Challenges to Infection Control of Hep C, B and HIV

Challenges to Infection Control of Hep C, B and HIV Infection control and cross contamination prevention are imperative to ensuring high quality patient care and quality of life for all patients. In the hemodialysis clinics and hospital units where patients are in end stage renal disease the prevention of infection is of utmost concern as it is directly correlated to lowered morbidity and mortality rates. Blood borne pathogens and bacteria are transmitted through poor infection control practices and lack of cross contamination prevention procedures. To understand the importance of infection control and cross contamination prevention, it is first imperative to understand the risks and consequences of infection transmittal in the hemodialysis unit. The hemodialysis unit is unique in that the procedure allows pathogens to enter the body through access sites, injection sites, and catheterization, all of which increase risk of infection for already ill patients. The following explores the most common concerns in infection transmittal as He patitis C and B, HIV, and common bacteria found in hemodialysis patients. This is followed by an exploration of methods in infection control, focusing on the procedures of cleaning, sterilization, and disinfection. An examination of staff education and training procedures that impact infection control and patient care follows. The research concludes with a summary and commentary. Research has often compared the incidences of HCV infections in hemodialysis and peritoneal dialysis in patients, finding that patients undergoing clinical bloodstream invasive hemodialysis procedures have three times higher rates of HCV infections (Horl et al 2004). This is reflective of nosocomial transmission of HCV within the clinical dialysis setting (Horl et al 2004). HCV is transmitted through cross-contamination, occurring through blood, shared cannulas, and equipment, and blood transfusions (Horl et al 2004 p 1390). A comparison of the outcome of hepatitis virus-positive and -negative kidney transplant and hemodialysis patients involved 384 kidney transplant patients (67 HBsAg positive, 39 anti-HCV positive, 278 hepatitis negative), transplanted between 1987 and 2001, and 403 hemodialysis patients (128 HBsAg positive, 83 anti-HCV positive, 192 hepatitis negative) who had started hemodialysis and were referred to the kidney transplant waiting list during the same period (Visn ja et al 2008). Comparison of the groups survival rates, adjusted for patient age, showed that all kidney transplant patients survived longer than hemodialysis patients (p Thirty-two outpatient hemodialysis providers in the United States voluntarily reported 3699 adverse events to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) during 2006 (Klevens et al 2008). Among the 599 isolates reported, 461 (77%) represented access-associated blood stream infections in patients with central lines, and 138 (23%) were in patients with fistulas or grafts (Klevens et al 2008). The microorganisms most frequently identified were common skin contaminants (e.g., coagulase-negative staphylococci) (Klevens et al 2008). Hepatitis C (HCV) among maintenance hemodialysis patients has limited data on the incidence and prevalence. According to Bennett, Brachman and Jarvis (2007 p 360): In 2002, 63% of dialysis centers tested patients for anti-HCV, and 11.5% reported having (symbol) 1 patient who became anti-HCV positive in 2002. The incidence rate in 2002 was 0.34% among centers that tested for anti-HCV, the prevalence of anti-HCV among patients was 7y.8%, a decrease of 25.7% since 1995. In the facilities that tested, the reported incidence was 0.34% and the prevalence3 was 7.8%. Only 11.5% of dialysis facilities reported newly acquired HCV infection among their patients. The most efficient transmission of HCV is through direct percutaneous exposure to blood, central to the epidemiology of HCV transmission is the infected patient (Bennett, Brachman and Jarvis 2007 p 360). Staff members in hemodialysis clinics have similar rates of infection as other healthcare workers, between 1-2% (Bennett, Brachman and Jarvis 2007). The risk factors of HCV infection in hemodialysis clinics include blood transfusion from unscreened donors and the number of years the patient has undergone hemodialysis treatment (Bennett, Brachman and Jarvis 2007). The years of hemodialysis treatment is an independent risk factor that is strongly associated with high HCV infection rates, where the time of hemodialysis treatment increases the prevalence of HCV infection (Bennett, Brachman and Jarvis 2007). Patients undergoing hemodialysis for less than five years have a 12% chance of infection, while patients receiving dialysis for more than 5 years have a 37% chance of infection (Bennett, Brachman and Jarvis 2007). Dialysis related HCV outbreak research is indicative that HCV transmission occurs due to inadequate infection control practices of supplies and machinery (Bennett, Brachman and Jarvis 2007). During hemodialysis, monitors such as the venous pressure monitor is used to as a protective system against external blood loss, wh ere blood may leak through clamps on infusion lines (Horl et al 2004). Pressure of the leak is sense through an air-filled tube that connects the venous bubble to the monitor, which senses the pressure of the blood flow; however blood losses up to 40 ml/min may be undetectable by the sensor equipment (Horl et al 2004). Cross-contamination during invasive practices occurs when blood enters the air-filled tube and contacts the monitoring machinery where the pressure protectors are inserted into the line or connective areas (Horl et al 2004). Hydrophobic and impermeable flexible membranes used may become wetted with blood, and thus pressure changes are not transmitted to the sensor and the monitor itself does not function accordingly, indicating that cross contamination may have occurred (Horl et al 2004). The CDC reported three outbreaks of HCV infection from 1999-2000 for patients in chronic hemodialysis centers (Bennett, Brachman and Jarvis 2007). Cross contamination opportunities were the common indicator of infection, where observations of cross contamination included: Equipment and supplies that were not disinfected between patient use (Bennett, Brachman and Jarvis 2007 p 360). Use of common medication carts to prepare and distribute medications at patient stations (Bennett, Brachman and Jarvis 2007 p 360). Sharing of multidose vials, which were placed at patients stations on the top of the hemodialysis machine (Bennett, Brachman and Jarvis 2007 p 360). Contaminated priming buckets that were not routinely changed or cleaned and disinfected between patients (Bennett, Brachman and Jarvis 2007 p 360). Machines surfaces that were not routinely cleaned and disinfected between patients (Bennett, Brachman and Jarvis 2007 p 360). Blood spills that were not cleaned up promptly (Bennett, Brachman and Jarvis 2007 p 360). The sharing of multidose vials or injectable medications has been a source of high cross contamination. According to Finelli (et al 2002 p 58: â€Å"In 2002, 52.8% of centers reported that medications from multidose vials were drawn into syringes in preparation for patient administration in a dedicated medication room or an area separate from the treatment area, 24.6% reported that medications were prepared on a medication cart or a medication area within the treatment area, 3.7% at the dialysis station, and 18.9% in other areas. In 2002, the incidence of HBV infection was significantly higher among patients in centers where injectable medications were prepared on a medication cart or medication area located in the treatment area compared to a dedicated medication room (Table 13). However, the incidence of HCV infection was not significantly different by location where injectable medications were prepared. The incidence of HBV results are of particular concern because all medications, supplies, and equipment for HBsAg-positive patients should be dedicated for their use and not used by HBV-susceptible patients. Outbreaks of HBV infection have occurred when multipledose medication vials were available in the treatment area and used for both infected and susceptible patients, although isolation procedures for HBsAg-positive patients were in place for equipment and other supplies. To avoid contamination in the general hemodialysis population, medications should be prepared in a centralized area separate from the treatment area, and supplies and equipment should be shared only if they are disinfected between patients.† Furthermore, in dialysis centers where multiple infections clustered around timeframe a common exposure event is suggested as being likely due to supply carts moved from station to station which carried clean supplies and blood contaminated items such as biohazard containers, sharps disposal containers, and other containers contaminated or used to contain patients blood (Bennett, Brachman and Jarvis 2007). Due to the cross contamination opportunities and incidences, it is recommended that routine testing of hemodialysis patients for anti-HCV occur on admission and reoccur every six months (Bennett, Brachman and Jarvis 2007). HIV patients often undergo hemodialysis over other options of dialysis therapy when they are in advanced stages of the disease, as hemodialysis has lowered incidences of protein loss and peritonitis (Henrich 2003). Hemodialysis is also preferred over CAPD for patience with cognitive motor dysfunction (Henrich 2003). However, concerns of transmission of HIV infection during hemodialysis in clinical dialysis units exist as patient to patient, patient to staff, and staff to patient risks of cross contamination (Henrich 2003). The risks of HIV transmission from patient to patient is extremely unlikely in dialysis units that conform to the practice guidelines recommended by the CDC† (Henrich 2003 p 341). The CDC examines that individual dialysis units had no HIV nosocomial transmissions for patients undergoing hemodialysis treatments in clinical settings (Henrich 2003). Furthermore, a study of multiple dialysis centers across the USA found no instances of HIV seroconversion over a 48 week period (Henrich 2003). Thus there is a negligible risk of HIV transmission, and therefore HIV patients do not require dedicated machines or isolation while undergoing hemodialysis when the clinicians follow the CDC guidelines (Henrich 2003). HIV has not been shown to be transmittable through hemodialysis machines as the pore size of dialyzer membrane is between 1 and 7 nm, and the HIV virus is 105 nm (Henrich 2003). The use of the same dialysis machine between HIV positive and negative patients is not correlated with the transmission of HIV in the clinical setting, provided that disinfection procedures for dialyzers and dialysis machines are followed for both non-HIV positive and HIV positive patien ts (Henrich 2003). It is important to note that when the disinfection and cross contamination procedures are ignored, HIV outbreaks in dialysis clinics can occur (Henrich 2003). This is represented by recent outbreaks of HIV in Columbia, Argentina, and Egypt hemodialysis clinics. In Columbia it was found that the transmission of HIV was due to the cross contamination of dialysis access needles and sharing of inadequately disinfected site access needles (Henrich 2003). In Argentina the cross use of filters and multidose heparin vials was shown to be the likeliest reason for the transmission of HIV (Henrich 2003). In Egypt, syringes were used for more than one patient, allowing the cross contamination to occur (Henrich 2003). While HIV patient to patient transmission has not occurred in Westernized clinics, it is imperative that adequate procedures for dialyzer and dialysis access devices are continuously utilized as a precautionary and preventative method (Henrich 2003). For healthcare workers, patient to staff transmission is a high concern. Interestingly, only one incidence of patient to staff HIV transmission has been recorded in the United States, which occurred through a needlestick injury (Henrich 2003). Yet risk still exists, where research statistics show reported incidences of 5 needlestick exposures and 28 skin and mucous membrane exposures for every 10,000 dialyses. (Henrich 2003 p 320) However, only one instance of HIV seroconversion due to patient to staff transmission has been reported by the CDC, but that should not diminish the risk that HIV transmission can occur, most likely due to needlestick injuries in hemodialysis clinics (in peritoneal dialysis, it may occur through improper handling of PD effluent) (Henrich 2003). Staff to patient transmission is also a concern. According to Henrich: To date, there have been no reports of transmission of HIV from a health care worker to a patient in a dialysis setting. There are other important issues in dialysis units that accept patients with HIV infection. Patients with HIV infection are prone to infection with myobacterium tuberculosis. In contrast to HIV, M. tuberculosis infection is an aerosol-transmitted infection, and, therefore, precautions to prevent the spread of this infection to other patients should be taken. Importantly, M. tuberculosis infections among HIV infected patients are often multidrug resistant. Nosocomial transmission of multidrug tuberculosis has been described. In addition to tuberculosis, HIV infected patients are at increased risk of other communicable infections. Appropriate precautions should be observed to protect other patients in the dialysis facility and the staff caring for these patients. (Henrich 2003 p 342). Nontuberculosis mycobacterial (NTM) infections are a concern for all hemodialysis patients, particularly in clinics that practice the reuse of dialysis machinery (Nissenson and Fine 2005). NTMs have a predilection to colonization in water utilized for hemodialyzer reprocessing, where the CDC examined 115 dialysis centers in 1988 (Nissenson and Fine 2005). NTM recovery from water was found in 83% of these centers and 50% of all water samples of these centers (Nissenson and Fine 2005). An outbreak in Loiusiana that occurred in 1985 was due to inadequate sterilization of hemodialysis equipment, where 27 patients became infected with mycobacterium chelonei, 14 patients died over a one year period (Nissenson and Fine 2005). Similar outbreaks have occurred over the last twenty years, where bacterial contamination of reprocessed dialyzers was the main culprit (Nissenson and Fine 2005). No bactermias were found in patients who used only new dialyzers (Nissenson and Fine 2005). In a 1995 repo rt, an outbreak of klebsiella pneumoniae bactermia was shown to be due to cross contamination (Nissenson and Fine 2005). These incidences are attributed to failure to adequately use aseptic techniques during the reprocessing of dialyzers used by patients with bacteremia infections, thus allowing the contaminated dialyzers to spread to other patients in the hemodialysis clinics (Nissenson and Fine 2005). Viral infection has been the main epidemiologic concern in the hemodialysis units; however, bacterial infection is responsible for more than 30% of all causes of morbidity and mortality in Portuguese hemodialysis patients, vascular access infection being the culprit in 73% of all bacteremias (Ponce et al 2007). A prospective multicenter cohort study of bacterial infections incidence, conducted from January to July 2004 in five hemodialysis units, to record and track bacterial infections, using a validated database from CDC’s Dialysis Surveillance Network Program (Ponce et al 2007). The results are surmised: 4,501 patient-months (P-M) were surveyed, being dialyzed through a native fistula (AVF) in 60.6%, a graft (PTFE) in 31.3%, a tunneled catheter (TC) in 7.6%, and a transient catheter (C) in 0.5%. 166 hospitalisations were registered as target events and 182 intravenous antibiotic courses were assessed (Ponce et al 2007). Of these 182 antibiotic treatments, 47.8% included van comycin, only 30% had blood cultures drawn pretreatment, and only 36% were positive. The research found 98 infections at the vascular access site and 2.13 infections at other sites. The isolated microorganisms were Staphylococcus epidermidis in 40.1%, Staphylococcus aureus in 30.1%, Pseudomonas in 13.3%, and Escherichia coli in 3.3% (Ponce et al 2007). Researchers found that the number of target events and the bacterial infections incidence were remarkably homogeneous in the five Portuguese centers (Ponce et al 2007). The research concluded with the following major points: (1) High incidence of bacterial infections, causing major morbidity; (2) infectious risk is vascular access type-dependent, with dramatic rise in catheters; (3) underutilization of blood cultures to orient diagnosis and therapy, and (4) high rates of vancomycin prescription (Ponce et al 2007 p 136). Cetin (et al 2007) compared microbial findings and their resistance to antibiotics between hemodialysis patients and patients without end-stage renal failure with diabetic foot infections. An 18-month-long descriptive study analyzed bacterial isolates obtained from 32 hemodialysis (HD) patients with diabetic foot infection in an Antakya hemodialysis center and 65 patients with diabetic foot infection admitted to the Education and Research Hospital of Mustafa Kemal University, Turkey (Cetin et al 2007). The occurrence of gram-positive bacteria in the hemodialysis patients was found to be 59.0%, this rate in the other patients was 53.1% (Cetin et al 2007). The frequent bacterial species isolated in the hemodialysis patients were S. aureus (22.9%), followed by coagulase-negative Staphylococcus spp. (CNS) (19.7%), the microorganisms in the other patients were found as CNS (20.7%), followed S. aureus (18.0%) (Cetin et al 2007). The researches recommend that antibiotic therapy in HD patien ts with diabetic foot infection should be more closely guided by culture findings and antimicrobial susceptibility results (Cetin et al 2007). Patient’s exposure to dialyzer reprocessing allows for a potential for blood borne bacterial infections to occur, where the majority of NTM infections are due to the improper reprocessing techniques (Nissenson and Fine 2005). In recent history, there have been few indications of invasive infections from reprocessed dialyzers; however there are no current and reliable estimates of infection risk attributed to dialyzer reuse in hemodialysis (and other dialysis) clinics (Nissenson and Fine 2005). Standardization of reprocessing techniques has resulted in acceptably low risk of bacterial infections of modern dialyzer reuse (Nissenson and Fine 2005). Infection control practices in hemodialysis units reduce the risk of patient to patient transmissions through directly or indirectly contaminated devices (Mayhall 2004). Devices may include equipment, supplies, environment surfaces (floors, tables), and the personnel’s hands (Mayhall 2004). Practices should be routinely carried out for all patients in the hemodialysis units as there is increased potential for blood contamination during hemodialysis, where many patients undergoing hemodialysis are colonized or infected with pathogens (Mayhall 2004). Practices established for infection control include stringent measures for the prevention of HBV due to the ability of HBV to survive on surfaces and contaminate dialysis machines (Mayhall 2004). Patients with increased risk for transmission of pathogens such as antimicrobial resistant strains may require additional precautions such as dedicated (non-reuse) dialyzers (Mayhall 2004). Infection surveillance and other events is importa nt to monitor the infection control practices and ensure their effectiveness (Mayhall 2004). Chronic hemodialysis patients should have routine HBV and HCV infection tests and these tests should be reviewed promptly (Mayhall 2004). This allows the facility to identify potential cross contaminations before they result in an epidemic, allowing for proper infection control measures and possible staff retraining based on the test results (Mayhall 2004). It is important to note that test results must be communicated to other units of the facility when patients are moved for care, for example a HCV positive patient moves from hemodialysis to ICU allowing for better patient care (Mayhall 2004): Routine HCV testing should include use of both a screening immunoassay to test for anti-HCV and supplemental or confirmatory testing with an additional, more specific assay. Use of NAT for HCV RNA as the primary test for routine screening is not recommended, because few HCV infections will be identified in anti-HCV negative patients. However, if alanine amino-transferae levels are persistently abnormal in anti-HCV negative patients in the absence of another etiology, testing for HCV RNA should be considered. Blood samples collected for NAT should not contain heparin, which interferes with the accurate performance of this assay (Mayhall 2004 p 1152) Procedures for cleaning, disinfection, and sterilization for infection control in a hemodialysis center are important to reduce cross contamination, and do not differ greatly from those in other health care settings. However, the uniqueness of the hemodialysis setting allows for higher potentials for blood contamination due to the routine vascular system access that increases the potential for cross contamination of blood borne pathogens (Mayhall 2004). Critical medical items that require stronger disinfection and disposal techniques include needles and catheters and other equipment that requires invasive procedures (Mayhall 2004). Semicritical equipment includes those that come in contact with the mucous membranes, such as endoscopes (Mayhall 2004). Noncritical equipment is that which comes into contact with the skin, such as blood pressure cuffs. Hemodialysis units should maintain infection control policies that prevent cross contamination based on these critical levels to ensure t hat infection potential is reduced (Mayhall 2004). Specifically related to needles as critical medical equipment in the hemodialysis unit, the CDC issued the following statement regarding infection control and cross contamination: â€Å"To prevent transmission of both bacteria and bloodborne viruses in hemodialysis settings, CDC recommends that all single-use injectable medications and solutions be dedicated for use on a single patient and be entered one time only. Medications packaged as multidose should be assigned to a single patient whenever possible. All parenteral medications should be prepared in a clean area separate from potentially contaminated items and surfaces. In hemodialysis settings where environmental surfaces and medical supplies are subjected to frequent blood contamination, medication preparation should occur in a clean area removed from the patient treatment area. Proper infection control practices must be followed during the preparation and administration of injected medications. This is consistent with official CDC recommendations for infection control precautions in hemodialysis and other health-care settings. Health departments and other public health partners should be aware of the n ew CMS conditions for ESRD facilities. All dialysis providers are advised to follow official CDC recommendations regarding Standard Precautions and infection control in dialysis settings. Specifically, CDC has recommended the following: ‘Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. Once a needle has entered a vial labeled for single use, the sterility of the product can no longer be guaranteed’. (MMWR 2008:875-876). Environmental surfaces that are frequently touched, such as equipment and tables, should be cleaned after each patients hemodialysis procedure with a detergent or detergent germicide (Mayhall 2004). This cleaning step is imperative to preventing cross contamination, but may be often overlooked. The cleaning process interrupts the cross contamination and transmission routes, and should be completed each time the equipment is used (Mayhall 2004). Patient to patient transmission of viruses and pathogens through the hemodialysis machine and its various components is an environmental risk, where the external surfaces such as the control pane and attached waste containers used for priming, as well as blood tubes and other items such as dialyzer caps and medication vials that may come into contact with the machine surfaces are all potential vehicles for cross contamination (Alter et al 2001). Microorganisms, including resistant bacterial spores, are killed by sterilization. The procedures for sterilization are generally steam cleaning or ethylene oxide gas used on critical medical equipment. However for equipment that is heat sensitive, FDA approved liquid chemicals can be used according to the manufacturer’s directions and with appropriate exposure timeframes (Alter et al 2001). High-level disinfectant may kill viruses and bacteria, but is not adequate for killing bacterial spores that exist in high numbers (Alter et al 2001). High-level disinfection includes heat pasteurization and chemical sterilants (also must be FDA-approved). The sterilants and high-level disinfectants can be used on medical devices, but not on environmental surfaces (Alter et al 2001). For environmental surfaces, the CDC recommends intermediate-level disinfectants that kill bacteria and most viruses (Alter et al 2001). This includes tuberculocidal hospital disinfectant and diluted bleach. Lo w-level disinfectants such as general purpose cleaners kill most bacteria and are designed for environmental surfaces, these can also be used on noncritical medical devices in accordance with manufacturer’s labels (Alter et al 2001). It is important to note that antiseptics such as chlorhexidene and iodine are designed for use on skin and are ineffective for cleaning medical equipment and environmental surfaces (Alter et al 2001). Prior to disinfection and sterilization, it is imperative that hemodialysis clinics support the use of germicidal detergents (Alter et al 2001). Germicidal detergents remove organic material such as blood and feces, as well as dirt and debris (Alter et al 2001). Dirt, debris, and organic material act as a protective shield for microorganisms by blocking or inactivating disinfectants and sterilants (Alter et al 2001). Therefore, hemodialysis clinics must add germicidal detergents to their cleaning and sterilization regimens (Alter et al 2001). Training and education of staff and patients is underlined as the most imperative component to ensuring the quality of infection control practices. Chronic hemodialysis clinics should update practices and policies to ensure that they are implemented and rigorously followed, where efforts should center on the education of new staff members and continuing education for tenured staff. Emphatically, hemodialysis units should consult CDC recommendations and approved practices to ensure that they are following the most appropriate and up to date infection control procedures. Staffs working in renal units are frequently unaware of the level of microbiologic contamination in their dialysis fluid arising from the presence of biofilm in the dialysis machines and the water distribution network (Hoenich and Levin 2003). Bacterial fragments generated by such biofilms are able to cross the dialysis membrane and stimulate an inflammatory response in the patient (Hoenich and Levin 2003). Such inflammation has been implicated in the mortality and morbidity associated with dialysis (Hoenich and Levin 2003). The desire to improve treatment outcomes has led to the application of more stringent standards for the microbiologic purity of dialysis fluid and to the introduction of ultraclean dialysis fluid into clinical practice (Hoenich and Levin 2003). Other researchers found that blood exposure is common for healthcare workers in hemodialysis, requiring the use of gloves when in contact with patients and patient equipment followed by appropriate hand washing techniques. Researchers examined staff members from a sample of 45 US hemodialysis facilities though anonymous survey questionnaires. The results show that of the 420 (69%) responses as: registered nurses, 41%; dialysis technicians, 51%; and licensed practical nurses, 8%. Only 35% of all respondents reported that dialysis patients were at risk for blood borne virus infections, and only 36% reported always following recommended hand hygiene and glove use practices (Shimokura et al 2006). Technicians, over registered nurses, reported more frequent compliance and measures for cross contamination prevention (Shimokura et al 2006). Compliance with recommended hand hygiene and glove use practices by hemodialysis staff was very low, and understanding of the reasons for compliance is seemingly ignored by some licensed nurses (Shimokura et al 2006). Infection control practices specific to the hemodialysis setting, and the reasons for these practices, was poorly understood by all staff (Shimokura et al 2006). This underlines that infection control training should be tailored to this setting and should address misconceptions of cross contamination and the risks of infections (Shimokura et al 2006). In one case of staff education, researchers reported an increase in Gram Negative Bacillus (GNB) infection in patients with long term catheters (LTC) (Mayor et al 2005). An objective was set to design an action plan and a new working methodology in order to eradicate the infection and the cause (Mayor et al 2005). Three periods were established in the prospective follow-up of LTC patients: the pre-epidemic period (01/94 to 03/99), with a bacteraemia every 144 days per patient, the epidemic period (04/99 to 12/00) with a bacteraemia every ten days per patient, and the post-epidemic period (01/01 to 04/02) (Mayor et al 2005). A multidisciplinary working group was established, which produced action plans for nursing and technical staff (Mayor et al 2005). The working methodology of the service was studied and analysed by means of a review (Mayor et al 2005). The dialysis and connector cultures were positive for GNB, confirming that they were of the same genetic origin (Mayor et al 2005) . An evaluation of the periods was carried out, studying the working methodology, to which no changes were made between the pre-epidemic and epidemic period (Mayor et al 2005). In the post-epidemic period, a number of changes were made to the care dynamic, with no other bacteraemia arising to date (Mayor et al 2005). Adapting and improving protocols is a good indicator of quality. The role of nursing staff communication, education, training and practices are vital in prevention of GNB (Mayor et al 2005). At Sentara Bayside (SBH), Leigh (SLH), Norfolk General (SNGH) and Virginia Beach General (SVBGH) Dialysis Units, researchers examined the ability of hemodialysis clinical areas of each hospital according to The JCs National Patient Safety Goals (NPSG) knowledge of Standards of Care/ANNA (Grier-Smith 2008). The research found that staff is able to articulate standards and requirements, where monthly and hourly rounds at each unit occur as well as peer to peer unit evaluations and daily huddles prior to work day based on behavior based expectations, the environment of care, and constant daily checks and balances (Grier-Smith 2008). The adherence to peer to peer communications, behavior support, and team work has been instrumental in supporting staff ability in the hemodialysis clinics to maintain strong positive scores in knowledge of standards of care, this underlines the importance of staff training and education that is continuously supportive of behaviors associated with lowering i nfection risks and

Their Eyes Were Watching God Essay -- Essays Papers

Theyre Eyes Were Watching God A Voice With Experience In Zora Neale Hurston’s novel, Their Eyes Were Watching God, many critics have argued over whether or not the main character, Janie, finds her voice by the end of the novel. Yet many seem to be confused as to what her "voice" is. Her voice is her ability to express her thoughts and display her emotions verbally. Many relate the question of Janie’s voice to her amount of emotional strength (her ability to confront her problems or run away from the current situation rather than be isolated in it), yet these things are a completely different matter entirely. While Janie’s emotional strength varies throughout the novel, her voice is always there. Her voice is proven from the beginning when she argued about housework with her first husband, Logan, and it became even more evident in her relationship with her next husband, Joe. She did not speak to Joe often because he did not mean much to her and she did not waste her energy on always arguing with him. But when she found a subject on which she wanted to speak her mind, she always did. Many seem to think that Janie found her voice towards the end of the novel because that is when she spoke most often. Yet the reason she spoke more is because she had someone who she cared about and to whom she wanted to speak to (her husband, Tea Cake). In her trial in defense of killing Tea Cake (the situation in which many argue that Janie’s silence was proof that she had not yet found her voice), her silence has nothing to do with whether or not she is emotionally strong or has a voice. Her silence is the result of the love she felt with Tea Cake. Though she felt very emo tional, Janie understood that love was not something you could express verbally and she therefore chose not to speak. In Janie’s first relationship with Logan, it becomes clear that Janie had both her voice and emotional strength. Expecting that marriage would bring love, Janie married a farmer, Logan Killicks, at a young age. Yet her relationship with him was not what she expected. He was ugly and lazy and didn’t even give a thought to Janie’s feelings. He forced her to do extra work and never treated her like the woman she was. When after hours of housework, and Logan asked her to chop wood for him one day, Janie finally felt that she needed to protest, saying "... ...e is saying that you have to experience love to understand it, and that it would have done her no good to try to express verbally what she felt for Tea Cake. At the end of the novel, Janie walked away from the trial with both her voice that had been with her throughout her whole life, the emotional strength that she had gained through her love with Tea Cake (and which had continued even after his death), and something that she had not known before: experience. (Experience with death, love, marriage, and life in general.) Many argue that Janie found her voice towards the end of the novel because that is when she spoke the most. Yet Janie had had her voice throughout, from her loveless marriage with Logan, to her abusive relationship with Joe, and through her heavenly time spent with Tea Cake. Tea Cake didn’t help Janie find her voice, but instead just gave her something to use it on. Yet while critics will argue forever over the questions of Janie’s voice and emotional strength, it is unquestionable that she walked away from it all with a new sense of knowledge and experience. And with these things, Janie was cabab le of dealing with whatever new challenge came her way.

A Critique of the Crito and an Argument for Philosophical Anarchism

A Critique of the Crito and an Argument for Philosophical Anarchism by Forrest Cameranesi In this essay I will present a summary and critique of Plato’s dialogue Crito, focusing especially on Socrates’ arguments in favor of his obligatory obedience to the Athenian state’s death sentence.In response I will argue the position that no one naturally holds any obligation to obey the arbitrary commands of another (or any body of others such as a state), and further that no one can come to hold such obligations even by contract; although people may still be obligated to obey commands issued to them, when what is commanded is obligatory independent of it being commanded by anyone.Thus I will argue that that if, as both Socrates and Crito presume, the command that Socrates be executed is contrary to true justice (that is, contrary to any natural moral obligations, independent of its legality), then Socrates has no obligation to obey it; and in fact those tasked to carry o ut the order are morally obligated to disobey it, and by their obedience become conspirators to a moral crime. The dialogue begins with Socrates in prison, awakening to Crito’s presence in his cell, Crito having bribed the guards to gain entry.After brief pleasantries and some talk of when the day of Socrates’ execution will fall, Crito admits to Socrates that his purpose there is to free him from prison and take him abroad to Thessaly, which he assures him can be successfully done thanks to the aid of a number of foreign benefactors. But Socrates is hesitant to leave, believing himself obliged to remain and allow his punishment to be completed, even though his sentence, they both concede, is unjust.Still, Socrates is eager to be convinced otherwise, if Crito can do so by means of reason, and so Crito plies Socrates with many arguments in favor of his escape, arguing not only that it is possible and desirable to escape, and that Socrates could live well outside of Athe ns, but that it is the just thing to do: for the sake of the welfare of his children, who will suffer without his care; for the sake of standing fast against his enemies in the state of Athens, who are attempting to wrong him by this sentence; and for the sake of his friends’ reputations, which will be besmirched by those who know either Socrates nor his friends, and will think that Socrates died only because his friends could not or would not buy his freedom. But Socrates dismisses these arguments, especially the last, arguing at length that the opinions of the many are not a relevant consideration in any such decision; a very important argument, to which I will return later in this essay. For now the relevant point is that Socrates' only concern, in the question of whether or not to escape, is whether or not escaping is just; not what people at large may think of their decision or what other consequences may follow from it.On the topic of justice, and counter to Critoâ€⠄¢s argument that Socrates is obliged to fight back against wrongs committed against him, Socrates suggests (and Crito accepts) the principle that to return harm for harm is harmful, to return evil for evil is evil, to return injustice for injustice is unjust, etc. ; and thus that such vengeance ought not be perpetrated, for it is just as harmful, evil and unjust as the act being avenged, and one must never do such wrongs.Socrates considers it harmful and unjust to the state to disobey its laws, and feels thus obligated to obey them instead, for to do otherwise would be harmful, unjust, and wrong; and here I disagree with Socrates. Though I accept his principle of justice, that one must not return wrongs in kind for to do so is merely to do more wrong, I do not believe that merely resisting attempted harm to oneself necessarily harms the attacker; and even if the attacker does suffer harm from the resistance it is as a result of his own wrongdoing, not any wrongdoing on the part of the defendant.If someone attempts to strike at me, I step out of his way, and he falls on his face as a consequence, I have not harmed him, although he has come to harm. If he attempts to strike at me, I hold up a shield, and he injures his fist upon it, I have not harmed him, although he has come to harm. Somewhat more analogously to the case at hand, â€Å"harm† may come to a street gang initiate whose initiation task is to mug me, inasmuch as he loses his status within the gang (and perhaps the gang itself loses status in the community), should I evade him and escape; but certainly I did not do that harm, though it was a consequence of my actions.Likewise, â€Å"harm† may come to the state as a consequence of successful disobedience against it, inasmuch as its power and thus its authority will be less respected, but this is not the same as the disobedient one directly harming the state, say in the way a foreign conqueror would. None of these situations involve doing anything directly to harm the aggressor, but rather only the consequences of the aggressor’s own actions failing. Thus, such resistance is not prohibited by the principle that one ought never do harm, for one is not doing harm merely by evading harm, even if harm indirectly results as a consequence of such evasion.Certainly we would not say that it is obligatory to allow oneself to be assaulted or robbed, even if we say that to retaliate in kind is forbidden. In all these circumstances, the aggressors are being harmed as a consequence of their own actions; and in the latter two cases, of the mugger and the unjust state, they suffer only in their reputation, losing the respect or fear and subsequent power they might have otherwise enjoyed, yet which, for their failure, they do not deserve.In my third example, as in the case before Socrates and Crito, the only loss suffered is a loss of reputation and the power that reputation often entails. This connection between reputation and power is an important facet of my argument, for it is self-evident to me that the only significant power the state itself has is its reputation, the respect and obedience that people give to it; with no obedient subjects to enforce its laws over those who are not so obedient, or with insufficient portions of the populace willing to tolerate such enforcement, the state would have no power.In fact I argue that in such a case the state would not exist; and really, that no states ever truly exist, in any strict sense. There are merely masses of people, with an assortment of opinions on what is good, bad, morally neutral, permissible, impermissible, and obligatory; all of whom exert whatever influence they can manage, by whatever means they find best, to see that their opinions on such matters are enforced — that justice, as they understand it, prevails. And when some person or block of people manages to secure sufficiently unchallenged influence ver the behavior of the other people in an area (that is, when sufficient people act to enforce one code of behavior and a sufficient portion of the remainder tolerate them), we falsely attribute the existence of some sort of social entity above and beyond the collection of individual people, and call that entity the â€Å"state†. But even a monarch only has his power because enough people believe in and support the monarchy, and enough of the remainder tolerate it; as has been demonstrated wherever a monarchy was overthrown from within by a democratic revolution.It is important to note, however, that this does not mean that democracy entails legitimacy; it only means that all states are on some deep level democratic, differing only in the degree that the people delegate their power to other people, in effect casting their vote as â€Å"whatever he says. † The prevailing opinions may still be entirely wrong; I merely claim that it will nearly always be the majority opinion which prevails. I say â⠂¬Å"nearly† because this phenomenon is dependent upon the relatively small differences in true personal power between most individuals, which are quickly diluted in larger groups, but still present in sufficiently small groups. A knight may be stronger and more skilled than any peasant, but it does not take many fed-up peasants working together to counter the power of that knight, so as the size of the group the knight is a part of grows, his relative power over the whole group decreases rapidly, unless it is bolstered by the support or at least tolerance of other members of the group.Thus for groups of any significant size, the differences in personal power between individuals can be safely ignored, and so the determining factor is not who supports a position but how many support it). The opinions of the people who encompass the legislature of this â€Å"state† — be it one person as in an absolute monarchy, some minority in an oligarchy, or the majority in a dir ect democracy — then become â€Å"the law†.Those things judged by such people as obligatory become required by law; those things judged as forbidden become prohibited by law; and those things judged as permissible are allowed by the law. But in any form of government, especially in a direct democracy such as ancient Athens, the laws of men are nothing but the opinions of men backed by power, that power resting ultimately in the will of the majority; the only differences between government thus being the degree and structure of power delegation, and what the opinions of those delegates are.With it thus established that states are no more than masses of people and their laws no more than the opinions of said people backed by power, not only do I object to Socrates’ insistence that he must be obedient to the state’s death sentence, but it is plainly obvious to me that Socrates himself ought to conclude this, if he was to be consistent with his own earlier po sition that the opinions of men, as such, are irrelevant, no matter what power they may be backed by. But why, my dear Crito, should we care about the opinion of the many? † says Socrates. â€Å"Good men †¦ are the only persons who are worth considering†. Crito eventually concedes this point, agreeing that the opinions of the many are irrelevant; only the opinions of good men matter. But what is it that makes a man good? Is that not part of what is at question here: which sorts of acts are right and which are wrong, which are just or unjust? (A good man, I take it, being one who acts rightly or justly).Certainly being good cannot be merely being seen as good in the eyes of the many, or supporting the commands of the many, for then the opinions of the many and the opinions of good men could never conflict, as good men by definition would always be of the opinion that the majority is right; and Socrates' statements differentiating their opinions would make no sense. So Socrates must agree that goodness is something objective, independent of the opinions of the many.Yet in the dialogue, after Socrates and Crito discuss at some length their agreement to disregard the opinions of the many in considering what ought or ought not be done, and to consider only what is or is not just, Socrates proclaims â€Å"From these premises I proceed to argue the question whether I ought or ought not to try to escape without the consent of the Athenians†. But from where does this concern for the consent of the Athenians come, when we have just disregarded the opinions of the many (in this case the many of Athens); for what is consent if not simply the opinion that something ought to be permitted?Socrates answers, in the voice of the Laws of Athens (speaking to him): â€Å"You, Socrates, are breaking the covenants and agreements which you made with us at your leisure, not in any haste or under any compulsion or deception, but having had seventy years to thi nk of them, during which time you were at liberty to leave the city, if we were not to your mind, or if our covenants appeared to you to be unfair. In short, Socrates is concerned with his obedience to the people of Athens (or at least the government collectively representing them) because he feels he has implicitly agreed to be bound by the decisions of the Athenian government by remaining in the city. But in response I argue that no one can, by any contract implicit or explicit, alter the natural moral obligations which are binding on all men at all times.The most exemplary and broadly agreeable instantiation of this principle is that one cannot sell oneself into slavery, for all men have natural rights (which is to say, obligations naturally owed to them by others) which they cannot give up even if they so choose.For instance, if we grant that all are naturally obliged to refrain from striking me except in such instances as I consent to them doing so, then while I may vary whethe r or not I consent to be struck, and thus vary whether or not it is morally permissible to strike me at that moment, I cannot vary whether or not it is morally permissible to strike me contrary to my consent, for it is naturally obligatory that none do so. That is, I cannot, in a morally binding way, agree that â€Å"henceforth so-and-so may strike me as he pleases regardless of my consent at that moment†.Any such contract offering terms contrary to natural obligations is invalid; and thus contracts of slavery, whereby one waives all of ones natural rights (which is to say, all obligations naturally owed to oneself by others), are the epitome of invalid contracts. This relates to the situation at hand with Socrates and Crito in that a contract to obey the arbitrary commands of some entity (e. g. the state of Athens), provided only that they are issued forth in prescribed proper manner (e. . by the formal proceedings of the Athenian court) and otherwise irrespective of the con tents of those commands, seems to me no different than a contract to slavery, with the entity in question (the state) as the slave master; for what is slavery but complete subjugation to the arbitrary will of another? Socrates himself admits this similarity, saying (once again in the voice of the Laws, speaking to himself) â€Å"can you deny in the first place that you are our child and slave? Yet Socrates has a reply here as well, already quoted above: he has had many years in which he was free to leave the city if he did not wish to be bound by its laws, and by remaining he has implicitly agreed to be bound by them. Certainly a man cannot be a slave if he is free to leave his bonds at any time. But I respond that even such â€Å"voluntary† bonds are contractually invalid, for remaining on the lands of another still does not make one subject to the arbitrary will of the landowner. The only obligation owed to the owner of some property, as such, is to refrain from acting upo n his property contrary to his consent.Likewise the only punishment the property owner may apply simply for disobeying his commands (but not violating any natural obligations, e. g. harming someone or their property, which may warrant further punishment) is to refuse him the use of his property; in the case of land, ejecting him from the premises. By voluntarily entering and remaining in my home, my guests do not become subject to my arbitrary authority, to be enforced as I see fit; at most I have the authority to eject them from my home, if I grow tired of their presence there.Nor by voluntarily entering a corporate office do I become subject to the authority of the corporation, beyond the revocability of my permission to remain therein. Likewise, even if we grant that the city of Athens is the property of the state of Athens (i. e. of its people collectively, rather than parcelled out into individually owned plots), the greatest punishment morally justified simply for behaving in ways the state dislikes (but not in any way which is truly unjust) is banishment from the city.Thus, while the state may have the moral authority to forbid and punish legitimate injustices (which I agree it does, though no more so than any individual), it does not have the moral authority to enforce its arbitrary will upon those who reside within its borders; it merely has the authority to eject them from its lands if it chooses to do so, for which it needs no cause at all, if it is indeed the legitimate owner of those lands.Thus if Socrates truly believes that he has done nothing unjust, then he should not (if accepts my principle regarding contracts and natural obligations) feel subject to the punishment decreed for him, though he may concede the state’s authority to banish him, if he holds the state to be the legitimate owner of the city.I would further question whether it is right to presume that a state is the legitimate owner of its territory (rather than each citizen o wning their own portion in private, as well as some public portions in common), and thus whether it even has the authority to banish the disobedient; but that is another lengthy topic, for which I do not have room in this essay. In conclusion, I see no reason for Socrates to consider the will of the people of Athens (as channeled via their government) binding pon him; and I believe he should seek an answer to the question at hand, whether or not to escape from his punishment, solely by asking whether he has done anything to warrant that punishment — and it appears that he believes he has not. There is no guarantee that his opinion on this matter is correct; the state of Athens may in fact be correct, and thus Socrtes’ punishment just. But to defer to the public opinion over one’s best judgment is never epistemologically sound.Men of reason do not turn to authority, even democratic authority, to answer questions of biology or chemistry or physics, but instead we appeal to evidence and sound logical arguments to determine the answers; and I see no reason why questions of ethics should be subject to any less rigorous and independent methodologies. By denying that any person, text, or institution has any special epistemic or alethic authority (the ability to magically divine or reveal the truth, or to create it by fiat), we do not deny the existence of objective truth.Nor by denying that any king, law book, or legislature has any special deontic authority (the ability to magically divine or reveal our obligations, or to create them by fiat) do we deny that there are objective standards of justice. In both cases we merely concede that we are all in the same standing regarding truth or justice, respectively; and we leave it to each individual to seek it for themselves, to sway others with arguments where they can, and to act upon it as they deem necessary or appropriate, regardless of decrees or prior agreements to the contrary.

Essay on Three Poems, One Theme Natures Perception of Time

In three poems – Old Woodrats Stinky House, The Mountain Spirit, and Boat of a Million Years – Gary Snyder uses the concept of deep time to show us how nature views time and implies that humanity needs to be able to see time the same way. Snyders poems imply that he believes people have forgotten their place in the natural world and that we should try to regain our respect for nature. Old Woodrats Stinky House explains what is wrong with how we perceive time. The Mountain Spirit shows why nature views time as more like a singular thing than a series of segments like humans do. Boat of a Million Years hints at a solution and implies that we should relax and follow natures example. First, the poem Old Woodrats Stinky†¦show more content†¦The poet is also implicitly telling us that we are ruining our planet by finishing the poem with: –Coyote says You people stay put here, learn your place, do good things. Me, Im traveling on. Coyote, the creator of the earth in this poem and often a deity of many First Nation cultures, is so disgusted with humanity that he decides to move on but he leaves with a message to learn your place. Gary Snyders poem implies that humanity has become detached with nature and that we need to learn our place and learn to stop pissing on everything. Second, the poem The Mountain Spirit is about a dialogue between the poets speaker (probably Gary Snyder himself) and a mountain spirit. Ceaseless wheel of lives the is first line of the poem – it is also repeated throughout the entire poem – is meant to show that life existed before and will continue to exist after mankind. The Ceaseless wheel of lives also suggests that time is not broken up into a series of segments. At one point in the poem, the mountain spirit remarks But what do you know of minerals and stone. The mountain spirits incredulity implies that Gary Snyder thinks people have a hard time understanding a large- scale view of time. Snyder goes on to tell a poem to the mountain spirit – a poem within a poem – that tells the story of the life of a mountain to illustrate how a mountain perceives time. TheShow MoreRelatedThe Magic Of Nature By William Wordsworth1498 Words   |  6 PagesCourse: LLT 1223 Date: 7 June 2016 The Magic of Nature â€Å"She Dwelt among the Untrodden Ways by William Wordsworth Overview: Romanticism and Nature The poem is written in three stanzas, rhymed, and has the characteristics of elegy (it is a lamentation song about someone’s death). It is also a ballad piece that tells part of the story. The poem was written by William when he was on a visit to Germany in 1978 (during the romanticism period). 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