IC in Care Series: The Emergency Department

By Kelly M. Pyrek

Competing priorities, life-and-death situations and a vast quantity of unknown variables are the hallmarks of the emergency department (ED), and compliance with infection prevention and control (IPC) principles and practices can be challenging. Katherine West, BSN, MSEd, CIC, points to the directive from the Occupational Health and Safety Administration (OSHA) -- CPL 02-02.069 -- that indicates that the delivery of healthcare should not be delayed. "Trauma response is more important than infection control compliance, and even OSHA recognizes that fact," West says. "We have a duty to meet the patient care needs."

That being said, abdication of IPC is not acceptable, and infection preventionists and ED personnel must work toward a manageable compromise that can still protect patients and healthcare professionals to a reasonable degree. Researchers are currently endeavoring to study the IPC needs of the ED and determine best practices for better outcomes, as well as determine standardized methods and definitions of compliance monitoring in order to be able to compare results across settings.

In their review, Carter, et al. (2014) examined published literature addressing adherence rates among ED personnel to selected infection control practices, including hand hygiene and aseptic technique during the placement of central venous catheters and urinary catheters, as well as rates of ED equipment contamination. Suitable studies revealed that hand hygiene compliance ranged from 7.7 percent to 89.7 percent, while other studies indicated that aseptic technique practices during urinary catheterization was lacking, and equipment contamination in the ED was persistent.

As Carter, et al. (2014) summarize, "The emergency department is an essential component of the healthcare system, and its potential impact continues to grow as more individuals seek care and are admitted to the hospital through the ED. Invasive procedures such as central lines are placed with increased frequency in certain EDs, but adherence to best practices (e.g., maximum barrier precautions) varies. ED clinicians also face numerous workflow challenges that may foster the spread of infections including crowding, frequent interruptions to care delivery, use of nontraditional care areas such as hallways and conference rooms, and close proximity of patients, who are often separated only by curtains. Given that many of these barriers have been identified as infection prevention threats, it is critical to understand the infection prevention practices of ED providers and their potential role in the risk of HAIs."

West points to a number of factors that complicate IPC in the emergency department. "The ED is a very challenging area for infection control because it is often a contracted services and staff miss many of the laws and procedures that are important. For example, many are not aware of the HIV testing laws in their state or that HIPAA does not prevent the release of source patient test results to the exposed employee. Rapid patient turnover may impede cleaning compliance.  So, compliance monitoring is important. In many facilities, staff is temp staff and that adds to the issues."

She also emphasizes the need to balance healthcare personnel safety with the need to protect patients. "There is a need to protect patients from infection as well as staff," West says. "For too long the duty to the patient has often been forgotten. With the new healthcare law, patient protection from infection becomes more important. Patient who develop infection two days after admission, that will be termed healthcare-associated and there may be no government reimbursement for the cost of extended stay and treatment. Staff training needs to focus on proper IV site prep, etc. Training is often not in accordance with requirements for infection control. Attendance at training is important and often not deemed as important."

Additionally, West emphasizes that "Infection preventionists often do not have enough time to do training in person, which is ideal, so there is time for questions to be answered and items clarified. Paperwork seems to take up so much time. Making rounds and observing care rendered in the ED is very important.  Compliance monitoring is key to risk and liability reduction and will also identify training needs. Rounds and training are the best way to interact with ED staff and identify problems."
Let's take a closer look at several key IPC areas in the ED.

Hand hygiene
Carter, et al. (2014) found that hand hygiene was the most commonly observed infection prevention practice in the studies they reviewed, and adherence rates varied widely. For example, several studies examined hand hygiene practices before and after interventions; Haas and Larson used WHO guidelines to assess the impact of a wearable alcohol hand sanitizer dispenser among ED personnel in a New York hospital. The researchers observed 757 hand hygiene opportunities; the adherence rate improved from 43 percent to 62 percent during the first intervention month of the study but was not sustained, with a 51 percent adherence rate after the second quarter.

Scheithauer, et al. (2013) acknowledges that the ED "represents an environment with a high density of invasive and thus infection-prone procedures," and sought to define the number of hand-rubs needed for an individual patient care at the ED and to optimize hand hygiene compliance without increasing workload. In this prospective tri-phase (6-week observation phases interrupted by two six-week interventions) before after study to determine opportunities for and compliance with hand hygiene per WHO protocol, the researchers evaluated 378 patient cases  with 5674 opportunities for hand-rubs (HR) and 1664 HR performed. They found that compliance significantly increased from 21 percent (545/2,603) to 29 percent (467/1,607), and finally 45 percent (652/1,464) in phases 1, 2 and 3, respectively. The number of HR needed for one patient care significantly decreased from 22 to 13 for the non-surgical and from 13 to 7 for the surgical patients due to improved workflow practices after implementing standard operating procedures (SOPs). In parallel, the number of HR performed increased from 3 to 5 for non-surgical and from 2 to 3 for surgical patients. Avoidable opportunities as well as glove usage instead of HR decreased by 70 percent and 73 percent, respectively.

Venkatesh, et al. (2011) conducted an observational study to identify predictors of hand hygiene in the ED. Compliance was 89.7 percent over 5,865 opportunities. The researchers found that observation unit, hallway or high-visibility location, glove use, and worker type predicted worse hand hygiene compliance. Hallway location was the strongest predictor (relative risk, 88.9 percent).

In their study at two university hospital centers, Martel, et al. (2014) found that 53 percent of nurses washed their hands after seeing the patient, and only 40 percent applied recommendation before. However, the researchers note, "given a great turnover of patients, nurses may have just washed their hands after the last patient assessment and be already decontaminated for the next. Some handwashing may have been missed because nurses often left our site of observation immediately before and after seeing the patient."

Aseptic technique during catheterization
In their review, Carter, et al. (2014) identified one study that observed aseptic technique during urinary catheterization. In this study, medical students used standardized observation tools to observe aseptic technique in one ED in the UK and another ED in New Zealand. Procedures observed included urinary catheterization, wound examination or closure, injections or intravascular cannulation, lumbar puncture, and pleural aspiration. Overall, 27 percent (UK) and 58 percent (New Zealand) of invasive procedures were performed using aseptic technique. Adherence to aseptic technique was reported in aggregate and not categorized by procedure type.

Regarding aseptic technique during central venous catheter insertion, Carter, et al. (2014) identified seven studies that examined central venous catheters inserted in the ED or by emergency medicine residents. One study examined the effect of a video review on the sterile technique practices of surgical and emergency medicine residents during the placement of central lines. Compliance to aseptic technique was higher among those who received the video-based online training than those who received paper-based training or no training (74 percent vs 33 percent, respectively). In a separate evaluation, the same research team also assessed maximum barrier precautions among primary and secondary operators through a video recording. Among elective central lines, maximum barrier precautions were used by 88 percent (99/113) of primary operators and 69 percent (31/45) of secondary operators or senior medical staff.

Contact precautions
Researchers have found variability of contact precaution policies in U.S. emergency departments. A study published in Infection Control and Hospital Epidemiology in 2014, Daniel J. Pallin, MD, MPH, and Jeremiah D. Schuur, MD, MS, both from Brigham and Women's Hospital, surveyed a random sample of U.S. EDs confirmed substantial variation in the adoption of policies relating to contact precautions. While most EDs have policies relating to contact precautions when specific organisms are suspected, a minority have such policies for the symptoms often caused by those organisms. This indicated that institutional policies do not mirror consensus recommendations by the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA) and other national bodies. The authors write, "The variation in policy that we observed leads us to recommend that emergency medicine organizations, such as the American College of Emergency Physicians, should enact policies addressing contact precautions in the ED."

Respiratory hygiene
As Rothman, et al. (2006) remind us, "The participation of emergency physicians and nurses is critical for effective responsiveness to respiratory threats in hospitals. ED personnel represent a critical link in the chain of communication and response, along the continuum from the community to the inpatient unit. Policies should anticipate responses to the complex spectrum of possible respiratory illnesses, from highly transmissible and unexpected emerging global diseases such as SARS to yearly influenza epidemics." They add, "Concerns about the potential spread of respiratory pathogens begin at the point of entry into the healthcare system and continue to the inpatient setting. Emergency personnel need to be aware of the potential for infection, illness, and transmissibility in a variety of potentially high-risk environments, including (1) emergency medical services (EMS) and triage settings (in which historical and clinical information may be limited and risk underestimated), (2) during performance of ‘‘high-risk’’ invasive airway procedures, and (3) during patient transport to the various inpatient units throughout the hospital."

Fusco and Puro (2012) observe that "The role of emergency departments in disease transmission dramatically emerged during the outbreak of severe acute respiratory syndrome (SARS). Subsequently, the Centers for Disease Prevention and Control and the World Health Organization issued new infection control guidelines that introduced respiratory hygiene and cough etiquette measures (e.g., covering of nose and mouth possibly with disposable surgical mask, adequate distancing among patients and careful application of hand hygiene) as part of standard precautions to be applied in all health care settings, to all patients with cough and other respiratory symptoms. A rigorous application of this set of infection control measures, including isolation if indicated, may significantly reduce the risk of disease transmission in emergency departments, thus protecting healthcare workers, patients and visitors. Mention about it should be included in all basic sets of indications for the management of community-acquired pneumonia in emergency departments."

Martel, et al. (2014) sought to determine the compliance with respiratory hygiene of triage nurses at two university hospital centers and to identify factors influencing compliance to the respiratory hygiene principles of emergency healthcare workers. An anonymous observation of compliance with respiratory hygiene by triage emergency nurses was performed, and a self-administered, voluntary questionnaire on attitudes, perceptions, and knowledge of respiratory hygiene guidelines was distributed to the healthcare workers in the ED. The researchers found the average compliance with respiratory hygiene measures of triage nurses was 22 percent; compliance of healthcare workers was 68 percent. Overall, 91.9 percent of respondents believed that a mask was an effective preventive measure. The main barriers to mask use by healthcare workers were “tendency to forget” (37.8 percent) and “discomfort” (35.1 percent). Despite clearly visible respiratory hygiene posters in both hospital sites, necessary materials such as masks and tissues were missing in 9.6 percent of the cases. Patient isolation and decontamination measures were rarely or never applied.

As Martel, et al. (2014) observe, "The emergency department is the point of entry into the hospital for many patients and as such constitutes a prime location for the propagation of respiratory infections. These communicable diseases can then be further spread into the hospital as well as back into the community, creating a significant societal burden."
Martel, et al. (2014) found that nurses frequently asked about fever and cough (82 percent), which could be explained by the fact that the emergency room evaluation sheet included an inquiry regarding cough and fever, but they rarely informed the patient of the need to wear a mask (18 percent). The researchers say this could be explained by a lack of knowledge regarding the increased transmission risk in the presence of fever and cough. However, despite the fact that the self-applied questionnaire was not completed by the same healthcare workers, 94.1 percent of them reported that they would recommend mask wearing to a patient with fever and cough. Even though hygiene equipment (such as masks) was present 94.4 percent of the time, only 18.3% of patients had applied the mask recommendations prior to triage.

Martel, et al. (2014) also point out that in spite of CDC recommendations, patient handwashing measures were never met. The absence of posters focusing on this measure, in contrast to the importance of wearing a mask by patient, may result in the slightly higher adherence to the mask precaution (18% vs 0%, respectively). The researchers note, "Several factors could explain that only 9% of nurses informed patients about proper mask technique. Some nurses were seen to request isolation precautions instead. Also, when masks were well positioned, nurses did not further address proper application. Moreover, some nurses may have overestimated patient knowledge regarding the need for mask to cover both nose and mouth and be changed when wet. Despite evidence that spatial separation can reduce droplet spread of infection, we showed a very low compliance to patient isolation (12%).We know that implementation of these measures in many crowded waiting rooms remains particularly difficult. However, both hospitals sites had well-identified areas for this purpose."

Martel, et al. (2014) recommend the following measures to standardize adequate practices:
1. Visual tools specifically designed for the emergency waiting room displayed prominently (e.g., on the door of the room), encouraging the following basic steps: disinfection of hands and wearing of mask by patient with fever and cough.
2. Modification of present visual tools in waiting rooms to mention real indications for mask wearing: coughing, sneezing, and runny nose and not only fever and cough because they are common.
3. Modification of the emergency department sheet, reminding nurses of the association between fever and cough and the need for patients to wear a mask.
4. Positive reinforcement of respiratory hygiene compliance by supervisors and training on respiratory hygiene/respiratory etiquette of emergency personnel with creation of measures such as online courses aimed at facilitating learning and improving accessibility and flexibility as well as reducing costs.

Equipment contamination
In their review, Carter, et al. (2014) identified four papers described equipment contamination in the ED: "Of primary focus was contamination with methicillin-resistant Staphylococcus aureus (MRSA). In one large ED from a United States tertiary care hospital, 7 percent (5/69) of environmental surfaces (chairs, keyboards, telephones, and others) were positive for MRSA compared with no positive sites (0/63) in an outpatient clinic. Another research team took 63 samples of computer mice in an ED in over a one-year period and found only normal skin flora, with no MRSA. In a United States ED, Frazee et al took surveillance cultures of ultrasonographic probes used in the ED; approximately two thirds (111/164) were contaminated with skin or environmental flora, eight samples had heavy growth of skin or environmental flora, and 3.7 percent (6/164) grew organisms including methicillin-sensitive S aureus, Aspergillus, Acinetobacter spp, and mixed Gram-negative rods. Finally, a researcher cultured the stethoscopes of ED nurses and physicians in three Canadian EDs. Of the 100 stethoscopes samples, 70 percent were contaminated. A majority of specimens grew coagulase-negative staphylococci (54/100)."

References:

Carter EJ, Pouch SM and Larson EL. Common infection control practices in the emergency department: A literature review. Am J Infect Control. 42 (2014) 957-62.

Fusco FM and Puro V. Infection control in the emergency department. CMAJ. 184(9):1065. Jun 12, 2012.

Martel J, Bui-Xuan EF, Carreau AM, Carrier JD, Larkin E, Vlachos-Mayer H and Dumas ME. Respiratory hygiene in emergency departments: Compliance, beliefs and perceptions. American Journal of Infection Control 42 (2014) 957-62.

Rothman RE, Irvin CB, Moran GJ, et al. Respiratory hygiene in the emergency department. Ann Emerg Med 2006;48:570–82

Scheithauer S, Kamerseder V, Petersen P, Brokmann JC,  Lopez-Gonzalez LA, Mach C, Schulze-Röbbecke R and Lemmen SW. Improving hand hygiene compliance in the emergency department: getting to the point. BMC Infectious Diseases 2013, 13:367.

Venkatesh AK, Pallin DJ, Kayden S and Schuur JD. Predictors of Hand Hygiene in the Emergency Department. Infect Control Hosp Epidemiol. 2011 Nov;32(11):1120-3.