1. 9/30/20161 Indiana State Nurses Association Convention September 16, 2016 Francesca C. Levitt, MSN, RN-BC, ACNS-BC Perioperative Clinical Nurse Specialist

2. Conflict of Interest The presenter has no conflicts of interest to disclose. 9/30/20162

3. 3 The Role of Perioperative Services in the Prevention of Hospital Acquired Infections Objectives: To identify gaps in care that may potentially contribute to a central line associated blood stream infection (CLaBSI) or catheter associated urinary tract infection (CAUTI) in the perioperative setting. To identify best practices related to infection prevention in the perioperative setting.

4. Clinical Nurse Specialist 3 Spheres of Influence Patient Nursing Organization/System 9/30/20164 Nursing System Patient

5. The Role of a Perioperative Services CNS Promote optimal surgical patient outcomes Identify gaps in care through objective data Collaborate to determine opportunities for improvement Design evidence based interventions Implement interventions Track outcomes data Celebrate successes and encourage staff 9/30/20165

6. Healthcare Associated Infections Central Line Associated Blood Stream Infections (CLaBSI) Catheter Associated Urinary Tract Infections (CAUTI) Surgical Site Infection Clostridium Difficile Pneumonia Others… 9/30/20166

7. Historical Perspective A CLaBSI or CAUTI that was identified during a patient’s hospitalization was attributed to the floor or unit where the patient was receiving care. If the device was inserted at the time of surgery, the operating room was not implicated or tied to the infection. 9/30/20167

8. Surgical Phases of Patient Care Pre-admission Testing Pre-operative Phase Intra-operative Phase Post Anesthesia Care Unit Inpatient/ Discharge 9/30/20168

9. Housewide Education CLaBSI Prevention Training 500 Perioperative Staff Members Central Line Insertion Central Line Access and Maintenance Blood Cultures Hand Hygiene RN Physician Collaboration 9/30/20169

10. Central Venous Catheter Insertion Physician Training Standardizing the insertion kits Full body drape Dressing supplies Drainage management 9/30/201610

11. RN Physician Collaboration Working together in the OR during insertion Full body drape Needleless valves to the sterile field Maintaining sterility Assisting with dressing placement 9/30/201611

12. Central Line Access and Maintenance Hand Hygiene 15 second scrub the hub and allow to dry Standardized Dressing Change Kits 2 masks Sterile gloves CHG wand Skin protectant 2 piece dressing 9/30/201612

13. AORN Guidelines Perioperative personnel should implement CDC guidelines to prevent central line infections. Use sterile technique and maximal sterile barrier precautions (i.e., hair covering, mask, sterile gown, sterile gloves, a sterile full body drape) when inserting central catheters. It is the perioperative nurses' responsibility to make sure this evidence-based guideline is followed to promote safety in all perioperative patients. 9/30/201613

14. Blood Culture Collection Discussion about false positive results Standardized kit Review of the aseptic procedure 9/30/201614

15. Data Collection Tool 9/30/201615 Date CVL Type (SC, IJ, EJ, Fem, PICC, Port, HD, SG) Dressing Clean & Dry (Yes/No) Dressing Intact & Occlusive (Yes/No) Dressing Dated & Current (Yes/No) Tubing Dated & Current (Yes/No) Stopcocks covered (Yes/No) Disconnected Tubing has Sterile Caps (Yes/No) Anesthesiologist / ANE Resident OR/Dept PACU RN _________________________________________ Hand hygiene and clean gloves prior to accessing central line 15 second scrub the hub and 15 second dry time Document needless cap (Smart Site) changes in Cerner Safety & Quality PACU Central Line Infection Prevention Observation Tool Central Line received from OR or Ancillary Department

16. Stopcock Contamination Researchers observed stopcock transmission events in 274 ORs and collected reservoir bacterial cultures. Stopcock contamination was identified in 23% of procedures. Patients, provider hands, and the environment may have contributed to the transmission events, however they concluded that the environment was the most likely source. 9/30/201616

17. CLaBSI Data 9/30/201617

18. Prevention of CAUTI Perioperative nurses should follow the CDC guidelines and evidence based recommendations for the prevention of catheter-associated urinary tract infections. Follow the health care organization's policies and procedures for urinary catheter insertion and care to prevent urinary tract infections. Perioperative personnel should insert catheters only for medically indicated conditions; use urinary catheters for surgical patients only as necessary as opposed to routinely; document the date and time of catheter insertion and remove the catheter as soon as possible postoperatively, preferably within 24 hours; strictly follow sterile technique when placing a urinary catheter; and allow only trained persons who are familiar with correct sterile technique and maintenance to insert urinary catheters 9/30/201618

19. 9/30/201619 Periurethral Cleansing Castile Soap

20. Urinary Catheter Insertion Use the contents of the kit in sequential order Castile soap for periurethral care Attach water syringe prior to insertion Non-dominant hand stays on patient at all times Feed catheter with sterile hand Inflate balloon with sterile hand Remove syringe with sterile hand Secure catheter in the OR when possible 9/30/201620

21. Prior to Transport 9/30/201621 Empty the collection bag

22. When Moving the Patient Do not put the urine collection bag on the patient’s abdomen or operating room table during lateral transfers or transport. Designate a staff member to secure the urinary catheter tubing to prevent accidental removal or urethral injury. 9/30/201622

23. Collection Bag Keep the urine collection bag below level of bladder at all times to prevent reflux of urine. Do not allow the urinary collection bag to make contact with the floor. 9/30/201623

24. Removing Unnecessary Urinary Catheters Does the patient meet criteria for a urinary catheter? If not, ask the surgeon for an order to remove the catheter or follow the hospital protocol. If there is an order to remove the catheter in the PACU, do so as soon as possible. 9/30/201624

25. CAUTI Data 9/30/201625

26. Future Initiatives Obtain regular, timely intraoperative CLaBSI and CAUTI specific data. Perform a deep dive on cases related to insertion Solicit staff input on barriers and challenges. Perioperative Services can make a huge difference in HAIs and the staff is motivated! 9/30/201626

27. References 1.AORN Guidelines for Perioperative Practice (2016). Recommendation VII, Perioperative personnel should take action to prevent the transmission of health care-acquired infections. 2.O'Grady NP, Alexander M, Burns LA, et al. (2011). Guidelines for the prevention of intravascular catheter-related infections. American Journal of Infection Control, 39(4 Suppl 1):S1-S34. 3.Loftus RW, Brown JR, Koff MD, et al. (2012).Multiple reservoirs contribute to intraoperative bacterial transmission. Anesthesia & Analgesia 2012;114(6):1236-1248. 4. https://www.cdc.gov/HAI/ca_uti/uti.htmlhttps://www.cdc.gov/HAI/ca_uti/uti.html 5.Guide to Preventing Catheter-Associated Urinary Tract Infections 2015– APIC apic.org/Resource_/EliminationGuideForm/0ff6ae59- 0a3a-4640 9/30/201627

28. Acknowledgements Sherri Ahaus Jennifer Dunscomb Dr. Larry Stevens Nikki Walke Dr. William Wooden Perioperative managers, shift coordinators, clinical educators and staff CNS colleagues 9/30/201628

29. 9/30/201629 Contact Information: Francesca Levitt, MSN, RN-BC, ACNS-BC Perioperative Clinical Nurse Specialist flevitt@iuhealth.org 317-670-1710

30. Questions? 9/30/201630