Bugs..Bugs Everywhere: Strategies for Reducing Multidrug Resistant Organisms in Your ICU

Bugs..Bugs Everywhere: Strategies for Reducing Multidrug Resistant Organisms in Your ICU Kathleen M. Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist / Educator / Consultant ADVANCING NURSING kvollman@comcast.net Northville Michigan www.vollman.com Disclosures Sage Products Speaker Bureau & Consultant Hill-Rom E.L. Lilly Merck ADVANCING NURSING LLC 2011 Session Objectives & Content Identify 2 modes of transmission for the spread of microorganism in the critical care environment Define key care practices based on the evidence that can reduce bacterial load and/or prevent the development of health care acquired infections Nursing care interventions directed at: Reducing MDRO s CLA-BSI VAP/HAP CA-UTI It is Time to Change!! 44,00 to 98,000 preventable death in hospitals related to medical errors annually (IOM report, 1999) 92,888 deaths directly attributable to safety indicators between 2005-2007 (HealthGrades 2009) Failure to rescue, pressure ulcers and post-op infections National Patient Safety Goals include prevention of HAI s HAI s the 5 th leading cause of death Lack of reimbursement for preventable injury 2013-lowest percent improvement/ 1% total Medicare cut $50 billion in total costs for preventable injury CMS Guidelines: If It s Not POA, We Won t Pay 10/08 Conditions No Longer Covered Falls Mediastinitis (after heart surgery) Avoidable Pressure Ulcers Vascular and Urinary Tract Infections from Catheters Never Events Objects left in body during surgery Air embolisms Blood incompatibility SSI post some orthopedic procedures & Bariatric Surgery Certain manifestations of poor blood sugar control DVT/PE following total knee and hip replacements Why Source Control? 2.5 million HAI s year/usa Everyday, 247 people die in the USA as a result of a HAI 99,000 deaths 5-10% of all patients admitted to US hospital annually contract HAI s (1 of every 10-20 patients) Higher nurse staffing results in lower HAI s* Cost estimated 28-34 billion a year HHS goal to reduce HAI s by 40% in 3 years (1 billion to assist in achieving goal) WHO 2005 Yokoe DS, et al. Infect Control Hosp Epidemiol 2008;29:S12-S21. Needleman J et al. N Engl of Med 2002;346:1715-1722 1

Health Care Acquired Infection Data Measurement NHSN 2006-2008 1545 hospitals in US Staph aureus/vre 56%/33% Resistance CLA-BSI/per 1000 cath days Range of pooled means 13( 1.3 (PICU)-5.5 (Burn ICU) VAP/per 1000 vent days Range of pooled means 0.5 (RICU) -10.7 (Burn ICU) HAP/per 1000 patient days 5-15 CA-UTI/per 1000 cath days Range of pooled means 3.1 (Med-Surg ICU)-7.4 (Burn ICU) www.premierinc.com/advisorlive accessed 08/25/2010 Rosenthal VD, et al. Am J of Infect Control, 2008;36:627-37 Edwards JR, et al. Am J of Infect Control, 2008;36:609-26 Hidron Ai, et al. Infect Control Hosp Epidemiol 2008; 29:996-1011 Reducing Environmental Load & Preventing Infection Through Creative & Fundamental Care Strategies MRSA/MDRO s: Making A Difference MDRO prevention, Hand Hygiene, CLA-BSI, CA-UTI The Facts: Each Patient with MRSA Infection Results In. What Does the Evidence Tell Us? 9.1 days longer in the hospital Extra cost between $7,000- $32,000 more (average $20,000) MRSA independently associated with of increase cost A 4% higher in-hospital mortality http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroguideline2006.pdf Filice GA, et al. Infect Control & Hosp Epidemiology, 2010;31:365-373 Target Modes of MRSA Transmission Person-person via hands of health care providers Personal equipment (e.g., stethoscopes, th PDAs) and clothing Environmental contamination maybe people? Carriers on the hospital staff Rare common-source outbreaks www.ihi.org 2

5 Million Lives Campaign: Reducing MRSA Hand hygiene Decontamination of environment and equipment Active surveillance cultures/rapid dx testing Contact precautions for infected and colonized patients/potential use of automated systems/preemptive isolation Practice the device bundles (VAP & BSI) Start in the ICU & have a clinical champion or opinion leader www.ihi.org Grundmann H, et al. Lancet 2006;368:874-885 Larson EL, et al, AJCC, 2010;19:1627 Vos MC, et al. Infect Control & Hosp Epidemiol, 2009;30:977-984 Huskins WC, et al. N Engl J Med. 2011;364(15):1407-18 Hand Hygiene is the Single Most Important Factor in Preventing the Spread of Infection Guidelines for Hand Hygiene in Health Care Settings If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations (1A) When hands visibly soiled or exposure to potential spore forming organisms, wash with either a non-antimicrobial or antimicrobial soap & water (IB) Decontaminate hands after removing ggloves When washing with soap & water, wet hands first, apply soap, rub vigorously for 15 seconds, rinse and dry. Use towel to turn of faucet. (Duration 40 seconds) Provide HCW with hand lotions & creams to minimize occurrence of irritant contact dermatitis (IA) Use multidimensional strategies to improve hand hygiene practice (IA) Do not wear artificial fingernails or extenders (IA) CDC. Hand Hygiene Guidelines: MMWR 2002; 51(No. RR-16):[1-45] WHO Hand Hygiene Guidelines 2009 Reasons for Non-Compliance Lack of knowledge on importance and how the hands become contaminated Lack of understanding of correct technique Understaffing and overcrowding Poor access Irritant contact dermatitis associated with frequent exposure Lack of institutional commitment to good hand hygiene Pittet D et al. Lancet Infect Dis. 2001;1:9-20 When to Wash Correct use can reduce colony forming units by 90%, incorrect use only 60%. 1-3mL correct amount per HH episode Lausten S, et al. Infect Control Hosp Epidemio, 2008;29:954-956 Pittet D. Infect Control Hosp Epidemiol, 2009;30(7):611-622 3

Measurement: Know Your Direction Hand Hygiene Measurement Methods Policies and guidelines will not increase hand hygiene compliance unless measurement and feedback are part of the process Make it Visible Direct Observation HCW Self-reporting Product Usage/Volume Automation monitoring can improve compliance Quinn B, presented www.hhreports.com at NACNS 2011 Increase use of alcohol hand rub (measure by volume use) correlated significantly (p=0.014) with improvement in MRSA rates Sroka www.hhreports.com S, et al. J of Hosp Infect, 2010;74:704-211 Haas and Larson Journal of Hospital Infection 2007;66:6-14 Polgreen PM, et al. Infect Control & Hosp Epidemiol, 2010;31:1294-1297 Improved & Correctly Performed Hand Hygiene Can Lower HAI s Effective Hand Hygiene 33% lower antibiotic resistance over time Reduced CLA-BSI s from 3.9 to 1.0 per 1000 catheter days Several investigators found that health careassociated acquisition of MRSA was reduced when the antimicrobial soap used for hygienic hand antisepsis was changed Trick et al. Infec Control Hosp Epidemiol, 2007;25:42-9 Zingg W, et al. Crit Care Med, 2009;37:2167-2173 Webster J, et Journal of Paediatric Child Health,1994, 30:59-64. Environmental Contamination as a Source of Health Care Acquired Pathogens Pathogen Survival Data Transmission Settings C. difficile Months 3+ Healthcare facilities MRSA d-weeks 3+ Burn units VRE d-weeks 3+ Healthcare facilities Acinetobacter 33 d 2/3+ ICUs P. aeruginosa 7 h 1+ Wet environments Hands equally become contaminated from commonly examined skin sites & environmental surfaces Hota B, Clin Inf Dis 2004; 39(8):1182-9 Stiefel U et al. Infect control & Hosp Epidemiol 2011;32:185-187. Application of Recommendations for Environmental Cleaning Resources to ensure effective cleaning and decontamination Use of a check list Clean equipment that is transported from room to room Dedicated equipment in isolation rooms Reduce load Education of healthcare workers and support staff Pre-intervention Change from use rooms of a occupied pour bottle by to MRSA bucket carrier immersion had new for acquisition applying disinfectant increase from to cleaning 2.9% to 3.9% cloth Post Feedback Intervention: method 1.5% using removal of intentional applied marks visible only under UV light (Datta R. Arch Intern Med 2011;17:491-494) Boyce JM et al Infec Control Hosp Epidemiol. 1997;18:62-627 Huang SS, et al. Arch Intern Med 2006;166(18):1945-1951 Improving Environmental Hygiene In 27 ICU s Decreased MDRO Transmission 27 acute care hospitals ( 25 beds to 709 beds) Fluorescent targeting method used to objectively evaluate the thoroughness of terminal room cleaning before and after a structured educational, procedural and administrative interventions Systematic covert monitoring was performed Results: 3532 environmental surfaces were assessed after terminal cleaning in 260 ICU unit rooms 49.5% of services cleaned it baseline Post-intervention with multiple cycles of objective performance feedback resulted in 82% of environmental services cleaned (p <.0001) Carling PC, et al. Crit Care Med, 2010;38:1054-1059 4

Traditional Bathing REDUCING THE BACTERIAL LOAD ON THE PATIENT: IMPACT ON MRSA/MDRO Why are there so nurwse! many bugs in here? Spreading Microorganism Bath Water: A Source of Health-Care Associated Microbiological Contamination Compared normal bath water with chlorhexidine bath water on 3 wards Without Chlorhexidine: All samples + for bacterial growth (14/23 > 10 5 cfu/ml) With Chlorhexidine: 5/32 grew bacteria with growth 240 to 1900 cfu/ml Gloved hands/bathing: objects touch grew significant numbers of bacteria Bath Basins: Potential Source of Infection Multicenter sampling study (3 ICU s) of 92 bath basins Identify & quantify bacteria in patients basins Sampling done on basins used > 2x in patients hospitalized > 48 hours & preformed 2 hours post bath Cultures sent to outside laboratory Qualitative vs. quantitative measures used to exclude growth that may have occurred in transport Bathing practices not controlled & no antiseptic soaps used to bathe Shannon RJ. et.al. Journal of Health Care, Compliance & Safety Control. 1999;3(4):180-184 Johnson D, et al. Am J of Crit Care, 2009;18:31-40 Bath Basins: Potential Source of Infection Results 98% of all cultures grew some form of bacteria after plating or enrichment Enrichment Results 54% enterococci. 32% for gram -, 23% for S aureus and 13% VRE (statistically significant) <10% growth rates for: MRSA 8%, P aeruginosa 5%, C albicans 3% & E coli 2% Johnson D, et al. Am J of Crit Care, 2009;18:31-40 Large Multi-Center Basin Evaluation For Presence of MDRO s Methodology 53 US & Canadian Hospitals Randomly selected basins for damp swab culture Central lab tested for MRSA & VRE & gram bacilli All basins were clean & were not visibly soiled Results: 199 basins (34.6%) from 52 hospitals were colonized with VRE 251 basins (43.6% from 47 hospitals had gram-negative bacilli 24 basins (4.2%) from 19 hospitals had MRSA Kaye, et al. Presented at SCCM January2011 5

ICU & Hospital Water Samples Systematic review published studies 1998-2005 (29 studies) 9.7%-68.1% of random ICU water samples + for Pseudomonas aeruginosa 14.2%-50% of patient infections were due to genotypes found in ICU water 9 hospital in New York city Bacteria recovered in every hospital 4-14 species identified 1/3 organism known to be responsible for HAI s Trautmann M, et al. Am J of Infect Control, 2005;33(5):S41-S49, Cervia JS, et al. Arch Intern Med, 2007;167:92-93 Bacteria Biofilm Organized communities of viable & non-viable microorganisms protected within a matrix of extracellular polysaccharides, nutrients & entrained particles Adhere to inert material (plumbing) Bacteria contain within Biofilm may be transmitted to at risk patients by direct contact with water used for ingestion, ice, washing Cervia JS, et al. Arch Intern Med, 2007;167:92-93 Pre-Op Prep Antisepsis must demonstrate a 3.0 log 10 from baseline in groin, 2.0 10 log reduction on the abdomen and maintain effectiveness for minimum of 6 hrs. CHG shower/bathing versus soap & water showed no difference in SSI (Cochrane EBR: 2007:CD004985) 2% prep cloth more effective in reducing bacterial load than 4% CHG solution that must be rinsed off/inguinal sites sustained action at 10min, 30 min, 6 hrs > than 4% (Edmiston CE. Et al AJIC, 2007;35:89-96) CDC recommends must bathe or shower night before Compliance issues, consistency in application, unable to bathe self Chlorhexidine is absorbed onto fibers of certain fabrics, particularly cotton (Denton GW. Chlorhexidine. In Block S, ed. Disinfection, Sterilization and preservation, 4 th ed. Philadelphia: Lea & Febiger, 1991:274-89) Innovative Strategy: Study Re-examine Pre-op Prep Methodology Observational study with a pre & post intervention period Baseline: Actively part of National SCIP program Pre-intervention pre-op prep was night before in home showering or washing with 4% CHG solution Post intervention: Pre-op prep preformed with a prepackaged 2% CHG prep product with instructions on its use Pre-package prep preformed at hospital prior to surgery Measured: Change in baseline SSI would occur with new prep process Cost savings Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com Innovative Strategy: Case Study Re-examine Pre-op Prep Results: 25 SSI s during historical period out of 5174 procedures (rate of 2.1%) 11 SSI s during interventional period out of 4266 procedure(rate 0.7%) 72% Difference Innovative Strategy: Case Study Re-examine Pre-op Prep Cost Savings Results: Before intervention: $648,471 for SSI s After intervention: $290,827 Cost of product: $8,721 Readmission savings: $177,937 Total Savings $526,860.00 Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com Harris H et al Infection Control Today. March 2008: www.infecctioncontroltoday.com 6

Bathing with CHG Basinless Cloths Prospective sequential group single arm clinical trial 1787 patients bathed Period 1: soap & water Period 2: CHG basinless cloth bath Period 3: non-medicated basinless cloth bath Veron MO et al. Archives Internal Med 2006;166:306-312 26 colonization's with VRE per 1000 patients days vs. 9 colonization's per 1000 patient days with CHG bath Veron MO et al. Archives Internal Med 2006;166:306-312 Addition of 2% CHG Baths to MRSA Bundle Reduces Rates Veron MO et al. Archives Internal Med 2006;166:306-312 MRSA bacteremia rates, MRSA colonization & new acquisition > 48 hrs post admission to 30 bed mix med-surg ICU Multimodal interventions: New line insertion guidelines (2002), Hand hygeine (2003), daily triclosan body wash (2004), tool for early line removal (2006), 2007 switch to 2% CHG cloth bathing, 1 % solution CHG applied nasally Greatest reduction in MRSA colonized patients occurred ith th d d il CHG Wyncoll D, et al. SCCM 2009; poster 643 2% CHG Cloth vs. Soap & Water Bathing for Reduction of HAI s in Med-Surg Effect of CHG Cloth Bath of HAI s in Trauma Patients Quasi-experimental study of 14,701 patients in 4 med-surg units (94 beds) in a 719 bed academic center Pre-post design: 7102 (control group soap & water) 7699 (experimental group 2% CHG cloth) Monitor hand hygiene and isolation compliance MRSA screening performed in both groups Results Study was stopped early because of efficacy 64% reduced risk of developing HAI s from MRSA & VRE (hazard ratio,.36 [95% CI, 0.2-0.8]; P=.01) More + MRSA colonization in CHG group so > isolation & hand hygiene Kassakian S, et al. Infect Control & Hosp Epidemiol, 2011;32:238-243 Retrospective analysis 6 months before and after institution of CHG bathing 12 bed level 1 trauma center 286 severely injured patients bathes 2% CHG cloth 253 severely injured patients bathed without CHG cloth Results: CHG bathed patients less likely to acquire a CLA BSI (2.1-vs. 8.4), MRSA VAP 1.6 vs. 5.7 & rate of colonization was significantly lowers; 23.2 vs.69.4 per 1000 patient days Evans HL, et al. Arch Surg, 2010;145:240-246 7

Strategies for Bathing to Reduce Source Control & Improve Skin Defense Basin Bath transmission of organisms time & effort # of supplies Harmful soaps Rough washcloths Cold/tepid water Scrubbing technique Contact Precautions For Infected and Colonized Patients A single-patient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation with infection control is necessary to assess the various risks associated with other patient placement options Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient s environment. Donning gown and gloves upon room entry and discarding before exiting the patient room is done to contain pathogens Siegle JD et al, CDC/Management of MRDO, 2006 Active Surveillance To Screen or Not to Screen? Begin with admission cultures only. Measure compliance; add the second culture when high (> 90%). ASCs of the anterior nares capture 80% of colonized adults ASC s of the anterior nares & wounds capture 92% of colonized adults Screen high risk Provide real-time notification of positive admission culture./pcr testing used as screening tool vs. dx Schedule consistent day of week for second culture. Measure transmission. Number or rate of patients who convert from negative to positive Flag colonized patients when discharged. Yokoe DS, et al. Infect Control Hosp Epidemiol 2008;29:S12-S21 www.ihi.org To Screen or Not to Screen? Clustered RCT of 9000 cases between 2005 & 2006 Evaluated the effect of surveillance for MRSA & VRE colonization & expanded used of barrier precautions compared with existing practice on incidence of MRSA & VRE infection Intervention ti group: 92% of ICU days either contact t or universal, Control group: 38% of ICU days (p<0.001) In intervention group: When contact precautions specified; gloves used median of 82%, gown 77% and hand hygiene 69% No difference in colonization & infection rates between ICU s that tested/screened patients & expanded precaution vs. those that did not Huskins WC, et al. N Engl J Med. 2011;364(15):1407-18 To Treat or Not To Treat for Carriage Systematic review of clinical trials to determine effectiveness of different approaches for eradicating MRSA carriage (especially pts with elective surgery) Uncomplicated cases, short-term nasal application of mupiricin remains the most effective treatment for advocating MRSA carriage 90% success rate post one week after treatment 60% success rate in longer follow-up S aureus carriers randomized to receive Mupiricin and skin washing with CHG or placebo Tx group demonstrated significantly lower S aureus infection rates (RR 0.42 [95% CI, 0.23-0.75] & shorter LOS (1.8 days, p=.04) Van Rijen M, et al. Cochrane Database Sys Rev 2008;4:CD006216 Ammerlaan HS, et al. Clin Infect Dis, 2009;48922-930 8

Sustained Reduction in HA-MRSA & Prevention of MRSA Transmission Using a MRSA ABC Bundle ABC s Beth Israel Medical Center Active surveillance cultures; Barrier precautions; Compulsive hand hygiene; Decontamination of equipment and the environment; Device bundles ; and Executive and union leadership. Compliance with hand hygiene, device bundles, maintenance of precautions, & environmental/equipment decontamination has been 90% or greater since 2005. Hospital-acquired MRSA infection decreased from 4.1 per 1,000 discharges in 2004 to 1.4 per 1,000 discharges in 2007. Molecular typing has failed to show transmission of MRSA strains in the health care system. Active surveillance has shown a range in colonization on admission from 2% in surgical patients, 5% in cardiac patients, and up to 20% in intensive care patients Resulted in decreases of other antibiotic-resistant bacteria. This initiative was cost-effective, resulting in $1.5 million avoided costs Ventilator Associated Pneumonia Creative Strategies The Vent Bundle To the VAP Bundle Applying evidence-based practice 5 activities that when done 100% of the time has Nurse-intervention shown a reduction bundle in demonstrated a 55.4% VAP reduction in the incidence of VAP LOS Maintaining Time on ET Vent tube cuff pressure between 20-25cm H2O Keeping Cost HOB elevated 30 to 45 Providing oral care every 2-4 hours HOB 30, Peptic Ulcer Disease (PUD) Curtin LJ. American Nurse Today, March 2011 prophylaxis, DVT prophylaxis, Sedation vacation, Daily assessment for SBT/ & Oral Care with antiseptic Modification Mobility, EVAC tube, OG vs. NGT Hospital Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia(VAP) VAP crude mortality approximately 10-40%. HAP crude mortality 15-18% Pooled mean ranges.5 (RICU) to 10.7 (Burn ICU) per 1000 ventilator days HAP rates 5-15 per 1000 patient days Est cost $30,000-$40,000 per VAP Calculated loss for VAP against matched controls=$12,780 Increase LOS up to 4-14 days Annual cost $2 billion dollars. Edwards JR, et al. Am J of Infect Control, 2007;35:290-301 Kollef MH, et al. Chest, 2005:128:3854-3862 Collard HR. Ann Intern Med. 2003;138:494-501 Restrepo MI, et al. Infect Control Hosp Epidemiol, 2010;31:509-515 Rello J. Chest. 2002;12:2115-2121 ATS Guidelines for HealthCare Acquired Pneumonia 2006 Coffin SE, et al. Infect Control & Hosp Epidemiol, 2008;29(1):S31-S40 Rosenthal VD, et al. Am J of Infect Control, 2008;36:627-37 Healthcare Acquired Pneumonia Risk Factor Categories Factors that increase bacterial burden or colonization Factors that increase risk of aspiration 9

Methodology: Oropharyngeal Colonization 89 critically ill patients Examined microbial colonization of the oropharynx through out ICU stay Used pulse field gel electrophoresis to compare chromosomal DNA Results: Diagnosed 31 VAPs 28 of 31 VAP s the causative organism was identical via DNA analysis Garrouste-Orgeas et. al. Am J Respir Crit Care Med. 1997;156:1647-1655 Methodology: Dental Plaque 49 elderly nursing home residents admitted to the hospital Examined baseline dental plaque scores & microorganism within dental plaque Used pulse field gel electrophoresis to compare chromosomal DNA Results: 14/49 adults developed pneumonia 10 of 14 pneumonias, the causative organism was identical via DNA analysis El-Solh AA. Chest. 2004;126:1575-1582 Endotracheal / Nasogastric Tube/ Sinusitis Carriage of oropharyngeal bacteria during intubation If cuff pressure < 20 cm 4x risk VAP Cuff pressure range btwn 25-40cm (JBI-Level A) with maintenance at 25cm-30cm of H2O pressure. Continuous monitoring resulted in a lower portion of out of range cuff pressure (11% vs. 51.7% p< 0.001) 001) NGT increases risk of sinusitis/gastric reflux & increases oropharyngeal colonization Use oral ET versus nasal (CDC-Cat IB) Sinusitis increases the risk of nosocomial pneumonia by 3 fold CDC. 2003 Guidelines for Prevention of Healthcare Associated Pneumonia; MMWR; 2004:53(no RR-3) Davis KA. J Intensive care Med, 2006;21(4):211-226 Muscedere J & Canadian Trails Group. J of Crit Care, 2008;23:126-137 Carstens J. Joanna Briggs Institute, 2010 Sole, ML, et al. AJCC, 2011;20:109-117 Brush CHX rinse alone CHX rinse in Combination Swab/Clean/Moisturize Suction All of the above Comprehensive Oral Care Program Comprehensive Oral Care Protocol: The Good Shepherd Study Methodology: Retrospective study 10 bed Med-Surg Protocol included: Covered Yankauer for non-traumatic oral suctioning, soft-suction toothbrush, thb h Suction Oral Swab, use of a 1.5% H 2 O 2 peroxide mouth rinse for cleansing, subglottic suction catheter used 4x daily, dedicated oral suction line for infection control and ease of use. Education provided and presence of clinical champion. Schleder B. et al. J Advocate Health 2002;4(1):27-30 10

Literature Review: Oral Care Impact of VAP Comprehensive Oral Care: Reduction in VAP from 5.6 to 2.2 (Schleder B. et al. J Advocate Health 2002;4(1):27-30) Reduction in VAP from 4.10 (2005) to (2.15) in 2006 with addition of CPC & comprehensive oral care. Vent bundle & rotational therapy already being performed Reduction in VAP from 12.0 to 8.0 (p=.060) with 80% compliance, vent bundle already being preformed, 1538 patients randomized to control or study group, Additional outcomes; vent days (p=.05), ICU LOS (p=.05) time to VAP (p= <.001) & reduction in mortality (p=.05) (Garcia R et al AJCC, 2009;18:523-534) Literature Review: Oral Care Impact of VAP Comprehensive Oral Care & CHG: Reduction in VAP to zero for 2 years, vent bundle, mobility, oral care & CHG with comprehensive education preformed (Murray TM et al. AACN Advanced Critical Care. 2007;18(2):190-199) Dickinson S et al. SCCM Critical Connections, 02/2008 Comprehensive oral care with CHG Heck K, et al. Presented at APIC 7/15/2010 Oral Suctioning with Position Change Prospective time sequenced non-randomized study 237 control (observation phase 9 months) 227 Interventional (7 months interventional) Difference in nursing protocol was oral suctioning prior to position change (11 additional suctions) All other nursing care the same Results: VAP: 6.51 to 2.04 per 1000 ventilator days ( p<0.002 ) Vent days: 28.8 + 17.2 vs. 20.2 + 4.0 (p <0.009) ICU LOS: 27.6 + 17 vs. 20.3 + 4.0 (p < 0.012) Suctioning before positional change only independent factor responsible for VAP decrease (p=0.003) Does Compliance Make A Difference? Oral care compliance & use of the ventilator bundle resulted in a 89.7% reduction in VAP Hutchins K, et al. Presented at APIC Annual Conference June 2008 Tsai, HH, et al. Am J of Med Sci, 2008;336;397-401 Risk of VAP Subglottic Secretion Drainage 5 level 2 trials conclude that subglottic secretion Mortality drainage is associated with a reduction in VAP Risk of Early VAP Muscedere J & Canadian Trials Group. J of Crit Care, 2008;23:126-137 Dezfulian C. et al. Am J of Med, 2005;118,11-18 HOB Research Methodology: 86 patients Randomly assigned to supine position or HOB 45 degrees (39 semi recumbent, 47 supine) Monitored clinical suspected & microbiologically confirmed nosocomial pneumonias Results: Microbiologically confirmed nosocomial pneumonia lower in the semi recumbent group 2/39 (5%) vs. 11/47 (23%) Supine position & enteral nutrition were independent risk factors for VAP & had the greatest number of VAP s 14/28 (50%) Drakulovic MB. et. al. Lancet. 1999;354:1851-1858 11

HOB Research Methodology Prospective multicenter trial randomly assigned to targeted 45 vs.10 HOB 112 to targeted 45 vs. 109 patients to 10 Continuous measurement of backrest elevation first wk kofmv Results Dx of VAP by bronchoscopic techniques Baseline characteristics similar Average elevations 10 group day 1 & 7: 9.8 & 16.1 45 group day 1 & 7: 28.1 & 22.6* Target 45 not achieved 85% of the time VAP: 10 = 6.5% vs. 45 = 10.7% *p <.001 Van Nieuwenhoven CA, et al. Crit Care Med, 2006;34:396-402 Goldhill DR et al. Amer J Crit Care, 2007;16:50-62 CLRT to Prevent VAP Methodology Prospective randomized controlled trial, 3 medical ICUs at a single center Eligible if ventilated < 48 hours & free from pneumonia, ALI or in ARDS 150 patients with 75 in each group 35 CLRT patients t allocated to undergo percussion before suctioning Measures to prevent VAP were standardized for both groups including HOB Results: CLRT vs. Control VAP: 11% vs. 23% p =.048 Ventilation duration: 8 + 5 days vs. 14 + 23 days, p =.02 LOS: 25 + 22 vs. 39 + 45 days, p =.01 Mortality: no difference Staudinger t, et al. Crit Care Med, 2010;38:486-490 Intervention to Decrease VAP Statewide Collaborative-Keystone ICU 112 ICU s from 72 hospitals reported data Examine 550,800 ventilator days Implementation of the CUSP/VAP Bundle/checklist Results: 71% in VAP rates in MI Median rate of VAP per 1000 vent days went 5.5 cases to 0 0 at 16-18 months (p<0.001) & 0 at 28-30 months (p<.001) Mean rate of VAP per 1000 vent days went 6.9 to 3.4 at 16-18 month follow up (p<0.001) & 2.4 at 28 to 30 months (p<.001) Composite compliance measured from 32% at baseline, 75% at 18 months & 84% at 28 months Inclusion of oral care was not measured Berenholtz SM, et al. Infect Control Hosp Epidemiol, 2011;32:305-314 Central Line - Associated Blood Stream Infections Creative Strategies 12

The Problem is Large 15 million catheters inserted ICU s per yr 80,000 CLA-BSI in U.S. ICUs annually 250,00 *541, 081 CLA-BSI s annually/ rate of 21.6 cases/per 1000 patient days (est.) Mortality: 18% (12%-25%) 31,000 deaths (1 in 4 die) NHSN CVC: 1.0 (PICU) 5.6 (Burn ICU) per/1000 cath days Rate may be higher in wards vs. ICU s*/use 16% PICC rates: 3.63 per 1000 cath days (Single center) Cost per episode: $18,000 300 million to 2.3 Billion LOS up to 12 days CDC. MMWR 2002; Rosenthal VD, et al. Am J of Infect Control, 2008;36:627-37 Edwards JR, et al. Am J of Infect Control, 2008;36:609-26 ;Perencevich EN, et al. JAMA, 2009;301:1285-1287 Coello R, et al. J Hosp Infect, 2003;53:46-57, *Zingg W, et al. J Hosp Infect 2009; *Al-Rawaifah OM, et al. Infect Control Hosp Epidemiol, 2009;30:1036-1044 Ajenjo MC, et al. Infect control Hosp Epidemiol, 2011;32:125-130 Blood Stream Infection (BSI) Prevention Bundle (IB) Remove/Avoid unnecessary lines (IA) Hand hygiene (IB) Maximal barrier (IB) Chlorhexadine h for skin prep (IA) Avoid femoral lines (IA) Education & Culture of Safety CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] http://www.guideline.gov/summary/summary.aspx?doc_id=13395&nbr=006806&string=cla-bsi Oct 2008 www.ihi.org Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov http://www.onthecuspstophai.org/ CDC Guidelines for Insertion Site Preparation What Does the Bundle Evidence Tell Us? Sterile technique; cap, mask, gown, gloves, and a large sterile drape (IA) Recommend 2% Chlorhexidine be the cleanser of choice if available (IA) Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter- Related Infections, 2011. www.cdc.gov Chlorhexidine vs Povidone Iodine for Catheter Site Care 2011 Recommendations: Site Location Avoid using the femoral vein for central venous access in adult patients (1A) Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement (1B) Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis (1A) Ann Intern Med 2002:136:792-801 Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov 13

2011: Additional Placement Guidelines Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. (IB) Use a CVC with the minimum number of ports or lumens essential for the management of the patient (IB) Promptly remove any intravascular catheter that is no longer essential. (IA) Use a sutureless securement device to reduce the risk of infection for intravascular catheters. (II) Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov CDC Recommendation for Catheter Replacement When adherence to aseptic technique cannot be ensured replace the catheter as soon as possible, i.e, within 48 hours. (IB) Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related related infections. (IB) Use a guidewire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is present. (IB) Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. (IB) Routine culture of the tip is not recommended.. CDC. Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov Dressing Care Use a transparent or gauze dressing to cover site (IA) Change transparent dressing and perform site care with a CHG based antiseptic every 7 days (IB) or more frequent if the dressing is soiled, loose, or damp; (IB) Change gauze dressings every 2 days or more frequent if the dressing is loose, soiled or damp (II) Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not despite EBP (1B) No recommendation is made for other types of chlorhexidine dressings. SHEA and IDSA, Infection Control and Hospital Epidemiology Oct 2008 Prevention of Catheter Infection: MMWR 2002;51 (No. RR-10):[1-29] Salgado CD, et al. Infect Control and Hosp Epidemi, 2007;28:684-688 Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov Care After Insertion Scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices.(ia) 3 sec, 10 sec & 15 sec scrub showed no difference in reducing bacterial load (Simmons S, et al. Crit Care Nurs Q, 2011;34:31-35) When needleless system used, consider a split septum valve versus a mechanical valve.(ii) Replace administration sets not used for blood, blood products or lipids at intervals not longer than 96 hours (IA) Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours of initiating the infusion. (IB) Change the needleless components at least as frequently as the administration set. (II) Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI (II ) Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov Additional Strategies Used When Basic Care Has Not Achieve Zero CHG Baths (II) CHG Dressings (IB) Antimicrobial impregnated CVC (IA) Antimicrobial locks (II) Appropriate nursing staff levels in ICUs. (1B) Coffin SE, et al. Infection Control & Hosp Epid, 2008;29(1):S31-S40 Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter- Related Infections, 2011. www.cdc.gov CHG Bathing Reduces CLA- BSI s 52 week, 2 arm, cross-over design clinical trial 22 bed MICU with 11 beds in 2 geographically separate areas 836 MICU patients 1 st 28 weeks: 1 hospital randomize to bathe with (Sage 2%) CHG cloths & the other unit bathe with soap & water 2 week wash out period 2 nd 24 weeks: methods were crossed over Measured: Primary outcomes: incidence of CA-BSI s & clinical sepsis. Secondary: other infections Bleasdale SC. et al. Arch Internal Med, 2007;167(19):2073-2079 14

CHG Bathing Reduces CLA-BSI s Results: CHG arm were significantly less likely to acquire a CA-BSI 4.1 vs. 10.4 infections per 1000 patient days Benefit against primary CA-BSI s by CHG cleansing after 5 days in MICU No difference in clinical sepsis or other infections CHG Bathing: Pre & Post Intervention Dixon, et al. Am J Infect Control 2010;38:817-21 Corcoran et al APIC 6/2009 Bleasdale SC. et al. Arch Internal Med, 2007;167(19):2073-2079 Additional Strategies Used When Basic Care Has Not Achieve Zero CHG Baths (II) CHG Dressings (IB) Antimicrobial impregnated CVC (IA) Antimicrobial locks (II) Appropriate nursing staff levels in ICUs. (1B) Coffin SE, et al. Infection Control & Hosp Epid, 2008;29(1):S31-S40 Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter- Related Infections, 2011. www.cdc.gov CHG-Impregnated Sponges for Prevention of CLA-BSI (IB) Methodology: Multi-center, randomized controlled trial 7 ICUs participated Included all patients who required arterial or central venous catheter for 48 hours or longer Use of CHG dsg vs standard dsg Already using maximal barrier precautions, try and use subclavian site for central line, use alcohol/povidoneiodine prep solution (not CHG) Looked at 3 day vs. seven day dressing change (but changed when dsg was loose, soiled or damp in all groups) Timsit JF, et al. JAMA 2009;301:1231-1241 CHG-Impregnated Sponges for Prevention of CLABSI (IB) Results: 1636 patients (3778 catheters, 28,931 catheter days) Median duration of catheter insertions 6 days (4-10) Use of CHG dressing decreased the CLA-BSI rate from: 1.3 per 1000 catheter t days to 0.4 per 1000 catheter t days Use of CHG dressing not associated with greater resistance of bacteria in skin samples at removal 8 episodes of contact dermatitis with patch ( 817 pts) No difference in site colonization between dressing changes at 3 days or 7 days Prevented 1 Major CLA-BSI per 117 Catheters Timsit JF, et al. JAMA 2009;301:1231-1241 2011: Antimicrobial CVC CDC Recommendations: Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin -impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. (IA) CDC. Prevention of Catheter Infection: MMWR 2002;51 Grady NP, et al. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. www.cdc.gov 15

Emerging Issues: Needleless IV Access Equipment Q-Syte InVision-Plus Safesite Neutral Clearlink Split system value designs are preferred over positive pressure mechanical valves because they are associated itdwith ithlower CLA-BSI CLABSI rates. PASV In 2008 FDA required 9 companies to conduct SmartSite post Plus market surveillance Ultrasite of MaxPlus positive displacement needless connectors Rupp ME, et al. Clin Infect Dis. 2007;44(11):1408-1414 FDA Medical Device Alert 2008 Smartsite Clave Interlink Posiflow CLC 2000 Berenholtz et al, 2004; Tsuchida et al, 2007 Intervention to Decrease CLA-BSI Statewide Collaborative-Keystone ICU 103 ICU s in state of Michigan reported data Examine 375,757 catheter days Implementation of the BSI Bundle/checklist Results Median rate of CLA-BSI per 1000 catheter days went 2.7 to 0 at 3 months ((p<0.002) Mean rate of CLA-BSI s per 1000 catheter days went 7.7 to 1.4 at 18 month follow up (p<0.002) in mortality when compared to other mid-west states 36 Months Post Initial Implementation: 90 of original 103 ICU s evaluated Results: Mean rate 1.1 per 1000 catheter days/ Median: Zero 2009: mean.88 per 1000 catheter days (personal communication) Pronovost P et al, N Engl J Med;2006;355:2725-2732 Pronovost P et al. BMJ, 2010;340:309 Liptiz-Snyderman A, et al. BMJ, 2011;342:219 On the CUSP: Stop BSI A National Initiative AHRQ government funded 3 year initiative HRET and American Hospital Association John Hopkins Quality & Safety Research Group MHA s Keystone Center for Patient Safety & Quality Goals: Eliminate CLA-BSI: <1/1000 catheter days, median 0 Improve safety culture by 50% Learn from 1 defect a month Build an infrastructure for future efforts Baseline and monthly CLA-BSI rate, hospital survey on patient safety & monthly survey on teamwork barriers http://www.onthecuspstophai.org/ Stop CLA-BSI: Progress Report Progress Report 45 state hospital associations recruited 700 hospital & 1100 hospital teams in 2009 14 additional states and the District of Columbia joined in 2010 Eight states, including Puerto Rico began in 2011 1.8 infections per 1000 days to 1.17 infections per 1000 days central line use (RR. 35%) in 22 states (350 hospitals) < 20% of US hospitals are participating CDC reported 58% drop in CLA-BSI between 2001 in 2008 6,000 lives saved 1.8 billion cost avoidance http://www.onthecuspstophai.org/ http:/blogs.wsj/health/2011/04/05/progress-onreducing-bloodstream-infections/ 16

CA-UTI s: Reducing Load Use of catheter increases risk Daily risk of acquisition of UTI: 3% to 7% Second common HAI & 80% attributable to indwelling catheterization CAUTI: associated with morbidity, mortality (2.3%), hospital cos ($589.00) & LOS 15%-25% of hospital patients may have a urinary catheter during admission Highest use; Trauma ICU units, Lowest use; Med-Surg Pooled mean CAUTI rates 3.1-7.5 infections per 1000 catheter days (Burn ICU highest, Med-Surg ICU s lowest) Add 1 day LOS per patient Joanna Briggs Institute EBR: 2007 Saint S., et al. Infect Dis Clinics North Amer 2003; 17:411-432. Weinstein JW, et al. Infect control Hosp Epidemiol, 1999; 20:543-548 Lo E, et al. Infect Contr & Hosp Epidemiol, 2008;29:S41-S50 Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s. 2009 CA-UTI Bundle Bladder Bundle CA-UTI Bundle ( Bladder Bundle ) Avoid unnecessary urinary catheters Insert urinary catheters using aseptic technique Maintain urinary catheters based on recommended guidelines. Review urinary catheter necessity daily and remove promptly http://www.bestcare.org.za/docs/prevent%20catheter%20ca-uti.pdf Core Recommendations Insert catheters only for appropriate indications (1B) Leave catheters in only as long as needed (1B) Ensure that only properly trained persons insert and maintain catheters (1B) Insert catheters using aseptic technique in sterile equipment ( acute care settings) (1C) Maintain a close drainage system (1B) Secure the system (1B) Maintain unobstructed urine flow (1B) Key the collecting bag below the level of the bladder at all times (1B) Core Recommendations Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing) is appropriate. (IB) Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue) If the CAUTI rate is not decreasing with a comprehensive strategy, consider using antimicrobal/antiseptic impregnated catheters. (IB) Practice hand hygiene in standard precautions according to CDC & HICPAC guidelines Expert Opinion HICPAC CA-UTI Guideline Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s. Draft June 2009 Appropriate Urinary Catheter Use Insert catheters only for appropriate indications and leave in place only as long as needed (1B) Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. (1B) Use urinary catheters in operative patients only as necessary, rather than routinely. (IB) Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate. (II) Further research is needed on the risks and benefits of suprapubic catheters as an alternative to indwelling urethral catheters in selected patients requiring short- or long-term catheterization. (No recommendation/unresolved issue) Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s. Final 2009 17

HICPAC CA-UTI Guideline HICPAC CA-UTI Guideline Proper Technique for Urinary Catheter Insertion Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. (IB) Ensure that only properly trained persons who know the correct technique of aseptic catheter insertion & maintenance are given this responsibility. (IB) Insert catheters using aseptic technique and sterile equipment (except chronic intermittent catheterization). (IC) Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. (IC) Antiseptic lubricants need not be used routinely to prevent CAUTI. (II) Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue) Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s. 2009, final Proper Technique for Urinary Catheter Insertion Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (IB) Consider using the smallest bore catheter possible, consistent with good drainage, to minimize urethral trauma. (II) Proper Techniques for Urinary Catheter Maintenance Maintain a sterile, continuously closed drainage system (IB) If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. (IB) Key the collecting bag below the level of the bladder at all times (IB) Urinary catheter systems with preconnected, Gould, CV et al. HICPAC sealed Guideline for cathetertubing junctions may reduce thecatheter-associated risk of CAUTI Preventing UTI s. compared 2009 to HICPAC CA-UTI Guideline Proper Techniques for Urinary Catheter Maintenance Maintain unobstructed urine flow. (IB) Keep the catheter and collecting tube free from kinking. (IC) Empty the collecting bag regularly using a separate collecting container for each patient, and avoid contact of the drainage spigot with the nonsterile collecting container. (IC) Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. (IC) Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) need not be used routinely to prevent CAUTI. (II) Do not change indwelling catheters or drainage bags at arbitrary fixed intervals. (IB) Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s. 2009 HICPAC CA-UTI Guideline Proper Techniques for Urinary Catheter Maintenance Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing) is appropriate. (IB) Avoid bladder irrigation unless obstruction is anticipated (II) If obstruction is anticipated, closed continuous irrigation may be used to prevent obstruction. (II) The bladder or collection bag need not be irrigated with antimicrobials routinely to prevent CAUTI. (II) Clamping indwelling catheters prior to removal is unnecessary. (II) Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s. 2009 Impact of UTI with Basin Bathing UTI Rate- Removal of Prepackaged Bath Product QTR 3 FY05 Rate/1000 Devic ce Days 20 18 16 14 12 10 8 50th percentile 6 4 2 0 QTR 1 QTR 2 QTR 3 QTR 4 QTR 1 QTR 2 QTR 3 FY05 FY05 FY05 FY05 FY06 FY06 FY06 McGuckin M, Torress-Cook A, et al APWCA Annual Meeting, Philadelphia, April 2007 The Effect of Bathing with Basin and Water and UTI Rate, LOS and Costs Unit Census: 14 Phases Product Cost/ No. of UTI I- Pre-Packaged Bathing Washcloths (9 months) II- Basin/Water (9 months) III- Additional Product Cost, UTI, LOS, COSTS $10,530 1 ($3.00) $3,510 2 ($1.00) Median 4 LOS 17 Days Median 4 Cost (4857.00) 25 175 $117,175 48 336 $224,916 $7,020 23 3 151 $107,741 1 Based on 3 packages of 8 towels each 2 Based Chen on product Yin-Yin,Chou cost of Yi-Chang,Chou towels, soap, Pesus.. and basin Infect Control Hosp Epidemiol 2005;26:281-287 3 Difference between phase I pre-package/phase II basin water 4 18

Reducing UTI s Through Basinless Bathing 89% Reduction CA-UTI 7.5 per 1000 catheter days to 4.42 per 1000 catheter days, then to.46 per 1000 catheter days Stone S, et al. 37th Annual APIC Educational Conference July 11-15, 2010 Simple Cost Effective Strategies to Reduce HAI s Was moved from the ICU to house-wide post initial project with similar results in Med-Surg Implementation: Utilize daily 2% CHG cloths for cleansing at night in any patient with a central line or foley catheter Focused on areas most prone to bacterial colonization from the neck down Corcoran F. Presented at APIC 2009 HICPAC CA-UTI Guideline Catheter Materials If the CAUTI rate is not decreasing with a comprehensive strategy, consider using antimicrobal/antiseptic impregnated catheters. (IB) Further research is needed on the effect of using antimicrobal/antiseptic catheters in reducing the risk of symptomatic UTI. (No recommendation/unresolved issue) Hydrophilic catheters may be preferable to standard catheters for patients requiring intermittent catheterization. (II) Silicone may be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. (II) Gould, CV et al. HICPAC Guideline for Preventing Catheter-Associated UTI s,2009 HICPAC CA-UTI Guideline Specimen Collection Obtain urine samples aseptically. (IB) If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (IB) Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (IB) Spatial Separation of Catheterized Patients Further research is needed on the benefit of spatial separation of patients with urinary catheters to prevent transmission of pathogens colonizing urinary drainage systems. (No recommendation/unresolved issue) Gould, CV et al. HICPAC Guideline for Preventing Catheter- Associated UTI s. 2009 Reminder Systems May Reduce Inpatient Catheter Use and Associated UTIs Reminder 56% reduction Stop Order 41% reduction Meddings J et al. Clin Infect Dis, 2010;51:550-560 19

Cost-Benefit Ratio CA-UTI vs. IAD & Pressure Ulcer Reducing Use Does it Reduce CA-UTI s Pre and post intervention study Unit clinicians developed indications for continue use of catheter (evidence-based) 6 month intervention period evaluated appropriateness of catheter daily 337 patients/1432 catheterization days were evaluated Duration of use significantly reduced (236.6 d/mo vs. 311.7 d/mo) CA-UTI s went from 4.7 per 1000 days to zero for the intervention period 11% inappropriate days Elpern EH, et al. Am J of Crit Care, 2009;18(6):535-541 Implementation: Utilize daily 2% CHG cloths for cleansing at night in any patient t with a central line or foley catheter Focused on areas most prone to bacterial colonization from the neck down Simple Cost Effective Strategies to Reduce HAI s Was moved from the ICU to house wide post initial project with similar results in Med-Surg Corcoran F. Presented at APIC 2009 Four E s Bugs Be Gone!!!! How to Get Started Engage: help staff understand the preventable harm Share stories about patients affected Estimate number of patients harmed Develop a business case Educate: ensure staff and senior leaders understand what they need to do to prevent injury and improve teamwork and communication Conference calls, webcasts, meetings Execute: how given the resources and culture they would ensure that all patients received the evidence Share with working, what s not Coaching calls Evaluate: project leader monitors that teens are using standardized definitions, report their data and make it transparent at the unit level Goeschel CA, et al. Nursing in Critical Care, 2011;16:35-42 20

In God We Trust! Notes on Hospitals: 1859 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. -Florence Nightingale Components of Successful Long Lasting Change Interventions To Ensure Patients Receive Evidence Vollman KM. Australian Crit Care, 2009;22(4): 152-154 Value Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Attitude & Accountability NSO Evidence based education Recognition of value and reinforcement Products/Processes that make it easy for the frontline caregiver to provide the care (make it part of the bundle) Bathing kits Placement on the med record Automated charting with flag reminders Frequent rounding/reinforcement of standard Multidisciplinary rounds/checklists Westwall S. Nursing in Critical Care, 2008;13(4):203-207 Abbott CA, et al. Worldviews on Evidence Based Practice, 2006:139-152 Fuchs MA, et al. J Nurs Care Qual, 2011;26:101-109 Interventions To Ensure Patients Receive Evidence Setting targets/celebrating successes Placement of new practice/education in orientation Attractive signs to outline protocol in the patient rooms near the products Compliance program with feedback to all caregivers Outcome measurement/feedback* Include RN s in Morbidity & Mortality peer review for VAP increased compliance/accountability & VAP rates Westwall S. Nursing in Critical Care, 2008;13(4):203-207 Abbott CA, et al. Worldviews on Evidence Based Practice, 2006:139-152 Fuchs MA, et al. J Nurs Care Qual, 2011;26:101-109 Nolan SC, et al. JONA, 2010:40(9):374-383 CREATE A SAFE PATIENT ENVIRONMENT Everyday hospital care activities increase the patients risk of INJURY & BACTERIAL INVASION Help reduce that risk by changing the routine ways you provide care & replace it with the evidence 21