Nosocomial Infections

What's Changed

-Evidence base for many infections -Standardized definitions -National benchmarks -Center stage in quality arena 1. public disclosure 2. pay for performance 3. public expectations -Switch from reactive to proactive

Old Infection Control

-Focus on surveillance -Reactive -Crisis Management -Based on education & good will

Droplet Precautions

-Prevent transmission of particles > 5 um size -Droplets produced when patient talks, coughs, sneezes -Private Room/cohort w another patient w same organism if no alternative -Mask for room entry -Mask for patient transportation out of room

SCIP (Surgical Care Improvement Project)

-Standard of care -STRONG evidence for 1. prophylactic antibiotics w/in 1 hr of incision 2. Antibiotic choice 3. Stopping w/in 24 hrs (48 hrs cardiac surg) -Individual hospital compliance is publicly reported on www.hospitalcompare.hhs.gov

Hand Hygiene (Standard Precautions Requirements)

-before/after touching patient's environment -immediately after removing gloves -between patients

Gloves (Standard Precautions Requirements)

-for touching blood, body fluids, secretions, contaminated items -for touching mucous membranes, nonintact skin

Empiric Isolation: Contact

1. Acute diarrhea & patient incontinent/diapered 2. Suspected C dificile (any age patient) 3. Vesicular rash 4. Respiratory symptoms-bronchiolitis, croup 5. History of infection/colonization w MDR organism (EX MRSA) 6. Abscess/draining wound

Minimal Hand Hygiene Standards

1. Alcohol gels -clean in & clean out -before & after gloves 2. Soap & water -C. difficile & Anthrax (spores) -visible dirt, blood, gunk, or debris

Standard Precautions

1. Blood 2. All body fluids & secretions -whether bloody/not -except sweat 3. Non-intact skin 4. Mucous membranes

Spaulding Classifications

1. Classification -level of patient contact -process required 2. Non-critical items -contacts intact skin (EX: BP Cuff) -low-level disinfection 3. Semi-critical items -contacts mucous membrane (EX: endoscope) -hi level disinfection 4. Critical items -contacts sterile tissue (EX: surgical instruments) -sterilization

HAI prevention bundles

1. Collections of evidence-based measures proven to prevent infections (VAP, CLABSI, UTI bundle) 2. Hardwired into daily work flow 3. Physician components (indications/insertions, daily assessment, discontinuation)

New Model

1. Evidence-based 2. Interventional 3. Process & Outcome 4. Performance Improvement 5. Safety Culture

Droplet Precautions Examples

1. Haemophilus influenze type B 2. Meningococcal infections 3. Mycoplasma pneumonia 4. Pertussis 5. Influenza virus 6. Mumps/rubella 7. Parvovirus 8. Adenovirus (+contact)

Fundamentals of Infection Prevention

1. Hand Hygiene 2. Cleaning, disinfection & sterilization 3. Isolation

Standard Precautions Requirements

1. Hand Hygiene 2. Gloves 3. Mask/Eye Protection/Face Shield 4. Gown 5. Patient Resuscitation

After 12 yrs...2 important things

1. Hand hygiene 2. Cleaning

Contact Precautions

1. Hand hygiene prior to donning gloves 2. Gown & gloves required for room entry 3. Remove gowns & gloves prior to exiting isolation room 4. Hand hygiene AFTER removing gloves 5. Dedicated noncritical care items (EX: stethoscopes)

Organisms in hospital surfaces

1. Influenza virus -Contamination: aerosolization after sweeping, survival on fomites -Survival Time: 24-48 hrs nonporous surfaces 2. Parainfluenza virus -Contamination: clothing & nonporous surfaces -Survival: 6 hrs clothing & 10 hrs nonporous 3. Noroviruses -Contamination: ships, environmental contamination, aerosolization -Survival: 14 days in stool samples, 12 days on carpets 4. Hep B Virus -Contamination: blood -Survival: 7 days 5. SARS-associated coronavirus -Contamination: ED environment, 2ndary attack rate events -Survival: 24-72 hrs on fomites & stool samples 6. Candida species -Contamination: fomites -Survival: 3 days to 14 days 7. Clostridium difficile -Contamination: environmental -Survival: 5 months hospital floor 8. Pseudomonas aeruginosa -Contamination: sink drains -Survival: 7 hrs glass slide 9. Acinetobacter baumanrii -Contamination: environmental -Survival 33 days plastic laminate surface 10. MRSA -Contamination: burn units -Survival: 9 wks after drying, 2 days plastic laminate surfaces 11. VRE -Contamination: environmental -Survival: 58 days countertops

Empiric Isolation: Droplet

1. Meningitis 2. Petechial/ Echymotic rash w fever 3. Respiratory viral infection (until determine specific virus & need contac vs droplet vs contact + droplet) 4. Paroxysmal/severe, persistent cough (if ruling out pertussis-ISOLATE)

Contact isolation by organism

1. Multidrug resistant bacteria (MRSA, VRE, MDR gram negative bacilli) 2. RSV/Parainfluenza 3. Enterovirus 4. HSV 5. Adenovirus (droplet & contact) 6. Varicella (contact & airborne) 7. C dificile 8. Scabies, lice

Contamination of Personal Equipment

1. Personal stethoscopes -dedicated scopes in isolation rooms -wipe off scope w alcohol after use 2. Blood pressure cuffs 3. Otoscopes -wipe off after use in isolation rooms 4. Ties, clothing -keep off patient & bedspace

Type of isolation precautions

1. Standard Precautions 2. Transmission based precautions -Contact -Droplet -Airborne

Airborne Precautions Examples

1. TB 2. Measles 3. Varicella 4. MERS/SARS 5. Disseminated Zoster (includes zoster in immune compromised host) -If patient has suspected/confirmed measles, varicella, disseminated zoster, then non-immune individuals should not enter

Common Hospital-Associated Infections (HAIs)

1. UTI 2. Bloodstream infection 3. Pneumonia 4. Surgical Site Infection (SSI) 5. Multiple Infections

.Empiric Isolation: Airborne

1. Vesicular rash 2. Maculopapular rash w coryza & fever 3. Cough, fever, upper lobe infiltrate 4. Cough, fever, pulmonary infiltrate in any location in HIV infected patient/patient at risk for HIV

Airborne Precautions

1. Wear N 95 respirator 2. Private, Negative, Air pressure room (required. keep doors closed) 3. Transportation Limit to essential travel (use surgical mask on patient during transport)

US HAI Prevalence

1/25 hospitalized patients 722,000 HAIs/yr in US 75K deaths/yr in US

Evidence for Hand Hygiene

1837-Puerperal fever rampant -Colleague died of puerperal sepsis-like syndrome after autopsy accident *Ignaz P Semmelweiss* noticed mortality higher in med students than midwifes -> Handwashing begins = 10x reduction in mortality

HAIs in Pennsylvania

2004: 11668 HAIs 7.5 HAIs per 1000 patients admitted 15.4% of patients died $2 bill additional hospital charges 205K additional hospital days

HAI in Houston

5-10% hospitalized patients 30% mortality 77K cases/yr 1-2bill/yr "The cost of doing business" "Normal" "Expected"

% Patients Receiving Preventative Antibiotics Before Surgery

94%: Top Hospitals 75%: US Average 66%: TX Average 52%: Memorial Hermann

% Patients Whose Preventative Antibiotics Stopped w/in 24 Hrs After Surgery

96%: Top Hospitals 70%: US Average 63%: TX Average 47%: Memorial Hermann

Sterilization

Complete absence of any microorganisms

Couple of things to keep in mind

Don't eat/drink in patient care units -linked to disease & outbreaks -OSHA & dept of health violations/fines ($400) No artificial nails Clothes If you're symptomatic (cough, fever, congestion) -see student health, get tested for flu (in season) or pertussis (anytime) -DO NOT work in hospitals/clinics while symptomatic Get vaccinated -influenza vaccine -pertussis vaccine (Tdap free) -Hep A & B Exposures -Stop, Wash, 1st Aid -Call hotline in back of badge

Empiric Isolation

Don't need to wait! -Patients w certain clinical syndromes & symptoms should be isolated while definitive diagnosis pending -If ruling out diagnosis based on clinical symptoms & diagnosis requires isolation-DO NOT WAIT FOR TEST RESULTS TO ISOLATE

Mask/Eye Protection/Face Shield (Standard Precautions Requirements)

During procedures & patient care activities likely to generate splashes, sprays, fluids, secretions

Bottom Line

HAIs do hurt & kill real people Long & short term consequences of HCW actions Nearly all infections preventable 0 = worthy goal

Housekeeping vs Bioquell

Housekeeping 72% Growth 28% No Growth Microbiology: -92% SSNA/Bacillus -6% GNRs -2% Micrococcus Bioquell 22% Growth 78% No Growth Microbiology -100% SSNA/Bacillus *Growth by room is more than 2x higher for housekeeping than bioquell

New Cleaning Technology

Hydrogen peroxide vapor (HPV) tech to reduce # micro-organisms in hospital room

CLABSI bundle (central line-associated bloodstream infection)

Insertion -Hand hygiene -Maximal barrier precautions -Chlorhexidine skin antisepsis -optimal catheter site selection, avoiding femoral lines Maintenance -Nursing care -Daily review of line necessity w prompt removal of unnecessary lines

CAUTI bundle (Catheter-associated Urinary Tract Infection)

Insertion & Care -Indications for catheterization -Standardized insertion & care Maintenance -Closed system -Aseptic technique -Secure foley -BBB (bag below bladder) -Daily assessment & discontinuation`

Bloodstream Infection (BSI)

Insertion & Maintenance Bundle compliance correlates w/ lower BSI rate

Pressing Problems

MDROs -MRSA -VISA & VRSA -MDR gram negatives (Acinetobacter, Pseudomonas, ESBLs, CRE) C Difficile Infections

Nosocomial Infections

Not present/incubating upon admission to hospital (48 hr rule) Cost exceed 4.5 bill/yr

Cultures of HCW gowns & gloves for full protection

Nursing personnel after Routine care of patients w MRSA: -65% contaminated gowns/uniforms -58% contaminated gloves White Coats: -69% contaminated after examining colonized patient -27% transferred to hands of HCW after touching white coat Rooms of MRSA+ Patients -MRSA Infected Patients: 73% contamination of room surfaces -MRSA Colonized Patients: 69% contamination of room surfaces

VAP bundle (VAP = ventilator-associated pneumonia)

Pathogenesis largely related to aspiration, so: -frequent suctioning -Head of bed > 30 degrees -Oral care -Early extubation

Financial Impact

Pneumonia -Increased LOS =15 - +$56K Bacteremia -Increased LOS = 11 - + $40K Wound -Increased LOS = 7 - + $3.1K UTI -Increased LOS = 1 - + $700 LOS = length of stay

Healthcare-associated Infections

Preferred term for nosocomial infections

Why isolate (or cohort) patients?

Prevent nosocomial transmission of microorganisms from infected/colonized patients to: -other patients, healthcare workers, visitors 1 of most important tools in infection prevention

Airborne Precautions

Prevent transmission of diseases transmitted by droplet nuclei (<5um size) or contaminated dust particles -Droplet nuclei remain suspended in air Don respirator prior to room entry Respirator must: 1. filter 1 um particles w >= 95% efficiency (N-95) 2. Fit different facial sizes 3. Fit tested to obtain leakage <10%

Contact Precautions

Prevent transmission of organisms from infected OR colonized patient thru direct/indirect contact -Direct: touching patient -Indirect: touching surfaces/objects in patient's environment Require private room/cohort w another patient infected/colonized w same organism

Gown (Standard Precautions Requirements)

Protect skin & prevent soiling of clothes during procedures & patient care activities likely to generate splashes, sprays, fluids, secretions

Cleaning

Removal (usu. w. detergent & water / enzyme cleaner & water) of adherent visible soil, blood, protein substances, microorganisms & other debris from surfaces, crevices, serrations, joints & lumens of instruments, devices & equipment by manual/mechanical process that prepares items for safe handling &/or further decontamination

Disinfection

Thermal/chemical destruction of pathogenic & other types of microorganisms -Less lethal than sterilization bc destroys most recognized pathogenic microorganisms but not necessarily all microbial forms (EX: bacterial spores)

BIOQUELL Process

Total Time = 90-120 min 1. Patient admitted 2. Patient discharged 3. EVS cleans room 4. Vents & doors sealed off 5. Machines run 6. Room scanned for lingering HPV 7. Vents & doors re-opened (Cycle)

Patient Resuscitation (Standard Precautions Requirements)

Use mouthpieces, resuscitation bags to avoid mouth to mouth resuscitation

Inanimate environment can facilitate transmission

contaminated surfaces increase cross-transmission

Public Reporting of HAIs

w/ HAI: $29K+ avg payment (3.5x w/o) 5.6% Died (8x w/o) w/o HAI $8K+ avg payment 0.7% died