Nevada RN - May 2019
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Page 10 • <strong>Nevada</strong> <strong>RN</strong>formation <strong>May</strong>, June, July <strong>2019</strong><br />
Antibiotic Stewardship<br />
Many nurses who read<br />
<strong>RN</strong>formation are not members<br />
of the <strong>Nevada</strong> Nurses<br />
Association (NNA) or the<br />
nationwide American Nurses<br />
Association (ANA) and, before I<br />
continue, the question at hand<br />
is:<br />
“What is your responsibility<br />
to prevent antimicrobial<br />
resistance?”<br />
ANA’s periodical, The American Nurse, published<br />
the article: “Strengthening nurses’ role in antibiotic<br />
stewardship” in October 2017. It begins; “The recent<br />
worldwide outbreak of Candida auris, a multidrugresistant<br />
fungus, underscores the criticality of<br />
robust institutional and community-based antibiotic<br />
stewardship programs. Improving antibiotic use is a<br />
patient safety issue.” The article focuses on what nurses<br />
can do to halt antimicrobial resistance. 1<br />
The January <strong>2019</strong> edition of The American Nurse<br />
updated the ANA’s 2017 concerns and the cover photo/<br />
text defines Candida auris as an emerging threat.<br />
The accompanying article: “Nurses’ response to an<br />
emerging threat” emphasizes the potential dangers<br />
of multidrug-resistant (MDR) Candida auris as a new<br />
world-wide peril. 2<br />
Also, in January <strong>2019</strong> Lei Chen, Ph.D. Sr.<br />
Epidemiologist at the Washoe County Health District<br />
sent out a bulletin instructing: “If your healthcare<br />
facility is located in Washoe County, should you have<br />
any suspected case of Candida auris, please call us<br />
immediately at 775-328-2447.”<br />
A Nurse’s Responsibility<br />
By Norman Wright, <strong>RN</strong>, BSN, MS<br />
History<br />
Anyone who has followed this column since 2016<br />
knows the problem of Antimicrobial Resistance (AR) is<br />
more extensive than the recent concerns with Candida<br />
auris, which is fungal not bacterial. Fungal Candida<br />
auris alarms go way beyond MRSA, VRE or other<br />
familiar MDR pathogens. Likewise, MDR organisms<br />
(meaning resistant to just three classes of antimicrobial<br />
agents) are now overshadowed by Carbapenemresistant<br />
Enterobacteriaceae (CRE) that can be PDRO<br />
(Pan Drug Resistant) meaning resistant to all classes of<br />
antibiotics.<br />
Recognizing AR is an ever-expanding global threat<br />
you may ask yourself - “What can one nurse do to<br />
avoid AR?” After all, you are a single person in a vast<br />
network of health care providers and, unless you are an<br />
APN, you cannot write an antibiotic order. You may feel<br />
powerless, so why try? Which brings us to one of the<br />
basic mandates of nursing – do no harm.<br />
The <strong>May</strong>, 2016 edition of ANA’s The American Nurse<br />
includes the article “Antibiotic stewardship for staff<br />
nurses” 3 which, under the heading of: “Role of the<br />
staff nurse” highlights these five actions:<br />
1. Ensure pertinent information about antibiotics is<br />
available at the point of care<br />
2. Question the antibiotic administration route<br />
3. Reassess antibiotic therapy in two to three days<br />
4. Review antibiotic therapy when your patient<br />
develops a new C. difficile infection<br />
5. Reconcile antibiotics during all patient-care<br />
transitions<br />
To rephrase, the first action is: Obtain and<br />
communicate accurate information about your patient’s<br />
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The second step, you must re-evaluate and question<br />
the prescribers’ initial antibiotic order, then three review<br />
subsequent C&S reports to determine if the antibiotic/<br />
antifungal is appropriate, or needed at all. Number 4<br />
asks you to determine if an allergic reaction, or C-diff,<br />
develops. Finally, if the C&S report shows an antibiotic<br />
is not needed, or the bacteria is resistant, you must<br />
communicate this information to the prescriber and get<br />
the initial order changed.<br />
Let’s get real<br />
Reality is some prescribers do not want to be<br />
questioned and any nurse who questions them gets<br />
bullied. When confronted by this type of behavior you<br />
have a decision to make, do you say, “I am sorry I will<br />
never question your order again,” or do you stand up<br />
and continue questioning?<br />
If you adhere to the premise of “Do No Harm” it<br />
is your responsibility to continue questioning, which<br />
admittedly may be difficult. Depending on the politics<br />
of the institution you work at, raising concerns have<br />
been known to place a nurse’s job in jeopardy. But this<br />
is a topic for another day.<br />
Back to basics<br />
Each time you neglect to perform proper hand<br />
hygiene you potentially cause harm. Likewise, if you<br />
observe someone failing to use proper transmissionbased<br />
precautions (isolation), it does not matter if they<br />
are a nurse, visitor, RT, PT, CNA, or a physician, call them<br />
out because they place your patient at risk for infection.<br />
Preventing an infection achieves two goals. Your<br />
patient was not harmed, and, if there is no infection<br />
there is no need to order an antibiotic.<br />
Be observant, explore your environment and find<br />
items harboring germs. For example, let’s look at<br />
privacy curtains. The American Journal of Infection<br />
Prevention published a study on how quickly a bedside<br />
curtain gets contaminated. The study found that 14<br />
days after freshly laundered hospital curtains were<br />
hung five of eight curtains were contaminated with<br />
MRSA. 4<br />
Now ask yourself - during patient care, did you ever<br />
realize the curtain was not providing enough privacy<br />
and you quickly close it with your soiled gloved hand?<br />
If yes you just contaminated the curtain. Later, before<br />
tending to the patient in the next bed you wash your<br />
hands, put new gloves on and again close the curtain!<br />
You have just contaminated your clean gloves with<br />
pathogens from the patient you previously cared for!!!<br />
Cross-contamination happens that quickly. Explore<br />
your environment for other similar scenarios to resolve.<br />
For additional information on preventing<br />
antimicrobial resistance go to www.nvasp.net – The<br />
website of the <strong>Nevada</strong> Antimicrobial Stewardship<br />
Program. We must preserve the power of antibiotics<br />
for future generations.<br />
Become involved and join the American Nurses<br />
Association, which enrolls you in <strong>Nevada</strong> Nurses<br />
Association. These organizations provide resources that<br />
will promote your nursing career, and antimicrobial<br />
stewardship.<br />
Citations:<br />
1) https://www.americannursetoday.com/nurse-roleantibiotic-stewardship/<br />
2) https://www.americannursetoday.com/candida-aurisemerging-threat/<br />
3) https://www.americannursetoday.com/antibioticstewardship-staff-nurses/<br />
4) https://www.ajicjournal.org/article/S0196-<br />
6553(18)30155-X/fulltext<br />
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