The SCOTVAN conferencethe national perspective

Evonne CurranNurse Consultant

Health Protection Scotland

In this presentation

• What is (not) available nationally– Guidance / Surveillance

• Organisms, Outbreaks, Environments, Equipment – high-infection risks

• What next!

National perspective CDI• Clinical definitions• Surveillance data

– National – published rates set targets– Local

• Guidance (national evidence based):– To prevent infection– To prevent outbreaks– To identify outbreaks– To stop outbreaks– To identify system weaknesses and to optimise systems

• Science– What is happening, strain type, epidemiology

44%

The secret to this success

• Single organism causing single infection category (severity may vary)

• Place of acquisition – usually hospitals (up to 12 weeks)• Way in – faecal oral (airborne dissemination)• What to do changes little: (antibiotics)• Minimal setting specific effect (apart from paeds)• Equipment changes little: designing out bugs• Environmental standards and environmental monitoring • Easy to relate cause to effect

– Infection - Antibiotics – Diarrhoea – CDI• Agreed definitions – easy to use• At a time of increasing patient risk

The risk became clear to the public who were not prepared to accept it (Beck)

• The public, press and politicians set the agenda for reduction and patient safety

Infections associated with vascular access• Multiple different organisms – difficult to count (locally and

nationally)• Different types of infections (insertion site, infusate, catheter)• Setting specific risks• Secondary infections (endocarditis, discitis, septic arthritis)• Delayed on-set• Not easy to relate cause to effect – lots going on…• ‘Lost in the maelstrom of healthcare activity’• Whose job is it anyway: practice / infection control /

pharmacy / patient safety• Pulling forces: safety, function, infection control, time-saving• Other competing complications – functioning of device, X-

reaction• Other similar smaller related issues – invasive devices• Complexity ++++++++++

From a national perspective• Surveillance

– improving local/national data in some settings (renal / ITU) related to some devices

– Marker organism Staphylococcus aureus

• Guidance – no comprehensive guidance of what device, when, how, drug administration gaps, no minimum environmental standards

IV medicines guidance

www.nmc-uk.org/.../nmcStandardsForMedicinesManagementBooklet.pdf

RCN 2010

Infection control

regular competency checking for staff, regular

reviews of training and regular quality control for those aseptic pharmacies

that are not licensed

No definition of regularHealthcare commission 2007

Audit commission

2001

Data – marker organism

• Commonest cause of HA-SAB venflons

• Activities to reduce Vascular Access infections caused by SAB will reduce those caused by CNS and many other organisms

The bundles (HPS / QIS)

• PVC

• CVC

• CNO supported initiative – reduce SABs

Sum up national situation

• Data and guidance need improved• No ideal model out there for this complex

procedure which is performed by extremely busy people in difficult sub-optimal conditions without environmental standards and quality control

Quiet areas free from distraction for the preparation of intravenous drugs do not exist in

the NHS (Curran 2010)

United Sates Pharmacopeia (USP) National Formulary, chapter 797

• Immediate use (1 hour) no more than 2 stabs and simple low risk products

Administration of Immediate-Use CSPs must begin within 1 hour from the start of their preparation; there is no requirement for the

duration of administration. http://www.usp.org/audiences/pharmacist/797FAQs.html

Organisms

The organisms Gram positives - Coagulase negative staphylococci

Staphylococcus

Gram negatives

Picture courtesy of CDC

Fungal Biofilms and Drug ResistanceMary Ann Jabra-Rizk,* William A. Falkler,* and Timothy F. Meiller*

EID 2004

Yeast: Grow, stick, biofilm, resistance, vulnerable patients

Outbreaks

The importance of aseptic technique in preventing even low level contamination

CID 2008 47 Dec

33/80 diagnosed 84-421 days postlast exposure

Pt to Pt transmission of HBV

• 30 papers – 33 outbreaks• 471 patients 16 fatalities• Transmission pathways

– 30% MDVs– 27% Capillary sampling

Lanini et al 2009

0

1

2

3

4

May8th

11th 14th 17th 20th 23rd

Epi Curve ICHE 2009 30 8

10/6

18/6

13/5

Variables

•How big a drug

•Over what time period 4

3

14/2412/0

10

Narayan et al

The importance of aseptic technique in drug preparation

• The ward ran out of pre made up infusions of hepsal.• 2 nurses made up infusions in batches• 12 – patients received the infusions• 5/12 got a blood stream infection A xylosoidans and or S.

marscens• 0/6 patients whose infusate was made up by nurse 1 got infection• 5/6 patients whose infusate was made up by nurse 2 got infection • Of the 5 who were infected

– 4 who had the infusion in the pm got infected immediately– 1 who had infusion in the morning became symptomatic

days later

Gordin et al ICHE 2007

The nurse……

• The outbreak organism was cultured from a nurse’s artificial fingernail, which the nurse used to open a vial of heparin that was mixed to make the flush solution

Gordin et al ICHE 2007

Endemic dangers

• 1093 ward prepared infusates found a contamination rate of 0.9%; and two cases of infusate–related bacteraemia (Macias et al., 2008).

‘strict asepsis could never be assured in a ward setting’

Zavery et al. (2005: 3).

Modes of transmission

• Healthcare worker (HCW) to patient • Patient-to-patient via HCW• Environment-to-patient due to HCW

actions or inactions

Reported modes of infusate contamination

• HCW with BBV cuts finger and bleeds into ampoule• Contamination and reuse of MDVs BBVs, bacteria and

parasites

• Re-using an administration set on wrong person

• Splash contamination during prep• Non-hub cleaning• Contamination of outside of ampoule getting on the

inside • Illegal tampering of hanging infusates• Opening ampoules with a false microbe laden nail

Parker 1995, Al-Saiguel et al 2000, MMWR 2003 Macedo de Oliveria et al 2005Jain et al 2005, Gillespie et al 2007 Hseush et al 1998 MMWR 2005, 2006, Jain et al 2005, Sacher et al 1991, Ostrowshy 2002Halkes & Snow 2007 Sitges-serra 1985, 1985 1984 Doit et al 2004 Nasser et al 2004

Drugs and Duration

• Propofol• Heparin• Anything over 12hours

• (Veber et al. 1994, Bennett et al. 1995, Halkes et al. 2003, Trepanier et al. 2003)

• (Al-Saigul et al. 2000, Centers for Disease Control 2005, Siegman-Igra et al. 2005, Gershman et al. 2008, Yang et al. 2008, Blossom et al. 2009)

Ability to grow in nutritionally poor solutions

• Pseudomonas putida in heparinised saline could survive refrigeration for up to 35 days (Perz et al. 2005)

• Burkholderia cepacia has the ability to grow in distilled water (Spencer 1995).

1,000,000 per ml of solution is not visible to the naked eye

Maki et al 1975

DRUGS ADDED TO THIS INFUSION

PATIENT UNIT No.

WARD ROUTE

DRUGDiluent…………………………

AMOUNT BATCH NO PREP’ED BY

CHECKED BY

Date /Time prepared EXP. DATE/TIME

DISCONTINUE IF CLOUDINESS OR PRECIPITATE DEVELOPS

Study of 2,934 PVCs

• Factors associated with phlebitis

Curran et al 2000

‘Immediate use’ infusions can be high risk

• Can be contaminated during preparation• Low level contamination can start biofilm formation• Higher level contamination will cause IR-BSI

– as soon as the infusion starts, – during the life-time of the infusion – or after it has completed

• Risk increases depending on the drug used, its sterility and the duration of the infusate

Equipment

• We need national experts in infection control / pharmacy / clinical practice / MHRA / IRIC to take this agenda forward

The risks for every new device are never recognised until usage begins

What is the most important bit

• Its rarely the ‘gadget’

Needlefree devices

• Prevent needlestick injury• Caused increase in CR-BSI (positive and

negative valved) Split septum better.

• Specific clamping – unclamping sequence if not right inadequate surface decontamination MHRA alert 2008

W.M Jarvis Recommendations • A smooth external septum surface with few if any gaps• A tight seal between the septum and the housing to reduce or

eliminate space for contamination to occur and biofilm to develop• Straight fluid pathway that facilitates flushing and reduces

internal surface for biofilm development• Little or no dead space in the fluid pathway• No moving parts (mechanical valves)• Does not require a clamping sequence – (clear message if does)• Transparent rather than opaque• Leur access with little or no blood reflux• Saline flush (not heparin)

What can we do now

• Common purpose – what is most important – Avoidance of usage– Aseptic technique (needs better defined) – Removal ASAP

• What comes first?• What is aseptic technique – should we be

using gloves?• Work with others to set the national agenda

Environments

• Pose a risk– No sink– No concurrent procedures

• Must have minimum environmental standards

There are fantastic examples out there of clinical experts who are

setting and performing the highest clinical standards and achieving

optimal safe practice.

How do we make this the norm?

MAINTENANCE

Continuing need assessmentContinuing care assessment

(Insertion site sepsis / infection)Replacement: dressings,

connections, administration sets

Flushing +/-Aseptic techniques

INSERTION

Clinical needCatheter type

Connections and sundriesDressingCare plan

Aseptic techniques (including antiseptics)

INVASIVE DEVICES

USAGE

SamplingAdministration of drugs

/ fluids / bloodsDrainage

Just in caseAseptic techniquesMandatory safety

redundancy checks andsafety steps

Quality assurance and quality controlPVC bundle + invasive device audit

Its still not joined up - yet

Infection

Control

Practice

Development

Clinicians

Clinicians

Clinicians

Clinicians

GuidanceProcurement

Qua

lity

Impr

ovem

ent

- SPSP

PatientReceiving optimal

IV care

Pharmacy

Expert

practitioner

New Equipment

New Evidence

Infe

ctio

n Con

trol

Practice

Development

Clinicians CliniciansClinicians Clinicians

Guidance

Procurement

Qua

lity

Impr

ovem

ent

- SPSP

PatientReceiving optimal

IV care

Pharmacy

Expert

practitioner

New Equipment

New Evidence