1. Preventing Nosocomial infections in Neonatal Intensive Care UnitsCongresoInternacional de Prevention de InfeccionesIntrahospitalarias Alan Picarillo, MD, FAAP Neonatologist UMassMemorial Healthcare Assistant Professor in Pediatrics University of Massachusetts Medical School 1

2. Disclosures I have no financial interests to disclose for this lecture I will be speaking about off-label use of a medication (chlorhexidine) during this lecture 2

3. Introduction Why are our smallest infants so vulnerable to hospital-acquired infections? 3

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5. Liberian Observer “Chinese doctor performs miracle surgery at JFK Hospital” Liberian Observer January 2010, online edition 5

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9. Introduction Why are our smallest infants so vulnerable to hospital-acquired infections? Very immature infants Immature immune systems Poor skin integrity Surgical procedures Central line placement Long length of stay Overcrowding 9

10. Overall burden of nosocomial infections In the US it is estimated that 5-10% of all hospitalized patients will have a nosocomial infection >90,000 deaths attributable each year to nosocomial infections in the United States 39,788 deaths from auto/motorcycle accidents 16,605 deaths from HIV/AIDS (2008) 138 deaths from airline accidents Can this be stopped? 10 http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf DOT data (1999-2003) CDC data http://www.cdc.gov/hiv/topics/surveillance/basic.htm#ddaids

11. Burden of nosocomial infections in neonates Late onset (>72 hours of age) sepsis occurs in 4.2% of all neonatal ICU admissions and 17.1% of infants <1.5kg. Rates of central line bloodstream infections are 37% higher in neonatal ICU patients than in adult ICU populations Is it possible to reduce nosocomial infections in neonates, or are the infections unavoidable? 11 Vermont-Oxford database (2009) NSHN CLABSI report (2011)

12. Decrease in nosocomial bloodstream infections for infants <1500 gms in Massachusetts NICUs (2006-2010) 12

13. Incidence of nosocomial bloodstream infection by hospital (2006-2010) 13

14. Quality Improvement Institute for Healthcare Improvement (IHI) model Key elements Aims Measures Changes (PBPs) Plan, do, study, act cycles (PDSA) 14

15. Quality Improvement Potentially better practices (PBPs) defined as a set of clinical practices that have the potential to improve the outcomes PBPs can be: Evidence based guidelines Derived from previous improvement efforts Based on literature review Expert recommendations 15

16. PBPs for preventing neonatal nosocomial infections PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients PBP 2: Ensure high compliance with optimal hand hygiene practices PBP 3: Ensure that all vascular catheters are inserted under optimal conditions PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters PBP 5: Remove vascular catheters in a timely manner VON Quality Improvement Kit: preventing nosocomial infection 16

17. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication In NICUs with low nosocomial infection rates, the staff belief was that infections were preventable and represented a breakdown in care NICUs with high rates, staff belief is that infections are inevitable and unavoidable complications of intensive care. A belief among staff that nosocomial sepsis is preventable leads to a motivation to improve. 17

18. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication Aim All staff will demonstrate knowledge of infection control All staff will demonstrate a belief that nosocomial infections represent a failure of optimal care and are preventable in most cases Measure: Percent of staff that accurately answers questions about knowledge of methods to prevent infection Pretest, education, post-test 18

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20. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication Changes to test: Leadership of unit visibly supporting infection prevention program Educational in-service for all staff Fact sheets, posters Create a slogan to help with team chemistry Display hospital’s infection rates for all to see (including parents/families) 20

21. PBP 1:Foster/Support Culture in Which Infection is Considered a Preventable Complication Barriers to change Lack of support from the entire institution to change staff mental model Lack of role modeling by senior leaders and opinion leaders in the hospital Potential risks Excessive exposure of staff to infection prevention can cause desensitization and reduce impact Staff may take offense and become resistant to change if it is implied or stated that they caused the infection and are being blamed 21

22. PBPs for preventing neonatal nosocomial infections PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients PBP 2: Ensure high compliance with optimal hand hygiene practices PBP 3: Ensure that all vascular catheters are inserted under optimal conditions PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters PBP 5: Remove vascular catheters in a timely manner VON Quality Improvement Kit: preventing nosocomial infection 22

23. PBP 2: Ensure high compliance with optimal hand hygiene practices Hand hygiene is an established and widely accepted intervention to reduce healthcare associated infections Recommended by expert bodies such as WHO and Center for Disease Control (CDC) 23

24. PBP 2: Ensure high compliance with optimal hand hygiene practices Aim: All NICU staff will practice optimal hand hygiene before and after every patient contact All staff will follow infection control recommendations about jewelry, accessories and clothing Measure: percentage of patient contacts in which providers practice optimal hand hygiene and have both arms exposed below the elbows. On periodic direct observation all staff will be without artificial nails or accessories (except for plain wedding bands). 24

25. PBP 2: Ensure high compliance with optimal hand hygiene practices Optimal hand hygiene Both arms are bare below the elbows Arms are free of jewelry except for plain wedding rings No artificial nails or colored nails 25

26. Right to Bare Arms Multiple studies of nosocomial infections have implicated caregivers and their hand hygiene practices Stethoscopes, providers’ white coats, cell phones and patient charts have all been found to harbor bacteria and have been attributed to play roles in outbreaks of nosocomial infections Several case reports of providers wearing artificial nails have been implicated in outbreaks of Pseudomonas sepsis in NICUs1 1. Am J Infect Control 2002; 30: 252-4 26

27. PBP 2: Ensure high compliance with optimal hand hygiene practices Optimal hand hygiene Both arms were bare below the elbows Arms are free of jewelry except for plain wedding rings No artificial nails Person sanitized their hands by using alcohol gel or by washing with soap and warm water prior to touching the patient (or patient’s equipment) and then immediately after patient contact 27

28. Donskey C and Eckstein B. N Engl J Med 2009;360:e3 28

29. PBP 2: Ensure high compliance with optimal hand hygiene practices Changes to test: Alcohol gel at convenient locations with easy visibility Offer staff personal alcohol gel dispensers Provide sinks of adequate depth with faucets that are easy to operate Use material from WHO hand hygiene kit “My five moments for hand hygiene” 29

30. Journal of Hospital Infection (2007) 67, 9-21 30

31. PBP 2: Ensure high compliance with optimal hand hygiene practices Changes to test: Alcohol gel at convenient locations with easy visibility Offer staff personal alcohol dispensers Provide sinks of adequate depth with faucets that are easy to operate Use material from WHO hand hygiene kit “My five moments for hand hygiene” Discourage scrubbing of hands and arms with brush Empower families to ask providers if they washed their hands before patient contact 31

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33. PBP 2: Ensure high compliance with optimal hand hygiene practices Barriers to change: Lack of culture where NICU professionals are not accepting of feedback and reminders about hand hygiene Lack of conveniently located alcohol-based dispensers or sinks and faucets Lack of systems to replenish hand hygiene resources Potential risks: Skin irritation from frequent use of alcohol-based hand rub Flammable 33

34. PBPs for preventing neonatal nosocomial infections PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients PBP 2: Ensure high compliance with optimal hand hygiene practices PBP 3: Ensure that all vascular catheters are inserted under optimal conditions PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters PBP 5: Remove vascular catheters in a timely manner VON Quality Improvement Kit: preventing nosocomial infection 34

35. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions Insertion of central venous catheters using good aseptic technique and maximal sterile barrier precautions after performing hand hygiene prevents infection during insertion of catheters High level of evidence to back the interventions 35

36. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions Aim: In all (100%) episodes of vascular catheter insertion, maximal barrier precautions will be followed and optimal preparation of insertion site will be performed Measure: Percentage of catheter insertion episodes in which inserters practiced hand hygiene followed maximal barrier precautions used “skin prep” agent chosen by unit allowed for sufficient drying time prior to insertion attempt. 36

37. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions There are approximately 15 different steps in placing a central vascular catheter under optimal conditions. How to ensure consistent practice among different individuals when performing a task with multiple steps 37

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39. Checklists Dr. Peter Provonost of Johns Hopkins proposed a small 5-item checklist for provider central line insertion. Wash hands with soap Clean the patient’s skin with chlorhexidine Place sterile drapes over entire patient Wear a sterile hat, mask, gown and gloves Place a sterile dressing after the line is in place 39

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41. Checklists Michigan Keystone initiative adopted the checklist developed by Dr. Provonost in their adult ICUs. (>100 ICUs participated) 66% decrease in infections within the first 3 months of introduction of checklist Sustained decrease for the next 4 years 41

42. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions Changes to test: Dedicated central line team with certification and/or demonstrate competency Use of an insertion checklist (US National Patient Safety Goal 07.04.01) Empower nurses to stop procedure if mistakes are made Consider chlorhexidine instead of Povidone-Iodine solution (Betadine) for skin prep Use drapes to cover the procedure field completely 42

43. Chlorhexidine Chlorhexidine is not currently FDA-approved for infants less than 2 months of age. Few studies available concerning use of chlorhexidine Biopatch experience Survey of neonatologists in 2009 reported 61% of university-based NICUs used chlorhexidine for skin preparation for vascular catheters Concern among respondents with infants< 1kg and premature infants <28 weeks gestation 43

44. PBP 3: Ensure that all Vascular Catheters are Inserted Under Optimal Conditions Barriers to change: Long-standing individual habit or unit practice of not wearing full barrier precautions Lack of availability of assistant to use checklist Emergency catheter placement as risk for precautions being skipped or shortcuts taken Controversy over safety of skin prep agents for preterm infants Potential risks: Skin irritation from chlorhexadine 44

45. PBPs for preventing neonatal nosocomial infections PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients PBP 2: Ensure high compliance with optimal hand hygiene practices PBP 3: Ensure that all vascular catheters are inserted under optimal conditions PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters PBP 5: Remove vascular catheters in a timely manner VON Quality Improvement Kit: preventing nosocomial infection 45

46. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters Contamination of the catheter hub contributes significantly to intraluminal colonization of vascular catheters. When entering the catheter, the access port should be prepped with alcohol using sufficient friction and allowing it to dry All connections should be performed under sterile conditions 46

47. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters Aims: During all episodes of luminal access of vascular catheters, optimal sterilization of the hub or entry point will be performed prior to accessing the catheter Measure: The percentage of times the luminal access of vascular catheters in which the providers appropriately sterilize the hub or entry point prior to access. 47

48. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters Changes to test: When infusion tubing is disconnected from vascular catheter, it should be placed on a sterile surface Provide sufficient quantity of alcohol wipes in convenient location Daily exam of catheter entry sites 48

49. PBP 4: Ensure High Compliance with Optimal Practices for the Maintenance and Use of Vascular Catheters Barriers to change: Common problem is not allowing for alcohol to dry before entering the hub When catheters are accessed in an emergency, proper hub care may not be performed Risks: none 49

50. PBPs for preventing neonatal nosocomial infections PBP 1: Foster and support unit culture in which nosocomial infection is considered a preventable complication, not an entitlement of NICU patients PBP 2: Ensure high compliance with optimal hand hygiene practices PBP 3: Ensure that all vascular catheters are inserted under optimal conditions PBP 4: Ensure high compliance with optimal practices for the maintenance and use of vascular catheters PBP 5: Remove vascular catheters in a timely manner VON Quality Improvement Kit: preventing nosocomial infection 50

51. PBP 5: Remove Vascular Catheters in a Timely Manner Indwelling catheters are a definite risk factor for nosocomial infection Prompt removal of a vascular catheter when it is no longer required is supported by good evidence Aims: All vascular catheters will be assessed at least once per day for necessity and unnecessary catheters will be removed Measure: Percentage of vascular catheters that are assessed each day for their necessity during daily rounds by the healthcare team; the need for infant’s vascular catheter is documented in the medical record. 51

52. Walking the line 52

53. PBP 5: Remove Vascular Catheters in a Timely Manner Changes to test: Have a staff member assigned to “walk the line” each day to act as a prompt to ask whether of not a vascular catheter is required for the infant’s care that day Develop strict criteria for removal of central catheters 53

54. PBP 5: Remove Vascular Catheters in a Timely Manner Barriers to change: Staff resistance to catheter removal “in case it may be needed” Lack of understanding that an indwelling catheter is a risk for infection Risks: Premature removal of a vascular catheter and needing to insert a new catheter in the next 1-2 days 54

55. Additional PBPs Avoid understaffing and overcrowding Ensure optimal environmental hygiene Antibiotic stewardship Use of breastmilk for enteral feeding Develop a plan for investigation and response to nosocomial infection outbreak 55

56. Summary Teamwork and leadership buy-in is required for changing the culture and therefore an essential tenet of quality improvement in reducing nosocomial infections Hand hygiene and a rigorous infection control program can prevent most healthcare associated infections Placement of vascular catheters, while clinically important to the care of neonates, also carry significant risk for infection 56

57. Summary Much evidence exists to mitigate the risk of infection from vascular catheters and many NICUs have employed these procedures to reduce the burden of catheter-associated infections Consider a reporting mechanism (“keeping score”) to allow for tracking nosocomial infections over time Identify units with low infection rates, evaluate their policies and procedures to see if they can be utilized in units with high infection rates 57

58. Who are our most important stakeholders? 58

59. Surveillance and Reporting Surveillance for nosocomial infections is crucial for comparing rates among units and studying the effect of preventative interventions Several different methods of reporting: Simple number of infections per time period (month, quarter, year) Number of infections/100 patient days Number of catheter-related infections/1000 catheter days 59

60. Surveillance and Reporting Data should be shared with physician, nursing and administrative leadership Data can be compared to historical data from individual hospital, national data or international reference point data (CDC/NHSN) 60

61. Five stages of grieving over outcome data Denial: these data cannot be right! Anger: why are they picking on me, I have too much work to do! Bargaining: my patients are sicker than everybody else, my NICU is different, I do not agree with the data definitions Depression: I cannot do anything about it anyway… Acceptance: OK, what can I do to improve the outcomes in my NICU Source: Dan Ellsbury, MD Pediatrix Medical Group 61

62. Surveillance and Reporting Mandated reporting in 18 states in the US Massachusetts requires all hospitals to report all nosocomial infections (catheter-related bloodstream infections, surgical site infections, etc) to the Center for Disease Control (CDC) The infection data is provided to the Massachusetts Department of Health and then the completed statistics are publically reported and available for patients and their families 62

63. Collaboratives Several states and countries are forming NICU collaboratives to share and compare data in order to evaluate which NICU has best practice in a certain area share that expertise with other NICUs Data transparency Integral part of a collaborative Tough barrier to overcome Memorandum of understanding between participating hospitals Helps further develop unity and a community of practice for the stakeholders 63