Emergency department

How does the emergency department impact infection control?

The emergency department (ED) is the gateway for many patients to inpatient units. As such, adherence to infection control guidelines and prevention can have a substantial impact on a patient’s subsequent hospital course.

Prevention and treatment of hospital acquired infections (HAIs) in the ED setting is challenging due to many factors inherent in the practice of emergency medicine. The fact that any patient demographic can be encountered on any given day necessitates the consideration of numerous potential pathogens. The logistics of patient flow, unpredictable volume, and fluctuating disease prevalence renders many effective practices, such as cohort nursing or waiting room separation difficult or impractical at times.

In emergency medicine, most presenting symptoms are unknown until the moment of patient triage and the final diagnosis is often established only after multiple encounters with providers. Because of these undifferentiated presentations, exposure of both providers and other patients is, to some degree, unavoidable. The sharing of chairs, pens, clipboards, phones, and restrooms by multiple patients in various stages of illness makes the ED waiting room and treatment area a potentially infectious environment for staff and patients alike.

Consistent and expedient execution of infection control measures can minimize such potential, but requires an investment of resources in areas such as education, engineering, and equipment in a time when most administrators are looking for cost reduction.

What elements of the emergency department are necessary for infection prevention and control?

Respiratory illness

Respiratory illnesses remain one of the most commonly spread HAI’s faced in the ED, especially during seasonal periods of high prevalence. Contagious and frequently encountered viral agents such as RSV, adenovirus, influenza, and rhinovirus pose particular challenges. While most facilities use isolation measures, cohort boarding, and encourage cough hygiene, a review of the literature on the effectiveness of some of these practices shows some surprising incongruities.

For example, pediatric patients admitted for RSV are usually placed on contact precautions in most hospitals. However, data on effectiveness of such measures on rates of HAI are mixed. Some studies show that gowns and gloves make little or no significant difference in rates of spread to unaffected patients and staff members. One study suggests the use of eye protection makes a difference while other studies indicate that only a combination of multiple PPE and cohort grouping lowers spread in units.

These inconsistencies suggest that staff compliance to infection control measures needs to be an ongoing emphasis of infection control. It is reasonable to extrapolate these findings and recommendations to patient care in the ED.

Even when recommendations appear straightforward, there are situations that require one to ‘read between the lines’ when it comes to implementation.

For example, the CDC recommends influenza patients be placed on droplet precautions based on particle size evidence. But the recommendations have short interjected caveats that suggest airborne precautions are used when performing procedures that may create aerosolized particles such as administration of nebulized medications. So, by that recommendation, the asthmatic patient with bronchospasm secondary to their influenza warrants droplet precaution except when they are receiving an aerosolized medication, in which case airborne precautions would be advised.

Given the physical layout and logistics of many EDs, including open rooms separated by curtains and care of patients in chairs and stretchers in open hallways, it is difficult to protect itinerant staff, adjacent patients, or visitors walking by such a patient who may be using a nebulizer.

Another challenge in respiratory illnesses is inoculation from fomite sources. Many of the common pathogens demonstrate infectivity from mucosal autoinoculation and survival on inanimate surfaces from hours to days. While many recommendations exist discussing the importance of terminal cleaning of rooms between patients, the challenge of rapid ED turnover poses another significant challenge to executing a strong HAI prevention plan within limited operating budgets.

The inability to adequately clean rooms between patient encounters is a huge potential infection control issue, especially considering that multi-drug resistant infections may not be elucidated at the time of disposition from the ED.

Adherence to work policies regarding sick staff members is also cited as a barrier to HAI reduction efforts. Viral shedding can be present for days both before and after symptoms develop. In the face of current nursing shortages, requiring sick providers to stay at home can be a costly and painful effort but needs to be done.

Central venous catheter infections

The care of critically ill patients often begins in the ED. The provision of early goal-directed therapy is greatly facilitated by invasive monitoring and central venous access.

Central venous line-associated infections (CVLAI) are a major target of infection prevention efforts. A long held misconception exists regarding central venous lines initiated in the ED as being more susceptible to infection than those placed in the ICU. Frequently, policies dictated lines placed in ED were changed within 24 hrs regardless of whether clinical signs of infection existed or not. Recent literature demonstrates that lines placed under standard sterile conditions have the same rate of catheter-associated infection as those placed in the ICU setting.

Another aspect of CVLAI is choice of placement site. Clear differences exist between the various sites with subclavian lines showing the lowest rate statistically. Accordingly, emergency physicians should be well versed with the rate of infection and complications of each technique such that optimal care is provided on a case-by-case basis.

Given the increasing length of stay that critical patients spend in the ED awaiting bed placement, central line placement in the ED will likely become a more common occurrence and ED staff should be familiar and adept at performing these procedures using sterile techniques.

Fomite transmission via durable medical equipment

The rise of community-acquired methicillin-resistant Staphylococcus aureus(CA-MRSA) incidence and subsequent presentation of patients to EDs seeking treatment of soft tissue infections adds an additional need to emphasize precautions to control spread from patient-to-patient. Adding to this concern, traditional predictors of colonization are becoming increasingly unreliable.

Recent literature suggests compliance with the simplest yet arguably most effective control measure, hand washing, may be difficult to enforce in the bustle of the chaotic ED. Other measures such as gowns and gloves may be viewed as unproven impediments in a setting where even a few additional minutes per patient can significantly delay crucial interventions.

Another area of concern is durable medical equipment used on multiple patients. Devices requiring intimate patient contact often require high-level disinfection that requires a considerable amount of time out of commission. Many previously reusable devices such as pelvic specula, laryngoscope blades, and blood pressure cuffs have been produced in disposable forms thus offering alternatives. Others however, may not be amenable to disposability. A notable example is bedside ultrasound.

An increasingly prevalent technology, bedside ultrasound offers tremendous utility to ED physicians. It can also be a source of infection spread if not properly and consistently absterged. Recently published data documents the presence of pathogenic organisms on probes immediately after use on patients, including MRSA and potentially multi drug resistant organisms.

Few providers would protest at the use of high-level disinfection between each use with intra-cavitary probes. On the other hand, most external surface probes are frequently cleaned using only alcohol or disinfecting wipes, which are FDA-approved for low level surfaces, such as counter tops or keyboards. Recent literature suggests this may be insufficient, especially with probes that may contact draining skin lesions or blood soiled skin as in trauma or other scenarios.

In these situations, more substantial, multi-step decontamination and disinfection should be used. One recommendation consists of saline soaked towels to thoroughly remove visible soiling followed by towel drying and then chemical wipe disinfection. Another option would be routine barrier use such as probe covers or placing a probe in a gel filled medical glove. These practices rarely affect image quality and may be similarly effective as mechanical decontamination before chemical disinfection.

Similar new technologies are on the horizon for emergency medicine providers. In an era where hospital administrators look to reduce healthcare-associated infection rates, adherence to cleaning and barrier methods must be utilized to ensure continued availability of new technologies to ED physicians.

Hand hygiene

Regardless of the setting, hand hygiene remains the most effective and least expensive infection control measure in healthcare. Despite concerted efforts on multiple levels to improve hand hygiene practices, compliance with hand hygiene remains extremely poor, averaging only 30-50%. Given the fast pace and crowded conditions of most EDs, this can only be assumed to be the same, if not worse, in the ED.

What are the conclusions of clinical trials or meta-analyses regarding infection control in the emergency department that guide current practices and policies?

Literature and recommendations specific to EDs are sparse. A melding of inpatient and outpatient practices seems reasonable but such measures often fail in translation from paper to practice. In this chapter, we will address some of the most commonly encountered obstacles, controversies, and possible interventions.

The ED presents a challenging environment for sound infection control practices. There are few databased recommendations specific to the ED that have proven to decrease the spread of infection. Practitioners should extrapolate data from both inpatient and outpatient sources, while keeping in mind those specific factors unique to ED care may make patients at higher risk of infectious complications.

Crowded waiting rooms, long wait times, close quarters in which patients are evaluated, and lack of private rooms are some of the many logistical factors that patients in the ED must contend with. Basic infection control techniques such as hand washing between patient encounters, cohort nursing assignments, and attempts to isolate potentially infectious patients should be a high priority for all EDs.

Controversies in detail.

Although not immediately an infection prevention measure, an important quality measure in the ED is the 1.6-hour recommendation for the receipt of antibiotics for community-acquired pneumonia. This recommendation is largely based on two retrospective cohort studies that showed a decreased mortality if antibiotics were given within either 4 or 8 hours of presentation, respectively.

Both of these studies used time to first dose of antibiotics as only one facet of pneumonia bundles implemented. In one study, the mortality benefit was negated when severity of illness was accounted for, although both did show reductions in hospital length of stay (LOS). Interestingly, mortality in both studies was increased if antibiotics were given within 2 hours of arrival. Other studies have failed to show a consistent increase in mortality or LOS with decreased time to antibiotic administration.

Implementation of target time to antibiotic therapy has resulted in increased rates of misdiagnosis, as well as concern over resource allocation and patient prioritization.

References

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