Infection prevention & control update for Clinical Council

Transcription

1 (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

2 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

3 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

4 Challenge 1: Staphylococcus aureus bloodstream infections

5 Healthcare S. aureus BSI: HNE 5

6 Calvary Mater SAB

7 Calvary Mater SAB

8 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

9 Hand hygiene & fomite control Detailed analysis: Q Do we consistently avoid contaminating patients: hands, equipment, clothing Q Is this critical practice accepted/ ingrained everywhere yet? HAIDET : every patient, every time

10 Challenge 2: Peripheral cannula-associated bloodstream and local infections

11 Recent SAB due to peripheral cannula

12 This patient died with sepsis due to cubital fossa cannula

13 Non-ICU peripheral cannula BSI All cannula infections at least 5-fold higher Ie 150/ year

14 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?

15 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

16 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

17 Challenge 3: Central line-associated bloodstream infections

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19 Central line insertion bundle

20 A central line insertion bundle

21 HNE Intensive care units declining central line associated bloodstream events (CLAB) 21

22 Neonatal ICU, JH Children s Hospital: declining late onset BSI 22

23 HCA Bloodstream infections- non-intensive care Row Labels Abdominal sepsis (other) Biliary/cholecystitis Cerebral inf (other) 1 Decubitus ulcer (infected) Endocard (native) Endocard (prosth) Endometritis 1 ENT (unspecified) 1 1 GI tract / mucositis Joint inf (other) Joint inf (TJR prosth) Line-assoc bstream inf Liver abscess / hepatitis 1 2 Mediastinitis 1 Meningitis (device-assoc) 1 1 Osteomyelitis Peritonitis (CAPD) Pneumonia (other) Reprod.tract inf(other) RTI (lower-other) 2 Sepsis (unk primary site) Skin(cellul/other) Soft tissue Spinal om/discitis UTI (device-associated) UTI (other) Vascular infn (not line-related) Wound infection (surgical) Grand Total

24 HCA BSI- non-intensive care- lv line events Row Labels Abdominal sepsis (other) Biliary/cholecystitis Cerebral inf (other) 1 Decubitus ulcer (infected) Endocard (native) Endocard (prosth) Endometritis 1 ENT (unspecified) 1 1 GI tract / mucositis Joint inf (other) Joint inf (TJR prosth) Line-assoc bstream inf Liver abscess / hepatitis 1 2 Mediastinitis 1 Meningitis (device-assoc) 1 1 Osteomyelitis Peritonitis (CAPD) Pneumonia (other) Reprod.tract inf(other) RTI (lower-other) 2 Sepsis (unk primary site) Skin(cellul/other) Soft tissue Spinal om/discitis UTI (device-associated) UTI (other) Vascular infn (not line-related) Wound infection (surgical) Grand Total Row Labels CL-dialysis/apheresis central line CL-hickman/broviac CL-permacath CL-PICC (peripherally inserted central line) CL-port (fully implanted central line) CL-shortterm central line PL-av fistula PL-intra-arterial line 1 PL-intravenous line Grand Total

25 Effective Insertion AND management bundles

26 Biopatch = A$6 or so per patch

27 Challenge 3: prevent central lineassociated 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)

28 Challenge 4: Healthcare associated urinary tract infection

29 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 Labels Row Labels BMT CES JFH 1 JHH KUR 1 1 MAI MMN MUS 1 NARM 1 NB 2 1 NCPT NMOR 2 SCO SIN 1 1 TAM WACF 1 * Melzer M, et al. Postgrad Med J 2013;89: WING 1 Grand Total

30 Post-TRUS biopsy sepsis Increasing incidence due to failures in prophylaxis Multi-resistant Gram negative bloodstream infections; especially recent travellers

31 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

32 Challenge 5: Antibiotic stewardship

33 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

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35 Problem resistant pathogens. Staphylococcus aureus MRSA, (VRSA) Vancomycin-resistant enterococcus Mycobacterium tuberculosis- mdr and xdr tb Gram negatives multi-resistance, carbapenem resistance

36 Declining Healthcare MRSA BSI events Inpatient (I) and non-inpatient (O) healthcare-associated SAB events, n=38 facilities 36

37 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

38 Mater hot case August 2013

39 Mater hot case August 2013 Drug resistant TB

40 Gram negative multi-resistance

41 CRE guideline : launch date September 2013

42 Antibiotic stewardship, Standard 3 Are the right patients being treated with the right antibiotics?

43 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

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45 HNE Smartphone app

46 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

47 National Antibiotic Utilisation Surveillance Program acute networks Other smaller locations centralised pharmacy data used Targets established for ceftriaxone / cefotaxime and fluoroquinolones

48 National comparisons: tertiary hospitals JHH is hospital L8!

49 Usage at other HNE hospitals

50 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

51 Scottish 4 C s : successful hospital and community sector program

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53 Challenge 5: antimicrobial stewardship 1. Governance and priority setting 2. Resources 3. Action: local clinician ownership criticalacute and community care settings; esp residential aged care

54 Other challenges Environmental hygiene/ cleaning Surgical site infection Ventilator-associated pneumonia Outbreaks and incidents

55 Recent HAI incidents/ outbreaks Location and date Event Patients affected Staff affected NICU, 2013 MRSA cluster 10 neonates, 2 mothers (colonised) F3, JHH VRE outbreak 26 (colonisations) Nil J3, JHH, June Gastroenteritis outbreak- norovirus Cardiovascular surgery, 2013 Belmont birthing service, 2013 Dialysis service 2012 Cluster of cardiac surgical infections, 2013 Cluster of neonatal Staph. aureus infections, 2013 Potential hepatitis B exposure 27 4 Nil 18 Nil Nil 55

56 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

57 2013_14 IPC operational plan finalised

58 Thank you 58