Reconciling patients and health professionals' perspectives for quality and safety in healthcare

All health professionals have important roles to play in actively affording patient safety through infection prevention and control, write Dr Ramon Z Shaban, Mary-Rose Godsell and Professor Jenny Gamble.

Healthcare associated infections are a global burden. Despite recent advances in treatment of disease, transmission of infections within healthcare settings continues to occur. Infection or colonisation of multi-resistant organisms (MROs) such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and gram-negative bacteria are endemic and ubiquitous.^{1, 2} In Australia, approximately 200,000 healthcare-associated infections occur each year, with increased morbidity and mortality, increased patient lengths of stay and healthcare costs. Clostridium difficile infection (CDI) is a more recent ongoing concern, particularly hypervirulent C. difficile (B1/NAP/027) that has been reported in northern hemisphere countries and more recently in Australia.^3,4 Outbreaks of gastroenteritis and norovirus occur with almost monotonous regularity in healthcare and healthcare-associated settings. Surgical site and bloodstream infections are an ongoing challenge.⁶ The costs of these and other healthcare-associated infection in human, financial and resources terms are significant.⁵ Fundamentally, healthcare-associated infection are a significant patient safety problem.^7,8

Healthcare-associated infections are, however, preventable.^{1, 2} The safety of patients and the care they receive is of increasing importance. Infection prevention and control is a primary antecedent to, and increasingly popular indicator⁷ of, the quality and safety of health care. It acknowledges that patients, visitors, and staff may be both recipients and the source of infection. In addition, equipment and the environment are contributing factors to healthcare-associated infection. Infection prevention and control programs use strategies to prevent healthcare-associated infections including setting up systems to provide, strengthen, monitor, and evaluate best practice through clinical governance structures within healthcare.¹

Effective work practices and procedures are used to mitigate these risks.⁸ In Australia, as in most developed countries, infection prevention and control is an important element of clinical governance framework in contemporary healthcare settings. The Australian Commission on Safety and Quality in Health Care has articulated a national framework for quality and safety framework inclusive of healthcare-associated infection. Key programs include surveillance, hand hygiene, and antimicrobial stewardship.⁹

Contemporary standards in infection prevention and control are comprised of a two-tiered system of Standard and Transmission-based Precautions.¹ The first tier, Standard Precautions, is the primary strategy for reducing the transmission of healthcareassociated infections. They are a group of routine infection prevention practices that apply to all patients regardless of suspected or confirmed diagnosis or presumed infection status. Standard Precautions include hand hygiene, safe use and disposal of sharps, respiratory hygiene and cough etiquette, waste management and appropriate handling of linen, routine cleaning of the environment and the use of personal protective equipment. The second tier, Transmission-based Precautions, comprise work practices that are carried out in addition to Standard Precautions for patients known or suspected to be infected or colonised with infectious agents that may not be contained by Standard Precautions alone. They are work practices and risk mitigation strategies when patients are colonised or there is a high index of suspicion of colonisation with epidemiologically significant organisms specific infectious. Three levels of precautions are used-contact, droplet, and airborne. The term Transmission-based Precautions replaced its predecessor Additional Precautions. This two-tiered system is fundamental to contemporary infection prevention and control, for which there is a considerable body of evidence to support its use.

Though considered fundamental for contemporary infection prevention and control practice, they are not without their challenges. Transmission-based Precautions are necessary for the prevention and control of health-care associated infection, yet research into patients’ experience of Transmission-based Precautions and other infection control measures has revealed negative consequences and outcomes, all of which reduce the quality of healthcare provided. There is a growing body of research that has criticised the quality of care provided by health professionals to patients where infection prevention and control measures, such as Additional Precautions or the now Transmission-based Precautions, are deployed.^{10, 11} Some literature ^{12, 13} has reported that health professionals are less likely to visit or interact with these patients in comparison to other patients, leading to less documentation of care and more preventable adverse events. Other studies have confirmed that isolated patients have articulated dissatisfaction with their care.¹⁴ Furthermore, the psychological effects, such as sensory deprivation¹⁵ and ethical concerns, such as difficulties in treating rehabilitation patients who are MRSA positive also affect the quality of care.¹⁶

Some researchers have argued that that scant data is available to inform the risk assessment of MRSA transmission of patients in rehabilitation units, which makes providing optimal care difficult. ¹⁶ Others report that for experience of Transmission-based Precautions and isolation bears both negative and positive experiences for patients.^{11, 12, 17} For some patients, Transmission-based Precautions and isolation-type practices results in detrimental psychological effects, including anxiety, stress and depression, but may also result in the patient receiving less or substandard care. Conversely, other patients report benefits by way of have quietness and having privacy of single rooms. Common to the experience of all patients are mechanisms for coping, including communication and the provision of information, as well as opportunities for improving the environment and the patient’s self-control of the situation. Fundamentally, health professionals must continue efforts to improve the patients’ experience of care under Transmission-based Precautions, in particular source isolation.¹¹

A largely unexplored area which has significant potential to realise these efforts relates to understanding health professionals’ perspectives and perceptions of caring for patients under Transmissionbased Precautions and source isolation. Gaining insight into these perspectives would provide further insight into developing ways to ameliorate the negative effects of being under Transmission-based Precautions.^{11, 18} Such inquiry is important if efforts to provide quality and safe healthcare are to be realised. Some research provides insight into health professionals’ workload in relation to the number of isolated patients, but there are missed opportunities to understand the experiences of health professionals’.¹⁹ There is a paucity of research about the health professionals’ experience of caring for patients under Transmission-based Precautions.²⁰ Understanding the health professionals’ perspective and the challenges therein may prove invaluable in closing the loop in improving the quality and safety in healthcare. Health professionals’ practices can influence the patients’ experience and quality of their care.^{11, 12, 21} These consequences are associated with particular health professional practices and behaviours which have not been the subject of systematic, sustained research. The published literature is largely silent on the health professionals’ experience of providing Transmissionbased Precautions.

All health professionals have important roles to play in actively affording patient safety through infection prevention and control. Research that connects the patient and health professionals perspectives with respect to healthcare-associated infection will add to the evidence-base of contemporary infection prevention and control practice.²¹ It will improve the quality and safety of healthcare through reducing the risks of adverse events ¹⁴, thereby the patients’ experience of healthcare. Moreover, this kind of research will help health professionals support their patients. Understanding the health professionals’ experience will inform measures to improve medical and nursing care practices, and therefore patient care. Finally, this kind of research would add to the evidence-base that supports contemporary health practice. Existing research has examined the patients’ experience of receiving care under isolation and Transmissionbased Precautions for specific healthcare-associated infection, namely MRSA, and which has been for a specific disease or an aspect of the precautions.^{12, 18, 22} Reconciling patients’ and health professionals’ experiences of Transmission-based Precautions are integral if efforts to improve the quality and safety of healthcare are to be realised. Patients are part of the equation. Health professionals are the other.

Dr Ramon Z. Shaban

Dr Ramon Z. Shaban is Senior Research Fellow (Infection Control and Infectious Diseases) within the Griffith Health Institute at Griffith University and Convenor of the Griffith Graduate Infection Control Program, and is also Senior Research Fellow within the Department of Emergency Medicine at the Princess Alexandra Hospital. He has particular interests and expertise in public health, infectious diseases and infection prevention and control in emergency and community care settings. Ramon is a Credentialed Infection Control Professional (CICP) and is Editor-in-Chief of the Australasian Emergency Nursing Journal.

Ms Mary-Rose Godsell

RN CICP MAdvPrac(Hons)

Western Australia Country Health Service

Professor Jenny Gamble

RN RM PhD

Griffith Health Institute, Griffith University

Research Centre for Clinical and Community Practice Innovation, Griffith Health Institute, Griffith University

Research Centre for Clinical and Community Practice Innovation

The Research Centre for Clinical and Community Practice Innovation within the Griffith Health Institute at Griffith University transforms health and community services through the development of collaborative, innovative and sustainable models of care and frameworks for practice among service providers and individuals, families and communities. The Centre and its members find solutions to critical healthcare challenges and undertake cutting edge research that results in better health and community care and improved quality of life.

References

1. National Health and Medical Research Council. Australian guidelines for the prevention and control of infection in healthcare: Commonwealth of Australia; 2010.

2. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall C, Wilcox MH. epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 2007;65(Supplement 1):S1-S59.

3. Stuart RL, Marshall C, McLaws M-L, Boardman C, Russo PL, Harrington F, Ferguson JK. ASID/AICA position statement – Infection control guidelines for patients with Clostridium difficile infection in healthcare settings. Healthcare Infection. 2011;16(1):33-39.

4. Mitchell B, Ware C, McGregor A, Brown S, Wells A. Clostridium difficile infection in Tasmanian public hospitals 2006–2010. Healthcare Infection. 2011;16(3):101-106.

5. Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D. Burden of endemic health-care-associated infection in developing countries: systematic review and metaanalysis. The Lancet. 2011;377(9761):228-241.

6. Australian Commisson for Safety and Quality in Health Care. Reducing harm to patients from healthcare associated infection:the role of surveillance2008.

7. Australian Health Ministers’ Conference. Communique` (Staphylococcus Aureus Bacteraemia (SAB) infections). In: Minister for Health DoHaA, edCanberra, Australia: Australian Government; 2011.

8. Australian Council on Healthcare Standards. The ACHS EQuIP 4 Guide Part 1- Accreditation standards, guideline, Sydney, AustraliaSydney: Australia; 2006.

9. Australian Commisson for Safety and Quality in Health Care. Healthcare Associated Infection (HAI). 2011. Accessed 13 September, 2011.

10. Barratt R. Behind barriers: Patient’s perceptions of hospital isolation for methicillin-resistant Staphylococcus aureus (MRSA). Brisbane: School of Nursing and Midwifery, Griffith University; 2008.

11. Barratt R, Shaban RZ, Moyle W. Patient experience of source isolation: Lessons for clinical practice. Contemporary Nurse. 2011;39(2):181-192.

12. Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalised patients: a systematic review. Journal of Hospital Infection. 2010;76(2):97-102.

13. Kirkland KB, Weinstein JM. Adverse effects of contact isolation. The Lancet. 1999;354(9185):1177-1178.

14. Stelfox HT, Bates DW, Redelmeier DA. Safety of Patients Isolated for Infection Control. JAMA. October 8, 2003 2003;290(14):1899-1905.

15. Gammon J. The psychological consequences of source isolation: A review of the literature. Journal of Clinical Nursing. 1999;8(1):13-21.

16. Pike JH, McLean D. Ethical concerns in isolating patients with methicillin-resistant Staphylococcus aureus on the rehabilitation ward: A case report. Archives of Physical Medicine and Rehabilitation. 2002;83(7):1028-1030.

17. Oldman-Prichard T. A nurse’s experience of isolation. Nursing Times. 2003;99(7):57.

18. Barratt R, Shaban R, Moyle W. Behind barriers: patients’ perceptions of source isolation for Methicillin-resistant Staphylococcus aureus. Australian Journal of Advanced Nursing. 2010;28(2):53-59.

19. Beaujean D, Blok H, Gigengack-Baars A, Kamp-Hopmans T, Ballemans K, Verhoef J, Weersink A. Five-year surveillance of patients with communicable diseases nursed in isolation. Journal of Hospital Infection. 2001;47(3):210-217.

20. Khan FA, Khakoo RA, Hobbs GR. Impact of contact isolation on health care workers at a tertiary care center. American Journal of Infection Control. 2006;34(7):408-413.

21. Godsell M. ‘Recognising Rapport’: Health professionals’ lived experience of caring for patients under Transmission-based Precautions in healthcare facilities. Brisbane, Australia: School of Nursing and Midwifery, Griffith University; 2011.

22. Criddle P, Potter J. Exploring patients’ views on colonisation with meticillin-resistant Staphylococcus aureus. British Journal of Infection Control. April 1, 2006 2006;7(2):24-28.