Is hospital design making us sicker - Wait for the RCT?

• Confirmation bias – looking for evidence to support a pre-conceived opinion, rather than looking for information to prove oneself wrong. 

We've written often about cognitive biases and how they influence medical decision making. How else can we explain one colleague demanding RCT evidence before supporting influenza vaccine mandates for healthcare workers while at the same time ignoring the lack of RCT evidence when pushing bare below the elbows?  And what about another colleague calmly supporting influenza vaccine mandates yet slamming bare below the elbows while wearing his professional white coat and demanding cluster randomized trials? Confirmation bias anyone? (note: both of those colleagues have been me at various points in my blogging "career")

We've also written often about hospital design and how it might be changed to improve infection control. On this subject there was a nice editorial in the NYT a few days ago by Dhruv Khullar that linked poor hospital design to excess healthcare associated infections, falls and noise impairing sleep. I've included his paragraph on HAI below.

"It’s no secret that hospital-acquired infections are an enormous contributor to illness and death, affecting up to 30 percent of intensive care unit patients. But housing patients together very likely exacerbates the problem. Research suggests that private rooms can reduce the risk of both airborne infections and those transmitted by touching contaminated surfaces. One study reported that transitioning from shared to private rooms decreased bacterial infections by half and reduced how long patients were hospitalized by 10 percent. Other work suggests that the increased cost of single-occupancy rooms is more than offset by the money saved because of fewer infections. Installing easier-to-clean surfaces, well-positioned sinks and high-quality air filters can further reduce infection rates."

If you click on the links like I did, you'll notice one links to a 2008 JAMA editorial, another to a single hospital, uncontrolled quasi-experimental (before-after) study, another to a cost-analysis based on data from a single ICU, and the last to a 2008 non-analytic literature review. Given how expensive it is to convert hospital space from double (or more) to single hospital rooms and how scant the evidence appears to be, I suggest we consider the opportunity costs of these recommendations. If we won't spend any money on robust hand hygiene compliance programs, why should we support these huge architectural changes? Shouldn't we have more studies that examine bathroom location, copper surfaces, room proximity to nursing stations, lighting, alert systems, etc etc, before we rebuild hospitals that we'll be stuck with for the next 30 years?

Take the case of the beautiful Rush University Hospital that opened in 2012 (image above). I drove by it 3 weeks ago and to my (not) surprise, it was no longer gleaming white but more of a zebra-striped white/grey/black from air pollution. The hospital, I assume, is now stuck with years of cleaning expenses after a marketing/architectural leader no doubt suggested "white=clean=hospital" and will have less money in their infection control budgets. Did someone study white buildings in industrial cities?

Why do we fight over cheap reversible policy changes and not over expensive irreversible changes to our hospitals? I'd much rather support bare below the elbows or even influenza vaccine mandates - programs that can be reversed if additional trial data becomes available - than these hugely expensive, irreversible architectural changes. I'm holding out for better randomized trial data.

image source: TERRA

Re-designing rooms and re-engineering care to reduce infections

There's an article in the Wall Street Journal on the hospital room of the future. It notes elements of architectural and product design that can reduce the transmission of infection. Take a look at the graphic above. You'll note, for example, that on entering the patient room the sink lights up in red to remind healthcare workers to wash their hands. There are a number of other examples of using design to reduce infection in the graphic. One not specifically designed for infection prevention that may still be useful in preventing infection is the large video monitor on the footwall of the room. Let's say I'm a consultant and I have influenza. I could still interact with the patient without being physically present, not feel guilty about staying home, and not risk transmitting influenza to the patient. Obviously I could not perform all the elements of a physical exam, but not all follow-up visits require an exam, though I have heard rumors that some doctors perform perfunctory exams for billing purposes only. Moreover, does every consultant and medical student need to exam the patient every day? Think of how many contaminated stethoscopes and dirty white coats are touching patients every day with the majority of those interactions adding no value to the care of the patient. Perhaps one physician could examine the patient and the rest skype in.

I've been thinking lately that we really need to carefully exam all the things we do in hospitals and then engineer out the opportunities for transmission of infection. I was reminded of this by a paper in Transactions on Healthcare Systems Engineering, which examines something as simple as how ICU nurses cover patients for each other while on breaks. This paper points out that by providing a structured coverage arrangement the number of unique persons interacting with any given patient are significantly reduced, which potentially reduces transmission of infection. I bet there are many such  examples where re-engineering patient care could reduce the potential for infection transmission.

Graphic:  Wall Street Journal

A handwashing nudge

As a hospital epidemiologist, I'm always looking for ways to nudge people to wash their hands. Nudges guide a person to do the right thing (i.e., encourage compliance) without a mandate. Here's the latest one, which was featured by NPR yesterday: the sink-urinal. This allows men to pee in the bottom part of the fixture and wash their hands in the top. It provides a constant reminder to wash your hands. It's environmentally friendly as it uses gray water (from the sink) to flush the urinal. Plus, it comes in an assortment of colors; what more could you ask for?

Photos: Ingus Bajars/Courtesy of Kaspar Jursons

Michael Graves takes on hospital design

For many years I have been a huge fan of the work of Michael Graves, the American designer and architect. Several years ago he became paraplegic, and through his own medical care began to realize how poorly hospitals are designed. In this TED talk he shares his views on this problem as well as potential solutions. He even talks about infection prevention!

Designing out the bugs

This month's Metropolis magazine, a publication that focuses on architecture and design, has a treat for hospital epidemiologists--the results of a design competition in the UK for hospital products that improve infection control. The title of the competition was "Design Bugs Out." The magazine's website has a photo gallery of the newly designed products. Check out the wheelchair that doubles as a beside commode--always good to think about multitasking! I also like the IV tubing that tells you when it needs to be changed.

Photo:  The Design Council