Deakin University: HNN320 Report on Clinical Governance & Leadership

This report details a nursing case study involving a 70-year-old diabetic woman, Janice, admitted to a nursing home with various health issues, including a urinary tract infection (UTI) and potential hospital-acquired infection (HAI). The report explores the clinical risks associated with Janice's care, particularly focusing on HAI, specifically Pseudomonas pseudomallei (melioidosis), and the role of nursing leadership and clinical governance in managing these risks. It identifies the sources of infection, symptoms, and diagnostic findings. The report analyzes the situation, evaluating the implemented interventions, and proposes preventative strategies, including infection control programs, hand hygiene protocols, and environmental control measures. It emphasizes the importance of patient-centered care, staff education, and adherence to standard precaution guidelines to reduce the risk of HAIs and improve patient outcomes. The report references relevant literature and provides a comprehensive overview of clinical risk management in a nursing context.

Running head:LEADERSHIP AND CLINICAL GOVERNANCE
LEADERSHIP AND CLINICAL GOVERNANCE
Name of the student
Name of the university
Author note

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Part I
Janice, 70-year old diabetic women were admitted in my nursing home named
Concorde Nursing Home. Janice was admitted with impaired vesicle function along with that
she had a knee replacement surgery. While I was going through her previous records, I found
that in December 1995, she was admitted in this nursing home because of uncontrollable high
blood sugar level. Her diabetic condition improved a little but because of vesicle dysfunction,
I admitted the patient in the geriatric ward and have given her permanent indwelling catheter.
The risk increases when the patient stays long in hospital, use indwelling catheters, overuse
of antibiotics and failure of healthcare givers to wash their hands. The source of infection can
be exogenous and as well as the exogenous source. The exogenous source is other patients,
inanimate objects, healthcare workers, the inanimate environment of the hospital such as
contaminated air, water, food, contaminated equipment and instruments and hospital waste.
The endogenous source is considered as normal intestinal flora or colonisers of skin. So, I
changed her catheter routinely and I took her urine sample to examine at AGHL. I was
responsible for dressing the wound that occurred during knee replacement. The report
showed a scanty growth of an enteric organism. After a week of catheterization, Janice’s
condition deteriorated and an increase in blood urea nitrogen is observed. I have seen her
develop a low-grade fever, overhydrated and uneasiness so I sent another urine sample of
Janice to AGHL for culture. Along with clinical symptoms, a biochemical study was done
which showed she was undergoing acute renal failure and shortness of breath. So, I arranged
for dialysis immediately and the patient's condition returned to the normal state. The report
showed pyuria of 400 leucocytes/mm3 of uncentrifuged urine, colonies of P. Pseudomallei
counting 2.5 X 103 colonies /ml and two enteric bacilli numbering >105 colonies/ml along
with that fungas Candida was also detected. Based on the value of the report, I changed
Janice’s catheter and irrigated her bladder with a 0.2% solution of neomycin sulphate as

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Janice explained her present situation and I examined her condition is related to UTI. On the
application of this, her body temperature decreased and started to feel good. An intravenous
pyelogram was conducted and I again examined her urine sample where no trace of P.
pseudomallei was found and then I discharged her. The pyelogram report showed moderate
distension of ureter along with obstruction at the lower end and proof of normal kidney
outline was obtained. A significant increase in the titer is seen in the blood specimen where
serological assay for antibody specific for P. Pseudomallei when done. The report gives a
result of different times when the serum was collected. Serum collected immediately after
recognition of P. pseudomallei is less than 5, two weeks after isolation of P. pseudomallei is
less than 5, four weeks after isolation of P. pseudomallei is 20 and the count after eight weeks
after isolation of P. pseudomallei is 80. Pseudomonas pseudomallei is a gram-negative
bacteria which causes melioidosis which is an uncommon infectious disease which is also
known as Whitmore disease. It is endemic in Southeast Asia and northern Australia where
my nursing home is situated. The mode of action of this organism is they attack the host
through an opening in the skin or by inhalation. The degree of infection of this disease in
public health is not much. However, The U.S Center for Disease Control and Prevention
estimated that about 1.7 million hospitalised patient gets infected by this infection and near
about 98,000 of patient dies out of this infection. HAI is considered as the top leading cause
of the deaths. This is a considered as nosocomial infection or hospital-acquired infection
which originated in hospital grounds. Samples of soils taken from hospital ground and
biochemical report from the patient’s urine sample confirms the communicability of the
infection.

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Part II
IDENTIFICATION
Hospital acquires infection occurs due to prolonged stay in the hospital, compromised
immune status, use of indwelling catheters, the prevalence of antibiotic-resistant bacteria,
failure of the health care workers to maintain hygiene. Her risk of getting affected by
hospital-acquired infection increased during urinary bladder catheterisation and respiratory
procedures such as mechanical ventilation, dressing or draining of surgical wounds,
intravenous procedures which delivering medication, transfusion or nutrition. She got
attacked with common hospital-acquired infections such as Urinary tract infection (UTI)
along with that other infection like pneumonia and invasive surgical procedures are also
suspected. UTI occurred to her after urinary catheterisation which is caused by a fungus
called Candida. It was suspected that prolonged antibiotic therapy may lead to pneumonia.
Another possible reason for Janice to get hospital-acquired infection is prolonged mechanical
ventilation, suctioning of material from the throat and mouth, respiratory intubation that leads
to colonisation of microorganisms in the throat area (Kalanuria, Zai & Mirski, 2014). The
source of infection can be exogenous and as well as the exogenous source. It has been found
that the exogenous source is other patients, inanimate objects, healthcare workers, the
inanimate environment of the hospital such as contaminated air, water, food, contaminated
equipment and instruments and hospital waste. Along with this, the endogenous source is
considered as normal intestinal flora or colonisers of skin. Invasive surgical procedures due to
her knee replacement can increase the patient’s risk to get infected during the dressing of the
surgical wound. Other wounds caused by burns, pressure sores and trauma were not
recognized which also leads to the HAI. A bacterium P. pseudomallei found in hospital
grounds is potentially responsible for hospital-acquired infection. The first sign of infection is
fever (Rowe et al., 2014). The symptoms of Janice include shortness of breath, low blood

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pressure, mental confusion, high white blood cell count and reduced urine output. In UTI
conditions, Janice reported having pain during urinating and blood is seen in the urine.
Breathing and inability to cough were her potential symptoms. The infection at knee
replacement area first swelled up and redness occurred and tenderness occurred on or around
the skin of the surgical site which leads to rapid destruction of deep layers of muscle tissue
and eventually leads to sepsis.
ANALYSIS
After analyzing Janice’s report traces of P. Pseudomallei colonies were first observed
in the urine sample and Melioidosis infection is confirmed. Additionally, the report says
traces of Candida was found and Janice reported pain during urinating and blood in the urine
which confirmed that she is infected with UTI too. Redness and tenderness was noticed in her
knee replacement area. According to Australian Institute of Health, it has been estimated that
83,096 Australians are infected with HAIs per year due to prolonged hospital stay with
71,186 urinary tract infection, 4902 Clostridium difficle infection, 3946 surgical site
infection, 1100 hospital-onset Staphylococcus aureus bacteraemia infection and 1962
respiratory infection. Following the preventative strategies will reduce the risk of getting
infected with the hospital-acquired infection and thus enhance patient safety.
EVALUATION
It is necessary for to adopt an infection control program which includes quality
control procedures in the nursing home that will lead to the incorporation of monitoring
programme that will help in tracking the infection rate along with that we must strictly adhere
to hand washing, sterilisation, use of an anti-bacterial coated venous catheter, wearing gloves,
masks for safety purpose, removal of nasogastric and endotracheal tubes, using silver alloy-
coated urinary catheters, sterilisation of medical instruments, reducing antibiotic therapy can
reduce and eliminate the risk of HAI if it is taken under practice. If this had been followed

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then Janice would not be affected with hospital-acquired infection. Phase II is built on HAI
policy toolkit and is based on a phone consultation with the stakeholders and in-person
meetings. The participating stakeholders represented local and state health agencies, patients,
consumers, hospital and hospital association, quality improvement organisations, healthcare
professionals, healthcare payers, outpatient clinics. The first step of this approach in my
clinical setting is identification of a set of infection that will be initially focussed, then
standardising definitions then comes the reporting process, metrics and evaluation mandating
public reporting of HAI rates and collaborative approach to prevent HAI in my nursing home
must be ensured (Waters et al., 2015). This will help her to overcome the potential risk
efficiently and revive back to normal life.
MANAGEMENT
Nurses play a pivotal role in managing healthcare-associated disease and should know the
following interventions:
 Hyperthermia intervention
 Health teaching
 Antibiotic therapy
 Psychosocial support
 Healthcare resources
Following these interventions would improve the condition of the patients in the clinical
settings thus reduce the risk of hospital- acquired infection. It is our duty to focus on giving
patient-centred care to Janice. The main aim of us should be providing patient centered care
rather than disease centered care. It is highly recommended to give a good read on CDC and
OSHA guidelines will help nurses like us to manage such infection efficiently and improve
the quality of care. Along with these, we should be well equipped with personal protective
equipment such as gowns, eye protection, respiratory masks, gloves, specimen collection,

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transporting patients, bagging Trash and linen in the checklist. The foremost important thing
that we must remember is preventing or reducing the infection is only possible is proper hand
washing is done. Hand washing for 15 secs and turning off the faucet with a dry towel is an
evidence based approach which we should maintain. Alcohol-based hand wash is also an
acceptable approach. We should wash hand before and after touching the patient, before and
after putting the gloves, after touching the blood, broken skin, mucous membrane and other
body substance and between doing different procedures on the same patient. Hand washing
with plain soap only removes soil and transient bacteria whereas hand antisepsis is the
removal of transient flora using alcohol-based hand rub or using anti-microbial soap
(Asadollahi et al., 2015). Barrier protection such as gloves, masks and protective eyewear,
aprons are our basic requirements that we must take under consideration to reduce the risk.
Following contact isolation, droplet isolation and airborne isolation are basic approaches that
we should follow so that the patient is kept safe. We must give importance to the potential
factor that can reduce the maximum of the infection is controlling the environment.
Environmental control like cleaning hospital environment according to the policies, proper air
ventilation, water pipes examination, proper waste collection and disposal, cleaning and
disinfection of equipment, proper linen collection, cleaning and distribution needs to be
assessed by us (Dancer, 2014). Another approach that we must engage ourselves in effective
staff health promotion and education. It is our duty to check the health history of our staffs
and provide proper immunisation, released him or her from work if sick (Pierzak & Nowak,
2017). We must engage ourselves in continuous education to get acquainted with new
techniques and thus enhancing our performance (Iedema et al., 2015). We must follow
standard precaution guidelines while dealing with HAI infected patients (Sarani et al., 2016).
We should know about surveillance activities such as operative procedures, critical care units,
targeted surveillance and outbreak investigation which will increase patient’s safety.

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References
Asadollahi, M., Bostanabad, M. A., Jebraili, M., Mahallei, M., Rasooli, A. S., &
Abdolalipour, M. (2015). Nurses' knowledge regarding hand hygiene and its
individual and organizational predictors. Journal of caring sciences, 4(1), 45.
Dancer, S. J. (2014). Controlling hospital-acquired infection: focus on the role of the
environment and new technologies for decontamination. Clinical microbiology
reviews, 27(4), 665-690.
Iedema, R., Hor, S., Wyer, M., Gilbert, G. L., Jorm, C., Hooker, C., & O'Sullivan, M. (2015).
An innovative approach to strengthening health professionals’ infection control and
limiting hospital-acquired infection: video-reflexive ethnography.
Kalanuria, A. A., Zai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the
ICU. Critical care, 18(2), 208.
Pierzak, M. T., & Nowak, E. (2017). Knowledge concerning the nursing staff hospital-
acquired infections in the prevention and transmission paths microorganisms living in
the hospital environment. Journal of Education, Health and Sport, 7(8), 993-1011.
Rowe, E. K., Leo, Y. S., Wong, J. G., Thein, T. L., Gan, V. C., Lee, L. K., & Lye, D. C.
(2014). Challenges in dengue fever in the elderly: atypical presentation and risk of
severe dengue and hospital-acquired infection [corrected]. PLoS neglected tropical
diseases, 8(4), e2777-e2777.
Sarani, H., Balouchi, A., Masinaeinezhad, N., & Ebrahimitabs, E. (2016). Knowledge,
attitude and practice of nurses about standard precautions for hospital-acquired
infection in teaching hospitals affiliated to Zabol University of Medical Sciences
(2014). Global journal of health science, 8(3), 193.

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Waters, T. M., Daniels, M. J., Bazzoli, G. J., Perencevich, E., Dunton, N., Staggs, V. S., ... &
Shorr, R. I. (2015). Effect of Medicare’s nonpayment for Hospital-Acquired
Conditions: lessons for future policy. JAMA internal medicine, 175(3), 347-354.