Do Contact Precautions Cause Depression?

STOP Contact Precautions?

Mike has written several time about his concerns for the side-effects of contact precautions. (see his kill contact precautions, personal view and adverse effects posts). His post "adverse effects" discusses Dan Morgan's systematic review that looked at the state of the literature measuring what has become dogma for many hospital epidemiologists and clinicians: contact precautions harm people. After completing this review, we weren't entirely comfortable with the literature, so we set out to complete our own series of studies seeking to assess the association between contact precautions and adverse outcomes. 

The first such study by Hannah Day, a PhD student working with Dan Morgan and me, has just been published in the March 2011 AJIC.  It was a pilot study that allowed us to gather baseline estimates to complete power calculations for the larger studies that will follow. She measured the baseline levels of depression and anxiety in patients admitted to non-ICU wards of an acute-care VA hospital. Of note: this study was a sub-study within an MRSA prediction-rule study that we'd published earlier and Dan Morgan posted on a few months ago. (see Veteran's Day MRSA post)

In 2009, 103 patients (20 on contact precautions and 83 unisolated) were approached within 48 hours of admission and received a questionnaire that included a body of questions called the HADS - Hospital Anxiety and Depression Scale. What did she find?  The HADS score was 2.2 points higher in patients on contact precautions (p=0.21).  The odds ratio for having either depression or anxiety was nearly twice as high on contact precautions (OR=1.87, 95% CI 0.61-5.69).  Yes, the study was under powered.  Intriguingly, the increased HADS scores associated with contact precautions exposure was higher in those patients newly isolated (<1 year since first isolated).

Before everyone gets too excited, what does a HADS score difference of 2.2 mean? Well, this study was too small to determine whether this increase was due to depression or anxiety.  Additionally, with the combined scale, a minimum difference of 3.0 is considered clinically significant.  Thus, even if there is an association, it may have little clinical meaning.  Finally, the HADS was measured on admission, so we were unable to determine if isolation "caused" the depression. To do that, we would need to do repeated measurements on admission and throughout the stay to see if there was a change in HADS later in the admission.  More exciting data to come...

Day HR et al. Am J Infect Control March 2011

DHHS releases 2010 Adverse Events in Hospitals report

The Department of Health and Human services just released an 81-page report titled: Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. Using a nationally representative random sample of 780 Medicare beneficiaries discharged in October 2008, physicians determined (1) whether an adverse event occurred, (2) whether the event was an NQF Serious Reportable Event or a Medicare hospital-acquired conditions, (3) what the level of harm was to the patient, and (4) whether the event was preventable.  Using this sample, they estimated that 13.5% of all hospitalized Medicare patients experienced an adverse event and in 1.5% the AE contributed to their deaths.  These extrapolate to 134,000 adverse events and 15,000 deaths in a single month. Multiply by 11.7498 (or 365.2425/31) if you want yearly estimates for an average year.  Yes, I'm being a smart a**, but multiplying by 12 is incorrect.

One thing we're always concerned about on this blog is the percent of HAIs that are actually preventable in the current 'get to zero' world that we live in.  In the DHHS report, physicians estimated that 44% of the AEs were preventable, 51% were not preventable and in 5% they were unsure.  The costs were $324 million in October 2008 or 3.5% of all hospitalization costs. They suggest that the FY2009 attributable costs of AEs were $4.4 billion, with two-thirds of the costs being associated with extended hospital stays.

So what about HAIs?  Table 3 in the report classifies the 128 AEs into categories and 19 or 15% of the AEs were HAIs.  Thus, 2.5% of all hospitalized Medicare patients had an HAI. There were 5 UTIs, 4 CLABSI, 4 other BSI, 4 RTIs and 2 SSIs.  The physicians classified only 60% of the infections as preventable.  I wonder if this will help Mike achieve one of his wishes for the 2010 New Year? I could probably dig deeper but I've got work to do and I don't want to ruin all of your fun.

Link: November 2010 DHHS Adverse Events in Hospitals report.

h/t: Megan McKenna

Adverse effects of contact precautions

There's a new systematic review on the adverse effects of contact precautions in the Journal of Hospital Infection. This paper's methods and findings are very similar to Dan Morgan's paper (with Dan Diekema, Kent Sepkowitz and Eli Perencevich as co-authors) from last year. There are a few papers that are not found in both reviews, but no newer papers are covered in the new review. The conclusions of the two papers are largely the same:  contact precautions are overall associated with adverse unintended consequences for patients in the observational studies that have been published.