5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD St. Gallen, 25-26 November 2016
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Epidemiology St. Gallen, 25-26 November 2016
Healthcare-associated infections in Children in European acute care hospitals Clinical settings (%) Country (N) Children with one or more healthcare-associated infections (%) PL 01 Poland FI 02 Finland CY 03 Cyprus IS 04 Iceland HR 05 Croatia NL 06 Netherlands EE 07 Estonia GR 08 Greece ES 09 Spain LU 10 Luxemburg PT 11 Portugal BE 12 Belgium UK 13 United Kingdom MT 14 Malta HU 15 Hungary NO 16 Norway DK 17 Denmark AT 18 Austria LV 19 Latvia BG 20 Bulgaria SI 21 Slovenia FR 22 France IE 23 Ireland SK 24 Slovakia LT 25 Lithuania IT 26 Italy RO 27 Romania DE 28 Germany CZ 29 Czech Republic 0% 50% 100% Paediatric intensive care Neonatal intensive care Neonatology Paediatric surgery General paediatrics (934) (413) (116) (39) (432) (529) (100) (744) (882) (63) (670) (936) (2857) (71) (878) (115) (30) (210) (336) (1193) (617) (367) (801) (1073) (619) (1166) (471) (280) (331) 0% 5% 4.2% [95%CI: 3.7-4.8%] 726 children with 770 healthcare-associated infections 10% Prevalence with 95% confidence interval 95% confidence interval of the prevalence survey 15% 20% Zingg W Lancet Infect Dis in press
Healthcare-associated infections in Children in European acute care hospitals Country (N) Distribution of major healthcare-associated infections (%) Estonia Estonia (6) Cyprus Cyprus (9) Norway Norway (4) Ireland Ireland (22) France France (10) Luxemburg Luxembourg (3) Greece Greece (45) Slovenia Slovenia (17) Latvia Latvia (11) Finland Finland (34) Spain Spain (56) Portugal Portugal (35) United Kingdom United Kingdom (126) Romania Romania (8) Belgium Belgium (47) Hungary Hungary (37) Croatia Croatia (28) Poland Poland (105) Austria Austria (8) Germany Germany (4) Czech Republic Czech Republic (4) Italy (25) Italy Bulgaria (39) Bulgaria Netherlands (35) Netherlands Slovakia (31) Slovakia Lithuania (14) Lithuania Iceland (3) Iceland Malta (3) Malta Denmark (1) Denmark 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Bloodstream infections Gastrointestinal infections Lower respiratory tract infections Urinary tract infections Eye ear nose throat infections Other infections Surgical site infections Zingg W Lancet Infect Dis in press
Healthcare-associated infections in different age groups 100% 90% 80% 70% 60% Bloodstream infections Lower respiratory tract infections Urinary tract infections Surgical site infections Gastrointestinal infections Eye ear nose throat infections Other infections 50% 40% 30% 20% 10% 0% <1 month 1-11 months 1-4 years 5-10 years 11 years Zingg W Lancet Infect Dis in press
Risk differences of impaired neurodevelopment (mental development index < 70) in neonates with and without sepsis umbrella review on neurological sequelae of healthcare-associated sepsis in very-low birth weight infants Haller S Eurosurveillance 2016; 21: pii=30143
Risk differences of cerebral palsy in neonates with and without sepsis umbrella review on neurological sequelae of healthcare-associated sepsis in very-low birth weight infants Haller S Eurosurveillance 2016; 21: pii=30143
Antibiotic resistance prevalence in routine bloodstream isolates from children s hospitals Bielicki JA Pediatr Infect Dis J 2015; 34: 734
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Modern infection prevention and control St. Gallen, 25-26 November 2016
SENIC Study on the Efficacy of Nosocomial Infection Control (1970-1975) 30% Without IPC 26% 20% 10% 0% 9% LRTI 14% SSI 19% UTI BSI 18% All HAI -10% -20% -30% -40% -27% With IPC -35% -31% -35% -32% Haley RW Am J Epidemiol 1985; 121: 182
Surveillance Technology Best practice 1970 1975 History of modern infection control NNIS (1970) SENIC (1970-1976) 1980 1985 1990 1995 2000 2005 2010 2015 2016 NHSN (2005) IHI (1991) INICC (2002) KISS (1996) HELICS (1994) IPSE (2005) EARSS (1998) ESAC (2001) HAI-NET EARS-Net (2008) ESAC-Net (2010) (2011)
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Prevention of central line-associated bloodstream infections St. Gallen, 25-26 November 2016
Insertion and maintenance bundle NICU Intervention strategy using an insertion and a maintenance bundle for catheter insertion and care 18 NICU s in State New York Schulman J Pediatrics 2011;127:436
Insertion and maintenance bundle NICU Establish a central line kit or cart to consolidate all items necessary for the procedure Perform hand hygiene with hospital-approved alcohol-based product or antiseptic-containing soap before and after palpating insertion sites and before and after inserting the central line Use maximal barrier precautions (including sterile gown, sterile gloves, surgical mask, hat, and large sterile drape) Disinfect skin with appropriate antiseptic (e.g. 2% chlorhexidine, 70% alcohol) before catheter insertion Use either a sterile transparent semipermeable dressing or sterile gauze to cover the insertion site Perform hand hygiene with hospital approved alcohol-based product or antiseptic-containing soap before and after changing the dressing Evaluate the catheter insertion site daily for signs of infection and to assess dressing integrity At a minimum, if the dressing is damp, soiled, or loose change dressing aseptically and disinfect the skin around the insertion site with an appropriate antiseptic (e.g. 2% chlorhexidine, 70% alcohol) Develop and use standardized intravenous tubing setup and changes Maintain aseptic technique when changing intravenous tubing and when entering the catheter including (scrub the hub Daily review of catheter necessity with prompt removal when no longer essential Schulman J Pediatrics 2011;127:436
Insertion and maintenance bundle NICU Statewide CLABSI rates adjusted for uniform CLABSI definition* declined by 40%, from 3.5 CLABSIs per 1000 central-line days to 2.1 CLABSIs per 1000 central-line days (risk ratio: 0.60; [CI95%: 0.48 0.75]; P < 0.0005) CLABSI: central line-associated bloodstream infections *Definition change: One positive blood culture yielding a normal skin contaminant (e.g. S. epidermidis) did not fulfill the case definition and two or more positive blood cultures for a skin contaminant drawn on separate occasions were required Schulman J Pediatrics 2011;127:436
SLUG Bug Multicenter improvement collaborative among 17 children s hospitals in the USA Piazza AJ Pediatrics 2016; 137: e20143642 Standardizing Line Care Under Guideline Recommendations
SLUG Bug Multicenter improvement collaborative among 17 children s hospitals in the USA Piazza AJ Pediatrics 2016; 137: e20143642
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Key components in organisation and structure of effective infection prevention and control St. Gallen, 25-26 November 2016
Systematic review and evidence-based guidance on organisation of hospital infection control programmes (SIGHT) Zingg W Lancet Infect Dis. 2015;15:212
Key components (ECDC SIGHT) 1 An effective infection control programme in an acute care hospital must include at least: one full-time specifically trained IC-nurse 250 beds; a dedicated physician trained infection control; microbiological support; data management support 2 To make sure that the ward occupancy does not exceed the capacity for which it is designed and staffed; staffing and workload of frontline health-care workers must be adapted to acuity of care; and the number of pool/agency nurses and physicians minimized 3 Sufficient availability of and easy access to material and equipment and optimized ergonomics Core components (WHO) An IPC programme with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing HAI and combating AMR through IPC good practices In order to reduce the risk of HAI and the spread of AMR, the following should be addressed: (1) bed occupancy should not exceed the standard capacity of the facility; (2) health care worker staffing levels should be adequately assigned according to patient workload At the facility level, patient care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR, including all elements around the WASH infrastructure and services and the availability of appropriate IPC materials and equipment 4 Use of guidelines in combination with practical education and training Evidence-based guidelines should be developed and implemented for the purpose of reducing HAI and AMR. Education and training of the relevant health care workers on guideline recommendations and monitoring of adherence with guideline recommendations should be undertaken to achieve successful implementation 5 Education and training involves frontline staff, and is team- and taskoriented 6 Organizing audits as a standardized (scored) and systematic review of practice with timely feedback 7 Participating in prospective surveillance and offering active feedback, preferably as part of a network 8 Implementing infection control programmes follow a multimodal strategy including tools such as bundles and checklists developed by multidisciplinary teams and taking into account local conditions 9 Identifying and engaging champions in the promotion of a multimodal intervention strategy 10 A positive organizational culture by fostering working relationships and communication across units and staff groups At the facility level, IPC education should be in place for all health care workers by utilizing team- and task-based strategies that are participatory and include bedside and simulation training to reduce the risk of HAI and AMR. Regular monitoring/audit and timely feedback of health care practices should be undertaken according to IPC standards to prevent and control HAIs and AMR at the health care facility level. Feedback should be provided to all audited persons and relevant staff Facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance with timely feedback of results to health care workers and stakeholders and through national networks At the facility level, IPC activities should be implemented using multimodal strategies to improve practices and reduce HAI and AMR Zingg W Lancet Infect Dis 2015;15:212 Storr J Antimicrob Resist Infect Control In press
Structures/activities Organisation/staffing Surveillance/feedback Resources/management Organisation/staffing Bed occupancy/workload Implementation Material/devices/ergonomics Guidelines Team- and task- oriented education and training Multimodal strategies Engagement of champions Organisational culture Creating a positive organisational culture
Infection Prevention and Control Structures/activities Organisation/staffing Surveillance/feedback Implementation Material/devices/ergonomics Guidelines Team- and task- oriented education and training Multimodal strategies Engagement of champions
Competences?
Hospital management IT Clinical departments IPC societies Nurses Doctors MoH Microbiology
Competency domains of infection prevention and control Zingg W Clin Microbiol Infect 2015; 21: 1052
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Implementation St. Gallen, 25-26 November 2016
Organisation culture Public Healthcare Legislation Healthcare workers Patient care Patient Staffing Resources Bed occupation Work load Guidelines/policies Training Infrastructure Material/devices Space
Organisation culture Public Healthcare CONTEXT Legislation Healthcare workers Patient care Patient Staffing Resources Bed occupation Work load Guidelines/policies Training Infrastructure Material/devices Space
5 Domains Damschroder L Implementation Sci 2009;4: 50
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Summary St. Gallen, 25-26 November 2016
Infection prevention and control = hand hygiene
Infection prevention and control is about healthcareassociated infections and antimicrobial resistance HAI ABR Surveillance of healthcare-associated infections, antimicrobial resistance and antimicrobial use is key Bloodstream infections are the most common healthcare-associated infections with serious longterm sequelae in very low birth weight infants Reserve-antibiotics are used predominantly for healthcare-associated infections
Antibiotic stewardship (together with prevention measures limiting transmission) helps to control emerging resistance Prevention focuses on reducing healthcare-associated infections and prevent emerging resistance Best practice interventions are effective in the prevention of healthcare-associated infections Best practice interventions are complex, taking place in a complex context
Establishing effective infection prevention and control needs a comprehensive approach taking into account ten evidence-based key components Infection prevention and control is everybody s business and thus, multidisciplinary strategies are needed to succeed Knowledge of implementation strategies help to establish effective infection prevention and control programmes
Swissnoso/HUG Swiss Point Prevalence Survey Regional trainings Pilot Train-the- (3 hospitals Mid/East) trainer Survey (All hospitals) Project group Data analysis of the survey 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 Preparation training material Translation of the database Final report Invitation of hospitals Feedback to hospitals 2016 2017 Final report
5 th Paediatric Infectious Disease Training Course Prevention of hospital acquired infections do we need more than hand hygiene? Walter Zingg, MD Thank you for your attention St. Gallen, 25-26 November 2016