19/05/2016. Psychological Impact of Protective Isolation in HSCT. Aims of the presentation. What does protective isolation mean?

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1 Psychological Impact of Protective Isolation in HSCT Colin Thain University of Central Lancashire Aims of the presentation Discuss rationale for protective isolation Consider the multiple impacts that protective isolation may manifest in HSCT recipients Examine the evidence about the psychological impact of protective isolation Consider possible responses to improve patient experience What does protective isolation mean? Wide range of protocols exist, locally developed Ventilation and filtration of air Protective clothing worn by those entering the room/unit Dietary restrictions Prophylactic antibiotics, anti-virals, anti-fungals Restrictions on access and contact with others Heightened skin and oral hygiene measures Infection surveillance measures 1

2 Rationale HSCT patients are profoundly immuno-compromised At risk from a wide range of bacterial, viral and fungal organisms, many of them opportunistic or endogenous Infections are major cause of morbidity and mortality in HSCT, even in reduced-intensity procedures Thus, it is thought that limiting exposure to potentially pathogenic organisms will reduce rates of infection and improve survival rates Does it work? There has been considerable debate as to whether protective isolation is effective Early studies in neutropaenic patients undergoing chemotherapy for leukaemia showed fatal infections and survival (e.g. Rodriguez et al, 1978) RCT in BMT, with LAF and decontamination, showed infections but no difference in survival (Buckner et al, 1978) HEPA filtration shown to number of Aspergillus organisms in air and risk of infection (Passweg et al, 1998) Does it work? Evidence is inconclusive (Mank and van der Lelie, 2003) Hayes-Lattin et al (2005) found evidence supporting many practices is weak Kruger et al (2001) found wide variation in practices in survey of 180 centres Schlesinger et al (2009) estimated protective isolation in HSCT provided 40% risk reduction (95% CI 28-50%) for 30- day all-cause mortality, but no independent contribution from barrier precautions 2

3 Holland et al (1977) 52 patients with leukaemia in isolator unit and LAF Nurse-rated behaviour scale, patient-completed questionnaire and patient diary Average 30 days in isolation Researchers expected severe psychological disturbance, akin to ICU psychosis Impact of severe illness over-rode all other variables in affecting patients psychological state Surprising emotional stability patients maintained positive attitude and denied the unit was more stressful than ordinary hospital room Patients did report that they missed human touch, leading to expressions of loneliness even in the presence of others Several patients reported being fearful of leaving unit 3

4 Sasaki et al (2000) studied 39 Japanese BMT patients in LAF rooms Profile of Mood States (POMS) completed pre-isolation, and 1 day before and 1 month after end of isolation Brief interview about mental state 2-3 times per week during isolation 41% experienced mental disorders during study High Tension Anxiety score on POMS, female gender and unrelated donor SCT identified as significant predictive factors Tecchio et al (2013) prospective longitudinal study of 107 patients (auto- and allo-sct) State-Trait Anxiety Inventory and Self-rating Depression Scale on admission and weekly 10% found to suffer clinically significant anxiety and depressive symptoms on admission Anxiety stable over time, but depressive symptoms significantly worsen during isolation (more than double no.) No difference between auto- and allo-sct patients Female gender, higher anxiety and obsessive-compulsive symptoms, lower performance status predictive of depression What do patients say? Number of qualitative studies which have incorporated patients experiences of protective isolation Collins et al (1989) semi-structured interviews with 6 auto-sct patients in isolation, days 3, 7, 12, 19 Physical side effects were of more concern isolation a means to an end. All patients understood rationale for isolation Methods of coping remarkably individual Importance of main supports: I wouldn t want to do it by myself a person has to have someone to listen, someone to go through this whole disease with them it s not just the isolation. 4

5 Prison Thain and Gibbon (1996) found that their participants views of isolation shifted:...at the time I accepted it because...i was under no illusions, I knew I was going to be in for 6 weeks. If I d been on my own all the time, I don t think I would have coped...well, I didn t like it when [husband] went to town in the morning, I couldn t wait for him to come back. I just couldn t wait to get out, I thought, I ll have to get out of here or I ll crack up completely. HSCT is isolating Cohen et al (2001) unstructured interviews with 20 auto-sct patients All experienced physical isolation I think these rooms are shut off from everything else in the world it s very isolating. It s very lonely. The most frightening to me was the idea of being locked up, so to speak. Isolated from friends and family Also an experience that others did not understand emotionally isolating HSCT is isolating Patients tried to protect family and friends from emotional burden In doing so, patients found themselves putting on a brave face, causing emotional isolation But presence of others helped reduce that emotional isolation Emotional presence was main source of social support patients appreciated nurses who went beyond caring for the physical 5

6 What helps? Presencing as described (Thain and Gibbon, 1996; Cohen et al, 2001) Asserting control personalising environment, structuring the day (Collins et al, 1989; Cohen et al, 2001); challenging staff (Xuereb and Dunlop, 2003), controlling use of blinds and lights (Gaskill et al, 1997) Contact with the outside world; information (Collins et al, 1989; Campbell, 1999) Nurses Be aware of the stresses that patients are going through, even when they appear to be coping Seek to see the world through the eyes of the patient Be there, not just be there to do Remember to listen, and take time Help prepare patients to re-enter the wider world patients still find leaving isolation worrying Conclusions It is difficult to separate the impact of isolation from the other stresses in HSCT For most patients, it seems that isolation is not necessarily a source of stress, although it can heighten other distress Some patients will experience anxiety and depression is there a place for assessment pre-transplant? We perhaps need to consider alternatives to isolation where possible 6

7 References Buckner, C.D., Clift, R.A., Sanders, J.E. et al (1978) Protective environment for marrow transplant recipients: a prospective study. Annals of Internal Medicine 89, Campbell, T. (1999) Feelings of oncology patients about being nursed in protective isolation as a consequence of cancer chemotherapy treatment. Journal of Advanced Nursing 30(2), Cohen, M.Z., Ley, C. and Tarzian, A.J. (2001) Isolation in blood and marrow transplantation. Western Journal of Nursing Research 23(6), Collins, C., Upright, C. and Aleksich, J (1989) Reverse isolation: What patients perceive. Oncology Nursing Forum 16(5), Gaskill, D., Henderson, A. and Fraser, M. (1997) Exploring the everyday world of the patient in isolation. Oncology Nursing Forum 24(4), Hayes-Lattin, B., Leis, J.F. and Maziarz, R.T. (2005) Isolation in the allogeneic transplant environment: how protective is it? Bone Marrow Transplantation 36, Holland, J., Plumb, M., Yates, J. et al (1977) Psychological response of patients with acute leukemia to germ-free environments. Cancer 40, References Passweg, J.R., Rowlings, P.A., Atkinson, K.A. et al (1998) Influence of protective isolation on outcome of allogeneic bone marrow transplantation for leukemia. Bone Marrow Transplantation 21, Rodriguez, V., Bodey, G.P., Freireich, E.J. et al (1978) Randomized trial of protected environment prophylactic antibiotics in 145 adults with acute leukemia. Medicine (Baltimore) 57, Sasaki, T., Akaho, R., Sakamaki, H. et al (2000) Mental disturbances during isolation in bone marrow transplant patients with leukemia. Bone Marrow Transplantation 25, Schlesinger, A., Paul, M., Gafter-Gvili, A. et al (2009) Infection-control interventions for cancer patients after chemotherapy: a systematic review and meta-analysis. Lancet Infectious Diseases 9, Tecchio, C., Bonetto, C. Bertrani, M. et al (2013) Predictors of anxiety and depression in hematopoietic stem cell transplant patients during protective isolation. Psycho-Oncology 22, Thain C.W. and Gibbon, B. (1996) An exploratory study of recipients perceptions of bone marrow transplantation. Journal of Advanced Nursing 23,