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A Program to Remove Patients from UnnecessaryContact PrecautionsRobert C. Goldszer, MD, MBA, Elise Tamplin, MPH, CIC, Deborah S. Yokoe, MD, MPH, Nancy Shadick, MD,Christiana Goh Bardon, MD, Paula A. Johnson, MD, Joanne Hogan, RN, MS, Terry Kahlert, RN, MS, and Anthony Whittemore, MD

Methicillin-resistant Staphylococcus aureus (MRSA)and vancomycin-resistant enterococci (VRE) infec-tions are increasingly prevalent in U.S. medical

centers [1,2]. Infections involving MRSA and VRE cause sig-nificant patient morbidity [3,4] and impose a substantialfinancial burden on hospitals and health care systems [5].Brigham and Women’s Hospital (BWH) in Boston has im-plemented a number of policies and procedures aimed atpreventing transmission of organisms between patients.These policies include hand disinfection programs and pro-cesses for rapid implementation of contact precautions forpatients known to be colonized or infected with MRSA orVRE, as recommended by the Centers for Disease Controland Prevention [6].

Having a large number of inpatients on precautions con-tributes to several problems with patient safety and per-ceived quality of care. First, staff personnel often are notcompliant with hand hygiene and use of dedicated equip-ment such as stethoscopes because of the need to apply pre-cautions to a large number of patients. Second, the require-ment for a private room may cause significant delays duringthe admission process, which is a major cause of dissatisfac-tion among patients and families. Because of this require-ment, patients also must occupy emergency departmentbeds when no emergency treatment is needed. Third, theenforced isolation associated with housing in a private roommay cause significant negative psychological impact to indi-vidual patients [7]. Fourth, health care providers must weargloves and gowns when caring for patients on contact pre-cautions, which may be viewed as inconvenient and thusmay result in less frequent and timely visits by providers [8].Last, because of the need for a private room and the wearingof gloves and gowns, patients in isolation receive less effi-cient and more costly care.

Isolation procedures increase costs of care. In a study doneby the care coordination department at BWH, over a 4 -weekperiod patients on contact precautions had 10.9 delay daysprior to transfer to an extended care facility versus 4.3 delaydays for similar patients not on precautions. Although only

20 of 128 (15%) patients in the 4-week period were on contactprecautions, they accounted for 32% of all discharge delaydays [9].

Major strategic goals of the hospital are to provide the cor-rect care for patients in the correct location and to ensure anappropriate length of stay. Isolation of patients was identifiedas an area that could be targeted to increase efficiency anddecrease costs. To improve patient satisfaction and efficiencyof care, we developed a process to remind physicians to con-sider ordering cultures in certain patients and to facilitateordering of the appropriate cultures.

Project Development Evaluation of PracticesAt BWH, contact precautions are initiated when a patient hasa microbiology culture that grows MRSA or VRE (clinicaland/or screening isolates), and precautions are continued dur-ing any subsequent readmission unless specific discontinua-tion criteria are met, including negative microbiology surveil-lance cultures. Review of hospital infection control quarterlysummary surveillance reports showed that for the past sever-al years, BWH has placed between 50 and 70 patients on con-tact precautions per month for MRSA, including patients withMRSA identified during previous hospital admissions andnewly identified cases. Between 30 and 40 patients have beenplaced on contact precautions per month for VRE.

Infection control leadership at the hospital had previouslyperformed a pilot study that revealed that 40% of a subgroupof patients on precautions for MRSA and/or VRE had 3 setsof negative surveillance cultures while off of antibiotics activeagainst the organism, satisfying the BWH criteria for discon-tinuation of contact precautions. The subgroup of patientsmost likely to meet precaution discontinuation criteria werepatients who had been on contact precautions for MRSA orVRE for 90 days or more. The medical literature supports theconcept that over time some patients previously colonized or

From Brigham and Women’s Hospital, Boston, MA.

infected with MRSA become negative for MRSA based onsurveillance cultures. The infection control unit at Bichat-Claude Bernard Hospital in Paris, France, reported that 47 of78 patients (60%) who had been MRSA-positive had negativecultures at the time of readmission [10].

Contact Precaution Reminder SystemA team was established to evaluate the current impact ofcontact precautions and to work on possible improvements.Key stakeholders represented on the development team in-cluded attending physicians, house staff, nursing, infectioncontrol, quality management, and care coordination. Theteam recommended a plan to provide real-time reminders tophysicians via the hospital computerized order entry systemwhen a patient is eligible for screening cultures. The teamalso developed a plan for educating users of the entry sys-tem and a plan for measuring the results of the project. Delaydays per month were measured using a medical care appro-priateness program that analyzes a sample of cases for eachof the hospital’s services and reports on causes of delay ofcare. Cases of delay due to waiting for an isolation bed werereported.

At BWH all orders are written with a computerized orderentry system. To write orders a physician must log into thecomputer system and into the patient’s chart. At the time oflogging into the patient’s chart, physicians are providedreminders. Prior to the contact precautions project, enteringinto the automated medical record of patients on precautionsfor MRSA and VRE produced an automated reminderaimed at alerting the provider to the need for contact pre-cautions. The new program included a revised reminder(Figure) that prompts the physician to consider evaluatingthe patient for ongoing MRSA/VRE colonization. Wedesigned the reminder with 2 electronic links. One link is toorder sets that allow the physician to order the appropriatecultures, and the other allows the physician to send an e-mailwith questions or communication to infection control clini-

cians. The reminder appears each time the physician entersthe patient’s chart. The new reminder only appears for pa-tients who have been on precautions for MRSA and/or VREfor at least 90 days. Because the date of initiation of precau-tions is entered into the system by the infection control prac-titioners, the computer system is able to automatically iden-tify all patients who have been on contact precautions for atleast 90 days and display the on-screen reminder. Providerscan then easily access the computerized order sets for order-ing nasal (and wound, if present) cultures for MRSA andstool or rectal cultures for VRE daily for 3 days. If all 3 cul-tures are negative and the patient is not receiving antibioticsto which the isolate is susceptible at the time the surveillancecultures are obtained, infection control clinicians remove thepatient from precautions.

Education of System UsersOnce the new reminder, order sets, and links were designedand ready to be implemented, we instituted a program toeducate physicians and staff about the program and how touse it. Project leaders presented the new program at facultyand house staff meetings, articles were published in physi-cian and nursing newsletters, and e-mail about the programwas sent to all clinicians.

ResultsBetween 1 August 2001 when the contact precaution re-minders first appeared and 1 May 2002, 351 hospitalizedpatients were on contact precautions for at least 90 days be-cause of colonization or infection with MRSAor VRE. MRSAand/or VRE discontinuation order sets were activated for92 (26%) of these patients. Of these 92 individuals with sur-veillance cultures ordered, 32 (35%) met discontinuation cri-teria and were removed from contact precautions. None ofthese 32 individuals have had a clinical isolate positive forMRSAsince they were removed from contact precautions. Inaddition, the number of calls and e-mail to infection control

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Figure. Computer screen announcement ofnew message to consider ordering culturesto assess need for continuing precautions.

has increased greatly, with clinicians communicating withquestions about possible removal of patients.

Based on analysis of patients causing delay days in 2001,an estimated 30 cases accounted for 122.6 days waiting forprecautions beds, with an average waiting time of approxi-mately 4 days per case. In 2002, a projected year-to-date99.6 cases accounted for 197 annual projected days waiting,an average of 1.97 days waiting per case (Table) [11]. Thecurrent estimated total cost of hospitalization per day is$1500; therefore, the cost savings of eliminating 2 days’ stayin 32 patients is $96,000. If the removal of isolation decreasedthe length of hospitalization by 4 days in each of these 32 pa-tients, the cost savings would be $192,000. The charge for aculture is $54.

Several patients have been readmitted after discontinua-tion of contact precautions, and only 1 has reacquired VREand needed precautions reinstituted. E-mail messages withresults of the program are now sent to key leaders for distri-bution every 2 months.

Discussion The use of control measures such as contact precautions canbe effective in preventing transmission of multiply resistantorganisms such as MRSA and VRE [12,13]. Patients infectedor colonized with these organisms can serve as a reservoirfor spread to other patients [14–16], with transmission occur-ring primarily via health care workers’ hands [17]. Adequatehand hygiene is the primary method of control. However, itis well known that compliance with hand hygiene guide-lines by health care providers is suboptimal [18]. Additionalcontrol measures including the use of gloves and gowns fordirect contact with patients and the patients’ environmenthave also been shown to reduce the risk of transmission[19,20]. However, the need for contact precautions for MRSAor VRE colonization or infection implementation of contactprecautions is a factor in decreasing patient and staff satis-faction and prolonging length of stay.

MRSA and VRE colonization may be lost over time in cer-tain patients [21–23]. For such patients, the negative aspects ofcontinuing contact precautions unnecessarily outweigh anypotential benefit. The presence or absence of MRSA coloniza-tion may be reliably determined through cultures of swabspecimens from the patient’s nares [24]. Similarly, the presenceor absence of VRE colonization can be determined throughcultures of stool or swab specimens from the rectal/perinealarea [25]. Thus, the development of a system to identify pa-tients who are most likely to no longer be colonized and tofacilitate microbiologic surveillance screening to verify the ab-sence of continued colonization could be of great benefit.

We have established a program to evaluate patients withspecific criteria aimed at discontinuing unnecessary precau-tions. The program provides real-time reminders and links

to order sets to facilitate the ordering of appropriate surveil-lance cultures, and is focused on patients most likely to meetdiscontinuation criteria. In the first 9 months of the program,we have removed 32 patients (35% of all patients screened)from unnecessary MRSA and VRE precautions. This has re-sulted in increased staff satisfaction and cost savings. Al-though screening cultures were not ordered for 74% of hos-pitalized patients who had been on contact precautions forMRSA or VRE for at least 90 days, many of these patientsmay have been receiving antibiotics active against MRSAand/or VRE during the hospitalization and were thereforenot eligible for discontinuation of screening. In addition,some of these individuals may have had hospital stays thatwere too short to complete the 3 days of screening culturesrequired for discontinuation.

There has been universal acceptance of the program bynurses, physicians, and patients. The educational programshave continued with presentations to the new incominghouse officers. Nurses and house staff are eager to remove un-necessary precautions to allow them to more efficiently carefor these patients. Providers feel there is improved satisfactionif contact precautions can be appropriately discontinued.

An added benefit of the program has been to raise con-sciousness about hand hygiene and infection control prac-tices among physicians, nurses, students, and other healthcare providers. More staff now think about precautions andare reminded to try to remove patients from isolationthrough the new system. The system also serves as a re-minder of the importance of these infections, their impact oncare, and the need to prevent spread of organisms.

ConclusionWe have learned several key lessons in implementing this project. First, it is necessary to involve all stakeholders in theplanning, education, and implementation of a quality im-provement project. Second, we recognized that a system thatis implemented to solve a specific problem must be easy to useand add efficiency to the physicians’ and nurses’ work loads.Computerized order entry allows real-time reminders andlinks to order sets. Our program has produced its expected

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Table. Delay Days Due to Resistant Organisms and EstimatedCost Impact

2001 2002

Cases resulting in delays 30. 99.6Delay days per case 4.09 1.97Total delay days 122.6 197.Approximate cost per day, $ 1500. 1500.Total extra costs, $ 183,900. 295,500.

results, proving beneficial for our patients, staff, and organi-zation. This program can be implemented at other medicalcenters to achieve strategic goals for managing patients with ahistory of colonization or infection by resistant organisms andmay yield similar results.

Corresponding author: Robert C. Goldszer, MD, MBA, Brighamand Women’s Hospital, 75 Francis St. PB-4, Boston, MA 02115,rgoldszer@partners.org.

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