Updated guidelines for infectious diseases in ED

New buzzwords: respiratory hygiene, cough etiquette

You'll need to make several changes to comply with updated isolation guidelines from the Centers for Disease Control & Prevention (CDC), which better address special environments and special populations such as EDs, says Doe Kley, RN, CIC, infection control coordinator at McKay-Dee Hospital in Ogden, UT.

Here are key changes in the CDC guidelines that will affect ED nurses:

• New terminology is used.

"The new 'buzzwords' are 'respiratory hygiene' and 'cough etiquette,'" says Kley. "Patients and visitors symptomatic with respiratory illness are asked to wear a mask, cover their coughs, dispose of tissues properly, and to perform hand hygiene."

The term "nosocomial infection" has been changed to "health care-acquired infection," and "negative pressure" rooms are now called "airborne infection isolation" rooms.

• There is clarification on when to don and remove personal protective equipment (PPE) when entering/exiting an isolation room.

"The correct technique is to don the PPE just before entering and to remove and discard the PPE just before exiting the isolation room," says Kley.

When transporting patients in isolation precautions, precautions should be reversed onto the patient. "For example, the transporter does not have to wear the PPE; instead, mask the patient," says Kley. The patient is masked if in droplet or airborne isolation precautions, but not for contact precautions. "To transport a patient in contact precautions, we should be sure that the infected site is covered," she says. "For all isolation patients, whether contact, droplet, or airborne, it is important that both the patient and the transporter perform hand hygiene upon exiting the isolation room."

• There are different requirements for various organisms.

The guideline now includes isolation recommendations for severe acute respiratory syndrome (SARS), norovirus, human metapneumovirus, and hemorrhagic fever viruses. "There are also new recommendations for Group A Strep (GAS) infections in adults," says Kley. These have been changed from standard precautions to droplet precautions for GAS pneumonia, and droplet and contact precautions for GAS-infected major draining wounds. "The new recommendations for extrapulmonary tuberculosis-infected draining wounds now call for contact and airborne precautions," she says.

• There are changes in isolation precautions for patients being transported. Visitors are addressed.

"Visitors were one of the bigger problems during the SARS outbreak a few years ago," says Kley. "They were an overlooked source of transmission. Consider screening visitors, especially during community outbreaks of flu," she says.

Update nurses

ED nurses at McKay-Dee will be educated on the updated guidelines, including standard precautions, the proper use of PPE, and isolation precautions for the newly included pathogens, says Teri Howick, RN, the ED's nurse educator. The ED is taking these steps to ensure nurses are complying with the CDC guidelines:

— Use secret observers. These individuals check to see that ED nurses are complying with hand hygiene, with monthly results posted, says Kley. "It's not so much that staff are being observed that improves their compliance; it's the feedback that you give them based on your findings," she says. "It is imperative to provide feedback to frontline staff, as they are the ones who can make the changes."

The secret observers are people who usually are in the ED so they don't arouse suspicion, says Howick. "They sit with a clipboard and observe several personnel as they enter and exit a room, and mark down if they wash or use an alcohol hand sanitizer," she says. "They have a minimum number of people they must observe in a certain time period, usually 30 minutes." In addition, observation will be done to ensure that ED staff members are selecting appropriate PPE and using it appropriately, says Kley.

— Remind staff and patients about respiratory hygiene.

"We've been advertising respiratory etiquette in the ED at the point of entrance for years, via signage and stations that contain masks and alcohol hand sanitizers," says Kley. "But we will likely do some re-emphasis with staff on the importance of this."

Posters explaining respiratory hygiene practices in English and Spanish are posted throughout the ED, with illustrated instructions for how to put on masks, along with available masks for coughing patients or visitors, says Howick.

A security desk is the first point of contact with ED patients and has a respiratory etiquette station with masks, tissues, and alcohol hand sanitizer. "The next 'gatekeepers' in the ED are the triage nurses," says Kley. Questioning patients about recent travel is an important part of triage, as it can give clues about what a patient was exposed to, she adds.

In the event of an epidemic or pandemic of an infectious disease, triage stations would be set up outside of the ED to screen patients and staff before entry into the facility, says Kley. "In this event, we would likely be turning visitors away. Security would be heavily involved."

— Make hand hygiene as easy as possible.

Bottles of alcohol hand sanitizer are made freely available in the ED: in patient rooms, on the wall outside the rooms, by all public areas, and next to telephones, says Kley. "Readily available hand sanitizer makes hand hygiene very convenient. It takes only a few seconds to rub it in," she says. (The guidelines are available at www.cdc.gov.)

Sources/Resources

For more information on the CDC's updated isolation guidelines, contact:

  • Teri Howick, RN, Nurse Educator, Emergency Department, McKay-Dee Hospital, 4401 Harrison Blvd., Ogden, UT 84403. Phone: (801) 387-2286. Fax: (801) 387-2244. E-mail: mkthowic@ihc.com.
  • Doe Kley, RN, CIC, Infection Control Coordinator, McKay-Dee Hospital Center, 4401 Harrison Blvd., Ogden, UT 84403. Phone: (801) 387-3294. Fax: (801) 387-3244. E-mail: Doe.Kley@intermountainmail.org.
  • Posters instructing patients on the correct way to put on masks are available at no charge from 3M Health Care. The posters feature patients with fever, rash or coughing and read, "If this is you, this is what to do!" with illustrated instructions. Five or few posters can be ordered at no charge. To order, call 3M Health Care Helpline at (800) 228-3957, Option 2, or send an e-mail request to healthcare@3m.com.
  • A slide set and posters that can be used to train emergency nurses on the correct way to don and doff personal protective equipment (PPE) can be downloaded at no charge from the Centers for Disease Control and Prevention (CDC). For more information, go to the CDC's web site (www.cdc.gov). Under "CDC For You," click on "Healthcare Providers," "Healthcare-Associated Infections," and "Infection Control Home." Under "Education & Training Tools," click on "Personal Protective Equipment (PPE) in Healthcare Settings."
  • A videotape on the correct use of PPE, titled Personal Protective Equipment in Healthcare Settings, is available for $27.50 plus $5.50 shipping cost. To order, contact: Public Health Foundation, Publication Sales, P.O. Box 753, Waldorf, MD 20604. Phone: (877) 252-1200. Fax: (301) 843-0159. E-mail: info@phf.org. Web: bookstore.phf.org.