At a time when Ebola and other emerging infections may first present at an emergency department (ED), researchers are finding a wide range of compliance — or lack thereof — with infection control measures.
In particular, there is room for considerable improvement in hand hygiene compliance and use of aseptic technique during catheter insertion in emergency departments.
Researchers conducting a literature review found that hand hygiene compliance in EDs ranged from 7.7% to 89.7%.1
"A variety of factors may have contributed to variation in hand hygiene adherence rates," says Eileen Carter, RN, BSN, lead author of the study. "We reviewed studies that were conducted in several countries. Differences in cultural practices, data collection procedures, and access to hand sanitizer and hand wash, may have contributed to the variation we saw in hand hygiene compliance."
Caveats noted, but low compliance with hand hygiene and other infection control precautions fits the narrative described at the APIC conference earlier this year by Jeremiah Schuur, MD, director of Quality, Patient Safety and Performance Improvement for Emergency Medicine at the Brigham and Women’s Hospital in Boston.
In a chaotic, often overcrowded ED, the prevailing mindset is that care must be administered quickly, engendering an "acceptability or normalization of deviance" with infection control measures, he said. (See HIC July 2014 p. 66.)
Catheters placed in ED may be lost to follow-up
In that regard, the literature review study also raises questions about aseptic technique during placement of central venous catheters and urinary catheters in EDs.
"There are a lot of lapses in technique for inserting invasive devices," says Elaine Larson, RN, PhD, FAAN, CIC, co-author of the study and associate dean for nursing research at Columbia University in New York, NY. "Most hospitals have a rule that if an invasive device is inserted under emergency conditions, then it should be re-inserted within 24 hours, but no one has ever studied that."
Indeed, the authors were unable to find any studies that looked at adherence to re-inserting invasive devices that initially were inserted in the ED.
"It’s very hard to tease out this information from electronic databases," Larson says.
Another problem is that hospital nurses and physicians might not even know where and when a catheter was inserted, she notes.
"Say the patient went from the ED straight to the operating room," she says. "They don’t know whether it was inserted in the ED or the operating room, depending on the charting."
Even as the health care field is trying to make electronic health records more useful, there remains information that is not collected.
"If there is not a field in the record that says the catheter went in at this time in the emergency department, then this information could be noted in electronic notes," Larson says.
But the date and place of insertion might not be mentioned at all. In addition, there are research needs for more information about whether central lines and urinary catheters inserted in an ED increase the risk of infections.
"Nobody even knows if the rule to re-insert the device even makes a difference," she adds. "It seems like a good idea — imagine trying to put in a urinary catheter in the hallway, but we don’t know."
Intervention studies that address ED catheter-associated urinary tract infections (CAUTIs) were largely educational based and aimed to improve the proportion of ED-placed urinary catheters that met medical appropriateness criteria, Carter says.
"Results were varied, indicating that education alone does not guarantee provider compliance," she adds.
Targeted HH campaigns work best
One thing the study does highlight is the importance of targeted hand hygiene campaigns. Studies from the U.S. and Italy showed sustained improvements in hand hygiene after a campaign. Observers used training materials from the World Health Organization prior to observing staff HH practices.
"Multimodal campaigns, which have focused on staff education and engagement, interdisciplinary champions, and performance feedback, have successfully increased hand hygiene rates," Carter says.
"However, ED hand hygiene improvement efforts should also consider unique barriers to compliance in the ED," she adds. "For instance, healthcare workers may provide care to patients in non-traditional care areas where hand sanitizer is not readily accessible, which was addressed by one of the studies we reviewed."
The literature review’s chief finding is that there is a need for improved compliance to infection prevention practices in the emergency department, Carter says.
"Future studies should evaluate the role of the ED in the transmission of infections," she adds.
Larson says additional research questions include:
- What is the impact of ED patient crowding on hand hygiene and aseptic technique?
"When you have patients lined up in the hallway, can staff practice aseptic technique and hand hygiene — even if there is not a sink or hand rinse nearby?" Larson wonders.
- Do staffing levels in the ED have a significant impact on infection risk?
Or is the problem related to the level and type of staffing in the ED, she says.
"Is there enough staff in the ED to use aseptic technique, and is the staff able to practice good infection control?" she adds.
"It’s possible to make aseptic technique a two-person job," Larson says.
One person can watch to make sure their colleague does not break technique.
- Do hospital employees follow their own organization’s guidelines and re-insert invasive devices within 24 hours, and do they even know about these guidelines?
- Carter EJ, Pouch SM, Larson EL. Common infection control practices in the emergency department: a literature review. Am J Infect Con 2014;42:957-962
