Hand Hygiene and Infection Control: What Happens Next?

Gonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University

What Dr. Wenzel does not know and What Dr. Edmond will not tell you.

Hand Hygiene and Infection Control: What Happens Next?

What Dr. Wenzel does know and What Dr. Edmond will tell you.Gonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University

Infection Control Timeline

Big Bang

10 billion and 20 billion years ago

Hotel-Dieu :Paris hospital founded in the 7th century

Many years elapse

0 Circa 600 AD

Infection Control Timeline

Leprosariums emerge in the Middle Ages

Lazarettos for plague victims established in Venice in the 15th century

Fever hospitals established in England in the early 19th century

Segregation of Infectious Patients

History: Ignaz Semmelweis• At the Vienna Lying-in

Hospital – Women who delivered on the street had

less risk of developing puerperal fever– Much higher risk of puerperal fever in

women delivered by physicians or medical students as opposed to those delivered by midwives

• Required that hands be washed with chlorinated lime after autopsies & between exams of pregnant women– Maternal mortality

decreased from 18% to 3%

History: Florence Nightingale and Louis Pasteur

• Developed the germ theory of disease in the late 1800s

•Importance of unsanitary hospital conditions and post operative complications

History: Advances in Surgical Infection Control

Joseph Lister introduced antiseptics in 1867

William Halstead introduced gloves in 1890

Johannes Mikulicz introduced masks in 1897

Infection Control Timeline: The Modern Era

First antibiotics, sulfonamides & penicillin, developed in the late 1930s

Robert Haley, MD 1970’s SCENIC Study

Hospitals with active infection control programs have a 32% lower incidence of nosocomial infections

R.P Wenzel MD, MSc1980: Founded Society of Healthcare Epidemiology; applied epidemiologic techniques to infection control

1961: MB Edmond born

So where are we now and what happens next?

Nosocomial Infections• 5-10% of patients admitted to acute care

hospitals acquire infections– 2 million patients/year– 70% are due to antibiotic-resistant organisms– ¼ of nosocomial infections occur in ICUs– 90,000 deaths/year– Attributable annual cost: $4.5 – $5.7 billion

• Cost is largely borne by the healthcare facility not 3rd party payers

Weinstein RA. Emerg Infect Dis 1998;4:416-420.Jarvis WR. Emerg Infect Dis 2001;7:170-173.

Shifting Vantage Points on Nosocomial Infections

Gerberding JL. Ann Intern Med 2002;137:665-670.

Many infections are inevitable, although

some can be prevented

Each infection is potentially

preventable unless proven otherwise

The medical literature is replete with studies identifying risk factors for nosocomial infections• Hand Hygiene• BSI

– Catheter type, insertion, maintenance

• VAP– Duration of intubation, gastric pH, HOB

elevation

• UTI– Catheter use and insertion, maintenance

Sadly, we as medical professionals frequently do not practice well known nosocomial infection risk reduction practices

Pressure from legislatures, consumer groups, third party payers and regulatory agencies has resulted in mandatory public reporting of nosocomial infections

This is now driving compliance with process of care measures that are associated with reductions in nosocomial infection risk

Help Consumers Union Stop Hospital Infections! Most people don't expect to go into a hospital and come out even sicker because of an infection they caught as a patient, but 1 in 20 do. And each year, about 90,000 people die from hospital acquired infections - a leading cause of death in the U.S. The annual cost to our health care system is $5 billion. Congress is considering a bill that would let hospitals keep information about their infection rates and medical errors a secret. People should be able to find out whether their hospital is doing a good job of controlling dangerous infections.

TAKE ACTION now to tell Congress to preserve state's rights to report on hospital infection rates.

http://www.consumersunion.org/pub/projectsandcampaigns.html

Status of Mandatory Reporting LegislationSeptember 2005

Enacted legislation Legislation introduced, under review or further study Legislation died/defeated

Source: APIC.Slide: courtesy of MB Edmond MD,MPH,MPA

Infection Control Process of Care Measures

• Hand Hygiene• Contact Precautions

– Gowns– Gloves

• HOB elevation for VAP prevention• CVC insertion measures

– Avoidance of femoral site– Maximal sterile barrier precautions– Proper antisepsis of skin– Prompt discontinuation of catheter use

30%-40% of all Nosocomial Infections are Attributed to Cross Transmission:

The Importance of Hand Hygiene

The inanimate environment is a reservoir of pathogens

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, C.diff, CNS and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

Hand Hygiene

Hand Hygiene Comment

Typical Compliance

Observational studies of hand hygiene report compliance rates of 5-81%

Common Reported Barriers To Compliance

Insufficient time, understaffing, patient overcrowding, lack of knowledge of hand hygiene guidelines, skepticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants and lack of hand hygiene promotion by the institution

Single most effective method to limit cross transmission

HCWs' perceptions of compliance with infection control practices

% of HCWs reporting compliance >80%

Position N (%) HandwashingContact isolation

Airborne isolation

Registered nurses 118 (36) 77 59 74

Resident physicians 99 (31) 62 61 92

Attending physicians 33 (10) 62 72 82

LPNs, patient care assistants

29 (9) 59 72 76

Others 45 (14) 73 79 69

Total 324 (100) 69 65 80

Berhe M, Edmond MB, G Bearman in AJIC 33;1 February 2005, 55-57

Majority of respondents reported excellent compliance with IC practices

Alcohol Based Hand Sanitizers

• CDC/SHEA hand antiseptic agents of choice– Recommended by CDC based

on strong experimental,clinical, epidemiologic and microbiologic data

– Antimicrobial superiority• Greater microbicidal effect • Prolonged residual effect

– Ease of use and application

Alcohol based hand hygiene solutionsQuick: 5- 15 seconds Easy to use

Very effective antisepsis due to bactericidal properties of alcohol

Arch Intern Med. 2000;160:1017-1021.

Hand Hygiene Educational Program Implemented

Direct Observation of Hand Hygiene

Incremental Increase in Alcohol Dispensers

Study Algorithm

Arch Intern Med. 2000;160:1017-1021.

•Improvement in Hand Hygiene Compliance

Results

Hand hygiene practice can be improved with education and greater accessibility of alcohol hand sanitizers

Hand Hygiene

• Single most important method to limit cross transmission of nosocomial pathogens

• Multiple opportunities exist for HCW hand contamination– Direct patient care– Inanimate environment

• Alcohol based hand sanitizers are ubiquitous– USE THEM BEFORE AND AFTER PATIENT

CARE ACTIVITIES

Hand Hygiene

• HCW’s perceive that their hand hygiene practice is excellent– Observational data does not support this

claim

• New technologies such alcohol based hand sanitizers make the practice of hand hygiene simpler than ever– There is simply no excuse for poor hand

hygiene compliance

Contact Precautions for drug resistant pathogens.

Gowns and gloves must be worn upon entry into the patient’s room

Glove Use for Infection ControlVariable Rationale Comment

Gloves

Prevent healthcare worker exposure to bloodborne pathogens

Prevent contamination of hands with drug resistant pathogens during patient care activities

Even with proper glove use, hands may become contaminated during the removal of the glove or with micro-tears that allow for microorganism transmission

Gown Use for Infection Control

Variable Rationale Comment

Gowns

Several studies have documented colonization of healthcare worker apparel and instruments during patient care activities without the use of gowns

The use of gloves and gowns is the convention for limiting the cross transmission of nosocomial pathogens, however, the incremental benefit of gown use, in endemic settings, may be minimal

What about the role of Universal Gloving For All Patient Care?

A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-

Resistant Pathogens G. Bearman MD,MPH

A. Marra, MD

C. Sessler, MD

W.R. Smith, MD

R.P. Wenzel MD, MSc

M.B. Edmond MD,MPH,MPA

Hypothesis• The effectiveness of universal gloving

(use of gloves for all patient care activity) in preventing the transmission of multidrug-resistant pathogens will be greater than the effectiveness of contact precautions for the following reasons: – Compliance with universal gloving will likely

be greater than compliance with contact precautions.

Bearman et al.

M e th o d s : S tu d y D e s ig n

0 1 2 3 4 5 6

M onth

C o n c u r re n t s u r v e i l la n c e fo r n o s o c o m ia l in fe c t io n s

V R E , M R S A s u rv e i l la n c e c u lt u re s o n a d m is s io n & e v e r y 4 d a y s

M e a s u r e h a n d h y g ie n e f r e q u e n c y

C o n ta c t p r e c a u t io n s fo r V R E , M R S A c o lo n iz e d / in fe c te d

p a t ie n t s

U n iv e r s a l g lo v in g : N o C o n ta c t P r e c a u t io n s

•CDC/NNIS NI definitions applied; surveillance performed by VCUMC IC Department

•Hand hygiene observations performed by trained observers

•Active surveillance nasal and rectal cultures were obtained on all patients within the unit

Bearman et al.

Methods

• Microbiologic Data– One rectal swab culture performed for VRE

and 1 nasal swab culture for MRSA performed on admission and every 4 days.

• Once a patient was culture positive; then no further cultures were obtained for that organism.

– Pulse field gel electrophoresis (PFGE) for genetic typing and antibiotic susceptibility testing were performed on all MRSA and VRE isolated after study was completed.

Bearman et al.

Methods

• Healthcare Questionnaire– Administered at the end of the study

protocol• Target: MRICU Nurses and Attending

Physicians– Focus:

» self reported compliance with infection control practice

» acceptability of universal gloving vs. standard of care.

Bearman et al.

MethodsAdditional Data Elements:

Phase I vs. Phase IILength of stay

MRICU occupancy rate per month

MRICU invasive devices utilization ratios

Nurse to patient ratio

Antibiotic usage: defined daily dose (DDD)

Bearman et al.

Results:

Variable Phase I Phase II P value

Total patient days

1090 1377 -

Total observations for IC compliance

1220 1102 -

Total patients screened for VRE

192 257 0.54

Total patients screened for MRSA

228 301 0.60

Bearman et al.

Results: Hand Hygiene Compliance

Phase I Phase II

Variable N Obs % N Obs % P-value

Hand Hygiene before patient contact

228 18.7 126 11.4 <0.001

Hand Hygiene after patient contact

704 57.7 578 52.5 0.011

A statistically significant reduction in hand-hygiene was observed in phase II

Bearman et al.

Results:Compliance with Contact Precautions vs. Universal Gloving

Variable

Phase I Phase II

PN % N %

Compliance with gloving for patients on contact precaution

387 89.4 N/A N/A N/A

Compliance with gowns for patients on contact precaution

335 77.4 N/A N/A N/A

Gowns and gloves for patients on contact precaution

328 75.7 N/A N/A N/A

Total Compliance: (Contact Precautions vs. Universal Gloving)

328 75.7 959 87.0 <0.001

Greater adherence during universal gloving was observedBearman et al.

Results: VRE screening

Variable Phase I Phase II P value

Total Patients Screened for VRE

192 257

Patients VRE positive upon admission to ICU

3 (1.5%) 3 (1.1) 0.70

Patients with VRE conversion during ICU stay

39 (20%) 35 (14%) 0.31

Days to acquire VRE

(median)8 9 0.79

No difference was observed in the rate of VRE acquisition

Bearman et al.

Results: MRSA Screening

Variable Phase I Phase II P value

Total Patients Screened for MRSA

228 301 -

Patients MRSA positive upon admission to ICU

11 (4.8%) 6 (2.0 %) 0.11

MRSA conversion during ICU stay 13 (5.7%) 15 (5.0%) 0.92

Days to acquire MRSA (median) 8 9 0.95

No difference was observed in the rate of MRSA acquisition

Bearman et al.

Results: MRSA PFGEMRSA Phase I Phase II

Number of Strains

21 25

Conversion: negative to positive

13

13/13 clonal (100%)

Type A1, A2, A3, A4

15

15/15 clonal (100%)

Type A1, A5

PFGE Types A1:13/21 (62%)

A2: 5/21 (23%)

A3: 1/21 (5%)

A4:1/21 (5%)

B: 1/21 (5%)

A1:18/25 ( 72%)

A5: 2/25 (8%)

C: 3/25 (12%)

D:2/25 (8%)

ALL MRSA conversions were with clonal isolates

Bearman et al.

Results: VRE PFGEVRE Phase I Phase II

Number of Strains

40 35

Conversion: negative to positive

39

20/40 clonal: (50%)

Type A, B

35

28/35 clonal (80%)

Type A, AA, AB

PFGE Types Type A: 16/40 (34%)

Type B: 4/40 (11%)

Type D:2/40

Type G: 3/40

Type H:2/40

Type J:2/40

Type K: 2/36

Type C,E,I, L,M,Q,R S,T: 1 each 9/40

Type A: 18/35 (51%)

Type AA: 4/35 (11%)

Type AB:4/35 (11%)

Type H: 2/35 (6%)

Types F,G,I,J,U,V,M:1 each 7/35 (20%)

Most VRE conversions were with clonal isolates

Results:Nosocomial Infections Rates

Outcome Phase I Phase II P

BSI/1000 catheter days

6.2 14.1 P<0.001

UTI/1000 catheter days

4.3 7.4 P<0.001

Pneumonia 0 2.3 P<0.001

A statistically significant increase in NIs was observed

Bearman et al.

Results: Nosocomial Infections Phase I Phase II

Infection # Organisms # Organisms

BSI 5 P. aeruginosa (1)

E. cloacae (1)

K. pneumoniae (1)

Prevotella species (1)

C. glabrata (1)

16 Coag. negative staph (6)

Enterococcal species (3)

VRE (1)

MRSA(2)

P. aeruginosa (1)

K. pneumoniae (1)

C. parapsilosis (1)

C. albicans (1)

UTI 6 E. coli (2)

E. cloacae (1)

C. albicans (3)

9 Coag. negative staph (1)

Enterococcal species (1)

P. aeruginosa(2)

E. coli (1)

C. albicans (2)

C. non-albicans (2)

VAP 0 NA 2 MRSA(1)

P.aeruginosa (1)

Results: Nosocomial Infections with VRE or MRSA

Phase I Phase II

Infection VRE MRSA VRE MRSA

BSI 0 0 1 2

UTI 0 0 0 0

VAP 0 0 0 1

4 VRE and MRSA infections were identified in Phase II

MRICU DemographicsPhase I Phase II P value Variable

5.3 6.8 0.07 Average length of stay

87% 92% 0.36MRICU occupancy rate per month

1:1.9 1:1.9 NS Nurse to patient ratio

Device utilization ratio Phase I Phase II P

Urinary Catheter 0.85 0.87 0.83

Central line 0.74 0.72 0.87

Ventilator 0.56 0.62 0.47

Utilization ratio=device days/patient days

Results: Antibiotic UsageDefined daily dose (DDD/1000 patients-day)

Antibiotic

DDD

Phase I

DDD

Phase II P value

B-lactams 391.6 352.9 0.075

B-lactam/inhibitor 210.1 211.5 1.0

Aminoglycosides 68.2 118.2 <0.001

Glycopeptides 190.1 226 0.079

Metronidazole 127.0 118.6 0.582

Quinolones 385.7 359.0 0.206

Total 1372.7 1386.2 0.806

The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults

Example:DDD of levofloxacin is 0.5grams, if 200 grams were dispensed in a period with 4,500 patient days:(200g/0.5g)/4,500 pt days X 1000= 89 DDD/1000 PD

Results:Questionnaire about IC compliance During Universal Gloving Study

• 34 respondents– 30 MRICU Nurses (45 eligible)– 4 Attending Physicians (7 eligible)

• Overall survey compliance 65%

Results:Questionnaire about IC compliance

Questionnaire Item: Proportion

Proportion of respondents indicating that universal glove use was impractical 12%

Proportion of respondents reporting good compliance with infection control measures

97%

Proportion of respondents reporting good compliance with Hand hygiene 97%

Results:Questionnaire about IC compliance

Questionnaire Item: Proportion

HCWs reporting less frequent entry into a patient room because of contact precautions

48%

Belief that proper glove use is more important than hand hygiene to limit the spread of nosocomial organisms

6%

Belief that the use of gloves is associated with decreased risk of cross-transmission of nosocomial organisms

94%

HCWs reporting no difference in skin problems (e.g., chapping, dryness, cracking)

93%

Results:Questionnaire about IC compliance During Universal Gloving Study

Overall better care is delivered when:

Contact Precautions

Universal Gloving

No difference

Majority of respondents felt that better care was delivered during the Universal Gloving Phase of the study

Universal Gloving Conclusions• Observed compliance with universal gloving

was significantly greater than compliance with contact precautions (gowns and gloves).

• However, greater compliance with hand hygiene was observed in the standard of care phase.

• No differences were detected between the two study phases for: – LOS, nurse:patient ratio,MRICU occupancy rate,

invasive device utilization, and antibiotic usage

Universal Gloving Conclusions• No differences in VRE and MRSA colonization was

observed between the two study phases.• In both phases, the majority of VRE and MRSA

conversions were of a clonal isolate• However, an increase in nosocomial infection rates

was observed during the universal gloving phase of the study• 4 VRE and MRSA nosocomial infections were

observed during the universal gloving phase

Universal Gloving Conclusions• HCWs found gloving acceptable and believed that the use of

universal gloving is associated with decreased risk of cross-transmission of nosocomial organisms

• HCWs believed that better care was delivered under the universal gloving phase

• Although universal gloving was highly accepted by the staff, its implementation should proceed with caution given the observed increase in nosocomial infection rates– The use of universal gloving may have lead to a

misperception of decreased cross transmission risk – This may have lead to decreased hand hygiene compliance

and a consequent increase in the rates of nosocomial infections

The importance of process of care measures in the reduction of nosocomial bloodstream infections

The CVC: Subclavian, Femoral and IJ sites

The intensity of the Catheter Manipulation

El Host

The CVC is the greatest risk

factor for Nosocomial BSI

As the host cannot be altered, preventive measures are focused on risk factor modification of catheter use, duration, placement and manipulation

The risk factors interact in a

dynamic fashion

Prevention of Nosocomial BSIs

• Limit duration of use of intravascular catheters– No advantage to changing catheters routinely

• Maximal barrier precautions for insertion– Sterile gloves, gown, mask, cap, full-size drape– Moderately strong supporting evidence

• Chlorhexidine prep for catheter insertion– Significantly decreases catheter colonization– Disadvantages: possibility of skin sensitivity to

chlorhexidine

Eliminating catheter-related bloodstream infections in the intensive care unit

– Purpose:– To determine whether a multifaceted systems

intervention would eliminate catheter-related bloodstream infections (CR-BSIs)

– Method:– Prospective cohort study in a surgical intensive

care unit (ICU) with a concurrent control ICU.

–Patients:– All patients with a central venous catheter in the

ICU

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.

Eliminating catheter-related bloodstream infections in the intensive care unit

Interventions Example

Staff Education

•All staff inserting central catheters were required to complete a web-based training program with post-test.

Creation of a catheter insertion cart

•Central catheter insertion cart that contains all equipment and supplies •Reduced the number of steps required for compliance

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.

Eliminating catheter-related bloodstream infections in the intensive care unit

Promotion of daily catheter Removal

Asked daily during rounds whether catheters or tubes could be removed

Evidence based checklist CVC insertion and for BSI risk reduction

Hand hygiene prior to procedure

Chlorhexidine skin preparation

Full-barrier precautions during CVC insertion

Subclavian vein as the preferred site

Maintenance of sterile field during procedure

Nurse

Empowerment

Procedure aborted if a violation in compliance with evidence-based guidelines was observed

SICU attending physician notified

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.

Eliminating catheter-related bloodstream infections in the intensive care unit

• Results:– During the first month nursing completed

the checklist for 38 procedures:• Eight (24%) for new central venous access,• 30 (79%) for catheter exchanges over a wire, • Three (8%) were emergent.

– Nursing intervention was required in 32% (12/38) of central venous catheter insertions

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.

Eliminating catheter-related bloodstream infections in the intensive care unit

BSI Rate 1st quarter

1998

BSI Rate 4th quarter

2002

January 2003- April 2004

Study ICU 11.3/1,000 catheter days

0/1,000 catheter days

0.54/1,000 catheter days

No crBSI over 9 months

Control ICU 5.7/1,000 catheter days

1.6/1,000 catheter days

Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.

Multifaceted, comprehensive program requiring CVC insertion education, with safety checks for proper hand hygiene, aseptic insertion procedure and operator

responsibility can result in reduction of nosocomial BSI in an ICU setting.

Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance

Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2, Gonzalo Bearman MD, MPH1,2

Divisions of Infectious Diseases1 and Quality Health Care2

Department of Internal Medicine

Virginia Commonwealth University School of Medicine

Richmond, VA, USA

Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance

Process Measure

MRICU STICU

Baseline

Q2-2004

Q3

(2004)

Q4

(2004)

Q1

(2005)P

value*

Baseline

Q2-2004

Q3

(2004

Q4

(2004)

Q1

(2005)P

value*

HH %

Opp

14/44

(32%)

31/91

(37%)

33/91

(36%)

50/108

(46%)

0.101 19/38

(50%)

42/80

(53%)

40/80

(50%)

49/100

(49%)

0.916

HOB %

Opp

28/51

(55%)

320/333

(96%)

450/454

(99%)

551/556

(99%)

<0.001 20/43

(47%)

229/307

(75%)

389/488

(79%)

275/361

(76%)

<0.001

Fem. CVC

% of Days

195/1093

(18%)

130/769

(16%)

80/879

(9.1%)

51/951

(5.4%)

<0.001 93/1109

(8.4%)

49/970

(5.1%)

14/1077

(1.3%)

26/920

(2.8%)

0.01

Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2, Gonzalo Bearman MD, MPH1,2

0

10

20

30

40

50

60

70

80

90

100

Q1-04 Q2-04 Q3-04 Q4-04 Q1-05 Q2-05

0

1

2

3

4

5

6

7

8

HOB compliance Pneumonia cases/1,000 ventilator-days

Head of Bed Elevation in VCU Medical ICU:Effect of Feedback

% C

om

pli

ance

wit

h H

OB

el

evat

ion

Baseline;no feedback

Performance feedback quarterly

Pn

eum

on

ia cases/1,000 ventilato

r-d

ays

Slide: courtesy of MB Edmond MD,MPH,MPA

Ask Yourself:

• If other professions can impose much tighter regulations to minimize risks, should we do the same?

• Are 3-5 infections/ 1000 patient days acceptable?

• Are we doing all that is possible to minimize risk?

United States & Canada: accident rates as of 12.31.2004

Airline Rate Events No. Flights

Air Canada 0.63 3 4.75 Million

Alaska Airlines 0.74 3 4.05 Million

Aloha Airlines 0.49 1 1.34 Million

American Airlines/Eagle 0.59 10 17.0 Million

Continental Airlines/Express 0.63 5 8.00 Million

Delta Air Lines 0.30 6 20.0 Million

http://www.airdisaster.com/statistics/

Conclusion• Risk reduction strategies for the prevention of

nosocomial infections are well defined in the literature– Lack of adherence to IC measures is recognized as

important in the pathogenesis of NIs– Sadly, HCWs overestimate their degree of compliance with

infection control measures

• Pressure from legislatures, consumer’s groups, hospital administration, third party payers and regulatory agencies will result in the mandatory public reporting of nosocomial infections.– Drive increase compliance with process of care measures

that are associated with reductions in nosocomial infection risk

Conclusion

• System level changes involving the measurement and feedback of adherence to IC measures are needed to implement risk reduction strategies consistently– BSI: enforcement of comprehensive

catheter use/care policies– VAP: HOB elevation– Hand hygiene- alcohol based sanitizers

“ I suppose that I shall have to die beyond my means”

Oscar Wilde, upon being told the cost of an operation