Combating Healthcare Associated Infections in the NHS 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 2006/7 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)
Responsibility for HCAI Clinicians Safe patient care Diagnosis Treatment Prevention Control Board/CEx CEx/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 infection 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 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; 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
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
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
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)
C. difficile deaths 1999-2005 1999 2001 2002 2003 2004 2005 DC mentions 975 1,214 1,428 1,788 2,247 3,807 UC 531 691 756 958 1,245 2,074 % as UC 54 57 53 55 55 54 Office of National Statistics
C. difficile profile 2005-06 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 CPhO/CEx letter Dec 2006
CMO/CNO/CPhO/CEx 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
C. difficile local targets Effective April 2007 PCT/Acute Trust agreement Part of annual contracts Sliding scale of percentage reductions SHA monitoring
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 New technology Training Targets and performance management
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 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!!
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
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
Providing the tools Cleanyour yourhands 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 Annual healthcheck 120 unannounced spot checks Improvement notices
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 revised to reflect CoP
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
High Impact Interventions (revised June 2007) 1. Central venous catheters 2. Peripheral line care 3. Dialysis catheters 4. Surgical site management 5. Urinary catheters 6. Ventilator management 7. Clostridium difficile
SL Guidance October 2006 MRSA screening June 2007 Blood Culture protocol Antimicrobial prescribing framework September 2007 Isolation and cohorting
BMJ elearning Training C. difficile video CPD module DoctorsNet CPD module Dialogue with Undergraduate Deans Tomorrow s s Doctors review group (GMC) Royal Colleges Postgraduate Deans
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
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
New Technologies/Products Rapid Review Panel Chief Medical Officer. Winning Ways,, December 2003. Department of Health. Towards cleaner hospitals and lower rates of infection,, July 2004 First meeting of the Rapid Review Panel, August 2004
Remit To provide a prompt assessment of new and novel equipment, materials and other products or protocols that may be of value to the NHS in improving hospital infection control and reducing hospital acquired infections
Products reviewed to date 198 reports issued 14 products reviewed at the end of September 20+ applications received for early December
Types of product reviewed Cleaning Products/Disinfectants Surface coatings Air decontamination Fabrics Hand cleansing Other Outside remit
It is not within the RRP remit to undertake the evaluation of products within the NHS or to influence procurement and the uptake of products into the NHS once recommendations are formulated. Integrated innovations process is being developed.
Summer 2007 Saving Lives issue 2 (June) C. difficile care bundle updated Antimicrobial prescribing best practice Improvement Team (formerly MRSA) Double funding (and size!) Extend remit to C. difficile DIPC review SACAR report J Antimicrob Chemother suppl Aug 2007 Antimicrobial framework
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
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
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
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