Evaluating risks of isolating and not isolating infectious patients

Thursday 26 October 2017

The proposal will be for National Institute for Healthcare Research (NIHR) Health services and Delivery of Care (HS&DR) Research Stream. Funding of about £500,000 will be sought for a project over 3 years. Application is in two stages: outline application. If it is short-listed we proceed to full application.

Background

Segregating infectious/potentially infectious patients can prevent the spread of infections including staphylococci, Gram negative bacteria and mycobacteria which are often multi-drug resistant. In the UK the decision to isolate infectious and potentially infectious patients depends on local policy. There is under provision of single room accommodation in many hospitals and when available it is often used for disruptive patients or those receiving end of life care. Even when single rooms are used for contagious patients the benefits of isolation are compromised because doors stay open and patients and equipment are moved in and out. The NHS would benefit from a framework to support management decisions concerning the best use of isolation accommodation based on evidence of the risks posed by patients with infections spread by different routes (e.g. airborne, direct contact) and under different circumstances (e.g. cubicle with door open/shut) 

IMPORTANT We are not suggesting that people who are not infected should not be nursed in single rooms - we are looking at optimal use of rooms. There is quite a reasonable literature about the risks of isolation to patients who are disoriented, lonely etc. and we will draw on this. Very little research has been undertaken about the risks not of isolating infectious/potentially infectious patients.

AIM Develop a framework to support management decisions concerning optimal use of isolation accommodation in acute hospitals to reduce infection risks

STUDY DESIGN There will be four workpackages (WPs)

WP1 will build a picture of how single rooms are allocated in the participating sites through a point prevalence survey in each of 5 sites with interviews to explore how decisions about isolation are taken and by whom. There will be fieldwork to see how accommodation is used: who is isolated/not isolated, doors open etc.

WP2 Mathematical modelling to establish risk of not isolating/poorly employing isolation principles in different scenarios:

  • Patient with airborne infection isolated/not isolated
  • Patient with contact spread pathogen isolated/not isolated
  • Detailed data will be collected on contamination/dissemination of patient environment and equipment

WP3 Will involve feedback of WP1 and 2 findings to the organisations and presentation of WP1 and 2 data to each site with detailed discussion:

Infection risks from the patient scenarios

  • How things might be done differently with current resources and feasibility
  • Additional resources and cost to optimise practice
  • Discussion will be digitally recorded with permission, transcribed and used to inform WP4.

WP4 will generate the management framework in close conjunction with the RCN and patient and health professional/manager stakeholder groups using a consensus decision-making technique e.g. nominal group technique  

SAMPLE – purposively selected hospitals (hospitals, not whole trusts because we know that single room provision varies a lot within trusts).

We need a patient/public involvement lay person to participate in the writing of the outline and full bid if short-listed by reading the drafts and making comments from a lay perspective, especially the lay summary (it will be 3,500 words). This can be done by email and if necessary I can visit the RCN headquarters or meet at another convenient location in London

The person will be a co-applicant on the application. They will need to be able to provide a brief CV if we are short-listed (nothing elaborate) and to navigate the NIHR website to sign off electronically that they agree to take part. The website is not very user-friendly but we can guide the person through by phone if necessary. What is crucial is that they look at their email often enough to see the e-invite in good time and respond promptly: the deadline really is the deadline even if people are ill etc. If we lose the lay co-applicant because they have not signed off, we lose the bid and have to re-submit 3 months later.

If the study is funded the lay person would need to be able to convene a small group of other lay people (3-4) who will play a part in every workpackage and an especially prominent one in WP4.

Most communication will be by email. There will be quarterly project management meetings but mostly they will be by teleconference

Travel will be paid. Time will at INVOLVE rates

In additional to the project management meetings every quarter participation will involve the lay group looking at draft and final reports, informing how findings are disseminated, reading data collecting tools and commenting on them, looking at the results of analysis and commenting, looking at the management tool and making suggestions about feasibility etc. The mathematical modelling will be very complex and we do not expect input into the technical aspects but we do expect sensible comments on implications for patients: e.g. if modelling shows that other patients in the same ward/hospital are at risk of infection, we expect comments about those consequences and implications for quality of care.