By Debra Wood, RN contributor
Placing patients in isolation provides an effective method of limiting
transmission of communicable diseases, a technique that has proven key in
staunching the spread of severe acute respiratory syndrome in 2003. But patients
often feel cut off from communication and a recent study indicated they also
suffer from more adverse events.
"Isolation is, unfortunately, a necessity in hospitals to protect the common
good," said Terri Rearick, RN, BS, CIC, administrator of safety services at
Children's Memorial Hospital in Chicago. "Make those decisions so the
appropriate patients are isolated, they are isolated at the appropriate category
of isolation and they are taken out of isolation as soon as appropriate. That
makes a difference. It sounds like an easy thing to do, but it’s not always so
Clinicians tailor the level of transmission-based precautions to the type of
infection and causative organism.
For instance, a methicillin-resistant Staphylococcus aureus (MRSA)-infected
wound requires contact precautions, gowns and gloves, but no mask, while a
patient with influenza should be placed on droplet precautions. Nurses would
wear a mask and eye protection whenever coming within three feet of the patient.
Airborne precautions, such as those for tuberculosis, require a private room
with negative air pressure and wearing of N95 respirators.
Patients in isolation often feel neglected, lonely and stigmatized. Even the
word isolation has a negative connotation for patients, said Lynette Tellefsen,
RN, CIC, assistant director of infection control at Florida Hospital in Orlando.
The gowns, gloves and masks form a barrier to the traditional sense of healing
and touch associated with nursing.
Now a study reported in the Journal of the American Medical Association
shows that isolation also might lead to poorer quality of care and adverse
The authors of "Safety of Patients Isolated for Infection Control" evaluated
records of patients with MRSA colonization or infection admitted to two North
American general-teaching hospitals and compared their stays with that of
patients in the same bed just before or after the study subjects’ admission to
ensure the two cohorts would receive care from the same team of caregivers, in
the same room and at the same time of the year.
Patients in isolation were more likely than controls to have vital signs
incompletely recorded, days with no vital signs and days with no nursing or
physician progress note in the chart. Isolated patients were twice as likely to
experience adverse events. But investigators found no difference in hospital
mortality. Patients also expressed more formal and informal complaints about
their care, including negative perceptions of treatment, access to staff,
communication, humaneness, cleanliness of the environment and billing problems.
Although the time required for gowning up to enter a room and peeling off
after delivering care forces nurses to limit trips into and out of isolation
rooms, it should not preclude meeting clinical standards. Batching tasks with
medication administration saves time, but nurses still need to check on patients
regularly, even if it is just a quick "hello" from the door for patients on
droplet or contact precautions.
Developing a specific action plan for each patient in isolation helps Florida
Hospital ensure nurses follow the same precautions, something patients find
important and reassuring.
"It takes a lot of planning. There is a lot that can be done for the person
in isolation, but it can’t be hit or miss," said Rearick, at Children’s
Memorial. Rearick suggests, when possible, that nurses time their care around
family visits, so professional interactions fill the greatest voids in time.
Families can bring books or games from home to provide distractions.
Tellefsen said Florida Hospital’s policy of allowing patients with MRSA wound
infections to go outside, as long as they wash their hands and change into a
clean gown and robe before leaving their rooms, has helped patients’ ability to
cope with the precautions.
Children’s Memorial has trained volunteers how to safely use personal
protective equipment and allows those proficient at it enter the rooms and
interact with patients. While volunteers do not provide nursing care, the visits
help patients pass the time. And as a representative from the facility, the
volunteer helps show concern for the patient’s emotional well being.
Nurses should explain to patients and families the reason for the
precautions, how long the patient will need to stay isolated and how to properly
apply protective equipment, so they can visit. Renée Patterson, CSP, infection
control manager at Ingham Regional Medical Center in Lansing, Michigan,
developed fact sheets about MRSA and other infection diseases with details about
precautions, which nurses can leave with family members.
Another tip from Tellefsen: Keep gowns and gloves by the door to make it
easier for staff to comply with precautions and provide care. Post the type of
precautions and what must be worn and remind people about hand washing.
Patterson, author of Infection Control Professional's Handbook, said
heavy workloads often prompt caregivers to take shortcuts, but skipping steps
can prove counter productive if more patients end up in isolation as a result.
Hand hygiene remains paramount in decreasing the spread of disease. Ingham
placed alcohol-based hand rub dispensers in every room to save time and improve
compliance. Patterson said, "When we implemented alcohol-based hand rubs, we saw
more than a 50 percent decrease in our isolation rates. We were working on other
things as well, so can we say it was 100 percent attributable to hand hygiene?
No, but it had a big part in it."
Patterson makes daily rounds and reviews culture results, then will discuss
the need for continued precautions with the patient’s physician.
While infection control experts agree that isolation techniques require extra
time and wearing personal protection can be uncomfortable and hot, they also
assert that nurses should not allow those impediments to interfere with
providing quality, safe care.
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