Hand Hygiene and Infection Control: What Happens Next?
Gonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University
What Dr. Wenzel does not know and What Dr. Edmond will not tell you.
Hand Hygiene and Infection Control: What Happens Next?
What Dr. Wenzel does know and What Dr. Edmond will tell you.Gonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University
Infection Control Timeline
Big Bang
10 billion and 20 billion years ago
Hotel-Dieu :Paris hospital founded in the 7th century
Many years elapse
0 Circa 600 AD
Infection Control Timeline
Leprosariums emerge in the Middle Ages
Lazarettos for plague victims established in Venice in the 15th century
Fever hospitals established in England in the early 19th century
Segregation of Infectious Patients
History: Ignaz Semmelweis• At the Vienna Lying-in
Hospital – Women who delivered on the street had
less risk of developing puerperal fever– Much higher risk of puerperal fever in
women delivered by physicians or medical students as opposed to those delivered by midwives
• Required that hands be washed with chlorinated lime after autopsies & between exams of pregnant women– Maternal mortality
decreased from 18% to 3%
History: Florence Nightingale and Louis Pasteur
• Developed the germ theory of disease in the late 1800s
•Importance of unsanitary hospital conditions and post operative complications
History: Advances in Surgical Infection Control
Joseph Lister introduced antiseptics in 1867
William Halstead introduced gloves in 1890
Johannes Mikulicz introduced masks in 1897
Infection Control Timeline: The Modern Era
First antibiotics, sulfonamides & penicillin, developed in the late 1930s
Robert Haley, MD 1970’s SCENIC Study
Hospitals with active infection control programs have a 32% lower incidence of nosocomial infections
R.P Wenzel MD, MSc1980: Founded Society of Healthcare Epidemiology; applied epidemiologic techniques to infection control
1961: MB Edmond born
So where are we now and what happens next?
Nosocomial Infections• 5-10% of patients admitted to acute care
hospitals acquire infections– 2 million patients/year– 70% are due to antibiotic-resistant organisms– ¼ of nosocomial infections occur in ICUs– 90,000 deaths/year– Attributable annual cost: $4.5 – $5.7 billion
• Cost is largely borne by the healthcare facility not 3rd party payers
Weinstein RA. Emerg Infect Dis 1998;4:416-420.Jarvis WR. Emerg Infect Dis 2001;7:170-173.
Shifting Vantage Points on Nosocomial Infections
Gerberding JL. Ann Intern Med 2002;137:665-670.
Many infections are inevitable, although
some can be prevented
Each infection is potentially
preventable unless proven otherwise
The medical literature is replete with studies identifying risk factors for nosocomial infections• Hand Hygiene• BSI
– Catheter type, insertion, maintenance
• VAP– Duration of intubation, gastric pH, HOB
elevation
• UTI– Catheter use and insertion, maintenance
Sadly, we as medical professionals frequently do not practice well known nosocomial infection risk reduction practices
Pressure from legislatures, consumer groups, third party payers and regulatory agencies has resulted in mandatory public reporting of nosocomial infections
This is now driving compliance with process of care measures that are associated with reductions in nosocomial infection risk
Help Consumers Union Stop Hospital Infections! Most people don't expect to go into a hospital and come out even sicker because of an infection they caught as a patient, but 1 in 20 do. And each year, about 90,000 people die from hospital acquired infections - a leading cause of death in the U.S. The annual cost to our health care system is $5 billion. Congress is considering a bill that would let hospitals keep information about their infection rates and medical errors a secret. People should be able to find out whether their hospital is doing a good job of controlling dangerous infections.
TAKE ACTION now to tell Congress to preserve state's rights to report on hospital infection rates.
http://www.consumersunion.org/pub/projectsandcampaigns.html
Status of Mandatory Reporting LegislationSeptember 2005
Enacted legislation Legislation introduced, under review or further study Legislation died/defeated
Source: APIC.Slide: courtesy of MB Edmond MD,MPH,MPA
Infection Control Process of Care Measures
• Hand Hygiene• Contact Precautions
– Gowns– Gloves
• HOB elevation for VAP prevention• CVC insertion measures
– Avoidance of femoral site– Maximal sterile barrier precautions– Proper antisepsis of skin– Prompt discontinuation of catheter use
30%-40% of all Nosocomial Infections are Attributed to Cross Transmission:
The Importance of Hand Hygiene
The inanimate environment is a reservoir of pathogens
~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
X represents a positive Enterococcus culture
The pathogens are ubiquitous
The inanimate environment is a reservoir of pathogens
Recovery of MRSA, VRE, C.diff, CNS and GNR
Devine et al. Journal of Hospital Infection. 2001;43;72-75
Lemmen et al Journal of Hospital Infection. 2004; 56:191-197
Trick et al. Arch Phy Med Rehabil Vol 83, July 2002
Walther et al. Biol Review, 2004:849-869
Hand Hygiene
Hand Hygiene Comment
Typical Compliance
Observational studies of hand hygiene report compliance rates of 5-81%
Common Reported Barriers To Compliance
Insufficient time, understaffing, patient overcrowding, lack of knowledge of hand hygiene guidelines, skepticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants and lack of hand hygiene promotion by the institution
Single most effective method to limit cross transmission
HCWs' perceptions of compliance with infection control practices
% of HCWs reporting compliance >80%
Position N (%) HandwashingContact isolation
Airborne isolation
Registered nurses 118 (36) 77 59 74
Resident physicians 99 (31) 62 61 92
Attending physicians 33 (10) 62 72 82
LPNs, patient care assistants
29 (9) 59 72 76
Others 45 (14) 73 79 69
Total 324 (100) 69 65 80
Berhe M, Edmond MB, G Bearman in AJIC 33;1 February 2005, 55-57
Majority of respondents reported excellent compliance with IC practices
Alcohol Based Hand Sanitizers
• CDC/SHEA hand antiseptic agents of choice– Recommended by CDC based
on strong experimental,clinical, epidemiologic and microbiologic data
– Antimicrobial superiority• Greater microbicidal effect • Prolonged residual effect
– Ease of use and application
Alcohol based hand hygiene solutionsQuick: 5- 15 seconds Easy to use
Very effective antisepsis due to bactericidal properties of alcohol
Arch Intern Med. 2000;160:1017-1021.
Hand Hygiene Educational Program Implemented
Direct Observation of Hand Hygiene
Incremental Increase in Alcohol Dispensers
Study Algorithm
Arch Intern Med. 2000;160:1017-1021.
•Improvement in Hand Hygiene Compliance
Results
Hand hygiene practice can be improved with education and greater accessibility of alcohol hand sanitizers
Hand Hygiene
• Single most important method to limit cross transmission of nosocomial pathogens
• Multiple opportunities exist for HCW hand contamination– Direct patient care– Inanimate environment
• Alcohol based hand sanitizers are ubiquitous– USE THEM BEFORE AND AFTER PATIENT
CARE ACTIVITIES
Hand Hygiene
• HCW’s perceive that their hand hygiene practice is excellent– Observational data does not support this
claim
• New technologies such alcohol based hand sanitizers make the practice of hand hygiene simpler than ever– There is simply no excuse for poor hand
hygiene compliance
Contact Precautions for drug resistant pathogens.
Gowns and gloves must be worn upon entry into the patient’s room
Glove Use for Infection ControlVariable Rationale Comment
Gloves
Prevent healthcare worker exposure to bloodborne pathogens
Prevent contamination of hands with drug resistant pathogens during patient care activities
Even with proper glove use, hands may become contaminated during the removal of the glove or with micro-tears that allow for microorganism transmission
Gown Use for Infection Control
Variable Rationale Comment
Gowns
Several studies have documented colonization of healthcare worker apparel and instruments during patient care activities without the use of gowns
The use of gloves and gowns is the convention for limiting the cross transmission of nosocomial pathogens, however, the incremental benefit of gown use, in endemic settings, may be minimal
What about the role of Universal Gloving For All Patient Care?
A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-
Resistant Pathogens G. Bearman MD,MPH
A. Marra, MD
C. Sessler, MD
W.R. Smith, MD
R.P. Wenzel MD, MSc
M.B. Edmond MD,MPH,MPA
Hypothesis• The effectiveness of universal gloving
(use of gloves for all patient care activity) in preventing the transmission of multidrug-resistant pathogens will be greater than the effectiveness of contact precautions for the following reasons: – Compliance with universal gloving will likely
be greater than compliance with contact precautions.
Bearman et al.
M e th o d s : S tu d y D e s ig n
0 1 2 3 4 5 6
M onth
C o n c u r re n t s u r v e i l la n c e fo r n o s o c o m ia l in fe c t io n s
V R E , M R S A s u rv e i l la n c e c u lt u re s o n a d m is s io n & e v e r y 4 d a y s
M e a s u r e h a n d h y g ie n e f r e q u e n c y
C o n ta c t p r e c a u t io n s fo r V R E , M R S A c o lo n iz e d / in fe c te d
p a t ie n t s
U n iv e r s a l g lo v in g : N o C o n ta c t P r e c a u t io n s
•CDC/NNIS NI definitions applied; surveillance performed by VCUMC IC Department
•Hand hygiene observations performed by trained observers
•Active surveillance nasal and rectal cultures were obtained on all patients within the unit
Bearman et al.
Methods
• Microbiologic Data– One rectal swab culture performed for VRE
and 1 nasal swab culture for MRSA performed on admission and every 4 days.
• Once a patient was culture positive; then no further cultures were obtained for that organism.
– Pulse field gel electrophoresis (PFGE) for genetic typing and antibiotic susceptibility testing were performed on all MRSA and VRE isolated after study was completed.
Bearman et al.
Methods
• Healthcare Questionnaire– Administered at the end of the study
protocol• Target: MRICU Nurses and Attending
Physicians– Focus:
» self reported compliance with infection control practice
» acceptability of universal gloving vs. standard of care.
Bearman et al.
MethodsAdditional Data Elements:
Phase I vs. Phase IILength of stay
MRICU occupancy rate per month
MRICU invasive devices utilization ratios
Nurse to patient ratio
Antibiotic usage: defined daily dose (DDD)
Bearman et al.
Results:
Variable Phase I Phase II P value
Total patient days
1090 1377 -
Total observations for IC compliance
1220 1102 -
Total patients screened for VRE
192 257 0.54
Total patients screened for MRSA
228 301 0.60
Bearman et al.
Results: Hand Hygiene Compliance
Phase I Phase II
Variable N Obs % N Obs % P-value
Hand Hygiene before patient contact
228 18.7 126 11.4 <0.001
Hand Hygiene after patient contact
704 57.7 578 52.5 0.011
A statistically significant reduction in hand-hygiene was observed in phase II
Bearman et al.
Results:Compliance with Contact Precautions vs. Universal Gloving
Variable
Phase I Phase II
PN % N %
Compliance with gloving for patients on contact precaution
387 89.4 N/A N/A N/A
Compliance with gowns for patients on contact precaution
335 77.4 N/A N/A N/A
Gowns and gloves for patients on contact precaution
328 75.7 N/A N/A N/A
Total Compliance: (Contact Precautions vs. Universal Gloving)
328 75.7 959 87.0 <0.001
Greater adherence during universal gloving was observedBearman et al.
Results: VRE screening
Variable Phase I Phase II P value
Total Patients Screened for VRE
192 257
Patients VRE positive upon admission to ICU
3 (1.5%) 3 (1.1) 0.70
Patients with VRE conversion during ICU stay
39 (20%) 35 (14%) 0.31
Days to acquire VRE
(median)8 9 0.79
No difference was observed in the rate of VRE acquisition
Bearman et al.
Results: MRSA Screening
Variable Phase I Phase II P value
Total Patients Screened for MRSA
228 301 -
Patients MRSA positive upon admission to ICU
11 (4.8%) 6 (2.0 %) 0.11
MRSA conversion during ICU stay 13 (5.7%) 15 (5.0%) 0.92
Days to acquire MRSA (median) 8 9 0.95
No difference was observed in the rate of MRSA acquisition
Bearman et al.
Results: MRSA PFGEMRSA Phase I Phase II
Number of Strains
21 25
Conversion: negative to positive
13
13/13 clonal (100%)
Type A1, A2, A3, A4
15
15/15 clonal (100%)
Type A1, A5
PFGE Types A1:13/21 (62%)
A2: 5/21 (23%)
A3: 1/21 (5%)
A4:1/21 (5%)
B: 1/21 (5%)
A1:18/25 ( 72%)
A5: 2/25 (8%)
C: 3/25 (12%)
D:2/25 (8%)
ALL MRSA conversions were with clonal isolates
Bearman et al.
Results: VRE PFGEVRE Phase I Phase II
Number of Strains
40 35
Conversion: negative to positive
39
20/40 clonal: (50%)
Type A, B
35
28/35 clonal (80%)
Type A, AA, AB
PFGE Types Type A: 16/40 (34%)
Type B: 4/40 (11%)
Type D:2/40
Type G: 3/40
Type H:2/40
Type J:2/40
Type K: 2/36
Type C,E,I, L,M,Q,R S,T: 1 each 9/40
Type A: 18/35 (51%)
Type AA: 4/35 (11%)
Type AB:4/35 (11%)
Type H: 2/35 (6%)
Types F,G,I,J,U,V,M:1 each 7/35 (20%)
Most VRE conversions were with clonal isolates
Results:Nosocomial Infections Rates
Outcome Phase I Phase II P
BSI/1000 catheter days
6.2 14.1 P<0.001
UTI/1000 catheter days
4.3 7.4 P<0.001
Pneumonia 0 2.3 P<0.001
A statistically significant increase in NIs was observed
Bearman et al.
Results: Nosocomial Infections Phase I Phase II
Infection # Organisms # Organisms
BSI 5 P. aeruginosa (1)
E. cloacae (1)
K. pneumoniae (1)
Prevotella species (1)
C. glabrata (1)
16 Coag. negative staph (6)
Enterococcal species (3)
VRE (1)
MRSA(2)
P. aeruginosa (1)
K. pneumoniae (1)
C. parapsilosis (1)
C. albicans (1)
UTI 6 E. coli (2)
E. cloacae (1)
C. albicans (3)
9 Coag. negative staph (1)
Enterococcal species (1)
P. aeruginosa(2)
E. coli (1)
C. albicans (2)
C. non-albicans (2)
VAP 0 NA 2 MRSA(1)
P.aeruginosa (1)
Results: Nosocomial Infections with VRE or MRSA
Phase I Phase II
Infection VRE MRSA VRE MRSA
BSI 0 0 1 2
UTI 0 0 0 0
VAP 0 0 0 1
4 VRE and MRSA infections were identified in Phase II
MRICU DemographicsPhase I Phase II P value Variable
5.3 6.8 0.07 Average length of stay
87% 92% 0.36MRICU occupancy rate per month
1:1.9 1:1.9 NS Nurse to patient ratio
Device utilization ratio Phase I Phase II P
Urinary Catheter 0.85 0.87 0.83
Central line 0.74 0.72 0.87
Ventilator 0.56 0.62 0.47
Utilization ratio=device days/patient days
Results: Antibiotic UsageDefined daily dose (DDD/1000 patients-day)
Antibiotic
DDD
Phase I
DDD
Phase II P value
B-lactams 391.6 352.9 0.075
B-lactam/inhibitor 210.1 211.5 1.0
Aminoglycosides 68.2 118.2 <0.001
Glycopeptides 190.1 226 0.079
Metronidazole 127.0 118.6 0.582
Quinolones 385.7 359.0 0.206
Total 1372.7 1386.2 0.806
The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults
Example:DDD of levofloxacin is 0.5grams, if 200 grams were dispensed in a period with 4,500 patient days:(200g/0.5g)/4,500 pt days X 1000= 89 DDD/1000 PD
Results:Questionnaire about IC compliance During Universal Gloving Study
• 34 respondents– 30 MRICU Nurses (45 eligible)– 4 Attending Physicians (7 eligible)
• Overall survey compliance 65%
Results:Questionnaire about IC compliance
Questionnaire Item: Proportion
Proportion of respondents indicating that universal glove use was impractical 12%
Proportion of respondents reporting good compliance with infection control measures
97%
Proportion of respondents reporting good compliance with Hand hygiene 97%
Results:Questionnaire about IC compliance
Questionnaire Item: Proportion
HCWs reporting less frequent entry into a patient room because of contact precautions
48%
Belief that proper glove use is more important than hand hygiene to limit the spread of nosocomial organisms
6%
Belief that the use of gloves is associated with decreased risk of cross-transmission of nosocomial organisms
94%
HCWs reporting no difference in skin problems (e.g., chapping, dryness, cracking)
93%
Results:Questionnaire about IC compliance During Universal Gloving Study
Overall better care is delivered when:
Contact Precautions
Universal Gloving
No difference
Majority of respondents felt that better care was delivered during the Universal Gloving Phase of the study
Universal Gloving Conclusions• Observed compliance with universal gloving
was significantly greater than compliance with contact precautions (gowns and gloves).
• However, greater compliance with hand hygiene was observed in the standard of care phase.
• No differences were detected between the two study phases for: – LOS, nurse:patient ratio,MRICU occupancy rate,
invasive device utilization, and antibiotic usage
Universal Gloving Conclusions• No differences in VRE and MRSA colonization was
observed between the two study phases.• In both phases, the majority of VRE and MRSA
conversions were of a clonal isolate• However, an increase in nosocomial infection rates
was observed during the universal gloving phase of the study• 4 VRE and MRSA nosocomial infections were
observed during the universal gloving phase
Universal Gloving Conclusions• HCWs found gloving acceptable and believed that the use of
universal gloving is associated with decreased risk of cross-transmission of nosocomial organisms
• HCWs believed that better care was delivered under the universal gloving phase
• Although universal gloving was highly accepted by the staff, its implementation should proceed with caution given the observed increase in nosocomial infection rates– The use of universal gloving may have lead to a
misperception of decreased cross transmission risk – This may have lead to decreased hand hygiene compliance
and a consequent increase in the rates of nosocomial infections
The importance of process of care measures in the reduction of nosocomial bloodstream infections
The CVC: Subclavian, Femoral and IJ sites
The intensity of the Catheter Manipulation
El Host
The CVC is the greatest risk
factor for Nosocomial BSI
As the host cannot be altered, preventive measures are focused on risk factor modification of catheter use, duration, placement and manipulation
The risk factors interact in a
dynamic fashion
Prevention of Nosocomial BSIs
• Limit duration of use of intravascular catheters– No advantage to changing catheters routinely
• Maximal barrier precautions for insertion– Sterile gloves, gown, mask, cap, full-size drape– Moderately strong supporting evidence
• Chlorhexidine prep for catheter insertion– Significantly decreases catheter colonization– Disadvantages: possibility of skin sensitivity to
chlorhexidine
Eliminating catheter-related bloodstream infections in the intensive care unit
– Purpose:– To determine whether a multifaceted systems
intervention would eliminate catheter-related bloodstream infections (CR-BSIs)
– Method:– Prospective cohort study in a surgical intensive
care unit (ICU) with a concurrent control ICU.
–Patients:– All patients with a central venous catheter in the
ICU
Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.
Eliminating catheter-related bloodstream infections in the intensive care unit
Interventions Example
Staff Education
•All staff inserting central catheters were required to complete a web-based training program with post-test.
Creation of a catheter insertion cart
•Central catheter insertion cart that contains all equipment and supplies •Reduced the number of steps required for compliance
Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.
Eliminating catheter-related bloodstream infections in the intensive care unit
Promotion of daily catheter Removal
Asked daily during rounds whether catheters or tubes could be removed
Evidence based checklist CVC insertion and for BSI risk reduction
Hand hygiene prior to procedure
Chlorhexidine skin preparation
Full-barrier precautions during CVC insertion
Subclavian vein as the preferred site
Maintenance of sterile field during procedure
Nurse
Empowerment
Procedure aborted if a violation in compliance with evidence-based guidelines was observed
SICU attending physician notified
Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.
Eliminating catheter-related bloodstream infections in the intensive care unit
• Results:– During the first month nursing completed
the checklist for 38 procedures:• Eight (24%) for new central venous access,• 30 (79%) for catheter exchanges over a wire, • Three (8%) were emergent.
– Nursing intervention was required in 32% (12/38) of central venous catheter insertions
Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.
Eliminating catheter-related bloodstream infections in the intensive care unit
BSI Rate 1st quarter
1998
BSI Rate 4th quarter
2002
January 2003- April 2004
Study ICU 11.3/1,000 catheter days
0/1,000 catheter days
0.54/1,000 catheter days
No crBSI over 9 months
Control ICU 5.7/1,000 catheter days
1.6/1,000 catheter days
Pronovost et al. Crit Care Med. 2004 Oct;32(10):2014-20.
Multifaceted, comprehensive program requiring CVC insertion education, with safety checks for proper hand hygiene, aseptic insertion procedure and operator
responsibility can result in reduction of nosocomial BSI in an ICU setting.
Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance
Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2, Gonzalo Bearman MD, MPH1,2
Divisions of Infectious Diseases1 and Quality Health Care2
Department of Internal Medicine
Virginia Commonwealth University School of Medicine
Richmond, VA, USA
Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance
Process Measure
MRICU STICU
Baseline
Q2-2004
Q3
(2004)
Q4
(2004)
Q1
(2005)P
value*
Baseline
Q2-2004
Q3
(2004
Q4
(2004)
Q1
(2005)P
value*
HH %
Opp
14/44
(32%)
31/91
(37%)
33/91
(36%)
50/108
(46%)
0.101 19/38
(50%)
42/80
(53%)
40/80
(50%)
49/100
(49%)
0.916
HOB %
Opp
28/51
(55%)
320/333
(96%)
450/454
(99%)
551/556
(99%)
<0.001 20/43
(47%)
229/307
(75%)
389/488
(79%)
275/361
(76%)
<0.001
Fem. CVC
% of Days
195/1093
(18%)
130/769
(16%)
80/879
(9.1%)
51/951
(5.4%)
<0.001 93/1109
(8.4%)
49/970
(5.1%)
14/1077
(1.3%)
26/920
(2.8%)
0.01
Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2, Gonzalo Bearman MD, MPH1,2
0
10
20
30
40
50
60
70
80
90
100
Q1-04 Q2-04 Q3-04 Q4-04 Q1-05 Q2-05
0
1
2
3
4
5
6
7
8
HOB compliance Pneumonia cases/1,000 ventilator-days
Head of Bed Elevation in VCU Medical ICU:Effect of Feedback
% C
om
pli
ance
wit
h H
OB
el
evat
ion
Baseline;no feedback
Performance feedback quarterly
Pn
eum
on
ia cases/1,000 ventilato
r-d
ays
Slide: courtesy of MB Edmond MD,MPH,MPA
Ask Yourself:
• If other professions can impose much tighter regulations to minimize risks, should we do the same?
• Are 3-5 infections/ 1000 patient days acceptable?
• Are we doing all that is possible to minimize risk?
United States & Canada: accident rates as of 12.31.2004
Airline Rate Events No. Flights
Air Canada 0.63 3 4.75 Million
Alaska Airlines 0.74 3 4.05 Million
Aloha Airlines 0.49 1 1.34 Million
American Airlines/Eagle 0.59 10 17.0 Million
Continental Airlines/Express 0.63 5 8.00 Million
Delta Air Lines 0.30 6 20.0 Million
http://www.airdisaster.com/statistics/
Conclusion• Risk reduction strategies for the prevention of
nosocomial infections are well defined in the literature– Lack of adherence to IC measures is recognized as
important in the pathogenesis of NIs– Sadly, HCWs overestimate their degree of compliance with
infection control measures
• Pressure from legislatures, consumer’s groups, hospital administration, third party payers and regulatory agencies will result in the mandatory public reporting of nosocomial infections.– Drive increase compliance with process of care measures
that are associated with reductions in nosocomial infection risk
Conclusion
• System level changes involving the measurement and feedback of adherence to IC measures are needed to implement risk reduction strategies consistently– BSI: enforcement of comprehensive
catheter use/care policies– VAP: HOB elevation– Hand hygiene- alcohol based sanitizers
“ I suppose that I shall have to die beyond my means”
Oscar Wilde, upon being told the cost of an operation