Infection Control Practices in Physician Offices

According to the National Health Statistics, in 2007 the total number of physician office visits approached one billion. I know that number is so 2007, but imagine how many that would be now that 2014 is almost over. Many of us have visited a physician’s office at least once if not more this year and will probably continue to do so again next year.

Numerous outbreak reports have described transmission of Gram-negative and Gram-positive bacteria, mycobacteria, viruses, and parasites in the ambulatory settings. In many instances, outbreaks and other adverse events were associated with breakdowns in basic infection prevention procedures (e.g., reuse of syringes leading to transmission of bloodborne viruses).

So you see where this is heading…yes..better infection control practice in physician offices. Patients deserve the same level of infection control protection whether they are treated in a hospital or ambulatory care setting, including physician offices. No..there shouldn’t be any difference in infection control practices. It is that simple yet I have seen many nurses practicing in physician offices who either forget this concept or think it doesnt apply to them since most infection control guides are geared towards hospital practice.

The CDC’s “Guide for Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care” is a summary guide of infection prevention recommendations for outpatient (ambulatory care) settings. The recommendations included in this document are not new but rather reflect existing evidence-based guidelines produced by the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee. This summary guide is based primarily upon elements of Standard Precautions and represents the minimum infection prevention expectations for safe care in ambulatory care settings.

Key recommendations for safe injection practices in ambulatory care settings:
1. Use aseptic technique when preparing and administering medications
2. Cleanse the access diaphragms of medication vials with 70% alcohol before inserting a device into the vial
3. Never administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing
4. Do not reuse a syringe to enter a medication vial or solution
5. Do not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more than one patient
6. Do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient
7. Dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle)
8. Dispose of used syringes and needles at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof.
9. Adhere to federal and state requirements for protection of HCP from exposure to bloodborne pathogens

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So if there are CDC guidelines for outpatient settings, why is it still an issue? Just a few thoughts on this..

  • Absence or lack of infection control policies
  • Lack of education and training on basic infection control practices
  • No compliance monitoring of the practitioners
  • No infrastructure to support an infection control specialist
  • Lack of quality measures or reporting mechanism for outbreaks and breaches
  • Lack of handwashing provisions in patient/treatment areas

Physician offices and other ambulatory care settings are structured differently than acute care facilities. If the physician office practice is part of a large hospital system or medical groups, infection control education and training are mandatory. Unfortunately, many  are single /private practice offices and don’t have the infection control policies and other resources. In some cases, they simply don’t care because there’s no regulatory agencies to police them, unless they are involved in such outbreaks. Many nurses work alone and become pre-occupied with tasks to get patients out the door, in some cases at the expense of implementing good infection control practices. Sad but true…

All patients deserve the same level of infection control protection whether they are treated in a hospital or ambulatory care setting; what if that patient is your mother/family member or a loved one?

References:

  1. Hsiao CJ, Cherry DK, Beatty PC, Rechsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. National health statistics reports; no 27. Hyattsville, MD: National Center for Health Statistics. 2010.
  2. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital Health Care-Associated Hepatitis B and C Virus Transmission: United States, 1998-2008. Annals of Internal Medicine. 2009;150:33-39.
  3. “Guide for Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care”

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So much to be Thankful for!!

So true, and as the author of this blog, I would like to  thank each of you for reading and supporting this blog. I hope I have provided you with good, relevant and practical information you can use in your daily practice. Thank you to each of you for your comments and posts. I am very grateful and hope for your continued support.

Wishing each of you a Happy Thanksgiving!

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Infusion Nursing Roundtable

I recently had the honor of participating in the RNFM Radio Infusion Nursing Roundtable with my colleagues, Ann Earhart, current INS president; Jim Lacy, current AVA president; and Sharon Weinstein, a past president of INS and past Chair of Infusion Nurses Certification Corporation (INCC).

For nurses interested in this growing area of specialty practice, this rich conversation is essential to understanding the state of infusion nursing in the 21st century. Click on the RNFM image below to listen:

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Many thanks to Kevin Ross and Keith Carlson from RNFM Radio for this wonderful opportunity. You can find more information about Kevin and Keith and RN FM Radio here.

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Positively bloody!

….as in  positive blood return when aspirating from central venous catheters (CVC).  Positive blood return means a free flowing blood return easily obtained on aspiration, and the color of whole blood. In other words, bloody RED, not pink-tinged. What a great feeling, knowing that the CVC is properly functioning and ready to use.Syringe_with_blood

NOT able to obtain a blood return from CVCs?  This might  indicate a problem.

  • If the tip of the CVC is in the lower thirds of the superior vena cava at the junction of the SVC and RA, then you should get a blood return. If you can’t get a positive blood return, do not use and assess the cause.
  • It is not an expectation for patients to do arm and shoulder movements or what most nurses refer to as “central line aerobics” while you aspirate for a blood return.
  • If unable to obtain a positive blood return, then there is a problem with the central line. Assess for possible drug precipitate, fibrin sheath, thrombus formation at tip of catheter, and mechanical problems such pinch-off syndrome, malpositioning of catheter tip, or catheter dislocation.

What if you call the physician and report the problem (inability to obtain blood return) and you are told to go ahead and use the CVC for infusion anyway. Should you?

Keep this in mind… Assessing for blood return is one of the key indications of a properly functioning CVC and  without a blood return, the use of the CVC can put the patient at risk of serious complications. 

A bloody reminder on Oct 31 – Happy Halloween to all!!!  Blood---Pumpkin---Grimace

 

 

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What? Seriously?

I’ve had conversations with several RN colleagues that left me saying, are you serious? I hesitated writing about this but I thought I’d share so we can all learn and avoid doing the same.

1. Whatever happened to those “multi-use” syringes? That’s crazy that I can’t reuse syringes when I’m just drawing up medication for injections and not using it on patients. 

  • Ok, I know what you’re thinking but this conversation came up during our discussion of the “One and Only Campaign” on safe injection practices. ONE NEEDLE, ONE SYRINGE, ONE TIME! If you are not familiar with this campaign. please click here  and read about it.
  • This RN looked at me like I had 10 heads.  I pointed to the icon on the syringe label. Have you looked at your syringe labels lately?

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  • Bottom line: Unless you are using glass syringes, which should be cleaned and sterilized after each use, before the next use, there is no such thing as “multi-use” syringe! The syringes in the US are disposable and as the label indicates, do not reuse! ONE NEEDLE, ONE SYRINGE, ONE TIME!
  • In case you are wondering, when is a syringe considered used? Check this post out – click here

2. An RN preparing to give a weight based medication to a patient states: I don’t weigh the patient each time they come, only in the beginning of their treatment. Why should I weigh them again, they can tell me if their weight has changed.

  • What? seriously? I’m sure all of you reading this are shaking your heads much like I did. So tell me, is this a case of lack of knowledge or just plain laziness? You be the judge.
  • Bottom line: one vital piece of patient-specific information, the patient weight, is especially important because it is often used to calculate the appropriate dose of a medication (e.g., mg/kg, mcg/kg, mg/m2). A prescribed medication dose can differ significantly from the appropriate dose as a result of missing or inaccurate patient weights.

3. An RN started a PIV without gloves. RN stated, I have never worn gloves when starting IV’s and I am very careful not to touch blood.

  • This scenario happening in 2014?? How long has it been since Blood borne pathogen and Needlestick Safety and Prevention Act became a federal law? It was the year 2000 and came into effect in 2001.
  • When asked why the RN wasn’t using gloves, the response was, never have and never will. (oy!)
  • Employer was made aware and stated, yeah, we know. Sad but true, they don’t seem to be concerned.
  • Bottom line: The law applies to all employers who have an employee(s) with occupational exposure (i.e., reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of the employee’s duties). These employers must implement the requirements set forth in the standard.

It was heart breaking to have these conversations with my nursing colleagues who are actively practicing nursing and providing patient care. Why are there nurses who think and act this way when there are standards of practice  and federal mandates that give us guidance? We have a responsibility to follow best practice/standards of practice to protect ourselves, the public and the patients we serve.  It’s always a convenient excuse to say that one didn’t know such standards or law exist. Let’s not forget, a person who is unaware of a law ( or in some cases, standards of practice)  may not escape liability for violating that law  merely because he or she was unaware of its content.

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NIOSH 2014 List of Antineoplastic & Other Hazardous Drugs in Healthcare Settings

This is an updated version of  the National Institute of Occupational Safety and Health (NIOSH) hazardous drugs list. So what’s new in this current update?

The text for the update to the 2014 list was updated and expanded to reflect the complexity of safe handling issues that have arisen over the past few years.  This was driven, in part, by the growing number of oral antineoplastic drugs and the addition of oral non-antineoplastic drugs.  The list was reformatted and some drugs have been deleted.

(a) Based on feedback from multiple sources, it was determined that the universal approach as described in the 2004 Alert on Hazardous Drugs for handling hazardous drugs was no longer feasible.

 (b) The list of hazardous drugs was separated into three categories: (Table 1) Antineoplastic drugs; (Table 2) Non-antineoplastic drugs; (Table 3) Drugs with adverse reproductive effects only; and (Table 4) Deleted drugs.

  (c)  It was noted that the majority of the antineoplastic drugs may have adverse reproductive effects and the drugs in the non-antineoplastic category that had adverse reproductive effects as a secondary reason for their listing was noted.

  (d) New drug listings for 2014 are indicated by red font and drugs in the non-antineoplastic category that also have adverse reproductive effects are indicated by blue font.

 (e) Also added is a matrix of common activities related to hazardous drug handling and recommendations for the use of personal protective equipment and ventilated engineering controls for each activity (Table 5).

 

Hazardous drugs include those used for cancer chemotherapy, antiviral drugs, hormones, some bioengineered drugs, and other miscellaneous drugs.  The NIOSH cautions that the list may not be all inclusive and recommend that each organization should create its own list of drugs considered to be hazardous. This perhaps explains why sometimes I notice a drug not on the hazardous list is considered hazardous by one organization but not by another.  In my experience, many oncology infusion centers follow the precautions recommended for hazardous drugs for all drugs they administer regardless of classification in a effort to standardize handling practices.

When a  drug is hazardous, various precautions should be applied when handling the drug.  Click here for the full publication of the 2014 NIOSH Hazardous Drug List.

NIOSH 2014

Acknowledgement:

Many thanks to Barbara MacKenzie and Thomas H. Connor for the  information and updates.

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Yearly Tribute 9/11

We will always remember…..September 11, 2001.

It was a day no one would ever forget. I remember exactly where I was and what I was doing at the time. I remember feeling lucky that although I was at an airport, I was not on an airplane.

We will always be grateful to the courageous firefighters, rescuers and first responders who risked their lives to save those in the rumbles of this dreadful day.

We will always remember those who died from this tragedy, whose memories we celebrate today.

But as we remember those who are no longer with us in this world, let us not forget those who survived or were left behind…those whose lives were forever changed..those who will always be guilty that they survived.

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