Perception of Care, Contact Precautions Entwined in Patients' Minds, Studies Find

By Kelly M. Pyrek

A recent study has found that patients placed in contact precautions were twice as likely to report perceived problems with care compared to patients without contact precautions, placing the common infection control practice at odds with hospital interests. These patient complaints are often reflected in diminished scores on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey, a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care developed by the Centers for Medicare & Medicaid Services (CMS) along with the Agency for Healthcare Research and Quality (AHRQ).

While many hospitals have collected information on patient satisfaction, prior to HCAHPS there was no national standard for collecting or publicly reporting patients' perspectives of care information that would enable valid comparisons to be made across all hospitals. In order to make "apples-to-apples" comparisons to support consumer choice, it was necessary to introduce a standard measurement approach. HCAHPS is a core set of questions that can be combined with a broader, customized set of hospital-specific items. The survey is designed to produce comparable data on the patient's perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. It is expected by CMS and AHRQ that public reporting of the survey results creates incentives for hospitals to improve their quality of care and enhance public accountability in healthcare by increasing the transparency of the quality of hospital care provided in return for the public investment.

The HCAHPS survey contains 21 patient perspectives on care and patient rating items that encompass nine key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. The survey also includes four screener questions and seven demographic items, which are used for adjusting the mix of patients across hospitals and for analytical purposes. The survey is 32 questions in length. Data submitted to the HCAHPS data warehouse is cleaned and analyzed by CMS, which then calculates hospitals HCAHPS scores and publicly reports them on the Hospital Compare website.

Contact precautions, which are routinely used in hospitals to prevent the spread of drug-resistant bacteria between healthcare workers and patients, mandate the use of disposable gowns and gloves by healthcare workers for all patient contact when a patient is in contact isolation. The impact of CP on patients' psyches has been debated by experts and weighed against the desire to stop the spread of healthcare-acquired infections (HAIs).
For example, a large retrospective cohort study found that those patients under contact precautions were much more likely to have made a complaint while in the hospital [Stelfox, et al. (2003)].  A recent case-control study used the Hospital Consumer Assessment of Healthcare Professionals and Systems (HCAHPS) questionnaire to measure inpatient satisfaction. Patients overall evaluation of the hospitalization was not affected by contact precautions; however, some HCAHPS measures were lower in patients under contact precautions [Gasink, et al. (2008)].  Another study of inpatients demonstrated an association between various forms of barrier precautions and lower HCAHPS scores for physician communication and staff responsiveness [Vinski, et al. (2012)].

As public reporting of patient satisfaction and patient outcomes becomes a national priority linked to hospital reimbursement, this study provides insight into how healthcare workers must balance evidence-based practice with a focus on patient satisfaction, says Preeti Mehrotra, MD, lead author of the study published in the October 2013 issue of Infection Control and Hospital Epidemiology. By creating a physical barrier, contact precautions may modify how healthcare workers interact with patients, affecting the patient experience and the perception of how care is delivered.

Studies have shown that by creating a physical barrier, contact precautions may modify how healthcare workers interact with patients, thereby affecting patients experience of care. (Morgan, et al. 2009) In addition, several studies have demonstrated that use of contact precautions has been associated with decreased healthcare worker visits, increased adverse events, and depression among inpatients. [Morgan, et al., 2009; Evans, et al. (2003); Stelfox, et al. (2003); Day, et al. (2012); Morgan, et al. (2013)]
In this latest study, Mehrotra and colleagues (2013) used a retrospective cohort study of 528 medical and surgical patients, comparing those patients who were placed in CP with those who were not in CP at the University of Maryland, Medical Center. Each participant underwent a standardized interview at enrollment in the study and on hospital days 3, 7, and 14, or until discharged. After discharge, the standardized interview and HCAHPS survey were administered by telephone for all patients who could be successfully contacted (88 patients). 

According to the researchers, patient perception of care was assessed by coded open-ended responses to standardized questions throughout hospitalization and after hospital discharge. Using a standardized interview, patients were asked the following questions: (1) Do you believe that there have been any problems with your care during this hospitalization? (2) Do you believe that you were hurt or stayed in the hospital longer than necessary because of problems with your care? (3) Do you believe that anyone made a mistake that affected your care during this hospitalization? These questions were developed and validated in multiple earlier studies. Patient responses were categorized into the following six different types: waits and delays, poor communication, environmental issues, poor coordination of care, poor interpersonal skill and unprofessional care, and lack of respect for patient needs and preferences.
Of the 528 study participants, 238 participants (45 percent) were under contact precautions at hospital admission. On hospital day 3, 298 participants (56 percent) remained in the hospital, including 149 (50 percent) under contact precautions. On hospital day 7, 55 subjects (10 percent) remained, of whom 28 (51 percent) were under contact precautions. Study subjects reported a total of 135 perceived problems with care. After adjusting for confounding variables, contact precautions were associated with more frequent perceived problems with care overall. Patients under contact precautions generally perceived that their care suffered from poor coordination and a lack of respect for patient needs and preferences.

The researchers report that patients under CP perceived a lack of respect for needs and preferences. As one patient had said, Nobody understood why I was so upset or anxious. I didnt get the emotional support I needed and nobody cared that that is what I really wanted and maybe needed. Still another patient remarked that I am isolated here. When people put on the gowns, I feel dirty and alone [They] even had to wear them when I was being wheeled around for tests.

As Mehrotra, et al. (2013) note, "It is unclear whether patients perceived care that was truly worse or whether the experience of being under contact precautions changed their perception of standard care. It would be of greater concern if the former were true, as suggested by past studies. However, even if care was standard, diminished perception of the quality of care can impact patient satisfaction and ultimately hospital reimbursement related to hospital HCAHPS scores. How hospitals can improve patient perception of care is unknown. The Centers for Disease Control and Prevention (CDC) recommends that, for patients under contact precautions, hospitals should counteract possible adverse effects on patient anxiety, depression, and other mood disturbances; perceptions of stigma; reduced contact with clinical staff; and increases in preventable adverse events, and the Society for Healthcare Epidemiology of America (SHEA) recommends that it is necessary to determine the safety of isolation and optimizing practice to ensure the best outcome of patients. A simple start with few downsides is staff education to correct for fewer patient visits and patient education to help patients better understand the reasons for contact precautions. Although standard CDC training is already implemented at our hospital regarding patient education about contact precautions, there is limited conversation regarding the positive and negative effects of contact precautions. Ultimately, if interventions cannot improve actual patient care and perceptions of care of those patients under contact precautions, a cost-benefit assessment may be necessary to determine when contact precautions have an overall beneficial effect for patients and should be used."

The researchers suggest interventions should be developed to ensure that all patients, whether placed in contact precautions or not, receive the same quality of care. This includes staff education to ensure more patient visits and patient education to help patients understand the reasons for contact precautions. Additionally, the researchers recommend starting a dialogue among healthcare management and workers regarding the positive and negative effects of patient isolation procedures.

Another recent study found that patients under CP have more symptoms of depression and anxiety at hospital admission but do not appear to be more likely to develop depression, anxiety, or negative moods while under CP. The researchers say that the use of contact precautions should not be restricted by the belief that contact precautions will produce more depression or anxiety. In this prospective frequency-matched cohort study at the University of Maryland Medical Center, a 662-bed tertiary care hospital in Baltimore, Day, et al. (2013) approached a total of 1,876 medical and surgical patients over the age of 18 years; 528 patients were enrolled from January through November 2010, and 296 patients completed follow-up on hospital day 3. The primary outcome was Hospital Anxiety and Depression Scale (HADS) scores on hospital day 3, controlling for baseline HADS scores. Patients under CP had baseline symptoms of depression 1.3 points higher and anxiety 0.8 points higher at hospital admission using HADS. Exposure to CP was not associated with increased depression or anxiety on hospital day 3. According to the researchers, on hospital day 3, patients under CP were no more likely than unexposed patients to be angry (20 percent versus 20 percent), sad (33 percent versus 38 percent), worried (51 percent versus 46 percent), happy (58 percent versus 67 percent ), or confused (23 percent versus 24 percent).

Day, et al. (2013) note, "We found that patients under contact precautions had more symptoms of depression and anxiety at hospital admission. However, over three days of exposure to contact precautions, we observed no increase in symptoms of depression or anxiety. Furthermore, we found no significant changes in anger, worry, happiness, sadness or confusion related to contact precautions." They add, "Contact precautions have been associated with worse outcomes. Our study provides evidence that while contact precautions are associated with depression and anxiety, depression and anxiety do not worsen with exposure to contact precautions. Use of contact precautions should not be restricted by the belief that contact precautions will produce more depression or anxiety, although patients placed under contact precautions may benefit from mental health assessment because of increased depression and anxiety at baseline."

References

Day HR, Perencevich EN, Harris AH, Gruber-Baldini AL, Himelhoch SS, Brown CH, Morgan DJ. Depression, anxiety and moods of hospitalized patients on contact precautions. Infect Control Hosp Epidemiol 2013:34:251-258.

Day HR, Perencevich EN, Harris AD, et al. Do contact precautions cause depression? a two-year study at a tertiary care medical centre. J Hosp Infect 2011;79:103107, doi: 10.1016/j.jhin.2011.03.026.

Day HR, Perencevich EN, Harris AD, et al. Association between contact precautions and delirium at a tertiary care center. Infect Control Hosp Epidemiol 2012;33:3439, doi: 10.1086/663340.

Evans HL, Shaffer MM, Hughes MG, et al. Contact isolation in surgical patients: a barrier to care? Surgery 2003;134:180188, doi: 10.1067/msy.2003.222.

Gasink LB, Singer K, Fishman NO, et al. Contact isolation for infection control in hospitalized patients: is patient satisfaction affected? Infect Control Hosp Epidemiol 2008;29:275278.

Mehrotra P, et al. Effects of Contact Precautions on Patient Perception of Care and Satisfaction: A Prospective Cohort Study. Infection Control and Hospital Epidemiology 34:10. October 2013.

Morgan DJ, Pineles LL, Shardell M, et al. The effect of contact precautions on healthcare worker activity in acute care hospitals. Infect Control Hosp Epidemiol 2013;34:6973.

Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control 2009;37:8593, doi: 10.1016/j.ajic.2008.04.257.

Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA 2003;290:18991905.

Vinski J, Bertin M, Sun Z, et al. Impact of isolation on hospital consumer assessment of healthcare providers and systems scores: is isolation isolating? Infect Control Hosp Epidemiol 2012;33:513516, doi: 10.1086/665314.