Patient-centred risk management strategy for multi-resistant organisms Infection Prevention Quality, Safety and Patient Experience February 2012

Update on VRE guidelines for hospitals

Guide The patient-centred risk management strategy for multi-resistant organisms (MROs) a guide for hospitals can adapt for local use The guide is not designed for residential care

Australian Guidelines for the Prevention and Control of Infection In Healthcare (2010) Based on: Australian Commission on Safety and Quality in Health Care (ACSQHC) Australian Guidelines for the Prevention and Control of Infection In Healthcare (2010) National approach Best available evidence Risk management framework Patient-centred 2 level strategy –Core –Additional strategies Antimicrobial stewardship promotion

Risk management framework Risk management principles applied to MROs 1. Avoid risk Not avoidable in healthcare Must be managed

2. Identify risk Who is at risk? What is infectious agent? 3. Analyse risk How is it transmitted? Why can this happen? How likely is it to happen? What are the consequences? Risk management principles applied to MROs

4. Evaluate risk What can be done to reduce or eliminate the risk? 5. Treat risk Who will do it? How will it be monitored? Risk management principles applied to MROs

Risk assessment and modified contact precautions Risk assessment and modified contact precautions already in place in many health services to p rioritise single rooms Risk factors: Patient population Setting/infrastructure Local experience of MRO Possible endemic MROs Degree of antimicrobial stewardship

Patient-centred risk management strategy for multi-resistant organisms Health care services can adapt to their local needs Transmission-based precautions for all MROs Designed for acute care health services

‘Routine Practices and Additional Precautions in Health Care Settings’; Health Canada, Revised July 2011 Adapted Provincial Infectious Diseases Advisory Committee (PIDAC) Routine Practices and Additional Precautions in all Health Care Settings revised July 2011 Based on “chain of infection” principles infectious agent source patient environment susceptibility of the host

Patient-centred risk management strategy for multi-resistant organisms Risk assessment for management of MROs Consider: Patient risks Environmental risks Organisational risks Patient risks Clinical/additional risk factors Colonised/infected Antibiotic exposure/use Decolonisation opportunities Patient population in hospital area/ ward

Risk assessment for management of MROs Environmental risks Layout hospital area/ward Environmental cleaning and disinfection Local prevalence of MROs Organisational risks Level of HCW training in infection control principles Background surveillance monitoring strategies Implementation of antimicrobial stewardship

Patient-centred risk assessment Using patient-centred risk assessment Emphasizes consistent practice of standard precautions Tailors the use of contact precautions to local conditions

Patient-centred risk assessment Advantages Current status of patient considered Low risk patients/settings Improved access to medical care Less demand on single rooms Reduced financial costs (consumables etc) Potentially less cancelled/postponed procedures Patient not feeling “isolated” Disadvantages Risk assess at each episode of care Standard precautions must be rigorously followed

Patient-centred risk management strategy for multi-resistant organisms MRO working group Infection prevention and infectious disease consultants representing 5 health services Feedback from regional Department of Health infection prevention consultants 4 pilot study hospitals large metro large regional medium sub regional medium private sub regional Outcome measures No increase in clinical specimens of MROs during pilot Number of times tool misinterpreted

Pilot Pilot results 6-8 weeks 52 patients with MRO risk assessed 17/52 standard precautions 35/52 transmission-based precautions Feedback No increase in clinical isolates of MROs Flow chart easy to use Uncertainty with terminology (changed) Scenarios helpful

Pilot Limited time for pilot Used the experience of 2 large health services who have risk assessment and modified contact precautions in place 1-2 years No increase in clinical isolates Local policies to assist risk assessment –specify which patient populations and which wards require single rooms and contact precautions

Patient-centred risk management strategy for multi-resistant organisms

Quick guide flow chart Appendix 1 of the strategy is a quick guide flow chart for assessment clinical risk and additional risk factors Set up with tick boxes Can completed for individual patients and filed in medical record Used as a wall chart Adapt locally, for example specify high risk patient populations and areas/wards

Where is the guide? Search: Infection prevention in Victoria

Patient-centred risk management strategy for multi-resistant organisms Patient-centred Risk-based approach Guide- adapt locally Acute hospitals Transmission based precautions for all MROs

Implementation resources- ACSQHC OSSIE toolkit Case studies Checklists Templates/ worksheets Action plans Project plans URL links Additional reading

Implementation resources 5 phase approach to change management developed by the Clinical Handover Initiative at ACSQHC O Organisational leadership S Simple solution development S Stakeholder engagement I Implementation E Evaluation and management

Acknowledgements: MRO working group members Rural Infection Control Practice Group (RICPRAC) members Patient-centred risk management strategy for multi-resistant organisms

Infection Prevention in health services Department Health Infection Prevention in health services initial contact: Theresa Williamson Acting Manager, Quality and Safety Programs who will liaise with the Director, Quality, Safety and Patient Experience regarding who best to advise For the moment all infection control advice will be managed from resources within the department. As usual communicable diseases matters: Communicable Diseases Prevention and Control Unit