Real Nurse

MRSA - Stating The Obvious - 2

2007-08-22T10:18:00.000Z

One of the most obvious features of ill people is the sweat. Sorry, but it's true. Anyone with a high temperaute will be sweaty as part of the body's temperature control; many ill people live with with cold sweats, night sweats and warm ward sweats. Warm ward sweats?

The average NHS ward is, to put it mildly, warm. In summer, this is largely due to the effects of the summer, combined with poor ventilation, no ventilation or inadequate air conditioning or broken controls. In winter, just plain stupidity.

Sure you could spend a few years and doubtless make a few reputations researching this - or you could apply common sense and first principles: Bugs love warmth and damp. Skin-dwelling bugs love warm, damp skin. Staph. aureus is a skin-dwelling bug. Logic suggests we may have ideal conditions for MRSA to thrive.

But why stop there? Take logic and common sense a little further; up the arms of nurses, for example. Nurses are getting good at using gloves*, and at hand cleansing. But it all stops at the wrist. Just watch nurses with patients who need physical care; the contact almost invariably reaches well above the wrist, indeed, it often goes to the shoulder, with all that sweat rubbing onto the uniform ... and off again at the next patient.

But all this is theoretical, surely? Isn't it?

1. Patients nursed in four-bed rooms are often discovered to be carrying MRSA by chance. Statistics at one hospital show that the other three patients carry a much higher risk of picking up hospital acquired MRSA than the average patient. No, it hasn't been published; it never will - it undermines their policy of not even isolating those patients.

2. That hospital had a pilot study which included screening every patient on the ward, once a week. Guess what? they found too many. So the weekly screening was stopped. Now they screen on discharge, so the damage is dicovered waaay too late. Government targets do not encourage looking for MRSA - you might find it! Go figure.

3. A few years ago, I had a job which entailed visiting a central London ICU several times each week. Patients there were nursed in pairs; so much equipment was shared (often sweaty) and nurses 'covered' for each other for breaks, etc. Over a period of several months, quite a few patients were found to have MRSA after admission; they were usually isolated on discovery - but in almost every case, the patient who had been 'paired' was later found to be positive.

I have no doubt, from my own observations, that warm wards increase the risks of MRSA transfer. As well as being a pretty unpleasant environment for both patients and staff. And all too common.

*wearing gloves can include wearing the same pair from patient to patient. Using gloves correctly isn't just about hand cleansing and putting them on properly - it's about changing them between patients.

Storing Up Problems

2007-08-03T10:30:00.000Z

I never fail to be amazed by bureaucracy's constant attempts to take over the world.

Recently, the ward got a big, bright, clean storeroom, replacing several smaller storage areas. Very nice, and very confusing, as everything had moved and autopilot no longer found what you needed.

But we were getting used to it, when our Stores Top Up Man went on holiday.

The stand-in guy couldn't find where to put some things, and, er, didn't bother. So we ran out of stuff. Unsurprisingly, Stand-In Guy didn't want to be blamed, and voiced his anger and frustration that items weren't stored in the order dictated by his catalog. His boss, of course, agreed.

We suggested (equally unsurprisingly), that we didn't think the catalog order was necessarily right for us, the users. One nice example is IV device dressings; the catalog, like the Drug Tariff, wanted to place these dressings with all the other dressings; we, inexplicably (duh!), wanted to place them adjacent to the IV devices.

Following the shouting matches, we've now moved on, like mature professionals, to a three hour meeting, with at least four people. So twelve hours of expensive professional time ... this one will run and run ...

MRSA - Stating The Obvious - 1

2007-08-03T10:28:00.000Z

MRSA - methicillin resistant staphylococcus aureus - is a fact of health service life in the UK, as, indeed in most of the world.

The newspapers are full of it - well, half truths about it - to the point when recently, a patient stopped at the ward door and refused point-blank to come in.

I don't blame him, really. It's no mystery that NHS wards are dirty places, and little mystery that patients often enter hospital without infection, and go home with it.

So why are MRSA policies so utterly lacking in common sense?

Isolating Patients

This is the first of several factors I'll be looking at over the next few weeks.

It seems fairly obvious to me that isolating a patient in a crowded four-bed unit is pretty much a non-starter. The other three patients have to be at increased risk, surely? Do we need to wait for someone to do some research, someone to die, or someone to sue, before that obvious fact finally gets accepted?

Sure MRSA is rarely airborne, and so there is a theoretical possibility of not transmitting the infection from one patient to the other three. But in the real world, with shared curtains, visitors moving chairs, domestic staff moving plates, nursing staff moving all manner of things, not to mention cancelling callbells and filling in charts ... does anyone on the planet believe that gloves are going to get donned and removed correctly 24/7?

One group of people ... hospital managers. No one else.

And even if normal human beings believed in that particular Santa, would they believe it right to take that gamble with three other sick people? With poor or non-existant warning signs? And you can bet that whatever notices do exist will not mention MRSA (not even in tiny print).

And even if they sold their souls and accepted that risk ... could it ever be right to do it without even telling those three patients? (not that they won't guess, and lose all respect for the staff ...).

Nursepower Crisis - Again! (Autumn 2006)

2007-06-11T21:34:00.000Z

I won't harp on too long about this, but I'd like to get it on record.

Yet again, the NHS - and the UK government - have got their planning wrong, and we have so many 'new' nurses, that many went on the dole last autumn.

And yet, just a few years ago, managers were swanning off to Australia to recruit nurses (passing Australian managers coming to the UK to recruit nurses). Round about the same time, colleges and universities were pressurised to enlarge their intakes.

Of course the plans weren't that wrong; the government long intended to increase the numbers, by enough to avoid decent wage rises - but this time they went too far, and got the bad publicity. But they are managing to hold back wages.

Supply and demand is very effective, and too many nurses does mean national nurse negotiators are weakened, plus the hidden wage cuts, of being able to use an E where an F was required before (substitute numbers from 'Agenda For Crap', if you can remember them).

'New' nurses may rest assured that the glut will not last long - but students should be aware that the future is not bright. What will this year's qualifiers find?

While there is a 'hold' on enticing nurses from developing countries, there is nothing to stop Common Market recruitment, except language. And rumour has it that Polish plumbers will soon be joined by Romanian RNs, Czech cardiac nurses, and, doubtless Maltese matrons and Former-Yugoslav-Republic-of-Macedonian managers - it's only a matter of time.

Don't get me wrong; I have no objection to English-speaking EU nurses, even if their English is not perfect (it's often as good as mine!). EU mobility could be an asset to ALL EU countries (not just the rich ones) , and could give useful and varied experience to individual nurses.

But it would be sweet if the NHS factored these figures into planning, and avoided a situation of wasting student nurse education - not to mention this regular dose of personal misery.

Based on an article written October 2006

Eusol - Tool of the Devil?

2007-05-31T19:46:00.000Z

I saw a nurse sacked about eight years ago for arguing with a surgeon about using Eusol. She knew it was 'bad' but had no idea what was bad about it. BS-ing a consultant who's used it for 20 years was a little unwise; especially in front of a patient.

I'm pretty sure the army still uses it, though my info may be 5 years out of date - but there's plenty of arguments in favour of using it in certain circumstances.

Never forget that Eusol *works* - and does not necessarily do any harm. It has largely diasappeared from hospital usage not because it is 'bad' - but because many other things are better.

There's a great article from Issue 1 of the Journal of Wound Care (1992) which has some 100 references; the most thorough review I've ever seen (I nearly got sacked for publishing it). There's been little research of note since.

"Rituals In Nursing" tritely exposed it's misuse, but history has simply repeated itself in reverse - now we 'don't use it' for no good reason, equally ritualistic, and devoid of rationale.

Those days, you could argue (and we did); you shouldn't use Eusol until you've read research that justifies the risk *in your circumstances*.

Today, you could argue just as powerfully, you shouldn't dismiss it, unless you've read the relevant reseach.

They dissed leeches; they dissed honey, they dissed maggots ... all vital parts of modern wound care, if you read the research.

They also started a NEW RITUAL, of cleaning wounds with saline alone, and people now do that, regardless of the type of wound, regardless of the local skin contaminants, regardless of MRSA "because research says so".

And you could bet £1000 they haven't read the research ... Because I happen to know that research *Does NOT* say so!! [Except for certain wound types in certain conditions]

Human Resources? Do they mean People?

2007-05-16T13:17:00.000Z

I've never quite understood the 'Human Resources' stuff - I remember when 'Personnel' wasn't a dirty word - in fact, I remember the day it became a dirty word.

Mary Gleason had just popped down to ask about maternity arrangements. She just heard that she was expecting, and was a little over anxious to get things right. "Please don't tell Sister just yet" she said, "I want to tell her myself when the doctor confirms my dates"

"No problem", said Avril in Personnel, "There's really no hurry for a good while yet". Mary returned to the ward. As she approached Sister's office to report back, Sister was just putting down the phone. "I hear congratulations are in order" She said. Mary never went to Personnel again.

Of course that kind of senseless stupidity is child's play compared to the games they play now.

The latest is this fear of being unfair to candidates. Now, I'm all for being fair to candidates, but there are limits. Thing is, they are so scared of tribunals, complaints and - whisper the word - lawyers, that they tend to appoint the person with the most threatening glare, rather than the one who's best for the job.

Of course I can understand that ward progress reports might be biased, and if, say, Sister didn't like men, then they could lose out.

Not to worry, there's always references; the referee is picked by the candidate, so they've been able to choose someone who will be fair, honest and constructive, and that's all we'll need. But no; it wouldn't do to let the interviewing panel read the references in advance; it might bias them one way or maybe another.

Fair enough, they can select at interview, read the references, and then make the appointment, can't they? Well, apparently not. Apparently it's unfair to ask referees for references for candidates who are not likely to be appointed, and potentially unfair on the candidates, if the reference fails to arrive in a timely manner.

So. Um. Well, best to appoint on the basis of interview, but not confirm until the selected person's reference has arrived. Er, no. That's unfair on the candidate too; all that awaitin' and a worryin' for the reference to arrive.

So you interview, select a candidate on the basis of interview, make the appointment, with the proviso that a negative reference may force a rethink.

And that never happens; no-one is going to risk the money - or the time - for a long boring court case.

So what happens is how it was put to me by a manager the other day "We appoint by interview - the best person on the day gets the job"

Think about that. All that leaning over backward to be fair to the candidate. But which candidate are they being fair to? And why aren't they being fair to the folk who get to work with the new member of staff - who may interview well, but be lazy, rude, smelly, incompetent and otherwise unpleasant?

And how fair is it to the patients that this schmuck will be responsible for?

Wasting Money - A Feature of Health Service Life

2007-03-21T02:15:00.000Z

Every time I think of waste, I think of managers. Can't think why; maybe it's because when I was a student, six wards shared one (nurse) manager. She know all the staff, she knew all the patients; indeed, on alternate week ends, she'd ask a student on each ward to take her round - and invariably she knew more about the patients than the student (and woe betide the student who tried to bluff their way round).

Now, the ward where I work shares managers with a handful of other wards; shares about 15 managers, most of whom wouldn't know a patient if they tripped over one - or most of the staff, either.

But there's so much management waste, and it makes me so angry, that I really cannot compose a useful post about that.

So let's look at lifts (Elevators, for nurses across the pond in North America).

Hospitals require lifts and lots of them; they get caned in daily use, and fail a lot. Or do they? My multi-floor block has five 'public' lifts facing each other in a central foyer. For the second time in ten years they are starting on a program of 'complete replacement' (Last time the program foundered after one new lift).

But why do lifts fail? I did a little research, and by and large, it's door problems, with occasional bearings giving out, and even more rarely, software problems. On a daily basis (if they are lucky), the lifts get swept out and the floor mopped, I guess by the people cleaning each foyer up the tower. There's no specific attention to the lift runners, and the non-specific attention involves dirt being swept into the runners on a daily basis.

At any one time, two or a maximum three lifts work. And at least one of them shows signs of oncoming problems, either the outer door snagging on rubbish on one or more floors - or the inner door catching on very floor. The one 'new' lift (just a few weeks old), the first of the replacement program, already has problems on two floors, and the runners are visibly silting up with grease, dust and grime.

I wouldn't expect the cleaning managers to spot it - they tend to hide, not even answering their bleeps, unless it's an outside phone call (if we need them, we go via switchboard and pretend to call from outside). But what about those other managers who have nothing better to do than design forms for us to fill in? You'd think an ambitious manager would like to be seen saving the trust many thousands of pounds, many wasted hours - and many buckets of frustration? No.

Ah! - why don't I report it? Well, the problem exists in virtually all London hospital tower blocks, and probably in every hospital tower in the country, if not the world. I did once report it at another site. I was, of course, ignored. I'm only a nurse, after all.

But the sadder explanation is that I cannot even find time at work to report the occasions when patients admitted to the Emergency department due to pain, arrive on the ward with no pain prescription. And yes, I have reported such events in the past.

Care to guess what the out come was? Nothing happened.

Pay Rise - What Pay Rise

2007-03-21T01:44:00.000Z

As is so often the case, Nurses in the UK have been shafted by the Government.

With inflation at 3.5% - and rising rapidly - we've been awarded what amounts to 1.9%

OK, hands up who expected more ....

With an excess of nurses at this time, due to an overprovision of education (still increasing last academic year), the government knows that they have got away with it again, despite all the kind words and genuine support for nurses that exists out there.

But, as ever, short term thinking by a short term bunch of cheap crooks. Yes, there is an election coming one day, and it's close enough for nurses to remember. Not 'New Labour' care, of course. But what will get them in the end is the downturn in nurses that will happen within a few years; they have guaranteed that no intelligent teen will enter nursing, just as the major retirement wave hits the profession.

Stupidly, they've done this just after cutting off the theft of nurses from developing nations, and are relying on stealing from the new members of the EU - but that is bound to fail, as far too few of them can speak enough English to get by. Sure, they'll try anyway - but having stirred up anti-immigrant feelings, that one will fail.

Nobody likes being shafted time after time; but at least we get to laugh at the idiots who are ruining the NHS one more time. Where do they find these people?

It is unlikely, of course, that this years stupidity will whack Gordon Brown in the eye, despite his native Scotland choosing to be more generous than the England and Wales bosses. But I suspect he's miscalculated.

He was probably intending to be mean - sorry, 'prudent' - this year, allowing him to appear generous next year, when the election is much closer. But with inflation beginning to slip from his grasp, he won't have that safety net. So he'll be even tighter next year. And that will end his 'honeymoon period', assuming it lasts that long.

Ritualistic Nursing - Pre-Injection Skin Cleansing

2007-02-09T21:42:00.000Z

"The World Health Organization (WHO) estimates that 12 billion injections are given annually, 5% of which are administered for immunization and 95% for curative purposes. Unsafe injection practices (especially needle and syringe re-use) are commonplace in low-income country health settings, and place both staff and patients at risk of infection with blood-borne viruses (BBVs)."

A fascinating bunch of statistics. But all the literature is clear that reusing and improperly sterilizing are the issues, even in the poorest of developing countries: "Eliminating unnecessary injections is the highest priority in preventing injection-associated infections. However, when intradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterile injection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries to the provider, and the prevention of access to used needles."

There's a lot of related literature, and it makes harrowing reading.

But nowhere do I find mention of routine skin cleansing with alcohol for injections (leaving IV aside, here). A few years ago, I read a paper that I cannot now find in Pubmed, that looked at the number of injections per annum in the US (many millions) and reviewed the number of infections that could be firmly linked to skin contamination. Zero.

So why is this routine still applied almost everywhere? OK, the cost and time are small - but it all adds up, and waste is waste.

There are always special cases, of course; patients with diabetes spring to mind as a subset at increased risk. But are they? "Routine skin preparation with alcohol before insulin injection markedly reduces skin bacterial-counts but may not be necessary to prevent infection at the injection sites."