Your next patient could acquire a life-threatening infection in your ED

Make it a top priority

You, and other ED nurses, may have been taking care of a patient for hours without realizing he or she has an infection that requires isolation. The fast-paced ED environment is an added challenge in preventing ED-acquired infections, according to Susan Gray, RN, BSN, CEN, an ED nurse at Greater Baltimore (MD) Medical Center. "Staff are in and out of rooms often," she adds.

Gray says that preventing ED-acquired infections has become "a top priority" in her ED. "It is an agenda item on the ED council about every month," she says. "We have hand-washing champions, as well as inservices on the proper ways to assist in the placement of central lines and on the proper use of isolation."

ED nurses now ensure the doctor is maintaining sterile procedure, says Gray, and that he or she does, in fact, stop a procedure if sterility is not maintained.

"Other changes have been how we assist and monitor physicians in placing central lines, placing our own peripheral IV [intravenous] lines, and the proper use of isolation," says Gray. To reduce ED-acquired infections, make these practice changes:

Use chlorhexidine instead of 70% isopropyl alcohol or povidone-iodine.

"The proper use of [chlorhexidine] has been crucial to our blood culture contamination rates," says Gray. "We use it to place all of our IV lines."

By making this change, says Kathy Karg Gutierrez, RN, BSN, CEN, care coordinator for the ED at Fletcher Allen Health Care in Burlington, VT, "we have seen a remarkable reduction of contaminated blood cultures."

The ED cut its contamination rate in half, from 3% down to 1.6%. "We are the largest collector of blood cultures, with one of the lowest rates in the hospital, which we are pretty proud of," says Gutierrez.

Use a central line protocol to reduce the risk of sepsis.

This includes a 30-degree head of the bed elevation for ventilated patients, says Gutierrez. "We are very focused on early antibiotics for sepsis and pneumonia patients," she adds.

If a patient requires a ventilator, use a mobile intensive care unit (MICU) order set.

Oral care is done if the patient requires it, says Gray, but the patient does not typically stay long enough in the ED to require this. "These patients usually make it out of the ED and into the MICU quickly, so this order set is then continued in the MICU," says Gray.

Use specific order sets for central line insertion.

"This allows the person assisting with the procedure to ensure patient safety and decrease infection," says Gray.

ED nurses use a checklist for items such as what the doctor inserting the line was wearing and what they used to clean the area. "It also allows the staff member to stop a procedure if they deem the doctor is not following proper procedure and putting a patient at risk," says Gray.

Make education mandatory on prevention of central line-associated bloodstream infections.

"This includes proper ways to draw blood and give medications and fluid through a central line," says Gray. (See related stories on monitoring hand washing, isolating patients quickly and preventing urinary tract infections, below.)

Sources

For more information on preventing ED-acquired infections, contact:

  • Janelle Glasgow, RNC, CPEN, Emergency Department, Nationwide Children's Hospital, Columbus, OH. E-mail: Janelle.Glasgow@nationwidechildrens.org.
  • Susan Gray, RN, BSN, CEN, Emergency Department, Greater Baltimore (MD) Medical Center. Phone: (443) 849-2226. E-mail: sgray@gbmc.org.
  • Kathy Karg Gutierrez, RN, BSN, CEN, Care Coordinator, Emergency Department, Fletcher Allen Health Care, Burlington, VT. Phone: (802) 847-2434. Fax: (802) 847-4802. E-mail: Kathy.Gutierrez@vtmednet.org.

Clinical Tip

Ask ED nurses to monitor hand washing

ED nurses at Greater Baltimore (MD) Medical Center monitor each other to ensure proper hand-washing techniques, such as the use of hand sanitizer, says Susan Gray, RN, BSN, CEN, an ED nurse. "We actually had fun with this," says Gray.

In addition to ED nurses reminding each other, doctors, nurses, and clerks got involved. "We had weeks assigned to the different levels of care to remind each other to wash in and out," says Gray. "We even had one clerk make a sign he would hold up to either remind or congratulate people for their hand washing."


Quicker isolation means less chance of infection

Prevent additional exposures

If a patient is on isolation status but there are no masks or gowns readily available, would you always take the trouble to locate these items? "If there are no masks or gowns, providers are apt to go in the room without, rather than restock," according to Kathy Karg Gutierrez, RN, BSN, CEN, care coordinator for the ED at Fletcher Allen Health Care in Burlington, VT.

For this reason, ED nurses place isolation carts right outside the patient's room with all the necessary supplies. "The carts set them up for success and make it more convenient to get dressed," she says. "By increasing the number of available carts, we have increased their use."

The team also created easy-to-use binders on the level of precaution that is appropriate for each disease process, says Gutierrez. To avoid confusion between airborne vs. droplet precautions, very simple pictures show what protective equipment is needed before entering the patients' rooms.

"Our binders were actually 'stolen' by the hospital infection team," says Gutierrez. "They liked it, which is flattering, since they were so nicely designed and simple to use."

Make others aware

If an ED patient has a known isolation status, such as vancomycin-resistant enterococci, this is flagged in the chart so all providers are aware of it, says Gutierrez. "This is helpful when choosing rooms for the patient," she says.

By recognizing the patient's infection status, ED nurses prevent additional exposures and keep the patient's condition from worsening, says Gutierrez.

As soon as the patient is quick-registered, the information on his or her isolation status is posted electronically. "With the information easily viewed on the tracking board, a chart doesn't have to be opened," says Gutierrez. "This makes the isolation status much easier to track for housekeeping and transport."

Give ED-specific info

At Fletcher Allen, teams of unit-based nurses tailor education to their specific units. "It's always better to hear from your peers than to read another e-mail about infection," says Gutierrez.

Informational e-mails are routinely sent out to ED nurses from the hospital's infection control group, says Gutierrez, "but the info is very dry and has little meaning to the bedside nurse." To get more attention, the unit nurses developed a PowerPoint presentation just for ED nurses, and even personalized it with staff photos.

"The ED has its own sense of humor, for sure. More viewers means more information delivered," says Gutierrez.

Individual ED nurses at Fletcher Allen are now alerted if a patient they cared for has a contaminated blood culture sample. "This has dramatically helped reduce our rates of infection," Gutierrez says. "No one wants to do a bad job. But if you don't know that you are doing something wrong, you will never change your practice."


UTIs decreased with these steps

ED procedures can become chaotic and rushed in order to get a patient off to testing or to surgery in a timely manner, says Janelle Glasgow, RNC, CPEN, an ED nurse at Nationwide Children's Hospital in Columbus, OH.

"However, insertion of a urinary catheter is not a life-saving measure," says Glasgow. "A few extra minutes can be taken to ensure that we are doing our best to protect our patients."

From January 2010 through July 2010, the hospital had 11 ED-acquired urinary tract infections, says Glasgow, but after the below interventions were implemented, there haven't been any:

  1. All patients have their perineal area or penis washed with either soap and water or with a commercially prepared cleansing towelette prior to catheter placement.
  2. Following the perineal cleansing procedure, the nurse inserting the Foley catheter must perform thorough hand washing or use an alcohol-based hand gel prior to beginning the procedure of placing the catheter.
  3. Any time a catheter is placed, the nurse performing the procedure must be observed by another staff member. This person checks that the patient was cleansed appropriately, that proper asepsis was maintained, and that the procedure was performed according to manufacturer's and nursing policy and procedure guidelines.
  4. The only staff permitted to insert a Foley catheter are nurses and LPNs with documented competency. "Physicians, including residents, fellows, medical students, and interns are not permitted to place a Foley catheter, except in special circumstances," says Glasgow.
  5. Foley catheter balloons are not inflated to check for patency of the balloon prior to insertion. "Inflating the balloon can make the deflated balloon larger and cause trauma to the urinary meatus," says Glasgow. "This will predispose the patient to a urinary tract infection."
  6. Placing a catheter during a trauma is avoided if at all possible.

"A catheter is only placed if absolutely necessary due to immobility of the patient, or in order to carefully assess [intravenous] fluid resuscitation," says Glasgow.