2.

0
CONTACT HOURS

HAI prevention:
The power is in your hands
Review evidence-based recommendations for hand hygiene
and prevention of healthcare-associated infections (HAIs)
such as ventilator-associated pneumonia, urinary tract
infections, surgical-site infections, and catheter-related
bloodstream infections.

By Douglas Houghton, CCRN, ARNP, MSN

Supported by an educational grant from GOJO Industries, Inc.

1
H
ealthcare-associated infections (HAIs) are a
serious and costly problem for healthcare, in
financial terms as well as in prolonged hospi-
talization and increased mortality. The Centers
for Disease Control and Prevention (CDC) estimates that
2 million patients in U.S. hospitals develop a HAI each
year, and more than 90,000 to 100,000 die as a result.1
Approximately 30% of intensive care unit (ICU)
patients develop HAIs, although rates vary significantly
based on the study population and the inpatient setting.2
In a 2004 Pennsylvania study, 12,000 patients developed
HAIs during their hospital stay, costing an extra $2 billion
in care and at least 1,500 preventable deaths. In this study,
urinary tract infection associated with indwelling catheters
was the most common HAI, and hospital-acquired pneu-
monia had the highest mortality rate at 29%. The average
cost to treat a Pennsylvania patient with an infection was
$29,000, compared to $8,300 for those who didn’t have an
infection.1
In critically ill patients, ventilator-associated pneumo-
nia is the most prevalent HAI, resulting in a 6.1 day aver-
age increased length of stay, a doubled mortality risk, and
additional hospital costs of approximately $10,000 to
$40,000 per episode.3 Since the problem in the United
States is estimated to cost in excess of $3.5 billion per
year in increased length of stay alone, providing cost effec-
tive ways to decrease the incidence of HAIs is obviously
of interest to patients, providers, and payors.2
The keystone of infection control
In 2002, the CDC released updated hand hygiene guide-
lines, prompted in part by continued development and
research in the field, such as alcohol-based hand rubs and
alternatives to antibacterial soaps and water. It’s a well
accepted and documented fact that hand hygiene decreas-
es rates of HAIs.4 Unfortunately, it’s equally well known
that healthcare workers of all disciplines consistently fail
to adhere to adequate hygiene practices. In fact, adherence
rates are lowest in ICUs, where multiple opportunities
exist for hand hygiene every hour due to the frequency of
patient care contacts.5 Heavy workload and poor staffing
also adversely affect hand hygiene compliance.4 It’s likely
that a sustained effort to promote hand hygiene will be
cost-saving instead of costly, when taking into account the
money saved from prevention of nosocomial infections.6
∞ Specific recommendations from the hand hygiene
guidelines: Any direct patient-care contact (including
contact made with gloves) or contact with objects in the
immediate patient vicinity is considered an “opportunity”
2
for hand hygiene. The CDC guidelines make a strong
recommendation that if hands aren’t visibly soiled, an
alcohol-based hand rub should be used for routinely
decontaminating hands between contacts. When hands
are visibly soiled with blood/body fluids or other pro-
teinaceous material, an antimicrobial or nonantimicrobial
soap and water are recommended for use.4 This recom-
mendation of an alcohol-based hand rub as the hand
hygiene method of choice if hands aren’t visibly soiled is
a change from previous guidelines, and has prompted
many institutions to change their practice and policies to
reflect this.
If exposure to Bacillus anthracis or Clostridium difficile is
suspected, it’s recommended to wash with antimicrobial
or nonantimicrobial soap and water as well as use gloves
for any contact. This is because alcohols, chlorhexidine,
and other antiseptic agents have poor activity against
spore-forming bacteria. The physical friction associated
with soap and water handwashing at least decreases the
contamination level.
When using an alcohol-based hand rub, apply to the
surface of one palm (amount per manufacturer’s direc-
tions) and rub over all hand surfaces until hands are dry.
When washing with soap and water, it’s recommended to
first wet hands before applying the product, rub vigorous-
ly for at least 15 seconds, and dry thoroughly. Use a paper
towel to turn off the faucet to avoid recontamination of
hands. For surgical hand antisepsis, using an antimicrobial
soap or an alcohol-based hand rub with persistent activity
is recommended before donning sterile gloves. When per-
forming surgical hand antisepsis using antibacterial soap,
scrub hands and forearms the length of time recommend-
ed by the manufacturer (usually 2 to 6 minutes). Long
scrub times (10 minutes) aren’t necessary.
When using an alcohol-based surgical handscrub prod-
uct with persistent activity, follow the manufacturer’s
instructions. Before applying the alcohol solution, prewash
hands and forearms with a nonantimicrobial soap and dry
hands and forearms completely. Apply the alcohol-based
product as recommended, then allow hands and forearms
to dry completely before donning sterile gloves. For all
healthcare providers in contact with patients at high risk
for infection, nails should be kept short (less than a quar-
ter-inch long) and artificial nails shouldn’t be worn.7
From an administrative standpoint, it’s imperative that
healthcare workers of all classifications receive adequate
education on when and how to perform hand hygiene. It’s
also vital that hand hygiene products be conveniently
located and easily visible to promote adherence.
∞ Recommendations for prevention of specific infec-
tious complications: Environmental and equipment
cleaning and disinfection between patients is another vital
concept worth repeating, which applies to all patient pop-
ulations and care settings. It may also be helpful to identi-
fy predisposing factors in each patient to most carefully
survey the highest risk individuals. Predisposing factors
can be classified into four major groups: underlying health
impairment, the acute disease process, invasive devices,
and treatment modalities such as steroid use and blood
transfusion.2
Hospital-acquired pneumonia
The majority of cases of hospital-acquired pneumonia
(HAP) are related to mechanical ventilation, known as
ventilator-associated pneumonia (VAP). Rates vary signif-
icantly among patient populations, with a median rate
ranging from 2.3 cases per 1,000 ventilator days in pedi-
atric ICUs, up to a median rate of 11.4 cases per 1,000
ventilator days in trauma ICUs. It’s the most common
nosocomial infection in ICU patients and the most lethal
of hospital-acquired infections.8,9 Hospital mortality of
ventilated patients with VAP is 46% compared to 32% for
ventilated patients who don’t develop VAP.9
The CDC released a document in 2003 updating its
previously published guidelines for HAP prevention.10
This document reviews sterilization and disinfection pro-
cedures for ventilation equipment, and also recommends
that disposables such as breathing circuits NOT be
changed on a routine basis, but only when malfuntioning
or visibly soiled. Specific highlights regarding direct
patient care interventions include:
∞ adherence to hand hygiene guidelines (as previously
described) before and after patient contact or contact with
respiratory equipment, whether or not gloves are worn
∞ vaccination of patients with the pneumococcal vaccine
if they’re over 65 years old, or if they’re 5 to 64 years of
age with a chronic health condition such as chronic
obstructive pulmonary disease, HIV, or diabetes mellitus
∞ use of noninvasive ventilation when possible
∞ removal of endotracheal and nasal/oral feeding tubes as
soon as possible to decrease aspiration risk
∞ elevation of the patient’s head in bed to 30 to 45
degrees (unless medically contraindicated) to help prevent
aspiration
∞ routine verification of feeding tube placement
∞ use of an orotracheal tube rather than a nasotracheal tube
to decrease the risk of hospital-acquired sinusitis and VAP
∞ use of an endotracheal tube with a suction port above
the cuff to facilitate suction of oral secretions that may
pool above the cuff; tube securing to prevent extubation
∞ frequent mouth care to decrease colonization of the
teeth and oral mucosa; contaminated oral secretions flow
to the subglottic area where they can be aspirated. A daily
oral hygiene rinse with a chlorhexidine-based solution
may reduce or prevent oropharyngeal colonization.11
∞ incentive spirometry and encouragement of deep
breathing; increased patient activity as feasible
∞ daily sedation vacations to patients to assess their readi-
ness for extubation; daily interruption of sedation resulting
in a markedly significant reduction in time on mechanical
ventilation (7.3 days to 4.9 days) in one study12
∞ peptic ulcer prophylaxis; decreasing gastric pH may
protect against a greater pulmonary inflammatory
response to aspiration of gastric contents13
∞ deep vein thrombosis (DVT) prophylaxis; according to
the IHI, while it’s unclear if there’s any association
between DVT prophylaxis and VAP rates, it’s still an
excellent practice for ventilated patients. The use of
sequential compression devices and anticoagulants are rec-
ommended unless contraindicated.13
Urinary tract infection
The second most common nosocomial infection in ICUs
is urinary tract infection (UTI). Virtually all (97%) are
associated with the presence of an indwelling urinary
catheter.14 Thus, the primary focus on eliminating UTIs
needs to be in the early removal of indwelling catheters as
soon as feasible. Few interventions other than removal
significantly decrease the infection rate, thus the CDC
hasn’t published any new guidelines for prevention of
catheter-associated UTIs since the first one was published
in 1981, although existing guidelines were reviewed in
2005. Strongly recommended interventions include:
∞ education of personnel in proper insertion and catheter care
∞ emphasis on hand hygiene when handling catheter or
equipment
∞ insertion of catheter using aseptic technique and sterile
equipment
∞ securing of catheter properly to avoid trauma and use of
a sterile closed drainage system, while maintaining unob-
structed urine flow
∞ obtaining urine samples aseptically
∞ catheterizing only when necessary (consider other
methods such as intermittent catheterization or condom
catheterization when appropriate).
Another intervention with a weaker recommendation
which affects nursing care is to avoid replacing indwelling
3
catheters on a regular, arbitrary basis. Urinary catheters
coated with silver-hydrogel are now commercially avail-
able.15 Antibiotic-coated catheters are also in develop-
ment, but no clinical trial results show a benefit in
humans at the present time.
Intravascular catheter-related infections
It’s estimated that approximately 80,000 catheter-related
bloodstream infections (CRBSI) occur per year, each gen-
erating additional costs between $34,000 and $56,000.16
The most recent guidelines from the CDC make very
specific recommendations for patient care, since there’s a
fairly large body of research in this area, such as random-
ized clinical trials with large sample sizes.
Background and pathogenesis
Not surprisingly, the dramatic increase in CRBSI corre-
lates with the dramatic increase in the use of indwelling
central venous catheters in the inpatient and outpatient
settings. Such catheters have provided reasonably safe and
reliable venous access for patients and providers, but
unfortunately the risk of infection remains a problem. The
most common mechanism by which CRBSI occurs is
through access of bacteria or fungi from the skin, which
then migrate down the catheter and into the bloodstream,
thus the focus of preventing infection in central venous
catheters is on skin prep and meticulous sterile technique
during insertion and handling of catheters.
Less common but still possible is the colonization or
infection of the catheter through hematogenous spread of
an organism from another distant infected site in the
patient, such as a UTI or VAP. The most common organ-
isms causing CRBSI are gram-positive organisms which
frequently colonize the skin, such as staphylococci and
enterococci.16 Fungal infection, usually with candida sp., is
also on the increase.
In addition to meticulous insertion and handling of
catheters, one successful method of minimizing CRBSI
has been through the use of catheters coated or impreg-
nated with antiseptic or antibiotic compounds. There are
several commercially available products, whose use in the
acute care setting has become the standard of care.
Highlights from the CDC guidelines for prevention of CRBSI
General measures:
∞ Strong evidence exists that education of healthcare
workers who insert or care for intravascular catheters is a
highly effective and risk-free means of decreasing infec-
4
tion rates. Many institutions now empower the bedside
nurse to halt the procedure if infection control measures
are violated during the insertion process.
∞ Maintenance of appropriate nursing staff levels, espe-
cially in ICUs, has been shown in multiple studies to cor-
relate highly with infection rates. Since each infection car-
ries such a high cost in terms of morbidity and mortality
(and actual finances), maintaining adequate nursing
staff/patient ratios is likely a cost-effective measure, as
well as ethically appropriate.
∞ I.V. teams or similar designated personnel should care
for intravascular catheters.
∞ Surveillance of the insertion site and monitoring for
signs of infection such as increased white blood cell count,
fever, or redness at the site is recommended. Date and
time of insertion and dressing changes should be recorded.
∞ Observation of hand hygiene guidelines before and
after all catheter care, including site palpation. Hand
hygiene should also be done before and after inserting,
replacing, accessing, repairing, or dressing an intravascular
catheter.
∞ Use of maximal barrier precautions, including sterile
gloves, gown, mask, and cap—as needed; covering the
patient from head to toe with a sterile drape with a small
opening for the insertion site should be done for all cen-
tral vascular access insertions.
Catheter and site choice:
∞ Use a catheter with the minimal number of lumens
necessary to provide adequate access. Choose the best site
for the individual patient; the subclavian site is recom-
mended if there’s no contraindication. Catheters used for
hemodialysis or pheresis should be placed in a jugular or
femoral vein to avoid venous stenosis.
∞ Use an antimicrobial or antiseptic impregnated catheter
for adults whose catheter is expected to remain in place
for at least 5 days. No recommendation can be made for
pediatric patients regarding the use of such catheters.
∞ Excess hair should be clipped, not shaved, at the inser-
tion site.
Site care:
∞ For site care prior to insertion, 2% chlorhexidine is the
preferred agent, although tincture of iodine, iodophor, or
70% isopropyl alcohol are also acceptable. For chlorhexi-
dine application, a back-and-forth motion is recommend-
ed, while a circular motion starting at the insertion site
and working outwards is recommended for the others. It’s
recommended that all agents be allowed to air dry before
proceeding for maximal effectiveness.
∞ Povidone-iodine or chlorhexidine are recommended for
site prep of neonates. The use of chlorhexidine in infants
of less than 1,000 grams has been associated with contact
dermatitis and should be used with caution in this popu-
lation.17 Cleanse the area with 0.9% saline, as isopropyl
alcohol isn’t recommended.
∞ For dressing regimens, sterile gauze with taped edges or
a transparent semipermeable dressing are both recom-
mended as equally acceptable options. If the patient is
diaphoretic or oozing from the site, gauze is recommend-
ed to minimize moisture retention under the dressing.
Gauze dressings should be changed every 48 hours, and
transparent semipermeable membrane (TSM) dressings
should be changed at least every 7 days or when the
dressing’s integrity is compromised. Gauze under a TSM
dressing should be considered a gauze dressing and
changed every 48 hours.
∞ It’s not recommended to use topical ointments or
creams at the insertion site in most cases.
Site selection and catheter replacement:
∞ Select the type of catheter, insertion technique, and site
with the lowest risk of complications for the type of ther-
apy required (both infectious and noninfectious).
∞ Peripheral intravascular catheters shouldn’t be replaced
more frequently than every 72 to 96 hours. In umbilical
catheters, it’s recommended to leave catheters in place
without routine changes unless phlebitis, infection, or
infiltration occur.
∞ It’s not recommended to replace central venous
catheters over a guide wire. Routine catheter site changes
don’t decrease infection rates, and the potential for
mechanical complications always exists when inserting
central catheters.
∞ Catheters inserted under emergent or nonsterile condi-
tions should be replaced as soon as is safely feasible, no
longer than 48 hours.
Equipment and device recommendations:
∞ Change I.V. administration sets no more frequently
than every 72 hours (including most total parenteral
nutrition sets not mixed with lipid emulsions), unless
infection of the catheter is suspected. For sets used to
administer lipid emulsions or blood products, change
every 24 hours. With propofol infusions, change sets
every 6 to 12 hours per manufacturer instructions, since
these solutions are highly prone to support bacterial
growth.
∞ Change most needleless access components with the
administration sets. Minimize contamination by wiping
the access port with an antiseptic prior to use, and access
only using sterile devices. Stopcocks shouldn’t be used.
∞ Complete blood product infusions within 4 hours of
infusion initiation.
∞ Use single-dose medication vials when possible and
don’t save leftover content of single-dose vials for later
use.
∞ Don’t use in-line filters to prevent infection.
The Institute for Healthcare Improvement (IHI) recommenda-
tions:
The IHI has also released a document outlining its evi-
dence-based recommendations for decreasing central line
infections. Its “bundle” of interventions are:
∞ adherence to hand hygiene
∞ maximal barrier precautions
∞ chlorhexidine skin antisepsis
∞ optimal catheter site selection, with subclavian vein as
the preferred site
∞ daily review of the need for central access, with prompt
removal of unnecessary access.18
Surgical-site infection
Surgical-site infections (SSIs) account for 14% to 16% of
all HAIs. Almost 30 million surgical procedures now
occur each year in this country, and infection at the surgi-
cal site contributes significantly to the morbidity and
mortality of this group, adding an average of 7 postopera-
tive inpatient days and posing significant hospital costs.19
SSI is the most common nosocomial infection among sur-
gical inpatients, comprising approximately 38% of all
infections affecting this population.20
The majority of the most serious infections resulting in
high mortality for this group are internal infections of the
body cavity or organ accessed during the surgical proce-
dure. Infection rates for particular operations and patient
groups vary widely, and it’s recommended that individuals
involved with a particular group or common operation
become familiar with occurrence rates to use as a bench-
mark for process improvement.8
In 1999, the CDC released evidence-based guidelines
making recommendations for practice, with the aim of
minimizing SSI. Criteria for identifying and diagnosing
SSI are also detailed. The pathogenesis of SSI usually
involves endogenous flora of the patient’s skin, hollow vis-
cera, or mucous membranes. The risk of SSI is directly
related to the virulence of the colonizing organism, the
quantitative presence of the organism, and the innate
resistance of the host (patient) to infection.
5
 Characteristics which may place patients at higher risk
for SSI include diabetes, nicotine use, steroid use, malnu-
trition, and a prolonged hospital stay.
Recommendations to decrease SSI
Preoperative:
∞ Identify and treat all other infections prior to an elec-
tive surgical procedure.
∞ Don’t remove hair preoperatively unless it will interfere
with the operation. If hair must be removed, it should be
done with electric clippers preferably, just prior to the
operation. Request that patients bathe with an antiseptic
agent the night before the operative day. Wash the inci-
sion site thoroughly prior to performing the preoperative
prep.
∞ Adequately control serum glucose levels in all diabetic
patients; particularly strive to prevent hyperglycemia peri-
operatively.
∞ Eliminate tobacco consumption for at least 30 days, if
possible, before the operation.
∞ Don’t wear hand or arm jewelry. In addition, keep nails
short and refrain from wearing artificial nails. Prior to the
first surgical scrub of the day, clean under each fingernail.
∞ Staff with potentially transmissible infectious illnesses
should report this and consult appropriate occupational
health personnel.
∞ Administer antimicrobial prophylaxis only when neces-
sary according to published recommendations for particu-
lar operations, and target the most common pathogens
specific to the operation. Administer the initial dose
intravenously, and with such timing as to ensure adequate
serum and tissue levels during the time the incision is
actually open—usually 1 hour prior to incision. Don’t rou-
tinely use vancomycin for antimicrobial prophylaxis.
Intraoperative:
∞ Follow the hand hygiene recommendations to prevent
SSI, as previously discussed.
∞ Keep ventilation in the operative suite positive with
respect to adjoining corridors or rooms. Air changes
should be at least 15 per hour, of which at least three
should be fresh air, filtered through approved filters. Air
should be introduced near the ceiling and exhausted near
the floor.
∞ Limit the number of personnel entering the operative suite.
∞ Include a mask that fully covers the nose and mouth
throughout the operation. A cap or hood should be worn
which fully covers the hair. Shoe covers aren’t recom-
mended for SSI prevention. Surgical sterile gowns should
6
be impermeable to liquid penetration. Sterile gloves
should be donned after gowning.
∞ Leave open heavily contaminated sites for delayed pri-
mary closure or secondary intention closure.
Postoperative:
∞ A sterile postoperative dressing should remain in place
for 24 to 48 hours. Follow hand hygiene guidelines and
use sterile technique when changing dressings or making
any contact with the surgical site.
∞ Educate the patient and the family on proper incision
care and signs/symptoms of a wound infection.
The IHI recommendations:
The IHI lists four components that it considers critical
markers of SSI prevention:
∞ appropriate use of antibiotics
∞ appropriate hair removal
∞ maintenance of postoperative glucose control for major
cardiac surgery patients
∞ maintenance of postoperative normothermia for col-
orectal patients.21
New research suggests that at least in colorectal surgery
patients, a higher fraction of inspired oxygen administered
during surgery and for a short time thereafter will
decrease the SSI rate in this population by almost 40%.22
Additional research may be needed in other populations
before this is added to guidelines for the general surgical
patient population.
Protection through good practice
It’s become quite apparent that the key to prevention of
many infections rests with our ability as clinicians to pro-
tect our patients by practicing good hand hygiene.
Through awareness of the CDC recommendations and
others, we can save lives, alleviate significant suffering,
and decrease care costs. ■
REFERENCES
1. Connolly, C. Data show scourge of hospital infections. The
Washington Post, Wednesday, July 15, 2005.
2. Vincent, J. Nosocomial infections in adult intensive-care units.
Lancet. 2003;361(9374):2068-2078.
3. Sadfar, N, Dezfulian, C, Collard, H, Saint, S. Clinical and economic
consequences of ventilator-associated pneumonia: a systematic
review. Crit Care Med. 2005;33(10):2184-2193.
4. Boyce, J, Pittet, D. Guideline for hand hygiene in health-care settings.
Morbidity and Mortality Weekly Reports. 2002;51(RR16):1-44.
5. Pittet, D, Mourouga, P, Perneger, T. Infection Control Program.
Compliance with handwashing in a teaching hospital. Ann Intern
Med. 1999;130:126-130.
6. Pittet, D, Sax, H, Hugonnet, S, Harbarth, S. Cost implications of a
 successful hand hygiene promotion. Infect Control Hosp
Epidemiol. 2004;25(3):264-266.
7. Woods, A. Key points in the CDC’s surgical site infection guideline.
Adv Skin Wound Care. 2005;18(4):215-223.
8. Centers for Disease Control and Prevention. National nosocomial
infections surveillance (NNIS) system report, data summary from
January 1992 through June 2004, issued October 2004. Am J
Infect Control. 2004;32:470-485.
9. Ibrahim, E, Tracy, L, Hill, C, et al. The occurrence of ventilator-
associated pneumonia in a community hospital: risk factors and
clinical outcomes. Chest. 2001;20(2):555-561.
10. Tablan, O, Anderson, L, Besser, R, et al. Guidelines for preventing
health-care associated pneumonia, 2003: recommendations of
CDC and the Healthcare Infection Control Practices Advisory
Committee. Morbidity and Mortality Weekly Report. 2004;53(RR-
3):1-36.
11. Pruitt, B, and Jacobs, M. Best-practice interventions: how can you
prevent ventilator-associated pneumonia? Nursing2006.
2006;36(2):36-42.
12. Kress, J, et al. Daily interruption of sedative infusions in critically
ill patients underlying mechanical ventilation. N Engl J Med.
2000;342(260):1471-1477.
13. The Institute for Healthcare Improvement (IHI). Getting started kit:
prevent ventilator-associated pneumonia. Available at:
http://www.ihi.org/NR/rdonlyres/A448DDB1-E2A4-4D13-8F02-
16417EC52990/0/VAPHowtoGuideFINAL.pdf. Accessed March 27,
2006.
14. Richards, M, Edwards, J, Culver, D, Gaynes, R. Nosocomial
infections in combined medical-surgical intensive care units in
the United States. Infect Control Hosp Epidemiol. 2000;21:510-
515.
15. Lai, K, Fontecchio, S. Use of silver-hydrogel urinary catheters on
INSTRUCTIONS
HAI prevention: The power is in your hands
TEST INSTRUCTIONS
• To take the test online, go to our secure Web site at
http://www.nursingcenter.com/NMGOJO.
• On the print form, record your answers in the test answer section of
the CE enrollment form on page 8. Each question has only one correct
answer. You may make copies of these forms.
• Complete the registration information and course evaluation. Mail the
completed form and registration fee of $21.95 to: Lippincott Williams
& Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will
mail your certificate in 4 to 6 weeks. For faster service, include a fax
number and we will fax your certificate within 2 business days of receiv-
ing your enrollment form.
• You will receive your CE certificate of earned contact hours and an
answer key to review your results. There is no minimum passing grade.
• Registration deadline is June 30, 2010.
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published by LWW
the incidence of catheter-associated urinary tract infections in
hospitalized patients. Am J Infect Control. 2002;30:221-225.
16. O’Grady, N, Alexander M, Dellinger, E, et al. Guidelines for the pre-
vention of intravascular catheter-related infections. Morbidity and
Mortality Weekly Report. 2002;51(RR-10):1-29.
17. Infusion Nurses Society. Infusion Nursing Standards of Practice.
Philadelphia, Pa: Lippincott Williams & Wilkins, January/February
2006.
18. IHI: Getting started kit: prevent central line infections. Available at
http://www.ihi.org/NR/rdonlyres/BF4CC102-C564-4436-AC3A-
0C57B1202872/0/CentralLinesHowtoGuideFINAL720.pdf.
Accessed March 27, 2006.
19. Martone, W, Jarvis, W, Culver, D, Haley, R. Incidence and nature of
endemic and epidemic nosocomial infections. in Bennett, J,
Brachman, P, eds. Hospital Infections. 3rd ed. Boston: Little, Brown
and Co., 1992. p. 577-596.
20. Mangram, A, Horan, T, Pearson, M, et al. Guideline for prevention
of surgical site infection, 1999. Infect Control Hosp Epidemiol.
1999;20(4):247-278.
21. IHI: Getting started kit: prevent surgical site infections. Available at
http://www.ihi.org/NR/rdonlyres/00EBAF1F-A29F-4822-ABCE-
829573255AB8/0/SSIHowtoGuideFINAL0803.pdf. Accessed March
27, 2006.
22. Belda, F, Aguilera, L, Garcia de la Asuncion, J, et al. Supplemental
perioperative oxygen and the risk of surgical wound infection: a
randomized controlled trial. J Am Med Assoc. 2005;294(16):2035-
2042.
ABOUT THE AUTHOR
Douglas Houghton is a critical care nurse practitioner in the trauma
ICU at Ryder Trauma Center, University of Miami/Jackson Health
System, Miami, Fla.
Earn CE credit online:
Go to http://www.nursingcenter.com/CE/NM and
receive a certificate within minutes.
together and deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other health care facilities
on nursingcenter.com. Call 1-800-787-8985 for details.
Provider Accreditation
Participants will earn 2.0 contact hours after completing this continuing
nursing education activity.
Lippincott Williams & Wilkins is accredited as a provider of continuing
nursing education by the American Nurses Credentialing Center’s
Commission on Accreditation.
This activity is also provider approved by the California Board of
Registered Nursing, Provider Number CEP 11749 for 2.0 contact hours.
This program has been approved by the American Association of
Critical-Care Nurses (AACN) for 2.0 contact hours, category A, file
number NM0608A, provider number 00014360. LWW is also an
approved provider in Florida #FBN2454 and Iowa #75. Certificates are
valid in all states.
7
 2.0
CONTACT HOURS

HAI prevention: The power is in your hands

GENERAL PURPOSE: To provide the registered professional nurse with an overview of healthcare-associated infections (HAIs), and evidence-based recommendations
for prevention.
LEARNING OBJECTIVES: After reading this article and taking the test, you should be able to: 1. Identify four types of HAIs and statistical evidence of their impact.
2. Describe the evidence-based recommendations for prevention of HAIs.
1. The CDC estimates that HAIs in the United
States annually cause more than
a. 10,000 to 20,000 deaths.
b. 40,000 to 50,000 deaths.
c. 70,000 to 80,000 deaths.
d. 90,000 to 100,000 deaths.
2. The annual cost of the increased length of stay
in the United States due to HAIs is more than
a. $3.5 million. c. $350 million.
b. $35 million. d. $3.5 billion.
3. In the 2004 Pennsylvania study described in
this article, what type of HAI had the highest
mortality rate?
a. hospital-acquired pneumonia
b. UTI associated with indwelling catheter
c. SSI
d. central line catheter-associated infection
4. The CDC recommends that hands visibly soiled
with blood or body fluids be decontaminated using
a. an alcohol-based hand rub.
b. chlorhexidine for 5 to 10 minutes.
c. soap and water for 10 minutes.
d. an antimicrobial or a nonantimicrobial soap and
water.
5. When exposure to Bacillus anthracis or
Clostridium difficile is suspected, hand hygiene
guidelines recommend
a. alcohol-based hand rub and gloves for any contact.
b. antimicrobial soap, making glove use an optional
choice for any contact.
c. antimicrobial soap and gloves for any contact.
d. nonantimicrobial soap washing for 6 to 10 minutes. a. limited to research only.
6. The majority of cases of HAP are related to
a. poor hand washing technique.
b. anesthesia and poor postoperative respiratory care.
c. a high rate of airborne bacteria in hospitals.
d. mechanical ventilation.
7. In the 2003 guidelines for HAP, the CDC recom-
mends
a. changing disposables, such as breathing circuits,
on a routine basis.
b. changing disposables, such as breathing circuits,
only when malfunctioning or visibly soiled.
c. use of a nasotracheal tube rather than orotracheal
tube.
d. bed head elevation to 25 degrees.
8. UTIs, the second most common nosocomial
infection in the ICU, is associated with
a. surgery.
b. inadequate I.V. fluids and dehydration.
c. presence of an indwelling urinary catheter.
d. poor hand washing technique.
9. The only intervention found to make a signifi-
cant difference in reducing catheter-associated
UTIs is
a. early removal of the indwelling catheter.
b. proper insertion of the catheter.
c. good hand washing technique.
d. replacement of indwelling catheters on a regular
basis.
10. Prevention of CRBSIs should focus on all of
the following except
a. using prophylactic antimicrobial topical ointment
at the insertion site.
b. proper handling of catheters.
c. sterile technique during insertion.
d. proper skin prep.
11. Use of central venous catheters impregnated
with antiseptic or antibiotic compounds to mini-
mize CRBSIs has been
b. unsuccessful.
c. of limited success.
d. very successful.
12. Which of the following statements are true
regarding SSIs?
a. They account for 40% of all HAIs.
b. They add an average of 10 days to postop inpa-
tient stays.
c. They’re the most common HAI among surgical
patients.
d. They’re a result of pathogens introduced from the
healthcare provider’s skin.
13. According to the author, all of the following
are risk factors for SSIs except
a. nicotine use.
b. coronary artery disease.
c. diabetes.
d. prolonged hospital stay.
14. Which of the following is recommended for
prevention of SSIs?
a. Shave hair at the incision site immediately before
the surgery.
b. Eliminate tobacco use within 24 to 48 hours
before the operation.
c. Control asthma with systemic steroid use preoper-
atively.
d. Control blood glucose levels in diabetic patients
perioperatively.
15. Which of the following statements is accurate
about use of antimicrobial prophylaxis for identi-
fied procedures?
a. The first dose is usually administered I.V. 1 hour
before the incision is to be made.
b. Administer the first dose I.V. at the time of incision.
c. Vancomycin I.V. is commonly used for prophylaxis.
d. Use multiple antimicrobials to ensure coverage of
multiple possible bacterial infection threats.
16. New research has demonstrated a 40%
reduction in SSIs following colorectal surgery
when
a. a higher fraction of inspired oxygen was adminis-
tered during surgery, and for a short time there-
after.
b. a higher fraction of inspired oxygen was adminis-
tered 2 days preoperatively and during surgery.
c. Vancomycin was given I.V. 1 week preoperatively
and 1 hour before the incision was made.
d. Vancomycin was given I.V. preoperatively and for 1
week postoperatively.

✄ ENROLLMENT FORM: Nursing Management, June 2008,

✄
HAI prevention: The power is in your hands
A. Registration Information: ❑ LPN ❑ RN ❑ CNS ❑ NP ❑ CRNA ❑ CNM ❑ other _________________
Last name ____________________________ First name ________________________ MI _____ Job title _________________________________ Specialty _________________________________
Type of facility ____________________________________ Are you certified? ❑ Yes ❑ No
Address _______________________________________________________________________________ Certified by __________________________________________________________________________
State of license (1) __________________________ License # ___________________________
City _______________________________________ State _________________ ZIP ______________
State of license (2) __________________________ License # ___________________________
Telephone _________________ Fax ____________________ E-mail ________________________ ❑ From time to time, we make our mailing list available to outside organizations to announce special offers.
Please check here if you do not wish us to release your name and address.
Registration Deadline: June 30, 2010 ❑ Please fax my certificate to me.
Contact hours: 2.0 Pharmacology hours: 0.0 Fee: $21.95
B. Test Answers: Darken one circle for your answer to each question.
a b c d a b c d a b c d a b c d a b c d
1. ❍ ❍ ❍ ❍ 5. ❍ ❍ ❍ ❍ 8. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍
2. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 9. ❍ ❍ ❍ ❍ 12. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍
3. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 13. ❍ ❍ ❍ ❍ 16. ❍ ❍ ❍ ❍
4. ❍ ❍ ❍ ❍
C. Course Evaluation* D. Two Easy Ways to Pay:
1. Did this CE activity's learning objectives relate to its general purpose? ❑ Yes ❑ No ❑ Check or money order enclosed (Payable to Lippincott Williams & Wilkins)
2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No ❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express
3. Was the content relevant to your nursing practice? ❑ Yes ❑ No
Card # _____________________________________________ Exp. date __________________
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________ Signature _______________________________________________________________________
NM0608A
*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.
HCE-CEU-HAI