Erlanger Infection Prevention Resident and df Fellow Orientation June 2011 1
Outline 1. Infection Prevention Program Bloodborne Pathogens/Exposure Prevention & Management Standard Precautions 2. Hand Hygiene 3. Isolation Precautions 4. Tuberculosis 5. Current Initiatives VAP, CLABSI, CAUTI 2
Infection Prevention Program Resource for information Surveillance and management of infection data Reporting to Health Department Regulatory compliance TOSHA, FDA, JCAHO, TN DOH 3
Bloodborne Pathogens Any pathogen that can be transmitted through contact with blood or items contaminated with blood and body fluid. HIV 03% 0.3% Hepatitis C 5-10% Hepatitis B 30% 4
Exposure Control Plan Includes: Actions taken by Erlanger to prevent exposures to bloodborne pathogens How Erlanger manages exposures when they do occur Located on the Intranet 5
Standard Precautions Used for all patients. All blood, body substances are considered potentially infectious. PPE includes Gloves Gowns Mask, Protective eyewear Goggles 6
PPE Responsibilities Hospital: Adequate supply Conveniently located Correct size HCW education Healthcare Worker: Wear it! Activate the safety devices Dispose of your own sharps!! Beware of the other guy Remove PPE at the point of use- No PPE in public areas! 7
What is an Exposure? Puncture injury from contaminated device. Splash of blood or body fluid into eyes, nose, mouth or onto broken skin. 8
Management of Exposures First aid to the exposed area Notify the unit manager or charge nurse Contact the House Supervisor ASAP Orders the labs Calls you the HIV results (1-2 hrs) Complete an Illness\Injury Injury form Contact Pam Scott for UTCOM paperwork p 9
Why don t I just order the labs myself on the patient? Documentation t ti of occupational exposure for follow-up Assure appropriate p labs are ordered. Expenses p for exposure work-ups should not be charged to the patient. 10
Wash In Wash Out Goals of the Campaign Prevent HAIs by improving compliance with hand hygiene by; Identifying barriers to compliance ce Encourage all staff to get comfortable with respectfully reminding EVERYONE to Wash In and Wash Out 11
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Hand Hygiene Methods Alcohol h l Hand Sanitizer Apply to palm of one hand, rub hands together covering all surfaces until dry Soap p and Water Wet hands with water, apply soap, rub hands together for at least 10-15 15 seconds DO NOT use alcohol hand sanitizer when hands are visibly contaminated or when caring for patients with C Diff 13
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Gloves are worn when entering the room Gowns are worn when chance of contaminating your scrubs (providing patient care) Equipment must be disinfected before use on another patient (including stethoscopes) 15
Gloves and gown upon entry regardless of patient contact Use for Multi-Resistant Organisms (MDROs); Resistant Acinetobacter Resist PA CALL Infection Prevention before discontinuing 16
Use for Clostridium difficile (C-Diff) infections and when ruling out Remember Do not use alcohol hand sanitizer Use bleach wipes 17
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Tuberculosis # Cases 2010 # New Cases 2009 U.S. 11, 181 11,540 Tennessee Hamilton County 193 148 7 6 Erlanger 5 5 Erlanger 2010 2009 HCW Conversion rate 0.08 % 0.06% Post-Exposure Conversion 2 0 19
TB Fast Facts AFB s ordered/tb suspected? ISOLATE Discontinue? 3 negative smears or cleared by Infectious Disease physician Exposed? You will be notified by IP when confirmed positive Had BCG? Still must get annual TB skin test unless can document a positive history. 20
TB Mask Facts N-95 fit test Upon hire and annually N-95 mask is required for room entry Cannot be fit tested with a beard Mask can be reused multiple times 21
Healthcare Associated Infections Affect 2 million Americans annually Account t for 50% of all hospital related complications National, State, facility initiatives ongoing 22
Current EMC Initiatives Preventing Ventilator Associated Pneumonias (VAPs) Preventing Central Line Associated Blood Stream Infections (CLA-BSIs) Preventing Catheter Associated Urinary Tract Infections (CA-UTIs) 23
VAP Prevention Use non-invasive ventilation (CPAP, BiPAP) Use Hi-Lo Evac tube when intubating Utilize sedation vacation and weaning protocols Avoid re-intubations whenever possible 24
Overall ICU VAP Data 40 VAPs (Non POA, Per CDC Guidelines) VAPs per 1,000 1000 Vent Days 20 r of O cc c urrenc es N um be 32 24 16 8 16 12 8 4 nt Day s, 000 Ve Ps Per 1 0 0 VA 25
Future Plans @ Erlanger to Decrease VAP Implement chlorhexidine gluconate (CHG) mouth rinsing i in TICU and NNICU Implement CHG bathing in selected ICUs Implement Pressure EZ cuff monitoring device for all ventilated patients 26
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CLA-BSI Prevention ention Maximum sterile barriers for insertion AVOID femoral lines in adults! Use CHG instead of Betadine Request assistance during insertion Remove unnecessary lines daily evaluation of need 28
Return completed form to Nurse Manager Do not place on chart NOT PART OF MEDICAL RECORD Central Venous Line Insertion Checklist Complete this form for all central venous line insertions to document procedural practices related to insertion technique. Central Line Bundle-Insertion Interventions 1. Insertion Site-Optimal Site Selection (subclavian is the preferred site for non-tunneled catheters in adults) 2. Hand Hygiene 3. Maximal Barrier Precautions 4. Use CHG for Prep Central Location (Unit): Date of Procedure: Line Insertion Site: Subclavian Preferred Site Jugular Femoral PICC UAC/UVC Line Type: Multilumen (All Types) PA Introducer PICC Vascath UAC/UVC Checklist Is this a line change over a wire? YES NO Procedure is: Non-Emergent Emergent Insertion Practices: Inserting Practitioner Assisting Nurse 1. Hands Cleansed (ask if unsure) YES NO YES NO 2. a. Mask, sterile gown, hair cover, sterile gloves 3. Large body drape used (covers head to thigh) YES NO YES NO * If no circle items not used YES NO All barriers required except sterile gown unless handling catheter or guidewire. 4. ChloraPrep used to prep site (preferred) e ed) YES NO N/A (Contraindicated in Neonates) If Betadine used allowed to dry? YES NO 5. Sterile field maintained YES NO 6. Why subclavian site not used (ask if unknown) Trauma to SCV Trauma to skin over SCV site Neonate Unsuccessful Attempts Agitated Patient Halo Traction Joint Contractures Body Habitus If other please explain: 7. More than 1 kit used? YES NO (HOW MANY? ) (Print clearly First and Last names) Inserted by: Pager # Nurse present for duration of procedure YES NO if no indicate reason: Name of Person Completing Form: Phone # Patient Label/MR# Name 29
Overall ICU CLA-BSI Rates Primary CLA-BSI (per CDC) CL Days Line Days @ NHSN Rate 6 1800 5 4 3 2 1500 1200 900 Central Line Associated BSIs C e ntral Lin e Days 1 600 300 0 0 30 Jul-08 Mar-111 Apr-11 May-111 Jun-111 Aug-08 Sep-08 Oct-08 88 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 99 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 00 Dec-10 Jan-111 Feb-11
Preventing CA-UTIs 1. Avoid unnecessary urinary catheters 2. Insert using aseptic technique 3. Review catheter necessity daily and remove promptly 31
Practices to Avoid Irrigating catheters Disconnecting the catheter from the tubing Replacing catheters at routine intervals; Only replace for mechanical problems (Obstruction) Replace after diagnosis of UTI and the patient has been on the appropriate p antibiotic 48 hrs These practices may actually increase the risk of infection and other complications. 32
CA-UTI Data Urinary Catheter Associated UTIs Urinary Catheter Days 35 3500 30 3000 25 2500 Urinary Catheter Associated UTIs Urinary Catheter Days 20 2000 15 1500 10 1000 5 500 0 0 O ct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 O ct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 33
Healthy Tips Do not come to work if you have a contagious illness such as pink eye, flu, strep throat, fever etc. See UTFP for treatment. Get a flu shot in the fall! 34
Questions About Infection Prevention? Contact the Infection Prevention Office at ext. 7239 from 7:30 am to 4:30 pm. After office hours, call the House Supervisor for assistance HS can reach us 24/7 35
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