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Infection Prevention Critical Care Connection Team Mount Auburn Hospital MLDupont, MSN, RN, CIC L. Infection Prevention Critical Care Connection Team Mount Auburn Hospital MLDupont, MSN, RN, CIC L. Mease, BSN, RN, SICU Manager J. Taylor, BSN, RN MICU Manager R. Wood Director Environmental Services

Infection Prevention Critical Care Connection Team Issues n MRSA SURVEILLANCE on ICU’s n VAP Infection Prevention Critical Care Connection Team Issues n MRSA SURVEILLANCE on ICU’s n VAP NO MORE n Eliminate Central Line Associated Blood Stream Infections n Clostridium difficile Elimination Strategies

Critical Care Team n The SICU and MICU Nurse Mangers have worked closely with Critical Care Team n The SICU and MICU Nurse Mangers have worked closely with the Director of Environmental Services and Infection Prevention on many projects. n A team approach highlighted many points of view, raises many questions and has provided the opportunity to “step out of the box”

MRSA SURVEILLANCE by Critical Care Team Active MRSA surveillance occurs on admission and discharge MRSA SURVEILLANCE by Critical Care Team Active MRSA surveillance occurs on admission and discharge from Critical Care (SICU & MICU) n On-going surveillance since 2005. n Interim nasal swabs are suggested if the patient is in critical care for 7 days. n Example: April 2008 MRSA Prevalence MICU admission: 6 positive / 72 swabs- 8. 3% transfer : 0 positive SICU admission : 5 positive /73 swabs— 6. 8% transfer: 0 positive n

MRSA SURVEILLANCE by Critical Care Team MRSA SURVEILLANCE by Critical Care Team

MRSA SURVEILLANCE n Education has been given to staff - “MRSA, VRE, ESBL WHAT MRSA SURVEILLANCE n Education has been given to staff - “MRSA, VRE, ESBL WHAT DOES IT ALL MEAN? ’ 20 MINUTE PRESENTATION to Critical Care Staff and Team Includes: Microbiology, risks, incidence, prevalence, surveillance and prevention

VAP NO MORE Zero VAP Team n n n n Zero VAP team set VAP NO MORE Zero VAP Team n n n n Zero VAP team set up in Nov. 2006 Looked at differences in both SICU and MICU Set up glove use for all room entry Full mouth care (brushing teeth and gums) twice a day and mouthcare (swab & suction) every 2 hours DVT Prophylaxis GI Prophylaxis Daily Critical Goal Care sheets outlining bundle Staff buy-in

VAP No More Zero VAP Team n Prevention - Separate suction for mouth care VAP No More Zero VAP Team n Prevention - Separate suction for mouth care and ETT suction - Covered Yankauer used for mouth care - Vent circuit tubing changed PRN - In line suction for ETT- deletes need for Ambu and instillation of Normal Saline -Change suction tubing, Yankauers and cannisters every 24 hours

VAP NO MORE Zero VAP Team Poster developed: by team Our AIM is ZERO VAP NO MORE Zero VAP Team Poster developed: by team Our AIM is ZERO Ventilator-Associated Pneumonia n Head of the Bed Elevated 30 -45 degrees Gloves with entry to every patient’s room Hand Disinfection- wash/disinfect your hands before and after every patient contact Brush patients entire mouth AT LEAST TWICE a day Mouthcare every 2 hours Daily Sedation Vacation- Daily wake up Protect Your Patient From Ventilator Associated Pneumonia

VAP No More Zero VAP Team n Prior to Team and Interventions, the VAP VAP No More Zero VAP Team n Prior to Team and Interventions, the VAP rate per unit: * MICU: January-December 2006= 0 SICU: January- December 2006 - 4 • MICU had adopted glove use for all room entry in 2005. • SICU had not adopted glove use for all room entry until November 2006.

VAP NO MORE Zero VAP Team Results After interventions in place: n MICU had VAP NO MORE Zero VAP Team Results After interventions in place: n MICU had zero VAPs November 06 - June 2007 n SICU had zero VAPs January-June 2007 n Post Script : MICU continued with 0 VAP for 2007 - for a total of 26 months (June 2005 - March 2008) SICU had 1 VAP in 2007 and zero VAP through March 2008 n

Team Effort to Eliminate Central Line Associated Blood Stream Infections n The team is Team Effort to Eliminate Central Line Associated Blood Stream Infections n The team is setting up a process in collaboration with the Intensivists Team for documentation of procedure observation. n The ICU’s use central line insertion kits which includes the equipment needed and ensures sterile technique during insertions.

Team Effort to Eliminate Central Line Associated Blood Stream Infections n Central Line Associated Team Effort to Eliminate Central Line Associated Blood Stream Infections n Central Line Associated Blood Stream Infections for October 01, 2007 -March 31, 2008 were: Rate per 1, 000 device days n MICU: 1 CLABSI/ 750 cline days= 1. 3 n SICU: 1 CLABSI/1020 cline days= 1. 0

Team Effort to Eliminate Central Line Associated Blood Stream Infections Protective Measures that have Team Effort to Eliminate Central Line Associated Blood Stream Infections Protective Measures that have been developed: n Added the Micro Clave to decrease blood back flow n Use of Biopatch n Weekly dressing changes and prn n Tubing changes every 72 hours n Flush line with Normal Saline

Clostridium difficile n Due to national concern about C. difficile in the environment. n Clostridium difficile n Due to national concern about C. difficile in the environment. n Mount Auburn Hospital has set up a separate category of Precautions: Contact Precautions Plus

Clostridium difficile Elimination Team Strategies A Root Cause Analysis was performed on a patient Clostridium difficile Elimination Team Strategies A Root Cause Analysis was performed on a patient that developed Clostridium difficile by the Chair of Quality/Safety. n Work flow patterns identified and the team has altered ways to get out of precaution rooms, where to bag specimens etc to meet precaution requirements The team is elated since both ICU’s will be moving into a new building in November 2008. n

Clostridium difficile Elimination Team Strategies n n Contact Precautions Plus sign alerts caregiver that Clostridium difficile Elimination Team Strategies n n Contact Precautions Plus sign alerts caregiver that the patient has C. difficile All staff entering the room must wear gowns and gloves Handwashing must occur- due to spores in the environment Concern had been raised over environmental contamination and Environmental Services is actively involved in cleaning and disinfection issues.

Clostridium difficile Elimination Team Strategies n As part of the team work on this Clostridium difficile Elimination Team Strategies n As part of the team work on this issue, Environmental Services has developed specific disinfectant guidelines for Contact Precaution Plus rooms. n Education has been on-going both with clinical and environmental staff. n Environmental Services is part of the Team.

Staff Determine a CONTACT PRECAUTIONS +PLUS+ n By the list that is provided to Staff Determine a CONTACT PRECAUTIONS +PLUS+ n By the list that is provided to them each morning by the supervisor n Looking for a Contact Precaution +PLUS+ sign on the door

New CONTACT PRECAUTIONS +PLUS+ Patients MUST have a johnny mop and caddie placed into New CONTACT PRECAUTIONS +PLUS+ Patients MUST have a johnny mop and caddie placed into the restroom. Johnny mops must be isolated from other patients. n Johnny mop and caddie MUST be disposed of in the trash after patient is discharged or transferred. n

Daily Cleaning of CONTACT PRECAUTIONS +PLUS+ n n n n n Wash hands, put Daily Cleaning of CONTACT PRECAUTIONS +PLUS+ n n n n n Wash hands, put on gloves and gown. Knock on door and announce yourself Remove trash Surface cleaning Clean restroom Floor care Inform patient you have finished Remove gown, gloves and wash hand with soap and water. Check off daily worksheet

Daily Floor Care of CONTACT PRECAUTIONS +PLUS+ n A disposable dust mop is used Daily Floor Care of CONTACT PRECAUTIONS +PLUS+ n A disposable dust mop is used to dry mop the floor and disposed of immediately after use. n A microfiber mop is used to wash the floor and used only on that room.

Discharge Room Cleaning of CONTACT PRECAUTIONS +PLUS+ Call the office before starting a discharge Discharge Room Cleaning of CONTACT PRECAUTIONS +PLUS+ Call the office before starting a discharge cleaning. n The supervisor will deliver the bleach to the staff mixed (1: 64) n Room MUST be cleaned twice. n n First cleaning bleach, second with hospital approved disinfectant

Discharge Room Cleaning of CONTACT PRECAUTIONS +PLUS+ n n n n n High dust Discharge Room Cleaning of CONTACT PRECAUTIONS +PLUS+ n n n n n High dust Surface cleaning with bleach first Clean restroom with bleach first Surface cleaning again with hospital approved disinfectant Cleaning restroom cleaning again with hospital approved disinfectant Floor care Remove gown, gloves and wash your hands with soap and water Make bed and organize furniture in room. Final room inspection, hang clean curtain. Enter bed as clean in the bed tracking system

Privacy Curtain cleaning of CONTACT PRECAUTIONS +PLUS+ n Privacy curtain must be taken down Privacy Curtain cleaning of CONTACT PRECAUTIONS +PLUS+ n Privacy curtain must be taken down and brought to the Laundry Area. n A clean curtain must be hung when the room has been cleaned

CONTACT PRECAUTIONS +PLUS+ Long Term Patients n. A report has been developed to identify CONTACT PRECAUTIONS +PLUS+ Long Term Patients n. A report has been developed to identify patients that have been inpatients for longer than 10 days. n The unit’s Nurse Manager and staff are informed by the ES Office that it is time to perform a terminal room cleaning. n Nursing will inform the ES Office when the patient is out of the room for test/procedure.

Infection Prevention Critical Care Connection Team n Questions Infection Prevention Critical Care Connection Team n Questions