A doctor stops a fellow physician in the hallway. “I have a patient with MRSA, influenza, C. diff and TB.”

“Geez, that’s horrible. What do you do for a patient like that?”

“I have him on a special diet of pancakes and flounder.”

“Pancakes and flounder! My god, that’s revolutionary! Does it work?”

“I don’t know. It’s the only thing that’ll fit under the door.”

I recently saw a young woman who was admitted for a GI bleed. During her admission, she developed a fever and a zealous physician ordered blood cultures and a rapid influenza swab. Knowing that influenza was unlikely in this patient with no respiratory symptoms, I discontinued the influenza swab, but not before infection control swept in and tossed the patient into airborne respiratory isolation. An overly zealous nurse obtained the swab despite my cancellation. Not surprisingly for a patient with no respiratory symptoms, her rapid influenza was negative. I wrote an order to discontinue respiratory isolation. The next morning, there she was, trapped behind the crime-scene tape that crosses the doors of patients in isolation, with an empty box of N95 masks outside her door. I asked why nobody had removed her from isolation as I’d asked. The answer: since she’d been swabbed for flu, she had to serve 7 days in isolation.

Nevermind that this is not in accordance with CDC guidelines, which recommend a surgical mask instead of an N95 mask–a recommendation based on good evidence. The same guidelines recommend droplet precautions, not airborne isolation. This is also supported by evidence, such as an Annals of Internal Medicine article that found airborne transmission, if it occurs, is not “a frequent enough occurrence to be of significant concern when considering control measures for most clinical settings.” These two things are probably being overcautious, but they are harmful to nothing except my hospital’s bottom line. If they have the money to spend on N95 masks, I’ll wear them. If they have the negative pressure rooms to use, then they are welcome to use them.

I am concerned with the bigger question: is my patient harmed by being in isolation. The answer is yes. Studies have shown that healthcare providers are half as likely to enter the room of patients in contact isolation. But a generally well-done article in JAMA lays out the actual harms that come from isolation. Of note, patients in isolation:
        - have 2.9 times as many days without a recorded physician progress note
        - are 7 times as likely to have a preventable adverse event
        - are far more likely to express dissatisfaction with their care

As the study authors conclude, the benefits associated with isolating those at risk of transmitting infection within the hospital must be balanced with the known individual risks associated with placing a patient in isolation. In the case of my patient, even if the transmission rate of influenza was 100%, her risk of an adverse event from being in isolation was much higher than her risk of transmitting flu–given her very low risk of flu in the first place. These considerations are especially important when we are talking about 7 days in isolation for suspected flu, or for indefinite isolation for MRSA carriage. We have an obligation to the public health, but we cannot jeopardize the patient in front of us.