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The control and prevention of infection in emergency departments (EDs) remains challenging because of the complexity of the environment and the consistently high attendance in many EDs. Emergency nurses play an essential role in infection prevention and control in this clinical area. The COVID-19 pandemic has refocused the need for emergency nurses to have a good knowledge and understanding of infection control processes and the clinical skills to protect themselves and patients alike. This article provides an overview of UK epidemiological perspectives, the main pathogens associated with healthcare infections, the importance of reducing pathogen transmission and the emergency nurse’s role in antibiotic stewardship.
Emergency Nurse. doi: 10.7748/en.2023.e2157
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Curr S, Baker E (2023) Managing infection prevention and control in the emergency care setting: an overview for emergency nurses. Emergency Nurse. doi: 10.7748/en.2023.e2157
TributePublished posthumously in memory of Sarah Curr
Published online: 04 April 2023
Keywords :
bacterial infections - communicable diseases - Clostridium difficile - coronavirus - Covid-19 - cross-infection - emergency care - hygiene - infection - infection control - infection prevention - meticillin-resistant Staphylococcus aureus - nursing care - streptococcus - urinary tract infections
The aim of this article is to provide an overview of the emergency department (ED) nurse’s role in infection prevention and control (IPC) in emergency departments. After reading the article and completing the timeouts, you should be able to:
• Recognise the ED nurse’s role in preventing infections and controlling transmission.
• Understand healthcare-associated infection (HCAI) epidemiology and promote important IPC measures in the ED.
• Critically consider the ED nurse’s role in preventing HCAIs and the use of aseptic non-touch technique (ANTT) in common procedures.
• Promote the ED nurse’s role in antimicrobial stewardship (AMS).
Maintaining infection prevention and control (IPC) including antimicrobial stewardship (AMS) is of primary importance in all healthcare settings – perhaps now more than ever as we live through the COVID-19 pandemic. The emergency department (ED) is the first point of contact for many people accessing healthcare, so IPC is of paramount importance here. Time constraints and patient throughput further add to this.
IPC is a fundamental aspect of professional, ethical practice, as it ensures the safety of patients, their significant others, visitors and healthcare professionals (HCPs) when HCPs deliver care. This can be linked back to the ‘4Ps’ – the core principles set out by the Nursing and Midwifery Council (NMC) (Box 1).
Prioritise people
2.2: Recognise and respect the contribution that people can make to their own health and well-being
3.1: Pay special attention to promoting well-being, preventing ill health, and meeting the changing health and care needs of people during all life stages
Practise effectively
6.1: Make sure that any information or advice given is evidence-based, including information relating to using any health and care products or services
6.2: Maintain the knowledge and skills you need for safe and effective practice
Preserve safety
19.3: Keep to and promote recommended practice in relation to controlling and preventing infection
19.4: Take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public
Promote professionalism and trust
22.3: Keep your knowledge and skills up to date, taking part in appropriate and regular learning and professional development activities that aim to maintain and develop your competence and improve your performance
Source: NMC (2018)
How is IPC relevant?
Identify how IPC applies to your practice and the requirements of your regulatory body
• Infection control remains key to the safety of patients and staff in the emergency department
• It is essential that infection control is everyone’s responsibility and that all healthcare professionals can identify, manage and prevent infection in the clinical setting
• Reducing the risk of infection transmission in the emergency department is important in reducing hospital length of stay, mortality and morbidity and improving patient experience
• Antimicrobial stewardship is the responsibility of all healthcare professionals and emergency nurses play an important role in ensuring that antimicrobials are used appropriately
It is important that nurses working in emergency care have a broad understanding of HCAI epidemiology to underpin their clinical practice, improve clinical outcomes and educate others. It is estimated that 653,000 HCAIs occurred in general hospitals in England in 2016-17 – around 4.7% of all admissions to hospital – resulting in 5.6 million occupied hospital bed days (Guest et al 2020). The mortality rate of the affected patients was around 3.5%, with approximately 22,800 deaths associated with HCAIs (Guest et al 2020). It is also estimated that 1.7% of HCPs working in England contracted a HCAI in that time – approximately 13,900 people – resulting in 62,500 days of lost work (Guest et al 2020). In total, HCAIs caused additional costs of approximately £2.1 billion in 2016-17, with 99.8% of this spending directly linked to patient care and treatment costs (Guest et al 2020).
The most frequently occurring HCAIs in high- and middle-income countries are: catheter-associated urinary tract infection (CAUTIs), surgical site infections, ventilator-associated pneumonia (VAP), hospital-acquired pneumonia and Clostridium difficile infections (Boev and Kiss 2017). The causative organisms vary by geographical location, but it is still important that ED nurses understand the epidemiology of the main organisms: methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococci (VRE); Clostridioides difficile (C. difficile); carbapenemase-producing organisms (CPO); and carbapenemase-producing Enterobacterales (CPE). Table 1 summarises these organisms, the risk factors and how they are transmitted.
| Pathogen | Description | Risk factors | Transmission |
|---|---|---|---|
| Methicillin-resistant Staphylococcus aureus (MRSA) | Around 30% of people in the UK have been colonised by Staphylococcus aureus, predominantly in their noses or throats or on their skin (Johnson et al 2005). MRSA is an S. aureus bacterium that has become resistant to many antibiotics. Infection with MRSA means that these bacteria are causing the person to be ill (Turner et al 2019) | Transmission in hospital can be caused by person-to-person contact or contact with a contaminated environment (Kourtis et al 2019) | |
| Vancomycin-resistant Enterococci (VRE) | Enterococci are bacteria that live in the gastrointestinal tract (GIT) normally without causing illness. Vancomycin is an antibiotic used to treat infections caused by Enterococci. Bacteria that have become resistant to vancomycin are referred to as VRE (Vehreschild et al 2019) |
| Transmission is caused by person-to-person contact or contact with a contaminated environment (Vehreschild et al 2019) |
| Clostridioides difficile (C. difficile) | Antibiotics can cause changes to the microbiome of the GIT whereby competing bacteria are destroyed. This allows C. difficile to grow exponentially. C. difficile produces toxins that cause pseudomembranous colitis in the GIT wall. Symptoms include watery diarrhoea, pyrexia and abdominal pain |
| Transmission is caused by person-to-person contact or contact with an environment contaminated with the bacterial spores (Keske and Letizia 2010) |
| Carbapenemase-producing organisms (CPO) and carbapenemase-producing Enterobacterales (CPE) | These organisms are very resistant to antibiotics including carbapenems (Puleston et al 2020). They produce carbapenemase, an enzyme that severely reduces the effectiveness of antibiotics (Zhao et al 2021). They normally live in the GIT, but if they enter other parts of the body they can cause infection |
| Transmission is caused by person-to-person contact or contact with a contaminated environment (Zhao et al 2021) |
The COVID-19 pandemic has been associated with high levels of mortality in all sections of society, following the emergence of the virus in the UK in 2020 (Islam et al 2021). The rapid scientific process that followed its emergence resulted in the fastest development of evidence-based healthcare in a generation, including novel treatments and effective vaccines (Baker and Lee 2020). Extensive social distancing laws and mask wearing were effective in controlling transmission in the community and hospital settings (Yang et al 2020). However, these measures have now been relaxed and COVID-19’s prevalence in the UK in March 2022 was 6.37%, which exceeded the previous peak of 4.41% in January 2022 during the height of the first wave of the disease’s new omicron variant (Wise 2022).
The long-term effects of COVID-19 on the wider community and individuals have yet to be fully identified; however, there is a growing understanding that ‘long COVID’ and social isolation will continue to affect individuals for many years to come (Baker and Clark 2020, Ayoubkhani et al 2022).
Emergency nurses have played an essential role in the care of patients with COVID-19. The pandemic has brought about overwhelming changes to emergency care IPC practices since 2020 and it remains important for emergency nurses to understand basic COVID-19 epidemiology, as part of ongoing efforts to reduce transmission in hospitals, prevent morbidity and mortality, implement effective IPC protocols, and apply treatment algorithms.
Concern has been growing about the emergence of patients who have the symptoms of mpox (Vivancos et al 2022). Mpox can enter the body through broken skin, the respiratory tract or mucous membranes (Yang 2022). Its symptoms include fever, muscle pain, lymphadenopathy and vesicular rash (Adler et al 2022). It does not spread easily between humans, with transmission most likely through contact with mpox lesions, contaminated clothing or bed linen, or droplets from someone who is infected with the disease and is coughing or sneezing (Mahase 2022).
Mpox is a member of the poxviruses family, which includes smallpox. However, the illness is far less virulent and transferable than smallpox, is normally self-limiting, and is associated with a low mortality rate (Yang 2022). The smallpox vaccine is about 85% effective against mpox (Adler et al 2022).
It is important that emergency nurses have a solid understanding of the signs, symptoms and risk factors for mpox, so they can protect themselves and others. A risk assessment is needed for any patients presenting with pyrexia and a rash, during which the patients should have full respiratory isolation until infection can be confirmed or refuted (UK Health Security Agency (UKHSA) 2022a).
The median incubation for mpox is approximately 12 days and HCPs who are confirmed contacts are expected to isolate themselves in their homes for 21 days (UKHSA et al 2022). Although the rates of detected infection with mpox have now substantially reduced within the UK setting, it remains vital that emergency nurses remain vigilant to potential further outbreaks and that emergency departments continue in their preparation and planning processes.
Since April 2021, centralised planning, guidance, leadership and surveillance to protect patients and HCPs from HCAIs has come from the newly formed UKHSA (Thornton 2021). The government reform underpinning this change aimed to refocus national planning and preparations, to ensure the UK is ready to tackle another future epidemic or pandemic.
UKHSA (2022b) provides the latest epidemiological information about outbreaks of infectious diseases, which emergency nurses can use to remain up to date. Having this wider understanding of IPC will enable emergency nurses to participate in policy development and be a greater part of the local implementation of policy.
How effective are your local infection control measures?
1) Access the UK Health Security Agency blog website at https://ukhsa.blog.gov.uk
2) Use the published blogs to make a list of the UK’s current infection prevention and surveillance priorities – for example, group A strep and norovirus
3) Identify the main methods your organisation is using to prevent cross-infection of these pathogens in your department, making reference to your local infection control guidance
4) Reflect using your previous experience on how effective each of these infection control measures are and identify the main factors that affect each method’s efficacy
There are multiple processes in place in the ED to manage the constant risk of transmitting infections (Wynn 2021). Table 2 provides an overview of these processes, starting with the most effective process and finishing with the least effective.
(Adapted from Wynn 2021)
PPE in your workplace
Think about where you work. What are the personal barriers and facilitators to using PPE effectively in your daily clinical practice? For example, how does overcrowding affect PPE compliance and how could this be alleviated, given your current resources?
HCPs are at risk of skin contamination from transient flora through contact with patients or their immediate environments. There is a strong evidence base supporting the efficacy of hand hygiene in eliminating transient flora and thus disrupting the spread of microorganisms, if it is undertaken effectively and regularly (Liang et al 2018).
The five moments for hand hygiene are (Bolton and McCulloch 2018, Liang et al 2018, World Health Organization (WHO) 2022):
• Before touching a patient.
• Before a procedure.
• After a procedure or body fluid exposure risk.
• After touching a patient.
• After touching a patient’s surroundings.
What affects compliance?
Access the hand hygiene audits in your department and make a note of the recent trends. What are the factors influencing compliance? How do they influence it?
Seo et al (2019)’s systematic review of the evidence base surrounding IPC in EDs highlighted five factors that affect compliance with hand hygiene:
• Registered nurses are more compliant than other allied HCPs.
• Higher levels of ED crowding substantially reduce compliance.
• Compliance is often improved when HCPs have positive attitudes and beliefs about hand hygiene.
• Regular hand hygiene audits improve overall compliance.
• The visible presence of an appropriately trained IPC practitioner improves compliance.
EDs are the first point of care delivery and there are various practices that increase the risk of HCAIs. Diagnosis and management often require the insertion of indwelling devices, such as catheters and venous access devices (VADs), as do interventions for critically unwell patients, such as ventilatory support. Emergency nurses therefore need to consistently maintain IPC measures that reduce the risk of HCAIs – specifically, aseptic non-touch technique (ANTT), which is ‘a specific type of aseptic technique with a unique theory and practice framework’ (ANTT 2022).
Catheter-associated urinary tract infections (CAUTIs) account for up to 50% of urinary tract infections (Health Protection Agency 2011) and result from unnecessary insertion, poor insertion technique and prolonged use of catheters (Meddings et al 2014). It is the ED nurse’s responsibility to recognise when catheterisation is required and to advocate for the patient if less invasive alternatives are available.
A catheter is likely to be needed in acute urinary retention, post-surgery, in critically unwell patients, when irrigation is required and in chronic incontinence (RCN 2021). However, catheterisation is not a standard approach for incontinence and should only be considered when other avenues have been explored.
It is the ED nurse’s responsibility to ensure that:
• The patient and family are aware of the benefits and disadvantages of a catheter, to enable informed consent.
• The most appropriately sized catheter is used.
• Appropriate hand hygiene, PPE and ANTT are used.
• Local anaesthetic lubricant is used to ensure ease of insertion and prevent trauma.
• The patient receives full information about the catheter and how to care for it.
Full details of the catheter type, size, date of insertion and rationale for insertion should all be documented.
Approximately 60% of hospital inpatients will have at least one VAD during their stay (Alexandrou et al 2015). The ED nurse will insert a high proportion of these, so must consider (Pittiruti et al 2021):
• The rationale for insertion.
• The device to be inserted.
• The device’s size and lumen gauge.
• Care bundles for the device.
Rationales for insertion include the need for intravenous medication and intravenous fluids.
Pittiruti et al (2021) recommends inserting the device in the veins of the forearms or upper arm – there is a greater risk of dislodgement from the veins of the hand, wrist and anti-cubital fossa. Sites where there are infections, open wounds, compromised skin, arteriovenous fistulas and dialysis should also be avoided, to reduce the risks of harm and HCAIs.
How can you prevent infection?
1) Reflect on your ANTT when inserting indwelling devices. What challenges do you face in maintaining ANTT? Consider whether the environment or time pressures affect this
2) Read Pittiruti et al (2021). Consider the section related to indwelling devices and compare this guidance with your own practice. Are there differences?
3) Access the latest audit in your area on compliance with insertion of peripheral VADs. What are the main areas where compliance needs work? How might this be achieved?
Part of the ED nurse’s role is to care for critically unwell patients, which includes those who require ventilation. Approximately 10% to 20% of ventilated patients in intensive care units develop VAP (Hellyer et al 2016). ED nurses must therefore have the knowledge and skill to care for this population, particularly as the average length of a patient’s stay in the ED is increasing (Lucero et al 2021) and thus critically unwell patients requiring ventilation are staying longer in EDs as well.
Reduction of VAP requires (Hellyer et al 2016):
• Patients to be nursed semi-recumbent with an elevated head position of 30º to 45°.
• Daily sedation interruptions, to assess readiness for extubation.
• Sub-glottic secretion drainage.
• Avoidance of unscheduled changes to ventilator circuits.
Correct hand hygiene, PPE and ANTT can all reduce the risk of infection; however, a core element of the ED nurse’s role in reducing HCAIs is critically considering if an intervention is required. For patients’ safety, ED nurses must advocate for those in their care and so should consider less invasive options that maintain oxygenation, when appropriate.
The use of antimicrobial medicine to inhibit or kill pathogens in humans, animals and plants is now commonplace (WHO 2021). However, the misuse and overuse of these medicines are leading to pathogenic microbes developing the ability to withstand their effects (Arnold 2017), resulting in treatments becoming less effective or even ineffective. These drug-resistant superbugs are now responsible for roughly 700,000 global deaths per annum (Interagency Coordination Group on Antimicrobial Resistance 2019), with one third of UTIs now displaying antimicrobial resistance (AMR) (National Institute for Health and Care Excellence (NICE) 2018). As a result, AMR is now recognised as one of the 10 biggest global threats to health (WHO 2015, 2021).
Between 2019 and 2020, 55,384 new antimicrobial resistant strains emerged (UKHSA 2021). This was the first decrease in the rate of AMR since 2016, but still meant there were more pathogens resistant to antibiotics. There is national and international recognition that more needs to be done to counter it.
AMS and surveillance have been built into public health policy (WHO 2015). This multi-pronged approach focuses on:
• Improving awareness and understanding.
• Strengthening knowledge.
• Reducing incidents of infection.
• Developing the case for sustainable investment.
• Reducing the use of antimicrobial medicine.
A core element of all nursing involves safe administration of medication, which includes considering the appropriateness of the prescription. Antimicrobials are widely prescribed in the ED, so the ED nurse has an important role to play in AMS.
The ED nurse’s role is multifactorial and includes but is not limited to (WHO 2015, van Huizen et al 2021):
• Monitoring inappropriate prescription and use of antibiotics.
• Recognising early systemic infections.
• Following proper process when taking microscopic and blood cultures.
• Ensuring IPC measures and safety checks are undertaken when administering intravenous (IV) antibiotics.
The prescribing of antibiotics increased in secondary care by 7.7% between 2013 and 2017 (NICE 2018). This is being addressed nationally, but ED nurses are more aware of local policies and can recognise and challenge inappropriate prescribing practices. This includes suggesting the prescriber consider oral antibiotics where appropriate. Prescribing antibiotics is a core part of AMS, but the ED nurse also has a responsibility to ensure that patients discharged with antibiotics are aware of their correct administration, as well as the importance of completing the full prescription.
ED nurses are likely to be aware of the IPC measures that should be used when preparing intravenous medication. However, they may not be aware of their role regarding treatment duration and dose – under-dosing and incorrect treatment duration can increase the risk of AMR (Bolla et al 2020). Therefore, while ED nurses should support others to ensure best practice is achieved and reduce AMR, they also need to examine their own practice to ensure they safely and correctly administer antimicrobials.
There has never been a greater need for consistent, high levels of effective IPC strategies in emergency care. It is every HCP’s responsibility to have the knowledge and skills needed to minimise the risk of transmitting infection. However, this can be very challenging in the ED, which is often overcrowded and over capacity.
In the wake of the COVID-19 pandemic and the recent surge of mpox, emergency nurses must ensure they have the confidence and competence to recognise, respond, report and reflect on the often rapidly evolving situation in care provision.
Revalidation
Now that you have completed the article you might like to write a reflective account as part of your revalidation: rcni.com/reflective-account
31 October 2023 / Vol 31 issue 6
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