IN REVIEW

HEALTHCARE ACQUIRED INFECTIONS



What is a healthcare associated infection?

"Healthcare-associated infections (HAI) are defined as infections not present and without evidence of incubation at the time of admission to a healthcare setting. As a better reflection of the diverse healthcare settings currently available to patients, the term healthcare-associated infections replaced old ones such as nosocomial, hospital-acquired or hospital-onset infections.” http://emedicine.medscape.com.

Types of HAIs

Central line infections

Catheter-associated urinary infections

Surgical site infections

Ventilator-associated infections

Clostridium difficile infections

Prevention

Over the last several weeks of blogging many topics about prevention have been covered. The prevention technique that is a consistent throughout is PROPER HAND HYGIENE. If healthcare workers followed proper protocol and appropriate technique think how many healthcare associated infections we could eliminate along with pain and suffering of patients.

HOW ARE YOU GOING TO PRACTICE DIFFERENTLY?

 Reference:

http://emedicine.medscape.com.



WHAT IS YOUR STATE DOING TO HELP PREVENT HAIs

Indiana

The Indiana State Department of Health is leading a state improvement initiative to prevent healthcare associated infections. The initiative is a two-year state collaborative effort to promote the prevention of healthcare associated infections.

“Indiana has been active in addressing healthcare associated infections. Most recently, the Indiana State Department of Health utilized a collaborative process to address Methicillin-resistant Staphylococcus aureus (MRSA) exposures and provide Indiana communities with current MRSA information and necessary tools to promote prevention strategies. The Indiana State Department of Health also created a toolkit for Clostridium difficile infections.”

In September 2009, the ISDH was awarded a grant from the CDC to support state healthcare associated infection initiative.

Using the grant money Indiana developed two projects:

1. “The development of a state plan for the prevention of healthcare associated infections
2. A state healthcare associated infection prevention initiative”

The purpose:

Develop an Indiana Plan for the Prevention of Healthcare Associated Infections

(Indiana has NEVER produced a state plan focusing on healthcare associated infections)

Goals

"Improve and identify healthcare associated infections by health care providers

Reduce the number of healthcare associated infections

Increase public and healthcare worker awareness of healthcare associated infections"

Objectives

"Create a State Plan for Healthcare Associated Infections

Develop and implement healthcare associated infections surveillance and reporting system

Develop and implement a healthcare associated infections prevention initiative”

Reference:

www.in.gov.





Economic Consequences of HAI

“Healthcare associated infections in hospitals impose significant economic consequences on the nation’s healthcare system”

Incidence

Approximately 4.5 HAIs for every 100 hospital admissions

Cost

“According to the CDC, each year, U.S hospitals experience 1.7 million health-care acquired infections, causing roughly 99,000 deaths at a cost of 37$ to 45% billion dollars”

Of these infections:

32% of all healthcare –associated infections are urinary tract infections

22% are surgical site infections

15% are pneumonia

14% are bloodstream infections

Cost to the patient

Patients who acquire a infection from surgery on average spend , an additional 6.5 days in the hospital

Five times more likely to be readmitted after discharge

Twice as likely to die

60% more likely to require admission to a hospital’s intensive care
unit

Surgical infections are believed to account for up to 10 million dollars annually

Reference:

www.cdc.gov

http://www.hpoe.org

PREVENTION OF CLOSTRIDIUM DIFFICILE

Prevention of C. Diff

What can hospitals do to help prevent C. diff?

Doctors, Nurses, Healthcare personnel need to do:

Proper hand hygiene before and after caring for patient. This can help prevent C.diff germs from being passed from one patient to another on their hands.

Ensure that environmental services thoroughly clean rooms and medical equipment that have been used for patients with C. diff.

Only give antibiotics as necessary

Use contact isolation precautions, this will help prevent C. diff from spreading to other patients and healthcare workers

Contact Isolation:

• Patients with C. diff should have private rooms if possible
• Healthcare providers must wear gloves and a gown over their clothing while caring for patients with C. diff
• Visitors must wear gown and gloves
• When leaving the room healthcare workers and visitors must remove their gown and gloves and wash their hands appropriately
• Patients are to remain in their room as much as possible, they should not go to common areas, such as, the gift shop or cafeteria

What can patients do to help prevent C. diff?

Patients and family members can make sure that ALL healthcare personnel clean their hands with soap and water or antibacterial rub before and after caring for patients

Only take antibiotics as prescribed by your physician

Be sure to wash your hands after going to the bathroom and before meals

What do patients to do when they go home from the hospital (after dx of C.diff)

• Patients may return to normal routine
• The diarrhea will resolve over time
• Take prescribed medication as ordered
• Wash hands often
• If patient develops more diarrhea once they return home, please call MD immediately

Reference:

http://www.cdc.gov/

"C. DIFF"

CLOSTRIDIUM DIFFICILE INFECTION

What is Clostridium difficile infection?

Germ that causes diarrhea

C. diff spores can live outside the human body for a very long time and can be found on things, such as bed linens, bed rails, bathroom fixtures, and medical equipment

Can spread person-to-person on contaminated equipment and on the hands of MDs, nurses, healthcare personnel, and visitors

Most often occurs in patients taking antibiotics

Signs and Symptoms

• Watery diarrhea
• Fever
• Loss of appetite
• Nausea
• Abdominal pain
• Abdominal tenderness

Risk Factors

Anyone who has taken antibiotic, risk increases if you take broad spectrum antibiotics to treat a wide range of bacteria, use several antibiotics, or take antibiotics for extended period of time.

Any person over 65 of age, the risk of infection is 10 times greater for people 65 and older when compared to younger people

Anyone who is hospitalized or have been recently, especially for a long period of time

Anyone who lives in a nursing home or ECF

Anyone with a weakened immune system or serious medical condition

Anyone who has had abdominal surgery or gastrointestinal procedure

Anyone is has a colon disease such as colorectal cancer

Anyone who has had C. diff infection before

antibiotics-without-prescription.com

Treatment

Antibiotics

In severe cases a person may have to have surgery to remove the infected portion of the intestines

Reference:

www.cdc.gov

http://www.mayoclinic.com/

PREVENTION OF CATHETER-ASSOCIATED BLOODSTREAM INFECTIONS

Prevention

What can hospital do to help prevent catheter-associated bloodstream infections?

Doctors/Nurses will need to do the following:

Choose a vein where the catheter can be safely inserted and where the risk of infection is low

Proper hand hygiene before placing the catheter

Wear a mask, cap, sterile gown, and sterile gloves when putting in the catheter to keep it sterile. Also cover the patient with sterile sheet

365healthcare.com

Clean the patient’s skin with an antiseptic cleanser prior to catheter placement

Proper hand hygiene, gloves, and clean the catheter opening with an antiseptic solution before using the catheter to draw blood or give medications

Proper hand hygiene and sterile technique when changing the catheter dressing


Assess everyday if the patient still needs to have the catheter, remove as soon as possible

Patients who have catheter need to do the following:

Ask doctors and nurses to explain why they need the catheter and how long they should expect to have it

Ask healthcare personnel if they are using proper prevention techniques when handling the catheter

healblog.net

Make sure ALL healthcare personnel clean their hands before caring for you

If the bandage comes off notify your healthcare team immediately

Inform healthcare team if you notice pain or redness at catheter site

Make sure visitors also follow proper hand hygiene before visiting you

Some patients may be sent home with catheter from the hospitals if so you need to do the following:

Make sure you understand how to care for the catheter, always ask your healthcare team questions, for example, how will I bath when I get home?

Make sure you have contact information of your healthcare team in case you have questions or problems after discharge

ALWAYS watch for s/s of infection, soreness or redness at the catheter site, fever, chills, if you notice any of these signs  call your healthcare team IMMEDIATELY

Reference:

www.cdc.gov

CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS

CENTRAL LINES

Central line associated infections cause thousands of deaths each year, yet these infections are preventable.

What is a central line?

A central line (central venous catheter) is a tube that is placed in a large vein in the neck, chest, or groin. It is used to provide the patient with medication or fluids, or to collect blood for medical testing.  Central lines are different from peripheral IV sites as these catheters access a major vein that is close to the heart and can remain in place for extended periods of time, weeks or months.

qhr.knowledgebase.co

What is a central line associated bloodstream infection?

• Abbreviated CLABSI
• Serious infection
• Occurs when germs such as bacteria or viruses enter the bloodstream through the central line
• In some cases, germs are introduced into the blood stream when the central line is accessed days or weeks after being inserted

Modifiable Risk Factors

“Insertion circumstances (Emergency > Elective)

Skill of inserter (General > Specialized)

Insertion Site (Femoral > Subclavian)

Skin antisepsis (70% alcohol, 10% povidone, chlorhexidine)

Catheter lumens (Multilumen > Single lumen)

Duration of catheter use (Longer duration of use greater risk of infection)

Barrier precautions”   Source: http://www.healthcare.gov

Diagnosis

According to Dr. Jeffery Band from http://www.uptodate.com/ one must meet at least one of the following criteria:

“Patient has a recognized pathogen cultured from one or more blood cultures and the pathogen is not related to an infection at another site.

Patient has fever, chills, and/or hypotension as well as positive laboratory cultures from two or more blood samples drawn on separate occasions which are not related to infection at another site and do not reflect contamination.

Patient <1 year of age has at least one of the following signs or symptoms: fever, hypothermia, apnea, or bradycardia (in addition to above criteria).”

Drawing blood cultures

Should be obtained from two to four blood draws from separate sites (right hand left forearm)

Should be drawn simultaneously

References:

http://www.healthcare.gov/compare/partnership-for-patients/safety/clabsi.html

http://www.cdc.gov/hai/pdfs/toolkits/CLABSItoolkit_white020910_final.pdf

http://www.hsag.com/

PREVENTION OF VAP

PREVENTION

Airway Managment  Obviously, the best way to prevent VAP is to limit the amount of time your patient requires mechanical ventilation. Remove a patient's ET tube as soon as possible, and to do everything possible to avoid repeat endotracheal intubation.  Daily assessment of readiness to wean ventilator.

Gastric Reflux Prevention  Many ventilator patients have nasogastric tubes that predispose them to gastric reflux; this increases the risk of aspiration. The most important intervention to prevent gastric reflux is to keep  the head of bed elevated 30-35 degrees at all times.

Equipment maintenance The CDC no longer calls for routine changes of the ventilator system, instead recommends changing it only when the equipment is visibly soiled or malfunctioning.

Oral care Per facility guidelines. No set standard noted, further research being conducted. Some research states oral care should be provided with chlorhexidine.

Cross contamination Prevention of transmission of microorganisms from healthcare workers to patients, following simple stand precautions can help prevent cross contamination

"Implement ventilator bundle:
Elevation of the Head of the Bed
Daily "Sedation Vacations" and Assessment of Readiness to Extubate
Peptic Ulcer Disease Prophylaxis
Deep Venous Thrombosis Prophylaxis
Daily Oral Care with Chlorhexidine"
from:http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx

Reference:

www.cdc.gov.

http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx

HOSPITAL-ACQUIRED PNEUMONIA VS. VENTILATOR-ASSOCIATED PNEUMONIA

What is Pneumonia?

• Very common illness
• Range from mild to life threatening,
• Caused by many different germs

What is hospital-acquired pneumonia?

• An infection of the lungs that occurs during a hospital stay.
• Patients in the hospital are usually sicker making it more difficult to fight off the infection
• The germs present in hospital are often more dangerous
• Occurs more often in patients who are on a ventilator

What is a Ventilator-associated Pneumonia (VAP)?

Ventilator-associated pneumonia (VAP) is a lung infection that develops in a person who is on a ventilator. A ventilator is used to assist the patient to breathe by giving supplemental oxygen through a tube placed in patient’s mouth. VAP infection can occur if germs enter the tube and get into the patient’s lungs.


nursing101.wikispaces.com

Risk factors for hospital-acquired pneumonia

• Alcoholism
• Aspiration of salvia or food
• Chest surgery
• Immunosuppressed individuals
• Chronic lung disease (COPD/Asthma)
• Elderly

Symptoms

healthhype.com

• Productive cough
• Chills
• Fatigue
• Fever
• General malaise
• Headahce
• Joint pain
• Loss of appetite
• Nausea and vomiting
• Pain with inspiration
• Shortness of breath

Assessment

• Crackles or decreased breath sounds
• Decreased oxygenation
• Respiratory distress

Tests

chrc.in

• Arterial blood gases
• Blood cultures
• Chest x-ray
• CBC
• Sputum cultures (gram stain)

Treatment

• Aims to cure the infection, antibiotic is chosen based on the results of sputum cultures
• Oxygen
• Respiratory treatments to help loosen mucus in lungs

Reference:

www.cdc.gov.

http://www.ncbi.nlm.nih.gov.

GLYCEMIC CONTROL AND SSI's

“According to the American Diabetes Association it is estimated that 12-25% of hospitalized adult patients have diabetes mellitus. With the increasing prevalence of diabetic patients undergoing surgery, and the increased risk of complications associated with DM, appropriate perioperative assessment and management are imperative.” http://emedicine.medscape.com

"An estimated 25% of diabetic patients will require surgery. Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage caused by the disease.” http://emedicine.medscape.com)

Tight control of blood glucose has been proven to reduce the rate of surgical infections.

roche.com

Currently, there is not a defined optimal target range for blood glucose to prevent in surgical patients, it has been suggested that 80-150mg/dl, will reduce the rate of postop surgical infections. Of course, the ultimate goal in the management of a diabetic patient is to achieve results equal to those in patients without DM.

Some evidence suggests that at least a quarter of diabetic patients are unaware of their disease, it may prove beneficial to screen all patients undergoing surgery. (At the facility I work at we currently check every patient who walks through our doors for diabetes. Every patient is screened 3 times via POC, if they have 1 blood sugar greater than 200mg/dl during the screening nurses initate the hyperglycemia protocols, which entails drawing an HbA1C, sliding scale coverage for BS greater than 150 until endocrinologist rounds and accu checks are changed to AC/HS. If they have two blood sugars greater than 150mg/dl we initiate the same protocol.  During our screening of all patients we diagnosis so many “new” diabetics it is scary, the disease is running rampant and most people are unaware of their condition.

General Preoperative Management

On day of surgery most patients will be advised not to take their diabetes medications, this will help reduce the number hypoglycemia events.

Patients who are on insulin are advice to reduce their bedtime basal dose the night before the surgery to prevent hypoglycemia while patient is not eating by mouth. Maintenance insulin maybe continued during surgery based on the recommendations of the physician.

Metabolic response to Anesthesia and Surgery

Surgery places considerable amount of stress on one’s body causing an increase in blood sugars


Anesthetic agents can also affect glucose metabolism resulting in hyperglycemia and possibly ketoacidosis

According the American Diabetes Association patients undergoing cardiac surgeries should have a blood glucose target of less than 150mg/dl, this will reduce mortality and reduce the risk of sternal wound infections.

Methods of achieving blood sugar control

“Because of the numerous potential perioperative complications in diabetic patients, close monitoring is imperative to maintain glycemic control, while minimizing hypoglycemia.” http://emedicine.medscape.com

After surgery patients who were taking oral agents may be able to resume their medications. Healthcare personnel need to assess if the oral medication is appropriate because of potential complications or if IV insulin is the best choices, as it is easily titratable.  


For example, Glyburide can cause hypoglycemia, has prolonged action, and is difficult to titrate. Metformin has potential risk of lactic acidosis and must be used cautiously in renal and CHF patients. Actos needs to be used cautiously in CHF patients and is also difficult to titrate.


Another method for controlling perioperative blood glucose is through the use of IV insulin. Several insulin protocols are available, including computer-based systems that will calculate the dosing based on the blood glucose. At the facility I work at we use such a computer based program for controlling BS postoperatively.

Discussion Topic: How to prevent SSI?

References:

http://emedicine.medscape.com

American Diabetes Association

WHAT ARE HOSPITALS DOING TO PREVENT SSIs?

To Prevent SSIs, doctors, nurses, and other healthcare providers:

Clean hands and arms up to their elbows with an antiseptic agent just prior to surgery

Clean hands with soap and water or an alcohol based hand rub before and after caring for patient

Remove body hair immediately before surgery using electric clippers if the hair is in the same area where the procedure will occur (never shave or use a razor)

Cleansed surgical site with chlorhexidine or povidone iodine to help kill germs

Wear hair covers, masks, gowns, and gloves during surgery to keep surgery area clean

Give antibiotics before surgery starts, in most cases antibiotics should be given within 60 minutes before the surgery starts and the antibiotics should be stopped within 24 hours after the surgery. Antibiotics are given 60 minutes beofre th first cut so that the concentration is at its highest when the intial incision is made

aboutlawsuits.com

Control blood glucose in diabetics and avoid preop/postop hyperglycemia

Keep nails short and do not wear artificial nails

Maintain positive-pressure ventilation in the ORs

Keep OR doors closed when possible



Sterilize all instruments according to published guidelines

Change scrub suits that are visibly soiled

The surgical dressing should remain intact for a minum of 24-48 hrs postoperatively. This will help promote healing and prevent contamination and disruption of the moist healing enviromnet. When dressing must be changed use steril technique.

Discussion Topics: Perioperative glucose control with cardiac procedures (I work in a cardiac hospital and I find this topic extremely intersting. At work we take extreme measures to control glucose perioperatively.) Does anyone have any thoughts about this topic?

References:

The American College of Surgeons Journal

http://www.strategiesfornursemanagers.com/

www.cdc.gov.

SURGICAL SITE INFECTIONS (SSI)

What are surgical site infections?

“Despite considerable research on best practice in refining surgical techniques, technological advances and environmental improvements in the operating room, and the use of prophylactic antibiotics, infection at the surgical site remains the second most common adverse event occurring to hospitalized patients” http://en.haiwatch.com

“Currently there are more than 40 million inpatient and 31 million outpatient surgeries performed each year in the United States, with at least 2% of these patients, or approximately 1.4 million, developing a surgical site infection.” http://en.haiwatch.com

 What is a Surgical Site Infection (SSI)?

A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place.

Some of the common symptoms of a surgical site infection are:

• Redness and pain around the area where you had surgery
• Drainage of cloudy fluid from your surgical wound
• Fever

Criteria for defining a surgical site infection:

• An infection must occur within 30 days of the surgery in order to be classified as a surgical site infection
• If the surgery includes implantation of device, for instance a pacemaker, or prosthesis then the window of opportunity for infection extends to one year
• Evidence of pus, cellulitis, incision and drainage of surgical site 
•  Diagnosis of SSI by MD

Patient risk factors for surgical site infection

• Age
• Gender
• Nutritional status/malnutrition
• Smoking
• Proper use of antibiotics intraoperative
• Pre-existing diabetes and/or preoperative hyperglycemia
• Obesity
• Pre-existing infection
• Dirty wound
• Hypothermia

 Treatment of SSI

 Most surgical site infections can be treated with antibiotics. The antibiotic given depends on the bacteria (germs) causing the infection. Sometimes patients with SSIs may also need another surgery to treat the infection.

References:

http://www.cdc.gov.
http://en.haiwatch.com/