Newborn Week 2013 Quality issues and Accreditation of newborn healthcare delivery systems
Newborn Week 2013
Quality issues and Accreditation of newborn healthcare delivery systems
Dr L S Deshmukh
MD,DNB,DM(Neonatology)
Professor,In charge (Neonatology)
GMC, Aurangabad
IntroductionNosocomial infections :
* In hospital acquired* Higher mortality rate* Longer
hospitalization* Increased cost
NICU ATTACK
Sources of nosocomial infection
PersonnelOther sourcesFomites – equipmentsEnvironmentInvasive procedures
Risk factors for nosocomial infections
Intravenous catheters and other invasive procedures
Ventilation / suctioning Medications Overcrowding Understaffing Prolonged hospital stay Contaminated enteral feed Health care workers Colonization by pathogenic organisms Other neonates with infection
Nosocomial infections HCWs get their hands contaminated
during– Taking a patient’s blood– Examination / Recording TPR / BP– Assisting patients for mobility– Inserting Catheters / Invasive devices– contact with a patient’s clothes / bed linen– Performing procedures– Wound-dressing– Inanimate objects - bed rails / bedside
tables / I.V. pumps
sepsis – DisasterWeeks of hard work
+Sleepless nights
+Carefully calibrated fluids
+ Meticulous titrated ventilator settings
- Inadequate asepsis
=
Nothing (Zero)Nosocomial infections ~ nightmare
Asepsis - Definition
Absence of germs / pathogensTwo types of techniques :
- Medical (Clean)- Surgical (Sterile)
Definition of TermsHand hygiene – A general term that applies to either handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.Hand washing – Washing hands with plain soap and water.Plain soap – Refers to detergents that do not contain antimicrobial agents or contain low concentrations.Antimicrobial soap – Soap containing an antiseptic agent.
Definition of Terms Antiseptic agents – Antimicrobial
substances that are applied to the skin to reduce the number of microbial flora. e.g. alcohols, chlorhexidine, iodine etc.
Antiseptic hand wash – Washing hands with water and soap containing an antiseptic agent.
Alcohol-based hand rub – An alcohol-containing preparation designed for application to the hands for reducing the number of viable micro-organisms on the hands.
Five parts of asepsisI. Practices that prevent entry of
microbes into the nursery environment
II. Practices that prevent proliferation of microbes in nursery.
III. Practices that prevent spread of microbes between babies.
IV. Practices that protect that newborn from developing infections.
V. Practices that enable better asepsis & administration.
Fight against Macro-organisms
Fight against Micro-organisms
I- Practices that prevent entry of microbes into the nursery environment
Maintain a clean environment outside the nursery.
Entry restrictions Hand washing
- Single most important intervention Gowns/masks/slippers Air changes :
- 12 air changes- 0.5 µ bacterial filters- ? Roll of exhaust fans
Contd….
I- Practices that prevent entry of microbes in to the nursery environment
Entry restrictions- Only Mothers Allowed- No Entry of infected infantsRegulated entry- Personnel of nursery- Personnel of allied services
II – Practices that prevent proliferation of microbes in nursery
Good house – keeping practices
- Floors- Refrigerators- Bins
II – Practices that prevent proliferation of microbes in
nurseryDecontamination of equipments : Imp
- Incubators & open care systems- Ventilators (change tubing daily)- Resuscitation bags & kits (have sufficient Nos.)- Laryngoscopes- Disposable Procedure sets (LP /Taps/ ExTx)
Develop “ Disposable Culture”
III – Practices that prevent spread of microbes between babies
In addition to Hand washing & “Disposable culture“
Prevention of overcrowding- At least 4-6 ft. space in between- Avoid overcrowding
Adequate Staffing :- Tertiary care, 1:1 ratio- 1:2 for cohorted babies- 1:3 for noninfectious, treated babies.- 1:4 for stable babies
Prohibit stock solutions Fomites –
Files/stethoscope/Exam.tools/pens/cups/ telephone
Laminar flow – for mixing / reconst. Drugs / TPN
IV – Practices that protectnewborn from developing infections
* Breast milk* Involvement of mother* Early discharge* Eye and cord care* Skin care ( position / probes / emollients )* Handling IV fluids & drugs
Contd…
IV – Practices that protect newborn from developing infections* Handling invasive lines & tubes
- Peripheral IV lines (Change every 72 hrs.)- Central lines (surgical scrub must)
* Do not keep, if not necessary - Peripheral IV lines a minute more- IV infusion for an hour more- Central line a day more
IV – Practices that protect newborn from developing
infections Minimize handling & breach of barriers
- Noninvasive monitoring- Clubbing together rounds
Aseptic precautions during procedures- Universal precautions- IV lines ( assess frequently)- Endotracheal intubation & suctioning- Chest tube insertion/LP/Ex transfusion.- Central lines insertions ( maintain sanctity)
Iatrogensis
V – Practices that enable better asepsis
Environmental surveillance - At least every month.
Record of positive cultures- Analyze data regularly- Develop antibiotic policy
Motivating staff- Most Important- Sweeper to consultant / In-charge- Regular meetings
Hand HygieneHistorical perspective :oUse of antiseptics – 19th centuryoLiquid chloride solution, 1825oIgnaz Semmelweis, 1846
Use of chlorine solution – Decreased mortality (First evidence)
In 1961, US Public Health services recommended hand washing for health personnel
Normal Bacterial Skin Flora» Normal human skin – colonized with
bacteria.Total bacterial count – 3.9x104 to 4.6x106
Transient Vs Resident flora’» Transient flora –
Superficial layersEasily removed with washingUsually acquired through patient contact / infected sourceUsual cause of nosocomial infection
» Resident flora :- More deeper- Not easily removed- May be pathogenic
Purpose of Handwashing
* Removal all dirt and debris* Reduce cross contamination from
microbes* Interrupt the fecal – oral route of
infection.* Reduce risk of hands acting as vectors* Breaks a link in a chain of infections.* Increase the image of cleanliness of
Health Care Personnel.
Indications for hand washing Hands are visibly dirty or
contaminated Before having direct contact with
patients Before donning sterile gloves Before doing procedures After handling contaminated body
fluids
Types of hand wash Routine / social Procedural (antiseptic) Surgical hand scrub ‘Time’ method / ‘stroke
count’ method Details must be followed Recommended time First - 2 min, then 30 sec.
Hand Rub
Selection of hand hygiene agents Must provide efficacious hand
hygiene with low irritancy potential.
Maximize acceptance by HCWs Should not be costly. Must have adequate information
from manufacturers. Friendly dispenser systems
Criteria for selection of disinfectant Broad spectrum of action Rapid action Ability to suppress microbial re-growth
for a prolonged period of time. Non-irritating to the skin Non allergenic Effective after the first use Visually and aesthetically acceptable Cost effective
Types of chemical disinfectants
* Phenolics (environmental disinfectants)- Black and white fluids- Active against a wide range of bacteria- e.g. Cresol & LYSOL
* Chloroxylenols (non irritant)- e.g. Dettol, Ibcol- High concentrations are required (2.5 – 5.0%)
* Chlorine releasing agents (Cheap)- Effective disinfectants- Rapidly effective against viruses, fungi, bacteria & spores.- Should be prepared daily
- e.g. Sterite, Chloros, PreseptContd….
Types of chemical disinfectants
• Iodine or Idophors- For hand disinfection or surgical scrub- e.g. tincture of iodine, povidone iodine (betadine)
• Aldehydes- e.g. Glutaraldehyde (Cidex), Formaldehyde (Formalin)- Nondamaging to metal, plastics, or rubber- Useful for heat sensitive items.
• Alcohols - e.g. ethyl alcohol 70% (ethanol), isopropranol- Rapid disinfection- Cheap
• Chlorhexidine - Skin antiseptic, used for procedures- Costlier
• Quaternary ammonium compounds • Hydrogen peroxide and related compounds• Ethylene oxide gas
Recommended disinfectants
* A chlorine releasing agent (virus – contaminated material)* Phenolic disinfectant (for routine use)* Hypochlorides and other chlorine
releasing agents (baths, toilets, wash basins)
* Glutaraldehyde – immersible metal objects
Performance Indicators for Hand Hygiene» Periodically monitor and record
adherence » Provide feed back» Monitor the volume of antiseptic
use / soap / towels» Monitor adherence to policies » During outbreaks, total
assessment.
Risk factors for poor hand hygiene practices
Physician status Higher work loadHandwashing agents cause irritation and
drynessSinks are inconveniently located/shortage of
sinksLack of soap, water and towelsOften too busy/ insufficient timeOvercrowdingLack of guidelines / protocols
Needs - “ Behavioral Change “
Optimal NICU design Adequate space (80-
100 sq. ft. for Level III) Minimum 6 ft. distance
between incubators / warmers
Facilities for hand wash Foot or elbow operated
taps Air circulation facility
Fumigation No additional benefit, provided
excellent house keeping and asepsis
Mostly done routinely Periodically / following epidemic During low occupancy Spraying may be used
Fumigation
Waste Disposal
Isolation of neonates
* Open wounds or skin lesions 0r acute gastroenteritis
* Strict hand washing* Use of individual
equipment* Use of disposable* Maintain optimum
distance
Nursery Outbreaks
Cluster of infection with same pathogens Common source • Contaminated equipments (Thermometers,Ventilators,Stetho) • Environmental reservoirs • Lapses in hand washing – Most IMP.
“neonatologist’s nightmare”
Be vigilant to detect an increased incidence of common organisms
Adopt a systematic approach Be prepared to be surprised
Nursery Outbreaks - Lessons
Infection control and prevention“best practices.”
staffing, spacing, cohorting, auditing cleaning effectiveness, auditing hand hygiene, frequent microbiologic
screening
Without commitment from everybody involved in care, Infection Control
becomes a “BIG JOKE”
CONCLUSIONS
• Hand washing & common sense are the best disinfectants.• Mother is the best nurse of the baby.• Breast milk is the best antidote.• “MININMAL HANDLING” is the key.• Conscious, determined efforts & health education is our moral responsibility.