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

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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)

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

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HCA Bloodstream infections- non-intensive care

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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

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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

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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

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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…

jferguson@hnehealth.nsw.gov.au

Thank you

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