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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:
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
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
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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