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12/2001
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Infection Control Today - 12/2001: The Contagious Patient
The Contagious Patient:
Identifying, Containing, and Treating Appropriately
By Enid K. Eck, RN, MPH, Barbara DeBaun, RN, BSN, CIC, Gina Pugliese, RN, MS
The Context of Contagion
Healthcare settings today are busy, crowded, noisy places with
overworked, distracted clinical staff and a wide assortment of
patients converging together in situations that are prone to
facilitating infectious disease exposures and transmission. With
the current national nursing shortage, even staff that normally
adhere to standard infection control policies and procedures find
themselves cutting corners and skipping critical steps because of
perceived time constraints or inadequate staffing.
To effectively manage the context of contagion and prevent potentially serious outbreaks
several factors should be considered including a facility's setting (i.e., rural vs. urban), the
types of services provided and patient acuity. The incidence of particular disease(s) in the
surrounding community, seasonal variations, and any unusual events or outbreaks should
be incorporated into facility and departmental plans for identifying, containing, and
appropriately treating a contagious patient.
Identifying the Contagious Patient
The cornerstone of effectively managing contagious patients is early and accurate
identification and diagnosis. Raising staff awareness and creating a heightened level of
vigilance is especially challenging at times when the occurrence of other diseases may
seem more likely.
Inaccurate information regarding specific modes of disease transmission or reduced index
of suspicion may serve as barriers to early identification of contagious patients or a
premature or inaccurate diagnosis of a particular clinical condition. Clinical and ancillary
staff should be educated regarding the particular clinical features of specific diseases so
that they are able to differentiate that disease from others that may have a similar clinical
presentation.
Educating Healthcare Staff
Staff should be educated regarding the principles of microbial pathogenicity, host
response, and their role in infection prevention. The general characteristics that contribute
to organism virulence and survival as well as the mechanisms for invasion,
dissemination, and proliferation are also important topics for staff to understand. By
using creatively designed, practical tools, staff can be sensitized to unique disease factors
and encouraged to consistently apply their knowledge to every encounter with a patient
and/or visitor.
The risks for exposure to microorganisms in healthcare settings are related to the mode of
transmission of the particular infectious agent, the source of the microorganism, the
duration or level of exposure, and the host response. To effectively identify the
contagious patient, a thorough medical and social history and complete physical
examination are very valuable tools in assessing various risk factors and estimating the
host response to particular infectious agents. Protocols that direct specific actions to
reduce the risks for exposure and containing potential infectious patients are essential.
In the opening scenario, distinguishing between the many ER patients with the "flu" and
the one patient with infectious MDR TB was a critically missed opportunity. Failure to
identify the contagious patient resulted in avoidable negative outcomes including:
additional exposures, several new infections, increased costs to the organization, and a
delay in effective treatment for the contagious patient.
Providing Feedback
Provide feedback to staff if/when avoidable exposures or outbreaks occur and reinforce
desired IC practices by acknowledging such actions when contagious patients are
promptly identified and potential exposures are avoided.
Containing the Contagious Patient
The hospital admitting office calls to notify the L&D staff that a young woman will be
arriving shortly for admission to one of the hospital's birthing rooms. She is in the final
stages of labor with her second pregnancy and is accompanied by her husband, mother,
and 3-year-old. The patient's record indicates that all the appropriate authorizations
have been signed for the toddler to remain with the family during delivery. The nurse
midwife who will be delivering the baby indicates that extensive education has been given
to the family and everyone is excited about sharing this wonderful event.
Upon admission, the patient is found to have several small papules and vesicles scattered
across her lower abdomen and buttocks, many of which are crusted over. She also
appears to have some tiny raised lines near her nipples. During the admitting exam the
patient frequently scratches the "rash" and explains that the itching has been "driving
her crazy" for the past several days. The admitting nurse notices that the toddler is
almost constantly scratching his head and appears to have a similar "rash" on his head
and neck.
After an uneventful delivery the patient is admitted to a semiprivate postpartum room.
Within 12 hours of delivery the patient is requesting medication to stop the itching. A
dermatology consult is ordered and upon further examination scrapings are obtained
from several of the patient's lesions. The resulting diagnosis is "Norwegian Scabies" and
a potential outbreak investigation is initiated.
Building the System From the Ground Up
If early and accurate identification is the cornerstone of effectively
managing the contagious patient, appropriate containment is the
foundation of infection prevention and control. For staff to initiate and
subsequently maintain appropriate containment of the contagious
patient, a comprehensive, thoughtfully designed system must be in
place.
That system must include an adequate number of rooms that are designated for isolation
of potentially infectious patients, readily available personal protective equipment (PPE),
and work flow or traffic patterns that decrease inadvertent exposures. Effective
communication mechanisms that assure that all staff are fully informed and prepared to
follow all containment procedures are essential.
Ideally, there should always be a room designated for patients with suspected airborne
infectious diseases, a private room with special ventilation (e.g., negative pressure, eight
air exchanges per hour, and air exhausted to the outside). If this is not available, a
supplemental resource such as portable HEPA air filtration units can be used. Other
components of an effective containment system may include readily available supply
carts or cupboards that are always stocked with necessary PPE and computer systems
prompts that connect diagnosis with appropriate containment strategies.
As Easy as Gambling in Las Vegas
To create an environment that facilitates doing the right thing(s) in managing contagious
patients, it is helpful to convene a multidisciplinary committee that works through
infection problems and control measures across departmental lines. The infection control
committee may serve such a role by developing and approving appropriate policies and
procedures.
However, if the necessary infrastructure is not developed and maintained concurrently,
barriers to adhering to established policies frequently develop. Eventually doing the right
thing becomes very difficult and unnecessary exposures and disease transmissions occur.
In contrast, if the infrastructure is thoroughly designed and supported, then all the right
infection containment procedures can become as easy as gambling in Las Vegas.
Use a "Secret Shopper" to Find the Gaps
To continuously improve the quality of an infection control program, it is important to
actually observe staff behavior during normal operations. This can be particularly
difficult if staff is familiar with all the infection control program personnel. One creative
solution is to use unobstructive observers like "secret shoppers" who simply observe the
IC practices or staff. Findings from such observational studies can facilitate
improvements in IC containment and prevention especially if specific gaps in practice are
identified.
Treating Appropriately
A 68-year-old woman is admitted to the ICU for post-operative care following a right hip
arthroplasty. In addition to a history of diabetes mellitus and chronic renal failure for
which she is receiving hemodialysis, her medical records indicate that during the past
five years she has had four previous hospital admissions. During each admission she was
treated with a wide variety of broad spectrum antibiotics for a number of "infections" for
which there are no positive cultures.
She routinely receives vancomycin as part of her hemodialysis regimen and prior to this
current surgical procedure she received vancomycin prophylaxis. Approximately 98
hours after surgery the patient has three consecutive temperatures of 38.5º C. The
surgical site appears inflamed with some purulent drainage. Cultures and sensitivities
performed on the expressed pus confirm the presence of vancomycin-resistant
enterococci (VRE).
The use of broad-spectrum antimicrobials has become so widespread that the challenge of
resistant organisms is becoming a regular event in most hospital settings. Many factors
have contributed to the current situation including: 1) provision of antimicrobials even
when the infectious agent is viral, 2) desire for more convenient dosings, and 3)
continued empiric use for presumed infections.
Comprehensive interventions should be developed to assure the appropriate use of
antimicrobial agents and adherence to clinical practice guidelines designed to prevent
infections. Mechanisms to provide routine review and discontinuation of antimicrobial
agents are also appropriate. Microbiology laboratories with the capacity for appropriate
identification and susceptibility testing are essential.
Conclusion
The challenges of identifying, containing, and appropriately treating contagious patients
are greater now than ever before as healthcare organizations seek to contain costs by
streamlining staff and services. As such, it becomes essential to have a system in place
that is on alert for patients or HCWs suspected of having a contagious disease. This
requires the leadership of the IC program, collaboration with the key departments and
staff, ongoing education to assure staff remain aware of their role in identification, and
isolation of patients with potentially communicable diseases. Because of the competing
priorities for quality and safety of the healthcare environment, containment of potentially
infectious patients often requires innovative strategies, including wall signs in key areas
describing common signs and symptoms of communicable diseases, and IC liaisons and
champions in each department. As resources continue to shrink, prevention of exposures
reduces the burdens of investigation, follow-up and treatment of workers, patients, and
visitors that become infected after exposure to a contagious patient.
Enid K. Eck, RN, MPH is the senior consultant for HIV and
infectious disease at Kaiser Permanente Medical Care Program in
Pasadena, Calif. Barbara DeBaun, RN, BSN, CIC is the infection
control manager at California Pacific Medical Center in San
Francisco, Calif. Gina Pugliese, RN, MS is the vice president of the
Safety Institute of Premier Safety Institute. She also holds associate
faculty positions at the University of Illinois School of Public Health
and Rush University College of Nursing in Chicago.
It is the height of flu season and the busy ER has been jammed all night with people who
are coughing, febrile, and complaining of general malaise. The ER doors open for the
hundredth time and a young family enters. The woman approaches the check-in
receptionist and explains that her husband has been sick for the past several days with a
cough that is keeping him awake at night. He has had a fever that causes sweating every
night, he feels very tired and came home early from his job at an area restaurant. The
clerk tells them that someone will be with them shortly and in the meantime, to please
wait in the general waiting room with the other patients.
Several hours later the young man is brought into an ER exam room where he is examined by
a medical intern and ultimately admitted to the hospital with R/O pneumonia. Eventually, he is
diagnosed with MDR tuberculosis and a full-scale exposure follow-up is initiated. Several
healthcare workers (HCWs) are identified with tuberculosis skin test conversio ns and
appropriate prophylaxis is initiated