Here are the facts: More than 1 million cases of catheter-associated urinary tract infections (CA-UTIs) occur each year in U.S. hospitals and nursing homes,and CA-UTIs account for up to 40% of HAIs. It is estimated that 25% of patients in the acute care setting will have an indwelling urinary catheter at some point in their hospitalization, and 69% of patients in medical ICUs hospitalized in NNIS hospitals from 1992-1997 had urinary catheters. 

So what’s the problem?  Catheter-associated urinary tract infections or CA-UTIs are generally assumed to be benign. However, CA-UTIs may be associated with significant complications, such as cystitis, pyelonephritis, infection, prostatitis, epididymitis, orchitis in males, and encrustation; less commonly, bacteremia and complications of metastatic infection including endocarditis, septic arthritis, endophthalmitis, and meningitis may occur. CA-UTIs are the second most common cause of healthcare-associated bloodstream infection. CA-UTIs increase length of stay by 1 to 3 days and add to overall patient costs, especially if bacteremia occurs. In addition, urinary catheters often precipitate unnecessary antimicrobial therapy, and are a major reservoir for resistant pathogens. One study has linked CA-UTIs and surgical site infections.

Can all CAUTI’s be avoided? No, not all catheter-associated urinary tract infections or CA-UTI are preventable. For example, there are certain factors that increase the risk of infection that may not be modifiable in a patient. However, there are many CA-UTI that are avoidable. The fact is, many urinary catheters are left in place longer than necessary, simply because physicians forget to look for the catheter, or reassess whether the patient still needs one.  A report published in the September issue of the journal Clinical Infectious Diseases suggests that hospitals can cut CA-UTI infections by 52% simply by implementing an  automatic reminder in the electronic health record or other system that requires a clinician to check daily on the catheter and determine whether it is still needed.

Need more incentive? As of October 1, 2008, Medicare discontinued reimbursement for the extra cost of treating catheter-associated urinary tract infections that occur while the patient is in the hospital. In addition, there is a national push to “get to zero” in the incidence of reportable healthcare-associated infection rates by the Agency for Healthcare Research and Quality (AHRQ), The Joint Commission, and the Association for Professionals in Infection Control (APIC) to name a few. And as of May 2011, The Joint Commission announced a new National Patient Safety Goal to prevent CAUTIs to be fully implemented by 2013.

Follow evidence-based practices! If we are to reduce the numbers of infections, clinicians will need to first follow evidence-based practices such as those in the CDC Guideline for the Prevention of Catheter-Associated Urinary Tract Infections 2009; the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), and The Joint Commission; Diagnosis, Prevention and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from IDSA;Clinical Fact Sheets by the Wound, Ostomy and Continence Nurses Society (WOCN); and other professional guidelines, and get back to the fundamentals for the care and maintenance of the urinary catheter.

Training videos can help get clinicians on board. Envision, Inc. has an award-winning staff training video that offers 1 Hour CE credit for nurses, available for free preview prior to purchase at http://www.envisioninc.net/index.php/programs/details/preventing_catheter_associated_urinary_tract_infections/.

Originally, this type of sterilization was intended for use only in an emergency, such as when a one-of-a-kind instrument was contaminated or dropped from the sterile field. Unfortunately, it has now become common place and used too frequently due to time and budget constraints. Because items do not recieve the complete traditional sterilization processing, professional groups and accreditation agencies believe that IUSS should not be  a routine practice, but rather used only in select clinical situations, and in a controlled manner.

“The reason that it’s not looked upon as a good solution is because oftentimes in the tight timeframe that we use, there are chances that corners may be cut; that during that rushed process to get the instrument turned around there could be processes and protocols that are missed completely, or at least not fully complied with. Immediate-use steam sterilization is denoted as a process that is used only in emergencies and only if the devices that are to be sterilized are compatible with that process.” - Natalie Lind, CRCST, CHL, FCS, IAHCSMM Education Director.

In this day and age, healthcare facilities are under great pressure to prevent surgical site infections. It seems obvious that items that do not receive full sterilization cycles are likely to be the source of infections. Surgical Technicians and Central Service professionals must become aware of the issues surrounding this form of sterilization, and the standards, regulations and best practices regarding its use. It is vital that immediate-use steam sterilization be utilized in accordance with professional guidelines; facility policies and procedures; as well as in strict compliance with validated written instructions provided by device manufacturers, sterilization equipment manufacturers, and container or textile manufacturers. This is especially critical for short sterilization cycles, as it takes time for steam to penetrate a sterilizer load and achieve an acceptable sterility assurance level.

In an effort to promote best practices regarding the use of IUSS, a multi-agency position paper was released January 2011 by the International Association of Healthcare Central Service Materiel Management (IAHCSMM), the Association for the Advancement of Medical Instrumentation (AAMI), the Association of peri-Operative Registered Nurses (AORN), the Association for Professionals in Infection Prevention and Control (APIC), the ASC Quality Collaboration,  and the Accreditation Association for Ambulatory Health Care (AAAHC) .  In addition, the Centers for Disease Control and Prevention (CDC) has recommendations, and The Joint Commission has standards regarding proper use and protocols for IUSS that must be followed and closely documented.

Envision, Inc. and IAHCSMM are proud to present a NEW 11 minute staff training program entitled “Protocols for Immediate-Use Steam Sterilization,”  part of the Of Critical Importance staff education series for Central Service and Operating Room professionals who process surgical instruments and devices.  For a preview of the program in it’s entirety, visit www.EnvisionInc.net.

HAI elimination is a top priority for the federal government.  In 2008, the U.S. Department of Health and Human Services (HHS) promoted the Action Plan to Prevent Healthcare-Associated Infections, which outlines national goals for prevention and key actions for achieving them. In 2009, a second action plan was introduced to Ambulatory Surgery Centers, primarly for the prevention of SSI.  In October 2008, the Centers for Medicare and Medicaid Services (CMS) stopped its reimbursement of five conditions they deemed “reasonably preventable” – three of which were HAIs, specifically CA-BSI, SSI and CA-UTI. VAP is to be added to the list in 2011.

So what makes an infection “reasonably preventable” ?  A new study by Umscheid, et al asserts that as many as 65% to 70% of cases of CA-BSI and CA-UTI, and 55% of VAP and SSI, may be preventable with current evidence-based strategies. In otherwords, there are many processes that are logical and when incorporated into the care of the patient will prevent most  infections. These include education of healthcare workers regarding these strategies, hand hygiene, the proper use of aseptic technique during the insertion and care of catheters and during surgical procedures, timely withdrawal of catheters and breathing tubes, and the proper use of antibiotics.

One of the most important tools in preventing HAIs is the use of surveillance – tracking the rates of infection in patients during and after their healthcare stay, and reporting these numbers to the National Healthcare Safety Network. The NHSN is a voluntary, secure, internet-based surveillance system managed by the Division of Healthcare Quality Promotion (DHQP) at CDC that is open to all types of healthcare facilities in the United States, including acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities.   If all healthcare facilities participated, we would have a greater understanding of the processes that need improvement, and how the use of preventative measures impact rates of infection. To learn more about the benefits of NHSN participation, visit http://blogs.cdc.gov/safehealthcare/.

There are those who point out that HAIs are not 100% preventable, even with the inclusion of evidence-based practice.  Of course, there is always the aspect of human nature: despite training and checklists, things will not be done perfectly every time.  Interventions can be costly for hospitals on tight budgets, and there are not enough Infection Preventionists to educate staff and keep up with surveillance. And most importantly, there are some patient populations who are inherently at greater risk for infection, regardless of how hard caregivers may try.  But naysayers are missing the point.  The implementation of evidence-based strategies across the board at hospitals, skilled nursing centers and ambulatory surgery centers will save the lives of tens of thousands, and prevent hundreds of thousands of HAIs.  Saving lives, while saving costs.  Thats a win-win situation.

For evidence-based training of healthcare professionals in the prevention of Central Line-Associated Bloodstream Infections, Ventilator-Associated Pneumonia, Surgical Site Infections, and Catheter-Associated Urinary Tract Infections, please visit www.envisioninc.net.  For a link to the study “Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs” by Umsheid et al, visit www.jstor.org/pss/10.1086/657912

While many of these procedures may seem low risk, without the proper knowledge or expertise they can result in unintended complications, infections, and medical errors. A successful outcome requires clinicians to perform many tasks: the evaluation and monitoring of the patient throughout the course of care; the use of safety protocols; and the practice of infection prevention, to name a few. 

“A patient’s response to medication cannot always be predicted. There are many complex interactions between the agents used, a patient’s physical health, and drug sensitivities. Moderate sedation or analgesia may easily progress to deep sedation and loss of consciousness, as well as other possible consequences such as respiratory depression, cardiac arrhythmia and hypotension. This is why moderate sedation should only be administered by appropriately trained, qualified and credentialed personnel who have a thorough understanding of the dosing and effects for the medications used, as well as for the reversal agents used to counteract them.” – Bernadette  Henrichs, PhD, CRNA, CCRN. Professor & Director, Nurse Anesthesia Program, Goldfarb School of Nursing at Barnes-Jewish College.

Healthcare professionals must become familiar with the new Centers for Medicare and Medicaid Services (CMS) regulations and interpretive guidelines for hospitals and ambulatory surgery centers (ASCs); standards by accreditation agencies such as The Joint Commission,  The Accreditation Association for Ambulatory Health Care (AAAHC),  American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), and DNV/NIAHO; guidelines by the Centers for Disease Control and Prevention (CDC); and professional association standards of practice, such as those offered by the American Society of Anesthesiologists (ASA),  the Society of Gastrointestinal Enterology Nurses and Associates (SGNA),  the American Association of Nurse Anesthetists (AANA), the Association of peri-Operative Nurses (AORN),  and the Infusion Nurses Society (INS).  These are the tools we need for a successful outcome, and to help us meet the highest standard of care.

Envision, Inc. has created a training program for healthcare professionals involved in the administration, care and monitoring of patients undergoing moderate sedation comprised of a 15 minute video and a comprehensive study guide.

After viewing this program and reading the study guide, the viewer will be able to:

• Identify the pharmacology of the medications and agents used in moderate sedation/analgesia
• Discuss how to deliver these medications safely
• List the elements of pre-procedural, procedural, and post-procedural assessment and monitoring of patients who receive moderate sedation/analgesia
• Discuss the safety and infection prevention protocols involved in delivering moderate sedation
• Identify current regulations, standards, recommended practices and guidelines that apply to the use of moderate sedation/analgesia

For more information on this program and a free preview prior to purchase, please visit the Envision, Inc. website at http://www.envisioninc.net/index.php/programs/details/moderate_sedation_complying_with_accreditation_and_regulatory_requirements/.

Patient education + handwashing + surgical site preparation + sterility in operating rooms = low surgical infection rates.

That’s what the Oconee Medical Center in Seneca, SC accomplished after setting a goal of zero infections.  According to the state Department of Health and Environmental Control, the Oconee Medical Center reported 4 infections out of 70 hip procedures, 3 infections out of 144 knee replacements, and ZERO infections during 1,445 adult inpatient days and during 499 critical care patient days!  When asked how the center achieved these rates, Heather Goss, Marketing Director at the facility cited various efforts:

• Strict infection prevention protocols throughout the hospital, particularly related to patient education, hand washing, surgical site preparation, and sterility in ORs
• Active surveillance screening for resistant bacteria upon patients arrival
• A stand alone Joint Center unit that is segregated from the sick patient population
• A partnership with Duke University Medical Center to have access to an infection control network for on-site support and resources

For years, evidence-based guidelines and standards from the CDC, AORN, APIC, SHEA, AHE and IAHCSMM have provided the guidance for reducing the rates of pathogenic organisms found on the patient body, as well as environmental sources that can contribute to infection.  It is a multi-pronged approach that cannot rely solely on half-hearted efforts.  As OMC has proven, it takes dedication by everyone in the facility - management, infection prevention and control, healthcare professional staff, housekeeping and central services - to drastically reduce rates of infection.

OMC is a model for hospitals everywhere that need to improve their infection rates. In order to get to zero, education and re-education of staff and patients must be a part of the plan. Envision, Inc. is proud to provide training programs in a wide range of infection prevention titles specifically for the OR developed with professional associations and renowned experts.  For more information, please visit our website at www.EnvisionInc.net.

To read the story on OMC, please visit http://www.independentmail.com/news/2010/nov/10/oconee-medical-center-recognized-low-infection-rat/?print=1

Friday October 15th will be the 3rd annual celebration of Global Handwashing Day. Launched by the Public-Private Partnership for Handwashing with Soap (PPPHW), the goal of Global Handwashing Day is to 1) Foster and support a global and local culture of handwashing with soap, 2) Shine a spotlight on the state of handwashing in each country, and 3) Raise awareness about the benefits of handwashing with soap.  While it primarily revolves around schools and children, it is also a reminder to healthcare professionals and individuals everywhere of the importance of hand hygiene for preventing infection.

Microbes that can be spread on the hands of healthcare staff include Candida, Rotavirus, Adenovirus, Hepatitis A virus, Streptococcus pyogenes (Group A Strep), Clostridium difficile, Klebsiella and drug-resistant organisms such as Staphylococcus aureus (including MRSA) and Vancomycin-resistant Enterococcus (VRE).  These microorganisms are found in large numbers in non-intact skin such as wounds, but can also be found on intact skin such as the armpit, trunk and hands. This is why taking a pulse or blood pressure reading can contaminate the hands of healthcare professionals even after seemingly ‘clean’ procedures. Pathogens can survive on the hands for long periods of time and be transferred to door knobs, bed rails and other frequently touched surfaces where they can be picked up and carried to susceptible patients.

There are three types of hand hygiene:

Hand antisepsis using an alcohol-based waterless antiseptic hand rub. Alcohols are more effective than antimicrobial soap and should be used in all clinical situations except when hands are visibly soiled.

Handwashing, either with plain soap and water or with antimicrobial soap and water.  Antimicrobial soap can be used for all clinical situations and should be used for removing blood or body fluids. Additionally, plain or antimicrobial soap should be used when hands are visibly dirty, before eating, and after using the restroom.

Surgical hand antisepsis, using either an alcohol-based hand rub with persistent activity or an antimicrobial soap, recommended before donning sterile gloves.

Schools and communities can improve children mortality rates and improve general health by learning how and when to use soap and water to wash hands. And by following the recommendations of guidelines such as by the Centers for Disease Control and Prevention (CDC) and WHO, we can reduce the numbers of patients who acquire healthcare-infections. Let’s build upon a commitment to patient safety by using excellent hand hygiene practices, and clean up our act.

For more information on Envision, Inc.’s staff and patient education videos on hand hygiene, please visit http://tinyurl.com/2dlnefh.

Please visit the Global Handwashing Day website to find useful tools and resources to promote Global Handwashing Day in your healthcare facility, school, or community. www.globalhandwashingday.org

Please visit the World Health Organization’s “Clean Care is Safe Care” site for a variety of resources including guidelines for providers, patient empowerment materials, the latest technological advances in hand hygiene adherence measurement, frequently asked questions, and links to promotional and educational tools published by the WHO, universities, and health departments. www.who.int/gpsc/tools/faqs/about/en/index.html

To review the CDC Guideline for Hand Hygiene in Healthcare Settings: www.cdc.gov/handhygiene

Nearly as long as there have been antibiotics there have been drug-resistant bacterial strains.  Selective pressure due to overprescribing as well as improper usage by patients allow bacteria to develop defenses against antibiotics.  And after years of warnings by health officials, we are now seeing the presence of superstrains – bacteria that are impervious to all of our available antibiotic medications. 

Recently, bacteria carrying a gene called NDM-1 have been found in several people in the US and Canada, mainly in individuals who obtain medical treatment in India.  What makes these drug-resistant bacteria different from other super bugs such as methicillin-resistant staphylococcus areus (MRSA) is the ability of the bacteria to produce an enzyme that disables carbapenam antibiotics - considered last-ditch treatments for infections that don’t respond to other antibiotics.  Furthermore, the mutation is easily passed between different species of microbes, including three found in the U.S., E. coli, K. pneumoniae, and E. cloacae.

In particular the enzyme called Klebsiella pneumoniae carbapenamase, or KPC, has become a common and dangerous threat in US hospitals and nursing homes. Found primarily in New York and New Jersey, there are more than 35 states now fighting these bacteria. According to Arjun Srinivasan, a medical epidemiologist at the Centers for Disease Control and Prevention, “we really don’t have ideal antibiotic therapies for these bacteria.”  Indeed, the antibiotics of last resort have effectively been neutralized by these bacteria. 

Read more: http://healthland.time.com/2010/09/23/ndm-1-isnt-a-superbug-but-its-still-scary/#ixzz10T4Dzq5o

Effective antibiotics against these strains are still many years away; so until then, the best defense is prevention. In 2009, the CDC released a guideline that calls for the use of Contact Precautions, enhanced hand hygiene and surveillance in hospitals with carbanepem-resistant organisms. To read this guideline, please visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

From an empathetic and economic perspective, palliative care makes sense; and now a new study shows that palliative care and end-of-life planning when offered early in the diagnosis helps cancer patients lead longer and better lives.  In the 3 year study, 151 patients with advance lung cancer received cancer treatment as well as palliative care.  These patients lived two months longer than those who received cancer treatment without palliative services, and showed marked improvement in overall quality of life.  The study was published in the Aug. 19 issue of the New England Journal of Medicine.

“We were surprised by the magnitude of impact that palliative care had on quality of life, which normally decreases over time in these cancer patients, and the magnitude of the impact it had on depression. The survival benefit was the most surprising thing. Cancer care and palliative care are not mutually exclusive. Providing both is not only feasible, but beneficial. “  Jennifer S. Temel, MD, oncologist at Massachusetts General Hospital (MGH) Cancer Center in Boston and co-author of the study. From: “Cancer Patients Live Longer With Palliative Care,” on WedMD, August 19, 2010. http://tinyurl.com/2arjtno

In fact, psychological and emotional assessments are extremely important in identifying feelings of anxiety, depression, loss of dignity, and helplessness that can result from patients facing or fearing lack of control. Psychological distress can have devastating consequences for the patient, including amplifying the intensity of pain and diminishing the ability to make appropriate treatment decisions.

Ideally, palliative care should begin at the time of diagnosis. However, only 75% of hospitals offer palliative care, it is often offered towards the final days of life, and many physicians fail to offer it to their patients at all, often due to a “rescue mentality” where death is seen as failure.  But palliative care can assist patients and their families in making better decisions about what is helpful and what is fruitless, and help make their time together a healing experience.  Patients and their families need to ask for these services from their physicians and local hospital systems.

“The mission statement of every health system I know is it provide the best care we possibly can to families and patients who will want to come back and see us again. Palliative care fits right in with the mission statement of every health system that I know.” - Thomas Smith, MD, FACP, Medical Director of the Thomas Palliative Care Program at the Virginia Commonwealth University Massey Cancer Center.

Physicians, nursing staff, chaplains, social workers, physical therapists…all those involved in the care of patients can benefit from training on how to provide physical, psychological, social, cultural and advance-care planning assessments; offer patient and family education; have crucial conversations regarding tough decisions; and learn the clinical symptoms of impending death.  Envision, Inc. has an award-winning video developed in conjunction with the Thomas Palliative Care Program, and is ideal for Veteran Affairs hospitals and other health care facilities wanting to improve their end-of-life programs.   For more information on the video, and to see a free preview prior to purchase, please visit  http://www.envisioninc.net/index.php/programs/details/to_care_always_quality_care_at_the_end_of_life/.

The start of the flu season will be upon us soon, and once again healthcare workers as a group have an opportunity to decrease the spread of influenza in our communities and in our healthcare facilities. How?  With vaccination.  It is one of the most important things that healthcare workers in hospitals and outpatient settings can do to prevent transmission of influenza to patients, and prevent catching the flu themselves.

The most efficient method of preventing these outbreaks and the associated morbidity and mortality is through pre-exposure vaccination. Healthcare personnel (HCP) are at high risk for acquiring influenza infection due to their exposure to ill patients as well as their exposure in the community. Because those persons who are at greatest risk of developing complications of influenza are exposed to healthcare personnel in a variety of in patient and outpatient settings, an important strategy to decrease exposure to these high risk individuals is to immunize healthcare workers. - APIC Position Paper: Influenza Immunization of Healthcare Personnel, 2008.

Many hospitals have set high benchmarks for personnel vaccination rates driven by research, accreditation requirements and mandatory vaccination policies. And yet, despite recommendations by the CDC, APIC, and other healthcare organizations, and despite the evidence that  vaccination can and does make a difference in lowering patient deaths by 40 percent and improving patient safety, healthcare personnel vaccination rates remain low.  What are the reasons for the 46% vaccination rate, and how can this be overcome?

Here are some interesting facts: Personnel who decline vaccination have egg allergy, religious or philosophical convictions, or a history of Guillain-Barre. But this is a small percentage of those who are unvaccinated year after year. It seems that the remainder are likely to be socially isolated from others who choose vaccination, or simply have misconceptions regarding vaccination.  This is why the most successful campaigns in hospitals today incorporate staff education to target individuals who persistently decline vaccination.

Envision, Inc. has created a 12 minute visual presentation to address questions and concerns staff may have about vaccination in an effort to promote their participation in an influenza vaccination program.  http://www.envisioninc.net/index.php/programs/details/dispelling_the_myths_influenza_education_vaccination_and_prevention/

This program will dispel some of the myths surrounding the flu vaccine by:

• Explaining modes of transmission and the impact on patients
• Describing symptoms of flu, risk factors for complications, and treatment options
• Outlining flu prevention techniques that reduce transmission
• Explaining vaccine options and their possible side effects
• Addressing the need for a declination statement if not vaccinated

Let’s make 2010 the most successful year for healthcare worker vaccination!  The life you save might just be your own.

Sources: Health-Care Worker Vaccination Rates Remain Perilously Low. http://www.sciencedaily.com/releases/2010/03/100317091255.htm

APIC Position Paper: Influenza Immunization of Healthcare Personnel. http://www.apic.org/AM/Template.cfm?Section=Home1&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTFILEID=11049

www.flu.gov

www.cdc.gov/flu/

Joint Commission monograph: http://www.jointcommission.org/PatientSafety/InfectionControl/flu_monograph.htm

“Patient falls take a huge toll and have a tremendous cost to that patient in terms of functioning and co-morbidities. Patients who fall have longer lengths of stays. It [also] adds tremendous financial burden to organizations.” - Melissa Fitzpatrick, RN, MSN, FAAN

The problem of patient falls is multi faceted: it is a financial albatross (to patients and organizations), a risk management issue, and a huge patient safety concern. In fact, the problem of falls in hospitals and other healthcare facilities is so great that The Joint Commission initiated a National Patient Safety Goal “to reduce the risk of patient harm resulting from falls”. In addition (and to offer the greatest incentive) the Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the cost of care following “preventable events”, including patient falls.

Research has shown that fall risks increase as the number of risk factors increase. A  multi-disciplinary team of nurses, patient care assistants, physicians, physical therapists, pharmacists, etc. must all work collaboratively to first assess the patient for risk factors for falls, and then create a fall prevention program.  Although Nurses can’t prevent all patients from falling, they can implement evidence-based interventions that have proven to reduce falls based on the individual needs of the patient. Whenever possible, the patient should also be educated on various ways to prevent falls while at the hospital and at home.

Patient falls can and should be prevented. Envision has a comprehensive staff education program (18 minute video and study guide) entitled “Preventing Patient Falls: A Team Approach” to educate healthcare professionals on evidence based practices to meet accreditation standards and federal regulations.   We also offer an 11 minute Patient Education video entitled “Partners in Care…Your Role In Fall Prevention.”  To preview the programs prior to purchase, visit our website at www.EnvisionInc.net or http://tinyurl.com/2cnzdzm.