Doctors induction 2012

Infection Control and Infection Control and Antibiotic PrescribingAntibiotic Prescribing

Dr A. Keith MorrisDr A. Keith Morris

Overview

Transmission Based PrecautionsPeripheral Vascular Catheter (PVC)C. DifficileHand decontaminationDeath certificationCommunicationOHSAS & needle stick injuriesMRSA screeningAntibiotic prescribing

What is NHS Fife doing to prevent HAI?

NHS Fife is doing alot and you are expected to do your part

Process will be different in Fife Infection Control Manual on

intranet Ward Boards Antibiotic management Protecting YOU from the patient

and the patient from YOU

Infection control Infection control terminologyterminology

Older terms that now should not be usedOlder terms that now should not be used- “Universal precautions”- “Universal precautions”- “Enteric precautions”- “Enteric precautions”

Standard infection control precautions

Standard precautions

Transmission based precautions

Transmission based Transmission based precautionsprecautions

SupplementSupplement standard precautions. standard precautions.

specify precautions to individual patients specify precautions to individual patients documented/suspected of being infected or documented/suspected of being infected or colonised with highly transmissible and/or colonised with highly transmissible and/or epidemiologically important pathogens or epidemiologically important pathogens or clinical clinical syndromessyndromes

Three typesThree types

ContactContact

DropletDroplet

AirborneAirborne

Transmission Based Transmission Based PrecautionsPrecautions

Infection Control Manual found on the Infection Control Manual found on the right hand side of the NHS Fife right hand side of the NHS Fife Intranet home pageIntranet home page

Has all you need to know for every Has all you need to know for every infectious organism you will come infectious organism you will come across but…….across but…….

If in doubt call the Infection Prevention If in doubt call the Infection Prevention & Control Team x28833& Control Team x28833

C. difficileC. difficile

How good are we?How good are we?

NHS Fife has one of the lowest rates of CDI in Scotland

C. difficile rate( per 1000 OCBDs) in >65s in Fife compared to Scotland

00.40.81.21.6

Q32008

Q42008

Q12009

Q22009

Q32009

Q42009

Q12010

Q22010

Q32010

Q42010

Q12011

Q22011

Q32011

Quarter

Ra

te p

er

10

00

O

CB

D

Rate per 1000 OCBD in ≥ 65 in NHS Fife Rate per 1000 OCBD (≥ 65) Scotland

C. difficile Microbiologist will contact the ward to

speak to the FY1/FY2 about the case You need to be able to assess the

severity Know which antibiotic to give

depending on the severity In Fife there is a CDI care pack.

Consists of-C. difficile Notification Form-CDI Medical Management Form-Stool chart – monitored daily-Algorithm for the Management of CDI

Clostridium difficile associated disease (CDAD) – MEDICAL MANAGEMENT This form should be used for all adults (>16yrs old) diagnosed with C. difficile infection. The form should be entered in the patient’s medical notes as part of the record of their care. Name: Date of birth: Hospital Number: CHI Number:

Address:

PRINT NAME GRADE DAY DATE SEVERITY OF

CDAD (severe, non-severe or asymptomatic – see below)

SIGNATURE

(these columns need only be filled in the first time an individual signs the form)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 IN ALL CASES

Patients must be fully assessed by medical staff when they are identified as being C. difficile positive. The need for any currently prescribed antibiotics should be reviewed and if possible stopped or a narrower

spectrum agent chosen. Discuss with duty microbiologist if in doubt. Antimotility agents and gastric acid suppressive therapy should be stopped. Fluid, electrolyte and nutritional status must be assessed and replaced/supplemented if indicated. Severity of CDAD must be assessed and managed accordingly (see below). Assessment must be carried out

at least daily until the patient has been asymptomatic for 48hours, though beware, relapses can occur. The outcome of the assessment must be recorded on this sheet each day. This includes weekends and patients must be handed over to the hospital at night team to ensure this happens.

If active management of CDAD is not being pursued this should be clearly documented, with the reason, in the patient’s medical notes. Further completion of this form is then not required.

SEVERE DISEASE If the patient meets any of the following criteria they should be managed as having severe CDAD:

Admitted to ITU for treatment of CDAD or its complications Suspicion of/confirmed pseudomembranous colitis, toxic megacolon, ileus Temperature >38.5oC White cell count <1.5 or >15 X109/L Serum albumin <25mg/l Acutely rising serum creatinine or creatinine >1.5 times baseline Colonic dilatation on CT scan >6cm Patient immunocompromised (eg neutropenic, on immunosuppressive therapy)

Severe cases (or if >/= 3rd episode of CDAD) must be: Started on oral vancomycin 125mg qid for 10 days if able. Discussed with the duty microbiologist to discuss whether there is a need for alternative/additional antibiotic

management and to arrange stool culture for C. difficile. NON-SEVERE DISEASE (symptomatic but do not meet any of criteria for severe CDAD) and 1st or 2nd episode of CDAD Treat with oral metronidazole 400mg tid for 10 days If no improvement after 5 days of metronidazole, change to oral vancomycin 125mg qid for 10 days ASYMPTOMATIC C. DIFFICILE POSITIVE PATIENTS Antibiotics active against C. difficile are not required. IF ANY UNCERTAINTY REMAINS PLEASE CONTACT CONSULTANT MICROBIOLOGIST TO DISCUSS

What else you should be What else you should be doingdoing

Monitor – fluid balance and nutritional status with U&Es, albumin

Stop gastric acid suppressants Contact precautions Wash hands with soap and

water

Hand Decontamination Hand hygiene is the most important action to

prevent the spread of infection

Use alcohol rubs if hands socially clean

Hands MUST be washed after removing gloves

Use alcohol gel before EVERY patient contact

If patient has diarrhoea or vomiting must wash hands with

soap and water

Hand decontamination –Hand decontamination –SPSP expectSPSP expect

Bear below the elbows plus removal of watches Bear below the elbows plus removal of watches and rings with stonesand rings with stones

Wet hands AND THEN apply soap to all surfacesWet hands AND THEN apply soap to all surfaces Rinse handsRinse hands Dry hands with paper towelsDry hands with paper towels Dispose of paper towels with out contaminating Dispose of paper towels with out contaminating

handshands Switch off tap without re-contaminating your Switch off tap without re-contaminating your

handshands

CMO letter (2011)13 CMO letter (2011)13

This makes it mandatory in Scotland to inform the This makes it mandatory in Scotland to inform the Infection Prevention Control Team if any of the Infection Prevention Control Team if any of the following terms are written on either part of a death following terms are written on either part of a death certificate certificate

MRSAMRSA – inform Procurator fiscal – inform Procurator fiscal C. difficileC. difficile – – inform Procurator fiscalinform Procurator fiscal Death during an outbreakDeath during an outbreak – inform Procurator fiscal – inform Procurator fiscal Hospital acquired infection contributed to deathHospital acquired infection contributed to death S, aureus S, aureus bacteraemia – all SAB related deaths to be bacteraemia – all SAB related deaths to be

investigated and the report sent to the Procurator investigated and the report sent to the Procurator fiscalfiscal

If any of these criteria fulfilled discuss with the patient’s consultant before completing the MCCD

Communication Patients with an infectious disease or

syndromes e.g. D&V, MUST NOT be transferred or sent for investigation without warning the receiving unit

This requires documentation on transfer letters, and investigation requests

Follow up results as soon as available if patient has moved elsewhere

Peripheral Vascular Catheters (PVCs)

All PVCs to have the time & date of insertion clearly labelled on the dressing

Insertion sticker in the Medical notes (A&E- printed on front sheet of A&E record)

Maintenance sticker in the nursing notes (nurses perform this task)

PVC change after 72 hours DO NOT take blood cultures through PVCs

Make your life easy switch to oral agents!

I feel assured! Are you?

Ensure an Insertion Label is completed for every venflon inserted

Every patient… Every time!

Further details from ward staff

Date & time

visible

Insertion site clearly visible

What else have I to do once I have inserted a venflon?

Date & time of insertion to be written on venflon

dressing

Complete an Insertion Label

example

Place label in medical notes / episode of care

sheet

Venflon to be checked daily. Complete a daily

check labelexample

Peripheral Vascular Catheter Care Bundle HPSCannula site:Cannula gauge / colour:Still in use / required

Y NAbsence of inflammation / extravasation

Y NDressing intact and dated & timed

Y NInserted for less than 72 hours Y NHand hygiene before & after all PVC bundlechecks Y NPlease circle PVC removed PVC left in situReason for removal:Date: / / Time:

Insertion stickersInsertion stickers

Collect them when you collect other Collect them when you collect other items for the PVC insertionitems for the PVC insertion

Where do you find them on blood Where do you find them on blood trolleys and nursing stationstrolleys and nursing stations

Insert them into the medical notes Insert them into the medical notes after you have inserted the venflon after you have inserted the venflon and completeand complete

Does strict PVC Does strict PVC management have an management have an

effect?effect?

Intervention

Quarterly SAB rate per 1000 OCBDs

0.000

0.200

0.400

0.600

0.800

Q1 20

08

Q2 20

08

Q3 20

08

Q4 20

08

Q1 20

09

Q2 20

09

Q3 20

09

Q4 20

09

Q1 20

10

Q2 20

10

Q3 20

10

Q4 20

10

Q1 20

11

Q2 20

11

Quarter

Rat

e p

er 1

000

OC

BD

s

NHS Fife Scotland

SABs and youSABs and you All hospital acquired SAB will be investigated.All hospital acquired SAB will be investigated.

MRSA SAB will be investigated with a member of the senior MRSA SAB will be investigated with a member of the senior management team presentmanagement team present

SAB acquired in hospital are predominantly due to medical SAB acquired in hospital are predominantly due to medical devices or pressure soresdevices or pressure sores

If a SAB occurred on your patient you will have to explain any If a SAB occurred on your patient you will have to explain any failings in the management of the PVC, pressure sores, etc.failings in the management of the PVC, pressure sores, etc.

Make your life easy remove PVCs, catheters and ask the nursing Make your life easy remove PVCs, catheters and ask the nursing staff about pressure sores and broken skin. staff about pressure sores and broken skin.

All SAB related deaths to be reported to the Infection Prevention All SAB related deaths to be reported to the Infection Prevention & Control office& Control office

Mandatory MRSA screening Mandatory MRSA screening in Scotlandin Scotland

All elective admissions (except All elective admissions (except obstetrics & paediatrics)obstetrics & paediatrics)

All emergency and elective All emergency and elective admissions to ICU, vascular, admissions to ICU, vascular, orthopaedics and renal unitorthopaedics and renal unit

Clinical Risk Assessment on all other Clinical Risk Assessment on all other patientspatients

If answer positive to If answer positive to ≥1 of three ≥1 of three questions then patient screened questions then patient screened

OHSASOHSAS

Know you immune status too:Know you immune status too: HBVHBV Chicken poxChicken pox MumpsMumps MeaslesMeasles RubellaRubella

Needle Stick Injuries

What to do Who to inform (line manager,

OHSAS) Who performs risk assessment Who takes blood (patient and

HCW) Where to get PEP

Antibiotic Stewardship

NHS Fife is different.....!

Why has antibiotic Why has antibiotic control become so control become so

important?important? Increasing antibiotic resistance in FifeIncreasing antibiotic resistance in Fife Lack of new antibiotics in the pipe Lack of new antibiotics in the pipe

lineline C. difficileC. difficile

““The age of liberal antibiotic policies is over. The The age of liberal antibiotic policies is over. The time for antibiotic restriction has arrived”time for antibiotic restriction has arrived”

Dr Keith MorrisDr Keith Morris

20082008

What are we trying to do in What are we trying to do in Fife?Fife?

Restrict the use of certain antibiotics/antifungals Restrict the use of certain antibiotics/antifungals with out Microbiology or ID approvalwith out Microbiology or ID approval

Abbreviated antibiotic guidance for common Abbreviated antibiotic guidance for common infections applicable to all in-patient areasinfections applicable to all in-patient areas

Making antibiotic guidance accessibleMaking antibiotic guidance accessible-Pocket guidance-Pocket guidance

-Ward posters-Ward posters Full guidance available in the intranetFull guidance available in the intranet Collect data on antibiotic consumptionCollect data on antibiotic consumption Provide surveillance information to wardsProvide surveillance information to wards AMT controls antibiotic use in FifeAMT controls antibiotic use in Fife

Examples of restrictionExamples of restriction The The onlyonly use of ceftriaxone is meningitis use of ceftriaxone is meningitis Ceftriaxone to be removed form drug Ceftriaxone to be removed form drug

cupboards on adult general medical & cupboards on adult general medical & surgical wardssurgical wards

Meropenem and tigecyclineMeropenem and tigecycline TemocillinTemocillin Linezolid Linezolid VoriconazoleVoriconazole

Is it having any effect?Is it having any effect?

Always think..

Does this patient really need an antibiotic?

If the patient is clinically stable with a raised WCC or temperature they do not need antibiotics?

Have a plan for what antibiotics to prescribe if patient deteriorates

If a patient has had 5 days of an empirical antibiotic and not improved they are on the incorrect antibiotic or source control has not been established

Know the NHS Fife….Know the NHS Fife….

Dress codeDress code

-For everyone in NHS Fife-For everyone in NHS Fife

Boards for wardsBoards for wards

-Operational division only-Operational division only

Healthcare Environment Healthcare Environment Inspectorate Scotland Inspectorate Scotland

(HEIS)(HEIS) A branch of SGHDA branch of SGHD Inspect ALL acute hospitals in ScotlandInspect ALL acute hospitals in Scotland Expect FY and STS doctors to know about and followExpect FY and STS doctors to know about and follow

-Dress code-Dress code-Where to find the Infection Control Manual-Where to find the Infection Control Manual- National surveillance for infection prevention- National surveillance for infection prevention

-SSI surveillance for hip arthroplasty & C -SSI surveillance for hip arthroplasty & C sectionssections

-SABs & -SABs & C. difficileC. difficile-Hand hygiene audits -Hand hygiene audits -Cleaning audits-Cleaning audits

-Where to find ward results for the above -Where to find ward results for the above

Summary

NHS Fife will have different practice to where you have come from and where you trained e.g. C. difficile & PVCs

Follow NHS Fife practice not what you think is best practice

ALL medical devices and areas of broken skin will give rise to infection if you do not manage them. THINK ABOUT THEM

If in doubt ask -I/C ext 28833-The switchboard for “duty microbiologist”

And one final request…