Infection Prevention

1. Infection Prevention Jeneene Kitz, RN, CIC and Linda Salinas, MD

2. Infection ControlBackground • A discipline that applies epidemiologic and scientific principles to prevention/reduction of nosocomial infection rates • Proven to reduce healthcare associated infections and be cost-effective • Infection control (IC) programs are mandated by the Joint Commission For Accreditation of Hospitals • Guidance from the Centers for Disease Control and Prevention (CDC) • Requires organizational commitment to a culture of safety for success

3. IC Functions and Responsibilities Direct Indirect Surveillance Education Outbreak investigations Disinfection/sterilization of equipment Prevention of infections due to intravascular catheters, ventilators, urinary catheter, surgical site infections Oversight of new products related to healthcare associated infections Antibiotic stewardship Employee health Construction

4. A Typical Meeting Agenda • Review and approval of Previous Minutes • Regular Reports Targeted Surveillance (CLABSIs, VAPs, CAUTIs, etc) Biological Testing of Sterilizers Dialysis Water Quality Employee Health Services Drug Susceptibilities Special Investigations Construction Activity • Old Business Influenza vaccination • New Business Video “hand hygiene” C. difficile enhancements to Meditech • Policy Review New bed bug policy

5. The Father of Infection Control • Ignaz Semmelweis • “Savior of Mothers” • Etiology, Concept and Prophylaxis of Childbed Fever • Ridiculed and rejected by his contemporaries • Died in an asylum at 47 http://en.wikipedia.org/w/index.php?title=Ignaz_Semmelweis&oldid=347654128

6. The Legacy of Dr. Semmelweiss First Clinic had widely fluctuating mortality rates but ~10% Second Clinic had ~4% mortality Instituted policy of handwashing using chlorinated lime solution First Clinic mortality immediately declines to 1-2% The positivists reject the theory http://en.wikipedia.org/w/index.php?title=Ignaz_Semmelweis&oldid= 347654128

7. Pioneers of Infection Control Louis Pasteur (1822-1895) Joseph Lister (1827-1912) The germ theory of disease Fermentation is caused by microorganisms and not spontaneous generation Proposed microorganisms infecting humans and animals cause disease Postulated exposure to heat, filtration or chemical solutions may eliminate the organisms English surgeon Influenced by Pasteur Pioneered sterile surgical techniques Introduced carbolic acid to sterilize instruments and wounds in 1867 Listeria named in his honor in 1940

8. Fast Forward • 1961: U.S. Public Health Service recommends hand washing before and after patient contact. Antiseptics have limited usefulness • 1975 & 1985: CDC publishes written handwashing guidelines. Alcohol-based solutions useful if no sink available • 1995 & 1996: Other IC groups release similar guidelines but now recommend either antimicrobial soap or alcohol-based product

9. MMWROctober 25, 2002 Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

10. Hand HygieneRationale • Bacterial counts on health care worker (HCW) hands range from 3.9 x 10⁴ to 4.6 x 10⁶ CFUs/cm2 • Transient flora colonize the superficial layers associated with healthcare associated infections amenable to hand hygiene • HCW hands may become persistently colonized with pathogenic flora

11. Pathogen Transmission via HCW Hands • Pathogens recovered from intact skin as well as draining wounds • Direct patient contact and respiratory-tract care most likely to contaminate HCW hands • Duration of care activity is strongly associated with bacterial intensity • Skin is shed daily, including it’s pathogens, onto inanimate surfaces

12. The Inanimate Environment Can Facilitate Transmission . Xrepresents VRE culture positive sites Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL

13. The Hands Give It Away • A: Imprint of ungloved HCW hand following abdominal exam of a patient colonized with MRSA • B: Imprint following alcohol-based hand hygiene New England Journal of Medicine Volume 360:E3 January 15, 2009

14. Hand Hygiene RecommendationsA Few Highlights • If hands are not visibly soiled, use an alcohol-based rub • Decontaminate hands before direct patient contact • Decontaminate hands after contact with pt intact skin • Decontaminate hands after contact with inanimate objects in the immediate pt vicinity • Decontaminate hands after removing gloves • Keep natural nail tips less than ¼ inch long Guideline for Hand Hygiene in Health-Care Settings; MMWR 2002:51(RR-16)

15. Hand Hygiene Adherence • Observational studies have shown an overall average of about 40% (5%-81%) • Methods and definitions of adherence are very variable • High activity rate and physician involvement associated with lowest adherence • Dirty tasks, performance feedback and availability of alcohol rub associated with highest compliance • In a recent study, a 1% increase was estimated to save $40,000 annually in a 200 bed hospital ² Erasmus V. Infect Control Hosp Epidemiol 2010;31:283-294 ²Cummings K. Infect Control Hosp Epidemiol 2010;31:357-64

17. Standard Precautions Standard Precautions are the basic level of infection control that should be used in the care of all patients all of the time • Use standard precautions in the care of all patients to reduce the risk of transmission of microorganisms from both recognized and non-recognized sources of infection. • Applies to blood, all body fluids, secretions and excretions (except sweat) whether or not they contain visible blood; non-intact skin; and mucous membranes. • Personal protective equipment (PPE) to carry out standard precautions includes: Gowns, Masks, Eye protection and Face shields

18. Transmission Based Precautions • Standard precautions with the addition of… Airborne Infection Isolation Droplet Contact

19. MRSA-VRE-RSV C. difficile

21. Barrier Precautions

22. The Cost of C. difficile • Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually • •Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually • •Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually • Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33. Dubberke et al. Emerg Infect Dis. 2008;14:1031-8.Dubberke et al. Clin Infect Dis. 2008;46:497-504. Elixhauser et al. HCUP Statistical Brief #50. 2008

24. Infection Control and Prevention • Enviornmental contamination is due to spore persistence which are highly resistant to routine disinfectants • Can survive weeks to months • Rate of surface contamination increases with severity of diarrhea, incontinence • “High touch” surfaces such as light switches has been implicated in outbreaks

25. Diagnosis by Nose

28. PARTNERING TO HEAL TEAMING UP AGAINST HEALTHCARE- ASSOCIATED INFECTIONS

29. The U.S. Department of Health and Human Services (HHS) created Partnering to Heal as part of a wide effort to improve the quality, safety and affordability of health care for all Americans.

30. Preventing healthcare-associated infections requires both a change in behavior and a change in the organization’ s culture • For change to work, healthcare providers must work in teams and hold each other accountable at every level • Leadership has made zero-percent healthcare-associated infections(HAIs) a goal, as should all healthcare workers • Encouraging others to embrace infection prevention protocols requires effective communication skills, even in the face of confrontation

31. ARE ZERO INFECTIONS POSSIBLE? YES! HOW? • By adhering to infection prevention methods; i.e. hand hygiene, barrier precautions • Utilize evidenced-based “bundles” prevention measures with all patients at risk of HAI • Accountability – HCW’s holding each other accountable for performing at the highest level of patient safety standards