INFECTION PREVENTION Part 2

Biofilm Fast Facts The best way to prevent biofilm…remove the device. Biofilm is bacteria that adheres to implanted/indwelling devices ( i.e.; Endotracheal Tubes, Central Lines, Urinary Catheters, Implants) or damaged tissue forming a slimy layer resulting in infection. Form on living and non-living surfaces; where is there is moisture in support of bacterial growth Bacteria in biofilm are highly resistant to antibiotics (1,000 X more resistant than the same bacteria not growing in a biofilm). Indwelling devices when inserted, may readily acquire biofilms on the inner or outer surfaces. The organisms commonly associated with indwelling devices and biofilms are Staph epidermidis, Enterococcus faecalis, E. coli, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae, and other gram- negative organisms. The best way to prevent biofilm…remove the device. Take a proactive approach  Query the physician  Get the device out!

Pathogenic consequences of Biofilm in indwelling devices Early formation of biofilm Antibiotic resistant biofilm forms a sticky matrix that cannot be penetrated by antibiotics. A well established pseudomonas biofilm has grown thick over time and calcified (white areas) rendering aveolus inactive.

VAE VENTILATOR ASSOCIATED EVENTS

Ventilator Associated Events (VAE) Previously known as Ventilator Associated Pneumonia (VAP) Definitions for VAE “VAC” Ventilator Associated Condition “IVAC” Infection Related Ventilator Associated Condition possible” VAP definition 2 “probable” VAP definitions Applies to patients≥ 18 years of age who are on mechanical ventilation for ≥3 calendar days.

VAE Prevention Strategies HOB 30 degrees prevents the pooling of secretions Oral care every 2 hours reduces oral / subglottic bacteria Sedation Vacations in preparation for weaning from the vent Deep Vein Thrombosis prophylaxis to prevent venous stasis Peptic ulcer prophylaxis to decrease risk of stress ulcers

CLABSI CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION

What is Considered a Central Line? For the purposes of mandated reporting, the following are considered central lines: Hemodialysis Catheters Portacaths PICC Lines Umbilical Catheters Central Venous Catheters

CLABSI Prevention Strategies Aseptic technique when changing the dressing Appropriate disinfection of hubs and ports Adherence to all elements of the Central Line Insertion Practices(CLIP).

Central Line Insertion Practices (CLIP) Standardizing best practice for insertion techniques ensures better patient outcomes Insertion Practices Proper Hand Hygiene Full barrier precautions including Gown Gloves Mask Eyeshield Cap Full Drape Avoid use of the femoral vein Chlorhexidine-based Antiseptic Prep (betadine is permitted on neonates)

Standard Disinfection of Hubs and Injection Ports 07.04.01 EP#12 Use of alcohol port protectors (CUROS caps) on ALL ports, ALL the time Green cap must be in place for 3 minutes in order to be effective “If the cap is green, the port is clean.” Excludes pediatric population a (risk of foreign body ingestion) Scrubbing the hub for 10 seconds between each infused medication is REQUIRED when delivering multiple IVP medications Demonstrate time frame for scrubbing the hub Reusable Equipment: Discard any left over strands of CUROS prior to disinfection of IV poles and replace with new strands of caps to prevent cross Contamination between patients.

Use of Catheter Checklist 07.04.01 EP# 6 Use of Catheter Checklist Prior to Insertion of central line Provide patient printed education on Central Line Infections. Obtain “Central Line Packet” (with patient name &MR# ) from forms fast. Complete all asterisked sections of the central line checklist during procedure. After Insertion Fax Central Line Checklist to Infection Control at 1334. Place checklist in medical record.

Routine Evaluation of Central Lines for Removal 07.04.01 EP#13 Routine Evaluation of Central Lines for Removal Daily evaluation of indwelling devices (i.e., endotracheal tube, central line, urinary catheter) is documented on the progress note by the Physician. Unchecked progress notes for patients with indwelling devices are considered incomplete documentation and should be flagged for completion. Applies to inpatient areas or outpatient units if patients are held ≥ 24 hours

CAUTI CATHETER ASSOCIATED URINARY TRACT INFECTIONS

Indications for Urinary Catheters Urinary Retention Urinary Obstruction Strict I & O Surgeries involving the genitourinary tract Surgical Patients (Discontinue by post-op day 2) Acute genitalia wounds End of life comfort care Stage 3 or 4 pressure ulcers (skin cannot be kept dry otherwise)

That’s no banana smoothie

CAUTI Prevention Strategies Use indwelling catheters only when medically necessary Use aseptic technique during insertion of the catheter Use of stabilization device (statlock) to the patient’s body to prevent urethral tension Peri Care  Peri Care  Peri Care Maintain sterile closed drainage system that hangs below the bladder Maintain unobstructed flow with catheter tubing free of dependent loops Aseptic technique during specimen collection Document the time of insertion AND discontinuation Request a physician order to remove catheters when no longer needed

Document indication for urinary catheters Documentation Document indication for urinary catheters

SSI SURGICAL SITE INFECTIONS

O.R. Excellence Surgical Care Improvement Project (SCIP) Sponsored by the Centers for Medicare & Medicaid Services (CMS) in collaboration with: American Hospital Association (AHA) Centers for Disease Prevention and Control (CDC) Institute for Healthcare Improvement (IHI) The Joint Commission (TJC) Goal: Reduce the incidence of surgical complications by following a specific set of evidence-based practices aimed at reducing SSIs.

Prevention Strategies of SCIP Preoperative Bath with Chlorhexidine (CHG) removes surface bacteria from skin Hair removal with clippers decreases the risk of impairing the skin integrity Antibiotics are given within 60 minutes of incision The antibiotic is more effective, resulting in better outcomes for the patient   Postoperative Normo-thermia promotes the healing process Antibiotics discontinued within 24 hours post op reduces risk of developing a drug resistance  Remove urinary catheters 24-48 hours post op reduces risk of Catheter Associated Urinary Tract Infection (CAUTI)

Patient / Family Education BEFORE a procedure or the insertion of any device, provide the patient with printed education from KRAMES: CLABSI – NPSG>Central line associated infections print “Central Line Infections” VAE-NPSG print “Healthcare Associated Pneumonia” SSI - print “Preventing Surgical Site Infections” CAUTI – Search CAUTI DOCUMENT ANY EDUCATION IN MEDITECH

References Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007. Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf Chiarello L, Jackson M, Rhinehart E, Siegel JD, and the Healthcare Infection Control Practices Advisory Committee (HICPAC) (2006). Management of Multidrug-Resistant Organisms In Healthcare Settings. http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC) (2008) Guideline for Disinfection and Sterilization in Healthcare Facilities, Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf Lynne Sehulster, Ph.D., Raymond Y.W. Chinn, M.D., Center for Disease Control and Prevention / Healthcare Infection Control Practices Advisory Committee (HICPAC) (2003), Guidelines for Environmental Infection Control in Health-Care Facilities http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

References Carolyn V. Gould, MD, MSCR; Craig A. Umscheid, MD, MSCE; Rajender K. Agarwal, MD, MPH; Gretchen Kuntz, MSW, MSLIS; David A. Pegues, MD and the Healthcare Infection Control Practices Advisory Committee (HICPAC) (2009), Guideline for Prevention of Catheter Associated Urinary Tract Infections. Atlanta GA. Association for Professionals in Infection Control and Epidemiology (2009), Guideline to the Elimination of Ventilator Associated Pneumonia, APIC Washington DC. Society for Healthcare Epidemiology of America (SHEA) / Infectious Diseases Society America (IDSA) (2008), Strategies to prevent Ventilator-Associated Pneumonia in Acute Care Hospitals, Infection Control and Hospital Epidemiology, vol. 29.supplement 1. Centers for Disease Control and prevention /Healthcare Infection Control Practices Advisory Committee (2003), Guideline for Prevention of Healthcare Associated Pneumonia. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm Guidelines for the Prevention of Intravascular Catheter-Related Infections, Centers for Disease Control and Prevention 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf