I have been working in infectious diseases as a clinician over 10 years and continue to be struck by two things. One is how we as healthcare providers assume that we know how the patient is feeling and two, how little effort is spent in setting the stage, inviting a conversation and having a meaningful dialogue with the patient that addresses their concerns- their concerns, not ours.
Two understudied areas that are interests of mine are infection prevention and antibiotic stewardship
Setting the Stage for a Dialogue
Infection prevention in the hospitalized patient is no easy task. More and more, we see patients needing to be placed in contact precautions because of colonization or infection by a resistant organism. One day it’s business as usual and the next, all the healthcare workers coming into the room are wearing gowns and gloves. Such an experience, while commonplace for healthcare workers, may be quite frightening for the patient. Multiple studies have shown that patients in contact precautions for Methicillin-resistant Staphylococcus aureus feel stigmatized, isolated and bewildered. A question about their perceptions regarding contact precautions may help to set the stage for a dialogue which will leave the patient feeling much more comfortable. However, most of the time, contact precautions are not addressed and the patient may leave the hospital at time of discharge, no wiser about their multidrug resistant carrier state than before.
Changing our Approach
Clostridium difficile is an increasingly important healthcare-associated pathogen which causes diarrhea and associated with considerable morbidity and mortality. In my clinical infectious diseases practice, I see many patients with recurrent or recalcitrant C. difficile infection. With rare exception they all say the same thing: The doctor asks me if the diarrhea has improved. When I say yes it has, the conversation immediately moves on to a different topic. But improved diarrhea does not mean it’s gone. For many patients with C. difficile infection, returning to their pre-infection state of health may take many weeks of months. Yet, questions about quality of life and accidental bowel leakage- so important to patients- are rarely asked. A change in our approach to gather patient perceptions about their illness as a starting point and not our own pre-conceived ideas may go a long way to eliciting symptoms and outcomes perceived to be important by patients.
Understanding Patient-Centered Interventions
Healthcare worker hand hygiene is critical for the prevention of healthcare-associated infection. Monitoring compliance with hand hygiene is routine in infection prevention, but compliance in general with hand hygiene remains suboptimal. The patient may have a crucial role in promoting healthcare worker hand hygiene but this key stakeholder is rarely brought into the discussion from the get-go. The result is that interventions focused on patient engagement and empowerment for promoting hand hygiene rarely work because they don’t have the heft of the patient’s experience incorporated in them. A better understanding of patient-centered interventions to promote healthcare worker hand hygiene compliance is needed.
Patients’ own hand hygiene is also an area that deserves study because there is a paucity of data on how often and how well patients are able to wash their own hands while hospitalized. In a survey at our facility, we found that most patients reported that they always washed their hands while at home but not always while they were in the hospital. Asking the patient stakeholders what intervention may be of value here is important and we have found that small bottles of hand gel increase patient self reported hand hygiene.
Recent reports from the CDC indicate that antibiotics are overused in the hospital and that robust antibiotic stewardship programs may reduce antibiotic misuse and overuse. A number of provider focused interventions such as restriction of antibiotics, audit and feedback have been shown to improve antibiotic use but no studies have examined patient perceptions regarding the type of antibiotics prescribed while in the hospital. Might the patient have a role here? In a recent study, where we undertook semi-structured interviews of hospitalized inpatients, we found that patients expressed surprise that there was usually a discussion of antibiotic use in the outpatient setting, but rarely in the inpatient setting. A discussion of antibiotic use here may help keep the patient more informed about future antibiotic choices and side effect discussions.
“Nothing about Me without Me”
The common thread through all the scenarios described above is that the the patient’s perception and opinion is rarely sought when it could be so valuable in infection prevention. We must always remember the mantra of patient-centered care, “nothing about me without me.”
Editor’s Note: You can read about the successful methodologies Dr. Safdar put in place to prevent hospital-acquired infections at the University of Wisconsin Hospital and learn of their dramatic results. We’ve spotlighted her award-winning initiatives here.