Based on guidelines published by the Centers for Disease Control (CDC), health care organizations have adopted surveillance and contact precaution protocols for multi drug resistant organisms (MDRO), including methicillin-resistant Staphylococcus Aureus (MRSA)[i]. At Tulane Medical Center (TMC), patients are placed on contact precautions if they have an active MRSA infection or have been colonized with MRSA within the last twelve months. Despite the widespread use of these costly measures, their efficacy and value in infection control and patient care remain unclear.
The underlying literature that forms the basis for contact precautions in the CDC guidelines for MDROs was evaluated. We searched PubMed and Cochrane Library for articles investigating the cost of contact precautions, their efficacy in preventing hospital-acquired MDRO infections including MRSA, and their impact on patients, providers and hospital administrators. Additionally, the impact of contact precautions on the experiences of individual patients, residents and ancillary staff at TMC were distilled through individual interviews.
The literature cited in the CDC guidelines for contact precautions are studies based in epidemic settings, with strict surveillance, and intense decolonization measures. The protocols used in these studies are not routinely utilized in current practice settings[ii]. The direct cost of contact precautions has been demonstrated to be $35 more for non-ICU patients and $42 more for ICU patients as compared to patients not on contact precautions[iii]. A study by Martin et al found that there was an annual cost of $2.7million when accounting for gowns, gloves and nursing time[iv]. These patients also experience an extended length of stay (LOS) due to delays in diagnostic testing and transfers to post-acute care facilities[v] [vi]. Patient care also suffers; patients on contact precautions see their physicians less frequently and for less time[vii] [viii]. As a consequence, these patients are also more likely to feel a lack of respect, have concerns with their care and are more likely to report dissatisfaction when surveyed. Some studies even note increased depression, anger and anxiety for these patients[ix]. The Veterans Affairs (VA) MRSA study in 2011 demonstrated that contact precautions were only effective when included in a bundle with hand hygiene implementation[x] [xi]. Contact precautions in isolation can even be counterproductive to infection control; providers had lower rates of hand hygiene compliance with patients on contact precautions[xii]. In addition, contact precautions are associated with higher rates of certain medical errors and adverse events (table 1).
While there is equivocal evidence on the effectiveness of MRSA prevention and contact precautions, the proof of their negative impacts is robust. Influenced by CDC guidelines, hospital risk management and infection control departments have entrenched these policies into the inpatient setting. Given the rising costs of healthcare and the clear impacts to patient safety and wellbeing, the ubiquitous use of contact precautions should be reevaluated.