Transcript Infection Control Measures in the ICU

Infection Control Measures in the ICU:
A day in the life of a bacterium in the
ICU
B. Taylor Thompson, MD
Director, MICU
Massachusetts General Hospital
Associate Professor of Medicine
Harvard Medical School
[email protected]
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Presentation Outline
Nosocomial transmission
• Where bacteria live and how
they get around
• Infection Control in the ICU:
–Central role for and hygiene
• Review the MGH experience
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WHO Global Safety Challenge
First Target (2005-2006)
– Health Care Associated Infections
– Hand Hygiene as cornerstone
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5 Essential Steps for Cross Transmission
Pittet et al Lancet Infect Dis 20064
ICU patients are rapidly colonized
with pathogenic bacteria
• Skin colonized in hours to days
– Staph. aureus, Proteus mirabilis, Klebsiella
spp. present @ 100-106 CFU /cm2 skin
• Perineal/inguinal > axilla > trunk > upper
extremities and hands
• Dialysis/CRF, diabetes, dermatitis, broad
spectrum Abx increase risk
• Patients shed 106 squames/day ->
widespread contamination of the room
Reviewed in Pittet et al Lancet Infect Dis 20065
5 Essential Steps for Cross Transmission
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Pittet et al Lancet Infect Dis 20066
Transmission to Hands from Skin
and Environment
Pittet et al Lancet Infect Dis 2006
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Transfer to the hands of health care
workers (HCWs) hands: I
• “Clean Activities” (lifting, taking radial
artery pulse, measuring blood pressure)
– Up to 100-1000 cfu from HCWs hands
• HCWs intercepted before hand wash in
MRSA colonized patient
– 17% of worker’s gloves positive
Phillips, BMJ 1977; McBride, J Hosp Inf 2004
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Transfer to the hands of health care
workers (HCWs) hands: II
• Surveillance cultures of HCWs hands in ICU
– 21% of MDs; 5% of nurses positive (n=328)
• Serial Cultures of NSICU HCWs hands
– 100% positive for GNR and 64% positive for staph
aureus at least once
• Rings, artificial or long nails, dermatitis increase
frequency of hand contamination of HCWs
Daschner, J Hosp Inf 1988; Maki, Ann Int Med 1978; Trick, Clin Inf Dis 2003
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More contamination with more care
Pittet, Arch Int Med 1999
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Contamination of Healthcare
Workers with VRE during Routine
Patient Examinations
At least one site
33/49 (67%)
Gloves (Hands)
31/49 (63%)
Gowns
18/49 (37%)
Stethoscopes
15/49 (31%)
All three sites
12/49 (24%)
Stethoscope after wipe
1/49 (2%)
Zachary, Infect Control Hosp Epidemiol. 2001
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5 Essential Steps for Cross Transmission
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Pittet et al Lancet Infect Dis 200612
Bacterial Survival times on hands
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Acinetobacter spp
E. coli
Klebsiella spp
VRE
Pseudomonas sp
Rotavirus
60 min
6 min (mean)
2 min (mean)
60 min
30 min; 180 in sputum
16% survive 20 min;
2% survive 60 min
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Contamination of ICU Patient Charts
• Sterile swab of outside of binders/charts
kept outside the ICU room
Percent of ICU charts culture positive by organism
Panhotra Am J Infect Control 2005
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5 Essential Steps for Cross Transmission
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Pittet et al Lancet Infect Dis 200616
Hand washing compliance rates by
occupation
Occupation
Compliance
OR (95% CI)
Nurse
52%
1.00
Physician
30%
2.80 (1.9-4.1)
Nursing Assistant
47%
1.28 (1.0-1.5)
Other
38%
2.15 (1.4-3.2)
Pittet D et al. Ann Intern Med 1999; 130:126
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5 Essential Steps for Cross Transmission
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Pittet et al Lancet Infect Dis 200618
MGH Nosocomial MRSA
1995-1999
Cases per 1000 patient-
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Q4/95
Q2/96
Q4/96
Q2/97
Q4/97
Q2/98
Q4/98
Q2/99
Q4/99
Quarters
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Strategies to decrease transmission
• Proven or Proposed Strategies
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–
–
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–
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Antibiotic stewardship
Proper hand hygiene
Cohorting patients
Reducing LOS
Gowns and gloves
Isolation of patients
Appropriate staffing ratios
Antibiotic crop rotation
Surveillance cultures
Decolonization of patients (chlorhexidine body washes, muciprocin)
Decolonization of health care worker carriers
• Paucity of RCTs on efficacy of individual approaches
• Efficacy of an individual approach may vary by pathogen
• Near eradication of a pathogen from a hospital (or a
country) requires a bundle of approaches (eg. “Search
and Destroy” in the Netherlands)
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Compulsive Antibiotic Prescribing (CAP)
• CAP is a widespread and serious affliction
– First year medical students are free of the disease
– Interns and first year residents are severely
afflicted…life-long habit difficult to break
– CAP is supported by a well organized group of
antibiotic pushers
• Antibiotics Anonymous
– Self help group, available 24 hours, will talk you
through the urge to prescribe more than two
antibiotics, other abuses
Lockwood et al, NEJM p465-466, 1974
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Is isolation safe for the patient?
• Cases: Consecutive patients admitted and
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isolated for MRSA
Controls: Patients in the same room immediately
before and after a case
Similar baseline characteristics
Cases
– More likely to have unrecorded vital signs, absent MD
progress notes, and to complain about their care
– Twice the rate of preventable adverse events
– Similar mortality (17% cases vs 10% controls, p=0.16)
Stelfox , JAMA 2003
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Communication Campaign
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MGH Hand Hygiene (HH) Campaign
• 2000 HH Task Force (D. Hooper and P. Wright)
– Cal stat dispensers hospital wide
• 2002 Poster/Educational Campaign
• 2004
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8% wash before contact, 48% after contact
HH Champions on each floor -> Pizza
New Poster Campaign
Monitoring and feedback of HH rates by unit/floor,
RN/MD
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MGH Hand Hygiene Campaign
• 2005-2006
– Benchmark against peers (more peer pressure)
– “On the spot” Coffee Central coupons
– Patients as advocates: patient learning center
• 2007
– HH Quality incentive program: if rates of HH
before and after patient contact > 90% on a
given floor/ICU, monetary bonus paid at years
end to RNs, MDs. Rates/reminders sent to
units monthly
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MGH Quarterly Hand Hygiene rates: 2004-07
Before contact
After contact
*with the patient or patient’s environment
High: 93%
High: 90%
47%
8%
JCAHO expectation: 90%
Target for 2007: 90%
MGH goal: 100%
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MGH Healthcare-associated and Admission MRSA
1200
Nosocomial
Present OA
1115
1000
1040
No. of Cases
985
800
767
600
623
400
438
382
383
409
347
290
200
248
177
319
303
299
242
205
167
105
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
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Conclusions
• Nosocomial transmission of pathogenic
bacteria creates a major health burden
• Multifaceted interventions are needed for
high level control: proper hand hygiene is
the cornerstone of prevention efforts
• Isolation of patients may place them at risk
for errors of omission
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Thank you
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