Risk Management Summit

Infec&on Control in Healthcare 09-‐05-‐12

Andreas Voss, MD, PhD 1

Welcome to the hospital

Despite our best intentions …

… not all problems are preventable

1 in 10 pa&ents “gets hurt”

Control of antibiotic use

Control of antibiotic use

New an&bio&cs

New

MDR

-‐MO’s

Spread of multi-resistant pathogens



Environmental dissemination of NDM-1

Walsh et al. Lancet ID 2011;11:355

Environmental dissemination of NDM-1: NDM-1 positive samples


blaNDM-‐1-‐posi&ve bacteria were recovered from 12 of 171 seepage samples and 2 of 50 water samples.

used for drinking and food prepara&on

Green squares = 51 seepage

samples where genes were found (underes&ma&on)

Environmental dissemination of NDM-1: NDM-1 positive samples

•  20 NDM-‐1-‐posi&ve strains were present in the samples, including: –  Enterobacteriaceae, Citrobacter freundii, E coli, and K pneumoniae (commonly carry blaNDM-‐1)

–  Shigella boydii, V cholerae, Aeromonas caviae.

–  Various non-‐fermenters not previously reported to carry blaNDM-‐1: Pseudomonas aeruginosa (and other P. spp), Sutonella indologenes, Stenotrophomonas maltophilia, Achromobacter spp, and Kingella denitrificans.


New Delhi metallo-beta-lacatamse

Not a “superbug” (= single bacterial species) but a transmissible gene1c element

encoding mul&ple resistance genes

Estimated income for India by 2012: US$2 billion

Connell Tourism Mangement 2006;27:1093



Do you enjoy traveling? ESBL bacteria in patients with travellers’ diarrhoea

•  ESBL significantly more frequent in travelers returning from Middle EAST, India or Asia

Tham, SJID, 2010, 275

Food as a source of MDR-mo’s

ESBL +

Yes, I am mul&-‐drug resistant!

ESBL in chicken, meat and humans

•  A high prevalence of ESBL genes was found in raw chicken meat (79.8%).

•  Gene&c analysis showed that the predominant ESBL genes in chicken meat and human rectal swab specimens from the same area were iden&cal. These genes were also frequently found in human blood culture isolates.

•  Typing results of Escherichia coli strains showed a high degree of similarity with strains from meat and humans.

Overdeveste et al EID 2011;17:1216

New sources of MRSA

Pigs & calves



Personnel Protective Equipment

In the post SARS era …

… we tend to forget while more might come !

first MRSA isolate was recovered within 72 h of ICU admission

first MRSA isolated ager 72 h of ICU admission P < 0.01

Pre-‐SARS Post-‐SARS

SARS

Clin Infect Dis 2004;39:511-‐516

MRSA: import vs acquired

Multi-vial device: re-capping



Multi-vial device: sealed ?

Meet your new surgical team

Jane Tom Leonardo

Disinfec&on and steriliza&on Hospital Cleaning

•  In-‐ or out-‐sourced •  Detergent vs disinfectants •  Standardized vs manual (beds, scopes, …)

•  Costs vs quality

HCWs & Infection Control

Infec&on control



HH compliance in the Netherlands

Disregard to guidelines

What is the problem?

If hospital bugs would look like this – compliance with hand hygiene would be 100% Dangerous micro-organism: MRHW

Mul&-‐Resistant Health-‐care Worker

a

MRHW

•  Resistant to good advice

•  Allergic to (professional) guidelines

•  Non-‐compliant with IC measures

•  Blind to HAIs (especially their own)

•  Other prioro&es

How to change HCWs behavior?

•  Just presen&ng something “new” or “beker” will not change their behavior …

•  We should learn from marke&ng professionals

•  “ People are willing to change of they feel: good, flakered, powerful or sexy” not when bombareded with facts (Hodgkin 1999)



Gimme an Rx! Cheerleaders Pep Up Drug Sales

Onya, the Redskins cheerer (who asked that her last name be withheld, ci&ng team policy), has her picture on the team's Web site in her official bikini-‐like uniform and also reclining in an actual bikini. Onya, 27, who declined to iden&fy the company she works for, is but one of several drug representa1ves who have cheered for the Redskins

… my new infection control nurses

A&F stole my idea … Try to find out what your customer wants!

² Many &mes we offer our help assuming that we know what HCWs need and how we can help them … whereas our assump&ons and reality frequently differ !

Poli&cally incorrect, biased and personal

They old measures work !

Hand hygiene With bed-‐side dispensers and pocket-‐bokles any excuse to not reach out for the alcoholic handrub is gone. Thus, …. “Just do it!” Furthermore, hand hygiene should be seen as only one of the classical preven&ve measures all of which deserve our aKen1on and HCW’s compliance.



Surveillance

HAI-‐surveillance Internal quality versus public repor&ng. Repor&ng real HAI rates (e.g. VAP) instead of low public rates and crea&ng new diseases such as ven&lator-‐associated trachea-‐bronchi&s

GI Infections

GI-‐tract infec&ons Increasing rates of C. difficile and norovirus. With regard to norovirus: impact on the pa&ent outcome as well as the overall possibility to deliver care is frequently underes&mated

The unnecessary and wrong use of an&bio&cs needs to stop. In the light of the emergence of MDR-‐m.o.’s we can not afford to booster the trend by selec&ng more resistance and waist the limited an&microbials we have during indica&ons that need no or other an&bio&cs.

Fighting community and zoonotic pathogens

CA-‐MRSA, LA-‐MRSA, NDM-‐1 & Co. Emerging pathogens and mobile transmissible elements through the food-‐chain/bio-‐industry or from travellers to countries with poor sanita&on will be a major challenge to infec&on control

Influencing public and political expectations

YES to “zero tolerance” but NO to zero infec&ons! Zero HAIs is impossible. This gives consumers a completely wrong picture and encourages poli&cians & insurances to come up with unwanted rules.



Hospital-structure

Up-‐hold and improve hospital structure and “HCW to pa&ent ra&o’s” to allow infec&on control measures to be applied, and improve hospital design to allow op&mal workflow.

Commerce

Outsourcing of clinical microbiology and infec&ous diseases services are contra-‐produc&ve to what makes Infec&on Control work in countries like the NL: direct accessibility and integra&on (within the healthcare sevng) of all infec&ous diseases services

Culture change

Why do healthcare workers believe that if they adhere to 70% of the rules that they are doing an outstanding job? In other industries that is a reason to get fired!

Behavioral science

How to integrate behavioral science into infec&on control educa&on? We will not change HCWs behavior by con&nuously blaming them for what they do wrong.

Final wisdom of behavioral science

“Before you cri&size someone you should walk a mile in their shoes …

… that way, if he gets angry, he'll be a mile

away, and you have their shoes ”

Homer Simpson

Risk Management Summit

Technology

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