Tasty Morsels of EM 098 – #FRCEM Infection Control

31 Jul

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

One of the least sexy topics in EM…

Mainly from the OHEM and LITFL wonderful article on hand washing

What are the 5 moments of hand hygiene?

  • 5 Moments of hand hygiene
    • before touching a patient
    • before a procedure
    • after a procedure or body substance exposure risk
    • after touching a patient
    • after touching a patient’s surroundings
  • use alcohol for most things
    • use soap and water when visibly contaminated
    • norovirus or C.diff

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What are Standard/Universal Precautions?

  • hand hygiene
  • PPE
    • gloves with fluids or non intact skin
    • apron if chance of splash to clothes
    • mask, face shield, eye protection if chance of fluid splash to mouth or eyes
    • Facemasks
      • note the american system is where the N95 etc came from.
      • European regulations define “filtering face pieces” or FFP masks
      • the NHS has a useful guidance leaflet on when to use surgical mask via FFP3 mask in respiratory viruses
      • surgical mask (and gown and gloves)
        • for close patient contact in something like ordinary flu
      • FFP3 (needs appropriate fit testing)
        • potentially aerosol generating procedures
        • where a patient is known/suspected to have an infection spread via the aerosol route
      • order for PPE removal is gloves, apron or gown, eye protection, mask

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How are some common infections spread?

  • this actually a remarkably tricky question to find a clear answer to. My usual source from sheer laziness (wikipedia) says that flu is both airborne and droplet so I got a bit confused and read through the 209 page CDC Guidance. Beginning page 91 is a great table listing all the infections and the recommended contact precautions
  • Firstly what are the modes. From the RCH
    • Contact
      • direct – touching
      • indirect – bug on a surface near by
      • droplet – bug in some secretion that is aerosolised and might hit you with a sneeze
    • Airborne
      • spread by remaining in the air even after the droplet has dried up

Selected examples of when to use which measure:

  • Standard precautions
    • Anthrax
    • gastro (norovirus)
  • Contact
    • bronchiolitis
    • gastro (rotavirus)
  • Droplet
    • pandemic influenza
    • meningitis
    • mumps
    • B19
    • ebola (though it gets its own special set of precautions)
  • Airborne
    • Varicella (though with shingles you can be a bit more relaxed if they’re covered)
    • Measles
    • SARS
    • TB

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Describe some contemporary potential epidemic threats for the UK and infection control procedures

Ebola

  • Public Health England have a whole bunch of resources
  • RCEM have their own
  • some nuggetts
    • a filovirus (not filo…)
    • 2-21 days incubation
    • not a very robust virus and easily killed with alcolol or soap and water
    • transmitted by direct contact with body fluids not aerosol
    • not infectious until symptomatic
    • big danger for staff is in removal of PPE
  • two screening questions
    • affected area or cared for an ebola case within 21 days
    • fever (>37.5) or history of fever in 24 hrs
  • PPE
    • double gloves with extra-long cuffs
    • fluid repellent single use coveralls
    • ankle-length endoscopy apron
    • surgical cap
    • full face shield (visor)
    • close fitting fluid repellent mask (they don’t say which but presumably not an FFP3)
    • wellingtons

MERS CoV or Avian Influenza

  • again PHE are all over MERS CoV and Avian Flu
  • St Emlyns have covered it
  • The big difference in terms of infection control is that both are aerosol spread so that means breaking out the FFP3 masks for all contact (not just aerosol generating)
  • this is where the negative pressure isolation room is needed but it’s rarely available
  • and probably a good idea to ask the patient to wear a surgical mask when they present at registration until in their room
  • I’ve seen a few sources suggesting to keep the oxygen flow <6L/min as hopefully that means less aerosolising of the infection

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