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NO SUCH THING!

September 12, 2014 Leave a comment

As we wait to hear more news as to how the comedienne, Joan Rivers, is doing following her “minor” throat surgery and subsequent respiratory/cardiac arrest, I am reminded of the phrase I used to preach to my staff early on in this ambulatory movement.

I remember working in the hospital recovery room managing 13 recovering outpatients a day mixed in with the inpatients. On this particular day one of the outpatients scrunched into the preop “holding” room was an 18 year old female coming in for a local D & C. I recall hearing the OR staff refer to her as “just a local”. At that time the hairs on the back of my neck stood straight up, as subconsciously I registered that there couldn’t possibly be “no such thing” as “just a local”. Sure enough a few hours later, the doors from the OR corridor burst open and anesthesia propelled a bed on which lay this same young woman being bagged with an ambu bag. During the hand-off communication, the anesthesia resident advised me that she had experienced an apparent allergy to the local—lidocaine. It was touch and go for a while, but ultimately the allergic reaction abated. When interviewing this patient in preparation for her discharge, I queried her regarding any previous such reactions. She confided in me that she had undergone some recent dental work during which she had experienced problems with her mouth swelling, etc. She allowed as how she had not told the physician or the anesthesia provider because she didn’t think it was important—–BUT, neither had they ASKED!!! We clearly could have lost this patient just from the lack of a detailed preoperative history.

The collecting of a thorough preoperative history as part of the preop assessment is a challenge always, whether the patient is an inpatient OR an outpatient. However, it becomes even more crucial in the outpatient setting where the amount of time allocated for the collection of data can be minimal in the face of busy, busy schedules, short staff, and the effort, and time, required to reach patients over the phone vs. visiting them in their hospital room. Nevertheless, such information is crucial in assuring patient safety and a safe outcome.

We do not know what the issue was with Joan Rivers. Was it a drug reaction?…a drug overdose?…some underlying, previously undetected condition? I recall the incident of a few years ago regarding an 8 year old patient in one of the surgery centers. The child came in for pe tubes and an adenoidectomy.The patient had a history of Transposition of the Great Vessels which had been repaired during infancy. He was under the care of a cardiology, was active in school playing flag football, was symptom free of any lingering health problems. A medical clearance was obtained from his cardiologist. The decision was made to do the tubes first followed by the adenoids using an LMA device to protect the airway. Bottom line, once the surgeon inserted the electrosurgery pencil ( he made no incision),the patient bled out in a bit over 1 and ½ minutes. Even the post did not reveal what happened. The point is that we, who work in ambulatory surgery, must NEVER be complacent. We must NEVER assume that the procedure being performed is “just another pe tube, etc.” We must NEVER assume that anything is routine. We must NEVER assume nothing will ever happen. We must, rather be ever vigilant through all established processes. We must never assume that a detailed patient history/assessment isn’t required. I hear so often that certain practices reserved for general anesthesia patients are not implemented for “just a local”. At one time in the ambulatory industry, local patients did not have a comprehensive H&P performed. Rather, a “procedure specific H&P” was considered adequate. CMS put the kebash on that practice with the new regulations of 2009. Too often “just a local” can turn into a major disaster!

What can be done to decrease the possibility of a catastrophe occurring in the surgery center? I would suggest:

  • Perform a comprehensive preoperative assessment on ALL patients. Demand that the patient’s H&P have been performed within the last 30 days and that it adequately documents the patients health status. I recently had an EGD performed at a corporate/physician owned “chain” center. No member of the ASC staff contacted me preoperatively to conduct a preop assessment, and during my preop visit with my physician (whom I adore and respect immensely.), he spent most of the time at the desk across the room with his back to me filling out forms on the EMR. As a knowledgeable HCP I KNOW my health status, but I should have screamed, “Hey, LOOK AT ME! This visit was followed by my annual healthy patient visit. The same thing happened. This physician, who has been my FP for many years, listened to my heart in one spot on my chest, did not auscultate my lungs any further than what he might have heard while listening to my heart, did not palpate my ankles, my glands, my belly, didn’t look in my ears,…but he sure did get that EMR filled out, and the lab requisitions! Is this happening to your patients?

As nurses, it is our responsibility to make sure that our patients are safe. It is our job to read that H&P. It is our job to collect a thorough patient assessment and to alert the physician/anesthesia provider to special conditions, or conditions not heretofore disclosed. Talk to the patient about previous medication issues from anesthesia to pain medications, to locals….all of it.

CMS says that the physician must update the H&P on the day of the procedure. Initiate a policy whereby the patient is not taken back to the OR unless the physician has been at the patient’s bedside as required by CMS.

  • Be alert regarding the drugs patients are being given. The nurse in the operating room is ultimately responsible for patient safety.       Confirm with the anesthesia provider the drug and dosage. Observe the patient. Watch the monitors. We are getting reports that not only is the anesthesia provider playing on the Notepad, but the circulating nurses are also joining in this fun Who is watching the patient?

Nurses complain about anesthesia not being vigilant during procedures. They complain about those games, the stockbroker calls, but what do they do about it?

Complete an incident report and forward it to your manager EVERYTIME you see inattention being given to the patient.

  • Use those alarms! The Joint Commission and CMS continue to beat us over the head for failure to use the alarms in the centers. Use an alarm log. Walk through with your staff and identify every alarm in the center.       Activate it such that all persons working in the center will recognize what the alarm sounding is …and where it is. Check those alarms to make sure they work. In the ORs, and PACU, make sure they are never turned down or off….and they continue to be turned off throughout the country. Perhaps the status of the alarms needs to be added to the Surgery Flow Sheet? Perhaps it is going to take a requirement for such documentation for it to be taken seriously.
  • Check the equipment.

Are you familiar with the equipment, its state of readiness for patient procedures, and its maintenance history? ADA receives numerous incident reports on an ongoing basis regarding malfunctioning equipment during a surgical procedure. Who in your organization is responsible for determining the equipment is in good working order PRIOR to its being used on a patient—-PRIOR to the start of the case? Does your organization demand that an Equipment Assessment be performed on any and all pieces of equipment that either could cause injury to a patient during a procedure, or whose absence due to a breakdown, could cause harm to a patient? If so, how often is this information updated? Who reviews it?

Is it shared with staff members? Too often, we see it done just to meet a standard prior to a survey.

Finally, beware of ROTE! Beware of performing while on auto-pilot. ThisCondition occurs where staff perform the same type of procedure over and over  and over. The advantage is that they become experts in that procedure. The danger is that they can do the procedure “in their sleep”….kinda like driving home, pulling into your driveway and wondering how you got there ‘cause you ave no recollection of the drive home. This goes with being alert, but even more so.

In conclusion, remember nothing more than this: The patient is someone’s child, mother, father, husband, wife, brother, sister, etc. His life is in your hands. You  are his advocate, his Patient Safety Officer.

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Categories: Uncategorized

WHAT? MORE SHOTS?

September 12, 2014 Leave a comment

Measle cases have hit a 20-year high in the United States. CDC believes that the number of reported cases may be more elevated due to unvaccinated international travelers.

Between Jan1, 2014 and May 23 of this year, 288 measles cases were reported to CDC, the highest since 1994.

According to CDC homegrown measles was, essentially, eliminated in 2000,.but cases imported from those unvaccinated travelers and patients traveling abroad continue to infect unvaccinated Americans.

A large outbreak in the Phillipines was connected to 138 cases this year involving the Ohio Amish community, as well as that in Pennsylvania.

Unvaccinated residents of the US provide a “welcome wagon” for measles imported from abroad. Measles is still common in Europe, Asia and Africa. The Phillipines has reported more than 32,000 measles cases and 41 deaths from January to April 20, 2014.

CDC recommends not only children receive the vaccination, but adults who were not previously immunized or are unsure of their immunity status.

The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for vaccinating healthcare personnel in the United States has made recommendations for vaccination of HCP to include HCP in long-term care centers, nursing homes, skilled nursing facilities, physician’s offices, hospitals, rehabilitation centers, urgent care centers, outpatient clinics, home health care and emergency medical services. Ambulatory Surgery Centers fall under outpatient clinics.

According to this report (discussed in this article), many HCP are at risk for exposure to, and possible transmission of, vaccine-preventable diseases because of their contact with patients or infective material from patients. Employers and HCP have a shared responsibility to initiate reasonable precautions to prevent transmission of vaccine-preventable diseases. Vaccinations are an integral part of the organization’s Infection Prevention Program. .Inclusion of this process into the active IPP could substantially reduce the number of susceptible HCP as well as the potential risks of transmitting vaccine-preventable diseases to their patients and other persons with whom they come in contact.

In so far as the Hepatitis-B vaccination is so widely acceptable among HCP, we will not be discussing this vaccination in this article. Rather, we shall be discussing the efficacy of the influenza and rubeola vaccines, specifically..Additional information regarding other childhood diseases will also be included.

Influenza:

According to the Advisory Committee report influenza causes an estimated average of >200,000 hospitalizations and 3,000-4,900 deaths annually in the United States. The majority of influenza-related severe illnesses and deaths occur among persons with chronic medical conditions, infants, young children, seniors and pregnant women. Reducing the risk for influenza among higher risk patients is a focus of influenza prevention strategies.

HCP are especially susceptible to exposure in their workplace, and are, thus, at risk for transmission of influenza to their patients and other HCP. A study conducted among hospital staff reported 37% were experiencing flu-like symptoms during the active “flu” season. The average staff member lost 7 days of work. Of concern, however, are those HCPs who continue to work while experiencing flu symptoms, thus infecting all in their environment. While few expansive studies have been conducted, one study did report that HCP receiving the vaccination had fewer respiratory infections associated with influenza.

Influenza outbreaks of severe respiratory illness among HCPs have been associated with low HCP vaccination rates. Vaccination of HCPs can provide additional protection for those patients who are at risk for influenza, but who cannot receive the vaccination;e.g., infants, the elderly, pregnant women, those with sever allergic reactions, and the immuno-suppressed, among others.

Barriers to HCP acceptance of the influenza vaccination include:

  • Fear of vaccine side-effects (especially influenza-like symptoms0
  • Insufficient time or inconvenience
  • Perceived ineffectiveness of the vaccine,
  • Perceived low likelihood of contracting the flu
  • Avoidance of medication
  • Fear of needles

CMS has mandated that the flu vaccine be offered to all staff to include physicians and allied health staff. In addition, the organization is to calculate its percentage of staff compliance annually and develop strategies for improving compliance. Such strategies might include:

  • Encouraging the staff person’s desire for self-protection,
  • Identifying previous acceptance of the vaccine,
  • Capitalizing on the desire to protect patients and their family
  • Stressing the effectiveness of the vaccine
  • Developing a campaign to include posters and educational material identifying the benefits of vaccination
  • Vaccination of leaders
  • Making the vaccination process easy and stress-free
  • Providing intranasal vaccine for those staff who dislike needles

Those staff who refuse the vaccine should sign the Declination Form themselves stating the reason for the declination. The Employee Health Nurse/Infection Preventionist should calculate total compliance and shall identify annual compliance goals to reach the CMS goal of 90% by 2020.

Effectiveness of the vaccine varies from year to year and is specific to the individual and to the strain in circulation.Vaccine strains are selected for inclusion based on international studies identifying those in circulation.

Measles

Measles is a highly contagious illness that is transmitted by droplets and is airborne spread. Prior to the national immunization program being implemented in 1963 an estimated 3-4 million persons in the US acquired measles annually. Approximately 500 persons a year died, and 1000 had permanent brain damage from encephalitis. Measles remains widespread in countries outside the Western Hemisphere with an estimated 20 million cases reported each year. The United States continues to experience international importation leading to transmission to unvaccinated residents with resultant outbreaks.

Of reported cases, over half of the patients had never been vaccinated.

Vaccine coverage in the US is high with 90.5% of adolescents having received the vaccination.

Medical settings played a prominent role in perpetuating outbreaks of measles. Because of the severity of the disease, infected persons are most likely to seek medical care in primary-care settings. Because of the greater risk of exposure, HCPs are at a higher risk for contracting the illness. Some studies show this risk as high as 19% greater than the general population. Studies show that immunity among those having received the vaccination in infancy remain at 93-95% through the ages of 6-49 years.

The recommendation from the Advisory panel is that all HCP should have demonstrated evidence of immunity to measles. This information should be documented and readily available in the employee’s health file.

New York, Oklahoma, Rhode Island and New Jersey have laws regarding the proof of measles immunity and do not allow for religious or philosophic exemptions.

The measles vaccine is given in conjunction with rubella and mumps thus protecting the patient from all three infections.

Mumps

Adults experiencing either measles or mumps may react severely requiring intensive care in the hospital setting.

There is a concern that the reporting of mumps infections may be under-reported, as in some patients, the symptoms are minimal. The highest rates occur among dentists and Health Care Persons. Mumps outbreaks have occurred in the US as late as 2010 in the northeastern region of the U.S.with 3,400 cases reported. Of these only 7 were healthcare workers. Most likely, the HCPs were infected by the patients.

It is estimated that as high as 13-14% of healthcare workers lack antibodies to the mumps virus This author knows, personally, of two HCPs who contacted the disease at work and ended up in the intensive care unit fighting for their lives.

The Advisory Committee recommends all persons who work in health-care facilities should have presumptive evidence of immunity to mumps.

Rubella

Rubella (German measles) is a viral disease characterized by a rash, low-grade fever and malaise. Prior to the vaccine being licensed in the US, reported rubella diseases were at 57,686 annually. This disease could lead to encephalitis, fetal deaths, miscarriages, stillbirths, various other birth defects to include blindness, deafness, mental retardation and congenital heart defects. From 2005-2009 54 cases were reported. 23 of these were import-related. Rubella importation is expected to continue.

Only three states (as of 2011) have laws mandating proof of rubella vaccination among HCPs with no exceptions. The Advisory Committee recommends vaccination, or proof of immunity among all HCPs.

Whooping Cough

Pertussis is a highly contagious bacterial infection that was once prevalent in the US. Like the other infections discussed above contact is through respiratory secretions. Symptoms in the early stage are indistinguishable from other upper respiratory infections.

Vaccinated adolescents and adults whose immunity wanes (5-10 years from the most recent dose of the vaccine, are an important source of pertussis. Outbreaks across the US occur frequently. Some are misdiagnosed and result in continued transmission in the population. One report included a young mother who unknowingly had pertussis and passed it to her infant who had not, as of yet, been vaccinated, and who subsequently died.

In healthcare settings transmission can occur from patients, visitors or HCPs. Exposure

is difficult to define in the healthcare environment. The exposure is highest in those facilities catering to pediatric patients; however, even in ambulatory settings not catering to pediatric patients, children may abound in the waiting room.

Summary:

Care of the patient exhibiting any of the above infectious processes, must include the masking of the patient. Part of the patient’s preoperative assessment should include the status of his childhood immunizations and the presence of any symptoms that might be indicative of the infections discussed above.

The Employee Health Program should include the status of the employee’s childhood immunizations, and, if the employee has no knowledge of his status, titers should be drawn with results placed in his employee health file. If no antibodies are present, re-immunization or a booster shot should be indicated.

It is time for Ambulatory Surgery Centers managers to fully embrace the hazards that failure to become knowledgeable about their staff’s health status regarding childhood immunizations and to incorporate this information into their basic employee health program.

Categories: Uncategorized
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