Looking Beyond Ebola: Designing Tomorrow's ED for Infection Control

Published on December 20, 2014
Whenever there is an infectious disease scare, critical eyes turn on the emergency department. The key is to look forward, not back, and design new EDs with infection control principles in mind from the beginning.

In the event of large-scale pandemics, external covered spaces proximate to the ED can be used for initial intake and screening.

Ebola. MERS. H1N1. SARS. Since the turn of the century global public health experts have responded to no less than four large-scale public health crises. While creating a lot of interest – and a fair amount of panic – each has served as a reminder of the importance the ED has as one of the first lines of defense in responding to many infectious threats in our communities.

A few years ago I was working with a large Canadian hospital that was planning a new ED. As the discussions and planning turned to infection control, the topic that dominated the discussion was designing an ED that could handle another SARS-like pandemic. What was nearly lost in the discussion was how EDs should be designed to support infection control processes at both macro and micro levels. It got me thinking about how well many EDs are, or are not, designed to protect our patients and staff from the very real threats that come from just being in the ED environment.

A study completed at a large urban ED in the United States showed that during the average 8-hour shift, each patient came within one meter of a median of five other patients, and each staff member was within one meter of just over 13 other staff members and four patients (Lowery-North). This level of close-proximity contact between staff and patients highlights just how easy and frequent community transmission of infectious pathogens can be in the ED.

EDs should be designed to support infection control processes at both macro and micro levels. It got me thinking about how well many EDs are, or are not, designed to protect our patients and staff from the very real threats that come from just being in the ED environment.

Hospital-based risks of infectious disease transmission also deserve considerable attention when planning a new or renovated ED. Also known as healthcare-associated infections (HAIs), these include catheter-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia. In the landmark 1999 publication entitled ‘To Err is Human,’ the Institute of Medicine estimated that, in the United States alone, as many as 98,000 people die in hospitals annually from medical errors, including HAIs. Morbidity and mortality concerns aside, the cost of HAIs to a health system can be staggering. Multiple studies in the early part of this century have convincingly documented the economic impact of poor infection control methodologies (Dimick, Lansford, Shannon, Tambyah, Warren, Warren) The most recent data on HIAs suggest that up to 70% of these conditions can be avoided using existing evi- dence-based strategies (Umscheid).

Mitigating the transmission of infectious pathogens beyond source patients in the ED does not happen by accident; it occurs by design. The interplay between processes, human behavior, facility/campus design and technology all come together to keep everyone safe from harm.

Blueprint shows negative pressure ventilation isolation rooms located in close proximity to intake areas, which reduces the risk of exposure to other patients and visitors.

The Arrival Sequence - Keeping Everyone Else Safe

Delays in identifying patients with potentially infectious conditions translate into increased transmission exposure. An illustrative example can be seen in 2003 when the SARS virus reached Toronto. A family caregiver of the first index case arrived at a busy ED that was ill-prepared and, quite likely, improperly designed to handle such a highly infectious situation. As a result, 126 nosocomial infections of patients and staff with SARS resulted from this single patient encounter (Varia).

Design Tip: Designing the arrival experience to mitigate infectious pathogen exposure begins with placing Personal Protective Equipment (PPE) in easy reach of patients, visitors and staff. Proper signage should direct those entering the facility with a fever and suspected contagious infection to apply appropriate PPE, which happens to be stored in the same location. Hand hygiene stations should be located at every access point to the ED for patients and visitors as well as in high-traffic locations such as the triage rooms and registration areas.

Reducing Pathogen Transmission in the Treatment Area

One of the more concerning pathogens in the clinical setting is methicillin-resistant staphylococcus aureus (MRSA). A study of MRSA contamination in an ICU setting in the UK demonstrated that MRSA contaminations were most commonly documented in spaces under the patient bed (38%), as well as on workstations (17%), monitors (19%) and ledges behind beds (13%) (Hardy). In the same study, 43% of patients who were found to be colonized with MRSA during their hospital stay became colonized while in the hospital setting.

Locating a sink at the entry to a treatment station increases compliance with hand hygiene activities.

Design Tip: One of the most important design considerations to prevent easy transmission of infectious pathogens in the ED including MRSA is the use of single-patient rooms separated by solid walls as opposed to multi-bedded rooms with patient separated by curtains, mobile screens or other soft barrier devices. A study undertaken in a Canadian ICU demonstrated that conversion of the clinical area to single-patient rooms resulted in clinically significant and substantial decreases in Clostridium difficile, vancomycin-resistant enterococcus and MRSA incidence (Teltsch). While the cost of single patient rooms may seem prohibitive in some healthcare systems, the return on investment with respect to lower incidence of HAIs is clear.

Recently, attention has turned to so-called “self-disinfecting” surfaces such as copper that are showing early promise with respect to reducing contamination and subsequent HAIs (Niiyama, Weber). While the research into these technologies is promising, there has yet to be reproducible large-scale studies that have reliably reproduced these findings. Further study is warranted in this area.

Promoting Staff and Patient Hand Hygiene

Clinician compliance with hand hygiene has been lackluster on a global scale. A recent study of hand hygiene compliance among clinicians at six major public hospitals in Kuwait demonstrated that ED staff was compliant with hand hygiene only 15% of the time after activities described as “dirty contacts” by the Fulkerson scale (Al-Wazzan). Similar results have been documented around the globe, including in Spain, France, Saudi Arabia, the UK, New Zealand and a host of other countries (Novoa, Moret, Basurrah, Al-Damouk). In the case of Kuwait, a number of facility design considerations were listed as reasons for poor compliance. This included not enough disposable paper-based hand towels (23%), sink locations not appropriate (17%) and not enough alcohol-based rub (9%).

Clinician compliance with hand hygiene has been lackluster on a global scale. A recent study of hand hygiene compliance among clinicians at six major public hospitals in Kuwait demonstrated that ED staff was compliant with hand hygiene only 15% of the time after activities described as “dirty contacts” by the Fulkerson scale.

In a study of hand hygiene compliance at a large hospital in Ethiopia, significant gains were made from the implementation of a multimodal hand hygiene campaign based on World Health Organization (WHO) guidelines (Schmitz). In the case of proper hand hygiene, very simple, and often low-cost, design solutions combined with behavioral modification can be implemented to promote compliance and create queues to promote patients, visitors and staff hand hygiene.

Design Tip: Ensuring the ED is designed with adequate hand hygiene stations or antiseptic dispensers is essential. At a minimum, there should be dedicated resources for hand hygiene at every patient treatment station; in staff work and break areas; in patient, staff and visitor toilets; in soiled utility rooms; in medication dispensing and preparation areas; and, anywhere that food for consumption is stored or available. More advanced EDs have begun placing hand sanitizer and antiseptic stations at the entry to every treatment station and some have considered going as far as to create audible or visible alarms when someone enters a treatment station without first engaging in hand hygiene activities. Hospitals that have explored the use of wearable alcohol gel dispensers have found limited success in these tools in isolation of other hand hygiene initiatives (Haas).

Planning For The Next Pandemic

One of the more challenging aspects of designing new EDs surrounds planning for the infrequent, but extremely dangerous, eruption of an epidemic or pandemic. EDs improperly designed and operated can result in exacerbation of the already difficult situations created during explosions of communicable diseases such as Ebola, MERS, influenza, RSV and the like. While it’s easy to get caught up on planning for Ebola, MERS and other new diseases, it’s important not to lose perspective. The WHO estimated that every year there are 250,000-500,000 deaths worldwide that can be attributed to influenza (WHO).

Proper hand hygiene is essential to proper infection control in the ED. hand washing stations in common areas and designed for patients of all ages increases hand hygiene compliance.

Many of the process and design elements considered standard for good infection control practices can be leveraged on a much larger scale for pandemic planning. The key to managing pandemics stemming from contagious pathogens consists of a number of key concepts: social segregation of affected patients; proper barrier precautions to prevent spread to care providers and, subsequently, other patients and staff; appropriate ventilation for airborne pathogens; and, appropriate decontamination of patients, care providers, treatment areas, equipment and supplies.

An essential design consideration for pandemics and other surge situations is rapid, easy access, to an adequate supply of PPE to properly protect the ED staff involved in patient care. The ED should be designed with adequate storage space for all PPE necessary to provide patient care for an extended period of time reflective of the time is would be expected to mobilize and deliver the second supply of PPE. Ideally, the in-ED PPE will be located in one place and housed in mobile carts that allow for easy deployment in any part of the ED or in external environments.

Once inside the confines of the ED, appropriate spaces must be provided to ensure potentially-infectious patients are segregated from the general patient population and visitors. Adequately sized segregated waiting area should be provided to limit exposure to the general population. Ideally, these spaces will be physically contained from other areas of the ED and contain an adequate number of hand hygiene resources. In instances where airborne transmission is a concern, appropriate ventilation design including negative pressure ventilation should considered. In the case of the H1N1 pandemic, one academic medical center in the United States developed a drive-thru ED to completely socially segregate suspected H1N1 cased from the general ED population (Weiss). Similarly, a children’s hospital in Houston established a mobile team that screened presenting patients in a covered area outside of the ED (Cruz).

Once treatment is ready to commence, care should be provided in segregated areas of the ED separate from the general population. This is best accomplished in EDs where a specific zone or pod can be physically cordoned off from the rest of the department. In some instances, large gathering spaces such as a staff dining room or hospital lobby have been used as an alternative. Regardless of the space used, adequate supplies, equipment, medical gasses, monitoring tools, and staff are essential in the area to limit travel into and out of this space.

Multiple waiting areas designed into the new ED better enable the facility to separate potentially contagious patients from the general patient population during intake, screening and while awaiting a treatment station.

Finally, circulation paths for patients, staff and visitors from the exterior of the building into the ED, and from the ED to diagnostic areas and the inpatient platform must be considered, again, with the goal of limiting contact between pandemic patients and those not infected or involved in the care delivery process.

Conclusion

Community and hospital-associated infections continue to represent a challenge to ED design and planning. Developing a rigorous design process using a multimodal approach that combines process redesign, human behavior modification, proper facility design and leveraging technology properly will better prepare EDs to successfully manage both day-to-day care of patients with infectious pathologies while ensuring proper preparation for the day the next pandemic arrives.

  • Additional references:

Al-Damouk M, Pudney E, Bleetman A. Hand hygiene and aseptic technique in the emergency department. J Hosp Infect 2004;56:137-41.

Al-Wazzan B, Salmeen Y, Al-Amiri E, Abul A, Bouhaimed M, Al-Taiar A. Hand hygiene practices among nursing staff in public secondary care hospitals in Kuwait: self-report and direct observation. Med Princ Pract 2011;20:326-31.

Haas JP, Larson EL. Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department. Academic Emergency Medicine 2008;15:393–396

Varia, M, Wilson, S, Sarwal, S, McGeer, A, Gournis, E, Galanis, E et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. Canadian Medical Association Journal. 2003; 169: 285–292

Weber DJ, Anderson D, Rutala WA. The role of the surface environment in healthcare-associated infections. Curr Opin Infect Dis. 2013 Aug;26(4):338-344.

Weiss EA, Ngo J, Gilbert GH, Quinn JV. Drive-through medicine: a novel proposal for rapid evaluation of patients during an influenza pandemic. Ann Emerg Med. 2010;55 (3): 268-273.

This article originally appeared in Issue 15 of Emergency Physicians International.

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