Category Archives: infection control

Con(fused)tact precautions

Whilst “festivus”1 is generally a happy time for most of us, unfortunately people still become unwell, and our hospital beds remain occupied. One of the beds in a large Australian acute care facility has accommodated a family friend who has undergone surgery and some moderate rehab after falling at home.

Given some predisposing conditions, the family friend was at risk of acquiring a HAI, and it is disappointing to report they required treatment for various types of HAIs. They were also found to have VRE, and were promptly placed into a single room, under Contact Precautions.

Puzzled Confused Lost Signpost Showing Puzzling Problem

Whilst this family has much to be sorry and concerned about, what concerns them greatly, and what they have found most upsetting, is the inconsistent information and advice they receive on a daily basis from healthcare workers on the specific precautions that they, as family visitors, must take. Gloves, no gloves, mask, no mask, cloth gown, plastic apron… they have had almost every combination of precautions recommended. They  have even been scolded by a HCW for wearing “inappropriate” attire, whilst all the time directly observing a broad array of PPE adopted by different HCWs as they enter the room. They feel confused, angry, and upset. They lack confidence in the HCW knowledge of what is required, and feel powerless in seeking clarification of what they should be doing.

I find this troubling on several fronts. First, inconsistency. If HCWs caring for patients with MROs are giving family visitors different messages on PPE, then chances are they don’t quite understand what is required to prevent spread (evident by HCW inconsistency in their own PPE). Second, why are family visitors made to feel as though they have endangered the lives of not only their relative, but also of every other patient in the hospital when they are simply doing as they are told. And third, I don’t suspect for one minute that this situation is unique to this ward, hospital, city, or country. This scenario will likely be repeated daily in all types of facilities (see also NOTE below).

As we know, HAI prevention requires multiple interventions all being applied correctly. Whilst the momentum of antimicrobial stewardship in the fight against AMR has rightly attracted much energy, and the importance of environment is emerging , a basic understanding of precautions, and consistency of PPE messaging for HCWS and visitors is surely a simple and measureable intervention we should not lose sight of.

Phil

  1. Seinfeld 1997 – Episode 10, Season 9.

NOTE – this may be due to a lack of robust evidence and debate about Contact Precautions (see here for an example), nevertheless, messages (policy) within a facility should surely be consistent.

 

Infection, prevention & control and Aboriginal and Torres Strait Islander People.

The Snake, the Staff and the Rainbow Serpent : A Call to ‘Fill the Gap’ in research relating to infection, prevention and control and Aboriginal and Torres Strait Islander People.

(Written by Victoria Gregory)1

 

Aboriginal and Torres Strait Islander people are the oldest surviving culture in the world, yet they will live approximately 10 years less than other Australians. Some contributing factors include indigenous people are at higher risk for emerging infectious diseases compared to other populations (Butler et al 2001). Examples of infectious diseases include respiratory tract infections, infections with antimicrobial-resistant organisms, and bacteremia and meningitis caused by Streptococcus pneumoniae, zoonotic diseases, viral hepatitis, Helicobacter pylori and respiratory syncytial virus infections, diseases caused by Group A and B streptococcus, tuberculosis, Haemophilus influenzae type b, and Neisseria meningitides (Butler et al 2001).

Here are some specific examples:

  • According to data from ‘healthinfonet’ between 2009 and 2013 tuberculosis notifications were 11 times higher for Indigenous people than for Australian born non-Indigenous people.
  • In 2014-15, Aboriginal and Torres Strait Islander people were three times more likely that non-indigenous people to be admitted to hospital for influenza and pneumonia.
  • In 2014, there were 170 cases of invasive meningococcal disease notified in Australia with 21 cases (12%) identified as Aboriginal; an increase from 2013 where 13 cases (8.7%) were identified as Aboriginal and one identified as Torres Strait Islander (0.7%).
  • In 2015, hepatitis C notifications were five times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people and the rate of HIV diagnosis was just over twice as high for Aboriginal and Torres Strait Islander people than non-Indigenous people. Notification rates for gonorrhoea were also 10 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. For syphilis, notification rates were six times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people. For chlamydia, notification rates were three times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people.
  • Skin infections are also common in Aboriginal and Torres strait Islander Communities (The Lowitja Institute).

These data paint a real and bleak picture, but there are many success stories, including:

  • An initiative by Australians for Native Title and Reconciliation group in 2007 which reported on successful Aboriginal and Torres Strait Islander health projects, such as:
    • ‘Tune into your health: Nunkawarrin Yunti Aboriginal Health Service’ where young people developed lyrics and songs about health issues affecting their community, a song called ‘It’s in your blood’ increased knowledge and awareness of Hepatitis C.
    • ‘Keeping safe with a snake: Marie Stropes International Australia’ an initiative raising awareness of sexual health.
    • ‘Mooditj: Sexual health and positive life skills’ an initiative by the Family Planning Association of Western Australia.
    • Healthworkforce Project and the Shalom Gamarada Ngiyani Yana Residential Scholarship program which has increased the numbers of Aboriginal and Torres Strait Islander students studying medicine and health at UNSW.
  • The implementation of the nationally funded Hib disease vaccination in 1993 which resulted in decrease of notifications of invasive Hib disease by more than 95%.
  • The painting above, ‘Healthcare in the Western Desert’ was created as part of an innovative project building mutual trust and respect involving Aboriginal artists from the Wankatjunka, Kakutja and Walpirri language groups and second year medical students from the University of Notre Dame during the students’ Remote Area Health Placement in the Kimberly. It highlights the 3 ‘snake and staff’ images representing the medical profession as well as symbols depicting women and children from the local communities and coloured squares representing the medical clinics and a number of circular jila (waterholes). The act of painting together transcended cultural differences and led to an evolution of knowledge and understanding for all participants.

Indigenous communities are at high risk for many infectious diseases, but there is limited research specifically relating to Indigenous health in relation to infection, prevention and control in Australia. Culturally appropriate research and ‘bottom-up’ prevention and control strategies, as well as long term commitment to their implementation is urgently required. It is our responsibility to mainstream Aboriginal and Torres Strait Islander equality in all the valuable work that we do in the infection, prevention and control sphere. This blog is a reminder of the alarming statistics around infections and a call to work on closing the gap in health outcomes in Australia.

This blog was written by Victoria Gregory.

References

  1. Australians for Native Title and Reconciliation. antar.org.au
  2. Closing the Gap Prime Minister’s Report 2017. Closing the gap.pmc.gov.au
  3. Australian Indigenous HealthInfonet.http://healthinfonet.ecu.edu.au/ Retrieved 29.11.17
  4.  Butler, J. C., Crengle, S., Cheek, J. E., Leach, A. J., Lennon, D., O’Brien, K. L., & Santosham, M. (2001). Emerging infectious diseases among indigenous peoples. Emerging infectious diseases, 7(3 Suppl), 554.
  5. The Lowitja Institute. http://www.crcah.org.au/search/site/infection
  6. The University of Notre Dame, Australia. http://www.nd.edu.au/news/media-releases/2017/077

 

 

 

Some take aways from #ACIPC17 Conference, Canberra

Congratulations to the organisers of ACIPC Conference 2017 Parliament_House_Canberra_Dusk_Panoramain Canberra. Well done to the Conference Committee and the Scientific Committee. A great program and venue adding to the always enjoyable catch up with colleagues local, national and international.

There were many highlights. Due to other commitments, I missed a few of the major plenaries. Nevertheless, I came away with some clear take home messages from those I did get to, here are just a few of them…

  1. An emerging theme from the presentations was that of public reporting and financial penalties (PR&FP) associated with healthcare associated infections (HAIs). The likelihood that Australia needs to accept that these are inevitable for a range of HAIs is clear. In case you missed it, Benjamin Magid presented an excellent talk touching on the Australian Commission for Safety and Quality in Health Care use of what are called Hospital Acquired Complications, that use administrative coding data to detect healthcare associated infections, and which I have blogged about previously.
    One of the many advantages of living and working in Australia and hosting keynotes from the US is that they often provide a window to the future. At various stages, Prof Pat Stone, A/Prof Dev Anderson and Dr Susan Huang all related stories about their experience of PR&FP. From their experience it would seem, at some point in time, the implementation of PR&FPs does eventually turn into a positive for infection prevention (and hence our patients). From what we hear, PR&FPs seem to result in a recognition of infection prevention that subsequently provide opportunities to increase resources. Thats not to say there was no pain during the “journey”, and we should be prepared for that. Although Dev Anderson did argue against the notion of PR&FPs in the final debate, he was quick to tweet afterwards that in fact he does support it! Finally on this point, we should continue to explore better use of existing data if validated, strive to minimise the burden of data collection, and consider whether current HAI definitions are suitable for the PR&FP environment.
  2. The quality of the free papers gets better every year. The addition of the quick poster presentations and the new format of the 3 minute research presentations was a celebration of the excellent research being undertaken in our field. Updates on current studies (e.g. the large and complex REACH project) further added to our awareness of exciting work being undertaken by our colleagues. The next few years will see many of these projects yield new knowledge and fill sessions of conferences to come!
  3. The consumer voice is powerful. The presentation delivered by Mathew Ames left many in the auditorium not only in tears, but also resolute about the work we undertake.
  4. Finally for now, I believe the pop up sessions during lunch were a big winner. Informal yet intimate, a great way to get close to those people who are always hard to find at conferences. A great initiative hopefully here to stay..

But thats just some of my impressions from the sessions I saw. You might have seen something completely different. If so, comment below and let us know…

Looking forward to Brisbane in 2018.

TIP: Next year, if you have trouble remembering the correct Twitter hashtag, think  character count efficiency...save the character count by dropping the “20” from “2018”

#ACIPC18

 

Phil
Disclosure – ACIPC Board member (President Elect) and member of the ACIPC Conference Scientific Committee 2017

The Cerberus of science – dealing with ethics committees

We asked a colleage, Hannah Rosebrock, to write a blog for us, thank you Hannah.

In Greek mythology, Cerberus guards the gate of the underworld to prevent the dead from leaving. In social and clinical science, this role is fulfilled by ethics committees who stand as guardian between researchers and Cerberusparticipants and prevent the latter to be exploited by the former for the sake of science. The role of the Cerberus is a necessary one – although not very flattering, Cerberus is depicted as a three-headed beast. In the context of ethics committees, its three heads are called bureaucracy, officialdom and inefficiency.

According to the National Health and Medical Research Council (NHMRC) there are more than 200 HRECs operating in organisations and institutions throughout Australia (find a list of human Research Ethics Committees registered with NHMRC here). Although all HRECs base their decisions on the same principles deprived from the same National Statement on Ethical Conduct in Human Research, every HREC has its own application procedures, forms and processes. Further, gaining approval from one ethics committee is no vouch for approval from another ethics committee.

This lack of standardisation specifically affects multi-site projects which led to the founding of the National Mutual Acceptance Scheme (NMA) in 2013. Under the NMA scheme, multi-site research projects do not have to gain ethics approval from every site the project is conducted at but only once, from a NMA certified HREC. As of August 2017 the scope of the NMA scheme covers all human research conducted at a public health organisation in Queensland, New South Wales, the Australian Capital Territory, Victoria, South Australia, and – the latest addition to the scheme – Western Australia. Note: Northern Territory, Tasmania, and private health organisations are not included in the NMA scheme. Still, you might be tempted to think, that the NMA scheme has de-bureaucratised the ethics application process, and to some extent, this is true. There is certainly less duplication (if you don’t count private health organisations, Northern Territory and Tasmania). However, researchers are still fighting with a lack of standardisation, as every state has multiple NMA certified HRECs[1] and application procedures vary between and within states. This multitude in ethics committees, applications processes and forms, seems unnecessarily confusing, given that they are all assessed and certified by the same body (the NHMRC) for their compliance with the same criteria based on the same National Statement of Responsible Conduct in Human Research.

Independent of the HREC approval, researchers have to seek approval from the relevant Research Governance office (RGO) for each site the project is conducted at. There is no such thing as a mutual acceptance scheme for research governance approval, every site has its own assessing criteria for determining the site’s suitability for conducting a given research project. This adds to the generally labour-some and tedious process of gaining ethics approval.  In terms, this uses resources, and most commonly tax payer funded resources. In one Australian study, the cost of obtaining ethics and relevant approvals was $348,000 or 38% of study budget.

Applications for HREC approval are often no less than 63 pages; applications for Research Governance approval encompass about 23 pages – exclusive the extensive supporting documentation required, which can be up to another 150+ pages. Applications to both, HREC and RGO’s vary, with some still requiring submission in hardcopy by snail-mail, (additionally to email, USB and online forms) and will only be assessed, once received in hardcopy. This method is unnecessarily prone to error. To simplify, you must take steps away, rather than adding additional steps. The entire process is so focussed on detail that researchers, as well as assessing HREC and RGO officials can’t see the wood for the trees anymore. So much information is requested that even low-risk research projects that involve none to minimal involvement with participants, and thus hardly justify the use of the term ‘participants’, seem to turn into a second Stanford prison experiment throughout the process.

 

[1] Queensland has 7 NMA certified HRECs, New South Wales has 11, Victoria has 7, South Australia has 5 and Western Australia has 3 (Australian Capital Territory has 1). Find a full list here.

Outside the box: Infection prevention beyond the hospital walls

The recent article published in the MJA by Agostino and colleagues from the Hunter New England area provided data that could be described as not so startling, but nevertheless alarming. Their study aimed to identify groups at risk of MRSA infection, as well as the proportion of patients with MRSA but no history of recent hospitalisation (previous 12 months).

In their large cohort, they found that “young people, Indigenous Australians, and residents of aged care facilities, are disproportionally affected by CA-MRSA infections”.

Two comments in their Discussion caught my eye. The authors call for:

  • the focus of control measures to move from the healthcare setting to the community
  • national surveillance of MRSAphotodune-598972-think-outside-the-box-xl

The results of this study are not so startling because the findings are consistent with previous studies, alarming because this is another piece of evidence highlighting the deficits of our local knowledge.

This brings me to my next point. I am excited to be part of a team conducting a large study exploring infection prevention in Australian residential and aged care facilities. Led by Prof Brett Mitchell, together with Prof Ramon Shaban and Dr Deborough MacBeth, we aim to mimic a recent program of work  that generated so much rich information about infection prevention in our hospital facilities. Here are links to a sample of some of papers from this work:

This cross sectional study aims to explore governance, education, practice, surveillance and competency and capability – five key domains relating to infection prevention and control. All aged care homes in Australia are in the process of being contacted.

The findings of this study will be significant, they will:

  • further support ACIPC to refine the role and scope of practice of ICPs and better target education strategies,
  • inform decision-makers faced with accessing and planning infection control resources in settings outside hospitals.
  • guide future research priorities in this area
  • understand priorities and gaps in infection control services

If you receive an invitation to participate, I strongly encourage you to do so.

We look forward to sharing our findings with you during 2018.

Phil

The burden of HAIs in Australia

Today, we published an article in Infection, Disease and Health estimating the number of HAIs occuring in Australia each year. [1]

To do this, we undertook a systematic review of the peer reviewed literature between 2010 and 2016. We identified 24 articles that reported the incidence of HAIs in Australian hospitals.

Overall, data from these multi centred studies suggested 83,000 HAIs per year in Australia. UTIs are were the most common, followed by C.difficile, SSIs, respiratory infections and Staphylococcus aureus bacteraemia. HAI burden.png

Of course, these numbers are a very  large underestimate given the lack of or incomplete data on common infections. It is also limited to data published in the peer reviewed literature.

Incidence data on infections such as pneumonia, gastroenterological and bloodstream infections (other than SAB) were not identified, thus potentially
missing up to 50% of infections. That being the case, the

PPS blog incidence of HAIs in Australia may be closer to 165,000 per year.

Don’t believe me? Have a look at the results of point prevelance studies in Europe (right). Respiratory tract infections, bloodstream infections and others account for a large proportion of HAIs.  Of course, Australia has not had a PPS undertaken in 30 years, so we don’t really know. However, for readers of this blog, you will know that will soon change.

A figure of 200,000 HAIs per year in Australia is commonly cited, however, this figure was derived from one study undertaken several years ago (a sign of what was available at the time). Our study, may, in part, demonstrate the increasing number of publications on HAIs in Australia. We are certainly not suggesting a reduction in HAIs and any such claim based on the findings of our study should be immediately dismissed.

There are some other equally important findings from our study:

  • There needs to be a determination and action by state and national government bodies to achieve consensus on national HAI definitions
  • We need national approaches to HAI surveillance and transparent regular reporting. Australia is so far behind other countries in this regard [2] [3]
  • In the absence of action by government, we call on those undertaking HAI surveillance (especially incidence) to report your data in the peer reviewed literature

We also found there is little information about healthcare associated respiratory infections, such as pneumonia. Maybe it is in the too hard basket (nice blog by Martin Keirnan which says it all). Well, I think we should do something about healthcare associated pneumonia – at the very least, understand the incidence and risk factors a little better. I am working on it…..

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Footnote: Some of the research I have been involved with has been supported by donations from the public. For that, I am very grateful. Should you or your company wish to make a tax deductible donation, you can do so here.

References

  1. Mitchell, BG., Shaban, R., MacBeth, D., Wood, CJ., Russo, PL (2017). The burden of healthcare-associated infection in Australian hospitals: A systematic review of the literature. Infection Disease and Health. https://doi.org/10.1016/j.idh.2017.07.001
  2. Russo, P. L., Cheng, A. C., Richards, M., Graves, N., & Hall, L. (2015). Healthcare-associated infections in Australia: time for national surveillance. Australian Health Review, 39(1), 37-43.
  3. Russo PL, Cheng AC, Mitchell BM, & L, H. (2017). Healthcare associated infections in Australia – Tackling the “known unknowns”! Australian Health Review, (published online 7 March 2017), http://dx.doi.org/10.1071/AH16223

 

Australian HAI Point Prevalence Study is Coming

Followers of this blog will know how passionate Phil Russo and Brett Mitchell are about the need for national surveillance and a point prevalence study (PPS). Map Aus2We are very pleased to let you know that a HAI PPS is coming, by way of a research project.

For more information, please see www.ipcca.com.au/pps