Archive for the ‘infection control’ Category

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The Grave Dangers Facing Medical Aid Workers in ‘Insecure’ Regions

September 29, 2010

I recently heard from Jacqueline Koch, a senior communications officer with the global medical aid group, Merlin. As described in a recent AJN photo-essay on Merlin’s work in Gaza (for the best view, click through to the PDF version), the organization partners with local health organizations and trains health workers to provide care in response to natural and man-made disasters. Ms. Koch has now shared with AJN a first-person account of one Pakistani woman’s experiences working with flood victims, which includes a description of that worker’s own family’s suffering as a result of the flood. This account, which will appear tomorrow along with several photos, is prefaced below by Ms. Koch, who provides context for Azra Habib’s story. The security issues raised by Ms. Koch are frightening, in that we now see an already taxing kind of health care work becoming even more perilous because of the threat of physical attacks like the murder of 10 medical aid workers in Afghanistan back in August.—Jacob Molyneux, senior editor/blog editor

A toddler recovering from dehydration brought on by acute watery diarrhea in Merlin's DTU in Charsadda.

‘Senseless but simple.’ In Pakistan, alongside a breadth of man-made and natural disasters, there are many occupational hazards and cruel ironies, especially for aid and health workers. It’s senseless but simple: delivering aid, providing medical care, and saving lives can potentially make you a target.

For any Pakistani national health worker who is working for an international nongovernmental organization (INGO), the danger multiplies. Not only can they themselves be threatened, but so can their parents, siblings, spouses, children, and extended families. They face armed attacks, death threats, robbery, kidnapping for high ransom, and the very real possibility of murder.

Many must navigate these dangers by refraining from visiting nearby family, living in close proximity of their offices, and hiring guards to escort their children to and from school. When working in the field, many opt to leave hats and jackets with INGO logos and ID cards behind, alongside their BlackBerries and anything else that might identify them. They have little choice but to dramatically alter the rhythm of their lives in order to save lives—including their own. But these measures are not always foolproof.

Not just in Pakistan. Merlin, an international medical aid organization, recently published a report outlining the impact of violence, conflict, and insecure environments on health workers, who are central to achieving the United Nations Millennium Development Goals. For those delivering essential health care in fragile or conflict-affected states, it is “A Grave New World.”

As one female health worker in Pakistan in conflict-affected Swat Valley (and who asked for anonymity) noted:

“The militants were against family planning, saying women must stay in the home. As a Lady Health Visitor, I was suspected of providing family planning and therefore at risk. During the militant regime, I could not reach women, I couldn’t meet my patients. If someone knew what my job was, they would have cut me to pieces. I often think about it, I think about my children, because my job is something my family needs. My family needs my job to survive. But I had to stop working here during the regime. I left. While I was away, I thought about my patients, I thought about those who I left behind and who didn’t have anyone to care for their health.” Read the rest of this entry ?

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When Timely Nurse Removal of Urinary Catheters Reduces UTI Rate

August 19, 2010

By Christine Moffa, MS, RN, AJN clinical editor

Ever since we started the Cultivating Quality column at AJN, manuscripts featuring evidence-based quality improvement projects have been pouring in. There is a lot of great work being done at the bedside by practicing nurses, and this column provides the opportunity to share their ideas with others.

Lancaster General's CAUTI rates, fiscal yrs 2007-2009 (click to enlarge)

This month’s Cultivating Quality installment, Reducing Rates of Catheter-Associated Urinary Tract Infection, comes from Joyce Wenger, MS, RN, the infection control performance improvement coordinator at Lancaster General Hospital, Lancaster, PA. According to the CDC, urinary tract infections (UTIs) account for more than 30% of hospital-associated infections, and almost all are “caused by instrumentation of the urinary tract.” Nursing staff were able to reduce catheter-associated urinary tract infection (CAUTI) rates using a three-pronged approach “beginning with education, progressing to tests of new and better products, and ending with the nurse-driven protocol for catheter removal.”

That last part is my favorite. In most facilities a doctor or nurse practitioner has to write an order before a Foley catheter can be removed from a patient. Patients may end up spending several days at increased risk for UTI because of an unnecessary urinary catheter in place. This hospital came up with a plan to give nurses the autonomy to remove them—which makes sense, since they’re the ones checking the patient daily. The team at Lancaster General created the following list of criteria that patients need to meet in order to maintain a Foley catheter. If not, then the nurse can remove it.

A nurse keeps the Foley catheter in place if

  • a urologist is on the case; the catheter cannot be removed without the urologist’s approval.
  • a physician has ordered that the catheter not be removed (the medical reason to continue or criteria for removal should be documented).
  • a physician has documented “medical necessity” within the last 24 hours.
  • the patient is unresponsive or comatose.
  • the patient is receiving palliative or hospice care.
  • the patient has received IV sedation within the last 12 hours.
  • the patient has received IV inotropic agents within the last 24 hours.
  • there is an order for IV diuretics to be given every six or fewer hours.
  • the patient is undergoing ultrafiltration.
  • acute or worsening renal failure is evident (that is, there has been a creatinine level increase of 1 mg/dL or more above the admission or baseline level).
  • surgery has been performed within the last 24 hours.
  • a pressure ulcer might be soiled if the catheter is removed and the patient is incontinent.

But I’d recommend reading the entire article and seeing how these interventions compare to those at your facility. We’d love to hear what you think about it.

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Watch Out for Dengue Fever in Travelers

August 2, 2010

By Diana J. Mason, PhD, RN, FAAN, editor-in-chief emeritus

Dengue Distribution, Western Hemisphere (CDC)

You may have heard that in late July the Centers for Disease Control and Prevention (CDC) issued an advisory on dengue infection, which can lead to dengue fever or dengue hemorrhagic fever, noting that dengue is becoming an epidemic in tropical and subtropical areas of the world, with recent or ongoing outbreaks occurring in Puerto Rico; in Key West, Florida; and the Caribbean. It’s particularly important for nurses to be alert for symptoms of dengue fever among people who have returned from travel to tropical areas. Symptoms may include fever, eye pain, joint pain, rash, and bleeding. The greatest danger is from dengue hemorrhagic fever, which can lead to death.

For more on dengue infection (including its detection, treatment, and prevention), see the April 2008 article on the topic in AJN. And as always, please let us know here if you’ve encountered it recently yourself as a clinician—or traveler.

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Scutari: A Blog Post Will Never Do Justice To This Visit

July 22, 2010

This is the second to last in a series of posts by Susan Hassmiller, Robert Wood Johnson Foundation Senior Adviser for Nursing, that chronicle her summer vacation spent retracing Florence Nightingale’s influential career.

Scutari was a “tragedy of epic proportions of which bureaucratic muddle and sheer human incompetence played the larger part, thrown in with a measure of bad luck.”

–Mark Bostridge, from his book, Florence Nightingale: The Making of an Icon

The Hospital: What Florence Experienced
It is almost incongruent that a woman who wrote more than 14,000 letters and 200 books said upon arriving at Scutari Hospital, a converted army barracks, that she was without words to describe what she saw. Of course, as time caught up with her, the words flowed quite freely. Death and mutilation surrounded her in this well-known deathtrap.  Her nurses slept (“in catnaps”) in cramped quarters. Men were cramped into rooms and spilled out into the long corridors as they lay on straw beds on cold stone floors. Attendants had to walk over the men who were, by Nightingale’s command, a requisite 18 inches apart. More men died than lived.

Nightingale in Scutari ward/Library of Congress, via Wikimedia Commons

Nightingale hardly slept, took her meals by the spoonful, and spent most of her time caring for the men, overseeing the band of nurses she brought with her (some were hardworking and disciplined, while others were not), administering the overall operation of the system, fundraising, constantly devising ways to make improvements to save more men and, of course, recording everything. She recorded for herself as evidence for her improvements and to teach lessons, but also to publicize the horrors of the situation to decision makers and the public back in London. The London Times and her good friend Sidney Herbert, the Secretary at War, made good use of her reports, which led to myths that she was a spy.

No man was ever allowed to die alone. Either Nightingale or one of her nurses stood over each man with an accordion lantern (not a genie lamp) day and night, to provide comfort until his passing. Nightingale was said to insist that she be present at every operation, as brutal as it was. Chloroform was not used until the second quarter of the war, well after Nightingale arrived.

What I Experienced…
Scutari is the current home of the Turkish First Army and its administrative offices. Security is extremely tight and no pictures were allowed. The Nightingale Museum, which is visited infrequently because special permission and logistics are required to get in, is in one of the four towers of the massive fortress structure. In the long corridors to get to the tower, marble floors now glisten and windows sparkle from daily cleanings—immaculate conditions are the order of the day.

So you have to use your imagination and historical reference to place yourself in her bloody boots. I did. I saw the rooms where they would have been, and imagined how I would have to listen to the screams of grief and step over those who have died. I imagined the nurses making their constant rounds, up and down these very long corridors, doing all they humanly could. I know now that there was no such thing as a “genie’s lamp,” as is the myth in all the pictures. What the nurses carried were cotton accordion lamps, one of which I purchased at the same Grand Bazaar in town where Miss Nightingale bought hers. I did shed a few tears when I walked away with my purchase, knowing what the lamp symbolized. Read the rest of this entry ?

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Ms. Nightingale as an Applied Statistician

July 20, 2010
By Sue Hassmiller, PhD, RN, FAAN (latest in a series of posts by Hassmiller, who’s spending her summer vacation retracing crucial steps in Florence Nightingale’s innovative career)
 
Here at the home of Florence Nightingale, Embley Park (for more on Embley Park, see last week’s blog post), approximately 100 people have convened to study the impact of the “Lady with the Lamp.” The lady herself was multifaceted, and so is this crowd of scholars. There are nurse leaders, of course, but also museum curators, historians, educators, and biographers. They are all interested in their own piece, but also in how their piece fits into the bigger whole of her life. Today we heard Professor Thomas from the University of Southampton School of Business discuss her contributions as an applied statistician.
   

Nightingale in Scutari ward/Library of Congress, via Wikimedia Commons

Representing mortality. Early in her life, Ms. Nightingale identified the need for hospitals and healthcare systems to collect and use data to improve care. She asked what use are statistics “if we don’t know what to make of them?” She is credited with developing the famous “coxcomb” illustration, which was a multidimensional way of depicting mortality rates. She used statistics at Scutari Hospital (also called Selimiye Barracks) in Turkey to guide her actions and used statistics and data in the London Times to convey the travesty of the Crimean War. 

Institutional and cultural barriers. But Nightingale didn’t just rely on data for getting more of what she needed for the soldiers—she also used storytelling . . . a lesson that’s not lost on me in terms of affecting policy today. However, and this is a big however, just as they do today, politics, context, and culture reigned supreme. Read the rest of this entry ?

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Nightingale as QI Expert and Hospital Designer

July 13, 2010

By Sue Hassmiller, PhD, RN, FAAN (this is the 4th in a series of posts by Hassmiller retracing Florence Nightingale’s influential and innovative career) 

Seeing the famous St. Thomas’ Hospital today, I thought Florence Nightingale would roll over in her grave with disgust! What were they thinking, I asked the tour guide? Well, she said, it was the ‘60s. No excuse, I barked back! Prince Charles doesn’t like it either, if that makes you feel any better, she responded.

Applying best practices. The most visually prominent buildings in the hospital now consist of a couple of plain, brown, nondescript, blocklike structures—not anything like Nightingale, once the most famous hospital designer in the world, would have had it. Or, rather, did have it. Her friend, Queen Victoria, laid the first stone and Florence Nightingale contributed to the design and relocation of the St. Thomas’ Hospital of the mid-1800s, with the intention of applying best practices she had brought back from the Crimean War as well as her own research and statistics. 

Nightingale was much sought after as a master designer of hospitals; architects, physicians, and royalty from around the world asked her advice. And here was supposed to be her masterpiece . . . but her version of St. Thomas’ is just about gone.

Physical, spiritual, mental health needs. Nightingale envisioned the relocated and rebuilt St. Thomas’ as a beautiful series of pavilions where different patients with different ailments lay. Read the rest of this entry ?

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A Weekend With Florence In London

July 12, 2010

Editor’s note: The two entries below, written on Saturday and Sunday in London, are the latest in a series of posts by the Robert Wood Johnson Foundation’s Senior Adviser for Nursing, Susan Hassmiller, who’s spending her summer vacation retracing the footsteps of Florence Nightingale and reflecting on the implications of Nightingale’s work for nurses today.

Saturday: Westminster Abbey (London)

I arrived in London for my vacation today. They tell me it is uncharacteristically hot (nearly 90 degrees), so that gave me full license to have ice cream . . . not once, but twice! And although the “official” Florence Nightingale tour hasn’t started, I didn’t waste time getting a head start on my quest to better understand the contributions of Ms. Nightingale. Read the rest of this entry ?

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The Nightingale Immersion Experience

July 12, 2010

Susan Hassmiller, the Robert Wood Johnson Foundation’s Senior Advisor for Nursing, is traveling through Europe on a tour developed in honor of the centennial of Florence Nightingale’s death. This is the second of two preliminary posts she gave us last week before taking to the skies; click here for the first. Starting later today (so check back this afternoon!) with a first post from London, Hassmiller will report on her trip, what she’s learning, and why Florence Nightingale is as relevant as ever to nurses’ work today. 


I’m still in immersion mode,
learning all I can about Florence Nightingale—the “Lady with the Lamp” (a name Wikipedia succinctly explains)—as I get ready for my trip. What have I learned so far? Well, I’m blown away. Read the rest of this entry ?

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Protection or Harm — What Are You Doing at the Bedside?

June 21, 2010

By Peggy McDaniel, BSN, RN

by sergis blog/via Flickr

If I knew then what I know now. In my current nursing role I promote best practices, particularly around reducing bloodstream infections and preventing intravenous medication errors. When I was at the bedside, I did not know what I do now. I now read many articles and studies around infection control and am much more aware of what can be done to reduce risk and improve quality of care. I wonder how many bedside nurses understand the “why” behind the mandate for hand hygiene compliance? 

Thirty-four percent compliance. A recent study (here’s a useful summary, and here’s the study abstract) published some dire statistics that only confirm what other studies have shown in recent years: during routine care, clinicians (nurses and doctors) only followed hand hygiene compliance guidelines 34% of the time. Some additional details should not be overlooked as well. Clinicians tended to perform hand hygiene more often after procedures or when exposed to blood. This implies that clinicians are much more concerned with protecting themselves than their patients. Even with much focus on increasing hand hygiene compliance and many dollars being spent on technology to monitor and promote compliance, the statistics reveal that we have a long way to go.

Does our training instill in us the respect we should have for microbes and transmission of microbes? Does theory taught in microbiology classes today take the next step to connect the idea that the “bugs” that cause infection can often be stopped dead by just not passing them along? What do you think? I’d like to know. I went to school over 25 years ago and while I was a staff nurse I always heard the call to wash my hands—but I will admit that the call did not always translate into action. I was busy, there was always one more task to do, and after all, hadn’t I just put on or removed some gloves? Didn’t all of that count? Read the rest of this entry ?

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