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
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