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Update to carbapenemase-producing Enterobacteriaceae (CPE) Transmission Risk Area (TRA) classifications in Victorian health services

The list of TRA classified wards within Victorian hospitals at: https://www.vicniss.org.au/healthcare-workers/cpe-transmission-risk-areas-tra/ has recently been updated to include a new area where local transmission has been identified.

The Victorian CPE Incident Management Team (VCIMT) recommended control measures have been applied and appropriate screening put in place within all listed TRA settings. Please note that there is no requirement to isolate or screen any patients transferred to a receiving facility outside of a TRA. The Department of Health and Human Services will continue to update health services with any TRA changes.

Access to this information is restricted to relevant health professionals. To register for the VICNISS website and have access the TRA summary follow the steps in the attached guide. If you have any issues at all please don’t hesitate to contact the VICNISS Coordinating Centre.

Review of Victorian Guideline on CPE

As you may be aware the CPE guidelines are currently being updated with an anticipated release in April 2017. The revised guideline no longer requires health services to perform a 6 monthly point prevalence screen (PPS) for CPE in the high risk areas, i.e. ICU, haematology ward and transplant ward. The revised draft CPE guideline states: Health services may undertake PPS based on local risk assessments.

As many of you may be currently planning your 6 monthly CPE PPS you may wish to reconsider, as the Department of Health and Human Services, will not require the previously expected PPS data submission on the 31st July 2017. Health services can make their own local risk assessment to continue or discontinue future CPE PPS.

In addition, health services are no longer required to submit an annual audit of their compliance with the CPE guidelines. The revised guidelines will state: “Local audits of CPE management are not required to be submitted to DHHS or VICNISS. In some circumstances, DHHS may initiate an audit of healthcare facility preparedness and response arrangements. This will be communicated in writing should it be required”.

Did you know you can compare your hospital surveillance results with other Victorian hospitals?

Do you want to compare your hospital surveillance results with other Victorian hospitals? VICNISS de-identified reports are available for SAB, CDI CLABSI and SSI modules. If you would like access to these reports please update your details via the User Portal.

On 3 November 2016 WHO released Global Guidelines for the Prevention of Surgical Site Infection. No international evidence-based guidelines had previously been available and there are inconsistencies in the interpretation of evidence and recommendations in existing national guidelines. The new WHO guidelines are valid for any country and suitable to local adaptations, and take account of the strength of available scientific evidence, the cost and resource implications, and patient values and preferences. The guidelines can be accessed at: http://www.who.int/gpsc/ssi-prevention-guidelines/en/ The only Australian data reported in these guidelines is from Victoria.  See the 'infection control literature review' below for a summary of the intra-and post-operative measures.

Commencing 2017-2018 VICNISS is changing to electronic submission and management of surveillance plans and associated data quality checks. Webinars detailing all the upcoming changes will be provided on May 2nd, 11th and 17th @ 1000hrs. Registration details to follow by separate email. These changes will affect all hospitals – large and small – and all ICPs involved in surveillance data collection and submission should aim to attend a session.

Surgical site infections are a complication of surgery with the potential for devastating outcomes, of which, many are deemed to be “reasonably preventable” with medical intervention. VICNISS has developed an SSI investigation guide to enable thorough investigation of each surgical site infection, The investigation tool is designed to assist ICPs and others to determine:

• What was the primary cause of the infection?

• Was there a delay in either identifying or treating a primary infection?

• Was the treatment for the primary infection as per local/national guidance?

• Was the patient’s perioperative management consistent with local protocol, care plan etc.

This guide is for hospital use, i.e. not routinely submitted to VICNISS, however in the event of a hospital having an unusually high number of SSIs, the Department of Health and Human Services may request a copy of the investigation guides and details of subsequent action taken by the hospital.

The VICNISS manual is currently being updated and the new manual should be available by 1st July 2017. A Webinar to outline and discuss any changes is planned for June 2017. Details will be provided as soon as possible.

Gold Standard Auditor (GSA) Workshops in 2017

• June 5th & 6th at Austin Hospital, Heidelberg
• September 26th and 27th at Box Hill Hospital (note change of dates and venue)

If you would like to register for any of the above workshops please go to http://www.hha.org.au/ForHealthcareWorkers/workshops/workshop-online-booking.aspx and select the correct workshop from the drop down list at question 7 (Choose the workshop you would like to register for).

If you would like to host a Gold Standard Auditor Workshop at your hospital please contact jennifer bradford@mh.org.au for further information.

Have you trained new General Autidtors in your facility? Don't forget that if you train any General Auditors you must register them on the HHA Auditor Register.

Late mobile data?

Late mobile data? A new process has been added to HHCApp to prevent mobile data that is synced after the audit is complete, from changing the dataset. Any Hand Hygiene Compliance data on a mobile device that has not been synced before the audit changes to 'Complete' will now go automatically into a 'local audit' when the device is next synced. This local audit is generated by the database and will be named with the auditors 'username' and the date/ time of the sync. Example: 'IgnazS_temp_audit_20160713_1156'  

The 75% target for health care workers employed during the influenza period to be vaccinated, remains unchanged in the 2017 HCW Influenza Vaccination Campaign.

2017 HCW vaccine is a quadrivalent vaccine. There are two vaccine brands supplied this year:

• FluQuadri (Sanofi Pasteur)
• Afluria Quad (Seqirus) – this vaccine is only indicated for use in people aged 18 years and over 

VICNISS has reviewed the 2017 HCW influenza vaccination protocol, however there are no significant changes.

A number of resources are available now on the VICNISS website (www.vicniss.org.au), these include: protocol, data form (hardcopy) and instructions, template for HCW influenza vaccination declaration form, as well as links to promotional material order forms, and the recording for the recently held webinar.

The 2017 HCW Influenza campaign is 3rd April, 2017 to 4th August 2017. Surveillance data to be submitted by 18th August 2017

Vaccine manufacturer – GlaxoSmithKline – has reported a longterm shortage in supply of Engerix-B vaccine. This is the commonly used hepatitis B vaccine in the healthcare worker immunisation programs. This does not impact the supply of Engerix-B paediatric dose.

There is an alternative Hepatitis B vaccine – H-B-VaxII from Seqirus. Please refer to the Australian Immunisation Guidelines. This vaccine can be ordered by hospital pharmacies as an alternative supply. Be mindful that the demand on the Seqirus – H-B-Vax II will be high over the next few months until the Engerix B stock has returned to normal.

Note:

• “Interchangeability of hepatitis B vaccines The Engerix-B and H-B-Vax II vaccines are manufactured by different processes, and the HBsAg content of an ‘equivalent’ dose is different. Although switching of vaccine brands is not recommended, in cases where the brand of vaccine used for previous doses is not known, another age-appropriate ‘equivalent’ dose brand …may be used.”( Pp 219 Australian Immunisation Guidelines)

In view of the potential difficulties for accessing a hepatitis B vaccine, the VICNISS Point Prevalence Survey for the 2017-2018 surveillance year will be EITHER the HCW Hepatitis B immunity module or HCW Measles Immunity module.

2016 VICNISS QA Project In 2016,

20 hospitals in the smaller hospital group participated in a QA project to check the completeness and accuracy of surveillance data collected and submitted to VICNISS. The modules being audited included the MRSA, VRE, SAB, HCW Influenza Vaccination uptake module and the Occupational Exposure Incident module.

Individual participating hospitals have already received their site specific report, however, it is worth mentioning at this point that the accuracy of MRSA infection data was 47.5%. Since completing the audit, both the MRSA and VRE modules have been reviewed and updated to facilitate accuracy and completeness of data collection.

Many thanks to all the ICPs who participated and assisted with the QA project.

Hepatitis B Point Prevalence Survey

The required PPS for the 2016-2017 surveillance year is the Hepatitis B immunity module. ICPs have until June 30, 2017 to submit data for this survey.

Please note: hospitals that participated in the QA project or the DHHS Blood Borne Virus scopying survey, both in 2016, are exempt from completing the PPS.

Aged Care National Antimicrobial Prescribing Survey (acNAPS)

The official data collection and submission time for the 2017 acNAPS is between Monday June 19th and Friday September 1st. Online training sessions will be held from mid-June. Further information can be obtained by phoning (03) 9342 9415 or emailing support@naps.org.au

WHO guidelines for prevention of surgical site infections: intra- and post-operative measures

In addition to pre-operative prevention measures, intra- and post-operative SSI prevention strategies have been summarised by the World Health Organisation as a published review (Lancet Infect Dis 2016; 16: e288–303). Each recommendation is graded according to strength (strong or conditional) and quality.

Intra- and post-operative measures for SSI prevention are summarised as sixteen recommendations, including:

(i) Adult patients undergoing general anaesthesia with endotracheal intubation for surgical procedures should receive 80% fraction of inspired oxygen intraoperatively and, if feasible, in the immediate postoperative period for 2–6 h,

(ii) Warming devices are suggested for use in the operating room and during the surgical procedure for patient body warming,

(iii) Protocols are suggested to be used for intensive perioperative blood glucose control for both diabetic and non-diabetic adult patients undergoing surgical procedures,

(iv) Goal-directed fluid therapy is suggested for use intraoperatively,

(v) Either sterile disposable non-woven or sterile reusable woven drapes and surgical gowns can be used during surgical operations,

(vi) Plastic adhesive incise drapes with or without antimicrobial properties should not be used,

(vii) Consider the use of wound-protector devices in clean-contaminated, contaminated, and dirty abdominal surgical procedures,

(viii) Consider the use of irrigation of the incisional wound with an aqueous povidone-iodine solution before closure, particularly in clean and clean-contaminated wounds,

(ix) Antibiotic incisional wound irrigation before closure should not be used,

(x) Prophylactic negative-pressure wound therapy on primarily closed surgical incisions is suggested in high-risk wounds, while taking resources into account,

(xi) Triclosan-coated sutures are suggested to be used in all types of surgery,

(xii) Laminar airflow ventilation systems should not be used for patients undergoing total arthroplasty surgery,

(xiii) Perioperative surgical antibiotic prophylaxis should not be continued because of the presence of a wound drain for the purpose of preventing SSI,

(xiv) The wound drain should be removed when clinically indicated; no evidence was found to make a recommendation on the optimal exact timing,

(xv) No type of advanced dressing should be used over a standard dressing on primarily closed surgical wounds, and

(xvi) Surgical antibiotic prophylaxis administration should not be prolonged after completion of the operation.

These recommendations are a valuable resource for hospital infection programs in developed countries. However, given the quality of evidence, conditional recommendations must be evaluated locally by stakeholders, and in the context of the patient and surgical factors most frequently encountered within an individual healthcare facility.