Infection control in intensive care. Sandra Fairley Senior Nurse, Neurocritical Care

Transcription

1 Infection control in intensive care Sandra Fairley Senior Nurse, Neurocritical Care

2 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Admit to Intensive Care Unit HCAI +++ Ventilator associated pneumonia Antibiotics Clostridium Difficile Antibiotic resistance MRSA Vascular access device HCAI + Site infection Bacteraemia Surgical procedure HCAI ++ Surgical wound infecton Increased length of stay Increased morbidity and mortality

3 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Vascular access device HCAI + Ventilator associated pneumonia Surgical procedure HCAI ++ Surgical wound infecton Site infection In 2001 More patients Bacteraemia 8.2% treated in 2006 more quickly Estimated to be 9% of patients Admit More to Intensive gravely Care Unit ill patients admitted to NHS hospitals High HCAI bed 6.4% +++ occupancy in 2011 rates in England Increased length of stay Increased morbidity and mortality Antibiotics Clostridium Difficile Antibiotic resistance MRSA

4 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Admit to Intensive Care Unit HCAI +++ Ventilator associated pneumonia Antibiotics Clostridium Difficile Antibiotic resistance MRSA Vascular access device HCAI + Site infection Bacteraemia Surgical procedure HCAI ++ Surgical wound infecton Increased length of stay Increased morbidity and mortality

5 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Admit to Intensive Care Unit HCAI +++ Ventilator associated pneumonia Antibiotics Clostridium Difficile Antibiotic resistance MRSA Vascular access device HCAI + Site infection Bacteraemia Surgical procedure HCAI ++ Surgical wound infecton Increased length of stay Increased morbidity and mortality

6 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Admit to Intensive Care Unit HCAI +++ Ventilator associated pneumonia Antibiotics Clostridium Difficile Antibiotic resistance MRSA Vascular access device HCAI + Site infection Bacteraemia Surgical procedure HCAI ++ Surgical wound infecton Increased length of stay Increased morbidity and mortality

7 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Admit to Intensive Care Unit HCAI +++ Ventilator associated pneumonia Antibiotics Clostridium Difficile Antibiotic resistance MRSA Vascular access device HCAI + Site infection Bacteraemia Surgical procedure HCAI ++ Surgical wound infecton Increased length of stay Increased morbidity and mortality

8 Risks to the patient of health care acquired infection (HCAI) Patient admitted to hospital Risk of HCAI Vascular access device HCAI + Site infection Bacteraemia Surgical procedure HCAI ++ Surgical wound infecton Increased length of stay Increased morbidity and mortality Admit to Intensive Care Unit Antibiotics Clostridium Difficile Antibiotic resistance MRSA HCAI +++ National Audit Office 2009 World Health Organisation 9,000 deaths with MRSA or C. Difficile as underlying 50% HCAI cause deaths or contributory attributable factor to poor hand hygiene Cost = 1.06 billion in UK Ventilator associated pneumonia

9 Lessons from the past Link between hand hygiene and infection Established in 1860

10 Lessons from the past Embedded in religious and cultural habits as measure of personal hygiene for centuries 1847 Ignaz Semmelweiss Father of hand hygiene Link between hand washing & spread of disease 1854 Florence Nightingale Pioneer of evidence based practice with hand washing at its core 2002 Healthcare Infection Control Practices Advisory Committee Alcohol handrub standard of care Hand washing reserved for particular situations 2005 World Health Organisation (WHO) First global hand hygiene improvement strategy Pasteur and Lister Scientific proof of link 2000 Didier Pitier Improved hand hygiene compliance with alcohol handrub

11 Lessons from the past Embedded in religious and cultural habits as measure of personal hygiene for centuries 1847 Ignaz Semmelweiss Father of hand hygiene Link between hand washing & spread of disease 1854 Florence Nightingale Pioneer of evidence based practice with hand washing at its core Asepsis theory rejected by the Instituted compulsory washing and medical community during his Demonstrated disinfecting of that hands hand of washing all who lifetime entered prevented the the obstetric spread ward of Later proven childbirth by fever the work 2002 of Cut mortality rate from 16% to 3% Pasteur and others Healthcare Infection Control Practices Advisory Committee Alcohol handrub standard of care Hand washing reserved for particular situations 2005 World Health Organisation (WHO) First global hand hygiene improvement strategy Pasteur and Lister Scientific proof of link 2000 Didier Pitier Improved hand hygiene compliance with alcohol handrub

12 Lessons from the past Embedded in religious and cultural habits as measure of personal hygiene for centuries 1847 Ignaz Semmelweiss Father of hand hygiene Link between hand washing & spread of disease 1854 Florence Nightingale Pioneer of evidence based practice with hand washing at its core 2005 World Health Organisation (WHO) First global hand hygiene improvement strategy 2002 Healthcare Infection Control Practices Advisory Committee Alcohol handrub standard of care Hand washing reserved for particular situations Pasteur and Lister Scientific proof of link 2000 Didier Pitier Improved hand hygiene compliance with alcohol handrub Every nurse ought to be careful to wash her Identified hands frequently connection during between the day Most significant legacy as hygiene and illness many years She hygienist and statistician before must Pasteur s ever be on germ guard theory against want of cleanliness

13 Lessons from the past Embedded in religious and cultural habits as measure of personal hygiene for centuries 1847 Ignaz Semmelweiss Father of hand hygiene Link between hand washing & spread of disease 1854 Florence Nightingale Pioneer of evidence based practice with hand washing at its core 2002 Healthcare Infection Control Practices Advisory Committee Alcohol handrub standard of care Hand washing reserved for particular situations 2005 World Health Organisation (WHO) First global hand hygiene improvement strategy Pasteur and Lister Scientific proof of link 2000 Didier Pitier Improved hand hygiene compliance with alcohol handrub

14 Lessons from the past 1847 Ignaz Semmelweiss Embedded in religious and cultural habits as measure of personal hygiene for centuries Hand hygiene compliance improved with alcohol hand rub Father of hand hygiene Link between hand washing & spread of disease This should be the standard of care with hand washing reserved for particular situations 2002 Healthcare Infection Control Practices Advisory Committee Alcohol handrub standard of care Hand washing reserved for particular situations 2005 World Health Organisation (WHO) First global hand hygiene improvement strategy 1854 Florence Nightingale Pioneer of evidence based practice with hand washing at its core Pasteur and Lister Scientific proof of link 2000 Didier Pitier Improved hand hygiene compliance with alcohol handrub

15 Lessons from the past Embedded in religious and cultural habits as measure of personal hygiene for centuries 1847 Ignaz Semmelweiss Father of hand hygiene Link between hand washing & spread of disease 1854 Florence Nightingale Pioneer of evidence based practice with hand washing at its core 2002 Healthcare Infection Control Practices Advisory Committee Alcohol handrub standard of care Hand washing reserved for particular situations 2005 World Health Organisation (WHO) First global hand hygiene improvement strategy Pasteur and Lister Scientific proof of link 2000 Didier Pitier Improved hand hygiene compliance with alcohol handrub

16 Present day issues 2012

17 Present day issues Hand hygiene compliance MRSA Clostridium Difficile Surgical site infection Intravenous line infection Ventilator-associated pneumonia Antibiotic resistance

18 Introduction of surveillance and targets In UK reducing risk of HCAI Clostridium MRSA bacteraemia Difficile has become national priority 1.3% 2% in in 2006 with the introduction of 0.4% 0.1% in 2011 surveillance and targets

19 Hand hygiene Most basic thing we can do but the easiest thing to get wrong! Mandatory training Monthly hand hygiene audits Strict dress code Bare below the elbow No jewellery Plain wedding band allowed No wrist watch No nail varnish

20 count MRSA 40 Quarterly MRSA bacteraemia 2001 to UCLH target 2011 = = Apr to Jun 2001 Jul to Sep 2001 Oct to Dec 2001 Jan to Mar 2002 Apr to Jun 2002 Jul to Sep 2002 Oct to Dec 2002 Jan to Mar 2003 Apr to Jun 2003 Jul to Sep 2003 Oct to Dec 2003 Jan to Mar 2004 Apr to Jun 2004 Jul to Sep 2004 Oct to Dec 2004 Jan to Mar 2005 Apr to Jun 2005 Jul to Sep 2005 Oct to Dec 2005 Jan to Mar 2006 Apr to Jun 2006 Jul to Sep 2006 Oct to Dec 2006 Jan to Mar 2007 Apr to Jun 2007 Jul to Sep 2007 Oct to Dec 2007 Jan to Mar 2008 Apr to Jun 2008 Jul to Sep 2008 Oct to Dec 2008 Jan to Mar 2009 Apr to Jun 2009 Jul to Sep 2009 Oct to Dec 2009 Number of MRSA bacteraemias Quarterly counts not validated

21 MRSA Elective admissions All patients screened in pre-admission clinic or on admission to hospital - MRSA Rapid Test (MRAP) If MRSA positive Prescribed 5 day course of antiseptic skincare Chlorhexidine body wash and shampoo Antibiotic nasal ointment - mupirocin Chlorhexidine body powder Planned surgery takes place on day 5 Chlorhexidine skin prep at operation site Teicoplanin 800mg IV + gentamicin 1.5mg/kg intra-op

22 MRSA Emergency admissions with unknown MRSA status Take MRSA screen MRSA Rapid Test (MRAP) Pre-op apply mupirocin to inside of nose Chlorhexidine skin prep at operation site Add Teicoplanin 400mg IV to conventional surgical prophylaxis intra-op Continue MRSA suppression post-op until screen reported

23 Clostridium Difficile Isolate only in presence of diarrhoea and until no diarrhoea for at least 48 hours Use soap and water for hands not alcohol gel Environmental cleaning with Chlorine Dioxide UCLH Target 2012 = 44 Careful Restrict antibiotic use of proton Financial prescribing pump penalty inhibitors of 1 million for every case over target Antibiotics 1st line: Metronidazole 400mg PO tds for days If poor response after one week change to Vancomycin 125mg PO qds for days 1st line in severe cases: Vancomycin 125mg PO qds for days

24 Surgical site infection National Hospital rates Surgical April site June infections 2012 account for up to 20% of all HCAI Hospital Spinal surgery: stay doubled 2% 5% (national 65 of patients million/year average undergoing 2.1%) UK surgical procedure develop Cranial a wound surgery infection : 1.7% (national average 1.9%) Skin prep = Chlorhexidine with Tint 2% chlorhexidine gluconate in 70% isopropyl alcohol with tint 2-3 fold decrease in wound infection rates when compared to aqueous povidone iodine Intra-op Surgical prophylaxis Single dose antibiotic adequate for most surgical procedures Post-op Wound dressing and suture removal protocols

25 Intravenous lines Improved design of vascular access devices Closed system Needle free Protocols Insertion Duration Line dressings Chlorhexidine impregnated

26 Visual Infusion Phlebitis (VIP) Score Early detection of IV site infection Insertion details Who inserted the line and when Daily observation of insertion site using VIP Score Cannula removal details VIP score Valid and reliable measure for determining when to remove a peripheral intravenous line

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28 Ventilator-associated pneumonia Elevation of head of bed to 30 o -45 o Reduce risk of VAP Internationally Respiratory infections accepted evidence-based 419% th largest ventilation-related contributor guidelines to to prevent HCAI in VAP UK Tubing management Replace when visibly soiled and according to manufacturer s instructions Prevent condensate entering airway Suctioning of respiratory secretions Wear examination gloves and decontaminate hands before and after suction procedure Oral hygiene Chlorhexidine mouth wash QDS Sedation holding Reduce duration of mechanical ventilation and risk of VAP Gastric ulcer and DVT prophylaxis Prevent complications of critical care

29 Prudent antibiotic prescribing Waiting Guidelines for objective on antibiotic data to diagnose infection Guidelines before treatment on best practice with antimicrobial in taking prescribing blood cultures help eliminate drugs for suspected help ITU acquired reduce infections risk of does contaminated their not misuse worsen samples mortality and might be associated with better outcomes and use of antimicrobial drugs The Lancet Infectious Diseases October 2012

30 Prudent antibiotic prescribing ICU Antimicrobial Guidelines Author(s) Owner/Sponsor Clinical Guideline - DRAFT Local use Dr R Hurley (on behalf of Critical Care Delivery Group) Prof P Wilson, Consultant Microbiologist Dr B Macrae, Consultant Microbiologist Dr N Shetty, Consultant Microbiologist Dr C Curtis, Consultant Microbiologist Dr S Morris-Jones, Consultant Microbiologist Ms P Panesar, Lead Pharmacist, Microbiology Critical Care Delivery Group Updated All ALWAYS prescriptions antimicrobial take cultures must guidelines have BEFORE a STOP for starting for ward ITU or REVIEW antibiotic patients date therapy Review By Date Responsible Director 1 st January 2013 (or earlier if new evidence becomes available) Dr R Hurley Chair of Critical Care Delivery Group Monitoring Committee Target Audience Critical Care Delivery Group Antimicrobial Usage Committee All medical, nursing and pharmacy staff Related Trust Documents/Policies Number of Pages and Appendices Equalities Impact Assessment Gentamicin dosing guideline Adults Neutropenic sepsis guideline Clostridium difficile treatment guideline Meningitis treatment Endocarditis treatment 7 pages Low

31 Informing patients and their relatives Not only the behaviour of health care professionals that determines the risk of HCAI but also the behaviour of patients and visitors to our hospitals

32 Thoughts for the future The HCAI basics Most is costly HCAIs will for continue occur the patient in to the be and key to for intensive infection health care care control organisations unit in (23.4%) the ITU Reducing Patients the Hand probability are hygiene sicker of HCAI will General Have continue more cleaning invasive to be of the a devices priority environment Need Isolating more worldwide hands infected on patients care We know they work!

33 Thank you