1. Changing World: Perianesthesia and Infection Prevention by:Doris Nordbye, RN MA Infection Preventionist Abbott-Northwestern Hospital

2. Objectives: The Learner will be able to: Define resistant pathogens that may be encountered in the Perianesthesia enviroment. Describe Isolation Practices which assist in the prevention of transmission of disease. Outline interventions which assist in the reduction: o Central Line Associated Blood Stream Infections (CLABSI) o Catheter Associated Urinary Tract Infections (CAUTI) o Surgical Site Infection (SSI) o C Diff

3. Introduction Obama signs bill to increase antibiotic research Gov focus on Health Aquired Conditions Public reporting of Central Line infections, UTI, and SSI. No reimbursement for HAI EBOLA MERS-COV ERCP Scopes and CRE

4. Microbiology: The Super Bugs

5. MRSA Methicillin Resistant Staph Aureus (MRSA) ◦ Normal flora to some. ◦ Usually found nares, skin and throat ◦ Colonization vs Infection ◦ Causes life-threatening infections ◦ SSI with MRSA increase risk of death by 10% ◦ Transmission unwashed hands.

6. ESBL Extended Spectrum Beta-Lactamase (ESBL) ◦ Seen with gram neg rods ie E Coli, K Pneumonia, Family Enterobacteriaceae ◦ Highly resistant ◦ Difficult to treat ◦ Usually seen in the urinary tract and the gut but can cause wound and blood stream infections. ◦ Transmission unwashed hands

7. C Diff ◦ Normal intestinal flora. ◦ Spore former ◦ C Diff has been found to also shed from the skin. ◦ Spreads on unwashed hands and contaminated surfaces.

8. C Diff Spore forming, gram positive rod that produces exotoxins (toxins A & B) New hyper virulent strain (NAP1) Produces greater levels of toxins A and B

9. C Diff Risk Factors Antibiotic use ◦ clindamycin, quinolones, 3 rd gen cephalosporins Nursing home or group home residence Immunosuppressive meds Hospitalization (within last 90 days) Surgery Proton pump inhibitor use

10. C Diff Risk factors Non-compliance with isolation practices ◦ gowning and gloving Non-compliance with hand hygiene ◦ soap and water hand washing (not alcohol foam) Inadequate environmental cleaning / disinfection

11. CRE Carbapenamase Resistant Enterobacteriaceae (CRE) ◦ 128 species of Bacteria within this family ◦ Highly resistant and share resistance with others. ◦ Long courses of antibiotic therapy or devices ◦ Can contibute to death in up to 50% of infected patients. ◦ Healthy people do not get CRE. ◦ Requires urgent aggressive action.

12. VRE Vancomycin Resistant Enterococcus (VRE) ◦ Normally found in the intestines and female genital tract. ◦ Can cause UTI, BSI or Wound Infection ◦ Risk VRE with long term antibiotic, hospitalized, weakened immune system, surgery, or medical devices.

13. Precautions/Isolation Designed to prevent transmission Enteric precautions require handwashing with soap and water. Airborne precautions used with small droplets i.e. TB Droplet Precautions used for large droplet transmission. i.e. Influenza

17. Enteric Precautions

18. Bundles

19. Bundles “It takes a village to prevent HAI”

20. Bundles Quality Improvement intervention where multiple distinct interventions (that may or may not be individually effective) are “bundled” together during procedures that carry a high intrinsic risk of a complication in the expectation that these will result in and additive benefit to achieve a desired outcome.

21. Bundles Usually consists of 3 – 5 evidence-based practices. Infection Prevention today is the implementation of bundles to prevent infection.

22. CLaBSI Bundle Developed as a result of multi-facility double-blinded and large patient populations. Implementation of CLABSI Bundles have reduced CLABSI by 49% across the country.

23. Central Line Insertion Bundle Use the subclavian vein unless contraindicated. Avoid the femoral vein. Do not routinely replace catheters Use maximal sterile barrier protection Use a full body drape. Use Antiseptic with Alcohol Hand Hygiene before insertion Empower Health care personnel to stop if breach in sterile technique.

24. Central Line Maintenance Bundle Hand hygiene before touching “Scrub the Hub” 10-15 seconds and allow to dry. Use alcohol or CHG to “scrub the hub” Do not use creams or ointments on site. Change Dressing every 5-7 days. Do not reinforce. Use an occlusive dressing.

25. Catheter Associated UTI Dropped 19% across the country. Increasing attention ◦ To reasons for insertion of foley catheters. ◦ Insertion techniques ◦ Early removal

26. CaUTI Bundle Use foleys in operative patients only as necessary. ◦ Urologic or other surgery on contiguous structures of the genitourinary tract. ◦ Prolonged duration of surgery ◦ Anticipated to receive large volumes of fluid. ◦ Anticipated to receive diuretics ◦ Monitoring of urinary output ◦ Assist in healing of sacral or perineal wounds.

27. CaUTI Bundle Only properly trained individuals should insert. Hand hygiene before and after insertion. Pericare before insertion Use sterile technique to insert Secure the foley after insertion Remove as soon as possible. ◦ SCIP protocol indicate by PO Day 2. ◦ Catheters inserted for prolonged duration of surgery should be removed in PACU.

28. CaUTI Bundle Maintenance Maintain a closed system Maintain unobstructed flow Perform Pericare Do not clean periurethral area with antiseptic. Clean with soap and water. Do not allow drainage bag to touch the floor.

29. CaUTI Work to be done Develop system of alerts/reminders to assess for continued need. Develop guidelines/protocols for nurse- directed removal Develop guidelines and algorithms for appropriate peri-operative catheter management.

30. Reduce surgical site infection (SSI) Most common hospital aquired infection Nationally seen SSI drop 19% Difficult bundle development ◦ Very few double blinded multifacility studies. ◦ Most studies are single facility small volume studies. Must build consensus for development and implementation. Improvement stems from interventions that span the “continuum of care”.

31. Patient Preparation Smoking ◦ Quitting as little as 3 weeks prior to elective procedure can have an impact. Bathing: ◦ Reduce the bioburden ◦ All patients having elective surgery should have a bath/shower before arriving. ◦ Some facilities are showering after patient arrives. ◦ MRSA and MSSA thrive on the skin Glycemic Control

32. Patient Preparation Administer prophylactic antibiotics within one hour of surgery. ◦ Over 120 kilos receive 3 grams. ◦ Redose after 2 half lifes of the antibiotic during procedure. Hair Removal ◦ No hair removal or clip only as necessary. ◦ If necessary, done outside of the operating room. Use an alcohol-based skin prep. Maintain normothermia

33. Post Op Bundle Hand hygiene before touching wound. Teach patient to perform hand hygiene before touching wound. Dressing: ◦ If dressing needs to be changed, use sterile technique. ◦ Dressing should remain in place for 24 to 48 hours.

34. Post operative If dressing needs to be changed, cleanse wound before replacing dressing. Maintain Post operative glucose

35. Hand Hygiene