Learning Objectives
By the end of this section, you will be able to:
- Identify how the nurse can promote patient safety through infection control
- Recognize important principles when dealing with multidrug-resistant organisms
- Verbalize steps the nurse can take to prevent occupational exposure
Healthcare organizations are required to meet quality and safety needs for patients, staff, and visitors. An organization’s stated commitment to a culture of patient safety can directly enhance infection prevention. The goal of infection prevention is to decrease the risk of infection to patients and healthcare personnel, identify and correct problems that are recognized as deterrents to infection prevention, minimize risks associated with procedures, and maintain compliance with hospital and governmental policies associated with infection prevention. The CDC has recognized the urgent issue of microorganisms that are resistant to drugs and the immediate need for intervention. Furthermore, the American Nurses Association promotes safeguarding antibiotics and the integration of a comprehensive approach to preventing inappropriate use.
Maintaining Patient Safety through Infection-Control Measures
The role of nursing in patient safety and infection prevention is significant. Nurses provide care at the bedside and have the direct ability to impact care and influence positive patient outcomes by helping to identify and prevent the spread of infectious agents. The interventions implemented by a nurse have an integral role in infection prevention. Nurses are part of the team responsible for executing appropriate isolation protocols, modeling infection-control measures, monitoring others for safe practice, identifying barriers to appropriate practice, and educating patients and other interdisciplinary team members as needed. Specific protocols for isolation and infection control will depend on several factors including mode of transmission, environmental circumstances, and available resources.
Standard Precautions: Tier 1
The first tier of precautions to protect healthcare staff and patients from infection are standard precautions. These precautions apply to all patients, regardless of their diagnosis or presumed infection status. The components of standardized precautions include hand hygiene, respiratory hygiene, cleaning and disinfecting, personal protective equipment, safe injection practices, needlestick and sharps injury prevention, and waste disposal.
Transmission-Based Precautions: Tier 2
In situations where standard precautions are not adequate to prevent infection transmission, transmission-based precautions. These types of precautions are specific to infections and should be implemented immediately following patient presentation of signs and symptoms specific to certain infections. These precautions fall into the categories of airborne, droplet, and contact. Transport for patients who are under transmission-based precautions should be limited and only done when essential.
Patient Conversations
Mental Health Needs for Patients on Isolation Precautions
Scenario: The nurse is entering a negative pressure airborne isolation room. The patient has a diagnosis of pneumonia and has tested positive for COVID-19. The nurse recognizes that the patient breakfast tray is sitting on the bedside table, uneaten.
Nurse: Hi, Mr. Garces. How are you feeling? Were you not hungry this morning?
Patient: (not looking at the nurse) I was . . .
Nurse: It there something wrong? Are you feeling nauseous?
Patient: No. I was hungry, but when my breakfast tray got here, it was very cold. It must have sat outside the door for a while before the tech brought it in. I feel like everyone forgets about me since I’m stuck in this room.
Nurse: I’m so sorry to hear that happened. I will call down to dietary right now to get a new hot tray sent up. I understand being sick and in an isolation room can be difficult. Do you want to talk about how you are feeling?
Patient: It’s just really lonely in here. I don’t want my family to come visit me and get sick. But I miss talking to them.
Nurse: I see you have your cell phone on the nightstand. Have you been able to call them?
Patient: No, I forgot my phone charger at home, and the battery ran out days ago.
Nurse: We have an extra charger at the nurse’s station I can bring in. It is very important to be able to stay in contact with loved ones and have someone to talk to. Technology has made that a lot easier these days.
Patient: That would be great and mean a lot to me. Thank you.
Airborne Precautions
When a patient is known or suspected to be infected with pathogens that are transmitted through droplet nuclei, airborne precautions should be used. Patients on airborne precautions, such as those being treated for chicken pox or measles, should be placed in negative pressure rooms. If a negative pressure room is unavailable, the patient should be masked and placed in a private room with the door closed. The personal protective equipment (PPE) for airborne isolation includes the use of a fit-tested NIOSH-approved N95 or higher-level respirator. If transport outside of the room is necessary, patients must wear an N95 mask. These precautions prevent the pathogen from gaining access to the hospital’s ventilation and possibly infecting other patients.
Droplet Precautions
The use of droplet precautions are implemented when patients are known or suspected to be infected with pathogens transmitted by respiratory droplets from coughing, sneezing, and talking. Patients in acute care should be placed in a single patient space. The PPE needed when treating patients in droplet isolation includes donning a mask upon entering a room and discarding it before exiting the room. If transport outside of the room is necessary, patients must wear a surgical mask.
Contact Precautions
The use of contact precautions are indicated for patients who have known or suspected infections that can be transmitted through direct skin-to-skin contact or indirect contact with environmental surfaces or equipment. Patients in acute care should be placed in a single patient space. The PPE needed when treating patients in contact isolation includes gloves and an isolation gown whenever touching the patient, discarding them before exiting the room. Disposable or dedicated patient equipment should be used for the patient. When it is unavoidable to utilize common use equipment, ensure that it has been properly cleaned and disinfected before use on another patient. (Figure 10.11) provides a quick guide comparing contact, droplet, and airborne precautions.
Dealing with Multidrug-Resistant Organisms
The impact of HAIs extends past the individual patient level. At the community level, it has been linked to the development of multidrug-resistant infections. In other words, many HAIs are caused by multidrug-resistant organisms (MDROs), which are bacteria that have become resistant to certain antibiotics, so much so that these antibiotics can no longer be used to control or kill the bacteria.
Examples of MDROs include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and multiresistant gram-negative bacilli. HAIs that are caused by antibiotic-resistant bacteria are of particular concern, because they are typically difficult to treat and pose a significantly higher risk for severe illness and complications.
Life-Stage Context
Susceptibility to Infection
The overall misuse and overuse of antibiotics has created a risk of MDROs to all populations, yet older adults have increased risk. Older adults tend to spend more time in hospitals and/or long-term care facilities with more chronic conditions, which increases exposure to different pathogens. Furthermore, age-related physiologic changes decrease immune system efficiency, thus increasing vulnerability to such infections.
Unfolding Case Study
Unfolding Case Study #2: Part 7
Refer back to Unfolding Case Study #2: Part 5 for a review on the patient data.
| Diagnostic Test Results | Sputum culture positive for methicillin-resistant Staphylococcus aureus (MRSA) |
| Provider’s Orders | 2230: New Orders Infectious disease consult. Titrate supplemental oxygen to maintain saturation > 92 percent. Continue droplet precautions. |
Nursing Advocacy for Patient Safety
Nurses in all disciplines have the responsibility to ensure patients are receiving the safest care. Health care today is more complex than ever, and patients have more complex needs and conditions. Progress in treatments means more extensive intervention, prevention, monitoring, and care. By advocating for wellness and safety for patients, nurses can contribute to high-standard working environments with improved regulations and patient-centered policies. Safer healthcare environments lead to positive patient outcomes. Education is another consideration in the role of an advocate. Nurses often are the ones educating patients and/or their families on specific care needs, as well as how to navigate the healthcare system as a whole. Adjusting for specific needs and learning styles of the patient/family is critical to provide effective education. Nursing advocacy demonstrates an increased level of investment in safety by taking the extra time to meet the needs of the patients.
Preventing Occupational Exposure
It is vital that healthcare workers are able to recognize and reduce risks associated with exposure to blood, bodily fluids, and biologic hazards. The recent emergence of the previously unknown pathogen COVID-19 highlights the critical need for safety in health care and the increasing importance for protecting against pathogens.
Latex Sensitivity
Latex products are made from a natural rubber, and sensitivity can develop if there is repeated exposure. Individuals in health care wear gloves at a much higher frequency than the general public; the increased exposure places them at a higher risk for developing sensitivity, which could lead to allergy. If a nurse has indicated a sensitivity to latex, alternative products should be used, such as latex-free gloves made of neoprene or vinyl. In addition, such nurses should avoid areas where latex is likely to be inhaled, such as an area of high prevalence in the use of latex gloves. Some symptoms of a latex allergy include itching, rash/hives, sneezing, watery/itchy eyes, skin redness, cough, wheezing, and difficulty breathing. For patients with a latex allergy, prevention is key for good outcomes. All clinicians involved in caring for the patient should be a part of the prevention plan to avoid incidental exposure.
Reducing Risk Exposure
Identifying why and how exposures occur is a critical component to the success of a healthcare prevention program. All healthcare employees must receive proper training and education regarding how to reduce their risk for exposure. Emphasis must be placed on following proper hand hygiene, and proper personal protective equipment (PPE) protocols can greatly reduce risk of exposure. Compliance must also be recognized when removing PPE to prevent contamination. PPE can not only protect the patient but also the nurse providing care to the patient who may be contagious or pose a risk to specific populations. Reducing exposure to toxic medications, such as chemotherapy, and following proper protocols for disposal of medications are important for nurses to understand. Following safety procedures and protocols along with using clinical judgment is the best way for nurses to minimize their risk.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety: Disposing Sharps Safely
Definition: Quality and Safety Education for Nurses (QSEN) competencies were designed to emphasize key elements that pre-licensure nursing students should be competent in at the time of graduation. Safety is defined as minimizing risk of harm to patients through both systems effectiveness and individual performance.
Clinical scenario: Nurses should have the following knowledge and skills regarding disposal of sharps:
- Do not throw a needle or sharp in the trash. Dispose of it in a marked sharps container immediately after use (Figure 10.12).
- Never recap a used needle; lay it down or remove a used needle from a disposable syringe.
- When disposing of a needle in the sharps container, never use force or reach into the container.
- If a needlestick occurs, immediately report the incident, and follow your facility’s guidelines and protocols.
Improving Sharps Safety
Sharp injuries are among the top occupational threats to nurses and healthcare workers. Needlestick injuries can occur at any point during the use, disassembling, or disposing of needles. Sharp injuries put workers at risk for blood-borne diseases, such as hepatitis B, hepatitis C, and HIV. Needles that are not disposed of properly can cause injury to any individual who encounters them unexpectedly. The term sharps includes needles as well as other objects, such as lancets, razor blades, scissors, clamps, pins, staples, and glass items.
The Needlestick Safety and Prevention Act (2000) made needle safety a top priority in hospitals. It is critical, however, that all healthcare workers are aware of and alert to the dangers associated with sharps. Needlestick safety should focus on education and prevention. All healthcare workers should receive hands-on employee training that focuses on the use, handling, and disposal of all sharps. All sharps do not have the same safety mechanisms. Therefore, hands-on training with the sharps currently being used or those that will be adopted must be a priority to ensure nurse and patient safety. Policies and procedures should be implemented regarding safe disposal of sharps and should include routine evaluation of sharps container access. All containers should be fitted with a tight lid and placed at shoulder height with safety features that reduce exposure to fingers and hands.
Safety Devices
It is recommended that healthcare facilities use needleless systems whenever possible. Needleless systems use adaptors and Luer-locks in conjunction with IV tubing and vials, allowing access through a valve system. When the use of a needleless system is not feasible, safety devices should be put into place. Safety-engineered sharps are devices with a built-in safety feature or mechanism that effectively reduces the risk of needlesticks. Examples of safety-engineered sharps include syringes with guards or sliding sheaths (Figure 10.13), retractable needle systems, and shielded or retracting scalpels.