA comment. Since MRSA has been declining for several years in the background, it would have been nice to see MSSA decline too.

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