I'd like to acknowledge the dedicated nurses from Texas Health Presbyterian who cared for the recently deceased Mr. Duncan. They, along with the nurses at Emory University in Atlanta and Nebraska Medical Center in Omaha who cared for patients with Ebola, deserve our admiration.
Nurses working in many different areas are appropriately concerned with exposure to Ebola. Of course, nurses in emergency departments and primary care clinics become the first line of defense, but those in day care and school nursing are also worried about detecting a suspect case.
Where do you get your information? Is it the CDC, WHO, your state and local health departments, CNN? Those of us in infection prevention and emergency preparedness have been inundated with email alerts, webinars and conference calls that sometimes provide conflicting and overwhelming advice.
While official CDC recommendations may continue to evolve, this checklist provides the key areas on which to focus: http://www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf.
1. Identifying a suspect case as soon as they enter your facility is vital. Nurses conducting screening and triage should ask if the patient has a TRAVEL HISTORY within the past 21 days and be aware of the symptoms of Ebola (fever > 101.5, headache, weakness, muscle pain, diarrhea, vomiting.)
2. Implement standard, contact and droplet precautions. Use personal protective equipment. At a minimum, wear a gown (fluid resistant or impermeable), facemask, eye protection (goggles or face shield) and gloves. Additional PPE may be needed depending on volume of body fluid involved or the procedures being done.
3. Practice putting on and REMOVING the PPE so you do not contaminate yourself. We are sometimes too casual with gowning and gloving for other isolation cases - don't let this be your routine.
4. Notify the appropriate leadership and infection prevention department at your facility who will contact the Health Department.
5. Finally, learn your facility's plan on how to handle patients with Ebola and other potentially infectious diseases. Which room should the patient be placed, where is the PPE kept, how do I reach the infection control nurse? Nurses have always risen to challenging cases and I believe will continue to do so if we are properly informed and have adequate protection.
We've had some summer for infectious diseases - chikungunya in the Caribbean and of course Ebola in West Africa. When a friend was diagnosed with Babesia, I thought I'd learn more about this tickborne disease often occurring during warm months.
Babesiosis is carried by the Ixode tick that lives on deer mice and other small mammals. The babesia parasite travels from the deer mouse attaches itself to a person for a blood meal. Although rare, transmission from mother to babies during pregnancy or delivery and through contaminated blood transfusions has occurred. For this reason, individuals infected with babesia should refrain from donating blood. Other than perinatal transmission, there is no person-to-person transmission and only standard precautions are necessary to care for these people.
The Ixode tick can be found in the Northeast and Upper Midwest area of the U.S. New York State, Minnesota and Wisconsin have the highest case loads. (http://www.cdc.gov/parasites/babesiosis/data-statistics.html)
After the parasite infects the red blood cells, the person can be asymptomatic or have flu-like symptoms including fever, chills, head and body aches, nauseas, anorexia and fatigues. More dramatic symptoms include splenomegaly, jaundice, hypotension, hemolytic anemia, thrombocytopenia and DIC.
Symptoms may appear anywhere from one week after infection to months later. Diagnostic clues are proteinuria, elevated LFTs, BUN and creatinine but the diagnosis is made by a blood smear.
Currently, no treatment is recommended for asymptomatic people infected with babesia. For symptomatic patients, antimicrobial therapy with one of two drug combinations is required: atovaquone plus azithromycin or clindamycin with quinine.
The nursing care of these patients may also include supportive treatment: antipyretics, vasopressors, blood transfusions, mechanical ventilation and hemodialysis.
Follow these preventive strategies:
1. Walk on clear trails and avoid contact with woodlands, grassy areas and brush since the ticks love these areas.
2. It takes the tick 36- 48 hours to transmit the parasite after attaching to the person so daily tick checks when returning from wooded areas is crucial. These ticks are tiny so check all body parts. See it in comparison to the size of a penny! (http://www.cdc.gov/parasites/babesiosis/prevent.html)
3. Shower when you come indoors
4. Wear light covered clothing that cover all parts of your arms and legs
5. Use a repellant - DEET may be used on your skin - check with your pediatrician, especially for infants. Permethrin can be applied to clothing and bedding (if you're the camping type.)
Recommendations on how to remove a tick can be found at http://www.cdc.gov/ticks/removing_a_tick.html
Although my friend required an ICU stay, I'm glad to say he's recovering nicely.
By Vicki Allen, MSN, RN, CIC, infection prevention manager for CaroMont Health in Huntersville, N.C. She serves on the Association for Professionals in Infection Control and Epidemiology's (APIC's) Communications Committee
Will fist bumps replace handshakes in the hospital? This is the question recently bantered about in the news media as well as respected medical journals such as the American Journal of Infection Control (AJIC), published by the Association for Professionals in Infection Control and Epidemiology (APIC), and the Journal of the American Medical Association. Considering the focus on healthcare associated infections, ongoing low compliance for hand hygiene and transmission of infections in hospitals, "fist bumping" may be an option. Fist bumping, a dap greeting gesture made popular by President Barack Obama and First Lady Michelle Obama during the 2012 election campaign along with studies such as this one published in the August issue of AJIC is certainly worth review and consideration.
"The Fist Pump: A More Hygienic Altnerative to the Handshake," published as a Brief Report in the August issue of AJIC, provides a laboratory model study from the United Kingdom assessing the transfer of bacteria in three greetings: the handshake, high five and fist bump. First of all a definition for dap greetings might be helpful. Dap greetings are essentially an urban form of greeting one another by the bumping of fists together, meant as a form of respect. The results from this study suggest dap greetings result in reduced transmission of bacteria between participants vs. that of the traditional handshake. The actual amount of transfer of bacteria during a handshake was variable, dependent on the length and strength or grip of the handshake. Results from the Mela/Whitworth study indicate nearly twice as many bacteria are transferred during a traditional handshake compared with a high five. However, the fist bump consistently was found to transmit the lowest amount of bacteria.
Hand hygiene, appropriate cleaning of patient equipment and environment are known practices in helping to prevent the spread of pathogens in the healthcare environment. The question remains whether or not healthcare facilities should implement the fist bump. This study certainly raises awareness of yet another factor to consider in making our patients safe as well as the prevention and transmission of infections in the healthcare environment and is certainly worth considering. Most likely the "fist bump" will catch on quickly with the younger generation; however, us "grandma" types might need a bit more convincing. Regardless, my CEO reminded me, "its time has come."
The annual APIC conference was held from June 6 to June 9 in sunny Anaheim. Thousands of professional from around the world attended. Each year the conference is increasing the use of technology. In recent years, certain sessions are broadcast on the web for anyone to watch. Last year's topic was infection control involvement in disasters - namely the earthquake in Japan and Hurricane Sandy on the East Coast. One of this year's sessions that was broadcasted discussed becoming a leader by developing communication and team building skills. There was an active group of IPs tweeting about their favorite sessions and commenting on the very active exhibit hall. APIC also launched an app "APIC 2014" to facilitate note taking, contacting colleagues and previewing slides. (Sorry password needed.)
One of the most fun uses of technologies was launched four years ago- the Film Festival Viewers' Choice Award. Fourteen videos were submitted and the winner was chosen by "the People"- sort of like THE VOICE for Infection Preventionists. The topics included hand hygiene, use of personal protective equipment and why need that Foley. The winning film is titled "Today, I Vow." In a brief one minute and 14 seconds, there is a pull on your heartstrings for following proper infection prevention measures. Congratulations to the winners - Norton Healthcare in the Midwest.
Here is a link to the video: http://ac2014.site.apic.org/highlight/film-festival/
In an abstract presented June 7 at the 41st Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC), a researcher analyzed archival data from the California Department of Public Health to determine the relationship between vaccinating healthcare personnel against influenza and the rate of influenza-like illness in the surrounding community. The conclusion was that for every 15 healthcare providers who receive the influenza vaccination, one fewer person in the community will contract an influenza-like illness.
"This study suggests that there is a strong connection between how many healthcare personnel are vaccinated against the flu and how many cases of influenza-like illnesses are reported in the community," said James F. Marx, PhD, RN, CIC, investigator and founder of Broad Street Solutions, an infection prevention consultancy. "More research would be helpful to further understand the impact of vaccinating healthcare workers on community influenza rates."
Influenza-like illness causes more than 200,000 hospitalizations each year and, on average, 24,000 people die as a result, according to the CDC. For the 2011-2012 influenza season, the influenza vaccination rate of California hospital healthcare personnel was 68%. If 90% of California healthcare personnel were vaccinated (the goal set by the federal government'sHealthy People 2020 initiative) there would be about 30,000 fewer cases of influenza-like illness in California.
APIC recommends that all healthcare facilities require annual influenza immunization as a condition of employment unless there are compelling medical contraindications. Read the APIC position paper on influenza vaccination.
In response to the CDC listing urinary tract infections as one of the five most common types of healthcare-associated infections (HAIs) in the U.S., the Association for Professionals in Infection Control and Epidemiology (APIC) has issued an updated Implementation Guide, available as a free, online download to help healthcare organizations prevent these infections in their patients.
The new edition of the Guide to Preventing Catheter-Associated Urinary Tract Infections (CAUTI) expands on the 2008 Elimination Guide and contains updated content on the epidemiology and causes of CAUTI, as well as detailed information on surveillance and reporting. An estimated 17%-69% of CAUTI could be prevented, totaling 380,000 infections and 9,000 deaths related to CAUTI per year.
Distribution of this guide as a full-access online resource from the APIC website is made possible by the Agency for Healthcare Research & Quality (AHRQ) through the national On the CUSP: Stop CAUTI project. On the CUSP: Stop CAUTI aims to reduce mean rates of CAUTI in U.S. hospitals by 25%. The initiative is working with APIC, state organizations, and more than 900 hospital units in 41 states across the country to implement the CUSP and CAUTI reduction practices.
Healthcare-associated vancomycin-resistant enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (CD), and other multidrug-resistant organisms (MDRO) were decreased among patients after adding ultraviolet environmental disinfection (UVD) to the cleaning regimen, according to a study published in the June issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).
In this retrospective study led by the Department of Infection Prevention and Control at Westchester Medical Center in Valhalla, N.Y., researchers discovered that the rate of healthcare-associated infections caused by MDRO and C. difficile was significantly lower during the 22 months of UVD use compared with the 30-month period before UVD (2.14 cases per 1,000 patient-days vs 2.67 cases, respectively). This decline in incidence occurred despite missing 24% of UVD opportunities.
UVD is a disinfection method that uses ultraviolet light to kill microorganisms in the patients' environment.
"Although there were many other simultaneous infection control interventions occurring at our hospital that could have contributed to the reduction in VRE acquisition, the rates experienced during UVD are the lowest incidence rates of VRE at our institution for the past 10 years and were sustained for 22 months," the study authors wrote.
In addition to use for contact precaution discharges, UVD was used weekly in the dialysis unit, and for all burn unit discharges. UVD could be requested for rooms of long-stay patients or for discharges in units with high prevalence of MDRO or CD.
"Use of UVD as an adjunct to routine discharge cleaning of contact precautions rooms was feasible and temporally associated with a significant decrease in hospital-acquired MDRO plus CD in our institution," conclude the authors.
Note: The hospital did not receive any financial support or discounts on equipment for the study.
APIC has a members' only listserv called IP Talk. Several recent posts dealt with how to clean shared electronic devices used in healthcare. People were asking for advice on how to clean devices such as keyboards, workstations on wheels or hand-helds like iPADs. This issue will continue to increase with the expansion of electronic medical records, mobile data collection tools and point of care screening devices. If you try an online search for disinfecting computer keyboards, there are citations from 2001 and earlier - which mention the bacterial laden foci they can be.
Yet, there are no straightforward answers. The general recommendation is to check the company's website and follow the manufacturer's instructions. Yet these are not very helpful because the disinfectant wipes used in healthcare often cannot be used on computer screens. There are screen covers that do answer this problem. One of the responders also felt that healthcare was slow to embrace alternative methods for cleaning or items that are easier to clean like rubber-type keyboards. Staff definitely wants clean items but there has to be a simple way to clean these devices and it should be clear who is to clean them.
How often do you wipe off your WOW or what about your own phone?
I've often wondered how they clean the devices on display that are used all day long at electronic stores. I happened to read this thread when I was working on a communal computer work station - as I bet many of you do every day. It did prompt me to clean not only the computer and keyboard, but the desk and phone as well.
Global leaders in enteral nutrition delivery systems are accelerating the international effort to enhance patient safety with Stay Connected, a communications initiative in coordination with the forthcoming ISO standards to reduce medical device tubing misconnections. The Global Enteral Device Supplier Association (GEDSA) - a non-profit trade association made up of manufacturers, distributors, and suppliers - is getting word out about the new standard at conferences and symposia, through an email campaign and on the Stay Connected website.
The website is the information hub for the initiative, which is divided into three phases: Aware, Prepare and Adopt, each of which will include information and tools to help organizations transition to the new connectors. ISO 80369-1 is the global design standard that establishes requirements for connectors for liquids and gases in healthcare applications. Site visitors can sign up to receive updates about the initiative throughout the transition.
GEDSA Executive Director Tom Hancock underscored the importance of this unified endeavor. "While the overall effort to reduce tubing misconnections is not new, this level of international communication and collaboration (between organizations that compete directly with one another) is going to be a big part of the initiative's success."
According to information provided by the Agency for Healthcare Research and Quality (AHRQ), KPC (Klebsiella pneumoniae carbapenemase) is not as well-known as other drug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), but it raises alarm bells in healthcare because it is resistant to known treatments and kills more than half of patients who become infected with it.
KPC is a type of carbapenem-resistant Enterobacteriaceae, or CRE, a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. AHRQ has published a toolkit to help hospitals control and prevent this source of healthcare-associated infection.
AHRQ funded leading KPC researchers from Boston University School of Public Health and Montefiore Medical Center in New York, to develop the "Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit," which hospitals can use to control and prevent KPC outbreaks.
The toolkit provides tools to help institutions assess their readiness for change, implementing a program and monitoring outcomes. The toolkit is available at www.ahrq.gov/cretoolkit.
Nurses' Week starts on May 6 - 12 and ends on May 12 - Florence Nightingale's birthday. This national event recognizes the contributions we make to the community. Of the multiple things we do for and with our patients, I think our overall focus is to keep our patients safe. We do this through direct care, via interdisciplinary relationships we've formed and through patient advocacy. Our impact also extends beyond our workplace as we are often resources for our friends, families, places of worship and our children's schools. Many of us also make contributions through nursing related volunteer work. How many of you have helped at a shelter, taught a hygiene class to kindergarteners or checked blood pressure at a county fair? This focus on keeping people safe may be our greatest impact. Patients recognize this which may be one reason why nursing was voted the most trusted profession in a 2013 Gallop poll.
One resource to further support our efforts for patient safety is the 10 Patient Safety Tips for Hospitals from the Agency for Healthcare Research and Quality lists. Nurses have a role in most of these tips but a direct impact in at least 5: preventing central line infections and DVTs, patient education about blood thinners, good discharge planning and involvement on effective teams. And I bet we'd all appreciate our work environments more if nurses had increased involvement with tip number 7: Use good hospital design principles. Evidence-based principles for hospital design can improve patient safety and quality by avoiding fall hazards, optimize hand hygiene, improve cleanliness, promote quiet and minimize distractions during tasks like medication preparation.
Thanks for you contributions to patient safety and our profession.
Happy Nurses Week!
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.