Tackling HCAI in the NHS strategy and actions

1
Tackling HCAI in the NHS-strategy and actions

• Professor Brian Duerden
• Inspector of Microbiology and Infection Control,
• Department of Health, London

2
2007 -The challenge of HCAI

• 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)

• 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
  

3
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

4
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

5
Infection is different. .it spreads!
6
Biology

• Microbial populations
• Human populations
• Human behaviour

7
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

8
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

9
And then.POLITICS(and the media hype)
10
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

11
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

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
The 1994 DH/PHLS Report (North Manchester
outbreak of 1991-2)
15
C. difficile voluntary reporting 1991 2005
England, Wales and Northern Ireland
16
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

17
C. difficile deaths 1999-2005
Office of National Statistics
18
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

19
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

20
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

21
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

22
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.

23
..legislation

• Health Act 2006
• Statutory Code of Practice
• Compliance assessed by the Healthcare Commission

24
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

25
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

26
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

27
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

28
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

29
SL Guidance

• MRSA screening October 2006
• C. difficile control CMO,CNO,CPhO,CEx letter
  December 2006
• Coming soon
• Blood Culture protocol
• Antimicrobial prescribing framework

30
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??

31
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

32
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.

33
CMO/CNO/CPhO C. difficile guidance Dec 2006

• Antibiotic prescribing
• Limit broad spectrum agents
• Limit IV and oral courses
• Prompt diagnostic tests Toxins AB
• isolates for typing if outbreak suspected
• Isolation/segregation/cohorting of cases
• Infection control handwashing, gloves, gowns
• Decontamination/cleaning increase
• Chlorine-based disinfectant

34
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

35
WW Action area 6.Management and organisation

• Chief Executives 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

36
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!!

37
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)

38
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

39
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

40
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

41
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