Long waits put your emergency patients at high risk for contracting infections
Holding patients in hallways partly is to blame
Overcrowding, higher-acuity patients being held in hallways, and The Joint Commission's new National Patient Safety Goals (NPSGs) for 2009: It's the "perfect storm" to put hospital-acquired infections on the top of any ED nurse's priority list.
The goals contain three new requirements for preventing methicillin- resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff), and drug-resistant organisms, all of which are on the rise in EDs. And because admitted patients are being held in EDs for hours or even days, the risk of hospital-acquired infections is even higher, says Shelley Calder, RN, CEN, MSN, clinical nurse specialist for the ED at Beth Israel Deaconess Medical Center in Boston.
Which is the most challenging NPSG for ED nurses? The need to prevent health care-associated infections due to multiple drug-resistant organisms, according to several emergency nurses interviewed by ED Nursing.
Many patients present with symptoms of infection, including C-diff, which may cause diarrhea, abdominal pain, or foul-smelling stool, says Karen Smith, RN, MSN, director of nursing for the ED at MetroHealth Medical Center in Cleveland. These symptoms can be linked to many diagnoses, Smith says. Part of the plan of care is to send a stool specimen for further testing, she says. "This could mean days before a definitive diagnosis is made," Smith says. "As a result, exposure to other patients, health care providers, family, and friends may occur."
Also, ED nurses obtain only a limited health history from patients, and they often care for patients with poor medication compliance and without primary care physicians, adds Michelle Underwood, RN, BSN, MBA, nursing supervisor/clinical nurse educator for the ED at Baylor Medical Center at Irving (TX). "These patients are at increased risk for infection or complications secondary to other disease processes they may have — for example, an insulin-dependent diabetic," she says.
A patient might be prescribed an antibiotic for a skin infection and discharged from the ED, but cost of the prescription might result in noncompliance. "This may result in a secondary visit to the ED for worsening infection, as well as increased exposure to the community for untreated infection," says Underwood.
Baylor's ED nurses work with social workers to identify patients at risk for noncompliance by completing a psychosocial assessment. Red flags include patients who don't have a primary care physician, recurrent visitors, patients who use the ED for their primary care needs, and patients with a complicated medical history or chronic medical conditions.
"This allows us the opportunity to intervene when appropriate," says Underwood. "We assist with purchasing prescriptions and educating patients about the importance of medication compliance and appropriate follow-up care."
Risks also are increased because the ED is not a "controlled setting," says Smith. "Due to the activity and acuity in the department, patients may be transferred from room to room, from room to hallway, and room to other support departments for further testing," she says.
Think about the long term
Taking appropriate precautions such as isolation might be a straightforward matter on an inpatient floor but next to impossible for ED nurses. "The big piece is us recognizing that the patient is positive and doing our best to keep them isolated," says Calder. "This is challenging when patients are held in hallways."
Calder says she works with critical care unit nurses to identify interventions that ED nurses can do, so that ED patients aren't put at risk for infections while waiting for an available bed. "We can't always move our patients out immediately, and we cannot run an ICU down here," she says. "But there are some critical things we can do for our patients."
In emergent situations, appropriate infection control measures might not be maintained, acknowledges Calder. "Obviously, the patient's life-threatening condition is the first priority. But when your resuscitation is completed, you have to think of the long term," she says.
Overcrowding, higher-acuity patients being held in hallways, and The Joint Commission's new National Patient Safety Goals (NPSGs) for 2009: It's the "perfect storm" to put hospital-acquired infections on the top of any ED nurse's priority list.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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