1. Preventing Healthcare Associated Infections W. Charles Huskins, MD, MSc Associate Professor, Pediatrics Mayo Clinic

2. Small things, done well together, can make a big difference

3. Objectives Identify risk factors for central line infections Describe practice strategies for line infection prevention Review hand washing technique

4. Central Line Associated Bloodstream Infections (CLABSI)

5. Minnesota Health Care Quality Measures – Statewide Quality Report - 2010 Report http://www.health.state.mn.us/healthreform/measurement/report/index.html

6. Garland JS, et al. Infect Control Hosp Epidemiol 2008; 29:243-9 Extraluminal Intraluminal

7. Preventative Intervention: Scrub the Hub Scrub all injection caps for 15 seconds prior to accessing Peripheral and central lines (adult/pediatric/neonate) Use alcohol wipe Allow to dry Before blood draws, infusions, flushes…anytime the catheter is accessed

8. PICU Interventions Improve facilities for hand hygiene Use 2% chlorhexidine for line insertions for all patients >1kg or >14 days old Reduce central line entries Advance enteral feedings more quickly Reduce unnecessary laboratory tests Convert IV to po medications Switch from bolus to continuous sedation if appropriate Reprogram pumps to administer prn doses of medications

9. Children’s Hospital-Wide Intervention Continue to emphasize Insertion bundle Standard maintenance practices – dressing change, hub change, administration set change Daily assessment of need for line, promptly remove unneeded lines Additional efforts to prevent contamination during line entry

10. Central Line Entry Bundle Emphasize that line entry is a invasive procedure Combine several interventions that can work together to reduce risk Improve disinfection of hub Reduce likelihood of contamination of hub Reduce unnecessary line entry Integrate into/redesign line entry workflow to reinforce adherence Pilot test new devices to disinfect and protect hub from contamination

11. Standard Precautions and Strict Isolation to Prevent Spread of Clostridium difficile and Antimicrobial Resistant Bacteria

12. MB3B Hand Hygiene Initiative

13. Coming to a Bed Near You (at the Point of Care)…

14. Environmental Cleaning with Bleach Bleach wipes used daily Clean all surfaces: Crib hand rails & bars and bassinets surfaces Door handles Light switches Tray tables Bathroom sink handles Additional forgotten surfaces: Computer keyboards Telephones

15. Interventions to Prevent Healthcare Associated Infections Small things, done well together, can make a big difference CLABSI Reduce line entries Scrub the hub Protect the hub Remove line when it is no longer needed or convert to a lower risk line Standard & Isolation Precautions Wash hands upon entry in the ICU Place and use hand rub at the point of care Give direct feedback on compliance Use bleach wipes for environmental cleaning

16. Nosocomial Urinary Tract Infections

17. Definitions Catheter-associated urinary tract infection Symptomatic infection Asymptomatic bacteriuria

18. Maki DG & Tambyah PA. Engineering out the risk with urinary catheters. Emerg Infect Dis 2001;7:342. Pathophysiology

19. Maki DG & Tambyah PA. Engineering out the risk with urinary catheters. Emerg Infect Dis 2001;7:342. Bacteriuria and Urinary Catheters Days Log colony forming units / ml

20. Duration of Catheterization Daily Prevalence of Bacteriuria Garibaldi et al. Factors predisposing to bacteriuria during indwelling uretheral catheterization. N Engl J Med 1974;291:215.

21. Alternatives to Indwelling Urinary Catheters Intermittent catheterization Diapers External bag collectors (infants & children) Condom catheters

22. Catheter Insertion Catheters should be inserted by trained personnel Wash hands before insertion, preferably with an agent with antimicrobial activity Clean the periurethral area and apply an antiseptic Use a sterile catheter and drainage system Use aseptic technique

23. Closed Sterile Drainage 26% of catheters disconnected at some time Risk of infection the day after disconnection was 2 times the risk if there was no disconnection Platt et al. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;I:893.

24. Closed Sterile Drainage Platt et al. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;I:893.

25. Care of Indwelling Urinary Catheters Maintain a closed sterile drainage system Monitor for obstruction of urinary flow Inspect for encrustations Maintain the drainage reservoir below the level of the bladder Use individual containers to empty drainage reservoirs Wash hands before and after touching the catheter or the drainage system

26. Questions?