1. Doctors induction 2012 Infection Control and Antibiotic Prescribing Dr A. Keith Morris

2. Overview Transmission Based Precautions Peripheral Vascular Catheter (PVC) C. Difficile Hand decontamination Death certification Communication OHSAS & needle stick injuries MRSA screening Antibiotic prescribing

3. 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

4. Infection control terminology Older terms that now should not be used - “Universal precautions” - “Enteric precautions” Standard infection control precautions Standard precautions Transmission based precautions

5. Supplement standard precautions. Supplement standard precautions. specify precautions to individual patients documented/suspected of being infected or colonised with highly transmissible and/or epidemiologically important pathogens or clinical syndromes specify precautions to individual patients documented/suspected of being infected or colonised with highly transmissible and/or epidemiologically important pathogens or clinical syndromes Three types Three types Contact Contact Droplet Droplet Airborne Airborne

7. Transmission Based Precautions Infection Control Manual found on the right hand side of the NHS Fife Intranet home page Infection Control Manual found on the right hand side of the NHS Fife Intranet home page Has all you need to know for every infectious organism you will come across but……. Has all you need to know for every infectious organism you will come across but……. If in doubt call the Infection Prevention & Control Team x28833

8. C. difficile

9. How good are we? NHS Fife has one of the lowest rates of CDI in Scotland

10. 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

12. What else you should be doing Monitor – fluid balance and nutritional status with U&Es, albumin Stop gastric acid suppressants Contact precautions Wash hands with soap and water

13. 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

14. Hand decontamination –SPSP expect Bear below the elbows plus removal of watches and rings with stones Bear below the elbows plus removal of watches and rings with stones Wet hands AND THEN apply soap to all surfaces Wet hands AND THEN apply soap to all surfaces Rinse hands Rinse hands Dry hands with paper towels Dry hands with paper towels Dispose of paper towels with out contaminating hands Dispose of paper towels with out contaminating hands Switch off tap without re-contaminating your hands Switch off tap without re-contaminating your hands

15. CMO letter (2011)13 This makes it mandatory in Scotland to inform the Infection Prevention Control Team if any of the following terms are written on either part of a death certificate MRSA – inform Procurator fiscal MRSA – inform Procurator fiscal C. difficile – inform Procurator fiscal C. difficile – inform Procurator fiscal Death during an outbreak – inform Procurator fiscal Death during an outbreak – inform Procurator fiscal Hospital acquired infection contributed to death Hospital acquired infection contributed to death S, aureus bacteraemia – all SAB related deaths to be investigated and the report sent to the Procurator fiscal S, aureus bacteraemia – all SAB related deaths to be investigated and the report sent to the Procurator fiscal If any of these criteria fulfilled discuss with the patient’s consultant before completing the MCCD

16. 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

17. 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!

18. 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

19. 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 label example Peripheral Vascular Catheter Care Bundle HPS Cannula site: Cannula gauge / colour: Still in use / required Y N Absence of inflammation / extravasation Y N Dressing intact and dated & timed Y N Inserted for less than 72 hours Y N Hand hygiene before & after all PVC bundle checks Y N Please circle PVC removed PVC left in situ Reason for removal: Date: / / Time:

20. Insertion stickers Collect them when you collect other items for the PVC insertion Collect them when you collect other items for the PVC insertion Where do you find them on blood trolleys and nursing stations Where do you find them on blood trolleys and nursing stations Insert them into the medical notes after you have inserted the venflon and complete Insert them into the medical notes after you have inserted the venflon and complete

21. Does strict PVC management have an effect? Intervention

22. SABs 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 management team present MRSA SAB will be investigated with a member of the senior management team present SAB acquired in hospital are predominantly due to medical devices or pressure sores SAB acquired in hospital are predominantly due to medical devices or pressure sores If a SAB occurred on your patient you will have to explain any failings in the management of the PVC, pressure sores, etc. If a SAB occurred on your patient you will have to explain any failings in the management of the PVC, pressure sores, etc. Make your life easy remove PVCs, catheters and ask the nursing staff about pressure sores and broken skin. Make your life easy remove PVCs, catheters and ask the nursing staff about pressure sores and broken skin. All SAB related deaths to be reported to the Infection Prevention & Control office All SAB related deaths to be reported to the Infection Prevention & Control office

23. Mandatory MRSA screening in Scotland All elective admissions (except obstetrics & paediatrics) All elective admissions (except obstetrics & paediatrics) All emergency and elective admissions to ICU, vascular, orthopaedics and renal unit All emergency and elective admissions to ICU, vascular, orthopaedics and renal unit Clinical Risk Assessment on all other patients Clinical Risk Assessment on all other patients If answer positive to ≥1 of three questions then patient screened If answer positive to ≥1 of three questions then patient screened

24. OHSAS Know you immune status too: HBV HBV Chicken pox Chicken pox Mumps Mumps Measles Measles Rubella Rubella

25. 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

26. Antibiotic Stewardship NHS Fife is different.....!

27. Why has antibiotic control become so important? Increasing antibiotic resistance in Fife Increasing antibiotic resistance in Fife Lack of new antibiotics in the pipe line Lack of new antibiotics in the pipe line C. difficile C. difficile “ The age of liberal antibiotic policies is over. The time for antibiotic restriction has arrived” Dr Keith Morris 2008

28. What are we trying to do in Fife? Restrict the use of certain antibiotics/antifungals with out Microbiology or ID approval Restrict the use of certain antibiotics/antifungals with out Microbiology or ID approval Abbreviated antibiotic guidance for common infections applicable to all in-patient areas Abbreviated antibiotic guidance for common infections applicable to all in-patient areas Making antibiotic guidance accessible Making antibiotic guidance accessible -Pocket guidance -Ward posters Full guidance available in the intranet Full guidance available in the intranet Collect data on antibiotic consumption Collect data on antibiotic consumption Provide surveillance information to wards Provide surveillance information to wards AMT controls antibiotic use in Fife AMT controls antibiotic use in Fife

29. Examples of restriction The only use of ceftriaxone is meningitis The only use of ceftriaxone is meningitis Ceftriaxone to be removed form drug cupboards on adult general medical & surgical wards Ceftriaxone to be removed form drug cupboards on adult general medical & surgical wards Meropenem and tigecycline Meropenem and tigecycline Temocillin Temocillin Linezolid Linezolid Voriconazole Voriconazole Is it having any effect?

30. 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

31. Know the NHS Fife…. Dress code Dress code -For everyone in NHS Fife Boards for wards Boards for wards -Operational division only

32. Healthcare Environment Inspectorate Scotland (HEIS) A branch of SGHD A branch of SGHD Inspect ALL acute hospitals in Scotland Inspect ALL acute hospitals in Scotland Expect FY and STS doctors to know about and follow Expect FY and STS doctors to know about and follow -Dress code -Where to find the Infection Control Manual - National surveillance for infection prevention -SSI surveillance for hip arthroplasty & C sections -SABs & C. difficile -Hand hygiene audits -Cleaning audits -Where to find ward results for the above

33. 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”

34. And one final request…