Infection prevention in the emergency department

Effect of multimodal diagnostic approach using deep learning-based automated detection algorithm for active pulmonary tuberculosis

In this study, we developed a model to predict culture test results for pulmonary tuberculosis (PTB) with a customized multimodal approach and evaluated its performance in different clinical settings. Moreover, we investigated potential performance improvements by combining this approach with deep learning-based automated detection algorithms (DLADs). This retrospective observational study enrolled patients over 18 years of age who consecutively visited the level 1 emergency department and underwent chest radiograph and sputum testing. The primary endpoint was positive sputum culture for PTB. We compared the performance of the diagnostic models by replacing radiologists' interpretations of chest radiographs with screening scores calculated through DLAD. The optimal diagnostic model had an area under the receiver operating characteristic curve of 0.924 (95% CI 0.871-0.976) and an area under precision recall curve of 0.403 (95% CI 0.195-0.580) while maintaining a specificity of 81.4% when sensitivity was fixed at 90%. Multicomponent models showed improved performance for detecting PTB when chest radiography interpretation was replaced by DLAD. Multicomponent diagnostic models with DLAD customized for different clinical settings are more practical than traditional methods for detecting patients with PTB. This novel diagnostic approach may help prevent the spread of PTB and optimize healthcare resource utilization in resource-limited clinical settings.

Understanding routine (non-outbreak) respiratory protective equipment behaviour of hospital workers in different clinical settings - lessons for the future post COVID-19

BACKGROUND

The COVID-19 pandemic has drawn attention to the importance of facial (respiratory and eye) protective equipment (FPE). Optimal use of FPE in non-outbreak situations, will enable frontline staff, such as emergency department (ED) clinicians, to adapt more rapidly and safely to the increased demands and skills required during an infectious disease outbreak.

METHODS

A survey, designed to determine the attitudes, beliefs and knowledge of HCWs around the use of FPE for protection against respiratory infections, was distributed to staff in a respiratory ward, an adult ED and a paediatric ED in Sydney, Australia prior to COVID-19.

RESULTS

The survey revealed differences between the respiratory ward and the EDs and between professional groups. ED staff, particularly paediatric clinicians, were less likely than ward staff to use FPE appropriately during routine care. Medical staff were more likely to work outside of IPC policies.

DISCUSSION

The busy, relatively chaotic ED environment presents unique challenges for optimal compliance with safe FPE use when caring for patients with respiratory symptoms.

CONCLUSIONS

Building upon the lessons of the pandemic, it is timely to address the specific infection prevention and control needs of the ED environment to improve FPE compliance during non-outbreak situations.

Prolonged length of stay is associated with reduced hand hygiene compliance in the emergency department: A single centre retrospective study

OBJECTIVE

To examine whether patient flow factors in the ED such as prolonged length of stay are associated with hand hygiene (HH) compliance.

METHODS

We conducted a retrospective study at an urban district hospital utilising available data from January 2018 to December 2021. Compliance to the World Health Organization five moments of HH expressed as percentage of total moments observed were collated every 2 months. Patient flow measures including proportion of patients referred or discharged within 4 h (LOS4), proportion of patients with ED length of stay >24 h (LOS24) and total number of patient presentations, were obtained for each 2-month periods. The association between these patient flow measures and HH compliance was examined using Pearson's correlation (P < 0.05).

RESULTS

The results showed a moderate and significant association between rates of HH compliance and LOS24 (r = -0.48, P = 0.025). That is, lower proportion of patients with ED length of stay >24 h was associated with improved HH compliance. There was no significant correlation between HH compliance and LOS4 (r = 0.38, P = 0.085) or total number of ED presentations (r = -0.30, P = 0.17).

CONCLUSIONS

The findings show that prolonged ED length of stay may explain, at least partly, lower rates of HH compliance. Improvements in ED HH compliance should also include strategies that enhance patient flow.

Effects of the physical environment on children and families in hospital-based emergency departments: A systematic literature review

Every year, millions of children seek care in emergency departments (EDs) for various conditions. Though the physical environment of the ED provides the context and setting for care delivery, influences workflows, and shapes interactions between users, the noisy, sterile, stimulating nature of the ED can be counter-therapeutic to pediatric patients and families. This systematic literature review investigates this complex dynamic and asks how the physical environment of emergency departments affects children and their families or guardians. Using PRISMA methods, this review searched four databases to identify and analyze twenty-one peer-reviewed articles that explored the impacts of the physical environment of hospital-based EDs on children or family members. Several themes emerged from the literature - concerning control, positive distractions, family and social supports, and designing for a safe and comfortable experience - that illustrate opportunities for future ED design and highlight knowledge gaps and avenues for future research.

Stakeholder experiential knowledge as evidence in redesigning health-care facilities for improved usability

Purpose

Evidence-based design (EBD) is traditionally limited to using empirical research findings based on randomized controlled trials. The purpose of this study is to explore stakeholder experiential knowledge as alternate credible evidence in redesigning health-care facilities for improved usability.

Design/methodology/approach

This research, based on critical participatory action research, involved a case study of redesign and post-occupancy evaluation (POE) of an emergency department (ED) at Holy Family Hospital, Techiman, Ghana. Observation, interviews and document analysis were used to collect data in the redesign and POE. The data was analyzed through directed content analysis.

Findings

Findings indicate that the redesign interventions, generated from stakeholder experiential knowledge, led to improved effectiveness, efficiency and satisfaction in the ED. This presents stakeholder experiential knowledge as alternate credible evidence in EBD. Furthermore, the POE revealed that open and flexible spatial arrangement, zoning care areas according to severity, and providing staff-support amenities are some redesign interventions for improving ED usability.

Practical implications

Compared to the hard and controlled nature of experimental research knowledge, the soft and fluid experiential knowledge of stakeholders could be more useful for health-care redesign process, especially in iteratively structuring design thinking and making choices.

Originality/value

This paper contributes to theory by validating and illustrating stakeholder experiential knowledge as credible evidence for EBD. Practically, it provides strategies, based on POE findings, for designing EDs to improve usability.

How to improve hospital admission screening for patients at risk of multidrug-resistant organism carriage: a before-and-after interventional study and cost-effectiveness analysis

Background

Infection prevention and control (IPC) is a prioritised task for healthcare workers in emergency department (ED). Here, we examined compliance with admission screening (AS) and additional precautions (AP) measures for patients at risk of infection with multidrug-resistant organisms (MDROs) by using a two-stage, multifaceted educational intervention, also comparing the cost of a developed automated indicator for AS and AP compliance and clinical audits to sustain observed findings.

Methods

In the first stage, staff in the ED of the University Hospitals of Geneva, Switzerland, were briefed on IPC measures (AS and AP). A cross-sectional survey was then conducted to assess barriers to IPC measures. In the second stage, healthcare workers underwent training sessions, and an electronic patient record ‘order-set’ including AS and AP compliance indicators was designed. We compared the cost–benefit of the audits and the automated indicators for AS and AP compliance.

Results

Compliance significantly improved after training, from 36.2% (95% CI 23.6% to 48.8%) to 78.8% (95% CI 67.1% to 90.3%) for AS (n=100, p=0.0050) and from 50.2% (95% CI 45.3% to 55.1%) to 68.5% (95% CI 60.1% to 76.9%) for AP (n=125, p=0.0092). Healthcare workers recognised MDRO screening as an ED task (70.2%), with greater acknowledgment of risk factors at AS considered an ED duty. The monthly cost was higher for clinical audits than the automated indicator, with a reported yearly cost of US$120 203. The initial cost of developing the automated indicator was US$18 290 and its return on investment US$3.44 per US$1 invested.

Conclusion

Training ED staff increased compliance with IPC measures when accompanied by team discussions for optimal effectiveness. An automated indicator of compliance is cheaper and closer to real-time than a clinical audit.

Can Emergency Department Wait Times Predict Rates of Hospital-Acquired Clostridioides difficile Infection? A Study of Acute Care Facilities in New York State

OBJECTIVE

Clostridioides difficile is the most common hospital-acquired pathogen and persists in the environment for extended periods. As a common entry point for patients with diarrhea, and a setting providing fast-paced, high-volume care, emergency departments (EDs) are often sites of C. difficile contamination. This study examined the relationship between average patient wait times in the ED before admission and overall hospital-acquired C. difficile infection (HA-CDI) rates in New York State acute care hospitals.

METHODS

A random-effects regression analysis compared each facility's annual average ED wait time for admitted patients with that facility's average (HA-CDI) rates for patients entering through the ED. This model controlled for known clinical and nonclinical predictors of HA-CDI: average length of stay; case mix index; total discharges, a measure of hospital size; and percent Medicare discharges, a proxy for advanced age.

RESULTS

Emergency department wait times had a significant and positive relationship with HA-CDI rates. Facilities experience an additional 0.002 cases of HA-CDI per 1000 patient discharges with every additional minute patients spend in the ED (P = 0.003), on average. Emergency department wait times also had the largest effect size (0.210), indicating that they explain more of the variance in HA-CDI rates for patients entering through the ED than some of the best-known predictors of HA-CDI.

CONCLUSIONS

The relationship between ED wait times and eventual HA-CDI warrants further exploration. These findings suggest efforts to reduce ED wait times for admitted patients or more rigorous environmental cleanliness strategies in the ED, as possible avenues for HA-CDI prevention.

Diagnostic Utility of CD64 and CD38 Biomarkers for the Differential Diagnosis of Infections

Purpose: Identification of infection type in patients with fever is particularly important in the emergency departments (EDs) of hospitals. This study aimed to evaluate the performance of two biomarkers, namely the modified neutrophil CD64 (nCD64) index and CD38 present on T cells, using flow cytometry. Methods: A total of 305 potentially infected patients with fever were admitted to the ED of Zhongda Hospital (Nanjing, China) between March 2021 and August 2021. This study grouped 180, 30, and 65 patients as having bacterial (local, Gram-positive, and Gram-negative infections), viral, or no infections, respectively, based on their diagnostic outcomes and clinical records. Results: The expression level of traditional/modified nCD64 was significantly increased in the bacterial infection group, especially in case of patients infected with Gram-negative bacteria, and the main infectious strains were Staphylococcus and Escherichia coli. Similarly, CD3⁺CD38⁺ cell percentages were elevated in patients with viral infections, which were mostly caused by Epstein-Barr virus and cytomegalovirus. CD38 expression is age dependent, and high percentages of CD3⁺CD38⁺ cells were observed in children with viral infections. For the prediction of bacterial infections, the area under the curve (AUC) of modified nCD64 (AUC: 0.800) was significantly higher than that of C-reactive protein and heparin-binding protein but slightly lower than that of traditional nCD64 (AUC: 0.831). The AUC, specificity, and sensitivity values for the prediction of viral infections using CD3⁺CD38⁺ cells percentages in children were 0.899 (0.785-1.000), 96.2%, and 85.9%, respectively. Conclusion: nCD64 levels and CD3⁺CD38⁺ cell percentage are potential biomarkers that facilitate identification of patients with bacterial and viral infections.

Ventilation Performance Evaluation of a Negative-Pressurized Isolation Room for Emergency Departments

Due to the emergence of COVID-19 becoming a significant pandemic worldwide, hospitals are expected to be capable and flexible in responding to the pandemic situation. Moreover, as frontline healthcare staff, emergency department (ED) staff have a high possibility of exposure risk to infectious airborne. The ED isolation room will possibly and effectively isolate the infected patient, therefore safekeeping frontline healthcare staff and controlling the outbreak. However, there is still limited knowledge available regarding isolation room facilities specifically for the emergency department. In this study, field measurement is conducted in an ED isolation room located in Taiwan. CFD simulation is employed to simulate and investigate the airflow and airborne contaminant distribution. Instead of high air-change rates (ACH) that purposes for dilution, this study proposes the arrangement of exhaust air grilles to improve the contaminant removal. The results reveal that the exhaust air grille placed behind the patient’s head is optimized to dilute airborne contaminants.

The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine

Background

Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls.

In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team’s service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service.

Methods

The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service.

A retrospective analysis was performed of the team’s first 12 months of operation using the prospectively maintained service database.

Results

Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations.

Conclusion

Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00536-x.

Occupational accidents of emergency medicine residents in Turkey

Objectives. Healthcare workers face many biologic, chemical, physical and psychosocial hazards and risks in their work environment. Our research aimed to examine the types and frequency of occupational accidents, their notification status and predisposing factors to which emergency medicine residents (EMRs) were exposed in the last 12 months in Turkey. Methods. This research is a national, multicenter, online descriptive survey study. Participants' descriptive features, characteristics of occupational accidents they were exposed to in the last 12 months and their use status of personal protective equipment (PPE) were examined. Results. We found that 215 EMRs were exposed to 1919 occupational accidents in the last 12 months, and only 287 of these accidents were reported. All participants had at least one occupational accident in the previous 12 months. PPE was not used in 37.9 and 44% of biologic and chemical transmission accidents, respectively. The PPE use frequency of the EMRs in necessary situations for examination gloves, surgical masks, respirators, goggles, gowns and face shields was 60, 19, 19, 8, 15 and 4%, respectively. Conclusion. The actual number of occupational accidents was determined to be considerably higher than those reported. PPE use habits of EMRs were less than they should be.

Frequency, etiologies, risk factors, and sequelae of falls among patients with brain metastases: A population- and institutional-level analysis

Background

Falls in patients with cancer harbor potential for serious sequelae. Patients with brain metastases (BrM) may be especially susceptible to falls but supporting investigations are lacking. We assessed the frequency, etiologies, risk factors, and sequelae of falls in patients with BrM using 2 data sources.

Methods

We identified 42 648 and 111 patients with BrM utilizing Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2008-2016) and Brigham and Women’s Hospital/Dana-Farber Cancer Institute (BWH/DFCI) institutional data (2015), respectively, and characterized falls in these populations.

Results

Among SEER-Medicare patients, 10 267 (24.1%) experienced a fall that prompted medical evaluation, with cumulative incidences at 3, 6, and 12 months of 18.0%, 24.3%, and 34.1%, respectively. On multivariable Fine/Gray’s regression, older age (≥81 or 76-80 vs 66-70 years, hazard ratio [HR] 1.18 [95% CI, 1.11-1.25], P &lt; .001 and HR 1.10 [95% CI, 1.04-1.17], P &lt; .001, respectively), Charlson comorbidity score of &gt;2 vs 0-2 (HR 1.08 [95% CI, 1.03-1.13], P = .002) and urban residence (HR 1.08 [95% CI, 1.01-1.16], P = .03) were associated with falls. Married status (HR 0.94 [95% CI, 0.90-0.98], P = .004) and Asian vs white race (HR 0.90 [95% CI, 0.81-0.99], P = .03) were associated with reduced fall risk. Identified falls were more common among BWH/DFCI patients (N = 56, 50.4% of cohort), resulting in emergency department visits, hospitalizations, fractures, and intracranial hemorrhage in 33%, 23%, 11%, and 4% of patients, respectively.

Conclusions

Falls are common among patients with BrM, especially older/sicker patients, and can have deleterious consequences. Risk-reduction measures, such as home safety checks, physical therapy, and medication optimization, should be considered in this population.

Emergency department visits and inpatient hospitalizations among older patients with brain metastases: a dual population- and institution-level analysis

Background

Older patients with brain metastases (BrM) commonly experience symptoms that prompt acute medical evaluation. We characterized emergency department (ED) visits and inpatient hospitalizations in this population.

Methods

We identified 17 789 and 361 Medicare enrollees diagnosed with BrM using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2010-2016) and an institutional database (2007-2016), respectively. Predictors of ED visits and hospitalizations were assessed using Poisson regression.

Results

The institutional cohort averaged 3.3 ED visits/1.9 hospitalizations per person-year, with intracranial disease being the most common reason for presentation/admission. SEER-Medicare patients averaged 2.8 ED visits/2.0 hospitalizations per person-year. For patients with synchronous BrM (N = 7834), adjusted risk factors for ED utilization and hospitalization, respectively, included: male sex (rate ratio [RR] = 1.15 [95% CI = 1.09-1.22], P < .001; RR = 1.21 [95% CI = 1.13-1.29], P < .001); African American vs white race (RR = 1.30 [95% CI = 1.18-1.42], P < .001; RR = 1.25 [95% CI = 1.13-1.39], P < .001); unmarried status (RR = 1.07 [95% CI = 1.01-1.14], P = .02; RR = 1.09 [95% CI = 1.02-1.17], P = .01); Charlson comorbidity score >2 (RR = 1.27 [95% CI = 1.17-1.37], P < .001; RR = 1.36 [95% CI = 1.24-1.49], P < .001); and receipt of non-stereotactic vs stereotactic radiation (RR = 1.44 [95% CI = 1.34-1.55, P < .001; RR = 1.49 [95% CI = 1.37-1.62, P < .001). For patients with metachronous BrM (N = 9955), ED visits and hospitalizations were more common after vs before BrM diagnosis (2.6 vs 1.2 ED visits per person-year; 1.8 vs 0.9 hospitalizations per person-year, respectively; RR = 2.24 [95% CI = 2.15-2.33], P < .001; RR = 2.06 [95% CI = 1.98-2.15], P < .001, respectively).

Conclusions

Older patients with BrM commonly receive hospital-level care secondary to intracranial disease, especially in select subpopulations. Enhanced care coordination, closer outpatient follow-up, and patient navigator programs seem warranted for this population.

Initiative to Increase the Rate of Emergency Department Physician Preprocedure Time-out Documentation

The preprocedure time-out is an important safety measure to verify patient identity and accuracy of a planned procedure. The time-out is an institutional and Joint Commission requirement. However, physicians in our emergency departments (EDs) document it inconsistently. We aimed to improve physician preprocedure time-out documentation for deep sedation (ketamine and/or propofol) from 75% to 90%, and separately for cutaneous abscess incision and drainage (I&D) from 94% to 98% by June 2020.

Methods

We analyzed 1 year of baseline data and weekly electronic medical record (EMR) reports from November 2019 through June 2020. Our outcome measures were the rate of physician time-out documentation for deep sedation and I&D, respectively; our process measure was physician engagement. Our interventions included education, monthly reminders and updates, individualized feedback for insufficient documentation, EMR deep sedation, and I&D procedure note optimization, and academic and financial incentives. We used statistical process control chart quality improvement rules for discerning special versus common cause variation.

Results

Physician documentation of a preprocedure time-out improved from 75% to 100% for deep sedation and from 94% to 99.3% for I&D. These improvements remained sustained. All physicians were eligible for the financial bonus, and 40 (63%) met Maintenance of Certification credit requirements.

Conclusions

Using quality improvement methodology, we increased physician time-out documentation for deep sedation and I&D through education, feedback, and systems enhancement. We improved Joint Commission regulatory compliance and reduced potential harm through these safety checks. Future studies may quantify patient safety effects and examine the efficacy of similar interventions for other procedures.

Sticky apps, not sticky hands: A systematic review and content synthesis of hand hygiene mobile apps

OBJECTIVE

The study sought to identify smartphone apps that support hand hygiene practice and to assess their content, technical and functional features, and quality. A secondary objective was to make design and research recommendations for future apps.

MATERIALS AND METHODS

We searched the UK Google Play and Apple App stores for hand hygiene smartphone apps aimed at adults. Information regarding content, technical and functional features was extracted and summarized. Two raters evaluated each app, using the IMS Institute for Healthcare Informatics functionality score and the Mobile App Rating Scale (MARS).

RESULTS

A total of 668 apps were identified, with 90 meeting the inclusion criteria. Most (96%) were free to download. The majority (78%) intended to educate or inform or remind users to hand wash (69%), using behavior change techniques such as personalization and prompting practice. Only 20% and 4% named a best practice guideline or had expert involvement in development, respectively. Innovative means of engagement were used in 42% (eg, virtual or augmented reality or geolocation-based reminders). Apps included an average of 2.4 out of 10 of the IMS functionality criteria (range, 0-8). The mean MARS score was 3.2 ± 0.5 out of 5, and 68% had a minimum acceptability score of 3. Two had been tested or trialed.

CONCLUSIONS

Although many hand hygiene apps exist, few provide content on best practice. Many did not meet the minimum acceptability criterion for quality or were formally trialed or tested. Research should assess the feasibility and effectiveness of hand hygiene apps (especially within healthcare settings), including when and how they "work." We recommend that future apps to support hand hygiene practice are developed with infection prevention and control experts and align with best practice. Robust research is needed to determine which innovative methods of engagement create "sticky" apps.

Factors Influencing Emergency Department Nurses' Compliance with Standard Precautions Using Multilevel Analysis

Standard precautions protect patients and nurses from infection. Nevertheless, compliance with standard precautions is lower among emergency department nurses than other nurses. We examined the individual and organizational factors that influence emergency department nurses’ compliance with standard precautions via a cross-sectional study. A self-reported questionnaire survey was administered to 140 nurses working in nine emergency departments in South Korea. It included items regarding ethical awareness and standard precaution self-efficacy at the individual level as well as safety environment, organizational culture for infection control, and degree of compliance with standard precautions at the organizational level. Individual and organizational predictors were identified using a multilevel analysis. The results indicated that 81.1% of nurses’ compliance with standard precautions was influenced by individual differences, while only 18.9% was influenced by organizational differences. Individual- and organizational-level predictors explained 46.7% and 55.4% of the variance in emergency department nurses’ compliance with standard precautions, respectively. Emergency department nurses’ compliance with standard precautions was predicted by ethical awareness and standard precaution self-efficacy at the individual level and by organizational culture for infection control at the organizational level. Our findings provide evidence for the need to improve facilities and human resource management as well as the organizational culture for infection control.

Characterizing Emergency Department Use in Assisted Living

OBJECTIVES

Little is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL.

DESIGN

Observational retrospective cohort study.

SETTING AND PARTICIPANTS

We identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds).

METHODS

With Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions.

RESULTS

Risk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina.

CONCLUSIONS AND IMPLICATIONS

We observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED.

CD169 and CD64 could help differentiate bacterial from CoVID-19 or other viral infections in the Emergency Department

The identification of a bacterial, viral, or even noninfectious cause is essential in the management of febrile syndrome in the emergency department (ED), especially in epidemic contexts such as flu or CoVID-19. The aim was to assess discriminative performances of two biomarkers, CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), using a new flow cytometry procedure, in patients presenting with fever to the ED during epidemics. Eighty five adult patients presenting with potential infection were included during the 2019 flu season in the ED of La Timone Hospital. They were divided into four diagnostic outcomes according to their clinical records: no-infection, bacterial infection, viral infection and co-infection. Seventy six patients with confirmed SARS-CoV-2 infection were also compared to 48 healthy volunteers. For the first cohort, 38 (45%) patients were diagnosed with bacterial infections, 11 (13%) with viral infections and 29 (34%) with co-infections. mCD169 was elevated in patients with viral infections, with a majority of Flu A virus or Respiratory Syncytial Virus, while nCD64 was elevated in subjects with bacterial infections, with a majority of Streptococcus pneumoniae and Escherichia coli. nCD64 and mCD169 showed 90% and 80% sensitivity, and 78% and 91% specificity, respectively, for identifying patients with bacterial or viral infections. When studied in a second cohort, mCD169 was elevated in 95% of patients with SARS-CoV-2 infections and remained at normal level in 100% of healthy volunteers. nCD64 and mCD169 have potential for accurately distinguishing bacterial and acute viral infections. Combined in an easy and rapid flow cytometry procedure, they constitute a potential improvement for infection management in the ED, and could even help for triage of patients during emerging epidemics.

Compliance to Screening Protocols for Multidrug-Resistant Microorganisms at the Emergency Departments of Two Academic Hospitals in the Dutch-German Cross-Border Region

Infections caused by multidrug-resistant organisms (MDROs) are associated with prolonged hospitalization and higher risk of mortality. Patients arriving in the hospital via the emergency department (ED) are screened for the presence of MDROs in compliance with the screening protocols in order to apply the correct isolation measures. In the Dutch–German border region, local hospitals apply their own screening protocols which are based upon national screening protocols. The contents of the national and local MDRO screening protocols were compared on vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and carbapenemase-producing and carbapenem-resistant Enterobacteriaceae (CPE/CRE). The practicality of the screening protocols was evaluated by performing an audit. As a result, the content of the MDRO screening protocols differed regarding risk factors for MDRO carriage, swab site, personal protective equipment, and isolation measures. The observations and questionnaires showed that the practicality was sufficient; however, the responsibility was not designated clearly and education regarding the screening protocols was deemed inappropriate. The differences between the MDRO screening protocols complicate patient care in the Dutch–German border region. Arrangements have to be made about the responsibility of the MDRO screening, and improvements are necessary concerning education regarding the MDRO screening protocols.

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

Aim and objective

To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital.

Materials and methods

The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures.

Result

The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles.

Conclusion

Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success.

How to cite this article

Singh N, Kalyan G, Kaur S, Jayashree M, Ghai S. Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room. Indian J Crit Care Med 2021;25(5):557–565.

Plastic wrap combined with alcohol wiping is an effective method of preventing bacterial colonization on mobile phones

INTRODUCTION

Using mobile phones for communication in emergency departments is a common practice; however, several studies have demonstrated that they may act as vectors for bacteria and viruses. This study evaluated the effectiveness of plastic wrapping in decreasing bacterial contamination on mobile phone surfaces.

METHOD

We used culture dishes and a luminometer to detect bacterial colonies and contamination on the phone surfaces.

RESULT

Our experiment showed that bacterial colonies exist on mobile phones before and after work. We found that wiping with 75% alcohol sanitizers effectively reduces the number of colonies on either a mobile phone or a temporary plastic covering. In addition, we found that bacterial colonies do not contaminate or adhere to plastic wrap any easier than to mobile phones.

CONCLUSION

These results demonstrated the effectiveness of plastic wrap for protecting mobile phone surfaces against bacterial colonization. In addition, applying a layer of plastic wrap protects the phone from potential damage due to the alcohol.

Effectiveness of negative pressure isolation stretcher and rooms for SARS-CoV-2 nosocomial infection control and maintenance of South Korean emergency department capacity

Objective

There are growing concerns regarding the lack of COVID-19 pandemic response capacity in already overwhelmed emergency departments (EDs), and lack of proper isolation facilities. This study evaluated the effectiveness of the negative pressure isolation stretcher (NPIS) and additional negative pressure isolation rooms (NPIRs) on the maintenance of emergency care capacity during the COVID-19 outbreak.

Methods

A before and after intervention study was performed between February 27, 2020 and March 31, 2020 at the ED of Chungbuk National University Hospital, Cheongju, South Korea. A total of 2455 patients who visited the ED during the study period were included. Interventions included the introduction of the NPIS and additional NPIRs in the ED. The main outcome of the study was frequency of medical cessation. Secondary outcomes were the average number of ED visits and lengths of stay.

Results

After the intervention, average frequency of medical cessation was significantly decreased from 1.6 times per day (range 0–4) in the pre-intervention period to 0.6 times per day (range 0–3) in the post-intervention period (p-value <0.01). On the other hand, the number of patients visiting the ED increased significantly from 67.2 persons per day (range 58–79) pre-intervention to 76.3 persons per day (range 61–88) post-intervention (p value <0.01). However, there were no statistically significant differences in the average ED length of stay across the study phases (p value = 0.50).

Conclusions

This intervention may provide an effective way to prepare and meet the ED response needs of the COVID-19 pandemic.

Quality of Respiratory Infection Disease Prevention in Outpatient and Emergency Departments in Hospitals in Inner Mongolia, China: An Exit Poll Survey

Purpose

Measures to prevent respiratory infection diseases (RIDs) in hospitals are important to protect both patients and physicians. In 2003, an outbreak of severe acute respiratory syndrome occurred in Inner Mongolia Autonomous Region (IMAR) of China. We aimed to evaluate competency in RID prevention procedures in terms of hospital performance and physician behavior.

Patients and Methods

We conducted a cross-sectional study in 10 tertiary general public hospitals in 3 cities of IMAR. In each hospital, we chose the respiratory and ear–nose–throat outpatient departments (OPDs) and the emergency department (ED) to invite patients with symptoms of cough to join the study before they consulted a physician. After their consultation, we asked the patients to complete a checklist to score the performance of the departments and the behavior of their physicians in terms of RID prevention practices according to international professional guidelines.

Results

From 711 respondents, in the domain of hospital performance, display of posters on directive to wash hands after coughing/sneezing had an average score of 0.452 (range 0–1), while other cough etiquette items had scores averaging between 0.33 and 0.39. The average score for air ventilation was 0.66. For physicians’ performance, informing patients the location of handwashing facilities scored the highest (0.62), while low scores were seen for offering a mask to coughing patients (0.14) and encouraging coughing patients to distance themselves from others (0.17). Most RID prevention procedures received low scores in EDs in both hospital performance and physician behavior domains.

Conclusion

Hospitals in IMAR should improve their performance in RID prevention procedures, especially in giving information to RID patients through the display of posters. The practice of physicians in preventing respiratory infection spread was suboptimum. ED staff and hospital administrators should improve their procedures to prevent the spread of respiratory infections, especially given the increasing occurrences of global pandemics such as COVID-19.

Flow cytometry evaluation of infection-related biomarkers in febrile subjects in the emergency department

Aim: In an Emergency Department (ED), the etiological identification of infected subjects is essential. 13 infection-related biomarkers were assessed using a new flow cytometry procedure. Materials & methods: If subjects presented with febrile symptoms at the ED, 13 biomarkers' levels, including CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169), were tested and compared with clinical records. Results: Among 50 subjects, 78% had bacterial infections and 8% had viral infections. nCD64 showed 82% sensitivity and 91% specificity for identifying subjects with bacterial infections. mCD169, HLA-ABC ratio and HLA-DR on monocytes had high values in subjects with viral infections. Conclusion: Biomarkers showed promising performances to improve the ED's infectious stratification.

Role of the interferons in CD64 and CD169 expressions in whole blood: Relevance in the balance between viral- or bacterial-oriented immune responses

Introduction

CD64 expression increases on neutrophils during bacterial infections. Recently an increase in CD169 expression has been discovered on monocytes during viral infections. Generally, interferons α (IFNsα) and IFNsγ are key drivers of the infectious host immune response. The purpose of this study was to explore if a link exists between these IFNs and both biomarkers.

Methods

Whole blood samples from healthy volunteers were stimulated with either IFNs, interleukins, or infectious extracts, to mimic an infectious state. Expressions of CD64 and CD169 were assessed in these samples by multiple flow cytometry methods, over precise kinetics.

Results

The expression of CD64 was statistically higher in samples stimulated with IFNγ, and CD169 in those stimulated with IFNα (and all other type I IFNs). Surface expressions are directly induced by their respective IFNs via Janus kinase/signal transducer and activator of transduction pathways within 6 to 8 hours of incubation. Mixing both types of IFNs seemed to indicate that they partially inhibit each other.

Conclusions

The induction of CD169 on monocytes and CD164 on neutrophils by type I and type II IFNs confirms the relevance of these markers for assessing between a viral‐ vs bacterial‐oriented immune response.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

Checklist for infection control in the emergency department

The risk of encountering human-to-human infections, including emerging infectious diseases, should be adequately and appropriately addressed in the emergency department. However, guidelines based on sufficient evidence on infection control in the emergency department have not been developed anywhere in the world. Each facility examines and implements its own countermeasures. The Japanese Association for Acute Medicine has established the "Committee for Infection Control in the Emergency Department" in cooperation with the Japanese Association for Infectious Diseases, Japanese Society for Infection Prevention and Control, Japanese Society for Emergency Medicine, and Japanese Society for Clinical Microbiology. A joint working group has been established to consider appropriate measures. This group undertook a comprehensive and multifaceted review of infection control measures for emergency outpatients and related matters, and released a checklist for infection control in emergency departments. This checklist has been prepared such that even small emergency departments with few or no emergency physicians can control infection by following the checklist, without committing any major errors. The checklist includes a control system for infection control, education, screening, and vaccination, prompt response to suspected infections, and management of the risk of infection in facilities. In addition, the timing of the check and interval at which the check is carried out are specified as categories. We hope that this checklist will contribute to improving infection control in the emergency department.

Clinical research assessment by flow cytometry of biomarkers for infectious stratification in an Emergency Department

Aim: Management of patients with infections within the Emergency Department (ED) is challenging for practitioners, as the identification of infectious causes remains difficult with current techniques. A new combination of two biomarkers was tested with a new rapid flow cytometry technique. Materials & methods: Subjects from the ED were tested for their CD64 on neutrophils (nCD64) and CD169 on monocytes (mCD169) levels and results were compared to their clinical records. Results: Among 139 patients, 29% had confirmed bacterial infections and 5% viral infections. nCD64 and mCD169 respectively showed 88 and 86% sensitivity and 90 and 100% specificity for identifying subjects in bacterial or viral conditions. Conclusion: This point-of-care technique could allow better management of patients in the ED.

Assessment of Health Facilities for Airborne Infection Control Practices and Adherence to National Airborne Infection Control Guidelines: A Study from Kerala, Southern India

INTRODUCTION

Nosocomial transmission of airborne infections, such as H1N1, drug-resistant tuberculosis, and Nipah virus disease, has been reported recently and has been linked to the limited airborne infection control strategies. The objective of the current study was to assess the health facilities for airborne infection control (AIC) practices and adherence to the National AIC (NAIC) guidelines, 2010.

MATERIALS AND METHODS

A cross-sectional study was conducted in 25 public and 25 private hospitals selected from five randomly selected districts in the state of Kerala. A checklist with 62 components was developed based on the NAIC guidelines. Frequencies, percentages, and mean with standard deviation were used to summarize facility risk assessment and compliance to guidelines.

RESULTS

Most of the facilities had infection control committees 35 (70%). Annual infection control trainings were held for staff in 21 (42%) facilities. Twenty (40%) facilities were not familiar with NAIC guidelines. Counseling on cough etiquette at registration was practiced in 5 (10%) institutions. Cross ventilation was present in outpatient departments in 27 (54%) institutions. Sputum was disposed properly in 43 (86%) institutions. N95 masks were available in high-risk settings in 7 (14%) health facilities.

CONCLUSION

There exist deficiencies in adherence to all components of NAIC guidelines including administrative, environmental, and use of personal protective equipment in both government and private hospitals in the state.

Interventions to improve hand hygiene compliance in emergency departments: a systematic review

The emergency department (ED) is where hand hygiene problems are significant as the procedures in the ED are often high risk and invasive. To date, there have been no comprehensive reviews on hand hygiene in EDs. The aim of this study was to investigate hand hygiene compliance (HHC) rate, factors affecting the HHC rate, and intervention strategies to improve HHC in EDs. Electronic databases were used to search for research published from 1948 to January 2018. The databases included ovidMEDLINE, ovidEMBASE, the Cochrane Library, CINAHL, Koreamed, and Kmbase. All study designs were included. Two reviewers independently extracted the data and assessed the bias risk using reliable and validated tools. A narrative synthesis was performed. Twenty-four studies, including 12 cross-sectional surveys and 12 interventional studies, were included. Of the 12 interventional studies reviewed, only 33% (N = 4) reported HHC rates of more than 50%. Factors that influenced HHC included types of healthcare worker, hand hygiene indication, ED crowding, positive attitudes towards HHC, patient location, auditing hand hygiene, and type of shift. Almost all of the studies (83.3%) applied multimodal or dual interventions to improve HHC. A range of strategies, including education, monitoring and providing feedback, campaigns, and cues, effectively improved HHC. The review findings indicate that there is a room for improvement in HHC in EDs. Future randomized controlled trials are necessary to determine which intervention modalities are most effective and sustainable for HHC improvement.

Tuberculosis infection via the emergency department among inpatients in South Korea: a propensity score matched analysis of the National Inpatient Sample

BACKGROUND

Emergency departments (EDs) carry a high risk of infectious disease transmission and have also been implicated in tuberculosis (TB) outbreaks.

AIM

To determine if patients who visit EDs have an increased risk of TB infection. Using South Korean inpatient sample data (2012), the risk of TB occurrence during 90 days after hospitalization for patients admitted via EDs was compared with that for patients admitted via outpatient clinics.

METHODS

The data of the 2012 Health Insurance Review and Assessment Service - National Inpatient Sample were used. TB diagnosis was based on International Classification of Diseases Version 10 [all TB (A15-A19), pulmonary TB (A15-A16) and extrapulmonary TB (A17-A18)].

FINDINGS

After propensity score matching using the demographic and clinical characteristics of the patients, 191,997 patients (64,017 patients admitted via EDs and 127,908 patients admitted via outpatient clinics) were included in this study. There was no significant difference in baseline patient characteristics between the two groups. The percentage of patients with TB admitted via EDs was higher than that of patients admitted via outpatient clinics. The likelihood of active TB occurrence was 30% higher for all TB [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.12-1.52] and pulmonary TB (HR 1.30; 95% CI 1.10-1.53) in patients admitted via EDs compared with patients admitted via outpatient clinics; this difference was significant. However, no difference in the occurrence of extrapulmonary TB was observed between the two groups.

CONCLUSIONS

The likelihood of TB infection was greater in patients admitted via EDs than in patients admitted via outpatient clinics.

A survey on infection control in emergency departments in Japan

Aim

Infection control in the emergency department is important for hospital risk management; however, few clinical guidelines have been established. This study aimed to determine whether hospitals in Japan have infection control manuals, and investigate the contents of manuals, consulting systems, and isolation facilities for emergency departments.

Methods

A total of 517 hospitals certified as educational institutions for board‐certified acute care physicians in Japan were requested between March and May 2015 to provide a written evaluation of the infection control in the emergency department.

Results

A total of 51 of 303 (16.8%) hospitals had no manuals regarding infection control in the emergency department. Among 250 hospitals having emergency department manuals, 115 (46.0%) did not include contents regarding disinfection and sterilization for imaging examination rooms, and only 44 (17.6%) had criteria for contacting the emergency medical service when patients are suspected of, or diagnosed with, communicable diseases. Of the 303 hospitals, 277 (91.4%) prepared specific manuals for the 2009 pandemic influenza. Of the 303 hospitals, 80 (26.4%) did not prepare manuals for the Ebola virus disease outbreak in West Africa in 2014. Furthermore, 92 (30.4%) of the 303 hospitals did not have any negative‐pressure isolation rooms.

Conclusions

Practices and guidelines necessary for infection control in the emergency department were not sufficiently covered in the hospitals studied. Education, information sharing, and a checklist for preparing manuals are needed to establish better infection control systems in emergency departments.

Hospital-Acquired Pneumonia among Inpatients via the Emergency Department: A Propensity-Score Matched Analysis

Background: Hospital-acquired pneumonia (HAP) is an inflammatory condition of the lung that develops at least 48–72 h after admission. HAP is contracted by both intensive care unit (ICU) and non-ICU patients, but no studies have examined the risk of HAP in patients admitted to the emergency department (ED). This study investigated the risk of developing HAP in ED patients and compared the occurrence of HAP 3–10 days after the first day of hospitalization in patients hospitalized via ED with those hospitalized via outpatient clinics. Methods: We analyzed the 2010 National Inpatient Sample data collected by the Health Insurance Review and Assessment Service in South Korea. After propensity score matching for age, sex, residential area, hospital, and diseases, 153,130 inpatients (76,565 admitted via ED and 76,565 admitted via outpatient clinics) were included in the analysis. The diagnosis of pneumonia was based on the International Classification of Diseases and Related Health Problems 10th Revision (Pneumonia, all (J12–J18); Pneumonia, bacterial (J13–J15); Pneumonia, non-bacterial (J12, J16, J17); and Pneumonia, unspecified (J18)). Results: The percentage of newly diagnosed cases of pneumonia in inpatients admitted via ED was significantly higher than that in inpatients admitted via outpatient clinics. After propensity score matching for baseline characteristics, the likelihood of developing pneumonia (excluding the category of ‘Pneumonia, non-bacterial’) in inpatients hospitalized via ED was significantly increased by 1.33–1.97-fold. The cumulative incidence of pneumonia was also significantly higher in patients admitted via ED than in those hospitalized via outpatient clinics. Conclusions: ED visits may be an important risk factor for the development of HAP.

Infection Prevention and Control in Pediatric Ambulatory Settings

Since the American Academy of Pediatrics published its statement titled "Infection Prevention and Control in Pediatric Ambulatory Settings" in 2007, there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent the transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated every 2 years, and enforced. Many of the recommendations for infection control and prevention from the Centers for Disease Control and Prevention for hospitalized patients are also applicable in the ambulatory setting. These recommendations include requirements for pediatricians to take precautions to identify and protect employees likely to be exposed to blood or other potentially infectious materials while on the job. In addition to emphasizing the key principles of infection prevention and control in this policy, we update those that are relevant to the ambulatory care patient. These guidelines emphasize the role of hand hygiene and the implementation of diagnosis- and syndrome-specific isolation precautions, with the exemption of the use of gloves for routine diaper changes and wiping a well child's nose or tears for most patient encounters. Additional topics include respiratory hygiene and cough etiquette strategies for patients with a respiratory tract infection, including those relevant for special populations like patients with cystic fibrosis or those in short-term residential facilities; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices; appropriate use of personal protective equipment, such as gloves, gowns, masks, and eye protection; and appropriate use of sterilization, disinfection, and antisepsis. Lastly, in this policy, we emphasize the importance of public health interventions, including vaccination for patients and health care personnel, and outline the responsibilities of the health care provider related to prompt public health notification for specific reportable diseases and communication with colleagues who may be providing subsequent care of an infected patient to optimize the use of isolation precautions and limit the spread of contagions.

Comparing the protective performances of 3 types of N95 filtering facepiece respirators during chest compressions: A randomized simulation study

OBJECTIVE

Healthcare providers in emergency departments should wear respirators for infection protection. However, the wearer's vigorous movements during cardiopulmonary resuscitation may affect the protective performance of the respirator. Herein, we aimed to assess the effects of chest compressions (CCs) on the protective performance of respirators.

METHODS

This crossover study evaluated 30 healthcare providers from 1 emergency department who performed CC with real-time feedback. The first, second, and third groups started with a cup-type, fold-type, and valve-type respirator, respectively, after which the respirators were randomized for each group. The fit factors were measured using a quantitative fit testing device before and during the CC in each experiment. The protection rate was defined as the proportion of respirators achieving a fit factor ≥100.

RESULTS

The fold-type respirator had a significantly greater protection rate at baseline (100.0% ± 0.0%) compared to the cup-type (73.6% ± 39.6%, P = .003) and valve-type respirators (87.5% ± 30.3%, P = .012). During the CC, the fit factor values significantly decreased for the cup-type (44.9% ± 42.8%, P < .001) and valve-type respirators (59.5% ± 41.7%, P = .002), but not for the fold-type respirator (93.2% ± 21.7%, P = .095).

CONCLUSIONS

The protective performances of respirators may be influenced by CC. Healthcare providers should identify the respirator that provides the best fit for their intended tasks.

The Utility of Preliminary Patient Evaluation in a Febrile Respiratory Infectious Disease Unit outside the Emergency Department

A febrile respiratory infectious disease unit (FRIDU) with a negative pressure ventilation system was constructed outside the emergency department (ED) of the Samsung Medical Center in 2015, to screen for patients with contagious diseases requiring isolation. We evaluated the utility of the FRIDU during 1 year of operation. We analyzed 1,562 patients who were hospitalized after FRIDU screening between August 2015 and July 2016. The level of isolation recommended during their screening at the FRIDU was compared with the level deemed appropriate given their final diagnosis. Of the 1,562 patients screened at the FRIDU, 198 (13%) were isolated, 194 (12%) were reverse isolated, and 1,170 (75%) were not isolated. While hospitalized, 97 patients (6%) were confirmed to have a contagious disease requiring isolation, such as tuberculosis; 207 patients (13%) were confirmed to be immunocompromised and to require reverse isolation, mainly due to neutropenia; and the remaining 1,258 patients (81%) did not require isolation. The correlation coefficient for isolation consistency was 0.565 (P < 0.001). The sensitivity and negative predictive value of FRIDU screening for diagnosing contagious disease requiring isolation are 76% and 98%, respectively. No serious nosocomial outbreaks of contagious diseases occurred. During FRIDU screening, 114 patients were admitted to the resuscitation zone due to clinical instability, and three of these patients died. The initial isolation levels resulting from FRIDU screening were moderately well correlated with the isolation levels required by the final diagnosis, demonstrating the utility of pre-hospitalization screening units. However, the risks of deterioration during the screening process remain challenges.

Hand Hygiene Compliance in the Setting of Trauma Resuscitation

INTRODUCTION

Healthcare-associated infections are a significant health burden, and hand hygiene (HH) is an essential prevention strategy. World Health Organization (WHO) 2009 guidelines recommend washing hands during five moments of patient care; 1)before touching a patient; 2)before a clean procedure; 3)after body fluid exposure; and 4)after touching a patient or 5)patient surroundings. HH opportunities at these 5 moments are frequent and compliance is low (22-60%). Infection risk is particularly high in trauma patients, and HH compliance during active trauma resuscitation has yet to be evaluated.

MATERIALS AND METHODS

Using video surveillance, all healthcare worker (HCW)-patient interactions for 30 patients were retrospectively reviewed for HH compliance according to WHO guidelines and glove use during initial resuscitation at a level-1 trauma center.

RESULTS

342 HCW-patient interactions and 1034 HH opportunities were observed. HH compliance with the WHO moments was 7% (71/1034) overall; 3% (10/375) before patient contact, 0% (0/178) before a clean procedure, 11% (2/19) after body fluid contact, 15% (57/376) after patient contact and 2% (2/86) after contact with the environment. Glove use was more common, particularly before (69%) and after (47%) patient contact and after body fluid contact (58%). No HH was observed before clean procedures, but HCW donned new gloves 75% of the time before bedside procedures. If donning/removing gloves was included with HH as compliant, compliance was 57% overall.

CONCLUSION

HH opportunities are frequent and compliance with WHO HH guidelines may be infeasible, requiring significant amounts of time that may be better spent with the patient during the golden hour of trauma resuscitation. In an era where more scrutiny is being applied to patient safety, particularly the prevention of inpatient infections, more research is needed to identify alternative strategies (e.g. glove use, prioritizing moments) that may more effectively promote compliance in this setting.

A healthy degree of suspicion: A discussion of the implementation of transmission based precautions in the emergency department

Background

Emergency department (ED) presentations have increased significantly domestically and internationally. Swift identification and implementation of transmission based precautions (TBP) for patients known or suspected of having an epidemiologically important pathogen is important. ED staff, particularly triage nurses, are pivotal in detecting and preventing infection, including healthcare associated infections (HAI).

Methods

MEDLINE, CINAHL, PubMed and Ovid were searched for articles published between 2004 and 2015 using key search terms: infection control/prevention and emergency department(s), triage, and transmission based precautions and emergency department(s), and triage, to identify common themes for discussion. Systematic review/meta-analysis was not in the scope of this exploration.

Findings

Themes were identified relating to HAI and ED practices and grouped into: assisted detection of conditions for which TBP is required, ED and TBP, mass-causality event/bioterrorism/pandemic/epidemic, infection control not TBP and multi-resistant organisms not TBP. The literature is heavily influenced by worldwide epidemic/pandemics and bioterrorist risks resulting in increased awareness of the importance of swift identification of syndromes that require TBP, but only in these situations.

Conclusion

Implementation of appropriate TBP, changing triage practices, training and measures to assist decision-making could assist in preventing HAI in the ED context. A systematic quantitative review of the literature is recommended to guide practice change research.

Communicable Diseases and Outbreak Control

Infectious disease during an emergency condition can raise the death rate 60 times in comparison to other causes including trauma. An epidemic, or outbreak, can occur when several aspects of the agent (pathogen), population (hosts), and the environment create an ideal situation for spread. Overcrowding, poor regional design and hygiene due to poverty, dirty drinking water, rapid climate changes, and natural disasters, can lead to conditions that allow easier transmission of disease. Once it has been established that an emergency condition exists, there must be a prompt and thorough response for communicable disease control. A camp should be created, and the disease managed rapidly. The overall goals are rapid assessment, prevention, surveillance, outbreak control, and disease management.

Emergency Department Catheter-Associated Urinary Tract Infection Prevention: Multisite Qualitative Study of Perceived Risks and Implemented Strategies

BACKGROUND

Existing knowledge of emergency department (ED) catheter-associated urinary tract infection (CAUTI) prevention is limited. We aimed to describe the motivations, perceived risks for CAUTI acquisition, and strategies used to address CAUTI risk among EDs that had existing CAUTI prevention programs.

METHODS

In this qualitative comparative case study, we enrolled early-adopting EDs, that is, those using criteria for urinary catheter placement and tracking the frequency of catheters placed in the ED. At 6 diverse facilities, we conducted 52 semistructured interviews and 9 focus groups with hospital and ED participants.

RESULTS

All ED CAUTI programs originated from a hospitalwide focus on CAUTI prevention. Staff were motivated to address CAUTI because they believed program compliance improved patient care. ED CAUTI prevention was perceived to differ from CAUTI prevention in the inpatient setting. To identify areas of ED CAUTI prevention focus, programs examined ED workflow and identified 4 CAUTI risks: (1) inappropriate reasons for urinary catheter placement; (2) physicians' limited involvement in placement decisions; (3) patterns of urinary catheter overuse; and (4) poor insertion technique. Programs redesigned workflow to address risks by (1) requiring staff to specify the medical reason for catheter at the point of order entry and placement; (2) making physicians responsible for determining catheter use; (3) using catheter alternatives to address patterns of overuse; and (4) modifying urinary catheter insertion practices to ensure proper placement.

CONCLUSIONS

Early-adopting EDs redesigned workflow to minimize catheter use and ensure proper insertion technique. Assessment of ED workflow is necessary to identify and modify local practices that may increase CAUTI risk.

Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding

OBJECTIVES

Emergency department (ED) crowding results from the need to see high volumes of patients of variable acuity within a limited physical space. ED crowding has been associated with poor patient outcomes and increased mortality. The authors evaluated whether ED crowding is also associated with reduced hand hygiene compliance among health care workers.

METHODS

A trained observer measured hand hygiene compliance using standardized definitions for 22 months in the 40-bed ED of a 475-bed academic hospital in Toronto, Ontario, Canada. ED crowding measures, including mean daily patient volumes, time to initial physician assessment, and daily nursing hours, were obtained from hospital administrative and human resource databases. Known predictors of hand hygiene compliance, including the indication for hand hygiene and the health care workers' professions, were also measured. Hand hygiene data, measured during 20-minute observation sessions, were linked to aggregate daily results for each crowding metric. Crowding metrics and known predictors of hand hygiene compliance were then included in a multivariate model if associated with hand hygiene compliance at a p-value of <0.20.

RESULTS

Hand hygiene compliance was 29% (325 of 1,116 opportunities). Alcohol-based hand rinse was used 66% of the time. Nurses accounted for 68% of hand hygiene opportunities and physicians for 18%, with the remaining 14% attributed to nonphysician, nonnurse health care workers. The most common indications for hand hygiene were hand hygiene prior to (35%) and hand hygiene following (52%) contact with the patient or his or her environment. In multivariate analysis, time to physician assessment > 1.5 hours was associated with lower compliance (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.51 to 0.89). Additionally, compliance was lower for nonnurse, nonphysician health care workers (OR = 0.51, 95% CI = 0.33 to 0.79) and higher for hand hygiene performed after contact with the patients or his/her environment, compared to hand hygiene performed before contact with the patient or his/her environment (OR = 2.0, 95% CI = 1.5 to 2.7). Daily patient volumes and nursing hours were not associated with hand hygiene compliance.

CONCLUSIONS

ED hand hygiene compliance was low. Increased time to physician assessment was associated with reduced compliance, suggesting an association between crowding and compliance. Strategies that minimize ED crowding may improve ED hand hygiene compliance.