Infection Prevention

Issues up close – Fighting the invisible

IT’S NOT UNUSUAL for RNs to encounter an alphabet soup of harmful microorganisms as
they go about their practice. But how they and their institutions prepare for those encounters
can make a huge difference both in their own health and the health of others.

Some pathogens are well-known within healthcare
settings, such as methicillin-resistant Staphylococcus
aureus
(MRSA) and Clostridium difficile. Others
are emerging, including carbapenem-resistant
Klebsiella pneumonia and New Delhi metallo-betalactamase-
1, a genetic mutation that can create more
superbugs.

“If nurses see blood or get it on their uniforms, it’s
obvious,” notes Nancy Hughes, MS, RN, director of the
American Nurses Association’s (ANA) Center for Occupational
and Environmental Health. “But what about
threats that aren’t visible?”

To prevent the spread of harmful microorganisms
within healthcare facilities
and into the community (and vice versa),
nurses need to take proper precautions.
Chief among these are strict hand hygiene,
use of personal protective equipment
(PPE), and good clinical judgment, according
to nurse experts.

“Nurses want to provide good
care and respond quickly to patients,”
says Cindy Groves, BSN,
RN, COHN-S, who’s on the board of
the American Association of Occupational
Health Nurses, an organizational affiliate
of ANA. “And they might not want to
hassle with the gown or mask because they
think they’re going into the room just to answer
a question. But patients often say, ‘As long as you’re
here, can you…?’. The next thing you know, they may
want you to hand them their newspaper, adjust their
pillow, or change their dressing. You don’t want to be
caught unprepared.”

Why not don PPE?

The reasons staff may not take adequate
precautions go beyond the
invisible nature of pathogens,
and include factors such as
high workloads, time pressures,
lack of quick access to
PPE, and the unexpected.
Nurses also are notorious for
always wanting to put the patient first and their own
health second, Hughes points out. So they may take
quick actions to care for a patient despite the risk of
inadvertently contaminating themselves.

Andrew Harding, MS, RN, CEN, NEA-BC, FAHA,
agrees and speaks to the unpredictability of emergency
nursing. (He co-wrote “The use and need for standard
precautions and transmission-based precautions in the
emergency department,” published in the April 2011
Journal of Emergency Nursing.) “The challenge of emergency
nursing, for one, is the time factor,” says Harding,
clinical nurse specialist, Nursing Education and Research,
Good Samaritan Medical Center in Brockton,
Mass., and an ANA member. “ED nurses are
trying to see people as fast as they come
through the door, and sometimes they
might have a [high patient] load. Also,
these patients haven’t been
worked up yet, so nurses don’t
know what pathogens a person
may have.

“Emergency nurses have been
known to rush in and put their bare
fingers into a chest. But taking the
time to put on gloves or other PPE is
time well spent. It’s like when you’re
on a plane and they say, ‘When traveling
with a child, put your own oxygen
mask on first.’ It’s not about sacrificing
yourself, it’s about safety.”

Other factors that come into play at
some facilities involve availability and
risk perception. “If supplies [such as
PPE] aren’t easily accessible, nurses and
other staff are less likely to use it,”
states Barbara Russell, MPH, RN, CIC,
director of Infection Prevention and
Control at Baptist Hospital in Miami
and Florida Nurses Association member.
“Also, some nurses realize the risk
of not using PPE, and some do not. It’s a mixed bag.”
She also believes an increasing number of nurses don’t
understand when the lab is reporting a critical value for
an organism resistant to antibiotics.

Additionally, Hughes believes facilities must ensure a
culture of safety that promotes the use of PPE infectioncontrol
measures and holds everyone accountable.
“Employers must understand that by protecting nurses
and other healthcare workers, we are protecting patients,”
she says.

The battle against superbugs

“One of the main roles of the employee health nurse
is to advocate for and ensure employee safety,” states
Groves, clinical manager at Beloit Health System in
Wisconsin. “We need to make sure nurses are protected
against all hazards—radiation, poor ergonomics, and
microorganisms.”

And although facilities generally provide infectioncontrol
content through new employee orientation and
in-service programs, nurse experts say it may not suffice.
They point out that ongoing, comprehensive messages
on infection-prevention practices and risks are
key. “Everyone knows standard precautions,” Harding
says. (These include good hand hygiene, gloves, masks,
gowns, and eye protection and are based on which
body fluids a nurse may encounter in a given situation,
such as a patient who has a cough versus one with
traumatic injuries.) But studies have found that healthcare
workers don’t wash their hands as often as they
should—even though it’s a vital way to break the transmission
cycle of infectious organisms, Harding says.

The World Health Organization points to five instances
when healthcare workers should wash their
hands: before touching a patient, before performing a
clean or aseptic procedure, after body-fluid exposure
risk, after touching a patient, and after touching a patient’s
surroundings.

Russell adds that there’s currently a movement to institute
universal gloving because of poor compliance
with hand hygiene. “Most healthcare staff use gloves all
the time anyway,” she says. “But when they do, they
need to remember to change gloves between patients
and activities. For example, if you put up a side rail,
you need to change gloves before you work on a patient’s
dressing. Then you have to change gloves again.”

Adherence to contact precautions for patients with
contagious infections is a murkier issue, according to
Russell. All facilities look to the Centers for Disease
Control and Prevention for infection-control practices,
but some leeway exists in its guidelines. For example,
some facilities may require only that staff wear gloves
and a gown when working with a MRSA-infected
patient, while others require staff to put on a gown,
gloves “and x, y, and z,” Russell states. Some facilities
automatically require contact precautions for any patient
who has a history of MRSA; others don’t.

“We’d rather focus on who really needs it,” Russell
says of her hospital. “And nurses need to stop and
think: What am I doing? How can I protect myself and
others? Superbugs can be outsmarted by critical thinking
skills.”

Finally, facilities must ensure that the correct PPE is
available to all staff when needed and correct disinfectants
are being used. Harding notes that colonies of
pathogens may reside in places staff may not think of
routinely. For example, a recent exploration of his ED
found the highest pathogen levels on phones, keyboards,
and door handles rather than floors and bedrails.

Going into the community

Superbugs also exist in the community. Some nurses
and organizations have expressed concerns about contributing
to this increasing threat and harming their
families by bringing pathogens home from the workplace.
The Association of periOperative Registered
Nurses (AORN), an organizational affiliate of ANA, has
had long-standing recommended practices on surgical
attire and preventing the spread of infectious agents.

“AORN is all about protecting nurses and patients
and developing recommended practices based on the
highest level of evidence,” says AORN perioperative
nursing specialist Sharon Van Wicklin, MSN, RN, CNOR,
CRNFA. Since 1975, AORN has recommended nurses
refrain from wearing and laundering their scrubs at
home. But in 2004, it provided guidelines on how to
wash scrubs at home if needed. However, as of October
2010, AORN is recommending surgical attire be
laundered only in a healthcare-accredited laundry facility.
The recommended practices also address other attire,
such as shoes, jewelry, and identification badges.

AORN recently partnered with healthcare organizations
for an eight-city tour to educate nurses and others
on best practices around infection-control methods.
“We want to keep ourselves safe from contracting
pathogens,” Van Wicklin states. “We also want to make
sure we’re not bringing them into the community and
to our families. And we want to make sure we’re not
bringing anything from the community or our families
into our workplaces. It’s a circular process.” (For more
information, go to http://www.aorn.org/.)

Nurse experts in other specialties also suggest RNs
launder their work clothes separately and keep shoes,
stethoscopes, and other equipment at their work sites.
For more information about ANA’s efforts on occupational
and environmental health, go to http://nursingworld.org/ and click on the “Occupational and Environment”
tab at the top.

Susan Trossman is a senior reporter for ANA.

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