2012 middle tn apic chapter evidence-based strategies to tackle the three most common sources of...
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2012 Middle TN APIC Chapter
Evidence-Based Strategies to Tackle the Three Most Common Sources of HAIs: Contaminated Hands, Environmental
Surfaces, and Skin
Cindy Winfrey, MSN, RN, CICSenior Medical Science Liaison
PDI Healthcare
2012 Middle TN APIC Chapter
Financial Disclosures
PDI Healthcare-Employee
2012 Middle TN APIC Chapter
Objectives
• Discuss the impact of contaminated environmental surfaces, hands (of both patients and healthcare providers), and skin in the transmission of Healthcare Associated Infection
• Review the current research gaps for pediatric Infection Prevention literature
• Discuss strategies to meet and exceed Joint Commission NPSG 7
• Discuss patient and family involvement and empowerment strategies to reduce the incidence of HAIs
2012 Middle TN APIC Chapter
Could this be You?
2012 Middle TN APIC Chapter
What do these have in common?
2012 Middle TN APIC Chapter
2012 Middle TN APIC Chapter
The Importance of a Checklist
2012 Middle TN APIC Chapter
WHO Checklist for Safer Surgical Care
2012 Middle TN APIC Chapter
Transmission of Infection
2012 Middle TN APIC Chapter
How Does Transmission Occur?
Patient
Healthcare Worker
Environmental Surfaces
Patient Care Equipment
2012 Middle TN APIC Chapter
Pathogens of Significance
Pathogens of
Concern
Yeasts
ESBL
Klebsiella
MRSA
E. Coli
RSV
2012 Middle TN APIC Chapter
Examples of multidrug resistance inHAI pathogens
Acinetobacter baumannii About 75% are multidrug resistant*
10% increase from 2000 Pseudomonas aeruginosa
About 17% are multidrug resistant* Staphylococcus aureus
MRSA causes about 55% of HAIs (Antimicrobial-Resistant Pathogens Associated with Healthcare Associated Infections, Annual Summary of Data Reported to the NHSN at CDC, 2006-2007)
* Percent Acinetobacter baumannii and P. aeruginosa in ICUs that are multidrug-resistant, NNIS and NHSN, 2000-2008. Includes ICUs only (MICU, SICU, MSICU) and device-related infections only (CLABSI, CAUTI, VAP).
2012 Middle TN APIC Chapter
How do you view mortality?
2012 Middle TN APIC Chapter
Healthcare-Associated Infections (HAIs) 1 out of 20 hospitalized patients
affected Associated with increased mortality Attributed costs: $26-33 billion
annually HAIs occur in all types of facilities,
including: Long-term care facilities Dialysis facilities Ambulatory surgical centers Hospitals
2012 Middle TN APIC Chapter
Outbreaks vs. Endemic Problems Endemic problems represent the majority of HAIs Device-associated infections
Catheter-associated urinary tract infections (CAUTI) Central line-associated Blood stream infections (CLABSI) Ventilator-associated Pneumonia (VAP)
Procedure-associated infections Surgical site infections (SSI)
Adherence problems Antimicrobial stewardship Hand hygiene Isolation precautions
2012 Middle TN APIC Chapter
Changing Landscape of Healthcare Growing populations at risk
Immunocompromised individuals Low birthweight, premature neonates Transplant recipients on immunosuppressive therapy
Special environments Intensive care and burn units Infusion services
2012 Middle TN APIC Chapter
HHS Action Plan 5-year GoalsMetric National 5-year
Prevention Target Source
Central line-associated bloodstream infections 50% reduction NHSN
Adherence to central-line insertion practices 100% adherence NHSN
Clostridium difficile infections and hospitalizations 30% reduction NHSN, NHDS, HCUP
Catheter-associated urinary tract infections
25% reduction NHSN
MRSA invasive infections (population) 50% reduction EIP
Surgical site infections 25% reduction NHSN
Surgical Care Improvement Project measures 95% adherence SCIP
NHSN – CDC’s National Healthcare Safety Network EIP – CDC’s Emerging Infections ProgramNHDS – CDC’s National Hospital Discharge Survey SCIP – CMS’s Surgical Care Improvement ProjectHCUP – AHRQ’s Healthcare Cost and Utilization Project
2012 Middle TN APIC Chapter
Sources of Evidence
2012 Middle TN APIC Chapter
Holistic Bundled Approach
2012 Middle TN APIC Chapter
Impact of Neonatal CLABSI
• Inherent risk with CVCs • Difficult to identify and treat • Prolonged & often frequent exposure to
antibiotics • Major contributor of morbidity and mortality • Increased length of stay and hospital costs • Infants are especially vulnerable
2012 Middle TN APIC Chapter
Challenges to Skin Antisepsis:Evidence-Based Approaches
Prepping the skin – Chlorhexidine (CHG) vs Alcohol vs Povidone-Iodine – CHG shown to be more effective due to residual effect.– CHG/alcohol solutions: 0.5% to 3.15% CHG– CHG/aqueous solutions: 0.5% to 4%– CHG recommended by the CDC Guideline for all but < 2 months
• But, in <1000 gms, CHG associated with skin irritation– Andersen J Hosp Infect 2005 (2% CHG/aqueous) – Garland Pediatr Infect Dis J 1996 (2% CHG/alcohol)
• CHG studies currently being conducted for safety in neonates • 61% of US NICU Medical Fellowship Directors reported using CHG
– Tamma ICHE, 2010 NICU compromise
2012 Middle TN APIC Chapter
The Debate of CHG in Neonates
2012 Middle TN APIC Chapter
Skin Antiseptic Agents• Choice varies with age
– Population based complications – < 2 months
• EGA • Post natal age
• Agents – 2 to 3.15% CHG - alcoholic formulation – CHG - aqueous formulation – Povidone iodine
• Removal considerations – Normal Saline– Sterile Water
2012 Middle TN APIC Chapter
Survey of Neonatal CHG Use
• Survey of Neonatology Fellowship Directors in the United States
• 61% reported use of CHG for skin antisepsis for neonates – 51% limited use on basis of birth weight, gestational age
or chronological age. – Skin reactions (erythema, erosions, burns) occurring
primarily in those weighing <1500 grams were reported by 51%.
– No difference in adverse events between the alcoholic or aqueous CHG preparations
Tamma, Aucott, & Milstone, 2010
2012 Middle TN APIC Chapter
Primary Skin Disinfectant Used for Most PICC Insertions Insertions
Respondents - 194 N %Alcohol only 0 0Povidone iodine only 56 28.8Povidone iodine/alcohol 23 11.8Alcohol then povidone iodine 9 4.6PI total 88 45.22% Chlorhexidine/alcohol 70 35.93.15% Chlorhexidine/alcohol 3 1.52% Chlorhexidine/aqueous 4 2.1CHG total 77 39.5Combination PI/CHG 28 14.3Total CHG 53.8
Sharpe & Pettit 2009
2012 Middle TN APIC Chapter
FDA Releases New Labeling
2012 Middle TN APIC Chapter
2012 Middle TN APIC Chapter
Do You Have These?
2012 Middle TN APIC Chapter
Best Practices for Disinfection of Non-Critical Items
Examples include surfaces in the environment
and medical equipment used in patient care
2012 Middle TN APIC Chapter
2012 Middle TN APIC Chapter
Hand Hygiene Technique
2012 Middle TN APIC Chapter
EVIDENCE-BASED PRACTICE
2012 Middle TN APIC Chapter
Where do you even begin?
2012 Middle TN APIC Chapter
State of prevention knowledge and science Guidelines developed for each type of infection and
based on systematic reviews of medical literature Prevention of central line-associated blood stream infections Prevention of catheter-associated urinary tract infections Prevention of surgical site infections Prevention of healthcare-associated pneumonia Management of multidrug-resistant organisms
Recommendations graded according to evidence Guidelines contain many recommendations Current efforts to help prioritize interventions that are
most effective
2012 Middle TN APIC Chapter
Adherence to infection control guidelines is incomplete Many HAIs are preventable with current
recommendations Failure to use proven interventions is unacceptable Only 30%-38% of U.S. hospitals are in full
compliance Just 40% of healthcare personnel adhere to hand
hygiene Insufficient infection control infrastructure in non-
acute care settings has allowed major lapses in safe care
2012 Middle TN APIC Chapter
Local success fuels national prevention
Unit Facility
RegionalNational
2012 Middle TN APIC Chapter
CDC knowledge and data fuels local to national CLABSI prevention
UnitFacilityPittsburgh Regional
Healthcare Initiative
First successful, large-scale
CLABSI prevention
demonstration project
Regional
Subsequent projects
based upon CDC
prevention:• Michigan
Keystone
• Institute for Healthcare Improvement
• Others
NationalNational
expansion of CLABSI
prevention 60% Reduction in CLABSI between
1999-2009 • State-based
public reporting using NHSN
• State/regional prevention collaboratives (CUSP, Recovery Act projects)
• CMS/IPPS – hospitals report CLABSIs for full Medicare payment
Inputs
Outputs
Outbreak Investigations
Prevention Research
(e.g. chlorhexidin
e bathing)
NHSN Data
CDC Guidelines
2012 Middle TN APIC Chapter
The need for HAI prevention researchH
ealth
care
-ass
ocia
ted
Infe
ction
Preventable
Prevention Approach Unknown
Prevented
Need for complete implementation of practices known to prevent HAIs
Need for ongoing research to identify new strategies to prevent the remaining HAIs
2012 Middle TN APIC Chapter
Prevention
Hand hygiene
Skin antisepsis
Dressing
Injection cap/needleless connector
No touch technique
2012 Middle TN APIC Chapter
Payors
MedicalProfessionals
Consumers
Public Health
Patients
GovernmentHealthcareFacilities
Safe Healthcare is Everyone’s Responsibility
2012 Middle TN APIC Chapter
2012 Middle TN APIC Chapter
Hypothetical ? • If you knew……………………….
• That you could do something simple, easy, cost effective, and that was
• Evidence-Based, but took a little extra time…..
• Would you do it?????
2012 Middle TN APIC Chapter
Questions
• Whose Infection will you prevent when you return to your institution?
• Contact Information:– Email: [email protected]– Phone: 719-306-2616