Hardware or software? Interventions for a sustainable infection control programme Joost Hopman, MD, DTMH Consultant Microbiologist, Head of Infection Control.

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Presentation transcript:

Hardware or software? Interventions for a sustainable infection control programme Joost Hopman, MD, DTMH Consultant Microbiologist, Head of Infection Control Unit Radboud University Medical Centre Nijmegen, The Netherlands Senior Lecturer Community Health, Stellenbosch University, South Africa Hosted by Claire Kilpatrick WHO Infection Prevention and Control Global Unit International Ambassador Program www.webbertraining.com September 22, 2016

Learning Objectives 1. Identify components of infrastructure that could be improved from IPC perspective 2. To evaluate quality monitoring systems for cleaning and disinfection 3. Compare interventions in high and low resource settings

Infectiepreventie=Teamwork Prof. Andreas Voss Prof. Shaheen Mehtar (ICAN,Stellenbosch University) Prof. Benedetta Allegranzi (Infection Control Unit – WHO HQ) Prof. Hans van der Hoeven Drs. Cathy van Beek Prof. Paul Verweij/Prof. Fred Sweep/Prof. Heiman Wertheim Prof. Stefaan Berge Prof. Robert Sauerwein Dr. Jack Meintjes (Stellenbosch University) Dr. Alma Tostmann Dr. Chantal Bleeker-Rovers Drs. Nannet van der Geest Dr. Janette Rahamat IPC unit Tygerberg hospital Afdeling Service bedrijf Afdeling Medische microbiologie

Why infection prevention? Fu Qiao, MD Infection Control Practitioner West China Hospital, 4300 beds, Sichuan University. Resistentie Wensen Chen, MPH,MBBS Jiangsu Province Hospital, 3000 beds

China- CARSS surveillance data 1338 hospitals 4de Netherlands, 2014, E. coli Cephalosporine resistance 5,7% EU, 2014, E. coli Cephalosporine resistance 12%

Future of Hospitals less Bricks, more Bytes, and a different Behaviour less and Safer Bricks, more Bytes, and a different Behaviour

Implementation J.Hopman, arts-microbioloog, Hoofd HIP

Five moments

Radboudumc Campaign Clear message and strong leadership Board of directors and Department leadership Intake meetings with head of departments Advisory board: chair Medical staff, chair nursing staff, chair patient advisory council Choice of Module A module B A: Infrastructure, education, feedback of compliance data B: A + accountability culture Evaluation meetings with head of department 35 clinical departments 2 departments module B

Infrastructure Technical improvements: Beddispensers and walldispensers Addressing allergy and allergy prevention Standardized instructions Reminders Rules with regard to clothes and jewelry: Foam, gels and different flavors of disinfectants

Why Handdisinfection? Education All clinical departments: Staff - head IPC Nursing -IPC nurse

Awareness in the departments IPC linked nurses Internally educated on IPC Central figure for IPC in the department Supervised by IPC nurse Hospital wide meetings with linked nurses from all departments Themes Difficulties, challenges and best practices

Measuring Hand hygiene Compliance Baseline in 2011: 4 major departments 38% compliance

Next steps hand disinfection in 2016 Focus on OPD Keeping up good practices Leadership/role models Accountability for behavior Patiënt participation for specific patient groups Sharing of best practices

Conclusion Multi-modal approach of WHO can be highly effective: Facilitate towards an optimal infrastructure Compliance Measurements and Feedback Education of HCW is underestimated Hospital-Leadership: Full support Personal commitment Adequate Budget

Detection of Transmission in NICU DNA Markers as Surrogate Indicators David G. Oelberg, et al, Pediatrics, 2000

Lessons from history Edmonds, et al, Applied Microbiology, 1972 Teres, et al, The Lancet, 1973 Removal of the ‘Cholera’ handle of the Broad Street Pump, London,1854 Ayliffe, et al, The Lancet, 1974

ICU in Radboudumc Radboud university medical center: 953 patient beds 50 single bed ICU rooms, 35 beds operational Selective digestive tract decontamination (SDD)1 Low MRSA and VRE rates Standard contact precautions Increasing global resistance (GNB) 2 outbreaks related to the sinks Klebsiella pneumoniae ESBL Enterobacter cloacae ESBL 1N Engl J Med 2009; 360:2138-2141, may 2009

Study methods Study design: intervention study Objective:to investigate the effect of the removal of all hand washing sinks from the patient rooms at the Intensive Care unit on the MDRO colonisation rate in ICU patients Study period: Pre-intervention study period: 12 months prior to sink removal Post intervention period: 12 months after sink removal Intervention: In the summer of 2014, hand washing sinks were removed from all patient rooms at all intensive care units and a ‘water-free’ method of patient care was introduced.

Methods Patient selection: All patients admitted at the ICU during the pre or post intervention periods Length of stay: Investigate the effect of prolonged LOS on colonization Selective digestive tract decontamination: routine weekly screening Gram negative Bacilli (GNB) Yeast Main outcome measures: 1.The MDRO colonisation rate : the number of primary positive microbiological results 1000 ICU admission days 2.Colonisation rate ratio: colonisation rate post-intervention colonisation rate pre-intervention

Results Pre-intervention 1351 patients Median age 62 y [IQR 50-70] June 2013 - May 2014 September 2014 - august 2015 intervention Pre-intervention 1351 patients Median age 62 y [IQR 50-70] Post-intervention 1307 patients Median age 63 y [IQR 52-71]

Segmented regression analysis of the interrupted time series data Statistically significant immediate effect on the colonisation rate of gram negative bacilli, but not on the colonisation rate of yeasts LOS>3days

Conclusion This study showed that removal of the hand washing sinks from all patient rooms at the ICU and the introduction of ‘water-free’ patient care resulted in a statistically significant decrease of patient colonization with ICU-acquired GNB . This decrease in patient colonization was even more apparent for patients with an increased LOS.

Anti-bacterial coating of surfaces? Nano-coating toetsenborden J.Hopman, et al, unpublished data

MRSA-positive patients tend to shed their own strain of MRSA into the near-patient environment. Two-thirds of HCW will acquire the patient’s strain on gloved hands or apron. Without direct contact 4 out of 10 will still exit the room carrying the patient’s strain of MRSA on hands or apron.

Mean proportion of positive results of cultures of environmental and hand samples decreased in period 2 and remained low thereafter CID 2006:42 June Hayden

The environmental detection rate for MRSA or VRE was 24 The environmental detection rate for MRSA or VRE was 24.7% compared with 4.9% for multi-resistant gramnegative bacteria

“ The most common nosocomial pathogens( gram positives and Enterobacteriaceae) may well survive or persist on surfaces for months and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed.”

Sources for transmission INDIRECT Bedpans/urinals Dressing trolleys Mattresses Mops & buckets Hand disinfection equipment DIRECT Hands- contact Nasal-droplet Throat- droplet Stool-aerosol

What is included in housekeeping? Differs from one country to another and from one hospital to another House keeping falls under a separate section and is not a nursing duty However, the nurse-in-charge is responsible for the cleanliness of the ward and surrounding areas. Time pressure, number of nurses available!!

House keeping Cleaning of the ward and surrounding areas Removal of waste Removal of linen Stocks of fresh linen Replacing waste containers Replacing hand decontamination items Cleaning ward disinfectors Cleaning non clinical equipment

Systems to evaluate environmental cleanliness, process indicators Visual inspection ATP Fluorescence marker Microbiology Bacterial or viral culture PCR

Average RLU cleaned by domestic staff were 64% lower compared with surfaces cleaned by clinical supportive staff

Transfer from rail to fingertip ranged from 22%-38%

Training of domestic service personnel J.Hopman et al, JHI 2015

Mechanical versus manual bed cleaning J.Hopman et al, JHI 2015

Mechanical versus manual bed cleaning J.Hopman et al, JHI 2015

J.Hopman, JHI 2015

Adenosine triphosphate (ATP) levels (relative light units: RLU) measured before and after manual cleaning in South Africa under ‘routine’ circumstances. Measurements of three locations on 96 beds.

Adenosine triphosphate (ATP) levels (relative light units: RLU) measured on three locations on 150 beds in The Netherlands and 96 beds in South Africa after manual cleaning under ‘routine’ circumstances. ns, not significant.

Tygerberg Academic Hospital: percentage of beds with <250 relative light units (RLU) measured by ATP categorized by type of detergent used for cleaning. Fresh Soap, N = 26; Combination, N = 4; Sparkle, N = 34; Handysan, N = 24; D-germ, N = 2; Bioscrub, N = 6

less and Safer Bricks, more Bytes, and a different Behaviour Conclusions less and Safer Bricks, more Bytes, and a different Behaviour Standardized infection prevention is essential for implementation Focus on 3 pillars: Hand hygiëne and standard precautions Transmission-based precautions Cleaning and disinfection Included in nursing and MD programs! Hospital design and infrastructure has major impact on IPC High resource settings Low resource settings Feedback of observations!

Keep it empty!

September 26 (Free Teleclass – Broadcast live from the annual conference of the Infection Prevention Society – www.ips.uk.net) HOW CAN WE IMPROVE IMPROVEMENT? Dr. Mary Woods, University of Cambridge Academy of Social Sciences September 27 (Free Teleclass – Broadcast live from the annual conference of the Infection Prevention Society – www.ips.uk.net) Debate: ARE CONTACT PRECAUTIONS ESSENTIAL FOR THE MANAGEMENT OF PATIENTS WITH MDROs? Prof. Eli Perencevich, University of Iowa & Dr. Fidelma Fitzpatrick, Royal College of Surgeons in Ireland September 28 (Free Teleclass – Broadcast live from the annual conference of the Infection Prevention Society – www.ips.uk.net) USING SCIENCE TO GUIDE HAND HYGIENE SURVEILLANCE AND IMPROVEMENT Prof. Eli Perencevich, University of Iowa