Contact precautions linked to fewer and shorter patient visits

Health care workers spent less time with patients who were on contact precautions, based on results from a prospective study in the January 2013 issue of Infection Control and Hospital Epidemiology.

Patients on contact precautions for drug-resistant infections had almost 40% fewer visits from health care workers. Further, when they did visit, health care workers spent significantly less time in the rooms of patients on precautions, reported Dr. Daniel Morgan and his associates.

Dr. Daniel Morgan

On a positive note, handwashing hygiene improved when health care workers saw patient on contact precautions (Infect. Control Hosp. Epidemiol. 2013;34:69-73).

"Contact precautions modify health care workers’ behavior. This has positive and negative consequences," Dr. Morgan, the lead author, said in an interview.

"Health care workers should be aware of the tendency to visit patients less often and question their own behavior when caring for these patients," said Dr. Morgan of the University of Maryland and the Veterans Affairs (VA) Maryland Health Care System, Baltimore. "Do they visit them less often? Are they at risk of missing anything because a patient is on precautions? Are they creating workarounds for the inconvenience that may impact the patient?"

Research is underway looking at outcomes of patients on isolation and ways to improve these outcomes, "but for a start, it is important that health care workers consider how their behavior may be shaped by contact precautions," he added.

In the prospective cohort study, the activity of health care workers at four acute hospitals was observed for 1-hour periods over 19 months. The trained observers – so-called "secret shoppers" – observed a total of 7,743 visits over 1,989 hours in seven intensive care units and six medical surgical wards at three VA Hospitals and at one medical center, the University of Maryland Medical Center in Baltimore.

Patients on contact precautions had 2.78 visits per hour from health care workers, compared with 4.37 visits per hour among those not on precautions, a statistically significant difference.

Health care workers also spent significantly less time – nearly 18% less – with patients on contact precautions. Time spent per hour was 14 minutes for patients on precautions and 17 minutes for other patients. The time spent with patients in ICUs, however, was similar irrespective of contact precautions.

Health care workers were almost 16% more likely to comply with proper hand hygiene techniques when exiting the rooms of patients on contact precautions. Proper hand washing was observed 63% of the time when leaving the room of a patient on precautions and 47% of the time when exiting the room of a patient not on precautions. This statistically significant difference was "more pronounced" in the ICU setting, the authors wrote.

Contact precautions did not appear to affect compliance with hand hygiene when entering a patient’s room. Overall, the compliance rate with gowns and gloves was 66% for patients on contact precautions.

The compliance rates for hand hygiene and use of gown and gloves recorded in the study were lower than the rates hospitals often report to hospital regulators, but they are in the range of what is routinely reported in more rigorous research, Dr. Morgan said in an interview.

The reduced contact between patients on contact precautions and health care workers was "likely" caused by the "inconvenience of donning gowns and gloves," the authors wrote. The lack of a difference in contact in the ICU could be the "higher acuity of care" or the higher nurse-to-patient ratio, whereby gloves and gowns do not need to be changed as frequently.

The "unintended consequences" of contact precautions are a particular concern now that contact precautions have become more common with programs like the Department of Veterans Affairs MRSA Prevention Initiative, Dr. Morgan and his associates said. The decrease in contact with health care workers "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 protocols to prevent pressure ulcers, they suggested.

The only non-ICU units observed in the study were in VA hospitals, which was one of the limitations of the study cited by the authors. The strengths of the study included the nearly 2,000 hours of observations at hospitals in different parts of the country.

"We don’t know whether less frequent visits to the patient room necessarily means more adverse events," Dr. Anthony Harris, professor of epidemiology and public health at the University of Maryland, said in an interview. Previous research indicating that contact precautions led to adverse events had some serious methodological flaws.