Patients' perceptions of methicillin-resistant Staphylococcus aureus and source isolation: a qualitative analysis of source-isolated patients

'Put in a room and left': a qualitative study exploring the lived experiences of COVID-19 isolation and quarantine among rehabilitation inpatients

BACKGROUND

The SARS-CoV-2 (COVID-19) pandemic has resulted in significant changes to health care delivery and the patient's experience in hospital. Changes for those who contracted COVID-19 or were close contacts included isolation and quarantine, visitor restrictions and changes to usual models of care to reduce viral transmission. Traditional models of inpatient rehabilitation utilise communal spaces (e.g. shared gyms and dining rooms) and involve a multidisciplinary team interacting with the patient daily.

OBJECTIVES

To report the experience of COVID-19 related isolation and quarantine among rehabilitation inpatients and their family members who experienced a nosocomial outbreak and to make recommendations for rehabilitation units.

METHODS

A qualitative phenomenological methodology using semi-structured telephone interviews.

RESULTS

19 semi-structured interviews were conducted comprising of 13 general rehabilitation inpatients and 6 family members. Five themes were established: (1) the impact of social and physical isolation; (2) boredom and limited access to therapy; (3) the impact of technology; (4) inadequate information sharing and (5) positive experiences and things done well. Several novel insights were identified including: the desire for increased social interaction from staff to compensate for a lack of visitors; the impact of physical and cognitive deficits on a patient's ability to reach basic items around their room or call for help, and the unique impact of isolation and quarantine on individuals who have a history of trauma, discrimination or mental illness.

CONCLUSIONS

This study establishes key areas that should be considered by rehabilitation units globally to adjust traditional models which are not suitable in this pandemic. Strategies to mitigate the impact of isolation include providing training to increase use of technologies such as tablet devices, increased staff social engagement to reduce isolation and tailoring the environment to suit specific patient groups.KEY MESSAGESCOVID-19 related isolation and quarantine has a significant and unique impact on patients with cognitive and physical impairments such as those in inpatient rehabilitation. Patients who are required to isolate in inpatient settings expressed a desire for compensatory increased social interaction from staff and required specific assistance with basic daily tasks while isolated. The study makes key recommendations for other rehabilitation units to integrate into their approach for managing patients required to isolate or quarantine.

Hospital patient experiences of contact isolation for antimicrobial resistant organisms in relation to health care-associated infections: A systematic review and narrative synthesis of the evidence

BACKGROUND

The alarming growth of antimicrobial resistance organisms (AMRs) and the threat caused by health care-associated infections require hospitalized individuals who are infected or colonized with AMRs to be cared for in isolation, predominantly in single rooms. None of the existing reviews focus on or specifically address the patient's experience of being cared for in contact isolation when affected by AMRs exploring this specific context.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance for the conduct of systematic reviews was applied. Five databases were searched from inception to April 2019, with keywords related to adult patient experiences, AMR, and contact isolation. The evidence was certified by 2 reviewers. Principles of thematic analysis were used to produce a narrative synthesis of the findings.

RESULTS

Eighteen eligible studies were identified. Narrative synthesis resulted in 3 overarching categories reflecting the patient experience: privacy versus loneliness; emotional responses to isolation; quality of care, recovery, and safety in isolation.

CONCLUSIONS

This review synthesizes existing evidence reflecting the patient experience of contact isolation. Study findings were often contradictory and may not reflect contemporary health care, such as shorter hospital stays, or societal preferences for greater privacy. Further research focusing on contemporary health care contexts is recommended.

Potential causal effect of contact precautions and isolation on Clostridioides difficile infection in the hyperendemic setting: Interrupted time-series analyses before and after implementation

BACKGROUND

Recent studies disputed the effectiveness of efforts to comply with contact precautions and isolation (CPI) considering relatively low intra-hospital transmission rate of healthcare facility-associated Clostridioides difficile infection (HCFA-CDI). We evaluated the potential causal effect of CPI on HCFA-CDI occurrence by comparing the incidence rate (IR) for different time periods with and without CPI implementation.

METHODS

Long-term observational time-series data were separated into three periods (pre-CPI: January 2012-March 2016, CPI: April 2016-April 2021, post-CPI: May 2021-December 2022). CPI was suspended owing to the restriction of isolation rooms during the COVID-19 pandemic. We inferred potential causal outcomes by comparing predicted and observed IRs of HCFA-CDI using interrupted time-series analyses, including the Bayesian structural time-series or autoregressive integrated moving average (ARIMA) model in the R-language or SAS software.

RESULTS

The monthly observed IR (44.9/100,000 inpatient-days) during the CPI period was significantly lower than the predicted IR (90.8) (-50.6% relative effect, P = 0.001). However, the observed IR (52.3) during the post-CPI period was significantly higher than the predicted IR (39.1) (33.6%, P = 0.001). The HCFA-CDI IR decreased during CPI (-14.3, P < 0.001) and increased post-CPI (5.4, P < 0.001) in the multivariable ARIMA model, which controlled for antibiotic usage, handwashing with soap and water, and number of toxin tests.

CONCLUSIONS

Various time-series models revealed that CPI implementation had a potential causal effect on the reduction of HCFA-CDI incidence.

Understanding patient and healthcare worker experiences and perspectives of multidrug-resistant organisms

Objectives

Transmission of MDR organisms (MROs) such as carbapenemase-producing Enterobacteriaceae (CPE) and VRE in healthcare facilities is a major issue globally. Knowledge gaps exist, including the impact of these microorganisms on patients, and healthcare worker understanding of infection control approaches for MROs. This study aimed to explore patient and healthcare worker experiences and perspectives of MROs.

Methods

A sequential exploratory mixed-methods study was performed at a large metropolitan acute and subacute hospital. This involved semi-structured face-to-face interviews with patients with confirmed MROs to explore their understanding of these microorganisms and perceptions of their time in hospital. Healthcare workers participated in an online survey about their understanding of MROs and the care of patients with these microorganisms. Qualitative data were analysed using the COM-B framework, and were triangulated with the descriptive quantitative analysis.

Results

The overarching theme from the triangulated data was uncertainty amongst both patients and staff about MROs. Insufficient explanations from staff left patients lacking a proper understanding of their diagnosis, and patients felt that staff did not always follow isolation protocols. Staff felt they did not receive enough education on MROs. However, patients felt that the overall care they received was very good, and most valued the privacy gained from being in isolation.

Conclusions

This study demonstrates that there is a need to focus on new strategies of communication with patients and staff education to improve understanding of MROs and increase adherence to protocols.

Patients with multi-drug-resistant organisms feel inadequately informed about their status: adverse effects of contact isolation

BACKGROUND

Contact isolation of patients with multi-drug-resistant organisms (MDROs) is an essential element of infection prevention strategies in hospitals worldwide. However, this practice may be associated with adverse side effects on patients' health and well-being.

AIM

This study was the first to assess mental health and well-being variables among isolated patients compared with non-isolated control patients in a German cohort.

METHODS

We conducted a matched case-control study among N = 267 patients admitted to a tertiary care teaching hospital in Germany. Their levels of anxiety, depression, loneliness, and dissatisfaction with their hospital experience were assessed using a questionnaire. Additionally, among isolated patients, it was evaluated how well they felt informed about their MDRO status.

FINDINGS

In our cohort, patients under contact isolation were significantly more dissatisfied than non-isolated control patients but did not show higher levels of anxiety, depression, and loneliness. A large proportion of patients felt insufficiently informed about their MDRO status. This lack of information was the strongest predictor of dissatisfaction among isolated patients.

CONCLUSION

These findings underline the importance of adequate patient communication. It is essential for patients' well-being to receive timely, relevant, and understandable information about the background and consequences of their infection or colonisation with MDROs.

The effect of an isolation-coping programme on patients isolated for colonization or infection with multidrug-resistant organisms: a quasi-experimental study

BACKGROUND

The global increase in the prevalence of vancomycin-resistant enterococci (VRE) and carbapenem-resistant Enterobacterales (CRE) among multidrug-resistant organisms (MDROs) has necessitated contact precaution and isolation in medical institutions. Contact isolation has a negative effect on the mental health of patients, but few interventions have addressed this issue.

AIM

This study evaluated an isolation-coping programme developed for patients colonized or infected with VRE or CRE.

METHODS

To mitigate the negative effects of isolation due to having MDRO, an infection control nurse in the present study 1) developed an isolation-coping programme and 2) validated the programme's effect on the uncertainty, anxiety, depression, and knowledge of patients isolated because of MDRO (VRE or CRE) using a pre-post quasi-experimental design.

FINDINGS

The experimental group (n=56) received education and emotional support via the isolation-coping programme, while the control group (n=55) received only verbal isolation guidelines provided by the medical institution. Compared with the control group, the experimental group showed a reduction in uncertainty (t=-8.925), anxiety (Z=-6.131), and depression (Z=-5.379), and better knowledge (Z=-8.372) (p<.001 for all).

CONCLUSION

The novel isolation-coping programme is an effective intervention to improve uncertainty, anxiety, depression, and knowledge in patients isolated with VRE or CRE.

Coping Strategies Used by Older Adults to Deal with Contact Isolation in the Hospital during the COVID-19 Pandemic

Due to the COVID-19 pandemic, many older adults have experienced contact isolation in a hospital setting which leads to separation from relatives, loss of freedom, and uncertainty regarding disease status. The objective of this study was to explore how older adults (55+) cope with contact isolation in a hospital setting during the COVID-19 pandemic in order to improve their physical and psychological wellbeing. The realist evaluation approach was used to formulate initial program theories on coping strategies used by (older) adults in an isolation setting. Twenty-one semi-structured interviews with older patients (n = 21) were analysed. This study revealed that both emotion-focused coping strategies as well as problem-focused coping strategies were used by older adults during contact isolation. The study also uncovered some new specific coping strategies. The results have useful implications for hospital staff seeking to improve the wellbeing of older adults in contact isolation in hospitals. Problem-focused coping strategies could be stimulated through staff performing care in a person-centred way. Trust in staff, as part of emotion-focused coping strategies, could be stimulated by improving the relationship between patients and staff.

Impact of admission to high-risk isolation room on patients' and healthcare workers' perceptions: A qualitative cross-assessment Approach

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The consequences of hospital admission of high-risk infectious patients into special rooms have been only rarely investigated.

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Our work is based on semi-structured interviews of 14 patients and 16 Health Care Workers and shows that patients housed with specific precautions have a negative representation of these spaces and a feeling of confinement as opposed to those admitted without precautions.

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Health Care Workers also have a negative view of these rooms.

Introduction

High-risk isolation units (HRIU) house patients at high risk of transmitting infectious agents, notably patients with suspected viral hemorrhagic fever or smear-positive tuberculosis. Admission to HRIU can alter the quality of care and impact patients’ and healthcare workers’ (HCWs) anxiety and dissatisfaction.

Methods

The Infectious Diseases Department of the Bichat Claude Bernard Hospital in Paris houses a 7–bed HRIU. We conducted a qualitative study based on individual semi-structured interviews to assess the perceptions of both patients and HCWs.

Results

We interviewed 14 patients and 16 HCWs routinely working in the HRIU. All 8 patients subject to isolation precautions and 1 of the 6 patients not subject to isolation precautions expressed a negative representation of the room with a feeling of confinement, stigma, and mistrust. They also reported a lack of information from healthcare staff and a need for entertainment, activities, and visits from relatives. HCWs did not like working in this unit because of the anteroom's technical constraints and a loss of frequent contact with patients. They also expressed a feeling of insecurity working in these units despite the use of interphones.

Conclusion

Placing patients in an HRIU not only affects their emotions, but also impacts HCWs both emotionally and organizationally. Alert systems, intercoms, and videoconferencing systems can improve safety and security as well as exchanges with patients and their relatives. Psychological support is needed for patients who are subject to isolation precautions and for their attending HCWs.

Perceptions of Dutch nurses carrying methicillin-resistant Staphylococcus aureus: a qualitative study

Background

Carriers of methicillin-resistant Staphylococcus aureus (MRSA) experience a variety of personal and social consequences, despite the asymptomatic nature of carriage. Some of these consequences are inherent to the application in practice of strict infection prevention guidelines. However, the experiences of nurses carrying MRSA have not been documented. This study aimed to describe the experiences of nurses carrying MRSA to get insight into the impact of MRSA carriage on nurses in a country with a “search-and-destroy” policy for MRSA.

Methods

A qualitative study was conducted among eighteen nurses who experienced MRSA carriage and were working in healthcare organizations in the Netherlands (e.g. hospitals, nursing homes and home care). Semi-structured interviews were conducted using an interview guide. The interviews were audio tape recorded, transcribed and analyzed using thematic analysis.

Results

MRSA carriage has an impact on the life of nurses during four distinct phases: becoming aware of carrying MRSA, processing information and guidance, experiencing consequences of carriage and, when applicable, a life after eradication of MRSA. Each phase was found to be associated with negative consequences. The impact of MRSA carriage on the daily life of nurses is mostly influenced by the experience of consequences of MRSA carriage – including a ban to work with patients, eradication treatment with antibiotics, and social isolation from others – despite the asymptomatic nature of MRSA carriage itself. In addition, lack of information and guidance increased the impact of carriage.

Conclusions

This study shows nurses experience various consequences of MRSA carriage, despite the asymptomatic nature of carriage. The work ban, eradication treatment and social isolation influenced the nurses’ work-related future, personal health and social environment. The impact of carriage may be reduced by clear information and guidance, and support from others. Therefore, sufficient information and guidance needs to be given to MRSA carriers by healthcare organizations.

Needs and concerns of patients in isolation care units - learnings from COVID-19: A reflection

With strict measures in place to contain the spread of coronavirus disease 2019, many have been isolated as suspected or confirmed cases. Being isolated causes much inconvenience for the patients and family. Patients' and next-of-kins’ needs and concerns during isolation will be shared together with suggestions for key process improvements. Our hospital’s Senior Patient Experience Managers contact all patients admitted to the isolation wards on a daily basis to provide some form of support. Common issues raised were gathered and strategies to help with their needs and concerns were discussed. Being in isolation is a challenging period for both patients and family. Nonetheless, we can implement measures to mitigate against the adverse effects of isolation. Patient education, effective and efficient means of communication, close monitoring for signs of distress and anxiety, and early intervention could help patients cope better with the whole isolation experience. Nursing management may want to consider implementing the measures shared in the article to manage patient’s stress while not compromising on staff safety.

'. . . and then no more kisses!' Exploring patients' experiences on multidrug-resistant bacterial microorganisms and hygiene measures in end-of-life care A mixed-methods study

BACKGROUND

In end-of-life care hygiene, measures concerning multidrug-resistant bacterial microorganisms may contradict the palliative care approach of social inclusion and be burdensome for patients.

OBJECTIVES

To integrate patients' perspectives on handling multidrug-resistant bacterial microorganisms at their end of life, their quality of life, the impact of positive multidrug-resistant bacterial microorganisms' diagnosis, protection and isolation measures on their well-being and patients' wishes and needs regarding their care.

DESIGN

A mixed-methods convergent parallel design embedded quantitative data on the patients' multidrug-resistant bacterial microorganisms' trajectory and quality of life assessed by the Schedule for the Evaluation of Individual Quality of Life in qualitative data collection via interviews and focus groups. Data analysis was performed according to Grounded Theory and qualitative and quantitative results were interrelated.

SETTING/PARTICIPANTS

Between March 2014 and September 2015 at two hospitals adult patients diagnosed with multidrug-resistant bacterial microorganisms and treated in a palliative care department or a geriatric ward were included in the sample group.

RESULTS

Patients in end-of-life and geriatric care reported emotional and social impact through multidrug-resistant bacterial microorganisms' diagnosis itself, hygiene measures and lack of information. This impact affects aspects relevant to the patients' quality of life. Patients' wishes for comprehensive communication/information and reduction of social strain were identified from the focus group discussion.

CONCLUSION

Patients would benefit from comprehensible information on multidrug-resistant bacterial microorganisms. Strategies minimizing social exclusion and emotional impact of multidrug-resistant bacterial microorganisms' diagnosis in end-of-life care are needed as well as adaption or supplementation of standard multidrug-resistant bacterial microorganisms' policies of hospitals.

Source isolation and patient wellbeing in healthcare settings

Multi-resistant bacteria pose an increasing and significant challenge to public health. Isolation precautions in patients with multi-drug-resistant bacteria and other communicable infectious agents can be associated with adverse effects. Although few would dispute the need for such practices in preventing the spread of transmissible infections, patients' perspectives of isolation suggest that the imposed environment creates barriers to their physical, social and emotional needs. This article reviews the literature to uncover any reliable evidence supporting the assertion that the experience of isolation in healthcare settings impacts adversely on patient wellbeing. Database searches identified 25 relevant papers published between 1990 and 2017. A number of studies claimed to have uncovered an association between negative patient experiences and isolation.

The stigmatisation of source isolation: a literature review

Background

Isolation precautions in patients with multi-drug-resistant bacteria and other communicable infectious agents can be associated with adverse effects. Patients' perspectives of isolation suggest that the imposed environment and procedures create barriers to their physical, social and emotional needs.

Aims

The purpose of this paper is to review the literature to uncover any reliable evidence supporting the assertion that stigma is a significant characteristic of the experience of source isolation in healthcare settings.

Methods

The methodological framework of Arksey and O'Malley was applied to this review. A total of 14 papers identified from 189 abstracts screened were included in the review.

Results

The research reviewed suggests a clear association between stigmatisation and isolation in which stigma does have a direct negative effect on patients placed in hospital isolation. None of the studies found evidence to the contrary.

Conclusions

The implications of this literature review for policy-makers and healthcare professionals suggest that when isolation or other forms of constraint are implemented and in use, patients must be provided with strengthened forms of support, including social and emotional support, and given access to healthcare of optimal quality to prevent the associated adverse effects of isolation as much as possible.

Experiences of carriers of multidrug-resistant organisms: a systematic review

OBJECTIVES

A comprehensive overview of the ways control measures directed at carriers of multidrug-resistant organisms (MDRO) affect daily life of carriers is lacking. In this systematic literature review, we sought to explore how carriers experience being a carrier and how they experience being subjected to control measures by looking at the impact on basic capabilities.

METHODS

We searched Medline, Embase and PsychINFO until 26 May 2016 for studies addressing experiences of MDRO carriers. Twenty-seven studies were included, addressing experiences with methicillin-resistant Staphylococcus aureus (n = 21), ESBL (n = 1), multiple MDRO (n = 4) and other (n = 1, not specified). We categorized reported experiences according to Nussbaum's capability approach.

RESULTS

Carriage and control measures were found to interfere with quality of care, cause negative emotions, limit interactions with loved ones, cause stigmatization, limit recreational activities and create financial and professional insecurity. Further, carriers have difficulties with full comprehension of the problem of antimicrobial resistance, thus affecting six out of ten basic capabilities.

CONCLUSIONS

Applying Nussbaum's capability approach visualizes an array of unintended consequences of control measures. Carriers experience stigmatization, especially in healthcare settings, and have limited understanding of their situation and the complexities of antimicrobial resistance.

The socio-economic impact of multidrug-resistant nosocomial infections: a qualitative study

The burden of healthcare-associated infections (HCAIs) has traditionally been measured using clinical and economic outcomes. We conducted semi-structured interviews with 18 patients or their caregivers affected by HCAI caused by multidrug-resistant organisms to better understand the human impact of HCAI. Most patients had misconceptions about HCAI and antimicrobial resistance, leading to strong negative feelings towards HCAIs despite positive views of their healthcare providers. Communication issues across power imbalances need to be addressed to help deal with trauma of HCAIs. A holistic approach to HCAIs incorporating patient perspectives will likely help guide policymakers developing solutions to improve patient outcomes.

Understanding the patient experience of health care-associated infection: A qualitative systematic review

BACKGROUND

The global burden of health care-associated infection (HAI) is well recognized; what is less well known is the impact HAI has on patients. To develop acceptable, effective interventions, greater understanding of patients' experience of HAI is needed. This qualitative systematic review sought to explore adult patients' experiences of common HAIs.

METHODS

Five databases were searched. Search terms were combined for qualitative research, HAI terms, and patient experience. Study selection was conducted by 2 researchers using prespecified criteria. Critical Appraisal Skills Programme quality appraisal tools were used. Internationally recognized Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were applied. The Noblit and Hare (1988) approach to meta-synthesis was adopted.

RESULTS

Seventeen studies (2001-2017) from 5 countries addressing 5 common types of HAI met the inclusion criteria. Four interrelated themes emerged: the continuum of physical and emotional responses, experiencing the response of health care professionals, adapting to life with an HAI, and the complex cultural context of HAI.

CONCLUSIONS

The impact of different HAIs may vary; however, there are many similarities in the experience recounted by patients. The biosociocultural context of contagion was graphically expressed, with potential impact on social relationships and professional interactions highlighted. Further research to investigate contemporary patient experience in an era of antimicrobial resistance is warranted.

Murthy AR, Krasilovsky AM. Behavioral Health Support for Patients, Families, and Healthcare Workers

During the 2014–2016 Ebola outbreak in West Africa, over 850 healthcare workers contracted Ebola, and over 500 died. These tragic numbers underscore the need for strict adherence to infection control precautions when caring for patients with Ebola and other diseases that are both highly infectious and potentially fatal. In addition to the use of personal protection equipment (PPE), such measures include source isolation of infected patients. In the process of confining infectious pathogens, however, it is essential that health systems do not overlook the psychological needs of patients nor that of the medical staff who care for them. This chapter is divided into two sections. The first explores the experiences of patients cared for in source isolation, highlighting the possible iatrogenic psychological consequences of treatment in a biocontainment unit. Strategies for mitigating the potentially harmful psychological effects of isolation are reviewed, including considerations for children. The second section considers the experiences of healthcare workers. The discussion outlines the psychological impact of treating patients with infectious diseases, risk factors for emotional distress, and strategies to promote psychological well-being and resilience.

Patient autonomy and disclosure of material information about hospital-acquired infections

Hospital-acquired infections are nowadays a major health care problem worldwide. The morbidity and mortality associated with them are highest in intensive care units, but their effects are identifiable in virtually any medical department. Information about hospital-acquired infections, especially about their preventive measures, are rarely presented nowadays in a correct fashion to patients. This article aims to present, in a structured manner, the theoretical and practical aspects related to disclosure of hospital-acquired infections-related information to patients and its importance in preventing their spread. We will analyze both the conceptual framework for disclosing medical information related to nosocomial infections (autonomy, veracity, social justice, the principle of double effect, the precautionary principle, and nonmaleficence) and the practicalities regarding the disclosure of proper information to patients.

Examining the online approaches used by hospitals in Sydney, Australia to inform patients about healthcare associated infections and infection prevention strategies

Background

Provision of information plays a critical role in supporting patients to be engaged or empowered to be involved with infection prevention measures in hospitals. This explorative study evaluated the suitability, readability and accessibility of information on healthcare associated infections (HCAIs) and infection prevention strategies targeted at patients from the websites of 19 acute care public hospitals in Sydney, Australia.

Methods

We included hospitals with greater than 200 beds in the sample. We examined online information targeted at patients on HCAIs and infection prevention and compared it using the Suitability Assessment of Material (SAM) and Simple Measure of Gobbledygook (SMOG) readability formulas for suitability, readability and accessibility.

Results

Thirty-six webpages were identified as being relevant and containing information about HCAIs or infection prevention. Based on the SAM/SMOG scores, only three webpages were found to be ‘superior’. Many of the webpages scored poorly in content, literacy, graphics, learning stimulation and cultural appropriateness. In comparison, most of the webpages scored well in the layout and typography. The majority (97%) of the materials were written at a level higher than the recommended reading grade level. Lastly, the websites scored poorly on the ability to locate the information easily, as messages about HCAIs/infection prevention were usually embedded into other topics.

Conclusion

While providing information online is only one approach to delivering messages about infection prevention, it is becoming increasingly important in today’s technology society. Hospitals are neglecting to use best practices when designing their online resources and current websites are difficult to navigate. The findings point to the need to review patient information on HCAIs regarding suitability, readability and accessibility.

Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) at a palliative care unit: A prospective single service analysis

BACKGROUND

The emergence of multidrug-resistant bacterial microorganisms is a particular challenge for the health care systems. Little is known about the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant Gram-negative bacteria (MDRGNB) in patients of palliative care units (PCU).

AIM

The primary aim of this study was to determine the carriage of MRSA among patients of a PCU at a German University Hospital and to assess whether the positive cases would have been detected by a risk-factor-based screening-approach.

DESIGN

Between February 2014 and January 2015 patients from our PCU were tested for MRSA carriage within 48 hours following admission irrespective of pre-existing risk factors. In addition, risk factors for MRSA colonization were assessed. Samples from the nostrils and, if applicable, from pre-existing wounds were analysed by standardized culture-based laboratory techniques for the presence of MRSA and of other bacteria and fungi. Results from swabs taken prior to admission were also recorded if available.

RESULTS

297 out of 317 patients (93.7%) fulfilled one or more MRSA screening criteria. Swabs from 299 patients were tested. The detection rate was 2.1% for MRSA. All MRSA cases would have been detected by a risk-factor-based screening-approach. Considering the detected cases and the results from swabs taken prior to admission, 4.1% of the patients (n = 13) were diagnosed with MRSA and 4.1% with MDRGNB (n = 13), including two patients with MRSA and MDRGNB (0.6%). The rate of MRSA carriage in PCU patients (4.1%) was elevated compared to the rate seen in the general cohort of patients admitted to our University Hospital (2.7%).

CONCLUSIONS

PCU patients have an increased risk to carry MRSA compared to other hospitalized patients. Although a risk factor-based screening is likely to detect all MRSA carriers amongst PCU patients, we rather recommend a universal screening to avoid the extra effort to identify the few risk factor-negative patients (<7%). As we did not perform a systematic MDRGNB screening, further studies are needed to determine the true prevalence of MDRGNB amongst PCU patients.

The relationship between subjective perception and the psychological effects of patients in spatial isolation

Background: Spatial isolation is a common infection control measure, but negative psychological effects are often neglected. We investigated which factors influence the perception of single room isolated patients.

Methods: In the present correlative cross-sectional study, 32 isolated patients have been interviewed within three departments of the Heidelberg University Hospital, one of Germany’s largest hospitals. The following questionnaires were used: 10-Item Big Five Inventory (BFI-10), Positive and Negative Affect Schedule (PANAS), Hospital Anxiety and Depression Scale (HADS) and a self-developed questionnaire to evaluate the individual experience of isolation. Data were analysed using correlation and regression analysis.

Results: A significant positive correlation was found between the isolation period and anxiety (r=.42, p<.05). Interestingly, a significant positive correlation was demonstrated between the duration of contact to nursing staff and negative daydreaming (r=.89, p<.01). The activity watching television was associated with higher levels of anxiety (r=.38, p<.05). Surfing the internet had a positive relationship with thinking about beautiful things (r=.41, p<.05).

Conclusions: Our study results have implications how to improve the psychological situation of patients during spatial isolation. Contact between nursing staff and patients is crucial, since this contact significantly associated with negative daydreaming, probably due to increased neediness of emotional and physical care in some patients. The duration of the isolation has an influence on the experience of anxiety. Activities to cope with the isolation, however, not always have positive effects on the well-being of the patient.

Effects of Methicillin-Resistant Staphylococcus aureus/Multiresistant Gram-Negative Bacteria Colonization or Infection and Isolation Measures in End of Life on Family Caregivers: Results of a Qualitative Study

BACKGROUND

Little is known about the experiences of family caregivers of hospitalized patients with confirmed methicillin-resistant Staphylococcus aureus/multiresistant gram-negative bacteria (MRSA/MRGN) diagnosis at the end of life. The study at hand is a subproject of an interdisciplinary cooperation project that aims at developing a patient-, family-, and team-centered approach in dealing with MRSA/MRGN-positive hospitalized patients in palliative and geriatric care.

OBJECTIVES

The present study aimed to assess the individual effects of the patient's MRSA/MRGN colonization or infection and isolation measures on family caregivers.

DESIGN

Between April 2014 and September 2015, all known family caregivers associated with an MRSA/MRGN-positive patient from a palliative care unit, a hospital palliative care support team, and a geriatric ward were considered for study participation. A qualitative interview study with family caregivers and an additional focus group was conducted. Data were analyzed using the principles of Grounded Theory.

RESULTS

Family caregivers (N = 62) raised suggestions regarding the provision of information and communication on the MRSA/MRGN diagnosis and hygiene measures from staff members and the consistency of hygiene procedures. Family caregivers requested not to be stigmatized or being disadvantaged due to the MRSA/MRGN diagnosis of the patient, and they wished to receive psychosocial and emotional support.

CONCLUSIONS

Staff members and institutional stakeholders should be aware that family caregivers might be burdened and upset by positive MRSA/MRGN diagnosis and the required hygiene measures. The need for detailed and understandable information on MRSA/MRGN, adequate communication between staff members and family caregivers, and support for family caregivers should be of special attention in particular in end-of-life care.

Assessing patient and caregiver understanding of and satisfaction with the use of contact isolation

BACKGROUND

Contact isolation is a method used for limiting the spread of antimicrobial-resistant organisms when caring for patients. This policy has been linked to several adverse outcomes and less patient satisfaction. We assessed patient and caregiver understanding and satisfaction with the use of contact isolation.

METHODS

A prospective survey of >500 patients in contact isolation at our institution was performed during 2014. Participants responded to a series of statements relating to contact isolation, using a 5-point Likert scale. Responses were assessed for overall positivity or negativity and further compared according to floor type or designation.

RESULTS

Of the patients, 48.7% responded to the survey; 70 caregivers also responded. Patient and caregiver responses were similar and were positive overall. Most respondents felt safer because of the use of contact isolation and because it prevented infections. A smaller majority of respondents also thought the policy was adequately explained to them and adhered to by staff.

CONCLUSIONS

In the largest collection of respondents surveyed to date about contact isolation and its impact on them, the policy was viewed positively, both by patients and caregivers. There is still room for improvement in the area of patient education regarding the use of contact isolation.

Staff experiences of caring for patients with extended-spectrum β-lactamase-producing bacteria: A qualitative study

BACKGROUND

Patients who become carriers of antibiotic-resistant bacteria are sometimes stigmatized by health professionals. Staff members' fears of becoming infected could affect their willingness to care for these patients.

METHODS

The purpose of this study was to increase the knowledge of what it means for staff in acute care settings and nursing homes to care for patients with extended-spectrum β-lactamase (ESBL)-producing bacteria. Assistant nurses, registered nurses, and physicians from acute care settings and nursing homes were interviewed. A modified version of Grounded Theory was used for the analysis.

RESULTS

The analysis resulted in the core category "to operate as an expert in a chaotic environment" in acute care settings. Despite a lack of resources, hospital staff try to provide the best possible care for patients with ESBL. The analysis of the interviews in the nursing homes resulted in the core category "the employee who, despite uncertainty, provides good care." Despite some fear, and a lack of knowledge, the study participants tried to provide the residents with good care.

CONCLUSION

Staff in acute care settings and nursing homes must have adequate knowledge and reasonable working conditions to be able to provide high-quality care for patients and residents who are ESBL carriers.

[Psychological impacts of being a carrier of multi-drug resistant bacteria]

Learning that they are a carrier of multi-drug resistant bacteria and being placed in isolation to prevent transmission has significant psychological repercussions for the patient and their families. Through therapeutic education, caregivers adapt their support to the patient's experience, raising their awareness of prevention.

Relationship between knowledge and attitudes of methicillin-resistant Staphylococcus aureus and hand hygiene behavior in Veterans with spinal cord injury and disorder

The objective of this analysis was to understand the relationship between knowledge and attitudes regarding methicillin-resistant Staphylococcus aureus and hand hygiene behavior based on a baseline survey administered to Veterans with spinal cord injuries and disorders. Higher knowledge was associated with higher attitude scores (r = 0.35, P = .003), but knowledge and attitudes were not associated with behavior. Also, those with quadriplegia had higher knowledge scores (P = .03). Knowledge and attitudes, although related, do not appear to fully explain patients' hand hygiene behavior.

Involving patients in understanding hospital infection control using visual methods

AIMS AND OBJECTIVES

This paper explores patients' perspectives on infection prevention and control.

BACKGROUND

Healthcare-associated infections are the most frequent adverse event experienced by patients. Reduction strategies have predominantly addressed front-line clinicians' practices; patients' roles have been less explored.

DESIGN

Video-reflexive ethnography.

METHODS

Fieldwork undertaken at a large metropolitan hospital in Australia involved 300 hours of ethnographic observations, including 11 hours of video footage. This paper focuses on eight occasions, where video footage was shown back to patients in one-on-one reflexive sessions.

FINDINGS

Viewing and discussing video footage of clinical care enabled patients to become articulate about infection risks, and to identify their own roles in reducing transmission. Barriers to detailed understandings of preventative practices and their roles included lack of conversation between patients and clinicians about infection prevention and control, and being ignored or contradicted when challenging perceived suboptimal practice. It became evident that to compensate for clinicians' lack of engagement around infection control, participants had developed a range of strategies, of variable effectiveness, to protect themselves and others. Finally, the reflexive process engendered closer scrutiny and a more critical attitude to infection control that increased patients' sense of agency.

CONCLUSION

This study found that patients actively contribute to their own safety. Their success, however, depends on the quality of patient-provider relationships and conversations. Rather than treating patients as passive recipients of infection control practices, clinicians can support and engage with patients' contributions towards achieving safer care.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that if clinicians seek to reduce infection rates, they must start to consider patients as active contributors to infection control. Clinicians can engage patients in conversations about practices and pay attention to patient feedback about infection risk. This will broaden clinicians' understandings of infection control risks and behaviours, and assist them to support appropriate patient self-care behaviour.

MRSA care in the community: why patient education matters

In primary care, patients are prescribed decolonisation treatment to eradicate meticillin-resistant Staphylococcus aureus (MRSA). This complex treatment process requires the patient to apply a topical antimicrobial treatment as well as adhering to rigorous cleaning regimens to ensure the environment is effectively managed. A pilot study was carried out that involved developing an enhanced, nurse-delivered education tool, training a community nurse to use it, then testing its use with a patient. Three interviews were carried out: one with a patient who received usual care, one with a patient who received the enhanced education and one with the community nurse who delivered the enhanced education tool. The patient who received the enhanced education reported better knowledge and understanding of the application of treatment than the patient who did not. These results are interesting and point the way forward for larger research studies to build on the learning from this limited exploration and develop more effective management of MRSA in primary care.

Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: a pilot randomized controlled trial

OBJECTIVES

To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D).

DESIGN

Blinded, block-randomized controlled pilot trial.

SETTING

Two Department of Veterans Affairs (VA) SCI Centers.

PARTICIPANTS

Veterans were recruited March-September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings.

INTERVENTION

Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education.

OUTCOME MEASURES

Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation.

RESULTS

Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25-3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI -0.08-2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care.

CONCLUSIONS

A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants' knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.

Reducing the risk of infection associated with vascular access devices through nanotechnology: a perspective

Intravascular catheter-related infections are still a major problem in health care and are associated with significant morbidity, mortality, and additional cost. The formation of microbial biofilm on catheters makes these infections particularly complicated, as microbial cells that detach from the biofilm can lead to infection, and because these microorganisms are highly resistant to many antimicrobial agents; thus, catheter removal is often required to successfully treat infection. To reduce the risks of catheter-related infections, many strategies have been applied, such as improvements in aseptic insertion and post-insertion care practices, implantation techniques, and antibiotic coated or impregnated materials. However, despite significant advances in using these methods, it has not been possible to completely eradicate biofilm infections. Currently, nanotechnology approaches seem to be among the most promising for preventing biofilm formation and resultant catheter-related bloodstream infection (especially with multi-resistant bacterial strains). In this review, current knowledge about catheter technology and design, the mechanisms of catheter-related bloodstream infection, and the insertion and care practices performed by medical staff, are discussed, along with novel, achievable approaches to infection prevention, based on nanotechnology.

Reducing health care-associated infections: patients want to be engaged and learn about infection prevention

BACKGROUND

Multidrug-resistant organisms (MDROs) are common in health care-associated infection (HAI). The aim of this study was to examine patient's willingness to learn about MDROs and HAIs and their preferred ways of education about MDRO HAIs.

METHODS

Interviewer-administered questionnaire at a tertiary care academic medical center. We recruited a sample of 100 adult patients who had HAI and were placed in contact precautions.

RESULTS

Ninety-six percent of patients had heard of MDROs. Ninety-eight percent of patients thought that their involvement in learning about MDROs was very important or important. Most of the patients thought that receiving information about MDROs would probably or definitely help them to make choices that would improve their health care. Patients expressed interest in more than 1 form of educational material: 70% chose written material, 57% verbal information, 53% an informational video, and 50% Internet-based material. Patients with a higher level of education were more likely to prefer written material. Patients emphasized simple language and incorporation of actual patient stories.

CONCLUSION

Hospitalized patients with MDROs in our study believed that involvement on their part was important. Individuals' level of education affected their preference regarding choice of educational material, but most patients prefered receiving written or verbal information. Patient preferences must be incorporated into education to increase engagement for prevention of MDROs and HAIs.

Living with extended-spectrum β-lactamase: a qualitative study of patient experiences

BACKGROUND

Extended-spectrum β-lactamase (ESBL) is an enzyme that conveys resistance to most β-lactam antibiotics. Infections caused by bacteria producing ESBL are often difficult to treat because of general multiresistance, and hospital care may be necessary even for nonserious infections.

METHODS

The aim of this study was to increase our understanding of how infected individuals perceive their situation as "carriers" of multiresistant bacteria. A modified version of grounded theory was used to analyze 7 open interviews.

RESULTS

The analysis resulted in the core category Being thrown into the scary and unknown without a map and compass. All informants thought they had received no or insufficient information about ESBL from the health care providers. Informants who had been given some information still had many unanswered thoughts and reflections. Health care staff were lacking in knowledge about ESBL and their own fears that led to the use of extreme hygiene measures, which increased the stigma for the patient.

CONCLUSION

To manage their life situation, it is important that persons diagnosed as carriers of ESBL-producing bacteria receive adequate information from the attending doctor.

Understanding factors that impact on public and patient's risk perceptions and responses toward Clostridium difficile and other health care-associated infections: a structured literature review

BACKGROUND

Clostridium difficile is the most common health care-associated infection and a major cause of death and increased morbidity. It is vital that patients and the public are provided with the right information and communication to assist them to understand their role in preventative measures. Successful implementation of communication and management strategies hinges on individuals' risk perceptions.

METHODS

We performed a structured literature review to examine the evidence regarding public and patients' risk perceptions and responses toward Clostridium difficile and other health care-associated infections. Fourteen studies were included.

RESULTS

Only 1 study was specific to Clostridium difficile, and 7 were related to other health care-associated infections. Many reported limited understanding of the technical issues of the infection, concerns of transmission to family and friends, inadequate information available, and distrust. The media were one of the main sources of information. Both emotional and physical responses highlighted the level of confusion, fear, anxiety, and anger.

CONCLUSION

Empirical research of risk perceptions toward Clostridium difficile is limited. Without well-researched studies examining risk perceptions and responses, there is a danger of developing and implementing communication and management strategies that do not meet the needs of our patients or the public.

Effects of the contact isolation application on anxiety and depression levels of the patients

This study was aimed to assess the effects of contact isolation application on anxiety and depression levels of the patients, the effects of certain sociodemographics and patient characteristics on anxiety and depression levels, and the thoughts of the isolated patients about contact isolation. This non-randomized quasi-experimental study was carried out with 60 isolated and 57 non-isolated patients with hospital infection. The data were acquired from Hospital Anxiety and Depression Scale (HADS-A (anxiety) and HADS-D (depression)) and patient information form. There was no statistically significant difference between the anxiety and depression levels of the isolated and non-isolated patients. In the isolated patients, the depression points were higher in patients who were, women, received primary education and had lower income levels. Of the patients, 86.4% of them told that they were happy to be in the isolation room. Contact isolation application did not affect anxiety and depression levels of the patients. However, personal attributes increased the development of depression. In contact isolated patients, personal attributes should be taken into consideration in nursing care planning to prevent development of depression.

Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: a qualitative assessment of knowledge, beliefs, and behavior

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare-associated infection. Individuals with spinal cord injuries and disorders (SCI/D) are at high risk of MRSA colonization and infection. The Department of Veterans Affairs (VA) released guidelines to prevent the spread of MRSA in Veterans with SCI/D; however, available patient educational materials did not address the unique issues for this population.

OBJECTIVE

To assess perceptions of SCI/D providers and Veterans with SCI/D regarding MRSA and their educational needs about MRSA prevention, with an ultimate goal of developing patient educational materials that address the issues unique to SCI/D.

METHODS

Purposive samples of SCI/D providers (six groups) and Veterans with SCI/D (one group) at two VA facilities participated in 60-90-minute focus group sessions. Qualitative data were analyzed using latent content and constant comparative techniques to identify focal themes.

PARTICIPANTS

Thirty-three providers (physicians and nurses working in inpatient, outpatient, and homecare settings) and eight Veterans participated.

RESULTS

Three overarching themes emerged from the analysis: knowledge about MRSA, hand hygiene, and barriers to educating Veterans with SCI/D.

CONCLUSIONS

SCI/D providers and Veterans with SCI/D identified gaps in general MRSA knowledge, gaps in knowledge of good hand hygiene practices and of required frequency of hand hygiene, and barriers to educating Veterans with SCI/D during inpatient stays. Future educational materials and strategies should address these gaps.

Methicillin-resistant Staphylococcus aureus (MRSA) management in palliative care units and hospices in Germany: a nationwide survey on patient isolation policies and quality of life

BACKGROUND

For palliative care settings, little is known about the benefits of specific methicillin-resistant Staphylococcus aureus containment regimens and the burdens patient isolation imposes on affected patients, their families, and professional caregivers.

AIM

To explore the current practice of MRSA management and its impact on inpatients' quality of life as perceived by professional caregivers.

DESIGN

Survey of inpatient palliative care institutions using 23-item questionnaires (infrastructural data: six items, management process: 14, clinical significance: three).

SETTING/PARTICIPANTS

All palliative care units (179) and hospices (181) listed in Germany's directory of palliative care services. The χ(2) test was used to test for differences; significance level: p ≤ 0.05.

RESULTS

229 of 360 questionnaires were returned. More than 90% of the responding institutions employed specific MRSA protocols. Lack of resources was a more important issue for palliative care units than for hospices regarding availability of single rooms (p = 0.002) and staffing (p = 0.004). Compared to hospices, palliative care units more frequently isolated MRSA patients (p = 0.000), actively treated colonization (p = 0.026), assessed the efficacy of eradication (p = 0.000), provided information on MRSA management to patients (p = 0.014) and relatives (p = 0.001), more often restricted patients' activities (p = 0.000), and reported a negative impact on quality of life (p = 0.000).

CONCLUSIONS

Rigorously applied MRSA protocols impose significant burdens at the end of life. Research on clinical outcomes including quality of life may identify interventions of questionable benefit. The issue of handling MRSA should be studied as a model for the management of other highly complex conditions and special needs such as patient isolation.

MRSA model of learning and adaptation: a qualitative study among the general public

Background

More people in the US now die from Methicillin Resistant Staphylococcus aureus (MRSA) infections than from HIV/AIDS. Often acquired in healthcare facilities or during healthcare procedures, the extremely high incidence of MRSA infections and the dangerously low levels of literacy regarding antibiotic resistance in the general public are on a collision course. Traditional medical approaches to infection control and the conventional attitude healthcare practitioners adopt toward public education are no longer adequate to avoid this collision. This study helps us understand how people acquire and process new information and then adapt behaviours based on learning.

Methods

Using constructivist theory, semi-structured face-to-face and phone interviews were conducted to gather pertinent data. This allowed participants to tell their stories so their experiences could deepen our understanding of this crucial health issue. Interview transcripts were analysed using grounded theory and sensitizing concepts.

Results

Our findings were classified into two main categories, each of which in turn included three subthemes. First, in the category of Learning, we identified how individuals used their Experiences with MRSA, to answer the questions: What was learned? and, How did learning occur? The second category, Adaptation gave us insights into Self-reliance, Reliance on others, and Reflections on the MRSA journey.

Conclusions

This study underscores the critical importance of educational programs for patients, and improved continuing education for healthcare providers. Five specific results of this study can reduce the vacuum that currently exists between the knowledge and information available to healthcare professionals, and how that information is conveyed to the public. These points include: 1) a common model of MRSA learning and adaptation; 2) the self-directed nature of adult learning; 3) the focus on general MRSA information, care and prevention, and antibiotic resistance; 4) the interconnected nature of adaptation; and, 5) the need for a consistent step by step plan to deal with MRSA provided at the time of diagnosis.

Knowledge, awareness, and attitudes regarding methicillin-resistant Staphylococcus aureus among caregivers of hospitalized children

OBJECTIVES

To explore knowledge, awareness, and attitudes among caregivers of hospitalized children with regard to methicillin-resistant Staphylococcus aureus (MRSA).

STUDY DESIGN

We developed and administered a bedside questionnaire to caregivers of hospitalized children in contact isolation for MRSA colonization or infection.

RESULTS

Of 104 caregivers approached, 100 (96%) consented to participate. The caregivers' children included 28 (28%) newly recognized as colonized or infected with MRSA during the hospitalization and 72 (72%) previously identified as colonized or infected with MRSA. Eighteen (18%) caregivers had no knowledge of MRSA. Twenty-nine (29%) were unaware that their child had MRSA, including caregivers of 9 newly identified patients with MRSA and 20 patients with previously identified MRSA. Of the 71 caregivers aware of their child's MRSA status, 89% had concerns; 77% worried about risks of future MRSA infection, 51% worried about spreading MRSA, and 16% described a feeling of stigma. Worries were more common among caregivers of children with newly identified MRSA (P < .05).

CONCLUSION

Caregivers of children hospitalized with MRSA are frequently unaware that their child has MRSA. Among those aware of their child's MRSA status, many have concerns and worries. Caregivers of children with newly identified MRSA more often are worried and may need additional education and reassurance.

Adverse effects of isolation in hospitalised patients: a systematic review

The use of transmission precautions such as contact isolation in patients known to be colonised or infected with multidrug-resistant organisms is recommended in healthcare institutions. Although essential for infection control, contact isolation has recently been associated with adverse effects in patients. We undertook a systematic review to determine whether contact isolation leads to psychological or physical problems for patients. Studies were included if (1) hospitalised patients were placed under isolation precautions for an underlying medical indication, and (2) any adverse events related to the isolation were evaluated. We found 16 studies that reported data regarding the impact of isolation on patient mental well-being, patient satisfaction, patient safety or time spent by healthcare workers in direct patient care. The majority showed a negative impact on patient mental well-being and behaviour, including higher scores for depression, anxiety and anger among isolated patients. A few studies also found that healthcare workers spent less time with patients in isolation. Patient satisfaction was adversely affected by isolation if patients were kept uninformed of their healthcare. Patient safety was also negatively affected, leading to an eight-fold increase in adverse events related to supportive care failures. We found that contact isolation may negatively impact several dimensions of patient care. Well-validated tools are necessary to investigate these results further. Large studies examining a number of safety indicators to assess the adverse effects of isolation are needed. Patient education may be an important step to mitigate the adverse psychological effects of isolation and is recommended.