By: Sherri Jankowski, RN
Hospitals have been under the gun to reduce hospital acquired infections and patient injuries for several years now by government agencies such as CMS. Fines and sanctions have been used as incentives to reduce these occurrences in order to bring down the additional expenses that happen when more care and longer hospital stays or readmissions are necessary. In a recent Kaiser Health News update by Jordan Rau on 12/2/15, the report stated both good and bad statistics since 2013, with many that have stalled at unacceptable levels. While some negative outcomes may be less avoidable, many of these statistics can continue to improve with more vigilant and better nursing care.
For example, between 2013 and 2014, the number of post-surgical pulmonary embolisms decreased by 30%. This is a remarkable amount of people, considering Kaiser reported that “12 out of every 100 hospital stays resulted in 4 million infections and other potentially avoidable injuries”. Monitoring blood work closely for any indication of increased clotting factors and giving blood thinners as ordered obviously can pay off and prevent people from suffering or worse. Assessing respirations and lung sounds after surgery are standard nursing care and can also play a part in catching these complications early enough to prevent permanent damage or worse. It is obvious this standard of care is increasingly being met.
The other area most notable for decrease in infections involved Foley catheters. Infections from Foley catheters dropped 38%. Nurses are doing a better job of removing catheters as soon as they are no longer needed and Foley cath care has become a primary focus for nurses and nursing assistants. Making sure tubing is draining properly and remaining non-contaminated are critical parts of Foley cath care. These efforts are working and helping to drastically reduce the amount of infections known to be caused by Foley catheters, decreasing overall costs.
More needs to be done though.
While it was noted that there were 17% less complications than in 2010, by 2013 it appears that these complications have leveled off and some increased. Some of the most common continue to be bed sores, falls, and negative reactions to drug treatment for diabetes, and kidney damage to people after receiving contrast dyes for various tests. One of the most glaring increase was in MRSA (methicillin resistant staphylococcus aureus bacteria), which is noted to be up 55% in 2014. And according to the AHA report, they estimate a 25% increase in femoral artery puncture to 74,000 people undergoing the very common procedure of angiography.
Nurses can play a large part in reducing many of these problems, with the exception of the increase in femoral artery puncture probably being out of their control. Nurses do assess for post-procedural bleeding and notify physicians immediately, while taking steps to stop the bleeding. However, there isn’t much they can do during the procedure itself.
But what about bedsores and falls?
These problems have been with us since at least the 1800’s and many nurses feel they have exhausted all efforts when writing care plans to manage these issues. With bedsores, the obvious intervention is changing positions at least every two hours. Some patients are more compromised than others and are at a much higher risk for breakdown, so other disciplines come into play, such as dieticians to deal with increasing protein stores. But as a nurse, or nursing assistant, maybe we need to look at how often we change positions and what positons we are using. Being creative with fabrics that are on or under those bony prominences and use of pillows can be helpful. Sometimes those clinically aseptic bed linens can be pretty stiff and rough on tender skin. Switching from beds to chairs more frequently can also be helpful. What about care planning some different types of linens or furniture for the room?
And then there are the falls. Unfortunately, patients/residents have the right to fall. So many risks are involved with each individual that can contribute to this possibility. But we can take many steps to prevent injuries from when those falls do occur. Just when you think you have written the last possible intervention for that falls care plan for one of your frequent fallers, they go and fall again. Nurses make great detectives, when given the time. And that is what it takes. Time to figure out why that person is falling, especially frequently. Have you thought of trying a nanny-cam? Exactly what is this person trying to do and how are they going about it? This could be helpful to therapy for instructions and practice on movements, as well as to nursing for knowing what is so important that they are getting up on their own without any assistance? Sometimes we have to think out of the box. Crash mats and alarm pads aren’t enough for everyone. Motion sensors have become much less expensive and might be more helpful than alarm pads that unfortunately let nurses know someone has already fallen, rather than preventing an injury causing fall.
Checking for potential medication interactions and bad reactions aren’t just for the doctor or pharmacy to do. Nurses need to remind the pharmacy to do a medication review when a new medication is ordered. Pharmacists are the scientists behind the medications nurses are ordered to give. When a new order comes through, a med review is often something that should be done. Diabetics usually have several meds, and when they are ordered something new to treat their diabetes, it is best practice to make sure that there is nothing in that new medication that may interact adversely with whatever else they are taking. Don’t be afraid to mention this to the physician and the pharmacy. This can prevent an adverse reaction instead of the intended outcome. And then monitor the patient closely after they receive their new medication for up to two weeks for efficacy as well as any adverse reactions.
The same goes for radiology or nuclear studies that utilize a contrast agent. When was the last time your patient had their kidney function tested? Just checking on a shellfish allergy may not be the only thing to determine. Prior to using a contrast agent, especially if your patient has never had any and is unaware of any potential kidney problems, their kidney function should be tested. Just a routine panel for most people would most likely be enough. Sometimes there are things that we just can’t foresee. But reminding the physician that this might be a good idea to prevent any potential adverse effects is something any nurse can and should do.
And addressing MRSA that is on an alarming 55% increase over 2014 may be the last item, but by far not the least. Since the 1980’s, MRSA has gone from a highly isolated disease in hospitals to a wide-spread community acquired infection. Handwashing remains the single most preventative method of stopping the spread of this disease. Aseptic cleaning of surfaces and items that may have come into contact with someone who has MRSA is also important. This doesn’t just apply to the health care profession any longer. Children, and people of all ages, need to be taught to properly wash their hands, nails, and wrist areas, with appropriate soap, friction, and warm water, for 20 seconds. Aseptic cleaning in home bathrooms and kitchens and community areas such as gyms and locker rooms need to be done on routine schedules.
MRSA is not the only superbug out there. I have no doubt that future studies may show similar increases of VRE, C-Diff, and the latest, CRE, as well as other problems that continue to adversely affect our patients.
What can we do as nurses?
As nurses we can do something about this. Just as we can about most of the issues in this article. Learn to think out of the box. Write care plans that are effective and timely to solve your patient’s issues. Involve the physicians and other disciplines. We are the front line of defense against so many of these issues. Hopefully, when they compare 2016 stats to the preceding years, we will see a decrease in the issues noted this time around.