What are the elements of “STEEEP”?

Safe

Timely

Effective

Efficient

Equitable

Patient-centered

What is the takeaway message of To Err is Human?

Errors are caused by faulty systems, process, and conditions that lead people to make mistakes or fail to prevent them.

What is a Sentinel Event?

IT is an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof.

Includes process variation for which a recurrence would carry a significant chance of serious adverse outcome.

What does a "Sentinel" event signal?

What are the elements of the “No Needless List?”

No needless deaths

No needless pain or suffering

No helplessness in those served or serving

No unwanted waiting

No waste

No one left out

Definition of Medical Harm:

Unintended injury resulting from or contributing to by medical care (incl. absence of indicated medical treatment), that requires additional monitoring, treatment, hospitalization, or that results in death.

Is unintended injury considered medical harm if it is not considered preventable?

Yes

Is unintended injury considered medical harm if it was not a result of a medical error?

Yes

Is unintended injury considered medical harm if it did not occur within a hospital?

Yes

What are nurse-sensitive indicators?

They are outcomes most affected by nursing care.

Patient-Safety Indicators:

An administrative-based tool developed by AHRQ.  They are increasingly being used to measure potential in-hospital patient safety problems

What do Matthews and Pronovost suggest are among the best methods to improve quality and reduce the costs of care?

Standardization

What does the Complex Adaptive Systems assert regarding “causality?”

It is bidirectional, not unidirectional, involving the interaction of two or more entities.  From these complex interactions emerge unpredictable behavior patterns leading to small changes that may or may not lead to wide-spread changes.

What is the “Swiss Cheese Model” in regards to patient harm?

It visualizes an alignment of gaps in the system that result in harm.

What is a “Near Miss?”

An event or situation that could have resulted in an accident or injury, or illness, but did not, either by chance or through timely intervention.

What is an “Adverse Event?”

Adverse occurrences directly associated with care or services provided.

What are “Active Failures?”

Errors and violations caused by workers closest to the “sharp end” or the system (e.g., patient care).

According to Woods (1998), what is a major barrier to making progress in safety and quality?

Failure to appreciate the complexity of work.

The cognitive or invisible work required in complex work environments is demanding and often has four characteristics:

Dynamism

Large number of parts and connectedness between parts

High Uncertainty

Risk

Characteristics of High Reliability Organizations (HROs):

“Preoccupation with failure” – treat any lapse as a symptom that something is wrong. 

“Reluctance to simplify interpretations” – take deliberate steps to create a more nuanced picture of details surrounding a failed process

“Sensitivity to Operations” – maintain an ongoing concern with the unexpected.  HROs look for and deal quickly with latent failures before an event occurs

“Commitment to resilience” – Focus on detecting, containing, and bouncing back from adverse events.  Adverse events do not disable HROs.

“Deference to expertise” –Authority moves to people with the most expertise regardless of rank.

What are some gaps and latent failures confronting nurses in the midst of care delivery?

-          Missing equipment

-          Interruptions

-          Waiting for access to needed systems and resources

-          Lack of time to complete interventions that were judged necessary to reach desired outcomes

-          Inconsistencies in how information was communicated

What are some nurse strategies for dealing with, or adapting to, the gaps and latent failures controlling nurses in the midst of care delivery?

-          Anticipating, or forward thinking

-          Proactive monitoring of patient status to detect early warning signals (hyper vigilance!)

-          Strategic delegation and hand-off decisions to maintain flow of workload.

-          Individualized paper memory aids –  your “brain” – keeping you on task

-          “Stacking” management of activities to be done – highest priority is always changing!

What are some factors that have contributed to Drug-Resistant Microbial Strains?

-          Overprescription of antibiotics

-          Use of inappropriate antibiotics for the infecting organisms

-          Incomplete use of antibiotic prescriptions as symptoms subside

-          Harboring and spreading of resistant organisms by carriers who remain symptom-free

-          Increased use of antibiotics in farming, thus contaminating milk and meat

Does Vancomycin-resistant Enterococcus (VRE) infect patients that are healthy?

No, it typically infects patients that are already sick – requires a very susceptible host.

What are some risks for acquiring drug-resistant infection?

-          Persons who have been previously treated with antibiotics

-          Persons who are hospitalized, particularly when they receive antibiotic treatment for long periods of time

-          Persons with weakened immune systems, (ICU, cancer, or transplant wards)

-          Persons who have undergone surgical procedures, such as abdominal or chest surgery

-          Persons with medical devices that stay in for some time (e.g., urinary catheters or central intravenous catheters)

The term used to described those who have drug-resistant Staphylococcus aureus bacteria on or in their bodies but have not yest become ill through the infection of a wound or other area of tissue.

MRSA Colonization

Where is MRSA often found on the body?

Nose, groin, underarm areas

Once colonized with MRSA, how long can a person remain a carrier?

From a few weeks up to several years.

During the colonization period, what is a big concern regarding MRSA carriers?

They are not only at an increased risk for infecting others, but also themselves.

What is the most common method of contracting C. difficile diarrhea and colitis?

The use of antibiotics

What is the “process” of a C. difficile infection ?

Antibiotics kill a large quantity of our “good” bacteria in the bowel and upsets the normal balance.  This decrease in the levels of good bacteria leaves the bowel open to be populated by increased numbers of unhealthy bacteria  Also leaves the bowel open.

What is inflammation?  What causes it?

It is the body’s response to injury or infection.  Injury may be due to physical agents, chemical agents, or microorganisms.

What is the term used to describe a protective vascular reaction that delivers fluid, blood, and nutrients to the injured area?

Inflammation

What is the inflammatory response?

  Arterioles at injury dilate = increased blood flow = redness and warmth

Inflammatory mediators delivered to the site = increased permeability of vessels à edema

 Edema = pressure on nerves à pain

  WBCs ingest/destroy organisms and cellular debris à increased WBC count

What are they types of exudate that accumulate at the injury site?

◦       Serous:  clear, like plasma

◦       Sanguineous : contains RBCs

◦       Purulent:  contains WBCs and bacteria

What is the difference between Acute and Chronic infections?

Acute

Develop rapidly (e.g., common cold:1-2 days, flu: 1-3 days)

Chronic

Symptoms develop slowly, and may take months to resolve (Hepatitis B ,C )

What is the characteristic of a localized infection?

It occurs at a specific site, and involves local inflammation

What are the signs and symptoms of a localized infection?

Look for signs and symptoms of inflammation:

◦       Heat, redness, pain/tenderness, swelling

◦       Drainage (bloody, serous, purulent)

◦       Abscess (localized collection of pus)

◦       Cellulitis (involves cellular and connective tissue)

What are characteristics of systemic infection?

Involves infection of one or more parts/organs of the body and may be fatal.

What are signs and symptoms of a systemic infection?

More generalized (than those of localized infection).  They include fever, fatigue, malaise, lymph node swelling.

What is a Systemic Inflammatory Response?

It is the worst case scenario.  Sepsis.

◦       Also known as systemic inflammatory response syndrome (SIRS)

◦       Serious medical condition caused by the body's response to an infection.

◦       Leads to widespread inflammation and blood clotting. 

◦       Blood clotting during sepsis causes reduced blood flow to limbs and vital organs, and can lead to organ failure or gangrene (damage to tissues).

What is the cause of SIRS (Systemic inflammatory response syndrome)?

The body’s response to an infection

What are symptoms of sepsis?

•          Decreased urine output

•          Fast heart rate

•          Fever

•          Hypothermia 

•          Shaking

•          Chills

•          Warm skin or a skin rash

•          Confusion or delirium

•          Hyperventilation (rapid breathing)

The CDC’s System of Isolation Procedures consists of what two “Tiers?”

Standard precautions (barrier)

•          All body fluids of all patients should be considered hazardous, regardless if a diagnosis is known

Transmission-based precautions

•          Applies to clients with documented or suspected infections with highly transmissible or epidemiologically important pathogens by contact, droplet or airborne modes of transmission

What are Standard Precautions?

•       Primary strategy for nosocomial infection control by reducing transmission

•       Applies to blood, all body fluids, secretions, excretions, except sweat

•       Environmental control: disposable equipment and utensils, sharps management, mouthpieces, bags for resuscitation

•       Patient room assignments

•       Patient transport precautions

Infection control: What is "Mode of Transmission?"

Refers to the way in which the pathogen moves or is carried from the source’s portal of exit

•          Contact

–        Direct

–        Indirect

•          Droplet

•          Airborne

•          Vehicle 

•          Vector

Airborne Precautions - criteria

Measles

VZV

TB

MRSA, VRE, RSV, C. difficile, and shingles would call for what kind of precautions?

What PPE is required for contact precautions?

◦       Precautions: glove and gown; dedicated equipment

Droplet nuclei <5μm (small droplet)

◦       Can stay suspended and widely dispersed by air currents

◦       droplets >5μm

Measles, VZV, and TB would call for what precautions?

simple mask (for provider when in room, for patient when he/she out of room); dedicated equipment

◦       Neuropenic patients (neutrophils < 500/mm3)

–   Burns, chemotherapy, radiation therapy, immunosuppressive medications

◦       Private room / Door closed

◦       Meticulous hand hygiene by patient, HCWs, visitors

◦       Restrict visitors with infectious diseases

◦       No fresh fruit, vegetables (controversial), flowers, plants, uncooked meat/fish

◦       Limited social interactions can cause psychological problems, especially with children

The absence of pathogenic, or disease producing, microorganisms

Medical asepsis (aka clean technique)

◦       Includes procedures used to reduce and prevent the spread of pathogens

◦       e.g., using gloves, cleaning the environment

Surgical asepsis (aka sterile technique)

◦       An object must be free of all microorganisms

What is the single most important infection control practice?

Hand Hygiene

When should you perform hand hygiene?

}  Beginning & end of shift

}  Before  client contact

}  Between contacts with different clients

}  Before & after contact with wounds, dressings, specimens, bed linens

}  Before eating

}  After removing gloves

}  Before performing any invasive procedure

}  Before administering medications

}  After contact with secretions or excretion

}  Before & after using bathroom

}  After sneezing, coughing, or blowing nose

What are the types of Hand Hygiene?

◦       Soap-water should be used when:

   Hands are visibly soiled

  Before and after eating

   After using the restroom

◦       Gels/foams can be used at any other time (except if patient has C. difficile-alcohol is not effective against this pathogen)

When is it not appropriate to use alcohol-based hand sanitizers?

–   Hands are visibly soiled

–   Before and after eating

–   After using the restroom

 When a patient has C. difficile – alcohol is not effective against this pathogen

What are barriers used in Clean Technique?

◦       Gowns

◦       Masks

◦       Caps and Shoe Coverings

◦       Gloves – latex, vinyl

◦       Private Rooms

◦       Equipment and Refuse Handling

What are practices are dictated by Clean Technique?

}  NEVER TOUCH WITH BARE HANDS ANTHING THAT IS WET COMING FROM A BODY SURFACE

}  Use clean, nonsterile when touching blood, body fluids, secretions, excretions, contaminated articles

}  Put on gloves just before touching mucous membranes or nonintact skin

}  Changes glove between procedures

}  Remove gloves promptly after use, before touching items and environmental surfaces

}  ALWAYS WEAR GLOVES DURING CLIENT CARE WHEN YOUR SKIN IS ABRADED

Is it okay to touch a patient with bare hands if your own skin is abraded?

No

PPE: Mask, eye protection, face shield – What are their purposes?

◦       Used to protect mucus membranes of eyes, nose, mouth during procedures and patient care activities likely to generate splashes or sprays

◦       Masks protect wearer from inhaling large-particle droplets (lose effectiveness over time)

PPE: What are gowns used for in Clean Technique?

To protect skin and prevent soiling of clothing during procedures and patient care activities likely to generate splashes and sprays.

Is it necessary to use a sterile gown during Clean Technique?

No.  It does not need to be sterile.  Just clean and unused.

During sterile technique, what should you look for on a sterile object’s packaging?

Packaging and Expiration dates

If you turn your back on the sterile field, is it still sterile?

No.  Always face the sterile field.

What is the rule regarding sterile articles?

Sterile articles touch only other sterile articles (or they lose their sterility).

Principles of Sterile Technique:

planning and preparing the environment to eliminate organisms introduced to the client by the procedure

•          Personnel should be free of infectious disease (resp, diarrhea, rashes)

•          No street attire in OR

•          Shoe, hair, beard covered by caps and masks

•          No jewelry on hands, nails clipped short

True or false:  A sterile object is still sterile after it touches an article outside the sterile field?

False

T/F: A sterile objet remains sterile only when touched by another sterile object.

True

T/F: Only sterile objects may be placed on a sterile field.

True

T/F: A sterile object of field out of range, or an object held below a person’s waist can still be called sterile, as long as it is out of range for less than three seconds.

False

T/F: A sterile object or field becomes contaminated by prolonged exposure to air.

True

T/F: When a sterile surface comes in contact with a wet, contaminated surface, the sterile field becomes contaminated by capillary action.

True

T/F:  The edges of a sterile field or container are considered to be sterile, as long as you haven’t touched them with ungloved hands.

Flase.  There is a 1” unsterile “border” around the sterile field that is considered to be contaminated. ‘

T/F: It is permissible to use a sterile object past its expiration date, so long as it is within one month.

False

How might you prevent unnecessary traffic and air currents around your sterile field?

◦       Close the doors.

◦       Unfold drapes or wrappers slowly.

◦       Do not sneeze, cough, or talk excessively over the sterile field.

◦       Do not reach across the sterile field.

If you contaminate yourself or the sterile field, what must you do?

Re-establish your sterile field by beginning again.

When you are uncontaminated during sterile technique, may you enlist your colleagues to assist you by obtaining equipment you may need?

Yes

What is a nosocomial infection?

An infection associated with healthcare delivery.

What are the four types of healthcare-associated affections that account for 80% of reported infections?

}  35% Urinary tract (catheter associated) - Today

}  20% Surgical site – Week 2

}  15% Bloodstream (intravascular devices) – Week 6

}  10% Pneumonia (ventilator associated) – Week 3

What are some Prerenal conditions that affect the process of urinary elimination?

  Factors that decrease circulating blood flow through the kidneys with subsequent decreased perfusion to renal tissue

Decreased renal blood flow

  Outside of the urinary system

◦       Decreased intravascular volume: deydration, hemorrhage, burns, shock

◦       Altered peripheral vascular resistance: sepsis, anaphylactic reactions

◦       Cardiac pump failure: HF, MI, Hypertensive heart disease, valvular diseases, pericardial tamponade

What are intrarenal factors that affect the urinary elimination process?

  Factors that cause injury directly to the glomeruli or renal tubules interfering with their normal filtering, reabsorptive, and secretory functions

Within the kidney filtration areas

◦       Ureteral, bladder, or urethral obstruction: calculi, blood clots, tumors, stricture

◦       Prostatic hypertrophy

◦       Neurogenic bladder

◦       Pelvic tumors

◦       Retroperitoneal fibrosis

What are the symptoms of a Urinary Tract Infection:

–   Dysuria, N/V, fever, chills, fatigue

–   Older persons – confusion or vague abdominal discomfort

–   Cystitis:  frequency, urgency

–   Hematuria:  blood in urine

–   Bacteriuria may lead to urosepsis

–   Pyleonephritis:  flank pain, tenderness; fever; chills

–   CAUTI – often asymptomatic

What is hematuria?

Blood in urine

What is dysuria?

Pain when urinating

If urinary output is less than or equal to 30 mL/hr for two consecutive hours, do you have to call the MD?

Yes

What is the most common causative organism in UTIs?

E. coli

Are UTIs more common in women or men?

Women because of the proximity of anus and urethra

                Poor hand hygiene, failure to wipe front to back

Why are men less susceptible to UTIs?

They have a longer urethra, and have an antibacterial substance secreted by the prostate that protects against infection.

What is the indication for a straight (intermittent) urinary catheter?

To relieve urinary retention.  Also for paraplegics who intermittently catheterize themselves throughout the day.

What is a CAUTI? 

Catheter-associated urinary tract infection.

Is a CAUTI a nurse-sensitive outcome?

Absolutely.

What is the percentage of patients who develop a UTI after 7 days of having an indwelling catheter?

50%

Is it appropriate to place an indwelling catheter for a patient who requires prolonged immobilization?

Yes

Is it appropriate to place in indwelling catheter for a patient with acute urinary retention or bladder outlet obstruction? 

Yes

What are appropriate indications for indwelling urinary catheters?

◦       Acute urinary retention or bladder outlet obstruction

◦       Accurate measurement of urine output in critically ill patients

◦       Selected perioperative  situations

◦       Patient requires prolonged immobilization

◦       To assist in healing of open sacral or perineal wounds in incontinent patients

◦       End-of-life care

What is a “Care Bundle?”

◦       Collection of guidelines and interventions that, when consistently followed, have been shown to improve outcomes.

What are the elements of a CAUTI CareBundle?

◦       Insert catheters for appropriate indications only

◦       Leave catheters in place only as long as needed

◦       Ensure that only properly trained persons insert and maintain catheters

◦       Insert catheters using sterile technique

◦       Maintain a closed drainage system

◦       Maintain unobstructed urine flow

◦       Practice hand hygiene and standard precautions

T/F:  A care bundle will effectively improve outcomes, provided at least 75% of the guidelines are followed.

False.  Outcomes are improved when care bundles are completely and consistently followed.

What is the best determinant cause of CAUTI?

  Sterile technique broken during insertion

  Length of dwell time

  Older age

  Female sex

  Closed drainage system

Answer: Length of dwell time.

What is a Bladder Ultrasound (BUS)?

A non-invasive portable US devise that mesasures urine that is attached to a screen capable of visualizing the bladder

What is a bladder ultrasound (BUS) used to measure?

It is used to measure post void residual (PVR)

Would we utilize a bed pan for a patient with a spinal injury, body or leg casts?

Yes, we use them for conditions that restrict the patient from turning.

T/F:  A bedridden female can use a bedpan for urination, but not defecation

False.  Can be used for both.

When Habit Training/Toileting, why is it necessary to void each time your baseline voiding schedule indicates, even if you don’t feel the need to void?

This prevents the bladder from overfilling, which can lead to uncontrollable urine leakage associated with a sudden urge to urinate, or a cough, laugh, or sneeze.

When Habit Training/Toileting, should you go every time you have a strong urge to go?  Or should you stick to a schedule?

Make every effort to put off urinating between your scheduled voiding, even if you have a strong urge to urinate. 

What is the most common healthcare associated infection?

a.       Ventilator-assisted pneumonia

b.      CAUTI

c.       Central catheter-associated bloodstream infection

d.      Surgical site infection

When a urinary catheter remains indwelling for a month, the risk of bacteriuria is:

a.       25%

b.      60%

c.       90%

d.      100%

Antibiotic-impregnated catheters have been found to be effective in reducing CAUTI incidence for

a.       72 hours

b.      7 days

c.       2 weeks

d.      1 month

Biofilm develops :

a.       On every indwelling medical device

b.      Only on indwelling urinary catheters

c.       Primarily on antibiotic-impregnated urinary catheters

d.      Primarily on venous access devices

Which statement is correct about biofilm?

a.       It enhances bactericidal activity

b.      It’s composed primarily of cellular material

c.       It’s initially composed of several species of microorganisms

d.      Removing the catheter is the best way to eradicate biofilm

Some evidence exists that CAUTI can be reduced by:

a.       Routine meatal care with soap and water

b.      Routine meatal care with an antiseptic periwash

c.       Routine catheter irrigation with 0.9% sodium chloride solution

d.      Application of antibacterial ointment to the meatus

Best practice recommendations include changing long-term drainage bags

a.       Every 14 days

b.      Every month

c.       Every 6 weeks

d.      Only as necessary based on clinical indications

According to the CDC, an indwelling catheter may be appropriate if the patient:

a.       Is incontinent

b.      Is nearing death

c.       Has pain upon movement

d.      Prefers indwelling to intermittent catheterization

Sterile technique is not required for inserting:

a.       Antibiotic-impregnated catheters

b.      Siler alloy-covered catheters

c.       Intermittent catheters in the home setting

d.      Urinary catheters with an expected dwell time of 1 day or less

Securing a catheter after insertion helps in all of the following except:

a.       Promoting patient comfort

b.      Prevented urethral traction

c.       Slowing bacterial colonization

d.      Decreasing urethral lining damage

The number one predictor of CAUTI is

a.       A break in sterile technique during insertion

b.      Failure to use a reminder system

c.       Failure to use securement devices routinely

d.      Prolonged catheter dwell time

Which of the following is a CAUTI bundle strategy?

a.       Maintain a closed drainage system

b.      Use antibiotic-impregnated catheters

c.       Wash the meatus with soap and water following bowel movements

d.      Administer prophylactic antibiotics for duration of catheter placement

For bladder emptying dysfunction, the CDC recommends

a.       Catheter irrigation

b.      External catheters

c.       Indwelling catheters

d.      Intermittent catheterization

The CDC recommends ultrasound bladder scanners to

a.       Reduce unnecessary catheter insertions

b.      Reduce unnecessary catheter irrigations

c.       Prevent premature catheter removal

d.      Identify the need for catheter removal