#SHEA2017 & Behaviour Change (bundle?)

change_ahead

Clearly the current toolkit for the ICP extends well beyond knowledge of infection prevention and control. Amongst others throw in a dose of psychology, implementation science and behaviour change.

Matthew Kreuter is a leading national public health expert in the field of health communications at Washington University in St Louis, and at the SHEA Spring Conference presented a plenary titled May the Forces be with You: Understanding How to Change Behaviour. Krueter packed in a lot of useful information in his presentation. Much of what he said I believe really underlined the importance of a comprehensive implementation strategy.

There is no substitute for taking time to understand the people you are dealing with and the environment they work in. One of the biggest challenges in behaviour change and infection prevention is we don’t always see the consequences of our action (the missed hand hygiene > unclean hand > contaminated environment > patient colonisation > breach of first line defences > infection), and not every bad action will necessarily result in an adverse outcome. Furthermore, HCW’s may suffer from a curse of “smartness”,  i.e. “I know my patients best” which can lead to rejection of guidelines.

Some of the key messages I took away from this talk include:

  • The easiest behaviours to change are the simple ones that have clear and immediate benefits “to me”
  • When planning behaviour change, focus on identifying meaningful benefits and personalise the consequences. The consequences need to be relevant
  • Utilise authentic stories of the consequences. Sadly we have no end of patients who have suffered as a result of a HAI, consider involving them and their stories
  • Other factors that work include credible messengers (peers, champions) performance feedback and aspirational identity

Kreuter concluded by listing 4 factors that work MORE:

  1. Policies
  2. Environment
  3. Organisational Culture
  4. Engineering and Design, or
  5. a combination of these

note he didn’t use the term “Bundle”!

 

Phil

#SHEA2017 Spring Conference and the International Ambassador Program

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Some of the SHEA IAP’s at the Arch in St Louis, Mo

I was recently honoured to be a member of the Society for Healthcare Epidemiology of America (SHEA) International Ambassador Program (IAP) at the SHEA Spring Conference in St Louis, Missouri.

If you don’t know about the SHEA IAP, I strongly encourage you to find out more about it here. It provided me the opportunity to meet 17 other ambassadors from across the globe, attend a special pre-conference program that included a visit to Barnes-Jewish Hospital, (saw my first ever fully automated microbiology lab) attend the SHEA Foundation dinner (where we were privileged to be present for a special dedication to Denis Maki), and of course attend the SHEA Spring Conference.

SHEA combine a full conference with a Training Certificate Course in Healthcare Epidemiology which is available to conference delegates. This was quite handy as I was able to junto into a few Epi sessions to brush up on a few skills.

There were many learnings and observations from my time in St. Louis, and I will get my thoughts in order and post them on this blog over the next week or so.

Phil

Declaration: The SHEA IAP is also supported financially by 3M, and I’d like to express my gratitude to both SHEA and 3M for their support.

 

Would you like some antibiotics?

This is part two of my blog from Cambodia. The first part is here What can $6m buy you

I have spend some time at Angkor Hospital for Children and have been amazed. Amazed at the challenges faced and amazed at the quality of infection control given the limited resources. The IC program consists of continous prospective surveillance of all HAIs, hand hygiene, feedback of infection data, environmental cleaning (twice a day), cleaning audits, training, good governance and the list goes on.  Hand hygiene compliance is above 80%, but not all moments have been introduced yet (1000+ moments a month observed). IMG_2308

The fact that a hospital here can undertake continous surveillance of all HAIs is quite amazing. They asked if I could benchmark them against some Australian hospitals/what the rates are in Australia. And there we ended back to where this blog always seems to – a lack of co-ordinated, meaningful HAI surveillance at the national level in Australia.  But enought of that, see Phil’s blog for the pub test.

Not all is of course perfect, but given the resources, I think it is quite extrordinary. Another difficultly (apart from ovecrowding, lack of resources, limited clean water etc etc) is a some local work suggesting 60+% of patients coming into the hospital are colonised with a MRGN, mainly resistant in some form. That got us talking a lot about strategies and future work, but I also have myself an challenge….

This test invovled me trotting up to a local pharmacy. It went like this “My wife has a cut on her arm, it is inflammed/red”. That is pretty much it. The response:

  • Pharmacy 1 – topical cream that consistent of gentamicin, erythromycin and clotrimazole, all combined in one convenient tube. I asked about oral amoxicillin and was told “antibiotics you swallow are only for infections on the inside, the don’t work anywere else”.
  • Pharmacy 2 – Ciprofloxacin was handed to me.

Dishartened, I changed my tack. I went to another pharmacy and said “My wife has a cough and fever”. They asked if it was a dry cough. I said no, productive sputum. I was handed paracetamol. Yeah! There is hope.

This blog, I hope, illustrates the challenges  in infection control (&AMR) in a resource deprived country. We need to support our colleagues in our region, in any way we can. OneHealth is a global issue.

(By the way, I did not purchase any of the antibiotics, so as not to contribute to the issue).

 

 

 

 

 

The Pub Test

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For many Australians there is a long held tradition of going to the pub at the end of the day/week to discuss life’s big questions (a practice not native to Australia I’m sure). Sadly, the pubs I frequented in my youth are now apartments (because we need more of those!) and like the live music they used to support, they are gradually disappearing from our urban landscape.

Anyhow, arising from the communal attempt to discuss worldly issues, comes the term “the pub test”.  Briefly, the pub test seeks to evaluate the views of “ordinary Australians” on certain issues. In my home state of Victoria, the recent application of the pub test has resulted in the downfall of several senior politicians who were accused of rorting their privileges by making extravagant travel claims. Though arguably they may not have breached any rules (stretching them perhaps). The media applied the pub test and the punters down at the pub believed the politician’s behaviour was unacceptable. In an impressive display of the power of the popular vote, these politicians have been stood down.

Now I’m not convinced of the rigour of the pub test, not the least I suspect the results may be influenced by the pubs location and the time of night you visited, but nevertheless it got me thinking, what if we applied the pub test to the state of infection prevention in Australia?

I wonder if these statements, reflecting some of our local infection prevention issues, would pass the pub test?

  • Some people get an infection as a result of their healthcare, but we’re not really sure how many Australians this happens to.
  • If you are infected with a ‘superbug’ in some hospitals, sometimes the staff that look after you will be wearing gowns, gloves and masks, and sometimes they wont.
  • If you are placed in a room that was previously occupied by a patient with a ‘superbug’ you are probably at a higher risk of being infected with that ‘superbug’ than if you are placed in another room.
  • Not all hospitals use the same criteria to identify an infection.
  • If you ask a hospital CEO which of the surgeons in their hospital has the highest infection rate, they probably wont tell you.

(I can think of many other examples to put to the pub test, and I invite you to share yours).

What would be the reaction of the ‘ordinary Australian’ to these statements? Would the power of the popular vote on these issues catch the eye of those in authority?

 

Declarations: I occasionally go to a pub – Phil

 

 

What can $6m buy you?

The ability to run a children’s hospital for a year of course.Image result for angkor childrens hospital

I am in Siem Reap (Cambodia) at present and spending some time at Angkor Children’s Hospital. The hospital run entirely on donations and is the only children’s hospital in Cambodia. All services provided free. I won’t bore you with some stats, but here are some impressive figures considering the budget:

  • 27,000 ED patients a year
  • 132,000 outpatient visits
  • 880 intensive care admissions a year
  • Average cost of an ER visit $7, ICU $820 a stay.

Cambodia is a very poor country with a neonatal mortality of 18 per 1000 live births. 32% of children under 5 are stunted, 24% are underweight. Just $500 will is enough to provide weekly lectures to nurses for year; $5000 enough to buy medication for all ICU patients for 6 weeks.Image result for angkor childrens hospital

The most common hospital diagnosis are respiratory infections, asthma, gastro and sepsis. Over the next few days, I am meeting the Cambodia Oxford Medical Research Unit team, spending some time looking at infection control issues and challenges and similarly with nursing education and development. On infection control, the issues are significant, Gram negative resistance is a real problem (more on that to come in another blog).

If you want to know more about Angkor Children’s hospital, try this Angkor Hospital Video

More to come on infection control successes and challenges.

Brett

(Note: Pictures were not taken by me, rather publicly available)

 

Making antimicrobial resistance and the control of communicable disease, like infection control, is really everyone’s business.

As I reflect on another year, there have been many headline issues in infection control and communicable diseases. One headline was arguably the brightest, loudest and most prominent—antimicrobial resistance. In many respects 2016 was the year for antimicrobial resistance (AMR). The march of resistance and the grave concerns therein, particularly with the spread of carbapenem-resistant Enterobacteriaceae or CRE, have focused the attention of many. Global recognition and focus came via the United Nations as well as multi-national whole of government emphasis of AMR as a priority in the United Kingdom, the United States and other countries around the world. The year also saw a much-needed corrective global focus and attention on access and excess rather than overuse and misuse. All made for interesting times for clinicians, patients and consumers, and society in general. It also makes for interesting times for what comes next. In considering the priorities for research and innovation, the following seem to me to be some of the important focal areas for the future:

One priority focal point should be the formal designation of the control of communicable diseases, the spread of infection and antimicrobial resistance as societal, political, health and research priorities within a One Health approach. As we have seen, the United Nations declared AMR as a global health priority, only forth health priority to be so declared. The WHO and its many divisions applied renewed focus of AMR around the world. The United States and United Kingdom has posited AMR squarely as a whole-of-government and whole of society issue. Others have followed suit in various forms. Doing so matters. Such declarations matter. They transact change. Such designations focus the efforts and attention turn of governments, NGO, researchers, funding bodies, industry, clinicians, educators and society more broadly. Some doubt the significant and weight of such declarations as declared health and/or research priorities. To those I say try de-designate an existing health or research priority that has unfinished business and see what happens. For example removing cancer from Australia’s list of national health and research priorities would never be entertained, and any attempt would attract unanimous condemnation. The new and impressive Australian Medical Research Future Fund and Australian Medical Research and Innovation Priorities 2016-2018 have AMR and the control of communicable diseases as core priorities. Such designation is commended, but more is needed. AMR should be a national designated national health priority, as it is one issue that underpins so many health areas. It also underpins the fabric of society.

Another focus should be the acceleration and expansion of infection-excluding diagnostics and technology. While technology and resources for rapid and definitive diagnosis is the ultimate goal, excluding infection attributable injury and disease that has a reliance on antibiotics would go a long way to reducing our use of antibiotics. 

Closely related to this is the need for intense and considered focus on new and renewed countermeasures. This should include, but is not limited to, One Health vaccine development for conditions that have reliance on antimicrobials, drug discovery, rapid definitive diagnostics at both bench and bedside, utility of non-classic pharmacological interventions such as bacteriophages, and the standardisation of laboratory testing.

Moreover, we should focus on extending the evidence and practice base that is we know works (or not as the case may be) in human health and non-health related context into animal, agricultural and environment sectors for a truly One Health approach. Is it not time equivalent of the Five Moments for Hand Hygiene for veterinarians?

Finally, and not before time, it’s time cast of the armoury of own specialist professions and embrace the many in non-clinical professions, and call upon them to join be part of the solution to AMR. It is high time we harnessed existing and new knowledge into human factors and behaviour modification to bring about whole of societal change within a One Health approach. This should focus on existing evidence base for non-infection control and non-health to effect changes in human factors for reliance on antibiotics for all populations across the lifespan and across One Health. So much is known about behaviour change in the non-health areas, as marketing and behavioural sciences. It is difficult to see how these cannot be applicable (or relevant in some form) to AMR. What we can learn from our non-clinical peers about changing people behaviours from the commercial work is enormous. Moreover, such focus must be across the spectrum of disease and illness including prevention, treatment, rehabilitation and coalescence.

AMR is not, and can no longer be considered, a problem for just for clinicians both human and veterinary, and industry to solve. It is a whole of society challenge, and many of the solutions are non-clinical. It, like infection control, is everyone’s business.

 

#ACIPC16 Melbourne (part II)

screen-shot-2016-12-12-at-20-47-20In case you weren’t aware, many of the slides presented at #ACIPC16 are now available for viewing on the conference website

A/Prof Deb Friedman (@friedmanndeb) from Barwon Health had the unenviable task of presenting the Top Infection Control papers of 2016. Always a tough ask depending on your interests…however Deb covered pretty much everything including:

  • —Hand hygiene
  • IC activities
  • Contact Precautions/ Infection transmission/ CPE screening
  • Decontamination/ M. chimaera
  • —HCW vaccination
  • —Acinetobacter, RSV spread by air
  • —Norovirus spread
  • —Antimicrobial stewardship
  • —Chlorhexidine bathing/ FMT for MDROs
  • —Ebola virus/ PPE doffing
  • —Zika virus inactivation

It was all presented within time and with a story line! Clearly I cant mention them all, so here’s a couple. Pelat et al (1) demonstrated through the use of modelling that improving HH compliance from 55% before patient contact and 60% after patient contact to 80% before and after patient contact, would reduce the proportion of patients who acquire ESBLs within 90 days by 91%, they also found that antibiotic restriction had the lowest impact. Testament to the quality of local research, another top pair quoted was Mitchell et al (2) that identified from a survey of 40 infection prevention units: 36% of IP time was spent doing surveillance: 56% collecting data, 27% collecting data on compliance with IC activities, 17% feedback of HAI data. Casanova et al (3) demonstrated contamination post doffing recommending effective hand  hygiene afterwards.

Professor Gill Harvey from the University of Adelaide presented a keynote talk on Moving from Evidence to Practice, highlighting that good research is not enough to guarantee its uptake in practice. To improve the chance of interventions being implemented we need to get better at understanding what is being implemented, who is involved in the intervention, the culture and characteristics of the environment it is to be implemeted, and how the intervention effects everybody.

Finally, I really enjoyed the session on Communication. Presentations from Dr Becky Freeman (@DrBFreeman) from The University of Sydney, on Social Media and Public Health  who added to Maslow Hierarchy of Needs with “WiFi” holding up the pyramid! Becky posed the question, how many screens do we have in the house? (in a household of 5 adults I just counted 12 and thats not including TV’s). Mr Paul McNamara (@meta4RN) from Cairns presented on all the delights of using Twitter for professional purposes, Ms Claire Hewitt (@ClaireyHewitt) from St.Vincents Private Melbourne presented on the benefits of blogging, with a reminder that blogging allows you to control your own message, and demonstrated the excellent blog at St.Vincents, even the CEO blogs! This excellent session finished with Mr Anthony Carr from NPS presenting Communication in Practice  demonstrating the many ways NPS uses media to communicate.

Thanks to all those mentioned above, enjoyed your work.

Phil

Declaration – I am a Director of ACIPC and a member of the ACIPC Conference Scientific Committee.

  1. Pelat C et al Infect Control Hosp Epidemiol 2016;37(3):272-80.
  2. Mitchell et al, Infection,Disease and Health 2016;21(1):36-40
  3. Casanova LM, Infect Control Hosp Epidemiol. 2016 Oct;37(10):1156-61