Journal Review: Isolation nation: ASC and unintended consequences

Isolation nation: ASC and unintended consequences

Diekema DJ, Edmond MB. Look before you leap: Active surveillance for multidrug-resistant organisms. Clin Infect Dis 2007; 44:1,101-1,107.

Hospitals in the United States are under increasing pressure to perform active surveillance cultures (ASC) for detection of methicillin-resistant Staphylococcus aureus (MRSA) and other pathogens among newly admitted patients. Results of such cultures can then be used to direct contact precautions to prevent transmission of MRSA in health care settings. "However, using active surveillance cultures to expand contact precautions is a complicated and resource-intensive intervention that has the potential for several unintended adverse consequences," the authors warn.

They reviewed the literature and cited several studies documenting some of the consequences of contact isolation, which — according to the Centers for Disease Control and Prevention — goes beyond basic hand hygiene and standard precautions to include the following key elements:

• Place the patient in a private room or group colonized and infected patients in cohorts.
• Wear gloves when entering the room, and wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent, or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing.
• Limit the movement and transport of the patient from the room to essential purposes only.

They don't call it isolation for nothing

While such measures can help prevent the spread of MRSA from colonized patients throughout the hospital, they do not come without some cost to the patient in contact isolation. The most often-cited adverse effect of contact precautions is reduced interaction between health care workers and patients. Three studies performed in different health care centers and settings (a medical intensive care unit, a surgical intensive care unit and ward, and two inpatient medical wards) reported remarkably similar findings, the authors report.^1-3 In all cases, the implementation of contact precautions resulted in about a 50% reduction in contacts between health care workers and patients, including a reduction in the frequency of examination by attending physicians, they reported. "We are unaware of published studies that have attempted to counteract this consequence of contact precautions or that have provided effective solutions to the problem," they state in the article. "We recommend performing educational interventions to encourage providing equally attentive care to all patients."

In addition, during observation of adherence to contact precautions, the frequency with which health care workers entered the rooms of patients for whom contact precautions were implemented, compared with a sample of rooms in which the patients were not subject to contact precautions, could be used to monitor this phenomenon, they recommended. "If contacts between health care workers and patients remain significantly reduced for patients for whom contact precautions are implemented, more aggressive educational efforts (e.g., posters and screensavers) could be introduced," they reasoned.

Another adverse effect of contact precautions is an increase in feelings of isolation and loss of control that can result in anxiety and depression. A cross-sectional study in which 22 geriatric patients for whom contact precautions were implemented for MRSA were compared with control subjects who were matched for age, sex, diagnosis, level of functional independence, and cognitive function found significantly increased rates of anxiety and depression among patients subject to contact precautions.⁴

"Increasing contacts between health care workers and patients may reduce this effect," the authors note. "Other measures include efforts to decrease a sense of isolation and instill a greater sense of control by arranging for increased social contact. Support and consultation from social work, physical and occupational therapy, clinical psychology, or psychiatry departments may also be helpful."

Moreover, some hospital departments should be exempted from the active surveillance culture program if the benefits of contact precautions are outweighed by the deleterious effects on the therapeutic plan, they recommend. This would include the psychiatry department, because isolation could exacerbate psychiatric symptoms and interfere with direct observation of the patient. Inpatient palliative care departments that serve only terminally ill patients also should be exempted. Another problematic department is that of inpatient rehabilitation, because contact precautions have been shown to prolong duration of stay and time to reach rehabilitation goals, as well as to increase patient anger.^5,6 Another study reported an increase in noninfectious adverse events among patients for whom contact precautions were implemented, compared with control subjects.⁷

"We hope that increasing contacts between health care workers and patients can reduce the risk for many of these adverse events," the authors conclude. "Nonetheless, it is imperative that hospitals monitor the incidence of these adverse events among patients for whom contact precautions are implemented, compared with hospitalwide rates of adverse events. Interventions to improve patient safety can then be implemented as indicated by findings of individual institutions."

References

1. Kirkland KB, Weinstein JM. Adverse effects of contact isolation. Lancet 1999; 354:1,177-1,178.
2. Evans JL, Shaffer MM, Hughes MG, et al. Contact isolation in surgical patients: A barrier to care? Surgery 2003; 134:180-188.
3. Saint S, Higgins LA, Nallamothu BK, et al. Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control 2003; 31:354-356.
4. Tarzi S, Kennedy P, Stone S, et al. MRSA: Psychological impact of hospitalization and isolation in older adult population. J Hosp Infect 2001; 49:250-254.
5. Alfano AP, Patel JS. Rehabilitation outcomes in spinal cord injury: Persons in isolation versus nonisolation [poster 191]. Abstracts of the 64th Annual Assembly of the American Academy of Physical Medicine and Rehabilitation (Chicago). Arch Phys Med Rehabil 2003; 84:E37.
6. Kennedy P, Hamilton LR. Psychological impact of the management of methicillin-resistant Staphylococcus aureus (MRSA) in patients with spinal cord injury. Spinal Cord 1997; 35:617-619.
7. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA 2003; 290:1,899-1,905.