In addition to serving as dean of the Evelyn L. Spiro School of Nursing at Wagner College (Staten Island, N.Y.), Paula Dunn Tropello, EdD, FNP-BC, focuses on global and disaster nursing. As a Medical Reserve Corps member and a mass-care provider certified through the American Red Cross, Tropello has worked with students and patients in Uganda, Nicaragua, and Haiti, and in the aftermath of U.S. hurricanes Andrew and Katrina.
The Clinical Advisor asked Tropello this question: Should nurse practitioners (NPs) and physician assistants (PAs) be reviewing their blood-and-body-fluids precautions and practices in general in light of the Ebola crisis?
Here is her response, which she gave to us shortly before the CDC’s October 20, 2014, issuance of new guidance for health-care workers who are specifically caring for persons with Ebola:
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Because the primary-care setting is often the first contact an ill patient has with the health-care system in the United States, the question you pose raises both ethical and practice issues for those PAs and NPs who work on the front lines and/or precept students who might be in a position to care for an undiagnosed Ebola-infected individual.
Being vigilant with history-taking, especially in terms of the patient’s travel and contacts, is crucial in light of the “ground zero” patient in America who had traveled from West Africa to Texas, and in light of the fact that local is now global with daily flights into the United States from areas in which Ebola is more prevalent.
The diagnosis was missed in a Texas emergency department, and possible exposures were likely prior to the day of diagnosis, so that contact tracing took place during the 21-day period of incubation. The unprecedented urban outbreak in at least 5 countries since the initial case in December 2013 (MMWR. 2014;63[25]:548-551), along with the marked delay of a coordinated response from global health leaders, makes the possibility of this disease becoming endemic very real.
Since the AIDS crisis of the 1980s, standard precautions have been advised for clinicians to use with all patients; i.e., proceed on the presumption of a blood- or body-fluid-borne disease with all patients until proven otherwise.
However, many clinicians have not practiced these precautions regularly in a primary-care environment and find themselves working with paraprofessionals who may not have been as well-trained, but handle body specimens and often do intake. In addition, providers are rushed to see many more patients with managed care in place; therefore, history-taking and complete assessments might be compromised and communication breakdowns can occur.
When faced with a crisis situation in health care, fear is always a factor and education/knowledge can be the cure. At Wagner College Evelyn L. Spiro School of Nursing, for example, as the outbreak continued overseas at the start of this semester, we implemented the requirement that every single person who engages in patient contact, from undergraduate through masters and doctoral levels, view and sign his or her understanding of a video retraining all in blood and body-fluid precautions, along with discussion of front-line adherence to protocol.Not only are the NP clinical courses including this initiative, but it has been shared with the PA program as well.
Any infectious disease poses threats to the public. If putting a spotlight on the importance of not letting down one’s guard and not allowing protocol adherence to slip assists in protecting clinicians and patients, it is worth the retraining initiatives in this disease and others to follow. (193-4)
Paula Dunn Tropello, EdD, FNP-BC, is the dean of the Evelyn L. Spiro School of Nursing at Wagner College in Staten Island, N.Y.
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