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2012 Middle TN APIC Chapter

Evidence-Based Strategies to Tackle the Three Most Common Sources of HAIs: Contaminated Hands, Environmental

Surfaces, and Skin

Cindy Winfrey, MSN, RN, CICSenior Medical Science Liaison

PDI Healthcare


Financial Disclosures

PDI Healthcare-Employee


Objectives• Discuss the impact of contaminated environmental surfaces,

hands (of both patients and healthcare providers), and skin in the transmission of Healthcare Associated Infection

• Review the current research gaps for pediatric Infection Prevention literature

• Discuss strategies to meet and exceed Joint Commission NPSG 7

• Discuss patient and family involvement and empowerment strategies to reduce the incidence of HAIs


Could this be You?


What do these have in common?

http://www.tsa.gov/index.shtm

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The Importance of a Checklist


WHO Checklist for Safer Surgical Care


Transmission of Infection


How Does Transmission Occur?

Patient

Healthcare WorkerEnvironmental

SurfacesPatient Care Equipment


Pathogens of Significance

Pathogens of

Concern

Yeasts

ESBL

Klebsiella

MRSA

E. Coli

RSV


Examples of multidrug resistance inHAI pathogens

Acinetobacter baumannii About 75% are multidrug resistant*

10% increase from 2000 Pseudomonas aeruginosa

About 17% are multidrug resistant* Staphylococcus aureus

MRSA causes about 55% of HAIs (Antimicrobial-Resistant Pathogens Associated with Healthcare Associated Infections, Annual Summary of Data Reported to the NHSN at CDC, 2006-2007)

* Percent Acinetobacter baumannii and P. aeruginosa in ICUs that are multidrug-resistant, NNIS and NHSN, 2000-2008. Includes ICUs only (MICU, SICU, MSICU) and device-related infections only (CLABSI, CAUTI, VAP).


How do you view mortality?


Healthcare-Associated Infections (HAIs) 1 out of 20 hospitalized patients

affected Associated with increased mortality Attributed costs: $26-33 billion

annually HAIs occur in all types of facilities,

including: Long-term care facilities Dialysis facilities Ambulatory surgical centers Hospitals


Outbreaks vs. Endemic Problems Endemic problems represent the majority of HAIs Device-associated infections

Catheter-associated urinary tract infections (CAUTI) Central line-associated Blood stream infections (CLABSI) Ventilator-associated Pneumonia (VAP)

Procedure-associated infections Surgical site infections (SSI)

Adherence problems Antimicrobial stewardship Hand hygiene Isolation precautions


Changing Landscape of Healthcare Growing populations at risk

Immunocompromised individuals Low birthweight, premature neonates Transplant recipients on immunosuppressive therapy

Special environments Intensive care and burn units Infusion services


HHS Action Plan 5-year GoalsMetric National 5-year

Prevention Target Source

Central line-associated bloodstream infections 50% reduction NHSN

Adherence to central-line insertion practices 100% adherence NHSN

Clostridium difficile infections and hospitalizations 30% reduction NHSN, NHDS, HCUP

Catheter-associated urinary tract infections

25% reduction NHSN

MRSA invasive infections (population) 50% reduction EIP

Surgical site infections 25% reduction NHSN

Surgical Care Improvement Project measures 95% adherence SCIP

NHSN – CDC’s National Healthcare Safety Network EIP – CDC’s Emerging Infections ProgramNHDS – CDC’s National Hospital Discharge Survey SCIP – CMS’s Surgical Care Improvement ProjectHCUP – AHRQ’s Healthcare Cost and Utilization Project


Sources of Evidence


Holistic Bundled Approach


Impact of Neonatal CLABSI

• Inherent risk with CVCs • Difficult to identify and treat • Prolonged & often frequent exposure to

antibiotics • Major contributor of morbidity and mortality • Increased length of stay and hospital costs • Infants are especially vulnerable


Challenges to Skin Antisepsis:Evidence-Based Approaches

Prepping the skin – Chlorhexidine (CHG) vs Alcohol vs Povidone-Iodine – CHG shown to be more effective due to residual effect.– CHG/alcohol solutions: 0.5% to 3.15% CHG– CHG/aqueous solutions: 0.5% to 4%– CHG recommended by the CDC Guideline for all but < 2 months

• But, in <1000 gms, CHG associated with skin irritation– Andersen J Hosp Infect 2005 (2% CHG/aqueous) – Garland Pediatr Infect Dis J 1996 (2% CHG/alcohol)

• CHG studies currently being conducted for safety in neonates • 61% of US NICU Medical Fellowship Directors reported using CHG

– Tamma ICHE, 2010 NICU compromise


The Debate of CHG in Neonates


Skin Antiseptic Agents• Choice varies with age

– Population based complications – < 2 months

• EGA • Post natal age

• Agents – 2 to 3.15% CHG - alcoholic formulation – CHG - aqueous formulation – Povidone iodine

• Removal considerations – Normal Saline– Sterile Water


Survey of Neonatal CHG Use

• Survey of Neonatology Fellowship Directors in the United States

• 61% reported use of CHG for skin antisepsis for neonates – 51% limited use on basis of birth weight, gestational age or

chronological age. – Skin reactions (erythema, erosions, burns) occurring

primarily in those weighing <1500 grams were reported by 51%.

– No difference in adverse events between the alcoholic or aqueous CHG preparations

Tamma, Aucott, & Milstone, 2010


Primary Skin Disinfectant Used for Most PICC Insertions Insertions

Respondents - 194 N %Alcohol only 0 0Povidone iodine only 56 28.8Povidone iodine/alcohol 23 11.8Alcohol then povidone iodine 9 4.6PI total 88 45.22% Chlorhexidine/alcohol 70 35.93.15% Chlorhexidine/alcohol 3 1.52% Chlorhexidine/aqueous 4 2.1CHG total 77 39.5Combination PI/CHG 28 14.3Total CHG 53.8

Sharpe & Pettit 2009


FDA Releases New Labeling


Do You Have These?

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Best Practices for Disinfection of Non-Critical Items

Examples include surfaces in the environment

and medical equipment used in patient care


Hand Hygiene Technique


EVIDENCE-BASED PRACTICE


Where do you even begin?

http://www.jointcommission.org/

http://www.ins1.org/


State of prevention knowledge and science Guidelines developed for each type of infection and

based on systematic reviews of medical literature Prevention of central line-associated blood stream infections Prevention of catheter-associated urinary tract infections Prevention of surgical site infections Prevention of healthcare-associated pneumonia Management of multidrug-resistant organisms

Recommendations graded according to evidence Guidelines contain many recommendations Current efforts to help prioritize interventions that are

most effective


Adherence to infection control guidelines is incomplete Many HAIs are preventable with current

recommendations Failure to use proven interventions is unacceptable Only 30%-38% of U.S. hospitals are in full

compliance Just 40% of healthcare personnel adhere to hand

hygiene Insufficient infection control infrastructure in non-

acute care settings has allowed major lapses in safe care


Local success fuels national prevention

Unit FacilityRegional

National


CDC knowledge and data fuels local to national CLABSI prevention

UnitFacilityPittsburgh Regional

Healthcare Initiative

First successful, large-scale

CLABSI prevention

demonstration project

Regional

Subsequent projects

based upon CDC

prevention:• Michigan

Keystone• Institute for

Healthcare Improvement

• Others

NationalNational

expansion of CLABSI

prevention 60% Reduction in CLABSI between

1999-2009 • State-based

public reporting using NHSN

• State/regional prevention collaboratives (CUSP, Recovery Act projects)

• CMS/IPPS – hospitals report CLABSIs for full Medicare payment

Inputs

Outputs

Outbreak Investigations

Prevention Research

(e.g. chlorhexidin

e bathing)

NHSN Data

CDC Guidelines


The need for HAI prevention researchHe

alth

care

-ass

ocia

ted

Infe

ction

Preventable

Prevention Approach Unknown

Prevented

Need for complete implementation of practices known to prevent HAIs

Need for ongoing research to identify new strategies to prevent the remaining HAIs


Prevention

Hand hygiene

Skin antisepsis

Dressing

Injection cap/needleless connector

No touch technique


Payors

MedicalProfessionals

ConsumersPublic Health

Patients

GovernmentHealthcareFacilities

Safe Healthcare is Everyone’s Responsibility


Hypothetical ? • If you knew……………………….

• That you could do something simple, easy, cost effective, and that was

• Evidence-Based, but took a little extra time…..

• Would you do it?????


Questions

• Whose Infection will you prevent when you return to your institution?

• Contact Information:– Email: [email protected]– Phone: 719-306-2616

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