Risk Management Summit

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Risk Management Summit, Amsterdam 10th May 2012

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Risk Management Summit

  1. 1. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Welcome to the hospital Despite our best intentions … Control of antibiotic use 1  in  10  pa&ents  “gets  hurt”   … not all problems are preventable Control of antibiotic use Spread of multi-resistant pathogens New  MDR-­‐MO’s   New  an&bio&cs  Andreas  Voss,  MD,  PhD   1  
  2. 2. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Environmental dissemination of NDM-1 Walsh  et  al.    Lancet  ID    2011;11:355   Environmental dissemination of NDM-1: 
 Environmental dissemination of NDM-1: 
 NDM-1 positive samples NDM-1 positive samples used  for  drinking     •  20  NDM-­‐1-­‐posi&ve  strains  were  present  in   and  food  prepara&on   the  samples,  including:   –  Enterobacteriaceae,  Citrobacter  freundii,  E   coli,  and  K  pneumoniae  (commonly  carry  blaNDM-­‐1)     –  Shigella  boydii,  V  cholerae,  Aeromonas   caviae.     blaNDM-­‐1-­‐posi&ve  bacteria  were  recovered  from  12  of   –  Various  non-­‐fermenters  not  previously   reported     171  seepage  samples  and  2  of  50  water  samples.   to  carry  blaNDM-­‐1:     Green  squares  =   Pseudomonas  aeruginosa  (and  other  P.  spp),   51  seepage   samples  where     Sutonella  indologenes,  Stenotrophomonas   genes  were  found   (underes&ma&on)   maltophilia,  Achromobacter  spp,  and  Kingella   denitrificans.   Walsh  et  al.    Lancet  ID    2011;11:355   Walsh  et  al.    Lancet  ID    2011;11:355   New Delhi metallo-beta-lacatamse Estimated income for India by 2012: US$2 billion Not  a  “superbug”  (=  single  bacterial     species)  but  a  transmissible  gene1c  element   encoding  mul&ple  resistance  genes   Connell Tourism Mangement 2006;27:1093Andreas  Voss,  MD,  PhD   2  
  3. 3. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   ESBL bacteria in patients with 
 Do you enjoy traveling? travellers’ diarrhoea •  ESBL  significantly  more  frequent  in  travelers   returning  from  Middle  EAST,  India  or  Asia   Tham,  SJID,  2010,  275   Food as a source of MDR-mo’s Yes,  I  am   mul&-­‐drug   resistant!   L  +   ESB ESBL in chicken, meat and humans New sources of MRSA •  A  high  prevalence  of  ESBL  genes  was  found  in  raw  chicken   meat  (79.8%).     Pigs & calves •  Gene&c  analysis  showed  that  the  predominant  ESBL  genes   in  chicken  meat  and  human  rectal  swab  specimens  from   the  same  area  were  iden&cal.  These  genes  were  also   frequently  found  in  human  blood  culture  isolates.     •  Typing  results  of  Escherichia  coli  strains  showed  a  high   degree  of  similarity  with  strains  from  meat  and  humans.     Overdeveste  et  al      EID    2011;17:1216  Andreas  Voss,  MD,  PhD   3  
  4. 4. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Personnel Protective Equipment In the post SARS era … MRSA: import vs acquired first  MRSA  isolate  was  recovered  within  72  h  of  ICU  admission     P  <  0.01   first  MRSA  isolated  ager  72  h  of  ICU  admission   SARS   Pre-­‐SARS   Post-­‐SARS   …  we  tend  to  forget  while  more  might  come  !   Clin  Infect  Dis    2004;39:511-­‐516   Multi-vial device: re-cappingAndreas  Voss,  MD,  PhD   4  
  5. 5. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Multi-vial device: sealed ? Meet your new surgical team Jane   Leonardo   Tom   Hospital Cleaning Disinfec&on  and  steriliza&on   •  In-­‐  or  out-­‐sourced   •  Detergent  vs  disinfectants   •  Standardized  vs  manual   (beds,  scopes,  …)   •  Costs  vs  quality   HCWs & Infection Control Infec&on  control  Andreas  Voss,  MD,  PhD   5  
  6. 6. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   HH compliance in the Netherlands What is the problem? Disregard  to  guidelines   If hospital bugs would look like this – compliance a   with hand hygiene would be 100% Dangerous micro-organism: MRHW Mul&-­‐Resistant     Health-­‐care   Worker   MRHW How to change HCWs behavior? •  Resistant  to  good  advice   •  Just  presen&ng  something  “new”  or  “beker”   will  not  change  their  behavior  …   •  Allergic  to  (professional)  guidelines   •  We  should  learn  from  marke&ng  professionals     •  Non-­‐compliant  with  IC  measures     •  “  People  are  willing  to  change  of  they  feel:   •  Blind  to  HAIs  (especially  their  own)   good,  flakered,  powerful  or  sexy”  not  when   bombareded  with  facts  (Hodgkin  1999)   •  Other  prioro&es  Andreas  Voss,  MD,  PhD   6  
  7. 7. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Gimme an Rx! 
 … my new infection control nurses Cheerleaders Pep Up Drug Sales  Onya,  the  Redskins  cheerer   (who  asked  that  her  last  name   be  withheld,  ci&ng  team  policy),   has  her  picture  on  the  teams   Web  site  in  her  official  bikini-­‐ like  uniform  and  also  reclining   in  an  actual  bikini.  Onya,  27,   who  declined  to  iden&fy  the   company  she  works  for,  is  but   one  of  several  drug   representa1ves  who  have   cheered  for  the  Redskins     A&F stole my idea … Try to find out what your customer wants! ² Many  &mes  we  offer  our  help  assuming  that  we  know  what   HCWs  need  and  how  we  can  help  them  …    whereas  our   assump&ons  and  reality  frequently  differ  !   They old measures work ! Hand  hygiene     With  bed-­‐side  dispensers  and  pocket-­‐bokles   any  excuse  to  not  reach  out  for  the  alcoholic   handrub  is  gone.    Thus,  ….  “Just  do  it!”       Furthermore,  hand  hygiene  should  be  seen   as  only  one  of  the  classical  preven&ve   measures  all  of  which  deserve  our  aKen1on   and  HCW’s  compliance.   Poli&cally  incorrect,  biased  and  personal  Andreas  Voss,  MD,  PhD   7  
  8. 8. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Surveillance GI Infections HAI-­‐surveillance     GI-­‐tract  infec&ons     Internal  quality  versus  public  repor&ng.   Increasing  rates  of  C.  difficile  and   Repor&ng  real  HAI  rates  (e.g.  VAP)  instead  of   norovirus.    With  regard  to  norovirus:   low  public  rates  and  crea&ng  new  diseases   impact  on  the  pa&ent  outcome  as  well   such  as  ven&lator-­‐associated  trachea-­‐ bronchi&s   as  the  overall  possibility  to  deliver  care   is  frequently  underes&mated   Fighting community and The  unnecessary  and  wrong  use  of   an&bio&cs  needs  to  stop.  In  the  light  of  the   zoonotic pathogens emergence  of  MDR-­‐m.o.’s  we  can  not  afford   to  booster  the  trend  by  selec&ng  more   CA-­‐MRSA,  LA-­‐MRSA,  NDM-­‐1  &  Co.       resistance  and  waist  the  limited   Emerging  pathogens  and  mobile   an&microbials  we  have  during  indica&ons   transmissible  elements  through  the  food-­‐ that  need  no  or  other  an&bio&cs.     chain/bio-­‐industry  or  from  travellers  to   countries  with  poor  sanita&on  will  be  a   major  challenge  to  infec&on  control   Influencing public and political expectations YES  to  “zero  tolerance”  but  NO  to  zero   infec&ons!    Zero  HAIs  is  impossible.  This   gives  consumers  a  completely  wrong   picture  and  encourages  poli&cians  &   insurances  to  come  up  with  unwanted   rules.  Andreas  Voss,  MD,  PhD   8  
  9. 9. Infec&on  Control  in  Healthcare   09-­‐05-­‐12   Hospital-structure Commerce Outsourcing  of  clinical  microbiology  and   Up-­‐hold  and  improve  hospital  structure   infec&ous  diseases  services  are  contra-­‐ and  “HCW  to  pa&ent  ra&o’s”  to  allow   produc&ve  to  what  makes  Infec&on   infec&on  control  measures  to  be   Control  work  in  countries  like  the  NL:   applied,  and  improve  hospital  design  to   direct  accessibility  and  integra&on   allow  op&mal  workflow.   (within  the  healthcare  sevng)  of  all   infec&ous  diseases  services   Culture change Behavioral science How  to  integrate  behavioral  science   into  infec&on  control  educa&on?     Why  do  healthcare  workers  believe  that   We  will  not  change  HCWs  behavior  by   if  they  adhere  to  70%  of  the  rules  that   con&nuously  blaming  them  for  what   they  are  doing  an  outstanding  job?  In   they  do  wrong.   other  industries  that  is  a  reason  to  get   fired!   Final wisdom of behavioral science “Before  you  cri&size  someone  you  should  walk  a   mile  in  their  shoes  …     …  that  way,  if  he  gets  angry,  hell  be  a  mile   away,  and  you  have  their  shoes  ”   Homer  Simpson  Andreas  Voss,  MD,  PhD   9  

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