the scotvan conference the national perspective evonne curran nurse consultant health protection...
TRANSCRIPT
The SCOTVAN conferencethe national perspective
Evonne CurranNurse Consultant
Health Protection Scotland
In this presentation
• What is (not) available nationally– Guidance / Surveillance
• Organisms, Outbreaks, Environments, Equipment – high-infection risks
• What next!
National perspective CDI• Clinical definitions• Surveillance data
– National – published rates set targets– Local
• Guidance (national evidence based):– To prevent infection– To prevent outbreaks– To identify outbreaks– To stop outbreaks– To identify system weaknesses and to optimise systems
• Science– What is happening, strain type, epidemiology
44%
The secret to this success
• Single organism causing single infection category (severity may vary)
• Place of acquisition – usually hospitals (up to 12 weeks)• Way in – faecal oral (airborne dissemination)• What to do changes little: (antibiotics)• Minimal setting specific effect (apart from paeds)• Equipment changes little: designing out bugs• Environmental standards and environmental monitoring • Easy to relate cause to effect
– Infection - Antibiotics – Diarrhoea – CDI• Agreed definitions – easy to use• At a time of increasing patient risk
The risk became clear to the public who were not prepared to accept it (Beck)
• The public, press and politicians set the agenda for reduction and patient safety
Infections associated with vascular access• Multiple different organisms – difficult to count (locally and
nationally)• Different types of infections (insertion site, infusate, catheter)• Setting specific risks• Secondary infections (endocarditis, discitis, septic arthritis)• Delayed on-set• Not easy to relate cause to effect – lots going on…• ‘Lost in the maelstrom of healthcare activity’• Whose job is it anyway: practice / infection control /
pharmacy / patient safety• Pulling forces: safety, function, infection control, time-saving• Other competing complications – functioning of device, X-
reaction• Other similar smaller related issues – invasive devices• Complexity ++++++++++
From a national perspective• Surveillance
– improving local/national data in some settings (renal / ITU) related to some devices
– Marker organism Staphylococcus aureus
• Guidance – no comprehensive guidance of what device, when, how, drug administration gaps, no minimum environmental standards
IV medicines guidance
www.nmc-uk.org/.../nmcStandardsForMedicinesManagementBooklet.pdf
RCN 2010
Infection control
regular competency checking for staff, regular
reviews of training and regular quality control for those aseptic pharmacies
that are not licensed
No definition of regularHealthcare commission 2007
Audit commission
2001
Data – marker organism
• Commonest cause of HA-SAB venflons
• Activities to reduce Vascular Access infections caused by SAB will reduce those caused by CNS and many other organisms
The bundles (HPS / QIS)
• PVC
• CVC
• CNO supported initiative – reduce SABs
Sum up national situation
• Data and guidance need improved• No ideal model out there for this complex
procedure which is performed by extremely busy people in difficult sub-optimal conditions without environmental standards and quality control
Quiet areas free from distraction for the preparation of intravenous drugs do not exist in
the NHS (Curran 2010)
United Sates Pharmacopeia (USP) National Formulary, chapter 797
• Immediate use (1 hour) no more than 2 stabs and simple low risk products
Administration of Immediate-Use CSPs must begin within 1 hour from the start of their preparation; there is no requirement for the
duration of administration. http://www.usp.org/audiences/pharmacist/797FAQs.html
Organisms
The organisms Gram positives - Coagulase negative staphylococci
Staphylococcus
Gram negatives
Picture courtesy of CDC
Fungal Biofilms and Drug ResistanceMary Ann Jabra-Rizk,* William A. Falkler,* and Timothy F. Meiller*
EID 2004
Yeast: Grow, stick, biofilm, resistance, vulnerable patients
Outbreaks
The importance of aseptic technique in preventing even low level contamination
CID 2008 47 Dec
33/80 diagnosed 84-421 days postlast exposure
Pt to Pt transmission of HBV
• 30 papers – 33 outbreaks• 471 patients 16 fatalities• Transmission pathways
– 30% MDVs– 27% Capillary sampling
Lanini et al 2009
0
1
2
3
4
May8th
11th 14th 17th 20th 23rd
Epi Curve ICHE 2009 30 8
10/6
18/6
13/5
Variables
•How big a drug
•Over what time period 4
3
14/2412/0
10
Narayan et al
The importance of aseptic technique in drug preparation
• The ward ran out of pre made up infusions of hepsal.• 2 nurses made up infusions in batches• 12 – patients received the infusions• 5/12 got a blood stream infection A xylosoidans and or S.
marscens• 0/6 patients whose infusate was made up by nurse 1 got infection• 5/6 patients whose infusate was made up by nurse 2 got infection • Of the 5 who were infected
– 4 who had the infusion in the pm got infected immediately– 1 who had infusion in the morning became symptomatic
days later
Gordin et al ICHE 2007
The nurse……
• The outbreak organism was cultured from a nurse’s artificial fingernail, which the nurse used to open a vial of heparin that was mixed to make the flush solution
Gordin et al ICHE 2007
Endemic dangers
• 1093 ward prepared infusates found a contamination rate of 0.9%; and two cases of infusate–related bacteraemia (Macias et al., 2008).
‘strict asepsis could never be assured in a ward setting’
Zavery et al. (2005: 3).
Modes of transmission
• Healthcare worker (HCW) to patient • Patient-to-patient via HCW• Environment-to-patient due to HCW
actions or inactions
Reported modes of infusate contamination
• HCW with BBV cuts finger and bleeds into ampoule• Contamination and reuse of MDVs BBVs, bacteria and
parasites
• Re-using an administration set on wrong person
• Splash contamination during prep• Non-hub cleaning• Contamination of outside of ampoule getting on the
inside • Illegal tampering of hanging infusates• Opening ampoules with a false microbe laden nail
Parker 1995, Al-Saiguel et al 2000, MMWR 2003 Macedo de Oliveria et al 2005Jain et al 2005, Gillespie et al 2007 Hseush et al 1998 MMWR 2005, 2006, Jain et al 2005, Sacher et al 1991, Ostrowshy 2002Halkes & Snow 2007 Sitges-serra 1985, 1985 1984 Doit et al 2004 Nasser et al 2004
Drugs and Duration
• Propofol• Heparin• Anything over 12hours
• (Veber et al. 1994, Bennett et al. 1995, Halkes et al. 2003, Trepanier et al. 2003)
• (Al-Saigul et al. 2000, Centers for Disease Control 2005, Siegman-Igra et al. 2005, Gershman et al. 2008, Yang et al. 2008, Blossom et al. 2009)
Ability to grow in nutritionally poor solutions
• Pseudomonas putida in heparinised saline could survive refrigeration for up to 35 days (Perz et al. 2005)
• Burkholderia cepacia has the ability to grow in distilled water (Spencer 1995).
1,000,000 per ml of solution is not visible to the naked eye
Maki et al 1975
DRUGS ADDED TO THIS INFUSION
PATIENT UNIT No.
WARD ROUTE
DRUGDiluent…………………………
AMOUNT BATCH NO PREP’ED BY
CHECKED BY
Date /Time prepared EXP. DATE/TIME
DISCONTINUE IF CLOUDINESS OR PRECIPITATE DEVELOPS
Study of 2,934 PVCs
• Factors associated with phlebitis
Curran et al 2000
‘Immediate use’ infusions can be high risk
• Can be contaminated during preparation• Low level contamination can start biofilm formation• Higher level contamination will cause IR-BSI
– as soon as the infusion starts, – during the life-time of the infusion – or after it has completed
• Risk increases depending on the drug used, its sterility and the duration of the infusate
Equipment
• We need national experts in infection control / pharmacy / clinical practice / MHRA / IRIC to take this agenda forward
The risks for every new device are never recognised until usage begins
What is the most important bit
• Its rarely the ‘gadget’
Needlefree devices
• Prevent needlestick injury• Caused increase in CR-BSI (positive and
negative valved) Split septum better.
• Specific clamping – unclamping sequence if not right inadequate surface decontamination MHRA alert 2008
W.M Jarvis Recommendations • A smooth external septum surface with few if any gaps• A tight seal between the septum and the housing to reduce or
eliminate space for contamination to occur and biofilm to develop• Straight fluid pathway that facilitates flushing and reduces
internal surface for biofilm development• Little or no dead space in the fluid pathway• No moving parts (mechanical valves)• Does not require a clamping sequence – (clear message if does)• Transparent rather than opaque• Leur access with little or no blood reflux• Saline flush (not heparin)
What can we do now
• Common purpose – what is most important – Avoidance of usage– Aseptic technique (needs better defined) – Removal ASAP
• What comes first?• What is aseptic technique – should we be
using gloves?• Work with others to set the national agenda
Environments
• Pose a risk– No sink– No concurrent procedures
• Must have minimum environmental standards
There are fantastic examples out there of clinical experts who are
setting and performing the highest clinical standards and achieving
optimal safe practice.
How do we make this the norm?
MAINTENANCE
Continuing need assessmentContinuing care assessment
(Insertion site sepsis / infection)Replacement: dressings,
connections, administration sets
Flushing +/-Aseptic techniques
INSERTION
Clinical needCatheter type
Connections and sundriesDressingCare plan
Aseptic techniques (including antiseptics)
INVASIVE DEVICES
USAGE
SamplingAdministration of drugs
/ fluids / bloodsDrainage
Just in caseAseptic techniquesMandatory safety
redundancy checks andsafety steps
Quality assurance and quality controlPVC bundle + invasive device audit
Its still not joined up - yet
Infection
Control
Practice
Development
Clinicians
Clinicians
Clinicians
Clinicians
GuidanceProcurement
Qua
lity
Impr
ovem
ent
- SPSP
PatientReceiving optimal
IV care
Pharmacy
Expert
practitioner
New Equipment
New Evidence
Infe
ctio
n Con
trol
Practice
Development
Clinicians CliniciansClinicians Clinicians
Guidance
Procurement
Qua
lity
Impr
ovem
ent
- SPSP
PatientReceiving optimal
IV care
Pharmacy
Expert
practitioner
New Equipment
New Evidence