Early Recognition and Management of Sepsis for HHS

1. Early Recognition and Management of Sepsis for HHS Meeting 3 Pat Posa RN, BSN, MSA, CCRN-K, FAAN Quality Excellence Leader SJMHS

2. Early Recognition and Management of Sepsis • Welcome • Program design • Evidence-based and best practice education and training on protocols and tools necessary for early recognition of sepsis • Interactive and integrated team approach with all health professionals • Case-based approach • Utilizes Performance Improvement Plan • Includes home health agencies and discharging facility • Required data collection over the period of the improvement project and beyond and includes how to track and trend the data

3. Early Recognition and Management of Sepsis • Results: participating agencies implementing a sepsis protocol such that: • Improved screening and identification of septic patients receiving home health services • Improved identification of patients with sepsis • Improved early interventions for patients with sepsis • Reduced admission or readmission (30 and 90 days) • Reduce the severity of sepsis when admission is required • Assessment of current infection prevention practices for pneumonia, UTI’s and wounds • Implement one infection prevention practice to close the gap between current state and best evidenced based practice for each infection • Reduce mortality rates for those with sepsis (save lives) • Agency Expectations: • Implement sepsis screening tool and treatment protocols as provided in Early Recognition and Management of Sepsis Program • Participate in monthly learning sessions • Participate in a coaching call between session 1 and 2 • Submission of process data

4. Program overview • Pre-work prior to first session (watch a video) • 3 in-person 90 minute session (consecutive months) • 1 virtual 60 minute session • One coaching call between session 1 and 2

5. What We Did Last Meeting • Discussed implementation Strategies • Patient Education • Other Educational Tools • Reviewed the sepsis screening audit

6. Agenda for Today’s Meeting • Review homework • Discuss infection prevention strategies for PNA, UTI and wounds • Define homework

7. Round Robin • Complete steps 4*-6 on action plan • Develop and implement education plan for all staff • Define go live date for screening • Develop and implement patient/family education plan for sepsis • Define audit process and collect first one *4-if not done

8. Identification, Evaluation, and Prevention of Wound Infection Erik Wilson MS RN-BC WCC CPHQ Director of Nursing and Quality Optimal Care Inc.

9. Identification and Evaluation of Wound Infection Levels of Bioburden Bowler, P. (2003) Bacterial Growth Guideline: Reassessing its Clinical Relevance in Wound Healing. Ostomy Wound Manage. 2003;49(1) Retrieved from http://www.o-wm.com/content/bacterial-growth-guideline-reassessing-its-clinical-relevance-wound-healing-0 on June 22, 2018

10. Identification and Evaluation of Wound Infection Sibbald RG, Browne AC, Coutts P, Queen D. Screening evaluation of an ionized nanocrystalline silver dressing in chronic wound care. Ostomy Wound Manage 2001; 47(10): 38-43.

11. Bacterial Balance – Host Control • Contamination • Presence of non-replicating organisms • Arise from normal flora, external environment, and endogenous sources • Colonization • Replicating bacteria without host reaction • Bacteria are not pathogenic and do not necessitate abx tx

12. Bacterial Burden – Loss of Host Control • Critical Colonization • Organisms remain on the surface and impede wound healing; • No penetration to soft tissue has occurred • Infection • Microorganisms invade soft tissue and an inflammatory response is generated • Local inflammation and pus formation

13. SEPSIS Coggins, T (2010). Signs of infection in chronic wounds. McKnights Long-Term Care News: Guest Column. Taken from https://www.mcknights.com/guest-columns/signs-of-infection-in-chronic-wounds/article/191017/ on June 22, 2018

14. Preventing Wound Infection • Regular principles of handwashing • When and why for sterile vs clean technique • Clean Technique – “until research proves otherwise” • No sufficient evidence that supports the use of sterile over clean (Bryant and Nix, 2015) • Recommendation: Clean, no-touch technique (Bryant and Nix, 2015) • Home environment typically uses clean technique with occasional exceptions for sterile • Post operation first 48-72 hours • Special patient populations (High risk, unstable; Onc/Chemo) • Specific physician order Bryant, R.A., Nix D.P. (2015). Acute and chronic wounds: Current management and concepts 5th edition. Mosby Elsevier, St Louis, MS.

15. Preventing Wound Infection • Clean, No-Touch Technique (Bryant and Nix, 2015) • Maintain a controlled environment that is the most clean it can be • Prepare a sterile field (Sterile Drape non-permeable, prep supplies)* • Mandate use of sterile primary and sterile secondary dressing • Sterile cotton tipped applicator should be used to probe, fill, and pack wounds • Cleaning solutions and devices that hold solutions are sterile and have maintained sterility (swab tips with ETOH) • Non-sterile gloves are used *If no sterile drapes ensure supplies are organized in their sterile packaging Bryant, R.A., Nix D.P. (2015). Acute and chronic wounds: Current management and concepts 5th edition. Mosby Elsevier, St Louis, MS.

16. Wound Cleansing • Cleaning technique – Method of selection and why • Complications with wound cleansing (Bryant and Nix, 2015) • High Pressure (PSI) – wound irrigation, cleaners and sprays should not be less than 4 PSI nor exceed 15 PSI • Greater than 15 PSI forces bacteria to penetrate the wound further • Less than 4 PSI will NOT remove necessary bacteria • Is debris an issue? - if not, make sure to select a saline spray over a wound cleanser • Cleansers are not selective • Cleansers/preps that kill harmful bacteria also kill good bacteria, be thoughtful in your choice • Preps: Dakins, betadine, hydrogenperoxide (taboo) Bryant, R.A., Nix D.P. (2015). Acute and chronic wounds: Current management and concepts 5th edition. Mosby Elsevier, St Louis, MS.

17. Preventing Infection – Wound Care Walk Through – Clean, No Touch Dressing Removal Wound Bed Preparation Lay sterile, non-permeable Prep sterile supplies on drape without touching (include supplies you will clean wound with, less irrigation device) DON non-sterile gloves Cleanse/irrigate wound and periwound Wipe with sterile gauze or abd pad (not touching wound w/gloves) Remove gloves Wash hands • Wash Hands • DON non-sterile gloves • ETOH swab the irrigation device • Remove Dressing • Evaluate Drainage • Discard Dressing • Remove Gloves • Wash Hands *If no sterile drapes ensure supplies are organized in their sterile packaging

18. Preventing Infection – Wound Care Walk Through – Clean, No Touch Wound Care Assessment Wound Care Performance Prep-peri wound if required Apply primary dressing (if filling, packing, or applying ointments/creams use sterile applicators) Apply Secondary dressing if required Apply securement sources Clean and discard soiled materials (follow agency policy on discarding) Remove gloves Wash hands • Ensure the most adequate lighting is available to you • DON non-sterile gloves • Obtain wound culture if required* • Measure LxW dimensions • Use sterile cotton tip applicator for tunnels and undermining • If contamination occurs repeat wound bed prep cleansing otherwise… • Continue to wound care performance

19. Wound Care Highlights • Always clean the wound prior to assessing the status of the wound • Differentiae bacterial balance, burden, and infection • Normal wound healing: bottom up (collagen matrices) and edge contraction (myofibroblasts) • Know how the dressing selection may effect or alter wound healing • Ex: Santyl vs. Accuzyme

20. Obtaining a wound culture • NEVER obtain a wound culture on a wound that has not be cleansed • Do not take culture from an older dressing • Prior to obtaining culture, only cleanse with Saline • Cleansers/sprays will alter results • Use a “zig-zag Z” method while applying gentle pressure to expectorate fluid from the wound bed • Best effort to avoid slough (yellow) and eschar (black) tissue • Avoid periwound • Be a “steward” unless Empirical treatment is necessary • Obtain prior to initiation of abx

21. Teaching Patients and Caregivers • #1 – General infection control practices are critical • Ensure you have wound treatment plans in place that are inclusive • Infection prevention and control • Step-by-step instructions for dressing removal, wound bed prep, and wound care performance • Back up plans for dressing malfunction • Understand “clean environment” principles • Nutrition, exercise, pain plans • Agency protocol for teaching is up-to-date • Patient’s and Caregivers need monitoring materials • Stoplights • S/sx of infection

22. Wound: Current State Assessment *Recommended but not required

23. Pneumonia

24. Pneumonia Objectives • Define Pneumonia (PNA) • Identify risk factors of PNA • Identify signs and symptoms of PNA • Review PNA prevention strategies

25. Pneumonia Statistics • Leading cause of death due to infectious disease in the USA, sixth leading cause of death overall >65, leading cause for NH. • >900, 000 CAP cases in population over 65. • Mortality rate in USA about 5%. • Medicare paid 17.4 billion in 2004 for readmissions (about 17%).

26. Statistics…. Out of 12 million fee-for-service Medicare beneficiaries: • 20% readmitted within 30 days • 34% readmitted within 90 days • 54% readmitted within one year • 68.9% discharged with medical condition died within a year • 53% discharged with surgical condition died within one year.

27. Pneumonia • Infection of one or both lungs, lobar, segmental, or bronchial • More than 30 different causes • Can be serious, even fatal, especially for very young/very old. • Pneumococcal vaccine, influenza vaccine, and ACE inhibitors may have protective effect.

28. Risk Factors for Pneumonia • Inadequate oral hygiene • Immobility/Poor functional status • Aspiration • Difficulties in swallowing • Altered Mental Status • Co-morbidities • Lack of immunization • Smoking

29. The Older Adult At Risk • Cognitively impaired • Diminished swallow and cough reflex • Functionally dependant • Dry mouth • Multiple medications • High rate tooth decay • Behavioral problems during oral hygiene Research Dissemination Core. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center; 2002 Nov. 48 p. Marik PE. et al. Chest; 2003; 124:328–336

30. Significant Independent Predictors of Aspiration Pneumonia • Dependent for feeding • Dependent for oral care • Number of decayed teeth • Tube feeding • Multiple medical diagnoses • Number of medications • Dry mouth • Smoking Langmore SE. et al. Dysphagia 1998;13:69-81

31. Pathogenesis  Prevention

32. Pathogenesis  Prevention

33. Risk Factor Categories for Health Care Acquired Pneumonia • Factors that increase bacterial burden or colonization • Factors that increase risk of aspiration

34. Factors that Increase Bacterial Burden or Colonization • Extreme age, severe underlying condition/ immunosuppression • Administration of antibiotics • Agents which raise the gastric pH • Withholding gastric feeding • Mechanical ventilation • Immobility/Microaspiration • Lack of oral care • Poor infection control practices • Contaminated respiratory equipment/contaminated condensate • Saline administration

36. Oropharyngeal Colonization Methodology: • 49 elderly nursing home residents admitted to the hospital • Examined baseline dental plaque scores & microorganism within dental plaque • Used pulse field gel electrophoresis to compare chromosomal DNA Results: • 14/49 adults developed pneumonia • 10 of 14 pneumonias, the causative organism was identical via DNA analysis El-Solh AA. Chest. 2004;126:1575-1582

37. Practices in Oral Care That’s not the way we do it here!!! • Culture cup, ½ H2O2, ½ sterile H2O…little bit of mouthwash • Lemon glycerin swabs • Toothette with water &/or mouthwash • No oral care

38. Lemon & Glycerin Swabs • Harmful • Hastens drying of mucosa by depleting the saliva reserve caused by over-stimulation of salivary glands by lemon juice • Citric acid has no moisturizing capabilities • Irritates oral mucosa & decalcifies teeth • Glycerin is a trihydric alcohol that absorbs water causing drying Foss-Durant Am et al. Clin Nurs Res. 1997;6(1):90-104 Krishnasamy M. Eur J Cancer Care. 1995;4(4):173-177 Regnard C et al. Br Med J. 1997;315(7114):1002-1005 Van Drimmelen JR et al. Nurs Res 1969;18:327-332

39. Oral Care Reduces Pneumonia In Nursing Homes • 11 nursing homes in Japan over 2 year period • 417 enrolled / 366 residents analyzed (death from other causes) • 184 received oral care program/182 did not • Tooth brushing after each meal (teeth or dentures) & 1x weekly review by dentist/or hygienist Methodology Results Yoneyama et al. JAGS. 2002;50:430-433

40. Oral Care Reduces Pneumonia In Nursing Homes Residents • Oral care improves swallowing and cough reflex sensitivities Watando A. et al. Chest, 2004;126:1066–1070)

41. Brush & Swab • 77% more clean proximal sites with brushing • 44% more clean crevice sites with brushing • Benefit of brushing is directly correlated with technique • Foam swabs could not remove plaque from sheltered areas on or between teeth Pearson LS. et. al. J of Adv Nursing. 2002;39(5):480-489 Toothbrush; grade D, Swabs; unresolved, Use of flexible suction catheter post oral cleansing; Grade D (Berry AM et al. AJCC, 2007;16:552-563)

42. Brushing Removes Plaque • Methodology: • 34 volunteers. • Double-blind crossover study. • Examine the amount and % of plaque removed with a single brushing with 3 solutions (Sodium Bicarb, Crest, Cologate). • Results: • Significantly higher % of plaque removed with one minute brush using Sodium Bicarb. Mankodi et al. J Clin Dent. 1998; 9(3):57-60

43. Proposed Oral Care Plan Dependenton Oral Care Independent Ability to expectorate Unable to expectorate Weekly assessment Encouragement to perform tooth brushing /denture cleaning minimum x2 daily Assist with brushing teeth/clearing out debris & /or cleaning dentures using with CPCafter each meal/night & moisturize following cleaning Brush teeth (dentures) /clear debris using suction toothbrush am & pm with CPCfollowed by moisturizing Assist oral cleansing (dentures)/clear debris after lunch & dinner using a suction swab with CPCfollowed by moisturizing denture cleaning

44. Oral Care Protocol

45. Your Role in Preventing Pneumonia • Proper hand hygiene • Comprehensive Oral Care • Prevention of Aspiration • Swallow screens • Proper positioning during eating/feeding and sleep • Immunizations • Mobility/ Lung expansion • Adequate nutrition

46. Current State Assessment related to PNA Prevention Practices

47. PNA Prevention Action Plan

48. Preventing CAUTIs and UTI’s Through Evidence Based Care Practices

49. Pathogenesis of CAUTI • Source: colonic or perineal flora on hands of personnel • Microbes enter the bladder via extraluminal {around the external surface} (proportion = 2/3) or intraluminal {inside the catheter} (1/3) • Daily risk of bacteriuria with catheterization is 3% to 10%; by day 30 = 100% APIC Guide to Preventing CAUTI

50. Disrupting the Lifecycle of the Urinary Catheter 1. Preventing Unnecessary and Improper Placement 1 • Maintaining Awareness & Proper Care of Catheters 4. Preventing Catheter Replacement 2 4 3 3. Prompting Catheter Removal www.catheterout.org; (Meddings. Clin Infect Dis 2011)