Prospective evaluation of hospital isolation room capacity

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Summary

Risk assessment is used to determine the need for isolation in single rooms. Limited availability of isolation rooms and/or operational needs may compromise this process. This article reports the results of a 12-month prospective observational study of every infection control request for isolation in a 1100-bed teaching hospital. In addition, four point-prevalence surveys of the usage of single rooms were carried out. Data were collected on the incidence of new clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates per ward and these were correlated with rates of isolation failures for MRSA cases. There were 845 requirements for patient isolation, of which 185 (22%) could not be met (isolation failures). Three-quarters of the requirements for isolation were due to MRSA or Clostridium difficile. The proportion of isolation failures was consistent for most organisms and conditions but varied markedly between clinical specialities (0–57%). Reasons for failure to isolate included no single rooms available, all single/isolation rooms occupied (for both isolation and non-infection-control reasons), limitations on the use of single rooms in mixed-sex wards and patient-specific reasons. Only a minority of the available single rooms were occupied for infection control reasons (12–19%). There was a statistically significant correlation between isolation failures and MRSA incidence (Spearman's rho 0.596, P < 0.001). In only one case where a ward had ≥30% of its beds provided in single rooms was there an instance of failure to isolate. In conclusion, insufficient capacity to isolate patients with potentially transmissible pathogens is common and may compromise infection control requirements. Either isolation capacity must be increased or evidence-based risk assessment must be applied to situations where demand for isolation exceeds availability. Further information is needed on the consequences of isolation failure.

Introduction

Healthcare-associated infections (HAI) are a major cause of morbidity, mortality and increased cost to healthcare providers. In the UK, the Chief Medical Officer for England and Wales has reiterated the need to reduce the impact of HAI on hospital patients.1 Isolation of hospital patients, usually in single rooms, which may or may not have anterooms or controlled air flow, is intended to interrupt the transmission of potential pathogens between patients and/or staff. There are currently no formal, consensus guidelines for patient isolation in England and Wales. This contrasts with the USA where the Centers for Disease Control and Prevention (CDC) have issued guidance.2 A joint working group of interested UK societies and the Public Health Laboratory Service (now part of the Health Protection Agency) produced a review of hospital isolation and infection-control-related precautions that broadly echoed US guidance, although with less detail.3

There is currently no evidence-based guidance in the UK on the proportion of single rooms per speciality that are required either for isolation or other patient management needs such as terminal care. The UK working group described isolation as a ‘counsel of perfection’ in recognition that although isolation may be requested regularly, it is frequently not possible. However, the authors are unaware of any published data on the frequency of failed attempts to isolate patients. Similarly, the impact of these isolation failures on the control of communicable diseases is unclear. Therefore, a prospective, 12-month study was conducted to determine why patients with potentially transmissible pathogens could not be isolated after advice from an infection control nurse, the duration that such isolation failures persisted, and the ongoing placement of affected patients. The authors have documented the extent of isolation facilities in a large teaching hospital and how closely this provision meets current infection control needs, particularly in respect of meticillin-resistant Staphylococcus aureus (MRSA), and have investigated a correlation between rates of failure to isolate and MRSA prevalence.

Section snippets

Study setting

The study was undertaken in Leeds General Infirmary, one of two large hospitals that form part of the Leeds Teaching Hospitals National Health Service (NHS) Trust. The hospital has approximately 1150 beds distributed across 60 wards, and is typical of a large UK NHS teaching hospital with a wide range of medical and surgical specialities (adult and children's) and a number of regional specialities, which include neonatal, cardiothoracic surgery and neurosciences. The hospital has 45 intensive

Results

For the raw data, see Appendix A.

At the time of the study, there were 194 single rooms, equivalent to 17% of all beds. The pattern of provision of single rooms was very variable, with a median number of two rooms per ward (range 0–14). Approximately 60% of wards had two single rooms or less. The median number of single rooms (percentage of total beds) by hospital wing in order of the age of the buildings (oldest first) was two (16%), three (17%) and two (18%). During the 12-month period of data

Discussion

Patient isolation to limit the spread of nosocomial pathogens is a mainstay of infection prevention and control programmes worldwide. However, the true efficacy of isolation as a control measure for some organisms, particularly MRSA, remains uncertain.4, 5 Recently, isolation of MRSA-positive patients in single rooms in the intensive care setting was found to be no more effective than a combination of standard and contact infection control precautions (minus isolation) in the prevention of

Acknowledgements

The authors thank the Leeds Teaching Hospital NHS Trust Infection Control Team for its support. The study was supported by research grants from the Department of Health, NHS Estates and the Health Foundation.

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