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Tackling HCAI in the NHS -strategy and actions. 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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tackling hcai in the nhs strategy and actions

Tackling HCAI in the NHS-strategy and actions

Professor Brian Duerden

Inspector of Microbiology and Infection Control,

Department of Health, London

2007 the challenge of hcai
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 Q1 1741

Q2 1652

Q3 1542

C. difficile infection

2001 22008

2002 28986

2003 35537

2004 43672

2005 49850

(voluntary reporting, England, Wales, NI)

2004 44314

2005 51767

2006 55681

(England, mandatory)

2007 -The challenge of HCAI
responsibility for hcai
Clinicians

Safe patient care

Diagnosis

Treatment

Prevention

Control

DIPC

Corporate environment

Make it happen

Government/DH

Set standards

Ensure priority

Monitor outcome

Legislation

Performance management

Responsibility for HCAI
1970 2000 a dichotomy
Microbiology & Infection Control

New antibiotics

New societies

New journals

New guidelines

New diseases

Infection control was the province of the IC specialists

Modern medicine

Increased life expectancy

Cancer treatment

Immunosuppression

Complex surgery

Cardiac, Neurosurgery

Orthopaedic

Chronic illnesses

Renal dialysis

Infection – a nuisance

1970 – 2000: a dichotomy
biology
Biology

Microbial populations

Human populations

Human behaviour

reducing hcai
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

getting ahead of the curve 2002
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
hcai 2003 04
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
mrsa target
MRSA Target
  • ‘Halve MRSA infections by 2008’
    • MRSA bacteraemia
    • Baseline 2003-04; Start date April 2005
    • Monthly returns
    • 3-monthly publication from Jan 2007
  • Depends upon mandatory surveillance being accurate and timely
healthcare associated infections
Healthcare Associated Infections
  • MRSA - not the only one!
  • Clostridium difficile
  • Glycopeptide resistant enterococci
  • ESBL-producing E. coli etc
  • Acinetobacter baumannii
  • Norovirus
slide13
C. difficile “new superbug” hits the national press Mon. June 6th 2005. Jeremy Laurance – Health Editor, The Independent
mandatory surveillance 2004 5
Mandatory surveillance 2004 - 5
  • January 2004
    • All NHS Trusts in England
    • Report all cases of C. difficile disease
      • Toxin +ve diarrhoea
    • Patients 65 years and older
  • Results
    • 2004 : 44,314
    • 2005 : 51,767
    • 2006 : 55,681
c difficile deaths 1999 2005
C. difficile deaths 1999-2005

Office of National Statistics

c difficile profile 2005 07
C. difficile profile 2005-07
  • 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
  • HCC report on Stoke Mandeville July 2006
  • CMO/CNO/CPhO/CEx letter Dec 2006
  • Local targets April 2007
how do we change bad habits
How do we change bad habits?
  • Enhanced surveillance (HPA)
    • MRSA & C. difficile
  • Clinical practice protocols
  • Cleanliness and hygiene
    • hand hygiene
    • environmental cleaning
  • Management
    • emphasis on infection control
  • Training
improved c difficile surveillance
Improved C. difficile surveillance
  • Individual web entry
  • All patients over 2 years
  • Core data
    • Identifier; age; sex
    • Date of sample
    • Location of patient
    • Reporting laboratory
  • Started April 1, 2007
c difficile voluntary page
C. difficile voluntary page
  • Risk factors
    • Health services contact
    • Antibiotic history
    • PPIs
    • Specialty
    • Augmented care
  • Suggest 2 – 4 weeks, 4 times a year?
  • Local assessment; national pooling
providing the tools
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…….

legislation
…..legislation
  • Health Act 2006
    • Statutory Code of Practice
    • Compliance assessed by the Healthcare Commission
health act 2006 code of practice
Health Act 2006 – Code of Practice
  • 11 core duties
    • Management, Organisation and Environment
    • Clinical Care Protocols
    • Healthcare Workers
      • Training in Infection Control
      • Own health protection
  • Policy components & references to support compliance
  • SL assessment revision to reflect CoP
saving lives toolkit
‘Saving lives’ toolkit
  • Two components
    • Self assessment tool – based on 9 challenges

now being revised to reflect CoP

    • 5 high Impact Interventions (Care Bundle approach)

now increased to 8 plus guidance notes

self assessment tool
Self-assessment tool
  • Assurance statements for Core Duties (11)
    • 1. General duty to protect patients, staff and others from HCAI
    • 2. Appropriate management systems for IPC
    • 3. Assess risks of HCAI and take action to reduce/control
    • 4. Provide and maintain a clean environment
    • 5. Provide information to patients and public
core duties cont
Core duties (cont.)
  • 6. Provide information when patients move from one healthcare provider to another
  • 7. Ensure cooperation within healthcare provider
  • 8. Provide adequate isolation facilities
  • 9. Ensure adequate laboratory support
  • 10. Adhere to policies and protocols for IPC
  • 11. HCW to be free from and protected from infections and to be educated in IPC
high impact interventions
High Impact Interventions
  • Preventing microbial contamination
    • Basic asepsis and hygiene
  • a Central venous catheters

b Peripheral line care

c Dialysis catheters

  • Surgical site management
  • Urinary catheters
  • Ventilator management
  • Clostridium difficile
sl guidance
SL Guidance
  • MRSA screening – October 2006
  • C. difficile control – CMO,CNO,CPhO,CEx letter December 2006
  • Coming soon
    • Blood Culture protocol
    • Antimicrobial prescribing framework
mrsa screening october 2006
MRSA screening – October 2006
  • Advisory/guidance to NHS Trusts
  • Focus on own high-risk groups
    • Elective orthopaedic, cardiovascular, neurosurgery – pre-admission
    • Emergency surgery – elderly orthopaedic/trauma?
    • All elective surgery?
    • ICU & HDU admission and weekly
    • Renal dialysis
    • Admissions from other hospitals, healthcare settings
    • All emergency admissions??
screening and decolonisation
Screening and decolonisation
  • Screening methods
    • Swab, direct plating on chromogenic agar
    • Swab, into selective broth, then plate
    • Rapid tests, eg PCR etc
  • Decolonisation regimen
    • MRSA positive
    • All initially; stop on negative result?
    • All, irrespective of screening?
  • Isolate patient if possible
objective
Objective

All trusts, as a matter of urgency, should review their policies for MRSA screening to determine the most appropriate initial approach to screening for their patient population.

cmo cno cpho c difficile guidance dec 2006
CMO/CNO/CPhO C. difficile 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
management priority responsibility
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
ww action area 6 management and organisation
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
dipc role
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!!
performance management
Performance management
  • SHA performance managers
  • PCT local C. difficile targets 2007
  • Recovery and Support Unit (DH) Task Force
    • MRSA & C. difficile figures
    • Monitors programme activities
    • Identifies Trusts for SL reviews and visits
  • Healthcare Commission
    • Annual assessments (scores and ratings)
    • National Study 2005/6
    • Legislation compliance (Improvement notices)
target performance management
Target performance management
  • DH Recovery and Support Unit 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
improvement programme
Improvement programme
  • National Performance Improvement Network (PIN)
    • Meets 4 times a year
  • Saving Lives self assessment reviews
  • Improvement visits
    • DH team;2-day interviews
    • Develop local action/recovery plan
a wake up call
A wake-up call……..
  • We have accepted these infections as ‘normal’
  • Patients
    • Can be very ill
    • Can die
    • Stay in hospital longer
    • May need major surgery
  • Significant NHS resources could be better used
goal government dh use
Goal (Government/DH) - use
  • Political imperative
  • Measurement
  • Target setting
  • Professional support
  • Performance management AND
  • Legislation

To change human behaviour (clinical & managerial) to

  • Overcome the biology of HCAI