Patient Safety Tip of the Week
October 18, 2016
Yet More Questions on Contact Precautions
One of our recurrent themes has been unintended consequences
of contact isolation precautions (see the list of our prior columns at the end
of todays column). Previous research has shown that 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.
In our May 2016 What's
New in the Patient Safety World column More
Debate on Contact Precautions
we noted that Morgan and colleagues at the University of Maryland, who have
done much of the work weve 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.
But not all studies have found more adverse events in
patients on contact isolation. Two publications (Croft
2015a, Croft
2015b) also came from the University of Maryland researchers and were part
of a PhD dissertation (Croft
2015c). The first study (Croft
2015a) compared non-ICU hospital ward patients (medical and surgical) and found
that preventable adverse events did not significantly differ between 148 patients
on contact precautions on admission and 148 matched patients not on contact
precautions. And hospital ward patients on contact precautions were less likely
to experience noninfectious adverse events during their hospital stay than
patients not on contact precautions. The second study (Croft
2015b) addressed patients in ICUs and found that In ICUs where healthcare
workers donned gloves and gowns for all patient contact, patients were no more
likely to experience adverse events than in control ICUs. Thus, concerns of
adverse events resulting from universal glove and gown use were not supported. The
authors suggest that similar considerations may be appropriate regarding use of
contact precautions.
Consider also that adherence to all elements of contact
isolation precautions has always been less than optimal. One study which did 1300
observations at 11 teaching hospitals found that compliance with all 5
recommended components (hand hygiene before and after patient encounter,
donning of gown and glove upon entering a patient room, and doffing upon
exiting) was only 28.9% (Dhar
2014). They also found that as the proportion of patients in contact
isolation increases, compliance with contact isolation precautions decreases.
Placing 40% of patients under contact precautions represented a tipping point
for noncompliance with contact isolation precautions measures
So what is the current status of contact isolation
precautions in the US and what changes might we expect? Russell and colleagues,
acknowledging that the risk:benefit ratio of contact
precautions for methicillin-resistant Staphylococcus aureus (MRSA) and
vancomycin-resistant enterococcus (VRE) remains controversial and that use of interventions
such as daily bathing with chlorhexidine gluconate have become more widespread,
did a cross-sectional survey of physicians in the Emerging Infections Network (Russell
2016). Over 90% of respondents routinely use contact precautions for MRSA
and VRE, with the most widely used trigger being a positive culture for these
pathogens. They found that 92% perform routine chlorhexidine gluconate bathing
and 67% perform S. aureus decolonization with mupirocin for 1 or more subsets
of inpatients. 23% reported using either hydrogen peroxide vapor or
ultraviolet-C room disinfection at discharge. But practices for discontinuation
of isolation varied widely. They also noted that free text responses frequently
conveyed frustration and variation in the application, practice, and process
for initiation and discontinuation of contact precautions. They conclude that
the heterogeneity of practices and policies was striking and that evidence-based
guidelines regarding contact precautions and other interventions are needed.
And now several studies have suggested that elimination of
contact isolation precautions may not be detrimental. Edmond and colleagues (Edmond
2015) found that discontinuation of contact precautions for patients with
MRSA and VRE colonization/infection had no impact on device-associated
hospital-acquired infection rates in an academic medical center. And in a
hematology-oncology unit with a high prevalence of VRE colonization the
incidence of VRE bacteremia remained stable after discontinuation of VRE
surveillance and contact precautions (Almyroudis
2016). Aggregated antibiotic utilization and nursing hours per
patient days were similar between the 2 study periods.
It will, of course, be difficult to do a randomized
controlled trial to determine whether contact precautions achieve beneficial
outcomes that exceed any unintended negative consequences. But a new
before/after study suggests that doing away with contact precautions may not be
harmful. Martin and colleagues (Martin
2016) analyzed laboratory-identified clinical culture rates 1 year before
and after routine contact precautions for endemic MRSA and VRE were
discontinued and chlorhexidine bathing was expanded to all units at 2
California hospitals. Discontinuing routine contact precautions for endemic
MRSA and VRE did not result in increased rates of MRSA or VRE after 1 year. Of
course, this was not a randomized controlled trial. And the concurrent
chlorhexidine intervention is a confounding factor. But the results are still
strongly suggestive that routine contact precautions may not be necessary.
Moreover, the financial savings to the hospital from
elimination of routine contact precautions in the Martin study were
substantial. When combining isolation gown and chlorhexidine costs, the health
system saved $643,776 in 1 year. Considering average room entries and donning
time, estimated nursing time spent donning personal protective equipment for
MRSA/VRE before the change was 45,277 hours/year (estimated cost, $4.6
million). They conclude that with cost savings on materials, decreased
healthcare worker time, and no concomitant increase in possible infections,
elimination of routine contact precautions may add substantial value to
inpatient care delivery.
Another recent study demonstrated that flagging patients has
having MRSA/VRE can lead to unwanted hospital operational consequences (Shenoy
2016). Shenoy and colleagues performed a
retrospective cohort study at the Massachusetts General Hospital and found that
MRSA/VRE designation was associated with delays in time to bed arrival,
increased likelihood of acuity-unrelated within-hospital transfers and extended
length of stay. They conclude that efforts to identify patients who have
cleared MRSA/VRE colonization are critically important to mitigate inefficient
use of resources and to improve inpatient flow.
So you should consider all the above in developing your
policies on contact precautions. 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 could be made on
a case-by-case basis in most circumstances and you need to consider both
healthcare workers and visitors (see our May 2016 What's New in the Patient Safety World
column More
Debate on Contact Precautions
regarding visitors). You may want to audit your current compliance with
contact precautions. 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. And pay careful attention to developing criteria and mechanisms for
discontinuation of such precautions.
Some of our prior
columns on the unintended consequences of contact isolation:
- January 17, 2012 Delirium
and Contact Isolation
- March 25, 2008 More
on MRSA
- January 2013 More
on the Downside of Contact Isolation
- April 29, 2014 More
on the Unintended Consequences of Contact Isolation
- May 2016 More
Debate on Contact Precautions
References:
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
Croft LD, Liquori M, Ladd J, et
al. The Effect of Contact Precautions on Frequency of Hospital Adverse Events. Infection
Control & Hospital Epidemiology 2015; 36(11): 1268-1274, 2015 Nov
Croft LD, Harris AD, Pineles L, et
al. The Effect of Universal Glove and
Gown Use on
Adverse Events in Intensive Care Unit Patients. Clinical
Infectious Diseases 2015; Advance Access published May 11, 2015
http://cid.oxfordjournals.org/content/early/2015/05/10/cid.civ315.full.pdf
Croft L.The Effect of Contact
Precautions on the Frequency of Hospital Adverse Events. Doctor of Philosophy
Dissertation 2015; Universitiy of Maryland
http://archive.hshsl.umaryland.edu/bitstream/10713/4612/1/Croft_umaryland_0373D_10645.pdf
Dhar S, Marchaim
D, Tansek R, et al. Contact Precautions More Is Not
Necessarily Better. Infection Control & Hospital Epidemiology 2014; 35(3):
213-219. Published online: 10 May 2016
Russell D, Beekmann SE, Polgreen PM, et al. Routine Use of Contact Precautions for
Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus:
Which Way Is the Pendulum Swinging? Infection Control & Hospital
Epidemiology 2016; 37(1): 36-40, 2016 Jan
Edmond MB, Masroor N, Stevens MP,
et al. Infect Control Hosp The
Impact of Discontinuing Contact Precautions for VRE and MRSA on
Device-Associated Infections. Infect Control Hosp Epidemiol 2015; 36(8): 978-980
Almyroudis NG, Osawa
R, Samonis G, et al.. Discontinuation
of Systematic Surveillance and Contact Precautions for Vancomycin-Resistant
Enterococcus (VRE) and Its Impact on the Incidence of VRE faecium
Bacteremia in Patients with Hematologic Malignancies.
Infect Control Hosp Epidemiol 2016; 37(4): 398-403. Published online January
11, 2016
Martin EM, Russell D, Rubin Z, et al. Elimination of Routine
Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and
Vancomycin-Resistant Enterococcus: A Retrospective Quasi-Experimental Study. Infection
Control & Hospital Epidemiology 2016; First View Published online: 26 July
2016, pp. 1-8
Shenoy ES, Lee H, Hou T, et al. The Impact of Methicillin-Resistant
Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) Flags
on Hospital Operations. Infection Control & Hospital Epidemiology 2016; 37(7):
782-790 Published online: 29 March 2016
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