PIC-NICIAP Module on Infecti

on Prevention

Pediatric

Infection

Control in

Nursing Homes, Hospitals

ICU &

Clinics Lecture 4: Infection Control in PICU and Bundle Care

Safer - Healthcare

Lecture Plan – 40 min

0102030405

PICU Practice and precaution

Surgical : Handwash

Skin Pre : PICU

Bundles in PICU

Surveillance & Monitoring

“

3

Everyday Routine

Remove BlazerShirt Sleeve Folded

Remove Watch, Rings etc

On Call DoctorChange into scrubs

Thermal can be worn inside

Hand Wash

Hand Rub

What do you see? What is X?

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive

Enterococcus

culture

The Pathogens are Everywhere

Six bedded PICU

“Your 5 moments for hand hygiene

at the point of care*

*Adapted from the WHO Alliance for Patient Safety 20067

5 moments.mp4

Skin colonized in hours to days

– Staph. aureus, Proteus mirabilis, Klebsiella spp. @ 100-106 CFU /cm2 skin

Perineal/inguinal > axilla > trunk > upper extremities and hands

Dialysis/CRF, diabetes, dermatitis, broad spectrum Abx increase risk

Patients shed 106 squames/day -> widespread contamination of the room

PICU patients are rapidly colonized with pathogenic bacteria

Reviewed in Pittet et al Lancet Infect Dis 2006

Easily Available & Accessible Hand Rub

10

“More AdviseDuring PICU Procedure: Hand preparation

• All hand jewelries (e.g. rings, watches and bracelets) must be removed

• Finger nails should be trimmed to <0.5 cm with no nail polish

• Avoid wearing long sleeves, ties should be tucked in, house coats are

discouraged and wearing scrubs is encouraged.

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“Routine hand washing < 1min

Surgical hand ‘scrub’ 5-6 min

Use of alcohol rubs/gels 20-30 Sec

Hand Hygiene includes

“Before Procedures in PICU

• Surgical Handwash

13

Surgical Hand Wash.mp4

“As a general rule

If the risk is to the patient ‘Sterile’ gloves are required.

If the risk is to the user ‘Non-sterile’ gloves will suffice

16

Gloves

“ Gown• Wear a gown to prevent soiling of clothing and skin during

procedures that are likely to generate splashes of blood, body fluids, secretions or excretions

• The sterile gown is required only for aseptic procedures

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“Shoe and head coverings

They are not required for routine care in PICU

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“

19

Neutropenia and immunological disorderDiarrheaSkin rashesKnown communicable diseaseKnown carriers of an epidemic strain of bacterium.

Screen all PICU patients for the following – they ideally need isolation

Assess the need for isolation / precautions : Daily

20

For Infectious disease patient

We prevent infection from spreading out

Like transplant / chemotherapy ICU Units

We protect immunocompromised patient

For example standard air conditioning

For normal units

Identify The Type Of Isolation Needed

21

“Architecture and layout of

PICU• The unit may be situated close to the OT and ER , but should be away from the main ward areas

• Central air-conditioning systems : recirculated air must pass through appropriate filters

• Recommended that all air should be filtered to 99% efficiency down to 5 μm

• Air movement should always be from clean to dirty areas

• Minimum of 6 total air changes /room/hr, with 2 air changes per hour composed of outside air

• Isolation facility should be with both negative- and positive-pressure ventilations

• Adequate space around beds is ideally 2.5-3 sqm

• Adequate number of washbasins should be installed

• Alcohol gel dispensers are required at the ICU entry, exits, every bed space and every workstation

• There should be separate medication preparation area

• There should be separate areas for clean storage and soiled and waste storage and disposal

• Adequate toilet facilities should be provided 22

Critical Care BundlesWhat are they?

A "bundle" is a group of evidence-based care components for a given disease

that, when executed together, may result in better outcomes

than if implemented individually

CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION

The Central Line Bundle and

YOU!

Sources of intravascular catheter infection

SkinVein

Intraluminal from tubes and hubs

Haematogen from distant sites

Extraluminal from skin

Focus of prevention of infections

SkinVein

Insertion site

Focus of prevention of infections

SkinVein

Insertion site

HubsTubes

Catheters

Incidence density Events per 1000 device-days

Central venous catheter (CVC)2.7/1000 catheter-days

PICCs2.1/1000 catheter-days

Tunneled CVCs1.6/1000 catheter-days

Peripheral venous catheters0.5/1000 catheter-days

Risk for CLABSI

Choose Catheter Wisely

Maximal Barrier Precautions Operator & supervisor (or anyone at risk for crossing the sterile field:

For the Patient For the Assistant (within Field)

Note: people in the same room who are not involved with the procedure (and who are not at risk for crossing the sterile field) do not need to wear maximal barrier precautions

The femoral site should be avoided.• Higher rate of infectious complications• Higher rate of thrombotic complications

The preferred order of preference ( to prevent infection):

1) Subclavian 2) Internal Jugular 3) Femoral

Choice of Site

Merrer, et al. 2001, JAMA; 286:700-7

Central Line Insertion Bundle

Hand hygiene

Maximal barrier precautions

Chlorhexidine skin antisepsis

Optimal catheter site selection

Daily review for line necessity and

prompt removal of lines

Care of Site

Scrubbing injection caps with alcohol for 15 seconds prior to accessing

Maintainace Bundle

Other PointsAntibiotic ointments should not be used at the insertion site because there is a potential risk of developing resistance as well as an increase in the risk of colonization with Candida species.

A higher number of lumens in central line increases infection risk.

Catheters impregnated internally and externally with the antibiotics minocycline and rifampin have been shown lower infection rates compared with externally coated chlorhexidine/sulfadiazine catheters

Tubing for peripheral and central lines should be changed no more frequently than every 72 hours for routine fluids. Infusion sets used for blood, blood products, and lipid infusions should be changed within 24 hours of starting the infusion. For arterial lines, the tubing and the transducer should be changed at 96-hour intervals.

Closed system using collapsible infusion bags

Rosenthal. Am J Infect Control 2004;32:135Franzetti. Epidemiol Infect 2009;137:1041

Epidemiology and Prevention of Bloodstream Infections

Peripheral IV Canula Bundle

Ventilator-Associated Events (VAE)

VAE Definition Algorithm Summary

Positive results of microbiological testing

Possible Ventilator Associated Pneumonia (PVAP)

General evidence of infection/inflammationInfection-related Ventilator-Associated Complication

Ventilator Associated Condition (VAC)

Patient on Mechanical ventilation > 2 daysBaseline period of stability or improvement,

followed by sustained period of worsening oxygenation Respiratory Status Component

Infection InflammationComponent

Additional evidence

FIO2 or Peep

VAP – Physiology

VAP – Prevention Bundle

Elevation of head of bed

Daily 'sedation vacations'

Readiness to extubate

Peptic ulcer disease prophylaxis

Deep-venous thrombosis prophylaxis

Daily oral care with chlorhexidine.

Other Points for VAP prevention

Cuffed ET preferred

Less aspiration risk

Closed ET Suction Catheter preferred

Good Oral Hygiene

.

Cuff PressureOf 20 cm H2O

is essentialTo prevent aspiratio

n

0.12% chlorhexidine oral rinse solution

Other Points in VAP Bundle

The condensate should be routinely removed from the circuit through the use of a trap.

Ventilatory circuits should be changed when visibly soiled or malfunctioning.

Consider noninvasive ventilation whenever possible Prefer oral intubations to nasal unless contraindicated

The heat moisture exchanger may be better than the heated humidifier

Other points in

VAP Bundle

Insertion ◦ Insert only for specific reasons

Urinary output in critical ill Neurogenic bladder dysfunction Prevent contamination of sacral wounds Terminal care

◦ Competent HCW to insert ◦ Aseptic technique ◦ Closed system with bag below bladder

Urinary Catheter Care

Management

◦ Review need for catheter daily◦ Empty when ¾ full and use clean container for each patient◦ Secure catheter to leg/abdomen◦ Urine samples from sampling port only◦ Hand hygiene & PPE before and after any catheter care

Urinary Catheter Care Bundle

Bladder Bundle

Surgical Safety - Bundle‘Zero SSI’ - Goal

Removal of body hair with clippersPre-operative showering with chlorhexidine soapPreparation of the surgical field with alcoholic chlorhexidine 2%Adequacy of antimicrobial prophylaxisIntraoperative and post-operative glycaemic and central temperature control.

Monitoring the compliance to implementation of preventive bundles

Teach – Relearn Bundles RegularlyStaff Feedback is also Important

Thank you