Use of contact precautions has been a mainstay in the prevention of transmission of infectious diseases within hospitals. But contact precautions do have a downside (see our multiple columns listed below). 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, DVT, medication errors, and fluid/electrolyte disorders among other preventable adverse events. In addition, depression, anxiety, and lower satisfaction have been found more often in patients on contact isolation. Hence, a conundrum: how should we use contact precautions (who, when, how long, etc.)?
A new study found that, after discontinuing routine CP (contact precautions) for endemic MRSA/VRE, the rate of noninfectious adverse events declined, especially in patients who no longer required isolation (Martin 2018). Noninfectious adverse events (ie, postoperative respiratory failure, hemorrhage/hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma) decreased by 19% (from 12.3 to 10.0 per 1,000 admissions) from the preintervention to the postintervention period. There was no significant difference in the rate of infectious adverse events after CP discontinuation. Patients with MRSA/VRE showed the largest reduction in noninfectious adverse events after CP discontinuation, with a 72% reduction (from 21.4 to 6.08 per 1,000 MRSA/VRE admissions).
A previous study by Martin and colleagues (Martin 2016) had shown that removal of contact precautions (CPs) for endemic MRSA and vancomycin-resistant Enterococcus (VRE) did not increase the prevalence of either pathogen and resulted in hospital savings of an estimated $643,776 in one year.
Another recent study (Bearman 2018) investigated the impact of discontinuing contact precautions among patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) on rates of healthcare-associated infection (HAI). CPs were discontinued as one of a series of infection prevention interventions. The rate of HAIs declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 and 6.25 per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days for device-associated HAI following discontinuation of contact precautions. They concluded that discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures, was not associated with an increased incidence of MRSA and VRE device-associated infections.
These studies are reassuring. The current Martin study supports the hypothesis that contact precautions are associated with non-infectious adverse events. But it also suggests that we can, in fact, reduce the use of contact precautions and reduce the rates of those non-infectious adverse events without increasing the rates of infections.
Some of our prior columns on the unintended consequences of contact isolation:
Martin EM, Bryant B, Grogan TR, et al. Noninfectious Hospital Adverse Events Decline After Elimination of Contact Precautions for MRSA and VRE. Infect Control Hosp Epidemiol. 2018; Published online: 10 May 2018, pp. 1-9
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. Infect Control Hosp Epidemiol. 2016; 37(11): 1323-1330
Bearman G, Abbas S, Masroor N, et al. Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis. Infect Control Hosp Epidemiol 2018; 39(6): 676-682