I know there are mixed opinions about the flu vaccine but I'm curios to hear nurses' reactions to the recent measles outbreaks here in the United States, partially associated with undervaccianted people.
Through aggressive immunization strategies, measles was declared eliminated in the U.S. in 2000. That means we had eliminated continued transmission for longer than 12 months. However, there are more than 20 million cases worldwide, with a high concentration in Southeast Asia, Africa and the Middle East. It can lead to pneumonia, encephalitis and problems with pregnancy and is still a significant cause of morbidly and mortality in those parts of the world. Although measles has been eliminated here, there are still outbreaks each year. Most of the initial cases in these outbreaks are associated with travel but when there is a weak link in the immunity chain, the opportunity for transmission exists.
Measles is a highly contagious virus spread through the airborne route. Therefore, people who are non immune - whether they are too young for vaccine, never took the vaccine for their own reasons or failed to develop immunity - can easy become infected with the virus.
In 2013, there were 189 cases of measles compared to an annual average of 60 cases and 2014 is getting off to a bad start. There are 2 large outbreaks in the U.S. Sixteen adults and five children have measles in Orange County, California. In New York City, there have been 25 cases about evenly split between adults and children. (https://a816-health29ssl.nyc.gov/sites/NYCHAN/Lists/AlertUpdateAdvisoryDocuments/HAN_Measles_April%201%202014.pdf)
In addition to travel related cases, measles has been transmitted in health care settings. Is your ED, clinic or doctor's office prepared for this?
Staff working in these areas should:
- Instruct front line staff including receptionists and security guards to alert the nursing staff if a patient comes in with a cough and rash
- Recognize the signs of measles: cough, fever, coryza, conjunctivitis, a maculopapular rash
- PROMPTLY isolate the patient in an airborne isolation room (i.e., one with negative pressure.) If an AIIR is not available, place the person in a closed exam room with a mask on. Don't use this room for at least 2 hours after the patient leaves
- Post Signage alerting the patients with fever and rash to immediately notify staff.
- Call the Health Department - even for suspect cases
- Finally, ensure that you and your family have immunity to measles.
March 2 through 8, 2014 was National Patient Safety Awareness week. This annual event is hosted by the National Patient Safety Foundation, a not -for -profit organization whose aim it to help create a world where patients AND health care workers are from harm. (http://www.npsf.org/)
As an infection preventionist, my primary focus is preventing harm by reducing health care acquired infections (HAIs) and occupational exposures to infectious agents. The Joint Commission continues to emphasize this measure as part of National Patient Safety Goal number 7 that applies to hospitals, behavioral health and ambulatory care. I aim to make my priority align with the other members of the health care team.
In reality, there are many competing demands for the nurse and the NPSF's aim is much broader than infection prevention. The larger umbrella of patient harm includes medication errors, falls and wrong site surgery. This year, NPSF focused on prevention of diagnostic errors. They estimate that 40, 000-80,000 deaths occur annually due to incorrect, missed or delayed diagnosis. While some of these events seem more like medical issues, nurses are patient advocates and can play a key role in averting many of these adverse occurrences.
What do you see as the most dangerous harm to your patients and more importantly, how can it be rectified?
Over the last three months, my fiercely independent 94-year-old relative has been hospitalized three times for pneumonia, a fall and CHF. Up until then she lived in her own room within a complex that provided meals and some housekeeping services. She has reluctantly come to the conclusion that she had to transfer to the next level of care - called an infirmary at her residence, not actually a nursing home but functions much like one.
Because of this experience, I realized the value of the APIC consumer alert "How to be a good visitor at a nursing home"
It lists several practical tips for visiting loved ones. I arrived late one evening after attending a bridal shower - pleasantly, the staff did not mind that it was already 8pm. But I wondered if they would ask me not to visit if I arrived showing flu like symptoms. This is one of the first tips given: Stay home if you are sick. It also mentions 5 specific illnesses that could wreck havoc in a long-term care facility or other communal residences: GI illnesses, influenza, human metapneumovirus, adenovirus and respiratory syncytial virus.
The third recommendation was to reduce clutter - truly a challenge for my relative, as we had to consolidate her belongings from her spacious room into this smaller room. Of course, it makes it easier to clean the area but rest assured it was hard to tell her that some items needed to be tossed.
Hand hygiene is stressed and many LTC facilities have alcohol based hand rubs available. Certainly staff members are tuned into the importance of this practice. This may be an opportunity to develop a program for hand hygiene for residents and visitors.
Does your unit conduct environmental or safety rounds? Perhaps, they are called something different but the focus is the same. A team makes rounds on a regular schedule to determine if your area and the care your patients receive are in compliance with best practice and regulatory agencies.
The team members are from nursing, pharmacy, infection prevention, safety, building services and patient representative. I often find there is a lot of overlap on what team members want. For example, the pharmacist is worried about unsecured meds for misuse by patient but I worry about them too for sterility sake. Everyone is on the lookout for clean equipment - the infection prevention reason is obvious but it also impacts on patient satisfaction. Building services is worried about the correct disposal of regulated medical waste AND I'm worried about it too because I don't want you to have a needle stick.
Sometimes, it sounds like these rounds are conducted merely to appease regulatory agencies. When you see the safety team on your unit have you ever said, "Oh, is The Joint Commission coming again?" The rounds can identify system problems that place barriers to compliance. I often find it's a good time for on-the-spot education as it makes it more credible.
I think the best use of these rounds is to improve patient and staff safety not be a hit list of errors but some nurses feel it just points out what they are doing wrong. Let us hear your take on rounds.
Hope you had a wonderful holiday and that your New Year is off to an exciting, productive start. On my list of things to do better in 2014, I'm adding getting paperwork completed more quickly.
Many nurses feel we provide excellent care but we are often bogged down with documentation. It's easy to overlook the importance of charting when you have many patients and their families vying for your attention.
From an infection prevention perspective, we need to know that certain key standards of care have been delivered - and the only way to show this is through documentation. Much of my time is devoted to monitoring adherence to these standards.
For example, when was that Foley inserted - and by whom? Is there a valid reason documented why the 60-year-old functional female still needs that catheter? Did your patient have his pre-op chlorhexidine shower? Did you deliver the antibiotics for his surgery on time?
Of course, we want these measures to be documented because it tells us the patient received appropriate care. But they can also tell us what may have been missed if there is an adverse outcome.
My time is also spent intervening when the standards are not being achieved. Working with the staff, we can determine: is it a product problem, a knowledge deficit or is the solution not appropriate to the problem? And of course, all of this is detailed in reports that I hope to disseminate more timely.
How is documentation handled at your job- are you entirely on electronic medical records - or a hybrid version? Has this helped with delivering care?
It's mid - December and I have yet to mention influenza this season.
Perhaps that is because, unlike last year, the flu has been off to a slow start in most of the country. At this time in 2012, we were already being inundated with flu cases in schools, clinics, private doctor's offices and of course emergency rooms. In addition to that, Families Fighting Flu (http://www.familiesfightingflu.org/) estimates that children "miss more than 38 million days of school and 5 million sporting events due to the flu" each year.
While the vaccine is never 100% effective, a statistical model used by the CDC indicated that last year vaccination averted 79,000 flu related hospitalizations and 6.6 million flu cases. And this was in a year when no more than 50% of those eligible to be vaccinated took one. (www.cdc.gov/mmwr/pdf/wk/mm6249.pdf)
There are many efforts under way to help increase the number of people who are immunized against influenza this year. There are preservative-free vaccines and egg free vaccines to help minimize effects in those with reactions or allergies. New York City has implemented a policy that children between 6 months of age and 5 years of age who attend licensed preschool or day care should be vaccinated. Several states are requiring certain health care workers to be vaccinated - some require a mask be worn if the person does not take the vaccine. The Centers for Medicare and Medicaid require hospitals and long-term care facilities to report the percent of staff vaccinated (and residents for the nursing homes.) CMS has not invoked financial penalties for low compliance rates but they may in the future.
Will this be enough to help achieve the 2020 Healthy People Goal of 90% vaccination rates? Hard to tell - but it's still not too late to get you, your family and your patients protected.
International Infection Prevention Week was celebrated from Oct. 20-26. At my facility, we pushed it back to Halloween and called our event "Spooked by Germs. " The Infection Prevention department co hosted the Fair with the perioperative team because we knew it would increase traffic to the booths and it proved to be a great collaborative effort.
There were flu shots - of course- and we had the Department of Health and Human Services' Partnering to Heal video available. (http://www.hhs.gov/ash/initiatives/hai/training/) Our peri-op nurse educator organized a Jeopardy game with categories such as: hand hygiene, surgical asepsis and personal protective equipment. I'm not sure who scored the most points and won the big prizes but everyone had fun and learned something new. We used educational handouts that were suitable for our staff as well as the visitors who were waiting for their loved ones.
The APIC website had a great variety of crossword puzzles, word search and pamphlets. (http://professionals.site.apic.org/the-week-iipw/resources/rise-to-the-occasion/) Everyone left with a pumpkin faced goodie bag -which I'm sure you know included hand sanitizer among the candy.
This week (Nov. 11-15) is Perioperative Nurses' Week -which gives me a chance to share in their celebration for safe patient care.
When I first began as an Infection Preventionist, staff often asked about terminally cleaning a room by fogging it. This was usually requested after a particularly contaminated case or for patient with lice. The staff was referring to a practice of fogging a room with a chemical or steam in an attempt to destroy any microbes and other living things like a pesky louse.
I'd never actually seen this method. It was abandoned because there was no scientific evidence that it changed the "flora" of the patient room. Additionally, one of the chemicals used - paraformaldehyde - is no longer registered for use with the EPA. And finally, it was inconvenient because the room was unusable for a period of time.
More recently, the recognition that a patient's room can serve as a fomite for transmission of organisms has renewed interest in more encompassing methods of room disinfection. For example, in a 2006 article, Kramer and his colleagues report that Klesbiella species can last from 2 hours - months and C. difficile spores can last for 5 months!
Technologies to address this concern have been introduced in hospitals. One technology is the use of vaporized aqueous hydrogen peroxide. A portable machine is wheeled into a vacated area and the vapor is delivered into this closed space. Another example is the use of ultraviolet radiation to decontaminate a room. The unit is placed in a room and is timed to work while the environmental service staff remains safely outside the room. Both of these technologies have been used in other industries - air handling and water treatment (UV) and pharmaceutical and medical device sterilization (peroxide). Both methods have been shown to reduce microbial contamination.
Rooms must still be physically cleaned before use of these technologies. But traditional cleaning is sometimes ineffective and these technologies have the advantage of disinfecting all surfaces that are exposed to the light or the chemical.
While far from commonplace, these technologies have been successfully implemented for cleaning high risk areas such as OR and isolation room so keep an eye out for them in your facility.
The week of Sept. 8 was designated to recognize health care environmental services workers (EVS). Regardless of your work setting, the patients notice the cleanliness of their rooms and the facility. And of course, we nurses often hype on the job that is done or not done by the environmental care workers.
We should not underestimate the valuable role of these support workers to improving patient safety. There is growing evidence that the environment can be a vector for transmission of pathogens and in my next blog I'll mention some new technology for cleaning and disinfection.
Right now, I'd like to focus on how the patient perceives the housekeeper's job.
The environment is reflected in question 8 of the in the Hospital Consumer Assessment of Health Plans Survey (or Hospital CAHPS®). (www.hcahpsonline.org/surveyinstrument.aspx)
According to Hospital Compare, the current national benchmark is that 73% of patients felt that their room and bathroom were always clean. Because of the importance of room cleanliness, many facilities are implementing programs and practices that help emphasize the work of the EVS department - visual cues like a tent card with the EVS staff's name on the over bed table or a liner on the clean toilet. Staff members are being coached on checking with the patient if there's anything else the EVS team member can do.
On this note I had a funny incident when visiting my father in-law in the hospital. The housekeeper assured him several times that she had cleaned the room, the bathroom and the floors. She asked repeatedly, "Do you need anything else?" Not realizing why she was so persistent in telling what she had accomplished, my father- in-law later asked me, "Did she want a tip?"
So let's hope cleanliness of our facilities speak for themselves - you can check your hospital's scores at the Hospital Compare site. www.medicare.gov/hospitalcompare
In the past 6 months, my local Medical Reserve Corps had been activated twice to help staff a Point of Distribution (POD) clinic to provide prophylaxis for Hepatitis A exposures.
The first episode involved a restaurant worker. The index case in the second incident was a market worker who potentially exposed 2000 people.
Hepatitis A is a virus that is spread by the fecal oral route from either person to person contact or by eating contaminated food or water. For example, the CDC is investigating an outbreak in 10 states that affected more than 150 people who consumed pomegranate berry mix. The disease has an incubation period of approximately 28 days and it usually resolves on its own. Symptoms are more likely to occur in adults whereas the disease is usually asymptomatic in children. A small percentage of people have relapse of their symptoms in the first 6 months.
Treatment is directed at symptoms as there is no specific therapy. Vaccination against Hepatitis A is recommended for all children at age 1 year, for persons who are at increased risk for infection (e.g. travelers to areas where the disease is endemic), for persons who are at increased risk for complications from Hepatitis A (e.g. people with Hepatitis C infection), and for anyone wishing protection.
Have you ever rushed to get CIPRO from the employee health service when you heard you had a patient with meningitis? I'm often asked about patients with meningitis - which ones need isolation, which types of meningitis mean SOME staff members need prophylactic antibiotics? This question tends to arise in the summer because there are more cases of enteroviral meningitis at this time of year in the U.S.
It can be confusing because the term meningitis simply means an inflammation of the membranes surrounding the brain and spinal cord. Several different organisms can cause it - in fact the CDC lists five separate types of meningitis. The symptoms-headache, fever, stiff neck, photophobia - can be similar regardless of the origin.
In general, bacterial meningitis tends to be more severe than viral meningitis. Some bacterial meningitis are spread by close contact with respiratory secretions like when intubating a patient but most are not as contagious as the cold or the flu.
In fact, only meningitis caused by meninogoccus or Haemophilus influenzae type b are indications for preventive antibiotics. And then it should only be used for people who had intimate contact with the sick person. Patients with either of these two types of meningitis should be placed on droplet precautions.
Other preventive strategies include:
- Following the vaccine schedule for yourself and children
- Wash your hands thoroughly and often, especially after changing diapers, using the toilet, or coughing or blowing your nose.
- Clean contaminated surfaces, such as doorknobs or the TV remote control, with soap and water and then disinfect them with a dilute solution of chlorine-containing bleach.
- Avoid kissing or sharing a drinking glass, eating utensil, lipstick, or other such items with sick people or with others when you are sick.
Have healthy summer.
As part of its ongoing mission to eliminate needlestick and sharps injuries in healthcare, Safe in Common (SIC) has issued the "Top 10 Golden Rules of Safety." This set of guidelines was outlined in conjunction with supporters to unify the industry around efforts to fight needlestick injuries and raise awareness about effective prevention techniques.
The outline for the Top 10 Golden Rules of Safety was released at the annual Association for Professionals in Infection Control and Epidemiology (APIC) Convention earlier this month.
The list is predicated on making injuries a "never event" and dictates that personnel using or purchasing sharps consider the following rules:
- The design and activation of the safety mechanism is automatic and will not interfere with normal operating procedures and processes
- The device is intuitive and requires no additional steps for use than equivalent standard/conventional device
- The contaminated, non-sterile sharp will be rendered safe prior to removal or exposure to the environment
- Activation of the safety mechanism does not require the healthcare worker to undertake any additional steps during normal process/protocols providing patient care
- Activation of the safety mechanism will not create additional occupational hazards (such as aerosolization, splatter, exposure to OPIM, etc.)
- Activation of the safety mechanism does not cause additional discomfort or harm to the patient
- The device will be ergonomically designed for comfort, allowing for automatic one-handed use during all stages of patient procedure
- The safer engineering control is available in sizes and iterations appropriate for all areas of use relevant to the patient care needs
- Disposal of safety device will not increase waste disposal volumes but should incorporate designs to reduce waste
- The used safety device will provide convenient disposal and mitigate any risk of reuse or re-exposure of the non-sterile sharp
"For the first time, the most experienced healthcare leaders have joined together to outline the rules for what it takes to keep all healthcare personnel safe and free of injury," said Barbara DeBaun, RN, MSN, CIC and Improvement Advisor for Cynosure HealthCare environments, who helped advise Safe in Common on these guidelines . "With these rules, we're getting the industry thinking about where we are and where we need to go to make safety a priority and injuries a never event."