C Diff. The infection that can run rampart in nursing homes and hospitals. Nursing Homes Magazine has an article about this nasty illness we deal with, often:

Clostridium difficile—also known as C. diff—is a bacterium commonly found in hospitals and long-term care (LTC) settings. Infection can lead to diarrhea, colitis, and other symptoms that can be debilitating and even deadly, particularly in the elderly. In recent years, there have been several reports of infection affecting both individuals and whole groups of patients treated in hospitals and healthcare facilities around the world. Based on available reports, hundreds of thousands of people experience symptoms related to C. diff infection each year, and that number is growing as more virulent and resistant strains emerge.

Some interesting facts:

Although clinicians report that C. diff spores are present in most hospital and LTC settings, many questions remain as to why some infected patients go on to develop symptoms while others do not. In fact, most of those infected—70–90%—experience no symptoms at all. Others go on to develop symptomatic disease and potentially recurrent life-threatening symptoms.

I always assumed those who tested positive for C Diff had the symptoms as well.

While discontinuation of antibiotic therapy is generally the first-stage treatment, it can also introduce serious risks for some patients. A sudden cessation of treatment might reexpose patients to the infection that therapy was originally intended to treat or prevent. Also, after cessation of antibiotic therapy, treatment typically—and paradoxically—involves the use of antibiotic therapy. This makes C. diff infection one of the few health problems that is both caused by and treated with antibiotics.

This makes sense of course.

There have also been some difficulties recorded with the use of antibiotic therapy to treat this infection. Patients treated with metronidazole, an antibiotic commonly used to treat moderate infection, show a failure rate of at least 10% and a recurrence rate reaching 30% or more. Many experts also express concern that treatment with vancomycin, prescribed for more severe cases of infection, could be contributing to greater drug resistance among other infection-causing organisms. In recent years, there have been many reported cases of selection of vancomycin-resistant Enterococcus species following treatment with the antibiotic.

NOT what we need: C Diff to become a superbug.

Many infectious disease specialists believe that new and more virulent strains of C. diff could someday represent a potentially serious threat to public health. As researchers explore possible correlations between strain virulence and higher incidences of community-acquired CDAD, clinicians have become particularly concerned about strains of community-acquired CDAD occurring in people who have not previously been treated with antibiotics. A recently discovered epidemic C. diff bacterium produces up to 20 times more toxin than other strains and, even more ominously, appears to be resistant to fluoroquinolone antibiotics such as ciprofloxacin and levofloxacin. This strain has thus far been found only in hospitalized patients and some LTC facilities and not in the community.

And this news doesn’t surprise me at all: Community acquired C Diff. The challenges this will present will be very difficult to deal with.

Heightened awareness of C. diff could help facilities develop more effective preventive strategies to reduce incidences of infection. Most basic strategies call for increased attention to personal hygiene. Because the primary means of transmission seems to be via the hands of healthcare workers and other patients and residents, proper sanitation (handwashing) and barriers (gloves, gowns) are considered by infectious disease experts to be the most effective measures of disease control in healthcare settings. Regular and thorough cleaning of patient rooms with antibacterial cleaning agents—including bleach at a 1:10 dilution in water—can be effective in reducing the presence of C. diff spores in the environment.

We can’t say it LOUD enough: WASH YOUR HANDS. WITH SOAP AND WATER. DO not use gel sanitizers- they don’t kill all the spores. I know of a few nursing homes in my area that insist the staff DO USE the gels, and also, use the gels to wipe down surfaces and door knobs! These places have entire units of residents infected and re-infected with C Diff…it’s because they’re not following the proper hand cleaning procedures.

CDC Web Site on C Diff

The Joint Commission releases new Patient Safety Goals:

(OAKBROOK TERRACE, Ill. – June 25, 2007) The Joint Commission today announced the 2008 National Patient Safety Goals and related Requirements for each of its accreditation programs and its Disease-Specific Care Certification Program. The Goals and Requirements, recently approved by the Joint Commission’s Board of Commissioners, apply to the nearly 15,000 Joint Commission-accredited and certified health care organizations and programs.

Major changes in this sixth annual issuance of National Patient Safety Goals include a new Requirement to take specific actions to reduce the risks of patient harm associated with the use of anticoagulant therapy, and a new Goal and Requirement that address the recognition of, and response to unexpected deterioration in a patient’s condition. The new anticoagulant therapy Requirement addresses a widely-acknowledged patient safety problem and becomes a key element of the Goal: Improve the safety of using medications. It is applicable to hospitals, critical access hospitals, ambulatory care and office-based surgery settings, and home care and long term care organizations. The new Goal and Requirement respecting the deteriorating patient will ask hospitals and critical access hospitals to select a suitable method for enabling care-givers to directly request and obtain assistance from a specially-trained individual(s) if and when a patient’s condition worsens. Each of the foregoing new Requirements has a one-year phase-in period that includes defined milestones. Full implementation is targeted for January 2009.

In addition, an existing Requirement to assure the timely reporting of critical test results has been extended to the long term care program. Further, for all programs, the Requirement that addresses hand hygiene also has been expanded to permit use of the World Health Organization (WHO) Hand Hygiene Guidelines as an alternative to the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

Finally, the Requirement to limit and standardize drug concentrations that is part of the Goal to improve the safety of using medications will be retired as a National Patient Safety Goal, but organization compliance will continue to be evaluated as part of the Medication Management standards.

Read more at the JCAHO’s site.

We’ve all seen this happen: A resident is admitted on a Friday afternoon when doctors are no where to be found; family tells us the patient is “doing well” and the discharge summary from the hospital tells us the patient is stable. THEN, we find out the truth over the weekend. The resident is NOT stable and needs attention nursing homes are not able to provide. This case is interesting. The death of a resident is at issue. Specifically the nursing home and some staff are being charged with negligence because they allowed the resident’s 02 to run dry; the nursing home defense is claiming the resident should not have been admitted on a
Saturday in an unstable condition.

BIG RAPIDS – Attorneys representing six former nursing home employees charged in the death of a 50-year-old patient pointed the finger of blame elsewhere during a court hearing Monday, saying Sarah Comer died because Spectrum Health transferred her to the home before she was stable.

That is in contrast to the state attorney general’s claim that Comer died because the home’s employees allowed her oxygen tank to run empty.

The long-running preliminary hearing, which began last August and has resumed sporadically ever since, is to determine whether there is enough evidence for the former employees to stand trial.

Defense attorneys began laying the groundwork Monday to prove Comer died not from lack of oxygen, but because she had an irregular heartbeat when transferred from Spectrum’s Meijer Heart Center to Metron of Big Rapids.

“This woman should never have been released from Spectrum,” David Nickola, one of seven defense attorneys, said during a break in the hearing. “It’s a matter of making a buck and someone dying.”

Comer was found dead the morning of Jan. 16, 2005, 16 hours after she was transferred from Spectrum’s Butterworth Campus.

The state attorney general contends she died because a nurse aide and two nurses at Metron of Big Rapids allowed her oxygen tank to run empty.

Another nurse, former administrator Robert Koch and former medical director Rudy Ochs are charged with falsifying records to cover-up Comer’s cause of death.

Earlier in the long-running hearing, Dr. Gregory Sandman, former head of the hospital’s intensive care unit, testified Comer was stable when she was transferred to Metron of Big Rapids.

On Monday, Gary Jeromin, a former respiratory therapist for Metron, said he tried in vain to convince his bosses at the Cascade Township-based company not to accept patients with respiratory problems on Fridays, Saturdays or Sundays, since no respiratory therapist was on duty weekends.

Comer was admitted on a Saturday.

“This is really crazy,” testified Jeromin, who is not a defendant in the case. “We get these patients with no notice at all showing up at our door.”

Much is at stake here. Depending upon the outcome of this case, nursing homes will look at the policy regarding accepting admissions on weekends and off hours. Also, this proves a point in sending a nurse or the DON to the actual hospital and making an assessment BEFORE accepting a resident…we do this at my work. No matter what the discharge summary tells us, we send in our own people to check things out.

Senator Grassley is asking the GAO to make sure non profit hospitals are not abusing the nearly tax-free status they enjoy. This makes sense…because our government allows these hospitals to not pay taxes in exchange for extra funding for patient care AS well as free or nearly free care for the poor and disadvantaged. We want to make sure the hospital leadership isn’t taking this all for granted.

U.S. Sen. Charles Grassley wants federal investigators to find out whether nonprofit hospitals deserve the billions of dollars they receive in tax exemptions.

The Iowa Republican sent a letter Thursday to the Government Accountability Office, asking for a broad investigation into the issue.

“We need to get a better handle on how nonprofit hospitals are fulfilling their requirement to serve the community in exchange for the generous tax breaks they receive,” Grassley said in a news release. “This is especially important as policymakers talk about helping the uninsured.”

Many hospitals, including almost all in Iowa, are defined as charities. They are exempt from most taxes on property and income.

Critics say many hospitals fail to earn those exemptions.

Hospital supporters say they provide many benefits, including billions of dollars of charity care and care for patients on Medicaid, which does not cover all costs.

It will be interesting to see the results of the investigation- which isn’t on the table yet…so it will likely be years before we know.

People are catching MRSA more and more often now- out in their communities as well as via a hospitalization. Scientists are working on vaccines to create immunity to this menace.

MRSA, a type of staph infection resistant to most antibiotics, is affecting more and more healthy people as a new strain emerges in the general community. The infections are becoming increasingly resistant to antibiotics as a new, more potent strain emerges outside the hospital — especially among athletes who come in close contact. Typically, MRSA doesn’t get worse than a skin boil, but it can lead to severe problems and sometimes death.

“It hits healthy people. It actually seems to be much more virulent, and it can produce toxins and actually make people very sick, very quickly,” Tom Talbot, M.D., an infectious disease epidemiologist at Vanderbilt University in Nashville, explained.

That’s why scientists are developing a vaccine to stop MRSA in its tracks.

In one study, the Staphylococcus aureus Polysaccharide Conjugate Vaccine, or StaphVAX, appeared to protect 94 percent of people.

This sounds promising.

This is a little old- from the beginning of March. It seems MRSA and copper do not go together. Interesting.

Stainless steel door handles and taps at a hospital are being replaced with copper ones in an effort to reduce the presence of the superbug MRSA.

Scientists think properties found in copper can reduce its presence, as opposed to stainless steel, a commonly used metal in health centres.

Birmingham’s Selly Oak Hospital is swapping steel for copper in an 18-month trial to test the findings.

At least 5,000 people are likely to die every year from the MRSA infection.

Unions in NY state are suing the state over the planned restructuring of the state’s health care centers and hospitals.

ALBANY, N.Y. — Three of the state’s biggest public employee unions on Tuesday sued to block the state over the planned restructuring of the health care system announced last year.

In November, the so-called Berger commission recommended closing nine small hospitals and seven nursing homes in New York in a plan billed as one of the most sweeping health care reforms ever proposed by a state.

All 16 facilities would be forced to close by mid-2008 to reduce a statewide glut of hospital beds. Dozens more would be forced to merge, downsize or change the type of care they offer.

A suit filed by the Civil Service Employees Association is challenging the commission’s recommendations for Erie County Medical Center in Buffalo, Van Duyn Home and Hospital and Upstate Medical Center in Syracuse and Glendale Nursing Home in Schenectady County.

Suits by United University Professions and the Public Employees Federation are challenging the recommendation to privatize SUNY Upstate Medical Center in Syracuse by merging it with Crouse Hospital.

The suits were all filed in state Supreme Court.

Health Department spokesman Marc Carey said a total of 12 suits have been filed against the commission, three of which were already dismissed.

“As of January 1, the commission’s recommendations have the force of law,” he said. “The department was given the task of implementing those recommendations and that is what we are doing now.”

This is different from the stance these unions had just a month ago when they supported most of these plans. I guess they acted prematurely; I do think it’s too late now for action like this. It’s difficult to see nursing homes closed down and residents moved to other places; even when it make sense financially.

When a resident or patient falls, and hits their head, nursing staff have serious responsibility to monitor the possible effects. Brain injuries are life altering events and sometimes we can prevent this from happening. By intervening at critical times, we have a big impact on people.

Nursing Home Magazine’s October Issue has guild lines that are sound and should be followed. CNA’s often play an important role in helping the nurse perform neurological exams. It’s vitally important to be timely when you’re asked to help with these exams. The best scenario would be for the nurse and CNA to go together to do this.

Protecting Your Residents and Facility
A crisis of the neurological system can be the most challenging to monitor and evaluate for any healthcare professional. Whether it’s a brief check of neurological status or a comprehensive neuro exam, a nurse’s assessment may uncover nervous system dysfunction before it is too late. Therefore, it is essential that every nursing facility has policies and procedures, coordinated by the medical director, to guide and address when and how these exams should be done. Consider the following when developing your plans:

1. Have a licensed nurse perform neurological checks after all unwitnessed falls involving residents with a history of confusion or residents with a suspected head injury.

2. Check for signs and symptoms of head injury, which include one or more of the following:

* unusual drowsiness or can’t be awakened (easily or at all), mental confusion, slurred speech
* nausea and forceful or repeated vomiting, stiff neck and fever
* seizure activity
* unequal pupils, papillary response, or accommodation
* clumsy walking, stumbling, or other problems with use of extremities, areas of numbness, parasthesias
* headache (mild or severe), dizziness, double vision, or blind spots
* increased blood pressure or a marked drop in blood pressure
* decrease in pulse and/or increased and shallow respirations (these are associated with intracranial pressure)
* unequal grasp and/or nonexistent extremity movement (these are associated with cerebral damage)

Right here is where CNA’s are often called upon to assist with these exams. We’re the ones who will first encounter residents and patients who:
*Cannot be aroused as usual or who seem more tired than normal
*Have a fever
*Respirations that are different- slow and deep or fast and shallow
*Complain of a headache
*Vomit
*Experience dizzy spells or complain of double vision
*have a change in their normal B/P readings
*Cannot hold onto things they normally can- dropping a hairbrush or comb, for example
THESE observations should be reported the nurse immediately. Not in an hour. Not after care is given.

3. Conduct an initial thorough exam at the location where the resident was found, without moving him or her. Wear gloves when necessary and provide as much privacy as possible.

4. Evaluate the level of consciousness and mentation of the resident. A change is usually the first clue to a deteriorating condition. Since terms, such as lethargy, are frequently used imprecisely, it is wise to descriptively document how the resi-dent responds.

5. Check pupil reaction, blood pressure, temperature, pulse, respirations, grasp, and active range of motion of all extremities. If neck or spinal injury is suspected, keep the resident still and call for emergency help.

6. Obtain orthostatic blood pressures per facility protocol. Move the resident to his or her bed only after a full assessment of injuries or potential injuries is complete, and use a method that will protect the resident from any further injury.

7. Perform neurological checks according to the frequency indicated on the medical director’s or attending physician’s orders. In addition, subsequent assessments should be problem-focused, zeroing in on the parts of the nervous system affected by the resident’s condition. The resident’s diagnosis and the acuity of his or her condition will determine how extensive your problem-focused assessments will be and if you should conduct them more frequently.

8. Be sure to compare your findings with those of previous exams. Through comparison, you’ll be able to spot changes and trends and, when necessary, intervene quickly and appropriately.

9. Immediately notify the resident’s physician of any sign of deterioration in the resident’s status.

Initally after a fall, the resident/patient should not be moved by the CNA. Get the nurse. I have worked with nurses who will refuse to come right down to assess the situation- they’re in the middle of a med pass or something. This is not acceptable. If this happens go to the next person in the chain of command. If no such person is in house, inform the nurse that you will not move the resident/patient until an assessment is completed. And go stay with your resident/patient.

Learn what a full neuro exam is and what tools are needed, in case you’re asked to get them together. Every facility should have a kit with these items all ready for use and clearly labeled.

More about neuro checks:
Neurological assessment: A refresher
The Precise Neurological Exam (pictures included)