Advanced infection prevention training CIP Consulting LLC

Overview of Intermediate Infection Prevention Training Adult learning Change Theory Components of a successful Infection prevention program CDC Surveillance Definitions (“Big 4) Outbreak investigation Basic NHSN features IP in the OR Basic concepts of cleaning and disinfection Hand hygiene

Clean hands are happy, healthy hands!!!!! “Foam in Foam out”

Surveillance Surveillance should be based on sound epidemiological and statistical principles Surveillance methods continue to evolve and should be designed in accordance to current recommended practices and should consist of defined elements Surveillance plays an important role in identifying outbreaks, emerging infectious diseases, and bioterrorist events.

Components of Surveillance Surveillance Methods Facility wide Periodic (Quarterly) Targeted Outbreak Thresholds Collecting Relevant Data Managing Data Analyzing and Interpreting Data Communicating Results

Surveillance 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.

Surveillance 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!!

Surveillance Periodic Monitoring a selected unit, device or procedure for a specified time period. Can be useful to monitor for changes in a stable process.

In god we trust, all others bring data

Collecting Relevant Data Using Definitions for data collection Determine the population or event to study Determine the time period for observation Write your definition or use an established one e.g. CDC NHSN Apply the definition consistently Write or find a data collection tool What are you doing with your data??? Are you collecting just to collect Are you logging on multiple logs Why are you collecting the data???

Data Collection Concurrent or retrospective data collection Advantages of concurrent surveillance: You can interview care gives Observe patients and patient care Implement immediate prevention and control measures Clusters and outbreaks can be identified quickly Disadvantages of concurrent surveillance: Very time intensive Incomplete records

Data Collection Advantages of retrospective data collection: Medical record is complete and can be reviewed quickly Disadvantages of retrospective data collection: May be a delay in finding outbreaks or clusters.

Collecting Relevant Data Review your data collection for accuracy and effectiveness Check for flaws in the data Check your data sources (patient based, lab based, post discharge surveillance letters, post op calls) Validate if you make changes Sources of data

Managing Data Record data systematically Be consistent (data collection tool) Flow sheet or line list Can others look at the data and understand it Think about how you may want to manipulate or analyze the data later Computer system Software for analysis (Excel)

Analyzing Data Analyzing is the reason we do surveillance Compare Data Analyze promptly to identify needs for intervention Compare Data Same definitions Same patient population, risk group Proper denominator Device Days Patient Days Surgical Cases

Analyzing Data Compare or Benchmark Interpretation and Significance Historically against your own rates Against other hospitals of similar size National Rates (Review NHSN report as a group) Interpretation and Significance Use of statistics Data interpretation pit falls Reporting Data

Statistics Statistics 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 ...)

Statistics Statistics may reveal underlying patterns in data not normally observable. If used correctly, statistics can separate the probable from the possible Statistics can not make bad data better - "garbage in, garbage out"

Statistics Infection Preventionist routinely use statistical methods to: Prepare reports for committee Identify problems or outbreaks Monitor the impact of interventions Identify areas for improvement

Statistics Some commonly used statistical methods in health care are: Measure of central tendency Mean Median Mode Measures of Dispersion Standard Deviation Range Variance Mean 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:

Statistics Statistical process control Measures of frequency Incidence rate Prevalence rate Ratio Proportion Statistical process control Control Charts

Statistics Incidence Prevalence # of new cases X Constant # at risk # of existing cases Constant

Statistics Pitfalls A high rate does not necessarily indicate a problem Intensity of surveillance Small denominator Sample size usually not less than 25 Surgical procedures for devices at least 50

Practice Now let’s calculate the Mean, Median, Mode, and Range for the following: 7, 9, 6, 7, 8, 5 31, 32, 35, 35, 37, 41, 42, 44, 52, 56 2, 12, 4, 11, 3, 7, 10, 5, 9, 6

Practice Patient DOA DOD Date of + MRSA result Mr. Jones 5/1 5/28 5/7 Mrs. Smith 5/9 5/15 Ms. Goldie 5/25 Joe Black 5/10 5/22 Mr. Chevy 5/12 6/25 5/13 Mrs. Ford 5/14 Mr. Dodge 5/27 Miss Prissy 5/21 6/5 Mr. Bill 6/10 Ms. Barn 5/30 6/7 6/2

Practice Date # of patients 5/1 25 5/11 15 5/21 26 5/2 27 5/12 16 5/22 20 5/3 5/13 22 5/23 5/4 21 5/14 5/24 24 5/5 5/15 5/25 23 5/6 28 5/16 5/26 5/7 5/17 5/27 5/8 5/18 5/28 17 5/9 5/19 5/29 5/10 5/20 5/30 5/31

Practice Using the two previous slides, calculate the incidence of MRSA for the month of May What is the prevalence of MRSA on 6/1 with the patient days being 425?

Practice Physician Surgeries Infections Doctor A 25 Doctor B 200 1 Doctor B 200 1 Doctor C 56 2 Doctor D 89 Doctor E 178 Doctor F 500 Doctor G 39 Doctor H 145 Doctor I 6 Doctor J 95 Doctor K 115

Device Related Data Devices strongly correlated with infection Urinary catheters Central lines Ventilators # of device assoc infections x 1000 # of device days

Central Line BSI Example 4 BSI Infections 120 patients 1420 line days 4500 Patient days What is your rate?????

HA 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 days Good references – APIC MRSA Elimination guide CDC MDRO guidelines

What do you do with the Data? Communicate/Report Data Look for trends (Analysis) Implement Changes (Action plan) Monitor, Track and report Effect of Interventions

Communicating Data What to report How to report Chart Graph Pie Chart Bar Charts Graph Line Graph Control Chart

Make Things Self-Explanatory Title Time Period Location Values Unit Labels Definitions

Modern Hospital Hospital Acquired Infections April 2008 Number of infections Rate per 1000 patient days UTI 2 3.3 SSI Pneumonia BSI Other 1 1.6 Total 3 5.0

Hospital Acquired Infections by site 2007

SICU Central line associated bacteremia (CLAB) 4th Quarter 2010 Analysis: December rate represents one CLAB. Documented compliance with the insertion bundle.

Rapid Sterilization Rate August 2010 – November 2010 Analysis: November rate represents 11 items rapidly sterilized. 1 dropped instrument 9 consignment instruments 1 sterile instrument set unavailable Action Plan: Review consignment policy to ensure it states that vendors bring instruments in for full sterilization Continue to monitor

Surgical 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

Lumbar Interbody Infection Rate July 2010 – October 2010 Analysis: No SSI identified since surveillance began. Action Plan: Continue to do surveillance and discuss prevention measures

Needle Sticks Injuries in ER 2007

Needle Stick Injuries

Advanced Infection prevention Class Comparing the rates

Rate comparisons Some questions the Infection Preventionist may be asked to answer in regards to data are: Are the findings statistically significant Was the sample size large enough to demonstrate a difference? Are the groups being compared truly similar?

The Null Hypothesis When 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

P-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").

P-value More 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.

P-value Typically, 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.

P-value Let’s Practice http://www.openepi.com/OE2.3/Menu/OpenEpiMenu.htm

Surgical 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 surgery American Society of Anesthesiology (ASA) Score Surgical wound classification

Standard 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 - http://www.cdc.gov/hai/QA_stateSummary.html#6

FIRST STATE-SPECIFIC HEALTHCARE-ASSOCIATED INFECTIONS SUMMARY DATA REPORT January – June, 2009

SIR SIR = 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)

Review and Practice

Let’s Review!! Question You 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?

Answer 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?

Question How often does the infection prevention committee have to meet? What are some items on a good infection prevention agenda?

Collecting Data Question My IC surveillance plan states that I do quarterly CA-UTI rates, how do I calculate this rate?????

Answers If 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)

Question What if my surveillance plan states that I do surgical site surveillance on patients that have had gallbladder surgery? How do I calculate the rates?

Answer You 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 100 1/22 X 100 = 4.5 infections per 100 surgeries for that month. Where do you find the comparison rate? (Review the NHSN report)

Is this a CLAB? Patient admitted through the ER for acute MI on 11/28/2010, taken to ICU TLSC 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.

CLAB 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?

Is 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.

CLAB? 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”.

Surgical 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%

Is 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 no acute infiltrates” Remained intubated after surgery Vent settings FIO2 40, RR 10, TV 480, PS 8, Peep 5 10/6/2010 CXR “complete obliteration of L hemidiaphram consistent with consolidation”. “Reduced lung sounds” Purulent sputum WBC 6.3 Temperature of 102.0 Increased vent settings to FI02 70, RR 16, TV 480, Peep 10.

VAP 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 negative IC reviewed case with ID physician who agreed the case fit the CDC VAP Criteria 1 definition.

Is 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 99.5. The physician discharges the patient on Keflex, does not get a UA with culture. IS this a CA-UTI???

Criterion Urinary Tract Infection (UTI) Symptomatic Urinary Tract Infection (SUTI) Must meet at least 1 of the following criteria 1a Patient had an indwelling urinary catheter in place at the time of specimen collection and at least 1 of the following signs or symptoms with no other recognized cause: fever (>38°C), suprapubic tenderness, or costovertebral angle pain or tenderness a positive urine culture of ≥105 colony-forming units (CFU)/ml with no more than 2 species of microorganisms. ----------------------------------------------------OR------------------------------------------- Patient had indwelling urinary catheter removed within the 48 hours prior to specimen collection fever (>38°C), urgency, frequency, dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness

CLAB? 24 year old admitted from ER trauma center to ICU on July 14, 2010. 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 103.8 (39.9). You have the following data. Blood cultures 2/4 positive for MRSA Sputum culture reveals few yeast Cath tip no growth Urine culture < 20,000 cfu candida

CLAB? 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.

CLAB/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 trach Increased ventilator settings needed Rhonchi, 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 MRSA 8/10/2011 Blood culture 2/4 + MRSA

Identifying Hospital acquired pneumonia – 3 parts to PNU 1 Radiologic criteria Patient 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. Consolidation c. Cavitation

Signs 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

AND 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 sounds Worsening gas exchange (O2 desats, increased oxygen requirements, or increased ventilation demand.

VAP 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…

Read 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.

NHSN 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; and inflammation that results from tissue response to injury or stimulation by noninfectious agents, such as chemicals.

VAP 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 line Recognized 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.

CA-UTI On 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 38.9 Complains of abdominal pain (secondary to colon resection surgery on admission date of surgery) WBC 19,000 Foul smelling urine Urinalysis shows 2+ protein, + nitrate, 2+ leukocyte esterase, WBC -, 3+ bacteria. Culture was 10,000 CFU E-coli.

Identification and Categorization of SUTI Indwelling Catheter at the Time of Specimen Collection

CA-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.

Looks like ABUT, no s/s…. And urine culture matches blood culture….

SSI? 55 year old female patient had an abdominal hysterectomy on August 16, 2011. August 20, 2011 The 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, 2011 Culture grew Enterobacter species

A superficial incisional SSI (SIP or SIS) must meet the following criterion: Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision patient has at least 1 of the following: a. purulent drainage from the superficial incision b. organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision c. 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).

SSI? 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 space The surgeon opened the wound and drained the abscess on April 14, 2011, specimen sent to the lab for culture. Culture reveals MSSA.

An 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 procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and patient has at least 1 of the following: a. purulent drainage from a drain that is placed through a stab wound into the organ/space b. organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination d. diagnosis of an organ/space SSI by a surgeon or attending physician. Organ space – what specific site?

Organ/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 LUNG BRST MED CARD MEN DISC ORAL EAR OREP EMET OUTI ENDO SA ----- (Spinal abscess) EYE SINU GIT UR IAB VASC IC VCUF JNT ***Last class, question about Breast implant. Classify as deep or organ space? Superficial - skin and subcutaneous tissue Deep - 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.

NHSN Training Slides SSI/CAUTI BRIEF REVIEW OF nicu/clab

HAI Event Facility Type Reporting Start Date Healthcare Facility HAI Reporting to CMS via NHSN – Current and Proposed Requirements DRAFT (8/5/2011) HAI Event Facility Type Reporting Start Date CLABSI Acute Care Hospitals Adult, Pediatric, and Neonatal ICUs January 2011 CAUTI Adult and Pediatric ICUs January 2012 SSI Colon and abdominal hysterectomy I.V. antimicrobial start (proposed) Dialysis Facilities Positive blood culture (proposed) Signs of vascular access infection (proposed) Long Term Care Hospitals * October 2012 Inpatient Rehabilitation Facilities MRSA Bacteremia January 2013 C. difficile LabID Event HCW Influenza Vaccination OP Surgery, ASCs October 2013 SSI (proposed) Outpatient Surgery/ASCs January 2014 * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN 97

NHSN 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 http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

Review of Sterilization Processes

Before 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.. AORN Hand 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!!!

Decontamination Room Negative air? Temperature range (optimal 60-65 degrees) Humidity ( optimal 30%-60%) No Fans! PPE? Doors/pass through windows? Enzymatic cleaner….. Cleaning brushes Manual cleaning or Automated washer? Work flow Hand washing Negative air? AORN/Chapter 667 Temp AORN/Chapter 667 ACH at least 6 IF 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 room Brushes – 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.

Instrument Preparation Inspection Distribution of instruments in trays/peel packs Single use devices Chemical indicators are placed in each package. Sterilization wrap Rigid containers Inspected for cleanliness and proper function

Sterilization A 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? http://www.onesourcedocs.com/

Instrument Cycle Temp. Exposure Time Single & Dual Insert Sets Prevac 121 +3°C 15 min. Single & Dual Insert Sets Prevac 132 +3°C 14 min. Multiple (2-3) Insert Sets Prevac 132 +3°C 40 min.

Sterilizers Drain strainers Sterilizer gaskets When was the last time the sterilizer was cleaned? What does the manufacturer recommend?

Methods of Sterilization – Steam Pre-Vacuum Gravity Flash Hydrogen peroxide gas plasma Ethylene Oxide Peracetic acid

Prevac Sterilization Air 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.

Gravity 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.

It 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”

Immediate 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 confusion Accreditation 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)

Immediate use sterilization Multi-Society position statement also focuses on personnel requirements involved in reprocessing activities Personnel should: Be knowledgeable Exercise critical thinking and judgment Implement standardized practices Supervising organization should: Ensure appropriate training and education Ensure staff competency Ensure related resources are available

Immediate use sterilization should NOT be performed in the following situations Sterilization of Implants - except in a documented emergency situation where no other option is available For convenience or as a substitute for insufficient instrument inventory Sterilization of devices using cycles that have not been validated for that device or sterilizer Sterilization of devices that are sold sterile and intended for single use only Post-procedure decontamination of instruments used on patients who may have Creutzfeldt-Jacob disease (CJD) or similar disorders

Follow manufacturer instructions for immediate use sterilization The device manufacturer’s written instructions for reprocessing any reusable device must be followed The 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

Different types of steam sterilization cycles for immediate use sterilization Gravity cycles for unwrapped nonporous items (routine metal instruments) is 3 minutes at 270⁰ - 275⁰ Gravity cycles for unwrapped nonporous items, porous items, and items with lumens are sterilized together, minimum exposure time and temp is 10 minutes at 270⁰ - 275⁰ Reference – ANSI/AAMI ST79:2010 (8.62 Flash sterilization parameters)

Different 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)

Flash Sterilization Log

Quality Control, physical parameters Time, temperature, and pressure recorders, displays, digital printouts Initials of reviewer Every load – this is part of load release criteria.

Quality control, chemical indicators Visual identification - processed vs. unprocessed packs Verify sterilant penetration Verify air removal (prevacuum sterilizers – Bowie Dick) Pack monitoring Load monitoring Load release Six classes of chemical indicators Each class has different performance specifications

Class 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

Class 2 Chemical Indicators Class 2 – Bowie Dick Daily Air Removal Test for Prevac Sterilizers

Class 3 Chemical Indicators Internal indicators Not used in steam sterilization Single-variable indicators Peracetic acid concentration Hydrogen peroxide concentration

Class 4 Chemical Indicators Class 4 indicator (single/multi-variable) – Internal chemical indicators, not to be used for release of loads. Internal indicators React to two or more critical variables Indicate exposure at stated values of chosen parameters Is NOT correlated to the BI kill

Class 5 Chemical Indicators Class 5 – Integrating indicators Internal indicators and challenge packs Respond to all critical parameters Performance correlated to the BI For gravity and pre-vacuum cycles Monitors more of sterilization cycle than BI test

Class 6 Chemical Indicators Class 6 Emulating Indicators Respond to all critical variables Performance correlated to the sterilization cycle – tighter tolerance Monitors more of the total sterilization cycle than other sterilization monitoring products

Process 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.

Quality control, chemical indicators Positioning of the indicators and process challenge devices Should be placed flat in the area of the sterilizer chamber and load that represent the greatest challenge (cold point) to the cycle Normally in the front, bottom section of the sterilizer, near the drain Should be identified by the sterilizer manufacturer

Quality 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. Weekly Every load containing an implantable device

Record 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 identifier Exposure time and temperature with initials of the operator? BI test results Bowie Dick test results Chemical indicator response Have 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.

In 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 106-107

Implant load Every 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

Practice – what type of reprocessing? Bedside tables Laryngoscope blades Surgical instruments Vaginal ultrasound probes Endoscopes Temporal Thermometers Cardiac Catheters

Thank you!!!!! Infection prevention matters!!!!