1. 1 Healthcare Associated Infections & Antimicrobial Consumption in Long-Term Care Facilities. (HALT) Mags Moran & Mary Rooney Community Infection Control Nurse Managers Donegal and Sligo/ Leitrim PCCC Areas, HSE West. Improving Patient Safety through Infection Prevention & Control.

2. 2 What is Community Infection Control? Cover ALL services outside of acute hospital, all ages- from cradle to grave! Populations: Donegal= 160,927 Sligo/ Leitrim= 97,048 Expert advice to:

3. 3 Background: Healthcare associated Infection (HCAI) An infection that someone acquires in hospital or after receiving healthcare treatment.  Includes treatment in outpatient clinics, nursing homes and other healthcare settings. Up to 70% HCAI is preventable (1) – first do no harm In Ireland:  4.9% (up to 13%) acute care, 2006 (2)  4.1% (up to 26%) long term care, 2011 (3).

4. 4 Preventing Healthcare Associated Infections is good for patients and saves money! NICE (UK) 2011 (4) savings estimates % HCAI reduction MRSA bloodstream infection anticipated cost reduction C. difficile anticipated cost reduction Total cost reduction 5%£ 203,000£ 4,650,000 £ 4,853,000 10%£ 406,000£ 9,290,000 £ 9,696,000 15%£ 609,000£ 13,940,000 £ 14,549,000

5. 5 What is Antibiotic Resistance? Antibiotics save lives - Most of modern medicine & surgical interventions only possible with antibiotics Overuse of antibiotics = bugs becoming resistant to antibiotics (i.e. the antibiotic won’t work) More difficult to treat = Infections with antibiotic resistant bugs Healthcare-associated = Many infections due to antibiotic resistant bugs are HCAI

6. 6 What did we measure? Prevalence Study on Healthcare Associated Infections (HCAI) in Long Term Care Facilities The Study collected figures on: 1) How many residents had a Healthcare associated infection 2) How many residents were on Antibiotics 1 st time such data was collected in Long term care settings! HSE North West (Donegal/ Sligo/ Leitrim) took part both years & accounted for 19.4% of the total facilities participating at National level.

7. 7 What did we find in 2011? HCAIsAntibiotics TherapeuticProphylactic National4.1%10.1%58%39% Donegal7%10.9%61%31% Sligo/ Leitrim 4.4%9.3%59%41%  Pressing problem: Donegal/ Sligo/ Leitrim: 10% increase in Prophylactic (Preventative) Antibiotic use

8. 8 So what were our ‘Drivers’ for Patient Safety?

9. 9 Good Infection Prevention & Control practices + Antimicrobial Stewardship is essential in all healthcare settings to prevent healthcare associated infections and the emergence of antimicrobial resistance (5).

10. 10 Action 1: Nursing Governance Compliance with all infection prevention and control Policy Procedures & Guidelines-  Developed an Implementation Audit Tool & Monitoring Checklist Strong Infection Control Link Nurse Programme- Reviewed urine specimen results-  Empowered nurses to do more in relation to laboratory reports Circulated Guidance-  Diagnosis & Management of Urinary Tract Infections in Long Term Care Residents (6).

11. 11 Action 2: Antimicrobial Stewardship Assess the use of prophylactic antibiotics on a case by case basis.  Inappropriate antibiotic use increases the risk of C difficile infection and Antimicrobial Resistant organisms. Local action- Presented HALT results to local GP networks Local antibiograms/ resistance profiles Now working with GPs in relation to antibiotic prescribing in long-term care.

12. 12 Action 3: Governance & Antimicrobial Stewardship working together….. Pilot Project March 2012 = Antibiotic Care Bundle  based on the ‘Day 3 Review Rule’:  Continuing use of broad- spectrum antibiotics beyond 3 days alters the patients’ normal flora/ defence mechanisms  ESSENTIAL that antibiotics are reviewed  switched to narrow spectrum antibiotics within 3 days  or discontinued if appropriate.

13. 13

14. 14 D/S/L Local PCCC AM Prescribing Guidelines Each of our 2 Acute Hospitals have ‘Reserved’ Lists of Antimicrobial Agents, which our non- acute services benefit from…….. LGH! SGH!

15. 15 Supports & Challenges Regional Community Infection Control Committee Drugs & Therapeutics Committees x 2 Antimicrobial Stewardship: limited resources to carry out surveillance of antibiotic consumption: ‘if we can’t measure it, we can’t manage it’! Need specialist expertise for the community  No dedicated Consultant Microbiologist  No dedicated community based antimicrobial pharmacist

16. 16 Benefits & Outcomes

17. 17 In Summary, Active Surveillance is a key component of Infection Prevention & Control. Robust information- profiling our rates of Healthcare Associated Infections & usage/ consumption of antibiotics. Culture of surveillance embedded Clear commitment to address patient safety initiatives relating to healthcare associated infections & antimicrobial stewardship issues from all- (top down).

18. 18 We need: More education - members of the public, staff and prescribers o about antibiotic resistance & healthcare associated infections, and how each has a role to play in reducing their occurrence! More community-based Infection Prevention & Control Nurses! We applaud that healthcare associated infections & antibiotic resistance is being addressed under the appropriate heading of Patient Safety at National level!

19. 19 We acknowledge & say ‘Thank You’ to- All the facilities that took part in this project Our General Managers & all Service Managers The staff in Health Protection Surveillance Centre Dr. Fidelma Fitzpatrick, National HALT co-ordinator & National Clinical Lead -Healthcare Associated Infection Clinical Care Programme For this opportunity today to put HCAI & Antimicrobial Consumption on a National DoH Patient Safety Agenda!

20. 20 References 1. Umscheid et al 2011. “Estimating the proportion of healthcare associated infections that are reasonably preventable & the related mortality and costs”. Journal of ‘Infection Control & Hospital Epidemiology’: 2011: Feb- 32 (2): 101-104. 2. HSE/HPSC 2006. “The 3 rd Prevalence Survey of Healthcare Associated Infections in Acute Hospitals”. (In collaboration with HIS & ICNA). http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/2006HospitalPreva lenceSurvey/Results/File,2459,en.pdf http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/2006HospitalPreva lenceSurvey/Results/File,2459,en.pdf 3. HSE/HPSC 2011. “European Point Prevalence Study on Healthcare Associated Infections & Antibiotic use in Long Term Care Facilities”. http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HCAIinlongtermcar efacilities/HALTproject2011/Results/File,12869,en.pdf http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/HCAIinlongtermcar efacilities/HALTproject2011/Results/File,12869,en.pdf 4. NICE 2011. “Healthcare Associated Infections: Costing Report, November 2011. http://www.nice.org.uk/media/840/29/HCAIAdviceCostingReport.pdfhttp://www.nice.org.uk/media/840/29/HCAIAdviceCostingReport.pdf 5. HSE/ HPSC 2009. ‘ Guidelines for Antimicrobial Stewardship in Hospitals in Ireland, December 2009’. http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialResistanceinIreland SARI/AntibioticStewardship/Publications/File,4116,en.pdf http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/StrategyforthecontrolofAntimicrobialResistanceinIreland SARI/AntibioticStewardship/Publications/File,4116,en.pdf 6. HSE/HPSC 2011. Diagnosis & Management of Urinary Tract Infection in Long Term Care Residents >65yrs. http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12929,en.pdf http://www.hpsc.ie/hpsc/A- Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,12929,en.pdf