Background: Emergency Departments (EDs) are at the front line of hospital care and, as such, are vulnerable to infection control problems. It follows that the periods of high patient load (HPLPs), which are basically overcrowding and the resource utilization to the limit, may lead to the intensification of the non-compliance with the infection control protocols and, therefore, the increase of healthcare-associated infections (HAIs) risk.

Objective: The primary objective of the study was to compare the compliance rate with the infection control measures during normal and high-patient-load periods among healthcare workers (HCWs) in a tertiary care ED and, also, to find out the perceived barriers to the compliance during the surges.

Methods: To answer the research questions, the authors implemented a parallel convergent mixed-methods design that was put in place for half a year. The quantitative part contained 1200 direct, structured observations of HCWs (nurses, physicians, and technicians) regarding their compliance with hand hygiene, personal protective equipment (PPE) use, and surface disinfection. As for the qualitative part, it consisted of 25 in-depth, semi-structured interviews with the staff of the ED, which explored the barriers and facilitators. Patient load was gauged through the National Emergency Department Overcrowding Scale (NEDOCS).

Results: The overall compliance to infection control protocols as observed was statistically significantly less during the HPLP (58.4%) as compared to the normal-load periods (72.1%, p < 0.001). The hand hygiene compliance upon patient contact fell from 75.3% to 61.8% (p < 0.01). The PPE compliance recorded the largest drop, that is, from 70.5% to 52.1% (p < 0.001). Non-compliance to infection control during HPLPs, according to the results of qualitative research, could be related to four primary factors: (1) heavy cognitive load and task saturation, (2) shortage of physical resources and space, (3) perceived contradiction between speed of care and safety, and (4) leadership and cultural factors.

Conclusion: In the emergency room, infection control is one of the first things to be compromised when there is a high patient load. And the problem of reducing such compliance cannot be solved by only one method, it requires addressing not only the individual behavior side of the matter but also the systemic side of workload management, resource allocation, and safety culture issues that can resist operational pressure.