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Advice P.R.N.

doi: 10.1097/01.NURSE.0000604736.39631.49
Department: ADVICE P.R.N.
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Hidden tuberculosis hazard for deer hunters...launching a health screening business...best practices for sharps disposal...for patients with sepsis, draw blood specimens first

Nursing2019 will seek professional advice on any reasonable question related to nursing. Send queries to Michael Jones, Nursing2019, Wolters Kluwer, Two Commerce Square, 4th floor, 2001 Market St., Philadelphia, PA 19103, or send an e-mail to Michael.D.Jones@wolterskluwer.com with “Advice” in the subject line.

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TUBERCULOSIS

Hidden hazard for deer hunters

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I work in an outpatient clinic in a rural area. At this time of the year, I often see patients with injuries and other problems related to hunting. One of my patients asked me if deer can transmit tuberculosis (TB) to people. I said I had never heard that but would look into it. What can you tell me?—L.S., PA.

In September, the CDC issued a report about a case of bovine TB (Mycobacterium bovis) in a 77-year-old Michigan man who contracted the disease while field-dressing a deer. This form of TB is found rarely in domestic cattle and more commonly in wild bison, elk, and deer. Although the risk of transmission to humans is unclear, hunters have contracted the disease through open wounds on the hand and/or by inhaling aerosol while removing diseased viscera from an infected animal.

Like Mycobacterium tuberculosis, which is more common in humans, M. bovis can lead to latent or active TB, especially in immunocompromised hosts. To minimize the risk, the CDC recommends that all hunters use personal protective equipment while field-dressing deer.

Source: Sunstrum J, Shoyinka A, Power LE, et al. Notes from the field: zoonotic Mycobacterium bovis disease in deer hunters—Michigan, 2002-2017. MMWR Morb Mortal Wkly Rep. 2019;68(37):807-808.

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HEALTH SCREENING

Is this a risky business?

I am interested in starting my own wellness business, which would involve doing biometric finger-stick screenings for employees of small businesses. This would include a lipid panel and glucose levels. I realize I cannot diagnose or treat, and I will have a disclaimer stating that. But as an RN, can I legally do routine finger-stick screening tests without provider oversight, such as a standing order signed by a physician?—P.C., ILL.

Although the law varies from state to state, our legal consultant advises against performing biometric screening without a standing order or other provider oversight. Many states handle the matter with language like this: “A nurse/paramedic/certified medical assistant may administer and read certain point-of-care testing under the order of a licensed prescriber.” In other words, RNs may perform tests and interpret results if a licensed prescriber is overseeing the process.

With this in mind, our consultant says it would be legally risky to start a business offering biometric screening without first obtaining the services of a licensed prescriber for clinical oversight and medical ordering. This piece of the puzzle also requires obtaining all required business licenses, insurance, and malpractice coverage.

Any nurse who wants to start such a business should first contact his or her Board of Nursing for information on the scope of practice limitations in this area of practice. The next step is to call the state division of corporations for information on how to incorporate a business.

Legally, this is a bit of a gray area, but at the end of the day, you are likely to need a licensed prescriber in the mix. Good luck!

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SHARPS DISPOSAL

All bottled up

Many of my patients ask me how to dispose of their used needles and other sharps. Some put their sharps in empty water bottles, but I don't think they are sturdy enough to be safe. How should I advise them?—W.D., KY.

The FDA recommends immediately placing used needles and other sharps in an FDA-cleared sharps disposal container, which can be obtained through pharmacies, medical supply companies, and online. As an alternative, patients can use a strong plastic container such as a laundry detergent or bleach bottle, not a water bottle. The container should be leak-resistant, remain upright during use, and have a tight-fitting, puncture-resistant lid. When the container is about 3/4 full, the patient should seal the lid with duct tape, label the container, and place it in household trash. Sharps should never be recycled or flushed down a toilet.

Tell patients to follow state and community guidelines for proper sharps disposal. For more information, refer them to www.safeneedledisposal.org, which provides an interactive map showing safe disposal guidelines for all 50 states.

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TREATING SEPSIS

Be quick on the draw

When caring for patients with sepsis, the nurses draw blood specimens for culture before initiating empiric antibiotic therapy as directed by hospital policy. In some circumstances, waiting for staff to perform a blood draw delays the start of antibiotic therapy for these seriously ill patients. Given the importance of starting treatment as soon as possible, would starting the antibiotic first and drawing blood specimens shortly afterward make that much difference?—D.C., NEV.

Yes it could. A recent report indicates that in patients with severe sepsis, initiating antibiotic therapy first can significantly reduce the sensitivity of blood culture results.1

In a study involving 325 adult patients with severe sepsis, blood culture specimens were obtained before and within 120 minutes after initiation of antibiotic therapy (median time, 70 minutes). Preantibiotic specimens were positive for one or more microbial pathogens in 31% of patients. In contrast, postantibiotic specimens were positive for one or more microbial pathogens in only 19% of patients. The absolute difference in the proportion of positive specimens between pre- and postantibiotic testing was 12%. In addition, sensitivity of postantibiotic cultures was only about 53%.

An effective drug regimen depends on accurate culture and sensitivity test results. The latest evidence supports obtaining blood culture specimens before initiating treatment whenever possible.

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REFERENCE

1. Cheng MP, Stenstrom R, Paquette K, et al Blood culture results before and after antimicrobial administration in patients with severe manifestations of sepsis: a diagnostic study. Ann Intern Med. [e-pub ahead of print September 17, 2019]
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