Infection prevention & control

A trust wide approach to reducing

Healthcare Associated Infections

Infection Prevention & Control Team

Is Infection Control old news?

• Maidstone and Tunbridge Wells NHS Trust – 2006//7. More than 1,170 patients infected with Clostridium difficile; 90 patients died over 30

month period. 264 had infection at time of death

• Stoke Mandeville NHS Trust – 2004/5. Over 30 patients died as consequence of 2 outbreaks of infection caused by

Clostridium difficile

• Altnagelvin Hospital, Londonderry/Royal Jubilee Maternity Hospital,

Belfast – 2011. Four babies died from outbreak of Pseudomonas aeruginosa. Infected taps and mixer

values responsible

Is Infection Control old news?

• James Cook University Hospital – 2009. Guidelines put into place to protect patient from Clostridium difficile not adhered to an

inquest heard in 2012 relating to patient death from Clostridium difficile and aspergillosis

This is the front page of the Times and

was quoted by the House of Lords and

Commons and by the National Audit Office

AVERAGE COST OF a UK MRSA/Clostridium difficile CASE - £5000.00

AVERAGE HOSPITAL STAY:

MRSA – 18 DAYS (K.V. Menon et al – J.Rcoll. Surg. Edinburgh 1999)

Clostridium difficile – 20 days (M H Jen et al, Alimentary Pharmacology & Therapeutics, 2011)

Although the financial cost is important, more so is the

cost to the patient through acquiring an infection

through no fault of their own.

The Health and Social Care Act 2008

• Legislation

• Annual inspection by the CQC

• Applies to all staff within the

organisation

The Health and Social Care Act 2008 • You need to be aware of this legally

binding document.

• All healthcare providers must be

registered with the CQC and must abide

by the 10 duties set out in this

document.

• The CQC will visit unannounced yearly

to check we are complying with this

document.

• They will look at things such as isolation

facilities, cleanliness of

equipment/environment.

The Health and Social Care Act 2008

• They will speak to any member of staff

randomly available there it’s important

that everyone is aware of this document.

• Document also ensures staff safety

precautions are in place such as up to

date policies and OHD services.

What is expected of you? • All staff should be aware of the IPC policies and must practice and

promote compliance.

• All staff should be able to challenge poor practice/non compliance

and know who to escalate concerns to

• All staff are responsible for updating their own knowledge and

disseminating any education and training to colleagues

• All staff should be aware of and be involved in the corporate agenda

What is expected of you? All Trust staff

• Policy compliance

• Challenge/support colleagues

• Education

• Corporate agenda

• Patient management

• Surveillance

• Audit

• Competency

ICPT

• Patient review

• Training

• Surveillance

• Outbreak management

• Audit

• Specialist advice and support

• Lead on DOH initiatives

• IPC policies

Infections – some you may know, some

you may not…

Carbapenemase-producing

Enterobacteriaceae

Global spread of Carbapenemase-producing Enterobacteriaceae

Carbapenemase-producing Enterobacteriaceae (sometimes called CPE) is the name

given to a group of bacteria that have become very resistant to antibiotics including those

called carbapenems. Many of these bacteria live harmlessly in the gut and help you

digest food. However, if they get into the wrong place such as the bladder or bloodstream

they can cause infection.

These types of multi-resistant organisms are of great concern going forward.

Extended-Spectrum

Beta-Lactamases (ESBLs)

• Multi resistant gram negative

bacteria

• Isolation / IPC precautions

• Medical assessment /

treatment

• IPC review / advice

Extended-Spectrum

Beta-Lactamases (ESBLs)

• E.coli, pseudomonas and klebsiella

• All require isolation – usually carried in the

bowel – so could have prolonged carriage,

screening not feasible.

• Colonisation or infection – treatment usually IV

meropenum

• Sputum/wounds reculture 48hours following

treatment if negative stop isolation

• B/C & urine don’t reculture can discontinue

isolation when treatment completed and there is

no faecal incontinence

HCAI Targets: MRSA • Mandatory target

• Screening

• Decolonisation

• Pathway

• Isolation

• Hand hygiene

• Cleaning

• Equipment

• Communication

HCAI Targets: MRSA

• Screening – discuss elective and emergency admission screens, PPP’s

– new swabs. Pre op theatre cases eradication and teicoplanin.

• Pathways reinforce the importance of documentation.

• Discuss isolation within 2 hours of knowing and isolation in bays with

stop sign trolley and datix risk assessment depending on where the

MRSA is.

• Cleaning discuss daily cleaning with actichlor plus, and all equipment

that leaves the room to be decontaminated.

• Communication discuss completed discharge letters and advise any

other services that the patient will require…

HCAI Targets: MRSA

• Correct decolonization therapy for a newly diagnosed MRSA patient is

Mupiricin TDS & Octenisan OD for 5 days including hair washed with

Octenisan twice within the 5 days.

HCAI Targets: Clostridium difficile • Mandatory target

• Isolation

• Hand hygiene

• Antibiotic review

• Pathway

• Stool chart

• Daily review

• RCA

• Surveillance

• Communication

• Positive/unconfirmed

positive

HCAI Targets: Clostridium difficile • Huge importance of prompt isolation/appropriate STOP sign/door closed

• Use of soap and water not alcohol gel

• Importance of avoiding antibiotics known to select for C-diff (previous

treatment).

• Review of start/stop date.

• Appropriate antibiotic treatment for severity of CDI

• Unconfirmed cdiff is GDH and PCR present but toxin A&B neg – still needs

treating as cdiff pos but won’t be seen unless requested on the cdiff ward

rounds.

• Complete documentation – importance of documenting stool score and

frequency

• IPC daily review to ensure pt safety

• RCA for trust attributed CDI

• Importance of communication

HCAI Targets: Clostridium difficile

• Clostridium difficile toxin detected patients room you need to request for

a Terminal clean with HP fog

• A patient with Clostridium difficile be transferred out of isolation 48

Hours after symptoms have stopped

Previously positive patients – MRSA

and Clostridium difficile

Not only South Tees…

Outbreak management • Gastroenteritis outbreak assessment tool

• Patient assessment

• Isolation

• Specimen collection

• Outbreak pack

• Hand hygiene

• Cleaning

• Documentation

• Communication

• Outbreak instructions

Outbreak management

• If a patient develops sudden onset of diarrhoea – your initial actions

should be; – Medical review

– antibiotic review

– isolate (terminal clean bed space)

– complete stool chart

– obtain stool sample on request from medical team

Diarrhoea Assessment Tool

The Diarrhoea Assessment Tool

(DAT) is to be complete for all

patients who develop diarrhoea. A

member of the medical team must

be involved in any decision

making regarding stool sampling.

Gastroenteritis Outbreak Assessment Tool

Communicable diseases in staff:

• Discuss chicken pox measles – know

your status check with OHD

• D&V 48hours symptom free inform

OHD send a specimen

Communicable diseases in staff:

Hand Hygiene

Chlorine

handwash

Hand Hygiene

Semmelweis identified in the 1800’s that

there was a direct link between hand

hygiene and cross infection. These are

still discussions we find ourselves

having in the 21st century.

Hand Hygiene

• Every effort goes into encouraging

hand washing and still not everyone

does it.

• Hand-washing promotion is out of

step with the realities of hand

hygiene. So, what else can we do?

Hand Hygiene

• Alcohol gel can be used to implement

the ‘my 5 moments for hand hygiene’

concept for the majority of hand

hygiene opportunities.

• Soap and water must be used when:

– hands are visibly soiled

– the patient has infectious vomiting

and/or diarrhoea

– for direct contact with bodily fluid

– outbreaks of diarrhoea & vomiting

(unless otherwise stipulated by the

IPCT)

Hand Hygiene

• Hand wipe / hand hygiene should

always be asked/provided to patients

prior to meal times

Isolation principles

• Applying IPC principles

can reduce transmission

dramatically.

Isolation principles

• Gloves and aprons –

single use, no wandering

around.

Isolation principles

• Isolation green for

clostridium difficile and

diarrhoea

• Yellow for MRSA / ESBL

• Blue for TB is in the

making

IPC principles

• Dispose of sharps at point

of care

• Never re-sheath a needle

• Don’t overfill

• Sharps injury

• Bleed it, wash it, cover it,

report it

IPC principles

£1.20 25p

Clinical waste Domestic waste

Decontamination - 3 stage process

• Cleaning

– soap and water

– wipes

• Cleaning is the most important stage and must be done first

• Clinell wipes for general cleaning, all equipment to be used on more

that 1 patient must be cleaned after each use.

Decontamination - 3 stage process

• Disinfection

– chlorine releasing agent

• Patient in isolation should have designated equipment.

• Decontamination certificates to be utilised if equipment is being sent to

other departments, medical engineering etc..

Decontamination - 3 stage process

• Sterilisation

– CSSD

• No local decontamination should be occurring.

• Single use sign and application - can’t decontaminate locally and reuse.

Actichlor® Plus 1.7g tablets

• Actichlor Plus contains a chlorine compatible detergent that enables

cleaning and disinfection in a one-step procedure. Active ingredient is

sodium dichloroisocyanurate (NaDCC)

• Would be used for daily decontamination of an isolated patient’s room

• Releases the active compound hypochlorous acid when added to water

• Should be mixed in a ventilated room

• Do not screw lid tightly while mixing to allow escape of the gases

• Rinse of equipment that touches patient skin and stainless steel

Actichlor® Plus 1.7g tablets • General Environment

– 1 tablet / 1 litre of water (1,000ppm of available chlorine)

– Cold water 20 mins to dissolve

– Dispose of after 24hours

– Minimum 5 min contact time prior to rinsing and drying

• Blood spills

– 10 tablet / 1 litre of water or 1 tablet / 100mls of water

– (10,000ppm of available chlorine)

– Cold water 20 mins to dissolve

– Dispose of after 24hours

– Minimum 2 min contact time prior to rinsing and drying

• Can not be used directly on urine, vomit or

faecal matter

• Must be rinsed if the equipment comes into

contact with the patient skin

Environment

• IPC principles all staff responsible for keeping the ward/department

environments clean and tidy.

• Domestics can’t get into clean if the environment is cluttered, resulting

in dust collections etc…

• Use the friends and family test – would you be happy for you or your

rels to receive care here?

• IPC conduct a yearly environmental audit, CM’s do regular walk round

checks.

• PII wards are audited more regularly as well as wards who score less

that compliant 85%.

Environment

• IPCT - yearly environmental audit

• Action plan

• HCAI repository

• Re-audit

• Responsibility

• Friends and family test

Infection Prevention and Control Team

Telephone:

• JCUH - ext 54800

• FHN - ext 63901

• Middlesbrough, Redcar & Cleveland, Hambleton & Richmond

Locality

ext - 54800

Email: InfectionControl.Team@stees.nhs.uk