Hand hygiene in the emergency department

ICHE has an interesting paper up on hand hygiene (HH) in the Brigham and Women’s emergency department. As part of a QI program, the ED deployed 5 trained observers and an infection preventionist to performing HH audits for 16 months. Impressively, they covered all days of the week, and all shifts (much of our data on HH comes from weekday first-shift observations, which may differ from what one might find on weekends or at night). The overall adherence was good, at ~90% (the observers were known to the ED personnel, but this is still an excellent rate of HH). The most notable findings included (a) physicians had slightly higher adherence than nurses, which runs counter to the conventional wisdom, (b) transport personnel had the lowest adherence (<70%), and (c) hallway location (which by definition translates to an overcrowded ED) was associated with lower adherence (82%, compared with 91% in a private room).

Because I’m always on the lookout for more reasons to despise contact precautions, I immediately seized on this last finding. As Mike and his colleagues pointed out in a study published in March of this year, difficulty in finding beds for patients requiring contact precautions is one factor that exacerbates ED overcrowding. At Mike’s hospital, patients who required contact precautions waited in the ED for an hour longer than those who did not. Active detection and isolation programs make this problem even worse, as pointed out in this Irish study—patients colonized or infected with MRSA waited 2.5 hours longer in the ED than did those who were not identified as being at high-risk for MRSA.

In other words, not only does ED overcrowding lead to poorer HH and increased risk of pathogen transmission, but the patient population in many EDs may be “enriched” with MDRO carriers (who stay in EDs longer while awaiting a bed)!