Clinical Practice Material

Background:

Saline shortages are expected through the end of the year because of:

• A 20 % rise in demand of saline from January to March 2014.
• Harsh winter weather delayed saline deliveries to providers.
• An increased demand with decreased product availability.
• More stringent Food and Drug Administration (FDA) inspections to ensure product sterility since:
• Saline has been contaminated with bacteria, mold and glass particles.
• FDA discovered leaks in saline bags.

Implications:

Those who require hydration may not receive it such as:

• Individuals undergoing dialysis
• Patients in an acute care setting

Recommendations:

In response to the saline shortage RNs are encouraged to:

• Revise policy and protocols to conserve supplies.
• Use smaller saline bags when possible.
• Transition patients who are able to tolerate oral hydration to drink water.
• Consider importing FDA approved saline from Spain and Norway.

Background information: 
Misuse of single-dose medication vials are one of the causes of the transmission of recently reported avoidable bacterial infections. Single-dose vials do not contain preservatives and are susceptible to bacterial contamination. Using these vials more than one time increases the likelihood for bacterial contamination, growth and infection. The Centers for Disease Control and Prevention (CDC) report that misuse and adverse events have been reported in both inpatient and outpatient settings. Implication for the patient:

The CDC reported that patients are being exposed unnecessarily to bacteria that cause life-threatening infections. A significant contributing factor to the misuse of vials is the lack of adherence to safe infection control practices and to aseptic techniques within health care organizations. Less-than-optimal practices such as multiple use of a single-dose vial may contribute to life-long treatment and even death.

Recommendations from CDC and the Joint Commission:

• Use the single-dose vial once.
• Follow aseptic techniques.
• Practice safe infection control practices as outlined by your healthcare organization.
• Follow safe injection and infection control practices.
• Discard the vial after a single use; used vials should never be placed back on drug carts.
• NEVER combine leftover contents of single-dose vials.
• NEVER store used single-dose/single-use vials for later use, no matter what the size of the vial.
• Conduct regular quality checks on clinical units to look for open vials.
• Discard any vial if its sterility has been compromised or is questionable- even if the vial is unopened and/or unused.
• Provide annual education on injection safety and on preventing the misuse of vials for all staff who administer injections, including new and temporary staff.
• Before discharge, provide injection safety education to patients and caregivers who will use injectable medical products as part of a home health regimen. Use teach-back methods to assure understanding.
• Create a culture within which the reporting of unsafe injection and infection control practices or near misses is viewed as a necessary step to improve safety.

Background:
Between January 2009 and June 2012, there were 98 reported alarm-related events with 80 resulting in patient deaths, 13 in permanent loss of function, and five requiring additional care. Alarm equipped devices are essential in providing safe care in critical care settings such in: emergency rooms, intensive care units, and critical care units. When used properly, medical alarms provide crucial information to the clinician which is used to make medical and treatment decisions. One identified problem is that a single patient care unit may have over 100 alarm signals in a single shift, leading to clinician desensitization and "alarm fatigue." In response to the alarms, clinicians may turn off the alarm, turn the volume down, or change the alarm limits which can often have fatal results.

Contributing factors to the misuse of medical alarms:

• Alarm fatigue
• Improper alarm settings
• Absent or inadequate alarm systems
• Equipment malfunctions and failures
• Alarm settings inappropriately being turned off
• Alarm settings not integrated with other medical devices
• Inadequate staffing to support or to respond to alarm signals
• Alarm signals not audible in all of the necessary clinical care areas

Recommendations:

• Establish a cross-disciplinary team to address alarm safety
• Re-establish priorities for the adoption of alarm technology
• Provide an ongoing staff training program for safe alarm management
• Develop guidelines for tailoring alarm settings and limits for individual patients
• Identify default alarm settings and alarm limits appropriate for each level of care
• Ensure a process for safe alarm management and response in high-risk clinical areas
• Implement guidelines for alarm settings used in high-risk areas or high-risk clinical situation

The recommendations offer hospitals a framework on which to assess their individual circumstances and develop a systematic, coordinated approach to alarms. By making alarm safety a priority, lives can be saved.

For additional information go to:
http://www.jointcommission.org/sentinel_event.aspx

Background
The Centers for Disease Control and Prevention has identified a potentially fatal antibiotic-resistant bacterium which has surfaced in over 200 U.S. hospitals and long-term care facilities. The bacterium named Carbapenem-Resistant Enterobacteriaceae (CRE) has contributed to patient mortality in nearly 50% of individuals which become infected. CRE are in a family of more than 70 bacteria called Enterobacteriaceae, including Klebsiella pneumoniae and E. coli, which are typically found in the gastrointestinal tract.

Who is at risk?
Patients whose care requires devices such as ventilators, urinary catheters, or intravenous catheters, have a prolonged hospital stay, and patients who are taking long courses of certain antibiotics are among those at risk for CRE infections. 

Implications for practice:

• The overuse of antibiotics contributes to the development of highly resistant bacteria
• CRE bacteria can transfer their antibiotic resistance to other bacteria of the same type
• Antibiotics are ineffective which leads to potentially un-treatable infections

Educate your patients to:

• Inform your healthcare provider if you have been hospitalized in another facility or country
• Take antibiotics only as prescribed
• Ask all health care providers to wash their hands with soap and water or an alcohol-based hand rub before and after touching your body
• Clean your own hands often, especially:

1. Before preparing or eating food
2. Before touching your eyes, nose, or mouth
3. Before and after changing wound dressings or bandages or handling medical devices
4. After using the bathroom

Recommended best practice:
To reduce the spread of CRE bacteria, the CDC requests health-care facilities take the following preventative steps:

• Strictly enforce infection-control precautions
• Cohort patients and segregate equipment after CRE exposure
• Communicate to facilities when patients with CRE are transferred
• Safely prescribe antibiotics

For More Information:
https://www.cdc.gov/cre/about/

Background: 
Tuberculosis (TB) is an infectious bacterial disease caused by Mycobacterium tuberculosis and commonly affects the lungs. A new multi-drug resistant tuberculosis (MDR-TB) is spreading and is resistant to all anti-TB drugs. MDR-TB does not respond to isoniazid and rifampicin, the two most powerful anti-tuberculosis drugs. 

How is TB spread? 
TB is transmitted from person to person via droplets from the throat and lungs of people with the active respiratory disease and by coughing, sneezing, and talking. 

What are the signs and symptoms of TB? 
Fever, night sweats, weight loss, coughing up blood-tinged sputum, chest pains, and weakness 

Who is at risk? 
Individuals who are relatively poor, poor sanitation, malnutrition, HIV/AIDS, smokers, diabetics, immunosuppressed, and those who live in third-world countries 

What causes MDR-TB? 
The primary cause of multidrug resistance is mismanagement of TB treatment. Most people with tuberculosis are cured by a strictly followed, six-month drug regimen that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs or use of ineffective formulations of drugs can cause drug resistance 

Nursing implications: 
The primary cause of MDR-TB is inappropriate treatment, inappropriate or incorrect use of anti-TB drugs, or use of poor quality medicines, can all cause drug resistance. MDR-TB is treatable and curable by using second-line drugs. However second-line treatment options are limited and recommended medicines are not always available 

Recommendations:
Pursue high-quality directly observed therapy (DOT) expansion and enhancement to: 

• ensure early case detection and diagnosis 
• provide standardized treatment with supervision and patient support 
• ensure effective drug supply and management 
• monitor and evaluate performance and impact 
• address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations 
• contribute to health system strengthening based on primary health care 
• engage all care providers 

For additional information go to: https://www.cdc.gov/tb/about/drug-resistant.html

Background: 
A national survey of Registered Nurses revealed that only 45% to 50% of nurses in the United States had earned a baccalaureate degree in nursing (BSN). A multitude of studies have reported a direct relationship between the level of education of the registered nurse and patient outcomes. 
 
Significance: 
Providing quality patient has become increasingly complicated over the last decade due to: 

• Rapid advances in medical knowledge and technology requiring more highly skilled nursing care 
• Patients are older and more acutely ill in need of highly skilled and nursing care 

Patient Safety: 
Studies have demonstrated that organizations with higher rates of nurses with a BSN degree are associated with significant reductions in adverse patient outcomes such as: 

• Lower rates of failure to rescue 
• Lower rates of patient mortality 
• A ten-point increase in a hospital’s percentage of BSN prepared nurse is associated with a reduction of 2.12 to 7.47 deaths for every 1,000 patients per year 

Recommendations: 
The Institute of Medicine (IOM) recommends that at least 80 percent of the nursing workforce hold a baccalaureate degree by 2020. Nursing practice has become more sophisticated, and outdated educational requirements are no longer adequate.

Learn more

Background: 
The Agency for Healthcare Research and Quality (AHRQ) reported that despite quality improvement initiatives and significant amounts of resources invested to improve patient safety, there has been little improvement in adverse patient events from 2006 to 2008.
 
What is a Patient Safety Practice? 
A patient safety practice is a process that reduces the probability of an adverse event. 
Practice implications: Many low costs improvements can significantly improve patient outcomes 

Strongly recommended best practice: 

• Preoperative and anesthesia checklists are effective in preventing operative and post-operative events 
• Bundles that include checklists prevents central line-associated bloodstream infections 
• Interventions to reduce urinary catheter use, catheter reminders, stop orders, and catheter removal protocols decrease urinary tract infections 
• Bundles that include HOB elevation, diligent oral care with chlorhexidine, subglottic-suctioning endotracheal tubes and sedation breaks reduce ventilator-associated pneumonia 
• Hand hygiene 
• “Do Not Use” list for hazardous abbreviations 
• Multiple interventions to eliminate pressure ulcers: 
• Barrier precautions to prevent healthcare-associated infections 
• Use of real-time ultrasound for central line placements 
• Interventions to improve prophylaxis for venous thromboembolism 
• Interdisciplinary fall prevention strategies 
• Use of clinical pharmacists to reduce adverse drug events 
• Medication reconciliation 

For more information: www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html

Background: 
In November 2012, the National Alert Network (NAN) reported that the U.S. Pharmacopeial Convention (USP) updated labeling standards for Heparin Sodium Injection, USP and Heparin Lock Flush Solution, USP (including heparin prefilled flush solutions). The labeling changed from dose of drug per ml, to the identification of the total amount of drug per vial. These revised standards were official May, 1, 2013. 

Significance: 
Misreading of the label has led to dangerous and deadly heparin overdoses. 

Implications for Practice: 
Pharmacists, staff nurses, physicians, nurse educators, and risk managers need to have a heightened awareness of the heparin label changes. 

Recommended Best Practices to Minimize Patient Risk: 

• Computer databases should express drug amounts to be consistent with vial labeling. 
• Separate heparin vials and use older vials with older labels first before dispensing the vials with updated labeling. 
• Completely transition to newly labeled heparin and discard older vials. 
• Place high-alert drug warnings on automated medication dispensers. 
• Restrict multi-dose heparin vials. 
• Keep unit stock vials as small as possible to limit the potential of heparin overdoses. 
• If a heparin bolus is required, consider heparin bolus doses dispensed from a pharmacy. 

Background 
Substance Abuse and Mental Health Services Administration (SAMHSA) recently reported that the drug known as Ecstasy or Molly has increased by 128% in the last six years. The greatest increase is seen primarily by emergency room providers in individuals from 12 to 21 years old. Ecstasy is both a stimulant and a hallucinogenic street drug. It typically is taken orally, but it can also be snorted or smoked. The drug produces feelings of increased energy and euphoria and distorts users' sense and perception of time. 

Recommendations and implications for nursing practice 
An accurate diagnosis is the first step toward treatment and recovery. However, diagnosing people with drug and alcohol disorders can be complex, especially when these disorders occur simultaneously. There are obstacles to a correct diagnosis: such as, individuals who are seeking care may be unwilling to discuss their addiction, and healthcare providers may be unaware of the signs and symptoms of drug/alcohol abuse and dependence. 

The increase in this dramatic rise in the younger population concerning due to the serious health risks involved with Ecstasy use and the higher potential for abuse when Ecstasy is mixed with alcohol. The drug can produce a variety of negative health effects, including anxiety and confusion, that can last a week or longer. In addition, the drug has been associated with hypertension, as well as renal and cardiac failure.