Working together to prevent infection

Patients are entering care homes colonised with organisms acquired in hospital that are resistant to antibiotics, then care homes are becoming “reservoirs” for infection, the Care Quality Commission has warned. This has created a “revolving door” situation, with patients being readmitted to hospital for conditions that could be managed within a care home.1 The problem of transmission between care homes and the acute sector was a key theme recently explored at the Infection Prevention Society’s annual congress, in Harrogate, where Professor Mark Wilcox gave a presentation entitled: “MRSA in care homes – a reflection of hospitals or the community?” Head of microbiology at the Leeds Teaching Hospitals, Prof. Wilcox pointed out that, in the Leeds area, more than 50% of MRSA bacteraemias occurring in elderly medicine patients were associated with care home residents. Furthermore, in an audit of practice (based on 1996 guidelines), only 19% of care homes met the critical standards for caring for residents with MRSA. He explained that there have been very few studies looking at the prevalence of MRSA colonisation in UK care homes and a large-scale study was therefore carried out in 2005/6 in over 700 care homes in Leeds, to evaluate prevalence and risk factors. The study found that MRSA and MSSA colonisation rates were 22% and 20% respectively. Risk factors identified included: • Care homes with a low ratio of nurses to beds. • The location of residents in a care home within a deprived area. • Male sex. • Presence of an invasive device. • Recent hospitalisation. He warned that strategies that attempt to transfer models of practice directly to the community sector are “woefully inadequate” and “doomed to failure”. A two-year study has therefore sought to determine the effects of infection prevention advice, education and training on staff knowledge, practice and prevalence in over 60 care homes in the Leeds area, he revealed. The aim of the study was to improve practice through education on hand hygiene, for example, as well as introducing improvements to the environment such as access to hand hygiene facilities. A stepped approach to implementing the interventions was adopted and the effects of the interventions measured after each step. The impact of the intervention was assessed in relation to hand hygiene, the environment and knowledge. Before the intervention, the environmental audit score was 69%, which increased to 85% after the initiative; hand hygiene compliance improved from 64% to 82%, while educational scores were also raised. The intervention had a direct effect on practice in relation to these three areas, but did not reduce the overall carriage rates. In fact, prevalence increased at certain intervals when patients were swabbed, then decreased again on other occasions. This was perplexing given the fact that the interventions had been successfully implemented, raising the question: “What other factors were influencing this fluctuation in levels of MRSA carriage?” Further investigation found that 70% to 90% of the 2,514 residents included in the study had encountered some form of healthcare contact, which “confirmed suspicions that healthcare contact is a significant driver of MRSA.” Important factors were the number of admissions in the last 12 months, the number of admission days in the last 12 months, whether the nursing home had “nursing” patients as opposed to just residents, and whether there had been an invasive device used. Male sex was also an independent risk factor. The involvement of an invasive device and male sex were also identified as highly significant as predictors of mortality, but hospital admission within the last 12 months and even MRSA colonisation status were not, which he found surprising. “For unexplained reasons, the epidemic of community-acquired MRSA being seen in other countries, such as the US, is yet to reach the UK,” he commented, pointing out that community-acquired strains were not found to be prevalent in the study cohorts. He believed that the interventions had been effective but not uniformly across all care home residents and care settings. There were significant variations between private and local authority care homes and those with and without nursing facilities for reasons that needed to be investigated through further research.

Poor communication

The Care Quality Commission has also raised concerns about the lack of communication between care homes and hospitals. A recent report by the Commission found that there was a need for hospitals and care homes to provide information about infections to each other to make sure that people with, or recovering from, an infection are cared for properly and to reduce the chances of other people being infected. The report highlights that this information is not provided in a coordinated way with 17% of the care homes participating in the study saying that they received no information on infections at all when people were discharged from a hospital to their care. Even when information was received, this could be weeks late, incomplete or illegible. This was not thought to be due to a lack of commitment or will on the part of hospital staff, but because they are overloaded with work. However, the Commission suggested that this may be because the information provided when a person is discharged is sent to their GP, as specified by the NHS standard contract, and not to their care home. Furthermore, homes that only provide personal care seemed to have the greatest difficulty in accessing information from hospitals. Crucially, ambulance crews, a common link between hospitals and care homes, are often left out of the information loop, even though they could perform a vital role both in caring for people and transferring information about their care needs. The Commission also pointed out that if ambulance crews are not told about a patient’s infection status, they could facilitate further transmission of infections. The Commission’s survey revealed that the ways in which health and social care staff communicated with each other about infections varied, with the most common being verbally. This is contrary to the NHS standard contract, which specifies that this information should be presented in a written summary. The survey also found that staff were sometimes confused by data protection, patient consent and confidentiality issues, which could lead to inefficient communication. The Commission pointed out that this is a complex area, involving different pieces of legislation and guidance, which may explain why this information is provided inconsistently. Current Department of Health guidance states that information should not be shared by clinicians with a third party without informed consent, but this may be difficult to obtain in some circumstances. Clinicians and care home staff rightly focus on the rights and needs of the individual and it is likely that data is withheld for the best reasons. The Commission concluded that attempts to protect the rights of an individual may result in unsafe practice by undermining infection prevention and control measures and called for clearer guidance. The Commission expected care homes to use indicators to track their performance on infection prevention and control, in relation to the following areas: • The number of infections. • Compliance with hand washing and cleaning. • Adherence to best practice for enteral feeding. • Adeherence to best practice for catheter management. However, the survey found that majority of respondents (61%) used no performance indicators at all. Other areas of concern included the fact that care homes have not fully implemented national guidelines published in 2006 designed to prevent and control infections.