Thursday, December 27, 2018
MANAGE NURSING CARE AT HOME, How? Part 3, Infection, Contamination, HIPAA
Homes, as well as hospitals, have got to maintain strict practices if infection of the patient or the caregivers is to be avoided. This brief presentation cannot cover all important aspects of infection control, but it should help you understand the major issues.
The basic elements of infection are viruses, bacteria, and fungi (yeast, etc.). Viruses are not quite alive, but they capture the mechanisms of a cell to enable themselves to be replicated, often damaging the host; flu and HIV viruses are familiar. Bacteria are single-celled organisms that can replicate on their own but use the host to enhance their growth; gastro-intestinal ailments and skin wound infections are typically due to bacteria. Fungi are single-celled or multi-celled organisms that, like bacteria, feed off the host; they spread by producing spores; “yeast” infections are due to fungi.
A systematic approach to infection control looks at the following items:
Sources: Infected people are the major hazard. Post notices that people with colds should not come in the house or the room. That includes nurses, unless they are wearing respiratory equipment, not just masks, but equipment that completely filters what they exhale (e.g., through a HEPA filter, a High-Efficiency Particulate Air filter, an “absolute filter” 99.9+% efficient). Face masks allow leakage around the edges in contact with the skin and are usually made of low-efficiency filter material. They do prevent spit from speaking or coughing from becoming airborne. Unfortunately, the patient may come home from the hospital with an infection (“nosocomial” or “iatrogenic”), perhaps “colonized,” quite possibly a danger to the staff and family.
Transmission: Coughing, talking, sneezing, as well as shedding from exposed skin, make the organisms airborne, allowing them to travel to the patient, unless the patient is breathing air which is filtered by an absolute filter. Direct surface contact occurs when the patient is touched by someone who is contaminated. Indirect surface contact occurs when a contaminated person touches a surface that is subsequently touched by the patient or by someone who touches the patient. Instruments brought into contact with the patient can carry infectious agents (“germs”), which are particularly dangerous when the skin is broken, or the probe goes inside the body. Food and drink and medicines can bring dangerous biological agents, as well, although the stomach is not sterile, and its acidity generally handles the destruction of most organisms without allowing illness.
Barriers: For airborne transmission, one can try to direct clean air toward the patient and against the flow of contaminated air; pharmaceutical and microelectronics manufacturing cleanrooms are kept at higher pressures than their environments, and the pressure in a ventilator mask can be set so as not to become a slight vacuum when the patient inhales, so that it is always at a “positive pressure” with respect to the air in the room. Contact transmission from caregivers and others is reduced using disposable gloves, which themselves must be kept clean or replaced frequently. Sometimes, a second pair is worn over the first, so that a change can be made readily when the outer pair become contaminated. Caregivers and visitors should wash their hands thoroughly before and after coming in contact with the patient, preferably with an antibacterial soap. Ideally, objects brought into contact with the patient would be clean and sterile, but in practice those objects making external contact are cleaned and disinfected (e.g., with alcohol/water or vinegar/water solutions), rather than sterilized (e.g., with bleach or iodine solutions or submersion in boiling water), which is appropriate for internal contact or contact with broken skin. Wounds and sores are protected with antibiotic ointments or petroleum jelly and with impermeable coverings such as bandages, except where exposure to the air through a gauze dressing is prescribed instead.
Removal: Although little can be done to remove airborne agents once inhaled, those that settle on the skin can be removed with washing and disinfecting or even using sterilizing solutions. Where cuts are involved, the value of sterility may be offset by the possible chemical harshness of a sterilizing agent, leading to the use instead of various “antibacterial” solutions that include soap and anti-microbial chemicals, or simply soap, or an alcohol/water solution and rubbing with the fabric containing it. Harmful chemicals that are ingested are sometimes removed by encouraging vomiting, using an emetic liquid, but one rarely knows that a liquid with dangerous germs has recently been ingested.
Hardening the target: To make the patient less susceptible to infection is a major goal of the maintenance of general good health, including optimal nutrition and adequate sleep. Viral infections must be defeated by the patient; vaccinations help prepare the immune system for this battle. For the elderly, however, flu shots are often only 50% efficient, and for younger people only somewhat better. We require our nurses to get vaccinated against the flu, as do the patients and the family.
Remedy: If the patient becomes ill, the causal organism is determined, and medicine prescribed, if available. As noted, little can be done about most viruses once they are active, except to maintain the patient’s general health. For a urinary tract infection, a common ailment in chronic illness situations, a urine sample is taken and tested against available drugs, a “culture and sensitivity” test, which will indicate to which antibiotics the organism is “sensitive,” meaning susceptible. Secretions from the lung, sputum, can be analyzed similarly for the same purpose. An infected wound will be treated by a broad-spectrum antibiotic cream or ointment, often after receiving wiping with a disinfectant or a sterilizing agent in a pad. These infections can lead to more general, systemic, infections which must be caught immediately (by noting elevated temperature, pulse rate, respiration rate) and treated with antibiotics, administered orally, by gastric tube, intravenously, or by intra-muscular injections, as ordered by the doctor.
The considerations for contamination control are like those for infection control, except that it would be unusual for a contaminating chemical to reach the patient in a dose large enough to cause illness. Sources need to be identified and eliminated or minimized. Transmission through the air is prevented using clean air flowing toward the source rather than from it or using filters, filtered air supply, and facemasks for the patient and caregivers. Face masks generally will reduce the inhaled concentration of airborne solids and liquids (aerosols) but not eliminate them and rarely are they effective on toxic gases, should any be present.
Spills of liquids and powders need to be cleaned up carefully and thoroughly. A spill should be absorbed in a wiper that is then discarded; next, the area is rinsed with clean water, and that water absorbed, and that wiper discarded, too. Wipe from the cleanest toward the dirtiest, from the driest toward the wettest. Gloves should be used. Using a damp wipe on the patient’s skin will transfer some skin oils and salts from caregiver to patient, unless the wipe is held in a glove. Liquids or powders spilled onto the floor represent a hazard from reduced traction for the staff, leading to slips and falls. Even a dry cloth or paper on the floor can represent a hazard; we lost a nurse for three months after she slipped on a dryer anti-static sheet in our laundry room. [She should not have dropped it, should have picked it up, should have not stepped on it, but “should” doesn’t mean “didn’t.”]
Removal of contaminants from the patient is normally done with soap and water or alcohol and water, again with a gloved hand holding a clean, damp wipe. Removal is completed when the surface is wiped dry.
This section alerts you to the risk of running afoul of the Federal Health Information Portability and Accountability Act of 1996, HIPAA. Basically, you want to keep medical information confidential. Grant (2014) describes the mechanisms necessary to achieve and maintain compliance. He represents a company that offers services of this kind: The Compliancy Group, LLC. “LLC” for “Limited Liability Corporation” means they have taken steps to incorporate and limit their liability, just in case. In case of what? In case someone takes their advice, gets in trouble with the Feds, and tries to blame Grant and Group. They offer The Guard, to control the audit process: “regulatory review, risk analysis, risk management, document management, and incident management.” You can contact them at email@example.com.
A homeowner is not likely to need the Group’s services but is well advised to keep the medical information of the patient restricted to those with what the government calls “need to know.” The doctors treating the patient will likely want the protection of signed acknowledgment of their HIPAA policies, restrictions, and practices designed to safeguard patient information.
The seriousness of these HIPAA issues is reflected in the costs of the ebooks on the topic at Amazon. The first 15 in terms of relevance ranged from $1 to $430, with half costing $25 or more.
The manager of nursing care at home should assure that sensitive information is not stored on computers connected to the Internet and that paper copies be carefully handled to prevent theft or loss.