Ebola, One Year Later: What We Learned for the Next Big Epidemic

November 6, 2015

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

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

U.S. hospitals have not seen a case of Ebola virus disease since November 11, 2014, when Dr. Craig Spencer was discharged from Bellevue Hospital Center in New York City. While the number of new infections has declined dramatically in the West African countries where the 2014–2015 epidemic began, it is virtually certain that the disease will continue to resurface.

This epidemic was by far the largest and most geographically widespread Ebola epidemic to date, with approximately 28,000 cases (suspected, probable, or confirmed) and more than 11,000 deaths in Liberia, Guinea, and Sierra Leone, the three hardest-hit countries. The seven other countries affected account for a combined total of 34 confirmed (and two probable) cases and 15 deaths.

According to a recent WHO report, these numbers include (through March of this year) 815 confirmed or probable cases among health care workers, more than half of whom were nurses or nurses’ aides. (Doctors and medical students made up about 12% of total health care worker cases.)

This epidemic has been, for some, a wake-up call about the ease of global disease transmission. The ever-increasing movement of humans and animals over and between continents has created what virologist Nathan Wolfe refers to as a “giant microbial mixing vessel.” Before U.S. health care collides with the next deadly virus, it might be helpful to review some of what we’ve learned from these events.

  • As Paul Farmer, a physician with decades of experience in outbreak control, emphasized late last year: “weak health systems, not unprecedented virulence or a previously unknown mode of transmission, are to blame for Ebola’s rapid spread.”
  • People with Ebola are more likely to survive when they have access to critical care services—care that is unavailable (or inaccessible) in many countries.
  • In monitoring the first large cohort of Ebola survivors, we are learning about possible residual effects of Ebola, including eye pain, blurred vision, hearing loss, swallowing difficulties, arthralgias, sleep problems, neurological changes, and memory loss and confusion. The virus can persist in semen for at least nine months. Pauline Cafferkey, a Scottish nurse who contracted Ebola while working in Sierra Leone, developed meningitis last month, 10 months after she was thought to have recovered from the infection. Ebola virus was detected in her cerebral spinal fluid.
  • More than 30 years ago, people with HIV and the nurses who cared for them were often shunned by family, friends, and coworkers. Neither Ebola nor HIV is spread by casual contact (here’s CDC information on what’s known about transmission risks), but experience during this Ebola epidemic has shown that people with “new” or “scary” infections continue to be stigmatized, even by health care workers.
  • Many nurses had not been using long-standing personal protective equipment (PPE) donning and doffing protocols in everyday practice—there was a scramble to reemphasize these protocols after the first case of Ebola arrived in the U.S.
  • Years of “bottom line” management in U.S. hospitals have left many facilities with inadequate staff, fewer education and training resources, and multiple systems issues that have impeded disaster preparedness and compromised the quality of protective gear and other supplies available to staff.
  • Content-hungry print and electronic media interfere with evidence-based responses to infectious disease threats when they pander to fear and hysteria. The damage during this epidemic ranged from unnecessary quarantine of asymptomatic individuals to willful denials of actual transmission risk in the U.S. to euthanizing the dog of a Spanish nurse after she contracted Ebola.

Read the rest of this entry »


Preventing Newborn Falls

November 4, 2015
Photo by Joseph Sacchetti.

Photo by Joseph Sacchetti.

An acquaintance of mine once admitted to dropping her newborn baby while feeding her in the middle of the night. At the time I inwardly scoffed—how can someone be that tired, I thought judgmentally. Fast-forward to a few years later when I can now speak as a new mother—and to being that tired.

Sleep deprivation is no joke. And it doesn’t necessarily begin when the baby is born. The last few months of pregnancy and the discomfort that comes with it make for difficult sleep preceding the birth.

Many maternity units now promote “rooming in,” where a newborn baby stays in the mother’s room rather than with the nurses in the nursery. This makes newborn fall prevention an important issue. Take poor sleep in the last months of pregnancy and the physical and mental exhaustion of labor and add pain and limited mobility from the birth itself, especially a C-section birth; large rails on hospital beds making the transfer of one’s baby from bassinet to the mother’s bed difficult; and possible pain meds for mom, and the recipe could spell disaster.

In my case, with an emergency C-section and limited mobility, I found it very hard to pick my baby up from his bassinet and bring him into my hospital bed for a feeding. Luckily my husband stayed in the hospital room overnight and the nurses checked in around the clock, but not all mothers may be as fortunate.

In the November Safety Monitor column, “Preventing Newborn Falls While Supporting Family Bonding,” the Pennsylvania Patient Safety Reporting System highlights examples of such falls, pointing out that most occur “between midnight and 7 AM.” The article also highlights what hospitals—and nurses—can do to prevent these occurrences. Newborn fall prevention programs might include: Read the rest of this entry »


Final Connection: An ICU Nurse Revises Her Feelings About Cell Phones

November 2, 2015
Illustration by Denny Bond. All rights reserved.

Illustration by Denny Bond. All rights reserved.

Many of us have a love-hate relationship to smartphones, and each person (and generation) draws the line in the sand between invasiveness and usefulness in a different place. Cynthia Stock, the critical care nurse who wrote the Reflections essay in the November issue of AJN, “Final Connection,” starts her brief and moving story with honesty about such matters:

On Monday, if you had asked me how I feel about cell phones, I would have come up with this: I hate to listen to the drone of conversation coming from the person next to me on the treadmill at the gym. I don’t care about trouble with the HOA. I don’t care about a son who can’t decide on a career as a director or an actor. I work out to smooth the kinks in my soul from a job that requires me to navigate a relationship with life and death.

Today, ask me how I feel about cell phones. . . .

A good essay or story often centers around a reversal of some sort. What the protagonist believed may not be so true after all, or may be more complicated than first thought. As you can probably guess, in the course of the essay the author finds that she must revise her opinion of cell phones. Time and the pressures of geographical distance are sometimes felt more urgently in the ICU.

Read the rest of this entry »


AJN in November: New Cancer Survivorship Series, Holistic Nursing, Safe Opioid Use, More

October 30, 2015

AJN1115.Cover.2nd.inddOn this month’s cover, a nurse provides care to a patient at Clearview Cancer Institute in Huntsville, Alabama. The photo was chosen as the third-place winner of AJN’s 2015 Faces of Caring: Nurses at Work contest. Photographer Kim Swift shot the photo while shadowing her sister, a nurse, for a day. Swift sought to capture what she calls “the trust factor” between patients and nurses. She found a prime example of that relationship when she noticed the way one patient looked at her nurse as he explained an aspect of her cancer treatment.

To read the first in a series of AJN articles on cancer survivorship from the Memorial Sloan Kettering Cancer Center, see “Adverse Late and Long-Term Treatment Effects in Adult Allogeneic Hematopoietic Stem Cell Transplant Survivors.” This article—the first of several on cancer survivorship—summarizes the identification, evaluation, and management of potential treatment-related effects in adult survivors of hematopoietic stem cell transplants, with special focus on cardiovascular disease risk factors.

Some other articles of note in the November issue:

CE Feature:Imagery for Self-Healing and Integrative Nursing Practice.” Research suggests that that the use of imagery can help reduce patients’ pain and anxiety and improve their quality of life and outlook on their illness. The second article in a five-part series on holistic nursing describes how imagery can be used to encourage patients’ healing process and presents an imagery technique and a sample script to use in practice.

Clinical Feature: Prescription Opioid Analgesics: Promoting Patient Safety with Better Patient Education.” Inappropriate use of prescription opioids has increased sharply in the past two decades in the United States. Patients and caregivers must have an adequate understanding of safe use, storage, and disposal of opioids to prevent adverse drug events in patients and others. Using a case study, the author of this article examines the risks of nonmedical opioid use in postoperative patients and highlights the nurse’s role in patient education to avoid adverse outcomes.

From our Safety Monitor column: Preventing Newborn Falls While Supporting Family Bonding.” Recent studies and reports suggest that newborn injuries, such as falls, may be an unintended consequence of leaving newborns with fatigued parents in the first hours and days of life. This article addresses the circumstances behind newborn falls in hospitals when infants are in the care of family members, and reports on steps hospitals—and nurses—can take to effectively prevent these accidents. Read the rest of this entry »


Practical Steps for Nurses to Reduce Prescription Opioid Diversion

October 28, 2015

By Shawn Kennedy, AJN editor-in-chief

“Opioids diverted from friends and family members who have legitimate prescriptions are a major source of abused prescription opioids.”

More than 800 lbs. of drugs have been collected in Lycoming County, PA, since drug collection boxes were placed in law enforcement agencies over a year ago, allowing residents to safely dispose of unwanted drugs. Here the drugs are separated from their containers before incineration. Photo courtesy of Karen Vibert-Kennedy / Williamsport Sun-Gazette.

More than 800 lbs. of drugs have been collected in Lycoming County, PA, since collection boxes were placed in law enforcement agencies over a year ago, allowing residents to safely dispose of unwanted drugs. Here the drugs are separated from their containers before incineration. Photo courtesy of Karen Vibert-Kennedy / Williamsport Sun-Gazette.

Amid recent reports from the CDC drawing attention to a prescription painkiller and heroin overdose epidemic, last week President Obama announced an initiative to address both prescription drug and heroin abuse in the United States. In addition to a PR campaign involving sports figures and celebrities, the initiative mandates education and training for those who prescribe controlled substances and steps to improve access to treatment for drug addiction.

This epidemic can’t be blamed on a single cause, and as the CDC points out, any meaningful solution must also address such crucial issues as significant state by state variations in prescribing patterns.

Another crucial contributor is the diversion of legitimately prescribed opioid medications, which we addressed in our August issue with a CE article by Renee Manworren and Aaron Gilson: “Nurses’ Role in Preventing Prescription Opioid Diversion.” The article is free. Here’s an excerpt from the overview: Read the rest of this entry »


Medical Marijuana: A Nurse’s Primer

October 27, 2015

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog.

Illustration by J Paradisi.

Illustration by J Paradisi.

Since I wrote “Marijuana Legalization and Potential Workplace Pitfalls for Nurses Who Partake” in July 2014, a few things have changed. For one, Measure 91 passed in Oregon, making it the third state to legalize recreational marijuana. Medical marijuana, however, has been legal since 1998 in Oregon, currently one of 23 states nationwide.

Also, when I wrote the earlier post, I was an infusion nurse—now, as an oncology nurse navigator, I’m asked about medical marijuana often, and I need to know the answers, as do all nurses practicing in states with legalized medical marijuana. Nurses working in oncology, emergency departments, pain management, infusion clinics, and pediatrics have high exposure to patients with medical marijuana cards.

By ‘knowledge,’ I don’t mean knowing everything, but knowing where to find what you need to know. In Oregon, for example, information about medical marijuana is found at the Oregon Medical Marijuana Program (OMMP). The Web site includes qualifying diagnoses, a downloadable handbook, an application packet with instructions, and a list of approved dispensaries. While retail issues surrounding recreational marijuana are still being sorted out, medical dispensaries in Oregon sell recreational marijuana to clients aged 21 and older.

Patients using medical marijuana are as diverse as the illnesses and side effects they use it to treat: PTSD, seizure disorders, chronic pain, inflammatory illness, and of course the adverse effects of chemotherapy, including nausea and vomiting, anxiety, sleeplessness, anorexia, and hot flashes associated with endocrine suppression therapy. Read the rest of this entry »


Catheter Ablation of Atrial Fibrillation: Essentials for Nurses

October 23, 2015

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.

A postablation case was a rarity for me, even as an experienced ICU nurse. While floating to the cardiac ICU one day, I received a patient from the cath lab who had just undergone the procedure for recurrent atrial fibrillation.

My colleagues, experienced in electrophysiology care, gave me a heads up—“Just watch her rhythm. That’s the most important thing.” But no one could provide a standard protocol for me to follow in her care. While I had the usual critical care protocol for monitoring patients, and the orders given to me for this patient, before she arrived I did a little online searching to determine how to tailor my care for her needs.

The catheter ablation procedure involves electrical ablation of tissue around the circumference of the pulmonary veins, the most common site for atrial fibrillation triggers (A). Lesions are created through the use of an irrigated radiofrequency ablation catheter (B). Illustration by Anne Rains.

The catheter ablation procedure involves electrical ablation of tissue around the circumference of the pulmonary veins, the most common site for atrial fibrillation triggers (A). Lesions are created through the use of an irrigated radiofrequency ablation catheter (B). Illustration by Anne Rains.

I set my patient’s alarms, and myself, on high alert for arrhythmias and treated my patient’s insertion site as I would a cardiac catheterization site—monitoring it for bleeding, signs of hematoma, or infection. But a protocol for care would have been welcome, as this cardiac electrophysiology procedure can often lead to unexpected complications that require immediate action—ones you might not originally think of, like a stroke or flash pulmonary edema.

The lack of standardized care guidelines for nurses after an atrial ablation is a good reason to read one of AJN‘s October CE articles, “Catheter Ablation of Atrial Fibrillation.” Coauthor Linda Hoke discusses what to expect, how to prepare, and complications to avoid when caring for patients having this procedure done. Read the rest of this entry »


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