Reverse Isolation not recognized by CDC
Reverse isolation was eliminated as an isolation category by the Centers for Disease Control (CDC) in the mid 1980’s. There are three types of isolation: Transmission-Based (Contact), Airborne, and Droplet. Reverse Isolation was eliminated as it was not found to improve outcomes for neutropenic patients, and isolation is a negative experience for the patient.
Note: there is a CDC recognized Protective Isolation which is to be used for hematopoietic stem cells bone marrow transplant patients only.
Not being an official CDC isolation category hasn’t stopped the practice of Reverse Isolation. It does explain why there isn’t an order called Reverse Isolation in our (Cerner) computer system, or, in our hospital, why a laminated “Reverse Isolation” sign cannot be found among the pile of other laminated, colored isolation signs.
No worries- providers use free text to order it in the computer, and nurses hand-write “Reverse Isolation” signs to post on patient’s doors.
“Evidence does not support the use of reverse isolation in hospitals…the use of reverse isolation procedures should be discouraged as they are unlikely to be of benefit, and commonly cause anxiety and confusion for patients, families, and healthcare workers” Sheshadri and Baumann 2008.
Rationale for Use
When asked, nurses gave the following reasons:
- It feels right. It’s intuitive (if patient is neutropenic), it’s to shield my patient. (Even if they have been on chemo for months, and shop at Costco and stopped to get gas on their way in.)
- If the personal protective equipment (PPE) is on the cart outside the door, I’m putting it on!
- When in doubt, more PPE is better. So put it all on
- We’ve always done it that way
- The patient’s family expects it
- The doctor ordered it
These are some of the reasons it’s hard to change practice. Note that no one mentioned evidence as a reason. Some nurses passionately defend the practice. One of the problems is educating and reassuring patients and families, as well as educating nurses and providers.
Here’s a true recent example:
There is an isolation cart outside the room of Steven, a 26 year old chemo patient with neutropenia. The cart is piled with boxes of gloves, gowns, masks.
There is a crude handwritten sign on the door “Isolation- Check at nurses Station” Susie, the day shift RN, dons gown, gloves, and mask when entering the room. Albert, the night RN, wears a mask only.
The wife, who stays day and night, dutifully dons all (PPE) and even holds her husband’s hand while wearing nitrile gloves. The provider who ordered Reverse Isolation in the first place makes late rounds. He enters wearing his lab coat and no PPE, but gels his hands.
By now, the wife has a meltdown and doesn’t know what to do or who to believe. True story- the wife stood in the doorway and demanded “Does anyone know what they’re doing? Everyone tells me something different.”
So in addition to worrying about her husband, she now doesn’t trust her provider and caregivers to take care of her husband.
Neutropenic precautions are not a form of isolation. The CDC and Oncoloogy Nurses society (ONS) recommend not allowing fresh flowers or plants for immunocompromised patients. Remember that an apple can be washed, a banana and orange peeled, so they’re OK. Most hospitals don’t serve much fresh fruit, anyway! Visitors who are ill should remain home. Again, neutropenic precautions do not constitute isolation.
Finally, we all have to remember that hand hygiene is the optimal prevention, and it’s the most important thing we can do to protect our patients.
Until next time friend,
http://www.cdc.gov/hicpac/2007IP/2007ip_part2.html#e obtained 12.04.2014
http://www.oncologypractice.com/co/journal/articles/0511628.pdf obtained 12.03.2014
Sheshadri, S. and Baumann, M.Reverse isolation for Neutropenic Patients. Comunity Oncology. November 2008.