Memo Should Hospital Continue Contact Precautions for Patients With Mrsa
Nurse Cynthia Drew puts on an isolation gown before entering a room to see a patient in the ICU. Photo by Chris Joseph Taylor / MCT / Newscom.
Infections resulting from methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) have focused our attention on infection-control practices. In 2007, the Centers for Disease Control and Prevention (CDC) revised its guidelines on transmission-based (isolation) precautions. One major change was the recommendation that gowns and gloves be donned upon entry to the room of any patient on contact precautions. But while rates of MRSA and VRE have indeed dropped, critics of the 2007 regulations say that contact precautions aren't the only reason for the decline and that they keep clinicians away from a patient's bedside, diminishing the quality of care and increasing depression and feelings of isolation in patients.
Even before the newer recommendations were made, studies showed that contact precautions resulted in 25% to 50% fewer patient–clinician interactions and were associated with less patient satisfaction and other adverse outcomes. Recent evidence also suggests that other strategies, such as aggressive hand hygiene and chlorhexidine bathing, may be more important in reducing transmission. And although contact precautions against both organisms are recommended by the CDC, the 2007 guidelines do give hospitals the option of investigating alternative approaches.
"This is not a one-size-fits-all approach," Alexander J. Kallen, a medical epidemiologist and outbreak response coordinator at the CDC, told AJN. "People will decide what's best for their facilities."
A growing number of U.S. hospitals are reexamining the practice of assigning contact precautions to patients with MRSA or VRE. By emphasizing alternative approaches to containing multidrug-resistant organisms, these hospitals hope to keep infection rates down while putting away the unpopular gloves and gowns.
Last year Virginia Commonwealth University Medical Center (VCUMC) in Richmond did just that. After a yearlong trial in which most patients with VRE and MRSA were maintained under standard precautions only, there was no increase in MRSA infection rates. Administrators at the 865-bed teaching hospital decided to keep the new policy in place.
The issue is clearly getting more consideration as journals across health care disciplines devote attention to it. In the fall of 2014, JAMA published an opinion piece by Daniel J. Morgan and colleagues calling for reconsideration of the use of contact precautions to prevent VRE and MRSA infections. And a survey of physician members of the Emerging Infections Network showed that 18% of respondents were considering stopping or altering the practice. "I hope we become less dogmatic about what needs to be done," said Morgan, an associate professor at the University of Maryland School of Medicine in Baltimore, in an interview with AJN. He considers the CDC guidelines outdated, given improvements hospitals have made in infection control.
Many of the trends that have allowed hospitals to consider relaxing contact precautions come from good practices at the patient level, such as improved hand hygiene, bathing patients with chlorhexidine, and care bundles that reduce infections in patients with central lines or on ventilation.
Before VCUMC decided to reduce its use of contact precautions, many of those practices were in place, including a hand hygiene–compliance rate that had exceeded 85% for four straight years. During the year VCUMC tested its hypothesis, contact precautions were used only with patients infected or colonized with MRSA or VRE who had wound drainage not contained within a dressing or uncontained respiratory secretions. Keeping the gowns and gloves off proved popular with staff and patients, too, and resulted in a savings of $700,000 in materials, hospital officials said.
"More and more people are interested in looking at this. Everyone feels the same way: contact precautions are a barrier to good care," said Michael B. Edmond, a former administrator at VCUMC who is now chief quality officer at the University of Iowa Hospitals and Clinics in Iowa City.—John Welsh, RN
REFERENCE
Morgan DJ, et al. JAMA 2014;312(14):1395-6; Bearman G, Stevens MP. Curr Infect Dis Rep 2012;14(6):620-6; Morgan DJ, et al Am J Infect Control. 2009;37(2):85–93
Source: https://journals.lww.com/ajnonline/Fulltext/2015/03000/Reconsidering_Contact_Precautions_for_MRSA_and_VRE.8.aspx
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