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

Cathet eter er an and A Acces ess I Infect ections Step ephan anie B e Booth AHA, CCHT In c colla llaboratio ion wit ith Ale lex Kalle llen, M MD, M MPH and o an other er C CDC collab aborative e mem ember ers December 2, 2012 Nothing to Disclose 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 ontrol and P revention. National Center for E merging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

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 on spine • Paralysis and other issues • Decreased quality of 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 of cen enter ers an and car are e for ab about 60% 60% o of 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 otent ntial f for or e environ onment ntal b blood ood cont ontamination on  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 ospitalization on 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

Adjusted Hospitalization Rates, by Principal Diagnosis & Modality 51% increase Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; USRDS 2012 Annual Report .

BSI SI R Risk Fa Factors St Study AV f fis istula la AV AV g graft Per erman anen ent Tem emporar ary CVC CV CV CVC NHS N 2006 0.5/100 pt 0.9/100 pt 4.2/100 pt 27.1/100 pt months months months 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 Care Ca Survei eillan ance an e and data a Conduct survei eillan ance e for BSIs an and o other er d dial alysis e even ents feed eedbac ack u using NHSN 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 other 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 Use an e an al alcohol-based chlorhexidine ( (>0.5%) s solution as antise sepsi sis s 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 or 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 oint ntment nt Apply ly b bacit itracin in/g /gramic icid idin in/p /poly lymix ixin in B o oin intment o or or c chlorhexi xidine- povido po done-iod odine ointment nt to o catheter e exi xit s sites during impregnated s sponge dressing c g change OR u use a chlorhexidine-impreg egnated ed dressi ssing 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 Per erform monthly han and hygien ene au e audits w with feed eedbac ack of ob observation ons result lts to clin linic ical l staff. Cathet eter er c car are/ e/ Per erform quar arter erly au audits o of vas ascular ar ac acces ess c car are e an and vas ascular ar ac acces ess cathet eter er ac acces essing t to en ensure ad e adher eren ence e to ob observation ons 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 ont-lin line clin linic ical l staff. http://www.cdc.gov/dialysis/collaborative/interventions/index.html Collaborative Audit Tools & Protocols http://www.cdc.gov/dialysis/collaborative/tool-resources/index.html

Inter erven entions: Education & Cathet eter er Re Reduction Staf aff ed education an and Provide regular training o g of s staff o on i infection control compet eten ency 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 Provide e stan andar ardized ed ed education t to al all p patien ents on an and en engag agem emen ent infe in 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

Bloodstream infection rates before and after intervention in 17 facilities participating in the CDC Dialysis Bloodstream Infection Prevention Collaborative 31% decrease 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

Access-related bloodstream infection rates before and after intervention in 17 facilities participating in the CDC Dialysis Bloodstream Infection Prevention Collaborative 53% decrease 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 /