Infection Control Today - 09/2004: Healthcare Workers

Healthcare Workers, EMTs
Extend the Front Lines in the Battle Against Infection

By Kris Ellis

Emergency medicine personnel deal with a vast array of demanding and complex situations on a daily basis. In a day and age in which any number of infectious microorganisms and agents of bioterrorism could wind up in any given community, emergency medical technicians (EMTs) and others on the front lines must be prepared for the worst. A significant component of this preparation involves infection control. Emergency medical services (EMS) can play a vital role in containing the spread of infectious diseases both in terms of protecting themselves and others from exposure. This is an area that infection control practitioners (ICPs) are increasingly aware of.

Similarly, hospital and emergency department (ED) waiting rooms warrant close attention as well. With the potentially large number of patients waiting to be seen in relatively close proximity, mass exposure is a possibility. Furthermore, patients often present similar symptoms, especially during flu season, making initial differentiation between mild and dangerous bugs dif. cult. ICPs must also be prepared to meet this challenge head-on.

At the EMS level, the effort to control infection is indirectly built into the basic tenet of protecting oneself.

A lot of it is self-preservation to start with, says William Coll, BA, M. Pub. Aff., LP, REHS, clinical commander and infection control officer for the Austin-Travis County Emergency Medical Services Department. The primary focus is on personal protection and making sure we take appropriate precautions relative to each situation.

An EMT can utilize varying levels of personal protective equipment (PPE) in order to maintain their own safety and prevent the acquisition of infection from patients. A lot of our training is in early recognition beginning to have your suspicions about a patient even as you move in, says Coll.

Invariably, the basic level of protection is gloves. However, Coll explains it is sometimes challenging for EMTs to hold off on donning their gloves until it becomes absolutely necessary. If gloves are applied too early, of course, they could become contaminated themselves. How many doorknobs have you handled, how many things could have put a tear in the gloves? The possibilities are endless, he says. This is a concept Coll tries to instill in his department.

If it becomes apparent that droplet or airborne exposure is a concern due to coughing, more PPE is in order. We work in a six-foot zone relative to droplet protection, where you start to move into that zone with an eye toward whether or not it will be necessary to put on goggles and a mask, because now Im getting into that place where the patient is coughing, Coll explains.

If signs of respiratory or infectious disease are detected, and after the proper precautions are taken, EMS personnel begin the process of collecting information from the patient. The effort to get a history of the patients problem and circumstances is vital in order to gain insight and subsequently notify the hospital and health department if there is a potentially serious threat.

EMTs are not responsible for the actual differentiation and diagnosis of symptoms, however. It shouldnt be the role of EMS and . rst responders, says Coll. But, one of the things weve tried to tie in is attempting to understand who has communicable disease in the broadest sense.

Nonetheless, if EMS personnel suspect a patient is harboring an infection that may pose a danger to the community, they must ensure that the ED is noti. ed about the situation. Preparation on the ED side can eliminate confusion and delays. then youre positioning the patient so that when you deliver them to the ED theres a plan to insert the patient into the appropriate place, whether it be a negative pressure room or whatever the hospital is able to accommodate relative to the circumstance, says Coll.

The ED Waiting Room

The ED itself, and the waiting room in particular, have been the subject of recent efforts to escalate infection control measures and awareness. The Toronto SARS outbreak was a sobering wake-up call to many in terms of the need for such a focus.

That really made us all stop and think about infection transmission in the ERs and it probably, for the first time, really established a series of algorithms as to how to handle patients, particularly with respiratory disease who are coughing, sneezing, etc. during the influenza season and with the possibility of SARS being out there somewhere, says Dr. Ted Eickhoff, professor emeritus in the Division of Infectious Disease at the University of Colorado Health Sciences Center. I think what we all recognize now, more clearly than ever before, is that the ED waiting room is a place we have to pay attention to.

To this end, many facilities are turning to guidelines such as the CDCs Respiratory Hygiene/Cough Etiquette in Healthcare Settings in order to institute precautionary measures. This etiquette is intended to stem the spread of any and all respiratory infections within the healthcare setting and is designed to be part of a facilitys standard infection control practices.1 Components include:

  • Visual alertsalerts such as signs (in multiple languages, if necessary) at facility entrances instructing all who enter to notify healthcare personnel if they have symptoms of respiratory infection and to practice the respiratory and cough etiquette.
  • Respiratory hygiene/cough etiquette: all individuals with symptoms of respiratory infection are advised to cover the nose and mouth when coughing or sneezing, use tissues to contain respiratory secretions and then dispose of them, and perform hand hygiene. To facilitate compliance with these measures, facilities are advised to provide the appropriate materials such as tissues, no-touch waste receptacles and alcohol-based hand rub.
  • Masking and separation of those with respiratory symptoms: facilities are advised to make masks available to persons with symptoms during periods of high infection activity in the community. If space allows, patients should be encouraged to sit at least three feet away from each other in common waiting areas.
  • Droplet precautions: healthcare workers (HCWs) are advised to use droplet precautions in addition to standard precautions when examining patients with respiratory symptoms.

Instituting and enforcing this protocol in waiting rooms has been an important accomplishment for many facilities and ICPs.

We had a subcommittee that we formed which started out as a SARS group and then turned into a universal respiratory etiquette group, says Bobbie Welch, MT, RN, CIC, an infection control specialist at Yale New Haven Hospital. As far as the waiting room, thats been very successful, at least at Yale.

We have developed signs which we have in English, Spanish and Mandarin, she explains. Weve also built a PurellĀ® standwhat we have is a large post like youd put a light on, but instead we have Purell dispensers on all four sides.

Welch points out that these components are most effective when incoming patients confront them immediately. Thats right at the entrance, she says. People coming in are directed to go and wash their hands first, and then if they have respiratory symptoms they would be directed to put on a mask. We have a station with masks, tissues and a wastebasket. Thats worked really well.

The effort and investment certainly paid off at Welchs facility during last years flu season. We had less people getting sick, and if they did get sick it was less severe, she says. There was a very good response and I think the community is actually looking for these types of things now.

The positive response generated by this system prompted other departments to put it to use as well. We have it not only in our two EDs, but we also have it in the primary care clinics here, and all the other clinics adopted it this year, says Welch. We were trying to protect people from the flu because it was a really bad flu season. We were also trying to protect people from the possibility of SARS, which we didnt have a suspected case of this year, but we dont know whats going to happen next year.

This sense of uncertainty underscores the importance of being vigilant at all times, even during the off-season. Were preparing for the worst and actually this is not just for the season were doing this year-round because people come in with severe summer colds as well, says Welch.

Great strides have been made toward preventing exposure in the waiting room at other facilities as well. I think some of our success had to do with the fact that were fortunate enough, in our infection control program, to have one of us who is dedicated to the ER, so it helps that they have a central person, says Kathleen Schomer, RN, BSN, CIC at the University of Colorado Hospital. Schomer monitors the hospitals outpatient settings.

Prompted by a severe flu season, components of the respiratory etiquette were also instituted in Schomers facility. We had a horrible flu outbreak in Colorado last year and we put masks and hand gels in the waiting room and asked patients who were coughing to utilize the masks and use the gel to clean their hands, she says.

Aided by the media and a responsive state health department, public reaction and compliance was positive. We had a good response because there was such a media blitz here about the number of hospitals who, daily, had hundreds of patients sitting in common waiting rooms coughing, says Schomer. The entire citys message was the same; it wasnt just one hospital that was showing leadership it was an entire community effort.

As far as our clinics and exposures having gone down in those areas, Id like to think its because we do a lot of teaching and updating with communicable disease exposure in those areas, Schomer continues, again demonstrating the need for constant attention and commitment to education and prevention efforts.

One such effort at Schomers hospital involved a drill set up by the medical director and safety team which simulated circumstances that led to suspicion of a SARS case. Everyone did really well as far as nursing and physicians taking a history and having the red flag go off that this might be a SARS case. Also getting the patient into proper isolation not letting the patient go back into the common waiting area, she says.

The only thing we didnt do well was think about setting up our command center, so the lesson learned was very valuable. The process of differentiating common flu from a potentially more serious infection such as SARS begins almost immediately at most facilities. It should start with the triage nurse, who is usually the first person someone who comes into the ER with symptoms would encounter, says Eickhoff. Again, if there are respiratory disease symptoms, the person should be masked. So the differentiating process starts right up front. Then, its the ER doctors who go to the next level and try to sort through what this actually is.

Because of similar symptoms, it can be dif. cult to make a definitive conclusion right away. In the case of SARS, epidemiologic evidence is the most important factor most patients diagnosed with SARS have come in contact with another SARS patient or have been in a geographic area where transmission has been established.2 A number of factors may also be indicative of anthrax infection as opposed to flu, such as a normal lymphocyte count, chest X-ray abnormality and lack of runny nose.

It is, however, dif. cult to determine whether an infection may or may not be particularly dangerous judging strictly by outward symptoms. Its the whole assessment that gives doctors feelings about whether this is just simple influenza or something more than that, says Eickhoff. There is no single sign or symptom that would make it or break it for me.

Even before a diagnosis is made, EMTs, ICPs and patients themselves can do their part to prevent the spread of infection. Working together, these groups have the capacity to aid in protecting the health of the community.

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