Frequently Asked Questions

Transcription

1 Frequently Asked Questions What are the requirements for license renewal Licenses Expire Registered Nurses - Every 2 years on May 31 of the even year. Licensed Practical Nurses - Every 2 years on January 31 of the odd year. Contact Hours Required 20 (All hours are allowed through home-study) How do I complete this course and receive my certificate of completion? On-Line Submission: Go to and follow the prompts.you will be able to print your certificate immediately upon completion of the course. Fax or Submission: Fax to (386) , be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates ed to the address provided.* Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid address is the quickest and most efficient way to receive your certificates when submitting via fax, or mail. Submissions without a valid address will be mailed to the address provided at registration. How much will it cost? Cost of Courses Course Title Contact Hours Price Infection Control: Standards for Nursing Practice 8 $29.00 Patient Safety: Implementation of National Safety Standards for Nurses 4 $19.00 Wound Care: Priorities for Nursing 8 $29.00 BEST VALUE SAVE $ Entire 20-hour Course 20 $21.95 Are you approved by ANCC? Yes. Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Illinois accepts courses offered by an ANCC provider. Are my credit hours reported to the Illinois board? No. The board performs random audits at which time proof of continuing education must be provided. Is my information secure? Yes! Our website is secured by Thawte, we use SSL encryption, and we never share your information with third-parties. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state s board website to determine the number of hours required for renewal, and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Page i

2 Table of Contents CE for Illinois Nursing Professionals CHAPTER 1: INFECTION CONTROL: STANDARDS FOR NURSING PRACTICE Page 1 Healthcare providers must understand and be vigilant about the prevention of infection and the control of infectious diseases. Hand hygiene campaigns and an emphasis on infection control education with required updates have been implemented in all types of healthcare settings. This course provides content related to the most current standards in accordance with national, state, and agency guidelines. CHAPTER 2: PATIENT SAFETY: IMPLEMENTATION OF NATIONAL SAFETY STANDARDS FOR NURSES Page 38 Safety comes first in patient care and in health care environments. This course presents the latest National Patient Safety goals as well as strategies for nursing. CHAPTER 3: WOUND CARE: PRIORITIES FOR NURSING Page 58 Wounds may be acquired from many different sources. It is critically important that nurses know how to assess wounds, their origins, the patient s risk factors, and/ or other co-morbidities that may affect the healing process. This course focuses on the all aspects of wounds including identification, assessment, and wound care dressings and products to help wound healing. Also included are strategies to prevent the incidence of preventable wounds. Course Participant Sheet Page 93 Course Evaluation Page 94 All 20 Hrs ONLY $ Why are your colleagues using Elite? The course literature was very comprehensive. I have been a nurse for over 30 years and was surprised at how much information I gained from your courses. - Martha P., RN I am happy I received this course package that I can review whenever I have time. I was able to expand my nursing knowledge to understand my patients history better. - Linda C., RN This is the first time I used your company and I m happy to see that there are written course books that I can read instead of completing courses on the computer, thank you. - Deborah S., LPN Elite Continuing Education All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and are not actual customers. Page ii

3 Chapter 1: Infection Control: Standards for Nursing Practice 8 Contact Hours Release Date: 2/15/2016 Expiration Date: 2/15/2019 Audience Infection control is a serious health care responsibility. This course was developed for nursing professionals responsible for caring for patients at risk of developing a hospital acquired infection. Purpose statement Healthcare providers must understand and be vigilant about the prevention of infection and the control of infectious diseases. Hand hygiene campaigns and an emphasis on infection control education Learning objectives Upon completion of this course, the student will master the following objectives: Define terminology related to infection prevention and control. Discuss the process of infectious disease, including the source of infectious agents, modes of transmission, host susceptibility, and stages of infection. Discuss common healthcare-associated infections, including risk factors for development of these infections, and organisms causing these infections. How to receive credit Read the entire course, which requires a 8-hour commitment of time. Depending on your state requirements you will asked to complete either: An attestation to affirm that you have completed the educational activity. OR completed the test and submit (a passing score of 70 percent is required). Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through April 30, 2017); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Faculty Wanda M. Baker, MN, RN, FNP, CNE Wanda Baker began her nursing career by graduating from the Associate Degree Nursing Program at Greenville Technical College in Greenville, South Carolina. After 11 years of clinical practice and the completion of both Bachelors and Masters degrees she returned with required updates have been implemented in all types of healthcare settings. This course provides content related to the most current standards in accordance with national, state, and agency guidelines. Discuss the term multiple drug-resistant organism, including the effect of these infectious agents on infection prevention and control. Outline types of bloodborne pathogens and how they spread in healthcare settings. Discuss the role of national agencies in maintaining public health and security. Describe how infection control prevention concepts are applied in professional practice. Discuss immunization programs in place in the United States and the role these programs play in infection prevention and control. Note: Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment and Course Evaluation. Print the Certificate of Completion. Board of Nursing, Provider # ; Florida Board of Nursing, Provider # ; Georgia Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). to the same Associate Degree Program as a faculty member. For the subsequent 24 years she taught in multiple areas of the program, developed new courses, implemented simulation, and directed curriculum revision and accreditation activities. During this time she completed a Family Nurse Practitioner program and obtained Page 1

4 certification as a Nurse Educator. She was the Academic Program Chair for the last 8 years before retiring at the end of She currently teaches part time for the college, works as an education consultant, and volunteers for the American Red Cross. Content Reviewer Patricia Gellasch, MS, APN-C Activity Director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/Commercial Support and Non-Endorsment It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2016: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Introduction Healthcare-associated infection causes increasing healthcare costs, as well as significant morbidity and mortality. According to the Centers for Disease Control and Prevention, about one in every twenty-five patients has an infection related to their hospital care [22]. In 2011, an estimated 75,000 patients died during hospitalization due to healthcare-associated infections [22]. In the same year, an estimated 722,000 healthcare-associated infections were reported in United States acute care hospitals [22]. In efforts to decrease the numbers of healthcare-associated infections, the Centers for Disease Control and Prevention established partnerships with public health agencies to create measurable targets that correlate with specific areas of the Healthy People 2020 objectives. One such area addresses healthcare-associated infections and describes target measures to reduce central line-associated bloodstream infections and invasive healthcare-associated methicillinresistant Staphylococcus aureus infections [21]. Healthcare providers must understand and be vigilant about the prevention of infection and the control of infectious diseases. Hand hygiene campaigns and an emphasis on infection control education with required updates have been implemented in all types of healthcare settings. It is critical that all healthcare providers implement the most current standards in accordance with national, state, and agency guidelines. This Infection Prevention and Control course provides content important to healthcare providers, specifically nurses, working in all healthcare settings. The content provided includes the following: An overview of terminology related to the topic. Discussion of the infectious disease process. Descriptions of common healthcare-associated infections. Discussions related to drug resistant organisms and bloodborne pathogens. Discussions related to the role of national agencies. Descriptions of infection control prevention in practice settings. Discussion of immunization programs for the public and healthcare providers. Nurses completing this course will find a succinct synthesis of data from national publications. In addition, multiple resources that provide expanded content are listed. Nurses should uses these resources to stay current with updates to specific guidelines, as changes are made based on research findings and practice standards. Terminology Healthcare providers must be familiar with terminology specific to infection prevention and control. The following section provides definitions for terminology related to content within this course. Airborne infection isolation room (AIIR): Formerly, negative pressure isolation room, an AIIR is a single-occupancy patientcare room used to isolate persons with a suspected or confirmed airborne infectious disease [6]. Airborne precautions: A set of practices used to prevent transmission of infectious agents that remain infectious over long distances when suspended in the air [6]. Antibody: Immunoglobulin produced by the body in response to a specific antigen [19]. Antigen: Foreign material capable of inducing a specific immune response [19]. Antimicrobial: Antibacterial agent that kills bacteria or suppresses their growth [4]. Antiseptic: Substance that prevents or arrests the growth or action of microorganisms by inhibiting their activity or by destroying them [4]. Asymptomatic: An absence of symptoms or signs of illness in an infected person, often called a carrier [19]. Bacteremia: Laboratory-confirmed presence of bacteria in the bloodstream [1]. Bacteria: These single-cell organisms are the most significant and most commonly observed infection-causing agents [19]. Bloodborne pathogens: Microorganisms in blood that can cause illness in humans [24]. Carrier: Person who has an organism but lacks apparent signs and symptoms; one who is able to transmit an infection to others [19]. Page 2

5 Colonization: Proliferation of microorganisms on or within body sites without detectable host immune response, cellular damage, or clinical expression; colonization and carriage are synonymous [6]. Cohorting: The practice of grouping patients infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible patients (cohorting patients) [14]. Common vehicle: A contaminated material, product, or substance that serves as an intermediate means by which an infectious agent is introduced into a susceptible host through a suitable portal of entry [16]. Contact precautions: A set of practices used to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient s environment [6]. Convalescent period: The period during which recovery from an illness occurs [16]. Disinfection: Process used to destroy microorganisms; destroys all pathogenic organisms except spores [4]. Droplet precautions: A set of practices intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions [6]. Droplet nuclei: Microscopic particles < 5 µm in size that are the residue of evaporated droplets and are produced when a person coughs, sneezes, shouts, or sings [6]. Endemic: Something that occurs with predictability in one specific region or population and can appear in a different geographical location [16]. Endogenous: Infection in which the causative organism comes from microbial life harbored within the person [16]. Engineering controls: Removal or isolation of a workplace hazard through technology; AIIRs, a Protective Environment, engineered sharps injury prevention devices and sharps containers are examples of engineering controls [6]. Exogenous: Infection in which the causative organism is acquired from outside the host [16]. Fomite: An inanimate object, such as a stethoscope, sphygmomanometer, dish, doorknob, toilet seat, or an article of clothing that may be contaminated with infectious organisms and serve in their transmission [6]. Full stage of illness: The presence of specific signs and symptoms related to a disease process [16]. Fungi: Plant-like organisms (molds and yeasts) that can cause infection [16]. Hand hygiene: A general term that applies to any one of the following: 1) handwashing with plain (non-antimicrobial) soap and water); 2) antiseptic hand wash (soap containing antiseptic agents and water); 3) antiseptic hand rub (waterless antiseptic product, most often alcohol-based, rubbed on all surfaces of hands); or 4) surgical hand antisepsis (antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient hand flora and reduce resident hand flora) [14]. Healthcare-associated infection (HAI): An infection that was not present on admission to a healthcare institution and develops during the course of treatment for other conditions; this term has replaced the term nosocomial infection [14]. Host: Animal or person on or within which microorganisms live [16]. Immune: Person with protection from a previous infection or vaccination who resists reinfection when re-exposed to the same agent [10]. Incubation period: The time from the moment of exposure to an infectious agent until signs and symptoms of the disease appear [16]. Infection: The transmission of microorganisms into a host after evading or overcoming defense mechanisms, resulting in the organism s proliferation and invasion within host tissue(s) [6]. Infection prevention and control program: A multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcare-associated infections are implemented and followed by healthcare personnel, making the healthcare setting safe from infection for patients and healthcare personnel [14]. Infectious disease: The consequences that result from invasion of the body by microorganisms that can produce harm to the body and potentially death [16]. Isolation: Protective procedure designed to prevent the transmission of specific microorganisms; also called protective aseptic techniques and barrier techniques [6]. Methicillin-resistant Staphylococcus aureus (MRSA): Staphylococcus aureus bacterium that is not susceptible to extended-penicillin antibiotic formulas, such as methicillin, oxacillin, or nafcillin; MRSA may occur in a healthcare or community setting [1]. Multidrug-resistant organisms (MDROs): In general, bacteria (excluding M. tuberculosis) that are resistant to one or more classes of antimicrobial agents and usually are resistant to all but one or two commercially available antimicrobial agents [14]. Normal flora: Persistent nonpathogenic organisms colonizing a host [16]. Parasites: Organism that lives on or in a host and relies on it for nourishment [16]. Pathogen or infectious agent: A biological, physical, or chemical entity capable of causing disease; biological agents may be bacteria, viruses, fungi, protozoa, helminthes, or prions; synonymous with the terms causative agent and etiologic agent [19]. Personal protective equipment (PPE): A variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. PPE includes gloves, masks, respirators, goggles, face shields, and gowns [6]. Portal of entry: The path(s) by which an infectious agent enters the susceptible host, including eyes, nose, ears, mouth, breaks in the skin, needle pricks, wounds, injury, surgery, and intravenous sites [16]. Portal of exit: The path(s) by which an infectious agent leaves the reservoir [16]. Prion: A small infectious agent that is neither bacterial, fungal, nor viral and contains no genetic material [4]. Prodromal stage: The period of early symptoms of a disease occurring after the incubation period and just before the appearance of the characteristic symptoms of the disease [16]. Reservoir: A source of an infectious agent which may be a person, animal, plant, soil, substance, or combination of these, where a causative agent survives and multiplies in sufficient amounts to be transmitted to a new host [16]. Respiratory hygiene/cough etiquette: A combination of measures designed to minimize the transmission of respiratory pathogens via droplet or airborne routes in healthcare settings [6]. Standard precautions: A set of infection prevention guidelines that combine the major features of Universal Precautions and Body Substance Isolation guidelines and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents [14]. Sterilization: The process by which all microorganisms, including spores, are destroyed [4]. Susceptible host: A person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting infection or disease when exposed to the agent [16]. Transmission: Any mechanism by which a pathogen is spread by a source or reservoir to a person [16]. Transmission-based precautions: Precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions [6]. Vaccination: Suspensions of antigen preparations intended to produce a human immune response to protect the host from future encounters with the organism [10]. Page 3

6 Vancomycin-resistant Enterococcus (VRE): Enterococcus bacterium that is resistant to the antibiotic vancomycin [1]. Vancomycin-resistant Staphylococcus aureus (VRSA): Staphylococcus aureus bacterium that is not susceptible to vancomycin [1]. The infectious disease process Infectious diseases are caused by pathogenic microorganisms, commonly called germs, which include prions, viruses, bacteria, fungi, and parasites. These germs can be transmitted directly from person to person; from animal to person; or from mother to unborn child, or indirectly, when a person touches an object that contains germs. Once germs are transmitted to a susceptible host, infection can occur. The infectious disease process requires three elements: a source, or reservoir, of infectious agents; a mode of transmission for the agent(s); and a susceptible host with a receptive portal of entry [16]. Sources of infectious agents Infectious agents present in healthcare settings are transmitted primarily from human sources, but are also present on inanimate environmental sources. Human reservoirs include patients, healthcare personnel, and family members or other visitors. Individuals may have active infections, may be in the asymptomatic or incubation period of an infectious disease, or may be transiently or chronically colonized with pathogenic microorganisms, particularly in the respiratory and gastrointestinal tracts. The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) are also a source of healthcare-associated infections [16]. Modes of transmission Several classes of pathogens can cause infection, including bacteria, bacterial spores, viruses, fungi, protozoa, parasites, and prions. The modes of transmission vary by type of organism and some infectious agents may be transmitted by more than one route. Importantly, not all infectious agents transmit from person to person. The three principal routes of transmission are contact, a common vehicle, and vector borne [16]. The most common mode of transmission, contact transmission, is divided into two subgroups: direct contact and indirect contact. Direct contact transmission occurs when microorganisms transfer from one infected person to another person without a contaminated intermediate object or person. Examples of infections transmitted via this route include the following [5] (specific microorganisms causing these infections are discussed in a later section of this course): Conjunctivitis. Cytomegalovirus. Diphtheria. Gastroenteritis. Hepatitis A. Hepatitis B. Hepatitis C. Herpes simplex. Human immunodeficiency virus (HIV). Measles. Meningococcal disease. Mumps. Parvovirus. Pertussis. Poliomyelitis. Rabies. Rubella. Scabies and pediculosis. Staphylococcal infection or carriage. Group A streptococcus infections. Tuberculosis. Vaccinia. Varicella. Viral respiratory infections. Page 4 Vector: Nonhuman carriers such as mosquitoes, ticks, and lice that transmit organisms from one host to another [16]. Virulence: Degree of pathogenicity of an organism [16]. Virus: Smallest of all microorganisms; can be seen only by using an electron microscope [16]. Indirect contact transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. Examples of opportunities for indirect contact transmission by healthcare providers include [6] : Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient. Patient care devices (electronic thermometers, glucose-monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients. Shared toys may become a vehicle for transmitting respiratory viruses among pediatric patients. Instruments that are inadequately cleaned between patients before disinfection or sterilization (endoscopes or surgical instruments) or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial and viral pathogens. Clothing, uniforms, laboratory coats, or isolation gowns used as personal protective equipment (PPE), may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent. Although contaminated clothing has not been implicated directly in transmission, the potential exists for soiled garments to transfer infectious agents to successive patients. The transmission of healthcare-associated pathogens from one patient to another via the hands of healthcare providers requires the following sequence of events [6] : Organisms present on the patient s skin, or that have been shed onto inanimate objects in close proximity to the patient, must be transferred to the hands of healthcare providers. Healthcare equipment, supplies, or surfaces can become contaminated with pathogens and become a fomite, or an inanimate object contaminated with infectious organisms. These organisms must then be capable of surviving for at least several minutes on the hands of personnel. Next, handwashing or hand antisepsis by the worker must be inadequate or omitted entirely, or the agent used for hand hygiene must be inappropriate. Finally, the contaminated hands of the caregiver must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient. Extensive evidence cited in the 2002 document Guideline for Hand Hygiene in Health Care Settings [7] published from the Centers for Disease Control and Prevention and outlined below, suggests that the contaminated hands of healthcare personnel are contributors to indirect contact transmission of agents capable of producing infection. This section mentions previously undiscussed microorganisms, and a later section provides an overview of healthcare-associated infections and the agents causing these infections. Several investigators have studied transmission of infectious agents by using different experimental models. In one study, nurses were asked to touch the groins of patients heavily colonized with gram-negative bacilli for 15 seconds as though they were taking a femoral pulse. Nurses then cleaned their hands by washing with plain soap and water or by using an alcohol hand rinse. After cleaning their hands, they touched a piece of urinary catheter material with their fingers, and the catheter segment was cultured. The study revealed that touching intact areas of moist skin of the patient transferred enough organisms to the nurses

7 hands to result in subsequent transmission to catheter material, despite handwashing with plain soap and water. The transmission of organisms from artificially contaminated donor fabrics to clean recipient fabrics via hand contact also has been studied. Results indicated that the number of organisms transmitted was greater if the donor fabric or the hands were wet upon contact. Overall, only 0.06 percent of the organisms obtained from the contaminated donor fabric were transferred to recipient fabric via hand contact. Staphylococcus saprophyticus, Pseudomonas aeruginosa, and Serratia spp. were also transferred in greater numbers than was Escherichia coli from contaminated fabric to clean fabric after hand contact. Organisms are transferred to various types of surfaces in much larger numbers (i.e., >104) from wet hands than from hands that are thoroughly dried. Hand antisepsis reduces the incidence of health care-associated infections. An intervention trial using historical controls demonstrated in 1847 that the mortality rate among mothers who delivered in the First Obstetrics Clinic at the General Hospital of Vienna was substantially lower when hospital staff cleaned their hands with an antiseptic agent than when they washed their hands with plain soap and water. In the 1960s, a prospective, controlled trial sponsored by the National Institutes of Health and the Office of the Surgeon General demonstrated that infants cared for by nurses who did not wash their hands after handling an index infant colonized with S. aureus acquired the organism more often and more rapidly than did infants cared for by nurses who used hexachlorophene to clean their hands between infant contact. This trial provided evidence that, when compared with no handwashing, washing hands with an antiseptic agent between patient contacts reduces transmission of health care-associated pathogens. Trials have studied the effects of handwashing with plain soap and water versus some form of hand antisepsis on health careassociated infection rates. Healthcare-associated infection rates were lower when antiseptic handwashing was performed by personnel. In another study, antiseptic handwashing was associated with lower health care-associated infection rates in certain intensive-care units, but not in others. Health care-associated infection rates were lower after antiseptic handwashing using a chlorhexidine-containing detergent compared with handwashing with plain soap or use of an alcohol-based hand rinse. However, because only a minimal amount of the alcohol rinse was used during periods when the combination regimen also was in use and because adherence to policies was higher when chlorhexidine was available, determining which factor (i.e., the hand-hygiene regimen or differences in adherence) accounted for the lower infection rates was difficult. Investigators have determined also that health careassociated acquisition of MRSA was reduced when the antimicrobial soap used for hygienic handwashing was changed. Increased handwashing frequency among hospital staff has been associated with decreased transmission of Klebsiella spp. among patients; these studies, however, did not quantitate the level of handwashing among personnel. In a recent study, the acquisition of various health care-associated pathogens was reduced when hand antisepsis was performed more frequently by hospital personnel; both this study and another documented that the prevalence of health care-associated infections decreased as adherence to recommended hand-hygiene measures improved. Outbreak investigations have indicated an association between infections and understaffing or overcrowding; the association was consistently linked with poor adherence to hand hygiene. During an outbreak investigation of risk factors for central venous catheterassociated bloodstream infections, after adjustment for confounding factors, the patient-to-nurse ratio remained an independent risk factor for bloodstream infection, indicating that nursing staff reduction below a critical threshold may have contributed to this outbreak by jeopardizing adequate catheter care. The understaffing of nurses can facilitate the spread of MRSA in intensive-care settings through relaxed attention to basic control measures (e.g., hand hygiene). In an outbreak of Enterobacter cloacae in a neonatal intensive-care unit, the daily number of hospitalized children was above the maximum capacity of the unit, resulting in an available space per child below current recommendations. In parallel, the number of staff members on duty was substantially less than the number necessitated by the workload, which also resulted in relaxed attention to basic infection-control measures. Adherence to handhygiene practices before device contact was only 25 percent during the workload peak, but increased to 70 percent after the end of the understaffing and overcrowding period. Surveillance documented that being hospitalized during this period was associated with a fourfold increased risk of acquiring a healthcare-associated infection. This study not only demonstrates the association between workload and infections, but it also highlights the intermediate cause of antimicrobial spread: poor adherence to hand-hygiene policies. Adapted from Centers for Disease Control and Prevention (2002). Evidence based practice alert! Research shows that the contaminated hands of healthcare personnel are contributors to indirect contact transmission of agents capable of producing infection. The implementation of stringent hand hygiene practices is of utmost importance to prevent the transmission of infectious agents to patients receiving care in healthcare settings [7]. Guideline for hand hygiene in healthcare settings. Retrieved from [7]. Droplet transmission is a form of contact transmission, and the direct and indirect contact routes may transmit some infectious agents this way. However, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks during procedures such as suctioning, endotracheal intubation, cough induction by chest physiotherapy, and cardiopulmonary resuscitation. Evidence for droplet transmission comes from epidemiological studies of disease outbreaks, experimental studies and from information on aerosol dynamics. Studies have shown that the nasal mucosa, conjunctivae, and, less frequently, the mouth, are susceptible portals of entry for respiratory viruses [16]. Airborne transmission, also a form of contact transmission, occurs by dissemination of either airborne droplet nuclei or small particles in the respirable size range containing infectious agents that remain infective over time and distance. Microorganisms carried in this manner may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face-to-face contact with, or been in the same room with, the infectious individual [16]. Common vehicle transmission of infection occurs from sources other than infectious individuals, and includes common environmental sources or vehicles such as contaminated food, water, medications, or intravenous fluids. Vector-borne transmission of infection occurs from sources other than infectious individuals or environmental sources, such as mosquitoes, flies, rats, and other vermin [16]. Numerous factors influence differences in transmission risks including host factors, environmental factors, and pathogen or infectious agent factors. Host and environmental factors include the population characteristics, intensity of care, exposure to environmental sources, length of stay, and frequency of interaction between patients with each other and with healthcare personnel. Pathogens or infectious agent factors include variances in degrees of infectivity, pathogenicity, size of inoculums, route of exposure, and duration of exposure [16]. Page 5

8 Host susceptibility [16] Infection is the result of a complex interrelationship between a potential host and an infectious agent. Most of the factors that influence infection and the occurrence and severity of disease relate to the host. However, characteristics of the host-agent interaction as it relates to pathogenicity, virulence, and anti-genicity are also important, as are the infectious dose, mechanisms of disease production, and route of exposure. There is a spectrum of possible outcomes following exposure to an infectious agent. Some people who are exposed to pathogenic microorganisms never develop symptomatic disease, while others become severely ill and even die. Some individuals are prone to becoming transiently or permanently colonized but remain asymptomatic. Still others progress from colonization to symptomatic disease either immediately following exposure or after a period of asymptomatic colonization. The immune state at the time of exposure to an infectious agent, interaction between pathogens and virulence factors intrinsic to the agent are important predictors of an individual s outcome. Some hosts are more naturally resistant to infection because of stronger immune systems and more secure barriers to infection, such as healthy, intact skin, and mucous membranes. Humans are protected by mechanisms such as cilia (hair-like tendrils in the nose that filter inhaled air and trap microorganisms) and the acidic ph of the digestive tract, urinary tract, or vaginal area, which promotes a healthy balance of bodily flora and fauna. In the lungs, white blood cells (macrophages) devour microorganism in the process of phagocytosis. Stages of infection [16] An infection may develop in a susceptible host when the chain of infection remains intact. Defined stages of infection include the incubation period, the prodromal stage, and the full stage of illness. The convalescent period follows these stages. The incubation period occurs between the pathogen s invasion of the body and the appearance of symptoms of infection. During this stage, the organisms grow and multiply. The length of incubation may vary. For example, the common cold has an incubation period of one to two days, whereas tetanus has an incubation period ranging from two to twenty-one days. A person is most infectious during the prodromal stage. During this stage, early signs and symptoms of disease are present but may be vague and nonspecific, ranging from fatigue and malaise to a lowgrade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection has the potential to spread. Healthcare-associated infections [18] Healthcare-associated infections are infections that people acquire while they are receiving treatment for another condition in a healthcare setting. Healthcare-associated infections can be acquired anywhere healthcare is delivered, including inpatient acute care hospitals, outpatient settings such as ambulatory surgical centers and end-stage renal disease facilities, and long-term care facilities such as nursing homes and rehabilitation centers. According to the Centers for Disease Control and Prevention, healthcare-associated infections include the following: Central line-associated bloodstream infections. Catheter-associated urinary tract infections. Ventilator-associated pneumonia. Surgical site infections. Page 6 Host factors such as extremes of age and underlying diseases such as diabetes, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), malignancy, and transplants can increase susceptibility to infection. A variety of medications that alter the normal body flora can also increase susceptibility to infection such as antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs. Surgical procedures and radiation therapy impair defenses of the skin and other involved organ systems. Indwelling devices such as urinary catheters, endotracheal tubes, central venous and arterial catheters, and synthetic implants facilitate development of healthcareassociated infections by allowing potential pathogens to bypass local defenses that would ordinarily impede their invasion. These devices also provide surfaces for development of biofilms that may facilitate adherence of microorganisms and protect from antimicrobial activity. Some infections associated with invasive procedures result from transmission within the healthcare facility while other arise from the patient s endogenous flora. The transmission of infection can be demonstrated as a chain with six links as follows [16] : 1. The pathogen or causative agent. 2. The reservoir, which can be human, animal, or environmental, that serves as the source for the pathogen. 3. The portal of exit from the reservoir. 4. The mode of transmission. 5. The portal of entry into a susceptible host. 6. The host that is susceptible to the pathogen. The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. Symptoms that are limited, or occur in only one body area, are referred to as localized symptoms, whereas symptoms manifested throughout the entire body are referred to as systemic symptoms. The convalescent period involves recovery from the infection. Convalescence may vary according to the severity of the infection and the patient s general condition. The signs and symptoms disappear, and the person returns to a healthy state. However, depending on the type of infection, there may be a temporary or permanent change in the patient s previous health state even after the convalescent period. An infection s potential for reoccurrence depends on the infectious agent and its ability to repeat the cycle of stages within the same host. Host factors also influence reoccurrence of infection due to the body s ability to produce immune responses that may prevent a repeat of the same infection. The use of vaccinations also influences the infectious process when the host develops immunity to specific disease producing agents. These infections are associated with a variety of risk factors, including [18] : Use of indwelling medical devices such as bloodstream, endotracheal, and urinary catheters. Surgical procedures. Injections. Contamination of the healthcare environment. Transmission of communicable diseases between patients and healthcare providers. Overuse or improper use of antibiotics.

9 Nursing consideration: Many healthcare facilities have protocols that specify aspects of nursing care for patients at risk for, or already experiencing, healthcare-associated infections. The following section describes diseases and organisms commonly associated with healthcare-associated infections and has been taken from the Centers for Disease Control and Prevention webpage located at [1]. Acinetobacter is a group of bacteria commonly found in soil and water. Outbreaks of Acinetobacter infections typically occur in intensive care units and healthcare settings housing very ill patients. While there are many types or species of Acinetobacter and all can cause human disease, Acinetobacter baumannii accounts for about 80 percent of reported infections. Acinetobacter infections rarely occur outside of healthcare settings. Burkholderia cepacia, also called B. cepacial, is the name for a group or complex of bacteria that can be found in soil and water. Burkholderia cepacia bacteria are often resistant to common antibiotics. Burkholderia cepacia poses little medical risk to healthy people; however, it is a known cause of infections in hospitalized patients. People with certain health conditions, like weakened immune systems or chronic lung diseases (particularly cystic fibrosis), may be more susceptible to infections with Burkholderia cepacia. Clostridium difficile is a bacterium that causes an inflammation of the colon; this condition is called colitis. Diarrhea and fever are the most common symptoms of Clostridium difficile infection. Overuse of antibiotics is the most important risk for getting Clostridium difficile infection. Clostridium difficile is also called C. difficile, C. diff, and CDI (Clostridium difficile infection), CDAD (Clostridium difficile-associated disease). Clostridium sordellii is a rare bacterium that causes pneumonia, endocarditis, arthritis, peritonitis, and myonecrosis. Clostridium sordellii bacteremia and sepsis (bacteremia is when bacteria is present in the bloodstream; sepsis is when bacteremia or another infection triggers a serious body-wide response) occur rarely. Most cases of sepsis from Clostridium sordellii occur in patients with other health conditions. Severe toxic shock syndrome among previously healthy persons has been described in a small number of Clostridium sordellii cases, most often associated with gynecologic infections in women and infection of the umbilical stump in newborns. Clostridium sordellii is also called C. sordellii. Carbapenem-resistant enterobacteriaceae (CRE) are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria that can become carbapenem-resistant. In healthcare settings, CRE infections most commonly occur among patients who are receiving treatment for other conditions. Patients whose care requires devices like ventilators, urinary catheters, or intravenous catheters, and patients who are taking long courses of certain antibiotics are most at risk for CRE infections. Gram-negative bacteria cause infections including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis in healthcare settings. Gram-negative bacteria are resistant to multiple drugs and are increasingly resistant to most available antibiotics. Gram-negative infections include those caused by Klebsiella, Acinetobacter, Pseudomonas aeruginosa, and E. coli., as well as many other less common bacteria. Hepatitis means inflammation of the liver and also refers to a group of viral infections that affect the liver. The most common types are hepatitis A, hepatitis B, and hepatitis C. The delivery of healthcare has the potential to transmit hepatitis to both healthcare workers and patients. Outbreaks have occurred in outpatient settings, hemodialysis units, long-term care facilities, and hospitals, primarily as a result of unsafe injection practices; reuse of needles, finger-stick devices, and syringes; and other lapses in infection control. Human immunodeficiency virus (HIV) is the virus that can lead to acquired immune deficiency syndrome (AIDS). HIV destroys blood cells called CD4+ T cells, which are crucial to helping the body fight disease. This results in a weakened immune system, making persons with HIV or AIDS at risk for many different types of infections. Transmission of HIV to patients while in health care settings is rare. Most exposures do not result in infection. Influenza is primarily a community-based infection that is transmitted in households and community settings. Each year, 5 percent to 20 percent of U.S. residents acquire an influenza virus infection, and many will seek medical care in ambulatory healthcare settings (e.g., pediatricians offices, urgent-care clinics). In addition, more than 200,000 persons, on average, are hospitalized each year for influenza-related complications. Healthcare-associated influenza infections can occur in any health care setting and are most common when influenza is also circulating in the community. Therefore, influenza prevention measures should be implemented in all health care settings. Supplemental measures may need to be implemented during influenza season if outbreaks of healthcare-associated influenza occur within certain facilities, such as long-term care agencies and hospitals. Klebsiella is a type of Gram-negative bacteria that can cause healthcare-associated infections including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. Increasingly, Klebsiella bacteria have developed antimicrobial resistance, most recently to the class of antibiotics known as carbapenems. Klebsiella bacteria are normally found in the human intestines (where they do not cause disease). They are also found in human feces. In healthcare settings, Klebsiella infections commonly occur among sick patients who are receiving treatment for other conditions. Patients who have devices like ventilators or intravenous catheters, and patients who are taking long courses of certain antibiotics are most at risk for Klebsiella infections. Healthy people usually do not get Klebsiella infections. Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that is resistant to certain antibiotics called betalactams. These antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin, and amoxicillin. In the community, most MRSA infections are skin infections. More severe or potentially life-threatening MRSA infections occur most frequently among patients in health care settings. Mycobacterium abscessus, also called M. abscessus, is a bacterium distantly related to the ones that cause tuberculosis and leprosy. It is found in water, soil, and dust. It has been known to contaminate medications and products, including medical devices. Healthcare-associated Mycobacterium abscessus can cause a variety of infections that require medical attention. Infections due to this bacterium are usually of the skin and the soft tissues under the skin. It can also cause lung infections in persons with various chronic lung diseases. Noroviruses are a group of viruses that cause gastroenteritis in people. Gastroenteritis is an inflammation of the lining of the stomach and intestines, causing an acute onset of severe vomiting and diarrhea. Norovirus illness is usually brief in people who are otherwise healthy. Young children, the elderly, and people with other medical illnesses are most at risk for more severe or prolonged infection. Like all viral infections, noroviruses are not affected by treatment with antibiotics. Pseudomonas infection is caused by strains of bacteria found widely in the environment; the most common type causing Page 7

10 infections in humans is called Pseudomonas aeruginosa. Serious Pseudomonas infections usually occur in people in the hospital and/or with weakened immune systems. Staphylococcus aureus (staph), is a bacterium commonly found on the skin and in the nose of about 30 percent of individuals. Most of the time, staph does not cause any harm. These infections can look like pimples, boils, or other skin conditions and most are treatable. Tuberculosis, also called TB is caused by a bacterium called Mycobacterium tuberculosis. Transmission of Mycobacterium tuberculosis is a recognized risk to patients and healthcare personnel in healthcare facilities. Transmission is most likely to occur from patients who have unrecognized pulmonary tuberculosis or tuberculosis related to their larynx, are not on effective anti-tuberculosis therapy, and have not been placed in tuberculosis isolation. Transmission of Mycobacterium tuberculosis in healthcare settings has been associated with close contact with persons who have infectious tuberculosis, particularly during the performance of cough-inducing procedures such as bronchoscopy and sputum induction. Mycobacterium tuberculosis is spread through the air and can travel long distances. Cases of multidrug-resistant tuberculosis (MDR-TB, which includes Multiple drug-resistant organisms The previous section notes several antimicrobial-resistant bacteria such as CRE, MRSA, VISA and VRSA. These infectious agents are labeled as multiple drug-resistant organisms (MDROs), and according to the Centers for Disease Control and Prevention publication Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006, they have important infection control implications that either have not been addressed or received only limited consideration in previous isolation guidelines. This section uses excerpts from the CDC s publication to cover content related to the prevention and control of these infections. The full document, with reference citations, may be found at cdc.gov/hicpac/pdf/mdro/mdroguideline2006.pdf [14]. MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA, VRE), these pathogens are frequently resistant to most available antimicrobial agents. These highly resistant organisms deserve special attention in healthcare facilities. In addition to MRSA and VRE, certain gram-negative bacteria, including those producing extended spectrum beta-lactamases (ESBLs) and others that are resistant to multiple classes of antimicrobial agents, are of particular concern. MDRO infections have clinical manifestations that are similar to infections caused by susceptible pathogens. However, options for treating patients with these infections are often extremely limited. For example, until recently, only vancomycin provided effective therapy for potentially life-threatening MRSA infections and during the 1990 s there were virtually no antimicrobial agents to treat infections caused by VRE. Although antimicrobials are now available for treatment of MRSA and VRE infections, resistance to each new agent has already emerged in clinical isolates. Similarly, therapeutic options are limited for ESBL-producing isolates of gram-negative bacilli, strains of A. baumannii resistant to all antimicrobial agents except imipenem, and intrinsically resistant Stenotrophomonas sp. These limitations may influence antibiotic usage patterns in ways that suppress normal flora and create a favorable environment for development of colonization when exposed to potential MDR pathogens. Increased lengths of stay, costs, and mortality also have been associated with MDROs. Two studies documented increased mortality, hospital lengths of stay, and hospital charges associated with multidrug-resistant gram-negative bacilli (MDR-GNBs), including an NICU outbreak of ESBL-producing Klebsiella pneumoniae Page 8 extensively drug-resistant tuberculosis [XDR-TB]), have been recognized and are more difficult to treat. Vancomycin-intermediate Staphylococcus aureus (VISA) and vancomycin-resistant Staphylococcus aureus (VRSA) are specific staph bacteria that have developed resistance to the antimicrobial agent vancomycin. Persons who develop this type of staph infection may have underlying health conditions (such as diabetes and kidney disease), devices going into their bodies (such as catheters), previous infections with methicillin-resistant Staphylococcus aureus, and recent exposure to vancomycin and other antimicrobial agents. Vancomycin-resistant Enterococci (VRE) are specific types of antimicrobial-resistant bacteria that are resistant to vancomycin, the drug often used to treat infections caused by enterococci. Enteroccocci are bacteria that are normally present in the human intestines and in the female genital tract and are often found in the environment. These bacteria can sometimes cause infections. Most vancomycin-resistant Enterococci infections occur in hospitals. Taken from Centers for Disease Control and Prevention (2006). Diseases and Organisms in Healthcare Settings. Retrieved from and the emergence of third- generation cephalosporin resistance in Enterobacter spp. in hospitalized adults. Vancomycin resistance has been reported to be an independent predictor of death from enterococcal bacteremia. Furthermore, VRE was associated with increased mortality, length of hospital stay, admission to the ICU, surgical procedures, and costs when VRE patients were compared with a matched hospital population. However, MRSA may behave differently from other MDROs. When patients with MRSA have been compared to patients with methicillinsusceptible S. aureus (MSSA), MRSA- colonized patients more frequently develop symptomatic infections. Furthermore, higher case fatality rates have been observed for certain MRSA infections, including bacteremia, poststernotomy mediastinitis, and surgical site infections. These outcomes may be a result of delays in the administration of vancomycin, the relative decrease in the bactericidal activity of vancomycin, or persistent bacteremia associated with intrinsic characteristics of certain MRSA strains. Mortality may be increased further by S. aureus with reduced vancomycin susceptibility (VISA). Also some studies have reported an association between MRSA infections and increased length of stay, and healthcare costs, while others have not. Finally, some hospitals have observed an increase in the overall occurrence of staphylococcal infections following the introduction of MRSA into a hospital or special-care unit. The prevalence of MDROs varies temporally, geographically, and by healthcare setting. For example, VRE emerged in the eastern United States in the early 1990s, but did not appear in the western United States until several years later, and varies in prevalence by state. The type and level of care also influence the prevalence of MDROs. ICUs, especially those at tertiary care facilities, may have a higher prevalence of MDRO infections than do non-icu settings. Antimicrobial resistance rates are also strongly correlated with hospital size, tertiarylevel care, and facility type (e.g., long-term care facilities, LTCFs). The frequency of clinical infection caused by these pathogens is low in LTCFs. Nonetheless, MDRO infections in LTCFs can cause serious disease and mortality, and colonized or infected LTCF residents may serve as reservoirs and vehicles for MDRO introduction into acute care facilities. Another example of population differences in prevalence of target MDROs is in the pediatric population. Point prevalence surveys conducted by the Pediatric Prevention Network (PPN) in eight U.S. PICUs and 7 U.S. NICUs in 2000 found < 4 percent of patients were colonized with MRSA or VRE compared with percent were

11 colonized with ceftazidime- or aminoglycoside-resistant gram-negative bacilli; < 3 percent were colonized with ESBL-producing gramnegative bacilli. Despite some evidence that MDRO burden is greatest in adult hospital patients, MDRO require similar control efforts in pediatric populations as well. During the last several decades, the prevalence of MDROs in U.S. hospitals and medical centers has increased steadily. MRSA was first isolated in the United States in By the early 1990s, MRSA accounted for percent of Staphylococcus aureus isolates from hospitalized patients. In 1999, MRSA accounted for >50 percent of S. aureus isolates from patients in ICUs in the National Nosocomial Infection Surveillance (NNIS) system; in 2003, 59.5 percent of S. aureus isolates in NNIS ICUs were MRSA. A similar rise in prevalence has occurred with VRE. From 1990 to 1997, the prevalence of VRE in enterococcal isolates from hospitalized patients increased from <1 percent to approximately 15 percent. VRE accounted for almost 25 percent of enterococcus isolates in NNIS ICUs in 1999, and 28.5 percent in There is ample epidemiologic evidence to suggest that MDROs are carried from one person to another via the hands of HCP. Hands are easily contaminated during the process of care-giving or from contact Bloodborne pathogens The Occupational Safety and Health Administration (OSHA) define bloodborne pathogens as microorganisms that are present in human blood and can cause disease in humans [24]. These pathogens may be transmitted via the following routes: Blood contact. Breast milk. Open wounds. Organ transplant. Percutaneous (sharps/needle sticks). Perinatal. Sexual contact. Transfusions. Transplacental. Healthcare providers come in contact with body fluids that can spread infectious blood borne pathogens. These body fluids include the following [24] : Amniotic fluid. Blood (and any fluid from the body containing visible blood). Cerebrospinal fluid. Pericardial fluid. Peritoneal fluid. Pleural fluid. Semen. Synovial fluid. vaginal secretions Vound exudate. It is important to note that feces, mucous, saliva, sweat, tears, urine, and vomit are not body fluids that spread bloodborne pathogens unless they have visible blood mixed with them. There are three major pathogens associated with bloodborne infections. These include: Hepatitis B (HBV). Hepatitis C (HCV). Human immunodeficiency virus (HIV). The following section contains excerpts from the Centers for Disease Control and Prevention publication titled Exposure to Blood: What Healthcare Personnel Need to Know, The full document, with reference citations, may be found at bbp/exp_to_blood.pdf [2]. with environmental surfaces in close proximity to the patient. The latter is especially important when patients have diarrhea and the reservoir of the MDRO is the gastrointestinal tract. Without adherence to published recommendations for hand hygiene and glove use HCP are more likely to transmit MDROs to patients. Thus, strategies to increase and monitor adherence are important components of MDRO control programs. Rarely, HCPs may introduce an MDRO into a patient care unit. Occasionally, HCP can become persistently colonized with an MDRO, but these HCP have a limited role in transmission, unless other factors are present. Additional factors that can facilitate transmission, include chronic sinusitis, upper respiratory infection, and dermatitis. Adapted from Centers for Disease Control and Prevention (2006). Management of Multidrug-Resistant Organisms in Healthcare Settings. Retrieved from MDROGuideline2006.pdf [14]. Nursing consideration: With the increase of multiple drug-resistant organisms in healthcare settings, it is vital that nurses utilize stringent hand hygiene and appropriate transmission precautions at all times. Healthcare personnel are at risk for occupational exposure to bloodborne pathogens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary with factors such as these: The pathogen involved. The type of exposure. The amount of blood involved in the exposure. The amount of virus in the patient s blood at the time of exposure. Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection. For a susceptible person, the risk from a single needle stick or cut exposure to HBV-infected blood ranges from 6-30 percent and depends on the hepatitis B e antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individuals who are HBeAg positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg negative. While there is a risk for HBV infection from exposures of mucous membranes or nonintact skin, there is no known risk for HBV infection from exposure to intact skin. The average risk for infection after a needle stick or cut exposure to HCV- infected blood is approximately 1.8 percent. The risk following a blood exposure to the eye, nose or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported. There also has been a report of HCV transmission that may have resulted from exposure to nonintact skin, but no known risk from exposure to intact skin. The average risk of HIV infection after a needle stick or cut exposure to HlV-infected blood is 0.3 percent (i.e., three-tenths of 1 percent, or about 1 in 300). Stated another way, 99.7 percent of needle-stick/cut exposures do not lead to infection. As mentioned above, hepatitis B vaccine has been available since 1982 to prevent HBV infection. All healthcare personnel who have a reasonable chance of exposure to blood or body fluids should receive hepatitis B vaccine. Vaccination ideally should occur during the healthcare worker s training period. Workers should be tested one to two months after the vaccine series is complete to make sure that vaccination has provided immunity to HBV infection. Hepatitis B immune globulin (HBIG) alone or in combination with vaccine (if not previously vaccinated) is effective in preventing HBV infection Page 9

12 after an exposure. The decision to begin treatment is based on several factors, such as: Whether the source individual is positive for hepatitis B surface antigen. Whether you have been vaccinated. Whether the vaccine provided immunity. There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Neither immune globulin nor antiviral therapy is recommended after exposure. For these reasons, following recommended infection control practices to prevent percutaneous injuries is imperative. There is no vaccine against HIV. However, results from a small number of studies suggest that the use of some antiretroviral drugs after certain occupational exposures may reduce the chance of HIV transmission. Post-exposure prophylaxis (PEP) is recommended for certain occupational exposures that pose a risk of transmission. However, for those exposures without risk of HIV infection, PEP is not recommended because the drugs used to prevent infection may have serious side effects. Nursing consideration: Nurses should utilize standard precautions with all patients. This will prevent exposure to bloodborne pathogens [24]. Evidence-based practice alert! Healthcare personnel who have received the hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection despite exposure [2]. Adapted from Centers for Disease Control and Prevention. Exposure to Blood: What Healthcare Personnel Need to Know. Retrieved from [2]. Healthcare agencies should have written protocols to implement when a healthcare provider is exposed to a bloodborne pathogen. These protocols should include pathogen testing for both the source individual as well as the exposed healthcare provider, post-exposure treatment if indicated, and post-exposure follow-up. National efforts for maintaining public health and security Many national groups and agencies participate in efforts to protect the public and healthcare providers from infection. These include the Centers for Disease Control and Prevention, the National Healthcare Safety Network, the Healthcare Infection Control Practices Advisory Committee, the Society for Healthcare Epidemiology of America, and the National Institute of Occupational Safety and Health. The Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is tasked with increasing the health security of our nation by conducting research and providing health information. The organization protects the public from health, safety, and security threats in the United States and abroad [11]. To accomplish its mission, the Centers for Disease Control and Prevention has the following focus areas [11] : Health security confronting global disease threats through advanced computing and lab analysis of huge amounts of data to find solutions quickly. Putting science into action tracking disease and finding out what is making people sick and the most effective ways to prevent it. Helping medical care bringing new knowledge to individual healthcare and community health to save more lives and reduce waste. Fighting diseases detecting and confronting new germs and diseases around the globe to increase national security. Nurturing public health building strong, well-resourced public health leaders and capabilities at national, state, and local levels to protect Americans from health threats. Healthcare-associated infection prevalence survey [22] The Centers for Disease Control and Prevention s Healthcare- Associated Infection Prevalence Survey provides an updated national estimate of the overall problem in U.S. hospitals. Based on a large sample of acute care hospitals in the United States, the survey found that on any given day, about 1 in 25 hospital patients had at least one The National Healthcare Safety Network The National Healthcare Safety Network (NHSN) is the nation s most widely used healthcare-associated infection tracking system. NHSN provides facilities, states, regions, and the nation with data needed to identify problem areas, measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections [12]. In addition, NHSN allows healthcare facilities to track blood safety errors and important healthcare process measures such as healthcare personnel influenza vaccine status and infection control adherence rates [17]. healthcare-associated infection. There were an estimated 722,000 healthcare-associated infections in United States acute care hospitals in About 75,000 hospital patients with healthcare-associated infections died during their hospitalizations. More than half of all healthcare-associated infections occurred outside of the intensive care unit. The table below provides a breakdown of the types of these infections. Estimates of healthcare-associated infections occurring in acute care hospitals in the United States, Major site of infection Estimated numbers Pneumonia 157,500 Gastrointestinal illness 123,100 Urinary tract infections 93,300 Primary bloodstream infections 71,900 Surgical site infections from any inpatient surgery 157,500 Other types of infections 118,500 Estimated total number of infections in hospitals 721,800 The full report is available online at: [22]. The National and State Healthcare-Associated Infections Progress Report is an annual report that gives a closer look at the healthcareassociated infections most commonly reported using NHSN. The report describes national and state progress in preventing central line-associated bloodstream infections, catheter-associated urinary tract infections, select surgical site infections, hospital-onset Clostridium difficile infections (C. difficile), and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia (bloodstream infections) [13]. Page 10

13 The current report is based on 2013 data. On the national level, the report found the following [13] : A 46 percent decrease in central line-associated bloodstream infections between 2008 and A 19 percent decrease in surgical site infections related to the ten select procedures tracked in the report between 2008 and A 6 percent increase in catheter-associated urinary tract infections between 2009 and 2013; although initial data from 2014 seems to indicate that these infections have started to decrease. An 8 percent decrease in hospital-onset MRSA bacteremia between 2011 and A 10 percent decrease in hospital-onset C. difficile infections between 2011 and The full report is available online at: [13]. The Healthcare Infection Control Practices Advisory Committee The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a group assembled to provide advice and guidance to the Centers for Disease Control and Prevention and the Secretary of the Department of Health and Human Services. This guidance and advice includes infection control practices; strategies for surveillance, prevention, and control of healthcare-associated infections; antimicrobial resistance; and other related events in United States The Society for Healthcare Epidemiology of America [26] The Society for Healthcare Epidemiology of America (SHEA) is a group that represents physicians and other healthcare providers with expertise in healthcare epidemiology, infection prevention, and antimicrobial stewardship. The group s mission is to promote the prevention of healthcare-associated infections and antibiotic resistance The National Institute of Occupational Safety and Health [25] The National Institute of Occupational Safety and Health (NIOSH) was established as part of the Occupational Safety and Health Act of 1970 and is part of the Centers for Disease Control and Prevention. The group s mission is to develop new knowledge in the field of occupational safety and health and to transfer that knowledge into practice. Its mandate is to provide every man and woman in the nation safe and healthful working conditions and to preserve our human resources. The employees represent fields that include epidemiology, medicine, nursing, industrial hygiene, safety, psychology, chemistry, statistics, economics, and many branches of engineering. The strategic goals and objectives for include the following: healthcare settings. The group is comprised of infection control experts in the fields of infectious diseases, healthcare epidemiology, healthcare-associated infections and healthcare-related events, epidemiology, health policy, health services research, public health, and related fields [8]. The 1998 document titled Guideline for Infection Control in Health Care Personnel is the basis for current infection prevention and control is healthcare settings [8]. and to advance the fields of healthcare epidemiology and antibiotic stewardship. The expert findings that come from these efforts provide policy and practice guidelines that improve patient care and healthcare provider safety in all healthcare settings. Goal 1: Conduct research to reduce worker illness and injury, and to advance worker well-being. Goal 2: Promote safe and healthy workers through interventions, recommendations and capacity building. Goal 3: Enhance international worker safety and health through global collaborations. Many infection prevention and control guidelines are published by the groups or agencies described in the previous section. Healthcare providers can locate the current research, statistics and guidelines by utilizing the information provided by these resources. Infection control prevention concepts [6] All healthcare facilities are required to implement and monitor infection control prevention plans for healthcare providers and the patients for which they care. The Centers for Disease Control and Prevention provides guidance for both broad and specific infection control practices with an abundance of website-based information. One such document titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings provides the basis for this next section of the course, outlining various practices for both the prevention and control of infectious diseases. The full document, with reference citations, is available at cdc.gov/hicpac/2007ip/2007isolationprecautions.html [6]. Selected excerpts from the document follow and provide information related to infection prevention and control. Part II Fundamental Elements to Prevent Transmission of Infectious Agents in Healthcare Settings II.A. Healthcare system components that influence the effectiveness of precautions to prevent transmission II.A.1. Administrative measures Healthcare organizations can demonstrate a commitment to preventing transmission of infectious agents by incorporating infection control into the objectives of the organization s patient and occupational safety programs. An infrastructure to guide, support, and monitor adherence to Standard and Transmission-Based Precautions will facilitate fulfillment of the organization s mission and achievement of the Joint Commission on Accreditation of Healthcare Organization s patient safety goal to decrease HAIs. Policies and procedures that explain how Standard and Transmission-Based Precautions are applied, including systems used to identify and communicate information about patients with potentially transmissible infectious agents, are essential to ensure the success of these measures and may vary according to the characteristics of the organization. A key administrative measure is provision of fiscal and human resources for maintaining infection control and occupational health programs that are responsive to emerging needs. Specific components include bedside nurse and infection prevention and control professional (ICP) staffing levels, inclusion of ICPs in facility construction and design Page 11

14 decisions, clinical microbiology laboratory support, adequate supplies and equipment including facility ventilation systems, adherence monitoring, assessment and correction of system failures that contribute to transmission, and provision of feedback to healthcare personnel and senior administrators. The positive influence of institutional leadership has been demonstrated repeatedly in studies of healthcare providers adherence to recommended hand hygiene practices. Healthcare administrator involvement in infection control processes can improve administrators awareness of the rationale and resource requirements for following recommended infection control practices. Several administrative factors may affect the transmission of infectious agents in healthcare settings: institutional culture, individual worker behavior, and the work environment. Each of these areas is suitable for performance improvement monitoring and incorporation into the organization s patient safety goals. II.A.1.a. Scope of work and staffing needs for infection control professionals The effectiveness of infection surveillance and control programs in preventing nosocomial infections in United States hospitals was assessed by the CDC through the Study on the Efficacy of Nosocomial Infection Control (SENIC Project) conducted In a representative sample of US general hospitals, those with a trained infection control physician or microbiologist involved in an infection control program, and at least one infection control nurse per 250 beds, were associated with a 32 percent lower rate of four infections studied (CVC-associated bloodstream infections, ventilator-associated pneumonias, catheterrelated urinary tract infections, and surgical site infections). Since that landmark study was published, responsibilities of ICPs have expanded commensurate with the growing complexity of the healthcare system, the patient populations served, and the increasing numbers of medical procedures and devices used in all types of healthcare settings. The scope of work of ICPs was first assessed in 1982 by the Certification Board of Infection Control (CBIC), and has been re-assessed every five years since that time. The findings of these task analyses have been used to develop and update the Infection Control Certification Examination, offered for the first time in With each survey, it is apparent that the role of the ICP is growing in complexity and scope, beyond traditional infection control activities in acute care hospitals. Activities currently assigned to ICPs in response to emerging challenges include: 1) surveillance and infection prevention at facilities other than acute care hospitals e.g., ambulatory clinics, day surgery centers, long term care facilities, rehabilitation centers, home care; 2) oversight of employee health services related to infection prevention, e.g. assessment of risk and administration of recommended treatment following exposure to infectious agents, tuberculosis screening, influenza vaccination, respiratory protection fit testing, and administration of other vaccines as indicated, such as smallpox vaccine in 2003; 3) preparedness planning for annual influenza outbreaks, pandemic influenza, SARS, bioweapons attacks; 4) adherence monitoring for selected infection control practices; 5) oversight of risk assessment and implementation of prevention measures associated with construction and renovation; 6) prevention of transmission of MDROs; 7) evaluation of new medical products that could be associated with increased infection risk. e.g., intravenous infusion materials; 9) communication with the public, facility staff, and state and local health departments concerning infection control-related issues; and 10) participation in local and multi-center research projects. None of the CBIC job analyses addressed specific staffing requirements for the identified tasks, although the surveys did include information about hours worked; the 2001 survey included the number of ICPs assigned to the responding facilities. There is agreement in the literature that 1 ICP per 250 acute care beds is no longer adequate to meet current infection control needs; a Delphi project that assessed staffing needs of infection control programs in the 21st century concluded that a ratio of 0.8 to 1.0 ICP per 100 occupied acute care beds is an appropriate level of staffing. A survey of participants in the Page 12 National Nosocomial Infections Surveillance (NNIS) system found the average daily census per ICP was 115. Results of other studies have been similar: 3 per 500 beds for large acute care hospitals, 1 per beds in long term care facilities, and 1.56 per 250 in small rural hospitals. The foregoing demonstrates that infection control staffing can no longer be based on patient census alone, but rather must be determined by the scope of the program, characteristics of the patient population, complexity of the healthcare system, tools available to assist personnel to perform essential tasks (e.g., electronic tracking and laboratory support for surveillance), and unique or urgent needs of the institution and community. Furthermore, appropriate training is required to optimize the quality of work performed. II.A.1.a.i. Infection control nurse liaison Designating a bedside nurse on a patient care unit as an infection control liaison or link nurse is reported to be an effective adjunct to enhance infection control at the unit level. Such individuals receive training in basic infection control and have frequent communication with the ICPs, but maintain their primary role as bedside caregiver on their units. The infection control nurse liaison increases the awareness of infection control at the unit level. He or she is especially effective in implementation of new policies or control interventions because of the rapport with individuals on the unit, an understanding of unit-specific challenges, and ability to promote strategies that are most likely to be successful in that unit. This position is an adjunct to, not a replacement for, fully trained ICPs. Furthermore, the infection control liaison nurses should not be counted when considering ICP staffing. Nursing consideration: Infection control nursing is a specialty area that is responsible for recognizing, isolating, and preventing healthcareassociated infections that impact patient outcomes and the safety of healthcare providers [23]. II.A.1.b. Bedside nurse staffing There is increasing evidence that the level of bedside nurse staffing influences the quality of patient care. If there are adequate nursing staff, it is more likely that infection control practices, including hand hygiene and Standard and Transmission-Based Precautions, will be given appropriate attention and applied correctly and consistently. A national multicenter study reported strong and consistent inverse relationships between nurse staffing and five adverse outcomes in medical patients, two of which were HAIs: urinary tract infections and pneumonia. The association of nursing staff shortages with increased rates of HAIs has been demonstrated in several outbreaks in hospitals and long-term care settings, and with increased transmission of hepatitis C virus in dialysis units. In most cases, when staffing improved as part of a comprehensive control intervention, the outbreak ended or the HAI rate declined. In two studies, the composition of the nursing staff ( pool or float vs. regular staff nurses) influenced the rate of primary bloodstream infections, with an increased infection rate occurring when the proportion of regular nurses decreased and pool nurses increased. II.A.1.c. Clinical microbiology laboratory support The critical role of the clinical microbiology laboratory in infection control and healthcare epidemiology is described well and is supported by the Infectious Disease Society of America policy statement on consolidation of clinical microbiology laboratories published in The clinical microbiology laboratory contributes to preventing transmission of infectious diseases in healthcare settings by promptly detecting and reporting epidemiologically important organisms, identifying emerging patterns of antimicrobial resistance, and assisting in assessment of the effectiveness of recommended precautions to limit transmission during outbreaks. Outbreaks of infections may be recognized first by laboratorians. Healthcare organizations need to ensure the availability of the recommended scope and quality of laboratory services, a sufficient number of appropriately trained laboratory staff members, and systems to promptly communicate epidemiologically important results to those who will take action

15 (e.g., providers of clinical care, infection control staff, healthcare epidemiologists, and infectious disease consultants). As concerns about emerging pathogens and bioterrorism grow, the role of the clinical microbiology laboratory takes on even greater importance. For healthcare organizations that outsource microbiology laboratory services (e.g., ambulatory care, home care, long-term care facilities, smaller acute care hospitals), it is important to specify by contract the types of services (e.g., periodic institution-specific aggregate susceptibility reports) required to support infection control. Several key functions of the clinical microbiology laboratory are relevant to this guideline: Antimicrobial susceptibility by testing and interpretation in accordance with current guidelines developed by the National Committee for Clinical Laboratory Standards (NCCLS), known as the Clinical and Laboratory Standards Institute (CLSI) since 2005, for the detection of emerging resistance patterns, and for the preparation, analysis, and distribution of periodic cumulative antimicrobial susceptibility summary reports. While not required, clinical laboratories ideally should have access to rapid genotypic identification of bacteria and their antibiotic resistance genes. Performance of surveillance cultures when appropriate (including retention of isolates for analysis) to assess patterns of infection transmission and effectiveness of infection control interventions at the facility or organization. Microbiologists assist in decisions concerning the indications for initiating and discontinuing active surveillance programs and optimize the use of laboratory resources. Molecular typing, on-site or outsourced, in order to investigate and control healthcare-associated outbreaks. Application of rapid diagnostic tests to support clinical decisions involving patient treatment, room selection, and implementation of control measures including barrier precautions and use of vaccine or chemoprophylaxis agents (e.g., influenza, B. pertussis, RSV, and enteroviruses). The microbiologist provides guidance to limit rapid testing to clinical situations in which rapid results influence patient management decisions, as well as providing oversight of point-ofcare testing performed by non-laboratory healthcare workers. Detection and rapid reporting of epidemiologically important organisms, including those that are reportable to public health agencies. Implementation of a quality control program that ensures testing services are appropriate for the population served, and stringently evaluated for sensitivity, specificity, applicability, and feasibility. Participation in a multidisciplinary team to develop and maintain an effective institutional program for the judicious use of antimicrobial agents. II.A.2. Institutional safety culture and organizational characteristics Safety culture (or safety climate) refers to a work environment where a shared commitment to safety on the part of management and the workforce is understood and followed. The authors of the Institute of Medicine Report, To Err is Human, acknowledge that causes of medical error are multifaceted but emphasize repeatedly the pivotal role of system failures and the benefits of a safety culture. A safety culture is created through 1) the actions management takes to improve patient and worker safety; 2) worker participation in safety planning; 3) the availability of appropriate protective equipment; 4) influence of group norms regarding acceptable safety practices; and 5) the organization s socialization process for new personnel. Safety and patient outcomes can be enhanced by improving or creating organizational characteristics within patient care units as demonstrated by studies of surgical ICUs. Each of these factors has a direct bearing on adherence to transmission prevention recommendations. Measurement of an institutional culture of safety is useful for designing improvements in healthcare. Several hospital-based studies have linked measures of safety culture with both employee adherence to safe practices and reduced exposures to blood and body fluids. One study of hand hygiene practices concluded that improved adherence requires integration of infection control into the organization s safety culture. Several hospitals that are part of the Veterans Administration Healthcare System have taken specific steps toward improving the safety culture, including error reporting mechanisms, performing root cause analysis on problems identified, providing safety incentives, and employee education. II.A.3 Adherence of healthcare personnel to recommended guidelines Adherence to recommended infection control practices decreases transmission of infectious agents in healthcare settings. However, several observational studies have shown limited adherence to recommended practices by healthcare personnel. Observed adherence to universal precautions ranged from 43 to 89 percent. However, the degree of adherence depended frequently on the practice that was assessed and, for glove use, the circumstance in which they were used. Appropriate glove use has ranged from a low of 15 percent to a high of 82 percent. However, 92 percent and 98 percent adherence with glove use have been reported during arterial blood gas collection and resuscitation, respectively, procedures where there may be considerable blood contact. Differences in observed adherence have been reported among occupational groups in the same healthcare facility and between experienced and non-experienced professionals. In surveys of healthcare personnel, self-reported adherence was generally higher than that reported in observational studies. Furthermore, where an observational component was included with a self-reported survey, self-perceived adherence was often greater than observed adherence. Among nurses and physicians, increasing years of experience is a negative predictor of adherence. Education to improve adherence is the primary intervention that has been studied. While positive changes in knowledge and attitude have been demonstrated, there often has been limited or no accompanying change in behavior. Self-reported adherence is higher in groups that have received an educational intervention. Educational interventions that incorporated videotaping and performance feedback were successful in improving adherence during the period of study; the long-term effect of these interventions is not known. The use of videotape also served to identify system problems (e.g., communication and access to personal protective equipment) that otherwise may not have been recognized. Nursing consideration: There are multiple opportunities for nurses to implement and participate in research studies related to the use of engineering controls and adherence to infection control concepts. Use of engineering controls and facility design concepts for improving adherence is gaining interest. While introduction of automated sinks had a negative impact on consistent adherence to hand washing, use of electronic monitoring and voice prompts to remind healthcare workers to perform hand hygiene, and improving accessibility to hand hygiene products, increased adherence and contributed to a decrease in HAIs in one study. More information is needed regarding how technology might improve adherence. Improving adherence to infection control practices requires a multifaceted approach that incorporates continuous assessment of both the individual and the work environment. Using several behavioral theories, Kretzer and Larson concluded that a single intervention (e.g., a handwashing campaign or putting up new posters about transmission precautions) would likely be ineffective in improving healthcare personnel adherence. Improvement requires that the organizational leadership make prevention an institutional priority and integrate infection control practices into the organization s safety culture. A recent review of the literature concluded that variations in organizational factors (e.g., safety climate, policies and procedures, education and training) and individual factors (e.g., knowledge, perceptions of risk, past experience) were determinants of adherence to infection control guidelines for protection against SARS and other respiratory pathogens. Page 13

16 II.B. Surveillance for healthcare-associated infections (HAIs) Surveillance is an essential tool for case-finding of single patients or clusters of patients who are infected or colonized with epidemiologically important organisms (e.g., susceptible bacteria such as S. aureus, S. pyogenes [Group A streptococcus] or Enterobacter- Klebsiella spp; MRSA, VRE, and other MDROs; C. difficile; RSV; influenza virus) for which transmission-based precautions may be required. Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a healthrelated event for use in public health action to reduce morbidity and mortality and to improve health. The work of Ignaz Semmelweis that described the role of person-to-person transmission in puerperal sepsis is the earliest example of the use of surveillance data to reduce transmission of infectious agents. Surveillance of both process measures and the infection rates to which they are linked are important for evaluating the effectiveness of infection prevention efforts and identifying indications for change. The Study on the Efficacy of Nosocomial Infection Control (SENIC) found that different combinations of infection control practices resulted in reduced rates of nosocomial surgical site infections, pneumonia, urinary tract infections, and bacteremia in acute care hospitals; however, surveillance was the only component essential for reducing all four types of HAIs. Although a similar study has not been conducted in other healthcare settings, a role for surveillance and the need for novel strategies have been described in LTCFs and in home care. The essential elements of a surveillance system are: 1) standardized definitions; 2) identification of patient populations at risk for infection; 3) statistical analysis (e.g. risk-adjustment, calculation of rates using appropriate denominators, trend analysis using methods such as statistical process control charts); and 4) feedback of results to the primary caregivers. Data gathered through surveillance of high-risk populations, device use, procedures, and/ or facility locations (e.g., ICUs) are useful for detecting transmission trends. Identification of clusters of infections should be followed by a systematic epidemiologic investigation to determine commonalities in persons, places, and time; and guide implementation of interventions and evaluation of the effectiveness of those interventions. Targeted surveillance based on the highest risk areas or patients has been preferred over facility-wide surveillance for the most effective use of resources. However, surveillance for certain epidemiologically important organisms may need to be facility-wide. Surveillance methods will continue to evolve as healthcare delivery systems change and user-friendly electronic tools become more widely available for electronic tracking and trend analysis. Individuals with experience in healthcare epidemiology and infection control should be involved in selecting software packages for data aggregation and analysis to assure that the need for efficient and accurate HAI surveillance will be met. Effective surveillance is increasingly important as legislation requiring public reporting of HAI rates is passed and states work to develop effective systems to support such legislation. II.C. Education of HCWs, patients, and families Education and training of healthcare personnel are a prerequisite for ensuring that policies and procedures for Standard and Transmission- Based Precautions are understood and practiced. Understanding the scientific rationale for the precautions will allow HCWs to apply procedures correctly, as well as safely modify precautions based on changing requirements, resources, or healthcare settings. In one study, the likelihood of HCWs developing SARS was strongly associated with less than 2 hours of infection control training and lack of understanding of infection control procedures. Education about the important role of vaccines (e.g., influenza, measles, varicella, pertussis, pneumococcal) in protecting healthcare personnel, their patients, and family members can help improve vaccination rates. Education on the principles and practices for preventing transmission of infectious agents should begin during training in the health professions and be provided to anyone who has an opportunity for contact with patients or medical equipment (e.g., nursing and medical staff; therapists and technicians, including respiratory, physical, occupational, radiology, and cardiology personnel; phlebotomists; housekeeping and maintenance staff; and students). In healthcare facilities, education and training on Standard and Transmission-Based Precautions are typically provided at the time of orientation and should be repeated as necessary to maintain competency; updated education and training are necessary when policies and procedures are revised or when there is a special circumstance, such as an outbreak that requires modification of current practice or adoption of new recommendations. Education and training materials and methods appropriate to the HCW s level of responsibility, individual learning habits, and language needs, can improve the learning experience. Education programs for healthcare personnel have been associated with sustained improvement in adherence to best practices and a related decrease in device-associated HAIs in teaching and nonteaching settings and in medical and surgical ICUs. Several studies have shown that, in addition to targeted education to improve specific practices, periodic assessment and feedback of the HCWs knowledge, and adherence to recommended practices are necessary to achieve the desired changes and to identify continuing education needs. Effectiveness of this approach for isolation practices has been demonstrated for control of RSV. Patients, family members, and visitors can be partners in preventing transmission of infections in healthcare settings. Information about Standard Precautions, especially hand hygiene, Respiratory Hygiene/ Cough Etiquette, vaccination (especially against influenza) and other routine infection prevention strategies may be incorporated into patient information materials that are provided upon admission to the healthcare facility. Additional information about Transmission- Based Precautions is best provided at the time they are initiated. Fact sheets, pamphlets, and other printed material may include information on the rationale for the additional precautions, risks to household members, room assignment for Transmission-Based Precautions purposes, explanation about the use of personal protective equipment by HCWs, and directions for use of such equipment by family members and visitors. Such information may be particularly helpful in the home environment where household members often have primary responsibility for adherence to recommended infection control practices. Healthcare personnel must be available and prepared to explain this material and answer questions as needed. Evidence-based practice alert! Requiring healthcare providers to update infection prevention and control training at regular intervals has been shown to increase compliance with protocols and policies [6]. Page 14

17 II.D. Hand hygiene Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings and is an essential element of Standard Precautions. The term hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products (gels, rinses, foams) that do not require the use of water. In the absence of visible soiling of hands, approved alcohol- based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience. Improved hand hygiene practices have been associated with a sustained decrease in the incidence of MRSA and VRE infections primarily in the ICU. The scientific rationale, indications, methods, and products for hand hygiene are summarized in other publications. Nursing consideration: The term hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products (gels, rinses, foams) that do not require the use of water. Evidence-based practice alert! In the absence of visible soiling of hands, approved alcohol- based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbiocidal activity, reduced drying of the skin, and convenience [6]. The effectiveness of hand hygiene can be reduced by the type and length of fingernails. Individuals wearing artificial nails have been shown to harbor more pathogenic organisms, especially gram-negative bacilli and yeasts, on the nails and in the subungual area than those with native nails. In 2002, CDC/HICPAC recommended (Category IA) that artificial fingernails and extenders not be worn by healthcare personnel who have contact with high-risk patients (e.g., those in ICUs, ORs) due to the association with outbreaks of gram-negative bacillus and candidal infections as confirmed by molecular typing of isolates. The need to restrict the wearing of artificial fingernails by all healthcare personnel who provide direct patient care or by healthcare personnel who have contact with other high risk groups (e.g., oncology, cystic fibrosis patients), has not been studied, but has been recommended by some experts. At this time such decisions are at the discretion of an individual facility s infection control program. There is less evidence that jewelry affects the quality of hand hygiene. Although hand contamination with potential pathogens is increased with ring-wearing, no studies have related this practice to HCW-topatient transmission of pathogens. Evidence-based practice alert! Individuals wearing artificial nails have been shown to harbor more pathogenic organisms, especially gram-negative bacilli and yeasts, on the nails and in the subungual area than individuals with native nails [6]. II.E. Personal protective equipment (PPE) for healthcare personnel PPE refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The selection of PPE is based on the nature of the patient interaction and/or the likely mode(s) of transmission. Guidance on the use of PPE is discussed in Part III. Designated containers for used disposable or reusable PPE should be placed in a location that is convenient to the site of removal to facilitate disposal and containment of contaminated materials. Hand hygiene is always the final step after removing and disposing of PPE. The following sections highlight the primary uses and methods for selecting this equipment. II.E.1. Gloves Gloves are used to prevent contamination of healthcare personnel hands when 1) anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; 2) having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route e.g., VRE, MRSA, RSV; or 3) handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces. Gloves can protect both patients and healthcare personnel from exposure to infectious material that may be carried on hands. The extent to which gloves will protect healthcare personnel from transmission of bloodborne pathogens (e.g., HIV, HBV, HCV) following a needle stick or other puncture that penetrates the glove barrier has not been determined. Although gloves may reduce the volume of blood on the external surface of a sharp by percent, the residual blood in the lumen of a hollowbore needle would not be affected; therefore, the effect on transmission risk is unknown. Gloves manufactured for healthcare purposes are subject to FDA evaluation and clearance. Nonsterile disposable medical gloves made of a variety of materials (e.g., latex, vinyl, nitrile) are available for routine patient care. The selection of glove type for non-surgical use is based on a number of factors, including the task that is to be performed, anticipated contact with chemicals and chemotherapeutic agents, latex sensitivity, sizing, and facility policies for creating a latex-free environment. For contact with blood and body fluids during non-surgical patient care, a single pair of gloves generally provides adequate barrier protection. However, there is considerable variability among gloves; both the quality of the manufacturing process and type of material influence their barrier effectiveness. While there is little difference in the barrier properties of unused intact gloves, studies have shown repeatedly that vinyl gloves have higher failure rates than latex or nitrile gloves when tested under simulated and actual clinical conditions. For this reason either latex or nitrile gloves are preferable for clinical procedures that require manual dexterity and/ or will involve more than brief patient contact. It may be necessary to stock gloves in several sizes. Heavier, reusable utility gloves are indicated for non-patient care activities, such as handling or cleaning contaminated equipment or surfaces. During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from clean to dirty, and confining or limiting contamination to surfaces that are directly needed for patient care. It may be necessary to change gloves during the care of a single patient to prevent crosscontamination of body sites. It also may be necessary to change gloves if the patient interaction also involves touching portable computer keyboards or other mobile equipment that is transported from room to room. Discarding gloves between patients is necessary to prevent transmission of infectious material. Gloves must not be washed for subsequent reuse because microorganisms cannot be removed reliably from glove surfaces and continued glove integrity cannot be ensured. Furthermore, glove reuse has been associated with transmission of MRSA and gram-negative bacilli. When gloves are worn in combination with other PPE, they are put on last. Gloves that fit snugly around the wrist are preferred for use with an isolation gown because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands. Gloves that are removed properly will prevent hand contamination. Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal. Page 15

18 Nursing consideration: Hand hygiene must be performed after glove removal to prevent the transmission of infectious material remaining on hands. II.E.2. Isolation gowns Isolation gowns are used as specified by Standard and Transmission- Based Precautions, to protect the HCW s arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. The need for and type of isolation gown selected is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. The wearing of isolation gowns and other protective apparel is mandated by the OSHA Bloodborne Pathogens Standard. Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered PPE. When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. The routine donning of isolation gowns upon entry into an intensive care unit or other high-risk area does not prevent or influence potential colonization or infection of patients in those areas. Isolation gowns are always worn in combination with gloves, and with other PPE when indicated. Gowns are usually the first piece of PPE to be donned. Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed upper body areas are protected. Several gown sizes should be available in a healthcare facility to ensure appropriate coverage for staff members. Isolation gowns should be removed before leaving the patient care area to prevent possible contamination of the environment outside the patient s room. Isolation gowns should be removed in a manner that prevents contamination of clothing or skin (Figure). The outer, contaminated, side of the gown is turned inward and rolled into a bundle, and then discarded into a designated container for waste or linen to contain contamination. II.E.3. Face protection: Masks, goggles, face shields II.E.3.a. Masks Masks are used for three primary purposes in healthcare settings: 1) placed on healthcare personnel to protect them from contact with infectious material from patients e.g., respiratory secretions and sprays of blood or body fluids, consistent with Standard Precautions and Droplet Precautions; 2) placed on healthcare personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a healthcare worker s mouth or nose, and 3) placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (i.e., Respiratory Hygiene/Cough Etiquette). Masks may be used in combination with goggles to protect the mouth, nose and eyes, or a face shield may be used instead of a mask and goggles, to provide more complete protection for the face, as discussed below. Masks should not be confused with particulate respirators that are used to prevent inhalation of small particles that may contain infectious agents transmitted via the airborne route as described below. The mucous membranes of the mouth, nose, and eyes are susceptible portals of entry for infectious agents, as can be other skin surfaces if skin integrity is compromised (e.g., by acne, dermatitis). Therefore, use of PPE to protect these body sites is an important component of Standard Precautions. The protective effect of masks for exposed healthcare personnel has been demonstrated. Procedures that generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either Page 16 a face shield (disposable or reusable) or mask and goggles. The wearing of masks, eye protection, and face shields in specified circumstances when blood or body fluid exposures are likely to occur is mandated by the OSHA Bloodborne Pathogens Standard. Appropriate PPE should be selected based on the anticipated level of exposure. Two mask types are available for use in healthcare settings: surgical masks that are cleared by the FDA and required to have fluid-resistant properties, and procedure or isolation masks. No studies have been published that compare mask types to determine whether one mask type provides better protection than another. Since procedure/isolation masks are not regulated by the FDA, there may be more variability in quality and performance than with surgical masks. Masks come in various shapes (e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment (e.g., ties, elastic, ear loops). Healthcare facilities may find that different types of masks are needed to meet individual healthcare personnel needs. II.E.3.b. Goggles, face shields Guidance on eye protection for infection control has been published. The eye protection chosen for specific work situations (e.g., goggles or face shield) depends upon the circumstances of exposure, other PPE used, and personal vision needs. Personal eyeglasses and contact lenses are NOT considered adequate eye protection ( gov/niosh/topics/eye/eye-infectious.html). NIOSH states that, eye protection must be comfortable, allow for sufficient peripheral vision, and must be adjustable to ensure a secure fit. It may be necessary to provide several different types, styles, and sizes of protective equipment. Indirectly-vented goggles with a manufacturer s antifog coating may provide the most reliable practical eye protection from splashes, sprays, and respiratory droplets from multiple angles. Newer styles of goggles may provide better indirect airflow properties to reduce fogging, as well as better peripheral vision and more size options for fitting goggles to different workers. Many styles of goggles fit adequately over prescription glasses with minimal gaps. While effective as eye protection, goggles do not provide splash or spray protection to other parts of the face. The role of goggles, in addition to a mask, in preventing exposure to infectious agents transmitted via respiratory droplets has been studied only for RSV. Reports published in the mid-1980s demonstrated that eye protection reduced occupational transmission of RSV. Whether this was due to preventing hand-eye contact or respiratory droplet-eye contact has not been determined. However, subsequent studies demonstrated that RSV transmission is effectively prevented by adherence to Standard plus Contact Precautions and that for this virus routine use of goggles is not necessary. It is important to remind healthcare personnel that even if Droplet Precautions are not recommended for a specific respiratory tract pathogen, protection for the eyes, nose and mouth by using a mask and goggles, or face shield alone, is necessary when it is likely that there will be a splash or spray of any respiratory secretions or other body fluids as defined in Standard Precautions. Disposable or non-disposable face shields may be used as an alternative to goggles. As compared with goggles, a face shield can provide protection to other facial areas in addition to the eyes. Face shields extending from chin to crown provide better face and eye protection from splashes and sprays; face shields that wrap around the sides may reduce splashes around the edge of the shield. Removal of a face shield, goggles and mask can be performed safely after gloves have been removed, and hand hygiene performed. The ties, earpieces and/or headband used to secure the equipment to the head are considered clean and therefore safe to touch with bare hands. The front of a mask, goggles and face shield are considered contaminated.

19 Nursing consideration: Face shields, goggles, and masks should be removed after gloves have been removed and hand hygiene has been performed. II.E.4. Respiratory protection The subject of respiratory protection as it applies to preventing transmission of airborne infectious agents, including the need for and frequency of fit-testing is under scientific review and was the subject of a CDC workshop in Respiratory protection currently requires the use of a respirator with N95 or higher filtration to prevent inhalation of infectious particles. Information about respirators and respiratory protection programs is summarized in the Guideline for Preventing Transmission of Mycobacterium tuberculosis in Healthcare Settings, Respiratory protection is broadly regulated by OSHA under the general industry standard for respiratory protection which requires that U.S. employers in all employment settings implement a program to protect employees from inhalation of toxic materials. OSHA program components include medical clearance to wear a respirator; provision and use of appropriate respirators, including fittested NIOSH-certified N95 and higher particulate filtering respirators; education on respirator use and periodic re-evaluation of the respiratory protection program. When selecting particulate respirators, models with inherently good fit characteristics (i.e., those expected to provide protection factors of 10 or more to 95 percent of wearers) are preferred and could theoretically relieve the need for fit testing. Issues pertaining to respiratory protection remain the subject of ongoing debate. Information on various types of respirators may be found at and in published studies. A user-seal check (formerly called a fit check ) should be performed by the wearer of a respirator each time a respirator is donned to minimize air leakage around the face piece. The optimal frequency of fit-testing has not been determined; re-testing may be indicated if there is a change in facial features of the wearer, onset of a medical condition that would affect respiratory function in the wearer, or a change in the model or size of the initially assigned respirator. Respiratory protection was first recommended for protection of preventing U.S. healthcare personnel from exposure to M. tuberculosis in That recommendation has been maintained in two successive revisions of the Guidelines for Prevention of Transmission of Tuberculosis in Hospitals and other Healthcare Settings. The incremental benefit from respirator use, in addition to administrative and engineering controls (i.e., AIIRs, early recognition of patients likely to have tuberculosis and prompt placement in an AIIR, and maintenance of a patient with suspected tuberculosis in an AIIR until no longer infectious), for preventing transmission of airborne infectious agents (e.g., M. tuberculosis) is undetermined. Although some studies have demonstrated effective prevention of M. tuberculosis transmission in hospitals where surgical masks, instead of respirators, were used in conjunction with other administrative and engineering controls, CDC currently recommends N95 or higher level respirators for personnel exposed to patients with suspected for confirmed tuberculosis. Currently this is also true for other diseases that could be transmitted through the airborne route, including SARS and smallpox, until inhalational transmission is better defined or healthcare-specific protective equipment more suitable for preventing infection are developed. Respirators are also currently recommended to be worn during the performance of aerosol-generating procedures (e.g., intubation, bronchoscopy, suctioning) on patients with SARS Co-V infection, avian influenza and pandemic influenza (See Appendix A). Although Airborne Precautions are recommended for preventing airborne transmission of measles and varicella-zoster viruses, there are no data upon which to base a recommendation for respiratory protection to protect susceptible personnel against these two infections; transmission of varicella-zoster virus has been prevented among pediatric patients using negative pressure isolation alone. Whether respiratory protection (i.e., wearing a particulate respirator) would enhance protection from these viruses has not been studied. Since the majority of healthcare personnel have natural or acquired immunity to these viruses, only immune personnel generally care for patients with these infections. Although there is no evidence to suggest that masks are not adequate to protect healthcare personnel in these settings, for purposes of consistency and simplicity, or because of difficulties in ascertaining immunity, some facilities may require the use of respirators for entry into all AIIRs, regardless of the specific infectious agent. Procedures for safe removal of respirators are provided. In some healthcare settings, particulate respirators used to provide care for patients with M. tuberculosis are reused by the same HCW. This is an acceptable practice providing the respirator is not damaged or soiled, the fit is not compromised by change in shape, and the respirator has not been contaminated with blood or body fluids. There are no data on which to base a recommendation for the length of time a respirator may be reused. Nursing consideration: Nurses must be aware of the steps for donning and removing personal protective equipment. The following charts outline these steps [15]. Reprinted from Centers for Disease Control and Prevention. Poster: Sequence for Donning and Removing Personal Protective Equipment. Retrieved from [3]. Page 17

20 Page 18

21 Page 19

22 Page 20

23 II.F. Safe work practices to prevent HCW exposure to bloodborne pathogens II.F.1. Prevention of needlesticks and other sharps-related injuries Injuries due to needles and other sharps have been associated with transmission of HBV, HCV, and HIV to healthcare personnel. The prevention of sharps injuries has always been an essential element of Universal and now Standard Precautions. These include measures to handle needles and other sharp devices in a manner that will prevent injury to the user and to others who may encounter the device during or after a procedure. These measures apply to routine patient care and do not address the prevention of sharps injuries and other blood exposures during surgical and other invasive procedures that are addressed elsewhere. Since 1991, when OSHA first issued its Bloodborne Pathogens Standard to protect healthcare personnel from blood exposure, the focus of regulatory and legislative activity has been on implementing a hierarchy of control measures. This has included focusing attention on removing sharps hazards through the development and use of engineering controls. The federal Needlestick Safety and Prevention Act signed into law in November, 2000 authorized OSHA s revision of its Bloodborne Pathogens Standard to more explicitly require the use of safety-engineered sharp devices. CDC has provided guidance on sharps injury prevention, including for the design, implementation and evaluation of a comprehensive sharps injury prevention program. II.F.2. Prevention of mucous membrane contact Exposure of mucous membranes of the eyes, nose and mouth to blood and body fluids has been associated with the transmission of bloodborne viruses and other infectious agents to healthcare personnel. The prevention of mucous membrane exposures has always been an element of Universal and now Standard Precautions for routine patient care and is subject to OSHA bloodborne pathogen regulations. Safe work practices, in addition to wearing PPE, are used to protect mucous membranes and non-intact skin from contact with potentially infectious material. These include keeping gloved and ungloved hands that are contaminated from touching the mouth, nose, eyes, or face; and positioning patients to direct sprays and splatter away from the face of the caregiver. Careful placement of PPE before patient contact will help avoid the need to make PPE adjustments and possible face or mucous membrane contamination during use. In areas where the need for resuscitation is unpredictable, mouthpieces, pocket resuscitation masks with one-way valves, and other ventilation devices provide an alternative to mouth-to-mouth resuscitation, preventing exposure of the caregiver s nose and mouth to oral and respiratory fluids during the procedure. II.F.2.a. Precautions during aerosol-generating procedures The performance of procedures that can generate small particle aerosols (aerosol-generating procedures), such as bronchoscopy, endotracheal intubation, and open suctioning of the respiratory tract, have been associated with transmission of infectious agents to healthcare personnel, including M. tuberculosis, SARS- CoV and N. meningitidis. Protection of the eyes, nose and mouth, in addition to gown and gloves, is recommended during performance of these procedures in accordance with Standard Precautions. Use of a particulate respirator is recommended during aerosol-generating procedures when the aerosol is likely to contain M. tuberculosis, SARS-CoV, or avian or pandemic influenza viruses. II.G.Patient placement II.G.1. Hospitals and long-term care settings Options for patient placement include single patient rooms, two patient rooms, and multi-bed wards. Of these, single patient rooms are preferred when there is a concern about transmission of an infectious agent. Although some studies have failed to demonstrate the efficacy of single patient rooms to prevent HAIs, other published studies, including one commissioned by the American Institute of Architects and the Facility Guidelines Institute, have documented a beneficial relationship between private rooms and reduction in infectious and noninfectious adverse patient outcomes. The AIA notes that private rooms are the trend in hospital planning and design. However, most hospitals and long-term care facilities have multi-bed rooms and must consider many competing priorities when determining the appropriate room placement for patients (e.g., reason for admission; patient characteristics, such as age, gender, mental status; staffing needs; family requests; psychosocial factors; reimbursement concerns). In the absence of obvious infectious diseases that require specified airborne infection isolation rooms (e.g., tuberculosis, SARS, chickenpox), the risk of transmission of infectious agents is not always considered when making placement decisions. When there are only a limited number of single-patient rooms, it is prudent to prioritize them for those patients who have conditions that facilitate transmission of infectious material to other patients (e.g., draining wounds, stool incontinence, uncontained secretions) and for those who are at increased risk of acquisition and adverse outcomes resulting from HAI (e.g., immunosuppression, open wounds, indwelling catheters, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living). Single-patient rooms are always indicated for patients placed on Airborne Precautions and in a Protective Environment and are preferred for patients who require Contact or Droplet Precautions. During a suspected or proven outbreak caused by a pathogen whose reservoir is the gastrointestinal tract, use of single patient rooms with private bathrooms limits opportunities for transmission, especially when the colonized or infected patient has poor personal hygiene habits, fecal incontinence, or cannot be expected to assist in maintaining procedures that prevent transmission of microorganisms (e.g., infants, children, and patients with altered mental status or developmental delay). In the absence of continued transmission, it is not necessary to provide a private bathroom for patients colonized or infected with enteric pathogens as long as personal hygiene practices and Standard Precautions, especially hand hygiene and appropriate environmental cleaning, are maintained. Assignment of a dedicated commode to a patient, and cleaning and disinfecting fixtures and equipment that may have fecal contamination (e.g., bathrooms, commodes, scales used for weighing diapers) and the adjacent surfaces with appropriate agents may be especially important when a single-patient room cannot be used since environmental contamination with intestinal tract pathogens is likely from both continent and incontinent patients. Results of several studies to determine the benefit of a single-patient room to prevent transmission of Clostridium difficile are inconclusive. Some studies have shown that being in the same room with a colonized or infected patient is not necessarily a risk factor for transmission. However, for children, the risk of healthcareassociated diarrhea is increased with the increased number of patients per room. Thus, patient factors are important determinants of infection transmission risks, and the need for a single-patient room and/or private bathroom for any patient is best determined on a case-by-case basis. Cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent. It is generally preferred not to place severely immunosuppressed patients in rooms with other patients. Cohorting has been used extensively for managing outbreaks of MDROs including MRSA, VRE, MDR-ESBLs; Pseudomonas aeruginosa; methicillin-susceptible Staphylococcus aureus; RSV; adenovirus keratoconjunctivitis; rotavirus; and SARS. Modeling studies provide additional support for cohorting patients to control outbreaks Talon. However, cohorting often is implemented only after routine infection Page 21

24 control measures have failed to control an outbreak. Assigning or cohorting healthcare personnel to care only for patients infected or colonized with a single target pathogen limits further transmission of the target pathogen to uninfected patients but is difficult to achieve in the face of current staffing shortages in hospitals and residential healthcare sites. However, when continued transmission is occurring after implementing routine infection control measures and creating patient cohorts, cohorting of healthcare personnel may be beneficial. During the seasons when RSV, human metapneumovirus, parainfluenza, influenza, other respiratory viruses, and rotavirus are circulating in the community, cohorting based on the presenting clinical syndrome is often a priority in facilities that care for infants and young children. For example, during the respiratory virus season, infants may be cohorted based solely on the clinical diagnosis of bronchiolitis due to the logistical difficulties and costs associated with requiring microbiologic confirmation prior to room placement, and the predominance of RSV during most of the season. However, when available, single patient rooms are always preferred since a common clinical presentation (e.g., bronchiolitis), can be caused by more than one infectious agent. Furthermore, the inability of infants and children to contain body fluids, and the close physical contact that occurs during their care, increases infection transmission risks for patients and personnel in this setting. II.G.2. Ambulatory settings Patients actively infected with or incubating transmissible infectious diseases are seen frequently in ambulatory settings (e.g., outpatient clinics, physicians offices, emergency departments) and potentially expose healthcare personnel and other patients, family members and visitors. In response to the global outbreak of SARS in 2003 and in preparation for pandemic influenza, healthcare providers working in outpatient settings are urged to implement source containment measures (e.g., asking coughing patients to wear a surgical mask or cover their coughs with tissues) to prevent transmission of respiratory infections, beginning at the point of initial patient encounter as described below in section III.A.1.a. Signs can be posted at the entrance to facilities or at the reception or registration desk requesting that the patient or individuals accompanying the patient promptly inform the receptionist if there are symptoms of a respiratory infection (e.g., cough, flu-like illness, increased production of respiratory secretions). The presence of diarrhea, skin rash, or known or suspected exposure to a transmissible disease (e.g., measles, pertussis, chickenpox, tuberculosis) also could be added. Placement of potentially infectious patients without delay in an examination room limits the number of exposed individuals, e.g., in the common waiting area. II.H. Transport of patients Several principles are used to guide transport of patients requiring Transmission-Based Precautions. In the inpatient and residential settings these include 1) limiting transport of such patients to essential purposes, such as diagnostic and therapeutic procedures that cannot be performed in the patient s room; 2) when transport is necessary, using appropriate barriers on the patient (e.g., mask, gown, wrapping in sheets or use of impervious dressings to cover the affected area(s) when infectious skin lesions or drainage are present, consistent with the route and risk of II.I. Environmental measures Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions. In general, these procedures do not need to be changed for patients on Transmission-Based Precautions. The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient). The frequency or intensity of cleaning may need to change based on the patient s level of hygiene and the degree of environmental contamination and for certain for infectious agents whose reservoir is the intestinal tract. This may be especially Page 22 In waiting areas, maintaining a distance between symptomatic and non- symptomatic patients (e.g., >3 feet), in addition to source control measures, may limit exposures. However, infections transmitted via the airborne route (e.g., M tuberculosis, measles, chickenpox) require additional precautions. Patients suspected of having such an infection can wear a surgical mask for source containment, if tolerated, and should be placed in an examination room, preferably an AIIR, as soon as possible. If this is not possible, having the patient wear a mask and segregate him/herself from other patients in the waiting area will reduce opportunities to expose others. Since the person(s) accompanying the patient also may be infectious, application of the same infection control precautions may need to be extended to these persons if they are symptomatic. For example, family members accompanying children admitted with suspected M. tuberculosis have been found to have unsuspected pulmonary tuberculosis with cavitary lesions, even when asymptomatic. Patients with underlying conditions that increase their susceptibility to infection (e.g., those who are immunocompromised or have cystic fibrosis) require special efforts to protect them from exposures to infected patients in common waiting areas. By informing the receptionist of their infection risk upon arrival, appropriate steps may be taken to further protect them from infection. In some cystic fibrosis clinics, in order to avoid exposure to other patients who could be colonized with B. cepacia, patients have been given beepers upon registration so that they may leave the area and receive notification to return when an examination room becomes available. II.G.3. Home care In home care, the patient placement concerns focus on protecting others in the home from exposure to an infectious household member. For individuals who are especially vulnerable to adverse outcomes associated with certain infections, it may be beneficial to either remove them from the home or segregate them within the home. Persons who are not part of the household may need to be prohibited from visiting during the period of infectivity. For example, if a patient with pulmonary tuberculosis is contagious and being cared for at home, very young children (<4 years of age) and immunocompromised persons who have not yet been infected should be removed or excluded from the household. During the SARS outbreak of 2003, segregation of infected persons during the communicable phase of the illness was beneficial in preventing household transmission. transmission; 3) notifying healthcare personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission; and 4) for patients being transported outside the facility, informing the receiving facility and the medi-van or emergency vehicle personnel in advance about the type of Transmission-Based Precautions being used. For tuberculosis, additional precautions may be needed in a small shared air space such as in an ambulance. true in LTCFs and pediatric facilities where patients with stool and urine incontinence are encountered more frequently. Also, increased frequency of cleaning may be needed in a Protective Environment to minimize dust accumulation. Special recommendations for cleaning and disinfecting environmental surfaces in dialysis centers have been published. In all healthcare settings, administrative, staffing and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in transmission. During a suspected or proven outbreak where an environmental reservoir is suspected, routine cleaning procedures should be reviewed, and the need for additional trained cleaning staff should be assessed.

25 Adherence should be monitored and reinforced to promote consistent and correct cleaning is performed. EPA-registered disinfectants or detergents/disinfectants that best meet the overall needs of the healthcare facility for routine cleaning and disinfection should be selected. In general, use of the existing facility detergent/disinfectant according to the manufacturer s recommendations for amount, dilution, and contact time is sufficient to remove pathogens from surfaces of rooms where colonized or infected individuals were housed. This includes those pathogens that are resistant to multiple classes of antimicrobial agents (e.g., C. difficile, VRE, MRSA, MDR-GNB). Most often, environmental reservoirs of pathogens during outbreaks are related to a failure to follow recommended procedures for cleaning and disinfection rather than the specific cleaning and disinfectant agents used. Certain pathogens (e.g., rotavirus, noroviruses, C. difficile) may be resistant to some routinely used hospital disinfectants. The role of specific disinfectants in limiting transmission of rotavirus has been demonstrated experimentally. Also, since C. difficile may display increased levels of spore production when exposed to non-chlorinebased cleaning agents, and the spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended the use of a 1:10 dilution of 5.25 percent sodium hypochlorite (household bleach) and water for routine environmental disinfection of rooms of patients with C. difficile when there is continued transmission. In one study, the use of a hypochlorite solution was associated with a decrease in rates of C. difficile infections. The need to change disinfectants based on the presence of these organisms can be determined in consultation with the infection control committee. Detailed recommendations for disinfection and sterilization of surfaces and medical equipment that have been in contact with prion-containing tissue or high risk body fluids, and for cleaning of blood and body substance spills, are available in the Guidelines for Environmental Infection Control in Healthcare Facilities and in the Guideline for Disinfection and Sterilization. II.J. Patient care equipment and instruments/devices Medical equipment and instruments/devices must be cleaned and maintained according to the manufacturers instructions to prevent patient-to-patient transmission of infectious agents. Cleaning to remove organic material must always precede high level disinfection and sterilization of critical and semi-critical instruments and devices because residual proteinacous material reduces the effectiveness of the disinfection and sterilization processes. Noncritical equipment, such as commodes, intravenous pumps, and ventilators, must be thoroughly cleaned and disinfected before use on another patient. All such equipment and devices should be handled in a manner that will prevent HCW and environmental contact with potentially infectious material. It is important to include computers and personal digital assistants (PDAs) used in patient care in policies for cleaning and disinfection of non-critical items. The literature on contamination of computers with pathogens has been summarized and two reports have linked computer contamination to colonization and infections in patients. Although keyboard covers and washable keyboards that can be easily disinfected are in use, the infection control benefit of those items and optimal management have not been determined. In all healthcare settings, providing patients who are on Transmission- Based Precautions with dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing transmission. When this is not possible, disinfection after use is recommended. Consult other guidelines for detailed guidance in developing specific protocols for cleaning and reprocessing medical equipment and patient care items in both routine and special circumstances. In home care, it is preferable to remove visible blood or body fluids from durable medical equipment before it leaves the home. Equipment can be cleaned on-site using a detergent/ disinfectant and, when possible, should be placed in a single plastic bag for transport to the reprocessing location. Nursing consideration: Patients on transmission-based precautions need to have dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) to prevent transmission of infectious organisms. II.K. Textiles and laundry Soiled textiles, including bedding, towels, and patient or resident clothing may be contaminated with pathogenic microorganisms. However, the risk of disease transmission is negligible if they are handled, transported, and laundered in a safe manner. Key principles for handling soiled laundry are 1) not shaking the items or handling them in any way that may aerosolize infectious agents; 2) avoiding contact of one s body and personal clothing with the soiled items being handled; and 3) containing soiled items in a laundry bag or designated bin. When laundry chutes are used, they must be maintained to minimize dispersion of aerosols from contaminated items. The methods for handling, transporting, and laundering soiled textiles are determined by organizational policy and any applicable regulations; guidance is provided in the Guidelines for Environmental Infection Control. Rather than rigid rules and regulations, hygienic and common sense storage and processing of clean textiles is recommended. II.L. Solid waste The management of solid waste emanating from the healthcare environment is subject to federal and state regulations for medical and non-medical waste. No additional precautions are needed for nonmedical solid waste that is being removed from rooms of patients on When laundering occurs outside of a healthcare facility, the clean items must be packaged or completely covered and placed in an enclosed space during transport to prevent contamination with outside air or construction dust that could contain infectious fungal spores that are a risk for immunocompromised patients. Institutions are required to launder garments used as personal protective equipment and uniforms visibly soiled with blood or infective material. There are few data to determine the safety of home laundering of HCW uniforms, but no increase in infection rates was observed in the one published study and no pathogens were recovered from home- or hospital-laundered scrubs in another study. In the home, textiles and laundry from patients with potentially transmissible infectious pathogens do not require special handling or separate laundering, and may be washed with warm water and detergent. transmission-based precautions. Solid waste may be contained in a single bag (as compared to using two bags) of sufficient strength. Page 23

26 II.M. Dishware and eating utensils The combination of hot water and detergents used in dishwashers is sufficient to decontaminate dishware and eating utensils. Therefore, no special precautions are needed for dishware (e.g., dishes, glasses, cups) or eating utensils; reusable dishware and utensils may be used for patients requiring transmission-based precautions. In the home and other communal settings, eating utensils and drinking vessels that are II.N. Adjunctive measures Important adjunctive measures that are not considered primary components of programs to prevent transmission of infectious agents, but improve the effectiveness of such programs, include 1) antimicrobial management programs; 2) postexposure chemoprophylaxis with antiviral or antibacterial agents; 3) vaccines used both for pre and postexposure prevention; and 4) screening and restricting visitors with signs of transmissible infections. Detailed discussion of judicious use of antimicrobial agents is beyond the scope of this document; however the topic is addressed in the MDRO section (Management of Multidrug- Resistant Organisms in Healthcare Settings dhqp/pdf/ar/mdroguideline2006.pdf). II.N.1. Chemoprophylaxis Antimicrobial agents and topical antiseptics may be used to prevent infection and potential outbreaks of selected agents. Infections for which postexposure chemoprophylaxis is recommended under defined conditions include B. pertussis, N. meningitidis, B. anthracis after environmental exposure to aeosolizable material, influenza virus, HIV, and group A streptococcus. Orally administered antimicrobials may also be used under defined circumstances for MRSA decolonization of patients or healthcare personnel. Another form of chemoprophylaxis is the use of topical antiseptic agents. For example, triple dye is used routinely on the umbilical cords of term newborns to reduce the risk of colonization, skin infections, and omphalitis caused by S. aureus, including MRSA, and group A streptococcus. Extension of the use of triple dye to low birth weight infants in the NICU was one component of a program that controlled one longstanding MRSA outbreak. Topical antiseptics are also used for decolonization of healthcare personnel or selected patients colonized with MRSA, using mupirocin as discussed in the MDRO guideline 867, II.N.2. Immunoprophylaxis Certain immunizations recommended for susceptible healthcare personnel have decreased the risk of infection and the potential for transmission in healthcare facilities. The OSHA mandate that requires employers to offer hepatitis B vaccination to HCWs played a substantial role in the sharp decline in incidence of occupational HBV infection. The use of varicella vaccine in healthcare personnel has decreased the need to place susceptible HCWs on administrative leave following exposure to patients with varicella. Also, reports of healthcare-associated transmission of rubella in obstetrical clinics and measles in acute care settings demonstrate the importance of immunization of susceptible healthcare personnel against childhood diseases. Many states have requirements for HCW vaccination for measles and rubella in the absence of evidence of immunity. Annual influenza vaccine campaigns targeted to patients and healthcare personnel in LTCFs and acute-care settings have been instrumental in preventing or limiting institutional outbreaks and increasing attention is being directed toward improving influenza vaccination rates in healthcare personnel. Transmission of B. pertussis in healthcare facilities has been associated with large and costly outbreaks that include both healthcare personnel and patients. HCWs who have close contact with infants with pertussis are at particularly high risk because of waning immunity and, until 2005, the absence of a vaccine that could be used in adults. However, two acellular pertussis vaccines were licensed in the United States in Page 24 being used should not be shared, consistent with principles of good personal hygiene and for the purpose of preventing transmission of respiratory viruses, Herpes simplex virus, and infectious agents that infect the gastrointestinal tract and are transmitted by the fecal/oral route (e.g., hepatitis A virus, noroviruses). If adequate resources for cleaning utensils and dishes are not available, disposable products may be used. 2005, one for use in individuals aged and one for use in ages years. Provisional ACIP recommendations at the time of publication of this document include adolescents and adults, especially those with contact with infants < 12 months of age and healthcare personnel with direct patient contact. Immunization of children and adults will help prevent the introduction of vaccine- preventable diseases into healthcare settings. The recommended immunization schedule for children is published annually in the January issues of the Morbidity Mortality Weekly Report with interim updates as needed. An adult immunization schedule also is available for healthy adults and those with special immunization needs due to high-risk medical conditions. Some vaccines are also used for postexposure prophylaxis of susceptible individuals, including varicella, influenza, hepatitis B, and smallpox vaccines. In the future, administration of a newly developed S. aureus conjugate vaccine (still under investigation) to selected patients may provide a novel method of preventing healthcare-associated S. aureus, including MRSA, infections in high-risk groups (e.g., hemodialysis patients and candidates for selected surgical procedures). Immune globulin preparations also are used for postexposure prophylaxis of certain infectious agents under specified circumstances (e.g., varicella-zoster virus [VZIG], hepatitis B virus [HBIG], rabies [RIG], measles and hepatitis A virus [IG]). The RSV monoclonal antibody preparation, Palivizumab, may have contributed to controlling a nosocomial outbreak of RSV in one NICU, but there is insufficient evidence to support a routine recommendation for its use in this setting. II.N.3. Management of visitors II.N.3.a. Visitors as sources of infection Visitors have been identified as the source of several types of HAIs (e.g., pertussis, M. tuberculosis, influenza, and other respiratory viruses and SARS). However, effective methods for visitor screening in healthcare settings have not been studied. Visitor screening is especially important during community outbreaks of infectious diseases and for high risk patient units. Sibling visits are often encouraged in birthing centers, postpartum rooms and in pediatric inpatient units, ICUs, and in residential settings for children; in hospital settings, a child visitor should visit only his or her own sibling. Screening of visiting siblings and other children before they are allowed into clinical areas is necessary to prevent the introduction of childhood illnesses and common respiratory infections. Screening may be passive through the use of signs to alert family members and visitors with signs and symptoms of communicable diseases not to enter clinical areas. More active screening may include the completion of a screening tool or questionnaire which elicits information related to recent exposures or current symptoms. That information is reviewed by the facility staff and the visitor is either permitted to visit or is excluded. Family and household members visiting pediatric patients with pertussis and tuberculosis may need to be screened for a history of exposure as well as signs and symptoms of current infection. Potentially infectious visitors are excluded until they receive appropriate medical screening, diagnosis, or treatment. If exclusion is not considered to be in the best interest of the patient or family (i.e., primary family members of critically or terminally ill patients), then the symptomatic visitor must wear a mask while in the healthcare

27 facility and remain in the patient s room, avoiding exposure to others, especially in public waiting areas and the cafeteria. Visitor screening is used consistently on HSCT units. However, considering the experience during the 2003 SARS outbreaks and the potential for pandemic influenza, developing effective visitor screening systems will be beneficial. Education concerning Respiratory Hygiene/ Cough Etiquette is a useful adjunct to visitor screening. II.N.3.b. Use of barrier precautions by visitors The use of gowns, gloves, or masks by visitors in healthcare settings has not been addressed specifically in the scientific literature. Some studies included the use of gowns and gloves by visitors in the control of MDRO s, but did not perform a separate analysis to determine whether their use by visitors had a measurable impact. Family members or visitors who are providing care or having very close patient contact (e.g., feeding, holding) may have contact with other patients and could contribute to transmission if barrier precautions are not used correctly. Specific recommendations may vary by facility or by unit and should be determined by the level of interaction. SECTION III: Precautions to Prevent Transmission of Infectious Agents There are two tiers of HICPAC/CDC precautions to prevent transmission of infectious agents, standard precautions and transmission-based precautions. Standard precautions are intended to be applied to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of standard precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel. Evidence-based practice alert! Standard precautions must be used for all patients to prevent the transmission of infectious agents among patients and healthcare personnel [6]. Transmission-based precautions are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Since the infecting agent often is not known at the time of admission to a healthcare facility, transmission-based precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or a transmissible infectious etiology is ruled out. Examples of this syndromic approach are presented in Table 2. The HICPAC/CDC Guidelines also include recommendations for creating a protective environment for allogeneic HSCT patients. The specific elements of standard and transmission-based precautions are discussed in Part II of this guideline. In Part III, the circumstances in which standard precautions, transmission-based precautions, and a protective environment are applied are discussed. See Tables 4 and 5 for summaries of the key elements of these sets of precautions. III.A. Standard precautions Standard precautions combine the major features of universal precautions (UP) and body substance isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered (Table 4). These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). Nursing consideration: Standard precautions must be used on all patients and include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. The application of standard precautions during patient care is determined by the nature of the HCW-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Education and training on the principles and rationale for recommended practices are critical elements of standard precautions because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances. An example of the importance of the use of standard precautions is intubation, especially under emergency circumstances when infectious agents may not be suspected, but later are identified (e.g., SARS-CoV, N. meningitides). The application of standard precautions is described below and summarized in Table 4. Standard precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands or via equipment used during patient care. III.A.1. New elements of standard precautions Infection control problems that are identified in the course of outbreak investigations often indicate the need for new recommendations or reinforcement of existing infection control recommendations to protect patients. Because such recommendations are considered a standard of care and may not be included in other guidelines, they are added here to standard precautions. Three such areas of practice that have been added are: Respiratory yygiene/cough etiquette, safe injection practices, and use of masks for insertion of catheters or injection of material into spinal or epidural spaces via lumbar puncture procedures (e.g., myelogram, spinal or epidural anesthesia). While most elements of standard precautions evolved from universal precautions that were developed for protection of healthcare personnel, these new elements of standard precautions focus on protection of patients. III.A.1.a. Respiratory hygiene/cough etiquette The transmission of SARS- CoV in emergency departments by patients and their family members during the widespread SARS outbreaks in 2003 highlighted the need for vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting (e.g., reception and triage areas in emergency departments, outpatient clinics, and physician offices). The strategy proposed has been termed respiratory hygiene/cough etiquette and is intended to be incorporated into infection control practices as a new component of standard precautions. The strategy is targeted at patients and accompanying family members and friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a healthcare facility. The term cough etiquette is derived from recommended source control measures for M. tuberculosis. The elements of respiratory hygiene/cough etiquette include 1) education of healthcare facility staff, patients, and visitors; 2) posted Page 25

28 signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends; 3) source control measures (e.g., covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate); 4) hand hygiene after contact with respiratory secretions; and 5) spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. Covering sneezes and coughs and placing masks on coughing patients are proven means of source containment that prevent infected persons from dispersing respiratory secretions into the air. Masking may be difficult in some settings, (e.g., pediatrics, in which case, the emphasis by necessity may be on cough etiquette. Physical proximity of <3 feet has been associated with an increased risk for transmission of infections via the droplet route (e.g., N. meningitidis and group A streptococcus and therefore supports the practice of distancing infected persons from others who are not infected. The effectiveness of good hygiene practices, especially hand hygiene, in preventing transmission of viruses and reducing the incidence of respiratory infections both within and outside healthcare settings is summarized in several reviews. These measures should be effective in decreasing the risk of transmission of pathogens contained in large respiratory droplets (e.g., influenza virus, adenovirus, B. pertussis and mycoplasma pneumoniae. Although fever will be present in many respiratory infections, patients with pertussis and mild upper respiratory tract infections are often afebrile. Therefore, the absence of fever does not always exclude a respiratory infection. Patients who have asthma, allergic rhinitis, or chronic obstructive lung disease also may be coughing and sneezing. While these patients often are not infectious, cough etiquette measures are prudent. Healthcare personnel are advised to observe droplet precautions (i.e., wear a mask) and hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Healthcare personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high risk patients. If this is not possible, then a mask should be worn while providing patient care. III.A.1.b Safe injection practices The investigation of four large outbreaks of HBV and HCV among patients in ambulatory care facilities in the United States identified a need to define and reinforce safe injection practices. The four outbreaks occurred in a private medical practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic. The primary breaches in infection control practice that contributed to these outbreaks were 1) reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag) and 2) use of a single needle/ syringe to administer intravenous medication to multiple patients. In one of these outbreaks, preparation of medications in the same III.B. Transmission-based precautions There are three categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. transmissionbased precautions are used when the route(s) of transmission is (are) not completely interrupted using standard precautions alone. For some diseases that have multiple routes of transmission (e.g., SARS), more than one transmission-based precautions category may be used. When used either singly or in combination, they are always used in addition to standard precautions. When transmission-based precautions are indicated, efforts must be made to counteract possible adverse effects on patients (i.e., anxiety, depression and other mood disturbances, perceptions of stigma, reduced contact with clinical staff, and increases in preventable adverse events in order to improve acceptance by the patients and adherence by HCWs). workspace where used needle/syringes were dismantled also may have been a contributing factor. These and other outbreaks of viral hepatitis could have been prevented by adherence to basic principles of aseptic technique for the preparation and administration of parenteral medications. These include the use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication. Whenever possible, use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients. Outbreaks related to unsafe injection practices indicate that some healthcare personnel are unaware of, do not understand, or do not adhere to basic principles of infection control and aseptic technique. A survey of US healthcare workers who provide medication through injection found that 1 percent to 3 percent reused the same needle and/or syringe on multiple patients. Among the deficiencies identified in recent outbreaks were a lack of oversight of personnel and failure to follow-up on reported breaches in infection control practices in ambulatory settings. Therefore, to ensure that all healthcare workers understand and adhere to recommended practices, principles of infection control and aseptic technique need to be reinforced in training programs and incorporated into institutional polices that are monitored for adherence. III.A.1.c. Infection control practices for special lumbar puncture procedures In 2004, CDC investigated eight cases of post-myelography meningitis that either were reported to CDC or identified through a survey of the Emerging Infections Network of the Infectious Disease Society of America. Blood and/or cerebrospinal fluid of all eight cases yielded streptococcal species consistent with oropharyngeal flora and there were changes in the CSF indices and clinical status indicative of bacterial meningitis. Equipment and products used during these procedures (e.g., contrast media) were excluded as probable sources of contamination. Procedural details available for seven cases determined that antiseptic skin preparations and sterile gloves had been used. However, none of the clinicians wore a face mask, giving rise to the speculation that droplet transmission of oralpharyngeal flora was the most likely explanation for these infections. Bacterial meningitis following myelogram and other spinal procedures (e.g., lumbar puncture, spinal and epidural anesthesia, intrathecal chemotherapy) has been reported previously. As a result, the question of whether face masks should be worn to prevent droplet spread of oral flora during spinal procedures (e.g., myelogram, lumbar puncture, spinal anesthesia) has been debated. Face masks are effective in limiting the dispersal of oropharyngeal droplets and are recommended for the placement of central venous catheters. In October 2005, the Healthcare Infection Control Practices Advisory Committee (HICPAC) reviewed the evidence and concluded that there is sufficient experience to warrant the additional protection of a face mask for the individual placing a catheter or injecting material into the spinal or epidural space. Nursing consideration: Transmission-based precautions, which include contact precautions, droplet precautions, and airborne precautions, are used when the route(s) of transmission is (are) not completely interrupted using standard precautions alone. III.B.1. Contact precautions Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient s environment as described in I.B.3.a. The application of contact precautions for patients infected or colonized with MDROs is described in the 2006 HICPAC/CDC MDRO guideline. Contact precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single- patient room is preferred for Page 26

29 patients who require contact precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). In multi-patient rooms, >3 feet spatial separation between beds is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients. Healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient s environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV). Nursing consideration: Caring for patients on contact precautions requires the healthcare worker to wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient s environment. III.B.2. Droplet precautions Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions as described in I.B.3.b. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. Infectious agents for which droplet precautions include B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitides, and group A streptococcus (for the first 24 hours of antimicrobial therapy). A single patient room is preferred for patients who require droplet precautions. When a single-patient room is not available, consultation with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of > 3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) for close contact with infectious patient; the mask is generally donned upon room entry. Patients on droplet precautions who must be transported outside of the room should wear a mask if tolerated and follow respiratory hygiene/cough etiquette. Nursing consideration: Caring for patients on droplet precautions requires the healthcare worker to wear a mask (a respirator is not necessary) for close contact with patients; the mask is generally donned upon room entry. III.B.3. Airborne precautions Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV) as described in I.B.3.c and Appendix A. The preferred placement for patients who require Airborne Precautions is in an airborne infection isolation room (AIIR). An AIIR is a singlepatient room that is equipped with special air handling and ventilation capacity that meet the American Institute of Architects/Facility Guidelines Institute (AIA/FGI) standards for AIIRs (i.e., monitored negative pressure relative to the surrounding area, 12 air exchanges per hour for new construction and renovation and 6 air exchanges per hour for existing facilities, air exhausted directly to the outside or recirculated through HEPA filtration before return). Some states require the availability of such rooms in hospitals, emergency departments, and nursing homes that care for patients with M. tuberculosis. A respiratory protection program that includes education about use of respirators, fit-testing, and user seal checks is required in any facility with AIIRs. In settings where Airborne Precautions cannot be implemented due to limited engineering resources (e.g., physician offices), masking the patient, placing the patient in a private room (e.g., office examination room) with the door closed, and providing N95 or higher level respirators or masks if respirators are not available for healthcare personnel will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an AIIR or returned to the home environment, as deemed medically appropriate. Healthcare personnel caring for patients on Airborne Precautions wear a mask or respirator, depending on the disease-specific recommendations (Respiratory protection II.E.4, Table 2, and Appendix A), that is donned prior to room entry. Whenever possible, non-immune HCWs should not care for patients with vaccine-preventable airborne diseases (e.g., measles, chickenpox, and smallpox). Nursing consideration: Caring for patients on airborne precautions requires the healthcare worker to don a mask or respirator prior to entering an airborne infection isolation room. Adapted from Centers for Disease Control and Prevention (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved from cdc.gov/hicpac/2007ip/2007isolationprecautions.html [6]. TABLE 4: Recommendations for application of standard precautions for the care of all patients in all healthcare settings (See Sections II.D.-II.J. and III.A.1) Component Recommendations Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts. Personal protective equipment Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin. Gown During procedures and patientcare activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated. Mask, eye protection (goggles), face shield* Soiled patient-care equipment Environmental control Textiles and laundry During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation. Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene. Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas. Handle in a manner that prevents transfer of microorganisms to others and to the environment. Page 27

30 Needles and other sharps Patient resuscitation Patient placement Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container. Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions. Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection. Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter [e.g., triage and reception areas in emergency departments and physician offices]) Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible. *During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols (e.g., SARS), wear a fit-tested N95 or higher respirator in addition to gloves, gown, and face/eye protection. Taken from Centers for Disease Control and Prevention (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved from cdc.gov/hicpac/2007ip/2007isolationprecautions.html [6]. Preventing infection in the community The CDC and state and local public health departments share responsibility for prevention and control of infection in the community. Methods of infection prevention include sanitation techniques (e.g., water purification, disposal of sewage and other potentially infectious materials), regulated health practices (e.g., the handling, storage, Vaccination programs [10] Vaccines are suspensions of antigen preparations that are intended to produce a human immune response to protect the host from future encounters with the organism. Vaccines provide immunity, or protection from an infectious disease. The goal of vaccination programs is to use wide-scale efforts to prevent specific infectious diseases from occurring in a population. Public health decisions about vaccination efforts are complex. When administered, vaccinations utilize antigens from a specific infectious material to stimulate an immune response by the recipient, or host. The host becomes immune by producing antibodies, which recognize a subsequent exposure to the infection. This enables a resistance to the disease by the host. Vaccinations will not cause illness packaging, and preparation of food by institutions), and immunization programs. In the United States, immunization, or vaccination programs, have markedly decreased the incidence of infectious diseases. The final section of this course discusses vaccination programs for both the public and for healthcare providers. or disease in the recipient and are continually studied for effectiveness and complications. Risks and benefits for the person and the community must be evaluated in terms of morbidity, mortality, and financial cost and benefit. Because no vaccine is completely safe for all recipients, contraindications on package inserts of a vaccine and the CDC-produced Vaccine Information Statements must be heeded. These documents provide details about studied experiences with allergy and other complications and provide crucial information about refrigeration, storage, dosage, and administration. More than fifty vaccines are currently licensed in the United States. The table below lists the most common vaccinations as well as information relating to the disease the vaccines prevent [3]. Vaccine-preventable diseases and the vaccines that prevent them Disease Vaccine Disease transmission Disease symptoms Disease complications Chickenpox Varicella Air, direct contact. Rash, tiredness, headache, fever. Diphtheria DTaP Air, direct contact. Sore throat, mild fever, weakness, swollen glands in neck. Haemophilus influenzae type b Hib Air, direct contact. Asymptomatic unless bacteria enter the blood. Hepatitis A HepA Personal contact, contaminated food or water. Hepatitis B HepB Contact with blood or body fluids. Fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice, dark urine. Fever, headache, weakness, vomiting, jaundice joint pain. Influenza Flu Air, direct contact. Fever, muscle pain, sore throat, cough, extreme fatigue. Measles MMR Air, direct contact. Rash, fever, cough, rhinorrhea, pinkeye. Infected blisters, bleeding disorders, encephalitis, pneumonia. Enlarged heart muscle, heart failure, coma, paralysis, death. Meningitis, mental retardation, epiglottis pneumonia, death. Liver failure. Chronic liver infection, liver failure, liver cancer. Pneumonia. Encephalitis, pneumonia, death. Page 28

31 Mumps MMR Air, direct contact. Swollen salivary glands, fever, headache, tiredness, muscle pain. Pertussis DTaP Air, direct contact. Severe cough, runny nose, apnea. Polio IPV Through the mouth. Sore throat, fever, nausea, headache. Meningitis, encephalitis, inflammation of testicles or ovaries, deafness. Pneumonia, death. Paralysis, death. Pneumococcal PCV Air, direct contact. Pneumonia. Bacteremia, meningitis, death. Rotavirus RV Through the mouth. Diarrhea, fever, vomiting. Severe diarrhea, dehydration. Rubella MMR Air, direct contact. Rash, fever, and swollen lymph nodes. Tetanus DTaP Exposure through cuts in skin. Adapted from Centers for Disease Control and Prevention. Facts for Parents: Diseases & the Vaccines that Prevent Them. Retrieved from [3]. Stiffness in neck and abdominal muscles, difficulty swallowing, muscle spasms, fever. Very serious in pregnant women-can lead to miscarriage, stillbirth, premature delivery, and birth defects. Broken bones, breathing difficulty, death. Evidence-based practice alerts! [20] Nearly everyone in the U.S. got measles before there was a vaccine, and hundreds died from it each year. Today, most doctors have never seen a case of measles. More than 15,000 died from diphtheria in 1921, before there was a vaccine. Only one case of diphtheria has been reported to the CDC since An epidemic of rubella (German measles) in infected 12.5 million Americans, killed 2,000 babies, and caused 11,000 miscarriages. In 2012, nine cases of rubella were reported to the CDC. Immunizations for healthcare providers [9] Because of their contact with patients or infective material from patients, many healthcare providers (e.g., physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers, and administrative staff) are at risk for exposure to and possible transmission of vaccine-preventable diseases. The following section outlines recommendations from the CDC using a document titled Immunization of Healthcare Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). The full document, with reference citations, is available at mmwr/preview/mmwrhtml/rr6007a1.htm [9]. Diseases for Which Vaccination Is Recommended On the basis of documented nosocomial transmission, HCP are considered to be at substantial risk for acquiring or transmitting hepatitis B, influenza, measles, mumps, rubella, pertussis, and varicella. Current recommendations for vaccination are provided below. Hepatitis B Epidemiology and risk factors Hepatitis B is an infection caused by the hepatitis B virus (HBV), which is transmitted through percutaneous (i.e., breaks in the skin) or mucosal (i.e., direct contact with mucous membranes) exposure to infectious blood or body fluids. The virus is highly infectious; for nonimmune persons, disease transmission from a needle stick exposure is up to 100 times more likely for exposure to hepatitis B e antigen (HBeAg)-positive blood than to HIV-positive blood. HBV infection is a well recognized occupational risk for U.S. HCP and globally. The risk for HBV is associated with degree of contact with blood in the work place and with the hepatitis B e-antigen status of the source persons. The virus is also environmentally stable, remaining infectious on environmental surfaces for at least 7 days. Nursing consideration: The hepatitis B virus is highly infectious and can remain infectious on environment surfaces for at least seven days. In 2009 in the United States, 3,371 cases of acute HBV infection were reported nationally, and an estimated 38,000 new cases of HBV infection occurred after accounting for underreporting and underdiagnosis. Of 4,519 persons reported with acute HBV infection in 2007, approximately 40 percentwere hospitalized and 1.5 percent died. HBV can lead to chronic infection, which can result in cirrhosis of the liver, liver failure, liver cancer, and death. An estimated 800, million persons in the United States are living with chronic HBV infection; these persons serve as the main reservoir for continued HBV transmission. Evidence-based practice alert! Disease transmission from a needle-stick exposure to hepatitis B positive blood is up to 100 times more likely than that from HIV-positive blood [9]. Vaccines to prevent hepatitis B became available in the United States in 1981; a decade later, a national strategy to eliminate HBV infection was implemented, and the routine vaccination of children was recommended. During , the rate of new HBV infections declined approximately 84 percent, from 8.5 to 1.1 cases per 100,000 population; the decline was greatest (98 percent) among persons aged <19 years, for whom recommendations for routine infant and Page 29

32 adolescent vaccination have been applied. Although hepatitis B vaccine coverage is high in infants, children, and adolescents (91.8 percent in infants aged months and 91.6percent in adolescents aged years), coverage remains lower (41.8 percent in 2009) for certain adult populations, including those with behavioral risks for HBV infection (e.g., men who have sex with men and persons who use injection drugs). Hepatitis B in healthcare settings During 1982, when hepatitis B vaccine was first recommended for HCP, an estimated 10,000 infections occurred among persons employed in a medical or dental field. By 2004, the number of HBV infections among HCP had decreased to an estimated 304 infections, largely resulting from the implementation of routine pre-exposure vaccination and improved infection-control precautions. The risk for acquiring HBV infection from occupational exposures is dependent on the frequency of percutaneous and mucosal exposures to blood or body fluids (e.g., semen, saliva, and wound exudates) containing HBV, particularly fluids containing HBeAg (a marker for high HBV replication and viral load). The risk is higher during the professional training period and can vary throughout a person s career. Depending on the tasks performed, healthcare or public safety personnel might be at risk for HBV exposure; in addition, personnel providing care and assistance to persons in outpatient settings and those residing in long-term-care facilities (e.g., assisted living) might be at risk for acquiring or facilitating transmission of HBV infection when they perform procedures that expose them to blood (e.g., assisted blood-glucose monitoring and wound care). A Federal Standard issued in December 1991 under the Occupational Safety and Health Act mandates that hepatitis B vaccine be made available at the employer s expense to all healthcare personnel who are exposed occupationally to blood or other potentially infectious materials. The Federal Standard defines occupational exposure as reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that might result from the performance of an employee s duties. Occupational Influenza Epidemiology and risk factors Influenza causes an estimated average of >200,000 hospitalizations and 3,000-49,000 deaths annually in the United States. The majority of influenza-related severe illnesses and deaths occur among persons with chronic medical conditions, infants and young children, seniors, and pregnant women. Reducing the risk for influenza among persons at higher risk for complications is a major focus of influenza prevention strategies. Influenza transmission in healthcare settings HCP are exposed to patients with influenza in the workplace and are thus at risk of occupationally acquired influenza and of transmitting influenza to patients and other HCP. In a cross-sectional survey of hospital house staff (physicians in training), 37 percent reported influenza-like illness during September-April, and 9 percent reported more than one respiratory illness. Length of illness varied (range: 1-10 days; mean: 7 days), as did days of work missed (range: 0-10 days; mean: 0.7 days). Infected HCP who continue to work while ill might transmit influenza to patients, many of whom are at increased risk for severe outcomes from influenza. HCP are therefore recommended for routine annual influenza vaccination. Few randomized trials of the effect that influenza vaccination has on illness in HCP have been conducted. In one randomized trial of 427 HCP, influenza vaccination of HCP failed to decrease episodes of respiratory infection or duration of illness but was associated with a 28 percent decrease in absenteeism (from 1.4 days to 1.0 day) attributable to respiratory infections. No laboratory confirmation of influenza was obtained in this study. In another randomized trial among HCP, vaccination was associated with a significantly lower rate of serological evidence of influenza infection, with a vaccine efficacy rate Page 30 Safety and Health Administration (OSHA) vaccination practice requirements (e.g., preexposure and postexposure antibody testing) are based on current ACIP recommendations. OSHA regulations might have accelerated the use of hepatitis B vaccine in HCP. Nursing consideration: Healthcare employers must offer the hepatitis B vaccine to healthcare providers at risk for exposure to blood or other infectious materials. Data from a national, cross-sectional survey demonstrated that during , an estimated 75 percent of HCP had received the 3-dose hepatitis B vaccination series. Since 2002, rates of 1-dose and 3-dose vaccination coverage have remained stable. Data obtained through the National Health Interview Survey (NHIS) in 2009 demonstrated a 1-dose coverage rate of percent and a 3-dose rate of percent among HCP aged years. Similarly, data obtained through the National Immunization Survey-Adult (NIS-Adult) in 2007 demonstrated a 3-dose coverage of 62 percent among HCP aged years. The Healthy People 2020 goal (objective no. IID-15.3) of a hepatitis B vaccination coverage rate of 90 percent among HCP has not been achieved. Recommendations Two single-antigen hepatitis B vaccines, Recombivax HB (Merck & Co., Inc., Whitehouse Station, New Jersey) and Engerix-B (GlaxoSmithKline Biologicals, Rixensart, Belgium) and one combination hepatitis A and hepatitis B vaccine, Twinrix (GlaxoSmithKline Biologicals), are available in the United States. Primary vaccination consists of 3 intramuscular doses of hepatitis B vaccine or of the combined hepatitis A and hepatitis B vaccine. The hepatitis vaccine series does not need to be restarted if the second or third dose is delayed. Detailed vaccination recommendations are available in previously published guidelines. Vaccine schedules are available at In adults, hepatitis B vaccine always should be administered into the deltoid muscle. Longer needles (up to 1.5 inches in length) might be required for obese adults. of 88 percent for influenza A and 89 percent for influenza B (p<0.05); however, no significant differences were noted in days of febrile respiratory illness or absenteeism. Influenza can cause outbreaks of severe respiratory illness among hospitalized persons and long-term-care residents. Influenza outbreaks in hospitals and long-term-care facilities have been associated with low vaccination rates among HCP. One nonrandomized study demonstrated an increase in HCW vaccination rates and decrease in nosocomially acquired, laboratory-confirmed influenza in a hospital after a mobile cart-based HCP vaccination program was introduced. Several randomized controlled studies of the impact of HCP vaccination on morbidity and mortality in long-term care facilities have been performed. These studies have demonstrated substantial decreases in all-cause mortality and influenza-like illness. However, studies which examine and demonstrate efficacy in preventing more specific outcomes (e.g., laboratory-confirmed influenza illness and mortality) are lacking. Recent systematic reviews suggest that vaccination of HCP in settings in which patients also were vaccinated provided significant reductions in deaths among elderly patients from all causes and deaths from pneumonia, but also note that additional randomized controlled trials are warranted, as are examination of more specific outcomes. Preventing influenza among HCP who might serve as sources of influenza virus transmission provides additional protection to patients at risk for influenza complications. Vaccination of HCP can specifically benefit patients who cannot receive vaccination (e.g., infants aged <6 months or those with severe allergic reactions to prior influenza vaccination), patients who respond poorly to vaccination (e.g., persons aged 85 years and immune-compromised persons), and

33 persons for whom antiviral treatment is not available (e.g., persons with medical contraindications). Although annual vaccination has long been recommended for HCP and is a high priority for reducing morbidity associated with influenza in healthcare settings, national survey data have demonstrated that the vaccination coverage level during the season was 52.9 percent. Considerations regarding influenza vaccination of HCP Barriers to HCP acceptance of influenza vaccination have included fear of vaccine side effects (particularly influenza-like symptoms), insufficient time or inconvenience, perceived ineffectiveness of the vaccine, perceived low likelihood of contracting influenza, avoidance of medications, and fear of needles. Factors demonstrated to increase vaccine acceptance include a desire for self-protection, previous receipt of influenza vaccine, a desire to protect patients, and perceived effectiveness of vaccine. Strategies that have demonstrated improvement in HCP vaccination rates have included campaigns to emphasize the benefits of HCP vaccination for staff and patients, vaccination of senior medical staff or opinion leaders, removing administrative barriers (e.g., costs), providing vaccine in locations and at times easily accessible by HCP, and monitoring and reporting HCP influenza vaccination rates. Intranasally administered live attenuated influenza vaccine (LAIV) is an option for healthy, nonpregnant adults aged <50 years who dislike needles. The practice of obtaining signed declinations from HCP offered influenza vaccination has been adopted by some institutions but has not yet been demonstrated to exceed coverage rates of >70-80 percent. Institutions that require declination statements from HCP who refuse influenza vaccination should educate and counsel these HCP about benefits of the vaccine. Each healthcare facility should develop a comprehensive influenza vaccination strategy that includes targeted education about the disease, including disease risk among HCP and patients, and about the vaccine. In addition, the program should establish easily accessible vaccination sites and inform HCP about their locations and schedule. Facilities that employ HCP should provide influenza vaccine at no cost to personnel. The most effective combination of approaches for achieving high influenza vaccination coverage among HCP likely varies by institution. Hospitals and healthcare organizations in the United States traditionally have employed an immunization strategy that includes one or more of the following components: education about influenza, easy access to vaccine, incentives to encourage immunization, organized campaigns, institution of declination policies, and legislative and regulatory efforts (e.g., vaccination requirements). Beginning January 1, 2007, the Joint Commission on Accreditation of Healthcare Organizations required accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners and to report coverage levels among HCP. Measles Epidemiology and risk factors Measles is a highly contagious rash illness that is transmitted by respiratory droplets and airborne spread. Severe complications, which might result in death, include pneumonia and encephalitis. Before the national measles vaccination program was implemented in 1963, almost every person acquired measles before adulthood; an estimated 3-4 million persons in the United States acquired measles each year. Approximately 500,000 persons were reported to have had measles annually, of whom 500 persons died, 48,000 were hospitalized, and another 1,000 had permanent brain damage from measles encephalitis. Through a successful 2-dose measles vaccination program (i.e., a first dose at age months and a second dose between ages 4-6 years) and better measles control throughout the region of the Americas, endemic transmission of measles was interrupted in the United States, and measles was declared eliminated from the country in However, measles remains widespread in the majority of countries Standards are available for measuring vaccination coverage among HCP as a measure of program performance within a healthcare setting. Beginning January 2013, the Centers for Medicaid Services will require acute care hospitals to report HCP influenza vaccine as part of its hospital inpatient quality reporting program. Recommendations Vaccination Annual influenza vaccination is recommended for all persons aged 6 months who have no medical contraindication; therefore, vaccination of all HCP who have no contraindications is recommended. The influenza vaccine is evaluated annually with one or more vaccine strains updated almost every year. In addition, antibody titers decline during the year after vaccination. Thus, annual vaccination with the current season s formulation is recommended. Annual vaccination is appropriate and safe to begin as early in the season as vaccine is available. HCP should be among the groups considered for prioritized receipt of influenza vaccines when vaccine supply is limited. Two types of influenza vaccines are available. LAIV is administered intranasally and is licensed for use in healthy nonpregnant persons aged 2-49 years. The trivalent inactivated vaccine (TIV) is administered as an intramuscular injection and can be given to any person aged 6 months. Both vaccine types contain vaccine virus strains that are selected to stimulate a protective immune response against the wild-type viruses that are thought to be most likely in circulation during the upcoming season. Use of LAIV for HCP who care for patients housed in protective inpatient environments has been a theoretic concern, but transmission of LAIV in healthcare settings has not been reported. LAIV can be used for HCP who work in any setting, except those who care for severely immunocompromised hospitalized persons who require care in a protective environment. HCP who themselves have a condition that confers high risk for influenza complications, who are pregnant, or who are aged 50 years should not receive LAIV and should be administered TIV instead. An inactivated trivalent vaccine containing 60 mcg of hemagglutinin antigen per influenza vaccine virus strain (Fluzone High-Dose [sanofi pasteur]) is an alternative inactivated vaccine for persons aged 65 years. Persons aged 65 years may be administered any of the standard-dose TIV preparations or Fluzone High-Dose. The majority of TIV preparations are administered intramuscularly. An intradermally administered TIV was licensed in May 2011 and is an alternative to other TIV preparations for persons aged years. Nursing consideration: Nurses must be able to differentiate between HBV and HAV including modes of transmission, pathophysiology, treatment, and types of vaccines available [24,69,70]. outside the Western Hemisphere, with an estimated 20 million measles cases occurring worldwide and approximately 164,000 related deaths. Thus, the United States continues to experience international importations that might lead to transmission among U.S. residents and limited outbreaks, especially in unvaccinated populations. During , a total of 557 confirmed measles cases were reported in the United States from 37 states and the District of Columbia (annual median: 56; range: 37 in 2004 to 140 in 2008), representing an annual incidence of less than one case per million population. Of the 557 reported case-patients, 126 (23 percent) were hospitalized (annual median: 16; range: 5-29); of these, at least five case-patients were admitted to intensive care. Two deaths were reported, both in Of the 557 reported case-patients during , a total of 223 (40%) were adults, including 156 (28 percent) aged years and 67 (12 percent) aged 40 years. Of the 438 measles cases among U.S. residents, 285 (65 percent) cases were considered preventable (i.e., Page 31

34 occurred among persons who were eligible for vaccination but were unvaccinated). The remaining 153 (35 percent) cases were considered nonpreventable. Cases were defined as nonpreventable if they occurred among U.S. resident case-patients who had received 1 dose of measlescontaining vaccine, if patients were vaccinated as recommended if traveling internationally, or if they were not vaccinated but had other evidence of immunity (i.e., were born before 1957 and therefore presumed immune from natural disease in childhood, had laboratory evidence of immunity, or had documentation of physician-diagnosed disease) or for whom vaccination is not recommended. During , a total of 12.5 percent (one of eight) of measles cases reported to CDC among HCP occurred in persons born before 1957; the other seven cases occurred among HCP born after Measles-mumps-rubella (MMR) vaccination policies have been enforced with variable success in United States healthcare facilities over the past decade. Even though medical settings were a primary site of measles transmission during the measles resurgence, as of September 2011, only three states (New York, Oklahoma, and Rhode Island) had laws mandating that all hospital personnel have proof of measles immunity and did not allow for religious or philosophic exemptions. Vaccine coverage in the United States is high; in 2010, a total of 91.5 percent of children aged months had received 1 dose of MMR vaccine; during , a total of 94.8 percent of kindergartners had evidence of two doses; and in 2010, a total of 90.5 percent of adolescents had evidence of two doses. Nationally representative data on MMR vaccine coverage of U.S. HCP are not available. Measles transmission and the costs of mitigating measles exposures in healthcare settings Healthcare-associated cases of measles are of public health concern. Because of the severity of measles, infected persons are likely to seek medical care in primary healthcare facilities, emergency departments, or hospitals. Medical settings played a prominent role in perpetuating outbreaks of measles transmission during the measles resurgence and were a primary site of measles transmission in a healthcare-associated outbreak in During , a total of twenty-seven reported measles cases were transmitted in U.S. healthcare facilities, accounting for 5 percent of all reported U.S. measles cases. Because of the greater opportunity for exposure, HCP are at higher risk than the general population for becoming infected with measles. A study Mumps Epidemiology and risk factors Mumps is an acute viral infection characterized by fever and inflammation of the salivary glands (usually parotitis). The spectrum of illness ranges from subclinical infection (20-40 percent) to nonspecific respiratory illness, sialadenitis including classic parotitis, deafness, orchitis, and meningoencephalitis; severity increases with age. In the prevaccine era, mumps was a common childhood illness, with approximately 186,000 mumps cases reported in the United States per year. After the introduction of the Jeryl Lynn strain mumps vaccine in 1967 and the implementation of the 1-dose mumps vaccine policy for children in 1977, reports of mumps cases in the United States declined 99%. During , an increase in reported mumps cases occurred, primarily affecting unvaccinated adolescents and young adults. In the late 1980s, sporadic outbreaks continued to occur that affected both unvaccinated and 1-dose vaccinated adolescents and young adults. In 1989, a second dose of MMR vaccine was recommended nationwide for better measles control among school-aged children. Historically low rates of mumps followed with only several hundred reported cases per year in the United States during In 1998, a national goal to eliminate mumps was set for However, in 2006, a total of 6,584 mumps cases were reported in the United States, the largest U.S. mumps outbreak in nearly twenty conducted in 1996 in medical facilities in a county in Washington state indicated that HCP were nineteen times more likely to develop measles than other adults. During , in the twenty-three healthcare settings in which measles transmission was reported, eight cases occurred among HCP, six (75 percent) of whom were unvaccinated or had unknown vaccination status. One healthcare provider was hospitalized in an intensive care unit for 6 days from severe measles complications. During a healthcare-associated measles outbreak in Arizona in 2008 with fourteen cases, six cases were acquired in hospitals, and one was acquired in an outpatient setting. One unvaccinated healthcare worker developed measles and infected a hospital emergency room patient who required intensive care following hospital admission for measles. High costs also are involved in evaluating and containing exposures and outbreaks in healthcare facilities, as well as a substantial disruption of regular hospital routines when control measures are instituted, especially if hospitals do not have readily available data on the measles immunity status of their staff and others included in the facility vaccination program. In 2005 in Indiana, one hospital spent more than $113,000 responding to a measles outbreak, and in 2008 in Arizona, two hospitals spent $799,136 responding to and containing cases in their facilities. The Arizona outbreak response required rapid review of measles documentation of 14,844 HCP at seven hospitals and emergency vaccination of approximately 4,500 HCP who lacked documentation of measles immunity. Serologic testing at two hospitals among 1,583 HCP without documented history of vaccination or without documented laboratory evidence of measles immunity revealed that 138 (9 percent) of these persons lacked measles IgG antibodies. Recommendations Vaccination All persons who work in healthcare facilities should have presumptive evidence of immunity to measles. This information should be documented and readily available at the work location. Recently vaccinated HCP do not require any restriction in their work activities. Presumptive evidence of immunity to measles for persons who work in healthcare facilities includes any of the following: Written documentation of vaccination with two doses of live measles or MMR vaccine administered at least 28 days apart. Laboratory evidence of immunity. Laboratory confirmation of disease. Birth before years. Whereas overall national mumps incidence was 2.2 per 100,000 population, eight states in the Midwest were the most affected, with cases per 100,000 population. The highest incidence (31.1 cases per 100,000 population) was among persons aged years (e.g., college-aged students), the majority of whom had received two doses of mumps-containing vaccine. Of the 4,017 case-patients for whom age and vaccination status were known, 1,786 (44 percent) were aged 25 years (incidence: 7.2 cases per 100,000 persons); of these 1,786 patients, 351 (20 percent) received at least two doses, 444 (25 percent) received one dose, 336 (19 percent) were unvaccinated, and 655 (37 percent) had unknown vaccination status. Since the 2006 resurgence, two additional large U.S. mumps outbreaks have occurred, both during , one among members of a religious community with cases occurring throughout the northeastern United States and the other in Guam; both outbreaks primarily affected children and adolescents in crowded environments who had received two doses of vaccine. Vaccine coverage in the United States is high; in 2010, approximately 91.5 percent of children aged months had received one dose of MMR vaccine; during , a total of 94.8 percent of kindergartners had evidence of two doses. In 2010, a total of 90.5 percent of adolescents had Page 32

35 evidence of two doses. Nationally representative data on MMR vaccine coverage of U.S. HCP are not available. Mumps transmission and the costs of mitigating mumps exposures in healthcare settings Although healthcare-associated transmission of mumps is infrequent, it might be underreported because of the high percentage (~20-40 percent) of infected persons who might be asymptomatic. In a survey of 9,299 adults in different professions conducted in 1968, before vaccine was used routinely, the rate of mumps acquisition was highest among dentists and HCP, with rates of 18 percent among dentists and 15 percent among physicians (37 percent for pediatricians), compared with 9 percent among primary and secondary school teachers and 2 percent among university staff members. In the post-vaccine era, mumps transmission also has been documented in medical settings. During a Tennessee mumps outbreak during , a total of 17 (12 percent) of 146 hospitals and three (50 percent) of six long-term-care facilities reported one or more practices that could contribute to the spread of mumps, including not isolating patients with mumps, assigning susceptible staff to care for patients with mumps, and not immunizing susceptible employees. Healthcare-associated transmission resulted in six cases of mumps infections among healthcare providers and nine cases of mumps infections among patients. In Utah in 1994, two healthcare providers in a hospital developed mumps after they had contact with an infected patient. During the 2006 outbreak, one healthcare facility in Chicago experienced ongoing mumps transmission lasting 4 weeks. Rubella Epidemiology and risk factors Rubella (German measles) is a viral disease characterized by rash, low-grade fever, lymphadenopathy, and malaise. Although rubella is considered a benign disease, transient arthralgia and arthritis are observed commonly in infected adults, particularly among postpubertal females. Chronic arthritis has been reported after rubella infection, but such reports are rare, and evidence of an association is weak. Other complications that occur infrequently are thrombocytopenia and encephalitis. Infection is asymptomatic in 25-50percent of cases. Clinical diagnosis of rubella is unreliable and should not be considered in assessing immune status. Many rash illnesses might mimic rubella infection and many rubella infections are unrecognized. The only reliable evidence of previous rubella infection is the presence of serum rubella IgG antibody. Of primary concern are the effects that rubella can have when a pregnant woman becomes infected, especially during the first trimester, which can result in miscarriages, stillbirths, therapeutic abortions, and congenital rubella syndrome (CRS), a constellation of birth defects that often includes blindness, deafness, mental retardation, and congenital heart defects. Postnatal rubella is transmitted through direct or droplet contact from nasopharyngeal secretions. The incubation period ranges from twelve to twenty-three days. An ill person is most contagious when the rash first appears, but the period of maximal communicability extends from a few days before to seven days after rash onset. Rubella is less contagious than measles. In the prevaccine era, rubella was an endemic disease globally with larger epidemics that occurred; in the United States, rubella epidemics occurred approximately every seven years. During the global rubella epidemic, an estimated 12.5 million cases of rubella occurred in the United States, resulting in approximately 2,000 cases of encephalitis, 11,250 fetal deaths attributable to spontaneous or surgical abortions, 2,100 infants who were stillborn or died soon after birth, and 20,000 infants born with CRS. The economic impact of this epidemic in the United States alone was estimated at $1.5 billion in 1965 dollars ($10 billion in 2010 dollars). During the 2006 multistate U.S. outbreak, 144 (8.5 percent) of 1,705 adult case-patients in Iowa for whom occupation was known were healthcare providers (Iowa Department of Public Health, unpublished data, 2006). Whether transmission occurred from patients, coworkers, or persons in the community is unknown. During the outbreak in the northeastern region of the United States, seven (0.2 percent) of the 3,400 case-patients were healthcare providers, six of whom likely were infected by patients because they had no other known exposure. Exposures to mumps in healthcare settings also can result in added economic costs because of furlough or reassignment of staff members from patient-care duties or closure of wards. In 2006, a Kansas hospital spent $98,682 containing a mumps outbreak. During a mumps outbreak in Chicago in 2006, one healthcare facility spent $262,788 controlling the outbreak. Recommendations Vaccination All persons who work in healthcare facilities should have presumptive evidence of immunity to mumps. This information should be documented and readily available at the work location. Recently vaccinated HCP do not require any restriction in their work activities. Presumptive evidence of immunity to mumps for persons who work in healthcare facilities includes any of the following: Written documentation of vaccination with two doses of live mumps or MMR vaccine administered at least twenty-eight days apart. Laboratory evidence of immunity. Laboratory confirmation of disease. Birth before Evidence-based practice alert! The incubation period for rubella ranges from twelve to twenty-three days. An ill person is most contagious when the rash first appears, but the period of communicability begins a few days before the rash onset, resulting in transmission of the disease without knowledge [9]. After the rubella vaccine was licensed in the United States in 1969, reported rubella cases decreased from 57,686 in 1969 to 12,491 in 1976, and CRS cases reported nationwide decreased from 68 in 1970 to 23 in Declines in rubella age-specific incidence occurred in all age groups, including adolescents and adults, but the greatest declines were among children aged <15 years. During , a resurgence of rubella occurred, primarily among older adolescents and young adults, because the initial vaccination strategy targeted children. During this resurgence, 62percent of reported rubella cases occurred among persons aged >15 years compared with 23percent of cases during As a result of the change in the epidemiologic profile of rubella, in 1977, ACIP modified its recommendations to include the vaccination of susceptible postpubertal girls and women. In 1989, a second MMR vaccination dose was recommended in response to large measles outbreaks nationwide. During , the annual numbers of rubella and CRS cases were extremely low, with twenty-three reported rubella cases in 2001, a total of eighteen in 2002, a total of seven in 2003, and a total of nine in Rubella was declared eliminated from the United States in During , a total of fifty-four cases of rubella were reported; the majority of the cases occurred among persons aged >20 years. Of the reported cases, twenty-three (43 percent) were import-associated; only two outbreaks of rubella were reported during this time, and both involved only three cases (CDC, unpublished data, 2009). Since 2005, only four cases of CRS have been reported, with two cases reported in 2009; three (75 percent) cases were acquired internationally, and the other had an unknown source (CDC, unpublished data, 2009). Rubella importations are expected to continue in the immediate future. Page 33

36 As of September 2011, only three states (i.e., New York, Oklahoma, and Rhode Island) had laws mandating that all hospital personnel have proof of rubella immunity and did not allow for religious or philosophical exemptions. Additional states had requirements for specific types of facilities or for certain employees within those facilities, but they did not have universal laws mandating proof of rubella immunity for all hospital personnel. MMR vaccine coverage in the United States is high; in 2010, an estimated 91.5 percent of children aged months had received 1 dose of MMR vaccine; during , a total of 94.8 percent of kindergarteners had evidence of two doses (148); and in 2010, a total of 90.5 percent of adolescents had evidence of two doses. Nationally representative data on MMR vaccine coverage of U.S. HCP are not available. Rubella transmission and the costs of mitigating rubella exposures in healthcare settings No documented transmission of rubella to HCP or other hospital staff or patients in U.S. healthcare facilities has occurred since elimination was declared. However, in the decades before elimination, rubella transmission was documented in at least ten U.S. medical settings and led to outbreaks with serious consequences, including pregnancy terminations, disruption of hospital routine, absenteeism from work, expensive containment measures, negative publicity, and the threat of litigation. In these outbreaks, transmission occurred from HCP Pertussis Epidemiology and risk factors Pertussis is a highly contagious bacterial infection. Secondary attack rates among susceptible household contacts exceed 80 percent. Transmission occurs by direct contact with respiratory secretions or large aerosolized droplets from the respiratory tract of infected persons. The incubation period is generally seven to ten days but can be as long as twenty-one days. The period of communicability starts with the onset of the catarrhal stage and extends into the paroxysmal stage. Symptoms of early pertussis (catarrhal phase) are indistinguishable from other upper respiratory infections. Nursing consideration: The symptoms of early pertussis (catarrhal phase) are indistinguishable from other upper respiratory infections; therefore, the risk of exposure to the infection prior to diagnosis is high. Vaccinated adolescents and adults, whose immunity from childhood vaccinations wanes five to ten years after the most recent dose of vaccine (usually administered at age 4-6 years), are an important source of pertussis infection for susceptible infants. Infants too young to be vaccinated are at greatest risk for severe pertussis, including hospitalization and death. The disease can be transmitted from adults to close contacts, especially unvaccinated children. Vaccination coverage among infants and children for diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine remains high. In 2010, coverage for children aged months who have received 4 doses of DTaP/diphtheria and tetanus toxoids and pertussis vaccine (DTP)/diphtheria and tetanus toxoids vaccine (DT) was 84 percent. Among children entering kindergarten for the school year, DTaP coverage was 93 percent. Vaccination coverage for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine was 68.7 percent among adolescents in 2010 and <7 percent among adults in Tdap vaccination coverage among HCP was 17.0 percent in Disease in healthcare settings and impact on healthcare personnel and patients In hospital settings, transmission of pertussis has occurred from hospital visitors to patients, from HCP to patients, and from patients to HCP. Although of limited size (range: 2-17 patients and 5-13 staff), documented outbreaks were costly and disruptive. In each outbreak, Page 34 to susceptible coworkers and patients, as well as from patients to HCP and other patients. No data are available on whether HCP are at increased risk for acquiring rubella compared with other professions. Recommendations Vaccination All persons who work in healthcare facilities should have presumptive evidence of immunity to rubella. Adequate rubella vaccination for HCP consists of one dose of MMR vaccine. However, because of the two-dose vaccination requirements for measles and mumps, the use of the combined MMR vaccine will result in the majority of HCP receiving two doses of rubella-containing vaccine, which should provide an additional safeguard against primary rubella vaccine failure. Recently vaccinated HCP do not require any restriction in their work activities. Presumptive evidence of immunity to rubella for persons who work in healthcare facilities includes any of the following: Written documentation of vaccination with one dose of live rubella or MMR vaccine. Laboratory evidence of immunity. Laboratory confirmation of rubella infection or disease. Birth before 1957 (except women of childbearing potential who could become pregnant, although pregnancy in this age group would be exceedingly rare). HCP were evaluated for cough illness and required diagnostic testing, prophylactic antibiotics, and exclusion from work. During outbreaks that occur in hospitals, the risk for contracting pertussis among patients or staff is often difficult to quantify because exposure is not well defined. Serologic studies conducted among hospital staff indicate that exposure to pertussis is much more frequent than suggested by attack rates of clinical disease. In one outbreak, seroprevalence of pertussis agglutinating antibodies among HCP correlated with the degree of patient contact and was highest among pediatric house staff (82 percent) and ward nurses (71 percent) and lowest among nurses with administrative responsibilities (35 percent). A model to estimate the cost of vaccinating HCP and the net return from preventing nosocomial pertussis was constructed using probabilistic methods and a hypothetical cohort of 1,000 HCP with direct patient contact followed for ten years. Baseline assumptions, determined from data in the literature, included incidence of pertussis in HCP, ratio of identified exposures per HCP case, symptomatic percentage of seroconfirmed pertussis infections in HCP, cost of infection-control measures per exposed person, vaccine efficacy, vaccine coverage, employment turnover rate, adverse events, and cost of vaccine. In a ten-year period, the cost of infection control would be $388,000 without Tdap vaccination of HCP compared with $69,000 with such a program. Introduction of a vaccination program would result in a net savings as high as $535,000 and a benefit-cost ratio of 2.38 (i.e., for every dollar spent on the vaccination program, the hospital would save $2.38 on control measures). Recommendations Vaccination Regardless of age, HCP should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap and regardless of the time since their most recent Td vaccination. Vaccinating HCP with Tdap will protect them against pertussis and is expected to reduce transmission to patients, other HCP, household members, and persons in the community. Tdap is not licensed for multiple administrations; therefore, after receipt of Tdap, HCP should receive Td for future booster vaccination against tetanus and diphtheria. Hospitals and ambulatory-care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates (e.g., education about the benefits of vaccination, convenient access, and the provision of Tdap at no charge).

37 Varicella Epidemiology and risk factors Varicella is a highly infectious disease caused by primary infection with varicella-zoster virus (VZV). VZV is transmitted from person to person by direct contact, inhalation of aerosols from vesicular fluid of skin lesions of varicella or herpes zoster (HZ), a localized, generally painful vesicular rash commonly called shingles, or infected respiratory tract secretions that also might be aerosolized. The average incubation period is fourteen to sixteen days after exposure to rash (range: ten to twenty-one days). Infected persons are contagious an estimated one to two days before rash onset until all lesions are crusted, typically four to seven days after rash onset). Varicella secondary attack rates can reach 90 percent among susceptible contacts. Typically, primary infection with VZV results in lifetime immunity. VZV remains dormant in sensory-nerve ganglia and can reactivate at a later time, causing HZ. Before the U.S. childhood varicella vaccination program began in 1995, approximately 90 percent of varicella disease occurred among children aged <15 years. During , national varicella vaccine coverage among children aged months increased from 27 to 90 percent, leading to dramatic declines of >85 percent in varicella incidence, hospitalizations, and deaths. The decline in disease incidence was greatest among children for whom vaccination was recommended; however, declines occurred in every age group including infants too young to be vaccinated and adults, indicating reduced communitywide transmission of VZV. Current incidence of varicella among adults is low (<0.1/1,000 population), and adult cases represent <10 percent of all reported varicella cases. National seroprevalence data from demonstrated that, in the early vaccine era, adults continued to have high immunity to varicella. In this study, 98 percent of persons aged years had VZV-specific IgG antibodies. However, with declining likelihood of exposure to VZV, children and adolescents who did not receive two doses of varicella vaccine could remain susceptible to VZV infection as they age into adulthood, when varicella can be more severe. The clinical presentation of varicella has changed since the implementation of the varicella vaccination program, with more than half of varicella cases reported in 2008 occurring among persons who were vaccinated previously, the majority of them children. Varicella disease in vaccinated children (breakthrough varicella) usually has a modified or atypical presentation; the rash is typically mild, with <50 lesions that are more likely to be predominantly maculopapular than vesicular. Fever is less common, and the duration of illness is shorter. Nevertheless, breakthrough varicella is infectious. One study indicated that vaccinated children with varicella with <50 lesions were only one third as infectious as unvaccinated children whereas those with 50 lesions were as infectious as unvaccinated children. Because the majority of adults are immune and few need vaccination, fewer breakthrough cases have been reported among adults than among children, and breakthrough varicella in adults has tended to be milder than varicella in unvaccinated adults. The epidemiology of varicella in tropical and subtropical regions differs from that in the United States. In these regions, a higher proportion of VZV infections are acquired later in life. Persons emigrating from these regions might be more likely to be susceptible to varicella compared to U.S.-born persons and, therefore, are at a higher risk for developing varicella if unvaccinated and exposed. Disease in healthcare settings and impact on healthcare personnel and patients Although relatively rare in the United States since introduction of varicella vaccine, nosocomial transmission of VZV is well recognized and can be life-threatening to certain patients. In addition to hospital settings, nosocomial VZV transmission has been reported in longterm-care facilities and a hospital-associated residential facility. Sources of nosocomial exposure that have resulted in transmission include patients, HCP, and visitors with either varicella or HZ. Both localized and disseminated HZ in immunocompetent as well as immunocompromised patients have been identified as sources of nosocomial transmission of VZV. Localized HZ has been demonstrated to be much less infectious than varicella; disseminated HZ is considered to be as infectious as varicella. Nosocomial transmission has been attributed to delays in the diagnosis or reporting of varicella or HZ and in failures to implement control measures promptly. In hospitals and other healthcare settings, airborne transmission of VZV from patients with either varicella or HZ has resulted in varicella in HCP and patients who had no direct contact with the index casepatient. Although all susceptible patients in healthcare settings are at risk for severe varicella disease with complications, certain patients without evidence of immunity are at increased risk: pregnant women, premature infants born to susceptible mothers, infants born at <28 weeks gestation or who weigh 1,000 grams regardless of maternal immune status, and immunocompromised persons of all ages (including persons who are undergoing immunosuppressive therapy, have malignant disease, or are immunodeficient). VZV exposures among patients and HCP can be disruptive to patient care, time-consuming, and costly even when they do not result in VZV transmission. Studies of VZV exposure in healthcare settings have documented that a single provider with unrecognized varicella can result in the exposure of >30 patients and >30 employees. Identification of susceptible patients and staff, medical management of susceptible exposed patients at risk for complications of varicella, and furloughing of susceptible exposed HCP are time-consuming and costly. With the overall reduction in varicella disease attributable to the success of the vaccination program, the risk for exposure to VZV from varicella cases in healthcare settings is likely declining. In addition, an increasing proportion of varicella cases occur in vaccinated persons who are less contagious. Diagnosis of varicella has become increasingly challenging as a growing proportion of cases occur in vaccinated persons in whom disease is mild, and HCP encounter patients with varicella less frequently. Although not currently routinely recommended for the diagnosis and management of varicella, laboratory testing of suspected varicella cases is likely to become increasingly useful in healthcare settings, especially as the positive predictive value of clinical diagnosis declines. Recommendations Vaccination Healthcare institutions should ensure that all HCP have evidence of immunity to varicella. This information should be documented and readily available at the work location. HCP without evidence of immunity to varicella should receive two doses of varicella vaccine administered four to eight weeks apart. If >8 weeks elapse after the first dose, the second dose may be administered without restarting the schedule. Recently vaccinated HCP do not require any restriction in their work activities; however, HCP who develop a vaccine-related rash after vaccination should avoid contact with persons without evidence of immunity to varicella who are at risk for severe disease and complications until all lesions resolve (i.e., are crusted over) or, if they develop lesions that do not crust (macules and papules only), until no new lesions appear within a twenty-four-hour period. Evidence of immunity for HCP includes any of the following: Written documentation of vaccination with two doses of varicella vaccine. Laboratory evidence of immunity or laboratory confirmation of disease. Diagnosis or verification of a history of varicella disease by a healthcare provider. Diagnosis or verification of a history of HZ by a healthcare provider. Adapted from Centers for Disease Control and Prevention (2011). Immunization of Healthcare Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Retrieved from [9]. Page 35

38 Conclusion Healthcare providers, specifically nurses, have an important role in the prevention and control of infectious diseases. In all healthcare settings, patient safety and protection is dependent upon healthcare providers understanding and being vigilant in the practices related to infection prevention and control. This course has covered basic concepts related to infection prevention and control in healthcare settings and has provided information to help References 1. Centers for Disease Control and Prevention. Diseases and Organisms in Healthcare Settings. Retrieved from 2. Centers for Disease Control and Prevention. Exposure to Blood: What Healthcare Personnel Need to Know. Retrieved from 3. Centers for Disease Control and Prevention. Facts for Parents: Diseases & the Vaccines that Prevent Them. Retrieved from 4. Centers for Disease Control and Prevention (2008). Guideline for Disinfection and Sterilization in Healthcare Facilities. Retrieved from Nov_2008.pdf 5. Centers for Disease Control and Prevention (1998). Guideline for Infection Control in Health Care Personnel. Retrieved from 6. Centers for Disease Control and Prevention (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Retrieved from hicpac/pdf/isolation/isolation2007.pdf 7. Centers for Disease Control and Prevention (2002). Guideline for Hand Hygiene in Healthcare Settings. Retrieved from 8. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. Retrieved from 9. Centers for Disease Control and Prevention (2011). Immunization of Healthcare Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Retrieved from Centers for Disease Control and Prevention. Immunization: The Basics. Retrieved from cdc.gov/vaccines/vac-gen/imz-basics.htm 11. Centers for Disease Control and Prevention. Mission, Role and Pledge. Retrieved from cdc.gov/about/organization/mission.htm 12. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN). Retrieved from Centers for Disease Control and Prevention. National and State Healthcare-Associated Infections Progress Report. Retrieved from Centers for Disease Control and Prevention (2006). Management of Multidrug-Resistant Organisms in Healthcare Settings. Retrieved from MDROGuideline2006.pdf 15. Centers for Disease Control and Prevention. Poster: Sequence for Donning and Removing Personal Protective Equipment. Retrieved from nurses advocate for the safety and protection of the patients and others for which they care. The course outlined key information to enable nurses to be current with practice guidelines that have been based on research findings and professional standards of care. However, it is critical that healthcare providers utilize updated resources to stay current with specific guidelines as changes are made based on additional research findings and changes to practice standards. 16. Centers for Disease Control and Prevention (2006, 2012). Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics. Retrieved from Centers for Disease Control and Prevention (2013). Prevention Status Reports. Retrieved from Centers for Disease Control and Prevention. Types of Healthcare-associated Infections. Retrieved from Centers for Disease Control and Prevention. Vaccines and Immunizations: Glossary. 20. Retrieved from Centers for Disease Control and Prevention. What Would Happen If We Stopped Vaccinations? Retrieved from Centers for Disease Control and Prevention. Winnable Battles: Healthcare-Associated Infections. Retrieved from Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. (2014). Multistate Point-Prevalence Survey of Health Care Associated Infections. The New England Journal of Medicine, 370: March 27, Retrieved from nejm.org/doi/full/ /nejmoa GraduateNursingEDU.Org. Infection Control Nurse. Retrieved from org/infection-control/ 25. Occupational Safety & Health Administration. Bloodborne Pathogens and Needlestick Prevention. Retrieved from The National Institute of Occupational Safety and Health. About NIOSH. Retrieved from The Society for Healthcare Epidemiology of America. Mission and History. Retrieved from Page 36

39 INFECTION CONTROL: STANDARDS FOR NURSING PRACTICE self assessment Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your answer sheet. 1. The infection control nurse is interested in statistics related to healthcare-associated infection rates. Which of the following agencies would provide the nurse with this type of data? a. The Society for Healthcare Epidemiology of America. b. National Healthcare Safety Network. c. Healthcare Infection Control Practices Advisory Committee. d. National Institute of Occupational Safety and Health. 2. The nurse is providing an in-service on infection prevention and control for staff. Which of the following would be a PRIORITY for the nurse to emphasize? a. Wearing gowns. b. Wearing gloves. c. Using masks. d. Hand hygiene. 3. The nurse is caring for a patient with a positive PPD test and an abnormal chest x-ray. Which of the following precautions should the nurse implement? a. Standard precautions. b. Airborne precautions. c. Contact precautions. d. Droplet precautions. 4. The nurse is caring for a patient with C. difficile diarrhea. Which of the following precautions should the nurse implement? a. Standard precautions. b. Airborne precautions. c. Contact precautions. d. Droplet precautions. 5. An infection control nurse is observing staff caring for patients on contact precautions. Which of the following actions would require the infection control nurse to intervene? a. A nurse dons a gown and gloves prior to entering the patient room. b. A nurse performs hand hygiene before leaving the patient room. c. A nurse removes a gown after leaving the patient room. d. A nurse leaves a gown inside the room when exiting. 6. The nurse is caring for a patient with influenza. Which of the following precautions should the nurse implement? a. Standard precautions. b. Airborne precautions. c. Contact precautions. d. Droplet precautions. 7. A patient asked the nurse what the term standard precautions means. Which of the following statements would be a correct response by the nurse? a. Masks should be worn when caring for patients that are sick. b. Gloves need to be worn for contact with blood and body fluids. c. A private room is needed for these patients. d. We are not allowed to explain that term to patients. 8. A new nurse asks the preceptor what the term transmission-based precautions means. Which of the following statements would be a correct response by the preceptor? a. We have to wear masks and gowns when in the patient s room. b. Gloves and gowns need to be worn for patient contact. c. They are used for infections transmitted by routes not covered by standard precautions. d. It means the same thing as standard precautions. 9. The nurse is preparing a vaccination for a child when the mother asks why the injection is necessary. Which of the following statements would be the best response by the nurse? a. Your child s physician ordered it. b. There are federal laws specifying vaccines that are required. c. Please direct this questions to your child s physician. d. Vaccines prevent infectious diseases by providing immunity to the infection. 10. The nurse is preparing a vaccination for a child when the mother asks how the vaccine will work. Which of the following would NOT be an appropriate statement by the nurse? a. The vaccine contains small amounts of antigens that will cause immunity in your child. b. Vaccines have no associated side effects or risks. c. Your child will not get the disease for which the vaccine was intended. d. Vaccines are studied for their benefits and risks. Answers: 1.B 2.D 3.B 4.C 5.C 6.D 7.B 8.C 9.D 10.B Page 37

40 Chapter 2: Patient Safety: Implementation of National Safety Standards for Nurses Release Date: 2/15/2016 Expiration Date: 2/15/2019 Audience National patient safety standards are a core competency for nursing practice. This course is for all nurses who are responsible for providing patient care. 4 Contact Hours Purpose statement Safety comes first in patient care and in health care environments. This course presents the latest National Patient Safety goals as well as strategies for nursing. Learning objectives Implement patient care designed to achieve National Patient Safety Goals. Describe how to prevent never-ever events. How to receive credit Read the entire course online or in print which requires a 4-hour commitment of time. Depending on your state requirements you will asked to complete either: Page 38 An affirmation that you have completed the educational activity. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through April 30, 2017); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Board of Nursing, Provider Faculty Adrianne E. Avillion, D.Ed., RN Dr. Avillion is an accomplished nurse educator and published healthcare education author. Dr. Avillion earned her doctoral degree in Adult Education and her M. S. from Penn State University, along with a BSN from Bloomsburg University. Adrianne has served in various nursing roles over her career in both leadership roles and as a bedside clinical nurse. She has published extensively and is a frequent presenter at conferences and conventions devoted to the specialty of continuing education and nursing professional development. She currently owns and is the CEO of Strategic Nursing Professional Development, a business that specializes in continuing Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for continuing education, Elite implemented mechanisms prior to the Explain how to reduce the occurrence of non-reimbursable hospital-acquired conditions. A mandatory test (a passing score of 70 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the mandatory Self-Assessment and Course Evaluation. Print your Certificate of Completion. # ; Florida Board of Nursing, Provider # ; Georgia Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). education for healthcare professionals and consulting services in nursing professional development. Additionally, she writes on safety issues in her role as editor and writer of a newsletter for The National Association of Physicians Nurses as well as incorporates safety education as part of continuing education tutorials for various continuing education companies Content Reviewer Nancy J. Denke, DNP, ACNP-BC, FNP-BC, FAEN Activity Director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.

41 Sponsorship/Commercial Support and Non-Endorsment It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2016: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Introduction Safety first! There is not a practicing healthcare professional who would not agree that safety first is (or should be) the guiding principle of patient care services. Given that, why are medical errors the third leading cause of death in the United States? Why, according to recent research, do nearly 440,000 Americans die annually from preventable hospital errors [1]? EBP alert! Research shows that an alarming number of healthcare consumers die from preventable medical errors. It is imperative that nurses and their healthcare colleagues comprehend safety mandates and safety research findings and then implement the recommendations into all aspects of their practice [1,2]. Clearly, it is essential for all healthcare providers to improve the safety of the environment in which patient care is delivered. Accrediting National Patient Safety Goals It is a typically hectic evening at one of the Hazelmoor Community Hospital medical units. A notice has been shared and posted that concerns the latest National Patient Safety Goals. Nurses are requested to familiarize themselves with these goals and how the hospital plans to achieve them. The nurses know that they must eventually make time to review this information, but that time is not tonight as it is just too busy, and patient care comes first. Nor is there time the next evening. Nor the next. Time goes by, and as one nurse puts it, Our patients come first. We can t stop to read a bunch of stuff when we should be taking care of patients. That s why safety is compromised. All of this paper work and theory! The people that write History of the National Patient Safety Goals The National Patient Safety Goals (NPSGs) are a set of standards which address the highest-priority patient safety issues that The Joint Commission promotes and utilizes to implement major changes in patient safety [3]. The NPSG program was established in 2002 and the first set of NPSGs was effective on January 1, The purpose of establishing such goals was to assist accredited organizations in addressing specific areas of concern regarding patient safety [4]. How are the NPSGs developed, and who develops them? According to The Joint Commission website, a panel of widely recognized patient safety experts advise The Joint Commission on the development and updating of NPSGs [4]. This panel is called the Patient Safety Advisory Group and is comprised of nurses, physicians, pharmacists, risk managers, clinical engineers, and other professionals who have hands-on experience in addressing patient safety issues in a wide variety of healthcare settings. bodies and national organizations such as The Joint Commission and the Institute of Medicine have conducted research, published reports, and issued mandates regarding safety measures that should, and must, be implemented. But, how much is the average healthcare professional aware of such research and the rationale behind mandates and recommendations? The purpose of this educational program is to discuss three critical topics related to essential safety standards: National Patient Safety Goals. Never ever events. Centers for Medicare and Medicaid Services conditions that are not reimbursable if not present upon admission. The educational program will also explain how nurses can implement the recommendations and mandates of these standards to improve patient safety as well as the quality and appropriateness of their practice. these things should try being out here actually taking care of patients. Then maybe they d see what it s like in the real world! Does the preceding situation sound familiar? Have you heard colleagues make similar statements? Have you made such comments yourself? You are not alone. Many healthcare professionals do not have a clear understanding of the National Patient Safety Goals, or how achieving these goals will improve patient care. It is not enough to distribute facts about these goals and what should be done to achieve them. Leaders of healthcare organizations have an obligation to explain how these goals were identified, how each organization developed a plan for achieving these goals, and most importantly, how the goal achievement will improve patient care. The Patient Safety Advisory Group works with staff from The Joint Commission to identify emerging patient safety issues, and advises The Joint Commission on how to address those issues in NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, and/or in Center for Transforming Healthcare projects [4]. Large amounts of data are generated by the collaboration of The Joint Commission and the Patient Safety Advisory Group. How does The Joint Commission determine patient safety issue priorities for NPSGs when faced with so much information? Input is solicited from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders. Based on this input, The Joint Commission identifies priority patient safety issues, and how to best address them. The Joint Commission also determines if an NPSG is applicable to a specific accreditation program. If so, the goal is adapted to be program-specific [4]. Page 39

42 Nursing consideration: Nurses may be concerned that the people who have input into the development of safety priorities lack current experience in patient care delivery. One way to alleviate these concerns, and to encourage staff nurses to become more involved in implementing NPSG recommendations is to encourage them to become more involved with The Joint Commission Perhaps they may even become a member of the Patient Safety Advisory Group or become active in another Joint Commission process. For more information about the Patient Safety Advisory Group, contact the Executive Vice-President and Chief Medical Officer of The Joint Commission at +1 (630) , or access The Joint Commission website for more information ( NPSGs alert! What exactly are the responsibilities of the Patient Safety Advisory Group? As stated directly on the website, the group [5] : Annually recommends program-specific NPSGs for adoption by The Joint Commission Board of Commissions. Reviews draft patient safety recommendations for potential publication in The Joint Commission s periodic Sentinel Event Alert advisory, and advises Joint Commission staff as to the evidence for, and face validity of these recommendations as well as their practically and cost of implementation. Recommends potential future topics for Sentinel Event Alert. Assesses and facilitates learning initiatives about sentinel events, Sentinel Event Alerts, and the National Patient Safety Goals, including the implementation and effectiveness of the National Patient Safety Goals. Learning initiatives include: online tools such as Frequently Asked Questions and PowerPoint presentation;, tool kits to facilitate implementation of the National Patient Safety Goals; and education seminars and workshops. Current National Safety Goal priorities Samantha is a registered nurse who was recently appointed as a member of her hospital s Safety Advisory Council. She is preparing to attend her first meeting. The focus of the meeting will be a review of the newly published National Patient Safety Goals (NPSGs). Samantha is a bit uneasy about this focus as her role as a staff nurse has been to implement actions mandated by the hospital to comply with the goals. Now she is going to be in a position to help design actions that she and her colleagues must implement. This is a major responsibility, and Samantha is both excited and apprehensive about her new accountability as a leader. Samantha and other stakeholders must not only follow organizational mandates in regards to compliance with NPSGs, but must become active participants in the decision-making process of how these goals can be achieved. Since their establishment in 2002, the NPSGs have evolved to become one of the most important methods of promoting and enforcing major safety changes in healthcare organizations. Recent changes, in addition to existing goals, have concentrated on preventing 2016 Hospital National Patient Safety Goals The following summaries are based on information taken from The Joint Commission web site s easy-to-read version of the goals [6]. The easy-to-read version is intended for the general public as well. For the exact language of the goals, access: Identify patients correctly. Use at least two ways to identify patients. For example, use the patient s name and date of birth. This will make sure that each patient gets the correct medications and treatments. Make sure that the correct patient gets the correct blood when receiving a blood transfusion. Nursing consideration: Nurses must always be sure to identify patients in at least two ways prior to administering medications and blood products. Nurses may be tempted to ignore this simple safety mandate, especially if they know the patient well. But, ignoring the mandate even once makes it easier to ignore it again, and then again. Nurses also serve as role models for colleagues bound by the same mandate. Nurses must always use at least two methods to identify each patient [6]. Improve staff communication. Get important test results to the right staff person on time. hospital-acquired infections and medication errors, promoting surgical safety, ensuring correct patient identification, enhancing communication between staff, and identifying patients at risk for suicide. The most recent 2016 goal is to reduce the harm associated with clinical alarm systems [3]. Before discussing the implications of the newest goal related to the safety of hospital alarm systems, we must review the other goals highlighted in the 2016 NSPGs. Each goal was developed to evaluate the safety and the quality of care provided for patients in the different care arenas which include hospitals, home-care, ambulatory care, behavioral health, critical-access hospitals, laboratories, long-term care, nursing-care centers, and office-based surgery. To access information about each 2016 NPSGs, go to this website link: For the purpose of this educational program, we will focus on the hospital, ambulatory care, and home-care goals. Nursing consideration: Communication is essential to reduce errors. Research shows that appropriate communication enhances patient safety [7]. Research shows that poor communication can contribute to medical errors while good communication can help to reduce their occurrence [7]. However, improving staff communication is not limited to just getting test results to the right person in a timely manner. Communication involves sharing information as a team about the patient s status and progress toward desired outcomes. Use medicines safely. Before a procedure, label medicines that are not labeled, for example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who take medications to thin their blood. Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Page 40

43 Nursing consideration: In addition to complying with the preceding directives, nurses must ensure medication lists are reconciled each time a patient is transferred from or accepted from another healthcare facility or patient care area. Educate patients and families how to safely take their medications at home. Have them demonstrate safe self-medication practices. Do not ask them simple yes and no questions such as Do you know what side effects your medication can cause? Instead, ask them Tell me what side effects your medicine can cause and what you should do if these happen. Be sure to assess their knowledge in a practical way. Use alarms safely. Make improvements to ensure that alarms on medical equipment are heard and responded to on time. This is a major addition to the 2016 NPSGs. It will be discussed in detail later in this program. Prevent infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO). Set goals for improving hand cleaning, and use these goals to improve hand cleaning. Use proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent blood infection from central lines. Use proven guidelines to prevent infection after surgery. Use proven guidelines to prevent infections of the urinary tract that are caused by catheters Home Care National Patient Safety Goals This summary is taken directly from The Joint Commission s easy-toread version [10]. Identify patients correctly. Use at least two ways to identify patients. For example, use the patient s name and date of birth. This ensures that each patient gets the correct medicine and treatment. Use medicines safely. Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Nursing consideration: Nurses should have patients or families demonstrate safe self-medication. It is not enough to simply give them information about their medications and ask yes or no questions such as, Do you understand how to take your medicine? Instead have them explain what side effects might occur and what to do about them, or have them actually demonstrate how to administer a specific medication. Prevent infection. Use the hand cleaning guidelines from the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO). Set goals for improving hand cleaning. Use these goals to improve hand washing. Nursing consideration: Nurses must teach patients and friends appropriate hand washing techniques. This includes when and how to implement the techniques. EBP alert! Research shows that proper hand washing is the most effective way to prevent the spread of infections in hospitals [8]. Nurses have an obligation to share research findings that show that this and other infection control interventions really do help to prevent infection. Adults are more likely to apply knowledge in the work setting if they have evidence that specific interventions actually work. Identify patient safety risks. Find out which patients are likely to try to commit suicide. Nursing consideration: The prevalence of mental illness makes it almost a certainty that nurses, no matter where they practice, will care for persons who are currently experiencing a mental illness. It is estimated that 25 percent of all adults in the United States will develop at least one mental illness during their lifetime [9]. Nurses must be aware of the signs and symptoms as well as information from the patient s personal and family history that indicate a patient is at risk for suicidal behavior. Prevent mistakes in surgery. Make sure that the correct surgery is conducted on the correct patient, and at the correct location on the patient s body. Mark the correct place on the patient s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made. Nursing consideration: It is essential that nurses be alert to the possibility of any potential errors in the surgical setting and act swiftly to prevent their occurrence. Prevent patients from falling. Find out which patients are most likely to fall. For example, is the patient taking any medicines that might make them weak, dizzy or sleepy? Take action to prevent falls for these patients. Nursing consideration: Nurses must also be alert to other safety hazards or issues in the patient home that contribute to falls such as scatter rugs, highly polished floors, wet surfaces and mobility difficulties. Identify patient safety risks. Find out if there are any risks for patients who receive oxygen. For example, are there fireplaces in the patient s home? Nursing consideration: Nurses must teach patients and families how to avoid hazards associated with oxygen therapy. Increasing the awareness of contraindications when a family member is on oxygen therapy, such as smoking, must be communicated to persons visiting the home where oxygen is in use Ambulatory Care National Patient Safety Goals The following summary is taken from The Joint Commission s easyto-read version [11]. The 2016 goals for ambulatory care are similar to those of hospitals and include: Identify patients correctly. Use medicines safely. Prevent infection(s). Prevention of mistakes in surgery. Page 41

44 2016 NPSG: Clinical alarm safety Ben is an experienced cardiovascular care nurse. He is working on the step-down cardiac care unit, and has been one of the leaders on the unit for many years. A new nursing employee is touring the unit with the nursing director as part of her hospital orientation. She comments, Isn t anyone worried about all of the alarms going off? Nobody seems to be concerned. Ben explains that, Most alarms are actually false. You get to know what is real and what isn t. For instance, we have one man whose alarm goes off all the time because he s a really restless sleeper. At that moment the code for cardiac arrest is heard coming from the room of the man who is a restless sleeper. His cardiac monitor alarm had been going off for several minutes. Unfortunately, the alarm had been ignored and now the patient is in cardiac arrest. Alarm fatigue occurs when the daily number of alarm signals, such as bells, beeps, and tones from medical devices (especially physiological devices), overwhelms healthcare personnel with information. This can actually desensitize healthcare personnel to the alarms themselves. Nurses and other healthcare professionals may turn alarm volumes down in an effort to control noise levels. Turning down the volume may create an unsafe environment for the patient. After a period of time, clinicians may not respond to alarms simply because the alarms have become part of the normal background noise of a unit, and no longer trigger concern [12]. EBP alert! Research shows that 80 to 99 percent of alarms generated by devices such as ventilators, blood pressure monitors, and electrocardiograms are false and/or do not actually need any clinical intervention [13]. Clinicians are becoming desensitized to the sounds of alarms, and experiencing alarm fatigue. Nurses and other healthcare professionals must work with each other to make eliminating alarm fatigue a priority. This can be accomplished by avoiding unnecessary monitoring, and educating clinicians to the full potential of devices. The extent to which alarm fatigue has adversely affected patients is not precisely known. The United States Food and Drug Administration s Manufacturer and User Facility Device Experience Database listed 566 alarm-related deaths between January 2005 and June This number is believed to under-represent the actual cases [12]. From 2009 to 2012, The Joint Commission reported 98 alarm-related events, 80 of which resulted in death, 13 resulted in permanent loss of function, and five resulted in unexpected additional care or extended stays. Since sentinel event reporting to The Joint Commission is voluntary, some experts believe that this number represents less than ten percent of such adverse occurrences [13]. Healthcare safety experts agree that alarm fatigue is becoming worse, and the consequences of this are perilous [4,12,13]. In June 2013, The Joint Commission approved a new NPSG on clinical alarm safety for hospitals and critical access hospitals. This goal was implemented in two phases. Phase one began on January 1, 2014 when hospitals were required to establish alarm safety as an organizational priority, and to identify the most important alarms to manage based on their internal situations. Phase two began on January 1, 2016 and hospitals are expected to develop and implement specific components of policies and procedures, and to educate staff in the organization of alarm system management [4]. The Joint Commission points out that clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety [14]. The Joint Commission also notes that the problem of alarm safety is multifaceted. Alarms may be difficult to detect. There may be numerous alarm signals that tend to desensitize staff and contribute to persons missing or even ignoring alarm sounds. Some staff members may even turn off alarms to decrease the amount of noise on a particular unit [14]. Desensitization to alarms may have serious or even fatal consequences for patients. Page 42 In addition to The Joint Commission, several organizations have compiled useful information about safely managing alarm systems. For example, the Advancement of Medical Instrumentation (AAMI) founded in 1967, is a nonprofit organization with a mission to develop, manage, and use safe and effective healthcare technology. On the organization s website, they are described as the primary source of national and international consensus standards for the medical device industry as well as a source of practical information, support, and guidance for healthcare technology and sterilization professionals [15]. More detailed information can be found at their website: Another source of information is the ECRI Institute, an independent nonprofit organization whose mission is to benefit patient care by promoting the highest standards of safety, quality, and costeffectiveness in healthcare [2]. The institute accomplishes its mission through research, publishing, education, and consultation. ECRI s goal is to be the world s most trusted, independent organization providing healthcare information, research, publishing, education, and consultation to organizations and individuals in healthcare [2]. The ECRI Institute compiles an annual top ten list of patient safety concerns based on its review of patient safety event reports, research requests, and root-cause analyses submitted to the ECRI Institute PSO. This is one of the first patient safety organizations (PSOs) to be federally certified under the provisions of the Patient Safety and Quality Improvement Act (PSQIA). The ECRI Institute s report is not simply a list. It recommends that healthcare organizations use the list of patient safety concerns as a starting point for their patient safety discussions and for establishing their patient safety priorities [2]. The ECRI Institute also provides some free safety resources on its website: Since the ECRI Institute began publishing its list of top health technology hazards in 2007, alarm hazards have been at or near the top of the list [2]. Although the current Joint Commission emphasis is on alarm fatigue, the ECRI Institute is encouraging healthcare organizations to look beyond alarm fatigue, and investigate the incidence of alarms that do not activate when a patient is in distress. According to the senior project officer at the institute, alarm-related adverse events, whether due to missed alarms or unrecognized alarm conditions, can often be traced to alarm systems that were not configured appropriately. The ECRI Institute recommends that organizations examine their alarm configuration policies and procedures and ensure that they address the full range of factors that can lead to alarm hazards [2]. January 4, 2016: The Safety Council is meeting today, the first regular work day of the new year. Members of the council are reviewing their compliance with The Joint Commission s alarm safety goal. Compliance was to have been achieved on January 1, The Safety Council members are confident that the policies and procedures that have been in place since October 2015 adequately meet Joint Commission standards; however, they are not going to relax. Today, council members are going to review safety data, including adverse events reports, particularly those relating to alarm safety. They have also invited several staff nurses and therapists, who work daily on units that are sometimes bombarded by the constant noise of alarms, to attend the meeting. Members want to know how these healthcare professionals have been implementing policies and procedures, and what revision suggestions they may have to further enhance patient safety. Nursing consideration: The preceding example of a fictional Safety Council demonstrates the importance of constantly reviewing actions undertaken to meet safety standards. It also emphasizes the importance of soliciting feedback from practitioners who work with these identified safety dilemmas every day.

45 Experts note, that in order to adequately address patient safety and clinical workflow, an overall plan must be developed to manage clinical interruptions. This plan must include [16] : Addressing alarms (e.g. physiological monitors). Responding to alerts (e.g. critical lab notification). Communicating with members of the healthcare team. Nursing consideration: In order to effectively address the problem of alarm safety, nurses should also know what types of adverse events have occurred that are linked to problems with alarms. What types of alarm-related adverse events have been reported? According to information from the U. S. Food and Drug Administration s Manufacturer and User Facility Device Experience database, falls, delays in treatment, ventilator use, and medication errors were causes of death or common injuries related to alarms [12]. Factors that contributed to these injuries or fatalities included [12] : Absent or inadequate alarm systems. Improper alarm settings. Alarm signals that were not audible in all areas. Nursing consideration: Key recommendations from The Joint Commission and other safety experts regarding alarm safety include [12] : Establish a cross-disciplinary team to address the potential effect of alarm fatigue in all patient care areas. Create priorities for the adoption of alarm technology. Train clinical care teams on safe alarm management and response in high-risk areas and on the safe use of the devices. Ronald Wyatt, MD, MHA, medical director of the division of healthcare improvement at The Joint Commission as of November 2015, suggests that healthcare organizations begin their alarm safety efforts by determining the baseline number of device alarms per day. They should then be able to answer the following questions [13] : How many alarms required a clinical intervention? How many alarms resulted in harm or death? What are the organization s current monitor alarm default parameters? How can we adjust alarms to indicate actionable alarms? Nursing consideration: Nurses are all too well aware that many alarms do not actually indicate an actual patient problem or emergency. Some experts recommend that clinicians work with engineers and equipment manufacturers to customize the configuration of alarms and avoid the overlapping of redundant alarms. These changes must demonstrate a means for staff to quickly recognize alarms that need immediate attention. Additionally, some experts say that unnecessary patient monitoring results in excessive nuisance alarms. Patients should be monitored only when it is clinically necessary. Alarms should be individualized for each patient to make the alarms most effective [13]. It is necessary for all healthcare organizations to have a documented and functional work plan to achieve the alarm National Patient Safety Goal [17], in addition to the specific requirements and explanations outlined in the 2016 Joint Commission National Patent Safety Goals [18]. The Joint Commission Sentinel Event Alert published on April 8, 2013 provides very helpful information to deal with the problem of alarms [19]. The Joint Commission Sentinel Event Alert of April 8, 2013 focuses on medical device alarm safety in hospitals. The Joint Commission s Sentinel Event database includes 98 alarm-related events (80 of which led to fatalities) reported from January 2009, to June The majority of events, 94 of 98, occurred in hospitals. The majority of the 94 events occurred in telemetry, intensive care, general medicine, and emergency department areas [19]. For the alarm-related events reported to The Joint Commission, major contributing factors included [19] : Absent or inadequate alarm system(s). Improper alarm settings. Alarm signals that were not audible in all areas. Alarm signals inappropriately turned off. EBP alert! Research shows that the preceding factors have contributed to alarm-related problems. All nurses must be familiar with research findings related to this issue and be advocates for the reduction of alarm-related incidents [19]. Additional factors that contributed to alarm-related sentinel events have been identified by The Joint Commission. These include [19] : Alarm fatigue. Alarm settings that have not been customized to the individual patient or patient population. Inadequate staff training or education on the proper equipment use and functioning. Inadequate staffing to support or respond to alarm signals. Alarm conditions and settings that are not integrated with other medical devices. Equipment malfunction and failure. EBP alert! Research shows that alarm fatigue is the most common contributing factor related to alarm-related sentinel events. Thus, all clinicians must take every possible action to resolve the problem of alarm fatigue [19]. So now we know the major factors that contribute to alarm-related adverse events. What do we do about them? The Joint Commission, the Association for the Advancement of Medical Instrumentation (AAMI), and ECRI Institute have compiled a number of recommendations for the reduction of patient harm related to alarm systems [2,19] : Organizational leadership must ensure that there is a process for safe alarm management and response in high-risk areas identified by the organization. Prepare an inventory of alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions. Identify the default alarm settings and the limits for such devices. Establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas and for high-risk clinical conditions. Alarm alert! When establishing such guidelines, include identification of situations when alarm signals are not clinically necessary [19]. Establish guidelines for tailoring alarm settings, and limits for individual patients. These guidelines should address situations when limits can be modified to minimize alarm signals, and the extent to which alarms can be modified to minimize alarm signals. Inspect, check, and maintain alarm-equipped devices to provide accurate and appropriate alarm settings, proper operation, and detectability. Alarm alert! The frequency of inspection, checking, and maintenance activities should be based on established criteria such as manufacturers recommendations and risk levels [19]. All members of the clinical care team should receive education and training on the organization s process for safe alarm management and response in high-risk areas, and on the safe use of the alarmed medical devices on which they rely. To help in the reduction of nuisance alarm signals, it is recommended that single-use sensors be changed according to manufacturer s recommendations, unless contraindicated. Assess the acoustics in the patient environments to determine if critical alarm signals are audible. Organizational leadership must re-establish priorities for the adoption of alarm technology. Note that the priority-setting process Page 43

46 should drive technology adoption rather than allowing technology to drive priority-setting. Establish a cross (interdisciplinary) team that includes representation from clinicians, clinical engineering, information technology, and risk management to address alarm safety and the potential impact of alarm fatigue in all patient care areas. Never ever events What does the term never ever event mean? First introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), the term never ever event is used to describe especially shocking medical errors (such as wrong-site surgery) that should never occur. The list of never ever events has grown over time to include adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable [21]. The current list, revised in 2011, consists of 29 events, grouped into seven categories [21] : Surgical events. Product or device events. Patient protection events. Surgical events Carolyn is a young nurse who is about to begin her dream job as a surgical nurse in a prestigious operating theater at a major metropolitan medical center. She has had three years of experience as a staff nurse on a large post-operative surgical unit, and has recently completed her operating room orientation. Today she and her colleagues are dealing with a heavy caseload of outpatient surgeries. The next patient is scheduled to have a partial mastectomy of the right breast. Dr. Marlene Mason, the surgeon scheduled to perform the operation, has a reputation of being a bully and verbally abusive to the nurses working with her. One of Carolyn s colleagues whispers a warning to her, Be alert today. This is Mason s fourth case today and she s in a horrible mood. One of her patients went downhill during surgery this morning and died soon after the surgery was completed. Dr. Mason enters the operating room and immediately begins complaining about the way the nurses have set up the room. She spots Carolyn and groans, Don t tell me I have to deal with some new kid that doesn t know what she s doing. I need competent help in here! OK let s get this over with. It s a simple partial mastectomy of the left breast so even you should be able to deal with it. Carolyn is horrified and explains that the procedure is to be performed on the right, not the left, breast. The surgeon becomes agitated and accuses Carolyn of insubordination and orders her from the room. Get out! Don t you think I know what I m doing? It s the left breast! She shoves Carolyn towards the exit as Carolyn s supervisor arrives. The supervisor clarifies that the surgery is to be performed on the right breast and tells the operating room team to take a time out until this situation is under control. The preceding example is an example of a never ever event that is on the verge of occurring. Unfortunately, healthcare professionals are not strangers to circumstances that are out of control. The response to such circumstances is to ALWAYS act in the best interest of the patient. Carolyn acts appropriately in the best interest of the patient to avoid the tragic occurrence of a never ever event. Surgical never ever events include [21] : Surgery or other invasive procedure performed on the wrong body part. Surgery or other invasive procedure performed on the wrong patient. Wrong surgical or another invasive procedure performed on a patient. Unintended retention of a foreign object in a patient after a surgery or another procedure. Intra-operative or immediate postoperative/post-procedure death in an American Society of Anesthesiologists Class I patient. Share information about alarm-related incidents with appropriate organizations such as The Joint Commission, the Food and Drug Administration, AAMI, and the ECRI Institute. Nursing consideration: All staff nurses should be encouraged to contribute input to the development of safe alarm management. They must also be encouraged to seek membership on appropriate councils that address patient safety and quality. Care management events. Environmental events. Radiologic events. Criminal events. The never ever sentinel events most often reported to The Joint Commission are [21] : Wrong-site surgery (13.5 percent). Suicide (12 percent). Op/post-op complications (11 percent). Delay in treatment (8.3 percent). Medication error (8.2 percent). Patient fall (6.3 percent). Nursing consideration: All nurses, not just those who work in the surgical suite, must be aware of surgical never ever events. All nurses contribute, to some extent, to the prevention of surgical never ever events. Fortunately, wrong-site, wrong-procedure, and wrong-patient surgery (WSPE) events are relatively rare. Research suggests that such errors occur once out of every 112,000 surgical procedures. To put this in perspective of individual hospitals, this statistic means that an individual hospital would only experience one such error every five to ten years. However, this estimate is based on procedures performed in the operating room. If procedures performed in other settings (such as ambulatory surgery centers) were included, the rate of such occurrences may be significantly higher [22]. The Joint Commission has developed a universal protocol for the prevention of WSPEs. The following is a summary of the critical factors of this protocol taken directly from the organization s website. For the complete protocol, access The Joint Commission website: [23]. Conduct a pre-procedure verification process. Verify the correct procedure, for the correct patient, at the correct site. When possible, involve the patient in the verification process. Identify items that must be available for the procedure. Use a standardized list to verify the availability of items necessary for the procedure. Match the items that are to be available in the procedure area to the patient. Mark the procedure site. For spinal procedures, mark the general spinal region on the skin. Special intraoperative imaging techniques may be used to locate and mark the exact vertebral level. Mark the site before the procedure is performed. If possible, involve the patient in the site marking process. The site is to be marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, site marking may be delegated to some medical residents, physician assistants, or advanced practice registered nurses. Page 44

47 Ultimately, the licensed independent practitioner is accountable for the procedure, even when delegating site marking. The mark must be unambiguous and used consistently throughout the organization. The mark is to be made at or near the procedure site. The mark should be sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site. For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site, use your organization s written, alternative process to ensure that the correct site is operated on. Perform a time-out. Note that the procedure is not to start until all questions or concerns are resolved! Recall that a time-out was called in the sample scenario at the beginning of this section in order to resolve the conflicts that were occurring. Conduct a time-out immediately before starting an invasive procedure or making an incision. A designated team member starts the time-out. The time-out is to be standardized. Product or device events A senior year nursing student is providing patient care to a woman who is on mechanical ventilation following a severe car wreck. The student notices that the safety inspection tag on the ventilator expired a few weeks ago. She also notices that her patient has developed a low-grade fever. Could there be some type of contamination of the ventilator? The student reports her findings to the staff nurse responsible for the patient who tells her, Oh, it s not the ventilator. Bio-engineering is so busy that sometimes they can t check every single piece of equipment on time. It s only a couple of weeks late. Unfortunately, the patient s condition deteriorates, and it is determined that the ventilator was harboring bacteria that led to the patient developing pneumonia. The preceding scenario is an example of a never ever that should have been prevented. According to the National Quality Forum s Health Care Never Events, product or device events include [21] : Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting. Patient protection events Mr. Burns is 92 years old and is being discharged from the hospital today following treatment for pneumonia. He has had trouble understanding his discharge instructions. He also displays problems with short-term memory and the ability to perform self-hygiene. Mr. Burns is a widower and his only child, a daughter, lives nearly 700 miles away. Should Mr. Burns be discharged to his home? What obligations do his caregivers have to protect his safety after discharge? This scenario is a good example of a potential patient protection event. Discharging Mr. Burns without further assessment of his ability to function safely at home, or an assessment of his home environment and resources would be negligent. His caregivers have an obligation to ensure his safety. Current assessment indicates Mr. Burns may be unable to make decisions and live safely in his home environment. Patient protection events are among the never ever events identified by the National Quality Forum. These include [21] : Discharge or release of a patient/resident of any age, who is unable to make decisions, to anyone other than an authorized person. Care management events The administrative team and members of the quality/risk management council are meeting under emergency circumstances. A patient has The time-out involves the immediate members of the procedure team including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. During the time-out, the team members must agree, at a minimum, on the correct patient identity, correct site, and the correct procedure to be conducted. When the same patient has two or more procedures, if the person performing the procedure changes, another time-out needs to be performed before starting each new procedure. Document the completion of the time-out. The amount and type of documentation is to be determined by the organization. Surgical event alert! As of October 1, 2015 there were 92 wrongpatient/wrong-site/wrong-procedure errors reported to The Joint Commission for the 2015 calendar year [25]. Author s note: The remainder of the National Quality Forum s Healthcare never ever events are summarized in the following sections [21]. Because of, in part, their scope and number, generalized suggestions for achievement are provided. Patient death or serious injury associated with the use of or function of a device in patient care, in which the device is used for functions other than as intended. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting. Nursing consideration: Some suggestions for preventing the preceding never ever events include [21,24] : Remain alert to any drugs, devices, or biologics that have expired expiration or inspection dates, and take immediate action to remove/replace/check such items as appropriate. Monitor all equipment for any evidence of malfunction, and take immediate action to replace/repair such equipment. Monitor connections between catheter connections to prevent air embolism. Patient death or serious disability associated with patient elopement (disappearance). Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility. Nursing consideration: Nurses must work collaboratively with all members of the healthcare team to develop and implement policies and procedures to ensure that patient protection events do not occur. These policies and procedures should include [21,24] : Assessment of a patient s ability to make decisions, including his/her ability to return to a safe environment after discharge. Implementing safeguards to avoid patient elopement from the healthcare setting. Assessment of a patient s mental health, including assessment for suicidal ideation. Such assessment should be conducted on all patients. died as the result of a serious medication error. Some members of the council want to fire the nurse who made the error and blame the Page 45

48 entire tragic adverse event on her. Other council members point out that the error was not just one person s fault, but a combination of events resulting from a flawed medication administration process. A true organizational culture of safety does not play the blame game. An error is seldom the fault of one person. Persons who are interested in improving patient safety should look to improve the processes and systems that are the foundation of any healthcare organization functions. Never ever care management events include [21] : Patient death or serious injury associated with a medication error. Patient death or serious injury associated with unsafe administration of blood products. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy. Artificial insemination with the wrong donor sperm or wrong egg. Patient death or serious injury associated with a fall while being cared for in a healthcare setting. Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a healthcare facility. Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, and/or radiology test results. Nursing consideration: The preceding care management never ever issues are broad in scope and numerous in number, and affect many aspects of patient care. Preventing these events includes following policies and procedures, improving patient/family education, assessing the effectiveness of patient/family education, ensuring excellent communication and collaboration among healthcare team members, and participating in continuing education and training to keep knowledge and skills current [2,21,24,26]. Environment events Environmental never events include [21] : Patient death or serious injury associated with an electric shock while being cared for in a facility, excluding events involving planned treatments such as electric counter-shock. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. Patient death or serious injury associated with a burn incurred from any source while being cared for in a facility. Patient death or serious injury associated with the use of or lack of restraints or bedrails while being cared for in a facility. Radiologic events The specific factor identified in the radiologic event category is the introduction of a metallic object into the MRI area associated with the death or serious injury of a patient or staff member [21]. It is imperative Criminal events Criminal never ever events include [21] : Any incidence of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider. Abduction of a patient/resident of any age. Death or significant injury of a patient or staff member resulting from a physical assault that occurs in or on the grounds of a healthcare setting. Additional safety concerns identified by the ECRI Institute As mentioned earlier, the ECRI Institute compiles an annual list of the top ten safety concerns for healthcare organizations. In 2015, the number one identified concern was alarm hazards, which has been discussed in detail. But what are the remaining nine concerns? A summary of the ECRI Institute s additional nine concerns follows. It is likely that these concerns are of importance to most, if not all, healthcare organizations. 1. Data integrity: Incorrect or missing data in EHRs and other health IT systems. Information technology (IT) can help to improve communication, provide swift access to essential data, and reduce errors for all members of the healthcare team. However, in order for IT to improve safety, a system must be in place to ensure that data in the electronic healthcare records (EHRs) are accurately and appropriately transferred to the various IT systems within an organization. Nursing consideration: Prevention of environmental events involves teamwork among clinical and non-clinical staff members. If equipment is malfunctioning, it should be immediately removed from service, and the appropriate department notified for repair and/ or replacement. If a piece of equipment has outdated safety check documentation, the appropriate department must be notified for repair and/or replacement. The use of any type of restraining device must strictly adhere to legal mandates and organizational policies and procedures [2,21,24,26]. that anyone working with a patient undergoing an MRI be alert to the introduction of any metallic objects in the MRI area. A checklist must be completed to assure patient eligibility for this procedure. The leadership of all healthcare organizations must have policies and procedures in place to ensure that all persons working in or having privileges to work in a facility have the appropriate licenses and credentials to fulfill the roles for which they have been hired. Appropriate security must be in place to prevent patient/resident abduction and/or physical assault. Policies and procedures must also address what to do in the event of acts of (or threatened acts of) violence so that patients, visitors, and staff members are kept as safe as possible. Education and training should be provided regarding how to deal with violence in work settings [2,21,24,26]. According to the ECRI report, examples of data integrity failures include [2] : Appearance of one patient s data in another patient s record. Missing data or delayed data delivery. Clock synchronization errors between medical devices and systems. Default values used by mistake. Fields pre-populated with erroneous data. Inconsistencies in patient information when both paper and EMR are used. Outdated information copied and pasted into a new report. Page 46

49 Nursing consideration: Nurses and their colleagues must remember to evaluate any IT issues that may and can contribute to an adverse event. Data entry is only as accurate as the person who is entering the information. The configuration of the IT system must also be evaluated. How easy is it to have multiple patient records open on a user s screen at one time? What, if any, are the identification checks to make sure that data is entered for the correct patient? How easy is it to cut and paste information? How can old or no longer accurate information be deleted from the active portion of a patient s record? These are just some of the questions that arise when reviewing the role IT may play in errors. Nurses must be vigilant in assisting in the evaluation of the IT process in their organizations and in the effectiveness of EHRs. 2. Managing patient violence. EBP alert! Research shows that workers in healthcare and social assistance settings are five times more likely to be victims of nonfatal assaults or violent acts than average workers in all other occupations [27]. This makes managing workplace violence imperative, and a top priority in the healthcare setting. A current review of the literature indicates that violence occurs in all healthcare settings, not just in the emergency department (ED) [2]. The ECRI Institute lists Managing Patient Violence as number three in their 2015 list of top ten patient safety concerns. The report suggests the following actions to help manage/prevent patient violence [2] : Acknowledge that the problem of violence is occurring in all healthcare organizations/facilities and is not limited to specific areas such as the ED. Provide all staff with training and education in de-escalation strategies, behavioral health, and management strategies when physical violence is threatened or actually occurring. Hire adequate security staff. Develop and implement a facility-wide safety plan that considers all levels of risk, from a single acute episode, to an active shooter, to a threat that requires evacuation of the facility. 3. Mix-up of IV lines leading to misadministration of drugs and solutions. The risk of IV line mix-ups is more likely in critical care areas where multiple lines are often in place. However, the risk exists in all healthcare settings where patients or residents (e.g. long-term care residents) may need several types of medication [2]. The ECRI Institute recommends the following actions to prevent IV infusion-line confusion [2] : Trace all lines back to their origin before making connections. Develop and implement a policy and procedure for positioning different lines on different sides of the patient. Label each infusion line with the name of the drug or solution being infused. Do not force connections. If force is required, it should probably not be connected. Nursing consideration: Since nurses are those who administer drugs or solutions via IV lines, this safety concern is especially critical to their practice. Incorporating ECRI Institute recommendations into applicable policies and procedures should help to avoid IV line mix-ups. 4. Care coordination events related to medication reconciliation. The ECRI Institute has identified medication reconciliation as its fifth top ten patient safety concerns [2]. The prevention of medication errors is an ongoing healthcare concern, and medication reconciliation is of utmost importance. The Agency for Healthcare Research and Quality has identified the following recommendations for accurate medication reconciliation [28] : Develop a single medication list that is shared by all disciplines for documenting the patient s current medications. Clearly define roles and responsibilities for each discipline involved in the medication reconciliation process. Standardize the medication reconciliation process throughout the organization. Simplify the medication reconciliation process as much as possible by eliminating unnecessary redundancies. Make the right thing to do the easiest thing to do within the parameters of normal legal practice. Develop effective prompts or reminders for consistent behaviors as they pertain to the medication reconciliation process. Educate patients, families, or other caregivers on the medication reconciliation process. Ensure that the medication reconciliation process meets all pertinent legal and regulatory requirements. Nursing consideration: Note that medication reconciliation can be problematic upon admission to acute care or outpatient facilities unless the patient and/or family have kept accurate records of the patient s medications. It should be a top nursing priority to educate patient and family about the necessity of keeping thorough and accurate medication records. This includes not only prescription medications, but over-the-counter medications, vitamins, minerals, herbal preparations, and any other supplements being taken. 5. Failure to conduct independent double checks independently. Failure to conduct truly independent double checks can, and does lead to errors. The ECRI Institute recommends the following recommendations to make sure that independent double checks are completed [2] : The second patient care provider who is performing the double check needs to look at all facets of the process including patient identity, indication and appropriateness, drug or blood type, dose, programmed infusion rate, and route. The second provider should not receive conclusions from the first provider. For example, suppose the first provider says to the second provider, I get a dose of 5,000 units of heparin. What do you calculate? The second provider already has a clue about what he or she thinks the answer should be. The second provider should calculate the dosage without hearing what the first provider calculated. Obtain staff buy-in for the independent double check process. Risk management and research findings regarding errors linked to the failure to adhere to independent double checks should be shared with clinical staff. Investigate systems processes and issues. The organization should be prudent when determining which processes require independent double checks. 6. Opioid-related events. EBP alert! The use and prescription of opiates has increased dramatically in recent years. So has opioid misuse and abuse. In fact, in 2011, the number of ED visits related to opioid misuse and abuse were over 420,000. This is double the number of visits recorded in Therefore, nurses and other patient care providers must be alert to the likelihood of encountering patients who may be misusing or abusing opioids [2]. The ECRI Institute identified two issues of major concern regarding opioid prescriptions and the potential for opioidrelated events. First, there is a concern that prescribers are ordering the same amount of hydromorphone as they would morphine, even though hydromorphone is about seven to Page 47

50 Page 48 seven and one half times as potent as morphine. This can lead to overdose and dangerous adverse effects [2]. The second issue is that prescribers sometimes do not differentiate between patients who are opioid-tolerant (defined as patients who have been taking an opioid of a threshold dosage for at least one week) from those who are described as opioid-naïve (meaning patients who have not been taking an opioid of a threshold dosage for at least one week). Failure of prescribers to consider these two issues of major concern can lead to serious, even fatal consequences [2]. Nursing consideration: Research shows that patients may share their opioid medications with family members or friends. Research also shows that family members and friends may help themselves to such medications without the patient s knowledge or consent. It is imperative that nurses educate patients and families regarding the dangers of opioid misuse [2]. In order to reduce/avoid opioid-related events the ECRI Institute recommends that [2] : Prescribers participate in continuing education regarding safe opioid prescribing and the potential dangers of failing to adhere to safe-prescribing standards. All healthcare professionals should participate in continuing education regarding safe opioid prescribing as well as recognition of opioid use, misuse, and abuse, and strategies to intervene. Patients and families must be educated about opioid safety including how to properly store and dispose of opioids. Healthcare organizations must monitor their adverse events for evidence of opioid-related events, and take steps to prevent their occurrence. 7. Inadequate reprocessing of endoscopes and surgical instruments. Even though endoscopes and surgical instruments are extremely difficult to clean (requiring multiple steps to ensure cleanliness), healthcare organizations reprocess thousands of reusable surgical instruments and devices on a daily basis. Failure to thoroughly clean such devices may allow organisms to remain on the devices (i.e. fomite ). Some organisms may not be affected by disinfection or even sterilization. Even if thorough cleaning is accomplished, organisms may grow if equipment is not thoroughly dried.2 In other words, reprocessing requires thorough cleaning, disinfection, sterilization (as appropriate), and drying. The Association for the Advancement of Medical Instrumentation (AAMI) suggests the following steps to improve the quality of medical device and surgical instrument reprocessing [29] : Cleaning and disinfection/sterilization of reusable devices are separate but equally important actions that must be performed before each patient use according to manufacturer s written instructions for use of the device. Follow the manufacturer s instructions for cleaning, disinfection, and/or sterilization of devices. Create a multidisciplinary committee to review priorities and establish a plan for implementing them. Representatives should be sourced from the operating room, infection control, healthcare technology management endoscopy, risk management, quality improvement, safety, education, and materials management groups and teams. Share lessons learned with other healthcare organizations and learn from other organizations as well. Establish formal written procedures for reprocessing. Know and implement the current standards, recommended practices, and manufacturer s written instructions for use. Include central sterile processing in the act of purchasing decisions for medical devices. Separate and standardize functions and locations. In other words, separate central service from reprocessing. Train and educate staff regarding appropriate reprocessing. Assess organizational compliance with standards and regulations. Examples of tools for assessment can be found at: fda.gov/medicaldevices/deviceregulationandguidance. 8. Inadequate patient handoffs related to patient transport. Research shows that when a patient is transported within the healthcare facility to another clinical setting or between units within the facility, a risk for harm exists [2]. But transport does not pose the only danger as the change of shift report (also a form of handoff ), if not performed correctly, also can endanger the patient [30]. Handoff is defined as the process of transferring responsibility for patient care. Sign-out is the act of relaying information regarding the patient [30]. The risks involved with handoff and sign-out vary with the acuity of the patient. However, even so called low-risk patients are at risk if the processes of handoff and sign-out are not executed accurately. The Joint Commission requires that each patient handoff communication include a standardized interactive approach to promote safe transfers. The ECRI Institute s report on the 2015 top ten safety hazards identifies several recommendations to build a process that enhances safety and reduces risk during handoff and sign-out [2,30]. Include transport-related incidents (including handoff and signoff information) as part of adverse event, and near-miss adverse event, reporting. Identify units and areas that are most often involved in transport and safety hazards. Establish criteria for determining the level of transport needed. Ensure that the necessary equipment is available for transport and that responsibility has been assigned for maintenance of therapies, and troubleshooting of equipment problems during transport. Determine the training, competency, and experience required of personnel performing the transport, and ensure that those personnel possess such training, competence, and experience. Develop and implement tools, forms, and checklists that facilitate handoff communication among all team members. 9. Medication errors related to pounds and kilograms. Errors involving mix-ups between pounds and kilograms often occur in emergency departments, but can occur in any setting, including the home. These kinds of errors generally involve pediatric patients, whose small bodies often react quite adversely, even fatally, to an inaccurate mediation dose [2,31]. Pediatric drug doses are weight-based, and the recommended doses are administered in relation to weight in kilograms. However, in many healthcare settings, children are weighed in pounds, and medication measurements must then be converted to kilograms. This conversion can be inaccurately calculated, thus leading to medication errors [31]. The Emergency Nurses Association s (ENA) position statement in support of weighing pediatric patients only in kilograms includes the following information [31]. Pediatric weights should be measured and documented in kilograms only. Scales used to weigh pediatric patients should be configured to only record weights in kilograms. Pediatric weights should be documented in a prominent place on the medical record. Electronic medical records (EMR) should be standardized to allow only kilograms for pediatric weight entries.

51 The actual weight of the pediatric patient should be considered to be part of the mandatory nursing assessment unless patients need resuscitation or emergent stabilization. For the pediatric patient needing resuscitation or emergent stabilization, there should be a standard method of estimating weight in kilograms. The pediatric patient s weight in kilograms must be included in an interdisciplinary or intradisciplinary patient handoff report. Nursing consideration: Note that the weight in kilograms must be utilized as a function of all handoffs to facilitate safety, and decrease adverse effects related to handoffs and sign-outs. The ECRI Institute offers these suggestions for reducing the risk of medication errors related to pounds and kilograms [2]. Hospital-acquired conditions The phrase hospital-acquired condition (HAC) refers to conditions that patients acquire while receiving treatment for another condition in an acute care health setting [32]. On July 31, 2008, in the Inpatient Prospective Payment System (IPPS) Fiscal Year 2009 Final Rule, the Centers for Medicare and Medicaid Services (CMS) included ten categories of HACs that, if they occurred, were not reimbursable by Medicare [33]. These categories are, for most if not, all organizations, never ever events as well. As of 2015, the list of categories has been expanded to 14 and include the following items [33] : Foreign object retained after surgery. Air embolism. Blood incompatibility. Stage III and IV pressure ulcers. Falls and trauma. Fractures. Dislocations. Intracranial injuries. Crushing injuries. Burn(s). Other injuries. Manifestations of poor glycemic control. Diabetic ketoacidosis. Non-ketotic hyperosmolar coma. Hypoglycemic coma. Secondary diabetes with ketoacidosis. Secondary diabetes with hyperosmolarity. Catheter-associated urinary tract infection (CAUTI). Vascular catheter-associated infection. Foreign object retained after surgery The problem of surgical items accidentally left inside the body after surgery has existed since the beginning of the practice of surgery. The contemporary preferred term for this problem is Retrained Surgical Items (RSI) rather than retained foreign bodies, or objects, or URFOs [35]. Nursing consideration: Retained objects are usually detected immediately after the procedure by X-ray, during routine follow-up medical visits, or from the patient s reports of pain or other forms of discomfort [34]. However, RSIs can be discovered hours to years after the initial operation [35]. Therefore, nurses must remain alert to the possibility of RSI and always ask patients about any history of surgical procedures during nursing assessment. The most frequent retained surgical items are [34] : Soft goods, such as sponges and towels. Small miscellaneous items, including un-retrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters, and pieces of drains. Ensure that pediatric scales (calculated in kilograms) are readily available in all areas of the organization. Document and display weights only in kilograms in the electronic healthcare record (EHR). Integrate digital scales with the HER to eliminate or reduce the need for data entry. Use clinical decision support functions that compare recorded weights with expected weights. Purchase infusion pumps with dose error reduction components. Avoid storing any high-alert drugs or other medications that have the potential to cause patient harm if weight-based doses are miscalculated in clinical areas. Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG). Surgical site infection following bariatric surgery for obesity. Laparoscopic gastric bypass. Gastroenterostomy. Laparoscopic gastric restrictive surgery. Surgical site infection following certain orthopedic procedures. Spine. Neck. Shoulder. Elbow. Surgical site infection following cardiac implantable electronic device (CIED). Deep vein thrombosis (DVT)/pulmonary embolism (PE) following certain orthopedic procedures. Total knee replacement. Hip replacement. Iatrogenic pneumothorax with venous catheterization. Nursing consideration: Beginning in fiscal year 2015, the HAC reduction program mandated by the Affordable Care Act, requires the CMS to reduce hospital payments by one percent for hospitals that rank among the lowest-performing 25 percent in regards to HACs [32]. Thus, it is essential that all nurses be especially vigilant in preventing HACs. They must also appreciate where their organizations stand in regard to HAC performance. It is important that nurses be familiar with policies and procedures established to prevent HACs in their organizations. This educational program provides information to support nurses in their efforts to reduce/prevent HAC occurrence. Nails and other sharps. Instruments, most commonly malleable retractors. Research shows that the retention of surgical items has significant monetary implications. The Pennsylvania Authority estimated that the average total cost of care related to the retention of such items is about $166,000, which includes legal defense, indemnity payments, and surgical costs not reimbursed by the CMS. Other studies estimate that the medical and liability costs are $200,000 or more per incident [34]. What are the most common root causes of RSIs reported to The Joint Commission? These causes are [34] : Absence of policies and procedures. Failure to comply with existing policies and procedures. Problems with hierarchy and intimidation. Communication failure with the physicians. Failure of staff members to communicate important patient information. Inadequate or incomplete staff education. Page 49

52 In the October 17, 2013 Sentinel Event Alert [34], The Joint Commission recommended a number of strategies to reduce RSIs and improve safety. A summary of some of the most essential information follows. For the complete report, access this online pdf: assets/1/6/sea_51_urfos_10_17_13_final.pdf. Establish effective processes and procedures. Establish a reliable and standardized counting system. Develop and implement effective evidence-based, organization-wide standardized policies and procedures for the prevention of RSIs. Establish an effective counting procedure. The Joint Commission directly recommends that a counting procedure should [34] : Be performed audibly and visibly by two persons engaged in the process. The surgical team should verbally acknowledge verification of the count. Include counts of items added to the surgical field throughout the surgery or procedure. Include counts of soft goods, needles/sharps, instruments, and small miscellaneous items. The team should document unretrieved device fragments. Verify that counts printed on prepackaged sponges and instrument sets are correct. Handle any discrepancies according to the organization s policy. Be performed before the procedure begins in order to establish a baseline count; before the closure of a cavity within a cavity; before wound closure begins; at skin closure or end of procedure; and at the time of permanent relief of either the scrub person or the circulating registered nurse. Be applicable in all settings where invasive procedures are performed. Be reviewed periodically and revised as appropriate. Air embolism Intravascular air embolism is a preventable HAC that occurs when air enters the vascular system [36,37]. Air embolism is a serious, lifethreatening event. It occurs when there is a direct connection between a source of air and the vascular system, and the pressure gradient allows the entry of this air into the bloodstream [37]. Common causes of air embolism include [36,38] : The entry of air through open intravenous (IV) and infusion systems. Examples include disconnection and open stop-cock. EBP alert! Research shows that the amount of air that enters the vascular system is influenced by the patient s position, and the height of the vein in relation to the right side of the heart [36]. Thus, nurses must be aware of proper patient positioning at all times! Infusion lines that are not properly filled or completely vented. During parallel infusions where gravity and infusion pumps are connected together. Errors that occur during the performance of a pressure infusion. Air entering the intravascular system during surgical procedures that require the opening of the vascular system such as neurosurgical, vascular, gynecological, or orthopedic procedures. The Pennsylvania Patient Safety Authority has published the following suggestions to prevent air embolism associated with central venous access devices (CVADs) [37]. During insertion [37] : Place the patient in Trendelenburg position with a downward tilt of 10 to 30 degrees during central line placement. Avoid CVAD insertion during patient inspiration. If the patient is able, ask him/her to hold his/her breath and perform a Valsalva maneuver. Establish effective wound opening and closing procedures. Wound opening and closing procedures should include: Inspection of instruments for signs of breakage before and after use. Adherence to the organization s established counting procedure. Methodical wound exploration. Empowerment of any member of the operative team to call a closing time-out prior to the initial closing count to allow for an uninterrupted count. Perform intra-operative radiographs. Intra-operative radiographs should be performed: When the surgical count is incorrect [34]. When the operative procedure is determined by the surgical team to be at high risk for retained surgical items. Nursing consideration: If the counts remain unreconciled after initial radiologic examination, the surgical team should consider additional imaging or further wound exploration. Effective communication. Effective communication is essential. The Joint Commission recommends that an organization should institute team briefings and debriefings as a standard part of the surgical procedure. This allows any team member to express concerns regarding patient safety. Additionally, the surgeon should verbally verify the results of the counting procedure. Appropriate documentation. Document the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken if count discrepancies occur. Safe technology. The Joint Commission suggests that organizations research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration. After insertion [37] : Make sure that all catheters and connections are intact and secure. Occlude the catheter and/or the needle hub. Make sure that all self-sealing valves are functioning accurately. Ensure proper care and maintenance of CVADs by: [36,37,62,63] Making sure that all lumens are capped and/or clamped. Using Luer-lock connections for needleless IV ports and selfsealing valves. Using infusion pumps with air-in-line sensors for all continuous infusions. Completely priming all infusion tubing, and expelling air from syringes before any injection or infusion. Using an air-eliminating filter on infusion tubing sets whenever necessary. Removing air from infusion bags when infusing fluids using inflatable pressure infusors. Fully priming contrast media injectors. Checking for air prior to each injection. Tracing lines and double-checking all connections. Taking all steps necessary to prevent misconnections. Inspecting the insertion site, catheter, and all connections regularly to assess for any breaks or openings that could allow air into the system. Ensuring the integrity of the central line dressing surrounding the insertion site. Using caution when moving or repositioning the patient to prevent pulling on the central line and compromising the integrity of the closed system. Teaching patients and/or families how to manage infusion therapy. Page 50

53 During removal of CVAD [37,62,63] : Place the patient in Trendelenburg position. If this is not possible the supine position may be used. Position the catheter exit site at a height that is lower than the height of the patient s heart. Cover the exit site with gauze. Apply gentle pressure while removing the catheter in a smooth, slow, and constant motion. Ask the patient to hold his/her breath and perform a Valsalva maneuver as the last portion of the catheter is removed. If the patient is unable to do this remove the CVAD during patient expiration. Place pressure on the site until hemostasis occurs. A time frame of one to five minutes is recommended. Blood incompatibility It is 3PM, and the end of a particularly stressful eight-hour shift. Blood arrives from the blood bank for two patients: Mr. Robert Morino (who is Type A positive), and Mr. Roger Moran (who is Type A negative). Sandy, the RN responsible for the nursing care of both Mr. Morino and Mr. Moran is feeling stressed and anxious. It is snowing, and she wants to leave on time in order to be home before her young children arrive from their after-school activities. Without instituting the independent double check per hospital policy, Sandy begins administering the A positive blood to Mr. Moran, who quickly begins to have an adverse blood incompatibility reaction. The preceding scenario is truly a disaster that was waiting to happen. What are some things that contributed to this adverse event? Sandy is anxious and stressed and not focused on her work. Sandy failed to institute the independent double check required by hospital policy. The two patients had similar first and last names. The two patients had similar (yet different!) blood types. Blood incompatibility is preventable. What can nurses do to make sure that it does not occur? Let s start by reviewing what happens during an incompatibility reaction. There are four types of blood [39,40,41] : Type A (red blood cells (RBCs) have A-antigen proteins attached to them). Type B (RBCs have B-antigen proteins attached to them). Type AB (RBCs have both A-antigen and B-antigen proteins attached to them). Type O (RBCs have neither A- nor B-antigens). Blood is also classified by rhesus (Rh) factor. This is a specific RBC antigen in the blood. If this antigen is present, the blood type is Rh positive (e.g. such as in the case of Mr. Morino, who is A +). Absence of the antigen is classified as Rh negative. Most occurrences of blood incompatibility are due to human error. During an incompatibility reaction, the patient s immune system reacts Stage III and stage IV pressure ulcers In addition to the physical and emotional toll on patients, stage III and stage IV pressure ulcers carry a significant monetary burden as well. It is estimated that the cost of one stage III or stage IV pressure ulcer may be between $5,000 and $50,000 [44]. How are stage III and stage IV pressure ulcers described? Here are their determining characteristics [45] : Category/stage III: Full thickness tissue loss, although subcutaneous fat may be seen. Bone, tendon, or muscles are not exposed. Sloughing may be present, but it does not obscure the depth of tissue loss. There may be undermining and tunneling. The depth of this pressure ulcer depends on the anatomical location. For example, the bridge of the nose or the ear does not have (adipose) subcutaneous tissue and stage III ulcers in such locations can be shallow. However, in areas where there Apply a sterile occlusive dressing that remains in place for at least 24 hours. Change the dressing every 24 hours until the exit site has healed. Tell the patient to remain lying flat for 30 minutes after removal of the catheter. Nursing consideration: For the latest information on central line devices and other infusion issues access: The Infusion Nurses Society at index.cfm?pageid=1 The Association for Vascular Access at website/article.asp?id= against the wrong blood. The patient s immune system produces antibodies against any blood antigens not present in his/her own blood. Such a reaction can have serious, even fatal, consequences [39,40,41]. EBP alert! Research shows that the most serious transfusion complications occur within the first 15 minutes before, and the 15 minutes after initiation of each unit of blood. Thus, nurses must be particularly alert for reactions during these time periods [42]. Here are some suggestions for nurses to implement in order to avoid blood incompatibility reactions [39,42,43] : Facilitate the establishment of an interdisciplinary transfusion committee. This committee should include a transfusion safety officer. Ensure that policies and procedures relating to blood transfusion are reviewed and updated on an ongoing basis. Review the prescriber blood product ordering process. Review the patient s consent for blood product transfusion and make sure that the right for refusal appears on the consent. Ensure that there is a process for monitoring, tracking, and trending all blood samples for type and cross, type and hold, wrong blood in tube, mislabeled tubes, and issued blood components from the blood bank. Transfuse the patient within 30 minutes of blood product pick-up from the blood bank. Always confirm the identity of the patient using two identifiers. Institute independent double check per hospital policy. Double check the blood type of patients and the blood packs before each transfusion. Double check that all information (full patient name, address, blood type, etc.) on the label of the blood product matches the patient s information. Note that this means that the nurse MUST know the patient s blood type and other relevant information. Double check the blood product s label for expiration dates. Implement a bar code patient identification system as appropriate. is significant adipose tissue, ulcers can be exceptionally deep. Bone and/or tendon are neither seen nor are directly palpable. Category/stage IV: Full thickness tissue loss where bone, tendon, and/or muscle are exposed. Sloughing or eschars may be present, often with undermining and tunneling. The depth varies according to anatomical position. Ulcers may be shallow in areas that do not have (adipose) subcutaneous tissue (e.g. nose, ear). These types of pressure ulcers can extend into muscle and/or supporting structures such as fascia, tendon, or joint capsules, thus making osteomyelitis possible. Exposed bone or muscle is visible and/or directly palpable. Which patients are at risk for the development of pressure ulcers? Here are some factors that increase such risk. These are divided into Page 51

54 three primary areas including mobility/activity, perfusion (including diabetes), and skin/pressure ulcer status [44,46]. Advanced age: The elderly person s skin has less subcutaneous fat, which leads to decreased protection from pressure. Friction/ahear: Decreases the epidermal layer, reducing protection of the skin. Hypotension: Decreases the perfusion of local tissues, making skin more vulnerable to breakdown. Immobility: Lack of mobility can lead to sustained pressure on bony prominences. Length of stay in critical care units: The longer the length of stay is indicative of critical conditions associated with decreased mobility and/or position change, and increased shear force, all of which increase the risk for skin breakdown. Length of time on mechanical ventilation: Indicates inadequate oxygenation and the need to provide ventilation mechanically. Decreased oxygen levels means decreased oxygen to body tissues, including the skin. Moisture: Moisture (e.g. incontinence, sweat, failure to dry skin after bathing) contributes to skin breakdown, and in many cases, poor wound healing. Nutrition: Inadequate nutrition and decreased protein intake alters the proper state of the skin, contributing to skin breakdown. Pressure: The longer pressure is sustained, the more likely local tissue ischemia, edema, and tissue death occurs. Pressure scale risk scores: The higher the score on a pressure scale score, the greater the risk of pressure ulcer development. Vasoactive medications: Vasoactive medications, given to improve blood pressure, increase vasoconstriction, thus decreasing the perfusion of skin tissue. Falls and trauma Patient falls with serious injury are among the top ten sentinel events reported to The Joint Commission Sentinel Even Database. Since 2009, The Joint Commission has received 465 reports of patient falls with injuries. About 65 percent of those falls caused fatalities [47]. The Joint Commission reports that from January 2009 to October 2014, the most common contributing factors contributing to reported falls included [47] : Communication failures. Deficiencies in the physical environment. Failure to adhere to protocols and safety practices. Inadequate assessment. Inadequate staff orientation, supervision, staffing levels, or skills. Lack of leadership. EBP alert! Research shows that major factors to reduce falls and other adverse events are effective communication and interdisciplinary work [48]. Thus, nurses must work with their interdisciplinary colleagues to reduce/prevent falls. Suggestions for fall prevention include the following nursing interventions [47,48] : Establish an interdisciplinary fall team with representatives from all disciplines. Manifestations of poor glycemic control Nurses are essential to managing glycemic control for hospitalized patients. They perform and act on the results of blood glucose monitoring and medication administration. They also provide much of the patient/family education pertaining to glycemic management [49]. Research indicates that there are several factors that increase the risk of poor glycemic control in hospitalized patients. These include [49] : Insufficient nurse staffing. Nursing staff with excessive workloads. Page 52 Nursing measures to decrease the risk for pressure ulcer development include [44,46] : Performing skin assessment upon admission and at least once per shift thereafter. Skin inspection should be conducted more often on patients at high risk for pressure ulcer development. Document the results of all skin assessments. Identify patients at high risk for pressure ulcer development using a risk-identification scale. Incorporate results of skin assessment in change-of-shift reports and at any handoffs and sign-offs. Incorporate a schedule of turning and body repositioning, and document these actions. EBP alert! Research shows that shearing forces can be reduced by keeping the head of the bed no higher than 30 degrees [44,46]. Use appropriate positioning devices according to hospital policy and procedure. Keep skin warm and dry. Dry thoroughly after bathing. Remove skin secretions such as sweat and barrier creams. Use nonirritating, non-drying cleansing agents. Use moisturizers as appropriate. Keep bed sheets, clothing, etc., dry and wrinkle free. Take measures to avoid spasticity and contracture prevention. Ensure proper nutritional intake, especially protein. Promote mobility and self-position changes as appropriate. Remain alert to any skin changes (such as redness) that may suggest impending skin breakdown. Develop and implement policies and procedures to enhance safety and prevent falls. Implement a fall risk screening assessment. Assess patients on admission, and periodically throughout hospitalization. Determine if patient medications may cause dizziness, coordination problems, or other issues that may contribute to falls. Initiate fall prevention interventions such as providing the patients with no-slip socks, teaching them about the use of (and supervising the use of) mobility assistive devices, and making sure that the call bell is within reach, and that patients know how to use it. Create a culture of safety in which systems and process issues are evaluated as the primary causes of adverse effects, and in which open communication is supported. Initiate rounds at least hourly to evaluate the safety of the patients and their environments. Nursing consideration: If and when a fall does occur, a post-fall huddle should be conducted. This is done to evaluate: what risk factors for the fall existed: the circumstances surrounding the fall: and what measures should be taken to prevent future falls, including the review and revision of existing policies and procedures. Such a huddle is not conducted to cast blame, but to improve the culture of safety within the organization. Lack of effective and timely communication. Teaching hospitals in which inexperienced resident physicians may be providing care for complex, critically ill patients. EBP alert! Low nurse staffing undermines the culture of safety critical to the provision of safe and appropriate patient care. The organization s nurse leaders must evaluate staffing in terms of a culture of safety [49].

55 Suggestions for ensuring proper glycemic control include [49,50] : Establishing a system of interdisciplinary collaboration and open communication. Providing continuing education for nurses and physicians regarding glycemic control. Providing adequate patient/family education regarding glycemic control. Establishing policies and procedures that effectively guide glycemic control. Catheter-associated urinary tract infections Clara is a junior nursing student. She is taking care of a patient who has had an indwelling urinary catheter for three days. Clara is concerned about the possibility of infection, and asks the staff nurse responsible for the patient when it would be removed. The staff nurse is extremely busy and tells the student not to worry about a catheter when there are more urgent matters to attend to. Clara knows that hospital policy is that the catheter should be removed as soon as possible. She decides to talk to her instructor, and the resident physician when he sees the patient that morning. Are Clara s concerns valid? Are her actions appropriate? The answer to both questions is yes. Clara knows, as should all nurses, that hospital acquired catheter-associated urinary tract infections (CAUTIs) are a serious problem. A catheter-associated urinary tract infection (CAUTI) is considered to be a preventable complication by the Centers for Medicare and Medicaid Services and thus no additional payment is provided to hospitals for costs associated with CAUTIs. Unfortunately, CAUTIs are still the most common nosocomial infection. They account for up to 40 percent of infections reported by acute care hospitals. Such infections increases hospital costs and is linked to an increase in morbidity and mortality [51]. EBP alert! Research shows that [52] : 70 to 80 percent of CAUTIs are due to the presence of an indwelling urethral catheter. 12 to 16 percent of adult hospitalized patients will have a urinary catheter at some time during hospitalization. When an indwelling urethral catheter remains in place the daily risk of acquiring bacteria in the urinary tract varies from three to seven percent. Vascular catheter-associated infection More than five million patients require central venous access every year, and infection is the main complication of intravascular catheters in patients who are critically ill [53]. Every year, an estimated 250,000 cases of central venous catheter-associated blood stream infections occur in the United States. The cost per infection is an estimated $34,508-$56,000 [54]. Nurses and their interdisciplinary colleagues must make every effort to prevent such infections. The following interventions are important to the prevention of vascular catheter-associated infections: Hand hygiene. Proper hand hygiene is the most important infection control measure and the most effective way to prevent the transmission of healthcare associated infections [54,55]. Nursing consideration: Patients and families should be taught to observe if healthcare workers are washing their hands before and after providing patient care. They should be told to ask their healthcare providers to wash their hands if they have not done so. Monitoring blood glucose levels according to hospital policies and procedures, and intervening appropriately. Establishing an adequate system of nurse staffing to ensure adequate patient coverage. Ensuring that equipment used for blood glucose monitoring is in good working order and that all nurses know how to use such equipment. Nurses must do everything possible to find alternatives to insertion of indwelling catheters., If such catheterizations cannot be avoided, removal of indwelling catheters must be performed as soon as possible. Additional research findings show that [51] : The major risk factor for CAUTIs is prolonged catheterization. 25 percent of hospital in-patients, and up to 90 percent of patients in a critical care unit have a urinary catheter at some point during hospitalization. Unfortunately, such catheters are often inserted without an appropriate indication or remain in place after the need is no longer present. Most hospitals do not have effective strategies for preventing CAUTIs. Experts recommend the following actions to prevent CAUTIs [51,52] : Establish policies and procedures which include: indications for indwelling urinary catheterization, insertion guidelines, and limitation of insertion to those patients who meet criteria for use. All healthcare team members must document the indication for indwelling catheter placement upon admission, and daily. If the patient is admitted with a CAUTI, this must also be documented. Be sure that only trained, competent personnel insert urinary catheters. Provide education and training as needed. Ensure that supplies and equipment necessary for aseptic catheterization technique are readily available. Review the necessity of continuing indwelling catheters on a daily basis. Such catheters should be removed as soon as possible. Implement infection control surveillance programs which include the: development of any CAUTIs; and the development of appropriate action plans to reduce/prevent CAUTI occurrence. Nursing consideration: Nurses should ensure that indwelling catheters are properly secured to prevent movement and urethral traction. They must also ensure that a sterile, continuously closed drainage system is maintained [52]. The Centers for Disease Control and Prevention (CDC) and the Institute for Healthcare Improvement (IHI) both advocate that hand hygiene be performed before and after palpating the catheter insertion site; before and after inserting, replacing, accessing, repairing or dressing a venous access device; before donning and after removing gloves; when hands are visibly soiled or contaminated; before and after invasive procedures; and after using the bathroom. Palpation of the insertion site should not be performed after the application of skin antiseptics, unless aseptic technique is maintained [54]. Maximum sterile barrier precautions. Maximum sterile barrier precautions must be taken when inserting the venous catheter. These precautions include not only the person inserting the catheter, but anyone assisting with the procedure, and the patient as well [53,54]. Skin antisepsis. The IHI advocates the use of chlorhexidine skin antisepsis. The CDC prefers the use of a two percent chlorhexidine solution but a tincture of Page 53

56 iodine or 70 percent alcohol can be used [54]. Skin antisepsis should be performed at the time of insertion and with every dressing change [54,55]. Selection of catheter site. The site of insertion is important to optimal outcomes. The use of the subclavian site is preferred to the jugular or femoral sites in adults to minimize infection risk [54,55]. Dressing change. Dressings for insertion sites must be impermeable to water vapor. Use of sterile gauze, a sterile transparent, semipermeable dressing, or a chlorhexidine-impregnated sponge dressing that covers the catheter insertion site should be initiated. Topical antibiotic ointments or creams should not be applied to the insertion site because of the possibility of promoting fungal infections or pathogen resistance. Dressings are changed when they become wet, loose, or soiled. Surgical site infections The prevention of surgical site infections is imperative. In the operating room setting, breaks in sterility, and a failure to follow established protocols for infection control put the patients at risk for surgical site infections [56]. Some strategies to prevent surgical site infections include the following interventions [56,57] : Healthcare providers must cleanse their hands and arms up to their elbows with an antiseptic agent just prior to surgery. Healthcare providers must cleanse their hands with soap and water or an alcohol-based hand cleanser before and after caring for each patient. Deep vein thrombosis Deep vein thrombosis (DVT) affects about 350,000 Americans every year [59]. In the hospital setting DVT is listed as a preventable HAC. Nurses and other healthcare providers must first be aware of factors that place patients at higher risk for the development of DVT. These include [58] : Using birth control pills or hormone therapy. Having blood clotting disorders. Some malignancies. Increasing age. Being overweight or obese. Immobility. Personal or family history of DVT or pulmonary embolism. Pregnancy. Smoking. Having vein disease(s). CVAD dressing are generally changed weekly for a transparent semipermeable dressing, and every 48 hours for a gauze dressing [54]. Assessment and removal. The catheter should be removed as soon as it is no longer indicated. The risk for infection increases with the length of time the device is left in place, and decreases when the catheter is removed [54]. EBP alert! The risk for infection has declined with the standardization of aseptic care and the requirement that insertion and maintenance of catheters be performed by experienced staff members. Education of staff in the insertion and maintenance of intravascular catheters is required, and staff competency must be periodically evaluated. Nurses must demonstrate competency in the care of patients with vascular catheters [54,55]. If hair needs to be removed from the surgical site, an electric clipper must be used. A razor should NOT be used. Patients and families should be educated to not touch the surgical wound or dressings. Healthcare providers caring for patients after surgery should adhere to strict hand hygiene standards. They should also change dressings according established policies and procedures. Nursing consideration: As stated earlier in this education program hand hygiene is the most effective way to prevent infections. Nurses must help to ensure that all colleagues and visitors adhere to hand hygiene protocol. Strategies for the prevention of DVT include [58,59] : Administrating anticoagulant therapy as indicated. Promoting early movement and mobilization. Facilitating position change in patients who have difficulty moving themselves. Applying compression stockings or pneumatic compression devices as ordered and indicated. Teaching patients and families about the importance of early movement and position change. Nursing consideration: Most of the interventions to prevent DVT are easily implemented. However, busy nurses and other healthcare professionals may forget to implement tasks as simple as position change or teaching patients the importance of early movement and position changes. They must remain alert to the possibility of DVT development and how to prevent it! Iatrogenic pneumothorax with venous catheterization A pneumothorax is a collapsed lung, and the result of air leaking into the space between the lungs and the chest wall. In most cases of pneumothorax, only a portion of the lung collapses [60]. Pneumothorax can be due to [60,61] : Chest injuries. Underlying lung diseases. Ruptured lung air blisters. Mechanical ventilation. Certain invasive procedures, such as venous catheterization. Certain risk factors for pneumothorax include [60] : Age: Pneumothorax due to ruptured air blisters is most likely to occur in patients between 20 and 40 years of age. Gender: Men are more likely to have a pneumothorax than women. Genetics: Some types of pneumothorax seem to run in families. History of pneumothorax: A previous pneumothorax event predisposes an individual to experience another pneumothorax. Lung disease: Patients with underlying lung disease, particularly chronic obstructive pulmonary disease (COPD) are more likely to suffer a pneumothorax. Mechanical ventilation: Patients requiring mechanical ventilation are at higher risk for pneumothorax. Smoking: The risk increases with the number of cigarettes smoked as well as the length of time the patient has been smoking. Iatrogenic pneumothorax (iatrogenic means something that is accidentally caused during medical treatment or procedure) has been identified as a preventable HAC. Thus, it is important to be able to identify appropriate steps to take to prevent such occurrence during venous catheterization. Such steps include [61] : Page 54

57 Identifying patients at higher risk for pneumothorax during catheterization and being especially alert for problems. Ensuring the use of a standardized method of venous catheter insertion according to established policies and procedures. Ensuring that insertion is performed by physicians who have adequate experience in catheter insertion. Using ultrasound during catheterization to guide catheterization. Using ultrasound, chest radiography, and CT scanning for early recognition of pneumothorax. In summary Nurses must be familiar with HACs identified as preventable by the CMS and by organizations that emphasize safety and appropriateness of care. There are currently (as of this writing) 14 categories of HACs identified by the CMS. However, there may be additional categories identified in the future. There may also be additions to other never-ever events and these will most likely be revisions and additions to The Joint Commission National Patient Safety Goals. Nurses have a professional responsibility and moral obligation to keep themselves informed about current and future safety issues such as National Patient Safety Goals, never-ever events, and CMS identified preventable HACs. Thanks to modern technology, nurses Nursing consideration: In the event of a pneumothorax during the procedure, a standardized treatment algorithm for management of pneumothorax has been shown to improve outcomes and decrease the length of hospitalization. Nurses must work with the healthcare team to develop such an algorithm and be familiar with the interventions identified in the algorithm [61]. can access such information on relevant internet websites such as the CMS and The Joint Commission websites. Nurses also have a professional obligation to become involved in how their employing organizations address safety issues. They should volunteer for committees and task forces and act as patient advocates at all times. Nurses must support their organization s efforts to enhance safety and well-being of patients, visitors, and employees. In addition to adhering to safety mandates, they should help teach their colleagues how to establish and maintain a culture of safety. All employees are responsible for patient safety. Nurses are on the front-line of all safety initiatives and should act as leaders in the safety process. Page 55

58 References 1. Hospital Safety Score. (2013). Hospital errors are the third leading cause of death in U.S., and new hospital safety scores show improvements are too slow. Retrieved November 7, 2015 from ECRI Institute. (2015). Top ten patient safety concerns for healthcare organizations. Retrieved October 28, 2015 from 3. Patient Safety Network. (2014). National patient safety goals. Retrieved October 28, 2015 from psnet.ahrq.gov/resources/resource/2230/national-patient-safety-goals. 4. The Joint Commission (2015). Facts about the National Patient Safety Goals. Retrieved October 28, 2015 from Material.pdf. 5. The Joint Commission (2015). Facts about the Patient Safety Advisory Group. Retrieved November 6, 2015 from 6. The Joint Commission (2015) Hospital Patient Safety Goals. Retrieved November 7, 2015 from 7. Nursezone.com. (2010). Nurses, communication and patient safety. Retrieved November 9, 2015 from Safety_34498.aspx. 8. Medline Plus. (2015). Infection control. Retrieved November 10, 2015 from medlineplus/infectioncontrol.html. 9. Centers Diseases Control and Prevention (CDC). (2011). CDC report: Mental illness surveillance among adults in the United States. Retrieved December 30, 2011 from mental1healthsurveillance/fact_sheet.html. 10. The Joint Commission (2015). Home care National Patient Safety Goals. Retrieved November 7, 2015 from The Joint Commission (2015). Ambulatory Care National Patient Safety Goals. Retrieved November 6, 2015 from Pevtzow, L. (2013). New guidelines to reduce alarm fatigue. Retrieved November 11, 2015 from Appold, K. (2015). Noise complaint. The Hospitalist, 19(6), Retrieved November 11, 2015 from The Joint Commission (2015) Hospital National Patient Safety Goals. Retrieved November 14, 2015 from Advancement of Medical Instrumentation (AAMI). (2015). About AAMI. Retrieved November 14, 2015 from mber=1342&navitemnumber= Extension Health Care. (2015). The countdown is on: Complying with The Joint Commission alarm safety goal. Retrieved October 28, 2015 from countdown-complying-joint-commission-alarm-safety-goal//. 17. Hyman, W. A. (2014). A work plan for The Joint Commission Alarm National Patient Safety Goal. Journal of Clinical Engineering, 39(1), The Joint Commission (2015) National Patient Safety Goals. Retrieved November 15, 2015 from The Joint Commission (2015). The Joint Commission Sentinel Event Alert. Issue 50, April 8, Retrieved November 14, 2015 from alarms_4_5_13_final1.pdf. 20. Patient Safety Network. (PSNET). (2014). Never events. Retrieved October 28, 2015 from psnet.ahrq.gov/primers/primer/ Patient Safety network (PSNET). (2015). Wrong-site, wrong-procedure, and wrong-patient surgery. Retrieved November 15, 2015 from The Joint Commission (no date given). The universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Retrieved November 16, 2015 from jointcommission.org/assets/1/18/up_poster1.pdf. 23. Minnesota Department of Health. (2013). Minnesota s 29 reportable adverse health events. Retrieved November 17, 2015 from HCPro. (2015). Joint Commission: Procedure errors, retention of foreign body, suicide top sentinel event list. Accrditation Insider, November 16, 2015 Retrieved November 17, 2015 from hcpro.com/acc /joint-commission-procedure-errors-retention-of-foreign-body-suicidetop-sentinel-event-list.html. 25. McKeon, L. (2011). Preventing never events: What frontline nurses need to know. Nursing made Incredibly Easy, 9(1), Retrieved November 18, 2015 from nursingmadeincrediblyeasy/fulltext/2011/01000/preventing_never_events What_frontline_ nurses.10.aspx. 26. Hospitals & Health Networks. (2015). Addressing violence in the health care workplace. Retrieved November 18, 2015 from Agency for Healthcare Research and Quality (AHRQ). (2012). Medications and clinical handoffs (MATCH) toolkit for medication reconciliation. Retrieved November 18, 2015 from gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match3.html. 28. Pyrek, K. M. (2013). Improper reprocessing targeted as one of healthcare s most dangerous hazards. Retrieved November 19, 2015 from Patient Safety Network (PSNet). Handoffs and signouts. Retrieved November 27, 2015 from psnet.ahrq.gov/primers/primer/9/handoffs-and-signouts. 30. Sitko, E. R. (2013). Leading medication safety groups endorse position on weighing pediatric patients in kilograms. Retrieved November 30, 2015 from advanceweb.com/features/articles/avoiding-medication-errors.aspx. 31. Lake Superior Quality Innovation Network. (2015). Understanding the hospital-acquired condition reduction program. Retrieved November 30, 2015 from HAC_fact_sheet.pdf. 32. CMS.gov. (2015). Hospital-acquired conditions. Retrieved November 1, 2015 from gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html. 33. The Joint Commission Sentinel Event Alert. (2013). Preventing unintended retained foreign objects. Retrieved November 30, 2015 from URFOs_10_17_13_FINAL.pdf. 34. Nothing Left Behind. (2015). Retained surgical items. Retrieved November 30, 2015 from nothingleftbehind.org/. 35. [36] Safeinfustiontherapy.com. (2015). Causes of air embolism. Retrieved December 2, 2015 from int/hs.xsl/7701. html 36. [37] Pennsylvania Patient Safety Authority. (2012). Reducing risk of air embolism associated with central venous access devices. Retrieved December 2, 2015 from aspx. 37. IV Infusion Home. (2015). Air embolisms and IV therapy. Retrieved December 2, 2015 from ivinfusion.wordpress.com/2015/03/23/air-embolisms-and-iv-therapy/. 38. Colledge, H., & Boskey, E. (2015). ABO incompatibility reaction. Retrieved December 3, 2015 from Chen, Y.B. (2014). ABO incompatibility. Retrieved December 3, 2015 from medlineplus/ency/article/ htm. 40. Mesa, R. A. (2013). Blood transfusion: Is there a universal blood donor type? Retrieved December 3, 2015 from American Society of Registered Nurses. (2008). Blood transfusion error prevention: Nurses role. Retrieved December 3, 2015 from Pennsylvania Patient Safety Authority. (2010). Improving the safety of the blood transfusion process. Retrieved December 3, 2015 from AdvisoryLibrary/2010/Jun7(2)/documents/33.pdf. 43. Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit. Critical Care Nurse, 33(6), National Pressure Ulcer Advisory Panel (NPUAP). (2015). NPUAP pressure ulcer stages/categories. Retrieved November 4, 2015 from npuap-pressure-ulcer-stagescategories/. 45. Kirman, C. N., et al. (2015). Pressure ulcers and wound care treatment & management. Retrieved December 4, 2015 from The Joint Commission (2015). New sentinel event alert focuses on preventing falls. Retrieved November 7, 2015 from preventing_patient_falls/. 47. Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and improvement in high reliability organizations. OJIN: The Online Journal of Issues in Nursing, 18,(2). Retrieved November 6, 2015 from ANAPeriodicals/OJIN/TableofContents/Vol /No2-May-2013/Fall-Program-Measurement. html?css=print. 48. McHugh, M. D., Shang, J., Sloan, Dm. M., & Aiken, L. H. (2010). Risk factors for hospital-acquired poor glycemic control : A case-control study. Retrieved December 7, 2015 from nlm.nih.gov/pmc/articles/pmc /. 49. Durkin, M. T. (Ed.). (2013). Professional guide to diseases (10th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. 50. American Association of Critical Care Nurses (AACN). (2011). Catheter-associated urinary tract infections. Retrieved November 7, 2015 from cathassocuti-nov11.pcms?menu=practice. 51. Evelyn, L. et al. (2014). Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Retrieved November 8, 2015 from Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010). Prevention of central venous catheter-related infection in the intensive care unit. Retrieved November 8, 2015 from content/14/2/ Siegel, M., & Kramer-Cain, J. (2013). Vascular catheter-associated infections. Retrieved November 8, 2015 from Busby, S. R. et al. (2015). Assessing patient awareness of proper hand hygiene. Nursing2015, May, 2015, Safety Monitor. (2014). Infection prevention practices in ambulatory surgery centers. AJN, 114(7), CDC et al. (no date given). FAQs: Surgical site infections. Retrieved December 9, 2015 from American Academy of Orthopaedic Surgeons. (2015). Deep vein thrombosis. Retrieved December 9, 2015 from WebMD. (no date given). How to prevent deep vein thrombosis (DVT). Retrieved December 10, 2015 from Mayo clinic. Pneumothorax. Retrieved December 10, 2015 from Zarogoulidis, P. et al. (2015). Pneumothorax as a complication of a central venous catheter insertion. Retrieved December 10, 2015 from Agency for Healthcare Research and Quality (AHRQ). (2014). Appendix 3. Guidelines to prevent central line-associated blood stream infections. Retrieved February 15, 2016 from gov/professionals/education/curriculum-tools/clabsitools/clabsitoolsap3.html. 62. Agency for Healthcare Research and Quality (AHRQ). (2015). Why focus on central line-related bloodstream infections (CLASBSIs) Retrieved February 15, 2016 from default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4a-crbsi-bestpractice.pdf. Page 56

59 Patient safety: IMPLEMENTATION OF NATIONAL SAFETY STANDARDS FOR NURSES SELF ASSESSMENT Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your answer sheet. 1. The ECRI Institute has identified a number of safety concerns. Based on the Institute s report, which of the following statements accurately represents an identified safety concern? a. Research shows that patients may share their opioid medications with family members and friends. b. Cleaning and disinfection/sterilization of reusable devices represent the same action. c. Medication errors related to pounds and kilograms generally involve elderly patients. d. The nursing department should develop a patient medication list that is separate from the list shared by all disciplines. 2. In order to avoid air embolism associated with CVADs: a. Ask the patient to take a deep breath during CVAD insertion. b. Avoid clamping CVAD lumens. c. Avoid applying pressure while removing the catheter. d. Place the patient in Trendelenburg position during catheter placement. 3. To prevent surgical site infections healthcare providers: a. Must cleanse hands up to their wrists with antiseptic agents just prior to surgery. b. Should use a razor to remove hair from the surgical site. c. Teach patients not to touch surgical wound dressings. d. Avoid using alcohol-based hand cleansers since these dry the skin and promote skin breakdown. 4. A patient with type B negative blood: a. Has B antigen proteins and positive Rh factor. b. Has both B antigens and the Rh factor. c. Has neither A nor B proteins. d. Has both A and B proteins but no Rh factor. 5. The risk of poor glycemic control is increased by: a. Insufficient nurse staffing. b. Lack of timely communication. c. Lack of glycemic control experience by resident physicians. d. All of the above. 7. Actions that should be taken to avoid hospital acquired conditions include: a. Having the surgical team document unretrieved device fragments. b. Asking a patient to take deep breaths during the insertion of a CVAD. c. Knowing that the most serious transfusion complications occur within the first hour before and after initiation of each unit of blood. d. Recognizing that the femoral site is the preferred site in adults for venous catheter insertion. 8. Which of the following actions adheres to The Joint Commission recommendations for operating room counting procedure? a. One person performs an audible and visible counting procedure. b. A counting procedure is first performed at the time the surgical incision is made. c. Surgical team members include counts of items added to the surgical field throughout the surgery. d. The surgical team does not include soft goods in the count. 9. Which of these actions shows an accurately performed double check when blood product administration is required? a. The first nurse says to the second nurse This blood is labeled Type A positive. That s right isn t it? b. The first nurse asks a nursing assistant to verify the patient s identity. c. The first nurse asks a blood bank technician to verify the blood type while commenting that this getting a second check is a waste of time. d. The first nurse asks the second nurse to double check the accuracy of all of her preparations to administer a blood product. 10. The most effective way to prevent transfer of hospital acquired infections, including vascular catheter-associated infections, is: a. Skin antisepsis. b. Hand hygiene. c. Maximum sterile barrier precautions. d. Proper dressing changes. 6. Which of the following statements pertaining to iatrogenic pneumothorax is accurate? a. Ultrasound should be used during catheterization to guide catheterization. b. Iatrogenic refers to a pneumothorax that is deliberately induced. c. Women are more likely to have a pneumothorax than men. d. Pneumothorax due to ruptured air blisters is most likely to occur in patients over the age of A 2.D 3.C 4.A 5.D 6.A 7.A 8.C 9.D 10.B Page 57

60 Chapter 3: Wound Care: Priorities for Nursing Release Date: 12/12/2015 Expiration Date: 12/12/2018 Audience This course was developed for health care professionals responsible for the assessment and care of patients who may have wounds or who are at risk for developing wound. 8 Contact Hours Purpose statement Wounds may be acquired from many different sources. It is critically important that nurses know how to assess wounds, its origin, the patient s risk factors, and/or other co-morbidities that may affect the healing process. This course focuses on the all aspects of wounds Learning objectives Upon completion of this course, student will master the following objectives: Describe the normal anatomy and pathophysiology of the skin. Compare and contrast various types of acute and chronic wounds. Identify each of the phases of wound healing. Identify factors that affect the normal healing process. Describe the nurse s responsibility in assessing and documenting wounds. How to receive credit Read the entire course, which requires a 8-hour commitment of time. Depending on your state requirements you will asked to complete either: An attestation to affirm that you have completed the educational activity. Accreditation and approvals Elite is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through April 30, 2017); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Board of Faculty Stephani Hunt, MSN, RN, WCC, OMS, ONC Stephani Hunt is an accomplished nurse and nurse educator. She received her bachelor s degree in nursing from Northeastern University, Boston. Her master s was received from Framingham State University, Framingham, MA. Currently, Stephani works as a Clinical Nurse Educator at Elliot Health Systems, Manchester, NH. She is also a wound care and ostomy management specialist and works with both nursing and medical staff related to the education and management including identification, assessment, and wound care dressings and products to help wound healing. Also included are strategies to prevent the incidence of preventable wounds. Explain how wounds are diagnosed. Identify treatment modalities for various types of wounds. Identify nursing interventions used to prevent acute and chronic wounds from occurring. Discuss the legal implications for nurses caring for patients with wounds. OR completed the test and submit (a passing score of 70 percent is required). Note: Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment; and Print the Certificate of Completion. Nursing, Provider # ; Florida Board of Nursing, Provider # ; Georgia Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). of patients with complex wounds and ostomies. Stephani holds certifications in Wound Care, Ostomy Management, and Orthopedics. She is also a Basic Life Support Instructor. Content Reviewer Adrianne Avillion D.Ed., RN Activity Director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Page 58

61 Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for CNE, Elite implemented mechanisms, prior to the planning and implementation of the CNE activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the CME activity. Sponsorship/Commercial Support and Non-Endorsement It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer The information provided at this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2016: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or p professional services expert licensed in your state. Elite Professional Education, LLC had made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and are not actual customers. outbreaks of meningitis on college campuses, or as seen in current outbreaks of measles (the most contagious of childhood diseases) in unvaccinated populations. Healthcare professionals must help patients and families consider whether the potential side effects of vaccination outweigh the benefits of immunization. With appropriate immunization programs, it is hoped that more and more vaccine-preventable diseases can be eradicated. Introduction Wounds may be acquired from many different sources, such as bites, burns, punctures, scrapes, skin tears, surgery, and disease processes. Pressure ulcers and chronic wounds are often the result of immobility or venous or arterial insufficiencies. Therefore, it is important to assess the wound, taking into consideration the origin, the patient s risk factors, and/or other co-morbidities that may affect the healing process. There are many wound care dressings and products that may be prescribed by providers, so it may be difficult to understand the reason one product and/or type of dressing may be utilized over another. Ideally each facility should have a wound-care nurse to ensure that the proper dressings and/or products are being utilized appropriately for various types of wounds. However, realistically, a wound-care Anatomy and physiology of the skin [17] In order to understand the various types of wounds that may occur, it is imperative to recognize the duty and purpose of each layer of skin and how it relates to the healing process. The skin is the largest organ of the body and its primary mode of defense. If there is a break or injury to the skin, it will affect homeostasis and can affect the overall health of the patient. The total surface of the skin is about 22 square feet, and roughly 8 pounds [19]. The majority of literature concludes that skin has four major functions [19] : Acts as a barrier for protection of underlying structures against microorganisms and infectious agents. Protects and regulates the body temperature through conduction, convection and radiation. Aids in elimination of waste. Prevents dehydration. Nursing consideration: The skin is the body s primary mode of defense. Nurses should not only be aware of this but teach colleagues, patients, and families about the importance of the skin to general health and well-being. The skin is composed of three major layers [123] : Epidermis The epidermis is the most important layer of the skin because it is on the outside, exposed to the environment. Every single environmental encounter involves the skin, from the air, rain, chemicals, clothing, etc. The epidermis is composed of melanocytes (which produce the pigment and color of skin), Langerhans Cells (which aide in immunity), Merkel Cells (which are responsible specialist may not be easily accessible. Therefore, it is imperative that nurses are enlightened and knowledgeable about the various types of wounds and products to ensure that proper treatment is provided. There are many variables that affect the healing process. Throughout this educational offering, we will review the most common types of wounds and provide insight into the proper identification and treatment of these various types of wounds. We will also review normal anatomy and physiology of the skin, in order to understand just what is going wrong when a wound develops. Understanding why a wound forms allows the nurse to identify the wound type, initiate preventative interventions, and assess additional risk factors placing the patient at risk. for sensations such as light touch and distinguishing shapes), and dead cells packed with a tough protein called keratin. It can vary in thickness depending on the anatomical location. For instance, the epidermis on the eyelids is about 0.5mm thick, while the thickest areas (like the palms and soles of the feet) are up to 1.5 mm thick. The epidermis has a limited supply of blood to with which to provide nutrients and thus depends upon the diffusion of nutrients from the underlying connective tissue, the dermis. In areas exposed to frequent pressure or friction, it will thicken and harden to form corns or calluses in order to protect the underlying tissue and prevent damage [123]. The epidermis is composed of four to five layers of cells [123] : The stratum germinativum (basal cell layer) is the bottom layer of the epidermis. It forms basal stem cells that divide, forcing the older cells to advance towards the surface. This layer also contains melanocytes, and determines the color of skin. Merkel cells are also present in this layer, and are responsible for many aspects of the sense of touch, like light touch and distinguishing shapes and patterns. The stratum spinosum consists of squamous cells or keratinocytes, which are the most abundant of the epidermal cells [141]. This is the thickest layer of the epidermis, and allows the passage of substances through the skin. Because of this, Langerhans cells are present in this layer, which invade during any injury or infection and alert the immune system to fight off the pathogens that penetrate into the skin. Page 59

62 The stratum granulosum and stratum lucidium are the next layers of the epidermis, and as cells move through them on their way to the surface, they become bigger, flatter, and stronger in order to provide protection. The stratum corneum is the outermost layer of the dermis. It contains around 30 layers of dead, scaly, keratinized cells that make it waterproof. These keratinocytes form the protective barrier of the skin. The average life of a keratinocyte is about a week, after which it will shed (exfoliate). On average, humans shed 200 gm of dead skin cells every day, which are continuously replaced with new dead skin cells [108]. If the stratum corneum is not intact, the normal skin bacterium can invade deeper into the skin, eventually accessing the bloodstream [17]. Dermis The dermis is a deeper layer, located above the adipose tissue, also known as subcutaneous tissue [17] and is comprised of specialized cells and structures with a rich blood, lymphatic and nerve supply [123]. The dermis is composed mainly of collagen, but it has elastin, fibrin and other fibrous connective tissue that allows it to be flexible and increases its strength [108]. When there is an injury, collagen production increases and forms scar tissue. The thickness of the dermis size varies from 1.5 mm to 4 mm in thickness and is composed of two layers, the papillary and reticular layer [17] : The papillary layer (the top layer of the dermis) contains a thin vascular network, and brings nutrients to the skin, as well as aiding in body temperature regulation by controlling dilation and constriction of the vessels within it [123]. The reticular layer of the dermis is deeper and much thicker. Its collagen fibers provide structure and elasticity to the skin. In addition, all of the structures within the dermis, like the hair follicles and glands, are supported and held in place by this layer of the dermis [17]. The jobs of the dermis include (but are not limited to): Sense of touch: The dermis has an extensive network of nerve endings, which allows a patient to feel touch, pressure, temperature, pain and the urge to scratch/itch (pruritus), by relaying these sensations to the brain [136]. Temperature regulation: Sweat glands are located in the dermis, which allows sweat to be released, evaporate, and in turn cool the body. Much of the water the body is made up of is stored in the dermis, so its integrity is a major concern for overall wellbeing. As mentioned above, vasodilation and vasoconstriction in the dermis also aides in the thermoregulation of the body [17]. Hair growth: Hair follicles are located in the dermis, which also aides in temperature regulation and protection. Waterproofing: Sebaceous (oil) glands are present in the dermis and in addition to keeping the skin soft, the oil released is slightly acidic, and prevents the overgrowth of microbes [32]. Feeding the skin: Blood vessels are located in the dermis and deliver nutrients to the skin. Hypodermis (subcutaneous tissue) Beneath the dermis, there is another layer of connective tissue, composed of fat and loose connective tissue, that connects the overlying dermis to the underlying muscle [77].This layer s functions include insulation for temperature regulation, shock absorption from external traumas, and energy storage from fat [123]. This layer is not present in all areas of the body (like the knuckles, nose, tops of the ears, etc.), so consideration should be given to these areas when there is an injury, as the same shock absorption and protection is not present here as other anatomical locations [77]. The skin s layers also work together to: Synthesize and regulate vitamin D, which affects Calcium and Phosphorus absorption abilities, thus affecting bone strength and growth/regrowth [150, 127]. Maintain homeostasis by preventing water loss, protecting against microorganisms, protecting the internal organs from environmental assaults, and using lymphatic and vascular tissues to respond to inflammation, injury, and infection [34]. Nursing consideration: Nurses must be familiar with the anatomy and physiology of the skin in order to provide safe and appropriate care to all patients. Since the skin is the first barrier of defense nurses must be able to assess the skin thoroughly and accurately. Such assessment depends on possession of accurate knowledge of the anatomy and physiology of the skin. Overview of types of skin injuries: acute and chronic wounds The definition of a wound is an injury to living tissue, typically one in which the skin is cut or broken [133]. Anytime there is a break in the outer layer of skin, also known as the epidermis, there is a wound. Depending upon the nature and degree of the wound, the overall wellbeing of the patient may be affected by the injury and/or complications related to it. Nurses must be able to recognize the type of injury, resulting wound, and correct response quickly in order to reduce the risk of wound and systems related complications. This is especially important with wounds that have been contaminated due to the mechanism of the injury or other environmental exposures. Wounds can be acute or chronic. Acute wounds are wounds that follow a predictable healing pattern and can include (but are not limited to) abrasions, lacerations, puncture wounds, surgical wounds, burns and skin tears [61]. Chronic wounds are wounds that do not follow a predictable healing pattern because they are stuck in one stage of healing, the inflammatory stage. We will discuss the stages of healing in depth during this activity. There are 3 types of chronic wounds: pressure ulcers, vascular ulcers, and diabetic ulcers. Surgical and other acute wounds can also be non-healing and develop into chronic wounds due to infection, underlying disease, or additional injury [61]. Acute wounds Abrasions, excoriations or scrapes These terms are typically used interchangeably and are defined as superficial breaks in the epidermis of the skin due to friction, force or rubbing against an abrasive surface and/or a fall [18]. Therefore, if there is an abrasion, excoriation, or scrape, the deepest layers of the skin (the dermis and hypodermis) remain intact. If bleeding is present, it is typically a slow oozing flow, and the skin injury will usually heal without antimicrobial treatment in the absence of a foreign body [18]. Abrasions and excoriations can occur from things like a fall, trauma, frequent cleaning with rough materials (such as with an incontinent patient, or around a leaking stoma), and contact with anything that can remove the top layers of skin. Certain activities, as well tripping or falling in your everyday activities, can result in abrasions. Excoriations can also occur as a result of the scratching associated with pruritus, common with dry Page 60 skin, certain medications, and underlying diseases (like renal disease, hypothyroidism, and diabetes) [79]. Some activities that are common causes are listed below: Bicycling (falling from a bike can cause road rash). Playing baseball (from sliding in to bases). Skateboarding (falling from a skateboard while it is moving). Nursing consideration: Since tripping or falling can lead to wounds such as abrasions, nurses must be especially alert to patient populations that are at high risk for falls, such as the elderly and those with compromised mobility.

63 Bites Bites An animal, insect, or a human can inflict a bite, eliciting potential tissue and/or nerve damage, infection and disease. Typically, the presentation and type of wound created by a bite is specific to the particular source, such as: Dog bites can appear as a laceration, puncture, or avulsion (when skin is separated from the body) and typically have components of a crush injury as a dog s bite elicits large amounts of force as it clamps down [96]. Cat bites occur most frequently on the arms and hands. They have a much higher rate of infection, as the very sharp teeth of cats are more likely to cause a puncture that penetrates deeper into tissues and other anatomical structures, like tendon and muscle [96]. Spider bites from species known to be venomous can cause both local, often unnoticed minor wounds that look like an insect bite, or open wounds with necrotic tissue and systemic symptoms. In addition, the bite wound can act as a portal for bacteria, increasing the overall risk for infection. Two examples of well-known wound causing spider bites are [105] : Black widow spider: Symptoms usually begin within an hour after a bite, and can radiate throughout the body, especially to the abdomen and chest, often accompanied by severe cramping and diaphoresis. The bite itself typically begins as a small, red, and minimally painful bump that many patients do not notice. Fang marks may be visible upon inspection [43]. Brown recluse spider: Pain is usually more gradually with this type of spider bite than other types, and typically begins to increase around 8 hours after the bite takes place. A resulting ulcer can develop as tissue around the bite site begins to die and slough off. This tissue necrosis does not typically last more than 10 days, but as every person reacts differently to venom, the path is unpredictable. Bacterial infections are common in this type of bite wound, and the full course of healing can take months and effect everyday function (e.g. hand bite with damage to fingers or decreased range of motion) [105]. A human bite is no different than an animal bite; and also has a high risk of infection without treatment [156]. There are several main types of injuries that occur with bites: a closed-fist injury, chomping injury, laceration or puncture wound and an avulsion injury [121, 65]. Each of these examples is elaborated upon below: Closed fist injury occurs when a closed fist comes in contact with a tooth [156], like what may occur during a fight. Chomping injuries occur on the nose, ears and fingers, when another person bites down on them [65]. Bruises Bruises (also called contusions) Bruising is the visible result of blood vessels that are broken or damaged during an accident, injury, or trauma. They do not break the skin and appear as a purple discoloration that over time can change to a yellow or brown color as the damaged vessels heal and reabsorb the blood that was leaked into the soft tissue [111]. Anything can cause a bruise on the skin, but patients at the highest risk include the elderly, those taking corticosteroids, patients with certain underlying diseases and individuals at risk of falling. If a bruise appears with no identifiable cause, or seems more severe than the noted injury, the nurse should assess for a family Burns Burns Non-fatal burns are a leading cause of morbidity [155], often requiring prolonged hospital stays, and can cause permanent disability, disfigurement, and other life threatening co-morbidities (like infection and dehydration) [97]. They are caused by exposure to thermal, chemical, electrical, or radiation energy [85]. Friction burns are Puncture and laceration wounds can be a result of any type of bite, and can penetrate into deeper underlying tissue. If the puncture wound is over a joint, the risk of severe infection is higher and must be treated quickly in order to prevent loss of function and additional tissue damage [90]. Avulsion injuries occur when the skin is torn away from the underlying tissue, and can be seen commonly on the ears, nose, cheeks, and scalp with bites to the head [65]. All bites are capable of producing an infection, but human bites can also potentially transmit the hepatitis B and human immunodeficiency virus (HIV). About 1% of Emergency Room visits can be attributed to animal bites, although it is estimated that 50% of bites go unreported, as many people do not seek treatment immediately or attempt treatment at home. Although bites in general most commonly occur in adults, bites to the head and neck are more likely in children, as they are more frequently face-to-face with animals [69]. EBP alert! Since research shows that an estimated 50% of bites go unreported 69, it is possible that serious consequences of bites may go overlooked. Nurses and other healthcare professionals should teach patients and families to report all bites and seek medical evaluation of bites. One of the things that make a bite different and higher risk than many other wounds is the vast array of bacteria found in the mouth. There are several strains of bacteria that are commonly found in mouths, meaning that depending the type of mouth (cat, human, dog, etc.) that causes the bite, certain infections are more likely. The most common type of bacteria found in animal bites, especially dog and cat bites, is the Pasteurella Multocida species. The resulting infection can have a rapid onset (with symptoms appearing in as little as 24 hours), and can lead to deeper infections such as osteomyelitis (bone infection), tendosynovitis (tendon infection), and septic arthritis (joint infection) [55]. Other types of bacteria that may be found in animal bites include but are not limited to staphylococcus aureus, staphylococcus epidermidis, streptococcus and escherichia coli (E. coli) [2]. Human bites are typically composed of both aerobic and anaerobic bacteria, like streptococcus, staphylococcus, eikenella Fusobacterium, and Prevotella [28]. Both animal and human bites can cause infection by introducing the normal human skin flora and oral flora of the biter into the underlying tissue [27]. history of any clotting disorders, hemophilia or whether the patient is taking any anticoagulants or nonsteroidal anti-inflammatories (NSAIDS). Anticoagulants and NSAIDs thin the blood, and can make bleeding, especially after injury, easier [38]. Nursing consideration: Nurses must be sure to teach patients/ families who are taking anticoagulants and/or NSAIDs or who have a personal or family history of clotting disorders about their increased risk for bruising or prolonged bleeding after injury. a combination of an abrasion and heat, and result from skin contact with a hard surface (i.e. road rash) [14]. Thermal Thermal burns are the result of an outside heat source that increases the temperature of the skin to the point of tissue death. Sources like fire, metals, and steam, can cause these types of burns. Page 61

64 Chemical Chemical burns occur without a heat source due to contact, ingestion, inhalation or injection of acids, alkalines, solvents or vesicants. Ingesting bleach or drain cleaner, contact with hydrofluoric acid, and mustard gas exposure are some examples causes of chemical burns. These burns may not be apparent immediately, and can sometimes appear days after exposure. Electrical Electrical burns are the result of contact with electrical current. Things like faulty electrical wiring, electrical cords, high voltage power lines, or failure to turn the electricity off while working on electrical systems can cause these types of burns. Radiation Radiation burns are due to exposure to radiation sources, like x-ray or radiation therapy, or sources of ultraviolet light, like the sun. There are three classifications of burns [85] : Superficial (first-degree) burns Superficial burns do not extend past the epidermis, and cause minimal damage. They can be painful and unsightly, but do not blister or cause lasting damage to underlying structures. Repeat superficial burns like sunburns however, can increase the skin s susceptibility to other diseases and conditions, like skin cancer. Partial thickness (second-degree) burns Partial thickness burns extend into the dermis. These burns often result in blistering, and are usually filled with serious fluid. They are usually very painful. Full thickness (third-degree) burns Full thickness burns can extend into to any level of tissue, such as tendon and muscle, and can have a charred or white appearance. These burns damage the nerves, and often, less pain is felt as a result. These types of burns can have a big impact on body image, overall mobility and function, and risk for infection. Everyone is at risk for suffering from a burn, but those with the highest risk factors are children, as burns are the 11th cause of death Lacerations or cuts Lacerations or cuts Lacerations or cuts are typically the result of a blow from a blunt object, a fall and/or contact with a sharp object that results in the tearing of soft tissue. These injuries typically bleed and are often contaminated by the bacteria present on the object that caused the damage [75]. Depending on the object or force that created Perineal dermatitis Perineal dermatitis (Moisture-Related Skin Damage or MASD) Research has demonstrated that incontinence, perineal skin breakdown and pressure ulcers often coincide together [11]. Perineal dermatitis occurs due to contact with moisture, especially urine and feces, which oversaturates the skin. Excessive sweating and other bodily fluids (like wound drainage) can also be a cause MASD. Oversaturation prevents the skin from protecting against the passage of irritants through its protective barrier. Bodily fluids can be a MASD causing irritant, but what is used to clean the bodily fluids can also cause skin damage. Using alkaline soaps or cleansers to clean incontinent patients can change the acidity of the Punctures Punctures Puncture wounds are inflicted by sharp objects entering the skin. Depending on the depth and object used to create the injury, the bleeding may be minimal, and the wound may close quickly. These wounds are prone to infection, as the skin flora and foreign debris from the puncturing object can be introduced in to the tissue [75]. Common causes of puncture wounds include, but are not limited to, glass shards, wood splinters, nails, pins, as well as handheld tools, scissors, and in children aged 1-9 [155]. The American Burn Association (2012) reported the following statistics [20] : 70% of burns were men. Children accounted for 19% of cases, and the elderly (60 or over) accounted for 12%. 69% of burns occurred in the home. Deaths related to burns increased with patient age and size of area burned, while inhalation injuries increased the likelihood of death by 16 times. Nursing consideration: Nurses should know the incidence and prevalence of burn injuries in order to provide appropriate preventive patient/family education. With a burn injury, collagen is lost, creating abnormal osmotic and hydrostatic pressure gradient, which causes the movement of intravascular fluid into the interstitial space [21]. During and after the cellular injury, mediators of inflammation are released to begin the stages of healing. As the burned tissue is no longer viable or helpful in the healing process, most treatments aim to remove or replace the dead tissue, as well as promote the maintenance and regrowth of healthy tissue. Treatment is based on the percentage of body surface affected, areas affected (lungs, hands, groin, face and feet are high risk), type of burn (electrical and chemical burns are recommended to be treated at burn centers), and age (children have less skin surface area, so the percentage affected is usually higher) [21]. According to the American Burn Association [21], between 2003 and 2012 admissions to burn centers were primarily caused by flames in the home, with scalding listed as the second leading cause. A scald is a burn caused by a liquid, but the extent the liquid damages tissues is dependent upon the temperature of the liquid and the length of time of exposure. Scald burns are the most common type of burn in children under 5 [21]. the injury, the wound can be irregular, jagged, or linear with even edges (knife, axe, etc.). It is important to note that how the laceration occurred, as it will determine how the normal healing process will be affected, what underlying tissues were likely to be affected, as well as the risk of infection to the injured area [96]. skin, and can cause over drying, irritation and cracking, which can lead to not only discomfort, but bacterial and fungal infections. Towels and cloths can be rough and harsh on the skin as well, so soft or specially made clothes should be used for cleaning incontinent episodes, and rubbing the area should be avoided [41]. Nursing consideration: Special care must be paid to promote bladder training in order to decrease incontinence, which places the patient at risk for skin breakdown. If incontinence does occur, meticulous skin care must be provided using non-alkaline cleansers [11,41]. knives. If the wound occurs on or involves the head, chest, abdomen, bone, joint, or causes numbness and tingling, the patient should see a doctor right away for evaluation and treatment [35]. These high risk areas are more likely to involve underlying structures and are to develop infections that can affect function and overall health. Page 62

65 Skin tears Skin tears Are defined as a traumatic injury resulting from separation of the epidermis from the dermis that occur from friction and shearing forces (blunt force traumas or accidental bumps) or mechanical lifting of the top layers of the skin. Skin tears often occur in the extremities, especially in the elderly, but can occur anywhere on the body. They are often associated with the use of adhesives and medical devices, especially if being moved, removed, or repositioned by another person, as the caregiver cannot feel when the damage is occurring [163]. Risk factors for skin tears include, but are not limited to [44] : Use of steroid medications. Fragile skin due to age related changes, medications, or underlying disease. Immobility impairment. Poor vision (more likely to cause accidental injury). Dependence on others for ADLs (increased risk for accidental injury caused by others). Poor nutrition. Use of assistive devices (braces, equipment, etc.). Skin tears can be classified into 3 categories, based upon the degree of tissue loss related to the injury [44] : Category 1: No loss of tissue. The tear leaves tissue that covers the dermis entirely or is within 1 mm of the wound edges. Two subcategories exist to characterize the type of tear: Linear: The tear is a line with wound edges that are easy to approximate. Flap: The tear creates a skin flap, but meets the above criteria. Chronic wounds Pressure ulcers are often called decubitus ulcers or bedsores by clinicians and laypeople. The Agency for Healthcare Research and Quality (AHRQ) accepts pressure ulcer as its preferred term, as does much of the literature [11]. Since 2007 however, the Joint Commission (TJC) has provided definitions differentiating the terms decubitus ulcer and pressure ulcer [88] : Decubitus ulcer is the term used to describe the breakdown of the skin and subcutaneous tissue due to prolonged, unrelieved pressure over a bony prominence. Malnutrition, paralysis, and/or physical deformity can cause this breakdown. The word decubitus means recumbent or horizontal posture. Pressure ulcer is a broader term that includes decubitus ulcers, but also includes other ulcerations like medical device related pressure injuries, such as those caused by braces, prosthetic limbs, dental prosthesis, CPAP machines, etc. The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction [129]. Pressure ulcers are caused by impaired blood supply and tissue nutrition resulting from pressure, or a combination of pressure and shear, over bony or cartilaginous prominences [129]. Shear occurs when the surface tissue and the underlying tissue are pulled in different directions, like when a patient slides down in bed (their skin will be pulled up as it sticks on the sheets and bed due to friction, while their body slides downward). This pressure compresses and cuts off or decreases the blood flow to the area, resulting in ischemia, tissue damage and tissue death [99]. Risk factors that make the development of pressure ulcers more likely include, but are not limited to, advanced age, immobility, certain medications, and excessive moisture. There are certain disease processes and conditions that may also predispose an individual to developing pressure ulcers, such as: Cognitive dysfunction leaves the patient in many cases unable to communicate pain and discomfort, making it unlikely that they will ask for assistance moving if not prompted, or report a problem area [15]. Category 2: Partial tissue loss. Two subcategories exist, minimal tissue loss (less than 25%), and moderate tissue loss (over 25%). Category 3: Full loss of the epidermal flap, and full exposure of the dermis. Surgical wounds A surgical wound is defined as a deliberate incision produced during a surgical procedure. It is made in a controlled environment using aseptic technique [98]. A surgical site infection (SSI) is classified as an infection occurring at a surgical site within 30 days of the initial incision, and accounts for 38% of nosocomial infections [23]. Although there is a risk of infection with any surgical procedure, the following are some of the risk factors are associated with higher infection rates [23] : Abdominal surgery, especially in obese patients. Prolonged anesthesia time. Contaminated or dirty wound. Chronic or severe underlying illnesses. Immunosuppression. Existing wound, infection, or injury. Prosthesis (hip replacement, knee replacement, etc.). Smoking. Absence or delayed pre-surgical antibiotic prophylaxis. Nursing consideration: Surgical site infections following certain surgeries and invasive procedures are among the Medicare nonreimbursable hospital-acquired conditions. Thus, it is imperative that nurses make every effort to prevent such infections. Any condition that causes immobility, like a hip fracture, muscle contractures, or trauma. Disorders that result in loss of sensation, such as spinal cord injuries (SCI) and cerebrovascular accidents (CVA). Local nerve damage (like foot drop) can also be a risk factor, as pressure, friction and shear from devices and activity may not be felt or noticed until after damage has been done [95]. Conditions that cause gradual damage to nerves, brain function, and affect movement, like Alzheimer s Disease and Parkinson s Disease [126]. Chronic and unstable diseases of the cardiopulmonary system, such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) can lead to decreased oxygenation and perfusion of the tissues [11]. Chronic diseases of the endocrine system, like Diabetes Mellitus (DM). Diabetes can not only put a patient at risk for developing ulcers, but reduces the ability to heal an ulcer that is formed, as well as increases the risk for wound infection [79]. Chronic diseases of the gastrointestinal system (GI), that can cause or be a result of malnutrition, vitamin deficiencies and obesity increase the risk for wound development and reduce the healing potential. Gastrointestinal bleeding reduces the available blood that can be sent to tissues, as well as causing nutritional deficiencies, which can weaken the skin and well as prevent new tissue formation [11]. Chronic diseases of the hematological system, such as anemia, polycythemia and myeloproliferative disorders, as they disrupt the supply of blood and nutrients to the skin [126]. With sickle cell anemia, a patient may develop lower extremity ulcers that can resemble venous ulcers or other injuries to the lower extremities. This is due to inflammation and injury caused by the blockage of blood flow that is a result of the abnormally shaped cells [44]. Chronic diseases of the peripheral vascular system, such as atherosclerotic disease, chronic venous insufficiency and lymphedema prevent blood flow or venous return throughout the body, starving the tissues and breakdown, while also decreasing healing potential [11]. Page 63

66 In the 1980s, the National Pressure Ulcer Advisory Panel (NPUAP) developed a national staging system for pressure ulcers. In 2007, the NPUAP revised its guidelines, including the original four stages and adding two stages on deep tissue injury and unstageable pressure ulcers. Pressure ulcers are classified in the following stages [129] : Suspected deep tissue injury (SDTI): Presents as a purple or maroon (sometimes mistaken for an accident induced bruise) area that is a result of damage to the underlying soft tissue as a result of pressure or shear. A blood blister is also considered a SDTI, as the skin is still intact, but underlying tissue damage is evident. Tissue that is boggy, mushy or has a different temperature than surrounding tissue can be a warning that a SDTI is developing and damage has occurred. These types of injuries are difficult to detect in darker skinned individuals. Stage 1 pressure ulcers: Presents as a reddened area that is nonblanchable, typically over pressure points. The skin is still intact, but may be painful, have temperature variations from surrounding tissue, or be softer or firmer than surrounding tissue. These, as well as SDTIs, can be much harder to identify in darker skinned individuals. Think of a time you may have been leaning on your elbow for too long and it turned red and painful for a while until the pressure was relieved for an extended period of time; this is a stage 1 pressure ulcer. Stage 2 ulcers: Present as a partial thickness skin loss that involves the epidermis, dermis and/or both layers. They are visible as shallow craters, serous, or serosanguinous blisters. Slough is never present in a stage 2 pressure ulcer, so if it is present, the ulcer is at least a stage 3. Blisters can occur from a variety of friction and shear related causes, and wounds are often mistakenly classified as a stage 2 ulcer when they are not a result of pressure. In addition, if bruising is present at the site of the blister, deep tissue injury is present. Think of a blister on your heel from too much walking. This is the result of pressure on the area, as well and friction and shear, and is classified as a stage 2 pressure ulcer. Slough or eschar can never be present in a stage 2 ulcer. Stage 3 ulcers: Are full thickness skin loss ulcers that involve subcutaneous tissue, but do not extend into muscle, bone, tendon, or other underlying structures. Undermining and tunneling may be present, as well as slough and necrotic tissue. Stage 3 pressure ulcers can develop quickly in areas with little tissue, like the nose, ears, and the back of the head, even though they may appear very shallow. Stage 4 ulcers: Are full thickness wounds that extend into the muscle, bone, or other underlying structures. Slough, eschar, tunneling, and undermining often occur. In addition, infection into deep tissues like bone (osteomyelitis) is more likely to occur and can lead to sepsis, as these areas are exposed or close to the surface. Like stage 3 pressure ulcers, areas with little tissue like the nose and ears can develop stage 4 pressure ulcers quickly and easily. Unstageable ulcers: Present as a full thickness tissue loss in which the base of the wound bed, therefore the depth of the wound, is completely obscured by necrotic tissue. These wounds can only be staged when the necrotic tissue is removed or expelled by the body. As necrotic tissue can only be present in a stage 3 or 4, the wound will be at least this stage once it can be visualized. Nurses should follow the NPAUP staging system and their own employer s policies to ensure compliance and accurate assessment of wounds across the continuum of care. Once the wound has been staged, it needs to be reassessed frequently to monitor for any improvement or deterioration of the wound. Keep in mind that a wound can never be reverse staged, for example, if a wound starts off as a stage 4, but fills in and no longer has bone and muscle visible, it cannot become a stage 3. The depth of the original tissue damage is still at the level of a stage 4, and the tissue will always remain weaker at the site, therefore it is considered a healing or stage 4 [115]. The frequency of assessments usually depends upon the venue in which the patient is being seen, and is typically determined by facility or agency Page 64 policy [29]. For example, in an outpatient or home care setting, it is not realistic to expect that a wound will be assessed daily, so they may create guidelines suggesting weekly or bi-weekly wound assessments. Nursing consideration: All nurses need to be able to differentiate among the various pressure ulcers in order to perform proper assessment and monitoring. Pressure ulcers typically develop over a bony prominence due to continuous pressure on the tissue [79]. The following are common sites for pressure ulcer development: Sacrum. Greater trochanter. Ischial tuberosity. Heel. Lateral malleolus. Recently, more attention has been paid to medical device related pressure injuries. These can occur from any medical device or equipment used on a patient. Indwelling catheters, CPAP machines, nasogastric tubes, oxygen tubing, chest tubes, tracheostomy ties and appliances, bedpans, and many other pieces of equipment have been identified as common causes of device related injuries. The NPUAP recommends the following in order to prevent such injury [128] : Choose the correct size of medical device(s) to fit the individual. Cushion and protect the skin with dressings in high risk areas (e.g. nasal bridge). Remove or move the device daily (or more often if possible) to assess skin. Avoid placement of device(s) over sites of prior, or existing pressure ulceration. Educate staff on correct use of devices and prevention of skin breakdown. Be aware of edema under device(s) and potential for skin breakdown. Confirm that devices are not placed directly under an individual who is bedridden or immobile. Be vigilant when turning patients to avoid rolling them onto equipment (Foley catheters, chest tubes, etc.). Be sure to remove all equipment from the bed when finished with a procedure (IV caps, syringes, medication cups, etc.). Nursing consideration: Nurses must be sure to teach colleagues, patients, and families how to prevent the development of pressure ulcers. Not all healthcare professionals are well-versed in pressure ulcer prevention, and nurses have an obligation to provide needed education. Similarly, patients and families must also be taught preventive strategies. With most pressure ulcers, if the pressure is alleviated, the erythema that may be present will usually resolve within in a few hours without any lasting tissue damage [12]. If the pressure continues without relief and/or a change in position, the body s inflammatory response will cause platelet aggregation, forming micro thrombi that block the blood flow in the skin s vasculature and cause ischemia and potentially necrosis of the surrounding tissues [84], leading to ulceration. Although there are many variables that contribute to the risk of developing pressure ulcers, some risks can be removed or mitigated with safe, diligent care. This involves early recognition of the risk factors as well as initiating and performing interventions for prevention, and assessing the wound to develop a treatment plan [12]. Vascular ulcers Vascular ulcers are the result of peripheral vascular disease, which causes decreased perfusion of the tissues, poor venous return, or both. They are often chronic and difficult to heal, and are classified as follows [68] : Arterial (Ischemic): Arterial ulcers are the result of poor blood flow to the legs, resulting in ischemia and tissue damage or death. Causes of arterial disease include [164] :

67 Arteriosclerosis (hardening of the arteries). Atherosclerosis (thickening of the arteries, due to the buildup of fatty materials). Diabetes (calcifies the vasculature). Limited mobility. Renal disease. Previous ulcers. Arterial ulcers can be present anywhere distal to impaired arterial supply, but are usually found below the knees, and on the feet, heels, and toes. Characteristics of arterial wounds are as follows [62] : The wound margins are even, sharply demarcated and punched out. The wound may be superficial or deep. The wound beds may be pale, dusky, or have evidence of decreased or absent wound healing. The wound is painful, especially when the legs are elevated (often at night), as the blood supply is further decreased. Are associated with shiny, hairless, blue tinted, or cold white legs and feet (think about it, if there are limited nutrients going to the tissues, there are limited resources to grow hair or strengthen skin). Muscle cramps are often present, especially when walking, due to the decreased blood supply. This is called intermittent claudication. Venous stasis Venous stasis ulcers are one of the top 10 most common medical problems in the western world [1], and are caused by the pooling of blood in the lower extremities, due to either inadequate calf muscle pumping, thrombosis, or disease. Fluid is leaked into surrounding tissues, inflammation occurs, and ulcers form as tissue damage and death occurs. The following conditions and risk factors can cause venous stasis ulcers to develop [79] : Previous ulcers (scar tissue and previously damaged structures). Trauma. Severe edema. Thrombosis (blood clot). Pregnancy. Obesity. Immobility and/or decreased calf pumping ability. Venous ulcers can be present anywhere between the knee and ankle, with the inner ankle (medial malleolus) being the most common site. Characteristics of venous wounds are as follows [62] : The wound margins are irregular. The surrounding tissue is often stained or darkened. (hemosiderin staining), mottled, or reddened. The staining is due to the spilling of components that transport iron into the tissues, which over time collects and changes the appearance of the skin. The area can be itchy, dry, or scaly. Leg pain is often relieved by elevating the feet (encourages venous return). The skin may be hardened and tough. Edema and drainage are common in the legs and the wound itself as the fluid collecting in the area cannot return to circulation, and is forced out of the tissue or wound. The wounds are superficial to partial thickness. The wound beds vary in appearance from ruddy, beefy red to a superficial fibrinous gelatinous necrotic covering that may occur suddenly with healthy-appearing tissue underneath. The wound is typically painless unless infected. Mixed arteriovenous ulcers Some patients present with both arterial and venous disease, and can have both types of ulcers at the same time, or ulcers that share characteristics with both disease processes. Diabetic ulcers Those with diabetes are at higher risk for ulcers due to a variety of factors, especially those with poor glucose control. Many develop neuropathies (numbness, pain, or tingling), that can result in the inability to feel objects they are stepping on or the effects of poorly fitting footwear. In addition to this, diabetes can cause poor circulation, decreased ability to heal injuries and fight infection, and foot deformities [22]. They are typically noted over pressure points, and although mostly found in the feet, specifically the toes and base of the first metatarsal (big toe), they can occur anywhere there is repeated friction or pressure. Diabetic ulcers often have a callused ring around the wound edges, and if infected can have a green or yellow surface crust that is sometimes accompanied by a foul odor [62]. PHASES OF WOUND HEALING AND THE HEALING PROCESS Once tissue damage occurs, there are four phases of healing that occur to repair and return tissue (ideally) to its optimal level of functioning. These phases must occur in order for a wound to heal appropriately [142] : 1. Hemostasis At the moment injury occurs, the body enters the first phase of healing. Vasoconstriction occurs and platelets rush to the site to form a clot (or plug) to prevent blood loss. When platelets activate, they release hormones, cytokines, and chemokines, which attract inflammatory cells to the area, thus leading to the next phase of wound healing. 2. Inflammatory phase The second phase of healing begins about minutes after injury, and occurs when fibrin and thrombin are activated, which causes inflammatory cells to migrate to the area. These inflammatory cells promote vasodilation and increased vascular permeability. This increased blood flow brings the immune cells needed to fight microbes introduced into the tissue by the injury, in addition to beginning to debride the wound and flush out foreign material. Over the course of about 3 days, macrophages, neutrophils, and lymphocytes flood the area, each targeting different microbes and/or types of wound debris. Chronic and non-healing wounds are wounds that are stuck in this second phase of healing and cannot progress to form new tissue. 3. Proliferative phase New tissue is formed in the third phase of wound healing. It begins 3-5 days after the initial injury, and overlaps with the inflammatory phase. Granulation tissue and new vasculature is created, and epithelialization (the movement of cells across the surface of the wound) continues. The migration of epithelial cells also helps to debride the wound of necrotic tissue, by forcing it to disconnect from the underlying healthy tissue. As the amount of inflammatory cells decreases, the amount of fibroblasts increase. Fibroblasts are responsible for the production of collagen and elastin, which over the course of 5-15 days, contracts and closes the wound. This is the re-growing phase of wound healing. 4. Maturation phase In the maturation phase, collagen organizes, the wound is remodeled, and scar tissue is formed. Water is reabsorbed from the scar, and as the collagen begins to move closer together and cross-link, the scar becomes smaller and harder. This phase begins roughly 21 days after the initial injury, and may continue indefinitely. This phase is responsible for returning tensile strength to the tissue, but the damaged tissue can never return to its original strength, and will remain about 80% as strong as it was before. This is one reason why a healed pressure ulcer is more likely to recur in the same spot, because the tissue will always be weaker. This phase can also be prolonged by the presence of comorbid diseases or conditions, as well as medications. This stage is evident when you see a scar turn from purple or red, to shiny and white, as the tissue is attempting to return to baseline over time [72]. EBP alert! Research and study have led to the identification of wound healing phases. Nurses must be aware of the characteristics of each phase so that they can effectively monitor wound healing. Page 65

68 Factors that affect the healing process There are certain co-morbidities, lifestyles and/or medications that patients may be taking that can affect the ability of their skin to heal appropriately. The most common factors that contribute to improper or decreased wound healing are [73] : Age Aging of the body affects the structure and function of the skin. During the aging process, the basement membranes of the skin thin and become fragile, increasing the risk for wound development. The body s inflammatory response also changes and slows, and wound healing is delayed. There are physical findings in the elderly that affect their ability to heal appropriately within the layers of the skin, such as [73, 109] : Epidermal changes [109] : Thinning of the epidermis (although the amount of cells remains the same, they become thinner, providing less of a barrier). Decrease in new cell production to replace old and damaged tissue. Decreased and slower immune response and immunity Page 66 triggering cells in the skin. Decrease in the number of melanocytes. This is the reason for the translucent appearance of the skin in elderly individuals. The remaining melanocytes can form larger spots of pigment, or liver spots. and may be noticeable in areas that have been exposed to sunlight. Dermis [109] : Strength and elasticity is decreased (this process is called elastosis) due to changes in collagen and elastin, leading to a leathery or weathered appearance. This is also more evident in sun exposed skin (solar elastosis). The blood vessels feeding the skin become fragile and are damaged easily. The result is frequent or easy bruising (senile purpura). The sebaceous glands gradually produce less and less oil, especially in women. This allows the skin to become dry, itchy, and prone to cracking, making both wounds and infections more likely. Sweat glands produce less sweat, making temperature regulation difficult. Hypodermis: The subcutaneous fat layer thins, leaving less protection and insulation, and predisposing the skin to pressure injuries and temperature regulation abnormalities. Nursing consideration: Geriatric skin assessment is of particular importance because of the changes in the skin of older adults. Nurses must be aware of these changes and intervene accordingly. Nutrition It is imperative that the patient has optimal nutritional intake to promote healing. If the patient lacks the necessary nutrients, the wound is unable to produce the cells needed for tissue repair and growth. Below are some examples of how nutrition affects cells needed in the healing process [73, 59, 84] : Protein Proteins are necessary for the production of new cells. When the body is malnourished, ability of the body to form new tissue is decreased or in extreme cases, nearly stopped. Fat Fat is necessary for wound healing as it provides energy to the cells in every phase of the healing process. Zinc Zinc deficiency slows the rate of epithelial cell production and collagen synthesis, thus decreasing the strength of the skin and its ability to prevent wound formation, as well as slowing the rate of healing once a wound is present. Vitamin C Not only is vitamin C necessary for bone strength and healing, it is also a factor in collagen formation, and is frequently recommended as a supplement in patients with healing wounds. Vitamin A This vitamin also helps with collagen synthesis and epithelialization. It is especially useful in patients taking steroids to help combat the skin and wound related side effects. Magnesium Magnesium is vital in the synthesis of protein and collagen. Obesity [73, 84] Obese patients have a large amount of adipose tissue, which is poorly vascularized, leaving the tissues, especially incisions and wounds, ischemic. Obese patients are at higher risk for wound dehiscence (increased tension at the surgical site), surgical site infection, wound infection, delayed wound healing, pressure related injuries, and moisture related skin infections (due to the trapped moisture in skin folds, friction from skin folds rubbing against each other, or the inability to clean effectively). Obesity is also linked to other risk factors associated with wound healing (e.g. Diabetes). The nurse can reduce the risk of complications of dehiscence and herniation by encouraging the patient to utilize a binder or splint over the incision during straining or coughing [54]. Infection [73, 84] A wound cannot heal in the presence of infection, as the body s natural response to invading microbes is to keep the wound in a constant state of inflammation (phase 2 of wound healing). The wound will essentially get stuck in this phase and will be unable to move on to the next phase. Bacteria can also affect the formation of granulation tissue by hindering it, or causing overgrowth. Presence of debris or necrotic tissue: Necrotic tissue and debris in a wound hinders new tissue from growing, provides a breeding ground for bacteria, and prolongs the inflammatory phase of wound healing. Dead material is not useful tissue for the body and must be removed in order for a wound to completely. In addition, tissue can grow over debris during the healing process, trapping it or causing to migrate and cause additional damage [3]. Moisture Moisture can both encourage and impede healing. A moist wound environment promotes re-epithelialization, decreases pain, encourages the natural healing process, and reduces scarring [89]. If too much moisture is present however, maceration occurs, and the skin becomes overhydrated, mushy, and unable to progress or grow new tissue. It takes on a white appearance (like prune fingers). If the moisture is related to incontinence, the irritants and ph level changes resulting from repeat exposure to the body fluids, soaps, and cleaning materials can lead to further skin breakdown and delayed healing [143]. Xerosis (excessively dry skin) Excessively dry skin causes several changes that put the patient at risk for wound development. Cracking, fissures, and scaling are commonly present, opening up the underlying tissue to microbes and infection. The elasticity and strength of the skin is decreased in this state as well, making it prone to breakdown and additional injury. Xerosis is most common in the hands and feet, and is especially prevalent in the elderly population due to the changes that occur in aging skin [116]. Diabetes Diabetes affects wound healing immensely, and not only elevates the risk of developing a wound, but also slows or stops the healing process from occurring. With hyperglycemia, the basement membrane permeability is altered, decreasing the amount of nutrients delivered to the tissues. Diabetes also affects the body s immune system and places the patient at a higher risk for infection [84]. One commonly recognized diabetes related ulcer is a diabetic foot ulcer (DFU), which is typically the result of the poor perfusion, neuropathy, and decreased healing potential, and often leads to chronic, non-healing ulcers [73]. Vascular disease Vascular disease prevents adequate blood flow to tissues and induces hypoxia in a wound bed for a prolonged period of time. If the blood flow is not restored, the wound cannot heal. Decreased blood flow as seen in arterial disease, prevents the nutrients and oxygen rich blood from ever reaching the tissues. Venous stasis disease prevents the blood and fluid from returning to circulation, leading to edema, which increases pressure on the tissues and vasculature from the inside, and also prevents nutrients from reaching the tissues [73]. Medications Certain medications can place patients at risk for developing wounds as well as prevent existing wounds from healing.

69 For example, steroid medications decrease inflammation, preventing wounds from entering or passing through the second phase of wound healing. In addition, they prevent new epithelial cells and collagen from forming, increase blood sugar levels, and increase the risk of infection [84]. Non-steroidal anti-inflammatory drugs have been shown in some studies to slow the rate of wound healing by inhibiting the inflammatory response as well. Patients on chemotherapeutic drugs are at especially high risk for wounds and poor healing potential, as the nature of these medications is to inhibit cell production in diseases like cancer. These drugs also inhibit the body s immune system, making the patient much more susceptible to infections [73]. Smoking One of the effects of nicotine is vasoconstriction, which leads to decreased tissue perfusion and ultimately ischemia to the tissues. Clot formation is also more likely, as nicotine increases platelet stickiness and encourages them to adhere to one another, blocking off blood flow [84]. Smoking also decreases the elasticity and strength of skin tissue, increasing the likelihood of wound formation and making healing more difficult once a wound is present [73]. It is imperative to correctly identify any potential skin injuries in order to prevent additional complications. Once a wound or skin breakdown has been noted, nurses and practitioners need to properly assess the patient by gathering a complete history of present illness, current/ past medical history, medications and a social history, as each of these variables may affect the healing process. Once the history has been obtained, it is essential to assess the patient completely, not just the wound site itself. Wound history and initial assessment Alcohol Alcohol consumption can affect wound healing both during intoxication, and as a result of chronic alcohol consumption. According to Guo and DiPietro (2010), angiogenesis (development of new blood vessels) in a wound is decreased by 61% during intoxication, even with just one exposure. When exposed chronically, nutrition, immunity, and new tissue formation are all affected negatively, resulting on wounds or preventing the healing of existing ones [84]. Stress When the body is stressed, a fight or flight response is induced. This response increases the body s Cortisol levels (a glucocorticoid), which when present in high levels for prolonged periods of time, can inhibit immune function and suppress inflammation in a similar way as steroid medications. Susceptibility to wound formation and infection, and prevention of healing can all be results of the body s response stress. Other underlying disease can have these effects as well, and as the body fights to heal one injury or illness, it has fewer resources to use in the healing process [94]. There are numerous organizations, protocols, and guidelines to help reduce the incidence and prevalence of pressure ulcers nationwide. The Agency for Healthcare Research and Quality (AHRQ) has released and revised several clinical guidelines aimed at preventing and treating various types of wounds, in the hopes of reducing related incidence and mortality [11]. Skin risk assessment tool Every patient admitted to a facility must have a skin assessment done within 24 hours. Although requirements may differ with hospital policies, recommendations by accrediting bodies and literature generally support a full skin assessment within 4-8 hours of arrival, using an approved skin assessment risk tool. An initial skin risk assessment should also be performed in the Emergency Room or upon arrival by transfer to a new facility [12]. Nurses complete an initial skin assessment to reduce the risk of pressure ulcers and skin breakdown during the hospitalization, by identifying problem areas early and implementing early interventions to prevent the wound from progressing. The National Database of Nursing Quality Indicators (NDNQI) recommends that a full skin assessment should be done upon admission, daily, with every transfer (unit-to-unit or facility-to-facility), and with any changes in the patient s condition or identification of risk factors [124]. If the facility where a nurse is employed recommends skin assessments or reassessments are to be completed more frequently, the nurse must adhere to the employer s protocol. The Joint Commission (TJC) has included the prevention of healthcare-acquired pressure ulcers in their 2015 patient safety goals for both acute and long-term care settings. They require the use of a validated skin risk assessment tool, like the Braden and Norton scales. The Braden Scale was developed in 1984 and is the most widely used risk assessment tool for predicting the development of pressure ulcers and skin breakdown during a hospitalization admission. The Braden Scale measures skin areas for [152] : Sensory perception (the patient s ability to respond to meaningful pressure-related discomforts). Skin moisture (the degree to which the skin is exposed to moisture). Activity (the patient s degree of physical activity). Mobility (the patient s ability to change and control body position). Nutrition (food intake). Friction/shear (sliding down in bed frequently, being dragged instead of lifted during repositioning, rubbing against equipment, etc.). To determine what level of risk a patient falls into using the Braden Scale, the nurse must assign a number to each of the six categories objectively (using a 1-4 scale of severity or impairment), add up the sum of the numbers, then correlate that number with the numbers assigned to each level of risk. Studies have shown that using this scale in conjunction with good nursing care and judgment is a reliable tool to predict the risk of pressure ulcers [152] : Scores of 19 to 23 indicate the patient has no risk. Scores of 15 to 18 indicate the patient is at risk. Scores of 13 to 14 indicate the patient is at moderate risk. Scores of 10 to 12 indicate the patient is at high risk. Scores of 9 or less indicate the patient is at very high risk. Some factors that can temporarily influence the Braden scale criteria are: Fever (can cause excessive moisture & dehydration). Diastolic pressure below 60 (results in decreased perfusion). Hemodynamic instability (the body will shunt blood from skin to vital organs to maintain perfusion). Intubation (unable to move without assistance). Nerve blocks/epidurals (decrease sensation temporarily). GI distress or illness (unable to eat normally for a temporary period of time). Cast or brace (may cause friction on underlying skin, or force the patient to drag themselves or be dragged with repositioning). Nursing consideration: Nurses must be very familiar with their organizations policies and procedures regarding skin assessment and follow them carefully. They must also receive the proper education and training to effectively use whatever skin risk assessment tools their organizations mandate. Page 67

70 Patient history Nurses should collect a thorough history from the patient or caregiver to ensure all potential risk factors for wound development or delayed healing are taken into consideration. Even if skin breakdown appears minor, or the patient is presenting with an unrelated problem, it is vital that nurses are thorough in collecting the history. Patients may not always be forthcoming with this information because they do not realize the significance of it, or may have forgotten about it. Nurses who ask all of the appropriate questions could find the missing link in collecting the pieces to the puzzle. The nurse should inquire about any skin conditions, diseases, or injuries, and identify the following if a wound is noted [12] : What is the mechanism of injury? It is important to determine the mechanism of an injury and what type of environment the wound was created. This information helps to determine additional possible damage (aside from the obvious) that could have been done, the likelihood that foreign bodies are present, and if there is increased risk for future breakdown in affected areas [60]. The type of wound, depth of injury, and tissue affected will determine how the healing process progresses, risk of infection, as well as help the nurse identify or prevent any associated co-morbidities. For example: Bite wounds must be evaluated for crush injuries and other soft tissue damage (tendons, ligaments, muscle, etc.). This mechanism of injury is highly prone to infection [27]. Stab wounds should be evaluated for the depth of injury and any damage done to internal structures (blood vessels, joints, organs, etc.). Often, a surgeon is consulted if any structures are involved, especially in high risk areas, like the chest, head, neck, or abdomen [4]. Crush injuries damage any type of tissue involved. This type of injury may be a combination of bone fractures, vascular injury, and nerve damage. In addition, those with crush injuries (especially prolonged) can develop rhabdomyolysis and renal failure. This is a result of the potentially toxic byproducts of muscle and tissue death being released into the system and damaging the kidneys [151]. Lacerations or abrasions from blunt force trauma or accidents can contain fragments of the weapon/instrument/ or surface that came in contact with the wound. The risk for infection is higher if the surface that created the wound was highly contaminated (e.g. knife used to cut chicken) [75]. Chronic wounds can signify a mechanism of injury that is internal, and help the nurse and caregivers identify interventions to treat the underlying cause. For example, diabetes and vascular diseases can cause chronic non-healing wounds. Wound assessment and documentation Once a thorough history has been collected, the nurse must assess the wound and surrounding tissue. The size, length, and depth of the wound bed needs to be measured and documented. Tissue type, amount of each tissue type, exudate (drainage), odor, anatomical location, and signs of infection must also be assessed and recorded. To ensure consistency between caregivers, these wound characteristics have descriptive language and processes for assessment that should be followed [79]. Measure the size of the wound It is important to assess and record the size, length, width and depth of the wound. The size is always measured in the same way, on every patient, with every wound, and always in centimeters (cm) [115] : Nurses should imagine a clock and think of 12 o clock as the patient s head and the 6 o clock as the patient s feet. Always measure the length from 12 o clock to 6 o clock and the width Page 68 Where is the wound? Nursing consideration: The location of the wound is important to identify and document as specifically as possible. Not only does it help others on the healthcare team locate the wound during their assessments and treatments, but thorough documentation provides specific information that can be used to determine the healing progress. In addition, the location of the wound can alert the team if more detailed assessments are necessary or if underlying structures are likely to be involved. For example, if the wound is over the knee, close monitoring of range of motion and signs of infection will be warranted, as the joint may be involved or at risk [79]. How old is the injury? Research has demonstrated that if the injury is greater than six hours old, it is likely already too contaminated to be closed using primary intention and may need to be healed using secondary or tertiary intention. The longer the wound is open to air or other surfaces without cleaning or treatment, the more likely it is to become infected. The risk of abnormal scarring is also higher, as healing begins immediately, even if the wound bed is not in an ideal healing state [158]. Is the wound painful? The presence or absence of pain, as well as the characteristics of the pain reported should be assessed and noted. Some patients will require pre-medication in order to better tolerate dressing changes if they experience pain with the procedure. If the pain is burning or accompanied by tingling, it can indicate that the wound is neuropathic in nature, or if the pain gets worse while a limb is dependent, it could indicate venous insufficiency. These can be important clues to a wound s origin or barriers to healing. What are the patient s risk factors? Healing potential and risk for additional injury can be determined by assessing any other co-morbidities or conditions the patient might have. Diabetes, steroid use, malnutrition, cardiovascular disease, etc. are indicators that healing may be a delayed or unlikely for a patient. Extrinsic factors like homelessness, financial problems, and lack of healthcare can also be potential risk factors, as the patient may choose to be non-compliant with care if they do not have the resources to do so. Physical abilities are also a concern for a patient with a wound. For example, if a patient has little use of their right arm, but they have a wound on their left arm, they will be unable to care for it alone, and will need assistance. The location of a wound can be a risk factor in and of itself. If the patient s wound is on the patient s coccyx, and they have no assistance at home, they will be unable to care for the wound themselves. This location is a at high risk to begin with, as the patient will likely have to sit during periods of the day, in addition to the fact that they cannot see or maybe even reach the area if a problem arises [79]. between 9 o clock and 3 o clock at the longest and widest points. The clock system is also helpful in identifying where structures, tissue types, characteristics, etc. of the wound are located, and ensuring that anyone who looks at the wound bed at any time knows exactly where you were looking when you made the assessment [115]. Depth can be measured using a Q-Tip. As depth can vary within the wound bed, the actual depth measurement is determined by the deepest part of a wound. Once the Q-Tip is inserted, the nurse should use the thumb and forefinger to grasp the spot where the depth is equal with the surface of the skin. The tip of the Q-Tip below the fingers is then measured to determine the depth of the wound [115]. Undermining can occur as a result of friction and shear (as these forces can result in separation of the epidermis and dermis), and

71 can be seen as a separation of tissue near the surface of a wound. This is measured by first determining where the undermining occurs using the clock system. Depth of the undermining should also be determined, but using the same Q-Tip technique used to determine the depth of the wound. The Q-Tip is inserted underneath the flap of overlying tissue until resistance is met. This depth can vary throughout the edges of the wound, so it is important to feel all the way around and note depth differences [115]. Tunneling can occur from improper packing of a wound, but can also occur when infection is present. The tunnel, or sinus tract, can go in any direction, and be any depth. The nurse should gently move a Q-Tip around the edges of the wound and into deeper tissues to see if any tunnels exist. If they do, a Q-Tip should be used to measure the depth, if possible. Tunnels can leave dead space in a wound, resulting in abscesses or worsening infection. If tunnels are present, some dressings and treatment choices may avoided. For example, if a tunnel is noted but the origin or end of the tunnel cannot be determined, a negative pressure wound VAC dressing is contraindicated, as it can pull fluid or infection from an unknown space into a wound, or damage tissues at the other end [165]. Determine the tissue depth Over the years, various organizations have developed guidelines to ensure health care providers are able to describe and classify the depth of wounds into specific categories. These classifications are used to standardize assessments [117] : Superficial wounds involve only the epidermis, and usually heal quickly with few complications. Mild abrasions and stage 1 pressure ulcers are examples of superficial wounds. Partial thickness wounds involve both the epidermis and the dermis, but do not extend any further. They appear pink and painful, but never contain slough or necrotic tissue. A stage 2 pressure ulcer is an example of a partial thickness wound, as it only extends into the dermis. Full thickness wounds extend into the subcutaneous tissue and beyond. Stage 3 and 4 pressure ulcers are considered full thickness, as they involved deeper tissues. Typical examples include deep lacerations, full thickness (fourth degree) burns, medical device related ulcers on the nose and ears, and surgical and traumatic wounds. Full thickness wounds heal by debriding damaged tissue and re-growing new granulation tissue. Ensure whatever is being used to measure the wound does not get re-used on other wounds or other parts of the same wound. Crosscontamination can occur if one wound is infected and another is not, or if a Q-Tip is used to measure into an abscessing tunnel and then used to measure a non-infected tunnel. Enough products should be brought in to the room or examination area to ensure that clean products can be used throughout the assessment [79]. Assess wound drainage The nurse should examine the wound and note any exudate (wound drainage), by documenting the precise amount (if measurable) and appearance with each wound assessment. The amount and characteristics of exudate can change throughout the healing process, and can signify complications, so as much detail as possible should be included. It is important to document the color, amount, consistency and odor of the wound drainage [119] : Color The appearance of the exudate should be described. Exudate is the body s way of getting inflammatory and immune cells to the area, as well as keeping the wound in an ideal moist environment. The color, consistency, and odor of the exudate can vary with different wound bed conditions, and can indicate whether a wound is healing appropriately or if any barriers to healing exist. Exudate is generally a good thing, as long as it is the right types, at the right time, and in the right amounts [5]. Serous fluid is plasma, and appears thin and watery (think of a blister) and is a normal part of the inflammatory process in small amounts. Copious amounts of serous fluid can indicate the presence of a large amount of bacteria, and the provider should be notified for further evaluation if this is noted [119, 5]. Sanguineous fluid is fresh blood. It appears as bright red, and can also be normal in small amounts during the inflammatory phase. If blood is noted as the healing process progresses or after treatments, it can be an indication of wound bed trauma [119, 5]. Serosanguinous fluid is thin and watery in consistency, and appears pink. It is the result of both serous fluid and blood mixing. The presence of serosanguinous fluid can indicate that the capillaries and tissues have been damaged, and is often seen after traumatic dressing changes or treatments [119, 5]. Purulent drainage is typically thick and looks milky or opaque, and can come in a variety of colors like white, tan, yellow, green, or brown. It is never normal in a wound bed, and is almost always a sign of infection. The consistency and color of purulent drainage is determined by the type of invading bacteria (as the bacteria die off, they stick in the exudate) and by the body s own immune and inflammatory cells that are present to fight the infection (white blood cells, red blood cells, etc.). This type of drainage often gives off a foul odor [119, 5]. Seropurulent drainage is a mixture of serous drainage and purulent drainage, so it is thin, but can also come in a variety of colors, with a variety of odors. This type of drainage is also an indicator that an infection is present and the body is attempting to fight it by sending its inflammatory cells to the area [5]. Describe the appearance of the wound tissue Various types of tissue can be found in a wound bed. The type of tissue, as well as the amount of each tissue type identified, should be assessed and documented in as much detail as possible. Percentage amounts are typically used to convey this (for example, 75% granulation tissue, and 25% slough) [115]. Granulation tissue is new connective and vascular tissue (which gives it its red color) being formed to fill in the wound areas where tissue has been lost. It appears as beefy red, bumpy, and uneven, and is a sign that the wound is in the proliferative phase of healing. Too little of this tissue (hypogranulation) can be due to infection, underlying disease, and malnutrition, as the formation of new tissue is not supported by the body. The opposite problem can also occur, and is called hypergranulation. This type of tissue growth results in granulation tissue that extends above the surface of the skin. A wound cannot fully heal in this scenario either as the epithelial cells that are attempting to migrate across the surface of the wound cannot move over the mound of tissue [146]. Necrotic tissue (dead tissue) can appear as black, brown, yellow or white, and can be hard and tough or soft and moist. A wound cannot heal completely in the presence of necrotic tissue, so whether the body debrides the wound on its own or a provider does it, it must be removed to enter the final phase of wound healing. Two types of necrotic tissue can be found in a wound: Slough is a yellow or cream colored dead tissue that occurs as cells in the wound bed die and collect throughout the wound bed. It is usually stringy or gooey in consistency, and can either be attached to the wound bed, or separated and easy to remove. Slough is present in most chronic wounds, as tissue cells die in about 3 weeks and can build up underneath dressings unless removed [9]. Eschar is dead tissue that is black, tan or brown in color, and tends to be rough and hard. It can be debrided by a provider or the body can naturally debride it over time. Often providers will cut a series of lines into the eschar to allow moisture in in Page 69

72 order to soften the tissue and encourage the body to expel it on its own [10]. Epithelializing tissue appears as a shiny white layer over the surface of the healing tissue, and is the body s way of attempting to provide a new protective layer over the wound. This tissue advances from the edge of the wound inward, as long as there are no barriers (hypergranulation, infection, etc.). Even though it advances from the edges, it can still be seen throughout the wound in many cases as the process of covering the wound bed does not happen evenly. It is sometimes described as white shiny islands dotted throughout the new tissue [25]. Poorly healing wound tissue appears as pale pink, dusky, or blanched. This tissue is usually poorly vascularized and lacking the nutrients necessary for healing. This can be due to underlying disease, infection, and any other condition that prevents the wound from healing properly. It is often described as clean, but non-granulating tissue. It is not dead tissue, but is lacking the ideal wound healing environment. Typically, if this environment is provided, the tissue will begin to granulate. Wound edges The wound edges should be inspected for signs of healing as well as barriers to healing. There are several important characteristics to assess about the wound edges [115] : Are the wound edges undefined or under defined, meaning are the wound edges unable to be clearly distinguished wound outline? Are the edges attached or unattached to wound bed? Are the edges rolled under (Epibole)? Epibole occurs when the epithelial cells begin migration toward the center of the wound, but the wound bed is not in contact with the wound edges. The epithelial cells travel down the wall of the wound and hit other epithelial cells located along that wall. These cells know that their migration is over when they make contact with other epithelial cells on the other side of the wound, so when they hit the other epithelial cells on the wall of the wound instead, they think the healing process is done, and they stop migrating. The wound cannot heal entirely if epibole is present. Is hyperkeratosis present? This is callous like tissue formation around the wound and at the edges. It is often seen Page 70 in diabetic foot ulcers. Is the tissue fibrotic or scarred? Fibrotic tissue is hard or rigid to touch. It is often the result of repeat trauma or ulceration to an area, but can also be the result of abnormal scarring processes (like keloid scarring). Surrounding skin (peri-wound area) Note if there are any abnormalities or concerning characteristics, such as [79] : Maceration, which can occur when the wound and surrounding tissue is exposed to excessive amounts of moisture, and takes on a white and wrinkled appearance. This can happen with Diagnosing wounds Proper diagnosis of the type of wound, cause, and any associated conditions or co-morbidities is key to proper wound healing. If a wound is not properly diagnosed, then the patient may receive ineffective treatment, exacerbating the injury and decreasing the potential for the wound to heal. The NPUAP has noted that the most challenging wounds to diagnose are chronic wounds on the lower extremities, as they may be related to neuropathy, ischemia, venous hypertension pressure, or a mix of any of these causes [129]. The primary care provider and/or provider responsible for the care of the wound may order certain labs and/or diagnostic tests to help determine the degree of damage and underlying factors that may affect the healing process. The following laboratory, are some examples: Laboratory work Basic metabolic profile (BMP) is used to assess for electrolyte imbalances, blood glucose level, and renal function [110]. This test is especially important in diabetics and those known to be malnourished. external exposure moisture (sitting in urine and feces) or from the wound s own exudate. Dressings are needed to decrease the amount of drainage if maceration is noted [115]. Erythema can be an indication of underlying inflammation, most often caused by infection. It is bright red and often hot to the touch. Unblanchable redness can also indicate pressure damage (stage 1 pressure ulcer). Eccymosis, or bruising, is an indication of trauma or damage to the tissue and vasculature under the skin. Edema or induration is swelling or firmness around an incision or wound edges, and can be an indication of infection. Dusky redness or bluish hue can be a sign that vascularity of the periwound area is poor. Dark red areas are often noted in the legs, and can be a result of poor venous return, as hemosiderin leaks into tissue and is left behind, staining the skin [29]. Excessive dryness of the skin or abnormal texture can lead to hyperkeratosis or skin cracks. Lesions or rashes can indicate a disease process or underlying infection. Assess and document the circulation, sensation and movement distal to the wound [107]. It is important to assess for arterial or venous disease, because it may actually be the cause of the wound and can impede the ability of the wound to heal. A patient with arterial deficits should be referred to a surgical specialist immediately. If there is a wound or skin breakdown is noted on any of the patient s extremities, the nurse needs to assess the distal circulation, sensation, and movement to determine the extent or presence of deficits. Assess and document the range of motion (ROM) and strength of the affected and/or adjacent extremities. Decreased range of motion can be not only a result of tissue damage, but a cause of additional tissue damage and ulceration. This is especially likely if the patient has decreased sensation as well or is required to wear a brace or supportive device which can also cause pressure, friction and shear to the already affected area. Decreased strength can prevent the patient from moving or repositioning in the same way those with normal strength would, thus predisposing them to skin injury [79]. Nursing consideration: It is essential that nurses document all wound assessment findings objectively and with as much specificity as possible. The preceding recommendations for assessment and documentation should provide the nurse with a thorough set of guidelines for accurate wound assessment and documentation. A coagulation study (PT, PTT, INR, Platelets, certain blood factors, etc.) is used to evaluate for coagulation abnormalities, especially if the wound is to be debrided. Examples of abnormalities include Coumadin or heparin overdose, Factor V Leiden, Hemophilia, etc [169]. Complete blood count (CBC) is used to assess for leukocytosis, anemia and thrombocytopenia. Leukocytosis is elevated white blood cells (WBC) and indicates an inflammatory response [83]. Sometimes, those with immune compromise (cancer, HIV, AIDS, etc.) or who are currently fighting another illness, may exhibit Leukopenia instead of Leukocytosis. This is when the WBC count drops to below normal because they are being used up faster than the body can produce new ones. This can also be a sign of infection or impending sepsis [102]. Anemia is exhibited by low hemoglobin and hematocrit, and depending upon the actual cause of the anemia, other factors such as the mean corpuscular volume (MCV) and mean

73 corpuscular hemoglobin (MCH) may be altered. It is important to identify anemia in any patient with a wound because it will prolong the healing time due to the lack of oxygenation and perfusion necessary to produce new tissue [7]. Thrombocytopenia is a low platelet count that may be caused by fever, infection, underlying immune disease, certain medications, and other factors. Low platelet count can put the patient at risk for bleeding [106]. C-reactive protein (CRP) is used to assess for inflammation, and may be ordered to measure baseline levels as well as to monitor the effectiveness of treatment. CRP is not a specific test for any certain disease, but a marker to evaluate an inflammatory response in the body [101]. Protein, albumin, & pre-albumin are used to assess the patient s nutritional status, presence of underlying disease, as well as liver and kidney function. Low serum protein can be indicative of underlying cancer, malnutrition, poor dietary protein, or renal loss. Albumin is the most abundant protein in the body, and can be low for a variety of reasons as well, including those previously mentioned. Checking the serum albumin level is important, as it has a longer half-life than most other proteins, and can indicate long term malnourishment in a patient. Serum pre-albumin is sensitive for relatively acute malnutrition because the half-life is two to three days (rather than 21 days for albumin). Obtaining the levels of all three of these proteins can paint a more accurate and inclusive picture of a patient s nutritional status [36]. Cultures In order to assess for any pathogens present in the wound, blood and wound cultures are often taken to determine the most appropriate therapy. One should not assume that just because a wound is open that it is infected, as detailed below [74] : Colonization is defined as the presence of organisms without any clinical signs and/or symptoms of infection. All wounds have bacteria present in varying amounts and types, depending on the location and cause of the wound, just as it is present on healthy skin. All wounds are considered colonized. Wound infection is a contamination with a pathogenic organism that invades into deeper healthy tissue, and elicits an immune response from the host. Responses can be local, like edema, redness and heat, or systemic, like fever, chills, or lab value changes. Wound cultures should be obtained by first rinsing and cleaning the wound. If the wound is swabbed prior to cleaning, the culture will measure the surface bacteria, and not the underlying infecting bacteria or fungus, thus making the culture inaccurate. If further testing is required, the doctor may obtain a punch biopsy (see below) of the tissue in the wound, which gives a more specific and detailed picture of exactly where and how the organism is affecting the area [86]. EBP alert! Clinical research and study show that wounds must be rinsed and cleaned prior to obtaining the culture to avoid measuring surface bacteria [86]. Nurses must not only be aware of this, but must be sure to teach their colleagues about the proper way to obtain wound cultures. [48, 45] MRSA MRSA is a staphylococcus aureus infection that is resistant to treatment with methicillin and other similar drugs that typically and historically treated staphylococcus infections. MRSA has become prevalent in the community and hospitals nationwide. The CDC reports the following: 33% of people carry S. Aureus in their noses, and 1 in 50 people are colonized with MRSA. Although the rates of life threatening MRSA infections are declining in the healthcare setting (down 54% due to increased monitoring and screening), it is still a major problem in the community and in healthcare. There were over 75,000 invasive MRSA infections in the United States population in ,670 people out of every 100,000 will experience an invasive MRSA infection in some way. MRSA can colonize in the nares and on the skin and can be spread by skin to skin contact, use of contaminated objects, sharing of equipment, lack of hand washing, etc. Athletes, hospital patients, military personnel, children in daycare, and others in close contact with one another and using common objects are at highest risk. Immunocompromised patients (cancer, AIDES, HIV, organ transplant, etc.) and other co-morbidities can make not only the general risk for infection go up, but may contribute to breaks in the skin and altered skin integrity, making MRSA infection more likely. Considerations that place people at risk for MRSA infection also include: Patients who reside in a long-term care facilities or who have been hospitalized for more than 14 days. Patients with invasive catheters, including but not limited to devices for dialysis, central lines, and Foley catheters. Patients with recent antibiotic use, especially if the course of antibiotics was not finished. MRSA typically presents as a spontaneous appearance of a raised red lesion, with surrounding warmth, redness, pain, and swelling, sometimes accompanied by pus or a fever. The infection can begin by looking like a spider bite, and many patients present thinking this is what they are experiencing, but unless confirmed as a spider bite, it should be treated as a bacterial skin infection. In order to confirm the diagnosis, cultures are completed immediately if MRSA is suspected. The patient s overall health condition and whether hospitalization is required will determine the treatment plan. If the patient is admitted to the hospital, he or she will typically be prescribed vancomycin. In many cases, the infection can be drained, but if it cannot, or additional structures may have been affected, further exploration may be necessary. Nursing consideration: In order to prevent transmission, all health care workers should wash their hands, follow universal and contact precautions, keep the patient in isolation and disinfect all materials that come in contact with the patient. Patients should have their own supplies while hospitalized, and they should never be shared. Diagnostic tests In addition to laboratory data and cultures, the following diagnostic tests may also be ordered [57] : Plain radiography (X-rays), CAT scan (CT) and magnetic resonance imaging (MRI) to assess for any underlying abnormalities, abscesses, and/or foreign bodies. It is important to obtain an X-ray with any accidental injury or if a patient presents with an incomplete history because injury caused by a foreign body and subsequent wound infection could be present. Foreign bodies can prevent the healing process and cause infection as debris and retained fragments can both introduce and harbor bacteria. X-rays may also be ordered for any significant animal bite, such as a dog bite, since many dog bites cause crush injuries and damage to the surrounding tissues. These tests can also be helpful in diabetic wounds to assess for bone deformities. Abscesses and pre-existing infections can also be identified using these diagnostic tests, allowing for treatment and alerting the provider to the need for additional testing in many cases [96]. Vascular ultrasonography (US) is used to evaluate for venous disease or occlusion [86]. Doppler waveforms are utilized to help the provider or caregiver assess for the presence, strength, and location of pulses [86]. Transcutaneous oxygen pressure is used to assess the oxygenation level of the tissues, and can help determine arterial insufficiencies [86]. Page 71

74 Ankle/brachial index (ABI) is completed to evaluate for arterial disease and insufficiencies. This is done by dividing the blood pressure in the ankle (whichever ankle has the highest blood pressure) with the brachial blood pressure, which gives the provider an idea of how much blood flow is reaching the ankle. This test is inaccurate in people with vascular calcification, therefore, it is not useful in many diabetics. The readings indicate the following [114] : 0.9 to 1.3 is normal. Above 1.3 is indicative of calcified vessels. Below 0.9 Indicates arterial insufficiency, to varying degrees: 0.4 to 0.9 can be associated with claudication and pain. Treatment of wounds In order to maintain overall homeostasis and promote wound healing, factors including tissue perfusion, nutrition, pain, underlying disease, healing ability, and any co-morbidities should be considered so the best treatment decisions can be made. Antimicrobials There are a plethora of bacterial or fungal sources for causing infection, but not every wound is infected simply because one of these sources has been identified. Topical and systemic antimicrobials are frequently used in the treatment of wounds, especially chronic ones. Many believe that these antimicrobials are necessary with an open wound, regardless of the lack of signs or symptoms of infection, but this is not always the case. Overuse of antimicrobials can lead to resistance and the creation of superbugs, which leads to two times the mortality rate of non-resistant bugs. Careful consideration should be given to the use of antimicrobials in a wound or systemically when a wound is present to prevent unnecessary use. The patient s history, current state of the wound bed, bacterial burden of the wound, healing potential and other factors should be considered when making this choice [66]. Nursing consideration: The concern about the development of antibiotic-resistant pathogens is a growing concern in the healthcare community. It is important that nurses support interventions, such as the stopping the inappropriate use of antibiotics, to decrease such resistance. Debridement Debridement is a method of treatment that involves the removal of necrotic tissue so that granulation can occur and the underlying wound can progress in the healing process [8]. There are various types of debridement: Autolytic debridement involves the use of the body s own enzymes and healing processes to rehydrate, soften and liquefy, then expel the eschar, debris, and slough from the wound. When a scab falls off after an injury, this is an example of autolytic debridement [160]. This type of debridement is often achieved with the use of occlusive or semi-occlusive dressings that keep the body s own fluids in the wound bed, providing a moist wound healing environment, and encouraging the patient s own system to heal the wound. Although effective in many cases, this method should not be used in infected wounds or wounds that need to be debrided quickly [160]. Enzymatic debridement involves the use of chemical enzymes (usually in the form of an ointment) that breaks down necrotic tissue. Most enzymatic debridement ointments on the market today (e.g. Santyl) do not damage healthy tissue, but can cause inflammation when it comes in contact with it. Although quicker in many cases than autolytic debridement, if a wound needs to be debrided quickly, enzymatic debridement may not be appropriate [160]. Below 0.4 is severe obstruction, and can progress to ulcerations, pain, and gangrene. This level is limbthreatening, and a vascular specialist should be consulted. Biopsies Biopsies may be done to assess for potential complications of certain wound injuries. The most common type of biopsy is a punch biopsy in which a small, circular instrument is used to sample the wound tissue. This is commonly done in wounds that have not responded to treatment, or if malignancy is suspected [134]. Biopsies of other tissues can be helpful as well, for example, a bone biopsy can allow the provider to see exactly which organism is causing osteomyelitis and select the correct treatment, and is in fact, the gold standard for such a diagnosis [66]. A dressing used in conjunction with enzymatic debridement needs to be compatible with the medication being used on the wound bed, as these products can be neutralized or react with certain treatments, like silver or iodine wound dressings [145]. Mechanical debridement involves the removal of unhealthy tissue by force [160]. Examples of mechanical debridement include wet-to-dry dressings, in which a moist dressing is applied to the wound bed, allowed to dry, and then pulled off. Wet-to-dry dressings should be avoided if possible and are considered by most wound care specialists to be a substandard treatment, as they cause damage to healthy tissue, can cause bleeding, and are painful to the patient [56]. Studies have shown that bacteria can penetrate 64 layers of gauze to reach the wound bed [118]. The inadequate dressing, trauma to the wound bed, and inability for the wound to return to its ideal temperature (discussed later in this course) all create an environment that is not conducive to healing and at a higher risk for infection [118]. Other types of mechanical debridement include ultrasound, hydrotherapy (pulse-lavage), as well as whirlpool therapy [160]. Surgical (sharps) debridement involves the removal of necrotic tissue (either in an operating room or at the bedside) by cutting it away. This can be done with scalpels or sharp surgical tools, or with lasers. This is the quickest way to remove dead tissue, and can be used in infected and non-infected wounds. Surgical debridement is often the chosen method of debridement when a limb is at risk, or deeper tissue may be affected. If the procedure is to be done by the bedside, the patient should be pre-medicated with pain medication, and all supplies should be ready and available for the provider. Sharps debridement should only be performed by those who are trained and according to state determined scope of practice guidelines [160]. Maggot debridement therapy (MDT) uses medical grade sterile fly larvae (maggots) to debride a wound. The maggots use their own enzymes to dissolve and eat the dead tissue in the wound bed, and do not damage the healthy tissue in any way. This method can also be used in infected wounds, and can completely debride a wound in the space of about a week. Although completely safe, MDT is not commonly used as it still carries somewhat of a stigma with its use. Patients do not feel pain, but can sometimes feel a tickle or movement in the wound due to the movement of the maggots. New ways of introducing the maggots into the wound are being introduced as this type of debridement gains popularity again. One such method holds the larvae in a breathable pouch, which is placed in the wound bed. The maggots will release the enzymes used to break down the dead tissue and debride the wound, all while remaining contained. The pouch is removed 48 to 72 hours after placement, before the larvae turn into flies [160, 132]. Page 72

75 The aim of applying a dressing is to protect the wound and provide the ideal environment for healing. Often the TIME framework (tissue, infection, moisture, and edge) is used to identify barriers to healing and provide treatments or dressings that addresses these barriers [64]. Tissue: The provider or caregiver needs to determine if the tissue in the wound bed is healthy, clean but non-granulating, or necrotic. The type of tissue in the wound bed is a major factor in determining the dressing or treatment. If a wound bed is completely covered in eschar, debridement may be necessary before certain types of dressings or additional treatments are initiated. The determination of the type of tissue in the wound builds the basis for the entire treatment of the wound, and as the tissue types change, the treatments should as well [64]. Infection: Determining the presence of infection or high bacterial load is vital to the treatment of a wound. Dressings exist with various types of antimicrobial properties (like silver or iodine), and can be used in an infected wound, potentially in conjunction with systemic antimicrobials, to decrease this bioburden. The use of these dressings and treatments should be stopped when the wound is no longer infected, and frequent re-assessment of the infection status of a wound should take place. The compatibility of these dressings should also be considered when choosing treatments. For example, silver is deactivated by normal saline, so sterile Dressings water should be used to cleanse the wound if a silver antimicrobial dressing is being utilized. Manufacturer guidelines for wound care products should always be followed when treating a wound [144]. Moisture: The wound should be assessed for both excessive moisture and excessive dryness when choosing a dressing. Excessive moisture can lead to wound maceration and decreased ability to heal. In this case, dressings that absorb and wick moisture away from the wound bed should be used. Wounds that are too dry also prevent the healing process, and can put the wound at risk for infection when cracks or fissures occur. Dressing should be chosen that promote moisture retention, or can be used in conjunction with gels or moisture adding wound fillers [64]. Edge: The wound edges are important to asses as well. If the wound edges are not advancing and contracting, then the wound will remain open. As reviewed earlier in this course, epithelial cells will not advance if the edges are rolled under, as they have been tricked into thinking that the wound is closed by coming in contact with the wound wall. In some cases, the wound edges will need to be debrided, and dressings chosen that will support the growth of new cells, as well as allow them to migrate. Macerated, cracked, jagged, and discolored (among other characteristics) edges can give vital clues to the treatment needs at any given time [64]. Types of dressings Nursing consideration: It is important for the nurse to understand the types and purpose of dressings to ensure the ideal and most appropriate dressing is applied to a wound for adequate healing. A dressing that is ideally suited in the early stages of treatment of infected, malodorous or necrotic wounds may not be appropriate for the later stages of healing. For example, sterile maggots have been used to treat wounds rapidly and cost-effectively, but some researchers suggest maggot dressings should not be applied to all types of wounds or throughout the entire healing process. Similarly, a dressing that promotes angiogenesis and the production of granulation tissue may not be equally suitable for the final epithelialization stage of wound closure. The previously discussed factors should be taken into consideration when choosing a dressing, and reassessed throughout the continuum of care. The workload of the staff should also be established and feasibility assessed. If a dressing needs to be changed every 8 hours, the ability of the staff to complete the dressing change is vitally important. If the recommended use criteria cannot be met, another dressing should be chosen. Comfort and usability (especially if the patient will need to perform dressings themselves) should also be considered [33]. In addition to workload, the wound bed itself can be negatively impacted by frequent dressing changes when the temperature drops due to cleaning and exposure. Cleansing and opening the wound up to air decreases surface temperature, and a change of as little as 2 degrees can affect the healing process. Every time a dressing change is done, the temperature of the wound bed is decrease for up to forty minutes, altering the body s inflammatory and immune response for up to 4 hours, meaning if a dressing is to be changed every 6 or 8 hours, the wound bed is only at its ideal temperature for ¾ or ½ of the day. This one of the reasons why modern dressings are being engineered to stay in the wound for longer periods of time than dressings used in decades past [139]. Absorptive dressings are made of super absorbent materials, like cotton, cellulose, or rayon, and can be used alone or in conjunction with another dressing (as some are not self-adhesive). These dressings prevent the wound exudate from staying in the wound and macerating the tissue, and are designed to not adhere to the wound bed, so removal is usually painless for the patient. They can be used on wounds with moderate to large amounts of exudate, and should not be used on a dry wound, as damage from overdrying can occur [159]. Examples include Xtrasorb, Primapore, and Optilock dressings. Alginates are soft, nonwoven fibers that are derived from the natural fibers in seaweed. They are used in wounds with moderate to heavy exudate due to their absorptive properties (using them on dry wounds can over dry the wound and cause desiccation). When the fibers are in contact with wound exudate, they take on a gellike consistency and remain soft and comfortable in the wound, making it ideal for packing into irregular and deep wounds, or wounds with tunnels. They are available in pads, ribbons, and ropes, and do not typically come in a self-adhesive form, which means a secondary dressing is required in most cases. The typical length of time the dressing can be left on is 3-5 days, but can be changed earlier if the dressing is oversaturated or leaking [33]. Examples of alginates include Algicell, Durafiber, and Maxsorb dressings. Biological dressings are dressings that mimic human skin, to promote coverage and healing of a wound (often used in burn injuries). Adherence to the wound bed needs to be established in order for these dressings to work, so rejection of the foreign tissue or use in a wound without a uniform thickness can predispose these dressings to failure [120]. Examples include Dermagraft, Proderm, Apligraf, and Integra skin substitutes. Gauze & non-woven dressings are dry, varied in absorbency potential, and can come in sterile or non-sterile packaging. They are used to cover, pack or fill a wound. Woven gauze should be avoided in wounds, as the fibers can get left behind when the gauze is removed, increasing the risk of infection and causing an inflammatory response to the foreign body [159]. Examples include Curad, Excilon drain and IV sponges, and Cosmopor dressings. Foams are indicated for absorption and protection. They are typically used on wounds with moderate to heavy exudate, and contain small cells that hold moisture away from the wound. Most foams are non-adhesive (although some come in bordered forms), which makes them ideal choices for patients with adhesive allergies. The absorption of fluid can be visualized on the foam Page 73

76 dressing as it changes color or becomes darker as it traps liquid. Once the dressing is significantly saturated, it will not be able to hold more fluid, and should be changed. This will be a different time period depending on the individual wound, so the dressing should be monitored closely. These dressings often also come in antimicrobial varieties for use on infected wounds [33, 159]. Examples of foam dressings include Allevyn, Aquacell Foam, Lyofoam, Mepilex Foam, and Polymen nonadhesive dressings. Hydrocolloid dressings provide an environment that prevents the evaporation of moisture from dry wound beds, so they should not be used in wounds with moderate or heavy exudate. They come in the form of occlusive adhesive wafers, pastes, or powders and can stay on the wound for up to 7 days. The adhesive wafer dressings should not be used on infected wounds as the dark, moist, and sealed environment they create can increase bacterial burden. As these dressings are waterproof, they are often used with dry wounds that are exposed to incontinence fluids [33, 159]. Examples of hydrocolloids are DuoDerm, Replicare, and Nu-Derm. Hydrogel dressings are used to rehydrate the wound bed and create a moist wound healing environment in order to promote autolytic debridement. They can come in gel form, which is applied directly to the wound bed and covered with a secondary dressing, or foams and hydrogel sheets, which are dressings impregnated with the hydrogel. These dressings should be changed at least every 2-3 days, or if the wound bed becomes macerated (indicating too much hydrogel was used) [33, 159]. Examples are Derma-gel, Spand-gel, and Aquasite gels or sheets. Hydrofiber is an absorptive textile fiber pad that is also available as a ribbon for packing of deep wounds. Hydrofiber works by combining with the wound exudate to produce a hydrophilic gel, maintaining a moist wound environment and generally providing comfort. Patients can sometimes feel a drawing sensation as the dressing absorbs the wound s moisture, but pain is rarely felt. These dressings should not be used on dry wounds, as they can cause desiccation [33]. Examples include Aqua-cell and ActivHeal AquaFiber dressings. Hydrophilic wound fillers are non-adherent materials that are placed into the wound to fill dead space and control exudate. They can come in the form of beads, gels, ointments, pastes, powders, and many other forms. They can be used in nearly every type of wound, and are typically activated when they come in contact with wound exudate. Dead space that is not filled can lead to abscessing and tunneling infections, so these dressings are frequently used for deep cavernous wounds [159]. Examples include Gold Dust, Multidex gel or powder, and Altrazeal powder dressing. Nutrition Proper nourishment contributes to the support and growth of new tissue, so patients should be encouraged to eat a well-balanced diet to maintain homeostasis. However, patients who are at the highest risk of inadequate wound healing are often also at high risk of nutrition imbalances and deficiencies. Below are some tips and recommendations for nutritional support and assessment for patients with high risk for developing wounds or with an existing wound [137] : For the average healthy adult, the daily protein requirements are approximately 0.8 to 1.0 grams of protein per kilogram (kg) per day. If the patient has an existing pressure ulcer, this requirement jumps to 1.2 to 1.5 grams of protein per kilogram (kg) per day in order to support the healing process. Examples of foods high in protein include beef, chicken, pork, turkey, eggs, liver, milk and cheese, but if a patient is unable or unwilling to eat high protein foods, protein supplements can be used, and are available in many different forms [137]. Serum albumin, pre-albumin, and protein levels are a good indicator of a patient s nutritional status. If an albumin level is less than 3.5 mg/dl, malnutrition should be suspected. As mentioned Page 74 Contact layers are non-adhesive layers that are placed on a wound bed that allow the wound exudate to flow through, but prevents direct contact with the material used. They are used to avoid sticking when the dressing is removed, and are useful on sensitive areas, or when underlying structures (like bone, tendon, organs, etc.) are visible in the wound. They are also frequently used on burns and skin grafts to prevent damage to the underlying tissue with dressing changes and inspections. Topical medications may still be used, as well as moisture controlling or moisture encouraging dressings or wound fillers [159]. Examples include Adaptic, Mepitel, Dermanet, and Telfa dressings. Antimicrobial dressings are dressings that decrease the bacterial burden of a wound. Some are also useful with fungal and viral contamination. The antimicrobial materials are typically impregnated into a variety of existing dressings, like hydrofibers, hydrogels, foams, etc. They can also be used in high risk areas, like tracheostomies, surgical sites, or central lines as prophylaxis or management of infection. Consideration should be given to the type of wound the dressing is being used on. For example, a silver hydrofiber dressing should not be used on a dry wound. It will not only increase the risk for desiccation of the wound, and must be moistened prior to application, but will not release its antimicrobial properties unless in contact with wound exudate. Antimicrobial dressings come in almost every shape and size a dressing is available in, and can decrease the need for systemic antibiotics if the infection is deemed to be local [159, 166]. Examples include Aquacell Ag, Hydrofera Blue Foam, Iodosorb, Acticoat, Allevyn Ag, Optifoam Ag, and many others. Transparent films are useful for clean, dry wounds having minimal exudate, and can also be used to secure an underlying absorptive material. They are used for protection of high-friction areas, areas that need to be visualized (like IV catheter sites), and areas that are difficult to bandage such as heels [33]. The advantages of transparent films include flexibility, and the fact that they are waterproof and can be used in areas that are exposed to liquids if appropriate for the wound. Transparent films should not be used on wound with moderate to large amounts of exudate, as the moisture will be held in and encourage maceration or cause the dressing to fall off [33]. Examples include Tegaderm and Op-site dressings. Island dressings are typically used over wounds closed by primary intention. They contain a pad made of a cellulose material to absorb surgical site drainage in small to moderate amounts surrounded by an adhesive border (much like a large Band-Aid). These dressings can sometimes exacerbate adhesive allergies, so patient history and identified sensitivities should be considered [33]. previously, total protein levels can be a good indicator of overall nutritional status over long periods of time, while pre-albumin levels are more short term indicators [137]. Energy is needed during the healing process as well, and the patient will often require a higher calorie diet to facilitate this. The exact amount of calories necessary is based on lab work, the patient s co-morbidities, and expected exertion or activity levels. A dietician should be consulted if a patient is at high risk for, or has an existing pressure ulcer in the presence of co-morbidities like renal disease, diabetes, liver disease, gastrointestinal bleeding or disease, and other diseases that affect the body s ability to process and eliminate nutrients. If a patient is suffering from an eating disorder, or is clearly malnourished, no additional co-morbidity is necessary for a consult, and nursing judgement can always be used to assess if a patient is at risk, no matter the diagnosis [137]. All patients should be encouraged to eat adequate servings of protein, carbohydrates, vitamins, minerals and trace elements to support wound healing, If unable to eat, parenteral nutrition can be provided and tailored to the patient s specific nutritional needs.

77 Fortified foods and supplements can also be added to a poor diet to assist the patient with decreased appetites. Certain medications are available that be prescribed by the provider that help increase the patient s appetite. A dietician and the provider can recommend or prescribe these interventions based on the patient s specific deficiencies and needs [137]. Patients who have vitamin or mineral deficiencies should receive supplemental treatment immediately to promote the progression of Pain Depending upon the depth of injury, structures involved, infection, and other co-morbidities, patients may experience varying levels of pain at a wound site. Therefore, it is important to assess pain levels according to the hospital policy as a baseline prior to any treatments, as well as before, during, and after administration of pain medications. Pain assessment should include all qualities of the pain that can be determined (radiating, exacerbated by, etc.). In addition to administering pain medications, there are other treatment modalities that may help reduce the pain level [42] : Cover the wound appropriately. Sutures If sutures are required, the nurse should inspect the wound routinely for infection, allergic reaction, dehiscence, and drainage. It is possible Methods of wound closure Another factor that contributes to the healing process is the method used to close the wound. The provider will choose the optimal manner for wound closure dependent upon the patient s history, the amount of tissue damaged or lost with the injury and the potential for/presence of existing infection [72]. The methods of wound closure include primary, secondary and tertiary (delayed primary) intentions [142, 72] : Primary intention involves the primary closure of the wound by mechanical means, such as tape, steri-strips, sutures, staples or glue. A surgical incision is typically closed through primary intention. The method of first intention is preferred if there is minimal tissue loss and the skin edges are well approximated. The wound will repair through the normal phases of the wound healing process. If the patient has no co-morbid conditions to prevent it, epithelialization begins and the incision line is resurfaced within 72 hours of closure. A healing ridge occurs along the incision line between days five and nine days after repair. The healing ridge is exhibited by firm edema or induration and it extends approximately one centimeter (cm) outside the incision line that appears around days 5-9 after the initial incision. It is important to assess for this ridge, as the lack of a healing ridge can indicate delays in healing, making the risk of dehiscence and infection much higher [115]. The advantage Tetanus vaccination [46] Tetanus is caused by the exotoxin produced by the bacteria Clostridium Tetani. The effect of this exotoxin is severe muscle spasms, often widespread, but most well known to be associated with the jaw (lockjaw). The bacteria is most often introduced into the body through a wound, and has an incubation period of 3 to 21 days, so the healing process. Consideration should be given, however, to any interactions the supplements may have with other treatments the patient is receiving. Leafy green vegetables, for example, are high in Vitamin K (a vitamin that affects clotting ability). Vitamin K is the antidote to Coumadin, so if the patient is on Coumadin therapy, the amount of Vitamin K ingested should be carefully monitored. Specific vitamins and minerals that affect healing were reviewed previously in this course [137]. Adjust support surfaces for the patient. Reposition the patient to a comfortable position that also leaves the wound in a non-stressed position. Reduce anxiety, as high levels of anxiety have been shown to increase reported pain levels experienced by a patient. If a dressing is sticking or causing pain or irritation in the wound bed, other dressing types should be considered. Distraction (like books, magazines, etc.) can be provided for the patient to look at during the procedure. for skin to grow over sutures if they are not removed, which can increase the risk for damage and infection. of primary intention healing is that closure occurs quicker, and if cared for properly by the nurse and patient, the risks of infection and wound complications are fewer. Secondary intention healing involves wounds that are left open to heal spontaneously due to significant tissue loss, damage and/ or bacterial contamination. The healing process is typically longer as the wound is allowed to form new granulation tissue and heal from the inside out. Deep and wide scars can form once the wound is healed. Secondary intention wound healing is often used in open abdominal wounds, dehisced wounds, stage three or four pressure ulcers, burn injuries, traumatic injuries and infected wounds to avoid abscessing. Tertiary intention (delayed primary) healing involves a combination of primary and secondary intention. This method can be chosen when a wound is contaminated and the risk of infection is high. The wound is left open initially (secondary intention) treated and cleaned, then surgically closed (primary intention). The primary goal of treatment with tertiary intention is to preserve healthy tissue, allow for debridement of necrotic tissue, decrease the risk of infection and abscessing, and promote the growth of new healthy tissue [147]. effects of the exotoxin are not seen immediately. This is a contributing factor in the fact that many tetanus infections can be linked back to minor wounds, for which the patient did not feel seeking treatment immediately was necessary. Nursing consideration: The CDC recommends that if a patient presents with any wound other than a clean, minor wound and does not have a clear history of at least three tetanus vaccinations, he or she should receive the tetanus immune globulin (TIG) and a tetanus vaccination. Tetanus immune globulin acts on tetanus already in the body by helping to remove the toxin, although it will not remove toxins already bound to nerve endings. It is important to remember that a previous tetanus infection does not lead to immunity, so appropriate precautions and treatments should be initiated regardless of tetanus illness history. Page 75

78 The CDC has released the following statistics about tetanus infections: The fatality rate associated with tetanus infection is 13%. The most common age group associated with tetanus infection is 50 years or older. Tissue perfusion/oxygenation It is imperative to ensure that there is adequate oxygenation and perfusion within the body as it is a foundation for wound healing. In order for oxygen to reach the tissues, the patient s airway must be protected or established, and can be a major concern especially with traumatic wounds. Blood loss is another factor associated with traumatic wounds, as well as internal bleeds (like a GI bleed). Patients presenting with trauma or illness that includes blood loss need to be monitored for signs and symptoms of poor perfusion and shock, which include the following [104] : Pale, mottled, diaphoretic skin. Tachycardia. Tachypnea. Hypotension (this is typically a late sign of shock). Pale and clammy skin. Dizziness and lethargy. Somnolence. Confusion. Once shock has been stabilized or the possibility of shock ruled out, there are other general factors that contribute to the body s inability to maintain adequate tissue perfusion and oxygenation, for example [154] : Nicotine from cigarette smoking or other nicotine delivery devices (vaporizers, gums, patches, etc.) decreases tissue oxygen by causing peripheral vasoconstriction. Hypovolemia will reduce the amount of circulating oxygenated blood. This can be a result of trauma, disease processes, surgery or any number of causes specific to the patient. Careful monitoring Wound cleansing [140] Wound cleansing is an important part of wound healing, as it removes foreign material, necrotic tissue, leftover medication, free-floating bacteria or contamination, as well as decreases odor, and should be done with every dressing change unless contraindicated. Cleansers can be specialty commercially prepared solutions or readily available products like normal saline and sterile water. Commercial cleansers often contain surfactants, which aid in the releasing and removal of contaminants like oil, bacteria, and foreign material. No matter what is used to cleanse a wound, it should be hypo-allergenic and non-toxic to healthy tissue. Reactions or contraindications should be considered when using a cleanser with certain types of dressings (e.g. normal saline with silver products), and manufacturer guidelines should always be followed. EBP alert! Research shows that it is important to maintain pressure of 5 to 15 pounds per square inch to ensure effective cleaning, and many nurses find a saline flush or bullet works well to achieve this. Most often, the wound will be rinsed with normal saline and manually cleaned with gauze or a cleansing pad, being careful not to leave fibers behind. The wound should be cleansed up to 1 inch outside of its edges, moving from the middle of the wound, out, and using a new clean piece of gauze for each circle. It should then be blotted and dried after cleansing and before a dressing is applied. IV drug users are at especially high risk for tetanus infection due to the repeated exposure to dirty and/or rusty needles. 59% of those with reported tetanus infection are male. of high risk patient should take place, and if bleeding or fluid loss is noted (nausea and vomiting, extreme diuresis, high fever/chills, etc.) is noted, IV fluids, blood products, or medications should be administered to mitigate the potential damage, as well as treating the cause of the bleeding or fluid loss if possible. If external blood loss is noted, pressure should be applied to the site until the bleeding stops or the damaged vessel is repaired. Diabetes can directly affect tissue perfusion, as it can lead to calcification of the vessels, and neuropathy that can prevent the patient from feeling any damage or pressure present. Poor glucose control is a major risk factor in perfusion related wounds and their ability to heal. Lung diseases like COPD or emphysema reduce the ability of the lungs to achieve adequate oxygenation, thus decreasing perfusion to all tissues and leading to tissue ischemia. Peripheral Artery Disease or Venous Insufficiency can both lead to severely under perfused tissues, which can result in ulceration. Severe edema (lymphedema, renal disease, low albumin, etc.) can cause pressure on the vasculature, thus preventing adequate blood flow to support tissue perfusion. In 2004, the Food and Drug Administration (FDA) approved a new solution to halt bleeding, QuikClot. QuikClot products are impregnated with Kaolin, an inorganic mineral that accelerates the body s natural clotting ability, by activating factor XII. Because it does not contain animal proteins, the risk of allergic reaction is extremely low. This can be used in patients presenting with a traumatic wound [138]. Although frequently used in the past, several irrigation solutions should be avoided or limited in wound care due to their cytotoxic properties and effect on healthy tissues [67] : Hydrogen peroxide has been shown in some studies to be cytotoxic, and research is conflicting regarding its antimicrobial properties. Iodine solutions tend to irritate, dye, and dry the skin it is used on. In addition, iodine solutions are also cytotoxic and can prevent granulation tissue from forming. This solution should only be used on grossly infected wounds for a period of 2 weeks or less. Sodium hypochlorite (Dakin s solution), is a mixture of water and bleach. It is useful in grossly infected chronic wounds, and has known bactericidal properties, but is also cytotoxic to healthy tissue. This solution should not be used for more than 7-10 days on any type of wound, and even less on superficial wounds, as healing processes can actually be prevented and hindered. Acetic acid (vinegar) has been used in wound care for its antimicrobial properties, and in an attempt to lower the ph of a wound bed that is too alkaline. Studies have shown that this treatment is not effective in the treatment of infection unless the organism is Pseudomonas Aeruginosa, and even at that, the results have been varied. Acetic acid is not available in sterile medical grade form, so is therefore rarely used in modern wound care [71]. Page 76

79 [131, 52, 6] Moisturizers Moisturizers are utilized to treat and prevent dry skin. Moisturizers should be oil and fragrance free, but should contain emollients. Antimicrobial lotions should be avoided if possible, as they have a high risk of allergic reaction and irritation, and can cause sensitization and resistance [131]. As water and moisture can actually dehydrate the skin, moisturizers should be applied after bathing, to all skin surfaces, paying special attention to areas typically affected by dryness, like the knees, elbows, and feet [52]. Other treatment options for chronic wounds Depending upon the severity and depth of the chronic wounds, such as pressure ulcers, diabetic foot ulcers and leg ulcers, there are other adjunctive therapies that can be used in collaboration with standard treatment modalities to promote wound healing and to prevent complications. Electrotherapy [148] Electrotherapy is the use of electrical currents to stimulate healing, reduce infection, decrease pain, improve cellular immunity, and increase perfusion, by placing electrodes near or on the wound. There are a variety of electrical stimulators with varying types and amount of current. One example of this type of therapy is Transcutaneous Electrical Nerve Stimulation (TENS), which is used mainly for pain control, especially in postoperative orthopedic patients. Most research available points toward the effectiveness and safety of electrotherapy, but it remains underutilized, mostly due to lack of familiarity with the treatment, and disagreement among researchers about the best method of delivery. Grafts or flap closures [92] Skin grafts are the use of animal, human, or one s own tissue to encourage and supplement the tissue growth in a wound. It can be used after the removal of tissue during a surgical procedure, with burn injuries, and in other partial to full thickness wounds. Grafts or flaps will not be successful in placed on tissue that will not support its adherence or growth, like bone, tendon, or nerves, due to their limited blood supply, so assessment of the wound bed is critical before a graft is placed. Necrotic tissue and wounds with high bacterial burden are also inappropriate wounds for graft placement, and debridement and/or treatment of infection is a vital prerequisite. Revascularization of the graft material begins 2-3 days after the application, making it crucial that care is taken to protect and nourish the site in order to promote adherence. Grafts can be synthetic (e.g. biological dressings), a xenograft (from another animal, often pigs), allograft (from another human), or autograft (from an uninjured part of the patient s own body). Hyperbaric therapy [37] Hyperbaric therapy involves placing the patient into a large chamber that delivers 100% oxygen at levels higher, and under greater pressure, than what are delivered from the atmosphere. Patients enter the chamber for a minute session, and can be in the chamber alone, or with others, depending on the type of chamber offered at the treatment facility. As the patient breathes 100% oxygen in a pressurized environment, the body becomes hyperoxygenized, delivers more oxygen to the wound bed, and stimulates the healing process. This method is used frequently with high risk skin graft EBP alert! Although in the past, moisturizers containing Vitamin E were frequently recommended for use on scars, research has shown that not only does this practice not provide any benefit, but in about ⅓ of the cases, scars actually worsened or dermatitis developed from use [6]. or flap patients, those with arterial insufficiency, tissue affected by radiation, ischemia due to crush injuries and compartment syndrome, burn victims, and for many other conditions. Negative pressure wound therapy (NPWT) Vacuum-assisted closure (VAC) was cleared for use by the FDA in It provides a continuous or intermittent suction by using a sponge inserted into the wound, covered by an occlusive dressing, which is connected with tubing attached to both the dressing and VAC device. This device maintains a moist wound environment, reduces bacterial burden, prevents maceration, and removes contamination in the wound. Other benefits of NPWT include [81] : Removing fluid from the extracellular space, reducing edema. Improving blood supply to the wound bed. Inducing wound shrinkage and closure. Insulating the wound bed and maintaining temperature. Stimulating inflammatory and immune responses and cell proliferation. Stimulating angiogenesis and formation of granulation tissue. Providing protection with an occlusive dressing. In 2006, NPWT gained approval for the treatment of complex, chronic wounds, such as diabetic foot ulcers, flaps, grafts, traumatic wounds, dehisced wounds, and is frequently used in the treatment of stage three and four pressure ulcers. The device consists of four parts, the wound filler (sponge), the dressing (usually a clear transparent film), connection tube, and VAC system, typically with removable canister. Variations of the vacuum system include smaller, home devices that are either rented or disposable, and specialized incisional VAC systems. Typically, the suction necessary to provide all of the above listed benefits is between 125 and 150 mmhg, but co-morbidities and other risk factors should also be considered when determining the prescribed number, and lower levels of suction may be indicated. VAC therapy should not be used on necrotic tissue, malignancies, or on patients with high risk of bleeding, as this may exacerbate these issues. Surgery Surgery may be necessary if the wound is not healing after treatment, contains large amounts of necrotic tissue, is grossly infected, or if the wound has failed to produce granulation tissue and growth needs to be stimulated. Surgeries performed for these purposes include [57] : Skin graft or flap placement. Incision and drainage (infected wounds). Surgical debridement. Surgical curettage for underlying osteomyelitis. Specific treatment of wounds Nursing consideration: In order to properly treat each wound, it is important to adhere to the generalized care of wounds considering tissue perfusion, nutrition, pain, wound cleaning, dressing changes and the potential need for sutures or surgery. The ultimate goal in treating all wounds is to control blood loss, minimize infection risk, protect the patient and the wound, encourage tissue healing and regrowth, and to provide comfort [12]. Treating chronic wounds can be complex and prolonged, and can include many different treatments and can change over time throughout the healing process [57]. Nurses must be familiar with the various specific wound treatments in order to provide accurate monitoring and appropriate patient care. Page 77

80 Treatment of abrasions and scrapes Typically, abrasions and scrapes do not require extensive treatment because they are only a superficial break in the skin. The primary treatment for abrasions and scrapes involves [79] : Controlling bleeding Pressure should be applied to the source of bleeding. As abrasions are superficial, it is acceptable to remove any foreign material that is evident in the wound that could continue to cause bleeding (glass shards, wood splinters, etc.), if the foreign object is embedded deeper in the wound, or has caused a laceration, the object should not be removed unless it is done so in a controlled environment (surgery, hospital procedure, etc.). Treatment of animal or human bites Antimicrobials Due to the prevalence and increased risk of infection with bite injuries, antibiotics are administered prophylactically as well as with any confirmed infection, the type of antibiotic administered is dependent upon the identified source. Most wounds do not develop signs and symptoms of infection until 24 to 72 hours after the bite [143]. Both aerobic and anaerobic bacteria can typically be found in bite wounds (54%), so proper antibiotic administration is important in the prevention treatment of bite related infections [28]. Aerobic: Page 78 Pasteruella multicida is a gram negative coccobacillus the most common isolate (present in dog, cat, and many other domesticated animal bites) that usually causes infection in conjunction with other microbes present in a bite wound. Research has demonstrated that pasteruella multicoida is best treated with a penicillin (PCN), carbapenems, or a tetracycline. Staphylococcus aureus, another common aerobic bacterium, can be introduced by both the biter s mouth and the victim s own skin as it breaks. Most S. Aureus infections can be treated easily, but Methicillin Resistant S. Aureus (MRSA) is becoming an ever-growing problem in healthcare. If a culture shows resistant bacteria, a sensitivity test should be completed to determine the best antibiotic for treatment. Anaerobic: The most common anaerobic bacteria found in bite wounds are [2] : Fusobacterium. Bacteriodes. Porphyromonas. Prevotella. Broad spectrum antibiotics should be administered regardless of the appearance of the wound, as bites are at high risk for infection and typically contain multiple strains of bacteria. Early treatment, even if the wound appears clean is critical as wounds that develop infections can sometimes have delayed visible changes. Sensitivities can be determined from a culture of the wound site for continued bacteria specific treatment of the wound or infection [28]. Cephalosporins (like Cephalexin), penicillinase-resistant Penicillins (like Dycloxicillin), Macrolides (like Erythromycin), Clindamycin (if given alone), and aminoglycosides should be avoided due to their lack of effectiveness against Eikenella Corrodens. Patients taking oral antibiotics at home should be instructed to finish the entire prescription to prevent the development of resistant strains of bacteria [28]. Viral contamination should also be considered in human to human bites, as it is possible for Human Immunodeficiency Virus (HIV), Hepatitis C, Herpes Simplex Virus (HSV), and Hepatitis B to be transferred, although this is extremely rare. Sexually transmitted disease like Syphilis can also be contracted when the bite victim comes in contact with the body fluids of the biter [31]. Cleaning The most important component of treating an animal bite wound is cleaning and irrigation. Because of the vast array of possible microbial and foreign material contamination in a bite, it is imperative to irrigate the wound immediately to flush out as much of this material Cleaning The wound should be rinsed and irrigated with normal saline or a wound cleanser and foreign material removed if superficial. Dressing Once the area has been cleaned and the bleeding has stopped, a non-adherent sterile dressing should be placed over the wound. This dressing should be changed if it becomes soiled or saturated with drainage. The frequency of the dressing change depends on the type of dressing used, so care should be taken to follow manufacturer guidelines for use [18]. as possible. Typically, normal saline is used, but various pressures and amounts vary depending on the severity of the bite injury [26]. Surgery Depending upon the depth of the injury and the condition of the surrounding skin, debridement may be required to remove any devitalized or severely damaged tissue. In addition, if underlying structures have been damaged, surgery may be required to repair them so function can be maintained or restored. For example, if tendons have been affected, they may need to be repaired or reconnected. If bones or joints have been injured or crushed, they may require fixation or exploration. Facial injuries often require a Plastic Surgery consult, as scarring is likely. If a bite site is infected, incision and drainage or irrigation may be necessary to cleanse the wound and help the body to rid itself of infection and contamination [30]. Sutures The closure of bite wounds remains controversial, as multiple sources of bacteria are likely to have been introduced, sometimes into deep tissue or structures in the wound. For the most part, closure by secondary intention or tertiary intention is recommended, to allow for treatment of existing or potential infection and prevent abscessing. In most cases, hand wounds, puncture wounds, infected wounds, or wound more than 12 hours old (unless a facial wound, in which case closure is acceptable in the absence of signs of infection to prevent scarring) should not be closed using primary intention. If sutures are used, the patient should always be given antibiotic prophylaxis and frequent assessment of the site should be conducted [30]. Hand wounds If a bite wound is infected or if the bite wound is on the hand, it is recommended that sutures be avoided due to the risk for loss of function and closed-space infection. Hand wounds should be wrapped in sterile gauze, splinted in a position of slight wrist extension, and then continuously elevated. If a part of the finger or hand has been avulsed (separated from the underlying tissue or structures) the avulsed tissue should be placed in a normal saline soaked sterile gauze wrap and placed in a cooler or ice water and transported with the patient [30]. Vaccinations Once the cleaning has been completed, there are other prophylactic vaccinations and/or medications that may need to be administered depending upon the patient s previous vaccination history and/or risk factors. Tetanus toxoid is administered as advised in CDC guidelines. If the patient has not received a tetanus vaccination for 5 years or more, treatment should include a tetanus immunoglobulin shot as well as a tetanus vaccination for treatment and prevention of tetanus infection [26]. Hepatitis B vaccine is administered as a prophylaxis for patients who have been bitten by known carriers of hepatitis B. The vaccine is given in 3 doses, and is % effective in patients that receive the full series. The patient should be given the hepatitis B immune globulin immediately (IG) at the time of injury because it will begin to work immediately; then the patient will be placed on a regimen (based on CDC guidelines) for prevention or treatment. The hepatitis B vaccine and IG should be given in the

81 deltoid muscle in adults, and the anteriolateral thigh in infants and neonates. Human immunodeficiency virus (HIV): Known or unclear exposure to HIV from the bodily fluids of another may require prophylactic antiviral treatments. The risk of transmission of HIV through a human bite is very small, so this treatment will likely be avoided unless exposure is confirmed. Usually the regimen includes multiple drugs used in conjunction with one another to prevent replication, production, and ability to use host tissues [47]. Rabies is a virus that affects the brain, and is most often fatal. The possibility of rabies infection should always be considered in animal bite cases. If the infection status of the animal cannot be determined, or rabies is suspected, rabies immune globulin (acts immediately) and rabies vaccine (works in about 2 weeks) should be administered as soon as possible. Ideally, treatment should start within 8 hours of initial injury. The rabies vaccine must be injected intramuscularly (IM) and never subcutaneous (SC), intradermal (ID), or intravenous (IV). In adults, the nurse should inject the vaccination into the deltoid muscle. Small children should receive the vaccination in the anterolateral zone of the thigh [58]. A bite from an animal infected with rabies is not only an infection risk for the patient presenting with the bite wound, but if that animal is still alive, it is a risk to other animals and people, so if a rabies infection is identified, local and national (CDC) health departments may need to notified so the level of risk can be identified and further infections prevented [49]. EBP alert! Follow-up [37] It is estimated that 10-15% of human bites become infected, and deaths occur per year in the United States due to infected dog bites. Many patients delay treatment if they deem the bite to be minor or do not see symptoms for several days after the injury. After a patient is seen for treatment, the nurse should advise the patient with a bite wound to inform their primary care provider (PCP) immediately if they experience any signs and symptoms of infection. In addition, patients treated on an outpatient basis and sent home after being seen in the ER should follow up with the PCP within 48 hours to reduce the risk of treatment failure and complications. A patient should be hospitalized if he or she is experiencing any systemic symptoms (fever, chills), progressing cellulitis, sudden loss of function or feeling, or change in color or temperature in the affected area. Failure to identify and treat the bite appropriately and efficiently may result in complications such as new cellulitis, tenosynovitis, septic arthritis, osteomyelitis, abscess and/or fatal sepsis. In addition, cat bites may cause cat scratch fever (which is typically self-limiting) and can result in adenopathy [70]. Treatment of bruising The treatment of bruising is predominantly superficial and the majority of bruises heal and reabsorb on their own with no treatment at all. The initial treatment, according to the AACW, includes [18] : Appling cold compresses for 15 to 20 minutes per hour while awake for the first 48 hours after injury. After the first 48 hours, applying warm compresses for comfort to the bruised area. Treatment of burns [112] It is crucial to ensure the patient receives safe, expert care when dealing with a burn. It is important that the patient is seen immediately to prevent long-term complications, such as cardiorespiratory distress and compromise. Major open wounds, inflammation, fluid shifts, and infection that can occur in burn patients, and can be life threatening. The type of injury will determine the primary treatment related to the burn injury, or the need for a referral to a specialized burn center. In all burn cases, airway should be assessed and maintained prior to any treatment of the burn site [157]. Clothing (as long as it is not stuck to the burn) should be removed, especially if the clothing has a chemical on it that has caused a burn. Be sure that the responding caregiver does not touch the chemicals themselves in the process of removing the clothing. The burn site should then be immersed in cool water at a temperature of 55 degrees Fahrenheit or cool compresses applied for minutes. Ice water should never be used, as it can further damage the tissue or surrounding tissue. Cooling the burned area decreases edema and prevents further heat damage, and can aid in the removal of chemical irritants. Additional treatments of burns include: Antimicrobials When a burn occurs, the tissue is damaged, and the body s protective layers and defenses are compromised, leaving then unable to fight invading microbes. Topical antimicrobials are often used to help combat this problem, in addition to any systemic antibiotics or antifungals that are deemed necessary [97]. Examples include: Silver sulfadiazine (Silvadene). Silvadene is often utilized because of its ability to fight gram-negative and gram-positive bacteria. Silvadene can be used with an open wound or one covered with a dressing. Lab work should be drawn routinely throughout its use however, due to the fact that it may Avoid massaging the bruised area, as this can cause additional damage and pain. Avoiding taking any NSAIDS or aspirin (ASA) products for pain relief as they act as blood thinners and can worsen bruising or cause additional bleeding. induce transient leukopenia (low white blood cells (WBC)). Therefore, the nurse should monitor the WBC and notify the doctor if the patient s WBC is decreasing. According to Hospenthal (2014), Silvadene should be discontinued if the WBC is lower than 1,500 in adults or 2,000 in children. The use of Silvadene should be avoided in the presence of sulfa allergies, with heavy eschar (it cannot penetrate through eschar effectively), or with concomitant use of collagenase products, as silver can decrease the effectiveness of collagenase products [80]. Mafenide acetate (Sulfamylon) [80]. Sulfamylon is a topical sulfonamide that is effective against gram-positive bacteria, including Pseudomonas strains. It works by interfering with bacterial folic acid synthesis. Sulfamylon cream should be applied daily or twice daily to a debrided area, and can be reapplied as needed if the burn wound is not entirely covered with the cream or is accidentally removed. If a dressing is required, apply a bulky wet dressing and rewet it every four hours. If the dressing remains intact and undisturbed, it can stay in place for up to 5 days. Pain at the application site, allergic reactions, and irritation at the site are common adverse effects associated with Sulfamylon cream. Silver nitrate. Works by coagulating cellular protein, which helps in the removal of excess granulation tissue when hypergranulation is present. It is an effective antimicrobial agent against gram-positive, gram-negative, and candida organisms, but has difficulty penetrating eschar. Additionally, on contact with the skin, Silver Nitrate turns black and discolors the area, and can only be used with occlusive dressings covering the site of application [80]. Page 79

82 Cleaning All burn wounds are initially sterile due to the mechanisms of burn trauma, but colonization can begin again almost immediately after the injury occurs. The focus of cleansing a burn site is to maintain a low bioburden and prevent infection to a compromised area of tissue. Burns be cleansed initially and then daily with a mild antibacterial cleansing agent (ex. Chlorhexidine 0.25% solution), saline solution or water. Solutions containing alcohol should never be used. Antimicrobials creams (like Silvadene) are usually applied to the sire after cleansing [157]. Debridement If the burn has any blisters or eschar, it needs to be removed with natural, enzymatic, mechanical and/or surgical debridement ideally within the first few days of after injury. Surgical debridement is often chosen initially in order to begin treatment of the underlying tissue or perform skin grafts to burn sites in a timely manner [85]. Dressings Prior to any dressing change and/or procedure, it is crucial that the nurse assesses the patient s pain level frequently and avoid waiting for complaints of pain to intervene, as this may make adequate pain management much less likely during treatment. Any type of dressing can be used, as long as it is not contraindicated for burns by the manufacturer, and is appropriate for the individual wound. It is imperative that manufacturer guidelines be checked before beginning treatment with a specialty dressing [80, 157, 100] : Superficial (first degree) burns: Superficial burns do not always require a dressing, and in many cases do not require treatment at all. Minor burns can be treated with a thin layer of antimicrobial cream or ointment, such as Silvadene. In many cases, however, superficial burns do not require antibiotic creams, and they may even be avoided, due to the risk of irritation and allergic reaction. Scent and oil free lotions can be used for comfort and promotion of autolytic debridement id the skin is not broken (think of a sunburn and managing dry and peeling skin). If a dressing is needed for protection or comfort at the burn site, a non-stick covering (Telfa, Adaptic, Meptitel, etc.) should be used to prevent further irritation or injury [112]. Superficial partial thickness (second degree) burns destroy the epidermal later and some of the dermis, but do not reach deeper tissues. They can be left open to air if they result in an intact blister, or covered with a sterile non-stick dressing if the blister has torn or the site is open. Blisters should never be popped or drained, as they contain the body s own inflammatory and immune cells, and also act as a protectant and provide a moist wound environment. If a blister opens, or an open area is present, the area should be cleansed, a thin layer of antibiotic cream applied, and a sterile nonstick dressing utilized for protection (like Telfa, Mepitel, or Adaptic). Broken blisters must be protected as they create a portal for infection to enter the underlying tissues [100]. Deep partial thickness burns (second degree): These burns are also second degree burns. They destroy all of the epidermal layer and most of the dermis, but do not extend into the underlying structures below. When skin is burned, and blisters appear immediately (not delayed appearance), this is an example of a deep partial thickness burn. These burns should be cleansed, antimicrobial cream applied, and covered with a non-stick dressing. If drainage is present, absorbent dressings can be used, as long as manufacturer guidelines include burns as acceptable wounds to treat. Full thickness burns (third degree): Full thickness burns extend into any level of tissue beneath the skin and typically appear black and charred or white and waxy. These burns require debridement, and an appropriate dressing should be applied during or after this is being achieved. Infection is a major concern with deep burns, so antimicrobial agents may be used in conjunction with other therapies, depending on the risk factors, location, and anatomical structures affected. These wounds can also cause fluid shifts and loss, so a dressing should be chosen to effectively protect against these losses and subsequent dehydration. Other treatment modalities There are other treatment modalities with burns, depending upon the severity of the burn, the patient s health history and/or access to health care, such as: Hydrotherapy It involves the patient being immersed into a body of water to facilitate cleansing and debridement of the burned area [93]. The unique advantages of implementing hydrotherapy in the treatment plan are [93] : Topical medications, adherent dressings and eschar are more easily removed during and after treatment, decreasing pain and additional skin damage. Facilitates movement and makes such movement easier and less painful through weightlessness and muscle relaxation. Can reduce bacterial load on the surface. However, as with any treatment, there may be disadvantages [93] : The patient may experience more anxiety before or during the hydrotherapy treatment. Electrolyte imbalances have been reported with use. Cross-contamination of wounds between patients, especially since several burn centers have reported outbreaks of specific bacteria that could be traced back to their hydrotherapy equipment. Treatment of lacerations or cuts The goal of treating lacerations includes prompt healing, minimizing the risk of infection and limiting cosmetic disfigurements. The first assessment that should be done is to ensure there are no other Tap water used to fill the hydrotherapy pools can be contaminated with P. Aruginosa, and can subsequently infect wounds exposed to it. Some patients report increased pain during or after treatments. Hyperbaric oxygen therapy (See Other Treatment Options section). Pain management Pain levels can vary with the depth of the wound and anatomical structures involved. Typically, the more superficial the burn, the more painful it is, as burns in to deep tissue tend to cause damage to the point of numbness. The nurse should pre-medicate with analgesics before dressing changes or painful procedures, as untreated pain can lead to unsuccessful rehabilitation and wound healing, and also puts increased stress on the body. Every patient is different, and burn pain can be some of the most intense and prolonged pain a patient can experience, so a regimen for pain management should be established and followed based off the individual patient s needs [53]. Vaccinations Some studies have shown that vaccination with P. Aeruginosa outer membrane proteins can be helpful in preventing Pseudomonas infections in burn wounds. This vaccination does not prevent against other strains or types of bacteria, however, so the treatment has not become widespread [78]. serious injuries present when a patient presents with a laceration, as lacerations frequently cut into underlying tissue and structures (tendon, bone, muscle, vasculature etc.). Once other injuries have been Page 80

83 ruled out, the bleeding should be controlled with direct pressure and elevation (if possible). Treatment for lacerations includes [96] : Cleansing [96] Cleanse and thoroughly irrigate with NS, sterile water, antimicrobial solutions, or wound cleansers. Avoid cytotoxic solutions like undiluted povidone iodine or hydrogen peroxide and rough brushes or materials as they can damage the healthy tissue and irritate the wound bed. If infection or contamination is suspected, a 1:10 ratio of povidone iodine and water can help decrease the bacterial burden and will cause minimal tissue damage, but should not be used long term [113]. A dry sterile dressing should be applied to the site after cleansing for protection, with the length of time before the next dressing change dependent on the type of dressing used (dressings should always be changed based on manufacturer recommendations). Debridement Necrotic, devitalized, adhered foreign material, or contaminated tissue should be removed in order to allow the healing process to progress through the phases of healing [113]. Closure Each wound is different, and the mechanism of injury, size and location of the wound, healing potential, and degree of contamination are considered when making the decision to close a wound or leave it to heal by secondary intention [113]. The majority of practitioners will close uncontaminated wounds using primary intention if they are less than six to eight hours old or less than 12 to 24 hours old if located on the face or scalp. Delayed primary closure is used if the wound is infected, old, or contains any foreign material. This type of closure gives the provider the ability to debride, treat infection, or explore the wound, and is usually done several days later. Sutures, staples, [135, 63] Treatment of perineal skin breakdown Perineal skin breakdown is irritation and inflammation of the skin of the perineum from contact with excessive moisture, usually caused by urinary or fecal incontinence. This causes the skin surface to become more alkaline, alters the protective acid base, and causes the skin to become more permeable and easily damaged by external forces like friction and shear. It presents as redness, swelling, excoriation, and often pain. In many cases, fungal infections are also caused by the excessive moisture and produce a bright red, swollen and weepy appearance. Irritation in this area can also occur due to an allergic reaction to skin care products being used [135]. Cleansing: Damage can also result from the frequent cleaning and bathing that is necessary with incontinent patients, especially when soaps and harsh cleaners, or rough towels or materials are used. Excessive moisture can actually dehydrate the skin, as well as soaps and cleansers that do not maintain the acid mantle at between 4 and 7 ph. Products containing alcohol should be avoided, as well as fragranced or high oil content cleansers. Dove, most Also Vesta bath products, and Johnson and Johnson Baby Bath are two examples of cleansers that do not affect the acid mantle ph levels, but many other products exist that are specially made for this purpose. If the area cleansed needs to be dried, the area should be gentle patted dry, not rubbed, as rubbing can excoriate and abrade the skin. Many no rinse incontinence wipes and cleaners also exist that leave behind a protective film to provide a second skin and extra layer of protection to the at risk skin [63]. Treatments: Treatment is case dependent, but many products exist to aid in the healing of incontinence related dermatitis. Barrier creams can be used in prevention, but also if minimal damage or irritation is present, as they place a barrier between the skin and the source of Treatment of pressure ulcers The goal of pressure ulcer treatment is to remove any necrotic debris and to maintain a moist wound bed that will promote healing and the adhesive strips and liquid tissue adhesives may be used to close the wound. Dressings A clean dry non-adherent dressing should be applied for protection of the wound until the wound edges are approximated and dry. If the wound is closed by secondary intention and packing is necessary, a fluff and stuff pattern should be followed so as not to pack the wound too fully (which puts pressure on the wound edges and can prevent closure) [113]. Tetanus Administer the vaccination, if necessary, according to CDC guidelines [46]. Medications In instances where infection is noted or suspected, the laceration is over or near a tendon, joint, bone, or due to a bite, systemic antibiotics will likely be prescribed. Topical antimicrobial creams or dressings may be used as well if systemic antibiotics are not deemed necessary. Antibiotic use should be limited to wounds at high risk for or with an existing infection, as antibiotic resistance is a growing problem and can make treatment difficult [113]. Other measures included in the treatment of lacerations include the following [113] : Avoid excessive movement of the affected area because it can prevent proper closure of the wound and approximation of the wound edges. Lacerations over joints should be immobilized with splints, and finger and hand lacerations with large bulky dressings for up to 2 days after suturing takes place to prevent dehiscence. Follow up with the PCP 48 hours after the injury occurred. After 48 hours, the wound can be cleaned with water or halfstrength hydrogen peroxide. The extremity should be elevated if possible to decrease swelling. irritation. If the area is already damaged, weepy, or open, barrier pastes or zinc oxide formulations may be used to provide a thicker barrier. It should be noted, that barrier pastes are not meant to be removed with every incontinence episode. They should be applied thickly and the contaminated top layer should be removed with cleaning, leaving an intact, clean barrier on the damaged skin. Pastes can cause excoriation to the underlying skin as they require scrubbing or rubbing to remove entirely, so they should only be used if absolutely necessary. Most barrier products either have an antifungal option, or can be used with antifungal powders or creams as well. Manufacturer guidelines should always be followed if using products concomitantly to ensure compatibility and the best possible outcomes [135, 63]. Prevention: Prevention of skin breakdown can be achieved using gentle products and cleansers, no rinse incontinence cleansers or cloths, moisture wicking materials (like pads, underpads, and specialty briefs), and frequent assessments are key. Moisturizers are also key in preventing the dehydration and damage of skin. Many manufacturers make hypoallergenic, fragrance and oil free moisturizers that can be used. Creams made with DMSO (not approved for use in the United States) should be avoided [130]. The source of the incontinence should be identified and addressed, and underlying causes removed if possible. For those patients that do not have a removable cause, a plan should be devised with the healthcare team to put prevention strategies in place. Fecal containment devices can be used in cases of high volume liquid stool (e.g. C.Diff infections), but may not be appropriate for every patient. Urinary catheters can be helpful in managing urinary incontinence, but their use should be carefully considered as they carry a high risk for infection and need frequent attention and hygiene if fecal contamination is present [63]. formation of granulation tissue, ultimately leading to wound closure. All pressure ulcers should be assessed frequently and treatment Page 81

84 adjusted as necessary on an ongoing basis to ensure the interventions provided remain appropriate and adequate throughout the continuum of care. Steps to take in order to provide the best possible treatment outcomes for patient with pressure ulcers include [130] : Ensure proper positioning [88] Pressure ulcers result from the compression of soft tissue against bony prominences. Therefore, it is important to ensure that the patient who is at risk of a pressure ulcer or who already has been affected by one is on a stringent repositioning schedule to avoid further damage or complications. At this time, the rule of thumb is to ensure that the patient is turned at a minimum of every two hours, or weight shifted while in a chair at least every 15 minutes. However, it should be noted that skin breakdown and injury can occur in less time, so repositioning should be customized to the patient and provided more frequently if necessary. Nursing consideration: Nurses and those under their supervision are frequently responsible for repositioning. NPUAP gives the following tips for repositioning [130] : Keep the head of bed under 30 degree when the patient is at rest or in bed for long periods of time to prevent friction and shear in the lower back, sacrum, and coccyx. If sitting in bed is necessary, the patient should be positioned to avoid slouching or crunching. 90 degree side lying positions should be avoided as well, and a 30 to 40 degree side lying position should be encouraged to prevent pressure on the bones of the ankle, knee, hip, shoulder, and elbow, and ear. The patient should be encouraged to reposition themselves if they are able to while either in bed or in a chair. Care should be taken to avoid positioning people over existing skin breakdown or reddened areas as this will cause further damage. Careful consideration and attention should be paid to the positioning of medical devices and equipment. Significant injuries have been reported due to pressure from devices like CPAP machines, oxygen tubing, chest tubes, Foley catheters, IV lines, bedpans, drains, and other equipment. Use lifting equipment to prevent dragging, which causes friction and shear. Form fitting or immobility devices should be assessed and the underlying skin inspected to be sure no friction, shear, or pressure causing injury. Specialty surfaces and devices [95] : Any patient who is at risk for an ulcer or who has an existing pressure injury upon admission should have a pressure-redistributing surface ordered. In order to alleviate pressure, a surface must produce less pressure than what it takes to compress the capillaries of the skin (capillary closing pressure) in order to prevent ischemia. Therefore, any pressure device needs to be below the capillary closing pressure of 12 to 32 mmhg to be considered effective. Nurses can monitor the effectiveness of the redistribution surface on the skin by observing the skin s color, temperature, presence or absence of impaired integrity, and capillary refill or blanchability. Research has demonstrated that pressure-reducing devices can significantly decrease the risk of developing any ulcers compared to standard hospital bed mattresses, but high cost is sometimes a factor and must be considered depending on the environment of use or ability for a patient to afford the equipment Recommendations for positioning include: Using pillows or foam to float the heels and keep them off of the bed. Using pillows and foam to keep knees and ankles from touching. Avoid ring cushions (donut-type) devices and seat cushions that have the bottom out appearance. They increase venous congestion and edema [13]. If repositioning is not possible, specialty beds with turning or repositioning abilities should be used. Consult the experts Wound care specialists should be consulted for ongoing treatment. Nutrition specialists or dieticians should be consulted to assess for nutritional deficits or additional needs in order to promote healing and tissue growth. If arterial or vascular problems are suspected, a vascular specialist or surgeon should be consulted for additional treatment. A general surgeon may be consulted to provide any debridement that may be required (depending on the state and regulations, sharps debridement can only be performed by certain disciplines. Check your state s regulations to see if any other disciplines may provide sharps debridement). Cast/equipment techs can be consulted for problems with fitting or sizing of a device (like a brace, or cast). Care of a pressure ulcer Cleaning the wound In order to properly clean a pressure ulcer, normal saline (NS) should be utilized. Do not use povidone iodine, iodophor, hydrogen peroxide, or Dakin s (sodium hypochlorite) solution for long term cleaning because they have been shown to be cytotoxic. NS is safe, and it is the preferred method unless the dressing is not compatible with NS solutions [129]. Deep wounds If a patient has a deep wound that requires wound cleaning and/or irrigation, a pressure of 5 to 15 pounds per square inch is necessary to effectively remove debris and surface bacteria. A 10 ml saline flush or bullet can be used for this purpose, and generally provides the pressure needed. Other methods are used as well, and as long as the pressure is not below or above the necessary levels, they are acceptable for use [140]. Eschar Notify the provider immediately for a treatment plan or removal. A pressure ulcer cannot heal appropriately if eschar is present because it prevents new granulation in the wound bed and it is an ideal source of bacterial growth [160]. Dressings The ideal dressing should protect the wound, provide a moist wound environment, control excess exudate, prevent the overgrowth of bacteria, and provide comfort. See above types of dressings for more information on different options that Page 82 are available for use. The patient s overall condition, allergies, ability of the nursing staff to provide the necessary care, and comorbidities should be considered when choosing a dressing [33]. Location Certain locations, such as the ear, make it challenging and tedious and difficult for the nurse to apply a dressing properly and efficiently. A variety of options exist for specialty sizes and shapes of dressings, but just like any other dressing, other patient considerations should be assessed when choosing which one to use. Location can affect the ability of the dressing to stay where it needs to stay, and to provide the wound with what it is intended to provide. Certain anatomical locations, wounds near contractures, wounds that extend into deeper cavities of the patient s body, or wounds in naturally moist areas (groin, perineum, scrotum, etc.) can make wound care difficult to perform and maintain. Sensitive or fragile areas may not be able to tolerate adhesive products, so alternative secondary dressings may be needed in these cases. Note: If you are treating a wound you do not have experience with, or that is out of the norm, and a specialist is not available for you to consult, most manufacturers of wound care products have wound care nurses available on their hotlines or to come to a facility to assist with questions about how to use their products.

85 Debridement Necrotic tissue is laden with bacteria. Devitalized tissue impairs the body s ability to heal and fight infection. If the wound has slough or eschar, it will require debridement (whether naturally or with assistance from the healthcare team), wound cleansing, dressing application and possible adjunctive therapy to ensure wound healing [3]. Other treatment modalities There are other measures that the nurse should consider to prevent further progression of the pressure ulcer and to facilitate the healing process, including [130] : Avoid the use of incontinent pads or briefs with plastic liners because the plastic holds moisture next to the skin and increases the risk for moisture associated dermatitis and breakdown. Avoid massaging at risk or damaged tissue, as this can promote inflammatory reactions and cause additional tissue damage. Lab work should be completed based on the patient s condition, and can include nutritional indicators, renal function tests, liver function tests, CBC, clotting factors, and any other area of concern to help develop a plan or remove risk factors if possible. Treating and managing bacterial colonization and infection [74] Research has demonstrated that the majority of wounds are colonized with bacteria, as there are many strains that naturally exist on the skin and body surfaces. Bacteria that enter the blood stream or lymphatic system can lodge into deeper soft tissue, joint spaces, prostheses, other body systems, and any other established wounds, increasing the risk of infection to or from areas unrelated to the original wound. Additional sources of infection should be monitored and can include: Foley catheters, urinary tract infections (UTI), sinus and respiratory infections, wound drains, and orthopedic infections. If there is any speculation of a bacterial infection, hypergranulation is present, or if the epithelization phase is not progressing within two weeks, then the wound should be biopsied. Wounds with a bioburden that reaches a level of 10 to the 5th power are considered infected, and wound healing is affected and impeded. If infection is confirmed, antimicrobial dressings should be utilized to decrease the bioburden in the wound. In cases where the wound infection is caused by a systemic or remote infection, systemic antibiotics should be considered. Treatment of punctures [35] The treatment regimen for punctures is similar to the general recommendations for abrasions and lacerations. It is important to first stop any bleeding, then to clean the wound and apply a clean dry Treatment of skin tears Due to the delicate nature of the skin, it is imperative that nurses care for skin tears gently. According to the AACW, the following guidelines should be implemented when caring for a skin tear [18] : Cleaning Clean with NS and pat dry or leave to air dry. If there is a skin flap present on, over or around the skin tear, the edges should be gently unrolled and approximated as closely as possible [44]. Dressing [44] In many cases, skin tears are caused by tape or medical adhesive removal. Transparent dressings are appropriate for a skin tear to facilitate healing and autolytic debridement Treatment of surgical wounds Depending upon the type of surgery and degree of wound contamination, various dressings may be applicable. The degree of contamination in a surgical wound can be classified as follows [149] : Clean wound No contamination or increased inflammation is noted. Respiratory, GI, or GU systems are not involved or exposed, and the wound can be, and typically is, closed by primary intention. Examples include thyroid surgery, orthopedic surgery, mastectomies, etc. Clean-contaminated wound The GI, GU, and respiratory tracts are involved, but no unusual contamination is noted. Examples include colorectal surgeries, cholecystectomy, pulmonary thrombectomies, etc. Contaminated wound Open, usually accidental, fresh wounds that have experienced a major break in sterile technique. There can be spillage from the GI or GU tract, or clear contamination from the respiratory tract. Non-purulent drainage and acute inflammation is present. Examples include inflamed or ruptured appendectomies, penetrating wound repair, diverticulitis surgery, etc. Dirty wound Old or already infected, devitalized tissue. May be the result of an old accident or previous procedure. Purulent drainage may be noted. Examples include wound debridement, abscesses, incision and drainage, perforated bowel surgeries, etc. It has become common practice to administer prophylactic antibiotics prior to and for 24 hours after many surgeries, especially colorectal, dressing. In many cases, the wound will no longer appear open, but the nurse should continue to assess for infection and treat accordingly. of the wound, but consideration should be taken regarding the mechanism of injury, amount of drainage, and strength of the surrounding skin. A contact layer or non-adherent dressing (Adaptic, Mepitel, Telfa, etc.) can be placed over the tear, covered with gauze or absorbent dressing, and secured with a gauze wrap to avoid the use of adhesives on the skin if the location allows. These dressings should be as lightly wrapped as is effective to keep it in place, so as not to create a tourniquet effect in an extremity. GI, orthopedic, and respiratory surgeries. The Infectious Disease Society of America suggests antimicrobial prophylaxis be given using the following guidelines [39] : Administer the first dose of antibiotics within the 60 minutes prior to the first incision. If the antibiotic requires a prolonged infusion time (like Vancomycin), it can be given earlier (but still within 120 minutes of the first incision). The particular antibiotics chosen are dependent upon the surgical site, the most common organisms isolated in the vicinity of the surgery, and the cost of the drug. Staphylococcus is present on healthy skin, and can be introduced into the body through surgery. Therefore, antibiotics that target this bacteria and other common skin flora (like cephalosporins) are common choices for prophylaxis. The most common prophylactic cephalosporin administered for prophylaxis is Cefazolin (Ancef, Kefzol), but other choices within the class or alternative classes may be used if a patient reports an allergy to Cephalosporins or Penicillins (cross allergies have been reported between these two classes). Vancomycin is often given in such cases, or if a patient is determined to have resistant strains of staphylococcus. The route of surgery, involved organ systems, and expected contamination levels are considered when choosing an appropriate antibiotic for pre-and post-prophylaxis. For example, with gastrointestinal surgeries, gram-negative and anaerobic bacteria are isolated, so antibiotics that fight both types of organisms should be administered. Page 83

86 Dressings Tips for choosing the right post-surgical dressing include [33] : Consider the frequency of the dressing change and whether the patient is able to take a shower daily. If the patient is able to shower, use a water proof dressing. Typically post-surgical dressings will be left in place for the first 24 hours to prevent contamination, but the dressing monitoring and care needs can also be based on surgeon preference or surgery type. If the patient has an open surgical wound that is healing by secondary intention, the appropriate dressing should be based upon the size, depth, exudate, infection status/risk, moisture needs, and position of the wound. Diabetic foot ulcers The treatment of ulcers in the diabetic patient adds additional factors and considerations to the plan of care and wound treatment that would not necessarily always be included in a plan with a non-diabetic patient. Some of the factors are [162] : Glucose control. Local wound care considerations (callus control, etc.). Infection control and additional infection risk factors. Pressure relief, especially in neuropathic areas. Restoring blood flow (combat calcification, etc.). Diabetes can present risk factors like poor glucose control, a strained immune system, and poor healing potential, leading to a perfect storm of infection development. Several studies have shown that on average, 56% to 58% of patients being treated for diabetic foot ulcers (DFU) are clinically infected. About 20% of patients that present with an infected DFU will need to undergo a lower extremity amputation [162]. The most common pathogen identified in diabetic foot ulcers are aerobic gram-positive cocci (especially staphylococcus aureus). However, if the patient has a chronic wound or if they have been treated with antibiotics, gram-negative rods are also often present. Failure to treat diabetic foot ulcers adequately and efficiently may lead to further complications, such as osteomyelitis, gangrene, or cellulitis, which can then lead to sepsis or amputation. The severity of the infection, the cause, and the patient s co-morbidities should be considered when choosing the appropriate antibiotic. The TIME (Tissue debridement, inflammation & infection control, moisture balance, and epithelial edge advancement) framework is used when treating DFUs as well as many other wounds, but as mentioned, additional factors present with diabetes can make treatment complicated and prolonged. Tissue Although any debridement method can be used to remove necrotic tissue from a DFU, the gold standard technique is sharps debridement. Vascular status, infection status, and other co-morbidities should be considered before performing sharps debridement on a diabetic patient. Infection/inflammation The diabetic foot ulcer should be cleansed with NS, sterile water, or a commercial cleanser and thoroughly dried before the application of a dressing or medications. As with any other wound, the dressing choice should be dependent on the type of wound, location, and specific wound needs. Typically, diabetic wounds tend to be drier and have callused edges, so dressings that promote moisture, while preventing infection and allowing for other treatments take place (like offloading for example) are typically used. Moisture management The dressing should be changed according to manufacturer guidelines and the specific wound characteristics (exudate, tissue type, etc.). The wound should be assessed often for infection as the patient may not be able to recognize pain and signs of infection due to peripheral neuropathy and deformity. One of the biggest clues to infection in a diabetic patient is prolonged hyperglycemia. Epithelial/wound edges In order to allow the wound to heal and promote wound edge advancement, steps need to be taken to prevent additional damage and provide an ideal healing environment. Debridement of necrotic tissue and dressing choice contribute to this, but other interventions are equally as important. For example, assessment of shoe size and wear patterns can help Treatment of Vascular and Diabetic Wounds establish the cause of the ulcer, especially if the patient has limited or no feeling in the area, and allow for interventions that will help prevent further breakdown. Offloading is possible when the source of the pressure is identified. Total Contact Casts are the gold standard in offloading treatment of a DFU. It is molded to the patient to provide even distribution of pressure throughout the plantar surface as the patient walks. This device should not be applied by those who are not trained, as additional damage can result from improper application. Additionally, it should not be applied to patients with ischemia as the risk for further damage outweighs the benefits of use. There are many other offloading techniques, as simple as crutches, or as involved as specially made removable offloading casts and shoes. Cost and feasibility for each patient should be considered when choosing the best method. Vascular ulcers Factors that influence healing of leg ulcers include the size of the ulcer, other risk factors and co-morbidities, and the patient s willingness to comply with treatment modalities. The need for infection control, promotion of venous return, healing ability, exudate control, and avoidance of additional damage should be considered when choosing a treatment modality [68]. Venous [161] If the wound is related to venous insufficiency, it should be managed with strategies to promote venous return and create a microclimate within the wound bed that supports new tissue growth and healing. Compression (typically wraps or hosiery) and dressings that deliver growth factors or medications to encourage healing are often used together. Antimicrobial (systemic or topical) treatment may be indicated, and dressings can be chosen to aide in the reduction of bacterial burden as well. Compression therapy The majority of patients with venous leg ulcers benefit from utilization of compression bandages at the level appropriate to their vascular status. If the ulcer is the result of venous insufficiency, the external compression can range from 18 mmhg or lower, to 60 mmhg or higher, depending on the patient s need and co-morbidities. However, the results of the Arterial Brachial Index (ABI) determines the type and level of compression therapy: ABI above 1.2 may indicate calcified arteries and should not be compressed. Do not compress until further vascular studies are completed. ABI between full compression can be used, as little to no ischemia is noted. ABI between Use with caution, or use modified compression (reduced pressures). Some research has shown that in mixed arterial/venous ulcers, inelastic compression bandages (up to 40 mmhg) can actually be beneficial in promoting arterial flow as well as encouraging venous pump function, but should only be done by a specialist or one trained in wrapping technique and use. ABI lower than 0.5 do not initiate compression, refer to a vascular surgeon. Other treatments Other recommendations to prevent the exacerbation of venous insufficiency include: Elevate the legs above the level of the heart while sleeping. Page 84

87 Avoid standing or sitting for long periods of time. Sequential compression devices have been shown to be helpful in many patients with venous insufficiency who are hospitalized. Arterial/ischemic [68] Compression therapy or debridement should be avoided with arterial wounds as it can result in worsened ischemia, necrosis, or amputation. The mainstay of treatment is surgery with revascularization to restore the blood supply to the compromised limbs. In order to improve the blood flow, other medical conditions need to be controlled, such as hyperlipidemia, hypertension, and diabetes. Smoking and nicotine use should also be assessed and assistance with cessation should be provided. ABI levels should be obtained initially and on an ongoing basis to assess for worsening of the arterial insufficiency. Debridement may be avoided until the extent of the occlusions is determined as healing potential is drastically decreased. Other treatment considerations include: Avoid elevating the patient s legs, as it further decreases blood flow to the extremities. Avoid tight clothing or dressings. Frequently assess for changes in temperature, color, numbness and tingling, and other neurovascular changes in the affected extremity. Dressings that add moisture and protect the wound can be used as most arterial ulcers are dry with friable and weak surrounding tissue. Mixed arterial & venous ulcers [68, 161] If the wound is the result of both types of venous disease, the degree of disease stemming from both should be thoroughly assessed. Treatment for one could exacerbate the other and cause additional damage. Vascular specialists can help determine the appropriate interventions. Cellulitis [76] Cellulitis is an acute skin infection that can spread rapidly from the dermis to the subcutaneous tissue layers. Cellulitis can occur after any break in the skin (sometimes microscopic) where bacteria are able to penetrate the body s protective barriers. Staphylococcus aureus is a common cause of cellulitis, as the bacteria are found on many environmental surfaces, as well as the body s own skin surfaces. MRSA is a major concern for cellulitis infections, as it can be community and hospital acquired, and is becoming more prevalent. Those with diabetes, immunodeficiency, liver or kidney disease, and vascular disease are at much higher risk of developing cellulitis. The patient will typically exhibit erythema, edema, warmth, pain, fever and swelling. Erysipelas is a superficial form of cellulitis that involves the lymphatic system and it is characterized by streaking lines toward regional lymph nodes. If skin begins to slough off, blisters develop, crepitus is noted, progression is rapid, or bleeding is noted in the area (cutaneous hemorrhage), it can be an indication of the need for surgical intervention or severe life threatening infection (e.g. necrotizing fasciitis). The most commonly affected sites include the lower extremities, but it can occur anywhere, especially in the presence of underlying disease or high risk co-morbidities. Cellulitis is diagnosed by signs and symptoms, lab work, and cultures. The laboratory data may demonstrate leukocytosis, an elevated erythrocyte sedimentation rate (ESR), elevated C-Reactive Protein (CRP), and positive blood cultures in advanced infections. It can often be treated with oral or IV penicillin (PCN) if the most common organisms, staphylococcus and streptococcus, are the cause of the infection. The health of the patient and the severity of the cellulitis will determine the most effective course of treatment. In cases where antibiotic resistance is determined, or allergy to common treatment is present, alternatives (like Clindamycin and Vancomycin) can be used. If drainage is present, a culture and sensitivity should be done to further determine appropriate therapy. Other recommendations Nursing consideration: Nurses must teach patients to keep the area elevated to promote comfort and to decrease the edema, as long as elevation is not contraindicated. Throughout the day, cool sterile dressings, as well as antimicrobial dressings can be applied to areas with open lesions to remove exudate, manage bacterial burden, and promote comfort. Signs of worsening infection or systemic changes should be monitored closely, as well as indications for bone, tendon, muscle, or other deep tissue involvement. Any cellulitis over a joint (especially if a prosthetic joint is present) should include an orthopedic consult for evaluation and monitoring. Contact dermatitis [16] Contact dermatitis, is an inflammatory reaction that results from a substance coming in contact with the skin. It can occur from any number of exposures, and can be the result of the following causes: Allergic An allergic contact dermatitis is the result of direct contact with an allergen. As everyone s allergies and sensitivities are different, and the severity of reaction can vary greatly. Any allergy (especially new) should be monitored closely for progression or involvement with another body system and anaphylaxis. Common causes of allergic contact dermatitis include: Latex. Poison ivy. Jewelry. Makeup. Irritant Irritant contact dermatitis is the result of repeated exposure to irritating or toxic substance. With enough exposure, most foreign substances will irritate the skin, so those in jobs with that require frequent use of chemicals or frequent hand washing, like nurses, makeup artists, certain types of factory workers, etc. are at higher risk. Common causes of irritant contact dermatitis include: Hand sanitizers. Bleach. Soap. Acidic substances (battery acid, etc.). Nail polish remover. Moisture related Moisture related contact dermatitis is a form of irritant dermatitis. It is the result of exposure (usually prolonged) to moisture, and can happen from the moisture itself, the cleaning products used, or the substances in the moisture. Common causes of moisture related contact dermatitis include: Leaking ostomies. Diaper rash. Incontinence. Exudate from wounds. Leaking tube feedings. Osteomyelitis [91] Osteomyelitis is inflammation and infection in the bone. If a bone has experienced an injury or a break in its normally resistant outer layer, like a trauma or surgery, osteomyelitis can occur. Penetrating traumas, open chronic wounds, and retained foreign bodies are common causes. Less prevalent, but still reported, are instances caused by prostheses, like hip and knee replacements for example, which can cause biofilms to form on them. These biofilms can then spread into the already weakened or traumatized bones. There are a few different types of osteomyelitis: Hematogenous (seeding) osteomyelitis is the result of the introduction of bacteria into the bone from the structures Page 85

88 surrounding it. This can result from other infections, like a gastrointestinal infection, or nearby soft tissue infection, as sinus tracts can form that lead into bone. The most common strains of bacteria seen in this type of osteomyelitis are staphylococcus aureus and P. aeruginosa. Contiguous-focus and posttraumatic osteomyelitis are the results of direct exposure to the bacteria, often from trauma, prosthetic implants, fracture fixations, septic arthritis, etc., and makes up about 47% of all reported osteomyelitis cases. Osteomyelitis associated with vascular insufficiency occurs in patients with DM and vascular insufficiency, especially in the foot and ankle. Osteomyelitis most often presents with general feelings of malaise and lethargy, sometimes accompanied by a fever. Typically, the local and visual signs of infection (redness, swelling, pain, etc.) are gone after days 5-7, so osteomyelitis should still be considered even if these visual cues are not present. In addition, the following conditions should warrant further exploration to rule out infection, especially if present in a chronic or open wound: Bone exposed (or easily probed). Tissue necrosis overlying bone. Gangrene. Persistent sinus tract. Underlying open fracture. Underlying internal fixation. Wound recurrence. If a patient has a diabetic foot ulcer, osteomyelitis should be considered if the patient has any of the following signs or symptoms [91] : Deep or extensive ulcer, especially one that is chronic or over a bony prominence. An ulcer that does not heal. Bone that is visible or can be palpated with a metal probe, often exposed bone cannot be felt by those experiencing peripheral neuropathy. A swollen foot with a history of foot ulceration, especially with noted vascular impairment. A red, swollen toe. An unexplained high WBC or other inflammatory markers such as CRP or ESR. X-rays showing bone destruction beneath an ulcer. X-rays and/ or MRIs confirm the diagnosis of osteomyelitis. If radiographic findings suggest osteomyelitis, a histologic evaluation and bone biopsy culture may be considered. The treatment of osteomyelitis includes surgery to remove the infection in the bone, debridement and prolonged systemic antibiotic therapy. Antibiotics are administered depending on the source of bacteria, extent of bone infection and any co-morbidities. If bone is exposed in a wound, protection is key. It should be kept in a moist wound healing environment and never allowed to dry out. If a wound VAC or other alternative dressing is applied, be sure the bone is protected if fragile, and check manufacturer recommendations for use. Prevention of wounds Nursing consideration: Nurses can potentially reduce the Avoid keeping sharp objects in areas in which children could incidence of injury and co-morbid illnesses through educating access them. patients and their families about various risk factors related to their Always wear shoes to avoid stepping on something that may cause residence (e.g. fall risk), lifestyles (e.g. smoking), occupation and injury. hobbies. The social and financial history and status of a patient Promote the use of helmets and knee pads when riding a bicycle, should also be considered when educating about prevention [96]. three/four wheelers, rollerblades and a motorcycle. The patient should be encouraged to wear the appropriate size To prevent abrasions, cuts, scrapes, lacerations and/or punctures: helmet, and be sure it has not expired (some manufacturers print an Avoid risky behaviors that can increase the risk of injury. expiration date, which indicates if the filling and force absorption Be careful with sharp objects, such as knives, scissors, saws and material will degrade over time). trimmers. Avoid picking up any broken glass or razor blades with bare hands. Always carry knives, scissors and or any sharp object pointed Children should always be in safe, size-appropriate car seats downward and away from the body. placed in the suggested location and direction. Bites It is important to teach parents with children common safe practices around animals and recommendations if they are bitten [58] : The best preventive method is to avoid aggressive behavior with animals and to avoid unfamiliar animals. Teach young children to avoid provoking animals because it may lead to fewer incidents of animal bites. Never leave children unattended in the presence of animals. Burns In order to prevent burns, the patient should be educated to [100] : Turn off all electrical currents before attempting any repairs. Keep protective covers in the outlets, especially with children in the home. Repair frayed electrical wires immediately. Lower the water temperature in the home. Vaccinate all household animals for rabies. In the United States, it is mandatory for all domestic dogs and cats to be vaccinated against rabies. If bitten, people should seek medical care immediately. Research has demonstrated that if the patient delays medical care for more than 24 hours, he or she is more likely to develop an infection [30]. In addition, patients who require sutures should seek care within six hours of the injury to prevent colonization or infection in the wound [158]. Avoid loose clothing when cooking. Keep children away from the burners and place all pans on the back burner with the handle turned away from the front of the stove. Page 86

89 Pressure ulcers It cannot be stressed enough that pressure ulcers can be prevented. Nurses can contribute to the prevention of pressure ulcers through good nursing care, providing good nutrition, and maintaining proper hygiene [124] : Keep the skin and the bed linens clean, unwrinkled, and dry at all times, with as few layers as possible (2 or less is ideal). Any patient who is completely immobile, paralyzed, listless or incontinent should be turned frequently, at least hourly, cleaned, and the skin treated with incontinence products if indicated. Skin tears Each time the patient is turned, his or her skin should be reassessed to ensure that there is no erythema, ecchymosis, or tenderness in any areas of the skin. Keep a written log to ensure accountability of the staff to turn the patient every hour. Use appropriate mattresses, pillows and underpads remove controllable risk factors. Notify the treatment team immediately if any breakdown occurs on the skin. Nursing consideration: Nurses and nursing assistants hold the biggest key in preventing skin tears among the geriatric population when they care for them in a facility or at their home. It is essential that they know what actions to take to prevent skin tears. by offering fluids between meals, and use lotion on arms and legs twice a day. Protect from self-injury or injury during routine care by: Using a lift sheet to move and turn patients and to enforce transfer techniques that prevent friction or shear. In order to prevent skin tears, the following actions can be taken [163] : Pad bedrails, wheelchair arms and leg supports. Provide a safe environment. Support dangling arms and legs with pillows or blankets. Encourage patients to wear long sleeves or pants to protect their Use non-adherent dressings on frail skin. extremities. Use gauze wraps, stockinettes or other wraps to secure dressings Ensure the room has adequate light to reduce the risk of bumping rather than tape. into furniture or equipment and have the call light within reach. Use gentle, alcohol and fragrance free soap when cleaning the patient, Educate staff or family caregivers in the correct way of handling and avoid any harsh chemicals that will cause dry and cracked skin. patients to prevent skin tears. Maintain nutrition and hydration Lower extremity ulcers Diabetic foot ulcers [162] Often, as patient cannot feel the injuries, they are not noticed until Encourage patients to maintain adequate blood glucose control by intensive treatment is necessary. [68, 161] adhering to their diet, exercise regimen and taking any prescribed Vascular ulcers medications. In addition, patients should be instructed to see their Venous and arterial ulcer prevention will vary depending on PCP regularly to ensure ongoing care is adequate and appropriate. the degree of each disease present. Compression or surgical Plan a follow up or referral to a podiatrist for inspection and intervention could be necessary in the prevention of such wounds, regular care of the feet (about every 3 months). This is crucial but thorough assessment should be done before the implementation to identify and prevent problems before they become severe. of treatment. Legal Issues Surrounding Wound Care The second most common types of lawsuits are wound related, and primarily involve pressure ulcers, foot ulcers and leg ulcers [168]. Nursing consideration: It is imperative that nurses recognize the risk factors for wounds to ensure appropriate prevention and treatment modalities are initiated. They also must understand the importance of effective communication to ensure that the whole treatment team is able to provide the best care for the patient. When it comes to litigation and negligence, every discipline can be found responsible, and as the nurse is typically involved in the most hands-on and frequent interventions for the patient, every nurse must be vigilant in providing appropriate patient specific care [40]. Nurses have responsibilities and expectations bestowed upon them every time they accept the responsibility of care. In order for a nurse to prevent litigation and potential harm to a patient, each nurse be familiar with the policies, procedures and laws that guide their practice. Nurses can become familiar with these by [130] : Obtaining a copy of your nurse practice act for the state or states in which you practice (typically on your state s Board of Nursing website). Understand and review the policies and procedures at the facility or agency you are working for to ensure compliance. Understand and review the standing protocols and/or preventive protocols at the facility in which you are employed to ensure that you are abiding by the protocols and providing the standard of care expected of you. Page 87

90 Organizations As professionals, it is important to be involved in organizations that support the profession of nursing and to be affiliated with organizations based upon your areas of expertise. Nurses who work in areas in which they are responsible for caring for patients with wounds would benefit from becoming certified in wound care to enhance their credibility and to ensure that the nurse is continuously updated on the latest guidelines and research. Here are some organizations that are available for nurses to join: American Academy of Wound Management (AAWM) [24] Their mission is to advance the care of those with and at risk for wounds. The American College of Certified Wound Specialists (ACCWS) [40] is a membership organization that serves as an educational Closing Wound care remains a complex concept to grasp and understand because there are so many different types of wounds and treatment modalities. Nurses do not have control of the lifestyle choices that people make to put them at risk for acute wounds. Nurses can, however, control and prevent perineal skin breakdown, skin tears and pressure ulcers for any patient under our care or whom we are discharging home with a caregiver. It is imperative that nurses remain References 1. Abbade, L, Lastoria, S., & Rollo, H. (2011). Venous ulcer: Clinical characteristics and risk factors. International Journal of Dermatology, 50(4), doi: /j x 2. Abrahamian, F & Goldstein, E. (2011). Microbiology of animal bite wound infections. Clinical Microbiology Reviews, 24(2), Advanced Tissue. (2014). Understanding debridement: An important part of wound healing. Retrieved from 4. Advanced Tissue. (2014). Traumatic stab wounds and long term wound care. Retrieved from Advanced Tissue. (2014). Exploring the various types of wound drainage. Retrieved from Advanced Tissue. (2015). Ins and outs of lotions for wound healing. Retrieved from advancedtissue.com/ins-and-outs-of-lotions-for-wound-healing/ 7. Advanced Tissue. (2015). How does anemia affect wound healing? Retrieved from advancedtissue.com/anemia-affect-wound-healing/ 8. Advanced Tissues. (2014). Understanding debridement: An important part of healing. Retrieved From 9. Advanced Tissue. (2014). 4 tissue type categories of wound healing. Retrieved from advancedtissue.com/4-tissue-type-categories-wound-healing/ 10. Advanced Tissue. (2014). A brief overview of eschar. Retrieved from Agency for Healthcare Research and Quality. (2012). Pressure ulcer prevention and treatment protocol. Retrieved from Agency for Healthcare Research and Quality. (2015). Preventing pressure ulcers in hospitals. Retrieved from hospital/pressureulcertoolkit/ putool3. html#tiptop 13. AHRQ. (n.d.). Preventing pressure ulcers: A patient s guide. Retrieved from agedblinddisabled/res/vptc2/8%20paramedical%20services/preventing_pressure_ulcers_patient_ Guide.pdf 14. Agrawal, A., Raibagkar, S., & Vora, H. (2008). Friction burns: Epidemiology and prevention. Annals of Burns and Fire Disasters, 21(1), Ahn, H., Stechmiller, J., & Horgas, A. (2013). Pressure ulcer-related pain in nursing home residents with cognitive impairment. Advances in Skin and Wound Care, 26(8), American Academy of Dermatology. (2015). Contact dermatitis. Retrieved from org/dermatology-a-to-z/diseases-and-treatments/a---d/contact-dermatitis 17. American Academy of Dermatology (2015). The layers of your skin. Retrieved from aad.org/dermatology-a-to-z/for-kids/about-skin/the-layers-of-your-skin 18. American Association of Wound Care. (2005). ABCs of skin and wound care. Retrieved from aawconline.org/wp-content/uploads/2011/04/abcspublic.pdf 19. American College of Clinical Wound Specialists. (2015). About us. Retrieved from about-us/ 20. American Burn Association. (2012). National burn repository. Retrieved from ameriburn.org/2012nbrannualreport.pdf 21. American Burn Association. (2015). Burn incidence and treatment in the United States: Retrieved from resource and promotes advocacy, and provides support for certified wound specialists. Wound, Ostomy and Continence Nursing Society (WOCN) [167] is the only organization that offers wound care certification exclusively to nurses. The goal of the WOCN is to provide support, education, and credentialing to clinical wound specialists. National Alliance of Wound Care and Ostomy (NAWCO) [122] is a nonprofit, national multidisciplinary wound-care certification board and a wound-care professional membership organization. The goal of the NAWC is dedicated to the advancement and promotion of wound care through the certification of wound-care practitioners in the United States. knowledgeable and attuned to evidence-based practice guidelines while caring for all patients to ensure that the care provided is efficient and effective in preventing and managing any wound. There are many organizations researching and providing evidence-based practice guidelines and protocols; nurses need to ensure that they up to date on guidelines of the facility where they are employed and current literature and practice recommendations. 22. American Podiatric Medical Association. (2015). Diabetic wound care. Retrieved from www. apma.org/learn/foothealth.cfm?itemnumber= Anderson, D. & Sexton, D. (2015). Epidemiology of surgical site infection. Retrieved from Association for the Advancement of Wound Care. (2015). About AAWC. Retrieved from aawconline.org/ 25. ATI Nursing Education. (n.d.). The anatomy and physiology of wound healing. Retrieved from Baddour, L. & Endom, E. (2015). Patient information: Animal bites (beyond the basics). Retrieved from Baddour, L. (2015). Soft tissue infections due to dog and cat bites. Retrieved from uptodate.com/ contents/soft-tissue-infections-due-to-dog-and-cat-bites?source=see_link 28. Baddour, L. (2015). Soft tissue infections due to human bites. Retrieved from com/contents/soft-tissue-infections-due-to-human-bites?source=see_link 29. Baranoski, S. (2012). Wound Care Essentials (4th Ed.). Philadephia, PA: Wolters Kluwer. 30. Barrett, J. (2015). Human bites treatment and management. Retrieved from medscape.com/article/ treatment#d8 31. Barrett, J. (2015). Human bites. Retrieved from /article/ overview 32. Barel, A., Paye, M., & Maibach, H. (2014). Handbook of Cosmetic Science and Technology (4th edition). Boca Raton, FL: CRC Press. 33. Beldon, P. (2010). How to choose the appropriate dressing for each wound type. Wound Essentials, Blanpain, C. & Fuchs, E. (2009). Epidermal homeostasis: A balancing act of stem cells in the skin. National Review on Molecular Cell Biology, 10(3), Blasko, B. (2014). Puncture wound. Retrieved from puncture_ wound/page4_em.htm 36. Bertholf, R. (2014). Proteins and albumin. Retrieved from / viewarticle/823421_6 37. Bhutani, S. & Vishwnath, G. (2012). Hyperbaric oxygen and wound healing. Indian Journal of Plastic Surgery, 45(2), doi: / BLJ Best Practice. (2015). Assessment of easy bruising. Retrieved from com/ best-practice/monograph/1208.html 39. Bratzler, D., Dellinger, P., Olsen, K., Peri, T., Auwaerter, P., Bolon, M., Fish, D., Napolitano, L., Sawyer, R., Slain, D., Steinberg, J., & Weinstein, R. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacists, 70, Brent, N. (2012). But I left a voic and a note. Retrieved from com/legal-matters-vol1-no/ 41. British Journal of Nursing. (2015). Principles of skin cleansing in continence management. British Journal of Nursing, 24(18), S36-S Brown, A. (2014). Strategies to reduce or eliminate wound pain. Retrieved from nursingtimes.net/nursing-practice/specialisms/wound-care/strategies-to-reduce-or-eliminate-woundpain/ article 43. Bush, S. (2015). Widow spider envenomation clinical presentation. Retrieved from medscape.com/article/ clinical#b4 Page 88

91 44. Carville, S. (2011). Skin tears made easy. Wounds International, 2(4), Centers for Disease Control. (2012). Active bacterial core surveillance (ABCs) report: Methicillinresistant Staphylococcus Aureus, Retrieved from survreports/mrsa12.pdf 46. Centers for Disease Control. (2015). Tetanus: Epidemiology and prevention of vaccine preventable diseases. The pink book: Course textbook (13th Ed.). Retrieved from pubs/pinkbook/tetanus.html 47. Centers for Disease Control. (2015). HIV/AIDS. Retrieved from Centers for Disease Control. (2013). Methicillin-resistant Staphylococcus Aureus (MRSA) Infections. Retrieved from Centers for Disease Control. (2015). Rabies. Retrieved from Centers for Disease Control. (2015). Sickle cell disease: Complication and treatments. Retrieved from Centers for Disease Control. (2015). Vaccines & immunizations: Hepatitis B. Retrieved from Cleveland Clinic. (2015). About your skin. Retrieved from services/ dermatology-plastic-surgery/patient-education/about-your-skin 53. Cleveland Clinic. (2013). Burns. Retrieved from health/diseases_ conditions/hic_burn_pain 54. Cleveland Clinic. (2014). Pain Control. Retrieved from health/ treatments_and_procedures/hic_pain_control_after_surgery 55. Cross, S. (2015). Pasteurella Multocida infection. Retrieved from com/ article/ overview 56. Dale, S. (2011). Say goodbye to wet-to-dry wound care dressings: Changing the culture of wound care management within your agency. Home Healthcare Nurse, 29(7), Daley, B. (2015). Wound care treatment and management. Retrieved from medscape.com/article/ treatment 58. DeMaria, A. (2014). Patient information: Rabies (beyond the basics). Retrieved from uptodate.com/contents/rabies-beyond-the-basics?source=see_link 59. Demling, R. (2009). Anabolism, and the wound healing process: An overview. eplasty, 9, Deliverska, E. (2014). Mechanism of injury: A significant component in evaluation of maxillofacial traumatic patients status. Journal of IMAB, 20(1), doi: /jimab Demidova-Rice, T., Hamblin, M., & Herman, I. (2012). Acute and Impaired Wound Healing: Pathophysiology and Current Methods for Drug Delivery, Part 1: Normal and Chronic Wounds: Biology, Causes, and Approaches to Care. Advanced Skin and Wound Care, 25(7), doi: /01.ASW d0 62. Dermnetz. (2014). Leg ulcers. Retrieved from html 63. Doughty, D. (2006). Urinary and Fecal Incontinence: Current Management Concepts (3rd Edition). St. Louis, MO: Mosby Elsevier. 64. Dowsett, C. & Newton, H. (2006). Wound bed preparation: TIME in practice. Retrieved from Enyclopedia of Children s Health. (2015). Human bite infections. Retrieved from healthofchildren.com/ G-H/Human-Bite-Infections.html 66. European Wound Management Association. (2013). Antimicrobials and non-healing wounds: Evidence, controversies and suggestions. Journal of Wound Care, 22(5), S2-S Gabriel, A. (2015). Wound irrigation. Retrieved from article/ overview 68. Gabriel, E. (2014). Vascular ulcers. Retrieved from article/ overview#a8 69. Galli, S. (2015). Animal bites. Retrieved from overview#a6 70. Galli, S. (2015). Animal bites treatment and management. Retrieved from medscape.com/article/ treatment 71. Gethin, G. (2007). The significance of surface ph in chronic wounds. Wounds UK, 3(3), Galli, S. (2013). Wound Closure Technique. Retrieved from article/ overview 73. Guo, S. & DiPietro, L. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), Hanft, J. (2005). How to differentiate between infected wounds and colonized wounds. Retrieved from Heller, J. (2015). Laceration versus puncture wound. Retrieved from medlineplus/ ency/imagepages/19616.htm 76. Herchline, T. (2015). Cellulitis treatment and management. Retrieved from medscape.com/article/ treatment#d Herlihy, B. (2014). The Human Body in Health and Illness (5 th Edition). St. Louis, MO: Elsevier Saunders. 78. Herndon, D. (2007). Total Burn Care (3rdEdition). Philadelphia, PA: Saunders 79. Hess, C. (2013). Clinical Guide to Skin and Wound Care (7th Ed.). Philadelphia, PA: Wolters Kluwer. 80. Hospenthal, D. (2014). Burn wound infections treatment and management. Retrieved from emedicine.medscape.com/article/ treatment 81. Huang, C., Leavitt, T., Bayer, L., & Orgill, D. (2014). Effect of negative pressure wound therapy on wound healing. Current Problems in Surgery, 51(7), doi: /j.cpsurg Ignatavicius, D. & Workman, L. (2012). Medical Surgical Nursing: Patient Centered Collaborative Care (8th Edition). St. Louis, MO: Elsevier. 83. Inoue, S. (2015). Leukocytosis. Retrieved from overview#a5 84. Jeffrey, J. & Harrison, B. (2014). Wound healing: Part 1. Basic science. Plastic and Reconstructive Surgery, 133(2), 199e-207e. doi: /01.prs f9 85. Johns Hopkins Medicine. (n.d.). Burns. Retrieved from healthlibrary /conditions/dermatology/burns_85,p01146/ 86. Johns Hopkins Medicine. (n.d.). Wound and pressure ulcer management. Retrieved from The Joint Commission. (2015). National patient safety goals: Goal #14. Retrieved from jointcommission.org/assets/1/6/2015_npsg_ncc.pdf 88. The Joint Commission. (2008). Pressure ulcers: Standard FAQ details. Retrieved from jointcommission.org/standards_information/jcfaqdetails.aspx?standardsfaqid=163&programid= Junker, J., Kamel, R., Caterson, E., & Eriksson, E. (2013). Clinical impact upon wound healing and inflammation in moist, wet, and dry environments. Advances in Wound Care, 2(7), Kennedy, S., Stoll, L., & Lauder, A. (2015). Human and Other Mammalian Bite Injuries of the Hand: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons, 23(1), doi: / JAAOS Kishner, S. (2015). Osteomyelitis. Retrieved from com/ article/ overview#a7 92. Khosk, M. (2014). Full-thickness skin grafts. Retrieved from article/ overview#a6 93. Langschmidt, J., Caine, P., Wearn, C., Bamford, A., Wilson, Y., & Moiemen, N. (2014). Hydrotherapy in burn care: A survey of hydrotherapy practices in the UK and Ireland and literature review. Burns, 40(5), doi: /j.burns Lucas, V. (2011). Psychological Stress and Wound Healing in Humans. Wounds, 22(4), Lyder, C. 7 Ayello, E. (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. 96. Marx, J., Hockberger, R., & Walls, R. (2014). Rosen s Emergency Medicine: Concepts and Clinical Practice (8th Edition). Philadephia, PA: Saunders. 97. MedlinePlus. (2015). Burns. Retrieved from MedlinePlus. (2015). Surgical wound care. Retrieved from medlineplus/ ency/patientinstructions/ htm 99. Mayo Clinic. (2014). Bedsores (pressure sores). Retrieved from diseases-conditions/bedsores/basics/causes/con Mayo Clinic. (2015). Burns: first aid. Retrieved from Mayo Clinic. (2014). C-reactive protein test. Retrieved from Mayo Clinic. (2015). Low White Blood Cell Count. Retrieved from symptoms/low-white-blood-cell-count/basics/causes/sym Mayo Clinic. (2015). Osteomyelitis. Retrieved from osteomyelitis/basics/tests-diagnosis/con Mayo Clinic. (2015). Shock: First aid. Retrieved from Mayo Clinic. (2015). Spider bites. Retrieved from spider-bites/basics/symptoms/con Mayo Clinic. (2015). Thrombocytopenia. Retrieved from McCulloch, J. & Kloth, L. (2010). Wound Healing: Evidence-Based Management (4 th Edition). Philadelphia, PA: F.A. Davis Company McNeal, R. (2015). Structure and function of the skin. Retrieved from com/home/skin-disorders/biology-of-the-skin/structure-and-function-of-the-skin 109. MedlinePlus. (2014). Aging changes in skin. Retrieved from medlineplus/ ency/article/ htm 110. MedlinePlus. (2015). Basic metabolic panel. Retrieved from medlineplus/ ency/article/ htm 111. Medline. (2015). Bruises. Retrieved from MedlinePlus. (2014). Minor burns. Retrieved from patientinstructions/ htm 113. Merck Manuals. (2015). Lacerations. Retrieved from professional/ injuries-poisoning/lacerations/lacerations 114. Mohler, E. & Mitchell, E. (2015). Noninvasive diagnosis of arterial aisease. Retrieved from arch=ankle+brachial+index&selectedtitle=1~47&sectionrank=1&anchor=h #h Moore, M. (2010). Wound assessment. Retrieved from CE/WCEI_outline.pdf 116. Morgan, N. (2013). What you need to know about xerosis in patients with diabetic feet. Wound Care Advisor, 2(4), Morgan, N. (n.d.). Wound assessment: The basics. Retrieved from Satellite?blobcol=urldata&blobheadername1=Content-type&blobheadername2=Content-disposition&blobh eadername3=mdttype&blobheadervalue1=application%2fpdf&blobheadervalue2=inline%3b+fil ename%3d261%252f589%252f100435%2bwoundassessment1hr%2bnancy%2bmorgan.pdf&b lobheadervalue3=abinary%3b+charset%3dutf8&blobkey=id&blobtable=mungoblobs&blobwher e= &ssbinary=true 118. Morgan, N. (2012). Wet to dry. Retrieved from Morgan, N. (2012). Wound exudate types. Retrieved from woundexudate-types/ 120. Mosby. (2009). Mosby s Medical Dictionary (8th Ed.). Retrieved from thefreedictionary.com/biologic+dressing 121. Naga, O. (2015). Pediatric Board Study Guide: Last Minute Review. New York, NY: Springer National Alliance of Wound Care and Ostomy, (2015). About us. Retrieved from National Cancer Institute. (2015). Layers of the skin. Retrieved from melanoma/anatomy/layers.html 124. NDNQI. (2015). Pressure ulcer prevention: Interventions. Retrieved from nursingquality.org/ndnqipressureulcertraining/module3/pressureulcersurveyguide_14.aspx 125. National Geographic. (2015). Skin. Retrieved from health-and-human-body/human-body/skin-article/ 126. National Health System- UK. (2014). Pressure ulcer causes. Retrieved from / Conditions/Pressure-ulcers/Pages/Causes.aspx 127. National Health System-UK. (n.d). What does Vitamin D do? Retrieved from chq/pages/what-does-vitamin-d-do.aspx 128. National Pressure Ulcer Advisory Panel. (2013). Best practices for prevention of medical devicerelated pressure ulcers. Retrieved from /04/ Medical-Device-Poster.pdf 129. National Pressure Ulcer Advisory Panel. (n.d.). NPUAP pressure ulcer stages/categories. Retrieved from National Pressure Ulcer Advisory Panel. (2014). Prevention and treatment of pressure ulcers: Quick reference guide. Retrieved from 14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf 131. Nijhawan, R., Smith, L., & Mariwalla, K. (2013). Mohn Surgeon s use of topical emollients in postoperative wound care. Dermatological Surgery, 39(8), doi: /dsu Page 89

92 132. Opletalova, K., Blaizot, X., Mourgeon, B., Chene, Y., Creveuil, C., Combemale, P., Laplaud, L., Sohyer-Lebreuilly, I., & Dompmartin, A. (2012). Maggot therapy for wound debridement: A randomized multicenter trial. Jama Dermatology, 148(4), doi: / archdermatol Oxford Dictionary. (2015). Wound definition. Retrieved from definition/american_english/wound 134. Panuncialman, J., Hammerman, S., Carson, P., & Falanga, V. (2010). Wound edge biopsy sites in chronic wounds heal rapidly and do not result in delayed overall healing of the wound. Wound Repair and Regeneration, 18(1), Pather, P., Kynoch, K., & Coyer, F. (2015). The effectiveness of topical skin products in the treatment and prevention of incontinence-associated dermatitis: a systematic review protocol. JBI Database of Systematic Reviews & Implementation Reports, 13(5), doi: / jbisrir Paul, S. (2013). Skin. India, HarperCollins Posthauer, M. (2012). The role of nutrition in wound care. Advances in Skin and Wound Care, 25(2), QuickClot. (2015). About QuickClot. Retrieved from Sardina, D. (2009). Temperature effects on wound healing. Retrieved from net/2009/05/temperature-effects-on-wound-healing/ 140. Sardina, D. (2013). Is Your wound-cleansing practice up to date? Retrieved fromhttp:// woundcareadvisor.com/is-your-wound-cleansing-practice-up-to-date_vol2_no3/ 141. Sherwood, L. (2014). Human physiology: From cells to systems (9 th Edition). Body Defenses. Boston, MA: Cengage Learning Simon, P. (2014). Skin wound healing. Retrieved from / article/ overview#a Slachta, P. (2013). Assessing risk of pressure- and moisture related problems in long-term care patients. Wound Care Advisor, 2(3), Smith & Nephew. (2015). Antimicrobial dressings. Retrieved from key-products/advanced-wound-management/dressing-types/antimicrobial-dressings/ 145. Smith & Nephew. (2015). What is collagenase SANTYL ointment? Retrieved from Swezey, L. (2014). Abnormal wound healing (part 2). Retrieved from com/ abnormal-wound-healing-part-2/ 147. Sweezy, L. (2014). Types of wound closure. Retrieved from woundeducators. com/wound-closure/ 148. Ud-din, S. (2014). Electrical stimulation and cutaneous wound healing: A review of clinical evidence. Healthcare 2014, 2, doi: /healthcare University of Michigan Apps doe Surgical Trainees. (2012). Surgical wound classifications. Retrieved from /mast/ r_surgwoundclass.html 150. University of Oregon. (2015). Micronutrient information center: Vitamin D and skin health. Retrieved from vitamin-d 151. Vanholder, R. & Sever, M. (2015). Crush-related acute kidney injury (acute renal failure). Retrieved from Warner-Maron, I. (2015). The Risk of Risk Assessment: Pressure Ulcer Assessment and the Braden Scale. Annals of Long-Term Care, 23(5). Retrieved from Wound Care Education Institute. (2015). Skin & Wound Management Course. Live-Seminar Wilson, S. (2013). Perfusion. In S.F. Wilson & J.F. Giddens (Eds.), Health Assessment for Nursing Practice (5th Edition) St. Louis, MO: Elsevier Mosby World Health Organization. (2015). Burns: Fact Sheet. Retrieved from mediacentre /factsheets/fs365/en/ 156. World Health Organization. (2015). Human and animal bites and clenched fist injuries. Retrieved from World Health Organization. (2007). Management of burns. Retrieved from surgery/publications/burns_management.pdf 158. World Health Organization. (2009). Wound management. Retrieved from int/ surgery/publications/woundmanagement.pdf 159. Wound Educators. (2015). Wound dressings. Retrieved from /resources/ wound-dressings/ 160. The Wound Institute. (2013). Understanding debridement of sores. Retrieved from aawconline.org/tutorials/derm/dm x/dm x.pdf 161. Wounds International. (2013). Principles of compression in venous disease: A practitioner s guide to treatment and prevention of venous leg ulcers. Retrieved from media/issues/672/files/content_10802.pdf 162. Wounds International. (2013).International best practice guidelines: Wound management in diabetic foot ulcers. Retrieved from media/issues /673/files/ content_10803.pdf 163. Wounds International. (2011). Skin tears made easy. Wounds International, 2(4), Wound Source. (2015). Arterial ulcers. Retrieved from patientcondition/arterial-ulcersannalsoflongtermcare.com/article/risk-risk-assessment-pressureulcer-assessment-and-braden-scale 165. Wound Source. Tunneling wounds of sinus tracts. Retrieved from patientcondition/tunneling-wounds-or-sinus-tracts 166. Wound Source. (2015). Aquacell Ag extra hydrofiber wound dressing with Ionic Silver. Retrieved from Wound, Ostomy, and Continence Nursing Society. (2015). About us. Retrieved from wocn.org/ 168. Zulkowski, K. (2011). Legal proceedings: Pressure ulcers, patient care lawsuits, and you. Retrieved from Zehnder, J. (2015). Clinical use of coagulation tests. Retrieved from contents/clinical-use-of-coagulation-tests Page 90

93 wound care: priorities FOR NURSING self assessment Select the best answer for each question and check your answers at the bottom of the page. You do not need to submit this self-evaluation exercise with your answer sheet. 1. A chronic wound is: a. A wound that is progressing at a predictable rate. b. A wound that is stuck in the proliferative phase. c. A wound that shows signs of epithelialization. d. A wound that is stuck in the inflammatory phase. 2. The Braden Scale contains all of the following categories for risk EXCEPT: a. Activity. b. Medications. c. Moisture. d. Friction/shear. 3. Hypogranulation can be a sign of: a. Infection. b. Rapid healing. c. Imminent wound closure. d. Scab formation. 4. In order to assess the patient s nutritional status as part of the diagnostic process an order for should be obtained. a. C-reactive protein. b. Complete blood count. c. Basic metabolic profile. d. Protein, albumin & pre-albumin. 5. During which phase of wound healing are fibrin and thrombin activated, which causes inflammatory cells to migrate to the area? a. Hemostasis. b. Inflammatory phase. c. Proliferative phase. d. Maturation phase. 7. When assessing exudates the nurse notes a thick, milky, yellow drainage. She documents this as drainage. a. Serous. b. Sanguineous. c. Purulent. d. Serosanguinous. 8. A nurse applies Sulfamylon to a wound. This antimicrobial is effective since the wound is: a. Contaminated with Pseudomonas strains. b. Contaminated by gram-negative bacteria. c. Not covered with occlusive dressings. d. Not to be covered with a dressing. 9. Moisture related contact dermatitis can be caused by: a. Latex. b. Hand sanitizers. c. Leaking ostomies. d. Nail polish remover. 10. When providing nursing care for patients with cellulitis the nurse should: a. Keep the area elevated. b. Apply warm clean dressings during the day. c. Avoid applying antimicrobial dressings to open lesions. d. Obtaining a consult with a rheumatologist if the cellulitis is over a joint. 6. In order to accurately measure and document the size and depth of the wound the nurse should: a. Measure depth using a Q-tip. b. Imagine a clock and think of the patient s head as 6 o clock. c. Estimate the size of the wound in inches. d. Know that every wound is measured in a different way. 1.D 2.B 3.A 4.D 5.B 6.A 7.C 8.A 9.C 10.A Page 91

94 2017 Continuing Education Course for Illinois Nursing Professionals Customer Information All 20 Hrs ONLY $ What if I Still Have Questions? No problem, we have several options for you to choose from! Online at you will see our robust FAQ section that answers many of your questions, simply click FAQ in the upper right hand corner or us at office@elitecme.com or call us toll free at , Monday - Friday 9:00 am - 6:00 pm, EST. Elite Continuing Education Three Easy Steps to Completing Your License Renewal Step 1: Complete your Elite continuing education courses: 99 Review the course materials and complete the Course Participant Sheet. 99 Complete the course evaluation. To receive credit for your courses completion of the evaluation is mandatory. 99 Submit your course participant sheet, course evaluation along with your payment to Elite online, by fax, or by mail. Step 2: Receive your certificate of completion: 99 On-Line Submission: Go to and follow the prompts.you will be able to print your certificate immediately upon completion of the course. 99 Fax or Submission: Fax to (386) , be sure to include your credit card information. All completions will be processed within 2 business days of receipt and certificates ed to the address provided.* 99 Mail Submission: Use the envelope provided or mail to Elite, PO Box 37, Ormond Beach, FL All completions will be processed and certificates issued within 10 business days from the date it is mailed.* *Please note - providing a valid address is the quickest and most efficient way to receive your certificates when submitting via fax, or mail. Submissions without a valid address will be mailed to the address provided at registration. Step 3: Once you have received your certificate of completion you can renew your license online at profs/boards/nursing.asp, or mail in your renewal. You should receive your renewal notice within 90 days of the expiration date. In order to avoid late fees, your CE and license renewal must be completed by January 31 of the even year. Board Contact Information: IDFPR Illinois Center for Nursing James R. Thompson Center 100 West Randolph Street Suite Chicago, IL Phone: 888-NURSE07 [ ] Website: Page 92