Healthcare associated infections across the health and social care community Professor Brian Duerden CBE Inspector of Microbiology and Infection Control, Department of Health, London
Infection is different..it spreads!
HCAI Knows no boundaries across health and social care Bacteria move with people Affects all health and social care settings Responsibility across the whole health and social care community
Health and social care community NHS SHAs performance management PCTs commissioners and providers General practice Community hospitals Acute Trusts/FTs Mental Health Trusts Ambulance Trusts Independent sector Hospitals; independent treatment centres Nursing & care homes Health Protection Agency
The HCAI challenge.. MRSA bacteraemia 2001/2 7291 2002/3 7426 2003/4 7700 2004/5 7212 2005/6 7097 2006/7 6383 2007/8 4438 C. difficile infection >65 years 2004 44314 2005 51767 2006 55681 2007 50392...why?
1970 2000: a dichotomy Microbiology & Infection Control New antibiotics New societies New journals New guidelines New diseases Infection control was the province of the infection specialists Modern medicine Increased life expectancy Cancer treatment Immunosuppression Complex surgery Transplants Chronic illnesses Renal dialysis Long-term care Infection a nuisance
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
Responsibility for HCAI Clinicians & carers Safe patient care Diagnosis Treatment Prevention Control Boards/CEx CEx/managers Corporate environment Make it happen Government/DH Set standards Ensure priority Set targets Monitor outcome Performance management..and
.. legislation Health Act 2006 Statutory Code of Practice : all NHS bodies Compliance assessed by the Healthcare Commission Annual healthcheck Improvement notices Annual specialist inspections from 2008-9
Health and Social Care Act 2008 Care Quality Commission Extends COP to independent sector and all care settings Registration NHS bodies: 2009/10 Independent sector 2010/11 (continuation of current registration Care Standards Act) Compliance with revised Code of Practice Effective April 2009 Demonstrate compliance with registration Restructured; same content and purpose
HCAI focus 2004 and before Hospital acquired infection 2005-07 07 Other healthcare settings Healthcare associated Infections 2008 The wider health and social care community
MRSA Target 2005-08 08 Halve MRSA infections by 2008 MRSA bacteraemia Baseline 2003-04; 04; Start date April 2005 Depends upon mandatory surveillance being accurate and timely CEx sign-off Target measured April-June 2008
MRSA target.achieved! achieved! 2001/2 7291 2002/3 7426 2003/4 7700 2004/5 7212 2005/6 7097 2006/7 6383 2007/8 4438 2008/9 Q1 836 Quarterly average 1925 836 57% reduction
How have we changed practice? Management emphasis on infection control Enhanced surveillance (HPA) MRSA & C. difficile Clinical practice protocols Saving Lives & Essential Steps Cleanliness and hygiene hand hygiene environmental cleaning Training Targets and performance management Legislation Code of Practice
Saving lives & Essential steps Two components Self assessment tools for all types of organisation reflect CoP core duties High Impact Interventions (Care Bundle approach) 7 in Saving lives ; 3 in Essential steps - plus guidance notes
High Impact Interventions Saving lives Central venous catheters Peripheral line care Dialysis catheters Surgical site management Urinary catheters Ventilator management Clostridium difficile Essential steps Preventing the spread of infection Hand hygiene PPE Aseptic technique Safe disposal of sharps Urinary catheter care Enteral feeding
Saving lives guidance October 2006 MRSA screening June 2007 Blood Culture protocol Antimicrobial prescribing framework September 2007 Isolation and cohorting
MRSA target beyond 2008 Headline message: continue to improve The target is a ceiling Get as much below as possible Year on year reductions Mandatory surveillance system will continue SHA envelopes for the target SHAs performance manage Trusts within envelope Achieved or better at least maintain; aim to reduce further Not reached continue with performance management and monitoring to achieve the target and beyond
MRSA bacteraemia in the community Pre-48 hour cases: 30% of all cases RCA must include primary care Chronic conditions Indwelling devices Underlying pathology increasing susceptibility Repeat attenders Contact with healthcare settings Community hospitals Residential care..and so must the actions!
MRSA screening All elective admissions by March 2009 Not maternity, ophthalmic, dental, endoscopies DH monitors implementation from October All admissions asap and at latest by 2010-11 11
Why are we screening? Colonisation precedes infection mostly Colonised patient is At risk of developing an infection A possible source for transmission to others Isolate MRSA +ve+ patients if possible Screening AND decolonisation Reduces the risk for the individual Reduces the risk of transmission
Decolonisation Body wash, shampoo, nasal cream 5 days Success rate Depends on time eg 1 week, 90%; 3 months 60-70% BUT immediately reduces the bioburden of MRSA Covers the period of highest risk and of interventions
Screening and patient flow Where to screen and when? Pre-admission clinic On admission (emergency admissions) In primary care Nursing/care home patients? Who does it? Who administers the decolonisation regimen hospital and/or primary care..needs to be a partnership
C. difficile target present status C. difficile infection >65 years 2004 44314 2005 51767 2006 55681 2007 50392 2007/8 45334 + 2-642 years 10059
C. difficile voluntary reporting 1991 2005: England, Wales and Northern Ireland 50000 45000 40000 number of reports 35000 30000 25000 20000 15000 10000 5000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 year
1991-1994 1991-92 : large outbreak in Manchester 170+ cases; 17 deaths (at least) Elderly patients; winter High antibiotic use Reference Lab PyMS typing confirmed cross-infection Parliamentary questions! Smaller outbreaks widespread
C. difficile new superbug hits the national press Mon. June 6 th 2005. Jeremy Laurance Health Editor, The Independent
C. difficile deaths 1999-2006 1999 2001 2002 2003 2004 2005 2006 2007 DC record 975 1,214 1,428 1,788 2,247 3,807 6,480 8,324 UC 531 691 756 958 1,245 2,074 3,564 4,056 % as UC 54 57 53 55 55 54 55 49 Office of National Statistics
How does CDI happen? Broad spectrum antibiotics Transmissible spores Survive in environment C. difficile overgrowth and attachment Toxin production Toxin A (enterotoxin( enterotoxin) Toxin B (cytotoxin( cytotoxin) Binary toxin (? effect)
Clinical presentation and pathology Antibiotic-associated diarrhoea Mild, distressing, severe Dehydration, blood loss Pseudomembranous colitis Endoscopy,, histopathology Perforation Toxic megacolon
C. difficile epidemiology Acute hospitals (secondary care) 70-80% of cases Significant pre-48 hours component Community hospitals Nursing/care homes General population Small but may be significant
CDI Target 2008-2011 2011 National CDI target reduction 30% reduction by 2010-11, 11, baseline 2007-8 Performance management on SHA envelopes Population based (SHA and PCT) Differential reductions to reach standard rate (/10,000 population) Acute Trust targets post-48 hours after admission Standard per 1000 admissions Minimum reduction set for all
CMO/CNO/CPhO CPhO 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
Antibiotic policy CDI prevention Stewardship only use when good indication Restrict use of broad spectrum agents Reasons for prescribing recorded Stop dates review by pharmacists Prophylaxis single dose Audit, training and review Role of Antimicrobial Management Team
Antimicrobials unique therapeutics Aim to affect the bacteria not the patient Not specific to the disease agents Effect on normal flora Select for resistant organisms Induce vulnerability to some infections Mostly prescribed by non-specialists (in infection)
Preventing HCAI Ensure management attention Commissioning and monitoring Improve clinical care Hand hygiene Aseptic procedures Saving Lives and Essential Steps Care home guidance Antimicrobial stewardship Across the health economy Audit and training
Commissioning and delivery Commissioners to include IP&C in commissioned services Contract monitoring to include review of IP&C provision Target numbers Process monitoring Provider services to include IP&C
What is needed? Partnership across health and social care community IP&C in all provider units Common antimicrobial prescribing policy Commissioning expertise Requirements in contracts for IP&C Support in the community Advice Training Implementation