Blog | Tuesday, December 17, 2013

Let me hate on contact precautions some more


The very first post on the blog Controversies in Hospital Infection Prevention was written by Dan Diekema, MD, FACP, in March 2009. It was entitled, Why I Hate Contact Precautions, vol. 1. I remain a hater.

Results from three new studies add fuel to my fire:
(1) In one hospital, patients in contact precautions were found to wait approximately 10 hours longer for CT scans than those who were not in contact precautions. This is a reminder that there are downstream adverse effects of contact precautions that impact quality of care that perhaps we haven’t even thought about.
(2) Another paper (different journal, same authors as the first paper) was a retrospective cohort study of patient safety incidents before and after patients were placed in contact precautions. Medication errors were 1.5-fold higher under contact precautions, and patient injuries were over 3-fold higher.
(3) Dan Morgan and his colleagues at University of Maryland found that patients cared for under contact precautions were twice as likely to perceive that their care was poor. Specifically, they reported poor care coordination and lack of respect for their needs and preferences.

Here’s another paper on adverse events associated with contact precautions. In this study from two French ICUs, 1,150 patients were followed for adverse events. Outcomes for patients in contact precautions for multi-drug resistant organisms (MDRO) were compared to those who were not in contact precautions. Patients in contact precautions were 1.5-fold more likely to have hypoglycemia and hyperglycemia, 1.9-fold more likely to have anticoagulant prescribing errors, and 2.1-fold more likely to develop ventilator-associated pneumonia (VAP) due to an MDRO.

When I read the study results I couldn’t understand why there could be a causal relationship between contact precautions and anticoagulant prescribing errors. However, the authors later tell us that in these ICUs the patient charts (which are not electronic) are kept in the patient rooms.

I don’t think we can blame contact precautions on the higher risk of VAP due to an MDRO. There was no higher risk of VAP due to all pathogens in the contact precautions group. Since patients found to have MDROs would be transferred to contact precautions, it only makes sense that VAP due to MDRO would be more common in patients in contact precautions

There’s an old belief shared by bartenders that nothing good happens after 2 a.m. In my line of work, nothing good happens after contact precautions.Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.