1 / 52

Infection Control in ICU

Infection Control in ICU. Introduction. ICU patients are Immuno-compromised –as a non-specific response to critical illness or as a side effect of treatment Therefore they are at greater risk of nosocomial infection

irving
Download Presentation

Infection Control in ICU

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Infection Control in ICU

  2. Introduction • ICU patients are Immuno-compromised –as a non-specific response to critical illness or as a side effect of treatment • Therefore they are at greater risk of nosocomial infection • Multiple vascular catheters & tubes penetrate mucosal surfaces & increase risk of invasive infections

  3. Nosocomial Infections • Central line related infection • Ventilator associated infection • Urinary catheter related UTI • Post-op wound infection • Device related infection

  4. Epidemiology • Infected cases 7/100 admissions in Med ICU • Nosocomial Infections – 30%(/100 adm) • ESBLs > 50%, increased Death • Infection rate - 1.3% • Febrile Episodes – 5% • Klebsiella, Staph, E.coli – from patients

  5. My five moments for hand hygiene WHO Guidelines on Hand Hygiene in Health care. WHO 2009. WHO Library Cataloguing-in-Publication Data.

  6. Technique of Hygienic Hand Rub • Pour hand rub into palm (coin size) • First disinfect the tips of your finger & then rest of your hand • Contact time 30 sec • Rub until dry • Hygienic hand rub better than hygienic hand wash

  7. Moving between Patients • Wash hands or use alcohol disinfectant rub before leaving the bed • Do not share equipments between patients – separate BP instrument & stethoscopes for each bed • Do not use your own stethoscope which may be a vehicle for cross-infection

  8. Guidelines for the prevention of Intravascular catheter-related Infections Am J Infect Control 2011

  9. CRBSI; CDC Guidelines 2011 Selection of Catheters and Sites • CVCs – use the subclavian rather than the jugular or femoral • Avoid the subclavian in hemodialysis patients • Use US guidance • Minimize the number of ports or lumens • When adherence to aseptic technique cannot be ensured(in emergency) replace the catheter as soon as possible (within 48hrs) • Promptly remove catheters no longer essential

  10. CRBSI; CDC Guidelines 2011 • >0.5% CHG with alcohol • No ointments, except for dialysis patients • Replace gauze dressings q 2 days and TFDs at least q 7 days • Use CHG sponge dressings • No recommendations for other types of dressings • 2% CHG daily wash • Use sutureless securement device to reduce the risk of infection for intravascular catheters • Use coated CVCs • Greater than 5 days • Other strategies have failed

  11. CRBSI; CDC Guidelines 2011 • Do not routinely replace CVCs • Do not remove CVCs on the basis of fever alone • Do not use guidewire exchanges routinely to prevent infections • Do not use guidewire exchanges to replace catheters suspected of infection • Tubing changes • No more frequently than at 96 hours • No recommendation for intermittent sets • Blood, fat emulsions, 3-1 mixtures q 24 hours • Propofol infusions q 6 – 12 hours

  12. CRBSI; CDC Guidelines 2011 Needleless Devices • Change with administration sets no more frequently that 72 hours • “Scrub” the access port with an appropriate antiseptic (CHG, PVP, Iodophor, or 70% alcohol) • When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves.

  13. CRBSI; CDC Guidelines 2011 Pressure Monitoring Devices • Replace transducers at 96 hrs along with tubing, flush solution • Use closed flush system

  14. CRBSI; CDC Guidelines 2011 Education, Training, Staffing • Indication • Proper procedure for insertion • Maintenance • Appropriate Infection Control measures • Periodically assess knowledge(6 months) • Ensure appropriate nursing staff levels

  15. Central Line Bundle 5 key “Best Practices” • Hand Hygiene • Use of Maximal Barrier Precautions • Chlorhexidine for Skin Antisepsis • Optimal Insertion Site • Daily Review of Line Necessity & remove if not necessary

  16. CRBSI- What are Maximal Barrier Precautions? • For Provider: • Hand Hygiene • Non-sterile cap and mask • All hair should be under cap • Mask should cover nose and mouth tightly • Sterile gown and gloves • For the Patient • Cover patient’s head and body with a large sterile drape

  17. Maximal Barrier Precautions

  18. Chlorhexidine skin specialist • Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions. • Standard technique for Chlorhexidine is – • Prepare skin with antiseptic/detergent chlorhexidine 2 percent in 70 percent isopropyl alcohol. • Pinch wings on the Chlorhexidine applicator to break open the ampoule. Hold the applicator down to allow the solution to saturate the pad. • Press sponge against the skin, apply Chlorhexidine solution using a back and forth friction scrub for at least 30 seconds • Do not wipe or blot. • Allow antiseptic solution time to dry completely before puncturing the site (~2 minutes).

  19. CRBSI-Optimal Catheter Site Selection • Percutaneously inserted catheters are the most commonly used central catheters. • Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular & femoral site.

  20. CR-BSI Checklist • Before the procedure, did they: • Wash hands • Sterilize procedure site • Drape entire patient in a sterile fashion • During the procedure, did they: • Use sterile gloves, mask and sterile gown • Maintain a sterile field • Did all personnel assisting with procedure follow the above precautions

  21. CRBSI-Daily Review of Line • This will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of patient. • Necessary step to prevent infection includes, • Daily review of line necessity as part of multidisciplinary round is must. • Include assessment for removal of central lines as part of daily goal sheet. • Record time and date of line placement for record keeping purpose and evaluation by staff to aid in decision making of removal.

  22. CA-UTI; IDSA Guideline 2009 • Limiting Unnecessary Catheterization • Insertion technique–aseptic, sterile equip. • Sterile gloves, • Sterile drape, • Sterile sponges, • antiseptic solution for cleaning urethral meatus • a single-use packet of sterile lubricant jelly for insertion.

  23. CA-UTI-Management Bundle • Management of indwelling catheters • to properly secure indwelling catheters to prevent movement; • to maintain a sterile, continuously closed drainage system; • Not to disconnect the catheter and drainage tube • to replace the collecting system by use of aseptic technique and after disinfecting the catheter tubing junction when breaks in aseptic technique, disconnection, or leakage occur.

  24. CA-UTI Management Bundle • To maintain unobstructed urine flow. • To keep the collecting bag below the level of the bladder at all times. • To empty the collecting bag regularly; and to avoid allowing the draining spigot to touch the collecting container. • Cleaning of the meatal area as part of routine hygiene.

  25. CA-UTI; IDSA Guideline 2009 • Enhanced meatal care • not recommended for preventing CA bacteruria • No recommendation for CA-UTI • Closed catheter system with ports in the distal catheter for needle aspiration of urine • Routine catheter change – insufficient data • Discontinuation as soon as possible

  26. Urinary Catheter Care Monitoring • Urinary catheter (UC) care compliance is monitored once a day, every day. • The observer supervises and records how infection control procedures were performed by health care workers (HCWs) • UC on thigh without strangulating, • UC with collecting bag hanging, and not allowing urine reflux. • HCWs know that their practices are regularly supervised, but they are not aware of the precise moment in which observations are taking place.

  27. Urine c/s & Catheter replacement • Urine c/s prior to antibiotic • Indwelling catheter >2 weeks at the onset of CA-UTI, catheter should be replaced • Urine c/s should be obtained from the freshly placed catheter.

  28. CA-UTI Education & Training

  29. The Ventilator Bundle(IHI) 2004 • The key elements of the Ventilator Bundle are: • Elevation of the Head of the Bed • Daily “Sedation Vacations” and Assessment of Readiness to Extubate • Peptic Ulcer Disease Prophylaxis • Deep Venous Thrombosis Prophylaxis • Other potential additions • Oral Care Protocol • Mobility Protocol

  30. European care bundleCurr Opin Infect Dis 2009 1. no ventilator circuit tube changes unless specifically indicated; 2. strict hand hygiene practice with the use of alcohol based hand rub; 3. appropriately educated and trained staff; 4. sedation vacation and weaning protocol; 5. oral care with the use of chlorhexidine.

  31. Ventilator Bundles CDC • Elevation of the head of the bed (HOB) to 30º to 45º unless medically contraindicated, • Continuous removal of subglottic secretions, • Change of ventilator circuit no more often than every 48 hours, and • Washing of hands before and after contact with each patient

  32. Modifiable Risk Factors for VAP • Inadequate hand washing by staff, • Ventilatory circuit management practices, • Supine positioning of patients without backrest elevation, • Pooling of subglottic secretions • Previous antibiotic therapy, • Presence of a nasogastric tube, • Gastric alkalinization.

  33. Suctioning of oral secretions before each positional change has been shown to reduce the incidence of VAP J Clin Nurs 2009

  34. Oropharyngeal Decontamination American Journal of Critical Care. 2010 • 0.12% solution of chlorhexidine gluconate (chlorhexidine) 5 mL by oral swab twice daily (at 10 AM and 10 PM) • toothbrushing thrice daily, • both toothbrushing and chlorhexidine, • control (usual care). Conclusions : Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

  35. Saline installation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia Caruso P, Demarzo SE, Ruiz SAL, Denari S, Deheinzelin D. .ATS 2006 International Conference; May 19-24, 2006; • The incidence of VAP was significantly less in the arm receiving saline. Only 10.7% of these patients suffered VAP compared with 23.5% of those in the control group • Routine use of saline prior to suctioning, as is the standard practice in US ICUs, helps to prevent VAP without exposing the patient to any evident risk.

  36. Care of Ventilator Circuits & Prevention of VAP AARC evidenced based Clinical Practice Guidelines Respir Care 2003

  37. Summary of Recommendations • Ventilator circuits should not be changed routinely for infection control purposes. The maximum duration of time the circuits can be used safely is unknown • Evidence is lacking related to VAP & issues of heated vs HME, method for filling the humidifier & technique for clearing condensate

  38. Summary of Recommendations • Comparative trials with HME or active humidification have not demonstrated any differences in VAP. Crit Care Med 2007, J Hosp Infect 2007 • HME do not need to be changed daily for reasons of infection control or technical performance. They can be safely used for at least 48 hours.

  39. Summary of Recommendations • The use of closed suction catheters should be considered part of VAP prevention strategy & they do not need to be changed daily for infection control purposes. The maximum duration of time it can be used safely is unknown • Clinicians caring for MV patients should be aware of risk factors for VAP like nebulizer therapy, manual ventilation & patient transport.

  40. Halt Progression from Colonization to Infection • Extubate as early as possible • Remove central lines when not necessary • Remove Indwelling catheter • Change of IV lines, 3-ways, ventilator circuits, HME filters as per protocol • Prevention of VAP – suctioning, position,

  41. Gown Contamination an RCT • Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-hour Workday • Bacterial contamination occurs within hours after donning newly laundered short-sleeved uniforms. • After 8 hours of wear, no difference was observed in the degree of contamination of uniforms versus infrequently laundered white coats. • Our data do not support discarding long-sleeved white coats for short-sleeved uniforms that are changed on a daily basis. Journal of Hospital Medicine 2011.

  42. Hospital Uniforms Could Be a Source of Nosocomial Infections HospiMedica2011 • “The frequency of bacterial transmission from healthcare workers' clothing to patients is unknown. • Wearing short-sleeved coats or even having physicians discard their white coats could further reduce the cloth-borne transmission of pathogens. • The researchers also called for daily uniform changes, adequate laundering, plastic aprons for situations in which workers may contact body fluids, and strict hand hygiene

  43. Shoe Covers • Impact of Protective Footwear on Floor & Air Contamination in ICU • Con: Protective Footwear had no significant impact on floor contamination. MFJAI,2007

  44. Floor Mopping • As far as floor mopping is concerned, CDC does not give any specific frequency, however 3 to 5 times in a day with a strong disinfectant (not necessarily with antitubercular activity) is desired. • In our ICU(Hyderabad) we use 2% Bacilocid (Benzylkolnium with Gluteraldehyde) by adding 200ml in 10 Litres water. • We do the mopping three times a day as Bacilocid is an Excellent disinfectant.

  45. Housekeeping • The Mop head can be a big source of spreading infection, hence after each 30 minutes, the Mop head is immersed in Sodium Hypochloride solution for 3 minutes. • The walls are mopped by Bacilocid solution once every week and in between if visibly dirty. • The curtains are changed at least once every week and in between if they are visibly dirty.

  46. Visitors • Each area will need to draw up realistic rules to allow family interaction, to say goodbye to the dying & consistent with good medical practice for all patients in the ICU – Dr George John, Vellore

More Related