Michigan Renewal Bundle – Part 1

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The following course content

This Michigan License Renewal Bundle is broken down into 3 parts as per the requirement for Michigan Nurses which states: No more than 12 contact hours may be completed in a day.

This Part 1 features multiple interesting topics in one easy course and includes the required Implicit Bias, Human Trafficking, and Pain and Symptom Management courses. Upon completion of this Part 1 course, you will receive a certificate for 9 contact hours.

Course Outline

1. Human Trafficking – 1 contact hour (Meets MI BON Requirement)
2. Pain and Symptom Management – 2 contact hours (Meets MI BON Requirement)
3. Implicit Bias Training – 2 contact hours (Meets MI BON Requirement)
4. Infection Control and Barrier Precautions

Human Trafficking

Human trafficking is a significant humanitarian issue in the United States and the world that has continued to grow in the past several years despite government and public efforts to combat it. With increasing news coverage of high-profile human and sex trafficking cases, the problem was recently brought into the American public’s eye. However, the results published by the Polaris Project make it evident that human trafficking is not just a problem of the elite or occurring in poorer areas. It is within our own neighborhoods, workplaces, and throughout the State of Michigan.

Introduction   

The Polaris Project estimates that collectively there are over 25 million victims of human trafficking worldwide. These are individuals that have been forced into sexual or labor servitude. Of those, several hundred thousand are estimated to be in the United States (1). It is very difficult to estimate accurately as so often this is a crime that is unseen and hidden from the public eye. In 2021, there were 1186 contacts made concerning human trafficking reported within Michigan to the National Human Trafficking Hotline via telephone calls, texts, or online submissions. This ranks Michigan 5th of the top ten human trafficking hot spots in the U.S. 295 cases were reported and 429 victims were identified from these calls (2). These numbers exemplify the number of potential victims that are not reaching out for help.

Often, when human trafficking is discussed, a common misconception is that it is simply the transporting of humans. Human trafficking covers a much broader scope than this. It is  a modern age form of slavery and involves the exploitation of individuals for monetary or sexual gain. As stated by the Department of Homeland Security, “Human trafficking involves the use of force, fraud, or coercion to obtain some type of labor or commercial sex act” (3).

As defined by U.S. law, there are three categories of human trafficking (all from 1):

• Children under the age of 18 induced into commercial sex
• Adults (age 18 or over) induced into commercial sex through force, fraud, or coercion
• Children and adults induced to perform labor or services through force, fraud, or coercion

The majority of trafficking in the United States involves sex crimes, followed by labor. In North America, an uptick was noted of 16% for sexual exploitation and 25% for labor (4). These crimes may be occurring simultaneously to the same victim. Types of trafficking can include forced sex work, pornography, strip dancing, criminal enterprise and bonded labor in domestic servitude or migrant work. Outside of street prostitution, sex trafficking is most likely to be occurring in venues such as strip clubs, massage parlors, or other fictitious business fronts for prostitution. A major difference with sex trafficking of minors is that, unlike adults, force, coercion, or fraud does not need to be present for prosecution (5). As there are several different avenues for and types of human trafficking, recognition can be challenging.

Risk Factors

The profile of the human trafficking victim is not easy to define. Victims of human trafficking come from varied backgrounds that may or may not be what is expected or stereotypical. Victims may come from any race, socioeconomic status, color, religion, age, gender, sexual orientation, or gender identity, and on. The main commonality is that there is a layer of deception whereby the human trafficker is targeting a vulnerability in the victim. As stated by the Department of Justice, trafficking victims are deceived with “. . . false promises of love, a good job, or a stable life and are lured into situations where they are made to work in deplorable conditions with little or no pay” (5). There are some trends noted that do make certain populations more at risk, but keep in mind that this does not encompass all potential victims and vigilance should be taken to avoid assumptions.

The risk factors for human trafficking are just as varied and dependent upon the type of trafficking and method by which the abuser is able to hold the victim indentured or captive. This figurative prison may be physically, emotionally, or monetarily induced. The Center for Disease Control and Prevention (CDC) lists the following characteristics and factors (all from 6):

• Many victims are women and girls, though men and boys are also impacted
• Victims include all races, ethnicities, sexual orientations, gender identifies, citizens, non-citizens, and income levels
• Victims are trapped and controlled through assault, threat, false promises, perceived sense of protection, isolation, shaming, and debt

Several higher risk populations have been identified through the data gathered from the Polaris Project. It was found that children who were or had been within the foster care system or runaway homeless youth were more likely to encounter sexual victimization. Other factors include substance abuse, recent relocation or migration, unstable housing situations, and underlying mental health disorders (7).

As a population that is often overlooked, shamed, or lacks resources, members of the lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) community are more vulnerable to being subject to human trafficking. Up to 40% of homeless youth are part of the LGBTQ community and may not seek assistance for fear of being shunned (8).

Illegal and sponsored immigration remains at a higher risk of trafficking and exploitation. The National Human Trafficking Resource Center (NHTRC)  reports a significant number of calls that reference foreign nationals (2). Individuals wishing to become American citizens are lured with the promise of freedom in exchange for large fees that are made impossible to be worked off. While there are laws in place to prevent this type of trafficking, servant bondage is forced upon the victims who are in a new country and often lack resources or are unable to seek assistance due to cultural, language, and accessibility barriers. Further, cases have been reported where the employer or trafficker will withhold visas or identification  in order promote compliance and essentially hold the victim hostage (9).

Recruitment Techniques

A major tactic of the perpetrators of these crimes is to prey on vulnerable individuals with a lack of resources. Thus, a primary ploy used is a layer of deception whereby the human trafficker is targeting the needs or wants of the victim.

Traffickers are often individuals that the victim has come to trust. This may be a girlfriend or boyfriend, spouse, or other family member. Victims are also commonly sold to outside parties.

In cases of sexual trafficking, typically young women and men are groomed and given preferential treatment, gifts, and drugs until they become reliant upon the “John.” In other cases, individuals are tempted with the promise of a better life, or in the case of immigration, sponsorship for a visa (9).

Michigan and Federal Laws

In 2006, Michigan joined 26 other states in establishing a statute banning human trafficking. Today, there are 39 states that have committed to this crusade. The bill defined and prohibited the following:

• Forced Labor or Services MCL 750.462b
• “Labor” means work of economic or financial value.
• “Services” means an ongoing relationship between a person and an individual in which the individual performs activities under the supervision of or for the benefit of the person, including, but not limited to commercial sexual activity and sexually explicit performances.
• Debt Bondage MCL750.462c
• Enterprise Liability; Financially Benefitting MCL 750.462d
• Trafficking a Minor MCL 750.462e
• Covers both sex trafficking and labor trafficking of a minor
• NO Force Fraud or Coercion Required
• “regardless of whether the person knows the age of the minor” (10)

The bill was amended in 2010 to give victims the opportunity to seek damages that were due to bondage, suffering, and loss of quality of life in addition to any related medical costs incurred (10).

In 2014, Michigan legislation further bolstered the State’s position in the battle on human trafficking. Mandatory training for medical professionals was made a requirement of maintaining licensure. The Human Trafficking Commission and the Human Trafficking Health Advisory Board were created to track progress, garner funds through grants, and provide a means of connecting local government and non-government agencies access to resources and funding (11).

Safe Harbor provisions were put into law that protect minors from prostitution charges, classify minors found in prostitution to be human trafficking victims, and mandate that referrals are made to Child Protective Services (CPS) for mandatory investigation. Several changes were made to adult prostitution charges that are found to be in relation to a sex trafficking ring with the goal of protecting victims of sex trafficking crimes rather than punishing (11).

A specific U.S. Federal law addressing trafficking crimes was first enacted with the Trafficking Victims Protection Act of 2000. The bill has since been revised several times; however, the fundamental purpose is to provide guidance and authorization for the “three-pronged approach that includes prevention, protection, and prosecution” and covers both sex and labor trafficking (12).

Preventing Sex Trafficking and Strengthening Families Act of 2014 and The Justice for Victims of Trafficking Act of 2015 are both aimed at providing victims increased protection for exploitation and increased resources specifically aimed at prevention and support for child and youth sex trafficking crimes (12).

Mandatory Reporting in Michigan

Nurses in Michigan are classified as mandatory reporters for cases of suspected child abuse or neglect. Suspected human trafficking of a minor would fall under this category. Either a verbal or online report must be given to Centralized Intake (CI) at the Department of Health and Human Services. CI can be reached 24 hours a day by telephone at 1-855-444-3911 or register to submit an online report at https://newmibridges.michigan.gov/ under the Partnerships tab (13). If calling the hotline, a DHS-3200 form must be faxed or emailed within 72 hours of the initial report to CI. Online reporting eliminates the need to complete this form.

The following states the criminal and civil liability of failing to follow the law as a mandatory reporter:

In a civil action, the mandated reporter may be held liable for all damages that any person suffers due to the mandated reporters’ failure to file a report. In a criminal action, the mandated reporter may be found guilty of a misdemeanor punishable by imprisonment for up to 93 days and a fine of $500.

A person making a good faith report is protected from civil and criminal prosecution and cannot be penalized for making the report or cooperating with a CPS investigation (13).

Reporting of suspected adult human trafficking is not as clear regarding mandatory reporting. However, vulnerable adults suspected of being abused, exploited, or victimized fall under the same guidelines and are reported to CI in the same manner as above. Vulnerable adults in Michigan are defined as “A condition in which an adult is unable to protect himself or herself from abuse, neglect, or exploitation because of a mental or physical impairment or advanced age” (13).

Recognizing Signs of Human Trafficking

According to the Department of Health and Human Services, close to 90% of human trafficking victims visit a health care facility at least once while in servitude and are not identified as such by health care providers (14). This is due to a lack of education, lack of consistent use of identification and screening tools, and time constraints within the current health care system. As a mandatory reporter and healthcare team member, it is imperative to use best practice in recognizing the signs and symptoms as well as the tools that are available.

Signs and Symptoms

Human trafficking victims may present to a healthcare setting with primary or underlying signs that may be related to physical or mental abuse. These signs and symptoms may be related to the reason that they are seeking treatment or may be identified by the healthcare provider during a thorough assessment. The following physical and psychological sequelae may be noted during an assessment as potential evidence of victimization (all derived from 9, 15):

Signs of Abuse

Physical

• Unexplained or implausible injuries
• Bruising
• Wounds and Cuts
• Missing or broken teeth
• Closed head injuries
• Blunt force trauma

Neurological

• Headaches
• Migraines
• Memory loss or difficulty concentrating
• Vertigo
• Insomnia
• Brain trauma

Gastrointestinal

• Diarrhea
• Constipation

Dietary

• Malnutrition
• Anorexia
• Severe weight loss

Cardiovascular and Respiratory

• Tachyarrhythmias
• Hypertension
• Respiratory Distress

Reproductive System

• Sexually transmitted disease
• Vaginal and/or anal fissures
• Previous Abortions

Psychological

• Depression
• Suicidal Ideation
• Anxiety
• Self-harm including cutting or branding
• Drug and alcohol abuse
• PTSD symptoms
• Regression
• Anger
• Dissociative and depersonalization tendencies

Red Flags and Indicators

There are several characteristics that should be kept in mind as red flags during the interview and assessment that may indicate potential trafficking. These include, but are not limited to (all derived from 9, 15, 16):

• Tattoos that indicate ownership, a number, or tracking system or are out of character/obscene
• Inappropriate clothing for climate
• Workplace violence or abuse
• Unsanitary living conditions
• Multiple families or people sharing a living space that is too small
• Shares living space with employer
• Is not in control of financial assets
• Refusal to speak alone with health professionals
• Accompanied by individual that refuses to allow patient to speak for themselves or be alone
• Prostitution under age 18
• Answers are scripted
• Answers are implausible or contraindicate
• Appears younger or older than stated age

Interview Tools and Techniques

Check with your facilities protocol for specific guidance on assessment and examination protocols for suspected abuse victims. There are also many scripted interviewing tools available online that assist with asking targeted questions. First, it is important to establish the patient’s safety and to gain trust.

Gaining trust can be difficult and conducting assessments and interviews should be completed in a non-threatening environment with an unbiased and non-judgmental tone. Creating a space that is quiet and will not be interrupted is important. This will ensure that the potential victim feels safe communicating and is not concerned that she or he will be overheard. Present your demeanor in a non-threatening manner, at eye level, and focus on being attentive with observant listening. Maintain respectful eye contact to convey interest and reflective listening. If taking notes during the interview is required, explain to the patient what will be documented and what it will be utilized for (17).

The NHTRC offers a plethora of resources and scripted questions. The following are general questions on assessing if the individual is being forced into a situation and can be applied to any of the specific types of human trafficking (all from 17):

“Did someone control, supervise or monitor your work/your actions?”

“Was your communication ever restricted or monitored?”

“Were you able to access medical care?”

“Were you ever allowed to leave the place that you were living/working? Under what conditions?”

“Was your movement outside of your residence/workplace ever monitored or controlled?”

“What did you think would have happened if you left the situation? Was there ever a time when you wanted to leave, but felt that you couldn’t? What do you think would have happened if you left without telling anyone?”

“Did you feel that it was your only option to stay in the situation?”

“Did anyone ever force you to do something physically or sexually that you didn’t feel comfortable doing?”

“Were you ever physically abused (shoved, slapped, hit, kicked, scratched, punched, burned, etc.) by anyone?”

“Were you ever sexually abused (sexual assault/unwanted touching, rape, sexual exploitation, etc.) by anyone?”

“Did anyone ever introduce you to drugs, medications as a method of control?”

While screening tools provide a base for asking difficult questions, the NHTRC advises “Before screening, users should also be prepared to draw upon the expertise of local legal and medical staff and to refer identified trafficking victims to appropriate housing, health, and social services in their area . . . the tool is a complement to, not a substitute for, specialized training in human trafficking, good professional practice and victim-centered service” (17).

The NHTRC also provides a 24-hour national hotline that guides health professionals through completing assessments and determining the next best steps to intervene or offer the victim assistance. This is a very beneficial resource; however, it must be understood that calling NHTRC does not fulfill the mandatory reporting requirement for Michigan and the Centralized Intake (CI) at the Department of Health and Human Services is the only means of legally fulfilling the reporting obligation (17).

Interventions and Collaboration

When presented with a suspected human trafficking victim, it is likely that the individual will not be alone. Maintaining safety and support for the patient may require separation from the suspected trafficker. While this may not be possible, an attempt should be made to bring the patient to a room or examination area unaccompanied.

Be conscious of any cultural preferences that may affect the patient. If there are language barriers preventing meaningful communication, enlist the assistance of a professional interpreter. This is especially vital in cases where the accompanying visitor or family is attempting to interpret for the patient and may be filtering the victim’s responses.

For patients that seek healthcare related to sexual abuse, a Sexual Assault Nurse Examiner (SANE) assessment and rape kit should be obtained per facility protocol. With permission, patients should be tested for sexually transmitted infections including HIV, gonorrhea, UTIs, syphilis, and pubic lice, as well as a pregnancy test for females. Forced and coerced abortions are frequent among minor females in the sex industry (18).

Thorough documentation of the patient’s reported reason for visit, physical and neurological assessment including any trauma, bruising, wounds, changes in affect, and pertinent statements should be noted in the patient’s electronic medical record.

Educate yourself on local resources and be able to provide assistance with finding access to healthcare, mental health, and rehabilitative resources that are available in the community. Victims may not want to take pamphlets with them that may be found, so providing locations or addresses of shelters or clinics with operating times may be a safer option.

Collaborate with the healthcare team, law enforcement, and social work for suspected child or vulnerable adult trafficking.

Mandatory reporting of suspected cases of child abuse or trafficking is not encumbered by HIPAA disclosure when reporting to authorities; however, when reporting suspected adult trafficking, disclosure and permission must be granted unless there is an imminent threat to the safety of the patient, or the patient has been identified as a vulnerable population. Thoroughly assess if the individual meets criteria as a vulnerable adult and proceed accordingly. If the adult does not meet criteria, permission must be gained to report.

If a competent adult does disclose that they are a trafficking victim, determine if the patient is in immediate, life-threatening danger. If so, follow facility protocol and encourage and support the patient in reporting to a law enforcement agency. If there is no immediate danger, supportive care and assistance should be provided. The patient should be informed of the options available for social services, reporting, and resources. Creation of a safety plan is highly recommended (15).

Prevention

Prevention of human trafficking requires public education, awareness, and knowing how to properly respond when faced with suspicions. The Blue Campaign is a strategy from the Department of Homeland Security to bring national awareness to the issue and provide specialized training to law enforcement and federal employees. Blue Campaign pamphlets and other materials are available at their website, www.dhs.gov/blue-campaign, for distribution.

The Center for Disease Control takes the stance that sex trafficking is preventable via community awareness and acknowledging exploitation when it does occur. They state:

 “Strategies based on the best available evidence exist to prevent related forms of violence, and they may also reduce sex trafficking. States and communities can implement and evaluate efforts that:

• Encourage health behaviors in relationships
• Foster safe homes and neighborhoods
• Identify and address vulnerabilities during health care visits
• Reduce demand for commercial sex
• End business profits from trafficking-related transactions” (6).

One of the largest barriers to prevention in the healthcare system is the inability to recognize signs and symptoms. As cited above, a significant number of human trafficking victims have filtered in and out of healthcare systems without being recognized. This misses the opportunity to connect, provide resources, and offer further assistance. The NHTRC provides many resources for training within healthcare facilities and standardized forms and interviewing questions that may be tailored to individual situations and facility needs.

Resources

National Human Trafficking Resource Center

• Call: 1-888-373-7888
  SMS: 233733 (Befree) – Text “HELP” OR “INFO”
• Online chat: humantraffickinghotline.org/chat

This network provides healthcare facilities and individuals with information and connections to over 3,200 referral contacts that will assist human trafficking victims. These contacts include low or no-cost legal services, law enforcement agencies, social services, and anti-trafficking organizations. Communication is enhanced as dialect is available in English, Spanish, and 200 other languages.

Michigan Department of Health and Human Services

• Online: https://www.michigan.gov/mdhhs/
• Call: 1-855-444-3911

The MDHHS provides resources for the public and healthcare workers to report suspect or witnessed abuse or neglect of minors, vulnerable adults, and victims of domestic violence. It also provides guidance for mandatory reporting obligations in Michigan.

Michigan Human Trafficking Task Force

• Address:  P.O. Box 811653 Lansing, MI  48917
• Online: Welcome
• Email: Jane P. White, Director [email protected]

Works with a wide expanse of agencies to collaborate on meeting the needs of victims, communities, and law enforcement through volunteer work, funding, training, and resource support.

HEAL (Health, Education, Advocacy, Linkage) Trafficking

• Online: www.Healtrafficking.org

The HEAL Trafficking Direct Service Committee works to improve the clinical care for trafficked persons by providing opportunities for service providers to connect, access support, share information and promising practices, identify best practices, and expand the referral network.

National Center for Missing & Exploited Children

• Address: 333 John Carlyle Suite 125 Alexandria, VA   22314-3175
• 24 Hour Call Center: 1-800-THE LOST (1-800-843-5678)
• Online: http://www.missingkids.org/theissues/trafficking

Provides specialized technical assistance, analysis, and recovery services on cases involving child sex trafficking.

Pain and Symptom Management for Nurses

As a professional, you will learn that pain is a subjective, complicated symptom that afflicts every human at some point in their lives. Managing pain within healthcare settings is a challenge and must take into consideration patient-centered preferences, treatment goals, as well as guidelines and laws from governing bodies. For many years, opioids were the first line of defense against acute and chronic pain conditions. With the opioid crisis, this mindset has been required to change.  In this Michigan: Pain and Symptom Management course, you will be equipped with a fresh mindset regarding the types of pain, and how to treat them.

Epidemiology of Pain

Pain is a subjective, complicated symptom that afflicts every human at some point in their lives. Managing pain within healthcare settings is a challenge and must take into consideration patient-centered preferences, treatment goals, as well as guidelines and laws from governing bodies. For many years, opioids were the first line of defense against acute and chronic pain conditions. With the opioid crisis, this mindset has been required to change.  

Due to an overabundance of prescribing opioids, the opioid related death toll has continued to rise. Not only has this fatal epidemic resulted in untimely deaths for many, but it is also estimated that "For every 1 prescription opioid death, there are 20 specialty substance abuse treatment admissions, 45 emergency department visits for nonmedical use and adverse events, 156 people with substance use disorder and dependence, and 533 people using the drugs nonmedically overall" (1).  

This public health crisis has resulted in the conviction of pharmaceutical companies that were behind the political stronghold monopoly on pain management in America. As a result, the Federal government has collaborated with The Institute of Medicine (IOM) and the Centers for Disease Control (CDC), among many other experts in the field, to develop a plan that protects the American public from unintended opioid use and promotes a multi-disciplined, multi-modal approach to combating pain in America.  

Michigan: Pain and Symptom Management Statistics

Pain is a widespread public health concern that reaches every corner within America. In a 2011 report titled, Relieving Pain in America: A Blueprint for Transforming, Care, Education, and Research, the IOM revealed that pain affects nearly 100 million Americans and nationally costs upwards of 635 billion each year (2). Of these numbers, over 25 million American adults report that they suffer from pain daily, while 23.4 million state a significant amount of pain (3).  

Researchers gathered data from 8,781 American adult participants regarding individual perceptions of their overall health, underlying illnesses, and pain experiences within the previous three months. This study ranked pain on a scale of categories from one through four, with one being the least amount of pain, and four being the highest level of pain.  

From this data, it is estimated that almost 40 million individuals ranked themselves as living with pain at a category three or four. Individuals in these categories were also found more likely to have an accompanying disability, access healthcare on a more frequent basis, and have an overall worse quality of health and life (4). 

What is Pain and Why Does it Occur? 

Merriam-Webster defines pain as "a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort and emotional distress and typically results from bodily disorder (such as injury or disease) (5)".  

Pain is the body's defense to achieve a response against further damage from a perceived threatening stimulus. The brain perceives pain via specific pathways. Four stages of pain transmission occur: transduction, transmission, perception and modulation (6). 

Receptors within afferent fibers are activated when a potential threatening stimulus occurs. This initiates three stages of pain perception. Initially, pain sensitivity is triggered. From there, signals follow a network of peripheral neural pathways towards the spinal cord. Within the spinal cord is the dorsal horn, which contains neurons that translate and relay information about the painful or irritating peripheral stimulus to the thalamus and cortex to elicit a protective response (6,7). 

Pain can be further distinguished within two frameworks, chronic and acute, and by pain related conditions, such as inflammatory responses, nociceptive, and physiological dysfunctions.  

Michigan: Pain and Symptoms Management for Nurses - Identifying Types of Pain

Pain is classified by three distinct types: nociceptive, inflammatory, and neuropathic. Following are general descriptions of the types of pain; however, it must be noted that these pains can overlay each other and be occurring simultaneously.  

Nociceptive pain is that which is due to nerve impairment or injury and is the most common type of pain that occurs. It is sometimes noted as being central pain that is caused by repeated, potentially or harmful stimuli. The nociceptors activated in this type of pain are spread throughout the body within internal organs, bones, joints, and the integumentary system (6).

Nociceptive pain is generally described as radicular, somatic, or visceral depending on the nerve involvement. Examples of nociceptive pain include the sensation from touching a hot object, a broken arm, or a paper cut at the initial time of injury. It may also describe pain caused by cancer, arthritic changes, and ischemic pain that does not originate from nerve injury. 

Inflammatory pain is part of the cascade of sequelae that makes up the immunological defense to damage caused by heat, toxins, trauma, foreign substances, or infection. Neutrophils, along with prostaglandins, histamine, and other chemical mediators flood the location of injured tissues as a part of the bodies normal, inflammatory response. Classic signs include erythema, edema, and heat at the site of injury (6). Inflammatory pain can be seen in cases of an ankle sprain, cellulitis, and allergic reactions.  

Neuropathic pain is also often associated with a phenomenon called allodynia. Allodynia is the sensation of pain from an activity or event that is typically not associated with causing pain. Rather than being the result of a physiological event, neuropathic pain is pathologic in nature.

According to Yam, Loh, Tan, Adam, Manan, and Basir (2018), “This condition can be described as “pathologic” pain, because neuropathic pain actually serves no purpose in terms of defense system for our body, and the pain could be in the form of continuous sensation or episodic incidents” (6). It is thought to be caused by disorders affecting the peripheral or central nervous system and is linked to diseases that cause nerve damage such as trauma, toxins, diabetes, as well as certain viral infections, such as herpes zoster.

Chronic Pain vs Acute Pain

Acute pain is that which is short-term and self-limiting. The timeframe of acute pain is based on the expected healing process of the injurious event and may be up to six months. Chronic pain lasts beyond the expected period of healing or is recurrent.

Acute pain can usually be attributed by a defined contributing factor or event, such as appendicitis or a broken bone. Chronic pain can be related to a myriad of causes or the etiology may be unknown (6).

In clinical settings, pain lasting more than three months is typically used to define the transition from acute to chronic. As such, chronic pain must be treated and managed differently than acute pain. 

Michigan: Pain and Symptom Management for Nurses -

Risk Factors

Several risk factors have been identified that make it more likely for an individual to experience chronic pain. In general, age influences the prevalence of chronic pain by population, with those age 18 to 39 having an increased prevalence of chronic pain. This may be due to other age groups under-reporting. Those over 80 were found to report acute pain more often but were less likely to acknowledge chronic pain when asked. As well, cognitive decline, dementia and other age-related diseases must be considered as factors when collecting data. Chronic pain after surgery is reported at a higher rate amongst adolescents (7). 

Chronic pain is more likely to be experienced and reported by females over males. However, studies have shown that women experience pain differently than males at a lower threshold. Women have been found to be more likely to seek treatment for pain (7,8). 

Certain co-morbidities have been identified that are linked to an increase of chronic pain. Almost 90% of patients reporting chronic pain have significant co-morbidities. Co-morbidities with the highest link to chronic pain are cardiovascular and respiratory diseases and depression. The link between chronic pain also affects mortality rates. In those reporting severe chronic pain, the 10-year survival rate is decreases significantly. At ten years, those reporting severe chronic pain are twice as likely to have died from ischemic heart disease or respiratory disease than those with little to no pain (7). 

Depression and anxiety are reported at a rate four times higher in individuals with chronic pain than those living without pain (7). Specific conditions that have a higher rate of being linked to mental health disorders include (all from 8): 

• Arthritis 
• Fibromyalgia 
• Back/Neck pain 
• Chronic migraines 
• Menstrual-related pain
  

Other factors that have been found to influence the prevalence of reported chronic pain include (7,8): 

• Poverty 
• Self-identify as minority 
• Obesity 
• Manual labor occupations 
• Unemployed 
• Smoker 
• Alcohol use 
• Lack of physical activity 
• Poor nutrition 
• Low levels of Vitamin D 
• Post-surgical and medical interventions 
• Sleep Disorders

Physical and Psychological Elements of Pain

Pain elicits a response from the sympathetic nervous system (SNS) leading to signs and symptoms affecting all systems of the body. The following are some of the physical effects that pain may cause within each individual system. 

With the sensation of pain, the cardiovascular system anticipates an event that is threatening. The SNS produces a rush of adrenaline and cortisol that results in tachycardia, hypertension, and increased oxygen demand. The respiratory response includes elevated breathing that is shallow. The cortisol levels affect the endocrine system, resulting in a surge of glucose by triggering a release of glucagon from the liver that will keep up with the demands needed for the fight or flight response.

In contrast, with chronic pain, continued elevated cortisol levels may lead chronic hyperglycemia. The gastrointestinal system slows gastric motility which may lead to nausea, vomiting, and constipation. Chronic pain may lead to an increase in gastrointestinal discomfort, including irritable bowel syndrome. The urinary tract reacts to stress with oversensitivity leading to an increased urgency to urinate and, in some cases, incontinence (7).  

Physical indications of pain from the musculoskeletal system are displayed via piloerection, tremors, and muscle tension and rigidity. The nervous system reconfigures with the processing of pain and attempts to adapt to the additional stresses. Repeated episodes of acute pain can increase the risk of an individual developing chronic pain.

Cumulatively, the stresses and changes that occur on these systems have a negative effect on the immune system. The immune system is unable to keep up with the demands and becomes desensitized to repeated inflammation culminating in a lowered immune response. The lowered immune response then poses an increased risk of infection for the individual (5).

Pain Management

As guidelines have changed due to the opioid crisis, new evidence published by the CDC suggests that opioid dependency can occur in as little as a ten-day course of treatment. In addition, the American Pain Society and the American Society of Anesthesiologists have released guidelines that stress a multi-modal approach to pain management in the operative and recovery setting. Of the recommendations, the following were released as having high-quality evidence and strongly recommended (as cited in 8): 

“. . . that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults” 

“. . . that clinicians provide adults and children with acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications” 

“. . . that clinicians offer neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus” 

“. . . that clinicians consider surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy”. 

The shift has moved from starting patients on opioids after surgeries or other pain inducing procedures, to treating pain using the multi-modal approach which stresses using alternatives to opioids as the first line of defense. After the information detailed in this Michigan: Pain and Symptom Management course, we can defer to the CDC as your source of information regarding main management medications. The CDC further recommends and advises (8): 

“Nonopioid medications are not generally associated with development of substance use disorder. The number of fatal overdoses associated with nonopioid medications is a fraction of those associated with opioid medications. Nonopioid medications are also associated with certain risks, particularly in older patients, pregnant patients, and patients. With certain comorbidities such as cardiovascular, renal, gastrointestinal, and liver disease.

Nonpharmacological treatments can reduce pain and improve function in patients with chronic pain. These treatments can also encourage active patient participation in the care plan, address the effects of pain in the patient’s life, and can result in sustained improvement in pain and function with minimal risks. If opioids are used, they should be combined with nonopioid medication and nonpharmacological treatments, as appropriate.”

Pharmacological Pain Treatments

Opioids may be used for moderate to severe acute or chronic lower back pain, osteoarthritis, and neuropathic pain. Studies showing long-term efficacy are extremely limited. Opioids are suggested only after other non-opioid and non-pharmacological therapies have failed to provide relief. This class should be used with caution as may induce sedation, respiratory depression, nausea and vomiting, and constipation.  

Short Acting 

• Codeine 
• Hydrocodone/acetaminophen or ibuprofen 
• Oxycodone/acetaminophen or ibuprofen 
• Hydromorphone 
• Morphine 
• tramadol

Long Acting 

• Fentanyl 
• Hydrocodone 
• Methadone 
• Morphine 
• Oxycodone 
• Oxymorphone 
• Tapentadol
  

Anticonvulsants may be used for fibromyalgia, diabetic and other neuropathies, and neuralgias. Use with caution as significant drug-drug reactions have occurred. Dosing should be adjusted for renal impairment. May cause sedation, dizziness, dry mouth, weight gain, and edema. 

• Gabapentin 
• Pregabalin 
• Carbamazepine 
• Valproic acid
  

Antidepressants are commonly prescribed for fibromyalgia, low back pain with radiculopathy, migraines, neuropathies and neuralgias, and chronic musculoskeletal pain. Patient must be monitored for mood changes and is at an increased risk for suicide. Other side effects may include sedation, urinary retention, dry mouth, weight gain, and blurry vision. Cardiac patients must be monitored for arrythmias and blood pressure changes. 

Tricyclic Antidepressants 

• Amitriptyline 
• Desipramine 
• Nortriptyline
  

Serotonin-Norepinephrine Reuptake Inhibitors 

• Duloxetine 
• Milnacipran 
• Venlafaxine
  

Muscle Relaxers are effective for acute lower back pain and fibromyalgia. These may cause sedation and dizziness. Caution must be used when operating a car or machinery. Common muscle relaxers that may be prescribed include:

• Carisoprodol 
• Cyclobenzaprine 
• Metaxalone 
• Methocarbamol 
• Tizanidine
  

Topical agents are particularly helpful for osteoarthritic and rheumatoid arthritic pain as well as neuropathies. May be used for relief of sprains, strains, and back pain. The following are topical agents that may be found over-the-counter:

• Capsaicin 
• Diclofenac Topical Gel 
• Lidocaine 5% patches 
• Menthol/Salicylate
  

Non-Steroidal Anti-Inflammatory Drugs(NSAID)  may be used to treat backache, joint pain and inflammation, headache, arthritic pain, muscle aches and strains, and menstrual cramps. Caution to be used in patients with liver or kidney disease and alcohol misuse. NSAIDs may cause gastrointestinal discomfort or bleeding. Use with caution if patient in on anticoagulation therapy. Prescription and non-prescription NSAIDs include:

• Ibuprofen 
• Diclofenac 
• Indomethacin 
• Meloxicam 
• Naproxen 
• Celecoxib 
• Aspirin
  

Acetaminophen remains one of the most prescribed pain relievers for headache, backache, muscle ache, and joint pain. Caution must be used with liver disease and alcohol misuse. Dosage must not exceed 3,000 – 4,000 mg/day. 

Interventional Treatments include epidural or intraarticular glucocorticoid injections and arthrocentesis. Michigan: Pain and Symptom Management for nurses students should always defer to the CDC for up-to-date information on interventional treatments.  The CDC recommends these for short-term treatment of inflammatory diseases such as rheumatoid arthritis, osteoarthritis, rotator cuff disease and other radiculopathies.  

Adapted from (8).

Non-Pharmacological Treatment 

The CDC provides many strategies for healthcare providers to manage the challenges of patient pain control in a manner that lessens the need for opioid use and provides alternative options. Primarily, a patient-centered approach to treatment is now the gold standard and should include patient engagement.  

Suggestions and strategies to incorporate patient cooperation and engagement with their pain management plan include (all from 9): 

• Use reflective listening by maintaining eye contact, empathizing, and confirming understanding 
• Set agreed upon, reasonable and achievable goals 
• Discuss treatment options using a multi-modal treatment plan
  

As part of a multimodal therapy in treating pain, the CDC highly recommends incorporating exercise along with other psychologically based approaches into care. These may include: 

• Physical and occupational therapy and exercise such as swimming, yoga, walking, free weights, and other strength training. This can improve strength and posture, which may provide relief from lower back, hip, and osteoarthritic pain, improve fibromyalgia symptoms, and has been shown effective in preventing migraines (9).
• Cognitive behavior therapy (CBT) is a psychosocial training technique that addresses modifiable situation factors and cognitive processes that may affect the experience of pain. CBT aims to provide coping techniques, relaxation methods, and may include self-help instruction, professional counseling, or support group attendance (9).
• Heat Therapy
• Cryotherapy
• Massage
• Ultrasound
• Transcutaneous Electric Nerve Stimulation (TENS) units
• Acupuncture
• Hypnosis
• Stress Management
• Chiropractic Manipulation
• Herbal Preparations
• Aromatherapy

Federal and Michigan Laws on Opioid Prescribing and Use 

In 2016, the CDC reported that over 40 Americans were dying each day due to prescription opioid overdoses. The opioid crisis has been attributed to the over prescribing of opioids for pain and non-pain conditions with a lack of oversight leading to a 400% increase in opioid prescribing and sales since 1999 (10).

In response, the federal government implemented an initiative to combat the issue with improved education, guidelines, and treatment management. In October of 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, a 660-page bill was signed into law.

This comprehensive, bi-partisan legislation aimed to provide funding and expand access to increase treatment availability through Medicaid and Medicare, expand alternative non-opioid pain management treatment, set guidelines for improved patient education, and identify best practices.  

Prescription-drug monitoring program and the use of electronic prescribing for Schedule II and III medications is supported by the Federal government and allows individual states to have primary control over authorization and enforcement. The following are the regulatory practices specific to Michigan (10,11).

Drug Classification and Schedule in Michigan

Under the Public Health Code, Act 368, state and federal agencies monitor certain drugs based on their risk of addiction, dependance, and abuse characteristics. These controlled substances are categorized based on a system of Schedules I through V. There are three criteria that determines the drugs category: acceptable medical use, potential for abuse, and the predictive value of dependance if it is abused (14). The schedules are as follows: 

Schedule I drugs are considered to have no appropriate medical use and have an extremely high potential for abuse. Examples of Schedule I drugs include: 

• LSD 
• Heroin 
• Bath Salts 
• Quaaludes
  

Schedule II drugs have a high potential for abuse and may lead to psychological or physical dependance. Examples of Schedule II drugs include: 

• Fentanyl 
• Demerol 
• OxyContin 
• Morphine 
• Codeine 
• Marijuana
  

Schedule III drugs have a high potential for abuse and may lead to psychological or physical dependence. Examples of Schedule III drugs include: 

• Acetaminophen with Codeine 
• Vicodin 
• Suboxone 
• Ketamine 
• Anabolic Steroids
  

Schedule IV drugs have a low to moderate potential for psychological or physical dependence but have a lower risk for abuse. Examples of Schedule IV drugs include: 

• Ativan 
• Xanax 
• Valium 
• Soma 
• Klonopin
  

Schedule V drugs are a low potential for physical or psychological dependence or abuse. Examples of Schedule V drugs include: 

• Gabapentin 
• Robitussin 
• Ezogabine 
• Phenergan with Codeine
  

Michigan Laws

In 2016, Michigan, along with 32 other states, recognized the dramatic increase in deaths caused by overdoses in the United States. Overdose had become one of the leading causes of accidental death in the nation. The Good Samaritan Laws were introduced to encourage quick response to potentially fatal overdoses with a decrease in the fear for legal repercussion. 

Michigan’s Good Samaritan Law

As stated by Michigan Department of Health and Human Services: 

During a drug overdose, a quick response can save a life. However, people illegally using drugs sometimes fail to seek medical attention during an overdose for fear of alerting the police to their illegal drug use. In order to prioritize saving lives, Michigan passed a Good Samaritan law in 2016. 

Michigan’s Good Samaritan law prevents drug possession charges against those that seek medical assistance for an overdose in certain circumstances. This law makes saving lives the priority during a drug overdose, not criminal prosecutions of illegal drug users (11). 

The following are pertinent Public Acts and Laws enacted starting in 2017 that were put into effect to support the efforts of tackling the opioid crisis. This also gives structure to primary care providers ability to prescribe opioids and decreases the accessibility of opioids through (all from 13): 

Public Act 246 of 2017

Disclosure of prescription opioid information with the risks to minors and patients is required, beginning 6/1/18. This act also includes the use of the Start Talking form. The form includes the patient’s information, type of controlled substance containing an opioid, signature of patient or guardian, and number of refills allowed. The form required that the provider shares the following information to the patient regarding the substance having potential for abuse (MDHHS-5730, Rev. 3-20): 

1. The risks of substance use disorder and overdose associated with the controlled substance containing an opioid.
2. Individuals with mental illness and substance use disorder may have an increased risk of addictions to a controlled substance. (Required only for minors.)
3. Mixing opioids with benzodiazepines, alcohol, muscle relaxers, or any other drug that may depress the central nervous system can cause serious health risks, including death or disability. (Required only for minors.)
4. For a female who is pregnant or is of reproductive age, the heightened risk of short and long-term effects of opioids, including by not limited to neonatal abstinence syndrome.
5. Any other information necessary for patients to use the drug safely and effective as found in the patient counseling information section of the labeling for the controlled substance.
6. Safe disposal of opioids has shown to reduce injury and death in family members. Proper disposal of expired, unused, or unwanted controlled substances may be done through community take-back programs, local pharmacies, or local law enforcement agencies. Information on where to return you prescription drugs can be found at http://www.michigan.gov/EGLEDrugDisposal.
7. It is a felony to illegally deliver, distribute or share a controlled substance without a prescription properly issued by a licensed health care prescriber.

Public Act 247 of 2017

Requires prescribers to be in a bona fide prescriber-patient relationship prior to prescribing Schedules 2-5 controlled substances. These provisions were due to take effect on 3/31/18, however the implementation date has been pushed back by Public Act 101 of 2018. 

Public Act 248 of 2017

Requires the review of MAPS prior to prescribing or dispensing to a patient a controlled substance in a quantity that exceeds a 3-day supply, beginning 6/1/18. Further, the act requires that a licensed prescriber be registered with MAPS prior to prescribing or dispensing a controlled substance to a patient, beginning 6/1/18. 

Public Act 249 of 2017

Provides sanction for failing to comply with the new MAPS usage mandates, failure to establish bona fide prescriber-patient relationships, and failure to inform patients regarding the risks associated with the prescription of opioid drugs. 

Public Act 250 of 2017

Requires health professionals that treat patients for opioid-related overdoses to provide such patients with information regarding Substance Use Disorder Services, beginning 3/27/18. 

Public Act 251 or 2017

Requires prescribers treating for acute pain to not prescribe such patients with more than a 7-day supply of an opioid within a 7-day period, beginning 7/1/18. 

Public Act 252 of 2017

Provides that before dispensing or prescribing buprenorphine or a drug containing buprenorphine and methadone to a patient in a substance use disorder program, the prescriber shall review a MAPS report on the patient, beginning 3/27/18. 

Public Act 253 of 2017

Codifies Medicaid coverage for detox programs, beginning 3/27/18. 

Public Act 254 of 2017

Requires the Prescription Drug and Opioid Abuse Commission (PDOAC) to develop for Michigan’s Department of Education (MDE) recommendations for the instruction of pupils on the dangers of prescription opioid drug abuse, by 7/1/18. 

Public Act 255 of 2017

Requires MDE to make available to school districts a model program of instruction on the dangers of prescription opioid abuse, developed or adopted by the PDOAC, by 7/1/19. Further, beginning in the 2019-2020 school year, MDE shall ensure that the state include within its health education standards, instruction on prescription opioid drug abuse. 

Public Act 101 of 2018

Pushes back the effective date for the bona fide prescriber-patient relationship requirement to 3/31/19, on the date on which rules are promulgated.

CDC Guidelines and Recommendations on Prescribing and Use

The CDC continues to promote guidelines initiated in 2016 to support the U.S. government’s initiative to curb the increasingly troubling deaths related to opioid overdose. These guidelines were aimed at assisting primary healthcare providers in effectively managing and treating patient’s pain while addressing health and safety concerns. In relation to opioid use, the guidelines revolved around three main principles (all from 8):  

1. Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care. 
2. When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. 
3. Providers should always exercise caution when prescribing opioids and monitor all patients closely. 

Drug Diversion Within the Healthcare System

According to the Drug Enforcement Administration, the most commonly abused drugs are among five classes and are frequently used in the treatment of pain. These include opioids, depressants, stimulants, hallucinogenic, and anabolic steroids. Of these, the opioid fentanyl is the number one drug that is found to be involved in drug diversion cases (14).  

When used outside of medical purposes, fentanyl has a very high rate of fatality. Far from being just a public problem, the diversion of drugs is a significant problem for healthcare organizations and abusers can be found at all levels, from the C-suite to frontline staff. There are several signs of drug diversion, including poor appearance, failing job performance, uncharacteristic behaviors for the individual, and accessing medication that is not required for their job (14).  

The Joint Commission offers these guidelines for monitoring to identify potential trends and patterns that may indicate the occurrence of drug diversion in the clinical setting (all from 15):

Schedule II – V
Substances Are Removed

• Without provider orders 
• Under patients not assigned to the nurse 
• Under patients that have been discharged or transferred 
• Excessively by one individual 
• Actions involved:

1. Substitute drug is removed and administered while controlled substance is diverted
2. Verbal order for controlled substances is created but not verified by prescriber 
3. Prescription pads are diverted and used to forge prescriptions for controlled substances 
4. Provider self-prescribes controlled substances 
5. Patient alters written prescription 
6. Unadministered medication that is documented as given to patient  
7. Wastes are not completed according to policy and procedures 
8. Multiple discrepancies or overrides are noted  
9. Patient’s report unrelieved pain, despite increasing documented pain medication administration 
10. Assistance is frequently offered to administer medications for other nursing staff 
11. Expired controlled substances go missing or are diverted from medication dispensing systems
    

Individual policy and procedure should be followed when drug diversion is recognized in a clinical setting with consideration to the safety of the patients and offender both addressed. The drug diversion should be reported to an immediate supervisor or manager. Nursing management should contact Quality Control and initiate a thorough root-cause analysis.  

Risks of drug diversion include transmission of blood-borne pathogens, patient safety compromised due to impaired healthcare provider, uncontrolled patient pain, and potential for healthcare provider overdose. 

The Joint Commission advocates for a “see something, say something” approach to combatting healthcare provider drug diversion. A plan to prevent drug diversion within the health care organizations should include three approaches: prevention, detection, and response. Additionally, they state “Detection of drug diversion is challenging, and even the best efforts have not yet achieved complete eradication of diversion. Patient and workplace safety require effective reliable safeguards to maintain the integrity of safe medication practices protecting against diversion. Diversion prevention requires continuous prioritization and active management to guard against complacency” (15). 

Risks of Opioid Use and Misuse

Opioids target mu receptors in the brain and spinal cord. Through inhibition of GABA, dopamine is released. Opioid’s increased risk for addiction is due to the increase of circulating dopamine which is associated with increased pleasure responses. Opioid use has been clinically linked to an increase in addiction as well as substance use disorder. Substance use disorder has been defined by the American Psychiatric Association (APA) as “. . . a problematic pattern of use of an intoxicating substance, leading to clinically significant impairment or distress” (16). Per the APA, this is calculated by at least two of the following characteristics (all from 16): 

• The substance is often taken in larger amounts or over a longer period than it was intended 
• There is persistent desire or unsuccessful effort to cut down or control use of the substance 
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 
• Craving or a strong desire or urge to use the substance 
• Recurrent use of the substance, resulting in a failure to fulfill major role obligations at work, school, or home 
• Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use 
• Important social, occupational, or recreation activities are given up or reduced because of use of the substance 
• Recurrent use of the substance in situations in which it is physically hazardous 
• Use of the substance is continued despite having knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 
• Tolerance: a need for markedly increased amounts of the substance to achieve intoxication or desired effect OR a markedly diminished effect with continued use of the same amount of the substance 
• Withdrawal: characteristic withdrawal syndrome for that substance OR the substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms
  

A comparison study was performed based on information garnered in a 2016-2017 study group that focused on the use and misuse of opioids among individuals medicating with opioids inappropriately. This group was split into four categories and compared medical prescription opioid users AND prescriptions with the following: misusers without prescriptions, misusers of own prescriptions, and misusers with both types of misuse (14). 

Individual misusers without a prescription were typically younger, male, and unmarried versus misusers with prescriptions, whether using medically or misusing. It was found that misusers also had an alcohol disorder, used marijuana, and misused benzos and stimulants. As well, noted was that misusers were more likely to be nicotine dependent and to use cocaine and/or heroin (14). 

Prescription users were more likely to concurrently use prescribed benzodiazepines and stimulants. Depression among all misusers was higher compared with the medical users. The misuser also more commonly had received treatment from an inpatient mental health treatment center as well as had been prescribed a medication for a mental health condition. Overall, this group was not more likely to have a physical health condition (14). 

Perceived Barriers to Pain Management

As another consequence of the opioid crisis, a stigma has been cast upon individuals with chronic pain whether they are taking opioids or not. Healthcare professionals should be cautioned against projecting biases onto sufferers of pain as seeking pain medications for misuse reasons. As previously detailed, many patients experiencing pain have co-morbidities and are at a higher risk of having mental health issues in addition to pain.  

Barriers to non-opioid and non-pharmacological pain control may include insufficient medication regimen ordered to address patient’s pain, inadequate training, nursing workload, and a lack of collaborative approach by the healthcare team (17). Barriers to the use of non-pharmacological pain relief methods have been cited as (all from 17): 

• Inadequate training of personnel in how to examine pain and non-pharmacological control methods 
• Patients’ lack of cooperation in the use of non-pharmacological methods to relieve pain 
• Insufficient knowledge about non-pharmaceutical pain relief methods 
• Time-consuming methods of non-pharmaceutical pain relief 
• Nurse’s reluctance to use non-pharmaceutical pain relief methods 
• Failure to use non-pharmacological methods by the physician
  

The study found that with improved education, communication, and collaboration, improved pain management can be achieved by patients.  

Considerations and Interventions

Nursing care plans focused on pain management may be categorized by acute or chronic pain; however, the management and interventions are very similar for each. The outcomes should be specific to the patient presentation, disease process, and preferences (18).  

Pain Assessment and Screening Tools

Screening tools are one of the easiest and most effective ways to evaluate for pain. Some of the most commonly used tools in clinical care include (6, 18, 19): 

• Wong-Baker FACES Scale – may be used for children over the age of 3 and adults 
• FLACC and CRIES – used for infants 
• COMFORT Scale – May be used in children and cognitively impaired or sedated adults 
• Visual Analog Scale 
• Numerical Rating Scale
  

Pain should be also assessed by the patient reported characteristics using pain standardization scales such the McGill Pain Questionnaire. Some verbiage used to describe pain include (6): 

• Aching 
• Burning 
• Shooting 
• Stabbing 
• Throbbing 
• Tender
  

In addition to screening tools, the nursing assessment should include visualization of signs of pain that can include guarding or protecting certain areas of the body, facial changes such as grimacing or furrowing of brows, and other manifestations of pain such as restlessness, moaning, or crying (5).

Implicit Bias Training

Pre-Evaluation

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The following course content

Health equity is a rising area of focus in the healthcare field, as renewed attention is being given to ongoing data covering discrepancies and gaps in the accessibility, expanse, and quality of healthcare delivered across racial, gender, cultural, and other groups. Yes, there are some differences in healthcare outcomes purely based on biological differences between people of different genders or races, but more evidence points to the vast majority of healthcare gaps stemming from individual and systemic biases.  

Policy change and restructuring are happening at institutional levels across the country, but this will only get us so far. In order for real change to occur and the gaps in healthcare to close, there must also be awareness and change on an individual level. Implicit, or subconscious, bias has the potential to change the way healthcare professionals deliver care in subtle but meaningful ways and must be addressed to modernize healthcare and reach true equity.  

What is Implicit Bias?

So what is implicit bias and how is it affecting the way healthcare is delivered? Simply put, implicit bias is a subconscious attitude or opinion about a person or group of people that has the potential to influence the actions and decisions taken when providing care. This differs from explicit bias, which is a conscious and controllable attitude (using racial slurs, making sexist comments, etc.). Implicit bias is something that everyone has to some capacity, whether we are fully aware of it or not and it can influence our understanding of and actions towards others. The way we are raised, our unique life experiences, and individual efforts to understand our own biases all affect the opinions and attitudes we have towards other people or groups (6). This Michigan Implicit Bias training course will increase your awareness of implicit bias in your nursing practice.

Of course, this can be both a positive or a negative thing. For example, if a patient’s loved one tells you that they are a nurse, you may immediately feel more connected to them and go above and beyond the expected care as a “professional courtesy.” This does not mean that you dislike your other patients or their loved ones, it just means that you feel more at ease in the presence of another healthcare professional and this shapes your thoughts and behaviors in a positive manner.  

However, this is a rare case. Oftentimes, implicit biases have a negative connotation and can lead to care that is not as empathetic, holistic, or high quality as it should be. Common examples of implicit bias in healthcare include:  

• Thinking elderly patients have lower cognitive or physical abilities 
• Thinking women exaggerate their pain or have too many complaints 
• Assuming patients who state they are sexually active are heterosexual  
• Thinking Black patients delay seeking preventative or acute care because they are passive about their health 
• Assuming a chatty college student is asking for ADHD evaluation because she is lazy and wants medication to make things easier 
  

On a larger, more institutional and societal level, the effects of bias create barriers such as:  

• Underrepresentation of minority races as providers: in 2018, 56.2% of physicians were white, while only 5% were Black and 5.8% Hispanic (2). 
• Crowded living conditions and food deserts for minority patients due to outdated zoning laws created during times of segregation (15). 
• Difficulty obtaining health insurance for minority or LGBTQ clients, decreasing access to healthcare (3). 
• Lack of support and acceptance for LGBTQ populations in the home, workplace, or school as well as a lack of community resources can lead to negative social and mental health outcomes. 
• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the general population (13). 

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Implications

Once you have an understanding of what implicit bias in healthcare is, you may be wondering what it looks like on a larger scale and what it means in terms of healthcare discrepancies. With each passing year, more data is released that showcases the implications and outcomes of subconscious biases in healthcare, here are a few examples: 

• Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures. This can lead to missed or delayed diagnoses and treatment for patients of color (8).  
• A 2018 survey of LGBTQ youth revealed that 80% reported that their provider assumed they were straight or did not ask otherwise (11).  
• In 2014, a post-physician appointment survey showcased that over half of gay men (56%) respondents reported that they had never been recommended for HIV screening, despite their increased risk for contraction (9).  
• A 2010 study found that women were more verbose in their encounters with physicians and felt unable to fit all of their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (4). For centuries, any symptoms or behaviors that women displayed (largely related to mental health) that male doctors could not diagnose fell under the umbrella of “hysteria,” a condition that was not removed from the DSM until 1980 (18).  
• When treating elderly patients, providers may dismiss a treatable condition as part of aging, skip preventative screenings due to old age, or overtreat natural parts of aging as though they are a disease. Providers may be less patient, responsive, and empathetic to a patient’s concerns because they believe them to be cognitively impaired (16). 
  

Although these are only a few examples, there are obvious and substantial consequences of these biases; which is why it is vital that we address them in this Michigan Implicit Bias training course.  

Below, are just a few more examples of what the long-term effects of what implicit biases in healthcare can lead to if both institutional and personal behaviors are not addressed:  

• A 2020 study found that Black individuals over the age of 56 experience decline in memory, executive function, and global cognition at a rate much faster than white individuals. Data in this study attributes this difference to the cumulative effects of chronic high blood pressure more likely to be experienced and undertreated for Black Americans (14). 
• Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people, 14% of Black people 8.5% of white people are uninsured in the U.S. This leads to a lack of preventative care and screenings, a lack of management of chronic conditions, delayed or no treatment for acute conditions, and a later diagnosis with poorer outcomes of life threatening conditions (3). 
• A 2010 study reported men and women over age 65 were equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8%, respectively) (4).  
• About 12.9% of school aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (5).  
• Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (10)

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Impact of Historic Racism

In addition to discrepancies in insurance status and representation in medical textbooks and among medical professionals, there is a long history of systemic racism that has created generational trauma for minority families, leading to mistrust in the healthcare system and poorer outcomes for those marginalized communities.  

Possibly one of the most infamous examples is the Tuskegee Syphilis Study. This 1932 experiment included 600 Black men, about two thirds of which had syphilis, and involved collecting blood and monitoring the progression of symptoms for research purposes in exchange for free medical exams and meals. Informed consent was not collected and participants were given no information about the study other than that they were being “treated for bad blood”, even though no treatment was actually administered. By 1943, syphilis was routinely and effectively treated with penicillin, however the men involved in the study were not offered treatment and their progressively worsening symptoms continued to be monitored and studied until 1972 when it was deemed unethical. Once the study was stopped, participants were given reparations in the form of free medical benefits for the participants and their families. The last participant of the study lived until 2004 (6).  

The “father of modern gynecology,” Dr. J. Marion Sims, is another example steeped in a complicated and racially unethical past. Though he did groundbreaking work on curing many gynecological complications of childbirth, most notably vesicovaginal fistulas, he did so by practicing on unconsenting, unanesthetized, Black enslaved women. The majority of his work was done between 1845 and 1849 when slavery was legal and these women were likely unable to refuse treatment, sometimes undergoing 20-30 surgeries while positioned on all fours and not given anything for pain. Historically his work has been criticized because he achieved so much recognition and fame through an uneven power dynamic with women who have largely remained unknown and unrecognized for their contributions to medical advancement (21).  

Another example is the story of Henrietta Lacks, a young Black mother who died of cervical cancer in 1951. During the course of her treatment, a sample of cells was collected from her cervix by Dr. Gey, a prominent cancer researcher at the time. Up until this point, cells being utilized in Dr. Gey’s lab died after just a few weeks and new cells needed to be collected from other patients. Henrietta Lacks’ cells were unique and groundbreaking in that they were thriving and multiplying in the lab, growing new cells (nearly double) every 24 hours. These highly prolific cells were nicknamed HeLa Cells and have been used for decades in the development of many medical breakthroughs, including studies involving viruses, toxins, hormones, and other treatments on cancer cells and even playing a prominent role in vaccine development. All of this may sound wonderful, but it is important to understand that Henrietta Lacks never gave permission for these cells to be collected or studied and her family did not even know they existed or were the foundation for so much medical research until 20 years after her death. There have since been lawsuits to give family members control over what the cells are used for, as well as requiring recognition of Henrietta in published studies and financial payments from companies who profited off of the use of her cells (13).  

When considering all of the above scenarios, the common theme is a lack of informed consent for Black patients and the lack of recognition for their invaluable role in society’s advancement to modern medicine. It only makes sense that these stories, and the many others that exist, have left many Black patients mistrustful of modern medicine, medical professionals, or treatments offered to them, particularly if the provider caring for them doesn’t look like them or seems dismissive or unknowledgeable about their unique concerns. Awareness that these types of events occurred and left a lasting impact on many generations of Black families is incredibly important in order for medical professionals to provide empathetic and racially sensitive care. 

Exploring Areas of Bias

Culture

Cultural competence is an essential topic to cover as healthcare professional. There are many training and informational programs that cover how various religions, ethnicities, or beliefs can be integrated into medical practices. Students and staff members are often reminded that the highest quality of care must also meet the cultural needs a client may have no matter if these beliefs or needs differ from the provider’s.  An awareness of the potential variances in care, such as dietary needs, desire for prayer or clergy members, rituals around birth or death, beliefs surrounding and even refusal for certain types of treatments, are all certainly very important for the culturally sensitive healthcare professional to have (and the distinctions far too many for the scope of this course); however, there is also a fine line between being aware of cultural similarities and stereotyping. Since this course is a required Michigan Implicit Bias training, it is essential that this topic is covered. 

Clinicians should ensure that they understand that people hold different identities, beliefs, and practices across racial, ethnic, and religious groups. Remember that just because someone looks a certain way, or identifies with a certain group, does not mean all people within that group are the same. Holding assumptions about clients of a particular race or religion, without getting to know the individual needs of a client, is a form of implicit bias and may cause a client to become uncomfortable or offended.  

Simply asking clients if they have any cultural, dietary, or spiritual needs throughout the course of their care is often the best way to learn their needs without making assumptions or stereotyping. Overall, it should be thought of as extending care beyond cultural competence and working on partnership and advocacy for a client’s unique needs.

Age

Another common factor that can subconsciously change the way healthcare professionals interact with their patients is age. This can go both ways, including treatment of clients a certain way just because they are young or because they are old.  

For minors, or children under the age of 18, nearly all healthcare decisions fall on the parents. There are very few instances where clients under the age of 18 can consent to their own treatment without a parent present and these instances vary by state and typically center around very sensitive topics like STIs. However, being unable to consent to their treatment does not mean young clients should be left out of discussion surrounding their care and they should not be assumed to be incompetent or “too young to understand” (7, 21).   

Examples of implicit bias towards pediatric patients can include things like: 

• Ignoring clients and only addressing parents when discussing presenting problems, treatment options, or procedures 
• Dismissing a client’s questions or concerns as trivial or providing blanket statements like “Don’t worry.” 
• Assuming young clients do not understand when they are seriously ill or dying so avoiding the discussion altogether 
• Labeling crying or combative clients as “difficulty” or “bratty” when they are responding in age appropriate ways to fear or pain 
• Assuming clients are too young to be engaging in risky behaviors and not asking about topics like drugs, alcohol, or sex 
• Teens may feel like they are not taken seriously and will not engage in a trusting relationship with healthcare professionals (7, 21) 

Ways to combat implicit bias about pediatric clients and provide competent care regardless of age, include:  

• Recognizing unique questions or concerns as valid and addressing clients directly to help them feel respected and included in their care 
• Utilization of Child Life Specialists or other professionals designated to help guide clients through traumatic or painful experiences by utilizing age appropriate play or communication 
• Understanding that disclosure of accurate prognosis, even if it is poor, is psychologically beneficial to young clients and their families 
• Working knowledge of developmentally appropriate behavior, especially in stressful or unfamiliar settings 
• Standardize when certain behaviors or risks are discussed using current recommendations and not personal beliefs about when a client is “old enough” for certain behaviors (7, 21) 

On the opposite spectrum, as the Baby Boomer generation ages, there is a growing number of older adults in the United States. In 2016, there 73.6 million adults over age 65, a number which is expected to grow to 77 million by 2034. As of 2016, 1 in 5 older adults reported experiencing ageism in the healthcare setting (18). As the number of older adults needing healthcare expands, the issue of ageism and implicit bias regarding age must be addressed.  

Ways in which implicit bias regarding older age is present in healthcare includes:  

• Dismissing a treatable condition as part of aging  
• Overtreating natural parts of aging as though they are a disease 
• Stereotyping or assuming the physical and cognitive abilities of a patient purely based on age 
• Providers being less patient, responsive, and empathetic to a patient’s concerns or even talking down to patients or not explaining things because they believe them to be cognitively impaired 
• Elderly patients may internalize these attitudes and seek care less often, forgo primary or preventative screenings, and have untreated fatigue, pain, depression, or anxiety  
• Signs of elder abuse may be ignored or brushed off as easy bruising from medication of being clumsy (18) 

There are many reasons why ageist attitudes in healthcare may occur, including:  

• Misconceptions and biases among staff members, particularly those that have worked with a frail older population and assume all elderly people are frail.  
• Lack of training in geriatrics and the needs and abilities of this population. 
• Standardizing screenings and treatments by age may help streamline the treatment process but can lead to stereotyping. 
• Changing this process and encouraging an individual approach may be resisted by staff and viewed as less efficient. 

In order to combat ageism and make sure healthcare is appropriately informed to provide respectful, equitable care:  

• • Healthcare professionals can adopt a person-centered approach rather than categorizing care into groups based on age. 
  • Facilities can adopt practices that are standardized regardless of age. 
  • Facilities can include anti-ageism and geriatric focused training, including training about elder abuse. 
  • Healthcare providers can work with their elderly patients to combat ageist attitudes, including internalized ones about their own abilities (18). 

Sexuality and Gender Identity

A population that is commonly affected by implicit bias, especially in regards to their healthcare, are members of the Lesbian, Gay, Bisexual, Transexual, and Queer (LGBTQ) community. There are many unique health-related risks for this population including:  

• 2-3 times increased risk of suicide in youth 
• Increased rates of homelessness 
• Decreased preventative cancer screening rates in women 
• Increased obesity rates in women 
• Increased contraction of HIV 
• Highest rates of alcohol, tobacco, and drug use across all populations 
• Increased risk of victimization and violence 
• Increased risk for mental health disorders 
• Increased rates of being underinsured (15) 

An understanding of these risk factors is important for healthcare professionals and addressing implicit biases is necessary to help close gaps in care for this population. At the root of much of the biases regarding LGBTQ clients is a lack of understanding or cultural competence when caring for people in this community. It is important for healthcare professionals to familiarize themselves with the definitions and differences in sexuality, gender identity, and the many terms within those categories in order to have a better understanding of how these factors affect the health and safety of clients.  

Basic Terminology Lesson 

Sex: A label, typically of male or female, assigned at birth, based on the genitals or chromosomes of a person. Sometimes the label is “intersex” when genitals or chromosomes do not fit into the typical categories of male and female. This is static throughout life, thought surgery or medications can attempt to alter physical characteristics related to sex.  

Gender: Gender is more nuanced than sex and is related to socially constructed expectations about appearance, behavior, characteristics based on gender. Gender identity is how a person feels about themselves internally and how this matches (or doesn’t) the sex they were assigned at birth. Gender identity is not related to who a person finds physically or sexually attractive. Gender identity is on a spectrum and does not have to be purely feminine or masculine and can also be fluid and change throughout a person's life.  

• Cis-gender: When a person identifies with the sex they were assigned at birth and feels innately feminine or masculine.  
• Transgender: When a person identifies with the opposite sex they were assigned at birth. This can lead to gender dysphoria, or feeling distressed and uncomfortable when conforming with expected gender appearances, roles, or behaviors.  
• Nonbinary: When a person does not feel innately or overwhelming feminine or masculine. A nonbinary person can identify with some aspects of both male and female genders, or reject both entirely.  

Sexual orientation: A person’s identity in relation to who they are attracted to romantically, physically, and/or sexually. This can be fluid and change over time, so do not assume a client has always or will always identify with the same sexual orientation throughout their life.  

Types of sexual orientation include: 

-Heterosexual/Straight: Being attracted to the opposite sex or gender as oneself .

-Homosexual/Gay/Lesbian: Being attracted to the same sex or gender as oneself.  

-Bisexual: Being attracted to both the same and opposite sex or gender as oneself 

-Pansexual: Being attracted to any person across the gender spectrum, including non-binary people (9) 

The above terminology is a basic overview to promote cultural competence in healthcare professionals. There are many many more specific and nuanced terms that can be used, and language surrounding these issues is ever-evolving. When in doubt, the best practice is to simply ask a client about their gender identity and sexual orientation in a non-judgemental way and ask for clarification of any terms for which you are uncertain.  

Simply not asking or having only a vague understanding of how clients identify themselves and the sort of sexual relationships they engage in can leave huge holes in their care that put them at increased risk of missed diagnoses and care opportunities. Current data highlights the shortage of competent and knowledgeable healthcare providers in regards to LGBTQ issues and a lack of training in higher education regarding this topic.  

• In a 2018 survey of LGBTQ youth, 80% reported their provider assumed they were straight and did not ask (12).  
• In 2014, over half of gay men (56%) who had been to a doctor said they had never been recommended for HIV screening (10).  
• A 2017 survey of primary care providers revealed that only 51% felt they were properly trained in LGBTQ care (24).  

Some of the risks faced by this population may not even be fully realized at this time, as there is a huge under-representation of LGBTQ people in current studies across all health related areas, meaning gaps may exist that we haven’t even recognized yet (12).  

Community social programs for LGBTQ people are also lacking despite the evidence to support their efficacy, especially for individuals who do not have acceptance and support at home, in the workplace, or at school. Building these programs to provide a place of safety and acceptance is a public health concern and could serve to improve mental and physical health of LGBTQ people everywhere (12).  

In order to improve these conditions and close the gap for LGBTQ individuals, much can be done on the community level and in medical training.  

• Community programs should be available to create safe spaces for connection and acceptance 
• Cultural competence training in medical professions needs to include LGBTQ issues 
• Data collection regarding this population needs to increase and be recognized as a medical necessity, as it is largely ignored currently (12).  

Maternal Health

One of the more obvious places that implicit bias has tainted the healthcare industry is in maternal health. Repeatedly, statistics show that Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth.  

Let those numbers sink in and realize that this is a crisis.  

Pregnancy and childbirth are natural processes, but they do come with inherent risks for both the mother and baby; but in a modern society, women should feel comfortable and confident in their care, not scared they won’t be treated properly or not survive. Home births among Black women are on the rise as they seek to avoid the biases of the hospital setting and maintain control over their own experiences (17).  

A few examples that showcase the hesitance a Black woman might have with birthing in a hospital setting might include a lack of health insurance leading to poorer general health before pregnancy, a lack of prenatal care, or a lack of care in the weeks following pregnancy. However, the discrepancies still exist at an alarmingly high rate even when looking at minority women with advanced education and high income, indicating that a more insidious culprit, such as implicit bias, is hugely responsible (17). In order for true change to come, this topic must be addressed in this Michigan Implicit Bias training. A few notes that indicate the prevalence of implicit bias in healthcare throughout history are listed below:  

1. Biological differences between white and black women date back to slavery, including the belief that Black women have fewer nerve endings, thicker skin, and thicker bones and therefore do not feel pain as intensely. This is an entirely false belief. Unfortunately, Black and Hispanic women statistically have their perceived pain rated lower by healthcare professionals and are offered appropriate pain management interventions less often than white peers. 
2. Complaints from minority patients that may indicate red flags for conditions such as preeclampsia or hypertension are often downplayed or ignored by healthcare professionals.  
3. Studies show healthcare professionals may believe minority patients are less capable of adhering to or understanding treatment plans and may explain their care in a condescending tone of voice not used with other patients. For example, one in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. These patients are less likely to feel respected or like a partner in their care and may be  non-compliant in treatment recommendations due to feeling this way, however, this just perpetuates the attitudes held by the healthcare providers (17).

Interact Now!

Reproductive Rights

Branching off of maternal health, is reproductive justice. Biases surrounding the reproductive decisions of women may negatively impact the care they receive when seeking care for contraception or during pregnancy. While some of these inequities may be more profound for women of color, women of all races can be and are affected by biases surrounding reproduction, which is why it is being covered in this Michigan Implicit Bias training course. Examples of ways implicit bias may affect care include:  

Some healthcare professionals may believe there is a “right” time or way to become pregnant and feel pregnancy outside of those qualifiers is undesirable; this can stem from personal or religious beliefs. While healthcare staff are certainly entitled to hold these beliefs in their personal lives, if the resulting implicit biases are left unchecked, they can lead to attitudes and actions that are less compassionate when caring for their clients. Clients may feel shamed or judged during their experiences instead of having their needs addressed (7). Variables that may be perceived as unacceptable or less desirable include: 

• Age during pregnancy. Clinicians may feel differently about pregnant clients who are very young (teenagers) or even those who are in their 40s or 50s (7).  
• Marital status during pregnancy. Healthcare professionals may have beliefs that clients should be married when having children and may have bias against unmarried or single clients (7).  
• Number or spacing of pregnancies. Professionals may hold beliefs about how many pregnancies are acceptable or how far apart they should be and may hold judgment against clients with a large number of children or pregnancies occurring soon after childbirth.  
• Low income and minority women are more likely to report being counseled to limit the number of children they have, as opposed to their white peers (12).  
• Method of conception. Some healthcare professionals may have personal beliefs about how children should be conceived and may have negative opinions about pregnancies resulting from fertility treatments such as IVF or surrogacy (7). 
  

Personal or religious beliefs about contraception may also cause healthcare professionals to provide less than optimal care to clients seeking methods of birth control.

• Providers may believe young or unmarried clients should not be given access to contraception  because they do not believe they should be engaging in sexual activity (7). 
• Providers, or even some institutions such as Catholic hospitals, may withhold contraception from clients as they believe it to be immoral to prevent pregnancy. 
• Providers may push certain types or usage of contraception onto clients that they feel should limit the number of children they have, even if this does not align with the desires of the client. This includes the use of permanent contraception such as tubal ligation (12).  
• Providers may provide biased information about types of contraception available, minimizing side effects or pushing for easier, more effective types of contraception (such as IUDs), despite a client’s questions, concerns, or contraindications (12). One study showed Black and Hispanic women felt pressured to accept a certain type of contraception based on effectiveness alone, with little concern to their individual needs or reproductive goals (12). 
  

Personal or religious beliefs about pregnancy termination may impact the care provided and counsel given to pregnant clients who may wish to consider termination. Providers who disagree with abortion on a personal level may find it difficult to provide clear and unbiased information about all options available to pregnant women or may have a judgmental or uncompassionate attitude when caring for clients who desire or have had an abortion (7).

Case Study

Alexandria is a 22 year old Hispanic woman who has always wanted a big family of 3-5 children. She met her current boyfriend in college when she was 19 and became pregnant shortly afterwards. It was an uneventful pregnancy, and Alexandria had a vaginal delivery to a healthy baby girl at 39 weeks. When that child turned 2, Alexandria and her partner decided they would like to have another baby. At 38 weeks' gestation, Alexandria was at a prenatal appointment when her provider brought up her plans for contraception after the birth. The provider suggested an IUD and stated it could be placed immediately after birth, could be left in for 5 years, and would be 99% effective at preventing pregnancy. Alexandria stated she had an IUD when she was 17 and did not like some of the side effects, mostly abdominal cramping, and that she also might like to have another baby before the 5-year mark. Her doctor stated, “all birth control has side effects, and this one is the most effective. You are so young, do you really want 3 children by age 25 anyway?” 

Disability

Disabilities are emerging as an under-recognized risk factor for health disparities in recent years, and this new recognition is a welcome change as more than 18% of the U.S (15) population is considered disabled. Disabilities can be congenital or acquired and include conditions that people are born with (such as Down Syndrome, limb differences, blindness, deafness), those presenting in early childhood (Autism, language delays), mental health disorders (bipolar, schizophrenia), acquired injuries (spinal cord injuries, limb amputations, change in hearing/vision), and age related issues (dementia, mobility impairment).  

Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the population (15). People with disabilities are also much more likely to experience gaps in healthcare, including receiving preventative care and screenings less often, increased engagement in unhealthy behaviors such as smoking and lack of physical exercise, and increased risk of chronic health conditions (11a). Much of the health differences between those with and without disabilities comes down to social factors like education, employment (finances), and transportation which significantly affect access to care (15), however implicit biases among healthcare professionals can also play a role including:  

• Dismissing chronic client complaints or concerns as exaggerated or not serious enough to receive a complete assessment and therefore preventing or delay disability diagnosis 
• Assuming clients who no-show for appointments simply do not care enough about their health to participate 
• Assuming clients with physical disabilities or difficulty speaking are cognitively disabled as well 
• Assuming clients with cognitive disabilities are not smart enough to be included in discussions about their care 
• Assuming clients who are unemployed or change jobs frequently are lazy or unmotivated 
• Assuming clients requesting accommodations are asking for “handouts” 

While changes at community and government levels are needed to provide the social and economic support needed to increase access to preventive and acute care for disabled people, addressing implicit biases on the individual and institutional level will also make big strides towards improving equity for these clients (15). Suggestions include:  

• Standardizing and increasing assessments for disabilities 
• Ensuring transportation to and navigation within healthcare facilities meets ADA accessibility criteria to improve client attendance at appointments 
• Increasing familiarity with individual client diagnoses and how their disability affects their ability to process information and participate in their care and adjusting care accordingly 
• Having easily accessible information about this within a client’s chart to provide continuity of care among multiple providers 
• Routine screening for common risks of disabled clients including poverty, homelessness, lack of access to internet or transportation, etc 
• Regular continuing education on effective and respectful communication techniques and accommodations when interacting with disabled clients (11a) 

How to Measure and Reduce Implicit Biases in Healthcare

Assessing for Bias

In order for change to occur, there is a broad spectrum of transitions in individual thought and policy that must occur. Evaluating for the presence, and the extent, of implicit bias is one of the first steps.  

On the individual level, possible action include:  

• Identifying and exploring one’s own implicit biases. Everyone has them and we all need to reflect upon them. This goes beyond basic cultural competence and includes a deeper understanding of how your own experiences or environment may differ from someone else and may have caused you to feel or believe a certain way.   
• Attending training or workshops provided by your job and completing exercises in self-reflection will help you better understand where your biases are and the extent to which they may be impacting your behavior or actions at work and in your personal life. 
• Reflecting on how one’s biases affect actions. Once you have recognized the internal opinions you hold, you can examine ways that those opinions may have been affecting your actions, behaviors, or attitudes towards others. Reflect on your care of patients at the end of each shift. Consider if you made assumptions about certain clients early on in their care. Think about ways those assumptions may have affected your interactions with the client. Think about if you cared for your clients in a way that you would want your own loved ones cared for.  
• If you have the time, volunteer at events or in places that will expose you to people who are different from you. Use the opportunity to learn more about others, their lived experiences, and identify how often your implicit biases may be affecting your view of others before you even get to know them.  

On an institutional level, the measurement of biases can be more streamlined and may utilize tools like surveys.  

• Monitoring patient data and assessing for any broad gaps in diagnoses, preventative care and treatment rates, as well as health outcomes across racial, ethnic, gender, and other spectrums. Recognizing gaps or problem areas and assigning task forces to evaluate further and address the underlying issues.  
• Regularly poll clients and employees of healthcare facilities to determine who might be experiencing effects of bias and when. 
• Require employee participation in implicit bias presentations or courses, allowing employees to self-identify areas where they may be biased.

Interact Now!

Acting to Reduce Bias

Once the presence and extent of bias has been identified, individuals can make small, consistent changes to recognize and address those biases in order to become more self-aware and intentional in their actions. Some possible ways to address and reduce implicit bias on an individual level include:  

• Educating oneself and reframing biases. In order to change patterns of thinking and subsequent behaviors that may negatively impact others, you can work on broadening your views on various topics. This can be done through reading about the experiences of others, watching informational videos or documentaries, attending speaking engagements, and just listening to the experiences of others and gaining an understanding of how their lives might be different than yours.  
• Understanding and celebrating differences. Once you can learn to see others for their differences and consider how you can adapt your care to help them achieve the best outcomes for their wellbeing, you are able to provide truly equitable care to your clients. This includes understanding differences in experiences, perceptions, cultures, languages, and realities for people different from yourself, recognizing when disparities are occurring, and advocating for change and equity.  

When enough people have recognized and addressed their own implicit biases, advocacy can extend beyond individual care of clients and reach the institutional level where change is more easily seen (though no more important than the small individual changes). One of the most effective ways to make institutional level changes is through representation of minority groups in positions of power and decision making. Simply keeping structures as they are and dictating change without any evolution from leadership is not likely to be effective in the long term. Including minority professionals in positions of leadership or on decision making panels has the most potential to make true and meaningful change for hospitals and healthcare facilities. Examples of institutional level changes include:  

• Medical schools will need to take a broader, more inclusive approach when admitting future doctors, incentivize minority students to choose careers in healthcare, and invest in their retention and success (9).  
• Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1).  
• Universal health insurance, basic housing regulations, access to grocery stores, and many other socio-political changes can also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location (3).  
• Community programs should be available to create safe spaces for connection and acceptance for LGBTQ people. Laws and school policy need to focus on how to prevent and react to bullying and violence against LGBTQ individuals (12). 
• Cultural competence training in medical professions needs to include LGBTQ issues and data collection regarding this population needs to increase and be recognized as a medical necessity (12). 
• Medical professionals must be trained in the history of inequality among women, particularly in regards to mental health, and proper, modern diagnostics must be used. The differences in communication styles of men and women should be taught as well (20).  
• Medical facilities should emphasize respect of a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with a staff members’ own beliefs (14).  
• Healthcare facilities can adopt practices that are standardized regardless of age and include anti-ageism and geriatric focused training, including training about elder abuse (18). 

Obviously each geographic area will have differing demographics depending on the populations they serve. What works at one facility may not work at another. Hearing from the community is beneficial for keeping things individualized and allows facilities to gain perspective from the local groups they serve.  

• Town Hall style meetings, keeping hospital board members and employees local rather than outsourcing from travel companies (when possible), and encouraging community involvement from staff members are all great ways to keep a community centered facility and keep the lines of communication open for clients who may be having a different experience than their neighbor. 

Infection Control and Barrier Precautions

Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible.

Introduction   

The healthcare industry is held accountable to keep patients safe with nursing having a pivotal role. Nurses must adhere to the guidelines set in place to ensure that care is aimed at infection prevention for both healthcare workers and patients. Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention control are necessary. As is the use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings.  Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfecting, and sterilization is extremely important.

Element I

Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible.

Element I Objectives

At the conclusion of course work or training on this element, the learner will be able to: 

• Recognize the benefit to patients and healthcare workers of adhering to scientifically accepted principles and practices of infection prevention and control. 
• Recognize the professional’s responsibility to adhere to scientifically accepted infection prevention and control practices in all healthcare settings and the consequences of failing to comply. 
• Recognize the professional’s responsibility to monitor infection prevention and control practices of those medical and ancillary personnel for whom they are responsible and intervene as necessary to assure compliance and safety. 

The healthcare industry is held accountable to keeping patients safe, with nursing having a pivotal role. Nurses must adhere to the guidelines set in place to ensure that care is aimed at infection prevention for both healthcare workers and patients.

Statements from Relevant Professional and National Organizations

As the largest healthcare workforce in the nation, nurses are able to positively affect the rates of infection at the bedside. The Center for Disease Control asserts the minimum accepted practice of preventing infection is with the use of Standard Precautions, with the number one action in prevention being proper hand washing (3). 

The American Nurses Association refers to similar basic tenets of infection prevention: thorough hand washing, staying home when ill, ensuring vaccinations are complete and up to date, using appropriate personal protective equipment, and covering face when coughing or sneezing (4). 

In 2017, the CDC, ANA, and 20 other professional nursing organizations collaborated to create the Nursing Infection Control Education (NICE) Network. This team effort is aimed at introducing clear obligations and competencies for nursing and all healthcare providers to stop the spread of microorganisms within health care systems. Within these cores is the responsibility of nursing as leaders within healthcare, “To be successful, infection prevention programs require visible and tangible support from all levels of the healthcare facility’s leadership” (5). 

Implications of Professional Conduct Standards

As healthcare professionals that participate in and supervise care of patients, nurses are responsible for being knowledgeable of the guidelines set by State and federal bodies. Several of these will be touched on throughout this course. 

The responsibility also applies to delegated activities. The nurse must ensure that the five rights of delegation are considered when assigning a task to unlicensed assistive personnel and that appropriate infection control policies and protocols are being followed appropriately. Always refer to facility policies and procedures to avoid potentially adverse outcomes. 

Failure to follow the accepted standards of infection prevention and control may have serious health consequences for patients, as well as healthcare workers. Hospital acquired infections (HAI) have improved by 16% from 2011 to 2015; however, the CDC reports that in 2015 there were still approximately 687,000 HAIs with 72,000 resulting in death (6). 

In cases of nurses observing incompetent care or unprofessional conduct in relation to infection control standards, the chain of command should first be utilized. Taking consideration into the type of misconduct, the improper infection control infraction should be addressed according to facility policy. Charge nurses and managers would be wise to first address the issue with the nurse involved to gather information and address any education deficits. 

In cases where clear misconduct is evident, the National Council of State Boards of Nursing advises, “A nurse’s practice and behavior is expected to be safe, competent, ethical and in compliance with applicable laws and rules. Any person who has knowledge of conduct by a licensed nurse that may violate a nursing law or rule, or related state or federal law may report the alleged violation to the board of nursing where the conduct occurred” (7). 

Consequences of failing to follow accepted standards of infection prevention and control may result in a complaint investigation from your various state of employments Professional Misconduct Enforcement Systems. Upon investigation, penalties include, but are not limited to, reprimand and censure, fines totaling thousands of dollars per violation, and probationary terms. 

Severe misconduct may result in the loss or revocation of a nursing license. As well, in cases where the neglect to follow appropriate conduct has resulted in harm to a patient or co-worker, there is potential for professional liability through a malpractice suit brought against the nurse.

Methods of Compliance

Nurses are responsible for being knowledgeable of the licensure renewal requirements and targeted education in their state of practice. Refer to your specific state’s Board of Nursing for further guidance beyond the above-mentioned licensing requirements. 

Education of infection control best practice, complying with state requirements, and following the facility practices and policies will provide the best protection for self, patients, and staff in preventing and controlling infection during patient care.

Element II 

Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention control.

Element II Objectives

Upon completion of course work or training on this element, the learner will be able to: 

• Describe how pathogenic organisms are spread in healthcare settings 
• Identify the factors which influence the outcome of an exposure to pathogenic organisms in healthcare settings 
• List strategies for preventing transmission of pathogenic organisms 
• Describe how infection control concepts are applied in professional practice

Definitions

Pathogen or infectious agent:  A biological, physical, or chemical agent capable of causing disease. Biological agents may be bacteria, viruses, fungi, protozoa, helminths, or prions. 

Portal of entry: The means by which an infectious agent enters the susceptible host. 

Portal of exit: The path by which an infectious agent leaves the reservoir. 

Reservoir: Place in which an infectious agent can survive but may or may not multiply or cause disease. Healthcare workers may be a reservoir for several nosocomial organisms spread in healthcare settings. 

Standard precautions: A group of infection prevention and control measures that combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. 

Susceptible host: A person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting infection or disease when exposed to the agent. 

Transmission: Any mechanism by which a pathogen is spread by a source or reservoir to a person. 

Common vehicle: Contaminated material, product, or substance that serves as a means of transmission of an infectious agent from a reservoir to one or more susceptible hosts through a suitable portal of entry. 

Overview of Components of the Infectious Disease Process

The infectious disease process follows a particular sequence of events that is commonly described as the “The Chain of Infection.” Nurses must have a solid understanding of this process in order to identify points in the chain where the spread of infection may be prevented or halted. The sequence involves six factors: pathogen, reservoir, portal of exit, portal of entry, mode of transmission, and a susceptible host. The cyclical and consistent nature of the chain provides ample opportunities to utilize scientific, evidence-based measures in combating infection spread. 

Pathogens within healthcare are widespread and plentiful, putting patients and healthcare workers at particular risk for contamination. The manifestation of symptoms and mode of transmission is varied depending upon the characteristic of the specific infectious agent. Healthcare workers are at a much higher risk for bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus. Influenza, methicillin-resistant Staphylococcus aureus (MRSA), and Tuberculosis (TB) also poses a higher risk (1). Due to the immunocompromised systems of patients, these and many other pathogens cause a considerable risk and can result in HAIs such as Central Line-associated Bloodstream Infection (CLABSI), Catheter-associated Urinary Tract Infections (CAUTI), Surgical Site Infection (SSI), and Ventilator-associated Pneumonia (VAP) (1). 

Pathogens require a reservoir, which is typically a human or animal host; however, may also be from the environment, such as standing water or a surface. From the reservoir, the pathogen is spread via a mechanism such as body fluid, blood, or secretions. Common sites for contact within patient care include the respiratory, genitourinary, and gastrointestinal tracts, as well as skin/mucous membranes, transplacental, or blood. From here, the mechanism must come into contact with another portal of entry. Transmission may occur through respiratory, genitourinary, and gastrointestinal tracts, skin and/or mucous membranes, transplacental, and parenteral pathways. Some of these sites may have become compromised during patient care due to percutaneous injury, invasive procedures or devices, or surgical incisions. 

In order to acquire a pathogen, a mode of transmission must be provided. These can be from contact, transmission via a common vehicle, or vector borne. 

Contact with a pathogen may be categorized as direct, indirect, droplet, or airborne. Contact transmission is through direct or indirect contact with a patient or objects that have been in contact with the patient. Pathogens related to this include Clostridium difficile and multi-drug resistant bacteria such as MRSA. Droplet transmission occurs when a pathogen can infect via droplets through the air by talking, sneezing, coughing, or breathing. The pathogen can travel three to six feet from the patient. Airborne transmission occurs when pathogens are 5 micrometers or smaller in size and are capable of being suspended in the air for long periods of time. These types of pathogens include tuberculosis, measles, chickenpox, disseminated herpes zoster, and anthrax (2). 

Transmission may also occur through a common vehicle which affects multiple hosts and can come from food, intravenous fluid, medication, biofilms, or equipment that is shared and often leads to widespread outbreaks. Vector borne pathogens are derived from a living vector such as mosquitoes, fleas, or ticks. 

The last factor in the chain of infection is a susceptible host with a mode of entry. This is the reason that patients are at a much higher risk for developing secondary infections within the healthcare system.   

Factors Influencing the Outcome of Exposures

The human body provides several natural defenses to prevent infection from a pathogen. The most prominent defense is the integumentary system and focus should be on maintaining skin integrity to prevent a mode of entry. Respiratory cilia function to move microbes and debris from airway. Gastric acid is at an optimal pH level that prevents the growth of many pathogens. Bodily secretions provide defense through flushing out and preventing back-flow of potential infectious agent colonization.  The normal flora also provides a layer of defense that must take care to not be compromised through use of antibiotics. Probiotics are commonly administered to patients on antibiotics to prevent a secondary infection due to the normal flora being disrupted (3). 

Host immunity is the secondary defense that utilizes the hosts own immune system to target invasive pathogens. There are four types of host immunity (all from 3): 

• Inflammatory response is pathogen detection by cells in a compromised area that then elicit an immune response that increases blood flow. This inflammatory response provides delivery of phagocytes or white blood cells to the infected site response. The phagocytes are designed to expunge bacteria. 
• Cell mediated immunity uses B-cells and T-cells, specialized phagocytes, are cytotoxic cells which target pathogens. 
• Humoral immunity is derived from serum antibodies produced by plasma cells. 
• Immune memory is the ability of the immune system to recognize previously encountered antigens of pathogens and effectively initiate a targeted response. 

Pathogen or Infection Agent Factors

For each type of infectious agent, there are specific factors that determine the risk to the host. Infectivity refers to the number of exposed individuals that become infected. Pathogenicity is the number of infected individuals that develop clinical symptoms and virulence is the mortality rate of those infected. The probability of an infectious agent to cause symptoms depends upon the size of inoculum (amount of exposure), and route and duration of exposure (4). 

The environment is another factor that warrants attention in limiting the probability of exposure in the healthcare setting. Fomites are materials, surfaces or objects which are capable of harboring or transmitting pathogens. These can be bedside tables, scrubs, gowns, bedding, faucets, and any other number of items that are in contact with patients and healthcare providers (7). 

Equipment is also a common means of spreading infection, especially portable medical equipment that can come into contact with numerous patients in a day. This can include vitals machines, IV pumps, wheelchairs, and computers on wheels, among numerous other care items frequently used. Care must be taken to ensure cleaning in between each patient use. For patient’s in isolation, dedicated equipment for that patient should remain in the room for the duration of stay. 

Methods to Prevent the Spread of Pathogenic Organisms in Healthcare Settings

Standard Precautions

Standard precautions are the minimal amount of caution and procedure applied to typical patient care. According to the CDC, standard precautions are to be used in all patient care areas with critical thinking applied to “. . . common sense practices and personal protective equipment use” (5).  The primary of these is proper hand hygiene to be exercised by healthcare providers, patients, and visitors. They will be covered in further detail in this course. 

Standard precautions provide guidelines for respiratory hygiene and cough etiquette. The CDC recommends that the mouth and nose be covered with a tissue when coughing or sneezing, with appropriate disposal of the tissue in the nearest waste station. Hand hygiene is to be performed after any contact with any respiratory secretions or contact with potentially contaminated items (5). 

As mentioned, healthcare workers are at a higher risk for bloodborne infections due to handling of sharps. Approximately 385,000 needle sticks and sharps injuries are reported by healthcare workers in hospital settings each year (5). Standard precautions can be applied to ensure safe injection practices and will be further covered in Element III. 

Certain spinal procedures that access the epidural or subdural space provide a means of transmission for infection such as bacterial meningitis. The CDC states (all from 6): 

• Face masks should always be used when injecting material or inserting a catheter into the epidural or subdural space. 
• Aseptic technique and other safe injection practices (e.g., using a single-dose vial of medication or contrast solution for only one patient) should always be followed for all spinal injection procedures. 

For Patients Infected with Organisms other than Bloodborne Pathogens 

Special considerations must be given to patient populations that are infected with organisms other than bloodborne pathogens. During triage of a patient entering a facility, a thorough history should be obtained. This would include exposure to infectious agents, travel to certain countries in the world, and previous infections that are resistant to antibiotics (i.e., MRSA, VRE, or carbapenem-resistant Enterobacteriaceae). Patients that are identified with risk may be placed on the appropriate precautions in an isolation room. Infection prevention and the attending physician should be consulted immediately for further orders and treatment. 

Control of Routes of Transmission 

Controlling the routes of transmission is a key factor in preventing infection spread. Hand hygiene has been established as providing the primary prevention method. Care must be taken to follow guidelines for proper hand washing including: 

• Use antibacterial soap and water when hands are visibly soiled or when a Clostridium difficile infection is known or suspected. 
• Hands should be lathered ensuring all surfaces, between fingers, and under nails is covered and scrubbing should last at least 20 seconds. 
• Thoroughly rinse soap from hands with running water, pat dry with paper towel, and use paper towel to turn off faucet.
• Hand sanitizer that is at least 60% alcohol based may be used in between soap and water use. 
• A dime sized amount of hand sanitizer should be rubbed over surface of hands and fingers, then allowed to air dry. 

Barriers to proper hand hygiene include knowledge gaps and availability of appropriate supplies. Training programs to educate healthcare providers on proper hand washing should be accompanied with ongoing assessment and feedback to ensure that compliance is met. Incorporating hand hygiene into the professional development plan of each nurse is also recommended (7). Healthcare facilities should be diligent in ensuring that hand washing stations are located in convenient areas and that hand cleaning product is frequently monitored and refilled (7,8). Signage and educational materials may be posted in high traffic areas and at hand washing stations to encourage use by healthcare providers, patients, and visitors (7). 

Nurses and healthcare personnel must be aware of the potential of hand hygiene materials as being a possible source of contamination or cross-contamination. Hand hygiene dispensers are touched frequently with contaminated hands and must be frequently cleaned. Follow manufacturers recommendations for cleaning. 

Hand hygiene systems that allow product to be refilled pose a risk of contaminating the contents. If refilling is a requirement, this should be accomplished using aseptic technique as much as possible. Facilities should avoid purchasing this type of product and move to pre-filled dispensing units, if possible (10). 

Use of Appropriate Barriers

Appropriate barriers are essential in keeping patients and healthcare providers safe from transmitting or contracting pathogens. The type of PPE chosen depends on certain variables such as the patient care being provided, standard precautions, and transmission-based precautions. The minimal amount of PPE recommended are as follows: 

• Contact precautions require gloves and gowns. If bodily secretions may be contacted, a mask and eye protection are required. 
• Droplet precautions require a surgical mask. 
• Airborne precautions require the wearing of gloves and a gown as well as an approved N95 respirator mask that has been fit tested for the individual wearing. Negative pressure rooms that are able to filter 6 to 12 air exchanges per hour are also recommended (1). 

Be mindful that these are the minimal recommendations based solely on the identified transmission status of the patient. Selection of PPE should be made using critical thinking to identify potential risks depending on type of patient care being performed, procedure, behavioral considerations, and other factors that may deviate from the standard. 

The following are current recommendations from the CDC for donning and doffing (all from 11).

How to Put On (Don) PPE Gear

More than one donning method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of donning. 

1. Identify and gather the proper PPE to don. Ensure choice of gown size is correct (based on training). 
2. Perform hand hygiene using hand sanitizer. 
3. Put on isolation gown. Tie all the ties on the gown. Assistance may be needed by other healthcare personnel. 

Put on NIOSH-approved N95 filtering face-piece respirator or higher (use a facemask if a respirator is not available).

If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. Respirator/facemask should be extended under chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. 

-Respirator: Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator.

-Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie). If mask has loops, hook them appropriately around your ears.

      5. Put on face shield or goggles.

When wearing an N95 respirator or half face-piece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 

   6. Put on gloves. Gloves should cover the cuff (wrist) of gown. 

   7. Healthcare personnel may now enter patient room. 

How to Take Off (Doff) PPE Gear

More than one doffing method may be acceptable. Training and practice using your healthcare facility’s procedure is critical. Below is one example of doffing. 

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. 
3. Healthcare personnel may now exit patient room. 
4. Perform hand hygiene. 
5. Remove face shield or goggles. Carefully remove face shield or goggles by grabbing the strap and pulling upwards and away from head. Do not touch the front of face shield or goggles.
6. Remove and discard respirator (or face mask if used instead of respirator). Do not touch the front of the respirator or face mask. 
   -Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
   -Face mask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
7. The final step is to perform hand hygiene after removing the respirator/face mask and before putting it on again if your workplace is practicing reuse.

Appropriate Isolation/Cohorting of Patients with Communicable Diseases

Cohorting patients is a common practice within facilities, especially with limited rooms and an increasing number of patients with MDROs (12). In order to combat these issues, placing patients with the same type of pathogen in one room, when single rooms are not available is an option. The minimal standard for all patients is standard precautions. 

The CDC offers guidance for appropriately isolating or cohorting patients based on the type of precaution. 

Contact: Patients with a known or suspected pathogen that is transmitted via contact should be placed in a private room, if available. Cohorting can be achieved if the cohorted patients share the same type of pathogen (13). 

Droplet: Unless a single patient room is not available, patients in droplet precautions should only be cohorted if neither have an excessive cough or sputum production. The cohorts should be tested to ensure they are infected with the same type of pathogen. Immunocompromised patients are at an increased risk and should not be cohorted. Patients are to be separated at least three feet apart and a privacy curtain should remain drawn between their respective areas. Care providers must don and doff new PPE in between providing care to each respective patient (13). 

Airborne: An airborne infection isolation room (AIIR) with negative air pressure that exchanges air at least 6 to 12 changes per hour is required. The door must remain closed except for entry and exit. Cohorting of patients is not recommended except in the case of outbreak or large number of exposed patients (13). In these instances, the CDC recommends the following (13):   

• Consult infection control professionals before patient placement to determine the safety of alternative rooms that do not meet engineering requirements for AIIR. 
• Place together (cohort) patients who are presumed to have the same infection (based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at increased risk for infection (e.g., immunocompromised patients). 
• Use temporary portable solutions (e.g., exhaust fan) to create a negative pressure environment in the converted area of the facility. Discharge air directly to the outside, away from people and air intakes, or direct all the air through HEPA filters before it is introduced to other air spaces. 

Host Support and Protection

Vaccinations to preventable disease are highly recommended by numerous health organizations such as the CDC, World Healthcare Organization, and the Office of Disease Prevention and Health Promotion. As state by Healthy People 2020, “. . . infectious diseases remain a major cause of illness, disability, and death. Immunization recommendations in the United States currently target 17 vaccine-preventable diseases across the lifespan” (14). As healthcare providers, nurses are in a position to review the patient’s history for gaps in appropriate vaccination coverage and offer education to the patient. Additionally, healthcare providers hold an ethical responsibility to stay current on vaccinations and prevent transmitting known communicable diseases by receiving an influenza vaccination each year. 

Pre- and/or post-prophylaxis may be recommended during certain types of exposures or for patients at an increased risk for infection. This is commonly used for emergent or planned procedures and surgeries that access areas that are at higher risk for becoming a portal of entry, such as the respiratory, gastrointestinal, and genitourinary tracts. Antibiotics may be ordered when it is known that the sterile field has been broken during a procedure or there has been a concern of contamination of a wound or incision site. 

In cases of exposure to an infectious pathogen, the decision to treat includes factors such as the type of exposure, patient’s symptoms, time frame since exposure, the health status of the individual exposed, as well of the risks and benefits of the treatment. Pre-prophylaxis may be considered in the prevention of HIV for high-risk individuals. 

Typically, after an exposure, the host’s blood is drawn to determine pathogen risk regardless if there is a known pathogen. Post-exposure prophylactics are given within a short time frame from the exposure based on results. The individual that is exposed will have baseline testing for HIV, hepatitis B virus, and hepatitis C viral antibodies. Follow-up testing occurs six weeks, three months, and six months after initial exposure. 

Maintaining skin and immune system integrity is of the upmost importance to prevent the transmission of infectious pathogens. Nursing interventions to promote skin and immune system integrity are:   

• Perform a thorough skin assessment every shift and with changes in condition 
• Accurately document any wounds or incisions 
• Use gentle cleansers on skin and pat dry 
• Use moisturizers and barrier creams on dry or tender skin 
• Prevent pressure ulcer development by turning and repositioning patient every 2 hours 
• Maintain aseptic technique during wound care, dressing changes, IV manipulation or blood draws, and catheter care 
• Use neutropenic guidelines when providing care to immunocompromised patients 
• Encourage adequate nutritional and intake   

Environmental Control Measures

The cleaning, disinfection and sterilization of patient care equipment should be performed per the recommendations of the manufacturer. Cleaning should be performed between multiple patient use. For equipment that has been used in an isolation room, a terminal clean must be performed prior to being used in any other patient care. Additional information on this topic will be covered within Element V. 

Environmental cleaning personnel must be educated on the appropriate cleaning for all precaution patient environments. The Material Safety Data Sheets for all chemicals are to be available to all healthcare personnel for reference as to the proper use and storage. These should be referred to in order to ensure that the correct cleaning product is effective to terminally clean isolation rooms based on pathogen. 

Ventilation should be thoroughly managed and maintained by the environmental operations team. Negative pressure rooms should be consistently monitored, and alarms investigated to ensure proper air exchange. Concerns from nursing regarding ventilation issues should be directed to the environmental team for follow-up. 

Regulated medical waste (RMW) within the healthcare system that must follow state guidelines for disposal includes: 

• Human pathological waste 
• Human blood and blood products 
• Needles and syringes (sharps) 
• Microbiological materials (cultures and stocks) 
• Other infection waste (16) 

According to the CDC, “To ensure containment, RMW (except medical waste sharps) is required to be placed in plastic bags and then packaged in single use (e.g., corrugated boxes) or reusable rigid (e.g., plastic) or semi-rigid, leak proof containers before transport. Once packaged, RMW is either transported to a designated secure storage or collection area within the facility for third party pick-up, or to a generator’s on-site treatment facility” (15). 

Bodily fluid (urine, vomit, and feces) may be safely disposed of in any utility sink, drain, toilet, or hopper that drains into a septic tank or sanitary sewer system. Healthcare personnel must don appropriate PPE during disposal.

Element III

Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings.

Element III Objectives

Upon completion of course work or training on this element, the learner will be able to: 

• Define healthcare-associated disease transmission, engineering controls, safe injection practices, and work practice controls 
• Describe specific high-risk practices and procedures that increase the opportunity for healthcare worker and patient exposure to potentially infectious material 
• Describe specific measures to prevent transmission of blood-borne pathogens from patient to patient, healthcare worker to patient, and patient to healthcare worker via contaminated injection equipment 
• Identify work practice controls designed to eliminate the transmission of blood-borne pathogens during use of sharp instruments (e.g., scalpel blades and their holders (if not disposable), lancets, lancet platforms/pens, puncture devices, needles, syringes, injections) 
• Identify where engineering or work practice controls can be utilized to prevent patient exposure to blood-borne pathogens 

Definitions

Healthcare-associated infections (HAIs): Infections associated with healthcare delivery in any setting (e.g., hospitals, long-term care facilities, ambulatory settings, home care). 

Engineering Controls: Controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the blood-borne pathogens hazard from the workplace. 

Injection safety (or safe injection practices): A set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community. Injection safety includes practices intended to prevent transmission of blood-borne pathogens between one patient and another, or between a healthcare worker and a patient, and to prevent harms such as needlestick injuries. 

Single-use medication vial: A bottle of liquid medication that is given to a patient through a needle and syringe. Single-use vials contain only one dose of medication and should only be used once for one patient, using a new sterile needle and new sterile syringe. 

Multi-dose medication vial: bottle of liquid medication that contains more than one dose of medication and is often used by diabetic patients or for vaccinations. 

Work Practice Controls: Controls that reduce the likelihood of exposure to blood-borne pathogens by altering the way a task is performed (e.g., prohibiting recapping of needles by a two-handed technique). 

High-Risk Practices and Procedures Capable of Causing Healthcare Acquired Infection with Blood-borne Pathogens

Percutaneous exposures are a work hazard within the healthcare industry. There are approximately 5.6 million healthcare workers at risk, with nurses ranking number one. Studies have shown that needlestick injuries occur most frequently within a patient room or the operating room (1). 

Exposures can occur through not following safe practices. The following practices in handling contaminated needles and other sharp objects, including blades, can increase the risk for a percutaneous exposure and should be avoided.

• Manipulating contaminated needles and other sharp objects by hand (e.g., removing scalpel blades from holders, removing needles from syringes) 
• Delaying or improperly disposing (e.g., leaving contaminated needles or sharp objects on counters/workspaces or disposing in non-puncture-resistant receptacles) 
• Recapping contaminated needles and other sharp objects using a two-handed technique 
• Performing procedures where there is poor visualization, such as: 
  1. Blind suturing 
  2. Non-dominant hand opposing or next to a sharp 
  3. Performing procedures where bone spicules or metal fragments are produced
     

Mucous membrane/non-intact skin exposures occur with direct blood or body fluids contact with the eyes, nose, mouth, or other mucous membranes via the following.

• Contact with contaminated hands 
• Contact with open skin lesions/dermatitis 
• Splashes or sprays of blood or body fluids (e.g., during irrigation or suctioning)
  

Parenteral exposure is the subcutaneous, intramuscular, or intravenous contact with blood or other body fluid. Injection with infectious material may occur during the following scenerios.

• Administration of parenteral medication 
• Sharing of blood monitoring devices (e.g., glucometers, hemoglobinometers, lancets, lancet platforms/pens) 
• Infusion of contaminated blood products or fluids 
• Safe injection practices and procedures designed to prevent disease transmission from patient to patient and healthcare worker to patient
  

According to the CDC, unsafe injection practices have resulted in more than 50 outbreaks of infectious disease transmission since 2001.  As well, since that time over 150,000 patients were potentially exposed to HIV, hepatitis B virus, and hepatitis C virus solely due to unsafe practice (2). These deviations from best practice have resulted in one or more of the following consequences.

• Transmission of blood-borne viruses, including hepatitis B and C viruses to patients 
• Notification of thousands of patients of possible exposure to blood-borne pathogens and recommendation that they be tested for hepatitis C virus, hepatitis B virus, and human immunodeficiency virus (HIV) 
• Referral of providers to licensing boards for disciplinary action 
• Malpractice suits filed by patients
  

Pathogens including HCV, HBV, and human immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood. 

• Bacteria and other microbes can be present without clouding or other visible evidence of contamination. 
• The absence of visible blood or signs of contamination in a used syringe, IV tubing, multi- or single-dose medication vial, or blood glucose monitoring device does NOT mean the item is free from potentially infectious agents. 
• All used injection supplies and materials are potentially contaminated and should be discarded.
  

Proper infection control technique requires that healthcare providers must follow best practice to prevent injury and pathogen transfer. At all times, aseptic technique is to be used to prepare and administer an injection. The following are best practice guidelines.

• Medications should be drawn up in a designated “clean” medication area that is not adjacent to areas where potentially contaminated items are placed. 
• Use a new sterile syringe and needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. 
• Ensure proper hand hygiene (i.e., hand sanitizing or hand washing if hands are visibly soiled) before handling medications. 
• If a medication vial has already been opened, the rubber septum should be disinfected with alcohol prior to piercing it. 
• Never leave a needle or other device (e.g., “spikes”) inserted into a medication vial septum or IV bag/bottle for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid. 
• Medication vials should be discarded upon expiration or any time there are concerns regarding the sterility of the medication.
  

Never administer medications from the same syringe to more than one patient, even if the needle is changed. 

Never use the same syringe or needle to administer IV medications to more than one patient, even if the medication is administered into the IV tubing, regardless of the distance from the IV insertion site. 

• All the infusion components from the infusate to the patient’s catheter are a single interconnected unit. 
• All the components are directly or indirectly exposed to the patient’s blood and cannot be used for another patient. 
• Syringes and needles that intersect through any port in the IV system also become contaminated and cannot be used for another patient or used to re-enter a non-patient specific multidose medication vial. 
• Separation from the patient’s IV by distance, gravity and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items. 
• Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient. 

Dedicate vials of medication to a single patient, whenever possible. 

• Medications packaged as single use must never be used for more than one patient: 
• Never combine leftover contents for later use 
• Medications packaged as multi-use should be assigned to a single patient whenever possible 
• Never use bags or bottles of intravenous solution as a common source of supply for more than one patient 
• Never use peripheral capillary blood monitoring devices packaged as single-patient use on more than one patient 
• Restrict use of peripheral capillary blood sampling devices to individual patients 
• Never reuse lancets. Use single-use lancets that permanently retract upon puncture whenever possible 

Safe injection practices and procedures designed to prevent disease transmission from patient to healthcare worker. Fact sheet from OHSA can be found at https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf

Evaluation or Surveillance of Exposure Incidents

A plan to evaluate and follow-up on exposure incidents should be put into place at every facility. At a minimum, this plan should include the following elements: 

1. Identification of who is at risk for exposure
2. Identification of what devices cause exposure 
3. Education for all healthcare employees that use sharps. This would include that ALL sharp devices can cause injury and disease transmission if not used and disposed properly. Specific focus would include the devices that are more likely to cause injury such as:  

• Devices with higher disease transmission risk (hollow bore)
• Devices with higher injury rates (“butterfly”-type IV catheters, devices with recoil action)
• Blood glucose monitoring devices (lancet platforms/pens)

1. Identification of areas/settings where exposures occur
2. Circumstances in which exposures occur
3. Post exposure management - See Element VI

Engineer Controls

Engineer controls are implemented in order to provide healthcare workers with the safest equipment to complete their jobs. Safer devices should be identified and integrated into safety protocols whenever possible. When selecting engineer controls to be aimed at preventing sharps injuries the following should be considered: 

1. Evaluate and select safer devices 
2. Passive vs. active safety features 
3. Mechanisms that provide continuous protection immediately 
4. Integrated safety equipment vs. accessory devices:  

• Properly educate and train all staff on safer devices 
• Consider eliminating traditional or non-safety alternatives whenever possible 
• Explore engineering controls available for specific areas/settings

    5. Use puncture-resistant containers for the disposal and transport of needles and other sharp objects:  

• Refer to published guidelines for the selection, evaluation, and use (e.g., placement) of sharps disposal containers 
• National Institute for Occupational Safety and Health (NIOSH) guidelines –
  This is available at: http://www.cdc.gov/niosh/topics/bbp/#prevent  
  
• Use splatter shields on medical equipment associated with risk prone procedures (e.g., locking centrifuge lids) 

Work Practice Controls

General Practices

• Hand hygiene including the appropriate circumstances in which alcohol– based hand sanitizers and soap and water hand washing should be used (see Element II). 
• Proper procedures for cleaning of blood and body fluid spills: 
• Initial removal of bulk material followed by disinfection with an appropriate disinfectant. 
• Proper handling/disposal of blood and body fluids, including contaminated patient care items. 
• Proper selection, donning, doffing, and disposal of personal protective equipment (PPE) as trained [see Element IV]. 
• Proper protection of work surfaces in direct proximity to patient procedure treatment area with appropriate barriers to prevent instruments from becoming contaminated with blood-borne pathogens. 

Preventing Percutaneous Exposures

1. Avoid unnecessary use of needles and other sharp objects. 
2. Use care in the handling and disposing of needles and other sharp objects:  

• Avoid recapping unless absolutely medically necessary. 
• When recapping, use only a one-hand technique or safety device. 
• Pass sharp instruments by use of designated “safe zones.” 
• Disassemble sharp equipment by use of forceps or other devices. 
• Discard used sharps into a puncture-resistant sharps container immediately after use. 

Modify Procedures to Avoid Injury

1. Use forceps, suture holders, or other instruments for suturing
2. Avoid holding tissue with fingers when suturing or cutting
3. Avoid leaving exposed sharps of any kind on patient procedure/treatment work surfaces
4. Appropriately use safety devices whenever available:  

• Always activate safety features. 
• Never circumvent safety features. 

Element IV

Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfecting, and sterilization.

Element IV Objectives

Upon completion of course work or training on this element, the learner will be able to: 

• Describe the circumstances that require the use of barriers and personal protective equipment to prevent patient or healthcare worker contact with potentially infectious material
• Identify specific barriers or personal protective equipment for patient and healthcare worker protection from exposure to potentially infectious material

Definitions

Personal protective equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard. 

Barriers: Equipment such as gloves, gowns, aprons, masks, or protective eye wear, which when worn, can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials.

Types of PPE or Barriers and Criteria for Selection

Per OSHA guidelines, employers must provide employees with appropriate PPE that provides protection from any potential infectious pathogen exposure (1). PPE includes gloves, cover garb, masks, face shields and eye protection. All PPE is intended to provide a barrier between the healthcare worker and potential contamination, whether from a patient, object, or surface. 

Gloves are intended to provide coverage and protection for hands. There are several types of gloves to choose from and the type of patient care or activity should guide choice. 

• Sterile – to be utilized when performing sterile procedures and aseptic technique 
• Non-sterile – medical grade, non-sterile gloves may be used for general patient care and clean procedures (such as NG tube insertion) 
• Utility – not medical grade and should not be used in patient care
  

Choice in material for gloves is often is dictated by cost and facility preference. When given a choice, considerations should be made as to the types of material being handled. 

• Natural rubber latex – rarely used in facilities due to allergen risk 
• Vinyl – made from PVC, lower in cost, provides protection in non-hazardous and low-infection environments 
• Nitrile – more durable, able to withstand chemical and bio-medical exposure (2) 

An appropriately sized glove fits securely over the fingertips and palm without tightness or extra room. If a glove develops a tear or is heavily soiled, it should be replaced immediately. 

Cover garb is a protective layer to wear over scrubs or clothes to protect garments and skin. These include laboratory coats, gowns, and aprons. As with gloves, consideration should be given to size, sterility, type of patient care involved, and material characteristics of the gown. 

• Fluid impervious – does not allow passage of fluids 
• Fluid resistant – resists penetration of fluids, but fluid may seep with pressure 
• Permeable – does not offer protection against fluids 

Masks are intended to provide protection to the wearers mouth and nose, with respirators providing an extra layer of protection to the respiratory tract against airborne infection pathogens (1).

Goggles are designed to protect the eyes from splashes and droplet exposure, while face shields offer additional protection to the entire face. It is important to note that face shields are not designed to be a replacement for masks. 

The choice of PPE is based on the factors that are reasonably anticipated to occur during the patient care encounter. Potential contact with blood or other potentially infectious material can occur via splashes, respiratory droplets, and/or airborne pathogens. The type of PPE chosen will be based on standard or transmission-based precaution recommendations. Follow your facility policy and procedures for guidance on appropriate choice. The nurse will also need to anticipate whether fluid will be encountered, such as emptying a drain or foley collection device. In situations where a large amount of fluid is likely to be encountered, it would be wise to choose a higher level of protection, such as an impermeable gown, if available, and to wear eye protection to ward off splashes. 

Choosing Barriers or PPE Based on Intended Need 

Barriers and PPE is aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. 

Patient Safety 

Barriers, PPE, and hand hygiene is aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. This includes, but is not limited to: 

Sterile Barriers for Invasive Procedures

During invasive procedures, such as inserting a central line or during a surgery, staff directly involved performing the procedure or surgery must maintain sterility. Appropriate sterile PPE will be selected based on the type of procedure and the patient will be draped in sterile fashion according to recommended guidelines.  

Both the patient and caregiver should wear a mask during central line changes, with the caregiver adhering to aseptic technique (1). Specific policies of the organization should be referred to on the selection and donning and doffing of sterile protective equipment during surgical procedures.   

Masks for Prevention of Exposure of Droplet Contamination

Patients in droplet precautions pose a significant risk to healthcare workers and visitors. The patient, as well as anyone inside the patient's room, should wear a mask for the most effective prevention of transmission (1). The patient and patient's family must be educated on the importance of adhering to these guidelines while visitation is appropriate. During transport of a patient under droplet precautions, the patient should wear a mask, placed over the top of any oxygen delivery device, if needed.  

Employee Safety

Employees must ensure that they are evaluating the types of exposure that is likely to occur during patient care. Selection of PPE and appropriate barriers should consider the following: 

Barriers for Prevention of Contamination

Per the CDC, "use of PPE is recommended based on the anticipated exposure to blood, body fluids, secretions, or excretions" (3). The following are CDC guidelines based on the expected type of exposure or precaution; however, clinical judgement should be used based on the situation (all from 5): 

Standard precautions are to be used with any potential exposure to blood, mucous membranes, compromised skin, contaminated equipment or surfaces, and body fluids. Barriers may include gloves, gown, and eye and face protection. 

Employees must be judicious in identifying any precautions that are placed on a patient (ie. Contact, droplet, airborne) and following recommended PPE guidelines for protecting themselves and other patients.  

PPE should be donned prior to going into a patient room and doffed upon exit. PPE must never be worn in the halls or when going from one patient room to the next. All gloves must be changed in between use and hands washed or sanitized upon removal of gloves. 

Additionally, whenever possible, social distancing of 6 feet should occur within the work environment. When not possible, adherence to mask guidelines is sufficient.  

Masks for Prevention of Exposure to Communicable Disease

With the onset of Covid-19 across the globe, masks are an essential tool in preventing the transmission of communicable disease. At a minimum, medical masks should be donned during all patient care. During procedures or surgery, surgical masks are to be utilized.  

N-95 masks are reserved for patient care with known or suspected Covid-19, if airborne precautions are ordered, or during procedures that may aerosolize (such as during intubations and certain endoscopy procedures). The CDC recommends reserving surgical N-95 masks for healthcare providers "who are working in a sterile field or who may be exposed to high velocity splashes, sprays, or splatters of blood or body fluids".  Standard N95 respirators are recommended for all other care involving confirmed or suspected Covid-19 patients (5).

Guidance on Proper Utilization of PPE or Barriers

Proper fit is required for PPE to be effective. Gowns and gloves chosen should fit well, allow movement, and neither be too baggy or too tight. For particulate respirators, the CDC recommends the following regarding proper fit and use of particulate respirators: 

All workers who are required to wear tight-fitting respirators (e.g., N95 respirators, Elastomerics) must have a medical evaluation to determine the worker’s ability to wear a respirator, and if medically cleared, a respirator fit test needs to be performed using the same model available in the workplace (3, 4). 

Prior to donning PPE, it should be inspected for any anomalies, tears, or vulnerable spots. PPE that is compromised should be disposed of and a new garment selected. Nurses must give careful consideration to the selection of PPE to ensure that it is the correct type for the job and anticipate any circumstances where splashes or saturation of fabric is likely to occur. 

The PPE provided by the employer may be single use or re-usable. Always verify with manufacturer guidelines and facility policy on the correct usage and processing of worn garments. It is the facilities responsibility to ensure that re-usable gowns are laundered according to State guidelines. 

In order to prevent cross contamination, OSHA offers the following guidelines: 

• Personal protective equipment must be removed prior to leaving a work area 
• Garment penetrated by blood or other potentially infectious material must be removed immediately or as soon as possible 
• PPE must be discarded in “. . . an appropriately designated area or container for storage, washing, decontamination, or disposal” 
• Employers must ensure that proper hand washing is taking place after the removal of PPE
  

Healthcare facilities have a legal duty to protect their workers. Per OSHA, “One way the employer can protect workers against exposure to blood-borne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the virus that causes AIDS, is by providing and ensuring they use personal protective equipment, or PPE. Wearing appropriate PPE can significantly reduce risk, since it acts as a barrier against exposure. Employers are required to provide, clean, repair, and replace this equipment as needed, and at no cost to workers” (5). 

Employers and healthcare workers must understand the balance of cost versus benefit ratio in PPE selection and use. While it is important to be good stewards with resources, always erring on the side of caution and choosing PPE based on anticipated exposure risk is the most effective way to protect yourself and your patients. 

For selection, donning, doffing, and disposal refer back to Element II.

Element V

Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfecting, and sterilization.

Element V Objectives

At the conclusion of course work or training on this element, the learner will be able to: 

• Define cleaning, disinfection, and sterilization 
• Differentiate between noncritical, semi critical, and critical medical devices 
• Describe the three levels of disinfection (i.e., low, intermediate, and high) 
• Recognize the importance of the correct application of reprocessing methods for assuring the safety and integrity of patient care equipment in preventing transmission of blood-borne pathogens 
• Recognize the professional’s responsibility for maintaining a safe patient care environment in all healthcare settings 
• Recognize strategies for, and importance of, effective and appropriate pre-cleaning, chemical disinfection, and sterilization of instruments and medical devices aimed at preventing transmission of blood-borne pathogens.

Definitions

Contamination: The presence of microorganisms on an item or surface. 

Cleaning: The process of removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object 

Critical device: An item that enters sterile tissue or the vascular system (e.g., intravenous catheters, needles for injections). These must be sterile prior to contact with tissue. 

Decontamination: The use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles. 

Disinfection: The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects. 

High level disinfection: Disinfection that kills all organisms, except high levels of bacterial spores, and is affected with a chemical germicide cleared for marketing as a sterilant by the U.S. Food and Drug Administration (FDA). 

Intermediate level disinfection: Disinfection that kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a “tuberculocide” by the U.S. Environmental Protection Agency (EPA). 

Low level disinfection: Disinfection that kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA. 

Noncritical device: An item that contacts intact skin but not mucous membranes (e.g., blood pressure cuffs, oximeters). It requires low level disinfection. 

Semi critical device: An item that comes in contact with mucous membranes or non-intact skin and minimally requires high level disinfection (e.g., oral thermometers, vaginal specula). 

Sterilization: The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. 

Universal Principles

Instruments, medical devices, and equipment should be managed and reprocessed according to the recommended and appropriate methods regardless of a patient’s diagnosis, except for cases of suspected prion disease. 

Due to the infective nature and steam resistant properties of prion diseases, special procedures are required for handling brain, spinal, or nerve tissue from patients with known or suspected prion disease (e.g., Creutzfeldt-Jakob disease [CJD] or Bovine spongiform encephalopathy [BSE]). Consultation with infection control experts prior to performing procedures on such patients is warranted. 

Industry guidelines as well as equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions must be made available for each instrument, medical device, and equipment reprocessed. The CDC recommends that critical medical and surgical devices and instruments that would be expected to enter a system through body fluids, blood, or tissue be sterilized prior to use on each patient. (1).   

Potential for Contamination

The type of instrument, medical device, equipment, or environmental surface creates variables that are more likely to be a source of contamination. External contamination may be caused by the presence of hinges, crevices, or multiple interconnecting pieces. If able, these devices should be disassembled. Endoscopes provide a particular challenge for both internal and external contamination, due to their lumens as well as the crevices and joints present. The disinfectant must reach all surfaces and assurance that there are no air pockets or bubbles to impede penetration (2). These devices may be made of material that is not heat resistant, preventing sterilization. In these instances, chemicals must be utilized to provide disinfection. 

Once rendered sterile, there are multiple opportunities for potential contamination due to the frequency of hand contact with the device or surface. Packaging may be over handled and breached, or the item may come into contact with potential contaminants via poor storage, improper opening, or environmental factors. 

The efficacy of sterilization and disinfection is dependent upon the number and type of microorganisms present. There are several types of pathogens that carry an innate resistance, making successful decontamination more challenging (2). Most infections are caused by bacteria, followed by viruses, fungi, protozoa, and prions (3).  Due to the nature of their outer membranes, spores and gram-negative bacteria have a natural barrier that prevents the absorption of disinfectants. Bacterial spores are especially resistant against chemical germicides, as are the following pathogenic organism types (all from 2): 

• Coccidia – i.e., Cryptosporidium 
• Mycobacteria – i.e., M. tuberculosis 
• Nonlipid or small viruses – i.e., poliovirus, coxsackievirus 
• Fungi – i.e., Aspergillus, Candida 
• Vegetative bacteria – i.e., Staphylococcus, Pseudomonas 
• Lipid or medium-size viruses – i.e., herpes, HIV 

The number of microorganisms that are present on a medical instrument, device or surface affects the time that must be factored into disinfection and sterilization efficacy. As stated by the CDC, “Reducing the number of microorganisms that must be inactivated through meticulous cleaning, increases the margin of safety when the germicide is used according to the labeling and shortens the exposure time required to kill the entire microbial load” (2) 

In general, used medical devices are contaminated with a relatively low bioburden of organisms. Inconsistencies or incorrect methods of reprocessing can easily lead to the potential for cross-contamination (1). 

Steps of Reprocessing

Reprocessing medical instruments and equipment is completed sequentially dependent upon the instrument and the process chosen. 

Pre-cleaning is the process of removing soil, debris, lubricants from internal and external surfaces through mopping, wiping, or soaking. It must be done as soon as possible after use to lower the number of microorganisms present on the object. 

Cleaning may be accomplished manually or mechanically. Manual cleaning relies upon friction and fluidics (fluids under pressure) to remove debris and soil from inner and outer surfaces of the instrument. There are several different machines used in mechanical cleaning including ultrasonic cleaners, washer-disinfectors, washer-sterilizers, and washer-decontaminators. Studies have shown that automated cleaning is more effective than manual; however, the frequency of fluid changes must follow manufacturer guidelines to eliminate the risk of contaminating debris (1). 

Disinfection involves the use of disinfectants, either alone or in combination, to reduce microbial count to near insignificant. Common disinfectants used in the healthcare setting include chlorine and chlorine compounds, hydrogen peroxide, alcohols, iodophors, and quaternary ammonium compounds, among others. These products are formulated and then approved by the Environmental Protection Agency and Food and Drug Administration for specific uses. 

Sterilization is used on most medical and surgical devices that are utilized in healthcare facilities. This requires sufficient exposure time to heat, chemicals, or gases to ensure that all microorganisms are destroyed.   

Choice/Level of Reprocessing Sequence

The choice or level of reprocessing is based on intended use: 

• Critical instruments and medical devices require sterilization 
• Semi critical instruments and medical devices minimally require high level disinfection 
• Noncritical instruments and medical devices minimally require cleaning and low-level disinfection.
  

Manufacturer recommendations must always be consulted to ensure that appropriate methods, actions, and solutions are used. There is a wide variability of compatibility among equipment components, materials, and chemicals used. Rigorous training is required to appropriately to understand equipment heat and pressure tolerance as well as the time and temperature requirements for reprocessing. Failure to follow manufacturer recommendations may lead to equipment damage, elevated microbial counts on instruments after reprocessing, increase risk for infections, and possibly patient death.   

Effectiveness of Reprocessing Instruments, Medical Devices, and Equipment

Pre-cleaning and cleaning prior to disinfection is one of the most effective ways to reduce the microbial count. This is only effective when completed prior to disinfection. Disinfection relies upon the action of products to eliminate microbial count. Depending on the medical instrument or device design, the product may only be required to cover the surface. However, due to the lumens of scopes, crevices, or hinges on certain instruments, immersion products and dwell times may be required (4). 

The presence of organic matter, such as blood, serum, exudate, lubricant, or fecal material can drastically reduce the efficacy of a disinfectant. This may occur due to the presence of a barrier or the organic material acting as a barrier.  It may also occur from a chemical reaction between the organic material and the disinfectant being utilized. 

Biofilms pose a particular challenge and offer protection from the action of disinfectants. Biofilms are composed of microbes that build adhesive layers onto the inner and outer surfaces of objects, including instruments and medical devices, rendering certain disinfectants ineffective. Chlorine and Monochloramines remain effective against inactivating biofilm bacteria (1). 

Per the CDC, “. . . a given product is designed for a specific purpose and is to be used in a certain manner. Therefore, users should read labels carefully to ensure the correct product is selected for the intended use and applied efficiently” (1). The label will indicate the sufficient contact time with chemical solution to achieve adequate disinfection. 

After disinfection, staff and management must adopt a system of record keeping and tracking of instrument usage and reprocessing. Reprocessing equipment must be on a schedule to be maintained and regularly cleaned, according to manufacturer guidelines. 

There are several methods of sterilization used such as steam sterilization (autoclaves), flash sterilization, and more recently, low-temperature sterilization techniques created for medical devices that are heat sensitive. Selection depends upon the type of instrument, material, ability to withstand heat or humidity, and targeted microbes. 

There are several methods of ensuring that sterilized instruments are processed and tracked appropriately. Indicators or monitors are test systems that provide a way of verifying that the sterilization methods were sufficient to eradicate the regulated number of microbes during the process. These safeguards include: 

• Biologic monitors 
• Process monitors (tape, indicator strips, etc.) 
• Physical monitors (pressure, temperature gauges) 
• Record keeping and recall/ tracking system for each sterilization processing batch/item 

Studies have shown that the best-practice of handling and storage of reprocessed medical equipment and instruments uses a system of event-related shelf life, rather than time-related. The rationale for this lies in the theory that the sterile items are remaining sterile as long as the packaging is not compromised (2). Factors that are considered event-related include internal or external contamination such as damage to packaging, humidity, insects, vermin, open shelving, temperature fluctuations, flooding, location, and the composition of packaging material 

Standards for handling must also focus on protection of workers from health issues.   

Recognizing Potential Sources of Cross-Contamination in the Healthcare Environment

• Surfaces or equipment which require cleaning between patient procedures/treatments 
• Practices that contribute to hand contamination and the potential for cross-contamination 
• Consequences of reuse of single use/disposable instruments, medical devices, or equipment   

Factors that Have Contributed to Contamination in Reported Cases of Disease Transmission

At any point in reprocessing or handling, breaks in infection control practices can compromise the integrity of instruments, medical devices, or equipment. Specific factors include: 

• Failure to reprocess or dispose of items between patients 
• Inadequate cleaning 
• Inadequate disinfection or sterilization 
• Contamination of disinfectant or rinse solutions 
• Improper packaging, storage, and handling 
• Inadequate/inaccurate record keeping of reprocessing requirements   

Expectations of Health Professionals Based on Setting and Scope of Practice

Professionals who practice in settings where handling, cleaning, and reprocessing equipment, instruments, or medical devices is performed elsewhere (e.g., in a dedicated Sterile Processing Department) are responsible of understanding these core concepts and principles: 

• Standard and Universal Precautions (e.g., wearing of personal protective equipment) 
• Cleaning, disinfection, and sterilization (Sections III and IV above) 
• Appropriate application of safe practices for handling instruments, medical devices, and equipment in professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended 
• Verify with those responsible for reprocessing what steps are necessary prior to submission of pre-cleaning and soaking
  

Professionals who have primary or supervisory responsibilities for equipment, instruments, or medical device reprocessing (e.g., Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site) are responsible for understanding these core concepts and principles: 

• Standard and Universal Precaution 
• Cleaning, disinfection, and sterilization described in Sections III and IV above 
• Appropriate application of safe practices for handling instruments, medical devices, and equipment in professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended
  

Facilities must be fastidious in developing appropriate reprocessing practices that follow regulatory guidelines. When selecting appropriate methods, consideration must be given to the antimicrobial efficacy, time constraints and requirement of these methods, as well as compatibility.  Compatibility among equipment/materials includes the corrosiveness, penetrability, leaching, disintegration, heat tolerance, and moisture sensitivity. 

The toxicity of the products used can pose occupational and environmental hazards to staff and patients. Facilities must adopt policies and procedures to reduce exposure to harmful substances, monitor for harmful exposures, and train staff on reprocessing cleaning and chemicals. To reduce potential exposure to harmful substances, OSHA mandates that training for workers prior to use include (all from 5): 

• Health and physical hazards of the cleaning chemicals 
• Proper handling, use, and storage of all cleaning chemicals being used, including dilution procedures when a cleaning product must be diluted before use 
• Proper procedures to follow when a spill occurs 
• Personal protective equipment required for using the cleaning product, such as gloves, safety goggles and respirators 
• How to obtain and use hazard information, including an explanation of labels and SDSs
  

Other considerations in developing a safety plan for appropriate reprocessing practices include: 

• Potential for patient toxicity/allergy 
• Residual effects including antibacterial residual and patient toxicity/allergy 
• Ease of use 
• Stability of products, including concentration, potency, efficacy of use, and effects of organic material 
• Odor 
• Cost 
• Monitoring requirements and regulations 
• Specific labeling requirements for reprocessing single-use devices (specific information may be obtained at https://www.fda.gov/media/71405/download) 

Element VI

Prevention and control of infections and communicable diseases in healthcare workers.

Element VI Objectives

At the conclusion of course work or training on this element, the learner will be able to: 

• Recognize the role of occupational health strategies in protecting healthcare workers and patients 
• Recognize non-specific disease findings that should prompt evaluation of healthcare workers 
• Identify occupational health strategies for preventing transmission of blood-borne pathogens and other communicable diseases in healthcare workers 
• Identify resources for evaluation of healthcare workers infected with HIV, HBV, and/or HCV 

Definitions

Infectious Disease: A clinically manifest disease of humans or animals resulting from an infection. 

Communicable Disease: An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent from an infected person, animal, or inanimate source to a susceptible host. 

Occupational Health Strategies: As applied to infection control, a set of activities intended to assess, prevent, and control infections and communicable diseases in healthcare workers.   

Pre-Placement and Periodic Health Assessments

Occupational health strategies are aimed at ensuring that employees are healthy and stay healthy. Upon hiring, employees should undergo an initial health screening that reviews immunization records. The CDC suggests that healthcare workers are screened when newly hired and on a periodic basis to (all from 1): 

• Ensure sufficient immunity to vaccine-preventable diseases such as measles, mumps, rubella, varicella, hepatitis B, annual influenza and any other recommended or mandated requirements 
• Assess for and manage underlying conditions and illness that may affect workplace safety 
• Prevent, assess, and treat any potential infectious exposures or illness that may be acquired or transmitted within the healthcare setting 
• Initiate and continue personalized health counseling 
• Thorough history and physical   

A tuberculosis screening should be completed prior to new employees providing patient care and upon possible exposure for an existing employee.  A thorough assessment should include an evaluation of the following symptoms: 

• Fever 
• Cough 
• Chest pain, or pain with breathing or coughing 
• Night sweats 
• Chills 

A Mantoux tuberculin skin testing (TST) must also be completed. The test is performed by injecting a small amount of tuberculin to the epidermis of the forearm. The test is then evaluated for a reaction in 48 to 72 hours. If there is no reaction, the test result is negative. If reactive, a scale is used to interpret the measurement of induration and to direct further testing or treatment (2). 

When working in healthcare, nursing staff must be healthy to provide optimal care. This is especially true with vulnerable patients that have weakened immune symptoms. The following symptoms require immediate evaluation by a licensed medical professional: 

• Fever 
• Cough 
• Rash 
• Vesicular lesions 
• Draining wounds 
• Vomiting 
• Diarrhea 

Upon evaluation, there may be restriction from patient care activities and work clearance must be completed prior to a return.   

Management Strategies for Potentially Communicable Conditions

Management and the Infection Prevention department should collaborate and strategize to ensure that employees that have had an exposure or possible exposure are protected and have support in seeking treatment without fear of retaliation or job loss (3). Managerial support should prioritize: 

• Appropriate evaluation and treatment 
• Limiting contact with susceptible patients and staff  
• Placement in a non-clinical setting 
• Depending on severity of symptoms or potential transmission, a furlough until noninfectious may be necessary 

Specific Occupational Health Strategies for Prevention and Control of Blood-borne Pathogen Transmission 

Robust training and educational programs are essential for the prevention of healthcare worker exposure and transmission. Prevention strategies should include education, training, and availability of the following: 

• Information on potential agents such as HBV, HCV, and HIV 
• HBV vaccination (including safety, efficacy, components, and recommendations for use) 
• Hand hygiene 
• Appropriate PPE and barrier precautions (see Element II) 
• Sharps safety (see Element III) 
• Standard and Universal Precautions 
• Education on the availability of confidential and anonymous testing for blood borne pathogens (4)   

Post-Exposure Evaluation and Management

Each facility must make a plan for post-exposure evaluation and management in the case that any employee or patient experiences a potential or actual blood borne exposure. The plan should incorporate the following: 

1. Prompt evaluation by licensed medical professional 
2. Risk assessment in occupational exposures 
3. Recommendations for approaching source patient and healthcare worker evaluations 
4. Recommendations for post-exposure prophylaxis emphasizing the most current CDC guidelines 
5. Post-exposure management of patients or other healthcare workers when the exposure source is a healthcare worker requires that the patient be informed of the type of exposure, whether it is healthcare worker’s blood or other potentially infectious material. 

Airborne or droplet pathogens require several special considerations. The below guidelines should be applied appropriately.  

• Risk of exposure or illness 
• Testing 
• Options for and risks and benefits of post-exposure prophylaxis or treatment 
• Need for specialty care 
• Follow-up testing and treatment 
• Work restrictions, if indicated 
• Risk of transmitting infections to others and methods to prevent transmission, and 
• Signs and symptoms of illness to report after an exposure, including side effect of prophylaxis.   

Evaluation of Healthcare Workers Infected with HIV, HBV, HCV and/or other Blood-borne Pathogens

The CDC provides the following recommendations based on scientific evidence-based practice in relation policies to prevent infected health care personnel-related blood-borne pathogen transmission (3). 

• Strict adherence to Standard Precautions 
• Voluntary testing without fear of disclosure or discrimination 
• There is not mandatory screening of healthcare workers for blood-borne pathogens in every state. Such a program would cost millions of dollars and would not produce any appreciable gain in public safety. Negative antibody tests for HIV, HBV, and HCV do not rule out the presence of infection since it can take some time for measurable antibodies to appear.  

Criteria must be followed when evaluating infected health care workers for risk of transmission in order to adhere to laws protecting workers from discrimination. The following outlines a general assessment to determine the risks posed: 

1. Nature and scope of professional practice 
2. Techniques used in performance of procedures that may pose a transmission risk to patients 
3. Assessed compliance with infection control standards 
4. Presence of weeping dermatitis, draining or open skin wounds 
5. Overall health:  

• Physical health – ability to carry out duties with Cognitive status 

Element VII

Sepsis Awareness and Education

Element VII Objectives

At the conclusion of course work or training on this element, the learner will be able to: 

• Describe the scope of the sepsis problem  
• Describe persons at increased risk of developing sepsis 
• Identify common sources of infection that may lead to sepsis 
• Describe early signs and symptoms that may be associated with sepsis in adults and children and infants 
• Understand the need for immediate medical evaluation and management if sepsis is suspected 
• Educate patients and families on methods for preventing infections and illnesses that can lead to sepsis and on identifying the signs and symptoms of severe infections and when to seek medical care   

Definitions

Sepsis: a life-threatening condition caused by a host’s extreme response to infection. The Surviving Sepsis Campaign 2016 International Guidelines define sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. Earlier definitions defined sepsis as an inflammatory response to infection, while sepsis associated with organ dysfunction was identified as severe sepsis.

Septic shock: a subset of sepsis that manifests with circulatory and cellular/metabolic dysfunction; it is associated with a higher mortality risk.   

Sepsis – Scope of the Problem

Over 1.7 million Americans are diagnosed with sepsis each year, with the incidence rising by approximately 8% annually. Sepsis is a life-threatening medical emergency that requires early recognition and intervention. Sepsis occurs when the body overcompensates in response to an infection, resulting in multiple organ dysfunction and damage. Most sepsis cases are community-acquired. Early recognition and treatment are the most effective ways to combat sepsis. 

In 2013, New York State became the first in the U.S. to develop a state mandate that requires all hospitals to develop and adopt sepsis protocols. The mandate is dubbed “Rory’s Regulations,” after Rory Staunton, a 12-year-old boy whose death was attributed to lack of sepsis recognition. These protocols were required to adopt the following practices (all from 2): 

1. A process for the screening and early recognition of patients with sepsis, severe sepsis, and septic shock 
2. A process to identify and document individuals appropriate for treatment through severe sepsis protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care 
3. Guidelines for hemodynamic support with explicit physiologic and biomarker treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and time frame goals 
4. For infants and children, guidelines for fluid resuscitation with explicit time frames for vascular access and fluid delivery consistent with current evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children 
5. A procedure for identification of infection source and delivery of early antibiotics with time frame goals 
6. Criteria for use, where appropriate, of an invasive protocol and for use of vasoactive agents 

Medical staff also gained responsibility for the collection, use, and reporting of quality measures and mortality data to peers, including national, hospital and expert stakeholders (2).   

Causes of Sepsis

As stated by the Sepsis Alliance, “Sepsis is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death” (4). Bacterial infections commonly trigger sepsis, although other microbial infections (e.g., fungal, or viral) can also trigger sepsis.  The triggering infection most commonly originates from the lungs, urinary tract, skin, and/or gastrointestinal tract.  

Certain populations are at an increased risk of developing sepsis including: 

• The very young (under 1 year), and individuals 65 years of age and older 
• People with chronic conditions such as diabetes, lung disease, kidney disease, or cancer and 
• People with impaired immune systems   

Early Recognition of Sepsis

1. Manifestations of sepsis vary based on the type of infection and host factors 
2. Some people may have subtle sepsis presentations 
3. Signs and symptoms that may be associated with sepsis in persons with confirmed or suspected infection can include: 

• Altered mental state 
• Shortness of breath 
• Fever 
• Clammy or sweaty skin 
• Extreme pain or discomfort 
• High heart rate 

Signs and symptoms in children and the elderly may not present the same. In children and the elderly sepsis symptoms may present as above or any of the following: decreased temperature, pallor or bluish tone to skin, non-blanching rash, high respiratory rate, lethargy, and seizure. 

Sepsis can progress to more severe forms of sepsis, including septic shock. When septic shock occurs, the body’s inflammatory response causes extensive vasodilation throughout the body. This results in a sudden drop in blood pressure that can quickly lead to organ failure and damage (5). 

If a person presents with suspected or confirmed infection, healthcare professionals should assess for signs of, and risk factors for sepsis following facility sepsis protocols. 

Principles of Sepsis Treatment

Sepsis treatment starts with a prompt recognition and diagnosis. The diagnosis of sepsis starts with the assessment of a patient with a known or suspected infection. For adults, sepsis is defined as having two or more symptoms of systemic inflammatory response syndrome, which includes (all from 6): 

• Temperature (>38 o C or <36 o C) 
• Elevated heart rate > 90 bpm 
• WBC (<4×109/L or >12×109/L) 
• Respiratory rate (>20 breaths/min, PACO2<32 mm Hg 

Severe sepsis has traditionally been defined as having sepsis plus organ failure, while septic shock involved sepsis along with refractory hypotension after fluid resuscitation or requiring vasopressors to maintain hemodynamics (6). The standard changed in 2016 with the elimination of severe sepsis; however, most facilities still adhere to the above criteria. Follow sepsis protocol and bundles per facility. 

With recognition of sepsis and/or septic shock, previously state law mandated that one- and three-hour care bundles be created. While these may vary slightly per facility, Surviving Sepsis promotes a one-hour bundle that incorporates all the recommendations of the other bundles; yet, decreases the time to treat (all from 7):   

One Hour Bundle

1. Obtain lactate level. Reorder if initial lactate is > 2 mmol/L 
2. Obtain blood cultures prior to administering antibiotics 
3. Administer broad-spectrum antibiotics 
4. Rapidly infuse crystalloids at a rate of 30 mL/kg for hypotension or lactate ≥ 4 mmol/L 
5. If hypotensive post fluid resuscitation, administer vasopressors to maintain a mean arterial pressure ≥ 65 mmHg

In addition to blood cultures, type and screens may be ordered for urine, wound exudate, or respiratory secretions depending upon where the suspected infection is originating from. Blood tests may also include a complete blood count and basic metabolic panel to assess for any damage to the kidneys or liver. Other diagnostic imaging may include chest x-ray, CT, ultrasound, and MRI (8). 

Fluid resuscitation and vasopressors, if needed, will continue until the patient is hemodynamically stable. Physicians should be notified when blood cultures result in order to ensure that the ordered antibiotic is effective against the identified organism (8). 

Patient Education and Prevention

Patient education should strive to provide memorable and simple ways to stay free of infection. The number one method of preventing infection is adequate hand hygiene. The CDC also suggests that patients keep wounds and cuts clean and covered until healed. 

Patients at higher risk should be notified of their risk factors, including (all from 9): 

• Adults 65 or older 
• People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease 
• People with weakened immune systems 
• Sepsis survivors 
• Children younger than one
  

Patients should be educated on warning signs and symptoms of sepsis that are easy to remember. The Sepsis Alliance suggests the following acronym and verbiage for seeking immediate care (all from 4): 

T - Temperature

I - Infection

M - Mental Decline

E - Extremely Ill

Patients should be encouraged to give relevant history and information to clinicians, including if they have had a recent infection, sepsis in the past, or are immunocompromised. 

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