Making Sense of the Updated Sepsis Definitions

sepsis-definitions.pngLast month, new definitions for sepsis and septic shock (Sepsis-3) were released and published in the Journal of the American Medical Association (JAMA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) is the work of a consensus panel of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. There have been multiple revisions and evolutions to the definitions of sepsis and treatment strategies over the years as we continue to increase our understanding of the complex biology of sepsis and the physiologic effects of sepsis on the body. We are constantly adapting this knowledge to clinical practice. Despite advances in our understanding of sepsis biology, it remains a condition associated with high morbidity and mortality worldwide. Despite constant advances in pharmacologic treatments and organ support devices (i.e. mechanical ventilation, renal replacement therapies, etc.) early identification and treatment of patients with sepsis remains the cornerstone of improving survival. The new definitions simplify the classification of sepsis and provide tools to identify those with suspected infection that are at risk of developing complications of sepsis by utilizing the Sequential (sepsis-related) Organ Failure Assessment (SOFA) and qSOFA scores. 

The new definitions and risk assessment scores take the focus off inflammation and place it on the organ dysfunction related to the dysregulated host response that is sepsis. In fact, Sepsis-3 defines sepsis as “Life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” A lay term definition is also provided in the article describing sepsis as “a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs” (Singer et al. 2016). This provides helpful terminology in speaking with families about the complex and complicated condition. 

Why the change? 
Prior to the release of Sepsis-3, healthcare providers generally referred to four different levels of sepsis: systemic inflammatory response syndrome (SIRS), sepsis (SIRS in response to a confirmed infectious process), severe sepsis (sepsis plus organ dysfunction as evidenced by hypotension or hypoperfusion to one or more organs), and septic shock (sepsis with persisting arterial hypotension or hypoperfusion despite adequate fluid resuscitation).

Over the years, there has been much controversy over the SIRS criteria, as they are considered to have poor specificity and sensitivity for predicting the development of sepsis. The SIRS criteria – fever, tachycardia, tachypnea, leukopenia/leukocytosis – are present in many conditions, both in chronic medical illness and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration from poor intake and tachycardia from dehydration and fever can be treated outpatient and is at very low risk of progressing to septic shock despite meeting SIRS criteria. Furthermore, the “levels” of sepsis infers there is a continuum or spectrum that a patient with sepsis follows in the course of illness and this is not the case. 
 
What’s New: 
In a nutshell, the focus of the new definitions as described above is defining sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sequential (sepsis-related) Organ Failure Assessment (SOFA) is presented as a tool to identify organ dysfunction and the risk of a patient with infection in developing sepsis. SIRS has been eliminated from sepsis vocabulary, as has severe sepsis, which was considered redundant. So now we have: 
  1. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is measured by changes in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two points or more. In a patient with unknown baseline, the beginning score is zero. 
  2. Septic shock: a subset of sepsis with vasopressor requirement to maintain MAP >65 and serum lactate > 2 mmol/L in the absence of hypovolemia (i.e. after a patient has received adequate fluid resuscitation). 
The SOFA Score (Vincent et. al 1996) provides clinical measures to identify organ dysfunction; these criteria identify infected patients most likely to develop sepsis. Organ dysfunction is identified as an acute change in SOFA score of greater than or equal to two. These clinical variables include PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without the presence of vasoactive agents, Glascow Coma Scale, creatinine and urine output.  

The qSOFA (Quick SOFA) Criteria is an additional tool highlighted in Sepsis-3. The clinical variables of the qSOFA are: 
  • Respiratory rate > 22
  • Altered mentation (GCS < 15)
  • Systolic blood pressure ≤ 100
The presence of any two of these criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool can be utilized by the bedside nurse. 

Nursing implications of Sepsis-3
While these definitions will not change how we treat patients with sepsis or presumed sepsis, they do provide more straightforward terminology, as well as a bedside tool to evaluate a patient with infection, potentially allowing us to both identify at-risk patients sooner and treat earlier.  The presence of the qSOFA criteria in a patient with infection should prompt further evaluation of the patient and possible measurement of the more detailed SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the most up-to-date terminology surrounding sepsis improves care of our patients and allows for better communication of patient information to colleagues in a consistent manner. Nurses are in a key position at the bedside to monitor and identify patient in the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the septic patient.

With this information, we can improve our communication. In the past, we might have said, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. I just have a feeling this patient is declining; he looks like he might be septic.” Now, with our new definitions, we can say, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. Since admission, he has deteriorated clinically; his qSOFA score is two, he has a respiratory rate of 30 and his systolic blood pressure is 80. When he arrived in the ED, his SOFA score was one due to a creatinine of 1.5. Now his urine output is down to 15 mL/hr, and his MAP is 60. I think we need to order more labs and have someone come re-evaluate the patient for possible transfer to the ICU.” As nurses, we often know when something is changing and our patient’s clinical condition is headed in the wrong direction. Familiarization with these tools provides us with more objective data to present and support our concerns.      

It has now been several weeks since the release of Sepsis-3. In reviewing medical commentary, there are varying supports and criticisms of both the new definitions and on the utility of the SOFA and qSOFA scores. True, qSOFA and SOFA are not diagnostic of sepsis or septic shock, the SOFA is a predictor of mortality; but they provide objective data points that can be easily measured in the hospital setting. What remains unchanged is our goal of early identification and early treatment to reduce overall morbidity and mortality related to sepsis. Sepsis is a complex condition; in addition to overt symptomatology, there is complex biochemical, genetic and endogenous factors involved in the pathobiology of sepsis. Some pathways are well understood while others are only on the brink of being understood. 

I am personally happy with the new definitions and the simplicity of the diagnostic terms of sepsis vs. septic shock. I am looking forward to the improved dialogue and communication using the SOFA criteria. As with any changes in medicine, there is typically a lag time from publication to implementation. At my hospital, in particular in the ICU, there has certainly been a lot of buzz and support for the new terminology. I would love to hear how other hospitals and facilities have reacted to Sepsis-3! 

Megan Doble, MSN, RN, CRNP
References: 
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent  JL, Moreno  R, Takala  J,  et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.



 
Posted: 3/13/2016 7:10:31 AM by Lisa Bonsall, MSN, RN, CRNP | with 9 comments

Categories: Diseases & Conditions


For me, every month is Multiple Sclerosis (MS) Awareness Month – a patient’s perspective

By Kim Fryling-Resare

I was going to put together a collection of information and statistics to share about multiple sclerosis, but as I started to write, it became more about what I personally do to raise MS awareness. My hope is that my story will give insight and shed some light onto a patient’s perspective. I feel like understanding is one of the keys to better support and care for patients living with a chronic illness.   

multiple-sclerosis-awareness-month.pngMarch is MS Awareness Month – a topic near and dear to my heart. I’ve been living with relapse-remitting multiple sclerosis since 2003 and I try to live my life every day as if it is “MS Awareness Day.” 

Unfortunately, I’m not a scientist who will discover a cure. I’m not a neurologist or a nurse who will treat patients. And lastly, I’m not fortunate enough to be rolling in money that I could fund clinical trials or research studies. So what can I do to raise awareness about MS? 

I can SUPPORT.
Whenever I hear about someone who is newly-diagnosed, or someone who may be struggling with the disease, I’m always ready to hand out my phone number or email address. I know all too well that it can be a continuous struggle, but I want them to know they are not alone. There is hope, and they will get through this battle learning strategies to improve life and ultimately discovering how truly strong they are.

I can stay POSITIVE.
I went through all of the typical emotions after my MS diagnosis, and I had to go through the grieving process and let go of my life, or at least my perceived life, before MS. Now, I’m actually thankful for MS. I have let go of a lot of toxic people and negativity, and I try not to sweat the small stuff. I have chosen to take the path where I value life and take little to nothing for granted. 

I can EDUCATE.
I have always been very open about living with multiple sclerosis. I love shocking people with the fact that I have MS. I encourage questions and enjoy sharing my experiences and knowledge. There is a lot of misinformation out there and people tend to have such misconceptions about what MS looks like, and what it means to live with MS. It is such a varying disease that presents so differently and affects people in so many different ways. 

I can LIVE fully.
I live the best life that I can with MS, and along the way, I try to educate others on what MS is and what it means to people battling it every day, every month, every year. Raising awareness for MS and living fully is my way of advocating and giving back to the MS community. 

kim-fryling-resare.pngI will never give up HOPE.
I have this silly personal belief that if I say something, or believe something long enough, it will manifest and become reality. So…There will be a cure for MS. There will be a cure for MS. There will be a cure for MS…

To continue raising awareness, I’m marking my 13th year living with MS by participating in my first half marathon this summer. 13 years, 13.1 miles! Never give up!
 
Please use these free resources on NursingCenter to learn more about MS and to help spread awareness by sharing with your colleagues, patients, and the public.
 

The Journal of Neuroscience Nursing and the Journal of Infusion Nursing are both honoring MS Awareness Month by offering subscription discounts in March. Enter promotion code, WFS115GN, and take 40% off the subscription price for either journal.


 
Posted: 3/8/2016 8:30:26 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions Inspiration


February is American Heart Month!

american-heart-month.jpgDuring the month of February, we celebrate many great traditions – Black History Month, Valentine’s Day, and the birth of our forefathers to name a few. February is also American Heart Month, which was first declared by President Lyndon B. Johnson in 1964.1 Since that time, February has been dedicated to promoting cardiovascular health by many organizations, such as the American Heart Association1. Heart disease is the leading cause of mortality in both men and women in America.It is a disease that can largely be prevented through lifestyle modification1. Due to advances in medical therapies and better heart disease education, the number of deaths associated with cardiovascular disease has seen a steady decline over the last three decades1

This month brings back many memories for me.  My first job out of college in the mid-90’s was in the Intensive Care Unit (ICU) at a large medical center in mid-town Manhattan. This was a unique ICU setting where the staff rotated through the medical, coronary, surgical, and cardiovascular (post-operative) ICUs every few months.  It was during these first years that I gained an appreciation for cardiovascular disease and how it could be medically and surgically managed. In the medical ICU and coronary care unit (CCU), I cared for patients who were transferred from the Emergency Room with acute coronary syndrome (ACS) and were awaiting cardiac catheterization for diagnosis and possible angioplasty. The presentation of each patient varied widely. A stable ACS patient with mild symptoms, such as indigestion, could deteriorate rapidly into acute distress and severe chest pain and possibly full code. Stabilizing these patients with aspirin, oxygen supplementation, and sublingual nitroglycerin were critical and electrocardiogram (ECG) monitoring was of the utmost importance. I don’t think any nurse forgets witnessing ST-segment elevation for the first time. 

In the surgical and cardiovascular ICU, patients returned from the operating room with a tangle of wires, arterial lines, central lines, pulmonary artery catheters, as well as chest tubes, drains and complex surgical wounds.  Monitoring vital signs, titrating IV drips, managing oxygenation and potential bleeding were all part of the post-surgical course. Open-heart surgery patients had to be assessed frequently for elevated jugular venous pressure and pulsus paradoxus (a systemic drop in blood pressure during inspiration3), both impending signs of cardiac tamponade, an accumulation of fluid in the pericardial space. It didn’t occur too often, but when it did, it resulted in emergency subxiphoid percutaneous drainage – one of the more stressful moments for a new nursing graduate.

After a few years in New York I felt called back to Philadelphia. While attending graduate school, I worked nights in the Cardio-Thoracic Intensive Care Unit (CT-SICU) of a large teaching hospital, caring for patients following open heart surgery. I thought I had seen it all in New York and quickly realized that I had just scratched the surface when it came to caring for cardiac patients. Academic institutions often receive patients with very high acuity due to their ability to offer some of the most advanced treatment options such as intra-aortic balloon pumps (IABP), left ventricular and bi-ventricular assist devices (LVAD and BiVAD), extra-corporeal membrane oxygenation (ECMO), ventilators, and continuous hemofiltration and dialysis. There were moments when I felt more like a mechanic than a nurse working on multiple machines surrounding a fragile life at its center. 

Patients typically experience short stays and quick turn-overs in surgical ICUs, however, we had our fair share of patients who spent many weeks and months on our unit. Mr. B.* was one of those patients. Mr. B. was transferred from a local community hospital to our institution with severe heart failure. Mr. B., whose medical therapies had reached a maximum threshold, had been hospitalized multiple times with acute exacerbations of heart failure over the prior year. Each hospitalization worsened requiring increased doses of intravenous (IV) dobutamine and milrinone to improve his heart pumping capacity. Upon arrival Mr. B., who was categorized with Class 4 heart failure (severe), was evaluated by the team for heart transplant. At 64, he was above the upper limit for age exclusion, however he had no signs of lung, liver or kidney disease.  He was placed on the transplant list immediately and due to his critical condition the decision was made to place a left ventricular assist device (LVAD) to support his heart. Mr. B.’s post-operative course was riddled with complications. He experienced difficulty weaning from the ventilator and subsequently developed pneumonia. Anticoagulation was carefully titrated to prevent clotting in the LVAD, however this led to bleeding in the gastrointestinal tract. His blood glucose levels rose acutely requiring an IV insulin drip. He battled these challenges and once stabilized, Mr. B. was able to ambulate with his new device and begin rehabilitation in preparation for his transplant. He was extremely positive, cracking jokes with the nurses and always smiling. I could tell he was truly grateful for each day he was alive. Today, LVAD patients may be discharged home and are able to live comfortably with the device, some as a bridge to transplant and some as destination therapy if transplant is not an option. Mr. B. was with us for several weeks due to his complications, but was eventually discharged home.

One cold November morning, Mr. B. and his family were notified that there was a donor heart available and that he was a match. He was admitted back to our unit that afternoon and later that evening he received the gift of a new heart and a second chance at life. The surgery went extremely well. Mr. B. spent four days of recovery in the CT-SICU where we monitored him closely for rejection. He was then transferred to the general surgical ward for cardiac rehabilitation and was discharged from the hospital on post-op day 15.

The most gratifying part of being an ICU nurse is seeing your patients recover. Mr. B. returned often to say hello and thank you, which always warmed our hearts. He is one of many cardiac patients I will never forget. While Mr. B.’s story ends well, many more patients with cardiac disease are not as lucky. We as healthcare providers should continue to emphasize the importance of heart health education and lifestyle modification to prevent the progression of cardiac disease. Happy American Heart Month to all!
 
References
  1. American Heart Association (2016) American Heart Month. Retrieved from http://newsroom.heart.org/events/american-heart-month-events-and-info-3136417
  2. Center for Disease Control and Prevention (2016) Heart Disease Facts. Retrieved from http://www.cdc.gov/heartdisease/facts.htm
  3. UpToDate (2016) Pulsus Paradoxus in Pericardial Disease. Retrieved from http://www.uptodate.com/contents/pulsus-paradoxus-in-pericardial-disease
 
*Note: Any identifying characteristics are coincidental. 

 Myrna B. Schnur, RN, MSN

 
Posted: 2/17/2016 11:50:13 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


5 things nurses need to know about Zika virus

Be ready to answer questions and advise patients appropriately. For full updates on the Zika virus, visit the
Centers for Disease Control and Prevention.

5 things nurses need to know about zika virus1. What is Zika virus?
The Zika virus was first documented in May 2015 in Brazil. The virus is spread to humans via the bite of an infected mosquito, though transmission via blood transfusion and sexual contact have been reported. The symptoms include fever, rash, joint pain, and conjunctivitis. Though rare, there have been cases of Guillain-Barré syndrome in patients with suspected Zika infection.

2. Why is there a travel advisory for pregnant women?
There have been reports of poor pregnancy outcomes and microcephaly among babies of mothers infected with the Zika virus. Further investigation of this causal relationship is ongoing, however, to be cautious, the CDC recommends pregnant women and those trying to conceive avoid travel to areas with documented Zika virus transmission.

3. What should I include in my assessment of pregnant patients?
*Ask all pregnant women about recent travel, especially to areas with documented Zika virus transmission.
*Ask all pregnant women about the presence of symptoms consistent with Zika virus disease during or within two weeks of travel.
*In those with recent travel, be alert for ultrasound findings of fetal microcephaly or intracranial calcifications. If present, testing for Zika virus infection (in consultation with state or local health departments) is indicated.

4. What should be done if infection with Zika virus is confirmed?
In pregnant women with laboratory evidence of Zika virus infection, fetal growth and anatomy should be monitored via serial ultrasounds. Referral to a maternal-fetal medicine or infectious disease specialist is recommended. There is no specific treatment for Zika virus; supportive care is recommended.

5. How can those who are traveling prevent infection with the Zika virus?
To prevent Zika virus infection, and other mosquito-borne illnesses, recommendations include:
*Use insect repellants, as directed. (If using both sunscreen and insect repellent, the sunscreen should be applied first).
*Wear permethrin-treated clothing.
*Wear long-sleeved shirts and long pants.
*Keep mosquitoes outside, or if necessary, sleep under a mosquito bed net.
*Empty standing water from flowerpots, buckets, or other containers.
 
Reference:
Centers for Disease Control and Prevention. (2016, January 24). Zika virus. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/zika/
More Resources

 

Posted: 1/25/2016 3:12:35 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Diseases & Conditions


Ebola: Are We Better Prepared Today?

Ebola Virus Disease (EVD)The 2014 Ebola Virus Disease (EVD) outbreak of West Africa was a wake-up call for healthcare administrators and clinicians in the United States. EVD had been viewed as a third world problem, a crisis that would most likely never strike America. Last October, however, we witnessed the first patient diagnosed with EVD on U.S. soil, a Liberian man who ultimately passed away in a Dallas hospital after infecting two of his nurses, both of whom fully recovered. At the time, healthcare providers faced with the potential spread of the infectious disease had to piece together protocols based on limited knowledge and standards of care for patients infected with EVD. The majority of hospitals were unprepared should an infected patient walk into its Emergency Department (ED).  Most did not have appropriate isolation rooms, personal protective equipment (PPE) or adequate staffing to safely care for these patients. 

According to the World Health Organization (WHO), EVD remains a Public Health Emergency of International Concern (PHEIC)1. Two active chains of EVD transmission continue, one in New Guinea and one in Sierra Leone, resulting in approximately 5 new cases each week1. Are U.S. hospitals better prepared and are nurses safer today to care for patients with highly infectious diseases than they were a year ago? The answer may be yes for a handful of centers that have received advanced training, education and government funding, however, that is not the case for over 5,000 hospital institutions across the country. 

In response to the outbreak, the Centers for Disease Control and Prevention (CDC) established a three-tiered approach to guide hospitals and other emergency healthcare clinics in developing preparedness plans for patients under investigation (PUI) or with confirmed EVD2. According to this plan, hospitals can serve in one of three roles: as a frontline healthcare facility, an Ebola Assessment Hospital or an Ebola Treatment Hospital. 

All hospitals are considered frontline healthcare facilities and each plays a critical role in the identification, isolation and evaluation of PUIs for EVD. Once identified, the institution is responsible for informing the facility infection control department, as well as the state and local public health agency, and promptly placing the patient in isolation. The frontline hospital is not expected to provide prolonged care for the patient for more than 12 to 24 hours and should coordinate immediate transfer of the patient to an Ebola assessment hospital or Ebola treatment hospital.3 

Ebola assessment hospitalsEbola assessment hospitals are facilities that are prepared to receive and isolate PUIs and care for the patient until diagnosis of EVD can be ruled out or confirmed and until discharge or transfer is completed. They should be prepared to care for PUIs for up to 96 hours, should be equipped with adequate PPE for four to five days and ensure that staff members involved in or supporting patient care are appropriately trained for their roles. This includes demonstrated proficiency in putting on and taking off PPE, proper waste management, infection control practices, and specimen packaging and transport.3

Ebola treatment hospitals are facilities that plan to care for and manage a patient with confirmed EVD for the duration of the patient’s illness. These centers must meet minimum criteria determined by the CDC, including infection control capacity, physical infrastructure, staffing resources, PPE supplies, waste management processes, worker safety training, environmental services and laboratory set up.3 Staff must be trained in and have practiced putting on and taking off PPE for Ebola, as well as providing clinical care using PPE. CDC Ebola Response Teams (CERTs) are ready to deploy to any Ebola treatment center to provide technical assistance for infection control procedures, clinical care and logistics of managing patients with EVD as soon as the health department or hospital requests assistance.3

Fifty-five hospitals have been identified as Ebola assessment centers. Of those, nine hospitals have been designated as Ebola regional treatment centers and have received government support and advanced training to meet the CDC minimum criteria. The Department of Health and Human Services (HHS) does not mandate that every state adopt this approach, however, all are encouraged to identify Ebola assessment hospitals that can successfully manage PUIs or confirmed cases of EVD.2

The CDC released comprehensive guidelines for frontline hospitals in the management of patients with EVD from identification through treatment. The recommendations are not government mandated and can be expensive to implement, therefore most facilities have not instituted these safe practices nor have they provided training to their frontline nurses. The responsibility falls on healthcare administrators, local state departments of health and the Occupational Safety and Health Administration (OSHA) to ensure these guidelines have been executed.

California is one state that has issued mandatory safeguards to protect healthcare workers from EVD by requiring hospitals to provide head-to-toe PPE and comprehensive training for staff caring for Ebola patients.4 The guidelines require California hospitals to provide staff with full-body protective suits that meet the ASTM F1670 standard for blood penetration and the F1671 standard for viral penetration and that leave no skin exposed or unprotected.4 Hospitals must also provide powered air-purifying respirators with a full cowl or hood for the head, face and neck of any RN or other staff member who provides care for a suspected or confirmed Ebola patient. Hands-on training must be provided for any worker who is at risk of exposure.4 These regulations are mandatory in California and if hospitals do not comply with the guidelines, they will incur fines and penalties. 

The precedent set by California is one that should be adopted by every state and local health department across the country. All nurses deserve adequate information and training on the care of EVD patients and their safety and well-being must remain the highest priority. Do you believe that your institution is prepared today to care for an EVD patient? Do you feel that you have received adequate training and that you would be at minimal risk of contracting EVD or other highly contagious diseases? (You can see how some nurses responded to this question in this JONA article.) Please let us know how you feel by leaving a comment!
 

In-Person Ebola Training should be mandatory and include:5

  • Learning to don (put on) and doff (remove) the PPE – performed under direct observation following itemized and standardized verbal instructions; practiced four to six times; no one is allowed in the warm zone (anteroom) or hot zone (patient room) without donning full PPE under close observation and direction of trained nurses
  • Performing routine tasks while wearing multiple layers of PPE
  • Enhancing safety skills: slowing down; paying attention to sharp objects, stopping and thinking through movements before beginning a task; placing one’s immediate safety before the needs of the patient; always working in pairs – one nurse cares for the patient, while the second nurse watches for breaks in PPE, disinfects the environment, prepares trash for removal, and assists with turning or two-person procedures
  • Handling waste: moving slowly when handling bedpans, canisters and urinals, always covering the container; all liquid waste is decontaminated for 15 minutes before flushing
  • Cleaning and disinfecting healthcare environments
References:
1. World Health Organization (WHO) website accessed October 21, 2015. 
2. Department of Health and Human Services (HSS) website accessed October 21, 2015. 
3. Centers for Disease Control and Prevention (CDC) website accessed October 21, 2015 
4. Cable, J. (2014). Nurses Urge OSHA to Adopt California’s Ebola Safeguards. EHS Today website. Retrieved October 21, 2015.
5. Johnson, S., Barranta, N., & Chertow, D. (2015). Ebola at the National Institutes of Health – Perspectives from Critical Care Nurses. AACN Advanced Critical Care, 26(3), 262-267. 
More Resources
What You Need to Know About Ebola Virus [FREE CE]
CDC Guidelines: Preparing US Hospitals for Ebola
CDC Guidelines: Hospital Preparedness: A Tiered Approach – Preparing Frontline Healthcare Facilities   
CDC Guidelines: Hospital Preparedness: A Tiered Approach – Preparing Ebola Assessment Hospitals 
CDC Guidelines: Hospital Preparedness: A Tiered Approach – Preparing Ebola Treatment Centers 
CDC Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola Factsheet
OSHA Factsheet: Cleaning and Decontamination of Ebola on Surfaces
OSHA/NIOSH/EPA Factsheet: Safe Handling, Treatment, Transport and Disposal of Ebola-Contaminated Waste
OSHA Factsheet: PPE Selection Matrix for Occupational Exposure to Ebola Virus
OSHA Bloodborne Pathogens Standard which covers exposure to Ebola
OSHA Personal Protective Equipment Standard (General Requirements)
OSHA Personal Protective Equipment Standard (Respiratory Protection)
OSHA Factsheet: Protecting Workers during a Pandemic
 Myrna B. Schnur, RN, MSN

 
Posted: 10/28/2015 6:42:15 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions


National Antibiotic Initiative

National Action Plan for Combating Antibiotic-Resistant Bacteria mrsaThe inappropriate and unnecessary overuse of antibiotics within hospital and outpatient settings has led to the rise of drug-resistant strains of bacteria over the past several decades. These “super” bugs cause 2 million illnesses and over 23,000 deaths in the U.S. alone, according to the Centers for Disease Control and Prevention (CDC)1. In March of 2015, the White House issued a National Action Plan for Combating Antibiotic-Resistant Bacteria. The goals of the plan include1:
  1. Slow the emergence of resistant bacteria and prevent the spread of resistant infections.
  2. Strengthen national one-health surveillance efforts to combat resistance.
  3. Advance development and use of rapid and innovative diagnostic tests for identification and characterization of resistant bacteria.
  4. Accelerate basic and applied research and development for new antibiotics, therapeutics, and vaccines.
  5. Improve international collaboration and capacities for antibiotic-resistance prevention, surveillance, control, and antibiotic research and development.
By 2020, a primary outcome of Goal 1 will be the establishment of antibiotic stewardship programs in all acute care hospitals and across all healthcare settings2. The core elements of hospital antibiotic stewardship programs will include1,2:
  • Establishing leadership commitment by dedicating necessary human, financial and information technology resources.
  • Appointing a single physician leader, ideally formally trained in infectious diseases, responsible for program outcomes.
  • Appointing a single pharmacist leader with drug expertise, responsible for working to improve antibiotic use.
  • Securing support from the multidisciplinary team, including infection prevention control, nursing, information technology, laboratory and quality improvement.
  • Implementing policies and interventions to improve antibiotic use, ensuring that patients receive the right antibiotic at the right time at the right dose for the right duration.
  • Implementing at least one recommended action, such as systemic evaluation of ongoing treatment after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours).
  • Monitoring antibiotic prescribing and resistance programs.
  • Educating clinicians about resistance and optimal prescribing.
Healthcare leaders and clinicians in all settings should focus efforts on implementing these recommendations in order to decrease antibiotic resistant bacteria.
References
Centers for Disease Control and Prevention: Get Smart for Healthcare. Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. 
The White House: National Action Plan for Combating Antibiotic-resistant Bacteria. Washington, D.C.
Myrna B. Schnur, RN, MSN

 
Posted: 9/25/2015 6:16:35 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions Patient Safety


Maternal Health Around The World [Infographic]

The Maternal Mortality Rate (MMR) is an issue in many countries that are often regarded to have the most advanced healthcare systems. In fact, the rate at which mothers are dying as a result of pregnancy or childbirth in the United States continues to rise despite the U.S. spending more money than any other country in the world in regards to pregnancy hospitalization and childbirth.
 
Nursing@Georgetown prepared a useful infographic on the topic of Maternal Health around the World in hope to explore not only the cause of these deaths but also how they may be prevented in the future. The infographic dives into some of the most important statistics such as leading causes, MMR across the world, the midwifery model, and more.

 

Brought to you by Nursing@Georgetown: Nurse Midwife programs

 

Posted: 7/1/2015 1:23:03 PM by Lisa Bonsall, MSN, RN, CRNP | with 4 comments

Categories: Diseases & Conditions


Middle East Respiratory Syndrome (MERS)

mers-3-(1).PNGMiddle East Respiratory Syndrome (MERS) has been making headlines since 2012 when it was first discovered in Saudi Arabia. A recent outbreak of MERS has occurred in the Republic of Korea affecting 150 people and claiming the lives of over a dozen to date. Close to 3,000 people in South Korea are under quarantine. Two unrelated cases of MERS were diagnosed in the United States in 2014 and both patients have made a full recovery. 

While not considered a public health emergency by the World Health Organization, viruses can mutate and could cause a global pandemic. As a healthcare provider, it is important that you have an understanding of MERS and appropriate infection control practices in order to identify and prevent its further spread. As an educator, you play a critical role in informing patients about the signs and symptoms of MERS and strategies to avoid contracting this highly contagious disease.



What is MERS?

MERS is caused by a coronavirus (CoV), a group of viruses that are responsible for illnesses ranging from the common cold to Severe Acute Respiratory Syndrome (SARS). Almost 1,200 cases of human MERS-CoV infection have been reported and over 440 deaths (35% mortality rate) have been attributed to it. The origin of the virus is unknown but is suspected to have come from an animal source. MERS-CoV is thought to spread from an infected person’s respiratory secretions, such as through coughing. The incubation period for MERS (time from exposure to MERS-CoV to symptoms) is typically five to six days but can range from two to 14 days. There are no specific treatments for patients aside from supportive therapy to relieve the symptoms. Patients with mild to no symptoms have made a full recovery.

Symptoms include:

  • Fever, cough, shortness of breath, runny nose, severe acute respiratory disease
  • Chills, chest pain, body aches, sore throat, malaise, headache
  • Diarrhea, nausea, vomiting, abdominal pain

Severe complications include: 

  • Pneumonia
  • Kidney failure

Who’s susceptible or at high risk?

  • People with pre-existing medical conditions such as diabetes, kidney failure, chronic lung disease
  • People with weakened immune systems such as cancer patients receiving chemotherapy or organ transplant patients receiving immunosuppressive drugs
  • Elderly

Need-to-know information for nurses

  • If your patient exhibits fever and symptoms of respiratory illness, assess if he or she has
    • traveled to a country in or near the Arabian Peninsula within 14 days of symptoms onset.
    • been in contact with someone who has traveled to the Arabian Peninsula within 14 days of symptoms onset.
    • a history of being in a healthcare facility (as a patient, worker or visitor) in the Republic of Korea within 14 days of symptom onset.
    • been in close contact with a confirmed MERS patient while the patient was ill.
  • MERS is a reportable disease and local health departments should be notified of any suspected MERS cases.
  • Strict infection-control measures should be used while managing suspected and confirmed cases of MERS, including hand hygiene; contact, droplet and airborne precautions along with full personal protective equipment – gown, gloves, mask and eye protection (goggles or face shield).  MERS patients should be placed in a negative pressure room. 
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Please visit the Centers for Disease Control and Prevention (CDC) for complete recommendations and Interim Guidance for Healthcare Professionals in the detection, evaluation and care of MERS patients.
References:
Todd, B. (2014). EMERGING INFECTIONS: Middle East Respiratory Syndrome (MERS-CoV). AJN, American Journal of Nursing, 114 (1).
Centers for Disease Control and Preventions (2015, June 12). Middle East Respiratory Syndrome (MERS).
World Health Organization (2015, June 13). Middle East respiratory syndrome coronavirus (MERS-CoV).

Myrna B. Schnur, RN, MSN

 
Posted: 6/16/2015 4:48:16 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments

Categories: Diseases & Conditions


Preload and Afterload – What's the Difference?

A recent Quick Quiz on our Facebook page resulted in a mix of responses. Do you know what word is used to describe the amount of stretch on the myocardium at the end of diastole? The responses were split between preload and afterload. 
 
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Let’s take a closer look at what these terms mean.

Preload

Preload, also known as the left ventricular end-diastolic pressure (LVEDP), is the amount of ventricular stretch at the end of diastole. Think of it as the heart loading up for the next big squeeze of the ventricles during systole. Some people remember this by using an analogy of a balloon – blow air into the balloon and it stretches; the more air you blow in, the greater the stretch. 

Afterload

Afterload, also known as the systemic vascular resistance (SVR), is the amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation. If you think about the balloon analogy, afterload is represented by the knot at the end of the balloon. To get the air out, the balloon must work against that knot. 

Cardiac Output & Cardiac Index

Cardiac output is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate; normal cardiac output is about 4 to 8 L/min, but varies depending on the body’s metabolic needs. Cardiac index is a calculation of the cardiac output divided by the person’s body surface area (BSA). 

So, if you answered ‘D’ to the quiz above, you’re right!
References
Gowda, C. (2008). Don't be puzzled by cardiovascular concepts. Nursing Made Incredibly Easy!, 27-30.
Smeltzer, S. B. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Warise, L. (2015). Understanding Cardiogenic Shock: A Nursing Approach to Improve Outcomes. Dimensions of Critical Care Nursing, 67-77.
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Posted: 5/26/2015 5:29:45 AM by Lisa Bonsall, MSN, RN, CRNP | with 9 comments

Categories: Diseases & Conditions


Measles Update

The current outbreak of measles, which has been linked to a California amusement park, continues to make headlines in the United States. The Centers for Disease Control and Prevention (CDC) is tracking data on the states affected and the number of cases. I encourage you to stay informed so you’ll be able to best educate your patients and answer their questions.

Before I get to the purpose of this post – to review transmission, signs and symptoms, and treatment of measles – I’d like to briefly address why we are seeing this resurgence in cases. In 1998, a study was published in the Lancet which suggested a link between the measles, mumps, and rubella (MMR) vaccine and autism. As a result, increased numbers of parents opted to refuse the MMR vaccine for their children. The researchers later retracted their study, and current evidence concludes that there is no association between vaccines and autism.

As nurses, we have a responsibility to educate patients about the importance of vaccinations and the implications when vaccine-preventable diseases reemerge. Measles is extremely contagious and can have serious complications, especially for certain high risk groups. Please stay informed about the current outbreak and recommendations for vaccinations. 

What is measles?


Measles is an acute viral illness, transmitted by direct contact with infectious droplets or by airborne spread. After exposure (the incubation period can range from seven to 21 days), a prodromal syndrome of high fever, cough, runny nose, and conjunctivitis is characteristic. Koplik spots (white or bluish-white spots on the buccal mucosa) may occur and then the development of the characteristic maculopapular rash, which typically spreads from the head to the trunk to the lower extremities, follows. 

 


Complications of measles

Common:

  • Otitis media
  • Bronchopneumonia
  • Laryngotracheobronchitis
  • Diarrhea

Severe:

  • Encephalitis
  • Respiratory complications
  • Neurologic complications
  • Subacute sclerosing panencephalitis (SSPE)

Who’s at risk for severe complications?

  • Infants and children younger than five years; adults over 20
  • Pregnant women
  • Immunocompromised patients

Need-to-know information for nurses

  • After appearance of the rash, infected patients should be isolated for four days in a single-patient airborne infection isolation room (AIIR).
  • Measles is a reportable disease and local health departments should be notified within 24 hours of suspected measles cases. 
  • Routine childhood immunization for MMR vaccine starts with the first dose at 12-15 months of age, and the second dose at 4-6 years of age or at least 28 days after the first dose. (More vaccine schedules and information, including contraindications to vaccination, can be found here.)

References
Finerty, E. (2008). Did you say measles? American Journal of Nursing, 108(12). 
Skehan, J. & Muller, L. (2014). Vaccinations: Eliminating Preventable Illness. Professional Case Management, 19 (6).
Wade, G. (2014). Nurses as Primary Advocates for Immunization Adherence. The American Journal of Maternal/Child Nursing, 39 (6). 
Centers for Disease Control and Prevention. (2015, January 30). Measles (Rubeola): For Healthcare Professionals.

Posted: 2/2/2015 3:29:18 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Diseases & Conditions


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