1. Insert name of presentation on Master Slide Health Care Associated Infections: Invasive Devices November 2011 Presenter: Liz Smith

2. HCAI Programme It started with; ‘Clean Your Hands’ Campaign Critical Care Improvement Program & Safer Patient 1: CVC bundle Safer Patient 2 : Clean your Hands and Sepsis Currently; 1000 Lives plus concentrating on reducing Catheter associated UTI (CAUTI) and bacteraemia from Peripheral Venous Cannula’s (PVC) Safer Patient ‘pass it on collaborative’ (England) similar to 1000 LP but concentrating on the insertion and maintenance bundles of both work streams. However 3 LHB within Wales contribute to both. BCU, AB & C&V

3. Common HCAIs Gastro-intestinal infections 20.6% Urinary Tract Infection19.9% Surgical Site Infection14.5% Pneumonia14.1% Skin and Soft Tissue10.4% Primary Blood stream 7% 69 E.T.M. Smyth et al (2008) Journal of Hospital Infection 69:230 - 248

4. Most common HCAI in Wales “Chest infections” – 24% –Lower respiratory tract infections and pneumonia together Surgical Site Infections 19% Urinary Tract Infections 16% 69 E.T.M. Smyth et al (2008) Journal of Hospital Infection 69:230 - 248

5. Infection Risks of Medical Devices Breach of normal defences –Skin –Urinary tract – urine flow Device Factors –Materials – plastics –Manipulation Administration of drugs Connection of giving sets Sampling Healthcare Factors –Resistant organisms within hospital environment –Hand hygiene standards of care givers –Insertion and maintenance practices Patient associated risk factors –Debilitated patients –Chronic diseases –Immunosuppression

6. Long term venous catheters first became widely available in the 1960s PICC lines 1975 Learning from others: Critical Care Programme; Central Vascular Catheters

7. Peripheral Vascular Cannulae Widely used since 1960s / 70s Almost standard part of treatment on admission to hospital!!

8. Peripheral Vascular Cannulae IVDs (all) are single most important cause of HA-BSI – US 0.5 blood stream infections per 1000 catheter days Health Board data (Wales) 2010 41% of patients had Peripheral cannulae in situ 1.6% infected Mayo Clin Proc. September 2006;81(9):1159-1171

9. Foley introduced urinary catheterisation in 1920s to reduce bleeding post prostatectomy. Urinary Catheters

10. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122(2):160–166 Humphreys H, Newcombe RG, Enstone J, et al. Four country healthcare associated infection prevalence survey 2006: risk factor analysis. J Hosp Infect 2008;69(3):249–257. Commonest HCAI in US – 32% 16% of HCAI in 2006 prevalence survey Wales were UTI. Attributable mortality as high as 13% in cases complicated by Bacteraemia.

11. Consequences of Infection Worsening condition of a patient with significant other underlying disease Severe local infection Systemic infection leading to death Loss of use of Medical Device Prolonged hospitalisation Increased cost of care –UTI cost £1,122 per patient.

12. Prevalence – Acute 2006 5734 adult in-patients surveyed 25% had an urinary catheter in situ or removed within the previous 7 days 1.7% of catheterised patients had a UTI 69 E.T.M. Smyth et al (2008) Journal of Hospital Infection 69:230 - 248

13. Prevalence – Acute 2010 Device Usage One Health Board –3% of patients had a central line in-situ –41% of patients had a peripheral line in-situ 1.6% infected (3) –21% of patients had an urinary catheter in-situ No CAUTI detected Personal Communication – Dafydd Williams pilot ECDC prevalence survey 2010

14. Prevalence – Long Term Care Facilities HALT prevalence study – July – August 2010 895 residents surveyed across Wales 9% (80pts) had urinary catheters present on the day of the service 6% (5pts) of catheterised patients had a CAUTI Personal Communication – Dafydd Williams HALT prevalence survey 2010

15. Increasing advances and complexity of therapies have resulted in increasing use of medical devices. Infection is an unwanted and often avoidable consequence of the use of medical devices. Ensuring evidence based practice is in routine use when medical devices are used will assist in our aim of reducing HCAI……………

16. What do we aim to achieve? Reducing Waste –Unnecessary placement of urinary catheters and peripheral vascular cannulae Reducing Harm –Infectious and other complications of medical devices –Eliminating preventable Healthcare Associated Infections in Wales Reducing Variation –Ensuring the same evidence based standard of care is put into practice for all patients wherever they are treated in Wales

17. Prevalence Survey 2011 Data collection this November 2011 Across whole of NHS Wales –All Health Boards and Trusts are engaged Data will be collected on the presence of medical devices (urinary catheters, PVC, CVC) Data collected on HCAI related to medical devices

18. Care Bundles Insertion and Maintenance –Urinary catheters –Peripheral vascular cannulae Developing documentation Engaging and enthusing teams

20. Taking the learning forward Examples of best practice being shared. Piloting is well advanced in most Health Boards for both urinary catheter and peripheral vascular cannula care bundles. Spread Plans.

24. The main difference between 1000LP and Safer Patient 3? S top - Is the device needed? Is there an alternative? T hink-What are the clinical indicators for use? Has the patient consented? O ptions-Management of alternative therapies. Document the rationale for use P revent-Health Care Associated Infections Document equipment used with traceability. Be vigilant with ‘Time in Time out’ prescription. Attention to detail.

25. Stop Order Before Insertion. –Clear clinical indication for insertion; to be documented in clinical notes Post insertion. Use it or lose it. –Use should re assessed every shift and reasons documented in clinical/nursing notes. –If the device has not been used for a whole shift, it should be removed

26. 1000 Lives Plus

27. 1000 Lives Plus – tackling new areas of harm Transient Ischaemic Attack (TIA) Rehabilitation following Stroke Chronic Heart Failure Hospital Acquired Thrombosis (HAT) Rapid Response to Acute Illness (RRAILS) Improving Medicines Management Reducing Healthcare Associated Infections (HCAI) Depression Dementia Preventing Acute Coronary Syndrome Patient Identifiers Enhanced Recovery after Surgery Reducing Falls in Intermediate Care Maternity Services

28. Where are we now and where are we going. Most organisations are in spread..small steps. More support to organisations who are in difficulty. Primary care, community and care homes Feb 6 th & 7 th

29. If we can improve care for one patient, then we can do it for ten. If we can do it for ten, then we can do it for a 100. If we can do it for a 100, we can do it for a 1000 And if we can do it for a 1000, we can do it for everyone in Wales.