We’ve discussed some of the unintended consequences of contact isolation in prior Patient Safety Tips of the Week (January 17, 2012 “Delirium and Contact Isolation” and March 25, 2008 “More on MRSA”). 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 also previously poor adherence to core measures for patients on contact isolation. And another 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).
Now another new study from the researchers at the University of Maryland (Morgan 2013) further quantifies some of the impact of contact precautions on patient care. They used a “secret shopper” methodology to observe and monitor certain aspects of care in patients on contact precautions compared to those not on such precautions. The patient population included both ICU patients and patients on general med/surg units. Patients on contact precautions had 36.4% fewer hourly visits by healthcare workers (HCW’s) than patients not on contact precautions (2.78 vs 4.37 visits per hour). They also had 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour). The latter difference, however, was largely accounted for by patients who were not in ICU’s (those in ICU’s did not have a significant difference in contact time with HCW’s). Those on contact precautions also had 23.6% fewer visitors.
On the positive side, hand hygiene on exiting rooms was higher in those on contact precautions (but there was no difference in hand hygiene on entering patient rooms).
This observational study did not assess outcomes of patient care nor did it look at adverse events. Nevertheless, it does reinforce the observation that patients in contact isolation (particularly those in non-ICU settings) have considerably reduced contacts and contact time with both providers and visitors, likely increasing the potential for more adverse events.
Make your decisions wisely about who and when to use contact isolation. But make sure that your care plan includes appropriate interventions and monitoring to ensure that patients on contact isolation get all their medical and psychological needs met.
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
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
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
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
Morgan DJ, Pineles L, Shardell M, et al. The Effect of Contact Precautions on Healthcare Worker Activity in Acute Care Hospitals. Infection Control and Hospital Epidemiology 2013; 34(1): 69-73
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