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The Power of One: Impacting Patient

Outcomes by Returning to the

BasicsBasics

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

ADVANCING NURSINGkvollman@comcast.net

Northville Michiganwww.vollman.com

Disclosures

• Hill-Rom

• Sage Products Speaker Bureau p& Consultant

• E.L. Lilly

• Merck

Session Objectives & Content

• Prevention is key: IPH model

• Define key care practices based on the evidence that can reduce bacterial load and/or prevent the development of health care acquired infections

B i C i t ti di t d t• Basic Care interventions directed at:

– Reducing MDRO’s

– CLA-BSI

– VAP/HAP

– CA-UTI

Quality & Safety Drivers

Institute for Medicine Evidence based practice movement Quality organizations

• Safer HealthCare Now (SHN)• Canadian Patient Safety Institute

Q b C i T th l t i h lth f t• Quebec Campaign: Together, lets improve healthcare safety• Patients for Patient safety Canada• IHI/VHA:100,000 lives campaign /5 million lives campaign• Clean Care is Safer Care/WHO

Regulatory agencies:• Accreditation Canada• Joint Commission

Public transparency Professional Nursing: Back to the Basics Economics

Why Source Control?

Canada

220,000 HAI’s year/Canada

8000 deaths yearly

USA

2.5 million HAI’s year/USA

Everyday, 247 people die in the USA as a result of a HAI

5 10% f ll ti t d itt d t8000 deaths yearly

Total cost for 1 infected MRSA pt =$12,216.00

$12,000 to $35,000

5-10% of all patients admitted to US hospital annually contract HAI’s (1 of every 10-20 patients)

6th leading cause of death in the US

Higher nurse staffing results in lower HAI’s*

*Hugonnet S et al CCM 2007;35:76-81*Pronovost PJ et al JAMA 1999;281:1310-1317*Needleman J et al. N Engl of Med 2002;346:1715-1722

WHO 2005Yokoe DS, et al. Infect Control Hosp Epidemiol 2008;29:S12-S21http://www.saferhealthcarenow.ca/EN/Interventions/aro_mrsa/Pages/default.aspx.

Health Care Acquired Infection Data

Measurement CNISP-PCSIN NHSN 2006-20081545 hospitals in US

Staph aureus/VREResistance

MRSA 1.93-2.19 56%/33%

CLA-BSI/per 1000 cathdays

ICU Range: 1.6-7.6Housewide: 8.9

Range of pooled means1.3 (PICU)-5.5 (Burn ICU)

VAP/per 1000 vent days ICU: 9.4 Range of pooled means( C ) ( C )0.5 (RICU) -10.7 (Burn ICU)

HAP/per 1000 patient days

- 5-15

CA-UTI/per 1000 cathdays

8.5 Range of pooled means3.1 (Med-Surg ICU)-7.4 (Burn ICU)

SSI/100 patient days 1.96 0.23 (Low risk GallBladder) – 26.6 (High risk Rectal Surgery)

Rosenthal VD, et al. Am J of Infect Control, 2008;36:627-37Edwards JR, et al. Am J of Infect Control, 2008;36:609-26 Hidron Ai, et al. Infect Control Hosp Epidemiol 2008; 29:996-1011http://www.phac-aspc.gc.ca

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Financial Burden to the Canadian Health System

• The HAI financial burden to the health care system has been estimated by measuring a number of indices including increased:– number of readmissions to hospital

l th f t– length of stay

– use of antimicrobials

– surveillance and isolation measures for AROs

– laboratory and radiological services attributable to diagnosing and managing HAIs

– overall direct or indirect costs

– cost attributable to outbreaks

http://www.phac-aspc.gc.ca/nois-sinp/guide/ps-sp/partI-eng.php[6/10/2011 3:28:32 PM]

Factors Impacting HAI’s Programs

• Factors Associated with Lower HAI’s (30% reduction)– Integrated infection control

program

– Culture change

– Leadership/Champion

– Use of proven best practices

– HAI surveillance

Rosenthal VD, et al. Am J of Infect Control, 2008;36:el-12Bonuel N, et al. Crit Care Nurs Quart, 2009;32:144-148

Safer HealthCare Now & Quebec Campaign: Together, Lets Improve Healthcare Safety!

• April 2008

– Falls in long term care

– ADE in long term care

– NACS (New approach to controlling superbugs)CS ( e app oac to co t o g supe bugs)

– VTE

• 6 Initial Intervention 2005

– RRT

– AMI

– Medication reconciliation

– Prevent central line infection

– Prevent Ventilator-Associated pneumoniahttp://www.saferhealthcarenow.ca/

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 sickin a Hospital that it should do the sick no harm.”

Florence Nightingale

Advocacy = Safety

Patient Advocacy/Safety Related to Clinical Practice

• Nurses knowledge of the evidence based care

• Ability to deliver the care to the right patient at the right time, every time it is needed

Th bilit t i t ti t i• The ability to communicate patient concerns in a concise, data driven manner and take appropriate action

• Understanding the chain of command when faced with resistance

Advocacy Starts with Us

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Achieving the Use of the Evidence

Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

NSOValueVollman KM.

Australian Crit Care, 2009;22(4): 152-154

Protect The Patient From Bad Things

Happening on Your Watch

Interventional Patient Hygiene

• Hygiene…the science and practice of the establishment and maintenance of health

• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategiesIncontinence Associated Dermatitis Prevention

Program

INTERVENTIONAL PATIENT HYGIENE(IPH)

Oral Care/ Mobility

VAP/HAP

HAND

Catheter Care

CA-UTI CA-BSI

Skin Care/ Bathing/Mobility

HASISSI

HYGIENE

Patient

Vollman KM. Australian Crit Care, 2009;22(4): 152-154

Reducing Environmental Load & Preventing Infection Through Creative &

Fundamental Care Strategies

Hand Hygiene Pre-op Prep Basinless BathingHand Hygiene, Pre op Prep, Basinless Bathing, CLA-BSI, CA-UTI

Hand Hygiene is the Single Most Important Factor in Preventing the Spread of

Infection

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WHO 1st Worldwide Patient Safety Campaign: Hand Hygiene

Pittet D. Infect Control Hosp Epidemiol, 2009;30(7):611-622

Factors Impacting HAI’s Programs

• Factors Associated with Lower HAI’s (30% reduction)– Integrated infection control

program

– Culture change

– Leadership/Champion

– Use of proven best practices

– HAI surveillance

Rosenthal VD, et al. Am J of Infect Control, 2008;36:el-12Bonuel N, et al. Crit Care Nurs Quart, 2009;32:144-148

Hand Washing Compliance

Findings: 1) Healthcare workers wash hands less

than 50% of time after direct patient contact.

2) Higher workload and activities of higher risk for transmission lower hand washing compliance

1981-2007 26 Years of Data/Research

Two models were created to simulate sequential patient contact by

2010 Researchq p y

non compliant hand hygiene worker Goal: To estimate the MRSA related cost of an incident of hand

hygiene non-compliance Results:

Model 1 42 MRSA infections, mean cost $47,092, mean cost per non-compliant event $1.98

Model 2 980 MRSA infections, mean cost $53,598, mean cost per non compliant $52.53

200 bed hospital incurs $1,779,283 in annual MRSA related expenses attributable to hand hygiene non-compliance

Cummings KL, et al. Infec Contol Hosp Epidemiol, 2010;31:357-364

WHO Hand Hygiene Tools 05/09

Alcohol-based Handrub Planning & Cost Tool

http://www.who.int/gpsc/5may/tools/system_change/en/index.html

Guidelines for Hand Hygiene in Health Care Settings

• If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations (1A)

• When hands visibly soiled or exposure to potential spore forming organisms, wash with either a non-antimicrobial or antimicrobial soap & water (IB)

• Decontaminate hands after removing gloves• When washing with soap & water, wet hands first, apply

soap, rub vigorously for 15 seconds, rinse and dry. Use towel to turn of faucet. (Duration 40 seconds)

• Provide HCW with hand lotions & creams to minimize occurrence of irritant contact dermatitis (IA)

• Use multidimensional strategies to improve hand hygiene practice (IA)

• Do not wear artificial fingernails or extenders (IA)

CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR-16):[1-45]WHO Hand Hygiene Guidelines 2009

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Reasons for Non-Compliance

• Lack of knowledge on importance and how the hands become contaminated

• Lack of understanding of correct techniqueq

• Understaffing and overcrowding• Poor access• Irritant contact dermatitis associated with

frequent exposure• Lack of institutional commitment to good hand

hygiene

Pittet D et al. Lancet Infect Dis. 2001;1:9-20

When to Wash

Pittet D. Infect Control Hosp Epidemiol, 2009;30(7):611-622http://www.saferhealthcarenow.ca/EN/HandHygiene/Pages/HandHygieneScholarlyLiterature.aspx

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

Key Components to Multimodal Strategy to Improve Adherence

• Education & motivation & strong commitment to improve hand hygiene by frontline workers & leadership

• Engage staff/Positive deviance culture• Institutional safety climate

Si l & t d di• Simply & standardize• Alcohol-based hand rub as primary method for hand

hygiene….right product• Reminders in the workplace/red line approach• Verified by competency, monitored compliance and

feedback/weekly initiallyWHO Guidelines 2009Pittet D. Infect Control & Hosp Epidemio, 2008;29:957-959Sax, H., et. al. Infection Control and Hospital Epidemiology 2009, 28, 1267-1274Erasmus, V. et. Infection Control and Hospital Epidemiology.2009 30(5), 415-419Bonuel N, et al. Critical Care Nursing Quarterly, 2009;32:144-148

Measurement: Know Your Direction

• Policies and guidelines will not increase hand hygiene compliance unless measurement and feedback are part of the process…Make it Visible

www.hhreports.comQuinn B, presented at NACNS 2011

Hand Hygiene Measurement Methods

• Direct Observation

• HCW Self-reporting

• Product Usage/Volume

• Automation monitoring can improve compliance

www.hhreports.comHaas and Larson Journal of Hospital Infection 2007;66:6-14Polgreen PM, et al. Infect Control & Hosp Epidemiol, 2010;31:1294-1297

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

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Improved & Correctly Performed Hand Hygiene Can Lower HAI’s

Effective Hand Hygiene

33% lower antibiotic resistance over time

Reduced CLA BSI’s from 3 9 to 1 0 per Reduced CLA-BSI’s from 3.9 to 1.0 per 1000 catheter days

Trick et al. Infec Control Hosp Epidemiol, 2007;25:42-9

Zingg W, et al. Crit Care Med, 2009;37:2167-2173Webster J, et Journal of Paediatric Child Health,1994, 30:59-64.

Five Key Interventions

1. Hand hygiene2. Decontamination of the environment

and equipment…?people3 Active surveillance cultures (ASCs)3. Active surveillance cultures (ASCs)4. Contact precautions for infected and

colonized patients5. Compliance with Central Venous

Catheter and Ventilator Bundles

www.ihi.org

Environmental Contamination as a Source of Health Care Acquired Pathogens

Pathogen Survival Data Transmission Settings

C. difficile Months 3+ Healthcare facilities

MRSA d-weeks 3+ Burn units

VRE d k 3 H lth f ilitiVRE d-weeks 3+ Healthcare facilities

Acinetobacter 33 d 2/3+ ICUs

P. aeruginosa 7 h 1+ Wet environments

Hota B, Clin Inf Dis 2004; 39(8):1182-9Stiefel U et al. Infect control & Hosp Epidemiol 2011;32:185-187.

Hands equally become contaminated from commonly examined skin sites & environmental surfaces

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– Dedicated equipment in isolation rooms– Reduce load– Education of healthcare workers and support staff

• Change from use of a pour bottle to bucket immersion for applying disinfectant to cleaning cloth

• Feedback method using removal of intentional applied marks visible only under UV light

Boyce JM et al Infec Control Hosp Epidemiol. 1997;18:62-627Huang SS, et al. Arch Intern Med 2006;166(18):1945-1951

• Pre-intervention rooms occupied by MRSA carrier had new acquisition increase from 2.9% to 3.9%

• Post Intervention: 1.5% (Datta R. Arch Intern Med 2011;17:491-494)

Improved Cleaning Reduces VRE Transmission

Routine cleaning reduces VRE transmission by 60%

Segers et al. JAMA, 2006;296:240-246

Improving Environmental Hygiene In 27 ICU’s Decreased MDRO Transmission

• 27 acute care hospitals ( 25 beds to 709 beds)• Fluorescent targeting method used to objectively

evaluate the thoroughness of terminal room cleaning before and after a structured educational, procedural and administrative interventionsinterventions

• 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

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REDUCING THE BACTERIAL LOAD ON THEBACTERIAL LOAD ON THE

PATIENT: IMPACT ON MRSA/MDRO

nurWse!

Traditional BathingWhy are there so many bugs

in here?

Spreading Microorganism

Bath Water: A Source of Health-Care Associated Microbiological Contamination

• Compared normal bath water with chlorhexidine bath water on 3 wards

• Without Chlorhexidine: All samples + for bacterial growth (14/23 > 105 cfu/ml)bacterial growth (14/23 > 105 cfu/ml)

• With Chlorhexidine: 5/32 grew bacteria with growth 240 to 1900 cfu/ml

• Gloved hands/bathing: objects touch grew significant numbers of bacteria

Shannon RJ. et.al. Journal of Health Care, Compliance & Safety Control. 1999;3(4):180-184

Bath Basins: Potential Source of Infection

• Multicenter sampling study (3 ICU’s) of 92 bath basins

• Identify & quantify bacteria in patients basins

• Sampling done on basins used > 2x in patients hospitalized > 48 hours & preformed 2 hours post bath

• Cultures sent to outside laboratory

• Qualitative vs. quantitative measures used to exclude growth that may have occurred in transport

• Bathing practices not controlled & no antiseptic soaps used to bathe

Johnson D, et al. Am J of Crit Care, 2009;18:31-40

Bath Basins: Potential Source of Infection

• Results– 98% of all cultures grew some form of

bacteria after plating or enrichment

• Enrichment ResultsEnrichment Results– 54% enterococci. 32% for gram -, 23%

for S aureus and 13% VRE (statistically significant)

– <10% growth rates for: MRSA 8%, P aeruginosa 5%, C albicans 3% & E coli 2%

Johnson D, et al. Am J of Crit Care, 2009;18:31-40

Large Multi-Center Basin Evaluation For Presence of MDRO’s

• 53 US & Canadian Hospitals

• Randomly selected basins for damp swab culture

• Central lab tested for MRSA & VRE & gram – bacilli

Methodology

• Central lab tested for MRSA & VRE & gram – bacilli

• All basins were clean & were not visibly soiled

Results:• 199 basins (34.6%) from 52 hospitals were colonized with VRE• 251 basins (43.6% from 47 hospitals had gram-negative bacilli• 24 basins (4.2%) from 19 hospitals had MRSA

Kaye, et al. Presented at SCCM January2011

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Waterborne Infections Study

• Hospital tap water is the most overlooked source for Health-care associated pathogens

29 evidenced based studies present• 29 evidenced-based studies present solid evidence of waterborne Health-care associated infections

• Transmission occurs via drinking, bathing, items rinsed with tap water and contaminated environmental surfaces

Anaissie E. et. al. Arch Int Med. 2002; 162:1483-92

Waterborne Infections Study

• Conservative estimates suggest significant morbidity and mortality from waterborne pathogens

Immunocompromised patients are at the• Immunocompromised patients are at the greatest risk

• Recommendation I: Minimize patient exposure to hospital tap water via bottled water and pre-packaged, disposable bathing sponges

Anaissie E. et. al. Arch Int Med. 2002; 162:1483-92

Bacteria Biofilm

• Organized communities of viable & non-viable microorganisms protected within a matrix of extracellular polysaccharides, nutrients & entrained particles

• Adhere to inert material (plumbing)

• Bacteria contain within Biofilm may be transmitted to at risk patients by direct contact with water used for ingestion, ice, washing

Cervia JS, et al. Arch Intern Med, 2007;167:92-93

ICU & Hospital Water Samples

• Systematic review published studies 1998-2005 (29 studies)– 9.7%-68.1% of random ICU water samples + for

Pseudomonas aeruginosag

– 14.2%-50% of patient infections were due to genotypes found in ICU water

• 9 hospital in New York city– Bacteria recovered in every hospital

– 4-14 species identified

– 1/3 organism known to be responsible for HAI’s

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

Pre-Op Prep

• Antisepsis must demonstrate a 3.0 log 10 from baseline in groin, 2.0 10 log reduction on the abdomen and maintain effectiveness for minimum of 6 hrs.

• CHG shower/bathing versus soap & water showed no difference in SSI (Cochrane EBR: 2007:CD004985)

• 2% prep cloth more effective in reducing bacterial load• 2% prep cloth more effective in reducing bacterial load than 4% CHG solution that must be rinsed off/Inguinal sites sustained action at 10min, 30 min, 6 hrs > than 4% (Edmiston CE. Et al AJIC, 2007;35:89-96)

• CDC recommends must bathe or shower night before– Compliance issues, consistency in application, unable to

bathe self

• Chlorhexidine is absorbed onto fibers of certain fabrics, particularly cotton (Denton GW. Chlorhexidine. In Block S, ed. Disinfection, Sterilization and preservation, 4th ed. Philadelphia: Lea & Febiger, 1991:274-89)

Innovative Strategy: Study Re-examine Pre-op Prep

• Methodology– Observational study with a pre & post intervention period– Baseline: Actively part of National SCIP program– Pre-intervention pre-op prep was night before in home

showering or washing with 4% CHG solution– Post intervention: Pre-op prep preformed with a pre-

packaged 2% CHG prep product with instructions on its use

– Pre-package prep preformed at hospital prior to surgery– Measured:

• Change in baseline SSI would occur with new prep process

• Cost savings

Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com

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Innovative Strategy: Case Study Re-examine Pre-op Prep

• Results: – 25 SSI’s during

historical period out of 5174 procedures (rate of 2 1%)(rate of 2.1%)

– 11 SSI’s during interventional period out of 4266 procedure(rate 0 .7%)

Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com

72% Difference

Innovative Strategy: Case Study Re-examine Pre-op Prep

• Cost Savings Results: – Before intervention:

$648,471 for SSI’s

– After intervention: $290,827

– Cost of product: $8,721

– Readmission savings: $177,937

Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com

Total Savings$526,860.00

Safer Health Care Now: Pre-Op Surgical Prep

• RECOMMENDATION:– Based on the evidence, the Safer Healthcare Now! SSI faculty

recommend that:

– The skin should be cleansed before surgery with a chorhexidine–based solution,

– Preferably with no rinse disposable chlorhexidine gluconateimpregnated wash cloths.

– Chlorhexidine is well tolerated and has shown a low incidence of hypersensitivity and skin irritation

Bathing with CHG Basinless Cloths

• Prospective sequential group single arm clinical trial

• 1787 patients bathedp

– Period 1: soap & water

– Period 2: CHG basinless cloth bath

– Period 3: non-medicated basinless cloth bath

Veron MO et al. Archives Internal Med 2006;166:306-312

Veron MO et al. Archives Internal Med 2006;166:306-312

26 colonization's with VRE per 1000 patients days vs. 9 colonization's per 1000 patient days with CHG bath

Veron MO et al. Archives Internal Med 2006;166:306-312

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Addition of 2% CHG Baths to MRSA Bundle Reduces Rates

– MRSA bacteremia rates, MRSA colonization & new acquisition > 48 hrs post admission to 30 bed mix med-surg ICU

– Multimodal interventions: New line insertion guidelines (2002) Handinsertion guidelines (2002), Hand hygeine (2003), daily triclosan body wash (2004), tool for early line removal (2006), 2007 switch to 2% CHG cloth bathing, 1 % solution CHG applied nasally

– Greatest reduction in MRSA colonized patients occurred with the once a day daily CHG body washing practices Wyncoll D, et al. SCCM 2009; poster 643

Effect of Daily Bathing with CHG on New Acquisition MRSA & VRE

• Quasi-experimental multicenter trial in 6 ICU’s in 4 academic centers (2004-2006)M d i id f MRSA• Measured incidence of MRSA & VRE colonization during a period of bathing with routine soap for 6 months and compared 6 months with daily bathing with chlorhexidine solution

• Skin condition not measured

Climo MW, et al. Crit Care Med, 2009;37(6):1858-1865

2% CHG Cloth vs. Soap & Water Bathing for Reduction of HAI’s in Med-Surg

• Quasi-experimental study of 14,701 patients in 4 med-surg units (94 beds) in a 719 bed academic center

• Pre-post design: 7102 (control group soap & water) 7699 (experimental group 2% CHG cloth)M it h d h i d i l ti li• Monitor hand hygiene and isolation compliance

• MRSA screening performed in both groupsResults• Study was stopped early because of efficacy• 64% reduced risk of developing HAI’s from MRSA & VRE

(hazard ratio, .36 [95% CI, 0.2-0.8]; P= .01)

• More + MRSA colonization in CHG group so > isolation & hand hygiene

Kassakian S, et al. Infect Control & Hosp Epidemiol, 2011;32:238-243

Basin Bath

Strategies for Bathing to Reduce Source Control & Improve Skin Defense

transmission of organismstransmission of organisms time & efforttime & effort # of supplies# of suppliesHarmful soapsHarmful soapsRough washclothsRough washclothsCold/tepid waterCold/tepid waterScrubbing techniqueScrubbing technique

Contact Precautions For Infected and Colonized Patients

• A single-patient room is preferred for patients who require Contact Precautions.

• When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patientassess the various risks associated with other patient placement options

• Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment.

• Donning gown and gloves upon room entry and discarding before exiting the patient room is done to contain pathogens

Siegle JD et al, CDC/Management of MRDO, 2006

To Screen or Not to Screen?

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Active Surveillance

• Begin with admission cultures only.– Measure compliance; add the second culture when high (>

90%).– ASCs of the anterior nares capture 80% of colonized adults– ASC’s of the anterior nares & wounds capture 92% of

colonized adultscolonized adults– Screen high risk

• Provide real-time notification of positive admission culture./PCR testing used as screening tool vs. dx

• Schedule consistent day of week for second culture.• Measure transmission.

– Number or rate of patients who convert from negative to positive

• Flag colonized patients when discharged.Yokoe DS, et al. Infect Control Hosp Epidemiol 2008;29:S12-S21www.IHI.org

To Screen or Not to Screen?

• Clustered RCT of 9000 cases between 2005 & 2006• Evaluated the effect of surveillance for MRSA & VRE

colonization & expanded used of barrier precautions compared with existing practice on incidence of MRSA & VRE infection

• Intervention group: 92% of ICU days either contact or universal, Control group: 38% of ICU days (p<0.001)

• In intervention group: When contact precautions specified; gloves used median of 82%, gown 77% and hand hygiene 69%

• No difference in colonization & infection rates between ICU’s that tested/screened patients & expanded precaution vs. those that did not

Huskins WC, et al. N Engl J Med. 2011;364(15):1407-18

To Treat or Not To Treat for Carriage

• Systematic review of clinical trials to determine effectiveness of different approaches for eradicating MRSA carriage (especially pts with elective surgery)– Uncomplicated cases, short-term nasal application of mupiricin

remains the most effective treatment for advocating MRSA carriageremains the most effective treatment for advocating MRSA carriage

– 90% success rate post one week after treatment

– 60% success rate in longer follow-up

• S aureus carriers randomized to receive Mupiricin and skin washing with CHG or placebo– Tx group demonstrated significantly lower S aureus infection rates

(RR 0.42 [95% CI, 0.23-0.75] & shorter LOS (1.8 days, p=.04)

Van Rijen M, et al. Cochrane Database Sys Rev 2008;4:CD006216Ammerlaan HS, et al. Clin Infect Dis, 2009;48922-930

All or NoneVentilator

Associated Pneumonia

The Vent Bundle…To the VAP Bundle

• Applying evidence-based practice• 5 activities that when done 100% of the time has

shown a reduction in– VAP

LOS

Nurse-intervention bundle demonstrated a 55.4% reduction in the incidence of VAP

– LOS– Time on Vent– Cost

• HOB 30°, Peptic Ulcer Disease (PUD) prophylaxis, DVT prophylaxis, Sedation vacation, Daily assessment for SBT/ & Oral Care with antisepticModification Mobility, EVAC tube, OG vs. NGT

• Maintaining ET tube cuff pressure between 20-25cm H2O• Keeping HOB elevated 30 to 45°• Providing oral care every 2-4 hours

Curtin LJ. American Nurse Today, March 2011

European VAP Bundle

• No ventilator circuit change unless specifically indicated

• Alcohol based hand h ihygiene

• Appropriately educated and trained staff

• Incorporation of sedation and weaning protocols

• Oral care with CHG Rello J, et al. Intensive Care Medicine, 2010;36:773-780

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Canada Ventilator-Associated Pneumonia(VAP)

• Incidence of VAP 10.6 cases per 1000 ventilator days• Estimated 4000 cases per year• 230 deaths (0 - 580 range)

Att ib t bl t lit 5 8%• Attributable mortality 5.8%• Accounts for 17,000 ICU days per year/2% of all ICU

days• Associated cost $30,000-$40,000 per VAP/minimiun

cost savings to system $14,000• Increase LOS 4.3 days per episode• Annual cost $46 million (10 to 82 million) per year

Muscedere JG. Et al. J of Crit Care, 2008;23:5-10

Healthcare Acquired Pneumonia

• Risk Factor Categories– Factors that increase

bacterial burden or colonization

– Factors that increase risk of aspiration

Factors that Increase Bacterial Burden or Colonization

Extreme age, severe underlying condition/ immunosuppression

Administration of

Suctioning/Saline administration

Lack of oral care Administration of

antibiotics

Agents which raise the gastric pH

Withholding gastric feeding

Mechanical ventilation

Poor infection control practices

Contaminated respiratory equipment/contaminated condensate

Immobility

Oropharyngeal Colonization

• 89 critically ill patients

• Examined microbial colonization of the oropharynx through out ICU stay

Methodology:

• Used pulse field gel electrophoresis to compare chromosomal DNA

Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156:1647-1655

Results:

• Diagnosed 31 VAPs• 28 of 31 VAP’s the causative organism was

identical via DNA analysis

Dental Plaque

• 49 elderly nursing home residents admitted to the hospital

• Examined baseline dental plaque scores &

Methodology:

microorganism within dental plaque

• Used pulse field gel electrophoresis to compare chromosomal DNA

El-Solh AA. Chest. 2004;126:1575-1582

Results:

• 14/49 adults developed pneumonia• 10 of 14 pneumonias, the causative organism was identical via DNA analysis

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Role of Salivary Flow

• Provides mechanical removal of plaque and microorganisms

• Innate & specific immune components (IgA, cortisol,components (IgA, cortisol, lactoferrin)

• Patients receiving mechanical ventilation have dry mouth which in turn contributes to accumulation of plaque & reduced distribution of salivary immune factors

Munro CL & Grap MJ. AJCC. 2004;13:25-34

Endotracheal / Nasogastric Tube/ Sinusitis

• Carriage of oropharyngeal bacteria during intubation• If cuff pressure < 20 cm 4x risk VAP• Cuff pressure range btwn 25-40cm (JBI-Level A) with

maintenance at 25cm-30cm of H2O pressure.– Continuous monitoring resulted in a lower portion of out of range cuff

pressure (11% vs. 51.7% p< 0.001)

• NGT increases risk of sinusitis/gastric reflux & increases oropharyngeal colonization

• Use oral ET versus nasal (CDC-Cat IB)• Sinusitis increases the risk of nosocomial pneumonia by 3

foldCDC. 2003 Guidelines for Prevention of Healthcare Associated Pneumonia; MMWR; 2004:53(no RR-3)Davis KA. J Intensive care Med, 2006;21(4):211-226Muscedere J & Canadian Trails Group. J of Crit Care, 2008;23:126-137Carstens J. Joanna Briggs Institute, 2010Sole, ML, et al. AJCC, 2011;20:109-117

BrushCHX i lCHX rinse alone

CHX rinse in CombinationSwab/Clean/Moisturize

Suction

All of the above

BRUSH & SWAB

• 77% more clean approximal sites with brushing

• 44% more clean crevice sites with brushing

• Benefit of brushing is directly correlated with• Benefit of brushing is directly correlated with technique

• Foam swabs could not remove plaque from sheltered areas on or between teeth

Pearson LS. et. al. J of Adv Nursing. 2002;39(5):480-489

Oral Care Reduces Pneumonia In Nursing Homes

11 nursing homes in Japan over 2 year period 417 enrolled / 366 residents analyzed (death

from other causes) 184 recei ed oral care program/182 did not

Methodology

184 received oral care program/182 did not Tooth brushing after each meal (teeth or

dentures) & 1x weekly review by dentist/or hygienist

Results

No OralNo Oral Oral CareOral Care p valuep value

FebrileFebrile 29%29% 15%15% p<.01p<.01

PneumoniaPneumonia 19%19% 11%11% p<.05p<.05

DeathDeath 16%16% 7%7% p<.01p<.01

MMSEMMSE IncreaseIncrease p<.05p<.05Yoneyama et al. JAGS. 2002;50:430-433

Solutions H2 O2

EBR: CHG; grade B evidence, Sodium Bicarb; unresolved, H2O2; unresolved, Salt solutions; unresolved; Tap water; not recommended, Sterile water; unresolved. (Berry AM et al. AJCC, 2007;16:552-563)

Review of Dental Literature Not Included

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14

H2 O2, Cetylpyridium Chloride (CPC) & Biotene

• >3% may cause harm, <1% no benefit in plaque removal.• Must be diluted properly, not with normal saline.• 3x a day mouth rinse with 1.5% H2 02 revealed no

mucosal damage, improved plaque scores and overall

H2O2

gingival health.

West TL et. al. Journal of Peridontol. 1983; 54(6):339Tombes MA et. al. Nursing Research. 1993; 42(6):332-337Beck S. Cancer Nursing. 1979; 2:185-189.

Gunsolley JC.J Am Dent Assoc 2006;137(12):1649-57Gomes BC et.al. Clin Prev Dentistry. 1984; 6:21-25Boyd RL. et. al. J Clin Periodentol.1989; 16:557-563

CPC• Cetylpyridium chloride had significant antigingivitis

effects in several individual studies• Used in some over the counter plaque reduction rinses (Crest rins

Biotene• Contains salivary enzymes• Moisturize, Some oral care kits

Recent Trials Reduction in VAP or Colonization with CHG or Povidone-iodine

• 2004: Grap (CHG via swab) • 2005: Fourier (CHG) (negative trial)• 2006: Koeman (CHG or CHG/colistin)

2006 M (CHG i b & t thb i )• 2006: Munro (CHG via swab & toothbrusing)• 2006: Sequin (povidone-iodine)• 2006: Mori (povidone-iodine)• 2008: Tantipong (CHG)2009, Sona (CHG)2009, Panchabhai (CHG)—no decrease

Oral Decontamination for the Prevention of Pneumonia in Mechanically Ventilated Patients:

Systematic Review and Meta Analysis

Meta Analysis• 298 articles screened• 11randomized controlled

trials used• 3242 patients

Chan EY, et al. BMJ, 2007;334:889

• 4 trails (1098 pts) no significant difference with oral antibiotics

• 7 trials (2144 pts) Oral application of antiseptics significantly reduced VAP rates

• No decrease in Mortality, mechanical ventilation or LOS

Comprehensive Oral Care Program

Comprehensive Oral Care Protocol: The Good Shepherd Study

Methodology:• Retrospective study 10 bed Med-Surg• Protocol included: Covered Yankauer for

non-traumatic oral suctioning, soft-suction t thb h S ti O l S b ftoothbrush, Suction Oral Swab, use of a 1.5% H2O2 peroxide mouth rinse for cleansing, subglottic suction catheter used 4x daily, dedicated oral suction line for infection control and ease of use.

• Education provided and presence of clinical champion.

Schleder B. et al. J Advocate Health 2002;4(1):27-30

Literature Review: Oral Care Impact of VAP

Comprehensive Oral Care:• Reduction in VAP from 5.6 to 2.2 (Schleder B. et al.

J Advocate Health 2002;4(1):27-30)• Reduction in VAP from 4.10 (2005) to (2.15) in 2006

with addition of CPC & comprehensive oral carewith addition of CPC & comprehensive oral care. Vent bundle & rotational therapy already being performed

• Reduction in VAP from 12.0 to 8.0 (p=.060) with 80% compliance, vent bundle already being preformed, 1538 patients randomized to control or study group, Additional outcomes; vent days (p=.05), ICU LOS (p=.05) time to VAP (p= <.001) & reduction in mortality (p=.05) (Garcia R et alAJCC, 2009;18:523-534)

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Literature Review: Oral Care Impact of VAP

Comprehensive Oral Care & CHG:• Reduction in VAP to zero for 2 years, vent bundle, mobility, oral care

& CHG with comprehensive education preformed (Murray TM et al. AACN Advanced Critical Care. 2007;18(2):190-199)

Dickinson S et al. SCCM Critical Connections, 02/2008

Comprehensive oral care with CHG

Heck K, et al. Presented at APIC 7/15/2010

Dental Brushing for Preventing VAP

• Prospective, simple blind, randomized trial of adult patients incubated for > 48 hours

• Randomized to oral care every eight hours with .12% CHG applied by gauze after suctioning oral

ti d √ ff ( t d d)secretions and √ cuff pressures (standard) or standard oral care plus electric toothbrushing

Results• Terminated after randomizing hundred 47 patients• No difference in VAP, mortality antibiotics three days

duration mechanical ventilation or hospital ICU length of stay in the two groups

Pobo A, et al. Chest, 2009;136:433-439

Oral Suctioning with Position Change

• Prospective time sequenced non-randomized study– 237 control (observation phase 9 months)

– 227 Interventional (7 months interventional)

– Difference in nursing protocol was oral suctioning prior to position change (11 additional suctions)position change (11 additional suctions)

– All other nursing care the same

• Results: – VAP: 6.51 to 2.04 per 1000 ventilator days ( p<0.002 )

– Vent days: 28.8 + 17.2 vs. 20.2 + 4.0 (p <0.009)

– ICU LOS: 27.6 + 17 vs. 20.3 + 4.0 (p < 0.012)

– Suctioning before positional change only independent factor responsible for VAP decrease (p=0.003)

Tsai, HH, et al. Am J of Med Sci, 2008;336;397-401

Does Compliance Make A Difference?

Oral care compliance & use of the ventilator bundle resulted in a 89.7% reduction in VAP

Hutchins K, et al. Am J Infect Control 2009;37:590-7

Subglottic Secretion Drainage

Risk of VAP

Mortality

5 level 2 trials conclude that subglottic secretion drainage is associated with a reduction in VAP

Dezfulian C. et al. Am J of Med, 2005;118,11-18

Mortality

Risk of Early VAP

drainage is associated with a reduction in VAPMuscedere J & Canadian Trials Group. J of Crit Care, 2008;23:126-137

Silver Impregnated Endotracheal Tube

• Endotracheal tube cuff that prevents leakage through a re-design

• Impregnated endotracheal tube that minimize the bacteria biofilm

• A phase III multicenter, prospective, randomized, controlled t i l d t t d i ifi t d ti f i bi l i lltrial demonstrated a significant reduction of microbiologically documented– VAP (4.8% in the silver group vs. 7.5% in the control

group, p < 0.05)• Cost effective analysis: Silver coated tube yielded $9,630 to

$16,356 per case of VAP prevented.• Retrospective examination suggests that the silver-coated

ETT may be associated with a reduce mortality in pts with VAP Kollef MH, et al. JAMA, 2008;300:805-814

Shorr AF, et al. Infect Control Hosp Epidemiol, 2009;30:759-763Afessa B, et al. Chesst, 2010;137:1015-1021

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1 2

3 4

Trauma unit targeted 16 in 24 hrs for HOB > 30 degrees & VAP rates from 4.0 to 1.0Laux L, et al. Crit Care Nurs Q, 2010;33:126-131

HOB Research

• 86 patients

• Randomly assigned to supine position or HOB 45 degrees (39 semi recumbent, 47 supine)

• Monitored clinical suspected & microbiologically

Methodology:

Monitored clinical suspected & microbiologically confirmed nosocomial pneumonias

Drakulovic MB. et. al. Lancet. 1999;354:1851-1858

Results:• Microbiologically confirmed nosocomial pneumonia

lower in the semi recumbent group 2/39 (5%) vs. 11/47 (23%)

• Supine position & enteral nutrition were independent risk factors for VAP & had the greatest number of VAP’s 14/28 (50%)

HOB Research

• Methodology– Prospective multicenter trial randomly assigned to targeted

45° vs.10° HOB– 112 to targeted 45° vs. 109 patients to 10°– Continuous measurement of backrest elevation first wk of

MVMV– Dx of VAP by bronchoscopic techniques

• Results– Baseline characteristics similar– Average elevations

• 10° group day 1 & 7: 9.8 & 16.1 • 45° group day 1 & 7: 28.1 & 22.6*

– Target 45° not achieved 85% of the time– VAP: 10° = 6.5% vs. 45° = 10.7%

Van NieuwenhovenCA, et al. Crit Care Med, 2006;34:396-402*p < .001

Goldhill DR et al. Amer J Crit Care, 2007;16:50-62Xue Y. Joanna Briggs Institute 2010

CLRT to Prevent VAP

• Prospective randomized controlled trial, 3 medical ICUs at a single center

• Eligible if ventilated < 48 hours & free from pneumonia, ALI or in ARDS

• 150 patients with 75 in each group

Methodology

• 150 patients with 75 in each group• 35 CLRT patients allocated to undergo percussion before

suctioning• Measures to prevent VAP were standardized for both groups

including HOB

Results: CLRT vs. Control• VAP: 11% vs. 23% p = .048• Ventilation duration: 8 + 5 days vs. 14 + 23 days, p = .02• LOS: 25 + 22 vs. 39 + 45 days, p = .01• Mortality: no difference Staudinger t, et al. Crit Care Med, 2010;38:486-490

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Ventilator Circuit Change

Hess DR et al, Respir Care 2003;48(9):869-879

Heat-Wired Exchange

Kola A. Intensive Care Med, 2005;31(1):5-11.

Effect of CHG Cloth Bath of HAI’s in Trauma Patients

• Retrospective analysis 6 months before and after institution of CHG bathing

• 12 bed level 1 trauma center– 286 severely injured patients y j p

bathes 2% CHG cloth– 253 severely injured patients

bathed without CHG cloth• Results: CHG bathed patients less

likely to acquire a CLA BSI (2.1-vs. 8.4), MRSA VAP 1.6 vs. 5.7 & rate of colonization was significantly lowers; 23.2 vs.69.4 per 1000 patient days

Evans HL, et al. Arch Surg, 2010;145:240-246

• 112 ICU’s from 72 hospitals reported data

• Examine 550,800 ventilator days

• Implementation of the CUSP/VAP Bundle/checklist

• Results: 71% in VAP rates in MI

Intervention to Decrease VAPStatewide Collaborative-Keystone ICU

– Median rate of VAP per 1000 vent days went 5.5 cases to 0 0 at 16-18 months (p<0.001) & 0 at 28-30 months (p<.001)

– Mean rate of VAP per 1000 vent days went 6.9 to 3.4 at 16-18 month follow up (p<0.001) & 2.4 at 28 to 30 months (p<.001)

– Composite compliance measured from 32% at baseline, 75% at 18 months & 84% at 28 months

– Inclusion of oral care was not measured

Berenholtz SM, et al. Infect Control Hosp Epidemiol, 2011;32:305-314

Comprehensive Evidence-Based Clinical Practice Guidelines: Prevention

• Recommend– Oral intubation route– New vent circuit for each

patient– Circuit change if soiled or

• Consider– Rotational therapy– Oral antiseptic rinses

• Not recommended– Bacterial filtersg

damaged– Change HME q 7days– Use of closed suction,

changed each patient and clinically indicated

– Subglottic drainage if expected >72 ventilation

– HOB 45 (when impossible as near)

– Use of iseganan

• No recommendations made– Use of systematic search for

sinusitis, aerosolized antibiotics, intranasal mupirocin

– Type of airway humidification– Timing of trach– Prone positioning

Muscedere J & Canadian Trails Group. J of Crit Care, 2008;23:126-13

Central Line -Associated Blood St I f tiStream Infections

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18

• Remove/Avoid unnecessary lines (IA)

• Hand hygiene (IB)

• Maximal barrier (IB)

Chl h di f ki (IA)

Blood Stream Infection (BSI) Prevention Bundle (IB)

• Chlorhexadine for skin prep (IA)

• Avoid femoral lines (IA)

CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29]http://www.guideline.gov/summary/summary.aspx?doc_id=13395&nbr=006806&string=CLA-BSI –Oct 2008www.ihi.orgGrady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.govhttp://www.onthecuspstophai.org/

Education & Culture of Safety

Canada CLI & CLM Bundle’s(All or None Strategy)

Central Line Insertion Bundle

Hand hygiene

Maximal barrier

Central Line Maintenance

Bundle Daily review of line

necessity & prompt removal of unnecessary Maximal barrier

precautions

Chlorhexidine skin antisepsis

Optimal catheter site selection

removal of unnecessary lines

Dedicated lumen for TPN Accessing the lumen

aseptically Checking entry site for

inflammation with every dressing change

http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Pages/gsk.aspx

Updated HICPAC Categorization Scheme for Recommendations

What Does the ‘Bundle’ Evidence Tell Us?

CDC Guidelines for Insertion Site Preparation

Sterile technique; cap, mask, gown, gloves, and a large sterile drape (IA)

Recommend 2% Chlorhexidine be the cleanser of choice if available (IA)

Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29]Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

What are Maximal Barrier Precautions?

• For Provider:

– Hands hygiene

– Non-sterile cap and mask

• All hair should be under cap

• Mask should cover nose and mouth tightly

– Sterile gown and gloves

• For the Patient

– Cover patient’s head and body with a large sterile drape

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Chlorhexidine vs Povidone Iodine for Catheter Site Care

Ann Intern Med 2002:136:792-801

2011 Recommendations: Site Location

• Avoid using the femoral vein for central venous access in adult patients (1A)

• Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement (1B)

• Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis (1A)

Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

2011: Additional Placement Guidelines

• Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. (IB)

• Use a CVC with the minimum number of ports or lumens essential for the management of the patient (IB)

• Promptly remove any intravascular catheter that is no longer essential. (IA)

• Use a sutureless securement device to reduce the risk of infection for intravascular catheters. (II)

Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

CDC Recommendation for Catheter Replacement

• When adherence to aseptic technique cannot be ensured replace the catheter as soon as possible, i.e, within 48 hours. (IB)

• Do not routinely replace CVCs, PICCs, hemodialysis catheters or pulmonary artery catheters to prevent cathetercatheters, or pulmonary artery catheters to prevent catheter-related infections. (IB)

• Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. (IB)

• Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. (IB)

• Routine culture of the tip is not recommended.• .CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29]

Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

Dressing Care

• Use a transparent or gauze dressing to cover site (IA)• Change transparent dressing and perform site care with a CHG

based antiseptic every 7 days (IB) or more frequent if the dressing is soiled, loose, or damp; (IB)

• Change gauze dressings every 2 days or more frequent if the dressing is loose, soiled or damp (II)

• Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not despite EBP (1B)

• No recommendation is made for other types of chlorhexidinedressings.

SHEA and IDSA, Infection Control and Hospital Epidemiology Oct 2008Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29]Salgado CD, et al. Infect Control and Hosp Epidemi, 2007;28:684-688Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

Care After Insertion

• Scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices.(IA)

• 3 sec, 10 sec & 15 sec scrub showed no difference in reducing bacterial load (Simmons S, et al. Crit Care Nurs Q, 2011;34:31-35)

• When needleless system used, consider a split septum valve versus a mechanical valve.(II)

• Replace administration sets not used for blood, blood products or lipids at intervals not longer than 96 hours (IA)

• Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours of initiating the infusion. (IB)

• Change the needleless components at least as frequently as the administration set. (II)

• Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI (II )

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Additional Strategies Used When Basic Care Has Not Achieve Zero

CHG Baths (II)

CHG Dressings (IB)

Antimicrobial impregnated CVC (IA)Antimicrobial impregnated CVC (IA)

Antimicrobial locks (II)

Appropriate nursing staff levels in ICUs. (1B)

Coffin SE, et al. Infection Control & Hosp Epid, 2008;29(1):S31-S40Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

CHG Bathing Reduces CLA-BSI’s (II)

• 52 week, 2 arm, cross-over design clinical trial• 22 bed MICU with 11 beds in 2 geographically

separate areas• 836 MICU patients

1st 28 k 1 h it l d i t b th– 1st 28 weeks: 1 hospital randomize to bathe with (Sage 2%) CHG cloths & the other unit bathe with soap & water

– 2 week wash out period– 2nd 24 weeks: methods were crossed over

• Measured: Primary outcomes: incidence of CA-BSI’s & clinical sepsis. Secondary: other infections

Bleasdale SC. et al. Arch Internal Med, 2007;167(19):2073-2079

CHG Bathing Reduces CLA-BSI’s (II)

Results: CHG arm were

significantly less likely to acquire a CA-BSI 4.1

10 4 i f ti

Bleasdale SC. et al. Arch Internal Med, 2007;167(19):2073-2079

vs. 10.4 infections per 1000 patient days

Benefit against primary CA-BSI’s by CHG cleansing after 5 days in MICU

No difference in clinical sepsis or other infections

CHG Bathing: Pre & Post Intervention

Dixon, et al. Am J Infect Control 2010;38:817-21

Corcoran et al APIC 6/2009

Additional Strategies Used When Basic Care Has Not Achieve Zero

CHG Baths (II)

CHG Dressings (B-I)

Antimicrobial impregnated CVC (A-I)Antimicrobial impregnated CVC (A I)

Antimicrobial locks (II)

Appropriate nursing staff levels in ICUs. (1B)

Coffin SE, et al. Infection Control & Hosp Epid, 2008;29(1):S31-S40Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

CHG-Impregnated Sponges for Prevention of CLA-BSI (IB)

Methodology:• Multi-center, randomized controlled trial • 7 ICUs participated• Included all patients who required arterial or central p q

venous catheter for 48 hours or longer• Use of CHG dsg vs standard dsg• Already using maximal barrier precautions, try and use

subclavian site for central line, use alcohol/povidone-iodine prep solution (not CHG)

• Looked at 3 day vs. seven day dressing change (but changed when dsg was loose, soiled or damp in all groups)

Timsit JF, et al. JAMA 2009;301:1231-1241

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CHG-Impregnated Sponges for Prevention of CLABSI (IB)

• 1636 patients (3778 catheters, 28,931 catheter days)• Median duration of catheter insertions 6 days (4-10)• Use of CHG dressing decreased the CLA-BSI rate from:

1 3 per 1000 catheter days to 0 4 per 1000 catheter days

Results:

– 1.3 per 1000 catheter days to 0.4 per 1000 catheter days

• Use of CHG dressing not associated with greater resistance of bacteria in skin samples at removal

• 8 episodes of contact dermatitis with patch ( 817 pts)• No difference in site colonization between dressing

changes at 3 days or 7 days

Timsit JF, et al. JAMA 2009;301:1231-1241

Prevented 1 Major CLA-BSI per 117 Catheters

2011: Antimicrobial CVC

CDC Recommendations:• Use a chlorhexidine/silver sulfadiazine or

minocycline/rifampin -impregnated CVC in patients whose catheter is expected to remain in p pplace >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. (IA)

CDC. Prevention of Catheter Infection: MMWR 2002;51Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov

01-CHSS Blue Plus-Antimicrobial Impregnated

02-Silver Impregnated-Antimicrobial Impregnated

03-Minocycline-Rifampin-Antibiotic

04-Miconazole & Rifampicin -AntibioticAl CVCs appear to be effective in reducing CLARifampicin Antibiotic

05-Benzalkonium Chloride Impregnated-Antimicrobial Impregnated

06-CHSS-Antimicrobial coated

Hockenhull JC, et al. Crit Care Med, 2009;3792): 702-712Matheos T, et al. Infect Control Hosp Epidemiol 2010;31:295-297

Al-CVCs appear to be effective in reducing CLA-BSI’s when compared to standard CVCs. It is important to establish whether this effect remains in settings where infection prevention bundles of care staff wishes routine practice

Emerging Issues: Needleless IV Access Equipment

Q-Syte

Clearlink

InVision-Plus NeutralSafesite

• Split system value designs are preferred over positive pressure mechanical valves because they

i t d ith l CLA BSI t

Clave

Posiflow

Interlink

CLC 2000

Smartsite

Ultrasite MaxPlus

SmartSite PlusPASVare associated with lower CLA-BSI rates.

• In 2008 FDA required 9 companies to conduct post market surveillance of positive displacement needless connectors

Rupp ME, et al. Clin Infect Dis. 2007;44(11):1408-1414FDA Medical Device Alert 2008

Berenholtz et al, 2004; Tsuchida et al, 2007

Interventions To Ensure Patient Receive Evidence

• Education…to all caregivers…it works*

• Ask Daily if line is needed

• Checklist, nurse

Empower nurses• Empower nurses

• Products/Processes that make it easy for the frontline caregiver to provide the care

• Measurement/Feedback**

• Simulation training of residents reduced CRBSI’s.***

* Parra AP, etal. Infect Control Hosp Epidemiol 2010;31(9):964-967**Westwall S. Nursing in Critical Care, 2008;13(4):203-207*** Barsuk JH, et al. Arch Intern Med, 2009;169:1420-1423

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• 103 ICU’s in state of Michigan reported data

• Examine 375,757 catheter days

• Implementation of the BSI Bundle/checklist

• Results

Intervention to Decrease CLA-BSIStatewide Collaborative-Keystone ICU

– Median rate of CLA-BSI per 1000 catheter days went 2.7 to 0 at 3 months ((p<0.002)

– Mean rate of CLA-BSI’s per 1000 catheter days went 7.7 to 1.4 at 18 month follow up (p<0.002)

– in mortality when compared to other mid-west states

Pronovost P et al, N Engl J Med;2006;355:2725-2732Pronovost P et al. BMJ, 2010;340:309Liptiz-Snyderman A, et al. BMJ, 2011;342:219

36 Months Post Initial Implementation: 90 of original 103 ICU’s evaluatedResults: Mean rate 1.1 per 1000 catheter days/ Median: Zero 2009: mean .88 per 1000 catheter days (personal communication)

On the CUSP: Stop BSIA National Initiative

• AHRQ government funded 3 year initiative

• HRET and American Hospital Association

• John Hopkins Quality & Safety Research Group

• MHA’s Keystone Center for Patient Safety & Quality

• Goals:– Eliminate CLA-BSI: <1/1000 catheter days, median 0

– Improve safety culture by 50%

– Learn from 1 defect a month

• Build an infrastructure for future efforts

• Baseline and monthly CLA-BSI rate, hospital survey on patient safety & monthly survey on teamwork barriers

http://www.onthecuspstophai.org/

Stop CLA-BSI: Progress Report

• Progress Report– 45 state hospital associations recruited 700 hospital & 1100

hospital teams in 2009

– 14 additional states and the District of Columbia joined in 20100 0

– Eight states, including Puerto Rico began in 2011

– 1.8 infections per 1000 days to 1.17 infections per 1000 days central line use (RR. 35%) in 22 states (350 hospitals)

– < 20% of US hospitals are participating

– CDC reported 58% drop in CLA-BSI between 2001 in 2008

• 6,000 lives saved

• 1.8 billion cost avoidance http://www.onthecuspstophai.org/http:/blogs.wsj/health/2011/04/05/progress-on-reducing-bloodstream-infections/

Canada’s Outcome

• The overall national mean for the Central Line-associated BSI rate per 1000 CLI days was reduced from a baseline of 5 to

t i d t f 0 3 t 0 8 i Ph Ia sustained rate of 0.3 to 0.8 in Phase I.

• Of the teams reporting data, 75% reached the national goal of <1.9 CLA-BSI per 1000 CLI days

http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Pages/default.aspx

CA-UTI’s: Reducing Load

• Use of catheter increases risk• Daily risk of acquisition of UTI: 3% to 7% • Second common HAI & 80% attributable to indwelling

catheterization• CAUTI: associated with morbidity, mortality (2.3%), hospital cos

($589 00) & LOS($589.00) & LOS• 15%-25% of hospital patients may have a urinary catheter during

admission• Highest use; Trauma ICU units, Lowest use; Med-Surg• Pooled mean CAUTI rates 3.1 -7.5 infections per 1000 catheter

days (Burn ICU highest, Med-Surg ICU’s lowest)• Add 1 day LOS per patient

Joanna Briggs Institute EBR: 2007Saint S., et al. Infect Dis Clinics North Amer 2003; 17:411-432.Weinstein JW, et al. Infect control Hosp Epidemiol, 1999; 20:543-548Lo E, et al. Infect Contr & Hosp Epidemiol, 2008;29:S41-S50Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI’s. 2009

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CA-UTI Bundle “Bladder Bundle”

• CA-UTI Bundle ( “Bladder Bundle”)– Avoid unnecessary urinary catheters– Insert urinary catheters using aseptic

t h itechnique– Maintain urinary catheters based on

recommended guidelines.– Review urinary catheter necessity daily and

remove promptly

http://www.bestcare.org.za/docs/Prevent%20Catheter%20CA-UTI.pdf

Core Recommendations

• Insert catheters only for appropriate indications (1B)• Leave catheters in only as long as needed (1B)

• Ensure that only properly trained persons insert and maintain catheters (1B)maintain catheters (1B)

• Insert catheters using aseptic technique in sterile equipment ( acute care settings) (1C)

• Maintain a close drainage system (1B)• Secure the system (1B)• Maintain unobstructed urine flow (1B)• Key the collecting bag below the level of the bladder at all

times (1B)

Core Recommendations

• Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing) is appropriate. (IB)

• Further research is needed on the use of antisepticFurther research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue)

• If the CAUTI rate is not decreasing with a comprehensive strategy, consider using antimicrobal/antiseptic impregnated catheters. (IB)

• Practice hand hygiene in standard precautions according to CDC & HICPAC guidelines

Expert Opinion

Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI’s. Draft June 2009

14

16

18

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ce

Da

ys

Impact of UTI with Basin Bathing

UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY05

0

2

4

6

8

10

12

QTR 1FY05

QTR 2FY05

QTR 3FY05

QTR 4FY05

QTR 1FY06

QTR 2FY06

QTR 3FY06

Ra

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0 D

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50th percentile

McGuckin M, Torress-Cook A, et al APWCA Annual Meeting, Philadelphia, April 2007

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

Unit Census: 14

Phases Product Cost/ No. of UTI

Median4

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

Chen Yin-Yin,Chou Yi-Chang,Chou Pesus.. Infect Control Hosp Epidemiol 2005;26:281-287

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

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89% Reduction

Reducing UTI’s Through Basinless Bathing

CA-UTI 7.5 per 1000 catheter days to 4.42 per 1000 catheter days, then to .46 per 1000 catheter days

Stone S, et al. 37th Annual APIC Educational Conference July 11-15, 2010

Simple Cost Effective Strategies to Reduce HAI’s

Implementation:• Utilize daily 2%

CHG cloths for cleansing at night in any patient with a central

Corcoran F. Presented at APIC 2009

with a central line or foleycatheter

• Focused on areas most prone to bacterial colonization from the neck down

Was moved from the ICU to house-wide post initial project with similar results in Med-Surg

Reducing Use…Does it Reduce CA-UTI’s

• Pre and post intervention study• Unit clinicians developed indications for continue use of catheter

(evidence-based)• 6 month intervention period evaluated appropriateness of catheter

daily337 ti t /1432 th t i ti d l t d• 337 patients/1432 catheterization days were evaluated– Duration of use significantly reduced (236.6 d/mo vs. 311.7

d/mo)– CA-UTI’s went from 4.7 per 1000 days to zero for the

intervention period– 11% inappropriate days

Elpern EH, et al. Am J of Crit Care, 2009;18(6):535-541

Cost-Benefit Ratio

CA-UTI vs. IAD & Pressure Ulcer

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Bugs Be Gone!!!!

How to Get Started

Four E’s• Engage: help staff understand the preventable harm

– Share stories about patients affected

– Estimate number of patients harmed

– Develop a business case

• Educate: ensure staff and senior leaders understand what they need yto do to prevent injury and improve teamwork and communication– Conference calls, webcasts, meetings

• Execute: how given the resources and culture they would ensure that all patients received the evidence– Share with working, what’s not

– Coaching calls

• Evaluate: project leader monitors that teens are using standardized definitions, report their data and make it transparent at the unit level

Goeschel CA, et al. Nursing in Critical Care, 2011;16:35-42

The things included in the measurement b l t th thi itt dbecomes relevant, the things omitted are

out of sight out of mindPeter F. Drucker

In God We Trust!

Potential Barriers

• Perception of lack of time or the importance

• Lack of evidence based education…just do it!!!!

• Absence of a define protocol/procedure

• Staff turnover/Replacement staff• Staff turnover/Replacement staff

• Inaccessibility of needed supplies

• No real clinical lead on the unit

• Lack of feedback on progress

• Lack of accountability/responsibility

O’keefe-McCarthy S, et al. Worldviews on Evidence Based Nursing, 2008:193-204Abott CA, et al. Worldviews on Evidence Based Nursing:2008:193-204

Interventions To Ensure Patients Receive Evidence

• Evidence based education

• Recognition of value and reinforcement

• Products/Processes that make it easy for the frontline caregiver to provide the care (make it part of the bundle)

• Bathing kits

• Placement on the med record

• Automated charting with flag reminders

• Frequent rounding/reinforcement of standard

• Multidisciplinary rounds/Checklists

Westwall S. Nursing in Critical Care, 2008;13(4):203-207Abbott CA, et al. Worldviews on Evidence Based Practice, 2006:139-152Fuchs MA, et al. J Nurs Care Qual, 2011;26:101-109

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Interventions To Ensure Patients Receive Evidence

• Setting targets/Celebrating successes

• Placement of new practice/education in orientation

• Attractive signs to outline protocol in the patient rooms near the products

• Compliance program with feedback to all caregivers

• Outcome measurement/Feedback*

• Include RN’s in Morbidity & Mortality peer review for VAP increased compliance/accountability & VAP rates

Westwall S. Nursing in Critical Care, 2008;13(4):203-207Abbott CA, et al. Worldviews on Evidence Based Practice, 2006:139-152Fuchs MA, et al. J Nurs Care Qual, 2011;26:101-109Nolan SC, et al. JONA, 2010:40(9):374-383

What Can You Do?

• Identify the challenges in your work environment• Work with your colleagues to identify solutions (don’t wait

for others to do it; if they were going to do it, it would already be done!)

• Look for tools to help youLook for tools to help you• Find evidence such as best practice guidelines to support

your plan and make your arguments more compelling• Approach her supervisor or the chief nursing officer of

your facility for support• Consult/network with experts in the field• Think globally why acting locally• Share your results so that best practices don’t just occur

in isolated pockets

CREATE A SAFE PATIENT ENVIRONMENT

Everyday hospitalcare activities increase the patients risk of INJURY & BACTERIALINJURY & BACTERIAL INVASION ……

Help reduce that risk by changing the routine ways you provide care & replace it with the evidence

Be Courageous

We all are responsible for the safety of our patients……Own the Issues

•“If not this, then what??”•“If not now, then when?”•“If not me, then who??”