Patient Safety Tip of the Week

January 17, 2012

Delirium and Contact Isolation

 

 

In our March 25, 2008 Patient Safety Tip of the Week “More on MRSA” we noted that there are unintended consequences of contact isolation. Kirkland and Weinstein (Kirkland 1999) found that healthcare workers who treated patients in contact isolation entered their rooms less frequently and had significantly less direct contact with them. Saint et al. (2003) found that attending physicians in two teaching hospitals were about half as likely to examine patients in contact isolation. Another study (Stelfox et al. 2003) showed that isolated patients are twice as the likely as control patients to suffer an adverse event during hospitalization. The difference was primarily due to preventable adverse events and included event such as falls, decubiti, and fluid/electrolyte disorders. In fact, the latter events were 8 times more likely in isolated patients. They also had a cohort of congestive heart failure patients in isolation and these patients were much less likely to have certain interventions and evidence-based care than a control group of congestive heart failure patients. And we have all seen that patients in contact isolation often do not get services such as active rehabilitation that they might get were they not in isolation. A review of the literature (Morgan 2009) found 15 studies relating to adverse outcomes of contact isolation and identified these in four main themes: less patient-healthcare worker contact, changes in systems of care that produce delays and more noninfectious adverse events, increased symptoms of depression and anxiety, and decreased patient satisfaction with care.

 

The University of Maryland group (Morgan 2011) had previously looked at the impact of contact isolation on quality core measures. They found that performance on several core measures for pneumonia (typically those measures that take place after the emergency room) had lower adherence though those for CHF, AMI and SCIP were not impacted. Of note, some of the measures that typically require spending more time with the patient (smoking cessation counseling, flu and pneumonia vaccination) were the measures that had lower adherence. Smoking cessation counseling was also less frequent in the CHF and AMI cohorts that were in contact isolation. A good slide presentation by Daniel Morgan, M.D., author of several of the University of Maryland studies noted above, is also available online (Morgan 2011 slides).

 

Now a new study from the University of Maryland (Day 2012) found that delirium was 75% more common in patients who are put into contact isolation during admission (as opposed to those placed in contact isolation at the time of admission). Though the study was retrospective and utilized administrative data, from which accurate diagnosis of delirium is difficult, the results are nevertheless impressive. Because delirium is typically undercoded in administrative data the authors used a proxy that also included unexplained use of antipsychotic drugs or use of physical restraints, measures that have been validated as better than ICD-9 coding for delirium alone. Logically, we’d say that patients put in isolation after admission likely had developed a hospital-acquired infection and are likely sicker so it is not surprising that delirium occurs more frequently in this population. To take that into consideration, the authors adjusted for comorbid conditions, ICU status, length of hospitalization, age, sex, etc. but there may still have been other confounding variables. Nevertheless, it certainly appears that we can add delirium as one of the untoward events associated with contact isolation.

 

Whether there is a causal relationship between contact isolation and delirium or not, the implications are clear. We must be extremely vigilant for delirium in patients we put in contact isolation and put in place the multimodality measures we use to prevent delirium or to help manage it once it has occurred. In many of our prior columns on delirium we have mentioned multimodality intervention programs that were promising in reducing the incidence or severity of delirium in hospitalized patients (see our Patient Safety Tips of the Week for October 21, 2008 “Preventing Delirium”, October 14, 2009 “Managing Delirium”, February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study”, March 31, 2009 “Screening Patients for Risk of Delirium”, January 26, 2010 “Preventing Postoperative Delirium”, August 31, 2010 “Postoperative Delirium” and our September 2011 What’s New in the Patient Safety World column “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”).

 

One of those interventions is HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week “Preventing Delirium”). Inouye et al (Inouye 1999) had shown in a landmark study of 852 medical patients aged 70 and older that management of 6 risk factors was able to reduce the incidence of delirium from 15% to 9.9%. The number of days with delirium and the number of episodes of delirium was also reduced by the intervention. The intervention targeted cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. This was strong evidence that a multicomponent intervention could be of benefit in reducing delirium.

 

Our August 31, 2010 Patient Safety Tip of the Week “Postoperative Delirium” had extensive recommendations from the 662-page guidance from NICE “DELIRIUM: diagnosis, prevention and management” that is probably the most comprehensive single-source document available on all aspects of delirium.

 

Some of those interventions are particularly difficult to implement when patients are in contact isolation. Those include things that promote familiarity and consistency, reassurance, reorientation, and others. Frequent assessment of hydration status and looking for potential sources of pain are often overlooked when patients are in contact isolation. Having family and friends have frequent contact with delirious patients is severely limited with contact precautions. Spending time using verbal or non-verbal de-escalation techniques with an agitated patient may be difficult when the patient is in contact isolation. And having a bunch of “masked men” sticking their heads into the room can be very distressing for such patients! This situation probably calls for interventions such as recording reassuring messages from loved ones for audio playback in the patient’s room.

 

And don’t forget another risk seen in the delirious patient that is potentially more dangerous when in contact isolation – the risk of suicide (see our Patient Safety Tips of the Week January 6, 2009Preventing Inpatient Suicides” and February 9, 2010 More on Preventing Inpatient Suicides” and our December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). There have been multiple cases of patients with delirium jumping from windows on med/surg inpatient units and ICU’s. So make sure your contact isolation rooms have tamper-proof windows even if you have video surveillance into those rooms. Similarly, make sure there are no chemicals or other toxic substances that a delirious patient might get into while in a contact isolation room.

 

All the potential unintended consequences of contact isolation need to be closely monitored for and every attempt should be made to ensure they do not happen. But now we need to add assessment, prevention and management of delirium to the list of things we must consider when we put a patient in contact isolation.

 

 

References:

 

 

Kirkland KB, Weinstein JM. Adverse effects of contact isolation. The Lancet 1999; 354: 1177-1178 http://www.thelancet.com/journals/lancet/article/PIIS0140673699041963/abstract

 

 

Saint S, Higgins LA, Nallamothu BK, Chenoweth C. Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control 2003; 31: 354-356 http://www.ajicjournal.org/article/S0196-6553(02)48250-8/abstract

 

 

Stelfox HT, Bates DW, Redelmeier DA. Safety of Patients Isolated for Infection Control. JAMA. 2003;290:1899-1905

http://jama.ama-assn.org/cgi/content/abstract/290/14/1899 (abstract)

http://jama.ama-assn.org/cgi/reprint/290/14/1899 (pdf)

 

 

Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control 2009; 37(2): 85–93

http://www.ajicjournal.org/article/S0196-6553%2808%2900685-8/abstract

 

 

Morgan DJ, Day HR, Harris AD, et al. The Impact of Contact Isolation on the Quality of Inpatient Hospital Care. PLoS One. 2011; 6(7): e22190

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141007/

 

 

Morgan D. Adverse Outcomes and Contact Precautions (slide presentation). 6/8/2011

http://www.sf2h.net/congres-SF2H-productions-2011/the-global-threat-of-multidrug-resistant-microorganisms-in-healthcare_adverse-outcomes-and-contact-precautions.pdf

 

 

Day HR, Perencevich EN, Harris AD, et al. Association Between Contact Precautions and Delirium at a Tertiary Care Center. Infection Control and Hospital Epidemiology 2012; 33(1): 34-39

http://www.jstor.org/pss/10.1086/663340

 

 

Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676

http://content.nejm.org/cgi/reprint/340/9/669.pdf

 

 

NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010

full guidance:

http://www.nice.org.uk/nicemedia/live/13060/49908/49908.pdf

 

NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010

summary document:

http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf

 

 

 

 

 

 

 

 

 

 

 

 


 


 

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