Infection Prevention
JC Readiness
August 2011
Department of Quality and Safety
Mount Auburn Hospital
Environment of Care: Areas of
Focus
SEPARATION OF CLEAN AND DIRTY
• Only clean/sterile items stored in clean utility space
• Clean items stored outside of designated clean utility or
clean storage space must be clearly labeled as clean
• Only dirty items stored in dirty utility room
• PPE (gloves, fluid resistant gowns, and faceshields)
should be routinely available in dirty utility areas
• No clean supplies stored under sinks
Environment of Care: Areas of
Focus
PATIENT EQUIPMENT
Every non-disposable patient equipment must have a
routine cleaning/disinfection schedule
• Non-critical items (contact only with intact skin of
patients - e.g. BP cuffs, pulse oximetry, etc.) Define
frequency/schedule i.e. between every patient, daily,
weekly AND whenever soiling occurs
Precaution Patients – equipment is designated to that patient
only or must be cleaned/disinfected after each use.
Environment of Care: Areas of
Focus
PATIENT EQUIPMENT
• Semi-critical (contact with mucous membranes of
patients e.g. thermometers, laryngoscopes, vaginal
probes, TEEs, flexible endoscopes)
1.
2.
3.
4.
Pre-cleaning process (using enzymatic detergent)
Timed immersion in liquid chemical (Cidex OPA/Meticide)
Triple rinse
Dried and stored in clean draw/cabinet (not open to air)
Intense scrutiny on quality control documentation (logs on test
strips and solution) and personnel training/competency.
Environment of Care: Areas of
Focus
PATIENT EQUIPMENT
• Critical Items (contact with normally sterile body cavities
e.g. biopsy forceps, bronchoscopes)
1. Decontamination and sterilization must be controlled/centralized
(i.e. SPD)
2. If sterilization performed outside SPD (e.g. OR – Immediate
Use Steam Sterilization) process must meet same standards as
SPD
Intense scrutiny on quality control documentation (e.g. cycle
contents and parameters, biological indicators) and personnel
training/competency.
NPSGs: Focus on Processes
of Care
NPSG.07.01 Hand Hygiene - Elements of
Performance
1. Implement CDC or WHO hand hygiene guidelines
MAH policy revised in 2011 to incorporate CDC specific
indications for hand hygiene (not just In and Out)
2. Set Goals for Performance
3. Improve Performance
6
CDC Indications
•Decontaminate hands before having direct contact with patients
•Decontaminate hands before donning sterile gloves
•Decontaminate hands before inserting invasive devices (non surgical procedure)
•Decontaminate hands after contact with a patient's intact skin
(e.g., when taking a pulse or blood pressure, and lifting a patient)
•Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings
•Decontaminate hands if moving from a contaminated-body site to a cleanbody site during patient care
•Decontaminate hands after contact with objects (including medical equipment) in the
immediate vicinity of the patient
•Decontaminate hands after removing gloves
•Before eating and after using a restroom wash hands with soap and water
WHO
5 Moments for Hand Hygiene – Critical times
when hand hygiene should be performed
“Five Moments”
Performance Goals
Overall Hand Hygiene Performance (Apr 10 -Jul 11)
100%
90%
80%
Target > 90%
70%
60%
50%
40%
30%
20%
10%
0%
9
Medical Safety Steering Committee June Meeting – 20
minutes of observations per month from all areas
Hand Hygiene Performance by Location
July 2011 (N = 278)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2
30
8
16 16
9
10 12 13 80 30
1
12 13
7
13
6
NPSGs: Focus on Processes
of Care
NPSG.07.03.01 Implement Best Practices to
prevent MDRO (MRSA, CDI, VRE, ESBL) Elements of Performance
1. Measure and monitor MDRO prevention processes and
outcomes
2. Educate patients, and their families as needed, who are
infected or colonized with MDRO about prevention
11
Measure and Monitor MDRO
Prevention
PROCESS
OUTCOME
Measure and Monitor MDRO
Prevention
PROCESS
OUTCOME
NPSGs: Focus on Processes
of Care
NPSG.07.04.01 Implement Best Practices to prevent central line
associated bloodstream infection (CLABSI) - Elements of
Performance
1. Educate patients and, as needed, their families about CLABSI Prevention
2. Perform hand hygiene prior to catheter insertion OR MANIPULATION
3. Do not insert catheters into femoral vein unless other sites are unavailable
4. Use supply/procedure cart that contains all necessary components for
insertion
14
NPSGs: Focus on Processes
of Care
NPSG.07.04.01 Implement Best Practices to prevent central line
associated bloodstream infection (CLABSI) - Elements of
Performance
6. Full barrier precautions (includes full body patient drape)
7. Standardized protocol to disinfect catheter hubs and injection ports
8. Standardized protocol to disinfect catheter hubs and injection ports
9. Daily evaluate all central venous catheters and remove
nonessential catheters
15
Process Measure: CL checklist
• Implemented in ED and OR
early 2011
100%
Bundle (Insertion) Performance Per Element
N=74 (Mar – July)
99%
90%
• Value stems from
empowered
assistant/observer to
monitor and attest to
standards of asepsis
80%
70%
61%
61%
62%
62%
60%
50%
40%
30%
20%
• Monitoring of checklist
usage ongoing
10%
0%
Checklist
Hand
Used
Hygiene
Maximal CHG Use
Site
Barriers
Selection
Outcome Measure (rate)
Central Line Associated Bacteremia Rates
Total Hospital FY2010 -2011 (to date)
CBI rates per 1000 central line days
2.00
1.80
1.60
Rate is Zero for July 2011!
1.40
(Rate is up compared to last year)
1.20
1.00
0.80
0.75
0.60
0.40
0.41
0.20
0.00
FY 10
FY 11
Newest NPSG: Full
implementation 2012
NPSG.07.06.01 Implement Best Practices to prevent indwelling
catheter-associated urinary tract infections (CAUTI) - Elements
of Performance
1. Insert according to evidence based guidelines addressing aseptic
technique, equipment, and supplies
2. Appropriate management including:
–
–
–
–
–
Securing catheters for unobstructed flow
Maintain sterility of collection systems
Aseptic collection of urine samples/replacing collection system when required
Maintain drainage bag below level of bladder
Daily assessment of medical necessity and prompt removal of unnecessary
catheters
3. Monitor compliance with best practices – i.e. auditing
18
Outcome Measure (rate)
Catheter Associated UTI
caUTI Rates by Unit
5.00
4.00
FY 10
4.14
UNIT
3.00
2.24
2.00
1.00
0.00
FY 10
FY 11
Jul-11
Foley
Foley
Cases Days Rate Cases Days
National
Rate
(50%ile)
FY 11
Rate
Foley
Cases Days Rate
MICU
4
1489
2.69
0
155
0.00
4
1659 2.41
N3
3
829
3.62
0
67
0.00
2
990
2.02
N7
3
461
6.51
0
82
0.00
1
392
2.55
N8
3
1213
2.47
0
152
0.00
2
1190 1.68
PCU
3
1338
2.24
1
166
6.02
6
1601 3.75
S3
15
2743
5.47
0
330
0.00
6
2965 2.02
S4
4
583
6.86
0
100
0.00
3
619
4.85
S5
0
0
0.00
0
0
0.00
0
0
0.00
SICU
7
1282
5.46
0
205
0.00
1
1687 0.59
ST3
3
864
3.47
0
100
0.00
2
902
2.22
WYM2
0
73
0.00
0
23
0.00
0
56
0.00
TOTAL
45
10875 4.14
1
1380
0.72
27
12061 2.24
1.7
1.4
1.4
1.4
1.2
1.4
1.4
0.0
1.4
1.4
0.0
SSI and VAP
NPSG.07.05.01 relates to prevention of
surgical site infections (SSI) – Elements of
Performance are essentially SCIP
measures
No NPSG related to VAP but MDPH
requires monitoring of VAP process
measures and rates (also tied to
reimbursement)