What are the guidelines for managing infectious patients in the ER (Emergency Room)/OPD (Outpatient Department) setting?

Policy Guidelines for Triage and Management of Infectious Patients in ER/OPD Settings

Immediate Triage and Screening Protocol

All patients presenting to the ER/OPD with fever, respiratory symptoms, or epidemiological risk factors for infectious disease must undergo immediate binary triage screening to separate potentially infectious patients from other patients before entering common waiting areas. 1, 2

Primary Triage Steps

• Establish a dedicated single isolation room with direct external access separate from the main waiting area for initial assessment of suspected infectious patients 1
• Screen all arriving patients at the entrance for fever (temperature >38°C), respiratory symptoms (cough, shortness of breath, sore throat), and recent travel or exposure history 1
• Place a surgical mask on any patient with respiratory symptoms immediately upon identification, regardless of suspected diagnosis 1
• Direct suspected infectious patients through a dedicated route that minimizes contact with other patients and unprotected healthcare workers 1
• Post visible signage in waiting areas promoting respiratory hygiene and cough etiquette 1

Risk Stratification Categories

Classify patients into four exposure risk categories to guide isolation and PPE requirements 2:

• No identifiable risk: No fever, respiratory symptoms, or epidemiological risk factors
• Low risk: Mild symptoms without significant exposure history
• Medium risk: Respiratory symptoms with fever or significant exposure history
• High risk: Severe respiratory distress, confirmed exposure to highly infectious disease, or clinical presentation consistent with airborne pathogen

Personal Protective Equipment Requirements

Healthcare workers must wear appropriate PPE based on the suspected mode of transmission before any contact with potentially infectious patients. 1, 3

Standard Precautions (All Patient Encounters)

• Perform hand hygiene with alcohol-based hand rub before and after all patient contacts 1, 4
• Use soap and water when hands are visibly soiled with body fluids 4
• Wear gloves for any contact with blood, body fluids, or contaminated surfaces 1

Droplet Precautions (Respiratory Infections)

• Surgical mask for healthcare workers when within 1-2 meters of the patient 1
• Eye protection (face shield or goggles) 1, 3
• Gown and gloves 1, 3
• Keep examination room door closed 1

Airborne Precautions (Tuberculosis, Measles, Varicella, COVID-19 with Aerosol-Generating Procedures)

• N95 respirator (or FFP2/P100 equivalent) that has been fit-tested for the individual healthcare worker 1, 3
• Eye protection (face shield or goggles) 3
• Gown and gloves 1
• Powered air-purifying respirator (PAPR) for healthcare workers who failed fit-testing or when N95 supplies are limited 3

Contact Precautions (Multidrug-Resistant Organisms)

• Gloves and gowns before entering the patient room 1, 5
• Remove PPE promptly after care and perform hand hygiene immediately 1, 5
• Dedicate non-critical equipment (stethoscopes, blood pressure cuffs) to individual patients 5, 4

Examination Room and Infrastructure Requirements

Each examination room must have a sink with hands-free faucet operation, alcohol-based hand rub dispensers, and adequate air exchange capacity. 1

Essential Room Features

• Install sinks with hands-free faucets and adjacent soap dispensers in every examination room 1
• Provide both alcohol-based hand rub and liquid soap in pump dispensers 1
• Avoid faucet aerators as they become contaminated with waterborne organisms 1
• Cover examination tables with disposable paper changed between each patient 1
• Maintain high air exchange rates (≥25 cycles/hour) to reduce viral load 1
• Use negative pressure rooms for airborne precautions when available 1, 3

Dedicated Isolation Areas

• Designate at least one single room with direct external access for ruling out highly infectious diseases 1
• Keep all doors closed when infectious patients are present 1
• Minimize equipment in isolation rooms to only what is strictly necessary 1
• Use disposable materials preferentially over reusable items 1

Diagnostic Testing and Screening Protocol

Perform rapid diagnostic testing at the point of triage to guide isolation decisions and prevent nosocomial transmission. 1, 6

COVID-19 and Respiratory Pathogen Screening

• Obtain RT-PCR nasopharyngeal swab for all patients with fever and respiratory symptoms before hospital admission 1
• Perform baseline chest imaging (CT scan preferred, chest X-ray or lung ultrasound if CT unavailable) for suspected COVID-19 patients 1
• Use point-of-care PCR testing when available to rapidly identify influenza and RSV within the triage setting 6
• Treat patients as infectious and implement full precautions if diagnostic results are unavailable and clinical suspicion is high 1

Multidrug-Resistant Organism Screening

• Screen patients with epidemiological risk factors (ICU admission, prolonged antibiotic therapy, recent hospitalization) for ESBL-producing Enterobacteriaceae and carbapenem-resistant organisms using rectal or perirectal swabs 1, 5
• Implement alert codes in the electronic medical record to identify patients with previous positive cultures 1, 5
• Apply pre-emptive contact precautions for patients transferred from ICUs or wards with known outbreaks 1, 5

Tuberculosis Screening

• Obtain chest radiography separately from other patients for any patient with pneumonia 1
• Perform systematic sputum examination for acid-fast bacteria when pneumonia is diagnosed 1
• Maintain airborne isolation until tuberculosis is definitively ruled out 1

Patient Placement and Cohorting

Isolate confirmed or suspected infectious patients in single rooms with dedicated bathrooms to prevent transmission. 1, 5

Isolation Room Assignment

• Place all patients with confirmed or suspected highly infectious diseases in single rooms immediately 1
• Assign patients with multidrug-resistant organisms to single rooms whenever possible 1, 5
• Keep isolation room doors closed at all times 1
• Limit the number of healthcare workers entering isolation rooms to only those directly involved in patient care 1

Cohorting When Single Rooms Unavailable

• Cohort patients infected with the same multidrug-resistant organism strain in designated areas 1, 5
• Consider cohorting dedicated staff to care for cohorted patients to reduce transmission risk 1
• Avoid placing virus-positive patients in rooms shared with non-respiratory illness patients 6

Patient Movement Restrictions

• Minimize patient transfers through the hospital 1
• Plan transfer routes to be as short as possible and clean/disinfect routes frequently 1
• Ensure patients wear surgical masks during any necessary transport 1
• Communicate infectious disease status when transferring patients to other healthcare facilities 1

Environmental Cleaning and Disinfection

Implement rigorous environmental cleaning protocols with appropriate disinfectants and monitor compliance through regular audits. 1, 4

Surface Decontamination

• Clean contaminated surfaces with detergent followed by 1:100 dilution of household bleach (contact time ≥1 minute) or EPA-approved disinfectant effective against tuberculosis and hepatitis B 1
• Use 1:10 bleach dilution or full-strength solution for blood spills if surface is not pre-cleaned 1
• Clean examination rooms between each patient, with more thorough cleaning if visible contamination present 1
• Disinfect all surfaces and electromedical devices after each procedure involving infectious patients 1

High-Touch Surface Protocol

• Clean rest rooms daily and whenever visibly soiled 1
• Disinfect frequently touched surfaces (door handles, light switches, bedrails) multiple times per shift 1
• Perform environmental sampling of surfaces during outbreaks to identify contamination 1, 5
• Consider unit closure for intensive cleaning during uncontrolled outbreaks 1

Equipment Management

• Dedicate non-critical equipment to individual infectious patients 1, 5, 4
• Disinfect shared equipment thoroughly between patient uses according to manufacturer specifications 5
• Remove unnecessary equipment from isolation rooms before patient arrival 1
• Disinfect personal items (stethoscopes, phones, ID badges, laptops) frequently 1

Healthcare Worker Protection and Training

Conduct mandatory educational programs for all staff on infection control principles, proper PPE use, and hand hygiene techniques. 1, 4

Education and Training Requirements

• Train emergency department teams specifically on managing highly infectious diseases 1
• Ensure healthcare workers understand the epidemiological importance of infectious organisms and effective prevention measures 1, 4
• Provide training on proper donning and doffing procedures with supervised practice 1
• Conduct regular multidisciplinary meetings to review adherence audits and provide feedback 1, 4

Hand Hygiene Compliance

• Monitor hand hygiene compliance and provide individual feedback to healthcare workers 4
• Prohibit artificial nails among all healthcare workers 4
• Ensure alcohol-based hand rub is available at every point of care 1
• Emphasize hand hygiene before and after glove use, as gloves do not replace hand hygiene 1, 4

Exposure Documentation

• Maintain a record of all healthcare workers involved in procedures on potentially infected patients 1
• Screen healthcare workers for colonization if epidemiologically linked to a cluster of cases 1
• Implement surveillance for healthcare worker infections during outbreaks 4

Administrative and Operational Measures

Establish administrative support with dedicated resources for infection prevention and control infrastructure. 4

Antimicrobial Stewardship

• Implement antimicrobial stewardship programs to restrict inappropriate antibiotic use and reduce selection pressure for resistant organisms 1, 4
• Review antibiotic prescribing patterns regularly and provide feedback to prescribers 1
• Limit use of specific antimicrobial agents based on local resistance patterns 5

Surveillance Systems

• Establish active surveillance for multidrug-resistant organisms in high-risk units (ICUs, units with high antibiotic use) 5
• Conduct point prevalence surveys when hospital-associated cases are identified 5
• Monitor for airborne infections during construction or renovation activities 4
• Review microbiology records for the preceding 6-12 months to identify unrecognized cases during outbreaks 5

Resource Allocation

• Provide adequate economic and human resources for infection prevention programs 4
• Include environmental services personnel in infection control infrastructure 4
• Maintain adequate supplies of PPE, hand hygiene products, and disinfectants 1
• Prepare pre-stocked supply carts with minimal but adequate materials for infectious patient care 1

Common Pitfalls and Critical Considerations

• Do not rely solely on symptomatic screening: Less than 50% of COVID-19 patients present with typical respiratory symptoms, making symptom-based screening insufficient 7
• Avoid delays in isolation: Place patients in isolation immediately upon suspicion rather than waiting for confirmatory testing 1
• Do not underestimate airborne transmission: Upgrade droplet precautions to airborne precautions whenever highly infectious disease is suspected, as transmission modes are often underestimated 1
• Prevent self-contamination: Healthcare workers must pay special attention to avoiding self-contamination during PPE removal, which is a high-risk moment for transmission 1
• Monitor for psychological effects: Isolation can cause clinical complications due to reduced contact with healthcare workers and decreased quality of life 1
• Ensure communication during transfers: Failure to communicate infectious disease status during patient transfers is a common breach of infection control 5
• Maintain adequate air exchange time: After aerosol-generating procedures, maintain airborne precautions for the appropriate duration based on room air exchange rates (99% of airborne contaminants removed in 18 minutes with high exchange rates) 3