Non-pulmonary Critical Care - part 10 pot

Patient contact, including contact with wounds and intact skin, can result in health care worker hand contamination.115–118 Areas of high nosocomial pathogen concentration on patient ski

pathogenic, they are of nosocomial significance when

introduced to the patient by invasive procedures and

indwelling devices Transient flora are acquired by

pa-tient contact or from the inanimate environment, are

loosely attached to the skin, and are more amenable to

removal by hand washing.114 These organisms are of

nosocomial significance and include MRSA,

vancomy-cin-resistant Enterococcus (VRE), and multiple

drug-resistant gram-negative rods.

Nosocomial pathogens can be recovered from

multiple hospital scenarios Patient contact, including

contact with wounds and intact skin, can result in health

care worker hand contamination.115–118 Areas of high

nosocomial pathogen concentration on patient skin

in-clude the axillae, trunk, perineum, inguinal region, and

hands.115,117,118

Hand hygiene should be practiced by health care

workers before and after all patient contact Several

methods of hand hygiene exist and include washing

with plain soap and water or using an antibacterial agent

such as alcohol, chlorhexidine gluconate, or triclosan as

either detergent washes or waterless hand rubs Soap and

water can remove loosely adherent transient skin;

how-ever, these agents have minimal antimicrobial activity.113

For effective reduction of bacterial count, a 30-second

hand rub is recommended Several factors should be

considered when choosing a hand hygiene agent for the

ICU, including microbicidal effect, skin irritability, ease

of use, and staff acceptance.

With respect to skin irritability, several studies

have demonstrated that hand washing with both plain

soap and water can result in skin irritation, dryness, and a

paradoxical increase in microbial counts on the

skin.119,120Medicated hand washing agents are

bacter-icidal (alcohol, chlorhexidine gluconate, triclosan) and

effectively reduced bacterial counts on the hands

More-over, chlorhexidine has the advantage of producing a

residual antibacterial effect, thereby limiting hand

re-contamination until the time of the next hand hygiene

episode.121

At least one study supports the effectiveness of

chlorhexidine as a hand antiseptic agent with regard to

infection control end points Doebbeling et al compared

different hand hygiene agents with the end result of

hand hygiene compliance observation and the reduction

of nosocomial infections in an ICU setting.122During an

8-month period, a prospective, multiple crossover trial

was conducted in three ICUs The trial involved 1894

adult patients exposed to alternate months of either

chlorhexidine or 60% alcohol solution with the optional

use of a nonmedicated soap A greater frequency of

nosocomial infections was seen with the combination

of alcohol and soap compared with the chlorhexidine

hand hygiene agent (202 vs 152) However, during

periods of chlorhexidine use, there was a corresponding

decrease in the rate of nosocomial infections and an

increase in hand hygiene compliance Although the microbicidal effect of chlorhexidine may have resulted

in fewer infections, the difference in nosocomial infec-tions was also likely due to increased compliance with hand hygiene practices Regardless, owing to their bac-tericidal properties, medicated hand hygiene agents, including chlorhexidine, alcohol, and triclosan, should

be considered products of choice, especially in environ-ments with elevated rates of drug-resistant pathogens Sadly, data on health care worker hand hygiene practice remain discouraging The reasons for poor compliance are multiple and have been studied by numerous investigators Observational studies of hand hygiene compliance report compliance rates of 5 to 81%.123–125Factors commonly cited that may influence poor adherence with hand hygiene include insufficient time, understaffing, patient overcrowding, lack of knowledge of hand hygiene guidelines, skepticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants, and lack of hand hygiene pro-motion by the institution.113

Even in the ICU setting, hand hygiene remains notoriously poor A British study performed both an observation and detailed survey of hand hygiene practices

in 16 ICUs.114Compliance with hand hygiene and proper glove use, observed in 381 (non-nurse) health care pro-fessionals, ranged from 9 to 25% Survey data suggested that poor compliance with hand hygiene in the ICU was secondary to multiple issues, including ineffective com-munication of infection control recommendations, insuf-ficient promotion of hand antisepsis, and a deficiency of infection control education.114 Poor compliance with hand hygiene was similarly observed by Kaplan and McGuckin in a tertiary-care American hospital.126 Physi-cian compliance with hand hygiene was 19%, whereas compliance by the nursing staff was 63% Greater com-pliance with hand hygiene was observed among the nursing staff with a 1:1 bed to sink ratio than those with a greater bed to sink ratio (76% vs 51%).126 Efforts to improve hand hygiene in the ICUs will likely require multiple, simultaneous interventions, in-cluding increased access to hand hygiene products In a study by Bischoff et al where alcohol-based hand sani-tizers were introduced to an ICU, the greatest increment

in hand hygiene compliance was observed when the hand sanitizer to health care worker ratio went from 1:4 to 1:1, thereby underscoring the importance of accessibility.123 The CDC now suggests promoting alcohol-based hand sanitizer access both by bedside dispensers and by health care worker pocket-sized dispensers.113Similarly, Pittet and colleagues127 improved overall compliance with hand hygiene by implementing a hospital-wide program with emphasis on education, promotion, and bedside, alcohol-based hand disinfection The 3-year campaign consisted primarily of hand hygiene promotion through large, conspicuous posters promoting hand hygiene

throughout patient care areas The project was supported

and heavily promoted by senior hospital management.

Additionally, alcohol-based hand rub solutions were

distributed in large amounts, mounted on beds/walls,

and given to health care workers to encourage packet

carriage for convenience of use During the study, seven

institution-wide hand hygiene observational surveys were

performed twice yearly Compliance with hand hygiene

improved from a baseline of 44% in 1994 to 66% in 1997.

Of note, hand hygiene improved markedly among

nurs-ing staff but remained poor for physicians Additionally,

over the study period, the overall prevalence of

nosoco-mial infections decreased from 16.9 to 9.9%, MRSA

transmission rates decreased from 2.16 to 0.93 episodes

per 10,000 patient days, and the consumption of

alcohol-based hand rub increased from 3.5 to 15.4 L per 1000

patient days Unfortunately, because multiple

interven-tions were employed simultaneously, the relative effect of

each component was difficult to properly assess Thus,

although the most efficient and effective means for

sustained improvements in hand hygiene compliance

have yet to be defined, measures should at least include

efforts that stress increased use of accessible, easy to use,

medicated hand hygiene products, coupled with a

hospi-tal-wide, administration-supported, high priority hand

hygiene educational and promotional campaign.

The Use of Gloves and Gowns to Limit

Cross-Transmission of Nosocomial Pathogens

Gloves should be worn to prevent health care worker

exposure to bloodborne pathogens and to prevent

con-tamination of hands with drug-resistant pathogens

dur-ing patient care activities Nevertheless, even with proper

glove use, hands may become contaminated during the

removal of the glove or with microtears that allow for

microorganism transmission.128Nevertheless, glove use

should not be a substitute for hand hygiene The

promotion of glove use may increase compliance with

hand hygiene protocols A recent study by Kim and

colleagues observed the rate of hand disinfection with

glove use and patient isolation.129 In this prospective,

observational study, hand hygiene and glove use

com-pliance were observed and measured in two ICUs of a

tertiary-care hospital Over a 40-hour period of

obser-vation, 589 opportunities for hand disinfection were

noted Overall hand hygiene compliance was 22% The

investigators found a statistically significant, positive

association between glove use and subsequent hand

disinfection (RR 3.9, 95% CI 2.5 to 6.0) Isolation

precautions did not significantly increase hand hygiene

compliance For infection control purposes, glove use

should be promoted as a means of limiting hand

con-tamination with drug-resistant pathogens such as

MRSA and VRE Additionally, glove use and hand

hygiene should be promoted concurrently.

Gowns Gowns have been used as part of contact precaution protocols to limit the spread of nosocomial pathogens.

Several studies have documented colonization of health care worker apparel and instruments during patient care activities without the use of gowns.130,131One study by Boyce et al demonstrated the efficacy of disposable gowns in the prevention of health care worker clothing contamination.132 Srinivasen et al prospectively meas-ured the effect of gown and glove use in a 16-bed medical ICU of a tertiary-care medical center.133Over

a 3-month period, all admissions to a medical ICU were screened for VRE by perirectal swab Patients who were culture positive for VRE were isolated by hospital policy, requiring the use of gown and gloves for patient care For the following 3 months, precautions were changed to glove use alone The VRE acquisition rate was 1.8 cases per 100 patient days at risk in the gown/glove group and 3.78 per 100 patient days during glove use alone (p ¼ 04).

Nevertheless, with regard to the end point of colonization and cross-transmission, there may be little incremental benefit to gown use over proper glove use and hand hygiene alone Pelke et al studied the effect of gowning in a neonatal ICU over an 8-month time frame employing alternating 2-month gowning and nongown-ing cycles.134The outcomes of interest were colonization patterns, necrotizing enterocolitis, respiratory syncytial virus, other nosocomial infections, mortality and hand washing The investigators failed to document any sig-nificant difference between the gowning and nongown-ing cohorts with respect to the rates of bacterial colonization, infection type, or mortality In addition,

no significant difference in hand hygiene practice was observed.134

Slaughter et al prospectively compared universal gloving versus universal gown and glove use on the acquisition of VRE in a medical ICU.135 Half of the

16 bed ICU was designated for universal gown and glove use during patient care activities, the other half was universal gloving for patient care activities Rectal sur-veillance cultures were taken daily from patients along with monthly environmental cultures of bed rails, bed-side tables, and other common objects in patient rooms.

The investigators found no superiority in the universal use of gowns and gloves versus use of gloves alone in preventing the rectal colonization of VRE in a medical ICU cohort.135 Thus, although the use of gloves and gowns is the convention for limiting the cross-trans-mission of nosocomial pathogens, the incremental ben-efit of gown use, in endemic settings, may be minimal.

TRANSMISSION-BASED PRECAUTIONS Transmission Based Precautions are for selected patients who are known or suspected to harbor certain infections.

These precautions are divided into three categories,

reflecting differences in disease transmission Some

dis-eases may require more than one isolation category The

essential elements of transmission-based precautions are

summarized in the following sections.

Airborne Precautions

Airborne precautions are designed to prevent diseases

that are transmitted by droplet nuclei or contaminated

dust particles Droplet nuclei, because of their size, can

remain suspended in the air for prolonged periods, even

after the infected patient has left the room Agents

requiring airborne precautions include Mycobacterium

tuberculosis, varicella-zoster virus, influenza, and measles

virus All patients needing airborne precautions should

be assigned to a private room with special engineering

and ventilation considerations The door to this room

must be closed at all possible times The isolation room

must be maintained at negative pressure in comparison

to the surroundings As such, droplet nuclei are

pre-vented from traveling into the environment In addition,

the air within the isolation room should either be vented

to the outside or passed through high-efficiency particle

filters.136

All personnel entering the isolation room are

required by federal regulations to don masks for

respi-ratory protection If a patient must move from the

isolation room to another area of the hospital, the patient

should be wearing a mask during the transport Anyone

entering the isolation room to provide care to the patient

must wear a special mask called a respirator These

respirator masks are approved by the National Institute

for Occupational Safety and Health and are capable of

filtering 1 mm particles with an efficiency of 95% (N-95

mask) By regulation, all health care workers must be fit

tested for N-95 masks and must be taught to check for

proper fit each time prior to use.136 Rapid airborne

isolation of patients with known or suspected

multi-drug-resistant M tuberculosis, along with proper N-95

mask use by health care workers, is essential to limit the

spread of this pathogen.

Droplet Precautions

Droplet precautions prevent the transmission of

organ-isms that travel via droplets generated during phonation,

sneezing, coughing, or invasive respiratory tract

proce-dures These particles are not suspended in the air for

extended periods and typically do not travel beyond

several feet from the patient Patients who require

droplet precautions should be placed in a private room

or should be cohorted with a roommate who is infected

with the same organism The door to the room may

remain open Health care workers should wear a mask

when within 3 ft of the patient Patients moving about

the hospital away from the isolation room should wear a mask Examples of diseases requiring droplet precau-tions are meningococcal meningitis, Haemophilus influ-enza, influinflu-enza, mumps, and German measles (rubella).

Contact Precautions Contact precautions prevent spread of organisms from

an infected patient through direct (touching the patient)

or indirect (touching surfaces or objects that have been in contact with the patient) contact This type of precaution requires the patient either be placed in a private room or

be cohorted with a roommate with the same infection Health care workers should don gloves upon entering the room After patient care or environmental contact, the gloves should be removed and hand hygiene should

be performed prior to leaving the room In addition, the use protective gowns has been advocated to decrease the risk of health care worker garment contamination Pa-tient care items used for a paPa-tient in contact precautions, such as a stethoscopes and blood pressure cuffs, should not be shared with other patients unless they are properly cleaned and disinfected before reuse Patients should be restricted to the isolation room.

Contact precautions are indicated for patients with drug-resistant pathogens such as MRSA, VRE, and multidrug-resistant gram-negative rods In addition, contact isolation is recommended for diarrheal illnesses

of infectious origin and for infections with Clostridia difficile.

Potential Adverse Effects of Isolation Practices The use of strict isolation practices may have a detri-mental impact on the process and quality of patient care Evans et al prospectively observed surgical patients both

in the ICU and on a general surgical floor Both in the ICU and on the surgical floor, surgical patients in contact isolation had fewer health care worker visits and less contact time overall despite a higher severity

of illness as measured by APACHE (acute physiology and chronic health assessment) II score.137 Stelfox

et al138studied the quality of medical care received by patients isolated for MRSA-related infection control precautions using a case control study design Although isolated and control patients had similar baseline char-acteristics, isolated patients were twice as likely as non-isolated patients to experience adverse events during their hospitalization These adverse events included supportive care measures and process of care measures such as days with incomplete or absent vitals signs, and days without documented nursing and physician prog-ress notes Additionally, patients on MRSA contact isolation expressed greater dissatisfaction with the qual-ity of their treatment.138Similarly, Saint and colleagues observed in a prospective cohort study of two in-patient

medical services, that patients in contact isolation were

half as likely to be examined by an attending physician as

nonisolated patients.139

Contact isolation may have a detrimental

psycho-logical impact on patients One cross-sectional matched

case control study compared contact-isolated versus

nonisolated elderly patients.140 The level of depressive

and anxiety symptoms exhibited by the contact isolation

group exceeded that of the noncontact isolation group.

Catalano et al prospectively studied the impact of

con-tact isolation on anxiety and depression in noncritically

ill hospitalized patients.141Patients in contact isolation

for either MRSA or VRE were compared with other

hospitalized patients with infectious diseases not

requir-ing isolation All patients were evaluated with the

Hamilton Anxiety and Depression Rating scale at

base-line and then later during the hospital course Although

no significant differences in baseline anxiety and

depres-sion scores were noted, for patients in contact isolation,

statistically significant higher scores on both scales were

reported later during the course of hospitalization.

Thus the optimal strategy for control of endemic,

resistant pathogens such as MRSA or VRE has yet to be

defined ICU directors will have to weigh the

infection-control benefits of patient isolation against the potential

risk of adverse events.

INFECTION CONTROL PROCESS-OF-CARE

MEASURES

Traditional infection control programs involve

surveil-lance and feedback of outcome measures, such as BSI

and VAP rates.142 Outcome measures are, however,

uncommon events that take longer to observe and also

may not directly relate to individual or group

perform-ance because they are frequently affected by factors

related to the patient and the healthcare system.143,144

However, process measures are attractive for several

reasons They provide operational and measurable

rep-resentation of performance, relate to individual and/or

group performance, and are easier to measure than

outcomes By potentially increasing overall

accountabil-ity, they create opportunities to monitor and improve

performance Provided a process measure and outcome

are linked, interventions that improves the process

measure should theoretically improve the outcome.145

In addition, several recent studies have shown that

performance feedback and accountability can have a

positive influence on hand hygiene compliance and on

the reduction of CRBSI and catheter-related urinary

tract infections.146,147

Berenholtz et al studied the effect of a

multi-faceted systems intervention on catheter-related BSIs in

the ICU.41The strategy included a quality improvement

team that implemented five interventions These were

staff education, the creation of a catheter insertion cart to

minimize the steps of catheter insertion, and the stand-ardized questioning of daily providers whether catheters could be removed.41 Most importantly, a checklist to ensure adherence to evidence-based guidelines for pre-venting CRBSIs was implemented along with the em-powerment of nurses to stop the catheter insertion procedure if a violation of the guidelines was observed.

Evidence-based catheter insertion process-of-care meas-ures included a nurse’s checklist for observed hand hygiene, patient skin antisepsis, and proper use of sterile gloves, gown, and drape Additionally, the checklist included confirmation that all personnel complied with infection control precautions and that a sterile field was maintained during the procedure The investigators observed that physicians followed infection control guidelines during 62% of the procedures During the intervention time period, a nursing intervention was required in 32% of all CVC insertions Following the intervention, the CRBSI rate in the study ICU de-creased from 11.3/1000 catheter days in the first quarter

of 1998 to 0/1000 catheter days in the fourth quarter of

2002 The CRBSI rate in the control ICU was 5.7/1000 catheter days in the first quarter of 1998 and 1.6/1000 catheter days in the fourth quarter of 2002 (p ¼ 56) As per the estimates of Berenholtz et al, the initiative may have prevented 43 CRBSIs, eight deaths, and

$1,945,922 in additional costs per year in the study ICU.

Wall et al similarly studied the impact of using real-time process measures to reduce catheter-related BSIs in the ICU.39An interdisciplinary team developed

a standardized, nursing checklist for CVC insertion.

Infection control practitioners scanned the completed checklists into a computerized database, thereby gener-ating real-time measurements for the process of CVC insertion These infection control process measures al-lowed the ICU team to directly monitor adherence to evidence-based guidelines After 2 years, the investiga-tors reported a persistent and historically low CRBSI rate Thus it appears that multifaceted programs ensur-ing maximal adherence with evidence-based infection control guidelines are effective in reducing the incidence

of catheter-related BSIs in the intensive care setting.

CONCLUSION The prevalence of hospital-acquired, antibiotic-resistant pathogens has increased significantly over the past

20 years Hospital infection control programs are seen

as increasingly important for the control of antibiotic-resistant organisms Strategies to control the spread of hospital-acquired infections by drug-resistant pathogens are multiple The patient, the health care worker, and the environment are reservoirs for drug-resistant pathogens.

For high-risk patients colonized with MRSA, such as surgical candidates and those in ICU, decolonization with nasal mupirocin should be considered Patients

colonized with resistant pathogens such as MRSA, VRE,

and drug-resistant gram-negative rods can contaminate

the environment As such, all health care facilities should

develop policies for the terminal and periodic disinfection

of patient care areas and environmental services

Cross-transmission of nosocomial pathogens by the hands of

health care workers has been well documented

Metic-ulous hand hygiene should be practiced with medicated

hand washing agents (alcohol, chlorhexidine gluconate,

triclosan) that are bactericidal and effectively reduce

bacterial counts on the hands Measures to promote

hand hygiene compliance should include efforts that

stress increased use of accessible, easy to use, medicated

hand hygiene products, coupled with a hospital-wide,

administration-backed, high priority hand hygiene

cam-paign Glove use is beneficial in limiting the

contami-nation of health-care worker hands but is not a substitute

for hand hygiene Concerns about the contamination of

personnel clothing with nosocomial pathogens has led to

the use of gowns for patients in contact isolation The

incremental benefit of gowns and gloves use may be

minimal Transmission-based precautions are useful for

the control of nosocomial infections and include contact,

airborne, and droplet precautions Aggressive surveillance

for asymptomatic reservoirs may be of value but is not

without controversy, including questions about efficacy

and effect on quality of care Other considerations for an

infection control program include antibiotic control

pro-grams and surveillance systems for infections with

noso-comial pathogens This type of surveillance is essential for

establishing endemic rates, defining outbreaks, and

de-veloping institution-specific antibiograms In the end,

the purpose of a hospital infections surveillance program

is to define endemic rates, recognize outbreaks, and

obtain data of value in recognizing the extent and

causation of the infections These data are later applied

for the planning and implementation of risk reduction

policies and interventions.

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