1. The ‘Taming’ of Health Care Acquired Infections (HCAI) Dr. Rashmi Sharma Consultant Microbiologist/Deputy DIPC FRCPath, MD, MRCOG 14/10/2011

2. The ‘t aming’ o f HCAI Define HCAI - cost to the patient and NHS Trust priority Antimicrobial Resistance MRSA and Clostridium difficile (C.diff) rates compared to previous years What is new?

3. World Health Organisation (WHO) definition - HCAI Patient admitted for reason other than infection – Not present or incubating at admission – >48h – Post discharge – Occupational infections in staff

4. HCAI 9% of all inpatients have HCAI at any one time 300,000 HCAI/year 5000 deaths and contribute to 15,000/year deaths £1 billion/year National Audit Office: - length of stay (LoS) - 2.5 times longer - hospital costs 3 times higher - higher GP, district nurse and hospital costs after discharge than uninfected patients

5. HCAI: Collateral damage DIRECT: £millions: Cost per infection episode; LoS; Lost work days Mortality; morbidity; complications PENALTY for breaching trajectory INDIRECT: Reputation, media & patient choice Litigation Staff morale & team confidence KPI

6. Proactive Approach The Infection Prevention Committee is ‘led’ by the CEO Trust is committed to reducing HCAI, key priority Case of C.diff or MRSA bacteraemia mandates involvement of an ED Introduction of ‘antimicrobial stewardship’

7. Proactive Approach Re-invigorating and massive launch of ‘hand hygiene’ Audits and surveillance Achieving and ‘bettering’ trust targets Launched pilot project- HPAT Working closely with our partners in the community

8. Global Crisis

9. Antibiotic resistance – A patient safety issue for all hospitals The emergence, selection and spread of resistant bacteria in hospitals is a major patient safety issue. –Infections with antibiotic-resistant bacteria can result in increased patient morbidity and mortality, as well as increased hospital length of stay. 1-2 –Antibiotic resistance frequently leads to a delay in appropriate antibiotic therapy. 3 –Resistance combined with poor infection control practice exacerbates the problem –Resistant organisms in faeces contaminate environment outside hospital contributing to increased community incidence of MSR organisms –Inappropriate or delayed antibiotic therapy in patients with severe infections is associated with worse patient outcomes and sometimes death. 4-6 9

10. 1998YEARS2004 Antibacterial resistance Antibacterial R&D. The Inverse Relationship

11. Antimicrobial Stewardship Launched recently Revision of the existing antimicrobial guidance in the Trust and the community Policies and revised prescription charts introduced to curb prolonged use of antibiotics Laboratory antimicrobial stewardship Ensure prudent prescribing

14. 69% reduction achieved on rates of C.diff infection when comparing 2010 to 2007

15. National Audit Office MRSA: between 2003-04 and 2008-09 we estimate that the NHS has saved between £45-59 million in treatment costs by reducing the rates of MRSA bloodstream infections and C-diff: between £97-204 million from 2006 to end of 2008 by reducing the rate of C.diff infections [www.nao.org.uk ]

16. Initiatives in BTH for tackling C.diff Antibiotic Stewardship Programme including revised formulary, 5-day stop, enhanced Micro support Hand hygiene, prompt identification/isolation, barrier nursing, various audits C.diff MDT meetings – disseminate learning issues to entire nursing / medical team

17. Audit & Surveillance AUDIT: An evaluation of system or processes. We perform audit to measure aspects of care provision against set and agreed standards. SURVEILLANCE: Comes from the French for “watching over”. The monitoring of a behaviour, activities or other changing information. In Infection Prevention it is used to monitor trends and patterns in disease/illness/infection.

18. What Next? Emerging global threat- carbapenemase producers (extremely resistant bacteria) Screening for these is required- National recommendation www.hpa.org.uk- more information on carbapenemase can be found on this website

19. Extremely resistant bacteria MDR is defined as non-susceptibility to at least one agent in three or more antimicrobial categories XDR is defined as non-susceptibility to at least one agent in all but two or fewer antimicrobial categories (i.e. bacterial isolates remain susceptible to only one or two categories) PDR is defined as non-susceptibility to all agents in all antimicrobial categories (i.e. no agents tested as susceptible for that organism)

20. Measures to combat it Screening high risk patients Environmental hygiene Hand hygiene Antimicrobial stewardship

21. Home Parental Antibiotic Therapy (HPAT) - Advantages Quality of treatment experience Reduced risk of HCAI Reduced hospital stay Release of hospital beds Cost-effective care Return to work possible

22. Patient eligibility Medically stable Meets inclusion/exclusion criteria Appropriate IV access Home circumstances appropriate –Support –Communications –Facilities

23. Blackpool Teaching Hospitals HPAT: June 2011 June: Sternal wound infection Liver abscess July 2011: Cellulitis [referred from Lancaster HPAT team] Cellulitis [GP referral] Great team work Enhancing quality project across whole health economy

24. The Role of Hand Hygiene in The ‘Taming’ of HCAI’s Sharon Mawdsley Lead IPN

25. Launch of new Hand Hygiene Policy 2011 Infection Prevention Team

26. Why change the policy? A doctors covert audit in 2010 showed a 37% compliance rate in hand hygiene In 2011, another covert audit showed 35% compliance Traditional audits show a compliance average of 95% Is this the Hawthorne effect? Clostridium difficile rates not improving as well as they should be We had two cases in April 2011 10 cases in May 2011 It is highly likely that non-compliance was a contributing factor There needs to be clear consequences for non- compliance

27. So what are we doing about it? Educating all staff and visitors Promoting the WHO five moments of hand hygiene Promoting competition through displaying audit results on the intranet Taking this information to staff in their own areas Re-issuing the ‘pledge’ Implementing a new covert audit process Outlining what the consequences of non-compliance are Equipping staff with all the tools they need to be compliant

28. So what can staff do about it? Read and sign the pledge Memorise the five moments and implement them Challenge their colleagues Be courteous if they are challenged Adhere to uniform policy/dress code Be bare below the elbows when in the patient zone Use appropriate PPE Use appropriate hand decontamination methods for each activity

29. So what are the consequences for staff? Peers, managers and covert auditors will informally challenge non-compliance Covert auditors will also take names. These names will be given to their manager Initial episode of non-compliance observed by an auditor will be dealt with by a manager verbally Repeated episodes will result in counselling by a manager Further episodes will lead to formal disciplinary action up to and including dismissal

30. So what are the 5 moments for staff?

31. What is the patient zone?

32. Patient zone This is an area in the immediate vicinity of the patient where care is provided It is an area which is likely to be heavily colonised with the flora of a patient It can be difficult to describe in certain care settings and may be mobile in others In this Trust, the patient zone is taken to be inside the curtains In a community or out patient setting, the zone is wherever the patient is examined or cared for

33. Moment 1 Before patient contact WHEN? Clean your hands when approaching a patient at the point of care WHY? To protect the patient from potential pathogens carried on your hands

34. Moment 2 Before a clean/aseptic procedure WHEN? Clean your hands immediately before any clean/aseptic procedure WHY? To protect the patient from potential pathogens from the environment and themselves being introduced invasively

35. Moment 3 After body fluid exposure risk WHEN? Clean your hands immediately after an exposure risk to body fluids, including after glove removal WHY? To protect yourself and the healthcare environment against potential pathogens from the patient and patient zone

36. Moment 4 After Patient Contact WHEN? Clean your hands after touching a patient, when leaving the point of care (patient zone) WHY? To protect yourself and the healthcare environment against potential pathogens from the patient The aim here is to prevent potential pathogens from the patient crossing the boundary between the patient zone and the healthcare zone

37. Moment 5 After contact with patient surroundings WHEN? Clean your hands after touching any object or furniture in the patient zone, even if the patient is not present or has not been touched, when leaving the patient zone WHY? To protect yourself and the healthcare environment against potential pathogens from the patient zone

38. What are the five moments for visitors and how will they know what they are?

39. Moment 1 ON ENTERING A WARD When? Use the alcohol hand rub located at the entrance. Why? To prevent taking harmful bacteria or viruses into the ward environment.

40. Moment 2 BEFORE PATIENT CONTACT When? Clean your hands when approaching the patient at their bedside. Why? To protect the patients skin from harmful bacteria or viruses.

41. Moment 3 BEFORE ASSISTING WITH PATIENT MEALS When? Before you handle patients food. Why? To protect the patient from swallowing harmful bacteria or viruses.

42. Moment 4 AFTER VISITING THE TOILET OR BATHROOM When? Please wash and dry your hands before leaving the toilet or bathroom. Why? To prevent you from spreading harmful bacteria or viruses around the hospital environment.

43. Moment 5 AFTER CONTACT WITH THE PATIENT SURROUNDINGS When? Clean your hands when you leave the patients bed side. Why? To protect yourself and to prevent spreading harmful bacteria or viruses around the hospital environment.

44. How will they know? They will be politely reminded by staff Coming soon to a wall near you…......

45. Any Questions?