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Infection Prevention in the Emergency Department

      Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.
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      References

      1. Centers for Disease Control and Prevention/National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey: 2010 Emergency department summary tables. Available at: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed February 15, 2014.

        • Niska R.
        • Bhuiya F.
        • Xu J.
        National Ambulatory Medical Care Survey: 2007 Emergency Department Summary.
        National Center for Health Statistics, Hyattsville, MD2010
        • Boyce J.M.
        • Pittet D.
        Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
        MMWR Recomm Rep. 2002; 51: 1-45
        • Pittet D.
        • Allegranzi B.
        • Sax H.
        • et al.
        Evidence-based model for hand transmission during patient care and the role of improved practices.
        Lancet Infect Dis. 2006; 6: 641-652
        • Voss A.
        • Widmer A.F.
        No time for handwashing? handwashing versus alcoholic rub: can we afford 100% compliance?.
        Infect Control Hosp Epidemiol. 1997; 18: 205-208
        • Reardon J.M.
        • Valenzuela J.E.
        • Parmar S.
        • et al.
        The time burden of alcohol-based hand cleanser when using nonsterile gloves.
        Infect Control Hosp Epidemiol. 2013; 34: 96-98
        • Pittet D.
        • Hugonnet S.
        • Harbarth S.
        • et al.
        Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
        Lancet. 2000; 356: 1307-1312
        • Gordin F.M.
        • Schultz M.E.
        • Huber R.A.
        • et al.
        Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub.
        Infect Control Hosp Epidemiol. 2005; 26: 650-653
      2. Clean Care is Safer Care Team. WHO Guidelines on Hand Hygiene in Health Care. World Health Organization, Geneva, Switzerland2009
        • Erasmus V.
        • Daha T.J.
        • Brug H.
        • et al.
        Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
        Infect Control Hosp Epidemiol. 2010; 31: 283-294
        • Rumgay S.
        • Macdonald S.
        • Robertson C.E.
        Hand-washing patterns and infection control in the accident and emergency department.
        Arch Emerg Med. 1984; 1: 157-159
        • Roane C.M.
        Registered nurses' use of universal barrier precautions in the pediatric emergency room.
        Pediatr Nurs. 1993; 19: 453-455
        • Meengs M.R.
        • Giles B.K.
        • Chisholm C.D.
        • et al.
        Hand washing frequency in an emergency department.
        Ann Emerg Med. 1994; 23: 1307-1312
        • Dorsey S.T.
        • Cydulka R.K.
        • Emerman C.L.
        Is handwashing teachable? failure to improve handwashing behavior in an urban emergency department.
        Acad Emerg Med. 1996; 3: 360-365
        • Pittet D.
        • Simon A.
        • Hugonnet S.
        • et al.
        Hand hygiene among physicians: performance, beliefs, and perceptions.
        Ann Intern Med. 2004; 141: 1-8
        • Al-Damouk M.
        • Pudney E.
        • Bleetman A.
        Hand hygiene and aseptic technique in the emergency department.
        J Hosp Infect. 2004; 56: 137-141
        • Saint S.
        • Bartoloni A.
        • Virgili G.
        • et al.
        Marked variability in adherence to hand hygiene: a 5-unit observational study in Tuscany.
        Am J Infect Control. 2009; 37: 306-310
        • Venkatesh A.K.
        • Pallin D.J.
        • Kayden S.
        • et al.
        Predictors of hand hygiene in the emergency department.
        Infect Control Hosp Epidemiol. 2011; 32: 1120-1123
        • Sánchez-Payá J.
        • Hernández-García I.
        • Camargo Ángeles R.
        • et al.
        Hand hygiene in the emergency department: degree of compliance, predictors and change over time.
        Emergencias. 2012; 24: 107-112
        • Larson E.L.
        • Albrecht S.
        • O'Keefe M.
        Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems.
        Am J Crit Care. 2005; 14: 304-311
        • Haas J.P.
        • Larson E.L.
        Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department.
        Acad Emerg Med. 2008; 15: 393-396
        • Scheithauer S.
        • Kamerseder V.
        • Petersen P.
        • et al.
        Improving hand hygiene compliance in the emergency department: getting to the point.
        BMC Infect Dis. 2013; https://doi.org/10.1186/1471-2334-13-367
        • Saint S.
        • Conti A.
        • Bartoloni A.
        • et al.
        Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany.
        Qual Saf Health Care. 2009; 18: 429-433
        • di Martino P.
        • Ban K.M.
        • Bartoloni A.
        • et al.
        Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation.
        Am J Infect Control. 2011; 39: 14-18
      3. Schuur JD, Kayden S, Goralnik E. Ongoing monitoring, prompt feedback, and reminders improve hand hygiene in a busy, urban emergency department. Agency for Healthcare Research and Quality Healthcare Innovations Exchange; 2011 [2/15/2014]. Available at: http://www.innovations.ahrq.gov/content.aspx?id=3071. Accessed February 15, 2014.

        • Gould D.J.
        • Moralejo D.
        • Drey N.
        • et al.
        Interventions to improve hand hygiene compliance in patient care.
        Cochrane Database Syst Rev. 2010; : CD005186
        • Schweizer M.L.
        • Reisinger H.S.
        • Ohl M.
        • et al.
        Searching for an optimal hand hygiene bundle: a meta-analysis.
        Clin Infect Dis. 2014; 58: 248-259
        • Jagger J.
        • Powers R.D.
        • Day J.S.
        • et al.
        Epidemiology and prevention of blood and body fluid exposures among emergency department staff.
        J Emerg Med. 1994; 12: 753-765
        • Denis M.A.
        • Ecochard R.
        • Bernadet A.
        • et al.
        Risk of occupational blood exposure in a cohort of 24,000 hospital healthcare workers: position and environment analysis over three years.
        J Occup Environ Med. 2003; 45: 283-288
        • Kelen G.D.
        • Hansen K.N.
        • Green G.B.
        • et al.
        Determinants of emergency department procedure- and condition-specific universal (barrier) precaution requirements for optimal provider protection.
        Ann Emerg Med. 1995; 25: 743-750
        • Centers for Disease Control and Prevention
        Recommendations for preventing transmission of infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus in the workplace.
        MMWR Morb Mortal Wkly Rep. 1985; 34 (691-695): 681-686
        • Centers for Disease Control and Prevention
        Recommendations for prevention of HIV transmission in health-care settings.
        MMWR Morb Mortal Wkly Rep. 1987; 36: 1S-18S
        • Centers for Disease Control and Prevention
        Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers.
        MMWR Morb Mortal Wkly Rep. 1989; 38: 1-37
        • Garner J.S.
        • Hospital Infection Control Practices Advisory Committee
        Guideline for isolation precautions in hospitals.
        Infect Control Hosp Epidemiol. 1996; 17: 53-80
      4. Occupational exposure to bloodborne pathogens-OSHA. Final rule.
        Fed Reg. 1991; 56: 64004-64182
        • Baraff L.J.
        • Talan D.A.
        Compliance with universal precautions in a university hospital emergency department.
        Ann Emerg Med. 1989; 18: 654-657
        • Kelen G.D.
        • DiGiovanna T.A.
        • Celentano D.D.
        • et al.
        Adherence to universal barrier precautions during interventions on critically ill and injured emergency department patients.
        J Acquir Immune Defic Syndr. 1990; 3: 987-994
        • DiGiacomo J.C.
        • Hoff W.S.
        • Rotondo M.F.
        • et al.
        Barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review.
        Am J Emerg Med. 1997; 15: 34-39
        • Evanoff B.
        • Kim L.
        • Mutha S.
        • et al.
        Compliance with universal precautions among emergency department personnel caring for trauma patients.
        Ann Emerg Med. 1999; 33: 160-165
        • Madan A.K.
        • Rentz D.E.
        • Wahle M.J.
        • et al.
        Noncompliance of health care workers with universal precautions during trauma resuscitations.
        South Med J. 2001; 94: 277-280
        • Chiang W.C.
        • Wang H.C.
        • Chen S.Y.
        • et al.
        Lack of compliance with basic infection control measures during cardiopulmonary resuscitation: are we ready for another epidemic?.
        Resuscitation. 2008; 77: 356-362
        • Kelleher D.C.
        • Carter E.A.
        • Waterhouse L.J.
        • et al.
        Compliance with barrier precautions during paediatric trauma resuscitations.
        Resuscitation. 2013; 84: 314-318
        • Henry K.
        • Campbell S.
        • Collier P.
        • et al.
        Compliance with universal precautions and needle handling and disposal practices among emergency department staff at two community hospitals.
        Am J Infect Control. 1994; 22: 129-137
        • Hammond J.S.
        • Eckes J.M.
        • Gomez G.A.
        • et al.
        HIV, trauma, and infection control: universal precautions are universally ignored.
        J Trauma. 1990; 30: 555-558
        • Henry K.
        • Campbell S.
        • Maki M.
        A comparison of observed and self-reported compliance with universal precautions among emergency department personnel at a Minnesota public teaching hospital: implications for assessing infection control programs.
        Ann Emerg Med. 1992; 21: 940-946
        • Rydman R.J.
        • Tannebaum R.D.
        • Zalenski R.J.
        An evaluation of hospital emergency department (HED) adherence to universal precautions.
        J Med Syst. 1994; 18: 207-220
        • Williams C.O.
        • Campbell S.
        • Henry K.
        • et al.
        Variables influencing worker compliance with universal precautions in the emergency department.
        Am J Infect Control. 1994; 22: 138-148
        • Picheansathian W.
        Compliance with universal precautions by emergency room nurses at Maharaj Nakorn Chiang Mai Hospital.
        J Med Assoc Thai. 1995; 78: S118-122
        • Kim L.E.
        • Evanoff B.A.
        • Parks R.L.
        • et al.
        Compliance with universal precautions among emergency department personnel: implications for prevention programs.
        Am J Infect Control. 1999; 27: 453-455
        • Madan A.K.
        • Raafat A.
        • Hunt J.P.
        • et al.
        Barrier precautions in trauma: is knowledge enough?.
        J Trauma. 2002; 52: 540-543
        • Sundaram R.O.
        • Parkinson R.W.
        Universal precaution compliance by orthopaedic trauma team members in a major trauma resuscitation scenario.
        Ann R Coll Surg Engl. 2007; 89: 262-267
        • Ellison A.M.
        • Kotelchuck M.
        • Bauchner H.
        Standard precautions in the pediatric emergency department: knowledge, attitudes, and behaviors of pediatric and emergency medicine residents.
        Pediatr Emerg Care. 2007; 23: 877-880
        • Reid S.M.
        • Farion K.J.
        • Suh K.N.
        • et al.
        Use of personal protective equipment in Canadian pediatric emergency departments.
        CJEM. 2011; 13: 71-78
        • Talan D.A.
        • Baraff L.J.
        Effect of education on the use of universal precautions in a university hospital emergency department.
        Ann Emerg Med. 1990; 19: 1322-1326
        • Kelen G.D.
        • Green G.B.
        • Hexter D.A.
        • et al.
        Substantial improvement in compliance with universal precautions in an emergency department following institution of policy.
        Arch Intern Med. 1991; 151: 2051-2056
        • Friedland L.R.
        • Joffe M.
        • Wiley J.F.
        • et al.
        Effect of educational program on compliance with glove use in a pediatric emergency department.
        Am J Dis Child. 1992; 146: 1355-1358
        • Sahdev P.
        • Lacqua M.J.
        • Harrigan N.
        • et al.
        Barrier precautions in trauma resuscitations: multivaried analysis of factors affecting use.
        Ann Emerg Med. 1994; 23: 823-827
        • Brooks A.J.
        • Phipson M.
        • Potgieter A.
        • et al.
        Education of the trauma team: video evaluation of the compliance with universal barrier precautions in resuscitation.
        Eur J Surg. 1999; 165: 1125-1128
        • Snyder G.M.
        • Thom K.A.
        • Furuno J.P.
        • et al.
        Detection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of healthcare workers.
        Infect Control Hosp Epidemiol. 2008; 29: 583-589
        • Hayden M.K.
        • Blom D.W.
        • Lyle E.A.
        • et al.
        Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients' environment.
        Infect Control Hosp Epidemiol. 2008; 29: 149-154
        • Morgan D.J.
        • Liang S.Y.
        • Smith C.L.
        • et al.
        Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers.
        Infect Control Hosp Epidemiol. 2010; 31: 716-721
        • Siegel J.D.
        • Rhinehart E.
        • Jackson M.
        • et al.
        • Health Care Infection Control Practices Advisory Commitee
        2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings.
        Am J Infect Control. 2007; 35: S65-164
        • Haley C.E.
        • McDonald R.C.
        • Rossi L.
        • et al.
        Tuberculosis epidemic among hospital personnel.
        Infect Control Hosp Epidemiol. 1989; 10: 204-210
        • Sokolove P.E.
        • Mackey D.
        • Wiles J.
        • et al.
        Exposure of emergency department personnel to tuberculosis: PPD testing during an epidemic in the community.
        Ann Emerg Med. 1994; 24: 418-421
        • Escombe A.R.
        • Huaroto L.
        • Ticona E.
        • et al.
        Tuberculosis transmission risk and infection control in a hospital emergency department in Lima, Peru.
        Int J Tuberc Lung Dis. 2010; 14: 1120-1126
        • Farizo K.M.
        • Stehr-Green P.A.
        • Simpson D.M.
        • et al.
        Pediatric emergency room visits: a risk factor for acquiring measles.
        Pediatrics. 1991; 87: 74-79
        • Bowen A.C.
        • Ferson M.J.
        • Palasanthiran P.
        Consequences of an unrecognized measles exposure in an emergency department.
        Emerg Med Australas. 2009; 21: 491-496
        • Varia M.
        • Wilson S.
        • Sarwal S.
        • et al.
        Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada.
        CMAJ. 2003; 169: 285-292
        • Chen Y.C.
        • Huang L.M.
        • Chan C.C.
        • et al.
        SARS in hospital emergency room.
        Emerg Infect Dis. 2004; 10: 782-788
        • Chang W.T.
        • Kao C.L.
        • Chung M.Y.
        • et al.
        SARS exposure and emergency department workers.
        Emerg Infect Dis. 2004; 10: 1117-1119
        • Moran G.J.
        • McCabe F.
        • Morgan M.T.
        • et al.
        Delayed recognition and infection control for tuberculosis patients in the emergency department.
        Ann Emerg Med. 1995; 26: 290-295
        • Solari L.
        • Acuna-Villaorduna C.
        • Soto A.
        • et al.
        A clinical prediction rule for pulmonary tuberculosis in emergency departments.
        Int J Tuberc Lung Dis. 2008; 12: 619-624
        • Moran G.J.
        • Barrett T.W.
        • Mower W.R.
        • et al.
        Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments.
        Ann Emerg Med. 2009; 53: 625-632
        • Asimos A.W.
        • Kaufman J.S.
        • Lee C.H.
        • et al.
        Tuberculosis exposure risk in emergency medicine residents.
        Acad Emerg Med. 1999; 6: 1044-1049
        • Lau J.T.
        • Fung K.S.
        • Wong T.W.
        • et al.
        SARS transmission among hospital workers in Hong Kong.
        Emerg Infect Dis. 2004; 10: 280-286
        • Seto W.H.
        • Tsang D.
        • Yung R.W.
        • et al.
        Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS).
        Lancet. 2003; 361: 1519-1520
        • Behrman A.J.
        • Shofer F.S.
        Tuberculosis exposure and control in an urban emergency department.
        Ann Emerg Med. 1998; 31: 370-375
        • Fusco F.M.
        • Schilling S.
        • De Iaco G.
        • et al.
        Infection control management of patients with suspected highly infectious diseases in emergency departments: data from a survey in 41 facilities in 14 European countries.
        BMC Infect Dis. 2012; 12: 27
        • Santos C.D.
        • Bristow R.B.
        • Vorenkamp J.V.
        Which health care workers were most affected during the spring 2009 H1N1 pandemic?.
        Disaster Med Public Health Prep. 2010; 4: 47-54
        • Centers for Disease Control and Prevention
        Occupational transmission of Neisseria meningitidis—California, 2009.
        MMWR Morb Mortal Wkly Rep. 2010; 59: 1480-1483
        • Cruz A.T.
        • Patel B.
        • DiStefano M.C.
        • et al.
        Outside the box and into thick air: implementation of an exterior mobile pediatric emergency response team for North American H1N1 (swine) influenza virus in Houston, Texas.
        Ann Emerg Med. 2010; 55: 23-31
        • Turnberg W.
        • Daniell W.
        • Seixas N.
        • et al.
        Appraisal of recommended respiratory infection control practices in primary care and emergency department settings.
        Am J Infect Control. 2008; 36: 268-275
        • May L.
        • Lung D.
        • Harter K.
        An intervention to improve compliance with transmission precautions for influenza in the emergency department: successes and challenges.
        J Emerg Med. 2012; 42: 79-85
        • Moore D.
        • Gamage B.
        • Bryce E.
        • et al.
        Protecting health care workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines.
        Am J Infect Control. 2005; 33: 88-96
        • Rothman R.E.
        • Irvin C.B.
        • Moran G.J.
        • et al.
        Respiratory hygiene in the emergency department.
        Ann Emerg Med. 2006; 48: 570-582
        • Longtin Y.
        • Akakpo C.
        • Rutschmann O.T.
        • et al.
        Evaluation of patients' mask use after the implementation of cough etiquette in the emergency department.
        Infect Control Hosp Epidemiol. 2009; 30: 904-908
        • Lee D.C.
        • Barlas D.
        • Ryan J.G.
        • et al.
        Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci: prevalence and predictors of colonization in patients presenting to the emergency department from nursing homes.
        J Am Geriatr Soc. 2002; 50: 1463-1465
        • Schechter-Perkins E.M.
        • Mitchell P.M.
        • Murray K.A.
        • et al.
        Prevalence and predictors of nasal and extranasal staphylococcal colonization in patients presenting to the emergency department.
        Ann Emerg Med. 2011; 57: 492-499
        • Wakatake H.
        • Fujitani S.
        • Kodama T.
        • et al.
        Positive clinical risk factors predict a high rate of methicillin-resistant Staphylococcus aureus colonization in emergency department patients.
        Am J Infect Control. 2012; 40: 988-991
        • Lu S.Y.
        • Chang F.Y.
        • Cheng C.C.
        • et al.
        Methicillin-resistant Staphylococcus aureus nasal colonization among adult patients visiting emergency department in a medical center in Taiwan.
        PLoS One. 2011; 6: e18620
        • Ro Y.S.
        • Shin S.D.
        • Noh H.
        • et al.
        Prevalence of positive carriage of tuberculosis, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococci in patients transported by ambulance: a single center observational study.
        J Prev Med Public Health. 2012; 45: 174-180
        • Dantas S.R.
        • Moretti-Branchini M.L.
        Impact of antibiotic-resistant pathogens colonizing the respiratory secretions of patients in an extended-care area of the emergency department.
        Infect Control Hosp Epidemiol. 2003; 24: 351-355
        • Martirosian G.
        • Szczesny A.
        • Silva Jr., J.
        Clostridium difficile in emergency room.
        Anaerobe. 2005; 11: 258-261
        • Shin B.M.
        • Moon S.J.
        • Kim Y.S.
        • et al.
        Characterization of cases of Clostridium difficile infection (CDI) presenting at an emergency room: molecular and clinical features differentiate community-onset hospital-associated and community-associated CDI in a tertiary care hospital.
        J Clin Microbiol. 2011; 49: 2161-2165
        • Vardy J.
        • Love A.J.
        • Dignon N.
        Outbreak of acute gastroenteritis among emergency department staff.
        Emerg Med J. 2007; 24: 699-702
        • Pallin D.J.
        • Camargo Jr., C.A.
        • Yokoe D.S.
        • et al.
        Variability of contact precaution policies in US emergency departments.
        Infect Control Hosp Epidemiol. 2014; 35: 310-312
        • Kac G.
        • Grohs P.
        • Durieux P.
        • et al.
        Impact of electronic alerts on isolation precautions for patients with multidrug-resistant bacteria.
        Arch Intern Med. 2007; 167: 2086-2090
        • Kho A.N.
        • Dexter P.R.
        • Warvel J.S.
        • et al.
        An effective computerized reminder for contact isolation of patients colonized or infected with resistant organisms.
        Int J Med Inform. 2008; 77: 194-198
        • Eveillard M.
        • Leroy C.
        • Teissiere F.
        • et al.
        Impact of selective screening in the emergency department on methicillin-resistant Staphylococcus aureus control programmes.
        J Hosp Infect. 2006; 63: 380-384
        • Centers for Disease Control and Prevention
        Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP).
        MMWR Recomm Rep. 2011; 60: 1-45
        • Saluja I.
        • Theakston K.D.
        • Kaczorowski J.
        Influenza vaccination rate among emergency department personnel: a survey of four teaching hospitals.
        CJEM. 2005; 7: 17-21
        • Piccirillo B.
        • Gaeta T.
        Survey on use of and attitudes toward influenza vaccination among emergency department staff in a New York metropolitan hospital.
        Infect Control Hosp Epidemiol. 2006; 27: 618-622
        • Rueckmann E.
        • Shah M.N.
        • Humiston S.G.
        Influenza vaccination among emergency medical services and emergency department personnel.
        Prehosp Emerg Care. 2009; 13: 1-5
        • Centers for Disease Control and Prevention
        Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 1128-1132
        • Boyce J.M.
        • Potter-Bynoe G.
        • Chenevert C.
        • et al.
        Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications.
        Infect Control Hosp Epidemiol. 1997; 18: 622-627
        • Boyce J.M.
        • Havill N.L.
        • Otter J.A.
        • et al.
        Widespread environmental contamination associated with patients with diarrhea and methicillin-resistant Staphylococcus aureus colonization of the gastrointestinal tract.
        Infect Control Hosp Epidemiol. 2007; 28: 1142-1147
        • Morgan D.J.
        • Rogawski E.
        • Thom K.A.
        • et al.
        Transfer of multidrug-resistant bacteria to healthcare workers' gloves and gowns after patient contact increases with environmental contamination.
        Crit Care Med. 2012; 40: 1045-1051
        • Huang S.S.
        • Datta R.
        • Platt R.
        Risk of acquiring antibiotic-resistant bacteria from prior room occupants.
        Arch Intern Med. 2006; 166: 1945-1951
        • Drees M.
        • Snydman D.R.
        • Schmid C.H.
        • et al.
        Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci.
        Clin Infect Dis. 2008; 46: 678-685
      5. Rutala WA, Weber DJ. Guideline for disinfection and sterilization in healthcare facilities, 2008. [2/15/2014.] Available at: http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf. Accessed February 15, 2014.

        • Otter J.A.
        • Passaretti C.L.
        • French G.L.
        • et al.
        Low frequency of environmental contamination with methicillin-resistant Staphylococcus aureus in an inner city emergency department and a human immunodeficiency virus outpatient clinic.
        Am J Infect Control. 2011; 39: 151-153
        • Kei J.
        • Richards J.R.
        The prevalence of methicillin-resistant Staphylococcus aureus on inanimate objects in an urban emergency department.
        J Emerg Med. 2011; 41: 124-127
        • Pugliese A.
        • Garcia A.J.
        • Dobson W.
        • et al.
        The prevalence of bacterial contamination of standard keyboards in an urban ED.
        Am J Emerg Med. 2011; 29: 954-955
        • Jones J.S.
        • Hoerle D.
        • Riekse R.
        Stethoscopes: a potential vector of infection?.
        Ann Emerg Med. 1995; 26: 296-299
        • Nunez S.
        • Moreno A.
        • Green K.
        • et al.
        The stethoscope in the emergency department: a vector of infection?.
        Epidemiol Infect. 2000; 124: 233-237
        • Tang P.H.
        • Worster A.
        • Srigley J.A.
        • et al.
        Examination of Staphylococcal Stethoscope Contamination in the Emergency Department (pilot) study (EXSSCITED pilot study).
        CJEM. 2011; 13: 239-244
        • Klevens R.M.
        • Edwards J.R.
        • Richards Jr., C.L.
        • et al.
        Estimating health care–associated infections and deaths in US hospitals, 2002.
        Public Health Rep. 2007; 122: 160-166
        • Mermel L.A.
        Prevention of intravascular catheter-related infections.
        Ann Intern Med. 2000; 132: 391-402
        • Warren D.K.
        • Quadir W.W.
        • Hollenbeak C.S.
        • et al.
        Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital.
        Crit Care Med. 2006; 34: 2084-2089
        • Pittet D.
        • Tarara D.
        • Wenzel R.P.
        Nosocomial bloodstream infection in critically ill patients: excess length of stay, extra costs, and attributable mortality.
        JAMA. 1994; 271: 1598-1601
        • Digiovine B.
        • Chenoweth C.
        • Watts C.
        • et al.
        The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit.
        Am J Respir Crit Care Med. 1999; 160: 976-981
        • Blot S.I.
        • Depuydt P.
        • Annemans L.
        • et al.
        Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections.
        Clin Infect Dis. 2005; 41: 1591-1598
        • Garrouste-Orgeas M.
        • Timsit J.F.
        • et al.
        Excess risk of death from intensive care unit–acquired nosocomial bloodstream infections: a reappraisal.
        Clin Infect Dis. 2006; 42: 1118-1126
        • Steele R.
        • Irvin C.B.
        Central line mechanical complication rate in emergency medicine patients.
        Acad Emerg Med. 2001; 8: 204-207
        • Theodoro D.
        • Bausano B.
        • Lewis L.
        • et al.
        A descriptive comparison of ultrasound-guided central venous cannulation of the internal jugular vein to landmark-based subclavian vein cannulation.
        Acad Emerg Med. 2010; 17: 416-422
        • LeMaster C.
        • Agrawal A.
        • Hou P.
        • et al.
        Systematic review of emergency department central venous and arterial catheter infection.
        Int J Emerg Med. 2010; 3: 409-423
        • Nagashima G.
        • Kikuchi T.
        • Tsuyuzaki H.
        • et al.
        To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization?.
        J Infect Chemother. 2006; 12: 363-365
        • Trick W.E.
        • Miranda J.
        • Evans A.T.
        • et al.
        Prospective cohort study of central venous catheters among internal medicine ward patients.
        Am J Infect Control. 2006; 34: 636-641
        • Chiang V.W.
        • Baskin M.N.
        Uses and complications of central venous catheters inserted in a pediatric emergency department.
        Pediatr Emerg Care. 2000; 16: 230-232
        • Ferguson M.
        • Max M.H.
        • Marshall W.
        Emergency department infraclavicular subclavian vein catheterization in patients with multiple injuries and burns.
        South Med J. 1988; 81: 433-435
        • LeMaster C.H.
        • Schuur J.D.
        • Pandya D.
        • et al.
        Infection and natural history of emergency department–placed central venous catheters.
        Ann Emerg Med. 2010; 56: 492-497
        • Guzzo J.L.
        • Seagull F.J.
        • Bochicchio G.V.
        • et al.
        Mentors decrease compliance with best sterile practices during central venous catheter placement in the trauma resuscitation unit.
        Surg Infect (Larchmt). 2006; 7: 15-20
        • Xiao Y.
        • Seagull F.J.
        • Bochicchio G.V.
        • et al.
        Video-based training increases sterile-technique compliance during central venous catheter insertion.
        Crit Care Med. 2007; 35: 1302-1306
        • Barsuk J.H.
        • Cohen E.R.
        • Feinglass J.
        • et al.
        Use of simulation-based education to reduce catheter-related bloodstream infections.
        Arch Intern Med. 2009; 169: 1420-1423
        • Marschall J.
        • Mermel L.A.
        • Classen D.
        • et al.
        Strategies to prevent central line–associated bloodstream infections in acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: S22-30
        • O'Grady N.P.
        • Alexander M.
        • Burns L.A.
        • et al.
        Guidelines for the prevention of intravascular catheter-related infections.
        Clin Infect Dis. 2011; 52: e162-193
        • Centers for Disease Control and Prevention
        Reduction in central line–associated bloodstream infections among patients in intensive care units: Pennsylvania, April 2001–March 2005.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 1013-1016
        • Pronovost P.
        • Needham D.
        • Berenholtz S.
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        N Engl J Med. 2006; 355: 2725-2732
        • Lemaster C.H.
        • Hoffart N.
        • Chafe T.
        • et al.
        Implementing the central venous catheter infection prevention bundle in the emergency department: experiences among early adopters.
        Ann Emerg Med. 2014; 63: 340-350
        • Pujol M.
        • Hornero A.
        • Saballs M.
        • et al.
        Clinical epidemiology and outcomes of peripheral venous catheter-related bloodstream infections at a university-affiliated hospital.
        J Hosp Infect. 2007; 67: 22-29
        • Trinh T.T.
        • Chan P.A.
        • Edwards O.
        • et al.
        Peripheral venous catheter-related Staphylococcus aureus bacteremia.
        Infect Control Hosp Epidemiol. 2011; 32: 579-583
        • Fakih M.G.
        • Jones K.
        • Rey J.E.
        • et al.
        Peripheral venous catheter care in the emergency department: education and feedback lead to marked improvements.
        Am J Infect Control. 2013; 41: 531-536
        • Shokoohi H.
        • Boniface K.
        • McCarthy M.
        • et al.
        Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients.
        Ann Emerg Med. 2013; 61: 198-203
        • Adhikari S.
        • Blaivas M.
        • Morrison D.
        • et al.
        Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines.
        J Ultrasound Med. 2010; 29: 741-747
        • Umscheid C.A.
        • Mitchell M.D.
        • Doshi J.A.
        • et al.
        Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.
        Infect Control Hosp Epidemiol. 2011; 32: 101-114
        • Lo E.
        • Nicolle L.
        • Classen D.
        • et al.
        Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: S41-50
        • Gould C.V.
        • Umscheid C.A.
        • Agarwal R.K.
        • et al.
        Guideline for prevention of catheter-associated urinary tract infections 2009.
        Infect Control Hosp Epidemiol. 2010; 31: 319-326
        • Gardam M.A.
        • Amihod B.
        • Orenstein P.
        • et al.
        Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections.
        Clin Perform Qual Health Care. 1998; 6: 99-102
        • Bhatia N.
        • Daga M.K.
        • Garg S.
        • et al.
        Urinary catheterization in medical wards.
        J Glob Infect Dis. 2010; 2: 83-90
        • Gokula R.R.
        • Hickner J.A.
        • Smith M.A.
        Inappropriate use of urinary catheters in elderly patients at a Midwestern community teaching hospital.
        Am J Infect Control. 2004; 32: 196-199
        • Fakih M.G.
        • Shemes S.P.
        • Pena M.E.
        • et al.
        Urinary catheters in the emergency department: very elderly women are at high risk for unnecessary utilization.
        Am J Infect Control. 2010; 38: 683-688
        • Hazelett S.E.
        • Tsai M.
        • Gareri M.
        • et al.
        The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care.
        BMC Geriatr. 2006; 6: 15
        • Gokula R.M.
        • Smith M.A.
        • Hickner J.
        Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of Foley catheters.
        Am J Infect Control. 2007; 35: 589-593
        • Fakih M.G.
        • Pena M.E.
        • Shemes S.
        • et al.
        Effect of establishing guidelines on appropriate urinary catheter placement.
        Acad Emerg Med. 2010; 17: 337-340
        • Dyc N.G.
        • Pena M.E.
        • Shemes S.P.
        • et al.
        The effect of resident peer-to-peer education on compliance with urinary catheter placement indications in the emergency department.
        Postgrad Med J. 2011; 87: 814-818
        • Burnett K.P.
        • Erickson D.
        • Hunt A.
        • et al.
        Strategies to prevent urinary tract infection from urinary catheter insertion in the emergency department.
        J Emerg Nurs. 2010; 36: 546-550
        • Fakih M.G.
        • Rey J.E.
        • Pena M.E.
        • et al.
        Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity.
        Am J Infect Control. 2013; 41: 236-239
        • Fakih M.G.
        • Watson S.R.
        • Greene M.T.
        • et al.
        Reducing inappropriate urinary catheter use: a statewide effort.
        Arch Intern Med. 2012; 172: 255-260
        • Rello J.
        • Ollendorf D.A.
        • Oster G.
        • et al.
        Epidemiology and outcomes of ventilator-associated pneumonia in a large US database.
        Chest. 2002; 122: 2115-2121
        • Muscedere J.G.
        • Day A.
        • Heyland D.K.
        Mortality, attributable mortality, and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumonia.
        Clin Infect Dis. 2010; 51: S120-125
        • Eckert M.J.
        • Davis K.A.
        • Reed R.L.
        • et al.
        Urgent airways after trauma: who gets pneumonia?.
        J Trauma. 2004; 57: 750-755
        • Eckert M.J.
        • Wade T.E.
        • Davis K.A.
        • et al.
        Ventilator-associated pneumonia after combined burn and trauma is caused by associated injuries and not the burn wound.
        J Burn Care Res. 2006; 27: 457-462
        • Eckert M.J.
        • Davis K.A.
        • Reed R.L.
        • et al.
        Ventilator-associated pneumonia, like real estate: location really matters.
        J Trauma. 2006; 60: 104-110
        • Evans H.L.
        • Zonies D.H.
        • Warner K.J.
        • et al.
        Timing of intubation and ventilator-associated pneumonia following injury.
        Arch Surg. 2010; 145: 1041-1046
        • Evans H.L.
        • Warner K.
        • Bulger E.M.
        • et al.
        Pre-hospital intubation factors and pneumonia in trauma patients.
        Surg Infect (Larchmt). 2011; 12: 339-344
        • Carr B.G.
        • Kaye A.J.
        • Wiebe D.J.
        • et al.
        Emergency department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients.
        J Trauma. 2007; 63: 9-12
        • Coffin S.E.
        • Klompas M.
        • Classen D.
        • et al.
        Strategies to prevent ventilator-associated pneumonia in acute care hospitals.
        Infect Control Hosp Epidemiol. 2008; 29: S31-40
        • Muscedere J.
        • Dodek P.
        • Keenan S.
        • et al.
        Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention.
        J Crit Care. 2008; 23: 126-137
        • Berenholtz S.M.
        • Pham J.C.
        • Thompson D.A.
        • et al.
        Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
        Infect Control Hosp Epidemiol. 2011; 32: 305-314
        • Sinuff T.
        • Muscedere J.
        • Cook D.J.
        • et al.
        Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study.
        Crit Care Med. 2013; 41: 15-23
        • McCoy T.
        • Fields W.
        • Kent N.
        Evaluation of emergency department evidence-based practices to prevent the incidence of ventilator-acquired pneumonia.
        J Nurs Care Qual. 2012; 27: 83-88
        • Weingart S.D.
        • Menaker J.
        • Truong H.
        • et al.
        Trauma patients can be safely extubated in the emergency department.
        J Emerg Med. 2011; 40: 235-239
        • Frazee B.W.
        • Fahimi J.
        • Lambert L.
        • et al.
        Emergency department ultrasonographic probe contamination and experimental model of probe disinfection.
        Ann Emerg Med. 2011; 58: 56-63
        • Sanz G.E.
        • Theoret J.
        • Liao M.M.
        • et al.
        Bacterial contamination and cleanliness of emergency department ultrasound probes.
        CJEM. 2011; 13: 384-389
        • Rodriguez G.
        • Quan D.
        Bacterial growth on ED ultrasound machines.
        Am J Emerg Med. 2011; 29: 816-817
        • Ma S.T.
        • Yeung A.C.
        • Chan P.K.
        • et al.
        Transvaginal ultrasound probe contamination by the human papillomavirus in the emergency department.
        Emerg Med J. 2013; 30: 472-475
        • Stone P.W.
        • Pogorzelska-Maziarz M.
        • Herzig C.T.
        • et al.
        State of infection prevention in US hospitals enrolled in the National Health and Safety Network.
        Am J Infect Control. 2014; 42: 94-99
        • Birnbach D.J.
        • Nevo I.
        • Scheinman S.R.
        • et al.
        Patient safety begins with proper planning: a quantitative method to improve hospital design.
        Qual Saf Health Care. 2010; 19: 462-465
        • Terp S.
        • Krishnadasan A.
        • Bowen W.
        • et al.
        Introduction of rapid MRSA PCR testing and antibiotic selection among hospitalized patients with purulent skin infections.
        Clin Infect Dis. 2014 Feb 18; ([Epub ahead of print])
        • Gilligan P.
        • Quirke M.
        • Winder S.
        • et al.
        Impact of admission screening for methicillin-resistant Staphylococcus aureus on the length of stay in an emergency department.
        J Hosp Infect. 2010; 75: 99-102
        • Huang S.S.
        • Septimus E.
        • Kleinman K.
        • et al.
        Targeted versus universal decolonization to prevent ICU infection.
        N Engl J Med. 2013; 368: 2255-2265
        • May L.
        • Cosgrove S.
        • L'Archeveque M.
        • et al.
        A call to action for antimicrobial stewardship in the emergency department: approaches and strategies.
        Ann Emerg Med. 2013; 62: 69-77