CONTROLLING THE GATE: EMERGING PATHOGENS IN THE ER RENE RAINEY, RRT, RN, BSN, MBA WHERE IT BEGINS EMERGENCY DEPARTMENTS ARE PRIMARY POINTS OF ENTRY FOR THOSE WITH COMMUNICABLE DISEASES ERs ARE HIGH RISK AREAS FOR DISEASE TRANSMISSION BECAUSE OF OVERCROWDING AND INFECTIOUS PATIENTS WHO ARE IN CLOSE PROXIMITY TO ONE ANOTHER ENVIRONMENTAL CONTROLS AND PROCESSES ARE NEEDED TO PREVENT SPREAD OF DISEASE TO PATIENTS AND STAFF WHERE IT BEGINS PROTOCOLS AND POLICIES IN PLACE THAT INCLUDE HOW TO TRANSPORT INFECTED PATIENTS ON DIAGNOSTIC JOURNEY STAFF SHOULD BE EDUCATED TO DETECT SYMPTOMS AND BEGIN APPROPRIATE ACTION FOR INFECTED PATIENTS ALL HEALH CARE WORKERS, PATIENTS, AND VISITORS SHOULD BE EDUCATED IN BASIC PREVENTATIVE MEASURES TO STOP SPREAD OF DISEASE RE-EDUCATION OF ED PERSONNEL WHO OFTEN BECOME COMPLACENT TO RISKS WHAT ABOUT EMS? PRE-HOSPITAL PERSONNEL MUST FOSTER AN UNDERSTANDING OF INFECTION CONTROL ER STAFF WORK UNDER BRIGHT LIGHTS; EMS WORKS IN THE DARK OF NIGHT OFTEN OBLIVIOUS TO BODY FLUIDS EMS PERSONNEL DO NOT WORK IN A CONTROLLED ENVIRONMENT! EMS ROUTINELY TRANSPORT BLOODIED VICTIMS FROM ACCIDENT SCENES WHICH EXPOSES THEM TO UNKNOWN RISKS KEY TO MANAGING PRE-HOSPITAL PERSONNEL INCLUDES EDUCATION OF INFECTION CONTROL PRACTICES FACT MANY MICROBES REMAIN VIABLE FOR DAYS OR WEEKS ON SURFACES WITHIN THE ENVIRONMENT THERE ARE MANY FACTORS THAT DETERMINE WHETHER OR NOT A MICROBE WILL SURVIVE OUTSIDE THE HUMAN BODY FOR EXAMPLE: THE HIV VIRUS DOES NOT REMAIN VIABLE FOR LONG OUTSIDE THE BODY AND CANNOT REPORDUCE WITHOUT A HOST HOWEVER, HEPATITIS B VIRUS CAN REMAIN VIABLE FOR UP TO 7 DAY OUTSIDE THE BODY AND IS INFECTIOUS DURING THAT TIME FACT CONTROLLING THE ENVIRONMENT INVASIVE PROCEDURES THAT PLACE ED PATIENTS AT RISK : CENTRAL LINES CONTROLLING THE ENVIRONMENT DRAINS: AESEPTIC TECHNIQUE IS NOT OPTIONAL MOST COMMOM COMPLICATION OF DRAINS IS INFECTION CONTROLLING THE ENVIRONMENT URINARY CATHERIZATION MORE THAN ONE HALF OF ALL HOSPITAL ADMISSIONS COME THROUGH THE EMERGENCY DEPARTMENT ED MUST AIM TO REDUCE UNNECESSARY CATHERIZATION CATHETERS ARE OFTEN PLACED IN ED WITHOUT APPROPRIATE INDICATION FOR USE UTIS ACCOUNT FOR 1/3 OF ALL HOSPITAL ACQUIRED INFECTIONS CONTROLLING THE ENVIRONMENT THE PRIVACY CURTAIN BATTLE OVER INFECTION HAS BEEN WAGED ON MANY SURFACES BUT IS OFTEN OVERLOOKED ON THE PRIVACY CURTAIN PRIVACY NEEDS TO BE BALANCED WITH INFECTION PREVENTION PRIVACY CURTAINS ARE NOT CLEANABLE BY WIPING DOWN LIKE MOST SURFACES MAY BE A COMMON SOURCE OF CONTAMINATION SINCE MECHANISM OF OPERATING CURTAIN IS TO TOUCH IT BY HAND CONTROLLING THE ENVIRONMENT VENTILATORS IN THE EMERGENCY DEPARTMENT CONTROLLING THE ENVIRONMENT VENTILATORS IN THE EMERGENCY DEPARTMENT PATIENTS PRESENT TO THE ED WITH CONDITIONS THAT MAY REQUIRE INTUBATION ONCE A DEFINITIVE AIRWAY HAS BEEN SECURED, VENTILATORY MANAGEMENT ENSUES IT IS IMPORTANT FOR ED PERSONNEL TO POSSESS THE MOST CURRENT INFORMATION PERTAINING TO CARE OF INTUBATED PATIENTS WITH PROPER INFORMATION, ED PERSONNEL CAN EFFECTIVELY CARE FOR VENTILATED PATIENTS WHILE IMPROVING OUTCOME CONTROLLING THE ENVIRONMENT THERE IS NO NEED TO WAIT FOR PATIENT TO BE ADMITTED TO ICU TO BEGIN EVIDENCE BASED PRACTICES TO PREVENT VAP INITIATING STRATEGIES WHILE PATIENTS ARE STILL IN THE ED HAS THE POTENTIAL TO SIGNIFICANTLY IMPROVE OUTCOMES CONTROLLING THE ENVIRONMENT THREE MAJOR COMPONENTS OF VAP PROTOCOL: PROPER MOUTH CARE ELEVATING HEAD OF BED BETWEEN DEGREES UNLESS CONTRAINDICATED MINIMIZING SALINE LAVAGE THESE IMPORTANT MEASURES HELP TO REDUCE INCIDENCE OF VAP IN HOSPITALIZED PATIENTS. CONTROLLING THE ENVIRONMENT DRAIN VENTILATOR TUBING BEFORE TURNING OR MOVING PATIENT DRAIN TUBING INTO WATER TRAPS, AWAY FROM PATIENT AND VENTILATOR EMPTY TRAPS INTO PROPER CONTAINER FOR DISPOSAL IF INTEGRITY OF CIRCUIT MUST BE BROKEN, MINIMIZE NUMBER OF TIMES NEEDED TO DRAIN USE PROPER INFECTION CONTROL PRECAUTIONS DURING CARE OF CIRCUIT CONTROLLING THE ENVIRONMENT VENTILATOR CONDENSATE IS CONSIDERED INFECTIOUS WASTE. NEVER DRAIN THIS WASTE BACK INTO THE HUMIDIFIER PNEUMONIA CAN EASILY DEVELOP IF CONTAMINATED CONDENSATE IS RE-INTRODUCED INTO THE SYSTEM CONTROLLING THE ENVIRONMENT HANDWASHING THE CDC RECOMMENDS THAT HEALTHCARE PROFESSIONALS WASH HANDS FOR A MINIMUM OF 40 SECONDS (IDEAL UP TO ONE MINUTE) BETWEEN PATIENTS AND WHENEVER EXPOSED TO CONTAMINANTS SURGICAL SCRUBS SHOULD BE MUCH LONGER AND DONE WITH SPECIAL ANTI-MICROBIAL SOLUTIONS CONTROLLING THE ENVIRONMENT HANDWASHING BEFORE ANY PROCEDURE HAS PROVEN EFFECTIVE AT REDUCING RATES OF HEALTHCARE ASSOCIATED INFECTION! CONTROLLING THE ENVIRONMENT WHAT ABOUT HAND SANITIZER? They are NOT an effective means for certain stubborn bacteria such as Clostridium Difficile (C-Diff) which may remain viable. C. Difficile spores survive routine environmental cleaning with detergents and alcohol-based gels. CONTROLLING THE ENVIRONMENT Contaminated aerosol droplets can stay suspended for greater than an hour and can travel up to 6-8 feet or more. An N95 mask is indicated in most cases but review your facility ID policy. CONTROLLING THE ENVIRONMENT VOLUNTEERS ENCOURAGE INFECTION CONTROL PRACTICES WITH VOLUNTEER PERSONNEL LEAD BY EXAMPLE WALK VOLUNTEERS THROUGH ER INFECTION PREVENTION PROTOCOL. THE TRAINING THEY RECEIVED MAY NOT BE SPECIFIC TO YOUR UNIT STOPPING THE SPREAD HANDS SHOULD BE CLEANED AFTER EVERY ENCOUNTER WITH: EQUIPMENT PATIENT ITEMS STOPPING THE SPREAD EQUIPMENT NON-DISPOSABLE SURFACES OF SUCH EQUIPMENT IN CONTACT WITH PATIENT BLOOD OR BODY FLUIDS MUST BE CLEANED, DISINFECTED OR STERILIZED CLEANING = WASHING ITEM WITH SOAP & WATER DISINFECTING = USE OF DISINFECTANT: KILLS SOME MICROORGANISMS STERILIZATION = EITHER CHEMICAL OR AUTOCLAVE: KILLS ALL MICROORGANISMS STOPPING THE SPREAD DISPOSABLE EQUIPMENT ONE PATIENT, ONE TIME! DISPOSE OF PROPERLY AFTER USE DISPOSING OF PROPERLY MEANS: STOPPING THE SPREAD REFERENCES AARC.org AHRQ Clinical Assessment in Respiratory Care, ed. 5, Egans Fundamentals of Respiratory Care, ed Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51. Medline OSHA.gov Pubmed The Centers of Disease Control and Prevention --