Risk factors in the management of antimicrobial agents in nursing

Fatores de risco na administração de antimicrobianos pela enfermagem: questões bioéticas

Antimicrobial agents are biotechnological drugs that limit pathogen growth or their destruction. Their use in clinical practice and in health institutions has changed the natural course of infections and caused positive changes against infectious diseases (Carneiro et al., 2011). Although their use has increased in more than 50% during the last 30 years and approximately 14% during the last five, the occurrence of resistant microorganisms has also risen (Fagan, Maehlen, Lindaek, & Berild, 2012).

Further, the unnecessary or inadequate employment of these drugs is associated with toxicity, increase in diseases and high costs of health care, coupled to their involvement in occurrences related to patients´ safety (Silva & Cassiani, 2013). On the other hand, studies from the point of view of Nursing on the risks in the inadequate administration of antimicrobial drugs are rare in the literature. Since risks consist in probable grave occurrences against the patient´shealth, the use of methods for risk analysis may provide knowledge on existing issues and their main causes, and the subsequent recommendation of corrective and preventive measures (Silva & Cassiani, 2013).

Risk factors related to the management of antimicrobial agents by the nursing team is thus highly relevant due to the possibility of great harm to patients, the environment and increase of microbial resistance. Current assay identifies risk factors in the management of antimicrobial drugs by the nursing team.

Current retrospective, descriptive and document-based analysis was conducted in a big general hospital in the central and western region of the state of Minas Gerais, Brazil, which attends patients of the Brazilian Health System (SUS), health insurances and paying persons. The reference hospital attends a population from 57 neighboring towns, of which 70% are SUS patients. Statistics show that there are approximately 15,200 hospitalizations/month, including patients suffering from cancer, a joint venture with the Association against Cancer of the Western region of Minas Gerais (ACCOM). The institution comprises 398 beds shared by patients attended by SUS, health insurances and paying patients, featuring 190,000 first aid procedures, 15,200 hospitalizations, 13,600 surgeries and 3,000 births annually.

The Hospital is also equipped with a Committee for the Control of Hospital Infection (CCIH) and a Service for the Control of Hospital Infection (SCIH). The former is composed of two physicians from the Adult Intensive Care Center and from the Children Intensive Care Center, a member of the Hospital´s General Management, an infectologist and a nurse.

The internal organizational structure of the latter committee comprises two physicians specialized in Infectology, one of whom is the technical specialist of the service, two nurses, one of whom is responsible for the coordination of the service, and a member from the administration board. The service is bound by internal routines and norms, with specific protocols for adult and children ICUs, special protocols for the use of antimicrobial drugs- prophylaxes, following Law 2616 published on the 12/5/1998 by the Ministry of Health. Its activities include training in continuous education once every three months or according to the institution´s needs, on infection rates throughout the epidemiological scanning undertaken by the SCIH nurses in the sectors. Training is provided to all professionals, particularly nurses.

Data were retrieved from the hospital records at the Medical and Statistical Archive Service (SAME), focusing on patients treated at the adult and children oncological clinic and at the hematological clinic.

The clinical charts of patients treated at the oncological clinic were selected since patients underwent several diagnostic and therapeutic procedures that prolonged their stay in the hospital, coupled to several re-hospitalizations. Therefore, the focused population is more exposed to colonization by antimicrobial-resistant microorganisms (Santos et al., 2012).

The criteria for the selection of the 203 charts included patients from the cancer or hematological clinics, using antimicrobial drugs, with nursing information between 2008 and 2011. A Collection Pathway, constructed for data harvesting from the records, was based on data in the literature on nursing activities related to the dispensing of antimicrobial drugs. Data on medical prescriptions for antimicrobial drugs were collected, related to nursing activities (dispensing) by nursing annotations.

Data were categorized, codified, registered and analyzed according to data bank and by programs IBM. Statistical Package for Social Sciences (SPSS) 21.0 and Excel version (21) 2010. Analyses were undertaken following descriptive statistics and given in contingency tables. Chisquare test and Fischer´s exact test were employed to assess differences in frequency distribution of variables, in cases where one of the 2x2 cells was lesser than or equal to 5.

The recommendations of the Brazilian Health (CNS/MS) 196/1996 were complied with for the ethical aspects of research on human beings. Research project was submitted to the Committee for Ethics in research prior to the start of data collection (Approval n. 288517). Since research was retrospective, the declaration of free consent was not asked, although secrecy and anonymity of the participants were guaranteed.

Participants´ age bracket ranged between 3 and 44 years (39.5 ± 26), with 55.2% males and 44.8% fales. Mean permanence period in the hospital was 15 days, with a maximum of 99 days (DP = 16); mean period using antimicrobial drugs ranged between 7 and 9 days.

Among the main diagnoses, there was a high prevalence of Acute Myeloid Leukemia (AML), with 68 patients (33.5%), followed by aplastic anemia, lymphomas, thrombocytopenia, and multiple myeloma. Hematological diseases were the main reasons for hospitalization with 172 patients (84.7%) (Table 1).

Data revealed that 133 (65.5%) patients from the oncological and hematological clinics had health complications and that 113 (55.7%) of the charts did not have any annotations on phlogistic signs made by the nursing team. Complications were observed in 90 (44.3%) patients, among which may be mentioned 25 (12.3%) ulcers caused by pressure; 43 (21.17%) had urinary infections and 22 (10.83%) had pneumonia. In the case of phlogistic signs, only charts with nurse´s annotations for inflammation (hotness, redness, tumor, pain and loss of function) were considered.

Further, 153 (75.4%) patients under analyses, of whom 28 (13.8%) presented febrile neutropenia, were not kept in preventive isolation.

It must be observed that ten (5%) prescriptions were incomplete, or rather, they lacked either the dosage of the medicine or the time for its dispensing.

In fact, 21 (10.3%) prescriptions were hand written. Most prescriptions (n = 198; 98%) were legible since most (n = 169; 87.2%) were written electronically (Table 2).

Table 3 shows that, although most antimicrobial drugs (n = 142; 70%) in medical prescriptions were checked as dispensed, the number of inadequacies, especially the timetable for their dispensing, was a rather frequent item. In fact, 33 (16.3%) were not dispensed at the right time as ordered, but according to the timetable conditioned by the nursing team on duty at that time. Table 4 forwards results of Chi-square test and Fischer´s exact test to verify whether there were any differences among hospitalized or not hospitalized patients according to the variables: prescription mode; annotation of phlogistic signs, dispensing at the right time; isolation. No statistically significant difference occurred in both situations.

Table 5 demonstrates results of Chi-square test and Fischer´s exact test for differences between patients who died and who survived, according to the variables: annotation for phlogistic signs, hospitalization period and demand for swabs. The table above reveals a high percentage of blanks with regard to annotations of phlogistic signs in the hospital records of patients who died (n = 84; 74.3%) and who survived (n = 49; 54.4%). There is statistically significant difference between these patients (χ2 = 8; 764; p ≤ 0; 002), or rather, the lack of annotations for phlogistic signs was greater in the group of hospital records of patients who survived when compared to that of patients who died.

Table 5 also reveals that in the case of the variable demand of swabs, 4 (44%) belonged to patients who died. Difference between the groups was statistically significant (χ2 = 6; 109; p ≤ 0.026), or rather, the number of demands for swab collection was greater in patients who died when compared to that of patients who survived. Table 6 shows results for Chi-square test and Fischer´s exact test to verify differences between patients with disease complications, according to the variables annotations of phlogistic signs, dispensing at the right timetable, hospitalization period, demand for swabs and isolation. Lack of annotations on phlogistic signs was greater in patients with no complications (n = 60; 53%) when compared to patients with complications (n = 10; 11%) (Table 6). There was a statistically significant difference among the groups (χ2 = 8; 764; p ≤ 0.0001) for this variable.

In the case of dispensing antimicrobial drugs on the hour, the patients´ records in which there was no drug dispensing at the right timetable showed that 31 (31%) belonged to patients with no complications and 24 (28%) belonged to those with complications. There was statistically significant difference between the groups (χ2 = 23; 924; p ≤ 0.024).

In the case of the variable hospitalization period, patients with complications were hospitalized for a shorter time or for a 15-day period when complications occurred (n=10; 16%). Difference between groups was statistically significant (χ2 = 12; 631; p≤ 0.0001).

The group with complications demanded swabs (n = 2; 22%), similar to the group without any complications. Fifty (28.8%) of patients´ records also reported this demand. There was a statistically significant difference between groups with and without complications (χ2 = 30; 428; p ≤ 0.0001).

The group with complications demanded swabs (n = 2; 22%), similar to the group without any complications. Fifty (28.8%) of patients´ records also reported this demand. There was a statistically significant difference between groups with and without complications (χ2 = 30; 428; p ≤ 0.0001).

Carneiro et al. (2011) also identified mean age of 39.5 ± 10.6 years for patients treated with antimicrobial drugs and demonstrated that pediatric age bracket and that of over-50-years population were the most indicated for antimicrobial therapy, due to the immunologic state and associated comorbidity, even though no difference between genders occurred in the use of the drugs. The authors also identified a predominance of males, with 56.0%, corroborating results in current analysis.

Studies on hospitalization period in 15 government- and private-run hospitals in Belo Horizonte MG Brazil showed that total mean hospitalization period was 18 days: 67% of patients were hospitalized between 1 and 15 days; 14% between 16 and 30 days and 19% for more than one month (Gomes, Bastos, Matozinhos, Temponi, & Meléndez 2011). A study in a hospital in the state of Rio Grande do Sul, Brazil, revealed that antimicrobial therapy duration averaged 9 (± 2.1) an important factor for the dissemination of to Boing, Vargas, & Boing (2007), malign leukemia had high hospital costs and ranked second in average hospitalization duration. Although it is not the disease with the highest mortality rate, leukemia requires high cost therapy on the pharmacological market, coupled to a combination of drugs, blood transfusions and hospitalizations that demands high permanence rates and re-hospitalizations. The above pathologies in hematological clinic are directly related to the febrile neutropenia described as secondary physiological reaction to cytotoxic chemotherapy. It is actually a medical emergence with immediate pharmacological intervention comprising wide spectrum antimicrobial drug caused by a morbomortality-related prognostic. This fact corroborated results in current study since the highest prevalence in the use of antimicrobial drugs was identified in patients from oncological and hematological clinics.

According to Bellesso, Costa, Chamone, & Llacer (2010), febrile neutropenia is a complication in chemotherapy-treated patients and may be fatal. Infection risks may increase according to the prolonged period with neutropenia. Patient´s isolation is recommended till a better definition in the treatment against the microbial agent. Since in this case patients are immunosuppressed, they are exposed to new bacteria of the hospital microbiota. Wide spectrum antimicrobial drugs are recommended immediately due to its high mortality complications. However, results showed that 13.8% of patients treated with antimicrobial drugs had febrile neutropenia but were not isolated in the hospital isolation ward.

Precaution measures or isolation by the nursing team is highly relevant. The onset of bacterial resistance to antimicrobial drugs causes multiresistant strains which are difficult to combat and which require total adhesion to precaution standards and isolation measures by health professionals in the assistance of hospitalized patients (Moura & Gir, 2007).

Since they are risk factors, several deficiencies were registered in the case of annotations for phlogistic signs by the nursing team. Based on results of inferential tests, clinical assessment of signs of infection by the nursing team is obviously important. However, a great number of complications occurred in the group which featured annotations. This fact may be related to the lack of measures for the prevention of complications associated with hospital infections. Deficiencies in annotations on phlogistic signs by the nursing team may worsen the hospital infection issues described as predominant in oncological patients. In fact, the nursing team should select priority strategies in the prevention of these diseases (Sanhudo, Moreira, & Carvalho, 2011).

No illegible medical prescriptions for antimicrobial drugs were identified in current analysis since prescriptions were electronically printed. However, Gimenes et al. (2011) underscore that electronically written prescriptions do not totally eliminate the possibility of mistakes in the process of drug dispensing. Errors may occur at the moment of filling the prescription form since the system provides means to copy prescriptions to facilitate the doctor´s administration of diseases. Actually, it is of great concern for all the health team since the prescribed drugs may bring about irreversible adverse events for the patients, including death. According to Gimenes et al. (2011), lack and omission of information at the moment of writing the prescription may cause mistakes by the health team during the treatment. The absence of a necessary item in the prescription induces mistakes in drug dispensing.

In the case of the doctor´s role in prescription writing, it should be enhanced that prescriptions are of primary relevance in the prevention and detection of adverse events mistakes in dose and time. Illegible or incomplete prescriptions, lack of protocols and institutional standardization of nomenclature of the prescribed drugs, copies, abbreviations and erasures contribute towards the occurrence of risk factors in drug dispensing (Gimenes et al., 2010).

There is a risk factor when the nursing team dispenses drugs outside the timetable prescribed in the doctor´s prescription. Since such behavior negatively affects the antimicrobial cycle and interferes in the enzyme inhibition process, some bacteria become insensitive to certain antimicrobial drugs and may inactivate a determined enzyme. Antimicrobial drugs with mechanisms on the enzyme inhibition become inactive due to the lack of a specific combat site (Guimarães, Momesso, & Pupo, 2010).

The determination of timetable in the dispensing of antimicrobial drugs in hospitals is the exclusive role of the duty nurse. The duty nurse in responsible for avoidance of mistakes in drugs with regard to the prescribed timing by the physician. However, the specific nurse should have knowledge on the characteristics of the therapy and the clinical conditions of the patient to avoid drug-drug and drug-food interactions and other medicine incompatibilities (Rodrigues & Oliveira, 2010).

Risk factors may be caused by communication failures between the health teams, resulting in mistakes in drug dispensing such as overdose, suspended drugs and anticipation of timetable or delays in dispensing (Santana, Sousa, Soares, & Avelino, 2012). However, it should be underscored that, based on inferential tests, there was no direct co-relationship between the variables re- hospitalizations and death when compared to timetable in drug dispensing by the nursing team. No difference between the variables re- hospitalization and death was detected

Another risk factor detected in current analysis comprised the lack of solicitation and collection of swabs by nurses. Swabs for collecting biological material from wounds and infected ulcers are the most commonly method used by nurses. The collection of swabs is highly relevant. One study emphasizes that 54% of health professionals specialized in wound care in the United States use swabs as a technique for the collection of material to identify microorganisms causing infectious processes. However, the technique is employed by a specialized health professional since flaws in any step during collection of the material for microbiological assessment may cause error in the identification of the etiological agent and inappropriate treatment may be meted out (Ferreira & Andrade, 2006).

In their studies on swab samples with infected wounds, Ferreira, Santos, & Sampaio (2004) identified 46 colonies of microorganisms, averaging 2.3 colonies per wound, by this technique, which is highly important for the adequacy of antimicrobial agents.

Several microbial agents may emerge in cultures undertaken by swab collection of secretions even though most bacteria have no clinical importance. There is no indication for culture when there is no evidence of any infection site. The collected material is relevant for the choice of an antimicrobial agent rather than for diagnosis (Kempfer et al., 2010).

It is thus highly relevant that the health team, especially nurses, handles and dispenses antimicrobial drugs in hospitals. The health team should dialogue and reflect on the risks involving such practices. The consent of all parties is required when ties exist on the type of antimicrobial drug and the best dispensing time, among others (Oliveira & Garrafa, 2011).

According to Corbellini, Schilling, Frantz, Godinho, & Urbanetto (2011), the safe dispensing of drugs depends on the health professional in the nursing team, who has to attend to six points in dispensing: correct drug, correct dose, correct patient, correct method, correct time and correct prescription. Risk factors related to errors by the team working directly on the patient in drug dispensing may bring to patients severe harm, liabilities due to long hospitalization period, need for diagnostic and therapeutic interventions, and even death, caused by complications acquired during the hospitalization period.

A reflexive and interdisciplinary process should be proposed and shared by the teams involved within the assistance system for adequate activities in health care that involve the well-being of the patient. It must be a discussion by the institution´s permanent team on the possibility of occurrences of risk situations within the process of antimicrobial drug dispensing and the methodology for the identification and assessment of events related to incorrect handling and dispensing (Dalmolin & Goldim, 2013).

The following risk factors related to the dispensing of antimicrobial drugs by the nursing team are lack of annotation on phlogistic signs of infection; inadequate timetable in drug dispensing; lack of precaution and isolation measures; swab collection.

The above factors cause risks and harm to patients and environment, and increase microbial resistance. Continuous education programs for nurses focusing on the safe dispensing of antimicrobial drugs are relevant.

Current study does not forward general terms on the phenomenon under analysis due to different institutional contexts and identified limitations. In fact, the small number of patients´ hospital records is the main limitation. Results in current analysis do not deal with all the aspects on the theme. Further exploratory and quantitative studies should be undertaken and studies on a qualitative approach are also worth doing to explore the causes and motivations in the identified risk behaviors.