Multidrug-resistant organisms (MDROs) continue to threaten patient safety and our ability to deliver effective care, so it’s no wonder that we err on the side of caution when it comes to dealing with them. One of the most visible measures to slow the spread of MDROs is the implementation of contact precautions – a measure so widespread that a lot of us now take it for granted. Positive MRSA nasal screen? Bring out the PPE cart. VRE in the urine two years ago? Break out the gowns and gloves. On the surface, this approach makes sense (pun intended) – if we place a barrier between our skin and the contaminated environment, we’re less likely to pick up these resistant organisms and move them around. Right?
Unfortunately, a lot of things that “should work” in medicine don’t pan out when you study them objectively, and I believe we can now place contact precautions firmly in this category. It turns out that most of our past data supporting the use of contact precautions came from small, uncontrolled studies with bundled interventions and poor compliance monitoring. When the Australian government commissioned a review of contact precautions back in 2008, their researchers found that only 10 of 358 papers on contact precautions could be considered acceptable quality. Even those 10 studies had issues with sample size, bundled interventions and inconsistent compliance.
The BUGG study in 2013 was the first large, randomized controlled trial of contact precautions in the US. It randomized 20 ICUs at different hospitals across the country to use either gown and gloves or standard precautions alone for patients with a history of MRSA or VRE. After nine months and over 26,000 patients receiving serial screening swabs for both organisms, there was no significant difference in rates of MRSA and VRE acquisition between the groups. The researchers also found no significant difference in rates of CLABSI, CAUTI, VAP or general adverse events. A study in Europe published the same year (Derde et al) had similar findings.
Since that time, the evidence against contact precautions has mounted considerably. Multiple studies have found that – not only do contact precautions have no impact on MDRO transmission rates – they actually cause measurable harm to patients, including:
- Longer time to inpatient admission
- Longer time to discharge
- Increased difficulty securing placement
- Fewer visits from healthcare workers
- Increased patient-reported depression and anxiety
- Increased falls, bleeding events, clotting events, respiratory failure, wound dehiscence, pressure ulcers and other noninfectious adverse events (probably because patients aren’t being visited as often…)
Still don’t buy it? I know – this involves undoing some deep-seated conditioning, but let’s take a look at how this has played out in the real world:
University of Massachusetts Memorial Medical Center (781 beds): discontinued contact precautions for MRSA and VRE in 2010 and saw no change in patient acquisition of these organisms with weekly surveillance over a year
Cambridge Health Alliance (260 beds): discontinued contact precautions for MRSA and VRE in 2014 and saw no change in patient acquisition of these organisms with surveillance over a year. At the same time, they estimated a $500,000 annual cost savings.
Virginia Commonwealth University Medical Center (865 beds): discontinued contact precautions for MRSA and VRE in 2013 and saw no change in patient acquisition of these organisms with surveillance over a year. They also estimated a $500,000 annual cost savings.
UCLA Health System (785 beds): discontinued contact precautions for MRSA and VRE in 2014 and saw no change in patient acquisition of these organisms with surveillance over a year. They estimated almost $650,000 in annual savings on supplies alone, plus an estimated $4.6 million worth of nursing time no longer spent donning and doffing PPE.
VA Community Living Center (270 beds): Across the CLC system, the VA saw their MRSA prevalence increase from 23% to 70% between 2007 and 2012 despite strict contact precaution policies. In 2013, one CLC tried stopping MRSA contact precautions - decolonizing MRSA-positive patients on admission instead. Four years later, their MRSA infection rate dropped 89%, and colonization rates dropped 72%.
Although most of the data to date have focused specifically on precautions for MRSA and VRE, we are also starting to see evidence that contact precautions don’t work for resistant Gram negatives either. A randomized study published earlier this year (Maechler et al) found that contact precautions had no impact on transmission rates for extended-spectrum beta-lactamase (ESBL)-producing organisms with more than 38,000 patients at 20 hospitals across four European countries.
So, to recap:
- Contact precautions don’t appear to work – certainly not for MRSA and VRE and probably not for many resistant Gram negatives either
- Implementing contact precautions harms patients
- Removing contact precautions in “real-world” situations saves a lot of money with no change in adverse outcomes
Personally, I’m quite comfortable removing contact precautions for MRSA and VRE at this point. My comfort level is increasing with resistant Gram negatives, although removing precautions is still on a case-by-case basis in that area. The jury is out on C. difficile – it has some unique features that make even Infectious Disease experts hesitant to try taking away precautions, and I’m not aware of any medical literature to that end. That said, I would not be at all surprised if we start seeing studies that show contact precautions do not benefit C diff either.
A paradigm shift in our approach to just MRSA and VRE has the potential to improve patient outcomes while saving the healthcare system millions. Doing away with a longstanding practice that seems like it should work can be anxiety-provoking, but rest assured that the change is well-supported for these two organisms. When it comes to preventing MDRO transmission, hand hygiene and environmental cleaning consistently show the greatest benefit. Gowns and gloves mostly just make us feel better.
If you’re a facility leader looking to make a policy shift on contact precautions, I encourage you to have the backing of a quality Infection Prevention team – ideally including an Infectious Disease physician. We have an opportunity here to improve healthcare delivery and save money while simplifying our day-to-day practice. Don’t waste it.