Among elderly residents of long term care facilities, a visit to the emergency department is associated with an increased risk of acquiring a new respiratory or gastrointestinal infection
- Correspondence to: Gail Lusardi, Department of Health Sport and Science, University of Glamorgan, Pontypridd, CF37 1DL, UK
Commentary on: 
Implications for practice and research
Further evaluation is needed of the consistency of application of Standard Infection Control Precaution guidelines/policies in the Emergency Department (ED).
Prospective studies are needed on assessment, novel strategies and use of resources to reduce ED visits in this group.
Microbiological evidence is required to quantify the risk of infection in the ED.
Elderly in long term care (LTC) facilities are at significant risk of infection from exposure in the ED.
The ED nurse needs to evaluate how to safely manage vulnerable groups to minimise the risk of healthcare associated infections.
Strategies are required to minimise the spread of infection to other residents in LTC facilities.
The elderly are at an increased risk of infection1 and research indicates that a client visit from a LTC facility to an ED is a frequent occurrence.2 This study is particularly important when considering the risk both to the individual who makes an ED visit and to others within their care facility or nursing home.2–5 Whilst rates of nosocomial infection have been studied in inpatient groups, this study is unique in investigating the risk of infection following an ED visit. Whilst there are clear guidelines for infection prevention in the ED, studies suggest precautions are often difficult to sustain.6 ,7
This was a large cohort study with matched controls involving 424 patients from 22 facilities who attended the ED for non-infectious reasons matched with 845 randomly selected controls from the same facility who did not attend the ED. The primary outcomes were diagnosis of a new acute respiratory or gastrointestinal tract infection 2–7 days after return from the ED. An expected rate of infection was calculated using data from a previous study. Trained staff conducted a blinded assessment of the diagnosis of infection through the retrospective analysis of patient data and charts. Statistical analyses included comparison of baseline characteristics using the Student t test and Fisher exact tests for continuous and dichotomous variables respectively and Charlson co-morbidity and the Katz independence indices were used to compare cases and controls. Multivariate analysis was performed to adjust for confounding variables and to identify effect modifiers. Logistic regression was conducted on the matched cohort data.
The findings revealed that 21 (5.0%) residents who visited that ED and 17 (2.0%) residents who did not visit the ED acquired new infections. The authors reported an adjusted OR of 3.9 (95% CI 1.4 to 10.8) for the risk of infection following a visit to the ED. Those attending the ED had a higher than average Charlson co- morbidity Index and were likely to be more dependent in comparison to those who did not attend the ED.
This is a well constructed study in which the authors acknowledge some limitations including: (1) lack of any microbiological evidence of infection, (2) use of retrospective analysis of patient charts/documents, (3) detection bias if the patients studied were monitored more closely than usual, and (4) inability to ascertain precise ED data.
While some findings were expected, for example, increased presence of visitors correlated with increased risk of infection, others were not, such as infected cases were more likely to have dined in their own room. Other infections not obvious in the 2–7 day post visit period, for example, methicillin-resistant Staphylococcus aureus and Clostridium difficile, were not examined, though the presentation of infection in the elderly often differs2 so potential infections may have been undiagnosed pre and post visit. Overall, this is a very interesting study which hopefully will stimulate further research.