Wednesday, May 16, 2012

News flash: Patients don't like isolation precautions!

A new study in the May issue of Infection Control and Hospital Epidemiology compares HCAHPS survey responses between patients who were isolated during hospitalization and those who were not. HCAHPS is a patient satisfaction survey used by CMS as part of its value based purchasing program. The study involved survey results from over 8,000 patients at the Cleveland Clinic, a hospital with a superb reputation for customer service. Of the isolated patients, nearly three-quarters were in contact precautions (of note, the authors point out that patients are not routinely isolated for MRSA or VRE at their hospital). Findings of note included:

  • Isolated patients were more likely to report problems with physician communication (treatment with respect and courtesy, careful listening, understandable explanations)
  • Isolated patients less commonly reported obtaining timely help after pressing the call button and less help with toileting
  • Isolated patients more commonly reported that their room was not kept clean
  • Isolated patients were less likely to recommend the hospital to friends and family
It's worth repeating that isolation is the only intervention in medical care in which the person receiving the intervention bears all the burden and accrues none of the benefit. In hospitals where compliance with hand hygiene is high, it's time to re-evaluate the incremental benefit of contact precautions on transmission of multidrug resistant organisms.


1 comment:

  1. This is a really thought provoking proposal. I’m not sold on prioritizing patient dissatisfaction with isolation precautions as a rationale for looking for other strategies, but I think in the bigger zeitgeist of evidence based improvement in practice, cost effectiveness, and the downstream health and business benefits of receiving/delivering what is perceived to be good customer service, it’s totally worth exploring the idea that a better way of preventing MDROs could be conceived and implemented.

    My brain immediately went to CDI. I came to nursing and the hospital environment after a respectable 8 year stint in biomedical research, so I only have about 16 months’ worth of observations, but in about 900 hours of direct patient contact, not once have I encountered a patient on enteric precautions who actually had active diarrheal symptoms. They were all waiting, sometimes days, to be “cleared” by three negative stool samples. Meanwhile, the trashcans repeatedly filled to overflowing with disposable gowns, and adherence to proper donning/doffing (or PPE use at all) was noticeably variable among staff. It has given me multiple excuses to think long and hard about the natural history and microbiology of CDI and whether the PPE that is used really does any good. Would excellent and consistent adherence to hand hygiene on the part of healthcare workers and bleach or other sporicidal methods of room decontamination – without PPE – be enough, at least in cases where the patient’s diarrhea has stopped?

    Recent evidence (link 1 at bottom) alluringly suggests that in a non-outbreak, endemic setting, transmission of C. difficile is not easily attributed to ward-based contact. To me this suggests that, among other things, disruption of the gut microflora (antibiotic use) (link: needs to be more widely recognized and addressed.

    Specific to HAIs of the GI tract, another simple measure I’m determined to work on is getting the patients themselves to wash their hands. I’ve helped patients to the restroom and back to their beds, then watched them reach straight for their food trays. More than once, I have seen this happen in elderly patients whose fingers were visibly soiled with fecal material. Of course I intervene with a soapy washcloth or hand sanitizer whenever possible, but how common is this phenomenon, and would addressing it make a difference in HAI transmission? Think of all the places those hands have been: door handles, finger pulse oximeters, toilet flush levers, bedrails on the hospital bed, the transport bed, the radiology bed… This is fecal-oral at its best, baby. What if hospitals included single-use towlettes on food trays, located sinks in accessible spots wherever possible (human process engineering), and campaigned energetically with nursing staff, dietary staff, and patients themselves to just wash their hands?

    So what would it look like to have moved past the knee jerk global use of isolation precautions? How would this be implemented on the ground in a way that would be better than what we achieve with the sort of “herd immunity” that mass use of barrier-type protection ostensibly provides? I think this is an idea worth exploring, with special attention to what human and microbial factors are really at play in the etiology and transmission of HAIs. To really get something like this right, it’s worth a collaboration between multiple stakeholders, including but not limited to physicians, infection preventionists, nurses, and patients.

    Sarah Timberlake, BS Microbiology, BS Nursing

    Link 1:;jsessionid=8F6ACB70287EB9E9710F5DE74BA9356D?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.1001172&representation=PDF