Emergency physicians and emergency department leaders are challenged to develop a rational and consistent approach to patients with potential infectious diseases. The Centers for Disease Control and Prevention (CDC) posted a nationwide health advisory in an effort to educate clinicians about a widespread outbreak of the measles.

Spot and Contain Contagions

Kristi L. Koenig, MD, FACEP, FIFEM, recently published a commentary that proposes a consistent approach to all persons presenting to an emergency medical services (EMS) provider or the emergency department who are a potential threat for infectious diseases or other hazards. Dr. Koenig suggests an approach based on “Vital Sign Zero.”

The concept encourages emergency personnel to obtain a focused history that allows rapid identification of patients at risk for spreading disease or contaminant to others. This should precede any attempts to obtain standard vital signs.

• For measles, this would mean the first contact in the ED or EMS would look for signs and symptoms that have a high predictive value (like a combination of fever, conjunctivitis, and cough; Koplik’s spots; or rash).
• For Ebola, the process would apply for someone who walks in and says, “I am a health care worker just returning from West Africa, and I have a fever and worked in an Ebola camp.”
• For active tuberculosis, the process would identify someone who presents and says, “I have a bloody cough and night sweats, and I returned several weeks ago from work in a developing country.”

Without sitting the patient down to obtain vital signs, personnel would move all of these “Vital Sign Zero” patients outside or to an appropriate area of the ED away from others. The patient would have a mask applied, and the personnel and space needed to manage the emergency would be mobilized. At that point, obtaining vital signs and a medical history and performing an examination using appropriate protection should occur.

Measles: What to Watch For

The current measles outbreak is being monitored by ACEP, and an expert panel convened to address the Ebola outbreak has developed a rapid education fact sheet for emergency physicians and other personnel. For emergency personnel, the “Vital Sign Zero” fact sheet would include these elements:

Measles (rubeola) is characterized by a prodrome of fever and the three C’s of cough, coryza (runny nose), and conjunctivitis. Fever can be measured as high as 105°F. The identification of two eruptions is pathognomonic for measles. The oral cavity will have Koplik’s spots, which usually precede the rash, and then the maculopapular rash erupts, usually beginning on the face. The rash spreads from head to trunk, then to the lower extremities, often involving the palms of the hands and soles of the feet. The rash typically appears about 14 days after a person is exposed. A patient is considered to be contagious from four days before to four days after the rash appears.

Of concern for emergency personnel is that some immunocompromised patients do not develop a rash.

Early identification in the ED is important so the patient can be immediately isolated from other individuals in the department. A mask should be applied to the patient. Emergency personnel should take isolation precautions to include, at a minimum, an N95 mask. Diagnosis is important so the patient can be monitored for complications and isolated for four days following appearance of the rash to minimize further spread.
All states require patients with the diagnosis of measles to be reported to the local health department.

EDs Key to Containing Infectious Diseases

Emergency physicians and other emergency personnel are very adept at responding to evolving challenges, including infectious disease threats. A consistent and reliable approach to patient care by the first emergency care worker can facilitate a safe environment for the patient and all emergency personnel.

The concept proposed by Dr. Koenig allows emergency physicians to organize approaches starting at the intake area of the ED that will allow targeted safety protocols and rapid identification of contagious patients.

James J. Augustine, MD, FACEP, is director of clinical operations at EMP in Canton, Ohio; clinical associate professor of Emergency Medicine at Wright State University in Dayton, Ohio; vice president of the Emergency Department Benchmarking Alliance; and on the ACEP Board of Directors.