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Evidence-Based Strategies to Tackle the Three Most Common Sources of HAIs: Contaminated Hands, Environmental Surfaces, and Skin Cindy Winfrey, MSN, RN, CIC Senior Medical Science Liaison PDI Healthcare. Financial Disclosures. PDI Healthcare-Employee. Objectives.

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Evidence-Based Strategies to Tackle the Three Most Common Sources of HAIs: Contaminated Hands, Environmental Surfaces, and SkinCindy Winfrey, MSN, RN, CICSenior Medical Science LiaisonPDI Healthcare
financial disclosures

Financial Disclosures

PDI Healthcare-Employee

  • Discuss the impact of contaminated environmental surfaces, hands (of both patients and healthcare providers), and skin in the transmission of Healthcare Associated Infection
  • Review the current research gaps for pediatric Infection Prevention literature
  • Discuss strategies to meet and exceed Joint Commission NPSG 7
  • Discuss patient and family involvement and empowerment strategies to reduce the incidence of HAIs
Examples of multidrug resistance in

HAI pathogens

  • Acinetobacterbaumannii
    • About 75% are multidrug resistant*
      • 10% increase from 2000
  • Pseudomonas aeruginosa
    • About 17% are multidrug resistant*
  • Staphylococcus aureus
    • MRSA causes about 55% of HAIs (Antimicrobial-Resistant Pathogens Associated with Healthcare Associated Infections, Annual Summary of Data Reported to the NHSN at CDC, 2006-2007)

* Percent Acinetobacterbaumanniiand P. aeruginosa in ICUs that are multidrug-resistant, NNIS and NHSN, 2000-2008. Includes ICUs only (MICU, SICU, MSICU) and device-related infections only (CLABSI, CAUTI, VAP).

healthcare associated infections hais
Healthcare-Associated Infections (HAIs)
  • 1 out of 20 hospitalized patients affected
  • Associated with increased mortality
  • Attributed costs: $26-33 billion annually
  • HAIs occur in all types of facilities, including:
    • Long-term care facilities
    • Dialysis facilities
    • Ambulatory surgical centers
    • Hospitals
outbreaks vs endemic problems
Outbreaks vs. Endemic Problems
  • Endemic problems represent the majority of HAIs
  • Device-associated infections
    • Catheter-associated urinary tract infections (CAUTI)
    • Central line-associated Blood stream infections (CLABSI)
    • Ventilator-associated Pneumonia (VAP)
  • Procedure-associated infections
    • Surgical site infections (SSI)
  • Adherence problems
    • Antimicrobial stewardship
    • Hand hygiene
    • Isolation precautions
changing landscape of healthcare
Changing Landscape of Healthcare
  • Growing populations at risk
    • Immunocompromised individuals
    • Low birthweight, premature neonates
    • Transplant recipients on immunosuppressive therapy
  • Special environments
    • Intensive care and burn units
    • Infusion services
hhs action plan 5 year goals
HHS Action Plan 5-year Goals

NHSN – CDC’s National Healthcare Safety Network EIP – CDC’s Emerging Infections Program

NHDS – CDC’s National Hospital Discharge Survey SCIP – CMS’s Surgical Care Improvement Project

HCUP – AHRQ’s Healthcare Cost and Utilization Project

impact of neonatal clabsi
Impact of Neonatal CLABSI

Inherent risk with CVCs

Difficult to identify and treat

Prolonged & often frequent exposure to antibiotics

Major contributor of morbidity and mortality

Increased length of stay and hospital costs

Infants are especially vulnerable

challenges to skin antisepsis evidence based approaches
Challenges to Skin Antisepsis:Evidence-Based Approaches

Prepping the skin

    • Chlorhexidine (CHG) vs Alcohol vsPovidone-Iodine
    • CHG shown to be more effective due to residual effect.
    • CHG/alcohol solutions: 0.5% to 3.15% CHG
    • CHG/aqueous solutions: 0.5% to 4%
    • CHG recommended by the CDC Guideline for all but < 2 months
  • But, in <1000 gms, CHG associated with skin irritation
    • Andersen J Hosp Infect 2005 (2% CHG/aqueous)
    • Garland Pediatr Infect Dis J 1996 (2% CHG/alcohol)
  • CHG studies currently being conducted for safety in neonates
  • 61% of US NICU Medical Fellowship Directors reported using CHG
    • Tamma ICHE, 2010

NICU compromise

skin antiseptic agents
Skin Antiseptic Agents
  • Choice varies with age
    • Population based complications
    • < 2 months
      • EGA
      • Post natal age
  • Agents
    • 2 to 3.15% CHG - alcoholic formulation
    • CHG - aqueous formulation
    • Povidoneiodine
  • Removal considerations
    • Normal Saline
    • Sterile Water
survey of neonatal chg use
Survey of Neonatal CHG Use
  • Survey of Neonatology Fellowship Directors in the United States
  • 61% reported use of CHG for skin antisepsis for neonates
    • 51% limited use on basis of birth weight, gestational age or chronological age.
    • Skin reactions (erythema, erosions, burns) occurring primarily in those weighing <1500 grams were reported by 51%. 
    • No difference in adverse events between the alcoholic or aqueous CHG preparations

Tamma, Aucott, & Milstone, 2010

best practices for disinfection of non critical items
Best Practices for Disinfection of Non-Critical Items

Examples include surfaces in the environment and medical equipment used in patient care

state of prevention knowledge and science
State of prevention knowledge and science
  • Guidelines developed for each type of infection and based on systematic reviews of medical literature
    • Prevention of central line-associated blood stream infections
    • Prevention of catheter-associated urinary tract infections
    • Prevention of surgical site infections
    • Prevention of healthcare-associated pneumonia
    • Management of multidrug-resistant organisms
  • Recommendations graded according to evidence
  • Guidelines contain many recommendations
  • Current efforts to help prioritize interventions that are most effective
adherence to infection control guidelines is incomplete
Adherence to infection control guidelines is incomplete
  • Many HAIs are preventable with current recommendations
  • Failure to use proven interventions is unacceptable
  • Only 30%-38% of U.S. hospitals are in full compliance
  • Just 40% of healthcare personnel adhere to hand hygiene
  • Insufficient infection control infrastructure in non-acute care settings has allowed major lapses in safe care
Local success fuels national prevention






CDC knowledge and data fuels local to national CLABSI prevention

  • Nationalexpansion of CLABSI prevention
  • 60% Reduction in CLABSI between 1999-2009
  • State-based public reporting using NHSN
  • State/regional prevention collaboratives (CUSP, Recovery Act projects)
  • CMS/IPPS – hospitals report CLABSIs for full Medicare payment


  • Subsequent projects based upon CDC prevention:
  • Michigan Keystone
  • Institute for Healthcare Improvement
  • Others



Outbreak Investigations

Pittsburgh Regional Healthcare Initiative

First successful, large-scale CLABSI prevention demonstration project


CDC Guidelines

Prevention Research (e.g. chlorhexidine bathing)



The need for HAI prevention research


  • Need for complete implementation of practices known to prevent HAIs


Healthcare-associated Infection

  • Need for ongoing research to identify new strategies to prevent the remaining HAIs

Prevention Approach Unknown


Hand hygiene

No touch technique


Skin antisepsis

Injection cap/needleless connector




Public Health

Safe Healthcare is Everyone’s Responsibility






Hypothetical ?

If you knew……………………….

That you could do something simple, easy, cost effective, and that was

Evidence-Based, but took a little extra time…..

Would you do it?????

  • Whose Infection will you prevent when you return to your institution?
  • Contact Information: