Posts Tagged Infection Control

Observations and Assessments

NOTIONS TO SMALL FOR A BLOG POST, ALL IN ONE PLACE, A.K.A. THE PERIODIC LINK DUMP.

Further to my post “Sleepy Sleepy Nurse”: Sleep or Die. Really.

My jobRegistered Nurse.

We don’t know as much about infection control as we think we do. “Less than a quarter of the Clostridium difficile cases in a hospital could be traced to patients in the same ward, challenging a common assumption about how the infection spreads.” Medscape summary. Original article here.

And we’re not as smart at Triage as we think we are. Analyzing the records of 519 patients aged 65 years or older who were triaged using the Emergency Severity Index, from University Hospital Basel in Switzerland, found that 117 patients were undertriaged and 15 were overtriaged.” Anecdotally, I think this is true. My only quibble is why the small sample size? I mean, 519 patients is two days of volume in a busy ED, which means only a few poorly trained triage nurses could skew the results.

Nurses’ Presenteeism and Its Effects on Self-Reported Quality of Care and Costs. I read the article and went “Meh.” Rather evades the real issues around presenteeism, i.e. workplaces penalizing nurses for taking sick time.

Oh, dear.

On the menu: Pink Slime! I swear I will never, ever buy ground beef ever again.

And they didn’t live happily ever afterReal life Disney princesses, fallen. A photo exhibit by Dina Goldstein. My favourite: Cinderella knocking back shots in a bar on Hastings Street in Vancouver’s Downtown Eastside.

Younger than the Happy Meal. An important reminder from Fred Clark the supposedly “eternal” truths about abortion maintained by evangelical Christians are of much more recent vintage than you think.

Great music in the cause of crap content. Dissecting the cultural significance of country music. Quote:

The conservative movement has been cannibalizing conservative art for years now, to the point where I’d say country music is far from a victory of conservative cultural or artistic success and is instead a mirror image of what conservative politics have become: easy and unthinking. No depth, all surface. Superficial and insular. Maybe I’m wrong, but building an entire genre on the back of the idea that regurgitating the same sound on top of the same basic premise over and over again hardly strikes me as a triumph of cultural conservatism.

What language do deaf people think in?

Ayn Rand is the Karl Marx of the Right. Mostly because she tells people with incredible amounts of privilege they are the real victims in life’s lottery. Quote: “She offers them something that is crucial to every successful political movement: a sense of victimhood. She tells them that they are parasitised by the ungrateful poor and oppressed by intrusive, controlling governments.”

The Reformed Whores respond to Rush Limbaugh: “I’m a slut.” Hugely funny and right on the money.

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Got Mine. Got Yours?

The flu shot, that is.

I got mine yesterday. And no, I did not get any flu-like symptoms. So get it over it, and go get the shot. Now. Especially if you’re a health care professional. What I wrote during the glory days of H1N1 two years ago still applies:

Finally, I won’t tell you to get the vaccine, because it’s professional, or that the hospital is making you anyway, or because it’s the right thing to do, or because you’re saving yourself the misery of having the flu for a week or two, though these are all more or less valid reasons. However, getting the shot will prevent you from being a complete tool when you pass the virus to someone compromised — maybe even one of your colleagues, a patient or even, God forbid, a loved one —  and end up killing them. I think this argument is nearly irrefutable.
So in summary: don’t be a tool. Get the shot.

Don’t make me nag you. Because you know I will.

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How Hospitals Punish Nurses for Being Sick

I admit it: I’ve gone to work sick when I should have stayed at home. I’ve gone with hacking coughs, sore throats, Fevers Not Yet Diagnosed, and probable gastroenteritis. I’ve gone in with migraines. Once when I was being treated for an I & D’d abscess, I went in with a saline lok, a kind of intravenous access to give me antibiotics. Should have stayed home, I confess, I know better, but there it is.

So I listened attentively to Brian Goldman’s CBC Radio show White Coat, Black Art this week (you can hear it at the link) on health care professionals coming in to work sick. We do it for reasons perhaps not unique to health care: we don’t want to let down the team, there’s no one to replace us, we’re indispensable. He mentions physicians being expected to show up unless dead or nearly so; nurses, when I was a student at least, were inculcated from our first clinical day that calling in sick was tantamont to being a bad nurse.*

However, the consequences of having sick health care professionals are, of course, unique: we tend to infect patients who are already compromised. As bad, or worse, we compromise our judgement: who can think clearly with a temperature of 39.8C, or while having to run to the toilet every ten minutes? Goldman suggests that a massive culture change in hospitals is necessary to let health care workers take sick days as needed. I agree. But it’s not going to happen any time in the near future: hospital administration itself is the biggest obstacle. There are clear choices in creating a culture that gives permission for nurses in particular to take sick time. I don’t believe hospitals have the will to make that cultural shift.

Let me explain: the problem of sick nurses, other health professionals and ancillary staff coming to work — I’m leaving out physicians, because in Ontario hospitals, they aren’t subject to the same scrutiny as nurses — highlights an internal conflict within hospital administration. In an ideal world, Infection Control in all hospitals would dearly like nurses and the rest to stay home if they’re sick. Patient safety, after all comes first. In the real world, however, hospital Human Resources departments do not consider infection control as a priority. Human Resources views sick time as a controllable cost, and frankly, sick nurses a problem to be managed.

It’s true in general that nurses take higher than average rates of sick time. The reasons for this are complex: we are, after all, exposed to infection on a daily basis, the nature of our work is highly stressful (which in of itself has health consequences), and sick time is an indicator of nursing morale which in many hospitals is quite poor. The job of human resources is to provide strong disincentives to nurses (and others) calling in sick. They d0 this in a couple of ways. In Ontario, hospitals cut sick pay for nurses by up to a third, depending on seniority. If you’re a sole-wage earner living paycheque to paycheque, it’s a substantial amount. Pragmatically speaking, if it’s between feeding your kids, and coming in sick, even if you are a conscientious nurse, guess which will win.

Further, nurses must cope with attendance management programs. In Ontario, and I know this is true in many American hospitals, nurses are subject to punishment if they take as few as three sick days, and made (with union acquiescence) to attend humiliating, disciplinary “attendance-management” meetings. For their part, hospital management and the union — the Ontario Nurses Association — will vehemently deny the attendance management process is disciplinary in nature. Personally, I have never been subject to attendance management. But I have seen nurses leave these meetings distressed to the point of tears, and I know of one nurse who left her position and the hospital because of Human Resource harassment. It’s discipline by other means and it’s a strong deterrent to taking sick leave. I’ve come in sick myself knowing I was close to the threshold of being put on “The Program.”

A conversation I had a few months ago with the Infection Control Nurse illustrates quite nicely this tension between the conflicting goals of Infection Control and Human Resources. The context was a mini-outbreak of gastroenteritis; three nurses were off sick. The Infection Control Nurse got wind of this outbreak, and wanted to ensure the nurses stayed home for 48 hours after the last symptoms, as per hospital policy. She wanted names, which I refused because of confidentiality.  She then wanted me to call the nurses. I refused again. I knew at least one of them was already in some difficulty with the attendance management program, and I was unsure about the rest.

“Well,” she said. “Let me call them.”

No, I said. I explained to her how Human Resources will punish the nurses for following hospital policy.

“Oh,” she said. “That’s a human resources issue, not an infection control issue.”

Actually, I thought, if you have an otherwise diligent, handwashing-fanatical nurse like me resisting infection control directives, human resource policy is an infection control issue.

In the end, hospitals must choose between trying (and mostly, I think, failing) to control sick time costs and making infection control truly a priority. It’s no good telling nurses to stay home if they are sick, only to turn around and punishing them for fulfilling what is really a professional obligation. Half-measures, like telling nurses to mask for their 12-hour shift, or to be “extra-diligent” in handwashing are impossible to enforce. Maybe some innovation is needed on how we look at sick time. One U.S. hospital I know of recognizes only 2-3% of employees abuse sick time, and assigns twelve days a year for “personal use,” no questions asked, after which HR begins to apply the screws. Nurses who leave part or all the personal days untouched get a payout of three of those days on a pro-rated basis. A change like that would indeed entail a massive culture shift. Present practice does not truly address infection control issues raised by health care professionals working sick, and sends conflicting messages to nurses. Either infection control is a priority for hospitals, or it isn’t. Which is it?

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*I’d be interested hearing from new grads whether this is still true.

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5 North Wins One, For a Change

The epic battle with my bête noir, Five North continues. Their latest tactic in patient avoidance? Over the weekend, they decided only to take patients with clear swabs.

Let me explain. As an infection control practice, to prevent the spread of nasties like MRSA and ESBL we collect nasal and rectal swabs on certain classes of patients thought to be at high risk of carrying these pathogens. Five North was requiring proof that all swabbed patients be cleared before accepting them for admission.

Of course, this is utter bullhockey. 5 North just makes things up, and then gets away with it. Nevertheless, on the weekend, the only recourse was to call the manager on-call.

So we called.

The manager-on-call was, in real life, Manager of Stores or Housekeeping or some other non-clinical department. In other words, both clueless and useless.

Oh well, she said, Let the patients stay in Emerg. Infection Control can sort it out on Monday. And of course, Infection Control needed to “assess the situation” in person before coming to a determination. We were screwed.

So 5 North managed to stay below its census while we were drowning in patients.

Ha ha, take that, Emergency Department!

And how did this serve quality patient care? You can probably guess.

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My New Favourite Word, Random Thoughts and Other Things I Don’t Understand

1. File this under I Don’t Understand. Regular readers of this blog will know I am a fanatical handwasher, because handwashing is the best way to reduce the spread of infection. And yet, even though I was in charge the last four days, and had no direct patient contract — a sort of preview to the joys to come in April, I suppose — and even though I wash my hands with the frequency of Lady Macbeth (Out, out damn MRSA!), I still got some sort of gastro. Ugh. Disgusting.

Especially when I think of how gastros are spread.

2. File this under Funny. My colleague Darla contracted it too, and she’s just as OCD about handwashing as me. So she’s telling me how she’s all pukey and poopy, and she says this:

Darla: And then I called my husband and told him to pick up pads and Immodium.

Me (blank stare):  ( . . . )

Darla: Well, I’m not using them together!

Will, I think this would make a great couple of panels.

Well, I thought it was funny.

3. Which leads to my new favourite word. So day before yesterday, I thought I was sick, but decided it would pass because I felt moderately better, and decided to soldier on, came in and of course felt immediately, immoderately worse. There is an expression for this, which is my new favourite word: presenteeism. This describes the problem of coming in to work when you got, say, gastroenteritis or something, resulting in the hidden costs decreased productivity, not to mention spreading the ick to your co-workers.

Nurses are are one of the worst offenders, because, as I have pointed out before, hospitals in Ontario and elsewhere and are annoyingly stupid and actively punish nurses who call in sick.

4. Again I don’t understand. When I was younger I listened to classical music endlessly. Bach and Beethoven were my homies. Now I’m listening to punk/alternative. A lot. Is this normal? Shouldn’t it be the other way around? Or is it just weird? Or am I grasping at the lost threads of a misspent youth?

5. Permit me to winge a little. And yeah, my furnace died yesterday, so I’m sitting in front of the laptop sick, wrapped in a blanket, with the fireplace roaring and reassuringly blowing hot air up the chimney. Fortunately it isn’t cataclysmically cold here in Toronto, so the pipes probably won’t freeze before it’s repaired. I also have a little electric heater warming my feet, if my parasitical cats would stop laying in front of it.

What? They have fur!

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A Fix for MRSA?

Bacteria, but not the good kind

Another tactic, if counter-intuitive (or maybe not), in the never-ending war on MRSA*: stop giving out so many damn antibiotics:

Norway’s model is surprisingly straightforward.

• Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.

• Patients with MRSA are isolated and medical staff who test positive stay at home.

• Doctors track each case of MRSA by its individual strain, interviewing patients about where they’ve been and who they’ve been with, testing anyone who has been in contact with them.

Haug unlocks the dispensary, a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What’s here? Medicines considered obsolete in many developed countries. What’s not? Some of the newest, most expensive antibiotics, which aren’t even registered for use in Norway, “because if we have them here, doctors will use them,” he says.

He points to an antibiotic. “If I treated someone with an infection in Spain with this penicillin I would probably be thrown in jail,” he says, “and rightly so because it’s useless there.”

[snip]

But can Norway’s program really work elsewhere?

The answer lies in the busy laboratory of an aging little public hospital about 100 miles outside of London. It’s here that microbiologist Dr. Lynne Liebowitz got tired of seeing the stunningly low Nordic MRSA rates while facing her own burgeoning cases.

So she turned Queen Elizabeth Hospital in Kings Lynn into a petri dish, asking doctors to almost completely stop using two antibiotics known for provoking MRSA infections.

One month later, the results were in: MRSA rates were tumbling. And they’ve continued to plummet. Five years ago, the hospital had 47 MRSA bloodstream infections. This year they’ve had one.

“I was shocked, shocked,” says Liebowitz, bouncing onto her toes and grinning as colleagues nearby drip blood onto slides and peer through microscopes in the hospital laboratory.

In Ontario, at least, provincial efforts to control the spread of MRSA focus on identifying and isolating patients with MRSA in health care facilities, and providing best practice guidelines for hospitals and health care professionals. Maybe a rethink of the paradigm is needed?

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*Methicillin-resistant Staphylococcus aureus. Particularly nasty and highly communicable. And kills lots of people — 2600 a year in Canada is one figure I’ve heard, but I can’t find any official figures, yet.

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Bad News to Brighten Your Day

Two studies in the Journal of the American Medical Association, neither particularly happy.

On one hand:

Data from a California study published today in the November 4 issue of the Journal of the American Medical Association have revealed that Swine Flu kills more than 1 in 10 of those it affects severely enough to put in a hospital. The study, conducted by the California Department of Public Health investigated H1N1 flu cases in California between April 23 and August 11, 2009, including fatality and other clinical features. The authors found that the overall fatality associated with H1N1 flu in California was 11 percent and was highest (18 percent – 20 percent) in persons aged 50 years or older.

On the other:

The spring outbreak of 2009 influenza A(H1N1) infection in Canada affected primarily young, female, and aboriginal patients without major comorbidities, and conferred a 28-day mortality of 14.3% among critically ill patients. A history of lung disease or smoking, obesity, hypertension, and diabetes were the most common comorbidities. Critical illness occurred rapidly after hospital admission and was associated with severe oxygenation failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

Why the difference?

I suspect that the data is a bit skewed  in the latter study — it focused only on patients admitted to ICU. And the young and previously healthy, I think (as a observation), are more likely to be admitted as a rule to ICU with influenza then the old with multiple co-morbities.

What’s really shocking are the mortality rates if hospitalized: 11% in the California study (up to 20% if older than 50), and 14.3% in the Canadian study.

Another good reason to get vaccinated.

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Doing the Right Thing

So what do you do if you come down with H1N1 influenza? Why, you come to work:

If the Alberta government is serious about slowing the spread of the H1N1 flu virus, it should amend the provincial Employment Standards Code to include protections for workers who follow the advice of public health authorities and stay home from work when they’re experiencing flu-like symptoms.

Without such protections, thousands of workers – especially those in low-wage, service sector jobs – will continue coming to work when they’re sick, thereby jeopardizing their own health and undermining efforts to bring the H1N1 pandemic under control.

That was the message delivered today by Alberta Federation of Labour president Gil McGowan to an audience of 500 registered nurses gathered in Edmonton to attend the United Nurses of Alberta’s annual general meeting.

“The employment standards codes in six other Canadian jurisdictions give workers the protections they need,” says McGowan.

“All of those codes say that workers cannot be disciplined, demoted or dismissed for taking time off work because of short-term illness. The Alberta code, on the other hand, doesn’t say anything at all about sick leave. As a result, workers whose employers don’t independently provide paid or unpaid sick leave – and we think that’s a majority or workers in Alberta – face the prospect of being punished for doing the right thing.

And not low-wage private sector jobs either. My own employer, Acme Regional Health — and I don’t think they’re unique in Toronto or in Ontario — actively and as a matter of policy punishes nurses taking sick days as a means of ensuring attendance. It’s said nurses have the highest sick time rate of any employment group. There are specific reasons for this: poor morale and stress are certainly factors, but the very nature of the job causes injury and illness. And hospital employers, rather than addressing the underlying issues related to sick time, choose to crack the whip, mostly, I think because it’s cheaper.

So, for example, nurses don’t get full pay when they take sick time: we are penalized by up to 1/3 of our pay, straight off our paycheques. And if we take more than a certain number of sick days in a year, we are further punished by a work-attendance programme — which is what we call it, The Programme — in which we are compelled (with union acquiescence) to attend any number of disciplinary meetings. For being sick.

All of which makes me wonder: how many nurses will come to work with H1N1? I know the high-minded and sanctimonious will argue that patient safety is paramount. Sick nurses should stay home. But a one-third cut in pay is a lot, and if it’s between being a one-income family, feeding your kids and paying your mortgage, and coming into work, pragmatically speaking, patient safety is going to take second place. Add on to these home-life pressures the subtle and not-so-subtle guilt, tacitly encouraged by hospital management, of letting down your colleagues by leaving them short-staffed.

Sick nurses will come to work. Which, I should add is exactly what hospital administrators hope, despite endless cant about patient safety.

Hospital wards everywhere provide the spectacle of the sick and injured caring for the sick and injured. It isn’t pretty. And again the question has to be asked: who cares for the nurses?

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Cheaper is Just as Good

Speaking of H1N1 (again, sorry), a study in JAMA compares the efficacy of N95 masks versus surgical masks. Guess what?

Our data show that the incidence of laboratory-confirmed influenza was similar in nurses wearing the surgical mask and those wearing the N95 respirator. Surgical masks had an estimated efficacy within 1% of N95 respirators. Based on the prespecified definition, the lower CI for the difference in effectiveness of the surgical mask and N95 mask was within –9% and the statistical criterion of noninferiority was met. That is, surgical masks appeared to be no worse, within a prespecified margin, than N95 respirators in preventing influenza.

I don’t imagine manufacturers of (those costly) N95 masks are very happy about this. Just wait for the counter-study. And the wails of complaint and refutation.

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Scenes from the H1N1 Pandemic

“My father sent me in. He was worried I had the swine flu. I’m not really sick, though.”

“I called my family doctor because I was short of breath, and he said to come right in.”

“I called my family doctor and she said they weren’t seeing flu patients and to come right in.”

“I called my family doctor, and she told me to come right in to get the flu shot because I wasn’t feeling well.”

“The flu clinic in ——— was too busy and they told me to come here for the shot.”

“I called Telehealth Ontario, and the told me to come right in.”

“I called Telehealth Ontario, and they said you would have a bed ready for me.”

“I called Telehealth Ontario, and they said I was too sick with the flu to stay at home.”

“I don’t want to drop dead like that kid in Vaughan.”

“I have fever, and a cough. And muscle and joint pain.”

“I have fever and miasmas.”

“I have a fever and I ache all over.”

“The doctor gave me antibiotics yesterday and told me I had the flu and I’m not any better.”

“I want Tamiflu.”

“I took Tylenol yesterday for the fever.”

“I gave her Tempra last night. ”

“I still have a fever.”

“A kid at his daycare has it, and so can we all get swabs?”

“My doctor sent me to get the swab.”

“I have a cough and fever and muscle and joint pain.”

“She is so short of breath unless you bring her right away she will die.”

“I have a fever and cough and shortness of breath.”

“I was exposed to someone confirmed with H1N1 a week ago.”

“I just came back from Cuba, and I think I have the flu.”

“I have a little cough for about a week.”

“I have had problems breathing, and a cough for three weeks.”

‘I’m allergic to the hand sanitizer.”

“Do I have to wear the mask?”

“The mask will make me vomit.”

“Does everyone here have the flu?”

“Is the wait long?”

“Can you please help us?”

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