Isolation

I have come across both of these articles recently. Working in the hospital isolation is a big deal so of course I looked at them.

From the AMA: Preventive Measures Shown to Cut CDiff Rates

And in the NY Times: When Isolation Hampers More Than Bacteria

As a bit of background, in a hospital someone is put into isolation when they are infected with MRSA, VRE, Chlostridium Difficile, or any other hospital-acquired infection. The patient is required to be placed in a private room. Everyone who enters the room is required to wear gloves and an isolation gown (this includes all family members and visitors). When the patient leaves the room he/she must wear gloves and an isolation gown. If you're not entirely familiar with this practice I would suggest reading the AMA article which also outlines some more interventions to reduce transmission of a hospital acquired infection (clostridium difficile).

Overall, both articles are fascinating from an epidemiological standpoint: the first is how drastically hospitals have been able to cut their infection rates by aggressively implementing the CDCs guidelines for isolation practices. There are little things included that one may not initially think of, such as placing the trash can near the door so gloves/gowns are removed as the person is leaving. But it also gives other issues to consider. C Diff in particular affects people who are on antibiotics or proton pump inhibitors (PPIs). In an attempt to reduce post-surgical infections, new guidelines have resulted in an increase in antibiotics (antibiotic prophylaxis). So how do we balance the need to reduce post-surgical infections with the need to decrease rates of C diff? This will require further study and cost-benefit analysis to find a better balance.

The second article not only interests me from an epidemiological standpoint, but also in terms of connections with patients (and, I'll admit it, my own laziness). Basically this article looks at the impact of all the isolation precautions on the patients and the connection between the patients and caregivers. Because following isolation precautions involves added time to gown/glove, it is uncomfortable (the gowns are stifling hot), and it hinders a person's natural movement and makes working with the patient harder. Not to mention, the sticky tabs on the gowns pull hair, the gloves makes a person's hand sweaty, and it's nearly impossible to find a decent vein without at least one finger degloved.

This article states outright what I see every day at work: when patients are in isolation staff members purposely reduce contact with them by lumping work into one single trip, having only one person gown up, asking patients questions from the doorway instead of going in, and the patients themselves (if able to walk) avoid coming out at times. It also points out that patients in isolation have more non-infectious complications such as falls, pressure ulcers, depression, anxiety, and most shockingly "as much as a 100% increase in the overall incidence of adverse events." Wow, the very precautions we put in place to decrease particular adverse events actually increase other events.

I latched on to this quote from the article:

In two separate studies, researchers at the Medical College of Virginia in Richmond found that the rate of infection was identical whether health care workers wore gowns and gloves with only the patients in isolation or whether they wore only gloves with all patients.

 First of all, because I would be super psyched if I only had to wear gloves with isolation patients. Second, because of the interesting results of wearing gloves with all patients. Although it sounds benign enough, physical contact and touch is a big part of medicine and even the thin barrier of gloves greatly reduces what a clinician can actually feel and garner from touch. (for an interesting article from a physician's perspective regarding touch and the inner-conflict arising from gloves with all patients check this out)

It will be interesting to not what comes of this finding: those who work in healthcare would love to get rid of the frustration of isolation precautions, patients would love to get rid of the hassle of isolation, hospitals would probably enjoy the break the budget would get without buying isolation gowns. But I'm guessing that it will not be a quick change: we as humans naturally think that more protection (and more visible protection) is always better regardless of the evidence against it. (For example, did you know that the suds from dishsoap and toothpaste don't affect cleaning ability?)