Infection prevention and control in the hospital

I) Hospital Epidemiology: An Evolving Field a) Traditionally, only need the term "HAI" i) Hospital-acquired Infection (HAI) - infections manifesting on day ? of hospitalization or later ii) Community-acquired - all other infections b) Modern world: more and more healthcare exposures outside of the classic, inpatient hospital setting i) Healthcare associated - infections occurring as a result of healthcare exposure - these include traditional "HAIs", but also include infections acquired in nursing homes, infusion centers, home health visits c) Classically, resistant pathogens were primarily acquired in the hospital or healthcare associated settings; but recently, more resistant pathogens are spreading in the community II) Role of Infection Control (IC) Department a) Prevent spread of infection in hospital through implementation of accepted standards, technology b) Conduct surveillance of hospital-acquired infections (HAI) i) Infections identified/manifest hospital day 3 or later c) Understand and analyze the epidemiology of HAI d) Report rates of infection to healthcare workers and administrators i) Benchmarks e) Implement interventions to decrease rate of HAI i) Targeted intervention III) HAI Surveillance a) Hallmark of IC b) Use CDC definitions to define HAIs i) Important that definitions are reproducible, if not always clinically perfect ii) Reproducibility allows for evaluation of a hospital's rates over time and comparisons with other hospitals c) Often involves manual and increasingly, automated data extraction from medical records d) HAI surveillance data used increasingly for CMS P4P, Joint Commission accreditation and public reporting IV) HAI: Scope of the Problem a) Approximately 2 million patients acquire HAI each year in the US i) ~ 10 HAI/1,000 patient days ii) ~ 100,000 deaths iii) ~ 5 billion dollars/year in attributable cost b) Increasing recognition of HAI as patient safety issue i) Regulatory - Medicare reimbursements ii) Media - Public reporting of hospital infections iii) Lawyers Table 1: Distribution of 504 Health Care-Associated Infections Infections were defined with the use of National Healthcare Safety Network criteria. CI denotes confidence interval. Table 2: Evidence that IC is cost-effective- pneumonia and surgical site infection are the biggest players

-3 -

V) Infection Control a) Aims to break the chain of infection at all three points WHat are the 3 points and ways to break the chain? VI) Limitations to efficacy of IC a) Resources b) Time c) Poor compliance by healthcare workers (HCWs) d) Changing epidemiology of healthcare i) Role of "healthcare-associated infections" ii) Pathogens (eg CA-MRSA) iii) Medical practice (invasive procedures in outpatient settings) iv) Resources VII) Modes of Transmission a) Contact Transmission (bacteria, most common) b) Droplet Transmission (influenza, meningococcus) c) Airborne/aerosol transmission (TB) d) Blood and Body Fluids (needlesticks: HIV, HCV) e) Food and Water f) Vector-borne VIII) Pathogenesis of HAI a) Usually ? infection b) ? usually precedes infection i) Both ?and ? patients are contagious c) Bugs are spread from patient to patient by healthcare workers i) Hands, equipment (eg stethoscope) ii) Transient colonization most common d) Role of environment e) Major risks: 2? i) More frequent contact with HCW, higher risk IX) Prevention: hand hygiene, contact precautions, patient isolation, cohorting X) Can Health Care Workers (HCWs) who are chronically colonized with resistant pathogens transmit it to patients? a) Yes - but this is uncommon. Most transmission is from transiently colonized unwashed hands/clothes/objects b) Good hygiene will prevent transmission in colonized HCW c) Evidence that transmission from chronically colonized HCWs can occur: i) Mediastinitis outbreak (Gaynes et al J Infect Dis 1991) ii) HCW with chronic sinusitis (Boyce et al Clin Infect Dis 1993) iii) A "cloud adult" (Sherertz et al Ann Intern Med 1996) XI) Indwelling Devices a) ? are major risk factors for HAI i) Central vascular catheters ii) Foley catheter iii) Endotracheal tube b) Devices are associated with increased HAI risk because: 3?

-i) Environmental source eg: environmental cleaning ii) Transmission eg: hand hygiene, isolation iii) The host eg: vaccination -bacterial -colonization -colonized and infected -indwelling devices , debilitated state -Short-term catheters -i) Patients who are sicker (more vulnerable) more often have devices ii) Devices bypass host defense systems iii) Devices are frequently handled/manipulated by healthcare workers

XII) HAIs of Special Importance a) Resistant bacteria? b) Antibiotic associated diarrhea? c) Respiratory contagious infections 4? XIII) Colonization with S. aureus Humans are the natural reservoir; 20-30% persistently colonized o Healthcare workers 27% o College students 29% o HIV 36% o Hemodialysis 52% o IVDU 55% o Diabetics on insulin 56% Colonization is risk factor for infection MRSA is transmitted from carriers to non-carriers in the hospital on the hands of health care workers Transmission is in-apparent XIV) S. aureus Colonization Sites Anterior nares Skin (axilla, groin, open lesions) Invasive devices provide opportunities to invade beyond skin and mucous membranes o Tracheostomy site o PEG site o IV/Catheter sites Urine catheter sites (Kluytmans et al. Clin Micro Rev 1997) Graph 1: Duration of MRSA Colonization XV) Consequences of MRSA Colonization a) Follow-up study of 209 patients with newly identified MRSA colonization b) Risk of infection assessed for 18 months c) 29% of the cohort (60 patients) developed a total of 90 MRSA infections d) 25/90 (28%) infections were bloodstream infections e) 50/90 (54%) infections were pneumonias f) 80% of infections occurred a new site (from original site of colonization or infection) 49% of new infections manifested after discharge from the hospital Huang et al, CID, 2003, 281-5 Graph 2: Days from MRSA Detection Until Infection or Death

-i) Methicillin-resistant Staphylococcus aureus (MRSA) ii) Vancomycin-resistant enterococcus (VRE) iii) Extended spectrum B-lactamases (ESBLs) iv) Carbapenem-resistant Enterobacteriaceae (CRE, KPC) v) Pseudomonas aeruginosa vi) Acinetobacter baumannii -i) Clostridium difficile (C. diff, CDAD, CDI) -i) Mycobacterium tuberculosis ii) Bordetella pertussis iii) Influenza, H1N1 iv) Respiratory Synctial Virus (RSV)

XVI) Prevention of HAI a) Standard, universal precautions i) Hand hygiene for all patients: before and after patient contact (1) Soap and water vs waterless (alcohol based) hand rub ii) Gloves, gowns, masks, eye protection when contaminated fluid/blood exposure is anticipated (1) Limit duration of indwelling devices (2) Limit antibiotic exposures (3) Discharge from hospital as soon as possible XVII) Contact or Barrier Precautions a) "Ramped up" precautions to prevent spread in the hospital b) Usually target "problem pathogens"- multi-drug resistant organism (MDRO), highly contagious or dangerous pathogens c) Continue Standard Precautions i) handwashing before & after each patient encounter d) Private room e) Gloves and gown on when entering the room i) Contaminated environment f) Remove gown and gloves before leaving room g) Use dedicated equipment (e.g. stethoscopes) whenever possible, and when this is not possible, disinfect stethoscope carefully XVIII) Other types of precautions a) Droplet i) Some infections spread by large droplets (1) Examples include ? ii) Surgical mask worn by provider b) Special respiratory, airborne i) Some infections spread by smaller particles (1) Tuberculosis, measles, varicella ii) ? (1) N95 worn by healthcare workers for TB XIX) Respiratory Etiquette a) To help prevent colds & flu in both patients and staff, please use tissues to contain secretions when coughing or sneezing & then throw the tissues in trash b) Perform hand hygiene after disposing of tissues c) "Respiratory Etiquette" signs are posted in the DMC Emergency Departments and in clinic reception areas for patient information d) Get your flu shot annually to protect your patientsyour family and yourself

-pertussis, influenza -Negative pressure room, special air handling, masks/respirators (N95) worn by healthcare workers

XXIII) Needlestick and Bloodborne Pathogen Exposures a) Common Causes of Needlesticks i) Patient movement ii) Manipulation of device iii) Improper disposal into sharps container iv) Mislaid sharp in environment: not using neutral zone in OR v) Performing procedure too quickly vi) Not wearing personal protective equipment (PPE) in procedures vii) Insufficient inservice on device and or procedure b) Safe Sharps Disposal i) Never recap, bend or break needles ii) Dispose in puncture resistant sharps container at point of use iii) Observe container mouth for overfilling or protruding sharps before disposal. iv) Avoid need to transfer sharps to someone by using tray or other receptacle v) Always activate safety feature, if present, after procedure c) Safe Sharps Practices in the OR: 2 ORS 208 i) Use a hands free technique and or verbally announce the transfer when passing sharps items between surgeon and scrub personnel. ii) Keep electrical surgical unit pencils secured in the holster when not in use. iii) Always load blades with an instrument. iv) Avoid recapping but if necessary use a one handed technique. v) Contain sharps in a designated neutral zone. d) Post Exposure Follow-UP i) Notify supervisor and do incident report ii) Immediately report to OHS and or Emergency room for off hours iii) Assessment of exposed HCW and source patient will be done for HIV, HBV and HCV iv) Prophylaxis will be ordered if necessary v) Follow up testing will be offered through Occupational Health Services XXIV) HAI: Take Home Messages and Ongoing Messages a) Take Home Messages i) HAI occur frequently and are often deadly ii) HAI are often preventable iii) Primary method of spread of HAI from patient to patient, is by ? (1) Usually via ? of hands (2) Hand hygiene is critical for prevention of HAI (3) Limit duration and use of invasive devices (e.g. foley catheter) b) HAI: Ongoing Challenges i) Reimbursement and public reporting are putting HAI under the microscope more and more ii) Economic hardships for hospitals will make implementation of new programs challenging iii) Increasing pressure and work being placed on healthcare providers (1) Expect improved compliance with hygiene, HAI prevention c) HAI: What can You Do to Help i) Wash hands before and after every patient contac ii) Observe infection control policy (e.g. regarding barrier precautions) iii) Recognize but do not mimic poor HCW behaviors/compliance iv) Set an example v) As beginners, utilize unique perspective to recognize unsafe situations, improve safety

-the hands of healthcare workers -temporary colonization -

XX) The Efficacy of Contact Precautions a) Inpatient population b) Weekly surveillance cultures; molecular methods to identify strains and track sources of new colonization c) No contact isolation: i) 0.14 transmissions per day ii) Translates to 4.5 transmissions/day/32-bed ward d) Contact isolation: i) 0.009 transmissions/day ii) Translates to 0.3 transmissions/day/32-bed ward e) 94% reduction in new cases XXI) Why are HAIs Common? a) In 34 published observational studies between 1981-2000, the AVERAGE rate of compliance with standard handwashing policies was 40% (range 5-81%) b) In an observational study that included 488 observations of HCWs caring for patients with MRSA, i) gloves, gowns were worn 65% of the time, ii) handwashing occurred in only 35% of encounters. iii) gowns, gloves and handwashing were all (properly) used in only 28% of encounters. Afif et al Am J Infect Control 2002 Graph 3: Contact Precautions: More Is Not Necessarily Better XXII) Why wear gowns and gloves upon entering the room, if I don't plan to touch the patient? a) 69% of patient rooms housing patients colonized with a multidrug resistant organism (MDRO) had environmental cultures positive for a MDRO b) 27% of all surfaces sampled in those rooms were positive for MDROs c) When nurses touched contaminated surfaces, their gloves became colonized 42% of the time Image 9: DAZO Fluorescent Marking Gel is a patented methodology and process for monitoring environmental cleaning Removes subjectivity, measures ? Use one applicator per room to prevent cross-contamination Continuous improvement/learning tool Graph 4: The percentage of high-touch objects prior to (A) and after (B) educational interventions in 3 hospitals (A,B, and C).

-thoroughness of disinfection cleaning