Transcript Changing World: Perianesthesia and Infection Prevention

Changing World: Perianesthesia
and Infection Prevention
by:
Doris Nordbye, RN MA
Infection Preventionist
Abbott-Northwestern Hospital
Objectives:
The Learner will be able to:
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Define resistant pathogens that may be encountered in
the Perianesthesia enviroment.
Describe Isolation Practices which assist in the
prevention of transmission of disease.
Outline interventions which assist in the reduction:
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Central Line Associated Blood Stream Infections (CLABSI)
Catheter Associated Urinary Tract Infections (CAUTI)
Surgical Site Infection (SSI)
C Diff
Introduction
Obama signs bill to increase antibiotic
research
 Gov focus on Health Aquired Conditions
 Public reporting of Central Line
infections, UTI, and SSI.
 No reimbursement for HAI
 EBOLA
 MERS-COV
 ERCP Scopes and CRE
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Microbiology: The Super Bugs
MRSA
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Methicillin Resistant Staph
Aureus (MRSA)
◦ Normal flora to some.
◦ Usually found nares, skin
and throat
◦ Colonization vs Infection
◦ Causes life-threatening
infections
◦ SSI with MRSA increase
risk of death by 10%
◦ Transmission unwashed
hands.
ESBL
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Extended Spectrum
Beta-Lactamase (ESBL)
◦ Seen with gram neg rods
ie E Coli, K Pneumonia, Family
Enterobacteriaceae
◦ Highly resistant
◦ Difficult to treat
◦ Usually seen in the urinary
tract and the gut but can
cause wound and blood
stream infections.
◦ Transmission unwashed
hands
C Diff
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C Diff
◦ Normal intestinal flora.
◦ Spore former
◦ C Diff has been found
to also shed from the
skin.
◦ Spreads on unwashed
hands and
contaminated surfaces.
C Diff
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Spore forming, gram positive rod that
produces exotoxins (toxins A & B)
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New hyper virulent strain (NAP1)
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Produces greater levels of toxins A and B
C Diff Risk Factors
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Antibiotic use
◦ clindamycin, quinolones, 3rd gen
cephalosporins
Nursing home or group home residence
 Immunosuppressive meds
 Hospitalization (within last 90 days)
 Surgery
 Proton pump inhibitor use
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C Diff Risk factors
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Non-compliance with isolation practices
◦ gowning and gloving
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Non-compliance with hand hygiene
◦ soap and water hand washing (not alcohol foam)
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Inadequate environmental cleaning / disinfection
CRE
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Carbapenamase Resistant
Enterobacteriaceae (CRE)
◦ 128 species of Bacteria within
this family
◦ Highly resistant and share
resistance with others.
◦ Long courses of antibiotic
therapy or devices
◦ Can contibute to death in up
to 50% of infected patients.
◦ Healthy people do not get
CRE.
◦ Requires urgent aggressive
action.
VRE
Vancomycin Resistant
Enterococcus
 (VRE)
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◦ Normally found in the
intestines and female
genital tract.
◦ Can cause UTI, BSI or
Wound Infection
◦ Risk VRE with long
term antibiotic,
hospitalized, weakened
immune system,
surgery, or medical
devices.
Precautions/Isolation
Designed to prevent transmission
 Enteric precautions require handwashing
with soap and water.
 Airborne precautions used with small
droplets i.e. TB
 Droplet Precautions used for large
droplet transmission. i.e. Influenza
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Enteric Precautions
Bundles
Bundles
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“It takes a village to prevent HAI”
Bundles
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Quality Improvement intervention where
multiple distinct interventions (that may
or may not be individually effective) are
“bundled” together during procedures
that carry a high intrinsic risk of a
complication in the expectation that
these will result in and additive benefit to
achieve a desired outcome.
Bundles
Usually consists of 3 – 5 evidence-based
practices.
 Infection Prevention today is the
implementation of bundles to prevent
infection.
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CLaBSI Bundle
Developed as a result of multi-facility
double-blinded and large patient
populations.
 Implementation of CLABSI Bundles have
reduced CLABSI by 49% across the
country.
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Central Line Insertion Bundle
Use the subclavian vein unless
contraindicated.
 Avoid the femoral vein.
 Do not routinely replace catheters
 Use maximal sterile barrier protection
 Use a full body drape.
 Use Antiseptic with Alcohol
 Hand Hygiene before insertion
 Empower Health care personnel to stop if
breach in sterile technique.
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Central Line Maintenance Bundle
Hand hygiene before touching
 “Scrub the Hub” 10-15 seconds and allow
to dry.
 Use alcohol or CHG to “scrub the hub”
 Do not use creams or ointments on site.
 Change Dressing every 5-7 days. Do not
reinforce.
 Use an occlusive dressing.
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Catheter Associated UTI
Dropped 19% across the country.
 Increasing attention
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◦ To reasons for insertion of foley catheters.
◦ Insertion techniques
◦ Early removal
CaUTI Bundle
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Use foleys in operative patients only as
necessary.
◦ Urologic or other surgery on contiguous
structures of the genitourinary tract.
◦ Prolonged duration of surgery
◦ Anticipated to receive large volumes of fluid.
◦ Anticipated to receive diuretics
◦ Monitoring of urinary output
◦ Assist in healing of sacral or perineal wounds.
CaUTI Bundle
Only properly trained individuals should
insert.
 Hand hygiene before and after insertion.
 Pericare before insertion
 Use sterile technique to insert
 Secure the foley after insertion
 Remove as soon as possible.
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◦ SCIP protocol indicate by PO Day 2.
◦ Catheters inserted for prolonged duration of
surgery should be removed in PACU.
CaUTI Bundle Maintenance
Maintain a closed system
 Maintain unobstructed flow
 Perform Pericare
 Do not clean periurethral area with
antiseptic. Clean with soap and water.
 Do not allow drainage bag to touch the
floor.
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CaUTI Work to be done
Develop system of alerts/reminders to
assess for continued need.
 Develop guidelines/protocols for nursedirected removal
 Develop guidelines and algorithms for
appropriate peri-operative catheter
management.
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Reduce surgical site infection (SSI)
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Most common hospital aquired infection
Nationally seen SSI drop 19%
Difficult bundle development
◦ Very few double blinded multifacility studies.
◦ Most studies are single facility small volume
studies.
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Must build consensus for development and
implementation.
Improvement stems from interventions that
span the “continuum of care”.
Patient Preparation
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Smoking
◦ Quitting as little as 3 weeks prior to elective
procedure can have an impact.
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Bathing:
◦ Reduce the bioburden
◦ All patients having elective surgery should have a
bath/shower before arriving.
◦ Some facilities are showering after patient arrives.
◦ MRSA and MSSA thrive on the skin
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Glycemic Control
Patient Preparation
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Administer prophylactic antibiotics within
one hour of surgery.
◦ Over 120 kilos receive 3 grams.
◦ Redose after 2 half lifes of the antibiotic during
procedure.
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Hair Removal
◦ No hair removal or clip only as necessary.
◦ If necessary, done outside of the operating room.
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Use an alcohol-based skin prep.
Maintain normothermia
Post Op Bundle
Hand hygiene before touching wound.
 Teach patient to perform hand hygiene
before touching wound.
 Dressing:
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◦ If dressing needs to be changed, use sterile
technique.
◦ Dressing should remain in place for 24 to 48
hours.
Post operative
If dressing needs to be changed, cleanse
wound before replacing dressing.
 Maintain Post operative glucose
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Hand Hygiene