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Contact isolation is an important infection control tool to prevent spread of infections. But patients in contact isolation experience more unintended consequences and adverse events than patients not in isolation. Our multiple columns on the unintended consequences of isolation are listed at the end of today’s column.
Since our last column, there has been one other good review of such consequences. Jiménez-Pericás et al. (Jiménez-Pericás 2020) compared adverse events (AE’s) in isolated patients to those in non-isolated patients in a large public hospital in Spain. The incidence of AE’s among isolated patients was 18.5% compared with 11% for non-isolated patients. (The incidence of isolated patients with AE’s was 16.5% compared with 9.5% non-isolated). The incidence “density” of patients with AE’s (per 1000 days/patient) among isolated patients was 11.8 compared with 4.3 among non-isolated patients. Most AE’s corresponded to healthcare-associated infections (HAI’s) for both isolated and non-isolated patients (48.6% vs 45.4%). Notably, there were significant differences with respect to the preventability of AE’s (67.6% among isolated patients compared with 52.6% among non-isolated patients). The authors concluded that AE’s were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAI’s as the primary cause. The authors conclude it is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient.
Note that this study preceded the COVID-19 pandemic. Unfortunately, the COVID-19 pandemic has filled our hospitals with many patients who require contact isolation. And many have experienced adverse events while in contact isolation.
There are a number of factors we’d expect to result in increased rates of adverse events in isolated patients in the COVID-19 era. First and foremost is the overloaded work burden on our healthcare workers, which meant less time was available for care of such patients. A second major factor was the paucity of PPE (Personal Protective Equipment). That undoubtedly led to fewer face-to-face contacts with patients in isolation. And, as noted by Taylor et al. (Taylor 2021) below, delays due to the need to put on PPE led to some staff not being able to prevent falls in some cases. And the ubiquitous presence of masks can impair communication, not only with patients but with other staff.
A new study (Taylor 2021) from the Pennsylvania Patient Safety Reporting System (PA-PSRS) database looked at adverse events in isolated patients in the COVID-19 pandemic. They identified 484 events from January 1, 2020 to September 30, 2020. Patient safety events in COVID-19 patients in isolation began in March 2020 and peaked in April and May 2020, where there was an average of 4.2 safety events per day impacting patients in isolation.
Falls accounted for 27% of the events. Both prevention and timely detection of falls can be impeded by various conditions associated with an isolation environment. Many of the falls occurred despite strategies to prevent falls being in place. Categories of associated factors most frequently identified in fall events were patient mental status (50%) and staff’s time to don PPE (37%). Notably, in 26% of the fall events the patient had not yet fallen when staff arrived at the entrance to the isolation room, but staff were unable to prevent the fall due to time required to don PPE.
Even detecting falls in patients in isolation can be problematic. In 20% of cases the patient was simply found unexpectedly on the floor. In 10% staff heard either a patient calling or heard a crash. 4% were alerted via a triggered heart or oxygen monitor, 4% by a video monitor or telesitter, 3% via a call bell, and 2% were from patient communication post-fall.
Medication-related adverse events accounted for 16% of reported events. 38% of those involved a dose omission, half of which involved an inhaled respiratory medication. Problems with equipment and supplies were common contributing factors. 9 events were related to use of an infusion pump, 4 of which involved broken tubing that was run from a pump outside the isolation room, under an active door, and to the patient inside the room. In another the infusion pump inside the isolation room was inaudible. Four events were related to not having a computer or scanner in the isolation room.
Issues related to skin integrity were actually the most frequently reported events (29%).\ but Taylor et al. did not describe the details of those. We encourage you to go to the Taylor article for details of all the other adverse events reported.
But we find the text comments in the reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database, especially those about contributing factors, to be even more important than the statistics. Problems visualizing the patient often had to do with closed doors, lack of windows or poorly placed windows, and lack of video monitoring or poor quality of video monitoring.
Auditory issues were also frequent. Inability to hear alarms was often due to closed doors, competing noise on the unit, and alarms either not set high enough to be audible outside the room or not designed to produce adequate decibel levels.
Taylor et al. noted a number of ways in which communication was impaired. Yes, masks or other devices covering the face did impair communication. In other cases, staff were at the door or hallway trying to communicate with the patient. And inability to visualize the staff’s face or name badge was also noted.
We already mentioned some of the equipment/supply issues, such as unavailability of PPE, lack of computers or barcode scanners in the isolation room, infusion pump tubing that was broken because it was running under doors, etc. Sometimes an inadequate wireless signal prevented quality video monitoring.
PPE-related issues included not only unavailability but also inadequate training on use of PPE and the prolonged time it took to don PPE.
The relative newness of several treatments and protocols led to unfamiliarity of the effects and potential reactions by some staff.
Mental status of patients was often impaired, making communication difficult but also likely contributing to certain types of adverse events (like falls, self-extubation, removal of catheters, etc.). Moreover, because family and friends were excluded from isolation rooms, staff were less likely to be alerted about patient behavior that might be risky.
Lastly, staff issues may have been contributing factors in some cases. This includes not only staff fatigue and burnout, but also the need to use staff on units they were unfamiliar with or involve them in procedures with which they were unfamiliar.
The Taylor article also provides many practical recommendations to address all these contributing factors. This is an article well worth your time reading. Its utility extends well beyond just those patients in isolation during the COVID-19 era, but to almost any patient in contact isolation.
Some of our prior columns on the unintended consequences of contact isolation:
Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al
Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study. BMJ Open 2020; 10: e035238
Taylor MA, Reynolds CM, Jones R. Challenges and Potential Solutions for Patient Safety in an Infectious-Agent-Isolation Environment: A Study of 484 COVID-19-Related Event Reports Across 94 Hospitals. Patient Safety 2021; 3(2): 45-62
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