Infection Control & Sage:
a Winning Combination
A Presentation for the
Annual Sage Products Sales Meeting
Chicago, IL, October 2, 2002
Robert Garcia, BS, MMT(ASCP), CIC
IC Responsibilities
• Range: all depts.
• Nosocomial infection
surveillance
• Communicable
diseases
• Employee health
• Sterilization assurance
• Medical devices
• Sanitation
• Antisepsis
• Engineering &
Construction
• Patient Safety
• Regulatory
requirements
• Bioterrorism planning
The IC Profession at a Crossroads
• 12,000 ICPs and dwindling
• Responsibilities up 75% in acute care and
81% in LTC
• Staffing has not changed for 60% of IC
departments or decreased nearly 25%
• 75% over 45 years of age
• Most nurses, but where are the nurses?
Jackson MM, Soule B, Tweetn SS. APIC Strategic Planning Member Survey, 1997. The Emerging
Healthcare Delivery Systems Task Force. APIC. AJIC AM J Infec Control 1998;26:113-25.
Lack of Nurses and Infection
• >15 studies and reports equate decreased
RN nursing staff with increasing
nosocomial infections
•
Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and quality of
care in hospitals. N Eng J Med 2002;346:1715-22
•
Jackson M, Chiarello L, Gaynes R, et al. Nurse staffing and health care –
associated infections: Proceedings from a working group meeting. AJIC AM J
Infec Control 2002;30:199-206.
Nosocomial Infections
•
•
•
•
•
•
4th leading cause of death in U.S.
>$4 billion dollar cost to hospitals
LTC, Ambulatory, others $ = unknown
Resistant organisms
IOM Report
Media reports
ECONOMIC PRESSURE
HEALTHCARE INFLATION
COST OF TECHNOLOGY
MEDICAID CUTS
MANAGED CARE
Prophetic Insight on Future Paths
“…Because we do not provide direct care
to patients, the value of our practice must
be demonstrated in other ways. We must
translate infection control activities into
proposals and systems that gain priority by
stressing quality and economy.”
• Pantelick EL. Hospital infection control: Dinosaur
or dynasty. Am J Infect Control 1989;17:56-61.
APIC Research Foundation Priorities
Project
• A review of the world’s literature on IC and
ID over the last 20 years
• Identified 65 of most published authors
• 43 responded to survey
• #1 top priority: Cost-effectiveness/financial
impact studies
Report from the Research Foundation, APIC Educational Conference
& International Meeting, June 2000, Minneapolis, MN.
What is at Stake?
• For infection control professionals:
– A necessary increase in institutional value
attained by sustained decease in infections and
demonstration of cost reductions
• For Sage:
– The confirmation that a proven and high quality
product does make a difference
– Enhanced market position
An Emerging Methodology
Interventional Epidemiology
“…IE examines all functions from a global health
care viewpoint; that is, it takes into consideration
the potent changes outside of a healthcare
organization and in response integrates this
knowledge into the internal process systems of
the facility.”
Garcia R, Barnard B, Kennedy V. The Fifth Evolutionary Era in Infection Control: Interventional
Epidemiology. AJIC Am J Infect Control 2000;28:30-43
People
Communication
Between Providers
Procedures
Analysis of System
Components Influencing
the Occurrence of
Ventilator-Associated
Pneumonia
Intubation/Extubation
Physicians
VAP surveillance rounds
(observational periods between IC
and nurses)
Suctioning (closed/oral)
Nurses
Oral Care
Respiratory Therapists
Pharmacists
Relay surveillance data
to healthcare providers
Cleaning & maintenance
of ventilator and
components
Feedback from healthcare
providers
Handwashing
Nutritional Specialists
Placement &
maintenance of
nasogastric tube
VAP
Mechanical ventilator (Heated humidifier or HME)
Vent circuits, filters
Closed suction system, oral suction catheters, water, other
suction devices, suction canisters/tubing
Tracheostomy devices
Nasogastric tubes
Nebulizers
Multidose vials
Laryngoscopes
Resusitation bags
Definition of VAP
Intubation/Extubation
Self-extubation
Closed suctioning
Semi-recumbent positioning
Handwashing
Oral & Dental Care
Cleaning of
Use of H2
ventilator/other devices
antagonists/sucralfate
Tracheostomy care
Ventilator circuits
Filters
Cleaning of laryngoscopes Nebulizers
Suction canisters
Enteral feeding
Resuscitation bags
Weaning
Placement and care of nasogastric tubes
Barrier equipment
Equipment & Devices
Policies
The Practice Arena of Interventional
Epidemiologists
Clinical
Financial
Customer
Satisfaction
How can SAGE Help Bolster IC Value?
• Provide a fresh perspective on infection
transmission
• Provide economic and clinical rationale
• Provide viable interventional methodologies
• Provide effective education
• Provide support for the span of the
partnership
Hospital Water:
Is it a Source for
Nosocomial Infections?
Causative
Agent
Reservoir
Susceptible
host
Portal of
exit
Portal of
entry
Mode of
Transmission
The Chain of Infection.
Components of the Infectious Disease Process.
Water as a Reservoir of
Nosocomial Pathogens
• It is known that organisms such as Pseudomonas
aeruginosa, Serratia marcescens, and
Acinetobacter calcoaceticus can replicate in
relatively pure water
• May be present in drinking water that has
acceptable limits of safety (<1 coliform
bacterium/100 mL).
P. aeruginosa Infections due to
Hospital Water Sources
• >12 reports indicating transmission and
development of infection from
contaminated hospital water
– Trautmann M, Michalsky T, et al. Tap water colonization with
Pseudomonas aeruginosa in a surgical intensive care unit and
relation to Pseudomonas infections of ICU patients. Infect Control
Hosp Epidemiol 2001;22:49-62.
Burn Infections
• Tap water has been cited as the source
for serious wound and sepsis
– Kolmos HJ, Thuesen B, et al. Outbreak of infection in a burn unit
due to Pseudomonas aeruginosa originating from contaminated
tubing used for irrigation of patients.
Infections from Hospital Sinks
• Many reports have identified the presence of
gram-negative bacteria in hospital sinks
• Organisms may survive for >250 days on sink
surfaces
– Simor AE, Ramage L, et al. Molecular and epidemiologic study of
multiresistant Serratia marcescens infections in a spinal cord injury
rehabilitation unit. Infect Control Hosp Epidemiol 1988;9:20-27.
Tip of the Iceberg
• More than 40 citations of water as a source of
nosocomial infections
• Anaissie et al estimate that >1,400 deaths occur
each year due to waterborne nosocomial
pneumonia due to P.aeruginosa alone
– Anaissie EJ, Penzak SR, Dignani C. The hospital water supply as a
source of nosocomial infections. A plan for action. Arch Intern
Med 2002;162:1483-92.
“…In such settings, hospital water may have
contaminated environmental surfaces (eg,
sinks, drains, and whirlpool baths), medical
equipment (eg, by rinsing tube feed bags,
endoscopes, respiratory equipment, etc., with
tap water), or health care providers, leading
ultimately to patient exposure.”
- Anaissie EJ, et al. The hospital water supply as a source of nosocomial infections.
A plan for action. Arch Intern Med 2002;162:1483-92.
How are Patients Exposed to Hospital Water?
•
•
•
•
•
•
•
Handwashing (cross-contamination)
Bedpans
Enteral feedings
Respiratory equipment
Drinking
Showering
Bed bathing
Basin Bath Drawbacks
•
•
•
•
•
High consumption of resources
Negative impact on nursing and patients
Damaging effects on the skin
Contamination risks with basins & water
Real economics of basins
Why Should Hospitals Care?
• Most of your patients skin is at risk
• Cost of skin breakdown in U.S.: $13 Billion
• Nosocomial contamination may lead to
nosocomial infection
• Cost of nosocomial infection: $5.9 Billion
• JCAHO Patient Safety Quality Indicators
• Patient ‘barometer’ for their quality of care
Source: Stone P. et al, Outcomes of ICU Working Conditions, Nov 2001
Nursing Shortage vs. Patient Outcomes
JCAHO Expert Panel Report
“Insufficient staffing not only
adversely impacts health care quality
and patient safety, it also compromises
the safety of nurses themselves”
Source: Joint Commission on Accreditation of Healthcare Organizations, August 2002
Damage to the Skin
•
Soaps can strip the acid mantle, raise the pH and
compromise the epidermis
• Washcloths introduce friction because they are harsh
and rough
• Soap and washcloths are fragile skin’s worst enemy
Sources:
Friers, S.A. Ostomy, Wound Management June 2001
Bryant R. A. Ostomy, Wounnd Management June 2001
Wysocki A. Acute and Chronic Wounds 2nd Edition 2000
Who’s Skin Are We Talking About?
• Your Patient
–
–
–
–
–
–
–
–
Majority are elderly
Most have pruritic skin condition
Epidermis and dermis are thinner
Skin has reduced barrier function
Reduced skin elasticity
Poor epidermal turnover
Lowered sebum production
Loss of subcutaneous fat and muscle
Source: Thomas MD, D., Clinical Journal of Medicine, Cleveland
Pressure Ulcers
• 1.6 million cases per year in acute care alone
• varied settings:
–
–
–
–
–
medical wards
surgery and operating rooms
intensive care units
rehabilitation centers
long term and home care
Prevalence of Pressure Ulcers
• Reported rates to be between 3% and 11%
• Two large studies:
– 9.2% (148 hospitals) 1
– 7% (116 hospitals) 2
1. Meehan M. Multisite pressure ulcer prevalence survey. Decubitus 1990;3:4-14.
2. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and
incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:209-15.
Cost Impact: Hospitals
• Unadjusted mean costs:
– With Pressure ulcers - $37,288
– Without pressure ulcers - $13,924
• Adjusted for admission predictors and nosocomial
infections:
– With pressure ulcers - $29,048
– Without pressure ulcers - $13,819
Allman RM, Goode PS, Burst N, et al. Pressure ulcers, hospital complications, and disease
severity: Impact on hospital costs and length of stay. Adv Wd Care 1999;12:23-30.
Basinborne Contamination Study
• Hospital personnel do not perceive basin bath water as significantly
contaminated
• 100% of the samples in the study were positive for bacterial growth, 60.8% were
gram negative
• The bacterial count in basin water was so high it was similar to the bacterial
count in the urine from patients with UTI’s
• Employee’s, wearing contaminated gloves used during the procedure, were
observed to touch many environmental surfaces.
• Basin water may serve as a reservoir of antibiotic resistant organisms
Source: Shannon R et al., Patient Bath Water as a Source of Nosocomial
Microbiological Contamination: An intervention Study using Chlorhexidine. J Healthcare
Safety Infect Control, 1999;3:180-84.
Basinless Bathing
• Removes the risk of basin contamination
• Removes the risk of waterborne contamination
• 8 washcloths to reduce transfer of organisms
• Mild cleanser helps maintain skins natural barrier
• Single-use helps reduce environmental/cross
contamination
• No water spills reduce slips & fall potential
Better Science and Patient Safety
What’s the Real Cost to Bathe with a Basin?
Nursing
$5.11
$6.84
per
bath
Energy, Water
& Sewer
$.10
Laundry
Processing
$.98
Materials
$.65
Source: Total Delivered Cost Analysis Database from U.S. hospitals 1997 - 2002, Sage marketing data on file.
Solid Economics
$6.84
total
$3.68
total
$5.11
Nursing Time
$1.83
Nursing Time
$1.73
$.98
Laundry &Linens
Basinless
Bath
$.10 Water,Sewer,Energy
$1.10 to $1.90
$.65
Materials
Basin Bath Cost
Basinless Cost
Source: Total Delivered Cost data analysis of U.S.hospitals 1997-2002
$1.90
$1.10
Linen Savings Summary
$100,000
Baylor University
Medical Center
Linen Dollars Saved
$90,000
$339,139
Cumulative
Savings
$94,425
$94,909
$80,000
$70,000
$70,677
$60,000
$50,000
$40,000
$36,010
$30,000
$24,851
$20,000
$18,266
$10,000
$0
Bath Blankets
Bath Towels
Straight Sheets
Wash Cloths
Fitted Sheets
Pillowcases
Jan. 1999 – Apr. 2002
Nursing Time Reallocated
90,000
89,870
Gallons Saved
80,000
70,000
72,783
60,000
2,499,200
Gallons
Saved
69,007
50,000
40,000
30,000
36,520
20,000
10,000
0
Time Spent per Bath
Water Consumption Savings
35
30
104,133
Cumulative
Nursing Hours
Created
35
minutes
25
20
15
10
10
minutes
5
0
1999
2000
2001
2002
BASINS
BASINLESS
Monthly Water Savings with Comfort Bath™
Jan. 1999 – Apr. 2002
Jan. 1999 – Apr. 2002
Time is on Your Side
Original Price
H
o
s
p
i
t
a
l
p
r
i
c
e
$5.50
$5.00
 New Concept
 High Distribution Margins
$4.00
 One or two Product Choices
$3.75
 Manufacturing Efficiencies
$3.00
 GPO Contracts
$2.25
$2.00
$2.05
 Multiple Product Choices
$1.90
$1.00
'96
'97
'98
'99
'00
$1.10
'01
'02
Ventilator-Associated
Pneumonia
Is Dental & Oral Care a Valid Part of
a Global Prevention Program?
VAP Facts
• Mechanical ventilation increases risk of
pneumonia 6-21 times (1% per day)
• Attributable mortality is 27% and increases
to 43% when etiologic agent is
P.aeruginosa or Acinetobacter sp.
• LOS with VAP is 34 days and 21 days
without VAP
What strategies have been
advocated in preventing VAP?
•
•
•
•
•
•
•
•
•
Ventilator circuit replacement
Semirecumbent positioning of patients
Closed suction catheter replacement
Heat and moisture exchanger replacement
Selective digestive decontamination
Oral and dental care
Stress ulcer prophylaxis
Enteral feeding methodologies
Weaning
People
Communication
Between Providers
Procedures
Analysis of System
Components Influencing
the Occurrence of
Ventilator-Associated
Pneumonia
Intubation/Extubation
Physicians
VAP surveillance rounds
(observational periods between IC
and nurses)
Suctioning (closed/oral)
Nurses
Oral Care
Respiratory Therapists
Pharmacists
Relay surveillance data
to healthcare providers
Cleaning & maintenance
of ventilator and
components
Feedback from healthcare
providers
Handwashing
Nutritional Specialists
Placement &
maintenance of
nasogastric tube
VAP
Mechanical ventilator (Heated humidifier or HME)
Vent circuits, filters
Closed suction system, oral suction catheters, water, other
suction devices, suction canisters/tubing
Tracheostomy devices
Nasogastric tubes
Nebulizers
Multidose vials
Laryngoscopes
Resusitation bags
Definition of VAP
Intubation/Extubation
Self-extubation
Closed suctioning
Semi-recumbent positioning
Handwashing
Oral & Dental Care
Cleaning of
Use of H2
ventilator/other devices
antagonists/sucralfate
Tracheostomy care
Ventilator circuits
Filters
Cleaning of laryngoscopes Nebulizers
Suction canisters
Enteral feeding
Resuscitation bags
Weaning
Placement and care of nasogastric tubes
Barrier equipment
Equipment & Devices
Policies
Ventilator Circuits
• Humidifier vs. HME technology
• CDC Draft: Do not change routinely, on the basis of
duration of use, the ventilator circuit (i.e., ventilator tubing
and exhalation valve, and the attached humidifier) that is
in use on an individual patient. Rather change the circuit
when it is visibly soiled or mechanically malfunctioning.
Cat IA [same as for HME - Cat II ].
– Kollef MH, Shapiro SD, Fraser VJ, Silver P, Murphy D, Trovillion
E, et al. Mechanical ventilation with and without 7-day circuit
changes: a randomized controlled trial. Ann Intern Med 1995;
123;168-74.
Semirecumbent Positioning
• CDC Draft: If there is no medical
contraindication, elevate at an angle of 30-45° the
head of the bed of a patient at high risk for
aspiration pneumonia, e.g., a person receiving
mechanical ventilation.…Cat IB
– Drakulovic MB, Torres A, Bauer TT, Nicholas JM,
Nogue S, Ferrer M. A Supine body position as a risk
factor for nosocomial pneumonia in mechanically
ventilated patients: a randomized trial. Lancet
1999;354:1851-58.
Closed Suction Catheters
• Manufacturers: replace at 24 hours
• CDC Draft: If the closed-system suction is used,
change the in-line suction catheter when it
malfunctions or becomes visibly soiled. Cat IB
– Kollef MH, Prentice D, Shapiro SD, Fraser VJ, Silver
P, Trovillion E, et al. Mechanical ventilation with or
without daily changes of in-line suction catheters. Am J
Resp Crit Care Med, 1997;156:466-72
Heat & Moisture Exchangers (HME)
• Hydroscopic vs. hydrophobic
• CDC Draft: …use a heat-moisture exchanger (HME) to prevent
pneumonia in a patient receiving mechanical ventilation. Cat II.
Change an HME…when it malfunctions mechanically or becomes
visibly soiled. Cat IB
• Davis K, Evans SL, Campbell RS, Johannigman JA, Luchette FA,
Porembka DT. Prolonged use of heat and moisture exchangers does not
affect device efficiency or frequency rate of nosocomial pneumonia.
Crit Care Med 2000;28:1412-18.
– Studied 220 consectutive SICU patients
– HME changed at 24h or 120h, measuring resistance and colonization
– No differences after 5 days in resistance or colonization
Stress Ulcer Prophylaxis
• Theory has it that modifying stomach acid
effects the bacterial colonization level
• “after all of this time and study, it is likely
that neither drug has any advantage in
significantly maintaining gastric flora and
reducing VAP.”
– Livingston DH. Prevention of ventilator-associated
pneumonia. Am J Surg 2000;179(suppl 2A):12S-17S.
Selective Digestive Decontamination
• Preventive decolonization on the theory that the
gut is a major source of VAP
• 30+ studies to date
• “…this selective pressure on the epidemiology of
resistance definitely precludes the systematic use
of SDD for critically ill patients”
– Eggimann P, Pittet D. Infection control in the ICU.
Chest 2001;120:2059-2093.
Evidence of the Need to
Control Oral and Dental
Colonization in Order to
Prevent VAP
1. Oral Cavity vs. Gastric Colonization
• “…decolonization approaches in the prevention of
nosocomial pneumonia strongly suggests that
oropharyngeal decontamination, indeed, represents the
effective part of SDD, and that the majority of antibiotic
use in SDD is unlikely to add beneficial effects”
– Bergmans DCJJ, Bonten MJM, Gaillard CA, Paling JC, van der
Geest S, van Tiel F, Besens AJ, et al. Prevention of ventilatorassociated pneumonia by oral decontamination. A prospective,
randomized, double-blind, placebo-controlled study. Am J Resp
Crit Care Med 2001;164:382-88.
2. Further Evidence...
• ...that oropharyngeal colonization rather than
gastric colonization leads to VAP
– Garrouste-Orgeas M, Chevret S, Arlet G, Marie O, Rouveau M, Popoff N,
Sclemmer B. Oropharyngeal or gastric colonization and nosocomial
pneumonia in adult intensive care unit patients. A prospective study based
on genomic DNA analysis. Am J Respir Crit Care Med 1997;156:164
– Bonten MJM, Gaillard GA, Van Tiel H, Smeets GGW, Van Der Geest S,
Stobberingh EE. The stomach is not a source for colonization of the upper
respiratory tract and pneumonia in ICU patients. Chest 1994;105:878-84.
3. Oral Pathogens & Respiratory Infect.
• 20 trial subjects on mechanical ventilation
• at 24h, all patients identified with potential
pathogens in oral secretions
• 67% of sputum cultures with pathogens
• 94% of oral suction devices colonized after
24h of use
Sole ML, Poalillo FE, Byers JF, et al. Bacterial growth in secretions and on suctioning
equipment of orally intubated patients: A Pilot study. Am J Crit care 2002;11:141-49.
4. Oral Pathogens & Respiratory Infect.
• A review article
• 6 articles cited as support for a relationship
between poor oral health and resp. infect.
• Bacteria from colonized dental plaque may
be aspirated into the lower airway
Scannapieco FA.Role of oral bacteria in respiratory
infection. J Peridont 1999;70:793-802.
* Available on Sage Intranet
5. Dental Plaque as a Contributor to VAP
• Fourrier E, Duvivier B, Boutigny H, Roussel-Delvallez M,
Chopin C. Colonization of dental plaque: a source of
nosocomial infections in intensive care patients. Crit Care
Med 1998;26:301-8.
– Study on dental plaque colonization and ICU nosocomial infs.
– Dental plaque occurred in 40% of pts.
– Colonization of dental plaque was highly predictive of nosocomial
infection
– Salivary, dental, and tracheal aspirates cultures were closely linked
6. Oral Decolonization: Use of Chlorhexidene
• DeRiso AJ II, Ladowski JS, Dillon TA, Justice JW, Peterson AC.
Chlorhexidene gluconate 0.12% oral rinse reduces the incidence of
total nosocomial respiratory infection and nonprophylactic systemic
antibiotic use in patients undergoing heart surgery. Chest
1996;109:1556-61.
– 353 pts undergoing coronary bypass surgery
– Used chlorhexidine gluconate (0.12%) as oral rinse to prevent nosocomial
infections
– Randomozed to receive CHG or placebo
– Overall reduction in nosocomial infections of 65% when using CHG
– Respirtaory infections were reduced 69% in CHG group
Subglottic Secretion Suctioning
• CDC Draft: Use an endotracheal tube with a
dorsal lumen above the endotracheal cuff to allow
drainage (by continuous suctioning) of tracheal
secretions that accumulate in the patient’s
subglottic area. CAT 1B
– Valles J, Artigas A, Rello J, et al. Continuous aspiration of
subglottic secretions in preventing ventilator associated
pneumonia. Ann Intern Med 1995;122:179-86.
– Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of
continuous subglottic suctioning in cardiac surgery patients. Chest
1999; 116:1339-46.
Biofilms
• Complex layers forming on the surfaces of
medical devices
• Contain “mother” bacteria which bread
pathogenic “free-floating” organisms
• Nearly impervious to antibiotics
– Donlan RM. Biofilms and device-associated infections. Emerging Infect
Dis 2002;2:277-81.
Biofilms & VAP
• Clear association between development of biofilm
and VAP
• “Conclusion: ET biofilms are clinically relevant, locate
closer to the patient than ventilator, and mature over time.
Staging of ET biofilms is possible and correlates with
increased pneumonia, LOS, and cost.”
– Bergstein JM, Thomas JG, Kincaid SD, et al. Endotracheal tube
biofilm stage correlates with outcome in surgical critical care
patients. [abstract] 1st Annual Joint Meeting, Surgical Infection
Society 22nd Annual Meeting Surgical Infection Society-Europe
15th Annual Meeting, May 2-4, 2002, Madrid, Spain. Surg Infect
2002;3:90.
Is there a comprehensive,
effective, and readily available
system to address many of the
factors that influence the
occurrence of VAP?
VAP Reduction by Oral Care:
A Successful Project
• Implemented the use of assessment tools
• Introduced Oral Care System
• From 5.6/1000 VD to 2.2/1000 VD
– Schleder B, Stott K. The effect of a
comprehensive oral care protocol on patients at
risk for ventilator-associated pneumonia. J Adv
Health 2002;4:27-30
CDC 2002 Draft Guidelines on
Pneumonia Prevention:
Does not address dental or oral
care as a factor in the
occurrence of ventilatorassociated pneumonia !!!!!! ?????
Summary: What Works in
Reducing VAP
•
•
•
•
•
Semi-recumbent positioning
Circuits-filters-closed suction = 1 system
Subglottic suctioning
Dental & oral care
Weaning
Summary on Dental & Oral Care
• Oral, rather than gastric colonization, plays
major role in VAP events
• Dental plaque acts as a source of pathogens
• Good supportive science
• Poor oral care contributes to swift biofilm
formation
• Good oral care reduces infection
Benefits of
Complete Oral Care System
• Closed system
• Provides major components of global
prevention program (dental/oral care &
subglottic suctioning)
• Provides anti-microbial solution
• Nurse friendly
• Provides assessment tools
My appreciation for your wonderful
support,
Robert Garcia, BS, MMT(ASCP)
Brookdale University Medical Center
One Brookdale Plaza
Brooklyn NY 11212
516-810-3093
rgarcia@brookdale.edu