In fact, because of their unique environment, EDs may often be accepted as anomalies to the general hospital culture. (See, for example, Azita G. Hamedani and Robert L. Wears' "Anyone, Anything, Anytime … All the Time," Annals of Emergency Medicine, June 2009.)

As such, EDs can be left behind in standard HAI prevention. Many EDs are complicit in this omission. Yet a select few EDs are deviating from the norm and making a meaningful contribution to HAI prevention. There may be much to learn from these positive examples.

A challenging setting

Australian researcher Marie Heartfield’s work notes that the ED differs substantially from other segments in hospitals. The physical environment of most EDs puts patients in close proximity, often with minimal separation. The high volume of visits and space constraints can lead to crowding and insufficient staffing to meet demands. The patient mix is more diverse than in other parts of the hospital and includes a range of ages, levels of acuity and presenting problems.

The ED is also known for performing numerous invasive procedures associated with HAIs. In addition, studies report that the largest proportion of preventable injuries in the hospital occur in the ED. 

Despite its differences, the ED is integral to both hospitals and communities. Recent ED visit data from the National Hospital Ambulatory Medical Care Survey reveal that the number of annual ED visits has increased by more than 40 percent in the last two decades. The ED contributes to half of nonobstetric inpatient admissions, and the increases in hospital admissions overall are largely attributable to ED admissions. The ED is part of the national safety net ensuring that medically underserved people receive essential care and is a de facto primary care site during evenings and weekends. It is also the front-line public health responder to medical disasters. 

The ED conundrum

This amalgam of ED attributes can present a conundrum for hospital executives considering strategies to address systemic HAI reduction. In light of the ED’s potential contribution to both HAI transmission and inpatient admission, can many EDs continue to be exempt from HAI prevention efforts? If not, how can EDs participate in those efforts without compromising their central operating tenets? When their unique environmental and occupational challenges are considered, can EDs comply with conventional prevention approaches?

Fourteen EDs studied in the United States from 2011 to 2013 by a research team at Brigham and Women’s Hospital in Boston are positive deviants among their peers in that they have deliberately chosen to address HAI reduction and prevention despite contextual challenges. In addition, they have sustained these efforts over time. These sites may hold the secrets to helping hospital executives adopt guidelines, approaches and resources to fit the ED’s distinct characteristics. They may also speak to HAI prevention approaches in high-volume service areas.

This study revealed that it is important to understand what motivates ED leaders to adopt and successfully implement comprehensive HAI prevention. Factors include: 

  • Ensuring regular collection and transparent dissemination of data on ED infection rates and associated morbidity, mortality and length of stay. 
  • Enlisting support of ED managers as HAI-prevention champions.
  • Engaging front-line ED staff in program development, implementation and sustainability.
  • Recognizing physical-space challenges and making modifications to the built environment as needed.
  • Highlighting patient safety and improving care as departmental goals.
  • Dedicating financial and human resources to training and monitoring. 
  • Acknowledging the ED culture, appealing to different sensibilities and adapting strategies to meet needs.

Because EDs have responsibility for the broadest array of hospital patients and conditions, and because they serve as an admission portal, ED leaders and staff must be included in hospitalwide quality improvement efforts. 

Leslie A. Mandel, Ph.D., M.A., M.S.M., is an associate professor of health administration and public health in the School of Health Sciences at Regis College in Weston, Mass. The following also contributed to this study: Corine Sinnette, M.A., M.P.H., research project manager in the Division of Rheumatology, Immunology and Allergy at Brigham & Women’s Hospital in Boston; Eileen J. Carter, Ph.D., R.N., associate research scientist at Columbia University School of Nursing in New York City and a nurse researcher at New York-Presbyterian Hospital; and Jeremiah Schuur, M.D., M.H.S., vice chair of quality and safety and chief in the Division of Health Policy Translation, Department of Emergency Medicine at Brigham & Women’s Hospital, and assistant professor of emergency medicine at Harvard Medical School in Boston.