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A national perspective on progress

A national perspective on progress. Professor Brian Duerden Inspector of Microbiology and Infection Control, Department of Health, London . MRSA bacteraemia 2001/2 7291 (Q Av)1823 2002/3 7426 (Q Av)1856 2003/4 7700 (Q Av)1925 2004/5 7212 (Q Av)1808

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A national perspective on progress

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  1. A national perspective on progress Professor Brian Duerden Inspector of Microbiology and Infection Control, Department of Health, London

  2. MRSA bacteraemia 2001/2 7291 (Q Av)1823 2002/3 7426 (Q Av)1856 2003/4 7700 (Q Av)1925 2004/5 7212 (Q Av)1808 2005/6 7097 (Q Av)1773 2006/7 Q1 1741 Q2 1651 Q3 1542 Q4 1447 6381 2007/8 Q1 1303 C. difficile infection 2001 22008 2002 28986 2003 35537 2004 43672 2005 49850 (voluntary reporting, England, Wales, NI) 2004 44314 2005 51767 2006 55681 2007 Q1 15639 Q2 13660 +2890 (<65) (England, mandatory) 2007 -The challenge of HCAI

  3. Clinicians Safe patient care Diagnosis Treatment Prevention Control Board/CEx/DIPC Corporate environment Make it happen Government/DH Set standards Ensure priority Monitor outcome Legislation Performance management Responsibility for HCAI

  4. Reducing HCAI…. Change the mindset • From: 1) create a system to deliver specialist clinical care 2) take measures to prevent infection • To: 1) create a safe environment for patient care 2) deliver specialist clinical care within that environment

  5. Getting Ahead of the Curve - 2002 Priorities identified • HCAI • bacteraemia (MRSA, GRE) • C. difficile associated diarrhoea • surgical site infection • Tuberculosis • Blood-borne & sexually transmitted viruses (and others!) • Antimicrobial resistance

  6. And then……….POLITICS(and the media hype)

  7. HCAI 2003 - 04 • Winning Ways - December 2003 • Strategy for HCAI • NAO Report - July 2004 • Critical of slow progress • Towards Cleaner Hospitals and Lower Rates of Infection - July 2004 • Action plan

  8. MRSA Target • ‘Halve MRSA infections by 2008’ • MRSA bacteraemia • Baseline 2003-04; Start date April 2005 • Monthly returns • 3-monthly publication from Jan 2007 • Monthly submission and DH/SHA review • Depends upon mandatory surveillance being accurate and timely – CEx sign-off

  9. Monthly MRSA bacteraemia figures August 06 to July 07

  10. MRSA reporting • Timeliness • CEO lock down • Data entry in time • Use voluntary screen to record info to focus effort • Extenuating circumstances • Duplicates • Repeats in untreatable patients • Responsible Trust (eg, renal satellite units)

  11. What do the data tell us? • Men >65 yrs are 43% of MRSA bacteraemias • (15% of all admissions nationally) • 80% of MRSA bacteraemias are in emergency admissions • (37% of total admissions) • 35% have been in hospital during the previous month • Length of stay over 7 days increases risk • 10% of MRSA bacteraemias come from nursing homes • 17% for pre-48 hour cases. • 30% diagnosed in first 48hrs • but 65% of these patients have touched health care setting in recent past • Risk factors • 14% - chronic wounds • 14% - central lines; 10% peripheral lines • 8% pneumonia

  12. Healthcare Associated Infections • MRSA - not the only one! • Clostridium difficile • Glycopeptide resistant enterococci • ESBL-producing E. coli etc • Acinetobacter baumannii • Norovirus

  13. C. difficile “new superbug” hits the national press Mon. June 6th 2005. Jeremy Laurance – Health Editor, The Independent

  14. C. difficile voluntary reporting 1991 – 2005: England, Wales and Northern Ireland

  15. Mandatory surveillance 2004 - 7 • January 2004 • All NHS Trusts in England • Report all cases of C. difficile disease • Toxin +ve diarrhoea • Patients over 65 years (over 2 years from April 2007) • Results • 2004 : 44,314 • 2005 : 51,767 • 2006 : 55,681 • 2007 : Q1 15639 • Q2 13660 + 2890 (<65y)

  16. C. difficile deaths 1999-2005 Office of National Statistics

  17. HCC assessment Definitely Probably Possibly Unlikely No What should we measure? Clinical experience 5-10% direct cause 5-10% probable contributory 30-day mortality 30% 60-day mortality 35-40% Deaths in CDI

  18. C. difficile profile 2005-06 • Public, media, politicians • HCC/HPA Survey published Dec. 2005 • NHS Trusts not following guidance • Antibiotic policies; prevention; management; infection control; reporting • Advisory letter from CMO/CNO Dec 2005 • Saving Lives HII (care bundle) June 2006 • HCC report on Stoke Mandeville July 2006 • CMO/CNO/CPhO/CEx letter Dec 2006

  19. CMO/CNO/CPhO/CEx guidance: Dec 2006 • Antibiotic prescribing • Limit broad spectrum agents • Limit IV and oral courses • Prompt diagnostic tests – Toxins A+B • isolates for typing if outbreak suspected • Isolation/segregation/cohorting of cases • Infection control – handwashing, gloves, gowns • Decontamination/cleaning – increase • Chlorine-based disinfectant

  20. C. difficile local targets • Effective April 2007 • PCT/Acute Trust agreement • Part of annual contracts • Sliding scale of percentage reductions • SHA monitoring

  21. How do we change bad habits? • Management • emphasis on infection control • Enhanced surveillance (HPA) • MRSA & C. difficile • Clinical practice protocols • Cleanliness and hygiene • hand hygiene • environmental cleaning • Training • Targets and performance management

  22. Management priority & responsibility • HCAI • NOT just the Infection Control Team • Trust Board • Chief Executive • Clinical ownership • ALL STAFF • DIPC is the focus • Responsibility • Authority – clinical and managerial • Resource allocation

  23. WW Action area 6.Management and organisation • Chief Executive’s responsibilities • Core part of Clinical Governance and Patient Safety programmes • Promote low levels of HCAI • Ensure actions are taken • Aware of legal responsibilities to identify, assess and control risks of infection • Appoint Director of Infection Prevention and Control

  24. DIPC role • Senior management – Board/CEx report • Professional credibility • Special expertise • Reporting line for ICT • Policy implementation • Performance management • Resource allocation • A champion & a manager!!

  25. Improved C. difficile surveillance • Individual web entry; started April 1, 2007 • All patients over 2 years • Core data • Identifier; age; sex • Date of sample • Location of patient • Reporting laboratory • [from Jan. 08 – in/outpatient; admission date]

  26. C. difficile voluntary page • Risk factors • Health services contact • Antibiotic history • Specialty • Augmented care • Emergency or elective • Suggest 2 – 4 weeks, 4 times a year? • Local assessment; national pooling

  27. Providing the tools • Cleanyourhands campaign • PEAT inspections for cleanliness • Saving Lives & Essential Steps • Root Cause Analysis tool • bacteraemia-specific version – Sept 2006 • MRSA screening advice - October 2006 • C. difficile guidance - December 2006 ……..and now…….

  28. …..legislation • Health Act 2006 • Statutory Code of Practice • Compliance assessed by the Healthcare Commission • Annual healthcheck • 120 unannounced spot checks • Improvement notices

  29. ‘Saving lives’ toolkit • Two components • Self assessment tool – now revised to reflect CoP core duties • 7 High Impact Interventions (Care Bundle approach) - plus guidance notes

  30. High Impact Interventions (revised June 2007) • Central venous catheters • Peripheral line care • Dialysis catheters • Surgical site management • Urinary catheters • Ventilator management • Clostridium difficile

  31. SL Guidance • October 2006 • MRSA screening • June 2007 • Blood Culture protocol • Antimicrobial prescribing framework • September 2007 • Isolation and cohorting

  32. Environmental hygiene • Hospitals should be clean! • Role of matrons & ward sisters • Routine cleaning • Hand-contact areas • Enhanced cleaning in infected areas • Use of disinfectants • Deep cleaning after discharge of infected patient • Cleaning of the bed and bed space • Medical equipment

  33. Training • BMJ eLearning • C. difficile video CPD module • DoctorsNet • CPD module • Dialogue with • Undergraduate Deans • Tomorrow’s Doctors review group (GMC) • Royal Colleges • Postgraduate Deans

  34. Target performance management • DH Task Force • Reviews MRSA bacteraemia and C. difficle figures • Monitors programme activities • Identifies Trusts for SL reviews and visits • SHA performance managers • Monthly review of Trust performance • PCT commissioners – C. difficile

  35. Improvement programme • National Performance Improvement Network (PIN) • Meets 3 times a year • Saving Lives self assessment reviews • Improvement visits • DH team;2-day interviews • Develop local action/recovery plan • Support implementation

  36. Summer 2007 • Saving Lives issue 2 (June) • C. difficile care bundle updated • Antimicrobial prescribing – best practice • ImprovementTeam (formerly MRSA) • Double funding (and size!) • Extend remit to C. difficile • DIPC –review • SACAR report – J Antimicrob Chemother suppl Aug 2007 • Antimicrobial framework

  37. Antibiotic policy - prevention • Restrict use of broad spectrum agents • Promote aminoglycosides (gentamicin etc) • Reasons for prescribing recorded • Stop dates – review by pharmacists • Prophylaxis – single dose • Audit, training and review • Role of Antimicrobial Prescribing Team/Committee

  38. Announcements Sept-Oct 2007 • National CD target - 30% reduction by 2011 • CMO PL on Death Certification • Deep cleaning (PM) • Matrons & Clinical Directors report to Boards quarterly • Dress code – bare below the elbow • MRSA screening – universal (asap) • Isolation and cohorting guidance • Regulator powers: fines and ward closures

  39. Dress code (mainly for doctors) • Bare Below the Elbow (BBE) • Short sleeves • No wrist watch • No wrist or hand jewellery (except plain wedding band) • Sleeves/cuffs and jewellery are impediments to hand hygiene and aseptic procedures • No ties (except bow ties) – they are readily contaminated and not washed! • No white coats! • Scrubs where appropriate, eg, theatre, ICU/HDU, A&E

  40. October 2007 HCC Report • Maidstone & Tonbridge Wells • Major outbreak Oct 2005 – Sept 2006 • Not reported to HPU until April 2006 • Misleading public announcements in June • SHA initiated review in early July and immediately referred to HCC • Findings • Very serious failures of management and clinical care

  41. National recommendations • C. difficile regarded as a diagnosis in own right • Commissioners to ensure acute trusts have guidelines in place • Education and training of junior doctors • Improve recording on Death Certificates • Reinforce antibiotic stewardship messages • NHS/HPA to agree clear and consistent arrangements for monitoring rates of CDI • Boards to understand role and responsibility of DIPC and receive regular information

  42. A wake-up call…….. • We must no longer accept these infections as ‘normal’ • Patients • Can be very ill • Can die • Stay in hospital longer • May need major surgery • Significant NHS resources can be better used

  43. Goal (Government/DH) - use • Political imperative • Measurement • Target setting • Professional support • Performance management AND • Legislation To change human behaviour (clinical & managerial) to • Overcome the challenge of HCAI

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