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Evaluation of the Inpatient Hospital Experience while on Precautions

Abstract:

The objective of this study was to assess the satisfaction and overall experience of hospitalized

patients who are managed using contact or airborne isolation precautions (precautions) compared

to patients not on precautions. Increased understanding of differences in patient satisfaction will

provide hospitals with a basis for process improvements. Recent Center for Medicare and

Medicaid Services (CMS) policy changes whereby hospital reimbursement is directly correlated

with patient satisfaction, add impetus to such initiatives. This study demonstrated small

variations in perceived positive experiences and related satisfaction of patients on precautions

when compared to patients on no precautions. Specifically, variations were apparent in areas

related to nurse communication, timely help from hospital staff, pain control and overall patient

satisfaction. No statistically significant difference in patient satisfaction was noted between the

groups, related to doctor communication; however patients on precautions expressed higher

satisfaction with treatment explanations than those not on precautions.

Background:

A major issue in delivery of health care today relates to the overall patient experience during the

inpatient hospital stay. Recently, several studies have been conducted to determine the adverse

effects that patients experience when under contact precautions or in isolation due to their

diagnoses. In the Stelfox, Bates, and Redelmeier (2003) study entitled “Safety of Patients

Isolated for Infection Control,” the treatment of patients in isolation versus contact precautions

was reviewed. Study results revealed that isolated patients were more likely to experience

adverse behaviors from clinical care practices including but not limited to lack of physician

attention and failure to record detailed patient medical status, and more formal displeasure of the

patient with the care provider. Similarly, “Adverse outcome associated with contact precautions:

A review of the literature,” by Morgan, Diekema, Sepkowitz, and Perencevich (2009), examines

specifically those patients on contact precautions. The researchers found that there is less patient-

health care worker contact, delays in recovery process and diminished quality of care outcomes

by the patient, including increased likelihood of depression and anxiety, and decreased overall

patient satisfaction with their care in relation to patients not on contact precaution. In addition, in

the Abad, Fearday, and Safdar (2010) study “Adverse effects of isolation in hospitalized patients:

a systemic review,” monitored the experiences of patients placed in isolation due to disease

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transmission concerns. In the study, the researchers found that patients were uninformed of their

healthcare, their safety and recovery were at risk, and physicians spent less time in contact with

patients. The three articles support that patient satisfaction during episodes of isolation and

contact precautions may be comprised.

Due to the recent federal health care reform legislation, many changes in the delivery and

payment of hospital care have been enacted. As a result of the Patient Protection and Affordable

Care Act (PPACA, 2010), value based purchasing incentives will be required by hospitals

starting FY 2013. Hospital performance will be evaluated based on a process of care measures

and experience of care dimensions. Thirty percent of the hospital incentive payment will be

made based on experience of care domain found through the Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS) fact sheet and survey from the Center for

Medicare and Medicaid Services. Each patient will be asked questions about their recent

treatment at the hospital; eight measures are specifically geared toward the patient’s experience

with care providers and the hospital environment. The higher the score for the hospital, the

greater the incentive payment the hospital receives. Therefore, it is to the hospitals advantage to

provide the patients with exceptional care and a positive patient experience.

Method:

A cross-sectional, convenience survey was performed in the general medicine wards at Yale-

New Haven Hospital. It is a 966-bed private, nonprofit teaching hospital. Yale-New Haven is

the largest acute care provider in southern Connecticut and one of the Northeast's major referral

centers. Yale-New Haven Hospital discharges more than 50,000 patients each year. At this

hospital, the contact precautions protocol requires that persons entering an isolation room wear

fit-tested N95 respirator, gloves and gowns. Airborne isolation precautions require patients to be

placed in negative pressure rooms and those entering the room to wear gloves, gowns and masks.

For the purpose of this study either type of situation was classified as a patient being on

“precautions”.

Patients in airborne isolation were eligible for inclusion in the study if they had been isolated for

at least two consecutive days. Non-isolated (no precautions) patients were eligible if they had not

been isolated during the hospitalization and had a stay of at least two days.

In the event that the participants initially chosen were unable to participate, due to being

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unavailable, unable, or asleep, the investigator moved on to the next target participant. Patients

on precautions selected for study inclusion were located in close proximity (e.g. same floor or

wing) to establish a consistency among the participants. If patients refused to participate the next

room was approached. The interviewer and interviewee took all necessary personal protective

precautions throughout recruitment, enrollment and interview activity portions of this study.

A literature review of similar studies was conducted and a draft survey instrument consisting of

hybrid versions of previous instruments was created, reviewed by the authors and finalized. The

interview tool and study methodology was reviewed by the human investigations committee and

was determined to be exempt from review.

Interview questions were generally yes/no or likert scale in nature. Open-ended comments

regarding responses were also collected. During the study period, the investigator obtained a

daily list of current inpatients being treated under contact, droplet, or air-borne isolation. From

the list patients were selected based on age, gender, type of isolation precautions, type of unit in

hospital, and length of stay.

Before the survey was administered patients were briefed on the purpose of the study and

permission to proceed with the survey questionnaire was requested. A paper-based copy of the

questions was brought into each patient interview. The paper-based copy was filled out during

the interview by the interviewer. Following each interview the interviewer entered the data into a

web database for analysis. The recruitment, enrollment and interviews were generally completed

in 15 minutes or less.

Patients were interviewed during their hospitalization to maximize participation, minimize recall

bias, and minimize collection of non-relevant data. The survey questions were designed to obtain

demographic data such as ethnicity, age, diagnosis, and length of stay and to explore patient

satisfaction with caregiver communication/explanations, timely assistance from hospital staff,

pain control and overall hospital experience.

Results:

Eighty-seven patients were interviewed between August 1 and August 19, 2011. All 87 patients

were under medical care. Out of the 87 patients, 59 were cared for under contact precautions and

28 were cared for under no precautions. Two patients on isolation precautions and one in non-

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isolation (no precautions) declined participation in the study. Table 1 illustrates that a total of 59

patients were on some type of precaution protocol (67.82%). Most of the patients were on

contact precautions (61%). Differences in baseline demographics between those patients with

and without precaution protocols applied are shown in Table 1.

Table 1:

Population Demographics

n=87  No  Precautions  (32.18%)  

Precautions  (67.82%)  

Age          10  to  19   1  (1.15%)   0  20  to  39   6  (6.90%)   7  (8.05%)  40  to  49   8  (9.20%)   10  (11.49%)  50  to  59   5  (5.75%)   14  (16.09%)  60  to  69   2  (2.30%)   11  (12.64%)  70  to  79   5  (5.75%)   10  (11.49%)  80  to  89   1  (1.15%)   7  (8.05%)  Gender          Female   13  (14.94%)   31  (35.63%)  Male   15  (17.24%)   28  (32.18%)  Race          Black   5  (5.75%)   15  (17.24%)  White   20  (22.99%)   39  (44.83%)  Other   3  (3.45%)   5  (5.75%)  

All patients were asked a series of questions on a four-point Likert scale reflecting their

satisfaction with elements of patient care including caregiver communication (nurse and doctor),

explaination of treatments (medications and procedures), timely help from hospital staff, pain

control, cleanliness and overall assessment of the hospital experience. The patient survey

questions and interview schedule are given in Appendix 1.

Tables 2 – 7 show the average scores for responses to indicated questions on a 4-point Likert

scale, where 1= never, 2= sometimes, 3= usually and 4= always.

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Graph 1: Patient Assessment of Effective Nurse Communication

Patients on precautions reported that nurses were not as intersted in their care and recovery, in

comparison to the patients not on precautions. Also, when questioned about nurses explanations,

being interrupted, and speaking too fast, precautions patients experienced these disastifactory

communications more frequently than those patients not on precautions. The greatest statistical

signficiance was found in the speaking too fast category with a p values of less than 0.0001.

Following this, was the frequency of nurse interruption with a p value of 0.0006.

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Graph 2: Patient Assessment of Effective Doctor Communication

Both patients on precaution and patients on no-precaution felt that the doctors always seemed

intersted in their care and recovery. However, patients on precautions reported higher instances

of confusing doctors’ explanations, being interrupted by doctors, and doctors speaking too fast

than did patients not on precuations. The categories with the greatest statistical significancy were

the difficulty of doctors explanations and doctor’s speaking too quickly both with p values of

less than 0.001 Doctors interrupting patients followed this with a p value of 0.002.

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Graph 3: Patient Assesment of Health Care Providers Treatment Explanations

Precaution and non-precaution patients were almost equally knowledgeable of the treatment

being received. Patients not on precautions reported that they less frequently received

descriptions of treatments in ways they could fully understand but there appeared to be limited

variation in the experience of explainations regarding the intent of new treatments for either

group.

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Graph 4: Patient Assessment of Timeliness of Help from Hospital Staff

Overall, both precautions and non-precaution patients reported timeliness of the hosptial staff in

regards to the prompness of call button and bathroom response. However, patients on

precautions did express a marginally less perceived adequate response to call buttons as

compared to patients not on precautions.

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Graph 5: Patient Assessmnet of Effectivness of Pain Control

While in general all patients reported that pain was usually or always controlled, those patients

on precautions expressed a slightly lower level pain control than those patients not on

precautions.

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Table 2: Patient Overall Rating of Hospital

Where 0 is the worst hospital possible and 4 is the best hospital possible, what number would you use to rate this hospital? Answer Options

1 Worst hospital

ever

2 3 4 Best hospital

ever

Rating Average

Response Count

Precautions 0 1 39 19 3.31 59 No Precautions 0 0 11 17 3.61 28 On a scale of 1 (worst possible) to 4 (best possible), those patients on precautions rated the

hospital an average of 3.31, those not on precautions rated it an average of 3.61. The p value of

this chart is 0.01.

Table 3: Patient Assessment of Possible Improvements

Are there ways your hospital experience can be improved? Please rank the following as less important to more important with 4 being most important and1 least important Answer Options Precautions No

Precautions More frequent visits by the doctor to check on you? 3.34 3.04 The doctor demonstrating interest in your care and recovery? 3.80 3.57 The doctor taking more time with you during your visit? 3.19 3.25 Having a clearer understanding of your illness and treatment? 3.19 3.29 More frequent visits by the nurse? 2.83 3.00 The nurse demonstrating interest in your care and recovery? 3.66 3.50 A greater sense that the nurse cares about you? 3.41 3.18 The nurse spending more time with you during visits? 2.83 2.93 The doctor asking if you understand your treatment and medications?

3.22 3.04

The nurse asking if you understand your treatment and medications?

3.08 3.07

The nurse asking if there is anything that she can help you with? 3.29 2.96 Having better quality food? 2.61 2.79 Comfortable room temperature? 2.95 3.18 Having a nicer room, lights, quieter, TV selection, etc.? 2.41 2.71

All patients ranked caregiver (nurse and doctor) demonstration of interest in their recovery as the

way their hospital experience could be most improved. Overall the patient care elements (nurse,

doctor, frequency and length of doctor visits) rated highest on the patients on precautions desired

elements for improved hospital experience. One exception was that patients on precautions did

not rate highly “nurses spending more time with you during visits”. Room temperature, food and

room quality were not issues noted as high ranking by patients on precautions. However, patients

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not on precautions rated comfortable room temperature and more frequent nurse visits higher

than patients not on precautions.

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Discussion:

Using a patient satisfaction survey, no significant difference in experience was found between

patients with or without precautions in response to questions regarding inpatient care. When

queried on all areas of patient care, patients on precaution and those on no-precaution reported

similar levels of patient satisfaction. Although patients on precautions expressed less satisfaction

in all areas, the difference is fairly minimal. Some have suggested that because nurses and

doctors have to take the time to put on protective wear when entering a precaution patient’s

room, they may visit the room less frequently (Abad et al. 2010). This may give patients an

impression that health care providers are less concerned with their well-being. Similarly, the

presence of personal protective equipment may cause the patient to feel more separated from

contact. Additionally, increased hospital acquired complications, most of which are preventable,

result from reduced contact with health care workers (DICON 2011). The period of stay could

also be a factor in the slightly lower ratings among the precaution patients. In general, precaution

patients stay longer in the hospital than non-precaution patients and are often readmitted at a

later time (Stelfox et al. 2003). Prolonged sickness could lower the satisfaction level of patients

and influence their questionnaire responses. Severity of illness may also negatively impact the

answers given and have resulted in lower averages among the precaution patients in contrast to

non-precaution patients. Conversely, because more efforts are required to visit a precaution

patient’s room, health care providers might have spent more time with such patients because

visits occurred less frequently. This may have been the reason that the ratings were generally

high and similar to the non-precaution patients’ averages.

One limitation of the study is due to patients who did not or were not able to participate. Their

answers could have influenced the study outcomes due to divergent experiences; responses from

these patients to the survey questionnaire could have differed significantly from those provided

by patients who participated. In addition, the use of a convenience sample versus a random or

assigned sample may have affected the study outcome. Because an unequal amount of precaution

and non-precaution patients were selected for participation in the study, the sample results may

have been impacted. Efforts were made to include all eligible patients, but the extent to which

the difference in availability of patients for interview may have affected the selected sample is

unknown. Also, due to the variability in the length of stay of patients in the hospital the average

amount of days in the hospital calculated is misleading. A majority of patients (95.4%) of

patients stayed in the hospital less than 30 days; however, three patients were hospitalized

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between100-116 days. The inclusion of these three patients in the study was to determine if the

length of stay impacted patient satisfaction levels, which was determined to be true. Finally, the

findings of this study may not be applicable to other setting with different patient populations

and/or processes in place for care delivery.

Boulding, Glickman, Manary, Schulman, and Staelin (2011) state, “patient- level measure not

only are more predicative and offer insights into a different dimension of hospital activities than

those obtained from clinical performance measure alone, but they also seem to be clinically

important in terms of providing a way to increase the quality of care (p.47). Based on the

findings of this study, a number of recommended actions to improve patient care can be

considered. In many hospitals, interventions are required for health care workers to optimize the

environment of care. One improvement that should be considered is increased staff education to

recognize specific patient behaviors and act in a way to accommodate the patient’s needs.

According to Gasink, Singer, Fishman, Holmes, Weiner, Bilker, and Lautenbach (2008), less

contact and attention received from healthcare workers by precautions versus non precautions

results in shortcoming in process of care as well as an effect on mood, psyche, and satisfaction.

When health care personnel are made aware of the complications and difficulties experienced by

patients on contact precautions or in isolation, understanding the potential difficulties

experienced by the patient may increase their sensitivity and potentially modify their activities.

Improved communications between health care providers and patients may result in higher levels

of trust and improved quality outcomes. Furthermore, greater social contact may lessen the

likelihood of depression, anxiety, and loneliness in patients (Morgan et al. 2009). These

recommended interventions could improve the patient experience while also increasing the

overall process of care and experience of care scores. This would likely result in higher incentive

payments and overall higher quality of patient care outcomes. Further study is required to

determine which approaches will most efficiently and effectively impact patients on precautions

satisfaction with their hospital experience.

References:

Abad, C., Fearday, A., & Safdar, N. (2010). Adverse effects of isolation in hospitalized patients:

A systemic review. Journal of Hospital Infection 76, 97 – 102.

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Boulding, W., Glickman, S.W., Manary, M.P., Schulman, K.A., & Staelin, R. (2011, January).

Relationship between patient satisfaction with inpatient care and hospital readmission

within 30 days. The American Journal of Managed Care 17(1), 41 – 48.

Duke Infection Control Outreach Network (DICON). (2011, April). Side effects of contact

precautions: Yellow means danger, delays, and depression for patients. Infection

Prevention News 6(4).

Gammon, J. (1998, June). Analysis of stressful effects of hospitalization and source isolation on

coping and psychological constructs. International Journal of Nurse Practitioner 4(2),

84-96.

Gasink, L.B., Singer, K., Fishman, N.O., Holmes, W.C., Weiner, M.G., Bilker, W.B., &

Lautenbach, E. (2008, March). Contact isolation for infection control in hospitalized

patients: Is patient satisfaction affected? Infection Control and Hospital Epidemiology

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<http://www.jstor.org/stable/10.1086/527508>.

Khan, F.A., Khakoo, R.A., Hobbs, G.R. (2006, September). Impact of contact isolation on health

care workers at a tertiary care center. American Journal of Infection Control 34(7), 408-

413.

Knowles, H.E. (1993, July 28- August 3). The experience of infectious patients in isolation.

Nursing Times 89(30), 53-56.

Kirkland, K.B., Weinstein, J.M. (1999, October 2). Adverse effects of contact isolation. Lancet

345(9185), 1177-1178.

Lewis, A.M., Gammon, J., Hosein, I. (1999, September). The pros and cons of isolation and

containment. Journal of Hospital Infection 43(1), 19 – 23.

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MacKellaig, J.M. (1987). A study of the psychological effects of intensive care with particular

emphasis on patient’s isolation. Intensive Care Nursing 2(4), 176 – 185.

Morgan, D. J., Diekema, D.J., Sepkowitz, K., & Perencevich, E.N. (2009). Adverse outcomes

associated with contact precautions: A review of the literature. American Journal of

Infection Control 37(2), 85 – 93.

Saint, S., Higgins, L.A., Nallamothu, B.K., & Chenoweth, C. (2003, October). Do physicians

examine patients in contact isolation less frequently? A brief report. American Journal of

Infection Control 31(6), 354-356.

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L. (2007, December). 2007 Guidelines for

isolation precautions: Preventing transmission of infectious agents in health care settings.

American Journal of Infection Control 35(10 Suppl 2), S65-164.

Stelfox, H. T., Bates, D.W., & Redelmeier, D.A. (2003, October 3). Safety of patients isolated

for infection control. The Journal of the American Medical Association (JAMA) 29(3),

1899-1905. Retrieved March 6, 2011 from <http://jama.ama-

assn.org/content/290/14/1899.abstract>.

Tarzi, S., Kennedy, P., Stone, S., Evans, M. (2001, December). Methicillin-resistant

Staphylococcus aureus: psychological impact of hospitalization and isolation in an older

adult population. Journal of Hospital Infections 49(4), 250-254.

Ward, D. (2000, February 10-23). Infection control: Reducing the psychological effects of

isolation. British Journal of Nursing 9(3), 162-170.

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Appendix 1: Survey Instrument

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