The intensive care unit (ICU) of the hospital has always been where the most vulnerable patients are kept, so they can be closely monitored and treated, often with a one-to-one ratio of nurse to patient, for the most scrupulous of care. Even with great advances in medical technology, these patients continue to be at the greatest risk for infection — infections that are often avoidable by taking a few simple precautions. Healthcare workers treating these patients literally hold life and death in their hands.
Philippe Eggimann, MD, and Didier Pittet, MD, MS, intensive care and infection control specialists, respectively, authored a paper five years ago that is still relevant today. “Nosocomial infections now concern 5 percent to 15 percent of hospitalized patients and can lead to complications in 25 to 33 percent of those patients admitted to ICUs,” they write. “The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices.”
Means of preventing these causes are now widely published, and yet, the infections continue. “Bundling” packages to prevent ventilator-associated pneumonia (VAP) have proven quite successful, as well as packages to avoid intravascular device-related infections. Is it a matter of distributing the information more widely? Is it that healthcare workers disdain change and simply stick to the old routines while ignoring new recommendations? Whatever the cause, there is clearly a need for change.
“The principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside,” write Eggimann and Pittet. “Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.”
Four distinct areas stand out as particular areas of concentration: preventing contact transfer, improving surface cleaning, preventing device-related infections, and altering hand hygiene compliance. Surface cleaning will be addressed in a companion article (see page 32); the remaining three factors are explored below.
Some of the main sources of contact transfer may be virtually invisible, because they are so ubiquitous in the healthcare setting.
“In any healthcare setting, in particular, critical care areas such as an ICU, you are dealing with a compromised patient,” explains Karen Williams, manager for infection control at Morristown Memorial Hospital in New Jersey. “They are sick by the time that they get into an acute care facility and more than likely have been treated for something prior to their admission. This potentially sets them up to have a resistant organism as the cause of their infection. These patients can then become a reservoir in a unit that can put other patients at risk as well as staff. Contact transmission can occur a few ways — via direct secretion contact with the patient, contact with a contaminated surface/piece of equipment, and healthcare workers’ hands. Any one of these transmission routes can be a significant problem for any facility.”
“Some of the areas in the ICU where I see potential problem are stethoscopes, handling patient charts, even clothing of clinicians (especially neckties). In busy, high-acuity ICUs, pressure situations tend to decrease compliance of hand hygiene and other infection control preventative practices. In the ICU, there are so many clinical personnel involved in patient care, this increases direct contact, thus increasing risk of organism transfer,” says Thomas Cherry, RN, BSN, clinical product manager of the critical care division of Cook Inc., a medical device manufacturer.
“[This includes] any area that requires contact from caregivers for use on/with/for patients, particularly invasive procedures and equipment, such as ventilators or other respiratory support, intravenous sites and ports, other catheters,” agrees Katie Calabrese, MSN, NNP, CNS, product manager/market management for Baxa Corporation.
Device-related infections have plenty of opportunities in the ICU.
“The multitude of devices at high risk for colonization and potential development of infection include urinary catheters, prosthetic surgical implants (heart-valves, orthopedic implants), intravascular catheters, and even surgical meshes,” explains Cherry. “According to the Centers for Disease Control and Prevention (CDC), the most effective prevention method is not to use them when not needed. And the continual need for such devices must be evaluated on a daily basis. When such invasive devices are needed, clinicians must be very careful while inserting and maintaining. It all starts with hand hygiene before and after contacting each individual patient. Secondly, maximum sterile barrier precautions during insertion of these devices must be adhered to, along with the use of appropriate skin antiseptic solutions, such as 2 percent chlorhexidine. Finally, many devices today have surface-modified antimicrobial coatings that have been scientifically proven to prevent organisms from colonizing on catheter surfaces, thus helping prevent biofilm from beginning the building process. The most studied are silver-coated Foley catheters, chlorhexadine/silver sulfadiazine-coated and minocycline/rifampin impregnated central venous and ventricular catheters. Even though these types of technologies exist, there has been slow adoption based solely on initial increased investment, not realizing the downstream savings of preventing infections.”
“Ventilator-associated pneumonia (VAP), catheter- related bloodstream infections (CRBIs), and urinary tract infections (UTIs) are often associated with ICU patients. The key is to minimize the length of time the device is in place,” says Sharon Krystofiak, MS, MT (ASCP), CIC, manager of infection control at Pittsburgh Mercy Health System. “Unfortunately, it isn’t always possible to discontinue the use of such equipment, so sometimes we have to select products that offer additional protection against infections, such as silver or antimicrobial coated catheters and items such as BioPatch, an antimicrobial dressing containing chlorhexidine gluconate that can be placed on the skin surrounding an intravascular catheter to reduce the presence of bacteria around the insertion site. Many hospitals are finding that better compliance with simple procedures, such as keeping the head of the ventilated patient’s bed elevated to a 30-degree angle to avoid aspiration, is significantly reducing the number of VAP cases. A little bit of hightech combined with ‘back to the basics’ strategies is making a big difference in patient outcomes.”
“Prevention is based on strict adherence to aseptic technique, which does include a clean environment (clean surfaces and clean caregiver hands decrease the risk of transferring and spreading would-be infectious organisms),” adds Calabrese. “Baxa is now sponsoring the STAR (Skills Training, Academics and Resources) Center to help train caregivers in best practices. This state-of-the-art learning center will offer didactic and hands-on training in aseptic technique and compliance to regulations for compounding sterile products. The center provides clean room, demonstration, and training space where participants can see industry best practices, view compliant facilities, and have the opportunity to demonstrate aseptic skills.”
“There are many national initiatives such as the Institute for Healthcare Improvement (IHI) 100,000 Lives campaign that outlines ways to prevent these infections,” Williams stresses. “In a nutshell, if devices are inserted appropriately, monitored for need, and discontinued as soon as possible, it will help in the prevention of infections.”
“The ICU is a high-risk environment for organism transfer due to the heavy traffic flow and large variety of healthcare personnel that can come into contact with patients,” explains Boyd Wilson, system director for infection prevention and control/epidemiology for the HealthEast Care System in Minnesota, which includes four hospitals and ICUs.
Length of stay and dwell time for the medical devices increase the risk for colonization with organisms and also for infection, he points out, and neurology patients on mechanical ventilation may be at increased risk for pneumonia due to aspiration of secretions if there are restrictions on elevating their head due to head trauma. The HealthEast Care System has recently placed an emphasis on infection control projects focused on the ICU, which include prevention of VAP, bloodstream infections, ventriculostomy and neuro device infections, as well as a Six Sigma project on hand hygiene improvement. In addition to participation in the 100,000 Lives campaign, the healthcare system also participated in a state initiative, Safest in America, which focused on preventing healthcare-associated infections.
“Consistent application of the ventilator bundle (elevation of head of the bed, daily assessment of readiness to wean, consideration of sedation reduction, DVT prophylaxis, and GI prophylaxis), in addition to standardized oral care protocol, can result in virtual elimination of ventilator pneumonia,” Wilson maintains. “Likewise, use of the central line bundle (maximal barriers for insertion, use of chlorhexidine for skin antisepsis, insertion site selection, daily assessment of line necessity) can also bring infection rates to zero. Consistent application of maximal barriers for insertion (whether in the OR or ICU) is key, as well as strict aseptic technique for the regular management of the devices. Education on best practices and device management policies is also important, and feedback on compliance with practices as well as infection rates is important to change the ICU culture and assure that all patient care personnel have an awareness and appreciation for the infection prevention work and outcomes.”
Hand hygiene compliance is simply not as good as it should be throughout the healthcare environment. But it seems particularly necessary in the ICU, where patients are so very vulnerable and may have multiple comorbidities or injuries that already predispose them to multiple infections. And choosing products that are appropriate to the environment is also an important consideration.
“The need to assure the efficacy of skin care products is often appreciated only after the transfer of pathogens from patient to caregiver, or caregiver hands to patient, has already taken place and the risk of healthcare associated infection (HAI) has increased,” says Simrit Sandhu, product manager of applied infection control for STERIS Corporation. “Due to the acuity level and vulnerability of patients in the ICU, it becomes even more imperative that the hand hygiene products in use have been tested to the highest clinical performance standards and effectively support compliance to hand hygiene protocols. By using clinically superior formulations, the ICU can improve hand hygiene compliance and thereby reduce the risk of potential HAI.
“The ideal hand hygiene products balance antimicrobial efficacy and moisturization, to maintain skin condition and encourage hand hygiene compliance,” Sandhu continues. “Active ingredients must also be compatible across formulations for handwash, lotion, and alcohol handrub to ensure efficacy. Staff needs to make product choice decisions using a continuum or regimen approach, rather than making individual product decisions that might result in incompatible products.”
Hospitals also need to create more stringent procedures for monitoring hand hygiene compliance in acute care areas, he adds, because patients in the unit are rarely in a position to remind healthcare providers to practice good hand hygiene.
“Hand hygiene needs to occur before and after each contact with patients. Recently marketed alcohol- based gels have shown to increase compliance in hand hygiene and have been proven to be effective, especially when readily available in each patient room or hallway before entering,” adds Cherry.
ICU nurses often care for more than one high-risk, high-acuity patient during their shift and it is relatively easy to go from one ICU room to another without performing hand hygiene, Krystofiak points out.
And, says Calabrese, it must be easy to do properly and quickly. “If the right materials and products are readily available, it is much easier to do the right thing,” she maintains.
Williams adds, “You need to provide as many opportunities for hand hygiene as possible. The problem is that you can offer many ways to clean hands, but staff has to take the responsibility to do it. Peers and patients need to be involved and vocal with their healthcare providers asking if they did wash their hands.”
“The hands of personnel and visitors can be problematic, if both groups of individuals do not wash their hands before handling equipment, personal items, or food,” agrees Harriett Pitt, RN, BSN, MSN, CIC, director of epidemiology, Long Beach Memorial Medical Center and Miller Children’s Hospital in California. “Altering habits is difficult at best.
Behavioral scientists have studied repeatedly how to change behavior, and hand hygiene is a behavior that is learned, usually at an early age. The CDC recommendations point to areas where appropriate products, education, and specific programs can help improve hand hygiene in healthcare providers working in the ICU.”
1. Eggimann P and Pittet D. Infection Control in the ICU. Chest. 2001;120:2059-2093.