The case against hospital beds


https://www.politico.com/agenda/story/2017/11/08/the-case-against-hospital-beds-000575

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Two summers ago, I opened The New York Times Magazine and saw a startling centerfold ad that seemed to foretell the future: a sweeping panoramic image of people relaxing and strolling in Central Park, overlaid with large block text that read, “IF OUR BEDS ARE FILLED, IT MEANS WE’VE FAILED.” You could hardly have guessed it was a hospital ad. The logo for the Mount Sinai Health System was stamped in the upper corner, almost like an afterthought.

Around the same time, I was beginning a project funded by the Robert Wood Johnson Foundation to examine whether hospitals and health care facilities are well designed for their modern purposes—to produce more health, rather than just deliver more health care. And it became clear that one of the most important challenges for hospitals to address will be a simple one: the association of hospitals with beds.

When the health care industry talks about hospitals, it tends to use the language of facility planners—one in which “patients” and “beds” are equivalent. This is the legacy of a very different era in medicine. Modern hospitals are historically rooted in the sanatoria and asylums of the mid-19th century, originally conceived to isolate patients with conditions such as tuberculosis and lunacy from the community, not to protect their rights. The move from open wards to closed rooms was perhaps the first major reform in hospital design—motivated by a need for isolation as our understanding of communicable diseases and infection control became more sophisticated.

Today, hospitals are struggling with the next reform—how to move on from an era when bedrest was the default medical therapy. When President Dwight Eisenhower had a heart attack in 1955—before we had beta blockers, angiograms and stents—his White House physician recommended prolonged bedrest. Today, bedrest is still the default treatment for stomach bugs and colds, certain types of musculoskeletal injuries and pregnancy conditions. And indeed, convalescing in bed has value for some conditions. But increasingly, we’re learning that even relatively short bed confinement can be unhelpful for many patients—and prolonged bedrest can be dangerous at worst. Getting up and walking, even after hip surgery, has been shown to improve circulation, prevent blood clots and promote wound healing.

However, this isn’t how hospitals are built. Currently, very few hospital spaces are designed with the assumption that most of our patients need to walk to be healthier. The patient in a gown staggering down a cluttered hospital hallway, IV pole in hand, is as comically out of place in real life as it is on TV. A patient canwalk, but it’s awkward. Patients are frequently required to dodge bustling clinicians, carts and stretchers along the way.

To fix the immediate challenge of letting patients walk in a building built around beds, some hospitals have begun investing in walking tracks or trails, as well as indoor and outdoor nonclinical-appearing “healing gardens.”

But our changing understanding of how people get healthier raises bigger design questions for hospitals—as well as the broader question of when hospitals are even the right place to get healthier. In my own specialty, obstetrics, there’s evidence that the current design of labor and delivery units may be associated with avoidable, and frankly harmful, C-sections. With colleagues at Boston’s Ariadne Labs and the MASS Design Group, we compared childbirth facilities across the country and found that there are no standards for how many labor rooms or operating rooms a hospital needs to have based on the number of babies it delivers. As a result, the capacity of hospitals to care for patients varied widely. Hospitals that had relatively more operating rooms and relatively fewer labor rooms tended to do more surgery.

Part of the reason may be that many of these units are retrofitted from spaces that were not originally intended to support normal labor. Indeed, for pregnant women, walking regularly throughout labor, particularly during the early phases, is thought to promote progress toward delivery.

Some corners of the health care world are already starting to embrace new, less bed-focused models of care. Ambulatory surgical centers have latched on to a strong business model for the growing number of operations for which several days in bed are neither required nor recommended. A venture-capital based birthing center franchise is currently aiming to do the same—birthing families are often admitted and discharged on the same day, and beds are in the corner of the room (for resting and breastfeeding after the baby is born), rather than in the center; the idea is to encourage the mom to use movement as much as possible to support her labor by literally sidelining the bed. Health systems are increasingly investing in other types of spaces where bedrest is not the default, including skilled nursing and rehabilitation facilities, as well as home visiting nurses and health coaches to help high-need patients with acute and chronic conditions stay out of the hospital.

It’s not just keeping patients in bed that could use a rethink—it’s keeping them all closed off. In 2017, both community and hospital-acquired infections are still a clinical concern, but the dominant threats to human health—heart disease and cancer, for instance—no longer require isolation. In fact, with the exception of a few acute instances in our lives, most of us benefit from the opposite. Former Surgeon General Vivek Murthy has recently characterized loneliness as the most common “pathology” he encountered in medical practice—insidious but present on an epidemic scale. Future hospitals may find opportunity to intentionally forge connections. A community hospital in Massachusetts recently created an early labor lounge for patients who did not yet need a labor and delivery room, but could not return home. Rather than curtaining her off, the lounge was set up to let mothers socialize with their families and with one another in a relaxing and comfortable setting. Anecdotally, the lounge seemed to be most effective at preventing premature hospital admission when it was full.

They may also get a boost from new payment models, in which health systems have an incentive to take on the challenge of population health management. Rather than getting paid by the procedure, which creates an incentive to put more patients in more beds and offer larger amounts of care, they’re opting for models in which they get paid for producing larger amounts of health—which requires considering where patients really get healthier, whether that’s at the hospital or in homes or in community settings. The future demands this shift, as year after year, the costs of care continue to rapidly outstrip the benefits.

Michael Murphy, a visionary architect who has pushed his field to consider ways that hospitals can better promote human health, claims that design is never neutral. He says design either hurts or it heals. The more we know about healing, the more it appears that health care spaces will need a different approach—one that sometimes looks more like a park than a long fluorescent hallway full of beds.

 

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