HCAIs remain centre stage

Cases of Clostridium difficile infection in patients aged 65 years and above increased by 17.2% in England in the latest period to be reviewed, according to new figures released by the Health Protection Agency (HPA).

The cases were up from 44,107 in 2004 to 51,690 in 2005. This increase is very likely to be due to both improved reporting and an increased number of cases, says the HPA. Reporting of cases over the same period has improved, with all 169 acute NHS Trusts providing the required information. Rates of infection were high in a wide range of hospitals throughout the NHS in England and these results establish clearly the scope for improvement. Mandatory surveillance of C. difficile covers cases in those aged 65 and older.

An additional 25% of cases occur in younger age groups.

The latest MRSA blood poisoning figures show that 3,517 cases of MRSA were reported in England between October 2005 and March 2006, down 1.5% from the previous six months. Since Government targets for the reduction of MRSA blood poisoning cases were set in 2003, there has been a decrease in annual cases as compared to the baseline year (2003/4), most marked in London, the worst affected region, and Yorkshire and the Humber, and a slight increase in the North West. Acute specialist and acute teaching Trusts have contributed significantly to reductions in MRSA since mandatory surveillance began in 2001, while many Trusts in other categories have shown marked fluctuations or slight increases.

Results from the enhanced mandatory MRSA blood poisoning surveillance system have been published for the first time. These give detailed information on cases including specialty, whether blood poisoning was present on admission and prior location of the patient. The enhanced surveillance shows that:

• 25% of patients with MRSA had the disease on admission to hospital – this is the subject of further investigation to establish the prior history, treatment and risk factors for these cases.
• The majority of patients with MRSA blood poisoning were admitted to general medical, general surgical or care of the elderly wards. 8% of the MRSA blood poisoning reports concerned renal patients.
• 15% of the patients reported with MRSA blood poisoning were diagnosed while in intensive care or in high dependency care.

DETAILED PICTURE
Sir William Stewart, chairman of the HPA, said: “This is the first time that the Health Protection Agency has published these figures together, and they provide a detailed picture of the challenge posed by healthcare-associated infections. This data will play a vital role in helping hospitals measure their performance. Rates are not the same across the country. Some hospitals are doing an outstanding job, others have much to do.”

Dr Georgia Duckworth, head of the Health Protection Agency’s HCAI Department, said: “Nationally the increase in C. difficile and limited decrease in MRSA cases indicate there is much work to be done, but today’s figures show some encouraging signs. Individual Trusts, such as the six who reported no MRSA blood poisoning cases at all and others with significant reductions in cases, are leading the way in reducing healthcare-associated infection.”

“The MRSA enhanced surveillance figures will be especially useful in identifying where the MRSA was acquired, allowing a more targeted approach to control. These figures will help us further understand the problem and show how we can best tackle the disease.”

“It is also important to remember that not all healthcare-associated infections are preventable. Some of these infections are the price we pay for advances in medicine that allow patients to survive who would have been unlikely to survive their illness a few years ago.”

Other data recently published includes:

• Mandatory surveillance data for glycopeptide-resistant enterococci (GRE) cases, which shows a continuing low level of infection. There were 757 cases in England from October 2004 to September 2005, compared to 628 in the previous year.

• Mandatory surveillance data of Surgical Site Infections, which shows there were 1,054 recorded in England between April 2004 and December 2005 in the 79,120 orthopaedic procedures for which information was collected – an overall infection rate of 1.34%. Infection rates were low for most surgical procedures, for instance 0.7% in knee replacements.

They were highest for hip hemiarthroplasties (3.9%), usually undertaken to repair fractures to the neck of femur. These patients tend to be older and have underlying illness, which affects their susceptibility to infection.

• The first results were from the Random Sampling Scheme, whereby C. difficile samples from across the country are typed by a national reference laboratory. Almost 30% of samples in 2005 were caused by C. difficile ribotype 027, which has previously been associated with major outbreaks. However, research has not yet shown a predictable relationship between type 027 and clinical severity.

• A report from the HPA on Clostridium difficile: findings and recommendations from a review of the epidemiology and a survey of directors of infection prevention and control in England. This includes the full analysis of a joint user study undertaken with the Healthcare Commission of hospital Trusts and a review of epidemiological data. This found that many Trusts were failing to adequately report outbreaks of C. difficile to the Health Protection Agency, and recommends that procedures for reporting outbreaks should be reviewed.

Draft code of practice
A draft code of practice for the prevention and control of healthcare-associated infection has recently been published by the Department of Health. The code will come into force when the final version is published on 2 October 2006, and it will form part of the Healthcare Commission’s annual health check for the period starting April 2007.

The Healthcare Commission will be using the code to assess NHS performance, and similar requirements will be introduced for the private and voluntary healthcare sector and care homes.

The code’s purpose is tohelp NHS organisations plan and implement HCAI prevention and control measures. Set out are criteria by which managers of NHS organisations, and other healthcare providers, should ensure that patients are cared for in a clean environment, where the risk of HCAI is kept as low as possible.

An introduction to the code states that the term “healthcare-associated infection” covers any infection by any infectious agent acquired as a consequence of treatment for a medical condition or acquired by a healthcare worker in the course of duties. The prevention and control of healthcare associated infection is a high priority for all parts of the NHS and it is of equal importance for healthcare providers in the independent and voluntary sectors.

Noted is how effective prevention and control of HCAI has to be embedded into everyday practice and applied consistently by everyone. It is especially important to have a high awareness of the possibility of HCAI in both patient and attendant to ensure early and fast diagnosis. This should result in effective treatment and containment of infection. Effective action relies on accumulating evidence that takes account of current clinical practices. The evidence base should be used to review and inform practice. All staff should demonstrate good infection control and hygiene practice. However, it is not possible to prevent all infections.

The document states that systems for the prevention and control of HCAI should address:

• Management arrangements to include access to accredited microbiology services.
• Clinical leadership.
• Application of evidence-based protocols and practices for both patients and staff.
• The design and maintenance of the environment and medical devices.
• Education, information and communication.

PROTECTED
The document states that every NHS organisation must ensure that, as far as is reasonably practicable, patients, staff and other persons are protected against risks of acquiring healthcare-associated infections through the provision of appropriate care, in suitable facilities, consistent with good clinical practice.

Those patients who present with an infection or who acquire an infection during treatment should be identified promptly and managed according to good clinical practice, both for treatment and to reduce the risk of transmission.

All NHS organisations must ensure that they have in place appropriate systems and arrangements for allocating responsibilities and accountability to all staff, contractors and other persons in the delivery of healthcare in order to protect patients from risks of acquiring infections. In particular, the arrangements should include:

• A board level agreement outlining collective responsibility for minimising risks of infection and the general means by which prevention and control of such risks is achieved.

• The designation of a director of infection prevention and control (DIPC) accountable directly to the board.

• The mechanisms by which the board ensures that adequate resources are available to secure effective prevention and control of HCAIs. The mechanisms would include an assurance framework, an infection control programme, and an infection control infrastructure.

• The provision of suitable and sufficient training, information and supervision for all relevant staff, contractors and other persons concerned with patient care on the measures required to prevent and control risks of infection.

• A programme of audit to ensure that key policies and practices are being implemented appropriately.

• A policy addressing, where relevant, admission, transfer, discharge and movement of patients between departments within and between healthcare facilities.

In a section considering the duty to provide and maintain a clean and appropriate environment for healthcare, the document states that NHS organisations must ensure that there are in place policies for the environment that take account of infection control advice. Lead managers must be designated for cleaning and decontamination.

All parts of premises in which healthcare is provided must be suitable for the purpose for which they are being used, must be kept clean and must be well maintained. Cleaning arrangements must detail the standards of cleanliness required in each part of the organisation’s premises, and the schedule for cleaning frequencies must be publicly available.

An adequate provision of suitable hand wash facilities and antibacterial hand rubs must be made. There must be effective arrangements in place for the appropriate decontamination of instruments and other equipment, and there must be adequate provision for linen and laundry supplies in line with national guidelines.

The dress code for staff (which should include uniforms) should ensure attire is clean and fit for purpose.

ISOLATION FACILITIES
The document stipulates that all NHS organisations providing inpatient care must ensure that they have adequate isolation facilities to prevent the spread of HCAIs. Also, the organisations must ensure that support for infection prevention and control is provided by a microbiology laboratory working to the standards as presently required for accrediation by Clinical Pathology Accreditation (UK).

Appropriate policies must be in place, where relevant, for infection prevention and control in clinical settings, the document states.

These policies should reflect national guidelines, where applicable, and evidencebased practice. Implementation of the policies should be monitored via the clinical governance system, and there should be evidence of a rolling programme of audit, revision and update.

To comply with the code, a number of core policies should be followed. These embrace standard (universal) infection control precautions; aseptic technique; major outbreaks of communicable infection; isolation of patients; safe handling and disposal of sharps; the prevention of occupational exposure to blood-borne viruses (BBVs) – including cases of injury caused by sharps; management of occupational exposure to BBVs and post-exposure prophylaxis; closure of wards, departments and premises to new admissions; disinfection policy; and antimicrobial prescribing.

Furthermore, there should be control of infections which may need a specific alert, taking into account local epidemiology and risk assessment. Considered in this area of control, as a minimum, should be MRSA, Clostridium difficile, and transmissible spongiform encephalopathies (TSE).

Other policies may be required, dependent on local circumstances. All policies should be clearly marked with a review date.

DUTY
Healthcare organisations have a duty to ensure that workers are free of communicable disease during the course of their work and are protected in the workplace from such disease. Furthermore, the duty covers education of the workers in the prevention and control of HCAI. There should be a record of training and updates for all staff, and details of infection prevention and control should be included in job descriptions, personal development plans and appraisals for all staff groups.

NHS organisations should ensure that all staff can access occupational health services.