A Nurse's Responsibility.
"What is your responsibility to prevent antimicrobial resistance?"
ANA's periodical, The American Nurse, published the article: "Strengthening nurses' role in antibiotic stewardship" in October 2017. It begins; "The recent worldwide outbreak of Candida auris, a multidrug-resistant fungus, underscores the criticality of robust institutional and community-based antibiotic stewardship programs. Improving antibiotic use is a patient safety issue." The article focuses on what nurses can do to halt antimicrobial resistance. (1)
The January 2019 edition of The American Nurse updated the ANA's 2017 concerns and the cover photo/ text defines Candida auris as an emerging threat. The accompanying article: "Nurses' response to an emerging threat" emphasizes the potential dangers of multidrug-resistant (MDR) Candida auris as a new world-wide peril. (2)
Also, in January 2019 Lei Chen, Ph.D. Sr. Epidemiologist at the Washoe County Health District sent out a bulletin instructing: "If your healthcare facility is located in Washoe County, should you have any suspected case of Candida auris, please call us immediately at 775-328-2447."
Anyone who has followed this column since 2016 knows the problem of Antimicrobial Resistance (AR) is more extensive than the recent concerns with Candida auris, which is fungal not bacterial. Fungal Candida auris alarms go way beyond MRSA, VRE or other familiar MDR pathogens. Likewise, MDR organisms (meaning resistant to just three classes of antimicrobial agents) are now overshadowed by Carbapenemresistant Enterobacteriaceae (CRE) that can be PDRO (Pan Drug Resistant) meaning resistant to all classes of antibiotics.
Recognizing AR is an ever-expanding global threat you may ask yourself--"What can one nurse do to avoid AR?" After all, you are a single person in a vast network of health care providers and, unless you are an APN, you cannot write an antibiotic order. You may feel powerless, so why try? Which brings us to one of the basic mandates of nursing--do no harm.
The May, 2016 edition of ANA's The American Nurse includes the article "Antibiotic stewardship for staff nurses" (3) which, under the heading of: "Role of the staff nurse" highlights these five actions:
1. Ensure pertinent information about antibiotics is available at the point of care
2. Question the antibiotic administration route
3. Reassess antibiotic therapy in two to three days
4. Review antibiotic therapy when your patient develops a new C. difficile infection
5. Reconcile antibiotics during all patient-care transitions
To rephrase, the first action is: Obtain and communicate accurate information about your patient's symptoms to the prescriber. I recommend using SBAR.
The second step, you must re-evaluate and question the prescribers' initial antibiotic order, then three review subsequent C&S reports to determine if the antibiotic/ antifungal is appropriate, or needed at all. Number 4 asks you to determine if an allergic reaction, or C-diff, develops. Finally, if the C&S report shows an antibiotic is not needed, or the bacteria is resistant, you must communicate this information to the prescriber and get the initial order changed.
Let's get real
Reality is some prescribers do not want to be questioned and any nurse who questions them gets bullied. When confronted by this type of behavior you have a decision to make, do you say, "I am sorry I will never question your order again," or do you stand up and continue questioning?
If you adhere to the premise of "Do No Harm" it is your responsibility to continue questioning, which admittedly may be difficult. Depending on the politics of the institution you work at, raising concerns have been known to place a nurse's job in jeopardy. But this is a topic for another day.
Back to basics
Each time you neglect to perform proper hand hygiene you potentially cause harm. Likewise, if you observe someone failing to use proper transmission-based precautions (isolation), it does not matter if they are a nurse, visitor, RT, PT, CNA, or a physician, call them out because they place your patient at risk for infection.
Preventing an infection achieves two goals. Your patient was not harmed, and, if there is no infection there is no need to order an antibiotic.
Be observant, explore your environment and find items harboring germs. For example, let's look at privacy curtains. The American Journal of Infection Prevention published a study on how quickly a bedside curtain gets contaminated. The study found that 14 days after freshly laundered hospital curtains were hung five of eight curtains were contaminated with MRSA. (4)
Now ask yourself--during patient care, did you ever realize the curtain was not providing enough privacy and you quickly close it with your soiled gloved hand? If yes you just contaminated the curtain. Later, before tending to the patient in the next bed you wash your hands, put new gloves on and again close the curtain! You have just contaminated your clean gloves with pathogens from the patient you previously cared for!!!
Cross-contamination happens that quickly. Explore your environment for other similar scenarios to resolve.
For additional information on preventing antimicrobial resistance go to www.nvasp.net--The website of the Nevada Antimicrobial Stewardship Program. We must preserve the power of antibiotics for future generations.
Become involved and join the American Nurses Association, which enrolls you in Nevada Nurses Association. These organizations provide resources that will promote your nursing career, and antimicrobial stewardship.
1) https://www.americannursetoday.com/nurse-roleantibiotic-stewa rdship/
4) https://www.ajicjournal .org/article/S01 966553(18)30155-X/fulltext
By Norman Wright, RN, BSN, MS
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|Title Annotation:||Antibiotic Stewardship|
|Date:||Apr 30, 2019|
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