Tips for cutting infection risks in the ED

ED makes prevention a top priority

You 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, experts recommend making 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.

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

Janelle Glasgow, RNC, CPEN, Emergency Department, Nationwide Children's Hospital, Columbus, OH. E-mail:

Susan Gray, RN, BSN, CEN, Emergency Department, Greater Baltimore (MD) Medical Center. Phone: (443) 849-2226. E-mail:

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: