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

2. MRSA context 2013

3. C diff context in 2014

4. Blood cultures 2013

5. 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

6. Top Five Bacteraemia
83% over 60
64% over 70

8. Top Five Bacteraemia

9. E. Coli Enhanced Surveillance April to June 2014

10. 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

11. 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

12. 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

13. 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

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

15. Evidence?

16. 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 ‘

17. 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

18. 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

19. 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

20. Complexity: What can I do?

21. Complexity: What can I do?

22. Complexity: What can I do?

23. Complexity: What can I do?

24. ?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.

25. 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.

26. 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.

27. 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.

30. 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

31. 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

32. 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

33. Outputs

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

35. Peripheral vascular cannulae

36. Central lines

37. HDUHB Pos/Neg Urines

38. HDUHB Pos/Neg by month

39. HDUHB Urine Samples

42. Top ten bacteraemia rate 2015

45. HDUHB Suppress/Release

46. Blood cultures 2013

47. Blood cultures 2014

48. 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

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