Contesting contact precautions

The debate over best practice may leave hospitalists wondering in which camp they and their hospitals belong.

If you want to get a roomful of infection control experts fired up, ask them about contact precautions.

“A decade ago, these pro/con sessions would get kind of ugly sometimes, because people believed what they believed and it wasn't necessarily driven by evidence,” said Preeti Malani, MD, a clinical associate professor of internal medicine at the University of Michigan in Ann Arbor.

One consideration with contact precautions is that they increase health care waste Photo by Thinkstock
One consideration with contact precautions is that they increase health care waste. Photo by Thinkstock.

In the intervening 10 years, evidence has been published about the costs and benefits of contact precautions. Yet the experts still have widely differing opinions—some use precautions for all in the ICU, while others have given up gowning even for some drug-resistant bacteria—and there's little hope of any agreement in the near future.

“In infectious disease and intensive care and hospital medicine, there are certain things we know definitively from evidence-based trials. In infection control, until recently, we have not had that level of science. But now finally, high-level science is being done to answer important infection control questions,” said Anthony Harris, MD, MPH, ACP Member, a professor in the department of epidemiology and public health at the University of Maryland in Baltimore.

The specialty's best hope for a definitive answer was a recent study led by Dr. Harris, in which 20 ICUs, with more than 25,000 patients, were randomized to universal gloving and gowning or usual care. The mixed results were published in the Oct. 16, 2013, Journal of the American Medical Association and only intensified the debate.

“We've given people in both camps what they want,” said Dr. Harris. The Benefits of Universal Glove and Gown (or BUGG) study found that precautions reduced acquisition of methicillin-resistant Staphylococcus aureus (MRSA) but had no effect on vancomycin-resistant Enterococcus (VRE) or adverse events.

“The camp that was very pro-contact precautions conclude[d], ‘Hey, we have definitive evidence that it works, so we should be using it more.’ They focus on the part of the study that shows no increase in adverse events and a decrease in MRSA acquisition with the use of contact precautions,” said Dr. Harris. “The camp that was against contact precautions said, ‘Hey look, your study had no effect on VRE, and that's maybe the case for other bacteria, and your study did show that health care workers go into patient rooms less often’” when contact precautions are used.

The debate may leave hospitalists wondering in which camp they and their hospitals belong. To help with the decision, experts offered some advice on evidence and factors to consider, whether you're in the ICU or the ward, screening for drug resistant-bugs, or just dealing with the diseases that arise.

Pros and cons

The arguments for contact precautions are both well known and intuitive. “If you've got organisms that are on you, then wearing gowns and gloves may make me less likely to pick them up on my hands and clothing and bring them to somebody else. That's common sense,” said Michael Gardam, MD, an infectious disease specialist and associate professor of medicine at the University of Toronto.

Given this basic biology, all of the experts believe in using contact precautions in cases where there's a high likelihood of transmitting a serious disease. Examples include patients with Clostridium difficile, drug-resistant gram-negative infections or open wounds containing MRSA or VRE.

But when the targeted bacteria are less transmissible or dangerous, or universal precautions are implemented to protect patients from others' germs, some experts worry that contact precautions could harm more than they help.

Many of their concerns stem from a finding that both camps agree on, and the BUGG study confirmed. “It is very clear that patients are not seen as often by health care workers if they're on contact precautions,” said Daniel J. Morgan, MD, a BUGG co-author, hospital epidemiologist and assistant professor at the University of Maryland in Baltimore. “Health care workers pretty clearly see it as a bother to put on gowns and gloves. When they're uncertain about whether they need to see a patient, they opt not to.”

Fewer visits could lead to a variety of negative effects: “More decubitus ulcers, more electrolyte disturbances, more falls—there are clearly patient safety issues. Then you have the issues of patients becoming more depressed or dissatisfied with their care,” said Michael Edmond, MD, FACP, a hospital epidemiologist and professor of internal medicine at Virginia Commonwealth University (VCU) in Richmond.

There is convincing evidence that patient satisfaction is lower when someone is on contact precautions, agreed Dr. Morgan. But, although he has led the search for evidence of other clinical harms, he's still not certain how significant they are. “I've published probably 10 articles on it, and it's not completely clear,” Dr. Morgan said.

Patients on contact precautions do appear to be more depressed, research shows. However, the causation isn't certain, according to Dr. Harris, who has studied the issue. “It looks like the patients who need contact precautions are sicker and have a higher incidence of [depression] at baseline, but it's not that contact precautions cause it,” he said. “Contact precautions may be a marker.”

Patients aren't the only ones who could potentially be harmed by contact precautions, though, opponents note. “For family members, it's uncomfortable,” said Dr. Edmond. “One of the images that always sticks with me is walking into the room of a dying patient and seeing all the family in gowns and gloves. That just really bothers me.”

The precautions increase health care cost and waste, too. “There are all these non-biodegradable gowns. I think about the amount of stuff that's going to end up in a landfill somewhere,” said Dr. Malani.

A local decision

The trash produced by contact precautions is something that affects all hospitals, but the other effects are likely to vary by facility, changing the balances of harms and benefits and helping to explain why the evidence and experts haven't come to universal conclusions.

Dr. Morgan offered an example. “There's a lot of variability [in whether] contact precautions limit a patient's ability to go to different things, like participate in rehabilitation or to leave the unit. If contact precautions don't limit those things, they probably don't have as much impact on patients' impressions of their care,” he said.

The ways that hospital staff members respond to contact precautions (compensating for seeing patients less often, for example) can affect patient outcomes, noted Dr. Malani, who wondered about the generalizability of the BUGG study's finding of no adverse effects from contact precautions. “It may be these are really high-quality ICUs and the nursing staff and the other staff are really aware [of the issue]. Does that translate to a smaller place that's not as well staffed?” she said.

Even hospitals that implemented precautions under the BUGG study disagreed about how the results applied. “Some of them have maintained it … and then others have dropped it altogether,” Dr. Malani said.

And those who favor less use of contact precautions don't think the policy is right for every hospital. VCU reduced use of contact precautions last year. “Our policy is we don't isolate MRSA or VRE, except in some unusual circumstances,” said Dr. Edmond.

The success of this policy relies on the hospital's excellent hand hygiene rates. “If your hand hygiene rates are poor, then I wouldn't be brave enough to do away with contact precautions,” Dr. Edmond said.

Hand hygiene is a key factor in the need for precautions, agreed Dr. Harris. “If you were able to wash your hands 100% of the time, I don't think you would necessarily need contact precautions,” he said. “But there's 40 years of research that showed that we cannot get health care workers to wash their hands more than 65% to 70% of the time.”

However, compliance is an issue with whatever policy you choose. “The biggest challenge with contact precautions is that people don't necessarily follow them very well,” said Dr. Gardam.

He, along with some other experts, thinks the prevalence and severity of bacteria in a hospital could be the deciding factor. Toronto General Hospital, along with some other Canadian hospitals,is still using precautions for C. difficile and MRSA but gave them up for VRE. “Pound for pound, it just doesn't cause the illness that C. difficile does,” Dr. Gardam said. “If you are going to use contact precautions, ask yourself, ‘Is this organism worth it?’”

Hospitals with different prevalence rates could make opposite choices. “A nonacademic intensive care unit that has no MRSA problem could take our data [from the BUGG study] to say, maybe rightfully so, that they don't need to use [universal precautions],” said Dr. Harris.

Think about both the organism and the patient, recommended Eli Perencevich, MD, ACP Member, professor of internal medicine and epidemiology at the University of Iowa in Iowa City.

“In high-risk groups in high-risk settings, universal contact precautions probably make sense, whereas in lower-risk settings, in low-risk populations, they should be used kind of sparingly,” he said. “If you're in a setting with high levels of multidrug-resistant Acinetobacter, which is very transmissible and very pathogenic for immunocompromised and ICU patients, it makes sense.”

Patient factors alone may be enough to justify precautions in some cases, suggested Dr. Malani. “Patients in the cardiac ICU who are getting new artificial left-ventricular-assist devices—a resistant infection in that setting would be devastating,” she offered as an example.

Although research has failed so far to definitively identify the patients and bacteria best targeted by contact precautions, it could do so in the future. “My hope would be that in 10 or 15 years, we would know which patients would benefit most … which patients are most likely to transmit … which health care worker-patient interactions are most likely to lead to transmission … which types of MRSA, VRE, gram-negative bacteria are more easily transmitted,” said Dr. Harris.

In the interim, physicians, units and hospitals will have to make their own decisions. “The hospitalists, like most people, should reread the key studies for themselves and make up their own opinions,” Dr. Harris said.

Other steps

Whatever conclusion you draw, some additional measures recommended by the experts can reduce the chances of ill effects on patients from avoiding or implementing contact precautions.

First, communicate the contact precautions policy, and its justification, to the staff that have to implement it. “Let's be really open and transparent about why we're doing this for certain organisms and not for others, and that should hopefully help people comply,” said Dr. Gardam.

When precautions are implemented, the tendency to visit patients who require them less frequently should also be discussed. “We need to make a better effort to make health care workers aware of this behavioral change that probably subconsciously occurs and figure out ways to deter this,” said Dr. Harris.

Clinicians should also keep in mind the finding of greater severity of illness and depression in contact precaution patients, whatever its cause. “Watch the person on contact precautions more closely because it's generally a sicker patient,” said Dr. Harris.

Consider methods to watch the patients in isolation without gowning and gloving—for example, marking off an area just inside the patient's room that can be entered without precautions. “You can actually go in and talk to the patient without having to [put on gowns and gloves],” said Dr. Gardam. (For more details on this method, see the September 2011 ACP Hospitalist Success Story. )

In academic settings, the hassle and the waste of precautions can also be reduced by not taking an entire crowd of students into isolation rooms. “Why don't we just pick one or two people to go in and the rest stand in the hallway?” Dr. Gardam said.

At hospitals where patients are isolated based on a history of colonization or infection, streamlined strategies for identifying patients who are no longer colonized can reduce the need for precautions, according to Erica S. Shenoy, MD, PhD, assistant chief of the infection control unit at Massachusetts General Hospital and instructor in medicine at Harvard Medical School in Boston. Her hospital swapped a requirement of 3 nasal cultures to prove clearance of colonization for a single polymerase chain reaction (PCR) test as part of a large pilot study.

PCR is faster and more sensitive than the cultures, but she recommends screening patients with a history of colonization by whichever method a hospital can afford. “Based on our experience, they'll be pleasantly surprised at how many patients are no longer colonized with MRSA,” Dr. Shenoy said.

Hospitals that want to back off on contact precautions even for infected patients should focus their attention on excellent implementation of other infection control measures. “We, for example, bathe every patient in our hospital with chlorhexidine every day,” said Dr. Edmond.

“A key thing that's not emphasized but is important is just using standard precautions, using gowns and gloves when you anticipate contact with a bodily fluid or wound dressing changes,” said Dr. Morgan.

Less use of contact precautions also requires a close eye on the bacteria in the hospital. “Institutions should be careful that they're monitoring different infections and different drug-resistant pathogens if they are going to remove contact precautions, because it's not really clear how to monitor and to be clear that you're not causing any problems,” said Dr. Morgan.