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When Bugs and Drugs Converge: Promoting Safe Practices in the Emergency Department
DANGER ZONE
WHEN BUGS AND DRUGS CONVERGE: PROMOTING SAFE PRACTICES IN THE EMERGENCY DEPARTMENT Author: Susan F. Paparella, MSN, RN, Horsham, PA Section Editor: Susan F. Paparella, MSN, RN
Earn Up to 8.5 CE Hours. See page 173. he impact of health care–associated infections (HAIs) in the United States on the safety and well-being of patients is staggering. Estimates from a national prevalence study of hospitals by the Center for Medicare and Medicaid Services in 2011 suggested that there were more than 700,000 HAIs in 1 year alone, with 1 in 25 patients being affected on any given day in US hospitals. Associated death rates were reported to be as high as 75,000 patients per year. HAIs are known to occur in all settings and are not limited to the highest acuity patients, because roughly 50% of the HAIs occurred outside of the ICU. 1 Equally as concerning regarding the safety of patients is the ongoing challenge of medication error prevention. The 2006 Institute of Medicine report entitled Preventing Medication Errors suggested that medication errors remained among the most common adverse events in health care, representing harm to more than 1.5 million patients each year. 2 Recognizing that these 2 serious risks converge every day in ED practice, it is important to call out these vulnerabilities and take affirmative steps to ensure that ED practitioners make safe choices to provide the best care possible. One of the primary infection control risks associated with medication administration is hand washing, or what has come to be known as “hand hygiene.” Early studies suggested that hand hygiene compliance rates before direct
T
Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP*), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention. * ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications. For correspondence, write: Susan Paparella, MSN, RN, Vice President, ISMP; E-mail: [email protected]. J Emerg Nurs 2015;41:141-3. Available online 12 December 2014 0099-1767 Copyright © 2015 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2014.11.003
March 2015
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patient care activities were as low as 25% to 50%. 3 Although national attention to this serious safety flaw has resulted in significant improvement in compliance, the environmental challenges in emergency departments to support this practice continue to prove difficult, and in some cases they remain unaddressed. Newly designed emergency departments with private rooms and state-ofthe-art triage locations are well equipped with sinks and hand-washing supplies, or at a minimum soapless sanitizers in each area. These easily accessible visual reminders, along with routine surveillance and role modeling, help staff comply with good practice. However, when emergency care is routinely provided (as in some locations across the US) in crowded hallways, converted closets, and behind makeshift rooms with movable screens, staff have limited accessibility to sinks or equipment to perform proper hand hygiene at the point of care. Although some persons may argue that it is easy in these cases to perform hand hygiene at a central location before approaching the patient, staff often find themselves in a quandary as they contaminate their often gloved hands while providing care, with no ability to turn to a nearby sink to wash or to reach for hand sanitizer. Instead, the only choice is to remove the gloves, leave the patient’s bedside, and walk back to a central location to find a suitable sink before managing the intravenous (IV) site, hanging the next bag of IV medication, or otherwise administering medications. In this scenario, effective hand hygiene could in reality be in question. Unfortunately, efficiency and convenience in caring for the patient without leaving the bedside will often take precedence over safety. The accessibility and use of nonsterile gloves as a routine part of patient care has helped to promote better practices, but as described, the availability of such infection control barriers in remote hallway locations is in question. National guidelines suggest that “…easy access to hand-hygiene supplies, whether sink, soap, medicated detergent, or alcohol-based hand-rub solution, is essential for optimal adherence to hand-hygiene recommendations. The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent hand washing or hand
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antisepsis.” 3 Let’s not forget to mention the multitude of other practitioners who approach these patients in hallway beds, also without immediate opportunity for hand hygiene. 3 To have an impact on the current infection control statistics and show consistent movement in a positive direction, it is vital that we seriously evaluate whether there are circumstances or environmental barriers in our emergency departments that do not allow for the most basic standards of hand hygiene in all cases, every time. Several other medication-use behaviors can have an impact on our ability to provide safe care without increasing the risk of an HAI. First is the failure of practitioners to place a sterile cap on the end of a secondary IV administration set after use, when it is disconnected from a primary IV site or saline lock. This failure may occur because sterile caps are not readily available, or in some cases, when unlicensed personnel are permitted to disconnect tubing and do not understand the need to protect the end with a sterile cap. In still other cases, the sterility of the tubing may be compromised when practitioners “loop” the tubing by attaching the exposed end of the IV tubing to a port on the same tubing as a means to “keep it sterile.” Often, however, it is unclear whether the port was properly disinfected prior to reattachment to itself, leaving this site vulnerable to contamination. This looping practice is not recommended by the Intravenous Nursing Society and should be brought to the attention of the Infection Control Committee or Nursing Practice Council for deliberation before being endorsed as safe practice. 4,5 Another medication use practice with potential infection control ramifications is the prespiking of IV fluids in advance of use. This practice is commonly seen in trauma bays and resuscitation rooms in anticipation of a critical patient. Although it is not mentioned in the US Pharmacopeia USP 797 guidelines, the advance preparation of immediate-use IV infusion bags is strongly discouraged by the Association for Professionals in Infection Control and Epidemiology. 6 If practice standards for trauma care require anticipatory preparation of IV infusion bags, ensure that they contain an expiration date/time and are discarded in a timely way after 24 hours. Yet another common risk that is often not considered is the failure of staff to properly disinfect the needleless ports before access. Although needleless systems have dramatically reduced the risk of needle-stick injuries of staff, there has also been a misunderstanding in the nursing profession that because the connection is needleless, disinfecting the access port is not necessary. Staff need to understand that the potential for contamination still exits. IV ports and vial stoppers should be disinfected by wiping and using friction with a sterile 70% isopropyl alcohol, ethyl/ethanol alcohol, iodophor, or other approved antiseptic swab. 6 Allowing the antiseptic to air dry is key to the effectiveness of the process but often is not done.
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Although unsafe injection practices were once thought to be rare, they have also been tied to cases of infectious disease transmission. More than 50 infectious outbreaks have occurred in US hospital and nonhospital settings, resulting in the transmission of serious bloodborne viruses, including hepatitis B and hepatitis C virus, to more than 600 patients when unsafe injection practices were used. 7,8 Staff need to understand the variety of risks associated with inappropriate reuse of syringes, needles, or insulin pens on more than one patient, 7,8 as well as the potential infection risk associated with use of multidose vials. Additional best practices resources to educate staff are available from the One and Only campaign by the Centers for Disease Control and Prevention and can be found at http:// www.cdc.gov/injectionsafety/1anonly.html. 9 Also, consider modifying a ool successfully used in Pennsylvania for a surgical infection control project to audit the safety of injection practices in your emergency department. This tool can be found at the following Web site: http:// patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/ 2013/Sep;10(3)/Pages/99.aspx. 10 Early identification of risky behaviors related to unsafe injection practices is key to prevention. Medication use and infection control practices often converge in the emergency department, with each requiring knowledge of the risks and critical scrutiny of practice for safety. Identification of at-risk behaviors through active surveillance and adoption of best practices will be important links toward the reduction of HAIs and events associated with medication use. REFERENCES 1. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med. 2014;370:1198-1208. http://www.nejm.org/doi/full/10.1056/NEJMoa1306801. Accessed November 20, 2014. 2. Aspden P, Wolcott J, Bootman L, Cronenwett LR, eds. Preventing Medication Errors Washington, DC: National Academies Press; 2006. 3. Centers for Disease Control, Prevention. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/ IDSA Hand Hygiene Task Force. MMWR. 2002;51(No. RR-16). http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Accessed November 20, 2014. 4. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S):S6-S110. http://www.ins1.org/files/public/ 11_30_11_xStandards_of_Practice_2011_Cover_TOC.pdf. Accessed November 20, 2014. 5. Institute for Safe Medication Practices. Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Saf Alert. 2007;12(15):1-2.
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6. Dolan SA, Felizardo G, Barnes S, et al. APIC position paper: safe injection, infusion, and medication vial practices in health care. Am J Infect Control. 2010;38:167-72. http://www.ncdhhs.gov/dhsr/memo/ apicpaper_051010.pdf. Accessed November 20, 2014. 7. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States healthcare settings. Am J Infect Control. 2010;38:789-98. www.premierinc.com/injectionpractices. Accessed November 20, 2014. 8. Institute for Safe Medication Practices. Hazard alert: reuse of insulin pen for multiple patients risks transmission of bloodborne disease. ISMP Medication Saf Alert. 2009;14(3):1-2.
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9. Centers for Disease Control and Prevention. One and Only Campaign. http://www.cdc.gov/injectionsafety/1anonly.html. Updated September 2, 2014. Accessed November 20, 2014. 10. Bradley S. Strategies to fully implement infection control practices in Pennsylvania ambulatory surgical facilities. Pa Patient Saf Advis. 2013;10 (3):99-106. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/ 2013/Sep;10(3)/Pages/99.aspx. Accessed November 20, 2014.
Submissions to this column are encouraged and may be sent to Susan F. Paparella, MSN, RN [email protected]
WWW.JENONLINE.ORG
143
WHEN BUGS AND DRUGS CONVERGE: PROMOTING SAFE PRACTICES IN THE EMERGENCY DEPARTMENT Author: Susan F. Paparella, MSN, RN, Horsham, PA Section Editor: Susan F. Paparella, MSN, RN
Earn Up to 8.5 CE Hours. See page 173. he impact of health care–associated infections (HAIs) in the United States on the safety and well-being of patients is staggering. Estimates from a national prevalence study of hospitals by the Center for Medicare and Medicaid Services in 2011 suggested that there were more than 700,000 HAIs in 1 year alone, with 1 in 25 patients being affected on any given day in US hospitals. Associated death rates were reported to be as high as 75,000 patients per year. HAIs are known to occur in all settings and are not limited to the highest acuity patients, because roughly 50% of the HAIs occurred outside of the ICU. 1 Equally as concerning regarding the safety of patients is the ongoing challenge of medication error prevention. The 2006 Institute of Medicine report entitled Preventing Medication Errors suggested that medication errors remained among the most common adverse events in health care, representing harm to more than 1.5 million patients each year. 2 Recognizing that these 2 serious risks converge every day in ED practice, it is important to call out these vulnerabilities and take affirmative steps to ensure that ED practitioners make safe choices to provide the best care possible. One of the primary infection control risks associated with medication administration is hand washing, or what has come to be known as “hand hygiene.” Early studies suggested that hand hygiene compliance rates before direct
T
Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP*), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention. * ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications. For correspondence, write: Susan Paparella, MSN, RN, Vice President, ISMP; E-mail: [email protected]. J Emerg Nurs 2015;41:141-3. Available online 12 December 2014 0099-1767 Copyright © 2015 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2014.11.003
March 2015
VOLUME 41 • ISSUE 2
patient care activities were as low as 25% to 50%. 3 Although national attention to this serious safety flaw has resulted in significant improvement in compliance, the environmental challenges in emergency departments to support this practice continue to prove difficult, and in some cases they remain unaddressed. Newly designed emergency departments with private rooms and state-ofthe-art triage locations are well equipped with sinks and hand-washing supplies, or at a minimum soapless sanitizers in each area. These easily accessible visual reminders, along with routine surveillance and role modeling, help staff comply with good practice. However, when emergency care is routinely provided (as in some locations across the US) in crowded hallways, converted closets, and behind makeshift rooms with movable screens, staff have limited accessibility to sinks or equipment to perform proper hand hygiene at the point of care. Although some persons may argue that it is easy in these cases to perform hand hygiene at a central location before approaching the patient, staff often find themselves in a quandary as they contaminate their often gloved hands while providing care, with no ability to turn to a nearby sink to wash or to reach for hand sanitizer. Instead, the only choice is to remove the gloves, leave the patient’s bedside, and walk back to a central location to find a suitable sink before managing the intravenous (IV) site, hanging the next bag of IV medication, or otherwise administering medications. In this scenario, effective hand hygiene could in reality be in question. Unfortunately, efficiency and convenience in caring for the patient without leaving the bedside will often take precedence over safety. The accessibility and use of nonsterile gloves as a routine part of patient care has helped to promote better practices, but as described, the availability of such infection control barriers in remote hallway locations is in question. National guidelines suggest that “…easy access to hand-hygiene supplies, whether sink, soap, medicated detergent, or alcohol-based hand-rub solution, is essential for optimal adherence to hand-hygiene recommendations. The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent hand washing or hand
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DANGER ZONE/Paparella
antisepsis.” 3 Let’s not forget to mention the multitude of other practitioners who approach these patients in hallway beds, also without immediate opportunity for hand hygiene. 3 To have an impact on the current infection control statistics and show consistent movement in a positive direction, it is vital that we seriously evaluate whether there are circumstances or environmental barriers in our emergency departments that do not allow for the most basic standards of hand hygiene in all cases, every time. Several other medication-use behaviors can have an impact on our ability to provide safe care without increasing the risk of an HAI. First is the failure of practitioners to place a sterile cap on the end of a secondary IV administration set after use, when it is disconnected from a primary IV site or saline lock. This failure may occur because sterile caps are not readily available, or in some cases, when unlicensed personnel are permitted to disconnect tubing and do not understand the need to protect the end with a sterile cap. In still other cases, the sterility of the tubing may be compromised when practitioners “loop” the tubing by attaching the exposed end of the IV tubing to a port on the same tubing as a means to “keep it sterile.” Often, however, it is unclear whether the port was properly disinfected prior to reattachment to itself, leaving this site vulnerable to contamination. This looping practice is not recommended by the Intravenous Nursing Society and should be brought to the attention of the Infection Control Committee or Nursing Practice Council for deliberation before being endorsed as safe practice. 4,5 Another medication use practice with potential infection control ramifications is the prespiking of IV fluids in advance of use. This practice is commonly seen in trauma bays and resuscitation rooms in anticipation of a critical patient. Although it is not mentioned in the US Pharmacopeia USP 797 guidelines, the advance preparation of immediate-use IV infusion bags is strongly discouraged by the Association for Professionals in Infection Control and Epidemiology. 6 If practice standards for trauma care require anticipatory preparation of IV infusion bags, ensure that they contain an expiration date/time and are discarded in a timely way after 24 hours. Yet another common risk that is often not considered is the failure of staff to properly disinfect the needleless ports before access. Although needleless systems have dramatically reduced the risk of needle-stick injuries of staff, there has also been a misunderstanding in the nursing profession that because the connection is needleless, disinfecting the access port is not necessary. Staff need to understand that the potential for contamination still exits. IV ports and vial stoppers should be disinfected by wiping and using friction with a sterile 70% isopropyl alcohol, ethyl/ethanol alcohol, iodophor, or other approved antiseptic swab. 6 Allowing the antiseptic to air dry is key to the effectiveness of the process but often is not done.
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JOURNAL OF EMERGENCY NURSING
Although unsafe injection practices were once thought to be rare, they have also been tied to cases of infectious disease transmission. More than 50 infectious outbreaks have occurred in US hospital and nonhospital settings, resulting in the transmission of serious bloodborne viruses, including hepatitis B and hepatitis C virus, to more than 600 patients when unsafe injection practices were used. 7,8 Staff need to understand the variety of risks associated with inappropriate reuse of syringes, needles, or insulin pens on more than one patient, 7,8 as well as the potential infection risk associated with use of multidose vials. Additional best practices resources to educate staff are available from the One and Only campaign by the Centers for Disease Control and Prevention and can be found at http:// www.cdc.gov/injectionsafety/1anonly.html. 9 Also, consider modifying a ool successfully used in Pennsylvania for a surgical infection control project to audit the safety of injection practices in your emergency department. This tool can be found at the following Web site: http:// patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/ 2013/Sep;10(3)/Pages/99.aspx. 10 Early identification of risky behaviors related to unsafe injection practices is key to prevention. Medication use and infection control practices often converge in the emergency department, with each requiring knowledge of the risks and critical scrutiny of practice for safety. Identification of at-risk behaviors through active surveillance and adoption of best practices will be important links toward the reduction of HAIs and events associated with medication use. REFERENCES 1. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med. 2014;370:1198-1208. http://www.nejm.org/doi/full/10.1056/NEJMoa1306801. Accessed November 20, 2014. 2. Aspden P, Wolcott J, Bootman L, Cronenwett LR, eds. Preventing Medication Errors Washington, DC: National Academies Press; 2006. 3. Centers for Disease Control, Prevention. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/ IDSA Hand Hygiene Task Force. MMWR. 2002;51(No. RR-16). http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Accessed November 20, 2014. 4. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S):S6-S110. http://www.ins1.org/files/public/ 11_30_11_xStandards_of_Practice_2011_Cover_TOC.pdf. Accessed November 20, 2014. 5. Institute for Safe Medication Practices. Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. ISMP Medication Saf Alert. 2007;12(15):1-2.
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6. Dolan SA, Felizardo G, Barnes S, et al. APIC position paper: safe injection, infusion, and medication vial practices in health care. Am J Infect Control. 2010;38:167-72. http://www.ncdhhs.gov/dhsr/memo/ apicpaper_051010.pdf. Accessed November 20, 2014. 7. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States healthcare settings. Am J Infect Control. 2010;38:789-98. www.premierinc.com/injectionpractices. Accessed November 20, 2014. 8. Institute for Safe Medication Practices. Hazard alert: reuse of insulin pen for multiple patients risks transmission of bloodborne disease. ISMP Medication Saf Alert. 2009;14(3):1-2.
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9. Centers for Disease Control and Prevention. One and Only Campaign. http://www.cdc.gov/injectionsafety/1anonly.html. Updated September 2, 2014. Accessed November 20, 2014. 10. Bradley S. Strategies to fully implement infection control practices in Pennsylvania ambulatory surgical facilities. Pa Patient Saf Advis. 2013;10 (3):99-106. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/ 2013/Sep;10(3)/Pages/99.aspx. Accessed November 20, 2014.
Submissions to this column are encouraged and may be sent to Susan F. Paparella, MSN, RN [email protected]
WWW.JENONLINE.ORG
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