Did your ED patient arrive with an infection?

If a patient comes to your ED with a pre-existing infection that goes unnoticed, the insurer likely will to refuse to pay for treatment because it will presume wrongly that the condition was acquired in the hospital.

"We are aware that insurers, Medicaid, and Medicare will refuse to pay for the treatment of infections, if thought to be hospital-acquired," says Cynthia Horn, BSN, ANM, CEN, an ED nurse at Singing River Hospital in Pascagoula, MS.

However, ED nurses face unique challenges in obtaining this information, compared to other hospital units. "Some patients aren't able to provide a detailed history upon their arrival. They may be too stressed to give an accurate history, aren't knowledgeable about their own history, or be otherwise incapacitated and unable to answer," says Kate MacKinnon, RN, CEN, nurse manager for emergency services at Signature Healthcare Brockton (MA) Hospital.

ED nurses at The University of Kansas Hospital in Kansas City screen each patient on arrival for a normal skin assessment, looking for breakdown or any wounds that might be present. "We are trying hard to identify wounds that are present prior to arrival, as these are CMS [Centers for Medicare & Medicaid Services] 'never events,' and do the appropriate documentation for them," says Brian W. Selig, RN, BSN, MHA, CEN, NE-BC, ED nurse manager. "This area has been challenging for us, and we continue to struggle with it in many cases. But we believe we are improving." To identify pre-existing infections in your ED, take these steps:

Ask all patients about known exposure to methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, Clostridium difficile, or extended-spectrum beta lactamase.

Also ask whether he or she had a positive tuberculosis skin test. "When at all possible, involve a family member in this interview process, especially if they are a caretaker of the patient," says MacKinnon. "Patients may have needs that require urgent or emergent attention, such as intubation. This makes it challenging to conduct a triage interview."

Inform others about the need for precautions.

Ancillary services such as radiology and transport might not see a sign on the door because they aren't at the bedside. Also make housekeepers aware. "They are informed when the patient is discharged or admitted and begin intensive 'precautions cleaning' of that room," says MacKinnon. "Communication is key to preventing the spread of infection."

Develop a policy.

Singing River's ED nurses comply with their hospital's policy to document, measure, and photograph all skin breakdowns. "We have been instructed to obtain urine samples, urine cultures, blood cultures, wound cultures, and to photograph wounds as the situation warrants," says Horn.


For more information on identifying ED patients with pre-existing infections, contact:

  • Cynthia Horn, BSN, ANM, CEN, Emergency Services, Singing River Hospital, Pascagoula, MS. Phone: (228) 809-5154. Fax: (228) 809-5052. E-mail: Cynthia.Horn@mysrhs.com.
  • Brian W. Selig, RN, BSN, MHA, CEN, NE-BC, Nurse Manager, Emergency Department, The University of Kansas Hospital, Kansas City. Phone: (913) 588-6506. E-mail: BSelig@kumc.edu.

Suspect infection? Then document this

Do you suspect that your ED patient might have a pre-existing infection? If so, "It's very important to give a thorough report to the accepting nurse and document the report," says Cynthia Horn, BSN, ANM, CEN, an ED nurse at Singing River Hospital in Pascagoula, MS. Horn advises documenting these items:

  • the size and location of wounds, and whether or not there is an odor;
  • the color, odor, amount, and consistency of the patient's urine;
  • the presence of cough and whether it is productive or nonproductive;
  • the color and texture of sputum;
  • the patient's home medications, as they might already have started treatment for an infection;
  • any abnormal findings.

"Make sure the pertinent lab tests have been ordered by the physician prior to admitted," says Horn. "If a patient comes in with fever, do not admit them without a chest X-ray, even if you are sure the patient has a urinary infection."

Clinical Tip

Check heels for skin breakdown

Take a quick look at your patient's heels when they are wheeled into triage, says Cynthia Horn, BSN, ANM, CEN, an ED nurse at Singing River Hospital in Pascagoula, MS.

"It's impossible to do a total body assessment for wounds in triage, but the heels will give you some good information about skin breakdown."

"The family usually brings them in with slippers or socks on in place of shoes," explains Horn. "It only takes a second to slip a sock down or remove slippers. If you see skin breakdown to the heels, there is a very good change that they also have breakdown in other areas."