What you should KNOW
What you should DO
Seth Johnson, RN,MSN,CNN
May 7, 2014
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1. How do you put a giraffe into a refrigerator?
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The correct answer is: Open the refrigerator, put in the
giraffe and close the door
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This question tests whether you tend to do simple
things in an overly complicated way
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
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2. How do you put an elephant into a refrigerator?
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Wrong Answer: Open the refrigerator, put in the
elephant and close the refrigerator.
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Correct Answer: Open the refrigerator, take out the
giraffe, put in the elephant and close the door.
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This tests your ability to think through the repercussions
of your actions
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
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3. The Lion King is hosting an animal conference. All the
animals attend except one. Which animal does not
attend?
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Correct Answer: The Elephant. The Elephant is in the
refrigerator
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This tests your memory
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
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OK, even if you did not answer the first three questions,
correctly, you still have one more chance to show your
abilities.
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According to Andersen Consulting Worldwide, around
90% of the professionals they tested got all questions
wrong. But many preschoolers got several correct
answers.
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Anderson Consulting says this conclusively disproves the
theory that most professionals have the brains of a four
year old.
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
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4. There is a river you must cross. But it is inhabited by
crocodiles. How do you manage it?
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Correct Answer: You swim across. All the Crocodiles are
attending the Animal Meeting.
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This tests whether you learn quickly from your mistakes
http://www.tik.ee.ethz.ch/~lubich/extdoc/jokes/quiz/answer4.html
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At the completion of this presentation
participants will be able to:
◦ Identify the treat of antibiotic resistance
◦ Identify patients at high risk for antibiotic resistance
◦ Identify the safe use of antibiotics
◦ Identify measures to prevent or reduce antibiotic
resistance
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Antibiotic resistance is a worldwide problem
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New forms of antibiotic resistance can cross
international boundaries and spread between
continents with ease
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World health leaders have described antibiotic
resistant microorganisms as “nightmare bacteria” that
“pose a catastrophic threat” to people in every country
in the world.
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The ability of bacteria or other microbes to resist the
effects of an antibiotic.
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Antibiotic resistance occurs when bacteria change in
some way that reduces or eliminates the effectiveness
of drugs, chemicals, or other agents designed to cure
or prevent infections.
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The bacteria survive and continue to multiply causing
more harm.
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When bacteria are exposed to antibiotics, they start
learning how to outsmart the drugs.
This process occurs in bacteria found in humans,
animals, and the environment.
Resistant bacteria can multiply and spread easily and
quickly, causing severe infections.
They can also share genetic information with other
bacteria, making the other bacteria resistant as well.
Each time bacteria learn to outsmart an antibiotic,
treatment options are more limited, and these
infections pose a greater risk to human health.
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Each year in the United States, at least 2 million
people acquire serious infections with bacteria that
are resistant to one or more of the antibiotics
designed to treat those infections.
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At least 23,000 people die each year as a direct result
of these antibiotic-resistant infections.
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Many more die from other conditions that were
complicated by an antibiotic-resistant infection.
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In addition, almost 250,000 people each year require
hospital care for Clostridium difficile (C. difficile)
infections.
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In most of these infections, the use of antibiotics was a
major contributing factor leading to the illness.
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At least 14,000 people die each year in the United
States from C. difficile infections.
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Many of these infections could have been prevented.
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Antibiotic-resistant infections add considerable and
avoidable costs to the already overburdened U.S.
healthcare system.
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Total economic cost of antibiotic resistance to the
U.S. economy - difficult to calculate.
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Estimates vary -ranged as high as $20 billion in
excess direct healthcare costs, with additional costs
to society for lost productivity as high as $35 billion a
year (2008 dollars)
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http://www.youtube.com/watch?v=RpKZvnJwicA&feat
ure=youtu.be
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Clostridium difficile
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Carbapenem-resistant Enterobacteriaceae (CRE)
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Drug-resistant Neisseria gonorrhoeae
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Multidrug-resistant Acinetobacter
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Drug-resistant Campylobacter
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Fluconazole-resistant Candida (a fungus)
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Extended spectrum β-lactamase producing
Enterobacteriaceae (ESBLs)
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Vancomycin-resistant Enterococcus (VRE)
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Multidrug-resistant Pseudomonas aeruginosa
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Drug-resistant Non-typhoidal Salmonella
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Drug-resistant Salmonella Typhi
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Drug-resistant Shigella
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Methicillin-resistant Staphylococcus aureus (MRSA)
◦ occurs most frequently among persons in hospitals and healthcare
facilities (such as nursing homes and dialysis centers) who have
weakened immune systems.
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Drug-resistant Streptococcus pneumoniae
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Drug-resistant tuberculosis
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Vancomycin-resistant Staphylococcus aureus (VRSA)
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Erythromycin-resistant Group A Streptococcus
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Clindamycin-resistant Group B Streptococcus
DIALYSIS FOR END-STAGE RENAL DISEASE
CANCER CHEMOTHERAPY
COMPLEX SURGERY
RHEUMATOID ARTHRITIS
ORGAN AND BONE MARROW TRANSPLANTS
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There are four core actions that will help fight these
deadly infections:
◦ preventing infections and preventing the spread of
resistance
◦ tracking resistant bacteria
◦ improving the use of today’s antibiotics
◦ promoting the development of new antibiotics and
developing new diagnostic tests for resistant bacteria
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Infections prevention reduces the amount of
antibiotics that have to be used and reduces the
likelihood that resistance will develop during therapy
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Ways that drug-resistant infections can be prevented:
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Immunization
safe food preparation
handwashing, and
using antibiotics as directed and only when necessary.
Preventing infections also prevents the spread of
resistant bacteria
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CDC gathers data on antibiotic-resistant infections,
causes of infections and whether there are particular
reasons (risk factors) that caused some people to get
a resistant infection.
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With that information, experts can develop specific
strategies to prevent those infections and prevent
the resistant bacteria from spreading.
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Single most important action needed - to greatly slow
down the development and spread of antibioticresistant infections is to change the way antibiotics are
used
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Up to half of antibiotic use in humans is unnecessary
and inappropriate and makes everyone less safe
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Antibiotic stewardship - always use antibiotics
appropriately and safely, only when they are needed to
treat disease, and to choose the right antibiotics and to
administer them in the right way in every case
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Because antibiotic resistance occurs as part of a
natural process in which bacteria evolve, it can be
slowed but not stopped.
Need for new antibiotics to keep up with resistant
bacteria as well as new diagnostic tests to track the
development of resistance
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http://www.youtube.com/watch?v=3klxO3Dt3jU
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Increased risk for getting a bloodstream infection
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Bloodstream infections are the second leading cause
of death in dialysis patients
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Infections also complicate heart disease, the leading
cause of death in dialysis patients
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Infection risk is higher
◦ weakened immune systems
◦ catheters
Infection Prevention in
Dialysis Settings
A Continuing Education (CE) Training Course for
Outpatient Hemodialysis Healthcare Workers
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Infection prevention and control
◦ Hand hygiene – observations
◦ Proper catheter /vascular care and reduction in catheters
◦ Proper cleaning measures
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Safe medication management
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Preparation
Handling
Storage
administration
Vaccination – patients and staff
Staff education and competency
Patient education and engagement
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Follow all necessary infection control recommendations,
including hand hygiene, standard precautions, and contact
precautions.
Diagnose and treat resistant infections quickly and
efficiently
Treatment options change often because resistance is
complex
Make sure to follow the latest recommendations to
ensure you are prescribing appropriately.
Only prescribe antibiotics when likely to benefit the
patient, and be sure to prescribe the right dose and
duration.
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When transferring patients, ensure the other facilities
are notified of any infection or known colonization.
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Keep tabs on resistance patterns in your facility and in
the area around your facility.
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Encourage prevention methods with your patients.
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Be sure they understand how to protect themselves
with vaccines, treatment, and infection control
practices such as hand washing and safe food handling
Decannulation Procedure:
1.
Perform hand hygiene
2.
Put on a new, clean pair of gloves
3.
Wear proper face protection
4.
Remove needles using aseptic technique
5.
Apply clean gauze/bandage to site
6.
Compress the site with clean gloves
7.
Remove gloves and perform hand hygiene
Catheter Connection Procedure:
1.
Perform hand hygiene
2.
Put on a new, clean pair of gloves
3.
Wear proper face protection
4.
Apply antiseptic to catheter hub and allow it to dry
5.
Connect the catheter to blood lines using aseptic technique
6.
Unclamp the catheter
7.
Remove gloves and perform hand hygiene
Catheter Disconnection Procedure:
1. Perform hand hygiene
2. Put on a new, clean pair of gloves
3. Wear proper face protection
4. Disconnect the catheter from blood lines using
aseptic technique
5. Apply antiseptic to catheter hub and allow it to dry
6. Replace caps using aseptic technique
7. Make sure the catheter remains clamped
8. Remove gloves and perform hand hygiene
1.
2.
3.
4.
5.
6.
7.
Perform hand hygiene
Put on a new, clean pair of gloves
Wear a face mask if required
Apply antiseptic to catheter exit
site and allow it to dry
Apply antimicrobial ointment
Apply clean dressing to exit site
Remove gloves and perform hand
hygiene
Photo provided by Stephanie Booth, used with permission
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Clean areas should be used for the preparation,
handling and storage of medications and
unused supplies and equipment
– Your center should have clean medication and
clean supply areas
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Contaminated areas are where used supplies
and equipment are handled
Do not handle or store medications or clean
supplies in the same area as where used
equipment or blood samples are handled
Clean area
Remember: Treatment stations are contaminated
areas!
Photo provided by Stephanie Booth, used with permission
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Any item taken to a patient’s dialysis
station could become contaminated
Items taken into the dialysis station
should either be:
– Disposed of, or
– Cleaned and disinfected before being taken
to a common clean area or used on
another patient
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Unused medications or supplies taken
to the patient’s station should not be
returned to a common clean area (e.g.,
medication vials, syringes, alcohol
swabs)
Photo provided by Marshia Coe and Teresa Hoosier, used with permission
Prepare all individual patient doses in a
clean area away from dialysis stations
• Prepare doses as close as possible to the
time of use
• Do not carry medications from station to
station
• Do not prepare or store medications at
patient stations
• CDC recommends that dialysis facilities:
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– Use single-dose vials whenever possible and
dispose of them immediately after use
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Do not use the same medication cart to deliver
medications to multiple patients
Do not carry medication vials, syringes, alcohol swabs, or
supplies in pockets
Be sure to prepare the medication in a clean area away
from the patient station and bring it to the patient station
for that patient only at the time of use
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Cleaning and disinfection reduce the risk of spreading an
infection
Cleaning is done using cleaning detergent,
water and friction, and is intended to
remove blood, body fluids, and other
contaminants from objects and surfaces
Disinfection is a process that kills many
or all remaining infection-causing
germs on clean objects and surfaces
◦ Use an EPA-registered hospital disinfectant
◦ Follow label instructions for proper dilution
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Wear gloves during the cleaning/disinfection process
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All equipment and surfaces are considered to be contaminated
after a dialysis session and therefore must be disinfected
After the patient leaves the station,
disinfect the dialysis station
(including chairs, trays, countertops,
and machines) after each patient
treatment
◦ Wipe all surfaces
◦ Surfaces should be wet with disinfectant and allowed to air dry
◦ Give special attention to cleaning control panels on the dialysis machines
and other commonly touched surfaces
◦ Empty and disinfect all surfaces of prime waste containers
Photo provided by Stephanie Booth, used with permission
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Before removing or transporting used
dialyzers and blood tubing, cap
dialyzer ports and clamp tubing
Place all used dialyzers and tubing in
leak-proof containers for transport
from station to reprocessing or
disposal area
If dialyzers are reused, follow
published methods (e.g., AAMI
standards) for reprocessing
AAMI is the Association for the Advancement of
Medical Instrumentation
Photo provided by Stephanie Booth, used with permission
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Vaccination of dialysis staff and patients
Preventing the spread of hepatitis B
Preventing the spread of bacterial infections
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Influenza
◦ Influenza or the “flu” is a respiratory infection that
infects the nose, throat, and lungs
◦ The flu is spread mainly by droplets that are made
when people with flu cough, sneeze or talk
◦ The single best way to prevent the flu is to get a flu
vaccine each year
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Hepatitis B
◦ Hepatitis B is a serious infection that affects the
liver. It can cause acute (short-term) or chronic
(long-term) infection and liver cancer
◦ Hepatitis B virus is easily spread through contact
with the blood or other body fluids of an infected
person
◦ Hepatitis B vaccine can prevent hepatitis B infection
•
Vaccinate all susceptible
patients against:
– Hepatitis B
•
Recommended vaccines for
patients include:
– Influenza (inactivated)
– Pneumococcal
•
Conduct routine testing for:
– Hepatitis B virus
– Hepatitis C virus
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Dialyze hepatitis B (HBsAg+) patients in a separate
room using separate machines, equipment,
instruments, and supplies
◦ Be sure to use a separate gown when treating these
patients
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•
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Staff members caring for patients with hepatitis B
(HBsAg+) should not care for HBV-susceptible
patients at the same time (e.g., during the same shift
or during patient changeover)
HBsAg+ means hepatitis B surface antigen (a lab test for hepatitis B virus) was positive
HBV-susceptible means anyone who has never been infected and lacks immunity to
hepatitis B virus
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Patients with catheters:
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1.Hand hygiene
2.General access care at home (e.g., bathing with a catheter)
3.Signs and symptoms of infection
4.How to respond if problems with catheter develop outside of
the dialysis center
◦ 5.Risks associated with catheters/importance of permanent
access
◦ 6.Basic infection control practices during catheter accessing
process (as a means to engage patients)
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Patients with other access types:
◦ 1.Hand hygiene
◦ 2.Washing the access site prior to treatment
◦ 3.General access care at home (e.g., don’t scratch or pick at
the site)
◦ 4.Signs and symptoms of infection
◦ 5.How to respond if problems with access develop outside
of the dialysis center
◦ 6.Basic infection control practices during cannulation
process (as a means to engage patients)
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Basic steps clinicians can take to prevent infections in
hemodialysis patients include:
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Promote fistula use
Get catheters out
Improve catheter care
Clean hands before and after every patient contact
Talk to patients about good vascular access care
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Follow Policies & Procedures
Heighten awareness on hand hygiene
Empower staff to own infection prevention practices
Create infection prevention / control team including
patients
Conduct unannounced audits / checks
Utilize toolkits from CDC, WHO, AHQR
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The overall goal for the Quality and Safety Education for Nurses
(QSEN) project is to meet the challenge of preparing future
nurses who will have the knowledge, skills and attitudes (KSAs)
necessary to continuously improve the quality and safety of the
healthcare systems within which they work
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QSEN define quality and safety competencies for nursing and
proposed targets for the knowledge, skills, and attitudes to be
developed in nursing pre-licensure programs for each
competency: patient-centered care, teamwork and
collaboration, evidence-based practice, quality improvement,
safety, and informatics
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Patient-centered Care
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Teamwork and Collaboration
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Evidence-based Practice (EBP)
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Quality Improvement (QI)
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Safety
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Informatics
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Recognize the patient or designee as the source of
control and full partner in providing compassionate
and coordinated care based on respect for patient’s
preferences, values, and needs
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Function effectively within nursing and interprofessional teams, fostering open communication,
mutual respect, and shared decision-making to
achieve quality patient care
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Integrate best current evidence with clinical expertise
and patient/family preferences and values for delivery
of optimal health care.
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Use data to monitor the outcomes of care processes
and use improvement methods to design and test
changes to continuously improve the quality and safety
of health care systems
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Minimizes risk of harm to patients and providers
through both system effectiveness and individual
performance
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Use information and technology to communicate,
manage knowledge, mitigate error, and support
decision making
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http://www.cdc.gov/cdctv/SnortSniffleSneeze/index.ht
ml
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What is the biggest room we all have?
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ROOM FOR IMPROVEMENT
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preventing infections and preventing the spread of resistance
tracking resistant bacteria
improving the use of today’s antibiotics
promoting the development of new antibiotics and developing
new diagnostic
tests for resistant bacteria
Infections that patients can get while receiving dialysis are
serious but preventable
Healthcare workers following infection control precautions and
other safe care practices are the key to prevention
Infection prevention is everyone’s responsibility
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1 CDC. Active Bacterial Core Surveillance Methodology (2012).
http://www.cdc.gov/abcs/index.html [Accessed 5/23/2013].
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2 CDC. Active Bacterial Core Surveillance (ABCs) Report, Emerging Infections
Program network, Group B Streptococcus (2011).
http://www.cdc.gov/abcs/reports-findings/ survreports/gbs11.pdf [Accessed
7/23/2013].
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3 CDC. Antimicrobial Susceptibilities Among Group B Streptococcus Isolates,
Active Bacterial Core Surveillance (ABCs) (2010).
http://www.cdc.gov/abcs/reports-findings/survreports/gbs10-suscept.html
[Accessed 7/23/2013].
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4. http://www.cdc.gov/nhsn/
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5. http://www.cdc.gov/dialysis/monitoring/Data-reports.html
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6. http://www.qsen.org/