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2.2 retos para controlar infecc. en noenatologia

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2.2 retos para controlar infecc. en noenatologia

  1. 1. Preventing Nosocomial infections in Neonatal Intensive Care UnitsCongresoInternacional de Prevention de InfeccionesIntrahospitalarias<br />Alan Picarillo, MD, FAAP<br />Neonatologist<br />UMassMemorial Healthcare<br />Assistant Professor in Pediatrics<br />University of Massachusetts Medical School<br />1<br />
  2. 2. Disclosures<br />I have no financial interests to disclose for this lecture<br />I will be speaking about off-label use of a medication (chlorhexidine) during this lecture<br />2<br />
  3. 3. Introduction<br />Why are our smallest infants so vulnerable to hospital-acquired infections?<br />3<br />
  4. 4. 4<br />
  5. 5. Liberian Observer “Chinese doctor performs miracle surgery at JFK Hospital”<br />Liberian Observer January 2010, online edition<br />5<br />
  6. 6. 6<br />
  7. 7. 7<br />
  8. 8. 8<br />
  9. 9. Introduction<br />Why are our smallest infants so vulnerable to hospital-acquired infections?<br />Very immature infants<br />Immature immune systems<br />Poor skin integrity<br />Surgical procedures<br />Central line placement<br />Long length of stay<br />Overcrowding<br />9<br />
  10. 10. Overall burden of nosocomial infections<br />In the US it is estimated that 5-10% of all hospitalized patients will have a nosocomial infection<br />>90,000 deaths attributable each year to nosocomial infections in the United States<br />39,788 deaths from auto/motorcycle accidents <br />16,605 deaths from HIV/AIDS (2008)<br />138 deaths from airline accidents<br />Can this be stopped?<br />10<br />http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf<br />DOT data (1999-2003)<br />CDC data http://www.cdc.gov/hiv/topics/surveillance/basic.htm#ddaids<br />
  11. 11. Burden of nosocomial infections in neonates<br />Late onset (>72 hours of age) sepsis occurs in 4.2% of all neonatal ICU admissions and 17.1% of infants <1.5kg. <br />Rates of central line bloodstream infections are 37% higher in neonatal ICU patients than in adult ICU populations<br />Is it possible to reduce nosocomial infections in neonates, or are the infections unavoidable?<br />11<br />Vermont-Oxford database (2009)<br />NSHN CLABSI report (2011)<br />
  12. 12. Decrease in nosocomial bloodstream infections for infants <1500 gms in Massachusetts NICUs (2006-2010)<br />12<br />
  13. 13. Incidence of nosocomial bloodstream infection by hospital (2006-2010)<br />13<br />
  14. 14. Quality Improvement<br />Institute for Healthcare Improvement (IHI) model<br />Key elements<br />Aims<br />Measures<br />Changes (PBPs)<br />Plan, do, study, act cycles (PDSA)<br />14<br />
  15. 15. Quality Improvement<br />Potentially better practices (PBPs) defined as a set of clinical practices that have the potential to improve the outcomes<br />PBPs can be:<br />Evidence based guidelines<br />Derived from previous improvement efforts<br />Based on literature review<br />Expert recommendations<br />15<br />
  16. 16. PBPs for preventing neonatal nosocomial infections<br />PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients<br />PBP 2: Ensure high compliance with optimal hand hygiene practices<br />PBP 3: Ensure that all vascular catheters are inserted under optimal conditions<br />PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters<br />PBP 5: Remove vascular catheters in a timely manner<br />VON Quality Improvement Kit: preventing nosocomial infection<br />16<br />
  17. 17. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication<br />In NICUs with low nosocomial infection rates, the staff belief was that infections were preventable and represented a breakdown in care<br />NICUs with high rates, staff belief is that infections are inevitable and unavoidable complications of intensive care.<br />A belief among staff that nosocomial sepsis is preventable leads to a motivation to improve. <br />17<br />
  18. 18. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication<br />Aim<br />All staff will demonstrate knowledge of infection control <br />All staff will demonstrate a belief that nosocomial infections represent a failure of optimal care and are preventable in most cases<br />Measure: <br />Percent of staff that accurately answers questions about knowledge of methods to prevent infection<br />Pretest, education, post-test<br />18<br />
  19. 19. 19<br />
  20. 20. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication<br />Changes to test:<br />Leadership of unit visibly supporting infection prevention program<br />Educational in-service for all staff<br />Fact sheets, posters<br />Create a slogan to help with team chemistry<br />Display hospital’s infection rates for all to see (including parents/families)<br />20<br />
  21. 21. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication<br />Barriers to change<br />Lack of support from the entire institution to change staff mental model<br />Lack of role modeling by senior leaders and opinion leaders in the hospital<br />Potential risks<br />Excessive exposure of staff to infection prevention can cause desensitization and reduce impact<br />Staff may take offense and become resistant to change if it is implied or stated that they caused the infection and are being blamed<br />21<br />
  22. 22. PBPs for preventing neonatal nosocomial infections<br />PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients<br />PBP 2: Ensure high compliance with optimal hand hygiene practices<br />PBP 3: Ensure that all vascular catheters are inserted under optimal conditions<br />PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters<br />PBP 5: Remove vascular catheters in a timely manner<br />VON Quality Improvement Kit: preventing nosocomial infection<br />22<br />
  23. 23. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Hand hygiene is an established and widely accepted intervention to reduce healthcare associated infections<br />Recommended by expert bodies such as WHO and Center for Disease Control (CDC)<br />23<br />
  24. 24. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Aim: <br />All NICU staff will practice optimal hand hygiene before and after every patient contact<br />All staff will follow infection control recommendations about jewelry, accessories and clothing<br />Measure: <br />percentage of patient contacts in which providers practice optimal hand hygiene and have both arms exposed below the elbows. <br />On periodic direct observation all staff will be without artificial nails or accessories (except for plain wedding bands). <br />24<br />
  25. 25. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Optimal hand hygiene<br />Both arms are bare below the elbows<br />Arms are free of jewelry except for plain wedding rings<br />No artificial nails or colored nails<br />25<br />
  26. 26. Right to Bare Arms<br />Multiple studies of nosocomial infections have implicated caregivers and their hand hygiene practices<br />Stethoscopes, providers’ white coats, cell phones and patient charts have all been found to harbor bacteria and have been attributed to play roles in outbreaks of nosocomial infections<br />Several case reports of providers wearing artificial nails have been implicated in outbreaks of Pseudomonas sepsis in NICUs1<br />1. Am J Infect Control 2002; 30: 252-4<br />26<br />
  27. 27. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Optimal hand hygiene<br />Both arms were bare below the elbows<br />Arms are free of jewelry except for plain wedding rings<br />No artificial nails<br />Person sanitized their hands by using alcohol gel or by washing with soap and warm water prior to touching the patient (or patient’s equipment) and then immediately after patient contact<br />27<br />
  28. 28. Donskey C and Eckstein B. N Engl J Med 2009;360:e3<br />28<br />
  29. 29. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Changes to test:<br />Alcohol gel at convenient locations with easy visibility<br />Offer staff personal alcohol gel dispensers<br />Provide sinks of adequate depth with faucets that are easy to operate<br />Use material from WHO hand hygiene kit “My five moments for hand hygiene”<br />29<br />
  30. 30. Journal of Hospital Infection (2007) 67, 9-21<br />30<br />
  31. 31. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Changes to test:<br />Alcohol gel at convenient locations with easy visibility <br />Offer staff personal alcohol dispensers<br />Provide sinks of adequate depth with faucets that are easy to operate<br />Use material from WHO hand hygiene kit “My five moments for hand hygiene”<br />Discourage scrubbing of hands and arms with brush<br />Empower families to ask providers if they washed their hands before patient contact<br />31<br />
  32. 32. 32<br />
  33. 33. PBP 2: Ensure high compliance with optimal hand hygiene practices<br />Barriers to change:<br />Lack of culture where NICU professionals are not accepting of feedback and reminders about hand hygiene<br />Lack of conveniently located alcohol-based dispensers or sinks and faucets<br />Lack of systems to replenish hand hygiene resources<br />Potential risks:<br />Skin irritation from frequent use of alcohol-based hand rub<br />Flammable<br />33<br />
  34. 34. PBPs for preventing neonatal nosocomial infections<br />PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients<br />PBP 2: Ensure high compliance with optimal hand hygiene practices<br />PBP 3: Ensure that all vascular catheters are inserted under optimal conditions<br />PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters<br />PBP 5: Remove vascular catheters in a timely manner<br />VON Quality Improvement Kit: preventing nosocomial infection<br />34<br />
  35. 35. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions<br />Insertion of central venous catheters using good aseptic technique and maximal sterile barrier precautions after performing hand hygiene prevents infection during insertion of catheters<br />High level of evidence to back the interventions<br />35<br />
  36. 36. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions<br />Aim: In all (100%) episodes of vascular catheter insertion, maximal barrier precautions will be followed and optimal preparation of insertion site will be performed<br />Measure: Percentage of catheter insertion episodes in which inserters <br />practiced hand hygiene<br />followed maximal barrier precautions<br />used “skin prep” agent chosen by unit<br />allowed for sufficient drying time prior to insertion attempt.<br />36<br />
  37. 37. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions<br />There are approximately 15 different steps in placing a central vascular catheter under optimal conditions.<br />How to ensure consistent practice among different individuals when performing a task with multiple steps<br />37<br />
  38. 38. 38<br />
  39. 39. Checklists<br />Dr. Peter Provonost of Johns Hopkins proposed a small 5-item checklist for provider central line insertion.<br />Wash hands with soap<br />Clean the patient’s skin with chlorhexidine<br />Place sterile drapes over entire patient<br />Wear a sterile hat, mask, gown and gloves<br />Place a sterile dressing after the line is in place<br />39<br />
  40. 40. 40<br />
  41. 41. Checklists<br />Michigan Keystone initiative adopted the checklist developed by Dr. Provonost in their adult ICUs. (>100 ICUs participated)<br />66% decrease in infections within the first 3 months of introduction of checklist<br />Sustained decrease for the next 4 years<br />41<br />
  42. 42. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions<br />Changes to test:<br />Dedicated central line team with certification and/or demonstrate competency<br />Use of an insertion checklist (US National Patient Safety Goal 07.04.01)<br />Empower nurses to stop procedure if mistakes are made<br />Consider chlorhexidine instead of Povidone-Iodine solution (Betadine) for skin prep<br />Use drapes to cover the procedure field completely<br />42<br />
  43. 43. Chlorhexidine<br />Chlorhexidine is not currently FDA-approved for infants less than 2 months of age.<br />Few studies available concerning use of chlorhexidine<br />Biopatch experience<br />Survey of neonatologists in 2009 reported 61% of university-based NICUs used chlorhexidine for skin preparation for vascular catheters<br />Concern among respondents with infants< 1kg and premature infants <28 weeks gestation<br />43<br />
  44. 44. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions<br />Barriers to change:<br />Long-standing individual habit or unit practice of not wearing full barrier precautions<br />Lack of availability of assistant to use checklist<br />Emergency catheter placement as risk for precautions being skipped or shortcuts taken<br />Controversy over safety of skin prep agents for preterm infants<br />Potential risks:<br />Skin irritation from chlorhexadine<br />44<br />
  45. 45. PBPs for preventing neonatal nosocomial infections<br />PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients<br />PBP 2: Ensure high compliance with optimal hand hygiene practices<br />PBP 3: Ensure that all vascular catheters are inserted under optimal conditions<br />PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters<br />PBP 5: Remove vascular catheters in a timely manner<br />VON Quality Improvement Kit: preventing nosocomial infection<br />45<br />
  46. 46. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters<br />Contamination of the catheter hub contributes significantly to intraluminal colonization of vascular catheters.<br />When entering the catheter, the access port should be prepped with alcohol using sufficient friction and allowing it to dry<br />All connections should be performed under sterile conditions<br />46<br />
  47. 47. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters<br />Aims: During all episodes of luminal access of vascular catheters, optimal sterilization of the hub or entry point will be performed prior to accessing the catheter<br />Measure: The percentage of times the luminal access of vascular catheters in which the providers appropriately sterilize the hub or entry point prior to access.<br />47<br />
  48. 48. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters<br />Changes to test: <br />When infusion tubing is disconnected from vascular catheter, it should be placed on a sterile surface<br />Provide sufficient quantity of alcohol wipes in convenient location<br />Daily exam of catheter entry sites<br />48<br />
  49. 49. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters<br />Barriers to change: <br />Common problem is not allowing for alcohol to dry before entering the hub<br />When catheters are accessed in an emergency, proper hub care may not be performed<br />Risks: none<br />49<br />
  50. 50. PBPs for preventing neonatal nosocomial infections<br />PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients<br />PBP 2: Ensure high compliance with optimal hand hygiene practices<br />PBP 3: Ensure that all vascular catheters are inserted under optimal conditions<br />PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters<br />PBP 5: Remove vascular catheters in a timely manner<br />VON Quality Improvement Kit: preventing nosocomial infection<br />50<br />
  51. 51. PBP 5: Remove Vascular Catheters in a Timely Manner<br />Indwelling catheters are a definite risk factor for nosocomial infection<br />Prompt removal of a vascular catheter when it is no longer required is supported by good evidence<br />Aims: All vascular catheters will be assessed at least once per day for necessity and unnecessary catheters will be removed<br />Measure: Percentage of vascular catheters that are assessed each day for their necessity during daily rounds by the healthcare team; the need for infant’s vascular catheter is documented in the medical record.<br />51<br />
  52. 52. Walking the line<br />52<br />
  53. 53. PBP 5: Remove Vascular Catheters in a Timely Manner<br />Changes to test:<br />Have a staff member assigned to “walk the line” each day to act as a prompt to ask whether of not a vascular catheter is required for the infant’s care that day<br />Develop strict criteria for removal of central catheters<br />53<br />
  54. 54. PBP 5: Remove Vascular Catheters in a Timely Manner<br />Barriers to change:<br />Staff resistance to catheter removal “in case it may be needed”<br />Lack of understanding that an indwelling catheter is a risk for infection<br />Risks:<br />Premature removal of a vascular catheter and needing to insert a new catheter in the next 1-2 days<br />54<br />
  55. 55. Additional PBPs<br />Avoid understaffing and overcrowding<br />Ensure optimal environmental hygiene<br />Antibiotic stewardship<br />Use of breastmilk for enteral feeding<br />Develop a plan for investigation and response to nosocomial infection outbreak<br />55<br />
  56. 56. Summary<br />Teamwork and leadership buy-in is required for changing the culture and therefore an essential tenet of quality improvement in reducing nosocomial infections<br />Hand hygiene and a rigorous infection control program can prevent most healthcare associated infections<br />Placement of vascular catheters, while clinically important to the care of neonates, also carry significant risk for infection<br />56<br />
  57. 57. Summary<br />Much evidence exists to mitigate the risk of infection from vascular catheters and many NICUs have employed these procedures to reduce the burden of catheter-associated infections<br />Consider a reporting mechanism (“keeping score”) to allow for tracking nosocomial infections over time<br />Identify units with low infection rates, evaluate their policies and procedures to see if they can be utilized in units with high infection rates<br />57<br />
  58. 58. Who are our most important stakeholders?<br />58<br />
  59. 59. Surveillance and Reporting<br />Surveillance for nosocomial infections is crucial for comparing rates among units and studying the effect of preventative interventions<br />Several different methods of reporting:<br />Simple number of infections per time period (month, quarter, year)<br />Number of infections/100 patient days<br />Number of catheter-related infections/1000 catheter days<br />59<br />
  60. 60. Surveillance and Reporting<br />Data should be shared with physician, nursing and administrative leadership<br />Data can be compared to historical data from individual hospital, national data or international reference point data (CDC/NHSN)<br />60<br />
  61. 61. Five stages of grieving over outcome data<br />Denial: these data cannot be right!<br />Anger: why are they picking on me, I have too much work to do!<br />Bargaining: my patients are sicker than everybody else, my NICU is different, I do not agree with the data definitions<br />Depression: I cannot do anything about it anyway…<br />Acceptance: OK, what can I do to improve the outcomes in my NICU <br />Source: Dan Ellsbury, MD Pediatrix Medical Group<br />61<br />
  62. 62. Surveillance and Reporting<br />Mandated reporting in 18 states in the US<br />Massachusetts requires all hospitals to report all nosocomial infections (catheter-related bloodstream infections, surgical site infections, etc) to the Center for Disease Control (CDC)<br />The infection data is provided to the Massachusetts Department of Health and then the completed statistics are publically reported and available for patients and their families<br />62<br />
  63. 63. Collaboratives<br />Several states and countries are forming NICU collaboratives<br />to share and compare data in order to evaluate which NICU has best practice in a certain area<br />share that expertise with other NICUs<br />Data transparency <br />Integral part of a collaborative <br />Tough barrier to overcome <br />Memorandum of understanding between participating hospitals<br />Helps further develop unity and a community of practice for the stakeholders<br />63<br />

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