Impact of Multidisciplinary Collaborative Intervention on Isolation Implementation in the Prevention and Control of Multidrug Resistance Infection—A Retrospective Study

Background: Isolation is important in the prevention and control of infection with multidrug-resistant organisms(MDROs) but implementation is weak. We aim to analyze the impact of multidisciplinary collaborative intervention on isolation in multidrug-resistant organism(MDRO) infection and determine the factors affecting the implementation of isolation measures. Methods: A retrospective analysis of the issuance of isolation orders for 1338 patients with MDRO infection and colonization in 10 months before and after multidisciplinary collaborative interventions carried out on November 1, 2018 at a teaching tertiary hospital in central China. Univariate analysis and multivariate logistic regression analysis were used to analyze factors affecting isolation implementation. Results: The overall issuance rate of isolation orders was 66.12%, which increased from 33.12% before the intervention to 75.88% after the intervention (P <0.000). The multidisciplinary collaborative intervention (OR = 0.154) is a promoting factor for the issuance of isolation orders, in addition to Length of stay(LOS)> 15d (OR = 0.459) and department (P <0.05). Conclusions: Multidisciplinary collaborative interventions related to isolation can promote doctors to issue isolation orders in accordance with regulations.


Background
MDRO infections seriously threaten the lives and health of patients and bring great pressure to hospital clinical treatment and infection management, it also brings a heavy economic burden to the medical and health systems all over the world [1,2]. Therefore, it's important to take effective measures to prevent and control the spread of MDROs [3].
The primary mode of spreading MDRO is contact, so an effective measure to control MDRO infections is contact precaution [4]. Since 1996, the US Centers for Disease Control and Prevention (CDC) has stated in its guidelines that MDRO infection control should comply with standard precautions and transmissionbased precautions [5]. Standard precautions apply to the health care of all hospitalized patients. Isolation precautions are recommended to implement for all patients with MDRO infections and colonization [6-8].
However, this recommendation is based only on the general consensus reached on the understanding of biological communication mechanisms. There is insu cient research on the implementation of isolation precautions, especially lacking in quantitative evidence [9][10]. There is still much to discuss. First, the recommendation and practical implementation of isolation precautions vary considerably [11][12]. Then there is no consensus as to the most effective infection prevention and control(IPC) measures to reduce transmission of MDROs [7].
Since the occurrence and spread of MDROs involve multiple disciplines and departments, the establishment of a multi-disciplinary collaborative team is of great signi cance for the prevention and control of MDROs. At present, the multidisciplinary team (MDT) is widely used in hospitals and medical centers in developed countries. Experts from different disciplines provide patients with diagnosis and treatment services for a certain disease [13], especially in cancer care. [14]. Previous studies have proven that MDT can improve clinical outcomes and coordinate services [15][16]. For example, the adoption of a multidisciplinary collaborative management model in the eld of prevention and control of MDROs can lead to a signi cant decrease in the infection rate of MDRO, including a signi cant increase in the implementation rate of isolation measures [17]. However, there are few studies on interventions speci cally for isolation prevention and control measures [9], and there is also a lack of research on the factors affecting the implementation of isolation measures for medical personnel.
MDRO colonized and infected patients are potential sources of nosocomial infection [18], and it is di cult to distinguish between MDRO colonization and infection in daily work [19], so it is also important to take isolation precautions for MDRO colonized patients, but most of the existing research only considered MDRO infected patients and patients with colonization were ignored.
This study considered both MDRO colonized and infected patients to discuss the implementation of their isolation precautions, as well as the analysis of the effects and in uencing factors of multidisciplinary collaborative intervention measures on doctors issuing isolation orders, to provide evidence-based evidence for promoting the implementation of isolation measures to reduce the transmission of MDROs.

Research design
This study conducted a retrospective study based on a tertiary teaching hospital in Hubei province of China, the hospital take a multidisciplinary collaboration interventions to control MDROs on November 1, 2018, we analyze the issuance of isolation orders for 1338 patients with MDRO colonization and infection in ten months before and after the interventions carried out, whether the patient adopts isolation measures is also compared to analyze the in uencing factors of isolation implementation.

Multidisciplinary Collaborative Intervention
In November 2018, to manage the prevention and control of MDROs better, the hospital organized and established a multidisciplinary collaborative group based on the updated Chinese consensus on prevention and control of MDROs (Chinese experts' consensus on prevention and control of multidrug resistance organism healthcare-associated infection.) [20]. The group including clinical experts and clinical microbiologists who are responsible for guiding the inspection, identi cation, early warning, monitoring and isolation of MDRO infection and colonization cases, and the person in charge of the Medical Service, Nursing Department and Hospital Infection Management Section is responsible for supervising and guiding the implementation of MDRO isolation precautions.
A multidisciplinary group meeting conducted once a month. The heads of each department performed statistical analysis on their respective isolation implementation or monitoring and summarized the problems in the work before the meeting. During the meeting, the team leader announced the clinical isolation implementation status of each department and pointed out several clinical departments with poor isolation implementation. The group discussed and analyzed the relevant issues and worked out solutions. After the meeting, the heads of clinical departments organized the solutions into a report and published it to each department and supervised the implementation.
Joint rounds carried out quarterly, on-site case analysis is conducted for key departments and departments with low isolation implementation rates, to discuss speci c problems in isolation implementation, and to improve isolation implementation plans.

Data Collection
The bacteria detected in the MDRO infection and colonization was limited to 5 species: Staphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli.
The collected variables include the dependent variable as the rate of issuance of isolation orders, the independent variable is intervention, the other control variable including the department, length of stay(LOS), infection susceptibility factors, specimen, infected site, gender, age.

Statistical analysis
A descriptive analysis of the implementation of isolation before and after the intervention. Univariate analysis and multivariate logistic regression analysis to analyze affecting factors of isolation implementation. Continuous variables are described as mean and standard deviation, and compared using student t test or Mann-Whitney U test as appropriate; categorical variable description is the number and percentage of isolation orders issued for each category, calculated using a chi-square test or Fisher's exact test as appropriate. Variables with P < 0.05 in Univariate analysis were considered potential independent variables and included in a multivariate logistic regression analysis. The unordered multiclassi cation variable sets the dummy variable with "Other" as the reference group, the results are expressed as odds ratio (OR) and 95% con dence interval (95% CI). All tests were two tailed, and signi cance was set at p value < 0.05 in multivariate analysis. All statistical analysis was performed using SPSS software (version 21.0).

Implementation rate of isolation before and after intervention
The total isolation implementation rate of 1338 patients with MDRO infection and colonization was 66.12%. Before the multidisciplinary collaborative intervention, 459 isolated medical orders should be issued, 152 isolated medical orders were actually issued, with an implementation rate of 33.12%. After multidisciplinary collaborative intervention, 879 isolated medical orders should be issued, and 667 isolated medical orders were issued, with an implementation rate of 75.88%. Failure to isolate the patients all, but after the intervention, the implementation rate of isolation orders increased signi cantly (P < 0.000).

Univariate Analysis Of Isolation Implementation Rate
Univariate analysis showed ( Table 1)

Discussion
The isolation implementation rate is still unsatisfactory. The overall isolation implementation rate of this study was 66.12%, 33.12% before intervention, and 75.88% after intervention, both of which were lower than the standards for isolation in the United States. Compared with research by Xu Chuan [21] (the isolation order issuance rate was 75.1% before the intervention, 95.36% after the intervention) and Liang Yanfang [22] (the isolation order issuance rate was 74.07% before the intervention, 98.48% after the intervention), their isolation implementation rate was higher than our research mainly because we included not only Patients with MDRO infection, but also colonized patients. Before the intervention, the number of colonized patients was more than the infected patients (269vs190) but the implementation rate was lower (30.9% vs 36.3%); after the intervention, the number of colonized patients was less than the infected patients (408vs471) but the implementation rate was higher (77% vs74.9%), the application effect of multidisciplinary collaborative intervention on colonized patients is better than that of infected patients, which re ects the necessity of the study to include colonized patients. However, in the actual implementation of isolation prevention and control measures, medical personnel generally do not attach importance to colonized patients as high as infected patients, resulting in a relatively low probability of colonization patients being taken isolation measures (58.64% vs 63.84%), so the overall isolation implementation rate after intervention in this study is still low. In addition, due to the low baseline level of isolation implementation rate before intervention, the isolation implementation rate after intervention is still not high in the short term, but the increased rate is the highest among the three studies, indicating that this study has achieved great intervention results from the perspective of the increase in isolation implementation rate. Research hospital should continue to strengthen the implementation of isolation measures for patients with MDRO infection and colonization.
Multidisciplinary collaborative intervention can increase the implementation rate of isolation. After taking multidisciplinary collaborative interventions, the implementation rate of issuing isolation orders is signi cant (P < 0.000  [27][28], especially when the patient is in the ICU, doctors will pay more attention to the isolation and prevention of these patients. An observational study of three locations in the New York City hospital network on contact isolation precautions also found that in the ICUs, the compliance rate of all isolation prevention and control measures was signi cantly higher than that of non-ICUs [12].
LOS more than 15 days also affect the isolation implementation rate because the LOS is related to MDRO infection. On the one hand, patients with more hospital stays have more serious condition, with low immunity and more invasive procedures, which increases the possibility of MDRO infections. On the other hand, MDRO infection will prolong the hospital stays of patients [28]. A study on the impact of hospital infections on the LOS in 68 hospitals in China found that MDRO infection increased the average LOS by one day, and the maximum number of days for CR-PA infection increased by 26 days [29]. Langeveld [30] also found that the MDRO group had an average of 25 more hospital stays than the non-resistant group.
More hospital stays will not only increase the infection rate, but also increase the mortality rate. Therefore, for patients with more hospital stays, doctors are more likely to take isolation prevention and control measures.
Our study has several limitations. Firstly, our research is single-centered. Then, our intervention patients come from different periods, there may be time or other confounding factors that introduced bias. In addition, this is an observational study that we cannot prove the cause and effect, nor can we speculate whether the patient's clinical outcome has improved through the effect of intervention on the implementation of isolation. Finally, although the implementation rate of isolation measures has been signi cantly improved in this study, the overall situation is still not ideal, this may be because our study only considered ten months before and after the intervention, and also indicated that there may be medical personnel themselves and external in uencing factors but we haven't conducted relevant investigations.

Conclusions
Isolation is an indispensable procedure in MDRO control, but the implementation rate is far lower than the policy standards; The implementation rate of isolation can be signi cantly improved by adopting multidisciplinary interventions including isolation measures. Patients staying in the ICU, LOS exceed 15 days, and with different susceptible factors should be properly managed and controlled, which will help increase the implementation rate of isolation.