What is the protocol for bed bug decontamination in the Emergency Room (ER)?

Bed Bug Decontamination Protocol in the Emergency Department

For bed bug-infested patients in the ER, immediately remove and bag all patient clothing in sealed plastic bags, launder items at ≥60°C (140°F) or tumble dry on hot cycle (>40°C) for at least 30 minutes, clean environmental surfaces with EPA-registered hospital disinfectants, and place the patient in contact precautions to prevent transmission to other patients and healthcare workers.

Immediate Patient Management

Clothing and Personal Items

• Remove all patient clothing, shoes, and personal fabric items immediately upon identification of bed bugs 1
• Seal all removed items in plastic bags at the point of care to prevent escape and environmental contamination 2
• Do not allow infested items to contact other surfaces or be transported through the facility unsealed 1

Isolation Precautions

• Place the patient in contact precautions immediately, as only 21% of bed bug-infested patients are appropriately isolated despite the transmission risk 1
• Provide the patient with hospital gowns and clean linens 3
• Use disposable patient-care items (blood pressure cuffs, thermometers) wherever possible to minimize cross-contamination 3

Laundry Decontamination Protocol

Hot Water Washing (Preferred Method)

• Wash all infested items at ≥60°C (140°F) with detergent, which kills all life stages including eggs 2
• This temperature is effective against adult bed bugs, nymphs, and eggs in a single wash cycle 2
• If hot water washing is unavailable, use warm water (36-38°C) with detergent, though this removes only 60-83% of live mites and requires repeated washing 4

Tumble Drying (Alternative or Adjunct)

• Tumble dry on hot cycle (>40°C) for at least 30 minutes as an effective standalone treatment or after washing 2
• This method is particularly useful for items that cannot tolerate hot water washing 2
• Ensure the dryer reaches and maintains >40°C throughout the cycle 2

Special Considerations for Delicate Items

• For items that cannot tolerate heat, freeze at -17°C for at least 2 hours, though note that 2.5 kg of dry laundry takes approximately 8 hours to reach this temperature 2
• Dry cleaning with perchloroethylene is effective against all life stages 2
• Avoid cold water soaking alone, as it kills active stages but has no effect on eggs 2

Environmental Decontamination

Surface Cleaning

• Clean and disinfect all surfaces the patient contacted using EPA-registered hospital disinfectants following manufacturer's instructions 3
• Pay particular attention to high-touch surfaces including bed rails, chairs, stretchers, doorknobs, and any equipment used 3
• Use either low- or intermediate-level disinfection as appropriate for the surface 3

Mattress and Stretcher Management

• Clean and disinfect moisture-resistant mattress covers between patient use with EPA-registered products 3
• If fabric covers are used, remove and launder in hot water cycle 3
• Inspect mattress covers for tears or holes; replace if integrity is compromised 3
• Keep mattresses dry and discard if they remain wet or stained 3

Equipment Decontamination

• Clean all medical equipment that contacted the patient with EPA-registered disinfectants 3
• Use disposable equipment whenever possible to avoid cross-contamination 3
• For reusable equipment, follow standard cleaning and disinfection protocols with particular attention to crevices where bed bugs may hide 3

Staff Protection and Precautions

Personal Protective Equipment

• Healthcare workers should wear gloves and gowns when handling infested patients or their belongings 3
• Practice hand hygiene immediately after glove removal 3
• Wash hands with soap and water if visibly contaminated 3

Critical Pitfall to Avoid

• Do not use insecticides in the ER setting, as 111 illnesses (including one fatality) were reported from bed bug-related insecticide use, with 81% involving pyrethroids or pyrethrins 5
• Insecticide application should only be performed by trained pest control professionals in appropriate settings, not in acute care environments 5
• Excessive insecticide application and inadequate notification were common factors contributing to illness 5

Documentation and Follow-Up

Patient Communication

• Inform the patient about the decontamination process without stigmatization, as 25% of bed bug-infested patients worry about receiving worse healthcare 1
• Provide education about effective bed bug management and the importance of professional pest control consultation 6, 5
• Advise against self-treatment with insecticides due to toxicity risks 5

Facility Notification

• Alert environmental services and infection control staff immediately 3
• Document the infestation and decontamination measures taken 1
• Monitor the treatment area for any signs of bed bug presence in subsequent days 6

Key Clinical Context

Bed bug infestations are increasingly common in ED patients, with 2% reporting current infestations and 37% reporting previous exposure 1. However, only 18% of infested patients report their infestation to providers 1. Infested patients are typically older (mean age 52 vs 41 years) and more likely to arrive by ambulance (57% vs 14%) 1. The resurgence of bed bugs globally, particularly in developed countries, makes this a relevant concern for emergency departments 6.