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2007 -The challenge of HCAI. MRSA bacteraemia2001/2 7291 (Q Av)18232002/3 7426 (Q Av)18562003/4 7700 (Q Av)19252004/5 7212 (Q Av)18082005/6 7097 (Q Av)17732006 Q1 1741 Q2 1652 Q3 1542
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1. Tackling HCAI in the NHS-strategy and actions Professor Brian Duerden
Inspector of Microbiology and Infection Control,
Department of Health, London
2. 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 Q1 1741
Q2 1652
Q3 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)
3. 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
4. 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
5. Infection is different
.
.it spreads!
6. Biology Microbial populations
Human populations
Human behaviour
7. 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
8. 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
9. And then
.POLITICS(and the media hype)
10. 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
11. 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
12. Healthcare Associated Infections MRSA - not the only one!
Clostridium difficile
Glycopeptide resistant enterococci
ESBL-producing E. coli etc
Acinetobacter baumannii
Norovirus
13. C. difficile new superbug hits the national press Mon. June 6th 2005. Jeremy Laurance Health Editor, The Independent
14. The 1994 DH/PHLS Report (North Manchester outbreak of 1991-2)
15. C. difficile voluntary reporting 1991 2005: England, Wales and Northern Ireland
16. 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 : 44,314
2005 : 51,767
2006 : 55,681
17. C. difficile deaths 1999-2005
18. 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
19. 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
20. 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
21. 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
22. 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
.
23.
..legislation Health Act 2006
Statutory Code of Practice
Compliance assessed by the Healthcare Commission
24. 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
25. 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
26. 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
27. 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
28. High Impact Interventions Preventing microbial contamination
Basic asepsis and hygiene
a Central venous catheters
b Peripheral line care
c Dialysis catheters
Surgical site management
Urinary catheters
Ventilator management
Clostridium difficile
29. SL Guidance MRSA screening October 2006
C. difficile control CMO,CNO,CPhO,CEx letter December 2006
Coming soon
Blood Culture protocol
Antimicrobial prescribing framework
30. 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??
31. 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
32. 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.
33. 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
34. 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
35. WW Action area 6.Management and organisation Chief Executives 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
36. 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!!
37. 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)
38. 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
39. 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
40. 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
41. 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