AHC Media

Efforts to control handling, sterile technique spares patient overmedication

The way you draw blood cultures for community-acquired pneumonia (CAP) patients can have a dramatic impact on your patient's outcome, according to Paula M. Neira, RN, JD, CEN, nurse educator for the Department of Emergency Medicine at The Johns Hopkins Hospital in Baltimore.

If a blood culture obtained in the ED is contaminated, a repeat culture must be drawn and processed. "This means your patient receives multiple antibiotics as providers attempt to find one that works, with the patient enduring the side effects," says Neira. "Once information is obtained from processing the blood cultures, targeted antibiotics can then be administered." Here are practices for blood culture collection used by ED nurses at The Johns Hopkins Hospital to prevent contamination and reduce delays in antibiotic administration:

Each shift, a specific staff member obtains all ordered blood cultures.

"In our ED, we designate a clinical technician as the 'blood culture tech,' and provide them with a telephone," says Neira. When a blood culture is ordered, the ED nurse calls the tech and informs him or her of the need for a culture collection."It makes obtaining the blood culture a sole-focus priority for someone, rather than being a task that must compete with other priorities," says Neira. "This [having multiple priorities] can lead to cutting corners that increases the potential for contamination."

Performance is audited daily in real time.

Neira stops the process if sterile technique is broken, and she suggests repositioning a patient's arm to minimize the need for re-palpation of the venipuncture site. "Nurses are reminded that blood culture collection is a sterile procedure that must be done meticulously," says Neira.

Blood cultures are not routinely drawn from vascular access devices.

This practice significantly increases the risk of contamination, says Neira. "Excluding the routine use of existing IV sites can lower contamination rates by as much as 70%," she says.

 "Limit use of these accesses to obtaining a blood culture only upon insertion, or if for a pre-existing access such as a central line or peripherally inserted central catheter, catheter sepsis is suspected."

Blood cultures are not routinely collected after antibiotics have been administered in the ED.

"In the event that blood cultures are ordered after antibiotics have been given, authorization should be obtained from department leadership before drawing the specimen," says Neira. "This allows for confirmation that the patient truly needs the culture and that the admission order is documented first in order to comply with the Joint Commission's core measure requirements."

1. Norberg A, Christopher, NC, Ramundo, ML, et al. Contamination rates of blood cultures obtained by dedicated phlebotomy versus intravenous catheter. 

This story was adapted from one originally published by AHC Media LLC (800-688-2421). 

Articles

To avoid retesting and possible antibiotic overuse, follow these four tips when drawing blood for a suspected case of community-acquired pneumonia.

4 tips for drawing blood for community-acquired pneumonia testing

Patients who metabolize codeine into morphine abnormally quickly at special risk

A report from the University of Western Ontario, Canada, being published in the Aug. 22 issue of 

 warns that codeine following a tonsillectomy could be fatal for some children.

Gideon Koren, Ivey chair in molecular toxicology at the Schulich School of Medicine & Dentistry at the university, zeroed in on the danger after investigating the death of a 2-year-old boy following a relatively easy operation to remove his tonsils. Koren is a pediatrics professor at Western and the University of Toronto, Ontario, and director of the Motherisk program at the Hospital for Sick Children in Toronto.

In this case, the toddler had a history of snoring and sleep-study confirmed sleep apnea. He was taken to an outpatient clinic, had the operation, and was taken home.

The mother was given syrup of codeine and instructed how to administer it. On the second night, the child developed a fever and wheezing, and he was found dead the next morning. Tests showed the mother had given the proper dosage, yet the child's body had high levels of morphine. The coroner asked Koren to look at the case.

"The sudden death of a healthy child was quite sobering because tonsillectomies are done every day, all over North America," says Koren. "And more and more of them are done on an outpatient basis, with the child going home the same day."

The child was found to have an ultra-rapid metabolism genotype that causes the body to process codeine at a faster rate, producing significantly higher amounts of morphine.

Last year Koren published research showing how mothers given codeine for pain following childbirth can pass toxic levels of morphine to their babies though breast milk, if they carry this genotype. Just over 1% of Caucasians carry this gene, but the incidence can be as high as 30% in those of African origin.

Koren has another concern about giving codeine to children following a tonsillectomy for sleep apnea. "If the apnea doesn't go away, codeine will also suppress the child's breathing," he says. "This demonstrates the need to keep children in hospital under surveillance for at least 24 hours to see if the apnea persists."

Codeine use for child tonsillectomies is being scrutinized after the surprise death of a Canadian child whose system metabolized codeine into morphine at an abnormally high rate.

Post-tonsillectomy codeine: Fatal for children?

CT scan, lumbar puncture can back up classic headache symptom

An ED physician at Brackenridge Hospital in Austin, TX, was about to give a triptan to a 42-year-old woman with a severe headache and a history of migraines. However, the treatment plan changed dramatically, due to a piece of information shared by an ED nurse.

"While the nurse was talking to the patient, she told her that the pain was significantly different than her migraines and that this was worse," says 

 RN, MSN, CNRN, clinical director of Brackenridge's Neurosciences, Brain & Spine Center in Austin, TX. "The nurse brought that information to the physician, who then ordered a CT scan which showed a subarachnoid hemorrhage."

Subarachnoid hemorrhage is one of the most deadly neurological emergencies, but it is often misdiagnosed, as often as 12% of the time, according to updated guidelines from the American Heart Association.

 Misdiagnosed patients are four times as likely to die or become disabled.

Any patient with an acute, new onset headache needs to be seriously considered as having a diagnosis of a ruptured aneurysm, says 

 MD, one of the authors of the guidelines and an associate professor of neurosurgery and radiology and director of the Cerebrovascular Program at New York City-based Mount Sinai School of Medicine.

Brandt advises looking for the classic symptom: The "worst headache" of the patient's life. "These are usually described as a 'thunderclap' or very sudden onset, sometimes with a loss or change in consciousness," says Brandt. "Other signs and symptoms include cranial nerve defects. Photophobia and nuchal rigidity may occur later."

If the headache is misdiagnosed as a new migraine, says Brandt, "only pain medications are given, because there are no other real symptoms on presentation. The most common demographics are women between the ages of 40 and 60, which are also the most typical type of patient to have headaches from other causes."

Patel notes that although "the worst headache of my life" is a classic sign, somebody who doesn't have a history of headaches with a headache severe enough to bring them to the ED "should be concerning enough" for you to consider subarachnoid hemorrhage.

Patients who come in with sudden, severe headaches should get an immediate CT scan to look for evidence of hemorrhage, says Brandt.

"The CT scan is approximately 95% effective in detecting the presence of blood if done early," she says. "There is a high percentage of patients who are at risk of re-bleeding during the first 24 to 48 hours after the initial hemorrhage. If the aneurysm or cause of bleeding is not identified and secured, then the mortality from this significantly increases."

Patel says if you still are concerned after a negative head CT scan, a lumbar puncture can be done. "That should pick up the last of the subarachnoid hemorrhages," he says. "After the diagnosis has been made, the goal of the ED is preventing re-rupture until the aneurysm can be secured, before the patient is transferred to the neurosurgical intensive care unit or another center."

Keeping the blood pressure under control is very important, says Patel. Hypertension is a predisposing factor to having a second hemorrhage, and the mortality from a second hemorrhage is 70% or higher, he says. "The second therapeutic measure that needs to be instituted is the loading of dilantin or another antiepileptic agent to prevent a seizure, which has also been associated with a higher risk of re-rupture," says Patel.

1. Bederson JB, Connolly S, Batjer H, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. 

As many as 12% of subarachnoid hemorrhages are misdiagnosed at the ED, leading clinicians to look past the classic symptoms to CT scans and lumbar punctures for proof.

Subarachnoid hemorrhage often misdiagnosed in ED

One flu truth: Both patients and workers must be protected

This could be a long contentious flu season between hospitals and frontline health care workers, particularly if serious H1N1 infections strike clinicians before a vaccine is available.

Some 100 registered nurses recently rallied in San Francisco as part of an organized protest by the California Nurses Association. The recent death of a 51-year-old nurse in California of H1N1 influenza A was followed by nurses taking to the streets and demanding transparency and accountability for preventing H1N1 the infection. The protest followed what is thought to be the first death of a nurse due to H1N1. The nursing group reported that the woman was a marathon runner in excellent health, but published reports also linked the death to a co-infection with methicillin-resistant Staphylococcus aureus (MRSA).

Though the source of infection is unknown, both MRSA and H1N1 could have easily been acquired in her hospital, Mercy San Juan Medical Center in Carmichael, CA. Indeed, given press reports that she spent long hours there daily, it's an odds-on bet that Karen Ann Hays died July 17 of a severe respiratory infection that had its origins at her worksite. MRSA strain type testing may tell the tale on the bacterial side of things, but the H1N1 source will probably never be known. The death of a frontline nurse even as H1N1 gathers to resurge sets an ominous tone for the coming pandemic season. In particular, co-infection with MRSA could occur in virtually any hospital in the country, ratcheting up the threat level to workers as the two epidemics intersect.

Younger nurses in particular may be at peril from H1N1, with older people apparently having some residual immunity that we can only hope holds through the cold months. On the respiratory protection issue, it's the ghosts of SARS again. An Institute of Medicine committee is expected to weigh in next month on the N95 vs. surgical mask debate, with a CDC advisory committee recommending the latter. The decision hinged on patient care issues, with the consensus being that-as a practical matter-it will be a logistical nightmare to try to get everyone to wear a N95 respirator while caring for what could be millions of unvaccinated H1N1 patients.

Nevertheless, the situation is subject to rapid change and raises some tricky issues. If health care workers demand protection from patients for example, how can they protest the mandatory vaccine initiatives in states like New York? Will they step up to be vaccinated for both seasonal and pandemic flu, ending decades of apathy and low compliance with seasonal flu-which kills some 36,000 people a year. Some unknown but undisputable number of those died after being treated by an unvaccinated flu-infected health care worker. Everybody knows it, but it's virtually impossible to quantify. Maybe the first pandemic in some 40 years will raise helpful issues on all sides, sweeping away this historical miasma to yield one flu truth: both patients and workers must be protected. They must actively try to protect others, including symptomatic patients wearing surgical masks when they seek care. There are plenty of lives to be saved on both sides of this debate.

The death of a Calif. nurse from H1N1 flu sparked both protests by fellow nurses as well as concern over the issue of healthcare worker safety during a flu pandemic.

Nurse's H1N1 death sets ominous pandemic tone

Community case management helps minimize ED visits

 RN, BSN, sees, something as simple as calling their physician for an appointment presents challenges they can't overcome.

"The telephone systems in most physician offices require them to push this button and that button to find the person they want to talk to, and they simply cannot do it. They often ask me if I can call their doctor for them. It's hard for people to navigate our complex health care system," she says.

As a community nurse case manager for Valley Health in Winchester, VA, Neff coordinates care for medically frail, indigent patients with complex medical and psychosocial needs.

The community case management program aims to prevent hospitalizations and emergency department visits and help patients live safely at home.

"Above and beyond that, our program moves into a realm that is so fundamental to nursing - caring for people who need a lot of help. Once you get outside the walls of the hospital, it's an eye-opener to see how people live and what little they have to get by on. These patients don't know how to access care. Many can't see very well, so they get confused about their medication. We help stabilize them so they can stay at home where they prefer to be," she says.

The community case management program is part of Valley Health's home health division and coordinates care for patients from three hospitals, Winchester Medical Center, Warren Memorial Hospital in Front Royal, and Shenandoah Memorial Hospital in Woodstock.

The program is free for patients who meet the criteria.

Patients eligible for community case management are medically frail with unmet nursing or psychosocial needs but don't meet the criteria for hospice or home health. They must be 18 or older, live within 25 miles of the hospital, and have a primary care provider. They must have been hospitalized two or more times or made three or more emergency department visits in a six-month period.

"Many of our patients live alone with a limited or nonexistent social support system. They have no family or limited family or the family lives a long way away or chose not to be involved in their care. I'm the only person some of the patients talk to during the week," she says.

Referrals come from the nurse case managers at the referring hospitals, from home health nurses, physicians, social service agencies, and free medical clinics in the community.

"We have a very strong case management program at Winchester Medical Center. The in-house case managers are very familiar with the assistance we offer and consider us as well as home health for patients who need help after discharge," she says.