Infection Control Today - 09/2004: Healthcare Workers

Healthcare Workers, EMTs
Extend the Front Lines in the Battle Against Infection

By Kris Ellis

Emergency medicine personnel deal with a vast arrayof demanding and complex situations on a daily basis. In a day and age in whichany number of infectious microorganisms and agents of bioterrorism could wind upin any given community, emergency medical technicians (EMTs) and others on thefront lines must be prepared for the worst. A significant component of thispreparation involves infection control. Emergency medical services (EMS) canplay a vital role in containing the spread of infectious diseases both in termsof protecting themselves and others from exposure. This is an area thatinfection control practitioners (ICPs) are increasingly aware of.

Similarly, hospital and emergency department (ED) waitingrooms warrant close attention as well. With the potentially large number ofpatients waiting to be seen in relatively close proximity, mass exposure is apossibility. Furthermore, patients often present similar symptoms, especiallyduring flu season, making initial differentiation between mild and dangerousbugs dif. cult. ICPs must also be prepared to meet this challenge head-on.

At the EMS level, the effort to control infection isindirectly built into the basic tenet of protecting oneself.

A lot of it is self-preservation to start with, saysWilliam Coll, BA, M. Pub. Aff., LP, REHS, clinical commander and infection control officer for the Austin-Travis County Emergency Medical ServicesDepartment. The primary focus is on personal protection and making surewe take appropriate precautions relative to each situation.

An EMT can utilize varying levels of personal protectiveequipment (PPE) in order to maintain their own safety and prevent theacquisition of infection from patients. A lot of our training is in earlyrecognition beginning to have your suspicions about a patient even as youmove in, says Coll.

Invariably, the basic level of protection is gloves. However,Coll explains it is sometimes challenging for EMTs to hold off on donning theirgloves until it becomes absolutely necessary. If gloves are applied too early,of course, they could become contaminated themselves. How many doorknobs have you handled, how many things couldhave put a tear in the gloves? The possibilities are endless, he says. Thisis a concept Coll tries to instill in his department.

If it becomes apparent that droplet or airborne exposure is aconcern due to coughing, more PPE is in order. We work in a six-foot zonerelative to droplet protection, where you start to move into that zone with aneye toward whether or not it will be necessary to put on goggles and a mask,because now Im getting into that place where the patient is coughing, Collexplains.

If signs of respiratory or infectious disease are detected,and after the proper precautions are taken, EMS personnel begin the process ofcollecting information from the patient. The effort to get a history of thepatients problem and circumstances is vital in order to gain insight andsubsequently notify the hospital and health department if there is a potentiallyserious threat.

EMTs are not responsible for the actual differentiation anddiagnosis of symptoms, however. It shouldnt be the role of EMS and . rstresponders, says Coll. But, one of the things weve tried to tie inis attempting to understand who has communicable disease in the broadest sense.

Nonetheless, if EMS personnel suspect a patient is harboringan infection that may pose a danger to the community, they must ensure that theED is noti. ed about the situation. Preparation on the ED side can eliminateconfusion and delays. then youre positioning the patient so that whenyou deliver them to the ED theres a plan to insert the patient into theappropriate place, whether it be a negative pressure room or whatever thehospital is able to accommodate relative to the circumstance, says Coll.

The ED Waiting Room

The ED itself, and the waiting room in particular, have beenthe subject of recent efforts to escalate infection control measures andawareness. The Toronto SARS outbreak was a sobering wake-up call to many interms of the need for such a focus.

That really made us all stop and think about infectiontransmission in the ERs and it probably, for the first time, really establisheda series of algorithms as to how to handle patients, particularly withrespiratory disease who are coughing, sneezing, etc. during the influenza seasonand with the possibility of SARS being out there somewhere, says Dr. TedEickhoff, professor emeritus in the Division of Infectious Disease at theUniversity of Colorado Health Sciences Center. I think what we all recognizenow, more clearly than ever before, is that the ED waiting room is a place wehave to pay attention to.

To this end, many facilities are turning toguidelines such as the CDCs Respiratory Hygiene/Cough Etiquette inHealthcare Settings in order to institute precautionary measures. Thisetiquette is intended to stem the spread of any and all respiratory infectionswithin the healthcare setting and is designed to be part of a facilitysstandard infection control practices.1 Components include:

• Visual alertsalerts such as signs (in multiplelanguages, if necessary) at facility entrances instructing all who enter tonotify healthcare personnel if they have symptoms of respiratory infection andto practice the respiratory and cough etiquette.

• Respiratory hygiene/cough etiquette: all individualswith symptoms of respiratory infection are advised to cover the nose and mouthwhen coughing or sneezing, use tissues to contain respiratory secretions andthen dispose of them, and perform hand hygiene. To facilitate compliance withthese measures, facilities are advised to provide the appropriate materials suchas tissues, no-touch waste receptacles and alcohol-based hand rub.

• Masking and separation of those with respiratorysymptoms: facilities are advised to make masks available to persons withsymptoms during periods of high infection activity in the community. If spaceallows, patients should be encouraged to sit at least three feet away from eachother in common waiting areas.

• Droplet precautions: healthcare workers (HCWs) areadvised to use droplet precautions in addition to standard precautions whenexamining patients with respiratory symptoms.

Instituting and enforcing this protocol in waiting rooms hasbeen an important accomplishment for many facilities and ICPs.

We had a subcommittee that we formed which started out as aSARS group and then turned into a universal respiratory etiquette group, saysBobbie Welch, MT, RN, CIC, an infection control specialist at Yale New HavenHospital. As far as the waiting room, thats been very successful, at leastat Yale.

We have developed signs which we have in English, Spanishand Mandarin, she explains. Weve also built a Purell® standwhat we have is alarge post like youd put a light on, but instead we have Purell dispensers onall four sides.

Welch points out that these components are most effective when incoming patients confront them immediately. Thats right at the entrance, she says. People coming in are directed to go and wash their hands first, andthen if they have respiratory symptoms they would be directed to put on a mask.We have a station with masks, tissues and a wastebasket. Thats worked really well.

The effort and investment certainly paid off at Welchsfacility during last years flu season. We had less people getting sick, and if they did get sickit was less severe, she says. There was a very good response and I thinkthe community is actually looking for these types of things now.

The positive response generated by this system prompted otherdepartments to put it to use as well. We have it not only in our two EDs, butwe also have it in the primary care clinics here, and all the other clinicsadopted it this year, says Welch. We were trying to protect people fromthe flu because it was a really bad flu season. We were also trying to protect people from the possibility ofSARS, which we didnt have a suspected case of this year, but we dont knowwhats going to happen next year.

This sense of uncertainty underscores the importance of beingvigilant at all times, even during the off-season. Were preparing for theworst and actually this is not just for the season were doing thisyear-round because people come in with severe summer colds as well, says Welch.

Great strides have been made toward preventingexposure in the waiting room at other facilities as well. I think some of oursuccess had to do with the fact that were fortunate enough, in our infectioncontrol program, to have one of us who is dedicated to the ER, so it helps thatthey have a central person, says Kathleen Schomer, RN, BSN, CIC at theUniversity of Colorado Hospital. Schomer monitors the hospitals outpatientsettings.

Prompted by a severe flu season, components of the respiratoryetiquette were also instituted in Schomers facility. We had a horrible fluoutbreak in Colorado last year and we put masks and hand gels in the waitingroom and asked patients who were coughing to utilize the masks and use the gelto clean their hands, she says.

Aided by the media and a responsive state health department,public reaction and compliance was positive. We had a good response becausethere was such a media blitz here about the number of hospitals who, daily, hadhundreds of patients sitting in common waiting rooms coughing, says Schomer.The entire citys message was the same; it wasnt just one hospital thatwas showing leadership it was an entire community effort.

As far as our clinics and exposures having gone down inthose areas, Id like to think its because we do a lot of teaching andupdating with communicable disease exposure in those areas, Schomercontinues, again demonstrating the need for constant attention and commitment toeducation and prevention efforts.

One such effort at Schomers hospital involved a drill setup by the medical director and safety team which simulated circumstances thatled to suspicion of a SARS case. Everyone did really well as far as nursing and physicians taking a history and having the red flag go off that this mightbe a SARS case. Also getting the patient into proper isolation not lettingthe patient go back into the common waiting area, she says.

The only thing we didnt do well was think about settingup our command center, so the lesson learned was very valuable. The process of differentiating common flu from a potentiallymore serious infection such as SARS begins almost immediately at mostfacilities. It should start with the triage nurse, who is usually the first person someone who comes into the ER with symptoms would encounter, saysEickhoff. Again, if there are respiratory disease symptoms, the person shouldbe masked. So the differentiating process starts right up front. Then, itsthe ER doctors who go to the next level and try to sort through what thisactually is.

Because of similar symptoms, it can be dif. cult to make a definitive conclusion right away. In the case of SARS, epidemiologic evidence is themost important factor most patients diagnosed with SARS have come in contactwith another SARS patient or have been in a geographic area where transmissionhas been established.2 A number of factors may also be indicative of anthraxinfection as opposed to flu, such as a normal lymphocyte count, chest X-rayabnormality and lack of runny nose.

It is, however, dif. cult to determine whether an infectionmay or may not be particularly dangerous judging strictly by outward symptoms.Its the whole assessment that gives doctors feelings about whether this isjust simple influenza or something more than that, says Eickhoff. There isno single sign or symptom that would make it or break it for me.

Even before a diagnosis is made, EMTs, ICPs and patientsthemselves can do their part to prevent the spread of infection. Workingtogether, these groups have the capacity to aid in protecting the health of thecommunity.