The Society for Healthcare Epidemiology of America (SHEA) recently published an Expert Guidance on Isolation Precautions for Visitors.1 This document is likely to prompt many, and possibly heated, discussions on whether or not to implement these recommendations. This article will only address contact precautions compliance, excluding droplet and airborne.
Transmission of organisms within a healthcare facility is a major concern for healthcare personnel (HCP), patients, and their families. Literature supports the idea that transmission of multidrug-resistant organisms involves the hands and potentially the clothing of HCPs. Although studies have demonstrated contamination of HCP apparel with potential pathogens, the role of clothing in transmitting organisms to patients has not been established.2 Since contaminated HCP clothing offers a theoretical risk of bacterial transmission, we use this reasoning to implement standard and contact isolation precautions for HCPs. But what about visitors? Should they adhere to the practice of wearing gowns and gloves while they are visiting the patient? Institutions that do not require compliance cite the lack of visitor interaction with other patients as well as the difficulty in enforcing isolation practices.
Excerpts from the expert guidance include these recommendations:
- Studies designed to evaluate the role of visitors in the horizontal transmission of organisms should be performed.
- The use of isolation precautions among visitors should be guided by the specific pathogen, underlying infectious condition, and whether the organism involved is endemic in the hospital and community.
- For endemic situations with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), do not use contact isolation precautions for visitors in routine circumstances.
- Visitors to patients with MRSA or VRE who interact with multiple patients should use contact isolation practices.
- Consider utilization of contact precautions for visitors to patients colonized or infected with extensively drug-resistant Gram-negative organisms, such as Klebsiella pneumoniae carbapenemase (KPC).
The rationale for item #3 is that in many areas, MRSA and VRE are prevalent in the community and limiting visitor contact may not be effective in breaking the chain of transmission. No published studies have evaluated the impact of visitor adherence with contact precautions in reducing the spread of MRSA, VRE, or other multidrug-resistant organisms (MDROs).1 The question that arises: Is our commitment to visitors wearing gowns and gloves in the room of a family member who has MRSA or VRE (when the visitor will not be moving between rooms) based on historical practices or on science?
SHEA has taken an important step in helping infection preventionists (IP) develop logical policies regarding this topic by surveying their members to determine and analyze facility policies and practices then making rational recommendations. As a family member or friend, have you ever sat in the room of a patient in contact precautions for hours on end, having to wear a gown and/or gloves while you are just reading a book or watching TV? One size does not necessarily fit all and accommodations should be made based on visitor and patient interaction. As the guidance article states, most visitors do not visit more than one patient, and therefore do not pose the risk of transmission of pathogens from room to room that can occur via HCPs or shared patient equipment.
I encourage you to discuss this guidance article within your department and at your infection prevention and control committee. Do you already exempt visitors from contact precaution compliance? Let us know how it is working. If not, do you monitor visitors for compliance? If they do not comply, who has to explain the rationale to them – the patient’s nurse or the IP? If visitors still do not comply, are they removed by security resulting in a public relations nightmare.
For those of you who have been in this field for a long time, you may remember Marguerite Jackson’s classic paper “From ritual to reason – with a rational approach for the future: An epidemiological perspective”3 where she carefully plotted the steps in a hypothetical case to determine if an infectious organism could be transmitted to an employee by a food tray. This effectively began the demise of the cardboard food tray – and is still good reading. We may want to apply the same principal to having visitors routinely wear a gown and gloves when in the room of a patient with MRSA or VRE.
1. Munoz-Price LS, Banach DB, Bearman G, Gould JM, Leekha S, Morgan DJ, Palmore TN, Rupp ME, Weber DJ, Wiemken TL. SHEA Expert Guidance: Isolation Precautions for Visitors. Infect Control Hosp Epidemiol 2015;36 (7): 747-758.
2. Bearman G, Bryant K, Leekha S, Mayer J, Munoz-Price LS, Murthy R, Palmore T, Rupp ME, White J. SHEA Expert Guidance: Healthcare Personnel Attire in Non-Operating Room Settings. Infect Control Hosp Epidemiol 2014; 35(2):107-121.
3. Jackson MM. From ritual to reason – with a rational approach for the future: An epidemiological perspective. Am J Infect Control 1984;12(4):213-220.