Infection Prevention & Control: Patient & Personnel Safety Imperative New House Staff Orientation, 2011

Transcription

1 VISIT IPCS WEB SITE ON INFONET: Details on isolation precautions when to order and for what duration these are needed by infection Infection Prevention & Control: Patient & Personnel Safety Imperative New House Staff Orientation, 2011 Charles P. Craig, MD Medical Director : On behalf of Infection Prevention & Control Welcome! Jan T. Aurand Infection Prevention & Control Specialist (IPCS), SJM-Livingston Rose Berton Admn. Asst., SJMHS Melanie Church IPCS, NICU, SJMH-AA Lynne Grimes IPCS, Ambulatory Care Cheryl Morrin IPCS, SJMH-AA Russ Olmsted Epidemiologist, SJMH-AA Gail Siedlaczek IPCS, SJMH-AA Suzanne Sutton IPCS, SJMH-AA & SJM-Saline

2 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.

3 Hand Hygiene: Not a New Concept but Primary Intervention to Prevent HAIs Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, Maternal Mortality (%) MDs Midwives ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

4 Ability of Hand Hygiene Agents to Reduce Bacteria on Hands % 99.9 Time After Disinfection log minutes 3.0 Bacterial Reduction Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Baseline Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

5 Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub

6 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

7 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 ~ Alcohol-based handrubs reduce time needed for hand hygiene ~ Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;

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9 Findings from HH Observations, Physicians, 2009, SJMH-Ann Arbor After Body Fluid Exposure Risk After Contact with Patient Surroundings After Gloves Removed No Hand Hygiene 11, 22.0% No Hand Hygiene 3, 12.5% No Hand Hygiene 83, 21.3% Hand Hygiene Compliance Outcomes, by Healthcare Role HC Worker = MD/Physician Hand Wash 21, 87.5% No Hand Hygiene 23, 40.4% Hand Wash 13, 22.8% Alcohol Hand Rub 21, 36.8% Hand Wash 33, 66.0% After Patient Contact Before Aseptic Task Before Patient Contact Alcohol Hand Rub 150, 38.5% No Hand Hygiene 7, 6.5% Alcohol Hand Rub 8, 7.5% No Hand Hygiene 134, 34.4% Alcohol Hand Rub 6, 12.0% Alcohol Hand Rub 108, 27.8% Hand Wash 157, 40.3% Opportunity Hand Wash 92, 86.0% Hand Wash 147, 37.8% Panel variable: Opportunity

10 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.

11 Reservoirs of multidrug-resistant organisms (MDROs): Environment The Inanimate Environment Can Facilitate Transmission represents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Duckro AN: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Arch Intern Med Feb 14;165(3):302-7 VRE: Vancomycin resistant enterococci

12 Preventing Device Associated Infections House Officers Are Key Participants: Impact of Implementing Evidence-Based Patient Care Practices aka the Keystone Experience at SJMHS: - See Pronovost P, et al NEJM 2006; 355: & BMJ Feb 4;340:c309.

13 Potential sources of infection for percutaneous intravascular device; Clin Infect Dis 2002;34:

14 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 CL 2. RN assist with CL insertion 3. CL Insertion Checklist 4. Feedback to staff on adherence and outcome data: CLABSI rate See also: Pronovost P., et al NEJM 2006; 355:

15 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: Rate Per 1,000 CL Days K-ICU Cent. Line Assoc BSI Prevent Project Before After All Teach Non Teach <200 B >200 B

16 March 2006 All Units CLABSI rate per 1000 catheter days SJMHS Compared to state of MI and National Healthcare Safety Network Qtr-4 April '04 June '04 CLABSI Best Practices Implemented July August '04 oct'04 Dec '04 Feb ' April '05 June '05 Aug ' Oct '05 Dec '05 Feb ' All Units Keystone MI NHSN 2005 BSI rate is YTD rate is 0.65

17 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

18 Keystone: Ventilator-associated Pneumonia (VAP) Prevention 1, SICU, SJMH-AA Jan-Dec-02 Jan-Dec.-03 Jan-June Total # of VAPs VAP Rate 1. Head of bed elevation, hand hygiene, oral care, suction technique, bed rotation,

19 CAUTI Prevention: Supporting Improvement through Use of Powerchart 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.

20 Prevention of Cathter-Associated UTI (CAUTI): Enter orders for appropriate indication; discontinue ASAP 17% to 69% of CAUTIs may be preventable meaning: 380,000 infections and 9000 deaths related to CAUTI per year could be prevented Maki, Emerg Infect Dis 2001; 7: 1-6

21 Epidemiology of Surgical Site Infection (SSI) Approximately 500,000 SSIs annually 1 Each SSI adds approximately 7-10 postoperative hospital days 1 Mortality is 2-11 times greater with an SSI 1 $11,874 - $34,670: average attributable per patient cost of SSI, adjusted to 2007 dollars 2 1. Anderson DJ et al. nfection Control and Hospital Epidemiology 2008;29;S51- S Scott RD, CDC Report, 2009.

22 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

23 Precautions For Personnel 1) Rational approaches - Leave your SCBA at home 2) Beware of the contaminated case syndrome

24 Use Standard Precautions (SP) For All Patient Care Glove use Mask & eye protection Hand hygiene Routine cleaning/ disinfection Gown use

25 Airborne Precautions Private Room: airborne infection isolation room TB: wear N95 Respirator VZV or measles: only enter room if immune Have patient wear a mask during transport Transmitted by airborne route Examples: Mycobacterium tuberculosis measles varicella zoster virus (VZV) [chickenpox]

26 Private Room Droplet Precautions PPE: wear mask when in pt. room Have patient wear a mask during transport Transmitted by cough or, sneeze Examples: Neisseria meningitidis Influenza Bordetella pertussis SARS-CoV

27 Examples of application at SJMHS: MRSA ICU & uncontained fluid, non-icu VRE all Cx + C. difficle infection Select gram with multidrug resistance

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

29 Sharps Injury Prevention, SJMHS Shielded syringes needleless IV system safety-designed angiocath. safety butterfly safety scalpel Sharps disposal containers 4

30 Warning: Blood or Other Potentially Infectious Materials Present. The biohazard label is placed on sharps containers, bags or storage space containing specimens

31 What Do I Do If I have an Occupational Exposure to Blood or Other Potentially Infectious Material? 1. Contact Employee Health Services ASAP at Follow instructions from EHS personnel Postexp. Prophylaxis more effective if provided as soon as possible after exposure 3. Screening test of patient patient source for HBV, HCV & HIV 4. Postexposure chemoprophylaxis available 24hrs/7days

32 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

33 Get Immunized! 2010/11 Influenza vaccine will be Available this Fall from Employee Health Services

34 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 & control Contact Infection Prevention & Control Services at extension if you have any questions or concerns.