Although hospital-acquired infections are reportedly declining, they continue to influence patient morbidity, mortality, and hospital costsReference Klevens, Edwards and Richards 1 ; therefore, the prevention of hospital-acquired infections remains a high priority in the United States.Reference Morgan, Pinele and Shardell 2 To improve infection prevention practices, several Department of Veterans Affairs (VA) and non-VA hospitals have used an innovative “safe zone” or “red tape zone” as a best practice.Reference Franck, Behan, Herath, Mueller and Marhoefer 3 , Reference Richmond, Bernstein, Creen, Cunningham and Rudy 4 A safe zone is a perimeter (typically demarcated by tape on the floor) in a patient’s room that identifies areas not requiring personal protective equipment (PPE). Previous studies have defined the safe zone as beyond an arm’s-length boundary from the patient bed, furniture, and other equipmentReference Muder, Cunningham and McCray 5 and a 3-foot red box extending from the threshold of the door.Reference Franck, Behan, Herath, Mueller and Marhoefer 3
The safe zone provides a visual reminder that the patient is in contact precautions, which may increase compliance with infection prevention practices.Reference Franck, Behan, Herath, Mueller and Marhoefer 3 – Reference Muder, Cunningham and McCray 5 Previous research suggests that healthcare workers (HCWs) are less likely to enter contact isolation roomsReference Franck, Behan, Herath, Mueller and Marhoefer 3 ; therefore, if utilization of a safe zone can reduce unnecessary PPE use, it may also increase patient/provider interaction for patients in contact isolation. In a prior study, a safe zone was cost-effective and reduced time spent donning PPE while increasing provider satisfaction and communication with patients.Reference Franck, Behan, Herath, Mueller and Marhoefer 3
Few studies have assessed safe zone utilization. One study found that approximately 30% of HCW interactions were performed within the safe zone in contact precaution rooms.Reference Franck, Behan, Herath, Mueller and Marhoefer 3 Furthermore, little is known about the interactions of HCWs in contact precaution rooms of patients with spinal cord injury/disorder (SCI/D). Owing to the limited mobility of SCI/D patients, HCWs may enter and exit rooms frequently and have many opportunities for patient contact. This study used secret observers to measure HCW activities and PPE compliance inside and outside of a hypothetical safe zone in patient rooms on inpatient SCI/D units. Because these patterns play a significant role in infection transmission, we also assessed variability in activities within the safe zone and by provider type (eg, nurse, physician) and patient contact precaution status.
METHODS
This was a prospective observational pilot study conducted in 2 SCI units at a large VA hospital. Each unit had 21 beds and included rooms with and without contact precautions. Direct observations were conducted from December 18, 2012, through March 22, 2013, to evaluate the opportunities when a potential safe zone could be used as well as compliance with PPE. The sample size was based on observation practices used by local infection control staff at the study hospital to collect regular hand hygiene compliance data. At the time of the study, infection control staff collected 20 observations from 3 observers for a total of 60 observations per month. This study was approved by the participating institutional review board and research and development committee.
Observers were trained research staff who assessed interactions among HCWs divided into 2 groups: (1) nursing staff (registered nurses and licensed practical nurses), and (2) medical staff (physicians, physician assistants, nurse practitioners) and allied health staff (eg, therapists, social workers, respiratory technicians). To reduce the Hawthorne Effect (ie, artificially increasing compliance rates owing to awareness of being observedReference Kohli, Ptak, Smith, Taylor, Talbot and Kirkland 7 ), the observers were staff involved in other research studies on the units who gathered data using the “secret shopper” method. Convenience samples of rooms were selected at various times of the day and week, with 5 rooms observed on average per day. To ensure a variety of interactions between HCWs and patients, observations were completed on numerous shifts throughout the week, with a minimum of 20 observations per shift.
The safe zone was defined as an area greater than 3 feet from all sides of the patient’s bed based on visible approximation (no tape on the floor). HCWs were unaware of our defined safe zone area. Observations were conducted as long as the patient’s door remained open. A patient encounter started when an individual entered the room and ended upon exit. Observers recorded details on a standardized data collection tool. Individuals were considered compliant with PPE if they donned gloves and gowns upon entry for contact precaution rooms. Any use of gowns was considered compliant, whether full or partial coverage (ie, not tying the gown at all).
Frequencies of PPE use, direct patient contact, and safe zone use as well as total HCW time in the room were calculated. These data were further stratified by HCW type, whether the patient was in contact precautions, and whether the HCW was within the safe zone. χ2 tests were used to obtain P values for assessing the association between PPE compliance and being in a safe zone. We considered P<.05 to be significant. All calculations were performed using SAS software, version 9.3 (SAS Institute).
RESULTS
During the study period, 191 visits were observed with an average duration of 6.48 minutes per observation/encounter. Among the total observations, 58.1% (111/191) were from nursing staff and 41.9% (80/191) from medical staff. Most patients were in contact isolation rooms (73.3% [140/191]), and 64.0% (121/189) of the encounters involved direct patient contact. Nursing staff had the highest frequency of encounters with direct patient contact (75.5% [83/110]), and all staff were more likely to have direct contact for patients in contact precaution rooms. Twenty-two percent (42/191) of all encounters, 17.1% (24/140) of contact precaution room encounters, and 58.8% (40/68) of encounters without direct patient contact remained within the safe zone. Medical staff were more likely to remain within the safe zone than nursing staff (30.0% [24/80] vs 16.2% [18/111]; P=.02).
Most HCWs donned gloves (66.4% [93/140]) or gowns (70.3% [97/138]) during encounters in contact precaution rooms (Table 1). PPE use was significantly lower for HCWs in the safe zone compared with HCWs outside of the safe zone. These findings were consistent when stratified by HCW type except there was no significant difference in medical staff compliance with gown use. Medical staff were more likely to comply with glove and gown use than nursing staff (Table 1). There were no significant differences in PPE compliance among HCWs in contact precaution rooms with no direct patient contact (Table 2). However, nursing staff were more likely to don gowns outside the safe zone than within the safe zone (55.6% [5/9] vs 10.0% [1/10]; P=.03) (Table 2).
TABLE 1 Compliance With Personal Protective Equipment (PPE) in Contact Precaution Rooms
NOTE. HCW, healthcare worker.
TABLE 2 Compliance with Personal Protective Equipment (PPE) in Healthcare Workers (HCWs) With No Direct Patient Contact in Contact Precaution Rooms
DISCUSSION
To our knowledge, this is the first study evaluating safe zone and PPE use among HCWs in an inpatient SCI unit. A noteworthy strength of this study was its unique ability to keep observers of HCW behavior secret because their presence was unquestioned by clinical staff on the units. Furthermore, our results showed that many encounters did not require direct patient or environmental contact. Specifically, 29.0% of encounters in contact precaution rooms included no direct patient contact, and it is these encounters that represent the potential for utilizing safe zones. Although our study showed a low percentage of HCWs who performed activities inside the safe zone (17.1%), HCWs may be more likely to remain in the safe zone with open implementation of a visible safe zone perimeter. Further research is needed to determine whether a demarcated visible perimeter increases safe zone activity and its impact on provider satisfaction and behavior.
PPE compliance rates in this study were consistent with previous studies.Reference Morgan, Pinele and Shardell 2 , Reference Gilbert 8 However, it is important to note that our study found higher PPE compliance rates among medical staff than nursing staff. Although this facility’s policy required HCWs to don PPE for contact precaution rooms, all HCWs in the safe zone were less compliant with PPE when compared with HCWs outside of the safe zone. There were no significant differences in these findings when analyzed by HCW type.
A limitation of this study is that it was a pilot conducted in a single facility with a small sample size and thus may not be representative of the larger non-SCI/D patient population. Furthermore, although observers were trained staff, there was likely imprecision in visually measuring a 3-foot safe zone. Moreover, there is limited evidence to support the concept that a 3-foot separation prevents transmission of infectious agents because some organisms could potentially contaminate surfaces or HCWs beyond the 3-foot perimeter. Also, our study did not account for the assumption of independence and multiple comparisons and may have overestimated the significance of results.
Despite these limitations, the safe zone intervention may be well suited to the SCI/D population, where patients often have overall low acuity but prolonged hospital stays requiring many nondirect contact interactions. SCI/D patients also have a high frequency of multidrug-resistant organisms resulting in contact precaution status and a high incidence of hospital-acquired infections.Reference Evans, LaVela and Weaver 9 Because transmission of multidrug-resistant organisms is largely dependent on direct patient or environment contact,Reference Morgan, Rogawski and Thom 10 medical staff who remain in the safe zone might be targeted for less restrictive PPE without appreciable increased risk of such transmission. This could provide significant cost savings for PPE and have an important impact on patient and provider satisfaction. Further research is needed to validate the findings of this study in a larger cohort to determine whether implementation of a safe zone with modified infection control measures improves patient/provider interaction without increasing multidrug-resistant organism transmission.
ACKNOWLEDGMENTS
We appreciate the work of Spinal Cord Injury Quality Enhancement Research Initiative staff for observations and VA infection control staff for observation practices.
Financial support. Health Services Research and Development Quality Enhancement Research Initiative (grant SCI 98-001).
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
Disclaimer. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
