Cathet eter er an and A Acces ess I Infect ections Step - - PowerPoint PPT Presentation

Step ephan anie B e Booth AHA, CCHT In c colla llaboratio ion wit ith Ale lex Kalle llen, M MD, M MPH an and o

• ther

er C CDC collab aborative e mem ember ers

December 2, 2012 Nothing to Disclose

Cathet eter er an and A Acces ess I Infect ections

Division of Healthcare Quality Promotion National Center for E merging and Zoonotic Infectious Diseases

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the C enters for Disease C

• ntrol and P

revention.

Introduc uction/ n/Backgr kground und

 2003:

2003: f first unlicensed dia ialy lysis is t technic icia ian

 2005:

2005: s studied and rec ecei eived ed C CCHT

 2007: b

bec ecam ame e chief ef techni hnician a n and nd e educ ucator

 2008:

2008: b bio-med edical al an and wat ater

• On NR

AA list of experts

 2010:

2010: s supervisor

 2012:

2012: d dialysis coordinator

What makes me want to change things?

• Perfect dialysis

patient

• Infection settled
• n spine
• Paralysis and other

issues

• Decreased quality
• f life

Summa mmary

 Highl

ghligh ght s several inf nfection n prevention n issue ues affecting ng the c e car are e of c chronic outpatien ent dial alysis patien ents

 Disc

scuss b ss bloodst stream i infections s and accesse sses

 CDC c

colla llaborativ ive

• Catheter care
• Access care

 Wha

hat can y n you d u do t to he help?

Dia ialy lysis is in in the Unit ited S States

 More t

e than an 5,600 dial alysis cen enter ers

 Provide c

e car are e for ab about 4 413,000 patien ents on P PD or HD (384, 384,000 H 000 HD)

 Cen

enter ers ar are u e usual ally f frees eestan anding

 Two provider

ers have e ab about 6 60% o

• f cen

enter ers an and car are e for ab about 60% 60% o

• f patients

US R DS 2012 Annual R eport

Infectio ion P Preventio ion in in O Outpatie ient Dia ialy lysis is Settings ngs

 Mini

nimum um stand ndards set by CMS C Cond nditions ns f for Cover erag age

 Gen

ener eral ally f follows CDC’s R Rec ecommen endations for Preventing T ng Trans nsmission n of Inf nfections ns Among ng Chr hroni nic Hemodialysis P Patients (2001) 2001)

 Most f

fac acilities es not over erseen een by I Infec ection P Preven entionist

• Infection Prevention generally responsibility of a single facility staff

member (nurse)

• This person often has multiple responsibilities

CDC recommendations available at: http://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf

Issue ues Sur urround unding I ng Inf nfection n Control in n Outpatie ient Dia ialy lysis is Settin ings

 Vuln

lnerable le p popula latio ion

• Multiple exposures to healthcare (MDR

Os)

 Freq

equen ent ac acces ess t to b bloodstream eam r req equired ed

 High pot

• tent

ntial f for

• r e

environ

• nment

ntal b blood

• od cont
• ntamination
• n

 On

On-sit ite a ancilla illary support often la lackin ing

• Lab capacity
• Consultation

 Often

en crowded ed/shar ared ed, “high i inten ensity” t trea eatmen ent sp space

• E

mphasis on efficiency

BLOODSTREAM I INFECTIONS

Cha hange nge i in A n Adjus usted All-Cau ause e & C Cau ause- Speci cific c Hos

• spitalization
• n Rates

es, by Modal ality

Period prevalent E S R D patients. Adj: age/gender/race/primary diagnosis US R DS 2012 Annual R eport

Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; USRDS 2012 Annual Report.

Adjusted Hospitalization Rates, by Principal Diagnosis & Modality

51% increase

BSI SI R Risk Fa Factors

St Study AV f fis istula la AV AV g graft Per erman anen ent CV CVC Tem emporar ary CV CVC NHS N 2006 0.5/100 pt months 0.9/100 pt months 4.2/100 pt months 27.1/100 pt months Dopirak et al. 0.13/100 pt months 3.5/100 pt months

Klevens et al. Semin Dial 2008:; 21:24-28 Dopirak et al. Infect Control Hosp E pidemiol 2002; 23:721-724

2009 – Estimated to be 41,000 central line-associated bloodstream infections in US hospitals 2008 – Estimated to be 37,000 access-related bloodstream infections among outpatient dialysis patients with catheters

Inter erven entions: Survei eillan ance e an and Cathet eter er Ca Care

Survei eillan ance an e and data a feed eedbac ack u using NHSN Conduct survei eillan ance e for BSIs an and o

• ther

er d dial alysis e even ents using C CDC’s N National al Heal ealthcar are e Saf afet ety N Net etwork (NHSN). Cal alculate e fac acility rates es an and c compar are t e to rates es in o

• ther

er facilit ilitie ies usin ing NHSN. A Activ ively ly share r result lts wit ith f front- lin line c clin linic ical s l staff. Chlo lorhexid idin ine fo for skin in antise sepsi sis s Use an e an al alcohol-based chlorhexidine ( (>0.5%) s solution as the fir irst lin line agent fo for s skin in antis isepsis is, partic icula larly ly fo for central l line i insertion and during d dressing change ges. Po Povidone-io iodin ine, prefe ferably ly wit ith a alc lcohol, l, o

• r 7

70% alc lcohol l ar are al e alter ernatives es. Catheter h hub ub cleansing g Clean eanse e cathet eter er hubs w with an an ap appropriate an e antisep eptic af after er the c e cap ap i is rem emoved ed an and b bef efore ac e acces essing. Ant ntimicrobial o

• int

ntment nt

• r c

chlorhexi xidine- impregnated s sponge dressi ssing Apply ly b bacit itracin in/g /gramic icid idin in/p /poly lymix ixin in B o

• in

intment o

• r

po povido done-iod

• dine ointment

nt to

• catheter e

exi xit s sites during dressing c g change OR u use a chlorhexidine-impreg egnated ed sp sponge d dressi ssing.

http://www.cdc.gov/dialysis/collaborative/interventions/index.html

Inter erven entions: Prac actice e Audits with Feed eedbac ack

Han and h hygien ene e

• b
• bservation
• ns

Per erform monthly han and hygien ene au e audits w with feed eedbac ack of result lts to clin linic ical l staff. Cathet eter er c car are/ e/ vas ascular ar ac acces ess

• b
• bservation
• ns

Per erform quar arter erly au audits o

• f vas

ascular ar ac acces ess c car are e an and cathet eter er ac acces essing t to en ensure ad e adher eren ence e to rec ecommen ended ed proced edures

• es. T

This includes es as asep eptic techni hnique ue whi hile c conne nnecting a ng and nd d disconne nnecting ng cathe heters a and nd d dur uring ng dressing c ng cha hange

• nges. S

Sha hare r resul ults with f front

• nt-lin

line clin linic ical l staff.

Collaborative Audit Tools & Protocols http://www.cdc.gov/dialysis/collaborative/tool-resources/index.html http://www.cdc.gov/dialysis/collaborative/interventions/index.html

Inter erven entions: Education & Cathet eter er Re Reduction

Staf aff ed education an and compet eten ency Provide regular training o g of s staff o

• n i

infection control topics, including ac acces ess car are an e and as asep eptic t tec echnique. Per erform c compet eten ency e eval aluation f for skills such as as cathet eter er car are e an and ac acces essing at leas east e ever ery 6 6-12 m months and u upon hire. . Pati tient e t educati tion an and en engag agem emen ent Provide e stan andar ardized ed ed education t to al all p patien ents on in infe fectio ion preventio ion topic ics in inclu ludin ing v vascula lar a access care, hand hygiene, r risks related to catheter u use, recognizing signs of i infection, a and i instructions for a access man anag agem emen ent w when en away from the d e dial alysis unit. Cathet eter er r red eduction Pursue efforts t to reduce catheters ( (e.g., t thr hrough patient ed education, v vas ascular ar ac acces ess coordinator) by y identifyi ying bar arrier ers t to p per erman anen ent vas ascular ar ac acces ess p plac acem emen ent an and cathet eter er r rem emoval al.

http://www.cdc.gov/dialysis/collaborative/interventions/index.html

31% decrease

Bloodstream infection rates before and after intervention in 17 facilities participating in the CDC Dialysis Bloodstream Infection Prevention Collaborative

Yi S et al. Reduction in Bloodstream Infections in Outpatient Hemodialysis Centers Participating in a CDC Prevention Collaborative. 2012 Annual NKF Spring Clinical Meeting, Washington DC

53% decrease

Access-related bloodstream infection rates before and after intervention in 17 facilities participating in the CDC Dialysis Bloodstream Infection Prevention Collaborative

Yi S et al. Reduction in Bloodstream Infections in Outpatient Hemodialysis Centers Participating in a CDC Prevention Collaborative. 2012 Annual NKF Spring Clinical Meeting, Washington DC

Colla llaborativ ive Websit ite & Tools ls

http://www.cdc.gov/dia ialy lysis is/colla llaborativ ive/

Summar ary: F Future N e Need eeds

 Antim

imic icrobia ial u l use

• Better understanding of inappropriate use
• Interventions to target common areas:
• Blood culturing
• S

urgical prophylaxis

• F

ailure to de-escalate or discontinue antimicrobials with negative cultures

 MDRO

ROs

• E

valuation of MDR O transmission in these settings

• Need for change in R

ecommendations

• Additional high risk groups (e.g., Patients on antibiotics)

 BSI p

prevent ntion

• n
• Better understanding of the E

pidemiology

• Additional interventions (e.g., role of needleless connectors)

What c can an a t a tec ech d do?

 Recogni

gnize your ur i importanc nce

 Mak

ake e sure y e you follow p policy an and p proced edure

• Accessing catheters
• Cleaning accesses
• Don’t cut corners

 Make s

sugge uggestions ns for cha hange nge

• S

tep forward and speak up

• Create a culture of safety

 Encourage unit

it p partic icip ipatio ion in in C CDC colla llaborativ ive

Tha hank nks for y your ur a attention. n.

Quest stions? s?