Infection Prevention in Primary Care

Objectives

• By the end of this presentation, you should be able to:- Verbalize the basic concepts of hand hygiene, standard precautions and

transmission-based precautions- Verbalize appropriate equipment cleaning techniques as related to

physician practice- Explain measures for preventing transmission of multi-drug resistant

organisms within the healthcare setting- Explain the fundamentals of antibiotic stewardship- Explain measures for preventing specific device associated infections,

including CAUTI, CLABSI, and VAP- Explain measures for preventing surgical site infections

Note: Sample Footnote

Healthcare-Associated Infections (HAI)• “A localized or systemic condition resulting from an

adverse reaction to the presence of an infectious agent or its toxin. There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting, unless a change in pathogen or symptoms strongly suggests the acquisition of a new infection.”*

*CDC, NHSN Patient Safety Component Key Terms, January 2012

Cost of HAI’s

Estimated Number of HAI’s per Year in U.S. Hospitals

Cost of HAI’s

• Overall direct annual cost of HAI to U.S. hospitals is $28 - $45 billion*

• Up to 70% of these are preventable*

*CDC, The Direct Medical Costs of Healthcare Associated Infections in US Hospitals and the Benefits of Prevention, 2009

Hospital Associated Infections - Regulatory

• (CMS), as a result of the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005, has defined many HAI’s as “never events”- Effective October 1, 2008, changes in the CMS impatient prospective payment

resulted in non-reimbursement for specific infections not present on admission in inpatients who were later discharged from acute care hospitals.

- Compliance with SCIP measures and specified hospital-acquired infection rates will affect credentialing and the individual facility’s reimbursement rate scale

- Beginning in 2013, payment determination will be based in part on hospital-acquired infections reported during CY 2011. The list of reportable hospital-acquired infections will continue to increase until 2015.

• Accreditation Organizations• State Health Departments

Standard Precautions

The first step in preventing infection• Hand Hygiene• PPE• Safe injection practices• Safe handling of potentially contaminated

equipment/ surfaces in the patient care area• Respiratory hygiene/cough etiquette

Infection Prevention 101• 1846 – Ignaz Semmelweis noted higher

puerperal fever rates in women whose babies were delivered by physicians compared with those delivered by midwives. He linked this increase to the practice of physicians moving directly from the autopsy suite to the obstetric ward. The rate was significantly reduced by implementing use of a chlorine antiseptic solution between suites

1881 – President Garfield died from an infection 3 months after he was shot by an assassin. The likely culprit was manure-stained hands of the President’s medical team, as they were also farmers.

Hand Hygiene

• The #1 way to prevent the spread of infection- 2-10 million bacteria between your fingertips and elbow- The number of bacteria on your fingertips doubles after

using the restroom- 80% of infections are transmitted by the human hand

Abbreviated Hand Hygiene Review:• Soap and water for 15-20 seconds required:

• When hands are visibly soiled• When leaving a C. difficile room/area• Before eating/ after using the restroom

• Hand sanitizing gel or soap and water required when:• Before and after having direct contact with the patient or their environment (monitored

as before entering or upon leaving the patient’s room)• Before donning gloves for a sterile procedure and after removing gloves• When moving from a dirty body site to a clean site

Hand Hygiene

• Before touching a patient, even if gloves will be worn • Before exiting the patient’s care area after touching

the patient or the patient’s immediate environment• After contact with blood, body fluids or excretions, or

wound dressings• Prior to performing an aseptic task (e.g., placing an IV,

preparing an injection)• If hands will be moving from a contaminated-body

site to a clean-body site during patient care• After glove removal

Hand Hygiene

• 15 seconds is longer than it seems…

• Start Washing!!

Personal Protective Equipment (PPE)• Facilities should assure that sufficient and appropriate PPE is available and readily

accessible to HCP- Educate all HCP on proper selection and use of PPE

• Remove and discard PPE before leaving the patient’s room or area• Wear gloves for potential contact with blood, body fluids, mucous membranes, non-

intact skin or contaminated equipment- Do not wear the same pair of gloves for the care of more than one patient - Do not wash gloves for the purpose of reuse- Perform hand hygiene immediately after removing gloves

• Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated- Do not wear the same gown for the care of more than one patient

• Wear mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids

• Wear a surgical mask when placing a catheter or injecting material into epidural or subdural space

Safe Injection Practices• Use aseptic technique when preparing and administering medications

• Cleanse the access diaphragms of medication vials with 70% alcohol before inserting a device into the vial

• Never administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is administered through an intervening length of intravenous tubing

• Do not reuse a syringe to enter a medication vial or solution

• Do not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more than one patient

Safe Injection Practices• Do not use fluid infusion or administration sets (e.g., intravenous tubing) for

more than one patient

• Dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle)

• Dispose of used syringes and needles at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof.

• Adhere to federal and state requirements for protection of HCP from exposure to bloodborne pathogens.

Environmental Cleaning• Establish policies and procedures for routine cleaning and disinfection of

environmental surfaces in ambulatory care settings

• Focus on those surfaces in proximity to the patient and those that are frequently touched

• Select EPA-registered disinfectants or detergents/disinfectants with label claims for use in healthcare

• Follow manufacturer’s recommendations for use of cleaners and EPA-registered disinfectants (e.g., amount, dilution, contact time, safe use, and disposal)

Equipment Cleaning• All reusable medical equipment should be cleaned and reprocessed

appropriately (according to the manufacturer’s recommendations) between patients, including:- Reusable blood pressure cuffs- Blood glucose meters- Surgical Instruments- Stethoscopes

• Observe procedures to document competencies of HCP responsible for equipment reprocessing upon assignment of those duties, whenever new equipment is introduced, and on an ongoing periodic basis (e.g., quarterly)

• Assure HCP have access to and wear appropriate PPE when handling and reprocessing contaminated patient equipment

Other Vehicles • High risk vehicles for transmission:

- Neckties:• Bacterial counts from hospital doctors’ ties are higher than those from shirts. American Journal of Infection

Control 2009; 37: 79-80

- Mean geometric bacterial count of 95 CFU - Staphylococcus aureus isolated on 64% of ties

- Lab coats, shirt sleeves: • Nursing and Physician Attire as Possible Sources for Nosocomial Infections. American Journal of Infection Control

2011; 39:555-9

- Up to 60% contaminated with pathogenic bacteria, including MDRO’s- Stethoscopes

• The stethoscope. A potential source of nosocomial infection? Archives of Internal Medicine 2007 Apr 14;157(7):786-90

- 38% of stethoscopes contaminated with Staphylococcus aureus, the majority contaminated with some pathogenic bacteria

- Charts• Periodic luminometer testing continues to show high levels of microbial contamination

- Portable electronic devices (IPADs, laptops)

Respiratory Hygiene/ Cough Etiquette

• Implement measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing throughout the duration of the visit.- Post signs reminding of good hygiene practices (i.e., cover

your cough)- Provide/offer masks, tissues, waste receptacle, and hand

hygiene station- Provide a separate waiting area for respiratory patients

High-Risk Healthcare-acquired Infections

Healthcare-Associated Infections• MDRO Infection:

- Any infection caused by a multi-drug resistant organism, including:

- Methicillin-resistant Staphylococcus aureus (MRSA)- Vancomycin-resistant Staphylococcus aureus (VRSA)- Vancomycin-resistant Enterococcus (VRE)- Carbapenemase-resistant Enterococcus (CRE)- Other resistant gram negative bacteria

• Clostridium difficile Infection (CDI):- A gastrointestinal infection caused by the organism

Clostridium difficile, generally occurs after antibiotic exposure

Multi-drug Resistant Organisms

• Clinical importance:- Result in increased length of stay, cost, morbidity, and

mortality- Significantly reduce treatment options- Prevalence steadily increasing

• Contributing factors:- Selective pressure from exposure to antimicrobial agents,

particularly fluoroquinolones- Increased rates of community-associated transmission and

infections- Inadequate adherence to infection control practices

Clostridium difficile Infection

• Recently became the most prevalent hospital-acquired infection

• Causes 20-30% of cases of antibiotic-associated diarrhea

• Epidemiology recently changed dramatically with emergence of new, more virulent strain

• Can result in- Diarrhea- Pseudomembranous colitis- Toxic megacolon- Death

Preventing MDRO’s and C. difficile

• Antibiotic Stewardship- Eliminate unnecessary antimicrobial exposure

• Discontinue unnecessary antibiotics• De-escalate empirical therapy on the basis of culture results• Eliminate redundant therapy

- Appropriate antibiotic selection• Limit use of fluoroquinolones and clindamycin• Use of antimicrobial with the most narrow spectrum possible• Use facility antibiogram to guide choices

- Limit TPN use

Preventing MDRO’s and C. difficile

• Antibiotic Stewardship- Optimize dosing based on

• individual patient characteristics• causative organism (avoid drug-bug mismatch)• site of infection• characteristics of the drug

- Use of guidelines and clinical pathways• Johns Hopkins Antibiotic Guide• Prebuilt order sets that utilize best practice guidelines

Preventing MDRO’s and C. difficile

• Early detection/testing- Documentation is critical

• Standard precautions- Alcohol gel use should be replaced with hand washing

with soap and water when caring for a patient with C. difficile

• Enhanced precautions (isolation)• Enhanced environmental cleaning

- Bleach should be used for environmental cleaning when caring for a patient with C. difficile

Device-Associated Infections• Catheter Associated Urinary Tract Infection (CAUTI):

- An HAI that occurs in a patient who had an indwelling urinary catheter in place within the 48 hour period before the onset of the UTI

- Most frequent DAI, 30-40%- Result in:

• Increased LOS• Increased cost (Average $15,000 per incidence)• Increased morbidity/mortality

Catheter Associated Urinary Tract Infection (CAUTI)

• Methods for Preventing CAUTI:- Use indwelling catheters only when medically necessary.- Consider alternatives to indwelling urethral catheters.

• Female urinals• External catheters if appropriate in men.

- Properly secure catheters after insertion to prevent movement and urethral traction.- Maintain a sterile closed drainage system, good hygiene at the catheter-urethral interface, and

unobstructed urine flow.

• Acceptable indications for urinary catheter use:- Urine output in the critically ill.- Management of urinary retention and/or obstruction.- Urinary incontinence posing a risk to the patient, such as major skin breakdown or protection of

nearby operative site.- Neurogenic bladder- Comfort care in the terminally ill.- Intractable pain.- Benign prostatic hypertrophy.

• *Perioperative: Surgical patients (18 and older) with a urinary catheter should have the catheter removed on Postoperative 1 or 2 (some exclusions apply)

CAUTI

• Inappropriate uses of a foley catheter:- As a substitute for nursing care of the incontinent patient.- As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void.- For prolonged postoperative duration without appropriate indications

• The continued need for an indwelling urinary catheter should be assessed and

documented daily. • Some tips on urine cultures:

- If no clinical symptoms/suspicion of UTI are present, order urinalysis with reflexive culture instead of UA with C&S

- Urinary catheter tips should never be cultured.- Urine cultures must be obtained using appropriate technique, such as clean catch collection or

catheterization.- Urine cultures should not be obtained as a routine on admission.- Urine cultures should not be obtained as a routine when discontinuing urinary catheter- Specimens from indwelling catheters should be aspirated through the disinfected sampling port only.

Device-Associated Infections• Central Line Associated Bloodstream Infection (CLABSI):

- A primary bloodstream infection in a patient that had a central line within the 48 hour period before the development of the BSI and that is not related to an infection at another site

- Approximately 11% of all HAI- Result in:

• Increased LOS• Increased cost (Average $22,000 per incidence)• Increased morbidity/mortality

CLABSI Prevention Components• Meticulous Hand Hygiene

- Must be performed prior to insertion of a central line.- Prior to donning gloves to remove dressing.- After removing gloves and prior to donning sterile gloves to apply central line dressing.- Prior to any manipulation or accessing of the central line. Including tubing hubs/ports.

• Maximal barrier Precautions- All central line kits at MSHA are now standardized with maximal patient body barriers.- Patient must have entire body draped with sterile drape when inserting a central line. No exceptions!- Proceduralist inserting the central line and all assistants that are over or near the sterile field must wear

sterile gloves and gowns, mask and hair cover.• Chlorhexidine skin antisepsis

- All MSHA central line insertion kits have chlorhexidine skin antisepsis. - The chlorhexidine is tinted.- Chlorhexidine has a residual effect, meaning that it kills bacteria for an extended period of time after

application .• Optimal site selection

- Preferred site is subclavian for adult patients.- Least preferred site is the femoral for adult patients.- Decision tree available

• Daily review of line necessity- Line necessity is documented on the Adult and Pediatric Catheter Treatment Record by nursing.- Central lines should be inserted only when absolutely needed and removed ASAP.

*The Central Vascular Catheter Insertion Procedure Note must be utilized for all central line/PICC insertions.

Device-Associated Infections• Ventilator Associated Pneumonia (VAP)

- Pneumonia that occurs in a patient who was intubated and ventilated at the time of, or within 48 hours before, the onset of pneumonia

- Result in:• Increased LOS• Increased cost (Average $38,000 per incidence)• Increased morbidity/mortality

VAP Prevention Components• Elevation of the Head of the Bed

- Elevation of the head of the bed is an integral part of the Ventilator Bundle and has been correlated with reduction in the rate of ventilator-associated pneumonia. The recommended elevation is 30-45 degrees for pediatrics and adult patients, and 15-30 degrees for neonates.

• Daily Sedative Interruption and Daily Assessment of Readiness to Extubate- Using daily “sedation vacations” and assessing the patient’s readiness to extubate are an integral part of the Ventilator

Bundle and have been correlated with reduction in the rate of ventilator-associated pneumonia. “Sedation Vacations” are not recommended in pediatrics due to the high risk of unplanned extubation. Include daily assessment of readiness to extubate in care/interdisciplinary rounds.

• Routine Oral Care- Ventilated adult patients require oral care every 2 hrs. Ventilated pediatric and neonate patients require oral care every

2-4 hours. Patients ventilated or not should have oral care with TEETH BRUSHED at least 2 times a day.• Hand hygiene before and after touching the ventilator, the patient or their surrounding.

- Everyone should perform appropriate hand hygiene prior to having contact with a patient of his surroundings, and again prior to manipulating ventilator, vent tubing, suctioning patient and providing oral care.

Healthcare-Associated Infections

• Surgical Site Infection (SSI):- Infection involving the site of a surgical procedure that

occurs within 30-90 days of the procedure, depending on the procedure type

- Result in:• Increased LOS• Increased cost (Average $100,000 per incidence)• Increased morbidity/mortality

SSI• Treat and control all infections prior to surgery; document infection• Educate patients on methods for preventing SSI’s• Preoperative shower or bath with antimicrobial agent (CHG)• Nares screen for Staph aureus and decolonization protocols for elective

procedures• Prepare skin of incision site using an approved agent and method• Follow all hand hygiene requirements:

- Perform surgical scrub for at least 5 minutes before first operation of day.- Between consecutive operations, perform surgical scrub 3 to 5 minutes

using approved disinfectant.

SSI

• Maintain glucose and body temperature within normal limits• Use antibiotic prophylaxis according to evidence based

standards- Appropriate selection- Appropriate timing: CMS guidelines: pre-op antibiotic is

given within 1 hour of surgical incision,2 hours for Vancomycin infusions.

- Appropriate discontinuation: antibiotics should be discontinued within 24 hours for surgical procedures and 48 hours for cardiac surgical procedures.

Objectives- Verbalize the basic concepts of hand hygiene, standard precautions and

transmission-based precautions- Verbalize appropriate equipment cleaning techniques as related to

physician practice- Explain measures for preventing transmission of multi-drug resistant

organisms within the healthcare setting- Explain the fundamentals of antibiotic stewardship- Explain measures for preventing specific device associated infections,

including CAUTI, CLABSI, and VAP- Explain measures for preventing surgical site infections

Note: Sample Footnote

Questions?