Infection prevention & control update for Clinical Council August 2013 Dr John Ferguson, Director, Infection Prevention and Control team (Previous presentations August 2010 Sept 2011 August 2012)
Infection prevention & control update for Clinical Council
August 2013 Dr John Ferguson,
Director, Infection Prevention and Control team
(Previous presentations August 2010 Sept 2011 August 2012)
Acknowledgements
• Infection control executive: Ms Sandy Berenger, Ms Alison Shoobert, Ms Christine West, Dr Rod Givney
• Our tireless infection prevention and control foot soldiers : – Nursing staff (CNC and CNS levels) with designated ICP
role – Infection Prevention and Control Liaison Nursing staff –
across all locations – Designated Staff Health personnel
5 Infection control challenges
1. Staphylococcus aureus BSI (SAB)* 2. Peripheral cannula-associated infections 3. Central lines-associated infections** 4. Urinary tract infections 5. Antibiotic stewardship
* National hospital performance indicator ** State performance indicator for ICUs
Challenge 1: Staphylococcus aureus bloodstream infections
Healthcare S. aureus BSI: HNE
5
Calvary Mater SAB
Calvary Mater SAB
Challenge 1: prevent SAB
1. Improve hand hygiene by healthcare staff- current compliance 84% (medicos 71%, nurses 88%); enable hand hygiene by patients [are these direct observational data accurate??
2. Improve asepsis 3. Surgical antibiotic prophylaxis, alcohol-based skin
prep for operative site 4. MRSA screening, contact isolation, selected patient
decolonisation
Hand hygiene & fomite control
Detailed analysis: http://intranet.hne.health.nsw.gov.au/hand_hygiene Q Do we consistently avoid contaminating patients: hands, equipment, clothing Q Is this critical practice accepted/ ingrained everywhere yet? ‘HAIDET’: every patient, every time
Challenge 2: Peripheral cannula-associated bloodstream and local infections
Recent SAB due to peripheral cannula
This patient died with sepsis due to cubital fossa cannula
Non-ICU peripheral cannula BSI
All cannula infections – at least 5-fold higher Ie 150/ year
Challenge 2: prevention of IV cannula sepsis
1. Avoid unnecessary usage 2. Avoid prolonged usage (max 72 hrs) 3. Avoid cubital fossa (max 24 hrs) 4. Correct asepsis during insertion and
management 5. Reliable and consistent patient observation
and documentation 6. Patient education ?
New asepsis requirements
• Developing aseptic ‘competency’ of those who train others to do procedures
• Credentialing of all those who perform procedures (iv cannulae, IDC, etc)
• Direct observational auditing of high risk procedures- eg. IV device insertion, IDC
Keys to asepsis
1. Pre-procedure hand disinfection/washing 2. Sterile field preparation adequate (i.e. environment, draping, layout of equipment) 3. Correct disinfection of invasive site performed correctly (not for IDC insertion) 4. Avoidance of contamination during procedure 5. Correct documentation of procedure
Challenge 3: Central line-associated bloodstream infections
Central line insertion ‘bundle’
A central line insertion ‘bundle’
HNE Intensive care units – declining central line associated bloodstream events (CLAB)
21
Neonatal ICU, JH Children’s Hospital: declining late onset BSI
22
HCA Bloodstream infections- non-intensive care
23
Row Labels 2008 2009 2010 2011 2012Abdominal sepsis (other) 8 12 13 25 23Biliary/cholecystitis 11 5 6 15 10Cerebral inf (other) 1Decubitus ulcer (infected) 2 2 1Endocard (native) 1 4 2 2Endocard (prosth) 1 2 2Endometritis 1ENT (unspecified) 1 1GI tract / mucositis 8 8 5 7 5Joint inf (other) 3 1 4 5 3Joint inf (TJR prosth) 5 4 2 7 1Line-assoc bstream inf 117 131 135 119 111Liver abscess / hepatitis 1 2Mediastinitis 1Meningitis (device-assoc) 1 1Osteomyelitis 1 1 1 3Peritonitis (CAPD) 2 1 3 1 4Pneumonia (other) 8 7 8 10 8Reprod.tract inf(other) 1 2 2 1RTI (lower-other) 2Sepsis (unk primary site) 52 66 149 86 83Skin(cellul/other) 6 8 8 8 7Soft tissue 6 6 3 5 7Spinal om/discitis 1 2 5UTI (device-associated) 20 17 31 34 34UTI (other) 7 10 27 25 31Vascular infn (not line-related) 5 3 3 3 5Wound infection (surgical) 9 11 11 3 16Grand Total 272 299 421 368 357
HCA BSI- non-intensive care- lV line events
24
Row Labels 2008 2009 2010 2011 2012Abdominal sepsis (other) 8 12 13 25 23Biliary/cholecystitis 11 5 6 15 10Cerebral inf (other) 1Decubitus ulcer (infected) 2 2 1Endocard (native) 1 4 2 2Endocard (prosth) 1 2 2Endometritis 1ENT (unspecified) 1 1GI tract / mucositis 8 8 5 7 5Joint inf (other) 3 1 4 5 3Joint inf (TJR prosth) 5 4 2 7 1Line-assoc bstream inf 117 131 135 119 111Liver abscess / hepatitis 1 2Mediastinitis 1Meningitis (device-assoc) 1 1Osteomyelitis 1 1 1 3Peritonitis (CAPD) 2 1 3 1 4Pneumonia (other) 8 7 8 10 8Reprod.tract inf(other) 1 2 2 1RTI (lower-other) 2Sepsis (unk primary site) 52 66 149 86 83Skin(cellul/other) 6 8 8 8 7Soft tissue 6 6 3 5 7Spinal om/discitis 1 2 5UTI (device-associated) 20 17 31 34 34UTI (other) 7 10 27 25 31Vascular infn (not line-related) 5 3 3 3 5Wound infection (surgical) 9 11 11 3 16Grand Total 272 299 421 368 357
Row Labels 2008 2009 2010 2011 2012CL-dialysis/apheresis central line 4 4 5 8 1CL-hickman/broviac 7 7 13 8 13CL-permacath 39 48 37 25 18CL-PICC (peripherally inserted central line) 13 20 20 18 26CL-port (fully implanted central line) 15 11 6 12 4CL-shortterm central line 19 15 22 11 16PL-av fistula 10 5 6 5 3PL-intra-arterial line 1PL-intravenous line 10 21 26 31 30Grand Total 117 131 135 119 111
Effective Insertion AND management bundles
Biopatch = A$6 or so per patch
Challenge 3: prevent central line-associated bloodstream infection 1. Ensure all inserters are credentialed 2. Adopt central line insertion bundle for all locations 3. Independent observational audit of compliance 4. Feedback and improvement 5. Adopt best practices ie. management bundle to
prevent late infection (> 7 days)
Challenge 4: Healthcare associated urinary tract infection
Healthcare associated bacteraemic UTI
• High mortality- up to 40% at 30 days*
• Strong assoc. with catheter use and age
• Incidence of HCA UTI much higher still
• Evidence of overuse of IDC
Count of SSSITE Column LabelsRow Labels 2008 2009 2010 2011 2012BMT 2 6 5CES 1 1 5JFH 1JHH 19 15 25 23 35KUR 1 1MAI 1 2 7 3MMN 5 8 10 8 17MUS 1NARM 1NB 2 1NCPT 1 1 2 6 4NMOR 2SCO 1 1 2SIN 1 1TAM 1 4 4 3WACF 1WING 1Grand Total 29 28 59 60 66
* Melzer M, et al. Postgrad Med J 2013;89:329–334.
Post-TRUS biopsy sepsis
• Increasing incidence due to failures in prophylaxis
• Multi-resistant Gram negative bloodstream infections; especially recent travellers
Challenge 4: prevent urinary tract infection
1. Avoid / minimise catheter exposure: policy on insertion indications, nurse initiated removal indications
2. Ensure all IDC inserters are trained/ credentialed 3. Audit asepsis of insertion and whether usage
reflects agreed indications 4. Measure incidence of nosocomial UTI 5. Improve post TRUS infection prevention
ACI CAUTI Project : Wendy Watts, Sandy Berenger TRUS biopsy sepsis study: Urology team
Challenge 5: Antibiotic stewardship
Why worry?
1. Many resistant pathogens have a greater ability to cause disease (virulence)- ADD to the existing burden of disease
2. In hospitals, increased capacity of these pathogens to spread between patients and from patients to staff
3. Increased likelihood of patient treatment failure and death from infection
Problem resistant pathogens….
• Staphylococcus aureus – MRSA, (VRSA)
• Vancomycin-resistant enterococcus
• Mycobacterium tuberculosis- mdr and xdr tb
• Gram negatives – multi-resistance, carbapenem
resistance
Declining Healthcare MRSA BSI events Inpatient (I) and non-inpatient (O) healthcare-associated SAB events, n=38 facilities
36
MRSA challenges
• Over 8000 patients ‘flagged’ as having MRSA on HNE records: large consequent demand for isolation
• Lack of single rooms some facilities • Increasing community MRSA problem, including
residential aged care • Better linkage HNE to medicare locals re MRSA
patient management and f/u required Extensively revised MRO policy compliance procedure about to be finalised… HealthPathways: MRSA approach to be developed
Mater hot case – August 2013
Mater hot case – August 2013
Drug resistant TB
Gram negative multi-resistance
CRE guideline : launch date September 2013
Antibiotic stewardship, Standard 3
Are the right patients being treated with the right antibiotics ?
• Executive organisational support/resourcing • Leadership and involvement of clinicians • Establish program governance through an
antimicrobial policy developed by senior clinicians and management
• Key roles for pharmacists, medical microbiologists and infectious diseases physicians
HNE Smartphone app
A I M E D- Prescribing standard
Principle
A ntimicrobial selection compliant with Therapeutic Guidelines A llergy to antimicrobial(s) assessed prior to prescription
I ndication for treatment documented
M icrobiological assessment- collect specimens PRIOR to first dose
E valuate at 48-72hrs: direct, cease, change to oral or consult
D uration or review date - should always be specified
• National Antibiotic Utilisation Surveillance Program – acute networks
• Other smaller locations – centralised pharmacy data used
• Targets established for ceftriaxone / cefotaxime and fluoroquinolones
National comparisons: tertiary hospitals
JHH is hospital L8!
Usage at other HNE hospitals
• Clinical peer review meetings- local ownership and quality improvement
• Microbiologist liaison with clinicians about critical results
• Antimicrobial rounds- post prescription review and feedback
• Audit and point prevalence surveys • Outcome measurement
Scottish 4 C’s : successful hospital and community sector program
Challenge 5: antimicrobial stewardship
1. Governance and priority setting 2. Resources… 3. Action: local clinician ownership critical-
acute and community care settings; esp residential aged care
Other challenges
• Environmental hygiene/ cleaning • Surgical site infection • Ventilator-associated pneumonia • Outbreaks and incidents…
Recent HAI incidents/ outbreaks
Location and date Event Patients affected Staff affected
NICU, 2013 MRSA cluster 10 neonates, 2 mothers (colonised)
Nil
F3, JHH VRE outbreak 26 (colonisations) Nil
J3, JHH, June Gastroenteritis outbreak- norovirus
27 4
Cardiovascular surgery, 2013
Cluster of cardiac surgical infections, 2013
18 Nil
Belmont birthing service, 2013
Cluster of neonatal Staph. aureus infections, 2013
5 1
Dialysis service 2012
Potential hepatitis B exposure
30 Nil
55
National developments
• ‘One Health’ approach to antimicrobial resistance control; improved national surveillance
• Intensive lobbying for a proper national communicable disease control capability
• Multi-resistant carbapenem resistant Gram negatives: new guidelines for screening: – International hospital transfers – Recent (12 months) overnight stay in either foreign hospital
or residential care setting
2013_14 IPC operational plan finalised…