adverse events and contact precautions 789
also been associated with fewer healthcare provider visits, shorter healthcare provider contact time, and lack of appro- priate documentation.21,24–28 These patients can experience delays in admission from the emergency room, delays in dis- charge to skilled nursing facilities, and increased hospital length of stay.21,29–32 Patients under CP also exhibited increased anxiety, increased depression, and lower satisfaction compared to patients not in isolation.21,33,34 Although the patient harms data are concerning, newer studies have revealed conflicting results. Another 2 recent studies found no increase in adverse events in patients on CP; such results have fostered ongoing uncertainty about the impact of CP on hospital adverse events.35,36 The University of California–Los Angeles (UCLA) Health
eliminated routine CP for endemic MRSA and VRE in 2014. Researchers there published a quasi-experimental study eval- uating the impact of discontinuing CP for these organisms on healthcare-associated infections with MRSA and VRE.6 Ende- mic was defined as a nonoutbreak setting, with stable baseline rates of MRSA (0.43 laboratory-identified clinical cultures per 100 admissions) and VRE (0.62 clinical cultures per 100 admissions). The study showed no increase in MRSA or VRE laboratory-identified clinical cultures, colonization, or rates of drug resistance, as well as significant savings in healthcare worker time and $643,776 per year on materials. The purpose of the present study was to determine the
impact of discontinuing routine CP for endemic MRSA and VRE on infectious and noninfectious adverse events.
methods Hospital Setting
This study was conducted at the Ronald Reagan UCLA Med- ical Center (RRUCLA), a 540-bed, tertiary-care, academic hospital with 154 intensive care unit (ICU) beds, a large transplant population, and a level 1 trauma center. All rooms are single occupancy and have alcohol-based hand rubs and sinks for hand hygiene. Contact precaution (CP) rooms are additionally equipped with signage, isolation gowns, and gloves.
Study Design
We performed a retrospective, nonrandomized, observational, quasi-experimental study comparing infectious and non- infectious adverse events at RRUCLA. The preintervention period was from June 1, 2013, to May 31, 2014, and the postintervention period was from July 1, 2014, to June 30, 2015. Routine CP were discontinued on July 1, 2014 for endemic MRSA and VRE, including infection, colonization, and prior history of MRSA and/or VRE.6 Chlorhexidine glu- conate (CHG) bathing had been required in ICUs since 2012, except in the neonatal ICU. Daily 2% CHG bathing was expanded throughout the preintervention period to eventually
include all patients by May 2014, except neonates and perinatal patients. Compliance with CHG bathing was documented in the medical record and was regularly audited. Adverse events data were collected for both periods. The calendar month of June 2014 was excluded from evaluation given that the new isolation policy changes were implemented during this month and CP was less consistent, making the data from this month less reliable. Adverse event data were collected retrospectively from 4 database sources: the Center for Medicare &Medicaid Service Hospital Acquired Conditions (HAC), Agency for Healthcare Research and Quality Patient Safety Indicators (PSI), National Healthcare Safety Network (NHSN), and the internal UCLA adverse-events reporting system.37–39 Prior to data extraction and analysis, our team reviewed all routinely reported adverse event categories in these databases and selected event types most likely to be impacted by lack of contact with healthcare providers. Adverse events deemed independent of provider contact time were excluded (Table 1). Noninfectious adverse events included falls and trauma, postoperative hemorrhage and/or hematoma, postoperative respiratory failure, wound dehiscence, pressure ulcer, and pulmonary embolism (PE)
table 1. Sources of Adverse Event Dataa
Event Reporting System
Outcome Data Infectious Adverse Events
NHSN HAC PSI X
Hospital-onset Clostridium difficile infections X Catheter-associated urinary tract infections X Central-line–associated bloodstream infections X Postoperative sepsis Surgical site infections
Ventilator-associated events
Noninfectious Adverse Events Falls and trauma Pressure ulcers
Postoperative respiratory failure Wound dehiscence
Postoperative hemorrhage and/or hematoma Pulmonary emboli and deep vein thrombosis
X X
X
X X X X X
X X NOTE. NHSN, National Healthcare Safety Network; HAC, hospital-
acquired conditions; PSI, patient safety indicators. aAn internal reporting system checked for all listed events if not otherwise reported to one of these agencies. Given the differences in reporting definitions, all events found in each system were included. If data could be collected from >1 source, data from all sources were included and duplicates of the same event were removed. Excluded conditions: accidental puncture or laceration, air embolism, birth trauma, blood incompatibility, death rate among surgical inpatients with serious treatable complications, death rate in low-mortality diagnosis related groups, foreign object retained after surgery, iatrogenic pneumothorax, manifestations of poor glycemic control, obstetric trauma rate, postoperative acute kidney injury requiring dialysis rate, transfusion reaction rate.
X
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