Designing To Accommodate The Short-Stay Patient
Many types of patients no longer meet inpatient admission criteria but still need to remain in a hospital bed for significant amounts of time, even though reimbursed as outpatients. So what’s the most appropriate setting for these patients that promotes the best clinical outcomes and patient/family experience, but doesn’t use the space and resources of an inpatient unit?
Some of these short-stay patients include:
- Post-surgical, procedural, and diagnostic recovery patients who usually require fewer than 12 hours to recover but may stay longer or overnight because of their home environment or if their procedure is late in the day
- Patients who require brief hospitalization and are discharged as soon as clinical conditions are resolved
- Patients entering through the ED, requiring treatment or monitoring in order to make a decision concerning their admission or discharge.
Traditionally, short-stay patients remain adjacent to individual departments, such as Level 2 recovery site near surgery for post-procedural stays or clinical decision units (CDUs) located near emergency. These areas must then remain open 24/7, or patients will be transferred to inpatient units at the end of the day; however, their stay is still reimbursed as an outpatient unless later reclassified.
In numerous studies, care in dedicated short-stay units has been shown to be equal or better in quality and lower in cost than inpatient care for specific conditions, especially when specific protocols are in place.
One option for smaller hospitals is to aggregate patients into a universal care unit (UCU) that is as close as possible to its feeder departments: emergency, surgery/interventional, and imaging. The beds can flex from a procedure-driven daytime patient volume to an observation stay overnight, providing a high utilization of rooms. Larger or tertiary hospitals may choose to aggregate short-stay patients by specialty. However, it’s important to note that a UCU location central to multiple departments may not allow for exterior views or windows.
So how should short-stay units be configured for “bedded outpatients”? Traditionally, observation units mimicked ED layouts, placing the highest priority closest to clinical workstations using open bays or rooms with full glass sliding doors. The bay or room size incorporates minimal clearances for equipment and staff and little or no accommodation for family.
The 2014 FGI Guidelines for Hospitals and Outpatient Facilities recommends a minimum of 120 square feet of clear area per room and one toilet per six patients. This type of setting may be appropriate for shorter or daytime stays, but seems inadequate for overnight stays and stays close to 24 hours. Longer stays dictate the need for more privacy, access to toilets, and noise and light control that are important for sleep. Also, though using an “outpatient status,” nurse staffing can be more similar to an inpatient unit, with a 1:5 nurse to patient ratio.
The stay is short, but the level of service can be intense. Many hospitals even use former med/surg units with smaller private patient rooms as short-stay settings, but proximity of these units to the departments generating patients can sometimes be problematic.
In new construction, it’s not cost-effective to build full acuity-adaptable inpatient rooms for short-stay patients, considering reimbursement reductions. But for any patient staying more than 12 hours or overnight, spaces should go beyond the traditional observation unit to include:
- Access to daylight and exterior views either in the room or adjacent
- Direct access to a toilet and separate showering facility
- Acoustical and visual privacy
- At least one comfortable seat for family in the room and family support space on the unit
- An ideal grouping of ten patient rooms to a workstation supporting a 1:5 nursing ratio.
- A manageable unit size with clear wayfinding – over forty beds could present administrative and logistical challenges.
It’s important that further research be conducted, concentrating on the short-stay patient and family experience and how designers can best create environments for this ever-growing clinical activity.