Preventing Healthcare Associated Infections

W. Charles Huskins, MD, MSc

Associate Professor, Pediatrics

Mayo Clinic

Small things, done well together, can make a big difference

Objectives

• Identify risk factors for central line infections

• Describe practice strategies for line infection prevention

• Review hand washing technique

Central Line Associated Bloodstream Infections (CLABSI)

Minnesota Health Care Quality Measures – Statewide Quality Report - 2010 Report

http://www.health.state.mn.us/healthreform/measurement/report/index.html

Garland JS, et al. Infect Control Hosp Epidemiol 2008; 29:243-9

Intra-luminal

67%

Extra-luminal

20%

Indeter-minate

13%Extraluminal

Intraluminal

Preventative Intervention: Scrub the Hub

• Scrub all injection caps for 15 seconds prior to accessing

• Peripheral and central lines (adult/pediatric/neonate)

• Use alcohol wipe• Allow to dry• Before blood draws,

infusions, flushes…anytime the catheter is accessed

PICU Interventions

• Improve facilities for hand hygiene

• Use 2% chlorhexidine for line insertions for all patients >1kg or >14 days old

• Reduce central line entries• Advance enteral feedings more quickly

• Reduce unnecessary laboratory tests

• Convert IV to po medications

• Switch from bolus to continuous sedation if appropriate

• Reprogram pumps to administer prn doses of medications

Children’s Hospital-Wide Intervention

• Continue to emphasize• Insertion bundle• Standard maintenance practices – dressing

change, hub change, administration set change• Daily assessment of need for line, promptly

remove unneeded lines

• Additional efforts to prevent contamination during line entry

Central Line Entry Bundle

• Emphasize that line entry is a invasive procedure

• Combine several interventions that can work together to reduce risk

• Improve disinfection of hub• Reduce likelihood of contamination of hub• Reduce unnecessary line entry

• Integrate into/redesign line entry workflow to reinforce adherence

• Pilot test new devices to disinfect and protect hub from contamination

Standard Precautions andStrict Isolation to Prevent Spread of

Clostridium difficile and Antimicrobial Resistant Bacteria

MB3B Hand Hygiene Initiative

Coming to a Bed Near You (at the Point of Care)…

Environmental Cleaning with Bleach

• Bleach wipes used daily

• Clean all surfaces:• Crib hand rails & bars and bassinets surfaces• Door handles • Light switches• Tray tables• Bathroom sink handles

• Additional forgotten surfaces:• Computer keyboards• Telephones

Interventions to Prevent Healthcare Associated Infections

Small things, done well together, can make a big difference

• CLABSI• Reduce line entries• Scrub the hub• Protect the hub• Remove line when

it is no longer needed or convert to a lower risk line

• Standard & Isolation Precautions• Wash hands upon entry

in the ICU• Place and use hand rub

at the point of care• Give direct feedback

on compliance• Use bleach wipes for

environmental cleaning

Nosocomial Urinary Tract Infections

DefinitionsCatheter-associated urinary tract

infection

• Symptomatic infection

• Asymptomatic bacteriuria

Maki DG & Tambyah PA. Engineering out the risk with urinary catheters. Emerg Infect Dis 2001;7:342.

Pathophysiology

Maki DG & Tambyah PA. Engineering out the risk with urinary catheters. Emerg Infect Dis 2001;7:342.

Bacteriuria and Urinary Catheters

Days

Lo

g c

olo

ny

form

ing

un

its

/ m

l

Duration of Catheterization

0

10

20

30

40

50

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Days

% o

f p

atie

nts

wit

h

bac

teri

uri

a

Daily Prevalence of Bacteriuria

Garibaldi et al. Factors predisposing to bacteriuria during indwelling uretheral catheterization. N Engl J Med 1974;291:215.

Alternatives to Indwelling Urinary Catheters

• Intermittent catheterization

• Diapers

• External bag collectors (infants & children)

• Condom catheters

Catheter Insertion

• Catheters should be inserted by trained personnel

• Wash hands before insertion, preferably with an agent with antimicrobial activity

• Clean the periurethral area and apply an antiseptic

• Use a sterile catheter and drainage system

• Use aseptic technique

Closed Sterile Drainage

• 26% of catheters disconnected at some time

• Risk of infection the day after disconnection was 2 times the risk if there was no disconnection

Platt et al. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;I:893.

Closed Sterile Drainage

00.10.20.30.40.50.60.70.80.9

1 2 3 4 5 6 7 >7

Days

Cu

mu

lati

ve I

nfe

cti

on

Rate

Unsealed connection

Sealed connection

Platt et al. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;I:893.

Care of Indwelling Urinary Catheters

• Maintain a closed sterile drainage system

• Monitor for obstruction of urinary flow

• Inspect for encrustations

• Maintain the drainage reservoir below the level of the bladder

• Use individual containers to empty drainage reservoirs

• Wash hands before and after touching the catheter or the drainage system

Questions?