Do physicians examine patients in contact isolation less frequently? A brief report

doi:10.1016/S0196-6553(02)48250-8

American Journal of Infection Control

Volume 31, Issue 6, October 2003, Pages 354-356

https://doi.org/10.1016/S0196-6553(02)48250-8 Get rights and content

Abstract

Background

Patients who are hospitalized and infected with multidrug-resistant bacteria are usually placed in contact isolation, which requires hospital personnel to gown and glove before patient examination. Contact isolation with active culture surveillance appears beneficial in preventing the spread of drug-resistant infections; however, contact isolation may impede the ability to examine patients as a result of the additional effort required to gown and glove. We assessed whether patients who are hospitalized and placed under contact precautions are examined less often by second- and third-year medical residents (ie, senior medical residents), and attending physicians during morning rounds.

Method

We conducted a prospective cohort study on the inpatient medical services at 2 university-affiliated medical centers. We directly observed senior medical residents and attending physicians during morning rounds, and recorded the contact precaution status of the patient and whether they were examined by either physician.

Results

Of a total of 139 patients, 31 (22%) were in contact isolation. Senior medical residents examined 26 of 31 patients (84%) in contact isolation versus 94 of 108 patients (87%) not in contact isolation (relative risk, 0.96; 95% confidence interval, 0.81–1.14; P = .58). In comparison, attending physicians examined 11 of 31 patients (35%) in contact isolation versus 79 of 108 patients (73%) not in contact isolation (relative risk, 0.49; 95% confidence interval, 0.30–0.79; P < .001).

Discussion

Attending physicians are about half as likely to examine patients in contact isolation compared with patients not in contact isolation.

Section snippets

Methods

A prospective cohort study was conducted at 2university-affiliated medical centers from October 1999 to March 2000. The study participants were senior medical residents (ie, second- and third-year residents in internal medicine), and attending physicians who were rotating on the general medicine and subspecialty services at the 2 medical centers. On several days per month during the study period (depending on the availability of the investigator), one of the study investigators (L.A.H.)

Results

total of 139 patients were evaluated, 31 (22%) of whom were in contact isolation. The percentage of patients examined differed by physician training level (Fig 1). Senior medical residents examined 26 of 31 patients (84%) under contact precautions versus 94 of 108 patients (87%) not under contact precautions (relative risk of being examined = 0.96; 95% confidence interval = 0.81–1.14; P = .58). Attending physicians, in contrast, examined 11 of 31 patients (35%) under contact precautions versus

Discussion

Our study has 2 important findings. First, attending physicians were about half as likely to examine patients under contact precautions compared with patients not under contact precautions. Almost two-thirds of patients in contact isolation were not examined during morning rounds by the attending physician. Second, resident physicians did not alter their examination behavior on the basis of contact precaution status of the patient.

The use of contact precautions in epidemic or outbreak

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A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit
Infect Control Hosp Epidemiol
(2002)

There are more references available in the full text version of this article.

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Recent studies disputed the effectiveness of efforts to comply with contact precautions and isolation (CPI) considering relatively low intra-hospital transmission rate of healthcare facility-associated Clostridioides difficile infection (HCFA-CDI). We evaluated the potential causal effect of CPI on HCFA-CDI occurrence by comparing the incidence rate (IR) for different time periods with and without CPI implementation.
Long-term observational time-series data were separated into three periods (pre-CPI: January 2012–March 2016, CPI: April 2016–April 2021, post-CPI: May 2021–December 2022). CPI was suspended owing to the restriction of isolation rooms during the COVID-19 pandemic. We inferred potential causal outcomes by comparing predicted and observed IRs of HCFA-CDI using interrupted time-series analyses, including the Bayesian structural time-series or autoregressive integrated moving average (ARIMA) model in the R-language or SAS software.
The monthly observed IR (44.9/100,000 inpatient-days) during the CPI period was significantly lower than the predicted IR (90.8) (−50.6% relative effect, P = 0.001). However, the observed IR (52.3) during the post-CPI period was significantly higher than the predicted IR (39.1) (33.6%, P = 0.001). The HCFA-CDI IR decreased during CPI (−14.3, P < 0.001) and increased post-CPI (5.4, P < 0.001) in the multivariable ARIMA model, which controlled for antibiotic usage, handwashing with soap and water, and number of toxin tests.
Various time-series models revealed that CPI implementation had a potential causal effect on the reduction of HCFA-CDI incidence.
Increased evidence for no benefit of contact precautions in preventing extended-spectrum <inf>β</inf>-lactamases-producing Enterobacteriaceae: Systematic scoping review
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Extended-spectrum β-lactamases-producing Enterobacteriaceae (ESBL-E) is a critical antimicrobial resistance pathogen, to which we need to pay the greatest attention. This study was aimed at uncovering the present evidence for the preventive effectiveness of contact precautions for patients colonized or infected with ESBL-E.
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Of the 355 articles found, 9, including 8 observational studies and 1 randomized controlled trial, were selected. Safety of discontinuing contact precautions was evaluated mainly in acute-care and long-term care hospitals. Consistently, all authors concluded that contact precautions can be safely discontinued in patients colonized or infected with ESBL-E.
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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.
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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.
Discontinuing CP did not negatively impact endemic MRSA HAI rates between pre-postdiscontinuation periods and saved costs for isolation materials.
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Citation Excerpt :
Overuse of CPs has the potential to cause harm. Prior studies have found that isolated patients receive less frequent personal contact from health care workers because of the additional effort required in adhering with CPs.79,80 CPs may be stressful for patients and their families, and isolated patients are prone to higher rates of anxiety, depression, adverse events, and medical errors.81

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Supported by a career development award from the Health Services Research and Development Program of the Department of Veterans Affairs and a Patient Safety Developmental Center Grant from the Agency for Healthcare Research and Quality (P20-HS11540) (Dr Saint).

Presented, in part, at the National Association of Inpatient Physicians 4th Annual National Meeting, Atlanta, GA, March 2001.

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Major ArticlesDo physicians examine patients in contact isolation less frequently? A brief report☆

Abstract

Background

Method

Results

Discussion

Section snippets

Methods

Results

Discussion

Lancet

Int J Infect Dis

Recommendations for preventing the spread of vancomycin resistance

Am J Infect Control

Guideline for isolation precautions in hospitals: the hospital infection control practices advisory committee [published erratum, Infect Control Hosp Epidemiol 1996;17:214]

Infect Control Hosp Epidemiol

Control of vancomycin-resistant enterococci: it is important, it is possible, and it is cost-effective

Infect Control Hosp Epidemiol

A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit

Infect Control Hosp Epidemiol

Major Articles
Do physicians examine patients in contact isolation less frequently? A brief report☆