The Effect of Contact Precautions on Healthcare Worker Activity in Acute Care Hospitals

University of Maryland School of Medicine, Baltimore, Maryland.
Infection Control and Hospital Epidemiology (Impact Factor: 3.94). 01/2013; 34(1):69-73. DOI: 10.1086/668775
Source: PubMed

ABSTRACT Background and Objective. Contact precautions are a cornerstone of infection prevention but have also been associated with less healthcare worker (HCW) contact and adverse events. We studied how contact precautions modified HCW behavior in 4 acute care facilities. Design. Prospective cohort study. Participants and Setting. Four acute care facilities in the United States performing active surveillance for methicillin-resistant Staphylococcus aureus. Methods. Trained observers performed "secret shopper" monitoring of HCW activities during routine care, using a standardized collection tool and fixed 1-hour observation periods. Results. A total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions (2.78 vs 4.37 visits per hour; [Formula: see text]) as well as 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour; [Formula: see text]). Patients on contact precautions tended to have fewer visitors (23.6% fewer; [Formula: see text]). HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions; [Formula: see text]). Conclusion. Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective. Hand hygiene and environmental cleaning are essential infection prevention strategies, but the relative impact of each is unknown. This information is important in assessing resource allocation. Methods. We developed an agent-based model of patient-to-patient transmission-via the hands of transiently colonized healthcare workers and incompletely terminally cleaned rooms-in a 20-patient intensive care unit. Nurses and physicians were modeled and had distinct hand hygiene compliance levels on entry and exit to patient rooms. We simulated the transmission of Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci for 1 year using data from the literature and observed data to inform model input parameters. Results. We simulated 175 parameter-based scenarios and compared the effects of hand hygiene and environmental cleaning on rates of multidrug-resistant organism acquisition. For all organisms, increases in hand hygiene compliance outperformed equal increases in thoroughness of terminal cleaning. From baseline, a 2∶1 improvement in terminal cleaning compared with hand hygiene was required to match an equal reduction in acquisition rates (eg, a 20% improvement in terminal cleaning was required to match the reduction in acquisition due to a 10% improvement in hand hygiene compliance). Conclusions. Hand hygiene should remain a priority for infection control programs, but environmental cleaning can have significant benefit for hospitals or individual hospital units that have either high hand hygiene compliance levels or low terminal cleaning thoroughness.
    Infection Control and Hospital Epidemiology 09/2014; 35(9):1156-1162. DOI:10.1086/677632 · 3.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective. Hand hygiene surveillance programs that rely on direct observations of healthcare worker activity may be limited by the Hawthorne effect. In addition, comparing compliance rates from period to period requires adequately sized samples of observations. We aimed to statistically determine whether the Hawthorne effect is stable over an observation period and statistically derive sample sizes of observations necessary to compare compliance rates. Design. Prospective multicenter cohort study. Setting. Five intensive care units and 6 medical/surgical wards in 3 geographically distinct acute care hospitals. Methods. Trained observers monitored hand hygiene compliance during routine care in fixed 1-hour periods, using a standardized collection tool. We estimated the impact of the Hawthorne effect using empirical fluctuation processes and F tests for structural change. Standard sample-size calculation methods were used to estimate how many hand hygiene opportunities are required to accurately measure hand hygiene across various levels of baseline and target compliance. Results. Exit hand hygiene compliance increased after 14 minutes of observation (from 56.2% to 60.5%; P < .001) and increased further after 50 minutes (from 60.5% to 66.0%; P < .001). Entry compliance increased after 38 minutes (from 40.4% to 43.4%; P = .005). Between 79 and 723 opportunities are required during each period, depending on baseline compliance rates (range, 35%-90%) and targeted improvement (5% or 10%). Conclusions. Limiting direct observation periods to approximately 15 minutes to minimize the Hawthorne effect and determining required number of hand hygiene opportunities observed per period on the basis of statistical power calculations would be expected to improve the validity of hand hygiene surveillance programs.
    Infection Control and Hospital Epidemiology 09/2014; 35(9):1163-1168. DOI:10.1086/677629 · 3.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective. To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients). Design. Cost analysis using decision modeling. Methods. We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature. Results. In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions. Conclusions. A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.
    Infection Control and Hospital Epidemiology 10/2014; 35(S3):S23-S31. DOI:10.1086/677819 · 3.94 Impact Factor