APIC 2014: The challenge of infection prevention in the emergency department

March 18th, 2015

As the “front door of the hospital” to both patients and pathogens, the emergency department (ED) is a critical setting for infection prevention that has a unique and often poorly understood work culture. As a result, infection prevention projects can quickly run aground if undertaken with the typical approaches used for other patient settings, a leading emergency medicine researcher told a packed audience at the ongoing conference of the Association of Professionals in Infection Control and Epidemiology (APIC) in Anaheim, CA.

‘I think it’s important for everyone in this room to look at the work environment of the ED,” says Jeremiah Schuur, MD, director of Quality, Patient Safety and Performance Improvement for Emergency Medicine at the Brigham and Women’s Hospital in Boston. “You go into work and your job is to take care of everybody that shows up as quickly as possible and you don’t get lot of [patient] information. There’s a huge pressure on being fast, because being fast will save someone’s life. It may not be everybody’s life, but if you are not fast there is going to be someone in the waiting room who is there too long.”

Schuur described a work force of committed professionals who nonetheless may cut corners on measures like personal protective equipment (PPE), an all too common problem that was cited by an infection preventionist in the audience.

“We deprioritize (PPE) and it’s a challenge,” Schuurr said. “People do that because in order to do your job sometimes you can’t take every step. You can’t put on precautions for every patient who has influenza-like illness, because at certain times of the year that would be one in every four patients and that would take all of the time we have.”

Instead of the typical inservice approach, emergency medicine workers respond better to stories and personal narratives that embody the importance of infection prevention in the chaotic setting, he added. These stories particularly resonate with ED workers if told by a member of their team or by someone who has worked in emergency medicine, Schuurr said.

For example, hand hygiene compliance improved considerably at one ED when an emergency nurse returned to work after being treated for breast cancer. “She [repeatedly] told her story about having been neutropenic and having to fear every person who came into the room when she was getting chemotherapy,” he said.

By the same token, IPs should enlist an ED champion to support an intervention, making sure the data generated is actionable, relevant to the setting, and promptly reported back. “Are you asking people to do things that are going to take five extra steps, which is going to make it impossible for them to do their jobs efficiently? [That is] ultimately going to undermine compliance.”

Schuur is one of the principal investigators in an ongoing project to identify successful infection prevention interventions in hospital emergency departments.

“I would make the case that the emergency department is a key portal for infection prevention,” he told APIC attendees. “There are about 130 million [patient] visits every year. It [varies] hospital to hospital, but overall, nationwide half of the admissions [come through the ED]. Over 2 million ICU admissions, and we place lots of devices which are then at risk for infection -- central lines, urinary catheters and intubation.”

For more on this story and all of our APIC coverage see the July 2014 issue of Hospital Infection Control & Prevention