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Guideline for the Management, Prevention and Control of Multi-resistant Gram-negative Bacteria (including Extended Spectrum Beta Lactamase Producing Microorganisms (ESBLs)) Reference No: G_IPC_25 Version: 3 Ratified by: Infection Prevention and Control Committee Date ratified: 25 August 2015 Name of originator/author: Cheryl Day, Countywide Lead Infection Prevention & Control Name of approving committee/responsible individual: LCHS Infection Prevention & Control Committee Date issued: 6 August 2015 Review date: August 2017 Target audience: All staff Distributed via: Website Lincolnshire Community Health Services NHS Trust Infection Prevention and Control Guideline Version Control Sheet Version 1 One 2 Two 3 Two 4 Two 5 Two 6 Two 7 Three 8 Three 9 Three 10 Three Section/Para/A ppendix Version/Description of Amendments Date Author/Amended by All New document May 2010 Cheryl Day All Change LCHS LCHS NHS Trust to Jan 2013 Lynne Roberts All Change “Infection Jan 2013 Control” to “Infection Prevention and Control” Lynne Roberts 9.3 Add monitoring table Jan 2013 Lynne Roberts Page 12 Add Equality Analysis Jan 2013 Lynne Roberts Page 11 Changed Microbiologist HPA to PHE Jan 2013 Lynne Roberts June 2015 Lynne Roberts and Document Replaced footer Appendix F Updated analysis Equality June 2015 Lynne Roberts Whole document Changed Workforce June 2015 and Development Team to Education and Workforce Team Lynne Roberts Whole document Added references Lynne Roberts guideline June 2015 Copyright © 2015 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. Guidelines for the management, prevention and control of Multi-resistant gram-negative bacteria (including Extended Spectrum Beta Lactamase producing microorganisms (ESBLs)) Contents 1. Introduction ................................................................................................................................... 5 2. What are multi-resistant gram negative bacteria (MRGNB) ........................................................... 5 3. Scope of Guidance ....................................................................................................................... 5 4. Purpose ........................................................................................................................................ 6 5. Key Responsibilities ...................................................................................................................... 6 5.1 Chief Executive ....................................................................................................................... 6 5.2 Board lead ............................................................................................................................... 6 5.3 Managers ................................................................................................................................ 6 5.4 Employees .............................................................................................................................. 6 5.5 The Infection Prevention Team ................................................................................................ 6 5.6 Education and Workforce Team .............................................................................................. 6 6. Training......................................................................................................................................... 7 6.1 Training delivery ...................................................................................................................... 7 6.2 Process to Check Training is completed .................................................................................. 7 6.3 Follow-Up of Non Attendance .................................................................................................. 7 7. Support for patients....................................................................................................................... 7 8. Measures to prevent and control the spread of infection ............................................................... 8 8.1 Treatment ................................................................................................................................ 8 8.2 Reduce risk of transmission..................................................................................................... 8 8.2.1 Hand hygiene.................................................................................................................... 8 8.2.2 PPE .................................................................................................................................. 8 8.3 Environmental controls ............................................................................................................ 8 8.3.1 Medical equipment ............................................................................................................ 8 8.3.2 Waste ............................................................................................................................... 8 8.3.3 Linen ................................................................................................................................. 8 8.3.4 Cutlery/crockery ................................................................................................................ 9 8.3.5 Environmental contamination ............................................................................................ 9 8.4 Pathology specimens .............................................................................................................. 9 8.5 Additional Recommendations .................................................................................................. 9 8.5.1 Community Hospitals ........................................................................................................ 9 8.5.2 Residential/nursing care homes ...................................................................................... 10 8.5.3 Patients own home ......................................................................................................... 10 8.5.4 Ambulance transportation ............................................................................................... 10 9. Monitoring, Surveillance and Audit .............................................................................................. 10 9.1 Outbreaks.............................................................................................................................. 10 9.2 Surveillance ........................................................................................................................... 10 9.3 Audit ...................................................................................................................................... 10 References ..................................................................................................................................... 11 Contributors: ................................................................................................................................... 12 Putting you first is at the heart of everything we do Page |3 Chairman: Chief Executive: Elaine Baylis QPM Andrew Morgan Lincolnshire Community Health Services NHS Trust Guideline for the management, prevention and control of Multi-resistant gramnegative bacteria (including Extended Spectrum Beta Lactamase producing microorganisms (ESBLs)) Guideline Statement Background The purpose of guideline is to implement a co-ordinated approach to the control of multi-resistant gram negative bacteria (including Extended Spectrum Beta Lactamase producing microorganisms (ESBLs)) in line with current Department of Health requirements for Infection Prevention and Control. Statement This guideline is comprehensive, formally approved and ratified, and disseminated through approved channels. It will be implemented for Lincolnshire Community Health Services NHS Trust. Responsibilities Compliance with this guideline will be the responsibility of the relevant Lincolnshire Community Health Services NHS Trust staff. Training The Infection Prevention Team will support/deliver any training associated with this policy. Dissemination Via intranet. Resource implication This guideline has been developed in line with the NHS Litigation Authority guidelines to provide a framework for staff within NHS Organisations to ensure the appropriate production, management and review of organisation-wide guidelines. Putting you first is at the heart of everything we do Page |4 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan Guideline for the management, prevention and control of Multi-resistant gram-negative bacteria (including Extended Spectrum Beta Lactamase producing microorganisms (ESβLs)) 1. Introduction The increasing prevalence of antibiotic resistant micro-organisms, especially those with multiple resistances, is causing international concern. Their control is vital. As antibiotic resistance makes infections difficult to treat, increases the length of severity of illness, the period of infection, adverse reactions, length of hospital admission and overall costs. 2. What are multi-resistant gram negative bacteria (MRGNB) Gram negative bacteria (GNB) are commonly found in the gastro-intestinal tract, in water and in soil. In hospitalised patients, colonisation of the gastro-intestinal tract and oropharynx is common. GNB can be part of the transient flora on the hands of healthcare workers. Some species of bacteria commonly found in the bowel (e.g. Escherichia coli, E.Coli, Klebsiella, Proteus, Pseudomonas Enterobacter and Acinetobacter) can develop multi-resistance to antibiotics where they become collectively referred to as Multi-resistant gram negative bacteria or MRGNB. MRGNB are seen most frequently in patients who have received broad spectrum antibiotics and where patients have diminished immunity. MRGNB may cause urinary tract infections, pneumonia and surgical site infections. Some MRGNB contain beta-lactamases which can destroy/inactivate even broad spectrum antibiotics such as cefuroxime and cefotaxime. These are referred to as extended spectrum beta lactamases or ESβL. ESβL-producing coliforms are resistant to intravenous cephalosporins and they are frequentlyresistant to many other antibiotics including ciprofloxacin and aminoglycosides. Multi-resistant Acinetobacter are defined as isolates which are resistant to any aminoglycoside and to any third generation cephalosporin. Some multi-resistant Acinetobacter strains are also resistant to carbapenem antibiotics (these strains are designated MRAB-C). Multi-resistant Pseudomonas are resistant to at least two of the following: ceftazidime or piperacillin/tazobactam or gentamicin (or other aminoglycoside) or ciprofloxacin. Multi-resistant Pseudomonas strains are occasionally resistant to carbapenem antibiotics. 3. Scope of Guidance This guideline is intended to guide practice of staff working within Lincolnshire Community Health Services NHS Trust. The principles contained within the guideline reflect best practices and applies to those members of staff who are directly employed by Lincolnshire Community Health Services NHS Trust. However, it is recognised that the management and control of multi-resistant organisms requires countywide action and this guideline may be used and adapted by other organisations as appropriate. Putting you first is at the heart of everything we do Page |5 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 4. Purpose This guideline applies to all relevant Lincolnshire Community Health Services NHS Trust employed staff. It sets out the arrangements within the organisation to prevent and control the spread of multi resistant gram-negative bacteria and to promote effective and evidence based patient care. 5. Key Responsibilities 5.1 Chief Executive Overall responsibility for matters relating to Infection Prevention lies with the Chief Executive to Lincolnshire Community Health Services NHS Trust. 5.2 Board lead The Director of Infection Prevention and Control (DIPC) has the board lead for Infection Prevention and Control for Lincolnshire Community Health Services NHS Trust. 5.3 Managers Managers have the responsibility to ensure that all staff are aware of this guideline and have received relevant induction/training. They will be responsible for ensuring staff have access to IPC guidance, highlighting staff training, areas for audit and areas for risk assessment and ensuring that infection prevention and control is embedded in their service delivery. 5.4 Employees All employees have a responsibility to abide by this guideline and any decisions arising from the implementation of it. Any decision to vary from this guideline must be fully documented with the associated rationale stated. It is important that staff report any concerns/difficulties in relation to implementing this guideline to their line manager. All accidents/Incidents deemed to be in breach of this guideline must be reported by the usual reporting mechanisms outlined by Lincolnshire Community Health Services NHS Trust. Employees have a responsibility to attend mandatory training/update training as identified within the Organisation’s Mandatory Training Matrix. 5.5 The Infection Prevention Team The Infection Prevention Team will review the guidance annually. In addition they will review the document in response to the publication of any urgent communications from the Department of Health. Assist managers with the audit of compliance with the guidance as required. Deliver associated Infection prevention and control training as required. 5.6 Education and Workforce Team The LCHS NHS Trust Education and Workforce Team has a responsibility to ensure the coordination of the learning and development of staff, as identified within the Workforce Development Policy and training matrix. Putting you first is at the heart of everything we do Page |6 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 6. Training 6.1 Training delivery Training requirements will be highlighted through the local training needs analysis. The Infection Prevention Team, will as appropriate in conjunction with Education and Workforce Team, provide education, as appropriate to all staff on corporate mandatory induction, clinical and non clinical mandatory update sessions. Further training needs may be identified through other management routes, including root cause analysis following an incident/infection control outbreak (see incident reporting and serious incident reporting policy). By agreement additional targeted training sessions will be provided by the Infection Prevention & Control team. 6.2 Process to Check Training is completed The statement of main NHS terms and conditions for employment for LCHS under Agenda for Change identifies that all staff will be expected to undertake appropriate and relevant training and development to enhance their performance in their post. Confirmation of staff completion of relevant training; commensurate with their job role (inclusive of mandatory training) will be achieved through: Corporate Induction Arrangements: Appointing managers will ensure that all employees are aware of the induction policy upon joining LCHS and ensure that the staff member is booked on the corporate mandatory induction. Non attendance is followed-up as identified below. Local Induction Arrangements: Line managers will ensure that all new staff receive a comprehensive local induction, within two weeks of the staff member commencing in their post, guided by the local induction checklist. The local induction checklist records the date corporate mandatory induction is undertaken. Line Managers are required to keep accurate records of staff training. Utilising this information, Line Managers review and discuss on an ongoing basis, training needs of staff and training attended. In addition, the Line Manager will review staff training attended as part of the annual development review, knowledge and skills framework and Agenda for Change progression. 6.3 Follow-Up of Non Attendance Mandatory Training (Corporate Mandatory Induction and Updates). The Education and Workforce Team will maintain attendance records for all induction and mandatory training session delivered. Non attendees will be notified to the appropriate line manager for action. 7. Support for patients This guideline will be publically available on the Lincolnshire NHS website. Patients will receive verbal and or written information appropriate to their episode of care. Lincolnshire Community Health Services NHS Trust can provide additional support to clients via the Patient Advice and Liaison Service (PALS) Putting you first is at the heart of everything we do Page |7 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 8. Measures to prevent and control the spread of infection 8.1 Treatment Avoidance of inappropriate prescribing is vital in the control of MRGNB. Treatment is a dvocated for those service users who have clinical signs of infection. Advice on antibiotic treatment is outside of the scope of this guideline. Advice can be obtained from the Consultant Microbiologist and the Medicines Management Team. 8.2 Reduce risk of transmission Use of Standard Precautions at all times for all patients is essential to prevent the spread of MRGNBs and ESβLs. Common routes of transmission are: Direct spread e.g. via healthcare workers hands Indirect spread e.g. via used healthcare equipment/environmental contamination 8.2.1 Hand hygiene. The main source of infection is via colonised or infected sites. Effective hand hygiene is essential before and after patient contact (See G_IPC_17 Hand Hygiene guidelines). 8.2.2 PPE Disposable single use plastic aprons and gloves must be worn for all direct patient contact or contact with the immediate environment, including bed making or when handling items contaminated with blood/body fluids. (See G_IPC_26 Standard Precautions guidelines). 8.3 Environmental controls 8.3.1 Medical equipment Medical equipment must where possible be dedicated for sole use with the patient. All equipment must then be appropriately decontaminated before it can be used on another patient/sending for repair. (See G_IPC_38 Decontamination of patient’s equipment) 8.3.2 Waste Follow the Trust guidelines for disposal of all waste across all settings 8.3.3 Linen Inpatient areas Daily change bed linen and personal clothing is recommended. Treat all linen as infected linen. Patients’ own clothes should be sealed securely in a water soluble bag and relatives requested to wash clothes at home at the highest temperature that will not damage the fibre (See G_IPC_06 Linen guidelines) Staff Uniforms; If laundered at home, uniforms should be washed separately at the highest temp for the item ideally on a 60ºc cycle (or higher temperature) followed by a tumble dry or iron. Uniforms should not be worn to and from work. (See P_HS_15 Uniform and Dress code policy). Putting you first is at the heart of everything we do Page |8 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan Patient’s own home Advise regular changes of bed linen and clothing. Wash clothes at home at the highest temperature that will not damage the fabric. 8.3.4 Cutlery/crockery Inpatient areas: reprocess in industrial style dishwasher In patient’s own home: no special precautions required. 8.3.5 Environmental contamination Inpatient areas: Isolation rooms must be cleaned at least daily, paying special attention to dust collecting areas and horizontal surfaces using dedicated/single use equipment. Rooms should be cleaned in accordance with the infection prevention and control policy isolation policy. The standard terminal cleaning procedure using a solution of proprietary combined 1000ppm available chlorine in detergent should be undertaken for vacated isolation rooms, paying spe cial attention to dust collecting areas, horizontal surfaces and floors, and curtain laundering. NB. Visible splashes to walls should be removed – full wall washing is not necessary. Patient own home: Normal household cleaning will be sufficient 8.4 Pathology specimens ‘Danger of Infection’ labels are not required (unless the patient has another condition requiring them). (See G_IPC_19 Specimen guideline) 8.5 Additional Recommendations 8.5.1 Community Hospitals Inpatients in Community Hospitals must be nursed in a single room. Isolation should continue until the patient has completed treatment and culture of a repeat specimen is negative. (See G_IPC_28 Management of patient in Isolation). If a single room is not available or the patient’s condition prevents isolation, a risk assessment must be carried out in association with the infection prevention and control team. See Management of Notifiable of infectious disease and food poisoning. If patient is to be isolated a clear explanation should be provided to both the patient and their visitors. Ensure that visitors are aware of the additional precautions they need to take. Visitors for patients will not be expected to wear aprons or gloves unless they are attending to the patient e.g. assisting in the delivery of personal care Patients should be allocated their own specific equipment e.g. commode, moving and handling equipment, wash bowls and blood pressure cuffs. Where possible single patient use equipment should be used and disposed off as clinical waste on patient discharge or discontinuation of isolation precautions. Patients may be discharged to their own homes. Ward staff must liaise with nursing/residential care homes or other hospitals and ambulance transport as appropriate. It is vital that an inter-hospital transfer form is completed and accompanies the patient. Putting you first is at the heart of everything we do Page |9 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 8.5.2 Residential/nursing care homes The majority of service users identified with a MRGNB will be colonised. Normal social contact with someone who is colonised with MRGNB does not pose a risk to healthy people There is no justification for refusing to admit a person with MRGNB into this type of environment. Patients/residents in the community setting with MRGNB/ESβL do not usually require isolation. They may share a room so long as neither they nor the person with whom they are sharing has open wounds, drips or catheters. Patients/residents can visit communal areas, e.g. dining room, television room and can mix with other residents/patients Normal laundry procedures are adequate, however if laundry is soiled and is heat labile it should be washed at the highest temperature the garment will withstand. On discharge patient rooms should be cleaned in accordance with local policy paying special attention to dust collecting areas, horizontal surfaces and floors, and curtain laundering. If a patient/resident requires hospital admission/transfer to another service provider an inter healthcare transfer form must be completed. This will enable a risk assessment to be undertaken to determine whether the patient should be isolated on admission. 8.5.3 Patients own home In general no special precautions are needed. 8.5.4 Ambulance transportation The ambulance service should be notified in advance by ward/clinical staff. An inter healthcare transfer form should be completed and accompany the patient. 9. Monitoring, Surveillance and Audit 9.1 Outbreaks The Infection Prevention monitor MRGNBs and ESBLs on behalf of Lincolnshire Community Health Services NHS Trust and will investigate any suspected outbreaks in line with the outbreak guidelines. Outbreaks will be reported as a serious incident and will be reported to and monitored by Quality and Risk and Risk Committee and the Infection Prevention and Control Committee. 9.2 Surveillance The Infection Prevention Team will monitor trends in relation to MRGNB where these are associated with service areas under their remit and on a monthly basis report those trends to the Director of Infection Prevention & Control, the Infection Prevention & Control Committee and the Trust Board. The Quality and Risk Committee will receive information on any specific concerns, escalated from the Infection Prevention and Control Forum relating to Infection prevention and control issues. The concerns will be assessed and action taken to address the issue identified. 9.3 Audit This guideline may be monitored to determine compliance either following an incident or by the forward audit programme. Putting you first is at the heart of everything we do P a g e | 10 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Compliance Audit & Manager/ surveillance IP&C Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan Monthly surveillance IP&C Committee IP&C Committee IP&C Committee References Department of Health (2000) UK Antimicrobial Resistance Strategy and Action Plan Department of Health (2002) Getting Ahead of the Curve: a strategy for combating infectious diseases Department of Health (2009) Health & Social Care Act 2008: Code of practice on the prevention and control of healthcare associated infections and related guidance, London Health Protection Agency. Investigations into multi-drug-resistant ESBL- producing Escherichia coli strains causing infections in England. http://www.hpa.org.uk/hpa/publications/esbl_report_05/ Putting you first is at the heart of everything we do P a g e | 11 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan Contributors: Persons involved in development of this guideline / procedure: Name: Designation: Gail Beckett Public Health England Dr Bethan Stoddart Pathlinks Members of the Infection Prevention Team LCHS Putting you first is at the heart of everything we do P a g e | 12 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan Appendix F. Equality analysis A. Briefly give an outline of the key objectives of the policy; what it’s intended outcome is and who the intended beneficiaries are expected to be Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details Will/Does the implementation of the policy\service result in different impacts for protected characteristics? B. C. D. To provide staff with guidelines on the management, prevention and control of Multiresistant gram-negative bacteria (including Extended Spectrum Beta Lactamase producing microorganisms (ESBLs)) This has an impact on all staff, patients and careers. None Yes Disability Sexual Orientation Sex Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers No √ √ √ √ √ √ √ √ √ √ If you have answered ‘Yes’ to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead – please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out Lynne Roberts by: Date: 02.04.15 Putting you first is at the heart of everything we do P a g e | 13 Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan