Archive for the ‘Infection control’ Category

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Ebola Changes You: Reflections of a Nurse Upon Return from Liberia

November 12, 2014

By Deborah Wilson, RN. The author is currently an IV infusion therapist with the Berkshire Visiting Nurses Association in Pittsfield, Massachusetts, and is completing her BSN at UMass Amherst. In October, she returned from Liberia, where she worked with Doctors Without Borders at a 120-bed Ebola treatment center. Names of patients mentioned in the article have been changed to protect patient privacy.

At the cemetery, newly dug graves

At the cemetery, newly dug graves

I have recently returned from Liberia, where I worked as a nurse for six weeks along with a dedicated team of physicians, nurses, and other professionals, treating 60 to 80 Ebola patients a day. My 21-day transition time is recently over and, although I am back at work and school, my heart is with the West African nurses who I worked with for those weeks in September and October.

I worked in a town called Foya, managing a 120-bed Ebola treatment center (ETC). During the first two weeks, I wondered if I would last. In the grueling heat, dressed up in all that personal protective equipment (PPE), constantly sprayed with chlorine, each day I was haunted by the question of whether I’d somehow gotten infected.

It all took its toll. Twice a shift the nursing team would put on PPE and enter the confirmed Ebola isolation area. People lay on mattresses on the floor, vomit and diarrhea everywhere. In our bulky gear, double-gloved, goggles fogging and sweat running out of every pore, we would insert IVs, push meds, try to help someone eat a little something, tell the hygienists that a body needed to be removed to the morgue.

So how did I go from wondering how I would make it through my six-week assignment to now actually considering going back? It was thinking about the nurses and teams who are still there going in every day, never having a 21-day transition period like mine to look forward to, all with colleagues and family who died during this devastating outbreak.

With staff at the 120-bed Ebola clinic in Foya

With staff at the 120-bed Ebola clinic in Foya

Our lives were in each other’s hands—we helped each other dress in PPE and double-checked each other before going in. Talking with one patient, I said, “we must look really weird,” and he laughed, which made us all laugh.

But there was not much laughter in the area for confirmed cases. We never knew who would live or die; sometimes the healthiest would suddenly be dead. We delivered babies who were so small and premature—I think about the young 19-year-old mother dying only an hour after her little boy had been placed in a white body bag and given a name so he could be identified in the morgue. I find myself wondering what her and her son would be doing now if there had been a way to save her.

I wonder about Joy, whose love and dedication to her husband touched all of us deeply. Daily she would come to the fence with his favorite food and George would come out and sit on the other side. When he got too sick to come outside, we dressed her in PPE and took her in, where she prayed with him. We all rejoiced when a pregnancy test revealed that Joy was pregnant, then saw her nearly immobilized with grief the next day when George died. Joy’s cries and sobs as the psychosocial team sat with her is something I still wake up to. I wonder how she is doing and where she is now. Will she have a boy or girl and what will she tell him/her about George?

The Liberian nurses still call me on the phone. They tell me that there is not one case of Ebola now in the ETC! Many have to go back to the health clinics where they worked before. All of them lost colleagues because, when sick people came to their clinics, they had no gloves, masks, or chlorine to protect them. Will they have basic protective equipment now?

They also haven’t been paid for September or October. The Liberian Ministry of Health keeps saying that they will get paid, but I fear that this outbreak has wreaked such havoc on the economy that they have risked their lives, working in conditions we will never have to endure, perhaps only to also risk earning no income as well for their efforts.

My three-week transition involved learning the news of the two nurses in Texas who were infected caring for Thomas Eric Duncan, of physician Craig Spencer testing positive in New York City and Kaci Hickox being locked up in an unheated New Jersey tent with no shower. At times I thought I would go mad—watching as a collective insanity gripped our nation about a virus unlikely to ever take hold in the U.S., I yearned for the day when we could instead turn our attention to what I believe this terrible epidemic in West Africa could really be teaching us: Read the rest of this entry ?

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Ebola: A Role for Nurses in Sharing the Facts

October 29, 2014

By Shawn Kennedy, AJN editor-in-chief

Screen Shot 2014-10-29 at 12.27.27 PMThe current Ebola crisis has everyone concerned over transmission, and rightly so. The public has been in a quandary as to who and what to believe. I can’t say I blame them. We should have been better prepared and anticipated that, given the situation in West Africa, we would eventually see a patient with Ebola present to a U.S. hospital ED (or clinic or urgent care center). What’s surprising is that it didn’t happen sooner.

I’d thought fears about widespread transmission of Ebola had abated after no more new cases arose from that of Thomas Eric Duncan in Dallas: his family, who were in the apartment with him during the time he was sick, did not contract Ebola and have since been released from quarantine; the two nurses who became ill treating Duncan have now been declared Ebola free and none of their contacts have become ill; no other nurses who provided care for him have fallen ill.

But with the onset of confirmed Ebola in a New York physician who had recently returned from caring for Ebola victims in West Africa, fears of widespread contagion resurfaced. Craig Spencer had been self-monitoring his symptoms while he went about his life; when he began to feel ill and developed a low-grade fever, he initiated a controlled transport in isolation to Bellevue Hospital.

And when nurse Kaci Hickox returned from volunteering in West Africa, she was caught in New Jersey’s new Ebola precautions and placed in mandatory quarantine in a tent outside a hospital in Newark. She protested, secured attorneys to advocate on her behalf (basing her protest on CDC recommendations that routine quarantine of nonsymptomatic health care workers is not justified), and was released to travel home to Maine, where she is now disputing Maine’s mandatory in-home quarantine and active monitoring requirement in favor of self-monitoring. Read the rest of this entry ?

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Addressing Nurses’ Urgent Concerns About Ebola and Protective Equipment

October 15, 2014

By Betsy Todd, MPH, RN, CIC, AJN clinical editor. (See also her earlier post, “Ebola: A Nurse Epidemiologist Puts the Outbreak in Perspective.”)

This is not a time to panic. It is a time to get things right.—John Nichols, blogging for the Nation, 10/12/2014

Scanning electron micrograph of filamentous Ebola virus particles budding from an infected VERO E6 cell (35,000x magnification). Credit: NIAID

Scanning electron micrograph of filamentous Ebola virus particles budding from an infected VERO E6 cell (35,000x magnification). Credit: NIAID

For years, nurses have tolerated increasingly cheap, poorly made protective gear—one result of health care’s “race to the bottom” cost-cutting. Now the safety of personal protective equipment (PPE) is being hotly debated as the Ebola epidemic spills over into the U.S.

If all nurses had access to impermeable gowns that extended well below the knee (and could be securely closed in back, had real cuffs, and didn’t tear easily); faceguards that completely shielded; N95 respirator masks that could be properly molded to the face; and disposable leg and shoe covers, we might not be having the same conversation. Yet how much protection can we count on from the garb we now have available, especially considering the minimal donning and doffing training given to most nurses?

While there is more to be learned about possible “outlier” modes of Ebola transmission, it’s pretty clear from past experience (including recent Ebola hospitalizations at Emory University Hospital and the University of Nebraska Medical Center, where no transmission has occurred) that standard, contact, and droplet precautions will virtually always prevent Ebola virus transmission. Because of the theoretical possibility that the virus could be aerosolized during procedures like intubation or suctioning, airborne precautions are usually added. (And from what we’ve seen, they’re being followed routinely, and not used only during aerosolizing procedures.)

Many organizations, including National Nurses United, are calling for hazmat-type gear and PAPR hoods (powered air-purifying respirators, which are HEPA-filtered) for staff who care for Ebola patients. Because most nurses have not used these, this more complex gear presents new challenges, especially because of the potential for self-contamination when worn and removed by untrained staff.

Specific techniques for donning and doffing PPE are not new, but many nurses have never been taught to pay attention to these details. One has only to look at staff in a contact precautions room, only half covered by their untied gowns, to understand why resistant organisms continue to spread within hospitals. Many clinicians may not have believed that their cavalier attitude towards PPE had anything to do with the next patient’s nosocomial MRSA pneumonia. During this Ebola epidemic, though, we are quickly learning that the proper use of PPE is a matter of life and death—ours. Read the rest of this entry ?

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Ebola: Infection Control Resources Make All the Difference

September 16, 2014

This post is follow-up to our widely shared post (“Ebola: A Nurse Epidemiologist Puts the Outbreak in Perspective”) by AJN clinical editor Betsy Todd. The author, Amanda Anderson, is a critical care nurse and graduate student in New York City who is currently doing a graduate placement at AJN two days a week. Her last post for this blog is here.

Ebola virus viron

By CDC microbiologist Cynthia Goldsmith, this colorized transmission electron micrograph (TEM) revealed some of the ultrastructural morphology displayed by an Ebola virus virion. CDC image library.

I don’t know a single nurse who likes caring for multiple isolation patients. The process of donning a new gown, pair of gloves, and mask each time you enter an isolated patient’s room is arduous and time-consuming. Personal protective equipment (PPE) clogs the garbage cans and can be hot and confining.

PPE has been in the news quite a bit lately because of Ebola. An interview with Liberian nurses by Hunter College’s Diana Mason on her WBAI radio show Healthstyles revealed that the Liberian Ministry of Health estimates 75% of virus victims are women—mostly nurses and caregivers. Nurses in West Africa might really love some of those pesky yellow isolation gowns.

Ebola can be a messy virus. Infected people have copious diarrhea and vomiting, often containing blood. The basics of care for Ebola patients should not be new to us; HIV and hepatitis can be spread in many of the same ways. We’ve got little to fear if we follow CDC guidelines for PPE and infection control. But in parts of Africa, where supplies we take for granted are scant, nurses and caregivers can’t even hold the hand of a dying patient or family member, much less clean them, without fearing for their lives.

As Mason’s interview reveals, many nurses are assigned 25 or more patients each shift in hospitals that lack electricity, running water, and gloves. (In an article for Buzzfeed, Jina Moore describes a nurse working in an Ebola ward who wears the isolation kit sent to her by the Liberian Ministry of Health. The kit includes a shower cap, gloves, and rubber bands for her wrists. Her ankles and neck are exposed, peeking out from her own short scrubs.) Read the rest of this entry ?

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Enterovirus D68: Precautions, Surveillance, Yes; Alarm, No

September 15, 2014

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

EV68-infographicAs news coverage focuses on the latest clusters of suspected—and, in some instances, confirmed—cases of human enterovirus D68 (EV-D68) as they occur in successive regions of the U.S., here’s a quick primer on what is known about EV-D68.

Is this a new, dangerous virus?
EV-D68, a non-polio enterovirus, is not a “novel” virus—the term used to describe emerging infections such as SARS and MERS. It’s more accurate to describe it as the CDC does: it is an “increasingly recognized” cause of respiratory infections, especially in children.

EV-D68 was first isolated in 1962. While reports of EV-D68 since then have been sporadic, the CDC in 2011 reported on clusters of this viral infection in Georgia, Pennsylvania, and Arizona as well as in Asia and Europe. It’s likely that there are hundreds or even thousands of EV-D68 infections every year in the U.S. But as with many other viral infections, they will range in severity, and an infection that looks like “a cold” isn’t usually brought to the attention of a health care provider.

According to the CDC, most enterovirus infections are actually asymptomatic; this may be the case with EV-D68 as well.

Diagnostic testing for EV-D68 involves RT-PCR and gene sequencing. Most hospital labs therefore are unable to test for it. Some readily available diagnostic tests do identify “enterovirus” but don’t type the virus further; some tests misidentify EV-D68 as a rhinovirus. (Specimens from suspect cases in the U.S. therefore almost always are handled by CDC labs.)

Because treatment is symptomatic, the lack of a widely available test for EV-D68 is not an issue for the patient. But as more sensitive and specific tests become more widely available, more cases will be correctly identified, and we can learn more about the course of the disease.

Genetically similar to cause of common cold.
EV-D68 belongs to a genus of viruses that includes polioviruses, rhinoviruses, coxsackieviruses, and echoviruses. It is not “polio-like.” Biologically and epidemiologically, it is most similar to human rhinoviruses, which cause the common cold.

Severe respiratory infections in children? Visitor restrictions?
While we are seeing reports of severe respiratory illness in patients with suspected or confirmed EV-D68, it should be noted, as the CDC points out, that many/most of those hospitalized with this and other respiratory infections are people with chronic conditions such as asthma or other health issues. Visitor restriction is a routine response in any hospital when there is a cluster of respiratory infections in the community. Read the rest of this entry ?

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Labor Day Déjà Vu – Nurses’ Views of Work, Then and Now

September 2, 2014

By Maureen Shawn Kennedy, AJN editor-in-chief

Photo from otisarchives4, via Flickr.

Photo from otisarchives4, via Flickr.

If you like nursing history, there’s a new blog called Echoes and Evidence by the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania. (The first post draws on a 2005 AJN article on how nurses over 100 years ago responded to a series of typhoid epidemics in Philadelphia.)

Because AJN is over 100 years old (115 next year), it has a rich archive that I’ve been digging into recently (see my post from last week about an article Virginia Henderson wrote for AJN 50 years ago, and from late June, about nurses and D-Day).

So it seems especially fitting, just after Labor Day, to point to a January 1953 article by Sister Mary Barbara Ann, a former president of the Iowa Nurses Association (INA), which detailed findings from a survey of 223 general duty nurses in Iowa to learn their opinions of the hospitals in which they worked. I won’t present her exact findings here—we’ve made the article free until the end of September: just click through to the PDF. (Subscribers can always access the archives.) But here’s how she summarized what she learned:

“They [general duty nurses] are asking only for reasonable working conditions in which they can feel happy and secure. They are pleading for recognition and appreciation for what they are as persons and as nurses. They are asking for personnel policies which they have a voice in formulating, which are written and available to all, and which will be strictly adhered to by both nurses and administrators.”

Sound familiar?

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Much Ado About a Fist Bump Study

August 4, 2014

hands touching illustrates post about fist bump study and germsBy Karen Roush, clinical managing editor

In this world of evidence-based care, is there anything to be said for common sense? Last week a study was published in the American Journal of Infection Control that found that a fist bump transmitted fewer organisms than a handshake.

Really? We know that hands carry untold numbers of organisms. We know that skin-to-skin contact transmits organisms. We know that duration of contact plays a role in how many organisms are transmitted. Did we need a study to tell us that hand-to-hand contact with less surface area for a shorter duration of time would transmit fewer organisms?

With the attention being paid to this study, you might think it was a major discovery. Why? Because it’s fun to talk about fist bumps versus handshakes? (David Letterman seems to think so; he recently opened his monologue with a joke about the study results.) Because we kind of like the visual of everyone, from the staid to the cool, walking around giving fist bumps?

Or perhaps, on a serious note, because we’re still struggling unsuccessfully to get people to simply wash their hands and are ready to jump on anything that mitigates the risk of transmission when they don’t? (Adherence to hand hygiene guidelines among health care workers remains low. Read our March 2013 CE–Original Research feature, in which authors Kate Stenske KuKanich and colleagues describe their evaluation of a hand hygiene campaign in an outpatient oncology clinic and an outpatient gastrointestinal clinic.) Read the rest of this entry ?

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