Emerging infections: the contact precautions controversy

Patient care experience with utilization of isolation precautions: systematic literature review and meta-analysis

BACKGROUND

Use of isolation precautions (IP) may represent a trade-off between reduced transmission of infectious pathogens and reduced patient satisfaction with their care.

OBJECTIVE

To perform a systematic literature review and meta-analysis to identify if and how IPs impact patients' care experiences.

DATA SOURCES

Medline, ClinicalTrials.gov, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsychInfo, HSRProj and Cochrane Library databases.

STUDY ELIGIBILITY CRITERIA

Interventional and observational studies published January 1990 to May 2019 were eligible for inclusion.

PARTICIPANTS

Patients admitted to an acute-care facility.

INTERVENTIONS

IPs versus no IPs.

METHODS

Six reviewers screened titles, abstracts and full text. Experience of care reported by patients using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was assessed as the outcome for the meta-analysis. Pooled odds ratios were calculated using the random-effects model. Heterogeneity was assessed using the I² value.

RESULTS

After screening 7073 titles and abstracts, 15 independent studies were included in the review. Pooling of unadjusted estimates from the HCAHPS survey demonstrated that IP patients were less likely to give top scores on questions pertaining to respect, communication, receiving assistance and cleanliness compared to the no-IP patients. Patients under IP with longer length of stay appeared to have more negative experiences with the care received during their stay compared to no IP.

CONCLUSIONS

Patients under IP were more likely to be dissatisfied with several aspects of patient care compared to patients not under IP. It is crucial to educate patients and healthcare workers in order to balance successful implementation of IP and patient care experiences, particularly in healthcare settings where it may be beneficial.

Contact Precautions More Is Not Necessarily Better

Objective.

To determine whether increases in contact isolation precautions are associated with decreased adherence to isolation practices among healthcare workers (HCWs).

Design.

Prospective cohort study from February 2009 to October 2009.

Setting.

Eleven teaching hospitals.

Participants.

HCWs.

Methods.

One thousand thirteen observations conducted on HCWs. Additional data included the number of persons in isolation, types of HCWs, and hospital-specific contact precaution practices. Main outcome measures included compliance with individual components of contact isolation precautions (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting) and overall compliance (all 5 measures together) during varying burdens of isolation.

Results.

Compliance with hand hygiene was as follows: prior to donning gowns/gloves, 37.2%; gowning, 74.3%; gloving, 80.1%; doffing of gowns/gloves, 80.1%; after gown/glove removal, 61%. Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%—4.9%) and with all 5 components (31.5%—6.5%) was observed. In multivariable analysis, there was an increase in noncompliance with all 5 components of the contact isolation precautions bundle (odds ratio [OR], 6.6 [95% confidence interval (CI), 1.15-37.44];P= .03) and in noncompliance with hand hygiene prior to donning gowns and gloves (OR, 10.1 [95% CI, 1.84—55.54];P= .008) associated with increasing burden of isolation.

Conclusions.

As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

Evaluation of conceptual frameworks applicable to the study of isolation precautions effectiveness

AIMS

A discussion of conceptual frameworks applicable to the study of isolation precautions effectiveness according to Fawcett and DeSanto-Madeya's (2013) evaluation technique and their relative merits and drawbacks for this purpose.

BACKGROUND

Isolation precautions are recommended to control infectious diseases with high morbidity and mortality, but effectiveness is not established due to numerous methodological challenges. These challenges, such as identifying empirical indicators and refining operational definitions, could be alleviated though use of an appropriate conceptual framework.

DESIGN

Discussion paper.

DATA SOURCES

In mid-April 2014, the primary author searched five electronic, scientific literature databases for conceptual frameworks applicable to study isolation precautions, without limiting searches by publication date.

IMPLICATIONS FOR NURSING

By reviewing promising conceptual frameworks to support isolation precautions effectiveness research, this article exemplifies the process to choose an appropriate conceptual framework for empirical research. Hence, researchers may build on these analyses to improve study design of empirical research in multiple disciplines, which may lead to improved research and practice.

CONCLUSION

Three frameworks were reviewed: the epidemiologic triad of disease, Donabedian's healthcare quality framework and the Quality Health Outcomes model. Each has been used in nursing research to evaluate health outcomes and contains concepts relevant to nursing domains. Which framework can be most useful probably depends on whether the study question necessitates testing multiple interventions, concerns pathogen-specific characteristics and yields cross-sectional or longitudinal data. The Quality Health Outcomes model may be slightly preferred as it assumes reciprocal relationships, multi-level analysis and is sensitive to cultural inputs.

Gloves, gowns and masks for reducing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in the hospital setting

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA; also known as methicillin-resistant S aureus) is a common hospital-acquired pathogen that increases morbidity, mortality, and healthcare costs. Its control continues to be an unresolved issue in many hospitals worldwide. The evidence base for the effects of the use of gloves, gowns or masks as control measures for MRSA is unclear.

OBJECTIVES

To assess the effectiveness of wearing gloves, a gown or a mask when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment.

SEARCH METHODS

We searched the Specialised Registers of three Cochrane Groups (Wounds Group on 5 June 2015; Effective Practice and Organisation of Care (EPOC) Group on 9 July 2013; and Infectious Diseases Group on 5 January 2009); CENTRAL (The Cochrane Library 2015, Issue 6); DARE, HTA, NHS EED, and the Methodology Register (The Cochrane Library 2015, Issue 6); MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to June week 1 2015); EMBASE (1974 to 4 June 2015); Web of Science (WOS) Core Collection (from inception to 7 June 2015); CINAHL (1982 to 5 June 2015); British Nursing Index (1985 to 6 July 2010); and ProQuest Dissertations & Theses Database (1639 to 11 June 2015). We also searched three trials registers (on 6 June 2015), references list of articles, and conference proceedings. We finally contacted relevant individuals for additional studies.

SELECTION CRITERIA

Studies assessing the effects on MRSA transmission of the use of gloves, gowns or masks by any person in the hospital setting when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment. We did not assess adverse effects or economic issues associated with these interventions.We considered any comparator to be eligible. With regard to study design, only randomised controlled trials (clustered or not) and the following non-randomised experimental studies were eligible: quasi-randomised controlled trials (clustered or not), non-randomised controlled trials (clustered or not), controlled before-and-after studies, controlled cohort before-after studies, interrupted time series studies (controlled or not), and repeated measures studies. We did not exclude any study on the basis of language or date of publication.

DATA COLLECTION AND ANALYSIS

Two review authors independently decided on eligibility of the studies. Had any study having been included, two review authors would have extracted data (at least for outcome data) and assessed the risk of bias independently. We would have followed the standard methodological procedures suggested by Cochrane and the Cochrane EPOC Group for assessing risk of bias and analysing the data.

MAIN RESULTS

We identified no eligible studies for this review, either completed or ongoing.

AUTHORS' CONCLUSIONS

We found no studies assessing the effects of wearing gloves, gowns or masks for contact with MRSA hospitalised patients, or with their immediate environment, on the transmission of MRSA to patients, hospital staff, patients' caregivers or visitors. This absence of evidence should not be interpreted as evidence of no effect for these interventions. The effects of gloves, gowns and masks in these circumstances have yet to be determined by rigorous experimental studies, such as cluster-randomised trials involving multiple wards or hospitals, or interrupted time series studies.

Clinical challenges in isolation care

OVERVIEW

In 2014, the authors published the results of a study investigating nurses' use of personal protective equipment (PPE) in the care of a live simulated patient requiring contact and airborne precautions. The 24 participants were video-recorded as they donned and doffed PPE. Variations in practices that had the potential to cause contamination were noted. In this article, the authors comment on those variations, analyzing each element of proper PPE protocols and examining why the behaviors are a safety concern for the nurse and a potential risk for disease transmission in the hospital or other clinical area. The authors note that making use of reflective practice for complicated care situations such as infection control may help nurses improve decision making in isolation care.

Effectiveness of contact precautions against multidrug-resistant organism transmission in acute care: a systematic review of the literature

Contact precautions are widely recommended to prevent multidrug-resistant organism (MDRO) transmission. However, conflicting data exist regarding their effectiveness. Prior systematic reviews examined contact precautions as part of a larger bundled approach, limiting ability to understand their effectiveness. The aim of this review was to characterize the effectiveness of contact precautions alone against transmission of any MDRO among adult acute care patients. Directed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, comprehensive searches of four electronic scientific literature databases were conducted for studies published in English from January 2004 to June 2014. Studies were included if interventional, original research, evaluating contact isolation precautions against MDRO transmission among inpatients. Searches returned 284 studies, six of which were included in the review. These studies measured four different MDROs with one study showing a reduction in transmission. Whereas studies were of high quality regarding outcome operationalization and statistical analyses, overall quality was moderate to low due to poor intervention description, population characterization and potential biases. Where compliance was measured (N = 4), it presented a threat to validity because it included select parts of the intervention, ranged from 21% to 87%, and was significantly different across study phases (N = 2). The poor quality of evidence on this topic continues to limit interpretation of these data. Hence, this conflicting body of literature does not constitute evidence for or against contact precautions. We recommend that researchers consider power calculation, compliance monitoring, non-equivalent concurrent controls when designing future studies on this topic.

Is patient isolation the single most important measure to prevent the spread of multidrug-resistant pathogens?

Isolation or cohorting of infected patients is an old concept. Its purpose is to prevent the transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and health care workers, who may subsequently transmit them to other patients or become infected or colonized themselves. Because the process of isolating patients is expensive, time-consuming, often uncomfortable for patients and may impede care, it should be implemented only when necessary. Conversely, failure to isolate a patient with multidrug-resistant microorganisms may lead to adverse outcomes, and may ultimately be expensive when one considers the direct costs of an outbreak investigation and the indirect costs of lost productivity. In this review, we argue that contact precautions are essential to control the spread of epidemic and endemic multidrug-resistant microorganisms, and discuss limitations of some available data.