Infec control measures in icu day in life of bacterium-mgh

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Infection Control Measures in the Infection Control Measures in the ICU:ICU:

A day in the life of a bacterium in A day in the life of a bacterium in the ICUthe ICU

B. Taylor Thompson, MDB. Taylor Thompson, MD

Director, MICUDirector, MICUMassachusetts General HospitalMassachusetts General HospitalAssociate Professor of MedicineAssociate Professor of Medicine

Harvard Medical SchoolHarvard Medical School

[email protected]@partners.org

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Presentation Presentation OutlineOutlineNosocomial transmission Nosocomial transmission

•Where bacteria live and how Where bacteria live and how they get aroundthey get around

•Infection Control in the ICU:Infection Control in the ICU:– Central role for and hygieneCentral role for and hygiene

•Review the MGH experienceReview the MGH experience

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WHO Global Safety WHO Global Safety ChallengeChallenge

First Target (2005-2006)First Target (2005-2006)– Health Care Associated Health Care Associated

InfectionsInfections– Hand Hygiene as cornerstoneHand Hygiene as cornerstone

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5 Essential Steps for Cross 5 Essential Steps for Cross TransmissionTransmission

Pittet et al Lancet Infect Dis 2006

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ICU patients are rapidly ICU patients are rapidly colonized with pathogenic colonized with pathogenic bacteriabacteria• Skin colonized in hours to daysSkin colonized in hours to days

– Staph. aureus, Proteus mirabilis, Klebsiella Staph. aureus, Proteus mirabilis, Klebsiella spp. present @ 100-10spp. present @ 100-1066 CFU /cm CFU /cm22 skin skin

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

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

• Patients shed 10Patients shed 106 6 squames/day -> squames/day -> widespread contamination of the roomwidespread contamination of the room

Reviewed in Pittet et al Lancet Infect Dis 2006

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Transmission to Hands from Transmission to Hands from Skin and EnvironmentSkin and Environment


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Transfer to the hands of health Transfer to the hands of health care workers (HCWs) hands: Icare workers (HCWs) hands: I

• ““Clean Activities” (lifting, taking Clean Activities” (lifting, taking radial artery pulse, measuring blood radial artery pulse, measuring blood pressure)pressure)– Up to 100-1000 cfu from HCWs hands Up to 100-1000 cfu from HCWs hands

• HCWs intercepted before hand wash HCWs intercepted before hand wash in MRSA colonized patientin MRSA colonized patient– 17% of worker’s gloves positive 17% of worker’s gloves positive

Phillips, BMJ 1977; McBride, J Hosp Inf 2004

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Transfer to the hands of health Transfer to the hands of health care workers (HCWs) hands: IIcare workers (HCWs) hands: II

• Surveillance cultures of HCWs hands in ICUSurveillance cultures of HCWs hands in ICU– 21% of MDs; 5% of nurses positive (n=328)21% of MDs; 5% of nurses positive (n=328)

• Serial Cultures of NSICU HCWs hands Serial Cultures of NSICU HCWs hands – 100% positive for GNR and 64% positive for staph 100% positive for GNR and 64% positive for staph

aureus at least onceaureus at least once

• Rings, artificial or long nails, dermatitis Rings, artificial or long nails, dermatitis increase frequency of hand contamination of increase frequency of hand contamination of HCWsHCWs

Daschner, J Hosp Inf 1988; Maki, Ann Int Med 1978; Trick, Clin Inf Dis 2003

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More contamination with more More contamination with more carecare

Pittet, Arch Int Med 1999

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Contamination of Healthcare Contamination of Healthcare Workers with VRE during Workers with VRE during Routine Patient ExaminationsRoutine Patient Examinations

At least one siteAt least one site 33/49 (67%)33/49 (67%)

Gloves (Hands)Gloves (Hands) 31/49 (63%)31/49 (63%)

GownsGowns 18/49 (37%)18/49 (37%)

StethoscopesStethoscopes 15/49 (31%)15/49 (31%)

All three sitesAll three sites 12/49 (24%)12/49 (24%)

Stethoscope after wipeStethoscope after wipe 1/49 (2%) 1/49 (2%)

Zachary, Infect Control Hosp Epidemiol. 2001

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Bacterial Survival times on Bacterial Survival times on handshands

• Acinetobacter sppAcinetobacter spp 60 min60 min

• E. coliE. coli 6 min (mean)6 min (mean)

• Klebsiella sppKlebsiella spp 2 min (mean)2 min (mean)

• VREVRE 60 min60 min

• Pseudomonas spPseudomonas sp 30 min; 180 in 30 min; 180 in sputumsputum

• Rotavirus Rotavirus 16% survive 20 16% survive 20 min; min;

2% survive 60 min2% survive 60 min

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Contamination of ICU Patient Contamination of ICU Patient Charts Charts

• Sterile swab of outside of Sterile swab of outside of binders/charts kept binders/charts kept outsideoutside the ICU the ICU roomroom

Panhotra Am J Infect Control 2005

Percent of ICU charts culture positive by organismPercent of ICU charts culture positive by organism

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Hand washing compliance rates by Hand washing compliance rates by occupationoccupation

Pittet D et al. Ann Intern Med 1999; 130:126

Occupation Compliance OR (95% CI)

Nurse 52% 1.00

Physician 30% 2.80 (1.9-4.1)

Nursing Assistant 47% 1.28 (1.0-1.5)

Other 38% 2.15 (1.4-3.2)

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1919

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Q4/95 Q2/96 Q4/96 Q2/97 Q4/97 Q2/98 Q4/98 Q2/99 Q4/99

Quarters

Cas

es p

er 1

000

pati

ent-

MGH Nosocomial MRSA MGH Nosocomial MRSA 1995-19991995-1999

2020

Strategies to decrease Strategies to decrease transmissiontransmission• Proven or Proposed StrategiesProven or Proposed Strategies

– Antibiotic stewardshipAntibiotic stewardship– Proper hand hygieneProper hand hygiene– Cohorting patientsCohorting patients– Reducing LOSReducing LOS– Gowns and glovesGowns and gloves– Isolation of patientsIsolation of patients– Appropriate staffing ratiosAppropriate staffing ratios– Antibiotic crop rotationAntibiotic crop rotation– Surveillance culturesSurveillance cultures– Decolonization of patients (chlorhexidine body washes, Decolonization of patients (chlorhexidine body washes,

muciprocin)muciprocin)– Decolonization of health care worker carriersDecolonization of health care worker carriers

• Paucity of RCTs on efficacy of individual approachesPaucity of RCTs on efficacy of individual approaches• Efficacy of an individual approach may vary by Efficacy of an individual approach may vary by

pathogenpathogen• Near eradication of a pathogen from a hospital (or a Near eradication of a pathogen from a hospital (or a

country) requires a bundle of approaches (eg. country) requires a bundle of approaches (eg. “Search and Destroy” in the Netherlands“Search and Destroy” in the Netherlands))

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Compulsive Antibiotic Prescribing Compulsive Antibiotic Prescribing (CAP)(CAP)• CAP is a widespread and serious affliction CAP is a widespread and serious affliction

– First year medical students are free of the First year medical students are free of the diseasedisease

– Interns and first year residents are severely Interns and first year residents are severely afflicted…life-long habit difficult to breakafflicted…life-long habit difficult to break

– CAP is supported by a well organized group of CAP is supported by a well organized group of antibiotic pushersantibiotic pushers

• Antibiotics AnonymousAntibiotics Anonymous– Self help group, available 24 hours, will talk you Self help group, available 24 hours, will talk you

through the urge to prescribe more than two through the urge to prescribe more than two antibiotics, other abusesantibiotics, other abuses

Lockwood et al, NEJM p465-466, 1974Lockwood et al, NEJM p465-466, 1974

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Is isolation safe for the Is isolation safe for the patient?patient?• Cases:Cases: Consecutive patients admitted and Consecutive patients admitted and

isolated for MRSAisolated for MRSA• Controls:Controls: Patients in the same room Patients in the same room

immediately before and after a caseimmediately before and after a case• Similar baseline characteristicsSimilar baseline characteristics• CasesCases

– More likely to have unrecorded vital signs, absent More likely to have unrecorded vital signs, absent MD progress notes, and to complain about their careMD progress notes, and to complain about their care

– Twice the rate of preventable adverse eventsTwice the rate of preventable adverse events– Similar mortality (17% cases vs 10% controls, Similar mortality (17% cases vs 10% controls,

p=0.16)p=0.16)

Stelfox , JAMA 2003

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Communication Campaign

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MGH Hand Hygiene (HH) MGH Hand Hygiene (HH) CampaignCampaign

• 2000 HH Task Force 2000 HH Task Force (D. Hooper and P. (D. Hooper and P. Wright)Wright)– Cal stat dispensers hospital wideCal stat dispensers hospital wide

• 2002 Poster/Educational Campaign2002 Poster/Educational Campaign

• 2004 2004 – 8% wash before contact, 48% after contact8% wash before contact, 48% after contact– HH Champions on each floor -> PizzaHH Champions on each floor -> Pizza– New Poster CampaignNew Poster Campaign– Monitoring and feedback of HH rates by Monitoring and feedback of HH rates by

unit/floor, RN/MDunit/floor, RN/MD

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MGH Hand Hygiene MGH Hand Hygiene CampaignCampaign• 2005-20062005-2006

– Benchmark against peers (more peer Benchmark against peers (more peer pressure)pressure)

– “ “On the spot” Coffee Central couponsOn the spot” Coffee Central coupons– Patients as advocates: patient learning centerPatients as advocates: patient learning center

• 20072007– HH Quality incentive program: if rates of HH HH Quality incentive program: if rates of HH

before and after patient contact > 90% on a before and after patient contact > 90% on a given floor/ICU, monetary bonus paid at years given floor/ICU, monetary bonus paid at years end to RNs, MDs. Rates/reminders sent to end to RNs, MDs. Rates/reminders sent to units monthlyunits monthly

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MGH Quarterly Hand Hygiene rates: MGH Quarterly Hand Hygiene rates: 2004-072004-07

After contactBefore contact

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1927

21

36 34 31 30 32

49 5245

6156

4654 52 49

7078

83 8690 88

51

62 63 62 62 59 61 62 59

71 71 7178 77

7175

7983

87 8690 91 92 93

0102030405060708090

100*with the patient or patient’s environment

8%

High: 90%

High: 93%

JCAHO expectation: 90% Target for 2007: 90% MGH goal: 100%

47%

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MGH Healthcare-associated and Admission MRSA

248

177

290

383

438409

347319

299

242

105

167

205

382

623

767

1040

985

303

1115

0

200

400

600

800

1000

1200

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

No. of C

ase

s

Nosocomial Present OA

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ConclusionsConclusions

• Nosocomial transmission of Nosocomial transmission of pathogenic bacteria creates a major pathogenic bacteria creates a major health burdenhealth burden

• Multifaceted interventions are needed Multifaceted interventions are needed for high level control: proper hand for high level control: proper hand hygiene is the cornerstone of hygiene is the cornerstone of prevention effortsprevention efforts

• Isolation of patients may place them Isolation of patients may place them at risk for errors of omissionat risk for errors of omission

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Thank youThank you

Infec control measures in icu day in life of bacterium-mgh

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