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More than 8 million healthcare workers are employed in settings where they are exposed to hazardous drugs by leaks, vapors, or residue. These can cause cancers, infertility, and other serious health problems. Up to 75 percent of antibiotics prescriptions in the U.S. are for upper respiratory infections (antibiotics work in only a fraction of these cases), with such misuse creating drug-resistant superbugs. At least 3.2 million Americans have hepatitis C and up to 85 percent don’t know they have a deadly but curable virus. Data are at the root of possible solutions to these and other real-world problems sought by students in the doctor of nursing practice (DNP) program at the Johns Hopkins School of Nursing. They are poring over the numbers, naturally, but also studying the people, the systems, the cultures, the hows, whys (and why-on-earth nots?) behind life-and-death issues.
Closing the Loop
In 2008, the chemo unit at Virginia Mason Medical Center in Seattle was not unlike most others nationwide. There was a system to alert for patient safety events, but not a comprehensive system to capture events or exposures involving staff members. There were policies in place for reporting exposures from spills or other events, yet no reports had been filed. This, Rachael Crickman, MN, RN, learned, was despite a number of hazardous drug spills. “Safety measures that I had benefitted from were not in place here,” she says of her first stop as a clinical nurse specialist. An oncology nurse herself for 15 years, Crickman suspected symptoms she’d noticed among nurses on the chemotherapy unit at a previous hospital - infertility, for instance - might be due to exposure over time to drugs that can vaporize, spill, or otherwise get free to contaminate shelves, floors, medical supplies, and other hospital units and even get into the outside environment.
Working through each link of the chemo drug chain - vendor to pharmacy to healthcare worker to patient - Crickman developed an intervention to begin to “close” the drug-handling system literally and figuratively, implementing it in 2010. She also worked to change the culture. That meant education, and subtlety. “There is a fine line between increasing awareness and spreading fear,” Crickman explains, adding that she made sure workers knew why surveillance over everything they touched and did had suddenly increased. “They weren’t being watched, they were being helped.”
The team repeatedly swipe-tested multiple surfaces in the unit for contamination, did cleanup, then swipe-tested again for improvement. Protective gear was standardized and placed at the point of use.
Now, Crickman gets to start over again in a brand-new building at Virginia Mason. “This is the time,” she says of the pending relocation from a 1930s building. “I want to test the environment of the old unit, then the unit in the new building” to make sure safety improvements don’t get lost in the move.
In the middle of cough-and-cold season, Melissa Jones-Holley, MSN, APRN, FNP-c, was standing her ground against superbugs. An intervention at Carroll Hospital Center My Care Now that she’d developed and helped to initiate had drastically cut antibiotic prescriptions for upper respiratory infections (URIs) at the Maryland clinics. And people were getting better anyway.
Too often, Jones-Holley explains, antibiotics are being prescribed unnecessarily. Patients get well either way, so the message received is too often: get URI, get antibiotics (feel better, stop taking the antibiotics, help create drug-resistant bacteria), repeat.
“We have taken steps to improve the health of our community,” Jones-Holley says of medical advances that brought so many killer microbes under control in the first place. “We’re not going back to a time when people died of simple infections.”
So, she embarked on an intervention to decrease antibiotics prescriptions by putting providers on a common course. Patients discharged without antibiotics receive materials that explain why, including a Centers for Disease Control and Prevention (CDC) pamphlet called Get Smart: Know When Antibiotics Work. Its message:
“Bacteria cause strep throat, some pneumonia, and sinus infections. Antibiotics can work.”
“Viruses cause the common cold, most coughs, and the flu. Antibiotics don’t work.”
“There is always going to be an insistent parent -- ‘This has worked for my child before’ -- and the key is to really have a conversation,” Jones-Holley says.
On a stormy day in Connecticut, Mary L. Blankson, APRN, pointed to an even more dark and ominous cloud approaching. At least 3.2 million Americans are infected with hepatitis C, which attacks the liver, and up to 85 percent don’t know it yet. At Community Health Center Inc., Blankson and her team are working to identify the unaware and then make sure care is there for them. The challenges are significant.
In 2012, the Centers for Disease Control made screening for the hepatitis C virus (HCV) a priority after research found that those born from 1945 to 1965 were more impacted than any other age group, Blankson explains.
Why this age group? “You know, sex, drugs, and rock-and-roll,” Blankson says of a generation perhaps more open to the types of risky behaviors that can lead to infection. Plus, she adds, “Back then we hadn’t even identified hepatitis C in the nation’s blood supply, so if you got a transfusion or maybe if you had a transplant …”
HCV is a killer, a leading cause of chronic liver disease and liver cancer in the U.S. It is also treatable, but many don’t act on it because they don’t know about it. The challenges: ID all of those who need treatment. Get them into care. Get primary care providers ready to treat them.
The good news is newer, more effective meds. The bad news? Those new drugs are more expensive. At $80,000 and up per regimen, health systems don’t want to treat those unready or unwilling to adhere to it or to abstain from dangerous or unhealthy behaviors. And this is where Blankson sees nurses having a great impact.
“How can I make these patients the best candidates possible, to set them up for success in their treatment? How do we as a team go about making sure there is adherence?”
Source: Johns Hopkins School of Nursing