Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis

Purssell, Edward; Gould, Dinah; Chudleigh, Jane

One way of balancing the various priorities is to use the GRADE Evidence to Decision Framework, which provides criteria for making recommendations at the individual, group and policy-levels, and provides a number of highly patient focussed criteria for doing this. In addition to the certainty of evidence and resource requirements, it also requires consideration of: the balance of desirable and undesirable effects; the impact upon equity; and the feasibility and acceptability of the intervention. [49] The last two of these might have very different outcomes when considered at the population and individual levels; and there is certainly evidence here that for the individual patient the balance of desirable and undesirable effects might be very different to that of the broader population. However, within the broad population of infected or potentially infected patients, some groups might have different needs. For example a study of people isolated for MERS found that while access to telephones reduced anxiety and anger; access to email, text and internet increased these. [50] This was not an area investigated in any depth in these studies. Another area where information may be lacking is that of age, as older people in particular might feel sadness and loneliness more; and gender, as women were more concerned about precautions and transmission while men were more resigned, rational and tended to cope better. [51] In some countries, such as the United States single-rooms have become the standard for new hospitals and so one might expect fewer adverse effects if everyone is in a single room, this being the norm. However it may be that a single room is necessary but not sufficient for these findings, and that it is the combination of a single room with an infection that leads to these results. Certainly it is far from clear that the long list of advantages claimed for single rooms which include reduced stress, the ability to deliver better care, and a lower probability of dietary or medication errors apply to this group of patients. [52] Caring for patients in single-rooms does have many challenges, but there is evidence that these can be mitigated in a general population; [9] however the expanding literature on how this can be done in a general population does not necessarily apply here due to the necessity of isolation procedures which are, by design, 'a barrier'. Therefore patients' needs for greater social interaction will need a solution quite benefit of choice about this which single rooms offer does not apply here. [53] Although this review has quantified the extent of the problem, we have not been able to find solutions in the literature. Care might be improved through increased staff attention with more resources being allocated to these patients, although the extra cost of contact precautions is already considerable, one estimate being that it was an extra $158.90 (95% CI $124.90 to $192.80) per patient day. [54] Alternatively new ways of working might be developed, perhaps using technology to mitigate some of these problems. What these might be is not clear however.