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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

The Red Box—An Infection Control Strategy to Increase Communication?

NOV 26, 2018 | SASKIA V. POPESCU
Isolation precautions are a part of life when it comes to hospitalization to halt the spread of disease and prevent other patients and staff from becoming ill. The advent of “flu season” brings with it more isolation precautions in hospitals. The halls of just about any hospital unit will be peppered with isolation signage and more clinicians will be donning personal protective equipment (PPE) prior to patient care.

Although these methods are pivotal to patient and staff safety, donning and doffing PPE is time-consuming, and therefore, often a barrier for health care workers to make frequent visits to a patient’s room. This can often leave patients feeling isolated and create a negative association with isolation precautions for both the staff and patients during their hospitalization. It can also negatively impact medical care.

To circumvent these issues, investigators on a new study tested a strategy for supporting isolation precautions while encouraging more health care worker-patient interaction through the use of a “red box”.

Just like a red line in the operating room and peri-op areas, the red box was a visual reminder. It was a designated area on the floor of a patient’s room created using red duct tape that extended 3 feet beyond the door of the room, but stopped more than 6 feet from the patient. The use of PPE was required outside of the red box; however, while inside, the health care workers could communicate with the patient without the use of PPE, while still maintaining a safe distance from the patient and contact with the environment.  

The goal was simple. Health care workers like nurses, could be able to stop by to check and see if patients in contact and/or droplet isolation precautions (ie, patients with organisms spread through contact or coughing/sneezing, like influenza), needed anything without having to don/doff PPE for a momentary interaction, while still maintaining isolation precautions. [Patients in airborne isolation were excluded.]

The investigators tested the red box in 50 patient rooms over the course of 2 years in the intensive care unit (ICU) of a large tertiary hospital.

As health care worker perceptions were a significant part of this study, voluntary questionnaires were used as well as secret observers to study the use of the red box. Patient perceptions where gathered from patients in isolation who were interviewed prior to discharge regarding their experience with the red box. The investigators also monitored changes in health care-associated infections (HAIs) during the study time and PPE compliance to ensure it did not facilitate poor infection control practices.

A total of 146 surveys were completed and the results were quite interesting.

The health care workers were overwhelmingly supportive of the red box and felt it facilitated more communication and saved time. Furthermore, they reported that the red box lessened barriers to care for contact isolation. Health care workers reported feeling wholly comfortable using the red box without a mask if the patient was in droplet isolation. Most health care workers used the red box to provide updates and test results, as well as discuss dietary needs.

The “secret shopper” observations found that 76% of health care workers used the red box to communicate with patients in isolation rooms and 92% remembered not to don PPE during that time. A total of 80% of health care workers who went beyond the red box used PPE and practiced hand hygiene.

Patient satisfaction scores also increased during the study time, as did positive responses noting improved perception of the frequency of health care worker contact. A total of 92% of the patients interviewed reported that there was rounding by the health care provider/worker every hour during the time the red box was used. 

Finally, the investigators reported that the number of HAIs did not increase during the study time and there was a significant decrease in the number of HAIs in the second year of study compared with the last year without the red box.

Overall, there is still more work to be done surrounding the use of a red box or safe area for health care workers to communicate with patients in isolation while avoiding PPE. The most important aspect of this red box practice is to ensure health care providers do not become complacent in using PPE use or go beyond the red box without PPE. 

However, this study demonstrates the success of an easily implemented infection prevention and control strategy to facilitate better patient care and communication with health care workers. Improving communication and interactions between patients and health care providers while maintaining isolation precautions is a challenging dilemma; however, the use of the red box may be a solution. Moreover, the decrease in PPE use seen during this study (while still maintaining a safe distance from the patient) could be a cost-saving measure.
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