Newborn Week 2013

Quality issues and Accreditation of newborn healthcare delivery systems

Dr L S Deshmukh

MD,DNB,DM(Neonatology)

Professor,In charge (Neonatology)

GMC, Aurangabad

IntroductionNosocomial infections :

* In hospital acquired* Higher mortality rate* Longer

hospitalization* Increased cost

NICU ATTACK

Sources of nosocomial infection

PersonnelOther sourcesFomites – equipmentsEnvironmentInvasive procedures

Risk factors for nosocomial infections

Intravenous catheters and other invasive procedures

Ventilation / suctioning Medications Overcrowding Understaffing Prolonged hospital stay Contaminated enteral feed Health care workers Colonization by pathogenic organisms Other neonates with infection

Nosocomial infections HCWs get their hands contaminated

during– Taking a patient’s blood– Examination / Recording TPR / BP– Assisting patients for mobility– Inserting Catheters / Invasive devices– contact with a patient’s clothes / bed linen– Performing procedures– Wound-dressing– Inanimate objects - bed rails / bedside

tables / I.V. pumps

sepsis – DisasterWeeks of hard work

+Sleepless nights

+Carefully calibrated fluids

+ Meticulous titrated ventilator settings

- Inadequate asepsis

=

Nothing (Zero)Nosocomial infections ~ nightmare

Asepsis - Definition

Absence of germs / pathogensTwo types of techniques :

- Medical (Clean)- Surgical (Sterile)

Definition of TermsHand hygiene – A general term that applies to either handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.Hand washing – Washing hands with plain soap and water.Plain soap – Refers to detergents that do not contain antimicrobial agents or contain low concentrations.Antimicrobial soap – Soap containing an antiseptic agent.

Definition of Terms Antiseptic agents – Antimicrobial

substances that are applied to the skin to reduce the number of microbial flora. e.g. alcohols, chlorhexidine, iodine etc.

Antiseptic hand wash – Washing hands with water and soap containing an antiseptic agent.

Alcohol-based hand rub – An alcohol-containing preparation designed for application to the hands for reducing the number of viable micro-organisms on the hands.

Five parts of asepsisI. Practices that prevent entry of

microbes into the nursery environment

II. Practices that prevent proliferation of microbes in nursery.

III. Practices that prevent spread of microbes between babies.

IV. Practices that protect that newborn from developing infections.

V. Practices that enable better asepsis & administration.

Fight against Macro-organisms

Fight against Micro-organisms

I- Practices that prevent entry of microbes into the nursery environment

Maintain a clean environment outside the nursery.

Entry restrictions Hand washing

- Single most important intervention Gowns/masks/slippers Air changes :

- 12 air changes- 0.5 µ bacterial filters- ? Roll of exhaust fans

Contd….

I- Practices that prevent entry of microbes in to the nursery environment

Entry restrictions- Only Mothers Allowed- No Entry of infected infantsRegulated entry- Personnel of nursery- Personnel of allied services

II – Practices that prevent proliferation of microbes in nursery

Good house – keeping practices

- Floors- Refrigerators- Bins

II – Practices that prevent proliferation of microbes in

nurseryDecontamination of equipments : Imp

- Incubators & open care systems- Ventilators (change tubing daily)- Resuscitation bags & kits (have sufficient Nos.)- Laryngoscopes- Disposable Procedure sets (LP /Taps/ ExTx)

Develop “ Disposable Culture”

III – Practices that prevent spread of microbes between babies

In addition to Hand washing & “Disposable culture“

Prevention of overcrowding- At least 4-6 ft. space in between- Avoid overcrowding

Adequate Staffing :- Tertiary care, 1:1 ratio- 1:2 for cohorted babies- 1:3 for noninfectious, treated babies.- 1:4 for stable babies

Prohibit stock solutions Fomites –

Files/stethoscope/Exam.tools/pens/cups/ telephone

Laminar flow – for mixing / reconst. Drugs / TPN

IV – Practices that protectnewborn from developing infections

* Breast milk* Involvement of mother* Early discharge* Eye and cord care* Skin care ( position / probes / emollients )* Handling IV fluids & drugs

Contd…

IV – Practices that protect newborn from developing infections* Handling invasive lines & tubes

- Peripheral IV lines (Change every 72 hrs.)- Central lines (surgical scrub must)

* Do not keep, if not necessary - Peripheral IV lines a minute more- IV infusion for an hour more- Central line a day more

IV – Practices that protect newborn from developing

infections Minimize handling & breach of barriers

- Noninvasive monitoring- Clubbing together rounds

Aseptic precautions during procedures- Universal precautions- IV lines ( assess frequently)- Endotracheal intubation & suctioning- Chest tube insertion/LP/Ex transfusion.- Central lines insertions ( maintain sanctity)

Iatrogensis

V – Practices that enable better asepsis

Environmental surveillance - At least every month.

Record of positive cultures- Analyze data regularly- Develop antibiotic policy

Motivating staff- Most Important- Sweeper to consultant / In-charge- Regular meetings

Hand HygieneHistorical perspective :oUse of antiseptics – 19th centuryoLiquid chloride solution, 1825oIgnaz Semmelweis, 1846

Use of chlorine solution – Decreased mortality (First evidence)

In 1961, US Public Health services recommended hand washing for health personnel

Normal Bacterial Skin Flora» Normal human skin – colonized with

bacteria.Total bacterial count – 3.9x104 to 4.6x106

Transient Vs Resident flora’» Transient flora –

Superficial layersEasily removed with washingUsually acquired through patient contact / infected sourceUsual cause of nosocomial infection

» Resident flora :- More deeper- Not easily removed- May be pathogenic

Purpose of Handwashing

* Removal all dirt and debris* Reduce cross contamination from

microbes* Interrupt the fecal – oral route of

infection.* Reduce risk of hands acting as vectors* Breaks a link in a chain of infections.* Increase the image of cleanliness of

Health Care Personnel.

Indications for hand washing Hands are visibly dirty or

contaminated Before having direct contact with

patients Before donning sterile gloves Before doing procedures After handling contaminated body

fluids

Types of hand wash Routine / social Procedural (antiseptic) Surgical hand scrub ‘Time’ method / ‘stroke

count’ method Details must be followed Recommended time First - 2 min, then 30 sec.

Hand Rub

Selection of hand hygiene agents Must provide efficacious hand

hygiene with low irritancy potential.

Maximize acceptance by HCWs Should not be costly. Must have adequate information

from manufacturers. Friendly dispenser systems

Criteria for selection of disinfectant Broad spectrum of action Rapid action Ability to suppress microbial re-growth

for a prolonged period of time. Non-irritating to the skin Non allergenic Effective after the first use Visually and aesthetically acceptable Cost effective

Types of chemical disinfectants

* Phenolics (environmental disinfectants)- Black and white fluids- Active against a wide range of bacteria- e.g. Cresol & LYSOL

* Chloroxylenols (non irritant)- e.g. Dettol, Ibcol- High concentrations are required (2.5 – 5.0%)

* Chlorine releasing agents (Cheap)- Effective disinfectants- Rapidly effective against viruses, fungi, bacteria & spores.- Should be prepared daily

- e.g. Sterite, Chloros, PreseptContd….

Types of chemical disinfectants

• Iodine or Idophors- For hand disinfection or surgical scrub- e.g. tincture of iodine, povidone iodine (betadine)

• Aldehydes- e.g. Glutaraldehyde (Cidex), Formaldehyde (Formalin)- Nondamaging to metal, plastics, or rubber- Useful for heat sensitive items.

• Alcohols - e.g. ethyl alcohol 70% (ethanol), isopropranol- Rapid disinfection- Cheap

• Chlorhexidine - Skin antiseptic, used for procedures- Costlier

• Quaternary ammonium compounds • Hydrogen peroxide and related compounds• Ethylene oxide gas

Recommended disinfectants

* A chlorine releasing agent (virus – contaminated material)* Phenolic disinfectant (for routine use)* Hypochlorides and other chlorine

releasing agents (baths, toilets, wash basins)

* Glutaraldehyde – immersible metal objects

Performance Indicators for Hand Hygiene» Periodically monitor and record

adherence » Provide feed back» Monitor the volume of antiseptic

use / soap / towels» Monitor adherence to policies » During outbreaks, total

assessment.

Risk factors for poor hand hygiene practices

Physician status Higher work loadHandwashing agents cause irritation and

drynessSinks are inconveniently located/shortage of

sinksLack of soap, water and towelsOften too busy/ insufficient timeOvercrowdingLack of guidelines / protocols

Needs - “ Behavioral Change “

Optimal NICU design Adequate space (80-

100 sq. ft. for Level III) Minimum 6 ft. distance

between incubators / warmers

Facilities for hand wash Foot or elbow operated

taps Air circulation facility

Fumigation No additional benefit, provided

excellent house keeping and asepsis

Mostly done routinely Periodically / following epidemic During low occupancy Spraying may be used

Fumigation

Waste Disposal

Isolation of neonates

* Open wounds or skin lesions 0r acute gastroenteritis

* Strict hand washing* Use of individual

equipment* Use of disposable* Maintain optimum

distance

Nursery Outbreaks

Cluster of infection with same pathogens Common source • Contaminated equipments (Thermometers,Ventilators,Stetho) • Environmental reservoirs • Lapses in hand washing – Most IMP.

“neonatologist’s nightmare”

Be vigilant to detect an increased incidence of common organisms

Adopt a systematic approach Be prepared to be surprised

Nursery Outbreaks - Lessons

 Infection control and prevention“best practices.”

staffing, spacing, cohorting, auditing cleaning effectiveness, auditing hand hygiene, frequent microbiologic

screening

Without commitment from everybody involved in care, Infection Control

becomes a “BIG JOKE”

CONCLUSIONS

• Hand washing & common sense are the best disinfectants.• Mother is the best nurse of the baby.• Breast milk is the best antidote.• “MININMAL HANDLING” is the key.• Conscious, determined efforts & health education is our moral responsibility.