LABOR AND DELIVERY
Safer at home?
One of my patients is 8 months pregnant. She is worried about the risk of contracting COVID-19 in the hospital and wants to deliver her baby at home with a nurse midwife. I advised her to discuss her concerns with the healthcare provider, but I am wondering—given the coronavirus pandemic, is delivering at home safer for now?—L.R., LA.
The American College of Obstetricians and Gynecologists (ACOG) considers hospital delivery to be much safer than home delivery, and the pandemic has not changed this position. Compared with hospital delivery, home births are associated with a two- to threefold increase in perinatal mortality.1,2 In a recent Message for Patients, ACOG reiterates that even in the pandemic, “the safest place...to give birth is still a hospital, hospital-based birth center, or accredited freestanding birth center.”1
Likewise, the American Academy of Pediatrics (AAP) recommends against planned home childbirth. However, both the AAP and ACOG recognize a patient's right to choose where to give birth. To help patients and providers make informed, evidence-based choices, the AAP recently published guidelines summarizing resuscitation, evaluation, and follow-up care for neonates born at home that is consistent with care provided for infants born in a medical care facility.2 For example, AAP recommends that each delivery be attended by two care providers, with at least one having the training, skills, and equipment to perform a full resuscitation of the infant if necessary. Both ACOG and AAP support the provision of care by nurse midwives who meet appropriate standards of education and certification.2
Protect your license
My hospital is revising the policy and procedure for medication reconciliation. My manager told us that nurses cannot reconcile medication discrepancies under the new policy. Is medication reconciliation no longer a nursing responsibility?—M.S., VT.
The term medication reconciliation is often used incorrectly. In fact, reconciliation is just one part of a “formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders.”1
Medication reconciliation is included in Goal 3 (Improve the Safety of Using Medications) of The Joint Commission's National Patient Safety Goals for 2020.2 As described in this goal, the process consists of five steps:1
- Develop a list of current medications.
- Document medication information (for example, name, dose, route, frequency, purpose).
- Compare the medications on the two lists and resolve discrepancies.
- Provide the patient (or family, caregiver, or support person) with written information on the medications the patient should be taking.
- Explain the importance of managing medication information to the patient at discharge or at the end of an outpatient encounter.
Steps 1 and 2, which involve compiling a comprehensive medication history, can be performed by RNs and LPNs, as well as by other healthcare professionals such as pharmacists, specially educated pharmacy techs, and licensed prescribers. Nurses can also perform Steps 4 and 5. However, Step 3, the act of “reconciliation,” requires the skills of licensed prescriber, such as a physician, NP, or physician assistant. Making these decisions is beyond a nurse's scope of practice.
The medication reconciliation process should be performed at every transition of care in which new medications are prescribed or existing prescriptions are rewritten. Your facility is protecting your license by clarifying the roles of healthcare professionals at each step of the process.
Skin lesions may accompany infection
I work in a primary care provider's office. Based on patient history and clinical presentation, the provider diagnosed COVID-19 in one of our patients, but the diagnosis was never confirmed with a lab test. The patient has since recovered. During a follow-up visit, she described an erythematous, nonpruritic rash she experienced on her torso during her illness. Could this have been related to her COVID-19 diagnosis?—C.D., NEV.
Yes. According to a recent report involving 88 Italian patients hospitalized with COVID-19, 18 (20%) experienced cutaneous signs and symptoms either at onset of COVID-19 symptoms or during their hospital stay. These included erythematous rash, widespread urticaria, and vesicles resembling those of varicella (chickenpox). The lesions typically appeared on the trunk and were not pruritic.1
To learn more about possible dermatologic manifestations, the American Academy of Dermatology (AAD) has created a registry for reporting skin lesion associated with COVID-19. The AAD encourages healthcare professionals, including nurses, to complete a short survey on patients with COVID-19 who develop dermatologic manifestations, and on patients with dermatologic conditions who contract COVID-19. Patient identifiers such as name or date of birth will not be collected and all deidentified information will be kept strictly confidential. Patients may be registered regardless of whether their COVID-19 diagnosis was confirmed by testing. Access the registry at www.aad.org/member/practice/coronavirus/registry.