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 2002/3 2003/4 2004/5 2005/6 2006 7291 7426 7700 7212 7097 Q 1 Q 2 Q 3 (Q Av)1823 (Q Av)1856 (Q Av)1925 (Q Av)1808 (Q Av)1773 1741 1652 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)

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

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

Infection is different……. it spreads!

Biology Microbial populations Human behaviour

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 Priorities identified HCAI – bacteraemia (MRSA, GRE) – C. difficile associated diarrhoea – surgical site infection Tuberculosis Blood-borne & sexually transmitted viruses (and others!) Antimicrobial resistance

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

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 ‘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 MRSA - not the only one! Clostridium difficile Glycopeptide resistant enterococci ESBL-producing E. coli etc Acinetobacter baumannii Norovirus

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

The 1994 DH/PHLS Report (North Manchester outbreak of 1991 -2)

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

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 : – 2005 : – 2006 : 44, 314 51, 767 55, 681

C. difficile deaths 1999 -2005 1999 DC 2001 2002 2003 2004 2005 975 1, 214 1, 428 1, 788 2, 247 3, 807 mentions UC 531 691 756 958 % as UC 54 57 53 55 1, 245 2, 074 55 Office of National Statistics 54

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/CPh. O/CEx letter Dec 2006 Local targets April 2007

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

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 Co. P

‘Saving lives’ toolkit Two components – Self assessment tool – based on 9 challenges now being revised to reflect Co. P – 5 high Impact Interventions (Care Bundle approach) now increased to 8 plus guidance notes

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. ) – 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 1. Preventing microbial contamination – Basic asepsis and hygiene 2. a Central venous catheters b Peripheral line care c Dialysis catheters 3. Surgical site management 4. Urinary catheters 5. Ventilator management 6. Clostridium difficile

SL Guidance MRSA screening – October 2006 C. difficile control – CMO, CNO, CPh. O, CEx letter December 2006 Coming soon – Blood Culture protocol – Antimicrobial prescribing framework

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 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 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/CPh. O 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 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 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 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 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 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 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……. . 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 Political imperative Measurement Target setting Professional support Performance management AND Legislation To change human behaviour (clinical & managerial) to Overcome the biology of HCAI