Infection Control in the Emergency Department

Introduction

Infection control is a crucial component of maintaining a safe, clean, and healthy environment for both patients and staff in the emergency department (ED). The ED presents unique challenges in infection control due to the high turnover of patients, varying levels of patient acuity, frequent interaction between healthcare staff and patients, and the simultaneous care of multiple patients. EDs are busy, multifaceted environments where overcrowding is common and infections can easily spread. It is of the utmost importance that all ED staff members follow strict protocols to protect themselves and their patients from the unnecessary spread of infection.

Hand Hygiene

The most effective way to prevent the spread of infection is by strict adherence to good hand hygiene practices. Hand hygiene in the ED consists of both handwashing and the use of alcohol-based hand rubs. The Healthcare Infection Control Practices Advisory Committee at the Centers for Disease Control and Prevention strongly recommends performing hand hygiene in a variety of clinical scenarios ( Table 27.1 ).

Table 27.1

Common Indications for Hand Hygiene in the Emergency Department

From Hand hygiene guidance. Centers for Disease Control and Prevention. Accessed June 11, 2022. https://www.cdc.gov/handhygiene/providers/guideline.html .

Indications for Hand Hygiene
Immediately before and after touching a patient or the patient’s immediate environment
Before performing an invasive procedure or handling invasive medical devices
Before moving from work on a soiled body site to a clean body site on the same patient
After contact with blood, body fluids, or contaminated surfaces
Immediately after glove removal

When hands are visibly soiled, they must be washed thoroughly with soap and water for at least 20 seconds. When hands are not visibly soiled, an alcohol-based hand rub is an acceptable alternative and is often preferred over handwashing due to evidence of better compliance. There is usually a dispenser of alcohol-based hand rub outside of every patient room in the ED, but there is not always a sink nearby. Whichever method is chosen, the key is to develop good habits of routine hand hygiene throughout any period of time in the ED.

Personal Protective Equipment

Use of personal protective equipment (PPE) is a critical component in infection control in the ED. When deciding when to wear certain PPE, healthcare workers must consider the established or potential risks in the immediate area. Healthcare workers wear PPE in order to protect themselves, the patients, and others from chemical, biological, and radiologic elements. Common PPE worn by ED staff includes, but is not limited to, gloves, gowns, face masks (surgical masks and N95 respirators), shoe and hair coverings, and eye protection (face shield or goggles). It is not only important to choose the correct PPE, but also to don (put on) and doff (take off) the PPE in the correct manner and order ( Fig. 27.1 ; See , Donning PPE; See , Doffing PPE).

A surgical mask ( Fig. 27.2 ) creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. It is loose-fitting, disposable, and is intended to be used only once. Surgical masks are effective at blocking large-particle droplets, splashes, or sprays that may contain infectious particles. However, a surgical mask does not filter or block small aerosolized particles in the air that may be transmitted by coughing, sneezing, or certain medical procedures. Historically, surgical masks were only worn during sterile medical procedures (e.g., lumbar puncture or central line placement), when caring for patients with high likelihood of respiratory droplet spread (e.g., active influenza infection) or body fluid exposure (e.g., during incision and drainage of an abscess). However, surgical masks are now commonly used to decrease the spread of disease, such as COVID-19, from the wearer to others in public as well as healthcare settings.

An N95 respirator ( Fig. 27.3 ) is a protective mask designed for efficient filtration of airborne particles. The name “N95” is based on a US standard that requires these masks to be able to filter out at least 95% of very small particles. N95 masks are intended to cover the nose and mouth completely and fit tightly on the wearer’s face. There are multiple manufacturers and styles of N95 respirators. Every healthcare worker must undergo yearly fit testing to ensure that they are matched with a brand, size and fit that provides full protection. Wearing a respirator that has not been fit-tested to the wearer may not protect them. Similar to surgical masks, N95 masks are intended to be single-use devices and are discarded after each patient encounter.

A powered air purifying respirator (PAPR) ( Fig. 27.4 ) provides battery-powered positive airflow through a filter to a hood or face mask and provides a higher level of protection from aerosolized particles. PAPRs can be worn on multiple occasions but must be cleaned and sanitized according to the manufacturer’s recommendations between each use. A PAPR is a good alternative to an N95 mask if the N95 mask does not fit properly due to an individual’s face shape or facial hair.

Infection Control Precautions

The first tier of infection prevention measures that are used on every patient in the ED are called standard precautions. These comprise the minimum protection required for the care of all patients, regardless of infection status. They are also referred to as universal precautions, because they should be applied at all times when administering patient care. These precautions include hand hygiene, use of PPE, safe disposal of sharps, cough etiquette (coughing into your arm or a tissue), safe injection of medications, use of sterile instruments and devices, and maintenance of a clean and disinfected environment.

When standard precautions are not enough to prevent transmission of infection, they are supplemented with transmission-based precautions. This second tier of infection prevention is used when patients have known or suspected infections that can spread through contact, droplet, or airborne routes. In the ED, patients requiring transmission-based precautions will have a sign on their door indicating the level of necessary precaution, as well as a cart outside of their room containing the necessary PPE. This PPE must be worn every time a staff member enters the patient’s room and is discarded immediately after leaving the room. This serves to protect the health of the staff member and to decrease the risk of transmission to other patients and staff in the department.

Contact precautions ( Fig. 27.5A ) are used for patients with known or suspected illness that spreads through physical touch (direct or indirect). ED staff must wear the appropriate PPE, including gloves and a gown, when taking care of patients placed on contact precautions. This PPE must be properly donned each time before entering a room and then doffed and disposed of upon exiting the room. Common skin infections that require contact precautions include methicillin-resistant Staphylococcus aureus (MRSA), herpes zoster (shingles), and monkeypox ( Table 27.2 ). ED staff also adhere to contact precautions when patients have an insect infestation such as bedbugs, lice, and scabies. The rooms of patients on contact precautions must be properly cleaned every day and after patient discharge. In cases of insect infestation, the patient room will require additional cleaning (a terminal clean), which is performed by environmental services.

Table 27.2

Infectious Organisms That Require Contact and Enteric Precautions, Along With Their Characteristics, Treatment, and Prevention

From Nepal H, Tewodros W. (2020) Microbiology lectures at Trinity School of Medicine, St. Vincent and the Grenadines.

Organ	Disease	Pathogen	Characteristics	Treatment	Prevention
Dermatologic	Chicken pox	Varicella zoster virus	Typically a vesicular childhood rash starting on the face and trunk	Analgesics, antiviral, antihistamines	Vaccine
	Shingles	Varicella zoster virus	Usually in adults, limited to a single dermatome, does not cross midline	Analgesics, antiviral, antihistamines	Vaccine
	Infection	Methicillin-resistant Staphylococcus aureus (MRSA)	Organism with acquired resistance to common methicillin antibiotics Particularly worrisome in setting of declining antibiotic treatment options	Antibiotic	Good hand and body hygiene Good antibiotic stewardship
Gastrointestinal	Colitis	Clostridioides difficile	Causes severe watery diarrhea Associated with antibiotic use Commonly a nosocomial (hospital-acquired) infection	Discontinue prior antibiotic and start an antibiotic targeted to C. difficile	Good hand and body hygiene Good antibiotic stewardship
	Infection	Vancomycin-resistant Enterococcus (VRE)	Organism with acquired resistance to the antibiotic vancomycin Particularly worrisome in setting of declining antibiotic treatment options	Antibiotic	Good hand hygiene Good antibiotic stewardship
	Gastroenteritis	Escherichia coli	Little or no fever, severe abdominal cramps, watery diarrhea followed by bloody diarrhea	Fluid repletion	Food and water safety Good hand hygiene
		Campylobacter jejuni	Watery diarrhea followed by foul smelling bloody diarrhea (10 or more stools/d), intense abdominal pain, fever, vomiting	Antibiotic	Food and water safety
		Salmonella	Inflammatory diarrhea with/without visible blood, nausea, vomiting, fever, abdominal cramps, myalgia, and headache Lasts 2–7 d	Usually resolves spontaneously	Food and water safety