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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. 

Infection Control and Barriers

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. 

Nurse Burnout

Introduction   

In May 2022, during Mental Health Awareness Month, the United States Surgeon General Dr. Vivek Murthy issued a new Surgeon General’s Advisory highlighting the urgent need to address the health worker burnout crisis nationwide. Citing existing challenges in the healthcare system and the long-term effects of the coronavirus pandemic, Dr. Murthy prioritized our healthcare workers' mental health to strengthen our nation’s public health infrastructure.  

This report stated that “…. up to 54% of nurses and physicians, and up to 60% of medical students and residents, suffering from burnout”.  Symptoms of burnout have indeed impacted the current workplace, and ongoing employee mental and physical exhaustion results in a vulnerable, compromised workforce (2).  

The lingering effects of post-pandemic burnout have affected every element of our current healthcare system. Healthcare professionals are leaving the profession at an alarming rate (due to illness and scheduled retirement), which translates to increasing shortages of providers. Coupled with additional vacancies due to ongoing mental health conditions (depression, anxiety, post-traumatic stress disorder), our healthcare system is experiencing significant gaps in its ability to provide quality care across the healthcare spectrum.   

While the legislature addresses healthcare burnout on a larger scale, nurse professionals owe it to themselves to recognize the signs and symptoms of nurse burnout and take appropriate action to protect themselves, their families, colleagues, and patients.  

Nurse Burnout vs. Compassion Fatigue 

Although the terms “nurse burnout” and “compassion fatigue” are often used interchangeably, they do refer to two separate conditions (4). Nurse burnout is the term used to describe emotional and physical exhaustion related to ongoing stressful working environments and associated responsibilities. Burnout has a gradual onset and usually occurs in behaviors such as decreased workplace productivity and persistent feelings of hopelessness, helplessness, and overwhelming exhaustion. 

Compassion fatigue, on the other hand, often emerges from some prolonged emotional stress or strain. It may occur after exposure to a traumatized individual more so than a workplace trauma. Signs and symptoms of compassion fatigue may manifest in such behaviors as anger, irritability, increased anxiety, and physical exhaustion. In comparing burnout to compassion fatigue, burnout appears to gradually rise to the surface, while compassion fatigue occurs more suddenly (5).  

Life As a Nurse 

An average day in the life of a nurse will include varying degrees of stress and long work hours. Both factors are known to affect one’s mental health, yet it is considered “a normal day’s work” when describing a day in the life of a nurse.  

In any workplace setting, a nurse's role includes a very demanding set of acceptable stressors (“part of the job”). Upon completing a highly stressful workday, nurses may head home to face additional demands on their time and energy levels (child/elder care, various household responsibilities, and community and church obligations, to name a few). This routine leaves little time for rest and recovery, both mind and body. 

All those demands on their time and attention can lead to compassion fatigue. The pandemic is a convincing example of both nurse burnout and compassion fatigue. Nursing professionals were repeatedly exposed to critically ill patients, many of whom did not survive. Staffing patterns were suboptimal, critical care beds and equipment were sorely lacking in some areas, and the daily stressors felt during a single shift seemed to repeat themselves. There was no quality “downtime” for nurses to take a well-deserved break, much less debriefing and regrouping/refocus efforts.  

This pandemic, a universal “once in a lifetime” event by any standard, affected everyone at some level. Nurse professionals were witnessing traumatic losses of life every day. Compassion fatigue, understandably so, began to surface. The healthcare community experienced anger, irritability, and increasing levels of anxiety. They took to the news media, voicing feelings of isolation, despair, anger, and devastation. They publicly spoke of sleep difficulties, increased workloads, and lack of appropriate lifesaving supplies, thus becoming more exhausted and cynical with each passing shift. When the pandemic crisis finally came under control, the landscape of nursing looked quite different (6).  

Nurses had resigned, transferred, or walked off their shifts. Early retirements and medical leaves of absence were increasing in number. Enrollments in nursing schools were down. The healthcare arena continues to suffer years later, looking for solutions to “heal thyself.”  

So, the question remains…. What can we do to reduce the risk of nurse burnout moving forward? 

Burnout Risk Factors

While no single factor causes nurse burnout, there are undoubtedly identifiable risk factors and patterns that heighten the risk. Early identification and intervention of such risk factors lower the chances of nurse professionals suffering personally and professionally. 

Increased workloads (due to staff call-ins, lack of patient care equipment, and lack of ancillary help) are a leading causative factor in nurse burnout. In addition, lack of support from senior leadership, unit managers, worksite colleagues, and other members of the organizational healthcare team impacts feelings of helplessness and hopelessness.  

Again, there is no single factor to point blame at, but there are often patterns of behavior that warrant further investigation at the workplace. In addition, nurse burnout is very individualized. What is harmful and hurtful to one nurse may not be seen as such to another nurse.  

The goal is to make the workplace environment supportive for all employees by creating (and nurturing) a culture that welcomes nursing input. By recognizing the bigger picture of individual and organizational safety, the nurse in crisis feels safe in stepping forward and seeking professional help in a supportive environment. 

While nurse burnout can occur in any area of nursing, from hospitals to clinics to home health settings and beyond, some areas are at higher risk for burnout. Nursing professionals in the intensive care and emergency care units are at higher risk for symptoms of burnout.  

Studies have shown that many specialty nurses experience anxiety, increasing exhaustion, and mounting frustration while on duty. Combined with a patient population often experiencing high rates of trauma-related mortality and complex illnesses, it is understandable that “typical workdays” may be filled with extremely high levels of workplace stress. 

Causes of Burnout 

An article published in the Journal of the American Medical Association identified some causes that directly impact nurse burnout (7). The authors found that nurses who routinely worked longer shifts (extra shifts, mandated overtime shifts) and experienced sleep deprivation exhibited symptoms of burnout. The combination of excessive work hours and inadequate sleep (as often occurred with shortened turnaround times and back-to-back shifts) resulted in increased patient care errors. These occurrences often compounded the feelings of helplessness and hopelessness (8).   

 Impact on (Individual) Health 

In the early stages of burnout, the nurse professional may feel overworked, underappreciated, and physically tired. While such symptoms may appear benign when occurring sporadically and “chalked up” to “just having a bad day,” repeated shifts like this may manifest into a more profound feeling of despair.  

It soon becomes challenging to continue working under such circumstances, further escalating the situation. To distance oneself from these feelings, the nurse professional may become cynical and jaded about their workplace, mentally distancing themselves from colleagues. These efforts only serve to isolate the individual further and exacerbate feelings of hopelessness and isolation while negatively impacting workplace efficacy (9).  

 Impact on Workplace/Organization Health 

The stressed out, overworked, and exhausted nurse professional may unknowingly / unintentionally compromise the quality of care. Feelings of helplessness and hopelessness can negatively affect the nurse’s judgment and critical thinking skills. Critical steps/tasks may be skipped when the nurse is tired and overworked.   

Nurse burnout negatively impacts job satisfaction and, in doing so, also negatively impacts patient care. The effect will be poor patient care, increased patient and family complaints, and poorer patient outcomes. Nurse burnout affects not only the individual but the organization. (10) 

Self-Care Strategies 

“I have come to believe that caring for myself is not self-indulgent. Caring for myself is an act of survival.”
— Audre Lorde (3). 

What is self-care? (12)  

In the most basic definition, self-care refers to doing things that will improve your physical and mental health. It is very subjective, and self-care strategies must focus on your needs, wants, and desires. As stated, nurse burnout is very individualized: what profoundly affects one nurse may not even bother the next nurse.  

The strategies discussed here are generic; they must be personalized to fit your specific needs and healing process.  

• A good night’s sleep: Limit caffeine intake before bedtime, no electronics 1-2 hours before sleep, lower room temperature to facilitate comfortable sleep, and blackout curtains. 
• Physical activity: Light-impact activities such as swimming, yoga, walking, bike riding, and other activities will be physically and mentally beneficial. 

• Diet: Maintain a balanced diet. Monitor hydration levels and limit caffeine products. The goal is to nourish your body to offset the adverse effects of stress. Cut down on processed food intake and “junk foods.”  
• Mental health: Journaling, podcasts, music, and joyful hobbies and activities (knitting, crafts, painting).   
• Homefront Maintenance: Calm surroundings foster the healing process. Keep the environment clean, uncluttered, and welcoming. Empty the sinks and dishwashers, fold the laundry, and make your bed. Aromatherapy, lighted candles, and essential oils are all ways to make your home a place to rest and relax. 

The list of “self-care “strategies is endless. Be sure to find an appropriate diet, activity, and behaviors that enable you to focus on building a balanced lifestyle. 

Organizational Strategies   

Healthcare organizations must provide structured support for their nurse professionals to ensure quality patient care.  Facility-wide strategies work best to identify and treat nurse stress and burnout early. 

• Nursing rounds- routinely meet with nursing staff and listen to their feedback. Ask the difficult questions (staffing patterns, scheduling issues) and be receptive to working on viable solutions.  
• Support staff in utilizing earned days off, vacation time/ paid time off.  
• Open lines of communication with staff experiencing signs of nurse burnout or compassion fatigue. Offer alternate job duties and work assignments if possible. 
• Acknowledge employee organizational loyalty (through retention bonuses, additional days off, gift cards, personalized thank-you letters, and personal development endeavors). 

• Encourage critical debriefings for staff members involved in essential/traumatic patient care encounters. 
• Openly promote facility resources available to staff, including all Employee Assistance Programs. 

Case study 

Marie is a 35-year-old Registered Nurse working full-time on a 16-bed ICU unit. She has been employed here for three years, beginning her employment at the start of the coronavirus pandemic. Marie works 12-hour shifts (7p-7a) with every other weekend off. Two of Marie’s nurses' coworkers recently resigned, leaving the unit chronically short-staffed.  

Marie has been working additional shifts to help her coworkers and has just completed a 50-hour work week. She was once again called into work early and arrived on only 4 hours of sleep the night before. The unit is at total capacity with 2 “ICU holds” in the Emergency Department. Marie has fallen behind on her patient care while intercepting repeated calls from the ED staff.  

Marie spent a long overdue break crying in the nurse's lounge. She confided to another staff member (Anne) that she is exhausted and overwhelmed by these work conditions and is considering resigning. Anne told Marie to take a few more minutes for her break and promised to discuss the situation with their charge nurse, Carol. Marie agreed.  

Anne discussed the situation with Carol, stating Marie is a great nurse who has been working too many shifts lately. Anne offered to pick up some of Marie’s current patient assignments to lower Marie’s stress level, hopefully. Carol approved and also took some of Marie’s patients. Marie finished her break, apologized to her coworkers for her “moment of weakness,” and promised, “it wouldn’t happen again.”  

 Resources 

The following links are provided for additional information on nurse burnout surveys. 

• MBI- Human Services Survey for Medical Personnel. 
• Burnout Self-Test 
• Maslach Burnout Inventory 

Conclusion

The healthcare workforce continues to be challenged by large numbers of scheduled retirements, an aging population, and medically complex patients. Nurse leaders must proactively hire and retain a healthy workforce (13). Healthcare organizations must invest in a workplace culture that supports workers' work/life balance. It is the key to ensuring the health and safety of our nation. 

Bullying in Nursing

Introduction   

In a time when bullying has become one of the most frowned upon behaviors, why is it thriving in the world of nursing? We’ve all heard the saying that “nurses eat their young”. It is a term that has been passed down the nursing ranks as each generation of nurses enters the workplace; unchanged and still true. We, as nurses, cannot permit such unhealthy and detrimental behavior to continue. In this course, we will discuss nurse bullying, why it happens and what we can do to break the curse. 

Definitions 

To fully understand nurse bullying and the issues that come with it, we must define some terms and phrases so that we are all on the same page.  

Nurse Bully 

A nurse bully is someone who repeatedly harasses and/or harms other nurses whom they believe they can dominate; they may also see them as less skilled or incompetent (5).  

Incivility 

Incivility is a type of lower-level bullying that entails more passive types of behavior. This is your mocking, gossiping, alienation, and general rudeness. The difference between incivility and actual bullying is that incivility may not actually harm the victim (6). 

Harassment 

Harassment is when someone torments or intimidates another person (4). 

Incidence Rate 

The nursing profession has historically been known as the most trusted profession. Nursing is also synonymous with caring and compassion. From the outside looking in, it may be difficult to believe that bullying could exist in such a respected and revered profession. The prevalence of bullying in nursing is staggering. Both new and seasoned nurses; young and old; nurses of every gender; and nurses of every walk of life report that they have been bullied on the job. These instances represent a wide variety of bullying behaviors which include verbal abuse, threatening, scapegoating, sabotage, and physical abuse (5). 

Incidence rates of bullying in nursing, as documented in a variety of studies, ranging from 17-85%. This includes incidents of verbal abuse, threatening, belittling, and even physical abuse.  With the prevalence of bullying so high among nurses, it is safe to say that virtually every nurse has been touched by bullying, whether victim, perpetrator, or observer (5). 

Why Does It Occur? 

What drives bullying behaviors? What makes a bully? There are a myriad of factors that come into play when discussing why bullying occurs.  

Anger and frustration are two strong emotions that can contribute to bullying behaviors. In today’s nursing work environment, anger and frustration are at the forefront of many nursing units. Nursing shortages have left many units understaffed and the nurses overworked. This frustration leads to anger when the nurses who have remained loyal, full-time staff see travelers come into their areas making higher pay. Lack of resources and the belief that they are unheard of also contribute to feelings of frustration (5). 

The belief that another nurse is less competent or altogether incompetent can also lead to bullying. When it is perceived that another nurse can’t do their job and therefore may leave tasks for the oncoming shift, the above-mentioned frustration sets in and bullying may result. Just the feeling of superiority over another nurse can have bullying effects on the nursing environment (1). 

Risk Factors 

There are some circumstances that contribute to the bullying climate. These are not excuses that give permission to the bullies, rather they are risk factors that have been identified as possible catalysts to bullying behaviors. 

Seniority 

Some nurses may feel that they have “paid their dues” and should have authority over their less-experienced peers. If this authority is not granted, the senior nurse may harbor feelings of underappreciation and lash out by being unhelpful or, to the extreme, harmful. The aim is to show how much this nurse is needed; they will refrain from helping the newer nurse or giving any advice (5). 

Insecurity 

When new nurses come into the workplace, the existing nurses may feel that they will be replaced. Nursing is an ever-evolving occupation with new technologies and treatments being developed all the time. A new nurse who was taught the most up-to-date trends in nursing may pose a threat to their job. This is when the nurse may start to bully the new nurse joining the team (1). 

Protection 

Some nurses become very attached to their patients. They may feel that no one else can give the same level of care that they can. As a result, they may see other nurses as incapable of providing care that is up to their standards. Only they can provide the care that their patients require. These perceived inadequacies can quickly turn into bullying behaviors (1). 

Education 

Differences in levels of education may also contribute to bullying. Nursing has many different levels of education and nurses from all these levels may work together on a single unit. Nurses with higher levels of education may feel superior and lash out at those with less education. RNs may treat LVNs differently than their RN peers (3).  

Types of Bullying 

It is important to note that not every bullying-type behavior can be construed as actual bullying. We all have bad days when things just don’t seem to be going right and we may react inappropriately. One of the key factors that differentiates bullying from a lapse in judgment is that bullying is a repeated or habitual behavior.  

This does not excuse the one-time behavior however, we must realize that not all poor behaviors are bullying. Nurse bullying may manifest itself in a variety of different behaviors. Below, we will discuss a few of these types of bullying. This is by no means an exhaustive list of all possible bullying behaviors; they are some of the behaviors that you may commonly see in the healthcare environment (5). 

Verbal abuse 

This may include being rude, belittling, criticizing, and threatening. We’ve all heard “sticks and stones may break my bones, but words will never hurt me”. This is a false saying as constant verbal abuse plays with our psyche as we rerun the taunts in our heads over and over. If heard enough, we may start to believe the bully’s words. 

Controlling 

Constantly telling another nurse what to do and how to do it. This is unsolicited advice that if not taken may escalate bullying behaviors. Controlling behaviors may also include certain “looks” and intimidating posturing. 

Ignoring/excluding 

Ignoring requests for help. Ignoring any suggestions to better provide care to the patients. Excluding that one nurse from lunch plans, work-related activities, or any after-work gatherings. 

Assigning heavy workloads 

Repeatedly assigning a nurse a heavy workload while everyone else’s load is relatively light. All the other nurses have time to sit and document while the one nurse is overwhelmed. 

Physical abuse 

Unwanted physical contact is usually violent in nature.  

Mobbing

This happens when a group of bullies band together to create an environment to force the victim to resign (2).  

Characteristics of a Nurse Bully 

Nurse bullies come in all shapes and sizes and come from all walks of life. There isn’t necessarily a template for what a nurse bully will look like. However, there are some characteristics that may help identify a nurse bully.  

You may encounter a nurse who bullies out of a sense of superiority. They will be condescending and have an entitled attitude. You will also recognize them by their “correcting comments” often spoken where others can hear. Next, we have nurses who bully because they have been offended by something said or done. They bully with an ax to grind. They may hold on to the grudge for a long time. Creating drama with the victim at the center will be their course of action; they will try to pull in other nurses to help ostracize their victim. Other nurse bullies will use rumors and gossip to bully their victim (3) 

These bullies love to dish out the put-downs but can’t take any back. They will become offended at the slightest criticism. There are others who will be very friendly at first. Bringing the victim in close to learn details of their lives and then using that information against them. They will weaponize all obtained information to lift themselves up.  Another characteristic is envy. There are those bullies who are envious of others. The envy could stem from something totally unrelated to nursing or the workplace. The victim, however, will most likely possess the item or characteristic that the bully is envious of. This bully is very bitter. Finally, there is the bully who plays favorites. They will favor their clique and ignore or exclude the victim (3). 

What Can You Do? 

There are many actions that you can take when you are either the witness or victim of nurse bullying. Though some bullies may be intentionally trying to intimidate a fellow nurse, there are those who are oblivious to the fact that they are bullies. They behave like a bully without knowing that they are perceived as such.  

The first action that you may want to take is to talk with the bully about the behavior. The bullying may end there. Once it has been brought to the bully’s attention that the behavior is being taken as bullying, change can occur. Communication may be all that is needed (5). Prior to speaking with the bully, try using empathy. Put yourself in the bully’s shoes to figure out what the motive for the behaviors may be. This may aid you in both the tone and direction of the conversation. 

Identifying a mentor in the workplace can also help you through a bullying situation. Having someone that you can talk to about the issue and seek their advice about how to handle the situation. Look for those nurses who can’t be bullied. Why do the bullies not prey on them? Why are they not intimidated? Often, these nurses are focused on the patient’s needs above all else and refuse to allow any situation to be about them or the bully (3). 

Talking with your manager or director is another prudent course of action. It is possible that these nurse leaders have the best vantage point to deal with and prevent nurse bullying. They work closely with the front-line staff nurses and should have the pulse of the unit. In their position of authority, they are also able to investigate and, if needed, conduct disciplinary actions.  

Unless your manager or director is the bully, a meeting with them to discuss any instances of bullying is needed. Contacting the Human Resources department is another step that can be taken. No matter the situation, it is always important to follow your facility’s policies and procedures and chain of command (3). 

Solutions to Nurse Bullying 

Nurse bullying has repercussions throughout the entire facility. According to a study from 2012, the cost for each individual who is bullied can be from thirty thousand to one hundred thousand dollars (3). This includes the cost of absenteeism, lower work performance, any therapies needed for physical and psychological issues, and increased turnover due to ongoing bullying.  

Nurse bullying can also play a big part in the overall feeling of “burnout” among nurses. Nurse bullying can lead to workplace errors which means it is crucial that organizations have strategies to combat any kind of bullying in the workplace. As nursing accounts for the majority of employees at most hospitals, curbing nurse bullying should be in the forefront. Here are some organizational strategies that should be considered: 

Culture of Safety 

Many organizations have adopted a “Culture of Safety”. The Culture of Safety promotes patient and colleague safety. It is the shared beliefs and values of the organization that influence behaviors and actions. Principles such as non-punitive reporting, communication of policies and expectations, recognition, and leadership modeling of behaviors all come into play in the Culture of Safety. All reports of bullying should be taken seriously (3). 

Admit that there is a problem 

Like any issue, the first step in fixing it is admitting that the problem exists in the first place. Bullying thrives in the darkness. Once it is brought to light and people are talking about it, it can be addressed. Even if there is no evidence of nurse bullying in your area, talking about and discouraging it may stop it from even starting (3). 

Elimination 

Try to eliminate factors that promote an environment of bullying. 

Commitment 

The organization should commit to a zero-tolerance policy when it comes to bullying. The policy on bullying should outline clear expectations along with the consequences that will be enforced if the policy is not followed. The policy should also include the organization’s social and online media sites (3). 

Accountability 

Nurses should be encouraged to hold each other accountable. You promote what you permit. As there are generally more bullying witnesses than actual bullies, nurses must be empowered to call out bullying. This can lead to a true change in the culture of an organization (3). 

Conclusion

Nurse bullying is a real problem that can affect any unit in any hospital. It creates a toxic work environment that we, as nurses, can no longer tolerate. In this post-COVID time, nursing shortages and nurse burnout are rapidly depleting the nursing ranks. It is time for nurses to call out bullying when they see it. It is time for nurse leaders to enforce the organizational consequences of nurse bullying.  

We must create safe environments for our new nurses (all nurses) to thrive. It is the only way that our profession will survive. Know the signs of nurse bullying and become the change within your organization. Empower your colleagues to do the same. Together, we can see an end to nurse bullying. 

Quality Improvement for Nurses

Introduction   

Welcome to the world of Quality Improvement (QI) in healthcare, a dedicated field committed to continually enhancing patient care and outcomes. Quality Improvement involves a systematic approach to identify, analyze, and address areas for improvement within healthcare processes, ultimately resulting in improved patient safety, satisfaction, and overall healthcare excellence (13). In this course, we will embark on a journey to explore the fundamental principles and practical applications of QI, explicitly tailored for nurses who aspire to make a positive impact in their healthcare settings.

As a nurse, you know the significance of providing high-quality patient care. However, you may wonder how you can actively contribute to improving the systems and processes in your workplace.

Imagine this scenario: You observe a recurring issue with medication administration, where doses are occasionally missed due to workflow inefficiencies. Through this course, you will acquire the knowledge and skills to apply QI methodologies like Plan-Do-Study-Act (PDSA) cycles to investigate such issues, implement changes, and monitor the impact of your interventions. By understanding QI principles and tools, you will be better equipped to collaborate with your colleagues, drive meaningful improvements, and ensure that your patients receive the best care possible.

What is Quality Improvement?

Quality Improvement (QI) in healthcare represents an ongoing, systematic effort to elevate the quality of patient care and healthcare services that involves identifying areas needing improvement, implementing changes, and evaluating the effects of those changes to ensure better patient outcomes (12).

Let’s envision a scenario where a hospital's surgical department grapples with a higher-than-average rate of post-operative infections. Through a QI initiative, the healthcare team can meticulously scrutinize the surgical processes, pinpoint potential sources of infection, and introduce evidence-based practices such as enhanced sterilization techniques or more rigorous antibiotic prophylaxis protocols. Over time, they can gauge the effectiveness of these changes by monitoring infection rates for a reduction.

Commonly used QI methodologies in healthcare include the DMAIC (Define, Measure, Analyze, Improve, Control) process and the Plan-Do-Study-Act (PDSA) cycle. These approaches provide structured frameworks for healthcare professionals to tackle issues systematically and iteratively. For example, imagine a bustling primary care clinic with extended patient wait times.

Here, the PDSA cycle can come into play using the systematic iterative steps below:

1. The team defines the problem (lengthy wait times)
2. The team proceeds to test a change (for example, adjusting appointment scheduling)
3. The team then scrutinizes the results and acts accordingly to refine the process.

History and Background of Quality Improvement 

The history and background of Quality Improvement (QI) in healthcare have a rich and evolving timeline, dating back to the early 20th Century, with significant developments occurring over the years. One pivotal moment in this journey was the introduction of statistical quality control by Dr. Walter A. Shewhart in the 1920s (24). Dr. Shewhart's pioneering work laid the foundation for using statistical methods to monitor and enhance processes, a concept that would become integral to QI initiatives (24). 

In the mid-20th Century, the contributions of Dr. W. Edwards Deming further propelled QI principles forward (7). Dr. Deming emphasized the significance of continuous improvement, active employee engagement, and process variability reduction. His ideas found fertile ground in post-World War II Japan, playing a crucial role in the nation's economic recovery and the emergence of renowned companies like Toyota, famous for its Toyota Production System (TPS), incorporating QI concepts (7). 

Until today, QI has become indispensable to healthcare systems worldwide (16). To illustrate, envision a scenario where a hospital grapples with a high readmission rate among heart failure patients. By scrutinizing historical data and implementing evidence-based protocols for post-discharge care, hospitals can effectively lower readmissions, enhance patient outcomes, and potentially evade financial penalties under value-based reimbursement models (16). 

Models 

At the heart of ongoing transformations in healthcare lies various Quality Improvement (QI) models. These models provide structured frameworks for identifying and addressing areas of improvement within healthcare systems (14). These models offer healthcare professionals a systematic approach to instigate meaningful process changes, ultimately resulting in elevated care quality. See some models below. 

Model for Improvement 

The Model for Improvement is a widely recognized and highly effective framework for Quality Improvement (QI) in healthcare. This is because it empowers healthcare professionals to systematically test and fine-tune their ideas for process improvement, ensuring that changes are grounded in evidence and proven effective (17).  

The Model for Improvement offers a structured and systematic approach to identifying, testing, and implementing changes to enhance healthcare processes and ultimately elevate patient outcomes.  

Developed by Associates in Process Improvement (API), this model revolves around the iterative "Plan-Do-Study-Act" (PDSA) cycle, which forms the foundational structure of QI initiatives (17). The Plan-Do-Study-Act (PDSA) cycle is a systematic approach that guides healthcare teams through quality improvement, and it comprises the four key phases below, each contributing to developing and implementing meaningful changes in healthcare practices (12). 

• Plan: In this initial phase, healthcare teams define the specific problem they aim to address, set clear and measurable goals, and craft a comprehensive plan for implementing the proposed change. For instance, if a hospital seeks to reduce patient wait times in the emergency department, the plan may involve adjustments to triage protocols or streamlining documentation processes. 
• Do: Once the plan is established, the proposed change is implemented, typically on a small scale or within a controlled or pilot environment. This enables healthcare professionals to assess the feasibility and potential impact of the change without making widespread adjustments. 
• Study: The study phase involves rigorous data collection and analysis to evaluate the effects of the change. In our example, the hospital would measure the impact of the new triage protocols on wait times, closely examining whether they have decreased as expected. 
• Act: Based on the findings from the study phase, the healthcare team makes informed decisions about the change. They may adopt the change if it has successfully reduced wait times, adapt it further for enhanced effectiveness, or, if necessary, abandon it.

The PDSA cycle's iterative nature means adjustments can be made, and the cycle repeats until the desired improvement is achieved (12).

Lean Model 

The Lean model, initially conceived in the manufacturing sector, has found considerable success and applicability in healthcare as a potent tool for process enhancement and waste reduction (22). At its core, Lean thinking revolves around the principles of efficiency and value optimization because it focuses on refining processes to eliminate wasteful elements while simultaneously delivering care of the highest quality (22).  

Healthcare organizations have adopted Lean methodologies to tackle many challenges, from reducing patient wait times to improving inventory management and elevating overall patient satisfaction (22). For instance, when a hospital is challenged with prolonged wait times in its outpatient clinic, it can apply Lean principles to systematically analyze the patient flow, pinpoint bottlenecks, and streamline processes.  

This might involve reconfiguring furniture to enhance flow, adjusting appointment scheduling, or implementing standardized work procedures. The ultimate objective is to cultivate a patient-centric, efficient environment that ensures timely access to care while meticulously conserving time and resources. 

Another integral aspect of Lean thinking is the unwavering commitment to continuous improvement and the pursuit of perfection through the systematic identification and eradication of various forms of waste (19). The forms of waste are often categorized into seven types: overproduction, waiting, unnecessary transportation, overprocessing, excess inventory, motion, and defects (19). By keenly identifying and addressing these forms of waste, healthcare organizations not only enhance the utilization of resources but also curtail costs and elevate the overall quality of care delivery. 

Six Sigma model  

The Six Sigma model is a robust and widely adopted healthcare method for improving processes and reducing mistakes (9). It was first used in manufacturing but is now used in healthcare to make processes more consistent and improved by finding and fixing mistakes and inefficiencies (9).  

An example is when a hospital is concerned about the accuracy of medication dosing for pediatric patients, a Six Sigma team might include: indicating the problem, gathering data on mistakes regarding dosing, and finding out why the mistakes happened. The strategy may encompass the implementation of standardized dosing protocols, refining staff training programs, and closely monitoring the medication administration process to ensure that mistakes are eliminated. 

Six Sigma uses a framework called DMAIC (Define, Measure, Analyze, Improve, Control) to make improvements. This framework utilizes data-driven tools to discern problems, quantify their origins, develop practical solutions, and institute control mechanisms to sustain improvements (11). Through this systematic journey, healthcare organizations position themselves to deliver care of elevated quality, curtail costs, and bolster patient safety.  

TeamSTEPPS model 

TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, is a teamwork and communication model designed explicitly for healthcare settings (4). Developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), TeamSTEPPS focuses on improving patient safety by enhancing team collaboration, communication, and decision-making among healthcare professionals (4). 

One key element of TeamSTEPPS is using structured communication techniques to prevent errors and misunderstandings. For instance, during patient handoffs from one healthcare provider to another, TeamSTEPPS emphasizes using a structured tool like SBAR (Situation, Background, Assessment, Recommendation) to convey critical information succinctly and accurately. This ensures that essential patient details are noticed, reducing the risk of adverse events (18). 

In a surgical team scenario, TeamSTEPPS principles can be applied to improve teamwork and communication among surgeons, nurses, and anesthesiologists. The model encourages briefings before procedures to set clear objectives, huddles during surgery to address emerging issues, and debriefings afterward to reflect on the process and identify areas for improvement. By fostering a culture of open communication and mutual respect, TeamSTEPPS contributes to safer, more efficient healthcare delivery (4). 

IOM Six Domains of Patient Care 

The Institute of Medicine (IOM), now known as the National Academy of Medicine, introduced the Six Domains of Quality in Healthcare as a framework to assess and improve the quality of patient care (14). These domains, introduced in 2001, encompass various aspects of care delivery and patient experience, helping healthcare organizations and providers identify areas for improvement (14). The domains serve as pillars for assessing the different dimensions of care delivery, ensuring that healthcare organizations and providers address the holistic needs of patients (14).  

Definitions  

The Six Domains of Patient Care are essential for providing high-quality healthcare. See definitions of each of the IOM's six domains of patient care below. 

• Safe: Safety is the foundational domain, emphasizing the importance of reducing the risk of patient harm. This includes preventing medical errors, preventing infections, and ensuring the safe administration of medications. Healthcare organizations implement safety protocols and engage in continuous monitoring to minimize risks (14). 
• Effective: Effective care ensures that patients receive evidence-based treatments and interventions that result in the desired outcomes. It involves using the best available scientific knowledge to make informed decisions about patient care avoiding unnecessary or ineffective treatments (14). 
• Patient-Centered: Patient-centered care focuses on individualizing healthcare to meet each patient's unique needs and preferences. It involves respecting patients' values and preferences, engaging them in shared decision-making, and delivering care with empathy and compassion (14). 
• Timely: Timely care emphasizes reducing delays in healthcare delivery. It includes providing care promptly and avoiding unnecessary waiting times for appointments, tests, and treatments. Timely care is especially critical in emergencies (14). 
• Efficient: Efficiency in healthcare means maximizing resource utilization and minimizing waste while providing high-quality care. This domain emphasizes streamlining processes, reducing unnecessary costs, and optimizing healthcare resources (14). 
• Equitable: Equitable care underscores the importance of providing healthcare that is fair and just, regardless of a patient's background, socioeconomic status, or other factors. It aims to eliminate healthcare access and outcomes disparities among different patient populations (14). 

Measures 

Measures in the context of the Institute of Medicine (IOM) six domains of patient care refer to the metrics and indicators used to assess and evaluate the quality of care provided in each domain. According to (14), the measures below are essential for monitoring and improving healthcare services. See details below. 

• The "Safe" domain measures focus on tracking and reducing adverse events and medical errors. Key indicators include rates of medication errors, hospital-acquired infections, falls, and complications from procedures. Safety measures also assess the implementation of safety protocols, such as hand hygiene compliance and patient identification bracelets. 
• Measures in the "Effective" domain assess how evidence-based practices and treatments are utilized. These measures include adherence to clinical guidelines, appropriate use of medications, and the success rates of medical interventions. Additionally, outcomes such as patient recovery, remission, or improvement are indicators of the effectiveness of care. 
• The "Patient-Centered" domain focuses on assessing the patient’s experience and satisfaction with care. Patient surveys and feedback are standard measures, evaluating aspects like communication with healthcare providers, involvement in decision-making, and overall satisfaction with the care received. Healthcare organizations also measure shared decision-making and respect for patient preferences. 
• Measures related to the "Timely" domain evaluate the efficiency of healthcare delivery. Key metrics include waiting times for appointments, diagnostic tests, and procedures. Additionally, measures track the timely delivery of urgent care and the avoidance of unnecessary delays in treatment. 
• Efficiency measures aim to quantify resource utilization and the reduction of waste in healthcare. Metrics may include the cost of care per patient, length of hospital stays, and resource allocation efficiency. Improvement in resource utilization and cost-effectiveness are vital indicators of efficiency. 
• Measures within the "Equitable" domain assess disparities in healthcare access and outcomes among different patient populations. Healthcare utilization and outcomes data are stratified by demographics, socioeconomic status, race, and ethnicity to identify and address inequities. Key indicators include access to preventive care, healthcare utilization rates, and health outcomes across various demographic groups. 

Nursing Quality Indicators 

According to (5), nursing quality indicators are essential metrics used to evaluate and improve the quality of nursing care in healthcare settings. These indicators provide valuable insights into nursing practice and patient outcomes, helping healthcare organizations and nursing staff deliver safe, effective, patient-centered care. Let's delve into some key nursing quality indicators and their significance below. 

Patient Falls 

Patient falls are a critical quality indicator in nursing care since they can result in severe injuries and complications for patients (5). As a result, healthcare organizations measure and monitor the rate of patient falls to identify trends and implement preventive measures.  

For example, when a hospital notices an increase in the rate of falls among elderly patients in a particular unit, they may introduce interventions such as nonslip flooring, improved lighting, and patient education as fall prevention strategies to reduce the incidence of falls. 

Medication Administration Errors 

Ensuring accurate medication administration is crucial in nursing practice because medication errors can lead to adverse events, including patient harm or death (5). Nursing quality indicators related to medication administration errors include the rate of medication errors and adherence to medication reconciliation processes (5). For instance, nurses are encouraged to verify patient allergies and cross-check medication orders to prevent errors. If there is an increase in medication errors in a healthcare facility, it may prompt a review of medication administration protocols and additional staff training.

Pressure Ulcers (Bedsores) 

Pressure ulcers are a quality indicator of patient skin integrity since they develop when patients remain immobile for extended periods (5). As a result, healthcare organizations measure the incidence and prevalence of pressure ulcers as an indicator of the quality of nursing care (5).  

Patient Satisfaction 

Patient satisfaction is a patient-centered nursing quality indicator since it reflects the overall patient experience and perception of care (5). Surveys and feedback mechanisms are used to measure patient satisfaction. For example, a scenario might involve patients receiving post-discharge surveys that assess various aspects of their hospital experience, including nurse responsiveness, communication, and pain management. Healthcare organizations can use this feedback to identify areas for improvement and enhance patient-centered care. 

In summary, nursing quality indicators encompass a range of metrics that evaluate nursing care quality, patient safety, and patient experiences. By monitoring and responding to these indicators, healthcare organizations and nursing staff can continuously improve their quality of care, leading to better outcomes and increased patient satisfaction (5). 

Data Collection 

Quality improvement data collection is a critical component of healthcare quality initiatives, providing the necessary information to assess the current state of care, identify areas for improvement, and monitor progress over time (2). Accurate and meaningful data collection enables healthcare organizations to make informed decisions, implement evidence-based interventions, and ultimately enhance patient outcomes. Let's explore the methods of data collection below. 

• Clinical Outcome Collection: Clinical outcome data collection is essential for assessing the effectiveness of healthcare interventions (2). For example, consider a scenario where a hospital is implementing a quality improvement project to reduce surgical site infections (SSIs) following orthopedic surgeries. Data collection would involve tracking the number of SSIs occurring over a specific period and collecting information on patient characteristics, surgical techniques, and post-operative care protocols. By analyzing this data, the healthcare team can identify trends, risk factors, and areas for improvement, ultimately leading to targeted interventions to reduce SSIs. 
• Patient Satisfaction Survey Data Collection: Patient satisfaction surveys are valuable tools for collecting data on patient experience (2). A primary care clinic that aims to improve patient satisfaction may administer surveys to patients after each visit, asking about aspects of care such as communication with healthcare providers, wait times, and overall experience. The collected data can reveal areas of strength and areas requiring improvement. For instance, if survey results consistently indicate longer-than-desired wait times, the clinic can adjust scheduling practices or implement strategies to reduce wait times and enhance patient satisfaction. 
• Process Measures Data Collection: Process measure data collection focuses on evaluating the efficiency and effectiveness of healthcare processes (2). For instance, in a medication reconciliation scenario, a healthcare organization might collect data on the accuracy and completeness of medication lists during care transitions. By tracking the frequency of medication reconciliation discrepancies, they can identify process inefficiencies and implement standardized protocols for reconciliation, leading to safer care transitions and reduced medication errors. 
• Adverse Event Reporting Data Collection: Adverse event reporting is a crucial mechanism for collecting data on incidents that result in patient harm or near misses (2). For example, consider a scenario where a nurse administers the wrong medication dose to a patient but catches the error before any harm occurs. Reporting this near-miss event allows the healthcare organization to investigate the root causes, implement preventive measures, and share lessons learned with the care team to prevent similar incidents in the future. 

Types of Data 

Data types play a crucial role in understanding the current state of care, identifying areas for improvement, and implementing evidence-based interventions (2). Let’s explore the different types of data used in quality improvement below. 

• Quantitative Data: Quantitative data involves numerical measurements and is particularly useful for assessing the frequency and extent of specific events or outcomes (2). For instance, in a hospital's quality improvement project focused on reducing hospital-acquired infections, the team collects quantitative data on the number of infections over time, allowing them to track trends and measure the impact of interventions, such as hand hygiene protocols or disinfection practices. 
• Qualitative Data: Qualitative data provides insights into the "why" and "how" behind healthcare processes and patient experiences (2). This data type is collected through interviews, focus groups, and open-ended surveys. For example, in a primary care setting aiming to improve patient satisfaction, qualitative data may be collected through patient interviews to gather in-depth information about their perceptions of care. Qualitative data can uncover nuances and provide valuable context to complement quantitative findings (2). 
• Patient-Reported Data: Patient-reported data includes information directly provided by patients about their health, symptoms, experiences, and preferences. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are standard data collection tools. In a scenario involving chronic disease management, patients with diabetes may be asked to complete a PROM assessing their quality of life and symptom management. This data helps healthcare providers tailor care plans to individual patient needs and preferences (2). 
• Process Data: Process data track the steps and activities involved in healthcare delivery to help assess the efficiency and effectiveness of care processes. For example, in a surgical quality improvement initiative, process data may include the time from patient admission to surgery, surgical team checklist completion, and adherence to anesthesia protocols. By collecting and analyzing process data, healthcare organizations can identify bottlenecks and areas for improvement in care delivery processes. 

In summary, quality improvement data collection relies on various data types, including quantitative, qualitative, patient-reported, and processed data. Each data type contributes to a comprehensive understanding of healthcare quality and supports evidence-based decision-making to enhance patient care and outcomes. 

Identification Stage  

The identification stage for quality improvement data collection is a critical initial phase where healthcare organizations and teams define what data to collect, why it is relevant, and how it aligns with their quality improvement goals (23). This stage is essential for ensuring meaningful data collection efforts will lead to actionable insights. Let's explore the identification stage in more detail. 

• Defining Objectives and Goals: During this stage, healthcare organizations must clearly define the objectives and goals of their quality improvement initiative (23). For instance, a hospital aiming to reduce readmission rates for heart failure patients may set a specific goal of reducing readmissions by 20% within the following year.  
• Selecting Relevant Metrics: Identifying the right metrics and data points is crucial, and organizations should choose metrics that directly relate to their quality improvement goals (23). Continuing with the example of reducing heart failure readmissions, relevant metrics might include the number of heart failure patients readmitted within 30 days, the reasons for readmission, and patient characteristics. By selecting these metrics, the organization ensures that data collection efforts are aligned with their specific improvement goal. 

• Determining Data Sources: Healthcare organizations must identify where the necessary data will be sourced (23). This may involve looking at electronic health records, claims data, patient surveys, or other sources. For instance, to collect data on heart failure readmissions, the hospital may extract relevant information from electronic health records, including admission and discharge dates, diagnosis codes, and patient demographics. 
• Creating Data Collection Protocols: Establishing clear data collection protocols is essential for consistency and reliability (23). Healthcare teams should define how data will be collected, who will be responsible for data collection, and the frequency of data collection. For example, in a hospital project aiming to improve hand hygiene compliance, data collection protocols might specify that trained observers will monitor hand hygiene practices at random intervals and record their findings on standardized forms. 

By carefully navigating the identification stage, healthcare organizations ensure that their quality improvement data collection efforts are purposeful and aligned with their goals. This sets the stage for collecting meaningful data to drive evidence-based decisions and interventions to enhance healthcare quality. 

Gathering Stage  

The gathering stage of quality improvement data collection is crucial for healthcare organizations to collect the identified data based on their quality improvement objectives and goals (23). This stage involves systematically collecting data from various sources and often requires careful planning and coordination to ensure data accuracy and completeness. Let's delve into the gathering stage in detail below. 

• Data Collection Methods: To gather data, healthcare organizations must determine the most suitable methods for collecting the identified data, which may involve a combination of electronic health records, patient surveys, direct observations, and administrative databases (23). For example, in a quality improvement project aimed at reducing hospital readmissions, data may be collected by reviewing electronic health records to track patient outcomes, conducting patient surveys to gather feedback on discharge instructions, and analyzing administrative data to identify trends in readmission rates. 
• Ensuring Data Accuracy and Consistency: Data accuracy is critical in the gathering stage, and organizations must implement procedures to collect data consistently and without errors (23). For instance, if a healthcare facility is collecting data on medication administration, nurses may use standardized protocols to accurately record medication administration times and doses. Regular training and quality checks may also be implemented to maintain data accuracy. 
• Timely Data Collection: Timeliness is another important aspect of the gathering stage, and data should be collected promptly to ensure it is current and relevant for analysis and decision-making (23). In a scenario involving tracking patient outcomes, healthcare teams may set specific intervals for data collection, such as collecting post-surgical complication data daily or weekly, depending on the project's requirements. 
• Data Security and Privacy: Protecting patient data is a paramount concern in healthcare. As a result, healthcare organizations must adhere to strict privacy and security protocols during the gathering stage to ensure that patient information is handled confidentially and complies with applicable laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) (23). For example, when collecting patient-reported data, organizations may anonymize responses to protect patient identities and comply with privacy regulations. 

By effectively managing the gathering stage, healthcare organizations can ensure that they collect accurate, timely, and secure data that will serve as the foundation for subsequent analysis and quality improvement efforts. 

Analysis stage  

The analysis stage for quality improvement data collection is a critical phase where collected data is processed, examined, and transformed into actionable insights. This stage involves various analytical techniques and tools to identify patterns, trends, and areas for improvement (2). Let's explore the analysis stage in detail below. 

• Descriptive Analysis: Descriptive analysis is the initial step in data analysis, focusing on summarizing and presenting data meaningfully (2). For example, in a quality improvement project aimed at reducing patient wait times in an emergency department, an analysis may involve calculating and displaying key statistics, such as average wait times, 95th percentile wait times, and the distribution of wait times (2). These descriptive statistics provide an overview of the current situation and help identify areas that need attention. 
• Root Cause Analysis (RCA): Root cause analysis is a critical aspect of the analysis stage, as it helps pinpoint the underlying causes of issues or problems (2). In our scenario, if the analysis reveals prolonged wait times in the emergency department, RCA may involve a thorough investigation into the factors contributing to the delays. Potential root causes include staffing shortages, inefficient triage processes, or bottlenecks in diagnostic testing. Identifying these root causes is essential for developing effective interventions. 
• Statistical Analysis: Statistical analysis plays a vital role in quality improvement by examining the relationships between variables and testing hypotheses (2). In reducing hospital readmissions, statistical analysis may be used to identify factors associated with readmission risk. For example, healthcare teams can use logistic regression to analyze patient data to determine which variables, such as comorbidities or medication adherence, are statistically significant predictors of readmission risk. This information can guide the development of targeted interventions for at-risk patients. 
• Benchmarking: Benchmarking involves comparing an organization's performance data with industry standards or best practices to identify performance gaps (2). When a hospital is looking to improve patient satisfaction, benchmarking may involve comparing its patient satisfaction scores to those of similar hospitals or national averages. Identifying areas where the hospital falls behind benchmarks can inform strategies for improvement, such as implementing best practices from higher-performing institutions. 

The analysis stage is critical for transforming raw data into actionable insights and understanding healthcare quality factors (2). Through descriptive analysis, root cause analysis, statistical techniques, and benchmarking, healthcare organizations can gain valuable insights that drive evidence-based decisions and interventions to improve care quality (6). 

Benchmarking 

The benchmarking stage in quality improvement data collection is a crucial phase where healthcare organizations compare their performance against established benchmarks or best practices (1). This gives healthcare organizations a clear understanding of their position relative to recognized standards and allows them to effectively identify areas for improvement, prioritize, and focus their improvement efforts (5). Let's delve into the benchmarking stage in detail below. 

• Defining Benchmarks: In the benchmarking stage, healthcare organizations must define the benchmarks or standards against which they will measure their performance. These benchmarks can be internal (comparing current performance to historical data) or external (comparing to industry standards, best practices, or similar organizations) (1). For example, a primary care clinic seeking to improve appointment scheduling efficiency may choose to benchmark its appointment wait times against industry benchmarks for acceptable wait times. 
• Collecting Comparative Data: Gathering data that allows for a meaningful comparison is critical in benchmarking, so healthcare organizations must collect data from relevant sources to measure their performance against the chosen benchmarks (1). Continuing with the appointment scheduling example, the clinic may collect data on the time it takes to schedule an appointment, the number of scheduling errors, and patient feedback. This data is then compared to industry benchmarks or best practices. 
• Identifying Performance Gaps: The benchmarking process reveals gaps or disparities between an organization's performance and the benchmarks to highlight improvement areas (1). For instance, if the clinic discovers that its appointment wait times are significantly longer than industry benchmarks, this identifies a performance gap that needs to be addressed to enhance patient access and satisfaction. 
• Developing Improvement Strategies: Healthcare organizations can develop targeted improvement strategies once performance gaps are identified. These strategies are based on evidence from the benchmarking process and aim to align performance with or exceed established benchmarks (1). In our scenario, the clinic may implement strategies such as optimizing appointment scheduling processes, enhancing staff training, or using technology to improve scheduling efficiency. 

Change Models in Healthcare 

Change models are essential frameworks used in healthcare, including nursing, to guide and manage the effective implementation of quality improvement initiatives (15). These models offer structured approaches to initiate, plan, execute, and sustain changes in healthcare practice (15). Let’s discuss some prominent change models used in nursing quality improvement below. 

• Kotter's 8-Step Change Model: Developed by Dr. John Kotter, this model emphasizes the importance of creating a sense of urgency, building a guiding coalition, and sustaining the change (15). For instance, in a nursing scenario focused on reducing hospital-acquired infections, the 8-step model would involve creating urgency by highlighting the impact of infections on patient safety, assembling a coalition of nurses and infection control specialists, and sustaining change by monitoring infection rates over time and continually reinforcing hygiene protocols. 
• Lewin's Change Management Model: Lewin's model consists of three stages: unfreezing, changing, and refreezing (15). Let's consider implementing a new electronic health record (EHR) system in nursing. Nurses first "unfreeze" by acknowledging the need for a new system and undergoing training. Then, they "change" by adopting the EHR and adjusting workflows. Finally, they "refreeze" by becoming proficient and maintaining the new system's use as a standard practice. 
• PDSA Cycle (Plan-Do-Study-Act): This model emphasizes iterative cycles of planning, implementing, observing, and adjusting (15). For instance, if a nursing unit aims to improve patient handoffs, they might "plan" by identifying handoff best practices, "do" by implementing changes, "study" by assessing the impact on patient outcomes, and "act" by making further refinements based on their findings. This continuous cycle allows for gradual, data-driven improvements. 
• ADKAR Model: The ADKAR model focuses on individual change management, and this could apply to a scenario where nurses are adopting new pain management protocols (15). Nurses would first need awareness of the change (A), followed by desire (D) to participate, knowledge (K) of how to implement the new protocols, ability (A) to do so, and reinforcement (R) to sustain the change over time. 

In summary, change models provide structured approaches to drive quality improvement initiatives in nursing, and by applying these models, nurses and healthcare organizations can systematically plan, implement, and evaluate changes to enhance patient care, safety, and outcomes (15).

Implementing Change 

Implementing changes for quality improvement in nursing is a multifaceted process that requires careful planning, effective communication, and the engagement of healthcare professionals at all levels. According to (15), successful implementation ensures that desired changes are integrated into daily nursing practice, improving patient outcomes. Let’s explore key strategies and considerations for implementing changes in nursing quality improvement below. 

• Engage Interdisciplinary Teams: According to (15), collaborative engagement is crucial when implementing changes in nursing practice, and healthcare organizations should assemble interdisciplinary teams that include nurses, physicians, administrators, and other stakeholders. For example, in a scenario involving the adoption of a new pain management protocol, nurses can collaborate with physicians to ensure the consistent application of evidence-based pain management practices. This team approach facilitates a shared understanding of the change and fosters buy-in from all parties. 
• Effective Communication: Clear and consistent communication is essential during the implementation phase, so nurses should communicate the rationale behind the change, its expected benefits, and the specific steps involved (15). For example, suppose a hospital is transitioning to a new electronic health record system. In that case, nurses can attend training sessions to understand its features and communicate effectively with patients about how it will enhance their care. This ensures that all stakeholders are informed and can adapt to the change seamlessly. 
• Training and Education: Providing adequate training and education is critical to equip nursing staff with the knowledge and skills to implement the change effectively (15). In the case of introducing a new wound care protocol, nurses would require training on the updated practices, wound assessment techniques, and the use of new wound care products. In addition to initial training, ongoing education would ensure that nursing staff stay current with best practices to provide quality care confidently. 
• Continuous Monitoring and Feedback: According to (15), implementing change is an ongoing process that requires constant monitoring and feedback since feedback mechanisms allow for adjustments and refinements to the change process. As a result, nursing quality improvement initiatives benefit from the regular collection and analysis of data to assess the impact of the change. For example, suppose a hospital introduces a sepsis screening tool. In that case, nurses can track the number of patients screened, identify missed cases, and evaluate whether early interventions have reduced sepsis-related mortality rates. By engaging interdisciplinary teams, fostering effective communication, providing training and education, and implementing continuous monitoring and feedback mechanisms, nurses can successfully implement changes that improve the quality of patient care and enhance overall healthcare outcomes (8). 

Evaluating Change 

Evaluating change for quality improvement in nursing is a critical phase that involves assessing the impact and effectiveness of implemented changes on patient care outcomes, safety, and the overall quality of healthcare services. According to (15), rigorous evaluation ensures that improvements are sustained, and necessary adjustments are made. Let’s explore key strategies and considerations for evaluating changes in nursing quality improvement below. 

• Establishing Clear Evaluation Metrics: To evaluate change effectively, it is essential to define clear and measurable evaluation metrics, and according to (15), these metrics should align with the specific objectives of the change initiative. For example, suppose a nursing unit has introduced a new hand hygiene protocol to reduce hospital-acquired infections. In that case, evaluation metrics may include the number of infections before and after the change, adherence to hand hygiene guidelines, and patient satisfaction scores related to cleanliness and infection prevention. 
• Data Collection and Analysis: Data collection is a fundamental component of the evaluation process, and nursing teams should collect relevant data using standardized methods and tools (15). In our scenario, data on infection rates can be collected regularly, and statistical analysis can be performed to determine whether the change has had a statistically significant impact. Nurses can then use run charts or control charts to visualize trends in infection rates over time, allowing for early detection of any potential issues. 
• Patient and Staff Feedback: Patient and nursing staff feedback is invaluable in evaluating change since patients' perspectives on the quality of care and their experiences following the change can provide insights into the initiative's effectiveness (15). Additionally, nursing staff can provide feedback on the practicality and feasibility of the new practices. For instance, nursing staff may suggest further improvements in infection control procedures. 
• Sustainability and Continuous Improvement: Evaluating change is not solely about assessing immediate outcomes but also ensuring sustainability and continuous improvement. According to (15), nursing teams should determine whether the positive effects of the change are maintained over time and whether there is room for further refinement. For example, when a nursing unit has reduced infection rates, regular audits and monitoring should continue to ensure sustained compliance with hygiene protocols. 

• Enhancing Medication Safety: Medication errors can have severe consequences for patients (6). A quality improvement project may target medication safety by introducing barcode scanning systems for medication administration, implementing double-check procedures for high-risk medications, and providing ongoing training to nursing staff. The project's effectiveness can be assessed by monitoring the number of medication errors reported and verifying that the new safety measures reduce the occurrence of such errors. For example, a nursing team could reduce the incidence of wrong-patient medication administration by implementing barcode scanning during medication administration. 

• Improving Nurse-to-Patient Ratios: Adequate nurse staffing levels are crucial for patient safety and quality of care (6). A quality improvement project may involve adjusting nurse-to-patient ratios based on patient acuity levels, introducing workload management tools, and conducting regular staffing needs assessments. In this case, the project's success can be measured by tracking patient outcomes, nurse workload, and patient satisfaction scores. For example, a nursing unit could reduce nurse burnout and improve patient care by optimizing staffing ratios during peak hours. 

• Enhancing Discharge Planning and Care Transitions: Effective care transitions from the hospital to home or other healthcare settings are essential to preventing readmissions and ensuring continuity of care (6). A quality improvement project may focus on improving the discharge planning process, including patient education, medication reconciliation, and post-discharge follow-up. Success can be assessed by monitoring readmission rates and patient-reported experiences. For example, a nursing team could work on reducing hospital readmissions by ensuring that patients receive thorough discharge instructions and have access to follow-up care. 

The above examples illustrate the diverse range of quality improvement projects in nursing, each addressing specific challenges to enhance patient safety and care quality.

Conclusion

In conclusion, this course provides essential knowledge and skills valuable for nurses aiming to deliver high-quality, safe, patient-centered care. Quality improvement in nursing is not merely a theoretical concept but a practical approach that can be applied to various aspects of healthcare, and one critical aspect to remember is the importance of interdisciplinary collaboration. As frontline caregivers, nurses must collaborate with physicians, administrators, pharmacists, and other healthcare professionals to drive improvements in healthcare delivery.  

As nurses continue to play a pivotal role in healthcare delivery, the knowledge and skills gained from this course will empower them to lead and actively participate in quality improvement initiatives. By applying quality improvement principles, nurses can contribute to better patient experiences, patient outcomes, and overall healthcare quality. 

Final Reflection Questions 

1. What have you learned from this course? 
2. Why is interdisciplinary collaboration essential for nurses to effectively implement quality improvement initiatives in healthcare settings, and how can nurses foster collaboration among healthcare professionals? 
3. How does the concept of continuous learning and adaptation align with the dynamic nature of healthcare, and what strategies can nurses employ to stay current with evolving best practices and guidelines? 
4. In what ways does Quality Improvement benefit both healthcare providers and patients?  
5. What are the potential challenges in implementing QI initiatives in a healthcare organization? 
6. In what ways has QI in healthcare become intertwined with the broader goals of healthcare reform, such as improving patient outcomes and reducing healthcare costs? 
7. What role does leadership play in the effective implementation of QI models? 
8. How can leaders promote a culture of continuous improvement within healthcare organizations? 
9. How do QI models facilitate interdisciplinary collaboration among healthcare professionals to drive improvements in patient care? 
10. What challenges might healthcare organizations face when attempting to adopt and sustain QI models, and how can these challenges be overcome? 
11. How does the "testing and learning" concept in the PDSA cycle align with the principles of evidence-based practice in healthcare? 
12. In what ways do QI models promote patient-centered care and patient safety, and can you provide examples of tangible improvements in these areas achieved through QI initiatives? 
13. How can the Six Sigma model contribute to the reliability and consistency of healthcare processes? 
14. Safe: What steps can healthcare organizations take to minimize the risk of medical errors and adverse events? 
15. Practical: How do healthcare providers ensure that evidence-based treatments and interventions lead to positive patient outcomes? 
16. Patient-centered: Why is it important to involve patients in their care decisions, and how can healthcare professionals effectively engage patients in the decision-making process? 
17. Timely: What are some key factors contributing to delays in healthcare delivery, and how can these delays be reduced to improve timeliness? 
18. Efficient: How can healthcare processes and workflows be streamlined to enhance efficiency and reduce waste? 
19. Equitable: What are some barriers to achieving healthcare equity, and how can healthcare organizations address these disparities? 
20. How can nurses actively involve patients in data collection to enhance patient-centered care? 
21. What tools or technologies are available to streamline data collection processes in nursing practice? 
22. How can nurses effectively collaborate with interdisciplinary teams to gather comprehensive data for quality improvement initiatives? 
23. What strategies can nurses employ to maintain patient privacy and confidentiality while collecting sensitive healthcare data? 
24. What methods can nurse use to analyze and interpret the data they collect to identify areas for improvement? 
25. Why must nurses regularly review and assess the data they collect to drive continuous quality improvement in healthcare settings? 
26. Regarding patient falls, what strategies can healthcare organizations implement to reduce the incidence of patient falls, and how can nursing staff actively contribute to fall prevention efforts? 
27. How can nurses ensure the accurate and safe administration of medications, and what measures can be taken to minimize medication errors? 
28. What are the key nursing practices and interventions that can prevent the development of pressure ulcers in hospitalized patients, and how can nursing staff collaborate to achieve this goal? 
29. Why is patient satisfaction an important nursing quality indicator, and what actions can nurses take to enhance the overall patient experience? 
30. What impact do nurse-to-patient staffing ratios have on the quality of nursing care, and how can healthcare organizations ensure safe nurse staffing levels? 
31. How can nurses enhance patient education to promote better understanding and self-management of their health conditions? 
32. How can you ensure that the data collected is reliable and valid? 
33. What role does standardization play in data collection for quality improvement? 
34. How can you establish baseline data for comparison in your quality improvement project? 
35. What challenges or obstacles might you encounter when collecting data for quality improvement? 
36. How frequently should data be collected to monitor progress in a quality improvement project? 
37. How can you involve frontline staff in the data collection to ensure accuracy? 
38. What measures can be taken to protect patient privacy and confidentiality during data collection? 
39. How can you analyze the data collected to identify trends or patterns? 
40. What actions should be taken if the data collected indicates a problem or deviation from the desired outcome? 
41. What strategies can ensure that data collection remains an ongoing and sustainable practice in healthcare quality improvement efforts? 
42. What are the potential challenges or resistance nurses might encounter when implementing changes using these models? 
43. How can a guiding coalition or interdisciplinary team be effectively assembled to support nursing quality improvement efforts? 
44. What strategies can nurses employ to sustain changes and prevent reverting to previous practices once implemented? 
45. How can nursing leaders ensure that staff have the necessary knowledge and skills to embrace the changes outlined in these models? 
46. How can nurses use these change models to promote a culture of continuous improvement in healthcare settings? 
47. How can nurses ensure their implementation changes align with evidence-based best practices and clinical guidelines? 
48. What potential challenges or barriers might nurse teams encounter when trying to implement changes for quality improvement? 
49. What strategies can address resistance to change among nursing staff and promote their active participation in the implementation process? 
50. How can nursing leaders effectively communicate the expected outcomes and benefits of the change to gain support and commitment from their teams? 
51. What are the advantages of using data and performance metrics to monitor the progress and impact of change implementation in nursing practice? 
52. How can nursing staff ensure that changes are sustained and become integral to their daily practice rather than temporary modifications? 
53. Why is it crucial to consider the sustainability of change when evaluating its long-term impact on nursing quality improvement? 
54. What challenges or obstacles might nurse teams encounter when collecting and analyzing data for change evaluation, and how can these challenges be addressed? 
55. How can nursing leaders encourage a culture of continuous improvement among their teams as part of the change evaluation process? 
56. What strategies can be employed to ensure that the feedback and insights gathered during the evaluation phase are actively used to refine and optimize nursing practices? 
57. What are the potential consequences of not conducting thorough and systematic evaluations of changes in nursing practice for quality improvement? 
58. How can nursing staff and healthcare organizations ensure that the lessons learned from change evaluations are applied to future improvement initiatives to enhance patient care outcomes? 

Workplace Violence Against Nurses

Introduction   

The role of the registered nurse, while fundamentally dedicated to the care and wellbeing of patients, has long been fraught with challenges that extend beyond the complexities of medical care. One such pressing concern is workplace violence, an issue that nurses confront with alarming frequency. Recent statistics show that healthcare workers, particularly nurses, are at a higher risk for workplace violence compared to other professions.  

Given the vital role nurses play in patient care and the broader healthcare system, it is imperative to understand the scope, sources, and solutions to this pressing issue. This continuing education course is dedicated to arming nurses with the knowledge, tools, and strategies to recognize, respond to, and prevent incidents of workplace violence, thereby ensuring their safety and the uninterrupted provision of quality care. 

Workplace Violence  

Definitions 

The Occupational and Safety Health Administration (OSHA) (3) defines workplace violence (WPV for the purpose of this course) as any act or threat of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the work site.  This can also include verbal, written, or acts of sabotage against an individual while they are at work. 

Workplace violence crosses all demographic barriers and is indiscriminate in who it can and does affect. Even seeing workplace violence influences morale, attendance, and the overall well-being of employees and their co-workers.  

Types of Violence  

Currently, there are four categories of workplace violence according to the American Nurses Association (5).  

1: Criminal Intent - normally involves theft from the business or employees. 

Example: Carol is working on documentation and notices a person lingering in the hallway. Carol doesn’t really think anything of it, assuming they are family members of one of the patients. Several minutes later, the person exits quickly from the supply room and down the stairs. Carol calls security to let them know, but they can’t locate the individual. After looking through the supply room, they find that several containers of wound dressing supplies are missing.  

2: Customer/client/patient - the individual becomes violent with employees while receiving services. 

Example: David was updating a family on their father’s critical condition. David could tell the family was upset, but the patient’s son seemed more frustrated than the others. During David’s explanation, the son grabbed David’s clipboard and yelled, “You’re not doing anything! You’re just letting him die!” The son then threw the clipboard at David’s head. David blocked the clipboard with his arm, receiving a rather deep cut as a result. Security became involved, and David had to go to the ER for treatment.  

3: Worker on worker - an employee bullies, attacks, or threatens another employee. 

Example: Emily was rounding when Dr. G. came onto the floor. This doctor was well known for being difficult to work with, and he always required the nurses to stand behind him in the room while he talked with his patients. Emily had one of Dr. G.’s patients today and was in the room, he asked her if the patient had ambulated. Emily told him they had not, but they planned to before and after lunch. The doctor made an audible sigh and while shaking his head at the patient said, “See…this is what I deal with every day. These nurses can’t get anything right. They’re all useless.” 

4: Personal relationship - involves a person who has an interpersonal relationship with the nurse, but no association with the nurse’s employer or the business. 

Example: Rebecca was walking to her car after work. Halfway to her car, she noticed an individual leaning against the trunk of her vehicle. Rebecca recognized this person as the someone her friend was currently dating. This person approached Rebecca aggressively and began yelling about gossiping and trying to break their relationship. Rebecca started back toward the building, hoping security was nearby, and was pursued by the female. Eventually, Rebecca made it to the building and got inside. Luckily, the door only opened with an employee badge, and Rebecca was safe. She went ahead to security.  

Currently, the customer/client type of workplace violence is the most prominent, especially in healthcare and toward nurses. The American Nurses Association (ANA) reports that OSHA does not require employers to implement workplace violence prevention programs, but it supplies voluntary guidelines and may cite employers for not supplying a workplace free from recognized serious hazards.  

Some states have legislated that employers develop a program while most states have advanced laws that amend existing statute for assaults of first responders by adding health care providers / nurses and/or increasing the penalty associated with such behavior. (3) 

It is worth noting that since there are, in most cases, no actual requirements for employers to provide safe work environments for nurses, preventing and dealing with WPV proves problematic. It falls on nurses to understand what constitutes WPV, how to manage it, how to cope with it, how to report it, and how to ensure action is taken and a resolution is reached when WPV occurs.  

Epidemiology 

Workplace violence can take many forms, and the possible varieties and scenarios are endless. Regardless of how it manifests, the effects of workplace violence are clear and widespread. It can affect productivity of employees, morale, attendance, turnover rates, quality of work, patient outcomes, and much more.  

Workplace violence can affect and involve workers, clients, customers, and visitors. WPV ranges from threats and verbal abuse to physical assaults and even homicide. In 2010, the Bureau of Labor Statistics (BLS) data reported healthcare and social aid workers were the victims of approximately 11,370 assaults by persons; a greater than 13% increase over the number of such assaults reported in 2009 (10). Almost 19% of these assaults occurred in nursing and residential care facilities alone. Unfortunately, many more incidents probably go unreported (5). 

Impact on Nurses Well-Being 

Workplace violence can take a heavy toll on nurses. These tolls can be emotional, mental, and physical as well as short-term or long-term. The seriousness of these injuries can vary widely ranging from minor upset to permanent injury and in worst cases, even death. (13) 

This harm doesn’t stop with the nurse. The effects of workplace violence may also include effects spanning the unit the nurse works on or even the entire facility. Low morale, reduced productivity, lack of trust in employers, and fear of going to work can be results of violent events occurring to even a single co-worker.  

Workplace violence can also have a financial effect on nurses and their employers related to lost time at work from injury or callouts, costs of care for treatment related to the incident (physical and/or psychological), or even legal fees. (13) 

Given that incidents of workplace violence are rapidly increasing, these impacts are expected to increase as well. It is easy to see how this harm is widespread and can potentially ripple outward into the nurse’s professional and personal life. The stress and harm do not stay at work, and can spread to the nurse’s family, social interactions, and more. 

Barriers to Reporting 

One way to combat workplace violence is knowledge of its existence, its nature, and its frequency. Unfortunately, there are many factors that either prevent or discourage nurses from coming forward with reports when they are the victims of WPV.  

A study presented in a Chinese nursing journal surveyed 325 nurses. Of these nurses, 266 were spread across 165 hospitals, and these hospitals were in 72 cities.   

A total of 172 nurses (64.7%) experienced violent incidents during the past year. Of these incidents, 45.5% were reported; and the reporting rate of physical assaults (69.0%) was higher than those of verbal abuse (36.9%), threatening behavior (51.7%), and sexual harassment (60.0%). Formal reporting accounted for 25.4% (15.4% in written form and 10.0% through a computer-assisted reporting system. 

 Almost half of the nurses (49.6%) said that the hospital had no reporting system, or they were uncertain about the reporting system. For reasons of not reporting, 51.9% of the nurses were unaware of how and what types of violence to report, and 50.6% of the nurses believed that the hospital paid greater attention to patients rather than staff. (7) 

Interestingly, almost fifty percent of the nurses surveyed had limited knowledge, if any, of a reporting system available to them, while fifty percent felt the hospital favored the patients over their own employees. Combined with an actual or perceived lack of supervisory support, this encourages an environment where nurses feel powerless to protect themselves or to take proper action when threatened or harmed. 

The Minnesota Nurses Association, in August of 2022, published a press release with the results of a nursing survey on the topic of workplace violence. In this survey, ninety-seven percent of the nurses surveyed observed WPV or harassment over the previous two years.  

The top reasons cited by nurses who did not report workplace violence were lack of time due to overwork and under-staffing, cited by fifty-eight percent of respondents, and lack of action by hospital management, cited by fifty-three percent of nurses in the survey. (4) 

It would appear from these studies that many nurses feel it is futile to report incidents of workplace violence they encounter, and even if they realized an incident was reportable, they may not be aware of a way to report it or have time to do it. This perceived powerlessness and sense of futility in the face of abuse and violence will only continue to worsen unless action is taken to remove barriers to reporting and for nurses to have access to aid and support for supervisory staff. 

Culture of Safety 

A commonly used phrase is “Culture of Safety”, but is there a standardized definition of what it is or could be? Many resources point to the safety of patients about medical errors, patient rights, and protecting the patient’s information, but few address the issue facing caregivers and especially nurses. However, there is no agreed-upon or standard definition of what exactly a “culture of safety” is or what it should look like.  

The American Nurses Association approaches the concept by saying, “Establishing a culture of safety in health care is essential to the security and well-being of your patients, staff, and organization. Effective nurse leaders embrace safety protocols that ensure their organization delivers a secure, protective environment that prioritizes patients and caregivers.” (12)  

Currently, there is only a single federal legislation in place about the issue. 

The only federal regulation currently in place is the General Duty Clause of the Occupational Safety and Health Act of 1970. This clause requires employers to supply a work environment free from recognized hazards that are causing or likely to cause death or serious physical harm. However, the general duty clause offers no specific recommendations about management of workplace violence.  

The Occupational Safety and Health Administration (OSHA) issued guidelines for workplace violence prevention for health care and social service workers. First issued in 1996 and later updated, the guidelines are only advisory. (1) 

It is paramount that nurses and other direct care providers accept the responsibility of creating policies and procedures within their organizations to define and enforce a work environment where violence is not tolerated and dealt with accordingly. 

There is currently a small body of research and work of the effects workplace violence has on nurses as human beings. Most of the evidence focuses on how workplace violence increases the risk nurses present to patients in the form of medical errors, staffing issues due to missed work, poor documentation, etc. 

The main body of evidence discussing how workplace violence affects nurses is noted in research around nurse burnout. A 2020 study published by the National Health Institute (10) states, “Workplace aggression is a source of extreme socio-emotional stress, which may lead to the experience of psychological strain.  

A large body of research shows that exposure to workplace aggression and violence may severely impair healthcare workers’ mental health, including symptoms of post-traumatic stress disorder, depression, and burnout.” 

This study also shows an important association with workplace aggression and violence targeting nurses and drastically increased levels of emotional exhaustion, depersonalization, and deep feelings of poor personal accomplishment. Over time, these feelings lead to complete burnout, and even worse, possibly psychological and/or physical conditions in the nurse affected.   

Even with this preliminary information and research, we still have a long way to go to show the full and far-reaching effects of workplace violence on nurses. Again, by being proactive and acting now, we as nurses can foster this research and bring to light the issues so they can be addressed. 

ANA Zero Tolerance Policy 

In 2019 the American Nurses Association (ANA) (2) release a brief titled “Reporting Incidents of Workplace Violence”. In it, they discussed several issues surrounding workplace violence, barriers to its reporting, and made recommendations to healthcare organizations on strategies relating to the issues of workplace violence.  

They also set forth a “Zero Tolerance Policy on Workplace Violence”, which provided some definitions and several recommendations on how to deal with WPV. 

The introduction to the “Culture of Safety” part of this brief is as follows:  

By prioritizing, developing, and sustaining an organizational culture focused on safety, we can drive the future of healthcare to a place where patients and those who care for them are free from harm. It is not only one of many priorities but is the overriding ethical imperatives for all leaders. (9) 

The ANA also suggested a three-level prevention strategy, each with a part for the employer and the employee. Essentially, the role of the employer is gathering data, providing a “safe” work environment, non-punitive reporting, and development of programs to provide a safe work environment for nurses. The employee’s role is to take part in the implementation and evaluation of said programs.  

Unfortunately, these are only suggestions and employers do not have to implement any programs or services to protect employees against workplace violence. Also, healthcare employers do not have to report any incidents to JCAHO who consider events of workplace violence to be “sentinel events”.  

In the end, it falls on the nurses and employees directly affected by WPV to assume the charge against workplace violence, hold employers accountable, communicate with local and state legislators, and effect change to protect themselves. 

Strategies to Prevent Workplace Violence 

To end nurse abuse for good, Boston-Leary says it takes every nurse speaking up and reporting abuse within an organizational culture that has an established process for allowing nurses to report abuse without fear of recrimination and then follows up with a resolution. (8) 

There are some suggested actions to help prevent and combat workplace violence in your practice setting. These actions include: 

Know the definition of abuse.  

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.” 

Agreeing on this definition is an important first step to achieving widespread acknowledgement of the distinct types of nurse abuse, particularly non-physical abuse, Boston-Leary explains. (8) 

Report Abuse 

Ask about how your workplace manages abuse reporting, whether it is in your current workplace or when you are applying for a position, Boston-Leary suggests. “Ask about how reporting abuse happens during any shift because there should be a reporting mechanism in place for everyone, even if it’s on a weekend or evening shift with no manager easily accessible to report to.” 
 
If (when) you do experience abuse, it’s essential that you speak up immediately and note any witnesses who could corroborate your description of the incident, she says. 
 
Even after you experience abuse and even if you didn’t report it, it’s important to share your past abuse with others to empower them to report abuse they experience. (8) 

Change Your Culture 

Join or meet a committee to build or strengthen zero-tolerance abuse policies. Based on ANA’s Zero Tolerance Policy on Workplace Violence, Boston-Leary suggests these crucial elements of a zero-tolerance abuse program: 

Stop violence before it starts through education to find risks and reduce vulnerabilities for workplace violence. 

Create an effective response to violence immediately after it occurs, including emergency care. 

Establish long-term responses that reduce the long-term negative effects of workplace abuse. (8)  

Communicate with your Legislator! 

Congress was considering legislation to #End Nurse Abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R 1195). If approved, this law would have required health care and social service industry employers to develop and implement a comprehensive workplace violence prevention plan that protects nurses and other healthcare professionals from on-the-job abuse. 
 
Boston-Leary believes legislators are very attuned to the trusted voice of nurses to share about what is happening in health care today (8). 

Nurse-led Strategies 

You can join these committees or work with your employer to create them. Collaborating with your supervisory staff and HR, you can create workflows, policies, reporting methods, and provide education on prevention of workplace violence and make a difference in your overall work environment.   

Regarding Your Legislators 

As mentioned before, 2021 Congress was considering federal legislation to end nurse abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195). The bill was passed by the House on April 16, 2021, but was never passed by the Senate.  

You can find your local and state legislator contact information very easily on the internet. A simple search for “how to find state legislator contact information” is a wonderful place to start. As a voting citizen, you have every right to contact them, and demand laws be created to protect you while you work.  

Below are some links to help you find elected officials: 

• https://www.usa.gov/elected-officials 
• https://www.usa.gov/state-governor 
• https://www.senate.gov/senators/senators-contact.htm 
• https://www.house.gov/representatives/find-your-representative 

Advocate for your own safety the same way you would for your patients!  

As nurses we aren’t afraid of stepping up to bat for our patients when they need something, but we are notorious for taking a hit and letting it slide, sometimes even to our own detriment.  

We owe it to ourselves to offer that same level of advocacy to ourselves and our co-workers.  

Resources 

The Joint Commission supplies resources available to report and learn about how to report workplace violence. The links included are for federal, state, professional, and other resources. The direct link to this page is: 

The Joint Commission: Workplace Violence Prevention Resources 

Local law enforcement  

As a private citizen, you are protected by laws about assault, battery, and other attacks on your person. You are within your rights to call the police on events of workplace violence, especially if your life or health are threatened, or you are physically attacked. It is likely your employer will not support you in this situation due to legal implications. It is best to ask your HR department and supervisory staff how these situations should be managed if they occur. 

Legal Counsel 

Consult with a lawyer about your legal rights in situations on workplace violence and how to best manage them. Be sure to bring scenarios, information on how your employer suggests dealing with these situations, and examples of violence you have seen or have experienced.  

Educate and Train Yourself 

Learn as much as you can about recognizing and managing workplace violence. Your employer may supply these courses, and if they don’t, it may be prudent to request them. Also, you can seek outside education and training on these topics including self-defense classes and crisis management courses. 

Practice Self-Awareness 

We all have inherent beliefs, perspectives, and feelings that can prevent us from acting in certain situations. Knowing yourself and understanding possible nuances within yourself that could be a detriment to you appropriately handling a situation of workplace violence could mean the difference between prevention and becoming a victim.   

Conclusion

Being an agent of change can be intimidating, terrifying, and even force us to deal with feelings and beliefs we didn’t even realize were in our way. Incidents of WPV have been rising sharply over the past several years, and there is no sign of slowing. It’s up to us as front-line workers, nurses, and co-workers to take responsibility for our own safety and work environment.  

Through cooperation and consistency, we can create and bring solutions to the workplace and hopefully one day, aid in the creation of laws that make our jobs safer for us to supply the care and support our patients need. We owe it to ourselves to take the necessary steps to show our employers it’s time to address this issue. “Be the change you wish to see in the world.” ~Mahatma Gandhi – 

Telemetry Basics - Rhythm Recognition

Introduction   

To truly understand telemetry, nurses must have knowledge about the anatomy of the heart and how electricity passes through it, how the electrocardiograph (EKG) works to receive and record the electrical activity, and how this information is transmitted via telemetry to the appropriate receiving device.

Defined as the transmission of instrumental readings by various methods such as radio waves or wires, telemetry gathers and transmits EKG readings to a central or remote monitor for interpretation and storage (71). The ability to read EKG rhythms from a variety of monitors consists of more than looking at a rhythm strip and identifying the rhythm. It consists of knowing the anatomy of the heart, how electricity travels through it and translates into the EKG we know, and what changes can happen based on injury, electrolytes, or other causes.

Heart Anatomy 101

As we know, the heart consists of four chambers, two atria—right atria (RA) and left atria (LA)—and two ventricles—right ventricle (RV) and left ventricle (LV)—working in a cycle to ensure adequate blood flow occurs. The heart receives blood from the inferior and superior vena cava (IVC and SVC) and enters the RA, moves to the RV, passes through the pulmonary artery (PA) and lungs, returns to the LA, enters the LV, and exits the heart through the aorta.

Heart cells, known as myocytes, are negatively charged, or “polarized” at rest. When these muscle cells contract, they become “depolarized” or positively charged. But how do the myocytes know when to contract? Less than 1% of the cells in the heart have a special role and name. These are known as the pacemaker cells and their role is to ensure that the heart beats. This is done through the action potential that is spontaneously created by the pacemaker cells. Some of these pacemaker cells have different speeds in depolarization, meaning that the fastest pacemaker cells are the ones controlling the speed. This will make more sense later when discussing specific cardiac rhythms (69).

Starting in the right atria, the sinoatrial node (SA node) is the primary group of pacemaker cells that determines the heart rhythm. The SA node, as well as the other pacemaker cells within the heart, progress through a rapid depolarization and repolarization process (2).

Pacemaker cells do not have a true resting potential, this means they are always in an “unstable” state to create spontaneous action potential. The action potential is the brief reversal of polarity in the cell; polarity consists of potassium (K⁺) in the cell with a negative charge, while sodium (Na⁺) and calcium (Ca⁺⁺) are outside of the cell with a positive charge (2).

Starting at the beginning of the cardiac cycle the pacemaker cells always have a membrane potential or voltage—the voltage of the cellular membrane as a result of permeability and concentrations of ions inside and outside the cell—of -60 microvolts (mV). From -60mV to -50mV the channels within the cells open, leading to a slow influx of Na⁺ inside the cell and a slow depolarization of the cell. Once the membrane voltage has reached the minimum threshold of -50mV the Ca⁺⁺ channels open, causing Ca⁺⁺ to move into the cell. This is known as the rising depolarization phase. The membrane voltage reaches the peak and the next thing that happens is the falling repolarization phase. This is where the K⁺ channels open to return the cell to a repolarized state (2).

(20)

Once these steps have occurred, the energy is transferred to surrounding cells, and the cardiac cycle continues. However, the action potential in the other myocytes is slightly different. Myocytes have a resting potential, which is different from the pacemaker cells. The resting potential is around -90mV and these cells only start the depolarization process when stimulated by an external force. During the end of the pacemaker cell’s action potential phase, additional Ca⁺⁺ is passed into the neighboring myocytes through gap junctions. The introduction of Ca⁺⁺ into the cell causes a sharp rise in the membrane voltage that approaches the threshold which is -70mVs. Once that threshold has been reached, the NA⁺ fast channels open and a rapid depolarization occurs since Na⁺ is brought into the cell. The Ca⁺⁺ slow channels open at -40mVs, further causing depolarization with Ca⁺⁺ entering the cell (2).

At the peak of cellular depolarization, the Na+ channels close, leading to a slight repolarization through some K⁺ entering the cell. This is minor as the Ca⁺⁺ channel is still open and continues to move K⁺ out of the cell. A plateau is created because of this and allows for the cell to go through two important phases. The first phase starts when the membrane voltage increases from the resting potential and continues until the plateau phase ends. This is known as the absolute refractory period and is where the myocytes relax before they can respond to additional stimuli. It prevents summation and tetanus which could lead to the heart not beating. The second phase is where additional Ca⁺⁺ is pulled out of the sarcoplasmic reticulum (SR) to further push K⁺ out of the cell (2).

The phase ends when the Ca⁺⁺ channel closes, extra Ca⁺⁺ is sent back to the SR, and K⁺ is allowed back into the cell. The sodium/potassium pump allows Na⁺ to exit the cell, returning the cell to its resting potential. This rapid process occurs in every myocyte for the life of the cell. Pacemaker cells are the only cells that can generate a heartbeat. Impulses from the nervous system can increase or decrease the heart rate, but they are influencing the pacemaker cell to generate more beats, not creating them (2).

It is important to note that there are several sets of pacemaker cells within the heart. The SA node starts the process, but there are a few others spaced out along the electricity’s path to ensure that the atria and ventricles of the heart have time to fill and properly contract. The second set of pacemaker cells is the atrioventricular node (AV node) where a slight delay of 0.01-0.05 meters per second (m/s) happens to make sure that the ventricles fill up adequately. The bundle of His takes the electric impulse to the left and right bundle branches and from there, the Purkinje Fibers are triggered. These fibers have a speed of 2-4 m/s to provide enough force to eject the blood from the ventricles (69).

Correlating all of this back to telemetry, scientific development within the medical profession has allowed us to visualize this electrical activity and translate it into an effective method of diagnosing cardiac conditions such as abnormal heart rates or cell death.

Types of Telemetry

EKG

There are many ways to view cardiac rhythms now, however, the oldest method is the EKG. During the late 1700s, the Italian physician Luigi Galvani was experimenting with electricity and animal tissue. His experiments spanned at least three decades and inspired other physicians during and after his time. Using legs removed from the bodies of frogs, Galvani theorized that “animal electric fluid” enabled the muscles within the legs to move when touched by metals; according to him, this was “natural” fluid and not created as static electricity or friction is. He went on to theorize that the brain is an essential part of creating the “electric fluid” with nerves as the conductors (6).

Jumping forward to 1842, Doctor Carlo Matteucci made a significant contribution to EKGs. During his time researching electrical detection in animals, he discovered the electrical currents within the heart that accompany each heartbeat. Thirty-five years after Matteucci, Augustus Waller was able to use a capillary electrometer and electrodes to perform the first human EKG. These electrodes were placed on the chest and back of the participant and were vital in demonstrating there was electrical activity that preceded the contraction of the ventricles. William Bayliss and Edward Starling improved upon Waller’s research by using improved capillary electrometers to demonstrate triphasic cardiac electrical activity (1).

The Dutch physician most noted for creating the EKG known today was Doctor Willem Einthoven. He was inspired by Waller and those before him to improve the capillary electrometer, successfully identifying five deflections that were initially named ABCDE. Having to factor for inertia, Einthoven implemented mathematic correlation, resulting in the traditional EKG rhythm strips we use today with the letters PQRST depicted in the image below. Einthoven is also responsible for coining the word electrocardiogram or electrokardiogram in Dutch. This is where providers get the “k” in EKG from (1).

While Waller’s EKG utilized ten electrodes, Einthoven was able to condense that number to three, eliminating the right leg and the mouth electrodes. These three leads created Einthoven’s triangle; an important concept still used today and that will be discussed later. All of Einthoven's work resulted in him being awarded the Nobel Prize in Physiology and Medicine in 1924 (1).

Bedside Monitor

Emergency departments (ED), intensive care units (ICU), and other specialized areas that require continuous monitoring of a patient’s EKG and vital signs utilize various bedside monitors to ensure they are receiving accurate, real-time information on the patient. Cords are used to connect the patient to the monitor. The electrodes to display and document cardiac rhythm and heart rate are applied to patients in the standard 5 lead placement displayed in the below image. The vitals displayed on the monitor can also be displayed outside the room on a screen with multiple patients. Nurses, paramedics, or trained telemetry monitor technicians can watch many of these monitors at a time.

(14)

The placement of the five leads consists of the following:

• RA: 2^nd intercostal space, anterior axillary on the right – some providers may put this lead higher on the chest or on the right arm
• LA: 2^nd intercostal space, anterior axillary on the left – some providers may put this lead higher on the chest or on the left arm
• RL: 8^th intercostal space, anterior axillary on the right – some providers may put this lead lower on the abdomen
• LL: 8^th intercostal space, anterior axillary on the left – some providers may put this lead lower on the abdomen
• V: 4^th intercostal space, right margin of the sternum

Note: Always follow the manufacturer’s instructions for specific lead placement.

Helpful Tip: Many healthcare providers quickly remember lead placement based on color is smoke (black) over fire (red) and snow (white) over grass (green). This leaves brown (chocolate) in the middle.

These bedside monitors can monitor pulse oximetry, respiratory rate, temperature, capnography, blood pressure, and arterial pressure. Some devices may have other unique monitoring features. These monitors may be portable or have a way to transfer the cords to a transport monitor. They come with alarms that can be adjusted based on the patient’s unique vital signs or hospital policy.

First responders have similar devices they use when transporting patients with the added benefit of having a defibrillator and a real-time feedback device built in (91).

Remote Monitoring

Remote cardiac monitoring is similar to bedside monitoring; however, the EKG rhythm, heart rate, and pulse oximetry are not displayed at the bedside. Instead, they are displayed in a different location, sometimes a monitor room, where a trained professional is watching many patients. When they recognize an abnormal rhythm, they will contact the appropriate staff to assess the patient. They may call for the leads to be removed, a change in rhythm, or a low battery.

The EKG leads are placed the same way as the bedside monitor leads are placed (always be sure to consult the manufacturer’s instructions). The information is transmitted wirelessly via wireless medical telemetry service (WMTS) from the “tele box,” but the leads must be wired to the box. WMTS does not use Wi-Fi and protects transmissions from Wi-Fi interference (48).

Mobile Cardiac Monitor and Event Monitor

A mobile cardiac or event monitor is a device attached to the skin that can perform continuous or event-specific monitoring. This device is attached to the patient’s chest near the heart and records when activated. This device is smaller than other portable cardiac monitoring devices like the Holter Monitor which will be discussed later. Information can be transmitted to the monitoring center to be reviewed by trained staff and/or artificial intelligence. Abnormalities like tachycardia, bradycardia, atrial fibrillation, or cardiac pauses are reported to a physician. The patient may or may not know about the rhythm abnormalities occurring as some patients are asymptomatic (18).

Event monitoring consists of the following methods (23):

• Patch monitor: depending on the manufacturer, the device is stuck to the chest and left on for a designated period of time.
• Loop memory monitor: the sensors always stay on the patient and the patient activates the devices to begin recording when symptoms occur in addition to a few minutes before the event starts and after it ends. There is an implanted option as well.
• Symptom event monitor: Patients place the monitor on them and activate it like a patch monitor, but only when symptoms start.

Insertable Monitor

Insertable or implantable cardiac monitors are just like mobile and event monitors, but they are surgically inserted into the patient. They perform the same actions, but there is an added benefit to these devices. If the patient has worn an external device in the past and has known cardiac arrhythmias, they may have an implanted cardioverter-defibrillator (ICD) inserted to detect and treat the abnormal rhythm. These devices are connected to the heart via wires (they may be placed in the right atria, the right ventricle, or both) and are operated by batteries that do need to be changed per manufacture direction. Patients and providers should be aware of magnets, or electrical signals from other devices that can interfere with the insertable device (61).

Healthcare providers can “interrogate” ICDs or pacemakers with a device created by the monitor’s manufacturer. When interrogated, the device’s information is transmitted to a monitor center who calls the provider to give them a verbal report of what the device has recorded; a paper copy is often faxed to the provider as well. Some newer interrogation devices may display the information of the device on the screen.

Holter Monitor

As mentioned with mobile cardiac monitors, the Holter monitor is another wearable device that can be used to monitor and diagnose cardiac arrhythmias outside of the hospital setting. This device consists of five electrodes and a monitor that the patient can wear or carry on them. It is similar to the remote telemetry devices used in the inpatient hospital setting as shown in the next image. Patients wear this device for a short time, and information is not transmitted to a monitor technician. Instead, information collected is sent to a monitoring center where it is interpreted and sent to the physician (58).

As covered in this section, there are many options for cardiac telemetry monitoring, and providers may encounter many types of them. It is important to know these devices and how they operate.

Lead Placement

Now that we have discussed the types of telemetry monitoring devices that are available, it is time to discuss how to properly place the EKG leads on a 12 lead, 15 lead, right-sided EKG, and where to place the V₄R lead.

12 Lead EKG

For the 12 lead EKG, providers should start with the four limb leads (14):

• RA: On the upper or lower right arm
• LA: On the upper or lower left arm
• RL: on the upper or lower right leg
• LL: on the upper or lower left leg

From there, the six pericardial leads are placed strategically around the chest to create a partial circle around the heart (14):

• V1: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V2: 4^th intercostal space, left margin of the sternum
• V3: sits midway between leads V2 and V4 on the left
• V4: 5^th intercostal space, mid-clavicular line on the left
• V5: 5^th intercostal space, anterior axillary line on the left (aligned horizontally with V4, between V4 and V6) on the left
• V6: 5^th intercostal space, mid-axillary line on the left (aligned horizontally with V4)

15 Lead EKG

The 15 lead EKG uses the same leads as the 12 lead EKG, but it adds V7, V8, and V9, known as the posterior leads, to encompass the posterior angles of the heart (14):

• V7: left posterior axillary line (aligned horizontally with V6, across from V5)
• V8: tip of the left scapula (aligned horizontally with V6, across from V4)
• V9: left of the spinal column (aligned horizontally with V6, across from V3)

Right Sided EKG

The right-sided EKG is important to rule out the diagnosis of a right-sided myocardial infarction (MI) or ischemia in or out while treating a patient. Lead placement is the same for the four limb leads, but the 6 precordial leads are flipped (14):

• V1: 4^th intercostal space, left margin of the sternum
• V2: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V3: sits midway between leads V2 and V4
• V4: 5^th intercostal space, mid-clavicular line on the right
• V5: 5^th intercostal space, anterior axillary line on the right (aligned horizontally with V4, between V4 and V6)
• V6: 5^th intercostal space, mid-axillary line on the right (aligned horizontally with V4)

V4R Lead Placement

A full right-sided EKG is not always needed. Lead V4 on the right side of the heart is the most important lead when it comes to determining an MI on the right side of the heart (14):

• V1, V2, V3, V5, V6: same placement as the 12 and 15 lead EKGs.
  • V4 is removed and placed on the right side of the chest
• V₄R: 5^th intercostal space, mid-clavicular line on the right (Where it is located on a complete right sided EKG)
  • The “R” stands for right to ensure that those reading the EKG are aware that lead is on the right while the rest are located on the left side of the chest.

Limb Leads

Now that lead placement has been covered, we can now discuss how lead placement shows different parts of the heart.

Leads I, II, III, AVR, AVL, and AVF are considered limb leads when reading the EKG. It is important to note that the right leg lead is the grounding electrode and does not affect the EKG (83). Leads I, II, and III leads form a triangle over the chest known as Einthoven’s Triangle as reflected in the below image. Lead I always has negative polarity while lead III always has positive polarity. Lead II’s polarity depends on what side of the triangle is being discussed. If we are looking at lead I on the EKG, then lead II is positive, but if we are looking at lead III, then lead II is negative (82).

The importance of what leads are negative and positive comes from how electricity travels through the heart. It starts on the right side and moves to the left, so it would make sense for lead I to have negative polarity while leads II and III are positively charged (82). This is also why the height of a PQRST complex changes based on what lead is being looked at on an EKG as reflected below.

Augmented or unipolar leads AVR, AVL, and AVF have the heart as the negative electrode and the limb leads are the positive electrodes. AVR goes from the heart to the right arm lead, AVL goes from the heart to the left arm lead, and AVF goes from the heart to the left leg lead. Just as discussed with leads I, II, and III, the path of the electricity in the heart determines how the PQRST complex appears on the rhythm strip (82). Lead II is the preferred strip to read by providers due to the best view of the rhythm due to the way electricity travels through the heart and how lead II follows that path by starting at the right shoulder and going to the left leg.

The chest leads, V1 – V9, create a circle around the heart on a horizontal plane. These leads are unipolar as well, with the heart being the negative electrode. Multiple views of the heart are captured because of the many leads placed along the patient’s body. This can give providers valuable knowledge on what areas of the heart may be affected. The next image gives a visual depiction of how the leads display their view of the heart.

Reading EKGs: EKG Components

To be able to interpret EKGs successfully, nurses must first have knowledge about the EKG components displayed on the EKG strips and how each part correlates to a part of a single heartbeat.

P wave

The P wave is the first deflection from the isoelectric line or baseline. Correlating this to the heart, this is where the atria depolarize or contract. The contraction of the right atria starts at the beginning of the P wave while the contraction of the left atria begins in the middle and end of it. Normal P waves are apparent between 120 and 200 milliseconds (msec) before the upward deflection of the QRS complex (44)

PR Interval

The next part of the PQRST complex is the PR interval. The interval symbolized the time between the depolarization of the atria and the depolarization of the ventricle. The normal speed is 120 to 200 msec (44).

PR Segment

Next is the PR segment. This is similar to the PR interval but starts at the end of the P wave and ends at the start of the Q wave. This line is important because if there is a deviation from the isoelectric line, it could indicate a cardiac rhythm abnormality like Wolff-Parkinson-White syndrome which will be discussed later. The EKG may have a “slurred” upstroke from the P to R points on the EKG, making the Q wave appear to be on the isoelectric line. This is because the ventricles were stimulated or excited early, leading to a shortened PR interval. The “slurred” area is known as a delta wave (13).

QRS Complex

The QRS complex is where the ventricles depolarize and contract. The first downward deflection of the beat is the Q wave that lasts for < 0.05 seconds. It is present in all leads save for V1 and V3 due to the angle of the vector. The R wave is the upward deflection of the complex. R waves do not have a set height, but severely elevated R waves can be an indicator of ventricular hypertrophy. The second downward deflection is the S wave. Overall, the QRS complex is 0.07 to 0.10 seconds long and variations to this time can be an indicator of abnormal heart rhythms (17).

ST Segment

The ST segment starts when the S wave ends by returning to the isoelectric line and ends when the T wave begins. This period represented the completion of ventricular depolarization (17). The ST segment lasts 0.08 seconds to 0.12 seconds (51).

T Wave

The final wave in the standard EKG components is the T wave. This wave symbolizes the ventricles repolarizing. Inverted T waves can be an indication of past or current infections. A peaked T wave—as opposed to the normal curved T wave—can be caused by hypocalcemia, hyperkalemia, and left ventricular hypertrophy (17). The T wave runs from 0.01 seconds to 0.25 seconds (51).

The image below depicts the components of an EKG with labels to assist with understanding how the waves appear.

(4)

Reading EKGs: EKG Paper

The EKG paper has sets of squares, 25 little squares within one larger square. The smaller squares symbolize 0.04 seconds making the larger square 0.20 seconds. A single small square is 1mm while the large square is 5mm, this is because the larger square is five small squares tall.

(15)

Some EKG strips are presented in a six second format. To determine if the strip is a six-second, you must count the larger boxes. 30 larger boxes are required for the strip to be six seconds. Some may even have second markers that symbolize one second of time passed.

The 12 lead EKG can be more challenging to read and is often used to make an overall observation about the patient’s heart rate and rhythm. It can provide more information to providers than a single lead strip can. 

As discussed previously, the leads are placed along the path of the heart, and providers can determine what part of the heart may be affected by knowing what leads are placed where.

(51)

Now that we have discussed leads, lead placement, the PQRST complex, and EKG paper, it is time to cover different cardiac rhythms that you may encounter.

Rhythm Recognition

Normal Sinus (41):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic (curves above and then dips below the isoelectric line) in V1
  • Duration:
    • Less than 0.12 seconds
  • Rhythm Strip:

(29)

Sinus Bradycardia (87):

• Rate: less than 60bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    

(87)

• Signs and Symptoms:
  • None – depending on the patient
  • Cyanosis
  • Peripheral edema
  • Shortness of breath
  • Dizziness
  • Fatigue
  • Syncope or near syncope
  • Lightheadedness
• Causes (not limited to):
  • Normal physiology in an athlete
  • Medications like beta-blockers
  • Ischemia
  • Heart diseases
  • Sick sinus syndrome
  • Hypothermia
  • Hypothyroidism
  • Neuro-mediated bradycardia as caused by a vasovagal reaction
  • Pericarditis
  • Hypoxia

• Electrolyte imbalances

• Treatment:
  • None if asymptomatic, admission for observation may be indicated
  • Medications:
    • Atropine 0.5mg every 3 to 5 minutes for a maximum dose of 3mg
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker
  • Return patient to a normothermic state if hypothermic

Sinus Tachycardia (55):

• Rate: greater than 100bpm but less than 150bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(42)

• Signs and Symptoms:
  • Shortness of breath
  • Chest pain
  • Dizziness
  • Syncope or near syncope
  • Lightheadedness
  • Palpitations
• Causes:
  • Infection or sepsis
  • Medications
  • Withdrawal
  • Electrolyte imbalances
  • Blood loss or anemia
  • Dehydration
  • Hypoglycemia
  • Pulmonary embolism
  • Trauma
  • Cardiac tamponade
  • Myocarditis
  • Pregnancy
• Treatment:
  • Medications
    • Antibiotics
    • Antidotes or reversal agents
    • Insulin
    • Electrolyte replacement
    • Fluids
    • Heparin or other anticoagulant medications
  • Blood replacement
  • Surgery

1st Degree AV Block (68):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval greater than 0.20 seconds
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • A QRS complex always follows the P wave
• Duration:
  • Less than 0.12 seconds
• Rhythm Strip:

(32)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
• Causes:
  • Increased vagal tones in young patients
  • Fibrotic changes in the elderly
  • Cardiac disease
  • Inflammation
  • Medications
  • Electrolyte abnormalities
• Treatment:
  • None if asymptomatic
  • Medications
    • Antibiotics
    • Antidotes or reversal agents
    • Electrolyte replacement

2nd Degree Type I AV Block (Mobitz Type 1 or Wenckebach) (60):

• Rate: varies
• Conduction:
  • PR interval increases with each beat, eventually “dropping off” and another P wave appears
  • “Longer, longer, drop, that’s a Wenckebach.”
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(27)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
• Causes:
  • Increased vagal tones
  • Cardiomyopathy
  • Myocardial infarction
  • Cardiac surgery
  • Electrolyte abnormalities
  • Medications
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine if bradycardic
    • Antidotes or reversal agents
    • Electrolyte replacement

2nd Degree Type II AV Block (Mobitz II) (60):

• Rate: varies
• Conduction:
  • PR interval varies
  • QRS width 60-100ms when present
    • QRS does not follow all P waves
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • The P wave is:
      • Positive or above the isoelectric line in II and AVF
      • Biphasic in V1
    • Rhythm Strip:

(40)

• Signs and Symptoms:
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
  • Cardiac arrest
• Causes:
  • Structural heart disease
  • Amyloidosis
  • lymphoma
  • Cardiac tumors
  • Transcatheter placement of valves
  • Myocardial infarction
  • Genetics
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine does not work on these patients
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker since this rhythm can progress to a complete heart block or cardiac arrest

3rd Degree AV Block (78):

• Rate: varies, but usually bradycardic
• Conduction:
  • PR interval varies
  • QRS width 60-100ms when present
  • P wave and QRS complex do not communicate (called AV disassociation)
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(33)

• Signs and Symptoms:
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
  • Hemodynamic instability
  • Cardiac murmurs
  • Cardiac arrest
• Causes:
  • Cardiac surgery
  • Cardiac disease
  • Medications
  • Electrolyte imbalances
  • Lyme disease
  • Transcatheter aortic valve replacement
  • Myocardial infarction
  • Systemic lupus erythematosus
  • Sarcoidosis
• Treatment:
  • Medications
    • Atropine usually does not work, but can be administered
    • Epinephrine
    • Dopamine
    • Antidotes or reversal agents
    • Electrolyte replacement
  • Transcutaneous cardiac pacing or pacemaker

Premature Ventricular Contraction (PVC) (88):

• Rate: varies, underlying rhythm is usually normal sinus
  • The impulse to beat comes from the ventricles, not from the SA node
• Conduction:
  • PR interval varies, but in a regular PQRST complex PR interval is 120-200ms
  • PR interval after a PVC is longer due to the PVC and the retrograde concealed conduction goes back into the AV node junction.
  • PVC QRS width is at least 120ms but usually 160-200ms
  • Regular QRS width is 60-100ms
  • PR interval after a PVC is longer due to the PVC and the retrograde concealed conduction goes back into the AV node junction.
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    • Monomorphic: All PVCs are shaped the same

(38)

• Biomorphic: PVCs are shaped differently

(64)

• Bigeminy: Every PVC is separated by one sinus beat.

(35)

• Trigeminy: Every PVC is separated by two sinus beats.

(9)

• Ventricular Couplet: Two PVC beats in a row.

(9)

• Ventricular Triplet: Three PVC beats in a row.

(9)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Palpitations
  • Lightheadedness
  • Abnormal neck pulsation
  • Hemodynamic instability with frequent PVCs
  • Cardiac arrest
• Causes:
  • Hypoxia
  • Illicit drug use
    • Amphetamines
    • Alcohol
    • Cocaine
  • Electrolyte imbalances
  • Myocarditis
  • Mitral valve prolapse
  • Hypercarbia
  • Cardiomyopathies
  • Myocardial infarction
  • Medications
• Treatment:
  • None if asymptomatic
  • Medications
    • Beta-blockers
    • Calcium channel blockers
    • Amiodarone is for those with preexisting coronary artery diseases, but used with caution and close observation and monitoring
    • Antidotes or reversal agents
    • Electrolyte replacement
  • Cardiac ablation
  • Defibrillation if cardiac arrest occurs

Premature Atrial Contractions (PAC) (54):

• Rate: varies, underlying rhythm is usually normal sinus
• Conduction:
  • PR interval varies, but in a regular PQRST complex PR interval is 120-200ms
  • PAC
  • Regular QRS width is 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave:
    • Can be inverted
    • May be hidden in the T wave creating a hump or peaked T wave
  • These rhythms can come in the same variations as PVCs:
    • Bigeminy
    • Trigeminy
    • Couplet
    • Triplet
  • Rhythm Strip:

(37)

• Signs and Symptoms:
  • None
  • Palpitations
  • Shortness of breath
  • Anxiety
  • Signs and symptoms of heart failure
  • Early or additional heart sounds
  • Pauses in rhythm
• Causes:
  • Coronary artery disease
  • Left ventricular hypertrophy
  • Septal defects
  • Congenital heart deformities
  • Medications
    • Beta-blockers
    • Chemotherapeutic agents
  • Congestive heart failure
  • Diabetes mellitus
  • Hypertension
  • Chronic obstructive pulmonary disorder
  • Anxiety
• Treatment:
  • None if asymptomatic
  • Avoiding triggers
  • Medications
    • Beta-adrenergic blockers
    • Antiarrhythmic agents are used with caution and close observation and monitoring
    • Antidotes or reversal agents
    • Cardiac ablation

Ventricular Tachycardia (V Tach) (45):

• Rate: greater than 100bpm
• Conduction:
  • PR interval none
  • QRS width greater than 140ms
• P wave morphology:
  • Not present
• Non-sustained V-Tach: three or more ventricular beats over a maximum of 30 seconds.
• Sustained V-Tach: a run of V Tach for more than 30 seconds or less is treated by cardioversion
• Monomorphic V-Tach: all ventricular beats look the same
• Polymorphic V-Tach: the ventricular beats look different.
• Biphasic V Teach: where the QRS complexes alternate with each beat.
  • Digoxin intoxication
  • Long QT syndrome
• Rhythm Strip:
  • Monomorphic V-Tach

(11)

• Signs and Symptoms:
  • Palpitations
  • Shortness of breath
  • Chest pain
  • Syncope or near syncope
  • Signs of heart failure
  • Hemodynamic instability
  • ICD shocks if the patient has one
  • Cardiac arrest
    • Also known as pulseless V-Tach
  • Causes:
    • Ischemic heart disease
    • Acute coronary artery disease
    • Myocardial scar-related reentry
    • Congenital heart deformities
    • Cardiomyopathy
    • Illicit drugs
      • Cocaine
      • Digitalis toxicity
      • Methamphetamine
    • Medications
      • Beta-blockers
      • Chemotherapeutic agents
    • Electrolyte imbalances
    • Sepsis
    • Metabolic acidosis
    • Inherited cardiac channelopathies
  • Treatment:
    • Cardiopulmonary resuscitation (CPR) and defibrillation if no pulse present
    • Cardioversion if hemodynamically unstable and has a pulse
    • Treatment for myocardial infarction
    • Medications
      • Amiodarone, procainamide, sotalol
      • Antidotes or reversal agents
    • ICD
    • Cardiac ablation

Torsades de Pointes (V Fib) (25):

• Rate: none
• Conduction:
  • Polymorphic V-Tach with a prolonged QR interval
• P wave morphology:
  • Not present
• Rhythm Strip:

(12)

• Signs and Symptoms:
  • None
  • Syncope or near syncope
  • Dizziness
  • Lightheadedness
  • Hypotension
  • Rapid pulse
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Medications
      • Zofran causes a long QT interval (19)
    • Congenital prolonged QT:
      • Jervell and Lange-Nielsen
      • Romano-Ward syndrome
    • Bradycardia
    • Diuretic use
    • Female gender
    • Age
  • Treatment:
    • Electrolyte replacement
    • CPR and defibrillation
    • Medications
      • Epinephrine
      • Atropine
    • Cardioversion
    • Treatment of the underlying cause

Supraventricular Tachycardia (SVT) (72):

• Rate: Greater than 160bpm
• Conduction:
  • PR interval not present
  • QRS width less than 120 milliseconds = narrow complex, regular SVT
  • QRS width greater than 120 milliseconds = wide complex, regular SVT
• P wave morphology:
  • Not present
• Rhythm Strip:
  • Narrow complex, regular SVT

(30)

• Wide complex, regular SVT

(79)

• Signs and Symptoms:
  • None
  • Hypotension
  • Shortness of breath
  • Lightheadedness
  • Signs and symptoms of heart failure
  • Shock
• Causes:
  • Narrow complex, regular SVT - Orthodromic reentry phenomenon (56):
    • Accessory pathway that connects the atria and ventricles without passing through the AV node
    • A pulse goes through the AV node, down into the ventricles via the Bundle of His, up through the accessory pathway, and back into the AV node
  • Wide complex, regular SVT - Atrioventricular reentry phenomenon (57):
    • Signals from the SA node travel through the accessory pathway down the ventricles via the Bundle of His and up to the AV node, creating a backward cycle.
    • This is slower than the orthodromic SVT because it is traveling against the regular path of conduction, leaving to a wide QRS complex
  • Medications
  • Caffeine
  • Smoking
  • Stress
  • Alcohol
• Treatment:
  • None if asymptomatic
  • Vagal maneuvers
    • Bearing down
    • Blowing into a straw
  • Medications
    • Adenosine: 1^st dose 6mg, 2^nd dose 12mg
      • Ensure rapid saline flush after pushing medication as it has an extremely short half-life
    • Cardizem
    • Antidotes or reversal agents
  • Cardioversion
  • Cardiac ablation

 Ventricular Fibrillation (V-Fib) (3):

• Rate: none
• Conduction:
  • PR interval not present
  • QRS width not present
• P wave morphology:
  • Not present
• Rhythm Strip:

(39)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Sudden blow to the chest right over the heart
    • Medications
    • Anemia
    • Cardiomyopathy
    • Electrocution
    • Thoracic trauma
    • Heart surgery
  • Treatment:
    • CPR and defibrillation
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Asystole (59):

• Rate: none
• Conduction:
  • PR interval not present
  • QRS width not present
• P wave morphology:
  • May or may not be present
• Rhythm Strip:

(21)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Medications or illicit drugs
    • Blood loss
    • Cardiomyopathy
    • Electrocution
    • Trauma
  • Treatment:
    • CPR
      • Since there is no electrical activity with this rhythm, defibrillation cannot be used
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Pulseless Electrical Activity (PEA) (22):

• Rate: varies
  • There is no pulse with this rhythm despite the fact that it may appear as an organized rhythm
• Conduction:
  • PR interval none
  • QRS width greater than 110ms
• P wave morphology:
  • Not present
• The P wave is:
  • Not present
• Rhythm Strip:

(22)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Medications or illicit drugs
    • Blood loss
    • Cardiomyopathy
    • Electrocution
    • Trauma
    • Hypothermia
    • Pneumothorax or hemothorax
  •  Treatment:
    • CPR
      • Since there is no electrical activity with this rhythm, defibrillation cannot be used
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Atrial Flutter (73):

• Rate: varies
  • Depends on how many QRS complexes there are
    • Atrial rate 250-350 bpm
    • Ventricular rate 75-150bpm
  • P waves can come in blocks
    • 2 P waves per 1 QRS (2:1)
    • 3 P waves per 1 QRS (3:1)
    • 4 P waves per 1 QRS (4:1)
    • Intervals of P waves per 1 QRS (2:1 then 3: 1 then 2:1 then 4:1)
  • Conduction:
    • PR interval varies
    • QRS width 60-100ms
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
      • Sawtooth pattern
    • Rhythm Strip:

(31)

• Signs and Symptoms:
  • None
  • Palpitations
  • Fatigue
  • Syncope or near syncope
  • Shortness of breath
  • Regular or irregularly regular pulse
• Causes:
  • COPD
  • Heart failure
  • Atrial size abnormalities
  • Hypertension
  • Diabetes mellitus
  • Age
  • Male gender
• Treatment:
  • None if asymptomatic
  • Medications
    • Amiodarone
    • Cardizem
    • Metoprolol
    • Anticoagulation to prevent stroke
  • Catheter ablation
  • Treatment of the underlying cause

Atrial Fibrillation (AFib) (89):

• Rate: varies
  • Atrial rate 400-600 bpm
  • Ventricular rate 75-175 bpm
    • Anything over 100 is considered A Fib with rapid ventricular response (RVR)
  • Conduction:
    • PR interval varies
    • QRS width 60-100ms
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • Rhythm Strip:
      • A Fib

(28)

• A Fib RVR

(34)

• Signs and Symptoms:
  • None
  • Palpitations
  • Fatigue
  • Syncope or near syncope
  • Shortness of breath
  • Regular or irregular pulse
    • Patients can go in and out of A Fib or it can be permanent,
    • They can go in and out of RVR
  • Causes:
    • Heart disease
    • Genetics
    • Pulmonary embolism or other hemodynamic stressors
    • Obstructive sleep apnea
    • Heart failure
    • Pericarditis
    • Myocarditis
    • Myocardial infarction
    • Hypertension
    • Diabetes mellitus
    • Age
  • Treatment:
    • None if asymptomatic
    • Medications
      • Cardizem
      • Metoprolol
      • Amiodarone
      • Anticoagulation to prevent stroke
    • Catheter ablation
    • Treatment of the underlying cause

Idioventricular Rhythms (47):

• Rate: varies
  • Idioventricular rate 35-40bpm
  • Accelerated rate 60-120bpm
• Conduction:
  • PR interval not present
  • QRS width greater than 120ms but can be greater than 160ms
    • The normal conduction system does not transmit the signal to beat, the vertical signal is transmitted from cell to cell
  • P wave morphology:
    • Not present
  • Rhythm Strip:
    • Idioventricular rate

(36)

• Signs and Symptoms:
  • None
  • Palpitations
  • Fatigue
  • Lightheadedness
  • Syncope or near syncope
  • Cardiac arrest
• Causes:
  • Electrolyte imbalances
  • Reperfusion of cardiac cells after a myocardial infarction
  • Medications
    • Digoxin
    • Beta-adrenoreceptor agonists
  • Illicit drug use like cocaine
  • Cardiomyopathies
  • Congenital cardiac defects
  • Athletes
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine
    • Amiodarone or lidocaine
    • Reversal agents
  • Rarely cardiac pacing
  • Treatment of the underlying cause

Junctional Rhythms (52):

• Rate: varies
  • Junctional bradycardia less than 40bpm
  • Junctional escape rhythm 40-60bpm
  • Accelerated junctional rhythm 60-100bpm
  • Junctional tachycardia greater than 100bpm
• Conduction:
  • PR interval not present
  • QRS width 60-100ms
• P wave morphology:
  • Not present
• Rhythm Strip:
  • Accelerated Junctional Rhythm
    • Rhythms look the same but have more beats depending on the type of rhythm

(52)

• Signs and Symptoms:
  • None
  • Shortness of breath
  • Palpitations, intermittent or continuous
  • Fatigue
  • Lightheadedness
  • Syncope or near syncope
• Causes:
  • Electrolyte imbalances
    • Can be caused by anorexia nervosa
  • Thoracic trauma
  • Myocarditis
  • Reperfusion of cardiac cells after a myocardial infarction
  • Medications
    • Adenosine
    • Clonidine
    • Antiarrhythmics
    • Lithium
    • Digoxin
  • Sleep apnea
  • Hypoxia
  • Coronary artery disease
  • Congenital cardiac defects and repairs of these defects
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine
    • Reversal agents
  • Transcutaneous pacing
  • Permanent pacemaker
  • Treatment of the underlying cause

Bundle Branch Blocks (BBB) (43, 53, 70):

• Rate: varies
• Conduction:
  • Right BBB (RBBB):
    • QRS interval greater than 120ms
    • Septal depolarization that leads to a:
      • Small R wave being present in V1
      • Q wave in V6
    • The left ventricle’s contraction leads to and:
      • • S wave in V1
        • R wave in V6
    • The right ventricle’s contraction leads to an:
      • R wave in V1
      • Deep S wave in V6
    • Left BBB (LBBB):
      • QRS interval greater than 120ms
      • T wave inversion is due to abnormal repolarization
      • From first principles:
      • Septal depolarization that leads to a:
        • Q wave in V1
        • R wave in V6

• • • The right ventricle’s contraction leads to an:
      • R wave in V1
      • S wave in V6
    • The left ventricle’s contraction leads to and:
      • S wave in V1
      • R wave in V6
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • Rhythm Strip:
      • RBBB

(71)

• • • • LBBB

(71)

• Signs and Symptoms:
  • None
  • Lightheadedness
  • Syncope or near syncope
• Causes:
  • RBBB:
    • Myocardial infarction
    • Congenital cardiac defects
    • Pulmonary embolism
    • Myocarditis
    • Pulmonary hypertension
  • LBBB:
    • Myocardial infarction
    • Hypertension
    • Cardiomyopathy
    • Myocarditis
  • Treatment:
  • None if asymptomatic
  • Treatment of the underlying cause

Identifying Ischemia and Infarction

Known as coronary artery disease (CAD), acute myocardial ischemia is the decrease of blood flow to the heart by atherosclerosis or plaque. The atherosclerosis starts as a plaque streak within the large arteries and continues to build up. After the plaque has grown to a significant size, occlusion begins and blood flow to areas below the growing occlusion suffers a decrease in blood flow. This is what is known as ischemia (81).

When resting, patients may not experience any signs or symptoms. Upon exertion, however, patients may experience stable angina—chest pain, discomfort, pressure, etc.—as activity requires increased blood flow and the arteries constrict to pump blood through the body faster. This pain is relieved at rest and can be further treated by nitrates. The routine is what makes this stable angina (81).

Unstable angina begins once the artery has become occluded enough to create a significant obstruction of blood flow. Signs and symptoms can include chest pain or other discomfort that is challenging to relieve, even when at rest. Patients may be woken from sleep due to the pain and report that it takes longer for the pain to decrease or resolve completely. These signs and symptoms symbolize that the plaque within the artery is unstable and could potentially rupture (90).

Infarction is when the blood flow is completely obstructed and the cells below the obstruction begin to die off. This often occurs when the plaque within the artery ruptures, leading to the body’s natural clotting processing in an attempt to repair the rupture, and a complete occlusion of the artery occurs (46).

Now that we have discussed ischemia and infarction, it is time to discuss how a myocardial infarction (MI) appears on an EKG and how to identify it. You may also hear them referred to as STEMIs or ST-elevation myocardial infarction.

The progression of PQRST complex changes during an MI can start with hyperacute T waves. The T wave will increase with amplitude and become wider, while some ST elevation may be noted. This elevation begins to occur as injury to the heart muscle begins. From there, the ST elevation increases and creates the image often associated with an MI. Pathological Q wave may develop as the MI progresses. As discussed earlier, the Q wave is the first downward deflection of the QRS complex and is normally 1mm or less in depth. Pathological Q waves are measured by greater than 1mm wide or greater than 25% of the R wave’s amplitude (84).

T wave inversion occurs when the cells have become necrotized and begin to form fibrosis. Once all necrotized cells have become fibrotic, the Q waves will remain, but the T waves will become upright again (84).

(84)

These changes should be present in at least 2 contiguous leads or leads that are side by side. To discuss this more, we will refer to the 12 lead EKG photo we used earlier. It is important to know that there will be leads with ST elevation and there will be leads with reciprocal ST depression based on the type of MI and how these leads are placed in relation to the area of the heart that is being affected.