Figure 1

Figure 2

Table 1. Recommended Practices for Hand Hygiene in the Perioperative Setting

Basic Practices for Hand Hygiene: Recommended for All Acute Care Hospitals

• Select appropriate products (II).
  • For routine hand hygiene, choose an alcohol-based hand rub (ABHR) with at least 62% alcohol.
  • Antimicrobial or nonantimicrobial soap should be available and accessible for routine hand hygiene in all patient care areas.
  • For surgical antisepsis, use an ABHR that is specially formulated for surgical use, containing alcohol for rapid action against microorganisms and another antimicrobial for persistence, or use an antimicrobial soap and water. Scrub brushes should be avoided because they damage skin.
• Provide convenient access to hand hygiene equipment and products by placing them strategically and assuring that they are refilled routinely as often as required (III).
  • Sinks should be located conveniently and in accordance with the local applicable guidelines.
  • Dispenser location may be determined by assessing staff workflow patterns or use of a more formal framework, such as Toyota Production Systems shop floor management. Counters in product dispensers can show which dispensers are frequently used and which are rarely used.
    • It is important to place hand hygiene products in the flow of work to promote adherence.
    • Location of dispensers and storage of ABHR should be in compliance with fire codes.
• Involve HCPs in choosing products (III).
  • Various components of hand hygiene products can cause irritation, and products that are not well accepted by HCPs can negatively affect hand hygiene adherence.
• Perform hand hygiene with an ABHR or, alternatively, an antimicrobial or nonantimicrobial soap for the following indications (II).
  • Before direct patient contact.
  • Before preparing or handling medication in anticipation of patient care (eg, in medication room or at medication cart before patient encounter).
  • Before inserting an invasive device.
  • Before and after handling an invasive device, including before accessing intravenous devices for medication administration.
  • Before moving from a contaminated body site to a clean body site on the same patient.
  • After direct patient contact.
  • After removing gloves.
  • After contact with blood or bodily fluids.
  • After contact with the patient environment.
• Perform hand hygiene with antimicrobial or nonantimicrobial soap when hands are visibly soiled (II).
• Assess unit- or institution-specific barriers to hand hygiene with frontline HCPs for the purpose of identifying interventions that will be locally relevant (III).
• Implement a multimodal strategy (or “bundle”) for improving hand hygiene adherence to directly address the organization’s most significant barriers (II).
  • Use a bundled approach including enhanced access to ABHR, education, reminders, feedback, and administrative support. This combination of interventions has a significant collective impact on hand hygiene adherence.
  • At a minimum, use a bundled approach including education, reminders, and feedback.
• Educate, motivate, and ensure competency of HCPs (anyone caring for the patient on the institution’s behalf) about proper hand hygiene (III).
  • Educate HCPs through regular sessions at hire, when job functions change, and at least annually.
    • When possible use interactive means, such as fluorescing indicators, to simulate hand contamination and subsequent removal, and visual reminders, such as culture plates of hands or audience response systems, to keep the audience engaged.
  • Ensure competency of HCPs by testing knowledge of the indications for hand hygiene and requiring demonstration of appropriate hand hygiene technique.
  • Educate patients and families about hand hygiene on admission to healthcare facilities and when changes in circumstances warrant. Encourage patients and families to remind HCPs to clean their hands before care episodes.
  • Motivate HCPs to perform hand hygiene using positive message framing for hand hygiene messaging and posters.
  • Use behavioral frameworks and recognized behavioral techniques to plan and execute interventions.
• Measure hand hygiene adherence via direct observation (human observers), product volume measurement, or automated monitoring (II).
  • Decide on the type of measurement system on the basis of resource availability and commitment to using the data collected productively. Consider the advantages and limitations of each type of monitoring.
    • Use direct observation to elucidate contextual barriers to and facilitators of hand hygiene and to provide corrective feedback to individuals.
    • Use product volume measurement for large-scale benchmarking but complement with direct observation when possible.
    • Use automated systems to provide real-time reminders and generate feedback for quality improvement.

    Note: Be aware that such systems have been mainly used in research settings. They may be limited in their capacity to accurately measure opportunities within each patient care encounter. These systems can, however, measure a large sample of hand hygiene opportunities and can be useful for measuring trends over time and generating real-time displays for feedback.

• Provide feedback to HCPs on hand hygiene performance (III).
  • Provide feedback in multiple formats and on more than one occasion.
  • Provide meaningful data with clear targets and an action plan in place for improving adherence.
    • Meaningful data may include unit- or role-based adherence data rather than overall performance.
    • Real-time displays of hand hygiene adherence may provide some incentive for improvement on a shift-by-shift basis.

Special Approaches for Hand Hygiene Practices

• During norovirus outbreaks, in addition to contact precautions requiring the use of gloves, consider preferential use of soap and water after caring for patients with known or suspected norovirus infection (III).
• During C. difficile outbreaks or in settings with hyperendemic CDI, in addition to contact precautions requiring the use of gloves, consider preferential use of soap and water after caring for patients with known or suspected CDI (III).

Basic Practices for Prevention and Monitoring of CDI: Recommended for All Acute Care Hospitals

• Encourage appropriate use of antimicrobials (II).
• Use contact precautions for infected patients, single-patient room preferred (III for hand hygiene, II for gloves, III for gowns, III for single-patient room).
• Ensure cleaning and disinfection of equipment and the environment (III for equipment, III for environment).
• Implement a laboratory-based alert system to provide immediate notification to infection prevention and control (IPC) and clinical personnel about newly diagnosed CDI patients (III).
• Conduct CDI surveillance and analyze and report CDI data (III).
• Educate health care practitioners (HCPs), environmental service personnel, and hospital administration about CDI (III).
• Educate patients and their families about CDI as appropriate (III).
• Measure compliance with Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) hand hygiene and contact precaution recommendations (III).

Special Approaches for Preventing CDI

Approaches to minimize C. difficile transmission by HCPs

• Intensify the assessment of compliance with process measures (III).
• Perform hand hygiene with soap and water as the preferred method before exiting the room of a patient with CDI (III).
• Place patients with diarrhea under contact precautions while C. difficile testing is pending (III).
• After the patient becomes asymptomatic, prolong the duration of contact precautions until hospital discharge (III).

Approaches to minimize C. difficile transmission from the environment

• Assess the adequacy of room cleaning (III).
• Use a US Environmental Protection Agency (EPA)-approved sporicidal disinfectant or diluted sodium hypochlorite for environmental cleaning and disinfection. Implement a system to coordinate with environmental services if it is determined that sodium hypochlorite is needed for environmental disinfection (III).

Approaches to reduce the risk of CDI if C. difficile is acquired

• Initiate an antimicrobial stewardship program (II).

Approaches that Should NOT be Considered a Routine Part of CDI Prevention

• Patients without signs or symptoms of CDI should NOT be tested for C. difficile (II).
• C. difficile testing should NOT be repeated at the end of successful therapy in a patient recently treated for CDI (III).
• Do NOT routinely place patients who are on antimicrobials for other indications on CDI treatment to prevent CDI (III).

Table 2. Fundamental Elements of Accountability for Healthcare-Associated Infection Prevention

Key Points

• Urinary tract infection (UTI) is one of the most common hospital-acquired infections; 70%-80% of these infections are attributable to an indwelling urethral catheter.
  • The burden of CAUTI in pediatric patients is not well defined.
• Twelve to sixteen percent of adult hospital inpatients will have a urinary catheter at some time during admission.
• The daily risk of acquisition of bacteriuria varies from 3%-7% while an indwelling urethral catheter remains in situ.
• In one 3-year Canadian study, the incidence of urinary-to-bloodstream infections was 1.4/10,000 patient-days. All-cause 30-day mortality in these patients was 15%.
• Catheter use is associated with negative outcomes in addition to infection, including nonbacterial urethral inflammation, urethral strictures, mechanical trauma, and mobility impairment.

Basic Practices for Preventing CAUTI (recommended for all acute care hospitals)

Appropriate infrastructure for preventing CAUTI

• Provide and implement written guidelines for catheter use, insertion, and maintenance (III).
• Ensure that only trained, dedicated personnel insert urinary catheters (III).
• Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located (III).
• Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal. Record criteria for removal or justification for continued use (III).
• Ensure that there are sufficient trained personnel and technology resources to support surveillance for catheter use and outcomes (III).

Surveillance for CAUTI (if indicated on the basis of facility risk assessment or regulatory requirements)

• Identify the patient groups or units in which to conduct surveillance on the basis of risk assessment, considering frequency of catheter use and potential risk (eg, types of surgery, obstetrics, critical care) (III).
• Use standardized criteria, such as CDC's National Healthcare Safety Network (NHSN) definitions, to identify patients who have a CAUTI (numerator data) (III).
• Collect information on catheter-days and patient-days (denominator data) and indications for catheter insertion for all patients in the patient groups or units being monitored (III).
• Calculate CAUTI rates and/or standardized infection ratio (SIR) for target populations (III).
• Use surveillance methods for case finding that are documented to be valid and appropriate for the institution (III).
• Consider providing unit-specific feedback (III).

Education and training

• Educate healthcare personnel (HCP) involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters and procedures for catheter insertion, management, and removal (III).
• Assess HCP competency in catheter use, catheter care, and maintenance (III).

Appropriate technique for catheter insertion

• Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain (II).
• Consider other methods for bladder management, such as intermittent catheterization, where appropriate (II).
• Practice hand hygiene (based on CDC or WHO guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus (III).
• Insert catheters following aseptic technique and using sterile equipment (III).
• Use sterile gloves, drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a sterile single-use packet of lubricant jelly for insertion (III).
• Use as small a catheter as possible consistent with proper drainage, to minimize urethral trauma (III).

Management of indwelling catheters

• Properly secure indwelling catheters after insertion to prevent movement and urethral traction (III).
• Maintain a sterile, continuously closed drainage system (III).
• Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur (III).
• For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant (III).
• Obtain larger volumes of urine for special analyses aseptically from the drainage bag (III).
• Maintain unobstructed urine flow.
  • Keep the collecting bag below the level of the bladder at all times. Do not place the bag on the floor (III).
  • Keep catheter and collecting tube free from kinking (III).
  • Empty the collecting bag regularly using a separate collecting container for each patient. Avoid touching the draining spigot to the collecting container (III).
• Employ routine hygiene. Cleaning the meatal area with antiseptic solutions is unnecessary (III).

Special Approaches for Preventing CAUTI

Perform a CAUTI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CAUTI rates or SIRs despite implementation of the basic CAUTI prevention strategies listed previously.

• Implement an organization-wide program to identify and remove catheters that are no longer necessary using one or more methods documented to be effective (II).
• Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners (II).
• Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use (III).

Approaches that Should NOT be Considered a Routine Part of CAUTI Prevention

• Do NOT routinely use antimicrobial/antiseptic-impregnated catheters (I).
• Do NOT screen for asymptomatic bacteriuria in catheterized patients (II).
• Do NOT treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures (I).
• Avoid catheter irrigation (II).
• Do NOT use systemic antimicrobials routinely as prophylaxis (III).
• Do NOT change catheters routinely (III).

Urinary Catheter Reminder

Key Points

• Surgical site infections (SSIs) occur in 2%-5% of patients undergoing inpatient surgery.
• Approximately 160,000-300,000 SSIs occur each year in the US.
• SSI is now the most common and most costly hospital-acquired infection.
• Up to 60% of SSIs have been estimated to be preventable by using evidence-based guidelines.

Basic Practices for Preventing SSI

• Administer antimicrobial prophylaxis according to evidence-based standards and guidelines (I).
  • Adjust dosing on the basis of patient weight.
  • Redose prophylactic antimicrobial agents for long procedures and in cases with excessive blood loss during the procedure.
  • Use a combination of parenteral antimicrobial agents and oral antimicrobials to reduce the risk of SSI following colorectal procedures.
• DO NOT remove hair at the operative site unless the presence of hair will interfere with the operation. Do not use razors (I).
• Control blood glucose during the immediate postoperative period for cardiac surgery patients (I) and noncardiac surgery patients (II).
• Maintain normothermia (temperature of 35.5°C or more) during the perioperative period (I).
• Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation (I).
• Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (I).
• Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery (I).
• Use a checklist based on the WHO checklist to ensure compliance with best practices to improve surgical patient safety (I).
• Perform surveillance for SSI (II).
  • Identify, collect, store, and analyze data needed for the surveillance program.
  • Perform postoperative surveillance for 30 days; extend the postoperative surveillance period to 90 days for certain procedure categories.
  • Surveillance should be performed on patients readmitted to the hospital.
• Increase the efficiency of surveillance through utilization of automated data (II).
• Provide ongoing feedback of SSI rates to surgical and perioperative personnel and leadership (II).
• Measure and provide feedback to providers regarding rates of compliance with process measures (III).
• Educate surgeons and perioperative personnel about SSI prevention (III).
• Educate patients and their families about SSI prevention as appropriate (III).
• Implement policies and practices aimed at reducing the risk of SSI that align with evidence-based standards (eg, CDC, Association for periOperative Registered Nurses, and professional organization guidelines) (II).

Special Approaches for Preventing SSI

• Screen for S. aureus and decolonize surgical patients with an antistaphylococcal agent in the preoperative setting for high-risk procedures, including some orthopedic and cardiothoracic procedures (II).
• Perform antiseptic wound lavage (II).
• Perform an SSI risk assessment (III).
• Observe and review OR personnel and the environment of care in the OR (III).
• Observe and review practices in the postanesthesia care unit, surgical ICU, and/or surgical ward (II).

Approaches That should Not Be Considered a Routine Part of SSI Prevention

• DO NOT routinely use vancomycin for antimicrobial prophylaxis (II).
• DO NOT routinely delay surgery to provide parenteral nutrition (I).
• DO NOT routinely use antiseptic-impregnated sutures as a strategy to prevent SSIs (II).
• DO NOT routinely use antiseptic drapes as a strategy to prevent SSIs (I).

Table 3. Selected Risk Factors for and Recommendations to Prevent Surgical Site Infections (SSIs)