Welcome. My name is Kathleen Vollmann. I'm a clinical nurse specialist and a consultant, and I've published and lectured nationally and internationally on a variety of topics, specifically CAUTI and CLABSI prevention, and I've been part of the American Hospital Association and AHRQ program on reducing CAUTI and CLABSI in the ICUs in the United States. I've served as a subject matter expert for the Society of Critical Care Medicine, and I'm excited to be able to talk to you about what we can do with what we have, global prevention strategies to reduce catheter-based infections. I have some disclosures. Most importantly, I am a subject matter expert for CAUTI and CLABSI for the American Hospital Association, but I am also a consultant on the Speaker Bureau for Striker-Sage, La Jolla Pharmaceutical, the Tarot Medical, and I co-chair a Baxter Healthcare Advisory Board. I'm teaching, so you're going to get objectives. We're going to discuss the challenges hospitals have on all continents in reducing catheter-associated infections and outline a proven multidisciplinary approach to impact those infection rates. So, we're going to be talking about First World and low- and middle-income country challenges. So, to start that off with, 75% of the world's population lives in low- to middle-income countries. 50% of the ICU population in low- and middle-income countries are affected by HAIs, and in the United States, it's roughly about 20%. So, when we look at International Nosocomial Infection Control Consortium data, which they've been publishing for many years now, this is data from 2013 to 2018. It encompasses 664 intensive care units in 133 cities in 45 countries, and you can see the target is low- and middle-income countries, and they focus on CAUTI and CLABSI and VET data. So, when we look specifically at CAUTI and CLABSI, comparing low- to middle-income countries to the United States, CLABSI rates per 1,000 catheter days are 5.3 on average in low- and middle-income countries and 0.83 in the United States. For ventilator-associated events, again, per 1,000 ventilator days is roughly about 11.47 in low- to middle-income and in the United States, 1.3. CAUTI, much lower compared to those other two infections, 3.16 per 1,000 catheter days and 0.754 in the United States. The impact of these infections in low- and middle-income countries add to the length of stay, anywhere between 5 and 30 days, two times the mortality, and the cost is huge. In the United States, on average, the HAI cost is anywhere between $5,000 and $12,000, depending on which infection that you end up developing. And so, this really impacts people's lives, their livelihood, the amount of time the patient spends in the hospital, resulting in less beds available for other patients. So, it's an impact in low- and middle-income and in high-income countries. What impact did COVID have on this? Well, this was published data in 2020, and you can see CLABSI, 47% increase, CAUTI, 18% increase, and VAE, about a 45% increase. And this is in comparison data from 2019, when our infection rates were probably at some of the lowest points. So, this is data from the United States. And when there was a publication focusing on this data, they did a qualitative analysis to determine rationale for the potential increase, and these were some of the areas that the interviewees identified as challenges that they believe contributed to the increased infection rates. Shortage on PPE, the staffing changes that occurred, a significant number of travelers, also clinicians that were not part of the unit structure. They came from other parts of the hospital, so they probably didn't know the processes. Reduced frequency of contact, which resulted in potentially reducing some of the routine care practices that had become part of the infrastructure. Less chlorhexidine bathing, alteration in line cares, some related to the IV tubing going all the way out into the hallway, some related to scrub the hub, line and dressing integrity, because the patient was upside down for about 16 hours, so that made it difficult to do the routine auditing and assessment. There was increased line draws coming from these lines, creating greater exposure, and more blood cultures drawn from these lines as well. So, challenges to be able to achieve this care in high-income countries include team communication. Do the members respect each other? Do they have an infrastructure, like a multidisciplinary rounds, where every team member is able to communicate as part of that process? Does the front line have access to the infection data, so that they're able to make process improvements related to that? Resources. Are they available? Some types of resources may include the kits that are used, the insertion kits, the dressing kits. Other resources may be people resources, and that includes staffing issues, because we know data in the past. It was published quite a long time ago, but when the ratio went beyond one nurse for two patients, there was an increase in CLABSI rates. Multiple services. What impact does that have? When we look at multiple captains of the ship, making it difficult unless there is an infrastructure for communication, it creates challenges, competing priorities. As a part of that, without a head, then it's difficult to ensure that the practices are consistent throughout that ICU unit, and then ultimately compliance in the bundle of care that are evidence-based and proven to have an impact. What additional challenges exist for the low- to middle-income countries, besides the ones I just shared? Resources. They don't have kits. They have to put all of that together, and they may not have everything that they need. Surveillance systems are challenging. They're not set up like what we have here in the United States and in other high-income countries. Personnel and understaffing. Their staffing ratios are significantly higher, and that creates challenges, one, for being present on insertion and directing the sterility process, but also all the various maintenance management components that need to occur as part of everyday practice. One of the largest deficits is that they don't have anybody watching. In other words, a lack of an infection prevention control personnel that manage and address HAIs in the entire organization. Then something as simple as supplies for cleaning and soaps, so hands and environmental cleanliness, and then overall crowding that exists in those environments. The INICC created a roadmap, a multi-dimensional approach to be able to tackle these line infections, and they start with the basics. Surveillance system. We're going to go through these. Hand hygiene, fundamental. Education, multimodal. A component of staff accountability and their ability to change their behavior through feedback that comes from analyzing those infections and also looking at our processes, and then use of the bundles in improving compliance in that area. In surveillance systems, one of the techniques that's used in low to middle-income countries is antimicrobial prescription surveillance. They're taking a look at those patients that have had antibiotics prescribed, and then they combine that with a laboratory surveillance for potential infections, and then they pair the two up. What the data has shown is this is probably the most accurate estimate of HAIs without using the high-income country surveillance systems with very rigorous definitions like the National Health Safety Network system, and then sending that feedback to the unit level as soon as possible to be able to identify issues. It's a true fact and a challenging fact because if you don't identify the infection, you're not going to be able to fix it. Anywhere between 27% and 37% of middle-income countries do not have catheter-related infection surveillance. If you don't know, you don't work. As I said, hand hygiene is the single most important factor in preventing the spread of infection. The WHO has an extremely well-done comprehensive program that covers high-income, low-income, and middle-income countries in a multifaceted approach for addressing hand hygiene in the environment. No matter where you are in the world, health care providers clean their hands less than half the time that they should, whether you're in a high- or low-middle income country. One-third of the world's health care facilities may lack the hand hygiene resources directly at point of care, making it extremely difficult to clean your hands when you're supposed to. What are the guidelines coming from the CDC and the WHO? Alcohol-based hand hygiene is the frontline method for decontamination. You need to do it for that 20 to 30 seconds. We'll talk about strategies and also areas that are frequently missed when doing hand hygiene. If your hands are visibly soiled or exposed to a potential spore-forming organism, you want to wash them either with bacterial or non-antibacterial soap. The amount of time that you're washing is significantly longer, which is why the alcohol became the frontline. The data supports not using triclosan-containing soaps. Decontaminate the hands. Clearly, after wearing gloves, oftentimes we think the gloves are a protection and that we just change the gloves and we'll be fine. That's not the case. Providing health care workers with hand lotions and creams to be able to minimize contact dermatitis. One of the challenges that I see when I get out in the clinical area is these large tubs of lotion. They don't have a one-way valve, so it is a moist environment for microorganisms to breed. When you're thinking about providing that hand hygiene, individual use, or the concept of putting it in a container and having it managed by housekeeping, all the guidelines support multi-dimensional strategies to be able to improve hand hygiene. The CDC, I have not seen this in the WHO, talk about not wearing artificial fingernails or extenders because of the risk of bacteria underneath them. When we look, these posters are on the WHO website and I have used them to put them up in front of the sink and also in front of the hand hygiene or the alcohol-based hand hygiene so that it is a reminder for clinicians to be able to do this procedure effectively because it does make a difference. Oftentimes what gets missed are the thumbs, the tops, the palms, and the nails. We do know that if we can improve the effectiveness of our hand hygiene techniques, we can get a better kill from 60% to 90% on each episode of hand hygiene. Now what areas are frequently missed? Well, if you take a look at this representation, you can see the green is frequently missed and the purple is sometimes missed. So that gives you an idea of how best to target improving the technique for hand hygiene. The next step in that multidisciplinary approach and multi-dimensional approach is multimodal and frequent education. I'm very excited to say that the AHRQ has a web-based toolkit that is being launched for CAUTI and CLABSI prevention that has been developed based on the experiences and the knowledge of the team that worked on that program for many years. It will be free and accessible to all. Education, make it work, tip sheets, all sorts of things. If you get a chance, we're going to have a session on the toolkit at SCCM, so check that out. Signs, checklists, and then providing feedback. And from the high-income area, some of the things that have worked is having a unit-based quality nurse that it is their job to focus on the quality in the environment, auditing, real-time coaching, education, also having multi-specialty intervention team that may be able to assist on insertion components, and then support from leadership so that you get the right resources and the necessary people to make the right thing happen for the patient. Then the use of a feedback system. This will be available as part of the toolkit, and it's been tested out to learn from a defect. So basically, it's a modified root cause analysis where what I found with most of the infection preventionists that I've talked with is they know within 48 to 72 hours that it's likely going to be an infection. So I work with them to call up to the unit so the unit can then do an immediate learn from a defect when the patient is still on the unit. So that allows a couple of things. One, to physically look at the patient and look at where some areas of challenge may be and identify those. The second, it allows the clinicians to not just think of that infection as a number that gets placed on a chart, but actually a human being where harm has occurred. So it allows a strengthening of the do no harm component of the clinician's practice. So these tools will be available. The International Society for Infectious Disease created a consensus paper for managing and preventing catheter infections, and they did focus specifically on CLABSI. It is not much different than what we're familiar with in the United States with our bundles. Surveillance is critical. Care bundle on the insertion, selecting the appropriate site, hand hygiene, skin prep, and barrier precaution. And on the maintenance side, review as to whether you still need the catheter, hand hygiene, manage the hub, scrub the hub, and dressings. If you're using gauze every two days, change it. If you're using transparent every seven days. So in my experience of being out in those clinical environments and the other subject matters experience of the variation in practice that we've seen in high income countries, the first is with insertion. As soon as electronic health records came into being, well, not immediately, but close to it, those checklists moved into the EHR. And what I've seen happen is that the person who is inserting the catheter is the one that completes the checklist. That was not the purpose of the checklist. The purpose of the checklist was to have the reviewer or the observer complete that document and recognize and call for any breaks in sterile technique as a part of it. So something to think about. On the maintenance side, really wrapping that daily discussion into a process in your unit. It's not consistently happening in rounds. So we need to figure out a way to be able to hardwire that or do it separately. But a strategy, there's inconsistency in strategy application of daily discussion of need. Dressing disruption. Clearly in the literature associated with increased risk of infection, threefold on the second dressing disruption. So auditing and assessing how secure our dressings are and working on quality improvement related to that is important. Accessing the site, how we do it, monitoring that, whether we use passive disinfection or active disinfection. And then the last one, inconsistency in the delivery of chlorhexidine bathing. The type of chlorhexidine bathing as well as the efficacy doing it from the jawline down and actually just doing it. So when we look at the impact of that multidimensional approach that was introduced by the INICC to low and middle income countries, there are multiple publications that show the impact that that approach has had with decreases in infection from anywhere to 34% decrease to 76% decrease, which is huge. And lastly, the CDC is also participating in this global journey looking at networks and research to be able to save lives on the infection prevention component, as well as reducing antimicrobial resistance through different strategies. And we are really connected as a globe because if we all, and we saw that with the pandemic, that we are interconnected. And so it was great to see the initiation of this program, as well as all the work the WHO is doing. So I want to thank you very much for your time. And if you have any questions, please send me an email at kvolman.comcast.net. Have a wonderful Congress.

catheter-based infections

infection rates

challenges

hand hygiene

education

global collaboration