Improving Patient Safety in Inpatient Units—A Canadian Context

Trillium Health Centre–Mississauga’s new west wing was designed as an optimum inpatient care facility modeled with a focus on patient safety and improved patient outcomes. Based on the approved inpatient design from 2000-2001, Trillium Health Centre started to build the new wing in March 2007.

A $100 million, 177,000-square-foot addition, it marks a shift in inpatient unit design from the traditional inpatient settings seen elsewhere on Trillium’s Mississauga site and is the first inpatient wing design of its kind in Ontario, Canada. 

With a predominant focus on patient safety and the nursing work environment, the new wing features decentralized nurses’ units, bringing nurses closer to patients and improving ergonomics for nurses. Along with the increase in the number of private rooms (50% maximum approved based on 2003 standards), the new wing also includes healthcare provider sinks at each room entry, technological enhancements to connect patients directly with their clinicians, and innovative solutions to make semi-private rooms function optimally (individual access to washrooms, sunlight, and doorways).

Post SARS (severe acute respiratory syndrome), Canadian healthcare providers are more aware of the importance of being able control the spread of infection, isolate patients, practice good hand hygiene, monitor the distribution of patient medications, and provide timely bedside care. Traditional inpatient hospital design, however, has sometimes made it difficult for healthcare providers to implement these practices.

The lack of handwashing is the strongest predictor of cross contamination (Larson, 1998). Research has shown that the location of sinks improves handwashing. The provision of healthcare provider sinks in each entryway should encourage greater handwashing compliance. Medications and supplies are located in proximity to serve a cluster of patient rooms, thereby decreasing the potential for interruptions during medication administration and order transcription. 

Specifically related to patient safety, we were interested in determining the benefits of an increased number of private rooms and strategically placed handwash sinks on infection rates. The hypothesis was that these infections would be reduced through the use of private rooms and semi-private rooms with individual access (Chaudhury, Mahmood, and Valente, 2005); an improved ratio of handwash sinks with one at each room entry (Kaplan and McGukin, 1986); and an improved patient/toilet ratio (Korpela et al., 1995).

We also wanted to determine whether medication errors would decrease as a result of the isolated nursing alcoves and improved light levels. The hypothesis was that medication errors in the new wing would be reduced through a decentralized design (Reynolds et al., 1978) that improves the proximity of supplies to the patient and provides increased privacy with improved lighting levels.

In addition, we wanted to provide information regarding the impact the room design had on the number of patient falls. The hypothesis was that falls in the new wing would be reduced through the room design.

The new design provides more direct access to the bathroom with proximity from the headwall to the bath door, wide bath doors, and double-leaf doors in private rooms, which should reduce patient falls (Lieberman, 2004; Joseph, Fabacher, and Rubenstein, 1991, as cited in Dickinson, et al., 2004; Reiling et al., 2004). Having nursing staff closer to the patient would also reduce falls due to increased patient surveillance (Brown 2006, Stichler, 2007).

Data collection
To assess the impact of the physical environment on safety, a pre-/post-intervention design using mixed methods was used to compare various clinical outcomes and safety metrics before and after the move, including nosocomial infections, patient falls, and medication errors.

Pre-move antibiotic resistant organism (ARO) data was collected retrospectively and included data from November 2005 through December 2008. The pre-move data was then compared to post-move ARO data for the same units that now occupy the new wing. The start period for data collection for the new wing was from November 2009 through March 2010.