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/ (Q Av)1823 –2002/ (Q Av)1856 –2003/ (Q Av)1925 –2004/ (Q Av)1808 –2005/ (Q Av)1773 –2006 Q Q Q Q Q C. difficile infection – – – – – (voluntary reporting, England, Wales, NI) – – – (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 populations Human populations Human behaviour 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 Getting Ahead of the Curve 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 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 ; 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 Jeremy Laurance – Health Editor, The Independent

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

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

Mandatory surveillance 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 DC mentions 9751,2141,4281,7882,2473,807 UC ,2452,074 % as UC Office of National Statistics

C. difficile profile Public, media, politicians HCC/HPA Survey published Dec –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? 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……. ……..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 CoP

‘Saving lives’ toolkit Two components –Self assessment tool – based on 9 challenges now being revised to reflect CoP now being revised to reflect CoP –5 high Impact Interventions (Care Bundle approach) now increased to 8 plus guidance notes 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 High Impact Interventions 1. Preventing microbial contamination –Basic asepsis and hygiene 2. a Central venous catheters b Peripheral line care b Peripheral line care c Dialysis catheters 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,CPhO,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/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 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