By Kelly M. Pyrek
The Centers for Disease Control and Prevention (CDC) recommends placement of patients with a history of methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococcus (VRE) colonization on contact precautions (CP). However, without national guidelines to advise on if or when contact precautions may be discontinued, hospitals are left to determine for themselves when to remove patients from isolation, if at all.
Maintaining patients on CP status can lead to unintended consequences for patients as well as affect how care is delivered. Morgan and Diekema, et al. (2009) reviewed the studies highlighting unintended consequences associated with the use of CP, including additional adverse events, depression, delirium, and possibly worse patient satisfaction and quality of care. As Morgan and Diekema, et al. (2009) explain, "These outcomes are thought to stem from less healthcare worker (HCW) contact and stigmatization. Frequency of HCW contact has been reported to be approximately 50 percent less frequent in a range of acute care settings. Although visits are less frequent in patients on contact precautions, one study found only 22 percent less HCW contact time, suggesting that activities may be bunched into longer but less frequent visits. Furthermore, authors have suggested that compliance with hand hygiene may be better or worse with use of contact precautions or glove use."
In this article we look at two recent studies whose results further inform the ongoing discussion on the duration of CP.
A group of researchers in Boston set out to better understand current institutional CP practice in U.S. hospitals. Erica S. Shenoy, MD, PhD, of the Division of Infectious Diseases in the Department of Medicine and the Infection Control Unit at Massachusetts General Hospital in Boston and colleagues, conducted a nationwide survey of members of the Association for Professionals in Infection Control and Epidemiology (APIC). Survey questions addressed facility and respondent characteristics, infection control policies and CP discontinuation policies. Details of discontinuation policies included time since last positive culture prior to eligibility for CP discontinuation, use of microbiological assays to confirm clearance, and permissiveness of concurrent antimicrobial use. For policies requiring microbiological confirmation, respondents were queried regarding the screening site(s) and the timing and number of specimens collected.
Shenoy, et al. (2012) analyzed variation in protocols by examining the frequency of respondents with shared protocol elements as a proportion of all reported policies. Of 11,368 APIC members e-mailed, 3,057 responded (26.9 percent), with 2,580 (84.4 percent) reporting as working primarily in hospital settings. The responses of the inpatient practitioners were reported on in the study. According to the researchers, most survey respondents reported a mix of private and semiprivate, or all semiprivate, accommodations (1,830/2,580; 70.9 percent); 1,544/1,830 (84.4 percent) reported cohorting MRSA or VRE patients.
The majority of respondents reported institutional policies allowing for CP discontinuation in patients with a history of MRSA (1,873/2,580; 72.6 percent) or VRE (1,457/2,580; 56.5 percent), however a minority of respondents reported that they actively screened patients for these purposes. Of the 1,873 respondents reporting the existence of a MRSA CP discontinuation policy, 460 (24.6 percent) indicated that eligibility for screening depended on time since last positive MRSA culture. For policies where time was a consideration, 25.7 percent reported waiting times of less than six months, and 72.8 percent reported waiting about six months prior to screening.
The majority of respondents (1,465/1,873; 78.2 percent) reported a policy that required microbiological confirmation of clearance of MRSA colonization. Analysis of MRSA CP discontinuation policies revealed that clearance was based on the timing and number of specimens collected, the specimen collection site, and the time elapsed since last positive culture. The combination of reported requirements yielded 64 distinct MRSA CP discontinuation strategies, only two of which accounted for more than 5 percent of respondents. These two policies both required more than six months to elapse prior to screening and used a single sample from either the nares or the nares in addition to the original infection site.
Of the 1,457 respondents reporting the existence of a VRE CP discontinuation policy, 320 (22.0 percent) indicated that the policy considered time since last positive VRE culture when determining CP discontinuation eligibility. For policies where time was a consideration, 31.3 percent reported waiting less than six months, while 66.6 percent reported waiting about six months since most recent positive culture prior to screening.
The majority of respondents reported the existence of an institutional policy requiring microbiological confirmation of VRE clearance (1,122/1,457; 77.0 percent). Analysis of VRE CP discontinuation policies revealed that clearance was based on the timing and number of specimens collected, the collection site, and the time elapsed since last positive culture. The combination of reported requirements yielded 48 unique strategies, with four strategies accounting for more than 5 percent of respondents each. A single strategy requiring six months since prior positive culture and three specimens obtained from both the rectum and the original infection site at one-week intervals was reported by 17.2 percent of respondents.
Shenoy says she and her colleagues expected that there would likely be variation in CP discontinuation policies, but were surprised at the extent of the diversity reported.
"We anticipated there would be variation because of the lack of national guidance, and expected that institutions would have developed local strategies," Shenoy says. "When you read the CDC guidelines on this issue, you come away with two thoughts -- you could, after a period of time with a certain number of samples, consider someone cleared. On the other hand you could consider them colonized for life. Even within our own system of several affiliated hospitals there were slight variations in policies for CP discontinuation. I think what surprised us was how the many combinations of various policy elements resulted in so many distinct policies. For example, is your hospital actively screening patients or is it a passive approach? What kind of screening methods are you usingi.e. culture or molecular assays? How long do you wait before a patient is even eligible for screening, and then how long do you wait in between sequential screens? It is only when you combine these aspects to create a complete policy that the true extent of the variation is apparent."
Shenoy continues, "In the midst of this variation, there seemed to be one area of consensus: combining those institutions without discontinuation policies and those institutions that do not actively implement existing policieswe found that the vast majority of responding institutions have a de facto MRSA for life or VRE for life policy."
The anonymous nature of the survey did not allow the researchers to assess whether survey respondents differed from non-responders. Another limitation of the study was a response rate of 26.9 percent. While less than optimal, the researchers say this survey, the first of its kind, provides helpful insights into the diverse set of institutional policies in the absence of national guidelines.
"It is a smaller sample than desired," Shenoy acknowledges. "We also don't know if the people who responded are those who are really interested in this topic because they are wrestling with the issue and they want to know how their colleagues are handling the same concerns and if so did the respondents differ systematically in some way compared to non-respondents. While we can't compare the responders to the non-responders, I think our results provide a window into the ways that hospitals are coping with this challenge.
The Impact of CP
A new study indicates that CP tends to modify healthcare workers' delivery of care. Daniel J. Morgan, MD, MS, an assistant professor at the University of Maryland School of Medicine, and colleagues found when patients with MRSA and other antibiotic-resistant bacteria are isolated in the hospital, CP reduced the number of visits by healthcare workers and outside visitors, but also increased compliance with hand hygiene upon exit of patients rooms.
Over a 19-month period, the researchers conducted a prospective cohort study observing healthcare worker activity at four acute-care hospitals in the United States where trained observers performed secret shopper monitoring of healthcare worker activities during routine care using a standardized collection tool and fixed one-hour observations periods. CP were found to influence the actions of healthcare workers. Patients on contact precautions had 36.4 percent fewer visits from healthcare workers (2.78 visits/hour for patients on contact precautions and 4.37 visits/hour for those not on precautions). The difference was most evident among physicians and other providers, but less so in nurses. Importantly, healthcare workers were 15.8 percent more likely to perform hand hygiene upon exiting isolated patients rooms. The frequency of visitors was also impacted by contact precautions with 23 percent fewer visitors for patients on precautions.
Our study shows that contact precautions for patients with drug resistant infections modifies the care they receive, says Morgan. Fewer visits and increased hand hygiene are important in preventing the spread healthcare-associated infections, but clinicians and epidemiologists need to consider both the positive and negative aspects of these interventions, including the effect to patients mental wellbeing and perception of care.
As Morgan, et al. (2012) note, "We found that healthcare workers behaved differently when caring for patients on contact precautions. Healthcare workers 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 ...Less contact with healthcare workers 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. The resulting decrease in healthcare worker 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 Challenge of Removing Patients From CP
Shenoy points to the fact that in settings that allow cohorting, patients who have cleared colonization (but who have not been tested and confirmed as such) may be falsely cohorted with others who have active infection or colonization, thus risking reacquisition. Additionally, she emphasizes that the misclassification of CP patients wastes resources in the form of gowns and gloves, personnel time spent cleaning rooms and donning and doffing protective equipment, and reductions in bed availability and delays in bed assignment due to cohorting requirements.
"There is a growing body of literature that demonstrates the downsides of contact precautions," Shenoy says. "Several studies have demonstrated associations between CP and preventable adverse events, days where vital signs were not recorded, visits by physicians, and those were all worse for patients on CP. As we know, contact precautions for MRSA, VRE and for other MDROs are meant to protect patients. The challenge we face is putting the right patients on contact precautions for the right amount of time. For example, we found in the study that the majority of respondents reported that their hospital cohorts patients with the same CP status. Well, if patients clear colonization but we fail to identify them as no longer requiring CP, we are likely falsely cohorting such patients and potentially increasing their risk of new acquisition. One study looked retrospectively at patients who were falsely cohorted with MRSA colonized roommates. They found the risk of transmission was significantly increased to the falsely-cohorted roommate and, using strain-typing, confirmed transmission was the identical strain. There has been a lot of focus in the literature on identifying patients who require CP, but if we keep adding patients to the pool of patients labeled as colonized and not recognizing that colonization is most often not life-long we are likely exposing our patients to unnecessary risks and incurring avoidable costs."
Shenoy believes that policies for discontinuation of CP are influenced by the degree to which the natural history of colonization is understood or perceived by policy-makers. "In fact, we have limited data on the natural history of colonization of MRSA and VRE. We need more studies that examine people over time to see how long it takes for them to clear colonization. Such studies would inform the timing of screening. Despite this uncertainty, I think we still can move forward in this area and its incumbent upon us to do so to try to minimize risks to patients in as evidence-based way as possible. Our hospital, like many across the country, operates at a very high capacity so when we close beds because we can't find a match for a cohort patient, we are using our resources inefficiently and decreasing the quality of care for all patients."
Shenoy says another sizable challenge is that hospitals are resourced in different ways and that the kind of testing methodology institutions will use -- PCR versus culture -- the resources required to identify eligible patients and then screen them are not insignificant. Active surveillance, and in this case for the purposes of discontinuation of CP, is resource-intensive. Those surveillance costs have to be weighed against the potential benefits, both in terms of patient care, and avoidable costs associated with implementation of CP. In our current environment it is very difficult to dedicate those resources but it is essential to do so to improve patient care and safety."
Until such time as a national guideline on the discontinuance of contact precautions emerges, experts encourage clinicians to be mindful of their policies. As Morgan, et al. (2012) caution, "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." And as Shenoy, et al. (2012) add further, "Given the paucity of data to inform evidence-based guidelines, further research on the most effective strategies for discontinuation of CP in MRSA/VRE patients is needed. Such research could inform national guidelines to address the growing pool of colonized and resource-intensive patients."
Morgan DJ, Pineles L, Shardell M, Graham MM, Mohammadi S, Forrest G, Reisinger HS, Schweizer ML and Perencevich EN. The Effect of Contact Precautions on Healthcare Worker Activity in Acute Care Hospitals. Infection Control and Hospital Epidemiology 33:1 (January 2013).
Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control 2009;37:8593, doi:10.1016/j.ajic.2008.04.257.
Shenoy ES, Hsu H, Noubary F, Hooper DC and Walensky RP. National Survey of Infection Preventionists: Policies for Discontinuation of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidem. 2012.
Bearman GM, Marra AR, Sessler CN, et al. A controlled trial of universal gloving versus contact precautions for preventing the transmission of multidrug-resistant organisms. Am J Infect Control 2007;35:650655, doi:10.1016/j.ajic.2007.02.011.
Conterno LO, Shymanski J, Ramotar K, et al. Real-time polymerase chain reaction detection of methicillin-resistant Staphylococcus aureus: impact on nosocomial transmission and costs. Infect Control Hosp Epidemiol 2007;28(10):1134-1141.
Day HR, Perencevich EN, Harris AD, et al. Association between contact precautions and delirium at a tertiary care center. Infect Control Hosp Epidemiol 2012;33:3439, doi:10.1086/663340.
Doebbeling BN, Wenzel RP. The direct costs of universal precautions in a teaching hospital. JAMA 1990;264(16):20832087.
Drees M, Snydman DR, Schmid CH, et al. Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci. Clin Infect Dis 2008;46(5):678685.
Evans HL, Shaffer MM, Hughes MG, et al. Contact isolation in surgical patients: a barrier to care? Surgery 2003;134:180188, doi:10.1067/msy.2003.222.
Gasink LB, Singer K, Fishman NO, et al. Contact isolation for infection control in hospitalized patients: is patient satisfaction affected? Infect Control Hosp Epidemiol 2008;29:275278, doi:10.1086/527508.
Gilbert K, Stafford C, Crosby K, Fleming E, Gaynes R. Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs? Am J Infect Control 2010;38:515517, doi:10.1016/j.ajic.2009.11.005.
Hardy KJ, Oppenheim BA, Gossain S, Gao F, Hawkey PM. A study of the relationship between environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) and patients acquisition of MRSA. Infect Control Hosp Epidemiol 2006;27(2):127132.
Kirkland KB, Weinstein JM. Adverse effects of contact isolation. Lancet 1999;354:11771178, doi:10.1016/S0140-6736(99)04196-3.
Morgan DJ, Day HR, Harris AD, Furuno JP, Perencevich EN. The impact of contact isolation on the quality of inpatient hospital care. PLoS One 2011;6:e22190, doi:10.1371/journal.pone.0022190.
Saint S, Higgins LA, Nallamothu BK, Chenoweth C. Do physicians examine patients in contact isolation less frequently? a brief report. Am J Infect Control 2003;31:354356.
Shenoy ES, Walensky RP, Lee H, Orcutt B, Hooper DC. Resource burden associated with contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus: the patient access managers perspective. Infect Control Hosp Epidemiol 2012;33(8):849852.
Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control 2007;35(10):S165S193.
Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(10):S65S164.
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA 2003;290(14):18991905.