Non-pulmonary Critical Care - part 10 pot

pathogenic, they are of nosocomial significance when introduced to the patient by invasive procedures and indwelling devices. Transient flora are acquired by patient 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, vancomycin-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 include 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 loos ely adherent transient skin; however, 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, dr yness, and a paradoxical increase in microbial counts on the skin. 119,120 Medicated hand washing agents are bactericidal (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. 122 During 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 hygi ene compliance. Although the microbicidal effect of chlorhexidine may have resulted in fewer infections, the difference in nosocomial infections was also likely due to increased compliance with hand hygiene practices. Regardless, owing to their bactericidal 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%. 123–125 Factors commonly cited that may influence poor adherence with hand hygiene include insufficient time, understaffing, patient overcrowding, lack of knowledge of hand hygiene guidelines, skep ticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants, and lack of hand hygiene promotion 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. 114 Compliance with hand hygiene and proper glove use, observed in 381 (non-nurse) health care professionals, 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, insufficient 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 compliance 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 interventi ons, including increased access to hand hygiene products. In a study by Bischoff et al where alcohol-based hand sani- tizers were introduced to an ICU, th e 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. 113 Similarly, Pittet and colleagues 127 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 316 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 27, NUMBER 3 2006 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 nursing staff but remained poor for physicians. Additionally, over the study period, the overall prevalence of nosocomial 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 interventions 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 hospital-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 contamination of hands with drug-resistant pathogens during 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. 128 Nevertheless, 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 compliance were observed and measured in two ICUs of a tertiary-care hospital. Over a 40-hour period of observation, 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 su bsequent 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 contamination 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 limi t 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. 130,131 One 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 measured the effect of gown and glove use in a 16-bed medical ICU of a tertiary-care medical center. 133 Over 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. 134 The outcomes of interest were colonization patterns, necrotizing enterocolitis, respiratory syncytial virus, other nosocomial infections, mortality and hand washing. The investigators failed to document any significant 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 surveillance cultures were taken daily from patients along with monthly environmental cultures of bed rails, bedside 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-transmission of nosocomial pathogens, the incremental benefit 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. INFECTION CONTROL AND PREVENTION IN THE ICU/ BEARMAN ET AL 317 These precautions are divided into three categories, reflecting differences in disease transmission. Some diseases 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 prevented 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 multidrug-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 organisms that travel via droplets generated during phonation, sneezing, coughing, or invasive respiratory tract procedures. 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 precautions are meningococcal meni ngitis, Haemophilus influenza, influenza, 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. Th is 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 pro tective gowns has been advocated to decrease the risk of health care worker garment contamination. Pa- tient care items used for a patient 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 recomm ended 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 detrimental 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 assessmen t) II score. 137 Stelfox et al 138 studied 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 nonisolated 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 quality of their treatment. 138 Similarly, Saint and colleagues observed in a prospective cohort study of two in-patient 318 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 27, NUMBER 3 2006 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 psychological 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 contact isolation on anxiety and depression in noncritically ill hospitalized patients. 141 Patients in contact isolation for either MRSA or VRE were compared with other hospitalized patients with infectious diseases not requiring isolation. All patients were evaluated with the Hamilton Anxiety and Depression Rating scale at baseline and then later during the hospital course. Although no significant differences in baseline anxiety and depression 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 surveillance 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 performance 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 accountability, 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 multifaceted systems interven tion on catheter-related BSIs in the ICU. 41 The 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 standardized questioning of daily providers whether catheters could be removed. 41 Most importantly, a checklist to ensure adherence to evidence-based guidelines for preventing 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 measures 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 decreased 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. 39 An 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 investigators 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 in cidence 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 INFECTION CONTROL AND PREVENTION IN THE ICU/ BEARMAN ET AL 319 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 campaign. Glove use is beneficial in limiting the contamination 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. 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Effect of education and performance feedback on rates of catheter-associated urinary tract infection in intensive care units in Argentina. Infect Control Hosp Epidemiol 2004;25:47–50 324 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 27, NUMBER 3 2006 . health care worker clothing contamination. 132 Srinivasen et al prospectively measured the effect of gown and glove use in a 16-bed medical ICU of a tertiary -care medical center. 133 Over a 3-month. infection- control benefits of patient isolation against the potential risk of adverse events. INFECTION CONTROL PROCESS-OF -CARE MEASURES Traditional infection control programs involve surveillance. 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 measures included

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