Prevention of nosocomial infections

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At least 35-50% of all healthcare-associated infections are associated with only 4 patient care practices:

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Prevention of nosocomial infections

  1. 1. PREVENTION OF NOSOCOMIAL INFECTIONS Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Ivy Hospital Sector 71 MohaliWeb:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495
  2. 2. Principles of infection prevention At least 35-50% of all healthcare-associated infections areassociated with only 4 patient care practices:Hand hygiene and standard precautions.Use and care of urinary cathetersUse and care of vascular access linesPrevention of health care associatedpneumonia.
  3. 3. 1. System change Alcohol-based Access to• The 5 core handrub at point of care safe, continuous water supply, soap and towels components of the + WHO Multimodal 2. Training and Education Hand Hygiene + 3. Observation and feedback Improvement Strategy + 4. Reminders in the hospital + 5. Hospital safety climate
  4. 4. WhyDon’t Staff Wash their Hands? (Compliance estimated less than 50%)
  5. 5. Why Not?Skin irritationInaccessible hand washing facilitiesWearing glovesToo busyLack of appropriate staffBeing a physician
  6. 6. Why Not?Working in high-risk areasLack of hand hygiene promotionLack of role modelLack of institutional priorityLack of sanction of non-compliers
  7. 7. Decontaminate handsbefore having direct contact with patients or before inserting cvlsor other invasive devices that do not require surgical procedureafter having direct contact with a patient’s skinafter having contact with body fluids, wounds or broken skin ifnot visibly soiledafter touching equipment or furniture near the patientwhen moving from a contaminated body site to a clean-body siteduring patient careafter removing gloves
  8. 8. Successful PromotionEducationRoutine observation & feedbackEngineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs availablePatient education
  9. 9. Successful PromotionReminders in the workplacePromote and facilitate skin careAvoid understaffing and excessive workload
  10. 10. Hand Hygiene Techniques1. Alcohol hand rub2. Routine hand wash 10-15 seconds3. Aseptic procedures 1 minute4. Surgical wash 3-5 minutes
  11. 11. Areas Most Frequently Missed
  12. 12. Routine Hand Wash
  13. 13. Alcohol Hand RubsRequire less timeCan be strategically placedReadily accessibleMultiple sitesAll patient care areas
  14. 14. Alcohol Hand RubsActs fasterExcellent bactericidal activityLess irritating (??)Sustained improvement
  15. 15. Visible soilingHands that are visibly soiled or potentiallygrossly contaminated with dirt or organicmaterial MUST be washed with liquid soap and water
  16. 16. Prevention of Catheter-Associated Urinary Tract Infection (CA-UTI)Two main principles1 Avoid unnecessary catheterization2 Limit the duration of catheterization
  17. 17. Catheter insertion and maintenancePractice hand hygiene before insertion of the catheter before and after any manipulation of the catheter site
  18. 18. Catheter insertion and maintenanceInsert catheters by use of aseptic technique and sterileequipmentCleanse the meatal area with antiseptic solutions is unnecessary Routine hygiene is appropriateProperly secure indwelling catheters after insertion to preventmovement and urethral tractionMaintain a sterile, continuously closed drainage systemDo not disconnect the catheter and drainage tube unless thecatheter must be irrigated
  19. 19. What you should not do to prevent catheter associated UTIDo not use (avoid) catheter irrigationDo not use systemic antimicrobials routinely asprophylaxisDo not change catheters routinely
  20. 20. CATHETOR ASSOCIATED BLOOD STREAM INFECTIONS
  21. 21. Multimodal intervention strategies to reducecatheter-associated bloodstream infections: - Hand hygiene - Maximal sterile barrier precaution at insertion - Skin antisepsis with alcohol-based chlorhexidine- containing products - Subclavian access as the preferred insertion site - Daily review of line necessity - Standardized catheter care using a non-touch technique - Respecting the recommendations for dressing change
  22. 22. Education-based, multimodalprevention strategy of catheter related infections
  23. 23. HEALTH CARE ASSOCIATED PNEUMONIA
  24. 24. Prevention of Ventilator AssociatedPneumonia 1. Hand hygiene before and after patient contact, preferably by using alcohol based handrubbing 2. Avoid endotracheal intubation if possible 3. Use of oral, rather than nasal, endotracheal tubes 4. Minimize the duration of mechanical ventilation 5. Promote tracheostomy when ventilation is needed for a longer term 6. Glove and gown use for endotracheal tube manip
  25. 25. Prevention of VentilatorAssociated Pneumonia 7. Avoid non-essential tracheal suction 8. Oral hygiene with chlorhexidine 9. Backrest elevation 30-45o 10. Maintain tracheal tube cuff pressures (>20) to prevent regurgitation from the stomach 11. Avoid gastric overdistension 12. Promote enteral feeding 13. Careful blood sugar control in patients with diabetes 14. Selective decontamination of digestive tract (SDD )in selected cases
  26. 26. Continuous Removal of Subglottic Secretions  Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation
  27. 27. HOB ElevationHOB at 30-45o
  28. 28. Intubation and ventilation• Avoid intubation and reintubation• Prefer non-invasive ventilation• Prefer orotracheal intubation & orogastric tubes• Continous subglottic aspiration• Cuff pressure > 20 cm H2O• Avoid entering of contaminate consendate into tube/nebulizer• Use sedation and weaning protocols to reduce duration• Use daily interruption of sedation and avoid paralytic agents
  29. 29. Systemic and enteral antibiotics• Selective decontamination of the digestive tract (SDD) reduces the incidence of VAP.• But SDD not recommended for routine use• Prior systemic antibiotics helps to reduce VAP in selected patient groups but increases MDR
  30. 30. Stress bleeding, transfusion, hyperglycemia• Trend towards less VAP with sucralfate (vs H2 blockers) but increased gastric bleeding• Prudent transfusion, leukocyte-depleted red blood cell transfusion• Intensive insulin therapy to keep glucose 80 - 110 mg/dl Aspiration, body position • Semirecumbent position (30 - 45°) especially when receiving enteral feeding • Enteral nutrition is preferred over parenteral because of translocation risk
  31. 31. CLINICAL PULMONARY INFECTION SCORECriterion ScoreFever (°C) 38.5 but 38.9 1 >39 or < 36 2Leukocytosis <4000 or >11,000/L 1 Bands > 50% 1 (additional)Oxygenation (mmHg) PaO2/FIO2 <250 and no ARDS 2Chest radiograph Localized infiltrate 2 Patchy or diffuse infiltrate 1 Progression of infiltrate (no ARDS or CHF) 2Tracheal aspirate Moderate or heavy growth 1 Same morphology on Grams stain 1 (additional) Maximal scorea 12
  32. 32. "Bundled Interventions" to Prevent Common Health Care–Associated Infections and OtherAdverse EventsPrevention of Central Venous Catheter InfectionsEducate personnel about catheter insertion and care.Use chlorhexidine to prepare the insertion site.Use maximum barrier precautions during catheter insertion.Ask daily: Is the catheter needed?Prevention of Ventilator-Associated Pneumonia and ComplicationsElevate head of bed to 30–45 degrees.Give "sedation vacation" and assess readiness to extubate daily.Use peptic ulcer disease prophylaxis.Use deep-vein thrombosis prophylaxis (unless contraindicated).
  33. 33. Prevention of Surgical-Site Infections Administer prophylactic antibiotics within 1 h before surgery; discontinue within 24 h. Limit any hair removal to the time of surgery; use clippers or do not remove hair at all. Maintain normal perioperative glucose levels (cardiac surgery patients).a Maintain perioperative normothermia (colorectal surgery patients).a Prevention of Urinary Tract Infections Place bladder catheters only when absolutely needed (e.g., to relieve obstruction), not solelyfor the providers convenience. Use aseptic technique for catheter insertion and urinary tract instrumentation. Minimize manipulation or opening of drainage systems. Remove bladder catheters as soon as is feasible.
  34. 34. « Talking walls »
  35. 35. Thank you

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