Multisystem - Health-care Associated Infections, Palliative/Hospice/EOL Care

Healthcare-Associated Infections - when is it considered Healthcare associated vs. Community Acquired?

• healthcare associated - an infection that develops more than 48 hours after admission to the hospital

• community acquired - if the infection is identified WITHIN 48 hours after admission to the hospital

Central Line-Associated Bloodstream Infection (CLABSI) - what is it?

• a laboratory-confirmed bloodstream infection that develops within 48 hours of a central line placement and is not related to an infection at any other sites; RESULTING in longer hospital stays, increased costs, and an increased risk of death

Central Line-Associated Bloodstream Infection (CLABSI) - guidelines for prevention (INSERTION)

• ensure that processes are in place for insertion according to the guidelines

• optimize site selection (subclavian vein) as able; avoid femoral or IJ site if possible

• ensure that the team utilizes aseptic technique during insertion

• utilize maximal barrier precautions and personal protective equipment during insertion

• prepare the skin using chlorhexidine skin antisepsis

• use chlorhexidine patch/gel dressing over the insertion site (unless there is an allergy)

Central Line-Associated Bloodstream Infection (CLABSI) - guidelines for prevention (MAINTENANCE)

• practice hand hygiene prior to line manipulation/care

• provide a head-to-toe chlorhexidine bath daily for ICU patients

• disinfect catheter hubs, needleless connectors, and injection ports with mechanical friction for no less than 5 seconds with an antiseptic before accessing the catheter

• ensure the patency of the dressing, and change the dressing and tubing according to hospital policy

• do NOT routinely replace central lines (unless it is KNOWN that the insertion was performed emergently without antisepsis)

• discontinue central line if there are signs of an infection

• perform a daily review of line necessity

• use aseptic technique for dressing changes, ensuring dressing patecny at all times

• ensure that there is an appropriate nurse-to-patient ratio and limit the use of float nurses in ICUs

Central Line-Associated Bloodstream Infection (CLABSI) - guidelines for prevention (MONITORING)

• perform root cause analysis on line infections and develop action plans for improvement accordingly

• develop processes for measuring compliance with policies/procedures

• share quality monitoring and infection results with the staff

• assess competency of the staff who insert/care for lines

Catheter-Associated Urinary Tract Infection (CAUTI) - what is it?

• an infection of the urinary tract, where an indwelling urinary catheter was in place for more than 2 consecutive days in an inpatient location on the date of event, with day of device placement being day 1 AND an indwelling urinary catheter in place on the date of event or the day before

Catheter-Associated Urinary Tract Infection (CAUTI) - guidelines for prevention (utilization practices)

• avoid inserting an indwelling urinary catheter, if at all possible

• develop standardized, evidence-based reasons for insertion such as select operative procedures, acute urinary retention or bladder outlet obstruction, gross hematuria, a need for an accurate measure of urine output, to assist in the healing of open sacral or perineal wounds in incontinent patients, or for patients who require prolonged immobilization (such as potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures)

• perform a daily review of catheter need based on agreed upon hospital standardized criteria

• remove catheters as soon as they are no longer necessary; as per the CDC, when a catheter is placed during surgery and remains in place post-op, remove the catheter as soon as possible, preferably within 24 hours, unless there are appropriate indications for continued use

• implement a nurse-driven protocol to empower nurses to evaluate and discontinue unnecessary urinary catheters

• utilize alternative strategies (external catheters, intermittent straight catheterization)

Catheter-Associated Urinary Tract Infection (CAUTI) - guidelines for prevention (INSERTION AND MAINTENANCE PRACTICES)

• use aseptic technique during insertion

• make insertion a 2-person activity to reduce breaks in aseptic technique during insertion

• practice hand hygiene prior to/following catheter manipulation/care

• utilize standard precautions, including the urse of gloves and gowns, as appropriate

• employ routine catheter care, cleansing the meatal area (antiseptic solution is not needed); replace basin bathing with plain wipes

• maintain an unobstructed urine flow (such as ensuring proper securatement of the catheter, maintain tubing free of kinks or dependent loops, maintain the collection bag below level of bladder)

• do NOT disconnect/reconnect system components

• collect urine samples from the sampling port using aseptic technique

Catheter-Associated Urinary Tract Infection (CAUTI) - guidelines for prevention (PROCESS MEASURES)

• assess competency of clinicians who insert catheters; provide periodic training and competency assessments

• identify unit “CAUTI champions” whose role is to monitor patients with indwelling urinary catheters and ensure that standards for infection prevention are utilized by caregivers

• develop quality measures and share outcomes with the staff

• perform a root cause analysis for each infection and implement action plans based on those analyses

Multi-Drug Resistant Organisms - MOST COMMON ORGANISMS found in hospitals

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Vancomycin-resistant enterococci (VRE)

• Clostridium difficile (C. diff)

• Carbapenem-resistant enterobacteriaceae (CRE)

Multi-Drug Resistant Organisms - guidelines for prevention

• establish a culture where hand hygiene is exepcted of all caregivers

• develop an antibiotic stewardship and an antibiotic de-escalation program

• provide universal decolonization of ICU patients though chlorhexidine bathing and nasal decolonization

• focus on rapid identification of MDROs and the development of a strong containment program

• utilize team rounding/huddles to ensure that VAP/CLABSI/CAUTI evidence-based interventions (bundles) are followed and that antibiotic stewardship is practiced

• conduct a root cause analysis of infections that occur

• develop a process to assess that clinicians utilize contact precautions according to hospital policy

• develop processes for reliable cleaning of equipment/surfaces

• provide education regarding hand hygiene and when SOAP AND WATER (rather than hand gel) is required → following contact with patients with C. diff, when the clinician’s hands are VISIBLY soiled, after the clinician has used the restroom, and BEFORE the clinician eats

Palliative Care - what is it?

• the prevention and treatment of the SYMPTOMS and SIDE EFFECTS of a serious illness; physiological, emotional, social, and spiritual problems are considered

  • can be initiated anytime during a disease or life-threatening illness

  • type of care has been found to be most beneficial when it is initiated early

  • symptom management may include the management of pain, anxiety, dyspnea, urticaria, nausea/vomiting, constipation, and diarrhea, among other symptoms

• aggressive treatment MAY BE CONTINUED

• all critically ill patients deserve palliative care

• has been shown to improve survival, decrease resource utilization, and decrease hospital readmissions and cost of care

Hospice Care - what is it?

• the provision of symptom management for those with a TERMINAL ILLNESS

  • it INCLUDES palliative care, but disease-modifying treatments are discontinued unless they may provide symptom management

  • grief and bereavement services are included!!

End-of-Life Care (EOL) - what is it?

• supports the needs of patients and their families at the time of imminent death; it is ALWAYS part of hospice care, and it may or may not be a part of palliative care; it is provided to ALL patients who are at the end of their lives, regardless of whether or not palliative or hospice care were initiated

  • EOL care AVOIDS prolongation of the dying process

  • EOL care provides support to the patient’s family

Palliative/Hospice/EOL care (similarities)

• ALL INVOLVE:

  • advance care planning

  • focusing on patient/family wishes

  • optimizing quality of life