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Infection prevention and control
in nursing homes: a qualitative study
of decision-making regarding
isolation-based practices
Catherine Crawford Cohen,
1
Monika Pogorzelska-Maziarz,
2
Carolyn T A Herzig,
1
Eileen J Carter,
1,3
Ragnhildur Bjarnadottir,
1
Patricia Semeraro,
1
Jasmine L Travers,
1
Patricia W Stone
1
▸Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/bmjqs-
2015-003952).
1
Center for Health Policy,
Columbia University School of
Nursing, New York, New York,
USA
2
Jefferson School of Nursing,
Thomas Jefferson University,
Philadelphia, Pennsylvania, USA
3
NewYork-Presbyterian Hospital,
New York, New York, USA,
Correspondence to
Catherine Crawford Cohen,
Center for Health Policy,
Columbia University School of
Nursing, New York, NY 10032,
USA; chc2144@columbia.edu
Received 9 January 2015
Revised 29 April 2015
Accepted 4 May 2015
To cite: Cohen CC,
Pogorzelska-Maziarz M,
Herzig C T A, et al.BMJ Qual
Saf Published Online First:
[please include Day Month
Year] doi:10.1136/bmjqs-
2015-003952
ABSTRACT
Background Isolation-based practices in nursing
homes (NHs) differ from those in acute care. NHs
must promote quality of life while preventing
infection transmission. Practices used in NHs to
reconcile these goals of care have not been
characterised.
Purpose To explore decision-making in
isolation-based infection prevention and control
practices in NHs.
Methods A qualitative study was conducted
with staff (eg, staff nurses, infection prevention
directors and directors of nursing) employed in
purposefully sampled US NHs. Semistructured,
role-specific interview guides were developed
and interviews were digitally recorded,
transcribed verbatim and analysed using directed
content analysis. The research team discussed
emerging themes in weekly meetings to confirm
consensus.
Results We inferred from 73 interviews in 10
NHs that there was variation between NHs in
practices regarding who was isolated, when
isolation-based practices took place, how they
were implemented, and how they were tailored
for each resident. Interviewees’decision-making
depended on staff perceptions of acceptable
transmission risk and resident quality of life. NH
resources also influenced decision-making,
including availability of private rooms, extent to
which staff can devote time to isolation-based
practices and communication tools. A lack of
understanding of key infection prevention and
control concepts was also revealed.
Conclusions and implications Current clinical
guidelines are not specific enough to ensure
consistent practice that meets care goals and
resource constraints in NHs. However, new
epidemiological research regarding effectiveness
of varying isolation practices in this setting is
needed to inform clinical practice. Further,
additional infection prevention and control
education for NH staff may be required.
INTRODUCTION
Infections are a leading cause of morbid-
ity and mortality among nursing home
(NH) residents.
1
In the USA alone, an
estimated 1.6–3.8 million infections
occur in NHs annually.
2
Because NH
residents are at high risk for infection,
3
prevalence will likely continue to rise
given the global aging population
4
that
will increase demand for NH services
(1.5 million US residents today
5
com-
pared with an estimated 5.3 million by
2030
2
). Therefore, identifying effective
practices to reduce infection transmission
is necessary to manage health outcomes
and costs.
3
Isolation precautions are recommended
to prevent the spread of pathogens asso-
ciated with high morbidity and mortality,
such as multidrug resistant organisms
(MDROs).
6–8
This practice includes con-
fining an MDRO-infected resident to a
private room or cohorting if no private
rooms are available (ie, grouping together
patients colonised or infected with the
same organism by location during all
activities to prevent organism transmis-
sion to unaffected patients).
6–10
Infection
prevention guidelines also suggest using
standard precautions for contact with the
MDRO-infected resident (ie, hand
hygiene, use of gowns, gloves and other
personal protective equipment depending
on the anticipated exposure).
7
Further, it
is recommended that infected residents
should have dedicated disposable patient
ORIGINAL RESEARCH
Cohen CC, et al.BMJ Qual Saf 2015;0:1–7. doi:10.1136/bmjqs-2015-003952 1
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care equipment,
9
such as private commodes for
patients with a diarrhoeal disease,if private bath-
rooms are not available.
10
Studies concerning the
effectiveness of isolation precautions have had mixed
results and have been deemed to be of moderate or
poor quality.
11 12
Infection prevention and control guidelines are
based on evidence collected in acute care settings, and
therefore are not always practical or appropriate in
NHs where resources are more constrained and the
healthcare facility is often the residents’home.
67
Further, isolation has well established negative psycho-
logical effects,
13 14
for semiprivate and private room
isolation.
14
These adverse effects may be of greater
concern in a NH facility since it is also a primary resi-
dence. A qualitative description of isolation-based
infection control practices in this setting has not been
conducted. Therefore, it is important to understand
how NH staff balance benefits and drawbacks of isola-
tion in order to establish best practices that can be
implemented across facilities.
15
A gap in the literature exists regarding how it is
decided when and how to implement isolation
of infected residents in this setting. In a previous
survey of 331 NHs in Iowa, most facilities reported
use of isolation precautions for methicillin-resistant
Staphylococcus aureus or vancomycin-resistant entero-
coccus infections. The majority also reported cohort-
ing some residents infected with these organisms.
Staff in approximately a third of the NHs reported
that the need for private room placement depended
on the particular resident. However the survey did
not capture how it was determined that isolation or
cohorting was appropriate,
16
thus providing limited
insight into factors that may influence isolation prac-
tices versus cohorting. Therefore, the objective of this
study was to explore decision-making in isolation-
based infection prevention and control practices in US
NHs. Understanding variations in practice is necessary
to ensure that NH residents receive consistent, high-
quality care in this setting.
METHODS
A qualitative study was conducted. This study was a
secondary data analysis of a larger study regarding
infection control and prevention resources in NHs
(R01NR013687), which is described in detail else-
where.
17
Each NH was purposively selected with the
goal of obtaining variation in geographical region,
size, ownership status and three year infection control
deficiency citation performance. The deficiency cit-
ation score is derived from infection control-related
evaluation criteria found in annual, unscheduled
inspections by the state that are required for Medicare
and Medicaid certification and reimbursement (defi-
ciency citations indicate poor performance).
NHs were recruited through informational mailings,
follow-up phone calls and emails. At each facility, a
site contact was identified who then recruited individ-
ual interviewees based on our guidelines for inclu-
sion.
17
We aimed to recruit interviewees who were
familiar with the facility based on tenure and who
would provide a range of perspectives based on role
(eg, infection prevention directors, directors of
nursing, assistant directors of nursing, medical direc-
tors, environmental service workers and staff nurses).
Recruitment concluded when theoretical saturation
across the entire NH sample was achieved for all
infection control-related topics covered by the inter-
view guides.
18
Members of our study team (three male, five
female) conducted in-depth, semistructured interviews
from May through September 2013. Each interviewee
was interviewed once, one-on-one, with an interview
guide informed by Donabedian’s healthcare quality
theoretical framework
19
and tailored for each person-
nel type.
17
All interviewers were trained on in-depth
qualitative interviewing techniques and encouraged to
manually record field notes regarding observations
not captured in the interview. Interviews were digitally
recorded and transcribed verbatim. All interviewees
were informed of study goals and provided written
informed consent.
A directed content analysis of all transcripts was
performed (see online supplementary appendix A).
This analytical technique helps to determine the initial
coding scheme and is useful when existing theory or
prior research insufficiently describes a particular phe-
nomenon.
20
A keyword search of all transcripts was
conducted in NVivo 10 (QSR International)
21
soft-
ware using ‘isolation’and related terms (eg, isolate,
contact precaution, contact isolation, isolation precau-
tion, cohort, quarantine, outbreak, cart, special pre-
cautions, single room, private room, signs, mask,
gown, roommate) to highlight passages of text per-
taining to the phenomena of interest. A keyword
search is beneficial in content analysis when a large
volume of text is available as it allows researchers to
target passages with pertinent content to focus
in-depth analysis.
22
Using Microsoft Excel
23
software
to facilitate coding and analysis, CCC and MP-M
reviewed the extracted passages, generated a compre-
hensive set of primary and secondary codes and
drafted definitions for each. Emerging themes were
discussed weekly with all authors to ensure a shared
understanding. The authors followed the
Consolidated Criteria for Reporting Qualitative
Research checklist in writing this manuscript (see
online supplementary appendix B).
24
RESULTS
In total, 10 NHs were visited and 73 interviews were
conducted, with six to eight interviewees per facility.
On average, interviews lasted approximately 45 min.
Characteristics of the sample are described in detail
elsewhere.
17
A total of 1533 references in 75 passages
Original research
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(representing 72 of 73 transcripts) were identified in
the keyword search.
We found that isolation-based practices differed
between NHs. The residents who received these inter-
ventions and the way they were implemented varied
by facility. For example, some facilities automatically
used isolation practices for residents with new respira-
tory or gastrointestinal symptoms, positive laboratory
cultures and/or all residents admitted from a hospital
setting. Other NHs rarely isolated residents. There
was also variation with regard to whether isolation
practices were discontinued based on laboratory cul-
tures or upon resolution of symptoms. One exception
to the variation between facilities existed: colonisation
(ie, asymptomatic carriage) was not mentioned as a
consideration for isolation practices in any NH.
Further, none of the interviewees reported routine
screening of residents. As one interviewee stated, lack
of routine surveillance was part of a “don’t look,
don’t tell”approach to managing colonisation
(Participant 27: Medical Director, NH 4).
Throughout the narratives we found that decision-
making to use isolation practices was complex and
this could be attributed to four emergent themes: (1)
perceived risk of transmission; (2) conflict with
quality of life goals; (3) resource availability; and
(4) lack of understanding regarding infection preven-
tion and control. Each of these themes are outlined in
figure 1 and described in-depth below.
Perceived risk of transmission
Interviewees discussed practice decisions in the
context of organism transmission risk in specific situa-
tions and among individual residents. Most NHs’iso-
lation practices incorporated the concept of organism
‘containment’, that is, low perceived transmission risk.
This was a factor when staff decided the degree to
which an infected resident would be limited in social
and environmental contact.
Anything that can be contained, like MRSA
[methicillin-resistant Staphylococcus aureus], or VRE
[vancomycin-resistant enterococcus] in a wound. Or if
they have it in the urine, it’s in a bag so it’s contained.
[...] so if it’s contained, they can be cohorted.
(Participant 57: Infection Prevention Director, NH 8)
There appeared to be variation regarding the
emphasis on perceived organism containment, resi-
dent compliance, and surrounding residents’health
when deciding to initiate or discontinue isolation-
based practices and the nature of these practices.
Additionally, the concept of effective containment
varied, but generally applied to scenarios in which
infectious secretions or drainage stayed within a colos-
tomy bag or catheter, or were covered by personal
protective equipment, a dressing or clothing. As one
interviewee stated,
If it was contained, [...] you didn’thavetoisolate[...]a
catheter bag is closed…whereas if [there is …]nocath-
eter, no coverage; then you know they’re at risk.
(Participant 35: Minimum Data Set Coordinator, NH 5)
In contrast, interviewees mentioned Clostridium dif-
ficile most often as an example of an infection with
high transmission risk because it is ‘uncontrollable’
(Participant 17: Director of Nursing/Infection
Prevention Director, NH 3). A resident’s ability and
willingness to use appropriate personal hygiene, stand-
ard precautions and potentially personal protective
equipment outside of his/her room was also import-
ant. As explained by an administrator,
If [a resident with diarrhea is] sharing the toilet with
multiple people, then we [...] have to determine are
they cognitively with it enough to know to use a
bedside toilet? Or do we need to look at moving them
to not risk contaminating the other residents?
(Participant 47: Assistant Director of Nursing, NH 7)
Figure 1 Emergent themes from qualitative directed content analysis regarding isolation-based infection control and prevention
practices in nursing homes.
Original research
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Additionally, the overall health condition of a resi-
dent’s existing roommate(s) was also a key factor in
decision-making as explained below;
We carefully monitor […] if [a resident is] placed on
isolation, does their roommate have any open sores?
(Participant 73: Infection Prevention Director, NH 10)
Variations in isolation-based practices included
leaving a resident in a shared room, cohorting the
infected resident with other infected resident(s) or
transmission-based precautions in a private room.
Additionally, practices varied as to whether an infected
resident was allowed to leave his/her room, or was
encouraged to participate in activities outside the
room. As one interviewee stated,
If [residents] are on isolation we do put an isolation
gown on them and gloves, but they’re free to come
out of their room […] We try to get them to socialize,
too. (Participant 41: Director of Nursing/Infection
Prevention Director, NH 6)
Interviewees in almost all facilities believed that iso-
lation precautions were necessary when an infectious
organism could not be contained or controlled,
though this was not ideal.
Conflict with quality of life goals
The importance of resident quality of life and con-
cerns that isolation practices conflicted with resident
quality of life was pervasive throughout the inter-
views. As explained by one administrator,
If you have to isolate somebody or you have to put
restrictions on them because of an infection [...] you
have to balance the quality of life aspect. (Participant
9: Administrator, NH 2)
When discussing this balance, interviewees regarded
isolation as ‘horrible’(Participant 15: Administrator,
NH 3). This is further described in the quotes below:
‘We ’d love to never have anybody on isolation.
(Participant 3: Quality Improvement Coordinator, NH 1)
It’s almost like holding a person prisoner. (Participant
47: Assistant Director of Nursing, NH 7)
However, interviewees felt that isolation-based prac-
tices are an important aspect of preventing and con-
trolling infection. One administrator elaborated on
this sentiment:
We have a mission statement and the promise is to
keep our residents safe and secure [...] that includes
keeping them infection free as best as we can.
(Participant 1: Administrator, NH 1)
However, ways in which staff attempted to balance
the NH environment as a home and medical facility
differed based on perceptions of resident needs. For
example, at one facility socialisation among residents
was encouraged and the interviewee referred to
isolation as allowing residents to leave their rooms
while donning personal protective equipment (see the
previous section); staff in another NH did not want to
violate a resident’s privacy by placing a sign on the
resident’s door, let alone encourage personal protect-
ive equipment use outside a private room. As an
administrator explained,
We do not put signs up [for isolation] because that’s…
considered a violation of their rights. So, you have [a]
whole set of new issues in this home setting.
(Participant 47: Assistant Director of Nursing, NH 7)
In this way, differences in perception of what maxi-
mises quality of life led to variation in practice.
Resource availability
Interviewees mentioned that the NH resources influ-
enced isolation-based infection control practices; spe-
cifically, the availability of private rooms. For example,
If it’s [...] respiratory isolation, we can’t handle that
unless we can put them in a private room and usually
our private rooms are full. (Participant 24: Director of
Nursing, NH 4)
It was advantageous, therefore, if a NH had all
private rooms, as explained by one medical director,
One good thing about this facility is that every room is
a private room. [...the] need to isolate [an infected
resident] from one resident or bulk of residents
doesn’t arise (Participant 20: Medical Director, NH 3)
The extent to which staff were pressed for time in
daily practice was also a factor leading to variation as
being ‘in a hurry’could result in forgetfulness or lack of
awareness of appropriate isolation practices (Participant
43: Licensed Practical Nurse, NH 6). Having more time
and other resources that enabled communication
through multiple channels (eg, email, formal in-person
meetings and/or headset intercoms) raised awareness of
recent infections and/or changes in practice and were
facilitators to appropriate isolation practice. As
described by an infection prevention director,
[NH staff] can page me, they can stop me in the hallway.
I receive phone calls at home with questions [...] it’s very
important to have that communication because they
help me arrange private rooms, room changes.
(Participant 12: Infection Prevention Director, NH 2)
However, there was high variation across facilities in
the modes of communication.
Lack of understanding
In the majority of NHs, at least one interviewee
offered information that conflicted with commonly
accepted infection-related terminology. These state-
ments may indicate a lack of understanding regarding
key infection prevention and control concepts. Of
note, three of those interviewees were in charge of
infection prevention and control at his or her facility.
Original research
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The terms isolation and cohorting were used incon-
sistently among interviewees. Isolation was used to refer
to processes to isolate organisms (eg, personal protective
equipment use by the resident outside of his/her room)
as well as physically limiting interaction between resi-
dents and the surrounding environment. Isolation was
used by some as an umbrella term that also encom-
passed the concept of cohorting. Interviewees used the
term cohorting for various scenarios, some of which did
not match the definition of cohorting given by the
Centers for Disease Control and Prevention.
7
For
example, one interviewee described placing healthy
(low infection risk) residents with infectious residents as
cohorting and referenced these same guidelines, as long
as the non-infected roommate was ‘alert’and had no
‘open orifices’through which pathogens may be trans-
ferred (Participant 32: Director of Nursing, NH 5).
Another discussed that cohorting might include placing
residents with active infections caused by different
drug-resistant organisms together in the same room pro-
vided that the infections of each were ‘contained’and
the residents’provider(s) or families did not object to
this action (Participant 41: Infection Prevention
Director/Director of Nursing, NH 6).
For some interviewees, there were misunderstand-
ings about bacterial colonisation and the infection
risk it poses. For example in discussing this topic,
one interviewee stated that it is ‘safe’to place a
methicillin-resistant Staphylococcus aureus-colonised
resident with a roommate (Participant 50: Director of
Nursing, NH 7) and another stated that asymptomatic
residents are ‘not infectious’(Participant 53:
Administrator, NH 8).
Interviewees also noted fears of spreading infection
among the residents, and to themselves and their
families.
We had someone that was just admitted not too long
ago that had just a skin breakout […staff members]
were all very scared. They were gowning and gloving
and masking to go in the room. But [the resident]
wasn’t infectious…we had to call another in-service
and say look, [personal protective equipment] isn’t
needed. (Participant 48: Assistant Director of Nursing/
Infection Prevention Director, NH 7)
Appropriate use of personal protective equipment
was important to interviewees as observed inappropri-
ate use during a mandatory annual state inspection of
the facility may result in a deficiency citation and a
costly fine. Interviewees noted that education might be
key to alleviating fear of infection among staff as well
as fear, frustration and intentional non-compliance
among residents and their families in response to the
resident’s restricted location and/or activities.
DISCUSSION
We inferred from these rich data that differences
existed in isolation-based practices between facilities.
This study confirmed that a lack of private rooms and
other resources are barriers to isolation practices, as
demonstrated in previous work.
16
We found that
current practice to maintain a ‘home-like’environ-
ment was informed by perceptions of transmission
risk and resident quality of life. However, there were
clear misunderstandings among some interviewees
about current infection control terminology, recom-
mendations and concepts.
Variation in practice between NHs was conspicuous
and not surprising. According to clinical guidelines
for this setting, contact precautions and other
isolation-based infection prevention and control prac-
tices may be applied on a case-by-case basis to adapt
practice to the needs of the individual facility and resi-
dent.
25
We infer from our data that these practices in
NHs appear to be aligned with the clinical guidelines
in this way. Our findings also suggest that variation is
likely driven by a combination of factors including
quality of life perception and prioritisation, limited
availability of private rooms, and lack of routine
laboratory services and other resources. In particular,
the desire among interviewees to balance resident
quality of life and infection prevention and control
practices was striking and represents a specific chal-
lenge to infection reduction in this setting.
26
However, the degree to which NH staff are adjusting
practice based on perception rather than evidence
highlights ambiguity in published infection prevention
and control guidelines and an overall lack of infection
intervention effectiveness data specific to this setting.
A salient example of how care for residents may be
improved with new evidence is greater understanding of
transmission risk from residents colonised with MDROs
in NHs. Contact precautions are not required for all
MDRO carriers in this setting, but MDRO colonisation
should be a consideration for isolation when the risk is
high that the resident will infect others.
25
Our intervie-
wees either did not mention colonisation in discussion
of decision-making factors or stated specifically that
their NH lacked colonisation care protocols. This is
consistent with a previous survey in which 36% of NH
staff would not change their practices if they knew a
resident was colonised or infected with methicillin-
resistant Staphylococcus aureus or vancomycin-resistant
enterococcus.
27
That survey did not provide data about
why resident colonisation status would not affect inter-
viewee practices. While current guidelines advise NH
staff to make isolation decisions on a case-by-case
basis,
3625
removing colonisation status from the
decision-making process entirely does not seem congru-
ent with current clinical guidelines.
325
Guidelines and the evidence supporting them should
specifically address the relative transmission risk posed
by certain residents and practices. The American
Medical Directors Association, Society for Healthcare
Epidemiology of America and the Infectious Diseases
Society of America guidelines encourage covering
Original research
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draining wounds with dry dressings
625
but the extent
to which transmission risk is lower when secretions, col-
onisation, or infection are contained under a dressing,
within a device (ie, urinary catheter drainage bag), or
under clothing is not known.
36–8
Further, limited evi-
dence exists that the use of a bedside commode effect-
ively reduces infection transmission risk when no
private bathrooms are available.
10
The relative safety
and benefits of allowing infected individuals to attend
activities in shared spaces while donning personal pro-
tective equipment is not known. Therefore, practices
based on perceived containment of the infection
described here may not in fact be effective in preventing
transmission of pathogens between residents. As men-
tioned above, isolation precautions have been primarily
studied in acute care settings where the quality of data
produced has been poor.
11 12 28
More evidence regard-
ing processes for precaution discontinuation as well as
isolating residents when private rooms are not available
(eg, cohorting) would be beneficial for informed
decision-making. This new evidence may help ensure
consistent, high quality care for residents across NHs.
Further, more standard, and perhaps simplified, guide-
lines may be warranted as new setting-specific evidence
becomes available.
Given the inconsistent use of terminology and mis-
understandings of infection concepts among NH staff,
there may be a need to increase and/or reinforce
understanding of existing guidelines. For example,
although we cannot determine if interviewees’
descriptions of cohorting an infected resident with a
healthy resident in the same room represented an inef-
fective infection control practice, use of the term
cohorting was inconsistent with the definition of
cohorting provided in the Center for Disease Control
and Prevention's isolation precautions (ie, grouping
together patients colonised or infected with the same
organism by location during all activities to prevent
organism transmission to unaffected patients).
7
It is
doubtful that NH staff can apply the guidelines appro-
priately if the terminology is not understood.
Inconsistent use of terminology and other misunder-
standings revealed in these data may be due to the fact
that infection prevention directors in this setting typ-
ically have minimal training for this role and multiple
responsibilities.
17
However, training and education
would presumably have a greater impact to reduce
healthcare associated infections with the availability of
new evidence regarding infection prevention and
control practice effectiveness in this setting.
Limitations
While our sample was purposefully geographically dis-
persed and sampled for diversity, high heterogeneity
between NH facilities and resident populations
29
as
well as state laws and initiatives
30
purposeful sampling
may limit the transferability of study findings.
Although these data represent US NHs, themes may
be more broadly applicable. As interviews were semi-
structured to capture unanticipated and relevant
content, there was variation in specific follow-up
questions asked by each interviewer. Unless explicitly
stated by the interviewee, we cannot conclude that
certain decision-making factors, resources or practices
were either present or absent at a particular NH, nor
can we make conclusions about the relative import-
ance of specific factors at a given facility or how fre-
quently they were implemented. While we were not
able to have each interviewee review transcripts, in an
effort to conduct member-checking, each NH was
sent a summary of the findings from their facility and
no corrections were offered. Use of a keyword search
to identify passages of interest for our directed
content analysis may have limited this study if a rele-
vant passage was not identified. However, we are con-
fident this was not the case as two randomly selected,
full transcripts were reviewed to ensure the search
results highlighted all relevant sections. The keyword
search was therefore time-saving and helped to iden-
tify passages with content of interest.
CONCLUSION
There is wide variation in isolation-based infection
prevention and control practices in NHs. Additional
training may help staff better understand key infection
prevention and control concepts and definitions.
However, efforts to improve care in this setting
should focus on generating new effectiveness research,
which is necessary to understand which isolation-
based infection prevention and control practices are
associated with the lowest infection risk among NH
residents. Results of those studies can better inform
clinicians’decision-making regarding transmission risk
and appropriate practices for individual residents,
especially in cases of colonisation, cohorting and
other organism containment practices. New evidence
on these topics is required to ensure high-quality, con-
sistent care for this vulnerable population.
Acknowledgements The authors thank Nicholas Castle, Laurie
Conway, Andrew Dick, John Engberg and May Uchida for their
assistance in data collection and Victoria Raveis for her expert
guidance regarding qualitative analysis. The authors also thank
Elaine Larson and the advisory board of the Prevention of
Nosocomial Infections and Cost Effectiveness in Nursing
Homes (PNICE-NH) study for their contributions. The authors
are especially grateful to the staff of the NHs that participated
in the PNICE-NH study.
Contributors PWS, CTAH, EJC, CCC and MP-M made
substantial contributions to the conception and design of the
work. CTAH, EJC, CCC and MP-M contributed to the
acquisition of data. All authors contributed to the analysis and
interpretation of data, led by CCC and MP-M. All authors
contributed to drafting the work or revising it critically for
important intellectual content. All granted final approval of the
version published and agree to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated
and resolved.
Funding Funding for this study was generously provided by the
National Institute of Nursing Research (NINR R01
Original research
6Cohen CC, et al.BMJ Qual Saf 2015;0:1–7. doi:10.1136/bmjqs-2015-003952
group.bmj.com on May 27, 2015 - Published by http://qualitysafety.bmj.com/Downloaded from
NR013687). CCC was also supported by NINR (F31
NR015176-01 and T32 NR013454). EJC received financial
support from the NINR over the course of the study (F31
NR014599) and JLT is supported by the Jonas Center for
Nursing and Veterans Healthcare.
Competing interests MP-M has served as a consultant to
Becton, Dickinson and Company. This consulting work was not
related to the research presented in this article. The other
authors have no potential conflicts of interest to report.
Ethics approval Columbia University Medical Center
Institutional Review Board, University of Pittsburgh
Institutional Review Board and RAND Corporation
Institutional Review Board.
Provenance and peer review Not commissioned; externally
peer reviewed.
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Original research
Cohen CC, et al.BMJ Qual Saf 2015;0:1–7. doi:10.1136/bmjqs-2015-003952 7
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practices
decision-making regarding isolation-based
homes: a qualitative study of
Infection prevention and control in nursing
Jasmine L Travers and Patricia W Stone
Herzig, Eileen J Carter, Ragnhildur Bjarnadottir, Patricia Semeraro,
Catherine Crawford Cohen, Monika Pogorzelska-Maziarz, Carolyn T A
published online May 22, 2015BMJ Qual Saf
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