Chris Peredney MSN, RN, CNS-CP, CNOR

*Implementation of Effective Infection Prevention Practices (IPP)

*Discuss implementation of effective infection

prevention practices

*Historical challenges

*Varying practices from institution to institution

*Evidence based to best practice

*Next steps

* Historical challenges

*Airborne Infection Isolation

*Transporting from floor

*Does the isolation PPE need to stay on he whole case

*Transporting to PACU or ICU

*How long does a patient need to be in transmission precautions

*Airborne

*Airborne for Bronchoscopies and intubation of potential TB and/or other Airborne or Droplet

*Negative pressure

*Guidelines for Environmental Infection Control in Health-Care Facilities (CDC 2007)

*And ORs are….Positive

*Intubation outside of OR

*Brochoscopies outside OR?

* Then surgical case?

*PPE

*N95-Fit Testing

*PAPR-Not OR approved (CDC 2007)

*CAPR® -Not OR approved

*CAPR®

* Varying practices from institution to institution (or nurse to nurse)

*PPE at all times in OR

*PPE only when contacting patient

*Take off and landings

*Safe Zone* A Safe Zone is a designated area at the entrance to the

patient room where hospital staff and visitors can safely communicate with patients who are on precautions without the need for donning Personal Protective Equipment (PPE-gown and gloves)

*Use of N95

*Discontinuation of precautions

* Evidence based to best practice

*CDC-Healthcare Infection Control Practices Advisory Committee (HICPAC)

*APIC- Association for Professionals inInfection Control and Epidemiology, Inc.

*SHEA-Society for Healthcare Epidemiology of America

*AORN-Association of Perioperative Registered Nurses

*CDC-HIPAC

*Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007

* Guidelines for Environmental Infection Control in Health-Care Facilities (CDC 2007)

*Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities, 2009

*Guidance for Control of Carbapenem-resistant enterobacteriaceae (CRE) 2012 CRE Toolkit

*Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006

*GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999

* CDC-HIPAC-2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in

Healthcare Settings

*The Primary source for the recommendations in AORN Guidelines on transmission-based precautions

*CDC-HIPAC-2007 Guideline

*“Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment.”

*CDC-HIPAC-2007 Guideline

*“Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV)”

*CDC-HIPAC-2007 Guideline

*V.B.3.b. Gowns

*V.B.3.b.i. Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment 24, 88, 134, 745, 837. Category IB

* CDC-HIPAC-2006. Management of Multidrug-Resistant Organisms In

Healthcare Settings

*2007 guidelines defer to this for MDRO

*“higher case fatality rates have been observed for certain MRSA infections, including bacteremia, poststernotomy mediastinitis, and surgical site infections”

* CDC-HIPAC-2006. Management of Multidrug-Resistant Organisms In

Healthcare Settings

*“HCP caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Donning gown and gloves upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C.difficile, noroviruses and other intestinal tract agents; RSV)(109, 111, 274-277).”

*APIC

*Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings, 2nd Edition (2010)

*Gloves and gowns: “recommended for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Requiring persons to don gown and gloves upon room entry and discard them before exiting promotes compliance with this recommendation; helps ensure that hands and clothing do not become contaminated; and disrupts transfer of microorganisms to other patients or environments”

*The Society for Healthcare Epidemiology of America(SHEA)

*“Placing patients with MRSA colonization or infection under contact precautions may help reduce patient-to patient spread of MRSA within the hospital” (Quality of evidence II)

*II. Moderate “Evidence is rated as moderate quality when there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide.”

*AORN

* Recommended Practices for the Prevention of Transmissible Infections in the Perioperative Setting.

*Implementing AORN Recommended Practices for Prevention of Transmissible Infections. AORN J 98 (December 2013) 610-625.

AORNGuidelines

Recommendation I

*Health care workers should use standard precautions when caring for all patients in the perioperative setting.

*I.a. All personnel in the health care organization should follow established hand hygiene practices.1,2 [1: Strong Evidence]

*I.b. Perioperative personnel should wear PPE whenever the possibility exists for exposure to blood or other potentially infectious materials. [1: Strong Evidence/Regulatory Requirement]

AORNGuidelines

Recommendation II

*Contact precautions should be used when providing care to patients who are known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact or indirect contact.

*II.a.1. Perioperative personnel should don PPE upon room entry and discard PPE upon exiting the room when caring for a patient who requires contact precautions.

*II.c.3. When a patient who requires contact precautions is transported from one area to another, the nurse should notify the receiving team members that the patient is coming and what precautions should be taken to prevent transmission.1 [CDC 2007]

*Implementing AORNRP II (Patrick and Hicks 2013)

*Everyone providing care should don a gown and gloves, and those assisting with patient transfer to the OR should wear a gown and gloves until the patient is on the OR bed and is covered, being careful not to come into contact with any other surfaces in the room. The gown and gloves should be removed and the person’s hands sanitized before contact with any other surfaces, including telephones, pens, and charts, and before he or she leaves the room or immediate area.

*At the end of the surgical procedure, personnel should gown and glove again to remove drapes and transfer the patient to the transport bed.

*Transporting (Patrick and Hicks 2013)

*For patients undergoing surgery, the OR transporter should don a gown and gloves to assist the patient to the transport bed. After the transport bed is pushed to the doorway, the transporter should remove the PPE and sanitize his or her hands.

*A clean sheet can be draped over the patient, hanging outside the bedrails, to prevent others from coming into contact with contaminated surfaces during transport.

*Discontinuation of Contact

Precautions

*“Many hospitals have developed protocols for discontinuing contact precautions when a patient’s infection has resolved and there are several negative surveillance tests in the absence of antibiotics to demonstrate that the patient is no longer colonized with MRSA. Some hospitals choose to consider MRSA-colonized patients to be colonized indefinitely” (APIC 2014)

*The Society for Healthcare Epidemiology of America(SHEA)

*Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals: 2014 Update

*“Studies have suggested that patients may be persistent MRSA carriers for prolonged periods of time (median duration in one study, 8.5 months). Use of contact precautions for patients with a history of MRSA is recommended. The appropriate duration of contact precautions necessary for patients with MRSA, however, remains an unresolved issue”.

* Next steps

*A standardized approach using Evidence based practice and understanding of Periop work and patient flows

*A periop specific IC/IP policy

*Transporting to from OR

*Transporting within Periop

*Speaks to when isolation gowns and gloves need to be worn in OR

*From wheels in to wheels out?

* Just when exposure can occur?

* Critical thinking

*Why not Gown and glove all the

time

*“Several uncontrolled studies have reported conflicting results on whether patients in isolation are examined less frequently and for shorter periods compared with those not in isolation (SHEA 2014)

*Chance of contaminating the environment

*Impact on work flow

*Cost

*Next steps

*New Policy and Procedures

*Must involve Infection Control and seek harmony

*Must consider OR work flow

* In most places in the hospital staff is in the room to interact with patient

* In the OR there are periods of patient contact, but also periods where we are in contact with other non-patient contact areas

* APIC 2010 Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings, 2nd Edition

* Calfee, David P., MD, MS; Cassandra D. Salgado, MD, MS; Aaron M. Milstone, MD; Anthony D. Harris, MD, MPH; David T. Kuhar, MD; Julia Moody, MS; Kathy Aureden, MS, MT, CIC; Susan S. Huang, MD, MPH; Lisa L. Maragakis, MD, MPH; Deborah S. Yokoe, MD, MPH. Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals: 2014 Update The Society for Healthcare Epidemiology of America http://www.jstor.org/stable/10.1086/676534 accessed 1/21/15

* CDC 2006. Management of Multidrug-Resistant Organisms In Healthcare Settings,2006

* CDC 2007 Guidelines for Environmental Infection Control in Health-Care Facilities

* CDC,2012 Guidance for Control of Carbapenem-resistant enterobacteriaceae (CRE) 2012 CRE Toolkit http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf accessed 1/21/15

* PATRICK,MARCIA R., HICKS,RODNEY W. 2013 Implementing AORN Recommended Practices for Prevention of Transmissible InfectionsAORN J 98 (December 2013) 610-625. AORN, Inc, 2013. http://dx.doi.org/10.1016/j.aorn.2013.08.018 accessed 1/21/15

* Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdfaccessed 1/21/15

* Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health-care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American Society for Healthcare Engineering/American Hospital Association; 2004.