Tackling HCAI in the NHSTackling HCAI in the NHS-strategy and actions-strategy and actions

Professor Brian DuerdenProfessor Brian DuerdenInspector of Microbiology and Infection Inspector of Microbiology and Infection

Control,Control,Department of Health, London Department of Health, London

2007 -The challenge of HCAI2007 -The challenge of HCAI

MRSA bacteraemiaMRSA bacteraemia– 2001/2 7291 (Q Av)18232001/2 7291 (Q Av)1823– 2002/3 7426 (Q Av)18562002/3 7426 (Q Av)1856– 2003/4 7700 (Q Av)19252003/4 7700 (Q Av)1925– 2004/5 7212 (Q Av)18082004/5 7212 (Q Av)1808– 2005/6 7097 (Q Av)17732005/6 7097 (Q Av)1773– 2006 Q1 17412006 Q1 1741 Q2 1652Q2 1652 Q3 1542 Q3 1542

C. difficile C. difficile infectioninfection– 2001 220082001 22008– 2002 289862002 28986– 2003 355372003 35537– 2004 436722004 43672– 2005 498502005 49850(voluntary reporting, England, (voluntary reporting, England,

Wales, NI)Wales, NI)

– 20042004 4431444314

– 2005 517672005 51767– 2006 556812006 55681(England, mandatory)(England, mandatory)

Responsibility for HCAIResponsibility for HCAI

CliniciansClinicians– Safe patient careSafe patient care– DiagnosisDiagnosis– TreatmentTreatment– PreventionPrevention– ControlControl

DIPCDIPC– Corporate Corporate

environmentenvironment– Make it happenMake it happen

Government/DHGovernment/DH– Set standardsSet standards– Ensure priorityEnsure priority– Monitor outcomeMonitor outcome– LegislationLegislation– Performance Performance

managementmanagement

1970 – 2000: a dichotomy1970 – 2000: a dichotomy

Microbiology & Microbiology & Infection ControlInfection Control– New antibioticsNew antibiotics– New societiesNew societies– New journalsNew journals– New guidelinesNew guidelines– New diseasesNew diseases

Infection control was Infection control was the province of the IC the province of the IC specialistsspecialists

Modern medicineModern medicine– Increased life Increased life

expectancyexpectancy– Cancer treatmentCancer treatment

ImmunosuppressionImmunosuppression

– Complex surgeryComplex surgeryCardiac, NeurosurgeryCardiac, NeurosurgeryOrthopaedicOrthopaedic

– Chronic illnessesChronic illnessesRenal dialysisRenal dialysis

Infection – a nuisanceInfection – a nuisance

Infection is different…….Infection is different…….

…….it spreads!…….it spreads!

BiologyBiology

Microbial populationsMicrobial populations

Human populationsHuman populations

Human behaviourHuman behaviour

Reducing HCAI….Reducing HCAI….

Change the mindsetChange the mindsetFrom: From: 1) create a system to deliver specialist clinical 1) create a system to deliver specialist clinical

carecare2) take measures to prevent infection 2) take measures to prevent infection

To:To:1) create a safe environment for patient care1) create a safe environment for patient care2) deliver specialist clinical care within that 2) deliver specialist clinical care within that

environmentenvironment

Getting Ahead of the Curve - 2002Getting Ahead of the Curve - 2002

Priorities identifiedPriorities identified

HCAIHCAI– bacteraemia (MRSA, GRE)bacteraemia (MRSA, GRE)– C. difficile C. difficile associated diarrhoeaassociated diarrhoea– surgical site infectionsurgical site infection

TuberculosisTuberculosis

Blood-borne & sexually transmitted viruses (and Blood-borne & sexually transmitted viruses (and others!)others!)

Antimicrobial resistanceAntimicrobial resistance

And then……….And then……….

POLITICSPOLITICS

(and the media hype)(and the media hype)

HCAI 2003 - 04HCAI 2003 - 04

Winning Ways Winning Ways - December 2003- December 2003– Strategy for HCAIStrategy for HCAI

NAO Report - NAO Report - July 2004July 2004– Critical of slow progressCritical of slow progress

Towards Cleaner Hospitals and Lower Towards Cleaner Hospitals and Lower Rates of Infection Rates of Infection - July 2004- July 2004– Action planAction plan

MRSA TargetMRSA Target

‘‘Halve MRSA infections by 2008’Halve MRSA infections by 2008’– MRSA bacteraemiaMRSA bacteraemia– Baseline 2003-04; Start date April 2005Baseline 2003-04; Start date April 2005– Monthly returnsMonthly returns– 3-monthly publication from Jan 20073-monthly publication from Jan 2007

Depends upon mandatory surveillance Depends upon mandatory surveillance being accurate and timelybeing accurate and timely

Healthcare Associated InfectionsHealthcare Associated Infections

MRSA - MRSA - not the only one!not the only one!

Clostridium difficileClostridium difficile

Glycopeptide resistant enterococciGlycopeptide resistant enterococci

ESBL-producing ESBL-producing E. coliE. coli etc etc

Acinetobacter baumanniiAcinetobacter baumannii

NorovirusNorovirus

C. difficileC. difficile “new superbug” hits the national “new superbug” hits the national press Mon. June 6press Mon. June 6thth 2005. Jeremy Laurance – 2005. Jeremy Laurance –

Health Editor, The IndependentHealth Editor, The Independent

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

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

0

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10000

15000

20000

25000

30000

35000

40000

45000

50000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

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Mandatory surveillance 2004 - 5Mandatory surveillance 2004 - 5

January 2004January 2004– All NHS Trusts in EnglandAll NHS Trusts in England– Report all cases of Report all cases of C. difficile C. difficile diseasedisease

Toxin +ve diarrhoeaToxin +ve diarrhoea

– Patients 65 years and olderPatients 65 years and older

ResultsResults– 2004 : 44,3142004 : 44,314– 2005 : 51,7672005 : 51,767– 2006 : 55,6812006 : 55,681

C. difficile C. difficile deaths 1999-2005deaths 1999-2005

19991999 20012001 20022002 20032003 20042004 20052005

DC DC mentionsmentions

975975 1,2141,214 1,4281,428 1,7881,788 2,2472,247 3,8073,807

UCUC 531531 691691 756756 958958 1,2451,245 2,0742,074

% as % as UCUC

5454 5757 5353 5555 5555 5454

Office of National Statistics

C. difficile C. difficile profile 2005-07profile 2005-07Public, media, politiciansPublic, media, politiciansHCC/HPA Survey published Dec. 2005HCC/HPA Survey published Dec. 2005– NHS Trusts not following guidance NHS Trusts not following guidance – Antibiotic policies; prevention; management; Antibiotic policies; prevention; management;

infection control; reportinginfection control; reporting

Advisory letter from CMO/CNO Dec 2005Advisory letter from CMO/CNO Dec 2005HCC report on Stoke Mandeville July 2006HCC report on Stoke Mandeville July 2006CMO/CNO/CPhO/CEx letter Dec 2006CMO/CNO/CPhO/CEx letter Dec 2006Local targets April 2007Local targets April 2007

How do we change bad habits?How do we change bad habits?

Enhanced surveillance (HPA)Enhanced surveillance (HPA)– MRSA & MRSA & C. difficileC. difficile

Clinical practice protocolsClinical practice protocols

Cleanliness and hygieneCleanliness and hygiene– hand hygienehand hygiene– environmental cleaningenvironmental cleaning

ManagementManagement– emphasis on infection controlemphasis on infection control

Training Training

Improved Improved C. difficile C. difficile surveillancesurveillance

Individual web entry Individual web entry

All patients over 2 yearsAll patients over 2 years

Core dataCore data– Identifier; age; sexIdentifier; age; sex– Date of sampleDate of sample– Location of patientLocation of patient– Reporting laboratoryReporting laboratory

Started April 1, 2007Started April 1, 2007

C. difficile C. difficile voluntary pagevoluntary page

Risk factorsRisk factors– Health services contactHealth services contact– Antibiotic historyAntibiotic history– PPIsPPIs– SpecialtySpecialty– Augmented careAugmented care

Suggest 2 – 4 weeks, 4 times a year?Suggest 2 – 4 weeks, 4 times a year?

Local assessment; national poolingLocal assessment; national pooling

Providing the tools Providing the tools

CleanCleanyouryourhands hands campaigncampaignPEAT inspections for cleanlinessPEAT inspections for cleanlinessSaving Lives & Essential StepsSaving Lives & Essential StepsRoot Cause Analysis toolRoot Cause Analysis tool– bacteraemia-specific version – Sept 2006bacteraemia-specific version – Sept 2006

MRSA screening advice - October 2006MRSA screening advice - October 2006C. difficile C. difficile guidance - December 2006guidance - December 2006

…………..and now……...and now…….

……..legislation..legislation

Health Act 2006Health Act 2006

–Statutory Code of Practice Statutory Code of Practice

–Compliance assessed by the Compliance assessed by the Healthcare CommissionHealthcare Commission

Health Act 2006 – Code of PracticeHealth Act 2006 – Code of Practice

11 core duties11 core duties– Management, Organisation and EnvironmentManagement, Organisation and Environment– Clinical Care ProtocolsClinical Care Protocols– Healthcare WorkersHealthcare Workers

Training in Infection ControlTraining in Infection ControlOwn health protectionOwn health protection

Policy components & references to Policy components & references to support compliancesupport complianceSL assessment revision to reflect CoPSL assessment revision to reflect CoP

‘‘Saving lives’ Saving lives’ toolkittoolkit

Two componentsTwo components– Self assessment tool – based on 9 challengesSelf assessment tool – based on 9 challenges

now being revised to reflect CoP now being revised to reflect CoP – 5 high Impact Interventions (Care Bundle 5 high Impact Interventions (Care Bundle

approach)approach)

now increased to 8 plus guidance notesnow increased to 8 plus guidance notes

Self-assessment toolSelf-assessment tool

Assurance statements for Core Duties (11)Assurance statements for Core Duties (11)– 1. General duty to protect patients, staff and 1. General duty to protect patients, staff and

others from HCAIothers from HCAI– 2. Appropriate management systems for IPC2. Appropriate management systems for IPC– 3. Assess risks of HCAI and take action to 3. Assess risks of HCAI and take action to

reduce/controlreduce/control– 4. Provide and maintain a clean environment4. Provide and maintain a clean environment– 5. Provide information to patients and public5. Provide information to patients and public

Core duties (cont.)Core duties (cont.)

– 6. Provide information when patients move 6. Provide information when patients move from one healthcare provider to anotherfrom one healthcare provider to another

– 7. Ensure cooperation within healthcare 7. Ensure cooperation within healthcare providerprovider

– 8. Provide adequate isolation facilities8. Provide adequate isolation facilities– 9. Ensure adequate laboratory support9. Ensure adequate laboratory support– 10. Adhere to policies and protocols for IPC10. Adhere to policies and protocols for IPC– 11. HCW to be free from and protected from 11. HCW to be free from and protected from

infections and to be educated in IPCinfections and to be educated in IPC

High Impact InterventionsHigh Impact Interventions

1.1. Preventing microbial contaminationPreventing microbial contamination– Basic asepsis and hygieneBasic asepsis and hygiene

2.2. a Central venous cathetersa Central venous catheters b Peripheral line careb Peripheral line care

c Dialysis cathetersc Dialysis catheters

3.3. Surgical site managementSurgical site management

4.4. Urinary cathetersUrinary catheters

5.5. Ventilator managementVentilator management

6.6. Clostridium difficileClostridium difficile

SL GuidanceSL Guidance

MRSA screening – October 2006MRSA screening – October 2006

C. difficileC. difficile control – CMO,CNO,CPhO,CEx control – CMO,CNO,CPhO,CEx letter December 2006letter December 2006

Coming soonComing soon– Blood Culture protocolBlood Culture protocol– Antimicrobial prescribing frameworkAntimicrobial prescribing framework

MRSA screening – October 2006MRSA screening – October 2006

Advisory/guidance to NHS Trusts Advisory/guidance to NHS Trusts

Focus on own high-risk groupsFocus on own high-risk groups– Elective orthopaedic, cardiovascular, neurosurgery – Elective orthopaedic, cardiovascular, neurosurgery –

pre-admissionpre-admission– Emergency surgery – elderly orthopaedic/trauma?Emergency surgery – elderly orthopaedic/trauma?– All elective surgery?All elective surgery?– ICU & HDU admission and weeklyICU & HDU admission and weekly– Renal dialysisRenal dialysis– Admissions from other hospitals, healthcare settingsAdmissions from other hospitals, healthcare settings– All emergency admissions??All emergency admissions??

Screening and decolonisationScreening and decolonisation

Screening methodsScreening methods– Swab, direct plating on chromogenic agarSwab, direct plating on chromogenic agar– Swab, into selective broth, then plateSwab, into selective broth, then plate– Rapid tests, eg PCR etcRapid tests, eg PCR etc

Decolonisation regimenDecolonisation regimen– MRSA positiveMRSA positive– All initially; stop on negative result?All initially; stop on negative result?– All, irrespective of screening?All, irrespective of screening?

Isolate patient Isolate patient if possibleif possible

ObjectiveObjective

All trusts, as a matter of urgency, All trusts, as a matter of urgency, should review their policies for should review their policies for MRSA screening to determine MRSA screening to determine the most appropriate initial the most appropriate initial approach to screening for their approach to screening for their patient population.patient population.

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

Antibiotic prescribingAntibiotic prescribing– Limit broad spectrum agentsLimit broad spectrum agents– Limit IV Limit IV andand oral courses oral courses

Prompt diagnostic tests – Toxins A+BPrompt diagnostic tests – Toxins A+B– isolates for typing if outbreak suspected isolates for typing if outbreak suspected

Isolation/segregation/cohorting of casesIsolation/segregation/cohorting of cases

Infection control – handwashing, gloves, gownsInfection control – handwashing, gloves, gowns

Decontamination/cleaning – increaseDecontamination/cleaning – increase– Chlorine-based disinfectantChlorine-based disinfectant

Management priority & responsibilityManagement priority & responsibility

HCAIHCAI– NOTNOT just the Infection Control Team just the Infection Control Team– Trust BoardTrust Board– Chief ExecutiveChief Executive– Clinical ownershipClinical ownership– ALL STAFFALL STAFF

DIPC is the focusDIPC is the focus– ResponsibilityResponsibility– Authority – clinical and managerialAuthority – clinical and managerial– Resource allocationResource allocation

WW Action area 6.Management WW Action area 6.Management and organisationand organisation

Chief Executive’s responsibilitiesChief Executive’s responsibilities– Core part of Clinical Governance and Patient Core part of Clinical Governance and Patient

Safety programmesSafety programmes– Promote low levels of HCAIPromote low levels of HCAI

Ensure actions are takenEnsure actions are taken

– Aware of legal responsibilities to identify, Aware of legal responsibilities to identify, assess and control risks of infectionassess and control risks of infection

– Appoint Director of Infection Prevention and Appoint Director of Infection Prevention and ControlControl

DIPC roleDIPC role

Senior management – Board/CEx reportSenior management – Board/CEx reportProfessional credibilityProfessional credibility– Special expertiseSpecial expertise

Reporting line for ICTReporting line for ICTPolicy implementationPolicy implementationPerformance managementPerformance managementResource allocationResource allocationA champion & a manager!!A champion & a manager!!

Performance managementPerformance management

SHA performance managersSHA performance managersPCT local PCT local C. difficile C. difficile targets 2007targets 2007Recovery and Support Unit (DH) Task ForceRecovery and Support Unit (DH) Task Force– MRSA & MRSA & C. difficile C. difficile figuresfigures– Monitors programme activitiesMonitors programme activities– Identifies Trusts for Identifies Trusts for SL SL reviews and visitsreviews and visits

Healthcare CommissionHealthcare Commission– Annual assessments (scores and ratings)Annual assessments (scores and ratings)– National Study 2005/6National Study 2005/6– Legislation compliance (Improvement notices)Legislation compliance (Improvement notices)

Target performance managementTarget performance management

DH Recovery and Support Unit Task DH Recovery and Support Unit Task ForceForce– Reviews MRSA bacteraemia and Reviews MRSA bacteraemia and C. difficle C. difficle

figuresfigures– Monitors programme activitiesMonitors programme activities– Identifies Trusts for Identifies Trusts for SL SL reviews and visitsreviews and visits

SHA performance managersSHA performance managers– Monthly review of Trust performanceMonthly review of Trust performance

PCT commissionersPCT commissioners

Improvement programmeImprovement programme

National Performance Improvement National Performance Improvement Network (PIN)Network (PIN)– Meets 4 times a yearMeets 4 times a year

Saving Lives Saving Lives self assessment reviewsself assessment reviews

Improvement visitsImprovement visits– DH team;DH team; 2-day interviews2-day interviews– Develop local action/recovery planDevelop local action/recovery plan

A wake-up call……..A wake-up call……..

We have accepted these infections as We have accepted these infections as ‘normal’‘normal’PatientsPatients– Can be very illCan be very ill– Can dieCan die– Stay in hospital longerStay in hospital longer– May need major surgeryMay need major surgery

Significant NHS resources could be better Significant NHS resources could be better usedused

Goal (Government/DH) - useGoal (Government/DH) - use

Political imperativePolitical imperativeMeasurementMeasurementTarget settingTarget settingProfessional supportProfessional supportPerformance management ANDPerformance management ANDLegislation Legislation

To change human behaviour (clinical & To change human behaviour (clinical & managerial) tomanagerial) toOvercome the biology of HCAIOvercome the biology of HCAI