Data a Information a Action: Preventing Nosocomial Infections Technical Aspects

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Data a Information a ActionPreventing
Nosocomial InfectionsTechnical Aspects

• David D. Wirtschafter, MD
• Chair, Perinatal Quality Improvement Panel, CPQCC
• Dept of Pediatrics/Neonatology
• Kaiser-Permanente Medical Center, Los Angeles
• david.wirtschafter_at_kp.org
• Janet Pettit, R.N., M.S.N., N.N.P.
• Doctors Hospital
• Modesto, CA
• Member, Perinatal Quality Improvement Panel,
  CPQCC
• jspettit_at_sbcglobal.net

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The Message

• The BIG Picture
• Where are we?
• Where can we go?
• Reading the road signs (aka Diagnosis)
• Finding our position on the map (aka Trending)
• Tour Guide
• Hand Hygiene
• Lines and hubs
• Getting organized

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GRADING THE EVIDENCEMuir Gray 1997

• RCTs from multiple centers (Meta-Analysis)
• (Class I)
• RCTs from a single center
• (Class II)
• Pre-/Post or case-control studies from
  single/multiple centers
• (Class III)
• Evidence from well-designed non-experimental
  studies, preferably from more than one center
• (Class IV)
• Opinions of respected authorities, expert
  committees
• (Class V)

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Reducing Nosocomial Infection in the NICUCPQCC
Toolkit 2003and 2006 Revision(Class V)

• Writing Committee for 2003 Edition (on behalf of
  the PQIP)
• Courtney Nisbet, RN, MSN
• Janet Pettit, RN, MSN, NNP
• Richard Powers, MD
• Shukla Sen, RN, MSN
• David Wirtschafter, MD
• TOOLKIT AVAILABLE AT CPQCC.ORG
• 2006 Revision California Childrens Hospital
  NICU NI Prevention Study Group
• Search for Potentially Relevant Publications
  (PRPub) (JP, DW)
• Members to contribute other potentially relevant
  publications and experiences
• Members assess revision(s) to 2003 CPQCC
  Toolkits Best Practice statements and seek
  consensus on Revised Best Practices statements
• Members to present proposals to PQIP later

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The NI Challenge How Much Is Preventable?
Unchanging NI Rates, Highly Variable Rates and
Clearly Distinguishable Good Performers
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NIDefining Goals-Indicate Your Preference

• Best 10th percentile
• Best Quartile
• Best Half
• Not beyond the second standard deviation
• Other

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EXPLANATIONS FOR SUPERIOR PERFORMANCE

• CHANCE
• FAVORABLE CASE-MIX
• FAVORABLE ENVIRONMENT
• UNDER-REPORTING OF ADVERSE EVENTS
• HIGH QUALITY CARE
• William Edwards, MD/ VON/NIC/Q Phase I Report

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NIC/Q PROJECT-Phase IINFECTION OUTCOME (Class
III) HORBAR JD, et al. Pediatrics, 2001
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NIC/Q 2000 Program Effect In 6 NICUs CONS Rates
Before and After Inter-ventions Described (Class
III) Kilbride Pediatrics 2003
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CPQCC Member (Class III)
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But Clearly Rates Can Change!VON-CPQCC
CENTERS-CA 1(Class III)
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NI Rates before and after implementation of hand
hygiene (light blue column indicates quarter) and
vascular access device (initial-chartreuse,
repeated-striped quarters) cqi processes in
VON-CPQCC CA2 NICU
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Closed Medication System Associated with reduced
BSI rate. (Class III) Aly Pediatrics 2005
Data points estimated from their original Figure
2. CH Wash DC
PRPubPotentially Relevant Publication
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Prospective Evaluation of a Multi-Factorial
Prevention Strategy (Class III)Andersen J Hosp
Infect 2005

• Changes in hand washing solutions, Melbourne NICU
• Standardized deep line insertion packs
• Change to 2 acqueous CHG and 1 CHG in alcohol
  for skin antisepsis
• Mandatory removal of PIVs _at_ gt 48 hrs feeds gt
  120 ml/hr/d
• RESULTS
• N 174 newborns N 1359 devices
• Pre 21 BSI
• Post 9 BSI
• Problems with 2 CHG

PRPub
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Proactive Management of PICC results in
decreased NI in ELBWs (Class III)Golombek J
Perinatology 2002

• PICC Maintenance Team, Westchester NY NICU
• MD/NNP team that managed catheters daily (both
  placement and removal)
• Maximal barrier protection Tegaderm dressings
• Team inspected dressings daily
• Proactive removals if
• For catheters (if feasible) q 6 wks
• Unexplained CBC abnormality even if BC neg
• gt 3 repairs for leakage or breakage
• CRIs i from 15.8 to 5.1 CRI/1000 line days

PRPub
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Sustained Reductions in Neonatal NI Rates
Following A Comprehensive Intervention Program
(Class III)

• Physician and nursing education, UAB NICU
• Common improvement goals
• Hand hygiene and environment care
• Specialty nursing team for PICC placement, limits
  on umbilical catheter duration, increasing BM
  feeds, hastening feeding advancement
• Baseline infection rate 8.5/1,000 hospital days
• Post-intervention 1st year- i 26 (p0.002)
• 2nd -3rd year-i 29 (p0.001)
• Much of decrease associated with CONS, but other
  bacteria/fungi also fell significantly
• Schelonka. J Perinatology 2006

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Meta-Analysis Review of Risk Factors and Control
Factors for Catheter-Related BSI caused by PI
CVC (Class I) Safdar Medicine 2002

• Inexperienced, marginally skilled operator
• Site of insertion internal jugular femoral v
• Placement in old site over guide wire
• Limited use of sterile barriers
• Heavy colonization of insertion site
• Contamination of catheter hub
• Catheter placement gt 7 days

PRPub
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Meta-Analysis Review of Risk Factors and Control
Factors for Catheter-Related BSI caused by PI
CVC (Class I) Safdar Medicine 2002

• Maximal sterile barriers at the time of CVC
  insertion
• Use of CHG rather than povidone-iodine for
  cutaneous site disinfection
• Use of topical anti-infective ointments on the
  insertion site
• Impact of transparent polyurethane film dressings
• The use of multi-lumen rather than single-lumen
  CVCs
• The efficacy of anti-septic or silver impregnated
  cuffs/coatings

PRPub
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Applying the Science to the Prevention of CRI
(Class I)OGrady J Crit Care 2003

• Educating and training of operators who insert
  and maintain catheters
• Using full barrier precautions during CVC
  insertion
• 2 CHG for skin antisepsis
• Eliminating scheduled replacement of CVCs
• Using antiseptic/antibiotic impregnated
  short-term CVCs

PRPub
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Data to Effect Change A Tale of Two Views

• Science Facts-The Science of Nosocomial
  Infection Prevention
• Data What to measure and how
• Information What messages are there in these
  data
• Action What works to effectively change rates
• Arti-Facts-The Organizational Art of Bringing
  About Change
• Data What to measure and how
• Information What do these measure tell
• Action How can you effectively change yourself

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Baseball Right or Left-Handed Pitching?Managing
Change Technical or Social Aspects
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Managing Change Address Both The Technical and
Social Aspects
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So How To Proceed? The Managers Game Plan

• Use data to define your units challenges
• Use quality improvement cycles
• Proceed through the sequence of
• Data a Information a Action

Plan
Act
Do
Study
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Data a Information a Action PLAN Technical
Aspects

• Nosocomial Infection Facts In Your Unit
• What to measure
• How to measure
• How to display
• Facts About Nosocomial Infection Prevention
• Travelers Tales
• Evidence-based recommendations

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Technical Aspects re Selected NI Prevention
Practices-1

• Diagnosis (central line blood stream infection)
• Peripheral blood cultures and/or line cultures?
• Volume of blood cultured?
• Hand Hygiene Observations
• Pre-intervention typically 50 - 70 compliance
• Line Management Observations
• Line set-up practices no metric available
• Utilization of closed systems anecdotal only
• Hub care practices 57 -100

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Diagnosis-1

• Vermont-Oxford Network NI Definition
• All but CONS bacteria/fungus recovered from
  blood or CSF after DOL 3
• CONS recovered from blood or CSF after DOL 3,
  signs of generalized infection and antibiotic
  treatment for gt 5d
• Note this definition does not exclude the
  presence of other infectious foci.

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Diagnosis -2 National Nosocomial Infection
Surveillance (NNIS) Definition of Primary
Bacteremia (Garner Am J Infect Control 1988)

• No other infectious focus
• All but common skin contaminants at least one
  positive blood culture or
• Common skin contaminants
• signs of generalized infection AND
• one Bld Cult OR
• at least two Bld Cults OR
• IV line present and antibiotic treatment
  instituted
• Clinical Sepsis- Rx instituted, no other site
  and negative (or absent) blood culture.

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Diagnosis-3

• NICHD Neonatal Research Network
• Stoll J Pediatr 1996
• One positive blood culture drawn after 72 hrs of
  age plus presence of signs of infection
• UCSD Proposed Definition for CoNS Sepsis
• Craft J Perinatology 2001
• True CoNS infection. Simultaneously BC (gt1
  ml) from central line and peripheral site.
• If colony counts are available, gt 50 cfu/ml

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Diagnosis 4 Evaluation of 1 vs 2 Blood Cultures
to Diagnose Neonatal Sepsis (Class III)Sarkar
J Perinatology 2006

• Peripheral blood cultures (gt 1 ml) from 2
  different sites cleaned with povodine-iodine
• 186 culture pairs for EOS 83 for LOS
• 22 episodes of culture sepsis (20 infants)
• Only 1 Early Onset Sepsis (Listeriosis)
• All episodes had concordant positive BCs
• Differs from Jawaheer Arch Dis Child 1997 who
  showed that 0.5 ml sufficient to detect CONS.
• Smaller volume may be insufficient to detect
  other species
• One peripheral BC of gt 1 ml can detect sepsis

PRPub
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Additional Methods for Determining and Defining
CRI (Class IV)Bouza Clin Mirobiol Infect 2002

• Quantitative cultures peripheral vs catheter
  drawn
• Timing of culture positivity peripheral vs
  catheter drawn
• Cytocentrifugation and acridine orange staining
  of blood drawn from catheter
• Moreover, the use of antimicrobial-coated
  catheters may alter the definition of CRI

PRPub
31
Prevention of Contaminated Blood Cultures

• Skin Antisepsis Kits containing either alcoholic
  CHG or tincture of Iodine (Class II)
• Contamination rate differences (1/215 vs 3/215)
  N.S.
• Trautner Infect Control Hosp Epidemiol 2002
• Comparison of four antiseptic preparations for
  skin in the prevention of contamination of
  percutaneously drawn blood cultures-RCT (Class
  II)
• 2.6 (333/12,692 blood cultures) were
  contaminated. No significant differences
  between a) povidone-iodine b) tincture of
  iodine c) isopropyl alcohol and d) Persist
  (i.e. povidone-iodine with ethyl alcohol).
• isopropyl alcohol may be the optimal
  antiseptic for use prior to obtaining blood for
  culture, given its convenience, low cost and
  tolerability.
• Calfee J Clin Microbiol 2002

PRPub
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DATA Pre-meeting exerciseNI diagnostic process
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Understanding and TrendingYour NI Data Plan,
Do, Study, Act

• Case ascertainment
• Denominator ascertainment
• Interval between cases
• Cases per line days
• Stratified by birth weight
• Statistical process control charting
• Stratified by type of organism
• Risk-adjusted rates
• CPQCC, VON, other

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STUDY Interval (in days) Since Last CRI-The NICU
Equivalent to Accident Free Days at the
Worksite!
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STUDY SPC (Statistical Process Control) Charting
IllustratedCLBSI in the NICU
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STUDY Look At The DataFour Different Hospital
NI Profiles
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ACT Obtain and Augment Your Nosocomial Infection
Knowledge Base

• Facts About Nosocomial Infection Prevention
• Travelers Tales
• Evidence-based recommendations

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Vermont Oxford Network (VON)Neonatal Intensive
Care Collaborative
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Vermont Oxford Network-NIC/Q 2000
Habit for Change
Habit for Practice as Process
Habit for Evidence Based Practice
KNOWLEDGE BANK

• NETWORK DATABASE
• BETTER PRACTICES
• CLINICAL
• ADMINISTRATIVE

Habit for Collaborative Learning
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CHANGE IDEAS
Internal and External Process Analysis
Published Evidence
BENCHMARKING with Superior Performers
Round Robin Site Visits
Your Own Thinking and Experience
Plan
Act
Do
Study
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BETTER PRACTICE AREASNOSOCOMIAL INFECTION1998
Report NICQ Phase I (Class V) Horbar Pediatrics
2001

• HANDWASHING
• NUTRITION
• SKIN CARE
• DIAGNOSIS
• RESPIRATORY CARE
• VASCULAR ACCESS
• UNIT CULTURE

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Fight Bacterial Infections
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Key Milestones and Lessons LearnedNIC/Q
2000-Phase II (Class V) Kilbride Pediatrics 2003

• Prevention with an Attitude
• Nosocomial Infection is not an entitlement
• Fewer and more experienced providers draw fewer
  cultures
• Important Categories of Practice
• Skin of the patient
• Skin of the health care worker
• Lines and Hubs
• Accuracy of diagnosis
• Contamination of IV solutions
• PBP Prioritization
• 22 Overall PBPs
• 8 PBPs chosen as most relevant
• Final Synthesis 3 Group Consensus Statements

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Eight Prioritized Potential Best Practices
(Class V) Kilbride Pediatrics 2003

• Increase compliance with hand hygiene standards
• Improve accuracy of NI diagnosis
• Reduce line and hub contamination
• Maximize barrier protection when inserting
  central lines
• Decrease the number of skin punctures
• Decrease duration of IV lipid infusions
• Decrease duration of central venous line use

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Reducing Nosocomial Infection in the NICUCPQCC
Toolkit 2003and 2006 Revision(Class V)

• Writing Committee for 2003 Edition (on behalf of
  the PQIP)
• Courtney Nisbet, RN, MSN
• Janet Pettit, RN, MSN, NNP
• Richard Powers, MD
• Shukla Sen, RN, MSN
• David Wirtschafter, MD
• TOOLKIT AVAILABLE AT CPQCC.ORG
• 2006 Revision California Childrens Hospital
  NICU NI Prevention Study Group
• Search for Potentially Relevant Publications
  (PRPub) (JP, DW)
• Members to contribute other potentially relevant
  publications and experiences
• Members assess revision(s) to 2003 CPQCC
  Toolkits Best Practice statements and seek
  consensus on Revised Best Practices statements
• Members to present proposals to PQIP later

46
Handwashing a Hand HygieneScience and background

• Transient Microflora
• recently acquired pathogenic organisms
• Can be removed with friction and ordinary
  detergent
• Resident Microflora
• Prolonged presence
• Resistant organisms
• Colonization of fissures and deeper squamous
  layers
• Can only be removed with antiseptic agents

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Controlled Trials of Handwashing

• Failure of bland soap to eradicate resistant gram
  negative organisms
• Ehrenkrantz et al, Inf Control Hosp Epidemiol
  199112654-62
• Antiseptic soaps shown to be superior to bland
  soap in hand antisepsis
• Boyce et al Inf Control Hosp Epidemiol
  200021438-41
• Doebbeling et al, NEJM 199232788-93
• Kjolen et al, J Hosp Infect 19922161-71

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Effectiveness of Hand Antiseptic Agents

• Triclosan and Chlorhexidine gluconate provide an
  advantage by virtue of their immediate spectrum
  and residual effect
• Ayliffe et al, J Hosp Infect 198811226-43
• Larson et al, Infect Control 19878371-5

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Emergence of Alcohol as a Superior Hand
Antisepsis Agent

• Alcohol is an effective antiseptic agent
• At least as effective or more effective than
  antiseptic soap
• Girou et al, BMJ 2002325362
• Morrison et al, Infect Control 19867268-72
• Handwashing compliance improves with waterless
  alcohol gel products
• Bischoff et al, Arch Intern Med 2000 1601017-21
• Pittet et al, Lancet 20003561307-12

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Impact of Alcohol Gel on Drug-Resistant Bacteria
(Class III)

• Gordin Infect Control Hosp Epidemiol 2005
• 3 yr i MRSA and VRE no r Clostridia
• Boyce Infect Control Hosp Epidemiol 2006
• 3 yr h Gel Use to 85 no r Clostridia

PRPub
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Hand Hygiene Realities
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Hand Hygiene Misses
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DATA Pre-Meeting ExerciseHand Hygiene
Observations
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The HUB of the Problem
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The Deep Lines Hub

• Association of organisms colonizing the hub with
  bloodstream infection
• Bloodstream infection in lt 7 days catheter site
• Bloodstream infection gt 7 days hub colonization
• Maki et al, Infect Control Hosp Epidemiol
  199415227
• Sitges-serra and Girvent, World J Surg
  199923589-95
• Mahieu et al. J Hosp Infect 2001 48108
• Bakr. J Trop Pediatr 2003 49295
• Culture of same organism from bloodstream as well
  as catheter hub and skin around catheter entry
  site
• Salzman et al, J Infect Dis 1993167487-90
• Sitges-serra, Nutrition 19971330S-35S
• Mahieu et al. J Hosp Infect 2001 48108
• Mahieu et al. J Hosp Infect 2001 48 20

PRPub
56
Disinfect Connections When Opened

• Swab connection sites with antiseptic solution
  when connections are opened
• Salzman et al, J Clin Microbiol 199331475-9
• Sitges-serra et al, Nutrtion 19971330S-35S
• Needleless Systems
• Reduce risk of needle stick injuries
• Do not require break in system to access
• Can be adequately disinfected with isopropyl
  alcohol swabbing
• Arduino, et al, Am J Infect Control. 1997 Oct
  25(5)377-80.
• Brown, et al, . J Hosp Infect. 1997 Jul
  36(3)181-9.

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Hub Contamination
Areas where hub was placed on agar dish
After two days growth
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Prevention of Microbial Contamination of CV
Catheter Luers Needleless vs Standard Caps
(Class II)Casey J Hosp Infect 2003

• Needleless vs Standard caps
• Isopropyl alcohol vs 0.5 CHG/IPA vs
  IPA/povidone-Iodine
• To disinfect IV connections
• To disinfect skin prior to insertion
• Luer contamination rates at 72hr
• 6.6 NDL vs 18 STD (plt0.0001)
• Contaminated NDL 69 IPA vs 31 CHG vs 42 P-I
  (plt0.0001)
• Needleless-external compression seals
• 7.3 were internally contaminated
• Bottom Line Posi-Flow NDL connectors
  disinfected with 0.5CHG/70IPA had only a 1
  contamination rate.

PRPub
60
Increased CRBSI with Change in Type of Access
Port (Class III) Maragakis Infect Control Hosp
Epidemiol 2006

• Childrens Center (PICU, NICU, ped onc)
• Baseline CRBSI 1.55/1000 line days-while using
  a Clave Needleless
• New Line CRBSI 2.79/1000 line days after change
  (p0.01) to a positive pressure mechanical valve
  SmartSite plus Needlefree Valve
• Return CRBSI 1.43/1000 catheter days after
  reverting back to original injection port
  (12/04-3/05) p0.06
• NICU experience CRBSI h from 0.51/1000 line
  days to 1.34/1000 catheter days. p0.17
• Low baseline rates of CRBSI in all ICUs made
  detection of statistical significance difficult
  unless rates were pooled.
• h polymicrobial BSIs from 6.5 to 14 after
  change
• h gram negative bacilli from 17.7 to 28.1
• Others reported similar problems, resolved by
  returning to split-septum (MV) technology.

PRPub
61
Prospective Trials of Open vs Closed Systems
(Class II)Bouza J Hosp Infect 2003

• A needleless closed sytsem device (CLAVE)
  protects from intravascular catheter tip and hub
  colonization.
• Post-CV surgical ward.
• N352 pts 1774 catheters inserted
• N178 Clave N 174 COS (Conventional open
  system)
• Cath Tip Colonization/1000 line days 59 vs 84
  (p0.003)
• Hub colonization/1000 line days 7.6 vs 24.7
  (p0.002)
• CRBSI 3.78 vs 5.89 (p0.4) insufficient power

PRPub
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DATA Pre-Meeting Exerciseline set-up/blood draw
Kilbride Pediatrics 2003
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Prevention of CRI Using a New Disinfectable,Needle
less Connector RCT(Class II) Vebenes Am J
Infect Control 2004

• RCT of 243 pts 278 CVCs 420 bed Univ H
• Control usual 3-way stopcock
• CRBSI 5.0/1000 line days
• Study SmartSite Disinfectable, Needleless
  Connector swabbed with 70 IPA.
• Valve mechanism with the access closed by a
  silicone endoluminal embolus that becomes
  permeable when compressed
• CRBSI 0.7/1000 line days

PRPub
64
Umbilical Catheter Tubing Set-Up
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Peripheral Arterial Line Tubing Set-Up
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Umbilical Venous Line
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PICC Setup
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Prevention of Microbial Contamination of PICCs
Vancomycin-Heparin Locks (Class II) Garland
Pediatrics 2005

• PICC locked 20-30 min q 2 or 3 x/day
• NS vs Vancomycin 25 microgram/ml
• N 42 vs N 43
• RESULTS
• CRBSI 5 vs 30
• BSI/1000 line days 2.3 vs 17.8 (RR 0.13, CI
  o.o1-0.57)
• Vanco undetectable in infants blood
• Complications
• Hypoglycemia at end of lock period
• NS- 18 vs Vanco -6

PRPub
69
Treatment of Microbial Contamination of PICCs

• Haimi-Cohen et al. Vancomycin and ceftazidime
  bioactivites persist for at least 2 weeks in the
  lumen in ports-simplifying treatment of
  port-associated bloodstream infections by using
  the antibiotic lock technique. Antimicrob Agents
  Cemother 2001
• Droste et al. Stability and in vitro efficacy of
  antibiotic-heparin lock solutions potentially
  useful for treatment of CV CRI. J Antimicrob
  Chemother 2003
• Dannenberg et al. Ethanol-lock technique in the
  treatment of bloodstream infections in pediatric
  oncology patients with broviac catheter. J
  Pediatr Hematol Oncol 2003

PRPub
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Implementation of Guideline for Lines and Hub Care

• Prepping Protocol
• Silicone/latex needless ports
• perform hand hygiene
• establish a sterile surface
• use alcohol friction time for surface to dry.
• prep all surfaces to be connected, unless new
• Compliance continued efforts at adequate initial
  training and use of tools to assess compliance

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Scrub the Hub Before Each Entry
DMC
72
Scrub Before Disconnecting
73
Supplies Readily Available
74
Clean vs Sterile Surfaces
75
DATA Pre-Meeting ExerciseAccessing Lines
76
Intravenous Lines-Deep vs Peripheral?

• PICCs vs PIVs in lt 1 kg infants
• Liossis J Maternal-Fetal Neo Med 2003 (Class
  III)
• CRI 3/1138 PICC vs 12/1114 PIV line days
  (p.03)
• PICCs Chowhary Pediatr Surg Int 2001 (Class III)
• Fewer CRI when inserted in the OR
• ? Better sedationgtbetter control of field avoids
  contamination
• Long-term vs Short-Term Use of Umbilical Venous
  Lines. Butler Pediatrics 2006 (Class II)
• UVC up to 28 d vs UVC 7-10 d followed by PICCs
• CRI long-7.4 vs short-11.5 CRI/1000 line days
  (ns)
• Limited power, but suggestive that CDC guideline
  to limit UVCs to 14 days may need re-evaluation.
• CDC based on Durand Pediatrics 1986, Chathas Am J
  Dis Child 1990, Cairns Eur J Pediatr 1995

PRPub
77
CV Catheters-Single vs Multiple Lumen?

• Multiple vs Single Umbilical Venous Catheters
• Kabra Cochrane Database Syst Rev 2005 (Class I)
• quality of studiesis poor
• PIV use i in first week, but no difference in 1st
  month.
• Catheter malfunction h in ML-UVC
• CRIs in Multiple vs Single Lumen CVCs
• Dezfulian Crit Care Med 2003 (Class I)
• CRIs h (OR 2.15) in all studies, but, when only
  higher quality studies analzed, the difference
  disappears catheter colonization was not h

PRPub
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PICC vs PIVs for VLBW IV Rx(Class II) Janes J
Ped Surg 2000

• RCT of 63 infants, Ontario NICU, at 1 wk of age
  between PIV or PICC until no further IV Rx needed
• No difference in sepsis incidence, antibiotic
  courses or duration of IV use.
• Significant differences in
• Insertion attempts PICC 8.8 vs PIV 16.1
  (p0.008)
• Catheters utilized PICC 4.8 vs PIV 8.0
  (p0.002)
• Conclusion PICC is less painful. F/U required.

PRPub
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Maximum Sterile Barrier Precautions
80
CV Catheter Insertion

• Maximal Barrier Precautions
• Use of sterile cap, mask, gown, gloves and drape
• Shown to be more effective than sterile gloves
  and small drape alone
• Mermel et al, Am J Med 1991197S-205S
• Raad et al, Inf Control Hosp Epidemiol
  199415231-8

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CV Catheter Insertion

• Prepping the skin
• Chlorhexidine (CHG) vs Alcohol vs Povidone-Iodine
• CHG shown to be more effective due to residual
  effect.
• Garland Pediatr Infect Dis J 1995 (Class III)
• Chaiyakunapruk Ann Intern Med 2002 (Class I)
• But, in newborns, 2 CHG associated with
  complications.
• Andersen J Hosp Infect 2005 (Class III)
• Garland Pediatr Infect Dis J 1996 (Class III)
• CHG recommended by the CDC Guideline

PRPub
82
Skin Antisepsis
83
CV Catheter Insertion

• Maximal Barrier Precautions
• Site of Insertion OR safer than ICU
• Hirschmann J Hosp Infect 2001 (Class II)
• Chowdhary Pediatr Surg Int 2001 (Class III)
• Bacterial (CONS) contamination common (1/5) at
  time of insertion
• Hall Pediatric Surg Int 2005 (Class II)
• Disinfection of hands before gloving is
  significantly more efficacious than washing
• Hirschmann J Hosp Infect 2001 (Class II)

PRPub
84
Catheter Site Care Dressings

• Transparent allows direct visualization and
  requires fewer changes, but no other demonstrated
  clinical advantage.
• Gillies Cochrane Database Systematic Reviews
  2003 (Class I)
• Gauze absorbant for oozing blood
• Biopatch Chlorhexidine impregnated sponge
• Reduces infection rate in adults
• Neonatal study Garland Pediatrics 2001 (Class
  II)
• No better than Povidone-Iodine dressing
• 15 rate of CHG hypersensitivity
• See also Andersen J Hosp Infect 2005 (Class
  III)
• Infant and children CV Surgery study Levy
  Pediatr Infect Dis J 2005 (Class II)
• Biopatch vs transparent polyurethane site
  dressing
• Biopatch iCVC colonization, no effect on CRI

.
PRPub
85
Maintain Clean, Intact Dressing
86
Contamination of IV Solutions (Class II) Van
Grafhorst Critical Care Med 2002

• Simulated model of IV solution preparation by
  nurses in ICUs versus pharmaceutical technicians
  in a satellite pharmacy
• 6 large hospitals, Netherlands
• Syringes prepared from 10 ml ampules and
  rubber-compound-capped 50 ml vials
• Bacteria (mainly GPC) in 22 of syringes mixed
  from vials under ward conditions vs 1 under
  satellite conditions
• Bacteria (mainly GPC) in 2 of syringes mixed
  from ampules under ward conditions vs 0 under
  satellite conditions

PRPub
87
Reduce the Duration of Intravenous Lipid Use

• Rationale lipids have been shown to be
  immunosuppressive, easily contaminated and
  support growth of fungi and bacteria
• IV lipid use correlates with CONS bacteremia in
  the NICU
• Freeman NEJM 1990 (Class III)
• Avila-Figueroa Pediatr Infect Dis J. 1998 (Class
  III)
• Must balance the benefits of enhanced caloric
  intake with infectious risks
• introduction of early feeds is an important
  adjunct
• Kilbride Pediatrics 2003a (Class V)

88
Prefilled Flush Syringes
89
When to remove a deep line-1 Benjamin Pediatrics
2001

• Neonates with central catheters in whom
  bacteremia develops
• The outcome for patients in whom the central
  catheter was not removed within 24 hours of
  organism identification was significantly worse
  (46 vs 8 complication risk) than it was for
  those whose catheters were removed promptly.
• Recommends immediate removal for Staph aureus,
  gram negative rods and probably enterococcus

90
When to remove a central line-2 Karlowicz
Pediatr Infect Dis J 2002

• Neonates with CONS bacteremia
• Early removal lt 3 days vs late removal gt 3 days
• Rare complications in either group
• 43 incidence of CONS sepsis of gt 3 days in the
  late removal group vs 13 in the early removal
  group
• None of the infants with CONS lasting greater
  than 4 days was treated successfully with the
  line in place.
• Candida
• Early removal within 3 days of culture
• Duration of treatment 1-14 days (m 3)
• Deaths 0
• Late removal gt 3 days of culture
• Duration of treatment 1-24 days (m 6)
• Deaths

91
When to remove a central line-3

• Neonates with Enterobacteriaceae bacteremia
  Nazemi Pediatrics 2003(Class III)
• Attending choice as to removal time
• Early removal (lt 2 d) n15
• 9 CV lines replaced, with 2 that then became
  infected
• Late removal (gt 2 d) n38
• 45 treated successfully w/o removal
• 85 had only 1 day of bacteremia
• 24 had gt1 day of bacteremia
• Suggests 1-2 day attempt to save line

92
Conclusions

• Most important practices in reducing NI
• Hand hygiene
• Line management and hub care
• Evidence clinical trials or collaborative
  benchmarking must be individualized for each
  center if change is to be successfully
  implemented
• In reducing nosocomial infection,
  multidisciplinary behavioral changes are
  especially critical

93
Data a Information a Action ACTION-Technical
Aspects

• Integrating the technical and social aspects of
  change
• Building the team
• Prioritizing the work
• Doing the work
• Communicating the work
• Communicating the work
• Communicating the work
• Evaluating and providing feedback about the work

94
Plan Look At How Your Practices Affect Your NI
RatesKilbride Pediatrics 2003

• Diagnosis Sites of culture, method for cleaning
  site, amount of blood drawn
• Hand hygiene observations Agent(s) used,
  consistency of use, specific opportunities
  identified, artificial nails,
• Line Management minimization of ports, closed
  systems (piv, deep venous lines, umbilical
  lines) access methods (including hub care)

Sample observation forms available at cpqcc.org
95
Plan Look At How Related Medical Practice
Choices Influence NI Rates

• Feeding practices they affect your line days!!!
• When are feeds initiated and how fast are they
  advanced?
• Feeding success affects when lines are pulled (i
  risk)
• What you feed affects infection risks
• BM (at least banked milk for sure) lowers NEC
  rate (Lucas Lancet 1990, Hylanau Pediatrics 1998)
• BM affects enteric colonization (Go J Ped Surg
  1994, Ford J Ped Surg 1996)
• How you process and deliver feeds affects
  colonization
• bacterial risks on bacterial contamination of
  enteral feeding tubes in neonates (MehallJ Ped
  surg 2002)
• viral risks CMV (Red Book 2000 Vochem Peds ID
  Journal 1998 and Hamprecht. Lancet 2002)

96
Plan Look At How Related Medical Practice
Choices Influence NI Rates

• Line days (the number of times at-bat for hub
  access errors)
• compare to NNIS data (device days/1000 patient
  days)
• B WT/tile 10th 25th 50th 75th 90th
• lt1000 g 0.19 0.28 0.40 0.55 0.64
• 1001-1500g 0.09 0.15 0.25 0.41 0.55
• NNIS Report. American Journal Infection Control
  2002 29458
• Line anatomy How lines are set-up
• Kilbride Pediatrics 2003
• What goes through the lines, e.g. prolonged IL
  use
• Shiro J Inf Dis 1995 Freeman N Engl J Med 1990

97
Do Getting Started

• Team building
• Priority setting
• Establish your monitoring methodologies from the
  outset
• Getting your NI facts

98
Plan Before Do Setting Priorities

• For each opportunity for improvement, list its
• feasibility
• scale (one to many individuals involved)
• magnitude (little to great time, resources, etc)
• dependencies (other services, products)
• likelihood that planned change can be achieved
• utility
• previously demonstrated impact
• likelihood to influence NI rates in your unit
• summative variable priority
• you now have the information to develop actions!

99
Typical Action Agendas

• Hospital A
• hand hygiene
• diagnosis
• Hospital B
• hand hygiene
• line management
• Hospital C
• advancing feeds
• decreasing IL exposure
• decreasing line exposure

• Hospital D
• central line insertion methods
• decrease the number of skin punctures
• Hospital E
• reduce postnatal steroid use

100
FBI - HUB CARE IMPLEMENTATION

• Task Force formed and literature reviewed
• Hub Care/ Line Care guidelines developed
• One-on-one in-services/Line Care Skills
  Lab/Incentive program/Product in-services/Storyboa
  rd
• HUB CARE LOGO
• VASCULAR ACCESS/ HUB CARE AUDIT TOOLS

101
FBI - HUB CARE - BUY-IN

• Raising staff awareness by staff meetings, visual
  cues, on-going feedback, in-services, and
  literature review
• Staff involvement, recognition and incentives
• Self-audits of change in practice
• A positive attitude that change was possible

102
FBI - HUB CARE

• BARRIERS
• Resistance to change
• Scarce person-power
• Transitioning nursing leadership
• Inadequate product in-service and supply
• Lack of communication
• IMPLEMENTATION ADVICE
• Staff involvement in literature review/
  In-services (one-on-one)
• Visual cues/ Memos/ Updated information/ Positive
  feedback
• Adequate staffing and supplies
• Annual competency requirement/ Include in
  orientation program
• Supportive leadership