It’s that time of year: almost everyone is being discharged from hospital visits with an antibiotic. From pneumonia to skin infections to strep throat, there are a myriad of reasons your patients may leave with an antibiotic prescription. With microbial resistance on the rise, and because of the many complications of antibiotic use (C. Diff comes to mind), nurses play a crucial role in ensuring medication compliance and proper home use. Below are some tips for making sure you are teaching your patients correctly about their medications—from penicillin to Cipro and beyond.
1. Make sure your patients know to take their antibiotics with food, preferably at mealtimes.
Many antibiotics can upset the stomach or cause gastritis, so avoid taking them on an empty stomach. (The only antibiotics that should be taken on an empty stomach are ampicillin, dicloxacillin, rifabutin, and rifampin.) A heavy meal is not necessary, but a small snack can prevent indigestion.
2. It is imperative that the patient take the full bottle or dispensed amount, even if they start feeling better before completion.
In fact, it is very likely that the patient will feel better before the prescribed amount is finished. Even so, feeling better is not an indication that the bacteria are all gone. Patients who do not complete their entire prescription help promote antibiotic resistance, because any bacteria not killed yet can go on to reproduce with genes that allow them to avoid destruction by common antibiotics. Sometimes, emphasizing to patients that future antibiotics may not work for them can be an effective way to ensure compliance.
3. If the patient has a reaction to an antibiotic he or she needs to call their doctor immediately.
Several antibiotics can cause rashes or hives, or more seriously, an anaphylactic response. It is important to teach your patients to be on alert if it is a medication they’ve never taken before or if they have had reactions in the past.
For some specific classes of antibiotics, some additional teaching is required.
Fluoroquinolones, such as ciprofloxacin, levofloxacin, or moxifloxacin, can cause tendon injuries. Specifically, patients may experience peripheral neuropathy that can have permanent effects. Caution patients to immediately report any symptoms of pain, burning, pins and needles, or tingling or numbness. Rupture of the Achilles tendon is possible even with short-term use of these drugs.
Antibiotic–associated diarrhea is an overgrowth of usually harmless bacteria that live in the GI tract, most usually Clostridium difficile. In severe cases, C. diff can be life-threatening. The antibiotics most likely to cause a C. diff infection are fluoroquinolones and clindamycin, but diarrhea remains a risk when taking any antibiotic. To help prevent cases of C. diff, patients can take an over-the-counter probiotic or eat yogurt with live and active cultures (but yogurt must be ingested three times a day to be effective).
Certain antibiotics, such as tetracyclines (doxycycline) and fluoroquinolones, need to be separated from divalent cations—found in dairy products, antacids, and vitamins—by at least two hours. These antibiotics can also cause gastritis, so it is important to still eat them with a small meal to decrease this effect.
It’s no wonder our patients can be overwhelmed when taking antibiotics—there is a lot of information to remember! But proper patient education can help nurses play a role in preventing microbial resistance and ensuring safe medication compliance.
Evidence-based practice. Those three words seem to be all the buzz in health care in recent years, and there is a good reason why. Evidence-based practice (EBP) is the science of our nursing care: It keeps us current, up-to-date, and providing the best care to our patients for the best reasons.
When you break EBP down to its core, it’s an approach to making decisions and providing nursing care not just on the most current research, but also on the basis of personal clinical experience. It’s the why for your nursing care, validating your decision-making for certain tasks on the basis of outcomes and research. It incorporates the most relevant studies, literature reviews, and clinical cases, but it also emphasizes observations made in your own care over the tenure of your own practice. It aims to incorporate what you and others have found to be the most effective treatments, practices, and ideas. EBP improves patient outcomes and patient safety.
How can you bring EBP to your unit?
Use the Internet
It can be as simple as a Google Scholar search, checking Up-to-Date, or reviewing some of the recent articles from your nursing specialty’s society journal. Changes are easy to implement on the unit, whether you’re a staff nurse or a manager. Do you feel that shift report is rushed or could be improved for better patient safety? Take a look at what the literature says about the topic and what the evidence supports to increase patient satisfaction, outcomes, and safety. It’s often surprising just how much information is already published on a topic you may be interested it. Would your unit benefit from a subscription to the Annual Review of Nursing Research, the Journal of Perinatal Education, or Neonatal Network? Ask your manager to subscribe, or whether your hospital system can provide physical copies for unit reference.
Start a Unit Council
Evidence-based practice is best incorporated into nursing units with a dedicated safety nurse, educator, or EBP leader. In units without such a position, clinical practice councils can be formed by any nurse on a unit to bring together a core team of individuals to tackle unit-based issues and find literature-supported solutions. It is difficult to imagine a unit leader or manager who wouldn’t welcome this type of employee engagement in both patient safety and unit success.
It is easy to be discouraged when one considers the breadth of nursing research about a given topic. But the root of evidence-based care is in the real-world, at the bedside, and on the unit. It starts with the observation of a problem, and the drive to find the best way to fix it. You don’t have to fix the problems plaguing nursing as a profession; you are just aiming to fix issues on your own unit and in your own practice.
The PICO model can help you define a clinical question you’re attempting to address. It stands for problem, intervention, comparison, and outcome. Well-built questions identify all four components when reviewing the literature on a certain topic. It can help format your study, research, and plan of attack.
Involve New Graduate Nurses
Oftentimes, the nurses most familiar with research and clinical questions are the new graduates. New graduates today are given the tools to conduct EBP research, and have been taught the most cutting-edge and up-to-date recommendations for practice available.
After learning about cultural diversity by reading a nursing textbook, five nursing students from Pennsylvania College of Technology got to go out and experience diversity firsthand. Participating in a study abroad course, students traveled to the small town of Nueva Santa Rosa, Guatemala to treat patients in a medical clinic for seven days.
The Penn College students were led by Christine B. Kavanagh, the instructor of nursing programs, and accompanied by a larger volunteer group from Glens Falls Medical Mission. Glens Falls is based in New York and leads weekly trips to the small Guatemala community twice a year to help patients who live two hours away from the nearest hospital.
During their weeklong stint at the medical clinic, the group of volunteers saw over 1,300 patients by communicating through translators. They practiced in five clinical areas including triage, dental, pediatrics, women’s health, and general medicine, providing basic screenings, treatments, medical education, fluoride for dental care, and referrals to outside specialists when needed. Students were amazed by the positivity exuded by their patients who experience a wide variety of issues, not just medical.
Penn College offers a variety of study abroad courses, but this was the first time nursing students participated in a trip. After a successful mission, they hope to offer the course and service trip to nursing students every fall. In addition to the nursing trip, Penn College also offers a course in providing dental hygiene education in the Dominican Republic.
It seems that every day there are new discoveries in the field of Alzheimer’s disease. From new treatments to ways to screen for the disease, the condition is in the news as frequently as some politicians. How reliable are these findings, though? Are they published in reputable journals and are they anything more than snake oil? Here are four of the most recent new pieces about Alzheimer’s disease and a look into how likely they are to make an impact on patients’ lives.
The News: An article published in Forbes points to a research article in the scholarly journal Nature that studies the effect of aducanumab, an antibody that has shown promise in attacking the amyloid plaques that form between nerve cells in Alzheimer’s. In a double-blind, four-year trial, the infusion of the antibody showed marked improvement in the symptoms of Alzheimer’s in those with moderate disease indicators.
The Background: The Nature research paper, though compelling, has several flaws that most Alzheimer’s trials suffer from: the sample size. This study, though well planned, only tested the antibody on 145 patients and all were pooled from the United States. Although the study points to positive responses, the research is far from becoming a treatment for Alzheimer’s.
Implications: The study into aducanumab is certainly intriguing, but it is not convincing. Although it offers hope for those with Alzheimer’s, it is not a cure just yet. A larger study is necessary to even bring this treatment into trials, let alone present it for approval by the FDA. While interesting, the breakthrough may not be the miracle cure patients are looking for.
Indicative Gene Signatures
The News: According to an article published on ScienceDaily, a group of researchers have found that younger people with a particular gene signature can show a risk for Alzheimer’s early in life. This gene signature makes parts of the brain more susceptible to the proteins that form in the condition, causing the plaques that are so devastating to the neurons when Alzheimer’s begins in earnest.
The Background: The research was conducted by the University of Cambridge, and it was published in the journal Science Advances. The researchers studied the brain tissues from 500 healthy individuals and found this gene signature common to those that are found in Alzheimer’s patients. This pattern repeated itself in the healthy brain tissue and the Alzheimer’s identified brain tissue alike, though it does not indicate why the patients with healthy brain tissue had the signature and did not have the condition.
The Implications: As with most studies, more research needs to be done to plug up the holes in this study. Why are normal brains showing the same markings as Alzheimer’s brains? Could this be a coincidence? In any case, gene therapy is in its infancy so finding genes that are indicative of Alzheimer’s, while intriguing, does not actually help cure the disease in the immediate future.
Fast-Tracking BACE Inhibitors
The News: Unfortunately, drugs to treat Alzheimer’s are difficult to come by. One drug, named AZD3293, has shown some promise in treating mild to moderate cases of the condition by reducing the amount of amyloid buildup around the neurons. Although it has been fast-tracked, it is nowhere near ready to become a treatment for Alzheimer’s, as this article in the Wall Street Journal relates.
The Background: This new drug is supported by both Eli Lilly and AstraZeneca. The two companies are rivals in the pharmaceutical industry, but since the search for a drug is so elusive, the two have teamed up. They have even agreed to split profits from the drug, which is nearly unheard of. Unfortunately, other Alzheimer’s test drugs have caused severe liver issues and other problems in humans, and none have been viable as a drug to reverse or inhibit the disease, besides Aricept and Namenda.
The Implications: Drug companies are getting closer to finding a treatment for Alzheimer’s, and this fast track is promising. It shows that the FDA is convinced enough to give the green light and allow the companies to proceed. However, the search for a treatment still remains murky, and even this fast-tracked drug can pose problems. Although it can be a bright light in the darkness of Alzheimer’s, it could be another frustrating dead end.
The News: Instead of trying one method of combating Alzheimer’s, the researchers at Sutter Neuroscience Institute in Sacramento, California, are trying as many as five different methods to treat the disease, according to an article published in the Boston Herald. Among these, the use of the intravenous immunoglobulin antibodies, the effects of vitamin D on memory, and the ethnic implications of Alzheimer’s are all under investigation. All of these research projects are ongoing, but none have yet reached the point of publication.
The Background: Although this may seem like a scattershot method of looking for a cure, it actually makes sense. The current drugs for Alzheimer’s are woefully deficient. At best, they can give the patient an extra year of memory health, but they cannot stop the relentless march of the disease. They are inadequate at best, and the frantic search for some treatment means that this sort of research is the only way the medical profession is going to find something that works.
The Implications: Something in these research studies in Sacramento may end up being the cure for Alzheimer’s, or it may end up being something that slows its progress . . . or it may end up another dead end. The implication of this sort of study is the hope for a cure. It isn’t going to help patients now, and it probably won’t help patients in the near future. Someday, though, this sort of research will help patients. With the dedication of people like the researchers in Sacramento and across the country, a solution will eventually be found. It hasn’t been found yet, but everyone still keeps looking. That’s what counts.
A Day in the Life of a Nephrology Nurse
In honor of Nephrology Nurses Week, we wanted to give readers a peak into the daily life of nephrology nurses. Of course, especially in nursing, days can be quite different depending on the patients you’re serving or what department you’re working in. For the following three nurses, though, they’ve presented a glimpse of a typical day in nephrology.
Cindy Richards, BSN, RN, CNN Immediate Past President, American Nephrology Nurses Association Pediatric Renal Transplant Coordinator, Children’s of Alabama, Birmingham, Alabama
“The day in the life of a nephrology nurse can vary greatly! Nephrology nurses are more than just technical experts. There are many areas of knowledge that nephrology nurses provide to their patients other than just the technical aspects of dialysis care. Some of those may include the roles of caregiver, advocate, educator, facilitator, and mentor. Nephrology nurses may provide care in a hospital, a physician’s office, a dialysis unit, a nursing home, a prison, or a university. In fact, one of the best aspects of the specialty is the diversity of nephrology nursing roles and settings. Nephrology nurses can also help provide care to patients anywhere along the spectrum of renal disease. Chronic kidney disease (CKD) is listed in stages from 1 to 5, so nurses can work with patients anywhere on that continuum. Nephrology nurses’ responsibilities vary based on the setting. In an outpatient dialysis unit, the nurse is responsible for providing the dialysis therapy as ordered by the physician or nurse practitioner, as well as educating patients about their disease, their diet, their medications, and a host of other areas. If the patient chooses a home dialysis therapy, the nurse is responsible for teaching the patient and his or her family members how to perform that therapy in their home. In an inpatient hospital unit, the nurse is responsible for providing the acute care to help the patient recuperate sufficiently to be discharged home. A transplant coordinator is responsible for educating a patient about transplantation, coordinating a team to perform an evaluation to assess for suitability for transplant, and education and support after the transplant.”
Denise Delos Santos, RN, BSN Hemodialysis Nurse, Morristown Medical Center for Renal Ventures, Morristown, New Jersey
“Hemodialysis nurses provide care to patients with chronic kidney disease requiring hemodialysis. Hemodialysis involves teamwork, in which nurses work with certified hemodialysis technicians in giving direct patient care and coordinate their care with the health care team (nephrologists, dietitian, social worker, etc.). Hemodialysis nursing skills involve not only teamwork, but good assessment skills, technical skills, therapeutic communication, collaborative skills, documentation skills, good attention to detail, and leadership qualities. Patients receive dialysis three times a week; patients receive their treatment on a Monday-Wednesday-Friday schedule or Tuesday-Thursday-Saturday schedule. My day begins with arriving to the unit upon opening at 6 a.m. and ensuring all safety checks with the water treatment and dialysis machines/equipment were completed by the certified hemodialysis technicians. First shift patients are assessed upon arrival at their scheduled times. In our unit, one nurse is assigned to work with one technician to care for our ‘chair side’ stations, and the other nurse is assigned with another technician to the ‘bed side’ stations. After I perform the patient assessment and document accordingly in our computer system, we weigh the patient and calculate the goal of fluid removal for the treatment. We then proceed to initiate dialysis treatment. We monitor the patients during treatment, obtaining vital signs every half hour, and discontinue treatment when completed. Post-dialysis, we assure that the patients’ vital signs are stable, patients have been weighed, and they are safely escorted out of the unit. We then clean and disinfect each station before the next shift’s patient arrives. Hemodialysis nurses must monitor patients during treatment, assure dialysis prescription is followed per MD order, administer prescribed medications, ensure vital signs are stable before treatment and before discharging from the unit, coordinate with MDs as needed, refer patients to MDs, dietitian, or social worker as needed, refer patients to vascular access center to implement ‘fistula first,’ provide patient education, monitor patients’ monthly lab results, adjust dialysis medications per company protocol, etc. At the end of the work day, we make sure that the unit is tidied up and that all equipment was disinfected and ready for use for the following day.”
Joana Rengstorf, RN-BC, CMSRN, ONC Charge Nurse, Regions Hospital, St. Paul, Minnesota
“As a charge nurse in an acute care setting, I begin my shift getting report from the previous charge nurse. We discuss each patient’s needs and plan of care. We review staff assignments for the shift and discuss which staff may need more support based on their patients’ needs as well as the level of experience and proficiency of the staff working. After charge report, I complete chart reviews on all patients on my unit. I review lab results, nursing and provider notes, orders, and their daily schedule (peritoneal dialysis vs hemodialysis vs diagnostic procedures). I then round on each patient on the unit with the staff nurse to review the plan of care and discuss any questions I may have with the staff nurse. If there are urgent needs or questions, I assist the nurses with patient cares or by contacting providers. I then participate in multidisciplinary rounds and discuss treatment plans, help address any difficulty with patient compliance, and review discharge plans. Throughout the shift I provide support and education to staff nurses as needed.”
Because nephrology nurses often work with their patients for months or years, Richards says the biggest challenge is making sure not to cross professional boundaries and maintaining appropriate relationships with people they may see as extended family. For Delos Santos, the challenge is to work with patient compliance. “Patients are expected to comply with their fluid, dietary, and medication regimens,” she says. Despite this, many remain noncompliant, which leads to hospitalization and even death. Rengstorf agrees that noncompliance is an issue. For nurses, it’s also tough to maintain a healthy work-life balance, as working with patients with chronic illness can be difficult. Patients can feel frustrated and have expectations that can take a toll on their mental health and coping skills. This can lead to caregiver fatigue.
“My favorite part of being a nephrology nurse is getting to know the patients and working with my team,” says Delos Santos. “We are a big part of their lives as we are their ‘lifeline’ in providing dialysis. I believe that creating an environment of comfort and feeling at home is an important part of what we do.” “I love working with patients and their families over many months and years. As nephrology nurses, we get to assist the patient with attempting to achieve the highest quality of life they can attain,” explains Richards. “It’s also rewarding to help patients to stay healthy on dialysis in an attempt to receive a kidney transplant and transition from chronic dialysis therapy to a more normal lifestyle with a transplant or to help a patient stay as healthy as possible in order to delay the start of dialysis therapy.” Rengstorf loves her job as well. “It’s rewarding to know the care you provide is literally life-saving. When patients share stories about milestones and celebrations they were able to participate in, it is rewarding to know they are alive for those moments because of the dedication of those in my profession.”
Bill Warner, a concrete mixer driver in North Carolina, had always been a “strong” and “innovative” man, according to his wife, Carla. But after undergoing a routine endoscopic procedure at a local hospital in early 2013, the once robust 55-year-old developed a raging infection—a superbug—that rendered him “unable to do even the simplest tasks for himself,” his widow recounted last year in testimony before the U.S. Food and Drug Administration.
Warner, it turns out, had contracted Carbapenem-resistant Enterobacteriaceae, or CRE, a highly resistant bacteria that kills up to half of patients infected with it. The superbug ravaged Warner’s body. He lost more than 60 pounds, required tube feedings and was racked with excruciating pain. In November of 2013, after eight months of battling the infection, he died.
Drug-resistant organisms like the one that killed Warner are on the rise—and health officials warn that lethal infections will become more widespread unless the health care community takes aggressive action. Fueled in part by the overuse and misuse of antibiotics, drug-resistant germs cause more than 2 million illnesses and kill at least 23,000 Americans every year, according to the Centers for Disease Control and Prevention (CDC). Cases of Klebsiella pneumoniae carbapenemase (KPC), the most common type of CRE, have increased sevenfold over the past decade.
With a shrinking arsenal of antibiotics to combat these virulent infections, and a scarcity of new drugs in the development pipeline, health care officials warn that superbugs could lead to a global crisis. At the rate things are going, superbugs could kill 10 million people a year worldwide by 2050, according to one recent report on antimicrobial resistance backed by the British government.
The good news is that infection control experts say there is still time to act. Edward Septimus, MD, the medical director of infection prevention and epidemiology at HCA and a professor at Texas A&M Medical School, told attendees of last year’s international Infection Prevention Society (IPS) conference that the world is at a “tipping point.” With proper infection prevention strategies and better antimicrobial stewardship, he says, it’s still possible to slow the spread of supergerms, but “if we don’t take these warning signs seriously, we are going to be headed into a full-blown crisis.”
With that in mind, here’s a look at the three antibiotic-resistant pathogens that the CDC has classified as the most “urgent threats” and information on what nurses can do to help combat the problem.
Carbapenem-resistant Enterobacteriaceae (CRE)
The Threat: This so-called “nightmare” bug is not just one germ, but actually several different strains of bacteria within the Enterobacteriaceae family, which live in the gut. What all CREs have in common—and what makes them different from “normal” species of Enterobacteriaceae—is that they are resistant to carbapenems, powerful antibiotics generally reserved as “last-line” agents for the gravely ill. This leaves clinicians with few options in treating such infections. Symptoms vary, but CRE can cause sepsis, pneumonia, meningitis, and urinary tract and wound infections. Immunocompromised patients, and those being treated with invasive devices, such as central lines, urinary catheters, and mechanical ventilation, are more susceptible to illness.
Danger Zones: While CRE has been reported in most states, the pathogen—at least for now—is mostly confined to acute care hospital settings. Long-term acute care facilities are especially good at incubating the microbe. During the first half of 2012, 4% of short stay-hospitals reported a CRE infection, compared to 18% of long-term facilities, according to a 2013 CDC Morbidity and Mortality Weekly Report. Several CRE outbreaks around the country have been traced to a contaminated duodenoscope used in an endoscopic retrograde cholangiopancreatography (ERCP) procedure, which is used to diagnose and treat problems in the pancreas and bile ducts. Rooms of infected patients are also a breeding ground for CRE. The most contaminated areas include bedside tables, infusion pumps, and sheet surfaces that surround a patient’s pillow, legs and “crotch,” according to a 2013 study in the Journal of Clinical Microbiology.
What You Can Do: Hand hygiene is the number one way to prevent CRE infections and personal protective equipment should be used when caring for patients. Identifying infected patients early is also key. Hospitals should take pre-emptive precautions for patients transferred from high-risk facilities—and once a patient is found to have CRE, contact precautions should be initiated. Ideally, patients should be isolated in a single room. If that’s not possible, patients and staff should be “cohorted” to reduce the risk of transmission. There’s also growing evidence that bathing CRE-positive patients with antiseptic washes like Chlorhexidine can reduce contamination.
Clostridium difficile (C. difficile)
The Threat: This aggressive intestinal bug causes half a million infections in the United States each year and is responsible for one-third of all health care infections, according to the CDC. Toxins produced by C. difficile damage the lining of the intestine and lead to explosive and watery diarrhea. Older age, recent antibiotic use, and immune system dysfunction are all risk factors for developing C. difficile. The infection can be stubbornly difficult to eradicate and relapses are common.
Danger Zones: While some infections are occurring in the community, the vast majority of cases are contracted in health care facilities. Studies have shown that the hearty C. difficile spores can persist for up to five months on hard surfaces in hospital rooms. Hot spots for contamination include floors and bedrails—but windowsills, toilets, call buttons, telephones, and other objects also harbor the germ. C. difficile spores are often spread to other patients on the hands of nurses and other health care providers.
What You Can Do: Frequent handwashing with soap and water is the number one way to reduce the spread of C. difficile, as alcohol-based hand sanitizers DO NOT kill the bug. Patients should also be placed on contact precautions in single rooms. All visitors and caretakers should wear disposable gloves and gowns when entering a patient’s room, according to the CDC, and rooms should be cleaned daily with bleach or another EPA-approved spore-killing disinfectant.
Neisseria gonorrhoeae (N. gonorrhoeae)
The Threat: In 2006, there were five different treatment options for this common sexually transmitted disease. Today, the CDC warns, there is only one effective class of antibiotics left to treat gonorrhea—the cephalosporins—and new strains emerging in Japan, England, and other countries have proved to be impervious even to those treatments. Currently, the CDC recommends dual therapy for patients—an oral dose of azithromycin and single shot of ceftriaxone—and it is still “highly effective” here in the United States. Gonorrhea can be insidious, though, and women, in particular, may be asymptomatic. When symptoms do occur, they may experience vaginal discharge, abdominal pain, and painful urination. Men frequently present with burning pain upon urination and a purulent urethral discharge. Infection can also occur in throat and rectum.
Danger Zones: Unlike the other two pathogens mentioned in this article, drug-resistant gonorrhea is flourishing in the community—not the hospital. While anyone sexually active is at risk, gonorrhea is common among younger people, between 15 and 24 years of age, and disproportionately affects racial and ethnic minorities as well as men who have sex with men (MSM).
What You Can Do: Candy Hadsall, RN, MA, an STD nurse specialist with the Minnesota Department of Health, says the most important thing nurses can do is stay up to date on the latest CDC treatment guidelines and share the information with their colleagues. Infections should be treated right away with the two medications listed above—and treatment of sexual partners is also a top priority. More than three dozen states, including Minnesota, also provide “expedited partner therapy,” which allows providers to send patients home with a prescription to treat their sexual partners, though it’s still best for individuals to see a clinician so they can receive the IM injection that is most effective in curing the infection. Be sure to instruct patients to complete the entire prescription and to return for retesting by culture and antibiotic susceptibility testing if symptoms persist. Treatment failures should be reported to the health department. Sexually active MSM and women with new and/or multiple partners, or a partner with an STD, should be tested at least once a year for gonorrhea.