American College of Physicians: Internal Medicine — Doctors for Adults ®


Yet another use for duct tape

“Red box” isolation pilot reduces costs, saves time

From the September ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Stacey Butterfield

Where: Trinity Medical Center, a 504-bed, three-campus acute care facility located in Rock Island and Moline, Ill., and Bettendorf, Iowa.

The issue: Avoiding unnecessary use of personal protective equipment when caring for patients under isolation precautions.

Red masking tape on the floor delineates where hea...

Red masking tape on the floor delineates where health care workers can step inside an isolation patient's room without wearing protective equipment.


Until 2009, Trinity Medical Center had operated under the conventional, guideline-recommended protocol that any staff member entering the room of a patient under isolation precautions had to don personal protective equipment (PPE) (i.e., at least a gown and gloves). But after a meeting with clinicians, members of the hospital's infection prevention team began to consider whether this requirement was unnecessarily onerous.

“There were some complaints by physicians that they felt like they were wasting supplies when on a few occasions all they wanted to do was just peek their head in the door,” said Janet Nau Franck, RN, MBA, CIC, an infection preventionist and consultant for the hospital. Current guidelines recommend such precautions, Ms. Franck noted. “But the research indicates that there really isn't a risk of transmission of infection at the patient's door, because the caregiver is not in contact with the patient, nor their immediate environment.”

In search of a method to reduce wasted clinician time and PPE supplies without increasing the risk of infection, the team members found a simple and inexpensive solution in an unlikely place.

How it works

“They went to the hardware store and picked up a roll of two-inch red duct tape and applied it, extending from the threshold of the door inside the patient's room,” said Ms. Franck. The tape was used to mark off a red box on the floor directly inside the door. The three-foot-by-three-foot red box designated a safe space in which a clinician could stand and interact with a patient without donning protective gear.

“Let's say that the nurse was walking down the hall and knew that the patient had been experiencing pain or was in need of more face time,” said Ms. Franck. Under the new red box system, the nurse could make a quick stop “stopping in the box and taking a look at the patient, finding out if they need anything,” she explained. “It saved them a lot of time and money to do that instead of having to put the gown and gloves on for every interaction.”


Specifically, a pilot study of the red box, conducted between January 2009 and December 2010, calculated that it saved over $110,000 in unused PPE. “That was a conservative estimate because it really didn't take into account the 2,700 hours that had been saved,” said Ms. Franck, who presented the pilot results at the International Meeting of the Association for Professionals in Infection Control and Epidemiology in June.

The 2,700 hours were calculated from a time analysis finding that about 30% of clinicians' interactions with the isolated patients in the pilot were conducted in the red box. “That's greater than a full-time-equivalent staff person,” said Ms. Franck.

The experiment also scored well in a satisfaction survey of participating health care workers: a third of them said that the new system lessened barriers when communicating with patients, and about 80% believed that the red box allowed them to save time and communicate with patients more frequently.

How patients benefit

In addition to the measured results, Ms. Franck has observed some anecdotal effects that might improve infection prevention and control in the hospital. In the past, she would sometimes “walk past a room and see staff in a patient's room that didn't have their PPE on. They would say, ‘Oh, I didn't know.’” The red box, which is only placed in rooms on contact precautions, has eliminated that excuse. “It's very difficult to walk in a patient's room and not realize that this patient is on precautions. It's an excellent visual cue,” said Ms. Franck.

Next steps

The team hopes to find out more about how the program affects patients by surveying them directly. Currently, the red box system is explained to patients on admission. Their response has been generally positive but feedback has not been formally collected. “We would like to know what the perspective of a patient is. We feel like that's a topic for future research,” said Ms. Franck.


One particular focus of that research may be patients who are visually or hearing-impaired, factors that the Trinity team suspects might reduce the effectiveness of the red box. “For those patients, I think the staff needs to evaluate whether or not they should be using the red box,” said Ms. Franck. “If [the patient is] impaired in some respect … it would probably be a better idea for [the clinicians] to put on their PPE and go in the room where [the patient] can see and hear them.”

Lessons learned

In her presentation at the infection control meeting, Ms. Franck offered an action plan for hospitals interested in following Trinity's lead. “What we suggest is that they take the study and go to their leadership and share with them what their savings in time and money could be,” she said. “Try it on a pilot basis, maybe for a couple weeks in a few rooms.”

Words of wisdom

“It only costs $7 for a roll of red duct tape, yet the savings in time and cost were found to be substantial,” said Ms. Franck.


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