The dilemma of medical isolation

Isolation saves lives but crushes the spirit. It is sometimes inevitable and always devastating. Isolation protects us and those around us, but it can cost us our humanity. This is the dilemma of medical isolation: we need isolation to fight disease, but isolation itself can make us sick.

The past year has taught most of us what isolation is and what its consequences can be. We got to know social distancing, quarantine, lockdowns, and isolation in hospital wards. Of course, medical isolation is almost as old as medicine itself and will be with us beyond this pandemic.

In the past, however, isolation and its negative impact have never been center stage. One reason being that when patients enter isolation they literally disappear. And with all medical conditions that are out of sight they are also, to a degree, out of mind. COVID-19 changed that. That’s why now is the time to think about how we want to approach isolation in the future.

I am Dr Judith Brand of Sphaira Medical and this is the first installment in a series of articles about medical isolation where we want to explore its benefits, dangers, and suggest ways to improve the conditions of those who must undergo it.

Isolation comes in many shapes and sizes

So what exactly is medical isolation, where does it take place, what are its effects on health care quality, mental health and patient outcomes?

First, we need to distinguish between regular isolation and reverse isolation. The former describes a medical need to set precautions against the spread of an infectious agent from a colonized patient. Depending on the kind of colonizing germ, its transmission path and pathogenicity, the severity of isolation precautions vary. For example, the Norovirus causing severe gastroenteritis, is highly infectious, but it is only transmitted through smear infection.

We need other types of protective care to prevent it from spreading than, say, a tubercle bacterium, which a patient can transmit by coughing and thereby cause a droplet infection. Patients colonized by the same germ, can sometimes be in a cohort isolation room.

This setting differs from reverse isolation, in which the patient must be protected from the outside world because of his or her weakened immune system. Everyday germs that colonize the skin of a healthy person without adverse effects can cause serious and fatal infections in an immunocompromised patient.

Physicians are faced with the dilemma of having to protect the patient and others through isolation out of medical necessity on the one hand, but knowing the consequences for a person’s (mental) well-being on the other.

Digital relief — and its limits

With digital communication ubiquitous and video calls widely available, many believe that both isolated patients and their loved ones should be able to cope. But even with modern modes of communication, individuals experiencing quarantine or isolation remain at heightened risk of depression, anxiety, stress-related disorders, and anger compared to non-quarantined or non-isolated persons (4). Being alone in a hospital room, sealed off from physical touch and direct interaction, aggravates negative thinking especially in psychologically vulnerable cases.

Not just a psychological issue: the palatable effects of human withdrawal

Apart from the psychological aspect, isolation precautions negatively affect other dimensions of patient care. A 1999 study published in the Lancet showed that isolated patients have half as much contact with clinicians compared to control patients (1). Moreover, a team of researchers at the University of California conducted a clinical trial using real-time tracking devices for internal medicine physicians that showed physicians spend significantly less time with isolated patients (2).

Having to don and doff personal protective equipment (PPE) each time you enter and exit an isolation room creates a barrier for doctors. When time is scarce and isolated patients cannot leave their room, it apparently leads to less attention. The lower quality of medical care can also lead to a provably higher number of adverse events in isolated patients. Stelfox et. al showed in 2003 that isolated patients were twice as likely as control patients to experience adverse events during their hospitalization (31 vs 15 adverse events per 1000 days; P<.001) (3).

Isolation receives little attention in scientific research

There is a lack of innovative solutions — not only for the patients but for medical staff as well. There is a reason why the difference in both quantity and quality of care exists. Nurses and physicians feel uncomfortable, some are even afraid of being in contact with contagious patients (4).

In medical literature, one can often read that more research needs to be done in the author’s area of expertise. This is particularly the case with medical isolation. It is not yet a field of research in its own right and finding qualitative literature is a real challenge. The isolated patient literally needs to become more visible to ensure better care and outcome.

SARS-I and COVID-19 showed many of us for the first time how much suffering isolation causes. But the extent of isolation in everyday medical practice underscores the need for validated and innovative technologies that put patients first. We need more innovation to ease the burden on medical staff caring for isolated patients and to minimize the barrier between patients and their visitors.

That is what we are working for at Sphaira Medical.

Would you like to read more on this topic? In the next article, we will take a closer look at the medical and personal history of a patient who has undergone strict isolation.

Literature:

1. Kirkland KB, Weinstein JM. Adverse effects of contact isolation. Lancet. 1999 Oct 2;354(9185):1177–8. doi: 10.1016/S0140–6736(99)04196–3. PMID: 10513715.
2. Saint S, Higgins LA, Nallamothu BK, Chenoweth C. Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control. 2003 Oct;31(6):354–6. doi: 10.1016/s0196–6553(02)48250–8. PMID: 14608302.
3. Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003 Oct 8;290(14):1899–905. doi: 10.1001/jama.290.14.1899. PMID: 14532319.
4. Henssler J, Stock F, van Bohemen J, Walter H, Heinz A, Brandt L. Mental health effects of infection containment strategies: quarantine and isolation-a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci. 2021;271(2):223–234. doi:10.1007/s00406–020–01196-x