Prevention and Control of Infection in Care Homes Infection Prevention and Control Team Public Health Norfolk County Council January 2015
Content for today Importance of IPAC -refresher IPAC audits in Care Homes Identified common themes and trends: Laundry Sluice Housekeeping facilities Use of chlorine Cleaning schedules Uniform policy Hand hygiene/ppe Management of Outbreak Clostridium difficile MRSA Isolation technique Catheters
It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm (Florence Nightingale 1859)
Clinical Context 300,000 patients a year in England acquire a HCAI as a result of care in the NHS Cost to the NHS is estimated at 1 billion a year and 56 million of this is estimated to be incurred after discharge
Chain of Infection MRSA C. Diff Norovirus Susceptible People Animals Humans Surfaces Food Break in skin Membranes Inhalation Faeces Urine Vomit Blood Contact Droplet Airbourne
We all have a responsibility to break the links in the chain of infection and reduce the likelihood of an organism causing harm
Standard Precautions Hand Hygiene Use of Gloves PPE Safe handling of sharps Safe handling of waste Safe handling of soiled linen Environmental cleaning
My 5 Moments for Hand Hygiene 1. Before touching a resident 4. After touching a resident 2. Before clean/asceptic procedure 3. After body fluid exposure risk 5. After touching a persons surroundings
Uniform policy Studies have found that the public make conclusions about professionalism and trustworthiness Current perception of the general public is that uniforms pose an infection risk to patients and, when worn outside the clinical setting, the wider public. Reinforced by media Damaging effect on the relationship of trust that exists between professional carers and patients and the public image of healthcare professionals Loveday et al (2007)
Common themes in laundry No dirty to clean flow Concrete flooring Working from floor Clutter Damage No PPE No dedicated hand wash sink
Common themes in sluice Lack of sluice Dirty No designated hand wash sink Clutter Damage No PPE
Common housekeeping themes No disposal unit No dedicated hand wash sink Concrete flooring Clutter Damage No PPE
Cleaning schedules A robust schedule which includes who is responsible for cleaning items/equipment, what they should be cleaned with and the frequency of cleaning needs to be developed, this requires auditing
Example of cleaning schedule Area/ Item Frequency Responsibility Cleaning Materials H&S Precautions (Refer to product label) Method of Cleaning Checked By (initial)
OUTBREAKS Inform Manager PHE IP&C lead All staff Residents Relatives GP Ensure relevant people have been informed Seek advice re microbiological specimens
Norovirus Residents with diarrhoea and/or vomiting should be isolated for duration of symptoms Symptoms short lived, little warning, can be severe Environment at risk of heavy contamination causing rapid spread of infection Residents/staff should be excluded until 48 hours after symptoms have settled Enhanced cleaning regime required
Use of chlorine releasing agent 10,000 ppm disposable cloths/mops should be used on frequently touched surfaces at least twice daily Alcohol hand rub not effective in diarrhoea
Clostridium difficile (C.diff/CDI) C.diff is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants However, C.diff rarely causes problems in children or healthy adults, as it is kept in check by the normal bacterial flora
When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply rapidly and produce toxins which cause illness CDI ranges from mild to severe diarrhoea to, more unusually, pseudomembranous colitis
CDI Transmission Spores are produced when Clostridium difficile bacteria encounter unfavourable conditions, such as being outside the body Clostridium difficile is usually spread on the hands of healthcare staff and other people who come into contact with infected patients or with environmental surfaces (e.g. floors, bedpans, toilets) contaminated with the bacteria or its spores The spores are very hardy and can survive on clothes and environmental surfaces for long periods Soap and water hand wash and hypochlorite cleaning agents recommended
CDI risk factors People who have been treated with broad spectrum antibiotics People with serious underlying illnesses The elderly over 80% of Clostridium difficile infections reported are in people aged over 65 years (PHE 2014)
Number of CDI cases 2008/09 to 2014/15 (NNUH laboratory data)
MRSA MRSA (meticillin-resistant Staphylococcus aureus) is a bacterium from the Staphylococcus species that is resistant to meticillin and other antibiotics It commonly survives nose, groin, axilla without causing infection a state known as colonisation An MRSA bacteraemia (blood stream infection) can occur if MRSA enters particular sites in the body, for example, a surgical wound, indwelling device or the respiratory system
De-colonisation treatment Dual treatment of Octenisan and Mupirocin, unless Mupirocin resistant when naseptin is used as an alternative Re-screening if necessary then this should occur 2 days after decolonisation treatment has been completed. Include separate swabs of nose, groin and any breaks in skin, indwelling devices
MRSA Bacteraemia Norfolk Resident in care home Not previously known MRSA +ve prior to BSI Root cause associated with urinary catheter management Breakdown of communication between primary care, hospital, care home
Isolation Technique Single room remove any unnecessary furniture/items Equipment and bins for patient should be kept inside the room PPE required for patient care should be kept outside the room along with laundry skip Patient notes should be kept outside the room Bedpans/urinals should be disposed of directly into the sluice or bed pan washer. If a bed pan washer is not available then these items need cleaning with chlorine 10,000ppm
Hard surfaces/equipment to be cleaned with chlorine Avoid vigorous bed making! Crockery and cutlery can be put in a dishwasher which heats to 80 degrees Transporting of patients should be avoided unless essential Information for patient/relatives
1. Wash hands Process 2. Gloves, apron before entering the room 3. Deliver care/task/procedure in the room 4. Remove gloves, apron in the room and dispose in clinical waste bin 5. Wash hands in the room 6. Leave room in clean state
Indications for catheterisation in care homes Urinary tract obstruction Acute or chronic retention of urine Management of urinary incontinence when all other methods are not applicable
Infection routes in catheterassociated urinary tract infections
Reducing the risks of catheterassociated urinary tract infection Avoiding unnecessary catheterisation Aseptic technique Maintaining a closed drainage system Education of patients, nurses and care staff of catheter care
References SIGN (2006) Prevention and control of infection in care homes-an information resource. DH 2013 The Health and Social Care Act 2008 Prevention and control of healthcareassociated infections in primary and community care. NICE (2012) World Health Organisation Clean Care is Safer Care RCN
Questions?