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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