Surveillance of Healthcare Associated Infections (HAI) and Infection Control and Prevention Measures

Maureen Spencer, RN, M.Ed., CIC

Infection Control Manager

New England Baptist Hospital

mpspence@nebh.org

617 754-5332

Centers for Disease Control (CDC) Definitions of HAI

Surgical Site Infection (SSI): superficial, deep, organ/space Catheter Associated Urinary Tract Infection (CAUTI)  Ventilator Associated Pneumonia (VAP) Bacteremia (primary – no identified source) Central Line (CLABSI) Gastrointestinal System Infection

Clostridium difficile Norovirus

Cardiovascular System Infection Pacemaker Local line insertion site infection

Other - infections include skin infection (other than incisional wound infection), lower respiratory tract infection (excluding pneumonia), eye, ear nose, throat, and mouth infection.

NEBH Risk Population: Orthopedics

Total Hip Replacements Total Knee Replacements Total Elbow Replacements Total Ankle Replacement Total Shoulder Replacement Spinal Fusions (Posterior and Anterior) Laminectomies Others (quad repairs, carpal tunnel, hand, foot)also General Surgery and Medical Patients

2010 Risk Analysis

Total Hip Infections Clostridium difficile Physician Hand Hygiene

Risk Factors ASA scores > 3 Obesity Diabetes and high glucose levels (pre-diabetics) Previous surgery Previous infection Immunosuppressive therapy (eg Remicade) Skin and nasal colonization with MRSA Exposure to Extended Care Facilities Elderly population Lengthy surgery

Overall Orthopedic Surgical SiteInfection Rate Reduction

GENERAL SSI FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10(Oct-Apr)

# Infections 6 1 3 4 2 2 1 0# Procedures 1073 920 780 692 567 467 137Infection Rate 0.6 0.1 0.4 0.5 0.3 0.3 0.2 0

ORTHOPEDIC SSI# Infections 63 60 49 46 39 37 28 15# Procedures 8837 9669 9216 8986 9027 8884 8890 5783Overall Infection Rate 0.7 0.6 0.5 0.5 0.4 0.4 0.3 0.26#Hip Infections 14 5 4 7 5 5 10 5 Hip Prosthesis Rate 1.0 0.3 0.2 0.4 0.3 0.3 0.5 0.39 Hip 0 Index 0.0 0.0 0.0 0.4 0.14#Knee Infections 21 14 11 7 7 11 9 4 Knee Prosthesis Rate 1.6 1.0 0.7 0.4 0.3 0.5 0.4 0.27 Knee 0 Index 0.2 0.2 0.4 0.4 0.28#Laminectomy Infec. 6 9 7 7 12 4 0 2 Laminectomy Rate 0.7 0.9 0.6 0.8 1.3 0.5 0.0 0.61#Spinal Fusions Infec. 5 15 12 12 5 5 3 1 Spinal Fusion Rate 0.8 2.0 1.4 1.1 0.4 0.4 0.3 0.2

Chain of Infection

Sources for Infection

Hands # 1 Contaminated Equipment Patient’s endogenous flora Invasive procedures Contaminated environment Opportunistic pathogens

Computers on Wheels, Dynamaps, Rollaboards, IV Poles, Phones

CARE OF INDWELLING FOLEY SYSTEMS

URINARY CATHETERS

Indwelling catheter and condom catheters Should be last choice! Use silver impregnated latex catheters

Indications Fluid Measurement Urinary Retention Uropathy in urethra Open wounds or pressure sores around

your genitals or buttocks Frequently soiled with urine and skin

breakdown Severe illness or disability (intensive

care)

CATHETER CARE Wash hands before and after doing

catheter care Keep skin and catheter clean

Clean around catheter at least each day

Clean skin area after every bowel movement

Always keep bag below the level of bladder

Secure catheter to leg with securement device

Secure tubing in a downward flow when in bed

Place the catheter tubing so it does not kink or loop

ORAL CARE

Purpose: To reduce the bacteria so they can't be aspirated into the lungs and

cause infection. Prevent Aspiration!!

Technique: Oral swabbing, brushing teeth and rinsing on a regular basis

Kits included swabs and toothbrush that connect to suction devices

 

Hospital Linens

Linen cart – must be covered

Linen hamper – not overflowing

Dinamaps

Dinamaps must be disinfected BEFORE

each patient use

with germicidal

wipes in basket

Storage Bins for Products

Storage bins must be inspected and be kept clean from dust and dirt

Do not use supplies with visible dust and dirt on outside of package

Ceiling Tiles

Report stained ceiling tiles to Facilities 4-5010

These can grow fungus and may be a source of Aspergillus

If removed it must be done with a containment booth

Infection Control Precaution Manual

Manuals are located on the NEBH portal

Categories of Precautions = Mode of Transmission

Modes of Transmission: Direct contact with blood and bodily

fluids (HIV, HBV)

Indirect contact with contaminated items and patient care equipment and the environment (MRSA, VRE, C.difficile)

Droplet nuclei (Influenza, Pertussis, Bacterial Meningitis, SARS)

Airborne route (TB, Chickenpox, Measles)

Vector (West Nile Virus, Malaria, Ebola Virus)

Categories of Precaution Techniques

Standard Contact Special Contact Precautions

(C.difficile) Droplet Special Droplet Precautions Airborne

Precautions are used for both colonized and infected patients

Colonization:The complex process of new organisms becoming a part of the endogenous flora of an area of the body with no signs of active infection

Infection: The presence of signs and symptoms of a

host/pathogen response (fever, drainage, cough, purulence, inflammation, etc.)

Standard Precautions

Applies to everyone Hand washing Gloves, masks, eye protection and

gowns when deemed necessary to protect you

Cleaning patient care equipment between patient use with germicidal cloths

Environmental controls Careful handling of linen – no

overflowing bags Appropriate patient placement Use Needlesafety devices – no

recapping of needles

Precaution Materials

*Precaution Gowns*Gloves*Masks*Private Room*Precaution Cart *Signage – new Red signs*Dedicated Equipment (stethoscope, sphgmanometer,

commodes)*Cal Stat Alcohol Hand Rub*Red Bags for Medical Waste*Bleach wipes

Contact Precautions

Contact

- MRSA, VRE, Abscess, Cellulitis, Herpes Zoster, Impetigo, Staph aureus wound infections, Streptococcus wound infections

- Significant fecal incontinence

2/3 of feces is due to microorganisms

Contact Precautions

Gloves and Gowns for ALL entering the room – including visitors and family members

Mask if you are likely to be sprayed or splashed during wound irrigation or suctioning

Contact Precautions Techniques “Confine and Contain”

Inside the Room:• Covered linen hamper • Red lined trash container• Foam Alcohol Dispenser• Stethoscope and Blood Pressure Equipment• Small Red Bags for disposal of contaminated

dressings and items used in patient care• Only essential supplies should be brought into

room – at discharge left over supplies will be discarded

*Do not bring Computer on Wheels, Dynamap Equipment, Personal Stethoscope, Lab Coat in room

Discontinuation of Precautions for MRSA Infected and Colonized Patient

Requires three negative surveillance cultures from nares obtained on separate days.

And……one negative culture from original site of infection (urine, wound, g-tube, sputum, etc.)

REMEMBER Before sending an MRSA culture, the patient

must be off mupirocin (Bactroban) and antibiotic therapy for MRSA (Vanco, Bactrim, Zyvox, Daptomycin)

NEBH Program: Preoperative Outpatient Screening

Nasal swabs during prescreening Microbiology Laboratory PCR

detects presence of bacteria-specific DNA– Cepheid GeneXpert – Results within 24 hrs for S. aureus,

1 hr for MRSA Topical decolonization protocol

for patients found to be carriers of S. aureus or MRSA

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Treatment Protocol

•5-day application of intranasal 2% mupirocin - applied twice daily - for MRSA and MSSA positive patients.

•Daily body wash with chlorhexidine

•MRSA Patients - Vancomycin surgical prophylaxis in Bond Center

•Re-screen positive MRSA before surgery

•Contact precautions if positive

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MRSA/MSSA Eradication Results

From July 17, 2006 through April 2010

23,439 patients screened• 5412 (23%) positive for Staph aureus • 969 ( 4%) positive for MRSA

• Repeat nasal screens on MRSA patients revealed 78% eradication

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Time Period Inpatient surgeries # Surgical Infections Percent

FY06 10/01/05-07/16/06 5293* 24 0.45%

FY0707/17/06-09/30/07 7019 6 0.08%

FY08 10/01/07-09/30/08 6323 7 0.11%

FY09 10/01/08-09/30/09 6364 11 0.17%

*historical controls

% MRSA and Staph aureus SSI

Discontinuation of Precautions for VRE

Three negative rectal/stool specimen obtained on separate days

One negative cultures from original site of infection (urine, wound, g-tube, sputum, etc.)

REMEMBER Patient must be off antibiotic therapy for

VRE (Linezolid, Chloramphenicol, Doxycycline, high-dose Ampicillin

Special Contact Precautions

For Clostridium difficile colitis and suspected cases

Gowns and Gloves for ALL entering room

Hand washing to remove spores

Bleach wipes for all environmental cleaning

Careful and thorough room cleaning and disinfection to prevent spread

No Discontinuation of Precautions for Clostridium Difficile

Patient must remain on Contact Precautions throughout hospitalization when positive for C.difficile – even if diarrhea has stopped

No policy requiring surveillance cultures for C.difficile - it is a polymerase chain reaction (PCR) test.

Patients with C.difficile diarrhea are not to be brought to the OR – if necessary consult with Infection Control Manager

Other Precaution Issues

If you find a hole in a precaution gown –discard it

Document patient education in medical record – remember to educate family and visitors

Give patient and/or family the educational sheets in the top drawer of the precaution cart on VRE, MRSA or C.difficile

Consult with Infection Control Manager if you need additional assistant with patient education

Droplet Precautions

Influenza Meningitis - Hemophilus Meningococcemia Mumps Pertussis Rubella SARS

Droplet Precautions

Private Room (does not have to be a negative pressure room)

Masks for all entering the room

H1NI Influenza A

(Swine flu)

Airborne Precautions

Pulmonary Tuberculosis Sputum AFB Positive Chickenpox Disseminated

Herpes Zoster Measles Suspension in air

for hours

Airborne Precautions Negative Pressure Isolation Room (NPRI)

contact Facilities to prepare the room ventilation

NPIR at NEBH: ICU Rm 8 5West Room 539 4 West Room 439

N95 Respirator must be worn – or use the Positive Air Pressure Respirator (PAPR) from Respiratory Therapy

Door must be kept closed When transporting patient – place a surgical mask on

during transport (not a N95 respirator)

We Do Not Recommend Incisions opened to air with

contaminated steristripsBacteria feed off blood (and sugar)

Incisions are in exudative stage of wound healing first few post-op days

Sent home on day 3- 4 with incision and underlying tissues starting proliferative stage of wound healing

Wounds are susceptible to dehiscence

Solution: incisional adhesive with steristrips if worried about dehiscence

Standardization: Antimicrobial Dressing (AMD) By Nursing Staff

AMD secured with MeFix tape for protection from exogenous contamination and prevention of tape burn

Allow skin/incision to create proper temperature beneath dressing to enhance wound healing

Protect the incision from exogenous contamination until discharge

Protect the incision from trauma

Incision protected until discharge and then 48 hrs postop

Knee Dressings with Ace

Ace bandage one day postop with blood strikethrough after drain removed – nurses told to “reinforce” – another reason to have antimicrobial gauze beneath the ace bandage.

Initial postop dressing is usually an ace wrap for compression.

AMD gauze are in postop dressing kits to offer protection to the incision in first two days

Spine Service and Shoulders

AMD sealed with Tegaderm left on until discharge

AMD Island dressing – left on until discharge

Rotator cuff (and total shoulders) – Dermabond is being used or an AMD gauze covered by tegaderm – left on until discharge

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Hand Hygiene Educational Programs

Most Important Control Measure

HAND HYGIENE – wash off the dirt!

Wash hands several times a shift – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes

Steris Alcohol Foam, Liquid and Hand Wipes

Patients receive package of alcohol wipes

In each patient room, outside rooms, cafeteria and other areas

Wash hands often – before eating, before leaving work, after contamination

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Infection Control Liaison Program

Unit and Department-based liaisons Participate in educational activities Collect hand hygiene observations Precaution carts and direct care

observations Communicate information to staff Assist in implementing practice change Attend monthly meetings Contribute to an annual “Bug Beat Fair” Participate in Performance Improvement

Studies Clinical ladder for professional

advancement

In Summary…..

Healthcare-associated infections are a major problem in hospitals

Infection control measures, such as precaution techniques and hand hygiene have been shown to prevent the spread of nosocomial infections

Follow department-specific infection control policies and procedures

Report any problems immediately to your Manager and the Infection Control Manager x 4-5332