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Infection control
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- 2. INFECTION CONTROL Healthcare associated infection greatest risk a patient faces on admission to a hospital
- 3. A QUICK SURVEY Howmany of you Have encountered Nosocomial Infections? Have disclosed to families that it is a NI? Analyzed root cause of NI? Optimized your efforts to prevent it?
- 4. LET’S FACE REALITY Who pays for morbidity and additional costs related to NI? What happens if third party payment is denied for NI? Medicare in USA Do we have benchmarks?
- 5. BIG FOUR… Urinarytract infection Surgical site infection Pneumonia Blood stream infection
- 6. Prevention betterthan cure 20% can be prevented Infection control is the foundation
- 7. WHERE TO LOOKFOR? Tubes- ETT, RT, Foley, TT Lines- peripheral, central and arterial Personnel-doctors,nurses, care givers
- 8. HOW DO WEGO ABOUT… Standard precaution Transmission barrier Education Surveillance
- 9. ALCOHOL BASED HANDRUB-GOLD STANDARD 1. Terminates out breaks 2. Decreases transmission of MRSA 3. Gloves is not the answer 4. Allergic contact dermatitis 5. Generates more time
- 10. Routine Hand Hygiene Ref;ISCCM 2003 guidelines The scrub should be performed for a minimum of 2-3 minutes
- 11. Procedural Hand HygiEne Ref;ISCCM 2003 guidelines The scrub should be performed for a minimum of 2-3 minutes Hand drying - use sterile (autoclaved) towels
- 12. LINES Peripheral Central Arterial
- 13. INSERTION OF PERIPHERALIV CATHETERS Ref; ISCCM 2003 Guidelines once prepared, the site of insertion should not be palpated
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- 15. CENTRAL LINE Insertion Maintenance Replacement
- 16. INSERTION Empowerment Insertioncart or kit Maximal sterile barrier Site
- 17. CENTRAL LINE INSERTION BUNDLE Hand Hygiene Maximal Sterile Barrier Precautions Chlorhexidine Skin Asepsis Optimal Catheter Site Selection
- 18. MAINTENANCE Dressing Anyrole for systemic antibiotics Topical antibiotic Anticoagulant flush/ heparin lock
- 19. CENTRAL LINE MAINTENANCE BUNDLE Daily review of Central Line necessity and prompt removal of unnecessary lines Dedicated lumen for TPN Accessing the lumens aseptically Checking entry site during every dressing change
- 20. HAND HYGIENE strictly followed(even when gloves are worn) before and after injection, blood sampling, dressing or any contact with the CVC or insertion site Ref; ISCCM 2003 Guidelines
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- 22. Gauze dressing Transparent dressing MAINTENANCE OFCENTRAL LINES - DRESSING CHANGE
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- 24. CENTRAL LINE BUNDLE COMPLIANCE InterventionCompliance Hand Hygiene 62% Chlorhexidine antiseptic at procedure site 100% Draped entire patient in a sterile fashion 85% Used cap, mask & sterile gown 92% Used Sterile gloves 100% Sterile dressing applied 100%
- 25. REPLACEMENT Routine linechange not needed Purulence If not needed- plastic is out Over the guidewire exchange- No, No Emergency line< 48 hrs
- 26. CARE OF PRESSUREMONITORING SYSTEM Closed continuous flush system No dextrose containing solution Minimal manipulation No antibiotic lock technique
- 27. REPLACEMENT…. Disposable transducersystem- 96 hours Reusable transducer system- 48 hours
- 28. Chlorhexidine versus Povidone- IodineSolution Ref; Chlorhexidine Compared with Povidone-Iodine Solution for Vascular Catheter–Site Care: A Meta-Analysis Nathorn Chaiyakunapruk, PharmD, PhD; David L. Veenstra, PharmD, PhD; Benjamin A. Lipsky, MD; and Sanjay Saint, MD, MPH Ann Intern Med. 2002;136:792-801. Chlorhexidine is superior blood, serum, and other protein-rich biomaterials can deactivate the microbicidal effect of povidone-iodine but not chlorhexidine the residual effect defined as the long-term antimicrobial suppressive activity is prolonged (at least 6 hours) reduces the colony counts of coagulase-negative staphylococci
- 29. URINARY CATHETER CAUTI– What does it mean? 40% of all nosocomial infections Types of catheter 1. Short term 2. Long term indwelling
- 30. CAUTI Infection!! Why? Common mechanism 1. Extraluminal 2. Intraluminal
- 31. PREVENTION Closed drainagesystem Restricted catheter use Aseptic technique Unobstructed urine flow Catheter size
- 32. WHAT CAN WEDO? Catheter management Taping and anchorage Cleaning Disinfectant!!! Collection bag Discontinuation Transport
- 33. Suprapubic catheter Bladder irrigation Antimicrobial coated catheter Condom catheter
- 34. WHEN DO YOUREPLACE? Suspected UTI Decreases bacterial load Antibiotic penetrate biofilm poorly
- 35. URINARY CATHETER Urine samplecollection Urine can be aspirated from the catheter itself or through a port designed specifically for that purpose, but should not be taken from the collection bag. Remove an indwelling catheter and sample urine using a new catheter, when possible Ref: Thomas Fekete UpToDate 2008
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- 37. Orogastric tubes also preferred overnasogastric Nasal tubes obstruct maxillary antral drainage The orotracheal route is preferred for intubation Nasal route only as an exception
- 38. SECURING THE ETTUBE Method 1: Using standard sticking plaster (eg. Johnsonplast® ) Apply short strip to long 1” strip “ sticky” side up tails Tail secures tube Tail fixes to lip
- 39. Method 2: Usingtwill tape tie “Cow hitch” “Clove Hitch” Method 3: Commercially manufactured holders are now available SECURING THE ET TUBE
- 40. CONFIRMING TUBE POSITION Besidesauscultation, always confirm ET tube position on a chest radiograph Remember! Neck position affects ET tube tip movement. ET tip about 4cms above carina; level of aortic knob Always note the distance of the tube at the incisor teeth
- 41. VENTILATOR ASSOCIATED PNEUMONIA 48-72 hours of ventilation Progressive new infiltrates in CXR Leukocytosis and purulent tracheobronchial secretions
- 42. HOW DO YOUPREVENT Patient positioning 30-45 º Semi-recumbent position
- 43. SUPRAGLOTTIC CARE Continuous aspirationof supraglottic collection will reduce VAP rates (needs special tube) Accumulation of supraglottic secretions; may be aspirated with pressures not > 20 cm H2O. Specialised tube with a channel opening above the balloon
- 44. ORAL CARE Regular mouthcare to clear oral secretions & administer antiseptics (chlorhexidine) Preferably 8 hourly Remove oral airway Move ET tube to opposite corner Clear mouth of all secretions Paint mouth with 2% chlorhexidine Reduces rates of VAP
- 45. No evidenceto prefer CSS over OSS Cuff pressure Heated Vs unheated circuit Artificial nose Vs humidification Stress ulcer prophylaxis
- 46. Contact isolation Forpatients with multi-drug resistant bacteria Consists of standard precautions plus unsterile gloves whenever patient is touched, then handwashing or hand rub immediately Plastic gowns if extensive patient contact likely Dedicated equipment eg stethoscope, BP apparatus Sign at head of bed Single room or cohort nursing One on one nursing essential CONTACT ISOLATION
- 47. Standard precautionsplus contact precautions plus: Private room or sharing of room with anyone with a similar illness; if not feasible, patients should be minimum of 3 feet apart Surgical masks for anyone who goes within 3 feet of patient Patient masked when transported outside room For respiratory viruses DROPLET ISOLATION
- 48. For PTb,Varicella, Rubella Spreads beyond 3ft Separate room with ante- room & negetive pressure No re-circulation of air 6–12 exchanges per hour One per 100 beds Proper mask – N95 AIRBORNE ISOLATION
- 49. FUTURE IS LOOKING…. Dramatic proliferation of MDR organisms No new antibiotic in the horizon Mushrooming of ICUs in smaller towns Lack of strict adherence to protocols MAY DAY! MAY DAY!
- 50. ZERO RESISTANCE –SPANISH ARMADA Zero VAP and zero bacteremia Dedicated intensivist Exclusive infection control nurse Active surveillance Standardised cleaning protocol Built in educational modules
- 51. TAKE HOME MESSAGE Alcohol based hand rub is an eye opener Routine line change not needed Prophylactic antibiotic- definite NO Closed drainage system is a must 30-40º semi-recumbent position
- 52. Breaking myths, beliefs and barriers Advocating zero tolerance Rationale outlook towards local needs YES WE CAN
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