1. 2012 Middle TN APIC Chapter Evidence-Based Strategies to Tackle the Three Most Common Sources of HAIs: Contaminated Hands, Environmental Surfaces, and Skin Cindy Winfrey, MSN, RN, CIC Senior Medical Science Liaison PDI Healthcare

2. 2012 Middle TN APIC Chapter Financial Disclosures PDI Healthcare-Employee

3. 2012 Middle TN APIC Chapter Objectives Discuss the impact of contaminated environmental surfaces, hands (of both patients and healthcare providers), and skin in the transmission of Healthcare Associated Infection Review the current research gaps for pediatric Infection Prevention literature Discuss strategies to meet and exceed Joint Commission NPSG 7 Discuss patient and family involvement and empowerment strategies to reduce the incidence of HAIs

4. 2012 Middle TN APIC Chapter Could this be You?

5. 2012 Middle TN APIC Chapter What do these have in common?

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7. The Importance of a Checklist

8. 2012 Middle TN APIC Chapter WHO Checklist for Safer Surgical Care

9. 2012 Middle TN APIC Chapter Transmission of Infection

10. 2012 Middle TN APIC Chapter How Does Transmission Occur? Patient Healthcare Worker Environmental Surfaces Patient Care Equipment

11. 2012 Middle TN APIC Chapter Pathogens of Significance Pathogens of Concern YeastsESBLKlebsiellaMRSAE. ColiRSV

12. 2012 Middle TN APIC Chapter Examples of multidrug resistance in HAI pathogens  Acinetobacter baumannii  About 75% are multidrug resistant*  10% increase from 2000  Pseudomonas aeruginosa  About 17% are multidrug resistant*  Staphylococcus aureus  MRSA causes about 55% of HAIs (Antimicrobial-Resistant Pathogens Associated with Healthcare Associated Infections, Annual Summary of Data Reported to the NHSN at CDC, 2006-2007) * Percent Acinetobacter baumannii and P. aeruginosa in ICUs that are multidrug-resistant, NNIS and NHSN, 2000- 2008. Includes ICUs only (MICU, SICU, MSICU) and device-related infections only (CLABSI, CAUTI, VAP).

13. 2012 Middle TN APIC Chapter How do you view mortality?

14. 2012 Middle TN APIC Chapter Healthcare-Associated Infections (HAIs)  1 out of 20 hospitalized patients affected  Associated with increased mortality  Attributed costs: $26-33 billion annually  HAIs occur in all types of facilities, including:  Long-term care facilities  Dialysis facilities  Ambulatory surgical centers  Hospitals

15. 2012 Middle TN APIC Chapter Outbreaks vs. Endemic Problems  Endemic problems represent the majority of HAIs  Device-associated infections  Catheter-associated urinary tract infections (CAUTI)  Central line-associated Blood stream infections (CLABSI)  Ventilator-associated Pneumonia (VAP)  Procedure-associated infections  Surgical site infections (SSI)  Adherence problems  Antimicrobial stewardship  Hand hygiene  Isolation precautions

16. 2012 Middle TN APIC Chapter Changing Landscape of Healthcare  Growing populations at risk  Immunocompromised individuals  Low birthweight, premature neonates  Transplant recipients on immunosuppressive therapy  Special environments  Intensive care and burn units  Infusion services

17. 2012 Middle TN APIC Chapter HHS Action Plan 5-year Goals Metric National 5-year Prevention Target Source Central line-associated bloodstream infections 50% reductionNHSN Adherence to central-line insertion practices 100% adherenceNHSN Clostridium difficile infections and hospitalizations 30% reductionNHSN, NHDS, HCUP Catheter-associated urinary tract infections 25% reduction NHSN MRSA invasive infections (population)50% reductionEIP Surgical site infections25% reductionNHSN Surgical Care Improvement Project measures 95% adherenceSCIP NHSN – CDC’s National Healthcare Safety NetworkEIP – CDC’s Emerging Infections Program NHDS – CDC’s National Hospital Discharge SurveySCIP – CMS’s Surgical Care Improvement Project HCUP – AHRQ’s Healthcare Cost and Utilization Project

18. 2012 Middle TN APIC Chapter Sources of Evidence

19. 2012 Middle TN APIC Chapter Holistic Bundled Approach

20. 2012 Middle TN APIC Chapter Impact of Neonatal CLABSI Inherent risk with CVCs Difficult to identify and treat Prolonged & often frequent exposure to antibiotics Major contributor of morbidity and mortality Increased length of stay and hospital costs Infants are especially vulnerable

21. 2012 Middle TN APIC Chapter Challenges to Skin Antisepsis: Evidence-Based Approaches Prepping the skin – Chlorhexidine (CHG) vs Alcohol vs Povidone-Iodine – CHG shown to be more effective due to residual effect. – CHG/alcohol solutions: 0.5% to 3.15% CHG – CHG/aqueous solutions: 0.5% to 4% – CHG recommended by the CDC Guideline for all but < 2 months But, in <1000 gms, CHG associated with skin irritation – Andersen J Hosp Infect 2005 (2% CHG/aqueous) – Garland Pediatr Infect Dis J 1996 (2% CHG/alcohol) CHG studies currently being conducted for safety in neonates 61% of US NICU Medical Fellowship Directors reported using CHG – Tamma ICHE, 2010 NICU compromise

22. 2012 Middle TN APIC Chapter The Debate of CHG in Neonates

23. 2012 Middle TN APIC Chapter Skin Antiseptic Agents Choice varies with age – Population based complications – < 2 months EGA Post natal age Agents – 2 to 3.15% CHG - alcoholic formulation – CHG - aqueous formulation – Povidone iodine Removal considerations – Normal Saline – Sterile Water

24. 2012 Middle TN APIC Chapter Survey of Neonatal CHG Use Survey of Neonatology Fellowship Directors in the United States 61% reported use of CHG for skin antisepsis for neonates – 51% limited use on basis of birth weight, gestational age or chronological age. – Skin reactions (erythema, erosions, burns) occurring primarily in those weighing <1500 grams were reported by 51%. – No difference in adverse events between the alcoholic or aqueous CHG preparations Tamma, Aucott, & Milstone, 2010

25. 2012 Middle TN APIC Chapter Primary Skin Disinfectant Used for Most PICC Insertions Insertions Respondents - 194N% Alcohol only00 Povidone iodine only5628.8 Povidone iodine/alcohol2311.8 Alcohol then povidone iodine94.6 PI total8845.2 2% Chlorhexidine/alcohol7035.9 3.15% Chlorhexidine/alcohol31.5 2% Chlorhexidine/aqueous42.1 CHG total7739.5 Combination PI/CHG2814.3 Total CHG53.8 Sharpe & Pettit 2009

26. 2012 Middle TN APIC Chapter FDA Releases New Labeling

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28. Do You Have These?

29. 2012 Middle TN APIC Chapter Best Practices for Disinfection of Non-Critical Items Examples include surfaces in the environment and medical equipment used in patient care

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31. Hand Hygiene Technique

32. 2012 Middle TN APIC Chapter EVIDENCE-BASED PRACTICE

33. 2012 Middle TN APIC Chapter Where do you even begin?

34. 2012 Middle TN APIC Chapter State of prevention knowledge and science  Guidelines developed for each type of infection and based on systematic reviews of medical literature  Prevention of central line-associated blood stream infections  Prevention of catheter-associated urinary tract infections  Prevention of surgical site infections  Prevention of healthcare-associated pneumonia  Management of multidrug-resistant organisms  Recommendations graded according to evidence  Guidelines contain many recommendations  Current efforts to help prioritize interventions that are most effective

35. 2012 Middle TN APIC Chapter Adherence to infection control guidelines is incomplete  Many HAIs are preventable with current recommendations  Failure to use proven interventions is unacceptable  Only 30%-38% of U.S. hospitals are in full compliance  Just 40% of healthcare personnel adhere to hand hygiene  Insufficient infection control infrastructure in non- acute care settings has allowed major lapses in safe care

36. 2012 Middle TN APIC Chapter Local success fuels national prevention Unit Facility Regional National

37. 2012 Middle TN APIC Chapter CDC knowledge and data fuels local to national CLABSI prevention Unit Facility Pittsburgh Regional Healthcare Initiative First successful, large-scale CLABSI prevention demonstration project Region al Subsequent projects based upon CDC prevention: Michigan Keystone Institute for Healthcare Improveme nt Others National National expansion of CLABSI prevention 60% Reduction in CLABSI between 1999-2009 State-based public reporting using NHSN State/regional prevention collaboratives (CUSP, Recovery Act projects) CMS/IPPS – hospitals report CLABSIs for full Medicare payment InputsOutputs Outbreak Investigations Prevention Research (e.g. chlorhexidin e bathing) NHSN DataCDC Guidelines

38. 2012 Middle TN APIC Chapter The need for HAI prevention research Healthcare-associated Infection  Need for complete implementation of practices known to prevent HAIs  Need for ongoing research to identify new strategies to prevent the remaining HAIs

39. 2012 Middle TN APIC Chapter Prevention Hand hygiene Skin antisepsis Dressing Injection cap/needleless connector No touch technique

40. 2012 Middle TN APIC Chapter Payors Medical Professionals Consumers Public Health Patients Government Healthcare Facilities Safe Healthcare is Everyone’s Responsibility

41. 2012 Middle TN APIC Chapter

42. Hypothetical ? If you knew………………………. That you could do something simple, easy, cost effective, and that was Evidence-Based, but took a little extra time….. Would you do it?????

43. 2012 Middle TN APIC Chapter Questions Whose Infection will you prevent when you return to your institution? Contact Information: – Email: cwinfrey@pdipdi.com – Phone: 719-306-2616