Infection Prevention & Control: Patient & Personnel Safety Imperative

New House Staff Orientation, 2011Charles P. Craig, MD – Medical Director : On behalf of Infection Prevention &

Control – Welcome!Jan T. Aurand – Infection Prevention & Control Specialist (IPCS), SJM-LivingstonRose Berton – Admn. Asst., SJMHSMelanie Church – IPCS, NICU, SJMH-AALynne Grimes – IPCS, Ambulatory CareCheryl Morrin – IPCS, SJMH-AARuss Olmsted – Epidemiologist, SJMH-AAGail Siedlaczek – IPCS, SJMH-AASuzanne Sutton – IPCS, SJMH-AA & SJM-Saline

VISIT IPCS WEB SITE ON INFONET: http://infonet.trinity-health.org/departments/ipcs/Details on isolation precautions – when to order andfor what duration these are needed by infection

Why Are We Worried About Health Care-Associated Infections (HAIs)?

• 1.7 Million HAIs/yr

• Associated Mortality = 98,987 of the 1.7M

Klevins RM, et al. Pub Health Rep 2007;122:160-6.

Hand Hygiene: Not a New Concept but Primary Intervention to Prevent HAIs

Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850

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Hand Hygiene Intervention

~ Hand antisepsis reduces the frequency of patient infections ~

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Ability of Hand Hygiene Agents to Reduce Bacteria on

Hands

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

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Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

Efficacy of Hand Hygiene Preparations in Killing Bacteria

Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

Efficacy of Alcohol-based Handrub: a picture is worth a ton of randomized controlled trials

• Panel A (left): Culture of physician’s hand following ungloved abdominal exam of a patient – colonized in nares with methicillin-resistant S. aureus (MRSA)

• Panel B (right): Same worker’s hand after application of alcohol-based handrub (ABHR) Donskey CJ, et al. N Engl J Med 2009;360:e3

Time Spent Cleansing Hands:

one nurse per 8 hour shift

Hand washing with soap and water: 56 minutes

– Based on seven (60 second) handwashing episodes per hour– If nurses adherence to handwashing was perfect (100%),

based on recommendations, amount of time/ 8 hr shift = 16 hours!

Alcohol-based handrub: 18 minutes– Based on seven (20 second) handrub episodes per hour

Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.

~ Alcohol-based handrubs reduce time needed for hand hygiene ~

After Body Fluid Exposure Risk After Contact with Patient Surroundings After Gloves Removed

After Patient Contact Before Aseptic Task Before Patient Contact

Opportunity

No Hand Hygiene3, 12.5%

Hand Wash21, 87.5%

No Hand Hygiene23, 40.4%

Hand Wash13, 22.8%

Alcohol Hand Rub21, 36.8%

No Hand Hygiene11, 22.0%

Hand Wash33, 66.0%

Alcohol Hand Rub6, 12.0%

No Hand Hygiene83, 21.3%

Hand Wash157, 40.3%

Alcohol Hand Rub150, 38.5%

No Hand Hygiene7, 6.5%

Hand Wash92, 86.0%

Alcohol Hand Rub8, 7.5% No Hand Hygiene

134, 34.4%

Hand Wash147, 37.8%

Alcohol Hand Rub108, 27.8%

Hand Hygiene Compliance Outcomes, by Healthcare RoleHC Worker = MD/Physician

Panel variable: Opportunity

Findings from HH Observations, Physicians, 2009, SJMH-Ann Arbor

Gloving

• Wear gloves when contact with blood or other potentially infectious materials is possible

• Remove gloves after caring for a patient• Do not wear the same pair of gloves for the

care of more than one patient• Do not wash gloves

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

The Inanimate Environment Can Facilitate Transmission

~ Contaminated surfaces increase cross-transmission ~Duckro AN: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Arch Intern Med. 2005 Feb 14;165(3):302-7

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represents VRE culture positive sites

Reservoirs of multidrug-resistant organisms (MDROs): Environment

VRE: Vancomycin resistant enterococci

Preventing Device – Associated Infections

House Officers Are Key Participants:Impact of Implementing Evidence-BasedPatient Care Practices aka the Keystone Experience at SJMHS:

- See Pronovost P, et al NEJM2006; 355:2725-32 & BMJ. 2010 Feb 4;340:c309.

Potential sources of infection for percutaneous intravascular device; Clin Infect

Dis 2002;34:1232-42

MHA Keystone ICU Project: Prevention of Central Line-Associated Bloodstream Infections

1. Staff education on infection control practices– Central Line (CL) equipment cart;– 2% chlorhexidine gluconate skin

antiseptic; – Full patient drape;– cap, mask, gown, gloves – person

inserting CL2. RN assist with CL insertion3. CL Insertion Checklist4. Feedback to staff on adherence and

outcome data: CLABSI rate

See also:Pronovost P., et alNEJM 2006;355:2725-32.

Statewide impact of K-ICU on CLABSI Rates

• 66% reduction in CLABSI

• Interventions:– Hand hygiene– Max. barrier prec. during

insertion– CHG antiseptic on

insertion site– Avoid femoral CLs– Remove CL when not

needed• Pronovost P, et al. NEJM

2006;355:2725-32.

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CLABSI Best Practices Implemented July 2004

2005 BSI rate is 2.12

2006 YTD rate is 0.65

K-ICU Ventilator Bundle

• Improve care of ventilated patients– Elevate HOB– Frequent oral care; every 2 hrs – Provide DVT prophylaxis– Provide PUD prophylaxis– Hold sedation– Test for ability to extubate– Control glucose

Keystone: Ventilator-associated Pneumonia (VAP) Prevention1, SICU, SJMH-AA

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Total # of VAPs VAP Rate

Jan-Dec-02Jan-Dec.-03Jan-June-04

1. Head of bed elevation, hand hygiene, oral care, suction technique, bed rotation,

Order Sets for Indwelling Urinary Catheter (IUC)•The orderable for IUC Insertion includes a mandatory code set to include the following options:

–Acute urinary retention or obstruction–Need for accurate urinary output in critically ill patients–Perioperative use for selected surgical procedures –Open sacral or perineal wounds in incontinent patient–Prolonged immobilization (i.e., unstable thoracic or lumbar spine)–Comfort care/end of life care–Other

•All IUC insertion orders will have an appropriate indication documented at the time the initial order is placed.

CAUTI Prevention: Supporting Improvement through Use of Powerchart

Maki, Emerg Infect Dis 2001; 7: 1-6

Prevention of Cathter-Associated UTI (CAUTI): Enter orders for appropriate indication; discontinue ASAP

•17% to 69% of CAUTIsmay be preventable meaning: •380,000 infections and 9000 deaths related to CAUTI per year could be prevented

Epidemiology of Surgical Site Infection (SSI)

• Approximately 500,000 SSIs annually1

• Each SSI adds approximately 7-10 postoperative hospital days1

• Mortality is 2-11 times greater with an SSI1

• $11,874 - $34,670: average attributable per patient cost of SSI, adjusted to 2007 dollars2

1. Anderson DJ et al. nfection Control and Hospital Epidemiology 2008;29;S51- S61.

2. Scott RD, CDC Report, 2009.

Prevention of Surgical Site Infection: Modifying Risks

• Intrinsic Factors– Age– Glucose control– Obesity – Smoking cessation – Immunosuppressive

medications

• Extrinsic Factors– Hair removal – clip; no shaving– Rx Preoperative infection– Surgical hand antisepsis– Patient Skin preparation– Antimicrobial prophylaxis– Surgical technique– OR ventilation– Traffic control– Equipment sterilization

*Category A-II recommendation by both the CDC and the SHEA Compendium Workgroup

Precautions For Personnel

1) Rational approaches -Leave yourSCBA at home

2) Beware of the “contaminated case” syndrome

http://infonet.trinity-health.org/departments/ipcs/

Use Standard Precautions (SP) For All Use Standard Precautions (SP) For All Patient CarePatient Care

Hand hygiene

Glove use

Gown use

Mask & eye protection

Routine cleaning/disinfection

Airborne Precautions

Transmitted by airborne routeExamples:Mycobacterium tuberculosismeasles varicella zoster virus (VZV) [chickenpox]

TB: wear N95 RespiratorVZV or measles: only enter room if immune

Private Room: airborne infection isolation room

Have patient wear a mask during transport

Droplet Precautions

Transmitted by cough or , sneezeExamples:Neisseria meningitidisInfluenzaBordetella pertussisSARS-CoV

PPE: wear mask when in pt. room

Private Room

Have patient wear a mask during transport

Examples of application at SJMHS:MRSA – ICU & uncontained fluid, non-ICU

VRE –all Cx +

C. difficle infection

Select gram – with multidrug resistance

Contact Precautions – C Intended for those with C. difficile infection

Sharps Injury Prevention, SJMHS

Shielded syringesneedleless IV systemsafety-designed angiocath.safety butterfly safety scalpel

Sharps disposal containers 4

Warning: Blood or Other Potentially Infectious Materials Present.

The biohazard label is placed on sharps containers, bags or storage space containing specimens

What Do I Do If I have an Occupational Exposure to Blood or Other Potentially Infectious Material?

1. Contact Employee Health Services ASAP at 2-3297

2. Follow instructions from EHSpersonnel

3. Screening test of patient patient source for HBV, HCV & HIV

4. Postexposure chemoprophy-laxis available 24hrs/7days

Postexp. Prophylaxis more effective if providedas soon as possible afterexposure

Immunizations Available from Employee Health Services (EHS)

• Chickenpox vaccine – If you’ve never had natural chickenpox or unsure or no prior receipt of vaccine; contact EHS

• Hepatitis B virus (HBV) vaccine – 3 doses and test serum for evidence of response at 1-2 months after third dose. Measles, Mumps, Rubella (MMR) – you need two doses; if not sure ask EHS

• Influenza vaccine - offered each influenza season; one dose. –REQUIRED FOR ALL PERSONNEL

• Tdap (tetanus & pertussis) – REQUIRED BOOSTER DOSE FOR ALL PERSONNEL

Get Immunized!

2010/11Influenza vaccinewill be Available this Fall from Employee Health Services

Take Home Messages on Infection Prevention

• Use Hand Hygiene• Emphasize strict asepsis during insertion

of invasive devices• Protect yourself with immunization and

equipment

Thank you for your participation in infection prevention & controlContact Infection Prevention & Control Services at extension 2-3158 if you have any questions or concerns.