Transcript Bringing microbiology out of the back

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
–
–
–
–
–
–
2001/2
2002/3
2003/4
2004/5
2005/6
2006
7291
7426
7700
7212
7097
Q1
Q2
Q3
(Q Av)1823
(Q Av)1856
(Q Av)1925
(Q Av)1808
(Q Av)1773
1741
1652
1542
C. difficile infection
– 2001
22008
– 2002
28986
– 2003
35537
– 2004
43672
– 2005
49850
(voluntary reporting, England,
Wales, NI)
– 2004
44314
– 2005
51767
– 2006
55681
(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 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; 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 6th 2005. Jeremy Laurance –
Health Editor, The Independent
The 1994 DH/PHLS Report (North Manchester outbreak of
1991-2)
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 - 5
January 2004
– All NHS Trusts in England
– Report all cases of C. difficile disease
Toxin +ve diarrhoea
– Patients 65 years and older
Results
– 2004 :
– 2005 :
– 2006 :
44,314
51,767
55,681
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
C. difficile profile 2005-07
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
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…….
…..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
– 5 high Impact Interventions (Care Bundle
approach)
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
1.
Preventing microbial contamination
–
2.
Basic asepsis and hygiene
a Central venous catheters
b Peripheral line care
c Dialysis catheters
Surgical site management
4. Urinary catheters
5. Ventilator management
6. Clostridium difficile
3.
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