APIC 2014: Infection prevention in the ED
Being fast will save someone’s life.’
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 recently in Anaheim at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
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," Schuur 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, he said.
"I really can’t emphasize the importance of this enough," he said. "This has to be the emergency department’s initiative to get their support. As much as anything else, if it is not something the ED is really championing themselves it is going to fail."
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," Schuur told APIC attendees.
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," he said.
Schuur is one of the principal investigators in an ongoing project to identify successful infection prevention interventions in hospital emergency departments. He has received funding from the Agency for Healthcare Research and Quality to identify infection control practices that have been successfully implemented by EDs.
A key portal for infection control
"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."
The patient population is widely diverse, suffering from various maladies in very close proximity.
"Sometimes they are separated by curtains, a hallway and sometimes nothing," he said. "So there is a real obvious chance for there to be transmission. We may have someone who is on chemotherapy, someone who is neutropenic, someone from a skilled care facility who has a multidrug resistant organism."
ED staff vary from doctors and nurses to security staff, translators, and technicians who may have little medical training. The overriding prime mission of emergency medicine — the life-saving emergencies where seconds and minutes matter — actually occurs only about 5% to 10% of the time one works in the ED, Schuur said.
"But working in that situation engenders a certain acceptability or normalization of deviance," he said. "[The thinking is] if it’s OK to break rules in that situation, you might be able to do it in more situations. And so our culture prioritizes urgent intervention over refection — we value decisive action over circumspection."
Chronic crowding in many EDs certainly fuels that type of mindset, as workers often have insufficient space and manpower to provide the best care, he adds. ICU beds are rarely available within an hour and breakdowns in communication about "where the patient is from and where are they going" are far too common. "All of these will affect your ability to provide safe care and infection prevention," he said.
Another undermining factor is "goal conflicts" that ED workers use to rationalize non-compliance. "Why wash your hands if you don’t clean the blood pressure cuff, the pulse oximeter, and the bedside table?" Schuur said. "Why should I wear precautions when nobody ever comes to clean the bedside curtains? This goes along with the normalization of deviance."
Thus the IP with an infection prevention idea for the emergency department should enter the ED with eyes wide open and the full support of department leaders and administration. Once staff fully buy-in, positive momentum can build rapidly, says Schuur, who thought little about infection prevention until his young son developed an MRSA abscess on his arm — twice. Concerned that he was the source, Schuur brought an infection control rigor home after work that eventually translated into a growing interest in infection prevention in the ED in general.
Editor’s note: Part II of this story, focusing on the prevention of specific infections and improving hand hygiene in the emergency department, will be featured in our next issue.
Key strategies to improve ED infection prevention
Researchers on improving infection prevention in the emergency department recently recommended the general strategies below in Anaheim at the annual conference of the Association for Professionals in Infection Control and Epidemiology. The comments are from interviews they conducted during their project.
Leadership Support: Hospital, ED, key consult services (e.g., trauma)
• Helps to set expectations
• Necessary to secure funds and resources for initiative.
• Gain the support of leadership
"He got onboard and once he got onboard he was just a train. He’s a big train when it comes to infection [prevention], everything in the hospital when it comes to infections. He’s very supportive in giving us what we need." RN educator
Data Collection and Feedback
• Post data on flyers in the staff lounge or include in the ED newsletter
Staff Engagement
• Include staff on multidisciplinary committees
Champions
• Develop program cheerleaders (self-identified or chosen by management or leadership)
• Have devoted interdisciplinary champions as noted by this ED Chairman:
"If you don’t have a shepherd it doesn’t happen. It doesn’t have to be a physician, it really doesn’t. It has to be an interested champion who is willing to take the message to the streets, recognize that there are many different streets. You’ve got the attendings, the nurses, whoever."
Build Environment Modifications
• Ask staff "What are the structural barriers to compliance?" Great way to encourage the participation of frontline workers
Staff Training
• Make training a part of annual education and competencies
• Train new hires
Workflow Modifications
• Make it easy for staff to comply with workflow modifications
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