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Infection Control in ICU
Dr Samir Sahu Sr Intensivist & Director ICU Kalinga Hospital
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Introduction ICU patients are Immuno-compromised –as a non-specific response to critical illness or as a side effect of treatment Therefore they are at greater risk of nosocomial infection Multiple vascular catheters & tubes penetrate mucosal surfaces & increase risk of invasive infections
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Nosocomial Infections
Central line related infection Ventilator associated infection Urinary catheter related UTI Post-op wound infection Device related infection
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Epidemiology Infected cases 7/100 admissions in Med ICU
Nosocomial Infections – 30%(/100 adm) ESBLs > 50%, increased Death Infection rate - 1.3% Febrile Episodes – 5% Klebsiella, Staph, E.coli – from patients
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Identify Reservoirs Colonized & Infected patients
Environmental contaminations Common sources
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Before Entering the ICU
Leave your jacket or white coat outside (can carry flora from one patient to next) Neck ties dangle at all sorts of places – tuck them out of the way If you are going to stay in the ICU all day it is a good idea to wear OT dress to prevent contamination of clothes
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Before Approaching a Patient
Wash your hands thoroughly. If hands are socially clean you can use an alcohol disinfectant rub which is equally effective
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Moving between Patients
Wash hands or use alcohol disinfectant rub before leaving the bed Do not share equipments between patients – separate BP instrument & stethoscopes for each bed Do not use your own stethoscope which may be a vehicle for cross-infection
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Universal (Standard) Precautions
Wash hands before & after all patient & specimen contact Handle blood of all patients as potentially infectious Wear gloves for potential contact with blood or body fluids Place used syringes immediately in nearby impermeable containers. DO NOT recap or manipulate syringes in any way
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Universal (Standard) Precautions
Wear protective eyewear & mask if splatter with blood or body fluids is possible Wear gowns when splash with blood or body fluids is anticipated Handle all linen soiled with blood &/or body secretions as potentially infectious Process all laboratory specimens as potentially infectious
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Halt Transmission Improve Hand Washing Improve Asepsis
Barrier Precautions – gloves gown for colonized patients Eliminate any common source – disinfect environment Separate susceptible patients Close unit to new admission if necessary Adequate nurse to patient ratio
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Hand Hygiene-Normal Flora
Transient Flora from contact with patient & contaminated environmental surfaces in close proximity of the patient most commonly responsible for HCW associated infection removed by routine hand washing Resident Flora – coagulase –ve Staph, (sometimes Staph, Gm-ve, yeast etc)
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Hand Hygiene - Transmission
Skin colonizers – Staph. aureas, Proteus Klebsiella, Acinetobacter Can contaminate patient gown, bed linen, bed side furniture & other objects in proximity of the patient Staph & enterococci are resistant to dessication & therefore more common contaminate
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Hand Hygiene Practices
Wet hands transmit more bacteria Adherence – 40% 20 opportunities/hr
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Other Policies Finger nails – subungual region
Gloves – reduces contamination, prevents infection & transmission Rings – more colonization
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Hand Washing Single most important activity for reducing the transmission of infectious agents by contact & feco-oral routes Compliance is poor (48%) Noncompliance higher with physicians & attendants
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Hand Washing Reasons for poor compliance Shortage of staff
Higher patient workloads Availability, adequacy & distance of sinks Compliance may improve with alcohol based hand rub(20sec/120sec)
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Indications of Hand Hygiene
Soap & water (hygienic hand wash) - when soiled with blood or body fluids after going to toilet, eating Decontaminate (hygienic hand rub) before contact with patient (more important) - after patient contact (BP, lifting patient) after contact with equipments before giving IV lines (to prevent transmission)
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Technique of Hand Hygiene
Soap & water (Hygienic Hand wash) apply soap, rub vigorously for 15sec, dry (not to use multiple use towel) Surgical antisepsis remove rings, watch, bracelets scrub underneath of nails & wash scrub hands & forearm with antimicrobial soap for 2-6min
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Technique of Hygienic Hand Rub
Pour hand rub into palm (coin size) First disinfect the tips of your finger & then rest of your hand Contact time 30 sec Rub until dry Hygienic hand rub better than hygienic hand wash
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Improvement of Hand Hygiene Practices
Education of staff Improve adherence – introduction of hand rub Monitor adherence Encourage family members to remind Administrative – education, motivation, system change (availability of sinks, soap, role model, introduction of hand rub)
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My five moments for hand hygiene
WHO Guidelines on Hand Hygiene in Health care. WHO WHO Library Cataloguing-in-Publication Data.
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Barrier Nursing For serious infections or those colonized with antibiotic-resistant organism Do not enter unnecessarily Wear an apron Wash your hands & put on gloves Mask & Gowns depends on nature of the problem Instructions for entering the room is displayed Remove protective aprons etc. before leaving the room Wash hands before leaving the room & use hand rub once outside the room
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Reverse Barrier Nursing
For immuno-compromised patients Side room Barrier nursed to help protect them
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Chemical Disinfection of Equipments
Glutaryldehyde Completely immersed
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Central line Chlorhexidine 2% - reduces inherant resident flora
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Surface disinfection Around patient most important Clean & disinfect
Up to down Procedure of disinfection is more important than the disinfectant
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Infection Control Practices
Each room with own sink & trolley with equipment for patient care Caps, masks, shoe covers, & gloves are required at all times in patient rooms & bathroom Sterile gloves for wound care procedures Standard Precautions Hand hygiene procedures Cleaning once daily with tap water of the sink & environment surfaces using glutaraldehyde & sodium hypochlorite solutions
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Good Disinfection Practices
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Prevention UTI – sterile technique during insertion
- proper fixation to avoid soiling with stool Central line – sterile technique during insertion -- daily inspection of insertion site VAP – proper position - sterile technique during suction Minimise Invasive devices
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Prevention of CAUTI Insertion using aseptic technique & Sterile equipment
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Procedure of Catheterization
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Maintenance of Catheter
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Urinary Catheter Checklist
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The Ventilator Bundle The key elements of the Ventilator Bundle are:
Elevation of the Head of the Bed Daily “Sedation Vacations” and Assessment of Readiness to Extubate Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis Prophylaxis Other potential additions Oral Care Protocol Mobility Protocol The key elements of the Ventilator Bundle are: Elevation of the Head of the Bed Daily “Sedation Vacations” and Assessment of Readiness to Extubate Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis Prophylaxis Other potential additions like Oral Care Protocol & Mobility Protocol
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VAP Ventilator circuits Suctioning Humidifiers
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Central Line Bundle 5 key “Best Practices”
Hand Hygiene Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Optimal Insertion Site Daily Review of Line Necessity & remove if not necessary The science supporting the bundle components is sufficiently established to be considered standard of care. The Central Line Bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, results in better outcomes than when implemented individually. IHI therefore proposed the following key components for the central line bundle: Hand hygiene Maximal barrier precautions upon insertion Chlorhexidine skin antisepsis Optimal catheter site selection with subclavian vein as the preferred site for non-tunneled catheters Daily review of line necessity with prompt removal of unnecessary lines.
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What are Maximal Barrier Precautions?
For Provider: Hand Hygiene Non-sterile cap and mask All hair should be under cap Mask should cover nose and mouth tightly Sterile gown and gloves For the Patient Cover patient’s head and body with a large sterile drape Another way to decrease the likelihood of central line infections is to apply maximal barrier precautions in preparation for line insertion. A maximal barrier precaution means strict compliance with hand washing, wearing a cap, mask, sterile gown and gloves by the ICU personnel. The cap should cover all hair and the mask should cover the nose and mouth tightly. These precautions are the same as for any other surgical procedure that carries risk of infection. Maximal barrier precautions clearly decreases the odds of developing catheter-related bloodstream infections. Studies have shown that the odds of developing a central line infection were higher if maximal barrier precautions were not used. For pulmonary artery catheters, the risks of developing infection were twice as much for placement of central line catheters. A similar study found that the risk was six times higher for placement of central line catheters.
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Maximal Barrier Precautions
For the patient, maximal barrier precautions means covering the patient from head to toe with a sterile drape with a small opening for the site of insertion.
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Chlorhexidine skin specialist
Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions. Standard technique for Chlorhexidine is – Prepare skin with antiseptic/detergent chlorhexidine 2 percent in 70 percent isopropyl alcohol. Pinch wings on the Chlorhexidine applicator to break open the ampoule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against the skin, apply Chlorhexidine solution using a back and forth friction scrub for at least 30 seconds Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site (~2 minutes). Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions. Standard technique for Chlorhexidine is – Prepare skin with antiseptic/detergent chlorhexidine 2 percent in 70 percent isopropyl alcohol. Pinch wings on the Chlorhexidine applicator to break open the ampoule. Hold the applicator down to allow the solution to saturate the pad. Press sponge against the skin, apply Chlorhexidine solution using a back and forth friction scrub for at least 30 seconds Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site (~2 minutes). Always remember, to include chlorhexidine antisepsis as part of your checklist for central line placement. Include Chlorhexidine antisepsis kits in carts starting central line equipment. Many central line kits include povidone-iodine kits and these must be avoided. And please ensure that solution has dried completely before an attempted line insertion.
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Optimal Catheter Site Selection
Percutaneously inserted catheters are the most commonly used central catheters. Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular & femoral site. Percutaneously inserted catheters are the most commonly used central catheters. Several risk factors for blood stream infections have been identified which depend on the site of placement. In one study, Mermel et al. were able to demonstrate that a great majority of infections develop at the insertion site compared to the subclavian site.
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CR-BSI Checklist Before the procedure, did they:
Wash hands Sterilize procedure site Drape entire patient in a sterile fashion During the procedure, did they: Use sterile gloves, mask and sterile gown Maintain a sterile field Did all personnel assisting with procedure follow the above precautions Create CR-BSI Checklist. Get the whole step by step procedure in place. Check, Before the procedure, did they: Wash hands Sterilize procedure site Drape entire patient in a sterile fashion During the procedure, did they: Use sterile gloves, mask and sterile gown Maintain a sterile field And the Most Important is to check, - Did all personnel assisting with procedure follow the above precautions
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Central line Maintenance
Catheter site Dressing Anticoagulant flush Replacement of set, tubings, fluids Replcement
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Daily Review of Line This will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of patient. Necessary step to prevent infection includes, Daily review of line necessity as part of multidisciplinary round is must. Include assessment for removal of central lines as part of daily goal sheet. Record time and date of line placement for record keeping purpose and evaluation by staff to aid in decision making of removal. Daily review of central line necessity will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of the patient. Many times, central lines remain in place simply because of their reliable access and because personnel have not considered removing the line. However, it is clear that the risk of infection increases over time as the line remains in place and that the risk of infection is decreased if removed. Remember, It is important to empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. Include daily review of line necessity as part of your multidisciplinary rounds. Include assessment for removal of central lines as part of your daily goal sheets. Record time and date of line of placement for record keeping purposes and evaluation of staff to aid in decision making.
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Halt Progression from Colonization to Infection
Extubate as early as possible Remove central lines when not necessary Remove Indwelling catheter Change of IV lines, 3-ways, ventilator circuits, HME filters as per protocol Prevention of VAP – suctioning, position,
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Blood Cultures Minimum 2 sets(from two sites)
Disinfect puncture site with clorhexidine in 70% alcohol. Minimum volume 20ml in each set (use 20 ml syringe),(10 ml/bottle-2 bottles) 2nd set can be drawn immediately after 1st set. I bottle(10ml) aerobic, I bottle(10ml) anaerobic + 5ml fungal(if suspected) If suspecting CRBSI 1 set through central line & one from peripheral line. Femoral draw can be contaminated with Gm –ve organisms.
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Evidence for Blood Cultures
10ml yield 40%, 20ml - 70%, 60ml – 90% 33% yield in Sepsis (KHL 7%, Apollo 8%) Anaerobic infections 5% but anaerobic bottle supports growth of many facultative anaerobes like Strepto, Staph, E coli, Pseudo Aerobic+Anaerobic better than 2 aerobics (JCM 2011)
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Colonization Surveillance
Oropharyngeal Rectal Once a week/3 times per week Positive predictive value
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Detection Fever after 48hrs of intervention Increased TLC count
Urine – pus cells Wound – pus VAP – purulent sputum - new radiological shadow Evidence of Sepsis
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Modify Host Risk Treat underlying disease & complications
Control Antibiotic Use
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Visitors in ICU We allow one visitor to stay with the patient – Dr S K Jindal, PGI, Chandigarh Visitors are not allowed during the ICU rounds, during any procedure, or when patient is resting. Rest of the time 1-2 members of the family are allowed – Dr Subash Arora, Director ICU, Australia
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Visitors in ICU In the UK there are no restrictions & the relatives visit when they can. Relatives are asked not to visit during rounds, when procedures are being done or when there is other nursing care to be given (bath etc) – Dr Roop Kishen, UK Each area will need to draw up realistic rules to allow family interaction, to say goodbye to the dying & consistent with good medical practice for all patients in the ICU – Dr George John, Vellore
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Visitors in ICU - KHL Visitors will not be allowed during the rounds between 9am-11am & during handover between 7am-8am, 1pm-2pm, 7pm-8pm & during emergency procedures One attendant at a time No talking with sisters Not to sit near the patient Not to touch the patient
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Three steps to Wisdom Learning Discipline Prudence
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Global HAI Rates. Percentage of HAIs by Discharge
Global HAI Rates. Percentage of HAIs by Discharge. Kalinga Hospital , Mixed ICU
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Global HAI Rates. Number of HAIs by 1000 Bed Days
Global HAI Rates. Number of HAIs by 1000 Bed Days. Kalinga Hospital , Mixed ICU
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Device Associated Infections in INICC. Benchmarking
Victor D. Rosenthal,a Dennis G. Maki, Ajita Mehta, et al. International Nosocomial Infection Control Consortium (INICC) Report, Data Summary for , Am J Infect Control ;36: IVD-BSI: intravascular devices associated blood stream infection, VAP: ventilator associated pneumonia. CA-UTI: catheter associated urinary tract infection
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Device Associated Infection Rates
Device Associated Infection Rates. Central Line Associated Blood Stream Infection per 1000 Device Days. Kalinga Hospital , Mixed ICU January 2007-August 2007 / October 2008-Agust 2009 CL Days 3548 Number of CLAB 4 Pooled CLAB Rate x 1000 CL Days 1,1
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Device Associated Infection Rates
Device Associated Infection Rates. Catheter Associated Urinary Tract Infection per 1000 Device Days. Kalinga Hospital , Mixed ICU January 2007-August 2007 / October 2008-Agust 2009 UC Days 6223 Number of CAUTI 11 Pooled CAUTI Rate x 1000 UC Days 1,77
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Device Associated Infection Rates
Device Associated Infection Rates. Ventilator Associated Pneumonia per 1000 Device Days. Kalinga Hospital , Mixed ICU January 2007-August 2007 / October 2008-Agust 2009 Ventilator Days 2491 Number of VAP 21 Pooled VAP Rate x 1000 MV Days 8,43
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