Dublin North SARI Newsletter Issue 3, September 2010 Contents Education day on urinary catheter- associated infection Sharps safety in Community health settings Update on Measles When to suspect C. difficile infection Prevention of C. difficile outbreaks Sluice Room Audit Tool Antimicrobial consumption 2009 1. DATE FOR YOUR DIARY: Dublin North SARI Regional Committee Education Day – Tuesday November 23rd in Cappagh Hospital
Our third prevention of healthcare-associated infection educational day aimed at healthcare
staff working in the community will be held in the Lady Martin Auditorium, Cappagh Hospital
on Tuesday November 23rd at 1.30pm. The focus of this year’s day will be prevention of
No registration fee, however places are limited. To reserve a place please contact Ms 2. SHARPS SAFETY IN COMMUNITY HEALTH SETTINGS Dr. Blanaid Hayes, Consultant in Occupational Medicine, Beaumont Hospital
Contaminated sharps injuries (including needlesticks) can result in infection with hepatitis B, C and HIV. Though this is rare, these injuries can cause great anxiety to health care and
other staff who encounter used needles in the course of their work. Prevention of exposure
to oneself and others requires clinical healthcare workers (needle users) to observe good
practice at all times. The concept of the ‘Hierarchy of Risk Controls’ (see page 2), widely
used in the practice of occupational health and safety, is a useful model for sharps injury
prevention. The controls at the top of the list are more effective than those at the bottom e.g. PPE requires compliant behaviour by the user which can only be achieved with good
Standard Precautions (an example of an administrative control) must be implemented on
each occasion that a needle / sharp is used in clinical care.
Assume all patients are potentially infected with a blood borne virus
Prepare carefully for the task with appropriate PPE and equipment.
Seek assistance if you have concerns about the patient’s ability to cooperate.
You, as the user, are responsible for the disposal of the sharp.
Dispose of sharp immediately after use by bringing Cin bin to point of care.
Do not place sharp in kidney dish or other ‘interim’ container.
Do not resheath needles, or manipulate them by hand.
Take care when passing sharp instruments to colleagues
HIERARCHY OF RISK CONTROLS
¾ Blunt suture needles, ‘drawing up needles’ etc
¾ Safety device, automatically blunting needles and
4. Administrative controls:
¾ STANDARD PRECAUTIONS*, vaccination, supplies management
¾ Gloves, masks, goggles (to prevent contamination with splashes) and CIN
Report all exposures promptly to your Occupational Health Service or local Emergency Department 3. UPDATE ON MEASLES Ms. Celine O’ Carroll, Assistant Director of Nursing, Infection Prevention and Control, Mater Hospital. Measles is an acute viral illness, which is highly contagious and is spread by coughing and
sneezing. One case of measles can infect 15 – 20 unvaccinated people. Transmission of
measles is by droplet infection. The virus can remain viable on infected surfaces for up to 2
hours. The incubation period is 10 days (range 7 - 18 days) with a further 2 - 4 days before the rash appears. Patients are infectious from 4 - 5 days before to 4 days after the onset of
What are the symptoms of Measles?
Symptoms occur several days before the rash begins. These can include:
1. High fever (up to 105°F or 40.6°C) 2. Hacking cough
9. Small red lesions with blue - white centres (known as Koplik’s spots appearing on
The early symptoms usually disappear 1 - 2 days after the rash appears. The rash is a red,
blotchy rash that usually appears about 14 days after exposure to the virus and lasts 5 - 6 days. Measles can occur in late teens and young adults. The rash will be itchy and spreads
from the head and chest downward to the rest of the body. Other symptoms in adults may
include sensitivity to light, diarrhoea and earache.
How do I diagnose and manage measles? Diagnosis is usually made from a combination of the symptoms, especially the rash and the
presence of small white spots visible in the mouth.
No specific treatment so treatment focuses on relieving the symptoms. Where possible all
individuals should be treated at home. Only children and adults who develop severe
complications should be admitted to hospital. If this is the case, it is important to let the hospital know that you suspect measles, as the patient needs to be isolated in a single room on admission and only attended to by staff that have immunity to measles. The majority of people recover, however 30% of individuals will develop a complication,
which is more common in children under 5 years of age and in adults over 20 years of age The complications are:
Fatality rate is highest in children under 1 year, lowest in those aged 1 - 9 and rises again in teenagers and adults. Pneumonia accounts for 56 - 86% of measles-associated deaths.
The best prevention for measles is vaccination. This is in the form of MMR vaccine given to
children at 12 - 15 months of age, with a second dose at 4 - 5 years of age. For older
children who have not received 2 doses, MMR vaccine should be given as soon as possible. During measles outbreaks all susceptible individuals should be immunised within 72 hours of
contact, and if these individuals have had no previous vaccine, a second dose should be
For further information on Measles and the National Immunization Guidelines, please 4. WHEN SHOULD I SUSPECT C.DIFFICILE INFECTION? Dr. Fidelma Fitzpatrick, Consultant Microbiologist, Beaumont Hospital and HPSC The following mnemonic protocol (SIGHT) provides a useful framework when managing
suspected potentially infectious diarrhoea:
S Suspect that a case may be infective where there is no clear alternative cause for Isolate the patient and consult with the infection control team while determining G Gloves and aprons must be used for all contacts with the patient and their H Hand washing with soap and water should be carried out before and after each
contact with the patient and the patient’s environment.
The physical action of rubbing and rinsing is the only way to remove spores from hands. Alcohol-based hand rubs do not have reliable sporicidal T Test the stool - send a specimen immediately to your microbiology laboratory for C.
difficile testing. Specimens which cannot be examined promptly should be
refrigerated at 4oC in designated specimen fridges, and not stored in food or drug
5. Clostridium difficile outbreak prevention Ms. Aileen O' Brien, Infection Control/Communicable Disease Nurse Manager,Department of Public Health,HSE, Dr Steevens Hospital. Outbreaks of C. difficile can lead to severe illness and sometimes death for patients, and to
serious disruptions for staff and service provision. The risk of outbreak occurrence can be
minimised by following some simple and practical steps:
1. Vigilance / early detection
• Educate staff about C. difficile infection to facilitate early identification of possible
• Test the stools of patients with diarrhoea for C. diff. Diarrhoea is defined as three or more loose/watery bowel movements that take up the shape of their container (which are unusual or different for the patient) in a 24 hour
• Keep a stool chart for patients with diarrhoea, e.g. Bristol stool chart.
• Tell your local infection control nurse (if applicable) about new cases.
ISOLATE PATIENTS AS SOON AS THEY DEVELOP DIARRHOEA. DO NOT WAIT FOR LABORATORY CONFIRMATION. 2. Notification
• Notify confirmed cases of ‘Clostridium difficile associated disease*’ (see case
definition) to the Department of Public Health in Dr Steevens Hospital, by telephone
CASE DEFINITION: A confirmed C. difficile associated disease (CDAD)* case is a patient ears or older, to whom one or more of the following criteria applies:
• Diarrhoeal stools or toxic mega colon, with either a positive laboratory assay for C. difficile toxin A
cdA) and / or toxin B (TcdB) in stools or a toxin-producing C. difficile organism detected in stool
• Pseudomembranous colitis (PMC) revealed by lower gastrointestinal endoscopy. • Colo nic histopathology characteristic of C. difficile infection (with or without diarrhoea) on a
specimen obtained during endoscopy, colectomy or autopsy.
• The recommended first line treatment for symptomatic non-severe C. difficile
infection is oral Metronidazole 400mgs three times daily for ten days.
• See national guidelines for the treatment of recurrences or reinfection or seek advice
4. Infection control
• Isolate symptomatic patients in single rooms with clinical hand washing sink and
ensuite facilities, or provide a designated toilet / commode (patient should not use
ward general toilet facilities) until they are at least 48 hours symptom free (have a
formed or normal stool for that patient). Cohort patients, when isolation facilities are not available.
• Reinforce standard and contact precautions and provide written guidelines to staff.
• Review the patient’s clinical condition and antibiotic regimen – and stop inappropriate
• Wear apron and gloves for patient contact. Remove these immediately following
patient contact and wash hands using liquid soap and water.
• Clean the environment with detergent and water and disinfect with a chlorine based disinfectant at 1000ppm available chlorine at least daily, e.g. liquid
hypochlorite or sodium dichloroiscyanurate (NADCC) tablets.
• Use dedicated equipment for cases, e.g. commodes, slings, blood pressure cuffs.
• Ensure that bedpan washers are in good working order and that bedpans and
commodes are kept meticulously clean at all times – see sluice room audit tool in this
5. Appropriate antibiotic prescribing
• Antibiotic prescribing (types of agents and duration) should be reviewed with local
prescribers with the aim of reducing inappropriate use of broad-spectrum antibiotics.
This is particularly important where there is an increase in the number of cases of C.
When to suspect an outbreak?
An outbreak is defined as the occurrence of two or more linked CDAD cases over a specific
period of time, taking account of the usual rate or where the current number of CDAD cases
exceeds the expected number. A risk assessment needs to be performed where there are
two or more cases within an eight week period to determine if the cases are linked (i.e. cross
infection has occurred). In hospital settings this will be carried out by the local infection control team. In community settings, e.g. nursing homes and residential care facilities, the
Department of Public Health should be contacted for infection control advice and guidance.
When an outbreak of CDAD is suspected, an outbreak control team (OCT) should be
established. The decision to convene an OCT will be made by the Hospital CEO or general
manager / network manager or the PCCC local health office manager, on the advice of the Consultant Medical Microbiologist or the Medical Officer of Health (MOH) in the Department of
Further information: The C. difficile section on the HPSC website contains:
Factsheets (patient information leaflet, summary of infection control precautions
when caring for patients with CDI, summary of management guidelines)
Details of the case definitions and weekly reports
A variety of audit tools for healthcare facilities and care bundles
Links to international sites of interest
Community antibiotic prescribing guidelines:
Infection control advice is available from the Department of Public Health in Dr. Steevens Hospital, Aileen O’ Brien Telephone 01 6352173 and Helen Murphy Telephone 01 6352154. 6. SLUICE ROOM AUDIT TOOL Mr. Toney Thomas, Assistant Director of Nursing, Infection Prevention and Control, Beaumont Hospital. Below is an example of a sluice room audit tool, which can be downloaded
at For prevention of C. difficile it is essential that bedpan washers are functioning appropriately. Part B of the
tool should be completed on a weekly basis and a review of records on a monthly basis.
Audit of sluice rooms and Bedpan washers Ward management of bedpan washers Comments
There is documented evidence of routine maintenance schedule.
Washer / disinfectors are tested according to HTM 2030 standards.
Staff have received training on operation of the bedpan washer.
There were no episodes of bedpans being soiled after undergoing a
cycle. The protocol for manual disinfection of a bedpan is available and
Who changes detergent on the bedpan washers: HCA NURSE OTHER
Sluice room hygiene Comments
Washer / disinfector is available and in working order, to ensure correct
disposal & disinfection of bedpans & urinal. Bedpans / slipper pans / urinals / reusable jugs are visibly clean.
Bedpans / and urinals are stored inverted on racks.
Bottom of commode seats are clean (turn upside down & inspect).
Catheter stands are available, clean and in good state of repair.
Detergent can is available & connected to the washer.
The room is clean and free from inappropriate items.
Floors including edges and corners are free of dust and grit.
A sink is available for decontamination of patient equipment.
Clinical hand hygiene facilities are available including soap and
disposable paper towels. Washer/disinfector temperature control is in working order.
Holding temperature > 80º c for 1 min (observe a cycle).
Date Washer/disinfector was last tested / serviced.
7. Antimicrobial consumption in Dublin/North East region in 2009 Ms. Sarah Foley, Antimicrobial Pharmacist, Beaumont Hospital. Throughout 2007 to 2009 antimicrobial use in the Dublin and North East region has been consistently less than national consumption levels, whilst also following national seasonal
variation trends (Figure 1). Antimicrobial consumption is measured in defined daily doses per
1000 inhabitants per day (DID). In the Dublin and North East region the ‘Top 5’ most
commonly prescribed antibiotics were co-amoxiclav (26.8%), amoxicillin (16%),
clarithromycin (14.4%), doxycycline (5.8%) and flucloxacillin (4.6%) respectively (see Figure 2). In 2009, the highest consumption of antibiotics occurred in Louth. The DID for the county was 26.4 compared to a national consumption rate of 21.8. In the remaining regions
the defined daily dose per 1000 inhabitants was Dublin city (20), Fingal (16.8), Monaghan
(24.5), Cavan (22.3) and Meath (17). Figure 3
Figure 1: Community antibiotic use – National versus Dublin/North East region Community antibiotic consumption 2007 - 2009 r da 20.00 fin inha 10.00
Figure 2:Top 5 antibiotics – Dublin North/East versus National consumption Percentage of total antibiotic use in the community 2009 (Top 5) Antibiotic name Figure 3: Antibiotic consumption per region
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(Dreigende) Miskraam Inleiding De informatie over de (dreigende) miskraam kan voor u als handleiding dienen, wanneer bij u een miskraam is geconstateerd of wanneer u vermoedt een miskraam te gaan krijgen. Wat is een miskraam? Een miskraam, ook wel spontane abortus genoemd, is het verlies van een niet-levensvatbare vrucht in de eerste 16 weken van de zwangerschap. Vaginaal bloedv