Definitions. Healthcare Acquired Infection (HCAI)

Transcription

1 Infection Prevention and Control Assurance - Standard Operating Procedure 21 (IPC SOP 21) Alert Organisms Glycopeptide Resistant Enterococci (GRE) and Vancomycin Resistant Enterococci (VRE) Why we have a procedure? To ensure employees of the Black Country Partnership NHS Foundation Trust have a standard procedure to follow when caring for patients infected or colonised with Glycopeptide Resistant Enterococci (GRE), to minimise and manage the risks of transmission. The Health and Social Care Act 2008: Code of Practice for the NHS for the Prevention and Control of Healthcare Associated Infections (revised January 2015) stipulates that NHS bodies must, in relation to preventing and controlling the risk of Health Care Associated Infections (HCAI), have in place appropriate core policies/procedures. Implementation of this procedure will contribute to the achievement and compliance with the Act. What overarching policy the procedure links to? This procedure is supported by the Infection Prevention and Control Assurance Policy Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? This document applies to all staff employed by or working on behalf of the Black Country Partnership NHS Foundation Trust caring for patients as part of their role and job description. When should the procedure be applied? Effective prevention and control of healthcare associated infection (HCAI) must be embedded into everyday practice and applied consistently. This procedure must be applied when caring for patients with known or suspected GRE/VRE. Additional Information/ Associated Documents Infection Prevention and Control Assurance Policy Hand Hygiene Policy Antibiotic Prescribing Policy Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Infection Control Precautions Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 1 of 11 Version 1.0 April 2016

2 Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions Infection Prevention and Control Assurance - Standard Operating Procedure 3 (IPC SOP 3) - Surveillance of Infection and Data Collection Infection Prevention and Control Assurance - Standard Operating Procedure 4 (IPC SOP 4) - Reporting Incidents of Infection to Public Health England and/or the Local Authority Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks of Communicable Infection/Disease Infection Prevention and Control Assurance - Standard Operating Procedure 6 (IPC SOP 6) - Isolation Care of Patients in Isolation due to Infection or Disease Infection Prevention and Control Assurance - Standard Operating Procedure 14 (IPC SOP 14) - Undertaking a Patient Infection Risk Assessment Infection Prevention and Control Assurance - Standard Operating Procedure 16 (IPC SOP 16) Sharing Information with other Health and Social Care Providers Infection Prevention and Control Assurance - Standard Operating Procedure 18 (IPC SOP 18) - Post Infection Review (PIR) Working Party Report: Guidelines for the control of glycopeptide-resistant enterococci in hospitals (2006) Hospital Infection Society/Infection Control Nurses Association Aims To reduce the risk of GRE/VRE colonisation/infection by ensuring that Trust staff: Are alert to the risks of individual patients carrying or being infected by GRE/VRE. Isolate patients with GRE/VRE appropriately to reduce the risks of transmission To aid diagnosis by sending appropriate specimens to the laboratory in a timely manner To administer appropriate treatment as/when indicated To undertake a post infection review (PIR) on patients with GRE/VRE to review contributory factors and lessons learned Inform other healthcare providers of the patients infectious status when any transfers of care are planned either internally within the Trust or to external agencies To ensure good antibiotic stewardship to reduce the risk of GRE/VRE acquisition Definitions Healthcare Acquired Infection (HCAI) Infection IPCT Pathogenic Risk Assessment Healthcare associated infection (HCAI) refers to infections that occur as a result of contact with the healthcare system in its widest sense from care provided in the patient s own home, to general practice, hospital and nursing home care The presence of microorganisms on/in the body that is causing an adverse effect or host- response the person is unwell and has signs and symptoms of an infection Infection Prevention and Control Team A medical term that describes micro-organisms that can cause some kind of disease A process used to identify and potential hazards and analyse what could happen and to identify steps to be taken to reduce or minimise the risk Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 2 of 11 Version 1.0 April 2016

3 Antibiotic stewardship Coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration What is GRE/VRE? Enterococci bacteria are frequently found in the bowel of normal healthy individuals. There are many different species of enterococci, but only a few have the potential to cause infections in humans. They can cause a range of illnesses including urinary tract infections, bacteremia (blood stream infections) and wound infections. Glycopeptide-resistant Enterococci (GRE) are enterococci that are resistant to glycopeptide antibiotics (vancomycin and teicoplanin). GRE are sometimes also referred to as VRE (Vancomycin-Resistant Enterococci). From this point forward they will generally be referred to as GRE. There are 21 species of Enterococcus currently recognized, and of these, two species, E. faecalis and E. faecium, are the most important causes of enterococcal infections in humans. About 80-90% of enterococcal infections in humans are caused by E. faecalis, with another 5-10% caused by E. faecium; these are Gram positive cocci which normally colonise the gastro intestinal tract. In vulnerable patients they can cause infection e.g. urinary tract infection, wound infection, intravenous line infection, septicaemia, endocarditis, etc. These infections can usually be treated with amoxycillin or a glycopeptide (teicoplanin or vancomycin). When they become resistant to the glycopeptide antibiotics e.g. vancomycin or teicoplanin they become known as GRE. At Risk Groups Patients who are at risk of becoming colonised or infected with GRE are those who: Have a history of pervious hospitalizations Have had recent antibiotic therapy and/or multiple antibiotic therapies (particularly cephalosporin s and glycopeptides) Have underlying disease especially hepato-bilary disease Have permanent in-dwelling invasive devices e.g. percutaneous endoscopic gastroscopy (PEG) tubes or urinary catheters Are highly dependent patients (have been in ITU or HDU) in an acute hospital However, GRE are sometimes found in the faeces of people who have never been in hospital or have not recently been given antibiotics. GRE infections usually affect the most vulnerable of patients and can easily spread from patient to patient, leading to outbreaks of infection. Infections Caused by GRE In vulnerable patients GRE can cause a variety of infections e.g. urinary tract infection, wound infection, invasive IV line infection, septicaemia, endocarditis, cholangitis and meningitis. Enterococci are now the third most common cause of hospital-acquired infection being responsible for 10-12% of all HAIs. Colonisation is more frequent than true infection, the most common site of GRE colonisation is the large bowel. Alert organism surveillance from routine clinical specimens is the usual method of GRE surveillance in the UK. Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 3 of 11 Version 1.0 April 2016

4 The use of Glycopeptides and other antibiotics e.g. quinolones, encourages the emergence of GRE. Antibiotics therefore must be prescribed judiciously to prevent GRE from spreading. GRE may be spread in 2 main ways: The hands - GRE can spread on the hands of hospital and community staff. Hand washing therefore is an extremely important means of controlling infection. The environment - The environment/equipment that comes into close contact with patients may also be contaminated and serve as a source of contamination of staff hands. Thorough cleaning of the environment/equipment is therefore another essential measure as Enterococci may contaminate the environment around a patient and survive there for several days. During outbreaks GRE has been found on staff uniforms, bed linen, beds, commodes, floors, blood pressure cuffs, stethoscopes, locker tops, chairs and in bathrooms, etc. Screening for GRE When any type of infection is suspected it is normal practice to obtain a relevant specimen for microscopy, culture and sensitivity (M, C and S). It is important when sending faecal samples to the laboratory to include the patient s recent antibiotic history (any antibiotics prescribed in the previous 4 weeks); this may help to identify Enterococci as the infecting organism. All positive specimen results must be notified to the IPCT immediately by the Nurse-in-Charge caring for the patient. (The Microbiology laboratory will also usually inform the Infection Prevention and Control Nurse). Screening swabs should only be taken on the advice of the Infection Prevention and Control Team. Screening is usually undertaken during suspected outbreaks (two new cases of GRE detected in clinical specimens related in time and place) and in response to important incidents. Sites to be screened in both known positive and contact patients include: Stool specimen Rectal swab Perineal swab Nose swab should be taken from contact patients Routes of Transmission for GRE Throat swab In patients know to be carrying GRE it is also recommended taking wound swabs, leg ulcer swabs and swabs from invasive devices e.g. catheters etc. Faecal carriage of GRE may persist for months or years. Chronic carriers and those subject to frequent hospital admissions are a potential source of cross infection. Eradication attempts have not been proven successful or worthwhile however it may be necessary to treat a patient s clinical GRE infection. Informing the Patient of their Infectious Status The responsibility of informing the patient, relative/carer of the patients infectious status/test result lies with the clinical team (i.e. consultant or their deputy) caring for the patient during their in-patient stay Key Recommendations Treatment and Management Enterococci are poorly pathogenic and frequently cause colonisation rather than invasive infection. The healthcare team (including the microbiologist) should assess each patient to distinguish between colonisation and infection and then decide whether antimicrobial therapy and/or other interventions are necessary. Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 4 of 11 Version 1.0 April 2016

5 Treatment if required is usually based upon susceptibility testing of the organism involved as advised by the microbiologist. Caring for Patients in an In-patient Setting The decision to isolate individual patients affected by GRE should be based on the clinical needs and risk assessment. Ideally affected patients should be source isolated in single rooms [See Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Infection Control Precautions, Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions and Infection Prevention and Control Assurance - Standard Operating Procedure 6 (IPC SOP 6) - Isolation Care of Patients in Isolation due to Infection or Disease]. Patients with GRE and diarrhoea must be given priority for isolation and excluded from all communal therapies, therapy visits etc. The Infection Prevention and Control Team will advise on a case-by-case basis. Hand Hygiene Effective hand hygiene is the most important measure to prevent and control the spread of antimicrobial-resistant organisms. Hands should be decontaminated between each patient contact, including after the removal of gloves whether or not the patient is known to be colonised with GRE. (See Hand Hygiene Policy for more information). Environmental Cleaning Daily enhanced cleaning of the patient s environment must take place with sanitary spaces cleaned at least twice daily and immediately if visibly soiled [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination - Cleaning, Disinfection and Sterilisation]. Environmental cleaning is vitally important in preventing the spread of infection. The cleaning regime incudes the standard daily clean followed by disinfection with 1,000ppm chlorine solution with special attention to horizontal surfaces and dust collecting areas. Bedding must be changed daily. When the patient is discharged/transferred the room/bed-space must be terminally cleaned including curtain changes. Antimicrobial Stewardship Clinical teams must when prescribing antimicrobial treatment always: Refer to the Trust s Antibiotic Prescribing Policy and follow its guidance As part of patient ward reviews antibiotic prescribing should be reviewed, stopping any unnecessary prescriptions and changing those that do not comply with the Trust s policy guidelines, as should all medical teams when reviewing their patients Ward Pharmacists should check patient s prescription sheets as part of their review visits and liaise with the patient s doctor accordingly. (See Antibiotic Prescribing Policy for further information) Caring for Patients in Community Settings Patients in their own homes do not require additional infection prevention and control precautions [see Infection Prevention and Control Assurance - Standard Operating Procedure 1 (IPC SOP 1) - Standard Infection Control Precautions and Infection Prevention and Control Assurance - Standard Operating Procedure 2 (IPC SOP 2) - Transmission Based Precautions]. Restrictions should not be placed on normal social activity of any person living in the community because they have or previously had GRE. Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 5 of 11 Version 1.0 April 2016

6 Community staff visiting symptomatic patients should if possible visit last visit in the morning or afternoon and staff should avoid taking non-essential equipment into the patient s home. Any equipment used which is not single use disposable should be cleaned after use [See Infection Prevention and Control Assurance - Standard Operating Procedure 7 (IPC SOP 7) - Decontamination - Cleaning, Disinfection and Sterilisation]. Community staff must ensure strict hand washing with soap and water on completion of the visit (See Hand Hygiene Policy). Management of a Deceased Patient Measures must be taken as follows for patients known to be infected with GRE prior to their death in addition to standard last offices: Infection control precautions are the same as those used when the patient was alive Ensure all faecal soiling should be cleaned with soap and water Ensure a terminal clean of the bed/bedspace is undertaken clean all equipment and the environment initially with detergent and water followed by chlorine solution 1,000ppm available chlorine. Bed screens/curtains should be changed/laundered Cadaver bags are NOT required Patient/Carer Information Information for the patient/carer can be found in the patient information leaflet see appendix 2. Discharge/Transfer of Patients with GRE Transfers out - If a GRE positive patient is to be transferred to another hospital or other care provider, the receiving ward/department/care home should be notified prior to the transfer taking place this is the responsibility of the Nurse-in-Charge and the IPCT will inform the IPCT at the receiving hospital. This allows the receiving institution to take the necessary measures to protect vulnerable patients [See Appendix 1 and Infection Prevention and Control Assurance - Standard Operating Procedure 16 (IPC SOP 16) - Sharing Information with other Health and Social Care Providers]. Transfers between wards If a GRE positive patient is to be transferred to another ward the receiving ward/department should be notified prior to transfer this is the responsibility of the Nurse-in-Charge, in addition the IPCT must also be informed of the planned transfer PRIOR to the transfer taking place so that appropriate information and advice can be given. Discontinuation of Infection Control Precautions Carriage of GRE can be prolonged and clearance of GRE is difficult to establish. Infection control special precautions must not be discontinued without the approval of the IPCT. N.B When a patient with GRE is transferred/discharged the room/bedspace must have a terminal deep clean undertaken before its re-use this includes replacing curtains. Contact the Estates and Facilities Helpdesk to arrange on or ext.: 8010 Reporting All cases of GRE reported to the Infection Prevention and Control Nurse will be immediately escalated to the Director for Infection Prevention and Control. Formal reports following the completion a Post Infection Review will be submitted to the Infection Prevention and Control Committee and the Quality and Safety Steering Group to ensure lessons learned can be shared across the organisation. Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 6 of 11 Version 1.0 April 2016

7 Post Infection Review (PIR) for Patients with GRE Infection GRE can increase a patient s length of stay in hospital, the likelihood of complications and reduce the chances of a successful recovery. The Infection Prevention and Control Team recommend that a Post Infection Review (PIR) is completed to identify any critical points and contributory factors, and determine whether any preventative action(s) and improvement action(s) can be undertaken to reduce or control incidents of HCAI. [See Infection Prevention and Control Assurance - Standard Operating Procedure 18 (IPC SOP 18) - Post Infection Review (PIR) and Infection Prevention and Control Assurance - Standard Operating Procedure 4 (IPC SOP 4) - Reporting Incidents of Infection to Public Health England and/or the Local Authority]. GRE remains uncommon in a mental health/ learning disability environment therefore the review of cases as/when they occur can assist in any future management. Outbreaks/Periods of Increased Incidence of GRE In the unlikely incident of a period of increased incidence of GRE involving patients and or staff, the Infection Prevention and Control Team will convene an Outbreak Management Group if deemed necessary [See Infection Prevention and Control Assurance - Standard Operating Procedure 5 (IPC SOP 5) - Management and Recognition of Outbreaks of Communicable Infection/Disease]. Where there is evidence of GRE transmission and acquisition, the advice of the Consultant Microbiologist will be sought. Where do I go for further advice or information? Infection Prevention and Control Team Physical Health Matron Your Service Manager, Matron, General Manager, Head of Nursing, Group Director Your Group Governance Staff Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy Data Protection Act and Freedom of Information Act Please refer to overarching policy. Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 7 of 11 Version 1.0 April 2016

8 Appendix 1 Example of a Proforma Letter to GP/other Healthcare Provider Date: Dear Doctor/Healthcare Professional RE (insert patient s full name and NHS Number): The patient named above was recently an in-patient on Ward. During their hospitalisation, this patient was diagnosed as having Glycopeptide-resistant or Vancomycin resistant enterococci (delete as necessary) infection and was treated with: Antibiotic Dose Route Start date Duration of treatment We are therefore writing to inform you that there is a small chance following discharge/transfer that: Your patient could relapse with the infection or Remain colonised with the organism for a significant period of time. If the patient requires re-admission to a healthcare facility in the future please inform them that your patient previously had an infection/colonisation with this organism. Yours sincerely, Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 8 of 11 Version 1.0 April 2016

9 Author: XXX Department: XXX Ref.No: XXX Issue Date: XXX Review Date: XXX Will this prevent me from going home? Having GRE/VRE will not necessarily prevent you from going home. If you are being discharged to a nursing/residential home the hospital will inform the home of your condition prior to discharge. Appendix 2 What happens if I am admitted to a hospital again in the future? You may be given a single room and swabs taken from your rectum and any wounds will be sent to the laboratory. If these swabs are found to be clear you may be moved into the general ward where you can mix freely with other patients. Infection prevention and control is everyone s responsibility. Patients and visitors all have an important role to play in preventing the spread of healthcare associated infections. n Glycopeptide Resistant Enterococci (GRE) and Vancomycin Resistant Enterococci (VRE) Information for patients and carers If you require further advice or information, please contact the Trust s Infection Prevention and Control Team or a member of the ward/department staff. Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 9 of 11 Version 1.0 April 2016

10 What is Glycopeptide Resistant Enterococcus (GRE) and Vancomycin Resistant Enterococcus (VRE)? GRE is short for Glycopeptide Resistant Enterococcus; VRE is short for Vancomycin Resistant Enterococcus (VRE). Enterococcus is a bacterium which is carried harmlessly in the gut. GRE and VRE are types of Enterococcus which are resistant to the Glycopeptide type of antibiotics (vancomycin, teicoplanin); they were first detected in the UK in This resistance makes infections caused by GRE or VRE more difficult to treat. How did I get it? GRE and VRE can be found in the gut of animals fed with certain food supplements and can therefore enter the food chain and colonise humans. These bacteria can be in your body (usually the gut) but not make you unwell. This is called colonisation instead of infection as you feel well with no signs of infection. You may have had the GRE/VRE in your gut before you came into hospital and been unaware of this. GRE/VRE is most commonly spread on hands. If hands come into contact with GRE/VRE and are not washed or gelled thoroughly before touching someone else, GRE/VRE bacteria can be passed to the next person. How do you know I have GRE/VRE? A specimen was sent to the Microbiology laboratory for testing which has shown the organism. Will it affect me? You can have GRE/VRE in your gut without being aware of it, or being affected in any way. So it may not affect you physically at all. However in some people it can cause an infection. Your treatment in hospital won t be affected by having GRE/VRE. You can go for any tests, physiotherapy or occupational therapy that you may need in other departments. Your meals will also be served as usual. the GRE/VRE bacteria. How is GRE/VRE spread? From patients already carrying the germ, especially if they have diarrhoea. On hands that have not been washed properly after contact with an infected patient or equipment. You can help prevent the spread of infection by cleaning your hands. On the hands of Healthcare workers who have not washed their hands properly or used the hand gel after contact with an infected patient or equipment. You can help prevent the spread of infection by asking your Healthcare worker if they have cleaned their hands. On the hands of visitors who have not washed or gelled their hands properly after contact with an infected patient or equipment. You can help prevent the spread of infection by asking your visitor if they have cleaned their hands On your hands after going to the toilet. This may be from contact with a contaminated Alert Organisms toilet or Glycopeptide from your own Resistant bowel if Enterococcus you are already (GRE/VRE) carrying Page 10 of 11 Version 1.0 April 2016 Can I spread it to other people? People in hospitals are more at risk of infection because their body defence mechanisms are weakened by illness, surgery, drugs and procedures. You may be transferred to a single room to help prevent spread. Hospital staff may wear disposable aprons and gloves while performing tasks in your room. Prevention of infections rests mainly in encouraging good hand washing practices among staff, visitors and patients and also the use of the hand rub provided in your room. Due to the different types of infections in hospitals, it is important that you do not visit patients in other parts of the ward or in other wards in the hospital. Can GRE/VRE be treated? Treatment is not necessary in most cases. Despite being resistant to many of the normal antibiotics, treatment options are still available should infection occur. If antibiotic treatment is necessary your doctors will discuss this with you. Sometimes, GRE may clear or go away on its own although occasionally it can persist in your gut for long periods. There are no known methods which will specifically clear it from your gut. Will I have to stay in hospital? Patients do not have to stay in hospital until the GRE/VRE is cleared. You will be sent home when your general condition allows, regardless of whether you are still positive for GRE/VRE or not. Can I have visitors? You can have visitors but please seek advice from the nursing staff on the ward. All visitors will be asked to wash their hands will soap and water before entering and prior to leaving. What about my laundry? Personal laundry should be bagged and kept in your room for relatives/friends to collect as soon as possible. Items should be washed separately from the rest of your families laundry in the usual way with normal detergents ideally on a hot wash (60 C or above if the material will withstand the temperature). Hands must be washed with soap and water after handling your personal soiled linen. Good hand hygiene is the most important way to prevent the spread of Clostridium difficile Posters showing the best way to wash your hands are available at the hand wash sinks.

11 Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-COI-POL New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Control of Infection Executive Director of Nursing, AHPs and Governance Infection Prevention and Control Team Infection Prevention and Control Committee April 2015 Month/year SOP was approved April 2016 Next review due April 2019 Disclosure Status B can be disclosed to patients and the public Review and Amendment History Version Date Description of Change 1.0 Apr 2016 New Procedure established to supplement Infection Control Assurance Policy Alert Organisms Glycopeptide Resistant Enterococcus (GRE/VRE) Page 11 of 11 Version 1.0 April 2016