Hand Hygiene and Infection Control: What Happens Next?

1
Hand Hygiene and Infection Control What Happens
Next?
What Dr. Wenzel does not know and What Dr. Edmond
will not tell you.

• Gonzalo Bearman MD, MPHAssistant Professor of
  Medicine, Epidemiology and Community
  HealthAssociate Hospital EpidemiologistVirginia
  Commonwealth University

2
Hand Hygiene and Infection Control What Happens
Next?
What Dr. Wenzel does know and What Dr. Edmond
will tell you.
Gonzalo Bearman MD, MPHAssistant Professor of
Medicine, Epidemiology and Community
HealthAssociate Hospital EpidemiologistVirginia
Commonwealth University
3
Infection Control Timeline
Big Bang 10 billion and 20 billion years ago

• Hotel-Dieu
• Paris hospital founded in the 7th century

Many years elapse
0
Circa 600 AD
4
Infection Control Timeline
Segregation of Infectious Patients
Lazarettos for plague victims established in
Venice in the 15th century
Leprosariums emerge in the Middle Ages
Fever hospitals established in England in the
early 19th century
5
History Ignaz Semmelweis

• At the Vienna Lying-in Hospital
• Women who delivered on the street had less risk
  of developing puerperal fever
• Much higher risk of puerperal fever in women
  delivered by physicians or medical students as
  opposed to those delivered by midwives
• Required that hands be washed with chlorinated
  lime after autopsies between exams of
  pregnant women
• Maternal mortality decreased from 18 to 3

6
History Florence Nightingale and Louis Pasteur

• Importance of unsanitary hospital conditions and
  post operative complications

• Developed the germ theory of disease in the late
  1800s

7
History Advances in Surgical Infection Control

Joseph Lister introduced antiseptics in 1867 William Halstead introduced gloves in 1890 Johannes Mikulicz introduced masks in 1897
8
Infection Control Timeline The Modern Era
Robert Haley, MD 1970s SCENIC Study Hospitals
with active infection control programs have a 32
lower incidence of nosocomial infections
R.P Wenzel MD, MSc 1980 Founded Society of
Healthcare Epidemiology applied epidemiologic
techniques to infection control
First antibiotics, sulfonamides penicillin,
developed in the late 1930s
1961 MB Edmond born
9
So where are we now and what happens next?
10
Nosocomial Infections

• 5-10 of patients admitted to acute care
  hospitals acquire infections
• 2 million patients/year
• 70 are due to antibiotic-resistant organisms
• ¼ of nosocomial infections occur in ICUs
• 90,000 deaths/year
• Attributable annual cost 4.5 5.7 billion
• Cost is largely borne by the healthcare facility
  not 3rd party payers

Weinstein RA. Emerg Infect Dis 19984416-420. Jar
vis WR. Emerg Infect Dis 20017170-173.
11
Shifting Vantage Points on Nosocomial Infections
Many infections are inevitable, although some can
be prevented
Each infection is potentially preventable unless
proven otherwise
Gerberding JL. Ann Intern Med 2002137665-670.
12
The medical literature is replete with studies
identifying risk factors for nosocomial infections

• Hand Hygiene
• BSI
• Catheter type, insertion, maintenance
• VAP
• Duration of intubation, gastric pH, HOB elevation
• UTI
• Catheter use and insertion, maintenance

13
Sadly, we as medical professionals frequently do
not practice well known nosocomial infection risk
reduction practices
14
Pressure from legislatures, consumer groups,
third party payers and regulatory agencies has
resulted in mandatory public reporting of
nosocomial infections
This is now driving compliance with process of
care measures that are associated with reductions
in nosocomial infection risk
15
Help Consumers Union Stop Hospital Infections!
Most people don't expect to go into a hospital
and come out even sicker because of an infection
they caught as a patient, but 1 in 20 do. And
each year, about 90,000 people die from hospital
acquired infections - a leading cause of death in
the U.S. The annual cost to our health care
system is 5 billion. Congress is considering a
bill that would let hospitals keep information
about their infection rates and medical errors a
secret. People should be able to find out whether
their hospital is doing a good job of controlling
dangerous infections. TAKE ACTION now to tell
Congress to preserve state's rights to report on
hospital infection rates.
http//www.consumersunion.org/pub/projectsandcampa
igns.html
16
Status of Mandatory Reporting LegislationSeptembe
r 2005

• ? Enacted legislation
• ? Legislation introduced, under review or further
  study
• ? Legislation died/defeated

Source APIC.
Slide courtesy of MB Edmond MD,MPH,MPA
17
Infection Control Process of Care Measures

• Hand Hygiene
• Contact Precautions
• Gowns
• Gloves
• HOB elevation for VAP prevention
• CVC insertion measures
• Avoidance of femoral site
• Maximal sterile barrier precautions
• Proper antisepsis of skin
• Prompt discontinuation of catheter use

18
30-40 of all Nosocomial Infections are
Attributed to Cross Transmission The
Importance of Hand Hygiene
19
The inanimate environment is a reservoir of
pathogens
X represents a positive Enterococcus culture
The pathogens are ubiquitous
Contaminated surfaces increase
cross-transmission Abstract The Risk of Hand
and Glove Contamination after Contact with a VRE
() Patient Environment. Hayden M, ICAAC, 2001,
Chicago, IL.
20
The inanimate environment is a reservoir of
pathogens
Recovery of MRSA, VRE, C.diff, CNS and GNR
Devine et al. Journal of Hospital Infection.
20014372-75 Lemmen et al Journal of Hospital
Infection. 2004 56191-197 Trick et al. Arch Phy
Med Rehabil Vol 83, July 2002 Walther et al. Biol
Review, 2004849-869
21
Hand Hygiene
Single most effective method to limit cross
transmission
Hand Hygiene Comment
Typical Compliance Observational studies of hand hygiene report compliance rates of 5-81
Common Reported Barriers To Compliance Insufficient time, understaffing, patient overcrowding, lack of knowledge of hand hygiene guidelines, skepticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants and lack of hand hygiene promotion by the institution
22
HCWs' perceptions of compliance with infection
control practices
of HCWs reporting compliance gt80 of HCWs reporting compliance gt80 of HCWs reporting compliance gt80
Position N () Handwashing Contact isolation Airborne isolation
Registered nurses 118 (36) 77 59 74
Resident physicians 99 (31) 62 61 92
Attending physicians 33 (10) 62 72 82
LPNs, patient care assistants 29 (9) 59 72 76
Others 45 (14) 73 79 69
Total 324 (100) 69 65 80
Majority of respondents reported excellent
compliance with IC practices
Berhe M, Edmond MB, G Bearman in AJIC 331
February 2005, 55-57
23
Alcohol Based Hand Sanitizers

• CDC/SHEA hand antiseptic agents of choice
• Recommended by CDC basedon strong
  experimental,clinical, epidemiologic and
  microbiologic data
• Antimicrobial superiority
• Greater microbicidal effect
• Prolonged residual effect
• Ease of use and application

24
Alcohol based hand hygiene solutions
Easy to use
Quick 5- 15 seconds
Very effective antisepsis due to bactericidal
properties of alcohol
25
Study Algorithm
Incremental Increase in Alcohol Dispensers
Hand Hygiene Educational Program Implemented
Direct Observation of Hand Hygiene
Arch Intern Med. 20001601017-1021.
26
Results
Hand hygiene practice can be improved with
education and greater accessibility of alcohol
hand sanitizers

• Improvement in Hand Hygiene Compliance

Arch Intern Med. 20001601017-1021.
27
Hand Hygiene

• Single most important method to limit cross
  transmission of nosocomial pathogens
• Multiple opportunities exist for HCW hand
  contamination
• Direct patient care
• Inanimate environment
• Alcohol based hand sanitizers are ubiquitous
• USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

28
Hand Hygiene

• HCWs perceive that their hand hygiene practice
  is excellent
• Observational data does not support this claim
• New technologies such alcohol based hand
  sanitizers make the practice of hand hygiene
  simpler than ever
• There is simply no excuse for poor hand hygiene
  compliance

29
Contact Precautions for drug resistant pathogens.
Gowns and gloves must be worn upon entry into the
patients room
30
Glove Use for Infection Control
Variable Rationale Comment
Gloves Prevent healthcare worker exposure to bloodborne pathogens Prevent contamination of hands with drug resistant pathogens during patient care activities Even with proper glove use, hands may become contaminated during the removal of the glove or with micro-tears that allow for microorganism transmission
31
Gown Use for Infection Control
Variable Rationale Comment
Gowns Several studies have documented colonization of healthcare worker apparel and instruments during patient care activities without the use of gowns The use of gloves and gowns is the convention for limiting the cross transmission of nosocomial pathogens, however, the incremental benefit of gown use, in endemic settings, may be minimal
32
What about the role of Universal Gloving For All
Patient Care?
33
A Controlled Trial of Universal Gloving vs.
Contact Precautions for Preventing the
Transmission of Multidrug-Resistant Pathogens
G. Bearman MD,MPH A. Marra, MD C. Sessler,
MD W.R. Smith, MD R.P. Wenzel MD, MSc M.B. Edmond
MD,MPH,MPA
34
Hypothesis

• The effectiveness of universal gloving (use of
  gloves for all patient care activity) in
  preventing the transmission of multidrug-resistant
  pathogens will be greater than the effectiveness
  of contact precautions for the following reasons
  
• Compliance with universal gloving will likely be
  greater than compliance with contact precautions.
  

Bearman et al.
35

• CDC/NNIS NI definitions applied surveillance
  performed by VCUMC IC Department
• Hand hygiene observations performed by trained
  observers
• Active surveillance nasal and rectal cultures
  were obtained on all patients within the unit

Bearman et al.
36
Methods

• Microbiologic Data
• One rectal swab culture performed for VRE and 1
  nasal swab culture for MRSA performed on
  admission and every 4 days.
• Once a patient was culture positive then no
  further cultures were obtained for that organism.
  
• Pulse field gel electrophoresis (PFGE) for
  genetic typing and antibiotic susceptibility
  testing were performed on all MRSA and VRE
  isolated after study was completed.

Bearman et al.
37
Methods

• Healthcare Questionnaire
• Administered at the end of the study protocol
• Target MRICU Nurses and Attending Physicians
• Focus
• self reported compliance with infection control
  practice
• acceptability of universal gloving vs. standard
  of care.

Bearman et al.
38
MethodsAdditional Data Elements
Phase I vs. Phase II
Length of stay
MRICU occupancy rate per month
MRICU invasive devices utilization ratios
Nurse to patient ratio
Antibiotic usage defined daily dose (DDD)
Bearman et al.
39
Results
Variable Phase I Phase II P value
Total patient days 1090 1377 -
Total observations for IC compliance 1220 1102 -
Total patients screened for VRE 192 257 0.54
Total patients screened for MRSA 228 301 0.60
Bearman et al.
40
Results Hand Hygiene Compliance
Phase I Phase I Phase II Phase II
Variable N Obs N Obs P-value
Hand Hygiene before patient contact 228 18.7 126 11.4 lt0.001
Hand Hygiene after patient contact 704 57.7 578 52.5 0.011
A statistically significant reduction in
hand-hygiene was observed in phase II
Bearman et al.
41
ResultsCompliance with Contact Precautions vs.
Universal Gloving
Variable Phase I Phase I Phase II Phase II P
Variable N N P
Compliance with gloving for patients on contact precaution 387 89.4 N/A N/A N/A
Compliance with gowns for patients on contact precaution 335 77.4 N/A N/A N/A
Gowns and gloves for patients on contact precaution 328 75.7 N/A N/A N/A
Total Compliance (Contact Precautions vs. Universal Gloving) 328 75.7 959 87.0 lt0.001
Greater adherence during universal gloving was
observed
Bearman et al.
42
Results VRE screening
Variable Phase I Phase II P value
Total Patients Screened for VRE 192 257
Patients VRE positive upon admission to ICU 3 (1.5) 3 (1.1) 0.70
Patients with VRE conversion during ICU stay 39 (20) 35 (14) 0.31
Days to acquire VRE (median) 8 9 0.79
No difference was observed in the rate of VRE
acquisition
Bearman et al.
43
Results MRSA Screening
Variable Phase I Phase II P value
Total Patients Screened for MRSA 228 301 -
Patients MRSA positive upon admission to ICU 11 (4.8) 6 (2.0 ) 0.11
MRSA conversion during ICU stay 13 (5.7) 15 (5.0) 0.92
Days to acquire MRSA (median) 8 9 0.95
No difference was observed in the rate of MRSA
acquisition
Bearman et al.
44
Results MRSA PFGE
MRSA Phase I Phase II
Number of Strains 21 25
Conversion negative to positive 13 13/13 clonal (100) Type A1, A2, A3, A4 15 15/15 clonal (100) Type A1, A5
PFGE Types A113/21 (62) A2 5/21 (23) A3 1/21 (5) A41/21 (5) B 1/21 (5) A118/25 ( 72) A5 2/25 (8) C 3/25 (12) D2/25 (8)
ALL MRSA conversions were with clonal isolates
Bearman et al.
45
Results VRE PFGE
VRE Phase I Phase II
Number of Strains 40 35
Conversion negative to positive 39 20/40 clonal (50) Type A, B 35 28/35 clonal (80) Type A, AA, AB
PFGE Types Type A 16/40 (34) Type B 4/40 (11) Type D2/40 Type G 3/40 Type H2/40 Type J2/40 Type K 2/36 Type C,E,I, L,M,Q,R S,T 1 each 9/40 Type A 18/35 (51) Type AA 4/35 (11) Type AB4/35 (11) Type H 2/35 (6) Types F,G,I,J,U,V,M1 each 7/35 (20)
Most VRE conversions were with clonal isolates
46
ResultsNosocomial Infections Rates
Outcome Phase I Phase II P
BSI/1000 catheter days 6.2 14.1 Plt0.001
UTI/1000 catheter days 4.3 7.4 Plt0.001
Pneumonia 0 2.3 Plt0.001
A statistically significant increase in NIs was
observed
Bearman et al.
47
Results Nosocomial Infections
Phase I Phase I Phase II Phase II
Infection Organisms Organisms
BSI 5 P. aeruginosa (1) E. cloacae (1) K. pneumoniae (1) Prevotella species (1) C. glabrata (1) 16 Coag. negative staph (6) Enterococcal species (3) VRE (1) MRSA(2) P. aeruginosa (1) K. pneumoniae (1) C. parapsilosis (1) C. albicans (1)
UTI 6 E. coli (2) E. cloacae (1) C. albicans (3) 9 Coag. negative staph (1) Enterococcal species (1) P. aeruginosa(2) E. coli (1) C. albicans (2) C. non-albicans (2)
VAP 0 NA 2 MRSA(1) P.aeruginosa (1)
48
Results Nosocomial Infections with VRE or MRSA
Phase I Phase I Phase II Phase II
Infection VRE MRSA VRE MRSA
BSI 0 0 1 2
UTI 0 0 0 0
VAP 0 0 0 1
4 VRE and MRSA infections were identified in
Phase II
49
MRICU Demographics
Phase I Phase II P value Variable
5.3 6.8 0.07 Average length of stay
87 92 0.36 MRICU occupancy rate per month
11.9 11.9 NS Nurse to patient ratio
Device utilization ratio Phase I Phase II P
Urinary Catheter 0.85 0.87 0.83
Central line 0.74 0.72 0.87
Ventilator 0.56 0.62 0.47
Utilization ratiodevice days/patient days
50
Results Antibiotic UsageDefined daily dose
(DDD/1000 patients-day)
Antibiotic DDD Phase I DDD Phase II P value
B-lactams 391.6 352.9 0.075
B-lactam/inhibitor 210.1 211.5 1.0
Aminoglycosides 68.2 118.2 lt0.001
Glycopeptides 190.1 226 0.079
Metronidazole 127.0 118.6 0.582
Quinolones 385.7 359.0 0.206
Total 1372.7 1386.2 0.806
The DDD is the assumed average maintenance dose
per day for a drug used for its main indication
in adults ExampleDDD of levofloxacin is
0.5grams, if 200 grams were dispensed in a period
with 4,500 patient days(200g/0.5g)/4,500 pt days
X 1000 89 DDD/1000 PD
51
ResultsQuestionnaire about IC compliance During
Universal Gloving Study

• 34 respondents
• 30 MRICU Nurses (45 eligible)
• 4 Attending Physicians (7 eligible)
• Overall survey compliance 65

52
ResultsQuestionnaire about IC compliance
Questionnaire Item Proportion
Proportion of respondents indicating that universal glove use was impractical 12
Proportion of respondents reporting good compliance with infection control measures 97
Proportion of respondents reporting good compliance with Hand hygiene 97
53
ResultsQuestionnaire about IC compliance
Questionnaire Item Proportion
HCWs reporting less frequent entry into a patient room because of contact precautions 48
Belief that proper glove use is more important than hand hygiene to limit the spread of nosocomial organisms 6
Belief that the use of gloves is associated with decreased risk of cross-transmission of nosocomial organisms 94
HCWs reporting no difference in skin problems (e.g., chapping, dryness, cracking) 93
54
ResultsQuestionnaire about IC compliance During
Universal Gloving Study
Overall better care is delivered when
Majority of respondents felt that better care was
delivered during the Universal Gloving Phase of
the study
55
Universal Gloving Conclusions

• Observed compliance with universal gloving was
  significantly greater than compliance with
  contact precautions (gowns and gloves).
• However, greater compliance with hand hygiene was
  observed in the standard of care phase.
• No differences were detected between the two
  study phases for
• LOS, nursepatient ratio,MRICU occupancy rate,
  invasive device utilization, and antibiotic usage
  

56
Universal Gloving Conclusions

• No differences in VRE and MRSA colonization was
  observed between the two study phases.
• In both phases, the majority of VRE and MRSA
  conversions were of a clonal isolate
• However, an increase in nosocomial infection
  rates was observed during the universal gloving
  phase of the study
• 4 VRE and MRSA nosocomial infections were
  observed during the universal gloving phase

57
Universal Gloving Conclusions

• HCWs found gloving acceptable and believed that
  the use of universal gloving is associated with
  decreased risk of cross-transmission of
  nosocomial organisms
• HCWs believed that better care was delivered
  under the universal gloving phase
• Although universal gloving was highly accepted by
  the staff, its implementation should proceed with
  caution given the observed increase in nosocomial
  infection rates
• The use of universal gloving may have lead to a
  misperception of decreased cross transmission
  risk
• This may have lead to decreased hand hygiene
  compliance and a consequent increase in the rates
  of nosocomial infections

58
The importance of process of care measures in the
reduction of nosocomial bloodstream infections
59
The CVC is the greatest risk factor for
Nosocomial BSI
The risk factors interact in a dynamic fashion
As the host cannot be altered, preventive
measures are focused on risk factor modification
of catheter use, duration, placement and
manipulation
60
Prevention of Nosocomial BSIs

• Limit duration of use of intravascular catheters
• No advantage to changing catheters routinely
• Maximal barrier precautions for insertion
• Sterile gloves, gown, mask, cap, full-size drape
• Moderately strong supporting evidence
• Chlorhexidine prep for catheter insertion
• Significantly decreases catheter colonization
• Disadvantages possibility of skin sensitivity to
  chlorhexidine

61
Eliminating catheter-related bloodstream
infections in the intensive care unit

• Purpose
• To determine whether a multifaceted systems
  intervention would eliminate catheter-related
  bloodstream infections (CR-BSIs)
• Method
• Prospective cohort study in a surgical intensive
  care unit (ICU) with a concurrent control ICU.
• Patients
• All patients with a central venous catheter in
  the ICU

Pronovost et al. Crit Care Med. 2004
Oct32(10)2014-20.
62
Eliminating catheter-related bloodstream
infections in the intensive care unit
Interventions Example
Staff Education All staff inserting central catheters were required to complete a web-based training program with post-test.
Creation of a catheter insertion cart Central catheter insertion cart that contains all equipment and supplies Reduced the number of steps required for compliance
Pronovost et al. Crit Care Med. 2004
Oct32(10)2014-20.
63
Eliminating catheter-related bloodstream
infections in the intensive care unit
Promotion of daily catheter Removal Asked daily during rounds whether catheters or tubes could be removed
Evidence based checklist CVC insertion and for BSI risk reduction Hand hygiene prior to procedure Chlorhexidine skin preparation Full-barrier precautions during CVC insertion Subclavian vein as the preferred site Maintenance of sterile field during procedure
Nurse Empowerment Procedure aborted if a violation in compliance with evidence-based guidelines was observed SICU attending physician notified
Pronovost et al. Crit Care Med. 2004
Oct32(10)2014-20.
64
Eliminating catheter-related bloodstream
infections in the intensive care unit

• Results
• During the first month nursing completed the
  checklist for 38 procedures
• Eight (24) for new central venous access,
• 30 (79) for catheter exchanges over a wire,
• Three (8) were emergent.
• Nursing intervention was required in 32 (12/38)
  of central venous catheter insertions

Pronovost et al. Crit Care Med. 2004
Oct32(10)2014-20.
65
Eliminating catheter-related bloodstream
infections in the intensive care unit
BSI Rate 1st quarter 1998 BSI Rate 4th quarter 2002 January 2003- April 2004
Study ICU 11.3/1,000 catheter days 0/1,000 catheter days 0.54/1,000 catheter days No crBSI over 9 months
Control ICU 5.7/1,000 catheter days 1.6/1,000 catheter days
Multifaceted, comprehensive program requiring CVC
insertion education, with safety checks for
proper hand hygiene, aseptic insertion procedure
and operator responsibility can result in
reduction of nosocomial BSI in an ICU setting.
Pronovost et al. Crit Care Med. 2004
Oct32(10)2014-20.
66
Measurement and feedback of infection control
process measures in the intensive care unit
impact on compliance
Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2,
Gonzalo Bearman MD, MPH1,2 Divisions of
Infectious Diseases1 and Quality Health Care2
Department of Internal Medicine Virginia
Commonwealth University School of
Medicine Richmond, VA, USA
67
Measurement and feedback of infection control
process measures in the intensive care unit
impact on compliance
Process Measure MRICU MRICU MRICU MRICU MRICU STICU STICU STICU STICU STICU
Process Measure Baseline Q2-2004 Q3 (2004) Q4 (2004) Q1 (2005) P value Baseline Q2-2004 Q3 (2004 Q4 (2004) Q1 (2005) P value
HH Opp 14/44 (32) 31/91 (37) 33/91 (36) 50/108 (46) 0.101 19/38 (50) 42/80 (53) 40/80 (50) 49/100 (49) 0.916
HOB Opp 28/51 (55) 320/333 (96) 450/454 (99) 551/556 (99) lt0.001 20/43 (47) 229/307 (75) 389/488 (79) 275/361 (76) lt0.001
Fem. CVC of Days 195/1093 (18) 130/769 (16) 80/879 (9.1) 51/951 (5.4) lt0.001 93/1109 (8.4) 49/970 (5.1) 14/1077 (1.3) 26/920 (2.8) 0.01
Mezgebe Berhe MD1, Mike Edmond MD, MHA, MPH1,2,
Gonzalo Bearman MD, MPH1,2
68
Head of Bed Elevation in VCU Medical ICUEffect
of Feedback
Pneumonia cases/1,000 ventilator-days
Compliance with HOB elevation
Baselineno feedback
Performance feedback quarterly
Slide courtesy of MB Edmond MD,MPH,MPA
69

• Ask Yourself
• If other professions can impose much tighter
  regulations to minimize risks, should we do the
  same?
• Are 3-5 infections/ 1000 patient days acceptable?
• Are we doing all that is possible to minimize
  risk?

United States Canada accident rates as of 12.31.2004 United States Canada accident rates as of 12.31.2004 United States Canada accident rates as of 12.31.2004 United States Canada accident rates as of 12.31.2004
Airline Rate Events No. Flights

Air Canada 0.63 3 4.75 Million
Alaska Airlines 0.74 3 4.05 Million
Aloha Airlines 0.49 1 1.34 Million
American Airlines/Eagle 0.59 10 17.0 Million
Continental Airlines/Express 0.63 5 8.00 Million
Delta Air Lines 0.30 6 20.0 Million
http//www.airdisaster.com/statistics/
70
Conclusion

• Risk reduction strategies for the prevention of
  nosocomial infections are well defined in the
  literature
• Lack of adherence to IC measures is recognized as
  important in the pathogenesis of NIs
• Sadly, HCWs overestimate their degree of
  compliance with infection control measures
• Pressure from legislatures, consumers groups,
  hospital administration, third party payers and
  regulatory agencies will result in the mandatory
  public reporting of nosocomial infections.
• Drive increase compliance with process of care
  measures that are associated with reductions in
  nosocomial infection risk

71
Conclusion

• System level changes involving the measurement
  and feedback of adherence to IC measures are
  needed to implement risk reduction strategies
  consistently
• BSI enforcement of comprehensive catheter
  use/care policies
• VAP HOB elevation
• Hand hygiene- alcohol based sanitizers

72
I suppose that I shall have to die beyond my
means Oscar Wilde, upon being told the cost
of an operation