Things We Do For No Reason: Contact Precautions for MRSA and VRE

In addition, a prospective trial at a large academic center over two six-month intervals utilized universal gloving with emollient-impregnated gloves compared with CP and found no difference in MDRO acquisition. Universal gloving was associated with higher hand hygiene rates than CP.¹⁰ Another more recent retrospective observational study compared universal contact precautions (UCP) in ICUs to a historical nine-year baseline and concurrently to other nonuniversal CP ICUs. There was no significant decrease in MDROs during the UCP period compared with baseline or with non-UCP units.¹¹Further interest in and scrutiny of CP prompted a recently published meta-analysis of 14 studies in which CP were eliminated. The rates of transmission of MRSA, VRE, or other MDROs studied were not impacted by discontinuation.¹² One of the studies included two large academic medical centers and assessed the impact of discontinuing CP for endemic MRSA and VRE. The bundled intervention included the discontinuation of CP for all carriers of MRSA and VRE, except patients with draining wounds, maintaining high hand hygiene rates, and CHG baths for nearly all patients. There was no significant increase in transmission rates, and the intervention saved the health system an estimated $643,776 and 45,277 hours per year in healthcare worker time previously spent on donning and doffing personal protective equipment.¹³ Another large academic hospital published a time series approach of seven interventions to reduce healthcare-associated infections and noted no increase in MRSA or VRE transmission when CP were discontinued when combined with other horizontal preventions.¹⁴ Results were found to be similar in a high-risk population of patients with hematologic malignancies and hematopoietic stem cell transplantation, where both surveillance and CP for VRE were discontinued and did not impact the rates of VRE bacteremia.¹⁵

Multiple studies have examined the deleterious effects of CP, including a comprehensive systematic literature review of various adverse outcomes linked with CP.¹⁶ CP decrease the amount of time that healthcare workers (HCW) spend with patients,¹⁷ create delays at admission and discharge,¹⁸ increase symptoms of anxiety and depression in patients,^19,20 and decrease patient satisfaction with care.^21,22 In a study conducted at the Cleveland Clinic Hospital, physician communication, staff responsiveness, patients’ perception of cleanliness, and their willingness to recommend the hospital on the Hospital Consumer Assessment of Healthcare Providers and Systems survey were lower in each category for patients on CP when compared with patients not on CP.²² Patients who are on CP are six times more likely to experience an adverse event in the hospital, including falls and pressure ulcers.²³ A recent study from a large academic medical center demonstrated that noninfectious adverse events were reduced by 72% after discontinuing CP for MRSA and VRE. These events included postoperative respiratory failure, hemorrhage or hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma.²⁴

The financial costs of unnecessary CP have also been studied. A recent retrospective study examining a large cohort of patients on CP for MRSA demonstrated that when compared with nonisolated patients, those on MRSA CP had a 30% increase in length of stay and a 43% increase in costs of care. Patients isolated for MRSA were 4.4% more likely than nonisolated individuals to be readmitted within 30 days after discharge, unrelated to MRSA.²⁵ These data contribute to the growing evidence that a conscientious, patient-centered approach to CP is preferred to overly broad policies that compromise patient safety.