Financial Disclosures

1. Evidence-Based Strategies to Tackle the Three Most Common Sources of HAIs: Contaminated Hands, Environmental Surfaces, and SkinCindy Winfrey, MSN, RN, CICSenior Medical Science LiaisonPDI Healthcare

2. Financial Disclosures PDI Healthcare-Employee

3. 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. Could this be You?

5. What do these have in common?

7. The Importance of a Checklist

8. WHO Checklist for Safer Surgical Care

9. Transmission of Infection

10. How Does Transmission Occur?

11. Pathogens of Significance

12. Examples of multidrug resistance in HAI pathogens • Acinetobacterbaumannii • 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 Acinetobacterbaumanniiand 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. How do you view mortality?

14. 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. 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. 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. HHS Action Plan 5-year Goals NHSN – CDC’s National Healthcare Safety Network EIP – CDC’s Emerging Infections Program NHDS – CDC’s National Hospital Discharge Survey SCIP – CMS’s Surgical Care Improvement Project HCUP – AHRQ’s Healthcare Cost and Utilization Project

18. Sources of Evidence

19. Holistic Bundled Approach

20. 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. Challenges to Skin Antisepsis:Evidence-Based Approaches Prepping the skin • Chlorhexidine (CHG) vs Alcohol vsPovidone-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. The Debate of CHG in Neonates

23. 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 • Povidoneiodine • Removal considerations • Normal Saline • Sterile Water

24. 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. Primary Skin Disinfectant Used for Most PICC Insertions Insertions Sharpe & Pettit 2009

26. FDA Releases New Labeling

28. Do You Have These?

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

31. Hand Hygiene Technique

32. EVIDENCE-BASED PRACTICE

33. Where do you even begin?

34. 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. 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. Local success fuels national prevention National Regional Facility Unit

37. National CDC knowledge and data fuels local to national CLABSI prevention • Nationalexpansion 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 Regional • Subsequent projects based upon CDC prevention: • Michigan Keystone • Institute for Healthcare Improvement • Others Facility Unit Outbreak Investigations Pittsburgh Regional Healthcare Initiative First successful, large-scale CLABSI prevention demonstration project NHSN Data CDC Guidelines Prevention Research (e.g. chlorhexidine bathing) Inputs Outputs

38. The need for HAI prevention research Prevented • Need for complete implementation of practices known to prevent HAIs Preventable Healthcare-associated Infection • Need for ongoing research to identify new strategies to prevent the remaining HAIs Prevention Approach Unknown

39. Prevention Hand hygiene No touch technique Dressing Skin antisepsis Injection cap/needleless connector

40. Consumers Medical Professionals Public Health Safe Healthcare is Everyone’s Responsibility Patients Payors Government Healthcare Facilities

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. Questions • Whose Infection will you prevent when you return to your institution? • Contact Information: • Email: cwinfrey@pdipdi.com • Phone: 719-306-2616