Bugging Out: Strategies for Reducing Bacterial Load and Healthcare Acquired

Infections in your Unit

Kathleen M. Vollman MSN, RN, CCNS, FCCM, FCNS FAANClinical Nurse Specialist / Educator / Consultant

ADVANCING NURSINGkvollman@comcast.net

Northville Michiganwww.vollman.com

© ADVANCING NURSING LLC 2019

Disclosures for Kathleen Vollman

• Consultant-Michigan Hospital Association Keystone Center

• Subject matter expert for CAUTI and CLABSI, HAPI, C-Diff and Sepsis for CMS/HIIN

• Consultant and speaker bureau:– Sage Products LLC

• Will be addressing an off label use of a 2% CHG pre-op prep cloth

– Eloquest Healthcare– Urology division of Medline

Industries

Session Objectives

• Identify modes of transmission for the spread of microorganism in the healthcare environment

• Evaluate key evidence based care practices that can reduce bacterial load and/or prevent health care acquired infections.

• Discuss key program steps for creating a source control program within your practice environment or organization.

Notes on Hospitals: 1859

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

Advocacy = Safety

Harm in U.S HealthCare• Analysis of Scientific

Literature– Adverse events 3rd

leading cause of death– 1 in every 3 hospitalized

patient experiences preventable harm

– Est 400,000 individuals die from those injuries per year

Makary MA, et al. BMJ, 2016;353

Magill SS et al. NEJM 2014;370:1198-208Magill SS, et al. NEJM 2018;379:1732-1744

HAI 2011- 11,282 patients

2015 – 12,299 patients

Pneumonia .98% .89%CDI .54% .54%SSI .97% .56%BSI .44% .41%UTI .58% .32%GI other .22% .25%

Patients at risk for an HAI is 16% lower in 2015 versus 2011

Comparison of HAI’s between 2011 and 2015 in Acute care

Cost of MDRO’s

• 23,000 deaths associated with MDRO’s• Between $1700 to $4600 per stay• 2.39 billion in treatment costs• Staff bacteremia's 2017

– 119,000 blood stream infections– 20,000s death

• Rate of improvement has slowed nationally• VA’s have had 55% reduction in MRSA

Morbidity and Mortality Weekly Report (MMWR), March 2019Johnston KJ, et al Health Services Research, 2019 Mar 12. doi: 10.1111/1475-6773.13135

Common Routes of Transmission

HAI in the ICU was the patients’ endogenous flora (40%-60%); cross-infection via the hands of health care personnel (HCP; 20%-40%); antibiotic-driven changes in flora (20%-25%); and other(including contamination of the environment; 20%). Weinstein RA.. Am J Med 1991;91(Suppl):179S-184S.

Vertical vs. Horizontal

• Horizontal approach to infection prevention and control measures refers to broad-based approaches attempting reduction of all infections due to all pathogens– no screening– Universal nasal coverage– CHG bathing– No isolation– Limit lines/tubes– Hand hygiene

• Vertical approach refers to a narrow-based program focusing on a single pathogen (selective of the specific MDRO)– AST to identify carriers– Implementation of measures

aimed at preventing transmission from carriers to other patients

• Isolation• Hand hygiene

Wenzel RP and Edmond MB.. International Journal of Infectious Diseases 14S4 (2010) S3–S5

Reducing MDRO’s

Calfee DP, et al. Infect Control Hosp Epidemiol, 2014;35(7):772-796Huang SS, et al. New Engl J of Med, 2013;368(24):2255-65Health Research & Educational Trust (2017). MDRO Change Packect. Accessed at www.hret-hiin.org.

Hand Hygiene

Practice Device Bundles

Patient Decolonization

Decontamination of Environment

Antibiotic Stewardship

Contact Precautions/

Isolation

Hand Hygiene is the Single Most Important Factor in Preventing the

Spread of Infection

Healthcare providers clean their hands less than half of the times they should!!

Guidelines for Hand Hygiene in Health Care Settings• Alcohol-based hand rub frontline method for decontaminating

hands (20-30 seconds) • Visibly soiled or exposure to potential spore forming organisms,

wash with a non-antimicrobial or antimicrobial soap & water (40-60 seconds)

• Do not use Triclosan containing soaps• Decontaminate hands after removing gloves• Provide HCW with hand lotions & creams to minimize occurrence

of irritant contact dermatitis • Use multidimensional strategies to improve hand hygiene practice

(IA)• Do not wear artificial fingernails or extenders

CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR-16):[1-45]WHO Hand Hygiene Guidelines 2009Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178https://www.cdc.gov/handhygiene/science/index.html

Correct use can reduce colony forming units by 90%, incorrect use only 60%. 1-3mL correct amount per HH episodeLausten S, et al. Infect Control Hosp Epidemio, 2008;29:954-956

When to Wash

Pittet D. Infect Control Hosp Epidemiol, 2009;30(7):611-622WHO Hand Hygiene Guidelines 2009Ellingson K, et al. Infect control & Hosp Epidemiology, 2014;35(2): S155-S178

Wash In

Wash Out

Similar rates of HH complianceSunkesula VCK, et al AJIC, 2015;43:16019

Hand Hygiene Measurement Methods

• Direct Observation• Product Usage/Volume• Automation monitoring can

improve compliance• Electronic versus direct

observation more accurate in measuring compliance

Morgan DJ, et al. AJIC, 2012;40:955-959

Haas and Larson Journal of Hospital Infection 2007;66:6-14Polgreen PM, et al. Infect Control & Hosp Epidemiol, 2010;31:1294-1297Ellingson K, et al. Infect Control & Hosp Epidemiol, 2014;35(S2):S155-178

Increase use of alcohol hand rub (measure by volume use) correlated significantly (p=0.014) with improvement in MRSA rates Sroka S, et al. J of Hosp Infect, 2010;74:704-211

Hand Hygiene: Should We use Automated Systems

• Pro: Prolific amount of data; provider specific data

• Con: Lose real time correction; can be bulky and expensive

Without a process to address low compliance in a professional accountable manner it will just be a lot of data –Dr Talbot

HIIN 2018; Discovery and Direction Series: Horizontal Practices accessed at http://www.hret-hiin.org/resources/display/discovery-and-direction-series-horizontal-practices

The Environment

Substantial scientific evidence has accumulated that contamination of environmental surfaces in hospital rooms plays an important role in the transmission of several key health care–associated pathogens

Weber DJ, AMIC, 2016;44:77-84

Application of Recommendations for Environmental Cleaning

• Resources to ensure effective cleaning and decontamination• Use of a check list• Clean equipment that is transported from room to room• Dedicated equipment in isolation rooms• Reduce load-adequate time to clean• Education of healthcare workers and support staff

• Daily disinfection of non-critical surfaces vs. just visibly soiled• Feedback method using removal of intentional applied marks

visible only under UV light• Wipes that keep the surface wet for 1-2 minutes• Reusable cloths change with each room clean and use 3 per

room

Huang SS, et al. Arch Intern Med 2006;166(18):1945-1951Weber DJ, AJIC, 2016;44:77-84

Improving Environmental Hygiene In 27 ICUs Decreased MDRO Transmission

• 27 acute care hospitals ( 25 beds to 709 beds)

• Fluorescent targeting method • Systematic covert monitoring was performedResults:• 3532 environmental surfaces were assessed

after terminal cleaning in 260 ICU unit rooms• 49.5% of services cleaned it baseline• Post-intervention with multiple cycles of

objective performance feedback resulted in 82% of environmental services cleaned (p < .0001)

Carling PC, et al. Crit Care Med, 2010;38:1054-1059

No Touch Cleaning• Use of a no touch method leads to a decreased rate of infection in

patients subsequently admitted to a room where the prior occupant was colonized or infected.

• Use of a no touch method leads to a decreased rate of facility-wide colonization and infection.

• Hydrogen peroxide vapor & aerosolized significantly reduce MDRO load in terminal cleaning. (vapor:1.5 to 2.5hrs, aerosolized: 2-3hrs)– Aerosolized not well studied versus vapor– Contaminated surfaces reduced to 0% to <5%

• Ultraviolet–C to kill pathogens.– 10-45 minutes of use, C. difficile spores – 10-25 minutes for non-spore forming bacteria– Contaminated surfaces reduced <1% to <11%

Nerandzic MM, et al. BMC Infect Dis 2010 Jul 8;10:197Havill NL et al. Infect Control Hosp Epidemiol, 2012;33:507-512Sattar SA, et al. AJIC, 2013;S97-104Passaretti Cl, et al. Clin Infect Dis,2013;56:37-35Weber DJ, AJIC, 2016;44:77-84

Reducing the Load in the Environment: Additional Factors• Hospital curtains potential source of transmission1

– Novel curtains increase time to first contamination (7x longer)2

• Daily cleaning of high touch surfaces3

• Disinfecting surfaces (copper/silver coating)4

• ECG disposable or reusable?5

– Cluster-randomized controlled design– Match ICU’s randomized to get disposable

or reusable ECG– Measured infection rates

1.Trillis F, et al. Infect Control Hosp Epidemiol, 2008;29(11):1074-10762.Schweizer M et al. Infect Control Hosp Epidemiol 2012;33:1081-10853.Kundrapu S, et al. Infect Control Hosp Epidemiol 2012;33(10):1039-424. Salgado CD, et al. Infect Control Hosp Epidemiol 2013;34:479-865.Ablert NM, et al. Amer J of Critical Care, 2014;23:460-468

Reducing Bacterial Load on the Patient:

A Horizontal Strategy

Evidence Based Bathing Practices

Patient Decolonization

nurWse!

Traditional BathingWhy are there so many bugs

in here?

Soap and water basin bath was an independent predictor for the development of a CLABSI

Bleasdale SC, e tal. Arch Intern Med. 2007;167(19):2073-2079

Bath BasinsPotential Source of InfectionLarge multi-center study evaluates presence of multi-drug resistant organisms

Marchaim D, et al. Am J of Infect Control. 2012;40(6):562-564

3%35%

MRSA36 basins/28 hospitals

62%

Contaminated686 basins/88 Hospital

Colonized w/ VRE385 basins/80 hospitals

45%

Gram negative bacilli495 basins/86 hospitals

Total hospitals: 88Total basins: 1103

Used with Permission Advancing Nursing LLC      Copyright 2013 AACN and Advancing Nursing LLC

Mechanisms of Contamination

• Skin flora• Multiple-use basins

–Incontinence cleansing–Emesis–Product storage

• Bacterial biofilm from tap water

Shannon RJ, et al. J Health Care Safety Compliance Infect Control. 1999;3:180-184.Larson EL, et al. J Clin Microbiol. 1986;23(3):604-608.Johnson D, et al. Am J Crit Care, 2009;18(1):31-38, 41.Marchaim D, et al. Am J Infect Control. 2012;40(6):562-564.

Used with Permission Advancing Nursing LLC      Copyright © 2013 AACN and Advancing Nursing LLC

Waterborne Infection

Hospital Tap Water Bacterial biofilm Most overlooked source for pathogens 29 studies demonstrate an association with

HAIs and outbreaks Transmission:

-Drinking-Bathing-Rinsing items-Contaminated environmental surfaces

Immunocompromised patients at greatest risk

Anaissie EJ, et al. Arch Intern Med. 2002;162(13):1483-1492.Cervia JS, et al. Arch Intern Med, 2007;167:92-93Trautmann M, et al. Am J of Infect Control, 2005;33(5):S41-S49,

Used with Permission Advancing Nursing LLC      Copyright © 2013 AACN and Advancing Nursing LLC

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Impact on UTI with Basin Bathing

UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY05

McGuckin M, et al. AJIC, 2008;36:59-62,

The Effect of Bathing with Basin and Water and UTI Rate, LOS and Costs

Unit Census: 14Phases Product Cost/ No. of

UTIMedian4

LOS17 Days

Median4

Cost(4857.00)

I- Pre-Packaged Bathing Washcloths(9 months)

$10,5301

($3.00)25 175 $117,175

II- Basin/Water(9 months)

$3,5102

($1.00)48 336 $224,916

III- Additional Product Cost, UTI, LOS, COSTS

$7,020 233 151 $107,741

1Based on 3 packages of 8 towels each 2Based on product cost of towels, soap, and basin3 Difference between phase I pre-package/phase II basin water4

McGuckin M, et al. AJIC, 2008;36:59-62

*2% CHG cloth for bathing is consider an off label use of the product

*

The Evidence: Impact of 2% CHG Cloth Baths*Evaluate effect of daily bathing with CHG on acquisition of MDRO’s and incidence of CLABSI

9ICU’s & Bone Marrow Transplant unitRandomly assigned 7727 patient:a.No-rinse, 2% CHG

impregnated washcloths*

b.Non-antimicrobial, no-rinse bath cloths

Climo, M et al, N Engl J Med, 2013;368:533-542

Results of 2% CHG bathing

23% reduction 28%

reduction

50% reduction

90%reduction

*2% CHG cloth for bathing is consider an off label use of the product

Impact of 2% CHG Cloth Baths*Study to determine the best method for reducing spread of MRSA & MDROs

3 protocols tested:a)Swab for MRSA on admission to ICU

- Isolate if positiveb)Swab for MRSA on admission to ICU

- Isolate if positive- Nasal mucopiricin x 5 days- 2% CHG cloth* bathing for entire

ICU stayc)No swab

- Nasal mucopiricin x 5 days- 2% CHG bath* for entire ICU stay

Huang SS, et al. New Engl J of Med, 2013;368(24):2255-65.

Results: No Swab GroupUniversal Decolonization Demonstrated

37% reduction 44%

reduction

*2% CHG cloth for bathing is consider an off label use of the product

99 decolonization to prevent 1CLABSI

Noto MJ, et al. JAMA 2015;313:369+

Difference Between Climo & Noto Study

Dr Talbot: http://www.hret-hiin.org/resources/display/discovery-and-direction-series-special-approaches-and-essential-questions

Rhee Y, et al. Infect Control Hosp Epidemiol 2018;39:405–411

Differential Effects of Chlorhexidine Skin Cleansing Methods

• Prospective, randomized 2-center study with blinded assessment.

• To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin.

Method A- 2% CHG clothMethod B- 4% CHG liquid poured onto non-

medicated clothMethod C-4% CHG liquid on cotton wash cloth

CHG Bathing Process

Shan HN, et al. Crit Care Nurs Q, 2016;39:42-50*2% CHG cloth for bathing is consider an off label use of the product.

Monitor for compliance by assessing amount of CHG on the skin (Assay). Prevent sub-optimal concentrationsDonskey CJ, et al. American Journal of Infection Control 44 (2016) e17-e21

Cleansing of Patients with Indwelling Catheter

• Indwelling catheter care should occur with the daily bath (basinless bathing)*, as a separate procedure using clean technique

• There is no evidence to support 2x a day indwelling catheter care

• If a large liquid stool occurs, bathe the patient with basin less bathing

• Use separate cloths to clean front to back in the perineal area and 6 inches of the catheter**

• Apply barrier cloth to area of skin requiring protection

**Universal ICU Decolonization: An Enhanced Protocol. (Prepared by The REDUCE MRSA Trial Working Group, under contract HHSA290201000008i). AHRQ Publication No. 13-0052-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2013.

For Successful Banning of Basins for Patient Care

• We need to provide alternatives for the other functions:Current NewEmesis Emebags being installed in every

adult and ped pt. room, ACU, PACUStorage of patient items Clear plastic “baggies”

Trial of “Concierge List” to decrease waste of unused/unneeded products

Foot soaks Shampoo caps, prepackagedShampoo patient’s hair Shampoo caps par’d on all units24 hour urine, ice Store some basins in lab to be

dispensed with each 24 hour jug.Bath cloths with no insulation, cold halfway through bath.

Bath cloths with insulation to stay warm longer

Quinn B, et al. Presented at NACNS National Conference, March5-7th, 2015, San Diego Ca

Reducing MDRO’s

• Contact precautions for MRSA colonized & MRSA infected patients and VRE– Slower time from ER to inpatient bed

(1 hr)– Slower to discharge to extended care

facility (1.7 days)– Delays in diagnostic imaging– Visited by healthcare workers 20-

30% less– Greater patient dissatisfaction.

Calfee DP, et al. Infect Control Hosp Epidemiol, 2014;35(7):772-796Huang SS, et al. New Engl J of Med, 2013;368(24):2255-65Health Research & Educational Trust (2017). MDRO Change Packect. Accessed at www.hret-hiin.org.Morgan JD, et al. JAMA 2017;318(4):329-330

No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.

Morgan DJ, et al. Infect. Control Hosp. Epidemiol. 2015;36(10):1163–1172

Impact of D/C Contact Precautions for MRSA & VRE

Bearman G, et al. Infect Control Hosp Epidemiol 2018;39:676–682

• Quasi-experimental (2011-2016), Interrupted time series, CP changes April 2013

• Outcomes: MRSA & VRE HAI rates

PPE Compliance: Is There a Better Way to Measure this Bedside Direct Observation?

• In short, probably not• Need to identify not only if used but

used correctly• Need to track compliance, feedback

to end-users/leadership• Any other types of audits or a better

way?????

HIIN 2018; Discovery and Direction Series: Horizontal Practices accessed at http://www.hret-hiin.org/resources/display/discovery-and-direction-series-horizontal-practices

Contact Precautions/

Isolation

Improve Accuracy of Doffing Process• Novel gown to increase

compliance with effective of gown renewal

• Outcomes– Reduce waste,– Improve cleanliness of the

environment– Prevent contamination of staff

and environment

Personal communication Sharon Dickinson

Evidence- Based Strategies for

Reducing the Risk of CAUTIs

Practice Device Bundles

1

32

Ensure Aseptic Placement

Maintain Awareness and Proper Care of Catheters in Place

Prompt Removal of Unnecessary Catheters

Step 0: AVOID

INDWELLING

CATHETERIndwelling

Urinary Catheter

Reminders/stop orders use appropriateness criteria to prompt catheter removal

Place/keep urinary catheter only when appropriate

Daily review of continued need for urinary catheter

Optimize use of alternatives

Using Appropriateness CriteriaTo Reduce Catheter Use1,2

UC Indications ׀ 50AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI

Nurse Driven Intermittent Catheterization Program

• If no voiding within 4-6 hours of assessment pre-insertion or post removal, a bladder scan ultrasound used.

• Volume < 500mL, encourage the patient to void by using techniques to stimulate bladder reflex (cold water to abdomen, stroke inner thigh, run water, flush toilet).

• Continue to assess the patient and repeat the bladder scan in 2 hours if no voiding.

• If the bladder volume > 500mL, and intake is less than 3L a day-catheterize for residual urine volume rather than place an indwelling catheter.

• If volumes are greater/catheter goes back in 24hrs

If retention is suspected:

STOP CAUTI Sample Policy and Procedure http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/hcpr/cauti/documents/Sample%20Policy%20and%20Procedures.pdfUniversity of Virginia Health System nurse driven intermittent cath program

Before Placing an Indwelling Catheter, Please Consider if These Alternatives Would be Appropriate:

• Bedside commode, urinal, or continence garments: to manage incontinence.

• Bladder scanner: to assess and confirm urinary retention, prior to placing catheter to release urine.

• Straight catheter: for one-time, intermittent, or chronic voiding needs.

• External catheter: appropriate for cooperative men without urinary retention or obstruction.

Male and Female External Collection Devices

Challenges with Current Appropriate Alternatives: External Male Catheters

1 out of every 200 men is born with what’s medically known as ‘micro-penis

Buried Penis

Innovated Male External Catheter Study

• This project was conducted in a 107-bed long-term acute care hospital

• Timeline: The QI initiative started on 02/21/16

• Appropriate ECD Application: The nursing team was educated on appropriate assessment of male anatomy for ECD placement

• Measurement:– Before and after catheter

utilization and CAUTI infection ratesIncreased adherence to best

• Foley Catheter Appropriateness Criteria: Benign prostatic hypertrophy; neurogenic bladder; stage 3 and 4 sacral pressure injury; and strict I&O

• ECD Appropriateness Criteria: No restraints; no neurogenic bladder; no benign prostatic hypertrophy; and cooperative with no urinary issues

• ECDs were contraindicated:– Patient was unable to void or had

known urinary retention– Unhealed wound on glans penis– Active inflammation or infection

of the glans, foreskin or urethra

46% ↓

Average wear time: 48-72hrsZero Male CAUTI’s During Intervention

Alternative Female External Collection Devices

• How do they work?– They are placed between the

labia and the urethral opening– The devices are attached to wall

suction– When female voids, the urine

flows thru the fabric into the collection chamber at the distal end, the suction takes the urine to the collection container

Quality Improvement Project

• 18 bed adult SICU• 10 month pre/post QI study• Utilization of an external

female collection device • Daily rounds discussion

– Inter-professional discussion regarding indications

• Avoid placement • Early removal

• Measurement: CAUTI & SIR rates

Beeson T, Davis C & Vollman K. Presented at the NACNS Meeting in Austin Tx, March 2, 2018

Pre/Post Comparison Using Female External Device

Before After

CAUTI Rate 2.55 0.7

Standardized Infection Ratio (SIR)

1.395 0.381

IndwellingCatheter Days

↓ 9%

CDC, SHEA, IDSA, and NHS: Indications for Placement of Indwelling Catheter• Perioperative use for selected surgical procedures• Urine output in critically ill patients• Management of acute urinary retention and urinary

obstruction• Assistance in pressure ulcer healing for incontinent

patients• At patient request to improve comfort (SHEA) or for

comfort during end of life care (CDC)

How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for HealthcareImprovement; 2011. (Available at www.ihi.org).

Types Of TreatmentsRequiring Close UO Monitoring

• Bolus fluid resuscitation• Vasopressors• Inotropes• High dose diuretics• Hourly urine studies to measure life threatening

laboratory abnormalities

Are you responding hourly to the patient’s urine output??

I & O in Critical Care

Beascher T. J Wound Ostomy Continence Nurs. 2014;41(6):604-

608.

The Culture of Culturing

Recommandations on Urine Culture Management • Establish a preculture strategy that directs efforts at

how cultures are ordered rather than solely addressing issues after a UA or UC test is finalized:– Modify the electronic medical record to include appropriate and

inappropriate indications for UAs/UCs that address patient symptomology

– Eliminate automatic orders in care plans where appropriate– Provide education for all clinicians who order UCs with

emphasis on appropriate indications for UCs and UTI symptoms in catheterized and non-catheterized patients

– Carefully evaluate patients with fever and order UCs as appropriate

– Reflex urine testing should be considered only if used in conjunction with careful clinical evaluation for signs and symptoms of UT

Modify Your EMR Ordering Process• Incorporated mandatory selection of standardized

indications in EMR for ordering a UC in catheterized patients: – Suprapubic pain/tenderness– Acute gross hematuria– Costovertebral angle tenderness– New fever/rigors with clinical assessment negative for more likely

etiology– Acute alteration of mental status with clinical assessment negative

for more likely etiology– Alteration in medical condition with clinical assessment negative for

more likely etiology in patient whom fever may not be a reliable sign– Increased spasticity or autonomic dysreflexia in patients with altered

neurologic sensation

Shirley D, et al. Infect Control Hosp Epidemiol 2017;38:486-88.

Lowers urine cultures and CAUTI rates

Recommandations on Urine Culture Management

• Measure % of patients treated with antibiotics for urinary tract infection with catheter and no documented signs or symptoms of clinical infection (ASB)

• Ensure proper collection and handling of urine specimens:– Replace catheters in symptomatic patients before collecting a

specimen– Delineate policies and procedures and educate personnel on

the proper methods to collect Ucs– Standardize the use of refrigeration or preservative tubes in

all health care settings, including ambulatory clinics and EDs.

Garcia, R & Spitzer ED. American J of Infect. Control. Am J Infect Control. 2017;45(10):1143-1153.Health Research & Educational Trust (2017). : 2017. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org

Example: St Joseph Mercy Hospital Urine Culturing Tool

Alternate Approach: Focus on Ordering Not Test Result (Pts w/IUC)• KICKING CAUTI Campaign, study at 2 Veterans

Affairs health systems• One multifaceted intervention vs one comparison site

Trautner BW. JAMA Intern Med 2015;175:1120-27.

Urine Cultures ↓ by 71%

ASB Tx ↓ by 75%CAUTI Tx ↓ by 89%

Antibiotic Stewardship

• Program that promotes appropriate selection, dose, route and duration of antimicrobial therapy– Primary goal: optimize clinical outcomes while reducing

unintended consequences of antimicrobial use• Toxicity• colonization of pathogenic organisms• Antibiotic resistance

– Secondary goal: reduce health care costs associated with diseases such as CDI and antimicrobial resistance.

• Comprehensive programs both large & small hospitals shown ↓ in antimicrobial use between 22%-36% with annual savings of $200,000 to $900,000.

Health Research & Educational Trust (2017). Clostridium difficile Infection Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org.

Horizontal Approach: It Works

• Retrospective, observational study in the surgical ICU of a tertiary care medical center in Boston, MA, from 2005 to 2012

• N=6,697 patients in the surgical ICU

Traa MX, et al. Crit Care Med 2014; 42:2151–2157

↓21% per yearSince 2008 Zero MRSA infections

It is not enough to do your best; you must know what to do, and THEN do your best.

~ W. Edwards Deming

Bug Out

Contact Kathleen Vollman atkvollman@comcast.net

www.Vollman.com

https://www.medbridgeeducation.com/advancing-nursingHAI prevention courses by Kathleen Vollman