Human bocavirus (HBoV) is a pathogen classified within the genus Bocavirus of the Parvoviridae family, first discovered in respiratory tract specimen from Swedish children. It was then found among patients with respiratory illness in other parts of the world (Albuquerque, et. al., 1).
A study was made to see whether HBoV causes gastrointestinal disease as other Parvoviridae does among animals.
From January 2003 through December 2005, stool specimens were collected from 705 Brazilian children suffering from acute diarrhea. Children were less than 15 years of age, 314 (44.5%) of which were less than 2 years old, 190 (27%) were 2–5 years old, 120 (17%) were 6-10 years old, 61 (8.6%) were 11–15 years old, and 21 were unknown. Specimens were collected from 3 cities in Brazil with different sanitation conditions and socioeconomic background (Albuquerque, et. al., 2).
To confirm the presence of HBoV, DNA was screened by PCR. DNA sequences of the positive samples were arranged and analyzed.
Fourteen (2%) of 705 samples were tested positive for HBoV. Of the 14 HBoV affected patients, 11 were less than 2 years old, one was 3 years old, one was 11, and the other was 15 years old. More boys were affected than girls (Albuquerque, et. al., 3).
The specimens were earlier tested for other enteric viruses and bacteria such as rotavirus, norovirus, astrovirus, adenovirus, Escherichia coli, Salmonella spp., Yersinia enterocolitica, Campylobacter spp., and Shigella spp.. Results show that 84 samples out of the 705 (11.9%) contained rotavitus, 34 samples (4.8%) contained adenovirus, 24 samples (3.4%) are affected with norovirus, and 2 samples (0.3%) had astrovirus. Enteropathogenic bacteria were also found in 57 samples. On the other hand, potential pathogens, including HBoV, were found in 30.5% of the samples (Albuquerque, et. al., 3).
Of the 705 specimens, only 3 (21.4%) are infected with both HBoV and enteric viruses. All 14 HBoV-positive patients had diarrhea, but surprisingly, none exhibited any respiratory illness. A previous study by Vicente et. al. among children suffering from gastroenteritis showed 58.3% coinfection of HBoV and other intestinal pathogens (Albuquerque, et. al., 3).
Complications were exhibited by 4 of the HBoV-positive patients, two suffered from fever, one experienced vomiting, and one had bloody diarrhea. One patient was undergoing dialysis, while the oldest male participant was found to be HIV positive (Albuquerque, et. al., 3).
Studies are still being conducted to determine the full sequence of this DNA. And although findings hint that the virus reproduce in the human gut, there is no enough evidence on the relationship between the HBoV infection and gastroenteritis (Albuquerque, et. al., 4).
Works Cited
Albuquerque, M.C.M. et al. “Human bocavirus infection in children with Gastroenteritis, Brazil.” Centers for Disease Control and Prevention. 2007. Web.
The use of Foley catheter in ICU patients is an important predisposing factor to catheter related urinary tract infection. It is one of the leading causes of nosocomial infections. The aim of this thesis to review the literature regarding the practice problem of catheter related urinary tract infection and suggest how to develop evidence based practice plan to change the current strategy. The basic elements are to have a clear insight of indications of insertion. Reducing the period of catheter insertion and the use of close system for urine collection are essential simple steps towards better results. A multidisciplinary team should be in charge of planning evidence-based practice change of strategy, performing preintervention study, getting an internal board approval and performing a pilot postintervention study to judge the potential success of the plan.
Introduction and background
Nosocomial infections (acquired during hospital stay) represent a major threat to patient safety. Infections induced by devices such as ventilator associated pneumonia, and catheter induced urinary tract infections are serious for patients in special settings like the ICU (Rosenthal and others, 2006). Before discussing the practice problem of Foley catheter related urinary infections, appreciation should be given to the volume of the problem and recognize its definition.
Saint and colleagues, 2002, stated that catheter related hospital acquired infections are the most common iatrogenic infection seen in ICUs in the US. They assumed that it accounts for 31% of nosocomial infections, the daily incidence of bacteruria because of urinary catheterization is between 3 – 10% and 3% of these patients show bacteremia. They showed that each symptomatic case of hospital-acquired catheter related urinary tract infection (UTI) costs extra $676, and each case of hospital-acquired catheter related UTI costs an extra $2,836 (Saint and others, 2002). In a recent report, Tenke and colleagues, 2008, showed that nearly 40% of nosocomial infections are urinary tract infections and that 80% of cases result from premature urinary catheterization.
Most references agree that a value of 102 colony-forming units per ml (CFU/ml), in patient’s urine collected directly from the catheter (unvoided) is an important measure for bacteriuria (or urinary tract infection, as many authors use both terms interchangeably). In catheterized patients, rapid progression to double the number occurs in the first 72 hours. The criteria 102 CFU/ml urine may not apply for all patients as physical medicine and rehabilitation specialists claim that this figure holds true for disabled patients undergoing intermittent catheterization. Nevertheless, for male patients using external condom catheters, a criterion of 104 CFU/ml is accepted (Saint and Lipsky, 1999 and Maki and Tambyah, 2002).
A recent report by the National Healthcare Safety Network (NHSN), 2007, defined catheter associated urinary tract infection (CAUTI); as a urinary tract infection that occurs in a patient with an indwelling (Foley) catheter within 7 days from placing the catheter or within two days from discharge from the healthcare location. NHSN classified the event of CAUTI into symptomatic urinary tract infection (SUTI) and asymptomatic bacteriuria (ASB), thus identified the two interchangeable terms each to a specific condition. The CDC criteria for diagnosis of SUTI in adults are; first, the patient may have a fever (more than 38 degrees) with other urinary symptoms as urgency, frequency and tenderness in the suparpubic region with no other cause for the patient’s complaints. Alternatively, if urine culture show 105 organisms per ml of urine with no more than two organisms isolated. Either of these two criteria or one of them is diagnostic. Alternative criteria were given to suite different clinical situation and healthcare facilities (NHSN report, 2007).
The aim of this work is to; briefly, review the practice problem of urinary tract infection related to the use of Foley catheters in the ICU patients. In addition, to review the way to minimize the risk of this problem and suggest how to develop evidence based practice change of the current strategy.
Definition of Evidence Based Practice
Sackett and colleagues, 1996, defined Evidence Based Practice (EBP) as integrating individual clinical expertise with the best available external clinical evidence from systematic research. Therefore, knowing the standards of a particular EBP should provide the framework used to evaluate research literature for implementation of EBP into a practice setting. EBP that have attained generalization and proven effective in different clinical settings are likely those that can achieve high levels of effectiveness. Thus, for implementation of EBP we need to integrate research with guidelines and outcomes of met-analytic or multi-center studies (DeBourgh, 2001).
Methods
A review of multiple types of literature when researching this practice problem. The researcher sought for articles using the following databases:
National Center for Biotechnology-National Library of Medicine-National Institutes of Health.
Yahoo and Google databases. The researcher considered.org,.edu, and.gov terms with only one exception.
Keywords were urinary catheterization, urinary tract infection related to urinary catheterization and urinary catheterization in the ICU.
Findings
Problem analysis
Particulars of Foley catheter
A Foley catheter is a sterile thin rubber tube, and is used to drain the urinary bladder. Its main character is the presence of a balloon at the rounded end, at the other end, it has two portals, one is for urine, which into a urine bag. Alternatively, an attendant can perform bladder wash through this end; the other portal is for inflation (by injecting sterile water) or deflation of the balloon to take the catheter out. Because of the balloon, it called an indwelling (a within) catheter and can stay in place for many days (Desai and others 2001). Desai and colleagues, 2001 investigated UTI in ICU patients and studied urine samples collected from catheterized ICU patients versus 100 samples from non-catheterized patients of the same ICU. Their results showed the most common bacteria isolated were, E. coli, Proteus and Staphylococcus aureus. The most common source of E. coli was Foley’s catheters (48.21%), although the same strain colonizing the catheters was isolated in only 8.92% of UTI catheterized patients. They suggested that the high rate of colonization is because of long duration of catheter stay, the underlying condition of the patient or empirical usage of antibiotic. They inferred that high rate of colonization of Foley’s catheters plays a significant role in augmenting the risk of E. coli UTI infection in catheterized ICU patients (Desai and others, 2001).
Particulars of the ICU
Ylipalosaari, 2007, pointed out that ICU patients, despite the care and attention they get, are more vulnerable to nosocomial infections. Ylipalossaari, 2007, summarized the risk factors in ICU patients into three categories; first, factors related to patients characteristics (how acute the disease process is? Does the patient suffer neurological lesions and multiple traumas? Is the patient on immunosuppressive drugs or immune-compromised? …etc). Second, is the period of stay in the ICU, although it is difficult to determine whether the longer the patients stays, the more the possibility of infection. Alternatively, the patient stays for a greater number of days because of acquiring a nosocomial infection. Third, the risk may be exogenous as insertion of urinary catheters. In this study, Ylipalosaari, found that 95% of UTI occurring in the ICU are catheter associated, it is also higher in those who previously received antibiotics and is commoner in females (Ylipalosaari, 2007).
Organization practice
The practice of catheterizing critically ill patients has developed over the past 20 years. Alavaren and others, 1993, mentioned only few lines, the target was to use a sterilizing solution before catheter insertion (Povidone iodine), wearing gloves and using pre-sterilized instruments. With increasing awareness of the volume of the problem, the procedure became like performing a minor surgery. Thomsen and Setnik, 2006, stated that since most equipments needed for catheterization come in a pre-packaged tray, attention should be directed to elements not included in the tray. Examples of such elements are lidocaine gel, adhesive tapes, or other instruments to secure the catheter and the antiseptic solution. The process of catheterization includes injection of lidocaine (needless syringe) into the urethra (in non-circumcised males), using sterile gloves, and towels to wrap the lower patient area. The used in holding the skin of the genital area for sterilization is considered non-sterile. Despite these precautions, the incidence of catheter associated UTI is still high.
Early diagnosis and management is essential to prevent further deterioration of the patient’s health. In this context, the question is when to start treatment, as 90% of cases of bacteriuria during catheterization are asymptomatic; moreover, antibiotics are of limited value especially if the catheter is to stay for long time (Jacobson and others, 2008). Most physicians agree that careful observation for fever, problems related to the catheter (subjective or during daily examination), associated immunosuppressive or corticosteroid treatment represent a good indication for a complete urinalysis and start of antibiotic treatment (Jacobson and others, 2008).
Change of pattern of organization practice
Laupland and others, 2005, studied 4465 patients admitted to one ICU for more than 48 hours over three years to explore the incidence, microbiology, and risk factors for acquired urinary tract infection. Their results showed that 6.5 % of patients acquired ICU urinary tract infection. Females showed a higher relative risk and patients in medical care units showed the highest incidence (9%) followed by non-cardiac surgery ICU patients and the least were patients of cardiac surgery ICUs. A significant observation of this study was the significantly lower rate of UTI in ICU patients over the last two years of the work (2001-2002). The authors assumed the change was because of increased awareness of the problem and increased and or better use of antibiotics in the management. Better lab diagnosis or perhaps physicians did not ask for the same number of urinalysis, which reduced the diagnosis rate were other possible reasons.
Canes, agreed with Thomson and Setnik, 2006, that lesser rates of ICU acquired URTI are coming up because of increased commitment to aseptic techniques and increase maintenance of closed drainage systems.
Who is interested (Stakeholders) in catheter induced UTI
In 2006, Rosenthal and nine colleagues from eight countries (Brazil, Argentina, Morocco, Turkey, Peru, India, Mexico, and Colombia) conducted a study on device induced ICU acquired infection on 55 ICUs of 46 hospitals in the eight countries. They conducted the study for the International Nosocomial Infection Control Consortium. This study on such a scale reflects the international interest in this healthcare practice problem. The NHSN report in 2007 on the same problem reflects the interests of the US Department of Health and Human services. Regional offices of the World Health Organization are investigating the problem of device induced ICU acquired infections (the Regional Office of South East Asia, 2002 and the Regional Office of the East Mediterrenian report in 2005) which indicate global interest. These studies were motivated by the high rate of hospital-acquired infection in ICU patients in the developing countries (approximately three times higher than any other hospital setting) (Sallam and others, 2005).
On the level of a healthcare establishment, a multidisciplinary team should be interested. Infection control department, critical care staff, nephrologists, urologists, infective diseases physician, administration (ICU and hospital level) should all be involved directly or indirectly. ICU and hospital staff is encouraged to participate and engage in discussions (Reilly and others 2006).
Review of literature
Decision making for Foley Catheterization
Urinary catheters are either external (condom catheters) or internal, which in turn may be either urethral (Nelton and Foley catheters) or supra pubic. Indications of urinary catheterization can be diagnostic to obtain a sample of unvoided urine, in cases of cystography or cystourethrography or to distend the bladder prior to transvaginal or low abdominal ultrasonography. Alternatively, indication can be therapeutic as in patients with acute or chronic urinary obstruction, following urinary tract operations of nearby operation (hysterectomy). The only absolute contraindication to urinary catheterization is suspected or actual injury to the urethra (Thomson and Setnik, 2007).
Urinary catheters for therapeutic uses can be for short term (0-7 days) as in cases of instillation of chemotherapeutic drugs or acute urinary retention. They can be used for long term (up to 28 days), as in cases untreated bladder neck obstruction (as in cancer prostate), some cases of neurogenic bladder or neurogenic urinary incontinence especially when associated with skin complications. Alternatively, urinary catheters can be used on intermittent basis to reduce the incidence of catheter complications (Ramakrishnan and Mold, 2005).
Pathogenesis of catheter-induced UTI
Bacteria causing UTI have specific approaches to produce infection these include colonization of catheter, damaging urinary tract mucosal cells and multiplication. Introducing a device as Foley catheter may launch infection by introducing bacteria into the urinary tract. This may occur at the time of catheter insertion either through the lumen or along the interface between the catheter and urethral mucosa (in 66% of cases). Bacteria use the interface between the catheter and urethral mucosa as a scaffold to enter the bladder or, being forced by the introduction of the catheter, to enter directly to the bladder (34% of cases). Moreover, indwelling catheters favor bacterial colonization and may result in injury to the urethral epithelium during introduction or because of prolonged contact in long-term urinary catheterization. Long-term catheterization favors infection by disturbing the bladder mechanism of emptying with residual urine that favors growth of microorganisms. Causative bacteria (uropthogens) are fecal contaminants (E.coli), skin microorganisms or transitory bacteria that reside in pre-urethra. The most common causative bacteria are E. coli, Proteus mirabilis, Pseudomonas auregenosa and Staphylococcus aureus (Jacobson and others, 2008).
How to minimize the risk
There are five main strategies to minimize the risk of Foley catheter related urinary tract infection. First, to clarify decision making and reduce the time for catheter use, second, the use of closed system Foley catheter, third, the use of alternatives (condom catheters and supra-pubic catheters) whenever possible. Fourth, safeguard against bacterial colonization of the urethra and the urinary tract, lastly, to consider the use of alternative catheters (with new surfaces or catheters containing antibacterial agents) (Jacobson and others, 2008). Gokula and others, 2007, studied inapt use of indwelling catheterization in an emergency department. They also studied the effect of having a checklist with each catheter kit to complete by the staff. Result showed that proper use rate rose significantly from 37% to 51% and physician request to insert a catheter rose significantly as well, from 43% to 63%.
This resulted in marked decrease in the total number of catheter insertion (from 2188 in 2003 to 512 in 2005). They inferred that clarification of indication should make the decision making process appropriate and clearer. Jacobson and colleagues, 2008, reviewed studies that assumed 21-38 % of urinary catheterizations were initially not justifiable. Moreover, in one survey, they reviewed a 28 % incidence of catheters stayed longer than needed because they were “forgotten. Other studies reviewed by Jacobson and others, 2008, showed that 10 – 50 % of patients with short term catheters develop catheter related UTI and almost 100 % of patients with long term catheters develop catheter related UTI. Therefore, they suggested changing the catheter every 8-10 days to minimize the risk of infection.
In 2006, Reilly and colleagues stated that criteria-based Foley catheter guideline, clear indications and a daily checklist may result in reduction of catheter related UTI.
A closed system Foley catheter is one where the collection tube of the catheter fuses to the collection bag. It is reported to reduce the rate of Foley catheter related UTI from 100% after two weeks to 25%. Further reduction is aided by choosing the right size of the catheter and proper catheter care (Jacobson and others, 2008). Although the use of alternative catheters may reduce the risk of UTI, yet it is not without problem. Condom catheters are suitable for males with bladder neck obstruction and it needs special care to avoid skin excoriation, which in itself a predisposing factor to UTI. There are no controlled studies to elucidate the benefit of supra pubic catheters in reducing the rate of UTI (Jacobson and others, 2008). Proper catheter insertion under aseptic condition reduces the risk of UTI as it reduces trauma and possibly bacterial colonization. Irrigation of the bladder and the catheter with non-absorbed antibiotics (as neomycin) may help in reducing UTI risk (Reilly, and others 2006 Jacobson and others, 2008).
New types of long-term catheters are either new surface catheters (silver-coated) or antimicrobial urinary catheters (Saint and others, 2002). Johnson and others, 2006 performed an evidence based review study on the use of antimicrobial urinary catheters. They reviewed articles over a period of 40 years (1966-2005) in electronic databases. Only 12 studies qualified for systematic review, with all studies suggested protection bacteriuria. They concluded that based on fair quality evidence, antimicrobial urinary catheters can prevent bacteriuria in hospitalized patients with short term catheters inserted, however, success rate may vary according mainly to antibiotic coating. Karchmer and other, 2000, examined the effect of silver-coated silicone catheters in reducing UTI in hospitalized patients. They claimed that UTI rate reduced by 21% in the group of the study wards randomized to silver-coated catheters while the rate reduced by 32% in the group of patients to whom silver-coated catheters were used on the wards. They also claimed that the use of these catheters result in hospital savings in the range $14456 to $573293. Srinivasan and colleagues, 2006, conducted a study on 3,036 patients with catheters to compare the effects of silicon-based, silver-coated and hydrogel coated catheters in reducing the rate of catheter related UTI. They inferred that was no significant difference among the types used in preventing UTI. However, there was a possible statistics bias because of the difference among groups of patients.
Implementation of findings
In the stage of planning, a multidisciplinary team is necessary for successful control of Foley catheter related URI, as in any other evidence based practice change of policy. The team as suggested by Reilly and others, 2006 is to be formed mainly of an infection control nurse and an ICU nurse (selected by the chief nursing officer). The team is to include ICU manager, and infection control manager and the organization’s Six Sigma department for consultation. Nephrologists, urologists, critical care physicians, infectious disease physicians, the ICU head nurse are all consulted to develop the criteria for a guideline of use of Foley catheter. The more the team members, the less resistance hospital staff shows in the implementing phase (Reilly and others, 2006).
Other hospital staff is encouraged to get involved through discussions during ICU meeting, luncheons or prearranged possibly poster announced staff invitation. Based on the previous review, the plane should include an indication sheet for ordering a Foley catheter for a patient preferably attached to the catheter kit (Gokula and others, 2007). Decision making checklists as to the criteria indicating appropriate Foley catheter use (Reilly and others, 2006) and the criteria of NSHN, 2007 for symptomatic catheter induced UTI and asymptomatic bacteriuria. Guidelines for proper Foley catheter insertion should be clear and a part of the strategy change (Reilly and others, 2006). A data collection checklist (tool) for cases of Foley catheters can help reducing the period of catheter stay (Reilly and others, 2006 and Jacobson and others, 2008).
Product evaluation, education and discussing practical issues are all integral to implementing evidence based practice change. Therefore, a prepared binder is useful to educate ICU nurses and to use in meetings with other staff members. A preintervention study as regards present status of patient outcome should be helpful to manifest the necessity to change and, at a later stage, to compare the results with those of a pilot postintervention study (Reilly et al, 2006).
Having done that, the plan is subjected to approval by an internal board before implementation. Following approval, the team performs a planned pilot study to measure the potential success of the plan. Criteria for measuring success should comply with Six Sigma approach, which is a measure of quality that aims for near perfect standards. The basic goal for Six Sigma is to execute of a measurement-based strategy that looks primarily at process improvement and reducing variability. This can be achieved through one of the Six Sigma sub-strategies, DMAIC (Define, Measure, Analyze, Improve and Control) or DMADV (the same but Design and Verify instead of Improve and Control). The main criticisms for Six Sigma methodology are lack of originality, it points to the negative effects and it is based on random standards. These criticisms the possible critique for the data analyzed (Goh, 2002). Patients outcomes are measured (Foley catheter days, incidence of catheter related UTI, patient stay in the ICU and any significant morbidity associated with UTI) and compared with the preintervention study.
Conclusion
Urinary tract catheter related infection is prevalent among ICU patients. This practice problem affects the morbidity of patients and costly. A group of evidence-based guidelines for Foley catheterization is presented in this study. The core of these guidelines is to minimize the period of Foley catheter insertion and to standardize the criteria for insertion and those of diagnosis of catheter related UTI.
References
Rosenthal, V D., Maki, D G., Salomao, R. et al (2006). Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries. Ann Intern Med, 145, 582-591.
Saint S., Savel, R H. and Matthay, M A. (2002). Enhancing the Safety of Critically Ill Patients by reducing Urinary and Central Venous Catheter-related Infections. Am J Respir Crit Care Med, 165, 1475-1479.
Tenke, P, Kovas, B, Truls E. et al (2008). European and Asian guidelines on management and prevention of catheter-associate urinary tract infections. International Journal of Antimicrobial Agents, 31S, S68-S79.
Saint, S and Lipsky, BA (1999). Preventing Catheter-Related Bacteriuria: Should We? Can We? How? Arch Intern Med., 159, 800-808.
Maki D G. and Tambyah P A. (2001). Engineering Out the Risk of Infection with Urinary Catheters. Emerging Infectious Diseases, 7 (2), 1-6
The National Healthcare Safety Network (NHSN) Manual -National Center for Infectious Diseases. (2007). Patient Safety Component Protocol. Atlanta-Georgia: Department of Health and Human Services – Division of Healthcare Quality Promotion.
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M. et al. (1996). Evidence based medicine: what it is and what it isn’t. British Medical Journal, 312 (7023), 71-72
DeBourgh, G. A. (2001). Champions for evidence-based practice: a critical role for advanced practice nurses. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 12(4), 482-490
Desai, P J, Pandit, T, Mathur, M and Gogate A. (2001). Prevalence, identification and distribution of various species of enterocoli isolated from clinical specimens with special reference to urinary tract infection in catheterized patients. Indian Journal of Microbiology, 19 (3), 132-137
Yilpalosaari P. (2007).Infection in intensive care; epidemiology and outcome. Unpublished doctoral dissertation, Faculty of Medicine of the University of Oulu – Finland.
Alavaren, H F., Lim, J A., Velmont, M A. and Mendoza, M T. (1993). Urinary Tract Infection in Patients with Indwelling Catheter. Phil J. Microbiol Infect Dis, 22 (2), 65-74
Thomson T W. and Setnik, G S. (2006). Male Urethral Catheterization. N Engl J Med. 354, Web.
Jacobson, S.M., Stickler, D.J., Mobley, H.L.T. and Shirtliff, M.E. (2008). Complicated Catheter-Associated Urinary Tract Infections Due to Escherichia coli and Proteus mirabilis. Clinical Microbiology Reviews, 21 (1), 26-59
Laupland, K B, Bagshow, S M, Gregson, D B, et al. (2005). Intensive Care Unit-Acquired Urinary Tract Infections in a regional Critical Care System. Crit Care, 9 (2), R60-R65
Canes, D and Thomson, T W. and Setnik, G S. Male Urethral Catheterization: Correspondence. N Engl J Med. 355, 1178-1179
Sallam, S.A., Arafa, M.A., Razek, A.A. et al. (2005). Device-related nosocomial infection in intensive care units of Alexandria University Students Hospital. La Revue de Sante de la Mediterranee orientale, 11, 52-61.
Ramakrishnan, K. and Mold, J.W. (2005). Urinary Catheters: A review. The Internet Journal of Family Practice, 3(2), Web.
Gokula, R M, Smith, M A and Hickner J. (2007). Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. Am J Infect Control, 35, 589-593.
Reilly, L., Sullivan, P., Ninni, S. et al. (2006). Reducing Foley Catheter Device Days in an Intensive Care Unit. AACN Advanced Critical Care, 17 (3), 272-283.
Johnson, J R., Kuskowski, M A., Wilt T J. (2006). Antimicrobial Urinary Catheters To Prevent Catheter-Associated Urinary Tract Infection in Hospitalized Patients. Ann Intern Med, 144, 116-126.
Karchmer, T B., Giannetta, E T., Mutto, C E. et al. (2000). A Randomized Cross Over Study of Silver-coated Catheters in Hospitalized Patients. Arch Intern Med, 160, 3294-3298.
Srinivasan, A, Karchmer, T, Richards A. et al. (2006). A Prospective Trial of a Novel, Silicone Based, Silver Coated Foley Catheter for the Prevention of Nosocomial urinary tract infections. Infect Control Hosp Epidemiol, 27, 38-43.
Goh, T.N. (2002). A strategic assessment of Six Sigma. Quality and Reliability Engineering International, 18 (2), 403-410.
A literature review is a type of scholarly paper. Its main purpose is to summarize and analyze a number of articles, books, research papers dedicated to a specific topic with the goal of getting an understanding of it. This paper will provide a brief literature review of a number of articles on Infection in acute dialysis patients with central venous catheters.
The Review
Five distinct articles from various scholarly publications were chosen for this review. The majority of the articles were done by large teams of researchers with the purpose of providing a substantiated result that could be used to change the current medical practice. The topic of catheter-related bloodstream infections is highly relevant as they are associated with significant morbidity and mortality (Safdar et al., 2014). The presented articles offer possible solutions to this issue.
The earliest presented paper was published in 2001 and consisted of a randomized trial that compared povidone-iodine to a chlorhexidine gluconate-impregnated dressing as prevention methods against this type of infection. The researchers found that the chlorhexidine-impregnated dressing, when replaced weekly, was as effective as cutaneous disinfection. However, despite the effectiveness of the solution, the risk of local contact dermatitis when using chlorhexidine dressing prevents its use in low birth weight infants during their first two weeks of life (Garland et al., 2001).
Another inconclusive paper on the use of chlorhexidine antiseptic solution instead of an alcohol-based povidone-iodine solution was published in 2012. The research for the paper was conducted in a critical care unit. Despite the two-year-long periods of routine surveillance, no significant benefits to the use of chlorhexidine antiseptic solution were noted, and no cost advantage over the povidone-iodine solution was recorded. It is possible that the number of examined cases was limiting the study (Girard, Comby & Jacques, 2012).
The next examined paper was published by Leonard Mermel, and it focused on the predominant source of intervascular catheter infections. The author examines a variety of possible sources and concludes that both extraluminal and intraluminal routes of infection have to be considered when examining the issue of venous catheter-related infections. The author prioritizes catheter insertion and maintenance as possible precautions against both short term and long term infections. He notes that novel solutions should be implemented to reduce the risk of infections, such as antimicrobial dressings and catheter flush solutions (Mermel, 2010).
This sentiment is supported by a paper from 2015 on the use of chlorhexidine-alcohol for the prevention of intravascular catheter-related infections. Unlike the research paper from 2012, this group assembled 2547 patients and separated them into two large groups. The study compared chlorhexidine-alcohol solution against povidone iodine-alcohol for skin antisepsis. The research found that chlorhexidine-alcohol solution provided greater protection against short-term catheter-related infections and recommended that it should be included in all bundles for prevention of these types of infections (Mimoz et al., 2015).
A meta-analysis, from a year prior, found similar results. It focused on assessing the efficacy of a chlorhexidine-impregnated dressing for prevention of catheter-related infections. By examining nine randomized controlled trials, the research team found that the use of chlorhexidine-impregnated dressing is both beneficial in catheter colonization prevention and catheter-related infections. The research group recommends the use of this solution in patients at risk of infection and colonization (Safdar et al., 2014).
Conclusion
The examined body of knowledge reveals that chlorhexidine-alcohol based solutions could be beneficial as novel preventative measures for catheter-related infections and colonization. Despite the early reports of insignificant benefits, current information suggests that this method should be implemented for patients at risk of these types of infections.
References
Garland, J., Alex, C., Mueller, C., Otten, D., Shivpuri, C., Harris, M., … Maki, G. (2001). A randomized trial comparing povidone-Iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. PEDIATRICS, 107(6), 1431-1436.
Girard, R., Comby, C., & Jacques, D. (2012). Alcoholic povidone-iodine or chlorhexidine-based antiseptic for the prevention of central venous catheter-related infections: In-use comparison. Journal of Infection and Public Health, 5(1), 35-42.
Mermel, L. (2010). What is the predominant source of intravascular catheter infections?. Clinical Infectious Diseases, 52(2), 211-212.
Mimoz, O., Lucet, J., Kerforne, T., Pascal, J., Souweine, B., Goudet, V., … Timsit J. (2015). Skin antisepsis with chlorhexidine–alcohol versus povidone iodine–alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. The Lancet, 386(10008), 2069-2077.
Safdar, N., O’Horo, J., Ghufran, A., Bearden, A., Didier, M., Chateau, D., & Maki, D. (2014). Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection. Critical Care Medicine, 42(7), 1703-1713.
The National Patient Safety Goals (NPSG) are formulated by the Joint Commission annually and seek to address the most prominent contemporary issues in healthcare (The Joint Commission, 2019). They are separated into five categories: ambulatory health care, behavioral health care, critical access hospital, home care, and hospital. These groups are not exclusive, and the same goals may appear in several chapters.
The differentiation is used to identify critical points of interest for different institutions and care providers as outlined by the names. The Joint Commission also provides suggestions for possible methods to address each issue outlined in its goals, though it leaves interpretations to individual facilities. As such, the documents offer a comprehensive framework for problem identification and resolution for medical institutions around the nation.
Most of the recommendations are non-specific, even when detailed proposals are taken into consideration. According to The Joint Commission (2019), key hospital goals for 2019 involve patient identification, staff communication, safe medicine and alarm use, infection prevention, patient safety risk identification, and surgery mistake prevention. The facilities that follow the goals are expected to develop effective measures for the satisfaction of these needs via evidence-based practice.
With regards to hospitals, infection prevention is a prominent topic, with five different goals discussing the avoidance of conditions that result from various aspects of hospital treatments. This paper will focus on the goal, particularly in surgical environments, and the importance of hair removal for the purpose.
Your Hospital NPS Goal
The decision has been made to work towards fulfilling the goal NPSG.07.05.01 in the 2019 NPSG document. According to the Joint Commission (2019), the goal is to “implement evidence-based practices for preventing surgical site infections” through education, policy implementation, regular assessments, stakeholder data sharing, antimicrobial agent administration, and appropriate hair removal.
While healthcare institutions throughout the United States try to maintain the best possible standards in these areas, there are areas of contention, and evidence-based practice spreads gradually. In general, most facilities could improve their standards considerably if they could access a unified set of guidelines based on the latest findings. As such, the improvement process should involve data gathering on topics such as hair removal and its role in infection.
Your Hospital NPS Goal’s Interventions
The intervention determined to be necessary for the issue is an investigation into evidence-based practices surrounding hair and post-operative infection. The methods generally employed at the Center involve shaving the skin area where the operation will be taking place. However, the validity of the procedure is often in question, both with regards to the necessity of hair removal and the applicability of razors to the task.
Al Maqbali (2016) notes that when doing so is necessary, hair should not be removed with razors and suggests clippers and depilation cream as safer alternatives. As such, the program creators determined that hair removal should only be conducted if the growth interferes with the operation.
The reviewers also found that a change in the methods employed for the procedure is necessary. Allegranzi et al. (2016) provide a strong recommendation to avoid the use of razors at all times, whether before the operation or in the operating room and to employ clippers for hair removal. Shaving has the potential to increase the risk of infection compared to both shaving and no hair removal due to its tendency to damage and irritate the skin (Allegranzi et al., 2016). Clippers do not have the same issue, but they do not reduce infection incidence, either, and so should only be used if necessary (Al Johani, 2017). The new policy adopted at the Center is designed to comply with this recommendation.
Nursing-Focused Problem Example to Be Solved
Nurses usually perform hair removal at the direction of the surgeon. The determination of the need for the procedure is left to the discretion of the practitioner, but the nurse who is assigned the task determines the specific method used to remove the hair. Some nurses still have not adopted the latest hair removal policies, using razors for the job and endangering patients as a result. It is challenging to evaluate the difference between the two tools in practice without a dedicated experimental trial, and so they may not pay sufficient attention to the distinction. Furthermore, the environments of most operating rooms make oversight by other nurses challenging, and so dissemination of the latest knowledge happens slowly even if some staff members adopt contemporary practices.
Nursing-Focused Problem Solution
The proposed solution is to introduce alternate methods for preoperative hair removal that reduce the incidence of infection. Clippers appear to be the preferable option, as Al Johani (2017) supports their use as less likely to cause infection than that of razors. The goal is specific and measurable, as it requires that every nurse begins using clippers instead of whichever approach he or she was using before. It is attainable because the use of clippers does not require specialized training, and the tool is not expensive. It is relevant because it is likely to reduce postoperative infection rates. Lastly, it is timely, as it is possible to set a realistic deadline of one month.
Nursing-Focused Solution Implementation
The facility will assign a team of experienced nurses to gather evidence about the importance of the use of clippers in hair removal. They will formulate a guideline based on their findings and publish it for other staff members. They will then hold training sessions, in which they will explain the importance of using clippers and demonstrate how to use them safely. One session should be sufficient for each staff member, as it is possible to condense the necessary information to a sufficiently small amount. If the facility does not have enough clippers to accommodate its needs, it will purchase them in sufficient amounts. After the training, the nurses’ knowledge will be evaluated, and the use of razors in preoperative hair removal will be considered a deviation from best practice.
Nursing-Focused Solution Evaluation
The central statistic that will be tested as a measure of success for the program is the incidence of surgical site infections in patients undergoing surgery. The existing systems that are used to gather data on surgical site infections will continue functioning and collect data such as the amount of hair removal decisions for comparisons. Six months after the end of the training program should be sufficient to gather an adequate sample of patients to determine whether the implementation is effective. Success should manifest as a significant reduction in the proportion of patients that develop an infection after their surgery. Statistical analysis will likely be necessary to evaluate whether the decline is permanent.
Conclusion
The purpose of the NPSG is to improve the overall care quality in the nation by ensuring that each healthcare facility follows the latest guidelines. Infection prevention is a concern, especially in surgical sites, where proper hygiene is critical. Hair removal is an area where improvement is possible, as razors are both commonly used and unsafe. As such, it is possible to address the problem by using clippers for the procedure.
Six months after the end of the education, the data gathered throughout the period will be compared to that before it via statistical analysis to determine whether the proportion of the patients with infections decreases. A significant reduction in the incidence of surgical site infections is expected.
References
Al Johani, N. B. (2017). Nursing evaluation of risk factors associated with surgical site infection among coronary artery bypass graft patients at King Abdulaziz University Hospital. American Journal of Nursing, 6(3), 165-175.
Al Maqbali, M. (2016). Pre-operative Hair Removal: A Literature Review. International Journal of Nursing and Clinical Practices, 3(1), 1-6.
Allegranzi, B., Bischoff, P., De Jonge, S., Zeynep, N., Zayed, B., & Gomes, S. (2016). New WHO recommendations on preoperative measures for surgical site infection prevention: An evidence-based global perspective. The Lancet Infectious Diseases, 16(12), 276-287.
The Joint Commission. (2019). 2019 national patient safety goals®. Web.
Infectious diseases have always been and remain dangerous for the human body because of their ability to affect a large number of healthy people in a short period. Viruses are the carriers and contributors of human genetic information, which can be transmitted both sexually and asexually. In medical terms, these microorganisms are pathogens, the causative agents of infections. The number of illnesses caused by viruses is large, and many ailments are extremely dangerous, for instance, HIV. In microbiology, there is such a term as a nanobacterium – it is the particle of the minimal size that can penetrate a living organism. Often, nanobacteria cause infectious diseases, which, in turn, are not easy to treat because of deep tissue damage. The danger of such particles is that their behavior is not fully understood, and the risk of developing coexisting illnesses remains. Therefore, the implications of nanobacterial infections are the topic that deserves discussion and detailed consideration for determining the most frequent ailments and the ways of their treatment.
The Danger of Infectious Diseases
Infectious diseases differ from other illnesses with the fact that such ailments can result in a large-scale epidemic and affect many people. That is why doctors pay close attention to patients with certain symptoms. To prevent the further spreading of infection among the healthy population, it is recommended for people to be isolated, and special care should be taken when performing hygiene procedures. The causative agents of some diseases live and reproduce only in the human body, and they die when they are in the external environment. However, some viruses and bacteria remain viable due to their ability to stop their life cycle temporarily. After finding themselves in a favorable temperature regime and humidity, they begin to multiply again. According to Ansari, Sepahi, and Sepahi (2017), “one of the most controversial issues about nanobacteria relates to its resistance to physical and chemical agents as well as its strong heat resistance” (p. 5001). Therefore, the risk of infections is significant, and the study of this issue is topical.
Nanobacteria in Infectology
Nanobacteria represent a relatively new chapter in infectology and are the area for active learning. Although many issues concerning the detection of nanoparticles have not been finally solved, it is proved that these microorganisms are “known as calcifying nanoparticles” and were first described in 1998 (Yaghobee, Bayani, Samiei, & Jahedmanesh, 2015, p. 826). Throughout the developmental stages of infectology as a science, different trends have appeared. Today, an increase in the proportion of infectious illnesses’ chronic forms is a typical phenomenon in medicine. The actualization of conditionally pathogenic microorganisms is the factor that requires the increased attention on the part of microbiologists (Kutikhin et al., 2014). The danger of nanobacteria is due to not only the severity of diseases but also due to a complicated treatment that requires careful monitoring. The repeated infection of the organism, arising in the background of incomplete primary illnesses, is particularly dangerous. Therefore, the search for ways of timely identification and interventions is one of the priorities of modern science.
Various forms of infections manifestation caused by nanobacteria belong to different areas of medicine such as oncology, surgery, hematology, and other areas. This spread necessitates intensive work concerning the elimination of opportunities for the development of a favorable environment for the multiplication of nanoparticles and their impact on the human body. Modern infectology does not always cope with the outbreaks of epidemics, and the Ebola virus is the confirmation of such a threat. Thus, urgent measures are necessary, and knowledge about the causes of diseases and the features of their manifestations is essential.
The Causes of Nanobacterial Infections
There are several classes of nanobacteria that become lethal after they are embedded in the host cell. These genes start the synthesis of protein substances in cells, which destroys the protective and regulatory systems. Among them, it is possible to name oncology genes, apoptosis, and those that are capable of launching the synthesis of proteins in different tissues, causing autoimmune reactions. All the types of pathogenic microorganisms have different virulence, which means that under equal conditions, one type of bacteria will be more toxic to humans than another one.
There are different causes and ways of transmitting infections through nanobacteria. A contact-household method is one of the frequent ways of infection through public objects. With food, harmful microorganisms can penetrate healthy cells, for instance, through contaminated water. According to Cho and Min (2015), the sexual mode of bacteria transmission is often the cause of venereal diseases and the illnesses of the genitourinary system. As Kutikhin et al. (2014) note, a child in the womb may be infected with harmful microorganisms transplacentally when certain bacteria are transmitted from a mother. Laboratory research is the basic method for detecting a particular ailment in adult patients and children. For analysis, materials containing infections are taken – phlegm, saliva, mucus, blood, and urine. In case timely assistance is not available, dangerous consequences may occur.
The Forms of the Manifestation of Nanobacterial Infections
The clinical picture for nanobacterial diseases can be different. The emergence of specific symptoms depends on the type of pathogen, its location, the state of the patient’s organism, and the degree of the pathological process. A particular microorganism may enter the human body but does not cause the development of pathology immediately. A patient can be the carrier of the infection for a long time and not even suspect it. However, under the influence of provoking factors (stress, hypothermia, viral infections, and others), the activation of the pathogen may occur, and the disease will enter the open phase.
The manifestations of the infection caused by nanobacteria may be different. For instance, Ansari et al. (2017) note that “the biomineralization ability of nanobacteria may lead to calcification of the soft tissues, which in turn may result in other diseases” like stones in kidneys (p. 5001). Cho and Min (2015) focus on men’s diseases and mention prostatitis as one of the manifestations of infection. According to the authors, nanobacteria “commonly occur in prostatic stones,” which is the cause of severe discomfort and pain (Cho & Min, 2015, p. 93). As already mentioned, Kutikhin et al. (2014) researched the effect of microorganisms on the process of bearing the fetus in the womb and, in particular, the placenta state. As they argue, “placental calcification may be definitely added to the list of CNP-caused pathologies,” which explains the need for proper and careful treatment (Kutikhin et al., 2014, p. 4). In general, the situation is complicated by the fact that nanobacteria infections can “also be present in healthy adults” and manifest eventually (Yaghobee et al., 2015, p. 830). Therefore, it is essential to take tests timely and observe all the necessary precautions.
The Treatment of Nanobacterial Infections
As the treatment for nanobacterial infections, appropriate medications are prescribed. They can be bacteriostatic and stop the growth, propagation, and reproduction of bacteria and bactericidal that destroy microorganisms. It should be noted that there is a possibility of the development of antibiotic resistance when the causative agent of a particular illness adapts to the medication, and the medicine ceases to function. Along with antibiotics, the treatment of bacterial diseases includes the prescription of prebiotics and probiotics, which help restore the composition of useful intestinal microflora and prevent the development of dysbacteriosis. In addition, the reception of multivitamin complexes and drugs for strengthening immune defense are prescribed, which may contribute to improving well-being and increasing the resistance level to a certain illness. If the treatment process is correct and a patient complies with all the physicians’ recommendations, the outcomes of infectious ailments may be favorable, and no serious consequences appear in the future.
Conclusion
The implications of nanobacterial infections may be dangerous, and specific attention should be paid to the issues of determining and treating such illnesses. There are different ways of microorganisms’ penetrating the human body, and they are all studied to find the best options for prevention. The forms of such infections manifestations may be represented by various illnesses in men and women, adults and children, and in each case, appropriate treatment is prescribed. Careful compliance with proper therapy and specific measures aimed at preventing infection can help to avoid danger.
References
Ansari, H., Sepahi, A. A., & Sepahi, M. A. (2017). Different approaches to detect “nanobacteria” in patients with kidney stones: An infectious cause or a subset of life? Urology Journal, 14(5), 5001-5007. Web.
Cho, I. C., & Min, S. K. (2015). Proposed new pathophysiology of chronic prostatitis/chronic pelvic pain syndrome. Urogenital Tract Infection, 10(2), 92-101. Web.
Kutikhin, A. G., Yuzhalin, A. E., Borisov, V. V., Velikanova, E. A., Frolov, A. V., Sakharova, V. M.,… Golovkin, A. S. (2014). Calcifying nanoparticles: One face of distinct entities? Frontiers in Microbiology, 5(214), 1-5. Web.
Yaghobee, S., Bayani, M., Samiei, N., & Jahedmanesh, N. (2015). What are the nanobacteria? Biotechnology & Biotechnological Equipment, 29(5), 826-833. Web.
Sexually transmitted diseases (STDs) or venereal diseases (VD) occur when infections (STIs) pass from one carrier to another through sexual contact. However, some of the diseases can be transmitted through blood transfusions, unsterilized drug needs, and breastfeeding (from mother to infant). STIs represent a challenge because they lead to the occurrence of acute illnesses, infertility in both men and women, long-term disability, death, and psychological consequences. Even though such infections are more prevalent in countries with poor quality healthcare and low income, its adverse impact requires attention from the global healthcare sphere.
In the United States, STI prevention has taken the form of government policies that regulate the interventions, laws, and other administrative actions or practices. Such policies focus on the assessment and evaluation of a present situation regarding STI and the subsequent implementation of therapeutic and prevention actions (Leichliter, Seiler, & Wohlfeiler, 2016). For instance, expedited partner therapy (EPT) has been used as one of the main tools for delivering treatment to partners diagnosed with an STI. Policies that support EPT implementation have been enforced in more than forty jurisdictions. STI screening policies also play a role in the management and prevention of sexually transmitted diseases.
Researchers have conducted numerous studies on STI prevention as well as reviewed literature pertinent to this topic. For instance, Low, Broutet, and Turner (2017) collected data on the prevention, diagnosis, and treatment of STIs. They concluded that STI prevention procedures range from behavioral modifications (abstinence, monogamy, safe sex practices) to extensive education starting from schools. The basis behind effective STI prevention relies on the combination of government-enforced policies and individual practices that can significantly reduce the chances of STI occurrence in the population. While the policies depend on healthcare industry stakeholders, individual procedures are a matter of conscious choice and caution. For instance, when engaging in sexual activities, it is imperative to use contraception, ask potential partners about their history of STIs and STDs, and avoid risky sexual partners and behaviors. As identified previously, testing for STIs is another preventative and treatment measure that will help individuals identify possible infections and treat them immediately.
References
Leichliter, J. S., Seiler, N., & Wohlfeiler, D. (2016). Sexually transmitted disease prevention policies in the United States: Evidence and opportunities. Sexually Transmitted Diseases, 43(2 Suppl 1), 113-121.
Low, N., Broutet, N., Turner, R. (2017). A collection on the prevention, diagnosis, and treatment of sexually transmitted infections: Call for research papers. PLoS Med, 14(6), 1-23.
Discussing gynecological conditions with the patient may be challenging as it requires honesty and patience. An individual may refuse to believe the diagnosis, as well as become upset or aggressive. This report presents a reflection on the woman presented with vaginal discharge. It shows what medical professionals may experience while telling an individual about their diagnosis, as well as the short- and long-term impact of an STI on the patient’s life.
Discussing STIs with Patients
SL, a 29-year-old patient, presented in the office with vaginal discharge during my practicum experience. She reported yellowish vaginal discharge that had “a strong smell”. Moreover, the woman was concerned about occasional pain during sex. The patient notes that she has never been diagnosed with a sexually transmitted disease (STD) but has had abnormal vaginal discharge occasionally. SL had no significant family history of sexually transmitted infections (STIs); her partner has never been diagnosed with STDs or STIs. The woman noted that she used barrier contraceptive methods rarely as she found them “uncomfortable”. Reported symptoms allowed for consideration of chlamydia as priority diagnosis.
The selected drug therapy for the condition included a single dose of azithromycin orally (1mg). The choice of this treatment method was determined by its effectiveness; it is a commonly recommended regimen for chlamydia (Schuiling & Likis, 2017). An alternative drug therapy included 300mg of ofloxacin orally 2 times a day for a week. Follow-up care included referring SL’s current partner for screening to avoid reinfection, a test of cure in three weeks after treatment, and additional screening in three months (Centers for Disease Control and Prevention, 2015). The patient was advised to abstain from sexual intercourse until the treatment plan for both of the partners is completed.
My experience in telling the patient that she had an STI was complicated. As chlamydia is usually obtained during unprotected sex, SL was most likely infected by one of her partners (Nielsen, De Costa, Danielsson, & Salazar, 2017).
Her current partner, however, insisted that he did not have an STI. I provided the woman with all information about the condition, including the risk factors associated with it. At first, the patient refused to believe me as she “trusted her partner” and “he would never lie about it to her”. I tried to provide my full support and reassured SL that chlamydia could be treated quickly and effectively but some prevention measures were vital. The patient concluded that she could have obtained the infection from one of her previous partners.
The diagnosis will have a short-term effect on SL’s life as she will have to have a discussion about STIs with her partner, which may be challenging for her. The condition may cause fundamental changes in the woman’s relationships with her partner. I believe that the most significant long-term impact of the diagnosis on the patient’s life is that she will consider the benefits of barrier contraceptive methods. During the woman’s visit, I informed her about the risks associated with unprotected sexual intercourse, which may result in severe health complications. Moreover, SL will probably start to test for STIs regularly and avoid risky sexual behavior.
Conclusion
In the case of SL, who presented in the office with the symptoms of chlamydia, initiating the discussion about the condition was challenging. I informed the woman about the risk factors related to the infection and provided her with the recommendations to avoid recontamination. This case shows that patients may encounter difficulties while discussing their conditions, so it is vital to address their concerns and provide full emotional support.
References
Centers for Disease Control and Prevention. (2015). Chlamydial infections. Web.
Responsibilities of a Nurse in General Settings: Addressing the Threat of an Infection
Responsibilities of a Nurse During the Infection Control Practice
Prevention of hospital-acquired infections is a crucial process in the clinical setting. Therefore, as a nurse, one has to reduce the threat of infections, locate possible sources of a problem and eliminate them to ensure patients’ well-being (Singanayagam, Singanayagam, Wood, & Chalmers, 2011). The promotion of respiratory hygiene and cough etiquette along with the proper use of respiratory equipment should be deemed as critical responsibilities of a nurse (Coia et al., 2013; Faruquia & Mukundan, 2010). The case under analysis involved the management of HAI and particularly droplet infections. In the process, the Infection Control Assessment Tool for Outpatient Settings (Centers for Disease Control and Prevention, 2019) was used. The potential outcomes of infection control compliance include a rise in recovery rates among outpatients.
Steps and Strategies for Risk Assessment for Healthcare Associated Infections in Different Populations
Prior to introducing tools for the management of HAIs, a nurse has to evaluate the level of threat to which patients are subjected. The process of risk assessment should include the analysis of the geography to determine the possibility of conditions that may hinder the delivery of the necessary assistance for managing droplet infections (Chan, Bond, Adamson, & Chow, 2016). The culture and level of education of target populations should also be scrutinised as the factor that will affect the efficacy of HAIs prevention (Qiao, Huang, Zong, & Yin, 2018). The tool provided by the Department of Health and Human Services (2016) should also be incorporated into the framework. Finally, tools for controlling patients’ compliance with the suggested interventions will be required (Damani, 2003).
Strategies for Prevention of Healthcare Associated Infections: A Clinical Nurse’s Perspective
The task of preventing HAI is fraught with several challenges, the issue of education being the key one. Thus, revisiting the current approaches to disinfection, cleaning and, most importantly, advancement of self-care knowledge, is essential (Farrington, 2007). By making the guidelines for the sanitation and hygiene processes both for nurses and patients clear and concise, one will achieve noticeable progress (Steinkuller, Harris, Vigil, & Ostrosky-Zeichne, 2018). The location of hygiene facilities, such as tools for washing hands, also needs to be reconsidered for the visits of outpatients (The College of Physicians and Surgeons of Ontario, 2004).
Principles of Infection Control and Scientific Tools for Monitoring Infection Control Practice
The general principles and guidelines for controlling HAIs have remained basically the same, with the use of isolation techniques being quite common (Siegel, 2002). The promotion of cough etiquette will also help to identify and manage the cases that may potentially involve a threat of droplet infections (Zayas et al., 2013; Siegel, Rhinehart, Jackson, & Chiarello, 2007).
Reprocessing Methods for Assuring of Safety and Integrity of Patient Care Environment: Application and Critique
The current approach toward ensuring safety and preventing HAIs from occurring are geared extensively toward education and acquisition of key competencies. Therefore, the use of visual cues and sequenced instructions for hand hygiene and similar procedures must be deemed as crucial (Mash et al., 2011). In addition, environmental cleaning and surveillance should be used to enhance care (Ng, Le-Abuyen, Mosley, & Gardam, 2014; Hefzy, Wegdan, & Wahed, 2016).
Reflection on Applying Evidence-Based Practice (EBP) in the Clinical Environment
Description
Managing the needs of influenza (Influenza A virus) patients, especially young ones, is an extraordinarily challenging task (Centers for Disease Control and Prevention, 2019). The case under analysis showed that problems with signage and the lack of compliance with basic hygiene standards such as respiratory hygiene and cough etiquette might lead to serious health complications (Rodrigues, Coelho, & Tavares, 2018).
Feelings
When considering personal impressions of the situation that can be witnessed in the target clinical setting regarding outpatients presently, one is likely to feel rather discouraged due to the lack of resources. The case in question helped to learn the importance of Neuman’s Systems Model as a nursing theory. The fact that signage as one of the crucial aspects of nurse-patient communication is the key cause of failure is very disappointing.
Evaluation
The introduction of patient-friendly signage approaches will help to transfer information within the clinical setting, more effectively (Leonard, Verster, & Coetzee, 2014). The proposed change will help patients to acquire critical self-care skills and ensuring that critical principles of managing HAIs, such as cough etiquette and respiratory hygiene are followed exactly (Rousek & Hallbeck, 2011). Therefore, strategies that will allow shaping the signage process to encourage a better understanding between a nurse and a patient are needed.
Conclusions
The lack of numerous critical components of effective care has defined poor conditions for preventing the acquisition of droplet infections and particularly flu.a. The problem of cough etiquette is one of the main causes of flu.a development in outpatients, yet the issue under analysis is defined by a range of other factors that have been observed in the selected setting (Coia et al., 20213). For example, the lack of training opportunities, the absence of isolation rooms and no defined rules for signage have caused outpatients to become exposed to an array of HAIs, predominantly, flu.a.
Action
The key measures for improving the clinical care band addressing the HAI problem include a multimodal improvement strategy based on the suggestions of the World Health Organisation and several clinical studies (Hashim, Alkaabi, & Bharwani, 2014). One should reconsider instructions that nurses follow when tending to the needs of patients, including the hygiene requirements and the introduction of a patient-friendly signage system (Leonard et al., 2014). The next and most important step will be altering the current set of principles for promoting change and the improvement of the triage process. Patient and staff education geared toward avoiding potential health hazards and reducing risks should be regarded as the priority (The Centre for Health Protection, 2018). It is also worth considering isolation and similar interventions (Aiello et al., 2016). Thus, the problem of HAIs will be addressed in a proper manner.
References
Aiello, A. E., Simanek, A. M., Eisenberg, M. C., Walsh, A. R., Davis, B., Volz, E.,… Osgood, N. (2016). Design and methods of a social network isolation study for reducing respiratory infection transmission: The eX-FLU cluster randomized trial. Epidemics, 15, 38-55. Web.
The Centre for Health Protection. (2018). Guide to infection control in clinic setting. London, UK: The Centre for Health Protection.
Centers for Disease Control and Prevention. (2019). Influenza (flu). Web.
Chan, W. F., Bond, T. G., Adamson, B., & Chow, M. (2016). Identifying core competencies of infection control nurse specialists in Hong Kong. Clinical Nurse Specialist, 30(1), 1-9. Web.
Coia, J. E., Ritchie, L., Adisesh, A., Booth, C. M., Bradley, C., Bunyan, D.,… Phin, N. (2013). Guidance on the use of respiratory and facial protection equipment. Journal of Hospital Infection, 85(3), 170-182. Web.
The College of Physicians and Surgeons of Ontario. (2004). Infection control in the physician’s office. Vancouver, Canada: BC Centre for Disease Control.
The Department of Health and Human Services. (2016). Infection prevention and control assessment tool for outpatient settings. Washington, DC: Centers for Disease Control and Prevention.
Damani, N. N. (2003). Manual of infection control procedures (2nd ed.). Cambridge, UK: CUP.
Farrington, M. (2007). Infection control education: How to make an impact – Tools for the job. Journal of Hospital Infection, 65, 128-132. Web.
Faruqui, F., & Mukundan, D. (2010). 2009 pandemic influenza: A review. Current Opinion in Pediatrics, 22(4), 530-535.
Hashim, M. J., Alkaabi, M. S. K. M., & Bharwani, S. (2014). Interpretation of way-finding healthcare symbols by a multicultural population: Navigation signage design for global health. Applied Ergonomics, 45(3), 503-509. Web.
Hefzy, E. M., Wegdan, A. A., & Wahed, W. Y. (2016). Hospital outpatient clinics as a potential hazard for healthcare associated infections. Journal of Infection and Public Health, 9(1), 88-97. Web.
Leonard, A. L., Verster, A., & Coetzee, M. (2014). Developing family-friendly signage in a South African paediatric healthcare setting. Curationis, 37(2), 1-7. Web.
Mash, C., Baker, J., Foster, C., & Goldfarb, J. (2011). Improved infection control compliance using isolation signs that incorporate standardized colors, visual cues, and sequenced instructions. American Journal of Infection Control, 39(5), 445-447. Web.
Ng, J., Le-Abuyen, S., Mosley, J., & Gardam, M. (2014). A pragmatic approach to infection prevention and control guidelines in an ambulatory care setting. American Journal of Infection Control, 42(6), 671-673. Web.
Qiao, F., Huang, W., Zong, Z., & Yin, W. (2018). Infection prevention and control in outpatient settings in China – Structure, resources, and basic practices. American Journal of Infection Control, 46(7), 802-807. Web.
Rodrigues, R., Coelho, R., & Tavares, J. M. R. (2018). Healthcare signage design: A review on recommendations for effective signing systems. HERD: Health Environments Research & Design Journal, 1(1), 1-12. Web.
Rousek, J. B., & Hallbeck, M. S. (2011). Improving and analyzing signage within a healthcare setting. Applied Ergonomics, 42(6), 771-784. Web.
Siegel, J. D. (2002). Controversies in isolation and general infection control practices in pediatrics. Seminars in Pediatric Infectious Diseases, 13(1), 48-54.
Siegel, J. D., Rhinehart, E., Jackson, M., & Chiarello, L. (2007). 2007 Guideline for isolation precautions preventing transmission of infectious agents in healthcare settings. Washington, DC: CDC.
Singanayagam, A., Singanayagam, A., Wood, V., & Chalmers, J. D. (2011). Factors associated with severe illness in pandemic 2009 influenza a (H1N1) infection: Implications for triage in primary and secondary care. Journal of Infection, 63(4), 243-251. Web.
Steinkuller, F., Harris, K., Vigil, K. J., & Ostrosky-Zeichner, L. (2018). Outpatient infection prevention: A practical primer. Open Forum Infectious Diseases, 5(5), 53-60. Web.
Zayas, G., Chiang, M. C., Wong, E., Macdonald, F., Lange, C. F., Senthilselvan, A., & King, M. (2013). Effectiveness of cough etiquette maneuvers in disrupting the chain of transmission of infectious respiratory diseases. BMC Public Health, 13(1), 811-823. Web.
The article by Posada et al. (2010) focuses on the investigation of the effect produced by the hepatitis C virus (HCV) infection on patients’ neurobehavioral symptoms. Researchers note that despite the attention of scholars to neuropsychological deficits of HCV-positive individuals, little regard has been paid to behavioral manifestations. The study involves two groups with the almost identical number of participants (35 HCV- and 36 HCV+). To evaluate findings, Posada et al. (2010) have employed the multiple regression. The paper offers the analysis of the research methodology, variables, and the study design. Also, the strengths and weaknesses of research are discussed, and improvements for the research design are offered.
The research methodology used by the authors is the quantitative self-report approach. This study design has presupposed the respondents to complete the self-report version of the Frontal Systems Behavior Scale (FrSBe) (Posada et al., 2010).
The FrSBe contains 46 statements enabling the generation of a total front dysfunction score and three subscale scores, the latter including disinhibition, apathy, and executive dysfunction. The ratings of the FrSBe are on a Likert-type scale fluctuating from 1 to 5, where 1 means “almost never,” and 5 means “almost always” (Posada et al., 2010, p. 639). The higher the rating, the more abnormal behavior they denote.
The hypothesis of the study has been that HCV influences the central nervous system “in a subset of infected individuals” (Posada et al., 2010, p. 638). In order to test this hypothesis, the independent and dependent variables have been used. The behavioral symptoms of the HCV+ patients compose the independent variable. The dependent variable is represented by the “FrSBe T scores (after) for the total score and the three subscales scores,” where T stands for apathy subscale mean (Posada et al., 2010, p. 639). The authors emphasize that while the primary aim of the FrSBe is the evaluation of behavioral change in neurological conditions with a distinct onset, this approach has been widely exploited in the conditions without a clear onset.
The results of research indicate that HCV+ patients have significantly higher T scores on the FrSBe total as compared with HCV- individuals. The same results are reported for the disinhibition, apathy, and executive dysfunction (Posada et al., 2010). Meanwhile, at the group level, only one indicator, apathy, is clinically elevated in HCV+ participants. In the dimension of neuropsychological functioning, HCV+ patients have a significantly higher overall neuropsychological shortage than HCV- individuals.
The study’s major strength is the analysis of a previously under-examined factor related to the effect produced by HCV on individuals’ neurobehavioral symptoms. The biggest weakness is the sample size that is quite small. Still, the scholars note that the number of participants is comparable to that in similar studies. Another limitation is concerned with the primary purpose of the FrSBe. Initially, this scale was developed for the conditions having a clear onset. Since HCV does not have such a distinct onset, the scale may not have produced the most reliable results.
Several improvements may be offered for the selected research design. First of all, it is necessary to enroll a larger number of participants in order to gain more reliable results. Secondly, it is crucial to apply a more suitable scale for the condition under the investigation. Finally, a comparison between current and prior results should be made to observe the differences between them. Overall, despite some limitations, the study performed by Posada et al. (2010) has a great value for specialists dealing with HCV+ patients.
Reference
Posada, C., Moore, D. J., Woods, S. P., Vigil, O., Ake, C., Perry, W., …Grant, I. (2010). Implications of hepatitis C virus infection for behavioral symptoms and activities of daily living. Journal of Clinical and Experimental Neuropsychology, 32(6), 637-644. Web.
Urinary tract infections (UTIs) are among the most widespread types of infectious diseases in the world. UTIs are mostly caused by bacteria such as Escherichia coli, although some parasitic invasions are also possible (Huether & McCance, 2017). The classification of UTIs usually includes upper and lower types which are based on the place of the infection as well as complicated and uncomplicated conditions, depending on the state of the urinary tract (Hammer & McPhee, 2014).
Both upper and lower UTIs have a higher prevalence in women than in men. It can be explained by the fact that women’s urethra is short and is located near the anus, thus raising the danger of bacterial infection (Huether & McCance, 2017). Moreover, the infections are also common among older people and infants due to their responsiveness to bacteria. Overall, upper and lower UTIs have similar causes of disease and rates of prevalence among genders and ages, but their pathophysiology and clinical presentations differ.
Pathophysiology
UTIs are initiated by bacterial contamination or parasitic invasion into one’s urinary tract. In the case of lower UTIs such as cystitis, E. coli or other organisms enter the sterile urine and move upwards into the urethra, bladder, ureter, and kidney (Huether & McCance, 2017). The immune system responds to the infection which leads to the inflammation of the bladder. The bladder wall becomes edematous, creating pressure and the feeling of the bladder being full. Thus, the affected person feels the need to urinate frequently, although the bladder contains only a small volume of urine. Upper UTI is pyelonephritis – the infection of ureters and renal pelvis.
In this case, the bacteria (E. coli or others) make alkaline urine by splitting urea into ammonia (Huether & McCance, 2017). Furthermore, they spread along the ureters and initiate the inflammatory process which affects the pelvis, medulla, and calyces. Here, renal edema leads to purulent urine, pain, and abscesses.
The main similarity between the two UTIs is the cause of the infection – bacteria and parasites enter the tract but lead to different inflammatory responses. Thus, the differences include the site of edema as well as pus formation in pyelonephritis and pressure on the bladder in cystitis (Hammer & McPhee, 2014). One can see that clinical presentations of the diseases differ. Moreover, upper UTIs may result in other symptoms that are not constrained to the urinary tract, including fever and chills.
Patient Factors
Age and gender are the main patient factors that significantly affect the pathophysiology of UTIs. In female patients, the prevalence of UTIs is much higher than in males due to the position of their urethra. Females of all ages may be affected by UTIs, especially cystitis (Flores-Mireles, Walker, Caparon, & Hultgren, 2015). Women are also at risk of having frequent UTIs due to the alteration of the vagina’s microbiota.
Their care should recognize the effect of antibiotics, the primary way of treating UTIs, on the vagina in order to avoid repeating infections (Flores-Mireles et al., 2015). Another risk group is older people, including both female and male patients. In older men, the rate of UTIs becomes closer to that of older women (Schaeffer & Nicolle, 2016). Their diagnosis should also acknowledge the asymptomatic course of the infection and possible complications of the weakened immune system.
Conclusion
UTIs are a widespread problem that can affect individuals of all ages and genders. Its pathophysiology separates the infections into upper and lower ones. Pyelonephritis and cystitis have similar causes but different symptoms and pathophysiological processes. Women are more likely to acquire UTIs because of the urethra’s location and length. Older people, including both men and women, are also at risk of developing UTIs. These groups should be treated with antibiotics that do not alter the microflora of the body significantly.
References
Flores-Mireles, A. L., Walker, J. N., Caparon, M., & Hultgren, S. J. (2015). Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nature Reviews Microbiology, 13(5), 269-284.
Hammer, G. D., & McPhee, S. J. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.). New York, NY: McGraw-Hill Education.
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.
Schaeffer, A. J., & Nicolle, L. E. (2016). Urinary tract infections in older men. New England Journal of Medicine, 374(6), 562-571.