Improving the Segregation and Isolation of Patients with Respiratory Symptoms in the Emergency Department

Background:

Many patients with respiratory symptoms who are seen and treated in the emergency department and clinics are not promptly segregated and isolated according to best infection control practice guidelines. It is important to place a mask on the coughing patient upon arrival in the health system so that unprotected exposure to a potential infection can be prevented among employees and patients.

Objective: Our objective was to decrease unprotected exposure to influenza among employees in the emergency department (ED) through improvement in triage and appropriate masking of patients with respiratory symptoms.

Methods:

A quality improvement project was performed at Parkland Hospital and Health System, Dallas, TX, a public academic tertiary healthcare system with a 770-bed hospital and a busy emergency department that has over 130,000 patient visits annually. The duration of the project was 8 weeks during September and October 2009. A multidisciplinary team consisting of members from the emergency department, performance improvement and infection control was assembled. The current processes were mapped and leverage points were identified. The change hypotheses tested were: 1. Making ear loop masks available in all areas of the ED will increase the proportion of patients appropriately masked and 2. Educating the nurses in the ED regarding influenza symptoms and rapid masking will increase the proportion of patients appropriately masked. A cause and effect diagram was developed upon brainstorming during team meetings. Data were collected using tally sheets in the ED by staff nurses. Occupational Health provided data on employee exposures. Clinical quality outcomes were measured.

Results: During the project, Dallas County experienced increasing incidence of pandemic H1N1 influenza. In the 8 weeks of the improvement project, the proportion of patients appropriately masked upon arrival in the ED from 40%-78% during week 1 and 2 to 100% during weeks 6, 7 and 8. The proportion of patients appropriately masked during the last 4 weeks of the project was significantly higher than those appropriately masked during the first 4 weeks of the project. (94/115 vs. 113/120; p-value = 0.004). In the second 4 weeks of the improvement project, only 8 ED employees had an unprotected exposure to a patient with laboratory confirmed influenza, compared to 46 ED employees in the first 4 weeks.  

Conclusions:

Improved awareness among ED staff and improved availability of masks to patients at registration resulted in improvement of the proportion of patients appropriately masked upon arrival in ED and decreased unprotected exposures to influenza among ED staff. Several lessons for quality improvement in the organization were learnt during the project.