Running head: CONTACT PRECAUTIONS

Contact Precautions
Allison Maleksa
Minnesota State University, Mankato

Abstract

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This paper examines the policy in place for Mayo Clinic Health Systems in
regard to contact precautions. An analysis was conducted on current literature and
was then compared to the current policy guidelines. The Mayo Clinic Health Systems
policy outlines requirements for staff and visitors when they enter the environment
of the patient on precaution status. There are also responsibilities listed for all
healthcare professionals in regard to the implementation and management of
patients on contact precautions. The literature that was reviewed agreed upon the
importance of hand washing, donning personal protective equipment, and using
dedicated equipment and disinfection practices when entering the environment of a
patient on contact precautions. The Mayo Clinic Health Systems is in agreement
with these ideas and is using best practice in these situations. The literature also
revealed that patient isolation can have a negative effect on overall patient health
but the Mayo Clinic does not discuss suggestions for maintaining patient health
when in isolation.

Keywords: contact precautions, isolation, hand hygiene, personal protective

equipment

Contact Precautions
The Minnesota Department of Health (MDH) explains that contact precautions
are to be used while working with ill individuals and in the presence of stool
incontinence, draining wounds, uncontrolled secretions, pressure ulcers, presence of
a generalized rash or the presence of ostomy tubes and or any bags draining bodily
fluids (2014). Examples of such illness include Clostridium difficile (C. difficile),
methicillinresistant Staphylococcus aureus (MRSA), VRE, rotavirus, and norovirus
(Minnesota Department of Health, 2014). Contact precautions are for individuals
who are to come in contact with the patient or entering their room. The precaution
guidelines include wearing gloves and gowns and performing proper hand hygiene
(Virginia Department of Health, 2011). C. difficile and MRSA are both very serious
bloodstream infections and are among the infections in which contact precautions
are to be used (CDC, 2013; Virginia Department of Health, 2011). Unfortunately,
both of these infections are still prevalent today in our healthcare system. According
to the Center for Disease Control (CDC), nearly 250,000 people are hospitalized and
14,000 people die from Clostridium difficile every year (CDC, 2013). Although MRSA
rates have been declining over the years, likely due to increased awareness and
interventions to prevent the infection, two in every 100 people are carriers of this
infection. Because of this, MRSA still poses a major threat to patients today and
reinforces the need for contact precautions in our healthcare system (CDC, 2014). A
review of the contact precaution policy and comprehension of the literature is
important in order to properly follow the guidelines that are in place. It also allows

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for the identification of any possible changes that should be made and any barriers
that may be preventing compliance with the policy.
Review of Policy
Mayo Clinics contact precautions are to be applied to the Mayo Clinic setting
and for any patients in the hospital or ambulatory care setting. The purpose of the
contact precautions policy is to provide guidance for healthcare staff when caring
for patients whose illness may be transmitted through contact. The precaution
policy is meant to inform workers and maintain patient, family and staff safety. The
policy instructs all visitors and staff who are to come in contact with the patient to
perform hand hygiene before entering and leaving the room. Visitors are to wear
gloves and gowns when assisting with patient care but staff members are required
to wear gloves and gowns before entering the room and are to be removed before
leaving the room. The policy also suggests that equipment should be dedicated to
the patient requiring contact precautions whenever possible. If equipment is to be
removed from the room, it should be disinfected before removal. The contact
precautions policy goes on to describe the general responsibilities regarding contact
precautions for physicians, unit secretaries, nurses, transport staff, infection
prevention and control staff, and any staff conducting various tests and procedures.
The contact precautions policy also provides specific guidelines regarding isolation
set up, patient activities, ambulatory areas, equipment, supplies, dietary trays, and
after patient dismissal (Mayo Clinic Health System, 2014).
This policy was based on information provided by the Minnesota Department
of Health List of Diseases and the CDC Guideline for Precautions (MDH, 2015; CDC,
2007). The policy does not state when it was originally developed but it does note
that it was last updated in December of 2014. Although this was only a year ago,

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many things can change during a year in regard to new research leading to the
development of new best practices. It is hard to determine when guidelines should
be updated but it is important to do so in a timely matter in order to avoid
becoming outdated and staying current with evolving research in the healthcare
field (Garritty, Tsertsvadze, Tricco, Sampson, & Moher, 2010). I think as a health
care professional it would be great to see it updated at least every year to ensure
that the hospital is using the most current evidence based practice to provide safe
patient care.

Literature Review
Contact precautions can be viewed as impractical for facilities and may be
questioned because they are resource intensive and cause concern about social
isolation of patients (Trick et al., 2004; Marshall, Richards, & McBryde, 2013).
Although it may not always be the most convenient, many studies conclude that
contact isolation precautions are necessary to maintain patient and staff safety
(Marshall, Richards, & McBryde, 2013). Because some facilities find that contact
precautions are too extensive and impractical for their setting, there has been
instances in which modification have been made to the guidelines. For example,
many long term care facilities have modified CDC guidelines for contact precautions
(Trick et al., 2004). One particular facility found that increasing mandated glove use
and decreasing the use of isolation precautions has been shown to decrease
transmission of certain pathogens such as ceftazidime-resistant K. pneumoniae and
surprisingly did not lead to an increase in VRE and MRSA transmission. The study
found that mandating glove use was less resource intensive than isolation

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precautions and did not lead to patient consequences that are sometimes
associated with social isolation (Trick et al., 2004).
The same researcher also found that long term care facilities often focus on
preventing MRSA and VRE transmission but lack a focus on some of their most
common disease causing organisms such as ESBL-producing gram-negative bacilli
(Trick et al., 2004). It is likely that by expanding a facilitys focus, there would be an
increased chance for prevention and transmission of these pathogens. Research has
found that with rapid detection and proper management through the use of contact
precautions, there has been a decrease in MRSA acquisition in the ICU (Marshall,
Richards, & McBryde, 2013). Routine screening for MRSA in the ICU has also been
shown to lead to early identification and isolation of MRSA which decreases
transmission of MRSA in the ICU, throughout other non-ICU, and hospital wide
locations (Huang et al., 2006). These studies focused on MRSA transmission but the
information can be assumed applicable to other infectious pathogens.
Contact precautions are a form of isolation precautions and therefore require
the patient to be in a private room. Contact precautions can limit the interaction
between patient and family and patient and health care staff. Researchers have
found that cohort isolation and individual patient isolation are linked to a decrease
in bedside visits (Masse et al., 2013). The decrease in bedside visits may be due to
several factors. Patients who are on contact-isolation precautions may be perceived
in a negative fashion. They may be thought of as being sicker so if not necessary,
individuals will not spontaneously enter the room. Patient care in this situation may
also be considered to be more time consuming because of the need for healthcare
professionals to don a gown and gloves before entering, therefore limiting the
amount of times a healthcare professional will impulsively enter the room (Masse et

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al., 2013). With this being said, it is not surprising that contact isolation precautions
have often been shown to have a negative effect on patient behavior and the
therapeutic relationship between healthcare providers and patients (Masse et al.,
2013). These effects may also be another reason some facilities are modifying
contact precaution guidelines. Another serious concern with isolation precautions is
that less frequent visits by hospital staff could also lead to other preventable
complications in patients on isolation precautions (Masse et al., 2013). Some of
these complications could be related to falls, immobilization, and secondary
infections (Masse et al., 2013).
One particular research study found that preemptive isolation is often not
practiced for patients who are suspected to have MRSA. It can sometimes take up to
48 hours to receive test results. This means that contact precautions were not in
place for up to two days for individuals who may test positive for MRSA. This could
be another factor in the transmission of nosocomial infections such as MRSA (Huang
et al., 2006). The researchers encouraged the use of implementing rapid screening
tools and the importance of receiving test results as soon as possible in order to
decrease transmission of the infectious organisms (Huang et al., 2006). Although
this may be of some concern, research by Cheng et al. found that transmission of
MRSA can be reduced without patient isolation by promoting hand hygiene using
alcohol-based hand rub, implementing contact precautions, using dedicated medical
equipment and use of 2% chlorhexidine gluconate for daily bathing (Cheng et al.,
2014).
It has been observed that some healthcare professionals lack strict
compliance with contact precaution guidelines. Examples include failure to remove
gloves and gowns before leaving the isolated room and failure to preform adequate

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hand hygiene before entering and leaving the room (Cusini et al., 2015). This too
can be associated with healthcare workers lack of time in a busy schedule but could
also be an indication of lack of knowledge and enforcement of contact precaution
guidelines. Although it is not the only aspect of contact precautions and alone is not
enough to prevent transmission of infectious disease, the use of proper hand
hygiene is a contributing factor to the overall effectiveness of contact precautions
(Huang et al., 2006; Cheng et al., 2014). In one study, hand hygiene compliance
was found to be worse with contact precautions than any other hospital-wide hand
hygiene compliance (Cusini et al., 2015). Lack of hand hygiene before and after
patient contact could be associated with the false sense of safety when wearing
gloves, the thought that gloves eliminate the need for hand hygiene or that donning
personal protective equipment is time consuming therefore providing false reason
to bypass hand hygiene practices (Cusini et al., 2015). This information is very
alarming and the lack of proper hand hygiene is likely to be the cause of
transmission of infectious organisms. Because of these facts, one researcher
implemented modifications to their facilities contact precautions policy. By doing so,
they eliminated mandatory glove use, and found that hand hygiene practices were
significantly improved. It was also noted that further research is needed on the
effect of pathogen transmission (Cusini et al., 2015).
Evidence and Practice Comparison
Donning personal protective equipment and proper hand hygiene for anyone
who is to come in contact with the patient and their environment are two major
components of the Mayo Clinics contact precaution policy (Mayo Clinic Health
System, 2014). It was interesting to learn that many research studies have focused
on compliance with policy guidelines and hand hygiene practices. Many studies

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agreed with the Mayo Clinics guidelines and encouraged hand hygiene because
they found that the use of proper hand hygiene is major a contributing factor to the
overall effectiveness of contact precautions (Huang et al., 2006; Cheng et al., 2014).
Unfortunately, one study found that hand hygiene compliance was found to be
worse with contact precautions than any other hospital-wide hand hygiene
compliance (Cusini et al., 2015). I personally saw this at the Mayo Clinic Health
Systems in Mankato and believe that there needs to be an increase in enforcement
and education about the importance of hand hygiene. Another study eliminated
mandatory glove use, and found that hand hygiene practices were significantly
improved (Cusini et al., 2015). This differs from Mayos policy because they require
glove use for any patient on contact precautions.
Another major concern found in the literature was the effect that patient
isolation had on the patients overall health. The Mayo Clinic requires patients on
contact precautions to be placed in a private room (Mayo Clinic Health System,
2014). It would be interesting to know how or if the Mayo Clinic works to prevent
adverse effects of patient isolation. One research article also discussed the
importance of rapid screening and detection of infectious diseases in order to
prevent transmission (Huang et al., 2006). The Mayo Clinic policy recommends
initiating contact precautions after assessing the patient for infection risk and
reviewing protocol but it would also be interesting to know whether or not this is
encouraged in a rapid sequence and how long it takes to receive test results (Mayo
Clinic Health System, 2014). Overall, I found many similarities between the
literature and the policy and did not find any evidence suggesting that major
changes need to be made to the policy.
Reflection

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I found many of the research studies to be very interesting and found that
most of the information was very relatable to what I have seen and experienced in
my clinical practice thus far. I found that it was fairly easy to find research articles
on this topic. I had some difficulty with articles that were written over ten years ago
and deemed outdated. Early in the research process, it became obvious for the
need to filter out the hundreds of articles related to other isolation precautions such
as airborne and droplet precautions. Often, the articles I found had similar
foundations but differed in their specific ideas and practices. I think the differences
may have to do with differences in cultures based on geographic location,
differences in time because they were all conducted during various periods over the
past ten years and a difference in the research population.
During my time in clinical rotation this semester, I was able to work with
patients who were on contact precaution and their nurses. I witnessed several
instances of nurses entered the patient room without first donning gloves and
gowns if only for a brief amount of time. I also witnessed nurses failing to preform
adequate hand hygiene before entering and leaving the patients rooms. As some of
the articles suggested, I believe that this was due to patients on contact-isolation
precautions be perceived in a more negative way and caring for these patients is
often considered to be more time consuming thus leaving nurses feeling rushed and
not adhering to certain guidelines (Masse et al., 2013). As far as the policy goes, I
feel that there is not a need for any major practice changes in the policy. However,
based on the information I read and personal experience, I do believe that their
needs to be stricter compliance with donning proper personal protective equipment
and proper hand hygiene before entering and leaving the patient room. I believe
increased education on the topic could help healthcare professionals comply with

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the guidelines. A large case load of patients and understaffing can also be major
barriers to following the guidelines. These situations leave healthcare professionals
rushed and in a time crunch causing them to overlook certain aspects of the policy
in order to save time.
Conclusion
The Minnesota Department of Health states contact precautions are to be
used while working with ill individuals and in the presence of stool incontinence,
draining wounds, uncontrolled secretions, pressure ulcers, presence of a generalized
rash or the presence of ostomy tubes and or any bags draining bodily fluids (2014).
The contact precautions pertain to anyone who may be participating in patient care
such as visitors and any staff members who are entering the patients environment
(Mayo Clinic Health System, 2014). Contact precautions aid in preventing
transmission of infections from person to person and are a necessary component of
maintaining patient safety within the healthcare system. These precautions are
often used for very serious illnesses such as norovirus, VRE, MRSA and C. difficile
(MDH, 2014). A literature search revealed common themes regarding contact
precautions such as a lack of strict compliance, lack of proper hand hygiene, the
effects of patient isolation and the need for rapid detection and response to
infectious diseases. The Mayo Clinic Health System policy is in agreement with the
need for proper PPE, hand hygiene, and patient isolation but does not go into
further detail about possible complications and concerns regarding contact
precautions. Based on my experience and literature search, I believe that there are
no major changes that need to be made to the policy but I do believe there needs to
be more enforcement on strict compliance to the policy guidelines.

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sPatients.pdf