De voor en nadelen van isola-e Jan Kluytmans Amphia ziekenhuis Julius centrum UMCU
Conflicts of interest • • • •
Lid steering commiAee Pfizer Lid advisory board 3M, Johnson & Johnson Lid organisa-e HAI-‐Forum Fonda-on Merieux Heb een sterke voorkeur voor een-‐ persoonskamers en een betere reisklasse -jdens vakan-e en -jdens reizen voor het werk
Wie is mijn pa-ënt? • Geneeskunde is in toenemende mate individualis-sch en technocra-sch ingericht • Arts-‐pa-ënt rela-e is belangrijk uitgangspunt – Nadelen bij infec-eziekten door afgeleide effecten tgv pa-ëntaUankelijkheid – Behandeling van een pa-ënt kan gevolgen hebben voor succesvolle behandeling van de volgende pa-ënt
• Deze overwegingen moeten bij de behandeling worden meegenomen
Is isola-e goed? • Kortdurend meestal geen probleem
Pa-ënt na 1 dag isola-e
Pa-ënt na 7 dagen isola-e?
Isola-on • Solitary confinement, is a punishment or special form of imprisonment in which a prisoner is denied contact with other persons. • It has also been called a form of torture. • In some cases it is also used to protect the prisoner from others.
Nadelen voor de pa-ent? Stelfox et al. JAMA 2003;290:1899-‐905 onderzoek in 2 ziekenhuizen in US en Canada pa-ënten die vanwege MRSA-‐besmecng waren geïsoleerd vergelijken met controles die op dezelfde kamer, maar niet in bronisola-e, waren opgenomen • uitkomstmaten betroffen het zorgproces zelf, het optreden van ongewenste gebeurtenissen en de tevredenheid van de pa-ënt • • • •
Uitkomsten • Pa-ënten en controles waren over het algemeen goed vergelijkbaar • Het zorgproces verliep minder zorgvuldig bij de geïsoleerde pa-ënten • Geïsoleerde groep:
– 2,5 maal vaker geen vitale lichaamsfunc-es geregistreerd – ruim 2 maal vaker ongewenste gebeurtenissen – vrijwel volledig veroorzaakt werd door voorkombare gebeurtenissen (7 maal vaker in de geïsoleerde groep). • bv. vallen, decubitus en afwijkingen in de vocht-‐ en elektrolytenbalans
– de geïsoleerde pa-ënten waren significant ontevredener over de verleende zorg dan de controles – meer klachten -jdens de opname, zowel informele als formele klachten
Conclusies Isola-emaatregelen kunnen leiden tot een kwalita-ef minder goede zorg met ongewenste neveneffecten
Contact Isolation for Infection Control in Hospitalized Patients: Is Patient Satisfaction Affected? Leanne B. Gasink, MD, MSCE; Karyn Singer, BA; Neil O. Fishman, MD; William C. Holmes, MD, MSCE; Mark G. Weiner, MD; Warren B. Bilker, PhD; Ebbing Lautenbach, MD, MPH, MSCE The effects of contact isolation on patient satisfaction are unknown. We performed a cross-sectional survey and found that most patients lack education and knowledge regarding isolation but feel that it improves their care. In multivariable analysis, isolated patients were not less satisfied with inpatient care than were nonisolated patients. Infect Control Hosp Epidemiol 2008; 29:275-278
gical tient exam adjac ticip patie Th Syste istere dard expe the q after their call postd ques unab
Psychological impact of short-‐term isola-on measures in hospitalised pa-ents. Wassenberg M, Severs D, Bonten M J Hosp Infect. 2010 Jun;75(2):124-‐7
Cross-‐sec-onal matched cohort study Pa-ents were evaluated with the Hospital Anxiety and Depression Scale [HADS-‐ A (Anxiety) and HADS-‐D (Depression)], Visual Analogue Scale of EQ-‐5D (EQ VAS) and an isola-on evalua-on ques-onnaire In mul--‐variate analysis comorbidity was associated with EQ VAS (P=0.005), whereas all other variables were unrelated to HADS and EQ VAS scores. Pa-ents reported posi-ve associa-ons with isola-on measures. In conclusion, short-‐term infec-on control measures do not influence hospitalised pa-ents' levels of anxiety and depression and quality of life. Isolated pa-ents had a posi-ve actude towards the precau-ons taken.
Ongoing debate
• Isola-e heeq nadelen en is niet bewezen effec-ef – > handenwassen en dekoloniseren – 80% compliance………………………………..
Handhygiene compliance HHC%
49.8%
39.4%
31.5%
45.0%
51.0%
5 momenten van WHO • Sterke twijfel of deze in de prak-jk haalbaar zijn • De grootste pleitbezorgers van handhygiëne (inclusief de auteurs van het ar-kel) falen in de controle van MRSA in hun eigen ziekenhuis
zoiets Let’s talk about sex
Isola-e nuAeloos? Ondanks het veronderstelde gebrek aan bewijs is er nauwelijks twijfel dat isola-e een effec-eve maatregel is om overdracht van micro-‐ organismen te voorkomen ISOLATIE STAAT NIET TER DISCUSSIE BIJ: SARS EBOLA TBC Wat is de gemeenschappelijke factor?
Zelxescherming
Posi-eve effecten van isola-e • Nederlandse situa-e tav MRSA
Nederland 2005: <5 doden Tuesday, October 16, 2007
CDC es-mates 94,000 invasive drug-‐resistant staph infec-ons occurred in the U.S. in 2005
Methicillin–resistant staph aureus (MRSA) caused nearly 19,000 deaths in the United States in 2005 (compared with around 16,000 from AIDS) most of them associated with health care secngs
2009: laboratory based surveillance
Duitsland-‐Nederland: 34 -‐ 1 • 2009 MRSA sepsis • Noord-‐Rhein-‐Wes|alen: >1100 • Nederland: <40 • Sterqe: 10 – 20% – 110-‐220 extra doden per jaar
Amphia Hospital
Costs € 5.54 / admission
Revenues: >10 lives / year €10.11 / admission
Hoeveel isola-es? • Amphia ziekenhuis:
1,5% van alle opnames
<1 dag mediaan 6 dagen
0,2% van alle opnames
Conclusies • Met beperkte maatregelen is MRSA onder controle – Kosten-‐effec-ef – Veilige zorg Isola-e van <100 pa-ënten per jaar (meestal kortdurend) <> 70 bacteremiën met MRSA (≈10 levens)
• Nadelen zoveel mogelijk beperken
Omdenken
Eenpersoonskamers worden de norm • Kamertoewijzing • Het Jeroen Bosch Ziekenhuis heeq grotendeels éénpersoonskamers. Bij het toewijzen van de kamers (een-‐, twee-‐ of vierpersoonskamer) houden we rekening met uw persoonlijke omstandigheden en gezondheidstoestand. • Tijdens uw opname in het Jeroen Bosch Ziekenhuis kunt u tegen b etaling gebruik maken van zogenaamde comfortzorg (uitgezonderd dagopnames). – Dit houdt in: Verblijf op een eenpersoonskamer (mits die beschikbaar is).Dagelijks een krant.Gra-s telefoon, televisie en internet op de kamer, inclusief gra-s bellen naar vaste en mobiele nummers binnen Nederland.Een gezamenlijke aAen-e van de schoonheidsspecialist/ kapper/ medische pedicure. • In het JBZ betaalt u voor comfortzorg 125 euro per dag(dit tarief is vastgesteld voor 2013; prijswijzigingen voorbehouden). Sommige
pa-ënten zijn verzekerd voor comfortzorg via hun aanvullend verzekeringspakket.
Voordelen van isola-e voor de pa-ënt • 125 euro per dag – Eigen kamer – Eigen sanitair – Geen vervelende buren
Conclusies • Isola-e is een nucge maatregel om transmissie te voorkomen • Isola-e is een noodmaatregel en moet alleen worden ingezet als het echt nodig is – Isola-ekamers: pa-ëntvriendelijk ontwerp – Zorgmedewerkers: extra aandacht voor pa-ënt in isola-e
• Ziekenhuis migreert naar hoog-‐complexe zorg met erns-g zieke pa-ënt > standaard eenpersoonskamers
De toekomst • Pan-‐resistente Gram-‐nega-eve bacterien • Een paar voorbeelden
The last resort • Presenta-on of a case – Pa-ent #1 – 63 yo female – CVA during a holiday in Crete (Greece) – Neurosurgery – ICU for weeks – Transferred to Breda (The Netherlands) in June 2013
Case con-nued • Upon admission placed in isola-on (tes-ng for MRSA and other HRMO) • Klebsiella pneumoniae – Pan resistant (All beta-‐lactams, aminoglycosides (gentamicin intermediate), fluoroquinolones, trimethoprim-‐sulfamethoxazole, colis-n, -gecyclin, fosfomycin, chloramfenicol, nitrofurantoin)
Case con-nued • Placed in a single room with contact precau-ons • Aqer 1 week • A second pa-ent on the ward was found with a pan-‐resistant K. pneumoniae in pleural fluid (pa-ent #2) • Both pa-ents were placed in strict isola-on and dedicated nursing team • Twice weekly contact tracing of the en-re ward • No further spread
Case con-nued • One month later pa-ent #1 was discharged to a nursing home • Pa-ent #2 was discharged home (august 2013) • No infec-ons, no further spread
Carbapenemases in Europe Rapid communications
Eurosurveillance 2013
Carbapenemase-producing Enterobacteriaceae in Europe: a survey among national experts from 39 countries, February 2013 C Glasner1, B Albiger2, G Buist1, A Tambić Andrašević3, R Canton4,5, Y Carmeli6, A W Friedrich1, C G Giske7,8, Y Glupczynski9,
10 Table 1 M Gniadkowski , D M Livermore11,12, P Nordmann13,14 , L Poirel13,14 , G M Rossolini15, H Seifert16, A Vatopoulos17, T Walsh12, 18 1 2 1 , T Donker , D L Monnetstages , H Grundmann (
[email protected]) , N Woodford Description of the epidemiological of carbapenemase-producing Enterobacteriaceae (CPE) the European Survey on Carbapenemase-Producing Enterobacteriaceae (EuSCAPE) working group19
1.
Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands 2. European Centre for Disease Prevention and Control, Stockholm, Sweden Epidemiological scale DescriptionUniversity Hospital for Infectious Diseases, Zagreb, Croatia Stage 3. Department of Clinical Microbiology, 4. Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria No cases reported No cases reported 0 (IRYCIS), Madrid, Spain 5. Unidad de Resistencia a Antibióticos y Virulencia Bacteriana asociada al Consejo Superior de Investigaciones Científicas Sporadic occurence Single cases, epidemiologically unrelated 1 (CSIC), Madrid, Spain Single hospital outbreak Outbreak defined as two or more epidemiologically 2a 6. Division of Epidemiology, Tel-Aviv Sourasky Medical Centre, Tel-Aviv, Israelrelated cases in a single institution 7. Clinical Microbiology, MTC Unrelated - Karolinska Institutet, Karolinska University i.e. Hospital, Stockholm,unrelated Sweden introduction hospital outbreaks with independent, epidemiologically Sporadic hospital outbreaks 2b 8. Swedish Institute for Communicable Solna, Sweden or differentDisease strains, Control, no autochthonous inter-institutional transmission reported 9. National Reference Laboratory for Antibiotic Resistance Monitoring in Gram-negative Bacteria, CHU Mont Godinne, More than one epidemiologically related outbreak confined to hospitals that are part of a Université Regional spread Catholique de Louvain, Yvoir, Belgium 3 regional referral network, suggestive of regional autochthonous 10. Department of Molecular Microbiology, National Medicines Institute, Warsaw, Poland inter-institutional transmission 11. Norwich Medical School, University of East Anglia, Norwich, United Kingdom Multiple epidemiologically related outbreaks occurring in different health districts, suggesting Inter-regional 4 12. Sectionspread of Medical Microbiology IIB, School of Medical Sciences, Cardifftransmission University, Heath Park Hospital, Cardiff, United inter-regional autochthonous inter-institutional Kingdom 13. INSERM U914 «Emerging Resistance to Antibiotics», National Center forautochthonous Antibiotic Resistance, Endemic situation Most hospitals in a country Associated are repeatedly seeing Reference cases admitted from sources Faculté 5 de Médecine et Université Paris-Sud, K. Bicêtre, France 14. Medical and Molecular Microbiology Unit, Department of Medicine, Faculty of Science, University of Fribourg, Switzerland The15. table was reproduced from referenceMediche, [3]. Dipartimento di Biotecnologie Università di Siena, Siena; Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze; SOD Microbiologia e Virologia, Azienda Ospedaliera-Universitaria Careggi, Firenze, Italy
Figure Occurrence of carbapenemase-producing Enterobacteriaceae (CPE) in 39 European countries ba respective national experts, 2013
A Overall European situation regarding CPE using an epidemiological scale of nationwide expansion
CPE Non-visible countries Luxembourg Malta Cyprus
Epidemiological stages
Our case
No cases reported Sporadic occurence Single hospital outbreak Sporadic hospital outbreaks Regional spread Inter-regional spread Endemic situation Uncertain
B Geographic distribution of CPE by resistance mechanism using the same epidemiological scale
Endemic situa-on in Greece with pan-‐resistant K. pneumoniae Many ICU’s the majority of BSI carbapenemases VIM KPC MLST: ST258 is found most frequently Non-visible countries Non-visible countries Travel related (including hospitaliza-on) introduc-on is reported regularly Luxembourg Malta Cyprus
Luxembourg Malta Cyprus
VIM
KPC
Non-visible countries Luxembourg Malta Cyprus
Non-visible countries Luxembourg Malta Cyprus
Mainly Healthcare-‐related
OXA-48
NDM
Non-visible countries Luxembourg Malta Cyprus
Non-visible countries Luxembourg Malta Cyprus
Community
S-ll far away
KPC: Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae; NDM New Delhi metallo-beta-lactamase; OXA-48: carbape
Back to the case • Nov 2013 – Pan-‐resistent Klebsiella in a pa-ent in the surgical ward – Unexpected finding in a contact screening for ESBL – ???
• Pa-ent comes from a nursing home • Same nursing home were pa-ent #1 resides
Nursing home • In several screenings of residents, 4 cases are found (including the pa-ent in surgery) – Many breaks in basic infec-on control procedures – Gloves are used inappropriately – Extensive environmental contamina-on
• Cohor-ng of colonized residents • Opening a separate facility for the colonized residents
Extensive environmental contamina
r r r r m m m m lle lle lle lle be be be be be o o o o o o o o o o o o o o oo r r r r r r r r ro r r r r t t t t e d d d d d s n n n n n t th th th th ar ar ar ar ar ) ou co co co co co ba w ba w ba w ba w ba w n x d d d d d ) ) ) ) ) ) ) ) ) ) r m 4 e e e e e b b b b b b b b b b tie r e ( d b b b b b a e h o o o o o o o o o o s n t e d d d d d e as kn kn kn kn kn kn kn kn kn kn a t p on lif w r ( r ( r ( r ( r ( r ( r ( r ( r ( r ( an an an an an m rd h n e o o o o o o o o o o t a d d d d d s a n n o p e o o e o o e o o e o o e o o co dp : b : d : d : b : d : d : b : d : d : b : d : d : b : d : d yb CT tie tie Be Ke dE glu P1 P1 P1 P3 P3 P3 P4 P4 P4 P5 P5 P5 P6 P6 P6 Pa Pa lle tro
op
Date
n he ti c K
w
kt or ta
e bl
m oo hr
5-‐12-‐2013 10-‐12-‐2013 20-‐12-‐2013 23-‐12-‐2013 3-‐1-‐2014 10-‐1-‐2014 21-‐1-‐2014 7-‐2-‐2014 12-‐2-‐2014
Device used for mul-ple pa-ents
MLST plus (3042 alleles)
Outbreak strains from pa<ents and environment and an unrelated ST258 strain
Nursing home • Several challenges – Residen-al secng > limits control measures – Long dura-on of stay > accumula-on – Lower educa-onal level of HCW’s > compliance – Limited resources > screening is problema-c due to costs
Follow up • 1 pa-ent lost the strain spontaneously (only one posi-ve screening sample) • 2 pa-ents died ( one from urosepsis with outbreak strain) • 3 pa-ents were considered for treatment with fecal transplant – 2 succesfully treated – 1 (pa-ent #2) was repeatedly (8 -mes) nega-ve upon fecal screening > no fecal transplant
One more thing • 17 months later pa-ent #2 was admiAed with an abdominal sepsis • KPC posi-ve • Stayed on the ICU for 3 weeks and died form a sepsis with KPC posi-ve strain – 2 out of 6 colonized pa-ents died due to infec-on – 8 rectal cultures had been nega-ve……..
• Outbreak controlled by an agressive approach
Another Nursing Home Clinical Infectious Diseases Advance Access published January 26, 2015
MAJOR ARTICLE
Prevention of Colonization and Infection by Klebsiella pneumoniae Carbapenemase– Producing Enterobacteriaceae in Long-term Acute-Care Hospitals Mary K. Hayden,1,2 Michael Y. Lin,1 Karen Lolans,2 Shayna Weiner,1 Donald Blom,1 Nicholas M. Moore,3 Louis Fogg,4 David Henry,5 Rosie Lyles,6 Caroline Thurlow,1 Monica Sikka,1 David Hines,7 and Robert A. Weinstein1,6; for the Centers for Disease Control and Prevention Epicenters Program Departments of 1Medicine, Division of Infectious Diseases, 2Pathology, 3Medical Laboratory Science, and 4Nursing, Rush University Medical Center, 5 Department of Biostatistics, University of Illinois School of Public Health, 6Department of Medicine, Division of Infectious Diseases, Cook County Health and Hospital System, and 7Metro Infectious Disease Consultants LLC, Chicago, Illinois
Background. Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (hereafter “KPC”) are an increasing threat to healthcare institutions. Long-term acute-care hospitals (LTACHs) have especially high prevalence
Stepped wedge design:
introduc-on of a bundle to control KPC acquisi-on
Table 2. Adherence With Components of Intervention Bundle During the Intervention Period Adherence Measure Collection of admission surveillance swabsa Collection of every other week surveillance swabs KPC-positive patient-days on a cohort floor or in a private roomb HCW hand hygiene adherence at room entrance HCW hand hygiene adherence at room exit Donning gloves and gown before room entryc
No. Adherent/No. Opportunities
% Adherence
95% CI
2872/3152
91.1
90.1–92.1
5072/5316 17 921/19 295
95.4 92.9
94.8–96.0 92.5–93.2
365/1499
24.4
22.2–26.6
1304/1843 387/489
70.8 79.1
68.6–72.8 75.3–82.5
Abbreviations: CI, confidence interval; HCW, healthcare worker; KPC, Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae; LTACH, long-term acute-care hospital. a
Adherence was defined as collection of a rectal surveillance swab for KPC culture within 3 calendar days of admission. Median time from admission to availability of swab culture results was 3 days (interquartile range, 2–4 days).
b
Adherence was measured 3–6 days per week at each LTACH. Three LTACHs cared for KPC-positive patients on patient cohort wards. The fourth LTACH cared for KPC-positive patients in private rooms. The percentage of KPC-negative patient-days on a KPC cohort floor or in a room with a KPC-positive patient was 13% (5109/ 40 777). c
High-acuity unit rooms only, where universal contact isolation was in effect.
reached a plateau (34.3%; 95% CI, 32.4%–36.2%; P < .001 for ex-
in Figure 4A–D. There was a clear drop in rates of infection and
f KPC from any clinical culture and a 56% reduction cteremia (Table 3). Rates of bloodstream infection due hogen declined by 32%; blood culture contamination y 53%. The magnitudes of the reductions are displayed
DISCUSSION
Implementation of a bundled intervention was asso clinically important and statistically significant red
The results
Prevalence rate of Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC) rectal colonization during the pr Prevalence rate of Kinlebsiella pneumoniae arbapenemase–producing nterobacteriaceae ntion periods. Each data point the preintervention period crepresents the average prevalence E across the 4 long-term acute-c (KPC) rectal coloniza-on he preinterven-on nd included interven-on periods 1 semiannual point prevalence survey.during Only 2 tLTACHs (LTACHs D and C) aare in the week −17 point prevalence surve e already participating in the intervention at that time. During the intervention period, each data point represents the average preva s for 1 every other week point prevalence survey. Data for the first 52 weeks of the intervention are shown. P < .001 for exponent during the intervention period.
Acquisi-on of KPC
Figure 3. Incidence rate of Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae (KPC) rectal colonization during the intervention period. Each data point represents the number of patients who acquired KPC per 100 patient-weeks, averaged over the preceding 2 weeks. Definite incident cases and data for the first 52 weeks during which each of the 4 long-term acute-care hospitals participating in the study are shown. P = .004 for linear decline.
Yet, because l terization and population, be have not been the ability of L adds to our u able group of over the next In addition infection, coll on relative rat contamination cause the inte tion measures bundle comp KPC-specific CHG has bee
vide support for other healthcare facilities that are working to lower the burden of KPC in their patient populations. To our knowledge, this is the first multicenter study to show sustained decreases in cross-transmission of a multidrug-resistant pathogen and in healthcare-associated infections in an LTACH population. Patients in LTACHs are chronically critically ill [27] and at high risk of infection from multidrug-resistant organisms because of prolonged hospital stays, repeated antibiotic exposures, and elevated rates of medical device use [28, 29].
ceptibility of KPC to CHG [35], we found that CHG bathing was effective in reducing KPC skin colonization in LTACH patients [36]. Thus, CHG bathing may also have helped reduce cross-transmission of KPC by lessening the risk of healthcareworker hand contamination during direct care of KPC-positive patients. Still, active surveillance for KPC, contact isolation, and geographic separation of KPC-positive patients may have contributed to declines in KPC incidence, prevalence, and infection. Preintervention hand hygiene rates were not known, but
Clinical data
Table 3. Effect of Intervention Bundle on Clinical Cultures and Blood Culture Contamination Preinterventiona No. of Events
Outcome KPC in any clinical culture KPC bloodstream infection Bloodstream infection due to any pathogen Contaminated blood culture
Events/1000 Patient-days
Interventiona 95% CI
No. of Events
Events/1000 Patient-days
6
3.7
3.4–4.0
285
2.5
2.2–2.8
−1.2
.001
165 2004
0.9 11.2
.8–1.1 10.7–11.7
48 870
0.4 7.6
.3–.5 7.1–8.1
−0.5 −3.6
.008 .006
865
4.9
4.5–5.2
261
2.3
2.0–2.6
−2.6
.03
There were 178 516 patient-days in the preintervention period and 114 070 patient-days in the intervention period.
•
CID
•
Hayden et al
P Value
656
Abbreviations: CI, confidence interval; KPC, Klebsiella pneumoniae carbapenemase–producing Enterobacteriaceae. a
95% CI
Change in Event Rate
KPC bacteremia
Authors conclusions A bundled interven-on was associated with clinically important and sta-s-cally significant reduc-ons in KPC coloniza-on, KPC infec-on and all-‐cause bacteremia These results demonstrate that control is possible despite high coloniza-on pressure and repeated introduc-on of KPC-‐posi-ve pa-ents
My conclusions • 2 acquis-ons per 100 pa-ent weeks would mean 10 per week in a 500 bed facility • 0,4 KPC bacteremia’s per 1000 days equals 3 per week in a 500 bed facility • This is achieved with a very intensive approach • I consider this a failure of the health care system to deliver safe care
2 possible a simple combined e primary nd means CHs. As a and slope
ible conived meon. These hey were
ersion 19 1 (http://
Table 1. Characteristics of the Long-term Acute-Care Hospital Population, According to Study Period Preintervention Perioda
Intervention Perioda
3894
2951
Admissions, No. Admissions per month, mean (SD)
5282 231 (21)
3738 234 (22)
Age, y, mean (SD)
63 (16)
64 (16)
45.6
45.8
178 516
114 070
8.3
10.1
Variable Present on admission Patients, No.
Female sex, % Measured during hospital stay Patient-days, No. High-acuity unit patient-days, % Invasive medical device utilization, %b
Mechanical Absolute ventilation risk reduc-on 3,9%, CI 2,0%-‐5,8% 50.5 43.1
Central venous catheter Urinary bladder catheter Hospital stay, d, median (IQR) In-hospital mortality, %
50.3 63.0
51.9 50.9
28 (16–43)
26 (17–39)
21.5
17.6
xfordjournals.org/ at IDSA member on February 18, 2015
gering ocervention
Our current plans: Pandemic CRE Preparedness • Principle components: – Early warning and coordinated ac-on • Good microbiology with rapid feedback • Regional networks of microbiology laboratories with exper-se and regional mandate • Includes hospitals, LTCF’s, NH’s, General Prac-onners and Public Health
– Funding for control of outbreaks and taking screening cultures
Regional health-‐care clusters
Control of AMR • Requires – a fundamental change from pucng the individual pa-ent in the center towards thinking in systems with shared benefits – good microbiology (quality and quan-ty) including regular screening on high risk wards (Including NH’s) and communica-on beyond the individual ins-tutes – good infec-on control – an-bio-c stewardship
Infec-on control risk scan (iRIS)
IRIS: Risc profile ESBL carriage
Medical devices
7 %
An-bio-c usage
60%
46%
IRIS: Spiderplot for improvement A= Spread of ESBL (%); B= Healthcare-‐related infec-ons (%); C= unjus-fied medical devices(%); D= inappropriate use an-bio-cs (%); E= environmental contamina-on (RLU); F= handhygiene non-‐compliance (%); G=personal hygiene; H= precondi-ons
Improve Quality circle: Measure Analyse Improve Measure
iRIS select interven-ons perform interven-ons iRIS
How to be prepared?
Build BeEer Hospitals
Main principles Mostly single rooms Private sanitary equipment Reduce cleaning requirements Opera-ng rooms with con-nuous measurement of bundle compliance • Sufficient isola-on facili-es
• • • •
And finally • Dedicated professionals • Leadership • Measurement of outcome • And an old mission: a hospital should do to the sick no harm
With thanks to
Staff of the department of infec-on control Staff of the laboratory for microbiology Management board of Amphia Hospital
