Attacking the fecal veneer*

What an excellent start of 2017. A great study from the USA today in Lancet: In a pragmatic cluster-randomized crossover study they tested 4 patient room cleaning strategies on the effectiveness to reduce acquisition with relevant bacteria for the incoming patients. The conclusion states that “enhanced terminal room disinfection decreases the risk of pathogen acquisition.” Yet, this paper is so “data-dense” that you must read the methods (and supplements) to get the picture. In one shot: Not for C. diff, may be for MRSA and yes for VRE. Continue reading

Do single rooms reduce HCAI?

An interesting review article examines the relationship between three related variables: the proportion of single rooms, the size of the patient room and patient proximity, and the availability of antiseptic hand rub, with various HCAI indicators. The bottom line is that both a move towards a higher proportion of single rooms and larger patient rooms are associated with reduced HCAI, and making hand gels more available improves compliance with their use (unsurprisingly).

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Hand Hygiene, Surfaces and Modelling

maximum-occupancy-capacity-sign-s-0307

Interesting publication being highlighted as part of the WHO hand hygiene day in Leeds, UK suggests through modelling that the type of care, number of surface contacts and the distribution of surface pathogens are most likely to affect the relative quantity of pathogens accried on hands. The paper is published in ‘Indoor Air’, (not a journal that inhabits my bedside table) and we do have to remember that, as G.E.P Box stated, “Essentially, all models are wrong. But some are useful”.

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Single room survey: results

Following my blog last week reflecting on the debate published in the British Medical Journal on “Should hospitals provide all patients with single rooms?”, I asked the same question to Linkedin and Twitter. My informal poll received a total of 37 responses, which is not the largest survey you’ll ever see but probably a meaningful sample size. Overall, 54% of respondents answered ‘Yes’ and 45% answered ‘No’ (Figure).

single room surveyFigure: “Should hospitals provide all patients with single rooms”. Results from 37 respondents in online polls on Linkedin and Twitter.

An interesting feature of the survey was the difference between Linkedin and Twitter, with two third of respondents saying Yes on Linked vs. only 20% on Twitter. I suspect this is explained by the fact that most respondents on Twitter were frontline healthcare workers, who see first-hand the problems caused by placing patients in single rooms when they’d rather be in a bay, or when it compromises their safety.

As with most surveys, the listening to the comments that people make is probably more important than the answers they give, particularly to binary questions such as this one. The poll promoted some useful discussion on Linkedin, with several comments wrestling with the pros and cons of single rooms. I’ve collated a number of Tweets below, which illustrate the view of many frontline staff that a mixture of single rooms and bays is preferable:

  • Healthcare Infection ‏@HealthcareInfec, 4 Dec: “single rooms- a minimum requirement would be a good start & allows flexibility if needed. Certainly >50%.”
  • AllisonClaireBradley ‏@allisoncbradley, 3 Dec: “No for me too. Get so many requests from patients desperate to move out of isolation.”
  • Craig Bradley ‏@CraigBradleyF1, 3 Dec: “NO for so many reasons. We do well with 36%.”
  • Sue Millward @suemillward1, 3 Dec: “Not all patients want to be alone, Some pts need to be watched! So NO.”
  • Gary Thirkell ‏@pollygary 3 Dec: “depends on speciality. Yes for some and no for others. Ability to adapt the room a possibility.”
  • Infection Control ‏@uhcw_inf_con 3 Dec: “No. Isolation has psychological impact on patients & can effect falls risk amongst other things. Need holistic care.”

Clearly, there are some inherent problems with polls, not least the fact that those with strong opinions are more likely to respond and I have no idea how many people saw the survey and decided not to vote. The roughly 50:50 split in opinion on the single room issue is similar to the survey of patients commissioned by the Scottish government, which found that 41% of patients would prefer to be admitted to a single room.

Should hospitals provide single rooms for all patients? Whilst I would definitely prefer a single room if admitted to hospital, there are some strong arguments for a mixture of single rooms and bays in some specialties. So, I agree with the English recommendation of 50% single rooms as a minimum requirement.

Should hospitals provide all patients with single rooms?

hospital ward

The British Medical Journal recently published a ‘Head to Head’ debate between Prof Hugh Pennington and Dr Chris Isles addressing the question of: “Should hospitals provide all patients with single rooms?”

Prof Pennington made the case for 100% single rooms (see Table below), which provide infection control benefits; increased privacy, dignity and confidentiality; less noise results in sleep; intimate contact with families is easier; patients have more control over their immediate environment at a time when they have little control over what happens to them; there is better access for bed-side treatment; and bed management is improved, with less bed-blocking due to gender or infectious patients, resulting in fewer patient transfers.

Dr Isles countered with the case for a mixture of single rooms and bays (see Table below). His argument goes that ‘one room does not fit all’; patients crave company at what can be a very lonely time; patients in single rooms have less contact with healthcare workers, and patients will look out for each other when something goes wrong; and there is surprisingly poor evidence that increasing the proportion of single rooms reduces healthcare-associated infection.

Table: comparing the relative benefits of single rooms and multi-occupancy bays.single rooms bays

It’s interesting to note the variety in national approaches taken to advice on whether hospitals should provide single rooms for all patients. The USA and, more recently, Scotland recommend 100% single rooms, whereas England recommends 50% single rooms for newly built hospitals. There are also some ‘halfway house’ options to consider in terms of temporary or semi-permanent conversion of bays into single rooms, which may go some way to maximising the benefits of single rooms and bays.

If I had to spend time as a hospital inpatient, I’d want a single room. I appreciate that some would find social benefits from being accommodated in a four or six bed bay, but I’d like my own privacy please. And then there’s the risk of infection – healthcare workers are significantly more likely to perform hand hygiene before attending to a patient in a single room than in a bay. Plus, overall infection rates were lower in a unit composed of single rooms compared with a unit composed of a mixture of single rooms and bay. I know that I’d receive less visits from healthcare workers, and that this carries risks, but I’d still prefer a single room thank-you very much!

Article citation: Pennington H, Isles C. Should hospitals provide all patients with single rooms? BMJ 2013;347:f5695.

Other references:

  1. Teltsch et al. Arch Intern Med 2011; 171: 32-38.
  2. van de Glind et al. Health Policy 2007;84:153-161.
  3. Borg MA.  J Hosp Infect 2003;54:316–318.
  4. Haill et al. J Hosp Infect 2012;82:30-35.
  5. King et al. Building and Environment 2013;59:436-447.
  6. Moore et al. J Hosp Infect 2010;76:103-107.
  7. Jolley S. Nursing Standard 2005;20:41–48.
  8. Barlas et al. Ann Emerg Med 2001;38:135–139.
  9. Lawson & Phiri. Health Serv J 2000;110:24–26.
  10. Ulrich et al. White Paper #5. The Center for Health Design. 2008.
  11. Maben J. Nurs Manag 2009;16:18-19.
  12. PricewaterhouseCoopers. The role of hospital design in the recruitment, retention and performance of NHS nurses in England. 2004.
  13. Stelfox et al. JAMA 2003;290:1899–1905.
  14. Tarzi et al. J Hosp Infect 2001;49:250-254.
  15. Young & Yarandipour. Health Estate 2007;61:85-86.
  16. Mooney H. Nursing Times 2008;104:14-16.
  17. UK Dept Health. Ward layouts with single rooms and space for flexibility. 2005.

Photo credit: Ward at the Royal Free Hospital, c.1908; Royal Free Archive Centre.

More single rooms = less acquisition. A simple equation?

This isn’t exactly hot off the press (published in 2011) but I’ve only just come across it; it’s a great article and worth revisiting. Many hospitals worldwide suffer a chronic lack of single rooms to place patients requiring contact precautions, but also for patients with other needs such as increased privacy and dignity. There are pros and cons associated with increasing the proportion of single rooms, with a high proportion of single rooms usually requiring a higher staff:patient ratio, and patients in single rooms often having less staff contact and more likely to suffer feelings of isolation. The evidence that an increase in the proportion of single rooms reduces the transmission of healthcare-associated infection has been somewhat equivocal.

This Canadian study evaluated the impact of ‘privatization’ of an ICU. In March 2002, a 24-bed ICU (comprising two 10-bed rooms and four single rooms) was moved to a new 100% single room unit. A 25-bed ICU in a sister hospital (comprising 2, 5, 6 or 8-bed rooms) did not undergo any change in configuration and served as a comparison unit. Importantly, the two units shared the same infection control team, policies and practices. Patients admitted between 2000 and 2005 were studied for the acquisition of a range of pathogens. A unique and useful aspect of the study was to divide microbes into likely endogeneous or exogeneous acquisition. The key result reported was the change in rate ratio of the intervention ICU compared with the comparison ICU before and after the date of privatization of the intervention ICU. This was effectively an estimate of the percentage reduction in the rate in the intervention hospital associated with privatization.

Significant reductions where shown in most pathogens associated with exogenous acquisition, including C. difficile (43%), MRSA (47%) and Acinetobacter spp. (53%), and a substantial but non-significant reduction in Stenotrophomonas maltophilia (52%) (Figure). In addition, a combined analysis of C. difficile, MRSA and VRE also showed a significant reduction of 54%. Significant reductions were also shown for some pathogens in the exogenous/endogenous acquisition group, including Klebsiella spp. (38%). There was no significant change (4%) in the rate of coagulase-negative staphylococci and most other pathogens associated with endogenous acquisition. Perhaps not surprisingly, the authors also reported a reduction in the overall length of stay associated with the intervention.

single room

Figure: Change in the acquisition rate ratio of the intervention vs. comparison ICU before and after before (2001-2002) vs. after (2003-2005) privatisation. (* Not statistically significant.) 

As with all studies, this one is not without criticism. However, there are several aspects that I find particularly convincing. Firstly, whilst there were differences in the configuration of the two ICUs, the inclusion of a comparison unit was an important strength. Secondly, the authors evaluated all available pathogens, rather than focusing on an individual MDRO. Thirdly, and perhaps most convincingly, most pathogens associated with exogeneous infections were affected by the intervention whereas most pathogens associated with endogenous acquisition were not. Additional strengths include several “data-check” sensitivity analyses and an additional model to provide evidence that these were not transient reductions associated with moving to a new, clean unit. Many if not all of these important strengths are lacking from similar studies that have returned a negative result.

The simple equation that more single rooms = less acquisition of pathogens is firmly supported by this study. However, infection rates are not the only factors to be considered when contemplating a move to 100% single rooms. Staffing levels, patients views and up-front costs must be factored into the decision to move towards 100% single rooms.

Article citation:

Teltsch DY, Hanley J, Loo V, Goldberg P, Gursahaney A, Buckeridge DL. Infection acquisition following intensive care unit room privatization. Arch Intern Med 2011;171:32-38.