Beyond the Room: Allowing Patients on Contact Precautions to Venture Outside

In a full conference session on March 30, 2017, at the Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, Thomas Sandora, MD, MPH, associate professor at Harvard University, and hospital epidemiologist and medical director of Infection Control at Boston Children’s Hospital, shared some tips with conference attendees on ways that they can manage movement outside of the room for certain patients who are on contact precautions in the hospital.

Dr. Sandora began his presentation by highlighting the current guidelines that are in place that recommend the limitation of movement outside of the room for patients who are on contact precautions, such as the Hospital Infection Control Practices Advisory Committee (HICPAC)’s Guideline for Isolation Precautions, which was issued back in 2007. Some of the guidelines that are in place, such as the Management of MDRO in Healthcare Settings (2006) and the Guidance for Control of CRE in Acute Care Facilities (2009), do not specifically address movement outside the room for patients on contact precautions. Despite this, Dr. Sandora suggests that there are several reasons why institutions may choose to go against the guideline recommendations to create a more family-centered care approach that would allow patients who are on contact precautions to venture outside of their rooms.

Dr. Sandora proceeded to share a study that showed the potential adverse outcomes for patients on contact precautions who are not allowed to venture outside of their room, a study that worked to “endorse” this rationale. The systematic review, published in 2009, looked at 15 studies, paying close attention to the adverse outcomes related to contact precautions. According to Dr. Sandora, nine out of the 15 studies had standardized data collection as well as a control group. The findings? “Contact precautions across this literature were associated with less contact between patients and healthcare workers, [as well as] delays in care, and more noninfectious adverse events. They were [also] associated with increased symptoms of depression and anxiety among [these] patients and decreased patient satisfaction with care,” Dr. Sandora reported.

Conversely, when it came to research regarding movement outside of the room, Dr. Sandora showed a startlingly blank, white slide. “This slide summarizes all of the well-designed, robust research studies that have studied how to optimize movement of patients outside the room when they’re on isolation precaution,” said Dr. Sandora. “There’s nothing. Literally. So, if anyone is interested in this topic, we could use some quality research about how to do this.”

Because of the lack of quality research, Dr. Sandora provided conference attendees with several helpful tips that he and his colleagues use at Boston Children’s Hospital, and encouraged attendees to use what might work for them in their own institution.

His first tip? “Consider [movement outside the room] only for patients who are contact precautions and not the patients on other types of isolation precautions, like airborne and droplet. You might consider limiting it only to patients who are colonized with organisms that you’re interested in having precautions [for] and not with patients who have active infections,” said Dr, Sandora. He shared that at Boston’s Children Hospital, they have a few organisms, such as “selective multidrug-resistant organisms” with “lower stakes,” like methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE), for which they’ll “create a way for patients to be outside of the room.”

“If you’re going to do this,” he suggested, “I would encourage you to develop a set of factors that you might consider in deciding for each individual patient concerning whether or not you’ll allow them to have some time outside of their room.” The factors to consider include: age of patient, continence, behavioral issues, and family willingness to follow instructions. He warned that at Boston’s Children Hospital, they typically do not allow children to be outside of the room if they have: active respiratory syncytial virus (RSV), viral gastroenteritis, or Clostridium difficile infections.

“The next tip I would give you is to create a plan of how that time outside of the room is going to happen. Think about the destinations to which you’ll allow the patient and family to go, the route to get there, and the timing of when those visits could happen, how long you’ll let them be outside the room, and whether or not you want staff to accompany them,” Dr. Sandora continued. He suggested to allow these patients to take advantage of outdoor locations, (for example: the Boston Children Hospital’s garden), or places that have less patients, which means less potential for contact with other patients who are not on precautions. For this reason, Dr. Sandora said that mindfulness of scheduling room exits at times when other patients will be less likely to be around is also a good strategy.

For patients and families who you feel may be less compliant with instructions, you may want to think about using staff members to accompany them during the time outside of the room. Staff may also arrange private playtime, which entails working “with your child life [specialists] to have them bring play materials inside the patient’s room, so that they can be sort of distracted and having fun in the room and not have that urge to exit,” Dr. Sandora said. He also suggested closing off the activity room for a period of time for private playtime under supervision and then thoroughly cleaning it before re-opening it to other patients.

“The next tip is to create an approach for discontinuing the precautions for certain organisms, so that you don’t have people on precautions forever and there is actually a path to eventually be getting off of precautions,” continued Dr. Sandora. With these preparations in place, families are provided with a certain hope that eventually their child will be off precautions and not trapped inside of a room indefinitely.

Dr. Sandora next recommended addressing expectations through family education materials. He explained, “I think it’s actually very helpful for [the family] if they understand the rules and there’s clear guidance about it.” By having the expectations in writing, it not only makes the expectations clearer for families, but also shows them that these expectations are a hospital policy and not just a rule specific to their family. “This is what we can expect for all patients who would be in the same situation,” added Dr. Sandora, “[And] so, [by] normalizing the expectation a little bit, I think that for us, has been very helpful.”

Dr. Sandora also advised conference attendees to flag charts so that contact precautions can apply across encounters. Documenting the rules for each patient case in the medical record is also something that Dr. Sandora finds particularly helpful. An example of such a note made in a medical record would “say things like if the patient has to be outside the room, she can do so for thirty minutes up to three times a day and can only be on the unit back hallway. She has to be accompanied by a staff member who’s observing contact precautions,” among other statements. Dr. Sandora stressed that by having this documented, it ensures that everyone is “playing by the same set of rules” and is on the same page. Infection preventionists can also use this as a reference if they cannot remember the specific rules for one patient case.

“The final tip I want to give you, is just to be as consistent as you can,” said Dr. Sandora. “It’s a little bit difficult because everything in life is case-by-case, but the more consistent you can be, the better this will come off.” It’s important to understand that everything should be done on a case-by-case basis, and so a “blanket application to every patient” will probably not work, but being consistent in the way to approach these strategies and handle family expectations is essential.

“I think individualized rules can be developed to help support family-centered care, while at the same time trying to minimize the risk of transmission of these organisms. I think it’s really important to try to maintain consistency of your core principles, whatever they are, even in the face of the necessary flexibility that you have to have in considering each individual case, and the most important thing is to try and communicate your expectations clearly to families and staff,” Dr. Sandora concluded.

DISCLOSURES: None

SOURCE: SHEA Spring 2017 Conference

PRESENTATION: Managing Movement Outside the Room for Patients in Isolation Precautions