Masayuki Kato (Mie University)

Kyohei Yamaguchi (Mie University)

Akikazu Kato (Mie University)

Abstract

Japan enjoys the longest life expectancy in the world. However when compared in statistical figures among industrialized nations, the Japanese mortality rate of age one to four is quite high. Takei et al. (2008) claim that the lack of Pediatric Intensive Care Unit (PICU) beds is one of the major causes of the above phenomena. They note that the medical results are improved when seriously ill children patients are treated in the PICU. Because Japan carries out a national insurance policy, the reimbursement system controlled by the MHLW acts as the implementation method of developments in healthcare services. Here, facility features of newly completed PICUs are compared to clarify the high standards of physical environment. This facility is defined as D Hospital in this paper. According to the past study about the single-room PICU, “The average duration and frequency of visits by patient’s families increase” and “Nurses work more frequently by the bed” are considered as advantages. This paper aims to clarify the advantages and disadvantages of planning of single-room PICU.

Conclusions are following; 1) The space is adequate when the distance between beds is 4,000 mm. 2) However, the distance of 4,500 mm may have advantages. 3) Single-room has a great advantage from the viewpoint of FCC because the benefits of family stay are more significant to children patients. 4) The planning to secure adequate working area and good visibility are needed.

1. Introduction

Japan enjoys the longest life expectancy in the world. In addition The Japanese Ministry of Health, Labour, and Welfare (MHLW) claims that the infant mortality rate of those one-month after the birth is 1.8 in every 1,000 births, which is the lowest in the world (Tanaka, 2004). However, the MHLW claims in 2006 that the pediatric mortality rate of age one to four is 1.2 in every 1,000 births, which is 21^st ranking in the World. When compared to seven industrialized nations: France, USA, UK, Italy, Germany, Canada, and Japan, the figure in the USA is highest and that of Japan is the second highest at this age range (Tanaka, 2004). Therefore, it was considered as one of important issues in pediatric care in Japan. According to The Vital Statistics of the MHLW, recently, the pediatric mortality rate of age one to four decreased year by year except 2011 affected by the Great East Japan Earthquake from 40.2 per 100,000 people in 1994 to 19.3 in 2014 (MHLW,2018). One of the reasons include maintenance of medical system with a central focus on Pediatric Intensive Care Unit (PICU). However, as of 2006, the numbers of PICU beds were quite low and a guideline for maintenance was not established. (The Japanese Society of Intensive Care Medical, 2007) To implement the remedy for this situation, the MHLW revised the payment system for PICU service to enhance the development of pediatric emergency medicine in 2012, and even further in 2014.

According to the report of the MHLW, the number of PICU beds increased from 22 facilities and 145 beds in 2008 to 41 facilities and 256 beds in 2014 and the issue of PICU beds has gradually improved. However, Sakurai et al. claims that the number of PICU beds required is 487 beds, thus, the number is still insufficient by more than 200 beds (Sakurai et al, 2006). Moreover, it is predicted that a number of children’s hospitals needed to be relocated or re-build because of out-dated functions and over-aged facilities. Thus, it is assumed that continuous maintenance is necessary.

Children patients are more easily affected by their surrounding environment, and family-ties are stronger when compared to those of adult patients. Also, the rights of children patients and their families should be observed to enhance the Quality of Life (QOL). In terms of Family Centered Care (FCC), it is considered that planning with a focus on use of single-rooms has advantages. However, the general trend of PICU planning in Japanese children’s hospitals is the use of open-bay. Having the recent case of PICU development with half of bed provided as single-rooms in a twenty bedded unit, this paper aims to clarify the advantages and disadvantages of PICU planning with a focus on use of single-rooms. In this paper, a single-room is defined as a room in which four sides of the bed are segregated with partition walls or fittings.

2. Research Outline

In this study, a survey of behavioural observation was carried out to analyse the working area of PICU. This study looks into cases in which children patients were transported from the surgical operating department or those arranged with a number of medical equipment because of high-risk cases. In addition, a hearing survey on planning with a focus on single-room PICU was carried out to analyse the merits and demerits of single-room.

A Hospital is planned with two single rooms and a main open-bay bed area of eight beds. The distance between beds in the open-bay area is three meters or twenty feet which is comparatively narrow. An adjacent High Care Unit (HCU) is used integrally. And, the department floor area is comparatively large because the area for physicians’ resting room and pharmaceutical dispensing room, which are commonly used by two units, are counted as department area.

B Hospital is a case with high single-room rate counting seven of ten bedded unit. However, the distance between beds in the open-bay area is three meters and the width of single-rooms is 3.5m between wall ceenters. Thus, the distance between beds is comparatively narrow. In addition, the department floor area is the smallest among the cases.

At C Hospital, Surgical Intensive Care Unit (SICU) which is used integrally is considered as PICU. Two of total eight beds are provided as single-rooms and the distance between beds in open-bay area is 3.8~3.9m. Thus, the distance between beds is comparatively wide. In addition, Coronary Care Unit (CCU) and HCU are planned on the same floor and related diagnosis and treatment functions are provided accordingly to clinical subdivision. Therefore, the number of beds managed by single staff station is small.

D Hospital is a case with comparatively high single-room rate and eight of sixteen beds are provided as single-rooms. The width of single-room and the distance between beds in open-bay area is four meters which is comparatively wide. In this hospital, PICU occupies a certain floor length because the unit is placed in a newly constructed emergency & accident building. All beds are provided with windows and department floor area is 2~3 times the size of other cases.

3. Analysis on the Working Area of Open-Bay Beds

The distances between beds of hospitals which were completed before 2012 were less than 3,500 mm and those completed after 2012 were nearly 4,000 mm. In the survey of 2014, the average distance between beds was 3,430 mm and the size in two of thirteen hospitals were more than 4,000 mm. It is considered that cases which were built after 2012 were planned with relatively wide distance between beds. The planning cases like this may increase for the improved medical treatment environment in future. The distance between bed is defined in Fig 5.

Fig5. Distance between beds

3.1. Layout around the Bed while Patients Rested

Figures 6~8 show standard layout of medical equipment around the bed when there is no patient in four hospitals. C Hospital was not surveyed because all beds were occupied during the survey. The distance between beds of A Hospital is 3,000 mm, B Hospital 3,400 mm, C Hospital 4,000 mm, D Hospital 4,000 mm both of open-bay and single-room. A Hospital beds were placed in 45-degree angle to expand the working area because the distance between beds was more narrow than those of other hospitals. The essential pieces of medical equipment for diagnosis and treatment arranged around the bed, and others were arranged on the aisle side.

Fig6. Equipment Layout of Hospital A Fig7. Equipment Layout of Hospital B

　 Fig8. Equipment Layout of Hospital C

Table2.Equipment List

3.2. Layout around the Bed after Patient Transport

One of the main reason to enter PICU is the management of pre and post-operative care. The patient transportation from the surgical operating department is a frequently carried out case. In addition, more staff engaged in treatment and a large working area was necessary. Therefore, for the purpose of analysis on working area, these cases are considered important.

Figures 9~12 show the phases when a patient was transported from the surgical operating department to PICU at open-bay of D Hospital. Fig. 9 shows the phase when a patient was transported from the operating department by two doctors and three nurses. Thereafter, a sonogram was set up and a monitor was checked during the treatment (Fig. 10) and the patient was examined by the sonogram (Fig. 11). Furthermore, the patient was at a rest state after the area around the bed was cleared and extra equipment was removed (Fig. 12).

The extra medical equipment was moved to an adjacent bed area because the bed was unoccupied at this stage. If the distance between beds is secured as 4,000 mm, the treatments are carried out at ease. In addition, the treatment needing more space is possible in the open-bay depending on the condition of adjacent beds.

Fig9. Case of after Operation (phase1) Fig10. Case of after Operation (phase2)

Fig11. Case of after Operation (phase3) Fig12. Case of after Operation (phase4)

3.3. Layout around the Bed When a Patient was Examined and Treated

Fig. 13 shows the case of a haemodialysis patient in B Hospital. A number of equipment are arranged around the bed when a dialysis machine and an extracorporeal membrane oxygenation (ECMO) are used. Therefore, this is one of the cases that the security of the working area is necessary.

The working area is limited, if the dialysis machine and the cart are arranged at both ends of the bed. Therefore, it is considered that the distance between beds of 3,400 mm is slightly narrow as a working area. It is considered if the distance between beds is secured as 4,000 mm, the space is adequate in case of treatment with staff standing on both sides of bed.

Fig. 14 shows the case of cardio-vascular (CV) catheter exchange for a patient with heart disease in A Hospital. The number of medical equipment is small around the bed and beds are placed at 45 degrees angle. Therefore, it is considered that the working space is adequate.

Fig13. Case of Dialysis Fig14. Case of CV

3.4. Analysis on the Working Area

When a patient rests, the minimum number of medical equipment is arranged around the bed. Therefore, the distance between beds of 3,000 mm is considered to be adequate. However, when a patient is transported from the surgical operating department and a number of medical equipment are arranged around the bed, the distance between beds should be secured as 4,000 mm. Moreover, the working area can be expanded by moving the adjacent bed if it is unoccupied.

4. Analysis on the Working Area of Single-Room Beds

4.1. When ECMO is Used

Figures 15~21 show the treatment using ECMO for an emergency patient who was transported in D Hospital. In this case, a number of medical equipment and staff are necessary and it is considered that it is one of the most crowded cases around the bed. Adjacent single-rooms were unoccupied during the treatment and all doors between single-rooms were opened. In addition, equipment which were not used during the treatment were moved to adjacent single-room to secure space. A medicine cart which was used during the treatment was placed in adjacent single-room.

Fig. 15 shows the state of a patient at the time of transport and treatment was prepared. Thereafter, a patient was examined by a sonogram and a treatment by ECMO was started (Fig.16), stainless cart and electric knife, ECMO were brought inside (Fig.17). After a treatment by ECMO, the patient was examined by the sonogram and other treatment was started (Fig.18). After the treatment, the patient was examined by the sonogram again and a diagnostic x-ray apparatus (Fig.19). Finally, an electrocardiography was carried out (Fig.20) and a patient was at the rest state (Fig.21).

Carts could be arranged in adjacent bed rooms because single-room of D Hospital are divided with fittings, which are made of half walls and movable partition compatible to swinging doors. The number of the cases using ECMO is small. However, even if the distance between beds are secured by 4,000 mm, the working area is considered small if all pieces of equipment are arranged in working area, the adequate distance between beds may be considered as about 4,500 mm.

Fig15. Case of ECMO (phase1)

Fig16. Case of ECMO (phase2)

Fig17. Case of ECMO (phase3) Fig18. Case of ECMO (phase4)

Fig19. Case of ECMO (phase5) Fig20. Case of ECMO (phase6)

Fig21. Case of ECMO (phase7)

4.2. Analysis on the Working Area

It is considered the distance between beds of 4,000 mm is adequate when usual treatments are carried out. However, the distance between beds should be secured as about 4,500 mm because staffs who worked outside of working area were observed as in Section 3.2. and taking treatment by ECMO takes place as in 4.1. In addition, if rooms are divided with a movable partition like the one in D Hospital, it may be possible to secure a wider working area than usual.

5. Merits and Demerits of Planning with a Focus on Single-Room

5.1. Advantages of Planning of Single-Room

According to the staff hearing at D Hospital, patients who were transported from other hospitals, elder patents, and patients of the terminal period are tended to be placed in the single-room. PICU needs to correspond to a wide age range of 1-14 years old and the use of single-room is effective from the viewpoint of securing the privacy of patients with higher age. In addition, it is more effective against an infectious disease compared to using a curtain and/or a roll curtain in an open-bay setting.

According to the past study of the United States on the single-room PICU, it is noted that “The average duration and frequency of visits by patient’s families increase” and “Nurses work more frequently by the bed” are claimed (Erickson et al, 2011). Compared to an open-bay, it is hard to be affected by the situation of adjacent patients and it is easier to secure privacy. Therefore, it is assumed that the average staying time of patients’ families will increase in Japan as well. This will be a great advantage from the viewpoint of FCC because the benefits of families staying should be quite greater than those of adult patients.

5.2. Demerits and Countermeasures of Single-Room

(1) The Dead Angle Increases

According to the staff hearing at D Hospital, it was pointed out that nurses were listening to sounds in the environment to understand the situations. However, in a single room composition it was difficult to hear the sounds of distant beds from the staff station and the dead angle increases. In this hospital, the introduction of new systems and the increased number of staff is considered as countermeasures. In addition, it is also one of countermeasures to divide nursing units by clinical disciplines as in C Hospital, so that the number of beds in one unit will be smaller and the possibility of dead angle from staff station decreases.

(2) Working Area is Limited

In the open-bay, it is possible to expand the working area when adjacent beds are unoccupied. However, treatments are carried out in the limited working area if both sides of the single-room are fixed walls of the non-movable partition. It is one of countermeasures to use movable partition as in D Hospital and the distance between beds should be secured as about 4,500 mm.

6. Conclusion

The space is adequate with distance between beds is 4,000 mm at the time when a patient is resting and during transportation period. However, this distance is slightly narrow when a number of equipment are used. It is considered that distance of 4,500 mm may have more advantages. Also, in a single room situation use of movable partitions should be used to realize a similar flexibility of open-bay plan.

In addition, pros and cons of the single-room were considered with reference to staff hearing and the United States documents. The increase in the average duration of stay and frequency of visits of patient’s families was pointed out by this reference. It is a great advantage from the viewpoint of isolation of the infectious patients and securing privacy because it is difficult to be affected by adjacent patients.

On the other hand, problems are that the nurses’ movement lines are lengthened and it becomes difficult to grasp the state of patients from the staff station. The introduction of new nursing system, the increased number of staff, and the use of sub-divisional units by clinical disciplines may be needed.

As a whole, it is considered that the planning with a focus on single-room has enough advantages, however, the planning of securing working area and good visibility are needed to realize the scheme in the floor area hungry Japan.

7. Reference

American Hospital Association (AHA) Institute for Family-Centered Care (2004). Strategies for Leadership: Patient and Family-Centered Care. Retrieved from http://www.aha.org/advocacy-issues/quality/strategies-patientcentered.shtml

Erickson, C, Kattelmann, K, Remington, J, Ren, C, Helseth, C, Stevens, D (2011), Traditional open-bay versus single-family room neonatal intensive care unit: a comparison of selected nutrition outcomes, Research and Reports in Neonatology vol.1, pp.15–20.

Ministry of Health, Labour and Welfare (WHLW) (2018). Demographic statistics. (refer August 10th.2018), (language: Japanese).

Sakurai, T and Tamura, M (2006), A Study on the proper placement of Pediatric Tertiary emergency medical facilities holding Pediatric Intensive Care Unit, Children Care, Vol.110, No.5, pp.656～662 (language: Japanese)

Tanaka, T. (2004). Present Situation and Future Prospects of Pediatric Emergency Medicine. Tokyo: Shindan To Chiryo Sha (Diagnosis and Treatment Publishing), (language: Japanese).

The Japanese Society of Intensive Care Medical (2007); ‎Standards for the Establishment of Pediatric Intensive Care Unit, Japanese Society Intensive Care Medical, Vol.111, No.10, pp.627-638.