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Oral presentations Abstract ID: 4444 Outbreak of Panton-Valentine Leucocidin- associated Staphylococcus aureus (PVL-SA) skin infection linked to a diving club at a national sports centre: Case management, environmental assessment and control measures
Routine follow-up of a teenage child with a microbiologically confirmed Panton-Valentine Leucocidin-associated Staphylococcus aureus (PVL-SA) skin infection in January 2015 showed the child was a diver and that other children in the competitive club had had similar infections. The club confirmed that 5-10 children and a coach had been affected; at least two children remained symptomatic and the latest case was a new onset, suggesting ongoing transmission.
Information was sent to all parents of children attending the diving school. A site visit was undertaken and an online questionnaire was sent to all parents to allow case finding and to further elucidate risk factors for acquisition and transmission.
Three confirmed cases (all spa type t034 PVL-MSSA), two probable and five possible cases, all with soft-tissue infection were identified in this outbreak. All confirmed and probable cases had onset in spring 2014 except one, with onset in January 2015. Ninety-nine questionnaires were completed (269 clients were emailed). Whilst numbers of cases were too small to allow multivariable analysis, several likely routes of transmission were identified:
Sharing of shammy (diving) towels • •
Piling shammy towels at poolside • • Infrequent washing of shammy towels • • Shared equipment, e.g. harnesses in dry gym, with no cleaning between use
Control measures centred on reducing spread of infection by improving cleaning in the dry gym and at poolside. Further infection control measures focussed on education around washing and personalisation of shammy towels. Outcomes of the investigation were shared with the pool management team and diving club with a view to wider dissemination at national competitions.
Antimicrobial resistance (AMR) is an urgent public health concern.
Resistance can be accelerated with the imprudent use of antibiotics. Previous research suggests that inappropriate prescribing is apparent in practice; however, much of this has focused on doctors. With a growing number of nurses potentially prescribing antimicrobials, their practice is of particular concern.
The Reasoned Action Approach (RAA) model proposes that behavioural (advantages/disadvantages of carrying out the behaviour), normative (individuals or groups who would approve/disapprove; likely/unlikely to carry out this behaviour) and control beliefs (enablers or inhibitors to carrying out the behaviour) are the psychological foundation for human behaviour. In order to assess the beliefs of nurse prescribers, one-to-one, open-ended telephone interviews were carried out using the RAA model's guidance. Interviews were recorded and content analysed to identify the population's modal (most frequently occurring) salient (accessible) beliefs.
Twenty-seven nurse independent prescribers (NIPs), from a variety of settings across Scotland, were interviewed. The most frequently occurring advantage for managing patients presenting with upper respiratory tract infections without prescribing an antibiotic was the prevention of AMR (n=21, 78%), the disadvantage was stress from patient pressure/expectation (n=11, 41%). Other NIPs were most frequently mentioned as being most likely to manage patients without prescribing (n=11, 41%), with GPs least likely (n=16, 60%). Finally, having the time to educate/reassure/advise the patient was the most frequently mentioned enabler (n=24, 89%) and patient pressure was the greatest inhibitor (n=18, 67%).
Some of these findings are similar to those found in the literature; however, many others have emerged -one of the main categories being patient expectation and the challenges this creates when trying to manage patients without prescribing an antibiotic. This elicitation work has therefore identified the salient beliefs for this population and will be used to develop a national questionnaire.
Semi-invasive ultrasound probes (SIUPs) are a cornerstone in the diagnosis and treatment of patients; however, infection control concerns exist over the use of probes and their role as a vector for pathogen transmission. No guidance was available within NHS Scotland, and a number of health boards over recent years have requested expert advice on the use of and decontamination of SIUPs.
Health Facilities Scotland (HFS) conducted a national survey of transoesophageal (TOE), transvaginal (TV) and transrectal (TR) ultrasound probes to identify current decontamination practice across NHS Scotland. A scientific literature review was undertaken by HPS regarding the effectiveness of the decontamination of SIUPs, including a review of manufacturers' guidance.
The HFS national survey concluded there was an ongoing risk to patient safety regarding decontamination of SIUPs. The scientific literature review found SIUPs present a number of challenges in terms of decontamination. Studies have shown residual contamination on SIUPs when high level disinfection (HLD) is not performed and cases of cross-infection where transmission was linked to improper reprocessing of SIUPs.
The literature review found limited evidence upon which to make recommendations on universal HLD methods of decontaminating SIUPs. Review of manufacturer instructions highlights variation in decontamination instructions and lack of material compatibility of different makes and models of SIUPs. HPS and HFS worked together to produce the NHS Scotland Guidance for Decontamination of Semi-Critical Ultrasound Probes; Semi-invasive and Noninvasive Ultrasound Probes. The guidance was developed using a wide consultative method and included some health boards trialling the three decontamination systems covered within the literature review. Where evidence was lacking to inform the guidance, expert opinion was sought from the reusable medical devices expert advisory steering group, which consists of national decontamination and infection-prevention experts.
Surgical site infections (SSI) cause significant morbidity following caesarean sections (CS). CS surveillance commenced at Guy's & St Thomas' NHS Foundation Trust in 2010. An initial data validation took place in 2013, followed by a series of improvement initiatives which included a CS guideline and care plan both reflecting NICE recommendations, asepsis principles awareness for midwives and introduction of an Aquacel dressing left in situ for 5 days in 2015.
Data was collected using surveillance forms during inpatient stay and post discharge by community midwives up to 10 days. Patient postal questionnaires and telephone surveys were also used for post-discharge SSI data collection. Patient feedback was collected on general post-operative experience and experience with the new dressing.
We have demonstrated a reduction in our SSI rates from 13.3% in 2013 to 6.8% in 2015 through various interventions targeted at improving patient outcomes. We used patient feedback to improve patient experience and developed patient information leaflets to empower patients. Feedback from the dressing evaluation suggested that dressings were painful at removal, and when additional staff support was provided patients' experience with the dressing improved, highlighting the power of utilising patient feedback to improve patient safety and experience. The telephone survey was found to be a powerful method for detecting SSIs post discharge as it captured at least 40% of the infections. More than 80% of the infections were detected post discharge with a mean day to SSI presentation of 13 days. Our data was reproducible for the two validated quarters in 2013 and 2015, respectively.
Mupirocin is an important component in MRSA control specifically for nasal decolonisation, but resistance limits its use. Medical-grade honey (MGH) is used for the treatment of burns and infected wounds. The antimicrobial activity of natural honey may offer potential in MRSA eradication. We report the results of a randomised controlled trial (RCT) on nasal decolonisation of MRSA.
The purpose of this research was to compare the efficacy of MGH to mupirocin 2% to eradicate nasal MRSA.
Consenting MRSA-colonised patients were recruited and MGH 30% or mupirocin 2% was applied intra-nasally. Up to two courses of either treatment, three times a day for 5 days, was administered. Three consecutive negative MRSA screening results confirmed successful decolonisation.
The mean age of the study participants was 73.2 years and 36% were female. Of the 100 study participants, 93% were previously known MRSA cases, 89% had had a history of attempted decolonisation with 34% receiving two or more courses of nasal mupirocin, 43% had concomitant multidrug-resistant bacteria colonisation and 68% non-nasal site MRSA carriage. In total 57% (57) were isolated either in a single room or were cohorted with contact precautions. Of the 86 participants who completed the study protocol, 36% (18) in the intervention group and 50% (25) in the control group were decolonised (p=0.196, c 2 =1.675) in an intention-totreat analysis. The success rate for MGH and mupirocin was 43% and 57%, respectively, according to the protocol analysis. In total, 14% (14) participants were lost on follow-up, withdrawn or deviated from the allocated protocol.
The results from this first RCT of its type confirm the potential of MGH. However, further work is required to confirm the findings and optimise the concentration of MGH.
I do not have any conflict of interests to declare.
Decreased bacterial contamination of dental unit waterlines with the introduction of reverse osmosis water
Dental unit waterline (DUWL) systems are used to irrigate the oral cavity during treatment. These waterlines can become heavily contaminated with bacteria, leading to microbial biofilm formation despite decontamination and regular flushing. Leeds Dental Institute (LDI) uses a continuous dosing with 1% Alpron to achieve the water quality; however, we experienced repeated microbiological testing failures with the currently used Alpron system for water decontamination. A trial was instigated to investigate the contamination level and prevalence of bacteria in DUWL output water following the addition of reverse osmosis (RO) water instead of tap water. RO water has been purified by a process of diffusion and by applying an external pressure to reverse the natural solvent flow through a semi-permeable membrane.
RO water was added in four different dental chairs in LDI over a period of 18 weeks. Weekly microbiological testing of the water was carried out during this period, where a total of 72 water samples were collected from four different dental chairs and the bacteria (CFU/ml) were enumerated.
Over the 18-week period the introduction of RO water showed a reduction in the levels of bacteria in all four dental chairs when compared with the bacterial levels at baseline when Alpron and tap water were used. Mean results for all four dental chairs at baseline (before introduction of RO water) was 7.7×10 3 CFU/ml compared with a mean count of 3.2×10 2 CFU/ml with the RO water.
In this 18-week trial the introduction of RO water reduced bacterial counts in the routine water testing of four dental chairs. As a result of this, we intend to introduce the use of RO into all dental chairs within the dental institute, to provide consistent water quality for our patients and staff.
I do not have any conflict of interests to declare.
Hand hygiene to prevent infection in children is becoming increasingly important as Government policy seeks to reduce antibiotic prescribing. This study investigates whether hand hygiene education reduces absenteeism among school children. Study aims include student participation and engagement in science and development of a partnership with Cokethorpe School.
First-year A-Level students learnt about bacteria, transmission and hygiene. They swabbed sites around the school and took handprints on blood agar. An assembly was presented to children in the lower school (aged 4-11 years, approximately 150 pupils). Following this, younger students created posters for a competition, with winners receiving a giant Rhinovirus. Anonymised data on sick days for 4 weeks following the assembly in January 2016 and the same time-period in 2015 were obtained.
Older students successfully grew and examined bacteria from hands, door handles and other site cultures. Morphology and Gram staining suggested common bacteria were isolated between sites, although formal identification was not undertaken. There was no significant difference in the number of episodes between the two time periods (2015: n=43; 2016: n=46) . The number of halfdays recorded as sick was similar (2015: n=29; 2016: n=25) . There were more episodes of 1 day or more in 2016 due to an outbreak of scarlet fever that coincided with the study (2015: 14; 2016: 21, not significant) . Members of the Crook Public Engagement group chose the winning artwork, now on permanent display in the Children's Hospital, John Radcliffe Hospital, Oxford.
The null hypothesis was not refuted but secondary goals were successful with older students keen to do more. In September the older students plan to develop a questionnaire to establish what (if anything) young children take away from targeted messages around hygiene. Ongoing data collection and molecular biology experiments are also planned.
Once a patient becomes colonised with carbapenemase-producing Enterobacteriaceae (CPE), there are no recommended decolonisation strategies. This leads to uncertainty around how to manage known carriers of CPE while in hospital and on subsequent admissions. We evaluated the results of repeated CPE screens from known carriers to establish the pattern of colonisation.
From June 2015, our hospitals performed risk factor-based CPE screening of all admissions, universal screening in high-risk specialties, weekly screening in wards where known carriers were present, and contact tracing around newly detected carriers. During June-December 2016, 70 patients were known CPE carriers. The result of serial screens of each patient was scrutinised.
A total of 409 screens were collected from the 70 patients (median 4, range 1-28), with 247 (60.4%) negative and 162 (39.6%) positive. Of the 70 patients, 60/64 patients who had more than one screen (93.8%) had at least one negative screen during their hospital stay. Of the 51 that had least three screens, 24 (47.1%) had a "+-+" pattern, suggesting that apparent spontaneous decolonisation reverted to a positive carriage status.
Several factors could explain an apparent reversion from a negative to a positive screen in known CPE carriers, including acquisition of a different CPE following genuine spontaneous decolonisation, natural fluctuation in the level of gastrointestinal colonisation perhaps prompted by antibiotic exposure, or a poorly collected microbiological specimen. It is not possible for us to conclude which of these explains the observed apparent changes in carriage status, but the frequent reversion from an apparent negative carriage status to positive carriage status in known CPE carriers suggests that a negative CPE screen should not be interpreted as an indication of loss of colonisation in an individual who has previously been positive.
I do not have any conflict of interests to declare.
Safety-engineered devices (SED) became mandatory in UK healthcare facilities in May 2013; however, few publications are available as to the impact of the law on adoption of SED in the UK. Monitoring of activation is recommended as non-use and incorrect activation of SED are a common cause of post-procedure sharps injuries. This paper outlines a sharps container (SC) contents audit conducted in seven UK NHS trusts.
Reusable SCs (Sharpsmart, Daniels Corporation, Melbourne) were randomly selected from seven healthcare facilities (HCF) in central UK. Wearing protective apparel, the operator opened and decanted the SC and sorted and counted hollow-bore needles (HBN) into: SED and non-SED; capped vs. uncapped non-SED needles; and activated or non-activated SED. WinPepi v2.78 was used to calculate probability (p set at 0.05), relative risk and 95% confidence limits.
In total, 322 L of sharps (59.0 kg) from 22 SCs from seven hospital trusts were audited. Many devices were blood-contaminated. Of the 2425 HBN: 49.9% (1210) were SED; 16% of the SED were not activated. Of the 1215 non-SED, 13.4% were capped needles or needle-syringes. Overall, 52.7% of devices were discarded "sharp".
It is disturbing that over 50% of HBN were discarded sharp, indicating that a high proportion of UK clinical staff are unnecessarily at risk of sharps injuries while handling sharps. The high non-use of SED and non-activation of SED is also disturbing and needs further confirmation. Widespread SED evaluation and adoption (automatic and semi-automatic SED where feasible), repetitive competency training, and safety-ownership by staff, are needed.
I do not have any conflict of interests to declare.
Flomoxef belongs to cephamycin antibiotics, which cannot be hydrolysed by extended-spectrum beta-lactamase (ESBL). Hence, flomoxef can be used to treat infections caused by ESBL-producing organisms. This study was conducted to evaluate whether the susceptibility rates of flomoxef against ESBLproducing organisms were decreasing year by year.
At a regional hospital in southern Taiwan, from 2012 to 2015, all isolates of ESBL-producing organisms reported by the clinical laboratory were enrolled in this study. Screening of ESBL production was according to the recommendation of the Clinical and Laboratory Standards Institutes. The screened organisms included Escherichia coli, Klebsiella pneumoniae/oxytoca, and Proteus mirabilis, and a double disc method was used as a method for screening. The disc diffusion method was used for antimicrobial susceptibility testing of flomoxef. The interpretive criteria of flomoxef recommended by the manufacturer were as follows: zone size of susceptibility was ≥18 mm, that of intermediate resistance was between 13 and 17 mm, and that of resistance was ≤12 mm. All intermediate-resistant results were regarded as resistant results in this study.
A total of 296 CRPA isolates, including 136 in 2014 and 160 in 2015, were enrolled in this study. The susceptibility rates of imipenem, meropenem, and doripenem against CRPA were 6%, 4%, and 15%, respectively, in 2014. These were 9%, 19%, and 28% of imipenem, meropenem, and doripenem, respectively, in 2015.
This study found that doripenem had the highest susceptibility rates against CRPA, indicating that doripenem did not readily select CRPA. In contrast, imipenem had the lowest susceptibility rates, indicating that imipenem readily selected CRPA. These findings echoed previous studies. According to the results of this study, we suggest that doripenem should be regarded as the first choice when antipseudomonal carbapenems are used to treat infections caused by P. aeruginosa. In addition, doripenem may be the optimal carbapenem for empiric treatment of hospital-acquired infections because P. aeruginosa should be considered as the likely pathogen in these infections.
Aspergillus species are the most common and life-threatening fungal pathogens among immunocompromised patients, causing a wide range of infections depending on the immune status of the host. Notably, A. flavus is the leading cause of invasive aspergillosis in tropical and sub-tropical countries, including Iran. We therefore aimed to evaluate in vitro antifungal susceptibility (AFST) of nine antifungals against clinical and environmental Aspergillus section Flavi isolates collected in Iran from 2008 to 2014.
Acne is a pathological disorder and a chronic inflammation in the sebaceous follicles and one of the most widespread dermatology problems, and has affected millions of people worldwide. Bacterial and fungal skin flora agents are involved in its creation.
In this cross-sectional study, 70 clinical specimens from suspected skin with acne protests were collected by sterile swab and were streaked on an SDA medium containing chloramphenicol. The plates were incubated for 48 hours at 37°C. Suspected colonies were studied through microscopic examination and subsequent passage in accordance with standard mycology procedures, and the type of fungal colony colour specified in CHROM agar for isolation of the yeast. For final approval, the Candida Species Sequencing Method (ITS2, ITS1 regions) was performed, and susceptibility testing was performed to review Candida for drug-resistant isolates based on the CLSI method.
Of 70 clinical isolates studied, 11 species of Candida including C. parapsilosis (8, 72.73%), C. krusei (1, 12.5%), C. lusitaniae (1, 12.5%), C. kefir (1, 12.5%), and a Trichosporon asahii were identified and isolated. Study of susceptibility of C. parapsilosis isolates to various concentrations of the antifungal agents to isolate Cp1 has shown that the isolated Cp8 Cp5 with MIC5 equal to 32, 0.5, 0.25 and MIC90 of <64, <1, <0.5 μg/ml fluconazole, itraconazole and ketoconazole were respectively resistant. Apart from the isolation of Cp1 and Cp8, which had relative strength, almost all other species of C. parapsilosis isolates were susceptible to these drugs.
Current Australian antibiotic therapeutic guidelines recommend that symptomatic catheter-associated urinary tract infections (CAUTIs) should be treated by removing or changing catheters and treating CAUTIs based on results of cultures and susceptibility testing obtained from a new catheter. The empirical antibiotic therapy for severe UTIs is intravenous gentamicin and amoxy/ampicillin. Persons with spinal cord injury (SCI) with neurogenic bladders who require ongoing catheterisation often have asymptomatic bacteriuria. Current treatment of UTI in SCI is not well standardised with limited evidence.
ProSCIUTTU was a randomised controlled trial investigating whether probiotics reduce UTIs in participants with neurogenic bladder secondary to SCI. For study endpoint, participants had to meet clinical and microbiological criteria. The urine cultures and antibiotic susceptibility testing of endpoint participants were studied. The aim was to see whether empirical antibiotic therapy suggested by the therapeutic guidelines for severe UTI applies to SCI persons with catheters. Only a small number were tested for sensitivity to gentamicin. 2/6 of the Gram-positive were sensitive to ampicillin/amoxycillin. 9/36 grew Pseudomonas. Pseudomonas was susceptible to ceftazidime in 5/6 of UTIs and to gentamicin in 8/9 of UTIs.
Current Australian antibiotic guidelines for severe UTI are applicable for persons with SCI who are catheterised. However, if there is a history of prior colonisation or infection with Pseudomonas species, amoxy/ampicillin should be substituted with ceftazidime. It is reassuring that, despite prolonged catheterisation and frequent hospitalisation in this cohort of participants, the prevalence of multi-resistant organisms was low in each category of organism.
I do not have any conflict of interests to declare.
Urinary tract infections (UTIs) are very common in people with spinal cord injury (SCI). UTIs are increasingly difficult to treat as the organisms that cause them become more antibiotic-resistant. Probiotics have been found to be efficacious in preventing UTIs in post-menopausal women.
The main aim of this study is to determine whether probiotic therapy with combinations of Lactobacillus reuteri RC-14 + Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 (LGG-BB12) are effective in preventing UTI in people with SCI.
A double-blind factorial-design randomised controlled trial with 3-year recruitment was used.
The research took place in multiple spinal units in New South Wales, Australia with their rural affiliations.
Eligible participants were people with SCI and stable neurogenic bladder management. Two hundred and seven participants were randomised to one of four arms: RC14-GR1+LGG-BB12, RC14-GR1+placebo, LGG-BB12+placebo or two placebo capsules for 6 months. All regimens were indistinguishable in appearance and taste. Randomisation was stratified by bladder management type and inpatient status. The primary outcome was time to occurrence of symptomatic UTI.
Patients randomised to RC14-GR1 did not have a longer time to UTI than placebo (HR 0.68, 95% CI: 0.
We investigated antibiotic treatment of inpatients with indeterminate Clostridium difficile results (GDH positive, toxin negative) over the period October 2014 to May 2015 within one 609-bedded Acute Trust. We found that out of 67 patients identified with indeterminate C. difficile results, 26 (40%) were treated for C. difficile infection, including five who tested negative by PCR (Gene Expert) and were therefore treated inappropriately with antibiotics.
The management of indeterminate C. difficile cases was reviewed and a revised plan was implemented.
Evaluation of these changes was carried out by reviewing patients with indeterminate C. difficile results from September 2015 to April 2016. During this period only 19% (12/64) indeterminate patients were treated with antibiotics. An incidental finding was that the average length of stay for these patients decreased by 5 days and the average length of diarrhoeal symptoms decreased by 1 day (as defined as passing a Bristol score type 1 to type 4 and 48 hours symptoms free).
Further repeat evaluations should be utilised to ensure that this policy change is embedded in our Trust and continues to have a positive impact on patient outcome and care.
I do not have any conflict of interests to declare.
Like most developed countries, we take the water that comes out of our taps for granted. In reality, a lot of work goes on behind the scenes to ensure that our water is safe. Water safety is not the responsibility of one person or department. It requires a team approach, uniting outside agencies with in-house cooperation. Lapses in water safety can have devastating results, as the Pseudomonas aeruginosa outbreak in the Neo-natal Units in Northern Ireland demonstrated. The implementation of HTM 04-01 raised awareness of water safety, not only in augmented care areas but throughout our hospital.
Echoing the principles of the Saving Lives High Impact Interventions, the Water Safety Care Bundle recognises that all groups -South West Water, Site Services, Pro-economy, Water Assurance Group, Infection Prevention and Control, Serco and clinical staff -must play their part if water safety is to be maintained.
Each group has specific actions and responsibilities as set out in the Water Policy. Measurements of compliance include regular water sampling, total viable counts (TVC), flushing logs, observations on our "water walk arounds" and a review of sink traps during augmented care environmental sampling.
Standard Operating Procedures are now in place for positive Pseudomonas aeruginosa and Legionella samples. The Pseudomonas database for augmented care areas has increased our knowledge of strains within the hospital. Increased compliance of flushing is reflected in the TVCs.
Maintenance and improvement of the Water Safety Care Bundle depends on developing our relationship with South West Water and Pro-economy whilst encouraging clinical engagement within our Trust. Our network of infection prevention link practitioners will be essential to ensuring that water safety practices are maintained in a pressurised and fluid healthcare organisation.
Antimicrobial resistance is one of the defining public health problems of our age. New resistance mechanisms continue to emerge, making control of infection both more difficult and more important than ever. The rapid spread of carbapenem-resistant Enterobacteriaceae (CPE) is one of the most worrying examples, as it is usually asymptomatic, highly transmissible and is almost impossible to treat.
In 2015, University Hospitals of South Manchester (UHSM) introduced new initiatives to combat the growing number of CPE cases each month. Interventions were as follows: reactive Hydrogen Peroxide Vapour following discharge of CPE patients. This ensured that patients were being admitted to safe environments. Further to this, we introduced an HPV managed service which enabled us to decontaminate high-risk areas proactively and reduce environmental bioburden in shared areas such as toilets and sluices. In 2013, Public Health England published the "Toolkit", a package of interventions to help hospitals detect, manage and control CPE, which UHSM also implemented.
UHSM had some of the highest rates of CPE in the country. The interventions stated above led to substantial reductions in infections and outbreaks. The Trust has seen a 58% reduction in CPE incidences in 2015/2016 compared with 2014/ 2015. Evaluation suggests that compliance with the CPE Toolkit and the introduction of emergency and elective screening of patients who fit the criteria of admission to a hospital within 12 months, full multi-disciplinary team (MDT) outbreak meetings and the introduction of a HPV managed service has played a key part in this reduction.
UHSM will continue to identify methods of decontaminating areas we are currently unable to reach with HPV, and potentially look to implement new, faster technology for these areas. UHSM will also continue to train staff to ensure an ever greater compliance with the CPE Toolkit.
Pseudomonas aeruginosa is a ubiquitous and important opportunistic pathogen in the healthcare setting, particularly affecting those with impaired host or mucosal immunity. It is found in a wide range of moist, nutrient-limited environments and may colonise hospital and domestic water taps, sinks, drains, toilets, and showers. Here we report our experience in reducing the transmission risk of P. aeruginosa from water in a critical care unit.
To reduce the risk of transmission we examined: the role of disposal of patient waste water; the installation of new tap outlets that are redesigned either to prevent contamination or enable decontamination; the cleaning of taps appropriately; and the frequency of water sampling to identify outbreaks. Water samples were taken from the tap outlets and tested for the enumeration of P. aeruginosa via membrane filtration. Clinical surveillance of patients acquiring P. aeruginosa was monitored daily, with all strains being molecularly typed via pulse-field gel electrophoresis.
From the water sampling undertaken on the critical care unit, 25% of the outlets were positive for P. aeruginosa over a year. New taps are to be installed on part of the unit; in addition to this a new three-cloth cleaning method has been implemented, as well as using gel sheets to solidify patient waste water being disposed of in a macerator. All these initiatives have resulted in a reduced number of tap outlets being colonised with P. aeruginosa and the number of patients acquiring P. aeruginosa infections.
Superoxide water is composed of a number of active agents that predominantly include hypochlorous acid, sodium hypochlorite and chlorine. Different concentrations of these active agents exist in different superoxide compositions. Despite this, they are all known to be fast-acting antimicrobials with a broad spectrum of activity on planktonic micro-organisms, as well as clostridium spores, warranting their usage in the area of infection prevention and control. The efficacy of the different superoxide water compositions available has been reported on planktonic micro-organisms. However, the efficacy of superoxide waters on biofilms is lacking. Consequently, the aim of this study was to investigate the efficacy of a new superoxide composition on in vitro mono-culture and polymicrobial biofilms, utilising a range of different biofilm models relevant to infection prevention and control.
A range of clinically significant Gram-positive (including meticillin-sensitive and meticillin-resistant Staphylococcus aureus), Gram-negative (Pseudomonas aeruginosa, Acinetobacter baumannii), spore-forming bacteria (Clostridium difficile) and yeasts/fungi (Candida albicans and Aspergillus sp) were exposed to a novel superoxide formulation in various non-biofilm models. In addition, the anti-biofilm efficacy of the new superoxide composition was evaluated in numerous biofilm models that included the Centers for Disease Control (CDC) Biofilm Bioreactor, the Minimum Biofilm Elimination Concentration (MBEC) model, the drip slide model and a novel poloxamer model.
All antimicrobial studies evaluated on planktonic microbes demonstrated that the new superoxide composition was a fast-acting and effective broad spectrum antimicrobial following a contact time of only a few minutes. Within all the mono-culture and polymicrobial biofilm models evaluated, the new superoxide formulation also demonstrated effective anti-biofilm activity on both monoculture and polymicrobial immature and mature biofilms. Overall, this new superoxide water composition has demonstrated both a broad anti-microbial and anti-biofilm activity that would warrant its usage for applications in the prevention and treatment of biofilms.
Recent evidence has shown persistence of viable organisms in dry biofilms found in clinical settings even after terminal cleaning and disinfection. The work presented here demonstrates the use of a dry biofilm model to investigate the efficacy of various disinfectants with the overall aim of eliminating biofilm on dry environmental surfaces following appropriate cleaning/disinfection combinations.
Staphylococcus aureus (NCIMB 9518) biofilms were grown in tryptone soy broth on 10 mm diameter AISI 430 stainless steel discs at room temperature (20-23°C) for 12 days with rotation between wet and dry phases (at 37°C) every 48 hours. Dry biofilms were then exposed to disinfectant solutions with varying exposure times or wiped with disinfectant wipes using the ASTM2967-15 test. For comparison, wet biofilm of S. aureus grown for 48 hours and dried S. aureus inoculum on stainless steel discs (BS EN 13727) were used. Disinfectants included chlorine, glutaraldehyde and peracetic acid. Assessment of efficacy measured biomass reduction by crystal violet staining, biofilm recovery after 24 hours and beyond indicated by a pH indicator colour change in the growth medium and transfer of bacteria from surface to surface immediately and then 24 hours following intervention.
Dry biofilms were found to persist even after biocidal exposure -with a difference in susceptibility when compared with "wet" biofilm or planktonic bacteria dried on surfaces. The complete removal/destruction of dry biofilms from surfaces appears not to be currently achievable using current disinfectants without damaging the surfaces, although disinfectant wipes were more effective. Some biofilm recovery was observed with the colorimetric medium after 24-48 hours following some but not all interventions. The results highlight that while the aim of eliminating dry biofilm is not currently achievable, a realistic approach may still involve making surfaces safe by controlling biofilm regrowth and by preventing transfer of micro-organisms.
Hydrogen peroxide vapour (HPV) decontamination systems are increasingly used in hospitals to reduce the incidence of infections. Whilst HPV has demonstrated efficacy against many healthcare pathogens, it remains crucial to consider environmental factors (i.e. room-volume, furniture and construction) to ensure decontamination is effective. HPV providers validate their systems using biological indicators (BIs) containing 10 6 Geobacillus stearothermophilus spores. BIs require specialist facilities for growth, up to 7 days to confirm decontamination efficacy and can be unreliable. In this study, the possibility of monitoring decontamination efficacy using a thermostable adenylate kinase (tAK) "enzyme indicator" (EI) was evaluated. EIs showed proportional inactivation following HPV exposure and provided quantifiable and audible data within minutes. EIs could provide rapid reassurance on process efficacy for hospital infection control teams and HPV system providers.
BIs and EIs were exposed to HPV in a whole-room setting using a commercial system. The process was performed using a range of HPV exposure times, doses and environmental changes. Following exposure, remaining viability/ activity was assessed; BIs were incubated at 56°C and monitored for bacterial growth over 7 days whilst tAK activity was measured using ATP-luciferase assay in a benchtop luminometer.
EIs provided a rapid and sensitive measure of the HPV process. Both BIs and EIs were able to demonstrate sub-optimal HPV cycles, resulting from reduced time, dose and environmental factors. BIs gave a qualitative pass/fail answer within 7 days whilst EIs provided a quantifiable measurement within minutes.
High-risk acute and chronic wounds that demonstrate a poor response to prophylactic and therapeutic levels of antiseptics and/or systemic antibiotics, and deteriorate once the antimicrobial is removed, are considered a good marker for biofilm evidence. Biofilms in wounds have been documented and are considered to delay wound healing and increase the wound's propensity to infection. Consequently, it is important that for those wounds which are infected with a virulent biofilm, new anti-biofilm agents are developed which focus on breaking down the biofilm and preventing microbial re-attachment. In addition to this, biofilms are also known to house Acanthamoeba spp, enabling them to act as potential reservoirs of opportunistic pathogens and increasing a wound's risk of infection. The aim of this study was to evaluate the anti-microbial and anti-biofilm ability of a new patented broad spectrum anti-biofilm formulation designed to be used in central venous catheters, urinary catheters, skin and wound care.
The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) was determined against 50 clinical isolates -Gram positive (Staphylococcus epidermidis, S. aureus, meticillin-resistant S. aureus), Gram negative (Enterococcus faecium, E. faecalis, Klebsiella sp, E. coli, Enterobacter cloacae, Pseudomonas aeruginosa, Acinetobacter baumannii and Proteus sp) and yeasts/fungi. The anti-biofilm ability of this novel antibiofilm formulation was determined on preformed young (24 h) and old (6 months) biofilms. The anti-biofilm activity was also evaluated on pure cultures of Acanthamoeba spp and also Acanthamoeba spp that had ingested viable opportunistic pathogens.
The anti-biofilm agent was shown to be effective against both young and old biofilms. The anti-biofilm efficacy varied between species, with the greatest efficacy observed on Gram-positive bacteria. Acanthamoeba spp was eradicated following 24 hours exposure to the anti-biofilm composition. The antibiofilm formulation provides a novel alternative for wounds at risk of infection and/or infected.
I do not have any conflict of interests to declare.
Stethoscopes have been implied to transmit micro-organisms, including methicillin-resistant Staph aureus (MRSA) and Clostridium difficile. Therefore, a contaminated stethoscope could conceivably confer a significant risk of healthcare-associated infections (HCAIs). Currently, there is no consensus on optimal stethoscope cleaning methods. This study aims to assess current cleaning practices at four sites across the UK.
One hundred and ninety-nine responses were collected from healthcare providers at four UK NHS trusts. Both Likert-style and free-text questions were used to capture attitudes towards cleaning stethoscopes, current cleaning behaviours and potential suggestions to increasing stethoscope cleaning.
92.5% of respondents felt it is clinically important to clean the stethoscope regularly and 76.9% felt that clean stethoscopes could reduce the number of HCAIs. Reasons given against were that of a lack of evidence. Only 7.5% of respondents clean their stethoscope in between every patient, and 11% of respondents have never cleaned theirs. 61.3% of respondents noted that they use their stethoscope in isolation rooms, with 23% of those never cleaning their stethoscope either before or after the consultation. Better distribution of antiseptic wipes around clinical areas was identified as the best motivator to improve cleaning practices. Despite a consensus among medical professionals about the importance of stethoscope cleaning, current stethoscope cleaning practices are inadequate and could therefore play a role in infection spread. Personal stethoscopes are frequently used in isolation rooms, which is pertinent in view of previous reports demonstrating contamination of stethoscopes with micro-organisms such as C. difficile and MRSA. The study highlights that a better availability of antiseptic wipes in clinical areas may motivate healthcare providers to clean their stethoscopes more frequently. Future studies could look at the distribution of antiseptic wipes in clinical areas and also the role of visual reminders such as posters in improving current practices.
I do not have any conflict of interests to declare.
Emergency Departments (EDs) are facing an unprecedented future: unannounced audits by Infection Prevention and Control Teams and the Healthcare Environmental Inspectorate; arduous waiting time targets set by the government and treatment of an increasing number of patients with ever more complex conditions and needs -all of which contribute to the extreme challenges within an ED. Nevertheless, safe patient care is a fundamental priority in reducing healthcare-associated infection (HAI).
Six ED patient trolleys were selected from two acute University Hospitals that were either prepared (n=3) or had just been cleaned (n=3) for a new arrival to the department. Firstly, the trolleys were inspected for any visible contamination. Then, after the swabs were dipped into normal saline, the trolleys were swabbed on a symmetrical 10-15 cm section of the handrail, trolley frame and head rest. The swabs were immediately plated onto blood agar, sealed, then taken to the labs for an incubation period of 48 hours.
Three of the six trolleys had visible blood contamination. Total colony count ranged from 5 to >450 for each swab. The hand rail had the highest colony count of organisms, followed by the bed frame, then the headrest. Organisms included Staphylococcus aureus, Staph sp., Bacillus cereus, Bacillus sp., Dermacoccus nishinomiyaensis, Micrococcus luteus and Kocuria rhizophilia. No antimicrobial sensitivities or viral testing was conducted.
In spite of ED trolleys being cleaned between patient use and as per local protocol, blood and body fluid contamination and substantial bacterial counts remain. The number of HAIs which originate from an ED trolley is unknown; likewise, acceptable colony counts or organism species would be speculative. Therefore, a more proactive, robust approach is required to decrease visual contamination and potentially pathogenic micro-organisms which may compromise the care and safety of our patients.
The organisation's previous method of decontamination was to use a two-stage process of detergent and alcohol for patient equipment and medical devices. Observational evidence identified that this process was not being followed, with areas using just alcohol to disinfect equipment without prior cleaning, thus rendering the process ineffective.
The Infection Prevention Team (IPT) explored ways of improving compliance and it was decided that a combined detergent/disinfectant wipe could be beneficial. A trial was held to evaluate compliance and staff views on the change in practice and products. The areas chosen had been noted on audit to have poor compliance with equipment and medical device decontamination.
Collaborative working with IPT and Procurement enabled the exploration of a single-stage process for decontamination and the opportunity to standardise products across the organisation. The costs for using the single-step and two-stage processes were compared.
The combined detergent/disinfectant wipe was rolled out to all areas of the organisation across three separate inpatient sites. Following successful acute implementation and positive evaluation, the product was rolled out to community sites, ensuring a standardised city-wide approach to decontamination.
The roll-out was supported by the company, with training sessions delivered to all areas on correct usage, and dispensers were fitted bespoke to all clinical areas based upon need.
The introduction of a single-step approach to decontamination has shown an increase in compliance and a reduction in healthcare-associated infection (HCAI). Environmental assurance data has shown an average increase from 85% to 90% between December 2015 and February 2016. The Clostridium difficile infection rate reduced from 29.27 per 100,000 bed days on introduction to 8.65 following full implementation. The introduction and the change to a single supplier has also made a significant cost saving to the organisation.
A small number of patients undergoing cardiac surgery where cardiopulmonary bypass machines were used developed a surgical site infection (SSI) with Mycobacterium sp., including one locally. We report the measures implemented to reduce the risk of contaminated aerosols from heater cooler units (HCU) used in cardiothoracic surgery, guided by PHE and the MHRA.
Water and air sampling commenced in June 2015. The frequency of disinfection was increased in September 2015. The Trust has purchased a new HCU (an increase from five to six) to allow HCUs to be returned for manufacturer decontamination on a rotational basis, commencing September 2015. A dedicated tap with a point-of-use filter has been installed at Hammersmith for filling the machines. The HCUs have been located as far from the patient as possible, and surveillance for water-related organisms in SSIs has been enhanced.
All HCUs have grown Mycobacterium sp. in water and air. The proportion of air samples growing Mycobacterium sp. or overgrown with fungi was significantly lower after September 2015 (40% of 50 vs. 16% of 50, p=0.01). Use of disposable warming mattresses was maintained and decontamination of connectors included in disinfection routines.
We are looking at ways of capturing aerosols from the machines, and potentially moving HCUs out of theatres. Air and water testing for fungi has commenced to evaluate a potential further risk of aerosolising fungi in the theatre. The levels of Mycobacterium sp. are decreased and remain at a static level for both water and air.
I do not have any conflict of interests to declare.
Abstract ID: 4484
The impact of implementing a structured educational programme on hospital environmental cleanliness
McGill University Heath Centre, Royal Victoria Hospital, Montreal
Clostridium difficile infection (CDI) is considered to be one of the most uncontrolled nosocomial infections in a colorectal surgery unit "4NW" of a tertiary hospital in Montreal. Environmental contamination with CDI spores has been associated, in the literature, with its indirect transmission. Thus, appropriate environmental cleaning and disinfection in healthcare facilities remain a fundamental aspect of CDI control.
This study aims to determine whether the establishment of a structured educational programme based on repetitive teaching and cleaning monitoring could improve environmental cleaning practice.
We used an experimental design pre/post-test with a controlled group represented by 3W (a surgical unit), while 4NW represents the pilot unit. In both units, random rooms including frequently touched surfaces and equipment were tested using the fluorescence technique (Glo-Germ). Staff on 4NW exclusively received instant feedback on the audit result and were instructed repeatedly on proper cleaning. Rooms and equipment were retested on three other occasions. Pre-and post-intervention values were then compared. Our intervention was guided by the Model for Improvement as a framework using Plan-Do-Study-Act cycles to test the changes on a small scale.
The percentage of cleaned surfaces improved incrementally on 4NW between the trials and went from 28% pre-intervention to values of 70%, 72%, and 66%. The percentage of cleaned equipment had also improved and went from 11% to values of 46%, 71%, and 67%. No significant improvement was observed in the controlled unit where the results never reached 15% among nursing equipment and 52% among surfaces.
An educational programme may result in improvement of hospital environmental cleanliness. Such a programme should include efforts to control quality with continuous feedback to employees to effectively support the change.
This discussion of the evolving role of the Infection Prevention and Control (IPC) Champion takes place in the context of the ever-changing challenge of clinical staff providing support to IPC teams regarding communication and ownership of IPC within a Trust of over 6500 staff, providing mental health and learning disability services to patients across a large geographical area.
The evolving role 2004-2010 Traditional IPC "Link Nurse". Delivery model: Face to face on Trust sites, and staff attended educational sessions.
2010-2013 IPC "Link Practitioners". Commencement of annual study days, basic roles and responsibilities established and electronic quarterly newsletters introduced.
2014-Present IPC "Champions". Introduced annual induction days to support new champions. Continuation of annual study events for all providing training updates and networking opportunities.
Roles and responsibilities have been reviewed and updated. A contract between the champion, IPC team and ward manager has been developed which is linked to Knowledge Skills Framework and Infection Prevention Society competencies. An Intranet page and specific email account has been established which facilitates communication and education.
Biannual champion initiatives address relevant IPC issues and further develops the champion's role. Champions complete audits as part of their role to monitor, maintain and improve standards of IPC.
A questionnaire has been devised and disseminated to all champions to evaluate the success of introduced changes. Modern matrons support the role of champion and information is shared at the IPC Committee quarterly.
Initiatives delivered successfully:
-A poster was developed explaining the importance of decontaminating multiple patient equipment and is now displayed Trustwide. -Twenty-six areas received a "Sharp Safety" presentation.
-An electronic version of the Essential Steps Audit Tool was created and guidance for use disseminated to IPC champions.
Introduction day for champions However, nationally, the rate of improvement for CDI has slowed in recent years. A significant proportion of healthcare-acquired infections can be prevented by the adoption of evidence-based infection prevention and control standards.
Our acute Trust developed a bespoke Diarrhoea Assessment Management Pathway (DAMP record) to assist in the identification and management of the patient with potentially infective diarrhoea. The document promotes consistent record keeping and prompts staff to implement a bundle of risk-reducing interventions.
It is important for clinical staff to understand risk assessment, recognising infection potential in their patient group. Comprehensive assessment is required to establish type and possible cause of diarrhoea, to isolate the patient at the earliest opportunity and submit a stool sample for testing, where appropriate.
The DAMP record should commence following the patient's first episode of Bristol Stool Chart type 5-7. The Bristol Stool Chart is incorporated in the DAMP record. It is a comprehensive tool, informative guide and monitoring record requiring education and training, engagement and ownership by clinical teams. The pathway is subject to continuous audit and development by our team to measure compliance across the Trust, encouraging continuity of care throughout the patient journey.
The IPC supports ward teams in cultivating clinical excellence, positive communication and reinforcement of best practice. We engage with staff, sharing lessons learned as part of our ongoing commitment to patient safety.
In the Flu Plan for Winter 2014/2015, Public Health England stated that "Flu is an unpredictable but recurring pressure that the NHS and public faces each winter…" (PHE: 4). The same document also acknowledges that an increase in the uptake of the flu vaccine is still required for all healthcare workers (HCWs) with direct patient contact.
HCWs are at risk of occupational exposure, and can act as vectors in the transmission of the virus. Despite the risks associated with influenza, uptake in HCWs remains suboptimal.
In order to explore both local and worldwide attitudes toward the uptake of the influenza vaccine, a literature review was conducted as part of the "Management of an Infection Prevention and Control Service" (MICS) course at the University of Manchester, in January 2015. The aim was to explore potential methods of improving uptake amongst HCWs, based on some of the reasons given for non-acceptance of the vaccine. The literature search included research papers from France, the USA, Srinagar, the United Arab Emirates, Kuwait, Oman, the Republic of Korea and the UK. Papers selected were based on quantitative research, with findings expressed as numerical data. Primary sources were preferred over secondary sources.
Common themes were identified worldwide. Although influenza causes high numbers of deaths, vaccination rates amongst HCWs remain suboptimal. Aspirational rates of 75% were seldom achieved. Knowledge and understanding of the aetiology of the influenza virus was seen to directly affect uptake rates. Inhibiting factors, barriers and reasons for low uptake were similar across the world. There is a general acknowledgement that ongoing education regarding the risks and benefits of the vaccine for HCWs is essential, in order to minimise the effects of popular myths about flu and the flu vaccine. Education campaigns need to be innovative and ongoing. Information is essential!
Paediatric critical care units (CCUs) are highly specialist areas managing complex patients at increased risk of healthcare-associated infections. As a consequence, staff need more bespoke Infection Prevention Control (IPC) training to address their learning needs. Our IPC nursing team therefore wished to assess the existing knowledge of CCU nursing staff in order to provide an IPC training programme tailored to staff's needs.
A brief electronic survey of 10 questions, taking approximately 5 minutes to complete, was sent to all CCU nursing staff. The questions were unambiguous and asked nurses to rate their personal IPC knowledge, self-assess their ability to implement IPC best practices and suggest ideas for future IPC training.
Out of 269 questionnaires sent out, only 74 staff (26%) responded to the survey. The majority of respondents were band 5 or 6, reflecting the commonest nursing bands on our CCU. Analysing the responses, there was considerable confusion over the understanding of contact/droplet/airborne IPC isolation precautions and associated use of appropriate personal protective equipment. The survey did provide the IPC team with some very positive feedback both on staff engagement and future trainings needs.
Though most staff rated their personal IPC knowledge as above average, the survey did identify areas of weaknesses which require further IPC support. This will allow the IPC team to develop a more in-depth training programme to fit the needs of our CCU staff.
I do not have any conflict of interests to declare.
Developments in computer-generated visual imaging and mobile computing devices, combined with new research evidence on the behaviour of people and pathogens in hospitals, present opportunities for innovative training to prevent healthcare-associated infections (HAIs). Within this context, this poster summarises the development and evaluation of a new tablet-based tool.
A three-stage iterative prototyping and co-development process involved doctors, nurses, domestic staff and hospital staff in other job roles (n=150). Themes of pathogen location, pathogen survival (before and as a result of cleaning) and pathogen transmission were developed and visualised for each of three pathogens -MRSA, C. difficile and norovirus -using an evidence-based approach, e.g. employing pathogenic data showing recontamination after cleaning and covert observational data on "who touches what" in the ward setting. Context was provided through a virtual ward setting, enabling zoom-in and zoom-out to various locations and to provide macro/micro-scale views. Learning points, risk to patient and other text-based information relevant to job roles and tasks accompanied the visualisations. Data was acquired at each of the three stages from staff completing workbooks as they viewed and interacted with the prototype tool, and participated in group discussion.
Visualisations were engaging and supportive of different learning styles. They offered staff a new perspective on pathogens, being able to "see" them contextualised in the virtual ward, making them seem more real. Information proved relevant for different staff cohorts, with a mix of experience levels. They increased participants' awareness about pathogens by explaining "why" (through dynamic visuals and information) IPC procedures should be followed.
Further applications were suggested, including at clinical induction, education in schools/universities, and refresher courses.
This systematic process has established proof of concept for the tool. A stage 4 prototype is now being developed with the intention of trialling by IPC managers during in-ward use.
I do not have any conflict of interests to declare.
Increasing influenza vaccine uptake from 44% to 77%
Each year, particularly during winter, influenza is a significant cause of morbidity and mortality. The influenza vaccination has been shown to be effective at reducing the severity of illness and preventing death. For this reason the Department of Health has a vaccination policy for vaccinating frontline workers within the NHS. In 2013-2014 the target that NHS Trusts needed to meet was increased to 75% and the author's Trust at this time had an uptake of 44%.
The service improvement to increase uptake of the influenza vaccine had a number of components, which included a multidisciplinary team approach, education, launch events, offering vaccines at meetings and training, and social media. The infection prevention team and employee health and wellbeing teams worked collaboratively throughout the campaign as the "flu fighter team". Education was provided prior to the campaign commencing, with all teams who had a poor uptake being invited to a presentation on influenza which included how it is spread, signs and symptoms, risk groups and examples of outbreaks in the local area.
The campaign was launched with events at different venues across the Trust, with staff members being invited to have their vaccine, then enjoy a slice of homemade cake. Social media was used to support the campaign, with staff members having their photos taken holding a banner saying "we've had our flu jab have you had yours?" These were shared on social media and got staff members talking about having the flu jab.
The Trust has increased the uptake from 44% to 77% and has been the top mental health trust in England for the last 2 years.
Future steps should involve the further development of the educational element prior to commencing vaccinating staff members, in particular targeting areas with lower uptake figures.
In dental settings where the risk of cross-contamination and occupational infection is high, adequate use of personal protective equipment (PPE) is important. We held a series of infection control seminars for dental healthcare personnel and conducted a survey of the participants after the seminar. We report the current status of the use of PPE in Japanese dental facilities and the improvements reported after seminar participation.
A self-administered questionnaire was mailed to the 181 dental facilities who attended our infection control seminar.
We received a total of 74 responses (response rate 40.9%), of which 39 (52.7%) were from dentists, 24 (32.4%) from dental hygienists, 10 (13.5%) from dental assistants, and one (1.4%) from a pharmacist. A total of 43 facilities (69.6%) had been actively using PPE before attending our seminar. However, 49 facilities (66.2%) changed and/or increased the use after seminar participation. A total of 29 facilities (39.2%) increased glove use, 15 facilities (20.3%) improved correct glove use, 13 facilities (17.6%) started to change gloves between each patient, 29 facilities (39.2%) increased eye protection use, and 10 facilities (13.5%) introduced eye protection. In addition, six facilities (8.1%) started to change protective clothing between each patient, and six facilities (8.1%) newly introduced protective clothing.
Proper use of PPE is essential for infection control in dental settings. Although most dental facilities in Japan already comply with PPE, improvements were observed after participating in the infection control seminar. It was suggested that the seminar served as an effective learning opportunity for proper PPE use. We will continue to promote not only the necessity of PPE but also its correct use, which may contribute to improving infection control in dental settings.
I do not have any conflict of interests to declare.
Descriptive study of vaccination programme for nursing students, healthcare workers and caregivers in A prefecture in Japan
The vaccination programmes of hepatitis B (HBV), hepatitis C (HCV), measles, mumps, varicella, and rubella (ID) for nursing students and healthcarerelated workers (HCRW) including healthcare personnel and care workers have been varied, but not clarified. Therefore, the purpose of this study was to investigate the current vaccination programmes for HCRW in A prefecture in Japan.
After approval from the ethical committee of the institution to which the first author belonged, an anonymous self-reported questionnaire about vaccination programmes and their expense was distributed to the following institutions: 305 healthcare facilities, clinics, visit nursing stations, long-term care facilities, and public health centres which were randomly selected, and 14 nursing schools in A prefecture in Japan.
The response rate was 30.7%. Of nursing schools, 86% conducted HBV, HCV, and the above ID antibody titre tests. Also, about 60% of the nursing school carried out a tuberculin reaction test.
Among the healthcare facilities, all employees had to take the HBV antibody titre tests, and 19.2% of them carried out an HIV antibody titre test. Approximately 50% of them carried out the above ID antibody tests.
Although visiting nursing stations, long-term care facilities, clinics, and public health centres carried out HBV antibody titre tests and its vaccinations, the above four IDs antibody titre tests as well as TB screening tests were not conducted.
The cost of antibody titre tests were paid by 75% of nursing schools. The cost of vaccination of HBV and HCV and the above ID antibody titre tests were paid by 87.5% of nursing schools.
The percentage of nursing schools that performed the vaccination programme was fairly high; however, the percentages for other healthcare-related facilities were low.
As one of the largest teaching hospitals in the UK, our Trust's Infection Prevention and Control Team (IPCT) receives large numbers of calls each week surrounding personal protective equipment (PPE). Despite an isolation guideline outlining PPE use, there appears to be confusion from medical and nursing teams around what PPE to wear for certain infectious pathogens and for how long. Research from across the globe indicates this confusion is not a local issue.
The IPCT recognised the need for a tool to aid staff to learn, remember and recall PPE information. It was decided a visual tool should be created, that could be used as reference, but also a learning method. The PPE wheel was born.
The wheel is broken into four sections based on the transmission routes of the pathogens (droplet, contact, airborne, and faecal-oral). Each section is broken down into what PPE should be worn. In line with epic3 guidance, correct removal of PPE is included due to contamination risks upon removal.
Focus groups using patient care scenarios conducted across 10 units have established current levels of knowledge and confidence surrounding PPE use. These confirm the need for a tool, with widely varying confidence levels across the Trust (range: 0-80%). Knowledge of PPE was particularly poor when respiratory conditions were involved.
The tool was previewed at our 2016 IPC link staff study day. Staff felt the tool was potentially useful, and multiple requests for the finished tool were received. Final prototype development is scheduled for completion by December 2016 and the tool will be disseminated within the Trust during 2017. Evaluation of its efficacy in helping staff learn about PPE will be conducted via repeat focus groups at 3, 6, and 12 months after launch.
Provision of infection prevention and control (IPC) training for domiciliary care workers can be challenging. This group of staff are mobile workers with little or no access to electronic training or IPC resources during their working day.
To support the domiciliary care sector and their care workers with an easy access source of IPC education and information, we have developed an infection prevention workbook containing guidance for staff providing care at home. This follows on from the successful workbooks developed for Community Health and Social Care and General Practice.
This innovative 68-page workbook is A5 size, is suitable for a wide range of staff who provide care at home to service users, such as domiciliary and rehabilitation teams undertaking personal care or who assist with daily living activities. It is designed for all levels of staff and each member of staff should receive their own copy, working through at their own pace.
It provides latest national guidance, evidence-based information, 16 topics including seven standard precautions, four key topics and five specific infections. Each section includes "test your knowledge" questions. When 100% competence is achieved, managers sign the "Certificate of Completion", providing evidence for registration requirements. Staff should keep the workbook as evidence of learning and a reference guide for day-to-day working.
The workbook, published in March 2016, is now used locally and nationally. Positive feedback includes:
"The workbook is a brilliant resource and staff are lucky you are there to support them. Completion of the workbook would be an ideal way for Domiciliary Care agencies to demonstrate staff training".
"The workbook is excellent and a good source of information for our Support Workers".
Future steps should include raising awareness of the workbook with key stakeholders in public and private sectors.
I do not have any conflict of interests to declare.
Surgical site infection (SSI) rates are particularly high (up to 20%) in vascular surgery patients, reflecting the significant co-morbidities in this group. Dressings coated with highly hydrophilic Dialkylcarbamoylchloride (DACC) irreversibly bind multiple types of bacteria and should prevent their ingress into wounds. We aimed to determine if the use of coated postoperative dressings could reduce SSIs in non-implant vascular surgery.
Between August 2015 and February 2016, we followed 100 consecutive patients before and 100 after the introduction of DACC-coated postoperative dressings for surgical sites at a single vascular centre. Wounds were reviewed at day 5 and day 30 according to the ASEPSIS score to determine the presence of SSI. Dichotomous outcomes of SSI versus no SSI were assessed using a two tailed Chi-squared test with Yates correction.
The 200 patients included 120 males with mean age 63 (range 27-97) including 184/200 current or ex-smokers and 91/200 diabetics. SSI at 5 days was significantly lower in the DACC-coated dressings' group compared with standard dressings (1/100 versus 10/100: p=0.01). Subsequent SSI rate from 5 to 30 days between DACC and standard dressings was not significantly different (9/99 versus 9/90: p=0.85).
DACC-coated dressings showed a significant reduction in SSI rates at 5 days post procedure (p=0.01). No statistically significant difference in SSI was seen beyond 5 days post procedure. DACC-coated dressings appear to have value in SSI prophylaxis in this patient group and would warrant further investigation.
I do not have any conflict of interests to declare.
Nosocomial infection is becoming a leading problem for medical practitioners nowadays, placing an extra burden on individual patients worldwide. Nosocomial pneumonia caused by multidrug-resistant (MDR) pathogens is a major threat in intensive care unit patients in developing countries, with increasing numbers in Nepal. The aim of this study was to determine the aetiology of nosocomial pneumonia caused by MDR Gram-negative bacterial isolates.
A total of 100 Gram-negative bacterial strains isolated from patients diagnosed with nosocomial pneumonia were studied during 2011 and 2012 at Tribhuvan University Teaching Hospital (TUTH). Antibiotic sensitivity was determined using a modified Kirby Bauer Disc Diffusion method as described by the Clinical and Laboratory Standards Institute (CLSI).
Nosocomial pneumonia caused by the Acinetobacter calcoaceticus baumannii (Acb) complex was found to be predominant (36%), followed by Klebsiella pneumoniae (28%) and Pseudomonas aeruginosa (17%). Of the total isolates, 87% were MDR, which was much higher in Acb complex and Escherichia coli (100% each).
The emergence of MDR bacterial strains causing nosocomial pneumonia is increasing. The high prevalence of MDR has demanded special attention for the management of such patients and prevention of dissemination of such strains into hospitals.
Caesarean section (CS) surgical site infection (SSI) occurs in 11 to 18% of women in the published literature, with 84% of infections occurring after hospital discharge. In 2010 the Advisory Committee on Antimicrobial Resistance and Healthcare-Associated Infection recommended that CS SSI surveillance become mandatory. Our 5-year surveillance and quality improvement programme aimed to quantify and reduce SSI in a tertiary hospital delivering 5900 babies annually.
In 2010 a dedicated SSI surveillance programme was developed, introducing a surveillance form for all women who had a CS. Organ space, deep or superficial infections are recorded. A programme of practice auditing is ongoing.
Interventions were introduced in a stepwise fashion. These included utilising a 10-day midwifery pathway, disposable head clippers, a change in surgical wound dressings with application duration extended from 1 to 7 days, and a change of surgical site preparation solution. Alongside this, the programme focused on interpersonal relationships, and components included a dedicated surveillance co-ordinator, IT analysis of data, specific infection prevention and control training, and quarterly reporting of surveillance data at local governance meetings alongside practice audit results.
Surveillance form response rates increased from 30% to 62%. Initial SSI rate after CS was 19.1% in 2010, reaching and maintaining less than 8% by the end of 2012 and achieving 3.5% in quarter 2 of 2015.
A sustained improvement in SSI rates is achievable with a focused programme. While this involves increased effort initially, collaborative working between surgical, midwifery, and infection prevention and control teams can help the programme become embedded within the department to sustain change.
I do not have any conflict of interests to declare.
Enterococci are Gram-positive bacteria that commonly live in the bowel and occasionally colonise or infect the urinary tract. When spread occurs beyond the gut they can be responsible for other serious infections like endocarditis. Environmental contamination with enterococci can occur and become a source of infection to other patients. Enterococci are often sensitive to beta-lactam antibiotics like amoxicillin, glycopeptides (vancomycin, teicoplanin), linezolid, tigecycline and daptomycin.
In the last 3 years there has been an unexplained increase in beta-lactam and glycopeptide resistance in our hospital. In 2011-2013, there were 26 glycopeptide-resistant Enterococcus (GRE) cases while in 2014-2015, there were 60 GRE cases.
A retrospective analysis of clinical results from January 2011-December 2015 was performed. A review of patient notes was undertaken for cases in the last 2 years to identify contributory factors.
We identified 12 GRE cases in 2011, six in 2012 and eight in 2013 (26 GRE cases in 3 years). In 2014 and 2015 there were 19 and 41 cases of GRE. The majority of the samples, 57 out of 86 samples, were from urine, while 14 of them were from blood culture, and other samples were from wound swabs, faeces and other sites. From October 2014 onwards, a total of 65 isolates were sent for PFGE typing and results revealed several "clusters". The most common type was labelled LUTOPEC 5 (16/56).
Following a review of patients' notes from the last 2 years, most of the patients identified have acquired the GRE within 48 hours of hospital admission. The majority of specimens were from urine. Twelve patients had been treated with a glycopeptide (teicoplanin or vancomycin) before GRE was identified. Other risk factors were also analysed. A risk-based screening process may be required locally to limit further spread of this organism.
I do not have any conflict of interests to declare.
Enhanced Staphylococcus aureus Bacteraemia Surveillance (eSABS) to standardise the reporting of SAB infections were introduced nationally in 2014. This initiative aimed to better understand the cause of the SAB, to determine the potential avoidance and to intervene to minimise the risk of a SAB occurring due to the same cause again. The Infection Prevention and Control Team (IPCT) formed a group to facilitate the appropriate data collection. Focusing on risk and contributory factors, the group aimed to determine if SABs were avoidable or non-avoidable and engaged with the attributed clinical areas in order to identify any quality improvement opportunities. In addition, all cases were reviewed to ensure they were managed in line with guidance on management of proven or suspected SAB in adults.
Using the Plan Do Study Act cycle and the national eSAB tool, a surveillance form was created for the IPCT to investigate the SAB infection. This was used to identify the entry point, determine source and record procedures/interventions within the last 30 days. Assessments were made regarding medical history device placement, and whether the patient had any prosthetics. For quality improvement approaches the group reviewed the implementation and completion of bundles such as Peripheral, Central Vascular and Urinary Catheter bundles.
Weekly, the IPCT along with the multidisciplinary team discuss the results of the surveillance, review patient management and identify quality improvement opportunities. Hand hygiene and device bundles are audited if the SAB is found to be related to a device. IPCT engaged with clinical teams to assist with the implementation of bundles and support auditing. Clinicians in charge received a letter detailing the outcome of SAB surveillance, offering the chance to respond to the information. The medical microbiologists also offered to attend educational meetings for further SAB discussion if required.
This poster will demonstrate the reduction of surgical site infection (SSI) 3 years after the introduction of a dedicated SSI Surveillance Team (SSIST) into a large acute NHS Trust in 2012.
The NHS performed 9.920 million surgical procedures in 2014/2015 (most recent HES data), many posing a risk of SSI which remains largely unquantified. Published evidence is that SSI accounts for 16% of all healthcare-associated infection and remains a significant clinical and costly control.
The team monitors patients who have had knife-to-skin procedures (6195 patients in 2014/2015). Telephone questionnaires are completed at 30 days and the surveillance continues at 3 months, 6 months and 12 months if implants have been used. An electronic surveillance system (ICNet) is used to identify patients who are included in the surveillance and any subsequent admissions. Each SSI is categorised according to the published definition set by the Centre for Disease Control (CDC). Data is banded into four groups: patient reported only; post discharge (confirmed); readmission and inpatient. Risk factors are collected; however, these are reported on in response to specific enquiries or variances in data.
Anonymised feedback is provided to surgeons monthly via a data dashboard to allow a wider discussion within the Trust and to enable surgical colleagues to review their own data.
Confirmed infection rates reduced from 10% to 2.6%. In the initial period, savings were gained in bed days saved, reduced readmissions and theatre time through a decrease in patients requiring reoperation due to SSI. The reduction in SSI has continued across specialities. The average follow-up rate is 58%.
Continuous all-specialty SSI data provides a measure of continuous quality improvement at relatively low investment. The benefits should be discussed in the context of the wider NHS.
I do not have any conflict of interests to declare.
During the financial year 2015-2016 there were 34 Trust-apportioned cases of Clostridium difficile at Surrey & Sussex Healthcare NHS Trust.
A root cause analysis (RCA) investigation was carried out for each case, including a review with the commissioners to assess whether there have been any "lapses in care". An RCA theme analysis was carried out, in order to identify lessons learned.
Each RCA action plan is followed up and signed off by the relevant Division, and lessons learned are disseminated within the division and across the Trust. The main themes from the RCA investigations are:
1. Lack of diarrhoeal risk assessment and MDT review and documentation of this 2. Missed opportunity/delay to sample sending 3. Delay to patient isolation (requirement for complex patient transfer(s) to available single room) 4. Testing delay, e.g. unlabelled sample 5. Delay to commencement of CDI treatment 6. Prescription errors (inappropriate route of administration; incorrect dose interval; incorrect dose; unsigned dose)
In order to address the lessons learned, a number of initiatives have been put in place. These include:
A "Stop Assess Send" campaign to increase awareness of the importance of prompt stool and isolation • •
The management of diarrhoea is included in the quality improvement "Virginia Mason" programme
Japan Nosocomial Infections Surveillance (JANIS) is a voluntary national surveillance with more than 1800 participating hospitals. In Japan, where hospital epidemiologists are not common, surveillance is usually a part of an infection control practitioner's multiple, diverse responsibilities. However, the rate of data submission to JANIS is quite high (>95%) and the dropout rate is low (<3%).
Here we investigate which types of professionals are involved in JANIS.
We conducted on-site structured interviews using a questionnaire developed by a working group of infection control practitioners. Hospitals were chosen from JANIS member hospitals that participate in both the surgical site infection (SSI) and antimicrobial-resistant bacterial infection (ARBI) divisions.
A total of 20 hospitals in seven areas of Japan with beds counts ranging from 80 to 1063 (median, 355.5) were visited. More than two types of professionals are conducting surveillance at 13 (65%) and 17 (85%) hospitals for SSIs and ARBIs surveillance, respectively. The most prevalent profession in charge of SSI surveillance was nurse (90%), followed by medical doctor (60%) and clerk (30%). For the ARBI surveillance, they were nurse (90%), clinical microbiologist (75%), and medical doctor (60%). There was no association between hospital size (bed count) and whether the surveillance involved multiple professions or not (SSI division, 397 beds vs. 299 beds, p=0.57; ARBI division, 380 beds vs. 468.5 beds, p=0.84).
Most Japanese hospitals are conducting surveillance with multiple professionals that are keen to share data, regardless of hospital size. Although nurses and medical doctors play key roles, the workload for surveillance was shared with other professionals, which resulted in high sustainability. This interdisciplinary approach to surveillance may help improve infection control practices in all professions and departments.
I do not have any conflict of interests to declare.
Reducing CDI below the irreducible minimum: A multi-faceted approach
Walsall Healthcare NHS Trust
In April 2007 the Department of Health introduced targets to NHS Acute Trusts to focus reduction of Clostridium difficile (CDI) toxin-positive cases. C. difficile is the major cause of infective hospital-acquired diarrhoea in the UK, and has been associated with more than 16,000 cases per year in England and Wales. The targets look to reduce only the toxin-positive cases once patients are already symptomatic, but prior to this is improving the quality and safety of care by preventing colonisation from occurring in the first place. Colonisation can occur in one of three ways: contact with a healthcare worker; contact with a contaminated environment and from direct contact with a patient with C. difficile infection.
The aim of this work is not to look at the treatment of C. difficile infection, but to explain the measures used to prevent colonisation in the first place.
A multi-faceted approach has looked at daily side-room utilisation, isolation on diarrhoeal symptoms not results, standard precautions, environmental decontamination, 30-day health economy-wide patient review and self-directed staff learning packs. For each intervention, PDSA cycles have been used to evaluate and then disseminate interventions across the organisation.
The work has resulted in year-on-year reductions over the last 3 years, with results of 33 cases, then 16 and, for 2015/2016, seven cases against a target of 18. This has been identified by the Trust Improvement agency as exemplary and our approach is discussed to provide ideas for other organisations.
Royal Brompton & Harefield NHS Foundation Trust utilises a predictive surgical site infection (SSI) score, the Brompton Harefield Infection Score (BHIS), for patients undergoing coronary artery bypass graft (CABG) surgery. In 2015, analysis of over 4000 cases and 42 variables was performed, whilst also determining the impact of interventions to prevent SSIs. The study found no significant difference between skin prep solutions based on either chlorhexidine (CHG) 2% in 70% alcohol or povidone iodine (PVI) 10%. In this additional study, a separate cohort of 2375 cases was analysed to re-examine SSI as a dependent variable with independent variables of skin preparation and SSI risk category.
This research involved continuous, prospective surveillance on 2375 cases. It included 75 SSIs from January 2013-October 2015 (primary or re-admission), while simultaneously, data was collected for theatre skin prep solutions and BHIS risk group.
The results indicate:
The Although not RCT-level evidence, this study is relevant to our cardiac patient group. The application of the skin prep products is carried out in a consistent manner, with attention to application technique, drying time, etc. Our findings suggest that PVI 10% and CHG 2% products in alcohol are equally efficacious and safe in this patient group. This work can provide assurance to commissioners of the best available evidence for practice.
I do not have any conflict of interests to declare.
Setting up line surveillance to drive improvement
Central venous catheter-related blood stream infections (CRBSI) cause increased mortality and morbidity in patients; many of these are preventable using evidenced-based care. Matching Michigan is a national project focused on critical care units to reduce central line infection rates using a quality improvement programme. Following improvements in critical care, it was agreed that the principles should be adopted across the whole hospital, ensuring that all patients with central venous access devices (CVAD) received safe and effective care.
A CVAD Steering Group was set up to bring together all key stakeholders involved in the care of CVAD, including a lead clinician to oversee best clinical practice. It was important from the outset to establish an outcome measure to demonstrate improvements in practice, with the obvious measure being CRBSI. Potential CRBSI were identified by the microbiologists (numerator) and a process to collect the number of line days (denominator). All cases of CRBSI are investigated using root cause analysis (RCA) and the learning shared with the Steering Group to action changes to practice.
During the last 5 years, learning from CRBSI has allowed improvements to practice including standardised care pathways, training and competency framework, routine MSSA and MRSA screening and a change to chlorhexidine island dressings. Evidence of the improvement is seen in the surveillance data with the rate of CRBSI falling from 5/1000 line days in 2011 to 0.6/1000 line days.
We are able to monitor the rate of CRBSI for each department with patients with CVAD and we can accurately assess problems and spot trends at an early stage to implement effective change as required. Further work includes the development of a patient-held record and training package for patients in the community with their CVAD in place.
I do not have any conflict of interests to declare.
Building works danger on the ward: Works can release high numbers of concentrated organisms!
To keep the buildings in good physical condition means hospital renovation, and it has been proven that hospital-acquired infections occur in higher numbers when hospital renovations are taking place (Pini et al, 2007) ; this includes major and minor works (Chang et al, 2008) . Ross et al (2011) state that renovation should be delayed until patients have been moved to an alternative setting; however, this is not always possible and many works are necessary and must be done whilst patients are in situ. When emergency renovation is required then the patients may not be able to be moved, but Ross et al (2011) go on to discuss that measures can be put in place to minimise the risk to the patient.
The Trust's "Better Care Together" strategy states that changes will have to be made to existing facilities to ensure they are appropriate for 21 st century health care.
As part of the Infection Prevention (IP) annual plan, to maintain a clean and safe environment, the team will be involved in capital planning, supporting refurbishments and new builds. The IP team have worked closely with the estates team for IP training; we have invited external contractors to complete the same training focusing on the guidelines that HBN 00-09 (2013) sets out. We are working with the staff on the wards to understand the risks involved with works going on whilst patients are on the ward.
We are undertaking environmental audits with the Infection Prevention Society environmental audits structure. Evidence of improvement is the reduction of Clostridium difficile figures shown in the DIPC annual report.
We will continue to work with all staff that work within the hospital to ensure a clean and safe environment for our patients.
Vaginal discharge is one of the most common complaints seen in the gynaecology outpatient department (GOPD). Alteration in the balance of normal vaginal flora can lead to the overgrowth of other organisms that causes abnormal vaginal discharge.
One hundred and one patients attending the GOPD of Nepal Medical College and Teaching Hospital (NMCTH) between August 2011 and July 2013 with vaginal discharge were evaluated to determine microbiological aetiology. Three high vaginal swabs were taken from each patient who came to the outpatient department with complaint of vaginal discharge. These specimens were subjected to different microbiological evaluation using standard microbiological techniques.
Of the total patients studied, the mean (SD) age was found to be 30.15 (6.93) years. Around 57% (57.42%) of women had vaginal discharge of infectious aetiology. The most prevalent disease was bacterial vaginosis (29.7%) followed by candidiasis (24.75%). Of the total candidal infections, 56% were caused by Candida albicans and the remaining by Candida glabrata, Candida tropicalis, Candida parapsilosis and Candida krusei. Trichomoniasis was among the least common cause of vaginal discharge (0.99%). Two cases were identified as having intermediate vaginal flora. Some 42.57% of females who gave a history of abnormal vaginal discharge were found to have normal vaginal flora.
Our study concluded that the most common cause of vaginal discharge is bacterial vaginosis followed by candidiasis. Trichomoniasis was less prevalent in our part of the world. Although the syndromic approach for treatment of vaginal discharge is being followed, this study clearly depicted around 43% of those presenting with vaginal discharge had normal vaginal flora and were not in need of any treatment. Therefore, even if simple microbiological tests are employed in the final diagnosis of vaginal discharge, this would avoid unnecessary treatment and thus avoid the economical, social and psychological burden to the women in question, and also will avoid unnecessary exposure to drugs.
In 2013 the Betsi Cadwaladr University Health Board (BCUHB) had a large outbreak of Clostridium difficile infection (CDI), with background rates the highest in Wales. In response a range of actions were implemented. This included a collaborative study between BCUHB, Public Health Wales (PHW), and Nuffield Department of Medicine, Oxford, which used whole-genome sequencing in order to better understand the epidemiology of the CDI, and assist in targeting control measures.
A prospective cohort study of all laboratory-confirmed CDI cases between February and July 2015 was undertaken. Risk exposure data on cases, and organisational factors such as cleaning and staffing levels and both hospital and community antibiotic prescribing, were considered alongside phylogenetic information obtained by whole-genome sequencing. A comprehensive programme of stakeholder engagement was developed with the aim of using the information obtained to drive change. Tableau analytical software was used to aid visualisation of results.
Phylogenetic analysis of 76% of toxin-positive and 63% of toxin-negative CDI cases that were successfully sequenced indicated that the majority (75.9%) of CDI cases in North Wales were unrelated to others. The number of closely related cases was greater in samples from hospital settings than from the community. This implies that factors other than immediate healthcare environments are driving the number of cases in North Wales. Contextual data indicated considerable scope to improve both antibiotic stewardship and compliance with audits relevant to infection prevention. Visualisation of broad but relevant data using interactive analytical software has the potential to support the application of research findings to clinical and wider hospital practice. The process of stakeholder engagement to drive action in these areas will be discussed.
Surgical site infection (SSI) among patients after cardiac surgery is a lifethreatening complication. Some existing studies showed the effectiveness of daily chlorhexidine (CHG) bathing as a precaution to reduce bloodstream infections and SSIs. However, there is a lack of evidence of the effectiveness of daily CHG bathing among patients after cardiac surgery.
This study aimed to examine the effectiveness of preoperative CHG bathing on SSIs among patients undergoing urgent cardiac surgery, defined as patients who needed to enter ICU after admission and were scheduled for surgery within 72 hours.
We analysed patients with cardiovascular disease who underwent cardiac operations at our specialised hospital in Japan between 1 January 2014 and 30 April 2016. Preoperative CHG bathing was introduced from 1 January 2015 as a measure to prevent SSIs. We compared the data (such as demographic and laboratory data, treatment and drug used, and so on) with and without preoperative CHG bathing. SSI was defined using the CDC and National Healthcare Safety Network criteria. This study was approved by the Institutional Review Board of the hospital and Miyagi University in Japan.
Among 35 patients undergoing urgent cardiac surgery, 20 patients received the preoperative CHG bathing (CHG group) and 15 did not (non-CHG group). Demographic characteristics were similar between the groups. The incidence rates of SSI for CHG and non-CHG groups were 5% and 26.7%, respectively (relative risk 0.145; confidence interval 0.014-1.464; p=0.141). There was no statistically significant difference on SSI rates between the two groups; however, the incidence rate of the CHG group was decreased compared with the rate of the non-CHG group.
The Japanese Society for Infection Prevention and Control launched the device-associated infection surveillance project in neonatal intensive care units (NICUs). The purpose of this study was to evaluate the results and to explain our surveillance system during the first year.
This study was conducted from 1 January to 31 December 2015. Two types of device-associated infections in NICUs were selected to be surveyed: central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). In this surveillance, the protocol was based on the National Healthcare Safety Network (NHSN) surveillance system and used standard infection definitions from the Centers for Disease Control and Prevention (CDC) for international comparison. We used the clinical sepsis (CSEP) criterion for CLABSI in addition, to reduce the underestimation of CLABSI rate. NICU locations were categorised into two types: level III or level II/III. The data were collected for each of five birth-weight categories (<750 g, 751-1000 g, 1001-1500 g, 1501-2500 g, and >2500 g) and were compared with NHSN data.
A total of nine NICUs participated. Pooled mean incidence by birth-weight categories in level III was 3.4, 1.5, 0.0, 2.2, and 2.1 per 1000 central line days for CLABSI; 1.5, 0.0, 2.5, 2.6, and 2.5 per 1000 ventilator-days for VAP, respectively. Pooled mean incidence by birth-weight categories in level II/III was 17.7, 4.4, 4.0, 0.7, and 8.5 per 1000 central line days for CLABSI; 1.3, 0.0, 5.4, 5.3, and 9.8 per 1000 ventilator-days for VAP. There were 39 CLABSIs, and 26 (66.7%) of them were identified by CSEP criteria.
We have established the surveillance system of device-associated infections in the NICU. Incidence of CLABSI and VAP in this study was higher than that in NHSN.
In Japan, the durations of indwelling urinary catheters have been reported as longer than those in other developed countries including the United States and England. Catheter-related complications (CRC) include catheter-associated urinary tract infections (CAUTI) and catheter obstruction (CO). Although CAUTI has been well investigated, there are a lack of studies about CO. Therefore, the purpose of this study was to examine the incidence rate and risk factors of CAUTI and CO among patients with silicon-based and silver-coated Foley catheters (FC).
After the approval of the ethical committee in Miyagi University, a quasi-randomised trial was conducted. Adult in-patients with a new indication of indwelling urinary catheter were grouped into silver-coated FC (silver group) or silicon-based FC (silicon group). Binary variables were analysed using a chi-square test, and quantitative variables were analysed with the Mann-Whitney U test.
The results of 42 patients in the silver group and 16 patients in the silicon group were analysed. The mean durations of silver group and silicon group were 15.5 (SD 15.7) days and 18.3 (SD 17.9) days. The incidence rates of CRC were 4.8% (silver group) and 0% (silicon group) respectively (p=0.374). The incidence rates of CO were 28.6% (silver group) and 6.3% (silicon group) respectively (p=0.068). Female gender (p=0.005) and administration of antibiotics (p=0.005) were statistically significant factors for CO.
Although small sample size and non-equal numbers of both groups were the main limitations of this study, the type of FC could be a possible risk factor for CO. From the results of this study, CO happened more than CAUTI among inpatients with an indwelling urinary catheter. In addition, female gender is a risk factor for CO. Administration of antibiotics during indwelling FC showed a preventive effect on CO; however, this issue should be examined further.
The Japanese Society for Infection Prevention and Control launched the device-associated infection surveillance project in 2009. This surveillance project is designed to provide the society members and medical institutions with information on the occurrence of device-associated infections in Japan, and to make an international comparison of surveillance data. The objective of this presentation is to explain our surveillance system and to evaluate the results of 6 years.
Three types of device-associated infections were selected to be surveyed: central line-associated bloodstream infection (CLABSI); catheter-associated urinary tract infection (CAUTI); and ventilator-associated pneumonia (VAP) in intensive care units. In this surveillance, definitions and methods for calculating the infection rate used are in line with those specified in the National Healthcare Safety Network (NHSN) manual, in order to compare and analyse nationwide surveillance data from the United States and Europe. In terms of comparison with NHSN data from 2013, "medical-surgical ICU less than 15 beds" was selected for similar patient background.
Pseudomonas aeruginosa-linked catheter-associated urinary tract infections (CAUTIs) being the commonest device-associated infections, modified biomaterial catheters are of great importance as a preventive strategy. Azithromycin (AZM) has been proved to be effective against infections caused by Pseudomonas aeruginosa due to its antivirulence property. This study was designed to modify a silicone urinary catheter impregnated with AZM. Further, we have investigated the efficacy of these catheters in preventing CAUTIs in vitro and in vivo.
In vitro testing of AZM at Sub-MIC levels for antivirulence property was performed. Biocompatible silica sol-gels were tailored to enable a controlled release of AZM at the antivirulence concentrations. After characterisation, these catheters were tested for biocompatibility ex vivo using urothelial cell line (SV-HUC-1) as per the ISO-10993 guidelines. Further, the efficacy of these modified catheters was exploited to prevent the CAUTIs in an experimental animal model.
A three-layer coating process of 10% w/v of AZM on R e =32 (ethanol: TEOS) sol-gel system has resulted in controlled release. The in vitro release study has confirmed the controlled release at dosages with significant antivirulence activity. Further characterisations were performed using AFM, SEM and profilometer techniques. This modified biocompatible urinary catheter, confirmed by the ex vivo analyses, showed a reduced bacterial load in the implanted animals' tissues as compared with that of the infected control and silver nanoparticlecoated catheter-implanted animals. Decreased production levels of virulence factors were evident from the AZM-impregnated implant group animals in comparison with the other group animals. Renal damage markers showed reduced tissue damage in the modified catheter implantation group, which was further supported by histopathological evaluations. Given the preparation, characterisation and efficiency of a modified urinary catheter to prevent CAUTIs, the present data suggest great promise to avert nosocomial biofilm infections.
Screening for carriage of carbapenemase-producing Enterobacteriaceae (CPE) is an important measure in preventing in-hospital transmission. We implemented risk factor-based CPE admission screening in June 2015, using a modified version of the PHE Toolkit. Risk factors that trigger screening are overnight hospitalisation in the previous 12 months, and overseas residence. Implementing CPE risk factor assessment and screening into the admission pathway has proved challenging operationally.
A private patients ward in an acute NHS hospital Trust was selected for a quality improvement programme in collaboration with NHS Improvement to improve compliance with CPE admission screening. A measure of CPE screening compliance was calculated by determining the number of admissions with overnight hospitalisation in our Trust in the past 12 months (denominator) and the number of patients who were screened within 24 hours of admission (the numerator).
The intervention to improve compliance began in April 2016 and included a range of measures involving staff and patient education, information and investigation of barriers co-developed with the ward team. The rate of CPE screening was compared using a Fisher's Exact Test for June 2015-March 2016 (pre-intervention) and April-mid-June 2016 (intervention).
In total, 150 patients with overnight hospitalisation in the Trust were admitted to the private patients ward between June 2015 and mid-June 2016. Of 126 admissions, 71 (56%) were screened within 24 hours pre-intervention compared with 21 (88%) of 24 admissions during the intervention (p<0.05).
An intervention based on raising staff and patient awareness of the need for risk factor-based CPE screening significantly increased compliance in a private patients ward. Identifying patients colonised with CPE is vital for preventing "silent transmission" of CPE. We plan to extend this successful intervention across all private patients wards, and then across the Trust to improve compliance with CPE admission screening.
I do not have any conflict of interests to declare.
Elizabeth Marchant 1 , Ms Louise Bishop 1 , Mrs Debbie Flaxman 2 , Mrs Jenni Jagodzinski 2 , Dr Mahesh Nanjundapp 2 , Dr Prasanna Muniyappa 2 , Dr Rebecca Cordery 1
Since the introduction of the MMR vaccination in the UK in 1970, rubella notifications have fallen dramatically. Cases of congenital rubella syndrome (CRS) have also fallen significantly, and whilst now rare, three cases have been reported in the UK since January 2014.
In 2015, the South East London Health Protection Team was notified of a case of rubella infection and suspected CRS in a 17-day-old infant. We describe the risk assessment and infection control measures, as well as considerations relating to the cessation of rubella susceptibility screening in pregnancy.
The risk assessment considered patients, staff and visitors in the delivery suite and NICU. Ninety-six staff were identified as involved in the birth or care of the baby and required follow-up by Occupational Health.
Standard infection control precautions including hand hygiene and use of PPE were assessed as sufficient. The baby was isolated in a side room and was cared for by staff with documented immunity.
Infants with CRS can continue to excrete virus for more than a year, and therefore a weekly oral fluid sample was arranged to monitor duration of virus excretion as a marker of infectiousness.
A number of lessons learnt are highlighted, including a reminder of the importance of the MMR vaccine for all women of child-bearing age, in particular those arriving in the UK as children or young adults; of asking about history of rash in early pregnancy; the early consideration of CRS in infants with congenital abnormalities; and the importance of consistent staff MMR vaccination policies in healthcare organisations.
In April 2016, rubella susceptibility screening in pregnancy in England ended. This further highlights the importance of asking about history of rash in pregnancy and considering rubella as a possible cause of intrauterine growth restriction.
I do not have any conflict of interests to declare.
Limited voluntary surgical site infection surveillance (SSIS) is currently undertaken in England since data collection is considered resource intensive. Guy's & St Thomas' NHS Foundation Trust introduced an ICNet SSI module to the organisation in 2012 to improve efficiency in infection control / SSI data collection, management and security. This would release more time for other patient safety activities. Organisations could take advantage of the "Safer hospitals safer wards technology fund" launched in May 2013 to introduce similar suitable IT systems.
After initial collaborative work to introduce an efficient IT system, data for eligible surgical patients is now selectively imported into ICNet. This system links up a Galaxy theatre management system and Patient Administration system to facilitate eligible patients to be accurately monitored for SSIs. This has facilitated our organisation to sustain surveillance of 12 specialties with a surveillance team of only three staff (1 × band 7 team leader and 2 × band 3 HCAs).
Our surveillance has expanded from mandatory orthopaedic surveillance to effective continuous surveillance of 12 surgical specialties. The expansion could not have been achieved without an efficient IT data management system that eased the burden of data collection and gave us the following benefits: We have reduced the number of non-communicating password-secured IT applications we used for our surveillance from six to two and released time for effective caesarean section post-discharge surveillance and for raising awareness on SSIS. Huge cost savings were realised through reduction of SSIs and not recruiting additional staff to sustain our surveillance.
We are happy with our SSI module, which we modified to suit our needs. We are working hard to incorporate ASA scores in Galaxy to enable us to go "paperless".
Carbapenemase-producing Enterobacteriaceae (CPE) have begun to cause outbreaks in the UK. Risk factor-based screening of admissions for CPE was introduced in June 2015 to enhance universal screening of admissions to high-risk specialties. We explore whether increases in CPE screening resulted in the detection of further outbreaks.
From June 2015, our hospitals performed risk factor-based CPE screening of all admissions, universal screening in high-risk specialties, weekly screening in wards where known carriers were present, and contact tracing around newly detected carriers. Each CPE case identified and confirmed by PCR locally was sent to the reference laboratory for VNTR genotyping. An outbreak was defined as two of more cases of CPE with the same VNTR type with epidemiological links. We report the number of outbreaks of CPE since implementing enhanced CPE screening in June 2015.
The Trust experienced five separate outbreaks of CPE first identified in the 2015/2016 financial year: two K. pneumoniae NDM outbreaks (40 and four patients), two Klebsiella pneumoniae OXA-48 outbreaks (seven and seven patients), and a K. oxytoca GES-5 outbreak (14 patients). Of these patients, 55/72 (76%) were first identified by screening specimens. Only one CPE outbreak had been identified in the Trust previously (in 2013). Control measures included an emphasis on high-quality hand hygiene, cleaning of equipment and ward environment including hydrogen peroxide vapour (HPV) decontamination of patient rooms at the time of transfer or discharge of case patients, and continued screening. All outbreaks have been controlled.
We believe that enhanced screening for CPE has resulted in the detection of CPE outbreaks that would otherwise have gone undetected. Controlling these outbreaks has led to several challenges, including compliance with admission screening, staff education, and limited single rooms. We expect to detect more outbreaks of CPE as our screening programme continues.
I do not have any conflict of interests to declare.
In this study, we aimed to investigate nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage rates, risk factors and knowledge problems regarding nosocomial infections among nurses in Northern Cyprus.
In this cross-sectional study a stratified sampling method is used, and two state and two private hospitals were visited for data collection. Nasal samples were taken with swabbed liquid media and cultivated overnight. Cefoxitin (4 μg/ml) added Mueller Hinton Agar media and usual phenotypical tests were used to differentiate MRSA from other possible pathogens. Results were evaluated by using Fisher's Exact Test in SPSS v19.0.
The rate for nasal MRSA carriage among nurses was one of the highest (57.7%) reported in nurses to date, as the rate of nasal MRSA carriage varies in a range of 3.2-10.5% in such countries. The high rate of MRSA carriage among nurses in North Cyprus should be urgently taken into account, as nurses are the most important route for MRSA transmission. Moreover, 67.9% of the nurses, of which 54.7% were identified as carriers, had no knowledge about MRSA. Nurses who stated that they have information about this problem were found to be carriers with a rate of 64% (p=0.43). The most important reason for this emerging rate of MRSA carriage is due to low knowledge among nurses about MRSA precautions and lack of infection control strategies. There was a significant increase of nasal MRSA carriage as nurses work and get older. Ongoing education in MRSA prevention should be provided to nurses, including an evaluation of sufficient knowledge and skills, to come to a better point.
The IPS Trent Branch has undertaken a census of the IPC workforce within the Trent region following the findings from The Centre for Workforce Intelligence review in July 2015. This was conducted to help understand the IPC workforce and help support workforce planning.
A survey was conducted which included questions on the demographic data of IPC professionals, service provision, special interests, IPC activity, CPD opportunities and challenges faced by IPC professionals in the region. One hundred and thirty-nine people were invited to take part in the survey and this was sent out via Survey Monkey.
There were 45 responses to the survey, with 32 organisations and 33 teams being represented. The survey highlighted that there is no consistency with team structures within IPC in the Trent region. Secondary care seems to have more structure and different skill mixes compared with primary care. CCGs and local authorities are shown to have much less staffing and skill mix. The qualifications of IPC professionals varied and there is no consistency to level of qualification to pay banding, job tiles or roles and responsibilities.
IPC pay banding ranged from band 8C-band 4, with the most popular being Band 7.
IPC activities involved 67% support directly to patients, 95% support to HCWs, 83% surveillance, 95% audits, 98% teaching, 50% public engagement, 90% PIR/RCAs, 86% outbreaks, 38% research.
IPC professionals within Trent are facing the following challenges: lack of resources; lack of staffing; engaging with workforce; strengthening compliance with IPC; and raising the profile of IPC. Priorities must be given to exploring possible solutions to these challenges.
There is now a better understanding of the IPC workforce for Trent, which is crucial for supporting fellow IPC colleagues, understanding professional development requirements and developing proactive and innovative project work.
I do not have any conflict of interests to declare.
Optimising the use of bladder ultrasound scanners to improve the quality and safety of patient care and reduce costs: An economic assessment
Portable bladder ultrasound scanning offers a non-invasive, fast and painless method to measure urine volume in the bladder. As an alternative to bladder catheterisation, it has been shown to significantly reduce urinary tract infection (UTI) and increase patient comfort. However, despite being available for over two decades, its adoption has been slow and inconsistent.
A detailed, monetised case study was undertaken. Cost avoidance analysis was used to demonstrate avoided spend associated with bladder scanning. Data on actual use of scanners during a 1-month trust-wide audit was used to inform the assessment. The impact of scanning in both high and low-use environments was analysed. Cost consequence analysis was used to compare the existing approach to the management of bladder scanners, namely localised management by wards, with a centralised approach using the trust's Medical Equipment Library (MEL).
Avoided spend was estimated to be in the region of £1,226,822 per year. This did not include the cost of bacteraemia attributed to UTI, or benefits of using a scanner, such as avoidance of treatment delays and avoiding overnight stay in hospital. The set-up and running costs of a scanner were estimated to be met within 6 to 24 months, depending on usage, after which significant ongoing cost efficiencies would be realised over its 8-10-year lifespan. Management of the trust's fleet of bladder scanners within the MEL was considered advantageous in order to create efficiencies within the system.
Bladder scanners improve the quality and safety of patient care and reduce costs. This economic assessment has demonstrated the significant avoided spend associated with scanner use and identified the key benefits to patients, staff and the organisation as a whole. There is a compelling case for management of bladder scanners within a MEL to ensure resources are better allocated.
I do not have any conflict of interests to declare.
Commissioning for Quality and Innovation (CQINN) project: Reducing catheter-associated urinary tract infections, can change be sustained?
The 2012/2013 data from the monthly national "Safety Thermometer" revealed catheter-associated urinary tract infection (CAUTI) rates were consistently double the national average.
The IP&C team completed a baseline audit in March 2013 to assess urinary catheter usage, management and associated infections within the trust. This audit captured 502 adult in-patients who were reviewed for catheter usage; of these, 23% (113) had a urethral catheter in situ, and 17% (18) of the catheterised patients developed a CAUTI. As a result of this audit, North Derbyshire CCG established a Commissioning for Quality and Innovation (CQINN) goal. The Trust formulated an action plan to achieve this goal using a multi-modal approach.
On 6 th January 2015 the infection prevention and control team repeated the prevalence audit.
Key findings: In addition to this, since August 2014 there had been a sustained decrease in the number of hospital-acquired CAUTIs reported via the Trust's "Safety Thermometer" data and this has been sustained.
The project has seen a significant decrease in harm to patients, reducing length of stay for this patient group, improved patient flow within the organisation, and equating to potential cost savings of approximately £38,578 for CRHFT in line with evidenced-based research.
I do not have any conflict of interests to declare.
Cambridgeshire and Peterborough CCG, UK
Clostridium difficile can be limited through combinations of good practice and adherence to key policies. Root cause analysis (RCA) is used to examine the patient pathway with the intent of identifying lapses in care in the prevention, treatment and management of the disease. National guidance has focused on taking this a step further using a post-infection review (PIR) process. As nurses within the CCG, we have supported our providers to maximise the benefits of PIR and prevent avoidable infection.
A pilot project set up by NHS England (East) in 2013/2014 was based on a modified PIR used nationally for MRSA bacteraemia. Using this template, scrutiny of each individual patient care pathway is enabled for C. difficile cases following the initial RCA. All levels of care staff are engaged in the process. Providers are supported to embed best practice across their organisations and gain high profile at Board level. An agreed local Healthcare-Associated Infection (HCAI) Strategy focuses on the patient experience and recognises good practice by following national guidance to reach the irreducible minimum through non-sanctioned cases.
The project has reduced the number of C. difficile cases that have associated lapses in care whilst also recognising good practice. Over the last 3 years and through strengthening of the process, an increase in the number of non-sanctioned cases, i.e. no breaches in key policy identified, has risen from 17% in the pilot year to 50% in 2015/2016.
The joined-up whole-economy approach will continue to be key in future developments and the aspiration to further reduce the number of sanctioned cases.
I do not have any conflict of interests to declare.
Diane Holland, Lisa Bree, Rebecca Griffiths
In 2012/2013, data from the monthly national "Safety Thermometer" revealed catheter-associated urinary tract infection (CAUTI) rates were consistently double the national average. A baseline point prevalence audit was completed in March 2013 to assess urinary catheter usage, management and associated infections within the trust. This audit captured 502 adult in-patients who were reviewed for catheter usage; of these, 23% (113) had a urethral catheter in situ. 17% (18) of the catheterised patients developed a catheter-associated UTI. North Derbyshire Clinical commissioning group established a Commissioning for Quality and Innovation (CQINN) goal. The Trust formulated an action plan to achieve this goal using a multi modal approach.
The project has seen a significant decrease in harm to patients and shortened length of stay for this group of patients, and therefore has impact on the improvement of patient flow within the organisation.
Mar 13 n (%) Jan 15 n (%) % Change This paper explores the methodology used to create and sustain a change in practice when commissioners and providers utilise CQINNS to support and promote best practice and reduce harm.
There has been a plethora of research studies approximating the morbidity and mortality of patients with Clostridium difficile infection (CDI). As infection and prevention nurses, we wanted to investigate how to prevent transmission of CDI in the patient areas to prevent further harm to others from asymptomatic carriers, cross-infection, contamination from fomites, staff hands and the equipment they use. Following a CDI outbreak, a research forum was assembled and a research question hypothesised to identify asymptomatic carriage. The forum, Patient and Public Involvement, aimed to explain the study and how the survey would be conducted. The proposed survey was taken forward to the Ethics Committee for approval, who agreed it could go ahead.
All 11 adult hospital inpatient wards (seven) and inpatient units (four) were included in the study;
The study took place over the winter 2015-2016; There were a total of 407 patient samples collected: 154 faeces samples were analysed; 253 skin swabs were collected and analysed; A total of 22 faecal samples were found to be positive for Clostridium difficile asymptomatic colonisation; 0 (n0) skin swabs were shown not to have any carriage; These results show a prevalence of 14.3% asymptomatic positivity for Clostridium difficile asymptomatic colonisation;
All positive asymptomatic carriers had received antimicrobials within the last 3 months;
All positive asymptomatic carriers had received proton pump inhibitors within the last 3 months;
All positive asymptomatic carriers had received care in an Acute Hospital within the last 3 months.
It was predicted that the rate of colonisation would be approximately 20%. The actual results were 14.3%.
Isolating identified asymptomatic carriers of as C. difficile potentially confines and prevents further contamination of the environment, and staff employing extra precautions concerned with source isolation protects other vulnerable patients in the vicinity.
Water is considered to be pure and clean. In reality it can be the perfect medium in which micro-organisms can grow. Legionella, Pseudomonas Aeruginosa and Mycobacteria have all been associated with hospital outbreaks linked to water.
Our Trust is a large tertiary hospital that is located within the South West Peninsula. Opened in 1981, it is a maze of corridors, wards and departments that have been configured numerous times to meet the changing needs of health care. This has led to a cat's cradle of pipework, dead legs, sinks and outlets that present the perfect conditions for the creation of biofilms and the stagnation of water.
To reduce the risk of water contamination by micro-organisms, the Infection Prevention and Control team joined forces with Site Services to introduce the Water Walk Arounds.
Every Friday at 10:30, the Infection Control Nurse Consultant and the Mechanical Services Manager rendezvous at a designated location, schematic drawings in hand. With the Ward Manager, all water outlets are examined for cleanliness, integrity and frequency of use. Actual locations of pipes and outlets are compared with those on the drawings. Clinical participation is essential. A snap shot of actual clinical practice is gained and all parties can raise concerns directly to those who can facilitate action.
Remedial works are instigated. Sinks no longer in use and discovered dead legs/ends are removed. Within the year, the whole hospital is reviewed in this way.
Three hundred remedial works have been raised via this process. Water safety awareness has increased amongst Clinical Managerial staff. Schematic drawings are up to date and the Infection Control Team can give assurance to the Trust and the population it serves that a robust system for water safety is in place.
This system is set to continue as it benefits all parties involved.
I do not have any conflict of interests to declare.
The Infection Prevention and Control Team (IPCT) have developed an observation/ training programme to provide increased support and on-going development to improve infection prevention control standards in the clinical area. The two assessment units -male and female -were identified as areas that would benefit from the training programme. The assessment units are very busy clinical areas that can have up to 60 admissions and discharges per day. The aim of the training programme was to increase visibility of the Infection Control Team, to improve infection control practice and identify any learning needs that the areas might need.
Two infection control nurses visited the Assessment Units daily and observed practice; they collected data such as time spent on discharge bed cleaning. To clean a discharge bed area thoroughly should take 20 minutes. With the discharges and transfers to other ward areas, it was calculated that up to 6 hours a day could be spent on cleaning discharge bed areas; sometimes, due to pressures on nursing staff, this did not always occur.
Medication Kardex were audited -the pharmacist had introduced a SPARED (Samples, Policy, Allergy, Reason, End date and Daily review) campaign for the use of antibiotics for doctors and non-medical prescribers and the ERA (End date, Reason and Allergy) for nurses -to see if the end date of antibiotics, reason and allergies were documented. The nurses also audited the Diarrhoea Assessment Tool to ensure that it was being utilised correctly and that the medics were aware of patients with suspected infectious diarrhoea.
Following the project, the Trust introduced Environmental Support Workers (ESWs) to work in the Assessment Units; their role includes cleaning discharge bed areas, preparing beds for new admissions and transferring patients to the receiving wards. This allows nurses to care for their patients, and ensures that the bed areas are thoroughly cleaned ready for the next patient.
Based on the results from other audits, a "toolbox teaching" session on antibiotics, promoting the SPARED and ERA campaign, was devised and nurses were encouraged to sign up to be Antibiotic Guardians.
Diarrhoea Assessment Tools were not being utilised correctly; therefore, the infection prevention and control nurses (IPCNs) attended the areas and taught the nursing staff how to use them.
Being visible on the Units allowed the IPCNs to answer any queries that the staff may have had, and also ensured that patients had the correct isolation precautions and isolation stop signs.
The aim of the poster was to summarise the enhanced observation project the IPCNs had undertaken and hopefully roll out the project to other wards/ areas.
I do not have any conflict of interests to declare.
Diane Melling-Picken
On induction, staff receive theoretical infection control training, including the five moments for hand hygiene, using traditional didactic teaching methods. This has proved particularly challenging for nurses when English is not their first language as the lecture is delivered rapidly and provides little or no time for questions and discussion. Information from a matron indicated that whilst the overseas nurses on her ward were able to name the five moments for hand hygiene, they were unable to apply it to practice. Evidence for this was reflected in the monthly hand hygiene observation audits, which showed that compliance had fallen below the required standard of 85%. This suggested that a practical method of education was required to overcome the language issues.
The infection prevention nurse developed everyday nursing scenarios and, using a manikin rather than a real patient, worked with the overseas nurses who delivered "care" to the manikin. Other colleagues observed and questions were encouraged from all parties. The correct moment for hand hygiene and the rationale was explained at each intervention. A series of six sessions were undertaken, each lasting 20-30 minutes.
Verbal feedback from the matron and monthly hand hygiene observational audit results were used to measure the impact.
Compliance prior to the intervention was 75-80%. Following the intervention, compliance improved with scores of 85-90%.
This project has confirmed that demonstration and discussion has improved compliance in a clinical setting, at least in the short term. Audit will continue to determine whether the improvement will be sustained. Tailored hand hygiene sessions are now incorporated into the infection control training programme delivered to overseas nurses joining the Trust. It will be considered whether any other cohorts will benefit from this approach.
Staring over the abyss at the 2015/2016 C. difficile trajectory, the 6-month position (20 against a 26 annual total) was looking precarious. How could we get back on track? The light bulb moment: we needed to think differently!
The Best Practice Express became a Trust-wide theme with screensavers, catchy rhythms asking staff to get on board, and there were A-Z emails with photos updating the Trust on everyone's position. We rewarded areas for the number of C. difficile-"free" days rather than focusing on "how many" infections they had. Wards received posters, regular league tables, highlighted good and consistent practice, bronze, silver and gold stars, and cakes made to look like the Bristol Stool Chart.
We introduced a Trust Mascot, ran a competition to name it and "Colin Oscopy" was born. He became a "firm" favourite, spending time at the Trust Board, attending meetings, and having his own Twitter and Facebook pages.
(1) Engagement -the concept got people talking. People knew what The Train was, and liked the competition; senior clinicians were refreshed to be rewarded for achievements. Using the SIGHT Mnemonic, staff focus changed, engaged them and gave back responsibility for diarrhoea and infection prevention.
(2) Publicity -People were interested in C. difficile, from Board to Ward.
We took pictures and sent them out to show involvement in making the trajectory possible. "Where's Colin" was launched, letting staff track his "movements". He has a large, "firm" following and goes out with other teams to promote infection prevention.
We came in on trajectory: at 6 months, if we hadn't changed, we would have been 10 over.
Continuing the "Best Practice Express" theme, using the same methodology, we will add topic-specific carriages to the train, each quarter.
I do not have any conflict of interests to declare.
Cara Hollander 1 , Karin Joubert 1 , Natalie Schellack 2
In South Africa, administration of the DR-TB medication regimen has been simplified across four weight bands which accommodate the formulations available in the country, while complying with international requirements for minimum, maximum and average dose per kilogram. Broadly, at population level, people fall into one of three categories: responders, non-responders, and toxic responders, based on their inter-individual variation in DNA sequencing. These differences can result in under or over-dosing of the aminoglycosides (kanamycin/ KM) and polypeptides (capreomycin/CM), which may affect efficacy, or result in toxicity. To achieve this ideal concentration, pharmacokinetics and pharmacodynamics of KM/CM could be considered in reducing toxic effects, (ototoxicity and nephrotoxicity) and improving treatment outcomes. Thus, the aim of this study was to investigate the pharmacokinetics and pharmacodynamics of KM/ CM in patients with DR-TB and the relationship with hearing.
This exploratory, quantitative experimental research design is a multi-site study at Helen Joseph and South Rand Hospitals. The protocol reached saturation of data after enrolment of 20 participants, while undergoing audiological and pharmacological assessments at baseline and every 2 weeks for the first 3 months of treatment where possible, with 71 study visits in total. Creatinine clearance was measured, and overall outcome of treatment is being evaluated in relation to the pharmacokinetics.
Catheter-associated urinary tract infections (CAUTIs) are the most prevalent healthcare-associated infection globally and are one of the most common infections experienced in hospitals (Tambyah et al, 2012) . The Scottish Patient Safety Programme developed a CAUTI care bundle to tackle the problem of CAUTI and assist with its reduction in Scotland. As a recent innovation in patient safety, there is much we can learn from the implementation, embedding and normalising of CAUTI care bundles in everyday practice.
Normalisation process theory (NPT) (May et al, 2009 ) has been used to study the implementation of complex healthcare interventions in a variety of healthcare areas. Using qualitative methodology, semi-structured interviews were conducted with 26 clinical leaders responsible for implementation, from 15 NHS Boards using NPT as a guiding framework. Framework analysis methods were applied to explore how clinical leaders make sense of the work of implementing the CAUTI care bundle (coherence); how they engage with it (cognitive participation); enact it (collective action) and appraise its effects (reflexive monitoring).
Clinical leaders perceived the CAUTI care bundle approach to be a different way of working in comparison to previous urinary catheter management practices. There was general agreement that CAUTI care bundles met the needs of patients, staff and the organisation. A common challenge to implementation has been lack of consensus on the definition of CAUTI. Data illustrated that organisational support, staff education, awareness and stakeholder "buy-in" were paramount for success.
This paper will present findings illustrating key barriers and enablers to the introduction of CAUTI care bundles from the perspective of clinical leaders responsible for implementation.
I do not have any conflict of interests to declare.
Multidisciplinary review of urinary catheters to facilitate earlier removal
The duration of urinary catheterisation is a major risk factor in the development of catheter-associated urinary tract infection (CAUTI). Limiting catheter use and minimising the duration the catheter remains in situ are primary strategies for CAUTI prevention. There is evidence that nurse-initiated catheter removal protocols significantly reduce the length of time catheters are in situ, with a corresponding reduction in CAUTI (Adams et al, 2012). A practice development initiative took place on the Care of the Elderly wards at an acute Trust, the objective being to facilitate a multi-disciplinary review of each patient with a urinary catheter.
A practice development nurse (PDN) joined the multi-disciplinary (MDT) "whiteboard" meetings on the Care of the Elderly wards twice per week, for a period of 3 months. At this meeting, each patient with a urinary catheter was discussed with the aim of reviewing the clinical indication and facilitating early removal. The PDN also ran a number of ward-based education sessions on urinary catheter care and TWOC procedure. Surveillance of urinary catheter use took place for the duration of the initiative.
The number of catheters in situ during the surveillance period is shown below, compared with the previous surveillance period:
The data demonstrates a reduction in the number of urinary catheters in use on the Care of the Elderly wards and an improvement in the number of completed catheter care plans. It is acknowledged that the surveillance data is based on a snap shot of practice and the number of urinary catheters in situ at any one time is multi-factorial. However, this data provides some assurance that the review of urinary catheters at MDT meetings can facilitate a reduction in the number of catheters in situ and increase staff awareness. It is recommended that this initiative be implemented across the organisation.
I do not have any conflict of interests to declare.
Collaborative working enables ward teams to "C the difference"
Holly Slyne, Wendy Foster
In 2015/2016 the annual trust trajectory for patients developing Clostridium difficile infection (CDI) was exceeded by 48% and a comprehensive thematic analysis of these patients identified two key themes for improvement: prompt sampling and prompt isolation. The IPC team joined the NHS Improvement IPC Collaborative in April 2016 and used this driver to challenge three wards to improve quality collaboratively by reducing CDI incidence.
Plan, Do, Study, Act (PDSA) cycles were implemented to trial various tests of change surrounding prompt sampling and prompt isolation. Weekly meetings maintained momentum and drove the PDSA cycles and improvements forward. Infection Prevention Society isolation audit results and CDI incidence provided the two outcome measures.
Five tests of change proved successful and were ramped up through the PDSA cycles to develop products, improve and embed them. These were education around sampling myths, a daily bay challenge to identify patients in bays with diarrhoea, a sticker affixed to faecal specimen pots to assist in documentation processes, the inclusion of side room usage on the daily ward huddle sheet and a revised diarrhoea care plan. Together these five products have formed the "C the difference" toolkit.
Isolation audit results improved from 51% to 100%. Prior to the collaborative the average days between CDI cases was 12 days. Following the collaborative no patient developed CDI for 49 days. This is a success that has never before been achieved at the Trust since CDI surveillance commenced in 2009.
The collaborative generated engagement and IPC quality improvement led by ward teams. The next step is to share the "C the difference" toolkit across the Trust and to achieve the next goal, that no patient develops CDI under our care for 100 days.
I do not have any conflict of interests to declare.
Clostridium difficile improvement plan Rosslyn Young, Jane Ryan, Nina Fraser, Cindy Sawford, Sharon Clarke, Hilary Duthie, Steve Dolan
In 2015/2016 Bedford Hospital declared 23 cases of Clostridium difficile infection (CDI). Therefore, we commenced an improvement plan with the view to ensure, and decrease lapses in, care in relation to CDI. Two wards were chosen for the 90-day collaborative.
A project team including the Corporate Nursing Team, IPC, matron, ward manager and business administrator was formed.
We developed a driver diagram and project initiation document, and developed a new stool assessment chart. The two wards testing the chart were supported using the plan, do, study, act service improvement model.
Results Ward 2:
Week 6 and 7: Compliance has improved on Ward 1, but this is not the case for Ward 2. The reasons for non-compliance are different, and are now being shared with the wards in greater detail to help to influence a change in practice.
We have discovered that winning hearts and minds and effective leadership are fundamental to success, and so we are striving to involve the wider team.
Greater understanding of improvement methodology is a great asset to enable staff to lead similar change in the future independently.
I do not have any conflict of interests to declare.
As part of the infection prevention and control (IPC) stabilisation agenda across the Western Cheshire Health Economy, the CWP IPC team offered stabilisation visits to all care homes, including residential care facilities and hospices in the Vale Royal and Western Cheshire Clinical Commissioning Groups. This is a total of 85 care providers.
The aim of the visits was to support care providers with key infection prevention and control information, thus promoting safe and effective care: the opportunity for staff to receive IPC training during the visit and promoting the aseptic non touch technique (ANTT).
Thirty-five care providers accepted the offer of a stabilisation visit, eight in Vale Royal CCG and 27 in Western Cheshire CCG, which is equal to a 41% response rate. The service continues to promote these visits at link meetings, other communications opportunities and in the newsletters. This poster presentation will articulate key findings and areas for development following this programme of stabilisation visits.
Audit synopsis: In 2014 the Trust experienced a rise in Clostridium difficile infection and MRSA colonisation Trust-attributable infections. This triggered a review of assurance around environmental controls.
The audit process that was currently adopted was "Credits for Cleaning" (C4C) and the annual Infection Prevention Society (IPS) audit. The current methodology of auditing utilising the national Patient-Led Assessment of Care Environment (PLACE) process was not highlighting any concerns. There were no noticeable deficits in mandatory training compliance, and clinical areas were reporting 100% in hand hygiene.
An external inspection highlighted multiple issues around environmental standards and flaws in the environmental assurance process, impacting on patient care and increasing healthcare-associated infection (HCAI).
The Infection Prevention Team drafted a response and developed an audit tool that incorporated issues not previously addressed. The tool was agreed by the organisation and was reviewed by the Infection Prevention and Control Group, Matrons Group, Environment Group and the Patient Safety Information Group (PSIG). The audit questions are weighted to low, medium and high risk, and are not viewable by the auditor. Results are presented at the Infection Prevention and Control Group and the PSIG by exception, forming part of each ward's quality dashboard.
The audits were introduced onto the audit programme in all clinical areas. The average audit compliance has risen from 34% to 90%. This poster will demonstrate an effective method for sustained environmental controls addressing areas of modern healthcare environment not addressed through national tools.
I do not have any conflict of interests to declare.
Vickie Lam, Claire Oliver, Dr Richard Cooke
The role of an "infection prevention and control support worker" (IPCSW) is a newly created role within our existing IPC nursing team. Using the principles of a "healthcare assistant", the role has been established specifically to assist the IPC delivery plan and to release the qualified IPC nurses to focus on key strategic and operational issues.
Over the first 6 months since the post was established, the various tasks delegated to the IPCSW were reviewed. Success was measured by evidence of completion of tasks and feedback from the IPC team.
Using agreed methodologies, five IPC audits were successfully completed. These included auditing the storage of breast milk and decontamination of associated equipment, ward pantries, bed pan and commodes, ward environments, and hand hygiene compliance. The IPCSW also initiated the following projects: review of staff changing facilities; environmental cleanliness evaluation by ATP monitoring; water sampling for pseudomonas; training ward and domestic staff on disinfection practices; hand hygiene product evaluation on critical care and oncology units; introducing KWIK Isolation screens into the high dependency unit.
The IPCSW role is well established within the IPC team. The role allows for a targeted approach to IPC which is improving compliance Trust wide. A future area of role development will be supporting the Trust's surgical site surveillance programme.
I do not have any conflict of interests to declare.
In response to the PHE CPE Acute toolkit (2013), we implemented a screening and management protocol for an 1100-bed acute University NHS Foundation Trust. There was an unknown prevalence of CPE but considered low risk based on clinical isolates and no reported incidents of CPE within the region prior to implementation.
We identified existing patient admission pathways and adapted or developed their systems to include a CPE risk assessment with clinical teams. Electronic alert systems (via PAS, ICnet and Sunquest ICE) were updated to alert all positive and known "at risk" cases. Education and training was implemented by the IP&C team across the Trust, including a visual information poster.
Between May 2015 and May 2016 there were 171 patients tested for CPE; of these only 92 patients (54%) were reported to IP&C to add to the database and alerts system, with five positive CPE results (3% of 171 screens). Of the 92 reported cases, complete screens (three samples) were completed on 53 (56%) patients, with 90% of the incomplete screens due to the patient being discharged before all samples were collected. Twenty-seven countries were identified as the trigger for CPE screening from these 92 cases. There was one incident during this timeframe due to delayed isolation which required contact screening seven patients (0 positives).
One issue was that the IP&C team were unaware of 77 patients (46%) and therefore unable to add alerts or track the screening samples. Improvements are being developed to capture the data of all patients screened for CPE automatically to remove the need for separate notification processes. We propose a combined approach to screening with primary care services, which could address the issue with incomplete screens and offer cost savings, which warrants further consideration.
Sepsis is a major cause of mortality worldwide. Severe sepsis accounts for 1000 admissions to PICU every year in the UK. Of these 1000 admissions, 20% will die (i.e. 200 deaths per year). Improved pre-PICU care including early recognition, early use of antibiotics, generous fluids and cardiovascular support will greatly improve PICU outcomes. Adherence to APLS/ACCM-PALS guidelines is poor and no sepsis algorithm or consistent treatment plan was being used in RACH. No prior sepsis data had been collected in our hospital.
SPSP sepsis 6 protocol was implemented into our ED in 2014. We designed a sepsis recognition tool for nurse triage to determine whether a child is potentially septic. The tool triggers for an immediate senior doctor review and that doctor review determines whether the child requires sepsis 6 treatment. All children that present to the ED with an illness problem are screened by the recognition tool. We measure the time it takes from time of arrival to time of antibiotic administration and this is presented on a run chart and submitted to SPSP. We also measure many other aspects of our sepsis care (fluids, cultures). Of the four patients that have been transferred to PICU after sepsis 6 treatment in the ED we have a 0% mortality rate. We have had one death due to sepsis in our ED; this patient had a pre-hospital cardiac arrest.
Of our 66 patients treated by sepsis 6, 100% have been identified for senior doctor review by our recognition tool.
We are currently implementing sepsis 6 into our paediatric assessment unit, Dr Gray's (Elgin) emergency department and children's ward, as well as maintaining our standards within our ED. We are looking into pre-hospital sepsis management (paramedics/GP).
I do not have any conflict of interests to declare.
The Department of Health's High Impact Intervention (HII) -Peripheral intravenous cannula care bundle lists six actions to be performed at the time of insertion of peripheral cannulae. The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance requires that "registered providers must audit compliance against key policies and procedures for infection prevention". Effective audit of compliance is only possible if documentation is complete.
A baseline audit measured documentation of the HII actions on the anaesthetic charts of 50 consecutive patients who had cannulae inserted in theatre. Purposemade stickers of the HII care bundle actions were then placed on the anaesthetic charts of patients pre-surgery. Re-audit data were collected from a further 50 anaesthetic charts post intervention.
The six HII actions for peripheral cannula insertion were documented in 1/50 patients (2%) prior to intervention and in 26/50 patients (52%) post intervention (Fisher's exact test p < 0.0001).
Placement of stickers in anaesthetic charts significantly improves the documentation of the HII peripheral intravenous cannula care bundle actions in patients who have cannulae inserted in theatre.
This is a low-tech intervention which produces a high-impact improvement in documentation. Future print runs of anaesthetic charts will be re-designed to include this documentation.
I do not have any conflict of interests to declare.
Kirsty Ferguson 1 , Pamela Joannidis 2 , Infection Prevention & Control Team Audit Group 1
Healthcare Improvement Scotland (HIS) believes that every person in Scotland should receive the best health care possible every time they come into contact with health services. Standards set by HIS request healthcare providers to have in place a systematic programme of audit that includes monitoring of standard infection control precautions (SICPs) compliance. This, along with recommendation for an annual audit of infection prevention and control (IPC) policy and the implementation of transmission-based precautions (TBPs), led to development of a new tool in infection prevention and control.
During 2015 the Infection Prevention and Control Team (IPCT) reviewed existing audit tools to determine gaps as well as duplication. The results of this review helped shape a revised infection prevention and control audit tool (IPCAT) comprising four sections: SICPs, TBP, SPE and quality improvement (PVC, CVC, UCC).
Development of a revised audit tool was followed by user acceptance testing of a web-based platform for data capture. Audit data gathered is entered directly onto a tablet device, and once synchronised is available immediately via an audit dashboard. The senior charge nurse (SCN) is sent an automated email, and by accessing the dashboard can view audit data including scores and action plans. The audit dashboard can provide SCNs with data for their area and service leads with data for areas grouped. Software is designed to allow IPCTs access to audit action plans to monitor progress and an automated email is generated in response to overdue actions. A scheduler is available via the platform to facilitate IPCT audit planning.
Development of IPCAT has led to a streamlined audit process for NHS Greater Glasgow & Clyde, resulting in reduced administration time, real-time reporting and improved efficiency.
IPCAT provides a quality-driven audit process and both IPCNs and service users have reported satisfaction with the audit process.
Nationally there has been an increasing incidence of carbapenemase-producing Enterobacteriaceae (CPE) colonisation and infection in the UK; this includes a number of outbreaks in healthcare settings. Based on the learning from management of these outbreaks, a CPE toolkit was developed by Public Health England (PHE) to support staff in acute settings. In December 2014 this trust produced a policy, based on the toolkit, advising staff on the correct actions to ensure prompt detection of CPE and management to prevent transmission.
Staff knowledge of CPE was very limited prior to implementation of the toolkit. Promotion of key messages and a range of multi-faceted initiatives were delivered by the Infection Prevention and Control (IPC) Team to improve this and enhance compliance with the guidance. The electronic ordering system was amended to incorporate CPE screening and an alert was created for patients subsequently confirmed positive. Also, a question to identify high-risk cases was added to the current adult risk assessment document.
A quantitative audit was completed over a 1-week period during January 2016; the aims of the audit were to determine compliance with identification of high-risk cases, screening, isolation and addition of an alert to the electronic record.
Prior to introduction of the toolkit, patients were not routinely screened for CPE on admission. During the audit, 93 records were reviewed and 65.6% of high-risk cases were identified. All cases requiring screening had at least one sample submitted; however, only 11.1% had all of the required screening samples in accordance with policy. Where CPE was confirmed, 100% had the appropriate electronic alert added to their records.
Continued education to raise CPE awareness and policy across all departments is required; we aim to re-audit compliance with policy in 12 months.
The Primary Care Infection Prevention and Control (IPC) Team undertook 416 audits of General Practice (GP) and General Dental Practices (GDP) in 2015/ 2016. This process was to provide quality assurance that primary care providers are compliant with current IPC practice in line with the Health and Safety Care Act (2015).
The IPC team used a validated IPC audit tool and provided specialist IPC audit support to GPs and GDPs. The team also provided input into new-build and refurbishment projects, working closely with commissioners to provide oversight and receive assurance on IPC across a large geographical area.
Most practices scored 90% or higher in their IPC audits. For areas of noncompliance, the team made recommendations and assisted with the development of action plans. Practices that were identified as having sub-standard compliance with a score of <90% were considered for a follow-up.
The aggregated data identified key themes of non-compliance, including:
Environmental -challenging environmental conditions, non-compliant taps and hand-washing sinks, tiled splash back with grouted joints, storage of cleaning equipment, storage of vaccines in containers that were not webbed like baskets, and sharps containers not assembled and labelled correctly.
Staff health -suboptimal completion or information regarding hepatitis B vaccination and measles, varicella and rubella immunity status.
Staff knowledge -access to training, IPC policies out of date or not standardised.
The IPC team found that after follow-up on action plans, GPs and GPDs achieved >95% compliance with the audit.
The IPC team has produced a newsletter to inform other GPs and GDPs of these themes and guidance to how they may be resolved. The aggregated data provides an opportunity for shared learning across other primary healthcare providers.
I do not have any conflict of interests to declare.
Konstantinos Tsattalios, Colin Macduff, Sarah Henderson, Richard Laing
The Robert Gordon University
Healthcare-associated infections (HAIs) remain an important public health problem across the globe, affecting patients, healthcare staff and visitors. A prime focus of interventions aiming at tackling HAIs is the prevention and control of pathogens by increasing healthcare staff's adherence to hygiene regulations. However, despite the plethora of these interventions, only a few are structured based on theoretical underpinnings and even fewer authors explicitly describe how the design and development of the intervention is informed by the adopted theory. Yet, no systematic approach has been undertaken for providing clarity as to the importance of theory when conceptualising an intervention within the medical context.
Therefore, the current work refers to the design of an integrative literature review that aims at identifying a variety of relevant quantitative and qualitative evidence. More specifically, this systematic approach will answer what and how theory can be embedded and implemented at the design and development stage against HAIs.
All levels of evidence will be reviewed as potentially relevant sources of knowledge, from Level I (e.g. systematic reviews) to Level V (e.g. expert opinions). The structure of the search strategy as well as the data collection-analysis will be publically available (PROSPERO protocol registration) prior to, and during the course of, the actual review process.
Upon its completion, the findings will be disseminated in a health-related peer-reviewed journal. To the best of the authors' knowledge, this is the first in-depth systematic attempt to scope and integrate such a wide range of research and non-research evidence.
The final findings not only will summarise theories implemented within interventions but, more importantly, they will form a useful and practical guide for future research in this field, aiding scientists to decide what theory is more appropriate for their own study and how this can be achieved when developing an intervention against HAIs.
Dehydration is an increasing problem among older people, with frail, dependent nursing home residents being especially vulnerable. Consequences of dehydration include urinary tract infection and other morbidity. Infections in older people account for a considerable proportion of antimicrobial prescribing and associated problems of resistance. Factors which may lead to inadequate hydration of residents include poor staffing levels, lack of supervision and knowledge, and limited appreciation of the importance of hydration.
This project used service improvement methodology to optimise the hydration of residents, working in partnership with two nursing homes. Process maps and action effect diagrams were developed through observation and input from care home staff and residents/relatives to describe current systems and identify contributory factors and actions. Plan-do-study-act (PDSA) cycles were used to develop sustainable changes. Improvement was measured using hydrationlinked events, e.g. UTI, laxative/antibiotic use, staff/resident feedback, and number/volume of fluids consumed. Data was entered in statistical process control charts.
Observations identified fluid intakes of commonly less than 1000 ml/day, with fully dependent residents particularly at risk; food promoted in favour of fluids; and opportunities for drinks missed. PDSA cycles were used to introduce protected drinks time, testing new equipment to support residents' drinking, mealtime cards, and drinks menus to enhance choice of fluids. These changes resulted in more residents receiving drinks and an increase in individual fluid intake. A staff training programme on hydration was developed, with attendees reporting an increase in knowledge and anticipated change in practice.
Small changes to practice in care homes have the potential to ensure sustainable long-term service improvement and reduced morbidity and hospital admissions. The package of tested quality improvement initiatives and a staff training programme will be disseminated to other nursing homes. Learning could be applicable to acute care settings.
I do not have any conflict of interests to declare.
To swab or not to swab? That is the question Jane Tideswell
There are two techniques universally associated with wound swab procedure. They are the Z-Track (zig zag) method and the Levine method. Anecdotal evidence has shown that healthcare professionals are unaware of the existence of either process. I believe that it is necessary to promote that there is a researchbased, scientific process which underpins the rationale behind the swabbing of wounds. Definitive guidelines for this supposedly relatively simple procedure have yet to be established, hence my interest in the subject.
IPC standard precautions, to include hand washing, must be applied at all times before and during the swab procedure.
In the case of acute wounds which are suspected of being infected, the 10 point, Z-Track method should be executed. In the case of chronic wounds, where Biofilm formation may be present, it is argued that the Levine method of wound swabbing be implemented as it is crucial to apply gentle, downward pressure to release fluid from the deeper layers of the wound bed. Care should be taken to ensure that the swab only comes into contact with the wound surface.
Wounds must be cleansed with either tap water or normal saline prior to the swab being performed. Research suggests that in the instances of moist wounds, a wound swab may be used without pre-moistening the cotton tip with normal saline. Conversely, in the case of drier wounds, research suggests that swabs should always be pre-moistened with normal saline prior to collection to increase the chances recovering micro-organisms from the site of the wound. However, much debate surrounds this issue.
Necrotic tissue, slough or any other contaminated material should be removed from the wound bed before a representative wound swab sample is taken, as failure to do so may confound the microbiology results and lead to inappropriate antibiotic treatment.
If pus is present it is important that a sample be sent for culture. It is advised that aspiration using a sterile syringe to collect exudate (0.5 ml) from the wound is the preferred method.
Research suggests that there needs to be standardisation around how swabs should be taken, to include the correct labelling and transportation of the specimen to the microbiology laboratory. It is important to ensure that the patient's name, date of birth, specimen source, ongoing treatment, underlying co-morbidities as well as the time that the culture was taken be appropriately noted on the biohazard envelope, and to ensure that it is sent to lab within 4 hours if possible.
There is limited substantial quantitative data available for me to include in my abstract, as research studies into wound swabbing are limited and have generally been done using a small-scale sample of participants. Interestingly, numerous studies demonstrate that wound swabbing is historically grounded in ritualistic rather than evidence-based practice. Wound swabbing may appear to be a relatively simple procedure, but it is a subject for future discussion. I would argue that IPC need to be involved in the development of wound swabbing policies and protocols to ensure that swabs are collected in an evidencebased, consistent approach.
I do not have any conflict of interests to declare.
Infection control and cancer: A perfect storm Pat Cattini, Sarah Whitney
This poster will support Session 18b
Cancer is among the leading causes of death in the developed world. Most people with cancer die from infection, not their disease.
Treatments for cancer including surgery, radiation, chemotherapy, and transplant leave a patient more vulnerable to infection than a healthy adult of similar age. On top of this, the global threat of antibiotic resistance poses a particular risk. Antibiotics have revolutionised cancer treatment by enabling the use of more aggressive therapies, leading to higher survival rates. For this medically vulnerable group the loss of effective antibiotics would have dire ramifications.
A cancer hospital can be the setting for the perfect storm, with a collection of vulnerable patients, many from overseas, coupled with aggressive treatments which can cause unpleasant side effects such as leucopoenia, mucositis, and diarrhoea.
Key infection issues will be highlighted and considered, including: CRE, antimicrobial stewardship, treatment of neutropaenic sepsis, use of chemotherapy, C. difficile infection, pre-op screening to prevent SSI, IV lines and other invasive devices, viral respiratory infections, reactivation of viruses, loss of immunity, decontamination of the environment, use of probiotics and FMT.
As infection prevention specialists, we often focus on preventing exogenous infection and we don't always consider endogenous infection from the patient's own flora.
The poster will equip the reader with an overview and understanding of some of the complexities of preventing infection in cancer patients, promote discussion, and provide ideas for future strategies to help in the battle against cancer.
Cancer is the leading cause of death in the developed world. It has been predicted that resistant infections will kill more people than cancer by 2050. Further work needs to be undertaken to consolidate and strengthen current infection prevention knowledge and to develop new ideas which don't involve reliance on antimicrobials.
I do not have any conflict of interests to declare.
The World Health Organization's (WHO) guidance on the Core Components for Infection Prevention and Control (IPC) programmes is being revised with a view to basing this guidance on the best available evidence in order to support the prevention of healthcare-associated infections (HAI) and the global burden of antimicrobial resistance. With WHO approval, a systematic review was conducted to identify national core components for IPC programmes.
Five databases were searched for papers published between 2000 and 2015 reporting the effectiveness of national IPC programmes. Papers identified were screened against the eligibility criteria and further assessed according to Cochrane's Effective Practice and Organisation of Care (EPOC) study design criteria. Data were extracted and risk of bias assessments undertaken. The quality of the body of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, where appropriate.
One hundred and ten studies met the inclusion criteria, of which 26 studies met the EPOC design criteria. Four component themes were identified from the 26 studies: multimodal IPC programmes (n = 16); IPC care bundles (n = 4); IPC policies (n = 4); and IPC surveillance, monitoring and feedback (n = 2). The majority of interventions evaluated in the 26 studies focused on preventing a specified infection (central line-associated bloodstream infections being the most frequent) or HAI more generally, or promoting hand hygiene. Individual studies demonstrated effectiveness; however, only three (of the 26) studies had a low risk of bias.
While, impressively, 26 studies had a robust research design, there was variation in the rigour with which these were conducted. The range of interventions and outcomes measured limited synthesis of the findings, but strong policylevel recommendations can be made under the guidance of the WHO secretariat and expert group, as well as an outline of existing research gaps.
On the 2nd October 2016, over the course of 3 days, we moved from our 100-year-old hospital into a 270-bed new state-of-the-art hospital, Alder Hey in the Park, which was designed with the help of children and young people. The majority of children and their families now have their own room with en-suite facilities with park views, and patients have easy access to play areas on and outside their ward. Despite the move to the new building being meticulously planned and the infection prevention and control team being involved, there have been many challenges to overcome.
The handover of the building to the Trust took place less than 1 month before the move-in date.
This reduced the time available for commissioning of the building and areas such as theatres.
Snagging of building work led to repeat cleans having to be undertaken prior to sign-off.
The filling of commodities such as paper towel dispensers, soap and sanitiser dispensers not completed at the time of the move.
Cleaning schedules not completed.
Financial constraints resulted in equipment having to be brought over from the old hospital.
•• Increased number of water outlets requiring flushing and sampling for legionella and Pseudomonas. • • IPC signage -when unable to attach to walls and when cubicles have glass doors.
Being the first site in the UK to introduce equipment or products can create additional problems.
You can never have too much storage in wards/departments.
Development of ward/department-based infection control policies enabled staff to engage with IPC before the move.
The new building with more cubicles can make staff complacent.
A new hospital building may be easier to clean and to isolate patients, but commissioning and essential commodities must be available before the move.
I do not have any conflict of interests to declare.
Ten semi-structured interviews of nursing staff were carried out between February and April 2015. The interviews were audio recorded, transcribed verbatim and analysed using thematic analysis.
Thematic analysis identified two opposing responses from the participants. Four nurses commented the unit coped well with neonates on contact precautions whilst conversely four senior staff felt quite strongly there were serious challenges. Two staff had a more neutral response. Themes were associated with the environment and equipment, knowledge and communication, and concerns about how unintended breaches occurred. Two issues identified that appear unique to this unit are a lack of space causing unintended breaches of contact precautions by allowing the staff to multi-task, and delayed removal of signage resulting in some neonates remaining on contact precautions for longer than necessary. Issues identified that were common to other research studies were the requirement to challenge staff practice and provision of adequate supplies of gloves. Staff suggested changes to their unit that could improve compliance, for example standardisation of cot space, improved signage and training.
This research study has identified findings that appear unique to this unit and others which are more common to healthcare staff carrying out contact precautions in other NNUs.
An integrative literature review of factors influencing the effectiveness of handrubbing with ABHRs within clinical practice was conducted. The literature search was conducted systematically using CINAHL, MEDLINE, PROSPERO, ScienceDirect and Web of Science electronic databases. The search was limited to sources available in the English language and published between the years 1980-2015.
The search resulted in 26 eligible papers, including 16 experimental and 10 observational studies. Six themes emerged, including the effectiveness of handrubbing technique, influence of ABHR volume, duration of the handrubbing procedure, the effect of mechanical rubbing, the effect of hand size and acceptability of handrubbing technique. Technique, level of compliance with protocol, ABHR volume, time and friction were all shown to influence the effectiveness of handrubbing. Handrubbing with 3 ml of ABHR for at least 30 seconds using the six-step technique appears to yield the best results in antimicrobial efficacy. An interesting finding was that certain areas on hands might be more important than others during hand decontamination.
This review identified factors influencing the effectiveness of the handrubbing procedure which should be standardised for healthcare workers. The importance of covering all surfaces of the hands on the efficacy of handrubbing remains uncertain; thus, further research is required to investigate the contribution of each of the six steps to the effectiveness of the handrubbing procedure.
Bacterial transmission in an operating room from patient to equipment and healthcare providers' hands and even to the next patient in the operating room has been associated with healthcare-associated infection. Hand hygiene will interrupt transmission of microbes between patients, healthcare workers and the inanimate environment. In 2009, to address this patient safety risk, the Infection Prevention and Control Team began to work with the medical and nursing teams to embed the World Health Organization's concept of "My five moments for hand hygiene" in the Operating Department.
A graph will display the Operating Room hand hygiene audits results dated 2009-current.
Healthcare-associated infection (HCAI) is a worldwide patient safety issue. Compliance with hand hygiene guidelines has been demonstrated to be an effective method of reducing HCAI; however, it remains suboptimal and poorer amongst physicians compared with other healthcare workers. The aim of this study is to determine the relationship between a multimodal quality improvement intervention, incorporating observational hand hygiene auditing with individualised feedback to physicians, and the incidence of surgical site infection (SSI).
The research design is a quasi-experimental retrospective before and after study design. The aim was to test the hypothesis that the multimodal intervention would lead to at least a 1% drop (to 0.44%) in SSIs. The intervention incorporated: increased provision of alcohol-based hand rub; education; targeted observational hand hygiene auditing (OHHA) with individual feedback; and the introduction of a surgical site care bundle.
The outcome measures include: the rate of SSIs in patients who received an orthopaedic implant surgery and the proportion of observed hand hygiene compliance.
Surgical site surveillance data on 3703 patients were included in the before (n = 1806) and after (n = 1897) study. The risk of a patient developing an orthopaedic SSI decreased from 1.44% (n = 26), 95% CI (0.89-1.99) in the preintervention phase to 0.69% (n = 13), 95% CI (0.38-1.21) in the post-intervention phase, c 2 (1, n = 3703) = 5.05, p = 0.024.
There was a statistically significant increase in observed hand hygiene compliance overall to 91%, 95% CI (0.90-0.91), p < 0.01 and an 18% increase in compliance amongst consultant staff, p < 0.01.
There is a statistically significant reduction in SSI, with infection rates being reduced by half. There are statistically significant increases in observed hand hygiene compliance. Providing targeted individualised audit feedback significantly improves compliance with hand hygiene guidelines.
I do not have any conflict of interests to declare.
Reasons for poor hand hygiene compliance among healthcare workers in sub-Saharan countries Yetunde Ataiyero, Dr Judith Dyson, Dr Moira Graham
The prevalence of healthcare-associated infections (HCAI) in developing countries, especially sub-Saharan African (SSA) countries, has been underreported, and whilst the actual magnitude remains unknown due to deficient surveillance studies and lack of reliable data, estimates suggest this to be 2-20 times more prevalent than in developed countries. In SSA and South-East Asia, HCAI contribute 4-56% (75%) to all causes of mortality in neonates.
Contaminated hands of healthcare workers play a significant role in the transfer of these infections to and within patients. Conscientious hand hygiene practice is the simplest, most accessible, affordable and effective preventive method, although compliance with hand hygiene guidelines remains very low. In developed countries, reasons for poor compliance have been attributed to lack of hand hygiene facilities, type of ward, specialty and procedure and the professional category.
A systematic review which will assess the barriers to effective hand hygiene practices among healthcare workers from SSA countries.
Bearing in mind the selection criteria, a systematic literature search through electronic and subject-specific databases will be conducted. Peer-reviewed, primary studies published in English, conducted among hospital-based healthcare workers in sub-Saharan Africa and which reported on the barriers of hand hygiene practices will be included in this review.
A critical appraisal of the included studies will be done using the Critical Appraisal Skills Programme (CASP) tool to identify the strengths and weaknesses of the articles. The findings of the review will be analysed using thematic analysis and the key barriers will be presented. The similarities/differences in the identified barriers in both SSA and developed/western countries will also be identified.
We conducted a mixed-method study to develop knowledge of inherent and elective hand hygiene (HH) in clinical practice through the application of a new direct observation measurement tool, enhancing meaningful feedback. Difference in HH compliance for clinical activities categorised as inherent or elective was tested.
Two settings were selected: a cardio-thoracic ward (CT) and a renal-haemodialysis unit (RH). A powered sample of 20 (nurses, healthcare support staff) from each unit (N=40) were each observed for up to 1 hour by two researchers.
Reducing healthcare-associated infections through improving hand hygiene compliance amongst healthcare professionals remains topical. However, research evidence suggests that hand hygiene compliance remains sub-optimal across various geographical locations and healthcare settings. The aim of this poster is to report the outcomes of a recently published systematic review of peer-reviewed published studies, notably clinical trials, which focus on hand hygiene compliance among healthcare professionals.
Literature published between December 2009 and February 2014, which is indexed in PubMed and Cinahl, on the topic of hand hygiene compliance, was searched. Following examination of the 57 publications initially reviewed, the final number of papers appraised is 16.
A lack of homogeneity in research design made meta-analysis difficult to achieve; however, comparative analysis was possible. The majority of studies were conducted in the USA and Europe, in intensive care units and care of the elderly facilities. The nurse, the healthcare assistant and the doctor are the three categories of healthcare worker most often the focus of the research. Published studies demonstrate that moderate improvements to hand hygiene compliance rates were achieved when organisations adopted a multimodal approach, incorporating up to six strategies for change. The multimodal approaches used were either guided by the World Health Organization (WHO) hand hygiene framework or by an independently tested multimodal framework.
Hand hygiene compliance remains an important patient safety issue, as we strive to reduce healthcare-associated infection rates across the globe. The WHO multimodal hand hygiene framework is transferable to a variety of healthcare and education settings globally, and international research evidence suggests that moderate improvements in hand hygiene compliance rates can be achieved when it is adopted.
I do not have any conflict of interests to declare.
Abstract ID: 4488 Management of a Streptococcus pyogenes outbreak with macrolide resistance on an acute dementia unit
Two cases of Group A streptococcal (GAS) infection linked to a mental health unit were reported to the Health Protection Team. The cases were on separate male and female wards. One patient with invasive GAS (IGAS) was admitted to the hospital and treated, but subsequently died. Indirect transmission from the male patient to the female patient via a shared blood pressure monitor was identified as the likely transmission route. Five further cases of GAS infection with the same antibiogram were reported from patients with superficial wound infections on the male ward over the next 12 days. Typing of isolates supported epidemiological suspicion of patient-to-patient transmission of S. pyogenes with emm ST11.0, on the ward.
No staff carriers were identified. Patients were elderly with severe dementia and a range of co-morbidities. Non-compliance with isolation, screening and appropriate antibiotics posed particular challenges to outbreak control. In addition to enhanced infection control measures, outbreak decision pathways were developed in collaboration with the mental health team, local microbiologists and PHE reference laboratory experts. This aimed to support a multi-disciplinary team in developing individual screening and treatment plans for each patient to, as far as possible, identify carriers and treat all patients within a defined time period.
No further IGAS cases or transmission of GAS to other wards was reported. A low threshold for swabbing superficial wounds was maintained. Two further cases of GAS colonisation were detected and treated at 10 and 24 days after mass treatment completion. No further cases were detected on subsequent screening.
The unprecedented outbreak of Ebola Viral Disease (EVD) showed signs of extending internationally. The perceived threat would mean non-specialist units could encounter cases. Furthermore, two of the UK's high microbiological containment facilities, which handle the virus and deployed staff to West Africa, are within the Trust catchment.
The infection control team established a plan for the management of suspect cases presenting to the Emergency Department. The approach to PPE with EVD was far more complex than the usual procedures involving PPE. There was concern that the transmission of EVD in West Africa to some healthcare workers was by an undetermined route, but potentially through incorrect removal of PPE. A series of dressing/undressing drills based on military chemical, biological, radiological and nuclear drills was adopted. There were various challenges in establishing the plan, which are discussed.
Myth and misinformation about the virus abounded and was difficult to counter, causing a disproportionate level of fear and making planning difficult. Staff perceptions, and what staff were prepared (and not prepared!) to do, remained a factor in planning. Problems were encountered with the supply of PPE, due to high demand. Training opportunities for staff were limited, with no extra time allocated for training. Only staff that had volunteered and were prepared to manage potentially infected patients should be trained; this could limit the pool of available staff, although this was not found to be the case.
Five suspect cases presented to the Trust. Each was demanding on staff and resources, with associated costs and disruption. There was extra strain on the Emergency Department, already under pressure from the usual day-to-day activities, exacerbated by delays in sample transport and testing. Despite these challenges, the Trust plan ran smoothly and there was increased confidence in managing these patients, although maintaining training standards will be difficult.
I do not have any conflict of interests to declare.
Many cases of Middle East Respiratory Syndrome Corona Virus (MERS-CoV) have been confirmed worldwide. Around 80% of the cases have been diagnosed in the Kingdom of Saudi Arabia (KSA). The risk of international disease spread is especially worrying given the KSA's role as the home of the most important Islamic pilgrimage sites.
A cross-sectional study was carried out during Ramadan 2015 in the Holy Mosque in Mecca, Saudi Arabia. Self-developed questionnaires were collected from 417 Arab participants using convenience sampling.
The majority of the respondents (91.3%) were familiar with MERS-CoV. Saudis had a significantly higher knowledge about MERS-CoV compared with non-Saudis (56.92 ± 18.55 vs. 44.91 ± 25.46, p=0.001). The average knowledge was significantly higher in respondents who had received health advice on p=0.024) . With respect to stepwise linear regression, knowledge about MERS-CoV tended to increase by 14.23 (B=14.23%, p=0.001) for participants who were familiar with MERS-CoV, and by 8.50 (B=8.50, p=0.001) for respondents who perceived MERS-CoV as a very serious disease.
The Saudi Ministry of Health (MoH) has published annual recommendations for pilgrims, with special advice for elderly adults, children, pregnant women and those with chronic diseases, to preferably postpone their travel to Mecca, and for those who attend to maintain optimum preventive measures. However, many pilgrims are not aware of MERS-CoV infection in Saudi Arabia and its preventive measures. For instance, a study conducted in France that addressed MERS-CoV and its prevention among French Hajj pilgrims in pre-Hajj outpatient clinics showed that only 64.3% of the study participants were aware of MERS-CoV, and only 35.5% were aware of the Saudi MoH recommendation. Another study among Australian pilgrims showed that only about one-third of the pilgrims responded to the warnings they heard regarding MERS-CoV.
Multidrug-resistant Acinetobacter baumanii (MDR-Ab) has emerged as an important cause of outbreaks in the hospital setting. In 2015 a patient, having suffered a stroke, was repatriated from a developing country and admitted to an acute Trust in the North-East of England. Four weeks after admission the patient was found to be colonised with MDR-Ab.
Logistic considerations dictated that the patient remained in an open bay, alongside other patients, for a total of 6 weeks before being placed in isolation. During this time period the patient would have been, by virtue of a vigorous cough, highly infectious to patients and staff, and contamination of the environment would have been inevitable. Subsequently, other patients, across two adjoining wards, were found to be positive for the same organism.
Affected patients were isolated, with barrier precautions. Hand hygiene practices were reinforced. The entire ward environment and all equipment were cleaned and decontaminated using either hydrogen peroxide or ultraviolet light-based methods. All patients and many staff associated with the two wards were screened. Affected patients were decolonised with octenidine-related products and, where appropriate, nebulised colomycin. Affected patients who displayed signs of infection received antibiotic treatment that included nebulised and/or intravenous colistin. Ward practices were scrutinised.
Over a period of 6 months a total of 10 patients were found to be positive for MDR-Ab; four of these had genuine infection while six were merely colonised. Sinks and several items of equipment were found to be colonised with MDR-Ab. On one ward, items of respiratory equipment were being inappropriately decontaminated. None of the staff members tested were found to be colonised with MDR-Ab.
Despite the initial high level of spread of MDR-AB the outbreak was controlled relatively rapidly. Success was due to teamwork and implementation of established and novel measures.
I do not have any conflict of interests to declare.
A multi-speciality approach to an outbreak of Pneumocystis jirovecii: Interventions, investigations and further questions Justine Halliwell 1 , Lindsay Chesterton 1 , Deborah Gnanarajah 1 , Rebecca Turner 1 , Malcolm Guiver 2 , Cathy Winfield 1 , David Allotey 1 , Tom Bewick 1 and Richard Puleston 2 1 Derby Teaching Hospitals NHS Foundation Trust, 2 Public Health England
Pneumocystis jirovecci (PJ) is a host-specific, opportunistic fungal organism which causes pneumonia in immunosuppressed patients. Infection occurs via the respiratory route and may be caused by patient-to-patient transmission or via the environment. We report from a single centre from 2012 to 2015, highlighting the importance of a multi-disciplinary, collaborative approach and infection control measures during a suspected outbreak of PJ pneumonia (PJP).
Health Protection Scotland (HPS) produces a quarterly "Current and Emerging Threats (CET) Report", providing a continuous assessment of HAI/AMR threats in/to NHS Scotland. The format of this report was recently updated to include a formalised risk assessment and gap analysis to determine if existing health protection programmes, currently available national surveillance intelligence and infection prevention and control guidance are sufficient to mitigate emerging risks.
The CET report highlights international "threats" identified in the published literature (primarily informed by RSS feeds set up on the main public health websites) and a summary of all outbreaks and incidents reported to HPS. All threats are risk assessed using a defined SOP ("very high", "high", "moderate", "low" or "very low") to estimate potential impact on patients/services; for example, severity of disease, routes of ongoing spread and availability of effective treatment and controls. Threats assessed as moderate or greater are considered for action; for example, production of new guidance.
Since the introduction of a risk assessment and gap analysis, 36 "threats" have been identified: 10 in the literature and 26 reported by NHS Scotland. Of the 36 "threats", 27 were assessed as a moderate or greater risk; a gap analysis found that guidance, tools or other health protection programmes were already in place to mitigate the risk from these threats. In one case an alert was issued to clinical microbiologists and ID physicians in response to an identified threat from MCR-1 mediated colistin resistance.
The ongoing summary of "threats" in/to NHS Scotland provided by the CET report highlights service risk to NHS Scotland. The addition of a risk assessment and gap analysis ensures NHS Scotland is sufficiently prepared to respond to current and emerging threats, including epidemics.
I do not have any conflict of interests to declare.
Infection control outbreak pack: A rough and ready action card-based guide for care homes
Public Health England South West (PHESW) Health Protection Teams dealt with approximately 74 outbreaks of infections in care homes between October and December 2015. To help to reduce risks and to enhance management, a user-friendly outbreak pack was drafted in conjunction with care home managers and other community providers. Objectives were: to give clear and consistent advice to protect residents and staff from acquiring infection; to restrict spread; to clarify communication routes; and to provide information on common infectious diseases in care homes.
As part of my Health Protection/Infection Prevention and Control secondment remit to South Gloucestershire Council, I was in an ideal position to lead on the development of this initiative.
The health protection practitioner met with care home providers to scope the level of interest and enthusiasm, and contents and format were designed in conjunction with them and other community social care provider managers. Hard copies of packs were sent to all care homes in South Gloucestershire and adapted for use in other South West localities. This was followed by a 1-day workshop to formally launch the pack and to obtain feedback from stakeholders.
Pneumocystis jirovecii pneumonia (PCP) remains a very real threat to renal transplant recipients, and is associated with high mortality and morbidity rates. Clusters have been reported worldwide, but evidence to support the source and associated risk factors is lacking. Studies report cross-transmission of PCP between renal transplant cases particularly in the outpatient setting. Acquisition from an environmental source has some credibility also. An outbreak of 14 PCP cases in a national renal transplant centre was the focus of this study.
Following a 2013 national catch-up programme targeting unimmunised and partially immunised adolescents aged 10-16 years, and with continuing high coverage of the routine childhood MMR vaccination programme in England, measles incidence had been at historically low levels. However, an increase in measles cases was observed at the end of 2015 across London and the East of England.
Since the beginning of 2016 there have been almost 200 measles notifications across London. To date, 46 cases have been confirmed. The age range of confirmed cases is 0-47 years, with 24% being adolescents. Some 43% of cases have been hospitalised.
One of the main challenges is delay in diagnosis in cases presenting to A&E departments. Measles is sometimes not recognised, resulting in admissions to acute wards without isolation. This places patients at risk of severe disease, for example immunosuppressed individuals and unprotected staff at risk of measles. Assessing contacts and providing post-exposure prophylaxis is resource intensive.
Despite national recommendations that healthcare staff should have evidence of protection from measles, this is not always known and some exposed staff have had to be excluded from work until immunity was established. Some staff have been found to be susceptible, and there have also been a few cases confirmed in staff.
Systems should be in place so that all relevant Trust staff are aware of their responsibilities with regards to diagnosis and investigation of measles, and that all suspected cases are notified in a timely manner. Suspected cases should be isolated until a diagnosis of measles has been excluded. In addition, occupational health teams in hospitals and primary care should ensure that the measles immune status of all their staff has been assessed and MMR provided where appropriate.
In February 2016, there was a second outbreak of Norovirus. Were there two peaks of the same outbreak, or was it two Norovirus outbreaks one after another? This outbreak is compared with two previous outbreaks in the same hospital in 2010 and 2015. What have we learnt from these outbreaks, and are we doing anything differently?
Between 9 February 2016 and 27 May 2016 the PRUH reported 155 confirmed cases of Norovirus. At the highest outbreak peak, there were seven wards and eight bays closed, with at least 35 Norovirus inpatients (there are 25 wards in total on site). The epidemiology of this year's outbreak is still being studied to determine whether it was two outbreaks or two peaks. By 10 April 2016, the epidemic curve had reduced and there were fewer than 10 inpatients with Norovirus. After 10 April 2016, the ICNs advised two further wards to close in response to new Norovirus-positive results (including a ward with dementia patients). We closed the outbreak on 1 June 2016 after 2 weeks with no new hospital-acquired cases.
Challenges included: specimens not being collected and sent promptly; delays in obtaining Norovirus results; a prolonged outbreak or second outbreak; the majority of wards have shared facilities; the pressure of managing the outbreak, resources, time, prolonged working and team exhaustion; staff vacancy rate is still high despite a number of new nurses in post from the UK and abroad; low hand hygiene scores in some wards; some commode staining; insufficient patient care equipment on wards to segregate equipment for affected patients.
Despite higher numbers of Norovirus-positive patients in May 2016 during the second peak, hospital transmission decreased quickly. Were there two peaks or two outbreaks? Will sending the Norovirus isolates for sequencing help? The epidemiology of the Norovirus outbreak needs further analysis and discussion. Lessons learnt will be discussed at the after-action review meeting. Have we done enough to prevent any future recurrences?
I do not have any conflict of interests to declare.
Six patients in an acute ward were identified with Mycobacterium avium in their respiratory secretions during March 2016. The source implicated in this outbreak was an ice-making machine used for dispensing ice for patient consumption, located in the kitchen within the acute ward.
To identify the link of the ice-making machine to the outbreak, an inspection was carried out using a known audit tool with question-set recommendations. The machine was decommissioned, and back tubing was removed and sliced open to reveal the state of the lumen. Swabs of the lumen were taken and an acid-fast bacilli (AFB) smear was subsequently performed in the acute hospital's in-house laboratory. Additional swabs and water sample from the ice-making machine were sent to the Public Health England reference laboratory.
The ice-making machine complied with the audit tool used. Ice was dispensed directly from a nozzle into a receptacle on demand. It was cleansed regularly and was maintained according to a planned maintenance programme. However, a thick biofilm was found inside the lumen of the tubing connecting to the water supply. Bacillus was isolated from the AFB smear.
Microbiological testing confirmed that the ice-making machine was the likely source of the Mycobacterium avium outbreak. The existing infection prevention and control audit tool was not able to reveal the hygiene quality of the ice-making machine. This incident was an opportunity to review our audit tools for ice-making machines and assurance processes to prevent recurrence of the outbreak. It has opened discussions as to alternatives, such as manually making ice with the use of commercially available ice cube bags.
Infection Prevention and Control team, in-house laboratory staff and Public Health England. Background CPE (carbapenemase-producing Enterobacteriaceae) continues to be an emerging threat to safety of in-patients in acute healthcare settings.
As part of a CPE outbreak investigation, the infection prevention and control team obtained more than 100 environmental swabs during an outbreak of Klebsiella pneumoniae in two cardiac inpatient wards -one critical care unit and one medical ward -from March 2016 to May 2016. The swabs were obtained using an ordinary swab and subjected to the "meropenem Gram negative resistant" laboratory test using a CRE plate.
Out of 100 swabs, we identified a CPE -K. pneumoniae bla-IMP -from a hand hygiene sink in the kitchen, and multi-drug resistant (MDR) K. pneumoniae in the kitchen sink and in a patient bay hand hygiene sink. There were no MDR Gram negative organisms identified from patient equipment, soap dispensers, bed frames and mattresses.
As the test used was specifically for meropenem-resistant Gram negative bacteria, other important organisms were not captured. Five infection control nurses and one clinical support worker, with a total of 9 hours of work, were deployed in this environmental swabbing exercise. The activity has time and cost implications for the Infection Prevention and Control Service. There is a need to consider alternatives to microbiological sampling to link the environment to CPE outbreak.
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