When epidemiologically significant organisms or clinical indications for isolation are identified, actions must be taken by the patient care team to implement CP or other isolation precautions in an appropriate and timely manner. To assess the impact of CP on transmission dynamics and hospital resource utilization, it is essential to have accurate records of when, and for whom, CP are implemented. As more institutions adopt EHRs as their primary source of clinical documentation,18
the need for confidence in the accuracy and completeness of information entered into these records is critical. Electronic health records are recognized as rich sources of data, supporting not only requirements for mandatory reporting and reimbursement but also quality improvement and research initiatives.19,20
Inaccurate and inconsistent documentation limits the usefulness of electronic data for these purposes.21,22
Failure to document CP can also have a negative impact on infection control practices. A study by Vidal-Trecan et al23
found that the presence of a written provider order for isolation was the only observed factor that significantly improved implementation of isolation precautions.
To our knowledge, this is the first study to compare direct observation of isolation precautions with evidence of isolation recorded in an EHR. An electronic provider order and notation in nursing flow sheets for CP were simultaneously present for only 42.3% of patient rooms with CP signs, and 17.8% of rooms with CP signs had neither provider orders nor nursing documentation. Higher sensitivities for orders and nursing documentation were found for the last day of observation of each unique patient than for the first, indicating that CP documentation may improve over time. It is unclear whether this improvement is due to increased communication among the care team and with the Infection Prevention and Control Department, the ability of the EHR to display orders and nursing documentation from previous days, or some other factor.
The importance of consistent documentation of isolation practices and other procedures underscores the need for clear institutional policies regarding when, where, and how to record these measures. During the study period, hospital staff entered CP orders and recorded that isolation precautions were in place, despite the fact that these documentation practices were not required by infection control leadership at the time. The results of this study suggest that there was variation among staff in their understanding and/or execution of documentation procedures. Formal policies and training initiatives are necessary to standardize the way by which institutions document the implementation, continuation, and discontinuation of isolation protocols such as CP. Vendors and those who configure EHR systems can encourage appropriate documentation of CP by enhancing provider order entry systems and nursing flow sheets to automatically trigger prompts for isolation documentation when certain microbiology results become available. Consistency of nursing documentation for CP can be improved by constraining the choices of isolation categories to a uniform list.24
This study had some limitations. The first day of observation for each patient did not necessarily correspond with the first day that the patient was placed on CP, which limited our ability to draw conclusions about changes in rates of documentation over time. In addition, only specific provider orders for CP were extracted from the electronic record; general nursing orders, in which providers may have entered free-text comments requesting CP, were not evaluated. While the prevalence of general nursing orders that included a request for isolation precautions was not assessed, we believe that the ordering of CP via general nursing orders happened infrequently, and the availability of these data would not considerably change the results of the study. These limitations underscore the need for specific policies not only on what documentation is required but also on where to document isolation precautions and other procedures, because electronic charting systems often offer multiple entry fields.25
Although EHRs can be valuable sources of data, hospital administrators and researchers should carefully consider the validity of information gleaned from these systems at the aggregate level.
Because CP are recommended for interrupting transmission of pathogenic organisms in health care settings and also represent an economic burden to hospitals and a social burden to patients, we recommend that electronic surveillance systems be adopted for monitoring patients requiring isolation.8
While electronic surveillance systems are helpful for identifying patients who might require isolation precautions, hospitals should also consider reviewing the actions performed by members of the care team for patients indicated for CP. Among the actions that may be reviewed using EHRs are the placement of orders for isolation precautions by physicians or other providers and documentation of adherence to isolation precautions by nursing staff. Accurate and timely documentation is important for measuring the impact of infection control policies and interventions involving isolation precautions.