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Bioethics in Nursing

Introduction   

Nursing practice is deeply rooted in ethical principles that guide decision-making and patient care. Bioethics is a crucial aspect of healthcare that provides a framework for analyzing ethical dilemmas and promoting individualized patient-centered care respectfully and compassionately (1). Nursing ethics involves applying bioethical principles in practice, such as maintaining patient confidentiality and respecting autonomy (2). Nurses face ethical dilemmas regularly. One of the most common is providing care that conflicts with personal beliefs (3).

Definition and Purpose 

Bioethics is the study of ethical and moral principles guiding healthcare decisions and practices (4). Its purpose is to ensure that healthcare providers make informed decisions that respect patients' values, beliefs, and rights (5). 

Bioethics provides a framework for analyzing ethical issues in healthcare while considering the interests of the patients, their families, and the healthcare providers involved in their care (6). By understanding the definition and purpose of bioethics, nurses can develop a strong foundation for addressing ethical challenges in practice, such as informed consent, patient confidentiality, and when it may infringe upon others’ health and proper resource allocation (7, 8).

Principles of Bioethics 

The principles of bioethics include autonomy, beneficence, non-maleficence, and justice (9). Autonomy respects patients' decision-making capacity, beneficence promotes a patient's well-being, non-maleficence avoids any harm to the patient, and justice ensures fairness and equity for all involved in the patient’s care (10). 

These principles should serve as the guiding force in nursing practice; influencing the decisions related to patient care, research, and policy development (11, 12). Autonomy empowers patients to make informed choices about their care. This may include decisions that the patient’s family and even healthcare providers may disagree with personally. Beneficence compels nurses to act in the best interests of their patients and advocate for the patient’s desires (13). Non-maleficence reminds nurses to avoid causing harm; this includes not just physical but emotional and mental harm as well (14).

Types of Ethics and Professions 

Different professions have specific ethical guidelines, such as the American Nurses Association (ANA) Code of Ethics for nurses (15). Understanding the ethical framework of various professions is essential to the interdisciplinary healthcare approach (16). 

Interdisciplinary collaboration requires an understanding of diverse ethical perspectives and principles, an approach that coincides with an equally diverse patient population (17). Nurses should be aware of the ethical guidelines that govern their practice and be able to apply them in diverse healthcare settings. They must also be aware of their own beliefs and guidelines and how these may affect their decision-making, adversely affecting patient care (18).

Ethics in Nursing 

Nursing ethics involves applying principles in practice that benefit the patient, healthcare providers, and loved ones of the patient. Examples include things such as maintaining patient confidentiality and respecting autonomy, helping the patient make the right decision for themselves, and advocating for those decisions to others (19). One of the most difficult decisions nurses face involves those that conflict with their personal belief system (20). 

Nurses must be equipped with the knowledge and skills to navigate these ethical challenges and provide care that respects patients' values and beliefs while also nurturing their thoughts and feelings (21). By exploring bioethics in nursing, we can promote a culture of ethical practice that is compassionate and patient-centered (22). 

Henrietta Lacks Story 

Henrietta Lacks was a Black tobacco farmer who had her cancer cells taken without her knowledge or consent which led to numerous scientific breakthroughs, including the development of the polio vaccine (23). Her story raises important questions about medical ethics, racism, and the intersection of science and human compassion. 

In 1951, Henrietta Lacks was diagnosed with cervical cancer and began treatment at Johns Hopkins Hospital in Baltimore. During her treatment, a sample collection of her cancer cells was taken by her doctor, Dr. George Gey without her knowledge and or consent (24). Dr. Gey discovered that Henrietta's cells were extraordinary in nature and could be of great value for cancer research and future developments as they could survive and thrive in a laboratory setting thus making them ideal for scientific research. 

Henrietta's cells, known as HeLa cells, were soon being used in laboratories worldwide, leading to numerous scientific breakthroughs, including the polio vaccine development, in vitro fertilization, and gene mapping (25). However, Henrietta's family was never informed or financially compensated for the use of her cells, and her story remained largely unknown until the publication of Rebecca Skloot's book "The Immortal Life of Henrietta Lacks" in 2010 (23). 

Henrietta's story highlights the unethical practices that were common in the medical field at the time, particularly in relation to patients that lacked resources, particularly those belonging to minority groups (26). Her cells were taken without her consent, and she was never compensated or acknowledged for her contribution to science. This raised some very important questions about medical ethics, informed consent, and the exploitation of vulnerable populations. 

Still, Henrietta's story is a powerful reminder of the intersection of science and the need for personal autonomy (27). Her cells have been used to advance scientific knowledge, but they also represent a person, a family, and a community. The use of her cells without her consent or compensation is a violation of her humanity and a reminder of the need for ethical considerations in scientific research. 

Tuskegee Syphilis Experiments 

The Tuskegee Syphilis Study was a highly controversial and unethical medical experiment conducted on African American men in Macon County, Alabama between 1932 and 1972 (24). The study, led by the Department of U.S. Public Health Services, involved withholding treatment from hundreds of African American men infected with syphilis despite the availability of effective therapies, to study the natural progression of the disease (25). 

The men, who were mostly illiterate and poor, were not informed that they had syphilis, their partners were not informed of the disease, nor were they given treatment for the disease (26). Instead, they were given placebos and misleading information about their condition (27). The study continued for 40 years, during which time many of the men died from syphilis-related complications, and many others suffered serious health problems which included the spreading of syphilis to unsuspecting sexual partners (28). 

The Tuskegee Syphilis Study is widely regarded as one of the most unethical medical experiments in history. The study was conducted without the men's knowledge or consent, and it violated basic human rights and principles of medical ethics (30). By way of public outcry and shock, the awareness of these experiments led to major changes in the way human subjects are protected in medical research and a desire for closer oversight by governing groups (29).  

In 1974, a class-action lawsuit was filed on behalf of the men who were involved in the study, resulting in a multimillion-dollar settlement (31). The study also led to the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which developed guidelines for the ethical conduct of research involving human subjects (32). 

The Tuskegee Syphilis Study has had a lasting impact on the field of medicine and beyond (33). It highlighted the importance of informed consent and the need for ethical oversight in the field of medical research (34). It has also led to the increased scrutiny of medical experiments and a greater emphasis on protecting human subjects, their privacy, and most importantly honest care and explanations of medical conditions and treatments (35). 

Today, the Tuskegee Syphilis Study is remembered as a cautionary tale about the dangers of unethical medical research (36). It serves as a reminder of the importance of prioritizing the well-being and safety of people and the need for ongoing vigilance in ensuring that medical research is conducted ethically and responsibly, and ensuring there are the proper checks and balances in place to provide the oversight needed (37). 

The study also highlighted the need for diversity in medical research and the importance of including diverse populations in clinical trials (38). It led to increased efforts to address health disparities and to ensure that medical research is conducted in a way that is fair and equitable to all (39). 

In addition, the Tuskegee Syphilis Study led to changes in the way that medical research is regulated and overseen (40). It led to the establishment of institutional review boards (IRBs) and independent ethics committees (IECs) which are responsible for reviewing and approving research protocols and ensuring they meet the ethical standards set in place (41). 

Transparency and accountability in medical research have also been placed at the forefront of research since these events took place (42). Highlighting the importance of disclosing potential conflicts of interest and ensuring research is conducted in a way that is transparent and open to scrutiny; there inevitably was major change and growth that came from this huge medical injustice (43). 

The Tuskegee Syphilis Study was a highly unethical and controversial medical experiment that had a profound impact on the field of medicine and beyond. It highlighted the importance of informed consent, ethical oversight, and diversity in medical research, and led to major changes in the way medical research is conducted and regulated. In these ways, it acted as a catalyst of growth and change in the way the U.S. views and treats research participants. It serves as a reminder of the need for ongoing vigilance in ensuring medical research is conducted ethically and responsibly. 

The Tuskegee Syphilis Studies and Henrietta Lacks' cases highlight the importance of informed consent in research (23). 

Other examples include: 

• Abortion and reproductive rights (24) 

• Euthanasia and end-of-life care (25) 

• Gene editing and genetic research (26) 

• Healthcare access and disparities (27)

Research in Ethics 

Research ethics involves applying bioethical principles in research. Obtaining informed consent and ensuring participant confidentiality are two ways in which the provider can best provide ethical care to those that entrust the healthcare system with their voluntary well-being (28). 

Researchers must be aware of ethical principles that guide research and ensure their studies are conducted ethically and responsibly which puts the client first (29). 

Ethical Decision-Making 

Ethical decision-making involves critical thinking, moral principles, and professional standards (30). Nurses can use ethical frameworks, such as the ETHICAL model, to guide decision-making (31). Ethical decision-making is a crucial aspect of nursing practice as it enables nurses to navigate complex healthcare issues and promote patients' well-being (32). 

Conclusion 

Bioethics plays a vital role in nursing practice, ensuring that patients receive respectful and compassionate care. Understanding bioethical principles and applications is essential for nurses to provide high-quality care. By applying ethical principles and frameworks, nurses can navigate complex healthcare issues and promote patients' well-being. 

Introduction   

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. 

The following sections explore the sources and definitions of standards of professional conduct as they apply to infection prevention and control.  

Element I 

Rules of the Board of Regents, Part 29.2 (a)(13) 

New York (NY) law clearly defines the responsibilities of health professionals in having access to products, using, and adhering to scientifically approved techniques for “. . . the cleaning and sterilization or disinfection of instruments, devices, materials and work surfaces, utilization of protective garb, use of covers for contamination-prone equipment and the handling of sharp instruments” (1).  

These guidelines and rules are laid out within the Rules of the Board of Regents, Part 29.2 (a)(13). It is the responsibility of nursing to review and execute these standards throughout the healthcare continuum as follows (1): 

1. Wearing appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid-soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures. 
2. Discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient; washing hands and donning new gloves before performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids. 
3. Wearing appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur. 
4. Sterilizing equipment and devices that enter the patient’s vascular system or other normally sterile areas of the body. 
5. Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient’s body or using high-level disinfection for equipment and devices that cannot be sterilized before use for a patient. 
6. Using appropriate agents, including but not limited to detergents for cleaning all equipment and devices before sterilization or disinfection. 
7. Cleaning, by the use of appropriate agents, including but not limited to detergents, equipment, and devices that do not touch the patient or that only touch the intact skin of the patient. 
8. Maintaining equipment and devices used for sterilization according to the manufacturer’s instructions. 
9. Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques. 
10. Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized. 
11. Maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation. 
12. Refraining from all direct patient care and handling of patient care equipment when the health care professional has exudative lesions or weeping dermatitis, and the condition has not been medically evaluated and determined to be safe or capable of being safely protected against in providing direct patient care or in handling patient care equipment; and 
13. Placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking, and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide 
14. Part 92 of Title 10 (Health) of the Official Compilation of Codes, Rules, and Regulations of New York 

Under Part 92 of Title 10, it is the responsibility of healthcare professionals who are in a position of providing direct care or providing supervision over staff providing direct patient care to maintain competency in infection prevention and barrier precautions. The requirement is fulfilled via a New York board-approved coursework or training.  Coursework or training must be before initial licensing, subsequently renewed every four years, and maintained for six years after ceasing position or such work (2). 

Statements of Relevant Professional and National Organizations 

As the largest healthcare workforce in the nation, nurses are in a position 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 the 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 healthcare systems. Within these cores is the responsibility of nurses 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 who participate in and supervise the 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 increased overall from 2020 to 2021 in all infections including central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated infections, and methicillin-resistant staphylococcus aureus (MRSA). Only clostridium difficile (C-Diff) and surgical site infections (SSI) saw rates lower (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 infection control violation 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 provides advice, “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). 

The New York Board of Nursing can be reached via its website or at (518) 474-3817. The mailing address is Education Bldg., 89 Washington Avenue, 2nd Floor West Wing, Albany, NY 12234. 

The consequences of failing to follow accepted standards of infection prevention and control may result in a complaint investigation from New York’s Professional Misconduct Enforcement System. Upon investigation, penalties include but are not limited to reprimand and censure, fines of up to $10,000 per violation, and probationary terms. 

Severe misconduct may result in the loss or revocation of a nursing license. Also, 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 guidelines, renewal CEs, and targeted education in their state of practice. Refer to the NY Board of Nursing for further guidance beyond the above-mentioned licensing requirements. 

Education of infection control best practices, 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. 

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: How an infectious agent enters the susceptible host. 

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

Reservoir: A place in which an infectious agent can survive but may or may not multiply or cause disease. Healthcare workers may be a reservoir for a number of 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. 

Component of the Infectious Disease Process 

The infectious disease process follows a particular sequence of events that is commonly described as 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 many 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 varies depending upon the characteristics of the specific infectious agent.  

Healthcare workers are at a considerably 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 pose 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, and 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, 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 organisms such as MRSA.  

Droplet transmission occurs when a pathogen is able to infect via droplets through the air by talking, sneezing, coughing, or breathing. The pathogen is able to 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 living vectors 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 while within the healthcare system. 

Factors Influencing the Outcome of Exposures 

The human body provides several natural defenses against acquiring infection from a pathogen. The most prominent defense is the integumentary system, and the focus should be on maintaining skin integrity to prevent a mode of entry.  

Respiratory cilia function to move microbes and debris from the airway. Gastric acid is at a pH 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 within the gastrointestinal system also provides a layer of defense that must be protected from the action 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 host’s own immune system to target invasive pathogens. There are four types of host immunity (3): 

1. Inflammatory response is pathogen detection by cells in a compromised area that then elicit an immune response that increases blood flow. This inflammatory provides delivery of phagocytes or white blood cells to the infected site response. Phagocytes are designed to expunge bacteria. 
2. Cell-mediated immunity uses B-cells and T-cells, specialized phagocytes, are cytotoxic cells that target pathogens. 
3. Humoral immunity is derived from serum antibodies produced by plasma cells. 
4. 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 causing symptoms depends upon the size of the inoculum (amount of exposure), and the 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 that 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 may factor into the spread of 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’s use. For patients in isolation precautions, dedicated equipment for that patient should remain in the room for the duration of their stay. 

Methods to Prevent the Spread of Pathogenic Organisms  

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. This will be covered in detail further 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 contact with any respiratory secretions or potentially contaminated items (5). 

As mentioned, healthcare workers are at a higher risk for bloodborne infections due to the 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 infections 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 the 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 who are identified with a risk or history of any of these pathogens 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 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 are covered with scrubbing lasting at least 20 seconds. 
• Thoroughly rinse the soap from your hands with running water, pat dry with a paper towel, and use a paper towel to turn off the 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 the surface of hands and fingers, then allowed to air dry. 

Barriers to proper hand hygiene include knowledge gaps and the 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 potential source of contamination or cross-contamination. Hand hygiene dispensers are touched frequently with contaminated hands and must be frequently cleaned. Follow the manufacturer's recommendations for cleaning. 

Hand hygiene systems that allow products to be refilled pose a risk of contaminating the contents. If refilling is a requirement, this should be accomplished using an 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 the 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 (11): 

How to Put On (Don) PPE Gear: More than one donning method may be acceptable. Training and practicing using your healthcare facility’s procedure is critical. Below is one example of donning. 

1. Identify and gather the proper PPE to wear. Ensure the choice of gown size is correct (based on training). 
2. Perform hand hygiene using hand sanitizer. 
3. Put on an isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 
4. 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. The respirator/facemask should be extended under the chin. Both your mouth and nose should be protected. Do not wear a respirator/facemask under your chin or store it in a scrubs pocket between patients.  
   1. Respirator: Respirator straps should be placed on the crown of the head (top strap) and base of the neck (bottom strap). Perform a user seal check each time you put on the respirator. 
   2. Face mask: Mask ties should be secured on the crown of the head (top tie) and base of the neck (bottom tie). If the mask has loops, hook them appropriately around your ears.
5. Put on a 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 that 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 the gown. 
7. Healthcare personnel may now enter the patient’s room. 

How to Take Off (Doff) PPE Gear: More than one doffing method may be acceptable. Training and practicing 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 a gentle manner, avoiding forceful movement. Reach up to the shoulders and carefully pull the gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose of in a trash receptacle. 
3. Healthcare personnel may now exit the patient’s room. 
4. Perform hand hygiene. 
5. Remove face shields or goggles. Carefully remove face shields or goggles by grabbing the strap and pulling upwards and away from the head. Do not touch the front of your face shield or goggles. 
6. Remove and discard the respirator (or face mask if used instead of respirator). Do not touch the front of the respirator or face mask.  
   1. Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap, bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. 
   2. Face mask: Carefully untie (or unhook from the ears) and pull away from the face without touching the front. Perform hand hygiene after removing the respirator/face mask and before putting it on again if your workplace is practicing reuse.
7. 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 six 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 an outbreak or a 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 an 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 prevent disease are highly recommended by numerous health organizations such as the CDC, the World Healthcare Organization, and the Office of Disease Prevention and Health Promotion. As stated by the U.S. Department of Health and Human Services, “The United States will be a place where vaccine-preventable diseases are eliminated through safe and effective vaccination over 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 maintain current vaccinations and can 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, source of the patient’s symptoms, time frame since exposure, the health status of the individual exposed, as well as the risks and benefits of the treatment. Pre-prophylaxis may be considered in the prevention of HIV for high-risk individuals. 

Typically, after exposure, the host’s blood is drawn to determine pathogen risk regardless of if there is a known pathogen. Post-exposure prophylactics are given within a short time frame from the exposure based on results. The individual who 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 utmost 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 the skin and pat dry 
• Use moisturizers and barrier creams on dry or tender skin 
• Prevent pressure ulcer development by turning and repositioning the 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 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 patients.  

For equipment that has been used in an isolation room, a terminal clean must be performed before 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 precautionary 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 in terminally cleaning isolation rooms based on pathogens. 

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 Department of Environmental Conservation in New York, “In accordance with both federal and state requirements, and 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, a collection area within the facility for third party pick-up, or a generator’s on-site treatment facility” (16). 

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. 

Linen and laundry management is governed by Title 10: Section 83-1.17 which states (17) shared health facilities shall: 

• Provide a sufficient quantity of clean linen to meet the requirements of patients. 
• Separately bag or enclose used linens from infectious patients in readily identified containers distinguishable from other laundry. 
• Transport and store clean linen in a manner to prevent contamination. 

Food services are required to follow stringent standards under the New York State Department of Health’s Bureau of Community Environmental Health and Food Protection to ensure that food service establishments are maintained to reduce the incidence of food-borne illness. 

Environment controls include medical devices and systems that are put in place to isolate or remove the blood-borne pathogens hazard from the workplace. These include sharps disposal containers, self-sheathing needles, and safer medical devices, such as sharps with engineered sharps injury protections and needleless systems. Further information will be provided on this subject in Element III. 

Per facility specifications, continuous training and education should be provided to healthcare personnel on the various methods and modes of environmental control measures that are put in place to prevent and contain pathogen spread. 

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. 

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 bloodborne 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 also to prevent harm such as needlestick injuries. 

b 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 a new sterile syringe. 

Multi-dose medication vial: a 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 bloodborne pathogens by altering how a task is performed (e.g., prohibiting the recapping of needles by a two-handed technique). 

High-risk Practices and Procedures 

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 of percutaneous exposure and should be avoided: 

1. Manipulating contaminated needles and other sharp objects by hand (e.g., removing scalpel blades from holders, removing needles from syringes) 
2. Delaying or improperly disposing of sharps (e.g., leaving contaminated needles or sharp objects on counters/workspaces or disposing in non-puncture-resistant receptacles) 
3. Recapping contaminated needles and other sharp objects using a two-handed technique 
4. Performing procedures where there is poor visualization, such as: 

• • Blind suturing 
  • Non-dominant hand opposing or next to a sharp 
  • 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: 

• 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: 

• Administration of parenteral medication 
• Sharing of blood monitoring devices (e.g., glucometers, hemoglobinometers, lancets, lancet platforms/pens) 
• Infusion of contaminated blood products or fluids 
• Human bites, abrasions, or cuts 

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 techniques require that healthcare providers follow best practices to prevent injury and pathogen transfer. At all times, aseptic techniques should be used to prepare and administer an injection. The following are best practice guidelines: 

1. Medications should be drawn up in a designated “clean” medication area that is not adjacent to areas where potentially contaminated items are placed. 
2. Use a new sterile syringe and needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. 
3. Ensure proper hand hygiene (i.e., hand sanitizing or hand washing if hands are visibly soiled) before handling medications. 
4. If a medication vial has already been opened, the rubber septum should be disinfected with alcohol before piercing it. 
5. 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. 
6. 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. 

1. All of the infusion components from the infusate to the patient’s catheter are a single interconnected unit. 
2. All of the components are directly or indirectly exposed to the patient’s blood and cannot be used for another patient. 
3. 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. 
4. 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. 
5. 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. 

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

Safe injection practices and procedures are designed to prevent disease transmission from patient to healthcare worker. A fact sheet from OHSA can be found here. 

Evaluation/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 who use sharps. This would include that ALL sharp devices can cause injury and disease transmission if not used and disposed of properly. Specific focus should be on the devices that are more likely to cause injury such as:  
   1. Devices with higher disease transmission risk (hollow bore), and
   2. Devices with higher injury rates (“butterfly”-type IV catheters, devices with recoil action), 
   3. Blood glucose monitoring devices (lancet platforms/pens). 
4. Identification of areas/settings where exposures occur, and 
5. Circumstances by which exposures occur, 
6. Post-exposure management (See Element VI).  

Engineer Controls

Engineer controls are implemented 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: 
   1. Properly educate and train all staff on safer devices 
   2. Consider eliminating traditional or non-safety alternatives whenever possible 
   3. Explore engineering controls available for specific areas/settings 
5. Use puncture-resistant containers for the disposal and transport of needles and other sharp objects:   
   1. Refer to published guidelines for the selection, evaluation, and use (e.g., placement) of sharps disposal containers.  
   2. National Institute for Occupational Safety and Health (NIOSH) Guidelines 
   3. NYSDOH recommendations “Household Sharps-Dispose of Them Safely”  
   4. Use splatter shields on medical equipment associated with risk-prone procedures (e.g., locking centrifuge lids). 

Work Practice Controls 

1. General practices:  
   1. Hand hygiene including the appropriate circumstances in which alcohol-based hand sanitizers and soap and water hand washing should be used (see Element II) 
   2. Proper procedures for cleaning of blood and body fluid spills 
   3. Initial removal of bulk material followed by disinfection with an appropriate disinfectant 
2. Proper handling/disposal of blood and body fluids, including contaminated patient care items 
3. Proper selection, donning, doffing, and disposal of personal protective equipment (PPE) as trained (see Element IV) 
4. 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 
5. 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:  
   3. Avoid recapping unless medically necessary 
   4. When recapping, use only a one-hand technique or safety device 
   5. Pass sharp instruments by the use of designated “safe zones” 
   6. Disassemble sharp equipment by use of forceps or other devices 
   7. 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 

Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with 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 eyewear, 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/Barriers and Criteria for Selection 

Per OSHA guidelines, employers must provide employees with appropriate PPE that protects them 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 of material glove is made from is often 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 to 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 wearer’s 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 the 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/PPE Based on Intended Need 

Barriers and PPE are 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 

During invasive procedures, such as inserting a central line or during a surgery, staff directly involved in 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 a sterile fashion according to recommended guidelines (1). 

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). 

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 contamination prevention: 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 judgment 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, gowns, and eye and face protection. 
• Employees must be judicious in identifying any precautions that are placed on a patient (i.e., 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’s 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 diseases: With the onset of COVID-19 across the globe, masks are an essential tool in preventing the transmission of communicable diseases. At a minimum, a medical mask is to 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/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 consider 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 reusable. Always verify with the manufacturer’s guidelines and facility policy on the correct usage and processing of worn garments. It is the facility’s 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 bloodborne 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. 

Selection, donning, doffing, and disposal. See Element II 

ELEMENT V 

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

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. 

Non-critical 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 before 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 which sterile body fluids, blood, or sterile tissue be sterilized prior to use on each patient. (1). 

Potential for Contamination  

The type of instrument, medical device, equipment, or environmental surface cause 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). As well, these devices may be made of material that is not heat resistant, which prevents the ability to sterilize. 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 overhandled 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. Several types of pathogens 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 to 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 depending upon the instrument and the process chosen. 

Pre-cleaning is the process of removing soil, debris, and 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 the 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 the manufacturer's guidelines to eliminate the risk of contaminating debris (1). 

Disinfection involves the use of disinfectants, either alone or in combination, to reduce the 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 the 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’s 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 understand the various equipment heat and pressure tolerance as well as the time and temperature requirements for reprocessing.  

Failure to follow the manufacturer’s recommendations may lead to equipment damage, elevated microbial counts on instruments after reprocessing, increased risk for infections, and possibly patient death. 

Effectiveness of reprocessing instruments, medical devices, and equipment 

Pre-cleaning and cleaning before 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 are 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 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 sufficient contact time with the 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 the manufacturer’s 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 remain 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 the packaging, humidity, insects, vermin, open shelving, temperature fluctuations, flooding, location, and the composition of packaging material. 

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

Recognizing Potential Sources of Cross-Contamination in The Healthcare Environment  

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

Factors That Have Contributed to Contamination in Reported Disease Transmission Cases 

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 Regarding Differing Levels of Disinfection and Sterilization Methods 

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 for ensuring understanding of the 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 the area of professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended by NYSDOH. 
• 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 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 the area of professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended by NYSDOH 

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 requirements of these methods, as well as compatibility. Compatibility among equipment/materials includes 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 procedures and policies to reduce exposure to harmful substances, monitor for harmful exposures, and train staff using reprocessing cleaning and chemicals.  

To reduce potential exposure to harmful substances, OSHA mandates that training for workers before 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 

ELEMENT VI 

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

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 employees are healthy and keeping them 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 periodically ongoing 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 illnesses that may affect workplace safety 
• Prevent, assess, and treat any potential infectious exposures or illnesses 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 before a new employee provides 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 test (TST) must also be completed. The test is performed by injecting a small amount of tuberculin into 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 in the care of vulnerable patients who 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 possible restrictions from patient care activities and work clearance must be completed prior to return. 

Management Strategies for Potentially Communicable Conditions  

Management and the Infection Prevention department should collaborate and strategize to ensure that employees who 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 the severity of symptoms or potential transmission, a furlough until no symptoms are present may be necessary 

Prevention and Control Strategies for Bloodborne 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 bloodborne pathogens (4) 

Post-Exposure Evaluation and Management.  

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

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

Airborne or droplet pathogens require several special considerations. The above guidelines should be applied appropriately. As well, New York requires mandatory reporting of certain communicable diseases is required, including tuberculosis. The New York State Department of Health (NYSDOH) states: 

Reporting of suspected or confirmed communicable diseases is mandated under the New York State Sanitary Code (10NYCRR 2.10,2.14). The primary responsibility for reporting rests with the physician; moreover, laboratories (PHL 2102), school nurses (10NYCRR 2.12), daycare center directors, nursing homes/hospitals (10NYCRR 405.3d), and state institutions (10NYCRR 2.10a) or other locations providing health services (10NYCRR 2.12) are also required to report (5). 

NYSDOH follows the CDC's recommended guidelines when exposure to TB occurs. The HCW should be retested for TB using TST and be monitored for symptoms of disease progression. If found to have a TST reaction of 10 or more millimeters, the patient would be given high priority to receive drug treatment under the criteria of working within a high-risk setting (6). Drug treatment typically consists of 3 months of isoniazid once weekly in addition to rifapentine in adults and children over 2 years old. 

Post-exposure of other Airborne pathogens such as varicella, measles, mumps, rubella, and pertussis should be directed toward the most current federal, state, or local requirement for post-exposure evaluation and management. As with tuberculosis, mandatory reporting may be required. The Communicable Disease Reporting Requirements form may be found here. 

For additional, up-to-date information and guidance, the New York State Department of Health Bureau of Communicable Disease Control can be reached at (518) 473-4439 or (866) 881-2809 after hours. 

All patients and health care workers who have been potentially exposed to any pathogens should be educated and counseled about (all from 7): 

• 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 exposure, including side effects such as prophylaxis. 

Evaluation of Healthcare Workers Infected with Bloodborne Pathogens 

The NYSDOH provides the following rules and recommendations based on scientific evidence-based practice in relation to policies to prevent infected healthcare personnel-related blood-borne pathogen transmission (HIV, HBV, HCV) (all from 4): 

• Strict adherence to Standard Precautions 
• Voluntary testing without fear of disclosure or discrimination 
• Mandatory screening of New York HCW for blood-borne pathogens is not recommended. 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. 
• Employer notification of a blood-borne pathogen is not a requirement for employment 

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

1. Nature and scope of professional practice 
2. Techniques used in the 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. Ability to carry out duties with Cognitive status examination 

Expert Panels for Evaluating Healthcare Workers Infected with Bloodborne Pathogens 

Upon request, a blood-borne pathogen-infected HCW may seek advice from the NYSDOH regarding potential risk during patient care of blood-borne disease transmission. A state advisory panel would convene with, at minimum, representation by a state or local public officer, an epidemiologist, and an infectious disease expert (4).  

The purpose of the panel is to provide consultation to the MCW regarding the risk of blood-borne disease transmission related to occupation and to give recommendations on best practices, needs for limitations, modifications, or restrictions if there is an identified risk to patient care. Confidentiality is maintained with the restriction that recommendations are followed, and any restrictions are disclosed to the facilities where the HCW is currently employed or seeks future employment (4)

ELEMENT VII 

Sepsis awareness and education 

Definitions 

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

Scope of the Problem 

Over 1.7 million Americans are diagnosed with sepsis each year, with the incidence rising by approximately 8% annually. In New York, there are approximately 50,000 patients treated for severe sepsis and septic shock, resulting in just under 30% of patients dying each year (1).  

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. Seven in 10 patients with sepsis had recently used healthcare services or had chronic conditions requiring frequent medical care (1).  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 (2): 

• A process for the screening and early recognition of patients with sepsis, severe sepsis, and septic shock. 
• 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. 
• Guidelines for hemodynamic support with explicit physiologic and biomarker treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and time frame goals. 
• For infants and children, guidelines for fluid resuscitation with explicit time frames for vascular access and fluid delivery are consistent with current evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children. 
• A procedure for identification of infection source and delivery of early antibiotics with time frame goals; and 
• 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 report quality measures and for the mortality data of peers, including national, hospital, and expert stakeholders (2). 

This led to The New York State Sepsis Care Improvement Initiative, started in 2014, to increase early recognition of suspected sepsis and competence in implementing the new sepsis protocols by all healthcare professionals.  

This was to be achieved through mandatory training or coursework on sepsis (3). The goal was to stress the importance of timely initiation of evidence-based protocols to improve sepsis outcomes. 

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: 

• Babies (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  

• Manifestations of sepsis vary based on the type of infection and host factors. 
• Some people may have subtle sepsis presentations. 
• 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 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 (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 involves 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 the 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 (7): 

One Hour Bundle 

1. Obtain lactate level. Reorder if initial lactate is > 2 mmol/L 
2. Obtain blood cultures before 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 mm Hg. 

In addition to blood cultures, type and screens may be ordered for urine, wound exudate, or respiratory secretions depending upon where the suspected infection originates from. Blood tests may also include a complete blood count and a basic metabolic panel to assess for any damage to the kidneys or liver. Other diagnostic imaging may include chest X-rays, CTs, ultrasounds, and MRIs (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 (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 (4): 

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. 

Alzheimers Nursing Care

Introduction   

Alzheimer’s disease is a destructive, progressive, and irreversible brain disorder that slowly destroys memory and thinking. Alzheimer’s is the most common cause of dementia in older adults (1). For most people who have Alzheimer’s disease, symptoms first appear in their mid 60’s (1).  

Studies suggest more than 5.5 million Americans, most 65 or older, may have dementia caused by Alzheimer’s (1). It is currently listed as the sixth leading cause of death in the United States. It is essential to understand the signs and symptoms of Alzheimer’s dementia and how to manage the care of a patient, family member, or friend suffering from the disease. 

Dementia is the loss of cognitive functioning, such as thinking, remembering, reasoning, and behavioral abilities, such as a decreased ability to perform activities of daily living (1). The severity of dementia ranges from mild to severe. Dmentia’s mildest stage often begins with forgetfulness, while its most severe stage consists of complete dependence on others for general activities of daily living (1).  

History of Alzheimer’s 

Alzheimer’s disease is named after Dr. Alois Alzheimer. In the early 1900s, Dr. Alzheimer noticed changes in the brain tissue of a patient who had died of an unknown mental illness. The patient’s symptoms included memory loss, language problems, and unpredictable behavior.  

After her death, her brain was examined and was noted to have abnormal clumps known as amyloid plaques and tangled bundled fibers, known as neurofibrillary or tau tangles (1). These plaques and tangles within the brain are considered some of the main features of Alzheimer’s disease. Another feature includes connections of neurons in the brain. Neurons are a type of nerve cell responsible for sending messages between different parts of the brain and from the brain to other parts of the body (1).  

Scientists are continuing to study the complex brain changes involved with the disease of Alzheimer’s. The changes in the brain could begin ten years or more before cognitive problems start to surface.  

During this stage of the disease, people affected seem to be symptom-free; however, toxin changes occur within the brain (1). Initial damage in the brain occurs within the hippocampus and entorhinal cortex, which are the parts of the brain that are necessary for memory formation. As the disease progresses, additional aspects of the brain become affected, and overall brain tissue shrinks significantly (1).  

Signs and Symptoms & Diagnosis of Alzheimer’s Disease  

Memory problems are typically among the first signs of cognitive impairment related to Alzheimer’s disease. Some people with memory problems have Mild Cognitive Impairment (MCI) (2). In this condition, people have more memory problems than usual for their age; however, their symptoms do not interfere with their daily lives. 

Older people with MCI are at increased risk of developing Alzheimer’s disease. The first symptoms of Alzheimer’s may vary from person to person. Many people display a decline in non-memory-related aspects of cognition, such as word-finding, visual issues, impaired judgment, or reasoning (2).  

Healthcare providers use several methods and tools to determine the diagnosis of Alzheimer’s Dementia. Diagnosis and evaluation involve memory, problem-solving, attention, counting, and language tests. Healthcare providers may perform brain scans, including CVT. MRI or PET is used to rule out other causes of symptoms.  

Various tests may be repeated to give doctors information about how memory and cognitive functions change over time. They can help diagnose different causes of memory problems, such as stroke, tumors, Parkinson’s disease, and vascular dementia. Alzheimer’s disease can be diagnosed only after death by linking clinical measures with an examination of brain tissue in an autopsy (3).  

Stages of Disease  

Mild Alzheimer’s  

People experience significant memory loss and other cognitive problems as the disease progresses. Most people are diagnosed in this stage (1). 

• Wandering/getting lost  
• Trouble handling money or paying bills  
• Repeating questions  
• Taking longer to complete basic daily tasks 
• Personality/behavioral changes (1) 

Moderate Alzheimer’s  

In this stage, damage occurs in the area of the brain that controls language, reasoning, sensory processing, and conscious thought (1).  

• Memory and confusion worsen.  
• Problems recognizing family and friends  
• Unable to learn new things  
• Trouble with multi-step tasks such as getting dressed  
• Trouble coping with situations 
• Hallucinations/delusions/paranoia (1) 

Severe Alzheimer’s 

• Plaques and tangles spread throughout the brain, and brain tissue shrinks significantly. 
• Cannot communicate  
• Entirely dependent on others for care  
• Bedridden – most often as the body shuts down  

Prevention  

Many aging patients worry about developing Alzheimer’s disease and dementia. Especially if they have had a family member who suffered from the disease, patients may worry about genetic risk. Although there have been many ongoing studies on the prevention of the disease, nothing has been proven to prevent or delay dementia caused by Alzheimer’s disease (2).  

More research suggests that women are more likely to develop dementia and Alzheimer’s compared to men. Further research is needed to determine the role between genetics, sex, and Alzheimer’s risk (4).  

A review led by experts from the National Academies of Sciences, Engineering, and Medicine found encouraging yet inconclusive evidence for three types of interventions related to ways to prevent or delay Alzheimer’s Dementia or age-related cognitive decline (2):  

• Increased physical activity  
• Blood pressure control  
• Cognitive training  

Treatment of the Disease  

Alzheimer’s disease is complex and is continuously being studied. Current treatment approaches focus on helping people maintain their mental function, manage behavioral symptoms, and lower the severity of symptoms. The FDA has approved several prescription drugs to treat those diagnosed with Alzheimer’s (3).  

Treating symptoms of Alzheimer’s can provide patients with comfort, dignity, and independence for a more significant amount of time while simultaneously assisting their caregivers. The approved medications are most beneficial in the early or middle stages of the disease (3). 

Cholinesterase inhibitors are prescribed for mild to moderate Alzheimer’s disease; they may help to reduce symptoms. Medications include Rzadyne®, Exelon®, and Aricept® (3). Scientists do not fully understand how cholinesterase inhibitors work to treat the disease; however, research indicates that they prevent acetylcholine breakdown. Acetylcholine is a brain chemical believed to help memory and thinking (3). 

For those suffering from moderate to severe Alzheimer’s disease, a medication known as Namenda®, which is an N-methyl D-aspartate (NMDA) antagonist, can be prescribed. This drug helps to decrease symptoms, allowing some people to maintain certain essential daily functions slightly longer than they would without medication (3).  

For example, this medication could help a person in the later stage of the disease maintain their ability to use the bathroom independently for several more months, benefiting the patient and the caregiver (3). This drug works by regulating glutamate, an essential chemical in the brain. When it is produced in large amounts, glutamate may lead to brain cell death. Because NMDA antagonists work differently from cholinesterase inhibitors, these rugs can be prescribed in combination (3).  

Medications to be Used with Caution in those Diagnosed with Alzheimer’s  

Some medications, such as sleep aids, anxiety medications, anticonvulsants, and antipsychotics, should only be taken by a patient diagnosed with Alzheimer’s after the prescriber has explained the risks and side effects of the medications (3).  

Sleep aids: They help people get to sleep and stay asleep. People with Alzheimer’s should not take these drugs regularly because they could make the person more confused and at a higher risk for falls.  

Anti-anxiety: These treat agitation and can cause sleepiness, dizziness, falls, and confusion (3).  

Anticonvulsants: These are used to treat severe aggression and have possible side effects of mood changes, confusion, drowsiness, and loss of balance. 

Antipsychotics: they are used to treat paranoia, hallucinations, agitation, and aggression. Side effects can include the risk of death in older people with dementia. They would only be given when the provider agrees the symptoms are severe enough to justify the risk (3).  

Caregiving  

Coping with Agitation and Aggression  

People with Alzheimer’s disease may become agitated or aggressive as the disease progresses. Agitation causes restlessness and causes someone to be unable to settle down. It may also cause pacing, sleeplessness, or aggression (5). As a caregiver, it is essential to remember that agitation and aggression are usually happening for reasons such as pain, depression, stress, lack of sleep, constipation, soiled underwear, a sudden change in routine, loneliness, and the interaction of medications (5). Look for the signs of aggression and agitation. It is helpful to prevent problems before they happen.  

Ways to cope with agitation and aggression (5):  

• Reassure the person. Speak calmly. Listen to concerns and frustrations.  
• Allow the person to keep as much control as possible.  

• Build in quiet times along with activities. 
• Keep a routine. 
• Try gently touching, soothing music, reading, or walks. 
• Reduce noise and clutter.  
• Distract with snacks, objects, or activities. 

Common Medical Problems  

In addition to the symptoms of Alzheimer’s disease, a person with Alzheimer’s may have other medical conditions over time. These additional health conditions can cause confusion and behavior changes. The person may be unable to communicate with you about their circumstances. As a caregiver, it is essential to watch for various signs of illness and know when to seek medical attention for the person being cared for (6).  

Fever 

Fever could indicate potential infection, dehydration, heatstroke, or constipation (6).  

Flu and Pneumonia 

These are easily transmissible. Patients 65 years or older should get the flu and Pneumonia shot each year. Flu and Pneumonia may cause fever, chills, aches, vomiting, coughing, or trouble breathing (6).  

Falls 

As the disease progresses, the person may have trouble with balance and ambulation. They may also have changes in depth perception. To reduce the chance of falls, clean up clutter, remove throw rugs, use armchairs, and use good lighting inside (6). 

Dehydration 

It is important to remember to ensure the person gets enough fluid. Signs of dehydration include dry mouth, dizziness, hallucinations, and rapid heart rate (6).  

Wandering  

Many people with Alzheimer’s disease wander away from their homes or caregivers. As the caregiver, it is essential to know how to limit wandering and prevent the person from becoming lost (7).  

Steps to follow before a person wanders (7) 

• Ensure the person carries an ID or wears a medical bracelet.  
• Consider enrolling the person in the Medic Alert® + Alzheimer’s Association Safe Return Program®. 
• Alert neighbors and local police that the person tends to wander and ask them to alert you immediately if they are seen alone.  
• Place labels on garments to aid in identification. 

Tips to Prevent Wandering (7) 

• Keep doors locked. Consider a key or deadbolt. 
• Use loosely fitting doorknob covers or safety devices.  
• Place STOP, DO NOT ENTER< or CLOSED signs on doors.  
• Divert the attention of the person away from using the door.  
• Install a door chime that will alert when the door is opened.  
• Keep shoes, keys, suitcases, coats, and hats out of sight.  
• Make sure not to leave a person who has a history of wandering unattended.  

Conclusion

Alzheimer’s is a sad, debilitating, progressive disease that robs patients of their lives and dignity. As research continues on the causes, treatment, and prevention of the disease, healthcare workers and caregivers need to know the signs and symptoms of a patient with Alzheimer’s disease and potential coping mechanisms and management strategies of the disease. More information on the disease is available through several various resources, including:  

Family Caregiver Alliance  

800-445-8106 

NIA Alzheimer’s and Related Dementias Education and Referral Center  

800-438-4380 

Nursing Care in Lewy Body Dementia

Introduction   

Lewy body dementia is one of the more common causes of dementia. Currently it is the second most common dementia disorder following Alzheimer’s disease [2]. This condition is shown to affect more than 1.4 million people in the United States [1] [2]. Of dementia cases in older adults, Lewy body dementia is said to make up 5% of people with dementia [2]. Lewy body dementia is a disorder that progresses over time [1]. The progression of the disease differs between individuals and the severity of the symptoms [1].  

On average an individual lives between five to eight years after diagnosis [1]. Currently there is not a cure for this disease [1]. This course will examine the causes of this disease, signs and symptoms patients might experience, diagnostic tests, types of management, and educational resources for family members. This course is designed to inform nurses about this common disease and to use this information in their daily practice to care for their patients.  

Definition

Lewy body is an umbrella term that includes two separate diagnoses: Dementia with Lewy bodies and Parkinson’s disease dementia [5]. As these diseases progress, they develop together and are seen as one entity, not two separate conditions [4]. Lewy body dementia is a condition that involves neurocognitive disorders that include hallucinations, memory loss, behavior changes, and parkinsonism features [2]. This disease can also affect intellectual abilities and cause individuals to act out dreams during REM (rapid eye movement) sleep [2]. REM sleep behavior disorder sometimes may be experienced before any other symptoms are exhibited [2].   

Lewy body dementia is known for a buildup of deposits of alpha- synuclein proteins called Lewy bodies [1]. Diagnosing this condition can be difficult because many neurological disorders have similar symptoms. Lewy body dementia and Parkinson disease dementia are very similar. For a diagnosis of Lewy body dementia, there must be a cognitive impairment with motor symptoms occuring in less than 12 months [3].  Parkinson’s disease dementia affects an individual’s movements; cognitive symptoms appear later (greater than one year) [5].  

Lewy body dementia is known to affect older adults generally between the ages of 50 and 85 [2]. This disease is said to be underdiagnosed due to a large number of diagnoses occuring post-death during autopsies [4]. Several medications used to treat neurocognitive and behavioral symptoms in other conditions can worsen the symptoms of Lewy body dementia [4]. Therefore, an accurate diagnosis can impact an individual’s quality of life.  

Epidemiology 

Lewy body dementia affects a significant number of individuals in the United States. This condition is found more often in men than women [4]. Age is thought to be the greatest risk factor for an individual developing this disease [4]. An individual who has a family history of Lewy body dementia and Parkinson’s disease is at a higher risk for developing this condition [3].

Lewy Body dementia is more widespread in European, Asian, and African ethnic groups [3].  In individuals with Parkinson’s disease, the incidence of Parkinson’s disease dementia is said to be around 25-30% [4]. The incidence of individuals with Parkinson disease developing this type of dementia after having Parkinson’s for more than 20 years increases to around 83% [4].  

Pathophysiology 

There is a buildup of alpha- synuclein proteins that causes neurons to die in Lewy body dementia [2] [5].  As mentioned above in this course, this buildup of proteins is called Lewy bodies. The death of neurons that produce dopamine result in problems with movement, cognitive impairment, a decline in cognition, and sleep disturbances [4].  In Lewy body dementia there is a deficiency of acetylcholine [3]. There is also a decrease in acetylcholine with Alzheimer’s disease, but the deficiency is greater with Lewy body dementia [3]. The decrease in neurons that produce acetylcholine causes memory loss and learning impairment [4].  

The mutation of synuclein alpha and synuclein beta genes can cause dementia with Lewy bodies [2]. Mutations in apolipoprotein E and GBA genes are potential risk factors for developing the disease [2]. There have been cases where a buildup of alpha-synuclein was found during an autopsy, but the individual did not show any clinical signs of Lewy Body dementia when alive [4]. The function of these proteins in this condition is still undetermined [5]. 

Etiology 

The exact cause of Lewy body dementia is still unknown. While research is ongoing and new developments are occuring, the specific cause has not been determined. The accumulation of Lewy bodies cause cell death which causes symptoms, however, the reason for the buildup of Lewy bodies is still under research [5]. As mentioned earlier, there are specific gene mutations that have been shown to increase the likelihood of producing altered alpha- synuclein proteins, in turn causing them to clump together (forming the Lewy bodies) [2].  

The mutation of the GBA gene interferes with the function of lysosomes, which can affect the breakdown of the alpha- synuclein proteins, causing the proteins to accumulate [2]. The e4 allele type of the APOE gene has been shown to increase the risk of developing Lewy body dementia [2]. These clumps of Lewy bodies form inside and outside of neurons in different areas of the brain, where they can alter the function of the cell and can cause the cell to die [2].

The neurons that develop the neurotransmitter dopamine are especially impacted by these clumps of Lewy bodies, which was addressed earlier in this course [2]. Further research is required to find out why these Lewy bodies develop in certain individuals. Currently, age, genetics, and environmental factors are some of the greatest risk factors [3]. 

 ​

Clinical Signs and Symptoms 

Lewy body dementia is a progressive disorder – the signs and symptoms worsen over time. The symptoms that are more common are sleep changes, impaired behavior, movement, and cognition [5]. Research shows that the location of Lewy body accumulation impacts the clinical signs and symptoms the individual experiences [3]. If Lewy bodies develop in the brainstem and cerebral cortex first, the condition is called dementia with Lewy bodies, and the onset of the dementia is early [3]. If Lewy bodies accumulate in the brain stem and then develop into the cerebral cortex as time passes, the onset of dementia appears later, and this condition is called Parkinson’s disease dementia [3].  

Rapid Eye Movement Sleep Behavior Disorder 

Rapid eye movement (REM) sleep behavior disorder is sometimes the first clinical sign of dementia with Lewy bodies [2]. Individuals with this disorder move and talk while dreaming in their sleep [2]. The movements can be violent and cause the individual to fall out of bed [5]. Individuals may kick, punch, and scream in REM sleep (the second half of their sleep) [4]. REM sleep behavior disorder is seen in 76% of patients with dementia with Lewy bodies [4].   

This disorder can cause fractures and contusions in some individuals resulting from falling out of bed [4]. This can not only affect the individual, but also the sleep partner of the patient [4]. In some cases, separate sleeping arrangements are needed for the safety of the individual and their sleeping partner. A questionnaire by the patient and sleep partner is part of the diagnosis of REM sleep behavior disorder [14]. If the individual does sleep next to someone, this questionnaire can be helpful as most of the time the patient cannot recall the events while asleep [14]. Video polysomnography is required for a complete diagnosis of this disorder [14]. These events while asleep must be repeated to meet the diagnostic criteria [14]. 

Other Sleep Disorders 

Other disorders of sleep include sleepiness in the daytime, restless leg syndrome, confusion when awakened, and obstructive sleep apnea [4]. 

Visual Hallucinations 

Visual hallucinations are present in about 80% of individuals with Lewy body dementia [1]. Visual hallucinations are a core clinical symptom of dementia with Lewy bodies [4]. They are more common in women than in men [4]. Individuals are aware of these hallucinations and can tell others what they experienced [4]. Visual hallucinations are vivid to individuals and have been said to range from people walking around the house to seeing people that have died sitting next to them [6]. During the beginning stages of the disease, the hallucinations do not seem to affect the patient as much as when the disease progresses [6]. Patients are said to be afraid of these hallucinations in the later stages of the disease [6]. Nonvisual hallucinations are less common, however can occur in some patients [1]. These hallucinations include smelling or hearing something that is not in their surroundings [1]. 

Fluctuation in Cognition 

Fluctuation in cognition is also a clinical sign that is associated with dementia with Lewy bodies [4]. This symptom includes changes in attention, concentration, and alertness [5]. These changes are random and can differ day-to-day [1]. Symptoms can include delirium, and mimic symptoms that are caused by metabolic diseases, which can further the difficulty with identifying the correct diagnosis [4]. To diagnose dementia with Lewy bodies, one of the episodes must be confirmed [4]. These fluctuations can be present in other forms of dementia in their later stages but when present in earlier stages, they point to dementia with Lewy bodies [4].  

Memory loss that impacts activities of daily living can be found in later stages of Lewy body dementia [1]. Memory loss early on is more often a characteristic sign of Alzheimer’s dementia [1]. Confusion about the individual’s whereabouts, and inability to multitask can also occur in dementia with Lewy bodies [4]. 

Problems with Movement 

Problems with movement are signs of Lewy body dementia. Bradykinesia (slow movements) and rigidity occur in about 85% of individuals with dementia with Lewy bodies [4]. Tremor at rest is less common in individuals with this condition [4]. Loss of coordination and difficultly swallowing can occur [1]. Problems with movement greatly increase the risk of falls for these individuals [4]. This can place strain on the individual’s caregivers [4]. 

Autonomic Dysfunction 

Autonomic dysfunction can be present in dementia with Lewy bodies and Parkinson’s disease dementia. This symptom is seen in about 90% of patients with Lewy body dementia [4]. The symptoms that result from autonomic dysfunction can be constipation, urinary incontinence, orthostatic hypotension, erectile dysfunction, and dizziness [1] [4]. Orthostatic hypotension appears as early as five years prior to the diagnosis of Lewy body dementia [4]. Syncope and falls are usually the result of orthostatic hypotension [4]. Constipation can also occur earlier in the disease process [4]. 

Diagnostic Tests and Evaluations  

Throughout this course, it has been mentioned that Lewy body dementia is significantly underdiagnosed. Individuals are usually diagnosed as the disease progresses due to the symptoms that overlap with other forms of dementia and other neurological and psychiatric disorders [3]. An autopsy of the brain after death is one of the only ways to have a conclusive diagnosis of Lewy body dementia [16]. There are certain diagnostic criteria and diagnostic tests that are used to diagnose an individual with Lewy body dementia. 

Diagnosis by Symptoms 

Lewy body dementia is probable when an individual experiences dementia and two main features of the disease. Lewy body dementia is a potential diagnosis if the individual experiences progressive dementia and one main feature of the disease [3]. As discussed in the clinical signs and symptoms section of this course, key features of Lewy body dementia are cognitive fluctuations, dementia that progresses, problems with movement (signs of parkinsonism), REM sleep behavior disorder, and visual hallucinations [3] [16].  

Timing of symptoms is relevant for distinguishing between the two forms of Lewy body dementia [3]. Currently healthcare providers use the time span of one year to distinguish the two forms [3]. If dementia occurs within one year of the appearance of movement problems, then a diagnosis of dementia with Lewy bodies is used [3]. If an individual is diagnosed with Parkinson’s disease and starts experiencing symptoms of dementia more than one year after their Parkinson’s diagnosis, then Parkinson’s disease dementia is used [3]. Some indicative biomarkers in addition to clinical symptoms are used in diagnosis [4]. Some of these biomarkers can be found in cerebral spinal fluid (CSF) and are still under research [4].  

Cognitive Tests 

Cognitive testing can be used to show the cognitive impairment of patients with Lewy body dementia [3]. The Mini-Mental State Examination can be used as an initial screening test [4]. This exam tests cognitive function by focusing on concentration, orientation, and memory [15]. This test can be limited since symptoms of these patients can fluctuate day to day [3]. Another cognitive function test is the Montreal Cognitive Assessment (MoCA) [15]. Providers do not usually diagnose based on a single test; instead, they use the results to look for other signs and symptoms of Lewy body dementia [4]. 

Imaging Tests 

There are certain imaging tests that can help with diagnosis and distinguishing between other dementia disorders. A single-photon emission computerized tomography (SPECT) scan can help support a diagnosis [16]. This is a nuclear scan that can sense radioactivity [16]. If the SPECT scan shows a reduced dopamine transporter uptake in the basal ganglia, this can be a sign of Lewy body dementia [16]. This will separate the diagnosis between Lewy body dementia and Alzheimer’s disease [4]. Performing this scan alone will not lead to a possible diagnosis of Lewy body dementia; however, in combination with other diagnostic tests, the scan can lead to a more certain diagnosis [4]. Results from these scans can appear normal initially, and the scan may need to be repeated [4].  

An iodine- MIBG myocardial scintigraphy can be performed to support Lewy body dementia [16]. This would show decreased communication of cardiac nerves [16]. The results may be skewed by heart disease or certain drugs [4]. A CT or MRI may be used but these imaging tests can present mixed results [4]. With Alzheimer’s disease, significant atrophy is seen in the medial temporal lobes [4]. There is normally minimal atrophy in Lewy body dementia [4].  

As mentioned earlier in the course, video polysomnography is needed for the diagnosis of REM sleep behavior disorder [14]. This sleep study without the loss of muscle tone can also point towards a diagnosis of Lewy body dementia as REM sleep behavior disorder has now moved to a key feature of this disease [14]. 

Case Studies 

Case Study #1 

A 74-year-old male presents to his primary care provider after his wife reports abnormal behavior over the past several months. His wife reports the patient kicks and screams during sleep. The patient reports seeing little people walking around the living room during the day. The wife states the patient some days will fall asleep throughout the day while completing activities.  The patient states difficulty walking and muscle stiffness.  

The wife states last week the patient was supposed to go to the local grocery store to buy milk. After two hours passed, the wife called her husband as she was worried about him. He states he got lost finding the grocery store and did not know where he was. The wife said she had to drive to find her husband and bring him home. The patient also reports dizziness when standing. After the nurse obtained an orthostatic blood pressure, the patient was positive for orthostatic hypotension. 

• Which form of dementia is the patient most likely experiencing? 
• What type of symptoms is the patient experiencing that would point to that diagnosis? 
• What diagnostic tests or evaluations should the patient undergo? 
• What types of supportive treatment should the healthcare provider include in the treatment plan for this patient? 

Case Study #2 

A 70-year-old female presents to the emergency department via EMS after falling at home. The patient’s daughter called 911 after finding her on the floor when going to visit her. Upon arrival at the emergency department the patient is oriented to self. The patient does not know where she is or what happened to precipitate the fall. The patient has a past medical history of hypertension, diabetes type II, and Parkinson’s disease.  

The patient was diagnosed with Parkinson’s disease two years prior. The daughter states the patient has been forgetful lately and not acting like herself. The daughter reports that her mom’s behavior is different from day-to-day. An MRI and the National Institutes of Health Stroke Scale (NIHSS) are used to rule out a cerebrovascular accident. A complete blood count (CBC), a complete metabolic count (CMP), and urinalysis are obtained. The patient suffered a contusion to her right cheek and a right radius fracture. The patient states that she sees figures dancing in the room and smells popcorn. The patient appears to be frightened by the hallucinations. The patient’s daughter states for the last six months the patient has had difficulty swallowing and a reduced appetite.  

• Which form of dementia is the patient most likely experiencing? 
• What would the MRI of the patient most likely show? 
• What clinical signs of dementia is the patient exhibiting? 

Management 

Currently there is not a cure for Lewy body dementia, only supportive treatment. The management of this disease involves a multifaceted approach, including therapies, pharmacological treatments, and family support. 

Therapies 

Specific therapies can help with symptom management and help improve the individual’s quality of life. Occupational therapy can help improve a patient’s ability to complete activities of daily living. Speech therapy can help with swallowing coordination and improve the clarity and volume of speech [5]. Physical therapy can aid patients with problems with movement [5]. Mental health counseling can help individuals and their families with managing behaviors and their emotions [5]. 

Medications 

Pharmacotherapy can help with supportive treatment but can also worsen symptoms if certain medications are taken. Below are some examples of medications that are used by patients with Lewy body dementia. 

• Cholinesterase Inhibitors are used to help cholinergic activity to improve cognitive function [6].  

• Rivastigmine was one of the first of these drugs to be tested [6]. Patients were noted to have improved on their cognitive exams [6]. It is also shown to reduce hallucinations and lessen anxiety [6]. This class of drugs has been said to improve the quality of life for some patients [4].   

• Donepezil and Galantamine are also used to reduce dementia symptoms of hallucinations [6]. These drugs were initially targeted for patients with Alzheimer dementia, however, they are effective for individuals with Lewy body dementia as well [3]. A study was done stating even if there is not a sign of cognitive improvement, this should not be the criteria to stop the medication as this medication has been proven to protect the individual from further impairment of cognition [4]. 

• Atypical Antipsychotics are prescribed to patients that are not seeing a reduction of symptoms while on cholinesterase inhibitors [3]. These types of drugs are seen as controversial due to the many adverse effects that have been seen in patients [4]. Drugs such as haloperidol and olanzapine should be avoided in patients with Lewy body dementia as they can cause neuroleptic malignant syndrome (a life-threatening condition) [5]. Quetiapine, clozapine, pimavanserin, and aripiprazole are atypical antipsychotic drugs that can be used to improve agitation and help prevent cognitive fluctuations [5]. 

• Carbidopa-Levodopa can be used in patients to manage problems with movement [3]. This medication can cause side effects and can result in hallucinations, delusions, and increase confusion [3]. Providers should begin with low doses of this medication [3]. 

• Clonazepam is a benzodiazepine that can lessen the REM sleep behavior disorder that patients with dementia with Lewy bodies can experience [5]. Between 33-65% of patients with REM sleep behavior disorder can experience an injury while sleeping [5]. This medication has been proven to decrease injuries that occur during sleep [5]. Clonazepam can adversely affect individuals with gait disorders or sleep apnea [5]. 

• Melatonin is a hormone that can be used for patients that are affected by REM sleep behavior disorder (5). Studies have shown that the use of melatonin lessened the frequency and the severity of symptoms associated with REM sleep behavior disorder [5]. Melatonin can have side effects such as headaches in the morning, sleepiness during the day, and hallucinations [5]. 

• Memantine is used to treat dementia symptoms [5]. This medication is an NMDA receptor antagonist that stops effects of glutamate in the brain [5]. Memantine has been shown to improve symptoms of patients early in the disease [5]. 

Nursing Care 

As mentioned before, there is not a cure for Lewy body dementia. Caring for patients with Lewy body dementia includes supportive treatment. Nurses can play a significant role in caring for these patients and providing the family with support. Home health nurses can help with frequent assessment of the patient and their environment [3]. Environmental changes may be needed to protect the patient from falls and other accidents. Home health nurses can assess the type of assistance the patient would benefit from.  

Nurses can aid the family by providing education to assist in how to care for the patient. Family members and caregivers must be aware of the changes in behavior, fluctuations in cognition, and hallucinations that the individual might experience [3]. Nurses must also provide education to the caregiver of the patient on the side effects of certain medications, as they can affect an individual with this disease [7]. 

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Family Support 

Lewy body dementia is growing in recognition; however, many people might not be aware of this condition and the disease process. Family members need support from health care professionals to better care for their loved ones. Support can come in the form of education and preparing the family for the symptoms the individual may experience. The cognitive function of patients with this disease can be very limited [3]. Family members must be educated on monitoring the individual closely to promote safety [3]. These individuals are at a high risk for falling and developing aspiration pneumonia (due to swallowing difficulties) [3]. Family members should be educated in preparing for an emergency.  

Individuals with Lewy body dementia may need care and the family needs to know how to inform health care providers of their specific needs. It is important to educate family members that their roles in their past relationship with the patient will likely change due to the disease process. To prevent caregiver burnout, family members must be aware of their limitations and know when they need help [7]. Modifying the patient’s home may be needed for patient safety [3]. Each patient may have specific needs and family members should know what modifications may be necessary [3].  

Prognosis 

The prognosis of Lewy body dementia can be viewed as poor. As mentioned briefly earlier in this course, this disease is progressive and after diagnosis, the life expectancy is five to eight years [3]. The range of expectancy has also been attributed to delay in diagnosis, which can further delay supportive treatment to improve quality of life for the individual [3]. Patients can die from complications from the disease. Complications can include cardiac complications, falls, adverse effects from medications, pneumonia, and suicide [3].  

Compared to Alzheimer’s dementia, the risk of hospitalization or death due to respiratory infections is higher in patients with Lewy body dementia [8]. The median age at death is said to be similar between patients with Alzheimer’s dementia and Lewy body dementia [8]. The life expectancy from diagnosis to death is shorter in patients with Lewy body dementia [8]. The patient’s environment has been shown to play a role in the increased risk of mortality [8]. Patients in nursing homes have been shown to have a higher risk of mortality [8]. Caregivers can decrease the risk of complications by educating themselves on this disease and keeping their loved ones safe. 

Resources for Family Support  

Lewy body dementia is a diagnosis that can affect all aspects of an individual’s life and their family members lives. As nurses we must provide support for family members so they can better care for their loved ones and improve their quality of life. As recognition of this condition grows, family support resources are increasing. The Lewy Body Dementia Association is a nonprofit organization that raises awareness and provides support for families with individuals that suffer from Lewy body dementia [10]. Support groups can be found on their website to help families across the country in their local area [10].  

The Lewy Body Dementia Association was started by caregivers of individuals with this condition. They also focus on education and research into the disease. This association is a resource for family members [10]. 

Another resource for family members is The Lewy Body Dementia Resource Center. This is a nonprofit charitable organization that gives assistance and support to those who care for someone with Lewy body dementia [9]. This organization was founded by caregivers of individuals with Lewy body dementia. They have a support phone line that is available seven days a week to answer questions [9]. They also promote research and early diagnosis of this disease [9]. 

Research Programs 

Lewy body dementia is the second most common form of dementia in the United States [4]. This illness is thought to be underdiagnosed and commonly mistaken for other neurological disorders [3]. Research on Lewy body dementia can decrease the time it takes to diagnose a patient, and can help with management of the condition.  

The National Institute of Neurological Disorders and Stroke provides support for a variety of research endeavors for Lewy body dementia [11]. In 2021 The National Institute of Health spent $93 million dollars on Lewy Body dementia research [11]. One program is the Biomarkers for Lew body dementias program. This program aims to increase clinical data collection from patients with this condition, find biomarkers to expand further research, and allow access to the science community to help with further studies [11]. Another program is the Parkinson’s Disease Biomarkers Program. This program’s purpose is to collectively research with healthcare professionals, patients and family members, and technology professionals to increase biomarker research [11]. 

Biomarker research has been increasing in Lewy body dementia. A biomarker is a feature that can specifically indicate a certain disease [12]. For quite some time there were not any identified biomarkers for Lewy body dementia. There are certain biomarkers that aid in distinguishing Alzheimer’s disease from Lewy Body dementia [13]. These biomarkers can be assessed through imaging or in cerebral spinal fluid [13]. Currently these biomarkers are only helpful if another disease is doubtful [13].  

New biomarkers are needed to separate Alzheimer’s dementia from Lewy Body dementia and other neurological disorders [13]. Biomarkers that can help with early diagnosis would be beneficial for early treatment [13]. 

Conclusion  

Lewy Body dementia affects 1.4 million Americans [2]. The disease is underdiagnosed and often diagnosed incorrectly. Incorrect diagnoses can lead to worsening of symptoms and the administration of drugs that can lead to adverse effects.  

Educating healthcare providers and the community about Lewy body dementia can improve quality of life for individuals with the disease. As nurses, we must be informed about this disease to better educate our patients and their caregivers, and to know how to advocate for our patients.  

Sexual Harassment Prevention

Introduction   

Sexual harassment is a serious issue within the healthcare workplace. One systematic review research study found that sexual harassment rates against female nurses was as high as approximately 43% (5). According to an article published in the American Journal of Critical Care in 2021, recent studies estimate around 60% of female nurses and 30% of male nurses have reported sexual harassment (3).  

For both student and registered nurses, patients were the most likely perpetrators. However, this varies, and some research suggests that physicians and patient relatives were also at an increased likelihood of being perpetrators of sexual harassment toward registered nurses (8). It is important to remember that sexual harassment is not limited to female registered nurses; male nurses are also at risk of experiencing sexual harassment in the workplace. 

The impacts of sexual harassment affect nurses in many negative ways. There are obvious psychological consequences, but there is also evidence to suggest that work performance and productivity can also be negatively affected (12). Many states have recognized the significant impact of this issue and have taken measures to empower nurses to prevent and/or address sexual harassment. 

What Is Sexual Harassment?

Sexual harassment is commonly thought to be unwelcome contact. However, sexual harassment takes many forms. It can be defined as unwelcome sexual behaviors or actions which may be verbal, physical, mental, or visual (13). 

Listed below are some common examples of potential sexual harassment: 

• Actual or attempted rape or sexual assault 
• Pressure for sexual favors 
• Deliberate touching, leaning over, or cornering 
• Sexual looks or gestures 
• Letters, telephone calls, personal e-mails, texts, or other materials of a sexual nature 
• Pressure for dates 
• Sexual teasing, jokes, remarks, or questions 
• Referring to an adult as “girl,” “hunk,” “doll.” “babe,” “honey,” or other similar terms 
• Whistling at someone 
• Turning work discussions to sexual topics 
• Asking about sexual fantasies, preferences, or history 
• Sexual comments, innuendos, or sexual stories 
• Sexual comments about a person’s clothing, anatomy, or looks 
• Kissing sounds, howling, and smacking lips 
• Telling lies or spreading rumors about a person’s sex life 
• Neck and/or shoulder massage 
• Touching an employee’s clothing, hair, or body (4, 13) 

The U.S. Equal Employment Opportunity Commission defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.” Sexual harassment can also include offensive remarks about an individual’s gender or sexual orientation. No matter the type or amount of harassment, it can disrupt the workplace and potentially create a hostile work environment (10,11) As you can see, the definition of sexual harassment is broad and can encompass many situations. 

Why Are Nurses Vulnerable to Sexual Harassment?

Nurses are vulnerable to sexual harassment by the very nature of their position. The role of nursing surpasses many societal norms regarding physical contact and involves intimate care of patients both physically and emotionally. This role is often exploited by perpetrators – they may take advantage of a nurse’s position and caring demeanor as a means to harass them (8). 

Staff-on-staff harassment is also commonly reported by nurses (8). Nurses are potentially predisposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results. 

Key Points for Sexual Harassment

Sexual misconduct vs. sexual harassment – Sexual misconduct is a type of sexual harassment. Sexual behavior can turn into sexual harassment when the recipient receives the behavior in an unwelcome manner. The term “unwelcome” refers to unsolicited or uninvited behavior and undesirable or offensive behavior (11). 

Females and males can both be victims – Any unwelcome sexual behavior may be considered sexual harassment, regardless of the gender of the perpetrator and recipient. Male-on-male, female-on-female, female-on-male, and male-on-female types of harassment may occur (11). 

Sexual harassment can affect witnesses – Anyone who is affected by the sexually offensive conduct may be a victim. This may include a person witnessing or overhearing sexually-harassing behavior (1). 

It can occur outside the working environment – The “working environment” is not limited to the physical location of work. A “working environment” may be extended to any location where work occurs, such as remote locations, off-site locations, and temporary working locations (1, 11). 

It doesn’t only occur in person – Sexual harassment can occur on and off the clock. It can occur physically and virtually. Unwelcome sexual conduct through email, phone calls, texts, social media postings, and other mediums may constitute sexual harassment (6). 

Two Types of Sexual Harassment

1. Quid pro quo – Quid pro quo means “a favor for a favor.” In this sense, it refers to an authority figure (manager or supervisor) requesting a sexual favor in exchange for preferential treatment. This could be in the form of a promotion, raise, preferred assignment, or any other job benefit which they may affect (7).
2. Hostile work environment – Another method by which an individual may coerce sexual favors is through the threat or actuality of a hostile work environment. This refers to creating or threatening to create an intimidating, hostile, or offensive work environment in order to influence sexual favors or behavior (7).

What Should Nurses Do If They Experience Sexual Harassment?

If you feel you have been the victim of unwelcome sexual behavior (sexual harassment) there are avenues available to you for support and to report the behavior. 

• While it may not be an easy thing to do (or even possible), try to make it known that the sexual behavior is unwelcome and unwanted. It is your right to inform the person of your stance and to demand the behavior cease. Though this can be difficult and uncomfortable, it is often the most effective method (2). If you decide to confront the perpetrator, try to remain calm and de-escalate the situation as much as possible.   
• You should be explicit in explaining the behaviors that are unwelcome so that the perpetrator can fully understand his/her actions. If you are uncomfortable confronting the perpetrator, consider confiding in a close friend, coworker, or supervisor who can accompany you or advise you on the next steps. 
• Another way is to interrupt the harasser to distract them from the situation (2) 
• Next, make sure to document the scenario. Write down all of the details that you can recall; including any witnesses. This can be helpful in the future. 
• Reporting the issue through the appropriate channels is the next step. Oftentimes, this involves speaking with your supervisor and someone in human resources. While discussing the situation, do not make excuses for the perpetrator or try to “shrug it off.” 

How or whether you report sexual harassment is a personal choice, and you are not limited. However, you should strongly consider reporting the incident because it could escalate further in the future. The perpetrator may also be sexually harassing others. Every workplace should be free from sexual harassment and many states have laws protecting nurses against workplace sexual harassment, including harassment received from patients and family members. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints. However, you should not be discouraged from reporting through the appropriate avenues. 

 1. Within your organization.

You may contact your supervisor or human resources representative to report an incident. This is often a more comfortable route for nurses as they may be familiar with these individuals. Your organization should have policies and procedures for handling sexual harassment reports which may include escalation to law enforcement as necessary. This is often the fastest method for reporting. Remember that reporting to your supervisor, ethics officer, or human resources official does not preclude you from reporting to other agencies as appropriate. If you wish to remain anonymous, check with your organization to see if they have a policy that gives you that option. 

2. Law enforcement.

Criminal incidents of sexual harassment may be reported to law enforcement as appropriate. Oftentimes your human resource officer can assist in determining if this is necessary or required by state law. If you ever feel that your physical safety is threatened, do not hesitate to contact law enforcement. 

3. Office of Executive Inspector General (state government employees).

State employees may file a report directly with the OEG. To initiate a report, it is best to contact your ethics officer for guidance. 

4. U.S. Equal Employment Opportunity Commission (EOCC).

Sexual harassment is a violation of section 703 VII. The EOCC is charged with administering this statute and provides another option of relief for those who have experienced sexual harassment. The statute for reporting an offense to the EOCC is 180 days from the date of the incident. Of note, the EOCC may hold employers responsible for taking all steps to create an environment free of sexual harassment and can offer an additional avenue for support. This law may be extended up to 300 days depending in the state laws surrounding sexual harassment (10). 

Whistleblower Protections

Retaliation for reporting sexual harassment is illegal under both federal and state statutes. The U.S. Equal Employment Opportunity Commission prohibits retaliation aimed at employees who assert their rights to be free of harassment (9). 

Concluding Points

• Sexual harassment can take place in many venues and formats. It is broadly defined as any unwanted or unwelcome sexual behavior or advances. 
• Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions. 
• You have a right per federal and state laws to be free of sexual harassment in the workplace. 
• If you experience sexual harassment, you should tell the harasser to stop and report the incident in one of the various methods listed above. Do not forget to document provide a thorough report of the incident. 
• You have a right to report sexual harassment without retaliation per federal laws. 

Connecticut Domestic and Sexual Violence

Introduction   

Each year, more than 10 million men and women in the United States experience physical abuse from an intimate partner. One in three women and one in four men have experienced some form of physical violence from an intimate partner in their lifetime and one in 10 women has been raped by an intimate partner (18). Such experiences have a lasting impact on physical and mental wellbeing, employment and economic status, effects on children who may witness such abuse, and, in severe cases, may even result in death.  

Healthcare professionals are on the front lines of screening and prevention for domestic and sexual abuse and may be able to recognize early signs of abusive relationships, improve client connections to resources, and reduce the overall incidence of acute and long-term injury from abuse. This course aims to educate healthcare professionals on risk factors, signs of abuse, characteristics of abusers, and the role of healthcare in interrupting the abuse cycle.

Defining Domestic Abuse 

The Department of Justice defines domestic violence, or intimate partner violence, as “a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner.” Violence involving intimate partners accounts for 15% of all crime (18). There are various categories of abuse.  

• Physical 

Physically harming a partner by any manner, including hitting, slapping, shoving, etc. Can also involve denying medical care to someone in need as well as forcing drugs or alcohol use upon someone so as to alter their cognition. 

• Sexual 

Attempted or successful coercion to participate in sexual contact without consent. Includes rape (including within marriage), sexually demeaning, harming genitals, or forcing sexual acts after physical violence.  

• Emotional 

Patterns of chronic criticism, name-calling, or demeaning behaviors that damage a person’s self-worth.  

• Economic 

Use of coercion, fraud, or manipulation to restrict a person’s access to money, assets, or financial information. Or unethically acquiring and/or using someone’s economic resources through exploitation or improper conducting of power of attorney, guardianship, or conservatorship roles.  

• Psychological 

Threats or intimidation, forced isolation, destruction of property.  

• Technological  

Use of technology, such as online platforms, computers, mobile phones, cameras, apps, etc. to threaten, harm, control, harass, stalk, impersonate, or monitor another person (22). 

Each of these categories has its own nuances and examples, but all consist of acts or threats that influence the weaker or subordinate partner. For the purpose of this course, we will mostly cover physical and sexual abuse, but all forms of abuse are valid and many times overlap with each other. Abusers use tactics such as (22): 

• Intimidation 
• Manipulation 
• Humiliation 
• Isolation 
• Fear 
• Coercion  
• Blame 
• Injuries/pain 

Further information about the epidemiology of domestic violence will be covered below, but it is important to note that anyone can become a victim of domestic violence, including people of all races, ages, sexual orientations, and gender identities. People of all socioeconomic and education levels can be affected, and all types of relationships can be involved; including couples who are opposite-sex, same-sex, married, dating, co-parenting, or living together.  

Affected individuals include not only the abused, but also family members (particularly children), coworkers, friends, and other members of the abused person’s community. Frequently witnessing domestic violence as a child increases the risk of becoming a victim of domestic abuse or an abuser in adulthood by demonstrating this as a “normal” way of life (22).

Epidemiology of Abuse 

As discussed above, anyone can be a victim of domestic violence, however there are particular populations who are at an increased risk and more likely to be victimized. Awareness of these demographics is useful for healthcare professionals when trying to detect situations where abuse may be more likely. An overview of domestic violence prevalence for at-risk populations is discussed below. 

Gender 

Women are much more likely to be affected by domestic violence than men.  

• 1 in 3 women has experienced some form of physical violence form an intimate partner, though the severity varies widely. 
• 1 in 4 women has experienced severe intimate partner violence either of a physical or sexual nature, compared to 1 in 9 men.  
• 1 in 7 women have experienced a physical injury from an intimate partner, as opposed to 1 in 25 men.  
• 1 in 7 women has been stalked by a partner to a point where they feared harm; conversely 1 in 18 men have had this experience.  
• 1 in 10 women have been raped by an intimate partner. 
• 72% of all murder-suicides involve intimate partners and 94% of the victims of murder-suicides are women (18). 
• Women are at risk for contraception coercion, where a partner pressures them to become pregnant or tampers with contraception to cause pregnancy (1). 

Pregnant Women 

Pregnant women are particularly vulnerable, and their risk of abuse is higher during this time, further complicating the health risks of abuse. 

• 1 in 6 abused women is first abused during pregnancy 
• Over 320,000 women experience domestic violence during pregnancy annually (14) 

Ethnicity/Race 

Minority race groups are more at risk for experiencing domestic violence. Department of Justice (DOJ) survey data indicates that 51.3% and 17.7% of white women report having experienced physical and sexual violence respectively, while non-white women report experiencing these at 54% and 19.8% respectively (26).  

Among minorities, American Indian and Alaskan Natives are among the most at risk. This group experiences high poverty rates, particularly on reservations, increased drug and alcohol use, and minimal resources for Natives seeking culturally specific shelter or safety from abuse, all of which increases the risk and prevalence of domestic violence, particularly among Native women (26)​​​​ 

• Over 84% of Native women experience some form of violence during their life 
• American Indians are 3 times more likely to be a victim of sexual violence than all other ethnic groups 
• 55.5% of Native women experience domestic violence in their lifetime 
  • 66.6% experience psychological abuse from a partner 
  • Over half have experienced sexual assault (26) 

For the Black community, factors like racist societal and legal structures have created gaps in economic opportunities, education, access to healthcare, and access to safety/resources that puts Black men and women at higher risk of domestic violence than their white peers. Due to stereotypes and inconsistent cultural competence among law enforcement, jurors, and judges, Black victims of abuse are more likely to be arrested and less likely to be believed by the legal system than white victims (13). 

• 45.1% of Black women and 40.1% of Black men experience domestic violence of a physical or sexual nature in their lifetimes 
• 53.8% of Black women and 56.1% of Black men have been victims of psychological abuse in their lifetime 
• 8.8% of Black women have been raped by a partner in their lifetime 
• Homicide involving domestic partners was highest among Black women in 2017, at 2.5 per 100,000 (16) 

Age 

Opposing ends of the age spectrum are both at increased risk of victimization, with teens and young adults as well as elderly people being at higher risk than the rest of the population.  

Teens are at an increased risk due to their inexperience with dating and relationships and susceptibility to peer pressure. They may also feel hesitant to tell an adult about abuse for fear of consequences or punishment. They may not recognize behaviors as abusive right away and may perceive controlling or jealous behaviors as signs of love. Teens who have witnessed repeated domestic violence among parents or other family members may also believe that this is how normal relationships function.  

According to 2023 data, one in 12 high school students report physical violence and one in 12 report sexual violence in a dating relationship (5). 

• 1.5 million high school students are abused in a dating relationship annually (only 33% ever tell anyone about it) 
• 26% of teens are victims of cyber dating abuse; female teens were twice as likely to experience this as male teens 
• 57% of teens report knowing someone who has been physically, sexually, or verbally abused in a relationship (19) 

Older adults are also at an increased risk, often due to impaired physical or cognitive abilities that require them to rely on a caretaker. They may be isolated, with limited social support or without the ability to tell someone what is happening to them.  

• It is estimated more than 10% of older adults who live in communities experience physical, psychological, sexual, or financial abuse from a caretaker 
• Only about 1 in 14 of these incidents are reported 
• A spouse or intimate partner is the perpetrator in 57% of physical abuse, 87% of psychological abuse, and 40% of sexual abuse cases 
• 39% of firearm homicides involving older adults were committed by a domestic partner (21) 

LGBTQ Community

Though it is well-known that members of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) community are at increased risk of violence or harm. In the general population, awareness of domestic violence rates for the LGBTQ community is just beginning to rise, as most existing data is based on heterosexual relationships. Emerging data is revealing that people in the LGBTQ community experience domestic violence at equal or greater rates than their straight and cis-gender peers (20).  

*Note: A basic understanding of sex, gender, and sexual orientation is necessary when caring for members of the LGTBQ community so as to offer comprehensive and competent care. These common terms and their definitions are included below for anyone needing clarification.  

Quick 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, though 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 does not match) 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 

(11) 

There are elements of domestic violence that are specific to the LGBTQ community. One example is “outing” or threatening to disclose a person’s sexual orientation or gender identity without their consent. Threatening to out someone can be used as leverage or a power dynamic in psychological abuse, and actually outing someone can lead to an increased risk of rejection and physical or sexual harm depending on who the information is revealed to.  

Additionally, members of the LGBTQ community may be afraid to seek help in abusive situations or may even experience discrimination when they do seek help, putting them at greater risk of significant harm. Poorly trained staff, implicit biases of staff, and even gender-specific resources such as women’s shelters can be difficult to navigate for LGBTQ victims (20). Statistics about domestic violence in LBGTQ relationships include the following:  

• 61.1% of bisexual women and 43.8% of lesbian women report experiencing rape, physical violence, or stalking by a domestic partner at some point in their life; compared to 35% of heterosexual women 
• 37.3% of bisexual men and 26% of gay men report experiencing rape, physical violence, or stalking by a domestic partner at some point in their life; compared to 29% of heterosexual men 
• 26% reported experiences of near-lethal violence in male-male relationships 
• Fewer than 5% of all LGBTQ domestic violence victims seek orders of protection 
• Transgender people are more likely to experience domestic violence in a public setting compared to cis-gender individuals 
• Transgender individuals experience unique forms of psychological/emotional abuse such as being called “it” or being ridiculed for physical appearance 
• Bisexual individuals are more likely to experience sexual violence than other sexual orientations 
• Black LGBTQ individuals are more likely to experience physical violence from a partner than other races 
• White LGBTQ individuals are more likely to experience sexual violence from a partner than other races (20) 

Disabled Populations 

Nearly a quarter of all U.S. adults have some type of physical, cognitive, or emotional disability. People with disabilities are particularly vulnerable to domestic violence.  

• Nearly 70% of people who have a disability experience domestic abuse 
• People who have a disability are three times as likely to be sexually assaulted than their non-disabled peers (23) 

People with disabilities relying at least partially on others to function in their daily life are particularly vulnerable to being intimidated, isolated, or controlled by someone they trust (power imbalance). Some 75% to 80% of domestic abuse of people with a physical disability and 95% of abuse of those with a cognitive disability goes unreported. The types of abuse are often unique to the disability as well, including:  

• Invalidation or minimization of disability 
• Shaming or ridiculing for disability 
• Refusal to help with daily tasks such as bathing, dressing, or eating 
• Over or under medicating 
• Sexual acts without consent 
• Denying access to healthcare services/appointments or medications 
• Limiting access to mobility devices such as walkers, wheelchairs, or prosthetics 
• Withholding finances 
• Threatening abandonment (23) 

Certain populations with disabilities are more at risk than others.  

• Women who have a disability:  

• • 80% of women who have a disability report sexual assault 
  • 40% higher rates of domestic abuse  
  • Violence experienced by women with disabilities may be more frequent or of greater severity  
  • More likely to experience reproductive coercion, stalking, or psychological abuse 

• People in the LGBTQ community who have a disability: 

• • LGBTQ facilities may not be accessible for those with disabilities 
  • Disability services may not be competent with issues of the LGBTQ community 

• Black, Indigenous, People of Color (BIPOC) with disabilities:  

• • Increased risk for police brutality 
  • Half of Black people with disabilities have been arrested at least once by age 28 
  • Half of people killed by law enforcement have disabilities (23)​​​​

Geographic Location  

A person’s location also plays a role in the risk of domestic violence, with rural locations and homelessness increasing the risk.  

Twenty percent of U.S. residents live in a rural location (17). U​​​​nique characteristics of rural living increase the prevalence and severity of domestic violence in the following three ways.  

Geographic Isolation 

• 80% of rural counties do not have a domestic violence program 
• >25% of rural communities are more than 40 miles from the nearest domestic violence program 
• Rural communities lack robust public transportation, and many people are without a car 
• Decreased likelihood that a neighbor or community member will see or hear abuse occurring  
• Significantly increased time needed for first responders to arrive after an emergency call 
• Scarcity of housing options, especially of lower cost, make it difficult to leave (17) 

Social/Cultural Barriers 

• Rural regions are often more conservative with traditional gender roles (physical or sexual violence against women may be viewed as “normal”) 
• Physical and sexual violence or assault may be viewed as private matters not to be discussed outside of the home 
• Friends or family may encourage victims to stay in abusive relationships to avoid divorce or for children 
• Women may be shamed or not believed for reporting abuse 
• Small-town gossip or lack of anonymity may keep victims from pressing charges or seeking assistive services 
• Women may be less likely to have a job or financial independence from their partners (17) 

Poor or Impartial Criminal Justice Response 

• Domestic violence may be seen as commonplace and low priority among law enforcement 

• Law enforcement, prosecutors, or judges may have relationships with perpetrators or their families that impede their ability to be impartial 
• Law enforcement may hold a patriarchal sense of loyalty to other men and put that above the safety of women in the community (“Good ol’ boys club” attitude) (17) 

Due to geographic isolation and lack of resources, as well as potential lack of income or financial independence, many victims in rural locations wind up homeless if they leave an abusive relationship. This comes with its own significant struggles and risks and is often not sustainable, leading the victims back to live with their perpetrators rather than continue being homeless, essentially creating a vicious cycle between homelessness and abuse.  

• A 2003 survey revealed 46% of homeless women reported being a victim of physical or sexual abuse in the last year. 
• In 2005, 50% of U.S. cities cited domestic violence as a leading cause of homelessness. 
• Some landlords have a zero-tolerance policy for domestic violence and will either evict or refuse to rent in the first place to victims of domestic violence. This was as high as 28% in a survey in New York City (27)

Socioeconomic Status and Education Level

Though people of any socioeconomic status are susceptible to domestic abuse, those with a low socioeconomic status or education level are at an increased risk. This is in part due to the increased isolation and lack of available resources to people in poverty or with low education. Particularly, women who do not work outside of the home or do not have any professional skills with which to get a job are at risk of being more easily isolated or kept from utilizing resources. Those with lower education levels are also more likely to view physical or sexual violence within a relationship as “normal” and tolerate the abuse without attempting to leave.  

Women with household incomes below $75,000 annually are seven times more likely to experience physical or sexual violence than women whose household incomes are above $75,000 (27). 

There is also a circular relationship between low socioeconomic status and domestic violence, as victims of abuse are both more likely to be poor and also more likely to experience economic loss or financial insecurity due to the abuse. Access to money or work can also be restricted by the abuse as part of the attempt to maintain power and control.  

• Between 21-60% of abuse victims lose their jobs from abuse-related reasons (missing work, distracted or poor job performance, etc.) 
• Domestic abuse victims lose a combined eight million days of paid work annually due to injuries or home conflict (18). 

Immigrants, in particular, may be affected by this as they may be of lower education (or at least unable to fluently speak the language of the new country), often poor or without any assets, and may be unable to work or earn money. They may rely on an abusive partner for money, a place to live, and even communication, keeping them isolated in a relationship that feeds on control/power (25).​​​​

Health Implications of Abuse 

There are many health implications for people in abusive relationships. Acute or short-term injuries are typically physical in nature and include things like (9):  

• Cuts 
• Bruises 
• Broken bones 
• Concussions 
• Burns 

Additionally, only 34% of people who sustained a physical injury from domestic violence sought medical care for those injuries, meaning many may have poorly healed injuries or long-term sequelae from lack of proper treatment (18). 

There are also long-term consequences or chronic health conditions that result from domestic violence, including:  

• HIV or other sexually transmitted infections (STIs) from sexual abuse 
• Bladder and kidney infections  
• Circulatory/cardiovascular conditions 
• Asthma 
• Unintended pregnancy, including teenage pregnancy 
• Chronic pain 
• Arthritis or joint disorders 
• Gastrointestinal disorders or nutritional deficiencies 
• Neurological disorders including migraines and neuropathy 
• Sexual dysfunction (9) 

Mental health effects are also significant with victims experiencing increased rates of:  

• Anxiety 
• Depression 
• Post-traumatic stress disorder (PTSD) 
• Suicidal thoughts and attempts 
• Addiction to drugs or alcohol (9) 

Certain populations, such as individuals in the LGBTQ community, are already at an increased risk for mental health issues and suicidal ideations. Therefore, abused members of this population are at a further increased risk.  

Additionally, victims of abuse may experience social or economic consequences that in turn worsen their overall health through poorer living conditions, nutrition, and access to healthcare. Economic consequences include (9):  

• Interrupted or lost educational opportunities 
• Lost professional opportunities 
• Damage or destruction to property or items of value 
• Medical or legal debt 

Health implications may be dependent on age or situation as well. Among the unique risks are pregnant, very young, and very old victims.  

Abuse during pregnancy can result in intrauterine hemorrhage, preterm labor, or miscarriage. Chronic stress during pregnancy, lack of prenatal care, or trauma to the fetus can lead to long-term health effects of the infant once born (14). S​​​​ome women may also be victims of contraceptive or reproductive coercion, where an abuser pressures them to become pregnant or tampers with their contraception to cause pregnancy. Unwanted pregnancy puts these women into a more vulnerable position to be victims of abuse and the above complications (1).  

Surveys of youth show that 50% of teens and young adults who have experienced dating violence or rape have also attempted suicide compared to 12.5% of youths without a history of abuse (19). Domestic violence also increases the risk of pregnancy and STIs which can have a more extreme and lasting impact on teens, affecting reproductive or sexual health for the rest of their lives.  

For older adults, the risks are increased as well, with elderly victims of abuse having a shorter lifespan than their peers who are not abused. Mental health effects such as depression, anxiety, fear, isolation, loss of self-esteem, and feelings of shame, powerlessness, and hopelessness may be exacerbated because people in this age group are already struggling with a lack of independence or isolation from a social network. Overall, this can reduce quality of life and dignity in an already difficult period of decline (21).  

Exposure to domestic violence, even when not directly victimized, also has a lasting impact on health. Children are particularly vulnerable to witnessing or being exposed to abuse:  

• 1 in 15 children are a witness to domestic violence during childhood (of those, nearly 60% experience maltreatment themselves). 
• Homes with both child maltreatment and intimate partner violence often have more severe levels of abuse.  
• 1 in 5 child homicides between ages 2-14 are related to domestic violence cases (15). 

Children who are exposed to domestic violence may experience acute symptoms such as:  

• Anxiety 
• Aggression 
• Sleep disruption 
• Nightmares 
• Bedwetting 
• Concentration deficits or poor school performance 

Over time, children who are exposed to domestic violence are:  

• 3 times as likely to engage in violent behavior as their peers 
• More likely to be either perpetrators or victims in their own future relationships 
• At greater risk of health conditions like obesity, cancer, cardiovascular disease, substance abuse, depression, and unintentional pregnancy (15)

Perpetrators of Abuse 

It is important for healthcare professionals to not only recognize risk factors for victims of abuse, but also risks for becoming a perpetrator of abuse. Truly mitigating risks and reducing the prevalence of domestic abuse requires recognizing and offering services to victims, but also identifying potential abusers and providing interventions to stop abuse at the source.  

Risk Factors 

The conditions that lead to perpetrators becoming abusers are nuanced and multifaceted, involving individual experiences, past relationships, attitudes of the person’s community, and societal implications (4).  

Individual 

Individual risk factors are based on lived experiences, existing mental health conditions, and individual stressors. Individual risk factors include:  

• Poor self esteem 
• Low education level 
• Young age 
• Problem behaviors in youth 
• Drug or alcohol abuse 
• Depression or anxiety 
• Poor coping or problem-solving skills 
• Poor impulse control 
• Personality disorders 
• Isolation or few friends, small support network 
• Economic stress such as unemployment or low income 
• Hostile/misogynistic attitudes towards women and strict gender role of male dominance 
• Being physically or emotionally abused as a child 

Relationship 

Relationship risk factors are based on the characteristics of the people involved in the relationship and their attitudes and behaviors within the relationship. Relationship risk factors include: 

• Relationships with frequent jealousy, possessiveness, tension, or divorces and separation 
• One partner with clear dominance or control the majority of the time 
• Families undergoing economic stress or low income 
• Network of peers in aggressive or violent relationships 
• Parents with low education levels 
• Witnessing violence between parents during childhood 

Community 

Community risk factors are based on the attitudes and social norms of people in the neighborhoods, workplace, or schools a person is involved in. Community risk factors include:  

• High poverty and low education rates 
• High unemployment rates 
• High crime/violence rates 
• High drug use 
• Low sense of community among neighbors 

Societal 

Societal risk factors are based on the attitudes and political policies where a person lives on a broader scale, including city and state level. Societal risk factors include (4):   

• Emphasis on traditional gender roles (women at home/unemployed/submissive, men work and make family decisions) 
• Cultural norms of aggression 
• Weak education, health, and social policies or support 

Protective Factors 

There are some factors that are protective against becoming a perpetrator of abuse, even for people who may have grown up around domestic abuse. Protective factors include (4):  

• A strong social support network 
• Exposure to strong, positive relationships 
• An involved and neighborly community 
• Available services and resources within a person’s community 
• Access to stable and safe housing 
• Access to medical and mental health care 

The Cycle of Abuse 

In addition to recognizing who may become or be an abuser, it is important to understand and recognize the pattern or cycle of abuse and how perpetrators maintain control in the relationship. While each abuse scenario is unique, the overall patterns are the same and exist in a cycle which may progress quickly or over longer stretches of time. The four main stages are tension, incident, reconciliation, and calm (10). 

Tension Phase 

During the tension phase, there is a slow increase in the frequency and intensity of irritability, short temper, emotional outbursts, and impatience. There may be external factors such as life stressors, financial strain, work struggles, etc. that make the abuser feel out of control, adding to this rising tension. Victims may report “walking on eggshells” during this time, as they feel the tension build (10).​​​​ 

Incident Phase 

Once the tension builds to a breaking point, one or more abusive incidents will occur. Abuse perpetrators do not have an “anger problem” as they are able to control their emotions in places like work, school, or in public. The anger and aggression displayed by a perpetrator is an intentional use of power to regain or maintain control over the weaker partner in the relationship. Incidents can look like (10):  

• Intimidation 
• Threats 
• Physical violence 
• Sexual violence 
• Verbal violence (insults, name calling) 
• Shaming/humiliation 
• Blaming 
• Social isolation 
• Manipulation 

• Financial abuse 
• Emotional abandonment  

Abusers can use many methods of violence and a variety of tactics within each of those methods. The ultimate goal of all behaviors is to maintain control over the victim and remain in a position of power. Figure 1 below provides examples of specific behaviors within each type of violence.  

Figure 1. Domestic Abuse Intervention Programs (3) 

Reconciliation Phase 

Once the incident is over, the perpetrator feels a relief of tension, though the victim likely is at peak anxiety. The abuser may seem to show remorse in the form of apologies, affection, or promises to never become violent again. Victims are often willing to give abusers another chance during this stage because they seem to show genuine remorse or intent to reform (10).​​​​ 

Calm Phase 

Next the relationship moves into a calm phase where the perpetrator’s remorse dissipates, and they may begin to dismiss the incident by shifting blame or saying things like “it wasn’t really that bad.” For the victim, this can be confusing or feel like a letdown when the abuser’s previous intent to make changes fades. This eventually shifts back into rising tension and the cycle repeats itself (10).​​​​ 

Role of the Healthcare Professional in Abuse 

Given all of this knowledge about who is at risk and what goes on in an abusive relationship, you may be wondering how healthcare professionals can help or what your role entails. The responsibility of the healthcare professional lies in a few main areas of identifying and handling abuse situations.  

Risk Identification 

One of the first steps in disrupting the abuse cycle is identifying those most at risk. Part of this is through knowledge of risk factors and vulnerable populations and signs of abuse, as already covered in this course. Another means of identification is through routine screening of certain populations. Unfortunately, there is a limited number of screening tools available, and tools are almost exclusively targeted at women of reproductive age. Available tools assess for domestic abuse within the last year; there is no recommended appropriate interval to administer screening and it is at the provider’s discretion, though at least annually is typical (24). S​​​​ome examples of available screening tools include: 

• HARK (Humiliation, Afraid, Rape, Kick): A four-question tool that assesses emotional and physical violence 
• HITS (Hurt, Insult, Threaten, Scream): A four-item tool that assesses the frequency of domestic violence 
• E-HITS (Extended version of HITS): Includes an additional question to assess the frequency of sexual violence 
• PVS (Partner Violence Screen): A three-item tool that assesses physical abuse and safety 
• WAST (Women Abuse Screening Tool): An eight-item tool that assesses physical and emotional abuse from domestic partner (24)​​​​