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By Enid K. Eck, RN, MPH, Barbara DeBaun, RN, BSN, CIC, GinaPugliese, RN, MS
The Context of Contagion
Healthcaresettings today are busy, crowded, noisy places with overworked, distractedclinical staff and a wide assortment of patients converging together insituations that are prone to facilitating infectious disease exposures andtransmission. With the current national nursing shortage, even staff thatnormally adhere to standard infection control policies and procedures findthemselves cutting corners and skipping critical steps because of perceived timeconstraints or inadequate staffing.
To effectively manage the context of contagion and prevent potentiallyserious outbreaks several factors should be considered including a facility'ssetting (i.e., rural vs. urban), the types of services providedand patient acuity. The incidence of particular disease(s) in the surroundingcommunity, seasonal variations, and any unusual events or outbreaks should beincorporated 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 andaccurate identification and diagnosis. Raising staff awareness and creating aheightened level of vigilance is especially challenging at times when theoccurrence of other diseases may seem more likely.
Inaccurate information regarding specific modes of disease transmission orreduced index of suspicion may serve as barriers to early identification ofcontagious patients or a premature or inaccurate diagnosis of a particularclinical condition. Clinical and ancillary staff should be educated regardingthe particular clinical features of specific diseases so that they are able todifferentiate that disease from others that may have a similar clinicalpresentation.
Educating Healthcare Staff
Staff should be educated regarding the principles of microbial pathogenicity,host response, and their role in infection prevention. The generalcharacteristics that contribute to organism virulence and survival as well asthe mechanisms for invasion, dissemination, and proliferation are also importanttopics for staff to understand. By using creatively designed, practical tools,staff can be sensitized to unique disease factors and encouraged to consistentlyapply their knowledge to every encounter with a patient and/or visitor.
The risks for exposure to microorganisms in healthcare settings are relatedto the mode of transmission of the particular infectious agent, the source ofthe microorganism, the duration or level of exposure, and the host response. Toeffectively identify the contagious patient, a thorough medical and socialhistory and complete physical examination are very valuable tools in assessingvarious risk factors and estimating the host response to particular infectiousagents. Protocols that direct specific actions to reduce the risks for exposureand 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 criticallymissed opportunity. Failure to identify the contagious patient resulted inavoidable negative outcomes including: additional exposures, several newinfections, increased costs to the organization, and a delay in effectivetreatment for the contagious patient.
Provide feedback to staff if/when avoidable exposures or outbreaks occur andreinforce desired IC practices by acknowledging such actions when contagiouspatients are promptly identified and potential exposures are avoided.
Containing the Contagious Patient
The hospital admitting office calls to notify the L&D staff that ayoung woman will be arriving shortly for admission to one of the hospital'sbirthing rooms. She is in the final stages of labor with her second pregnancyand is accompanied by her husband, mother, and 3-year-old. The patient's recordindicates that all the appropriate authorizations have been signed for thetoddler to remain with the family during delivery. The nurse midwife who will bedelivering the baby indicates that extensive education has been given to thefamily and everyone is excited about sharing this wonderful event.
Upon admission, the patient is found to have several small papules andvesicles scattered across her lower abdomen and buttocks, many of which arecrusted 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 thepast several days. The admitting nurse notices that the toddler is almostconstantly scratching his head and appears to have a similar "rash" onhis head and neck.
After an uneventful delivery the patient is admitted to a semiprivatepostpartum room. Within 12 hours of delivery the patient is requestingmedication to stop the itching. A dermatology consult is ordered and uponfurther examination scrapings are obtained from several of the patient'slesions. The resulting diagnosis is "Norwegian Scabies" and apotential outbreak investigation is initiated.
Building the System From the Ground Up
Ifearly and accurate identification is the cornerstone of effectively managing thecontagious patient, appropriate containment is the foundation of infectionprevention and control. For staff to initiate and subsequently maintainappropriate containment of the contagious patient, a comprehensive, thoughtfullydesigned system must be in place.
That system must include an adequate number of rooms that are designated forisolation of potentially infectious patients, readily available personalprotective equipment (PPE), and work flow or traffic patterns that decreaseinadvertent exposures. Effective communication mechanisms that assure that allstaff are fully informed and prepared to follow all containment procedures areessential.
Ideally, there should always be a room designated for patients with suspectedairborne infectious diseases, a private room with special ventilation (e.g.,negative pressure, eight air exchanges per hour, and air exhausted to theoutside). If this is not available, a supplemental resource such as portableHEPA air filtration units can be used. Other components of an effectivecontainment system may include readily available supply carts or cupboards thatare always stocked with necessary PPE and computer systems prompts that connectdiagnosis with appropriate containment strategies.
As Easy as Gambling in Las Vegas
To create an environment that facilitates doing the right thing(s) inmanaging contagious patients, it is helpful to convene a multidisciplinarycommittee that works through infection problems and control measures acrossdepartmental lines. The infection control committee may serve such a role bydeveloping and approving appropriate policies and procedures.
However, if the necessary infrastructure is not developed and maintainedconcurrently, barriers to adhering to established policies frequently develop.Eventually doing the right thing becomes very difficult and unnecessaryexposures and disease transmissions occur. In contrast, if the infrastructure isthoroughly designed and supported, then all the right infection containmentprocedures 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 isimportant to actually observe staff behavior during normal operations. This canbe particularly difficult if staff is familiar with all the infection controlprogram 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 ICcontainment and prevention especially if specific gaps in practice areidentified.
A 68-year-old woman is admitted to the ICU for post-operative carefollowing a right hip arthroplasty. In addition to a history of diabetesmellitus and chronic renal failure for which she is receiving hemodialysis, hermedical records indicate that during the past five years she has had fourprevious hospital admissions. During each admission she was treated with a widevariety of broad spectrum antibiotics for a number of "infections" forwhich there are no positive cultures.
She routinely receives vancomycin as part of her hemodialysis regimen andprior to this current surgical procedure she received vancomycin prophylaxis.Approximately 98 hours after surgery the patient has three consecutivetemperatures of 38.5Âº C. The surgical site appears inflamed with some purulentdrainage. Cultures and sensitivities performed on the expressed pus confirm thepresence of vancomycin-resistant enterococci (VRE).
The use of broad-spectrum antimicrobials has become so widespread that thechallenge of resistant organisms is becoming a regular event in most hospitalsettings. Many factors have contributed to the current situation including: 1)provision of antimicrobials even when the infectious agent is viral, 2) desirefor more convenient dosings, and 3) continued empiric use for presumedinfections.
Comprehensive interventions should be developed to assure the appropriate useof antimicrobial agents and adherence to clinical practice guidelines designedto prevent infections. Mechanisms to provide routine review and discontinuationof antimicrobial agents are also appropriate. Microbiology laboratories with thecapacity for appropriate identification and susceptibility testing areessential.
The challenges of identifying, containing, and appropriately treatingcontagious patients are greater now than ever before as healthcare organizationsseek to contain costs by streamlining staff and services. As such, it becomesessential to have a system in place that is on alert for patients or HCWssuspected of having a contagious disease. This requires the leadership of the ICprogram, collaboration with the key departments and staff, ongoing education toassure staff remain aware of their role in identification, and isolation ofpatients with potentially communicable diseases. Because of the competingpriorities for quality and safety of the healthcare environment, containment ofpotentially infectious patients often requires innovative strategies, includingwall signs in key areas describing common signs and symptoms of communicablediseases, and IC liaisons and champions in each department. As resourcescontinue to shrink, prevention of exposures reduces the burdens ofinvestigation, follow-up and treatment of workers, patients, and visitors thatbecome infected after exposure to a contagious patient.
EnidK. Eck, RN, MPH is the senior consultant for HIV and infectious disease atKaiser Permanente Medical Care Program in Pasadena, Calif. Barbara DeBaun, RN,BSN, CIC is the infection control manager at California Pacific Medical Centerin San Francisco, Calif. Gina Pugliese, RN, MS is the vice president of theSafety Institute of Premier Safety Institute. She also holds associate facultypositions at the University of Illinois School of Public Health and RushUniversity College of Nursing in Chicago.
It is the height of flu season and the busy ER has been jammed all nightwith people who are coughing, febrile, and complaining of general malaise. TheER doors open for the hundredth time and a young family enters. The womanapproaches the check-in receptionist and explains that her husband has been sickfor the past several days with a cough that is keeping him awake at night. Hehas had a fever that causes sweating every night, he feels very tired and camehome early from his job at an area restaurant. The clerk tells them that someonewill be with them shortly and in the meantime, to please wait in the generalwaiting room with the other patients.
Several hours later the young man is brought into an ER exam room where heis examined by a medical intern and ultimately admitted to the hospital with R/Opneumonia. Eventually, he is diagnosed with MDR tuberculosis and a full-scaleexposure follow-up is initiated. Several healthcare workers (HCWs) areidentified with tuberculosis skin test conversions and appropriate prophylaxisis initiated.