Infection Control & Hospital Epidemiology
physician communication, nurse communication, staff respon- siveness, pain control, and overall care.
Methods
In this retrospective analysis, we prospectively collected HCAHPS patient experience data and Press Ganey patient satisfaction survey data from a single academic tertiary-care hospital.
Participants and time period
All patients who returned the Press Ganey HCAHPS surveys sent by the hospital between July 2011 and July 2016 were included in the study.
Exposure
Patients in isolation during their hospital stay were considered for inclusion in the exposure group. The isolation status included contact isolation (ie, glove and gown), droplet isolation (ie, glove, gown and face mask) and airborne isolation (ie, negative pressure room, glove, gown and N95 face mask). Patient isolation status data were obtained from the electronic health record, in which isolation status had been updated daily. For the purpose of this study, we defined the isolation group a priori as patients who were in isolation for at least 50% of their hospital stay. Patients on droplet or airborne isolation for at least 50% of their hospital stay constituted the “droplet” subgroup and the “airborne” subgroup, respectively. Patients discharged from the hospital who were not on any isolation during any part of their stay constituted the control group. Patients on some form of isolation for <50% of their hospitalization were excluded from the primary analysis.
Patient experience survey instruments
Responses to HCAHPS patient experience surveys sent by the hospital via mail to a random 50% sample of the discharged patients were utilized to assess patient experience. The develop- ment, testing, and methods for administration and reporting of the HCAHPS survey have been described previously.15 Addi- tionally, we obtained national hospital-level HCAHPS scores for 2017 reported by Centers for Medicare and Medicaid Services (CMS) on the Hospital Compare website. These national data were used to calculate hospital-level percentile scores for patient experience–related variables to help contextualize our findings and to demonstrate industry standards.16
Outcome variables
The HCAHPS patient experience survey responses on items related to nursing, physicians, pain control, staff responsiveness, and overall rating were the primary outcome variables. Patient experience with discharge, hospital environment, and selected physician and nursing Press Ganey items (survey items originated by Press Ganey but not part of the HCAHPS instrument) were outcome variables for additional exploratory analysis.
Covariates
Age, sex, race, payer type, length of stay (LOS), all-payer refined diagnosis-related group–severity of illness (APR-DRG SOI) index, and clinical service type (medicine, surgery, oncology,
195
neurological diseases, obstetrics and gynecology) were included as covariates in the analysis.
Statistical analysis
“Percent top box” scores were calculated for each survey item as the percentage of patients who responded “always” or “definitely yes” or “9” or “10” on the HCAHPS survey items. This procedure is consistent with CMS practice and prior studies.17 We used χ2 analyses and t tests to detect significant differences
between control and exposure groups for the different covariates that were included in the model. Survey responses were treated as binary outcome variables
(“top-box” vs “other”) and adjusted logistic regression was per- formed to test the effect of isolation exposure on giving a top box score. We used generalized estimating equations (GEE) to address clustering related to repeat responses by the same patient over different admissions. Sensitivity analysis using different thresh- olds for exposure (eg, isolated for >25% of hospital stay and >75% of hospital stay) yielded similar results, so we only report the primary analysis. Adjusted odds ratios (aORs) were calculated from GEE logistic regression parameter estimates to compare the odds of those exposed giving a top box score to controls giving a top box score. Logistic regression using GEE was also used when detecting a
dose response. We treated our exposure as a continuous measure of percentage of hospital stay spent in isolation and scaled it to measure 25% increments. All patients that spent any time in isolation were included. The dose-response analysis was adjusted for age, race, gender, payer, APR-DRG SOI index, length of stay, and service. All patients who were in isolation at any point in their hospital stay were included in the dose-response analysis. We calculated adjusted odds ratios (aORs) that measured odds of giving a top box score for each unit of increase in exposure where a unit increase was a 25% increase in isolation time. Each analysis was performed for the overall group of any form
of isolation and then within individual subgroups of “droplet” and “airborne” isolation types. Because we conducted multiple comparisons, Bonferroni correction was used to calculate a P-value threshold of .0046 for statistical significance. All analyses and data management were performed using SAS version 9.4 software (SAS Institute, Cary, NC).
Results
A total of 21,175 patients returned a HCAHPS survey during the study period, for a survey response rate of 35.4%. Among them, 2,359 were in isolation at any point in the hospital stay and 1,784 were in isolation for >50% of the hospital stay. Of those in iso- lation for >50% of their hospital stay, 402 patients were on droplet isolation precautions and 35 patients were on airborne precautions. Patients in isolation were older (mean age, 59.7 vs 58.1 years; P<.0001), were more frequently nonwhite (39% vs 26%; P<.0001), and had longer length of stay (mean LOS, 7.5 vs 5.0; P<.0001). They also differed in severity of illness and payer type (Table 1). The unadjusted analysis showed a broad dissatisfaction pattern
among isolated patients. They reported worse experience with nursing care (eg, nurses listened carefully, 72% vs 77%; P<.0001), physicians (eg, doctors explained, 73% vs 78%; P<.0001), staff responsiveness (eg, help toileting, 51% vs 63%; P<.0001).
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136 |
Page 137 |
Page 138 |
Page 139 |
Page 140 |
Page 141 |
Page 142 |
Page 143 |
Page 144 |
Page 145 |
Page 146 |
Page 147 |
Page 148 |
Page 149 |
Page 150 |
Page 151 |
Page 152 |
Page 153 |
Page 154 |
Page 155 |
Page 156
