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Service Delivery Innovation Profile

Electronic Isolation Flags and Weekly Rounds by Infection Control Staff Improve Adherence to Contact Precautions


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Snapshot

Summary

Infection control staff at the University of Chicago Medical Center take an active role in ensuring that appropriate patients get placed on contact precautions. To that end, they review daily microbiology laboratory reports and electronically flag the medical record of patients infected with a multidrug resistant organism, indicating the need for private room assignment and a contact isolation sign on the door listing the rules for entrance. Infection control staff also conduct weekly surveillance rounds to ensure that contact precautions are being followed for each flagged patient. If not, they ask nurses to arrange such precautions and provide education to improve future adherence. The program led to a significant, sustained increase in adherence to contact precautions, with the percentage of flagged patients placed in isolation rising from 58 percent to 90 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the percentage of flagged patients placed on contact precautions.
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Developing Organizations

University of Chicago Medical Center
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Date First Implemented

2004
August

Problem Addressed

Infection with multidrug resistant organisms represents a growing problem in hospitalized patients. The spread of such infections can lead to severe health problems (including death) and higher costs. While contact precautions (i.e., patient isolation, use of gown and gloves, and associated communication strategies) can reduce the spread of infection, many facilities struggle to identify infected patients and adhere to such precautions consistently.1
  • Growing number of infections: The prevalence of multidrug resistant organisms in U.S. hospitals has grown steadily in recent decades. For example, in the early 1990s, methicillin-resistant Staphylococcus aureus (MRSA) accounted for about 25 percent of all Staphylococcus aureus infections in hospitalized patients; by 2003, that figure had risen to nearly 60 percent.2 Vancomycin-resistant enterococci (VRE) prevalence has also increased, from less than 1 percent of hospitalized patients in 1990 to approximately 15 percent in 1997.2 
  • Leading to severe health risks, high costs: While clinical signs of infection may or may not be apparent, severe cases can lead to severe morbidity and, in some cases, death. Numerous clinical studies have found that multidrug resistant organisms increase lengths of stay, use of one or more later-generation antibiotics, costs, and mortality.2
  • Failure to identify, isolate infected patients: The effectiveness of hospital-based activities to control the spread of infection depends primarily on identifying infected patients and placing them on contact precautions. Many hospitals do not consistently identify those in need of isolation, particularly those testing positive for infection during a previous admission who may require isolation during subsequent admissions (since patients can harbor a multidrug resistant organism for up to 30 months).1 When infected patients are identified, adherence to contact precautions remains a challenge, even with use of electronic reminders and alerts.1

What They Did

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Description of the Innovative Activity

Infection control staff at the University of Chicago Medical Center take an active role in ensuring that appropriate patients get placed on contact precautions. To that end, they review daily microbiology laboratory reports and electronically flag the medical record of patients infected with a multidrug resistant organism, indicating the need for private room assignment and a contact isolation sign on the door. They also conduct weekly rounds to ensure that contact precautions are being followed for each flagged patient. If not, they ask nurses to arrange such precautions and provide education to improve future adherence. Key program elements include the following:
  • Electronic flagging of infected patients: Each day, the microbiology laboratory sends a report to the hospital’s infection control team listing patients with a positive culture for a multidrug resistant organism. Infection control practitioners enter an “isolation flag” into each patient’s electronic medical record (EMR) indicating the need for contact precautions (assignment to a private room, placement of a contact isolation sign on the door, and use of a gown/gloves when entering the room). The system also identifies patients who tested positive during previous admissions and automatically flags their charts, thus eliminating the need for a physician order for isolation.
  • Institution of contact precautions by anyone: Hospital policy allows any staff member (such as infection control practitioners and nurses) to initiate contact precautions based on the isolation flag, even without a physician’s order. The typical process for implementing contact precautions is outlined below:
    • Private room assignment: Admissions personnel responsible for patient room assignments (called bed desk attendants) assign flagged patients to a private room. The EMR does not allow the attendants to override an isolation flag, even if a physician’s written orders do not include an isolation order. Patients whose subsequent cultures become positive during their hospital stay are moved to a private room if they are in a shared room.
    • Nurse notification of isolation orders: When bed desk attendants telephone the unit charge nurse to inform him or her of the new admission or transfer, they also indicate the patient’s need for contact precautions.
    • Door sign placement: Nurses retrieve a preprinted green sign from a folder at the nursing station and place it on the patient’s door. The sign indicates that all staff and visitors entering the room must wear a protective gown and gloves. The sign also reminds staff and visitors to remove their gown and gloves before exiting the room.
  • Weekly rounding by infection control staff: Infection control staff conduct surveillance rounds on flagged patients every Tuesday (the same day they conduct their usual rounds) to make sure that they have been placed in a private room with the sign on the door. To assist with this task, infection control staff print a patient census that includes notes on the need for contact precautions (typically only a few patients on each unit require isolation). If a patient needing contact precautions has not been placed in a private room with the sign on the door, the rounding staff member talks with the patient's nurse to ensure such precautions are taken immediately, and provides general education about the importance of such precautions and how to find the isolation flag in the system.
  • Educational posters to increase awareness: Posters explaining the importance of contact precautions and how to find the isolation flags hang on the walls of each hospital unit.

Context of the Innovation

A 500-bed academic medical center located on the south side of Chicago, the University of Chicago Medical Center treats roughly 25,00 inpatients annually, with approximately 15 percent requiring contact isolation for multidrug resistant organisms. During initial informal surveillance, the infection control team noticed that only about 55 to 65 percent of patients requiring contact precautions had been appropriately isolated, despite the fact that they had flagged patients needing isolation in the EMR. They became particularly concerned about patients who had previously tested positive for MRSA or VRE but had not been isolated during a subsequent inpatient stay.

Did It Work?

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Results

The program quickly led to a significant increase in the percentage of infected patients placed on contact precautions, with these improvements being sustained over time.
  • Significant, rapid rise in adherence to contact precautions: The program quickly improved adherence to contact precautions, with the percentage of flagged patients placed on such precautions rising from 58 percent at implementation to 90 percent 16 weeks after program launch.
  • Sustained over time: Over the next 4 years (2004 to 2008), staff achieved greater than 90-percent adherence to contact precautions roughly three-quarters (74 percent) of the time. Since then, adherence has generally remained above 90 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the percentage of flagged patients placed on contact precautions.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Education for bed desk attendants: Upon investigation, infection control personnel learned that bed desk attendants often removed electronic isolation flags if the physician’s orders did not request isolation. To address this issue, they held a brief meeting with admissions staff to educate them about the importance of isolation and explain that the system would be changed to prevent overrides.
  • Adjustment to prevent overrides: Information technology staff adjusted the electronic system so that the isolation flag could not be overridden.
  • Nurse education: Infection control personnel sent information to nurse managers, who then discussed contact precautions at a staff meeting and showed nurses where to find the flag both in the EMR and on the census report. Some nurses did not know how to find the flag on the patient census, while others did not realize that they could order isolation themselves (without a physician order).
  • Institution of weekly rounding: The infection control team added contact precaution surveillance to its weekly rounding activities, as described earlier.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines. Contact precaution surveillance requires roughly 20 minutes per week for each of six infection control staff (a total of 2 hours of rounding time weekly).
  • Costs: Program costs are minimal, consisting primarily of one-time costs to print the educational posters.
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Funding Sources

University of Chicago Medical Center
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Adoption Considerations

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Getting Started with This Innovation

  • Incorporate periodic surveillance: Education initiatives, including those related to contact precautions, can lose their impact over time as busy staff face conflicting priorities. Routine surveillance helps keep contact precautions top-of-mind among staff.
  • Assign responsibility to appropriate staff: Nurses may be overwhelmed with the number of daily tasks they must complete, including participation in various quality improvement initiatives. Assigning primary responsibility to other staff—in this case, infection control personnel—can ensure near-complete adherence to contact precautions.
  • Determine appropriate frequency for surveillance: Infection control personnel decided that weekly surveillance represented a reasonable and practical approach. While resource constraints made daily surveillance impossible, staff felt that biweekly or monthly surveillance would likely not capture a sufficient number of nonadherent cases, nor would it serve as an adequate reminder to nurses.

Sustaining This Innovation

  • Incorporate into existing workflow: By incorporating contact precaution surveillance into their regular rounds, infection control staff can monitor adherence and educate nurses without excessive disruption to their work. Consequently, rounding does not become an onerous task and can be sustained over time.

More Information

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Contact the Innovator

Emily Landon Mawdsley, MD
Instructor, Section of Infectious Diseases
Associate Hospital Epidemiologist
Medical Director, Antimicrobial Stewardship Program
University of Chicago Medical Center
Chicago, IL
Phone (773) 834-8167
E-mail: Emily.mawdsley@uchospitals.edu

Innovator Disclosures

Dr. Mawdsley has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Mawdsley EL, Garcia-Houchins S, Weber SG. Back to basics: Four years of sustained improvement in implementation of contact precautions at a university hospital. Jt Comm J Qual Patient Saf. 2010 Sep;36(9):418-23. [PubMed]

Footnotes

1 Mawdsley EL, Garcia-Houchins S, Weber SG. Back to basics: Four years of sustained improvement in implementation of contact precautions at a university hospital. Jt Comm J Qual Patient Saf. 2010 Sep;36(9):418-23. [PubMed]
2 Siegel JD, Rhinehart E, Jackson M, et al. The Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention. Management of multidrug-resistant organisms in healthcare settings, 2006. December 29, 2009. Available at: http://www.cdc.gov/hicpac/mdro/mdro_3.html
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Original publication: October 12, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.