Prevention and Control of Infection in Care Homes Infection Prevention and Control Team Public Health Norfolk County Council January 2015
Content for today • Importance of IPAC -refresher • IPAC audits in Care Homes • Identified common themes and trends: Laundry Sluice Housekeeping facilities Use of chlorine Cleaning schedules Uniform policy Hand hygiene/PPE Management of Outbreak • Clostridium difficile • MRSA • Isolation technique • Catheters
‘ It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm’ (Florence Nightingale 1859)
Clinical Context • 300,000 patients a year in England acquire a HCAI as a result of care in the NHS • Cost to the NHS is estimated at £1 billion a year and £56 million of this is estimated to be incurred after discharge
Chain of Infection • MRSA • C. Diff • Norovirus Susceptible • Animals People • Humans • Surfaces • Food • Break in • Faeces skin • Urine • Membranes • Vomit • Inhalation • Blood • Contact • Droplet • Airbourne
We all have a responsibility to break the links in the chain of infection and reduce the likelihood of an organism causing harm
Standard Precautions Hand Hygiene Use of Gloves PPE Safe handling of soiled Safe handling of sharps Safe handling of waste Environmental cleaning linen
My 5 Moments for Hand Hygiene 1. Before 4. After touching a touching a resident resident 2. Before clean/asceptic procedure 5. After 3. After body touching a fluid exposure persons risk surroundings
Uniform policy • Studies have found that the public make conclusions about professionalism and trustworthiness • Current perception of the general public is that uniforms pose an infection risk to patients and, when worn outside the clinical setting, the wider public. • Reinforced by media • Damaging effect on the relationship of trust that exists between professional carers and patients and the public image of healthcare professionals • Loveday et al (2007)
Common themes in laundry • No dirty to clean flow • Concrete flooring • Working from floor • Clutter • Damage • No PPE • No dedicated hand wash sink
Common themes in sluice • Lack of sluice • Dirty • No designated hand wash sink • Clutter • Damage • No PPE
Common housekeeping themes • No disposal unit • No dedicated hand wash sink • Concrete flooring • Clutter • Damage • No PPE
Cleaning schedules • A robust schedule which includes who is responsible for cleaning items/equipment, what they should be cleaned with and the frequency of cleaning needs to be developed, this requires auditing
Example of cleaning schedule Area/ Item Frequency Responsibility Cleaning H&S Method of Checked By Materials Precautions Cleaning (initial) (Refer to product label)
OUTBREAKS Inform Manager Ensure relevant PHE people have IP&C lead been informed All staff Seek advice re microbiological Residents specimens Relatives GP
Norovirus • Residents with diarrhoea and/or vomiting should be isolated for duration of symptoms • Symptoms short lived, little warning, can be severe • Environment at risk of heavy contamination causing rapid spread of infection • Residents/staff should be excluded until 48 hours after symptoms have settled • Enhanced cleaning regime required
• Use of chlorine releasing agent 10,000 ppm • disposable cloths/mops should be used on frequently touched surfaces at least twice daily • Alcohol hand rub not effective in diarrhoea
Clostridium difficile ( C.diff/CDI ) • C.diff is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants • However, C.diff rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial flora
• When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness • CDI ranges from mild to severe diarrhoea to, more unusually, pseudomembranous colitis
CDI Transmission • Spores are produced when Clostridium difficile bacteria encounter unfavourable conditions, such as being outside the body • Clostridium difficile is usually spread on the hands of healthcare staff and other people who come into contact with infected patients or with environmental surfaces (e.g. floors, bedpans, toilets) contaminated with the bacteria or its spores • The spores are very hardy and can survive on clothes and environmental surfaces for long periods • Soap and water hand wash and hypochlorite cleaning agents recommended
CDI risk factors • People who have been treated with broad spectrum antibiotics • People with serious underlying illnesses • The elderly – over 80% of Clostridium difficile infections reported are in people aged over 65 years (PHE 2014)
Number of CDI cases 2008/09 to 2014/15 (NNUH laboratory data)
MRSA • MRSA (meticillin-resistant Staphylococcus aureus ) is a bacterium from the Staphylococcus species that is resistant to meticillin and other antibiotics • It commonly survives nose, groin, axilla without causing infection – a state known as colonisation • An MRSA bacteraemia (blood stream infection) can occur if MRSA enters particular sites in the body, for example, a surgical wound, indwelling device or the respiratory system
De-colonisation treatment • Dual treatment of Octenisan and Mupirocin, unless Mupirocin resistant when naseptin is used as an alternative • Re-screening – if necessary then this should occur 2 days after decolonisation treatment has been completed. Include separate swabs of nose, groin and any breaks in skin, indwelling devices
MRSA Bacteraemia Norfolk • Resident in care home • Not previously known MRSA +ve prior to BSI • Root cause associated with urinary catheter management • Breakdown of communication between primary care, hospital, care home
Isolation Technique • Single room – remove any unnecessary furniture/items • Equipment and bins for patient should be kept inside the room • PPE required for patient care should be kept outside the room along with laundry skip • Patient notes should be kept outside the room • Bedpans/urinals should be disposed of directly into the sluice or bed pan washer. If a bed pan washer is not available then these items need cleaning with chlorine 10,000ppm
• Hard surfaces/equipment to be cleaned with chlorine • Avoid vigorous bed making! • Crockery and cutlery can be put in a dishwasher which heats to 80 degrees • Transporting of patients should be avoided unless essential • Information for patient/relatives
Process 1. Wash hands 2. Gloves, apron before entering the room 3. Deliver care/task/procedure in the room 4. Remove gloves, apron in the room and dispose in clinical waste bin 5. Wash hands in the room 6. Leave room in clean state
Indications for catheterisation in care homes • Urinary tract obstruction • Acute or chronic retention of urine • Management of urinary incontinence when all other methods are not applicable
Infection routes in catheter- associated urinary tract infections
Reducing the risks of catheter- associated urinary tract infection • Avoiding unnecessary catheterisation • Aseptic technique • Maintaining a closed drainage system • Education of patients, nurses and care staff of catheter care
References • SIGN (2006) • Prevention and control of infection in care homes-an information resource. DH 2013 • The Health and Social Care Act 2008 • Prevention and control of healthcare- associated infections in primary and community care. NICE (2012) • World Health Organisation ‘Clean Care is Safer Care’ • RCN
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