The SCOTVAN conference the national perspective

1. The SCOTVAN conferencethe national perspective Evonne Curran Nurse Consultant Health Protection Scotland

2. In this presentation • What is (not) available nationally • Guidance / Surveillance • Organisms, Outbreaks, Environments, Equipment • high-infection risks • What next!

3. 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

4. 44%

5. 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

6. 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

7. 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 ++++++++++

8. 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

9. IV medicines guidance www.nmc-uk.org/.../nmcStandardsForMedicinesManagementBooklet.pdf

10. RCN 2010

13. Infection control

17. regularcompetency checking for staff, regular reviews of training and regular quality control for those aseptic pharmacies that are not licensed No definition of regular Healthcare commission 2007

18. Audit commission 2001

19. 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

21. The bundles (HPS / QIS) • PVC • CVC • CNO supported initiative – reduce SABs

22. 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)

23. 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

24. Organisms

25. The organisms Gram positives - Coagulase negative staphylococciStaphylococcus Stick

26. Gram negatives Grow well in nutritionally poor solutions Picture courtesy of CDC

27. Yeast: Grow, stick, biofilm, resistance, vulnerable patients Fungal Biofilms and Drug Resistance Mary Ann Jabra-Rizk,* William A. Falkler,* and Timothy F. Meiller* EID 2004

28. Outbreaks

29. CID 2008 47 Dec The importance of aseptic technique in preventing even low level contamination 33/80 diagnosed 84-421 days post last exposure

30. 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

31. 3 4 10 12/0 4 14/2 10/6 18/6 • Variables • How big a drug • Over what time period 13/5 Narayan et al

32. 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

33. 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

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

35. ‘strict asepsis could never be assured in a ward setting’ Zavery et al. (2005: 3).

36. Modes of transmission • Healthcare worker (HCW) to patient • Patient-to-patient via HCW • Environment-to-patient due to HCW actions or inactions

37. 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 2005 Jain et al 2005, Gillespie et al 2007 Hseush et al 1998 MMWR 2005, 2006, Jain et al 2005, Sacher et al 1991, Ostrowshy 2002 Halkes & Snow 2007 Sitges-serra 1985, 1985 1984 Doit et al 2004 Nasser et al 2004

38. 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)

39. 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).

40. 1,000,000 per ml of solution is not visible to the naked eyeMaki et al 1975

41. Study of 2,934 PVCs • Factors associated with phlebitis Curran et al 2000

42. ‘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

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

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

45. What is the most important bit • Its rarely the ‘gadget’

46. 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

47. 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)

48. 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

49. Environments • Pose a risk • No sink • No concurrent procedures • Must have minimum environmental standards

50. 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?