Wednesday, December 1, 2010

Isolation Pros and Cons

In a recent NY Times column, Pauline Chen discussed the downside of isolating patients with serious infections. She described an all too familiar scenario of a man who had a multidrug resistant infection of the abdominal wall and gradually withdrew from life as caregivers, frustrated by the elaborate isolation precaution rituals [gowns, gloves and sometimes masks], stopped interacting with him. I have observed many other problems with the isolation process.

The hospital infection control staff is quick to post signs isolating patients with methicillin-resistant staph aureus [MRSA] but other types of infections such as methicillin-sensitive staph aureus [MSSA] do not seem to require isolation. I don’t quite understand that philosophy. MSSA is just as virulent as MRSA. MRSA is simply harder to eradicate.

Most hospitals have a policy that if a patient has ever had MRSA, he must be isolated even if there is no evidence that he has a current active infection. Yes, he may be a carrier of MRSA, but so might any other patient [or by the way, hospital employee] who has not been tested for the organism. I recently took care of a patient who had a history of an MRSA urinary tract infection [UTI] many years ago. She was dutifully placed on isolation despite no proof that she was actively infected with or carrying MRSA.

In certain areas of the hospital such as the emergency department, radiology and the operating room, it is very difficult to maintain isolation due to the geography of those areas, the lack of familiarity with the details of the patient’s past history and the logistics of cleaning the radiology suite every time an isolation patient visits that area. For example, the patient with the previous MRSA UTI was not isolated in the ED because the information about the previous MRSA UTI was unknown to the ED staff.

At times the non-clinical personnel violate the isolation protocol perhaps unknowingly. Housekeeping people seem well-schooled but dietary workers remove food trays from isolation rooms and place them on carts with non-isolation trays. The uncovered trays are returned to the kitchen on elevators and through hallways.

If I visit an isolation patient and change a dressing while wearing gloves and without touching the patient’s bed or linens with my body, why must I wear a gown? Can staph jump and if so, how far?

I agree with one of the points Dr. Chen made in her article which is that all the fuss about isolation may cause the staff to miss the big picture. There needs to be a compromise between the strict but difficult to comply with and often breeched isolation policies and the need to see and relate to the patients. Perhaps the solution of gloves when examining all patients would suffice for even MRSA patients.

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