Editorials 8. Forte DN, Vincent JL, Velasco IT, et al: Association between educa tion in EOL care and variability in EOL practice: A survey of ICU phy sicians. Intensive Care Med 2012; 3 8 :4 0 4 -4 1 2
9. Douglas SL, Daly BJ, Upson AR: Neglect of quality-of-life consider ations in intensive care unit family meetings for long-stay intensive care unit patients. Crit Care Med 2012; 40:461 -4 6 7
Safety in Numbers...Really?* Life is the art of drawing sufficient conclusions from insufficient premises. -Samuel Butler M a u r e n e H arvey, M P H , M C C M
Douglas County, NV ICUs were originally designed as multi-bedded cubicles around a central station. Recently, there has been a trend toward build ing units with private patient rooms. The Guidelines for Design and Construction of Hospitals and Outpatient Facilities that become state regulations in most states require private rooms for medical-surgical units but not yet for critical care areas (1). Benefits of private rooms can include decreased infection risk, increased privacy, decreased sleep deprivation, decreased staff distractions, and increased family satisfaction (2-4). The biggest drawback is the space and costs required for building ICUs with private rooms. However, although it has not been adequately researched, these costs can be mitigated by benefits obtained through improved patient outcomes. Some nurses have reservations about private rooms because they do not believe they will be able to see as many patients at once and will be more isolated from advice and assistance of coworkers when providing patient care. It seems curious that none of us would book or tolerate a motel that expected us to share our rooms with other guests. Regulations recognize the need for privacy for medical-surgi cal patients. Yet, the most vulnerable and critically ill patients in ICU are allowed to be cared for in multi-bedded rooms. More research is required comparing multiple-patient to single-patient rooms in ICU to inform design teams. In this issue of Critical Care Medicine, Caruso et al (4) have made an important contribution. They found that the odds ratio of developing delirium in multiple- versus single-patient rooms was 4.03. ICU delirium is hard on patients, families, and staff and is largely untreatable. Furthermore, it is a strong risk fac tor for postintensive care syndrome (5). Although the study is limited as it was done in an oncology teaching hospital in Bra zil, the results are impressive. It is even more impressive when their delirium prevalence (13%) is considered. In the United States, the prevalence is usually found to be over 50%.
*See also p. 2204. Key Words: art of nursing; delirium; private rooms; safety The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0000000000000569 23 00
w w w .c c m jo u r n a l.o r g
Previous similar studies comparing single- to multiplepatient rooms have yielded mixed results. One possible reason for the difference found in the study by Caruso et al (4) is the fact that the two multiple-patient rooms had 10 and 13 beds. In many previous studies, the multiple-patient rooms had only 2-4 beds. Another difference in the study by Caruso et al (4) is that their patients were cared for by the same staff, whereas some previous comparisons have been done between units with different staff in different facilities. There is a factor that I am sure is an important confounder of results in critical care research on delirium, anxiety, agitation, pain, stress, sleep, and vital signs: the art of nursing. It can be a powerful therapeutic intervention. We have all observed great differences in the way ICU nurses deliver patient care. At their best, nurses treat patients with respect and compassion. They use eye contact, caring touch, reassurance, and quiet explanations of what is being done. They handle patients gently and try to cause as litde pain and distress as possible. They take the time to make the patient comfortable, identify their individual needs, and cre ate a healing environment. At their worst, nurses do not do seem to recognize the patient as a person and simply perform the tasks required. They are not as caring or gentle and can inflict great patient distress as a result. Although the art of nursing is described in broad terms in the literature, no tool exists to measure it (6-8). It would be difficult to create such a tool but that is not a good reason for not doing so. I believe measuring the art of nursing as a variable in many studies would decrease the variability in out comes and make a great contribution to care of the critically ill.
REFERENCES 1 . The Facility Guidelines Institute: Guidelines for Design and Construction of Hospital and Outpatient Facilities. Chicago, IL, Facility Guidelines Institute, 2014 2. Thompson DR, Hamilton DK, Cadenhead CD, et al: Guidelines for intensive care unit design. Crit Care Med 201 2; 40:1 5 8 6 -1 600 3. Hamilton DK, Shepley MM: Design for Critical Care: An EvidencedBased Approach. Boston, MA, Elsevier, 2010 4. Caruso P, Guardian L, Tiengo T, et al: ICU Architectural Design Affects the Delirium Prevalence: A Comparison Between Single-Bed and Multibed Rooms. Crit Care Med 2014; 4 2 :2 2 0 4 -2 2 1 0 5. Needham DM, Davidson J, Cohen H, et al: Improving long-term out comes after discharge from intensive care unit: Report from a stake holders' conference. Crit Care Med 2012; 4 0 :5 0 2 -5 0 9 6. Almerud S, Alapack RJ, Fridlund B, et al: Caught in an artificial split: A phenomenological study of being a caregiver in the technologically intense environment. Intensive Crit Care Nurs 2008; 2 4 :1 3 0 -1 3 6 7. Jasmine T: Art, science, or both? Keeping the care in nursing. Nurs Clin North Am 2009; 4 4 :415 -42 1 8. Morton PG, Fontaine DK: Critical Care Nursing: A Holistic Approach. Tenth Edition. Philadelphia, PA, Lippincott Williams and Wilkins, 2013 O ctober 2014 • Volume 42 • Number 10
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
9. Douglas SL, Daly BJ, Upson AR: Neglect of quality-of-life consider ations in intensive care unit family meetings for long-stay intensive care unit patients. Crit Care Med 2012; 40:461 -4 6 7
Safety in Numbers...Really?* Life is the art of drawing sufficient conclusions from insufficient premises. -Samuel Butler M a u r e n e H arvey, M P H , M C C M
Douglas County, NV ICUs were originally designed as multi-bedded cubicles around a central station. Recently, there has been a trend toward build ing units with private patient rooms. The Guidelines for Design and Construction of Hospitals and Outpatient Facilities that become state regulations in most states require private rooms for medical-surgical units but not yet for critical care areas (1). Benefits of private rooms can include decreased infection risk, increased privacy, decreased sleep deprivation, decreased staff distractions, and increased family satisfaction (2-4). The biggest drawback is the space and costs required for building ICUs with private rooms. However, although it has not been adequately researched, these costs can be mitigated by benefits obtained through improved patient outcomes. Some nurses have reservations about private rooms because they do not believe they will be able to see as many patients at once and will be more isolated from advice and assistance of coworkers when providing patient care. It seems curious that none of us would book or tolerate a motel that expected us to share our rooms with other guests. Regulations recognize the need for privacy for medical-surgi cal patients. Yet, the most vulnerable and critically ill patients in ICU are allowed to be cared for in multi-bedded rooms. More research is required comparing multiple-patient to single-patient rooms in ICU to inform design teams. In this issue of Critical Care Medicine, Caruso et al (4) have made an important contribution. They found that the odds ratio of developing delirium in multiple- versus single-patient rooms was 4.03. ICU delirium is hard on patients, families, and staff and is largely untreatable. Furthermore, it is a strong risk fac tor for postintensive care syndrome (5). Although the study is limited as it was done in an oncology teaching hospital in Bra zil, the results are impressive. It is even more impressive when their delirium prevalence (13%) is considered. In the United States, the prevalence is usually found to be over 50%.
*See also p. 2204. Key Words: art of nursing; delirium; private rooms; safety The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0000000000000569 23 00
w w w .c c m jo u r n a l.o r g
Previous similar studies comparing single- to multiplepatient rooms have yielded mixed results. One possible reason for the difference found in the study by Caruso et al (4) is the fact that the two multiple-patient rooms had 10 and 13 beds. In many previous studies, the multiple-patient rooms had only 2-4 beds. Another difference in the study by Caruso et al (4) is that their patients were cared for by the same staff, whereas some previous comparisons have been done between units with different staff in different facilities. There is a factor that I am sure is an important confounder of results in critical care research on delirium, anxiety, agitation, pain, stress, sleep, and vital signs: the art of nursing. It can be a powerful therapeutic intervention. We have all observed great differences in the way ICU nurses deliver patient care. At their best, nurses treat patients with respect and compassion. They use eye contact, caring touch, reassurance, and quiet explanations of what is being done. They handle patients gently and try to cause as litde pain and distress as possible. They take the time to make the patient comfortable, identify their individual needs, and cre ate a healing environment. At their worst, nurses do not do seem to recognize the patient as a person and simply perform the tasks required. They are not as caring or gentle and can inflict great patient distress as a result. Although the art of nursing is described in broad terms in the literature, no tool exists to measure it (6-8). It would be difficult to create such a tool but that is not a good reason for not doing so. I believe measuring the art of nursing as a variable in many studies would decrease the variability in out comes and make a great contribution to care of the critically ill.
REFERENCES 1 . The Facility Guidelines Institute: Guidelines for Design and Construction of Hospital and Outpatient Facilities. Chicago, IL, Facility Guidelines Institute, 2014 2. Thompson DR, Hamilton DK, Cadenhead CD, et al: Guidelines for intensive care unit design. Crit Care Med 201 2; 40:1 5 8 6 -1 600 3. Hamilton DK, Shepley MM: Design for Critical Care: An EvidencedBased Approach. Boston, MA, Elsevier, 2010 4. Caruso P, Guardian L, Tiengo T, et al: ICU Architectural Design Affects the Delirium Prevalence: A Comparison Between Single-Bed and Multibed Rooms. Crit Care Med 2014; 4 2 :2 2 0 4 -2 2 1 0 5. Needham DM, Davidson J, Cohen H, et al: Improving long-term out comes after discharge from intensive care unit: Report from a stake holders' conference. Crit Care Med 2012; 4 0 :5 0 2 -5 0 9 6. Almerud S, Alapack RJ, Fridlund B, et al: Caught in an artificial split: A phenomenological study of being a caregiver in the technologically intense environment. Intensive Crit Care Nurs 2008; 2 4 :1 3 0 -1 3 6 7. Jasmine T: Art, science, or both? Keeping the care in nursing. Nurs Clin North Am 2009; 4 4 :415 -42 1 8. Morton PG, Fontaine DK: Critical Care Nursing: A Holistic Approach. Tenth Edition. Philadelphia, PA, Lippincott Williams and Wilkins, 2013 O ctober 2014 • Volume 42 • Number 10
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
