Here at TMC

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Top Five Jan-Dec 2010

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OPD IN-PATIENT ICU OVERALL

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Healthcare Associated InfectionDefinition:

– A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s).

– There must be no evidence that the infection was present or incubating at the time of admission to the care setting.

– Clinical evidence may be derived from direct observation of the infection site or review of information in the patient chart or other clinical records.

CDC

The Bundles of CarePrevent Healthcare Associated Infection

It is a small straightforward set of practices – generally three to five –

that, when performed collectively, reliably and continuously,

have been proven to improve patient outcomes.

Ventilator Associated Pneumonia (VAP)

Patient was intubated and

ventilated at the time of or within 48 hours before the onset of the

event

NOTE: There is no minimum period of time that the ventilator must be in place in order for the PNEU to be considered ventilator-associated.

Annualize VAP vs Ventilator Utilization

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Device utilization Infection rates Linear (Infection rates)

Device utilization 0.25 0.23 0.21 0.24 0.33 0.37

Infection rates 19.59 11.58 8.01 6.98 12.11 5.01

2005 2006 2007 2008 2009 2010

The Bundles of Care in the Prevention of Ventilator Associated Pneumonia (VAP)

Details of Care Responsibility

• Hand hygiene before and after touching the patient RN MD

• Oral hygiene every after suctioning, turning to sides and feeding session RN

• Use suction catheter only ONCE or use Closed Suction System for 72hrs RN

• If there is no contraindication, elevate the head of bed at an angle of 30 – 450

RN MD

• Use of Endotracheal tube with subglottic suction MD

• Always check proper placement of feeding tube RN

• Assess patient’s intestinal motility RN

• Use daily sedation vacations and assess the patient’s readiness to extubate

MD

• Decrease pH of gastric content – give peptic ulcer disease prophylaxis MD

• Include deep vein thrombosis prophylaxis MD

• Remove devices such as ET, tracheostomy and/or enteral tubes from patients as soon as the clinical indications for these are resolved.

MD

Central Line Associated Bloodstream Infection (CLABSI)

CLABSI:

A central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event

NOTE: There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated.

Central line:

An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring.

Annualize CLABSI vs CL Utilization

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Device utilization Infection rates Linear (Infection rates)

Device utilization 0.1 0.12 0.09 0.1 0.21 0.22

Infection rates 9.76 10.7 2.1 1.81 2.97 2.93

2005 2006 2007 2008 2009 2010

Central Line Associated Bloodstream Infection (CLABSI)

Definition:• Presence of Central line

1. Patient has a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site.

2. Patient has at least 1 of the following signs or symptoms: fever (38.8C), chills, or hypotension

and signs and symptoms and positive laboratory results are not related to an infection

at another site and common skin contaminant (ie, diphtheroids [Corynebacterium spp], Bacillus [not B

anthracis] spp, Propionibacterium spp, coagulase-negative staphylococci [including S epidermidis], viridans group streptococci, Aerococcus spp, Micrococcus spp) is cultured from 2 or more blood cultures drawn on separate occasions.

Central Line Associated Bloodstream Infection (CLABSI)

Definition:• Presence of Central line

3. Patient #1 year of age has at least 1 of the following signs or symptoms: fever (38.8C, rectal), hypothermia (37.8C, rectal), apnea, or bradycardia

and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant (ie, diphtheroids [Corynebacterium spp], Bacillus [not B anthracis] spp, Propionibacterium spp, coagulasenegative staphylococci [including S epidermidis], viridans group streptococci, Aerococcus spp, Micrococcus spp) is cultured from 2 or more blood

Implantable Central Catheter

PICC

Infection Control Requirement for Central Line Insertion

1. Wash hands with soap and water; DRY with paper towel; Apply Sterillum from elbow up to hands for 1.5 minutes until dry.

2. Wear cap, mask, protective eyewear and sterile gown properly.

3. Wear sterile gloves.

4. Cleanse the insertion area with POVIDONE + ALCOHOL (Surgistat) from the insertion site in circular motion outward. Remove dripping and wait to dry. Do not wipe the painted area.

5. Place the sterile large drape exposing the operative site and fully covers the head down to toe.

7. Resident Assist should accomplish Central Line Insertion Checklist.

NIC on the floor shall attach this CLIP Form

to the Patient Chart if

Central Line insertion shall be

done in OR

ICU, ACSU, ER

insertion, the CLIP FORM is

attached to the package prepared by CPU. Make

sure that the form is

properly filled –up

by the RIC.

THE MEDICAL CITY

Ortigas Avenue, Pasig City, Philippines

HOSPITAL INFECTION CONTROL COMMITTEE

SURGICAL SITE INFECTION MONITORING FORM

This monitoring form shall be used only for patients who underwent any of the following procedures: Ceasarean Section, Coronary Artery Bypass Graft, Cholecystectomy, Ventriculostomy, Craniotomy, Ventricular Shunt and Central Line Insertion

This portion to be filled-out by the Infection Control Nurse

PATIENT NAME BIRTHDATE

SEX

CONTACT NO. MALE Mobile:

LAST NAME FIRST NAME MIDDLE NAME MM DD YY FEMALE Landline:

DATE OF OPERATION:

NAME OF PROCEDURE:

CO-MORBID CONDITION:

DATE OF DISCHARGE:

With On-going Wound Culture

Yes

No

Other comments: With Take Home Antibiotics Yes No If yes, please specify drug description, frequency and dose

ACCOMPLISHED BY: _______________________________________________________________________________

Signature Over Printed Name / Date / Time INFECTION CONTROL NURSE-IN-CHARGE

All shaded portion to be filled out by the Attending Physician/Resident-in-Charge. Tick all boxes that apply CONDITION OF SURGICAL WOUND ON DAY OF DISCHARGE

Purulent drainage or material

Pain or Tenderness

Redness

Heat Wound Spontaneously Dehisces Good Healing Seroma Fever

Other Comments: OBSERVED BY:

DISCHARGE REMINDER DISCUSSED BY: DISCHARGE REMINDER RECEIVED BY:

________________________________________ Signature Over Printed Name / Date / Time

ATTENDING PHYSICIAN/RESIDENT-IN-CHARGE

________________________________________ Signature Over Printed Name / Date / Time

NURSE-IN-CHARGE

________________________________________ Signature Over Printed Name / Date / Time

PATIENT/RELATIVE Nurse-In-Charge: Please cut the broken line and give the Discharge Reminder to the patient.

Hospital Infection Control Committee Copy OPR-SSI-ICC-002 Rev1Iss2 03-Jan-2011

DISCHARGE REMINDER Instructions on how to take care of surgical wound at home.

1. Always wash hands with soap and water before and after touching or changing the wound dressing. 70% Isopropyl or Ethyl Alcohol can also be used for cleaning hands.

2. Always prepare the materials needed before changing the wound dressing. 3. When changing the wound dressing, follow the physician’s instruction on how to change a wound dressing. Your

doctor will tell you how often to clean and change the wound dressing. 4. Throw away any used gauze pads. DO NOT REUSE. 5. Contact your physician in case pain or swelling on the operation site occurs.

Please inform/call The Medical City Hospital Infection Control Office on ____________________ regarding your wound healing status. You may contact these numbers: Landline Phone No. (02) 689-8244 or Mobile Phone No. 0916-4303065. You will be called upon by the Infection Control Nurse 30 days after your operation as part of our continuing service to you.

We always wanted to provide the best quality of service to all our patients and rest assured that any report given to us is considered CONFIDENTIAL.

Patient Copy

OPR-SSI-ICC-002 Rev1Iss2 03-Jan-2011

The ICN fill-up the form and attach to chart then inform NIC about the Discharge Instruction.

The RIC/AP shall fill-up the gray part on the day of discharge.

The NIC shall detach the lower portion of the form and give it to the patient on the day of discharge but retain the upper portion on the chart.

ICN will get the form to MID.

CHECKLIST FOR CARE AND MAINTENANCE OF CENTRAL & IV LINES

1. Mandatory HANDHYGIENE before and after Central Line (CL) access or manipulation.2. Access CL ports aseptically. Cleanse with 70% alcohol for at least 15 seconds, wait to

dry. Use ONLY sterile device.3. Wear sterile gloves and mask whenever accessing a CL or performing CL care.4. All CL in place but not currently being infused are to be flushed according to procedure

for CL and Implanted Ports i.e. Heparin/Normal Saline Flush.5. The IV tubing, add-on extension sets and stop cocks in use must be changed maximum

of 7 days when used for medications and IV fluids only.6. Change needleless access ports for locked CL every 72 to 96 hours.7. Patients with parenteral nutrition should have dedicated access port and tubing

changed every 24 hours.8. Change of CL dressing:

– every 7 days for transparent dressing if there is no visible soiling – every 48 hours for gauze dressing (Note: gauze under a transparent dressing is a

gauze dressing).– when the integrity of dressing is compromised or when the dressing is non-

occlusive.– when catheter is replaced.

9. Document IV tubing and CL changes in the KARDEX. (Nurse responsibility)

The Bundles of Care in the Prevention of Catheter Associated Urinary Tract Infection (CAUTI)

Details of Care Responsibility Hand hygiene before and after handling the system RN MD

Insert catheter only when necessary MD

Insert catheter using aseptic technique and sterile equipment

MD

Secure catheter with a tape at inner thigh for female and left or right hypogastric area for male

RN

Maintain closed sterile drainage RN

Maintain unobstructed urine flow RN

Aspirate urine samples aseptically from the catheter without opening the system

RN

Always keep the catheter bag lower than the level of the bladder but should not touch the floor.

RN

Identifying a Surgical Site Infection

1Incisional Site Infections

• Superficial• Deep

Organs/Space Infections

Mangram, AJ, et.al. 1999. Guideline for Prevention of SSI. Infection Control and Hospital Epidemiology. 20(4)

Surgical Site InfectionA superficial incisional SSI must meet one of the following criteria: Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision and patient has at least one of the following: a. purulent drainage from the superficial incision. b. organisms isolated from an aseptically obtained culture of fluid or

tissue from the superficial incision. c. at least one of the following signs or symptoms of infection: pain or

tenderness, localized swelling, redness, or heat, and superficial incision is deliberately opened by surgeon, and is culture-positive or not cultured. A culture-negative finding does not meet this criterion.

d. diagnosis of superficial incisional SSI by the surgeon or attending physician.

A deep incisional SSI must meet on of the following criteria: Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision and patient has at least one of the following: a. purulent drainage from the deep incision but not from the organ/space

component of the surgical site b. a deep incision spontaneously dehisces or is deliberately opened by a

surgeon and is culture-positive or not cultured when the patient has at least one of the following signs or symptoms: fever (>38°C), or localized pain or tenderness. A culture-negative finding does not meet this criterion.

c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination

An organ/space SSI must meet one of the following criteria: Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and patient has at least one of the following: a. purulent drainage from a drain that is placed through a stab wound into

the organ/space b. organisms isolated from an aseptically obtained culture of fluid or tissue

in the organ/space c. an abscess or other evidence of infection involving the organ/space that

is found on direct examination, during reoperation, or by histopathologic or radiologic examination

d. diagnosis of an organ/space SSI by a surgeon or attending physician.

THE MEDICAL CITY

Ortigas Avenue, Pasig City, Philippines

HOSPITAL INFECTION CONTROL COMMITTEE

SURGICAL SITE INFECTION MONITORING FORM

This monitoring form shall be used only for patients who underwent any of the following procedures: Ceasarean Section, Coronary Artery Bypass Graft, Cholecystectomy, Ventriculostomy, Craniotomy, Ventricular Shunt and Central Line Insertion

This portion to be filled-out by the Infection Control Nurse

PATIENT NAME BIRTHDATE

SEX

CONTACT NO. MALE Mobile:

LAST NAME FIRST NAME MIDDLE NAME MM DD YY FEMALE Landline:

DATE OF OPERATION:

NAME OF PROCEDURE:

CO-MORBID CONDITION:

DATE OF DISCHARGE:

With On-going Wound Culture

Yes

No

Other comments: With Take Home Antibiotics Yes No If yes, please specify drug description, frequency and dose

ACCOMPLISHED BY: _______________________________________________________________________________

Signature Over Printed Name / Date / Time INFECTION CONTROL NURSE-IN-CHARGE

All shaded portion to be filled out by the Attending Physician/Resident-in-Charge. Tick all boxes that apply CONDITION OF SURGICAL WOUND ON DAY OF DISCHARGE

Purulent drainage or material

Pain or Tenderness

Redness

Heat Wound Spontaneously Dehisces Good Healing Seroma Fever

Other Comments: OBSERVED BY:

DISCHARGE REMINDER DISCUSSED BY: DISCHARGE REMINDER RECEIVED BY:

________________________________________ Signature Over Printed Name / Date / Time

ATTENDING PHYSICIAN/RESIDENT-IN-CHARGE

________________________________________ Signature Over Printed Name / Date / Time

NURSE-IN-CHARGE

________________________________________ Signature Over Printed Name / Date / Time

PATIENT/RELATIVE Nurse-In-Charge: Please cut the broken line and give the Discharge Reminder to the patient.

Hospital Infection Control Committee Copy OPR-SSI-ICC-002 Rev1Iss2 03-Jan-2011

DISCHARGE REMINDER Instructions on how to take care of surgical wound at home.

1. Always wash hands with soap and water before and after touching or changing the wound dressing. 70% Isopropyl or Ethyl Alcohol can also be used for cleaning hands.

2. Always prepare the materials needed before changing the wound dressing. 3. When changing the wound dressing, follow the physician’s instruction on how to change a wound dressing. Your

doctor will tell you how often to clean and change the wound dressing. 4. Throw away any used gauze pads. DO NOT REUSE. 5. Contact your physician in case pain or swelling on the operation site occurs.

Please inform/call The Medical City Hospital Infection Control Office on ____________________ regarding your wound healing status. You may contact these numbers: Landline Phone No. (02) 689-8244 or Mobile Phone No. 0916-4303065. You will be called upon by the Infection Control Nurse 30 days after your operation as part of our continuing service to you.

We always wanted to provide the best quality of service to all our patients and rest assured that any report given to us is considered CONFIDENTIAL.

Patient Copy

OPR-SSI-ICC-002 Rev1Iss2 03-Jan-2011

The ICN fill-up the form and attach to chart then inform NIC about the Discharge Instruction.

The RIC/AP shall fill-up the gray part on the day of discharge.

The NIC shall detach the lower portion of the form and give it to the patient on the day of discharge but retain the upper portion on the chart.

ICN will get the form to MID.

The Bundles of Care in the Prevention of Surgical Site Infection (SSI)

Details of Care Responsibility• Oral Care including cleaning of tongue RN• 4% Chlorhexidine bath: first on the night of

surgery and second on the morning before surgery and must wear hospital gown

RN

• Use of CLIPPER in removing hairs RN

• Administration of ANTIBIOTIC Prophylaxis 60 minutes prior to skin incision or immediately after induction of anaesthesia

MD

• Maintain normal body TEMPERATURE RN

• Maintain normal level of blood SUGAR MD

Basic Wound Dressing• Change dressing of surgical wound after 48 hours after the procedure if no

soiling is observed.• Prepare materials for use including yellow waste bin.• Wash hands with soap and water then dry OR use Alcohol-based handrub.• Wear surgical mask and clean gloves. If splashes is anticipated, wear long

sleeve green gown properly.• Remove dressing, note for the appearance of the incision site like discharge,

etc. If the dressing sticks, wet with sterile water or NSS to loosen. Throw the old dressing into the waste bin together with the gloves used.

• Wash hands again with soap and water then dry OR use Alcohol-based handrub.

• Put on sterile gloves.• Clean the surrounding of the incision site with gauze wet with NSS: dab or

wipe gently to remove dried blood or material.• Observe the wound if needing new dressing or not.NOTE: Change gloves when moving to other body sites.• Waste generated should be disposed properly at the point of care.• Document the procedure.