Preeti Mehrotra

Effects of Contact Precautions on Patient Perception of Care and Satisfaction: A Prospective Cohort Study

OBJECTIVE Contact precautions decrease healthcare worker-patient contact and may impact patient satisfaction. To determine the association between contact precautions and patient satisfaction, we used a standardized interview for perceived issues with care. DESIGN Prospective cohort study of inpatients, evaluated at admission and on hospital days 3, 7, and 14 (until discharged). At each point, patients underwent a standardized interview to identify perceived problems with care. After discharge, the standardized interview and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were administered by telephone. Responses were recorded, transcribed, and coded by 2 physician reviewers. PARTICIPANTS A total of 528 medical or surgical patients not admitted to the intensive care unit. RESULTS A total of 528 patients were included in the primary analysis, of whom 104 (20%) perceived some issue with their care. On multivariable logistic regression, contact precautions were independently associated with a greater number of perceived concerns with care (odds ratio, 2.05 [95% confidence interval, 1.31-3.21]; P < .01), including poor coordination of care (P = .02) and a lack of respect for patient needs and preferences (P = .001). Eighty-eight patients were included in the secondary analysis of HCAHPS. Patients under contact precautions did not have different HCAHPS scores than those not under contact precautions (odds ratio, 1.79 [95% confidence interval, 0.64-5.00]; P = .27). CONCLUSIONS Patients under contact precautions were more likely to perceive problems with their care, especially poor coordination of care and a lack of respect for patient preferences.

The Effect of Contact Precautions on Frequency of Hospital Adverse Events.

OBJECTIVE To determine whether use of contact precautions on hospital ward patients is associated with patient adverse events DESIGN Individually matched prospective cohort study SETTING The University of Maryland Medical Center, a tertiary care hospital in Baltimore, Maryland METHODS A total of 296 medical or surgical inpatients admitted to non-intensive care unit hospital wards were enrolled at admission from January to November 2010. Patients on contact precautions were individually matched by hospital unit after an initial 3-day length of stay to patients not on contact precautions. Adverse events were detected by physician chart review and categorized as noninfectious, preventable and severe noninfectious, and infectious adverse events during the patients stay using the standardized Institute for Healthcare Improvements Global Trigger Tool. RESULTS The cohort of 148 patients on contact precautions at admission was matched with a cohort of 148 patients not on contact precautions. Of the total 296 subjects, 104 (35.1%) experienced at least 1 adverse event during their hospital stay. Contact precautions were associated with fewer noninfectious adverse events (rate ratio [RtR], 0.70; 95% confidence interval [CI], 0.51-0.95; P=.02) and although not statistically significant, with fewer severe adverse events (RtR, 0.69; 95% CI, 0.46-1.03; P=.07). Preventable adverse events did not significantly differ between patients on contact precautions and patients not on contact precautions (RtR, 0.85; 95% CI, 0.59-1.24; P=.41). CONCLUSIONS Hospital ward patients on contact precautions were less likely to experience noninfectious adverse events during their hospital stay than patients not on contact precautions.

Family-Centered Care and High-Consequence Pathogens: Thinking Outside the Room

Can we protect ourselves? Can we protect our community? With the emergence of the Ebola virus outbreak, these questions have captured the attention of the American audience; however, these issues are hardly new to the US health care system. Caring for individuals with presumptive or confirmed pathogens of high consequence, such as Ebola virus, Middle East respiratory syndrome coronavirus, pandemic influenza, and severe acute respiratory syndrome, to name a few, provokes not only technical but also ethical dilemmas to our current health care infrastructure. While we mostly understand the science of infectious disease transmission and recognize that intensive medical care generally improves outcomes, what remains less certain is how to provide supportive care safely and compassionately. This is especially apparent in the care of a vulnerable infected child. Parents are often encouraged to aid in hands-on care of their hospitalized child, making parental presence the cornerstone of family-centered care. However, in suspected or confirmed cases where pathogens are of high consequence, we posit that parental presence may pose significant risk to the patient, parents, health care professionals, and public. We believe infections with high-consequence pathogens fundamentally alter our risk-benefit calculus and that, in these scenarios, temporary physical separation of the infected child from parents is the most effective option for safe care delivery. We challenge the pediatric medical community to view patient isolation and parental separation not as a threat to family-centered care but rather as an opportunity to reflect on our care provision, foster innovation and creativity, and cultivate a new sensitivity in family centeredness. Family-centered care respects each child and family’s innate strengths and cultural values and views the health care experience as an opportunity to build on these strengths.1 However, in situations where infectivity or the risk of an adverse outcome with transmission is high, safety should be a guiding principle. It is from this unique perspective that we view the interaction between family engagement and infection prevention and control. Parental presence and participation in bedside care are encouraged in resource-endowed settings,2 whereas family members assume the role of bedside nurse in resourcechallenged settings. In resource-endowed settings where personal protective equipment is plentiful, researchers have assessed the effect of infection prevention practices on the delivery of family-centered care, mostly noting findings related to social isolation.3 The converse, evaluation of the effect of parental presence on infection prevention practices, has not been a focus of study. The management of high-consequence pathogens in children offers a unique set of infection control challenges. If parental presence is endorsed, should parents be required to don and doff personal protective equipment (PPE)? Which hospital staff members should enforce PPE training, compliance, and other prevention practices, such as postexposure prophylaxis, when indicated? How is a breach in isolation handled? Who assumes responsibility should a transmission occur? Should PPE be allocated to family members when supplies are limited? Given that the isolation of children with these infections would be protracted, should practices differ when risk of transmission is greatest? As many centers propose an additional health care professional in the room to assist with the care of children who are developmentally unable to cooperate, would adding a parent create an additional safety risk to the child, parent, and staff? Cultural and language barriers are a recognized challenge in infection prevention counseling in ideal settings. Given the need to depend on interpreter services, how can effective counseling regarding PPE be ensured? These difficult questions illustrate infection prevention complexities. Even if appropriate PPE and infection control practices could be implemented for a parent, this may serve as a barrier between parent and child. Lessons from severe acute respiratory syndrome have taught us that wearing masks inhibits effective communication.3 Reduced auditory and visual cues among wearers of PPE limit health care professional to patient and parent to child interactions. How likely would a child be to recognize his or her parent in PPE? We recognize that PPE can create psychologically and physically detrimental barriers between child and professional. We maintain that a physical barrier is both necessary and critical for the protection of all in cases of high-consequence pathogens. Opponents may argue whether parental PPE is necessary given that parents are often coexposed to the source of infection and have contact with their own infected child. Here, we can draw the following point of distinction: in ambulatory and emergency department settings where the majority of health preparedness guidelines traditionally focus, we recognize that enforcing parental separation could be a difficult task. However, in confirmed or highly suspected cases requiring care in an intensive care or biocontainment unit, we know that transmission can be prevented with meticulous PPE use by highly trained essential professionals. Cohorting infected or presumptively infected children VIEWPOINT

Implementation of Infection Prevention and Antimicrobial Stewardship in Cardiac Electrophysiology Laboratories: Results from the SHEA Research Network

Infection prevention in electrophysiology (EP) laboratories is poorly characterized; thus, we conducted a cross-sectional survey using the SHEA Research Network. We found limited uptake of basic interventions, such as surveillance and appropriate peri-procedural antimicrobial use. Further study is needed to identify ways to improve infection prevention in this setting.

Barriers to the use of face protection for standard precautions by health care providers

Health care providers sometimes choose not to use face protection even when indicated as part of standard precautions. We performed a survey of pediatric health care providers to determine barriers to the routine use of face protection. Lack of availability at the point of care and a perceived lack of need were the most commonly cited issues. Continuing education is needed regarding situations in which face protection is indicated for standard precautions.

Frequency of Adverse Events Before, During, and After Hospital Admission.

Objectives Adverse events (AEs) are unintended physical injuries resulting from or contributed to by medical or surgical care. We determined the frequency and type of AEs before, during, and after hospital admission. Methods We conducted a cohort study of 296 adult hospital patients. We used the standardized Institute for Healthcare Improvement Global Trigger Tool for Measuring Adverse Events to review the medical records of the hospital patients for occurrence, timing relative to hospital admission, severity, and preventability of AEs. We also identified the primary physiologic system affected by the AE. Results Among 296 patients, we identified 338 AEs. AEs occurred with similar frequency before (n = 148; 43.8%) and during hospital admission (n = 162; 47.9%). Fewer AEs occurred after discharge (n = 28; 8.3%). Half of all AEs (n = 169; 50.0%) were severe, whereas 47.9% (n = 162) were preventable. Conclusions AEs occur with similar frequency before and during hospitalization and may contribute more to hospital admissions than previously recognized. These findings suggest that efforts to improve patient safety should include outpatient settings in addition to the more commonly targeted acute care settings.

Clinical Utility of Preimplantation Homograft Cultures in Patients Undergoing Congenital Cardiac Surgery.

Institutional practice at our hospital (Boston Childrens Hospital) is to culture homografts before implantation during congenital cardiac surgery. Over a 4-year period, 5% (73 of 1376) of these cultures were positive, but the results had minimal clinical impact. Our experience demonstrates that there is limited utility in preimplantation cultures of cardiac homografts.

Upholding Family-Centered Care in the Face of High-Consequence Pathogens--Thinking Inside the Room--Reply.

mathematics. Because of the smaller subgroup sample size, however, the association of transient hypoglycemia with literacy and mathematics test proficiency was not significant using the less than 35 mg/dL cutoff or for the literacy model using the less than 45 mg/dL cutoff. We consider school-age achievement tests a meaningful realworld outcome that predicts important longitudinal outcomes suchashighschoolgraduation,collegeattendance,andlong-term adult success.2-5 Because ours was a retrospective observational study, we did not have access to neurodevelopmental testing, neurologic examinations, or intelligence tests. However, it is importanttopointoutthattheseassessmentsareuncommonlyperformed for most children. Further, our analysis excluded children with cognitive disabilities because they were unable to take the achievement tests. The excluded children (n = 11) were only 0.6% of the entire birth cohort. Therefore, the exclusion is unlikely to have influenced our results. This study could have not been performed in any other hospital that we are aware of because of a lack of universal glucose screening in other centers. We hope our article has reignited the debate about the impact of transient neonatal hypoglycemia on meaningful outcomes and promotes interest in finally performing the definitive prospective trial.