Journal of Gerontological Nursing

EDITORIAL 

"Isolation" in the Nursing Home Setting

Marguerite McMillan Jackson, RN, PhD, CIC, FAAN

Abstract

When Í came back from the hospital, they put me in isolation.. .they had to put on gowns and masks and gloves before they could come near me.. .!felt so badly because it was so contagious that I felt like a leper and I felt so unclean...! was away from my friends...! had to have paper cups and paper plates and plastic tableware and it had to be thrown away after every meal... I was not allowed out of the room at «//... (Larson, 1985).

These observations were made by a nursing home resident over a decade ago in an interview describing her experience being placed "on isolation" after Salmonella organisms were identified in a stool culture taken in the hospital (Jackson & Lynch, 1987). There was no outbreak of Salmonella going on at the time in either the nursing home, the hospital, or the community, so it is unlikely that the Salmonella was a new infection. It is possible that the Salmonella had been in her gall bladder for a long time, causing no problems until she had a gastrointestinal upset during hospitalization. Had the resident not gone to the hospital, she would not have been cultured. Had she not been cultured, the Salmonella would not have been discovered. Without the culture results, she would not have been put "on isolation" when she returned to the nursing home, and her life there would have gone on as usual. Even though more than 12 years have passed since this interview, many nursing homes still use diese strategies to "isolate" residents when certain organisms are identified with microbiology cultures. These practices are not based on science but on fear and misunderstanding of what really makes a difference in infection prevention and control.

The process described above starts when nursing home residents are transferred to acute care hospitals, and have microbiology cultures done as part of a diagnostic evaluation. Since organisms are always present in sputum, stool, wound drainage, and decubitus sites, and sometimes present in urine and blood, it is very common for the laboratory to report out a variety of organisms. Sometimes these organisms are resistant to a number of different antibiotics. Sometimes the organisms are given labels such as MRSA (methicillin-resistant Staphylococcus aureus) or VRE (vancomycin-resistant enterococcus) that strike terror in the hearts of many nursing home personnel who do not want to accept the resident back to their care. Many times, these organisms are not causing any illness ("infection") but are merely present ("colonization") in the resident's body. They have often been present for a long time, but were undetected because the resident is rarely cultured in the nursing home. Using results of cultures taken in an acute care hospital to make placement decisions in nursing homes is fraught with major problems, not to mention the severe psychological stresses for residents so clearly articulated above. For the sake of the residents and the facilities they call home, I would like to see these attitudes and beliefs change. This can happen best with accurate information based on science used in the context of the nursing home setting.

Some excellent new guidelines have recently been published that will be very helpful. The most focused for nursing homes was recently published by the California Department of Health Services as a Guideline for prevention of antibiotic resistant microorganisms in California longterm care facilities (1996). (See pages 40-47, this issue.) It provides very useful information to assist nursing homes in dealing with this complex issue, and makes the point that the nursing home is the resident's home, and "isolation" as described above is…

When Í came back from the hospital, they put me in isolation.. .they had to put on gowns and masks and gloves before they could come near me.. .!felt so badly because it was so contagious that I felt like a leper and I felt so unclean...! was away from my friends...! had to have paper cups and paper plates and plastic tableware and it had to be thrown away after every meal... I was not allowed out of the room at «//... (Larson, 1985).

These observations were made by a nursing home resident over a decade ago in an interview describing her experience being placed "on isolation" after Salmonella organisms were identified in a stool culture taken in the hospital (Jackson & Lynch, 1987). There was no outbreak of Salmonella going on at the time in either the nursing home, the hospital, or the community, so it is unlikely that the Salmonella was a new infection. It is possible that the Salmonella had been in her gall bladder for a long time, causing no problems until she had a gastrointestinal upset during hospitalization. Had the resident not gone to the hospital, she would not have been cultured. Had she not been cultured, the Salmonella would not have been discovered. Without the culture results, she would not have been put "on isolation" when she returned to the nursing home, and her life there would have gone on as usual. Even though more than 12 years have passed since this interview, many nursing homes still use diese strategies to "isolate" residents when certain organisms are identified with microbiology cultures. These practices are not based on science but on fear and misunderstanding of what really makes a difference in infection prevention and control.

The process described above starts when nursing home residents are transferred to acute care hospitals, and have microbiology cultures done as part of a diagnostic evaluation. Since organisms are always present in sputum, stool, wound drainage, and decubitus sites, and sometimes present in urine and blood, it is very common for the laboratory to report out a variety of organisms. Sometimes these organisms are resistant to a number of different antibiotics. Sometimes the organisms are given labels such as MRSA (methicillin-resistant Staphylococcus aureus) or VRE (vancomycin-resistant enterococcus) that strike terror in the hearts of many nursing home personnel who do not want to accept the resident back to their care. Many times, these organisms are not causing any illness ("infection") but are merely present ("colonization") in the resident's body. They have often been present for a long time, but were undetected because the resident is rarely cultured in the nursing home. Using results of cultures taken in an acute care hospital to make placement decisions in nursing homes is fraught with major problems, not to mention the severe psychological stresses for residents so clearly articulated above. For the sake of the residents and the facilities they call home, I would like to see these attitudes and beliefs change. This can happen best with accurate information based on science used in the context of the nursing home setting.

Some excellent new guidelines have recently been published that will be very helpful. The most focused for nursing homes was recently published by the California Department of Health Services as a Guideline for prevention of antibiotic resistant microorganisms in California longterm care facilities (1996). (See pages 40-47, this issue.) It provides very useful information to assist nursing homes in dealing with this complex issue, and makes the point that the nursing home is the resident's home, and "isolation" as described above is rarely, if ever, indicated. In addition, the Centers for Disease Control and Prevention (CDC) have recently published their 1996 Guideline for Isolation Precautions in Hospitals (Garner, 1996) that may be helpful to nursing homes, although the CDC is clear to point out that the Guideline is primarily for acute-care hospitals. A series of commentaries about the CDC Guidelines will be published in the June 1996 issue of the American Journal of Infection Control (Soule, 1996) that address some of the controversies and problems with implementation of the 1996 Guideline in both acute care and other settings.

I hope this information and these new resources will be of value to readers who work in the nursing home setting as well as readers who are advocates for compassionate care of geriatric patients in acute and long-term care settings.

REFERENCES

  • California Department oí Health Services. (1996, January 17). Guideline for prevention and control of antibiotic resistant microorganisms in California longterm care facilities. Sacramento, CA: California Department of Health Services, Department of Licensing and Certification.
  • Garner, J.S., & Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. (1996). Guideline for isolation precautions in hospitals. Infection Control and Hospital Epidemiology, 17, 53-80.
  • Jackson, M.M., & Lynch, P. (1987). An alternative to isolating patients. Geriatric Nursing, 8, 308311.
  • Larson, A.A. (1985). Rifes versus rights: Isolation procedures: Unwarranted impingement on patient freedom. (Videotape). Olympia, WA: Bureau of Nursing Home Affairs, Department of Social and Health Services.
  • Soule, B.S. (Ed.) (in press). Invited commentaries by Beth Stover, Gary Preston, Marguerite Jackson and Patricia Lynch in response to the 1996 CDC guideline for isolation precautions in hospitals. American Journal of Infection Control.

10.3928/0098-9134-19960501-05

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