Patient Safety Tip of the Week
April 29, 2014
More on the Unintended Consequences of Contact Isolation
An elderly nursing home resident with diabetes and dementia
was admitted to an acute care facility because of a UTI and hyperosmolar state
with increased confusion. Because of the presence of MRSA on a previous admission
the patient was placed on isolation and contact precautions. She subsequently
developed delirium and a sacral decubitus. Though she eventually recovered
enough to return to the nursing home, her acute care hospitalization was
prolonged and costs were over $50,000.
We’ve done a few columns on the unintended consequences of
contact isolation precautions (see the list at the end of today’s column).
Would the above patient still have developed the decubitus and delirium had she
not been put on isolation and contact precautions? We’ll never know for sure.
But we do know that less contact by healthcare workers (and visitors) with
patients in contact isolation leads to errors and omissions in care and other unintended
consequences.
A new study used location tracking via RFID chips embedded
in hospital ID badges to compare the amount of time interns spent with patients
in contact isolation vs those not in contact isolation (Dashiell-Earp
2014). They found that interns, on average, spent 5.2 minutes per day with
their patients in contact isolation vs. 6.9 minutes in those not in isolation
(p <0.001).
We and the authors of
that study are surprised at the low number of minutes per day that interns spend
in direct contact with even their non-isolation patients. Nevertheless, the
study again validates previous studies that patients having contact isolation
precautions have reduced contact with their physicians.
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”) and our January 2013 What’s
New in the Patient Safety World column “More
on the Downside 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 events 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).
Our January 2013 What’s
New in the Patient Safety World column “More
on the Downside of Contact Isolation” highlighted another study from
the researchers at the University of Maryland (Morgan
2013) further quantifying some of the impact of contact precautions on
patient care. 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.
These studies all 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.
The process used at some hospitals of cohorting
patients with MRSA may also raise their risk of reacquiring MRSA (or other
multiple drug resistant organisms).
One factor often not considered in studies on the impact of
contact isolation is the duration of the
isolation. While guidelines for putting a patient in isolation are
available, there are few evidence-based guidelines for discontinuation of
contact isolation, resulting in widespread variability of hospital protocols
for discontinuation of contact precautions (Shenoy
2012). Many patients are kept on isolation and contact precautions unnecessarily
because they never complete the screening criteria (Pegues
2013).
To evaluate the impact of passive vs. active MRSA screening
on contact precaution discontinuation, researchers at the Massachusetts General
Hospital did a randomized trial (Shenoy 2013).
One arm received the local standard of care (which relied upon identifying
candidates at risk for MRSA and getting 3 negative cultures 24 hours apart
before discontinuing contact precautions) and the other received active
screening with study staff immediately taking a nasal swab for culture and one
for PCR (polymerase chain reaction) testing for MRSA, repeated on subsequent
days. Patients in the active intervention arm had their contact precautions
discontinued over 4 times more frequently than those in the passive (standard
care) arm. Moreover, screening with the PCR technique revealed excellent
sensitivity, specificity, and positive and negative predictive values. The
number of contact precaution days avoided was substantial in the active
screening arm. In particular, the strategy of active screening with PCR
resulted in a 55% reduction in patient
days on contact precautions. Though PCR testing is more expensive than cultures
on a per test basis, the resultant avoidance of precaution days resulted in an
estimated annualized savings of over $1.5 million for the hospital.
Both the authors of the MGH study (Shenoy 2013)
and the accompanying editorial (Pegues
2013) suggest that use of electronic alerts and clinical decision support
tools might help get more patients screened appropriately and promptly, thereby
improving the effectiveness of such screening programs and avoiding more unnecessary
days in contact isolation.
A 2010 systematic review of the adverse effects of contact
isolation (Abad
2010) noted all of the unintended consequences noted above but also
stressed that patients on contact isolation are generally more dissatisfied
with their care. Those authors stress the importance of good communication with
such patients and preparing them emotionally prior to isolation.
Make your decisions wisely about who and when to use contact
isolation and make sure you appropriately assess the need for continued
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.
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”
References:
Dashiell-Earp CN, Bell DS, Ang AO,
Uslan DZ. Do Physicians Spend Less Time With Patients
in Contact Isolation? A Time-Motion Study of Internal Medicine Interns. JAMA Intern Med 2014; Published
online March 31, 2014
http://archinte.jamanetwork.com/article.aspx?articleid=1847570
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/
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
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
Shenoy E, Hsu H, Noubary
F, et al. National Survey of Infection Preventionists:
Policies for Discontinuation of Contact Precautions for Methicillin-resistant Staphylococcus
aureus (MRSA) and Vancomycin-Resistant
Enterococcus (VRE). Infect Control Hosp Epidemiol 2012; 33(12): 1272–1275
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3496276/pdf/nihms402097.pdf
Pegues DA. Editorial Commentary: Search,
Destroy, and Confirm: How to Maximize the Benefit and Reduce the Unintended
Consequences of Contact Precautions for Control of Methicillin-Resistant Staphylococcus aureus
Clin Infect Dis 2013; 57(2): 185-187
http://cid.oxfordjournals.org/content/57/2/185.extract?sid=ab8c6293-7918-45e0-a69d-15a8fe106dff
Shenoy ES, Kim J, Rosenberg ES, et al. Discontinuation
of contact precautions for methicillin-resistant staphylococcus aureus: a randomized controlled trial comparing passive and
active screening with culture and polymerase chain reaction. Clin Infect Dis 2013; 57(2): 176-84
http://cid.oxfordjournals.org/content/57/2/176.long
Abad C, Fearday A, Safdar N. Adverse
effects of isolation in hospitalised patients: a
systematic review. Journal of Hospital Infection 2010; 76(2): 97-102
http://www.medicine.wisc.edu/sites/default/files/Adverse_effects_of_isolation_Safdar_Abad.pdf
Print “PDF
version”
http://www.patientsafetysolutions.com/