1. Isolation and Modified Contact Precautions Exercise for MDROs
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

2. Objectives
Familiarize participants with CDC MDRO guidelines for patient placement
Discuss advantages and disadvantages of placement choices
Discuss appropriate placement of hand sanitizer in a facility
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

3. Choices for Placement Private room Cohort with roommate with same MDRO
highest priority to those patients who have uncontained secretions or excretions
Place with non-colonized roommate IF:
Roommate has NO immunosuppression or broken skin or indwelling lines or renal failure AND
Both roommates can wash hands AND
No draining wound AND
VRE or MDRGNB patient DOES NOT HAVE urinary or fecal incontinence
As you know, the best choice for patients colonized or infected with multi-drug resistant organisms is a private room. However, private rooms are often not available in many nursing homes.
So, the second-best choice is to cohort patients with a roommate who has the same MDRO. That means putting a patient who has MRSA with a roommate who also has MRSA or a patient who has VRE with a roommate who also has VRE. You would NOT put a patient with MRSA with a patient who has VRE. Why not?
{pause for answer from the audience}
The answer is that both roommates might become colonized with MRSA and VRE, and that’s enough of a problem …. However, even worse is that you might have transfer of genetic material from the vancomycin-resistant Enterococcus to the Staphylococcus aureus and end up with vancomycin-resistant Staphylococcus aureus, and that’s very serious.
So, to summarize, if two patients have the same MDRO, they can room together. If they have different MDROs, they usually cannot.
But sometimes you have limited rooms and cohorting is not possible. So, third choice is to place a colonized resident with a low risk non-colonized resident. You can do this if:
The non-colonized resident is not immunosuppressed, does not have broken skin (including fresh post-operative wounds), does not have indwelling lines such as central lines, foley catheters, etc., and does not have renal failure.
Both roommates need to be able to wash their hands.
Neither roommate can have a draining wound. That, of course would be very high risk for transmission.
And the colonized patient must not be incontinent of urine or feces. That’s particularly important for organisms shed in the stool such as resistant gram negative rods or vancomycin resistant enterococcus.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

4. What is the risk of transmission FROM this patient?
85 year old with a history of MRSA and:
No active infection
No acute medical problems
Indwelling central line s/p cancer chemotherapy
Able to wash hands on request
In order to cohort patients safely, you have to consider the risk of transmission FROM the patient as well as the risk of transmission TO the patient.
What is the risk of transmission FROM this patient? Does this patient need to be placed on contact precautions?
(allow discussion).
The risk is probably fairly low. This patient is colonized with MRSA but does not have uncontrolled secretions or excretions. The patient can wash hands on request.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

5. What is the risk of transmission TO this patient?
85 year old with:
No active infection
No acute medical problems
Indwelling central line s/p cancer chemotherapy
Able to wash hands on request
In order to cohort patients safely, you have to consider the risk of transmission FROM the patient as well as the risk of transmission TO the pa
So, what is the risk of transmission TO this patient?
(wait for answer)
The risk of transmission to this patient is higher in that he or she has an indwelling central line, so this is not a low risk patient. You could not place this patient with someone who has an MDRO
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

6. What is the risk of transmission from this patient?
85 year old with:
History of CRE
History of MRSA
Diarrhea due to Clostridium difficile
What is the risk of transmission FROM this patient?
(wait for answer)
You have at least two diseases to think about: CDI and CRE, both of which are shed in the feces. This is a very high risk patient, and have to be very careful about placement of this patient.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

7. What is the risk of transmission to this patient?
75 year old
Hypertension and CAD
s/p total knee replacement
Admitted for rehabilitation
And this patient .. Risk of transmission to this patient?
(wait for answer)
This patient has had recent surgery with placement of a prosthetic joint. This patient is a high risk patient and you should not place a patient with an MDRO with this patient.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

8. Modified Contact Precautions
Healthy residents:
Standard precautions
Gloves and gowns for contact with:
uncontrolled secretions,
pressure ulcers,
draining wounds,
stool incontinence and
ostomy tubes/bags
Residents dependent on staff for health and activities of daily living: contact precautions.
Contact precautions in long term care are more difficult than acute care because you can’t just apply the same rules to everyone. If you have a fairly healthy resident who is ambulatory, you can’t confine him or to his room for the rest of his life. That’s inhumane. So we have something called ‘modified contact precautions’ in nursing homes.
For healthy residents with MDROs, it is recommended that they be treated with standard precautions. The healthcare provider should wear gloves and gowns for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence and ostomy tubes or bags.
If the resident is dependent on staff for activities of daily living, then the person should be placed on contact precautions.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

9. Modified Contact Precautions (2)
PRIVATE ROOM OR COHORT
GLOVES
Touching the patient’s intact skin
Touching surfaces and articles in close proximity to the patient. 
Don gloves upon entry into the room.
GOWN
Clothing will have direct contact with the patient
Clothing will have contact with environmental surfaces or equipment in close proximity to the patient. 
Don gown upon entry into the room.  
Remove gown / gloves and observe HH before leaving the patient-care environment. 
How do you implement contact precautions? Remember if you are using contact precautions, you are protecting yourself against CONTACT with the patient or the patient-care environment. So, you will have gloves and gowns available right outside the door.
The healthcare provider must wash hands before entering the room and put on gloves and/or gown as follows:
Gloves are required for touching the patient or any surfaces and articles in the patient room. Gloves should be donned upon entry into the patient room.
Gowns are required if clothing will have direct contact with the patient or environmental surfaces in the patient room. Gowns should be donned upon entry into the patient room.
The healthcare provider should remove gowns and gloves and perform hand hygiene before leaving the patient room.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

10. Duration of Contact Precautions
Outbreak setting: continue contact precautions indefinitely for colonized and infected persons.
How long does someone who is colonized … or infected … have to stay on contact precautions?
It depends.
If you have an outbreak, they have to stay on contact precautions indefinitely. That’s right. If you are having ongoing transmission of the MDRO / if you are continuing to see new cases, then contact precautions must be maintained.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

11. Duration of Contact Precautions (2)
Non-outbreak setting: after antibiotics are discontinued for several weeks AND
the patient does not have a draining wound or uncontained secretions AND
there is no evidence of ongoing transmission in the facility AND
3 surveillance cultures one week apart are negative, contact precautions may be discontinued.
However, if you are not having an outbreak in your facility … if you are not having transmission; THEN you can follow this protocol to get your patient off contact precautions.
First, the patient has to be OFF ANTIBIOTICS for several weeks.
Second, the patient cannot have a draining wound or uncontrolled secretions.
Third, you must have no evidence of transmission within the facility. That means your infection control is stellar.
If you can meet all 3 criteria, you can check 3 surveillance cultures one week apart. If all 3 cultures are negative, contact precautions may be discontinued.
Those are very stringent criteria.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

12. ‘Rules’
Distribute 4 cards (patients) to each person. Place the remaining cards in a pile. Roll dice to determine who goes first.
Follow the ‘Modified contact precautions’ guidelines to ‘place’ one patient during your turn. “Place” a patient by putting the card on an open bed.
If you cannot ‘place’ a patient because all beds are full, roll the dice to identify the room (1-6), and flip a coin (heads = ‘window’ and tails = ‘hallway’) to identify the bed. The ‘patient’ in that bed is then removed and placed on the bottom of the pile.
If you do not have a suitable patient in your hand, draw from the pile until you find a patient appropriate for placement in the available bed(s).
Place hand hygiene dispensers appropriately.
Now we are going to play a game to see how much you know about patient placement. Each group should have a map of a nursing home on a roll of paper. To play the game, shuffle your cards (or patients), and give 4 cards to each person. Place the remaining cards in a pile on the table.
Roll your dice to determine who goes first.
Follow the ‘modified contact precautions’ guidelines to ‘place’ a patient in the nursing home. When you ‘place’ a patient, you simply put a card on top of a bed in the nursing home.
You will have to pay attention to whether your patient is colonized or infected with an MDRO. You will also have to pay attention to overall patient health, patient gender and other factors.
If you cannot ‘place’ a patient because all the beds are full, roll the dice to identify the room (1 through 6), and flip a coin to identify the bed (heads indicates the window bed and tails indicates the hallway bed). The ‘patient’ in that bed is then ‘discharged’ from the facility by placing him or her on the bottom of the pile.
If you cannot ‘place’ a patient because you do not have a suitable patient in your hand, draw from the pile until you identify an appropriate patient for placement in your nursing home.
Give your nursing home a name, and place hand hygiene dispensers throughout your nursing home so that dispensers are convenient for staff to use while engaged in patient care.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

13. Discussion Facilitator:
Choose a table (or two) and ask them to explain the patients they have placed together in a room and why they made that decision.
Choose a table (or two) and ask them to explain the decisions that they made regarding placement of hand hygiene dispensers.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services

14. Questions for Discussion
Did you run into any challenges in placing patients?
How would you resolve those challenges in your own facility?
What particular problems were created by the shared bathrooms?
How did you handle the C diff patients?
Will you change anything in your own facilities based on what you learned from this exercise?
Where did you put the HH dispensers?
Note to facilitator: after an appropriate interval, lead a discussion using these questions.
Division of Infectious Disease Epidemiology Office of Epidemiology and Prevention Services