- Email: [email protected]
Who is the failure: the patient or the healthcare system?
Letter to the Editor
CSIRO PUBLISHING
www.publish.csiro.au/journals/hi
Healthcare Infection, 2010, 15, 57–58
Who is the failure: the patient or the healthcare system? Marija Jane Juraja RN, Grad Cert Inf Ctrl, CICP The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, Australia. Email: [email protected]
Dear Editor, Patients with a new or known multi-resistant organism are usually isolated from other patients. This isolation is usually compounded by their lack of understanding of the multiresistant organism, how it is passed to others, and why they pose a risk to others.1 Therefore, patients with poor understanding of their condition, will often revert to a lower level of functioning when they are placed under stress. They can become assertive, have outbursts of temper, become non-compliant with treatment and even abscond or cease treatment. Family members who are seen as the primary support mechanism for the patient also develop feelings of isolation themselves, of which guilt, pity and even avoidance are evident. Staff are also perceived as providing an unsatisfactory level of care, as staff are seen as being reluctant to enter a patient’s room if in isolation, especially if they are required to put on personal protective equipment.2,3 This is perceived by staff as taking too much time and so they are more likely to spend a minimal amount of time with the patient.2,3 This then becomes a vicious cycle for the patient, the family and the staff, as the patient may receive a less than adequate treatment, be seen as not warranting treatment due to their behaviour and a failure of the healthcare system, and an even greater strain on a healthcare system that is already struggling.4 Details of the case A 48-year-old woman has been admitted into an acute care hospital with an infected leg ulcer. She is indigenous, her co-morbidities include: diabetes, alcoholism, peripheral neuropathy and vascular disease. She has had a below-knee amputation and is wheelchair-dependent. Her social history is poor with eviction from 11 residences in the past 12 months and is again currently homeless. She is at high risk of falls, is non-compliant with her treatment (often leaving half way through treatment) and repeatedly absconding from the hospital or from respite care. In the hospital she has special treatment with one-to-one nursing within a single room. She will quite often go down to the garden for a cigarette with her nurse and rarely has any other contact with other patients. Through her medical admission she has returned positive laboratory results for: methicillin-resistant Staphylococcus aureus (MRSA) from her leg ulcer and from her nose/groin/ axilla; Klebsiella oxytoca extended spectrum b lactamase producer (ESBL) in her urine; a multi-resistant Pseudomonas aeruginosa from her stump wound (intermediate sensitivity Australian Infection Control Association 2010
to colistin only); and lastly due to her extensive antibiotic treatment, a vancomycin-resistant Enterococcus (VRE) colonisation in her bowel. Discussion The hospital has a duty of care to this patient and to the community, as we want to ensure that she does not increase the spread of multi-resistance to other susceptible people, both in hospital and in the community. The patient is entitled to the same care and consideration as other patients, yet we seem to fail. What was realised after investigating her previous hospital admissions and personal history through case-note reviews, talking to her case managers, and to the patient, was that the patient did not understand her infectious status and that there was no clear pathway of managing this patient and coordinating her care within the hospital and externally within the community. The first issue was the patient feeling that she had no control of her situation, her poor social history and family isolation. Family members were reluctant to be involved in her care due to her infectious status. This made her psychologically withdraw and retaliate by taking control through absconding and therefore escalating her behaviour as highlighted by recent authors.5 The patient was empowered by being provided with opportunities to openly discuss her understanding of her infectious status, what the multi-resistant organisms were, and how she could prevent further resistance or infection through good personal hygiene, especially hand hygiene, covering wounds, eating well and completing treatment plans as directed by the medical staff. Having the indigenous social worker present with the medical staff and allied health staff ensured that the patient was being given the correct information in a language she could understand. Written information was also provided that she could give to her family members. Hospital staff also have a responsibility to ensure that patients understand the rationale around their care and why they are isolated. This in turn reduces their fear; decreases the stigma that they believe is attached to them by staff and family members, and improves compliance with care both in the hospital and in the community.3 The second issue was the staff reluctance, both within the ward and at the respite/residential care facility, to enter the patient’s room due to her multi-resistant organisms, and a lack of understanding in regard to her clinical care from hospital to community. The ward staff and the respite/ residential centre were provided with education on 10.1071/HI10005
1835-5617/10/020057
58
Healthcare Infection
M. J. Juraja
transmission-based contact precautions and the Infection Prevention and Control Unit developed two care pathway tools, based on risk assessment and management. The first pathway tool provided clear guidance on managing her multiresistance within the acute-care hospital with bed placement, personal protective equipment requirements, cleaning and visitor precautions. The second pathway tool utilised standard precautions and enhanced transmission precautions dependent on the associated risk for a respite centre/residential facility with room placement, rehabilitation staff/area requirements, linen management, cleaning and visitor precautions. By providing a pathway tool for in-hospital care and community care, there was reduced fear of transmission, stigmatism and an increased knowledge of standard and transmission-based precautions. Planning patient care delivery and post-discharge care must be balanced with the needs of infection prevention and control and the physical and emotional needs of the patient; this will then reduce preventable adverse events and provide further bed capacity for other patients in need.2,3,6
It is clear that a good clinical pathway tool with documented infection control guidelines that utilise the principles of risk assessment and management for the inpatient and the community has a incremental effect in reducing fear, increasing knowledge, decreasing discharge delays and improving communication between the hospital and the community, with stronger support/network links. Conflict of interest None reported. References 1.
2.
3.
4.
Recommendations/outcomes The final outcome has been that this patient has been wellmanaged within her residential facility after initially having some respite care and has been compliant with her personal hygiene and treatment. She also has not been readmitted into hospital for well over 12 months, whereas previously she was admitted every 2–3 weeks.
5.
6.
Denise Bulling PZ. Behavioral Health Guidelines for Medical isolation. University of Nebraska Public Policy Center; 2007. Available at: http://www.cism.nebraska.edu/ (last accessed 01/15/2010) Kelly-Rossini LP. The experience of respiratory isolation for HIVinfected persons with tuberculosis. J Assoc Nurses AIDS Care 1996; 7(1): 29–36. doi:10.1016/S1055-3290(96)80035-5 Butenko S. Patient Stories – The Impact of Additional Precautions and Isolation in Patients Colonised or Infected with VRE. ICASA. Adelaide: ICASA; 2009. Cruickshank M, Ferguson J, eds. Reducing Harm to Patients from Health Care Associated Infection: The Role of Surveillance. Australian Commission on Safety and Quality in Health Care; 2008. Safdar N, Maki D. Quality of Care and Satisfaction Among Patients Isolated for Infection Control. JAMA 2004; 291(4): 420–1. doi:10.1001/jama.291.4.420-b Maunder RH. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003; 168(10): 1245–51.
http://www.publish.csiro.au/journals/hi
CSIRO PUBLISHING
www.publish.csiro.au/journals/hi
Healthcare Infection, 2010, 15, 57–58
Who is the failure: the patient or the healthcare system? Marija Jane Juraja RN, Grad Cert Inf Ctrl, CICP The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, Australia. Email: [email protected]
Dear Editor, Patients with a new or known multi-resistant organism are usually isolated from other patients. This isolation is usually compounded by their lack of understanding of the multiresistant organism, how it is passed to others, and why they pose a risk to others.1 Therefore, patients with poor understanding of their condition, will often revert to a lower level of functioning when they are placed under stress. They can become assertive, have outbursts of temper, become non-compliant with treatment and even abscond or cease treatment. Family members who are seen as the primary support mechanism for the patient also develop feelings of isolation themselves, of which guilt, pity and even avoidance are evident. Staff are also perceived as providing an unsatisfactory level of care, as staff are seen as being reluctant to enter a patient’s room if in isolation, especially if they are required to put on personal protective equipment.2,3 This is perceived by staff as taking too much time and so they are more likely to spend a minimal amount of time with the patient.2,3 This then becomes a vicious cycle for the patient, the family and the staff, as the patient may receive a less than adequate treatment, be seen as not warranting treatment due to their behaviour and a failure of the healthcare system, and an even greater strain on a healthcare system that is already struggling.4 Details of the case A 48-year-old woman has been admitted into an acute care hospital with an infected leg ulcer. She is indigenous, her co-morbidities include: diabetes, alcoholism, peripheral neuropathy and vascular disease. She has had a below-knee amputation and is wheelchair-dependent. Her social history is poor with eviction from 11 residences in the past 12 months and is again currently homeless. She is at high risk of falls, is non-compliant with her treatment (often leaving half way through treatment) and repeatedly absconding from the hospital or from respite care. In the hospital she has special treatment with one-to-one nursing within a single room. She will quite often go down to the garden for a cigarette with her nurse and rarely has any other contact with other patients. Through her medical admission she has returned positive laboratory results for: methicillin-resistant Staphylococcus aureus (MRSA) from her leg ulcer and from her nose/groin/ axilla; Klebsiella oxytoca extended spectrum b lactamase producer (ESBL) in her urine; a multi-resistant Pseudomonas aeruginosa from her stump wound (intermediate sensitivity Australian Infection Control Association 2010
to colistin only); and lastly due to her extensive antibiotic treatment, a vancomycin-resistant Enterococcus (VRE) colonisation in her bowel. Discussion The hospital has a duty of care to this patient and to the community, as we want to ensure that she does not increase the spread of multi-resistance to other susceptible people, both in hospital and in the community. The patient is entitled to the same care and consideration as other patients, yet we seem to fail. What was realised after investigating her previous hospital admissions and personal history through case-note reviews, talking to her case managers, and to the patient, was that the patient did not understand her infectious status and that there was no clear pathway of managing this patient and coordinating her care within the hospital and externally within the community. The first issue was the patient feeling that she had no control of her situation, her poor social history and family isolation. Family members were reluctant to be involved in her care due to her infectious status. This made her psychologically withdraw and retaliate by taking control through absconding and therefore escalating her behaviour as highlighted by recent authors.5 The patient was empowered by being provided with opportunities to openly discuss her understanding of her infectious status, what the multi-resistant organisms were, and how she could prevent further resistance or infection through good personal hygiene, especially hand hygiene, covering wounds, eating well and completing treatment plans as directed by the medical staff. Having the indigenous social worker present with the medical staff and allied health staff ensured that the patient was being given the correct information in a language she could understand. Written information was also provided that she could give to her family members. Hospital staff also have a responsibility to ensure that patients understand the rationale around their care and why they are isolated. This in turn reduces their fear; decreases the stigma that they believe is attached to them by staff and family members, and improves compliance with care both in the hospital and in the community.3 The second issue was the staff reluctance, both within the ward and at the respite/residential care facility, to enter the patient’s room due to her multi-resistant organisms, and a lack of understanding in regard to her clinical care from hospital to community. The ward staff and the respite/ residential centre were provided with education on 10.1071/HI10005
1835-5617/10/020057
58
Healthcare Infection
M. J. Juraja
transmission-based contact precautions and the Infection Prevention and Control Unit developed two care pathway tools, based on risk assessment and management. The first pathway tool provided clear guidance on managing her multiresistance within the acute-care hospital with bed placement, personal protective equipment requirements, cleaning and visitor precautions. The second pathway tool utilised standard precautions and enhanced transmission precautions dependent on the associated risk for a respite centre/residential facility with room placement, rehabilitation staff/area requirements, linen management, cleaning and visitor precautions. By providing a pathway tool for in-hospital care and community care, there was reduced fear of transmission, stigmatism and an increased knowledge of standard and transmission-based precautions. Planning patient care delivery and post-discharge care must be balanced with the needs of infection prevention and control and the physical and emotional needs of the patient; this will then reduce preventable adverse events and provide further bed capacity for other patients in need.2,3,6
It is clear that a good clinical pathway tool with documented infection control guidelines that utilise the principles of risk assessment and management for the inpatient and the community has a incremental effect in reducing fear, increasing knowledge, decreasing discharge delays and improving communication between the hospital and the community, with stronger support/network links. Conflict of interest None reported. References 1.
2.
3.
4.
Recommendations/outcomes The final outcome has been that this patient has been wellmanaged within her residential facility after initially having some respite care and has been compliant with her personal hygiene and treatment. She also has not been readmitted into hospital for well over 12 months, whereas previously she was admitted every 2–3 weeks.
5.
6.
Denise Bulling PZ. Behavioral Health Guidelines for Medical isolation. University of Nebraska Public Policy Center; 2007. Available at: http://www.cism.nebraska.edu/ (last accessed 01/15/2010) Kelly-Rossini LP. The experience of respiratory isolation for HIVinfected persons with tuberculosis. J Assoc Nurses AIDS Care 1996; 7(1): 29–36. doi:10.1016/S1055-3290(96)80035-5 Butenko S. Patient Stories – The Impact of Additional Precautions and Isolation in Patients Colonised or Infected with VRE. ICASA. Adelaide: ICASA; 2009. Cruickshank M, Ferguson J, eds. Reducing Harm to Patients from Health Care Associated Infection: The Role of Surveillance. Australian Commission on Safety and Quality in Health Care; 2008. Safdar N, Maki D. Quality of Care and Satisfaction Among Patients Isolated for Infection Control. JAMA 2004; 291(4): 420–1. doi:10.1001/jama.291.4.420-b Maunder RH. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003; 168(10): 1245–51.
http://www.publish.csiro.au/journals/hi