Infection Prevention Resident Orientation June 2015
Purpose of this Discussion Review basic infection prevention practices IP Resources Bloodborne Pathogen Exposure Control Plan Tuberculosis Control Discuss your role in infection prevention Discuss current infection prevention initiatives at Erlanger
Resources IP Dept. @ ext 7239 House Supervisor/A1 Erlanger Intranet Policies & Procedures Infection Prevention Library Public Health Alerts and Documents folders Quick Reference tools
Infection Prevention Program Resource for information Surveillance and management of infection data Support process improvements to decrease infections Reporting to Health Department Regulatory compliance TOSHA, FDA, JCAHO, CMS and State
Bloodborne Pathogen Exposure Control Plan Located on the Erlanger Intranet-Policies and Procedures Infection Prevention Includes: Actions taken by Erlanger to prevent exposures to bloodborne pathogens How exposures are managed
Bloodborne Pathogens Any pathogen that can be transmitted through contact with blood or items contaminated with blood and body fluid. HIV 0.3% Hepatitis C 5-10% Hepatitis B 30%
Use Standard Precautions Not Random Precautions
Standard Precautions Used for all patients when you anticipate contact with blood or body fluids Main Component HAND HYGIENE Use of PPE including Gloves Gowns Masks Goggles/Protective eyewear
Prevention Responsibilities Hospital: Adequate supply PPE PPE Conveniently located Correct size PPE HCW education Healthcare Worker: Wear PPE! Activate the safety devices Dispose of your own sharps!! Get HBV vaccine Offer HBV vaccine Remove PPE at the point of use No PPE in public areas!
$7000 Cup of Coffee Protect Yourself
What is an Exposure? Puncture injury from contaminated device. Splash of blood or body fluid into eyes, nose, mouth or onto broken skin.
Management of Exposures First aid to the exposed area Notify the unit manager or charge nurse Contact the House Supervisor ASAP. They will Orders the labs on source Calls you the HIV & HBV results (1-2 hrs) Completes a non-employee exposure form Contact your program liaisons for follow-up information
Why don t I just order the labs myself on the patient? Documentation of occupational exposure for follow-up Assure appropriate labs are ordered. Expenses for exposure work-ups should not be charged to the patient. Outpatient exposures Get follow-up labs before patient leaves the area
Tuberculosis # Cases 2014 # Cases 2013 # Cases 2012 U.S. Not Available 9588 9951 Tennessee 151 143 164 Hamilton County 5 7 7 Erlanger 2 4 4 Erlanger 2014 2013 2012 2011 #HCW Tested 160 266 4144 4073 HCW Conversion rate 0 0 0.05% 0.09% Post-Exposure Conversion 0 0 2 4
TB Fast Facts AFB s ordered/tb suspected? ISOLATE in Negative Pressure room. Discontinue? 3 negative smears or cleared by Infectious Disease physician Exposed to TB? You will be notified by IP when/if confirmed positive Had BCG? Get Quantiferon Gold blood test or OK to get TB skin test if never tested unless documented positive PPD history or TB.
TB Mask Facts N-95 fit test Upon entry and per risk assessment N-95 mask is required for TB room entry Cannot be fit tested with a full beard Mask can be used for an entire shift
Healthcare Associated Infections (HAIs) Affect 2 million Americans annually Account for 50% of all hospital related complications CMS - Value Based Purchasing - can reduce payments to facilities by as much as 2% Now - CAUTI, CLABSI, MRSA BSI, CABG SSI, TAH SSI, Colon SSI To come CDIFF, HCW Influenza Vaccine rates National, State, facility initiatives ongoing
Top Priorities for Erlanger Improving Hand Hygiene Preventing Central Line Associated Blood Stream Infections (CLA-BSIs) Preventing Catheter Associated Urinary Tract Infections (CAUTIs) Ask every day- does the patient still need this line or foley TODAY? Be thoughtful when ordering cultures
Hand Hygiene Cornerstone of infection prevention CDC, WHO, SHEA Ignaz Semmelweiss, MD Hand Hygiene must be a top priority for all providers
Hand Hygiene Methods Alcohol Hand Sanitizer Apply to palm of one hand, rub hands together covering all surfaces until dry Soap and Water Wet hands with water, apply soap, rub hands together for at least 10-15 seconds DO NOT use alcohol hand sanitizer when hands are visibly contaminated or when caring for patients with C Diff
Bare Below the Elbows *For Direct Patient Contact Long sleeved shirts rolled up to elbows Jackets off or roll sleeves to elbows Tuck the tie Remove watch and bracelets; rings within EHS policy acceptable Secure scarves
CLABSI Bundle Insertion Checklist: On all insertions If non-compliant, fax checklist to IP Use sterile ultrasound covers Line maintenance Scrub the HUB! Curos cap on all ports Biopatch for femoral lines, PICCs, dialysis catheters, and CRRT lines Daily review of Line Necessity Remove unnecessary catheters ASAP
Actual Line Util Rate % of pt days where pt has a central line 36% 34% 32% 30% 28% 26% 24% 22% 20% NHSN Median % Total Days with Central Line Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 EHS Average FY13: 1.16 FY14 : 1.13 FY15 1.00 Central Line Associated BSI (CLABSI) Rate CLABSI per 1000 line days 3.5 3.0 2.5 2.0 1.5 1.0 0.5 Actual Rate EHS Fiscal Yr Avg NHSN Wtd Mean CLABSI Rate NHSN Weighted Median: FY13: FY14: FY15: 0.0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 0.95 0.97 0.96
Central Line Insertion Checklist 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 Location (Unit): Date of Procedure: Insertion Site: Subclavian Preferred Site Jugular Femoral PICC UAC/UVC Line Type: Multilumen (All Types) PA Introducer PICC Vascath UAC/UVC 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 4. ChloraPrep used to prep site (preferred) If Betadine used allowed to dry? YES NO * If no circle items not used YES NO All barriers required except sterile gown unless handling catheter or guidewire. YES NO N/A (Contraindicated in Neonates) YES 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 NO Agitated Patient Joint Contractures Unsuccessful Attempts Halo Traction 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
Preventing Catheter Associated Urinary Tract Infections (CAUTIs)
% of pt days where pt has a catheter 33% 32% 31% 30% 29% 28% 27% 26% 25% 24% 23% 22% 21% 20% 19% Urinary Catheter Utilization Rate Actual Urinary Cath Utilization Rate NHSN Median % of Total Days with Urinary Catheter Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Urinary Catheter Associated UTI (CAUTI) Rate 8 Actual Month EHS Fiscal Yr Avg NHSN Wtd Median Rate CAUTI per 1000 catheter days 7 6 5 4 3 2 1 0 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15
Prevent UTIs Avoid insertion without valid indication Evaluate the need daily! Use Condom caths Secure the catheter Keep it below the bladder
CAUTI rates near national average Nurse driven protocol for foley removal Antimicrobial foleys for ICU, IMCU, ED, and Surgery New foley order set for ICU patients being developed Urine Flex Protocol Rejects poor urine specimens
Change in Test Options and Test Names for Urinalysis and Urine for Culture New policy on intranet 8316.1093 Urine Reflex to Culture Current Test Ordered in Net Access Urinalysis (UA) / Macroscopic with Microscopic New Test Ordered in Net Access One of two tests will replace the standard Urinalysis(UA): Urinalysis Non-ID or Urinalysis with Reflex to Culture Explanation of Changes Order UA- Non-ID for patients without an infectious disease issue. This test will contain results for a standard UA. An order for a UA that is not ordered as UA-Non-ID will be sent for UA with Reflex to Culture. Urinalysis with Urine Culture UA with Reflex to Culture UA reflexes to a culture if criteria is met: ( 5 epithelial cells, 10 WBC, & no yeast). If >5 epithelials AND 10 WBCs the specimen is considered contaminated and no culture will be performed. Recollect the specimen. The unit will be notified by phone to recollect and a label will print on the unit. The unit staff will need to enter a new order and to recollect the specimen. After two recollects, the nurse should notify the physician to discuss how to proceed. It is recommended that the 2nd recollect be done by straight catherization. If 5 epithelials BUT <10 WBCs, the specimen is considered contaminated and no culture will be performed. However, do not recollect because the low WBC count also does not meet criteria and recollection will not increase the WBC count. Urine culture Urine Culture with Override An Override of the Reflex to Urine Culture protocol may be appropriate in specified patient populations such as renal transplant patients, febrile oncology patients, obstetrical patients, and a few others for whom the reason must be entered on the CPOE dropdown menu or on the written order. Overrides will be reviewed on an ongoing basis by Dr. J. Sizemore. Urine Culture Urine Culture (Pediatric Only) This order is restricted to pediatric patients and will be performed as ordered regardless of UA results.
Isolation Precautions Transmission-based Precautions Airborne Droplet See Quick Reference for Contact details Enhanced CD Pediatric Respiratory Protective/Neutropenic Precautions Not used at Erlanger
HCW -Gloves and gown upon entry regardless of patient contact Use for Multi-Resistant Organisms (MDROs); Acinetobacter P.Aeruginosa ESBLs CALL Infection Prevention before discontinuing
Erlanger Health System MDRO Rates 2011-2013 Rate per 1000 PD 14.00 12.00 10.00 8.00 6.00 4.00 2.00 0.00 2011 2012 2013 1. Discontinue contact precautions for patients with MRSA & VRE with the exception of NICU. 2. Education and improvements in implementation of standard precautions and enhanced precautions 3. Improve cleaning and disinfection for C Diff Bleach & Ultraviolet Light Disinfection
Prevent Transmission of Pathogens 1. Hand Hygiene 2. Disinfection of Equipment Focus on 3 Major Elements Wet Times - Hydrogen Peroxide wipes -1 minute & Bleach wipes -3 minutes 3. Appropriate Use of Gloves Wear gloves if contact with blood or body fluids, or visibly contaminated items Gloves are not required for every patient contact Gloves are not a substitute for hand hygiene Gloves should not be worn in common areas (elevators, hallways, etc)
Isolation FAQs Gown not required for family unless assisting with direct care. When testing for potentially contagious illness (e.g., C. Diff, Flu, TB, etc) ISOLATE!! Once C. diff. is positive, do not test again Isolate all draining wounds on contact precautions regardless of culture results
Other Tips Do not come to work if you have a contagious illness such as pink eye, flu, strep throat, fever etc. Get a flu shot in the fall! Get TDap vaccine Clean your stethoscope, scissors, hemostats between every patient with disinfectant wipes Change your scrubs daily and lab coat at least twice a week Clean your cell phone, digital devices (i-pad) daily
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
WHO 5 Moments of Hand Hygiene https://www.youtube.com/watch?v=lvrp3c5n3p8#aid=p9kpkrx4