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1

• 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)
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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
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Panelists
Rabih Darouiche
Peter Angood
Charles Denham

• 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

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Panelists
Jennifer Dingman
Mary Oden
David Classen
David Classen Future Picture of Prevention of
HAIs Mary Oden Challenges for Infection
Preventionists Jennifer Dingman The Role of
the Patient Advocate
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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
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Harmonization The Quality Choir
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2010 NQF Safe Practices for Better Healthcare A
Consensus Report

• 34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness

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Culture

• 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

Culture Meas., FB., and Interv.
Structures and Systems
ID and Mitigation Risk and Hazards
Team Training and Team Interv.
Consent Disclosure

Consent and Disclosure

• CHAPTER 3 Informed Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver

Informed Consent
Life-Sustaining Treatment
Disclosure
Care of Caregiver
Workforce

• CHAPTER 4 Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care

Nursing Workforce
ICU Care
Direct Caregivers

• 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

Information Management and Continuity of Care
Read-Back Abbrev.
Patient Care Info.
CPOE
Discharge System
Labeling Studies
Medication Management

• 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

• 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

Healthcare-Associated Infections
Central V. Cath. BSI Prevention
Hand Hygiene
Influenza Prevention
VAP Prevention
Sx-Site Inf. Prevention
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

Condition-, Site-, and Risk-Specific Practices
Wrong-site Sx Prevention
Press. Ulcer Prevention
DVT/VTE Prevention
Anticoag. Therapy
Contrast Media Use
Falls Prevention
Organ Donation
Glycemic Control
Pediatric Imaging
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HAI Guidelines
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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.

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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.

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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.

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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.

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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
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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 33501-5
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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
2007122160-6
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Calculation of Estimates of Healthcare-Associated
Infections in U.S. Hospitals Among Adults and
Children Outsideof Intensive Care Units, 2002
HRN high-risk newborns WBN well-baby
nurseries ICU intensive care unit SSI
surgical-site infections BSI bloodstream
infections UTI urinary infections PNEU
pneumonia
Klevens, Edwards, Richards, et al. Pub Health Rep
2007122160-6
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What Are the Costs of Healthcare- Associated
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

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• NQF Safe Practices 2010
• Healthcare-Associated Infections
• 19. Hand Hygiene
• Influenza Prevention
• CLABSI Prevention
• Surgical-Site Infection Prevention
• Care of the Ventilated Patient
• MDRO Prevention
• Catheter-Associated UTI Prevention

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New Highlights in Central Line-Associated
Bloodstream Infectionand Surgical-Site Infection
Prevention

• Rabih O. Darouiche, MD
• VA Distinguished Service Professor
• Director, Center of Prostheses Infectionat
  Baylor College of Medicine
• Safe Practices Webinar
• February 18, 2010

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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

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Overview of Presentation

• Address similarities and differences between
  CLABSI and SSI
• Assess the impact of these two infections
• Analyze potentially protective approaches

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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

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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

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Clinical Manifestations of infected CVC

• Exit site infection
• Tunnel infection
• Thrombophlebitis
• BSI

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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 billion16.8 billion

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Annual Death Rates in the U.S. for Selected
Infectious Diseases
31
Nosocomial Infections in the ICU
95 Urinary Catheters
86 Mechanical Ventilation
87 central lines
lt 55 33 55 70 32 gt70 35
N 14,177
National Nosocomial Infections Surveillance
(NNIS) (97 hospitals)
32
Gram-Positive Bacteremia in Cancer Patients Role
of the CVC
80
70
70
56
60
44
50
of Bacteremia with CVC as the source
40
30
30
20
10
0
Non-CRBSI
CRBSI
Non-CRBSI
CRBSI
Solid Tumor Malignancy
Hematologic Malignancy
33
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 exists
  (catheter-related BSI)

34
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

35
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 gt5 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

36
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.

37
Comprehensive Protective StrategyInfection
Control Bundle

• Hand washing
• Maximal barrier precautions
• 2 chlorhexidine-based skin antisepsis
• Avoiding femoral site if possible
• Removing unnecessary catheters

38
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

39
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 gt7 billion

40
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

41
Impact of Timing of Systemic Antibiotic
Prophylaxis on SSI
42
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 20103629-17

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Importance of the Skin

• Largest bodily organ
• Protective barrier
• Skin flora most common cause of SSI (and CLABSI)
• 80 of bacteria reside in epidermis

44
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

45
Commonly used Preoperative Antiseptics

• Povidone-iodine (Iodophor)
• Chlorhexidine gluconate
• Alcohol
• Combination products gt2 active agents

46
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

47
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
• OGrady, et al. Centers for Disease Control
  and Prevention. MMWR Morb Mortal Wkly Rep
  200251(RR-10)1-29
• CDC has not previously issued a preference as to
  type of preoperative skin antiseptics

48
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
  201036218-26

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Kaplan-Meier Curves for Freedom from
Surgical-Site Infection (Intention-to-Treat
Population)
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Chlorhexidine-Alcohol (CA) vs. Povidone-Iodine
(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

53
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
  

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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

55
Perspective

• Optimal prevention of CLABSI and SSI can
• Improve patient care
• Incur cost-savings
• Enhance infection control measures

56
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
57
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
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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
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(No Transcript)
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