BMA report on healthcare associated infections

The British Medical Association (BMA) has published a useful report titled Tackling healthcare associated infections through effective policy action.

The report examines the evidence base for the range of infection control policies, and identify areas for action in tackling the problem.

Whilst the report is intended for policy makers with strategic or operational responsibility for public health in the UK, it will be of interest to board members and healthcare professionals including managers.

The report can be freely downloaded here.

New Irish national standards for infection control

The Irish Health Information & Quality Authority (HIQA) has published its final national standards on infection control following a process of consultation on earlier draft standards. The final standards are a significant improvement on the draft versions.

The new National Standards for the Prevention and Control of Healthcare Associated Infections (HCAIs) are intended to:

- Create a person-centred approach to the prevention and control of HCAIs

- Promote a multidisciplinary and team-based approach within all health and social care services to the prevention and control of HCAIs

- Provide an impetus for the attainment of evidence-based best practice in the prevention and control of HCAIs

- Drive continuous quality improvement through effective management and regular performance monitoring and evaluation of services.

Despite being national standards for Ireland, many healthcare organisations in the UK and internationally will find the standards largely applicable in their context.

Download the HIQA National Standards for the Prevention and Control of Healthcare Associated Infections together with an associated guide to the standards here.

NAO publishes latest NHS infection control report

The National Audit Office (NAO) has published its latest report – Reducing Healthcare Associated Infections in Hospitals in England. This report builds on earlier NAO reports into healthcare associated infection published in 2000 and 2004.

The report points to real progress in dealing with infection control issues in hospitals. But there are still problems to address, including the finding that doctors are less likely to comply with good infection control practice.

According to the NAO “There has been a perceptible change in leadership, performance management and clinical practice in most trusts. The impact has not, however, been the same for all trusts. A quarter of hospital trusts have reduced MRSA bloodstream infection rates by over 80 per cent, but 12 per cent had an increase in MRSA bloodstream infections. Twenty nine per cent of hospital trusts have reduced C. difficile infections by over 29 per cent, but 19 per cent have had an increase in C. difficile infection. Moreover there has not been the same impact on other avoidable infections, where there is still a lack of robust and comparable surveillance information. The information that is available suggests that other healthcare associated bloodstream infections, including ones due to other antibiotic resistant organisms, may have increased. Most staff and patients are less aware of the risks of acquiring these other infections. There is scope therefore for hospitals to improve infection prevention and control further and make savings by tackling other healthcare associated infections.”

Key recommendations for trusts and trust boards set down in the NAO report include:

- Hospital trusts should extend root cause analysis to all serious infection incidents. The Department, Health Protection Agency and National Patient Safety Agency should implement a system for collating and sharing the key lessons from trusts’ analyses in the same way as for other serious patient safety incidents.

- Primary care trusts should require all providers to put in place assurance systems which demonstrate how they are complying with good infection control practice, for example, clinical audit compliance and root cause analysis.

- Hospital trusts should require staff to report healthcare associated infections which contribute to death, significant disability or injury, for one or more patients to the trust’s patient safety incident reporting system.

- Hospital trusts should have processes to provide their board with assurance that infection, prevention and control is the responsibility of everyone in the trust. For example as required by the Code of Practice, all staff should have performance objectives for complying with good infection control practice.

- Hospital trusts should have processes in place to assure their boards that there is effective control over the appropriateness of the antibiotics being prescribed.

- Primary care trusts should monitor hospital trusts’ and other healthcare providers’ antibiotic prescribing and take action to address inappropriate use.

- Primary care trust commissioners’ contracts with healthcare providers should explicitly state expectations of quality and safety with respect to reducing the risk of all healthcare associated infections.

Download the NAO report Reducing Healthcare Associated Infections in Hospitals in England plus associated survey, research and other materials here.

In Ireland, HIQA publishes final standards for infection prevention and control

The Health Information and Quality Authority in the Republic of Ireland (HIQA) has published its final version of its standards for infection prevention and control.

There are twelve standards underpinned by some 72 criteria. The Standards provide direction for health and social care providers on how to minimise and prevent Healthcare Associated Infections. They are designed to promote an environment that maximises patient safety, quality and accountability in health and social care services.

The standards are:

1. Governance and Management
2. Structures, Systems and Processes
3. Environment and Facilities Management
4. Human Resource Management
5. Communication Management
6. Hand Hygiene
7. Communicable /Transmissable Disease Control
8. Device Related Infections
9. Microbiological Services
10. Outbreak Management
11. Surveillance Programme
12. Antimicrobial Resistance

Download the full standards and associated guidance here.

Boards going further faster – DH guidance on MRSA targets and productivity

The Department of Health (DH) has issued a pocket guide “for chief executives and boards” on “meeting the MRSA target and increasing productivity.”

The guide states that “Sustainable improvement in HCAI requires board-level support and endorsement, with every trust having a prioritised action plan that is integral to its overall strategic direction. Achievement of the target will require the engagement and active involvement of all staff working at every level of the organisation, supported by the infection control team and identified ‘champions’.”

The guide does recognise that meeting the MRSA target is fundamentally a management (i.e. chief executive) issue and, refreshingly, does not seek to attempt to get the board to micromanage the issue. That said, the guide does include the usual DH pre-occupation with having a “non-executive champion” for reducing MRSA!

Download the pocket guide  here.

‘Substantial improvement’ in infection control at Maidstone and Tunbridge Wells NHS trust

The Healthcare Commission has found substantial improvements in infection control at Maidstone and Tunbridge Wells NHS Trust since an investigation by the watchdog in 2007 identified serious failings.

An estimated 90 people definitely or probably died as a result of Clostridium difficile, during two outbreaks of the infection at the trust in 2005 and 2006. It is estimated that a further 30 patients definitely or probably died of C. difficile between April 2004 and September 2005.

Immediately following its investigation, the Commission called for a range of changes to the way the trust cares for patients with infections and to its wider systems of prevention and control.

The Commission has now published a follow-up report detailing the trust’s progress in implementing the recommendations. It also published a report outlining findings from a routine spotcheck made in October 2008 to assess compliance with the hygiene code.

The Commission says the trust has made “huge strides” putting considerable effort and resource into improving infection control. It commends the trust for reporting its lowest rate of C. difficile infection in three years, for the period January to March 2008.

However the Commission has highlighted some areas that still require further work such as recruiting more nursing staff and learning from complaints and incidents.

The spotcheck in October found a number of breaches of the hygiene code. The most serious breach related to decontamination of equipment in the endoscopy unit. This had been addressed by the time the Commission made its final investigation follow-up visit to the trust in November.

Key improvements identified in the investigation follow-up report include:

- A re-structured board with new non-executive directors and many new directors. This new structure has clear lines of reporting and processes for escalating issues up to the board. Infection control is a consistent item at the top of the board’s agenda.
- New clinical governance and risk reporting structures which allow the trust to address key risks. A new head of governance and quality has been appointed who has revised the governance committee structure, creating four clinical governance directorates within the trust.
- Increased leadership, size and effectiveness of the infection control team led by a new director of infection prevention and control. There are two additional senior infection control nurses and a new microbiologist.
C. difficile is now recognised as a serious diagnosis in its own right, and a ‘care pathway’ has been designed and implemented for patients with the infection, ensuring they receive timely and appropriate care.
- Specific wards have been allocated for the isolation of infected patients.
- Better standards of cleaning and improvements to the hospital environment. Extra cleaning staff have been appointed, new audit systems implemented, and nurses find urgent cleaning needs are more rapidly addressed.
- The removal of beds and the installation of new wash basins to ensure appropriate spacing between beds and improved levels of cleanliness.
- An ongoing process for infection control training has been implemented, including areas such as hand hygiene techniques and sharps handling. The infection control team also runs an extensive training programme for other members of staff.

Areas requiring further work include:

- The recruitment of further nursing staff and continued work to ensure good basic nursing care.
Improvements to how the trust learns from complaints, incidents and serious untoward incidents (SUIs). The system for responding to complaints also needs to be reviewed.
- The trust is currently in the process of appointing a new medical director to the board. It must ensure this happens as soon as possible.
- The trust must embed the new clinical governance structure in day-to-day practice, ensuring that staff at all levels understand and follow the new ways of reviewing clinical care.

 For further information, click here.

See also related Healthcare Governance Review posts here, here, here, and here.

Healthcare Commission issues improvement notice over system failings relating to infection control

The Healthcare Commission has issued an improvement notice to Homerton University Hospitals NHS Foundation Trust, requiring urgent attention to its infection control systems.

While the trust’s rates of MRSA bloodstream infection and Clostridium difficile have generally been low, the Commission found significant breaches of the hygiene code during an unannounced inspection.

The inspection at Homerton University Hospital identified breaches of the Government’s hygiene code that gave inspectors cause for concern. These included arrangements for the decontamination of equipment, concern about adequacy of mandatory staff training, and lack of follow up to internal audits. There were also issues about reporting of information to the board to enable them to assure themselves that systems for preventing infection are in place and working in practice.

According to the Healthcare Commission “All trusts must drive rates of infection as low as they possibly can and to do this they must have all the necessary systems in place to deal with infection prevention and control. This is extremely important for patients. Relatively low infection rates are not enough; systems need to be in place to keep infection to a minimum.”

For further information, including a detailed analysis of the issues giving cause for concern and their link to relevant duties set out in the Government’s hygiene code, click here.

NAO study – Tackling Healthcare Associated Infections in Hospitals

The National Audit Office (NAO) is undertaking a study to review progress made by the NHS in tackling healthcare associated infections in hospitals since publication of its previous study on the subject in July 2004.

According to the NAO, tackling healthcare associated infections in hospitals is a key priority for the National Health Service. Around 8 per cent of patients have such an infection, the majority caused by bacteria or viruses and affect the urinary tract, surgical wounds, lower respiratory tract, skin and bloodstream. In 2006-07 there were over 6,000 cases of MRSA and 55,000 cases of Clostridium difficile.

The NAO has published two reports on the subject. The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England (February 2000) had a significant impact in raising the profile of this important issue and highlighted the need to improve prevention, management and control. Improving patient care by reducing the risk of hospital acquired infection (July 2004) reviewed progress against NAO and Committee of Public Account’s recommendations and noted that improvements were at best patchy and that serious challenges remained. Healthcare associated infections continue to be an issue within many hospitals.

This study will review progress made since the last NAO report. It will look at how well the centrally driven initiatives have been developed and implemented and will focus on the successes at trust and ward level and the impact on staff, patients and the public. It will examine the roles, responsibilities and relationships of the Department, the many arm’s length bodies that have a specific role in managing healthcare associated infection and the individuals at trust level who have specific responsibility for infection prevention and control. We will also seek to identify the effectiveness of various intervention strategies and the extent to which previously identified barriers and constraints have been overcome.

For further information, click here.

DH lunches consultation on regulating NHS bodies in relation to healthcare associated infections

The Department of Health (DH) in England has launched a 10 week consultation on ‘Changes to arrangements for regulating NHS bodies in relation to healthcare associated infections for 2009/10.’

The consultation document describes the draft regulations which will make it a legal requirement to protect patients, healthcare workers and others from identifiable risks of acquiring a healthcare associated infection. Under the draft regulations, individuals found gulty of an offence can be fined up to £50,000.

The document also explains the link with the restructured Code of Practice for the prevention and control of healthcare associated infections which enables the Care Quality Commission to use it as criteria for monitoring compliance with regulations. NHS providers will need to comply with these regulations as a requirement of their registration with the new Care Quality Commission.

In addition, the document describes the system of enforcement powers in the Health and Social Care Act 2008 that is intended to apply to providers should they fail to comply with the requirements of registration and makes proposals for secondary legislation to support these powers. The DH says that the  Care Quality Commission will publish further details of its enforcement policy in due course.

Download the DH consultation document here.

Scottish C.difficile review points to need for governance improvements

An independent review into failures at the Vale of Leven Hospital in Dunbartonshire recommends the development of policies on ”the governance of infection control, the development of clinical leadership to board level, improvements to patient communication, maintenance of a safe environment and death certification practices”.

The review, carried out by the Department of Public Health at Aberdeen University, examined how an outbreak of Clostridium difficile led to the deaths of nine people, and contributed to the deaths of nine more. The review report has been passed to the procurator fiscal to see if charges should be brought.

The report said: “The facilities at the Vale of Leven Hospital were inadequate for effective patient isolation and infection control, and there were frequent patient transfers between wards and other hospitals during this period.

The Scottish Cabinet Secretary for Health and Wellbeing Nicola Sturgeon said that “NHS Boards should be in no doubt – leadership, governance and accountability are the means by which patients and the families can have confidence in our hospitals.”

For further information, including access to the Aberdeen University report click here.

Ireland publishes Infection Control Standards

The Health Information and Quality Authority (HIQA) in Ireland has issued, for public consultation, draft national standards for the prevention and control of infections in health and social care settings, such as hospitals, nursing homes and hospices.

The standards, developed by the Health Information and Quality Authority with the input of an expert advisory group, will provide a national framework to improve the performance of healthcare settings in order to reduce healthcare associated infections.

Twelve Infection Prevention and Control Standards have been published which address issues including governance and management; hand hygiene; device related infections, antibiotic resistance, staffing, the physical environment and disease control.

Jon Billings, Director of Healthcare Quality at The Health Information and Quality Authority said; “Infection control is one of the most effective interventions in hospital practice. It helps safeguard patients while reducing costs on the system. Healthcare associated infections are largely preventable, but it requires a comprehensive and co-ordinated approach across the healthcare setting with a culture of hygiene embedded within the organisation.

“Ireland is not alone it its fight against healthcare associated infections – they are a serious concern in every country across the world. The World Health Organization (WHO) for example, estimates that at any given point in time 1.4 million people around the world will have a healthcare associated infection. In Ireland alone the number of MRSA bloodstream infections was 526 in 2007, a drop from 572 in 2006 (HPSC).

“These standards are not just about checking hospitals on an annual basis, but should be the benchmark which all of us, providers and users, expect from our hospitals on a daily basis. That is why we are giving everyone with an interest in this area, the chance to comment.” said Billings.

These are important draft standards and everyone has a right to have their view considered. Therefore, the Authority is now consulting with interested parties and the general public on the draft National Standards for Infection Prevention and Control. Information collected from this consultation will be used to inform the development of the final set of standards which will be launched later this year.

Read the press release here. Download the draft standards here. Download the guide to the draft standards here.

Deaths involving MRSA and Clostridium difficile – data reports for individual institutions from Office for National Statistics

The Office for National Statistics (ONS) has published its first report on deaths involving methicillin resistant staphylococcus aureus (MRSA) and Clostridium difficile (C. difficile) by individual communal establishment (for example, hospitals, hospices, nursing homes) where the death took place.

The report contains data for establishments which had a total of more than 2,500 deaths from all causes in both periods 2001-05 and 2002-06. These institutions (217 hospitals and one hospice) account for more than 80 per cent of the total number of deaths involving MRSA and C. difficile in England and Wales.

The report, and additional information, can be freely downloaded here.

BBC Panorama survey into hospital infection control finds room for improvement

The BBC’s Panorama programme has carried out an infection control survey of UK hospital trusts for tonight’s – 27 April 2008 – program How Safe is Your Hospital? 170 hospital trusts responded to the survey, which asked 16 key questions, including:

- What is the average hospital bed occupancy rate for general and acute beds in your Trust for the last twelve months?

- What is the ratio of isolation beds to total beds within the Trust?

- What percentage of your isolation beds are used for the isolation of infected patients in order to prevent further infection?

- Do you routinely test your staff with diarrhoea for C-Diff?

- Do you have a publicly available policy on the isolation of infected patients?

Some hospitals are doing better than others in key areas known to have an impact on infection, such as bed occupancy, isolation of patients and hand hygiene.

Inevitably, perhaps, the Panorama programme uses, as it’s key focus, Maidstone and Tunbride Wells NHS Trust, where 90 patients died of C-Diff and 1100 other were affected, and which was subjected to an investigation report by the Healthcare Commission.

Healthcare Governance Review believes that much more could be done with Panorama’s survey results.

The full Panorama infection control survey questions and results, together with a letter from Rose Marie Gibb, former Chief Executive of Maidstone and Tunbridge Wells NHS Trust, can be downloaded here.

Review of C.Diff at Ennis General Hospital, Ireland

The Health Service Executive in Ireland has released a report on key findings and recommendations relating to a “probable outbreak of Clostridium difficile at the Midwestern Regional Hospital Ennis (MWRHE) in March-April of 2007.”

Interestingly (and, perhaps, reassuringly?), there is little in the report that distinguishes it from a similar report that might be found in the NHS. In particular, there is the usual call for better infection control processes and procedures together with improved general management and, of course, governance over infection control.

The full report – Review of Increased Identification of Clostridium Difficile at Ennis General Hospital 2007 – can be downloaded here.

Healthcare Commission launches biggest ever NHS check on infection control

The Healthcare Commission has, today – 24 April 2008, launched a major programme of infection control inspection covering all 172 acute trusts annually as part of a drive to: reduce death and illness from healthcare-associated infections (HCAIs); improve the experience of patients in hospital; and increase public confidence in the NHS. The programme was established at the request of the Secretary of State for Health.

The Commission this week wrote to all acute trusts, calling on them to ensure that they have the necessary systems in place to minimise the risk to patients of catching a HCAI such as MRSA or Clostridium difficile.

In particular, trusts should check they are meeting the 11 mandatory duties outlined in the government’s hygiene code, which came into force as part of the Health Act 2006.

For further information on the Commission’s infection control inspection programme, click here.

 

New Healthcare Associated Infection (HAI) standards for NHSScotland

NHS Quality Improvement Scotland (NHSQIS) has published new HAI standards for the NHS in Scotland. The standards seek to make infection control ‘everybody’s business’. They emphasise the need for all staff to be involved in infection control, and that HAI initiatives are not solely the responsibility of infection control teams.

According to NHS QIS, “The aim of these standards is to build on the previous HAI standards, which focused principally on the NHS board structures and processes necessary to address HAI prevention and control. These redeveloped standards focus on the outcome measures that will demonstrate improved NHS board performance.”

 

There are five standards covering:

• compliance
• patient focus and public involvement
• prevention and control of infection
• environment and equipment, and
• education and training.

The new HAI standards can be downloaded here.

Improvement notice issued to Ipswich Hospitals NHS Trust over infection control failings

The Healthcare Commission has, today – 4 March 2008, issued an improvement notice to Ipswich Hospitals NHS Trust requiring changes to its infection control practices. The Commission made an unannounced visit to the trust on Monday 4 February and also made subsequent requests for documentation of policies and procedures on infection control. It found breaches of duty four of the hygiene code, which covers arrangements for clean and appropriate premises and decontamination of equipment. Under the duty, trusts are required to adhere to any guidance issued by the Department of Health surrounding decontamination.

The Commission found that the trust could not provide evidence of appropriate procedures in place around the use of four benchtop sterilisers or provide assurance that staff were competent in using the equipment. Also, surgical instruments were washed manually before being placed in the benchtop sterilisers, contrary to guidance that requires automated washing. 

This is the third improvement notice to be issued by the Healthcare Commission. The first was to Barnet and Chase Farm Hospitals NHS Trust in July 2007 and the second to Bromley Hospitals NHS Trust in January 2008.

Copies of the Healthcare Commission’s improvement notices can be downloaded here.

A copy of the hygiene code (The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections) is available here.

February 2008 issue of Health Care Risk Report focuses on infection control

With concerns regarding the impending Corporate Manslaughter Act becoming more prominent on board member’s and senior manager’s radar screens, it is fitting that this month’s issue of Health Care Risk Report (HCRR - Volume 14 Issue 3) should devote two articles to a ’special report’ on infection control. The first, from Professor Hilary Pickles, director of public health, and director of infection prevention and control at Hillingdon PCT, looks at the substantial risk posed to patients and organisations by infection and ‘plots a course’ for the role of the risk manager. The second article is an account, by Pat Anderson, editor of HCRR, of an interview with the Health and Safety Executive’s (HSE) healthcare-associated infection policy lead – Ian Strudley. From a governance, as well as a risk management perspective, both articles are essential reading for board members and senior managers. For example, Ian Strudley re-affirms HSE’s position that matters of clinical judgment are outwith its remit, but asserts that HSE ”will pursue investigations where patients and staff are put at risk because of poor systems of work.” And in the news section of this month’s HCRR there is a warning from the Health and Safety Executive that NHS trusts “must have a contingency plan outlining what will happen in the event of an outbreak of infection with an organism such as Clostridium difficile.”

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded at www.healthcareriskreport.com

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.