let’s work an outbreak … · together we are going to manage a published outbreak please share...
TRANSCRIPT
Let’s work an outbreak
Evonne Curran DNurs
Author: Outbreak Column JIP
Nurse Consultant Infection Control
@EvonneTCurran
6th November 11.30 -12.15
Together we are going to manage a
published outbreak
Please share insights as the outbreak
progresses!
Detection
PreventionSICPs;
What we do every day; Removing recognised
risks
PreparednessIts likely to happen;
Get ready – Practice;
Become able to detect;
This is what it looks like / to do...
ManagementStop transmission;
Investigate how / why & prevent recurrence
DetectionFrom clinical, lab, surveillance data, find outbreaks if present
Outbreak
Outbreak detection
• Goal: detect an outbreak if one is present
• Requirement: accurate situation awareness ASAP
• Situation awareness - 3 levels (Endsley, 1995 onwards)
1. Perception - what is present
2. Comprehension - so what
3. Prediction - what next
Decision-making follows SA
Good SA = Good decision-making
Outbreak Management
• Goal: Stop ongoing transmission find out why, how
& prevent recurrence
• Requirement: Accurate situation awareness
throughout
– As we get more data our SA changes
Outbreak management is a
team pursuit
Outbreak detection
Is it real?
Outbreak: real infections related in time and place
Unrelated cluster of real infections: (chance / surveillance / detection method change)
Related cluster of false infections: (lab error, contaminated kit, poor specimen taking)
No infection outbreak: (people acquired the organism in the setting but did not get sick)
The lab has phoned
“There is another Pseudomonas aeruginosa from blood in the Haematology unit;
that’s 16 so far this year.”
– Perception: what is happening?
– Comprehension: so what?
– Prediction: what will happen next?
Situation Awareness
• What is you / your team’s perception,
comprehension and prediction?
Perception: There is reported increase in the number
of pts with the same infection (BSI) with the same
species (Pa) in the same place
Comprehension: This is likely to be an outbreak
Prediction: If this is an outbreak...unless action is
taken more cases will arise!
John Snow
Contradiction:
If this was caused by bad air ‘miasma’
the lungs would be diseased.
The lungs are fine: the guts are rotten.
Insight: Whatever is causing this
disease, the the people are consuming
it...
Seeing what others don’t: the remarkable ways we
gain insights – Gary Kelin, Nicholas Brealey Publishing
Outbreak presentations
Single organism
Single organismMultiple infection
categories
Multiple organisms
GI: Norovirus or CDI
Resp: Legionella
BSI: Pseudomonas, or
S. aureus
SSI, SSTI
BSI, UTI,
Colonisation
SSI or BSI or SSTI
SSI, SSTI
BSI, UTI
Colonisation
Unknown organisms Similar symptoms
Single infection category
Single infection category
Multiple infection
categories
Outbreak possibilities here
Single organism
Single organismMultiple infection
categories
Multiple organisms
BSI: Pseudomonas
aeruginosa sp
SSI, SSTI
BSI, UTI,
Colonisation
BSI: Pseudomonas
aeruginosa spp
SSI, SSTI
BSI, UTI
Colonisation
Unknown organisms Similar symptoms
Single infection category
Single infection category
Multiple infection
categories
Exposure to X
Haematology patients
• Tend.....– Not to have had surgery (recently)
– Not to have wounds
– Not to have urinary catheters
– Not to require endoscopy, bronchoscopy, ERCP
– To have vascular access devices
– To require lots of IV drugs
– Not have other invasive devices
– Can have other sites of infection
– Are exposed to water when they wash
• NB– Eliminate nothing without evidence
– But ALWAYS go for the most common first!
What Immediate Control Measures?• Let them know you know....
• Isolate known positive patients (contact precautions) TBPs?
• Stop admissions?
• Stop showers?
• Make sure SICPs are being practiced (hand hygiene and use of gloves)?
• Assume environment / equipment contaminated and decontaminate?
What do you think?
• Active failure – Who has been doing what?
• The conditions that provoked the outbreak?
• Where is transmission occurring?
What do you want to know/do - NOW?
• Background levels of infection in this unit (and outwith)
• Define a case; Count all cases; Describe the cases (find additional cases)
• Look for a recent change in the system
• Present the data– Epi curve,
– Days from CVC to BSI,
– Days from admission to BSI)
– Ward plan (inc sinks, showers and other water outlets)
• Typing on available strains
• Hypothesis
• Consider environmental samples
• Identify procedures of interest - observations of practice (mock)
• Call an expert / ref lab in Pseudomonas
• Are SICPs in place?
Define a case: place, organism + / -
symptoms, time period
1. Any patient in hospital X with Pseudomonas
aeruginosa since 1 / 1 / 2007
2. Any patient from whom Pseudomonas aeruginosa
has been isolated from any specimen in the
haematology ward in hospital X since 1/1/2007
3. Any patient from whom Pseudomonas aeruginosa
has been isolated in blood in the haematology
ward since 1/1/20071
2
3
Count all the cases (find additional cases)
– where are you going to look?
• In the ward
• Patients transferred to another care facility
• In the computer (look back)
• In the community those discharged home
• In neighbouring facilities
• In the country
Background levels of the organism
Does not appear to be increasing elsewhere in the hospital
Not reported by other hospitals
Insights?
No new changes:
Procedures,
Kit,
Environment,
Staff
M to F reflectspatient
population
What are you going to sample?
• Environment:
– Shower heads / Water
• Equipment:
– Could have showed they were ‘minging’
• People:
– Are other patients colonised?
PFGE (2006 & 2007 results)
• 8 different PFGE types from blood 3 >1
– Type I = 7
– Type III = 17
– Non I or III = 6
• Shower heads
– Type I = 2
– Type III = 0
– non-type I or III = 2
Inference?
What are your Procedures of Interest?
• Did not disinfect pre access
• Frequent disconnection of CVCs and PVCs
• Where nurses handled syringes / other equipment
prior to IV – Flower vases
• Access to disinfectant poor
• Disposal of sharps and trays – poor
• No unusual water practices noted
IV & SICPs & how they use water
Place of interest – where IV prep took
place
• Administration sets were placed near sinks or
‘randomly around the bed’
• Where nurses handled syringes / other equipment
prior to IV – Flower vases
• Access to disinfectant poor
What is your hypothesis now?
• Most likely due to.......
Update your SA
• What is happening:
• So what:
• What next: (more control measures?)
Situation awareness
• What is happening: – IV procedures are facilitating contamination of drugs, of IV
catheters and infecting the patients
– The environment is conducive to high-level contamination with all micro-organisms; in particular Gram negative organisms
• So what:– Patients are at risk because IV procedures are unsafe
• What next: – More cases unless IV procedures changed
Their control measures....
• Disinfection pre access
• Keeping disconnected admin sets away from sinks
(!!!)
• Put flowers on the windowsills
• Adding chlorhexidine to Flower water (!!!)
• Cleaning shower heads and descaling – built in
filters
• Feedback of audit data
“A second audit was performed 53 weeks later”
“Flowers were banned and easy access to alcohol provided”
“Routine shower head cleaning instigated”
“No hand hygiene data were available”
If outbreak is due to poor IV procedures, then improvements should
have impacted on other organisms?
Further Audit
Further Control Measures
Recognition & Control Measures
Insight
Further Audit
Further Control Measures
Recognition & Control Measures
This was not provoked by a system change.
What are the outbreak provoking conditions?
Entropy & Inertia
Inertia: Unwillingness or inability to adapt to
changing situation
Entropy:
‘Inevitable and steady deterioration of a system or society
Weakly managed systems tend to become less organized and
focused.
Need to constantly work on maintaining an organisation’s
purpose, form and methods.’
Good Strategy Bad strategy: the difference and why it matters Richard Rumfelt
Over time.....
a lack of system monitoring within and
outwith the clinical area...
Lack of SA amongst frontline staff
Five things -
you would have done different
1. Find out which IV procedures
2. Data1. Days from insertion to infection
2. Days from injections to infection
3. Types of infusions (propofol)
4. Ward layout – mark showers, cases, pt stays (always one room?)
3. Ongoing audit / support / feedback (Environment / Procedures)1. Difficult to embed new habits quickly
2. DMAIC
3. BSI
4. E&T – re IV procedures; how do we check competency, policy
5. Find out - is there another way to do it?
6. Case control study
Outbreaks
Single organism
Single organismMultiple infection
categories
Multiple organisms
BSI: Pseudomonas
aeruginosa sp
SSI, SSTI
BSI, UTI,
Colonisation
BSI: Pseudomonas
aeruginosa spp,
CNS?
SSI, SSTI
BSI, UTI
Colonisation
Unknown organisms Similar symptoms
Single infection category
Single infection category
Multiple infection
categories
Hindsight bias
Foresight ≠ Hindsight
Who was right from the beginning
be honest?
Hindsight is not equal to foresight: the effect of outcome knowledge on judgement under uncertainty Fishhoff, B. Journal of
Experimental Psychology: Human Perception and Performance vol 1 (3) 1975 288-99
Our outbreak was:
An outbreak of Pseudomonas aeruginosa
bacteraemia in an haematology department
Dan Med J 2015; 62 (4)
Thank you for helping me work
the outbreak !