- Email: [email protected]
Clinical Issues—January 2011
CLINICAL ISSUES
1.2 www.aorn.org/CE
This Month f f
Use of indwelling urinary catheters for perioperative patients Key words: indwelling urinary catheter, urinary tract infection, Foley catheter.
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Managing an Acinetobacter baumannii outbreak Key words: Acinetobacter baumannii, opportunistic pathogen, health care-associated infection, colonization pressure, bloodstream infection.
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Frequently asked questions about meningitis Key words: bacterial meningitis, viral meningitis, meningococcal infection, pneumococcal polysaccharide vaccine, meningococcal polysaccharide vaccine, pneumococcal conjugate vaccine.
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Implementing droplet precautions Key words: droplet precautions, personal protective equipment.
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Use of indwelling urinary catheters for perioperative patients
QUESTION: We have perioperative nursing students in our OR periodically, and, recently, a student asked for clarification on the use of indwelling urinary catheters in perioperative patients. When is an indwelling urinary catheter needed for a patient undergoing surgery? What steps should be taken when inserting a urinary catheter? What should be involved in developing a urinary catheter quality improvement program?
ANSWER: The Centers for Disease Control and Prevention updated its Guideline for Prevention of CatheterAssociated Urinary Tract Infections1 in 2009. According to the updated guideline, indwelling urinary catheters should be placed in select patients for certain procedures, for example, for patients who are
undergoing urologic surgery or other surgery on bodily structures of the genitourinary tract,
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire January 31, 2014. doi: 10.1016/j.aorn.2010.10.010
© AORN, Inc, 2011
January 2011
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No 1 ● AORN Journal
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January 2011
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undergoing surgical procedures that will last for a prolonged period (catheters inserted for this reason should be removed in the postanesthesia care unit after completion of surgery), undergoing surgical procedures in which use of a large volume of infusions or diuretics is anticipated during the procedure, and in need of intraoperative monitoring of urinary output.
Only properly trained health care personnel should insert urinary catheters. The proper technique and considerations for placement of an indwelling urinary catheter are as follows:
f f
Perform hand hygiene before and after insertion or manipulation of the urinary catheter. Use sterile gloves, drapes, sponges, and appropriate antiseptic or sterile solutions for insertion and, if necessary, a single-use packet of lubricant jelly. Secure the urinary catheter after insertion to prevent movement and urethral traction. Use a closed drainage system after aseptic insertion of a urinary catheter. Maintain an unobstructed urine flow. Keep the urinary catheter bag below the level of the bladder at all times. Use a clean container if it is necessary to empty the catheter bag; avoid splashing and prevent contact of the drainage spigot with the nonsterile collecting container. Bladder irrigation is not recommended unless obstruction is anticipated (eg, as may occur with bleeding after prostatic or bladder surgery). Routine irrigation with antimicrobials is not recommended.
A quality improvement program should be in place to enhance the appropriate use of urinary catheters and to reduce the risk of catheterassociated urinary tract infections. The quality improvement program should include information for health care providers regarding the appropriate use of catheters, identifying and removing catheters that are no longer needed, and adhering to hand hygiene and proper care of catheters. Programs may include guidelines and protocols for nurse-directed removal of unnecessary urinary catheters; education and performance feedback regarding use of catheters, hand hygiene, and catheter care; and guidelines for perioperative catheter management such as procedure-specific guidelines for catheter placement, maintenance, and postoperative catheter removal and protocols for management of postoperative urinary retention, such as intermittent catherization and use of bladder ultrasound scanners.1
JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE Reference 1.
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of CatheterAssociated Urinary Tract Infections 2009. Atlanta, GA: Centers for Disease Control and Prevention; 2009. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTI guideline2009final.pdf. Accessed September 23, 2010.
Managing an Acinetobacter baumannii outbreak
QUESTION: Recently, we experienced an outbreak of Acinetobacter baumannii at our health care facility. What can we do to control the spread of this pathogen? 166
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AORN Journal
ANSWER: Acinetobacter species are aerobic, gram-negative, nonfermentative, coccobacillary rods.1 Acinetobacter baumannii has become a significant nosocomial opportunistic pathogen as evidenced by its
CLINICAL ISSUES increasing antimicrobial resistance.2 In the last several years, multidrug-resistant Acinetobacter species have been increasing and have caused numerous outbreaks.2-4 The National Nosocomial Infection Surveillance System (now the National Healthcare Safety Network) lists Acinetobacter as an increasing cause of health care-associated infections.3 Health care-associated infections caused by Acinetobacter include bacteremia, pneumonia, meningitis, urinary tract infections, and wound infections.2 Acinetobacter is also an increasing cause of infection in US soldiers wounded in military actions.4 In hospitalized patients, the mortality rate attributed to Acinetobacter infections has ranged from 8% to 25%.1 Acinetobacter can survive in the environment for weeks at a time on dry surfaces and in water.1 During in vitro testing of surfaces (eg, laminate, ceramic, stainless steel, rubber, polyvinyl chloride), Acinetobacter colonies survived for at least two weeks.1,5 Environmental contamination has been traced to respiratory care equipment, wound care procedures, humidifiers, and patient care items.2 A variety of factors increase a patient’s risk of acquiring multidrug-resistant Acinetobacter. Some of these factors include
a prolonged hospital stay, exposure to an intensive care unit, having been on a ventilator, colonization pressure (ie, the proportion of other patients colonized),6 exposure to antimicrobial agents, and having undergone surgery or an invasive procedure recently.
The underlying severity of the illness for which the patient was hospitalized may also be a risk factor.2 This pathogen is very difficult to contain, and data on its effects are limited. At one 950-bed, acute care university hospital, an infection control program “bundle” was instituted7 that included
www.aornjournal.org
emphasizing basic hand hygiene (eg, glove use, hand washing, use of alcohol-based hand rubs); placing colonized or infected patients on contact precautions in single rooms; performing active surveillance, which included weekly rectal, perineal, and pharyngeal swabs; culturing the hands of health care personnel caring for patients; performing strict environmental cleaning according to the Centers for Disease Control and Prevention guidelines for rooms or any equipment or devices used on patients;8 and holding regular meetings to educate and update staff members caring for these patients in any areas.7
The comprehensive bundle was effective in this setting for controlling what had become years of complex outbreaks with multidrug-resistant Acinetobacter.2 Implementing this bundle may prevent bloodstream infections and catheter-associated urinary tract infections, which is the leading cause of secondary bloodstream infection.1,8 JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
4. 5.
6.
Weber DJ, Rutala WA, Miller MB, Huslage K, SickbertBennet E. Role of hospital surfaces in the transmission of emerging health-care associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control. 2010;38(5 Suppl 1):S25-S33. Maragakis LL, Perl TM. Acinetobacter baumannii: epidemiology, antimicrobial resistance, and treatment options. Clin Infect Dis. 2008;46(8):1254-1263. Gaynes R, Edwards JR; the National Nosocomial Infection Surveillance System. Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis. 2005;41(6):848-854. Munoz-Price LS, Weinstein RA. Acinetobacter infection. N Engl J Med. 2008;358(12):1271-1281. Jawad A, Seifert H, Snelling AM, Heritage J, Hawkey PM. Survival of Acinetobacter baumannii on dry surfaces: comparison of outbreaks and sporadic isolates. J Clin Microbiol. 1998;36(7):1938-1941. Bonten MJ, Slaughter S, Ambergen AW, et al. The role of “colonization pressure” in the spread of vancomycinresistant enterococci: an important infection control variable. Arch Intern Med. 1998;158(10):1127-1132.
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7.
Rodríquez-Baño J, García L, Ramírez E, et al. Long-term control of hospital-wide, endemic multidrug-resistant Acinetobacter baumanii through a comprehensive “bundle” approach. Am J Infect Control. 2009;37(9):715-722. 8. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices
f f
Frequently asked questions about meningitis
QUESTION: Recently, we had a patient with meningitis come through the OR. I realize that meningitis is a serious disease but do not know enough about it. What should health care providers know about this disease?
ANSWER: Meningitis is an inflammation of the meninges, the superficial lining tissues of the brain and spinal cord. Pathogens that can cause meningitis include bacteria (eg, pneumococci, meningococci) and viruses (eg, herpes simplex virus, enteroviruses, aroboviruses, mumps).1 Spirochetes, fungi, and protozoa also may cause acute meningitis. The most common pathogens that cause bacterial meningitis are Neisseria meningitides, Streptococcus pneumoniae, Haemophilus influenza, group B streptococci, and Listeria monocytogenes.1,2 Types of meningococcal and pneumococcal invasive disease are meningitis, bacteremia, and pneumonia.3,4 Patients who survive meningococcal invasive disease have a 10% to 20% chance of experiencing sequelae, including limb loss from gangrene, extensive scarring, or cerebral infarction.4 Symptoms that may be helpful in determining a differential diagnosis include abrupt or subacute onset of headache, stiff neck, fever, nausea, and vomiting. A skin rash with petechiae may be evident with a meningococcal infection.5 Colonization of the nasopharynx with the causative pathogen occurs early.6 Diagnosis of meningitis is also determined by performing a lumbar puncture to obtain cerebrospi168
Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Atlanta, GA: Centers for Disease Control and Prevention; 2009. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTI guideline2009final.pdf. Accessed September 23, 2010.
AORN Journal
nal fluid for gram staining and fluid analysis. A computed tomography may be performed before the lumbar puncture to rule out focal, intracranial mass lesions, which could result in brain stem herniation and even death after a lumbar puncture because of increased pressure that results from the removal of lumbar spinal fluid.6 The patient should be placed on droplet precautions until the pathogen causing the symptoms is identified by Gram stain, blood culture, or lumbar puncture. All personnel and visitors should wear surgical masks to prevent transmission from close respiratory or mucous membrane contact with the patient’s respiratory secretions.7 Vaccines against some microbial strains that cause meningitis are available: Pneumococcal vaccines Pneumococcal polysaccharide vaccine (ie, PPV) targets 23 of the most common strains of S pneumoniae. This can be administered to children two years of age or older with underlying medical conditions and to persons 65 years of age or older. A 7-valent pneumococcal polysaccharideprotein conjugate vaccine (ie, PCV7) is available for children ages 23 months or younger and for children ages 24 to 59 months who have certain high-risk conditions.4,5 Meningococcal vaccines Tetravalent meningococcal polysaccharide conjugate vaccine (ie, MCV4) is administered to people 11 to 15 years of age and to college freshman. Tetravalent meningococcal polysaccharide
CLINICAL ISSUES
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vaccine (ie, MPSV4) is used in mass vaccination programs and for travelers and military personnel.3,6 One of the functions of the spleen is to facilitate the phagocytosis of encapsulated bacteria.8 Patients who have undergone a splenectomy are at high risk of infections from pneumococcal, meningococcal, and H influenza pathogens.9 The spleen acts as a filter for these pathogens; after splenectomy, if a patient without a spleen develops an infection with any of those pathogens, serious complications could result (eg, one patient developed a serious infection, with the resultant loss of all fingers and toes).9 During the preoperative assessment, nurses caring for a patient who has had a splenectomy should ask the patient whether he or she has received pneumococcal, meningococcal, and influenza vaccines. After surgery, during the transfer of the patient care information report, the transferring nurse should tell staff members on the receiving unit whether the patient has received these vaccines. Meningitis can be a serious and life-threatening disease. Droplet precautions should be used if a patient is suspected of having, or has, meningitis. Follow-up with information on the patient’s immunization history after splenectomy is critical in preventing infections with pneumococcal, meningococcal, or the influenza virus. Proper placement of the surgical mask will help protect health care personnel from the transmission of droplet-producing diseases.
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JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3. 4.
5.
6.
7.
8.
9.
Short WR, Tunkel AR. Changing epidemiology of bacterial meningitis in the United States. Curr Infect Dis Rep. 2000;2(4):327-331. van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006;354(1):44-53. Spiro CE, Spiro DM. Acute meningitis: focus on bacterial infection. Clin Rev. 2004;14(3):54. Ostrowsky B. Central nervous system infection. In: APIC Text of Infection Control and Epidemiology. 3rd ed. Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc; 2009; 95-1– 95-14. Pilishvili T, Noggle B, Moore MR. Pneumococcal. In: Manual for the Surveillance of Vaccine-Preventable Diseases. 4th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2008-2009. http://www.cdc.gov/vaccines/ pubs/surv-manual/chpt11-pneumo.htm. Accessed September 23, 2010. Cushing M, Cohn A. Meningococcal disease. In: Manual for the Surveillance of Vaccine-Preventable Diseases. 4th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2008-2009. http://www.cdc.gov/vaccines/ pubs/surv-manual/chpt08-mening.htm. Accessed September 23, 2010. Seigel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2007. http://www.cdc.gov/ ncidod/dhqp/pdf/guidelines/isolation2007.pdf. Accessed September 23, 2010. Dawson LJ. Infectious processes. In: Pathophysiology. 4th ed. Copstead LE, Banasik JL, eds. St Louis, MO: Saunders; 2010:160-180. Gwande A. The checklist manifesto: solutions for facing the risks complexity and cost of medicine. Presented at: The 9th Annual Educational Conference and International Meeting of the Association for Professional in Infection Control; June 2010; New Orleans, LA.
Implementing droplet precautions
QUESTION:
ANSWER:
A patient who came to our OR for surgery recently was on droplet precautions. Staff members could not come to a consensus on how care should be provided. What is involved in droplet precautions?
A variety of diseases require use of droplet precautions. Some of these diseases include group A Streptococcus, Neisseria meningitides, and pertussis. Droplet precautions require use of personal protective equipment. It is particularly important AORN Journal
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that the surgical mask be worn properly. This includes:
wearing the surgical mask with the ties secured at the middle of the head and back of the neck, ensuring that the flexible band is fit to the nose bridge, and ensuring that the mask fits snugly to the face and below the chin.
Health care providers must ensure that masks are applied by health care providers and visitors within a specific distance from the patient:
For a patient with Staphylococcus aureus in the nares, the health care provider or visitor should place the mask on his or her face within 4 feet of the patient.
If a patient is contaminated with an emerging or highly virulent pathogen, then the health care provider or visitor should place the mask on his or her face within 6 feet to 10 feet of the patient.1 JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
Reference 1.
Seigel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention. 2007. http://www.cdc.gov/ncidod/dhqp/pdf/ guidelines/isolation2007.pdf. Accessed September 23, 2010.
The author of this column has no declared affiliations that could be perceived as posing a potential conflict of interest in the publication of this article.
Bring Your Clinical Questions to AORN’s Team of Perioperative Nurse Specialists When you find yourself puzzled by a clinical issue, remember that AORN’s perioperative nursing specialists are just a telephone call away. For answers to your questions, contact the Center for Nursing Practice at (800) 755-2676. AORN’s Perioperative Standards and Recommended Practices is an excellent resource for perioperative nurses. Purchase your copy at www.aornbookstore.org.
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
1.2
Clinical Issues
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #11000; Session: #4031 Fee: Members $6 Nonmembers $12 The deadline for this program is January 31, 2014. Each applicant who successfully completes this program can immediately print a certificate of completion.
© AORN, Inc, 2011
January 2011
Vol 93
No 1 ● AORN Journal
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1.2 www.aorn.org/CE
This Month f f
Use of indwelling urinary catheters for perioperative patients Key words: indwelling urinary catheter, urinary tract infection, Foley catheter.
f f
Managing an Acinetobacter baumannii outbreak Key words: Acinetobacter baumannii, opportunistic pathogen, health care-associated infection, colonization pressure, bloodstream infection.
f f
Frequently asked questions about meningitis Key words: bacterial meningitis, viral meningitis, meningococcal infection, pneumococcal polysaccharide vaccine, meningococcal polysaccharide vaccine, pneumococcal conjugate vaccine.
f f
Implementing droplet precautions Key words: droplet precautions, personal protective equipment.
f f
Use of indwelling urinary catheters for perioperative patients
QUESTION: We have perioperative nursing students in our OR periodically, and, recently, a student asked for clarification on the use of indwelling urinary catheters in perioperative patients. When is an indwelling urinary catheter needed for a patient undergoing surgery? What steps should be taken when inserting a urinary catheter? What should be involved in developing a urinary catheter quality improvement program?
ANSWER: The Centers for Disease Control and Prevention updated its Guideline for Prevention of CatheterAssociated Urinary Tract Infections1 in 2009. According to the updated guideline, indwelling urinary catheters should be placed in select patients for certain procedures, for example, for patients who are
undergoing urologic surgery or other surgery on bodily structures of the genitourinary tract,
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www.aorn.org/CE. The contact hours for this article expire January 31, 2014. doi: 10.1016/j.aorn.2010.10.010
© AORN, Inc, 2011
January 2011
Vol 93
No 1 ● AORN Journal
165
January 2011
Vol 93
undergoing surgical procedures that will last for a prolonged period (catheters inserted for this reason should be removed in the postanesthesia care unit after completion of surgery), undergoing surgical procedures in which use of a large volume of infusions or diuretics is anticipated during the procedure, and in need of intraoperative monitoring of urinary output.
Only properly trained health care personnel should insert urinary catheters. The proper technique and considerations for placement of an indwelling urinary catheter are as follows:
f f
Perform hand hygiene before and after insertion or manipulation of the urinary catheter. Use sterile gloves, drapes, sponges, and appropriate antiseptic or sterile solutions for insertion and, if necessary, a single-use packet of lubricant jelly. Secure the urinary catheter after insertion to prevent movement and urethral traction. Use a closed drainage system after aseptic insertion of a urinary catheter. Maintain an unobstructed urine flow. Keep the urinary catheter bag below the level of the bladder at all times. Use a clean container if it is necessary to empty the catheter bag; avoid splashing and prevent contact of the drainage spigot with the nonsterile collecting container. Bladder irrigation is not recommended unless obstruction is anticipated (eg, as may occur with bleeding after prostatic or bladder surgery). Routine irrigation with antimicrobials is not recommended.
A quality improvement program should be in place to enhance the appropriate use of urinary catheters and to reduce the risk of catheterassociated urinary tract infections. The quality improvement program should include information for health care providers regarding the appropriate use of catheters, identifying and removing catheters that are no longer needed, and adhering to hand hygiene and proper care of catheters. Programs may include guidelines and protocols for nurse-directed removal of unnecessary urinary catheters; education and performance feedback regarding use of catheters, hand hygiene, and catheter care; and guidelines for perioperative catheter management such as procedure-specific guidelines for catheter placement, maintenance, and postoperative catheter removal and protocols for management of postoperative urinary retention, such as intermittent catherization and use of bladder ultrasound scanners.1
JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE Reference 1.
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of CatheterAssociated Urinary Tract Infections 2009. Atlanta, GA: Centers for Disease Control and Prevention; 2009. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTI guideline2009final.pdf. Accessed September 23, 2010.
Managing an Acinetobacter baumannii outbreak
QUESTION: Recently, we experienced an outbreak of Acinetobacter baumannii at our health care facility. What can we do to control the spread of this pathogen? 166
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AORN Journal
ANSWER: Acinetobacter species are aerobic, gram-negative, nonfermentative, coccobacillary rods.1 Acinetobacter baumannii has become a significant nosocomial opportunistic pathogen as evidenced by its
CLINICAL ISSUES increasing antimicrobial resistance.2 In the last several years, multidrug-resistant Acinetobacter species have been increasing and have caused numerous outbreaks.2-4 The National Nosocomial Infection Surveillance System (now the National Healthcare Safety Network) lists Acinetobacter as an increasing cause of health care-associated infections.3 Health care-associated infections caused by Acinetobacter include bacteremia, pneumonia, meningitis, urinary tract infections, and wound infections.2 Acinetobacter is also an increasing cause of infection in US soldiers wounded in military actions.4 In hospitalized patients, the mortality rate attributed to Acinetobacter infections has ranged from 8% to 25%.1 Acinetobacter can survive in the environment for weeks at a time on dry surfaces and in water.1 During in vitro testing of surfaces (eg, laminate, ceramic, stainless steel, rubber, polyvinyl chloride), Acinetobacter colonies survived for at least two weeks.1,5 Environmental contamination has been traced to respiratory care equipment, wound care procedures, humidifiers, and patient care items.2 A variety of factors increase a patient’s risk of acquiring multidrug-resistant Acinetobacter. Some of these factors include
a prolonged hospital stay, exposure to an intensive care unit, having been on a ventilator, colonization pressure (ie, the proportion of other patients colonized),6 exposure to antimicrobial agents, and having undergone surgery or an invasive procedure recently.
The underlying severity of the illness for which the patient was hospitalized may also be a risk factor.2 This pathogen is very difficult to contain, and data on its effects are limited. At one 950-bed, acute care university hospital, an infection control program “bundle” was instituted7 that included
www.aornjournal.org
emphasizing basic hand hygiene (eg, glove use, hand washing, use of alcohol-based hand rubs); placing colonized or infected patients on contact precautions in single rooms; performing active surveillance, which included weekly rectal, perineal, and pharyngeal swabs; culturing the hands of health care personnel caring for patients; performing strict environmental cleaning according to the Centers for Disease Control and Prevention guidelines for rooms or any equipment or devices used on patients;8 and holding regular meetings to educate and update staff members caring for these patients in any areas.7
The comprehensive bundle was effective in this setting for controlling what had become years of complex outbreaks with multidrug-resistant Acinetobacter.2 Implementing this bundle may prevent bloodstream infections and catheter-associated urinary tract infections, which is the leading cause of secondary bloodstream infection.1,8 JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
2.
3.
4. 5.
6.
Weber DJ, Rutala WA, Miller MB, Huslage K, SickbertBennet E. Role of hospital surfaces in the transmission of emerging health-care associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control. 2010;38(5 Suppl 1):S25-S33. Maragakis LL, Perl TM. Acinetobacter baumannii: epidemiology, antimicrobial resistance, and treatment options. Clin Infect Dis. 2008;46(8):1254-1263. Gaynes R, Edwards JR; the National Nosocomial Infection Surveillance System. Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis. 2005;41(6):848-854. Munoz-Price LS, Weinstein RA. Acinetobacter infection. N Engl J Med. 2008;358(12):1271-1281. Jawad A, Seifert H, Snelling AM, Heritage J, Hawkey PM. Survival of Acinetobacter baumannii on dry surfaces: comparison of outbreaks and sporadic isolates. J Clin Microbiol. 1998;36(7):1938-1941. Bonten MJ, Slaughter S, Ambergen AW, et al. The role of “colonization pressure” in the spread of vancomycinresistant enterococci: an important infection control variable. Arch Intern Med. 1998;158(10):1127-1132.
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7.
Rodríquez-Baño J, García L, Ramírez E, et al. Long-term control of hospital-wide, endemic multidrug-resistant Acinetobacter baumanii through a comprehensive “bundle” approach. Am J Infect Control. 2009;37(9):715-722. 8. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices
f f
Frequently asked questions about meningitis
QUESTION: Recently, we had a patient with meningitis come through the OR. I realize that meningitis is a serious disease but do not know enough about it. What should health care providers know about this disease?
ANSWER: Meningitis is an inflammation of the meninges, the superficial lining tissues of the brain and spinal cord. Pathogens that can cause meningitis include bacteria (eg, pneumococci, meningococci) and viruses (eg, herpes simplex virus, enteroviruses, aroboviruses, mumps).1 Spirochetes, fungi, and protozoa also may cause acute meningitis. The most common pathogens that cause bacterial meningitis are Neisseria meningitides, Streptococcus pneumoniae, Haemophilus influenza, group B streptococci, and Listeria monocytogenes.1,2 Types of meningococcal and pneumococcal invasive disease are meningitis, bacteremia, and pneumonia.3,4 Patients who survive meningococcal invasive disease have a 10% to 20% chance of experiencing sequelae, including limb loss from gangrene, extensive scarring, or cerebral infarction.4 Symptoms that may be helpful in determining a differential diagnosis include abrupt or subacute onset of headache, stiff neck, fever, nausea, and vomiting. A skin rash with petechiae may be evident with a meningococcal infection.5 Colonization of the nasopharynx with the causative pathogen occurs early.6 Diagnosis of meningitis is also determined by performing a lumbar puncture to obtain cerebrospi168
Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Atlanta, GA: Centers for Disease Control and Prevention; 2009. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTI guideline2009final.pdf. Accessed September 23, 2010.
AORN Journal
nal fluid for gram staining and fluid analysis. A computed tomography may be performed before the lumbar puncture to rule out focal, intracranial mass lesions, which could result in brain stem herniation and even death after a lumbar puncture because of increased pressure that results from the removal of lumbar spinal fluid.6 The patient should be placed on droplet precautions until the pathogen causing the symptoms is identified by Gram stain, blood culture, or lumbar puncture. All personnel and visitors should wear surgical masks to prevent transmission from close respiratory or mucous membrane contact with the patient’s respiratory secretions.7 Vaccines against some microbial strains that cause meningitis are available: Pneumococcal vaccines Pneumococcal polysaccharide vaccine (ie, PPV) targets 23 of the most common strains of S pneumoniae. This can be administered to children two years of age or older with underlying medical conditions and to persons 65 years of age or older. A 7-valent pneumococcal polysaccharideprotein conjugate vaccine (ie, PCV7) is available for children ages 23 months or younger and for children ages 24 to 59 months who have certain high-risk conditions.4,5 Meningococcal vaccines Tetravalent meningococcal polysaccharide conjugate vaccine (ie, MCV4) is administered to people 11 to 15 years of age and to college freshman. Tetravalent meningococcal polysaccharide
CLINICAL ISSUES
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vaccine (ie, MPSV4) is used in mass vaccination programs and for travelers and military personnel.3,6 One of the functions of the spleen is to facilitate the phagocytosis of encapsulated bacteria.8 Patients who have undergone a splenectomy are at high risk of infections from pneumococcal, meningococcal, and H influenza pathogens.9 The spleen acts as a filter for these pathogens; after splenectomy, if a patient without a spleen develops an infection with any of those pathogens, serious complications could result (eg, one patient developed a serious infection, with the resultant loss of all fingers and toes).9 During the preoperative assessment, nurses caring for a patient who has had a splenectomy should ask the patient whether he or she has received pneumococcal, meningococcal, and influenza vaccines. After surgery, during the transfer of the patient care information report, the transferring nurse should tell staff members on the receiving unit whether the patient has received these vaccines. Meningitis can be a serious and life-threatening disease. Droplet precautions should be used if a patient is suspected of having, or has, meningitis. Follow-up with information on the patient’s immunization history after splenectomy is critical in preventing infections with pneumococcal, meningococcal, or the influenza virus. Proper placement of the surgical mask will help protect health care personnel from the transmission of droplet-producing diseases.
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JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE References 1.
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3. 4.
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7.
8.
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Short WR, Tunkel AR. Changing epidemiology of bacterial meningitis in the United States. Curr Infect Dis Rep. 2000;2(4):327-331. van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006;354(1):44-53. Spiro CE, Spiro DM. Acute meningitis: focus on bacterial infection. Clin Rev. 2004;14(3):54. Ostrowsky B. Central nervous system infection. In: APIC Text of Infection Control and Epidemiology. 3rd ed. Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc; 2009; 95-1– 95-14. Pilishvili T, Noggle B, Moore MR. Pneumococcal. In: Manual for the Surveillance of Vaccine-Preventable Diseases. 4th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2008-2009. http://www.cdc.gov/vaccines/ pubs/surv-manual/chpt11-pneumo.htm. Accessed September 23, 2010. Cushing M, Cohn A. Meningococcal disease. In: Manual for the Surveillance of Vaccine-Preventable Diseases. 4th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2008-2009. http://www.cdc.gov/vaccines/ pubs/surv-manual/chpt08-mening.htm. Accessed September 23, 2010. Seigel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention; 2007. http://www.cdc.gov/ ncidod/dhqp/pdf/guidelines/isolation2007.pdf. Accessed September 23, 2010. Dawson LJ. Infectious processes. In: Pathophysiology. 4th ed. Copstead LE, Banasik JL, eds. St Louis, MO: Saunders; 2010:160-180. Gwande A. The checklist manifesto: solutions for facing the risks complexity and cost of medicine. Presented at: The 9th Annual Educational Conference and International Meeting of the Association for Professional in Infection Control; June 2010; New Orleans, LA.
Implementing droplet precautions
QUESTION:
ANSWER:
A patient who came to our OR for surgery recently was on droplet precautions. Staff members could not come to a consensus on how care should be provided. What is involved in droplet precautions?
A variety of diseases require use of droplet precautions. Some of these diseases include group A Streptococcus, Neisseria meningitides, and pertussis. Droplet precautions require use of personal protective equipment. It is particularly important AORN Journal
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that the surgical mask be worn properly. This includes:
wearing the surgical mask with the ties secured at the middle of the head and back of the neck, ensuring that the flexible band is fit to the nose bridge, and ensuring that the mask fits snugly to the face and below the chin.
Health care providers must ensure that masks are applied by health care providers and visitors within a specific distance from the patient:
For a patient with Staphylococcus aureus in the nares, the health care provider or visitor should place the mask on his or her face within 4 feet of the patient.
If a patient is contaminated with an emerging or highly virulent pathogen, then the health care provider or visitor should place the mask on his or her face within 6 feet to 10 feet of the patient.1 JOAN BLANCHARD MSS, BSN, RN, CNOR, CIC PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE
Reference 1.
Seigel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA: Centers for Disease Control and Prevention. 2007. http://www.cdc.gov/ncidod/dhqp/pdf/ guidelines/isolation2007.pdf. Accessed September 23, 2010.
The author of this column has no declared affiliations that could be perceived as posing a potential conflict of interest in the publication of this article.
Bring Your Clinical Questions to AORN’s Team of Perioperative Nurse Specialists When you find yourself puzzled by a clinical issue, remember that AORN’s perioperative nursing specialists are just a telephone call away. For answers to your questions, contact the Center for Nursing Practice at (800) 755-2676. AORN’s Perioperative Standards and Recommended Practices is an excellent resource for perioperative nurses. Purchase your copy at www.aornbookstore.org.
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
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his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the Learner Evaluation online at http://www.aorn.org/CE. Rate the items as described below. PURPOSE/GOAL To educate perioperative nurses about providing safe nursing care throughout the perioperative continuum. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss practices that could jeopardize safety in the perioperative area. Low 1. 2. 3. 4. 5. High 2. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #11000; Session: #4031 Fee: Members $6 Nonmembers $12 The deadline for this program is January 31, 2014. Each applicant who successfully completes this program can immediately print a certificate of completion.
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