Do contact precautions cause depression? A two-year study at a tertiary care medical centre

Modeling relaxed policies for discontinuation of methicillin-resistant Staphylococcus aureus contact precautions

OBJECTIVE

To evaluate the economic costs of reducing the University of Virginia Hospital's present "3-negative" policy, which continues methicillin-resistant Staphylococcus aureus (MRSA) contact precautions until patients receive 3 consecutive negative test results, to either 2 or 1 negative.

DESIGN

Cost-effective analysis.

SETTINGS

The University of Virginia Hospital.

PATIENTS

The study included data from 41,216 patients from 2015 to 2019.

METHODS

We developed a model for MRSA transmission in the University of Virginia Hospital, accounting for both environmental contamination and interactions between patients and providers, which were derived from electronic health record (EHR) data. The model was fit to MRSA incidence over the study period under the current 3-negative clearance policy. A counterfactual simulation was used to estimate outcomes and costs for 2- and 1-negative policies compared with the current 3-negative policy.

RESULTS

Our findings suggest that 2-negative and 1-negative policies would have led to 6 (95% CI, -30 to 44; P < .001) and 17 (95% CI, -23 to 59; -10.1% to 25.8%; P < .001) more MRSA cases, respectively, at the hospital over the study period. Overall, the 1-negative policy has statistically significantly lower costs ($628,452; 95% CI, $513,592-$752,148) annually (P < .001) in US dollars, inflation-adjusted for 2023) than the 2-negative policy ($687,946; 95% CI, $562,522-$812,662) and 3-negative ($702,823; 95% CI, $577,277-$846,605).

CONCLUSIONS

A single negative MRSA nares PCR test may provide sufficient evidence to discontinue MRSA contact precautions, and it may be the most cost-effective option.

Hospital patient experiences of contact isolation for antimicrobial resistant organisms in relation to health care-associated infections: A systematic review and narrative synthesis of the evidence

BACKGROUND

The alarming growth of antimicrobial resistance organisms (AMRs) and the threat caused by health care-associated infections require hospitalized individuals who are infected or colonized with AMRs to be cared for in isolation, predominantly in single rooms. None of the existing reviews focus on or specifically address the patient's experience of being cared for in contact isolation when affected by AMRs exploring this specific context.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance for the conduct of systematic reviews was applied. Five databases were searched from inception to April 2019, with keywords related to adult patient experiences, AMR, and contact isolation. The evidence was certified by 2 reviewers. Principles of thematic analysis were used to produce a narrative synthesis of the findings.

RESULTS

Eighteen eligible studies were identified. Narrative synthesis resulted in 3 overarching categories reflecting the patient experience: privacy versus loneliness; emotional responses to isolation; quality of care, recovery, and safety in isolation.

CONCLUSIONS

This review synthesizes existing evidence reflecting the patient experience of contact isolation. Study findings were often contradictory and may not reflect contemporary health care, such as shorter hospital stays, or societal preferences for greater privacy. Further research focusing on contemporary health care contexts is recommended.

Using spectral characterization to identify healthcare-associated infection (HAI) patients for clinical contact precaution

Healthcare-associated infections (HAIs) are a major problem in hospital infection control. Although HAIs can be suppressed using contact precautions, such precautions are expensive, and we can only apply them to a small fraction of patients (i.e., a limited budget). In this work, we focus on two clinical problems arising from the limited budget: (a) choosing the best patients to be placed under precaution given a limited budget to minimize the spread (the isolation problem), and (b) choosing the best patients to release when limited budget requires some of the patients to be cleared from precaution (the clearance problem). A critical challenge in addressing them is that HAIs have multiple transmission pathways such that locations can also accumulate 'load' and spread the disease. One of the most common practices when placing patients under contact precautions is the regular clearance of pathogen loads. However, standard propagation models like independent cascade (IC)/susceptible-infectious-susceptible (SIS) cannot capture such mechanisms directly. Hence to account for this challenge, using non-linear system theory, we develop a novel spectral characterization of a recently proposed pathogen load based model, 2-MODE-SIS model, on people/location networks to capture spread dynamics of HAIs. We formulate the two clinical problems using this spectral characterization and develop effective and efficient algorithms for them. Our experiments show that our methods outperform several natural structural and clinical approaches on real-world hospital testbeds and pick meaningful solutions.

Development and Validation of a Tool for the Prediction of Vancomycin-Resistant Enterococci Colonization Persistence-the PREVENT Score

Vancomycin-resistant enterococci (VRE) are nosocomial pathogens with increasing prevalence worldwide. Extensive hygiene measures have been established to prevent infection transmission in hospitals. Here, we developed a predictive score system (the predictive vancomycin-resistant enterococci [PREVENT] score) to identify the clearance or persistence in patients with a history of VRE carrier status at readmission. Over a cumulative 3-year period, patients with a positive VRE carrier status were included. The study population was recruited in two successive time periods and separated into training data for predictive score development and validation data for evaluation of the predictive power. The risk factors for persistent VRE colonization were analyzed in a univariable analysis before development of a logistic regression model based on the potential risk factors. The score points were determined proportionally to the beta coefficients of the logistic regression model. The data from 448 (79%) patients were used as the training data, and those from 119 (21%) as the validation data. Multivariable analysis revealed the following variables as independent risk factors: age of ≥60 years, hemato-oncological disease, cumulative antibiotic treatment for >4 weeks, and a VRE infection. The resulting logistic regression model exhibited an acceptable area under the curve (AUC) of 0.81 (95% confidence interval [CI], 0.72 to 0.91). The predictive score system had a sensitivity of 82% (95% CI, 65 to 93%) and a specificity of 77% (95% CI, 66 to 85%). The developed predictive score system is a useful tool to assess the VRE carrier status of patients with a history of VRE colonization. On the basis of this risk assessment, more focused and cost-effective infection control measures can be implemented. IMPORTANCE Given the increasing relevance of VRE as nosocomial pathogens worldwide, infection prevention and control measures, including patient isolation and contact precautions, are indispensable to avoid their spread in the hospital setting. In this study, we developed and validated the PREVENT score, a tool for rapid risk assessment of VRE persistence in patients with a history of previous VRE colonization. The score is designed to be easily performed, employing clinical information available in a regular admission setting and immediately providing information to inform the decision of whether to adopt patient isolation and contact precautions during the hospital stay. After validation, the score was shown to accurately identify patients with persistent VRE colonization upon admission, representing a suitable option as (i) a complementary method yielding preliminary results significantly more quickly than culture-based VRE detection techniques and (ii) an alternative strategy for VRE detection in settings in which microbiological VRE screening is not routinely performed due to limited resources.

Coping Strategies Used by Older Adults to Deal with Contact Isolation in the Hospital during the COVID-19 Pandemic

Due to the COVID-19 pandemic, many older adults have experienced contact isolation in a hospital setting which leads to separation from relatives, loss of freedom, and uncertainty regarding disease status. The objective of this study was to explore how older adults (55+) cope with contact isolation in a hospital setting during the COVID-19 pandemic in order to improve their physical and psychological wellbeing. The realist evaluation approach was used to formulate initial program theories on coping strategies used by (older) adults in an isolation setting. Twenty-one semi-structured interviews with older patients (n = 21) were analysed. This study revealed that both emotion-focused coping strategies as well as problem-focused coping strategies were used by older adults during contact isolation. The study also uncovered some new specific coping strategies. The results have useful implications for hospital staff seeking to improve the wellbeing of older adults in contact isolation in hospitals. Problem-focused coping strategies could be stimulated through staff performing care in a person-centred way. Trust in staff, as part of emotion-focused coping strategies, could be stimulated by improving the relationship between patients and staff.

Effect of antidepressant use on length of hospitalization in patients on anti-infective therapy

Compared to those without depression, acutely-ill patients with depression hospitalized for an infection usually have poor outcomes, including increased length of stay (LOS).

PURPOSE

The primary objective was to evaluate the LOS between patients receiving an anti-infective with and without any antidepressant use. Secondary objectives were to examine LOS based on acuity of care and age.

METHODS

Using a cross-sectional design, hospitalized adult patients who received anti-infective agents between January 1, 2017 and October 31, 2019 for ≥7 days were included. Univariate and multivariate analyses were conducted to determine statistical significance.

RESULTS

A total of 17,651 patient encounters were included in the study. Of all patient encounters, 5165 (29%) received antidepressants concurrently with anti-infectives, with mean age of 57 years ± 17.3. Patients receiving concurrent antidepressants experienced longer LOS compared with patients not receiving antidepressants [20 vs 16 days, 95% confident interval (CI): 3.98-5.18, p < 0.001]. Stratified by intensive care unit (ICU) admission during hospital encounters and age ≥ 65 years, patients receiving antidepressants had longer LOS (25 vs 18 days, CI: 5.63-8.61, p < 0.001, and 18 vs 15 days, CI: 2.39-4.04, p < 0.001, respectively). After controlling for gender and ethnicity, antidepressant use and ICU admission were independently associated with increased LOS.

CONCLUSION

Patients who received both an antidepressant and an anti-infective agent had significantly increased LOS, including those in the ICU and in the elderly population. Future studies are needed to assess the impact of concomitant antidepressant use on mortality and other clinical outcomes in patients hospitalized with an infection.

The occurrence of and risk factors for developing acute critical illness during quarantine as a response to the COVID-19 pandemic

BACKGROUND/PURPOSE

Early detection and timely quarantine measures are necessary to control disease spread and prevent nosocomial outbreaks of Coronavirus disease 2019 (COVID-19). In this study, we aimed to investigate the impact of a quarantine strategy on patient safety and quality of care.

METHODS

This retrospective cohort study enrolled patients admitted to the quarantine ward in a tertiary hospital in southern Taiwan. The incidence and causes of acute critical illness, including clinical deterioration and unexpected complications during the quarantine period, were reviewed. Further investigation was performed to identify risk factors for acute critical illness during quarantine.

RESULTS

Of 320 patients admitted to the quarantine ward, more than two-thirds were elderly, and 37.8% were bedridden. During the quarantine period, 68 (21.2%) developed acute critical illness, which more commonly occurred among patients older than 80 years and with a bedridden status, nasogastric tube feeding, or dyspnea symptoms. Bedridden status was an independent predictor of acute critical illness. Through optimization of sampling for COVID-19 and laboratory schedules, both the duration of quarantine and the proportion of acute critical illness among bedridden patients during quarantine exhibited a decreasing trend. There was no COVID-19 nosocomial transmission during the study period.

CONCLUSION

The quarantine ward is a key measure to prevent nosocomial transmission of COVID-19 but may carry a potential negative impact on patient care and safety. For patients with multiple comorbidities and a bedridden status, healthcare workers should remain alert to rapid deterioration and unexpected adverse events during quarantine.

Mental health effects of infection containment strategies: quarantine and isolation-a systematic review and meta-analysis

Due to the ongoing COVID-19 pandemic, an unprecedented number of people worldwide is currently affected by quarantine or isolation. These measures have been suggested to negatively impact on mental health. We conducted the first systematic literature review and meta-analysis assessing the psychological effects in both quarantined and isolated persons compared to non-quarantined and non-isolated persons. PubMed, PsycINFO, and Embase databases were searched for studies until April 22, 2020 (Prospero Registration-No.: CRD42020180043). We followed PRISMA and MOOSE guidelines for data extraction and synthesis and the Newcastle-Ottawa Scale for assessing risk of bias of included studies. A random-effects model was implemented to pool effect sizes of included studies. The primary outcomes were depression, anxiety, and stress-related disorders. All other psychological parameters, such as anger, were reported as secondary outcomes. Out of 6807 screened articles, 25 studies were included in our analyses. Compared to controls, individuals experiencing isolation or quarantine were at increased risk for adverse mental health outcomes, particularly after containment duration of 1 week or longer. Effect sizes were summarized for depressive disorders (odds ratio 2.795; 95% CI 1.467-5.324), anxiety disorders (odds ratio 2.0; 95% CI 0.883-4.527), and stress-related disorders (odds ratio 2.742; 95% CI 1.496-5.027). Among secondary outcomes, elevated levels of anger were reported most consistently. There is compelling evidence for adverse mental health effects of isolation and quarantine, in particular depression, anxiety, stress-related disorders, and anger. Reported determinants can help identify populations at risk and our findings may serve as an evidence-base for prevention and management strategies.

Multidrug-Resistant Organisms in Palliative Care: A Systematic Review

Background: Multidrug-resistant organisms (MDROs) are an important health care issue. Patients in Western societies often present an increased morbidity of chronic conditions accompanied by poor immune status and the use of devices. In particular, patients in palliative care (PC) are at greater risk of MDRO colonization, due to accompanying special devices and being hospitalized. Objective: To gain an overview of the literature regarding MDROs in PC. Design: Systematic review Data sources: On the 19th of October 2019 the databases " PubMed" and " CINAHL" were used to identify studies reporting on MDROs in PC; the search was updated on 16th of May 2020. Results: Seventeen out of 486 articles were included. Six represent qualitative data, 10 quantitative data, and one a mixed methods approach. Prevalence data range from 4.0% to 18%. MDRO colonization has a negative impact on patients and families. It leads to uncertainties and higher workload by staff members. Strategies for the management of MDROs in the field of PC are predominantly available for methicillin-resistant Staphylococcus aureus. Not even half of institutions utilize existing protocols. Recommendations for dealing with MDROs indicate required staff and time resources as well as information, communication, and specific knowledge. Conclusion: There is a great need for studies examining the prevalence of all MDROs in the PC setting. Additionally, not only patients but also a public enlightenment on MDROs should be provided to decrease knowledge gaps and therefore reduce transmission on MDROs.

Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis

OBJECTIVE

To systematically review the literature exploring the impact of isolation on hospitalised patients who are infectious: psychological and non-psychological outcomes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Embase, Medline and PsycINFO were searched from inception until December 2018. Reference lists and Google Scholar were also handsearched.

RESULTS

Twenty-six papers published from database inception to December 2018 were reviewed. A wide range of psychological and non-psychological outcomes were reported. There was a marked trend for isolated patients to exhibit higher levels of depression, the pooled standardised mean difference being 1.28 (95% CI 0.47 to 2.09) and anxiety 1.45 (95% CI 0.56 to 2.34), although both had high levels of heterogeneity, and worse outcomes for a range of care-related factors but with significant variation.

CONCLUSION

The review indicates that isolation to contain the risk of infection has negative consequences for segregated patients. Although strength of the evidence is weak, comprising primarily single-centre convenience samples, consistency of the effects may strengthen this conclusion. More research needs to be undertaken to examine this relationship and develop and test interventions to reduce the negative effects of isolation.

Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis

OBJECTIVE

To systematically review the literature exploring the impact of isolation on hospitalised patients who are infectious: psychological and non-psychological outcomes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Embase, Medline and PsycINFO were searched from inception until December 2018. Reference lists and Google Scholar were also handsearched.

RESULTS

Twenty-six papers published from database inception to December 2018 were reviewed. A wide range of psychological and non-psychological outcomes were reported. There was a marked trend for isolated patients to exhibit higher levels of depression, the pooled standardised mean difference being 1.28 (95% CI 0.47 to 2.09) and anxiety 1.45 (95% CI 0.56 to 2.34), although both had high levels of heterogeneity, and worse outcomes for a range of care-related factors but with significant variation.

CONCLUSION

The review indicates that isolation to contain the risk of infection has negative consequences for segregated patients. Although strength of the evidence is weak, comprising primarily single-centre convenience samples, consistency of the effects may strengthen this conclusion. More research needs to be undertaken to examine this relationship and develop and test interventions to reduce the negative effects of isolation.

Experiences of carriers of multidrug-resistant organisms: a systematic review

OBJECTIVES

A comprehensive overview of the ways control measures directed at carriers of multidrug-resistant organisms (MDRO) affect daily life of carriers is lacking. In this systematic literature review, we sought to explore how carriers experience being a carrier and how they experience being subjected to control measures by looking at the impact on basic capabilities.

METHODS

We searched Medline, Embase and PsychINFO until 26 May 2016 for studies addressing experiences of MDRO carriers. Twenty-seven studies were included, addressing experiences with methicillin-resistant Staphylococcus aureus (n = 21), ESBL (n = 1), multiple MDRO (n = 4) and other (n = 1, not specified). We categorized reported experiences according to Nussbaum's capability approach.

RESULTS

Carriage and control measures were found to interfere with quality of care, cause negative emotions, limit interactions with loved ones, cause stigmatization, limit recreational activities and create financial and professional insecurity. Further, carriers have difficulties with full comprehension of the problem of antimicrobial resistance, thus affecting six out of ten basic capabilities.

CONCLUSIONS

Applying Nussbaum's capability approach visualizes an array of unintended consequences of control measures. Carriers experience stigmatization, especially in healthcare settings, and have limited understanding of their situation and the complexities of antimicrobial resistance.

Comparing a single-day swabbing regimen with an established 3-day protocol for MRSA decolonization control

OBJECTIVES

Success of methicillin-resistant Staphylococcus aureus (MRSA) decolonization procedures is usually verified by control swabs of the colonized body region. This prospective controlled study compared a single-day regimen with a well-established 3-day scheme for noninferiority and adherence to the testing scheme.

METHODS

Two sampling schemes for screening MRSA patients of a single study cohort at a German tertiary-care hospital 2 days after decolonization were compared regarding their ability to identify MRSA colonization in throat or nose. In each patient, three nose and three throat swabs were taken at 3- to 4-hour intervals during screening day 1, and in the same patients once daily on days 1, 2 and 3. Swabs were analysed using chromogenic agar and broth enrichment. The study aimed to investigate whether the single-day swabbing scheme is not inferior to the 3-day scheme with a 15% noninferiority margin.

RESULTS

One hundred sixty patients were included, comprising 105 and 101 patients with results on all three swabs for decolonization screening of the nose and throat, respectively. Noninferiority of the single-day swabbing scheme was confirmed for both pharyngeal and nasal swabs, with 91.8% and 89% agreement, respectively. The absolute difference of positivity rates between the swabbing regimens was 0.025 (-0.082, 0.131) for the nose and 0.006 (-0.102, 0.114) (95% confidence interval) for the pharynx as calculated with McNemar's test for matched or paired data. Compliance with the single-day scheme was better, with 12% lacking second-day swabs and 27% lacking third-day swabs from the nostrils.

CONCLUSIONS

The better adherence to the single-day screening scheme with noninferiority suggests its implementation as the new gold standard.

The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study

BACKGROUND

Isolation precautions have negative effects on patient safety, psychological well-being, and healthcare worker contact. However, it is not known whether isolation precautions affect certain hospital-related outcomes.

OBJECTIVE

To examine the effect of isolation precautions on hospital-related outcomes and cost of care.

DESIGN

Retrospective, propensity-score matched cohort study of inpatients admitted to general internal medicine (GIM) services at three academic hospitals in Toronto, Ontario, Canada between January 2010 and December 2012.

PARTICIPANTS

Adult (≥18 years of age) patients on isolation precautions for respiratory illnesses and methicillin-resistant Staphylococcus aureus (MRSA) were matched to controls based on propensity scores derived from nine covariates: age, sex, Resource Intensity Weight, number of hospital readmissions within 90 days, total length of stay for hospital admissions within 90 days, site of admission, month of isolation, year of isolation, and Case Mix Group.

MAIN MEASURES

Thirty-day readmission rates and emergency department visits, hospital length of stay, expected length of stay, adverse events, in-hospital mortality, patient complaints, and cost of care in Canadian doll ars (CAD).

KEY RESULTS

A total of 17,649 non-isolated patients were admitted to the participating hospitals during the study period. We identified 1506 patients isolated for respiratory illnesses and 745 patients isolated for MRSA. Compared to non-isolated individuals, those on isolation precautions for respiratory illnesses stayed 17 % longer (95 % CI: 9 %, 25 %), stayed 9 % longer than expected (95 % CI: 3 %, 15 %), and had 23 % higher cost of care (95 % CI: 14 %, 32 %). Patients isolated for MRSA had similar outcomes, but they also had a 4.4 % higher (95 % CI: 1.4 %, 7.3 %) rate of readmission to hospital within 30 days.

CONCLUSIONS

Isolation precautions are associated with adverse effects which may result in poorer hospital outcomes. Balancing the benefits for the many with the harms to the few will be a future challenge.

Isolation Precautions Use for Multidrug-Resistant Organism Infection in Nursing Homes

OBJECTIVES

To examine factors associated with isolation precaution use in nursing home (NH) residents with multidrug-resistant organism (MDRO) infection.

DESIGN

Retrospective, cross-sectional analysis.

SETTING

Nursing homes with Centers for Medicare and Medicaid Services' certification from October 2010 to December 2013.

PARTICIPANTS

Elderly, long-stay NH residents with positive MDRO infection assessments.

MEASUREMENTS

Data were obtained from the Minimum Data Set (MDS) 3.0, Certification and Survey Provider Enhanced Reporting, and Area Health Resource File. Multivariable regression with facility fixed effects was conducted.

RESULTS

The sample included 191,816 assessments of residents with MDRO infection, of which isolation use was recorded in 12.8%. Of the NHs reporting MDRO infection in the past year, 31% used isolation at least once among residents with MDRO infection. Resident characteristics positively associated with isolation use included locomotion (23.6%, P < .001) and eating (17.9%, P < .001) support. Isolation use was 14.3% lower in those with MDRO history (P < .001). Residents in NHs that had received an infection control-related citation in the past year had a greater probability of isolation use (3.4%, P = .02); those in NHs that had received a quality-of-care citation had lower probability of isolation use (-3.3%, P = .03).

CONCLUSION

This is the first study to examine the new MDS 3.0 isolation and MDRO items. Isolation was infrequently used, and the proportion of isolated MDRO infections varied between facilities. Inspection citations were related to isolation use in the following year. Further research is needed to determine whether and when isolation should be used to best decrease risk of MDRO transmission and improve quality of care.

Assessing patient and caregiver understanding of and satisfaction with the use of contact isolation

BACKGROUND

Contact isolation is a method used for limiting the spread of antimicrobial-resistant organisms when caring for patients. This policy has been linked to several adverse outcomes and less patient satisfaction. We assessed patient and caregiver understanding and satisfaction with the use of contact isolation.

METHODS

A prospective survey of >500 patients in contact isolation at our institution was performed during 2014. Participants responded to a series of statements relating to contact isolation, using a 5-point Likert scale. Responses were assessed for overall positivity or negativity and further compared according to floor type or designation.

RESULTS

Of the patients, 48.7% responded to the survey; 70 caregivers also responded. Patient and caregiver responses were similar and were positive overall. Most respondents felt safer because of the use of contact isolation and because it prevented infections. A smaller majority of respondents also thought the policy was adequately explained to them and adhered to by staff.

CONCLUSIONS

In the largest collection of respondents surveyed to date about contact isolation and its impact on them, the policy was viewed positively, both by patients and caregivers. There is still room for improvement in the area of patient education regarding the use of contact isolation.

Strategies to Prevent Methicillin-ResistantStaphylococcus aureusTransmission and Infection in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their methicillin-resistantStaphylococcus aureus(MRSA) prevention efforts. This document updates “Strategies to Prevent Transmission of Methicillin-ResistantStaphylococcus aureusin Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Patient Isolation Precautions: Are They Worth It?

Isolation precautions are intended to minimize pathogen transmission and reduce hospital-acquired infections. More recently, the effectiveness of isolation precautions has been questioned because of increasing evidence of risks. These putative downsides are divided into a quantifiable monetary cost (i.e., a literal cost to the system) and clinically important but less easily quantifiable costs (i.e., "costs" to the patient). The authors also briefly review deisolation and alternatives to isolation. The present review is not arguing against appropriate isolation or precautions, simply that the authors consider both risks and benefits and disseminate up-to-date information. Their patient-focused goal is to mitigate risks for those who truly need isolating and to end isolation as soon as it is safe and appropriate to do so.

Impact of rapid screening for discontinuation of methicillin-resistant Staphylococcus aureus contact precautions

BACKGROUND

A history of methicillin-resistant Staphylococcus aureus (MRSA) is a determinant of inpatient bed assignment.

METHODS

We assessed outcomes associated with rapid testing and discontinuation of MRSA contact precautions (CP) in a prospective cohort study of polymerase chain reaction (PCR)-based screening in the Emergency Department (ED) of Massachusetts General Hospital. Eligible patients had a history of MRSA and were assessed and enrolled if documented off antibiotics with activity against MRSA and screened for nasal colonization (subject visit). PCR-negative subjects had CP discontinued; the primary outcome was CP discontinuation. We identified semiprivate rooms in which a bed was vacant owing to the CP status of the study subject, calculated the hours of vacancy, and compared idle bed-hours by PCR results. Program costs were compared with predicted revenue.

RESULTS

There were 2864 eligible patients, and 648 (22.6%) subject visits were enrolled. Of these, 65.1% (422/648) were PCR-negative and had CP discontinued. PCR-negative subjects had fewer idle bed-hours compared with PCR-positive subjects (28.6 ± 25.2 vs 75.3 ± 70.5; P < .001). The expected revenues from occupied idle beds and averted CP costs ranged from $214,160 to $268,340, and exceeded the program costs.

CONCLUSION

A program of targeted PCR-based screening for clearance of MRSA colonization resulted in expected revenues and decreased CP costs that outweighed programmatic costs.

Degowning the controversies of contact precautions for methicillin-resistant Staphylococcus aureus: A review

BACKGROUND

Contact precautions (CPs) are recommended to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission in institutions. Rising doubts about CP effectiveness and recognition of unintended consequences for patients have raised questions about the benefit. The objective of this study was to evaluate the effectiveness and adverse outcomes associated with CPs for prevention of MRSA transmission.

METHODS

We searched PubMed, Embase, and the Cochrane Library for articles related to effectiveness and adverse outcomes of CPs in patients with MRSA. Criteria for inclusion included the following: articles conducted in the United States, articles performed in an acute care setting, articles that were not a case series or review, and those with standardized collection of data or inclusion of case and control groups. Results were summarized and examined for potential limitations. Recommendations were based on our findings.

RESULTS

CPs reduced MRSA transmission in epidemic settings and in instances with high compliance, but a decrease in infection rates was not shown. Unintended consequences of CPs include decreased health care provider (HCP) time spent with patients, low HCP compliance, decreased perceptions of comfort from patients, and greater likelihood of patient complaints and negative psychologic implications.

CONCLUSION

In endemic settings, there are few data to support routine use of CPs to control the spread of MRSA. Education should be performed in hospitals to improve patients' perception of care and understanding of CPs when implemented and HCPs' adherence to good hand hygiene and standard precautions practices.

Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus

BACKGROUND

Whether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing.

OBJECTIVE

To provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals.

DESIGN

A literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE.

PARTICIPANTS

Hospital epidemiologists and infection prevention experts.

RESULTS

No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.

CONCLUSIONS

Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.

Infect Control Hosp Epidemiol 2015;36(10):1163–1172

Effects of contact precautions on patient perception of care and satisfaction: a prospective cohort study

OBJECTIVE

Contact precautions decrease healthcare worker-patient contact and may impact patient satisfaction. To determine the association between contact precautions and patient satisfaction, we used a standardized interview for perceived issues with care.

DESIGN

Prospective cohort study of inpatients, evaluated at admission and on hospital days 3, 7, and 14 (until discharged). At each point, patients underwent a standardized interview to identify perceived problems with care. After discharge, the standardized interview and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey were administered by telephone. Responses were recorded, transcribed, and coded by 2 physician reviewers.

PARTICIPANTS

A total of 528 medical or surgical patients not admitted to the intensive care unit.

RESULTS

A total of 528 patients were included in the primary analysis, of whom 104 (20%) perceived some issue with their care. On multivariable logistic regression, contact precautions were independently associated with a greater number of perceived concerns with care (odds ratio, 2.05 [95% confidence interval, 1.31-3.21]; P < .01), including poor coordination of care (P = .02) and a lack of respect for patient needs and preferences (P = .001). Eighty-eight patients were included in the secondary analysis of HCAHPS. Patients under contact precautions did not have different HCAHPS scores than those not under contact precautions (odds ratio, 1.79 [95% confidence interval, 0.64-5.00]; P = .27).

CONCLUSIONS

Patients under contact precautions were more likely to perceive problems with their care, especially poor coordination of care and a lack of respect for patient preferences.

Targeting MRSA: is it the right infection prevention goal?

Focus on universal infection prevention strategies, instead of targeted approaches, to reduce MRSA and other healthcare-associated infections.

Depression, anxiety, and moods of hospitalized patients under contact precautions

OBJECTIVE

To determine the association between contact precautions and depression or anxiety as well as feelings of anger, sadness, worry, happiness, or confusion.

DESIGN

Prospective frequency-matched cohort study.

SETTING

The University of Maryland Medical Center, a 662-bed tertiary care hospital in Baltimore, Maryland.

PARTICIPANTS

A total of 1,876 medical and surgical patients over the age of 18 years were approached; 528 patients were enrolled from January through November 2010, and 296 patients, frequency matched by hospital unit, completed follow-up on hospital day 3.

RESULTS

The primary outcome was Hospital Anxiety and Depression Scale (HADS) scores on hospital day 3, controlling for baseline HADS scores. Secondary moods were measured with visual analog mood scale diaries. Patients under contact precautions had baseline symptoms of depression 1.3 points higher (P<.01) and anxiety 0.8 points higher (P=.08) at hospital admission using HADS. Exposure to contact precautions was not associated with increased depression (P=.42) or anxiety (P=.25) on hospital day 3. On hospital day 3, patients under contact precautions were no more likely than unexposed patients to be angry (20% vs 20%; P=.99), sad (33% vs 38%; P=.45), worried (51% vs 46%; P=.41), happy (58% vs 67%; P=.14), or confused (23% vs 24%; P=.95).

CONCLUSIONS

Patients under contact precautions have more symptoms of depression and anxiety at hospital admission but do not appear to be more likely to develop depression, anxiety, or negative moods while under contact precautions. The use of contact precautions should not be restricted by the belief that contact precautions will produce more depression or anxiety.

The potential regional impact of contact precaution use in nursing homes to control methicillin-resistant Staphylococcus aureus

OBJECTIVE

Implementation of contact precautions in nursing homes to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission could cost time and effort and may have wide-ranging effects throughout multiple health facilities. Computational modeling could forecast the potential effects and guide policy making.

DESIGN

Our multihospital computational agent-based model, Regional Healthcare Ecosystem Analyst (RHEA).

SETTING

All hospitals and nursing homes in Orange County, California.

METHODS

Our simulation model compared the following 3 contact precaution strategies: (1) no contact precautions applied to any nursing home residents, (2) contact precautions applied to those with clinically apparent MRSA infections, and (3) contact precautions applied to all known MRSA carriers as determined by MRSA screening performed by hospitals.

RESULTS

Our model demonstrated that contact precautions for patients with clinically apparent MRSA infections in nursing homes resulted in a median 0.4% (range, 0%-1.6%) relative decrease in MRSA prevalence in nursing homes (with 50% adherence) but had no effect on hospital MRSA prevalence, even 5 years after initiation. Implementation of contact precautions (with 50% adherence) in nursing homes for all known MRSA carriers was associated with a median 14.2% (range, 2.1%-21.8%) relative decrease in MRSA prevalence in nursing homes and a 2.3% decrease (range, 0%-7.1%) in hospitals 1 year after implementation. Benefits accrued over time and increased with increasing compliance.

CONCLUSIONS

Our modeling study demonstrated the substantial benefits of extending contact precautions in nursing homes from just those residents with clinically apparent infection to all MRSA carriers, which suggests the benefits of hospitals and nursing homes sharing and coordinating information on MRSA surveillance and carriage status.

Association between contact precautions and delirium at a tertiary care center

OBJECTIVE

To investigate the relationship between contact precautions and delirium among inpatients, adjusting for other factors.

DESIGN

Retrospective cohort study.

SETTING

A 662-bed tertiary care center.

PATIENTS

All nonpyschiatric adult patients admitted to a tertiary care center from 2007 through 2009.

METHODS

Generalized estimating equations were used to estimate the association between contact precautions and delirium in a retrospective cohort of 2 years of admissions to a tertiary care center.

RESULTS

During the 2-year period, 60,151 admissions occurred in 45,266 unique nonpsychiatric patients. After adjusting for comorbid conditions, age, sex, intensive care unit status, and length of hospitalization, contact precautions were significantly associated with delirium (as defined by International Classification of Diseases, Ninth Revision), medication, or restraint exposure (adjusted odds ratio [OR], 1.40 [95% confidence interval {CI}, 1.24-1.51]). The association between contact precautions and delirium was seen only in patients who were newly placed under contact precautions during the course of their stay (adjusted OR, 1.75 [95% CI, 1.60-1.92]; P < .01) and was not seen in patients who were already under contact precautions at admission (adjusted OR, 0.97 [95% CI, 0.86-1.09]; P = .06).

CONCLUSIONS

Although delirium was more common in patients who were newly placed under contact precautions during the course of their hospital admission, delirium was not associated with contact precautions started at hospital admission. Patients newly placed under contact precautions after admission but during hospitalization appear to be at a higher risk and may benefit from proven delirium-prevention strategies.