Bon Secours Hospital Cork Infection Prevention and Control

Bon Secours Hospital Cork

• Infection Prevention and Control and it’s challenges! • Catriona Murphy. 2015 Presentation

Presentation Outline • Infection Prevention and Control Challenges for Primary Healthcare in 2015 – what are they and how best to deal with them. • Back to Basics.

Infection Prevention and Control Challenges for Primary Healthcare in 2015 • Multi-Drug Resistant Organisms (MDROs). • Antimicrobial resistance is a growing and significant threat to public health that is compromising our ability to treat infections effectively.

• Antibiotic resistance is a natural phenomenon in which bacteria evolve and develop traits which enable them to survive exposure to antibiotics. In the past, the problem of resistance to antibiotics was addressed by developing new antibiotics to which clinically important bacteria were not (at least initially) resistant.

Antibiotic Resistance 45% Meticllin-resistant Staph aureus (MRSA) 35% Vancomycinresistant enterococcus (VRE) Quinolone-resistant E coli 30% 25% 20% 15% Penicillin-resistant Strep pneumoniae 10% 5% 11 * 20 10 20 09 20 Year 20 08 07 20 06 20 05 20 04 0% 20 Proportion resistance 40% Erythromicin resistant S pneumoniae

MDROs • Methicillin Resistant Staphylococcus aureus (MRSA) • Vancomycin Resistant Enterococcus (VRE) • Extended-spectrum Beta Lactamase (ESBL) such as MDRO E Coli, Klebsiella pneumonia • Carbapenem resistant Enterobacteriaceae (CRE). • And many more to come…….

MDROs-management in Primary Healthcare • Carriage of MDRO is asymptomatic and therefore many carriers go undetected. This means that appropriate Infection Control practices, must be employed for all patients, not just for those known to be infected or colonised with MDRO.

MDROs-management in Primary Healthcare • Standard Precautions should be implemented by all healthcare workers when dealing with all patients at all timesregardless of whether they are infected or colonised with MDRO.

MDROs-diagnosis • Patients may be diagnosed with MDRO while in hospital – high risk patients or patients admitted to high risk areas are screened. • MDRO may be isolated from a clinical sample- eg urine. • Will be educated by IPCN if diagnosed while in hospital – may not always recall information. • Written and verbal information given.

MDROs-diagnosis • Information on all MRDO available on www. hpsc. ie/topics • Patient should be informed at next visit.

MDROs-Who is at Risk? • Patients transferred from hospitals outside Ireland • Patients admitted from other health care organisations, hospitals or nursing homes • Patient who had been an inpatient in another health care organisation within the previous twelve months. • Patients with long term in-dwelling devices e. g. supra-pubic catheter, urinary catheters, Peg tubes, long-term rehabilitated patients with ongoing contact with health care personnel (Day care, Respite, Home Help, Public Health, GP for dressings etc), .

MDROs-Who is at Risk • Identify high risk patients – if pyrexial send sample and consider appropriate antibiotic.

MRSA • MRSA- identify high risk patients and encourage screening if scheduled for surgical procedure- may need to be decolonised pre-op.

Patients deemed high risk for MRSA should be considered for preadmission screening & decolonisation particularly if for planned surgery • BSH offers a preadmission screening clinic for all patients undergoing orthopaedic implants & other surgeries • It is available to all high risk patients • Cost of € 120: covers initial screening, decolonisation treatment and follow up screening • Please contact the IPCN's at 021 4801619 if your patients would like to avail of this service • Patients from Kerry can be facilitated in BSH Tralee by contacting the IPCN's in Cork

MRSA Screening • Both nostrils (1 swab) • Perineum • Wounds, sites of damaged or abnormal skin (leg ulcers) and sputum if expectorating • Medical device sites e. g. insertion sites of intravenous catheters, drains, peg tubes, catheter urine samples. • Throat, both axilla and groins in KNOWN MRSA colonised patients and those who give a history of MRSA • All previously positive sites if still existent.

Clostridium difficile. • Clostridium difficile –Exposure to antibiotics- pre eminent factor. • 90% of nosocomial CDI occurs during or shortly after antibiotic therapy ( can occur up to 10 weeks after commencing an antibiotic) • It is essential that Clostridium difficile infection is considered as a differential diagnosis in all patients 2 years and older presenting with diarrhoea both in hospital and community settings and that specimens are sent in a timely fashion.

Infection Prevention and Control Challenges for Primary Healthcare in 2015 Patients now • Have Shorter hospital stay. • May be discharged with devices in situ. • Need suture removal and dressing changes. • May have minor surgical procedures carried out in your Practice. • Have Complex care increasingly delivered in the community

Urinary Catheters • Aseptic Technique for Insertion • Hand Decontamination and Clean Gloves for Manipulation. • No break in the connection between the catheter and the bag.

Urinary Catheters • All catheterisations carried out by healthcare workers should be aseptic procedures. After training, healthcare workers should be assessed for their competence to carry out these types of procedures.

When changing catheters in patients with a long-term indwelling urinary catheter: • Do not offer antibiotic prophylaxis routinely • Consider antibiotic prophylaxis for patients who: • have a history of symptomatic urinary tract infection after catheter change or • experience trauma during catheterisation (Haematuria after catheterisation or two or more attempts of catheterisation)

Urinary Catheters • Catheter insertion, changes and care should be documented • Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a patient's catheter, and must decontaminate their hands after removing gloves • Patients managing their own catheters, and their carers, must be educated about the need for hand decontamination before and after manipulation of the catheter

Urinary Catheters • Urine samples must be obtained from a sampling port using an aseptic technique.

Central Venous Catheters (CVC)

Vascular Access Devices • Hand decontamination before accessing or dressing a vascular access device (NICE 2012) • Aseptic technique for vascular access device catheter site care and when accessing the system (NICE 2012) • Avoid the use of multi dose vials, in order to prevent contamination of the infusates (NICE 2012)

Surgical Procedures • To reduce the risk of Surgical Site Infection (SSI) BSH has introduced a Surgical Site Care Bundle.

Surgical Site Care Bundle • Ensure skin is cleansed with 2% Chlorhexidine/70% Isopropyl Alcohol and allowed to dry. • Ensure patient’s body temperature is maintained throughout the procedure (35. 5 up to 4 hours post op). • Ensure prophylactic antibiotics are prescribed per local policy and administered within 60 minutes prior to incision. • Ensure patient’s blood glucose level is within defined limits throughout the procedure. • Wound dressing should not be disturbed for 48 hours postoperatively.

Patients having Surgical Procedures in Primary Health Care. • Be aware of the Care Bundle and how it may apply in your setting. • What skin prep is being used- is it allowed to dry prior to incision? • Is the patient warm? • Are they diabetic and what is their BSL? • How long is the dressing left undisturbed?

Patients having Surgical Procedures in Primary Health Care. • Aseptic technique. • Hand Hygiene.

How Best to Manage these Challenges? ? • • Back to Basics…………. Hand Hygiene. Standard Precautions Environmental and equipment cleaning. Antibiotic stewardship Vaccination. Stay Informed.

WHO 5 Moments of Hand Hygiene

Standard Principles: Hand Decontamination (WHO 5 moments) • Immediately before every episode of direct patient contact or care, including aseptic procedures • Immediately after every episode of direct patient contact or care • Immediately after any exposure to blood or body fluids • Immediately after any other activity or contact with a patient's surroundings that could potentially result in hands becoming contaminated • Immediately after removal of gloves. (NICE 2012)

Hand Decontamination • Decontaminate hands at point of care with an alcohol hand rub except in the following circumstances, when liquid soap and water must be used: • When hands are visibly soiled or potentially contaminated with body fluids or • Where there is potential for the spread of alcohol-resistant organisms such as Clostridium difficile (NICE 2012) • Hand hygiene technique with alcohol rub 20 – 30 seconds • Hand hygiene technique with soap and water 40 – 60 seconds

• Observational Hand Hygiene Auditing Commenced in BSH- 2008. • All Wards self audit – monthly. • If compliance is less than 90%- weekly auditing until sustained above this threshold. • IPCN’s audit randomly to validate data submitted. • Medical & Surgical staff audited on ward rounds. • All staff attend Hand Hygiene education programme. • Marked improvement in compliance since auditing commenced.

Hand Hygiene Compliance • If compliance is less than 90%- weekly auditing until sustained above this threshold for 4 consecutive weeks • Must aim for 100% compliance 100% of the time. • Do you think 100% compliance is an unrealistic target?

Hand Hygiene Compliance • Hand Hygiene is a patient safety issue.

Hand Decontamination Technique

Standard Precautions Standard precautions are designed to reduce the risk of transmission of micro-organisms from known and unknown sources of infection. These precautions apply to the care of ALL patients regardless of their diagnosis or presumed infection status. They apply to blood and all body substances, non intact skin and mucous membranes.

Standard Precautions • • • Skin Integrity & Immunisation Hand Hygiene Personal Protective Equipment (PPE) Sharps Management (Sharps Directive 2010/32/EU) Blood/ Body fluid exposure (needle stick injury / splash Occupational Health) • Blood and Body fluid spillage • Cleaning and environmental decontamination

Use of Personal Protective Equipment (PPE)

Protective Clothing • Aprons/Gowns (single use) • Gloves • Facial protection • Eye protection (risk of splash with body fluid / blood) • Masks →

PPE: Gloves • Gloves for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or to sharp or contaminated instruments. • Gloves must be worn as single-use items. • Gloves must be changed between caring for different patients, and between different care or treatment activities for the same patient.

PPE: Plastic Aprons & Gowns • Wear a disposable plastic apron if there is a risk that clothing may be exposed to blood, body fluids, secretions or excretions or • Wear a long-sleeved fluid-repellent gown if there is a risk of extensive splashing of blood, body fluids, secretions or excretions onto skin or clothing. (NICE 2012) • Use them as single-use items, for one procedure or one episode of direct patient care • Ensure they are disposed of correctly (NICE 2012)

PPE: Face Masks & Eye Protection • Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. • Respiratory protective equipment, for example a particulate filter mask, must be used when clinically indicated

PPE: Face Masks & Eye Protection Standard Surgical Mask (Flu, Neisseria Meningitis)

FFP 3 or High Filtration Mask (Pul TB: Measles & Chicken Pox (non immune staff))

Sharps Management Use sharps safety devices if a risk assessment has indicated that they will provide safer systems of working for healthcare workers, carers and patients (NICE 2012) European Sharps Directive 2013

Sharps Management High Risk Procedures include: • Intra-vascular cannulation, venepuncture and injection. Devices involved in these high risk procedures include: • IV cannulae • needles and syringes • winged steel needles (known as butterfly needles) • phlebotomy needles (used in vacuum devices).

Sharps Management • Sharps should not be passed directly from hand to hand, and handling should be kept to a minimum. (NICE 2003, amended 2012) • Used needles must not be bent or broken before disposal & must not be recapped

Sharps Management Sharps Containers: • Must be located in a safe position that avoids spillage, is at a height that allows the safe disposal of sharps, is away from public access areas & is out of the reach of children • Must not be used for any other purpose than the disposal of sharps • Must not be filled above the fill line & is disposed of when the fill line is reached • Should be temporarily closed when not in use • Should be disposed of every 3 months even if not full, by the licensed route in accordance with local policy. (NICE 2012)

Waste Disposal • Healthcare waste must be segregated immediately by the person generating the waste into appropriate colour-coded storage or waste disposal bags or containers defined as being compliant with current national legislation and local policies. (NICE 2012) • Healthcare waste must be labelled, stored, transported and disposed of in accordance with current national legislation and local policies. (NICE 2012) • Educate patients and carers about the correct handling, storage and disposal of healthcare waste. (NICE 2012)

Decontamination of Equipment & a clean environment ↑ • Equipment used in health care may be designated as single use, single patient use or reusable multi-patient use – always read the label if you are not sure if an item can be reused • Any equipment not designated as a single use item must be made safe following use to prevent micro-organisms being transferred from equipment to patients and potentially resulting in infection. • Cleaning is the critical element of the process and should always be undertaken thoroughly regardless of the level of decontamination required.

Decontamination of Equipment. • All items that are used between patients must be cleaned between patients. • Devise a cleaning list to ensure that all equipment is also cleaned weekly.

Vaccination • Encourage vaccination for high risk groups. • Flu Vaccination- Encourage your colleagues – including the GP. • Flu Vaccination is highly recommended for all Health Care Workers. • Mandatory in some countries/states. !

Stay Informed www. hpsc. ie Health Protection Surveillance Centre. Produce weekly reports on notifications of infectious diseases in Ireland. Is helpful to know what is circulating in the community.

Week 1 – 37 2015 Example of Notifications Mumps – 1, 638 (283 -2014) ↑ 1, 351 Norovirus – 1, 089 (469 -2014) ↑ 600 Rotavirus – 4, 048(1, 688 -2014) ↑ 2, 380 CDI-1, 378 (1, 238 -2014) ↑ 138

Summary • Standard Precautions- all patients at all times. • Hand Hygiene- WHO 5 Moments. • MRSA- identify high risk patients and encourage pre-op screening • C diff – consider as diagnosis if presenting with diarrhoea within 12 weeks of antibiotic treatment. • Equipment and environmental cleaning- consider a sign of sheet for weekly cleaning. • Vaccination- encourage patients and HCWs

Questions? ? ?

References • • CDC (2002) Guideline for Hand Hygiene in Health-Care Settings European Antibiotic Awareness Day (EAAD)-(2014) Key Messages- Public Health England National Institute for Health and Clinical Excellence (2012)Infection Prevention and control of healthcare –associated infections in primary and community care: NICE clinical guideline 139 (March 2012) guidance. nice. org. uk/cg 139 Royal College of Nursing (2012) Essential practice for infection prevention and control Guidance for nursing staff • WHO (2005) Guidelines on Hand Hygiene in Health Care (Advanced draft) • WHO (2006) www. who. int/gpsc/tools/Five_moments/en/ • SARI (2005) Guidelines for Hand hygiene in Irish Health Care Settings • HPSC- (2014)Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO)excluding MRSA in the healthcare setting