Bon Secours Hospital Cork Infection Prevention and Control in 2014 - - PowerPoint PPT Presentation

Bon Secours Hospital Cork

• Infection Prevention and Control in

2014 and Beyond

• Catriona Murphy.

Presentation Outline

• Infection Prevention and Control

Challenges for Primary Healthcare in 2014 – what are they and how best to deal with them.

• Back to Basics.

Infection Prevention and Control Challenges for Primary Healthcare in 2014

• 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.

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 times- regardless 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 all 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
• rganisation 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.

Infection Prevention and Control Challenges for Primary Healthcare in 2014

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 patients 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 patients 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.

WHO 5 Moments of Hand Hygiene

Standard Principles: Hand Decontamination (WHO 5 moments)

• Immediately before every episode of direct patient contact
• r 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
• rganisms 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

• Would you use an Airline that had 90%

compliance with Safety Procedures??

• Hand Hygiene is a patient safety issue.

Observational Hand Hygiene auditing in BSH Cork:

Overall Rate of compliance with hand hygiene per category of staff 2010 to 2013

0% 20% 40% 60% 80% 100% Compliance 2010 Compliance 2011 Compliance 2012 Compliance 2013 Compliance 2010 43% 61% 10% 51% 29% Compliance 2011 77% 88% 65% 63% 78% Compliance 2012 85% 90% 77% 85% 86% Compliance 2013 88% 94% 85% 89% 90% All Staff Nurses Doctors Auxilliary Other Health Care

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

Skin Integrity and Immunisation

• Cover all cuts & abrasions with a

waterproof dressing

• Hepatitis B vaccination

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 →

Protective Clothing

→ Masks: Standard surgical mask Fluid shield resistant mask Transmission based precautions e.g FFP3 mask

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

• f 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

• r excretions
• r
• Wear a long-sleeved fluid-repellent gown if there is a risk
• f 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)

FFP3 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.!

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.

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
• 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/cg139

• 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