Transcript Either positive or negative… Perception of being a role model

Making the Connection Conference
Summerside
You will not get influenza this winter and you
Considerations
andto
Treatment
Guidelines
will not send urine
the laboratory
only
for Older adults
(UTI’s,
URI’s, Influenza)
because
it smells:
Germ doctor’s wishes that can come true.
Greg German MD PhD FRCPC DTM&H
Medical Microbiologist &
Infectious Diseases Consultant
October 15, 2015
www.healthpei.ca/micro
No Disclosures
Objectives:
• 1. Discuss the new medical directive on urinary tract
infection management in long term care including the
use of RN initiated antibiotics, physician guidelines, rapid
testing, and nursing leadership.
• 2. Analyze the @Urinematters successfully collaboration
and tapping into new funds or tools for education
• 3. Establish a top 10 list of flu prevention strategies for
your home and work.
• 4. Strategize on how your health care role and rolemodeling plays a key part to prevent infections and
outbreaks.
The SUPERBUGS
Seniors (Age 65+)
• 17.3% of Island population (2013)
• Projected to about 1 in 3 by 2040
Cdiff Cases Per Year on P.E.I.
*
Total:
82
118
142
137
Cdiff Cases by Age
*
*2014 Data: Lab Generated pending
confirmation/validation by Provincial Epidemiologist
Very very bad E.coli
• XDRO
Extensively (Gram Neg) Drug Resistant Organism
PEI Public health reported since 2013
• For urines intermediate or resistant to 3 of 4
following groups of oral antibiotics
Cotrimoxazole “Septra or Bactrim”
Nitrofurantoin “Macrobid or Macrodantin”
Amox/clav or cefixime
Ciprofloxacin
XDROs in Urine by Age Bracket
11
54
139
31
117
84/10k
72
21/10k
235
30/10k
160
89/10k
LTC
Andrews Lodge
Atlantic Baptist Home
Beach Grove Home
Clinton View Lodge
Colville Manor
Dr. John Gillis Memorial Lodge
Garden Home
PILOT
Maplewood Manor
PILOT
Margaret Stewart Ellis Home
Park West Lodge
Prince Edward Home
PILOT
Riverview Manor
South Shore Villa
Stewart Memorial
Summerset Manor
Wedgewood Manor
Whisperwood Villa
Beds
221
100
131
35
52
78
133
48
40
39
120
48
56
23
82
76
126
XDRO per
10K Patient days
0.0
0.0
4.4
0.0
4.2
1.8
0.0
6.8
4.1
0.0
1.8
22.3
0.0
6.0
0.0
4.0
2.4
XDROs 2014
21
8
5
12
6
0
8
39
0
5
0
11
11
Sorting of plates into different
categories
GOOD
Quality due to transport?
Mixed Growth
No significant Growth
No growth
Pathogen
Non-pathogen
Riverview Manor Urines
N= 104 tests
Garden Home Urines
N = 203 tests
22%
25%
12%
37%
5.8%
15%
39%
23%
47%
7.3%
Plating characteristics
Average time to plating
Samples between 24-30
hours
20.3 hours
38%
11.6 hours
7.9%
More time = more contaminants
Problem Specifically
• Too many inappropriate specimens sent
When patient not clearly symptomatic
True Midstream urine collection challenges
Unable to obtain in/out catheter order easily
• Ciprofloxacin started before culture results
• Urine Specimen transport, pyuria
detection, and turn around unsatisfactory
Problem Generally
• Increase Cdiff
• Increase drug resistance
• Increase admissions due to
missing the target
• Increase IV antibiotic therapy
The Teams and Groups
Long Term Care UTI
Management Team
•
•
•
•
•
•
Shelley Woods (LTC CNO)
Shelley MacCallum
Kelly Blanchard
Pam Handrahan
Kim MacPhee
Jennifer Boswell (Antibiotic
Stewardship Pharm)
• Dr. German (Micro-Inf.
Diseases),
• Drs. Grimes, & MacLeod
(House Physicans)
Committees Involved
• PICPAC
Brenda Worth, Chair
• PD&T
Including Antibiotic
subcommittee
• Engagement Event
#UrineMatters a
CADTH cosponsored
event with 120
stakeholders
The Teams and Groups
Long Term Care UTI
Management Team
•
•
•
•
•
•
Shelley Woods (LTC CNO)
Shelley MacCallum
Kelly Blanchard
Pam Handrahan
Kim MacPhee
Jennifer Boswell (Antibiotic
Stewardship Pharm)
• Dr. German (Micro-Inf.
Diseases),
• Drs. Grimes, & MacLeod
(House Physicans)
Committees Involved
• PICPAC
Brenda Worth, Chair
• PD&T
Including Antibiotic
subcommittee
• Engagement Event
#UrineMatters a
CADTH cosponsored
event with 120
stakeholders
Nurse Initiated antibiotics by
medical directive
• Thames Valley Family Health Team
(London Ontario), 2011
Limited to usually young females as greater
than 2 medication or one blood thinner is a
contraindication
• Hamilton Family Health Team, 2014
Nurse able to give treatment course and
modify once susceptibilities are known
Nitrofurantoin and Benefits
• Less collateral damage:
Doesn’t target gut less resistance
Doesn’t target gut less C. difficle
• Costs
Inexpensive cost effective
Opportunity to safe fluroquinolone or
TMP/SMX for future use decrease need for
IV antibiotics
Use of Nitrofurantoin in Men
• Supported in the UK when pyleonephritis
or recurrent infection not suspected
• Appreciate may fail therapy due to lack of
prostate penetration
20% of all UTI,
50% of recurrent or associated with catheter
have prostate involvement
90% of men with febrile UTI
Nitrofurantoin and Side effects
•
•
•
•
•
•
Long term use  pulmonary fibrosis
Long term use  peripheral neuropathy
Long term use  hepatic toxicity
Renal damage  increased toxicity
G6PD Hemolytic Anemia
Lack of prostate penetration potential
clinical failure
• Lack of Vaginal penetration in elderly 
Relapse/Reinfections?
BEERS Criteria 2012
• Avoid for long-term suppression
• Avoid in patients with CrCl <60ml/min
BEERS Criteria 2015
• Avoid for long-term suppression
• Avoid in patients with CrCl <30 ml/min
• Quality of Evidence Low, Strength of Rec Strong
Nitrofurantoin in Kidney function
including males
• 600 bed long Island N.Y. Hospital
• Retrospective study
30 years of using across age / gender / GFR
Only one case of Autoimmune hemolytic
anemia.
Used >30 CrCl as cutoff
Cunha et al Journal of Chemotherapy 2014
Proposed Implementation and
Monitoring
•
•
•
•
To start at Three sites
Awaiting final layers of approval
Developing training tools / Video
Attempting to marshal resources for
quality tracking
GUIDELINES FOR
IMPLEMENTATION
• A 30 minute instructional video followed by a 10 minute
online quiz will be provided to nursing staff with a single
use personal web token.
• The nurse shall be provided the opportunity to retake the
quiz a total of three times in a one month period.
• When passed, the online quiz with email confirmation of
passing to the immediate supervisor and a copy of this
confirmation shall be printed and placed in the RN’s file.
• The video and quiz shall be retaken at least yearly.
Monitoring the Process
1. Percent of eligible residents enrolled at a facility.
2. Percent of RNs certified in medical directive at a facility.
3. Percent of urine specimens collected outside of medical
directive.
4. Frequency of Appendix A (Worksheet) successfully
completed by RN
5. Frequency of MD / NP using appropriate antibiotic(s).
6. Frequency of continuation orders for nurse initiated
antibiotic.
7. Frequency of requiring a 2nd or 3rd antibiotic per UTI
event.
8. Frequency of repeat UTI per resident per time period.
Monitoring Outcomes
1. Frequency of urine specimen collection from
facility per defined time period and by type of
urine collection.
2. Percent positivity of urine culture vs. mixed
growth vs. negative per defined time period
3. Frequency of ER transfer / hospital admission
4. Frequency of bacteremia
5. Frequency of UTI associated mortality
6. Change in urine culture antibiotic resistance per
time period
7. Stakeholder satisfaction
Fools gold vs. Really gold
In the Micro Lab
Improved microbiology
• When LTC checked
Treated as a careful urine
Glass Slide prepared in case
Gram stain for pyuria needed
Early reporting by fax/printer of
preliminary info
East side of Island: Moving
towards having urine specimens
plated at Kings County Memorial
and shipped the next morning
Recap
• Cdiff and XDROs are likely linked and
target our Seniors disproportionately
• Poor urine specimens lead to poor care
In and out catheter specimens preferred
Bed pans are dangerous
• Short term Nitrofurantoin is safe again
a good therapy for a RN to start via directive
• Our snowiest winter brought forth our
warmest interdisciplinary partnership.
What percentage of antibiotic
prescriptions are outside of acute
care hospitals?
A. 85%
B. 66%
C. 50%
D. 33%
E. 15%
#urinematters
Feb 10, 2015
120 Strong and
brave Islanders
• #coughmatters
Which Monster will really get us
• Sepsis 9,300 Canadians die a year (CIHI)
(~37 Islanders)
• 350 True Influenza Deaths per year (PHAC)
(~2-5 Islanders) 9! in 2015
• Cdiff 29,000 deaths in USA (2011)
~2900 in Canada, ~2 a year on the Island
Influenza
How you will not get the flu
1. Don’t touch your face or eyes
2. Get the flu shot for you and the family
3. See a doctor/NP quickly with a high fever
and you are at risk of severe flu
4. “Avoid sticky situations”
5. Be a role model for hygiene and etiquette
6. Protect your hands
7.
8.
9.
10.
http://www.travelmath.com/feature/airline-hygiene-exposed
Treatment Guidelines
In the clinic
•
•
•
•
•
•
•
Asthma / COPD
CHF / unstable Angina
Malignancy / Pregnancy / Obesity
Diabetes / CRF
>age 65, Chronic care facility
< 48 hours Start
>48 hours Offer / Consider (if Adult)
• During Flu Season ADD Oseltamivir (not
currently on PEI Pharmacare Formulary) 75mg
PO BID x 5 days for patients presenting within
48 hours of symptom onset AND
• Any of age ≥ 65,
• Obesity (BMI≥40),
• Diabetes Mellitus,
• Asthma or COPD,
• CHF or unstable Angina,
• Malignancy,
• Chronic Renal Insufficiency,
• Pregnancy including up to 4 weeks post-partum,
• Immune suppression (HIV, iatrogenic due to
medication, hyposplenism).
In the ER
Treat even if after 48 hours
• Progressive Disease
Chest pain
Poor oxygenation (Tachypnea, hypoxia,
laboured breathing
Confusion / delirium
Severe dehydration
Exacerbation of chronic disease (↑Cr ↑BS)
In the ICU
Progressive or complicated Disease
Treat all (5-10d)
•
•
•
•
•
Hypoxia, abnormal Xray, Ventilation
Severe CNS disease
Severe Sepsis
Myocarditis or Rhabdomyolysis
Secondary Bacterial infection (Persistent
high fever beyond 3 days)
• *Consider Zanamivir inhaled / IV
Uncommon Oseltamivir
Side effects
•
•
•
•
•
•
Nausea (4 to 10%)
Vomiting (2% to 15%)
Diarrhea (1 to 3%)
Epistaxis (1%)
Wheezing
Oseltamivir resistance
• When and How does influenza get it’s
name?
Italy: 1300’s A.D.
Astrological Influences
Influenza: Italian form of Latin influentia, "epidemic", originally used because
epidemics were thought to be due to astrological or other occult "influences".
–ICTVdB (2002)
Role Modeling
• Either positive or negative…
• Perception of being a role model positively
contributes to culture of approachability…
Somebody is Watching You!
Healthcare workers in
room with a senior staff
person or peer who did
not wash hands were
significantly less likely to
wash their own hands
80% less likely; p<0.001
Lankford EID 2003
Influence of Mentor Hand Hygiene
Practices on Student Practices
Snow AJIC 2006
• If the mentor attempted HH, the student was 70% more likely to
attempt HH
• Mentor’s HH practice was strongest predictor of student’s HH rate
Nursing Data IJNS 2013 A. Huis et al.
• Cluster randomized controlled trial in 67
nursing wards of three hospitals in the
Netherlands
• State of the Art Strategy vs.
• State of the Art Strategy + “Social
influence and Leadership”
State of the Art Strategy
• Education: Leaflet, website with quiz and
reward for partcipation, practical
demonstrations
• Reminders: Posters changed every 3
months, newletters, emails to opinion
leaders/ manager
• Feedback: Bar charts
State of the Art Strategy + enhanced
Team work and Role modeling
• Setting Norms and Targets
Three 60-90min ward sessions with goal
setting lead by manager and external coach
Analysis of barriers to determine how best to
adapt
Nurses address each other in case of
undesirable hand hygiene
• Commitment from manager
• Modeling by informal leaders
Demonstrate, model, instruct and stimulate
Results
Group
Baseline
Post Intervention
Followup
State of the art
(37 wards)
23%
42%
46%
Team / role model
(30 wards)
20%
53%
53%
64% relative improvement with team/role model
P<0.001
Preserve Hand Integrity
DO / TRY
DON’T USE / AVOID
Use your own moisturizer before leaving
house, consider long acting like Aveeno
washing with soap and water and then
use alcohol based hand rub just after .
Wear Gloves/Mitts to protect from winter
large bottle of moisturizer
Use facility provided moisturizer at start
of shift and PRN.
refill non-facility dispensers or personal
supply containers.
Seek occupational health / medical
assistance if pain, itchiness, or oozing
occurs.
a barrier cream unless coordinated by
occupational health.
Trust that Alcohol based hand rub is less
drying for your hands than soap and
water
jar or putty moisturizers (see below)
Influenza testing on PEI
•
•
•
•
MWF PCR testing except holidays
Stat or at least next AM testing available
Viral respiratory panel (off Island) limited
Nasopharyngeal swab for 13 and older
Youtube TFwSefezIHU for instructions
Physicians should aim to do in office
 Use N95 when you have them and fit tested
 JAMA 2009 302; 1865-71 Hamilton RCT no difference
Patients on Oxygen will receive combined NP
and throat swab in the same sample by RT
• Nasopharyngeal aspirate for ≤12
Take home messages
• Seniors are at greatest risk of infections
• Improving UTI management likely to make
a big difference
• #UrineMatters and #CoughMatters
• I believe you will not get the Flu
• Role modeling and team work critical for
above
Acknowledgements and Gratitude
Long Term Care UTI
Management Team
•
•
•
•
•
•
Shelley Woods (LTC CNO)
Shelley MacCallum
Kelly Blanchard
Pam Handrahan
Kim MacPhee
Jennifer Boswell (Antibiotic
Stewardship Pharm)
• Dr. German (Micro-Inf.
Diseases),
• Drs. Grimes, & MacLeod
(House Physicans)
Committees Involved:
• PICPAC
 Brenda Worth, Chair
 Dr. Heather Morrison
• PD&T
 Including Antibiotic
subcommittee
• Matters Events
 Lisa Pyke, CADTH
• Microbiology Labs
 Becky Moore & team
 Andrea Dowling & team
I want a safe, resilient, and sustainable health system for our family
One by one
Sepsis
• TIME is GOLDEN; every hour delay for septic
shock survival decreases by 7.5%1
Only ½ of hospitals make it to 6 hours or less
• For Severe Sepsis we miss the antibiotic boat
~40% of the time2
• Severe Sepsis mortality of ~40% in the ICU3
• Incidence of Severe Sepsis 40/100K/Year
• Non-Severe Sepsis ~60/100K/Year
1Kumar
et al. CCM 2006 34: 1589
2Mikkelsen et al. Chest 2010 138: 551-558
3CIHI
Sepsis What you can do
• Stage Better and faster
• Culture Better and faster
Page micro tech to gram and culture after 3-4 pm.
Early rough susceptibilities for day 1 blood cultures
• Source Control faster < 12 hours
• Profuse, oxygenate, and monitor lactate
• Start antibiotics Bigger, Smarter and faster
Loading doses for Vanco 25 mg/kg (Only 50% do)
Empiric sepsis guidelines www.healthpei.ca/micro
PCH-Bacteriology Laboratory on
Call with early results
•
•
•
•
Between 4pm and 3am
Any positive blood culture from ICU or Neonates
Any two positive blood bottles from a patient
Set up of direct “from the bottle” susceptibilities
and screening for MRSA
These are not reported but are known to the
laboratory / Medical Microbiologist
• Urine STAT Gram stain and Evening Setup
Septic patients with indwelling Foley catheter culture
ICU when requested
Start of antibiotics at QEH and PCH
• Using the computerized Sepsis Power
Plan at QEH 4 patients investigated 2 of 4
not given within an hour, and one given at
5 hours after order
• PCH Audit of 6 cases coded as Sepsis in
discharge diagnosis
No significant delay to antibiotics
Calling a code
•
•
•
•
•
•
A defined process
Multi-disciplinary
Clear communication
Specific Entry Criteria
Time sensitive
Quality focused
Code Sepsis
Code Sepsis
• A misc stat medication ordered by the
physician. NO OVERHEAD PAGE
• On its own or in conjuction with the Sepsis
Management PowerPlan
• Multidisciplinary response
Who does what when
• Top of the list of Tasks Nursing to Give,
clarify that all antibiotics are to be given STAT
• Pharmacy Confirms availability of ordered
antibiotics
• Emphasis on fluids > cultures > drug in <1hr
• Trackable as Code Sepsis stops at the start
of First Antibiotic
• Can also involve antibiotic stewardship and
laboratory in the future.
Code Sepsis
A new STAT medication called
• Code Sepsis: initiation of IV bolus,
culture(s) and antibiotics must be
performed in sequence and STAT in
first hour of diagnosis".
• Automatically activated with Sepsis
Management PowerPlan
Not specifically addressed in these
sepsis guidelines
Follow up
• Discontinuation of sepsis power plans for
Old skin and soft tissue
Community Acquired Pneumonia
• Reassessment after
6 months for Code sepssi
2 years for Sepsis antibiotics
Which Monster will really get us
• Sepsis 9,300 Canadians die a year (CIHI)
(~37 Islanders)
• 350 True Influenza Deaths per year (PHAC)
(~2-5 Islanders)
• 0 Ebola deaths in Canada
Nigeria 687US$/person, 167 M, Lagos 12-21M
20 Cases and 8 deaths and outbreak halted
October 10th……….Was this just luck???
Who is the real monster
anyway?
Acknowledgements:
• Trent Ferrish, Jennifer Boswell, and Wendy Cooke
• Provincial Drug and Therapeutics Committee
Iain Smith and Dr. Patrick Bergin Co-chairs
• Physician reviewers for Sepsis:
•
•
•
•
Dr. Lenley Adams
Dr. Patrick Bergin
Dr. Michael Irvine
Dr. Paul Seviour
Dr. Philip Champion (febrile neutropenia)
Dr. Barry Fleming (intra-abdominal)
Dr. Dan Smyth infectious disease Moncton City Hosp.
Julie Cole QEH Librarian
Vanessa Arseneau Micro-Antibiotic Susceptibility Tech 2
Becky Moore PCH-Microbiology lab supervisor