Doctors induction 2011

1. Doctors induction 2011 Infection Control and Antibiotic Prescribing Dr A. Keith Morris

2. Overview Transmission Based Precautions Peripheral Vascular Catheter (PVC) C. Difficile Hand decontamination Death certification Communication OHSAS & needle stick injuries MRSA screening Antibiotic prescribing

3. What is NHS Fife doing to prevent HAI? NHS Fife is doing alot and you are expected to do your part • Process will be different in Fife • Infection Control Manual on intranet • Ward Boards • Antibiotic management • Protecting YOU from the patient and the patient from YOU

4. Older terms that now should not be used - “Universal precautions” - “Enteric precautions” Infection control terminology Standard infection control precautions Transmission based precautions Standard precautions

5. Transmission based precautions • Supplement standard precautions. • specify precautions to individual patients documented/suspected of being infected or colonised with highly transmissible and/or epidemiologically important pathogens or clinical syndromes • Three types • Contact • Droplet • Airborne

7. Transmission Based Precautions • Infection Control Manual found on the right hand side of the NHS Fife Intranet home page • Has all you need to know for every infectious organism you will come across but……. If in doubt call the Infection Prevention & Control Team x28833

8. C. difficile

9. How good are we? NHS Fife has one of the lowest rates of CDI in Scotland

10. C. difficile • Microbiologist will contact the ward to speak to the FY1/FY2 about the case • You need to be able to assess the severity • Know which antibiotic to give depending on the severity • In Fife there is aCDI care pack. Consists of -C. difficile Notification Form -CDI Medical Management Form -Stool chart – monitored daily -Algorithm for the Management of CDI

12. What else you should be doing • Monitor – fluid balance and nutritional status with U&Es, albumin • Stop gastric acid suppressants • Contact precautions • Wash hands with soap and water

13. Hand Decontamination • Hand hygiene is the most important action to prevent the spread of infection • Use alcohol rubs if hands socially clean • Hands MUST be washed after removing gloves • Use alcohol gel before EVERY patient contact If patient has diarrhoea or vomiting must wash hands with soap and water

14. Hand decontamination –SPSP expect • Bear below the elbows plus removal of watches and rings with stones • Wet hands AND THEN apply soap to all surfaces • Rinse hands • Dry hands with paper towels • Dispose of paper towels with out contaminating hands

15. CMO letter (2011)13 This makes it mandatory in Scotland to inform the Infection Prevention Control Team if any of the following terms are written on either part of a death certificate • MRSA – inform Procurator fiscal • C. difficile – inform Procurator fiscal • Hospital acquired infection • S, aureus bacteraemia – all SAB related deaths to be investigated

16. Communication • Patients with an infectious disease or syndromes e.g. D&V, MUST NOT be transferred or sent for investigation without warning the receiving unit • This requires documentation on transfer letters, and investigation requests • Follow up results as soon as available if patient has moved elsewhere

17. Peripheral Vascular Catheters (PVCs) • All PVCs to have the time & date of insertion clearly labelled on the dressing • Insertion sticker in the Medical notes (A&E- printed on front sheet of A&E record) • Maintenance sticker in the nursing notes (nurses perform this task) • PVC change after 72 hours • DO NOT take blood cultures through PVCs Make your life easy switch to oral agents!

18. Ensure an Insertion Label is completed for every venflon inserted I feel assured! Are you? Date & time visible Insertion site clearly visible Every patient… Every time! Further details from ward staff

19. What else have I to do once I have inserted a venflon? Venflon to be checked daily. Complete a daily check label example Date & time of insertion to be written on venflon dressing Peripheral Vascular Catheter Care Bundle HPS Cannula site: Cannula gauge / colour: Still in use / required Y N Absence of inflammation / extravasation Y N Dressing intact and dated & timed Y N Inserted for less than 72 hours Y N Hand hygiene before & after all PVC bundle checks Y N Please circle PVC removed PVC left in situ Reason for removal: Date: / / Time: Complete an Insertion Label example Place label in medical notes / episode of care sheet

20. Insertion stickers • Collect them when you collect other items for the PVC insertion • Where do you find them on blood trolleys and nursing stations • Insert them into the medical notes after you have inserted the venflon and complete

21. Does strict PVC management have an effect? Intervention

22. SABs and you • All hospital acquired SAB will be investigated. • All SAB related deaths to be reported to the Infection Prevention & Control office • If a SAB occurred on your patient you will have to explain any failings in the management of the PVC, pressure sores, etc. • Make your life easy remove PVCs, catheters and ask the nursing staff about pressure sores and broken skin.

23. OHSAS Know you immune status too: • HBV • Chicken pox • Mumps • Measles • Rubella

24. Needle Stick Injuries • What to do • Who to inform (line manager, OHSAS) • Who performs risk assessment • Who takes blood (patient and HCW) • Where to get PEP

25. Mandatory MRSA screening in Scotland • All elective admissions (except obstetrics & paediatrics) • All emergency and elective admissions to ICU, vascular, orthopaedics and renal unit • Clinical Risk Assessment on all other patients • If answer positive to ≥1 of three questions then patient screened

26. Antibiotic StewardshipNHS Fife is different.....!

27. Why has antibiotic control become so important? • Increasing antibiotic resistance in Fife • Lack of new antibiotics in the pipe line • C. difficile “The age of liberal antibiotic policies is over. The time for antibiotic restriction has arrived” Dr Keith Morris 2008

28. What are we trying to do in Fife? Restrict the use of certain antibiotics/antifungals with out Microbiology or ID approval Abbreviated antibiotic guidance for common infections applicable to all in-patient areas Making antibiotic guidance accessible -Pocket guidance -Ward posters Full guidance available in the intranet Collect data on antibiotic consumption Provide surveillance information to wards AMT controls antibiotic use in Fife

29. Examples of restriction • The only use of ceftriaxone is meningitis • Ceftriaxone to be removed form drug cupboards on adult general medical & surgical wards • Meropenem and tigecycline • Temocillin • Linezolid • Voriconazole Is it having any effect?

30. Always think.. Does this patient really need an antibiotic? If the patient is clinically stable with a raised WCC or temperature they do not need antibiotics? Have a plan for what antibiotics to prescribe if patient deteriorates If a patient has had 5 days of an empirical antibiotic and not improved they are on the incorrect antibiotic or source control has not been established

31. Know the NHS Fife…. • Dress code -For everyone in NHS Fife • Boards for wards -Operational division only

32. Healthcare Environment Inspectorate Scotland (HEIS) • A branch of SGHD • Inspect ALL acute hospitals in Scotland • Expect FY and STS doctors to know about and follow -Dress code -Where to find the Infection Control Manual - National surveillance for infection prevention -SSI surveillance for hip arthroplasty & C sections -SABs & C. difficile -Hand hygiene audits -Cleaning audits -Where to find ward results for the above

33. Summary • NHS Fife will have different practice to where you have come from and where you trained e.g. C. difficile & PVCs • Follow NHS Fife practice not what you think is best practice • ALL medical devices and areas of broken skin will give rise to infection if you do not manage them. THINK ABOUT THEM • If in doubt ask -I/C ext 28833 -The switchboard for “duty microbiologist”

34. And one final request…