Preventing Hospital Acquired Infections The Physician’s Role

1. Preventing Hospital Acquired InfectionsThe Physician’s Role Shruti Gohil, MD, MPH Susan Huang, MD, MPH Linda Dickey, RN, CIC, MPH Epidemiology & Infection Prevention

2. Dawn of A New Era:Accountability, Transparency, and Best Practices • National concern over healthcare quality and patient safety • Rising healthcare costs • Centers for Medicare and Medicaid Services (CMS) considering financial penalties • Restricted reimbursements • Penalties for HAIs • Delivery System Reform Incentive Payments (DSRIP)

3. Healthcare Associated Infections (HAIs): A National Priority • Major Morbidity and Mortality • 1.7 million HAIs annually • 99,000 deaths annually • Costly • Annual direct medical costs: $28.4 - $33.8 billion (CDC) • Average duration of inpatient admissions has decreased while HAI frequency has increased* *Burke JP. N Engl J Med. 2003 Feb 13;348:651–6.  Stone PW, et al,  Am J Infect Control. 2002 May;30(3):145–52.

4. Types of HAIs • Central Line Associated Bloodstream Infections (CLABSI) • Catheter Associated Urinary Tract Infections (CAUTI) • Ventilator Associated Events (VAE) • Surgical Site Infections (SSI) • C.difficileInfections

5. Multidrug Resistant Organisms (MDROs) • Within 48 hours of admission, patient’s flora changes to match that of the hospital • Patient risk of HAIs increases with acquisition of MDROs • Main way to acquire MDROs is via • Health care worker transmissions • Environment • A cluster of MDROs is a signal for hospital transmission to patients

6. CRE – Carbapenemase Resistant Enterobactericeae • Most commonly Klebsiella • Resistant to most antibacterials • Mortality rates up to 50% • Rampant on the East Coast, now spreading to West • UCI EIP trying to prevent the organism from gaining foothold here

7. What is a Cluster? • Two or more cases of a relatively uncommon event or disease related in time and/or place greater than expected by chance • MICU – 4 Clusters in 2012, 3 of them VRE last ending December • Now with repeat cluster, Jan /Feb 2013 • 3T – 5 clusters in 2011, 4 of them VRE • Now with repeat cluster Jan/Feb 2013

8. Clusters by Unit2011 thru 2012

9. What is Special About MICU and 3 Tower? • 3T sees the highest patient turnover in patient admissions, discharges, and transfers • MICU accepts a lot of transfers from 3T and admits high risk patients from all areas of hospital and community

10. Clusters by Organism2011 thru 2012

11. Genetic Fingerprinting PFGE Testing • Highly specific and sensitive • Identifies single strains between patients or local environments • PFGE performed on isolates from: • Patients identified as part of unit cluster. • Results will show patterns to be different vs indistinguishable

12. MICU Cluster PFGE Result

13. Neighboring Rooms • Room 24 • Room 26 • Room 25

14. PFGE Interpretation • Patient 1 VRE present on admission • 2 days later neighboring patient (Patient 2) positive with the genetically same organism • Develops line infection one week later • Eventually Expires • 2 weeks later, Patient 3 becomes positive with genetically same organism • Pattern of VRE positivity in relation to time and location best consistent with a combination of healthcare worker transmission and environmental transmission

15. 3 Tower PFGE Result

16. Common Room

17. PFGE Interpretation • Patient 1 - VRE present on admission • Resided in 3T B19 for 4 days • 5 days AFTER this Patient 1’s departure, the next patient in 3T B19 is admitted • Another 5 days later, the Patient 2 is screened for VRE and is found to have genetically same strain as Patient 1 • The pattern of VRE positivity in relation to time and room location are best consistent with environmental transmission

18. Prevention Strategies • Hand Hygeine (HH) • Personal Protective Equipment (PPE) • Isolation Precautions • Bundling procedure kits • CLABSI Prevention • CAUTI Prevention • Surgical Site Prevention • Chlorhexidine Daily Bathing • Environmental Cleaning • Equipment/instrument Disinfection/Sterilization • Injection/Procedure Safety Highest Yield, Lowest Cost Intervention for Prevention of ALL Healthcare Associated Infections

20. The Data for Hand Hygiene and Personal Protective Equipment: • Reduces acquisition of multidrug resistant organisms1,2,3,4,9 • Reduces transmission of organisms5,6,10 • To patients • To environment • Reduces healthcare associated infections6,7,8,10 • CLABSI and CAUTI rates • C. difficilerates • Surgical Site Infections • Pittet, D, et al, Lancet ID 2006;6(10):641-652. • Pittet, D, et al, Lancet 2000;356:1307-12 • Larson EL, et al, Behav Med 2000;26:14-22 • Allegranzi, B et al, J Hosp Infect 2009;73(4):305-315 • Puzniak, L., et al, Clinical Infectious Diseases 2002, July 1:35 • Mangini, E., et al, Infection Control and Hosp Epi, Nov 2007;28 :11(1261-66) • Sanderson, PJ et al, J Hosp Infect 1992;21:85-93 • McFarland, LV et al, NEJM 1989;320:204-10 • Samore, MH et al, Am J Med;1996;100:32-40 • Ojajarvi, J , J Hyg 1980;85:193-203.

21. Ubiquitous Bacteria

22. Kramer A. BMC Infectious Diseases 2006;6:130

23. Joint Commission Expectations • Will conduct direct observations • Hand Hygiene • Personal Protective Equipment • Prior citations • Phones used without changing gloves, no cleaning • Gowns not worn or worn half on • HH lapses observed among staff, medical students, and physicians (e.g., Anesthesia) How are we faring at UCI currently?

24. Hand Hygiene Adherence at UCI • MD staff consistently below goal • Nursing Staff >90% compliance • Chronic problem 2012

25. Personal Protective Equipment Adherence at UCI • Attending MD compliance 60% • Nadir 20% in one quarter • Medical student compliance previously only 25% now improving 2012

26. Personal Protective Equipment Adherence at UCI • Most common infractions: • No use of PPE • PPE half on, half off • Other issues: • Use of phone or pager while in precautions 2012

27. Call to Action: Culture Change • Pattern of chronic underperformance by MDs requires a new approach • Responsibility for HH/PPE is not that of the Hospital, Infection Prevention, CMS, or Joint Commission It is a contract between each MD and the patient

28. MD Champions

29. How to be a Champion • “Doctor, I noticed you didn’t wash your hands” a) “Thanks for caring to let me know” b) “I just did, but I’ll do it again - thank you” c) “Thanks for the reminder. I’ll do it right now.” • Keeping others accountable.. • Remind students • Remind one another • “Everybody wash and gown up” d) “Remember… C. diff – soap and water”

30. Clean Your Things • Stethoscopes • After every use • Alcohol or Caviwipes • Contact precaution rooms • White Coats • Wash frequently • Visibly clean • Items You Use on Patients • Site Right, Glucometer • High touch (pagers, phones) • Wipe at least daily Use gloves

31. Case: Anesthesia and OR Hand Hygiene • Problem: CMS Citation for HH non-adherence in OR • Solution: • Patient Safety Vice Chair, ShermeenVakharia, MD identified issues specific to workflow/tasks • Implemented intervention: Sprixx personal hand sanitizer • Observed HH efforts still under way • So far, Attending Anesthesiologist HH improved from 50% to 70% in one month

32. Case: Medicine Resident Action Plan • Problem: Hand Hygiene among residents low • Solution: • Medicine Residency Director, Lloyd Rucker devised plan that highlights accountability and daily reminders • Morning huddle - Case Manager will remind team daily about the importance of HH/PPE • Hand washing officer of the day selected for each medicine ward team • Observe team during rounds, remind everyone to comply

33. Culture Change: Call to Action Ideas? We can and must do better!