Transcript Bringing microbiology out of the back

A national perspective on
progress
Professor Brian Duerden
Inspector of Microbiology and Infection
Control,
Department of Health, London
2007 -The challenge of HCAI
C. difficile infection
MRSA bacteraemia
–
–
–
–
–
–
2001/2
2002/3
2003/4
2004/5
2005/6
2006/7
– 2007/8
7291
7426
7700
7212
7097
Q1
Q2
Q3
Q4
6381
Q1
(Q Av)1823
(Q Av)1856
(Q Av)1925
(Q Av)1808
(Q Av)1773
1741
1651
1542
1447
1303
– 2001
22008
– 2002
28986
– 2003
35537
– 2004
43672
– 2005
49850
(voluntary reporting, England,
Wales, NI)
–
–
–
–
–
2004
2005
2006
2007 Q1
Q2
44314
51767
55681
15639
13660
+2890 (<65)
(England, mandatory)
Responsibility for HCAI
Clinicians
– Safe patient care
– Diagnosis
– Treatment
– Prevention
– Control
Board/CEx/DIPC
– Corporate
environment
– Make it happen
Government/DH
– Set standards
– Ensure priority
– Monitor outcome
– Legislation
– Performance
management
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
– Monthly submission and DH/SHA review
Depends upon mandatory surveillance
being accurate and timely – CEx sign-off
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Actual
Jul-07
Jun-07
May-07
Apr-07
600
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Monthly MRSA bacteraemia
figures August 06 to July 07
Trajectory
500
400
300
200
100
0
MRSA reporting
Timeliness
– CEO lock down
– Data entry in time
– Use voluntary screen to record info to focus
effort
Extenuating circumstances
– Duplicates
– Repeats in untreatable patients
– Responsible Trust (eg, renal satellite units)
What do the data tell us?
Men >65 yrs are 43% of MRSA bacteraemias
– (15% of all admissions nationally)
80% of MRSA bacteraemias are in emergency admissions
–
(37% of total admissions)
35% have been in hospital during the previous month
Length of stay over 7 days increases risk
10% of MRSA bacteraemias come from nursing homes
–
17% for pre-48 hour cases.
30% diagnosed in first 48hrs
– but 65% of these patients have touched health care setting in recent past
Risk factors
– 14% - chronic wounds
– 14% - central lines; 10% peripheral lines
–
8% pneumonia
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 6th 2005. Jeremy Laurance –
Health Editor, The Independent
C. difficile voluntary reporting 1991 – 2005:
England, Wales and Northern Ireland
50000
45000
number of reports
40000
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
DC
1999
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
Deaths in CDI
HCC assessment
–
–
–
–
–
Definitely
Probably
Possibly
Unlikely
No
What should we
measure?
Clinical experience
– 5-10% direct cause
– 5-10% probable
contributory
– 30-day mortality 30%
– 60-day mortality
35-40%
C. difficile profile 2005-06
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 letter Dec 2006
CMO/CNO/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
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 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!!
Improved C. difficile surveillance
Individual web entry; started April 1, 2007
All patients over 2 years
Core data
– Identifier; age; sex
– Date of sample
– Location of patient
– Reporting laboratory
– [from Jan. 08 – in/outpatient; admission date]
C. difficile voluntary page
Risk factors
– Health services contact
– Antibiotic history
– Specialty
– Augmented care
– Emergency or elective
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
Annual healthcheck
120 unannounced spot checks
Improvement notices
‘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.
2.
3.
4.
5.
6.
7.
Central venous catheters
Peripheral line care
Dialysis catheters
Surgical site management
Urinary catheters
Ventilator management
Clostridium difficile
SL Guidance
October 2006
– MRSA screening
June 2007
– Blood Culture protocol
– Antimicrobial prescribing framework
September 2007
– Isolation and cohorting
Environmental 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
Training
BMJ eLearning
– C. difficile video CPD module
DoctorsNet
– CPD module
Dialogue with
– Undergraduate Deans
– Tomorrow’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
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
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
Antibiotic policy - prevention
Restrict use of broad spectrum agents
Promote aminoglycosides (gentamicin etc)
Reasons for prescribing recorded
Stop dates – review by pharmacists
Prophylaxis – single dose
Audit, training and review
Role of Antimicrobial Prescribing
Team/Committee
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
Dress code (mainly for doctors)
Bare Below the Elbow (BBE)
– Short sleeves
– No wrist watch
– No wrist or hand jewellery (except plain wedding
band)
– Sleeves/cuffs and jewellery are impediments to
hand hygiene and aseptic procedures
No ties (except bow ties) – they are readily contaminated
and not washed!
No white coats!
Scrubs where appropriate, eg, theatre, ICU/HDU, A&E
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 must no longer accept these infections
as ‘normal’
Patients
– Can be very ill
– Can die
– Stay in hospital longer
– May need major surgery
Significant NHS resources can 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 challenge of HCAI