- Introduction
- Flow
- Infection prevention and control
- Reduced patients in emergency departments
- Staffing
- Treatment
- Appendices
Aim
No patient or staff member will acquire a nosocomial infection as a result of their time in the emergency department.
Background
From our inspection activity we know that good infection control improves the quality of care and outcomes for people. We know that COVID-19 changed the way emergency departments operated. However we need to move back to core infection, prevention and control procedures.
NHS England sets out 10 elements of standard infection control precautions (SICPs):
- patient placement/assessment of infection risk
- hand hygiene
- respiratory and cough hygiene
- personal protective equipment
- safe management of the care environment
- safe management of care equipment
- safe management of healthcare linen
- safe management of blood and body fluids
- safe disposal of waste (including sharps)
- occupational safety/managing prevention of exposure (including sharps)
Other measures adopted at the height of the pandemic that remain important are:
- general assessment and screening of high-risk infected patients across the range of infectious diseases
- appropriate isolation areas and facilities for all patients presenting with infections - for example, diarrhoea and vomiting, COVID-19, Ebola and Mpox
- protecting those that are vulnerable to infections - for example, people who are neutropenic or immunocompromised.
There is likely to be a need for structural reviews of departments to include:
- isolation areas
- resuscitation room
- other clinical areas, for example majors, minors, urgent treatment centre, paediatrics
- dedicated areas where aerosol generating procedures (AGPs) can be delivered safely
- areas for applying appropriate PPE based on infection risk and local and national guidance.
In good emergency departments we have seen
- good engagement with trust's infection prevention and control (IPC) leads
- adherence to local and national IPC best guidance practice, such as RCEM, NHS England and CQC
- good compliance with mandatory training for IPC
- observation in the workplace of up-to-date IPC processes and procedures following local and national policies - for example, hand washing, correct use of PPE and recognition of infectious patients
- a clear understanding among staff both within and outside the emergency department of appropriate PPE use for those patients who require an AGP
- appropriate areas for applying the correct PPE based on circumstance
- cleaning schedule that all staff adhere to
- access to prompt processes for screening and timely flow out of the urgent care system.
- Early assessment and recognition of assessment to enable isolation and prevent infection spread
- Observing good IPC procedures such as hand washing and PPE use
- Good uptake and understanding of training relating to IPC issues
- Procedures for preventing crowding in waiting rooms in relation to IPC - for example, full capacity protocol
Managing crowding in relation to infection control
Background
Emergency departments frequently:
- face surges of attendances - these may significantly increase the number of people within the footprint of the emergency department
- face exit block - patients who need to be admitted remain for extended periods of time within the department
- have staff within them that come from other departments to review patients - often as a team
In good emergency departments we have seen
- clear IPC signage relating to current standards
- methods to reduce the number of patients waiting at any one time
- choose and book type models of care
- virtual waiting rooms
- reduced numbers of staff who were not in the emergency department to review patients
- limited entrances and exits – the emergency department is not used as a short cut to other areas of the hospital
When considering infection control for children, the processes for assessment, isolation and PPE should be the same as adults. Separate children's emergency department must adhere to local and national guidance regarding children.
Consider making PPE less scary for children. See “Supersuits” by Katie Chappell.
- Appointment based systems. Some groups of patients need urgent and emergency care but can be reviewed via an appointment-based system. This helps reduce peaks and troughs of attendances within the emergency department. Examples include:
- patients with minor injuries referred via NHS 111
- patients with injuries who self-present after initial review and investigations are completed.
Clinical and executive feedback from the workshops we held in 2021
Suggested processes and ideas for improving patient safety
Maintain patient visibility
Many EDs have had to make substantial changes to meet requirements for social distancing and other IPC measures. For example, moving waiting areas or partitioning spaces. This can, in some instances, negatively affect staffs’ ability to see and observe patients at a distance.
Where this is the case, departments need to consider ways to ensure they maintain high levels of patient visibility across all sites.
Effectively cohort patients
It is important to avoid cohorting confirmed infectious patients with uninfected patients in the ED.
Regular monitoring and assessment
Trusts can carry out regular 'infection walkthroughs' in their EDs, so they can assess that:
- IPC protocols are in place and enforced
- segregated infection areas are fit for purpose
- donning and doffing areas meet required standards
- staff have been individually fit-tested and risk-assessed
- regular testing procedures for staff are in place.
Waiting room crowding
It is crucial to regularly assess the total number of patients in ED waiting areas against agreed capacity. Particularly in the context of infection risk from COVID-19.
Identifying potential crowding helps you decide when to use or escalate mitigation measures.
Examples of good practice
Point of care testing (POCT)
POCT speeds up decision making and reduces the length of stay for patients in the ED.
A mature, safe and well-functioning service will use POCT alongside early senior decision making. They will also use regular reporting to optimise use of this resource.
Adequate PPE provision for staff
Staff need to feel comfortable and safe in the ED. It is important to provide a consistent supply of laundered or disposable scrubs for staff working in areas with high numbers of infectious patients.
Example datasets that can drive possible safety improvements
- Nosocomial rates
- Trusts are able to intelligently monitor nosocomial rates. To do so, it is important to keep patient records that track:
- locations visited in the department
- length of time spent in non-admitted areas
- which members of staff treated or nursed them.
- Trusts are able to intelligently monitor nosocomial rates. To do so, it is important to keep patient records that track:
- Proportion of patients with suspected infection who receive point of care testing for flu and COVID-19
- Mean time for COVID-19 results
- Number of isolation cubicles with air exchange capability at least 10-12/min
- Number of negative pressure rooms
- Number of cubicles with doors as a proportion of total patient cubicles
- Proportion of staff fit tested for masks
- Reporting and monitoring of problems of PPE availability/usage though the incident reporting system
- Review of incidents reported regarding breaches to safe distancing capacity matrix or triggering of escalation plan.
Version history
Updated September 2023
We updated references to infection control procedures that have changed since the height of the COVID-19 pandemic. We also updated other minor references to the pandemic.
Updated October 2021
We held two workshops in 2021 for emergency clinicians and NHS executives. We added suggestions and good practice examples from those events. These updates refer more specifically to the pandemic.
Download and print
Listen
Podcast: Emergency departments responding to COVID-19 - Infection prevention and control
References
COVID-19: infection prevention and control (IPC)
Coronavirus (COVID-19): guidance
Safety alerts
RCEM Safety Flash: Buddy System
RCEM Safety Flash: Communication errors with PPE
RCEM Safety Flash: Salbutamol, peak flow and nebulisation advice during COVID-19
Improvement toolkit
Produced by front line clinicians in response to CQC’s Patient FIRST, this toolkit suggests a framework that NHS trusts can use to monitor and assess their progress in applying good practice principles.
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