1. UHS Bundled Approaches to the Prevention of Healthcare Acquired Infections
Maureen Spencer, M.Ed, BSN, RN, CIC, FAPIC
Infection Preventionist Consultant

2. HAI Reduction Bundles and Measures
CLABSI – central line associated bloodstream infections
CAUTI - catheter associated urinary tract infection
VAE and VAP - ventilator associated event, ventilator associated pneumonia
SSI - surgical site infection
CDI - clostridium difficile infection
CRE and MDROs - carbapenamase resistant enterobacterericiae, multiple drug resis orgs
IP Role in establishing working toward zero teams and bundled approaches

3. Healthcare Acquired Infections 2011- 2012 % Reduction
UHS 2012 Benchmark Rate
Infection Prevention Measures in Process
Catheter Associated UTI
(rate per 1000 Foley days)
57%
2.0
Infection Control Foley Catheter Tray and Silver Foley Catheter, CHG washcloths
CLABSI
(rate by 1000 catheter days)
54%
0.0
Central Line Insertion Kits, Alcohol Caps for Injection Hub Protection, CHG washcloths, Central Line Checklist
VAP (rate by1000 ventilator days)
11%
CHG rinse with oral care kits, VAP bundle checklist, CHG washcloths, nebulizer cleaning procedures, VAP rounds
CABG SSI (overall rate by surgical procedures)
71%
MRSA screening before surgery, CHG preop showers/cloths , Incisional sealants, CHG/alcohol skin prep
Total Hip (overall rate by surgical procedures)
15%
Total Knee (overall rate by surgical procedures)
50%
C.Difficile (rate per 10,000 patient days)
12%
4.0
Bleach wipes and bleach disinfectant solution, Rapid PCR Diagnostics for Early Diagnosis and Precautions, Enhanced environmental cleaning, cubicle curtain changes, room decontamination units for high rates
MRSA (rate per 1,000 patient days)
62%
0.4
CHG Washcloths, Pre-admission and Pre-op Screening, Rapid PCR Diagnostics for Early Diagnosis and Precautions

4. Central Line Associated Bloodstream Infections (CLABSI)

5. CLABSI Bundle and Practices to Prevent Infection
MD daily line necessity
Maximal Barrier Kit - Central line insertion kits – with antimicrobial catheters (CHG and Silver)
Impregnated CHG disc
Central Line Insertion Checklist
Alcohol cap protectors for injection hubs and 15 sec scrub the hub
Daily body cleanse with Sage CHG impregnated washcloths
Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. 2011
Bleasdale SC, et al. Arch Intern Med, Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007;67:2073-9

7. Confidential and Privileged Patient Safety Work Product
IP Rounds – check alcohol cap protectors on injection hubs and observe “scrub the hub” procedures
Confidential and Privileged Patient Safety Work Product

8. IP Rounds – Observe IV lines – Central, Peripheral, PICC, Mid-Lines, Dialysis

9. Catheter Associated Urinary Tract Infections

10. CAUTI Bundle and Practices to Prevent Infection
Nurse or MD Daily Foley
catheter necessity assessment
Bard Advance Infection control Foley Tray
Pre-connected system
Injection hub for urine
specimen sampling
Pericare Kits
Anti-reflux valve in bag
Frequent peri-care
Change system if seal broken
Daily body cleanse with Sage CHG washcloths
CDC Guidelines for Prevention of Catheter-Associated Urinary Tract Infections 2009

11. Confidential and Privileged Patient Safety Work Product
IP Rounds – Observations Foley Tubing not hanging properly with use of linen clip and Tamper Evident Seal Broken
Confidential and Privileged Patient Safety Work Product

12. Ventilator Associated Events and Pneumonia

13. VAE Bundle and Practices to Prevent Infection
Daily assessment of readiness to extubate – (daily sedation vacation, ventilator necessity)
Oral care q2-4 hrs
CHG oral rinse q 12 hrs
VAP Rounds and checklist
head of bed elevated 30 degrees
Peptic ulcer prophylaxis
Deep Vein Thrombosis prophylaxis,
CHG washcloths for daily bathing
Heck, K. AJIC 40 (2012) 877-9
Hutchins, K. AJIC 2009;37:590-7.

14. Surgical Site Infections

15. 7 “S” Bundle to Prevent SSI – Evidence Based Practices www. 7sbundle
7 “S” Bundle to Prevent SSI – Evidence Based Practices
SAFETY – is your OPERATING ROOM safe?
SCREEN – are you screening for risk factors and presence of MRSA & MSSA
SHOWERS – do you have your patients cleanse their body the night before and morning of surgery with CHLORHEXIDINE (CHG)?
SKIN PREP – are you prepping the skin with alcohol based antiseptics such as CHG or Iodophor?
SOLUTION - are you irrigating the tissues prior to closure to remove exogenous contaminants? Are you using CHG?
SUTURES – are you closing tissues with antimicrobial sutures?
SKIN CLOSURE – are you sealing the incision or covering it with an antimicrobial dressing to prevent exogenous contamination?

16. #1 – Safe Operating Room traffic control, number staff in room
air handling systems, filtration, grills
SCIP: hair clipping, warmers, oxygenation,
surgical prophylaxis, foley catheter removal 48 hrs
room turnover and terminal cleaning
surgical technique and handling of tissues
instrument cleaning/sterilization process, biological indicators
storage of supplies, clean supply bins, carts, tables, stationary equipment

17. Prevent Exogenous Contamination – Wound Protector/Retractor
Wound protector/retractor provides 360 of circumferential, atraumatic retraction, while significantly reducing surgical site infection and maintaining moisture at the incision
The self-retaining design of the wound protector/retractor effectively holds the incision site open, allowing the surgeon to easily access the operative field and maximize surgical assistance
Edwards J. P., MD. MPH. CPH., et al. Wound Protectors Reduce Surgical Site Infection: A Meta-Analysis of Randomized Controlled Trials. Ann Surg Jul; 256(1):
Cheng K. P., et al. ALEXIS O-Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections. Colorectal Dis.2012 Jun; 14(6):

18. #2 SCREEN for Risk Factors and MRSA and MSSA Colonization

19. Screening for MRSA and MSSA for High Risk Surgery (implants)
Pre-screening for MRSA and MSSA prior to inpatient surgery (ex: joint implants, mesh, vascular grafts, sternal wires, spine and neuro implants)
Molecular PCR (polymerase chain reaction) rapid technology provides one hour test results for pre-admission testing efficiency
Kim DH, Spencer M, Davidson SM, et al. J Bone Joint Surg 2010;92:
IHI Project JOINTS “Screen patients for Staph aureus (SA) carriage and decolonize SA carriers with five days of intranasal mupirocin and at least three days of CHG soap prior to surgery”

20. Decolonization Protocol
5-day application of 2% mupirocin - applied twice daily to each nares - for MRSA and Staph aureus screen positive patients
Daily body wash with chlorhexidine for 5 days before surgery
MRSA Patients – Vancomycin surgical prophylaxis

21. #3 – Showers with CHG

22. Decolonization Patient’s Skin
Pre-op Showers – night before and morning of surgery:
Liquid chlorhexidine shower or
CHG impregnated washcloths

23. #4 Skin Prep – alcohol based surgical skin prep

24. Dual Prep Surgical Skin Prep
Use an alcohol based skin antiseptic scrub prior to incision
Chlorhexidine 2%/alcohol 70%
Chloroprep
Iodophor/alcohol 72%
Duraprep or Prevail

25. # 5 Sutures – Antimicrobial Plus Sutures

26. Risk Factor: Bacterial colonization of the suture
Like all foreign bodies, sutures can be colonized by bacteria:
Implants provide nidus for attachment of bacteria1
Bacterial colonization can lead to biofilm formation1
Biofilm formation increases the difficulty of treating an infection2
Contamination
Colonization
Biofilm Formation
On an implant, such as a suture, it takes only 100 staphylococci per gram of tissue for an SSI to develop3
Every suture…medical implant:
Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27:
p252/Table1/footnote/definition of “implant”
Kathju S, Nistico L, Hall-Stoodley L, et al. Chronic surgical site infection due to suture-associated polymicrobial biofilm. Surg infect. 2009;10:
P460/col1/para3/lnes5-9
Nidus for attachment:
Ward KH et al. Mechanism of persistent infection associated with peritoneaI implants. J Med Microbiol. 1992;36:
p411/col1/para4/lines1-10;col2/para1/lines1-3;para5/lines1-10
Fewer bacteria required for infection:
Infection is harder to treat because of biofilm formation:
p460/col1/para3/lnes12-15;col2/para1/lines1-2
It only takes 100 staph:
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection.
Infect Control Hosp Epidemiol. 1999;27:
p253/col1/para6/lines3-7
Ward KH et al. J Med Microbiol. 1992;36:
Kathju S et al Surg infect. 2009;10:
Mangram AJ et al. Infect Control Hosp Epidemiol.1999;27:

27. Edmiston et al: Surgery 2013;154:89-100

28. #6 Solution – to Pollution is Dilution

29. Innovative Products to Prevent Exogenous Contamination – Chlorhexidine Irrigation System
New tissue irrigant – 0.05% CHG
Approved by the FDA for irrigation of mucous membranes and tissues
In vitro testing has shown >99% kill of MDROs challenged in mesh

31. #7 Skin Adhesive – seal the Incision or use special dressings

32. Prevent Exogenous Incision Contamination with Topical Incisional Adhesive (TSA)

33. Clinical Use of TSA in Orthopedic Total Joints
Hip: Sealed with adhesive covered with gauze and transparent dressing for incision protection
Knee: Sealed with incisional adhesive, covered with Telfa and a transparent dressing for incision protection
Healed incision

34. Which Would You Prefer For Your Patients???
Topical Incisional Adhesive (TSA)
Octyl Cyanoacrylate?,;,;,
,;,
Staples?
Sutures?

35. OTHER OPTIONS when Topical skin adhesives are not used or indicated

36. Antimicrobial (PHMB) Dressings with Hypoallergenic Fabric Tape
Spencer et al: The Use of Antimicrobial Gauze Dressing (AMD) After Orthopedic Surgery To Reduce Surgical Site Infections NAON 2010 Annual Congress - May 15-19, 2010

37. Antimicrobial Silver Dressings
Silver dressing absorbs exudate and contains it over incision – covered by a transparent dressing and left on until discharge – seals the incision from exogenous contaminants in hospital rooms
NAON – May 2006
Spencer et al: The Use of A Silver Gauze Dressing in Spine Surgery to Reduce the Incidence of MRSA Surgical Site Infections

40. 3. Chlorhexidine Showers 95% 4. Alcohol Based Antiseptics Chloroprep
Jan 2016
1. Safe OR
EOC Rounds
75%
Wound Protectors
40%
2. Screening for MRSA
Screening for MRSA
70%
Partial compliance
25%
Not screening (1) 5%
3. Chlorhexidine Showers
95%
4. Alcohol Based Antiseptics
Chloroprep
Duraprep
5. Surgical Irrigation
Bacitracin/Polymixin
Cefazolin
50%
Vancomycin
30%
Irrisept (CHG)
Other
6. Antimicrobial Sutures
7. Incisional Adhesive/Dressings
Dermabond incisional
adhesive
100%
Silver Dressing
65%
Patient Safety Work Product

41. Clostridium Difficile – Prevention and Control Measures

42. Recommended Prevention Measures
Special Contact Precautions and good hand hygiene
Room and equipment decontamination with PDI bleach wipes – remember to disinfect WOWs!
If rates are high (> 5 per 10,000 patient days) consider disinfecting all patient bathrooms with bleach
Evaluate and reduce the use of antibiotics that increase the risk of C. difficile infection
Early recognition of C difficile with the use of PCR rapid diagnostics for treatment and isolation/precautions

43. Commode Liners – Confine and Contain Liquid Infectious Waste
Use commode liners in ED, ICUs or other areas with limited access to soiled utility room to confine and contain liquid infectious waste

44. UVC Rapid Disinfector

45. HAI Reduction Teams
Surgical Site Infections: Director Surgical Services, OR Manager, SPD Director, Infection Control Manager, Two Surgeons, VP Patient Care Services, Director of Nursing, Nursing Manager, Clinical Educator, Microbiology Lab Director
Ventilator Associated Pneumonia: ICU Hospitalist, ICU Nurse Manager, ICU Nurse, Director of Anesthesia, ICU Clinical Educator, Respiratory Therapy, Infection Control Manager, Micro Lab
Central Line Assoc Bloodstream Infections: Surgeon who inserted most central lines, ICU Manager, Director of Anesthesia, ICU Clinical Educator, ICU Nurse, Infection Control Manager
Catheter Assoc UTI: Clinical Educator, Infection Control Manager, Chief Urology, Lab Director
MRSA Elimination: Infection Control Manager, Pre-admission testing, OR Director, Microbiology Lab Director, Two Surgeons, Director of Nursing, Patient Access Director,
Information Technology, ID physician
C.difficile: Chiefs of Surgery and Gastroenterology, ICU Nurse Manager, Micro Lab Director, Infection Control Manager

47. UHS Case Study: 25-hospital health care system in 7 states
IDN goals
Standardize practices across facilities
Implement evidence-based infection control practices
Identify potential risks for infection
Assessed wound closure practices in 12
different hospitals
Hospital system reported a drop in SSI rates for
37.5%
of categories tracked*
Reduced IDN inventory by
106
SKUs
In addition to completed programs, many programs in pipeline, including Willis Knighton, UCLA, NYU, Aurora, HCA, Texas Purchasing Coalition, Maine Health
Other 20% rated Take Aim “moderately” valuable
Sales growth numbers focused on WC & BIOPATCH. BIOPATCH up 13%, Plus sutures up 12%, PRINEO up 27%
* hip, knee, colon, and hysterectomy procedures ere tracked.
1. Data on file. Ethicon US, LLC. Take Aim Case Study
©2016 Ethicon US, LLC / / Confidential and proprietary information /

48. AORN #138 Boston
April, 2017

50. Patient Safety Work Product

51. The End