Not Thinking Outside the ‘Red Box’ Endangers Patients

October 22, 2020
Frank Diamond

Conference | <b>ID Week</b>

When healthcare workers using the red box stepped into the patients’ rooms, there was “significantly increased non-compliance” with PPE and hand hygiene protocols compared to those healthcare workers who went into rooms without red boxes.

The use of red boxes in hospitals should be re-evaluated because their presence in a patient’s room might lead to less compliance among healthcare providers to protocols for hand hygiene and personal protective equipment (PPE). This was the finding of one of a study unveiled at ID Week. Investigators with Northshore University Hospital in Manhasset, New York who conducted the study (“Assessment of Personal Protective Equipment Adherence in Red Box Using Remote Video Auditing”) describe the red box as an area at the entryway of a patient’s room. It’s where healthcare providers can conduct consultations with patients without having to wash their hands or don personal protective equipment (PPE).

What happens when those healthcare workers step out of the red box and into the patient’s room? To find out, investigators used remote video auditing in 4 hospital rooms with red boxes and 2 without. The prospective observational study—conducted between February 26, 2019 and February 27, 2020—captured 6959 patient encounters in the 6 rooms. The red boxes were a 3-foot area at the entrance to the patient’s room that were marked off by red tape and were more than 6 feet from the head of the patient’s bed. To do the study, investigators placed cameras at the entryways of the 6 rooms.

Using binomial regression models with a log link, trained individual observers reviewed adherence to using PPE such as gowns, gloves and masks and to hand hygiene.

When healthcare workers used the red box, 69.9% did not practice hand hygiene, 91.6% did not use gloves, and 95.2% did not use gowns. When healthcare workers using the red box stepped into the patients’ rooms, there was “significantly increased non-compliance” with PPE and hand hygiene protocols compared to those healthcare workers who went into rooms without red boxes.

Healthcare-acquired infection (HAI) rates were not significantly different between the red box rooms and those rooms without a red box. Nonetheless, investigators suggest that the red boxes may have created a false sense of security. They conclude that hospitals should consider educating healthcare providers about the optimal use of red boxes or discontinuing the red box use altogether.

Infection preventionists (IPs) should always keep their guard up against infection no matter where they happen to be in a hospital, said Saskia v. Popescu, PhD, MPH, MA, CIC, a member of Infection Control Today®’s Editorial Advisory Board. The headline of an article Popescu wrote for ICT® last month states the problem succinctly: “For Infection Preventionists Battling COVID: Beware of the Breakroom.”

Popescu wrote that “too commonly we focus on the risk of patient-facing interactions and not those outside of those care environments. For example, we often think the highest risk interaction is in the patient’s room but not in the breakroom, where people are eating and talking without masks on.”

Popescu cited a study published in the Center for Disease Control and Prevention (CDC)’s Morbidity and Mortality Weekly Report (MMWR) that looked at just how healthcare workers can become infected by COVID-19.

She concluded that the study’s findings point to “the need to address exposures that might have occurred outside the healthcare setting…. As these healthcare worker serology studies are designed and performed, we need more insight beyond just PPE use and symptoms, but also internal and external exposures, awareness and knowledge of infection prevention, and if they felt supported in their efforts to wear PPE.”