infection prevention clinical workbook

2018/19

Clinical Workbook part 1

Infection Prevention

Clinical Workbook

Good infection prevention and control are essential to ensure that people who use health and social care services receive safe and effec-tive care. Effective prevention and control of in-fection must be part of everyday practice and be applied consistently by everyone. Good management and organisational process-es are crucial to make sure that high standards of infection prevention and control are set up and maintained. As the regulator of health and adult social care in England, the Care Quality Commission (CQC) will provide assurance that the care peo-ple receive meets essential levels of quality and safety. The Health and social Care Act outlines what Hospitals in England, should do to ensure com-pliance with the registration requirement for cleanliness and infection control and sets out 10 compliance criteria. 1. Systems to manage and monitor the preven-tion and control of infection. These systems use risk assessments and consider how susceptible patients are and any risks that their environment and other patients may pose to them. 2. Provide and maintain a clean and appropriate environment in managed premises that facili-

3. Provide suitable and accurate information on infec-tions to patients and their visitors. 4. Provide suitable accurate information on infections to any person concerned with providing further support or nursing/ medical care in a timely fashion. 5. Ensure that people who have/ develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people. 6. Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection. 7. Provide or secure adequate isolation facilities. 8. Secure adequate access to laboratory support as appropriate. 9. Have and adhere to policies, designed for the indi-vidual’s care and provider organisations, that will help to prevent and control infections. 10. Ensure, so far as is reasonably practicable, that care workers are free of and are protected from expo-sure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care. The Health and Social Care Act 2008

Please read all the infor-mation and answer the questions in part 1 and 2. Please email these to Infection. Preven-

[email protected]

You will need to answer from the Workbook and score 8 correct answers in total to complete your update. We will inform you and Training dept. If you do not achieve the pass rate you will need to attend an Infection Prevention session in the lecture theatre.

Healthcare Associated Infection (HCAI)


The term HCAI covers a wide range of infections. The most well known include those caused by Methi-cillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA),

Clostridium difficile (C. diff) and Escherichia coli (E. coli).

HCAIs cover any infection contracted: - as a direct result of treatment in, or contact with, a health or social care setting. - as a direct result of healthcare delivery in the community. - as a result of an infection originally acquired outside a healthcare setting (for example, in the community) and brought into a healthcare setting by patients, staff or visitors and transmitted to others within that setting (for example, Norovirus). Infection prevention and control is a key priority for the NHS, and Public Health England (PHE) has a re-sponsibility to advise and support the NHS and others in their efforts to prevent HCAIs and any associat-ed risks to health. In 2011 and 2016, Airedale hospital took part in the Europe wide point prevalence survey of hospital ac-quired infection. Our HCAI rate has dropped from 6.8% to 5.5% which is excellent news, which shows that staff are ‘adhering to policies, designed for the individual’s care and provider organisations, that will help to prevent and control infections.’ (Criteria 9) .


Staphylococcus aureus (S. aureus) is a Gram positive bacterium that commonly colonises human skin and is carried in the nose, throat, axillae, toe webs and perineum without causing infection. Once the bacteria gains access to the body, i.e. through a cannula site or a surgical procedure, a mild to life-threatening infection may develop. S. aureus, (whether MSSA or MRSA) is one of the most common cul-prits associated with orthopaedic implant infection. Patients with an Orthopaedic joint, with a S. Aureus bacteraemia may go on to develop an implant infection in around 34% of cases’ Clinical services Journal 2010

S. aureus can produce toxins which can cause: Scalded skin syndrome which attacks skin cells, causing them to split causing large red weeping areas. Paediatrics patients and neonates are more at risk.

Toxic shock syndrome causing hypotension, fever, diarrhoea, skin shedding rash. Enterotoxin causes acute sudden onset gastroenteritis, when food is contaminated with S. Aureus, by interfering with electrolyte imbalance in the gut.

Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and causes extensive tissue necrosis and severe infection. It is carried by < 2% of isolates of S. aureus, (See Management of PVL associated Staphylococcus aureus infections (PVL-SA) Guideline on Aireshare)

Preventing the spread of infection Therefore good hand hygiene of both staff members and patients is needed to prevent transferring the germ around the ward/ hospital.

Staff should wear clean clothes or uniforms daily.

Staff should wear an apron for changing bed linen to prevent skin cells getting on their uniform and should dispose of used linen straight into a linen skip at the bed side, to prevent skin cells from becom-ing airborne. Hand gel should be applied between beds.

Staff should cover any cuts or abrasion with waterproof plasters to prevent themselves from getting wound infections from germs found in the hospital environment. (Contamination injury)

Staff and visitors should not sit on patients beds to prevent the transfer of organisms to or from the pa-tient.


Staphylococcus aureus that are resistant to Flucloxacillin are called MRSA as Methicillin was the previ-ous antibiotic used before Flucloxacillin came on the market. MRSA can vary in resistance to other antibi-otics.

Our bacteraemia (or blood stream infection) target is Zero MRSA Blood stream infections.

Screening Programme All acute admissions to hospital get screened for MRSA and some elective pa-tients. This is due to a DoH study that found that only 1% of elective admissions were MRSA colonised. The exceptions are patients coming for elective orthopaedic operations, pacemaker insertion and breast reconstruction surgery as the surgery is considered a high risk of infection.

Mupirocin resistant Since January 2017 we have seen a large increase in Mupirocin resistant MRSAs. This is partly due to the germ becoming more resistant and the lab using more sensitive testing equip-ment that picks up more cases than we would through the agar plate method that was previously used.

Management of cases/expectations- If a patient is found to be colonised from a nasal screen or infected from a swab/sample, they are either isolated (gold standard) or nursed in a bay with other low risk pa-tients who have no wounds, catheters or cannulae. The patient is prescribed 5 days of nasal antibiotic cream and 5 days of antiseptic body wash which supresses the MRSA present on the skin and allows healthy skin flora to take its place. (NB: Naseptin (used for pregnant mums) nasal cream is a 10day course.) The MRSA patient information leaflet explains how to correctly apply the suppression. Medical staff will decide treatment of any positive swab (e.g. wound) or sample (e.g. urine) with the micobiologist. The MRSA care pathway (Infection prevention Aireshare page) informs you of all the necessary actions needed to prevent further spread of infection whilst caring for the patient.

Post Infection reviews Any MRSA blood stream infection will have a post infection review (PIR), where nursing and medical staff meet to look at how the patient got the infection and whether it was preventable or unpreventable and lessons learned.

MRSA alert The yellow IC triangle symbol is above the patients name on the SystmOne ward board and it identifies the patient as having a history of MRSA colonisation or infection. For more information, see ‘MRSA Management Guideline’ on AireShare.

IC


Daily Risk assessment of low risk

/ and treatment


Monitoring for signs of a

catheter associated urine tract

infection

• Urinary catheters bypass the bodies

natural defence of the flushing action of

urine.

• They are frequently responsible for hospital

acquired urinary tract infections and are the

most common source of bloodstream

infections here at Airedale.

• Germs can enter the urinary tract due either

to poor aseptic technique on insertion, as a

result of contamination on staff members

hands during handling of the device, poor

personal hygiene of the patient, lack of post

insertion catheter care or simply the

catheter bag touching the floor thus allowing

germs access to the device.

Monitoring peripheral cannulae/

central line for signs of infections

Please

monitor

twice a day

Contamination of device- Ensure your hands are

washed and the tray cleaned with a detergent wipe.

Skin organisms- Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (Sani-cloth wipe) and allow to dry prior to the insertion

of a peripheral vascular access device.

The hub should be cleaned with a Sanicloth wipe for a minimum of 15 seconds and allowed to dry before

accessing the system.

Ensure medica-tion is aseptical-ly preparation to prevent contam-ination

Please monitor the Cannula twice a day for signs of phlebitis and record on the VIP chart


such as E. coli. These microorganisms are general-ly acquired from the hospital environment. Infection

risks associated with Peripheral vascular catheters’ Zhang et al. 2016

Ensure the point of insertion is visible under the dressing, allowing staff to check for signs of phlebitis. Ensure that the dressing is dated with the insertion date and the Visual Infusion Phlebitis score and cannula care plan (VIP) is filled in with the date of insertion and the name of the person who inserted the cannula.

Observations of the cannula site should take place twice a day. If any signs of phlebitis are observed then the guide below should be followed. Please ensure that AEFs are completed for any phlebitis that scores 2 or above.

There are four possible pathways leading to pe-ripheral vascular catheter (PVC) infection. The first is migration of microbes down the catheter tract, that is, through the ‘wound’ created to insert the catheter. These microbes may be from the patient’s skin, contaminated disinfectant or healthcare workers’ hands. The process may hap-pen on insertion if the catheter is contaminated and then introduced into the patient or via microbi-al migration at any time while the catheter is in situ. The insertion of a PVC provides a potential portal of entry for bacteria to cross from an unsterile ex-ternal environment to the normally sterile blood. The second route is via the catheter hub, which can become contaminated by healthcare workers’ or patients’ skin flora during connection of fluids, medicine administration or during extraction of blood. Nishikawa reported that bacterial contami-nation was more common in the hub area than indwelling catheter segments, and the hub seems an important risk in post-insertion care, in addition to adequate aseptic technique on catheter inser-tion (Nishikawa et al., 2010; Zingg and Pittet, 2009). The third route is for catheters to be contaminated directly by bacteria circulating in the bloodstream. That is, the patient has an existing bloodstream infection, and microbes are able to attach to the catheter as they pass by the device. The fourth is that of contaminated infusate, which may occur at the manufacturing stage (intrinsic) or during manipulation by healthcare workers (extrinsic). Research confirms that infusates other than water, including heparin, have great potential to form crystals in the intraluminal surface of PVCs, which can induce bacterial attachment and colonisation (Nishikawa et al., 2010).

Microbial attachment on the PVC surface is likely to be followed by biofilm development and matu-ration and dispersion of microbial cells from the biofilm into bloodstream. The most frequently iso-lated bacteria from PVCs are coagulase-negative staphylococci and Staphylococcus aureus. These bacteria can originate from the skin flora of the patient or the hands of healthcare workers and then reach the patients’ tissues and organs via the blood, causing serious infections and high mortality rates. Thus the infectious route for these organisms is likely skin–bloodstream; i.e. the bac-teria enter the bloodstream through PVC wounds in the skin and cause subsequent infection in oth-er organs. The next most common pathogens for PVC-related infections are Gram-negative bacilli


Lansoprazole

Encourage patients to wash their hands be-fore eating!

Follow the ‘Antimicrobial prescribing guidance’ on Aireshare or speak to the microbiologist

Follow the above slide.

Ensure environ-ment and equipment cleaned with Tristel Fuse.

Soap and water hand hygiene only. Hand gel does not kill C.difficile

We need at least a quarter of a sample pot of faeces. We need liq-uid and not lumps of faeces!


Often C.difficile patients pre-sent with confusion; dehydra-tion; acute kidney injury (AKI) due to profuse diarrhoea and possibly even a fall due to diz-ziness. Please remember to send a stool sample to rule out colitis caused by Clostridium difficile infection (C.diff) in these patients.

C.diff is an anaerobic germ, which means it thrives in the gut where no oxygen is pre-sent, but dies when exposed to oxygen. It overcomes this by being able to form a spore, where it wraps itself in a pro-tective layer and lies dormant in the environment, waiting to be picked up on hands and in-gested (eaten!). Getting patients to wash their hands with soap and water after opening their bowels will remove any C.diff spores present, thus preventing them from being left in the environment. Also getting patients to wash their hands before eating will prevent them from ingesting any spores, picked up from the environment. Please communicate with your ward domestic (or Domestic Supervisor on 4102) regarding: - if a patient has been using the communal toilets on the ward whilst having diarrhoea so that the toilets can be cleaned with Tristel fuse and spores removed from the environment. - which side rooms contain infected patients so that they can be cleaned twice daily with Tristel fuse.

Infection prevention- It is important to physically separate the symptomatic patient from other vulnerable patients in order to prevent the spread of Clostridium difficile. They should remain isolated in a single room until 48 hours free of symptoms. Please see the Clostridium Management Guideline for advice on treatment options or speak to the Microbiologist. The patients side room should ideally have its own toilet and the side room door should remain closed where possible, due to airborne dispersal of spores. The side room should be cleaned twice a day with Tristel fuse and the commode should get cleaned after each use. Allocate where possible specific equipment for the infected patient e.g. moving and handling slings, wash bowl, single patient use blood pressure cuff and tourniquet. These must be decontaminated after use.

Contact precautions- Non-sterile disposable gloves and plastic aprons should be donned outside the patients room and worn when in contact with the patient, any body fluids or their environment. Before leaving, gloves should be removed first (without contaminating your hands); then your apron (breaking the neck strap first and then your hands must be thoroughly washed with warm water and liquid soap and dried with paper towels before leaving the side room. Hygienic hand rub must not be used as an alterna-tive as this has no effect on Clostridium difficile spores.


The Secretary of State for Health has launched an ambitious challenge to reduce healthcare associated Gram-negative (E.coli, Klebsiella, and pseudomonas) bloodstream infections by 50% by 2021 and reduce inappropriate antimi-crobial prescribing by 50% by 2021. Gram-negative bloodstream infections are believed to have contributed to approximately 5,500 NHS patient deaths in 2015.

Enterobacteriaceae are a large family of Gram-negative bacteria that includes many of the more familiar pathogens (germs that cause disease), such as Salmonella, Escherichia coli or E. coli, Yersinia pestis (causes plague), Klebsiella and Shigella, Proteus, Enterobacter, Serratia, and Citrobacter. E. coli is a part of all human and animal gut flora and can be acquired from animals, other humans or through the food chain in uncooked food. Acquisition of E.coli causes no symptoms (unless the germ produces a toxin as in E.coli 157) as the body does not recognise E.coli as a pathogen. Gut flora are readily shared among family members, in prisons, hospitals, music festivals, anywhere where hand hygiene is poor and the en-vironment is contaminated with these germs. Trying to achieve this target set by the Secretary of State for Health is likely to be a far harder challenge than previous targets to reduce MRSA blood stream infections (BSI) and C. difficile, and the evidence base around which to develop preventive strategies is presently rather thin. Also, there are no accepted decolonization treatments for people colonized with Gram-negative bacteria. Consequently, the infection control strategies that have been successful in preventing MRSA BSI cannot be expected to work for BSI caused by Gram-negative bacteria. Several guidelines have been published on the prevention and control of multidrug-resistant Gram-negative bacteria, however, there are no guidelines that consider the preven-tion and control of all BSI caused by non resistant Gram-negative bacteria within healthcare settings. Jour-

nal of Hospital Infection, March 2018.


A total of 40,580 cases of E. coli bacteraemia were reported by NHS trusts in England between 1 April 2016 and 31 March 2017. These have been rising year by year, since the year 2000 but numbers of hospi-tal acquired cases (48hrs after admission) have stayed consistent each year at between 20-23%. The ma-jority of cases are community acquired, found in elderly people and occurred primarily through a urinary tract infection, that likely originated from their own bowel flora. A sentinel surveillance study in England looking at risk factors associated with E. coli Bacteraemia found that approximately half of the community-onset cases had some sort of healthcare intervention in the four weeks prior to the bacteraemia onset. 2016/17 AGH had 132 E. coli bacteraemia,15 cases were Hospital acquired.

It is the above 20-23% of hospital acquired cases that we need to aim to reduce. So how can we do this? - It is important that we ensure our patients drink plenty of fluid to aid the natural flushing effect of urine washing bacteria out of the bladder. Dehydrated patients are more prone to urinary tract infections!

- Ensuring that incontinent patients with pads are checked regularly and are thoroughly cleaned after each episodes of incontinence.

- Advising patients not to touch their line dressings or urinary catheters, unless their hands are clean and have been shown what to do.


Preventing Urinary Catheter associated Urinary tract infection.

Key recommendations- Wherever possible the patient must be taught to care for their own urinary catheter. This will help to prevent the risk of infection and will give the patient autonomy. When perform-ing catheter cares the nurse must always wear gloves (non- sterile) and wear a disposable apron. - All urinary catheters should be secured to the patient’s leg by a retaining strap; this is to prevent the catheter from sliding up and down the urethra. This could lead to trauma of the urethra, bladder neck, glans penis. It also prevents accidental disconnection or removal. Cleaning the catheter: Soap and water to clean the catheter is sufficient. This can be done in the shower or bath. Daily bathing should be encouraged Pratt et al (2001). A dispos-able wipe can be used to clean the catheter, away from the urethra. Talcum powder or antiperspirants/perfumes are not to be used around the catheter. The glans of the penis can be cleaned using a disposable wipe with soap and water. The foreskin, retracted for cleaning, must be replaced to prevent a paraphimosis. Make sure the male patients are aware of this so that they can prevent this from happening. Infection prevention: A ‘closed system’ is where the catheter stays attached to the leg bag/ valve. The only time the system is broken is when the leg bag/ valve is changed (every 7 days). Attaching a night bag does not break the system. Maintaining a sterile, continuously closed system is essential to the pre-vention of catheter associated infection. Modern closed systems have significantly reduced the incidence of bacteraemia. Breaches in the closed system, such as unnecessary emptying of the urinary drainage bag or taking a urine sample, will increase the risk of catheter related infection and should be kept to a minimum (Pellowe 2005). The bag should be emptied before it is three quarters full. - Catheter bags must not be allowed to touch the floor. They should be secured to the patient’s leg or set on a specifically designed catheter stand. Bacteria can travel up the catheter system and enter the body causing infection. The drainage bag must be kept below the level of the patient’s bladder at all times, (or emptied before a procedure i.e. turning or physiotherapy). It is essential to always wear gloves/apron and wash hands before and after contact with the catheter bag.


Page 18

All the answers to the below questions are found in this workbook. Please write your answers on this sheet and email to Infection Prevention Nurse James Stickland [email protected]

You will need to answer from the Workbook and score 8 correct answers in total to complete your update. We will inform you and Training dept. If you do not achieve the pass rate you will need to attend an Infection Prevention session in the lecture theatre.

1. What is the name of the toxin that ‘destroys white blood cells and causes extensive tissue necrosis and severe infection’?

A) Enterotoxin

B) Toxic shock syndrome

C) Panton Valentine Leukocidin

2. Patients admitted from ……… get commenced on MRSA suppression?

A) Home

B) Hospitals abroad

C) Nursing homes

3. What management of a patient found to be positive for MRSA is considered Gold standard?

A) Isolation

B) MRSA suppression

C) A post infection review

4. What is the 2nd route of infection via, in regards to peripheral vascular catheter (PVC)

infection?

A) Migration of microbes down the catheter tract

B) Contamination by bacteria circulating in the blood stream

C) The catheter hub

5. What are the next most common pathogens for PVC-related infections?

A) Coagulase negative staphylococci

B) Staphylococcus aureus

C) Gram-negative bacilli such as E. coli

6. How can we prevent C.diff spores form being ingested by patients?

A) Wash their hands before eating

B) Only eat hospital food

C) Only eat salads

7. Dehydrated patients are more prone to………?

A) Wrinkles

B) UTIs

C) Headaches

Please continue with Part 2.

infection prevention clinical workbook

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