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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).

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slide1

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)

slide2

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

slide5

Panelists

Peter Angood

Rabih Darouiche

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

slide6

Panelists

Mary Oden

Jennifer Dingman

David Classen

David Classen: Future Picture of Prevention of HAIs

Mary Oden Challenges for Infection Preventionists

Jennifer Dingman: The Role of the Patient Advocate

slide7

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

2010 nqf safe practices for better healthcare a consensus report
2010 NQF Safe Practices for Better Healthcare: A Consensus Report
  • 34 Safe Practices
  • Criteria for Inclusion
  • Specificity
  • Benefit
  • Evidence of Effectiveness
  • Generalization
  • Readiness
slide10

Culture

Consent & Disclosure

Consent and Disclosure

Workforce

Information Management and Continuity of Care

Medication Management

Healthcare-Associated

Infections

Condition- &

Site-Specific Practices

10

slide11

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

Structures

and Systems

Culture Meas.,

FB., and Interv.

Team Training

and Team Interv.

ID and Mitigation

Risk and Hazards

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

Direct

Caregivers

ICU Care

  • 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

Patient

Care Info.

Read-Back

& Abbrev.

Labeling

Studies

Discharge

System

CPOE

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

Hand Hygiene

Influenza

Prevention

Central V. Cath.

BSI Prevention

Sx-Site Inf.

Prevention

VAP

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

Organ

Donation

Glycemic

Control

Falls

Prevention

Pediatric

Imaging

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.

NQF CLABSI Prevention Safe Practice Specifications: 2010 Update

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.

NQF SSI Prevention Safe Practice Specifications: 2010 Update
the association for professionals in infection control epidemiology
The Association for Professionals in Infection Control & Epidemiology
  • MissionTo 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
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.

Visit www.apic.org/targetingzeroto learn more about the initiative and to access resources and practical tools

slide17

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

slide18

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

slide19

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

slide20

263,810

274,098

-967

-21

-28,725

244,385

TOTAL

HRN

WBN

Non-newborn ICU

= SSI

133,368

Other

BSI

22%

11%

SSI

20%

UTI

PNEU

36%

11%

424,060

129,519

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 2007;122:160-6

slide21

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
slide22

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
slide23

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

slide24

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
overview of presentation
Address similarities and differences between CLABSI and SSI

Assess the impact of these two infections

Analyze potentially protective approaches

Overview of Presentation
similarities between clabsi and ssi
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

differences between clabsi and ssi
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

clinical manifestations of infected cvc
Clinical Manifestations of infected CVC

Exit site infection

Tunnel infection

Thrombophlebitis

BSI

impact of clabsi
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

slide31

Nosocomial Infections in the ICU

95% Urinary Catheters

86% Mechanical Ventilation

87% central lines

< 55 = 33%

55 – 70 = 32%

>70 = 35%

N= 14,177

National Nosocomial Infections Surveillance (NNIS) (97 hospitals)

slide32

Gram-Positive Bacteremia in Cancer Patients: Role of the CVC

80%

70%

70%

56%

60%

50%

44%

% of Bacteremia with CVC as the source

40%

30%

30%

20%

10%

0%

Non-CRBSI

CRBSI

Non-CRBSI

CRBSI

Solid Tumor Malignancy

Hematologic Malignancy

slide33
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)

relationship between catheter colonization and bloodstream infection
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

ia recommendations in upcoming cdc guidelines for prevention of clabsi
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]

nqf clabsi prevention safe practice specifications 2010 update36
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.

NQF CLABSI Prevention Safe Practice Specifications: 2010 Update
comprehensive protective strategy infection control bundle
Comprehensive Protective StrategyInfection Control Bundle

Hand washing

Maximal barrier precautions

2% chlorhexidine-based skin antisepsis

Avoiding femoral site if possible

Removing unnecessary catheters

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

Potential Limitations of Traditional Infection Control Measures
reasons to optimize prevention of ssi
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

perioperative approaches for preventing ssi
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

a prospective randomized trial of nasal mupirocin plus chlorhexidine wash
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
importance of the skin
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
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

commonly used preoperative antiseptics
Commonly used Preoperative Antiseptics

Povidone-iodine (Iodophor)

Chlorhexidine gluconate

Alcohol

Combination products: >2 active agents

comparison of antimicrobial activity of antiseptic preparations
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

pressing need to compare clinical efficacy of antiseptic preparations in preventing ssi
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

prospective randomized 6 center clinical trial of 849 patients
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

chlorhexidine alcohol ca vs povidone iodine pi for prevention of ssi
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

new cms regulations effective 10 08 changes to inpatient prospective payment system
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

non reimbursable infectious conditions
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

perspective
Perspective

Optimal prevention of CLABSI and SSI can:

Improve patient care

Incur cost-savings

Enhance infection control measures

slide56

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

slide57

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

slide58

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