Semi-private Rooms Research Articles

Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines

BackgroundAcupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported. MethodsACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity. ResultsAcross 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2–22), needle retention time (M = 23.5 min, range 4–52), session length (M = 40.3 min, range 20–66), whether general recommendations were provided and completion of the session form. ConclusionTo the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs. Protocol registrationThe protocol of this study is registered at clinicaltrials.gov: NCT04880733.

Using a human-factors engineering approach to evaluate environmental cleaning in Veterans' Affairs acute and long-term care facilities: A qualitative analysis.

Environmental cleaning is important in the interruption of pathogen transmission. Although prevention initiatives have targeted environmental cleaning, practice variations exist and compliance is low. Evaluation of human factors influencing variations in cleaning practices can be valuable in developing interventions to standardized practices. We conducted a work-system analysis using a human-factors engineering (HFE) framework to identify barriers and facilitators to environmental cleaning practices in acute and long-term care settings within the Veterans' Affairs health system. We conducted a qualitative study with key stakeholders at 3 VA facilities. We analyzed transcripts for thematic content and mapped themes to the HFE framework. Staffing consistency was felt to improve cleaning practices and teamwork. We found that many environmental management service (EMS) staff were veterans who were motivated to serve fellow veterans, especially to prevent infections. However, hiring veterans comes with regulatory hurdles that affect staffing. Sites reported some form of monitoring their cleaning process, but there was variation in method and frequency. The EMS workload was affected by whether rooms were occupied by patients or were semiprivate rooms; both were reportedly more difficult to clean. Room design and surface finishes were identified as important to cleaning efficiency. HFE work analysis identified barriers and facilitators to environmental cleaning. These findings highlight intervention entry points that may facilitate standardized work practices. There is a need to develop task-specific procedures such as cleaning occupied beds and semiprivate rooms. Future research should evaluate interventions that address these determinants of environmental cleaning.

Care to Share? Patients in Private Rooms Are More Likely to Recommend a Hospital to Others.

A patient's likelihood to recommend a hospital is used to assess the quality of their experience. This study investigated whether room type influences patients' likelihood to recommend Stanford Health Care using Hospital Consumer Assessment of Healthcare Providers and Systems survey data from November 2018 to February 2021 (n = 10,703). The percentage of patients who gave the top response was calculated as a top box score, and the effects of room type, service line, and the COVID-19 pandemic were represented as odds ratios (ORs). Patients in private rooms were more likely to recommend than patients in semi-private rooms (aOR: 1.32; 95% CI: 1.16-1.51; 86% vs 79%, p < .001), and service lines with only private rooms had the greatest increases in odds of a top response. The new hospital had significantly higher top box scores than the original hospital (87% vs 84%, p < .001), indicating that room type and hospital environment impact patients' likelihood to recommend.

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study

To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process. A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities. Between December 2018 and May 2019 a total of sixty-two room observations (N=3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR=3.23), HTSs (OR=1.57), and reusable medical equipment (RME) (OR=1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR=0.71) and rooms in AC (OR=0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR=1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR=1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR=0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis. Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

Management of a large tuberculosis contact investigation related to a contaminated bone graft product used in spinal surgery

Background: In March–April 2021, 23 patients at a 906-bed hospital in Delaware had surgical implantation of a bone graft product contaminated with Mycobacterium tuberculosis; 17 patients were rehospitalized for surgical site infections and 6 developed pulmonary tuberculosis. In May 2021, we investigated this tuberculosis outbreak and conducted a large, multidisciplinary, contact investigation among healthcare personnel (HCP) and patients potentially exposed over an extended period in multiple departments. Methods: Exposed HCP were those identified by their managers as present, without the use of airborne precautions, in operating rooms (ORs) during index spine surgeries or subsequent procedures, the postanesthesia care unit (PACU) when patients had draining wounds, inpatient rooms when wound care was performed, and the sterile processing department (SPD) on the days repeated surgeries were performed. We created and assigned an online education module and symptom screening questionnaire to exposed HCP. Employee health services (EHS) instituted a dedicated phlebotomy station to provide interferon-γ release assay (IGRA) testing for HCP at ≥8 weeks after last known exposure. EHS managed all exposed HCP, including nonemployees (eg, private surgeons) via automated e-mail reminders, which were escalated through supervisory chains as needed until follow-up completion. The infection prevention team notified exposed patients, defined as those who shared semiprivate rooms with case patients with transmissible tuberculosis. The Delaware Division of Public Health performed IGRA testing. Results: There were 506 exposed HCP in ORs (n = 100), the PACU (n = 87), inpatient units (n = 140), the SPD (n = 54), and other locations (n = 122); 83% were employed by the health system. Surgical masks and eye protection were routinely used during patient care. All exposed HCP completed screening by December 17, 2021. Furthermore, 2 HCP had positive IGRAs without symptoms or chest radiograph abnormalities, indicating latent tuberculosis infection, but after further review of records and interviews, we discovered that they had previously tested positive and had been treated for latent tuberculosis infection. In addition, 5 exposed patients tested negative and 2 remain pending. Conclusions: This large investigation demonstrated the need for a systematic process that encompassed all exposed HCP including nonemployees and incorporated administrative controls to ensure complete follow-up. We did not identify any conversions related to this outbreak despite high burden of disease in case patients and multiple exposures to contaminated bone-graft material and infectious bodily fluids without respirator use. Transmission risk was likely reduced by baseline surgical mask use and rapid institution of airborne precautions after outbreak recognition.Funding: NoneDisclosures: None

Intra-NICU Patient Transfers: A Study of Frequency and Family and Staff Perceptions

Aims:(a) Quantify frequency of patient moves within a NICU with single patient and semi-private rooms (SPR). (b) Compare staff and parent perceptions of these moves.Methods:A hospital administrative database was evaluated to quantify the frequency of moves. A Room Change Questionnaire was devised to evaluate perceptions from NICU families and staff.Results:Most families reported experiencing at least 1 patient move (92 percent), with the majority reporting at least 3 moves (58 percent). Staff perceived moves as negative significantly more than parents (p &lt; .01), and overreported negative family perceptions (p &lt; .01). Overall, moves did not bother families (52 percent); however, most families who moved 3 or more times reported at least 1 negative perception (63 percent).Conclusion:SFRs increase the number of patient moves. NICU staff’s perception is significantly more negative than family’s perception; however, most families who were moved frequently reported at least 1 negative perception.

Discontinuing MRSA and VRE contact precautions: Defining hospital characteristics and infection prevention practices predicting safe de-escalation.

To define conditions in which contact precautions can be safely discontinued for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Interrupted time series. 15 acute-care hospitals. Inpatients. Contact precautions for endemic MRSA and VRE were discontinued in 12 intervention hospitals and continued at 3 nonintervention hospitals. Rates of MRSA and VRE healthcare-associated infections (HAIs) were collected for 12 months before and after. Trends in HAI rates were analyzed using Poisson regression. To predict conditions when contact precautions may be safely discontinued, selected baseline hospital characteristics and infection prevention practices were correlated with HAI rate changes, stratified by hospital. Aggregated HAI rates from intervention hospitals before and after discontinuation of contact precautions were 0.14 and 0.15 MRSA HAI per 1,000 patient days (P = .74), 0.05 and 0.05 VRE HAI per 1,000 patient days (P = .96), and 0.04 and 0.04 MRSA laboratory-identified (LabID) events per 100 admissions (P = .57). No statistically significant rate changes occurred between intervention and non-intervention hospitals. All successful hospitals had low baseline MRSA and VRE HAI rates and high hand hygiene adherence. We observed no correlations between rate changes after discontinuation and the assessed hospital characteristics and infection prevention factors, but the rate improved with higher proportion of semiprivate rooms (P = .04). Discontinuing contact precautions for MRSA/VRE did not result in increased HAI rates, suggesting that contact precautions can be safely removed from diverse hospitals, including community hospitals and those with lower proportions of private rooms. Good hand hygiene and low baseline HAI rates may be conditions permissive of safe removal of contact precautions.

Risk of Healthcare-Associated Transmission of Sever Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospitalized Cancer Patients.

BackgroundThere is limited information on the risk of hospital-acquired coronavirus disease 2019 (COVID-19) among high-risk hospitalized patients after exposure to an infected patient or healthcare worker (HCW) in a nonoutbreak setting.MethodsThis study was conducted at a tertiary care cancer center in New York City from 10 March 2020 until 28 February 2021. In early April 2020, the study institution implemented universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing at admission and retesting every 3 days through the hospital stay. Contact tracing records were reviewed for all exposures to SARS-CoV-2 positive patients and HCWs.ResultsFrom 10 March 2020 to 28 February 2021, 11 348 unique patients who were SARS-CoV-2 polymerase chain reaction (PCR) negative at the time of admission underwent 31 662 postadmission tests during their hospitalization, and 112 tested positive (0.98%). Among these, 49 patients housed in semiprivate rooms during admission resulted in 74 close contacts and 14 secondary infections within 14 days, for an overall attack rate of 18.9%. Among those exposed to a roommate undergoing an aerosol-generating procedure (AGP), the attack rate was 35.7%. Whole genome sequencing (WGS) corroborated transmission in 6/8 evaluated pairs. In addition, three transmission events occurred in 214 patients with significant exposure to 105 COVID-19 positive healthcare workers (1.4%).ConclusionsThe overall risk of hospital-acquired COVID-19 is low for hospitalized cancer patients, even during periods of high community prevalence. However, shared occupancy with an unrecognized case is associated with a high secondary attack rate in exposed roommates.

COVID-19 Conversion after Exposure in a Semiprivate Room at a Tertiary Care Center in Iowa, July–December 2020

Background: Hospital semiprivate rooms may lead to coronavirus disease 2019 (COVID-19) patient exposures. We investigated the risk of COVID-19 patient-to-patient exposure in semiprivate rooms and the subsequent risk of acquiring COVID-19. Methods: The University of Iowa Hospitals &amp; Clinics is an 811-bed tertiary care center. Overall, 16% of patient days are spent in semiprivate rooms. Most patients do not wear masks while in semiprivate rooms. Active COVID-19 surveillance included admission and every 5 days nasopharyngeal SARS-CoV-2 polymerase chain reaction (PCR) testing. We identified inpatients with COVID-19 who were in semiprivate rooms during their infectious periods during July–December 2020. Testing was repeated 24 hours after the first positive test. Cycle threshold (Ct) values of the two tests (average Ct &lt;30), SARS-CoV-2 serology results, clinical assessment, and COVID-19 history were used to determine patient infectiousness. Roommates were considered exposed if in the same semiprivate room with an infectious patient. Exposed patients were notified, quarantined (private room), and follow-up testing was arranged (median seven days). Conversion was defined as having a negative test followed by a subsequent positive within 14 days after exposure. We calculated the risk of exposure: number of infectious patients in semiprivate rooms/number of semiprivate patient-days (hospitalization days in semiprivate rooms). Results: There were 16,427 semiprivate patient days during July–December 2020. We identified 43 COVID-19 inpatients who roommates during their infectious periods. Most infectious patients (77%) were male; the median age was 67 years; and 22 (51%) were symptomatic. Most were detected during active surveillance: admission testing (51%) and serial testing (28%). There were 57 exposed roommates. The risk of exposure was 3 of 1,000 semiprivate patient days. In total, 16 roommates (28%) did not complete follow-up testing. Of 41 exposed patients with follow-up data, 8 (20%) converted following their exposure. Median time to conversion was 5 days. The risk of exposure and subsequent conversion was 0.7 of 1,000 semiprivate patient days. Median Ct value of the source patient was 20 for those who converted and 23 for those who did not convert. Median exposure time was 45 hours (range, 3–73) for those who converted and 12 hours (range, 1–75) for those who did not convert. Conclusions: The overall risk of exposure in semiprivate rooms was low. The conversion rate was comparable to that reported for household exposures. Lower Ct values and lengthier exposures may be associated with conversion. Active COVID-19 surveillance helps early detection and decreases exposure time.Funding: NoDisclosures: None

COVID-19 and homelessness: when crises intersect

COVID-19 and homelessness: when crises intersect

Secret Shopper Data on Private Prices in the Nursing Home Industry From 2008 to 2010.

Nationwide nursing home private-pay prices at the facility-level have not been available for researchers interested in studying this unique health care market. This study presents a new data source, Caregiverlist, for private-pay prices for private and semiprivate rooms for 12,000 nursing homes nationwide collected between 2008 and 2010. We link these data to publicly available national nursing home-level data sets to examine the relationship between price and nursing home characteristics. We also compare private-pay prices with average private-pay revenues per day for California nursing homes obtained from facilities' financial filings. On average, private-pay prices were $224 per day for private rooms compared with $197 per day for semiprivate rooms. We find that nursing homes that are nonprofit, urban, hospital-based, have a special care unit, chain-owned, and have higher quality ratings have higher prices. We find average revenues per day in California to be moderately correlated with prices reported by Caregiverlist.

734. Post-exposure Management of Influenza in Roommates at a Tertiary Care Cancer Center

BackgroundPost-exposure antiviral chemoprophylaxis with neuraminidase inhibitors (NI) is 80% effective in preventing influenza in household members. In hospital settings, management of exposed roommates has not been specifically addressed in clinical studies. Some experts recommend immunocompromised individuals exposed to influenza to receive therapeutic doses of NI as a preventive measure regardless of duration of exposure. The objective of this study was to determine optimal intervention in high-risk patients exposed to influenza based on duration of spatial overlap and viral testing at the time exposure is recognized.MethodsMSK is a 473-bed tertiary care cancer center. Infection Control performs contact investigation for cases diagnosed with influenza including baseline testing of exposed roommates using a multiplex PCR test. The primary team is notified of exposures and makes recommendations regarding prophylaxis. Retrospective review of patients considered exposed to influenza during three seasons was performed. Information on spatial overlap, prophylaxis, and viral testing was extracted.ResultsOut of 64 patients exposed, five (8%) developed influenza (table). Baseline testing was done in 51 (80%): none with overlap of <4 days were symptomatic or tested positive; 2/12 with overlap >4 days tested positive. Attack rate for those with exposure time <4 days who did not receive prophylaxis was 2.6%. No breakthrough infection occurred in the prophylaxis group. Post exposure follow-up revealed two more cases for those overlapping >4 days; a single case of breakthrough infection developed at 7 days, resistance testing was not performed, and patient responded to therapeutic doses of NI without persistent shedding.ConclusionDuration of overlap in semi-private rooms correlates with secondary cases of influenza. Prophylactic doses of NI are safe and effective for asymptomatic individuals with exposure <4 days to index case. For patients with spatial overlap >4 days, baseline testing is recommended to recognize cases early and interrupt nosocomial transmission. Overlap Duration, days Exposed Number Prophylaxis Administered Tested at Baseline Attack Rate % (Prophylaxis Group) Attack Rate % (No Prophylaxis Group) <2349 (26%)28 (82%)04% (1)2–4185 (28%)15 (83%)00>4126 (50%)8 (67%)16% (1)50% (3)Disclosures All authors: No reported disclosures.

Times Up! Manually Working to Remove Patients from Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus faecium (VRE) Isolation Precautions

BackgroundIn 2007 PA Act 52 identified the need to screen and isolate for MRSA in patients who were deemed a high-risk admission in order to prevent the spread of MRSA. High risk at UPMC PUH was determined to be patients who were arriving from an outside facility and patients who were being transferred to an intensive care unit. In 2002 VRE screening began in high-risk patients based on the fact that 80% of our Enterococcus faecium was resistant and there was an increase of VRE infections by 42%. After years of gathering data and isolating patients the decision was made to increase the screening of MRSA and VRE to all patients upon admission then weekly and at discharge. With increased surveillance the isolation density averaged around 15% for MRSA and 25% for VRE. As our facility had a decrease in beds due to renovations and still has semi-private rooms the isolation burden, though low was impacting patient flow. The objective was to ensure that the correct patient population remained in isolation while those who were no longer colonized could be removed.MethodsRemoval Criteria:VREMRSA>2 months since last positive>2 months since last positive>7 days since effective antibiotics>7 days since effective antibiotics3 negative stool or peri-rectal cultures at least 7 days apart3 negative nares cultures at least 24 hours apartTime Period: December 5, 2016 – May 12, 2017Manual review: (i) Gather all patients on a daily basis who have MRSA, VRE or a combo of both; (ii) eliminate all patients whose positive test is less than 2 months ago; (iii) evaluate to see if patient has been on antibiotics effective against MRSA/VRE for the past 7 days; (iv) Review for any prior negative swabs; (v) Call the unit and request swabs along with an email to the unit director; (vi) Follow up daily until patient is cleared.Results(i) 1707 = positive > 2 months ago; (ii) 1516 = eligible based on Antibiotics; (iii) §113= Cleared based on 3 negative swabs; (iv) 1382 Patients were discharged prior to receiving 3 negative swabs.Conclusion(i) 7% of patients were able to have isolation discontinued. (ii) Manual method is not as effective as electronic as many patients were discharged before swabs were obtained; (iii) Ideal circumstances is obtaining swabs on patients while they are not inpatients.Disclosures All authors: No reported disclosures.

Impact of rapid screening for discontinuation of methicillin-resistant Staphylococcus aureus contact precautions

A history of methicillin-resistant Staphylococcus aureus (MRSA) is a determinant of inpatient bed assignment. We assessed outcomes associated with rapid testing and discontinuation of MRSA contact precautions (CP) in a prospective cohort study of polymerase chain reaction (PCR)-based screening in the Emergency Department (ED) of Massachusetts General Hospital. Eligible patients had a history of MRSA and were assessed and enrolled if documented off antibiotics with activity against MRSA and screened for nasal colonization (subject visit). PCR-negative subjects had CP discontinued; the primary outcome was CP discontinuation. We identified semiprivate rooms in which a bed was vacant owing to the CP status of the study subject, calculated the hours of vacancy, and compared idle bed-hours by PCR results. Program costs were compared with predicted revenue. There were 2864 eligible patients, and 648 (22.6%) subject visits were enrolled. Of these, 65.1% (422/648) were PCR-negative and had CP discontinued. PCR-negative subjects had fewer idle bed-hours compared with PCR-positive subjects (28.6±25.2 vs 75.3±70.5; P<.001). The expected revenues from occupied idle beds and averted CP costs ranged from $214,160 to $268,340, and exceeded the program costs. A program of targeted PCR-based screening for clearance of MRSA colonization resulted in expected revenues and decreased CP costs that outweighed programmatic costs.

Assessing the Level of Bioburden and Rate of Contamination of High Contact Surfaces in Private, Semi-private and Ward Patient Rooms

Contamination of environmental surfaces in patient rooms presents a potential for transmission of healthcare-associated pathogens. The level and rate of contamination may be linked to the Number of patients per room and the type of high contact surface. A quantitative assessment of bioburden on high contact surfaces in the patient environment, pre- and post-cleaning was conducted and the rebound time to pre-cleaning levels in private, semi-private and ward rooms was compared.

Evidence based design for improved patient experience

In addition to the health benefits of improving acoustical comfort for patients and staff in healthcare environments, there is now a financial incentive. Since October 2012, Value Based Purchasing reimbursements of Medicare from the Federal Government is dependent in part upon Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey results, which includes a rating for the noise level at night. This study explores the relationship of sound level with their associated patient satisfaction scores from hospital noise surveys performed by Acoustics By Design. The noise study results are presented across different parameters such as the type of patient unit, patient noise levels, nurses’ station noise levels, time of day, and private versus semi-private rooms. Measurements were also performed prior to and after completion of acoustical/noise mitigation.

Determining the Optimal Configuration of Hospital Inpatient Rooms in the Presence of Isolation Patients

We study the optimal configuration of hospital inpatient rooms with private and semiprivate rooms when some of the patients have infectious diseases and need to be isolated. We assume that the demand is random and seasonal. We propose a computationally efficient solution procedure that is based on a stochastic program that uses asymptotic approximations for the system performance under different admission policies and show its accuracy for large systems. Using our model, we study the appropriateness of the recent trends in hospital design calling for 100% private rooms. We show that even with isolation patients such an extreme approach could result in a significant degradation in the access of patients to hospital beds.

A Benefit-Cost Analysis of Private and Semi-Private Hospital Rooms

The design of new hospital inpatient rooms is moving towards private (single occupancy) rooms. These rooms are generally preferred by patients and they may improve patient care, but they are more expensive to build and to staff than semi-private rooms. The question of their societal worth is important because hospitals are expensive, long-term investments and, once built, are prohibitively expensive to change. This paper presents a benefit-cost analysis of private rooms versus semi-private rooms in a proposed new hospital. We estimate that the net social benefit of a bed in a private room is about $70,000 more than a bed in a semi-private room.

Restricted visiting hours in ICUs: time to change.

THE SICKEST PATIENTS LIE IN INTENSIVE CARE UNITS (ICUs) facing fearful illness; surrounded by overwhelming noise from pulsating ventilators and monitors; invaded by the necessary ministrations of nurses; and overhearing, if they are awake, strange and portentous conversations. Professionals buzz about them, but these patients are mostly alone, separated from those who love them by restrictive ICU visiting policies, except at rigidly specified times or with the doled-out permission of the ICU staff. Restricting visiting in ICUs is neither caring, compassionate, nor necessary. Restricted hospital visiting hours began in the late 1800s for nonpaying patients in an attempt to establish order in the general wards. For many decades afterward, paying patients remained free to have visitors at almost any time in their private or semi-private rooms. In the 1960s, however, in an effort to protect the patient and the family from exhaustion caused by too many visitors (Kenneth Ludmerer, MD, Washington University, oral communication, April 23, 2004), hospitals instituted visiting hours broadly for both paying and nonpaying patients in ICUs (which were then being introduced) and the general wards. Today, most hospitals have liberalized visiting policies on intermediate care units, but strict ICU visiting hours are enforced despite increasing awareness that families have an active role in care, and despite increasing recognition among hospital staff of the rights and abilities of patients to make informed decisions. Perhaps the question to be answered is “Who is visiting whom?” In an effort to stabilize the details of ICU operations, health care institutions and professionals neglect the plausible assertion that they are the visitors in patients’ lives, not the other way around. Several months ago, the Institute for Healthcare Improvement (IHI) challenged a number of hospitals working on improvement of care to open their ICUs by instituting a totally unrestricted visiting policy. Several took up that challenge and have come forward to share what they learned from their tests of open visitation policies. Even proposing the idea of liberalizing ICU visiting hours, let alone implementing it, generates considerable resistance among nurses and physicians, who are largely focused on 3 worries: increased physiologic stress for the patient, interference with the provision of care, and physical and mental exhaustion of family and friends. While these concerns may seem reasonable, the evidence from the recent experiences at hospitals working with IHI, as well as from a small but growing body of literature, tell quite a different story. Physiologic Stress for the Patient. The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients’ stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress. However, liberalizing visiting hours may not be good for every patient. The goal is not universal implementation of unrestricted ICU visiting policies, but rather the achievement of patients’ control over the circumstances of their own care. It is important that patients be able to decide who can visit them and when, and accomplishing this requires that there not be a universal restriction outside the control of individual patients and families. Instead, patients who can do so should be allowed to determine their own visiting hours, and this information should be relayed to their family and friends. In other circumstances, family preferences may appropriately control the decision. Barriers to Provision of Care. The second concern is that the unrestricted presence of loved ones at the bedside will make it more difficult for nurses and physicians to do their jobs and may interfere with the delivery of care. The evidence suggests, however, that the family more often serves as a helpful support structure, increasing opportunities for patient and family education, and facilitating communication between the patient and clinicians. Family members may also be able to provide feedback to nurses and physicians more effectively than the critically ill patient can, creating a better working relationship for all.

Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients

Background: Nosocomial diarrhea is a common problem in hospitals, but the epidemiology, causes, and consequences of infectious and iatrogenic nosocomial diarrhea are rarely documented in follow-up or surveillance studies of nosocomial infections. The objective of this study was to describe the epidemiology of nosocomial diarrhea in a cohort study of hospitalized patients. Methods: The setting was a general medicine ward with a total of 30 beds in private or semiprivate rooms in a county hospital. A prospective cohort study of all consenting patients in the study ward was performed during an 11-month period. Patients were interviewed and cultures were obtained to check for stool pathogens within 48 hours of admission, and patients were followed up during their stay in the study ward. Data from medical notes, laboratory tests, antibiotic logs, and patient interviews were collected daily. Results: Among the 382 eligible patients, nosocomial diarrhea developed in 126 (32.9%): 37 cases were of infectious origin, 57 were iatrogenic, and 32 were of unknown origin. The most common causes of nosocomial diarrhea were Clostridium difficile and antibiotic therapy. Multivariate analysis revealed four risk factors for infectious nosocomial diarrhea: age, length of stay, number of antibiotics, and nasogastric tube feedings. Multivariate analysis also revealed four risk factors for iatrogenic nosocomial diarrhea: number of antibiotics, current gastrointestinal conditions, current renal conditions, and recent surgerey. Comorbidity associated with nosocomial diarrhea included increased risk of acquiring another type of nosocomial infection, increased risk of death, and increased length of stay. Conclusions: Nosocomial diarrhea was found to be common and associated with an additional burden of comorbidity. Analyses indicated different risk factors, depending on the etiology of nosocomial diarrhea (infectious or iatrogenic). Further studies are recommended to document the epidemiology and cost analysis of nosocomial diarrhea in other hospital populations.