Device related infections and prevention

 Laurl at ONS 

Welcome to today's hot topic chat! Today we have Brenda Shelton, who is here to talk to us about fever, infection evaluation and management. In addition, Amy will be coming later in the chat to continue the discussion about antibiotic therapy. Welcome, Brenda!

 brenda 

I see there is already a question- quite a good one. The question is; “I have heard that blood cultures are most effective if they are gathered before the patient reaches the spike of their fever. Is this true and why would it matter?”

 brenda 

Blood culture thresholds are designed to capture the temperature on the rise when the most organisms and best yield is there. Once temp is very high our body's cytokines kills some of the organisms.

 brenda 

We use 38.0 C for one hour or 38.3 once as our threshold. This translates to > 100.4 in Fahrenheit.

 brenda 

What is the threshold you all use for fever?

 debrajean 

38 C

 debrajean 

Do you remove valves prior to drawing blood cultures?

 brenda 

It still varies a lot but NCCN recommends the above and their document replaces the 2001 fever and infection in the HSCT pt document.

 debrajean 

Thank you!

 brenda 

We always go hub to hub for blood cultures, scrub very well with alcohol (chlorhexidine not approved for plastic). How about any of you?

 debrajean 

Our policy here has been to keep the valve on, but our contamination rate is high. I'd like to see us change.

 blueeyes1 

What are you all doing to help educate medical assistants about the patient's risk of sepsis and what to do with a septic patient? Do you have resources for nursing education?

 brenda 

Re: cultures: I would have to look at the references in our blood culture document to help you change your practice, so I will post the citations on the transcripts. This would be a valuable practice change as we all become more conscious of nosocomial infections and their consequences.

 debrajean 

Absolutely! Thank you! On the sepsis question, I have a case study scenario I use with nurses, CNAs get general info on hire, but we could definitely do more.

 brenda 

Patient education materials are great to use for that level of practitioner. They also have so much contact with patients that they are helpful reinforcers of education so we want to make sure they know what the patient has been taught and they do sterile procedures.

 brenda 

We do competency sign offs for sterile technique annually. I think we have a long way to go to help them with the actual sepsis piece.

 debrajean 

Sterile technique in general or for a specific procedure?

 brenda 

To debrajean- did you submit your case study for the ONS case studies in chemo book? It may not be too late!!!

 debrajean 

No I did not, but I could.

 brenda 

You should!!! Share- we will all benefit!!! If not there, I am sure there is a section in CJON where it could work as well. Contact me offline for help if you want or check with Laurl.

 debrajean 

We had a case recently where sepsis was missed b/c the pt was afebrile.

 Laurl at ONS 

You can email me at lmatey@ons.org and I'll help you get to the publishing folks!

 brenda 

Sterile technique- we do a real (venous access device) VAD dressing change with each one. We also got special permission for them to draw blood from some lines so sign that off as well. They also have monthly meeting and we try to use that format to teach infection control practices.

 brenda 

Sepsis and no fever!!! This is more common than one may think. I think it is about 10-20% of patients may have no or little fever. More common in gram negative infections, or in pts on high immunosuppressives. We recently had a severe sepsis late treated due to no fever in a late bone marrow transplant (BMT) pt on steroids.

 brenda 

More on low temp and sepsis- be really cognizant that low diastolic BP or low urine output/ weight gain have been research-proven to be early markers for impending sepsis and can be used as well as temp.

 blueeyes1 

BMT patients scare me; seems like you see non-specific symptoms like changes in their level of consciousness.

 debrajean 

I just created a second scenario about low urine output as a marker.

 debrajean 

The afebrile pt was a BMT pt- she had an abdominal perforation.

 blueeyes1 

Debra you need to publish these case scenerios.

 brenda 

Unfortunately, a BMT pt’s normal state is so immunocompromised that their symptoms are blunted. So debrajean you really also should help us reinforce urine output importance.

 brenda 

Interesting blue eyes- the abdomen is the most common source of gram negative organisms- lesson to be learned. Abdominal pain, weight gain, I > O, no fever, slight decrease in BP- BEWARE of shock!!!

 blueeyes1 

What steps have you taken at your facilities to help get the antibiotics on board in a timely manner?

 brenda 

Let's hear from some of you about blueeyes question.

 debrajean 

We have supportive care orders so the RN can initiate antibiotics (abx) immediately.

 brenda 

Do any of you have to work through (Infectious Disease) ID approval? There are a few good articles and abstracts with audit instruments to help identify the system issues in rapid antibiotic delivery. We have pre-approved first fever orders- still have some problems with the movement from paper to drug on inpatient units.

 brenda 

For obvious reasons some nurses wanted first dose antibiotics in the clinic but due to severe allergy potential, we have not done this.

 debrajean 

Our orders have been approved by many bodies; we use them on practically all oncology inpatients.

 brenda 

Sounds like a working system, but not true everywhere- it would make a great facilitated discussion at a local chapter meeting. We got some ideas from other local nurses.

 brenda 

How about the Emergency Dept (ED) transition and getting first antibiotics fast there? We got access to patient records for them and some places give pts a card of when last chemo was and what they received so antibiotics can get given before lab results.

 blueeyes1 

Does anyone utilize a febrile neutropenia risk assessment tool pretreatment and identify populations at greater risk?

 brenda 

The biggest challenge with ED is to look at their triage system and help them see where the neutropenic fever pt fits into their acuity system. Our discussions have helped it move up to chest pain level.

 debrajean 

I'm sorry I have to go- thank you for all the information I will be in touch with case studies- we did the same with chest pain; I give a lecture on neutropenia etc to the ED internship every quarter.

 brenda 

Re risk assessment- I WISH we did use one. The Multinational Association of Supportive Care in Cancer (MASCC) score is most well-known and universal across populations. I will post a reference on the transcripts. There are some others available- some on tear-sheets that can be used.

 blueeyes1 

Awesome, thanks.

 blueeyes1 

I heard that Neupogen® and Neulasta® are preventative but have little roll in the management of febrile neutropenia.

 brenda 

This is true as I read your question. These agents are licensed for use at the end of chemotherapy to reduce the length and depth of neutropenia. If you wait until the patient presents with neutropenia and fever, their benefit has not been proven. I believe there are some off label studies for patients with severe sepsis and neutropenia and I know there are still some who use after fever, but not considered conventional practice.

 brenda 

Have any of you been using galactomanan assays or beta glucan assays for detection of fungus?

 brenda 

So.... these two new tests are usually sent outs- can be blood or bronch specimen. Galactomanan is for aspergillus only and beta glucan for fungus in general. Both significant if positive, uncertain value if negative.

 hemeoncnurse 

When a person presents with fever, what is the total assessment picture you should obtain?

 brenda 

Physical exam can not be underestimated!!! Nurses and their very thorough exam often detect subtle infections. Next we culture all the wounds, lines, and places that can be reached.

 brenda 

There is considerable controversy about chest x-rays- we always do them, but often not helpful unless respiratory symptoms are present. The CXR lags behind clinical symptoms about 24 hrs

 brenda 

A new consideration is that if you have a patient with slight or profound hypotension, you should do a lactate. This will tell you if you have given enough fluids to perfuse the organs.

 brenda 

Fluids must perfuse the organs in sepsis to prevent organ failure. We are often so worried about fluid overload and capillary leak that we under administer fluids. Lactate levels help guide this if you do not have a CVP line.

 brenda 

Have any of you gotten lactate levels on febrile neutropenia pts?

 blueeyes1 

We follow the sepsis bundle recommendation. You are so right nurses are too worried about fluid overload, especially since our patient population is elderly. You have to drive home the point of circulatory collapse.

 brenda 

Yea- use of the sepsis bundle will become routine in 2010 when it becomes part of JCAHO. It is already done in ICUs... more…

 brenda 

Sepsis bundle is a group of interventions based upon the 15 best practices in sepsis. It is like a checklist to be done when a person presents with sepsis. I can post some slides of citations on the transcripts that are a quick summary.

 blueeyes1 

How do you all encourage patients to call early rather than waiting for clinic apt and walking (dragging) in near deaths door?

 brenda 

RE: bundle: Some best practices I can recall are early fluids, antibiotics in 6 hr (ha!!!- not for us), cultures before antibiotics, consider adrenal insufficiency, low volume ventilation, consider Xigris®  in some patients, head of bed elevation, deep vein thrombosis (DVT) prophylaxis, ulcer prophylaxis, Levophed® for hypotension.... how many is that?

 brenda 

Threats or rewards to get them to come early??? Depends upon the patient. I guess some just need to UNDERSTAND the gravity of the situation, some never learn. Education and support people buy in is probably the most important things to do.

 Laurl at ONS 

Brenda, how is the best way to detect influenza/RSV in immunocompromised pts?

 brenda 

Until recently, we were unable to get good culture returns on viruses and would unintentionally place pts at great risk by treating them with active virus. New labs can perform well but not on throat swabs- need to do nasopharyngeal wash- squirt preservative free saline up nose and have them blow their nose into a cup!!!. This past few weeks with H1N1 we also discovered NOT to do this in hallways- now must be done in an enclosed room.

 Laurl at ONS 

Ewww. The visual on that image is not pretty!

 blueeyes1 

Yes! Always in closed room with protective gear face shield mask and gown for worker if they are in the room and properly clean and air the room before use for next clinic patient.

 brenda 

Oh how common sense makes sense.....Excellent blueeyes- you are better than we started out to be.

 brenda 

Do any of you draw a discard with blood cultures from a line, or straight from the line?

 brenda 

Also, do you use resin culture bottles for patients on antibiotics?

 brenda 

There is controversy about whether a discard is needed when drawing from a line. We use one, but I worked another place that did not.

 Laurl at ONS 

We have about 3-4 more minutes and would love to hear a few more questions! In the meantime, don't forget to please visit our survey link and let us know what you think of these chats. The URL is http://research.zarca.com/k/RsTUTRsTQPsXYUSUsPsP

 brenda 

The resin culture bottles absorb antibiotic out of the blood in the specimen so the better the culture yield. Some hospitals have not believed this was valuable enough- I do in the immunocompromised. About 60% of septic shock patients who die are culture negative at time of death. I also encountered one hospital that uses resin bottles on all pts- we think it is too expensive.

 brenda 

Any final questions???

 brenda 

Laurl will remind me of all the things I promised to post on the transcript and I will send them along. Feel free to contact us if you think of other items later.

 brenda 

Bye...thanks everyone!!!

 Laurl at ONS 

Well, if no more questions, then thank you all for participating today! We appreciate your involvement and hope to see you at the next series - which starts Jul 21, on Psychosocial Issues.

 Laurl at ONS 

Have a great evening!

 blueeyes1 

Thanks Brenda

 brenda 

Thank you