Ic-01-042 Infection Control in Emergency Room

POLICIES AND PROCEDURES MANUAL
INFECTION CONTROL IN EMERGENCY ROOM

DOCUMENT CONTROL REVISION NO. EFFECTIVITY DATE PAGE
NO. JANUARY O1, 2019 1 of 13
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IC-01-042 DECEMBER 31, 2020
I. OBJECTIVES
1. To protect Emergency Department, other employee, patients and visitors from
exposure to infection.
2. To provide immediate care and isolation as needed for patients with
infectious/communicable diseases seeking treatment at the Emergency
Room (ER).
II. SCOPE
1. All physician and nurses.
III. DEFINITION OF TERMS

None
IV. POLICIES
1. The Staff members in ER department must understand and prevent the activities
which may increase the risk of infection to personnel and patients’ in accordance
with the below procedures.
2. Patients may present with varying degree of illness and disease with the potential of
contamination of the department environment.
3. Patient may present in a period of communicability (incubation period) of a
communicable disease not readily detectable.
4. An increase in the number of patients seen in the department with particular illness
e.g. influenza may alert Infection control to community outbreak, which may affect
the prevalence rate of Healthcare Associated infectious. (HAI).
5. The department may assist in the assessment and treatment of employee.
6. All health care workers and personnel in the Emergency Room and receiving
areas shall protect themselves from any infection and also recognize and
attempt to promptly isolate all patients with infections posing a risk to
nearby personnel, patients and visitors.
7. Patients shall be triaged upon entry at the Emergency Department according to

the type of communicable disease. They shall be admitted upon the disposition
of the Emergency Room Officer based on the policy of cases admissible in the
medical center.
8. The use of personnel protective equipment (PPE) shall be practiced based on

hospital policy. Please refer to Policies on the use of Personal Protective
Equipment.
Prepared by: Reviewed by: Conforme: Approved by:
JAN MARVIN M. PALIJO, MSN, RN GINA M. GARCIA, MD JM PALIJO MSN,RN/ R. RAYOS DEL SOL, MD NEIL ANDREW S.J. DE LUMEN, MD
CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

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IC-01-042 DECEMBER 31, 2020
9. Waste shall be segregated and disposed according to the hospital’s waste

management plan. Yellow waste bin shall be used accordingly for the
disposal of infectious waste. Please refer to Infectious Waste Management
10. All patients with infectious diseases shall be handled according to the
appropriate guidelines issued by the hospital’s Infection Control Committee.
11. The hospital shall not admit the following infectious diseases:
a. Diphtheria
b. Nodular or mixed type of Hansen’s disease
c. Severe Acute Respiratory Syndrome (SARS)
d. Meningococcemia
e. Uncomplicated Varicella
f. Uncomplicated Measles
12. For the diseases in no. 6, should the diagnosis be made after the admission, the
patient must be transferred to another institution if possible (Please refer to
applicable provisions in Policy on Influx of Patients During Community
Outbreaks). If the patient is to be admitted because of complications or risk of
transporting out to another hospital, the patient must be admitted to an
isolation room and strict standard and transmission based precautions shall be
applied.
13. Patients with active tuberculosis (ex. cavitary lesion on x-ray, positive sputum
AFB smear, without current anti- tuberculosis treatment) may be admitted if
with severe hemoptysis or in respiratory failure provided that he/she is placed
in an isolation room with negative pressure or private single room. Airborne
precautions are strictly implemented.
14. Diagnosis of an infectious disease shall be made by the attending physician
and/or his senior resident. The Nursing Supervisor must immediately be
notified of suspected or confirmed infectious cases so that necessary
isolation procedures may be implemented.
15. The Infectious Disease Consultant and/or Infection Control Nurses should also
be notified when patients with suspected or confirmed infectious diseases are
admitted for appropriate reporting to the Department of Health if applicable.
V. PROCEDURES
1. All personnel who function in the emergency room (ER) will adhere to stated policies
and practices to minimize the potential spread of disease and /or infections. Nursing
personnel shall be responsible for implementing necessary isolation precaution and

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IC-01-042 DECEMBER 31, 2020
interpreting these precautions to the patient, family and visitors who might be
affected.
1.1 Patients:
1.1.1 All blood product, secretion and excretions shall be handled as
potentially hazardous specimens. Appropriate barrier precautions
are to be used when in contact with blood and body secretions
(Refer to infection control Manual Standard Precaution Policy).
1.1.2 Specimen collected for analysis shall be placed in closed

containers for transport to the laboratory.
1.1.3 All specimens shall be labeled with the patients’ name. The
container will be placed into a plastic bag marked with biohazard
symbol.
1.1.4 Patients who require isolation precautions shall be informed

by nursing personnel of the required isolation practices. X-ray, Lab,
Ward personnel and other necessary departments shall be informed
of the need for patient isolation prior to patient transport to that
area, (Refer to Infection control isolation Policy IC-HW4-4).
1.2 Personnel:
1.2.1 Appropriate hand hygiene technique shall be utilized before

and after patient contact (Refer to Infection Control Manual Hand
Hygiene Policy).
1.2.2 Personnel shall comply with the existing employee health

requirements (Refer to Infection control Manual Employee health
Program).
1.2.3 Personnel with open draining lesions must not handle IV fluids
or pharmaceutical product or have patient contact. Appropriate
methods to prevent the transmission of an active infection should
be utilized.
1.3 Equipment:
1.3.1 Stretchers:

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1.3.1.1 Housekeeping personnel shall thoroughly clean the

stretchers on a daily basis with a disinfectant.
1.3.1.2 Housekeeping personnel shall wipe down the

mattress and side rail between patients with disinfectant.
The stretchers shall than covered with clean sheet.
1.3.1.3 ER personnel should change the stretchers sheet

between patients.
1.3.2 Non –sterile Equipment:
1.3.2.1 Large non-sterile equipment (i.e. suction machine, IV

pumps, Hypothermia machine) shall is cleaned after patient
use with a disinfectant.
1.3.2.2 All equipment in the ER (including the life pack, EKG

machine) shall be cleaned on a weekly basis by the ER
nursing staff with a disinfectant.
1.3.2.3 Exam tables, mayo trays, cabinets, exam light shall

be cleaned on a daily basis with a disinfectant by
housekeeping personnel.
1.3.2.4 Disposable supplies are thrown away after signal

patient use. Housekeeping personnel will dispose of trash
from ER/OPD as per Housekeeping schedule as needed.
1.3.3 Sterile equipment:
1.3.3.1 Used sterile equipment shall be cleaned after patient

use. All instruments shall be rinsed with water by the using
units in their dirty utility room and then placed in a covered
container that has an enzymatic solution, soaked two to five
minute or as long as required, then rinsed with water prior
to placing in an impervious. Decontaminated bag or CSSD
box for sharp instruments.
1.3.3.2 It is the responsibility of the ER staff to insure that all

sterilized items and medications, on the crash cart and all
other medications are within dates of expiration.

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1.3.3.3 ER staff will insure that all sterilized item are within
dates of expiration.
1.4 Emergency Department:
1.4.1 Counter tops and shelves: housekeeping personnel will wipe

counter tops down daily with a disinfectant; ER personnel will wipe
shelves down weekly.
1.4.2 Floor : The ER floor is first dry mopped ,than wet mopped with
a disinfectant by the housekeeping personnel .The housekeeping
department shall be notified by the ER nursing personnel for
additional necessary clean ups.
1.4.3 Sinks: The housekeeping staff with a disinfectant of cleans the

ER sinks daily. The ER nursing personnel will notify housekeeping
department of necessary additional clean-ups of the sinks.
1.4.4 Linen: Soiled linen in placed in the laundry hamper in the ER.
Soiled laundry shall be removed from the ER/OPD by the laundry
staff twice daily or more often as needed.
1.4.5 Blood Spills: (Refer to Infection Control manual Dealing With

Blood spills Policy).
1.5 Dressing Room:
1.5.1 All dressing packs and sterile accessories are kept in a closed
cupboard.
1.5.2 Items on top of work surface are to be kept at minimal, for

each shift supply only.
1.5.3 Dressing trolleys (Top and bottom shelves) are wiped down
with Disinfectant before and after each dressing. This solution to be
discarded after 24 hours of mixing.
1.5.4 After each clinic day or after a known infected wound case, the
dressing room is cleaned with Disinfectant by housekeeping staff.
1.6 Surgery
1.6.1 Establish a system for detecting post discharge infections and

report all related infections to infection control Team.

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1.6.2 Utilize surgical asepsis in performing all procedures.
1.7 Infectious cares:
1.7.1 It shall be responsibility of the ER nurse to ensure that

appropriate measures to prevent the spread of disease are
implemented in the case of the patient with an infectious disease. If
the patient is to be admitted to the hospital ER staff will notify the
receiving department that the patient is to be placed in Isolation
precautions if indicated, (Refer to Infection control Isolation policy)
1.7.2 Regulated Medical waste product shall be placed in the regular

trash by the ER personnel, and give to housekeeping to dispose of.
1.7.3 All instrument shall be rinsed with water by the using units in
their dirty room and then placed in a covered container that has an
enzymatic solution, soaked two to five minute or as long as
required, the rinsed with water prior to placing in an impervious
decontaminated bag.
1.7.4 Isolation linen shall be placed in one plastic bag. Soiled linen
should be carefully gathered together so as to confine any obvious
contamination within the center of the linen.
1.7.5 After patient transfer from the ER, housekeeping personnel

shall be notified to implement through decontamination procedure
as per housekeeping protocol.
1.7.6 Notify Infection control Team of all reportable disease.
1.8 Isolation Procedures

1.8.1 Standard and necessary transmission based precautions
must be observed at all times. Refer to Infection Control
Policies and Procedures on Isolation Precautions.
1.8.2 Hospital Precautions for Patients with Infectious Diseases

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Mode of Type of Duration Precaution Terminal

Disease/ Comments
Transmission Isolation Precaution to be Taken Disinfection
Condition
1. HIV, Direct Blood Duration of  Hand washing Yes Protective eyewear
Hepatitis B contact and body hospitalization  Gowning should be worn when
and C with fluids  Gloving suctioning a patient:
infected (Contact)  Yellow trash bag use caution when
materials, for handling blood and
blood, secretion/waste blood soiled articles.
body fluids, Take special
sexual care to avoid needle
contact injuries.
2. Cholera Fecal/Oral Contact Duration of  Hand washing Yes PPE mandatory
(Enteric) illness and  Yellow trash
until stools bag for
are linens/waste
culture (-)
3. Fecal Enteric According to  Hand washing Yes PPE mandatory
Gastroenteritis etiology  Yellow trash
bag for
linens/
discharges
4. Hepatitis A Primarily Contact One week  Hand washing Yes Can be admitted
Fecal after jaundice  Yellow trash in ward
bag for
linens/waste
5. Typhoid Fecal/Oral Contact 3 stool  Hand washing Yes Can be admitted
cultures at 24  Yellow trash in ward
hours apart bag for
are (-) or until linens/waste
clinically
improved.
6. Amoebiasis Fecal/Oral Contact Until stools  Hand Yes Trophozoites are not
are free of washing considered infectious
amoebic cyst should be
emphasiz
ed
 Yellow trash bag
for
contaminate
d
linens/waste
7. Chicken pox Respiratory Airborn Until lesions  Hand washing Yes Give zoster immune
(Varicella) and Contact e are crusted  Gowning globulin to immune
 Mask suppressed susceptible
 Yellow trash bag contacts at time of
 for exposure. Private
contaminated room or may cohort
linens/waste with other persons
with chicken pox.
8. Measles Respiratory Airborn From onset 
Hand washing Yes Pregnant Health Care
(Rubeola) and Contact e of catharal Gowning Worker should avoid
stage to 5 Mask  exposure
days after

Yellow trash
rash appears
bag for
linens/wast
e
9. Pulmonary Airborne Airborn Variable 2-3  Hand washing Yes Patients on treatment
Tuberculosis e weeks  Gowning for more than two
after  Mask weeks are considered
treatment non-infectious
(N95 for

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IC-01-042 DECEMBER 31, 2020
active
cases)
 Yellow trash
bag for
contaminate
d
linens/waste
10. German Respiratory Droplet 5 days after  Hand washing Yes Not be cared by
Measles Secretions onset of rash  Gowning susceptible pregnant
(Rubella) and Contact  Mask employee/worker
 Yellow trash
bag for
linens/wast
e
11. Diphtheria Respiratory Droplet Until 2  Hand washing Yes Contact should receive
Secretions negative  Gowning zoster immunization
cultures  Mask and antibiotics.
Unimmunized /close
 Yellow trash
contact should receive
bag for
diphtheria antitoxin.
contaminate
d
linens/waste
12. Bronchitis in Respiratory Droplet Duration of  Hand washing No Avoid close contact
children illness  Mask with
children at high risk
from respiratory illness
13. Pneumonia Respiratory Droplet Until  Hand washing Yes Single room preferred
infections  Mask
subsides  Yellow trash
bags for
linens/waste
s
14. Influenza A Respiratory Droplet Duration of  Handwashing Yes Should be admitted in
H1N1 Secretions illness  Mask a private room or
 Yellow Trash cohort
bag for
contaminate
d waste
15. Rabies Human Standar Duration of  Hand washing Yes Single quiet room
transmission d and illness  Yellow trash required
or a contact Contact bags for
with wound
linens/ waste
and
saliva
1.9 Sharps:
1.8.1 Needle shall not be recapped but placed in to a yellow plastic

sharp container and disposed of by housekeeping. (Refer Infection
Control Manual Needle Stick and sharp injury prevention).
1.10 PRECAUTION FOR PATIENT SUSPECTED OF HAVING A CHINKENPOX OR

MEASLES:
1.10.1 A nurse will:

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1.10.1.1 Isolate the child and parent and not allow them to
sit in the waiting rooms or preparation room, instruct the
patient and parents to stand outside the pediatrics
preparation room away from other patients or direct
her/him to an empty room if available.
1.10.1.2 Instruct special clinic patients to wait outside the

clinic (segregate from other patients).
1.10.1.3 Inform the clinic or the ER doctor immediately so

that the patient can be seen promptly.
1.10.1.4 Arrange a special room if possible away from the

clinic to examine the patient, prepare the patient in the
clinic (bringing scales from pediatrics room).
1.10.1.5 Wear disposable gloves gown and mask at all times

until disinfection has been completed (mask not necessary if
immune to chickenpox/measles).
1.10.1.6 Disinfect all equipment used (scale, cough, IVAC,

Diagnostic set. tape measure, stethoscope B/P cuff and
anything else the patient/parent touched) with hospital
approved disinfectant.
1.10.1.7 Send the autoclavable items to CSSD for cleaning

and disinfections.
1.10.1.8 Instruct the housekeeper to mop the floor and wipe

the doorknobs and chairs with approved disinfectant and
change curtain.
1.10.1.9 Dispose of all waste in yellow plastic bag.
1.10.1.10 Dispose of linen in plastic bag, which is yellow

liner hamper.
1.10.1.11 Wash hand with an antiseptic chlorhexidine

solution.
1.9.1.12 Provide the physician with a reportable disease

from and submit the completed from to the Emergency
Room Head Nurse.

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1.10.1.13 Place a notice on the outside of the door starting

the time; the room will be available for the next patient.
1.10.1.14 Expedite the exit of the patient by obtaining the

next appointment from the receptionist and prescription
from the pharmacist, if the other parent is not present.
1.9.2 The physician will:
1.9.2.1 See the patient promptly in a room on the same

floor
1.9.2.2 Wear disposal gloves, gown, and mask (mask not

necessary if immune to chickenpox/measles).
1.9.3 Instruct parent not to wait in pharmacy or laboratory waiting

rooms.
1.10 Precaution for patients with MRSA:
1.10.1 The nurse will:
1.10.1.1 Wear sterile gloves, gown and mask when dressing

the infected wound.
1.10.1.2 Send the autoclavable items used to CSSD for

cleaning and sterilization.
1.10.1.3 Dispose of all waste in yellow bag.
1.10.1.4 Dispose of linen in plastic bag, which is in yellow

liner hamper.
1.10.1.5 Wash hand with an antiseptic chlorhexidine

solution.
1.10.2 The physician will:
1.10.2.1 Wear sterile gloves, gown and mask when dressing

the infected wound.
1.10.2.2 Wash hands with an antiseptic chlorhexidine

solution. Refer to Infection Control manual Control of Multi
Drug Resistant Organisms (MDRO).

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2. Post-Mortem Care of Infectious Disease Cases

2.1 All health care worker attending to the expired patient shall be
responsible in knowing what type of infectious disease the patient has.
2.2 Personnel protective equipment (PPE), such as mask, gloves, and gown
shall be worn while doing the procedure. The following should be kept
in mind:
2.2.1 In case of torn gloves, immediately remove and
dispose them in a yellow trash bin, wash hands
thoroughly and then put on a new pair.
2.2.2 To avoid cross contamination, personal items shall not be

handled while wearing soiled gloves.
2.2.3 Used PPE shall immediately be disposed in their designated

containers.
2.3 Universal precautions shall be practiced for contact of blood and body
fluids.
2.4 All contraptions (ex. endotracheal tube, intravenous lines, chest

tube, foley catheter, etc.) used by the patient shall be disposed
directly into a yellow waste bin.
2.5 Disposable sharps / needles used by the patient shall be promptly

discarded into a puncture proof sharps container.
2.6 Placing of name tags and wrapping of the body to the post
mortem body bag (to prevent leakage of body fluids) shall be done
after the care.
2.7 Thorough hand washing / hand hygiene shall be done after the procedure.
2.8 Used reusable instruments shall undergo chemical disinfection

before washing, repacking and final sterilization.
2.9 Disinfection of items and equipment shall be done after use.
VI. REFERENCES
1. APIC 2014.

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VII. SIGN-OFF AND REVISION HISTORY
Owner
INFECTION CONTROL
Initiator
JAN MARVIN M. PALIJO, MSN, RN – CHIEF NURSING OFFICER
Reviewer
GINA M. GARCIA, MD – CHAIRMAN, DEPARTMENT OF MEDICINE
Approvals:
ARGYLL T. ARCIGAL, MD
CHIEF OF CLINICS
CHERRY PINK D. ORDINAL, MD

QMD Head

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IC-01-042 DECEMBER 31, 2020
RICO M. RAYOS DEL SOL, MD

Chief Medical Officer
NEIL ANDREW S.J. DE LUMEN, MD

President
Revision History
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POLICIES AND PROCEDURES MANUAL

INFECTION CONTROL IN EMERGENCY ROOM

III. DEFINITION OF TERMS

5. The department may assist in the assessment and treatment of employee.

7. Patients shall be triaged upon entry at the Emergency Department according to

8. The use of personnel protective equipment (PPE) shall be practiced based on

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

9. Waste shall be segregated and disposed according to the hospital’s waste

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1.1.2 Specimen collected for analysis shall be placed in closed

1.1.4 Patients who require isolation precautions shall be informed

1.2.1 Appropriate hand hygiene technique shall be utilized before

1.2.2 Personnel shall comply with the existing employee health

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1.3.1.1 Housekeeping personnel shall thoroughly clean the

1.3.1.2 Housekeeping personnel shall wipe down the

1.3.1.3 ER personnel should change the stretchers sheet

1.3.2 Non –sterile Equipment:

1.3.2.1 Large non-sterile equipment (i.e. suction machine, IV

1.3.2.2 All equipment in the ER (including the life pack, EKG

1.3.2.3 Exam tables, mayo trays, cabinets, exam light shall

1.3.2.4 Disposable supplies are thrown away after signal

1.3.3 Sterile equipment:

1.3.3.1 Used sterile equipment shall be cleaned after patient

1.3.3.2 It is the responsibility of the ER staff to insure that all

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1.4 Emergency Department:

1.4.1 Counter tops and shelves: housekeeping personnel will wipe

1.4.3 Sinks: The housekeeping staff with a disinfectant of cleans the

1.4.5 Blood Spills: (Refer to Infection Control manual Dealing With

1.5 Dressing Room:

1.5.2 Items on top of work surface are to be kept at minimal, for

1.6.1 Establish a system for detecting post discharge infections and

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1.6.2 Utilize surgical asepsis in performing all procedures.

1.7 Infectious cares:

1.7.1 It shall be responsibility of the ER nurse to ensure that

1.7.2 Regulated Medical waste product shall be placed in the regular

1.7.5 After patient transfer from the ER, housekeeping personnel

1.7.6 Notify Infection control Team of all reportable disease.

1.8 Isolation Procedures

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

Mode of Type of Duration Precaution Terminal

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1.8.1 Needle shall not be recapped but placed in to a yellow plastic

1.10 PRECAUTION FOR PATIENT SUSPECTED OF HAVING A CHINKENPOX OR

1.10.1 A nurse will:

Prepared by: Reviewed by: Conforme: Approved by:

CHIEF NURSING OFFICER CHAIRMAN, DEPARTMENT OF MEDICINE RZ DE LUMEN, MD PRESIDENT

1.10.1.2 Instruct special clinic patients to wait outside the

1.10.1.3 Inform the clinic or the ER doctor immediately so

1.10.1.4 Arrange a special room if possible away from the

1.10.1.5 Wear disposable gloves gown and mask at all times

1.10.1.6 Disinfect all equipment used (scale, cough, IVAC,

1.10.1.7 Send the autoclavable items to CSSD for cleaning

1.10.1.8 Instruct the housekeeper to mop the floor and wipe

1.10.1.9 Dispose of all waste in yellow plastic bag.

1.10.1.10 Dispose of linen in plastic bag, which is yellow

1.10.1.11 Wash hand with an antiseptic chlorhexidine