Universal precautions to whom?


 

 

Few weeks ago, on a sunday, one of my patients was dying. I know that they are all dying, but this specific one was really dying. I knew that it was a matter of time, and probably in the next few hours he would be gone. So, we made arrangements for his relatives be able to stay with him during his final moments. I entered his room probably four or five times during that shift, on one hand I wanted to be sure that he was comfortable, which he was, and offer support for the family, but on the other hand I didn’t want neither disturb, nor make the relatives anxious with my presence. In the end, he peacefully boarded Charon’s boat and left our world. But that’s not what this is gonna be about. My patient was colonized with MDR bacteria, and according to our hospital policies, even visitors must wear gloves and gowns if the patient is colonized with MDR bacteria. That’s what we’re gonna be discussing today. To see the family not being able to make skin contact with he patient, the gowns decharacterizing who they were, and the sense that somehow we were keeping them away from each other really bothered me. I know, hospital policies. But some hospitals don’t have this specific rule. Do we have any evidence to support this?

To begin with, I found 4 surveys that discuss this situation. In Brazil, only 2.4% of ICUs recommended the use of protective coverings for all visitors [1]; in the UK, only 4.9% required visitors to wear gowns and gloves [2]. While in France, 82% of ICUs required gowning procedures [3], and in 95% of Italian ICUs gowning was compulsory for visitors [4]. Well, when we have such different recommendations we can be sure of one thing: we don’t have good evidence to support any recommendation at all! In fact, the surveys agree that this recommendation increases costs, and that “current evidence does not support the wearing of protective clothing by relatives as a measure of infection control”. However, before we make any further discussion, let’s see what the literature has to say about this.

A study evaluating if wearing gloves and gowns for all patient contact in the ICU decreases the acquisition of MRSA or VRE compared with usual care [5]. The usual care recommended the use of gloves and gowns for patients known to have infection or colonization with MDR bacteria. Both groups decreased the acquisition of MRSA or VRE when comparing the baseline period with the study period, a good example of the Hawthorne effect. But when comparing the two groups, no difference was found. One of the secondary endpoints showed that the intervention decreased health care worker room entry, again, showing our laziness. Hand hygiene compliance was also evaluated, and it is shown on the table below:

The intervention group had better hand hygiene compliance after exiting the room. That makes sense, you gotta be extremely lazy not to wash your hands after wearing a glove, but the compliance rates are still ridiculous. A recent study published on Lancet Infectious Diseases [6] concluded that health-care workers were infrequently sources of S. Aureus transmission to patients in the ICU. One study [7] showed that if the patient is known to be colonized with VRE, the use of gowns were protective in VRE acquisition. And a cluster randomized trial[8] comparing the use of gloves and gowns prior to all patient contact with usual care, didn’t find any difference in noninfectious and infectious adverse events. Unfortunately, none of these studies evaluated separately those measures on visitors. Even if your institution has a protocol for contact precautions it doesn’t mean that it will be strictly followed. The overall compliance of health-care workers and visitors were, respectively, 76% and 65% [9] in one study. But ok, suppose you have a high compliance rate, still, skin or clothing contamination can occur in up to 46% of the time, according to simulations [10].

Despite all those numbers I showed you, we don’t have any study evaluating the role of contact precautions on visitors. The visitors only have contact with one patient. Ok, they interact with other visitors, with a hand shake, maybe a hug, and most of the time, that’s it (I said most of the time because probably all of us already heard some sexually related story involving visitors from different patients, but I think that’s an exception). Therefore, if we guarantee that all visitors wash their hand properly, PROBLEMO SOLVED!

But why, despite all the lack of evidence, we still have these recommendations for visitors? We’re trying to protect them, maybe we’re afraid, maybe the guys who make hospital policies don’t really know what we think about it. What I know is that although it might seems a good idea on a hospital policy perspective, it is a pretty crap idea when we look through a more human perspective, and the lack of evidence reinforces that way of thinking.

 

1.     Ramos FJ, Fumis RR, de Azevedo LC, Schettino G. Intensive care unit visitation policies in Brazil: a multicenter survey. Rev Bras Ter Intensiva. 2014;26(4):339-346.

2.     Hunter JD, Goddard C, Rothwell M, Ketharaju S, Cooper H. A survey of intensive care unit visiting policies in the United Kingdom. Anaesthesia. 2010;65(11):1101-1105.

3.     Burchardi H. Let’s open the door! Intensive Care Med. 2002;28(10):1371-1372.

4.     Giannini A, Miccinesi G, Leoncino S. Visiting policies in Italian intensive care units: a nationwide survey. Intensive Care Med. 2008;34(7):1256-1262.

5.     Harris AD, Pineles L, Belton B, et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA. 2013;310(15):1571-1580.

6.     Price JR, Cole K, Bexley A, et al. Transmission of Staphylococcus aureus between healthcare workers, the environment and patients in an intensive care unit: a whole-genome sequencing based longitudinal cohort study. Lancet Infectious Diseases. 2016.

7.     Puzniak LA, Leet T, Mayfield J, Kollef M, Mundy LM. To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Clin Infect Dis. 2002;35(1):18-25.

8.     Croft LD, Harris AD, Pineles L, et al. The Effect of Universal Glove and Gown Use on Adverse Events in Intensive Care Unit Patients. Clin Infect Dis. 2015;61(4):545-553.

9.     Manian FA, Ponzillo JJ. Compliance with routine use of gowns by healthcare workers (HCWs) and non-HCW visitors on entry into the rooms of patients under contact precautions. Infect Control Hosp Epidemiol. 2007;28(3):337-340.

10.     Tomas ME, Kundrapu S, Thota P, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA Intern Med. 2015;175(12):1904-1910.

 

 

Photo credit

Paul Foguenne 


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