The Effect of Contact Precautions on Healthcare Worker Activity in Acute Care Hospitals

Daniel J. Morgan, MD, MS; Lisa Pineles, MA; Michelle Shardell, PhD; Margaret M. Graham, MPH; Shahrzad Mohammadi, BS, MPH; Graeme N. Forrest, MBBS; Heather S. Reisinger, PhD; Marin L. Schweizer, PhD; Eli N. Perencevich, MD, MS

Disclosures

Infect Control Hosp Epidemiol. 2013;34(1):69-73. 

In This Article

Discussion

We found that HCWs behaved differently when caring for patients on contact precautions. HCWs were less likely to visit patients on contact precautions and spent less overall time with these patients. This was observed for ward care but not ICU care and was most evident among physicians and other providers but less so in nurses. Hand hygiene was performed more often after leaving the rooms of patients on contact precautions. Patients on contact precautions also tended to have fewer visitors.

From 1999 to 2003, 3 articles reported decreased frequency of HCW visits to patients on contact precautions. These were consistent in finding approximately half as many visits and 20% less contact time with patients.[10,11,18] Despite newer guidelines cautioning against changes in care associated with contact precautions[4] and recent patient safety initiatives, we found remarkably similar effects of contact precautions on HCW visits a decade later. The reason for decreased HCW-patient contact is likely inconvenience related to donning gowns and gloves.[5] It is unclear why HCW contact was not different in the ICU setting while it was lower in the ward setting. This could relate to single-patient rooms for all ICU patients, higher proportion of patients on contact precautions in the ICU, or higher acuity of care in the ICU. Another possibility is the higher nurse-to-patient ratio in ICUs, so that changing gowns/gloves may be less frequent.[19]

Less contact with HCWs suggests that other unintended consequences of contact precautions still exist. This is of particular concern, given that contact precautions are more widely used now than 10 years ago as a result of the Department of Veterans Affairs MRSA Prevention Initiative as well as other active surveillance programs.[2] 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).[6] Evidence has continued to accumulate that patients on contact precautions may experience worse outcomes, including more delirium,[7] more depression,[7] worse discharge instructions, and less smoking cessation counseling.[9]

We found variability in how contact precautions affected hand hygiene compliance on room entry, with some hospitals in our study observing increased compliance and others observing decreased compliance. This difference was not statistically significant, potentially because of the variability in observed hand hygiene compliance on entry between hospitals. In 1 other study that used a similar approach, no difference was found in hand hygiene compliance rates between patients with contact precautions and those without precautions.[20] However, in our study, as in others, there was a consistent increase in compliance after removal of gowns and gloves.

Past studies examining the effects of glove use on hand hygiene have reached differing conclusions. These studies have assessed multiple reasons for glove use, including as part of universal gowning and gloving, contact precautions, standard precautions, or for low-risk care.[12–14] Fuller et al[13] reported on 249 hours of observation over 15 hospitals. They found that use of gloves was associated with worse hand hygiene compliance. This was a study of standard precautions or low-risk gloving, since these patients were not on contact precautions.[13] In our study, there was a clear increase in hand hygiene after caring for patients on contact precautions. This association between contact precautions and hand hygiene at room exit would be expected to increase the ability of contact precautions to prevent transmission of MDROs.

Limitations of the study include the following: (1) non-ICU units were observed in only the VA hospitals in this study, making the findings less generalizable to non-VA settings; and (2) patient-level factors, such as severity of illness or other methods of case-mix adjustment, were not available (if patients on contact precautions were less acutely ill than other patients, less frequent visits could be appropriate). However, the opposite effect is more likely since colonization or infection with MDROs is typically associated with higher baseline illness severity.

Limitations not withstanding, this study has strengths, including nearly 2,000 hours of observations at 4 different US hospitals in geographically distinct areas using a standard observation tool. Because of the nearly 2,000 hours of observation, we were able to perform subanalyses based on type of HCW and visitors.

In summary, we found that patients on contact precautions had less HCW contact and visitor contact. Contact precautions had other effects, including increasing compliance with hand hygiene on room exit. 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.

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