In the
NEWS
News Director: Gail M. Pfeifer, MA, RN E-mail: [email protected]
Emergency Care in America Gets a Near-Failing Grade
E
mergency care is a fundamental part of our nation’s health care system. But with reduced ED capacity, along with rising demand—the result of an aging population, the influx of new patients brought about by health care reform, and demands on providers to decrease the numbers of preventable illnesses and injuries—the system is strained to the point of near failure. A new “report card” issued by the American College of Emergency Physicians (ACEP) gives the overall ED environment nationwide a grade of D+. The report assigns grades to several aspects of emergency care: access, D−; quality and patient safety environment (the use of “systems and protocols to improve lifesaving care and facilitate effective and efficient systems of care”), C; medical liability environment, C−; injury prevention and public health, C; and disaster preparedness, C−. The report is a follow-up to the ACEP’s 2009 report card, in which the system earned an overall grade of C−. That report identified a number of problems, chief among them ED crowding, and recommended steps to alleviate the situation; in the years since, however, excessive crowding and other problems have persisted—and in some cases are now worse. The nation’s lack of access to emergency care reflects an inadequate workforce: only 4% of physicians in the United States work in emergency care, yet EDs handle 11% of all outpatient care and 28% of all acute care visits. [email protected]
It also reflects diminished hospital capacity. The grades for disaster preparedness and quality and patient safety environment also declined, although some individual states have seen improvement. Much of the strain on EDs comes down to resources. On first reading, the report appears to be nothing but bad news, but as Maryfran Hughes, nursing director in the ED at Massachusetts General Hospital in Boston, explains, the results are mostly a reflection of systems and policies, rather than the quality of patient care. “We still feel a lot of pride in the quality [of the care we provide], even when we’re working in circumstances that are less than optimal,” Hughes says. A low grade in disaster response, for instance, might be, as it is in Massachusetts, a reflection of a dearth of “surge beds” (beds available for use in response to a sudden increase in need). “It’s not that we haven’t had enough drills or that the hospitals aren’t talking to each other.” In the report, the ACEP makes 11 recommendations to improve the nation’s emergency care, including protecting access to ED
Photo by Benjamin Norman / New York Times.
Access to care may still be the biggest problem.
care as health reforms are im plemented, pursuing state laws and programs to reduce preventable deaths and injuries, and funding education programs to address staff shortages, among others. In the meantime, the challenge for emergency care nurses is working around system and policy problems to provide the best patient care experience possible. “We’ve had overcrowding for more than 10 years, and we’ve done a lot with our inpatient colleagues [to manage it],” Hughes says, emphasizing the need for good communication. Improving communication can lead, for instance, to more quickly filling empty inpatient beds when they become available or to texting among nurses to determine how to move patients most efficiently. The full report is available at www.emreportcard.org.—Laura Wallis AJN ▼ April 2014
▼
Vol. 114, No. 4
15
In the
NEWS E-Cigarettes Raise Concerns
Photo by Matthew J. Lee / Boston Globe via Getty Images.
These unregulated products may not be harmless.
T
he use of electronic cigarettes, or e-cigarettes, is increasing among adult smokers and former smokers, and these products remain unregulated by the Food and Drug Administration (FDA), except when they’re sold for therapeutic reasons. The battery-powered devices deliver doses of nicotine and other additives via a vapor, and although the exact components vary by brand, e-cigarette cartridges may contain nicotine, a component to produce the vapor (an atomizer that heats up, turning a liquid, such as propylene glycol or glycerol, into vapor), and flavorings. In most states, there are no restrictions on sales to minors, but according to the Centers for Disease Control and Prevention (CDC), the devices seem to be growing in popularity among school-age children and teens (go to http:// 1.usa.gov/1hsHZWK for the entire report). 16
AJN ▼ April 2014
▼
Vol. 114, No. 4
According to the CDC, the use of e-cigarettes doubled among U.S. middle and high school students from 2011 to 2012; extrapolation from the percentages suggests that there may be as many as 1.78 million student users. Additionally, an estimated 160,000 students who said they’d used e-cigarettes had never smoked conventional cigarettes. The public health impact of ecigarette use remains uncertain. “There have been reports of exploding cartons and possible harmful ingredients in the product and in the vapor,” says Stella Bialous, president of Tobacco Policy International. Because they’re unregulated, she says, whether these products are safe isn’t yet known. There are also no data confirming the efficacy of e-cigarettes as a cessation device, says Bialous, although a study in the Lancet (November 16, 2013) found that e-cigarettes were “modestly effective” in helping smokers quit. The
level of abstinence from tobacco was similar to that observed with nicotine patches, and the study authors suggest that there may be potential for e-cigarettes in that context. E-cigarettes appeared to have no adverse effects, have a greater reach, and be more acceptable than nicotine patches, at least as observed in this study. The FDA had tried to block the importation of e-cigarettes from China until their safety, as well as their efficacy as a cessation device, had been demonstrated in clinical trials, but a federal judge overruled the agency in January. The FDA’s efforts were backed by several groups, including the American Cancer Society, the American Heart Association, Action on Smoking and Health, and the Campaign for Tobacco-Free Kids. The FDA has submitted a proposal to extend its authority over tobacco products to include e-cigarettes.—Roxanne Nelson
NewsCAP In 2009, 20 U.S. children and adolescents were hospitalized
each day for firearm injuries, data from the Kids’ Inpatient Database show. An estimated 7,391 hospitalizations resulting from firearm injuries occurred in children and adolescents, and 6% of patients died in the hospital. The overall rate of hospitalizations related to firearm injuries was 8.87 per 100,000 people younger than 20 years and was highest among 15-to-19-year-olds. Injuries stemming from assaults were the most frequent reason for hospitalization; those resulting from suicide attempts were least frequent. Profound race and sex differences were found. Of all those hospitalized, 89% were male and 47% were black. The findings were reported in the February issue of Pediatrics.
ajnonline.com
Mystery CKD in Central American Workers Better surveillance and patient care are urgently needed.
A
chronic kidney disease (CKD) of unknown cause and with unusual characteristics has claimed thousands of lives of agricultural workers in Central America over the past two decades. Members of the Directing Council of the Pan American Health Organization (PAHO) met recently and passed a resolution to speed investigations into the environmental and occupational causes behind this “serious public health problem that requires urgent action.” The PAHO recommendations include improvements to health services for patient care; better surveillance of at-risk communities; and alliances to uncover the condition’s causes, which can lead to appropriate, evidence-based interventions. The PAHO resolution, passed in October 2013, supports the similar San Salvador Declaration that was passed the previous April. The mystery CKD most often affects young men living in lowincome agricultural regions along the Pacific coast. However, the cases aren’t linked to diabetes and hypertension, the typical causes of CKD, which damage the kidney’s filtration system. Rather, this form of CKD damages the renal tubules. Environmental toxins, such as agricultural chemicals; unsafe working conditions; and inadequate intake of water while working in the heat are suspected factors. According to the Guardian (http://bit.ly/1cS2RPx), workers describe fainting and vomiting in sugar cane fields, where they [email protected]
work without any water for five hours or more in temperatures above 100°F. They also mix and spray agrochemicals without wearing gloves or other protective gear. El Salvador and Nicaragua have been hit especially hard by this unusual CKD, but high rates are also being seen in Sri Lanka and in India. Precise statistics on incidence and Walter Arsenio Rivera, 29, poses with his father, Antonio Arsenio Rivera, 58, in the cane fields of Chichigalpa, Nicaragua. Both men suffer from chronic kidney deaths are difficult to collect, although disease. Photo by Ed Kashi for La Isla Foundation/VII. PAHO statistics (http://bit.ly/O61BmH) indicate and 1,000 in Nicaragua currently that CKD-related hospitalizations receive dialysis. Thousands of peoin El Salvador rose 50% from ple in Central America have died 2005 to 2012, and nearly 1,500 from CKD in the past 10 years, of the 40,000 patients hospitalmost of them in Nicaragua and ized were younger than 19 years El Salvador. Experts believe that old. National transplantation the death toll alone in El Salvacenters report that 3,100 patients dor is at least 20,000.—Carol in El Salvador, 3,000 in Guatemala, Potera
NewsCAP Making the best of electronic health records. With the use of electronic health
records growing at a furious pace, assessing and optimizing their effectiveness becomes a national priority, and health information technology becomes an increasingly important part of U.S. health care. New Safety Assurance Factors for EHR Resilience (SAFER) Guides from HealthIT.gov provide self-assessment checklists; practice worksheets; and recommended practices for crucial areas, including patient identification, organizational responsibilities, and contingency planning. Each entry has a corresponding worksheet to aid improvement. Each guide can be downloaded as a PDF and has a link to an interactive Web-based tool at www.HealthIT.gov/saferguide. AJN ▼ April 2014
▼
Vol. 114, No. 4
17
In the
NEWS More States Limit Access to Abortions The number of laws restricting abortion soars.
The 205 new restrictions fall into 10 cate gories, four of which account for nearly half of those passed: bans on abortions after 20 weeks after fertilization, limits on medical abortions and on coverage by private health insurance, and regulations on providers. Back in 2000, the two most restrictive states were Utah and Mississippi, and both had five of the 10 restrictions on the Guttmacher list. By 2013, however, 22 states had five or more restricOn March 25, 2013, more than 300 people attended an abortion rights rally in Bismarck, North Dakota, to protest a package of measures that tions, and Louisiana had would give the state the toughest abortion restrictions in the country. enacted all of them. Photo by James MacPherson / Associated Press. In 2013, 27 states were considered hostile rom 2010 to 2013, state leg- to abortion rights, compared with islatures in the United States 13 states in 2000. At the same time, passed more laws restrictthe number of middle-ground ing women’s access to safe aborstates dropped from 20 to 10, and tion services (n = 205) than in the the number of supportive states previous 10 years combined (n = fell from 17 to 13. A third of U.S. 189), according to data compiled women lived in hostile states in by the nonprofit Guttmacher In- 2000, but by 2013, 56% lived in stitute (http://bit.ly/1c1zIRI). hostile states.
F
U.S. Senator Patty Murray (DWA) said on the 41st anniversary of Roe v. Wade, “These haven’t just been attacks on a woman’s right to choose, but it’s been an all-out assault on everything from shaming pregnant women to drafting politically-driven legislation intended to create geographical roadblocks for low-income and racial minorities wishing to access safe reproductive services.” In contrast, California has improved access to early abortions by allowing physician assistants, certified nurse midwives, and NPs to perform abortions. This January in North Carolina, a female federal judge struck down a 2011 law that forced abortion providers to show women an ultrasound image of the embryo or fetus before they have an abortion. And overall, abortion rates fell 13% from 2008 to 2011; according to a different Guttmacher report (http://bit.ly/1c1AT3J), that’s largely because of better contraceptives and the recession, rather than state restrictions.—Carol Potera
NewsCAP
Adolescents receive inaccurate information on emergency contraception. According to a study in
the January Journal of Adolescent Health, teens wanting to buy Plan B (levonorgestrel, used as emergency contraception) face barriers at pharmacies, where staff may cite ethical or moral objections to selling it; they may also be confused about dispensing rules, such as age limits, the need for a prescription, and confidentiality. Trained callers posing as 17-year-olds talked with employees at 943 pharmacies in five U.S. cities. They asked about that day’s availability of emergency contraception, age requirements, and the need for prescriptions or parental notification. Eighty percent of the pharmacies had Plan B in stock, but only 57% gave correct information about access. 18
AJN ▼ April 2014
▼
Vol. 114, No. 4
ajnonline.com
Updated Guidelines on Hepatitis B Protection for Health Care Personnel Those at risk for exposure to blood or body fluids should be vaccinated.
T
he rate of acute hepatitis B virus (HBV) infection in the United States has decreased, but health care personnel remain at risk for occupationally acquired infections, primarily from exposure to patients with chronic HBV infection. The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has updated its guidelines on prevention and postexposure management of HBV in health care workers (http://1.usa.gov/ 1mrRx6l), emphasizing the importance of vaccinating all health care personnel who may be exposed to blood or body fluids. In 1991, the ACIP recommended that postvaccination serologic testing for antibody to hepatitis B surface antigen (HBsAg) be considered for all health care personnel at risk for needlestick exposures. In 2011, the ACIP reaffirmed its recommendation that
unvaccinated and incompletely vaccinated health care personnel at “reasonably anticipated” risk for blood or body fluid exposure be vaccinated against HBV and that those at high risk receive serologic testing one to two months after completion of the vaccine series. The new report also provides guidance for all those working, training, or volunteering in health care settings who received (documented) hepatitis B vaccination years before beginning work at a facility. Because vaccine-induced HBsAg weakens over time, the CDC recommends preexposure assessment of HBsAg when workers are taken on, followed by one or more additional doses of vaccine in those whose serum HBsAg level is less than 10 mIU/mL (the minimum value considered to be protective). The CDC also advises all health care institutions to ensure that personnel receive training in recognizing and reporting exposures; have
systems in place to facilitate reporting and postexposure assessment; and provide readily accessible prophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, which should be administered as soon after exposure as possible to exposed personnel who are thought to be susceptible to HBV infection. No postexposure HBV management is necessary in exposed personnel who have documentation indicating receipt of a complete hepatitis B vaccine series and subsequent HBsAg levels of 10 mIU/mL or greater.—Karen Rosenberg
Got News? Send leads for stories about nursing practice or issues to ajnNews@wolterskluwer. com.
NewsCAP The proper attire for preventing hospital-acquired infections. The Society for Healthcare Epidemiol-
ogy of America has issued recommendations to help hospitals address the potential that the clothes worn by health care personnel have to transmit pathogens. The group found that there was little evidence from which to develop formal guidelines in nonsurgical settings but did conclude that guidelines would be helpful in light of the role fomites can play in transmitting microorganisms in the hospital. The recommendations on attire include a bare-below-the-elbows approach—in other words, short sleeves, no jewelry, no ties. The complete recommendations, published in February’s Infection Control and Hospital Epidemiology, emphasize that they are meant to help hospitals develop or modify voluntary measures that are “accompanied by a well-organized communication and education effort.” ▼
[email protected]
AJN ▼ April 2014
▼
Vol. 114, No. 4
19
NEWS
News Director: Gail M. Pfeifer, MA, RN E-mail: [email protected]
Emergency Care in America Gets a Near-Failing Grade
E
mergency care is a fundamental part of our nation’s health care system. But with reduced ED capacity, along with rising demand—the result of an aging population, the influx of new patients brought about by health care reform, and demands on providers to decrease the numbers of preventable illnesses and injuries—the system is strained to the point of near failure. A new “report card” issued by the American College of Emergency Physicians (ACEP) gives the overall ED environment nationwide a grade of D+. The report assigns grades to several aspects of emergency care: access, D−; quality and patient safety environment (the use of “systems and protocols to improve lifesaving care and facilitate effective and efficient systems of care”), C; medical liability environment, C−; injury prevention and public health, C; and disaster preparedness, C−. The report is a follow-up to the ACEP’s 2009 report card, in which the system earned an overall grade of C−. That report identified a number of problems, chief among them ED crowding, and recommended steps to alleviate the situation; in the years since, however, excessive crowding and other problems have persisted—and in some cases are now worse. The nation’s lack of access to emergency care reflects an inadequate workforce: only 4% of physicians in the United States work in emergency care, yet EDs handle 11% of all outpatient care and 28% of all acute care visits. [email protected]
It also reflects diminished hospital capacity. The grades for disaster preparedness and quality and patient safety environment also declined, although some individual states have seen improvement. Much of the strain on EDs comes down to resources. On first reading, the report appears to be nothing but bad news, but as Maryfran Hughes, nursing director in the ED at Massachusetts General Hospital in Boston, explains, the results are mostly a reflection of systems and policies, rather than the quality of patient care. “We still feel a lot of pride in the quality [of the care we provide], even when we’re working in circumstances that are less than optimal,” Hughes says. A low grade in disaster response, for instance, might be, as it is in Massachusetts, a reflection of a dearth of “surge beds” (beds available for use in response to a sudden increase in need). “It’s not that we haven’t had enough drills or that the hospitals aren’t talking to each other.” In the report, the ACEP makes 11 recommendations to improve the nation’s emergency care, including protecting access to ED
Photo by Benjamin Norman / New York Times.
Access to care may still be the biggest problem.
care as health reforms are im plemented, pursuing state laws and programs to reduce preventable deaths and injuries, and funding education programs to address staff shortages, among others. In the meantime, the challenge for emergency care nurses is working around system and policy problems to provide the best patient care experience possible. “We’ve had overcrowding for more than 10 years, and we’ve done a lot with our inpatient colleagues [to manage it],” Hughes says, emphasizing the need for good communication. Improving communication can lead, for instance, to more quickly filling empty inpatient beds when they become available or to texting among nurses to determine how to move patients most efficiently. The full report is available at www.emreportcard.org.—Laura Wallis AJN ▼ April 2014
▼
Vol. 114, No. 4
15
In the
NEWS E-Cigarettes Raise Concerns
Photo by Matthew J. Lee / Boston Globe via Getty Images.
These unregulated products may not be harmless.
T
he use of electronic cigarettes, or e-cigarettes, is increasing among adult smokers and former smokers, and these products remain unregulated by the Food and Drug Administration (FDA), except when they’re sold for therapeutic reasons. The battery-powered devices deliver doses of nicotine and other additives via a vapor, and although the exact components vary by brand, e-cigarette cartridges may contain nicotine, a component to produce the vapor (an atomizer that heats up, turning a liquid, such as propylene glycol or glycerol, into vapor), and flavorings. In most states, there are no restrictions on sales to minors, but according to the Centers for Disease Control and Prevention (CDC), the devices seem to be growing in popularity among school-age children and teens (go to http:// 1.usa.gov/1hsHZWK for the entire report). 16
AJN ▼ April 2014
▼
Vol. 114, No. 4
According to the CDC, the use of e-cigarettes doubled among U.S. middle and high school students from 2011 to 2012; extrapolation from the percentages suggests that there may be as many as 1.78 million student users. Additionally, an estimated 160,000 students who said they’d used e-cigarettes had never smoked conventional cigarettes. The public health impact of ecigarette use remains uncertain. “There have been reports of exploding cartons and possible harmful ingredients in the product and in the vapor,” says Stella Bialous, president of Tobacco Policy International. Because they’re unregulated, she says, whether these products are safe isn’t yet known. There are also no data confirming the efficacy of e-cigarettes as a cessation device, says Bialous, although a study in the Lancet (November 16, 2013) found that e-cigarettes were “modestly effective” in helping smokers quit. The
level of abstinence from tobacco was similar to that observed with nicotine patches, and the study authors suggest that there may be potential for e-cigarettes in that context. E-cigarettes appeared to have no adverse effects, have a greater reach, and be more acceptable than nicotine patches, at least as observed in this study. The FDA had tried to block the importation of e-cigarettes from China until their safety, as well as their efficacy as a cessation device, had been demonstrated in clinical trials, but a federal judge overruled the agency in January. The FDA’s efforts were backed by several groups, including the American Cancer Society, the American Heart Association, Action on Smoking and Health, and the Campaign for Tobacco-Free Kids. The FDA has submitted a proposal to extend its authority over tobacco products to include e-cigarettes.—Roxanne Nelson
NewsCAP In 2009, 20 U.S. children and adolescents were hospitalized
each day for firearm injuries, data from the Kids’ Inpatient Database show. An estimated 7,391 hospitalizations resulting from firearm injuries occurred in children and adolescents, and 6% of patients died in the hospital. The overall rate of hospitalizations related to firearm injuries was 8.87 per 100,000 people younger than 20 years and was highest among 15-to-19-year-olds. Injuries stemming from assaults were the most frequent reason for hospitalization; those resulting from suicide attempts were least frequent. Profound race and sex differences were found. Of all those hospitalized, 89% were male and 47% were black. The findings were reported in the February issue of Pediatrics.
ajnonline.com
Mystery CKD in Central American Workers Better surveillance and patient care are urgently needed.
A
chronic kidney disease (CKD) of unknown cause and with unusual characteristics has claimed thousands of lives of agricultural workers in Central America over the past two decades. Members of the Directing Council of the Pan American Health Organization (PAHO) met recently and passed a resolution to speed investigations into the environmental and occupational causes behind this “serious public health problem that requires urgent action.” The PAHO recommendations include improvements to health services for patient care; better surveillance of at-risk communities; and alliances to uncover the condition’s causes, which can lead to appropriate, evidence-based interventions. The PAHO resolution, passed in October 2013, supports the similar San Salvador Declaration that was passed the previous April. The mystery CKD most often affects young men living in lowincome agricultural regions along the Pacific coast. However, the cases aren’t linked to diabetes and hypertension, the typical causes of CKD, which damage the kidney’s filtration system. Rather, this form of CKD damages the renal tubules. Environmental toxins, such as agricultural chemicals; unsafe working conditions; and inadequate intake of water while working in the heat are suspected factors. According to the Guardian (http://bit.ly/1cS2RPx), workers describe fainting and vomiting in sugar cane fields, where they [email protected]
work without any water for five hours or more in temperatures above 100°F. They also mix and spray agrochemicals without wearing gloves or other protective gear. El Salvador and Nicaragua have been hit especially hard by this unusual CKD, but high rates are also being seen in Sri Lanka and in India. Precise statistics on incidence and Walter Arsenio Rivera, 29, poses with his father, Antonio Arsenio Rivera, 58, in the cane fields of Chichigalpa, Nicaragua. Both men suffer from chronic kidney deaths are difficult to collect, although disease. Photo by Ed Kashi for La Isla Foundation/VII. PAHO statistics (http://bit.ly/O61BmH) indicate and 1,000 in Nicaragua currently that CKD-related hospitalizations receive dialysis. Thousands of peoin El Salvador rose 50% from ple in Central America have died 2005 to 2012, and nearly 1,500 from CKD in the past 10 years, of the 40,000 patients hospitalmost of them in Nicaragua and ized were younger than 19 years El Salvador. Experts believe that old. National transplantation the death toll alone in El Salvacenters report that 3,100 patients dor is at least 20,000.—Carol in El Salvador, 3,000 in Guatemala, Potera
NewsCAP Making the best of electronic health records. With the use of electronic health
records growing at a furious pace, assessing and optimizing their effectiveness becomes a national priority, and health information technology becomes an increasingly important part of U.S. health care. New Safety Assurance Factors for EHR Resilience (SAFER) Guides from HealthIT.gov provide self-assessment checklists; practice worksheets; and recommended practices for crucial areas, including patient identification, organizational responsibilities, and contingency planning. Each entry has a corresponding worksheet to aid improvement. Each guide can be downloaded as a PDF and has a link to an interactive Web-based tool at www.HealthIT.gov/saferguide. AJN ▼ April 2014
▼
Vol. 114, No. 4
17
In the
NEWS More States Limit Access to Abortions The number of laws restricting abortion soars.
The 205 new restrictions fall into 10 cate gories, four of which account for nearly half of those passed: bans on abortions after 20 weeks after fertilization, limits on medical abortions and on coverage by private health insurance, and regulations on providers. Back in 2000, the two most restrictive states were Utah and Mississippi, and both had five of the 10 restrictions on the Guttmacher list. By 2013, however, 22 states had five or more restricOn March 25, 2013, more than 300 people attended an abortion rights rally in Bismarck, North Dakota, to protest a package of measures that tions, and Louisiana had would give the state the toughest abortion restrictions in the country. enacted all of them. Photo by James MacPherson / Associated Press. In 2013, 27 states were considered hostile rom 2010 to 2013, state leg- to abortion rights, compared with islatures in the United States 13 states in 2000. At the same time, passed more laws restrictthe number of middle-ground ing women’s access to safe aborstates dropped from 20 to 10, and tion services (n = 205) than in the the number of supportive states previous 10 years combined (n = fell from 17 to 13. A third of U.S. 189), according to data compiled women lived in hostile states in by the nonprofit Guttmacher In- 2000, but by 2013, 56% lived in stitute (http://bit.ly/1c1zIRI). hostile states.
F
U.S. Senator Patty Murray (DWA) said on the 41st anniversary of Roe v. Wade, “These haven’t just been attacks on a woman’s right to choose, but it’s been an all-out assault on everything from shaming pregnant women to drafting politically-driven legislation intended to create geographical roadblocks for low-income and racial minorities wishing to access safe reproductive services.” In contrast, California has improved access to early abortions by allowing physician assistants, certified nurse midwives, and NPs to perform abortions. This January in North Carolina, a female federal judge struck down a 2011 law that forced abortion providers to show women an ultrasound image of the embryo or fetus before they have an abortion. And overall, abortion rates fell 13% from 2008 to 2011; according to a different Guttmacher report (http://bit.ly/1c1AT3J), that’s largely because of better contraceptives and the recession, rather than state restrictions.—Carol Potera
NewsCAP
Adolescents receive inaccurate information on emergency contraception. According to a study in
the January Journal of Adolescent Health, teens wanting to buy Plan B (levonorgestrel, used as emergency contraception) face barriers at pharmacies, where staff may cite ethical or moral objections to selling it; they may also be confused about dispensing rules, such as age limits, the need for a prescription, and confidentiality. Trained callers posing as 17-year-olds talked with employees at 943 pharmacies in five U.S. cities. They asked about that day’s availability of emergency contraception, age requirements, and the need for prescriptions or parental notification. Eighty percent of the pharmacies had Plan B in stock, but only 57% gave correct information about access. 18
AJN ▼ April 2014
▼
Vol. 114, No. 4
ajnonline.com
Updated Guidelines on Hepatitis B Protection for Health Care Personnel Those at risk for exposure to blood or body fluids should be vaccinated.
T
he rate of acute hepatitis B virus (HBV) infection in the United States has decreased, but health care personnel remain at risk for occupationally acquired infections, primarily from exposure to patients with chronic HBV infection. The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has updated its guidelines on prevention and postexposure management of HBV in health care workers (http://1.usa.gov/ 1mrRx6l), emphasizing the importance of vaccinating all health care personnel who may be exposed to blood or body fluids. In 1991, the ACIP recommended that postvaccination serologic testing for antibody to hepatitis B surface antigen (HBsAg) be considered for all health care personnel at risk for needlestick exposures. In 2011, the ACIP reaffirmed its recommendation that
unvaccinated and incompletely vaccinated health care personnel at “reasonably anticipated” risk for blood or body fluid exposure be vaccinated against HBV and that those at high risk receive serologic testing one to two months after completion of the vaccine series. The new report also provides guidance for all those working, training, or volunteering in health care settings who received (documented) hepatitis B vaccination years before beginning work at a facility. Because vaccine-induced HBsAg weakens over time, the CDC recommends preexposure assessment of HBsAg when workers are taken on, followed by one or more additional doses of vaccine in those whose serum HBsAg level is less than 10 mIU/mL (the minimum value considered to be protective). The CDC also advises all health care institutions to ensure that personnel receive training in recognizing and reporting exposures; have
systems in place to facilitate reporting and postexposure assessment; and provide readily accessible prophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, which should be administered as soon after exposure as possible to exposed personnel who are thought to be susceptible to HBV infection. No postexposure HBV management is necessary in exposed personnel who have documentation indicating receipt of a complete hepatitis B vaccine series and subsequent HBsAg levels of 10 mIU/mL or greater.—Karen Rosenberg
Got News? Send leads for stories about nursing practice or issues to ajnNews@wolterskluwer. com.
NewsCAP The proper attire for preventing hospital-acquired infections. The Society for Healthcare Epidemiol-
ogy of America has issued recommendations to help hospitals address the potential that the clothes worn by health care personnel have to transmit pathogens. The group found that there was little evidence from which to develop formal guidelines in nonsurgical settings but did conclude that guidelines would be helpful in light of the role fomites can play in transmitting microorganisms in the hospital. The recommendations on attire include a bare-below-the-elbows approach—in other words, short sleeves, no jewelry, no ties. The complete recommendations, published in February’s Infection Control and Hospital Epidemiology, emphasize that they are meant to help hospitals develop or modify voluntary measures that are “accompanied by a well-organized communication and education effort.” ▼
[email protected]
AJN ▼ April 2014
▼
Vol. 114, No. 4
19
