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Research Letter |

Do Physicians Spend Less Time With Patients in Contact Isolation?  A Time-Motion Study of Internal Medicine Interns FREE

Cody N. Dashiell-Earp, MD, MBA1; Douglas S. Bell, MD, PhD1,2; Alexis O. Ang, MD, MPH1; Daniel Z. Uslan, MD, MS1,3
[+] Author Affiliations
1Department of Internal Medicine, David Geffen School of Medicine at University of California, Los Angeles
2Biomedical Informatics Program at the Clinical and Translational Science Institute, University of California, Los Angeles
3Division of Infectious Diseases, University of California, Los Angeles
JAMA Intern Med. 2014;174(5):814-815. doi:10.1001/jamainternmed.2014.537.
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Published online

The use of contact isolation precautions for patients colonized or infected with drug-resistant or easily transmissible organisms is a widely accepted strategy for reducing transmission of hospital-associated infections. Although hospitals throughout the country have implemented these practices at great logistical and financial expense, there are few high-quality data to support their use.

Isolation precautions have unintended consequences, including a reduction in time spent with health care providers, lower patient satisfaction, and more preventable adverse events.13 Only a few small studies have measured the impact of contact isolation on time spent by health care providers with patients. Given recent advances in spatial tracking technology, we set out to measure differences in time spent by internal medicine interns with patients in contact isolation rooms compared with those in nonisolation rooms.

The study was approved by the University of California, Los Angeles institutional review board. Using tracking devices attached to hospital identification badges, we collected real-time data on the location of 15 internal medicine interns working in our hospital between October 1, 2012, and December 31, 2012. The devices work by emitting radio-frequency identification (RFID) signals to a network of receivers located throughout our hospital. Based on the strength of the signal relative to the receivers, the location of the asset can be mapped to within a 5-foot radius.

For each intern, the tracking system recorded exact start and end times for each specific location they entered in the hospital. By combining these data with data on the isolation status of each room on a ward where all patients have individual rooms, we were able to compare time spent in isolation vs nonisolation rooms. New patient admissions typically occur in the Emergency Department, and therefore the encounters on the selected ward were primarily patient follow-up visits. SAS software, version 9.3 (SAS Institute Inc), was used to create a mixed model, and individual interns were used as random effects in the model.

There were 1156 encounters with isolated patients and 2467 encounters with nonisolated patients over 3 months of continuous observation. Interns visited isolated patients less often (2.3 visits per day compared with 2.5 visits per day) (P < .001) and spent less time per visit with isolated patients (2.2 minutes per visit compared with 2.8 minutes per visit) (P < .001) (Figure and Table). Thus, on average, interns spent 5.2 minutes per day with each of their isolated patients compared with 6.9 minutes per day with each of their nonisolated patients (P < .001).

Place holder to copy figure label and caption
Figure.
Average Time per Visit Spent by Interns to Isolation vs Nonisolation Rooms

Each data point represents 1 intern. Dashed line shows where values would be if time in isolation and nonisolation rooms were equal. Solid line shows the least-squares regression for the relationship between isolation room and nonisolation room time among interns (Pearson r = 0.65). There were 15 total observations.

Graphic Jump Location
Table Graphic Jump LocationTable.  Mean Time Spent by Each Intern per Visit to Isolation vs Nonisolation Rooms

We were surprised to discover that interns spend little time in direct contact with their patients, and even less time with those patients in contact isolation. Interestingly, in the most recent time-motion study of intern work flow, Block et al4 found that interns spent an average of 7.7 minutes per follow-up visit per day, which is comparable to our average of 6.9 minutes per patient per day for nonisolation patients. Nevertheless, the fact that trainees spend less time with isolated patients might explain why these patients experience more adverse events and have lower overall satisfaction,3,5 particularly if senior residents and attending physicians exhibit the same behavior.

Our results support a growing body of literature suggesting that contact precautions may impede patient care. Infection prevention strategies that minimize the barrier between physicians and patients, including hand hygiene, antimicrobial stewardship, and, as has recently been suggested, universal decolonization,6 should continue to be investigated because these methods may be more effective at reducing the spread of resistant organisms and less disruptive to patients. Further research is needed, both to better define the patient population for whom the benefits of contact isolation outweigh the risks and to develop strategies to ameliorate those risks for those who must be placed into isolation.

Corresponding Author: Cody N. Dashiell-Earp, MD, MBA, Department of Internal Medicine, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Ste 7501, Los Angeles, CA 90095-7417 (cdashiellearp@mednet.ucla.edu).

Published Online: March 31, 2014. doi:10.1001/jamainternmed.2014.537.

Author Contributions: Dr Dashiell-Earp had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Dashiell-Earp, Uslan.

Acquisition of data: Dashiell-Earp, Bell, Uslan.

Analysis and interpretation of data: Dashiell-Earp, Bell, Ang, Uslan.

Drafting of the manuscript: Dashiell-Earp.

Critical revision of the manuscript for important intellectual content: Dashiell-Earp, Bell, Ang, Uslan.

Statistical analysis: Bell, Ang.

Administrative, technical, and material support: Dashiell-Earp, Bell.

Study supervision: Uslan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was funded in part by National Institutes of Health (NIH) grant UL1TR000124.

Role of the Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We would like to thank Carlene Anteau, MS, RN, and Bianca Christenson, MBA, MPH, of Awarepoint Corporation for donating the RFID tags and for their technical support. Neither they nor Awarepoint received compensation for their contributions, and they were not involved in the data analysis.

Aboelela  SW, Saiman  L, Stone  P, Lowy  FD, Quiros  D, Larson  E.  Effectiveness of barrier precautions and surveillance cultures to control transmission of multidrug-resistant organisms: a systematic review of the literature. Am J Infect Control. 2006;34(8):484-494.
PubMed   |  Link to Article
Cooper  BS, Stone  SP, Kibbler  CC,  et al.  Isolation measures in the hospital management of methicillin-resistant Staphylococcus aureus (MRSA): systematic review of the literature. BMJ. 2004;329(7465):533.
PubMed   |  Link to Article
Stelfox  HT, Bates  DW, Redelmeier  DA.  Safety of patients isolated for infection control. JAMA. 2003;290(14):1899-1905.
PubMed   |  Link to Article
Block  L, Habicht  R, Wu  AW,  et al.  In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013;28(8):1042-1047.
PubMed   |  Link to Article
Mehrotra  P, Croft  L, Day  HR,  et al.  Effects of contact precautions on patient perception of care and satisfaction: a prospective cohort study. Infect Control Hosp Epidemiol. 2013;34(10):1087-1093.
PubMed   |  Link to Article
Huang  SS, Septimus  E, Kleinman  K,  et al; CDC Prevention Epicenters Program; AHRQ DECIDE Network and Healthcare-Associated Infections Program.  Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Average Time per Visit Spent by Interns to Isolation vs Nonisolation Rooms

Each data point represents 1 intern. Dashed line shows where values would be if time in isolation and nonisolation rooms were equal. Solid line shows the least-squares regression for the relationship between isolation room and nonisolation room time among interns (Pearson r = 0.65). There were 15 total observations.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Mean Time Spent by Each Intern per Visit to Isolation vs Nonisolation Rooms

References

Aboelela  SW, Saiman  L, Stone  P, Lowy  FD, Quiros  D, Larson  E.  Effectiveness of barrier precautions and surveillance cultures to control transmission of multidrug-resistant organisms: a systematic review of the literature. Am J Infect Control. 2006;34(8):484-494.
PubMed   |  Link to Article
Cooper  BS, Stone  SP, Kibbler  CC,  et al.  Isolation measures in the hospital management of methicillin-resistant Staphylococcus aureus (MRSA): systematic review of the literature. BMJ. 2004;329(7465):533.
PubMed   |  Link to Article
Stelfox  HT, Bates  DW, Redelmeier  DA.  Safety of patients isolated for infection control. JAMA. 2003;290(14):1899-1905.
PubMed   |  Link to Article
Block  L, Habicht  R, Wu  AW,  et al.  In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013;28(8):1042-1047.
PubMed   |  Link to Article
Mehrotra  P, Croft  L, Day  HR,  et al.  Effects of contact precautions on patient perception of care and satisfaction: a prospective cohort study. Infect Control Hosp Epidemiol. 2013;34(10):1087-1093.
PubMed   |  Link to Article
Huang  SS, Septimus  E, Kleinman  K,  et al; CDC Prevention Epicenters Program; AHRQ DECIDE Network and Healthcare-Associated Infections Program.  Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
PubMed   |  Link to Article

Correspondence

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