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welcome good evening everyone this is Dr rushali and I welcome you all on behalf of Netflix for this uh yet another interactive and an amazing session for today's session that's infection control practices in PSU which is a very important session because in ICU the patient is already critical uh there are germs bacterias viruses everywhere so what are the infection control practices you need to follow so for that we have with us Dr maninder daliwal he's the senior consultant PQ that is PSU and pediatric pulmonology at Amrita hospital faridabad he's done his mdps and after that he's done his Fellowship in pediatric Critical Care his areas of Interest or pediatric ICU pediatric respiratory medicine pediatric allergies and pediatric transplant intensivist he has about more than 30 PubMed index plus he has many books many chapters in books like academic pearls the picnic module he was also awarded the James played endowment award 2006 and the 2014 Asian Paint safety or so we welcome you on behalf of Netflix and all our doctors thank you so much for joining us and over to you so hi everyone so today we're going to discuss uh a very important topic uh infection control practices in pic and why is it important and how to go about it the myths the realities and what to do and what not to do so uh a disclaimer you have to update yourself with latest government of India policies this is just a guide to help her organize our pic infection control practices with changing time and is not a replacement for any state or government of India guidelines and you should follow the SOP of your hospital this discussion is for academic purpose only the infection control in healthcare system can be in hospitals can be nursing homes can mean opds clinics and ambulance but our Focus today is pediatric ICU originally it was called as nosocombia or Hospital acquired or Hospital onset infections now the preferred term is Health Care Associated infections we have to update ourselves and try not use these terms so what is uh Healthcare Associated infection it's an infection acquired in a hospital by a patient who was admitted for a reason other than infection and it was not there present at the time of infection or was not even incubating at the time of admission and it happened usually after 48 hours after admission we should be very clear with this definition and almost 10 percent of admitted patients have Healthcare infections in 12 countries but in developing countries risk may be as high as 25 percent and it is very very high in India so let us see a few cases a healthy baby is admitted in your ICU for phototherapy and he develops the sepsis that is not right a child undergoes of surgery and dwells post-op services a patient came from routine OPD visit but because the previous patient was a case of MRSA and he got the MRC pneumonia from this patient then this is not right and a patient admitted for a simple gastroenteritis drug pseudomonas patient as there was a patient next door who had pseudomonas this is the things that we should be avoiding for so with this we increase the patient suffering we increase the hospital stay we increase the level of care because he came for X we gave him Y and we increased the cost and the most deadly of all is that it can cause death also so the first rule in medicine is do seek no harm and with that let us start our presentation so who also recognize the problem up to 90 percent of healthcare workers do not clean their hands in some facilities it's a big number and infection can be very high in newborn babies and this ultimately will result in escalation of antibiotics and this will cause Hospital acquired infections and that will increase the cost so how to go about it is have strong infection control program in the hospital it should not be just a poster program it should be a program which has strong foothold in the hospital we should use green practices and practice hand hygiene and then antibiotics rewardship almost 20 percent of the all high Healthcare Associated infections are caused by multi drug resistant organism and in children it is the bloodstream infection which is very common and especially in the Pediatric ICU and Unitil ICU and adults it is a urinary tract infections followed by the surgical infections then the bloodstream infections and then the ventilator Associated pneumonia and pediatric patients are just not little adults children are very skilled at spreading germs isolation becomes very tricky when it comes to children and children are more Hands-On than adults resulting in high touch areas so it's difficult to practice infection controls we should always remember the chain of transmission there's a source in ICU which is an infectious person then there is a contaminated equipment medications on hand and then the second person who came for some other reason gets the infection transmitted to him so we have to break the chain either we start with strict ionizing we follow strict environmental cleaning and we follow personal protective equipment if we follow these three basic things in your ICU practice or even in your OPD practice we can break the chain believe me it is not tough to do but it has to be a behavior change it has to come from within it should not be forced upon now beef Outlook if a staph infection happens it can survive in the particular space for one year Crossing can survive in that particular ISU five five months if thorough cleaning and disinfection is not done to 30 months as you know back to five months so we have got these various organisms which have long length of survival on services and this has to be cleaned followed by disinfection and bugs that cause illness are found everywhere so therefore hand hygiene is not only for IQ people it is for the nurse the ward nurses even for school children it is for everybody to practice and the single most effective way is to practice the right way of hand wash and we should teach everyone it should start right how to correctly wash your hands then it becomes a behavior change and then we follow it up up to adulthood and we should create a hospital which is so strong that the infection cannot enter we should have our policies which are very strict and I remember these two dialogues from the movie rang de basanti okay and second system so you have to really work hard to bring a change so let us start with what is the preferred apron that you would like to wear in an OPD practice let us start from there we have got the three sets of aprons now the answer over here would be the first one because it is half sleeves and there are all closed buttons and keeps the tie in checked half little important because the sleeves are big then we rarely wash our hands properly and it creates a burden because we don't want to soil the sleeves so that's why it's important that we start wearing halfway aprons is it evidence proven no but it is common sense then we have got these Winters coming in and we have got these jacket Blazers which will be worn by many number of doctors or assistants coming to the hospital is it the right way because you're not going to wash your jacket every day you're not going to wash your coat every day and these are the places where the infection usually hides so you should wear those clothes that you're going to wash every day and tie the tuck inside and the sleeves should be folded if you're feeling cold you can be a thermals uh inside or you can actually we are apron over them but it's very important that coats jacket sweaters in ICU practice are not advised at all then we have these hands in which we believe in multiple number of stones there's nail polish long nails then the special watches and and many number of threads so if you are practicing ICU then all this is a strict strict no this should not be there in any person who even visits an ICU this is how your hand should look like this is the perfect way we have to have policies which have zero tolerance towards people who do not follow hand hygiene at all so this is how we'll be able to fight multi-dog resistant organisms and we have a hand wash station like this is this okay this doesn't look okay at all it has a wooden cabinet with the plumbing of is not seen the sink is not deep seated the wall is getting chipped the it's not a clean scenario at all you can see the sink is also dirty so this is a strict no you are creating more infection from your hand hygiene hand wash station so this is not tolerable at all you should have a hand wash station even in your OPD practice where there is paper towels liquid hand washer deep sink for good hand wash the wall should be tiled no wood there should be clean Plum plumbing and there should be a Dustbin below this so that your hand hygiene does not become a source of infection itself many number of studies are there and many number of procedures are there given by many societies but 2020 the national guidelines are there and it is easily downloadable so just practice type National guidelines for infection control it is by Ministry of Health and Family welfare government of India and try to follow them this is on the principles of education surveillance multimodal strategies so you come to the ifu everyday routine a consultant and a resident will work together but a consultant will remove his Blazer the shirt should be folded remove the watch Rings Etc and the on-call Doctor Who is going to stay in ISU for more than 12 hours he can change into scrubs and if feeling cold thermal can be worn inside then they should go for a hand wash and before entering the room then they will go for a hand rub again this is how we can be very strict in our policies and this will bring a change so if you see this Photograph we are going to see many number of X points now this was a photograph which was taken way back and this was published way back what does this x stand for so this was a photograph in the ICU way back in 2001 in Chicago they found that these are the places where there was positive enterococcus culture in the wooden surface on the file on the monitor on the ventilator onto the handshake on the Dustbin so this entry Focus was everywhere in that room and this was their why because we were not able to give proper aseptic precautions and high end hygiene principles of Just For example we have a six buried Intensive Care Unit and we have five patients over here who have actually cleaned patients then one more patient comes in with a multi-dug resistant organism in this particular bed and the doctoral nurse goes for a round when the doctor and nurse goes to see this particular patient they actually do not follow hand hygiene and from here they go to the next patient and they take the organism to this patient now they have transmitted the organism from here to there then from there they take the organism to the next patient because they have not followed hand drug principles or hand hygiene principles and from there the doctor and the nurse goes and spreads the infection to the hand sink and there to the nursing station so the whole ICU is now filled with acetino Vector klepsila the deadly organisms and it was this because why because they were not following simple hand hygiene moments this was how the patient came in this was how the IC was before and this is after they took the rounds this is what happened and then ultimately every patient is going to be on miropenum coleston and the bill is going to go very high because we were reluctant or we were lazy not to follow the principles of hand hygiene so these are the five moments of hand hygiene that are very important at point of care the first one is before patient contact you do a hand rub with the alcohol or with chloroxetine second is before aseptic procedure third point is after body fluid exposure risk fourth is after patient contact and fifth is after patient contact with the patient's surroundings that is you touch the surface of the bedside table also that is also a moment of hand hygiene so if you follow them strictly and believe me you will find that many number of the times you will touch before patient contact but you will not do it after patient contact or maybe after contact with the patient's surroundings you will not do it so these are the few laxes that can happen so you should have a monitoring system where the nerve or infection control nurse or the shadow people or the shadow nurses who actually see what is happening and then create a report and tell you what is happening now let us see a video describing the five moments of hand hygiene I would request them to please play the video uh tanushree or Fatima today we are going to demonstrate the five moments of hand hygiene yes so the video is playing okay let's examine the patient for the first moment of hand hygiene is before touching the patient foreign the second moment of hand hygiene is after touching the patients oh let's start the patient on oxygen yes well uh I cannot see the video so it's playing fine we are on the second point of contact the video no no but it's not I cannot see it I'll just rejoin you in the meanwhile it's playing after touching the patient's surrounding let us put a cannula for this the fourth moment of hand hygiene is before aseptic procedure the patient is coughing yes sister why don't we clean the situations with some gauze the fifth movement of hand hygiene is after touching the body fluids the disposal of the waves into the correct bin after removal of gloves hand wash should be done so we have completed the fan five moments of hand hygiene a routine mistake which is usually done in bedside practice the second sister has come directly from the other patient this is not right before touching this patient the sister should practice her fan steps of hand hygiene so we saw the five moments of hand hygiene so these are the moments where we actually uh uh falter because we do not follow them strictly and if we follow them believe me the MDR or your infection rate in your icus will come down drastically so pic patients are rapidly colonized with pathogenic bacteria also because we don't the pic patients do not take bath every day but they are tried to be cleaned but it doesn't happen clearly so skin is colonized within us within us the screen are colonized with staph aureus Proteus maximum in The Perennial inguinal and exhilar region and more the number of comorbidities like dialysis Aki patient diabetes dermatitis more the risk of the colonizers and believe me we've shed almost 10 to the power of 6 qualms per day and it causes wide stripped contamination of the room so we need to have these hand rubs which are easily available and very important they should be accessible also because we are we are lazy people we do not make an effort to go out of the way to go and get a hand looks clean we need to have them next to the bed we need to have them next to the crash trolley in the corridor we need them everywhere because we by default humans are very very lazy so during picu procedure we have to remove all the hand jewelries fingernails should be tripped avoid wearing long sleeved shirts so Hand hygiene routine hand washing that is before you enter picu and before or after leaving the PSU this routine hand wash is very important less than one minutes or your hands are soiled then the surgical hand scrub is for five to six minutes this is before you do any procedure in PSU even for collecting of blood culture or doing lumbar Punch or putting a central line artery line then the use of alcohol rub and gels will take 20 to 30 seconds that is that that you should follow when you are doing rounds from one patient to another this is the scrub that you should use I'm not saying the company but the scrub or for the hand wash in icus should be four percent chloration scrub and this is uh very very important that you get these scrubs not the ordinary soap water so let us see the second video of routine hand wash and then see the video of surgical hand wash routine hand wash switch on tap wet your hands take sufficient amounts to play the video with palm over Palm then right hand over the left awesome left hand over the right Dawson interlacing interlocking rotation of Thumbs tip of finger change of hand switch on water wash your hands like this [Music] take paper towels [Music] take the other paper towel [Music] thank you take water drains up to the elbows close the water take necessary amount 5 to 10 mL of floor Engine Solution rabbits up to the elbows by making lather similarly the other side then on the hand hygiene over the right over the left hand left over right hand interlacing interlocking thumbs fingers tip of fingers and then washing with the hands first one hand first cleaning up to the Elbow the other hand training up to the elbow and then holding the hand yes for both the videos played fine I can go okay so we have seen the routine hand wash it took less than one minute and it is simple to do and this is the who way how to do a routine hand wash and surgical hand wash again it has to be done for a period of five to six minutes so if you finish it within two minutes you again repeat the whole step that is very important then comes the style gloves and when to wear them and when to wear the non-strangers so as a general rule if the risk is to the patient then struggles are required but if the risk is to the user only then non-style gloves will suffice gown whenever you are doing a procedure then you should have a trial gown that is very very important then comes the thing of shoe and head coverings so if you see many number of guidelines which are given by Societies or guidelines which are given by studies in India and abroad they are saying that shoe cover in ICU is not required but this is directly taken from the guidelines by the ministry of government and health which basically says that ICU Footwear should be impervious souls and should be worn in ICU and it should be preferred over slippers and Footwear should be regularly cleaned to remove splashes of blood and body fluids so this is from this guideline which basically is shows that that if you are in ICU labor room or OT then Ico Footwear should be very much separate because these are the areas where you need to give maximum respect to the sterility of that place especially in OT and labor rooms and also ICU I see we are scared because of the risk of infection coming out also so it's not about infection going in but it's about infection which can spread from the ICU as well but you have to follow the whole uh sop of your hospital because it can change and they can have a different sop also as far as Skin preparation is concerned then it should be always in concentric circles moving away from the proposed incision side to the periphery and not in any other longitudinal weight and start using chlorhexidine with alcohol for your antiseptic for skin preparation uh Betadine is mostly for procedures which are done in OT because Betadine we need to apply it and we need to keep it for a period of minimum one minute to two minutes or even five minutes so that Betadine should dry and only when it is dry then the Betadine effects come in whereas in ICU people have got very less patients and they do not wait for the Betadine to dry so that thing should not be done assess the need for isolation uh precautions daily all patients which were earlier not requiring isolation can require isolation big big can get a overhead infection like a patient got admitted with something but had costume deficit diarrhea then the isolation precautions become very much different so the type of isolation in ICU negative pressure ICU is the one where basically when the door is opened then the air is actually sucked in from the hallway so that the patient who is having tuberculosis measles or chickenpox the droplets should not go out into the corridor but they should be sucked in inside the room and then thrown into the atmosphere through a filter so that's the importance of negative pressure room in almost every ICU we should have them because these patients will require special rooms negative pressure rooms even covert patients can be put over here then comes the positive pressure rooms these are the rooms that is required in your transplant and chemotherapy IC units where actually uh the air is moving from the room into the hallway because we do not want any infection from the hallway come coming inside the room so how much positive pressure should be there that is perfectly mentioned in the guidelines and neutral or standard rooms also will have basically a way type of positive pressure rooms where actually the air is actually pushed from the room into the ICU the architect and layout of ICU there should be a minimal of six year changes per room per hour with two air changes per hour composed of outside air and adequate space around the bed should be approximately 2.5 to 3 square meters and there should be a separate medication preparation area and if possible this should be near the OT or the ER so let us see the critical care bundles that should be followed in ICU uh a bundle is a group of evidence based care components for a given disease that when executed together may result in better outcomes than if implemented individually that means we have to do a number of things together so as to form a bundle which creates a positive outcome let us start with a Center Line bundle so we have got this central line which is placed and there can be infection which can come from the skin extra numeral or it can come from the intra-luminal from the tubes and the hubs or it can be from hematogenous from different sites so at insertion site you try to mostly clean it up and maybe apply a transparent dressing over it and check that dressing every day so that local infection or hematoma can be seen the hubs okay should be cleaned every time before you touch it and minimum for 15 seconds with a split and allow it to dry also that should be cleaned and choose a catheter wisely if you do not require a center line then do not put it and if you require a single port center line and use a single port because if the number of ports increase the risk of infection increases try to use pick lines pic lines have got very narrow or very small infection rates and if possible you can manage with peripheral venous catheters that is good follow maximum barrier precautions that is for the operator and supervisor they should have hand hygiene style gowns gloves cap and mask for the patient he should be covered from the head to the toe and not only in that particular area that you want to keep stability but should be head to toe covering and for the assistant again a hand hygiene cap and mask should be there the choice of site for Centerline should be subclavian internal jugular or femoral but if you think subclavian is an issue then Intel jugular femoral will also do but femoral lines should be avoided High rate of infections because it is near the genital area and higher rate of thrombotic complications also and the patient cannot walk with the femoral central line so the center line insertion consists of a proper hand hygiene a surgical hand rub maximum barrier precaution for the Doctor full body drape then Daily Review of the line then if it is not required then optimal catheter site selection and then scrub The Hub this is mostly missed by a nurse scrubbing the Hub so very important and if the line is not required remove the line as soon as possible again a point that scrubbing injection caps with alcohol for 15 seconds prior to accessing is very important it not only goes for the center line but it also goes for the various pores which are there in artery line and also for the ports in the IV fluid bottles the maintenance bundle should cover consists of at least transparent dressing chlorhexidine sponge is usually not available in India now and then securing the ports in a trial towel that is the maintenance bundle and you should check the line every day in transparent dressing is there any redness or any uh swelling or any discharge coming out from the insertion point antibiotic ointments should not be used at insertion site at all because the small amount of antibiotic ointment that you put there will create antibiotic resistance because that ointment is of no use whatsoever and then a higher number of lumens in Centerline increase the infection risk tubing for the peripheral and central line should be changed every 72 hours for routine fluids and for blood products and lipid infusions should not be for more than 24 hours and for arterial lines maximum day should be changed after fourth day these bottles where we prove the needle from the top and add some potassium or calcium in the diary fluid this is a wrong way you might not be cleaning it so it's very important we start using collapsible infusion bags because we cannot pick them from Top we prick them from another Port which is there in the bottom and that way we can clean it and then prick it so this is actually a problematic thing which is very difficult for the uh Behavior change to happen so we have to remove the uh these hard bottles only then peripheral IV camera bundle again disinfect with chlorhexidine then follow a transparent dressing maintenance every day check the VIP score should be done and if there is any redness or there is a pain then it can be removed especially in Pediatrics then there is something called as ventilator Associated events in pediatric the first thing is if the patient is on ventilator for two days and there is an increase in oxygenation then it is ventilator Associated condition and if then we suspect there is a infection or inflammation component with a change in the secretion or maybe rays in CRP then we can consider it to be infection rated when ventilator Associated complication and only when there is a positive result of microbiological testing then we call it a possible ventilator Associated pneumonia and there has to be a prevention bundle which means that you have to have a hidden elevation of more than 45 degrees in all ventilated patients if the patient is in shock then only you can bring it down the head in otherwise it's always a elevated to 30 to 45 degree then there should be a daily sedation vacation that means you stop the sedation and paralysis and you assess the Readiness to extubate then there should be a peptic ulcer prophylaxis that can be given in sick patients and DVD prophylaxis in adults is usually preferred other than that in pediatric we have to have a curved endotracial tube which is preferred a closed ET suction is preferred a good oral hygiene which should be done by a nurse by using 0.12 percent protein oral solution is good and cuff pressure should be measured daily and should be kept between 18 to 25 more than 25 will cause the stenosis to happen and the necrosis to happen and less than 15 will be of no much effect other points in web bundle is vented a circuit should be changed when they are visibly soiled or malfunctioning there is no upper limit for the number of days and heat moisture exchanger may be better and always consider non-vasive ventilation whenever possible this removes the VAP criteria only because you're not inserting that tube there's a bundle which is given in all government guidelines you should follow this web bundle to the point then generic catheter care is another point of infection insert only when there's a specific reason monitor the urinary output in critical l or neurogenic bladder or maybe terminal care you should have a competent healthcare worker to insert because that is the point maximum time the infection goes in you should have a aseptic technique and a closed system with the bag which is kept below the bladder on a patient empty the bag whenever it is 3 4 full and secure catheter to the leg and abdomen and hand engine and PPE before and after the catheter care is very important and review the catheter need daily but is not required to remove it that is the best way to prevent a infection so these are few few photographs to show you how to uh attach this police onto the patient when to empty it and the aseptic method of insertion and then the aseptic hand hygiene precautions that we should take monitoring the compliance to the implementation of prevention bundle is very important for the infection control practices if we do not Monitor and we do not tell them that they are doing this mistake or that mistake nobody will actually improve and for that we require the infection control nurses then the zones in housekeeping there is no dry sweeping or vacuum cleaners which are there in and should not be happening in their Ops also and if you are practicing in your clinics that is Zone B training should always precede disinfection that means you always rub and remove a blood stain and do not just put a alcohol over it and think it is disinfected so that means cleaning is very very important manual cleaning is very important step before you go for disinfection Zone C and Zone D is the one which we practice in hospitals and they should be almost Green Daily the frequency can be minimum three times in 24 hours and then the mob should also be cleaned and kept properly the level of disinfectant varies from area to area for your OPD settings load level disinfectants will be sufficient if you are doing in the clinics then cupboard shelves tools and other fixtures should be clean with detergent and water once a week fans and light should be clean with soaked and water Once A month's wet mop and you can have a schedule where Monday doors will be clean Tuesday the chair will be scrub Wednesday Dustbin would be scrubbed Thursday AC would be scrubbed and you can have these uh charts which are placed in your clinics and all this the spirit toilet cleaner the disinfectant should always be under lock and key you don't want a kid reaching that place and drinking something and creating a mess in your health care and always protect the cleaning person it's important that once you learn something you teach it to the people new people and then tell them to teach the thing back to you so that you will understand how much they have really understood and then you can teach them again so staff feedback is also very important it should not be just Euro directional Force because some things which are applicable in a hospital may not be applicable in a b hospital and we might need to adjust or change sometimes so thank you uh but we need to be sustained we have a challenge because we need to sustain and then only we will go forward so let's win the fight against Healthcare infections thank you thank you sir that was very informative uh you've covered all the important points especially those which might be missed on a regular practice so I'm sure you've explained very well and I'm sure our doctors have got here yes I I sometimes forget to do this or do that so I'm sure we are a step ahead in preventing Hai like you said and I'm sure all our doctors would share it with their colleagues as well that this was the interesting session and as you all know there would be a replay of this available later so please share with your colleagues and your Juniors your seniors so everyone is together in this fight against Hospital acquired infection so Dr Krishna Priya would like to ask what is the correct method to collect urine from a catheterized patient okay uh so the right way from a categorized patient if you can do is a super pubic aspiration if you can do that is the best way because that will avoid all contamination if you're not able to do that then the next Better Way best way is to disconnect from the Follies and let the urine dribble into the urinary culture bottle and then you can send it that is the best way not to collect it from the unary bag and not to collect it from the tubings the back tubings from the police directory only those two ways you can collect it okay I think those that was the question rest I think the presentation was very self-explanatory I'm sure many of us have understood with the pictures the videos especially love the videos it shows the efforts you've gone the lens that you have gone to make this session very interactive we love the videos just would like to add this for collecting blood culture then you have to send two bottles send two bottles that is one set and that is one from the center line one set and one set from the peripheral line so actually four set of bottles have to be sent for actually finding out whether it's a Center Line Associated bloodstream infection okay uh we have a question by Dr Krishna does the Foley need to be disinfected before reconnecting no no no I I don't understand does the foolies need to be disinfected before reconnect not not needed not needed use uh you should wear a non-style glove and just uh collect the urine and you can reconnect it no need it okay okay yes sir so those were the questions I think uh if we get any more questions uh Dr Fatima would be sharing them with you we have a reason I'll just check Dr venkat I have accepted your request you will get a pop-up to switch on your audience video yeah hi I'm Dr Sandeep I would like to know if uh do we need to clean the vaginal area or urethral area every day if a child is categorized okay uh again it is not required but if you can just clean it with the line if you think it is soiled then it's okay saline Gauss will do it but as a routine it's not required so visible soiling you need to clean it oh thank you thank you so much yes sir so Dr Krishna bhaiya says thank you Dr mahes says thank you excellent session thank you so yes so those were the questions so thank you so much sir thank you on behalf of Netflix on behalf of all the doctors thank you like I was saying the videos were very explanatory very nice and I really applaud you for the efforts that you've done your staff as well who supported in this Venture of yours to shoot a video they've really done nice you can see all the emojis that are coming up right now these are the feedbacks that our doctors gave us so thank you again and thank you to our audience as well.
Infection Control Practices in PICU
Nosocomial infections are an important preventable infectious complication & a leading cause of mortality in paediatric intensive care unit (PICU). Central line associated bloodstream infections, ventilator associated pneumonia and catheter-associated urinary tract infections are few to name. As the number of interventions and organ system support escalates, the greater are the associated risks. Empiric antibiotic treatment from early reduces mortality in sepsis. But it demands knowledge of the infection rates and of the sources, the pathogens involved as well as the common risk factors. Dr. Maninder Dhaliwal, Senior Consultant PICU, further elaborates.
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