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Patient Safety Tip
of the Week
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
We’ve done multiple columns on the unintended consequences
of contact precautions (see full list below). 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. Contact precautions for those with endemic MRSA are often
associated with longer admission wait times, longer length of stay, and delays
in transfers to long-term care facilities (Popescu
2019). Treating patients on contact precautions is cumbersome,
time-consuming, and resource-intensive, both in human and financial terms.
So, contact precautions clearly have some downsides. But do
they have an upside? That is, do they actually accomplish
their intended goal of reducing the transmission of infectious agents like
methicillin-resistant Staphylococcus aureus (MRSA) to other patients in the
hospital?
The answer to the latter is not so
clear cut. 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 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.
There may well be some interventions that can reduce use of
unnecessary contact precautions. One of the most common reasons for putting a
patient on contact precautions is testing positive for MRSA. A survey of
physicians in the Emerging Infections Network (Russell 2016)
found that 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 also found wide variation in other practices, like routine
chlorhexidine gluconate bathing or decolonization with mupirocin. Practices for discontinuation of isolation also
varied widely. And only 23% reported using either hydrogen peroxide vapor or
ultraviolet-C room disinfection at discharge.
Moreover, adherence to all elements of contact isolation
precautions has always been less than optimal and that, as the proportion of
patients in contact isolation increases, compliance with contact isolation
precautions decreases (Dhar 2014).
Most hospitals still use contact
precautions for MRSA-infected patients. But what to do about MRSA-colonized
patients has been less clear. A new study (Christie 2020) looked at the impact of replacing contract
precautions with targeted nasal and body decolonization for high-risk
MRSA-colonized patients in a 7-hospital network. They used an alcohol-based
nasal antiseptic twice daily plus daily 2% chlorhexidine gluconate bathing for
nasal and body decolonization, respectively.
They realized an 88% decrease in MRSA-isolation days, with
each hospital seeing a reduction. And MRSA bacteremia rates did not change
significantly during the study.
They then analyzed the impact on costs. Average daily cost
per patient was $42.32 for contact precautions versus $6.25 for nasal and body
decolonization. That totaled a savings of $430,604 for the hospital system over
a 10-month period.
A study at Boston’s Beth Israel Deaconess
Medical Center (Schrank
2019) looked at the impact of discontinuation of
contact precautions for patients with endemic MRSA and VRE colonization. Prior
to discontinuation of contact precautions, the mean monthly number of beds
closed daily for MRSA and/or VRE isolation ranged from 2.7 to 5.3. The estimate
of potential lost charges due to these bed closures before the policy change
was $9383 per 100 bed days. After implementation, there was no change in ED
wait times, patient satisfaction survey results, or rates or trends for patient
falls or pressure ulcers. A slight increase in incidence rates of nosocomial
MRSA did not meet statistical significance. There were significant reductions
in monthly expenditures on gowns (−61.0%) and gloves (−16.3%). The
authors concluded that discontinuation of contact precautions was associated
with an increase in bed availability and revenue recovery, and a reduction in
PPE expenditures, without significant change in other hospital operations
metrics or patient outcomes.
Our October 18, 2016 Patient Safety Tip of the Week “Yet More Questions on Contact Precautions”
also noted several other studies that showed financial benefits of
discontinuing contact precautions on MRSA-colonized patients without increasing
rates of MRSA transmission.
And our July 2018 What's
New in the Patient Safety World column “Contact
Precautions Conundrum” cited a study
which found that, after discontinuing routine 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 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.
So, more and more evidence is accumulating that shows contact precautions
might be safely discontinued in MRSA-colonized patients, providing financial
savings and perhaps reducing non-infectious adverse events, while not increasing
rates of MRSA infections. The Christie study (Christie 2020) suggests that using targeted nasal and body
decolonization for high-risk MRSA-colonized patients is an inexpensive
alternative to contact precautions.
Even if you still use contact precautions for MRSA-colonized patients,
you might see financial benefits by paying attention to when you can
discontinue contact precautions for them or other patients on contact precautions.
Our March 2018 What's New in the Patient Safety World column “Duration of Contact Precautions”
noted the SHEA (Society for Healthcare Epidemiology of America) expert
guidance on duration of contact precautions for acute care settings (Banach
2018).
Note that nasal decontamination may also be important in
patients undergoing outpatient surgery. A recent issue of Outpatient Surgery
had an article with some good tips about nasal decontamination (O”Connor
2020).
A second opportunity to reduce
isolation and contact precautions has to do with C. difficile. Once C. diff is
suspected, patients are often placed on contact precautions. When we began using
clinical decision support tools 13 years ago, one of our first algorithms was
designed for early identification of C. diff infections. An alert was triggered
on any patient receiving antibiotics who then had an order for an antidiarrheal
agent. That alert did identify many patients with C. diff infections, but it
also led to some unnecessary testing for C. diff and also contributed alert fatigue (even when we sent the alert to
nursing staff rather than physicians).
But several studies have taken the reverse approach: use of
clinical decision support tools to reduce the number of inappropriate tests for
C. diff infection (CDI). In addition to leading to unnecessary isolation and
contact precautions, inappropriate testing for CDI may lead to misdiagnosis and
unnecessary treatment of patients.
A recent systematic review looked at
the impact of clinical decision support alerts on C. diff testing (Dunn 2020). They found use of electronic alerts for diagnostic stewardship
for C. diff was associated with reductions in CDI testing, the proportion of
inappropriate CDI testing, and rates of CDI in most studies. However, they did
note that the occurrence of unintended adverse consequences and alert fatigue remain
understudied.
An example of an alert that might
reduce inappropriate orders for C. diff testing would be one that pops up if a
patient has received a laxative within 24 hours of the order. Others have used
markers of CDI such as clinically significant diarrhea, no laxative use within
24 hours, and confirmation of additional symptoms or risk factors, such as a
temperature higher than 100.4°F, abdominal pain or tenderness within 48 hours,
a white blood cell count of more than 15,000/mm3 or less than 4,000/mm3 within
48 hours, antibiotic use or a discharge from any health care facility within 30
days of testing (Fleming 2019). They found that implementation of such an
embedded electronic medical record decision-support matrix resulted in a 27%
reduction in total C. diff testing and a statistically significant improvement
in test fidelity after the intervention.
Kwon et al. (Kwon 2019) took a different approach. They used an electronic hard-stop
clinical decision support tool on repeat C. diff toxin enzyme immunoassay
(T-EIA) testing. They placed a hard stop in the EMR system, which limited
repeat testing within 96 hours of a negative test. They found a significant
reduction in the number of admissions that included repeat tests conducted
within 96 hours from an initial negative test, from 11% in the preintervention
period to 2% after the intervention was implemented.
Any intervention that prevents unnecessary isolation and
contact precautions (or shortens the duration of such precautions) is likely to
save your organization money while avoiding the many patient safety hazards associated
with contact precautions. The above examples provide some potential
opportunities for interventions.
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”
- October 18, 2016 “Yet
More Questions on Contact Precautions”
- March 2018 “Duration
of Contact Precautions”
- July 2018 “Contact
Precautions Conundrum”
References:
Popescu SV. A New Approach to Discontinuing MRSA/VRE
Isolation Precautions. ContagionLive/Infectious
Disease Today 2019; Aug 27, 2019
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
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
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
Christie J, Wright D, Liebowitz J, Stefanacci
P. Can a nasal and skin decolonization protocol safely replace contact
precautions for MRSA-colonized patients? American Journal of Infection Control
2020; Published online January 13, 2020
https://www.ajicjournal.org/article/S0196-6553(19)31058-2/fulltext
Schrank GM, Snyder GM, Davis RB,
et al The discontinuation of contact precautions for methicillin-resistant
Staphylococcus aureus and vancomycin-resistant Enterococcus: Impact upon
patient adverse events and hospital operations. BMJ Quality & Safety
Published Online First: 18 July 2019
https://qualitysafety.bmj.com/content/early/2019/07/19/bmjqs-2018-008926
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
Banach D, Bearman G, Barnden M, et
al. Duration of Contact Precautions for Acute-Care Settings. Infection Control
& Hospital Epidemiology 2018; 1-18. Published online: 11 January 2018
O”Connor
D. Nasal Antisepsis Done Right. 4 tips to stop staph where it lurks. Outpatient
Surgery 2020; XXI(1): January 2020
Dunn AN, Radakovich N, Ancker JS,
et al. The Impact of Clinical Decision Support Alerts on Clostridioides
difficile Testing: A Systematic Review. Clinical Infectious Diseases 2020;
Published online February 15, 2020
Fleming M, Hess O, Albert H, et al. Test stewardship,
frequency and fidelity: Impact on reported hospital-onset Clostridioides
difficile. Infection Control & Hospital Epidemiology, 40(6): 710-712
Kwon J, Reske K, Hink T, et al. Impact of an electronic hard-stop clinical
decision support tool to limit repeat Clostridioides
difficile toxin enzyme immunoassay testing on test utilization. Infection
Control & Hospital Epidemiology, 40(12), 1423-1426
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