Putting Evidence Into Nursing Practice: Four Traditional Practices Not Supported by the Evidence

Acute Opioid Withdrawal Precipitated by Blood Transfusion in a 21-Year-Old Male

COPD—more than just tobacco smoke

THE OR MANAGER sat and listened to the surgical services director's challenge: Reduce the surgical site infection (SSI) rate by 50%. "Our infection rate is only 1%, below the national average of 2% to 5%," she thought. "What more can we do?" But being a quality leader, she recognized that although the current SSI rate was admirable, reducing it even further would greatly benefit Saint Francis Medical Center in Cape Girardeau, Mo., and its patients. This article describes an initiative focused on preventing deep SSIs and their potentially devastating complications, as well as how resulting procedural changes dramatically reduced the facility's SSI rate. (For a general overview and guidelines, see How can SSIs be prevented?) Preliminary approach First, the previous 3 years of SSI data were analyzed. Statistically significant results showed that 62% of those infections involved skin and respiratory tract pathogens. This indicated possible contamination from environmental and human factors such as cleaning the facility, hand hygiene practices, and surgical staff and healthcare provider attire. After researching evidence-based practices, the hospital enhanced cleaning measures and introduced testing for methicillin-resistant Staphylococcus aureus (MRSA) carriers. Another finding revealed a relationship between an increase in SSI and patient comorbidities such as hypertension, obesity, peripheral vascular disease, tobacco usage, diabetes mellitus, obstructive sleep apnea, heart failure, and chronic obstructive pulmonary disease. We then considered how to support each patient's health status to reduce SSI risk. Looking for problems and solutions A team of medical staff caring for each patient assembled to look at each deep SSI in an apparent cause analysis (ACA) meeting. In one case, the caregivers found a problem with the patient's preexisting positive MRSA nasal culture. This patient had been treated with intranasal mupirocin but had received only cefazolin, not vancomycin as recommended.1 After staff members realized this, a procedural change was made. Patients presenting with a MRSA-positive culture are pretreated with intranasal mupirocin and I.V. vancomycin in addition to another appropriate antibiotic. For example, an orthopedic patient without beta-lactam allergy should receive cefazolin as a preoperative antibiotic. If this same orthopedic patient were MRSA-positive, he or she would receive both cefazolin and vancomycin preoperatively after pretreatment with mupirocin.2 Routine MRSA nasal swab testing was expanded to include preoperative patients undergoing orthopedic, neurosurgery, cardiovascular, and vascular surgery. Wound care specialists and surgeons were recommended to obtain swab wound culture specimens from the patient for any suspected infections. At that first ACA meeting, a pharmacist pointed out that we were giving patients half of the recommended dose for some antibiotics.2 To correct this problem, an update was added to the computerized provider order entry (CPOE) system with the pharmacy providing weight-based dosages of prescribed antibiotics. CPOE sets were updated to include pretreatment with mupirocin and vancomycin for patients who were MRSA-positive and to verify that surgeons' admission orders include both MRSA testing and treatment as well as the appropriate antibiotics, per American Society of Health-System Pharmacists guidelines.2 An antibiotic redosing schedule was hardwired into the electronic health record to remind anesthesia care providers to redose during long surgical procedures. Improving environmental care The healthcare professionals attending ACA meetings after each SSI successfully identified problems and implemented needed changes. For example, improved cleaning practices were implemented in the ORs. The new one-step 0.55% sodium hypochlorite cleaning wipe approved for the OR and patient-care areas kills fungi, spores, viruses, and bacteria, including Mycobacterium tuberculosis and Clostridium difficile.3 An educational review reminded staff members of proper cleaning techniques. The OR staff-development program included the enhanced cleaning protocol recommended by the Association of periOperative Registered Nurses (AORN).3 The environmental cleaning staff attended a staff-development program on this enhanced cleaning protocol. Another change was exchanging cotton string mops for microfiber mops. Although either type of mop is acceptable per AORN guidelines, one study found microfiber mops removed microorganisms more effectively (95%) than cotton string mops (68%).3 The environmental cleaning staff was assigned to clean rooms used during the weekend, which was previously done by the perioperative staff, to provide a terminally cleaned room as we improved overall cleaning practices. Improved lidded trash bins were provided for OR trash. More frequent trash pickups also helped prevent insects, such as flies, in the OR. Changing OR practices Staff and management recognize that although doors must be opened for patient and equipment traffic, the OR doors need to be closed to allow air exchanges to function properly. Air exchanges make the OR safer for patients and decrease the risk of SSIs.4 After education and reinforcement, the OR staff became more mindful to keep the doors closed. Another change involved covering male healthcare workers' facial hair with fine mesh beard covers. In addition, circulating nurses in the OR were asked to wear long-sleeved jackets while performing surgical skin prep, which helps prevent surgical site contamination from arm hair or skin cells that are shed during the procedure.5 Brushing up on hygiene issues Performing hand hygiene is a basic but critically important behavior for healthcare workers throughout any facility. Not only does performing hand hygiene protect the patient from healthcare workers' organisms, but it also protects healthcare workers from the patients' organisms.6 Proper hand hygiene includes wetting hands under warm running water, applying soap to all surfaces and rubbing for 15 seconds, then rinsing and drying with a paper towel, which is used to turn off the faucet. When hands are not visibly soiled, an alcohol-based antiseptic is an acceptable alternative. Proper technique for alcohol-based hand hygiene involves applying the gel and rubbing hands together until they are dry (approximately 20 seconds).7 The CDC recommends healthcare workers perform hand hygiene at these times: before and after touching the patient's intact skin after contact with any body fluids including blood, wounds, mucous membranes, and contaminated dressings after contact with furniture or medi-cal equipment in the patient's vicinity after removing gloves after touching a contaminated area of the patient's body and before touching anywhere else before eating and after using the restroom.7 Healthcare facilities may find the free Joint Commission Hand Hygiene Targeted Solutions Tool (TST) helpful.8 The recommended steps involve setting up a team that observes healthcare workers' hand hygiene practices and documents the observations in the TST. The tool generates charts and gives feedback on staff members' hand hygiene practices. For example, do nurses and other staff members wash their hands or use alcohol-based gel as they enter and leave each patient room? The TST can be found at www.centerfortransforminghealthcare.org/tst_hhy.aspx. Surgical hand rubs and scrubs A review of surgical hand scrubs was conducted during staff re-education. These AORN standards for hand rub include the following: removing jewelry putting on a surgical mask washing soiled hands with soap and water cleaning under fingernails before drying hands and arms applying the hand rub product to hands and arms and allowing it to dry before putting on a sterile gown and gloves. Always follow recommendations provided by the manufacturer of the surgical hand rub product. For those who prefer a surgical scrub, follow the first four steps of AORN standards for hand rub, then follow these steps: Scrub according to product instructions. Rinse hands and arms while holding your hands higher than your elbow. Enter the OR to dry your hands while keeping surgical clothes from getting wet before putting on a gown and gloves.7 Optimizing patient status During this project, staff members recognized that some patients arrive malnourished and some surgeries put patients at risk for protein depletion, especially gastrointestinal or cancer surgeries. This increases the risk of poor healing, infection, and pressure injuries.9 Changes intended to optimize nutrition began with patients scheduled for elective colon and cystectomy-ileal conduit surgeries. These patients are screened at the general surgeons' office preoperatively using the Malnutrition Screening Tool, which identifies malnourished patients and patients at risk for malnourishment based on recent weight loss and appetite.10 Patients are sent home with an immunonutrition drink to help reduce the risk of infection after major elective surgery and instructed to drink it twice a day for 5 days before surgery and the first 5 days postoperatively as soon as diet permits. In this population, nutritional optimization decreased the SSI rate from 5% to 1.5% and readmissions from 20% to 3%. The patients receiving this nutritional supplement have had no readmissions or infections. Because of the success of this program, it has been expanded to include all malnourished patients and patients at risk for malnutrition. Certain general surgeries put patients at increased risk for infection.10 During these surgeries, the general surgeons have begun irrigating the abdominal cavity with a chlorhexidine solution and applying new technology called negative-pressure incision therapy (NPIT). This NPIT protocol shows promise, lowering infection rates to 2% versus 11% when used after colorectal surgery.11 Educating patients and their caregivers about the best ways to prevent infections at home includes having them watch an educational video, "Keep it Clean: Preventing Surgical Site Infections," before leaving the medical center. This video provides instructions appropriate for both inpatient and outpatient surgical patients. Improving for the future Current analysis shows for the first 6 months of 2017, the facility's deep SSI rate is 0.1% and overall SSI rate is 0.3%, a new low. Analyzing data on that 0.1% population, we learned that 40% of those patients have diabetes mellitus. Evidence-based practice shows that maintaining normal blood glucose levels before and during surgery and immediately postoperatively helps the patient heal.12 Would optimal blood glucose control for a longer time frame postoperatively decrease the risk of deep SSI? This future challenge involves teaching patients to ensure they control their blood glucose levels after being discharged from the medical center. This project achieved a dramatic reduction in the deep SSI rate at our facility. The medical center staff is proud of our 0.1% deep SSI rate but continues working toward zero. How can SSIs be prevented?1,2 Efforts to decrease SSIs have been ongoing for years. Current best OR practices for preventing infections include the following: Timely delivery of prophylactic I.V. antibiotics within 1 hour before incision. I.V. vancomycin and fluoroquinolones should be infused over 2 hours. These antibiotics should be infused before tourniquets on the operative limb are inflated. Appropriate antibiotics (per guidelines) will be given. Antibiotics should be discontinued within 24 hours after surgery. Dosing of antibiotics should be weight-based. Redosing antibiotics for long surgical procedures is recommended at intervals of two half-lives. Razors to shave the surgical site have not been recommended for years because of the risk of nicks and of introducing bacteria into the area. Instead, clippers or a depilatory agent is appropriate preoperatively for hair removal if necessary. Maintaining the patient's blood glucose level at less than 180 mg/dL helps prevent infections and complications. Keeping the patient normothermic helps prevent blood loss and decreases the risk of SSIs. Using supplemental oxygen during and immediately following surgical procedures involving general anesthesia and mechanical ventilation helps improve tissue perfusion and healing and decreases the risk of SSIs. Alcohol-based surgical skin prep solutions (2% chlorhexidine gluconate in 70% isopropyl alcohol or povidone-iodine-alcohol), unless contraindicated, are associated with lower rates of infection than alcohol-free surgical skin prep solutions. Using an impervious plastic wound protector for abdominal surgery helps prevent SSIs.

American Association of Blood Banks (AABB) guidelines suggest that packed red blood cells (PRBCs) be administered through a dedicated intravenous (IV) catheter. Literature supporting this broad-scope declaration are scarce. Obtaining additional IV access is painful, costly, and an infectious risk. We evaluated the effect of co-incubating PRBCs with crystalloids and medications on PRBC hemolysis, membrane deformability, and aggregation, as well as medication concentration. PRBCs were co-incubated 5 minutes with plasma, normal saline (NS), 5% dextrose in water (D5W), Plasmalyte, epinephrine (epi), norepinephrine (norepi), dopamine (dopa), or Propofol (prop). Samples were then assessed for hemolysis (free hemoglobin, serum potassium), membrane deformability (elongation index [EI]), aggregation (smear, critical shear stress [mPa]) and drug concentration (High Performance Liquid Chromatography/Tandem Mass Spectrometry [LCMS-MS]). Significance (p ≤ 0.05) was determined by Wilcoxon-paired comparisons or Wilcoxon/Kruskall Willis with post-hoc Dunn's test. Compared to co-incubation with plasma: 1) co-incubation resulted in significantly increased hemolysis only when D5W as used (free hemoglobin, increased potassium); 2) EI trended lower when co-incubated with D5W and trended toward higher when co-incubated with prop; 3) aggregation was significantly lower when PRBCs co-incubated with NS, D5W, or Plasmalyte, and trended lower when co-incubated with epi, norepi, or dopa. Medication concentrations were between those predicted by distribution only in plasma and distribution through the entire intra- and extracellular space. Our data suggest that 5 minutes of PRBC incubation with isotonic crystalloids or catecholamines does not deleteriously alter PRBC hemolysis, membrane deformability, or aggregation. Co-incubation with D5W likely increases hemolysis. Propofol may promote hemolysis.

The evidence of efficacy was equivocal for educational interventions for health professionals in primary care on the proportion of COPD diagnoses confirmed with spirometry, the proportion of patients with COPD who participate in pulmonary rehabilitation, and the proportion of patients prescribed guideline-recommended COPD respiratory medications. Educational interventions for health professionals may improve influenza vaccination rates among patients with COPD and patient satisfaction with care. The quality of evidence for most outcomes was low or very low due to heterogeneity and methodological limitations of the studies included in the review, which means that there is uncertainty about the benefits of any currently published educational interventions for healthcare professionals to improve COPD management in primary care. Further well-designed RCTs are needed to investigate the effects of educational interventions delivered to health professionals managing COPD in the primary care setting.

Although hand hygiene (HH) is widely accepted as the most effective measure for preventing cross-infection in healthcare setting, overall compliance remains poor among health care workers (HCWs). The last 30 years have demonstrated a growing interest in many interventions determining effective strategies to enhance HH compliance. Based on those evidences, the World Health Organization guidelines on hand hygiene [1] have recommended multifaceted interventions as the most effective and sustainable tools to increase HH compliance, which consist of five components: system change, including availability of alcohol-based handrub at the point of patient; education of healthcare professionals; monitoring of HH practices and performance feedback; reminders in the workplace; and the creation of a HH safety culture [1]. Recently, many researches investigating factor associated with HH compliance have paid attention to behavioral aspects of HH compliance for more-pronounced and sustainable effect. The assumption that an individual's perceptions have a strong effect on each one's behavior brought about cognitive models [2], which may give an insight into HH behavior. A report [3] already stated 20 years ago that infection control field should learn from the behavioral science to achieve compliance of HCWs. Some models from psychology have been applied to evaluate predictors of health behavior [4]. HCW's behavior can be stratified into individual (intrapersonal), interpersonal, and community level [2]. Intrapersonal factors include individual's knowledge, attitudes, and belief and interpersonal factors include interpersonal process as like a group pressure. Community factors indicate networks and norms [2]. In particular, the specific from pressure on individual's behavior have been called as social network effects or peer effect [5]. The effect of role model for colleagues on HH compliance has already showed importance in a few quantitative [6] and qualitative researches [7]. A recent study [5] identified that the presence and proximity of other HCWs was associated with increased HH adherence and, more interestingly, the adherence increased the more as other HCWs became more crowded. Lee et al. [8] have assessed the improvement of HH compliance and the change of perceptions: intention, knowledge, motivation regarding HH in HCWs in a tertiary teaching hospital in South Korea from 2009 to 2012, where HH promotion programs including poster campaign, monitoring and feedback, and education have been actively conducted. Overall adherence with HH has dramatically increased during the period regardless of professional status or medical specialty. Lee et al. [8] focused on the perception change regarding HH as associated factor of enhanced adherence of HH. However, as the often-cited drawbacks to many intervention studies regarding HH is an independent causal relationship, this research is in danger of making the same mistake. While we can assess the change of perceptions of HCWs and the improvement of HH compliance, we cannot deduce an independent causality between the two facts, since they performed monitoring and performance feedback as well as education with special attentions to perceptions of being a role model for other colleagues. Similarly, Pittet et al. [9] identified awareness of being observed, the belief of being a role model, positive attitudes toward HH as associated cognitive factors of HH adherence. However they coupled observed each HCW's adherence to HH with each one's perceptions and demographic characteristics and conducted multivariate regression analysis for examining independent associated factors. Nevertheless, it is noteworthy that current study by Lee et al. [8] demonstrated astonishing improvement in adherence and in perception and attitude regarding HH during a short period through promotion programs. Although alcohol-based hand disinfectants had already been available since 2004, authors noted this single intervention did not enhance the HH compliance. Furthermore, while knowledge about HH indication and awareness of being observed was not significantly improved between 2009 and 2012, positive attitude toward HH promotion was sharply increased. HH promotion programs including education emphasizing role model could reinforce the positive attitude/perception in HCWs in a positive feedback manner. The inability to motivate HCWs' compliance with only some guidelines indicates that behavior regarding HH is a complex phenomenon [10]. Future HH promotion should consider not only expansion of physical facility like alcohol-based handrub or reminder, but also the dynamics of behavioral change based on the understanding of factors influencing HH cognition and behavior. Multi-level and multidisciplinary strategies regarding behavioral determinants would show great promise for achieving sustainable improvement in HCWs' HH.

Year in review 2017: Chronic obstructive pulmonary disease and asthma.

Hand Hygiene Behaviors Monitored by an Electronic System in the Intensive Care Unit

Studies of endothelial dysfunction in patients with respiratory diseases have become relevant in recent years. Perhaps endothelial dysfunction and high arterial stiffness bind bronchopulmonary and cardiovascular diseases. Aim . To reveal features of disturbances of arterial wall vasoregulatory function in patients with chronic obstructive pulmonary disease (COPD) in the presence and absence of arterial hypertension (HT). Material and methods . The study included 50 patients with COPD with normal blood pressure (BP) and 85 patients with COPD and HT. Control group was presented by 20 practically healthy men comparable in age with COPD patients. Tests with reactive hyperemia (endothelium-dependent dilation) and nitroglycerin (endothelium-independent dilation) were performed in order to evaluate endothelium function. The number of desquamated endotheliocytes in the blood was determined. Results . In patients with COPD and HT in comparison with COPD patients without HT and healthy individuals more pronounced damages of the vascular wall, endothelium vasoregulatory function disturbances and a tendency to the reduction in endothelium-dependent vasodilation were determined both during COPD exacerbation and remission. These differences were most pronounced during the COPD exacerbation. In patients with COPD and HT in comparison with COPD patients without HT the damage of the vascular wall was more pronounced during the remission and endothelium-dependent dilatation disorder – during the exacerbation. The revealed disorders in patients with COPD and HT were associated with smoking status (r=0.61, p<0.01), severity of bronchial obstruction (r=-0.49, p<0.05), and hypoxemia (r=-0.76, p<0.01). We noted relationships between the parameters of 24-hour BP monitoring and remodeling of the brachial artery (r=0.34, p<0.05), endothelium lesion (r=0.25, p<0.05), and impairment of its vasoregulating function (r=-0.58, p<0.05). At that, the following parameters were important: the average systolic and diastolic BP levels, the BP load and variability indices, the time and rate of morning surge in systolic BP, and the circadian rhythm of BP. Conclusion . The obtained data show the aggravation of the severity of the vascular wall damages and the reduction in the endothelium vasoregulating activity in patients with COPD after development systemic HT. This effect is more evident during the exacerbation of bronchopulmonary disease.

Is it possible to achieve 100 percent hand hygiene compliance during the coronavirus disease 2019 (COVID-19) pandemic?

Hand Hygiene Practices and Risk and Prevention of Hand Eczema during the COVID-19 Pandemic.

Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia

Despite widespread concern and knowledge about the need for infection prevention and control in health care, it is clear that adherence to strict infection control procedures is not always at an optimal level (El-Masri and Oldfield, 2012). Hospital Acquired Infection (HAI) may occur when these standards break down, and HAI is a commonly discussed media topic (Bates, 2012). Alarmingly, a recent outbreak of Hepatitis C in the USA, resulting from inappropriate interference by health staff with equipment (needles) (Ramer, 2012) reminds us that even when vigilant approaches are used to combat the spread of infection, the potential for contamination from blood-borne infections remains a real possibility. Blood-borne viral infections include human immunodeficiency virus (HIV), Hepatitis C virus (HCV) and Hepatitis B virus (HBV). Taking precautions alone is not sufficient; staffs need to be knowledgeable in the disease and spread of disease. It is important to note that the risk of disease spread is to both staff and patients, although most staffs are vaccinated to prevent HBV (DoHC, 2005). While discussion papers and research studies on the topics of blood-borne diseases such as HCV, HBV and HIV/Aids are reduced in number compared with the 1980s and 1990s, current literature appears to indicate that knowledge deficits exist among nurses with regard to both HCV (Frazer et al., 2011) and HIV/Aids (Delobelle et al., 2009), and education and training specifically on these topics seems to be inconsistent and in some cases minimal (Delobelle et al., 2009; Frazer et al., 2011). This editorial discusses how blood-borne viruses (BBVs) can be best prevented in the health care setting in order to highlight the need for ongoing vigilance. An increased incidence of HBV and HCV transmission in the USA is associated with unsafe medical practices (Moore et al., 2011) particularly in those persons aged over 55 (Perz et al., 2012). These two viruses are the most prevalent in the USA with an estimated 1·4 million persons chronically infected with HBV and 3·2 million persons chronically infected with HCV (Weinbaum et al., 2008). A BBV is transmitted through contact with blood or body fluids typically through sexual or household contact, intravenous drug use or other parenteral exposures (Wise et al., 2012). Within health care settings, BBV transmission occurs through direct percutaneous inoculation of infected blood via needlestick or sharps injury or by blood splashed onto broken skin or mucous membranes (Stein et al., 2003). Health care workers (HCWs) undertaking exposure-prone procedures (EPPs) are also at risk of contracting BBVs (DoHC, 2005). The average risk of occupational HIV transmissions associated with percutaneous exposure to blood is 0·32% (approximately 1 infection in 325 documented exposures to blood from HIV-infected individuals) and for mucosal exposures it is 0·03% (approximately 1 infection for each 3300) (Henderson, 2012). The risk of occupational HBV infection following a parenteral exposure from an HBV-infected source patient with circulating e antigen is between 19% and 37% (Werner and Grady, 1982). The risk of occupational infection with HCV following parenteral exposure to blood from HCV-infected source patient is estimated at 1·9% per exposure (Henderson, 2003). In 1985, following an HIV epidemic, the Centre's for Disease Control (CDC) developed recommendations for prevention of HIV transmission in health care settings known as universal precautions (UP) (CDC, 1987). Blood was identified as the single most important source of HIV and HBV (Garner and Hospital Infection Control Practices Advisory Committee, 1996). As it is impossible to identify all patients that are sero-positive to HIV, HBV or HCV, UP dictates that all patients should be regarded as a potential biohazard (Garner and Hospital Infection Control Practices Advisory Committee, 1996; DoH UK, 1998). However, body substance isolation precautions (aimed at regarding all moist and body substances as potentially infectious) are familiar to all nurses as they are in use since 1987 (Garner and Hospital Infection Control Practices Advisory Committee, 1996). CDC then produced a two tier isolation precaution system known as standard precautions (SP) (Garner and Hospital Infection Control Practices Advisory Committee, 1996; Siegel et al., 2007). The first tier is designed for the care of all patients in hospitals, regardless of diagnosis or presumed infection status. The second tier, ‘Transmission-Based Precautions’ is for patients known or suspected to be infected by a transmissible infection (Garner and Hospital Infection Control Practices Advisory Committee, 1996; Siegel et al., 2007). SP principles include hand hygiene, patient isolation, personal protective equipment (PPE), personal and environmental hygiene, appropriate management of linen and health care waste, including sharps. Hand hygiene is the most important principle to prevent the spread of infection (WHO, 2009; HPSC, 2011a, 2011b). Hand hygiene includes hand-washing with soap (or antimicrobial soap) and water or alcohol gel. It also prescribes that cuts and abrasions are covered with waterproof dressings (WHO, 2009; HPSC, 2011a, 2011b). Stein et al. (2003) illustrated that while doctors understood the importance of hand hygiene, only 7 in 10 followed it frequently in practice. Patients with a BBV should be risk assessed to determine the type of isolation required. Patients that are actively bleeding or with large open wounds require contact precaution isolation (Siegel et al., 2007). Signs alerting staff to the type of isolation should be placed on the door and appropriate PPE should be available. PPE such as gloves and/or apron are required in the event of exposure to blood or body fluids (Siegel et al., 2007). Seventy-one percent of doctors do not wear gloves when taking blood despite 83% believing it important (Stein et al., 2003). Masks are not usually necessary unless to protect from other active infectious diseases, e.g. a patient with pulmonary tuberculosis. The environment should be cleaned daily with detergent and water and disinfected in the event of blood or body fluid spill. Blood spills require appropriate action, e.g. use of spill kits with PPE; appropriate disinfection agents to kill any viruses present; disposable scoops and yellow health care waste bags. Blood spills must be managed and decontaminated to prevent persons becoming contaminated (Siegel et al., 2007). The environment and instruments can also become contaminated with blood. This can lead to infection outbreaks such as the case of podiatry instruments that were the source of an outbreak of HBV in a long-term care facility (Wise et al., 2012). Health care waste is divided into health care risk waste and health care non-risk waste (DoHC, 2010). Health care risk waste includes any item contaminated with blood. Blood-stained products must be appropriately discarded in the yellow health care risk waste stream. If blood is in liquid form, a yellow rigid spill-proof container is used. Needles and sharps should be discarded in designated sharps containers (DoHC, 2010). Needlestick injuries (NSI) or sharps injuries must be managed appropriately. US surveillance indicates more than 380 000 parenteral annual exposures to blood. This equates to nearly 1 in 10 US HCWs receiving a needlestick exposure annually (Panlilio et al., 2004). Alarmingly, Delobelle et al.'s figure (as reported by the nurses themselves in response to survey) was as high as 7 of 10. The discrepancies in figures could be due to underreporting of NSI, which does occur in health care, and it is believed that doctors are least likely to report NSI (Stein et al., 2003). It is very important for nurses in critical care who are exposed to an NSI to perform first-aid to the injury and report to their supervisor and Occupational Health /Emergency Department. Occupational exposure should be assessed and treated accordingly, for example by immunization, hepatitis B immune globulin and post exposure chemoprophylaxis for exposure to HIV. There are also emotional effects of such exposure such as stress (Henderson, 2012) which need to be dealt with as well as financial implications. The cost of management of occupational exposures to blood and body fluids can vary from $71 to $4838 per exposure (O'Malley et al., 2007). An EU directive (2010/32/EU) was published in May 2010 (Council Directive, 2010). Its objective is to achieve the safest possible work environment for HCWs through the prevention of sharps injuries. All health care organizations must comply with this directive, which becomes legally binding on 11 May 2013 (European Biosafety Network, 2010). Perz et al. (2012) determined that unsafe injection practices account for a proportion of HBV acquisitions in health care settings (e.g. use of multi-dose vials; incorrect administration of injections resulting in microscopic quantities of blood contaminating the environment). An outbreak of HCV was identified in an outpatient's clinic where myocardial perfusion imaging was undertaken (Moore et al., 2011). It was determined that a nuclear medicine technologist routinely drew flushes of saline solution from multi-dose vials using the same needle and syringe as had previously been used to administer radiopharmaceutical doses (Moore et al., 2011). In addition, Fischer et al. (2010) highlighted HCV transmission resulting from contamination of single-use medication vials used on multiple patients during anaesthesia administration. As a consequence, more than 50 000 persons required follow-up by Public Health. This investigation highlighted breaches in aseptic technique and deficiencies in oversight within outpatient settings. BBV outbreaks have also been caused through blood glucose monitoring. Five instances of HBV in UK care homes resulted from poor infection control practice in blood glucose testing (Duffell et al., 2011). HBV outbreak was also noted in a long-stay facility where blood glucose monitoring devices were not decontaminated between patients. This resulted in HBV transmission to at least six residents (Schaffzin et al., 2012). HCV has also been transmitted by shared spring-triggered capillary blood glucose monitoring (Desenclos et al., 2001). Recently, Perz et al. (2012) identified haemodialysis as another risk factor in blood-borne pathogen transmission, while several documented cases of patient-to-patient HCV transmission via colonoscope exist (González-Candelas et al., 2010). Most occupational exposures occur on wards (36%), operating theatres account for 17% of incidents (HPA, 2008). Once a BBV is diagnosed in a health care setting, a local investigation is necessary to determine whether the infection is considered as nosocomial. Under the Infectious Disease Regulations (1981) the Department of Public Health must be notified of HBV and HCV infections. A patient notification exercise (PNE) is undertaken using ‘Guidance on the management and investigation of potential exposure to BBVs in health care setting’ (DoHC, 2005). Surveillance is a key performance indicator in the management of HCAI. Early identification of outbreaks and active surveillance of occupational exposures is also necessary. Occupational exposures include percutaneous exposures, where skin has been broken by a needle or sharp, human scratches or bites and mucotaneous exposures (HPA, 2008). Between 1997 and 2008, 3773 occupational exposures to blood or other high risk body fluids were reported to the Health Protection Agency in the UK (HPA, 2008). Feedback from surveillance and good communication informs staff of risks and of appropriate precautions. A study by Donohue et al. (2012) included recommendations such as enhanced surveillance of BBV notifications; sufficient laboratory resources; improved hospital information systems; the establishment of a national register of possible incidents of BBV transmission and that findings of investigations should be published. These would contribute to the further prevention of BBV within the health care setting. Transmission of BBVs in health care settings was believed to occur most frequently during EPPs; however, there is growing evidence of patient-to-patient transmission via other routes (Donohue et al., 2012) including deficient policies and procedures, improper hand hygiene, preparation of medication in blood processing areas, blood glucose monitoring, common-use saline bags, reuse of syringes, reuse of single-dose vials and use of multi-dose drug vials (Kermode et al., 2005; Greeley et al., 2011; Donohue et al., 2012). Perz et al. (2012) concluded that health care exposures may represent an important source of new HBV and HCV infections among older adults especially in ambulatory care settings through reduced oversight and fewer infection control resources. Strategies associated with injury prevention include avoidance of unnecessary needle use; unnecessary insertion of intravenous catheters; use of needleless or protected needle infusion systems and use of safer needles (Henderson, 2012). Health care associated infections and outbreaks of BBV have occurred in health care settings therefore it is necessary that a good infection control programme is in place (HIQA, 2009). Hand hygiene and adherence to SP are important in the prevention of spread of infections (SARI, 2005; Siegel et al., 2007). Reducing occupational exposure will reduce occupational infections with BBVs (Henderson, 2012). Education of staff is essential. Stein et al. (2003) observed the attitudes and compliance of medical staff to UP and recorded reasons for non-compliance. It concluded that while 86% of nurse's s attested to UP compliance, only 41% of doctors did. Education, monitoring, sufficient resources and disciplinary action for poor compliance are all necessary to improve infection control in hospitals (Stein et al., 2003). Although safety-engineered devices have been designed to cover sharps and eliminate all ‘after-use’ injuries, NSI still occur if these devices are used incorrectly. Thorough training and monitoring of the correct use of these safety devices is required (Perry et al., 2004). This training, together with regular education on blood-borne diseases, and infection prevention and control policies and procedures in the critical care unit lead to better management and prevention of BBV and increased safety for both staff and patients. Where direct educational update on the topics is not readily available, critical care nurses may take the initiative to perform independent learning on the topic in line with the development of their professional portfolio. Professional literature and readings on the topic are widely available and act as a good resource for the nurse looking to explore this topic within their portfolio.

© 2021 British Association of Critical Care Nurses. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1111/nicc.12726

Beta Blockers and COPD