How to control infection critically ill patients

1. By
Amjad Tanveer
Infection Control in ICU
Prevention & Management of Critically ill patients
CLABSI CAUTI
VAP
Cardiac Care Nursing

2. OBJECTIVES
• Define Hospital Acquired Infection and HCAI?
• Why infection control in critically ill patients?
• Elaborate Risk Factors
• Explain Types of Device Associated Infections.
• Describe Prevention through key performance indicators.
• Brief Strategies to reduce infection rate.
OBJECTIVES
At the end of this presentation, students will be able to know about:

3. OBJECTIVES
• A hospital-acquired infection (HAI), also known as a
nosocomial infection, is an infection that is acquired in a
hospital or other health care facility. To emphasize both
hospital and nonhospital settings, it is sometimes instead
called a health care–associated infection (HAI or HCAI). Such
an infection can be acquired in hospital, nursing home,
rehabilitation facility, outpatient clinic, or other clinical
settings.
Nosocomial infection

4. Nosocomial infection Critically ill patients
Tablan OC. MMWR Recomm Rep. Mar 26 2007; 53(RR-3): 1-179

5. The most important HAIs are those related to invasive devices:
• Central line-associated bloodstream infections (CLABSI)
• Catheter-associated urinary tract infections (CAUTI)
• Ventilator-associated pneumonia (VAP)
• As well as surgical site infections (SSI).
Health care associated infections (HAI)

6. OBJECTIVES
•The Centers for Disease Control and Prevention (CDC)
estimates that three types of infections account for
two-thirds of all HAIs:
•Nurses play a key role in minimizing the occurrence of
these infections. In fact, CDC guidelines include nursing
specifc interventions for the prevention of each of them.
But the sad fact is that studies show clinicians don’t
reliably follow even the most basic recommendations
Conti…

7. Hospital Acquired Infections Preventable CLABSI
Scottish Executive Health Department (2008). Managing the Risk of Healthcare Associated Infection in NHS Scotland. Edinburgh: SHED

8. OBJECTIVES
• Intensive care units (ICUs) 10 % of total beds, more than 20 %
of all nosocomial infections are acquired in ICUs.
• ICU-acquired infections account for morbidity, mortality, and
expense.
• Improving infection prevention and control in ICU,s by following
of SOP,s and PCI guidelines all health care
worker for 24/7.
Why infection control in ICU,s

9. Cohort surveillance study of 46 hospitals in Central and South America,
India, Morocco, and Turkey. (as reported by NNIS)
Rate of infection
•Ventilator associated pneumonia (VAP)
24.1 cases per 1000 ventilator days (10.0 - 52.7)
•Central line associated bloodstream infections (CLABSI)
12.5 cases per 1000 catheter days ( 7.8 - 18.5)
•Catheter-associated urinary tract infections (CAUTI)
8.9 cases per 1000 catheter days (1.7 - 12.8)
Studies of ICU-associated infections

10. • 3-8% of the 6 million CVC inserted annually in the US are associated
with bloodstream infection (300,000 cases/yr) Attributable cost per
bloodstream infection is estimated to be $3,700 to $29,000.
• VAP occurs in up to 15% of patients receiving mechanical
ventilation.
• Hospital mortality for patients who develop VAP is 46%, compared
to 32% for patients who do not develop VAP
• Excess cost of ~$40,000 per patient
Warren, et al. Crit Care Med 2006;34:2084-2089
Catheter related infection burdens

11. • Compared to general patients, patients in ICUs have more
chronic & more severe acute physiologic derangements.
• The high frequency of use of catheters and devices provide a
portal of entry of organisms into the bloodstream.
• Multidrug-resistant pathogens MRSA and VRE are being
isolated with increasing frequency in ICUs
Factors contributing in infections

12. OBJECTIVES
•Presence of underlying comorbidities
•Presence of indwelling devices
•Frequent manipulations and contact with HCWs
•Long hospital courses prior to the ICU
admission, More Antibiotic Exposure
Conti… Risk Factors

13. Prevention Two Major Strategies
S
Infection Prevention and
Control Practices
1
Improve the efficacy and proper
utilization of antimicrobial therapy.
2

14. Antimicrobial therapy
Pharmacokinetic
Pharmacodynamics

15. Infection Control Measures

16. • Hand hygiene
• Use of personal protective equipment (e.g., gloves, gowns,
masks)
• Safe injection practices.
• Cleaning and disinfection of patient care equipment and medical
devices.
• Respiratory hygiene/cough etiquette.
• Waste segregation.
• Environmental cleaning.
Standard precautions include

17. Transmission Based Precaution

18. OBJECTIVES
• Isolation precaution are used to help stop the spread of
germs from one person to another. These precautions
protect patients, families, visitors, and healthcare workers
from the spread of germs.
Isolation precaution
• Contact Isolation
• Airborne Isolation
• Droplet isolation
Transmission Based Precaution

19. • Prefer the upper extremity for catheter insertion. Avoid femoral route
• Use maximal sterile barrier precautions (cap, mask, sterile gown and
• sterile gloves) and a sterile full-body drape while inserting CVC.
• Clean and Disinfect skin with 2% chlorhexidine.
• Use ultrasound-guided insertion if technology and expertise are available
• Use either sterile gauze or sterile, transparent, semipermeable dressing to
cover the catheter site.
• Replace the catheter site dressing only when the dressing becomes damp,
loosened, or visibly soiled.
Strategies to reduce CLABSI

20. • Evaluate the catheter insertion site daily and check if a transparent
dressing is present and palpate through the dressing for any tenderness
• Insertion date should be put on all vascular access devices.
• Use 2% chlorhexidine wash daily for skin cleansing to reduce CLABSI.
• Clean injection ports with an appropriate antiseptic , chlorhexidine, 70%
alcohol)
• Changed the cap, stop cocks when not in use or contaminated.
• Replace administration sets, including secondary sets and add-on devices,
every day in patients receiving blood, blood products, or fat emulsions.
• accessing the port only with sterile devices.
Conti…

22. • Insert catheters only for appropriate indications.
• Follow aseptic insertion of the urinary catheter.
• Maintain a closed drainage system.
• At all times the urinary catheter should be placed and taped above
the thigh and the urinary bag should hang below the level of the
bladder
• The urinary bag should never have floor contact.
• Change only if there are clinical indications such as infection or
obstruction, or when the closed system is compromised.
• Remove the catheter when it is no longer needed.
Strategies to reduce CAUTI

23. • Catheter / meatal junction
• Catheter / tube junction
• Outlet tube
Ports of Entry” for organisms

24. OBJECTIVES
• Prefer oral intubations to nasal unless contraindicated by expertise.
• Consider noninvasive ventilation whenever possible.
• Keep head elevated at 30-45° in the semi-recumbent body position.
• Daily oral care with chlorhexidine solution.
• Daily sedation vacation if feasible and assessment of readiness to
extubate
• Avoid re intubation whenever possible.
• Routine change of ventilator circuits is not required
Strategies to reduce VAP

25. OBJECTIVES
• Monitor endotracheal tube cuff pressure (keep it >20 cm H2 O).
• Prefer endotracheal tubes with a subglottic suction port to prevent
pooling of secretions around the cuff leading to micro aspiration
• The heat moisture exchanger may be better than the heated humidifier.
• Closed endotracheal suction systems may be better than the open
suction.
Strategies to reduce VAP

26. OBJECTIVES
• Feeding (bowel regimen)
Analgesia
Sedation
Thromboembolic prophylaxis & Test extubation readiness
Head-of-bed elevation
Ulcer prevention (peptic and skin)
Glucose control, GI Prophylaxis and Get OOB
FAST HUG
Jean-Louis Vincent, MD, PhD, FCCM Crit Care Med 2005; 33:1225–1229

27. • Radiographic evidence x 2 consecutive days
• New, progressive or persistent infiltrate
• Consolidation, opacity, or cavitation
• At least 1 of the following:
• Fever (> 38 degrees C) with no other recognized cause
• Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 WBC/mm3)
• At least 2 of the following:
• New onset of purulent sputum or change in character of secretions
• New onset or worsening cough, dyspnea, or tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
How Do We Diagnose VAP?

28. OBJECTIVES• High-quality cleaning and disinfection of all patient-care areas is
important, especially surfaces close to the patient (e.g. bedrails, bedside
tables, doorknobs and equipment.
• Some pathogens can survive for long periods in the environment,
particularly methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant Enterococcus (VRE), Acinetobacter species,
Clostridium difficile and norovirus
• Registered disinfectants or detergents that best meet the overall needs
of the ICU should be used for routine cleaning and disinfection.
Cleaning and disinfection

29. Contaminated Surfaces

30. Summary
s• Devices must only be used when medically necessary and be
removed when no longer needed.
• Implement Bundle Care approach including daily evaluation of
device necessity.
• Outcome and process surveillance
• Supplies & kits to facilitate compliance
• Commitment from everyone to prevent device related infection

31. OBJECTIVES

32. OBJECTIVES•
• The CDC also offers a CAUTI Toolkit that can be downloaded as either a PowerPoint presentation or a PDF file
• Another very useful, outline-styled summary of evidence-based prevention techniques is found in Strategies
to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals, a joint publication from the
Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).
• Recommendations from the Association for Professionals in. Infection Control and Epidemiology (APIC) can
be found in the Guide to the
Elimination of Catheter-Associated Urinary Tract Infections (PDF).
• A PowerPoint presentation from the University of Colorado explains protocols for Nurse-Driven Urinary
Catheter Removal (PPT)
References