To join the online webinar, go to: safetyleaders Online Access Password: Webinar1 (case-sensitive)

1. Welcome to the NQF Safe Practices for Better Healthcare Webinar: Updated 2010 CLABSI and SSI Practices: A New Standard of Care (Safe Practices 21-22) Hosted by NQF and TMIT To join the online webinar, go to: www.safetyleaders.org Online Access Password: Webinar1 (case-sensitive)

2. Welcome and Safe Practice Overview Charles Denham, MD Chairman, TMIT Co-chairman, NQF Safe Practices Consensus Committee Chairman, Leapfrog Safe Practices Program Safe Practices Webinar February 18, 2010

5. Panelists Peter Angood Rabih Darouiche Charles Denham Charles Denham: Welcome and Safe Practices Overview Peter Angood: HAI Clinical and Financial Implications and Policy Future Rabih Darouiche: New Highlights in CLABSI and SSI Prevention

6. Panelists Mary Oden Jennifer Dingman David Classen David Classen: Future Picture of Prevention of HAIs Mary Oden Challenges for Infection Preventionists Jennifer Dingman: The Role of the Patient Advocate

7. The Role of the Patient Advocate Jennifer Dingman Founder of Persons United Limiting Substandards and Errors in Healthcare (PULSE), Colorado Division Co-founder, PULSE American Division Safe Practices Webinar February 18, 2010

8. Harmonization – The Quality Choir

9. 2010 NQF Safe Practices for Better Healthcare: A Consensus Report • 34 Safe Practices • Criteria for Inclusion • Specificity • Benefit • Evidence of Effectiveness • Generalization • Readiness

10. Culture Consent & Disclosure Consent and Disclosure Workforce Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- & Site-Specific Practices 10

11. Culture • CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices] • Leadership Structures and Systems • Culture Measurement, Feedback, and Interventions • Teamwork Training and Team Interventions • Identification and Mitigation of Risks and Hazards Structures and Systems Culture Meas., FB., and Interv. Team Training and Team Interv. ID and Mitigation Risk and Hazards Consent & Disclosure Consent and Disclosure • CHAPTER 3: Informed Consent and Disclosure • Informed Consent • Life-Sustaining Treatment • Disclosure • Care of the Caregiver Informed Consent Life-Sustaining Treatment Disclosure Care of Caregiver Workforce • CHAPTER 4: Workforce • Nursing Workforce • Direct Caregivers • ICU Care Nursing Workforce Direct Caregivers ICU Care • CHAPTER 5: Information Management and Continuity of Care • Patient Care Information • Order Read-Back and Abbreviations • Labeling Studies • Discharge Systems • Safe Adoption of Integrated Clinical Systems including CPOE Information Management and Continuity of Care Patient Care Info. Read-Back & Abbrev. Labeling Studies Discharge System CPOE Medication Management • CHAPTER 6: Medication Management • Medication Reconciliation • Pharmacist Leadership Role Including: High-Alert Med. and Unit-Dose Standardized Medication Labeling and Packaging Med. Recon. Pharmacist Systems Leadership: High-Alert, Std. Labeling/Pkg., and Unit-Dose • CHAPTER 7: Hospital-Associated Infections • Hand Hygiene • Influenza Prevention • Central Venous Catheter-Related Blood Stream Infection Prevention • Surgical-Site Infection Prevention • Care of the Ventilated Patient and VAP • MDRO Prevention • UTI Prevention Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central V. Cath. BSI Prevention Sx-Site Inf. Prevention VAP Prevention MDRO Prevention UTI Prevention • CHAPTER 8: • Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention • Pressure Ulcer Prevention • DVT/VTE Prevention • Anticoagulation Therapy • Contrast Media-Induced Renal Failure Prevention • Organ Donation • Glycemic Control • Falls Prevention • Pediatric Imaging Condition-, Site-, and Risk-Specific Practices Wrong-site Sx Prevention Press. Ulcer Prevention DVT/VTE Prevention Anticoag. Therapy Contrast Media Use Organ Donation Glycemic Control Falls Prevention Pediatric Imaging

12. HAI Guidelines

13. Before insertion: Educate healthcare personnel involved in the insertion, care, and maintenance of central venous catheters (CVCs). At insertion: Use a catheter checklist at the time of CVC insertion. Perform hand hygiene prior to catheter insertion or manipulation. Avoid using the femoral vein for central venous access in adult patients. Use a catheter cart or kit with components for aseptic catheter insertion. Use maximal sterile barrier precautions. Use chlorhexidine gluconate 2% and isopropyl alcohol solution as skin antiseptic preparation in patients over two months of age and allow appropriate drying time per product guidelines. After insertion: Use a standardized protocol to disinfect catheter hubs, needleless connectors, and injection ports before accessing the ports. Remove nonessential catheters. Use a standardized protocol for non-tunneled CVCs in adults and adolescents for dressing care. Perform surveillance for CLABSI and report the data on a regular basis. NQF CLABSI Prevention Safe Practice Specifications: 2010 Update 13

14. Educate of healthcare professionals involved in surgical procedures. Educate the patient and his or her family as appropriate about SSI prevention. Conduct periodic risk assessments for SSI. Ensure that measurement strategies follow evidence-based guidelines. Provide SSI rate data and prevention outcome measures to key stakeholders. Administer antimicrobial agents for prophylaxis. When hair removal is necessary, use clippers or depilatories. Maintain normothermia immediately following colorectal surgery. Control blood glucose during the immediate postoperative period for cardiac surgery patients. Preoperatively, use chlorhexidine gluconate 2% and isopropyl alcohol solution as skin antiseptic preparation, and allow appropriate drying time per product guidelines. NQF SSI Prevention Safe Practice Specifications: 2010 Update

15. The Association for Professionals in Infection Control & Epidemiology • MissionTo improve health and patient safety by reducing the risks of infection and related adverse outcomes. • The preeminent voice in infection prevention Over 13,000 members worldwide with responsibility for infection prevention, control and hospital epidemiology in a variety of healthcare settings.

16. APIC Targeting Zero Initiative • Elimination Guides Evidence-based strategies to implement CDC guidelines, NQF Safe Practices and recommendations from the SHEA-APIC-IDSA Compendium • Guides to the elimination of SSIs, CR-BSIs, Mediastinitis, C. difficile, VAP and MRSA (hospital and long term care versions) help you bring science to the bedside • New guides in 2010 on A. baumannii, Hemodialysis and SSIs in orthopedics and oncology • Research 2006 MRSA & 2007 C. difficile Prevalence Studies, 2010 MRSA II Study • Education The most comprehensive program of live and online education to reduce infection, meet new and emerging regulatory requirements and understand the changing legal standard in acute, ambulatory and long term care settings Visit www.apic.org to learn more. Visit www.apic.org/targetingzeroto learn more about the initiative and to access resources and practical tools

17. HAI Clinical and Financial Implications and Policy Future Peter B. Angood, MD, FRCS(C), FACS, FCCM Senior Advisor, Patient Safety, National Quality Forum Member of Safe Practices Steering Committee Former Chief Patient Safety Officer and Vice President for The Joint Commission Safe Practices Webinar February 18, 2010

18. Background: Impact of HAIs • 5%-10% of hospitalized patients develop an HAI • 99,000 deaths per year • $20 billion per year1 • Risk of serious HAI complications is highest for patients requiring intensive care • Increasing number of HAIs • Sicker patient population • More complex procedures and equipment • Increasing antimicrobial resistance 1Stone PW, et al. AJIC 2005; 33:501-5

19. Estimated Number of Healthcare-Associated Infections in U.S. Hospitals by Subpopulation and Major Site of Infection, United States, 2002 Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

20. 263,810 274,098 -967 -21 -28,725 244,385 TOTAL HRN WBN Non-newborn ICU = SSI 133,368 Other BSI 22% 11% SSI 20% UTI PNEU 36% 11% 424,060 129,519 Calculation of Estimates of Healthcare-Associated Infections in U.S. Hospitals Among Adults and Children Outsideof Intensive Care Units, 2002 HRN = high-risk newborns; WBN = well-baby nurseries; ICU = intensive care unit; SSI = surgical-site infections; BSI = bloodstream infections; UTI = urinary infections; PNEU = pneumonia Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

21. What Are the Costs of Healthcare- Associated Infections? • U.S. • Total excess costs $32 million to $825 million annually • Most costs not reimbursed when DRGs are used or if costs are capitated • Preventing 6% of nosocomial infections offsets cost of $60,000 I.C. program • UK = cost £111 million/year and 950,000 lost bed days (1987) • Decrease NI rate by 20%, saves $15 million - $16 million

22. NQF Safe Practices – 2010: Healthcare-Associated Infections 19. Hand Hygiene • Influenza Prevention • CLABSI Prevention • Surgical-Site Infection Prevention • Care of the Ventilated Patient • MDRO Prevention • Catheter-Associated UTI Prevention

23. New Highlights in Central Line-Associated Bloodstream Infectionand Surgical-Site Infection Prevention Rabih O. Darouiche, MD VA Distinguished Service Professor Director, Center of Prostheses Infectionat Baylor College of Medicine Safe Practices Webinar February 18, 2010

24. Disclosure Statement • Co-invented antimicrobial-coated catheters that are licensed by Baylor College of Medicine to Cook Inc • Received educational and research grants from CareFusion • Do not plan to discuss off-label and investigational use of devices or drugs

25. Address similarities and differences between CLABSI and SSI Assess the impact of these two infections Analyze potentially protective approaches Overview of Presentation

26. Similarities Between CLABSI and SSI Both infections result primarily from breaking skin integrity Both infections are caused mostly by skin organisms Both infections occur at unacceptably high rates, can be difficult to manage, may require future intervention(s), and are expensive to treat

27. Differences Between CLABSI and SSI CLABSI manifests while the catheter is still in place, whereas SSI can manifest at any time after surgery, usually by 30 days post-op Microbiologic cause of CLABSI is almost always identified, whereas the microbiologic cause of SSI is unknown in many patients Occurrence of CLABSI can be attributed to various healthcare providers, whereas SSI is typically linked to the surgeon

28. Clinical Manifestations of infected CVC Exit site infection Tunnel infection Thrombophlebitis BSI

29. Impact of CLABSI Incidence: of the 6 million CVC inserted annually in the U.S., 250,000 result in BSI Management: cure often requires removal of the infected catheter and long antibiotic therapy Medical sequelae: attributable mortality 5%-25% Economic burden: cost of treatment is $10K-$56K; annual cost in U.S., $3 billion–$16.8 billion

30. Annual Death Rates in the U.S. for Selected Infectious Diseases

31. Nosocomial Infections in the ICU 95% Urinary Catheters 86% Mechanical Ventilation 87% central lines < 55 = 33% 55 – 70 = 32% >70 = 35% N= 14,177 National Nosocomial Infections Surveillance (NNIS) (97 hospitals)

32. Gram-Positive Bacteremia in Cancer Patients: Role of the CVC 80% 70% 70% 56% 60% 50% 44% % of Bacteremia with CVC as the source 40% 30% 30% 20% 10% 0% Non-CRBSI CRBSI Non-CRBSI CRBSI Solid Tumor Malignancy Hematologic Malignancy

33. Difference between Surveillance Definition (by National Healthcare Safety Network: NHSN) and Clinical/Microbiologic Definition of CLABSI Surveillance definition:includes all cases of BSI in patients with CVC in whom other sites of infection are excluded (catheter-associated BSI varies from from 1.3/1000 cath-days in medical surgical wards to 5.6/1000 cath-days in burn ICU) Clinical/microbiologic definition: includes only cases of BSI in patients with CVC in whom other sites of infection are excluded and microbiologic relationship of catheter to BSI exists (catheter-related BSI)

34. Relationship between Catheter Colonization and Bloodstream Infection Principle: catheter colonization is a prelude to catheter-related bloodstream infection Objective: to prevent infection by inhibiting catheter colonization

35. IA Recommendations in Upcoming CDC Guidelines for Prevention of CLABSI Staff education and training Insert CVC in subclavian catheters Place hemodialysis catheters in jugular or femoral veins Promptly remove CVC when no longer essential Hand wash with soap/water or alcohol-based hand rubs Utilize 2% chlorhexidine-based preparation for skin cleansing before inserting CVC, during dressing changes, and wiping access ports of needleless catheter systems Use sterile gauze or transparent semi-permeable dressings Use antimicrobial-impregnated CVC if expected duration of placement >5 days and CLABSI remains higher than goal set by institutions despite comprehensive strategy Guidelines for the Prevention of Intravascular Catheter-related Infections. Atlanta (GA): Centers for Disease Control and Prevention; 2010. [draft]

36. Before insertion: Educate healthcare personnel involved in the insertion, care, and maintenance of central venous catheters (CVCs). At insertion: Use a catheter checklist at the time of CVC insertion. Perform hand hygiene prior to catheter insertion or manipulation. Avoid using the femoral vein for central venous access in adult patients. Use a catheter cart or kit with components for aseptic catheter insertion. Use maximal sterile barrier precautions. Use chlorhexidine gluconate 2% and isopropyl alcohol solution as skin antiseptic preparation in patients over two months of age and allow appropriate drying time per product guidelines. After insertion: Use a standardized protocol to disinfect catheter hubs, needleless connectors, and injection ports before accessing the ports. Remove nonessential catheters. Use a standardized protocol for non-tunneled CVCs in adults and adolescents for dressing care. Perform surveillance for CLABSI and report the data on a regular basis. NQF CLABSI Prevention Safe Practice Specifications: 2010 Update

37. Comprehensive Protective StrategyInfection Control Bundle Hand washing Maximal barrier precautions 2% chlorhexidine-based skin antisepsis Avoiding femoral site if possible Removing unnecessary catheters

38. Although very essential, they: Are not easily enforceable Are not very durable Do not completely prevent infection Save some, but not enough, lives Potential Limitations of Traditional Infection Control Measures

39. Reasons to Optimize Prevention of SSI Unacceptably high incidence: the 30 million annual surgical procedures in the U.S. result in 300,000-500,000 cases of SSI Difficult management: may require repeated surgical interventions Serious medical consequences: tremendous morbidity and occasional mortality Soaring economic burden: annual cost of treatment in the U.S. is >$7 billion

40. Perioperative Approaches for Preventing SSI Non-antimicrobial approaches Normothermia Adequate oxygenation Tight glucose control Antimicrobial approaches Systemic antibiotic prophylaxis Nasal application of mupirocin Skin antisepsis

41. Impact of Timing of Systemic Antibiotic Prophylaxis on SSI

42. A Prospective Randomized Trial of Nasal Mupirocin Plus Chlorhexidine Wash • Rapid identification of nasal carriage by S. aureus followed by a 5-day course of nasal mupirocin plus chlorhexidine wash: • Reduces S. aureus infection (3.4% vs. 7.7%) • Decreases S. aureus SSI by almost 60% • Bode, et al. N Engl J Med 2010;362:9-17

43. Importance of the Skin Largest bodily organ Protective barrier Skin flora most common cause of SSI (and CLABSI) 80% of bacteria reside in epidermis

44. Factors that Support the Need for Optimal Skin Antisepsis Most pathogens that cause SSI are skin flora At least 2/3 of cases of SSI are incisional Most SSI are considered preventable Other preventive measures reduce but do not eliminate SSI

45. Commonly used Preoperative Antiseptics Povidone-iodine (Iodophor) Chlorhexidine gluconate Alcohol Combination products: >2 active agents

46. Comparison of Antimicrobial Activity of Antiseptic Preparations Chlorhexidine-based preparations are better than alcohol or iodine-based products in: Reducing colonization of vascular catheters Preventing contamination of blood cultures Decreasing contamination of surgical tissues

47. Pressing Need to Compare Clinical Efficacy of Antiseptic Preparations in Preventing SSI CDC guidelines for prevention of infections related to vascular catheters recommend antiseptic cleansing of the skin with 2% chlorhexidine-containing products O’Grady, et al. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 2002;51(RR-10):1-29 CDC has not previously issued a preference as to type of preoperative skin antiseptics

48. Prospective, Randomized, 6-Center Clinical Trial of 849 Patients Population: adult patients scheduled for abdominal or non-abdominal clean-contaminated surgery Randomization: hospital-stratified Intervention: preoperative skin cleansing with: ChloraPrep® (2% chlorhexidine gluconate-70% isopropyl alcohol = CA) 26-ml applicators; OR 10% povidone-iodine (PI) scrub and paint Evaluation: SSI was assessed by blinded evaluators Darouiche, et al. N Engl J Med 2010;362:18-26

50. Kaplan-Meier Curves for Freedom from Surgical-Site Infection (Intention-to-Treat Population)