Impact of Isolation on HCAHPS Scores: Is Isolation Isolating?

Background: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a national standardized survey of patients' perspectives of hospital care. The survey asks discharged patients 27 questions about their hospital stay, to assess critical aspects of their experience (nurse and doctor communication with patients, staff responsiveness to patient needs, communication about medications, pain management, discharge information, cleanliness and  quietness of the environment, rating of hospital, and would they recommend the hospital). A random sample of adult patients is surveyed between 48 hours and 6 weeks after discharge. HCAHPS scores are publically-reported and will become part of an institution's value-based purchasing rating by the Centers for Medicare and Medicaid Services and thereby impact reimbursement.

Objective: The objective of this study is to determine the effect of isolation for infection control on the patient experience as reflected in HCAHPS scores.

Methods: A query of the electronic health record for patients with an order for isolation between 1/1/10 and 9/30/10 was run. This list was compared with an internal database of HCAHPS respondents to generate a cohort of patients with both an order for isolation and a completed HCAHPS. Survey respondents who did not have an order for isolation were the comparator group. Top box scores for each category were compared across all domains. Data was analyzed using Chi-square, Wilcoxon-rank-sum, and Kruskal-Wallis tests as appropriate. Tests were performed at a 2-sided significance of 0.05. Analysis was performed using SAS version 9.1.

Results: January 1 to September 30, 2010, there were 1089 patients with an isolation order. A total of 8,436 HCAHPS surveys were returned, 2% (203) from patients who were isolated during their hospitalization. 149 (74%) patients were in contact isolation (gown and gloves) for multidrug-resistant organisms (113 patients) or for C. difficile (36 patients); 18 (8%) patients in airborne isolation (N95 respirator); and 30 patients (15%) in enhanced respiratory isolation for the H1N1 2009 pandemic influenza (gown, gloves, N95 respirator, face protection). Isolated patients were less likely to definitely recommend the hospital (76% vs. 82%, p=0.034) and to find the hospital always clean (60% vs. 68%, p=0.021). Being in isolation was significantly associated with lower mean scores in doctor communication (66% vs. 77%, p=0.0001) and staff responsiveness (48% vs. 58%, p=0.003).

Conclusions: Patient isolation was associated with a deleterious effect on patients' perception of cleanliness and care provided by doctors and nurses as measured by HCAHPS scores. HCAHPS scores may provide an objective measure to assess the impact of infection control policies on patients' perception of care and to guide intervention strategies to offset the negative effect of isolation.