We’ve done multiple columns on the unintended consequences of contact isolation precautions (see the list at the end of today’s column). Patients in contact isolation have less contact by healthcare workers (and visitors) and this may lead to errors and omissions in care and other unintended consequences like decubiti, delirium, falls, and fluid/electrolyte disorders among other preventable adverse events.
Morgan and colleagues, who have done much of the work we’ve previously cited on adverse consequences of contact isolation, have reconsidered contact precautions for endemic VRE and MRSA (Morgan 2015). They did a literature review, a survey of the SHEA Research Network members on use of contact precautions, and a detailed examination of the experience of a convenience sample of hospitals not using contact precautions for MRSA or VRE. They found that there is no high quality data to support or reject use of contact precautions for endemic MRSA or VRE and that hospital practices are widely varied. They concluded that higher quality research on the benefits and harms of contact precautions in the control of endemic MRSA and VRE is needed and that until more definitive data are available, practices in acute care hospitals should be guided by local needs and resources.
Most guidelines for contact precautions have been aimed at healthcare workers. But what about visitors? Last year SHEA (Society for Healthcare Epidemiology of America) reviewed the evidence, which is scant, and developed a consensus statement to deal with the issue in visitors (Stokowski 2016). The guidelines take into account several scenarios and recognize that visitors are unlikely to transmit pathogens in certain circumstances and they take into account practical considerations as well. Important considerations are the specific pathogen, the underlying infectious condition, and the endemicity of the organism in the hospital and the community. Therefore, recommendations really need to be on a case by case basis.
The guideline, of course, stresses the importance of hand hygiene and recommends all visitors should perform hand hygiene before entering and immediately after leaving a patient room. They note that hand washing with soap and water and proper use of an alcohol-based hand rub are acceptable. They stress the importance of ensuring that sinks and alcohol-based hand rub stations are easily accessible to visitors. Note our April 2016 What's New in the Patient Safety World column “” cited an article (Hobbs 2016) which demonstrated that when the hand sanitizers were placed in the middle of the lobby (with limited landmarks or barriers) visitors were 5.28 times more likely to use them.
The SHEA guideline says that visitors should be educated on the importance of frequent hand hygiene in the hospital setting and on the available options and proper techniques for performing hand hygiene. But they note that such education must be repeated often, particularly since conditions may change during a hospitalization. While most hospitals use signage to help visitors understand proper hand hygiene, few use oral/verbal education for visitors.
Perhaps somewhat surprising to some is that contact precautions might not always be needed for visitors in areas where MRSA or VRE are endemic. But if the visitor is likely to interact with multiple patients or if the patient is immunocompromised or if the visitors cannot perform good hand hygiene then contact precautions (gowns, gloves, etc.) should be used just as healthcare workers would use. In some cases hospitals might further limit or preclude visitation. But with some pathogens, like Clostridium difficile and Norovirus or extensively drug-resistant gram-negative organisms, full contact precautions would be recommended. Exceptions might be family members or other close contacts who would have likely already been exposed to those from a symptomatic patient.
For patient rooms under droplet precautions visitors would be expected to wear appropriate masks though, again, exceptions might be family members or other close contacts who would have likely already been exposed to those from a symptomatic patient. However, if the latter are symptomatic (eg. cough, fever) they would not likely to be allowed to visit anyone in the hospital. Incubation periods of the specific organism and virulence of the organism might also need to be taken into account in any recommendations. For patients on airborne restrictions (eg. TB or SARS) surgical masks would be used and visitors may require fit testing for recommended masks.
For known outbreaks or suspected infection with serious organisms (eg. Ebola) visitors would likely be restricted.
For visitors to patients with extended stays, isolation precautions are probably not practical and even wearing personal protective equipment (PPE) may be of unclear benefit but would be recommended when assisting in care delivery and contact with blood, body fluids, or non-intact skin is anticipated.
They have special considerations for family and household contacts of neonatal/pediatric patients, again noting a paucity of evidence to inform guidelines. They note how isolation precautions can interfere with bonding, breastfeeding, and family-centered care. But they also note the importance of distinguishing family and household visitors from non-household visitors.
The guidelines further note that “hospitals should only consider writing policies regarding visitors when they can be realistically enforced and regularly evaluated for compliance”. The Stokowski article notes that 77% of hospitals do not have active programs for monitoring visitor compliance with recommendations.
The guidelines are available from SHEA in pocket card format (SHEA 2015). They are also available on the SHEA apps for iOS and Android devices.
Decisions about who and when to use contact precautions should be made considering the potential benefits and potential harms, the clinical scenarios and epidemiology. Such decisions should be made on a case-by-case basis in most circumstances and you need to consider both healthcare workers and visitors. If you do implement contact precautions, make sure that your care plans include appropriate interventions and monitoring to ensure that patients on contact precautions get all their medical and psychological needs met.
Some of our prior columns on the unintended consequences of contact isolation:
Some of our other columns on handwashing and hand hygiene:
January 5, 2010 “How’s Your Hand Hygiene?”
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
May 24, 2011 “Hand Hygiene Resources”
October 2011 “Another Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re on Candid Camera”
August 2012 “Anesthesiology and Surgical Infections”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He Didn’t Wash His Hands After What!”
September 2015 “APIC’s New Guide to Hand Hygiene Programs”
November 2015 “”
April 2016 “”
Morgan DJ, Murthy R, Munoz-Price LS, et al. Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidemiol 2015; 36(10): 1163-1172
Stokowski LA, reviewed by Munoz-Price LS. Hospital Visitors and Isolation Precautions: Clearing Up the Confusion. SHEA (Society for Healthcare Epidemiology of America). In Medscape April 29, 2016
Hobbs MA, Robinson S, Neyens DM, Steed C. Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates.
Am J Infection Contol 2016; 44(3): 258-262
SHEA (Society for Healthcare Epidemiology of America). Expert Guidance: Isolation Precautions for Visitors. Published: 4/10/2015