HCAI in the NHS in England: Where are we now and what next?

Published on Friday, 28 August 2009 01:00
Written by Professor Brian Duerden CBE

Infection spreads! and it knows no boundaries across health and social care as bacteria travel with their human hosts. Healthcare Associated Infections (HCAI) affect all health and social care settings, whether in the NHS or the independent sector.

We face the challenge of HCAI, such as MRSA bacteraemia and Clostridium difficile infection, because modern medicine, while delivering improved treatment and increased life expectancy, tended to regard infection as a nuisance to be dealt with by the infection specialists.

We need to change the mindset to one that creates a safe environment for patient care within which we then deliver specialist care. Responsibility for HCAI control is a tripartite partnership between clinicians and carers, boards and managers, and the Government/Department of Health, and became a statutory responsibility in the NHS with the Health Act 2006 Code of Practice on HCAI.

The Health and Social Care Act 2008, came into force in April 2009, establishing a single regulator, the Care Quality Commission, and extending the CoP to the independent sector and all care settings. Registration is also extended to all NHS bodies and compliance with the CoP will be a requirement for registration.

The NHS can be congratulated on achieving the target to reduce MRSA bacteraemias by 50 per cent by 2008. In fact, the first three quarters of 2008/09, showed over 60 per cent reduction. How have we changed practice to achieve this?

Management now has a major emphasis on infection control; surveillance of HCAI is much enhanced; clinical practice protocols (Saving Lives and Essential Steps, High Impact Interventions) have been implemented; hand hygiene and environmental cleaning have been improved; and training in infection prevention and control is required for all NHS staff. The targets and performance management system backed by legislation that implemented the CoP have ensured that infection prevention and control are a top priority.

However, we must continue to improve. The target is a ceiling and individual Trusts and the NHS generally must get as far below it as possible to maintain year-on-year reductions. This leads to a zero tolerance approach to aim for a minimum number of infections. The mandatory surveillance and performance management systems will continue.

Zero tolerance does not mean ‘there will be no infections' as this is biologically implausible. However, there should be no tolerance of preventable or avoidable infections or of poor clinical practice, whether  this be in hand hygiene compliance, aseptic procedures or imprudent antibiotic prescribing.

The prevention of MRSA bacteraemia crosses the health and social care community. Cases diagnosed within the first two days of admission to hospital now represent one third of all cases and root cause analyses need to include practitioners in primary care who can relate infections to chronic conditions, indwelling devices, underlying pathology, and overall contact with health and social care settings.

Similarly, the actions from RCA can apply to all. Screening of all admissions to NHS hospitals will be implemented by 2010-11, at the latest. All elective admissions had to be covered by a screening programme by March 2009. The principle behind the screening programme is that colonisation generally precedes infection and a colonised patient is at risk of developing infection themselves and a possible source for transmission to others.

If possible, MRSA positive patients should be isolated, but in any case, a positive screen should be followed by decolonisation to reduce the risk for the individual and the risk of transmission. Decolonisation immediately reduces the bioburden of MRSA to cover the period of highest risk and of clinical interventions, so it needs to be done as close to the clinical treatment as possible. However, it must be recognised that re-emergence or re-colonisation can occur over a period of weeks or months.

The same partnership is needed to control C. difficile infection. The unacceptably high levels reached in 2006, started to come down in 2007-08, but there is still a lot to do and the ONS data remind us that this is an infection with significant mortality, especially in elderly and vulnerable people.

Spores of C. difficile shed by patients with diarrhoea contaminate the environment and are swallowed. If the person then receives antibiotics, the C. difficile can grow and produce their toxins that cause the disease. Although 70-75 per cent of cases occur in secondary care, there is a significant component of cases diagnosed on admission or in the community, particularly in health and social care settings.

The Government has set a target to reduce C. difficile infection by 30 per cent by 2010-11, and the indications are that this will be achieved. This target is based on PCT populations, with a sub-set applied to the acute hospital setting and the two must work together.

New guidance published in January 2009, reiterated and expanded on the basic prevention and control measures of prudent antibiotic prescribing, prompt diagnosis with isolation of cases, infection control measures that include hand washing and the use of gloves and aprons, and enhanced cleaning with chlorine-based disinfectants. These are the basis of the C. difficile SL high impact intervention.  

Preventing  HCAI requires management attention, effective clinical care, antimicrobial stewardship and comprehensive audit and training programmes. To make it happen, there should be a partnership of management responsibility based upon compliance assurance from board to ward, and personal responsibility reflected in job plans, mandatory training, CPD, and appraisal.

The compliance assurance should comprise both surveillance data on cases and audit results of processes and procedures (hand hygiene, clinical protocols, isolation protocols, antibiotic prescribing, cleanliness standards) and these should be reviewed at all management levels from units and wards through directorates/divisions to the board.

Commissioners need to include infection prevention and control requirements in their commissioned services and monitor contract delivery through target numbers and process monitoring. All of this requires partnership across the health and social care community to provide an unbroken chain of care in order to break the chain of infection.

Is your organisation doing enough to tackle HCAI? Is the Government doing enough to tackle HCAI? What barriers now exist to effectively target HCAI on the ground - have the problem areas evolved in response to the measures now implemented? Join the Debate - add your comment.

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