Impact of contact precautions on falls, pressure ulcers and transmission of MRSA and VRE in hospitalized patients

doi:10.1016/j.jhin.2014.09.003

Journal of Hospital Infection

Volume 88, Issue 3, November 2014, Pages 170-176

https://doi.org/10.1016/j.jhin.2014.09.003 Get rights and content

Summary

Background

Hospitals use contact precautions to prevent the spread of meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). There is concern that contact precautions may have adverse effects on the safety of isolated patients. In November 2010, the infection control policy at an academic medical centre was modified, and contact precautions were discontinued for patients colonized or infected with MRSA or VRE (MRSA/VRE patients).

Aim

To assess the rates of falls and pressure ulcers among MRSA/VRE patients and other adult medical-surgical patients, as well as changes in MRSA and VRE transmission before and after the policy change.

Methods

A single-centre retrospective hospital-wide cohort study was performed from 1^st November 2009 to 31^st October 2011.

Findings

Rates of falls and pressure ulcers were significantly higher among MRSA/VRE patients compared with other adult medical-surgical patients before the policy change (falls: 4.57 vs 2.04 per 1000 patient-days, P < 0.0001; pressure ulcers: 4.87 vs 1.22 per 1000 patient-days, P < 0.0001) and after the policy change (falls: 4.82 vs 2.10 per 1000 patient-days, P < 0.0001; pressure ulcers: 4.17 vs 1.19 per 1000 patient-days, P < 0.0001). No significant differences in the rates of falls and pressure ulcers among MRSA/VRE patients were found after the policy change compared with before the policy change. There was no overall change in MRSA or VRE hospital-acquired transmission.

Conclusion

MRSA/VRE patients had higher rates of falls and pressure ulcers compared with other adult medical-surgical patients. Rates were not affected by removal of contact precautions, suggesting that other factors contribute to these complications. Further research is required among this population to prevent complications.

Introduction

The Centers for Disease Control and Prevention (CDC) recommend the use of transmission-based contact precautions for patients with documented or suspected infection or colonization with epidemiologically important pathogens.¹ Based on these recommendations, many acute care facilities use infection control contact precautions to prevent the spread of multi-drug-resistant organisms, such as meticillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Patients placed under contact precautions are housed in private hospital rooms, and all healthcare workers involved in patient care are required to wear a gown and gloves while in the patient's room. However, while contact precautions are in common use, their efficacy in controlling the transmission of multi-drug-resistant organisms is unclear, compliance is poor, and contact precautions may result in unintended harmful consequences.2, 3, 4, 5, 6, 7 Specifically, reported consequences of contact precautions include: reduced patient contact with healthcare workers;2, 8, 9, 10, 11, 12 increased numbers of preventable adverse events;13, 14, 15 decreased psychological well-being;⁷ decreased patient satisfaction;¹³ delays in access to radiological examinations;¹⁶ and decreased quality of hospital care.¹⁷ Stelfox et al. reported that patients placed under contact precautions were eight times more likely to experience supportive care failures (e.g. falls, pressure ulcers, and fluid or electrolyte disturbances) than patients who were not placed under contact precautions.¹³ Unfortunately, the prevalence of MRSA and VRE infection has increased in acute care, chronic care and community settings, thus increasing the number of patients at risk of potential complications from contact precautions.

On 1^st November 2010, the infection control policy of the University of Massachusetts Memorial Medical Center, Worcester, MA, USA was changed to discontinue the use of contact precautions among patients colonized or infected with MRSA or VRE (MRSA/VRE patients). Noting the work of Stelfox et al.,¹³ the impact of the policy change on rates of falls and new-onset pressure ulcers among MRSA/VRE patients compared with the general patient population was studied. It was hypothesized that the rates of complications would decrease among MRSA/VRE patients, and the rate of hospital-acquired MRSA or VRE transmission would remain constant.

Section snippets

Design and setting

On 1^st November 2010, the University of Massachusetts Memorial Medical Center discontinued the use of contact precautions for MRSA/VRE patients. Patients colonized or infected with selected multi-drug-resistant organisms (e.g. extended-spectrum beta-lactamase-positive or carbapenemase-positive Gram-negative organisms, other highly multi-drug-resistant Gram-negative bacteria or vancomycin-resistant S. aureus), as well as those soiling the environment with secretions due to active draining

Patient characteristics

No significant differences were observed between demographic and clinical covariates for MRSA/VRE patients who had a fall or developed a pressure ulcer after the policy change compared with before the policy change (Table I). No significant difference in the Braden score for MRSA/VRE patients who developed pressure ulcers was found after the policy change compared with before the policy change.

Number of falls and pressure ulcers during study period

In total, 741 falls and 491 new-onset Stage 2 (or greater) pressure ulcers occurred during the

Discussion

Several studies have assessed the harmful effects of contact precautions.2, 8, 9, 10, 11, 12, 15, 16, 17 However, only two studies have reported on falls and pressure ulcers.13, 14 Stelfox et al. performed a matched cohort study between 1999 and 2002 at two academic medical centres in North America.¹³ Among patients colonized or infected with MRSA, they found that patients placed under contact precautions were eight times more likely to experience supportive care failures including falls and

Acknowledgements

Preliminary data were published in abstract form and presented at the Annual Meeting of the Infectious Disease Society of America on 19^th October 2012.

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Methicillin-Resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections (HAI). Contact isolation has been traditionally implemented to stop transmission but its impact is increasingly questioned.
A single center, retrospective, nonrandomized, observational, quasi-experimental study compared MRSA HAI rates between pre-/postdiscontinuation of MRSA contact isolation in a tertiary university hospital over 68 months. Data on primary outcomes, Central line-associated bloodstream infections and MRSA LabID bacteremia events, were analyzed by interrupted time series design using segmented Poisson regression modeling. As secondary outcomes catheter-associated urinary tract infections , ventilator-associated pneumonia , surgical site infections and hospital-associated pneumonia were compared using Fisher's exact tests. Current savings due to discontinuation were calculated based on gown use.
Two hundred and ninty-five patients developed 399 HAIs. Infection rates between pre- and postinterventions were as follows: Central line-associated bloodstream infections: (0.02% vs 0.02%; P-value = .64), MRSA LabID events: (0.01% vs 0.02%; P-value = .32), hospital-associated pneumonia: (0.01% vs 0.01%; P-value = .64), catheter-associated urinary tract infections: (0% vs 0.01%; P-value = .56), ventilator-associated pneumonia: (0.01% vs 0.01%; P-value = .32), surgical site infections (0.55% vs 0.15%; P-value = .03). Savings amount to $139,228 annually.
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After screening titles of 15,921 articles and abstracts of 196, and reviewing full texts of 50 studies, 19 studies were included. Studies were divided into three groups: four qualitative studies, seven observational studies suitable for meta-analysis, and eight other observational studies. Meta-analysis shows no adverse events related to clinical care or patients' experience associated with patient isolation.
More studies with correct methodology, including a control group and standardized inclusion criteria, must be conducted to confirm our results.
Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities
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Citation Excerpt :
No evidence was found from the studies published since 2004 meeting the inclusion criteria for the study design, which assessed the cost-effectiveness of CP. Additional evidence was obtained from national guidelines [197] and seven UBA studies [154,209–214] which attempted to discontinue CP in hospitals (including ICU and general wards). In one of these studies a nurse cohorting area was associated with a significant decrease in MRSA transmission. [209]
Does the removal of contact precautions for MRSA and VRE infected patients change health care-associated infection rate?: A systematic review and meta-analysis
2021, American Journal of Infection Control
Citation Excerpt :
We did not notice any differences among these sub groups (Test for subgroup differences: P = .52). Four studies12,14,19,22 investigated rates of hospital-associated VRE infection before and after removing CPs and used chlorhexidine, while 2 studies16, 26 did not use chlorhexidine. The pooled analysis for the four studies using chlorhexidine suggested evidence of difference between rates of hospital-associated VRE infection before and after stopping the CPs (RR, 0.79; 95% CI, 0.65-0.96; P = .01).
Update existing meta-analysis to analyze if discontinuation of contact precautions (CPs) for Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin resistant Enterococcus (VRE) colonization or infection affects hospital-associated MRSA or VRE infection rates.
We conducted a systematic review of 17 studies evaluating discontinuation of CPs for MRSA and VRE. Random-effects and fixed-effects models were used to determine the pooled risk ratios (RR) of preincidence hospital-associated infection rate to postincidence rate. Subgroup analysis was used to assess sources of heterogeneity.
No significant difference between rates of hospital-associated MRSA infection before and after stopping the CPs was observed (RR, 0.84; 95% confidence internal [CI], 0.71-1.01; P = .06). An inverse association was observed between discontinuation of CPs and rates of hospital-associated VRE infection (RR, 0.82; 95% CI, 0.72-0.94; P = .005). A subgroup analysis of 6 studies that used chlorhexidine, showed no difference between rates of hospital-associated MRSA infection with discontinuation of CPs (RR, 0.83; 95% CI, 0.69-1.00; P = .05). In 5 studies that did not use chlorhexidine, there was no difference between rates of hospital-associated MRSA infection with discontinuation of CPs (RR, 1.02; 95% CI, 0.55-1.88; P= .95).
There was no significant difference in rates of hospital-associated MRSA infection before and after removing CPs. Additionally, there were decreased rates of hospital-associated VRE infection following stoppage of CPs.
Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: An interrupted time series analysis
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Contact precautions (CP) are a widely adopted strategy to prevent cross-transmission of organisms, commonly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Some hospitals have discontinued CP for patients with MRSA or VRE; however, the impact on hospital-acquired infection rates (HAI) has not been assessed systematically.
Retrospective multicenter interrupted time series between 2002 and 2017 at three academic hospitals. Participating hospitals discontinued CP for patients with contained body fluids who were colonized or infected with MRSA or VRE. The primary intervention was stopping the use of CP. Secondary interventions were horizontal infection prevention strategies. The primary outcomes were rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia due to MRSA, VRE, or any organism using Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definitions.
Central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia rates trended down at each institution. There were no statistically significant increases in these infections associated with discontinuing CP. Individual horizontal infection prevention strategies variably impacted HAI outcomes.
Stopping the routine use of CP for patients with contained body fluids who are colonized or infected with MRSA or VRE did not result in increased HAIs. Bundled horizontal infection prevention strategies resulted in sustained HAI reductions.

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Impact of contact precautions on falls, pressure ulcers and transmission of MRSA and VRE in hospitalized patients

Summary

Background

Aim

Methods

Findings

Conclusion

Introduction

Section snippets

Design and setting

Patient characteristics

Number of falls and pressure ulcers during study period

Discussion

Acknowledgements

Am J Infect Control

Am J Infect Control

J Hosp Infect

Lancet

Am J Infect Control

Surgery

Am J Infect Control

Am J Med

J Chronic Dis

Int J Nurs Stud

The effect of contact precautions on healthcare worker activity in acute care hospitals

Infect Control Hosp Epidemiol

Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions

Infect Control Hospital Epidemiol