Denise M. Bleak MSN, PHN, CIC...uninfected patients 3. In groups: Discuss how to prevent recurrence...
Transcript of Denise M. Bleak MSN, PHN, CIC...uninfected patients 3. In groups: Discuss how to prevent recurrence...
Denise M. Bleak MSN, PHN, CIC Infection Prevention Specialist
Henry Mayo Newhall Memorial Hospital
“Seek and Destroy” strategy: Plan to neutralize transmission factors for Acinetobacter
2. Remember the risk factors for Acinetobacter and other organisms in uninfected patients
3. In groups: Discuss how to prevent recurrence of the infection in susceptible patients, and prevent further outbreaks,
Plan a outbreak control strategy using SWAT and war room strategy.
Distinguish between routine control measures for transmission of infection, and outbreak control measures.
Review methods of surveillance to use when determining that an outbreak exists in the healthcare facility or setting.
Discuss physician responses to the interventions used by patient care staff to control the outbreak: specifically Pharmacy, Nursing, and peers.
OutbreakPatient mortalityRoot cause analysis
• What is it• What happened• Transmission of the organisms and accelerating
factors• Action and mitigating factors
Reporting the Outbreak
“There is no greater calamity than lightly engaging in war. Lightly to engage in war is to risk the loss of our treasure.”
Sun Tzu, The Tao of War (Art of War), China
Here we issue a proposal for change
in tolerance levels in behavior in “noise”
Further explanation…
Infection preventionists issue a proposal for change
in tolerance levels …………….Zero in behavior ………………..Compliance in “noise”, for sensitivity to indicators
NEXT Review a few famous war battles and participants or leaders of war
F. Nightingale in a hospital some miles from the battlefield, lowered the rate of death and increased survival after injuries.
M. Seacole treated the soldiers on the field, prevented cholera, and also started a hospital unit near the battlefield.
Neither could work together.
http://www.spartacus.schoolnet.co.uk/WARcrimean.htm
Alexander’s horse, Bucephalus, whom he had ridden into battle in Greece and Persia, died in battle in India.
Alexander conquered much of the known world in the years 300-323, until his death.
He rode to Babylon, despite warnings not to travel (ravens fighting, men being sacrificed, even imbibing in poisoned drink).
Then he died.
President Lincoln reframed Civil War conflict from a battle between the Industrial Northern States and the Southern Agrarian States
to the conflict between right and wrong, and the moral imperative.
Lincoln died …….. defending the Union,
defeating slavery.
Rename the conflict to a battle listing the highest objective possible
“We win, they lose”.
“Of the four wars in my lifetime, none came about because the US was too strong”.
By “all-out fight”, Reagan did not mean military action.http://www.ashbrook.org/publicat/onprin/v10n6/garrity.html
Quarantine and vaccination to prevent smallpox: proven strategy
Modern Superheroes’ save the world!
May over-idealize the situation
Comic: Inside the Outbreaks: the Epidemic Intelligence Service
Don’t wait for the Emergency to be declared…Incident Command may do this for you.
It is not always an “incident” and may not fit into ICS: Emergency Preparedness is robust.
Modern management: lateral and horizontally integrated chains of command: ICS is not this model.
Seminal article AJIC, 2010:
“Barriers to implementing infection prevention and control guidelines during crises”
This is about experiences of health care professionals from dealing with SARS, C difficile, Avian flu and rubella
http://www.ajicjournal.org/article/S0196-6553(10)00454-2/abstract
4 generic barriers identified: lacking
� Imperative, or precise wording;� Easily identifiable instructions particular to
each profession; � Concrete performance targets;� Timely and adequate guidance on personal
protective equipment and other safety measures.
Wireless technology to control outbreaks
Los Angeles County Syndromic Surveillance System involves Infection preventionists, Public Health epidemiologists, Emergency departments, Admitting Departments, local Pharmacies, Physician offices and rapid care centers.
Quick group response
Neutralize threat
Protect surroundings
Clear command
Armed and protected
Media and influence on belief systems about the outcome of an infectious outbreak
Web page for Armor games :
“1 minute after the outbreak, 100 infected. 10 minutes after the outbreak: 100,000 infected”.
The Hot Zone: Ebola and SWAT responses
UCSF widely copied (13 pages)
Healthcare Quarterly (12) 1, 2009: 30-32:
ICES Report: Five Policy recommendations from Toronto's SARS outbreak to improve the safety and efficacy of restrictions on hospital admissions to manage infectious disease outbreaks.
Establish or verify the diagnosis and case(s).
Develop a case definition
Confirm the existence of an outbreak
Case finding
Compare current and baseline incidence
Notify Infection Control Chairman, Administration HMNMH, DHS
Implement control measures (isolate, culture, line list) based upon the magnitude of the problem
Characterize the outbreak according to person, place and time
Formulate a tentative hypothesis as to the likely cause
Test the hypothesis by utilizing an epidemiological approach• Case control study• Comparisons of organisms from similar cases
Demonstrate significant differences between cases and contracting population
Institute additional Infection Control measures.
Evaluate effectiveness of control measuresReport periodically and when concluded
1. What is Acinetobacter?
2. How does Acinetobacter resemble, and differ from, other bacterial colonizers in the inpatient unit?
“Because colonization is the rule and infection is the exception, colonized patients have no associated physical findings.
Patients with Acinetobacter infection have signs and symptoms related to the organ system involved, ie, wound infection, episodic outbreaks of nosocomial pneumonia, CAPD-associated peritonitis, nosocomial meningitis, or catheter-associated bacteruria.”
http://emedicine.medscape.com/article/236891-overview
1. What is Acinetobacter?
Gram negative Enterobacteraciae species
Several varieties: can be M D R O
Acinetobacter (not “Assetobacter” or “Acnebactro” or even “Ascenobacter”)
What does it need to flourish?
Food sourceWater sourceGrowth medium- also lives on surfacesBreaks in transmission control
APIC Guide to Multi-resistant Acinetobacter baumanii
With grateful appreciation to the Quality Compass program,The Health Advisory Board, 2008.
How does Acinetobacter resemble other bacterial colonizers in the inpatient ICU?
• Gram negative colonizing bacteria include Enterobacteraciae, and also Pseudomonads, etc.
• Remember the KES group acquires MDR traits: Klebsiella Enterobacter Serratia
Recall the immediate threat of “CRE” aka Carbepenem Resistant Enterobacteraciae.
How does Acinetobacter differ from other bacterial colonizers in the inpatient ICU?
• Intermittently seen, can live in situ or on surface• Seen in persons going back and forth to other
residential care and the hospital• Culturing of environment may or may not locate
any reservoir of Acinetobacter• Rapid spread within a few hours to same or other
sites in susceptible persons
Chain of Transmission:
Reservoir of Acinetobacter in ICU
Infectious Agent
Susceptible Host
Route of Transmission
Transmission-based
Evidence-based (how is the organism getting out of/being expressed by the index case)
Body Substance Isolation: could be involved here i.e.. Droplet precautions for novel infectious entities in tandem with this pathogen.
Contents:� Patient Safety/TJC mandates on outbreaks,
influx and Infection Prevention and Control
� Graphs and relevant data� Drugs and changes in therapeutics� Few, then progress to no cases� Is it truly gone? Look back (could be
hiding…)
Part of this success was our attention to Patient Safety.
Routine prevention of infections is centered around reliable, repeated
• routine surveillance, • control and • reporting systems.
Also mandated to plan for an influx of unexpected infection.
HAI’s are preventable20-30% can be preventedStructured, proactive and resilient
surveillance Identify outbreaks: robust identification
of new bacterial…pathogens
2010 Joint Commission Infection Prevention & Control Handbook for Hospitals
Graph of the outbreak
Simply Stated:
There are too many patients with the organism within a short period of time-
therefore, some cause or pressure is forcing the organism to multiply and infect several patients in a narrow area.
“Why is it a problem now?”
The reasons for infections are known,
such as lack of hand washing, failure to clean equipment and the ineffectiveness of isolation systems to confine the organism.
Also, there may be pressure for an organism to have increased bacterial resistance to selective antibiotics.
It places us on high alert when an
outbreak occurs. This puts into effect some
measures that would be considered
extraordinary, such as notification to the
Health Department and Administration.
2009
Don’t let Acinetobacter
become established
BATTLE CRY
One multisystem failure mortality, others recovered.
Number of cases in 6 weeks: 9, compressed into onset dates of three to four weeks.
Is it truly gone, or just hiding?What does APIC Guide say about this???
Ask anyone who was in the war room
The atmosphere was electric.
This energy was maintained in the Environment of Care during the outbreak.
How battle works & the study of actions in a war are useful.
Generals, lieutenants and soldiers are all used in varying ways.
Command hierarchy: chain of command.• (Method in which orders are passed and carried
out.)• Other military concepts are Rank, Accountability,
Feedback and Decision making.
4 generic barriers identified: (recall?)
� lack of imperative or precise wording;� lack of easily identifiable instructions
particular to each profession; � lack of concrete performance targets;� lack of timely and adequate guidance on
personal protective equipment and other safety measures.
“Scatter shot”: covering a wide range in a random way. Indiscriminate.
“Whimsy”: an odd and fanciful idea. A whim.
Democracy: a common set of agreed upon rules for a meeting to make the members comfortable and make the meeting run well.
Dictatorship: overbearing absolute authority of one individual, the leader.
How did “RANK”, “Accountability”, “Feedback” and Decision making apply to the following?
• Variance in cleaning by EVS• Hand hygiene by physicians• Status of screening cultures on all patients• Visitor control and restrictions• Information about isolation in entire unit• Wipes used on patients during outbreak
“Experience and evidence have taught us that the core components of infection prevention and control are
consistent application of proper hand-hygiene measures,
maintenance of a clean environment, use of barriers where appropriate, and prompt identification of patients at high risk of
colonization with a transmissible microorganism.”
Johnston BL and Bryce E. Hospital infection control strategies for vancomycin-resistant Enterococcus, methicillin-resistant Staphylococcus aureus and Clostridium difficile. Can Med J.180(6): 627-631. March 17, 2009.
Wireless technology to control outbreaksQuarantine and vaccination to prevent
smallpox John Snow and the Control of Cholera: the
Broad Street pump Inside the Outbreaks: the Epidemic
Intelligence ServiceWest Nile Virus: 1937 (one woman) to 2010,
world wideAnthrax vs. science, intentional
contamination. 2001 to present.
Fiction
Andromeda Strain, Michael CrichtonOutbreak and Contagion, Robin CookThe Stand, Steven KingPandemic, Daniel Kalla
Non-Fiction
Scurvy and saving lives of sailorsCholera in London and elsewhere1918 Spanish influenza outbreakHerpes simplexHIV/AIDSPolioCurrent battles raging to prevent patient
injury and death in hospitals in US
1 General2 Lieutenants4 Soldiers
Two sets of questions
Fifteen Minutes (sharing for five minutes)
On Day 1, a new Resistant organism is seen, in a given patient care unit, in one individual who has never had this infection.
Infection is presentNever colonized with organismOrganism is resistant and one that we
commonly place into isolation
Teams are assigned. General, read the following to the troops.
Now three additional patients near the first patient have also grown out isolates from body sites of the Resistant organism. It is Day Three from the first culture. All patients are alive and remain on the same unit.
Generals: finish the first Question. Sum up.
1. What is your battlefield plan?
Did you seek and destroy? How?
2. Was your battle group involved in neutralizing transmission factors?
What was different as compared to the everyday work?
New GeneralNew Soldiers (not the same people who
took orders. Switch the lieutenants and soldiers please.
QUIETLY
Now five patients, all from the same unit over 7 days, all have the Resistant organism in multiple sites.
1. With whom should the General be meeting?
Everyone suggest who is involved in the meeting.
2. When should the first meeting with stakeholders in the facility take place?
3. Did “everyone” get to contribute to idea-forming about how to stop this organism?
Are the groups clear that the outbreak continued even though the first group worked on it?
Is it logical to expect that an organism will respond immediately to actions taken to neutralize it or destroy it?
Generals, report:
Who met?
What was the main topic?
Who else was brought in to assist with the outbreak?
Is Emergency management involved?At what point did you reveal the outbreak to
the community, facility or physicians? Is the PIO involved? Is the Administrator involved?
Review content here to determine if you followed the OUTBREAK POLICY
UCSF widely copied (13 pages)
Healthcare Quarterly (12) 1, 2009: 30-32:
ICES Report:
Five Policy recommendations from Toronto's SARS outbreak to improve the safety and efficacy of restrictions on hospital admissions, to manage infectious disease outbreaks.
1 restrict non-urgent admissions for a reasonable time
2 public information campaigns to inform patients to seek care when necessary should be part of the campaign
3 develop urgent admission criteria for the most common surgical conditions
4 recognize limited impact of creating restrictions on surge capacity
5 implement strategies that protect access to highly regionalized tertiary care programs
1. Restrict non-urgent admissions2. Inform patients to seek care3. Develop urgent admission criteria4. Limit surge capacity5. Access protection to tertiary care
R I D L A
Popular- consider Return on Investment
• Effective?• Controlled?• Evidence-based?• Expensive?• Entertaining?
No vaccine against this organisms:
that is counter to usual military measures for all trainees during basic training
Two good recent articles:1. Nosocomial transmission of Acinetobacter
baumanii in Iraq at military presentation. IDSA07-0060_WhitmanTimothy_1.pdf(page 1 of 16)
http://www.military.com/features/0,15240,162552,00.html….about Acinetobacterinfections in military hospitals
Military demonstrating tactics to fight infections
By November 2008 cases were diminishing.
ICU was out of group isolation.
By December 2008 there were no new cases of Acinetobacter
To date:
There has been no established colonization nor prolonged incidence of this organism in the ICU or on any nursing unit.
Clostridium difficile increase
Associated decrease following control measures
Reference List attached to handout.
The joy of living
is
Living.
-Reich