Brace yourself: Flu cases can wreak havoc

CDC issues new guidelines

Look around your waiting room, and you’ll be sure to spot at least one coughing, sneezing flu patient. If you don’t take steps to prevent it, this individual can single-handedly create a disaster in your ED by spreading the disease to staff and other patients. Unless you want to work short-staffed until April, you should follow new guidelines from the Atlanta-based Centers for Disease Control and Prevention (CDC). (Editor’s note: Access the guidelines at

"The flu is here, and it is hitting harder than ever," says Lara Merana-Bailey, RN, BSN, ED educator at Hartford (CT) Hospital, who echoes the sentiments of many emergency nurses. "In our ED, we have also been seeing increased numbers of people who had the flu and got pneumonia from it."

At press time, 38 state health departments still were reporting widespread flu, and 6.2% of patient visits were due to flulike symptoms, according to the CDC. In addition, 93 flu-related deaths in children have been confirmed so far.

To limit exposure to flu in your ED, do the following:

• Wear appropriate personal protective equipment (PPE).

Current CDC guidelines recommend wearing a surgical mask in addition to standard precautions when caring for a patient with symptoms of a respiratory infection, especially if fever is present.

"I think that is the most important clinical practice change that we will need to make," urges Colleen Connelly, RN, BSN, an ED nurse and emergency preparedness manager at University of Utah Hospital in Salt Lake City. "ED nurses are some of the worst offenders, even though we take care of the trauma, the blood, the vomit, and the endless people in triage."

Despite this, many ED nurses feel invincible, adds Connelly. "We need to move away from that and embrace better respiratory hygiene," she argues. There has been debate in the ED as to whether nurses should wear N-95 masks when caring for flu patients, notes Connelly. "Our head infection control nurse feels that this is probably overkill. However, if staff feel more comfortable wearing the N-95, then we do not discourage it," she says.

Recently, when ED nurses cared for a potential severe acute respiratory syndrome (SARS) patient, Connelly observed that all removed their N-95 masks differently, but none did it correctly. "The patient did not end up having SARS, but it was clear to us that some of the nurses could have easily been infected because of the way they were removing their masks," she says.

Connelly took digital pictures of a nurse removing an N-95 mask correctly, added written captions to explain each step, and made posters to hang in the ED.

"Probably all of your staff know how to put on an N-95 mask, but how many know how to take it off without contaminating themselves or others?" she says. "We didn’t know, but the infection control staff did and were able to train us on how to do it."

• Make it easy for ED nurses to receive the vaccine.

At Utah Hospital, infection control nurses go to the ED multiple times during every shift to give flu shots, says Connelly. "I think most staff want to get a flu shot, but it is not that high on the priority list, especially for those that work nights. The last thing they want to do is come into the hospital on their day off," she says.

With this system, nurses don’t have to report to a certain location at specific times — all they have to do is roll up their sleeves, says Connelly. "It also ends up reaching people who had no plans on getting a flu shot, who say Hey, why not? Everyone else is getting one," she adds.

To encourage ED nurse to get the flu shot, Merana-Bailey has been providing the vaccine during all three shifts since October. "I announce overhead in the ED, Any staff member wanting a flu shot, come and see me,’" she says. Merana-Bailey estimates that she’s given 260 flu shots in the ED, covering 70% of staff.

• Be aware of potential risks involving the nasal spray flu vaccine.

At press time, the CDC did not have an official recommendation on whether health care workers vaccinated with FluMist, a newly approved intranasal influenza vaccine for the 2003-2004 flu season, (MedImmune, Gaithersburg, MD) should avoid close contact with immunocompromised individuals. Currently, CDC guidelines state that the use of inactivated influenza vaccine is "preferred" for health care workers.1

According to Jeffrey Stoddard, senior medical affairs director for MedImmune, there is "absolutely no contraindication" for health care workers to receive FluMist.

"The contraindications are specific to certain medical conditions," he says. "Health care workers should get immunized against the flu, and whether they choose to do so with FluMist or the injectable vaccine is really at their discretion."

Still, many EDs are choosing to err on the side of caution. ED nurses at Utah Hospital and Clinics were instructed not to get the intranasal vaccination before the flu season started, reports Connelly.

"Infection control decided against FluMist and made an announcement via our e-mail system," she says. "All ED nurses are required to check their e-mail religiously to keep up with the constant changes."


1. Harper SK, Fukuda K, Cox NJ, et al. Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention. Using live, attenuated influenza vaccine for prevention and control of Influenza. MMWR 2003; 52(RR13):1-8. 


For more information on managing flu patients, contact:

  • Lara Merana-Bailey, RN, BSN, Emergency Department, Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102-5037. Telephone: (860) 545-2926. Fax: (860) 545-2274. E-mail:
  • Colleen Connelly, RN, BSN, Emergency Preparedness Manager, University of Utah Hospital and Clinics, 50 N. Medical Drive, Salt Lake City, UT 84132. Telephone: (801) 585-3134. E-mail: