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A Measles Outbreak Requires Both Critical Thinking and Team Work
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A Measles Outbreak Requires Both Critical Thinking and Team Work Maureen Kroning, EdD, RN Working as a nursing supervisor in a health care facility can be extremely challenging, especially on nights, weekends, and holidays. A recent patient admission describes the challenges that occurred one Sunday morning working as a nursing supervisor and the essential need for both critical thinking and team work to prevent an infection outbreak.
W
orking as a nursing supervisor in a health care facility can be extremely challenging especially on nights, weekends, and holidays. What makes nursing supervision challenging on these days is the limited resources available compared with the sometimes overwhelming resources available week days from 9 a.m. to 5 p.m. From 9 a.m. to 5 p.m., most health care facilities have nursing managers, directors, senior administrators at work as well, as administrators for ancillary departments such as quality, infection control, lab, respiratory, and engineering among others. A recent patient admission describes the challenges that occurred one Sunday morning working as a nursing supervisor and the essential need for both critical thinking and team work to prevent an infection outbreak. THE PATIENT ADMISSION Early on Sunday morning, a young pregnant woman, 34-week gestation, came into the acute care hospital in labor. During the admission history, the patient reported to the nurse practitioner (NP) and the primary nurse that she was exposed to the measles virus about a month ago and about 2 weeks ago developed a sore throat, fever, and rash. The patient’s history enabled both the NP and primary nurse to utilize critical thinking skills, especially because they understood that this patient was a member of the Jewish orthodox community, which had a recent measles outbreak, resulting in this patient being at high risk for potential measles transmission during her pregnancy. According to the local department of health (DOH), this county has seen 108 confirmed cases of measles since January 2019 with the majority of cases being members of the Jewish orthodox community.1 The patient further reported that she did not go to her health care provider while she was sick, and her symptoms and rash resolved about a week later. Again the NP and primary nurse utilized excellent critical thinking skills by taking www.nurseleader.com
seriously that the patient had no documentation to confirm her timeline of the rash subsiding and knowing that the Centers for Disease Control (CDC) reports that from 4 days before the rash develops to 4 days after the rash subsides, an individual infected with measles is considered to be contagious. The NP also confirmed that the patient had no documentation of measles immunity and reported having no immunizations against measles. Critical thinking was also used by researching literature on measles in relation to pregnancy, which helped to make safe, competent decisions. For instance, research shows that nonimmune pregnant women who contract measles 10 days prior to delivery can transmit the virus to their unborn child.2 Because there was no documentation of the patient’s account for the timeline of her recent illness and now with the patient in active labor, the NP utilizing critical thinking calls the local DOH. However, the NP reaches a answering recording at the local DOH that said that no one is available at this time and, if needed, to call a new number that was provided at the end of the recording. The NP then proceeds to call the number provided, and the call is answered by the local police department who then reached out to the on-call person from DOH. Again an example of using critical thinking skills is when the neonatal nurse preparing for the birth of
KEY POINTS A recent weekend patient admission reinforced the importance of a collaborative team approach, utilization of critical thinking, researching best practice guidelines, and providing essential education to the healthcare team, patients, and their families. These elements were necessary to ensure safe and quality care was delivered. Month 2019
1
the patient’s unborn baby decides to call the New York State measles hotline to ask a few questions. Again, no one answers this phone line and a message informs the caller that the hours are Monday through Friday 9:00 a.m. to 5:00 p.m. It was about this time one of the nurses working in maternal child health said, “Doesn’t everyone know that things happen on weekends and holidays too”. I thought to myself, how true this statement is and how important both critical thinking and team work really are when encountering a potential measles case in the midst of a county outbreak. MEASLES According to the CDC, measles is a viral respiratory illness presenting with fever, malaise, cough, conjunctivitis, and a pattern of rashes known as Koplik spots, which are then followed by a maculopapular rash that lasts approximately 14 days after the measles exposure. Four days before the rash develops to 4 days after the rash resolves, the individual infected with measles is considered to be contagious.3 Measles was considered eliminated from the United States in 2000.3 However, according to the Rockland County Department of Health, international, measles-infected travelers arrived in the county in which the hospital is located, thereby exposing county residents to the disease.1 According to the local department of health, the county has had 108 confirmed cases of measles since January 2019, a disease spread by one of the most contagious viruses on earth. In fact, measles is so virulent that it can live 2 hours in the air after the measles-infected person leaves and can infect 90% of individuals who are nonimmune to measles.1 Understanding the virulence and high risk of transmission of measles to unvaccinated individuals made it essential to utilize both critical thinking and team work through the collaboration with the intraprofessional team. Researching current literature on measles and pregnancy helped guide decisions made for this patient case. According to OBGYN.net, the measles virus creates an increased risk of preterm labor and preterm delivery, leading to increased risk of complications and endangering both the mother and her unborn child. Measles can adversely affect nonimmune pregnant women and their fetuses/neonates, and if the measles exposure occurs just before delivery “in utero and intrapartum viral transmission is likely to cause a serious infection in the neonate.”4 Multiple studies show that nonimmune pregnant women are at increased risk of both morbidity and mortality.2 It was vital for the entire intraprofessional team to utilize critical thinking to ensure the safety of both staff and patients. CRITICAL THINKING With the county facing a measles epidemic, it was essential for the intraprofessional team to rely on their critical thinking skills. Nursing supervisors, often covering health care institutions when all administrators 2
Month 2019
are off, make decisions that affect both staff and patients, and thus need to consistently use their critical thinking skills and need to be able to work well with the health care facilities intraprofessional team. According to the Foundation for Critical Thinking, “Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought, and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.” Furthermore, “Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write.”5 When a patient exposed to measles and presenting in active labor was encountered, it was vital that critical thinking was applied in order to answer the many questions that arose throughout the day. Knowing and understanding that the patient lives in a community where a large number of confirmed measles cases occurred was 1 of the first steps in utilizing critical thinking skills. There was also no way to confirm the patient’s account of the course of her recent illness because she admitted to not seeking care from her health care provider when she became ill. Also, according to the patient, her symptoms and rash resolved about a week ago, leaving the proximity to the rash resolving and her labor too close to assume the patient was past the infectivity period. There were also many questions that needed to be answered in order to ensure that safe, competent decisions were made. Among the questions that arose included: will the patient require any special treatment and/or need isolation precautions, and what isolation and for how long will the patient require the isolation; these same questions applied toward the care of the patient’s soon-to-be newborn. There were also questions and decisions about laboratory requirements such as what lab tests needed to be obtained, where specimens would need to be sent to, and how long would it take to get lab results back. There were also decisions as to the newborn’s room placement and what registered nurse (RN) would care for the newborn. It was essential to collaborate with the intraprofessional team using critical thinking skills to thoroughly discuss all the questions that required answers. The intraprofessional team included: the patient’s obstetrician, NP, primary RN, nurse manager, director of maternal child health, and the infections disease practitioners, as well as the department of health. Team huddles to collaborate on this case occurred several times throughout the day. Also essential to include in this collaboration was the newborn’s neonatologist and the nurse who would be assigned to care for the child once mom’s delivery occurred. Collaboration and team huddling throughout the day was essential to ensure mom, baby, other patients on the unit and staff remained safe from a possible measles exposure. www.nurseleader.com
ACTION PLAN The team was proactive by placing precautions and interventions in place to ensure safe and competent care was delivered to both the mother and child. Because the patient had no measles immunity and reported that her rash had resolved approximately 1 week ago, critical thinking was needed to ensure the safety of everyone involved, and it was better to be overly cautious than risk the chance of exposing and potential infecting others with measles. For this reason, airborne precautions were initiated for both the mother and newborn, a 1 RN to 1 patient assignment for both mother and child was initiated in order to prevent cross contamination from occurring with other patients. Seward,6 an expert commentator, says, “If you suspect that a patient has measles, you should act quickly and promptly isolate the patient to avoid disease transmission.” Also, staff known to have immunity to measles were assigned to care for both mother and newborn. The neonatologist also prepared for any specific medical interventions needed for the newborn’s care. A respiratory therapist was alerted in the event the newborn required any respiratory support. It was also necessary to ensure the following shifts were staffed to care for the isolation and medical needs of both mother and child. The local DOH provided direction for lab requirements, and the hospital lab was alerted and directed on what, when, and how laboratory tests would be collected. The intraprofessional team understood that each patient case is unique and requires critical thinking and a team approach to make safe, competent decisions, yet they also recognized that it was important to use the learning that occurred from this case to help guide any future cases that came into the hospital. The team recognizes that general practice guidelines for suspected prenatal exposure to measles include: staff assessing the mother’s immunization/titer status for evidence of immunity and/or documentation of 2 measles, mumps, and rubella (MMR) vaccinations (administered at least 4 weeks apart and immunized $12 months of age). If negative titers and/or there is no documentation of 2 MMR vaccinations (administered at least 4 weeks apart and immunized $12 months of age), then it is essential to assess and develop a timeline for the exposure history, and assess and develop a timeline for any signs and symptoms of measles. Notification to the following promptly occurs: department of health, medical director of infectious disease, nursing director of infection control, neonatologist, laboratory, neonatal nurse, nurse manager and director of maternal child health. The department of health is instrumental in collaborating and directing decisions needed for patient placement and isolation needs. It is always safe to be extra cautious by isolating immediately any potential communicable disease such as measles and wait for confirmatory laboratory results www.nurseleader.com
to become available before taking off of isolation and potentially infecting others. CONCLUSION It is vital health care providers help pregnant mothers understand the importance of immunity to protect themselves and their unborn child from vaccinepreventable illnesses. For this particular case, both mom and baby did test positive for measles and thankfully both progressed through their hospital stay without any noted adverse effects. The intraprofessional team utilized critical thinking and ensured that both patients and staff were not exposed to the highly contagious measles virus. Health care institutions today need employees that have excellent critical thinking skills and can work well in an intraprofessional team. This case provided essential learning and the decisions made this unforgettable Sunday day will help guide the intraprofessional team for similar cases that may present to the hospital. Among all the things learned as a result of this case, the one thing that stood out was that not 1 person alone should make vital decisions about patient care. To truly ensure the safety of patients and staff, it requires a team approach, it requires a degree of being humble that not one of us alone knows all the answers, but by using critical thinking skills, working together as an effective team, and researching best practice, we can make informed decisions for the safety of our patients, families, communities, and the staff who are providing the patient care in situations such as this. REFERENCES 1. Rockland County. Measles information. 2019. Available at: http://rocklandgov.com/departments/health/measlesinformation/. Accessed March 15, 2019. 2. Rasmussen S, Jamieson D. What obstetric health care providers need to know about measles and pregnancy. Obstet Gynecol. 2015;126(1):163-170. 3. Centers for Disease Control and Prevention. Measles (Rubeola): For Healthcare Professionals. 2019. Available at: https://www. cdc.gov/measles/hcp/index.html. Accessed March 15, 2019. 4. White S, Boldt K, Holditch S, Poland G, Jacobson R. Measles, mumps, and rubella. Clin Obstet Gynecol. 2012;55(2):550-559. 5. Heaslip P. Critical thinking and nursing. 2008. The Foundation for Critical Thinking. Available at: https://www.criticalthinking. org/pages/critical-thinking-and-nursing/834. Accessed March 15, 2019. 6. Seward J. Suspect measles and act fast. Medscape. 2014. Available at: https://www.medscape.com/viewarticle/828508? src=par_cdc_stm_mscpedt&faf=1#vp_2. Accessed March 15, 2019.
Maureen Kroning, EdD, RN, is Nursing Chair at Rockland Community College in Suffern, New York, and a Nursing Supervisor at Good Samaritan Hospital in Suffern, New York. She can be reached at [email protected]. 1541-4612/2019/$ See front matter Copyright 2019 by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.mnl.2019.03.018
Month 2019
3
A Measles Outbreak Requires Both Critical Thinking and Team Work Maureen Kroning, EdD, RN Working as a nursing supervisor in a health care facility can be extremely challenging, especially on nights, weekends, and holidays. A recent patient admission describes the challenges that occurred one Sunday morning working as a nursing supervisor and the essential need for both critical thinking and team work to prevent an infection outbreak.
W
orking as a nursing supervisor in a health care facility can be extremely challenging especially on nights, weekends, and holidays. What makes nursing supervision challenging on these days is the limited resources available compared with the sometimes overwhelming resources available week days from 9 a.m. to 5 p.m. From 9 a.m. to 5 p.m., most health care facilities have nursing managers, directors, senior administrators at work as well, as administrators for ancillary departments such as quality, infection control, lab, respiratory, and engineering among others. A recent patient admission describes the challenges that occurred one Sunday morning working as a nursing supervisor and the essential need for both critical thinking and team work to prevent an infection outbreak. THE PATIENT ADMISSION Early on Sunday morning, a young pregnant woman, 34-week gestation, came into the acute care hospital in labor. During the admission history, the patient reported to the nurse practitioner (NP) and the primary nurse that she was exposed to the measles virus about a month ago and about 2 weeks ago developed a sore throat, fever, and rash. The patient’s history enabled both the NP and primary nurse to utilize critical thinking skills, especially because they understood that this patient was a member of the Jewish orthodox community, which had a recent measles outbreak, resulting in this patient being at high risk for potential measles transmission during her pregnancy. According to the local department of health (DOH), this county has seen 108 confirmed cases of measles since January 2019 with the majority of cases being members of the Jewish orthodox community.1 The patient further reported that she did not go to her health care provider while she was sick, and her symptoms and rash resolved about a week later. Again the NP and primary nurse utilized excellent critical thinking skills by taking www.nurseleader.com
seriously that the patient had no documentation to confirm her timeline of the rash subsiding and knowing that the Centers for Disease Control (CDC) reports that from 4 days before the rash develops to 4 days after the rash subsides, an individual infected with measles is considered to be contagious. The NP also confirmed that the patient had no documentation of measles immunity and reported having no immunizations against measles. Critical thinking was also used by researching literature on measles in relation to pregnancy, which helped to make safe, competent decisions. For instance, research shows that nonimmune pregnant women who contract measles 10 days prior to delivery can transmit the virus to their unborn child.2 Because there was no documentation of the patient’s account for the timeline of her recent illness and now with the patient in active labor, the NP utilizing critical thinking calls the local DOH. However, the NP reaches a answering recording at the local DOH that said that no one is available at this time and, if needed, to call a new number that was provided at the end of the recording. The NP then proceeds to call the number provided, and the call is answered by the local police department who then reached out to the on-call person from DOH. Again an example of using critical thinking skills is when the neonatal nurse preparing for the birth of
KEY POINTS A recent weekend patient admission reinforced the importance of a collaborative team approach, utilization of critical thinking, researching best practice guidelines, and providing essential education to the healthcare team, patients, and their families. These elements were necessary to ensure safe and quality care was delivered. Month 2019
1
the patient’s unborn baby decides to call the New York State measles hotline to ask a few questions. Again, no one answers this phone line and a message informs the caller that the hours are Monday through Friday 9:00 a.m. to 5:00 p.m. It was about this time one of the nurses working in maternal child health said, “Doesn’t everyone know that things happen on weekends and holidays too”. I thought to myself, how true this statement is and how important both critical thinking and team work really are when encountering a potential measles case in the midst of a county outbreak. MEASLES According to the CDC, measles is a viral respiratory illness presenting with fever, malaise, cough, conjunctivitis, and a pattern of rashes known as Koplik spots, which are then followed by a maculopapular rash that lasts approximately 14 days after the measles exposure. Four days before the rash develops to 4 days after the rash resolves, the individual infected with measles is considered to be contagious.3 Measles was considered eliminated from the United States in 2000.3 However, according to the Rockland County Department of Health, international, measles-infected travelers arrived in the county in which the hospital is located, thereby exposing county residents to the disease.1 According to the local department of health, the county has had 108 confirmed cases of measles since January 2019, a disease spread by one of the most contagious viruses on earth. In fact, measles is so virulent that it can live 2 hours in the air after the measles-infected person leaves and can infect 90% of individuals who are nonimmune to measles.1 Understanding the virulence and high risk of transmission of measles to unvaccinated individuals made it essential to utilize both critical thinking and team work through the collaboration with the intraprofessional team. Researching current literature on measles and pregnancy helped guide decisions made for this patient case. According to OBGYN.net, the measles virus creates an increased risk of preterm labor and preterm delivery, leading to increased risk of complications and endangering both the mother and her unborn child. Measles can adversely affect nonimmune pregnant women and their fetuses/neonates, and if the measles exposure occurs just before delivery “in utero and intrapartum viral transmission is likely to cause a serious infection in the neonate.”4 Multiple studies show that nonimmune pregnant women are at increased risk of both morbidity and mortality.2 It was vital for the entire intraprofessional team to utilize critical thinking to ensure the safety of both staff and patients. CRITICAL THINKING With the county facing a measles epidemic, it was essential for the intraprofessional team to rely on their critical thinking skills. Nursing supervisors, often covering health care institutions when all administrators 2
Month 2019
are off, make decisions that affect both staff and patients, and thus need to consistently use their critical thinking skills and need to be able to work well with the health care facilities intraprofessional team. According to the Foundation for Critical Thinking, “Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought, and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.” Furthermore, “Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write.”5 When a patient exposed to measles and presenting in active labor was encountered, it was vital that critical thinking was applied in order to answer the many questions that arose throughout the day. Knowing and understanding that the patient lives in a community where a large number of confirmed measles cases occurred was 1 of the first steps in utilizing critical thinking skills. There was also no way to confirm the patient’s account of the course of her recent illness because she admitted to not seeking care from her health care provider when she became ill. Also, according to the patient, her symptoms and rash resolved about a week ago, leaving the proximity to the rash resolving and her labor too close to assume the patient was past the infectivity period. There were also many questions that needed to be answered in order to ensure that safe, competent decisions were made. Among the questions that arose included: will the patient require any special treatment and/or need isolation precautions, and what isolation and for how long will the patient require the isolation; these same questions applied toward the care of the patient’s soon-to-be newborn. There were also questions and decisions about laboratory requirements such as what lab tests needed to be obtained, where specimens would need to be sent to, and how long would it take to get lab results back. There were also decisions as to the newborn’s room placement and what registered nurse (RN) would care for the newborn. It was essential to collaborate with the intraprofessional team using critical thinking skills to thoroughly discuss all the questions that required answers. The intraprofessional team included: the patient’s obstetrician, NP, primary RN, nurse manager, director of maternal child health, and the infections disease practitioners, as well as the department of health. Team huddles to collaborate on this case occurred several times throughout the day. Also essential to include in this collaboration was the newborn’s neonatologist and the nurse who would be assigned to care for the child once mom’s delivery occurred. Collaboration and team huddling throughout the day was essential to ensure mom, baby, other patients on the unit and staff remained safe from a possible measles exposure. www.nurseleader.com
ACTION PLAN The team was proactive by placing precautions and interventions in place to ensure safe and competent care was delivered to both the mother and child. Because the patient had no measles immunity and reported that her rash had resolved approximately 1 week ago, critical thinking was needed to ensure the safety of everyone involved, and it was better to be overly cautious than risk the chance of exposing and potential infecting others with measles. For this reason, airborne precautions were initiated for both the mother and newborn, a 1 RN to 1 patient assignment for both mother and child was initiated in order to prevent cross contamination from occurring with other patients. Seward,6 an expert commentator, says, “If you suspect that a patient has measles, you should act quickly and promptly isolate the patient to avoid disease transmission.” Also, staff known to have immunity to measles were assigned to care for both mother and newborn. The neonatologist also prepared for any specific medical interventions needed for the newborn’s care. A respiratory therapist was alerted in the event the newborn required any respiratory support. It was also necessary to ensure the following shifts were staffed to care for the isolation and medical needs of both mother and child. The local DOH provided direction for lab requirements, and the hospital lab was alerted and directed on what, when, and how laboratory tests would be collected. The intraprofessional team understood that each patient case is unique and requires critical thinking and a team approach to make safe, competent decisions, yet they also recognized that it was important to use the learning that occurred from this case to help guide any future cases that came into the hospital. The team recognizes that general practice guidelines for suspected prenatal exposure to measles include: staff assessing the mother’s immunization/titer status for evidence of immunity and/or documentation of 2 measles, mumps, and rubella (MMR) vaccinations (administered at least 4 weeks apart and immunized $12 months of age). If negative titers and/or there is no documentation of 2 MMR vaccinations (administered at least 4 weeks apart and immunized $12 months of age), then it is essential to assess and develop a timeline for the exposure history, and assess and develop a timeline for any signs and symptoms of measles. Notification to the following promptly occurs: department of health, medical director of infectious disease, nursing director of infection control, neonatologist, laboratory, neonatal nurse, nurse manager and director of maternal child health. The department of health is instrumental in collaborating and directing decisions needed for patient placement and isolation needs. It is always safe to be extra cautious by isolating immediately any potential communicable disease such as measles and wait for confirmatory laboratory results www.nurseleader.com
to become available before taking off of isolation and potentially infecting others. CONCLUSION It is vital health care providers help pregnant mothers understand the importance of immunity to protect themselves and their unborn child from vaccinepreventable illnesses. For this particular case, both mom and baby did test positive for measles and thankfully both progressed through their hospital stay without any noted adverse effects. The intraprofessional team utilized critical thinking and ensured that both patients and staff were not exposed to the highly contagious measles virus. Health care institutions today need employees that have excellent critical thinking skills and can work well in an intraprofessional team. This case provided essential learning and the decisions made this unforgettable Sunday day will help guide the intraprofessional team for similar cases that may present to the hospital. Among all the things learned as a result of this case, the one thing that stood out was that not 1 person alone should make vital decisions about patient care. To truly ensure the safety of patients and staff, it requires a team approach, it requires a degree of being humble that not one of us alone knows all the answers, but by using critical thinking skills, working together as an effective team, and researching best practice, we can make informed decisions for the safety of our patients, families, communities, and the staff who are providing the patient care in situations such as this. REFERENCES 1. Rockland County. Measles information. 2019. Available at: http://rocklandgov.com/departments/health/measlesinformation/. Accessed March 15, 2019. 2. Rasmussen S, Jamieson D. What obstetric health care providers need to know about measles and pregnancy. Obstet Gynecol. 2015;126(1):163-170. 3. Centers for Disease Control and Prevention. Measles (Rubeola): For Healthcare Professionals. 2019. Available at: https://www. cdc.gov/measles/hcp/index.html. Accessed March 15, 2019. 4. White S, Boldt K, Holditch S, Poland G, Jacobson R. Measles, mumps, and rubella. Clin Obstet Gynecol. 2012;55(2):550-559. 5. Heaslip P. Critical thinking and nursing. 2008. The Foundation for Critical Thinking. Available at: https://www.criticalthinking. org/pages/critical-thinking-and-nursing/834. Accessed March 15, 2019. 6. Seward J. Suspect measles and act fast. Medscape. 2014. Available at: https://www.medscape.com/viewarticle/828508? src=par_cdc_stm_mscpedt&faf=1#vp_2. Accessed March 15, 2019.
Maureen Kroning, EdD, RN, is Nursing Chair at Rockland Community College in Suffern, New York, and a Nursing Supervisor at Good Samaritan Hospital in Suffern, New York. She can be reached at [email protected]. 1541-4612/2019/$ See front matter Copyright 2019 by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.mnl.2019.03.018
Month 2019
3