Transcript Slide 1

TJC Infection Control Standards
2011 Supplement
Resources
National Healthcare Safety Network (NHSN)
 NHSN was previously known as the National
Nosocomial Infection Surveillance System
 It is a voluntary, web-based surveillance system by
CDC Healthcare Quality Promotion
 Goal to obtain national data on HAIs
 Hospitals and ASCs may participate in the network
 Available at www.cdc.gov/nhsn
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Risk Assessment
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Infection Preventionist Tools
www.infectionpreventiontools.com/home
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TJC Surveyor
 May look at both the infection control plan and your
risk assessment
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 May look for local statistics and data, relationship
with outside agencies and that you prioritized the
risks
 May look at your review of the last two years of
interventions and program related to hand hygiene
 May observe an OR cases and observe the
processing of instruments in Central Supply
1 www.unc.edu/depts/spice/jcaho.html
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Resources
 TJC has Speak Up Initiatives including five things
you can do to prevent infections
 www.jointcommission.org/GeneralPublic/Speak+Up/
about_speakup.htm
 Options to Increase Isolation Surge Capacity
 www.jcrinc.com/common/PDFs/document_collection/
resources/collections/00032482/00032984-0001.pdf
 Preparing for a Pandemic, EM Case Study, How the
Health First Hospital Developed a Pandemic
Influenza Plan
 www.jcrinc.com/common/pdfs/qualityandsafety/
preparing_for_a_pandemic_brevard_county_FL.pdf
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Spice
www.unc.edu/depts/spice
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TJC Crosswalk
http://www.jcrinc.com/common/pdfs/csr/forms%20and%20tools,%20newsletters/ic/CSR%20IC%20Self-Assessment%20June%20Update%20HAP%200709.doc
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www.cdc.gov/nhsn/mdro_cdad.html
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AORN Updated Surgical Attire
 All hospitals should be aware of the updated AORN
surgical attire recommended practice
 Hospital must launder all scrubs
 States wearing scrubs as street attire creates
exposure to infectious pathogens in the community
 Recommendations for safe footwear and wearing
jewelry
 Recommendation on cleaning of stethoscopes and
ID badges
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IV Spiking is 1 hour
 IV should not spiked more than one hour before use
 USP 797 requirement
 APIC also has out a position paper that advices
administering has soon as possible
 Hospitals should also have a safe injection
practices policy
 Hospitals should follow the 10 CDC guidelines
found in the isolation standards
 CMS also has an infection control sheet (15 pages)
that all ASCs must complete by the surveyor
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Reducing Surgical Site Infections
 Land mark trial shows that chlorahexidine reduces
surgical site infections instead of povidone-iodine
 This changes the standard of care
 Same edition of NEJM shows you can prevent
surgical site infections by swabbing nasal site
(rapid screen) and if staph aureus then decolonize
 This can be done by rinse with chlorahexidine
soap and use mupirocin nasal ointment
 NEJM 362;18-26 January 7
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Recent Issues
 June 2010 OSHA makes bold move to regulate
infection prevention and publishes in FR (new IC
police) Issued May 6, 2010
 June 2010 Environmental team at Mayo Clinic
wipes out C-diff with bleach wipe program
 June 2010 VA hospitals cut MRSA by 77% in ICUs
with active surveillance
 June 2010 SHEA and IDSA issues new C-diff
guidelines
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8 Things to Reduce Post-operative Pneumonia
 Researchers from VA Palo Alto Healthcare System
and Stanford University employed 8 things to
reduce pneumonia on the surgery floor
 1. Education of all surgical and ward nursing staff
about their role in pneumonia prevention
 2. Cough and deep-breathing exercises with
incentive spirometer
 3. Twice-daily oral hygiene with chlorhexidine
swabs
 4. Ambulation with good pain control
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8 Things to Reduce Post-operative Pneumonia
 5. Head-of-bed elevation to at least 30 degrees and
sitting up for all meals ("up to eat")
 6. Quarterly discussion of the progress of the
program and results for nursing staff
 7. Pneumonia bundle documentation in the nursing
documentation
 8. Computerized physician pneumonia prevention
order set in the physician order entry system.
 Wren SM, Martin M, Yoon JK, and Bech F. Postoperative
Pneumonia-Prevention Program for the Inpatient Surgical Ward.J
Am Coll Surg; April 2010, Vol. 210, Issue 4: 491-495
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Institute for Healthcare Improvement
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Source: www.shea-online.org
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Source: www.his.org.uk
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www.who.int/en
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www.theific.org
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Source: www.idsociety.org
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PA Patient Safety Authority
Source: www.patientsafetyauthority.org/Pages/Default.aspx
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Sterilized Equipment Issue
 Recent cases of improperly sterilized equipment.
 PA Safety Authority reports number of reported cases
of contaminated equipment from prior surgery
 Portland VA sent out 2,270 letters of TRUS guided
prostate biopsy equipment
 FDA alert July 2006 and 2009 on prostate biopsy
equipment
 Called bioburden
 Old dried blood and tissue came out of tissue protector
on drill, triple trocar full of dried blood, suture remained
on tunneler, and particles of tissue found on
cannulated instruments
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Sterilized Equipment Issue (continued)
 Adequate cleaning is required to remove all residual
that remains, if not prevents sterilization
 Many wipe instruments with wet lap or gauze
sponge with sterile water during or after procedure
 CMS and TJC issue information on flash
sterilization so make sure you pay attention to this
issue
 Soaking instrument in enzymatic solution after
procedure and follow manufacturers instructions
 Immediately soak all instruments
 May need to use brushes to remove material
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Cleaning of Medical Equipment
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MRDOs Resources
 CDC MRSA resources
 www.cdc.gov/ncidod/dhqp/ar_mrsa.html
 Includes fact sheet on MRSA, MRSA in
healthcare setting 2007, educational material,
data, lab testing and practices, etc.
 Isolation precaution 2007
 www.cdc.gov/ncidod/dhqp/gl_isolation.html
 VRE resources
 www.cdc.gov/ncidod/dhqp/ ar_vre.html
 Guidelines for Prevention of Surgical Site
Infections
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Resources
 APIC resources at www.apic.org and see
standards and guidelines
 Guidelines for Environmental Infection Control in
Health Care Facilities
 Guidelines for Prevention of Surgical-Site
Infections
 Recommendations for Preventing the Spread of
VRE
 Guidelines to Prevent Intravascular Catheter
Related Infections
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TJC NPSGs
 Many are on infection control
 Implement best practices to prevent multiple drug
resistant organisms MDROs
 Educate staff and patients about MDRO and
necessity for prevention
 Measure MRSA and CDAD (C-diff associated
disease)
 Clean and disinfect equipment and patient care
environment
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IHI ICU Improvements
 VHA united with IHI to improve ICU care
 Better control of blood sugars with glucose
monitoring protocols1
 Aggressive treatment of sepsis/blood stream
infections (see central line bundle)
 Prevention of ventilator associated pneumonia
(see VAP bundle), surgical infections
 Developed toolkits (order sets, protocols, daily
goal sheets), report templates for monthly
reporting of change
1 www.ihi.org
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Ventilator Bundle
 Head of bed (HOB) elevation > 30 degrees
 Deep venous thrombosis (DVT) prophylaxis
 Peptic ulcer disease (PUD) prophylaxis
 Daily sedation vacations
 Assessment of readiness of wean
 Oral care
 Use a checklist and document each!
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Central Line Bundle
 Hand hygiene
 Maximal barrier precautions upon insertion
 Chlorhexidine skin antisepsis
 Optimal catheter site selection with subclavian
vein as the preferred site for non-tunneled
catheters
 Daily review of line necessity with prompt removal
of unnecessary lines
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Sepsis Bundle
 Over 750,000 patients a year develop sepsis or
septic shock in the US
 Severe sepsis will kill 30% of infected patients and
another 20% will die within six months
 Surviving sepsis campaign
 Can listen to presentations
 Sepsis bundle lists seven tasks to be done during
first six hours
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Sepsis Resuscitation Bundle
 If hypotension, give serum lactate >4 mmol/L
(deliver initial minimum of 20 mL/kg of crystalloid
and vasopressors for arterial pressure less 65 mm
Hg)
 Bundle 5 is for persistent hypotension achieve
central venous pressure > 8mm Hg and venous
oxygen sat of > 70%
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Sepsis Management Bundle
 Administer low dose steroids with standardized ICU
policy
 Administer recombinant human activated protein C
(rhAPC) in accordance with a standardized ICU
policy. If not administered, document why the
patient did not qualify for rhAPC.
 Maintain glucose control >70, but <150 mg/dL.
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Sepsis Bundle
 Surviving Sepsis Campaign website1
 Sepsis bundle website2
 Dellinger RP, Carlet JM, Masur H, et al. Surviving
Sepsis Campaign guidelines for management of
severe sepsis and septic shock. Critical Care
Medicine. 2004;32(3):858-873.
 See IHI, Defeating Sepsis; 25% by 20093
1 www.survivingsepsis.org
2 www.survivingsepsis.org/implement/bundles
3 www.ihi.org/IHI/Topics/CriticalCare/Sepsis/ImprovementStories/
FSDefeatingSepsis25Percentby2009.htm
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Preventing UTI from Catheters
 Do not put in unless absolutely necessary
 Make sure meticulous care is followed in inserting
 Remove ASAP
 Document everyday considerations as to whether foley can
come out
 Follow evidence based literature and CDC guidelines on
preventing catheter associated UTI
 Many UTIs can be prevented with proper management of the
indwelling urethral catheter
 Maintain sterile closed system
 CDC 2009 guidelines at
www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
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Additional Resources
 2011 CDC Guidelines for Prevention of
Intravascular Catheter Related Infections, (pending)
 CDC Guidelines for the Prevention of catheterInduced Urinary Tract Infections, December 2009
 www.cdc.gov/hicpac/cauti/002_cauti_toc.html
 AHRQ toolkit
 www.ahrq.gov/qual/haiflyer.htm
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CA-UTI Resources
 Pa Patient Safety has toolkit to prevent CA-UTIs
 http://patientsafetyauthority.org/EducationalTools/PatientSafety
Tools/cauti/Pages/home.aspx
 APIC guidelines to eliminate catheter-associated
UTI
 AORN article Jan 2010 on new scip measure
regarding urinary catheter removal
 www.aorn.org/News/Managers/November2009Issue/Catheter
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CA-UTI Resources
 IDSA as the Diagnosis, Prevention, & Treatment of
Catheter-Associated Urinary Tract Infections in
Adults: 2009 International Clinical Practice
Guidelines from the Infectious Disease Society of
America
 http://cid.oxfordjournals.org/content/50/5/625.full
 Iowa Healthcare Collaborative toolkit
 www.ihi.org/IHI/Programs/ImprovementMap/PreventC
atheterAssociatedUrinaryTractInfections.htm
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Accreditation Connection, 6-28-2010
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www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
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Injection Safety CDC
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Advancing ASC Quality
 ASC Quality Collaboration has ASC tool kit for
infection prevention
 Includes one on hand hygiene and safe injection
practices
 Includes a basic and expanded version of the
toolkit
 Available at
www.ascquality.org/advancing_asc_quality.cfm
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2011 NPSG Chapter Outline
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Proposed for 2012 NPSG
 TJC is seeking comments on NPSGs for 2012
 Looking at two proposed additions
 Ventilator-associated pneumonia (VAP)
–Has seven elements of performance
 Catheter-associated urinary tract infections
(CAUTI)
–Has four elements of performance
 Comment period ended January 27, 2012
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2011 NPSG Chapter Outline
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Goal 7: Reduce the Risk of HAI
Goal: Reduce the risk of HAI
4 of 5 sections remain in 2011
Deleted 7 B on HAI as a sentinel event
In August 2010 Perspective noted changes to NPSG
07.04.01 and 07.05.01
NPSG.07.04.01 EP11
Added to use an antiseptic for skin preparation during
insertion of central line that is cited in the scientific
literature
Removed “use chlorahexidine” even though currently the
standard of care but in the event it changes
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Reduce Risk of HAI Infections
In August 2010 Perspective changes to NPSG
07.05.01 EP7 & 8 on implementing evidenced based
practices for preventing surgical site infections (SSI)
EP7 Administer antimicrobial agents for prophylaxis
for a procedure or disease
Removed “evidenced based practices”
Added to do this according to methods cited in the
scientific evidence or endorsed by professional
organizations
Removed give antibiotics one hour before the surgery and
discontinue within 24 hours or 48 for cardiothoracic patients
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Reduce Risk of HAI Infections
 EP8 Removed the section to “use clippers or
depilatories” when hair is removed
 Removed the note that shaving is an inappropriate
hair removal method
 Added to use a method that is cited in the scientific
literature or endorsed by professional organizations
 This is currently the standard of care
 However, this new wording is flexible so if the new
literature shows a new standard of care TJC does
not have to go back and revise the standard
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Reduce Risk of HAI Infections
In March 2010 Perspective change to
NPSG.07.03.01
The word “prevention” was accidentally omitted from EP3
in the 2010 NPSG publication
Patients and families should be educated, when needed,
who are colonized with MDRO about health-care associated
infection prevention strategies
Retained hand hygiene, MDRO, reducing central
line associated blood steam infections, and
preventing surgical site infections
Good resource is the April 2010 updates to the NQF 34
Safe Practices for Better Healthcare
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Hand Hygiene NPSG.07.01.01
 Reduce the Risk of HAI: Comply with current CDC
or WHO hand hygiene guidelines
 Has 3 EPs
 EP1 Implement a program that follows categories
1A, 1B, and 1C on one of the above
 EP2 Set goals for improving compliance with hand
hygiene guidelines
 EP3 Improve compliance with hand hygiene
guidelines based on established goals
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Implement Evidenced-Based Practices
 Implement evidenced-based practices to prevent
HAI due to multi-drug resistant organisms (MDROs)
 07.03.01 (7C)
 9 EPs
 Applies to, but not limited to, MRSA, VRE, C-Diff,
and MDRO gram negative bacteria
 Patients continue to acquire health care associated
(HAI) infections at an alarming rate
 Need prevention and control strategies
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Implement Evidenced-Based Practices
Increased focus on cleaning and disinfecting
equipment appropriately (IC.02.02.01)
Proper use of flash sterilization
Making sure all scopes are cleaned
according to the manufacturer
Cleaning the patient environment is also
important
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Evidenced-Based HAI Prevention
1. Conduct periodic risk assessment for
MDROs acquisition and transmission
 In time frame set by hospital
 See IC.01.03.01, EPs 1-5 that talks about
identifying the risk of acquiring and transmitting
infections
 Following slides on this provided for reference
 TJC infection control chapter very important and
dovetails with these infection control NPSGs
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Identify Risks for Transmitting Infections
 IC.01.03.01 Hospital identifies risks for acquiring
and transmitting infections
 EP1 Hospital identifies risks based on geographic
location, community, and population served
– NPSG.07.03.01 EP1 Conduct periodic risk assessments in time
frames set by hospital for multidrug-resistent organisms (MDRO)
acquisitions and transmission
– MDRO includes methicillin-resistant Staphylococcus Aureus
(MRSA), Vancomycin-resistant Enterococcus (VRE), Klebsiella,
and Acinetobacter
– CDC has free MDRO infection (and CDAD) surveillance and
training on the National Healthcare Safety Network (NISN)
– 1 www.cdc.gov/nhsn/wc_MDRO_CDAD.html
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Identify Risks for Transmitting Infections
IC.01.03.01
 EP2 Hospital identifies risk for acquiring and
transmitting infections based on the care and
treatment it provides (on MDRO)
 EP3 Look at risk for acquiring or transmitting an
infection by doing an analysis of surveillance
activities and other infection control data (including
MRDO and adverse tissue reactions)
 EP4 Review and identify risks annually and when
there is a significant change and get input from IP,
MS, nursing, and leadership including MRDO
 EP5 Prioritize these risks
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Evidenced-Based HAI Prevention MDRO
2. Educate staff and LIPS about HAI, MDROs, and
preventive strategies in orientation
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At hire and annually
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Use information from your risk assessment
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Education must reflect their diverse roles
3. Educate patient and their families about HAI
strategies who are infected or colonized with
MRDO, as needed
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Evidenced-Based HAI Prevention MDRO
 4. Implement a MDRO surveillance program based
on your risk assessment
 Surveillance may be targeted rather than
hospital-wide
 CDC has MDRO surveillance training at
www.cdc.gov/nhsn/wc_MDRO_CDAD.html
 Has many resources including training videos on
MDRO surveillance, slide sets, protocols,
reporting plan, etc.
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Evidenced-Based HAI Prevention MDRO
5. Measure and monitor MDRO prevention processes
and outcomes including; MDRO infection rates
using evidence based metrics, compliance with
evidenced based practice, and evaluate education
provided
6. Provide MRDO process and outcome data to key
stakeholders, nurses, doctors, LIPs and other
clinicians
7. Implement P&Ps to reduce transmission of MRDOs
which meet CDC and other professional
organization standards (APIC,SHEA,OSHA, AORN)
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Evidenced-Based Practices MDRO
8. Implement a laboratory based alert system that
identifies new patients with MDRO when
indicated by the risk assessment
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The alert system can be manual or electronic
and can use faxes, pages, telephones etc.,
9. Implement an alert system that identifies
readmitted or transferred MRDO positive patient
when indicated by risk assessment
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Alert system can be in a separate database or
integrated and can manual or electronic
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MRDOs Resources CDC
 Management of MRDOs in Healthcare Settings
2006, 74 pages, at
www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
 Provides strategies and practices to prevent
MRSA, VRE and other MDROs,
 Includes gram neg bacilli (GNB), E. coli and
Klebsiella pneumoniae, stenotrophomonas
maltophilia, burkholderia cepacia, and ralstonia
picketti
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MRDOs Resources
 CDC MRSA resources at
www.cdc.gov/ncidod/dhqp/ar_mrsa.html
 Includes fact sheet on MRSA, MRSA in healthcare
setting 2007, educational material, data, lab testing
and practices, etc.
 Isolation precaution 2007 at
www.cdc.gov/ncidod/dhqp/gl_isolation.html
 VRE resources at www.cdc.gov/ncidod/dhqp/ar_vre.html
 Guidelines for Prevention of Surgical Site Infections
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Resources
 APIC resources at www.apic.org and see
standards and guidelines
 Guidelines for Environmental Infection Control in
Health Care Facilities
 Guidelines for Prevention of Surgical Site
Infections
 Recommendations for Preventing the Spread of
VRE
 Guidelines to Prevent Intravascular Catheter
Related Infections
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Central Lines 07.04.01 (7D)
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Implement best practices to prevent central line
associated bloodstream infections,
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13 EPs
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IHI has how to guides and other resources at
www.ihi.org (Keystone project)
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EP1 Educate staff and LIPs involved in
procedures about HAI, central line infection and
importance of prevention
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Must do education in orientation and annually
and if procedure added to your job
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Revised How-to Kit Central Lines
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Central Lines
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Note that under reform law hospitals with ICUs
or NICU must report central lines infections on
the CDC National Healthcare Safety Network
(NHSN)
2. Educate patients and families before inserting
central line about central line associated
bloodstream infection prevention (BSI), as
needed
3. Implement P&Ps to reduce risk of BSI that meet
regulatory and evidenced based standards
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Central Lines 07.04.01
 P&P need to meet the regulatory requirements
 Need to be aligned with the CDC requirements
 And professional standards of care (APIC, AORN,
SHEA, etc.)
 4. Conduct periodic risk assessments for central
line infection, measure BSI (blood stream infection)
rate, and monitor compliance with best practices
and how effective the prevention efforts are
 Need to do risk assessment conducted in the time frames
defined by the hospital
 Surveillance is hospital wide and not targeted
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Central Lines
5. Provide CLAI (central line associated infection)
rate data and prevention outcome measurement to
staff and LIPs and clinicians
6. Use a catheter checklist and standard protocol for
central line insertion
7. Perform hand hygiene before catheter insertion or
manipulation
8. Do not put in femoral vein unless last resort for
adult patients
9. Use standardized supply care or kit for central lines
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Central Lines
10. Use standardized protocol for maximum sterile
barrier precautions during insertion
11. Use antiseptic for skin prep in patients during
insertion that is cited in the scientific literature or
endorsed by professional organizations
12. Use standardized protocol to disinfect catheter
hubs and injection ports before accessing
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Such as wipe vigorously for 15 sections and let dry
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Surveyor will ask to see the protocol or P&P
13. Evaluate all central lines routinely and remove
none essential catheters
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www.cdc.gov/ncidod/dhqp/dpac_uti_pc.html
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Surgical Site Infections (SSI)
 Implement best practices to prevent
surgical site infections
 There are 8 EPs
 1. Educate hospital staff and LIPs involved
in procedures about HAI, surgical site, and
the importance of prevention
 Educate during orientation, annually,
and if added to your job
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Surgical Site Infections
2. Educate patients and families, who are
undergoing surgical procedures, about
preventing surgical site infections (SSI)
3. Implement P&P to reduce SSI that meet
regulations and evidenced based practice
(such as the CDC and other professional
organizations)
4. Conduct periodic risk assessments for SSI,
select measures using best practices or
evidence based guidelines and monitor
compliance with them and how effective they
are
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Surgical Site Infections
5. Measure surgical site infection rates for the
first 30 days following a procedure that does
not involve inserting implantable devices

Measure for the first year procedures involving
implantable devices

Need to follow evidence based guidelines

Surveillance may to targeted to certain procedures
based on hospital risk assessment
6. Provide process and outcome data on SSI to
stakeholders etc, such as the SS infection
rate
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Surgical Site Infections
7. Antimicrobial agents for prophylaxis are
administered according to methods cited in the
scientific literature or endorsed by professional
organizations

Still want to be sure that prophylactic antibiotics are
administered timely in the operating room and
rebolused when indicated
8. When hair removal is necessary, use a method
that is cited in the scientific literature or endorsed
by professional organizations
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www.cdc.gov/hicpac/CAUTI_fastFacts.html
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www.cdc.gov/hicpac/Disinfection_Sterilization/
acknowledg.html
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www.cdc.gov/hicpac/pubs.html
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The End
Questions?
 Sue Dill Calloway RN Esq. CPHRM
AD, BA, BSN, MSN, JD
Medical Legal Consultant
614 791-1468
5447 Fawnbrook Lane
Dublin, Ohio 43017
[email protected]
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