Presentation on theme: "Advanced infection prevention training"— Presentation transcript:
1Advanced infection prevention training CIP Consulting LLC
2Overview of Intermediate Infection Prevention Training Adult learningChange TheoryComponents of a successful Infection prevention programCDC Surveillance Definitions (“Big 4)Outbreak investigationBasic NHSN featuresIP in the ORBasic concepts of cleaning and disinfectionHand hygiene
3Clean hands are happy, healthy hands!!!!! “Foam in Foam out”
4SurveillanceSurveillance should be based on sound epidemiological and statistical principlesSurveillance methods continue to evolve and should be designed in accordance to current recommended practices and should consist of defined elementsSurveillance plays an important role in identifying outbreaks, emerging infectious diseases, and bioterrorist events.
5Components of Surveillance Surveillance MethodsFacility widePeriodic (Quarterly)TargetedOutbreak ThresholdsCollecting Relevant DataManaging DataAnalyzing and Interpreting DataCommunicating Results
6Surveillance Facility wide In whole house surveillance, all HAIs are monitored in the facility. When whole house surveillance is conducted, overall infection rates should not be calculated. Instead calculate specific rates for each HAI. Overall rates are not sensitive enough to identify potential problems.Most facilities do not have the resources to do this.
7Surveillance Targeted In the 1990s the CDC shifted away from whole house to targeted surveillance. Targeted programs usually focus on high-risk, high-volume procedures or units.This give you the most bang for your buck!!
8Surveillance Periodic Monitoring a selected unit, device or procedure for a specified time period.Can be useful to monitor for changes in a stable process.
10Collecting Relevant Data Using Definitions for data collectionDetermine the population or event to studyDetermine the time period for observationWrite your definition or use an established one e.g. CDC NHSNApply the definition consistentlyWrite or find a data collection toolWhat are you doing with your data???Are you collecting just to collectAre you logging on multiple logsWhy are you collecting the data???
11Data Collection Concurrent or retrospective data collection Advantages of concurrent surveillance:You can interview care givesObserve patients and patient careImplement immediate prevention and control measuresClusters and outbreaks can be identified quicklyDisadvantages of concurrent surveillance:Very time intensiveIncomplete records
12Data Collection Advantages of retrospective data collection: Medical record is complete and can be reviewed quicklyDisadvantages of retrospective data collection:May be a delay in finding outbreaks or clusters.
13Collecting Relevant Data Review your data collection for accuracy and effectivenessCheck for flaws in the dataCheck your data sources (patient based, lab based, post discharge surveillance letters, post op calls)Validate if you make changesSources of data
14Managing Data Record data systematically Be consistent (data collection tool)Flow sheet or line listCan others look at the data and understand itThink about how you may want to manipulate or analyze the data laterComputer systemSoftware for analysis (Excel)
15Analyzing Data Analyzing is the reason we do surveillance Compare Data Analyze promptly to identify needs for interventionCompare DataSame definitionsSame patient population, risk groupProper denominatorDevice DaysPatient DaysSurgical Cases
16Analyzing Data Compare or Benchmark Interpretation and Significance Historically against your own ratesAgainst other hospitals of similar sizeNational Rates (Review NHSN report as a group)Interpretation and SignificanceUse of statisticsData interpretation pit fallsReporting Data
17StatisticsStatistics can summarize and simplify large amounts of numerical data.Using statistics one can draw conclusions about data.Statistics can help communicate findings clearly and meaningfully to others.Statistics can not prove anything- estimates are normally presented in probabilistic terms (e.g. we are 95% sure ...)
18StatisticsStatistics may reveal underlying patterns in data not normally observable.If used correctly, statistics can separate the probable from the possibleStatistics can not make bad data better - "garbage in, garbage out"
19StatisticsInfection Preventionist routinely use statistical methods to:Prepare reports for committeeIdentify problems or outbreaksMonitor the impact of interventionsIdentify areas for improvement
20Statistics Some commonly used statistical methods in health care are: Measure of central tendencyMeanMedianModeMeasures of DispersionStandard DeviationRangeVarianceMean One of the most useful and widely used techniques for doing this—one which you already know—is the average, or, as it is know in statistics, the mean.Median:
21Statistics Statistical process control Measures of frequency Incidence ratePrevalence rateRatioProportionStatistical process controlControl Charts
22Statistics Incidence Prevalence # of new cases X Constant # at risk # of existing cases Constant
23StatisticsPitfallsA high rate does not necessarily indicate a problemIntensity of surveillanceSmall denominatorSample size usually not less than 25Surgical procedures for devices at least 50
24PracticeNow let’s calculate the Mean, Median, Mode, and Range for the following:7, 9, 6, 7, 8, 531, 32, 35, 35, 37, 41, 42, 44, 52, 562, 12, 4, 11, 3, 7, 10, 5, 9, 6
25Practice Patient DOA DOD Date of + MRSA result Mr. Jones 5/1 5/28 5/7 Mrs. Smith5/95/15Ms. Goldie5/25Joe Black5/105/22Mr. Chevy5/126/255/13Mrs. Ford5/14Mr. Dodge5/27Miss Prissy5/216/5Mr. Bill6/10Ms. Barn5/306/76/2
26Practice Date # of patients 5/1 25 5/11 15 5/21 26 5/2 27 5/12 16 5/22 205/35/13225/235/4215/145/24245/55/155/25235/6285/165/265/75/175/275/85/185/28175/95/195/295/105/205/305/31
27PracticeUsing the two previous slides, calculate the incidence of MRSA for the month of MayWhat is the prevalence of MRSA on 6/1 with the patient days being 425?
28Practice Physician Surgeries Infections Doctor A 25 Doctor B 200 1 Doctor B2001Doctor C562Doctor D89Doctor E178Doctor F500Doctor G39Doctor H145Doctor I6Doctor J95Doctor K115
30Device Related Data Devices strongly correlated with infection Urinary cathetersCentral linesVentilators# of device assoc infections x# of device days
31Central Line BSI Example 4 BSI Infections120 patients1420 line days4500 Patient daysWhat is your rate?????
32HA MRSA rate calculation HA MRSA definition is developed to identify an MRSA case as “new”: MRSA isolated from clinical or surveillance culture obtained after the third calendar day of admission to the unit in a patient that had no prior MRSA by culture, molecular test, or by history.# of new MRSA patients on the unit/month × 1,000 # of patient days on the unit/month = hospital-associated MRSA rate per 1,000 unit patient daysGood references –APIC MRSA Elimination guideCDC MDRO guidelines
33What do you do with the Data? Communicate/Report DataLook for trends (Analysis)Implement Changes (Action plan)Monitor, Track and report Effect of Interventions
34Communicating Data What to report How to report Chart Graph Pie Chart Bar ChartsGraphLine GraphControl Chart
35Make Things Self-Explanatory TitleTime PeriodLocationValuesUnit LabelsDefinitions
36Modern Hospital Hospital Acquired Infections April 2008 Number of infectionsRate per 1000 patient daysUTI23.3SSIPneumoniaBSIOther11.6Total35.0
38SICU Central line associated bacteremia (CLAB) 4th Quarter 2010 Analysis:December rate represents one CLAB. Documented compliance with the insertion bundle.
39Rapid Sterilization Rate August 2010 – November 2010 Analysis:November rate represents 11 items rapidly sterilized.1 dropped instrument9 consignment instruments1 sterile instrument set unavailableAction Plan:Review consignment policy to ensure it states that vendors bring instruments in for full sterilizationContinue to monitor
40Surgical Site Infection Rate July 2010 – October 2010 Analysis:October rate translates to 1 infection – see attached case review.Action Plan:Continue monthly monitoring and discussion of prevention measures
41Lumbar Interbody Infection Rate July 2010 – October 2010 Analysis:No SSI identified since surveillance began.Action Plan:Continue to do surveillance and discuss prevention measures
45Advanced Infection prevention Class Comparing the rates
46Rate comparisonsSome questions the Infection Preventionist may be asked to answer in regards to data are:Are the findings statistically significantWas the sample size large enough to demonstrate a difference?Are the groups being compared truly similar?
47The Null HypothesisWhen comparing SSI rates, the hypothesis being tested is that the rates are not different. This is called the null hypothesis.A statistical test can be used to test the hypothesis and obtain a p-value
48P-value What is "Statistical Significance" (p-value)? The statistical significance of a result is the probability that the observed relationship or a difference in a sample occurred by pure chance ("luck of the draw"), and that in the population from which the sample was drawn, no such relationship or differences exist. Using less technical terms, we could say that the statistical significance of a result tells us something about the degree to which the result is "true" (in the sense of being "representative of the population").
49P-valueMore technically, the value of the p-value represents a decreasing index of the reliability of a result. P- values range from 0 – 1. The higher the p-value, the less we can believe that the observed relation between variables in the sample is a reliable indicator of the relation between the respective variables in the population.
50P-valueTypically, in many sciences, results that yield p .05 are considered borderline statistically significant, but remember that this level of significance still involves a pretty high probability of error (5%). Results that are significant at the p .01 level are commonly considered statistically significant, and p .005 or p .001 levels are often called "highly" significant.
52Surgical Site Risk Adjustment This is what adjusts for severity of illness. Should be procedure-specific. (Review NHSN SSI Data submission form)Based on 3 factors collected on all surgical patients:Length of surgeryAmerican Society of Anesthesiology (ASA) ScoreSurgical wound classification
53Standard Infection Ratio (SIR) What is a standardized infection ratio (SIR)?The standardized infection ratio (SIR) is a summary measure used to track HAIs at a national, state, or local level over time. The SIR adjusts for the fact that each healthcare facility treats different types of patients. For example, the experience with HAIs at a hospital with a large burn unit (a location where patients are more at risk of acquiring infections) cannot be directly compared to a facility without a burn unit. The method of calculating an SIR is similar to the method used to calculate the Standardized Mortality Ratio (SMR), a summary statistic widely used in public health to analyze mortality data. In HAI data analysis, the SIR compares the actual number of HAIs in a facility or state with the baseline U.S. experience (i.e., standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates.In other words, an SIR significantly greater than 1.0 indicates that more HAIs were observed than predicted, accounting for differences in the types of patients followed; conversely, an SIR of significantly less than 1.0 indicates that fewer HAIs were observed than predicted. Reference -
54FIRST STATE-SPECIFIC HEALTHCARE-ASSOCIATED INFECTIONS SUMMARY DATA REPORT January – June, 2009
55SIRSIR = Observed (O) HAIs Expected (predicted) (E) HAIs To calculate O, sum the number of HAIs among a reporting entity To calculate E, requires the use of the appropriate aggregate data from a standard population (NHSN)
58Let’s Review!!QuestionYou are assisting a new Infection preventionist with setting up her Infection prevention program. She is new to the role and just moved to the area and accepted the position of ICP at a local medical surgical hospital…What documents should she review first?
59Answer The following documents should be reviewed first. Infection prevention and surveillance plan. When was it last reviewed? Was a risk assessment done? Did the risk assessment include an MDRO assessment?2. TB control plan, when was the last TB risk assessment?3. Blood borne pathogen exposure plan, when was it last reviewed? Is there a sharps injury prevention team?
60QuestionHow often does the infection prevention committee have to meet?What are some items on a good infection prevention agenda?
61Collecting Data Question My IC surveillance plan states that I do quarterly CA-UTI rates, how do I calculate this rate?????
62AnswersIf your surveillance plan says that you calculate quarterly CA-UTI rates then the formula is…# of CA-UTI/# of Foley catheter days in that quarter X 1000.6/346 X 1000 = 17.3 CA-UTI per 1000 Foley catheter days for that quarter.How do you find out if this rate is ok? (Refer to the NHSN report)
63QuestionWhat if my surveillance plan states that I do surgical site surveillance on patients that have had gallbladder surgery? How do I calculate the rates?
64AnswerYou need to have a process in which you know the # of gallbladder surgeries for that month.Look at all those patients, have any of them returned for s/s of infection? If so, do the s/s match one of the CDC/NHSN HAI SSI definitions?# gallbladder patients found infected/# gallbladder surgeries X 1001/22 X 100 = 4.5 infections per 100 surgeries for that month.Where do you find the comparison rate? (Review the NHSN report)
65Is this a CLAB?Patient admitted through the ER for acute MI on 11/28/2010, taken to ICUTLSC placed in the ER, central line insertion bundle documented by physician.12/2/2010 temps to 100.9, hypotension, cultures taken, progress notes state fever likely due to “bacteremia”. CXR “lungs clear”Pt died 12/2/2010.12/4/2010 blood culture results ¾ blood cultures + for pseudomonas, sputum MRSA.
66CLAB Case review…Fits Criteria 1 of CDC definition of CLAB – “patient has a recognized pathogen cultured from one or more blood cultures and the organism cultured from the blood is not related to an infection at another site”.What else is the ICP going to report?
67Is this a CLAB?86 year old patient admitted 11/18/2010 for colon resection.PICC line placed 11/21/2010, the PICC nurse documented use of the insertion bundle components.Transferred to Step down unit on 11/23/2010 with PICC.POD 9 11/26/2010 temperatures up to 102, WBC 30, progress notes report “sepsis”, cultures taken, transferred back to ICU and intubated.12/2/2010 Enterococcus species in 2/4 blood culture bottles, moderate amount MSSA in sputum, urine negative.
68CLAB?Fits Criteria 1 of CDC definition of CLAB – “patient has a recognized pathogen cultured from one or more blood cultures and the organism cultured from the blood is not related to an infection at another site”.
69Surgical Site Infection Rate Example During the month of February, the ICP finds that there were three hip wound infections among patients undergoing total hip replacement. Dr. A performed 28 cases, Dr. B performed 26 cases, and Dr. C performed 6 cases. What is the surgical site infection rate for total hips in February?A. 3%B. 4%C. 5%D. 20%
70Is this a VAP? Case Review 78 year old undernourished frail male patient admitted for Colon resection on 10/1/2010.CXR on day of surgery “lungs have a hyper inflated appearance but noacute infiltrates”Remained intubated after surgeryVent settings FIO2 40, RR 10, TV 480, PS 8, Peep 510/6/2010CXR “complete obliteration of L hemidiaphram consistent withconsolidation”.“Reduced lung sounds”Purulent sputumWBC 6.3Temperature of 102.0Increased vent settings to FI02 70, RR 16, TV 480, Peep 10.
71VAP case review 10/7/2010 WBC 19.0 Temperature of 100.4 CXR “bibasilar densities same”“Rales”“Purulent sputum”Increased vent settings to FI02 80, RR 16, TV 480, Peep 10.Vent round documentation indicates that all components of the VAP prevention bundle were done on 10/6, 10/7, and 10/12.2. All final culture results negativeIC reviewed case with ID physician who agreed the case fit the CDC VAP Criteria 1 definition.
72Is this a CA-UTI??Patient was admitted on 2/6/2011 for gallbladder surgery, Foley catheter placed on admit at 0600 am.Surgery went well and catheter was discontinued on 2/6/2011 at 9pm.The patient had nausea and vomiting and was not discharged until 2/8/2011, before discharge the patient complained to the physician about pain with urination, temps The physician discharges the patient on Keflex, does not get a UA with culture.IS this a CA-UTI???
73Criterion Urinary Tract Infection (UTI) Symptomatic Urinary Tract Infection (SUTI)Must meet at least 1 of the following criteria1a Patient had an indwelling urinary catheter in place at the time of specimen collectionandat least 1 of the following signs or symptoms with no other recognized cause:fever (>38°C), suprapubic tenderness, or costovertebral angle pain or tendernessa positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms.ORPatient had indwelling urinary catheter removed within the 48 hours prior to specimen collectionfever (>38°C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness
74CLAB?24 year old admitted from ER trauma center to ICU on July 14, Upon admission her MRSA nasal screen was positive for colonization and she was placed in contact isolation.A central line was placed by the hospitalist in the CCU.On July 23, 2010 the patient spiked a fever of (39.9). You have the following data.Blood cultures 2/4 positive for MRSASputum culture reveals few yeastCath tip no growthUrine culture < 20,000 cfu candida
75CLAB? The following conditions are not infections: Colonization, which means the presence of microorganisms on skin, on mucous membranes, in open wounds, or in excretions or secretions but are not causing adverse clinical signs or symptoms.It is a CLAB, meets criteria 1, recognized pathogen in a patient with a central line, 1 BC +, no other recognized cause.
76CLAB/VAP or both??? Don’t pull your hair out July 31, 2010, 62 year old male admitted to your hospital with chemical burns to face, oral cavity, nasal cavity and respiratory distress. He is immediately taken to the OR for trach placement.PICC placed 8/3/2011.9 days after admission (8/9/2010) you note the following;Rusty brown foul secretions from the trachIncreased ventilator settings neededRhonchi, breath sounds used to be “diminished”WBC increased to 13.9, temps up to 40 degrees Celsius.8/9/2010 – CXR impression “persistent infiltrates”, 8/10/2010 “increasing infiltrates”.8/9/2011 “tracheal” culture = MRSA, E-coli.8/9/2011 Blood culture 2/4 + for MRSA8/10/2011 Blood culture 2/4 + MRSA
77Identifying Hospital acquired pneumonia – 3 parts to PNU 1 Radiologic criteriaPatient with underlying pulmonary or cardiac disease, must have two or more CXR with at least one of the following;One definitive CXR with the following criteria is acceptable in patients without underlying disease.a. New or progressive and persistent infiltrate.b. Consolidationc. Cavitation
78Signs and Symptoms At least one of the following; Fever (> 38˚ C or > 100.4˚ F) with no other recognized cause…… Hmmmm, had MRSA in Blood cultures….Leukopenia (< 4,000 WBC/mm, or leukocytosis > 12,000 WBC/mm)Altered mental status with no other recognized cause
79AND at least 2 of the following New onset of purulent sputum, or change in character of the sputum, or increased respiratory secretions, or increased suctioning requirements.New onset or worsening cough, or dyspnea, or tachypnea.Rales or bronchial breath soundsWorsening gas exchange (O2 desats, increased oxygen requirements, or increased ventilation demand.
80VAP or CLAB continued…I do not think it could be called a pneumonia criteria 1, due to the MRSA in the blood cultures….Lets look at pneumonia criteria 2 a bit closer…
82Read the fine print… “8”8. “Care must be taken to determine the etiology of pneumonia in a patient with positive blood cultures and radiographic evidence of pneumonia, especially if the patient has invasive devices in place such as intravascular lines or an indwelling urinary catheter. In general, in an immunocompetent patient, blood cultures positive for coagulase-negative staphylococci, common skin contaminants, and yeasts will not be the etiologic agent of the pneumonia. “9. Refer to threshold values for cultured specimens (Table 8). An endotracheal aspirate is not a minimally contaminated specimen. Therefore, an endotracheal aspirate does not meet the laboratory criteria.
83NHSN clarifications…. The following conditions are not infections: Colonization, which means the presence of microorganisms on skin, on mucous membranes, in open wounds, or in excretions or secretions but are not causing adverse clinical signs or symptoms; andinflammation that results from tissue response to injury or stimulation by noninfectious agents, such as chemicals.
84VAP or CLAB?I think that the chemical burns that the patient was admitted with would cause me to call this a CLAB criteria 1, not a VAP…Patient with a central lineRecognized pathogen in ¼ blood cultures.Did they use the insertion bundle on insertion?Is this documented?Has the dressing been changed per policy?Curious – did they pull the PICC line?Thoughts?May have been a clinical pneumonia diagnosis, but it did not fit the CDC pneumonia surveillance definition that we must follow.
85CA-UTIOn Post op day 3, a 49 year old female patient in the ICU with a Foley catheter has the following clinical symptoms. Is this a SUTI or ABUTI?Temp 38.9Complains of abdominal pain (secondary to colon resection surgery on admission date of surgery)WBC 19,000Foul smelling urineUrinalysis shows 2+ protein, + nitrate, 2+ leukocyte esterase, WBC -, 3+ bacteria.Culture was 10,000 CFU E-coli.
86Identification and Categorization of SUTI Indwelling Catheter at the Time of Specimen Collection
87CA-UTI?84 year old patient is hospitalized with malnutrition and CHF on July 1, 2011.Patient has a catheter in place and no signs or symptoms of infection.Day 9, July 10, 2011 the patient becomes unresponsive, is intubated and CBC shows WBC of 15,000. No fever.Patient is pan-cultured. Blood and urine both grow streptococcus pyogenes, urine >100,000 cfu’s.
88Looks like ABUT, no s/s…. And urine culture matches blood culture….
90SSI?55 year old female patient had an abdominal hysterectomy on August 16, 2011.August 20, 2011The upper aspect of the patients abdominal wound has purulent drainage with some redness and induration.Wound cultures sent to lab for culture, patient started on antibiotics.August 22, 2011Culture grew Enterobacter species
91A superficial incisional SSI (SIP or SIS) must meet the following criterion: Infection occurs within 30 days after the operative procedureandinvolves only skin and subcutaneous tissue of the incisionpatient has at least 1 of the following:a. purulent drainage from the superficial incisionb. organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incisionc. at least 1 of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and superficial incision is deliberately opened by surgeon and is culture positive or not cultured. A culture-negative finding does not meet this criterion.d. diagnosis of superficial incisional SSI by the surgeon or attending physician.There are 2 specific types of superficial incisional SSI: Superficial incisional primary (SIP): a superficial incisional SSI that is identified in the primary incision in a patient who has had an operation with 1 or more incisions (eg, C-section incision or chest incision for coronary artery bypass graft with a donor site [CBGB]).Superficial incisional secondary (SIS): a superficial incisional SSI that is identified in the secondary incision in a patient who has had an operation with more than 1 incision (eg, donor site [leg] incision for CBGB).
92SSI? Mrs. Perry had a spinal fusion performed on April 5, 2011. She began having intense, increased back pain on April 12, 2011.An MRI shows an abscess in the spinal epidural spaceThe surgeon opened the wound and drained the abscess on April 14, 2011, specimen sent to the lab for culture.Culture reveals MSSA.
93An organ/space SSI must meet the following criterion: Infection occurs within 30 days after the operative procedure if no implant1 is left in place or within 1 year if implant is in place and the infection appears to be related to the operative procedureandinfection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedureand patient has at least 1 of the following:a. purulent drainage from a drain that is placed through a stab wound into the organ/spaceb. organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/spacec. an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examinationd. diagnosis of an organ/space SSI by a surgeon or attending physician.Organ space – what specific site?
94Organ/space Organ/space SSI Organ/space Organ/space SSI. Indicate specific type: Specific sites are assigned to organ/space SSI to identify further the location of the infection.BONE LUNGBRST MEDCARD MENDISC ORALEAR OREPEMET OUTIENDO SA (Spinal abscess)EYE SINUGIT URIAB VASCIC VCUFJNT***Last class, question about Breast implant. Classify as deep or organ space?Superficial - skin and subcutaneous tissueDeep - deep soft tissues (eg, fascial and muscle layers)Organ space - organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure.
96NHSN Training Slides SSI/CAUTI BRIEF REVIEW OF nicu/clab
97HAI Event Facility Type Reporting Start Date Healthcare Facility HAI Reporting to CMS via NHSN – Current and Proposed Requirements DRAFT (8/5/2011)HAI EventFacility TypeReporting Start DateCLABSIAcute Care HospitalsAdult, Pediatric, and Neonatal ICUsJanuary 2011CAUTIAdult and Pediatric ICUsJanuary 2012SSIColon and abdominal hysterectomyI.V. antimicrobial start (proposed)Dialysis FacilitiesPositive blood culture (proposed)Signs of vascular access infection (proposed)Long Term Care Hospitals *October 2012Inpatient Rehabilitation FacilitiesMRSA BacteremiaJanuary 2013C. difficile LabID EventHCW Influenza VaccinationOP Surgery, ASCsOctober 2013SSI (proposed)Outpatient Surgery/ASCsJanuary 2014* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN97
98NHSN NHSN link http://www.cdc.gov/nhsn/ Find “Training” for the module you are going to follow.Yes, we are going to review CAUTI/SSI Training modules Recent updates to SSI/CAUTI protocols sent out by NHSN August 2011
101Before we can sterilize…. Check activities at point of use.How are instruments being kept moist?How are the instruments being transferred to decontamination area?Time between use and decontamination is minimized?Instruments should be maintained as fee of gross oil as possible during the surgical procedure. Are the instruments wiped as needed with sterile water during the procedure to remove gross soil? Are the lumens irrigated with sterile water as needed through the surgical procedure? Allowing the blood and body fluids to sit and dry can cause corrosion, pitting and really affect how the instruments are disinfected and then sterilized later…Contaminated instruments should be contained in a manner to prevent exposure of patients of personnel to BBP, OSHA requires that contaminated instruments be contained in a leak proof container to minimize the risk of exposing personnel to contaminants during transport..AORNHand carried – enclosed by a plastic bag or container with lid.Items placed on top of a transport cart must be contained (plastic bag)Items with sharp or pointed edges must be contained in a puncture resistant container, liquids must be contained in spill proof container.The transport container must be labeled to indicate bio hazardous contents.Do they clean the transport carts?Time between being taken to decontam and cleaning process is minimal!!!
102Decontamination Room Negative air? Temperature range (optimal degrees)Humidity ( optimal 30%-60%)No Fans!PPE?Doors/pass through windows?Enzymatic cleaner…..Cleaning brushesManual cleaning or Automated washer?Work flowHand washingNegative air? AORN/Chapter 667Temp AORN/Chapter 667ACH at least 6IF temp is too hot, they will not wear their PPE or may put a fan in the room.Do they wear their PPE? Gloves/fluid resistant gowns, goggles? If not, ask them if you can help get them better PPE.Doors and pass through windows should be kept shut, keeping them open disrupts the air flow between decontam and instrument wrapping roomBrushes – what do they look like? Are they ever cleaned? They can be run through the washer disinfector too. Do they have the right size brush for instruments they are cleaning?Manual cleaning - recommended to pre-soak, use enzymatic cleanser, then use of appropriate detergent, then final rinse., is the cleaning solution changed after each set of instruments?Mechanical washers!!!Has phases – cool water rinse, enzymatic rinse, ultrasonic cleaning, hot water rinse, lubrication rinse, drying cycle. How are you validating that the washer is working? AAMI recommends doing weekly/daily verification of the washer disinfector.
103Instrument Preparation InspectionDistribution of instruments in trays/peel packsSingle use devicesChemical indicators are placed in each package.Sterilization wrapRigid containersInspected for cleanliness and proper function
104SterilizationA disinfection process which results in the destruction of all forms of microbial life, including bacteria, fungi, viruses, and spores.Proper cleaning, wrapping, and placement in the sterilizer must come first.Proper time and temperature for items being sterilized. How does the manufacturer recommend that the item be sterilized?
105Instrument Cycle Temp. Exposure Time Single & Dual Insert Sets Prevac °C 15 min.Single & Dual Insert Sets Prevac °C 14 min.Multiple (2-3) Insert Sets Prevac °C 40 min.
106Sterilizers Drain strainers Sterilizer gaskets When was the last time the sterilizer was cleaned? What does the manufacturer recommend?
107Methods of Sterilization – SteamPre-VacuumGravityFlashHydrogen peroxide gas plasmaEthylene OxidePeracetic acid
108Prevac SterilizationAir is completely evacuated from the chamber by the vacuum. The steam injector helps eliminate the air out of the packages. Steam then penetrates the packages on all surfaces.
109Gravity Sterilization Gravity pushes the air through the packages and down through the drain. Sterilization begins when steam passes the thermometer and reaches the desired temperature.
110It is not called Flash Sterilization anymore… “Immediate Use Sterilization” “Is broadly defined as the shortest possible time between a sterilized item’s removal from the sterilizer and its aseptic transfer to the sterile field, it also implies that the sterilized item is used for the procedure for which it was sterilized for and not stored for future use, or held from one case to the another”
111Immediate use sterilization…. 2010 Association for the Advancement of Medical Instrumentation (AAMI) partnered with other healthcare organizations and regulatory agencies to develop a multi-society position statement to clear up confusionAccreditation Association for Ambulatory Health Care (AAAHC)Association for perioperative Registered Nurses (AORN)Association for Professionals in Infection Control and Epidemiology(APIC)ASC Quality Collaboration (ASCQC)International Association of Healthcare Central Service Materiel Management (IAHCSMM)
112Immediate use sterilization Multi-Society position statement also focuses on personnel requirements involved in reprocessing activitiesPersonnel should:Be knowledgeableExercise critical thinking and judgmentImplement standardized practicesSupervising organization should:Ensure appropriate training and educationEnsure staff competencyEnsure related resources are available
113Immediate use sterilization should NOT be performed in the following situations Sterilization of Implants - except in a documented emergency situation where no other option is availableFor convenience or as a substitute for insufficient instrument inventorySterilization of devices using cycles that have not been validated for that device or sterilizerSterilization of devices that are sold sterile and intended for single use onlyPost-procedure decontamination of instruments used on patients who may have Creutzfeldt-Jacob disease (CJD) or similar disorders
114Follow manufacturer instructions for immediate use sterilization The device manufacturer’s written instructions for reprocessing any reusable device must be followedThe cycle parameters required to achieve sterilization are determined by the design of the instrument, the characteristics of the load, the sterilizer capabilities, and the packaging (if used)Conflicting instructions (sterilizer manufacturer vs. device manufacturer)Reference: AAMI position statement on Immediate use sterilization 2/2011
115Different types of steam sterilization cycles for immediate use sterilization Gravity cycles for unwrapped nonporous items (routine metal instruments) is 3 minutes at 270⁰ - 275⁰Gravity cycles for unwrapped nonporous items, porous items, and items with lumens are sterilized together, minimum exposure time and temp is 10 minutes at 270⁰ - 275⁰Reference – ANSI/AAMI ST79:2010 (8.62 Flash sterilization parameters)
116Different types of steam sterilization cycles for immediate use sterilization Prevac sterilization of unwrapped nonporous items (routine metal instruments) is 3 minutes at 270⁰F.Prevac sterilization of unwrapped nonporous items, porous items, and items with lumens are sterilized together, minimum exposure time and temp is 4 minutes at 270⁰F.Reference – ANSI/AAMI ST79:2010 (8.62 Flash sterilization parameters)
118Quality Control, physical parameters Time, temperature, and pressure recorders, displays, digital printoutsInitials of reviewerEvery load – this is part of load release criteria.
119Quality control, chemical indicators Visual identification - processed vs. unprocessed packsVerify sterilant penetrationVerify air removal (prevacuum sterilizers – Bowie Dick)Pack monitoringLoad monitoringLoad releaseSix classes of chemical indicatorsEach class has different performance specifications
120Class 1 Chemical Indicators Class 1 – external, use on outside of every package unless the internal CI is visible.Class 1 – internal, some internal indicator strips
121Class 2 Chemical Indicators Class 2 – Bowie DickDaily Air Removal Test for Prevac Sterilizers
122Class 3 Chemical Indicators Internal indicatorsNot used in steam sterilizationSingle-variable indicatorsPeracetic acid concentrationHydrogen peroxide concentration
123Class 4 Chemical Indicators Class 4 indicator (single/multi-variable) – Internal chemical indicators, not to be used for release of loads.Internal indicatorsReact to two or more critical variablesIndicate exposure at stated values of chosen parametersIs NOT correlated to the BI kill
124Class 5 Chemical Indicators Class 5 – Integrating indicatorsInternal indicators and challenge packsRespond to all critical parametersPerformance correlated to the BIFor gravity and pre-vacuum cyclesMonitors more of sterilization cycle than BI test
125Class 6 Chemical Indicators Class 6 Emulating IndicatorsRespond to all critical variablesPerformance correlated to the sterilization cycle – tighter toleranceMonitors more of the total sterilization cycle than other sterilization monitoring products
126Process Control Device - PCD Process challenge device (PCD): Item designed to constitute a defined resistance to a sterilization process and used to assess performance of the process.
127Quality control, chemical indicators Positioning of the indicators and process challenge devicesShould be placed flat in the area of the sterilizer chamber and load that represent the greatest challenge (cold point) to the cycleNormally in the front, bottom section of the sterilizer, near the drainShould be identified by the sterilizer manufacturer
128Quality control, biological indicators Is the type of BI being used appropriate for the cycles being processed?BI’s are incubated following the manufacturer instructions?Daily vs. WeeklyEvery load containing an implantable device
129Record keeping and Infection prevention visibility in sterile process areas of the facility. Lot number – sterilizer number, date of sterilization and cycle #.Contents of the load detailed?Patient identifierExposure time and temperature with initials of the operator?BI test resultsBowie Dick test resultsChemical indicator responseHave a written mechanism for recall – “Suggested protocol for management of positive biological indicator in steam sterilizer” – Table 12 CDC guideline for disinfection and sterilization in healthcare facilities, 2008.
130In summary - routine load release The load was actually initiated.The sterilization cycle was appropriate for items processed.Every sterilizer load should be physically monitored (Time, temp, pressure).Every packaged item should be labeled externally with a process indicator (Class 1).And should contain an internal indicator (class 5 or 6).If desired a PCD containing a BI, or a PCD containing a class 5 or class 6 (CI challenge pack) in the area of the chamber and load considered to be least favorable to sterilization.Reference ANSI/AAMI ST79:2010, Pages
131Implant loadEvery load containing an implant should be monitored with a class 5 chemical indicator within a PCD that contains a BI.This may be used to release an implant load ONLY in an emergency! (do you have emergency release policy for implants?) “Annex L”Implants should be quarantined until the results of the BI are available. (“early readout or spore growth”)A class 6 emulating indicator within a PCD may be used as part of release criteria for loads containing implants.Reference ANSI/AAMI ST79:2010, Pages 103
132Practice – what type of reprocessing? Bedside tablesLaryngoscope bladesSurgical instrumentsVaginal ultrasound probesEndoscopesTemporal ThermometersCardiac Catheters