Transcript Preventing Nosocomial infections in Neonatal Intensive Care Units

Preventing Nosocomial infections in
Neonatal Intensive Care Units
Congreso Internacional de Prevention de Infecciones
Intrahospitalarias
Alan Picarillo, MD, FAAP
Neonatologist
UMassMemorial Healthcare
Assistant Professor in Pediatrics
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University of Massachusetts Medical School
Disclosures
• I have no financial interests to disclose for this
lecture
• I will be speaking about off-label use of a
medication (chlorhexidine) during this lecture
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Introduction
• Why are our smallest infants so vulnerable to
hospital-acquired infections?
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Liberian Observer
“Chinese doctor performs miracle surgery at JFK Hospital”
Liberian Observer January 2010, online edition
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Introduction
• Why are our smallest infants so vulnerable to
hospital-acquired infections?
– Very immature infants
– Immature immune systems
– Poor skin integrity
– Surgical procedures
– Central line placement
– Long length of stay
– Overcrowding
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Overall burden of nosocomial
infections
• In the US it is estimated that 5-10% of all
hospitalized patients will have a nosocomial
infection
• >90,000 deaths attributable each year to
nosocomial infections in the United States
– 39,788 deaths from auto/motorcycle accidents
– 16,605 deaths from HIV/AIDS (2008)
– 138 deaths from airline accidents
• Can this be stopped?
http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf
DOT data (1999-2003)
CDC data http://www.cdc.gov/hiv/topics/surveillance/basic.htm#ddaids
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Burden of nosocomial infections in
neonates
• Late onset (>72 hours of age) sepsis occurs in
4.2% of all neonatal ICU admissions and 17.1%
of infants <1.5kg.
• Rates of central line bloodstream infections
are 37% higher in neonatal ICU patients than
in adult ICU populations
• Is it possible to reduce nosocomial infections
in neonates, or are the infections
unavoidable?
Vermont-Oxford database (2009)
NSHN CLABSI report (2011)
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Decrease in nosocomial bloodstream infections for
infants <1500 gms in Massachusetts NICUs (2006-2010)
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22.2
21.2
VON
20.6
NeoQIC
19.2
20
17.4
17.1
14.6
15
12.6
11
10
8.8
5
0
2004
2005
2006
2007
2008
2009
2010
12
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Incidence of nosocomial bloodstream
infection by hospital (2006-2010)
2006
2007
2008
2009
2010*
30
25
20
15
10
5
0
1
2
3
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5
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Quality Improvement
• Institute for Healthcare
Improvement (IHI)
model
• Key elements
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Aims
Measures
Changes (PBPs)
Plan, do, study, act
cycles (PDSA)
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Quality Improvement
• Potentially better practices (PBPs) defined as a
set of clinical practices that have the potential
to improve the outcomes
• PBPs can be:
– Evidence based guidelines
– Derived from previous improvement efforts
– Based on literature review
– Expert recommendations
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PBPs for preventing neonatal
nosocomial infections
• PBP 1: Foster and support unit culture in which
nosocomial infection is considered a preventable
complication, not an entitlement of NICU patients
• PBP 2: Ensure high compliance with optimal hand
hygiene practices
• PBP 3: Ensure that all vascular catheters are inserted
under optimal conditions
• PBP 4: Ensure high compliance with optimal practices
for the maintenance and use of vascular catheters
• PBP 5: Remove vascular catheters in a timely manner
VON Quality Improvement Kit: preventing nosocomial infection
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PBP 1:Foster/Support Culture in Which Infection
is Considered a Preventable Complication
• In NICUs with low nosocomial infection rates,
the staff belief was that infections were
preventable and represented a breakdown in
care
• NICUs with high rates, staff belief is that
infections are inevitable and unavoidable
complications of intensive care.
• A belief among staff that nosocomial sepsis is
preventable leads to a motivation to improve.
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PBP 1:Foster/Support Culture in Which Infection
is Considered a Preventable Complication
• Aim
– All staff will demonstrate knowledge of infection
control
– All staff will demonstrate a belief that nosocomial
infections represent a failure of optimal care and
are preventable in most cases
• Measure:
– Percent of staff that accurately answers questions
about knowledge of methods to prevent infection
– Pretest, education, post-test
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PBP 1:Foster/Support Culture in Which Infection
is Considered a Preventable Complication
• Changes to test:
– Leadership of unit visibly supporting infection
prevention program
– Educational in-service for all staff
– Fact sheets, posters
– Create a slogan to help with team chemistry
– Display hospital’s infection rates for all to see
(including parents/families)
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PBP 1:Foster/Support Culture in Which Infection
is Considered a Preventable Complication
• Barriers to change
– Lack of support from the entire institution to change
staff mental model
– Lack of role modeling by senior leaders and opinion
leaders in the hospital
• Potential risks
– Excessive exposure of staff to infection prevention can
cause desensitization and reduce impact
– Staff may take offense and become resistant to
change if it is implied or stated that they caused the
infection and are being blamed
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PBPs for preventing neonatal
nosocomial infections
• PBP 1: Foster and support unit culture in which
nosocomial infection is considered a preventable
complication, not an entitlement of NICU patients
• PBP 2: Ensure high compliance with optimal hand
hygiene practices
• PBP 3: Ensure that all vascular catheters are inserted
under optimal conditions
• PBP 4: Ensure high compliance with optimal practices
for the maintenance and use of vascular catheters
• PBP 5: Remove vascular catheters in a timely manner
VON Quality Improvement Kit: preventing nosocomial infection
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Hand hygiene is an established and widely
accepted intervention to reduce healthcare
associated infections
• Recommended by expert bodies such as WHO
and Center for Disease Control (CDC)
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Aim:
– All NICU staff will practice optimal hand hygiene
before and after every patient contact
– All staff will follow infection control recommendations
about jewelry, accessories and clothing
• Measure:
– percentage of patient contacts in which providers
practice optimal hand hygiene and have both arms
exposed below the elbows.
– On periodic direct observation all staff will be without
artificial nails or accessories (except for plain wedding
bands).
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Optimal hand hygiene
– Both arms are bare below the elbows
– Arms are free of jewelry except for plain wedding
rings
– No artificial nails or colored nails
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Right to Bare Arms
• Multiple studies of nosocomial infections have
implicated caregivers and their hand hygiene
practices
• Stethoscopes, providers’ white coats, cell phones
and patient charts have all been found to harbor
bacteria and have been attributed to play roles in
outbreaks of nosocomial infections
• Several case reports of providers wearing artificial
nails have been implicated in outbreaks of
Pseudomonas sepsis in NICUs1
1. Am J Infect Control 2002; 30: 252-4
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Optimal hand hygiene
– Both arms were bare below the elbows
– Arms are free of jewelry except for plain wedding
rings
– No artificial nails
– Person sanitized their hands by using alcohol gel
or by washing with soap and warm water prior to
touching the patient (or patient’s equipment) and
then immediately after patient contact
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Donskey C and Eckstein B. N Engl J Med 2009;360:e3
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Changes to test:
– Alcohol gel at convenient locations with easy
visibility
– Offer staff personal alcohol gel dispensers
– Provide sinks of adequate depth with faucets that
are easy to operate
– Use material from WHO hand hygiene kit “My five
moments for hand hygiene”
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Journal of Hospital Infection (2007) 67, 9-21
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Changes to test:
– Alcohol gel at convenient locations with easy visibility
– Offer staff personal alcohol dispensers
– Provide sinks of adequate depth with faucets that are
easy to operate
– Use material from WHO hand hygiene kit “My five
moments for hand hygiene”
– Discourage scrubbing of hands and arms with brush
– Empower families to ask providers if they washed
their hands before patient contact
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PBP 2: Ensure high compliance with
optimal hand hygiene practices
• Barriers to change:
– Lack of culture where NICU professionals are not
accepting of feedback and reminders about hand
hygiene
– Lack of conveniently located alcohol-based dispensers
or sinks and faucets
– Lack of systems to replenish hand hygiene resources
• Potential risks:
– Skin irritation from frequent use of alcohol-based
hand rub
– Flammable
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PBPs for preventing neonatal
nosocomial infections
• PBP 1: Foster and support unit culture in which
nosocomial infection is considered a preventable
complication, not an entitlement of NICU patients
• PBP 2: Ensure high compliance with optimal hand
hygiene practices
• PBP 3: Ensure that all vascular catheters are inserted
under optimal conditions
• PBP 4: Ensure high compliance with optimal practices
for the maintenance and use of vascular catheters
• PBP 5: Remove vascular catheters in a timely manner
VON Quality Improvement Kit: preventing nosocomial infection
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PBP 3: Ensure that all Vascular Catheters
are Inserted Under Optimal Conditions
• Insertion of central venous catheters using
good aseptic technique and maximal sterile
barrier precautions after performing hand
hygiene prevents infection during insertion of
catheters
• High level of evidence to back the
interventions
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PBP 3: Ensure that all Vascular Catheters
are Inserted Under Optimal Conditions
• Aim: In all (100%) episodes of vascular catheter
insertion, maximal barrier precautions will be
followed and optimal preparation of insertion site
will be performed
• Measure: Percentage of catheter insertion
episodes in which inserters
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–
–
–
practiced hand hygiene
followed maximal barrier precautions
used “skin prep” agent chosen by unit
allowed for sufficient drying time prior to insertion
attempt.
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PBP 3: Ensure that all Vascular Catheters
are Inserted Under Optimal Conditions
• There are approximately 15 different steps in
placing a central vascular catheter under
optimal conditions.
• How to ensure consistent practice among
different individuals when performing a task
with multiple steps
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Checklists
• Dr. Peter Provonost of Johns Hopkins
proposed a small 5-item checklist for provider
central line insertion.
– Wash hands with soap
– Clean the patient’s skin with chlorhexidine
– Place sterile drapes over entire patient
– Wear a sterile hat, mask, gown and gloves
– Place a sterile dressing after the line is in place
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Checklists
• Michigan Keystone initiative adopted the
checklist developed by Dr. Provonost in their
adult ICUs. (>100 ICUs participated)
• 66% decrease in infections within the first 3
months of introduction of checklist
• Sustained decrease for the next 4 years
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PBP 3: Ensure that all Vascular Catheters
are Inserted Under Optimal Conditions
• Changes to test:
– Dedicated central line team with certification and/or
demonstrate competency
– Use of an insertion checklist (US National Patient
Safety Goal 07.04.01)
– Empower nurses to stop procedure if mistakes are
made
– Consider chlorhexidine instead of Povidone-Iodine
solution (Betadine) for skin prep
– Use drapes to cover the procedure field completely
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Chlorhexidine
• Chlorhexidine is not currently FDA-approved for
infants less than 2 months of age.
• Few studies available concerning use of
chlorhexidine
– Biopatch experience
• Survey of neonatologists in 2009 reported 61% of
university-based NICUs used chlorhexidine for
skin preparation for vascular catheters
– Concern among respondents with infants< 1kg and
premature infants <28 weeks gestation
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PBP 3: Ensure that all Vascular Catheters
are Inserted Under Optimal Conditions
• Barriers to change:
– Long-standing individual habit or unit practice of not
wearing full barrier precautions
– Lack of availability of assistant to use checklist
– Emergency catheter placement as risk for precautions
being skipped or shortcuts taken
– Controversy over safety of skin prep agents for
preterm infants
• Potential risks:
– Skin irritation from chlorhexadine
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PBPs for preventing neonatal
nosocomial infections
• PBP 1: Foster and support unit culture in which
nosocomial infection is considered a preventable
complication, not an entitlement of NICU patients
• PBP 2: Ensure high compliance with optimal hand
hygiene practices
• PBP 3: Ensure that all vascular catheters are inserted
under optimal conditions
• PBP 4: Ensure high compliance with optimal practices
for the maintenance and use of vascular catheters
• PBP 5: Remove vascular catheters in a timely manner
VON Quality Improvement Kit: preventing nosocomial infection
45
PBP 4: Ensure High Compliance with Optimal Practices
for the Maintenance and Use of Vascular Catheters
• Contamination of the catheter hub
contributes significantly to intraluminal
colonization of vascular catheters.
• When entering the catheter, the access port
should be prepped with alcohol using
sufficient friction and allowing it to dry
• All connections should be performed under
sterile conditions
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PBP 4: Ensure High Compliance with Optimal Practices
for the Maintenance and Use of Vascular Catheters
• Aims: During all episodes of luminal access of
vascular catheters, optimal sterilization of the
hub or entry point will be performed prior to
accessing the catheter
• Measure: The percentage of times the luminal
access of vascular catheters in which the
providers appropriately sterilize the hub or
entry point prior to access.
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PBP 4: Ensure High Compliance with Optimal Practices
for the Maintenance and Use of Vascular Catheters
• Changes to test:
– When infusion tubing is disconnected from
vascular catheter, it should be placed on a sterile
surface
– Provide sufficient quantity of alcohol wipes in
convenient location
– Daily exam of catheter entry sites
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PBP 4: Ensure High Compliance with Optimal Practices
for the Maintenance and Use of Vascular Catheters
• Barriers to change:
– Common problem is not allowing for alcohol to
dry before entering the hub
– When catheters are accessed in an emergency,
proper hub care may not be performed
• Risks: none
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PBPs for preventing neonatal
nosocomial infections
• PBP 1: Foster and support unit culture in which
nosocomial infection is considered a preventable
complication, not an entitlement of NICU patients
• PBP 2: Ensure high compliance with optimal hand
hygiene practices
• PBP 3: Ensure that all vascular catheters are inserted
under optimal conditions
• PBP 4: Ensure high compliance with optimal practices
for the maintenance and use of vascular catheters
• PBP 5: Remove vascular catheters in a timely manner
VON Quality Improvement Kit: preventing nosocomial infection
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PBP 5: Remove Vascular Catheters in a
Timely Manner
• Indwelling catheters are a definite risk factor for
nosocomial infection
• Prompt removal of a vascular catheter when it is no
longer required is supported by good evidence
• Aims: All vascular catheters will be assessed at least
once per day for necessity and unnecessary catheters
will be removed
• Measure: Percentage of vascular catheters that are
assessed each day for their necessity during daily
rounds by the healthcare team; the need for infant’s
vascular catheter is documented in the medical record.
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Walking the line
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PBP 5: Remove Vascular Catheters in a
Timely Manner
• Changes to test:
– Have a staff member assigned to “walk the line”
each day to act as a prompt to ask whether of not
a vascular catheter is required for the infant’s care
that day
– Develop strict criteria for removal of central
catheters
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PBP 5: Remove Vascular Catheters in a
Timely Manner
• Barriers to change:
– Staff resistance to catheter removal “in case it may
be needed”
– Lack of understanding that an indwelling catheter
is a risk for infection
• Risks:
– Premature removal of a vascular catheter and
needing to insert a new catheter in the next 1-2
days
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Additional PBPs
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•
•
•
•
Avoid understaffing and overcrowding
Ensure optimal environmental hygiene
Antibiotic stewardship
Use of breastmilk for enteral feeding
Develop a plan for investigation and response
to nosocomial infection outbreak
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Summary
• Teamwork and leadership buy-in is required for
changing the culture and therefore an essential
tenet of quality improvement in reducing
nosocomial infections
• Hand hygiene and a rigorous infection control
program can prevent most healthcare associated
infections
• Placement of vascular catheters, while clinically
important to the care of neonates, also carry
significant risk for infection
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Summary
• Much evidence exists to mitigate the risk of
infection from vascular catheters and many NICUs
have employed these procedures to reduce the
burden of catheter-associated infections
• Consider a reporting mechanism (“keeping
score”) to allow for tracking nosocomial
infections over time
• Identify units with low infection rates, evaluate
their policies and procedures to see if they can be
utilized in units with high infection rates
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Who are our most important
stakeholders?
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Surveillance and Reporting
• Surveillance for nosocomial infections is crucial
for comparing rates among units and studying the
effect of preventative interventions
• Several different methods of reporting:
– Simple number of infections per time period (month,
quarter, year)
– Number of infections/100 patient days
– Number of catheter-related infections/1000 catheter
days
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Surveillance and Reporting
• Data should be shared with physician, nursing
and administrative leadership
• Data can be compared to historical data from
individual hospital, national data or
international reference point data
(CDC/NHSN)
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Five stages of grieving over outcome data
• Denial: these data cannot be right!
• Anger: why are they picking on me, I have too
much work to do!
• Bargaining: my patients are sicker than
everybody else, my NICU is different, I do not
agree with the data definitions
• Depression: I cannot do anything about it
anyway…
• Acceptance: OK, what can I do to improve the
outcomes in my NICU
Source: Dan Ellsbury, MD Pediatrix Medical Group
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Surveillance and Reporting
• Mandated reporting in 18 states in the US
• Massachusetts requires all hospitals to report all
nosocomial infections (catheter-related
bloodstream infections, surgical site infections,
etc) to the Center for Disease Control (CDC)
• The infection data is provided to the
Massachusetts Department of Health and then
the completed statistics are publically reported
and available for patients and their families
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Collaboratives
• Several states and countries are forming NICU
collaboratives
– to share and compare data in order to evaluate which
NICU has best practice in a certain area
– share that expertise with other NICUs
• Data transparency
– Integral part of a collaborative
– Tough barrier to overcome
– Memorandum of understanding between participating
hospitals
– Helps further develop unity and a community of practice
for the stakeholders
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