Tackling Urinary Tract Infection: part of the Paradigm Shift in HCAI Management in Hywel Dda UHB Dr Mike Simmons

MRSA context 2013

C diff context in 2014

Blood cultures 2013

Top Ten Bacteraemia 2014 All Wales 81 24 14 9 7 5 4 3 Rate/100,000 bed days E coli MSSA Enterococcus Klebsiella Pneumo CNS Proteus Ps. Aeruginosa MRSA Enterobacter Aneurin Bevan 76 19 12 10 <4 6 Abertawe Bro Morgannwg 79 25 15 11 Betsi Cadwaladr 85 20 <3 Cardiff and Vale 69 29 17 <5 8 Cwm Taf 86 28 13 Hywel Dda 108 33 21

Top Five Bacteraemia 83% over 60 64% over 70

Top Five Bacteraemia

E. Coli Enhanced Surveillance April to June 2014

Hypothesis RCA of MRSA and C diff = antibiotic use Sepsis presenting in secondary care must be treated Reduce sepsis presentations → reduce exposure to antibiotics → reduce MRSA and C diff Whole health economy approach: infection prevention in the community as well as secondary care

The Paradigm Shift in Hywel Dda Continue to see all infections as intolerable i.e. Zero Tolerance to HCAI Recognise the big three: Respiratory Infection Urinary Infection Skin and Surgical Site Infection Engage, energise and empower all staff across the acute and community sector with special efforts to get upstream into the community

The Paradigm Shift in Hywel Dda Accept that Welsh Government will continue to challenge around MRSA and C diff Monitor E coli bacteraemia as a better surrogate for infections across our services

Prudence and Complexity: Actions to reduce HCAI Complexity science Squeeze multiple issues simultaneously Test every initiative or intervention with 2 rules: First: do no harm Second: seek and take the positive step or action

Evidence? Best kept HCAI public “secret” in Wales Caesarean section surgical site infection reductions

Evidence?

Transformational change Minimal Viable Transformation (MVT): change should be small and imperfect---- Deloitte ---- ‘Our transformation process is going to be small and imperfect -- we are going to do many small things that probably wont work straight away. However we will learn lessons from these ‘experiments’ and apply the learning to a better next small thing, making sure we progressively move towards the right direction -------- ‘ Ref: @whatsthepont

So What’s the Pont? Most transformation programmes are about BIG ideas where there is little room for failure Testing and development of small ideas is much lower risk and potentially leads to solutions that work better for people The Minimum Viable Product (MVP) approach offers something different that could be widely applied to most changes in public services Read this and other original posts by Chris Bolton at www.whatsthepont.com

Antibiotic use and the rules Rule 1: by default antibiotics cause harm Rule 2: positive action: prescribe when the benefits outweigh the harms Use the wrong antibiotic: harm Positive action: check Welsh Clinical Portal

Medical device use and the rules Rule 1: by default medical devices cause harm Rule 2: positive actions: life saving in acute event Review the need on a regular basis: change/remove when negative outweigh positive

Complexity: What can I do?

Complexity: What can I do?

Complexity: What can I do?

Complexity: What can I do?

?UTI 24/04/2016 Dr M D Simmons: Clinical information asks, "?UTI." Microbiology cannot answer that question because that requires clinical insight and none provided. In older adults in particular but in younger people depending on underlying pathology, asymptomatic bacteruria can occur and antibiotics should be reserved for clinical signs of infection. Sensitivities therefore suppressed pending clinical engagement with the on-call microbiologist if indicated.

Non-UTI clinical details 24/04/2016 Dr M D Simmons: The clinical details do not describe any clinical signs of urinary infection. Asymptomatic bacteruria is not an uncommon finding as people get older and inappropriate antibiotics can lead to further selection of antibiotic resistance. Sensitivities therefore suppressed but available from the on-call microbiologist if clinically indicated.

Dipstick results only 24/04/2016 Dr M D Simmons: Dipstick results only given on the request form; no clinical information regarding signs or symptoms, which should always be the precursor to using a dipstick. Asymptomatic bacteruria is commonplace in older patients but also in younger people if there are underlying anomalies and antibiotics should be reserved for clinical signs of infection. Sensitivities therefore suppressed. Please call the on-call microbiologist if antibiotics are clinically indicated.

No clinical details 24/04/2016 Dr M D Simmons: No clinical details provided, therefore no sensitivities reported. Please call the on-call consultant if antibiotics are indicated for clinical evidence of infection. Asymptomatic bacteruria in commonplace in older patients and antibiotics are not indicated and may select for increasingly resistant organisms.

Other early interventions Simple interventions to reduce risks around IV cannulation and line associated infection Simple interventions to reduce risk of pseudobacteraemia with Staph aureus

Cannulation Pack Cannulation Pack RML506-040 4 x Swab Non Woven 7.5 x 7.5cm 4ply 1 x Cannula Insertion Label 1 x Orange Bag, Folded 1 x Dressing Tegaderm IV 7x 8.5cm Ported 1 x Paper: Tissue/PE Folded 1 x Paper: Tissue/PE 1 x Chloraprep SEPP 0.67ml Applicator 1 x Pre-Filled Saline Syringe 10ml 1 x Tourniquet

Blood culture pack Blood Culture Pack RML506-039 3 x Swab Non Woven 7.5 x 7.5cm 4ply 1 x Orange Bag Folded 2 x Cotton Wool Balls Small 1 x Paper: Blue Tissue/PE Fldd & Fen 1 x Paper: Tissue/PE 1 x Chloraprep FREPP 1.5ml 1 x Blood Collection Adaptor (Blue) 1 x Tourniquet 1 x Blood Culture Patient Label 1 x Blood Collection Set - Push Button 21g 1 x Sani Cloth port & hub prep

Outputs

Blood culture contamination   HHDB 2014 HDHB 2015 HDHB 2016 Contam 938 888 934 Total 15064 16286 17892 Rate 6.23% 5.45% 5.22%

Peripheral vascular cannulae

Central lines

HDUHB Pos/Neg Urines

HDUHB Pos/Neg by month

HDUHB Urine Samples

Top ten bacteraemia rate 2015

HDUHB Suppress/Release

Blood cultures 2013

Blood cultures 2014

Next steps? Further “Safe to fail” experiments Continue and extend engagement Empower more of our staff Swansea University Elderly Gut Health Programme Continued improvement in quality and safety

InfectionControlTeam@wales.nhs.uk www.phw.org.uk