Neutropenic pt W/other isoloation pt

SolaireSolstice, BSN, RN · Dec 13, 2010

Well, our Onc and ID MDs would be flipping out and would start admitting their patients to other hopitals. We isolate our neutropenic patients alone, whether on contact precautions or not. One of our Onc MDs doesn't even like us to keep patients delivered flowers at the nurse's station; he would be apoplectic if we tried housing contact precautions with neutropenic patients. The ID MDs are a bit more pragmatic, especially when it comes to the MDROs. As long as we keep our neutropenic patients away from the ones w/ contact precautions and we wash our hands, they don't stress too much.

Contact precation patient are *usually* isolated alone on our floor, but of 28 rms, 24 of them are privates anyway, so if anything, we usually end up short semi privates rather than privates anyway. Trying to play musical beds to get 2 semis in the same room w/ the same precautions would be silly.

Our hospital has an infectious disease dept, which is actually part of our risk management dept. They make sure we have the correct isolation precautions in place on these types of patients and lately have been in charge of making sure those employees that didn't get the flu shot are wearing their masks. They seem *bored* to say the least, and could use something more interesting to do. Check and see if your hospital has a dept like this and bring up your concerns to them?

FrogKissingNurse · Dec 13, 2010

that is crazy! neutropenic patients are on reverse isolation! trying to keep our germs from them. if they have to share a room it should be with other neutropenic patients. anyone with mrsa or c diff would be the last patients that should be sharing rooms with neutropenic patients. those patients are in isolation as to not spread their stuff to other people. this is not a good situation for those neutropenic patients! as the nurse you should try to advocate for your patients and talk to your nurse manager about your concerns.

blondy2061h, MSN, RN · Dec 13, 2010

We have too many isolation and neutropenic patients for separate nurses to care for both. The whole point of gowning/gloving/handwashing is that you will not be spreading germs elsewhere. The evidence says this. Not washing hands and not gowning/gloving simply cannot be tolerated.

We do use separate equipment.

Shoe coverings are not backed by evidence as your shoe really should not be anywhere near the patient.

We have plastic blinds in our rooms that get bleached between patients. Rugs/curtains have no place in a hospital setting.

Crux1024 · Dec 13, 2010

that is crazy! neutropenic patients are on reverse isolation! trying to keep our germs from them. if they have to share a room it should be with other neutropenic patients. anyone with mrsa or c diff would be the last patients that should be sharing rooms with neutropenic patients. those patients are in isolation as to not spread their stuff to other people. this is not a good situation for those neutropenic patients! as the nurse you should try to advocate for your patients and talk to your nurse manager about your concerns.

i think you are misunderstanding what the op is saying.

the neutro iso's are being cared for by nurses that also have cdiff, mrsa, vre iso pts..not that theyre in the same room, but that the same nurse is taking care of the pts, in seperate rooms and now the neutropenic pts are coming up positive with the cdiff/vre/mrsa.

Crux1024 · Dec 13, 2010

I dont think that this is at all appropriate. Why?
Handwashing dosent always get done by all staff
Equipment isnt cleaned properly- just found out our CNA's are not cleaning equipment on those with C-Diff with soap and water- as those purple wipes used for the equipment do not kill the spores of C-Diff
Our clothing has got to have issues with contamination- especially our shoes! We dont wear shoe coverings (do you think that would help?)
We have these nasty curtains in the rooms that dont get routinely changed, only if they are visible soiled (eww)

I dont feel like the room assignments should matter. Everything should be cleaned and universal precautions used by all. I like the ideas of the plastic curtains. Im not sure why theres fabric curtains in rooms anyway! I dont wanna know whats growing on those things.

Would your hospital even consider keeping some rooms as "Neutropenic" only? I dont think that the one I work for would even consider it.

neuroms · Dec 13, 2010

That sounds seriously dangerous for patient outcomes. Think about systemic MRSA, C Diff, VRE. Do you have nurse councils? You guys should definitely approach the administration about the serious consequences of this decision that was probably made for the sake of 'efficiency'--stupid six sigma. If you are seeing a change in patient outcomes, most likely you're right. Maybe even offer to, or try to coordinate, a clinical study that can quantify such a poor decision.

While you try to make that happen, I hope you really watch out for your patients and push everyone else to do the same.

Quark09 · Dec 13, 2010

I just about DIED when I read your post!!! I was an infection control nurse and rounded at our main hospital and our sister facilities; that N E V E R would have flown. Does your facility have an infection control board? How in the name of the Flying Spaghetti Monster did anyone clear that? At that hospital we would do a bit of shuffling if we had to; occasionally a post-op would grumble at the loss of a private room, but it was not a common occurrence. We also initiated a "no scrubs out the door" policy; employees brought their street clothes with them and changed into them before going home (this because quite a few employees would be caring for MRSA/VRE/C-diff pts all day, then go pick up their kids from daycare [in their scrubs] and then head on over to Walmart [in their scrubs]).

Is there any way you can go to your nurse manager over this?

Belle Epoque · Dec 13, 2010

I see nothing wrong with the hospital policy as stated in the OP. There is no reason, if staff are practicing proper universal precautions and using PPE appropriately, that they shouldn't be caring for more than one ISO patient, whether it's reverse ISO or not.

If staff are not following proper protocol at your hospital then this needs to addressed by your infection control dept STAT. The solution isn't finding dedicated staff to care for a neutropenic patient as staffing levels rarely allow for such luxury, the solution is to educate and enforce proper infection control practices, monitor compliance and discipline those who are blatantly breaching ISO protocol.

caroladybelle, BSN, RN · Dec 14, 2010

Hello
I work on a Surgical/Onc floor and we routinely get our fair share of VRE, C-Diff, MRSA and so forth patients. We also have those that are neutropenic. We used to have "clean" staff that would care only for the neutropenic patients along with separate equipment to check vital signs. Our patients all are in private rooms.
Our hospital has now decided that if you use universal precautions that you could care for both neutropenic pt's along with those on other types of isolation together.
I have noticed that our neutropenic patients are now coming up positive with these other isolation infections, namely C-Diff- and all of the others
I dont think that this is at all appropriate. Why?
Handwashing dosent always get done by all staff
Equipment isnt cleaned properly- just found out our CNA's are not cleaning equipment on those with C-Diff with soap and water- as those purple wipes used for the equipment do not kill the spores of C-Diff
Our clothing has got to have issues with contamination- especially our shoes! We dont wear shoe coverings (do you think that would help?)
We have these nasty curtains in the rooms that dont get routinely changed, only if they are visible soiled (eww)
I know that C-diff can be caused by abx therapy and the neutropenic are typically on strong abx. Yet still even on strong abx I havent seen as much C-diff as I do now.
The staff originally wanted to have a few rooms dedicated to those with neutropenia, when now they can be next to a row of people with these diseases that need isolation.
What does your hospital do? What do you think?

First, I currently work in a facility that currently does much of the research for evidence-based practice. I have also worked at the NIH in Bethesda. Second, my pt population is virtually always immunocompromised pts, and most frequently BMT/hematological pts immunosuppressed by some of the highest risk chemo regimens. They often have ANCs of zero/WBC cts of 0-200 for weeks to monthes.

Several of the posters have evidently assumed that these are neutropenic pts housed with Contact isolation IN THE SAME ROOM. However the OP has clearly indicated that ALL pts that are neutropenic are in PRIVATE rooms not shared rooms. Thus, shared rooms are are not the issue.

I believe that the OP has objections to one nurse having both presumed "clean" neutropenic pts that are not on contact isolation and also having in his/her assignment contact isolation pts.

And her concern is that is not acceptable practice.

In my current and previous workplaces that do extensive research and have the evidence to back it up, it is appropriate that nursing can take pts of both types in an assignment safely, IF PROPER CONTACT/HANDWASHING PRECAUTIONS and disinfecting practices are done. And in my facility that is the standard. Given that there are surveillance cultures done on admission and weekly, and various testing can be done on new positives to track whether it is similar to another pts on the unit, they track it quite well, if needs be.

The bigger issue is....

WHY IN ALL THAT IS HOLY IS THERE NOT BEING PROPER HANDWASHING / DISINFECTING / PRECAUTIONS BEING DONE?

As someone who has experience in other, not so stellar facilities, I can say that frequently there is not proper signage or isolation gear available, many MDs refuse to surveillance test at-risk pts (embarassing for the pt, and inconvenient for MDs to adhere to precautions), very poor education and inadequate monitoring of practices. But by far, really poor ratios and too much emphasis on "customer service" (answering all lights in 10 seconds, those stupid pocket phones that they make nurses wear, not putting sinks in the hall for staff, because they "aren't pretty and look too hospitally") practices that hurt rather than help.

I was actually at a wellknown and wellheeled WPB arae facility that "looked" pristine, all private rooms, that had one of the worst infection rates. the problem : there were no hall sinks. For 40 beds, there was one med room sink, one desk sink and one outside of the iso room. All sinks were in the pt BR. While there was gel outside each room, we all know that often more is needed nad that washing your hands in the pts BR, is not always the cleanest. And in the entire time there I never saw isolation precaution carts used or signage (so messy looking and would embarass and inconvenience the wealthy clientele). Though I repeatedly found out my pts were positive for MRSA/VRE when I had the chance to see the chart.

I have MDs that if your nurses (like in someplaces that I worked) have 6-12 pts, there is virtually NO way that a nurse can race around to all the rooms, round with all the MDs, pass meds, and catch all call lights within the prescribed time limit, answer all those (often useless) phone calls and do all the proper handwashing, contact precautions CORRECTLY.

And housekeeping needs to more than a poorly educated, poorly reimbursed department. They are a very important infection control measure and are incredibly necessary to pts safety. Yet in too many places they get little respect and merely have a mop shoved in their hands.

To the OP:

You do not need separated nurse assignments, barring things like VISA or MDRX Acinebacter Baumanii (which should be max precautions/one to one). You need the staff's practice cleaned up, for the safety of all pts. It is not merely dangerous to your neutropenics that are endangered by the practices that you describe....neutropenics can grow and breed stuff that can be pretty infectious to nonneutropenic pts. And given that few facilities (beyond mine) actually routinely screen for MRSA/VRE/C'Diff, poor infection control practices that you ddescribe, endangers everyone.

Designated rooms are nice, but useless unless major changes are made in practice.

SolaireSolstice, BSN, RN · Dec 14, 2010

Ok, I get it. Totally misunderstood before, and now I can't edit. Yes, in our hospital we take care of patients that are neutropenic and other isolation patients at the same time. There doesn't seem to be much cross over from infection at all. Universal precautions cover the basic issues, and contact precautions cover the rest. We use disposable gowns on contact precaution which are kept outside those patient rooms, they are discarded when you leave the room. Signs are posted outside those patients rooms. We have the alcohol scrub on the wall between every couple of rooms, and sinks in the middle of each hallway.

The issues that you cite as being the reasons why to have seperate staff are issues that should be addressed regardless. Staff not washing hands? Why not? Cleaning equpiment? Put the correct wipes on a dedicated machine and keep that machine in the isolation room. Curtains? We use blinds, and that seems like something housekeeping should address. And floors are gross, so the shoes is a non-starter. Unless you are changing shoes when you walk into the "reverse isolation" side, you are tracking nasty stuff in there anyway from outside.

rn438 · Dec 14, 2010

the hospital I came from in Texas did have neutropenic precautions, but the hospital I work at now in another state has informed me that that Disease Control has informed them there is no such thing as reverse isolation and that standard precautions is enough. I guess it just depends on where you work ... this would be a good research project as common sense just tells me that things can be transmitted through your clothing / stethescope/ hands etc . Handwashing and alcohol gel doesnt always work 100 %, why would you not want to protect the severely immunocompromised? In a hospital of all places?