The Contagious Patient:
Identifying, Containing, and Treating Appropriately
By Enid K. Eck, RN, MPH, Barbara DeBaun, RN, BSN, CIC, Gina Pugliese, RN, MS
The Context of Contagion
Healthcare settings today are busy, crowded, noisy places with overworked, distracted clinical staff and a wide assortment of patients converging together in situations that are prone to facilitating infectious disease exposures and transmission. With the current national nursing shortage, even staff that normally adhere to standard infection control policies and procedures find themselves cutting corners and skipping critical steps because of perceived time constraints or inadequate staffing.
To effectively manage the context of contagion and prevent potentially serious outbreaks several factors should be considered including a facility's setting (i.e., rural vs. urban), the types of services provided and patient acuity. The incidence of particular disease(s) in the surrounding community, seasonal variations, and any unusual events or outbreaks should be incorporated into facility and departmental plans for identifying, containing, and appropriately treating a contagious patient.
Identifying the Contagious Patient
The cornerstone of effectively managing contagious patients is early and accurate identification and diagnosis. Raising staff awareness and creating a heightened level of vigilance is especially challenging at times when the occurrence of other diseases may seem more likely.
Inaccurate information regarding specific modes of disease transmission or reduced index of suspicion may serve as barriers to early identification of contagious patients or a premature or inaccurate diagnosis of a particular clinical condition. Clinical and ancillary staff should be educated regarding the particular clinical features of specific diseases so that they are able to differentiate that disease from others that may have a similar clinical presentation.
Educating Healthcare Staff
Staff should be educated regarding the principles of microbial pathogenicity, host response, and their role in infection prevention. The general characteristics that contribute to organism virulence and survival as well as the mechanisms for invasion, dissemination, and proliferation are also important topics for staff to understand. By using creatively designed, practical tools, staff can be sensitized to unique disease factors and encouraged to consistently apply their knowledge to every encounter with a patient and/or visitor.
The risks for exposure to microorganisms in healthcare settings are related to the mode of transmission of the particular infectious agent, the source of the microorganism, the duration or level of exposure, and the host response. To effectively identify the contagious patient, a thorough medical and social history and complete physical examination are very valuable tools in assessing various risk factors and estimating the host response to particular infectious agents. Protocols that direct specific actions to reduce the risks for exposure and containing potential infectious patients are essential.
In the opening scenario, distinguishing between the many ER patients with the "flu" and the one patient with infectious MDR TB was a critically missed opportunity. Failure to identify the contagious patient resulted in avoidable negative outcomes including: additional exposures, several new infections, increased costs to the organization, and a delay in effective treatment for the contagious patient.
Provide feedback to staff if/when avoidable exposures or outbreaks occur and reinforce desired IC practices by acknowledging such actions when contagious patients are promptly identified and potential exposures are avoided.
Containing the Contagious Patient
The hospital admitting office calls to notify the L&D staff that a young woman will be arriving shortly for admission to one of the hospital's birthing rooms. She is in the final stages of labor with her second pregnancy and is accompanied by her husband, mother, and 3-year-old. The patient's record indicates that all the appropriate authorizations have been signed for the toddler to remain with the family during delivery. The nurse midwife who will be delivering the baby indicates that extensive education has been given to the family and everyone is excited about sharing this wonderful event.
Upon admission, the patient is found to have several small papules and vesicles scattered across her lower abdomen and buttocks, many of which are crusted over. She also appears to have some tiny raised lines near her nipples. During the admitting exam the patient frequently scratches the "rash" and explains that the itching has been "driving her crazy" for the past several days. The admitting nurse notices that the toddler is almost constantly scratching his head and appears to have a similar "rash" on his head and neck.
After an uneventful delivery the patient is admitted to a semiprivate postpartum room. Within 12 hours of delivery the patient is requesting medication to stop the itching. A dermatology consult is ordered and upon further examination scrapings are obtained from several of the patient's lesions. The resulting diagnosis is "Norwegian Scabies" and a potential outbreak investigation is initiated.
Building the System From the Ground Up
If early and accurate identification is the cornerstone of effectively managing the contagious patient, appropriate containment is the foundation of infection prevention and control. For staff to initiate and subsequently maintain appropriate containment of the contagious patient, a comprehensive, thoughtfully designed system must be in place.
That system must include an adequate number of rooms that are designated for isolation of potentially infectious patients, readily available personal protective equipment (PPE), and work flow or traffic patterns that decrease inadvertent exposures. Effective communication mechanisms that assure that all staff are fully informed and prepared to follow all containment procedures are essential.
Ideally, there should always be a room designated for patients with suspected airborne infectious diseases, a private room with special ventilation (e.g., negative pressure, eight air exchanges per hour, and air exhausted to the outside). If this is not available, a supplemental resource such as portable HEPA air filtration units can be used. Other components of an effective containment system may include readily available supply carts or cupboards that are always stocked with necessary PPE and computer systems prompts that connect diagnosis with appropriate containment strategies.
As Easy as Gambling in Las Vegas
To create an environment that facilitates doing the right thing(s) in managing contagious patients, it is helpful to convene a multidisciplinary committee that works through infection problems and control measures across departmental lines. The infection control committee may serve such a role by developing and approving appropriate policies and procedures.
However, if the necessary infrastructure is not developed and maintained concurrently, barriers to adhering to established policies frequently develop. Eventually doing the right thing becomes very difficult and unnecessary exposures and disease transmissions occur. In contrast, if the infrastructure is thoroughly designed and supported, then all the right infection containment procedures can become as easy as gambling in Las Vegas.
Use a "Secret Shopper" to Find the Gaps
To continuously improve the quality of an infection control program, it is important to actually observe staff behavior during normal operations. This can be particularly difficult if staff is familiar with all the infection control program personnel. One creative solution is to use unobstructive observers like "secret shoppers" who simply observe the IC practices or staff. Findings from such observational studies can facilitate improvements in IC containment and prevention especially if specific gaps in practice are identified.
A 68-year-old woman is admitted to the ICU for post-operative care following a right hip arthroplasty. In addition to a history of diabetes mellitus and chronic renal failure for which she is receiving hemodialysis, her medical records indicate that during the past five years she has had four previous hospital admissions. During each admission she was treated with a wide variety of broad spectrum antibiotics for a number of "infections" for which there are no positive cultures.
She routinely receives vancomycin as part of her hemodialysis regimen and prior to this current surgical procedure she received vancomycin prophylaxis. Approximately 98 hours after surgery the patient has three consecutive temperatures of 38.5º C. The surgical site appears inflamed with some purulent drainage. Cultures and sensitivities performed on the expressed pus confirm the presence of vancomycin-resistant enterococci (VRE).
The use of broad-spectrum antimicrobials has become so widespread that the challenge of resistant organisms is becoming a regular event in most hospital settings. Many factors have contributed to the current situation including: 1) provision of antimicrobials even when the infectious agent is viral, 2) desire for more convenient dosings, and 3) continued empiric use for presumed infections.
Comprehensive interventions should be developed to assure the appropriate use of antimicrobial agents and adherence to clinical practice guidelines designed to prevent infections. Mechanisms to provide routine review and discontinuation of antimicrobial agents are also appropriate. Microbiology laboratories with the capacity for appropriate identification and susceptibility testing are essential.
The challenges of identifying, containing, and appropriately treating contagious patients are greater now than ever before as healthcare organizations seek to contain costs by streamlining staff and services. As such, it becomes essential to have a system in place that is on alert for patients or HCWs suspected of having a contagious disease. This requires the leadership of the IC program, collaboration with the key departments and staff, ongoing education to assure staff remain aware of their role in identification, and isolation of patients with potentially communicable diseases. Because of the competing priorities for quality and safety of the healthcare environment, containment of potentially infectious patients often requires innovative strategies, including wall signs in key areas describing common signs and symptoms of communicable diseases, and IC liaisons and champions in each department. As resources continue to shrink, prevention of exposures reduces the burdens of investigation, follow-up and treatment of workers, patients, and visitors that become infected after exposure to a contagious patient.
Enid K. Eck, RN, MPH is the senior consultant for HIV and infectious disease at Kaiser Permanente Medical Care Program in Pasadena, Calif. Barbara DeBaun, RN, BSN, CIC is the infection control manager at California Pacific Medical Center in San Francisco, Calif. Gina Pugliese, RN, MS is the vice president of the Safety Institute of Premier Safety Institute. She also holds associate faculty positions at the University of Illinois School of Public Health and Rush University College of Nursing in Chicago.
It is the height of flu season and the busy ER has been jammed all night with people who are coughing, febrile, and complaining of general malaise. The ER doors open for the hundredth time and a young family enters. The woman approaches the check-in receptionist and explains that her husband has been sick for the past several days with a cough that is keeping him awake at night. He has had a fever that causes sweating every night, he feels very tired and came home early from his job at an area restaurant. The clerk tells them that someone will be with them shortly and in the meantime, to please wait in the general waiting room with the other patients.
Several hours later the young man is brought into an ER exam room where he is examined by a medical intern and ultimately admitted to the hospital with R/O pneumonia. Eventually, he is diagnosed with MDR tuberculosis and a full-scale exposure follow-up is initiated. Several healthcare workers (HCWs) are identified with tuberculosis skin test conversions and appropriate prophylaxis is initiated.