CASO DI STUDIO: AFFRONTARE LA SFIDA DELLE RISORSE LIMITATE

“Queste raccomandazioni possono essere considerate estremamente impegnative nei contesti con risorse limitate. In particolare, la loro fattibilità al di là degli ospedali di assistenza terziaria dove vi sono risorse limitate, troppo poche risorse umane, assenza di materiali necessari e capacità di laboratorio scarsa o assente. Cosa si fa in questi contesti? Il ricovero dei pazienti portatori di germi di CP in queste strutture sarebbe un fattore molto favorevole per la diffusione di questi ceppi. Per tale motivo, bisogna considerare dove sia meglio prendersi cura di questi pazienti.

Potrebbe in effetti risultare migliore proibire il ricovero dei pazienti con CRO negli ospedali o nei centri di cura e cliniche senza un programma per la gestione di tali casi. Ovviamente richiederà delle misure associate, come linee guida tecniche, su come gestirli perché avranno bisogno di essere gestiti, ma è importante considerare l’opzione di non ricovero, confrontandola con i bisogni clinici e la sicurezza del paziente.”

STRUMENTI E RISORSE

Strumenti di supporto disponibili dell'OMS e di altre agenzie Strumenti e risorse relativi ai CRO

• Australian Commission on Safety and Quality in Health Care. Recommendations for the control of carbapenemase-producing Enterobacteriaceae (CPE). A guide for acute care health facilities

https://www.safetyandquality.gov.au/wp-content/uploads/2017/05/Recommendations-for-the-controlof-Carbapenemase-producing-Enterobacteriaceae.pdf

• US Centers for Disease Control and Prevention facility guidance for the control of carbapenem-resistant Enterobacteriaceae (CRE) - Novembre 2015 Update - CRE toolkit https://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf

• United States Agency for Healthcare Research and Quality (AHRQ) Carbapenem-resistant Enterobacteriaceae (CRE) control and prevention toolkit (2014) https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/cretoolkit/index.html

• Public Health England. Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae (Dicembre 2013). London: Public Health England, United Kingdom

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/329227/ Acute_trust_toolkit_for_the_early_detection.pdf

* Currently undergoing revision, issue date anticipated is Luglio 2019 for the consultation and testing phase. • Public Health England. Toolkit for managing carbapenemase-producing Enterobacteriaceae in non-acute and community settings (2015). London: Public Health England, United Kingdom

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/439801/CPE-Non-AcuteToolkit_CORE.pdf

*Currently undergoing revision, issue date anticipated is Luglio 2019 for the consultation and testing phase. • European Union/EEA guidance/guideline documents are available from Belgium, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Luxembourg, The Netherlands, Norway, Portugal, Poland, Slovakia, Slovenia, Spain, Sweden and the United Kingdom https://ecdc.europa.eu/en/publications-data/directory-guidance-prevention-and-control/prevention-and-control-infections-1

Risorse per l’implementazione dei programmi di IPC

• WHO core component implementation resources http://www.who.int/infection-prevention/tools/core-components/en/

• WHO Interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2018

http://www.who.int/infection-prevention/tools/core-components/facility-manual.pdf vedere in paricolare pag. 90: (a) sample action plan: monitoring/audit of IPC practices and feedback; pag. 99: sample action plan: built environment, materials and equipment for IPC.

• WHO IPCAF http://www.who.int/infectionprevention/tools/core-components/en/

• CDC Infection control assessment tools https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html

Strumenti sull’igiene delle mani

• WHO hand hygiene tools and resources (generali) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

•WHO hand hygiene self-assessment framework

http://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1

• WHO hand hygiene guide to implementation and associated resources http://www.who.int/infection-prevention/tools/hand-hygiene/en/

•WHO ‘Your Five Moments’ for hand hygiene poster

https://www.who.int/gpsc/5may/Your_5_Moments_For_Hand_Hygiene_Poster.pdf?ua=1

• WHO ‘How to handrub’ e ‘How to handwash’ posters https://www.who.int/infection-prevention/tools/hand-hygiene/workplace_reminders/en/

• WHO tools as reminders in the workplace (including application of the ‘Five Moments’ and a patient with: (a) postoperative wound; (b) central venous catheter; (c) peripheral venous catheter; (d) endotracheal tube; and (e) urinary catheter), with the aim to emphasize specific strategies within healthcare facilities and the use of these tools at the bedside http://www.who.int/infection-prevention/tools/hand-hygiene/en/

• WHO glove use information leaflet including the glove pyramid)

Strumenti relativi a precauzioni da contatto, isolamento e cohorting

• CDC standard precautions for all patient care

https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html

• CDC transmission-based precautions (including contact precautions)

https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.Html

• Society of Healthcare Epidemiology of America. Expert guidance duration of contact precautions for

acute-care settings

https://www.cambridge.org/core/journals/infection-control-and-hospital- epidemiology/article/duration-of-contact-precautions-for-acutecare-settings/94E38FDCE6E1823BD613ABE4E8CB5E56

• Society of Healthcare Epidemiology of America/CDC. Outbreak response training program. Defending against superbugs: an interactive case study managing an “outbreak” of carbapenem-resistant

Enterobacteriaceae (CRE) in a hospital setting

https://shea.med-iq.com/defending-againstsuperbugs-an- interactive-case-study-managing-an-outbreak-of-carbapenem-resistant-enterobacteriaceae-cre-in-a-hospital-setting.html

• NHS Scotland. Standard infection control precautions

http://www.nipcm.hps.scot.nhs.uk/chapter-1-standard-infection-control-precautions-sicps/

• NHS Scotland. Transmission-based precautions

http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmission-based-precautions-tbps/

• NHS Scotland. Toolkit for managing carbapenemase-producing Enterobacteriaceae (CPE) in Scottish non-acute care settings. (see page 11: risk assessment flow chart: management of individuals positive for CPE (colonisation or infection); see page 15: guidance for undertaking a risk assessment on managing individuals

positive for CPE (colonisation or infection) https://www.hps.scot.nhs.uk/resourcedocument.aspx?id=6220

• Public Health England. Carbapenemase-producing Enterobacteriaceae: early detection, management and control toolkit for acute trusts – risk prioritisation of infection prevention and control measures, screening and isolation (see page 10: who is responsible: front line employees in all units as part of admission process; see

page 13 for information on negative screens)

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/329237/ carbapenemase-producing_Enterobacteriaceae_Supplementary_Risk_Matrix_2014146.pdf

• European Centre for Disease Prevention and Control (ECDC). Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control (2017).

• ECDC Technical Report. Risk assessment on the spread of carbapenemase-producing Enterobacteriaceae (CPE) through patient transfer between healthcare facilities, with special emphasis on cross-border transfer (https://www.ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/110913_Risk_assessment _resistant_CPE.pdf).

Strumenti focalizzati sul paziente e il personale di assistenza

• Australian Commission on Safety and Quality in Health Care. Carbapenem-resistant Enterobacteriaceae

(CRE): patient information sheet

https://www.safetyandquality.gov.au/publications/cre-patient-information-sheet/

• NHS Scotland. Toolkit for managing carbapenemase-producing Enterobacteriaceae (CPE) in Scottish non-acute care settings (See pages 26, 29 and 32 for patient and family advice leaflets)

https://www.hps.scot.nhs.uk/resourcedocument.aspx?id=6220

• Patient information leaflet, Geneva University Hospitals, Geneva, Switzerland (French)

Utilizzo di strumenti a supporto dell’implementazione di igiene delle mani, precauzioni da contatto, isolamento e cohorting

Il Riquadro 20 presenta degli esempi in cui sono stati utilizzati degli strumenti per sostenere l’implementazione di igiene delle mani, precauzioni da contatto, isolamento e cohorting in caso di CRO e riassume (dove possibile) alcune lezioni chiave che possono essere utili per chi considera di utilizzare degli strumenti per rafforzare il loro approccio alla prevenzione e al controllo dei CRO.

Lacune attuali nella disponibilità degli strumenti

Vi sono alcune aree in cui lo sviluppo di nuovi strumenti è considerato utile per sostenere un’implementazione di successo. Tali strumenti potrebbero essere sviluppati a livello internazionale, nazionale o locale e questo manuale ha l’obiettivi di stimolare l’azione per affrontare tali mancanze. L’elenco seguente evidenzia gli strumenti che sono stati identificati per lo sviluppo prioritario.

 Igiene delle mani

▷ Applicazioni digitali a supporto dell’integrazione dell’igiene delle mani tra protocolli/procedure operativi standard.

 Precauzioni da contatto

▷ Strumenti di valutazione del rischio

▷ Algoritmi per un supporto decisionale

▷ Calcolatore di quantità di DPI e costi

▷ Video formativi, ad esempio, sull’utilizzo dei DPI

▷ Strumento di audit con sistema a punti per sostenere il miglioramento graduale

▷ Poster e segnali per identificare le aree di isolamento

 Isolamento e cohorting

▷ Algoritmi per un supporto decisionale

▷ Strumento per valutare i requisiti di base della struttura per isolamento e cohorting

▷ Strumenti per decidere quando interrompere l’isolamento e in quali condizioni questo deve avvenire (potrebbe far parte di un algoritmo)

▷ Indice di isolamento

▷ Strumenti di rapporto costi-benefici, inclusi costi per i pazienti

▷ Super-diffusori: come identificarli e livello di precauzioni da assumere.