Do you know how to manage infectious diseases in your ED?
Do you know how to manage infectious diseases in your ED?
ED nurses are the first line of defense against infectious diseases
Protect yourself and your colleagues against infectious diseases, and know how to manage them appropriately, urges Marjorie J. Stenberg, MA, MS, RN, CIC, CEO of Infection Control Support Services in Singer Island, FL, and a consultant for Veterans Affairs Medical Center in West Palm Beach, FL. "As ED nurses, you are the first line of defense, and have significant exposure to blood or body fluids, skin, mucous membranes, invasive procedures, and sharps. Also, you never know who you are working with," she says.
Infectious diseases are the number one killer globally, with more than 20 million deaths per year, reports Katherine L. Heilpern, MD, FACEP, interim residency director and assistant professor of the department of emergency medicine at Emory University School of Medicine in Atlanta, GA. "The number one killer of all is tuberculosis (TB), with more than six million deaths per year globally. In the United States, AIDS is the number one killer in 25-64 year olds, and influenza and pneumonia are the number one and two causes in [patients] older than age 65," she says.
Commonly seen infectious agents include tuberculosis (TB), drug-resistant Streptococcus pneumoniae (pneumonia, bacteremia, septic joint, meningitis, otitis media), viral syndromes, and Hemophilus influenzae (bronchitis and pneumonia), says Heilpern.
"Exposure may come from droplet transmission of highly infectious pathogens, as with meningitis, tuberculosis, and measles," says Heilpern. "Look for symptoms including fever and headache for meningitis, and coughing for TB, particularly in a patient who is homeless, HIV positive, a crack user, or a recent U.S. immigrant from areas with high rates of TB."
Here are some ways to improve management of patients with infectious diseases:
Identify infectious patients at triage. "Ask about blood tinged sputum, weight loss, night sweats, cough for greater than two weeks, and HIV-positive status with a cough," says Heilpern.
Suspect TB in the homeless, the elderly, immigrants from endemic areas, drug users, HIV-positive patients, patients who have had contacts with recent cases, patients with night sweats, or patients with weight loss or anorexia, says Stenberg. "But the good news is, patients really have to be coughing to give you pulmonary TB," she notes. "And children rarely spread it because their cough is weak and doesn’t get as far."
Protect staff and patients from exposure. Place all patients at risk for TB in a negative pressure respiratory isolation room immediately, away from other patients and staff, Heilpern recommends. "If no room is available (and all EDs should have one), place a surgical mask on the patient, place them in a room, and close the door. Some EDs have adopted a policy of rapid, immediate chest x-ray screen before the patient is actually brought into the ED. Obviously, the patient goes to x-ray with a mask."
However, one study found that only 1.9% of EDs have negative-pressure rooms.1 "The study reported that 19.6% of EDs have an isolation room, and the wait to see a physician averaged from 30 minutes to one hour. So the patient is sitting in a waiting room somewhere breathing in and out, and coughing," notes Stenberg. "Also, the wait to admission averaged two hours, even in facilities with a high TB rate."
Institute immediate closed door isolation of pediatric and adult patients with fever and headache who may have N. meningitidis or H. influenzae meningitis, both transmissible by respiratory droplet, says Heilpern. "Wear the appropriate high-filter mask when encountering all patients in respiratory isolation," she adds.
Nurses should have a high index of suspicion with any coughing patient, says Moody. "Put the patient in a negative-pressure room and wear a mask, especially if the cough has lasted more than two or three weeks, if there has been loss of weight, if the patient has nausea or difficulty eating, or they are [recent immigrants]," she adds.
Be aware of ED surveillance efforts. Emergency ID Net is a sentinel surveillance system for emerging infectious diseases, reports Heilpern. "Eleven academic EDs across the country are working in collaboration with the CDC [Centers for Disease Control and Prevention] to track several emerging infectious diseases: tuberculosis, Escherichia coli 0157:H7 (a food and waterborne infection and a cause of bloody diarrhea and possible renal failure in children), neurocysticercosis, and use of rabies protocols for animal bites," she says.
Communicate with other departments about a patient’s status. "You should flag the chart if a patient previously had VRE [vancomycin-resistant enterococcus] or MRSA [methicillin-resistant Staphylococcus aureus]," says Stenberg. "Those patients tend to come back repeatedly. That information needs to be communicated when you give report to the floor, so those employees use hand barriers or gloves to protect themselves from bodily fluids and feces."
Be aware of high-risk patients. Homeless patients are at higher risk for infectious diseases, notes Stenberg. "They have increased rates of infection due to poor nutrition, bad hygiene, and often use drugs and and have limited access to preventive care," she explains. "They are also possibly less able to take medications. If it’s an HIV-positive person with TB, they may have 10 or 12 medications a day that need to be taken at certain times. So you need to refer those patients to social services for help."
Illegal immigrants are also at higher risk, Stenberg says. "They are at high risk for TB, but they live in fear of health care settings disclosing their status, so they may not seek treatment," she explains.
Be especially wary of most infections in the elderly, people with underlying chronic diseases, such as renal failure or liver disease; those who are asplenic (especially for S. pneumoniae bacteremia); those with immunosuppression due to chemotherapy or malignancy; and those with HIV risk factors, says Gregory Moran, MD, assistant professor of medicine at UCLA School of Medicine in Sylmar, CA.
Don’t assume you can tell which patients are high risk. "The majority of our patients are older than age 50, so we predictably see things such as pneumonias in the elderly. But, in South Florida, we have the largest single population of individuals older than age 50 with HIV and AIDS," says Stenberg. "So you must never think that because a patient is elderly, they [do not pose] a bloodborne pathogen problem."
Use protocols. "The ED should have a folder with its protocol or policy for handling bloodborne pathogen exposures," says Stenberg. "This should also contain an algorithm for providing prophylaxis if necessary, the phone numbers of persons who may need to be called, such as an infectious disease [specialist], forms used for accident reporting, and counseling materials for individuals with exposure."
Having protocols that are easily accessible decreases liability risks, stresses Stenberg. "There should be a established protocol for anything infrequently treated that makes you go back to the books," she notes. "That expedites things and keeps people functioning at a level the institution requires. This also helps in risk management."
Know your community. "Every ED is slightly different than the next one down the street, so know what population is coming in," notes Stenberg. "In our VA facility, our patient mix is very different from the community hospital down the road whose patient population includes immigrants. They also tend to have more diseases from which our patients and staff are immunized, such as measles or mumps."
Stay current with education. "Nurses need to be firm in requesting that education be done in their department," Stenberg says. "It’s not easy for infection control to set up a program for the ED staff, unless they’re willing to do it two or three times so they can rotate the staff through. Instead of waiting, make infection control aware of the information you need. They may be able to prepare something nurses can read and take home, with a post test for credit."
Prepare to reduce risk of infection. "Patients may suffer some risk from absence of a sterile or clean environment in the prehospital setting, but that can also happen in the ED if you are not able to prep as you normally would, such as in trauma areas or sites of invasive procedures," says Stenberg. "Also, large bore needles may be inserted for rapid access for fluid. Those should be removed at the earliest possible moment in the ICUs or floors, because large bore needles become infected more frequently than smaller bore needles placed non-emergently."
Have a high index of suspicion for STDs in children. "We have noticed an increase in STDs in children of all ages, as well as adults," reports Barbara Moody, RN, CIC, manager of IC at Parkland Health and Hospital System in Dallas, TX. "We have seen a rise in children with herpes and also gonorrhea, which is frightening and abhorrent. Children who you assume have chicken pox may actually be herpetic."
Keep up to date with immunizations. Immunizations should include hepatitis A, hepatitis B, yearly influenza, the measles, mumps and rubella, polio, tetanus and diphtheria, pneumococcal vaccine for persons older than 50 years, and chicken pox for nonimmune individuals, says Stenberg.
"Communicable diseases are a constant in terms of exposure, so nurses need to be sure their immunizations are current," says Moody. "We are moving toward mandating vaccines for measles, mumps, rubella, and chicken pox unless you are allergic to [any of the vaccine’s] components. We just can’t afford to have these pockets of susceptible individuals."
Remind patients to cover mouth when coughing. "We have done a big Cover the Cough’ campaign, because doing that curtails the TB and prevents other respiratory illnesses," Moody reports. "We have signs in all the waiting areas to get people to cover their coughs, and to get everyone to speak up about people coughing outright."
Understand actual risks of transmission. "When nurses learn there is a chance of exposure to meningococcus disease, they usually demand prophylaxis, but it may be inappropriate," says Moody. "You actually need a direct splatter so the organisms land in your mouth or other mucous membrane."
Clean trauma rooms thoroughly. "Look for splatters and splashes and clean all bodily fluids and blood, especially in the trauma room," says Moody. "This is something that tends to be overlooked, but you need to be thorough."
Protect yourself from contaminants. "You need to develop a constant practice of separating whatever is contaminated from yourself," says Moody. "Nurses may have been taught in an era when transmission and bloodborne pathogens were fewer, so you must remember to always protect yourself."
Consider visitors who accompany the patient. Ask if anyone else with the patient about having symptoms, Moody advises. "Often the whole family comes in to show their support, or the mom or dad comes and [there is] no one to care for children [at home], so they may have five small children with them, all of who may have been exposed to a communicable disease."
Track patients with resistant organisms. "If a patient comes in with VRE or MRSA, we label our computer list so it shows they should be put into isolation as soon as they come up again," says Moody. "The ED staff check for those permanent markers."
Know what questions to ask at triage. "At triage, focus on infection control issues," says Moran. "Identify patients with meningococcus (rapidly progressive meningitis, with or without petechial rash), TB (cough usually > 2 weeks, hemoptysis, history of TB exposures, HIV risk factors, homeless, EtOH, prison, weight loss, night sweats), rashes suspicious for varicella, measles."
Look for complications of common diseases. "In the case of chicken pox or varicella, if a child has a lot of pain in one extremity or around the chicken pox, you have to worry about necrotizing fascitis," says F. Keith Battan, MD, FAAP, associate professor of pediatrics at the University of Colorado School of Medicine in Denver.
"A child with a sore throat who can’t open their mouth well, whether they have strep or not, makes you think about a peritonsilar absess or a retropharenteal cellulitis," Battan says. "If a child has any kind of impetigo or skin infection with rapidly progressing erythema with pain, you’d have to worry about an invasive strep disease."
Know which diseases are increasing. "Pertussis, or whooping cough, is making a big resurgence," says Battan. "Even if a child doesn’t have the classic whoop, if they have a chronic cough, you need to consider it. Even if the child has gotten one or two immunizations, [he or she] would still be susceptible to that. On exam, if a child has a lot of whitish oral and nasal secretions, think of pertussis," he notes. "Adults can also get whooping cough, but they usually manifest with more run-of-the-mill cold or cough type symptoms."
TB is making a comeback in many areas of the country, Battan says. "So with kids with chronic coughs or indolent fevers which have gone on for several weeks, it’s worth thinking about," he advises. "Risk factors [for TB include] overcrowding and lower socio-economic status."
However, serious bacterial infections in small children have decreased due to H. influenza vaccine, Moran reports. "They should decrease more in the future when the new Streptococcus pneumoniae vaccine comes into use, which is probably a couple of years away," he says.
Reference
1. Moran G, et al. TB infection control practices in United States EDs. Ann Emerg Med 1995;26: 283-289.
Sources
For more information about managing patients with infectious diseases, contact the following:
• F. Keith Battan, MD, FAAP. E-mail: [email protected]
• Katherine L. Heilpern MD, FACEP, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA. Telephone: (404) 616-2256. Fax: (404) 659-6012. E-mail: kheilpe@emory@edu
• Barbara Moody, RN, CIC, Parkland Health and Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235. E-mail: [email protected]
• Gregory J. Moran, MD, UCLA School of Medicine, Dept. of Emergency Medicine and Division of Infectious Diseases, Olive View - UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342. Telephone: (818) 364-3110. Fax: (818) 364-3268. E-mail: [email protected]
• Marjorie J. Stenberg, MA, MS, RN, CIC, 1070 Sugar Sands Blvd, Singer Island, FL 33404.
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