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