Nursing News

Improving Nursing Care for Patients in Isolation


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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 simple."

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 events.

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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