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Cardigans – a potential vector of infection?
Each winter cardigans or long sleeved tops under uniform tunics appear as part of clothing worn by carers, nurses and other staff providing resident care. Does this practice increase the risk of cross infection?
There are certainly studies that demonstrate that uniforms become contaminated with potential pathogenic organisms including Staphylococcus aureus, Clostridium difficile and Norovirus[1]. It is more difficult to find evidence that links contaminated uniforms with the transmission of pathogens to patients and residents.
Most contamination occurs in areas of greatest hand contact such as pockets and cuffs[2], which may the cause the wearer to re-contaminate their cleaned hands. Long sleeves may also become contaminated with bodily fluids, which then directly contaminate another resident through direct hands on care. This would be a great way to spread around those multi-drug resistant organisms that live in the bowel, such as ESBL, VRE and CRE!
The biggest risk of wearing long sleeves when delivering care involving patient contact is that hand hygiene cannot be carried out effectively. Anyone who has been taught hand washing using the Glitterbug gel and UV light will remember how the wrists were often left glowing, demonstrating that your wrists also get contaminated and need cleaning. In many healthcare facilities across the world, a ‘Bare Below the Elbows’ policy is used to ensure that effective hand hygiene is undertaken. This applies to the use of an alcohol based hand rub or gel, as well as washing with soap and water.
So the next time that you put your cardigan on or come to work with a long-sleeved top, remember that, prior to any patient contact remove the cardigan or roll up your sleeves and perform hand hygiene.
[1] Mitchell et al. Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature. Journal of Hospital Infection, 2015 Aug;90(4):285-92
[2]Loh et al. Bacterial flora on the white coats of medical students. Journal of Hospital Infection, 2000 May;45(1):65-8.
Contributed by:
Ruth Barratt
Infection Prevention & Control Advisor
infectprevent@gmail.com
Is a slip off a chair or off the side of the bed onto the floor a fall? Is a ‘controlled lowering’ by a staff member of a resident to the floor a fall?
When recording adverse events such as falls, it’s important for the purposes of consistent reporting and bench-marking that the same definition is used to define a ‘fall’. We suggest using the definition provided by the World Health Organisation (WHO) which states “A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.” The WHO falls prevention guidelines also report that “Globally, falls are a major public health problem. An estimated 424 000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries.”
Working in aged care related services means you are interacting on a daily basis with those in the high risk category for falls. WHO also report for example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. The Health Quality and Safety Commission New Zealand report “for every fall in hospital, there are five in aged residential care and another 40 at home and in the community. Between 2010 and 2012, a total of 200 people fell while in hospital care and broke their hips.“
The HCSL QA online bench-marking includes tracking of falls and falls related injuries so educating your staff to become familiar with the definition is important in ensuring data collected is accurate. Accurate data measurements also allow you to be aware of your start point for quality improvement projects which can then be measured at the end of a project to measure the degree of improvement.
In answer to the questions posed at the start of this article, if we apply the WHO definition, then both should be classified as falls. For those of you using the HCSL policy and procedure system, refer to the Falls Prevention Programme (document CS19) for more information on falls prevention.
‘Pressure injury’ according to ACC can be classified in some instances as a ‘treatment related injury’ and therefore you may have the option of gaining support / assistance from ACC in relation to treatment of the pressure injury. In their 2011 fact-sheet, ACC noted “Pressure areas are a significant source of treatment injury claims and impact on both patient morbidity and mortality (1). Between July 2005 and March 2011, ACC accepted 506 claims for pressure areas, and notified 45 as adverse events to the Ministry of Health”.
As pressure injuries are a key focus for Ministry of Health (MoH) this year, auditors will be looking closely at the documentation around identification, management, treatment / care planning and evaluation of these events. Ensure you have comprehensive evidence of your clinical management processes.
Also remember when you log a pressure injury into the adverse event reporting system, you include the stage of the pressure injury. In the HCSL QA online system click ‘pressure injury’ in the ‘type of event’ box and then in the box directly under that, you can record the additional detail of the stage of the pressure injury.
The required MoH notification forms can be found here. You will need the resident GP to complete a ACC45 form. Then contact ACC and rather than asking for what you want, ask what they can do to help. If you ask first, you may be missing out on something they could have provided access to.
For more information on seeking support contact Assistant ACC directly or the ACC Contracts Manager – CDHB Email: Leanne.davie@cdhb.health.nz
On a recent trip to Cambodia and Singapore I visited the older members of the community where they were being cared for and spend their final days. In Cambodia, where there are no formal aged care services; I found the older members of their communities being care for by each other in either family or Buddhist temple settings. The choice is often made by the oldest members of families in Cambodian society to leave home and move into a temple and take on the lifestyle of a Buddhist Monk or Nun.
I was honoured to have had the opportunity to visit these folk and talk with them about their lives and experiences. I asked them if they missed anything about their previous life. The answer when I’ve asked that same question of elder folk in New Zealand has resulted in a long list. These gentle folk smiled broadly at me and told me no, there was not a single thing they missed. Their families still came to visit them. It seemed that was all they needed from life as it was!
In caring for each other these ladies practiced the principles of person-centered care. They were not familiar with the term, were not trained nurses and were not carers who had received formal training. Never the less, they provided care as needed by those receiving it. This was about social housing and accommodation rather than a focus on infirmity, disability or ill health.
On my visit to a nursing home in Singapore, it was inspiring to see the elder ladies sewing staff uniforms and other elder men and women preparing vegetables. These would become meals of the children crèche down the road. These folk talked as they worked together. They were connecting and contributing. Making a difference. They were needed and had value. They held a high status within their community.
In the Singapore Nursing home residents lived in the nursing home in 8 bed units, men segregated from the woman. The sense of connection between residents however was obvious from the numbers of people I saw sitting beside other residents’ beds talking with them, interacting together and chatting as they worked.
There were trained nurses and the Welfare Officer who was a fountain of knowledge talked about person-centered care. The residents’ activities programme was full and could have easily been transferable to any NZ residential care facility.
The terms used were the same as ours but as I looked around I could see the implementation of person-centered care was very different from our interpretation of that type of service. Residents were certainly engaged, appeared happy and well care for.
What struck me however was how different our understanding of the term ‘person centered care’ is and how a society’s culture or organisational policies can mean our practice is very different.
This is an important factor to remember when recruiting staff that have been trained and work in other countries. When you describe something to an applicant you’re recruiting and they say they understand the concept, does it necessarily mean you have the same understanding. The picture in your mind of what the outcome will look like may be very different to their mind-view? Sometimes it pays to ask more questions!
Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents are (first two are key for residential care):
- Medication Care Guides for Residential Aged Care 2011 – MoH
- Standing Order Guidelines 2012 – MoH
- Medicines Act 1981 and Medicines Regulations 1984
- Misuse of Drugs Act 1975 and Regulations 1977
- Health Practitioners Competency Assurance Act 2003
Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments. Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished. Below are common errors which continue to be made:
| Aspect of medication management | Common Errors |
| Medication charts | Not datedNot signed by the prescriberNot signed by the General Practitioner or Nurse Practitioner at each review (3 monthly)Not legibleAllergies not documented (or inconsistent with other resident documents)Transcribing on medication charts or PRN signing sheetsPRN medication charting does not include ‘indication for use’Medication order does not include time, dose, frequency, route, type etc |
| Signing sheets | Missed signatures on the signing sheetsOnly one signature (instead of two) on controlled drug administration records and registerPRN medication not signed for accurately |
| Self-medicating residents | Competency to verify self-medication not signed by prescriberCompetency for self-medication not signed as having been reviewed by prescriber (3 monthly)Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order)Not retaining a current list of all medication ordered for self-medicating residents |
| Storage | Medication not securely stored (also see ARRC D15.3(c) Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy)Controlled drugs not stored in locked cabinet in locked roomDrug trolley left in common areas unlockedExpired medication continue to be stored on site (should be returned to pharmacy)Medication for resident who has been discharge or deceased remain on siteMedication fridge temperature not monitored / recordedLabels on medication containers not clear / legible |
| Identification of resident | Photograph not representative of current presentation of resident (photograph should be colour)Photograph of residents not validated regularly |
| Medication errors | Not reportedNot managed (through an adverse event management process to ensure identification of contributing factor and preventive measures). |
| Competency | All staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competencyAnnual review of medication competencies |
If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor. The risk is too high for the residents and your organisation. Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.
Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty. Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering. Refer to the Aged Related Residential Care Contract (ARRC) for further information.
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.
I ate the best crispest, crunchiest, juiciest, rosiest, sweetest most marvellous apple while I was driving home last night after attending a seminar. I had put it in my bag earlier for just such an occasion and it really was the very best apple.
You might be wondering why I’m writing about eating an apple. Well the point is I can eat an apple. I can eat an apple while driving a car. No-one should drink and drive and we are not allowed to text and drive but eating an apple while driving is still allowed.
The reason it was good to eat this most marvellous apple was that in order to eat it I first had to achieve a whole range of things. I had to have the money to pay for this crunchy crisp apple which confirms I have the financial reserves to not only pay for the petrol and maintenance for my car but also to pay for this beautiful rosy apple. I had to also remember that I liked apples along with remembering where the supermarket was to buy that most marvellous apple. I then had to recall where I’d parked my car and have the mental competence to get myself and my car and my apple out of the car-park and heading for home.
This all takes having an intact mind so I find it rather encouraging and reassuring that my mind seems to be working just fine.
To be able to eat this delicious thirst quenching juicy apple I had to have physical strength to drive my car and walk into the shop, buy the apple and walk with ease back to my car without getting short of breath in order to drive home. I had to have the muscular strength in my legs to walk, use the foot controls in my car with ease and have the physical reactions to stop in a hurry if I had to. All this being achieved while enjoying a gift of natures food, my wonderful apple. The hand dexterity needed to hold and manoeuvre that apple so I could bite the piece I wanted while steering the car was also something I take for granted. I realise I take for granted having healthy teeth to munch and crunch that beautiful apple. This all confirms my body and mind seem to still be functioning with strength and ease which I am very grateful for.
As I savoured every mouth full of this delectable apple while driving home tonight I wondered if when I’m 80 or 90 years old I will still be able to do this most enjoyable feat. I thought of all the things that must function for me to buy apples year after year. Will I have the ability to drive my car and walk into the supermarket and pick the nicest looking apple, pay for it and eat it with my natural teeth? Oh I do hope so.
To increase my odds of repeating this enjoyable drive home devouring delicious mouth full by delicious mouth full of apple, I decide I will need to take good care of myself. I will need to make sure I keep up my physical strength through regular exercise and eat a good diet to maintain a healthy weight. I will need to look after my eyesight with regular eye checks. I will remember to take regular visits to the dental hygienist and look after my teeth. I will manage my finances and enjoy reading books, socialising and learning new things to keep my mind active. And yes, I will continue to hope that with all the right self-cares and a bit of luck, when I am 80 or 90 years old I will be able to go to the supermarket to pick out the very best apple.
I’ve been working through the new Health and Safety at Work 2015 legislation and have concerns about how this applies to not only care facilities and new reporting requirements, but also to Villages. This legislation could cause all sorts of issues for you and in my view needs further clarification as to how it is to be applied to ARRC residential care setting and Villages that come under the RVA.
The Retirement Villages Association define a ‘Licence to Occupy’ as –
“Licence to occupy – This is the most common form of occupation right in New Zealand. A licence to occupy gives you the right to live in your residential unit and to use to village facilities according to the terms of the licence to occupy. The ownership of the land and building remain with the village operator.”
The new Health and Safety at Work Act 2015 which applies from the 4th of April 2016 requires a PCBU (Person Conducting a Business or Undertaking) to report notifiable injuries or illnesses and all notifiable incidents. Looking closer at the terminology used in the legislation is states in relation to responsibility to notify –
Health and Safety at Work Act 2015.
Sub Section part 2 – clause 37 Duty of PCBU who manages or controls workplace (this appears to apply to Village operators as well as ARRC providers)
(4) In this section, a PCBU who manages or controls a workplace—
(a) means a PCBU to the extent that the business or undertaking involves the management or control (in whole or in part) of the workplace; but
(b) does not include—
(i) the occupier of a residence, unless the residence is occupied for the purposes of, or as part of, the conduct of a business or undertaking.
The red text seems to be the rationale for notifications being required from care facilities but it would seem it also applies to village units, studios and apartments. How are you going to know if your village residents have had an injury or illness which is classified as notifiable?
Part 1 Section 23 – Meaning of notifiable injury or illness –
(1) In this Act, unless the context otherwise requires, a notifiable injury or illness, in relation to a person, means—
(a) any of the following injuries or illnesses that require the person to have immediate treatment (other than first aid):
(i) the amputation of any part of his or her body:
(ii) a serious head injury: (This could apply in the case of a fall where a resident has a knock to their head?)
(iii) a serious eye injury:
(iv) a serious burn:
(v) the separation of his or her skin from an underlying tissue (such as
degloving or scalping): (Does this apply to skin tears of a particular size?)
(vi) a spinal injury:
(vii) the loss of a bodily function: (Fall resulting in fracture?)
(viii) serious lacerations:
(b) an injury or illness that requires, or would usually require, the person to be admitted to a hospital for immediate treatment:
(c) an injury or illness that requires, or would usually require, the person to have medical treatment within 48 hours of exposure to a substance:
Implementing this into this sector may be difficult due to the rights to privacy of those living in ‘independent’ ORA situations. The key definer in this section is clause a) any of the following injuries or illnesses that require the person to have immediate treatment (other than first aid). If an ambulance is called to attend to a village resident this could be deemed ‘immediate treatment’.
Part 1 Section 24 – Meaning of notifiable incident –
(1) In this Act, unless the context otherwise requires, a notifiable incident means an unplanned or uncontrolled incident in relation to a workplace that exposes a
worker or any other person to a serious risk to that person’s health or safety arising from an immediate or imminent exposure to—
(a) an escape, a spillage, or a leakage of a substance; or
(b) an implosion, explosion, or fire; or
(c) an escape of gas or steam; or
(d) an escape of a pressurised substance; or
(e) an electric shock; or
(f) the fall or release from a height of any plant, substance, or thing; or
(g) the collapse, overturning, failure, or malfunction of, or damage to, any
plant that is required to be authorised for use in accordance with regulations;
or
(h) the collapse or partial collapse of a structure; or
(i) the collapse or failure of an excavation or any shoring supporting an excavation;
or
(j) the inrush of water, mud, or gas in workings in an underground excavation or tunnel; or
(k) the interruption of the main system of ventilation in an underground excavation or tunnel; or
(l) a collision between 2 vessels, a vessel capsize, or the inrush of water into a vessel; or
(m) any other incident declared by regulations to be a notifiable incident for the purposes of this section.
Clearly the majority of these apply to manufacturing and industrial sites however some could potentially be applied to the care and village setting.
What do you see as your liabilities? What is the responsibility for the operator in managing potential risk? Which assessment tools and accompanying definitions are we best to apply if any? If alcohol consumption by a resident or failing cognitive state is likely to contribute to their safety, where are the boundaries for responsibility between the resident and the operator?
Share your comments ….
Amberley Resthome and Retirement Studios
“I was referred to Gillian Robinson (HSCL) through a colleague as I knew I needed expertise help when starting out in the aged care industry. Little did I know I would get the best!
Working alongside someone as passionate as Gillian is a privilege which reflects the level of commitment she makes to you as a client. From the phone calls and emails, to the training sessions, to the continuous improvement guidance and depth of knowledge that is implemented in our system. I can’t thank Gillian enough for her support and have no hesitation in recommending her services to anybody in the healthcare sector.
She knows this industry inside and out and has played a pivotal role in our success as an organisation”.
Tracey Dimmock-Rump – Owner / Manager
I remember years and years ago hearing about the coming of the paperless society! Do you recall that? Have we achieved it? If anything, we’re surrounded by more and more paperwork. I receive enquiries on a regular basis from disgruntled nurses that are bogged down in paperwork and wanting to know if there is a simpler way to do things that will allow them time to get back to hands-on nursing; spending time with their residents.
I’m more than happy to help you with freeing up your time and still achieve all the necessities of documenting service provision. One way to do this is using smart computer software. I realise that up until recently our industry has not been ready for this however with the surge in uses of Facebook and other social networking sites, computers are not as intimidating as they once were!
I’m committed to getting your nurses back on the floor while working on the basis of continuous improvement and providing excellence in care based on evidence based practice. In order to help me develop the tools you need I’d appreciate you taking a few minutes to complete this quick and simple survey.
Thank you for your time and look forward to getting a solution that will allow you to get out of the office and back to your residents!
Contact Info
Level 2 / 9 Baigent Way, Middleton, Christchurch, NZ
+ 027 601 6401 (Support) or
+ 027 601 6400 (Director)
+ 027 601 6400 (Director)