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Online Access Password: Webinar1 (case-sensitive)
Welcome to theNQF Safe Practices for Better Healthcare Webinar:
Updated 2010 CLABSI and SSI Practices: A New Standard of Care(Safe Practices 21-22)
Hosted by NQF and TMIT
2
Charles Denham, MDChairman, TMIT
Co-chairman, NQF Safe Practices Consensus CommitteeChairman, Leapfrog Safe Practices Program
Safe Practices WebinarFebruary 18, 2010
Welcome and Safe PracticeOverview
3
5
Panelists
Charles Denham: Welcome and Safe Practices Overview
Peter Angood: HAI Clinical and Financial Implications and Policy Future
Rabih Darouiche: New Highlights in CLABSI and SSI Prevention
Rabih DarouichePeter AngoodCharles Denham
6
Panelists
David Classen: Future Picture of Prevention of HAIs
Mary Oden Challenges for Infection Preventionists
Jennifer Dingman: The Role of the Patient Advocate
Jennifer DingmanMary OdenDavid Classen
7
The Role of the Patient Advocate
Jennifer Dingman Founder of Persons United Limiting Substandards and
Errors in Healthcare (PULSE), Colorado DivisionCo-founder, PULSE American Division
Safe Practices WebinarFebruary 18, 2010
8
Harmonization – The Quality Choir
2010 NQF Safe Practices for Better Healthcare: A Consensus Report
34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness
9
1010
Information Management and Continuity of Care
Medication Management
Healthcare-Associated Infections
Condition- & Site-Specific Practices
Consent & Disclosure
Culture
Workforce
Consent and Disclosure
CHAPTER 7: Hospital-Associated Infections• Hand Hygiene• Influenza Prevention• Central Venous Catheter-Related Blood Stream
Infection Prevention • Surgical-Site Infection Prevention• Care of the Ventilated Patient and VAP • MDRO Prevention• UTI Prevention
Information Management and Continuity of Care
Medication Management
Healthcare-Associated Infections
Condition-, Site-, and Risk-Specific Practices
Consent & Disclosure
Wrong-siteSx Prevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag. Therapy
VAP Prevention
Central V. Cath.BSI Prevention
Sx-Site Inf.Prevention
Contrast Media Use
Hand HygieneInfluenza
Prevention
Pharmacist Systems Leadership:High-Alert, Std. Labeling/Pkg., and Unit-Dose
Med. Recon.
Culture
CPOE
Read-Back & Abbrev.
Discharge System
PatientCare Info.
LabelingStudies
Culture Meas.,FB., and Interv.
Structuresand Systems
ID and Mitigation Risk and Hazards
Team Trainingand Team Interv.
Nursing Workforce
ICU CareDirect
Caregivers
Workforce CHAPTER 4: Workforce• Nursing Workforce• Direct Caregivers• ICU Care
CHAPTER 2: Creating and Sustaining a Culture of Patient Safety (Separated into Practices]
Leadership Structures and Systems Culture Measurement, Feedback, and Interventions Teamwork Training and Team Interventions Identification and Mitigation of Risks and Hazards
CHAPTER 5: Information Management and Continuity of Care
Patient Care Information Order Read-Back and Abbreviations Labeling Studies Discharge Systems Safe Adoption of Integrated Clinical Systems including
CPOE
CHAPTER 6: Medication Management Medication Reconciliation Pharmacist Leadership Role Including: High-Alert
Med. and Unit-Dose Standardized Medication Labeling and Packaging
CHAPTER 8:• Wrong-Site, Wrong-Procedure, Wrong-Person
Surgery Prevention • Pressure Ulcer Prevention• DVT/VTE Prevention• Anticoagulation Therapy• Contrast Media-Induced Renal Failure Prevention• Organ Donation• Glycemic Control• Falls Prevention• Pediatric Imaging
Informed Consent
Life-Sustaining Treatment
Disclosure
CHAPTER 3: Informed Consent and Disclosure• Informed Consent• Life-Sustaining Treatment• Disclosure• Care of the Caregiver
Consent and Disclosure
Care of Caregiver
MDROPrevention
UTIPrevention
FallsPrevention
OrganDonation
GlycemicControl
PediatricImaging
12
HAI GuidelinesHAI Guidelines
Before insertion:• Educate healthcare personnel involved in the insertion, care, and
maintenance of central venous catheters (CVCs).At insertion:• Use a catheter checklist at the time of CVC insertion.• Perform hand hygiene prior to catheter insertion or manipulation.• Avoid using the femoral vein for central venous access in adult
patients.• Use a catheter cart or kit with components for aseptic catheter
insertion. • Use maximal sterile barrier precautions.• Use chlorhexidine gluconate 2% and isopropyl alcohol solution as
skin antiseptic preparation in patients over two months of age and allow appropriate drying time per product guidelines.
After insertion:• Use a standardized protocol to disinfect catheter hubs, needleless
connectors, and injection ports before accessing the ports.• Remove nonessential catheters. • Use a standardized protocol for non-tunneled CVCs in adults and
adolescents for dressing care.• Perform surveillance for CLABSI and report the data on a regular
basis.
NQF CLABSI Prevention Safe Practice Specifications: 2010
Update
13
• Educate of healthcare professionals involved in surgical procedures.• Educate the patient and his or her family as appropriate about SSI
prevention. • Conduct periodic risk assessments for SSI.• Ensure that measurement strategies follow evidence-based guidelines.• Provide SSI rate data and prevention outcome measures to key
stakeholders.• Administer antimicrobial agents for prophylaxis.• When hair removal is necessary, use clippers or depilatories. • Maintain normothermia immediately following colorectal surgery. • Control blood glucose during the immediate postoperative period for
cardiac surgery patients. • Preoperatively, use chlorhexidine gluconate 2% and isopropyl alcohol
solution as skin antiseptic preparation, and allow appropriate drying time per product guidelines.
NQF SSI Prevention Safe Practice Specifications: 2010
Update
14
The Association for Professionals in The Association for Professionals in Infection Control & EpidemiologyInfection Control & Epidemiology
• Mission To improve health and patient safety by reducing the risks of
infection and related adverse outcomes.
• The preeminent voice in infection prevention Over 13,000 members worldwide with responsibility for infection prevention, control and hospital epidemiology in a variety of healthcare settings.
APIC Targeting Zero InitiativeAPIC Targeting Zero Initiative• Elimination Guides
Evidence-based strategies to implement CDC guidelines, NQF Safe Practices and recommendations from the SHEA-APIC-IDSA Compendium – Guides to the elimination of SSIs, CR-BSIs, Mediastinitis, C. difficile, VAP and MRSA
(hospital and long term care versions) help you bring science to the bedside– New guides in 2010 on A. baumannii, Hemodialysis and SSIs in orthopedics and oncology
• Research
2006 MRSA & 2007 C. difficile Prevalence Studies, 2010 MRSA II Study
• Education
The most comprehensive program of live and online education to reduce infection, meet new and emerging regulatory requirements and understand the changing legal standard in acute, ambulatory and long term care settings
Visit www.apic.org to learn more.
Visit www.apic.org/targetingzero to learn more about the initiative and to access resources and practical tools
17
HAI Clinical and Financial Implications and Policy
FuturePeter B. Angood, MD, FRCS(C), FACS, FCCMSenior Advisor, Patient Safety, National Quality Forum
Member of Safe Practices Steering CommitteeFormer Chief Patient Safety Officer and Vice President
for The Joint Commission
Safe Practices WebinarFebruary 18, 2010
18
1Stone PW, et al. AJIC 2005; 33:501-5
Background: Impact of HAIs• 5%-10% of hospitalized patients develop an
HAI99,000 deaths per year$20 billion per year1
• Risk of serious HAI complications is highest for patients requiring intensive care
• Increasing number of HAIsSicker patient populationMore complex procedures and equipmentIncreasing antimicrobial resistance
19
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
Estimated Number of Healthcare-Associated Infectionsin U.S. Hospitals by Subpopulation and Major Site
of Infection, United States, 2002
20
HRN = high-risk newborns; WBN = well-baby nurseries; ICU = intensive care unit; SSI = surgical-site infections; BSI = bloodstream infections; UTI = urinary infections; PNEU = pneumonia
SSI20%
BSI11%
UTI36%
PNEU11%
Other22%
133,368
424,060
263,810
129,519
274,098
-967
-21
-28,725
244,385
TOTAL
HRN
WBN
Non-newborn ICU
= SSI
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
Calculation of Estimates of Healthcare-Associated Infectionsin U.S. Hospitals Among Adults and Children Outside
of Intensive Care Units, 2002
21
What Are the Costs of Healthcare-Associated Infections?
• U.S.Total excess costs $32 million to $825
million annuallyMost costs not reimbursed when DRGs are
used or if costs are capitated
Preventing 6% of nosocomial infections offsets cost of $60,000 I.C. program
• UK = cost £111 million/year and 950,000 lost bed days (1987)
• Decrease NI rate by 20%, saves $15 million - $16 million
NQF Safe Practices – 2010:Healthcare-Associated Infections
19. Hand Hygiene20. Influenza Prevention21. CLABSI Prevention22. Surgical-Site Infection Prevention23. Care of the Ventilated Patient24. MDRO Prevention25. Catheter-Associated UTI Prevention
22
23
New Highlights in Central Line-
Associated Bloodstream Infection
and Surgical-Site Infection Prevention
Rabih O. Darouiche, MDVA Distinguished Service Professor
Director, Center of Prostheses Infectionat Baylor College of Medicine
Safe Practices WebinarFebruary 18, 2010
• Co-invented antimicrobial-coated catheters that are licensed by Baylor College of Medicine to Cook Inc
• Received educational and research grants from CareFusion
• Do not plan to discuss off-label and investigational use of devices or drugs
Disclosure Statement
24
• Address similarities and differences between CLABSI and SSI
• Assess the impact of these two infections
• Analyze potentially protective approaches
Overview of Presentation
25
Similarities Between CLABSI and SSI
• Both infections result primarily from breaking skin integrity
• Both infections are caused mostly by skin organisms
• Both infections occur at unacceptably high rates, can be difficult to manage, may require future intervention(s), and are expensive to treat
26
Differences Between CLABSI and SSI
• CLABSI manifests while the catheter is still in place, whereas SSI can manifest at any time after surgery, usually by 30 days post-op
• Microbiologic cause of CLABSI is almost always identified, whereas the microbiologic cause of SSI is unknown in many patients
• Occurrence of CLABSI can be attributed to various healthcare providers, whereas SSI is typically linked to the surgeon
27
Clinical Manifestations of infected CVC
• Exit site infection
• Tunnel infection• Thrombophlebiti
s• BSI
Impact of CLABSI
• Incidence: of the 6 million CVC inserted annually in the U.S., 250,000 result in BSI
• Management: cure often requires removal of the infected catheter and long antibiotic therapy
• Medical sequelae: attributable mortality 5%-25%
• Economic burden: cost of treatment is $10K-$56K; annual cost in U.S., $3 billion–$16.8 billion
29
Annual Death Rates in the U.S. for Selected Infectious Diseases
Nosocomial Infections in the ICU
PNEU27%
OTHER6%LRI
4%EENT
4%CVS4%
GI5%
BSI19%
UTI31%
National Nosocomial Infections Surveillance (NNIS) (97 hospitals)
87% central lines
86% Mechanical Ventilation95% Urinary Catheters
N= 14,177
< 55 = 33%55 – 70 = 32%>70 = 35%
31
30%
70%
44%
56%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Non-CRBSI CRBSI Non-CRBSI CRBSI
Solid Tumor Malignancy Hematologic Malignancy
% o
f B
acte
rem
ia w
ith
C
VC
as
the
sou
rce
Gram-Positive Bacteremia in Cancer Patients: Role of the CVC
32
Difference between Surveillance Definition
(by National Healthcare Safety Network: NHSN)
and Clinical/Microbiologic Definition of CLABSI
• Surveillance definition: includes all cases of BSI in patients with CVC in whom other sites of infection are excluded (catheter-associated BSI varies from from 1.3/1000 cath-days in medical surgical wards to 5.6/1000 cath-days in burn ICU)
• Clinical/microbiologic definition: includes only cases of BSI in patients with CVC in whom other sites of infection are excluded and microbiologic relationship of catheter to BSI exists (catheter-related BSI)
33
Relationship between Catheter Colonization and Bloodstream
Infection
• Principle: catheter colonization is a prelude to catheter-related bloodstream infection
• Objective: to prevent infection by inhibiting catheter colonization
34
IA Recommendations in Upcoming CDC Guidelines for Prevention of
CLABSI
• Staff education and training• Insert CVC in subclavian catheters• Place hemodialysis catheters in jugular or femoral veins• Promptly remove CVC when no longer essential• Hand wash with soap/water or alcohol-based hand rubs• Utilize 2% chlorhexidine-based preparation for skin
cleansing before inserting CVC, during dressing changes, and wiping access ports of needleless catheter systems
• Use sterile gauze or transparent semi-permeable dressings
• Use antimicrobial-impregnated CVC if expected duration of placement >5 days and CLABSI remains higher than goal set by institutions despite comprehensive strategyGuidelines for the Prevention of Intravascular Catheter-related Infections. Atlanta (GA): Centers for Disease Control and Prevention; 2010. [draft]
35
Before insertion:• Educate healthcare personnel involved in the insertion, care, and
maintenance of central venous catheters (CVCs).At insertion:• Use a catheter checklist at the time of CVC insertion.• Perform hand hygiene prior to catheter insertion or manipulation.• Avoid using the femoral vein for central venous access in adult
patients.• Use a catheter cart or kit with components for aseptic catheter
insertion. • Use maximal sterile barrier precautions.• Use chlorhexidine gluconate 2% and isopropyl alcohol solution as
skin antiseptic preparation in patients over two months of age and allow appropriate drying time per product guidelines.
After insertion:• Use a standardized protocol to disinfect catheter hubs, needleless
connectors, and injection ports before accessing the ports.• Remove nonessential catheters. • Use a standardized protocol for non-tunneled CVCs in adults and
adolescents for dressing care.• Perform surveillance for CLABSI and report the data on a regular
basis.
NQF CLABSI Prevention Safe Practice Specifications: 2010
Update
36
Comprehensive Protective Strategy
Infection Control Bundle
• Hand washing• Maximal barrier precautions• 2% chlorhexidine-based skin antisepsis• Avoiding femoral site if possible• Removing unnecessary catheters
37
Although very essential, they: • Are not easily enforceable• Are not very durable• Do not completely prevent
infection• Save some, but not
enough, lives
Potential Limitations of Traditional Infection Control
Measures
Reasons to Optimize Prevention of SSI
• Unacceptably high incidence: the 30 million annual surgical procedures in the U.S. result in 300,000-500,000 cases of SSI
• Difficult management: may require repeated surgical interventions
• Serious medical consequences: tremendous morbidity and occasional mortality
• Soaring economic burden: annual cost of treatment in the U.S. is >$7 billion
39
Perioperative Approaches for Preventing SSI
• Non-antimicrobial approaches
•Normothermia
•Adequate oxygenation
•Tight glucose control
• Antimicrobial approaches
•Systemic antibiotic prophylaxis
•Nasal application of mupirocin
•Skin antisepsis40
Impact of Timing of Systemic Antibiotic Prophylaxis on SSI
41
A Prospective Randomized Trial of Nasal Mupirocin Plus Chlorhexidine
Wash
Rapid identification of nasal carriage by S. aureus followed by a 5-day course of nasal mupirocin plus chlorhexidine wash:• Reduces S. aureus infection (3.4% vs. 7.7%)• Decreases S. aureus SSI by almost 60%
Bode, et al. N Engl J Med 2010;362:9-17
42
Importance of the Skin
• Largest bodily organ
• Protective barrier
• Skin flora most common cause of SSI (and CLABSI)
• 80% of bacteria reside in epidermis
Factors that Support the Need for Optimal Skin
Antisepsis
• Most pathogens that cause SSI are skin flora
• At least 2/3 of cases of SSI are incisional
• Most SSI are considered preventable
• Other preventive measures reduce but do not eliminate SSI
44
Commonly used Preoperative Antiseptics
• Povidone-iodine (Iodophor)• Chlorhexidine gluconate• Alcohol • Combination products: >2 active
agents
45
Comparison of Antimicrobial Activity of Antiseptic
Preparations
Chlorhexidine-based preparations are better than alcohol or iodine-based products in:
• Reducing colonization of vascular catheters
• Preventing contamination of blood cultures
• Decreasing contamination of surgical tissues
46
Pressing Need to Compare Clinical Efficacy of Antiseptic Preparations in
Preventing SSI
• CDC guidelines for prevention of infections related to vascular catheters recommend antiseptic cleansing of the skin with 2% chlorhexidine-containing products
O’Grady, et al. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 2002;51(RR-10):1-29
• CDC has not previously issued a preference as to type of preoperative skin antiseptics
47
Prospective, Randomized, 6-Center Clinical Trial of 849 Patients
• Population: adult patients scheduled for abdominal or non-abdominal clean-contaminated surgery
• Randomization: hospital-stratified• Intervention: preoperative skin cleansing with:
• ChloraPrep® (2% chlorhexidine gluconate-70% isopropyl alcohol = CA) 26-ml applicators; OR
• 10% povidone-iodine (PI) scrub and paint• Evaluation: SSI was assessed by blinded
evaluators Darouiche, et al. N Engl J Med 2010;362:18-2648
Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population).
Type of Infection
Chlorhexidine-Alcohol (N=409)no. (%)
Povidone- Iodine
(N=440)no. (%)
Relative Risk(95% CI) P-Value
Any surgical-site infection 39 (9.5) 71 (16.1) 0.59 (0.41-0.85)
0.004
Superficial incisional infection
17 (4.2) 38 (8.6) 0.48 (0.28-0.84)
0.008
Deep incisional infection 4 (1.0) 13 (3.0) 0.33 (0.11-1.01)
0.05
Organ-space infection 18 (4.4) 20 (4.6) 0.97 (0.52-1.80)
>0.99
Sepsis from surgical-site infection
11 (2.7) 19 (4.3) 0.62 (0.30-1.29)
0.26
49
Kaplan-Meier Curves for Freedom from Surgical-Site Infection (Intention-to-Treat Population)
Proportion of Patients with Surgical-Site Infection, According to Type of Surgery (Intention-to-Treat Population).
Chlorhexidine-Alcohol Povidone-Iodine
Type of Surgery Nno.
Infected
(%) Infected N
no. Infected
(%) Infected
Abdominal 297 37 (12.5) 308 63 (20.5)
Colorectal 186 28 (15.1) 191 42 (22.0)
Biliary 44 2 (4.6) 54 5 (9.3)
Small intestinal 41 4 (9.8) 34 10 (29.4)
Gastroesophageal26 3 (11.5) 29 6 (20.7)
Non-abdominal 112 2 (1.8) 132 8 (6.1)
Thoracic 44 2 (4.5) 57 4 (7.0)
Gynecologic 42 0 (0.0) 40 1 (2.5)
Urologic 26 0 (0.0) 35 3 (8.6)51
Chlorhexidine-Alcohol (CA) vs. Povidone-Iodine (PI) for Prevention
of SSI
• CA significantly reduces SSI• Number of patients needed to receive
CA instead of PI to prevent one case of SSI: 17
• Delays onset of SSI • CA and PI have similar rates of
adverse events (including events related to study medication in 0.7% in each group) and serious adverse events
52
New CMS Regulations (effective 10/08) Changes to Inpatient Prospective
Payment System
10 non-reimbursable conditions met these criteria:
• High cost• High volume• Triggers a high-paying MS-DRG• May be considered reasonably preventable
through application of evidence-based guidelines
Federal Register, Volume 73, No. 161; 08/19/08
53
Non-reimbursable Infectious Conditions
• Catheter-associated urinary tract infection
• Vascular catheter-associated infection• Surgical-site infection-mediastinitis
after CABG• Surgery on various joints, including
shoulder, elbow, and spine
54
Perspective
Optimal prevention of CLABSI and SSI can:
• Improve patient care• Incur cost-savings• Enhance infection control measures
55
56
Future Picture of Prevention of Healthcare-
Associated InfectionsDavid Classen, MD, MSChief Medical Officer at CSC
Associate Professor of Medicine at the University of UtahInfectious Diseases Consultant, University of Utah School
of Medicine
Safe Practices WebinarFebruary 18, 2010
57
Challenges for Infection Preventionists
Mary A. Oden, RN, BSN, MHS, CICSenior Director, Cleveland Clinic Health System
Infection Prevention Program
Safe Practices WebinarFebruary 18, 2010
58
The Role of the Patient Advocate
Jennifer Dingman Founder of Persons United Limiting Substandards and
Errors in Healthcare (PULSE), Colorado DivisionCo-founder, PULSE American Division
Safe Practices WebinarFebruary 18, 2010
59
60