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Welcome to the
NQF 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
To join the online webinar, go to:
www.safetyleaders.org
Online Access Password: Webinar1 (case-sensitive)
Welcome and Safe Practice
Overview
Charles Denham, MD
Chairman, TMIT
Co-chairman, NQF Safe Practices Consensus Committee
Chairman, Leapfrog Safe Practices Program
Safe Practices Webinar
February 18, 2010
2
3
Panelists
Charles Denham
Peter Angood
Rabih Darouiche
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
5
Panelists
David Classen
Mary Oden
Jennifer Dingman
David Classen:
Future Picture of Prevention of HAIs
Mary Oden
Challenges for Infection Preventionists
Jennifer Dingman:
The Role of the Patient Advocate
6
The Role of the Patient Advocate
Jennifer Dingman
Founder of Persons United Limiting Substandards and Errors in
Healthcare (PULSE), Colorado Division
Co-founder, PULSE American Division
Safe Practices Webinar
February 18, 2010
7
Harmonization – The Quality Choir
8
2010 NQF Safe Practices for Better
Healthcare: A Consensus Report
34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness
9
Culture
Consent & Disclosure
Consent and Disclosure
Workforce
Information Management and
Continuity of Care
Medication Management
Healthcare-Associated
Infections
Condition- &
Site-Specific Practices
10
Culture
Structures
and Systems
Culture Meas.,
FB., and Interv.
Team Training
and Team Interv.
ID and Mitigation
Risk and Hazards
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
Consent
& Disclosure
Consent
and
Informed
Consent
Life-Sustaining
Treatment
Care of
Caregiver
Disclosure
Workforce
Nursing
Workforce
Direct
Caregivers
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
Information Management and Continuity of Care
Patient
Care Info.
Read-Back
& Abbrev.
Labeling
Studies
Discharge
System
CHAPTER 3: Informed Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver
CPOE
Medication Management
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
Med. Recon.
Pharmacist Systems Leadership:
High-Alert, Std. Labeling/Pkg., and Unit-Dose
Healthcare-Associated Infections
Influenza
Prevention
Hand Hygiene
Sx-Site Inf.
Prevention
VAP
Prevention
Central V. Cath.
BSI Prevention
MDRO
Prevention
UTI
Prevention
Condition-, Site-, and Risk-Specific Practices
Wrong-site
Sx Prevention
Contrast
Media Use
Organ
Donation
Press. Ulcer
Prevention
Glycemic
Control
DVT/VTE
Prevention
Falls
Prevention
Anticoag.
Therapy
Pediatric
Imaging
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
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
HAI Guidelines
12
NQF CLABSI Prevention Safe Practice
Specifications: 2010 Update
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.
13
NQF SSI Prevention Safe Practice
Specifications: 2010 Update
• 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.
14
The Association for Professionals in
Infection 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 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.
HAI Clinical and Financial
Implications and Policy Future
Peter B. Angood, MD, FRCS(C), FACS, FCCM
Senior Advisor, Patient Safety, National Quality Forum
Member of Safe Practices Steering Committee
Former Chief Patient Safety Officer and Vice President
for The Joint Commission
Safe Practices Webinar
February 18, 2010
17
Background: Impact of HAIs
• 5%-10% of hospitalized patients develop an HAI
 99,000 deaths per year
 $20 billion per year1
• Risk of serious HAI complications is highest
for patients requiring intensive care
• Increasing number of HAIs
 Sicker patient population
 More complex procedures and equipment
 Increasing antimicrobial resistance
1Stone
PW, et al. AJIC 2005; 33:501-5
18
Estimated Number of Healthcare-Associated Infections
in U.S. Hospitals by Subpopulation and Major Site
of Infection, United States, 2002
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
19
Calculation of Estimates of Healthcare-Associated Infections
in U.S. Hospitals Among Adults and Children Outside
of Intensive Care Units, 2002
263,810
274,098 TOTAL
Other
22%
-967 HRN
-21 WBN
-28,725 Non-newborn ICU
244,385 = SSI
HRN = high-risk newborns; WBN = well-baby
nurseries; ICU = intensive care unit; SSI =
surgical-site infections; BSI = bloodstream
infections; UTI = urinary infections; PNEU =
pneumonia
133,368
BSI
11%
SSI
20%
129,519
PNEU
11%
UTI
36%
424,060
Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6
20
What Are the Costs of HealthcareAssociated Infections?
• U.S.
 Total excess costs $32 million to $825 million annually
 Most 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
21
NQF Safe Practices – 2010:
Healthcare-Associated Infections
19. Hand Hygiene
20. Influenza Prevention
21. CLABSI Prevention
22. Surgical-Site Infection Prevention
23. Care of the Ventilated Patient
24. MDRO Prevention
25. Catheter-Associated UTI Prevention
22
New Highlights in Central LineAssociated Bloodstream Infection
and Surgical-Site Infection
Prevention
Rabih O. Darouiche, MD
VA Distinguished Service Professor
Director, Center of Prostheses Infection
at Baylor College of Medicine
Safe Practices Webinar
February 18, 2010
23
Disclosure Statement
• 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
24
Overview of Presentation
• Address similarities and differences between
CLABSI and SSI
• Assess the impact of these two infections
• Analyze potentially protective approaches
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
• Thrombophlebitis
• 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
30,000
25,000
Deaths per Year
20,000
15,000
10,000
5,000
0
CRBSI
MRSA
AIDS
Hep B
Tbc
Measles
Nosocomial Infections in the ICU
95% Urinary Catheters
86% Mechanical Ventilation
UTI
31%
PNEU
27%
87% central lines
< 55 = 33%
55 – 70 = 32%
>70 = 35%
BSI
19%
GI
5%
CVS
4%
EENT
4%
LRI
4%
National Nosocomial Infections Surveillance (NNIS) (97 hospitals)
OTHER
6%
N= 14,177
31
Gram-Positive Bacteremia in Cancer Patients:
Role of the CVC
% of Bacteremia with
CVC as the source
80%
70%
70%
56%
60%
50%
40%
44%
30%
30%
20%
10%
0%
Non-CRBSI
CRBSI
Solid Tumor Malignancy
Non-CRBSI CRBSI
Hematologic Malignancy
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
33
exists (catheter-related BSI)
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 strategy
Guidelines for the Prevention of Intravascular Catheter-related Infections.
Atlanta (GA): Centers for Disease Control and Prevention; 2010. [draft]
35
NQF CLABSI Prevention Safe Practice
Specifications: 2010 Update
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.
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
Potential Limitations of Traditional
Infection Control Measures
Although very essential, they:
• Are not easily enforceable
• Are not very durable
• Do not completely prevent
infection
• Save some, but not
enough, lives
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 antisepsis
40
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;362:18-26
48
Proportion of Patients with Surgical-Site Infection, According to Type of
Infection (Intention-to-Treat Population).
ChlorhexidineAlcohol
(N=409)
no. (%)
PovidoneIodine
(N=440)
no. (%)
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
Type of Infection
Relative Risk
(95% CI)
P-Value
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
N
no.
Infected
(%)
Infected
Abdominal
297
37
Colorectal
186
Biliary
Povidone-Iodine
N
no.
Infected
(%)
Infected
(12.5)
308
63
(20.5)
28
(15.1)
191
42
(22.0)
44
2
(4.6)
54
5
(9.3)
Small intestinal
41
4
(9.8)
34
10
(29.4)
Gastroesophageal
26
3
(11.5)
29
6
(20.7)
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)
Type of Surgery
Non-abdominal
51
Chlorhexidine-Alcohol (CA) vs. PovidoneIodine (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
Future Picture of Prevention of
Healthcare-Associated Infections
David Classen, MD, MS
Chief Medical Officer at CSC
Associate Professor of Medicine at the University of Utah
Infectious Diseases Consultant, University of Utah School of Medicine
Safe Practices Webinar
February 18, 2010
56
Challenges for Infection
Preventionists
Mary A. Oden, RN, BSN, MHS, CIC
Senior Director, Cleveland Clinic Health System
Infection Prevention Program
Safe Practices Webinar
February 18, 2010
57
The Role of the Patient Advocate
Jennifer Dingman
Founder of Persons United Limiting Substandards and Errors in
Healthcare (PULSE), Colorado Division
Co-founder, PULSE American Division
Safe Practices Webinar
February 18, 2010
58
59
60