Contact precautions, including gloves, gowns, and isolated rooms, have helped stem the transmission of hospital pathogens but have also had some negative consequences, according to findings from a new study.
Healthcare worker (HCWs) visited patients on contact precautions less frequently than other patients and spent less time with those patients when they did visit, report Daniel J. Morgan, MD, from the University of Maryland School of Medicine and the Veterans Affairs (VA) Maryland Health Care System, Baltimore, and colleagues. Moreover, patients on contact precautions also received fewer outside visitors.
"Less contact with HCWs suggests that other unintended consequences of contact precautions still exist," Dr. Morgan and coauthors write. "The resulting decrease in HCW contact may lead to increased adverse events and a lower quality of patient care due to less consistent patient monitoring and poorer adherence to standard adverse event prevention methods (such as fall or pressure ulcer prevention protocols)." The authors also point out that contact precautions have become more common in the past decade thanks to the advent of surveillance programs such as the VA's Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative.
The researchers conducted the study from April 29, 2010, to December 5, 2011, in 7 intensive-care units (ICUs) and 6 medical-surgical wards at 3 VA hospitals and the University of Maryland Medical Center. Results appear in the January issue of Infection Control and Hospital Epidemiology.
The investigators used a "secret shopper" protocol in which trained researchers observed randomly selected rooms on each unit at least 3 times a week at randomly selected times for a minimum of 1 hour at a time. The observers recorded the entry and exit times of HCWs and other visitors and whether the HCWs complied with contact precautions and hand hygiene on entering and leaving the room.
"Observers maintained their presence as 'secret shoppers' by bringing other reading material and having a prepared story that they were observing human factors related to HCW movement, if asked (which happened rarely after the first few weeks of study)," the authors explain. During the 19-month study period, they observed 7743 HCW visits during 1989 hours of observation.
Patients on contact precautions received 2.78 HCW visits per hour compared with 4.37 visits per hour for patients not on contact precautions ( P < .001). Overall, visit duration was 13.98 minutes per hour for patients on contact precautions compared with 16.98 minutes per hour for conventional patients ( P = .02). However, in a subgroup analysis, the difference was significant among patients on non-ICU, medical/surgical wards (8.59 vs 10.44 minutes/hour; P < .01) but not for ICU patients (16.39 vs 16.70 minutes/hour; P = .51).
In addition, the researchers noted outside visitors on 18.9% of observation periods for patients on contact precautions compared with 24.4% of observation periods for nonisolated patients ( P = .08).
The presence of contact precautions did appear to make HCWs more likely to wash their hands on leaving, but not entering, the patient's room. "HCWs were not significantly more likely to perform hand hygiene on room entry for patients on contact precautions (42.5% [706/1,660]) compared with other patients (30.3% [1,833/6,056]; P = .14)," the authors report. On exiting the room of a patient on contact precautions, however, HCWs maintained hand hygiene 63.2% of the time compared with 47.4% with other patients ( P <.001).
These observations are consistent with the findings of a smaller study conducted some years ago, according to Francesca Torriani, MD, professor of medicine in the Division of Infectious Diseases at the University of California, San Diego, School of Medicine. "The decrease in visits by providers, and in time spent with patients, and decreased visitors is meaningful particularly for non-ICU wards," she said in an email interview with Medscape Medical News.
"In my opinion, this study suggests that contact precautions should be initiated after careful weighing of the positive and negative effects on patient care and safety, as well as emotional well-being. The absence of significant differences in the ICU suggests that with increased acuity the need for provider interaction is recognized and outweighs the barrier to care of contact precautions. However, contact precautions initiated because of a regulatory mandate (such as MRSA Active Surveillance Testing and isolation in California) may be associated with unintended consequences that affect overall safety and quality of care," said Dr. Torriani, who was not involved in this research.
Study limitations include the fact that non-ICU wards were observed only in the VA hospitals, so the findings may not be generalizable to non-VA institutions, and that patient-associated factors such as severity of illness were not taken into account, the authors state.
The effect of limited contact on patient satisfaction also is unclear, Scott McClelland, MD, MPH, associate professor of medicine, epidemiology, and public health at the University of Washington School of Medicine and the university's School of Public Health, told Medscape Medical News in an email interview. The investigators "did not study whether this influenced patient satisfaction and clinical outcomes, and I think it is difficult to be sure about this effect," he said.
Dr. McClelland, who was not involved in this research, also points out that "the overall rates of hand hygiene for both contact precaution patients and those not on contact precautions were disappointingly low. These should be 100% on entry and exit from rooms, regardless of patient type."
Nevertheless, the authors conclude, "Contact precautions were found to be associated with activities likely to reduce transmission of pathogens, such as fewer visits and better hand hygiene, while exposing patients on contact precautions to less HCW contact and potentially more adverse events. Clinicians and healthcare epidemiologists should be aware of the way contact precautions modify care delivery. Researchers need to consider both the positive and negative aspects of interventions using gowns, gloves, and other aspects of patient isolation."
This study was supported by the VA Health Services Research and Development, the Association of American Medical Colleges/Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality. Dr. Morgan reports that he has received an unrestricted research grant from Merck. The other authors, Dr. Torriani, and Dr. McClelland have disclosed no relevant financial relationships.
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