HealthcareAssociatedInfectionsGovernanceGroup(HAIGG)

Date:Wednesday 17 December2014

Venue:WellingtonAirportConferenceCentre, (DeHavillandRoom)WellingtonTime:09.00–15.00

Present:SallyRoberts,Arthur Morris, DeborahWilliamson,BobBuckham,RuthBarratt, SheldonNgatai, GeoffreyRoche, JanePryer,DonMackieJaneO’Malley(Co-chairs),GabrielleNicholsonGrantPidgeon.

Invited:CatherineGerard (HQSC)GrantStorey (MoH), MurrayTilyard(BPAC)Apologies: HasanBhally,ChrisMcKenna,NoelineWhitehead

1.Welcomeandintroductions

DonwelcomedandintroducedGrant Pidgeontothegroupasthe newMedical Officers ofHealthrepresentative.

2.ConfirmationofTeleconferenceminutes(22 September 2014)

Minutesconfirmedandacceptedas trueandaccurate,with thefollowingamendments:

  • GabrielleNicholson’ssurnameto becorrected
  • DeborahWilliamson’ssurnametobe corrected
  • Staphylococcusaureus:aureustobe lower case,thenametobeinitalics

3.Action plan update

13.30Vaccinationforhealthcareworkers

A discussionwithin thegroup aroundvaccinationrequirements ofclinical staffwas held.Whilstmandatoryvaccinationcannot beincludedin theHealthDisability Services(InfectionPreventionAndControl)Standards(NZS8134.31:2008), itwas notedthat therewas no specificlegal reasonwhyvaccinationcould notbe incorporatedinto theNationalStandardsinsomeway,such asa statement that totheeffectthat “institutionscanencouragestaff toget vaccinated,”or “eachDHBshouldencouragevaccinationsamongststaff.” Itwasalso notedthatsuchapolicywasconsistent with the principlesofensuringworkplacesafety,andthatvulnerablepatientgroups,such astheimmunocompromised, orchildrenwith cancer, weretobe considered. Otherpoints wereraised:

  • Policies in Australianjurisdictionsandinstitutionswerediscussed,such asthepolicythat non- vaccinatedhealthcareworkers areto wear masks.
  • Haematologyandoncologyunitswereidentifiedaspoints wherestaffimmunisationwasparticularlyneeded.
  • Informingstaff oftheneedforstaffvaccinationat thecommencement of training,andat recruitmentstage, was asuggestedmeasure.
  • AtAucklandDistrict HealthBoard, a policy ofvoluntary vaccinationswasreplacedwithan ‘opt-out ’approach tostaffvaccinations.Thisnewapproachwassupportedbythe senior leadershipteamandconsultationwith healthcareworkersunionswasundertakenearlyin theprocess.For thosewhodid not takeuptheoffer,chose to

‘opt-out’, was senttothemviatheir manager todetermine thereasonfor thedecisionnot to bevaccinated.Seventeenpercentgavepersonal choiceas thereason;23%expressed apreferenceforrelyingon naturalimmunity.

  • Theneedto includecleaningstaff, wardclerks andothernon- medical staffinvaccinationprogrammes wasnoted.
  • Itwas notedthat thehealthcareworker unionissupportiveofhealthcareworkervaccinations

Ingeneral theprocessof reviewingthe NZStandardswasidentified asthekeyissue:

  • evidencebaseapproachneedsto beestablishedfora vaccinationrequirement tobeincorporatedintothe NZstandards.

Action:

JanePryerto drafta“statementofintent”tothe DirectorGeneralwhichraisesthe“awarenessandconsciousness" ofstaff expectation aroundvaccination toprotectvulnerablepatients.Theco-chairsaretospeakwithclinical leadersinearly2015 on theneedofa vaccinationpolicy forhealthcareworkers

SallyRobertsandRuthBarratttosharesuccessful approaches usedto increasestaffvaccinationuptake.

JaneO’Malleyto engage witha variety professional groups, including theNewZealandNursesOrganisation,onthismatter.

4.1CommunityAntimicrobial Resistance

MurrayTilyard,BestPracticeAdvocacyCentre(BPAC),gave apresentationon theuse ofantibiotics inthe community settinginNewZealand.HealsodemonstratedMedTech32, anonlineplatform (referral tool)thatcanbeused bygeneral practicestocalculatethe riskofaconditionbased onethnicity,age, social statusandothercriticalfactors,and cangeneratereferrals.The BPACguidelinesandother resourceswereintroduced.Keypointsofthepresentation areasfollows:

  • A recentpaperby AssociatedProfessorMarkThomas,Alesha J Smithand ProfessorMurrayTilyard,“Risingantimicrobial resistance:astrongreasontoreduceexcessiveantimicrobialconsumption in NewZealand”1,providessupportingevidencefortheneed toreduceantibioticsconsumption.
  • NewZealand’santibiotics use doesnotcomparefavourablywith that inothercountries.
  • There issomeregional variationwhich has notfullybeenexplained.Differingpatientdemographicsmayaccount for regional antibiotics use.
  • Greater longevityhasledtoan increase inmulti-morbidityandpolypharmacy,whichraisesthe needforimprovedprescribing.

1MarkThomas,AleshaJSmithandMurrayTilyard,“Risingantimicrobialresistance:astrongreasontoreduceexcessiveantimicrobialconsumptionin New Zealand”.TheNewZealandMedicalJournal23May2014,Volume127Number1394,pp72-84.

  • A needwasidentifiedfor better communicationsamongst thesecondarysector, forthe purposes ofreducingprescribingerrors.
  • Theneedfor newtechnologytogetherwithstrongclinical leadership and nationalconsistency was noted
  • BritishNational Formulary(BNF)advice has notbeen used byBPAC asitisnotbased on NewZealandinfectionprofilesandresistancepatterns.Currently ithasnotbeenpossible todevelopnewguidanceduetoalackofnational agreement.BPAC’sAntibioticsGuideisrecommended byDrTilyard as an interim solution.

Discussion

Itwas askedwhether therewas aprocessfor reviewingresponsibleprescribing. Inresponseitwas notedthat thereiscurrentlylimitedmeansforperformingreconciliationbetweenprimaryandsecondary care.Itwassuggestedreconciliationmaybe possiblethroughelectronicsystems,but thisdoesnothappencurrently.Theneedforappropriateclinicalsafeguards wasnoted.

Itwas notedthat 2013ratesfor antibioticsconsumptionshowed a decrease. ItwassuggestedthatBPAC’santibioticsbooklet,Antibiotics: ChoicesforCommonInfections,2beendorsed bytheMinistryofHealth.Inresponse itwas noted thatthe Ministryisdiscussingthismatter withPHARMAC.Itwasalsonotedthat the Antibioticstext could be circulatedandupdated.

Itwas notedthat thereare no independentguidelinesforantibiotic use available in NewZealandfor veterinarians. Itwas notedthat veterinaryusersareconcerned and wantMPItoaddressthe needforguidance.

4.2HealthQuality& SafetyCommission(HQSC)AtlasAMRSteeringGroup

CatherineGerrard (HQSC)presentedtheAtlasof HealthcareVariation, asystem forthecollation ofmedical datasets.3Anexampleoftheoutputs ofthissystem isthe HQSCreport,published in the NewZealandMedical Journal, “Variationinbenzodiazepineandantipsychotic use inpeople aged65 yearsandoverinNewZealand.”4Theutility ofthe Atlasapproach isasmuchtodo with thequestionsits resultspose as with theresultsthemselves.Thepioneerofthe Atlas approach is JohnWennberg, a leadingresearcher ofunwarrantedgeographicvariationinhealthcare.

  • Wherethedatapresentedcallsforexplanation, theAtlassystemhas atext bookforthe insertionofanexplanatorynote
  • Dataisencryptedatthe NHIlevel
  • Datainputs includehospital data, andantibioticresistancedatafrom ESR.Pharmaceutical dataissourcedfrom communitydispensing.

2Availableat:

3 NewZealandMedicalJournal(2014)June20;127(1396):67-78.

Available at: 1396/6169

Discussion

Itwas notedthatclinicalpharmacologistscaninfluenceprescribingpractices in a particularhealthcaresetting.Alsonotedwas theneedfor healthcarestrategiesto becommunicatedtothe lowerorganisationallevelsforimplementation.

4.3Best PracticeGuidelinesupdate

SallyRobertsoutlinedthenewlyreleasedAustralianTherapeuticsGuidelinesv15.Abestpracticeguidelinesfor antibiotics,andinviteddiscussion onthe suitability ofthisguidelineforthe secondarycaresectorinNewZealand. Theneedforsuchguidelines wasexplained:

  • SomeDHBshave noon-siteantibioticsexpertise; advice is sought attheinitiative ofindividual staffabout individualpatientsfrom largerneighbouringDHB’s
  • Considerablevariationinprescribingwithin an individual DHBhasbeenobserved
  • AmericanguidelinesarecurrentlybeingusedinsomeareasinNewZealand; theseguidelinesrecommend twice the dosagesrecommended in NewZealandin somecases
  • Therecommendedguidelineswouldneed tobe suitableforusebybothinfectiousdiseaseservices and non-experts.

A recommendedbasisforsuchaguidelinestext was the Australianresource,Antibioticversion 15,2014,published bytheTherapeuticsGuidelinesgroup.5

Discussion

Thefollowingpointswerediscussed:

  • the needtoestablishastraightforwardaccesspath fortheresourcewasnoted
  • itwas notedthat theproposedguidelinesalone willnotimprovestewardship
  • the needtomeasureperformance andfeed-backthisinformationwasnoted,i.e.theneed tomeasureimprovementsmade bytheestablishmentofthe newguidelines
  • itwas notedthat optimaluse ofantibiotics was a government strategicgoal (source:MedicinesNewZealandstrategy)
  • Itwas notedthat theguidelinesought to beapplicable toresidentialandprimarycare,as well as theworkofDHBs.
  • Consideration tobegiven tolocalneedsandvariationAgreed
  • Australia ismorealignedtoNewZealand– largenumber ofInfectiousDiseasesphysicianshave had inputintothedevelopment ofthe Australiantherapeuticguidelines
  • Acknowledgement that there isantibioticavailabilitydifferences between the twocountries
  • Consideradoptingthe onlineeditionofthe Australiantherapeuticguidelines(ATG)foruse insecondary care.Furtherdiscussionrequired toassessthe use ofthe ATGfor primarycare

5

Action:

  • Establishment ofa workinggroup ofNewZealandclinicianstoreviewtheAustraliantherapeuticguidelines(ATG)
  • Engagement withPHARMACand theTherapeuticsGuidelinesGroupon producingandendorsingaNewZealandeditionoftheATG
  • MembersofHAIGGto workcollaborativelyon someofthe discussionpointsaroundAMRwithagreed timeframes

4.4Updatefrom ESR

DebbieWilliamsonprovided an update oncurrentESRsurveillanceactivities:

  • ESBL-producingEnterobacteriaceae
  • Staphylococcusaureus
  • Neisseriagonorrhoeae.

Thepurpose ofthissurveillance is to providecontemporary information onantimicrobialsusceptibilityagainst antimicrobial agents, andtoprovideinformation onthestraintypesincirculation,e.g. information on localandregionaltransmission, emergenceofnewstrains,andcomparisonwithoverseasstrains.

Recent findings:

  • MRSAstrainCC398 hasrecentlyemergedinpigs
  • Hospital-onsetC.difficileinfection:data iscapturedfrom pilotsites
  • TheNewZealandMicrobiologyNetworkisnowoperational

Discussion onskinsepsisandtopical antibiotics.

Highlevelsofprescribingoffusidicacidprescribingweredescribed, anditwas notedthattherearediscussionsonchanging therulesaroundprescribing. Thefollowingpointsweremade:

  • pressureisplacedon prescribers bypatients,especially whencellulitisisdeveloping
  • the problemappearsto be aNewZealand-specificone
  • thereareregional variancesinDHBprescribingofcephalosporinconsumption
  • therehasbeenan increase in antimicrobial consumptionofantibiotics
  • theincrease infusidicacidconsumptionhasledto an increase infusidicacidresistanceinNewZealand.

Agreed:

Itwasagreedthat the HAIGGshouldprogresstheissueof topical use of antibioticsfor skininfections.The baselinewould need tobe established and definitionsto be used in infectionpreventionandcontrol would need tobespecified.

Action:

  • national datatobe presentedto andconsidered by the HAIGGmid-2015

5.ITandSurveillance

GabrielleNicholsonandDebbieWilliamsonprovided an update onIT andsurveillance.

Background

ESRand HQSC havebeenconcurrentlybut independentlyworkingtowardthedevelopmentofsystemstosupportbetterhealthoutcomesassociatedwithhealthcareassociatedinfections(HAI) andantimicrobial resistance(AMR). TheCommissionwantsto progressworkfor itsInfectionPreventionand Control(IPC)programme,inparticularregardingitsSurgical SiteInfectionImprovementProgrammeand thedelivery ofanationalsystem tosupport IPCpointofcareactivities.ESRhasbeencontractedbytheMinistryto progressworkforan enhancednational surveillancesystem to support AMRand hospital-onsetClostridiumdifficileinfectionsurveillance.

BoththeCommissionandESRhaveidentified aneedforaninvestment inIT tosupportqualityimprovementsinIPCpointofcareactivities,alongwithsurveillanceofAMRandHAIS.

Summary

  • theNationalITBoardhasprovidedspecificationsforthe envisionedsystem.
  • asteeringgroupcomprisingofESR, theMinistry ofHealth,andHQSCwilllead theprocess.
  • A proposalwill be provided from HQSCandESR tothe National ITBoardduring thenext financial year;

Discussion

Thefollowingpointswereraised:

  • Clinical leadershipwillrequireinputofDHBs ChiefFinancial OfficersandChiefExecutives
  • Theinputofahealtheconomist wasrequired; itwasrecommendedthat theMinistryofHealth’sChiefEconomist be consultedwith.
  • Theproposalwould be strongeriftheITsystem wascapable ofbeinglinked via theweb to other systems, such asprimary care
  • IftheproposedITsystemisplaced onthecriticalListit must be implemented byDHBITboardswithin fiveyears.

Agreed

  • agreement fromHAIGGwiththeproposedapproachofprocuringajointbusinesscase betweenHQSC, MoH andESR
  • A steeringgroup will be establishedearlyin theNewYear;itisintendedthatit willhaverepresentationfrom theNationalHealthITBoard.

Pharmacyupdate

BobBuckham providedthefollowingupdatesanddiscussionpoints:

  • NewZealandHospitalPharmaceutical Society ofNewZealandrole in vaccinatingduring theinfluenzaseason.
  • TheNewZealandMedical Association andtheNewZealandHospital PharmacyAssociationhaveprepared ajointvisionstatement,regardingcommunity- basedtreatmentofinfectionsandhowtheyaremanaged.
  • A UK“gatewayto treatment” wasdescribed, whereby ifapatientataGP surgerydoes not currentlymeet thetreatment threshold, theycan still begiven a prescriptionforuse ifneeded within alimitedtimeframealongwithinformationabout theinfectionandself-management
  • Theneedfor healthliteracyand supportpeopleforpatientswerediscussed.

6.Ebolatodate.

DonMackiepresentedanupdateontheEbolasituationandthe Ministrypreparednessactivities.

Keypoints:

  • Aroundonepersonpermontharrives in NewZealandfromEbola- affectedcountries;the NewZealandCustomsService hasgoodsystems inplaceforthetrackingofpassenger movements
  • The risktoNewZealandofacaseremainsvery low
  • Themechanismsformovinga sample tothe VictorianInfectiousDiseasesReferenceLaboratory(VIDRL) wastestedrecently andfound toworkwellwhen ahoaxpackagewasdelivered tothe officesoftheNewZealandHerald on 11November2014.
  • A highlevel ofinterest was notedamongst PrimaryCare, as indicatedbyattendancenumbersatarecentprimary careEbolainformationsessioninheldinAuckland–Similarseminarshavealso been heldinWellington
  • TheMoH roadshowswherewellreceived bythefourdesignated receivinghospitalsaroundthe country
  • NewZealandhave ajointagreementwithAustralia in contractingAspenMedical asthemedical serviceprovider for deploymentofNewZealanderswishing toworkinEbolaTreatment Centres

Discussion

  • TheEbolasituationhasprovided an opportunityforallPPE- relatedresponsibilitiesto be reviewedandwith aparticular resourcereviewon primarycarefacilities
  • Itwasnotedthat the resourcesrequiredforEbolareadiness,hasstretchedresourcesfor manyhealthcarefacilitiesaroundNewZealand
  • ConsultationwithInfectionPreventionandControlservices is variableacrossDHB’s

7.IPCPost graduatestudy

RuthBarrattproposedthatWaiarikiInstituteof Technologybe assistedinobtainingHealthWorkforceNewZealand, for their InfectionPreventionandControl Masters-level course. Itwas noted thatWaiarikiInstitute of Technologyhas beenteachingIPCaroundtwentyyears.

Thefollowingpointsweremade:

  • itwassuggestedthat thefirst stage was todecideonthe content andtype(Master’sdegree, diplomacourse,orotherwise)ofa suitable courseonIPC, basedon thehealthsector’sneeds, and thendetermine whobest to provide the course
  • itwassuggestedthatitwaspreferableto have asingleprovider forsucha course
  • itwassuggestedthatalarger university withgreater resourcingandbreadthandscopeofresearch activity,with asciencebackgroundandlaboratory, andanatmosphereof critical analysis,was apreferredsiteforsucha course
  • on theotherhand,itwas notedthatWaiarikiInstituteof Technologyhasanestablishedrecordof teachingIPC

Agreed

ItwasagreedthatHAIGGwould notethecoursecontent,identifytheneed,andfind astrategicpartnerfortheIPCcourse.

Action:

  • JaneO’Malleyto discuss withseveral keypeopleandorganisations ontheprocessofaccreditationoftertiary levelcoursesand with the NursingCouncilprocesses,coursecontent, andwherethe envisionedcourseisbestplacedinstitutionally.

8.Roundtheroom

RuthBarrattdiscussed a surveyreportontherole ofIPCteamsinNewZealand,AustraliaandAmericaandtheimpact thishason HealthcareAcquiredInfectionrates.Resultsnotyetpublished.For discussion at a laterdatewithinthegroup.

Discussion on recruitingnewHAIGG members

Itwassuggestedthat representativesfromprimary care,thePublicHealthGroup, andtheCollegeofGPsbesought for membershipwiththeHAIGG. Itwasalsosuggestedthatspecifications bedraftedfor newmembership, such as seekingmembers:

  • withnational oversight
  • withstrategicthinkingability
  • seen bytheir peers asknowledgeable.

DebbieWilliamson–ESR,publicationofthe antimicrobial consumptionreport dueoutinFebruary 2015

9.CloseofMeeting.