Transcript bartles-2---primary-care-conference-presentationx

Infection Prevention in Primary Care
Objectives
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By the end of this presentation, you should be able to:
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Note: Sample Footnote
Verbalize the basic concepts of hand hygiene, standard precautions and
transmission-based precautions
Verbalize appropriate equipment cleaning techniques as related to
physician practice
Explain measures for preventing transmission of multi-drug resistant
organisms within the healthcare setting
Explain the fundamentals of antibiotic stewardship
Explain measures for preventing specific device associated infections,
including CAUTI, CLABSI, and VAP
Explain measures for preventing surgical site infections
Healthcare-Associated Infections
(HAI)
• “A localized or systemic condition resulting from an
adverse reaction to the presence of an infectious
agent or its toxin. There must be no evidence that
the infection was present or incubating at the time
of admission to the acute care setting, unless a
change in pathogen or symptoms strongly suggests
the acquisition of a new infection.”*
*CDC, NHSN Patient Safety Component Key Terms, January 2012
Cost of HAI’s
Estimated Number of HAI’s per Year
in U.S. Hospitals
Cost of HAI’s
• Overall direct annual cost of HAI to U.S. hospitals is
$28 - $45 billion*
• Up to 70% of these are preventable*
*CDC, The Direct Medical Costs of Healthcare Associated Infections in US Hospitals and the
Benefits of Prevention, 2009
Hospital Associated Infections Regulatory
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(CMS), as a result of the Medicare Modernization Act of 2003
and the Deficit Reduction Act of 2005, has defined many HAI’s
as “never events”
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Effective October 1, 2008, changes in the CMS impatient prospective payment
resulted in non-reimbursement for specific infections not present on admission
in inpatients who were later discharged from acute care hospitals.
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Compliance with SCIP measures and specified hospital-acquired infection rates
will affect credentialing and the individual facility’s reimbursement rate scale
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Beginning in 2013, payment determination will be based in part on hospitalacquired infections reported during CY 2011. The list of reportable hospitalacquired infections will continue to increase until 2015.
Accreditation Organizations
State Health Departments
Standard Precautions
The first step in preventing infection
• Hand Hygiene
• PPE
• Safe injection practices
• Safe handling of potentially contaminated
equipment/ surfaces in the patient care area
• Respiratory hygiene/cough etiquette
Infection Prevention 101
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1881 – President Garfield died from an
infection 3 months after he was shot by
an assassin. The likely culprit was
manure-stained hands of the
President’s medical team, as they were
also farmers.
1846 – Ignaz Semmelweis noted higher
puerperal fever rates in women whose
babies were delivered by physicians
compared with those delivered by
midwives. He linked this increase to the
practice of physicians moving directly from
the autopsy suite to the obstetric ward.
The rate was significantly reduced by
implementing use of a chlorine antiseptic
solution between suites
Hand Hygiene
• The #1 way to prevent the spread of infection
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2-10 million bacteria between your fingertips and elbow
The number of bacteria on your fingertips doubles after
using the restroom
80% of infections are transmitted by the human hand
Abbreviated Hand Hygiene Review:
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Soap and water for 15-20 seconds required:
• When hands are visibly soiled
• When leaving a C. difficile room/area
• Before eating/ after using the restroom
Hand sanitizing gel or soap and water required when:
• Before and after having direct contact with the patient or their environment
(monitored as before entering or upon leaving the patient’s room)
• Before donning gloves for a sterile procedure and after removing gloves
• When moving from a dirty body site to a clean site
Hand Hygiene
• Before touching a patient, even if gloves will be worn
• Before exiting the patient’s care area after touching
the patient or the patient’s immediate environment
• After contact with blood, body fluids or excretions, or
wound dressings
• Prior to performing an aseptic task (e.g., placing an IV,
preparing an injection)
• If hands will be moving from a contaminated-body
site to a clean-body site during patient care
• After glove removal
Hand Hygiene
• 15 seconds is longer than it seems…
• Start Washing!!
Personal Protective Equipment (PPE)
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Facilities should assure that sufficient and appropriate PPE is available and readily
accessible to HCP
Educate all HCP on proper selection and use of PPE
Remove and discard PPE before leaving the patient’s room or area
Wear gloves for potential contact with blood, body fluids, mucous membranes, nonintact skin or contaminated equipment
Do not wear the same pair of gloves for the care of more than one patient
Do not wash gloves for the purpose of reuse
Perform hand hygiene immediately after removing gloves
Wear a gown to protect skin and clothing during procedures or activities where
contact with blood or body fluids is anticipated
Do not wear the same gown for the care of more than one patient
Wear mouth, nose and eye protection during procedures that are likely to generate
splashes or sprays of blood or other body fluids
Wear a surgical mask when placing a catheter or injecting material into epidural or
subdural space
Safe Injection Practices
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Use aseptic technique when preparing and administering medications
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Cleanse the access diaphragms of medication vials with 70% alcohol before
inserting a device into the vial
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Never administer medications from the same syringe to multiple patients,
even if the needle is changed or the injection is administered through an
intervening length of intravenous tubing
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Do not reuse a syringe to enter a medication vial or solution
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Do not administer medications from single-dose or single-use vials, ampoules,
or bags or bottles of intravenous solution to more than one patient
Safe Injection Practices
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Do not use fluid infusion or administration sets (e.g., intravenous tubing) for
more than one patient
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Dedicate multidose vials to a single patient whenever possible. If multidose
vials will be used for more than one patient, they should be restricted to a
centralized medication area and should not enter the immediate patient
treatment area (e.g., operating room, patient room/cubicle)
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Dispose of used syringes and needles at the point of use in a sharps container
that is closable, puncture-resistant, and leak-proof.
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Adhere to federal and state requirements for protection of HCP from exposure
to bloodborne pathogens.
Environmental Cleaning
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Establish policies and procedures for routine cleaning and disinfection of
environmental surfaces in ambulatory care settings
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Focus on those surfaces in proximity to the patient and those that are
frequently touched
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Select EPA-registered disinfectants or detergents/disinfectants with label
claims for use in healthcare
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Follow manufacturer’s recommendations for use of cleaners and EPAregistered disinfectants (e.g., amount, dilution, contact time, safe use, and
disposal)
Equipment Cleaning
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All reusable medical equipment should be cleaned and reprocessed
appropriately (according to the manufacturer’s recommendations) between
patients, including:
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Reusable blood pressure cuffs
Blood glucose meters
Surgical Instruments
Stethoscopes
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Observe procedures to document competencies of HCP responsible for
equipment reprocessing upon assignment of those duties, whenever new
equipment is introduced, and on an ongoing periodic basis (e.g., quarterly)
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Assure HCP have access to and wear appropriate PPE when handling and
reprocessing contaminated patient equipment
Other Vehicles
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High risk vehicles for transmission:
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Neckties:
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Bacterial counts from hospital doctors’ ties are higher than those from shirts. American Journal of Infection
Control 2009; 37: 79-80
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Lab coats, shirt sleeves:
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Nursing and Physician Attire as Possible Sources for Nosocomial Infections. American Journal of Infection Control
2011; 39:555-9
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The stethoscope. A potential source of nosocomial infection? Archives of Internal Medicine 2007 Apr
14;157(7):786-90
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38% of stethoscopes contaminated with Staphylococcus aureus, the
majority contaminated with some pathogenic bacteria
Charts
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Up to 60% contaminated with pathogenic bacteria, including MDRO’s
Stethoscopes
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Mean geometric bacterial count of 95 CFU
Staphylococcus aureus isolated on 64% of ties
Periodic luminometer testing continues to show high levels of microbial contamination
Portable electronic devices (IPADs, laptops)
Respiratory Hygiene/ Cough Etiquette
• Implement measures to contain respiratory
secretions in patients and accompanying individuals
who have signs and symptoms of a respiratory
infection, beginning at point of entry to the facility
and continuing throughout the duration of the visit.
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Post signs reminding of good hygiene practices (i.e., cover
your cough)
Provide/offer masks, tissues, waste receptacle, and hand
hygiene station
Provide a separate waiting area for respiratory patients
High-Risk
Healthcare-acquired Infections
Healthcare-Associated Infections
• MDRO Infection:
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Any infection caused by a multi-drug resistant organism,
including:
Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Staphylococcus aureus (VRSA)
Vancomycin-resistant Enterococcus (VRE)
Carbapenemase-resistant Enterococcus (CRE)
Other resistant gram negative bacteria
• Clostridium difficile Infection (CDI):
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A gastrointestinal infection caused by the organism
Clostridium difficile, generally occurs after antibiotic exposure
Multi-drug Resistant Organisms
• Clinical importance:
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Result in increased length of stay, cost, morbidity, and
mortality
Significantly reduce treatment options
Prevalence steadily increasing
• Contributing factors:
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Selective pressure from exposure to antimicrobial agents,
particularly fluoroquinolones
Increased rates of community-associated transmission and
infections
Inadequate adherence to infection control practices
Clostridium difficile Infection
• Recently became the most prevalent hospitalacquired infection
• Causes 20-30% of cases of antibiotic-associated
diarrhea
• Epidemiology recently changed dramatically with
emergence of new, more virulent strain
• Can result in
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Diarrhea
Pseudomembranous colitis
Toxic megacolon
Death
Preventing MDRO’s and C. difficile
• Antibiotic Stewardship
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Eliminate unnecessary antimicrobial exposure
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Appropriate antibiotic selection
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Discontinue unnecessary antibiotics
De-escalate empirical therapy on the basis of culture results
Eliminate redundant therapy
Limit use of fluoroquinolones and clindamycin
Use of antimicrobial with the most narrow spectrum possible
Use facility antibiogram to guide choices
Limit TPN use
Preventing MDRO’s and C. difficile
• Antibiotic Stewardship
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Optimize dosing based on
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individual patient characteristics
causative organism (avoid drug-bug mismatch)
site of infection
characteristics of the drug
Use of guidelines and clinical pathways
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Johns Hopkins Antibiotic Guide
Prebuilt order sets that utilize best practice guidelines
Preventing MDRO’s and C. difficile
• Early detection/testing
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Documentation is critical
• Standard precautions
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Alcohol gel use should be replaced with hand washing
with soap and water when caring for a patient with C.
difficile
• Enhanced precautions (isolation)
• Enhanced environmental cleaning
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Bleach should be used for environmental cleaning when
caring for a patient with C. difficile
Device-Associated Infections
• Catheter Associated Urinary Tract Infection (CAUTI):
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An HAI that occurs in a patient who had an indwelling urinary
catheter in place within the 48 hour period before the onset
of the UTI
Most frequent DAI, 30-40%
Result in:
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Increased LOS
Increased cost (Average $15,000 per incidence)
Increased morbidity/mortality
Catheter Associated Urinary Tract Infection
(CAUTI)
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Methods for Preventing CAUTI:
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Acceptable indications for urinary catheter use:
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Use indwelling catheters only when medically necessary.
Consider alternatives to indwelling urethral catheters.
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Female urinals
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External catheters if appropriate in men.
Properly secure catheters after insertion to prevent movement and urethral traction.
Maintain a sterile closed drainage system, good hygiene at the catheter-urethral interface, and
unobstructed urine flow.
Urine output in the critically ill.
Management of urinary retention and/or obstruction.
Urinary incontinence posing a risk to the patient, such as major skin breakdown or protection of
nearby operative site.
Neurogenic bladder
Comfort care in the terminally ill.
Intractable pain.
Benign prostatic hypertrophy.
*Perioperative: Surgical patients (18 and older) with a urinary catheter should have the
catheter removed on Postoperative 1 or 2 (some exclusions apply)
CAUTI
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Inappropriate uses of a foley catheter:
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As a substitute for nursing care of the incontinent patient.
As a means of obtaining urine for culture or other diagnostic
tests when the patient can voluntarily void.
For prolonged postoperative duration without appropriate indications
The continued need for an indwelling urinary catheter should be assessed and
documented daily.
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Some tips on urine cultures:
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If no clinical symptoms/suspicion of UTI are present, order urinalysis with reflexive culture instead of
UA with C&S
Urinary catheter tips should never be cultured.
Urine cultures must be obtained using appropriate technique, such as clean catch collection or
catheterization.
Urine cultures should not be obtained as a routine on admission.
Urine cultures should not be obtained as a routine when discontinuing urinary catheter
Specimens from indwelling catheters should be aspirated through the disinfected sampling port only.
Device-Associated Infections
• Central Line Associated Bloodstream Infection (CLABSI):
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A primary bloodstream infection in a patient that had a
central line within the 48 hour period before the development
of the BSI and that is not related to an infection at another
site
Approximately 11% of all HAI
Result in:
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Increased LOS
Increased cost (Average $22,000 per incidence)
Increased morbidity/mortality
CLABSI Prevention Components
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Meticulous Hand Hygiene
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Maximal barrier Precautions
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All MSHA central line insertion kits have chlorhexidine skin antisepsis.
The chlorhexidine is tinted.
Chlorhexidine has a residual effect, meaning that it kills bacteria for an extended period of time after
application .
Optimal site selection
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All central line kits at MSHA are now standardized with maximal patient body barriers.
Patient must have entire body draped with sterile drape when inserting a central line. No exceptions!
Proceduralist inserting the central line and all assistants that are over or near the sterile field must wear
sterile gloves and gowns, mask and hair cover.
Chlorhexidine skin antisepsis
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Must be performed prior to insertion of a central line.
Prior to donning gloves to remove dressing.
After removing gloves and prior to donning sterile gloves to apply central line dressing.
Prior to any manipulation or accessing of the central line. Including tubing hubs/ports.
Preferred site is subclavian for adult patients.
Least preferred site is the femoral for adult patients.
Decision tree available
Daily review of line necessity
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Line necessity is documented on the Adult and Pediatric Catheter Treatment Record by nursing.
Central lines should be inserted only when absolutely needed and removed ASAP.
*The Central Vascular Catheter Insertion Procedure Note must be utilized for all central line/PICC insertions.
Device-Associated Infections
• Ventilator Associated Pneumonia (VAP)
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Pneumonia that occurs in a patient who was intubated and
ventilated at the time of, or within 48 hours before, the onset
of pneumonia
Result in:
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Increased LOS
Increased cost (Average $38,000 per incidence)
Increased morbidity/mortality
VAP Prevention Components
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Elevation of the Head of the Bed
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Daily Sedative Interruption and Daily Assessment of Readiness to Extubate
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Using daily “sedation vacations” and assessing the patient’s readiness to extubate are an integral part of the Ventilator
Bundle and have been correlated with reduction in the rate of ventilator-associated pneumonia. “Sedation Vacations”
are not recommended in pediatrics due to the high risk of unplanned extubation. Include daily assessment of readiness
to extubate in care/interdisciplinary rounds.
Routine Oral Care
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Elevation of the head of the bed is an integral part of the Ventilator Bundle and has been correlated with reduction in
the rate of ventilator-associated pneumonia. The recommended elevation is 30-45 degrees for pediatrics and adult
patients, and 15-30 degrees for neonates.
Ventilated adult patients require oral care every 2 hrs. Ventilated pediatric and neonate patients require oral care every
2-4 hours. Patients ventilated or not should have oral care with TEETH BRUSHED at least 2 times a day.
Hand hygiene before and after touching the ventilator, the patient or their surrounding.
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Everyone should perform appropriate hand hygiene prior to having contact with a patient of his surroundings, and again
prior to manipulating ventilator, vent tubing, suctioning patient and providing oral care.
Healthcare-Associated Infections
• Surgical Site Infection (SSI):
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Infection involving the site of a surgical procedure that
occurs within 30-90 days of the procedure, depending on
the procedure type
Result in:
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Increased LOS
Increased cost (Average $100,000 per incidence)
Increased morbidity/mortality
SSI
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Treat and control all infections prior to surgery; document infection
Educate patients on methods for preventing SSI’s
Preoperative shower or bath with antimicrobial agent (CHG)
Nares screen for Staph aureus and decolonization protocols for elective
procedures
Prepare skin of incision site using an approved agent and method
Follow all hand hygiene requirements:
- Perform surgical scrub for at least 5 minutes before first operation of day.
- Between consecutive operations, perform surgical scrub 3 to 5 minutes
using approved disinfectant.
SSI
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Maintain glucose and body temperature within normal limits
Use antibiotic prophylaxis according to evidence based
standards
- Appropriate selection
- Appropriate timing: CMS guidelines: pre-op antibiotic is
given within 1 hour of surgical incision,2 hours for
Vancomycin infusions.
- Appropriate discontinuation: antibiotics should be
discontinued within 24 hours for surgical procedures and 48
hours for cardiac surgical procedures.
Objectives
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Note: Sample Footnote
Verbalize the basic concepts of hand hygiene, standard precautions and
transmission-based precautions
Verbalize appropriate equipment cleaning techniques as related to
physician practice
Explain measures for preventing transmission of multi-drug resistant
organisms within the healthcare setting
Explain the fundamentals of antibiotic stewardship
Explain measures for preventing specific device associated infections,
including CAUTI, CLABSI, and VAP
Explain measures for preventing surgical site infections
Questions?