1. Chonna Bartholomew RN,BS CareFusion Clinical Consultant
Prevention of Healthcare-Associated Infections Optimal Disinfection of Skin and Critical Contact Surfaces
Chonna Bartholomew RN,BS
CareFusion Clinical Consultant
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2. HAIs: A Costly Toll to U.S. Healthcare
2. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March 2009, Centers for Disease Control and Prevention. Accessed August 30, 2010 at:
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3. What Does It Mean To The Clinician?
Best Practice
What Does It Mean To The Clinician?
Provide consistent and repeated education on management and prevention of complications with intravenous catheters (IVs) and central venous catheters (CVCs)
Education results in improved practice which reduces complications
SHEA/IDSA HAI Prevention Compendium 2008.
Sherertz R, et al Ann Inter Med.
Coopersmith C, et al Crit Care Med
Warren D, et al Crit Care Med
O’Grady N, et al CDC Guidelines
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4. Skin Antisepsis Best Practice
CHG used for prepping prior to IV/CVC placement may help to reduce skin flora and maintains a residual effect for at least 48 hours
Use a gentle back and forth scrub for 30 seconds on a dry site (i.e. arm, abdomen) and a 2 minute scrub on a moist site (i.e. inguinal folds, axilla)
Allow the area to air dry for 3 minutes Do not blot or wipe away
Do not drape or use ignition source (e.g., cautery, laser) until solution is completely dry (minimum of 3 minutes on hairless skin; up to 1 hour in hair)
Preferred antisepsis 2% Chlorhexidine gluconate (CHG) with 70% Alcohol
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5. The Importance of Using an Applicator
vs.
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6. Best Practice Disinfection Procedures Surface Time Solution Technique
Depends on:
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7. Importance of Our Skin #1 Function: Protective Barrier Microorganisms
80% of resident and transient skin flora reside in the top 5 layers of the Stratum Corneum
Copyright CareFusion 2012
Brown E, Wenzel RP, Hendley JO. Exploration of the microbial anatomy of normal human skin by using plasmid profiles of coagulase-negative staphylococci: search for the reservoir of resident skin flora. J Infect
Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous
catheters. Int Care Med. 2004;30:62-67.
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8. Extra-luminal Contamination
Possible Causes:
Most often caused from poor site maintenance.
Not using full barrier Precautions with CVC insertion
Not maintaining Dry/Intact dressing
Not changing dressing per policy
Not securing CVC and allowing CVC to piston in and out of entry site
Greatest source of Central Venous Catheter (CVC) contamination that are in place for 10 days or less is
the patient’s own skin flora
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9. Normal bacterial flora seen on the skin:
Staphylococcus epidermidis
Staphylococcus aureus
Micrococcus species
Nonpathogenic neisseria species
Alpha-hemolytic and nonhemolytic streptococci
Diphtheroids
Propionibacterium species
Candida species
Acinetobacter species
Peptostreptococcus species
The most commonly reported pathogens causing HAIs:
Coagulase-negative staphylococci, Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus (MRSA) now account for more than 50% of all Staphylococcus aureus isolates obtained in ICUs
Candida spp
Enterococci
Gram negative bacilli
Naomi P. O'Grady, M.D., et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
Chapter 11:NORMAL MICROBIAL FLORA OF THE HUMAN BODy
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10. The Ideal Antimicrobial Agent for Skin
No or minimal systemic absorption
Persistence
Rapid
Broad spectrum
No inactivation by organic matter
1) Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control. 1988;16(6):253–266
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11. Choosing A Skin Prep Antiseptic
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12. Additional Best Practices
Meticulous hand hygiene
Daily bathing with CHG for patients with a CVC
CHG-impregnated dressings
Antimicrobial catheters
Intentional catheter selection
Maximum sterile barriers when inserting a CVC
Daily assessment of site necessity
Use of Needleless Connector (NC)
Process improvement plan
Reference 2011 Infusion Nursing standards of practice
2011 Infusion Nursing Standards of Practice
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13. Bacterial transmission The Risk of Hand-to-Patient Contact
The transmission of bacteria from one person to another happens almost exclusively via the hands, especially the hands of health care practitioners (HCPs)
Studies show hand washing and glove-wearing protocols lack effectiveness
An observational study was conducted at an oncology hospital to examine hand hygiene practices observed during 612 procedures that were performed by 67 HCPs.
RESULTS: The compliance was only 34.3% (n = 210)
References
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June Accessed January, 2008.
Sacar S. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. Am J Infect Control. 2006;34(9):
Kim PW. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control. 2003;31(2):
1. Siegel JD et al Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007.
Accessed January, 2008.
2. Sacar S. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. Am J Infect Control. 2006;34(9):
3. Korniewicz DM, El-Masri M. Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Appl Nurs Res May;23(2): Epub 2009
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14. Intra-luminal Contamination
Possible Causes:
Most likely caused by improper hub manipulation
Healthcare workers not washing hand or wearing gloves
Inadequate disinfection of the Needleless Connector
Not changing tubing per policy
Contaminated Infusate
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15. Critical Surface Disinfection Needleless Connector (NC)
Surface Disinfection depends on:
Surface, Solution, Friction and Time
Solid
Solid
Cannula activated Split septum
Slit on top
Antimicrobial
Hub and Thread contamination depends on:
Protocols, Practice, Technique and Antimicrobial Agents
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16. Different Surfaces May Require Different Time
Casey Elliott Reference
Casey AL, Elliot TSJ et al “A Laboratory Comparison of Microbial Ingress into Eight Different Needleless IV Access Devices” Presentation, 2012 ID Week Conference
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17. Ideal Antimicrobial for for Inanimate Disinfection
ALCOHOL
CHG
Immediate microbial kill
Dissolves oils and other residue from inanimate objects
Leaves no sticky residue
Maximum efficacy “in vitro” around 30 seconds
No affinity for inanimate objects
Leaves a sticky residue that can attract dirt and/or microorganisms
No affinity for inanimate objects: When CHG is used on inanimate objects, we do not witness the desired "persistent" effect that is seen on animate objects (i.e. the skin). CHG’s antimicrobial properties lie in its ability to bind to the skin, which allows it to remain persistent and maintain a minimum of a 2- logarithm for at least 48 hours
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18. Effectiveness Of Disinfecting Caps Depends On The Surface
Depends on surface of the needleless access device
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19. Disinfecting Caps May Reduce Bacteria With Some NCs
Smith, JS et al, “Optimal Disinfection Times for Needleless Connectors” Journal of the Association for Vascular Access Vol 17 No 3, July 2012,
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20. Disinfecting Caps May Eliminate Bacteria On Other NCs
Lange, V et al, “Advances in Infection Control Practice – Curos Port Protectors: An Evaluation of a New Disinfection Device” Presentation, 2009 APIC National Conference
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21. Scrub the “Hub” Keep in mind…
Hub disinfection (tubing or cap changes)
Technique is always the same….15 seconds, juicing an orange; let dry
Keep line closed as long as possible between NC changes
NC (every access)
Technique and Time may depend on the manufacturers directions for use; always let dry
Add notes
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22. Proper Protocol Standardize Practice Reduce Waste Improve Healthcare
Ultimately, advancements in Technology can help Standardize Best Practice
Proper Protocol Standardize Practice Reduce Waste Improve Healthcare
Save Healthcare dollars
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23. Thank you
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