michele barr, rn, bsn, cic jennifer perry, rn, bsn, cic, cphrm
TRANSCRIPT
CIP CONSULTING LLCBASIC AND INTERMEDIATE
INFECTION PREVENTIONMichele Barr, RN, BSN, CIC
Jennifer Perry, RN, BSN, CIC, CPHRM
COMMON SURVEY QUESTIONS
MICROBIOLOGY REVIEW
Basic Infection Prevention Training
STAIN…. WILL IDENTIFY To visualize microbes the lab can stain
them using two common staining methods.
1. Gram stain Gram + Purple Gram – Red
Gram Stain – allows identification of four basic groups of bacteria, and provide early suggestion of empiric antibiotics to use and possible initiation of isolation precautions.
2. Acid-fast stain
STAINS…. Acid-fast stain – The cells of some
bacteria and parasites are impervious to crystal violet and other dyes, so heat or detergents are used to force dye into this type of cell.
If smear +, look closely at the patient to determine if airborne isolation is needed.
1. S/S of TB?2. Look at most recent chest x-ray.
HOW ARE MICROBES CULTURED?
• Nutrient – type of plate• Optimal temperature - 35 – 37 degrees
C.• Atmosphere – does the microbe need
oxygen or carbon dioxide?• Collection – (Do you have a specimen
collection policy? Check with lab, and educate your people)
• Tissue culture – Some viral pathogens are more difficult to grow than bacteria, so non culture methods are used for their identification.
MIC STUDIES (MINIMUM INHIBITORY CONCENTRATION STUDIES)
MIC studies help determine antimicrobial susceptibility to antibiotics.
The lowest concentration of an antimicrobial that will inhibit the visible growth of a microorganism after incubation.
(examples of disk diffusion)
Other methods to determine MIC are broth dilution, E-test, and automated systems.
MIC The zone sites are looked up on a
standardized chart to give a result of 1. Sensitive2. Intermediate3. Resistant
The charts have a corresponding column which gives the minimum inhibitory concentration for that drug.
(Example of E-test)
R, I, S, DESIGNATIONS
For instance this culture report – the Ampicillin zone of inhibition was > 32, according to the CLSI guidelines that the lab uses, that zone of inhibition should be reported as “R”
ANTIBIOGRAM
Done annually by the Microbiology lab. Helps guide antibiotic usage, very
specific to the facility. See example in packet – let’s review!
DIRECT ANTIGEN TESTING• In addition to traditional culturing
methods, there are non-culture methods to detect microbes.
• EIA (Enzyme immunoassay) This procedure uses known specific antibodies which are reacted with a patient specimen. If the unknown patient antigen reacts with the antibody, a visible result can be observed by an enzymatic reaction. (i.e., Influenza A virus antibody, HIV, Strep kit)
• Advantage – rapid testing, agents that are difficult to grow, very specific identification.
DNA PROBES – ANOTHER NON-CULTURING METHOD
Matches DNA from an unknown agent, with nucleic acid segments from a known agent.
Lab frequently uses this method for genital specimens to detect Neisseria gonorrhea and Chlamydia.
PCR – POLYMERASE CHAIN REACTION - ANOTHER NON-CULTURE DETECTION METHOD.
PCR enzymatically enhances the number of nucleic acid molecules to the point that they can be detected.
Used to detect Toxoplasmosis, Enteroviruses, RSV, Pneumocystic carinii, and MTB.
Disadvantage – does not allow the testing of antimicrobial susceptibility testing.
PULSE FIELD GEL ELECTROPHORESIS PFGE technique can be used with
remarkable precision to determine relatedness of isolates from an outbreak…
ENVIRONMENTAL TESTING• “Can we culture the ice machine, I don’t
think they clean them, and I see some black sludge on the dispenser”
• Microbiological environmental testing is not generally recommended. In most cases no standards for comparison exist, so what are you going to do with the information?
• Just clean the ice machine and make sure that there is a scheduled cleaning procedure.
FUNGI
Some are well adapted human pathogens, but most are accidental pathogens that we acquire through decaying organic matter or airborne spores.• Two groups1. Yeasts – i.e. Candida species, Cryptococcus 2. Molds – i.e. Aspergillus species, histoplasma
capsulatum
What type of host plays an important part!Construction on an oncology ward higher risk
than construction on a medical surgical unit.
VIRUSES –
Cannot multiply on their own, need living cells to live and grow
Multiplication occurs in 5 steps1. Attachment2. Penetration3. Replication4. Maturation5. Release
PARASITES Vary in size and complexity, i.e. may be
single celled microscopic protozoa or complex worms over 10 feet in length!
Flukes, tapeworms, roundworms, and ectoparasites such as lice and scabies.
STAPHYLOCOCCUS AUREUS – MOST FREQUENTLY SEEN MICROBE IN HUMAN INFECTIONS.
Gram positive cocci, easily grown in the micro-lab.
Normal flora on skin. Common pathogen – possesses
numerous invasive enzymes which aid its pathogenicity.
Frequently resistant to the penicillin group of antibiotics, including the oxacillin-like agents (methicillin)
STAPHYLOCOCCUS AUREUS – MOST FREQUENTLY SEEN MICROBE IN HUMAN INFECTIONS Commonly seen as “R” to Oxacillin on the culture
report. MRSA – cannot be taken lightly!
MRSA was first isolated in the United States in 1968. By the early 1990s, MRSA accounted for 20%-25% of Staphylococcus aureus isolates from hospitalized patients.
1999, MRSA accounted for >50% of S. aureus isolates from patients in ICUs in the (NNIS) system.
in 2003, 59.5% of S. aureus isolates in NNIS ICUs were MRSA.
PSEUDOMONAS AERUGINOSA• Gram negative bacilli.• Most commonly associated with water.• Frequently a colonizing organism in
patients.• “Opportunistic pathogen”, takes
advantage of lowered defense systems of the host.
• Can be commonly resistant to multiple antimicrobial agents.
• Associated with outbreaks on healthcare systems.
MYCOBACTERIUM TUBERCULOSIS Referred to as an acid fast bacillus. Slow growing (can take 4-6 weeks to
grow) Spread by the airborne route – so if +
acid fast smear +, consider negative airflow.
If smear +, reportable to Oklahoma State health department.
HERPES SIMPLEX VIRUS Not seen by gram staining – it is a virus. Requires tissue culture to grow. Can a Healthcare worker (HCW) with a
herpes lesion on their lip work? What if they work in the NICU or
oncology? What if the HCW has a herpetic whitlow? How do you find the answers? (CDC
healthcare worker guidelines)
BASIC INFECTION PREVENTION TERMINOLOGY
INFECTION VS COLONIZATION WITH NORMAL FLORA• Colonization – presence of
microorganisms with multiplication but without tissue invasion or damage. (urine culture E-coli < 20,000 cfu, patient with no symptoms)
• Infection – entry and multiplication of an infectious agent in the tissues of a host. (urine culture E-coli >100,000 cfu, patient has fever, frequency, dysuria)
EXOGENOUS VS ENDOGENOUS Exogenous organisms are those that
come from outside the host.
Endogenous organisms are those that come from the host’s own flora.
AEROBIC VS ANAEROBIC Aerobic
needs oxygen, Containing oxygen; referring to an organism, environment, or cellular process that requires oxygen.
AnaerobicLacking oxygen; referring to an organism,
environment, or cellular process that lacks oxygen and may be poisoned by it.
OTHER TERMS
ASEPSISFreedom from infection or infectious material.
BACTERIOSTATIC Arresting the growth or multiplication of bacteria. An antibiotic may be classified as a bacteriostatic medication.
WBC COUNT AND DIFFERENTIAL• Normal WBC count is 5,000 – 10,000 • White blood cells originate in the bone
marrow.• Types of WBC1. Phagocytic – ingest and destroy
bacteria, protozoa, cells and cellular debris. (neutrophils, eosinophils, basophils, monocytes, and macrophages)
2. Non-phagocytic – important to immune function and produce antibody. (T and B lymphocytes)
HAND HYGIENE
2003 HAND HYGIENE GUIDELINES
This gentleman insisted his students clean their hands with a chlorine solution between each patient. He practiced in the 1800. Who is he?
A. Oliver Wendell HolmesB. Jack the RipperC. Ignaz SemmelweisD. Joseph Lister
HANDWASHING
• The most important measure you can use to prevent the spread the spread of infection.
2003 HAND HYGIENE GUIDELINES When washing hands with soap and
water, hands should be rub together vigorously for:
A. 6 secondsB. 15 secondsC. 20 secondsD. 3 minutes
2003 HAND HYGIENE GUIDELINES When hands are visibly dirty or
contaminated with proteinaceous material, hands should be wash with:
A. Antimicrobial soapB. Non-antimicrobial soapC. A chlorine solutionD. Both A and B
2003 HAND HYGIENE GUIDELINES It is not necessary to decontaminate
your hands if you are only touching intact skin.
A. TrueB. False
2003 HAND HYGIENE GUIDELINES Soap dispensers should be refilled:A. When 2/3 fullB. When ¾ fullC. NeverD. Only when completely empty
2003 HAND HYGIENE GUIDELINES Natural nail tip length should be:A. Less than ¼ inchB. Less than ½ inchC. Bitten to nubsD. Nails can be any length as long as they
are natural
2003 HAND HYGIENE GUIDELINES It is not the responsibility of the facility
to provide lotion to the HCW, but the facility should encourage the use of lotion to minimize the occurrence of dermatitis.
A. TrueB. False
2003 HAND HYGIENE GUIDELINES When performing surgical hand
antisepsis one should:A. Remove rings, watches and bracelets
before beginning the hand scrubB. Leave all jewelry on during hand scrub
so you can clean the jewelry and hands at the same time.
C. Remove only items that will be damaged by the water.
HAND WASHING
Wash hands to prevent transfer of microorganisms :
Before & after patient contact After gloves are removedBetween task on the same patient to prevent cross-contamination of different body sites
2003 HAND HYGIENE GUIDELINES If your hands have been exposed to
Bacillus anthracis, you should:A. Wash your hands with antimicrobial
soap B. Wash your hands with non-
antimicrobial soapC. Wash your hands with an iodophorD. A and BE. Cry
CLEAN HANDS ARE HAPPY, HEALTHY HANDS!!!!!
“FOAM IN FOAM OUT”
IT IS DECEMBER!GIVE THE GIFT OF GOOD HEALTH
TO OUR PATIENTS AND YOURSELF!“FOAM IN FOAM OUT”
If visibly soiled, wash with soap, water and friction
HAND HYGIENE COMPLIANCE Who collects the data at your facility? Audit tool (review sample tools) Calculation of Hand hygiene compliance
rates # of “yes” observations/Total # of
observations X 100
Communicate the data to the HCW’s.
HAND HYGIENE COMPLIANCE RATES
Jan-11 Feb-11 Mar-11 Apr-110
10
20
30
40
50
60
70
80
90
100
Monthly hand hygiene rate
Facility Goal
% C
om
pli
an
t w
ith
ha
nd
h
yg
ien
e
Analysis – The April rate increasedTo 92% from 82% due to increasedHand hygiene awareness and Discussion by administration at Facility “Town Hall meeting”.
Action Plan – Continue hand hygienediscussions by administration attown hall meetings andimplement administrative hand Hygiene rounds with IC dept. for increasedawareness.
DR. _______ SAYS…. GOT FOAM???? USE IT! BEFORE AND AFTER PATIENT CARE OR CONTACT WITH THE PATIENT ENVIRONMENT.
Hand hygiene matters!!!!!
Thank you Dr. ____
DR. ___________ IS SENDING SUBLIMINAL MESSAGES DURING ROUNDS….
Infection prevention dept. loves it!Thank you Dr. ______
HAND HYGIENE - KEEP IT FUN!Ideas to keep the ball rolling….• “Glow Germ” at staff meetings• Hand hygiene “huddles”• Hand hygiene videos to show at staff
meetings, orientation, advocate meetings, patient videos.
• Pictures of staff washing hands!http://www.cdc.gov/handhygiene/Patient_materials.html
http://www.hhs.gov/ash/initiatives/hai/training/partneringtoheal.html
http://web.me.com/danielwlieu/Hands/Infection_Prevention_and_Control.html
HAND HYGIENE - KEEP IT FUN!• Mandatory annual hand hygiene
educationhttp://www.cdc.gov/handhygiene/training/interactiveeducation/
• Small prizes or tickets for free food when you catch a HCW performing hand hygiene. (OFMQ – “thank you pocket card, be a life saver pocket card”
HAND HYGIENE - KEEP IT FUN!• Wear Hand hygiene apron when out on IC rounds,
make some for hospital managers.
• iScrub - iScrub Lite is available free from the iTunes App Store. Search for iScrub in the App Store
• Face book/Twitter
• Web page buttons –
DISEASE TRANSMISSION AND
ISOLATION
Basic Infection Prevention Training
INFECTIOUS DISEASE PROCESS Exposure
Incubation Period (time from exposure to onset of symptoms)
Onset of symptoms/clinical disease
Recovery, disability or death
CHAIN OF INFECTION Infectious agent Reservoir Portal of Exit Means of Transmission Portal of entry Susceptible Host
STANDARD PRECAUTIONS
Apply standard precautions to all:PatientsContaminated equipment, surfaces & materials
Use judgment to determine when personal protective equipment is necessary
STANDARD PRECAUTIONS
Wear face mask with eye shield
or mask & eye protection during
patient care activities that may
generate splashes or sprays of
blood or body fluids
STANDARD PRECAUTIONS
Prevent injury when using & disposing of needles or other contaminated sharp instruments
Immediately dispose of used sharps in puncture-resistant container
Do not recap using two-handed technique
STANDARD PRECAUTIONS
Keep work area clean
Minimize the splashing or spraying of blood or body fluids while performing procedures
Clean up spills of blood or body fluids promptly using gloves & approved disinfectant
STANDARD PRECAUTIONS
Remove gloves, gown, mask, eye protection before leaving work area
Gloves, gown, mask are not worn in halls, elevators, cafeteria, or gift shop
STANDARD PRECAUTIONS
Clean re-useable equipment
between patients to prevent
transfer of microorganisms to
other patients, staff
or environment
STANDARD PRECAUTIONS
Use:MouthpiecesResuscitation bagsVentilatory device
As an alternative to mouth-to-mouth resuscitation methods
CONTACT ISOLATION STANDARD PRECAUTIONS
Patients infected or colonized with:Epidemiologically important microorganisms
Transmitted by direct contact with the patient
Indirect contact with room surfaces or patient care items
CONTACT ISOLATION STANDARD PRECAUTIONS
Patient may have:IncontinenceDiarrheaIleostomyColostomyWound drainage not contained by dressings
CONTACT ISOLATIONSTANDARD PRECAUTIONS
Wear gloves and gown before entering room
Change gloves after contact with infective material
Remove gloves before leaving room & wash hands
Avoid contact with contaminated surfaces while leaving room
CONTACT ISOLATIONSTANDARD PRECAUTIONS
Limit transport to essential purposes
Communicate precautions to appropriate departments
Maintain Contact Isolation
CONTACT ISOLATIONSTANDARD PRECAUTIONS
Dedicate non-critical equipment to Contact Isolation patient
Clean & disinfect equipment between patients to avoid spread of microorganisms to other patients, staff, or environment.
Upcoming slide – when should contact isolation be discontinued????
DROPLET ISOLATION STANDARD PRECAUTIONS
Patients infected or colonizedwith
Microorganisms Transmitted by droplet from coughing, sneezing, talking, or performing procedures
DROPLET ISOLATION STANDARD PRECAUTIONS
Wear mask when working within three feet of patient
Limit transport to essential purposes
Minimize dispersal of droplets by masking patient if possible during transport
AIRBORNE ISOLATION STANDARD PRECAUTIONS
Patients infected with:
Pulmonary tuberculosis (TB)
Rubeola (measles)
Varicella (chicken pox)
AIRBORNE ISOLATION STANDARD PRECAUTIONS
Place patient in a negative air-flow isolation room
Keep room doors closed & patient in room
Limit transport to essential purposes & minimize dispersal of droplets by masking patient
AIRBORNE ISOLATION STANDARD PRECAUTIONS
Tuberculosis - wear particulate respirator to enter room
Varicella & Rubeola - susceptible care givers not to enter room if immune caregivers are availableSusceptible = maskImmune persons = no mask
CDC - MANAGEMENT OF MULTIDRUG-RESISTANT ORGANISMS INHEALTHCARE SETTINGS, 2006
General recommendations for all healthcare settings independent of the prevalence of multidrug resistant organism (MDRO) infections or the population served.
Administrative measuresMake MDRO prevention and control an
organizational patient safety priority.
CDC - MANAGEMENT OF MULTIDRUG-RESISTANT ORGANISMS (MDRO’S) IN HEALTHCARE SETTINGS, 2006
In healthcare organizations that outsource microbiology laboratory services (e.g., ambulatory care, home care, LTCFs, smaller acute care hospitals), specify by contract that the laboratory provide either facility-specific susceptibility data or local or regional aggregate susceptibility data in order to identify prevalent MDROs and trends in the geographic area served.(363) Category II
MDRO’S In ambulatory settings, use Standard
Precautions for patients known to be
infected or colonized with target MDROs, making sure that gloves and gowns are used for contact with uncontrolled secretions, pressure ulcers, draining wounds, stool incontinence, and ostomy tubes and bags. Category II
MDRO’S
Discontinuation of Contact Precautions. No recommendation can be made regarding when to discontinue Contact Precautions. Unresolved issue
Discussion
MDRO’S Intensified interventions to prevent
MDRO transmission. List combinations of control elements
that were selected and have been shown to reduced MDRO transmission rates in a variety of healthcare settings.
Active surveillance cultures Decolonization
APPENDIX A, ISOLATION GUIDELINE In packet, it is an A-Z reference that
details what type of isolation is needed for specific diseases and conditions.
Scabies Lice Influenza C-diff TB
C- DIFFICILE A spore forming anaerobic gram positive
bacilli which are particularly virulent because of the toxins they produce.
On April 11, 2005 at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA) infectious disease experts presented information concerning a new highly toxic strain of C- Diff. (NAP 1 strain_
C – DIFF PREVENTION Hand Hygiene – soap, water, and
friction. Alcohol hand foam is not effective in
killing the spores of C – Diff. CDC states in outbreak settings or settings with higher rates of c-diff, use hand washing only.
Contact Isolation – gloves and gowns when entering the room of patient with c-diff. The spores can be transmitted from person to person, as well as by persons touching objects (side rails, nurse call light) contaminated with the spores.
C – DIFF PREVENTION Use of hypochlorite disinfectant (bleach)
has been found to be more effective in killing the C-diff spores upon patient discharge.
Educate Health Care Workers
Prudent Antibiotic use.
TUBERCULOSIS Infectious disease caused by bacteria. Usually affects lungs. Other body parts can be affected.
TRANSMISSION Spread through air (droplet nuclei). Sneezing, coughing, speaking, singing
by individual with TB disease. Sharing the same air space with persons
with infectious TB disease.
SYMPTOMS OF TB Weak Weight loss Fever Night sweats Cough Chest pain Coughing up blood
TB INFECTION VS. TB DISEASE Have the
organism in their body.
No symptom.
Bacteria is inactive.
Have symptoms.
Are sick.
Bacteria is active and multiplying.
MULTI DRUG RESISTANT TB (MDR TB) One or more drugs can no longer kill TB
bacteria. High risk persons for MDR TB:
Persons who did not take their TB meds. Immunocompromised persons, i.e. cancer,
HIV infection.Persons previously treated for TB with an
ineffective regimen of drugs.
TREATMENT FOR TB
TB drugs for TB disease.
If infected may need to take TB drugs to prevent TB disease.
TB drugs are taken for 6-12 months.
REPORTABLE DISEASES IN OKLAHOMA Discuss Oklahoma Reportable Diseases Review PHIDDO system (open OSDH
website to review with the group) How do I get access to the system to
report?
http://www.ok.gov/health/Disease,_Prevention,_Preparedness/Acute_Disease_Service/Disease_Reporting/What_to_Report/index.html
INFECTION CONTROL RISK ASSESSMENTS
Basic Infection Prevention Training
ICRA’S
Annual Multi-disciplinary Risk Assessment – done prior to your annual IC surveillance plan review. Also review Example IC surveillance plan.
Construction Risk Assessment (review form)
TB Risk assessment (review form)
Multi-drug resistant Risk Assessment (Annual Antibiogram, historical date, data from SSI organisms, C-diff lab ID event)
Surveillance Methods1. Facility wide2. Periodic (Quarterly)3. Targeted (unit specific)4. Outbreak Thresholds
Collecting Relevant Data Managing Data Analyzing and Interpreting Data Communicating Results
COMPONENTS OF SURVEILLANCE
IN GOD WE TRUST, ALL
OTHERS BRING DATA
Using Definitions for data collectionDetermine the population or event to studyWrite your definition or use an established
one e.g. CDC NHSNApply the definition consistentlyWrite or find a data collection tool
Concurrent or retrospective data collection
COLLECTING RELEVANT DATA
Review your data collection for accuracy and effectiveness Check for flaws in the dataCheck your data sources (patient based, lab
based, post discharge surveillance letters, post op calls)
Validate if you make changes
COLLECTING RELEVANT DATA
Record data systematicallyBe consistent (data collection tool)Flow sheet or line listCan others look at the data and understand
it Think about how you may want to
manipulate or analyze the data laterComputer systemSoftware for analysis (Excel)
MANAGING DATA
Analyzing is the reason we do surveillanceAnalyze promptly to identify needs for
intervention Compare Data
Same definitionsSame patient population, risk group
Proper denominatorDevice DaysPatient DaysSurgical Cases
ANALYZING DATA
Compare or BenchmarkHistorically against your own ratesAgainst other hospitals of similar sizeNational Rates (Review NHSN report as a
group) Interpretation and Significance
Use of statisticsData interpretation pit fallsReporting Data
ANALYZING DATA
STATISTICSStatistics 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 can not make bad data better - "garbage in, garbage out"
STATISTICS Statistics may reveal underlying
patterns in data not normally observable.
If used correctly, statistics can separate the probable from the possible
STATISTICS Infection Preventionists routinely use
statistical methods to:Prepare reports for committee Identify problems or outbreaksMonitor 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
STATISTICSMeasures of frequency
Incidence rate Prevalence rate Ratio Proportion
Statistical process control Control Charts
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 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.
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 surgeryAmerican Society of Anesthesiology (ASA)
ScoreSurgical wound classification
SURGICAL SITE RISK ADJUSTMENT
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-SPECIFICHEALTHCARE-ASSOCIATED INFECTIONS SUMMARY DATA REPORT
January – June, 2009
SIRSIR = 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)
Communicate/Report Data
Look for trends (Analysis)
Implement Changes (Action plan)
Monitor, Track and report Effect of Interventions
WHAT DO YOU DO WITH THE DATA?
How to reportChart
Pie Chart Bar Charts
Graph Line Graph Control Chart
COMMUNICATING DATA
Title Time Period Location Values Unit Labels Definitions
MAKE THINGS SELF-EXPLANATORY
ANTERIOR INTERBODY (22554) INFECTION RATE 2013
• Analysis:– No SSI
identified since July case
• Action Plan: Continue to
do surveillance and discuss prevention measures
ROLES , CONCEPTS, AND ACTIVITIES VITAL TO A
SUCCESSFUL PROGRAM
ROLES VITAL TO PROGRAM SUCCESS• The Infection Preventionist has several
roles that are vital to the success of the program:– IP expert during surveys
• Be familiar with survey process• Stay prepared• Keep up-to-date on survey hot topics• Know your policy and procedures• If you don’t know, DON’T make it up!!!
ROLES VITAL TO PROGRAM SUCCESS• Collaborator with diverse departments– Maintenance
• ICRA• Water/Mold remediation
– Housekeeping• Cleanliness issues• Proper Chemical use and selection• In-services
– Employee Health• Work Restrictions• Education on Communicable Diseases
ROLE OF THE ICP Infection Prevention and control expert Mentor staff Role model for Infection Prevention and
Control Resource for the staff Design and implement effective
programs
ROLE OF THE ICP Liaison to public health Liaison in emergency preparedness Promote zero tolerance for HAIs Collect and analyze infection data Develop and review policies Consult on infection risk assessments,
prevention and control strategies
ROLE OF THE ICP Educate and direct interventions to
reduce infection risk Implement change mandated by
regulatory bodies Evaluate Product changes Evaluate Chemical changes Development of IC Surveillance plan and
annual evaluation Read and interpret guidelines
COMMITTEEAnnouncements that need to be recorded in
the minutesNews related to Infection PreventionUpdates from any construction projectsReports from regular surveillanceReports from Employee HealthReports from Dialysis water culturesReports from IC Rounding
ROUNDS One of the most important activities for
an IP is Rounding. Through rounding the IP:Develops relationships with staff Identifies educational opportunities Identifies breaches in practice Identifies cleaning and disinfection issues Identifies opportunities for improvement
Review rounding tool(s)
ESSENTIALS Join EPIC
Dues $25 annually Text books
APIC ManualControl of Communicable Diseases ManualThe Pink Book
Websites
FEDERAL AND STATE REGULATIONS
Basic Infection Prevention Training
STATE HEALTH REGULATIONS FOR HOSPITALS CHAPTER 667 Employee and/or worker Health
examinations chapter 667-5-4Pre employment exams for
Each employee full or part-time with or without patient care responsibilities
Physicians Emergency medical personnel Students Lab and pharmacy workers Volunteers and administrative staff Food service workers
CHAPTER 667
The pre employment health exam will include but not be limited to:
Immunization History Born before 1957 Born in 1957 or later Serologic screening
Tb Skin Testing2-step TestingBCG
Hepatitis B
CHAPTER 667 (e) Annual influenza vaccination program. Each hospital shall have an annual
influenza vaccination program consistent with the recommendations of the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices that shall include at least the following:
(1) The offer of influenza vaccination onsite, at no charge to all employees and/or workers in the hospital or acceptance of documented
evidence of current season vaccination from another vaccine source or hospital; (2) Documentation of vaccination for each employee and/or worker or a signed declination
statement on record from each individual who refuses the influenza vaccination for other than medical contraindications; and (3) Education of all employees and/or workers about the following:
(A) Influenza vaccination; (B) Non-vaccine influenza control measures; and (C) The symptoms, transmission, and potential impact of influenza.
(4) Each hospital influenza vaccination program shall conduct an annual evaluation of the program including the reasons for nonparticipation.
(5) The requirements to complete vaccinations or declination statements for each employee and/or worker may be suspended by the
hospital's medical staff executive in the event of a shortage of vaccine as recognized by the Commissioner of Health.
CHAPTER 667 TB Skin Test
Based on annual TB risk assessment
Communicable Diseases
CHAPTER 667
A file shall be maintained for each employee containing the results of the evaluations and examinations and the dates of illness related to employment.
CHAPTER 667
These are for Credentialed non-employees (physicians/mid-level providers)Such workers provide evidence of
immunization history and TB skin test consistent with the TB Control Program. It is in the form of a signed attestation statement.
CHAPTER 667
667-13-1 Infection Control ProgramProvide a sanitary environmentAvoid sources and transmission of infectionProvide written policies and procedures for:
identifying, reporting, evaluating, and maintaining records of infection among patients and personnel.
Ongoing review and evaluation of all aseptic, isolation and sanitation techniques employed in the hospital
Development and coordination of training programs in infection control for all hospital personnel.
CHAPTER 667
667-13-2 Infection Control CommitteeShall meet at least quarterlyAttendees – at least one person with
appropriate background who can speak for the relevant department(s) attends the meeting or is consulted.
CHAPTER 667
667-13-3 Policies and ProceduresThe infection control committee shall
evaluate, revise, and approve the type and scope of surveillance activities at least annually
Policies and Procedures shall be reviewed periodically and revised as necessary
CHAPTER 667
667-13-4 Policy and Procedure contentRecord of all reported infections generated
by surveillance activitiesHandling and disposal of biomedical wasteRelated to admixture and drug
reconstitution Indications for and type of isolation for each
specific diseaseA definition for nosocomial infectionDesignation of an Infection Control officer
CHAPTER 667
A program of orientation of new employees and other workers including physicians
A program of continuing education concerning infection control
CMS REGULATIONS (STATE OPERATIONS MANUAL)
482.42 Infection ControlProvide Sanitary environment to avoid
sources and transmissions of infections and communicable diseases.
Must have active program for the prevention and control and investigation of infections and diseases.
A person or persons must be designated as the Infection Control officer
CMS REGULATIONS• Log of incidents related to infections and
communicable diseases (review sample log)
• The CEO, medical staff and director of nursing MUST ensure that there are hospital programs and training related to infection control and they are responsible for the implementation of successful corrective action in problem areas
• Review the 16 page CMS IC surveyor audit tool.
MRSA BACTEREMIA & C- DIFF LAB ID EVENT
WHAT ABOUT HCW INFLUENZA?
CMS Mandatory Reporting
OSHA
Requires Bloodborne Pathogens Exposure Control Plan that must include the following: PurposeScopeDefinitionsExposure determination
OSHAControl Measures
Engineering Controls Work Practice Controls PPE (personal protective equipment)
Hepatitis B vaccinationPost exposure evaluation and follow-upSharps Injury logTraining and EducationRecordkeeping
OSHA Bloodborne pathogens 1910.1030 29CFR www.osha.gov/pls/oshaweb/owadisp.show_documen
t?p_table=STANDARDS&p_id=10051
1910.1030(c)(1)(iv)(B) Document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.
1910.1030(c)(1)(v) An employer, who is required to establish an Exposure Control Plan shall solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the Exposure Control Plan.
OSHA• TB Control plan and Risk Assessment• http://www.cdc.gov/tb/pubs/mmwr/
Maj_guide/Control_Elim.htm• Risk Assessment Appendix B must be
done annually.– Low– Medium– High
• Contact Investigation
THE IP IN THE OR
Intermediate Infection Prevention Training
Collaboration = key to success!!!
INFECTION PREVENTION IN THE OR
Use an audit tool to document the rounds.
How often should rounds be done? Who should do the rounds? Communicate the findings found during
OR rounds. Learn from OR co-workers!!! Thank
them Consider implementing an “OR best
practices” campaign, using AORN standards and recommended practices.
ROUNDS IN THE OR
Ensure that the patient gets appropriate pre-op antibiotic within an hour of “cut time.”
Keep patients warm, must be ≥ 96⁰ F
Apply skin prep according to manufacturer instructions, allow to dry before draping.
Hand hygiene before and after patient care.
Limit “traffic” in and out of room during surgical procedures.
“BEST PRACTICES” TO HELP PREVENT SURGICAL SITE INFECTIONS”
Be sure that the central line “insertion bundle” is used when central lines are placed. (Evidence based practice)
1. Hand hygiene prior to line insertion
2. Use Chlorhexadine skin prep and allow to dry.
3. Avoid the femoral site (it is associated with more bacteria)
4. Those inserting the line and any personnel assisting must wear sterile hat, mask, gown and large drape used to cover the patient during placement.
5. Assess the line every shift to ensure it is still needed, if not get an order to remove.
Use alcohol to “scrub the hub” before accessing the line for medications or blood draws.
BEST PRACTICES TO PREVENT CENTRAL LINE ASSOCIATED BACTEREMIA
2011 AORN recommended practices for preoperative patient skin antisepsis, pages 361-377.
Pre-op shower? What are your facilities policies? Is there a place to document?
Pre-op antibiotic given by anesthesia personnel within 60 minutes prior to incision
What are your SCIP #’s on this measure? How often are the surgery staff and
physicians informed of their SCIP data?
PRE-OP ROUNDS…TAKE A LOOK
OR appears clean – 2011 AORN recommended practices “Environmental cleaning”, pages 237-249.
OR facility in good repair Sub-sterile area appears clean Scrub sink area appears clean Interim (between cases) cleaning
performed Terminal cleaning
AUDIT TOOL, “OR ENVIRONMENT”
Ventilation requirements: 2011 AORN recommended practices, “Safe environment of care”, pages 218 – 220.
Positive pressure how often is this checked?
Doors closed during the case? Temperature between 68 and 73
degrees F Humidity monitored? ACH monitored? (OR, PACU, Sterile
storage)
“OR ENVIRONMENT”
During rounds, how are you seeing hands being cleaned before and after patient care?
1. Soap and water? 2. Is an alcohol product used if hands are
not visibly dirty?3. Who collects hand hygiene data for
your surgical area?4. How often are the results
communicated?5. Hand lotion, what is the staff using?
HAND HYGIENE
It is all about the hands!!!!!Keep them healthy
1. Short natural nails2. Remove fingernail polish if chipped3. Use hospital approved lotion4. Use soap water and friction for at least
15 seconds when washing
OR INFECTION PREVENTION “BEST PRACTICES”
Is the traditional surgical hand scrub being used?
If so, how long is the scrub? 3 or 5 minutes?
If your facility has moved to an alcohol based antiseptic surgical hand rub, are they following the manufacturers instructions for use?
Consider annual competency…
SURGICAL HAND SCRUB
OR “BEST PRACTICE” ARE YOU APPLYING THE AVAGUARD CORRECTLY?THE 3M MANUFACTURE INSTRUCTIONS SAY……
Apply to clean dry hands, use nail pick to clean under nails with first hand wash of the day.
Pump # 1
Dispense one pump (2 ml) into the palm of one hand. Dip fingertips of the
opposite hand into the hand prep and work under fingernails. Spread
remaining hand prep over the hand and up to just above the elbow.
Pump # 2
Dispense one pump (2 ml) and repeat procedure with opposite hand.
Pump # 3
Dispense final pump (2 ml) of hand prep into either hand and reapply to all aspects of both hands up to the wrists.
Allow to dry. Do not use towels!Applying correctly matters.
2011 AORN recommended practices, “Hand Hygiene”, pages 73-85.
Artificial nails should not be worn by healthcare personnel in the operative environment, any fingernail enhancement or resin bonding product is considered artificial.
Rings Watches and bracelets
NAILS AND JEWELRY…..
Remind co-workers and physicians of following opportunities for hand hygiene!!!!
Decontaminate hands after –
Contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)
If moving from a contaminated-body site to a clean-body site during patient care.
After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
MARCH INFECTION PREVENTION “BEST PRACTICES”
Sterile items left open no > than 30 minutes prior to patient entering room
Scrubbed persons maintain sterility of sterile gown, gloves, supplies
Hands remain above waist Sterile field constantly monitored Items introduced into sterile field
opened, dispensed, transferred by methods to maintain sterility/integrity
Items/devices dropped below level of the OR table are considered contaminated
STERILE FIELD – 2011 AORN RECOMMENDED PRACTICES FOR MAINTAINING A STERILE FIELD, PAGES 87-93
All personnel moving in/around sterile field do so in manner to maintain sterility
Adjacent sterile fields not at disparate heights
Separation of sterile team from non-sterile team maintained
Staff do not turn back to sterile field Traffic in and out of room kept to
minimum
STERILE FIELD
Safe injection practices used for IV tubing, fluids, medication vials?
CMS surveyor tool – “Injection Practices”
“Observations are to be made of staff who prepare and administer medications and perform injections (e.g., anesthesiologists, certified registered nurse anesthetists, nurses).”
Link to the 16 page surveyor tool - http://totalsol.vo.llnwd.net/o29/data/1080/infection_control_surveyor_worksheet.pdf
ANESTHESIOLOGY:
Aseptic practice used for all invasive procedures: (epidurals, blocks, IV insertion)
Anesthesia cart appears clean, who cleans after each case?
Cleans shared equipment (e.g., stethoscope) between cases
ANESTHESIOLOGY:
Keep patients warm during surgery – the recommendation is to keep patients ≥ 36.0 C (96.8 F) Remind anesthesia to monitor during surgery.
Date all multi-dose vials when you open, they are only good for 28 days after opening and maybe sooner if manufacturer recommends…
JANUARY INFECTION PREVENTION “BEST PRACTICES”
Appropriate eye protection used Sharps containers not overfull Shoe covers/boots if indicated Surgeons/first assistants double gloved
(recommended) Circulators wear gloves for handling
contaminated items. Performs hand hygiene after glove removal
Sharps are passed in a basin or by using neutral zone rather than by hand
Sharps safety devices
OSHA/BLOOD BORNE PATHOGENS
OR “BEST PRACTICES”
A fresh surgical mask should be worn for every procedure. Literature shows that after 4 hours surgical masks had decreased efficacy.
Surgical masks should be discarded after each procedure.
Surgical masks should not be worn hanging down from the neck.
(AORN 2011 perioperative standards and recommendations)
Patients with communicable disease handled appropriately
Sterile team removes gloves and performs hand hygiene at end of case
Policies regarding “Immediate Use Sterilization” are followed
Personnel appear free from communicable disease (no open skin lesions on hands/face)
Observers comply with “Observers Protocol” for Surgical Services
Surgical attire (AORN, CDC, SHEA) Clean, sterile, and soiled items are kept separate Instruments are kept moist during cases.
GENERAL INFECTION CONTROL:
INFECTION PREVENTION “BEST PRACTICES” FOR THE OR*INSTRUMENTS SHOULD BE KEPT FREE OF GROSS SOIL DURING SURGICAL PROCEDURES.*REMOVING GROSS SOIL AND MOISTENING SOIL AT THE POINT OF USE IMPROVES THE EFFICIENCY AND EFFECTIVENESS OF DECONTAMINATION.
1. Wipe instruments as needed with sterile surgical sponges moistened with sterile saline during the procedure to remove gross soil.
2. Instruments with lumens should be irrigated with sterile water as needed through the surgical procedure.
2011 AORN Standards and recommended practice, “Care of instruments”, pg 431
Yes!!!!!And there are audit tools for that too….
http://www.infectionpreventiontools.com/
http://www.ofmq.com/hai
http://www.ascquality.org/Library/sterilizationhighleveldisinfectiontoolkit/Sterilization%20Audit%20Checklist%20SPSmedical.pdf
http://www.ascquality.org/SterilizationHighLevelDisinfectionToolkit.cfm
www.cipconsultingllc.com
DO I NEED TO GO INTO THE INSTRUMENT PROCESSING AREA?
SEE YOU TOMORROW
THANK YOU!!