The National Audit Office’s report: “Reducing Healthcare Associated Infections in Hospitals in England” suggested that although progress has been achieved in relation to MRSA and Clostridium difficile, the Department of Health has “taken its eye off the ball” regarding other healthcare-associated infections, which are equally serious and constitute four-fifths of all infections.
Providing an overview of the current state of play, Karen Taylor OBE, National Audit Office, reported that investment in reducing HCAIs in the NHS was paying dividends – while annual expenditure on infection control reached £120 million, in 2007-2008, the savings achieved by reducing MRSA and C. difficile are estimated to total £141 million.
She pointed out that, at the start of the millennium, infection control was the “Cinderella of Cinderella services” and there was very little robust information available on incidence. However, resources dedicated to cleaning and infection control have now increased and managing HCAIs is now seen as a priority by hospital Trusts’ leadership teams; staff feel that boards are taking the lead in tackling the issue and infection control teams have identified this as an important factor in driving improvement.
There have also been some positive findings on the issue of individual responsibility – the requirement to comply with infection control guidance is now included in the job descriptions of all relevant staff in 61% of Trusts, while 62% of nurses and 33% of doctors are assessed on infection control as part of their regular review/appraisal.
Root cause analysis, when carried out effectively, has further helped to emphasise individual responsibility and has led to improvements in practice. In general, compliance with good practice on infection control is improving, although nurses remain more likely to comply than doctors and barriers to improvement remain. Among the issues highlighted by the NAO is the fact that the data reported to Trust boards is usually limited to MRSA and C. difficile. There is a lack of attention to other HCAIs, which are now showing worrying rises – for example, rates of E. coli and Klebsiella blood stream infection are now on the increase.
Despite the consensus on good practice compliance, adherence is still not universal and staff often fail to see a link between actions and the impact on safe care. The biggest threat remains antibiotic resistance – with poor data on hospital prescribing limiting the ability to evaluate the effectiveness of usage. Other barriers to further improvement identified by Trusts include: bed occupancy, the availability of isolation facilities and competing targets. The NAO also highlighted a lack of clarity on the roles and responsibilities of local and national organisations and a need for a “whole systems approach” – including a better understanding of the impact of movement of patients within and between hospitals, care homes and community.
The NAO concluded that national targets supported by mandatory surveillance and inspections have driven the reduction in MRSA bloodstream and C. difficile but the lack of progress on others highlights the need to continually strive to eliminate all avoidable infections. Improvements have not been evident across all Trusts and significant scope remains for hospitals to improve infection prevention and control further.
Towards zero tolerance
Sally Batley, head of the Improvement Network HCAI and DSSA Programmes, Department of Health, provided an update from the DH on national strategic support and guidance, and the journey towards zero tolerance. She explained that the Improvement Network was established to support the NHS in achieving its goal of delivering safe, quality care, with privacy and dignity.
She pointed out that the health service has made significant steps forward – the NHS is now 50% under its 50% target to reduce MRSA infections and the figure continues to be reduced even further. The target for C. difficile reductions is also being achieved ahead of schedule. “We have moved on from targets, however, and now have ‘the MRSA objective’ which follows a recommendation by the National Quality Board,” she commented.
As from April 2010, NHS organisations will now be set an objective for reducing MRSA infections, relative to the median, with the best-performers setting their objectives locally. It requires organisations with the highest rates to make the biggest reductions, and challenges the best performers to sustain their low rates and strive for further reductions where possible. The MRSA objective is based around a zero tolerance approach to preventable infections and is designed to further reduce variation in performance on MRSA bloodstream infections.
The emphasis is on a “whole health economy” approach to infection prevention and, for the first time, responsibility for reducing MRSA bloodstream infections is being shared between acute Trust and primary care organisations. It is hoped that this will introduce a greater focus on infections that could have originated in community and primary care settings.
“The message behind the objective is that ‘every case counts and every case matters’,” Sally Batley commented. “We want to reach a point where we virtually eliminate HCAIs.” Discussion is also underway to establish a new “C. difficile objective”, which is being launched this year, and will apply from April 2011. She predicted that this will also take a zero tolerance approach. “Only a few years ago, there was intertia in the system – there was a belief that ‘infections are inevitable’; that there is ‘nothing you can do’, but we have proven otherwise. People now believe in zero tolerance. It is everyone’s responsibility and everyone knows they can make a difference.
“The overuse of antibiotics is still a concern, however. The majority of PCTs collect information on this, but do not do anything with it. They need to change their belief systems and behaviour to drive this down,” she asserted. On a positive note there is a tangible difference in the cleanliness of hospitals, today, and compliance with best practice is now being regularly checked. Whereas hand hygiene audits used to be carried out once a year, there is an understanding that compliance needs to be checked more regularly. Chief executives now discuss root cause analysis and there has been a mindset change across the NHS and throughout organisations.
Sally Batley added that there is now no need to centrally fund a healthcareacquired infection programme, to move the initiative forward, as the campaign has now gathered its own momentum: “In our final year, the improvement network will look at leaving a legacy of sustainability to ensure that efforts to reduce infections continues to be managed locally,” she concluded.
• The annual Healthcare Associated Infections conference is organised by Healthcare Events and sponsored by Teva. www.healthcare-events.co.uk