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Improving patient care by reducing the risk of ... - Antibiotic Action

Improving patient care by reducing the risk ofhospital acquired infection: A progress reportREPORT BY THE COMPTROLLER AND AUDITOR GENERALHC 876 Session 2003-2004: 14 July 2004


The National Audit Officescrutinises public spendingon behalf of Parliament.The Comptroller and Auditor General,Sir John Bourn, is an Officer of theHouse of Commons. He is the head of theNational Audit Office, which employs some800 staff. He, and the National Audit Office,are totally independent of Government.He certifies the accounts of all Governmentdepartments and a wide range of other publicsector bodies; and he has statutory authorityto report to Parliament on theeconomy, efficiency and effectivenesswith which departments and other bodieshave used their resources.Our work saves the taxpayer millions ofpounds every year. At least £8 for every£1 spent running the Office.


Improving patient care by reducing the risk ofhospital acquired infection: A progress reportREPORT BY THE COMPTROLLER AND AUDITOR GENERALHC 876 Session 2003-2004: 14 July 2004LONDON: The Stationery Office£11.25Ordered by theHouse of Commonsto be printed on 12 July 2004


This report has been prepared under Section 6 of theNational Audit Act 1983 for presentation to the Houseof Commons in accordance with Section 9 of the Act.John BournNational Audit OfficeComptroller and Auditor General 12 July 2004The National Audit Office study team consisted of:Sonia Ashby, Judith Sedgwick andDr. Andrew Pearson (on secondment fromthe Public Health Laboratory Service/HealthProtection Agency) under the directionof Karen Taylor.This report can be found on the National Audit Officeweb site at www.nao.org.ukFor further information about the National Audit Officeplease contact:National Audit OfficePress Office157-197 Buckingham Palace RoadVictoriaLondonSW1W 9SPTel: 020 7798 7400Email: enquiries@nao.gsi.gov.uk© National Audit OfficeQuote from The Florence Nightingale Museum“As we approach the 150th anniversary of Florence Nightingale'srise to fame as the 'Lady with the Lamp' of the Crimean War, it isworth reflecting that her lasting legacy was as a 'PassionateStatistician.' Upon her return from the war she embarked on apainstakingly meticulous analysis of the mortality data whichenabled her to identify the underlying cause: poor sanitation. Shecreated new statistical diagrams to persuade the government to carryout fundamental health reforms. Florence Nightingale applied hermethods to civil hospitals in Britain, tackling the problems ofovercrowding, poor ventilation and lack of cleanliness with similarrigour and influence. Her Notes on Hospitals of 1863, though lesswidely known than Notes on Nursing, had a profound impact on thedesign and management of hospitals in Britain and throughout theworld. Through the use of carefully collected and accurate data shewas able to build her case to improve the quality of people's lives.Today her recommendations for creating comparative hospitalstatistics are startlingly relevant.”Alex AttewellDirectorFlorence Nightingale Museum


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTContentsSummary 1Part 1Hospital Acquired Infection is now a 9National Health Service PriorityDepartmental Initiatives have raised the profile 9and the priority of infection controlThere is a greater emphasis on 10performance monitoring"Winning Ways" re-emphasises the need for 10infection control to be given a high prioritythrough a set of "must do" actionsOther countries have developed strategies for 12preventing hospital acquired infection inresponse to increased awareness of risksPart 2Despite a higher profile at NHS trust 13level, wider factors stand in the wayof improving infection controlInfection control has generally had a higher 13profile in most NHS trustsWider factors complicate prevention and control 19Part 3Despite some local improvements 23the NHS still lacks sufficientinformation on the extent and costof hospital acquired infectionThere is still no comprehensive mandatory 23surveillance schemeCost information has not improved 30Though robust cost/benefit analyses are lacking, 31all available evidence continues to showprevention is better than treatmentPart 4Changing clinician and other 33staff behaviour in order to reducerisks requires multiple approachesto preventionBetter and more consistent information that 33is owned by NHS clinical staff is crucialto improving practiceReducing risks requires multiple approaches to 34prevention but barriers to effective practice remainThere is a need for improved awareness and 44uptake of technological innovation to engineerout risksApproaches taken by other countries 44Appendices1. Key developments and Departmental 45initiatives since the National Audit Officereport was published in February 20002. Comparison of the Committee of Public 47Accounts Report recommendations and theGovernment's Treasury Minute Response,and developments as at February 20043. Comparison of International Practices in the 50Management and Control of HospitalacquiredInfections4. The Management and Control of Hospital 52Acquired Infection in Other UK countries5. National Audit Office Study Methodology 556. Relationships between Department of Health 57key performance indicators on MRSA andControls Assurance data7. Chronology of developments in mandatory 59surveillance of hospital acquired infectionsBibliography 61Glossary 63Front cover: Florence Nightingale (1820-1910)Photographs: with thanks to University Hospital Lewisham NHS Trust for enabling us to photograph their staff.


Map showing proportion of Staphylococcus aureus bacteraemia isolates resistant to methicillin in various European countriesNo data0-10%10-20%20-30%30-40%Sweden0.740-50%Finland0.8Denmark0.9Estonia1.2Eire42.5UK43.9Holland1Belgium28.3Germany18.7CzechRep. 5.9Poland23.1Slovakia8.5Portugal38.1France32.8Italy38.2Austria10.6Hungary9Romania35.8Spain23.3Bulgaria32.8Slovenia13.8Croatia36.9Greece43.8NOTEData on levels of MRSA bloodstream infections as a proportion of all Staphylococcus aureus bloodstream infections show that theUnited Kingdom is amongst those with the highest levels in Europe.Source: European Antimicrobial Resistance Surveillance System (EARSS) 2002


IMPROVING PATIENT CARE BY REDUCING THE RISK OFHOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTSummary1 In February 2000 our report The Management and Control of Hospital AcquiredInfection in NHS Acute Trusts in England (HC 230 Session 1999-00) noted thatat any one time, 9 per cent of patients had an infection that had been acquiredduring their hospital stay. The effects varied from extended length of stay anddiscomfort to prolonged or permanent disability and, in at least 5,000 patientsa year, death. These infections were costing the NHS as much as £1 billion ayear and around 15 per cent could be prevented by better application of goodpractice, releasing resources of £150 million for alternative NHS use. 12 We found that good practice with respect to the prevention, control andmanagement of hospital acquired infection needed to be more widely knownand that there was a lack of basic comparative information on infection rates. Wewere concerned that there appeared to be a growing mismatch between whatwas expected of infection control teams and the staffing and other resourcesallocated to them, and identified considerable scope to improve performance. 13 The Committee of Public Accounts (the Committee) concluded inNovember 2000 that the lack of grip on the extent and costs of hospitalacquired infections impeded NHS trusts in targeting activity and resources tobest effect. In addition, the Committee said that a root and branch shift towardsprevention would be needed at all levels of the NHS if hospital acquiredinfection were to be kept under control. Such a shift would requirecommitment from everyone involved, and a philosophy that prevention iseveryone's business, not just the specialists. 24 Since then the Department of Health (the Department) has issued variousguidance and established a range of national advisory structures and expertcommittees to increase the priority given to this issue (Appendix 1). Yet, in theChief Medical Officer's December 2003 report, Winning Ways 3 , he stated thatsuch data as are available show that the degree of improvement has been small.5 We therefore examined whether our and the Committee's (Appendix 2)recommendations have been implemented, whether the management andcontrol of hospital acquired infection in NHS acute trusts has improved, andwhether there have been any discernible changes in patient outcomes. We alsoexamined how other countries are addressing these issues (Appendix 3 and 4).The study methodology is summarised at Appendix 5.summary1


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTOverall Conclusion6 Implementation of our and the Committee's recommendations has beenpatchy. There has been notable progress at trust level in putting the systems andprocesses in place and in strengthening infection control teams, but widerfactors continue to impede good infection control practice and there has beenlimited progress in improving information on the extent and costs of hospitalacquired infections. Progress in preventing and reducing the number ofinfections acquired whilst in hospital is dependent on changing staff behaviour,but change continues to be constrained by the lack of data, limited progress inimplementing a national mandatory surveillance programme that meets theneeds of the NHS, and a lack of evidence of the impact of different interventionstrategies. More specifically:iiihospital acquired infection now has a much higher profile and, at thecentral strategic level, has been accorded a higher priority with the launchof a number of key requirements;at trust level, higher priority is now generally given to hospital acquiredinfection, but the pursuit of other key policies and priorities can adverselyaffect attempts to improve infection control, a task made harder by theemergence of strains of multi-resistant bacteria, increasing antibioticresistance, and an increase in the number of outbreaks such as Norovirusreported by trusts;iii despite some local improvements in information, the NHS still lackssufficient information on the extent and cost of hospital acquired infection;ivfurther action is required using a range of approaches to change staffbehaviour to reduce the risks of hospital acquired infection.Actions taken by the Department have increased thepriority given to infection control7 Increasing priority has been given to the management and control of hospitalacquired infection at the national level, with the launch of a number of highprofile initiatives culminating in December 2003 with Winning Ways, whichaims to bring this issue into the mainstream of service developments. The1999-2000 clinical governance 4 and controls assurance initiatives 5 have beenparticularly instrumental in requiring NHS trusts to put systems and processesin place to improve infection control, and in providing a framework for clinicalquality improvement.8 External reviews and inspections of trusts infection control arrangements haveincreased. Whilst raising the profile of infection control there is some overlapand duplication, with a focus on structures and processes, and a limitedemphasis on evaluating changes in patient care. The different assessmentprocesses can also result in contradictory findings. Winning Ways notes that theDepartment has asked the Commission for Healthcare Audit and Inspection(now known as the Healthcare Commission) to give priority to this, and theyhave included this in their 2004 star ratings assessment, but again the focus ison processes and procedures.summary2


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTActions have been taken by trusts but wider factorsimpede good practice9 Infection control is a higher priority, with trusts making improvements to theirinfection control management arrangements and increasing their trust boards'involvement. Infection control team staffing levels have also increased,although wide variations between trusts remain. More teams have separateinfection control budgets but the amounts vary and 24 per cent claim that theirbudgets have decreased in real terms. Increased demands on infection controlteams with more surveillance and external inspections has meant that thereremains a mismatch between expectations placed on the teams and resourcesallocated to them. Implementing the action areas in Winning Ways, whilstaimed at all NHS staff, is likely to place further demands on infection controlteams. New risks, but also potential opportunities may arise from the changesto funding flows in the NHS under the Departmental initiatives Shifting theBalance of Power 6 , Patient Choice 7 , and Payment by Results 8 .10 The continuing problem of increasing antibiotic resistance, and the emergenceof strains of multi-resistant bacteria has increased the complexity of managingand controlling infection. During the 1990s the number of reported cases ofStaphylococcus aureus bacteraemias (bloodstream infections) have increasedyear on year with the number of cases of methicillin resistant (MRSA)bacteraemias increasing from less than 2 per cent in 1994 to around 35 per centin 2001. In the three years since the Department introduced mandatoryreporting in April 2001, the number of reported Staphylococcus aureusbacteraemias have increased from 17,933 to 19,311 (8 per cent) and the numberthat are methicillin resistant have risen from 7,250 to 7,647 (a 5 per centincrease). The overall proportion that is MRSA stands at 40 per cent. EuropeanAntimicrobial Resistance Surveillance System data for 2002 showed that theUnited Kingdom has amongst the worst rates in Europe 9 . Our survey of NHSacute trusts found that there has also been an increase in the number of infectionoutbreaks which have led to more wards and bays being closed for the purposeof outbreak control.11 Preventing infections continue to be adversely affected by other NHS trust-widepolicies and priorities as identified in our original report. The increasedthroughput of patients to meet performance targets has resulted in considerablepressure towards higher bed occupancy, which is not always consistent withgood infection control and bed management practices. Seventy-one per cent oftrusts are still operating with bed occupancy levels higher than the 82 per centtarget that the Department told the Committee it hoped to achieve by2003-04 after this issue was highlighted in our 2000 report. The lackof suitable isolation facilities also remains a concern for trusts, asdoes the increase in frequency of moving patients and a lack ofsufficient beds to separate elective and trauma patients.summary3


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTThe NHS still lacks sufficient information on the extentand cost of hospital acquired infection12 In contast to the Committee's recommendation that the Nosocomial InfectionNational Surveillance Scheme (NINSS) should be made mandatory, theDepartment decided to set up a Healthcare Associated Infection SurveillanceSteering Group (HAISSG), to provide them with urgent recommendations oninfection surveillance. The Group proposed a revised approach to mandatorysurveillance, and their first action was to introduce new mandatory laboratorybased MRSA bacteraemia surveillance from April 2001. In September 2002the Group was disbanded, and responsibility for taking forward surveillancewas transferred to the Public Health Laboratory Service (PHLS) which is nowpart of the Health Protection Agency (HPA) under a service level agreementwith the Department.13 Since then, there has been limited progress in the development, implementationand audit of other strands of mandatory surveillance. As a result, robustcomparable data other than on hospital wide MRSA bacteraemia data aretherefore not currently available for the NHS in England, and it is impossible toquantify with any certainty if there have been any changes in NHS trusts'infection rates. There has also been no progress in introducing a nationalpost-discharge surveillance scheme as recommended by the Committee.14 Our international comparisons study showed that all the countries reviewedhave established surveillance programmes, but variations in protocols andnumbers and frequency of hospital participation make direct comparisonunreliable. Nevertheless, national prevalence studies show rates of between4 and 10 per cent (compared with 9 per cent in the UK). During 2003 NorthernIreland, Scotland and Wales have collaborated in combining their datasets onorthopaedic surgical site infections over the last three years, which representsa major joint initiative to provide support to clinical teams in this area. InEngland, the Health Protection Agency implemented, new mandatoryorthopaedic surveillance from April 2004, under a service level agreement withthe Department.15 In our original report we calculated that hospital acquired infections werecosting the NHS around £1 billion a year. Because of the complexities involvedin identifying costs, few trusts have attempted to calculate their own costs norhave any attempts been made to refine or validate this estimate. Othercountries have had similar problems in developing robust up-to-dateevaluations of the economic impact of hospital acquired infection, but allconclude that the cost of introducing preventative measures is less than the costof treating such infections.summary4


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTChanging staff behaviour to reduce risks requires theadoption of multiple approaches to prevention16 Despite the increasing profile of hospital acquired infection and the publicationof guidelines on the measures required to contain the problem, there continuesto be non-compliance with good infection control practices. To improvepractice, a major change is required so that everyone accepts personalresponsibility. Feedback of specific local infection rates to clinical staff is vitalin engaging them in reviewing and changing their practice.17 The new mandatory national surveillance schemes do not currently enableclinicians to identify and reduce risks within their own specialty. In the absenceof ownership and access to such data, hospital acquired infection is stillperceived as a problem for the infection control team to deal with, andconsequently many of the issues identified as barriers to effective infectioncontrol practice in our original report still apply. Considerable improvementscould therefore still be made in: the coverage of education and training ininfection control to all groups of staff, particularly doctors; compliance withguidance on issues such as on hand hygiene, catheter care and aseptic technique;antibiotic prescribing in hospitals; hospital cleanliness; and consultation with theinfection control team on wider trust activities such as new build projects.18 There is scope to improve awareness of, and improvements in, technologicalinnovation to help engineer out risks, but there is a lack of clarity as to theevidence base required before new technologies are approved for use in theNHS. Winning Ways has acknowledged this, and as an initial step theDepartment announced that they would commission a rapid review of newprocedures and products for which claims of effectiveness to prevent or controlhospital acquired infection have been made.19 Winning Ways sets out for the local NHS seven areas together with details ofspecific actions that, if implemented, should enable trusts to improveprevention and control, including:■■■■■■■active surveillance and investigation of healthcare associated infection andantimicrobial resistant organisms;reducing infection risk by controlling the use of invasive devices,instruments and other equipment;reducing reservoirs of infection by improving bed managementand isolation facilities;adoption of high standards of hygiene and clinical practice;prudent use of antibiotics to minimise the emergence ofantibiotic resistant organisms;improving senior management commitment, localinfrastructure and systems;research and development to ensure that technologicalbreakthroughs in prevention and control are rapidlytranslated into benefits for patients.summary5


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTRecommendations20 Most of the above areas were included in our and the Committee's recommendations, andhave also been trailed in previous guidance. But implementation and compliance has beenpatchy. Our recommendations are aimed at helping the Department, and NHS trusts toovercome some of the constraints and to improve implementation and compliance.The Department should:abcdefghijclarify an implementation timetable for the various elements within the Action Areas inWinning Ways;work with the Health Protection Agency to expedite development of national mandatorysurveillance in a way that meets the needs of the NHS, and which provides robustcomparable data on hospital acquired infection, including information on high risk areassuch as intensive care and renal units. Investment in such a system would be offset by savingsfrom rate reductions;ensure that the national IT strategy accommodates the surveillance and other ITrequirements of infection control with links between microbiology, prescribing and patientadministration systems;in conjunction with the Health Protection Agency, evaluate the research in Case study Con managing outbreaks and our other findings, and commission research on bedmanagement and isolation, and develop evidence based guidance to help trusts balancebed management and infection control requirements;expedite the publication of the staffing toolkit and the planned guidance on the rolesand responsibilities of infection control teams. These should include clarification ofthe training, grade and experience required of the new Director of Infection Preventionand Control;actively engage with NHS commissioners to impress on them the importance that needsto be attached to trusts having effective infection control systems and processes in placeand that commissioners should consider including information on infection rates ininformation provided under Patient Choice.use the opportunity from recommendations made by the Healthcare Concordat i to ensurethat one inspection body takes the lead in assuring compliance with the new HealthcareStandards on infection control, and ensure that this is clearly linked to the Commission forHealthcare Audit and Inspection's (now known as the Healthcare Commission's) role asenvisaged in Winning Ways;expedite the production of a national infection control manual, ensuring that it builds onthe large amount of good practice that exists in individual trusts;continue to work with the Royal Colleges and professional bodies to ensure that infectioncontrol is a key component in undergraduate training;require infection control induction training to be mandatory for all staff, as for health andsafety and fire safety training, and require records to be maintained on this and on regularupdate training; andsummarykas a matter of urgency, define how the rapid review process of new procedures andproducts is to be implemented, and how the findings will be promulgated so that they canbe translated into practice at trust level with minimum delay.6iThe Healthcare Concordat is a code of objectives and practices agreed by bodies inspecting health and healthcarebodies in England.


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTThe Healthcare Commission should:lin developing the assessment/review framework for evaluating the new HealthcareStandards, consult trusts on suitable performance indicators for infection control whichmeasure outcomes rather than systems and processes;m work with other bodies such as the NHS Modernisation Agency and the National PatientSafety Agency to identify and promulgate good practice.NHS trusts should:nopqrstuvclarify and explain accountabilities, including the role, membership and responsibilities ofthe Hospital Infection Control Committee;actively demonstrate the commitment from the trust board and senior management insupporting and implementing the action plans in Winning Ways by ensuring that infectioncontrol regularly features as a trust board agenda item, and consider the inclusion ofcompliance with infection control practice as one of the criteria in staff appraisals;review infection control team staffing and other resources, including the designation of thenew Director of Infection Prevention and Control, and evaluate the adequacy of resourcescompared with the demands on the team (investment should provide commensurateimprovements in rates releasing resources for alternative use);ensure participation in all mandatory surveillance schemes, obtaining buy in from clinicalstaff through shared responsibility and appropriate and timely feedback of results;make better use of existing data, for example on antibiotic prescribing, to gain a widerperspective of the extent of hospital acquired infection;ensure all staff receive induction and update training, and use the new Electronic StaffRecords system to maintain records of staff education and training;require consultation with infection control teams to be a mandatory step in contracttendering procedures for new build projects, and for cleaning, laundry and catering services;demonstrate that infection control issues are included in patient and public consultationsunder the trusts clinical governance programme; andincrease public awareness of and compliance with good infection control practice andencourage their active participation in improving staff and visitor compliance.summary7


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT1Roles and responsibilities of Department of Health, the Health Protection Agency and NHS Trusts in relation tohospital acquired infectionDepartment of Health - responsible for:■ Setting overall policy issues in relation to public health matters;■ Managing performance of the NHS;■ Issuing policy and guidance;■ Through its 28 Strategic health authorities monitors performance of trusts.NHS Trust Chief Executive and Trust Board- responsible for:■ Ensuring that there are effective arrangements forinfection control within the Trust.Health Protection Agency responsible for:■ Developing and operating the surveillance programmefor hospital acquired infection under a service levelagreement with the Department of Health;■ Monitoring and helping to manage outbreaks of hospitalacquired infection;■ Through CCDCs, Regional Directors of Public Healthand Regional Epidemiologists protects public health bycontrolling communicable disease and infection.Hospital Infection Control Committee - responsible for:■■Endorsing all infection control policies, procedures and guidelines;Providing advice and support on the implementation of policies;■ Collaborating with the Infection Control Team to develop the annual infection control programme and monitoringits progress.The Hospital Infection Control Committee may comprise:TheInfectionControlTeamChiefExecutive orRepresentativeOccupationalHealthPhysician andOccupationalHealth NurseDirector ofInfectionControlSeniorClinicalrepresentativesNurseExecutiveDirector orrepresentativeConsultant inCommunicableDiseaseControlOtheridentifiedrepresentativesInfection Control Team (lead by the new Director ofInfection Prevention and Control) includes infectioncontrol doctor(s) and nurse(s) - responsible for:■■■Ensuring advice on infection control is available ona 24 hour basis;Producing the annual infection control programme in fullconsultation with the ICC, health professionals and seniormanagers. This programme will include surveillance ofinfection and an audit of the implementation andcompliance with selected policies;Providing education and training on the prevention andcontrol of hospital acquired infection to all grades ofhospital staff.Consultant in Communicable Disease Control (employed bythe Health Protection Agency) - responsible for:■■■■Surveillance, prevention and control of communicablediseases and infections in district; includingmanagement of outbreaks;Advising Health Authorities and Primary Careorganisations about service agreements forinfection control;Collaborating with ICT on management of outbreaksboth within hospitals and in the community;Providing epidemiological advice.Modern matrons and link nurses champion the importanceof infection control across the trust.Key:Main Accountabilitiespart oneSource: National Audit Office/Department of Health8


IMPROVING PATIENT CARE BY REDUCING THE RISK OFHOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTPart 1Hospital Acquired Infection is nowa National Health Service Priority1.1 In February 2000, our report showed that hospitalacquired infection was not seen as a priority within thehealth service. There was a need to strengthen thestrategic management of hospital acquired infectionboth nationally, and at NHS trust level. In a furtherreport in November 2000 the Committee of PublicAccounts (Committee) made two main points:■■The NHS did not have a grip on the extent and costof hospital acquired infection.A root and branch shift towards prevention wasneeded at all levels of the NHS, requiringcommitment from everyone, and a philosophy thatprevention should be everybody's business, not justthe specialists.1.2 This part of the report shows that the Department hasraised the status and profile of this issue through anumber of national initiatives and strategies(Appendix 1). These emphasise the priority that theDepartment expect the NHS to give to improving thestrategic management and control of hospital acquiredinfection. The main roles and responsibilities for themanagement and control of hospital acquired infectionare summarised in Figure 1.Departmental Initiatives have raisedthe profile and the priority ofinfection controlResponse to the Committee1.3 In February 2001, the Department accepted theCommittee's recommendations and detailed positiveactions aimed at raising the profile of this issue 10 . A fulllist of the Committee's recommendations, theDepartment's detailed response, and progress to date foreach recommendation is given at Appendix 2.Clinical governance and controls assurance1.4 "Clinical Governance: Quality in the new NHS 4 ",launched in March 1999, provided NHS organisationsand health care professionals with a framework forclinical quality improvement. Its main objective was toensure that quality was embedded within theprocedures and systems of accountability within eachtrust. Complementing the clinical governance initiativewere a set of 19 controls assurance standards. The firstof these, on infection control, was launched inNovember 1999 5 . The Department made it a mandatoryrequirement for NHS organisations to self-assess theirperformance against these standards."Getting Ahead of the Curve"1.5 In January 2002, the Chief Medical Officer's infectiousdiseases strategy "Getting Ahead of the Curve" gavefurther impetus to the need for action on "healthcareassociated infection", aimed at transforming the statusof infectious disease control from a 'Cinderella service'by bringing it into the mainstream of servicedevelopment. 11 The strategy recommended that theHealth Protection Agency should be created, combiningsome of the existing functions of the Public HealthLaboratory Service (PHLS) and three other nationalbodies (the National Radiological Protection Board, theCentre for Applied Microbiology and Research, and theNational Focus for Chemical Incidents). The objectivewas to provide an integrated approach to protecting thepublic against infectious disease as well as chemicaland radiological hazards.1.6 The new Agency was also required to deliver a localhealth protection service working with the NHS andlocal authorities to deliver specified functions relating tothe prevention, investigation and control of infectiousdiseases, as well as chemical and radiological hazards.This constituted a considerable re-organisation of thepublic health network including the rationalisation ofmicrobiology laboratories, with the transfer of the PHLSlaboratories that provide mostly general clinicalmicrobiology services to the NHS.part one9


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTpart one1.7 Part of the strategy focussed on improving the controlof "healthcare associated infection." The strategyacknowledged that this would, in part, be achievedthrough the implementation of the National Audit Officeand Committee of Public Accounts recommendations.However the strategy switched the emphasis fromhospital acquired infection to healthcare associatedinfection ii , in recognition of the fact that infections canbe transmitted via care and procedures in both primaryand secondary care setting settings, and can betransmitted from organisms in the patient's own bodywhich become invasive as their immune systems areimpaired. The strategy emphasised that the prevention ofhealthcare associated infection would requirecommitment from everyone, not just specialists ininfection control.There is a greater emphasis onperformance monitoring1.8 Our 2000 report was the first evaluation of NHS trusts'relative performance in managing and controllinghospital acquired infection. Since then the Departmenthas introduced a number of external performancemonitoring and review systems (Figure 2).1.9 In our September 2003 report "Achieving Improvementsthrough Clinical Governance" we mentioned concernsabout the proliferation of regulation and inspectionbodies and the risk of overlap and duplication. 12 Wenoted the work of the NHS Review Co-ordinationGroup whose aim is to try and improve co-ordinationand co-operation between relevant audit and inspectionbodies. This group has concluded that there are toomany reviewing organisations that do or may reviewinfection control and that it would be better that onlyone of them should provide the basic assurance ofcompliance with core standards on which the otherscan rely. 13 The wider issue of the increasing burden ofinspection is being addressed through the developmentof the Healthcare Concordat.1.10 The Government's NHS Plan (July 2000) included acommitment to introduce NHS performance ratings or"star ratings 14 ". The first set of ratings for 2000-01 waspublished in September 2001 based on a combination ofthe results of any Commission for Health Improvementreview, performance against key finance and activitytargets and a "balanced scorecard" of other qualitymeasures. Although there was no specific infectioncontrol indicator, from the outset hospital cleanliness wasincluded as one of the key indicators. In June 2003, theChief Medical Officer reported that MRSA bacteraemiaimprovement scores would be included as an infectioncontrol indicator for 2002-03 ratings. 15"Winning Ways" re-emphasises the needfor infection control to be given a highpriority through a set of "must do" actions1.11 The Chief Medical Officer's December 2003 report,"Winning Ways: Working together to reduce healthcareassociated infection in England 3 " recognises thatmodern healthcare has brought unprecedented benefitsbut also risks, and that no risk is more fundamental thanthe risk of infection. The report acknowledges thatinfection in hospitals cannot be completely eliminated,but that it can be substantially reduced, and whilst thisis a worldwide problem, the NHS in England is notperforming as well as some other European countries.1.12 The report notes that despite the extent of guidanceissued to the NHS, such data as are available show thatthe degree of improvement has been small. Forexample, the vast majority of trusts have not improvedtheir surgical site infection rates, and levels of MRSAbloodstream infections as a proportion of allStaphylococcus aureus bloodstream infections showthat this country has amongst the highest levels inEurope. Winning Ways therefore re-emphasises thepriority that needs to be given to infection preventionand control, setting out seven action areas that arenecessary to reduce the relatively high levels of certainhealthcare associated infections and to curb theproliferation of antibiotic resistant organisms.1.13 Winning Ways notes that the new Commission forHealthcare Audit and Inspection (now know as theHealthcare Commission) will be asked to makeinfection control a key priority when assessing hospitalperformance, and the implementation of Winning Ways- processes and procedures has been included as one ofthe balanced scorecard indicators for the 2004 starratings. During spring 2004 the Department consultedthe NHS and other interested parties on new HealthcareStandards for NHS organisations, in which infectioncontrol is featured in both the core and developmentalstandards. The outcome is expected to be announced inthe summer. The Healthcare Commission will assessNHS organisations performance against these standards.10iiAs this report focuses on the problem of preventing and controlling infections acquired in hospital we have continued to use the term "hospitalacquired infection".


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT2Regulatory and support landscape from an Acute NHS Trust's perspectiveThere are a number of regulatory bodies (blue) and other supporting bodies (pink) with responsibilities for infection control.The NHS Litigation AuthorityHandles the Clinical NegligenceScheme for Trusts, whichestablished standards in 1999 toprovide a framework for clinicalrisk management, includinginfection control. Assesses trustsagainst these standards.Strategic Health AuthoritiesMonitor performance of trustsand are accountable for deliveryof targets. Infection control didnot feature in these untilJune 2003. Also reviewcompliance with ControlsAssurance Standards.Commission for Health Improvement (replacedby the Healthcare Commission from 1/4/2004)Established in 1999. Reviews clinical governancearrangement in trusts, and regularly reviewsinfection control arrangements. Publishedperformance ratings for NHS trusts for the firsttime in 2003. MRSA bacteraemia improvementscores and infection control standard scores wereincluded for the first time in 2002/2003.The National Patient Safety AgencyFormed in 2001. Main role is toestablish and manage a nationalreporting system to learn from adversepatient incident, including hospitalacquired infections. They also initiatepreventative measures to help reduceunintended harm to patients, includingthe "cleanyourhands" campaign(see Case Study I)The NHS Purchasingand Supply AgencyEstablished in 2000 and is responsiblefor trusts purcahsing policies.Introduced high quality papertowels and is supporting the"cleanyourhands" campaign bydeveloping a range of alcohol handrubs and containers that meet theunique requirements of the NHS.NHS EstatesPublished Infection Control in the BuiltEnvironment in 2001, providingguidance on the planning, design andmaintenance of the healthcare buildingsand equipment. Also produced NationalStandards of Cleanliness. PatientEnvironment Action Teams (PEATs)undertake reviews on aspects of thepatient's environment.Health and Safety ExecutiveCarries out planned inspections ofhealth and safety standards inhealthcare premises, and may alsobecome involved in investigationsfollowing cases of occupationaldisease or serious incidents followingpatient infections, although this rarelyoccurs in practice.Source: National Audit OfficeAcute NHS TrustThe NHS Modernisation AgencyEstablished in 2001, the ModernisationAgnecy was designed to support the NHS andits partner organisations in the task ofmodernising services and improvingexperiences and outcomes for patients. Partof the Agency, The Clinical GovernanceSupport Team in conjunction with the RichardWells Research Centre, Thames ValleyUniversity, have been delivering the firstnational specialist Clinical GovernanceDevelopment Programme, on healthcareassociated infection.Medicines and Healthcare related productsRegulatory AgencyFormed from the Medical Devices Agency andthe Medicines Control Agency in 2003.Investigates adverse incidents related tomedical devices including those arising fromdecontamination problems and issues devicebulletins as a result of experience gained fromadverse incident investigations.The Health Protection AgencyFormed in 2003 and dedicated to protectingpeople's health and reducing the impact ofinfectious diseases (taking over from theformer Public health Laboratory Service),chemical hazards, poisons and radiationhazards. A key responsibility is monitoringand helping to manage outbreaks of hospitalacquired infection. The Department of Healthalso had a service level agreement with thePublic health Laboratory Service which wastransferred to the HPA, to develop surveillanceof infection rates.National Institute of Clinical ExcellenceEstablished in 1999 to provide patients, healthprofessionals and the public withauthoritative, robust and reliable guidance oncurrent "best practice". Published guidelineson infection control in primary andcommunity care in 2003.part one11


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTOther countries have developed strategiesfor preventing hospital acquired infectionin response to increased awarenessof risks1.14 Major international events associated with infectiousdisease problems such as the outbreak of SevereAcute Respiratory Syndrome (SARS), the spectre ofbio-terrorism, and concerns about the potentialemergence of other viruses such as new virulent strainsof influenza, have all increased the priority given to thisissue and focussed attention on the need for all countriesto have robust national infection control strategies.1.15 We commissioned a comparative review ofinternational practices in the management and controlof hospital acquired infection to see if there were anylessons that might be learned. 16 All of the countries inour review had developed a national strategy forpreventing hospital acquired infection in response tothreats of antimicrobial resistance and increasing ratesand costs of infection in healthcare facilities. Thedevelopment of more recent strategies in the USA,Australia, New Zealand and France have beeninfluenced by patient safety and risk managementagendas, and are closely linked to accreditation ofhealthcare services.1.16 Quality standards linked to hospital accreditationprocesses exist in the USA, Australia, New Zealand,Belgium, Denmark and France and include standards onhospital acquired infection. In Canada, Hong Kong andSingapore, in the aftermath of SARS, there is realevidence of a change in staff behaviours andcompliance with good practice has improvedsignificantly. Appendix 3 summarises the reviewfindings and, where relevant, international comparisonsare drawn on throughout the report.1.17 We also visited Scotland, Wales and Northern Ireland tosee how they were tackling hospital acquired infection.These countries have also developed or are in theprocess of developing strategies to tackle communicablediseases and standards to improve infection controlpractice (see Appendix 4).1.18 A summary of our study methodology is at Appendix 5.part one12


IMPROVING PATIENT CARE BY REDUCING THE RISK OFHOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTPart 2Despite a higher profile at NHS trustlevel, wider factors stand in the wayof improving infection control2.1 This Part examines the actions taken at NHS acute trustlevel since our report in 2000. In that report we showedthat infection control was not a priority within many trustsand that health authorities and trusts needed to do moreto improve strategic management. We reported a growingmismatch between what was expected of infectioncontrol teams and the staffing and other resourcesallocated to them to carry out their work, and thatpreventing infection could be adversely affected by othertrust wide policies, especially bed management practices.2.2 Since then the introduction of the controls assurancestandards has generally helped raise the profile and thesystems, procedures and accountability arrangementsare now largely in place in most trusts. There has alsobeen investment in infection control team resources.However, bed management policies, the drive to meetperformance targets, the increasing number of outbreaksand antibiotic resistance of infectious agents continue toconstrain good infection control practice.Infection control has generally had ahigher profile in most NHS trustsImprovements to NHS trust infectioncontrol arrangements2.3 Eighty per cent of chief executives reported that theyhad made changes to their infection controlarrangements since March 2000. The key drivers forthese changes were the need to demonstrateimprovements against the Controls Assurance standardfor infection control and the need to meet the ClinicalNegligence Scheme for Trusts assessment criteria.2.4 In ranking controls assurance as the main driver forchange, nine out of ten chief executives reported that itprovided the necessary framework for monitoring theirinfection control arrangements. Because self-assessmentof performance is mandatory, due consideration is givento this issue by senior management. As a result, mosttrusts have reported year on year improvement incompliance with the infection control standard, with theaverage overall compliance for acute NHS trustsincreasing from 64 per cent compliance in 2000, to68.6 per cent in 2001, 71.8 per cent in 2002 and76.8 per cent in 2003.2.5 Ninety-three per cent of trusts have incorporated thecontrol of infection into the trust's wider riskmanagement programme, and 87 per cent into theirclinical governance programme. And in 82 per cent,infection control is included in the trust's risk register.2.6 Over the last five years chief executives and trust boardshave increased the priority given to infection controlissues (Figure 3). All now have clearly defined lines ofaccountability leading to the board, and in 90 per centthe chief executive or a trust board representative(usually the director of nursing or chief nurse or themedical director) is a member of the NHS trust HospitalInfection Control Committee. There have beenimprovements in attendance at committee meetings, in73 per cent of trusts a board representative is present atover half of the committee meetings (compared witharound 60 per cent in 2000). In general, chief executivesare more aware of infection control issues, althoughfewer receive information on the amount spent oninfection control (17 per cent, compared with48 per cent in 2000).A mixed picture of actual performance oninfection control2.7 The Clinical Negligence Scheme for Trusts (CNST)provides a means for trusts to fund the cost of clinicalnegligence litigation whilst encouraging and supportingthe effective management of claims and risks. Every trustis independently assessed against these standards atleast once every two years. NHS trusts which achievecompliance with the standards are entitled to adiscount from their risk pooling contribution for twofinancial years (compliance at Level 1 gives the trust a10% discount; Level 2 a 20% discount and Level 3 a30% discount). Infection control criteria are containedwithin two of the seven core CNST general standardsand compliance with these contributes to achievingLevels 1, 2 and 3 of the scheme. Thus achievingcompliance will result in cost savings for trusts.part two13


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT3In general, the chief executives' awareness of infection control has increased in the last five yearsChief Executive or a nominated deputy is amember of the infection control committeeReceives minutes of the infectioncontrol committeeReceives the infection control committeeannual reportReceives information on rates of infectionReceives information on amount spent oninfection controlApproves annual programme forinfection control0 50 100Percentage of trusts20032000Source: National Audit Office census of acute NHS trusts, - comparing the results presented in our 2000 report (based on our autumn 1998 survey) withthe results from our summer 2003 survey2.8 Ninety per cent of infection control teams were aware ofthe results of the trust CNST risk assessment and ofthese: 10 per cent failed to reach Level 1; 63 per centachieved Level 1; 24 per cent Level 2; and 2 per centLevel 3. Case study A shows how one trust obtained adiscount due to improvements in infection control,investing this in further improvements.2.9 The Commission for Health Improvement's May 2003annual report "Getting better? A report on the NHS" 18 ,noted that control of infection has been a concern in aquarter of its reports on hospitals. These concernscovered hand washing, sterilisation of equipment andthe nursing of people who are known to be infectious.The report noted that the Commission had seen fewexamples of notable practice in infection control; goodpolicies did not always exist and, even when they did,they were often not followed sufficiently well to makethem effective.Infection control teams have been strengthened,but wide variations in resources remain2.10 In 2000, we showed wide variations in infection controlresources, an absence of Departmental guidelines oninfection control staffing and that in some trusts thenumber of beds that a single infection control nurse wasexpected to cover was unacceptably high.2.11 The results of our 1998 survey, which was the basis forour 2000 report, showed that there was an average ofone infection control nurse to 535 beds. Whilevariations between trusts remain, by June 2003 this ratiohad risen to one nurse to 347 beds (Figure 4a). Despitethis improvement, the ratio still falls short of one nurseto 250 beds, which is used by many countries as thetarget ratio. Recent research in America recommendsratios as high as one nurse to 100 beds because of theincreasing workloads and complexity of activitiesrequired to be under taken by infection control nurses. 19part two14


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY ASwindon & Marlborough Acute NHS Trust - Securing funding for infection control through improving theirCNST rating and reducing the CNST premium paidSituationOutcomesThe infection control team needed additional resources toimprove the service and to achieve Level 2 compliancewith the CNST requirements.ActionAn internal Controls Assurance Infection Controlassessment was undertaken and agreed by the Clinical RiskManager to be accurate. The required score for the criteriaof two of the standards could not be achieved withoutimproving their approach to surveillance which wouldrequire additional support in the form of IT hardware andsoftware, additional infection control nursing andsecretarial support, and office capacity. The total cost ofthis was estimated as £36,000 of which half would be aone off capital payment and half would have revenueconsequences as it was to fund additional staff. The totalamount of money required was estimated to be 18 per centof the discount savings available to the Trust if a Level 2CNST assessment was achieved.■■■■A surveillance nurse has been appointed and IThardware/software provided to support this post.Monthly alert organism/condition surveillance andquality indicator reports are provided to all directoratesand tabled at the trust monthly Clinical RiskManagement Committee.MRSA bacteraemias are monitored and incorporatedwithin the risk matrices of all directorates and the Trustrisk register.Surveillance following total knee replacements hascommenced and the vascular module will commencein April 2004.The Trust has been chosen to pilot one of the threeInfection Control Surveillance systems as part of theHPA ASEPTIC project. 17 Monies have been assured tosupport the pilot following the Trust achievements atCNST level 2 in 2003.2.12 In 2000 we noted that the Royal College of Pathologistsrecommended that between five and six sessions of adesignated consultant's time should be devoted toinfection control (equivalent to one whole timeequivalent infection control doctor per 1000 beds). Wefound that trusts now have, on average, 3.5 designatedmedical consultant sessions per week. Again, widevariations between trusts remain (Figure 4b). Theaverage planned coverage reported by infection controlteams was 4.2 sessions per week for infection controlactivities, showing that even if they were working at fullcomplement, they would still fall short of therecommended number.2.13 In 2000, we reported that 27 per cent of infectioncontrol teams had no clerical support, just over half hadless than one whole time equivalent, and aroundtwo-thirds considered that their clerical support wasinadequate. As at June 2003, there were still 21 per centof teams without clerical support and 68 per cent withless than one whole time equivalent (Figure 4c).2.14 Our earlier work and subsequent research hasdemonstrated the importance of having adequateclerical support. Not least because it is a waste ofvaluable expert resources for infection control nurses tobe spending a large proportion of time on clerical tasks.A number of chief executives identified the appointmentof clerical staff as one of the main staffing changesintroduced to improve their infection controlarrangements but the number of failed business casesfor these resources demonstrate that in some trusts it isstill not given sufficient priority.The role of link nurses, modern matrons andward housekeepers in prevention and control2.15 More trusts now use link nurses (82 per cent comparedwith 60 per cent). However, the numbers of link nursesvary between trusts, ranging from one to over onehundred, with the average per trust being around 54.Link nurses are not substitutes for infection controlteams but they can be an extremely effective way ofdisseminating and monitoring compliance with goodpractice. However, for link nurses to be effective, theircoverage needs to be widespread across a trust,therefore trusts operating with only a few link nursesmay not be realising the full potential of having a linknurse programme (examples of successful link nurseprogrammes were given in our original report, and inThe Challenge of Hospital Acquired Infection, publishedby the National Audit Office in 2001 20 ).part two15


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT4There continues to be variations in infection control team staffing levels between trustsa) The ratio of whole time equivalent infection control nurses to total number of beds in NHS trustsWTE Infection Control Nurses/Beds120010008006004002000Suggested target -1:250Mean 2003 -1:341NHS TrustsMean 1998 -1:527NOTES1 Moorfield's Eye Hospital and The Royal National Hospital for Rheumatic Diseases are unique cases in relation to Infection ControlNurses and have been omitted from the data analysis and graph.2 2 Trusts have been omitted from the data analysis and graph as they are outliers with WTE Infection Control Nurses per hospital bedsof 1:1500 and 0.2 Nurses for 525 beds - a ratio of 1:2625.b) The ratio of whole time equivalent infection control doctors to total number of beds in NHS trustsWTE Infection Control Doctors/Beds10009000800070006000Mean 1998 -5000Mean 2003 - 1:2,2584000 Royal College of Pathologists Guidelines 1:1,4663000- 1 WTE Infection Control Doctor: 1,000beds (99 Trust have 1 WTE to 1,000 or fewer2000beds, 53 more than 199810000NHS TrustsNOTES1 25 NHS Trusts did not identify any Infection Control Doctor sessions per week. They have subsequently been omitted from the dataanalysis and graph.2 Moorfield's Eye Hospital and The Royal National Hospital for Rheumatic Diseases are omitted as per 4a) Note 1.3 3 Trusts have been omitted from the data analysis and graph as they are outliers with WTE Infection Control Doctors per hospital bedsranging between 1:13,000 & 1:25,000.c) The ratio of whole time equivalent infection control clerical or support staff to total number of beds in NHS trustspart twoWTE Clerical or Support Staff/Beds70006000500040003000200010000Mean 2003 -1:1,654NHS TrustsNOTES1 34 NHS Trusts did not identify any WTE clerical or support staff. They have subsequently been omitted from the data analysis andgraph.2 Moorfield's Eye Hospital and Royal National Hospital for Rheumatic Diseases are omitted as per 4 a) Note 1.3 2 Trusts have been omitted from the data analysis and graph as they are outliers with WTE clerical support staff per hospital beds of0.1 clerical or support staff per 900 beds - a ratio of 1:9000, and 0.4 clerical or support staff per 1032 beds - a ratio of 1:2580.16Source: National Audit Office census of acute NHS trusts, Summer 2003


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT2.16 The public consultation that informed the NHS Plan in2000 provoked a call for the return of a matron figure, astrong clinical leader at ward level. In response, HSC2001/010 heralded the introduction of the new "modernmatrons" who were to be accountable for a group ofwards and be easily identifiable, visible, accessible andauthoritative figures. 21 One of the ten key tasks that theyare accountable for is the prevention of hospitalacquired infection and a second, related task, isimproving hospital cleanliness.2.17 In September 2003 a poll of 100 matrons identifiedpreventing infection and improving hospital cleanlinessas the most challenging of their ten areas ofresponsibility. 22 Our survey showed that 40 per cent ofinfection control teams felt that modern matrons hadbeen fairly pro-active in relation to infection control,particularly in raising awareness but 25 per cent felt thatthey were not at all pro-active. Teams felt that matronshad a large workload with many other priorities, andthere was a lack of clarity on their role as regardsinfection control. Their commitment also depended ontheir previous experience and interests.patient safety team structures. The post holder shouldbe professionally qualified and competent in themanagement of all matters of infection control, but notnecessarily a doctor. It is not a board level appointment2.21 We undertook a survey in February 2004 to evaluatethe implementation of this requirement and foundthat 87 per cent of respondents had appointed aDirector, 37 per cent nominated the Infection ControlDoctor to the post and 48 per cent either the MedicalDirector or Director of Nursing. All were staff withexisting roles and responsibilities. Concerns were raisedby trusts that only the Infection Control Doctor wouldhave sufficient expertise to adopt this role, and thedifference that it would make to the prevention andmanagement of infection.2.18 The NHS plan called for at least 50 per cent of trusts tohave a ward housekeeper service by 2004 to improvethe delivery of basic care services to patients andenhance the patient environment. Eleven patientfocusednational service standards have been agreed bystaff and patients and form the basis of the housekeeperrole, including ones on cleanliness and the control ofinfection. Latest figures from NHS Estates show that40 per cent of all hospitals and 53 per cent of largehospitals with over 100 beds have introduced a wardhousekeeping service. 23 Case study B shows how wardhousekeepers and modern matrons are being used toimprove infection control in two trusts.2.19 In response to Winning Ways, the Chief Nursing Officerin partnership with NHS Estates, is leading a newlyestablished working group of nurses, modern matrons,ward housekeepers, allied health professionals andinfection control experts to work out ways of preventingand controlling hospital acquired infection in theireveryday work.The Department's requirement is for all NHStrusts to designate a Director of InfectionPrevention and Control2.20 In December 2003, one of the key new actions inWinning Ways was that each trust must designate aDirector of Infection Prevention and Control, with thepower to impose tough new rules on each hospital. TheDirector is expected to oversee the implementation ofall infection policies, be responsible for the infectioncontrol team and report directly to the chief executiveand the board. The Director will also be an integralmember of the clinical governance committee andpart two17


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY BImproving infection control through the use of modern matrons and ward housekeepers in two NHS trustsin England(i)The role of the Modern Matron in reducing hospitalacquired infection at North Bristol NHS TrustThe Modern Matron role has been implemented in theUrology department at North Bristol NHS Trust as part of anorganisation wide strategy to address the problemsassociated with hospital acquired infection. This initiativehas been instrumental in engaging the multidisciplinaryteam. Collaboration and team working using clinicalgovernance structures have been influential in improvingpractice in the department.The Modern Matron facilitated and supported InfectionControl Nurse (ICN) visits and audit in clinical areas.Findings were then presented at the multidisciplinaryUrology Clinical Governance Sessions which arecoordinated by the Clinical Audit lead for the specialityand the Modern Matron. Issues that were identifiedincluded hand washing in the Out Patient Department(OPD) where invasive investigations took place. The ICNwas then invited to the OPD to work alongside the team toobserve practice. Feedback was given at the ClinicalGovernance session on the need to wear aprons to protectclothing from contamination, guidelines for glove usageand hand washing procedures, and subsequent changes topractice were noted immediately.Modern Matron meetings also provide an ideal forum toaddress practice issues and developments, and the ModernMatron has also supported infection control forums inother areas such as renal, neonatal unit, theatres andintensive care unit. The current programme aims to identifyand address emerging themes in relation to practice acrossthe Modern Matrons area of work, for example reviewingpractices relating to wound management during wardrounds which individual ward managers were unable toaddress. Audit programmes are also being developedwhich involve Modern Matrons such as on thedecontamination of patient equipment. Focus groups are tobe implemented for other specialities as the need arises, aswell as further training for Modern Matrons in managinghospital acquired infection.(ii)The role of the Ward Housekeeper in improving thehospital environment and cleanliness at the OxfordRadcliffe Hospitals NHS TrustWard Housekeepers work within the ward team and areresponsible to the Ward Sister/Manager. Their role is toprovide for the non-clinical needs of the patients andtherefore leaving nursing staff free to focus on clinical needs.The Oxford Radcliffe Hospitals NHS Trust has employed 35housekeepers who receive initial training with the infectioncontrol team on their induction, and then receive regularupdates. Their key responsibilities are for cleaning, thepatient environment and patient food. They have been ableto address areas which have fallen between theresponsibilities of nurses and domestic staff, or havesuffered because of other demands such as cleaning fans,commodes and chairs in between patients.Notable differences have been found between wards withhousekeepers and wards that do not have them, including:-■■■A 30 per cent increase in cleaning standards;Better management of viral gastro outbreaks, forexample in keeping up stocks of gloves and aprons;Increased availability of wall/bedside alcohol rub,soap and paper towels.Housekeepers are also responsible for enhancing thepatients' environment by reporting defects such as rippedcarpets, floor coverings and broken equipment, keepingbed areas clean and tidy, regularly changing flower water,and ensuring the appropriate segregation of waste.Introducing housekeepers has not always required additionalresources. There is growing evidence that nursing staff spendup to 30 per cent of their time on non-nursing activities andtherefore a reconfiguration of the existing team worked onsome wards.part two18


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAttempts to develop a staffing toolkit determinedthat a formulaic approach is not appropriate2.22 In response to the Committee's recommendation thatfurther research should be carried out to develop staffingguidelines for trusts, the Department, with input from theInfection Control Nurses Association and otherprofessional organisations, commissioned a study in2002 to examine the feasibility of producing a toolkit orformula to help trusts determine staffing levels forinfection control teams. We worked with the Departmenton the design of the study and shared with them the dataand other information from our original survey.2.23 The results, in April 2004, based on survey returns from140 infection control teams, found that the roles andresponsibilities of infection control staff are so complexand varied that guidance on the numbers needed perbed is not straightforward nor necessarily helpful.Instead the research provides a set of questions toenable teams to evaluate whether they have the systemsand competencies in place to work effectively, identifyneeds, and take appropriate action. Other countrieshowever still use the ratio of infection control nurse tobeds to help determine resources (Appendix 3).2.24 During 2003 the Association of Medical Microbiologistsalso reviewed the role and future of the InfectionControl Doctor. They identified that the job descriptionand competencies of the infection control doctor needto be reviewed and re-written, including considerationof the education and skills required and that there was aneed for guidance on the level of infection controldoctor resources needed. Whilst this should not beoverly prescriptive, the parameters that were consideredincluded the number of beds and specialties covered.Limited improvements in non-pay budgets andIT facilities2.25 In 2000, we reported that only 40 per cent of NHS trustshad a separate budget for infection control. Ourfollow-up survey showed that this has now increased to55 per cent. Although two-thirds of chief executiveshave approved real-term changes to infection controlstaffing resources, fewer than half have approvedchanges to the non-pay budget and, in 2002/03,24 per cent reported that their budget had actuallydecreased. Budgets vary considerably between trusts,with over half of infection control teams having budgetsof up to £6000, whilst one in twelve trusts reportedhaving budgets of over £20,000.2.26 IT facilities are vital for ensuring the efficient andeffective performance of infection control teams,particularly in relation to surveillance, research anddevelopment of training material. A number of reportshighlight the lack of IT as a major constraint for infectioncontrol teams (in 2000 we found that over half the teamsdid not have access to a computer). Sixty-three per centof infection control teams consider that they now haveadequate access to IT facilities, whilst 24 per cent haveonly a limited amount of access and 2 per cent have noaccess at all.2.27 Our workshop on Informatics in Infection Control, inOctober 2002, emphasised that the slow pace ofInformation Management and Technology developmentsin the majority of trusts and the lack of availability ofdenominator datasets from trust systems were hamperingattempts to improve surveillance of infection.2.28 In recognition of this, in 2002 the Departmentcommissioned the ASEPTIC project (A SystemEvaluation Project for Infection Control) to provide anindependent evaluation of existing or emerging ITsystems that might be able to support infection controlin hospitals. The project team reported in 2003,identifying three potential systems. 17 However, the issuehas been complicated by the wider IT developmentissues that have been taking place in the NHS.Following a meeting with the Information Authority theDepartment agreed that an evaluation of the threesystems would be undertaken.Wider factors complicate preventionand control2.29 Winning Ways acknowledges that infections in hospitalsand other healthcare settings are a major problem forhealth services around the world, including the NHS.Modern healthcare has brought unprecedented benefitsto patients, but has also increased the risk to patients ofcontracting infections. As have the major internationalevents such as Severe Acute Respiratory Syndrome andthe threat of bio-terrorism. Other factors within trusts arealso making the task harder, including government targetsand their impact on bed management practices, staffingshortages and the increased use of unqualified staff.Increasing antibiotic resistance and the numberof outbreaks in hospitals have become asignificant problem2.30 Our earlier work and reports by the Department andHouse of Lords Select Committee on Science andTechnology have highlighted the continuing and indeedgrowing problem of antibiotic resistance and theemergence of strains of multi-resistant bacteria that cancomplicate and indeed prevent recovery from surgicalinterventions. 24,25 Gastro-intestinal viruses can alsospread quickly through a hospital if not controlledeffectively. Infection outbreaks place significantdemands on the infection control teams and canimpact significantly on the running of the hospital,necessitating the closure of wards, bays and, in rarecases, whole hospitals.part two19


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY CAction taken to quantify the burden of and improve the management of gastroenteritis outbreaks in hospitalsin Avon, EnglandSituationA team of researchers and clinical staff headed by theGastrointestinal Diseases Division at the Health ProtectionAgency Communicable Disease Surveillance Centre andthe Avon Health Protection Unit sought to quantify theburden of outbreaks of gastroenteritis in three acute NHSTrusts in the Avon area over a 12 month period, fromApril 2002 to March 2003. The findings were presentedat the Infection Control Nurse Association Conferencein Telford, England in September 2003, and at theInternational Conference on Emerging Infectious Diseasesin Atlanta, USA in 2004.ActionActive surveillance was undertaken in order to capturecomplete and high quality data from the United BristolHealthcare, North Bristol and the Royal United HospitalBath NHS Trusts. Four major acute hospitals and elevencommunity hospitals were monitored under the surveillancenetwork. There are a total of 2900 acute beds in thesehospitals, which, on average maintain 95.6% occupancy.A strict definition of an outbreak, comprising of a series ofcases, was employed. When an event occurred meeting thisdefinition, specimens were taken for microbiologicalanalysis and the outbreak details were recorded.OutcomeA total of 227 hospital unit outbreaks, involving 2154patients were recorded, and 158 of these units were closedto new admissions across various specialties. Noroviruswas found to be the predominant aetiological agent in theoutbreaks where specimens were taken.The total cost of bed-days lost and staff absence was£1.97 million, or £657,000 per Trust. The true costs arelikely to be higher given that medical staff were alsoaffected, and that other costs will also be incurred foradditional cleaning, further bed blocking due to delayeddischarge and increased drug prescribing. The impact onpatients will also be considerable, particularly as manysurgical specialties were affected which will impact onwaiting times for surgical interventions.Comparisons were made to assess the impact of closing aunit. Although closing hospital units is a costly measure,the results showed that it is an effective way to control theduration of an outbreak. Units closed within the first threedays of an outbreak were contained significantly faster thanthose units which were not closed, or closed after thefourth day (7.9 versus 15.4 days, p=0.0023).part two2.31 Ward and bay closures as a result of infection problemsare rising. Two-thirds of trusts had ward closuresbecause of infection problems in 2000-01 increasing tofour out of five trusts in 2002-03. In 2000-01 the averagenumber of ward closures was 3.6, rising to 5 in 2001-02and 9.4 in 2002-03. The closure of bays has also risensignificantly but closure of whole hospitals due toinfection is rare, with only one per cent of trustsreporting that the whole hospital had to be closed toadmissions. Many ward and bay closures have been asa result of MRSA, but more frequently due togastroenteritis (principally as a result of norovirus)which a number of trusts consider to be endemic and tohave produced unprecedented problems during2002-03. Case study C identifies how closing a wardcan be the most effective option for a trust.Other priorities are making the task harderPerformance targets2.32 Given the pressure on meeting performance targets,recommendations to close a ward can have significantimplications. Twelve per cent of infection control teamsreported that their recommendation to close a ward orhospital to admissions for the purpose of outbreakcontrol was refused or discouraged by their chiefexecutive. Two per cent of teams also reported that theirstrategic health authority had refused or discouragedtheir recommendation. A number of strategic healthauthorities have responded to this problem byencouraging collaboration between trusts in their areaso as to minimise the impact of an outbreak. Othersnoted that they would only override a trusts' decision ifthere was evidence of mismanagement of the outbreak.20


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY DDevelopment of an MRSA-Free Zone in Elective Orthopaedics at Mid-Essex Hospital Services NHS TrustSituationIn April 1998, an orthopaedic unit was moved from adedicated orthopaedic hospital to a district generalhospital. The result was an increased MRSA acquisition rateof patients on the elective ward, and it was hypothesizedthat this was associated with elective orthopaedic bedsbeing used indiscriminately by emergency patients. Duringthe year 2000, 29 new cases of MRSA were identified, oneresulting in the death of the patient.ActionThe Trust Board were advised that the British OrthopaedicAssociation guidelines should be followed, separatingelective from emergency work and introducing an MRSAfree zone.■■Strict admission criteria were introduced for electiveorthopaedics and no inter-hospital transfers wereallowed. All patients due to have elective orthopaedicsurgery were screened at a pre-admission clinic forboth MRSA and methicillin sensitive Staphyloccusaureus (MSSA). Any MRSA positive patients were giveneradication therapy and admitted onto one of thetrauma wards for surgery rather than the elective ward.Glycopeptide prophylaxis was used in addition to theusual cefuroxime. Patients who were MSSA positivewere also given pre-surgery eradication therapy, butallowed on the elective ward. The practice of admittingday cases to the elective ward was stopped.A strict dress and behaviour code was also introducedinto the elective ward.■■■■Empty beds on the elective ward were "fed" from thetrauma ward, taking patients known to be MRSAnegative after screening. Not all trauma ward patientswere screened, only potential transfer candidates.Senior staff had ownership and involvement indesigning and delivering the policy.Use of bank and agency staff were minimised andnursing agencies were informed of the strict policy thathad been applied and that all staff were expected tocomply with the standard set.A strict behaviour and dress culture were introduced inthe theatre area. Only essential staff members wereallowed into theatre, and those who did go wereexpected to behave in accordance with the BritishOrthopaedic Association Guidelines.OutcomeIn the year prior to ring-fencing, 417 lower limbarthroplasties were performed. In the year after ringfencing, due to more predictable bed management andfewer complications, 488 lower limb arthroplasties wereperformed. This demonstrated a 17% increase in number ofpatients undergoing arthroplasty without increasing theatrecapacity or number of beds.The total number of all infections (including UTI, chest,superficial or deep surgical site wound infections etc.) inpost-operative patients reduced from 43/417 prior to ringfencing(9 of which were MRSA) to 15/488 after theintroduction of ring-fencing (p=


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTthat separating elective and non-elective patients waskey to improving patient care and reducing the risk ofinfection (see Case studies D and H) but many had realproblems achieving this, and a further 23 per cent felttheir patients were often placed on other wards or otherpatients were placed on their wards increasing infectionrisks. A third of infection control teams felt that shortageof beds reduced the time available for pre-operative careand that this was compounded by the having to ensureaccommodation in single sex wards.2.36 Many of the survey responses from trust seniormanagement identified difficulties reconciling themanagement of hospital acquired infection with thefulfilment of government performance targets. Almost50 per cent reported that waiting times for inpatienttreatment had caused conflicts, one third that trolleywaits in accident and emergency departments causedconflicts, and one in ten experienced difficulties inreconciling the management and control of hospitalacquired infection with other targets.Provision of isolated facilities2.37 In our original report, we found that isolation facilitiesin some NHS trusts had been significantly reduced andthat many infection control teams believed that facilitiesfor isolating patients were unsatisfactory, especially inconstraining efforts to deal with MRSA. 1 The Committeeof Public Accounts specified that increased investmentin isolation facilities was required. 2 In 2001, theDepartment assured the Committee that the need forisolation facilities was being addressed. 10 However in2003, we found that while 56 per cent of trusts hadundertaken a risk assessment to determine the numberand quality of isolation facilities in the last three years,only a quarter had obtained the required facilities. Thesewere generally as a result of a trust new build project.New NHS funding arrangements2.39 Under Shifting the Balance of Power, primary care trustsnow control a large proportion of the health budget andare responsible for commissioning services from NHSacute trusts. Our review of a sample of PCTs suggeststhat infection control services are incorporated as anoverhead into other commissioned activities. There is arisk that the attention of trusts will be directed at ensuringthe effective implementation of other operationalresponsibilities under these new arrangements and thatresources needed for effective prevention and control ofinfection could be undermined.2.40 Further risks may arise as a result of the forthcomingPatient Choice initiative and the national pricing tariff fortreatment which is being piloted during 2004-05 andwhich will be rolled out in 2005-06. Tariff pricing assignsa price to each type of surgery based on historicalinformation on the costs of different types ofinterventions. The funding that trusts receive for anoperation will be the same regardless of whether anycomplications arise which may result in an increasedlength of stay. For example hospital acquired infectionsincrease length of stay by an average of 11 days. Thesedevelopments may also affect the resources that trusts areprepared to invest, or have available to invest, inpreventing infection. However, opportunities may alsoarise from these initiatives, as trusts will be paid thenational tariff for all spells, and there will be an incentiveto reduce their costs by minimising length of stay inwhich hospital acquired infection is a main contributor.Staffing issuespart two2.38 Despite the overall increases in the number of clinicalstaff working in the NHS, staff shortages and reliance ontemporary agency staff is a continuing issue for manytrusts, particularly in London. Both have been shown toimpact on good infection control practice, as does theincreased used of unqualified staff. 26 Our analysis ofperformance indicators shows that the level of MRSA ina trust tended to be lower in those trusts that hadidentified higher levels of risk assurance in their selfassessment against the human resources controlsassurance standard. Also trusts which have improvedtheir MRSA scores were noted to have lower levels ofstaff sickness as indicated by higher staff sickness gradescores (Appendix 6).22


IMPROVING PATIENT CARE BY REDUCING THE RISK OFHOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTPart 3Despite some local improvementsthe NHS still lacks sufficientinformation on the extent and costof hospital acquired infection3.1 Research shows that surveillance, involving datacollection, analysis and feedback of results to clinicians iscentral to detecting infections, dealing with them, andultimately reducing infection rates. Our original reportconcluded that the lack of comparable data on rates andtrends of infections limited NHS trusts' understanding ofinfection problems. We noted that the NosocomialInfection National Surveillance (NINSS) Scheme,launched in 1996 iii , was starting to show the benefits ofsurveillance and recommended that the Departmentshould build on the success of the Scheme and encouragemore trusts to participate. The Committee of PublicAccounts concluded that the NHS did not have a grip onthe extent and costs of infection and recommended thatNINSS should be made mandatory for all trusts.3.2 We also reported that hospital acquired infections werecosting the NHS £1 billion a year, and that there wasscope for a fifteen per cent reduction, achieving annualsavings of £150 million a year. The Departmentaccepted that significant reductions with associatedcosts savings should be possible but did not expect tosee any tangible measurable progress until 2003. TheCommittee recommended that such progress wasessential if the NHS was to meet their duty andcommitment to patients.3.3 This part of the report shows that to date, there has beenlittle improvement in information on the extent and costof hospital acquired infection, and many of the keyestimates remain as presented in our original report(Figure 5). Whilst the Department has collected threeyears of data on MRSA bloodstream infections, thedecision not to develop NINSS but to develop othermandatory reporting systems means there is still a lackof robust information on the majority of infections atboth the local and national level. As a result it is still notpossible to say whether there has been any tangiblemeasurable progress. Indeed the information availablefrom those trusts who continued with NINSS suggeststhat the degree of improvement has been small. The lackof ownership of surveillance data by clinicians is likelyto be one of the main reasons.There is still no comprehensivemandatory surveillance schemeA changed approach to national surveillance3.4 Following our 2000 report, the Department establisheda Healthcare Associated Infection Surveillance SteeringGroup (HAISSG) chaired by an NHS Chief Executive toprovide the Department with urgent recommendationson infection surveillance needs at local, regional andnational level. This Committee was charged withbuilding on and improving the limited coverage ofNINSS and sub-groups were formed for post-dischargesurveillance, orthopaedic surgical site infectionsurveillance and hospital acquired bacteraemia. Insteadof making NINSS mandatory as recommended by theCommittee of Public Accounts, the Department decidedto adopt a new national approach to surveillance,starting with mandatory laboratory based MRSAbloodstream infection surveillance in April 2001.3.5 In September 2002, the Steering Group wasdisbanded and responsibility for implementing theirrecommendations on surveillance was given to the newHealth Protection Agency, including completing thedevelopment and roll out of the other mandatorysurveillance modules being piloted by the various subgroupsof HAISSG. These developments differed fromthat envisaged by the Committee of Public Accounts.Instead of developing mandatory specialty specificsurveillance of bloodstream, surgical site and urinarytract infections whose information would be fed back toclinicians to improve practice, the Department focussedon trust wide surveillance of MRSA bacteraemias andother specific organisms, together with plans formandatory reporting of orthopaedic surgical siteinfection. A chronology of the developments in nationalsurveillance is detailed at Appendix 7.part threeiiiThe aims of the Nosocomical Infection National Surveillance Scheme (NINSS) were:■ to improve patient care by assisting hospitals to change clinical practice and reduce rates and risk of hospital acquired infection; and■ to provide national statistics on hospital acquired infection for comparison with local results. 123


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT5The top five ways that hospital infections can be acquired and their estimated prevalence levelsBlood infections(bacteraemias: 6% of allhospital acquiredinfection)After surgery (11% ) Urinary infections (23%) chest infections (23%) skin infections (10%)Ten key points about hospital acquired infections■■■■■■■■■■at any one time 9 per cent of hospital patients has an infection caught in hospital;there are at least 300,000 hospital acquired infections a year;they are estimated to cost the NHS around £1 billion a year;they can mean 11 extra days in hospital (2.5 times longer than uninfected patients);the old and young and those with weakened immune systems due to illnesses are most at risk of catching one;the two strongest risk factors are the degree of underlying illness and the use of medical devices;there has been an increase in the number and frequency of infections resistant to common antibiotics for example the proportionof Staphylococcus aureus blood isolates resistant to methicillin (ie MRSA) was almost 40% in 2003, compared with just overtwo per cent in 1992 (figure 6), and is amongst the highest levels in Europe;hospital acquired infections may kill: a crude estimate suggests as many as 5,000 patients may die annually as a result of a hospitalacquired infection (death certificates mentioning MRSA as a cause increased from 53 in 1993 to 800 in 2002)not all hospital acquired infection is preventable but in our 2000 report, we noted that infection control teams believed that theycould be reduced by up to 15 per cent, avoiding costs of some £150 million; andthe degree of improvement has been small, for example trend data on over 60,000 operations in six categories of surgery, collectedbetween 1997-2003 shows that while 12% of hospitals had reduced their rates of surgical site infections, 3% had increased and thevast majority whilst there was no evidence of trend, most had close to or below the pooled mean.Source: National Audit Office, Health Protection Agency and London School of Hygiene and Tropical Medicinepart threeMRSA laboratory based surveillance data showsan increase in the frequency of infections that areresistant to common antibiotics with wideregional variations3.6 The decision to focus on MRSA surveillance reflectedthe Department's substantial concerns about the growthin both the number of Staphylococcus aureus infectionsand, more importantly, in the proportion that weremethicillin resistant. These concerns had been thefocus of a number of enquiries by the House of LordsSelect Committee on Science and Technologyand were supported by evidence from the PublicHealth Laboratory Services Communicable DiseaseSurveillance Centre's voluntary reporting system whichshowed year on year increases in both the number ofsuch infections and more importantly, in the proportionthat were methicillin resistant (Figure 6).3.7 Since the introduction of mandatory reporting theincrease in the numbers of Staphylococcus aureusinfections has continued (from 17,933 (7,250 MRSA) in2001-02 to 19,311 (7,647 MRSA) in 2003-04 - Figure 6).An analysis of aggregate data by region, by type ofhospital, shows that overall specialist hospitals havedecreased their rates but that in five regions, theaggregates data on general acute hospitals shows asignificant increase in both MSSA and MRSA rates (CDRReport 16 July 2004). Some individual general acutehospitals within these regions could well have reducedtheir rates. The Health Protection Agency is undertakingadditional analysis to identify performance at trust level.The European Antimicrobial Resistance SurveillanceSystem data for 2002 showed that the United Kingdomhas amongst the highest levels of MRSA in Europe (seemap opposite page 1). Researchers from St. George'sHospital, London and the Health Protection Agency alsofound that 77 cases of MRSA were reported in childrenunder 15 in 2000, compared to only four cases in 1990. 2724


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT6Number of Staphylococcus aureus bacteraemias reported under the voluntary and mandatory surveillance schemes20181614Number of reports (x 1000)1210864201992-93v1993-94 1994-95v v1995-96v1996-97v1997-98v1998-99v1999-00v2000-01v2001-02v2001-02m2002-03v2002-03m2003-04 2003-04v mFinancial Year (Apr-Mar)v = voluntary m= mandatoryNo susceptibility dataMSSA (methicillin sensitive)MRSA (methicillin resistant)NOTES1 The voluntary reporting scheme shows a year on year increase of MSSA, mainly as a result of more laboratories joining thevoluntary scheme and improved reporting overall. At the same time the proportion of MRSA to MSSA bacteraemias hasincreased year on year, indicating a real increase in MRSA bacteraemia infections.2 The introduction of the mandatory MRSA bacteraemia reporting scheme in April 2001, which operates alongside thevoluntary scheme, shows that the voluntary scheme has a degree of under-reporting. The three years of mandatory reportingshows that MSSA has increased year on year and MRSA has increased by 4.8% in the last year.Source: Health Protection Agency Communicable Disease Surveillance Centre3.8 MRSA bacteraemia mandatory surveillance data for2002-03 showed that in some general acute NHS trusts,rates were up to 7 times higher than others. Acomparison of the first three years of mandatoryreporting (Figure 7) shows that there are also markedregional variations, with the highest rates recorded inLondon. The South East, North West, North East andWest Midlands have seen year on year increases, whilstEast of England is the only region to show year on yeardecreases (CDR Report 16 July 2004).3.9 MRSA is a particular problem in high risk patients suchas those in intensive care, haematology and oncology,where the use of invasive techniques and intravasculardevices are more common. A subgroup of the HAISSGwas set up to explore the feasibility of expanding thecurrent national surveillance scheme on MRSA to onespecifically designed to obtain information on catheterrelated bloodstream infection in Intensive TherapyUnits (ITUs). A three month pilot surveillance exercisetook place in 2003 in three ITUs in England, this wasthen expanded into a further pilot phase in six ITUs.The results are expected to be reported in autumn 2004but early indications show that the subgroup believethe scheme may be feasible at a local level.3.10 A third of infection control teams told us thatmandatory reporting of MRSA bacteraemia has led toan increased awareness of infection control issues byclinical staff, and two out of five reported that it had ledto a review of clinical practice, for example intravenous(IV) line insertion and management. However, the mainbenefit appears to be increased senior managementawareness of infection control issues (70 per cent ofinfection control teams). 25part three


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT7Regional analysis of the number of methicillin resistant Staphylococcus aureus bacteraemias for each of the firstthree years of mandatory reporting18001600Number of reported MRSA bacteraemias1400120010008006004002000North EastYorkshire andthe HumberEastMidlandsEast ofEnglandLondon South East South West WestMidlandsNorth WestRegion2001/02 2002/03 2003/04NOTEBased on three years results of mandatory reporting of MRSA bacteraemias in acute NHS Trusts in England.Source: Health Protection Agency Communicable Disease Surveillance Centrepart three263.11 The main concerns on mandatory MRSA surveillancewere that the denominator data was inappropriate as itwas collected across the whole hospital, and as a result,clinical staff did not relate to it, and trust managementconsidered it to be a problem for the infection controlteam rather than clinicians. Infection control teams andclinicians suggested that MRSA bacteraemia ratesneeded to be part of star ratings if the information wasto be taken seriously, while noting that the rates aloneare not an indicator of the efficacy of infection controlprogrammes as the infections were not necessarilyacquired in hospital. Improvements in MRSAbacteramia rates were included in the star ratings for2002/03, but have not been included as an indicator for2003/04. Nevertheless mandatory surveillance hasincreased the profile of infection and hand hygiene asan intervention.In the absence of a national mandatory reportingsystem for surgical site infections, clinicians havecontinued to participate in voluntary surgical siteinfection surveillance3.12 In the absence of a national mandatory surgical sitesurveillance scheme, voluntary participation in NINSS(now known as the Surgical Site Infection SurveillanceSystem) continued and indeed has increased year onyear. By December 2003, the Health Protection Agencyhad data on around 150,000 operations from some 178hospitals. The box and whisker plot at Figure 8 showsthe wide variation in infection rates betweenparticipating hospitals and the potential for reduction inrates. This information is fed back to trusts and outlierswould be expected to investigate the underlyingreasons, including the extent to which case mix isa factor.3.13 Given the wealth of data collected over the last six yearswe worked with the Surgical Site Infection SurveillanceService of the Health Protection Agency to investigatetrends. Figure 9 shows that the seven largest surgicalcategories accounted for some 140,000 operations from175 hospitals and 349 sets of surveillance data from 125hospitals that had participated in three or more surgicalsite surveillance periods. An analysis of the trends inthese latter hospitals shows that 12 per cent of hospitalswith initial high rates of surgical site infection, hadreduced their rates; in 3 per cent the rate had increasedand, in the vast majority whilst there was no evidence ofa trend, most had rates that were close to or below thepooled mean (Figure 10).


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT8Distribution of the incidence of surgical site infection by category of surgical procedure. Data collected betweenOctober 1997 and December 2003% operations infected252015105Percentiles90th75th50th25th10th0Abdomial hysterectomyBile duct, liver or pancreatic surgeryCoronary Artery Bypass GraftGastric surgeryTotal hip replacementHip hemiarthroplastyKnee replacementLarge bowel surgeryLimb amputationOpen reduction of fractureSmall bowel surgeryVascular surgeryNOTES1 The Surgical Site Infection Surveillance Service (formerly NINSS) has collected data on surgical site infections in twelve categoriesof surgical procedures since October 1997. Participating hospitals collect data according to standard surveillance methods andcase-definitions. In acknowledging the resource intensity of this surveillance and the need to target activity according to localpriorities, the scheme was designed to be flexible. Hospitals were able to collect data in their chosen categories of surgical proceduresfor minimum 3-months periods, while still allowing for continuous surveillance.2 Each point represents the incidence of surgical site infection for a participating hospital contributing data on at least 30 operations.Percentiles are only shown where at least 10 hospitals contributed sufficient data. Hospitals outside the 10th and 90th percentilerepresent outliers. This surveillance has demonstrated significant variation in rates of SSI between hospitals.Source: Surgical Site Infection Surveillance Service, Health Protection Agency9Number of participating hospitals and operations in the seven largest surgical categoriesHospitals with 3+ surveillance periodsType of surgery No. of hospitals No. of operations No. of hospitals No. ofoperationsTotal hip prosthesis 140 43,805 93 40,880Hip hemiarthroplasty 121 14,751 65 13,376Knee prosthesis 127 32,786 87 30,568Large bowel 67 11,446 35 9,142Abdominal hysterectomy 76 10,715 32 7,676Vascular 48 6,678 26 5,204CABG 1 24 19,445 11 15,697Total 178 139,626 125 122,543NOTE1 Coronary artery by-pass graft.part threeSource: Surgical Site Infection Surveillance Service, Health Protection Agency27


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT10Summary of trends in rates of surgical site infection from hospitals participating in 3 or more periods of surveillancebetween October 1997 and December 2003Total hip prosthesis (40880)Knee prosthesis (30568)Type of surgeryHip hemiarthroplasty (13376)Large bowel (9142)Abdominal hysterectomy (7676)Vascular (5204)CABG (15697)0 20 40 60 80 100Number of hospitalsNo infections Decreasing trend Increasing trendBelow pooled mean Not significantly above pooled mean Above pooled meanNo trendNOTETrend analysis on 349 sets of surveillance data show that there has been a statistically significant decreasing trend in 42 (12%) hospitals.Most hospitals (235; 67%) had no evidence of trend and in most of these (212 hospitals) the rate was close to the pooled mean infectionrate. In a small number of hospitals (11; 3%) there was an increasing trend in infection rates and the rest had no infections.Source: Surgical Site Infection Surveillance Service, Health Protection Agency and the National Audit Officepart three283.14 These analyses provide useful information aboutdistribution of rates and trends in rates of surgical siteinfections, however they do not take into account anypatient or surgical risk factors. Detailed investigativework is necessary to understand cause and effect and toidentify wider lessons that might be relevant to otherhospitals. In March 2004 the Department commissionedthe Health Protection Agency to work with trusts todevelop tools to investigate infection rates.There has been limited progress in developingpost-discharge surveillance3.15 In our 2000 report we identified between 50 and70 per cent of surgical wound infections occurredpost-discharge but that only a quarter of infectioncontrol teams were carrying out any post-dischargesurveillance and that there had been no systematicevaluation of the reliability of different methods. TheDepartment told the Committee that they hadcommissioned some research and expected to have theresults in late 2000. The Committee recommended thatthese infections should be monitored through NINSS.3.16 The research results in September 2000 showed thatpatient reporting augmented by health care professionalreporting achieved the best results. However, the veryelderly, younger age groups, patients from ethnicminorities and those undergoing certain operativeprocedures are likely to be under-represented. In thelight of the changes to national surveillance, aHAISSG sub-group was established to take forwardwork on post-discharge surveillance. They focused onpiloting a programme for surveillance of surgical siteinfections after caesarean sections (the outcome has yetto be determined).3.17 We found that only 21 per cent of infection controlteams had carried out any post-discharge surveillancesince our last report. The most common methodswere: telephone follow-up (40 per cent); generalpractice reporting (23 per cent); patient completedquestionnaires (20 per cent); and out-patient follow-up(23 per cent). In addition, three-quarters of orthopaedicand vascular clinical leads noted that they carried out aform of post-discharge surveillance, as part of theirroutine clinical follow-up of patients. However,


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTinformation would generally be recorded in the patient'snotes and not held centrally nor analysed. Case study Eillustrates how one trust has demonstrated improvementin rates through its post-discharge surveillance.Other countries have adopted broadly similarapproaches to surveillance3.18 All of the countries in our comparison of internationalpractice have established surveillance programmes thatare managed and conducted by either governmentagencies or University Departments. 16 The most matureis the National Nosocomial Infections Surveillance(NNIS) System operated by the Centre for DiseaseControl and Prevention in the USA. This has influencedthe developments of the definitions and data collectionsystems in the other countries included in the review,including the United Kingdom. While all are broadlycomparable, in terms of methodology, variations inprotocols and numbers and frequency of hospitalparticipation make direct comparison unreliable,although the best available data to date are summarisedin Appendix 3.3.21 We asked infection control teams if they had performedany similar economic evaluations. Eleven per cent oftrusts told us that they had performed a calculationbased on the LSHTM method using the extended lengthof stay cost estimates, and 16 per cent that they hadperformed some other economic evaluation. Theseshowed a variety of results, but all demonstrate thesignificant burden of hospital acquired infection.For example:■■■A student project at Blackpool Victoria HospitalNHS Trust (now Blackpool Fylde and Wyre HospitalNHS Trust) calculated that the full cost of hospitalacquired bacteraemia in general surgical and ITUpatients over a 12 month period was £491,984;At Brighton and Sussex University Hospitals NHSTrust, the additional cost for 9 orthopaedic patientswith deep wound infections was calculated as£231,810 (see Case study H);University Hospital Lewisham NHS Trust estimatedthe cost of MRSA as £1.5 million per annum, andSt Mary's that Clostridium Difficile, could be costingthem upto £1.6 million; and3.19 Northern Ireland, Scotland and Wales recentlycollaborated to produce a report on the surveillance ofsurgical site infection related to procedures performedby orthopaedic surgeons in the three countries. 28 Thecombined dataset from 2001 to 2003 of some 15,213patient episodes will be used to develop infectioncontrol plans in orthopaedics and represents a majorjoint initiative to provide support to clinical teams inthis area.Cost information has not improvedThe £1 billion that hospital acquired infection isestimated to cost the NHS and the 5,000 deathsthat result are still the best estimates available3.20 In 2000, using information from the London School ofHygiene and Tropical Medicine (LSHTM) 29 , we notedthat hospital acquired infections may be costing theNHS £1 billion a year. While recognising that attributingcosts is complex and uncertain, this remains the bestestimate of the overall cost to the NHS currentlyavailable. The main determinants of this costing werethat patients with a hospital acquired infection incurredhospital costs that were on average three times thoseincurred by uninfected patients, equivalent to anadditional £3,000 per case and on average stayed inhospital 2.5 times (or 11 days) longer. As the study onlyincluded adult non-day cases, the full national costs ofhospital acquired infection are likely to be even higher.■A team of researchers in conjunction with threetrusts in the Bristol and Avon area have performeda study to estimate the economic burden ofgastrointestinal outbreaks for the period 2002-2003.This estimated the cost as £657,000 per trust (seeCase study C).3.22 Hospital acquired infections not only complicate illness,cause anxiety and discomfort but they can lead todisability and even death. In 2000, we noted that theDepartment's 1995 guidance estimated that as many as5,000 deaths may occur each year as a direct result ofcontracting an infection whilst in hospital, with 15,000deaths where infection was a contributory factor. 13.23 In 2002 30 and 2004 31 research projects funded by theOffice for National Statistics and the Health ProtectionAgency (PHLS in 2002) used mortality data to examinethe extent of deaths due to MRSA. Such data are notroutinely identified as there is no InternationalClassification of Diseases code for MRSA (or indeed forany other hospital acquired infections). Therefore deathcertificates mentioning MRSA were manually examined.The reviews concluded that the number of deaths whichmentioned MRSA increased from 51 in 1993 to 800 in2002, representing a 15 fold increase during this period.part three29


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY EPost discharge wound surveillance at the University College Hospital, Londonpart threeSituationThe increasing emphasis on accountability andperformance in the NHS has resulted in a pressure toprovide indicators of surgical performance. There are manypitfalls in these comparisons and they are potentiallymisleading if post discharge surveillance is not performedor different definitions of infection are compared.However, consistent audit of wound infection rates andfeedback to the surgeons is known to be effective inreducing infection rates over a period of 5 years i . At theUniversity College Hospital London (UCLH), surveillancewas performed in some surgical units but was incompleteand erratic as it depended on busy staff with a high rate ofturnover. Compliance with Controls Assurance and CNSTstandards also needed to be improved.ActionSurgical wound surveillance started at UCLH in May 2000using a grant from the Special Trustees and three full timesurveillance staff. In April 2002 the Trust took over thefinancial support of the project by "top slicing" from thesurgical directorates' budgets to fund four full timesurveillance staff. The reaction of the surgical directoratesto providing the funds was initially mixed, but evidenceof demonstrable savings have since overcome theirreservations. Part of the cost of surveillance was offset bythe fact that the existence of a comprehensive surveillancesystem helped to achieve a higher level of compliance inthe Clinical Negligence Scheme for Trusts, therebyreducing the insurance premium paid.Cardiothoracic surgery was monitored continuously fromApril 2002 and neurosurgery from September 2002. Otherspecialties were monitored for six months in each year,i.e. general, maxillofacial, plastics, obstetrics, gynaecology,urology and orthopaedics. Various methods were usedincluding observation of the wound, questioning of staff,examination of notes, interfaces with hospital computerdatabases and contacting patients at 1-2 months after theirsurgery by post or telephone with a series of 9 questionsconcerning the wound and any treatment. Approximately88 per cent of patients are followed up post-dischargeusing the above method.Three nurses and one health care assistant were trained tocollect the data but were not infection control nurses.Undergraduate students were used to enter the data intoiiithe computer and collect follow up information bytelephone. Patients were excluded if they stayed in hospitalless than two nights or if the operation did not involvecutting of tissue (e.g. endoscopy only). Sufficientinformation was collected to allow wound infections to bedefined using several different methods, includingASEPSIS ii wound scoring and the Centers forCommunicable Disease (CDC) definition. Aggregatedresults were fed back to the surgeons, hospitaladministration and ward staff quarterly and surgeonspecific rates were sent by post anonymised except forthe addressee.OutcomesBetween May 2000 and April 2003, 8329 patient recordswere entered into the database. There were reductions inthoracic surgery infection rates from 8.6% to 5.2%, andobstetrics from 4.5% to 0.8%, between the first and last yearsof surveillance. There were also significant decreases ininfection rates in cardiac surgery and obstetrics between2001 and 2002. There were no significant increases in anyother specialty. Changes to screening and prophylaxis werekey to the improvement in infection rates.More recently, the rates of infection up to November 2003have been reported for cardiac, thoracic, orthopaedic andurological surgery. Further reductions have beendemonstrated, falling consistently each year since 2001.The changes were 11.2% to 6%, 8.5% to 3.4%, 7.2% to0.9% and 7.2% to 2.6% respectively. The proportion ofinfections caused by MRSA has also fallen now to belowrates in 2000.Variations in consultant specific rates showed that higherrates of infection were associated with patient selectionand in some cases, surgical technique (in which case theclinical director intervened).Based on the validated assumption that wound infectionscould be reduced by 20% over 5 years, the informationgathered suggests this would be an annual saving of£105,000, in addition to intangible cost savings due toimproved quality of life, together with a reduction in thecosts from loss of earnings, litigation and insurancepremiums paid. The total budget for the programme is£91,600 per annum. However if the current rate ofreduction is sustained, savings 2-3 fold higher canbe expected.Haley RW. The scientific basis for using surveillance and risk factor data to reduce nosocomial infection rates. J Hosp Infect 1995;30 Suppl:3-14.ASEPSIS stands for Additional treatment, Serious discharge, Erythema, Purulent exudates, Seperation of deep tissues, isolation of bacteria, Stay asinpatient prolonged.30


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT3.24 The Chief Medical Officer in Winning Ways announcedplans to establish a national audit of deaths fromhealthcare associated infections which will investigate aproportion of deaths that occur to identify avoidablefactors and lessons to be learned from them, althoughthe details of the methodology have yet to beannounced. Fundamental changes to the way in whichdeaths are certified have also been proposed, enablingdeath certification to be done electronically andinformation from patient records to be linkedelectronically to the registration. Thus cases in whichhospital acquired infections may have played a role willbe more clearly identifiable. There are also plans tointroduce codes for antibiotic resistance in theinternational classification of diseases from 2006.Clinical Negligence Claims mentioningHospital Acquired Infections, in particularMRSA are increasing3.25 Hospital acquired infections can lead to NHS trustsincurring costs as a result of clinical negligence claims.The Department told the Committee that while therewas no centrally held information they believed thatthese costs were increasing. Since April 2002,information on all claims has been held by the NHSLitigation Authority although due to limitations of theclaims database, they are often unable to differentiatebetween claims involving infections in general andinfections acquired in hospital. Furthermore at present,only one cause can be recorded against each claim, soexcluding cases where hospital acquired infection was acontributory factor.11Number of clinical negligence claims where MRSAwas mentioned as a main or contributory factorIncident year Number of claims Reserves (damagesand costs)£1996-97 8 1,157,0781997-98 11 1,052,5021998-99 35 2,635,7371999-00 44 4,027,8203.26 Figure 11 details data provided by the NHS LitigationAuthority on cases where MRSA was mentioned in theincident details recorded on the claims database.Unfortunately, this data cannot be refined to clarifywhether it is being alleged that to acquire MRSA wasnegligent or whether it is recorded merely as a nonnegligentcomplication of the initial act. This data showsthat, by 1999-00, the latest year on which full claimsdata is available, the numbers of claims where MRSA isrecorded as part of the outcome was increasing. Theinitial indications are that the upward trend iscontinuing. On 1 April 2004, the NHS LitigationAuthority introduced a new database which will allowmore risk management information to be recorded oneach claim in the future. This will enable those claimswhere it is alleged that MRSA was acquired as a resultof negligence to be identified separately.3.27 Two thirds of chief executives told us that they were ableto separately identify clinical negligence claims whichwere due to hospital acquired infection. Fifteen per centof these had settled such claims, but the limitedinformation that was supplied showed that the costto the NHS between 2000-01 and 2002-03 for these19 hospitals was some £2.659 million.Though robust cost/benefit analyses arelacking, all available evidence continuesto show prevention is better than treatmentOnly a few trusts have carried out cost/benefitanalyses to demonstrate the impact ofimprovements at trust level3.28 Three in five infection control teams provided examplesof infection control activities that had been successful inreducing rates. However only 5 per cent were able toquantify this. Similarly only 4 per cent of orthopaedicdirectorates and one per cent of vascular directorateshad performed any economic evaluation of changes topractice that had improved the management and controlof infection. Some specific interventions, for examplechanging antibiotic regimens were shown to haveparticularly positive cost benefits (see Case study F).2000-01 45 3,607,211 12001-02 26 1,556,274 12002-03 8 177,500 1NOTE1 A claimant has three years to bring a claim therefore thefigures from 2000-01 onwards are not complete. Tosuccessfully litigate the claimant must show on thebalance of probabilities that the infection was required asa result of a negligent act, which is often not the casewith MRSA.part threeSource: NHS Litigation Authority31


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY FCost savings associated with the adoption of the Scottish Intercollegiate Guidelines Network (SIGN) onAntibiotic Prophylaxis in Surgery at Portsmouth Hospitals NHS TrustSituationThe SIGN guidelines on the use of antibiotic prophylaxis insurgery was published in July 2000, as this was recognisedas an area where there was greatest variation in practiceacross Scotland which might be addressed by evidencebasedpractice guidelines.In 1994 at Portsmouth Hospitals NHS Trust, a ConsultantMicrobiologist and Infection Control Doctor formulated apolicy on antibiotic prophylaxis with the general andvascular surgeons based on a single pre-operative dose.This was audited about a year later and showed goodcompliance. The Consultant was repeatedly unsuccessfulin convincing the orthopaedic surgeons and theycontinued to use three doses (one pre and two postoperatively). Over the years, several new consultants hadbeen appointed and the policy of single dose in generalsurgery had drifted. This, together with the use of veryprolonged courses of antibiotic therapy following ENT andhead and neck surgery, and the increase in MRSAcolonisation and post operative Clost.difficile diarrhoea,convinced the Consultant that a more forceful approach toantibiotic control was needed.ActionThe SIGN guidance provides an authoritative basis forprophylaxis and draws on good quality research. It allowedthe Consultant to state clearly which procedures neededprophylaxis and which did not, that a single dose wasadequate and that repeated doses for prolonged surgerywere generally unnecessary. Local guidance was writtenwhich included the antibiotics and dose, with alternativesto use in circumstances of allergy and resistance. This wasput out for consultation with a hyperlink to the SIGNguidance, so the full document could be read if need be.Following consultation and with the support of thepharmacy department, the policy was presented to thedistrict Formulary and Medicines Group which passed it.This has subsequently been ratified by the ClinicalGovernance Committee. This policy empowerspharmacists to cross off post operative doses of prophylaxisand to report any persistent transgression of the policy tothe Consultant.OutcomesThe major benefits of this policy are:-■■■that junior doctors and anaesthetic staff know what isgoing to be given for a procedure, rather than it varyingfrom consultant to consultant,reduced opportunity for colonisation of patients withresistant organisms; and.reduced direct costs of antibiotics. A three-doseregimen costs at least three times as much in drug anddelivery costs as a single dose regimen. So for 1,000procedures a month (the trust performed 722 majororthopaedic operations in November) at about £3 adose, the annual costs are £36,000 for single dose asopposed to £108,000 for a triple dose.The Trust plan to perform an audit of compliance with thenew policy in Summer 2004.Other non-UK countries have also haddifficulties in evaluating the economic impactof hospital acquired infection3.29 Up to date data on the economic impact of hospitalacquired infection is lacking in most countries, withsome referring to the economic costs that wereestimated in the 1980's by extrapolating the results fromthe SENIC study conducted in the USA. Publishedliterature in the field concentrates on how economicanalysis tools might be used to inform the issue ratherthan presenting analyses of the economic impact. Whatdata do exist, concentrate on the direct cost of treatment(Appendix 3). All of the analyses conclude that themean attributable costs of the infections were greaterthan the mean corresponding interventions.part three32


IMPROVING PATIENT CARE BY REDUCING THE RISK OFHOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTPart 4Changing clinician and otherstaff behaviour in order to reducerisks requires multiple approachesto prevention4.1 Despite the array of initiatives that the Department ofHealth have introduced and concerted efforts by infectioncontrol teams, hospital acquired infection remains asignificant problem for the NHS. While Winning Wayssets out a clear direction on the actions necessary toreduce the levels of infection and curb the proliferation ofantibiotic resistant organisms, it acknowledges that aplethora of previous guidance has not had the desiredeffect and that evidence based countermeasures ofknown effectiveness are not being implementedconsistently or rigorously in many hospitals4.2 The research on the staffing toolkit showed that it ispossible to comply fully with the infection controlstandard and adhere to other guidance and still notreduce hospital acquired infection. This is partly becausemost of the guidance addresses the behaviour of theinfection control teams who cannot directly affect clinicaloutcomes and also because this is a complex issue withinfections constantly evolving. As emphasised throughoutthis report, infection control must be everyone'sresponsibility, from clinicians, cleaners and ancillaryworkers to patients and relatives, but evidence that thismessage has been adopted is scarce. This part of thereport identifies some of the improvements that have beenmade and the constraints to better and more widespreadcompliance with prevention and control practices.Better and more consistent informationthat is owned by NHS clinical staff iscrucial to improving practice4.3 To target activities to improve practice, clinicians andother staff need robust comparable information oninfection rates, costs and patient outcomes (Figure 12).However, 18 per cent of infection control teams are notcarrying out any surveillance activities other than themandatory MRSA bacteraemia surveillance. Thirty-sixper cent of orthopaedic and 61 per cent of vasculardirectorates did not have data on rates and in thesedirectorates over a third stated that they had no plans todo any surveillance in the foreseeable future.4.4 Clinicians participating in our workshops agreed that itwas necessary to measure rates of infection, but that itwas important that the surveillance results were ownedby the clinicians. They also felt that infection ratesshould be measured as part of the continuousmeasurement of all postoperative complications.Orthopaedic and cardio-thoracic surgeons suggestedthat there should be a single national scheme for each oftheir specialties that would record all significantcomplications including surgical wound infections.Orthopaedic clinicians thought this could be done aspart of the National Joint Registry. Seventy per cent oforthopaedic directorates and 36 per cent of vasculardirectorates thought that ownership should beencouraged by having surgeon specific rates as part ofthe professional appraisal system.4.5 Our survey showed that in those trusts that had accessto comparative surveillance data, for example on MRSAor through participation in NINSS, higher than expectedrates of infection had led to changes in practice and inturn a reduction in infection rates. Eighty-four per centof orthopaedic surgeons and 93 per cent of vascularsurgeons undertake regular peer review or audit ofclinical practice, and many reported to have reviewedand/or changed their clinical practices as a result ofsurveillance or audit information. Case study G showshow a cardiothoracic unit in a London hospital reducedtheir rates of MRSA as a result of multiple interventionstrategies, and Case study H shows how an orthopaedicunit in a district general hospital reduced their infectionrates to zero as a result of a number of initiatives andchanges in practice.4.6 "Winning Ways" also calls for the new Inspector ofMicrobiology and the National Patient Safety Agency toensure that techniques such as "Root Cause Analysis"are developed for healthcare associated infection toinvestigate the underlying causes. We will be examiningthis in more detail in our forthcoming report on "Patientsafety and organizational learning in the NHS."part four33


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT12Using surveillance data to improve the quality of patient careCompareresults withlocal/nationalinformationand set targetCollaboratewith clinicalstaff throughclinical audit toimprove ratePatientCareUsesurveillancemethodologyto measureinfection rateContinuous qualityimprovementSource: Health Protection AgencyReducing risks requires multipleapproaches to prevention but barriersto effective practice remainDespite implementation of hand hygienecampaigns and increased availability of hand gel,compliance is still patchy4.7 The Committee of Public Accounts found it inexcusablethat compliance with guidance on hand-washing was sopoor, especially given the undisputed evidence thateffective hand hygiene is vitally important in the controlof infection. However, research evidence andexperience suggest that failure to comply is rarely due tolaziness or carelessness and that there are a largenumber of barriers to proper hand hygiene. Some aredue to poor knowledge of guidelines or lack ofeducation but other more important factors areinadequate facilities, time pressures and lack of accessto hand hygiene agents.4.8 An increase in hand-hygiene initiatives is one of the topthree changes that trusts say they have implementedsince the publication of our original report. We alsofound that alcohol hand rub is now much more widelyavailable. For example all of the orthopaedicdirectorates responding to our survey, and all but onevascular directorate, said it was available on wards, andin about a third of directorates it was available at allbeds. Some trusts have made non-compliance adisciplinary offence.4.9 Whilst there is evidence of some improvements,particularly following local hand-hygiene initiatives.compliance with good practice is not always sustainedand amongst some staff groups, particularly doctors,compliance is still very mixed. Evidence from HongKong, Singapore and Canada, where the outbreak ofSARS caused significant infection control problems andresulted in several hundred deaths, including somehealthcare workers, shows that there has been a wholesale change in staff behaviour and full compliance isnow part of the culture.part four34


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY GThe reduction of MRSA rates in the cardiothoracic directorate at Guy's and St Thomas' NHS TrustSituationIn May 2000, the cardiothoracic unit at Guy's and St Thomas' NHS Trust experienced a significant increase in the amountof MRSA, and two patients had died as a result.ActionIn collaboration with the infection control team, several changes to practice were introduced across the directorate:-InterventionUnit closure &cleaningPre-admissionscreening & isolationStaffingRevision of skinpreparationAntibiotic therapyHand decontaminationEducation of staff& patientsRegular monitoringMRSA care pathwayDescriptionAfter carrying out a full risk assessment, the unit was closed to admissions and surgery for2 weeks while a deep cleaning and disinfection programme was undertaken.Preadmission screening was extended to all patients who were due to have surgery in thecardiothoracic unit. If MRSA was detected, or if the status was unknown, the patient wasadmitted directly into a side room and nursed in isolation until a negative result was obtained.An isolation nursing team, comprising of established specialist cardiothoracic nurses wasintroduced as opposed to using agency nurses.All pre-operative shaving was stopped immediately and new hair clippers were introduced.Pre-operative skin disinfection was replaced with an alcoholic iodine solution.The prophylactic antibiotic therapy for treatment of MRSA was altered in line with currentguidelines which recommended teicoplanin 800mg and gentamicin 5mg/kg instead ofcefuroxime 1.5g.Alcohol hand gel dispensers were sited at the end of each bed, and aprons and gloves wereplaced prominently next to colonized patients.Staff were reminded of the importance of a good hand washing technique. Education ofpatients colonized with MRSA was also seen as a priority and leaflets were devised forthis purpose.The amount of MRSA infection in the unit was collated on a monthly basis. Results were fedback to staff in all areas in order to increase responsibility for the problem.To enable staff to adhere to best practice guidelines, a care pathway was devised combiningall relevant information.OutcomesFollowing the implementation of changes in practice in August 2000, there was an immediate reduction in acquiredinfections, and a significant reduction over the three year period following the changes (p < 0.01).part four35


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY HThe reduction of orthopaedic infection rates at the Princess Royal Hospital, Brighton & Sussex UniversityHospitals NHS TrustSituationIn 2000, the Infection Control Doctor put forward abusiness case to recruit a part time Infection controlsurveillance/audit nurse, on the back of the National AuditOffice Report, the Controls Assurance Standardrequirements and HSC 2000/002. The case pointed out thatthe Trust achieved only 31% against the Controls AssuranceStandard for infection control, failing in surveillance, auditand education.The new post was taken up in July 2000 by a seniornurse with an interest in surveillance and collecting data.At the same time, the orthopaedic surgeons had becomeincreasingly concerned over infection rates, evidencedby complications arising post-operatively, and at followupappointments.■■■Nurses have been trained to do dressings as a separateintervention, i.e. not when the patient is being washedin the morning and when the beds are being made. Aseparate clinical treatment room has been set up to takethe patient into to perform the dressing.Other improvements have been made, in staff education,standardising post-op dressings and the tightening up ofward/theatre housekeeping, with an increase in hoursspent by domestics in the theatre staff changing rooms,and improved access to alcohol gel (using minidispensers which clip onto the nurses uniform).Post-operative surveillance - the surveillance nursesends a reminder list to outpatients each week ofpatients coming for their 6 week outpatient follow upappointment. She requested feedback on these patientsof any complications that have arisen after discharge.ActionOver the subsequent two years, the following changeswere implemented, aimed at reducing infection rates:-■■■The setting up of separate elective and traumaorthopaedic wards which are closely managed with thefull support of bed managers. The wards are blockedfrom taking non-orthopaedic patients, and bedmanagers have adhered to this.Screening of elective patients. Those that tested positivelyreceive treatment as per an eradication protocolincluding oral antibiotics, skin cleanser and nasalointment. Patients that tested positively are usually keptuntil last on the theatre list and recover in theatre ratherthan the recovery room to avoid unnecessary contactwith other patients as an extra precaution.Patients admitted to the 27 bedded trauma ward are keptin a 6 bedded holding bay whilst they are screened, andmoved out onto the ward if they are clear. The ward alsohas 3 side rooms if patients test positively.OutcomesThe Princess Royal Hospital estimated that the cost ofinfections in the preceeding 6 months was £231,000,excluding the costs of additional treatment. This is based onthe calculation of the additional length of stay of 9 patientswho had acquired an infection after undergoing total hipreplacements over a 6 month period. Sixty-seven thousandpounds of this is related to one case, which resulted in anadditional 155 days spent in ICU. Since the changes wereimplemented, the unit now has a 0% infection rate, andhaving a designated elective ward resulted in a generalreduction in the length of stay. Physiotherapists have moretime to mobilise patients quickly by participating in groupwork, and therefore enabling them to be discharged earlier.Also, staff are more motivated and more able to focus onthe care of patients within their speciality.part four36


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT4.10 In 2002, the National Patient Safety Agency launched apilot hand-washing campaign aimed at improvingcompliance with hand hygiene in healthcare. Theobjective was to produce a toolkit of measures toassist healthcare organisations to improve patient safetyby reducing risks of infections, including empoweringpatients through the provision of greater information.Case study I provides a summary and update onthe project.4.11 A detailed report and guidance was also produced inthe USA by the National Center for Infectious Diseases,including clear recommendations on when handwashing or decontamination should be undertaken,hand-hygiene technique, surgical hand antisepsis andon the selection of hand washing products. 32There is growing recognition of a relationshipbetween hospital cleanliness and infection4.12 Hand hygiene is but a part of the issue of cleanliness inhospitals that has attracted a considerable amount ofParliamentary and public interest. The public and themedia believe that there is an undisputable linkbetween cleanliness and hospital acquired infection,and a review of international literature highlights agrowing recognition of the relationship between theeffective cleaning of hospitals and the health and safetyof patients and staff. 334.13 The NHS plan placed great emphasis on getting thebasics right and that patients should be able to receivehigh quality care in clean, tidy and welcomingsurroundings. In July 2000 the "Clean Hospitals"Programme was introduced and National Standards ofCleanliness were published by NHS Estates in 2001 34 ,including an audit tool for trusts to assess themselvesagainst the Standards. This tool was updated inAugust 2003 to provide greater clarity, and to ensure amore consistent application of the Standards. 35 NHSEstates also published a detailed Healthcare CleaningManual in March 2004. 36 The Scottish Executive HealthDepartment has also placed a significant emphasis onimproving environmental hygiene including theSeptember 2003 publication of an NHSScotland Codeof Practice for the Local Management of Hygiene andHealthcare Associated Infection (Appendix 4).4.14 In the NHS Plan, the Department allocated £61 millionover two years to finance the clean up of hospitals, (witha further £7 million allocated in 2003-04. PatientEnvironment Action Teams (PEATs) were set up,comprising volunteers from the NHS (includingrepresentatives of professional bodies such as theAssociation of Domestic Managers and the InfectionControl Nurses Association), as well as patientrepresentatives and private sector companies providingservices to the NHS. PEAT teams report on "patientenvironment" conditions, food services, and privacy anddignity issues, and award "traffic light" ratings to eachtrust. Trusts are graded as red (poor), yellow (acceptable)or green (good), and these form part of the HealthcareCommission's (formerly the Commission for HealthImprovement) star ratings performance indicator set.Components of the inspections were selected based onwhat patients had previously said were importantaspects of their journey through a department/hospital.4.15 The results from the fourth year of inspections show thatalmost 80% of the hospitals assessed (including nonacutetrusts) provide overall standards that areconsidered "good" with the remainder being assessed asmeeting "acceptable" standards. No hospitals have beengraded as poor since Autumn 2001.4.16 The analysis of our survey responses indicates that thestandard of cleanliness within hospitals remains aconcern. For example, only a third of Infection ControlTeams believe that standards have improved in over halfof the clinical areas in their trust over the last two years.Two in five believe that it has improved in less than aquarter of the clinical areas and one in ten thinkcleanliness has not improved at all. Similar concernswere raised from our survey of orthopaedic and vasculardirectorates. Around two in five orthopaedic andvascular clinical leads believe that the standard ofcleanliness within their directorate has improved.However there remains a significant number ofdirectorates (23 per cent of orthopaedic and 19 per centof vascular) reporting a perceived decrease in standards.4.17 Evidence from patient surveys also shows that there isstill room for improvement. The Department of Health'sAcute Inpatient Survey results for 2001/02 published in2003 showed that more than one in ten of patientsreported toilets and bathrooms to be not very clean ornot clean at all. 37 More than half of the patients surveyedreported their ward to be very clean and just over one inthree patients reported the ward to be fairly clean. Thereare wide variations between trusts and areas withintrusts. Half of the Commission for Health Improvement'sclinical governance reviews raised concerns aboutdécor, cleanliness, privacy or security. 18part four37


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY IThe National Patient Safety Agency "cleanyourhands" campaignSituationThe NPSA cleanyourhands campaign builds on workinitially undertaken at the Oxford Radcliffe Hospitals andhas incorporated learning from other centres bothnationally and internationally.ActionThe campaign and toolkit have been piloted in 6 NHSTrusts 1 . The contents of the prototype toolkit can be seen intable 1.AlcoholPosters/communicationmaterialsPatientinvolvementTable 1: prototype toolkitAt the point of care 2 /Near-patient(and/ or staff carried)Feedback data on consumptionEconomic caseGeneric 2 weekly change ofposters 3Staff champion postersA range of promotional materialsincluding enamel badgesGuide to implementationLeaflets; stickers; apronsPatient PosterThe toolkit has been constructed to assist front line staff inthe achievement of currently existing national guidelines,local policies and standards relating to hand hygiene withthe cornerstone of the toolkit consisting of alcohol handrubs at the point of care. Work is also being undertakento strengthen the role of Ward Housekeepers andModern Matrons in improvement. Involvement ofpatients and the public adds a novel aspect to attainingsustained improvements.OutcomesThe campaign was evaluated using a range of methodsincluding survey (staff and patient), observation, productusage, interview and direct feedback. The evaluation reporthas been produced and is currently being used as a basisfor enhancement and development of the toolkit prior tonational roll-out in 2004. The in-depth development workundertaken within 3 separate Trusts focusing solely onpatient involvement and empowerment 4 will feed in tooverall evaluation. A national campaign is scheduledduring 2004 following publication of the outcome of thepilot sites.The project has joined up with a range of organisationsconnected to hand hygiene and in particular is co-workingwith the NHS Purchasing and Supplies Agency who areleading on work related to supply and monitoring of use ofspecific alcohol hand rubs.Transferability into Primary Care is due to be assessedin 2004.1 Pilot Sites: Aintree; St Georges; York; North Lincs; Queens Medical Centre; Royal Devon & Exeter2 "At the point of care" has been shared with NPSA by Swindon and Marlborough NHS Trust3 Posters are currently being revised due to evaluation results and are the property of the NPSA4 Patient Empowerment Development Sites: St Cadocs, Wales; East Kent; Morecambe Baypart four4.18 The Liberal Democrat MP, Paul Burstow, in his 2002report Now wash your hands criticised the PEATinspections for focussing on wider environmental issuesand that only one standard directly related tocleanliness. 38 A follow-up report entitled Now washyour hands 2 continued to raise concerns on the prioritygiven to infection control in hospitals and their ability totackle "superbugs." 394.19 The PEAT assessment forms for 2004 have been revisedafter consultations with PEAT assessors and NHSmanagers in order to ensure a more consistent approachand to provide a greater range of information aboutstandards across hospitals. The forms have beensubdivided, allowing clearer distinctions to be made, forexample between the cleanliness and tidiness of abathroom. The "rating" mechanism has been changedfrom a traffic light scale to a 5 point scale (Excellent,Good, Acceptable, Poor and Unacceptable) with thefirst assessment under this revised rating expected to bepublished in the summer. This increased transparency isintended to help close the gap between the PEATinspection results and the clinicians' and patients'perception on the standard of cleanliness in hospitals.38


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTPre- and post-registration medical and nonmedicaltraining have very limited coverage ofinfection control issues.4.20 The House of Lords Select Committee report on FightingInfection recommended that the General MedicalCouncil, Nursing and Midwifery Council and the HealthProfessions Council should ensure that universitiesstrengthen the clinical and public health aspects ofinfection control in their undergraduate syllabus. 254.21 In our original report we highlighted important gaps inthe extent to which trusts ensured that education andtraining in infection control was provided to key healthcare staff, and that they needed to review their policiesto ensure all staff are targeted. In 2003, we found thatfew infection control teams maintained training records,but those that did estimated that between 80-90 per centof staff in most non-medical staff groups receivedinduction training. An important exception however isthe consultant doctor staff group, of which just underhalf received this training. The proportion of staffreceiving annual update training on infection control ismuch lower, with an average of around six out of tenreceiving annual updates, falling to around a quarter ofconsultant doctors. Typically staff receive between anhour and an hour and a half of induction training.4.22 The Department has recently awarded a contract to theUniversity of Salford, Faculty of Health and Social Careto develop a framework for health professionals learningbeyond first registration. This framework will addresshow staff can be freed up in order to attend courses,particularly update training, and to give it the samepriority as other mandatory training such as fire safetyand cardio-pulmonary resuscitation.4.23 A national specialist Clinical Governance DevelopmentProgramme on Healthcare Associated Infection andfunded jointly with the Department is currently beingdelivered in partnership between the ClinicalGovernance Support Team (part of the NHSModernisation Agency) and the Richard Wells ResearchCentre at Thames Valley University. The programme isaimed at improving the quality of services for patientsthrough working with multidisciplinary healthcareteams to reduce rates of healthcare associated infection.part four39


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTpart fourTranslating guidance and protocols into actionis slow4.24 The Controls Assurance Infection Standard requires thattrusts should have written polices, procedures andguidance for the prevention and control of infectionwhich reflect relevant legislation and publishedprofessional guidance, and that they should beimplemented. The Commission for Health Improvementidentified that even where good policies existed theywere often not followed sufficiently well, renderingthem ineffective. 184.25 In our original report we drew attention to the lack ofevidence based guidelines on the effectiveness ofmeasures to reduce hospital acquired infection, andidentified the need to improve the dissemination ofgood practice. National evidence based guidelines,commissioned by the Department of Health andproduced by Thames Valley University were publishedas a supplement to the Journal of Hospital Infection in2001. 40 However it was left to the infection controlteam to disseminate the guidelines across the trust.4.26 Two thirds of infection control teams considered that theevidence based guidelines on hand hygiene, use ofpersonal protective clothing, and safe use and disposalof sharps had been adopted by more than 75 per cent oftheir trust. However, only two fifths of teams feltthat the guidelines aimed at preventing infectionsassociated with the use of short term indwellingcatheters and insertion and maintenance of centralvenous catheters had been adopted by 75 per cent ofthe trust. More than 10 per cent of trusts had notadopted these latter guidelines.4.27 As 80 per cent of urinary tract infections can be tracedto indwelling urinary catheters and over 60 per cent ofblood infections are introduced by intravenous lines, thelower levels of uptake of these guidelines increases therisk of infection. In recognition of this, Winning Waysdrawing on the above guidelines, emphasises the needto reduce the infection risk from the use of catheters,tubes, cannulae, instruments and other devices as oneof the seven areas for action.4.28 In 2001 the Department commissioned a feasibilitystudy to consider producing a National InfectionControl Manual. However there has been little progresson this to date. Responses to our survey and in ourworkshop showed there was strong agreement on thevalue to NHS staff of a national manual that could beadapted for local and specialty use. Given the strongevidence of wide local variability in the use of existingguidelines, and significant reinvention of the wheel,there is a need for templates to facilitate localadaptation of national guidelines.The Antimicrobial Resistance Strategy has raisedawareness, GP prescribing has decreased, butless is known about hospital prescribing4.29 It is widely acknowledged that complacency, poorprescribing practice and misuse of antibiotics have ledto the emergence of drug resistance infections. TheDepartment issued a new Antimicrobial ResistanceStrategy and Action Plan in June 2000 to tackleantibiotic resistant infections, and the Committee ofPublic Accounts expected this work to lead to evidencebasedguidance on effective prescribing strategies.Winning Ways includes, as an action area, the prudentuse of antibiotics, drawing on the key points from theAntibiotic Resistance Strategy and also on the HospitalPharmacy Initiative for promoting prudent use ofantibiotics in hospitals, issued in December 2003.4.30 There is clear evidence of a steady decline in GPprescribing of antibiotics, and initiatives launched toimprove public awareness of this issue have beengenerally successful. However, there is still limitedinformation on hospital prescribing. Recent work inhospitals in the USA has considered using antibioticprescribing data as a marker for levels of hospitalacquired infection. 414.31 We found 5 per cent of infection control teams stilldo not have a written antibiotic policy in place.Eighty-eight per cent of the policies include advice onprophylactic use of antibiotics. Most trusts have madechanges to their antibiotic policies in the last threeyears, and in a number of cases they were able todemonstrate reductions in infections and associated costsavings (see Case Study F- paragraph 3.23).4.32 Research in the Netherlands demonstrated that hospitaldeaths among longer stay patients in intensive care unitscould be reduced by a quarter if patients were given acombination of prophylactic antibiotics; rates ofcolonisation by resistant organisms were lower andlength of stay shorter. 42 The cost of antibiotics was alsoreduced by 10 per cent, although the wider applicabilityof their findings remains uncertain, and in general,the evidence base on the use of prophylactics is stillnot conclusive.4.33 Microbiologists and pharmacists are mainly involved indeveloping and monitoring compliance with antibioticpolicies and compliance is also included in clinicalaudits in three out of five trusts. Case study J shows howone trust has developed a multidisciplinary approach toantibiotic management.40


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY JHammersmith Hospitals NHS Trust (HHNT) and Imperial College Multidisciplinary AntibioticManagement ProgrammeSituationThe Trust is a 1300 bedded acute specialist London Trust,which includes 4 hospitals. Annual expenditure on antiinfectives(£4 million) represents 20% of the Trust's totaldrug budget. A strong public health commitment andexperience of practice outside the UK led to thedevelopment of a multidisciplinary antibiotic managementmodel that promotes the role of the pharmacist.ActionSince 1996 HHNT has had a Multidisciplinary AntibioticSteering Group, chaired by the Chief Pharmacist. The groupincludes key figures from microbiology, infectious diseases,hospital epidemiology, infection control, and pharmacy,including the Infectious diseases (ID) pharmacist. Thegroup is chaired by the Chief Pharmacist. The group directsthe trust's antibiotic programme and the management ofthe ID Pharmacist. Surveillance and audit data from regulartrust-wide prevalence studies of antibiotic prescribing areused to target much of the activity. The antibiotic controlprogramme is integrated with the Infection Controlprogramme, both of which have a high clinical profile andmanagerial support within the Trust and are embedded inthe Clinical Governance framework.Outcomes from this programme include:■ Numerous direct reductions in antibiotics expenditure,as a result of focused action, either measured at a trustor directorate level or on a per bed level on the ICU's.The ID pharmacist post was fully established in 1997when it had been shown to produce annual recurrentsaving of in excess of £80,000 pa. In 2002/2003antibacterial expenditure in the Trust fell by 2% despitean overall 3% rise in patient activities associated withincreasing case mix complexity. This achievement isbeing sustained into 2003/04 where a further 4%reduction in expenditure is being projected.■A well-established Medical Directorate reserve antibioticpolicy was extended Trust-wide and was requested forimplementation in the Private Patient Service.■■■■■■■■Protocols to control the introduction of new drugs. Thepharmacy departments have introduced the need for'Mandatory order forms' to be completed beforelinezolid, caspofungin or voriconazole are dispensed.This has led to an increased awareness betweenpharmacy and prescribers regarding the appropriateuse of these new drugs and has contained their usewithin the Trust.Feedback networks to Directorates Infection 'LinkConsultants' for data regarding antibiotic prescribingand resistant organisms.The pharmacists have become integral members of theTrust's C difficile action group.Education programmes. These feature highly in thework of the ID pharmacist and has ensured thatantibiotic prescribing is an integral part of the InductionProgramme for new junior doctorsA number of local and regional networks have beenformed to provide peer support for both clinicians andpharmacists and to reduce duplication of effort.A national network for ID Pharmacists has beenformed, providing a forum for support sharing ofinformation.Methodology for antibiotic surveillance and audit inthe absence of electronic prescribing. Our studies showthat 34% of our in-patients are prescribed antiinfectivesat any time with the vast majority of thesebeing the right drug in the right dose for the rightduration in an appropriate combination. This enablesus to target action to the areas of less appropriateprescribing. Our approach has been published and isabout to adopted by most trusts in the London region.Promoting the role of ID Pharmacists nationally anddeveloping higher professional academic training bydeveloping and running a MSc programme InfectionManagement for pharmacists in collaboration withImperial and the Health Protection Agency, whichbegan in October 2003.■IV to oral switch programmes. A targeted IV to oralswitch programme within orthopaedics produced asignificant increase of oral use with the potentiallyinappropriate IV use being reduced from 69% to 12%.part four41


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTThere is scope for further involvement ofinfection control teams in other trust activities inorder to minimise infection risk4.34 In our original report we emphasised the importance ofseeking the advice and input of infection control teamsin key trust wide activities so as to minimise the risk ofinfection. We found that there has been someimprovement in the extent to which infection controlteams are always or generally consulted but there arestill a notable number of teams who are never consultedin these areas (Figure 13) nor in other areas whereinfection control advice could reduce risks, for examplein ensuring adequate ventilation systems are installed orin planning the numbers and spaces between beds.There is a need for improved awareness anduptake of technological innovation toengineer out risks4.35 Following our initial report we received a large numberof representations from companies who believed theyhad developed a product or new technology that wouldreduce or prevent hospital acquired infection but wereunable to find an outlet for their products. While wereferred them to NHS Estates or The NHS Purchasingand Supply Agency, it is unclear whether there is arobust methodology for evaluating effectiveness. Morerecent research into the use of hydrogen peroxidevapour to eradicate MRSA from ward surfaces 43 and onthe use of silver alloy indwelling catheters could alsoreduce the risk of contracting an infection whilst inhospital 44 (see Case study K).13Infection control teams are still not always consulted on wider hospital activitiesDisinfections and sterilisation of equipment85%13%Theatre ventilation and other airconditioning/air pressure control systems82%16%1%Reviewing plans for alterations andadditions to the clinical buildings77%22%Reviewing contracts for domesticand cleaning services58%20%16%Reviewing contracts for laundry services56%18%21%Bed management46%48%4%Reviewing private finance initiativebuilding plans40%12%27%Reviewing contracts for catering services34%21%38%Provision of infection control servicesin Service Level Agreements withPrimary Care Trusts33%18%43%% always/generally consulted % sometimes consulted % never consultedSource: National Audit Office census of acute NHS trusts, Summer 2003part four42


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT4.36 In Winning Ways, the Chief Medical Officer announcedthat £3 million of new funding was to be made availablefor high quality research and development into ways ofreducing healthcare associated infection. Included is arapid review process to assess new procedures andproducts which claim to be effective in preventing orcontrolling healthcare associated infection, althoughoptions for this are still currently being explored. Intime, the benefits of using the products should outweighthe costs, and savings can be made through fewerinfections being acquired (Case study K).4.37 Evidence on other developments that could be morewidely adopted, such as the use of safer needles in highrisk areas, were highlighted in our report A Safer Placeto Work: Improving the Management of health andsafety risks to staff. 45 Furthermore, there is growingevidence that appropriate ventilation systems in wards,theatres and isolation rooms are crucially important, butin many older buildings are somewhat lacking. Forexample negative pressure isolation rooms are vital tocombat infectious diseases but just over a third ofinfection control teams reported that they hadappropriate facilities (an average of 6.5 adult rooms and2.2 paediatric rooms). NHS Estates is currently in theprocess of formulating guidance for trusts on theprovision of isolation facilities, including negativepressure rooms.Approaches taken by other countries4.38 The strict and consistent application of guidelines forpreventing MRSA infections in Denmark and theNetherlands have proved to be successful in preventingthe organism from being endemic in healthcare facilitiesand these countries have the lowest rates in Europe,although the economic costs of the strategies have notbeen evaluated. The Hospitals in Europe Link forInfection Control Through Surveillance (HELICS)initiative may also provide the opportunity to furtherdevelop collaborative and consistent approaches to theproblems of preventing and controlling hospitalacquired infection.part four43


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCASE STUDY KReducing catheter associated urinary tract infections by using silver alloy-coated cathetersSituationUrinary tract infections (UTIs) account for 35 per cent of allhospital acquired infections and are costing the NHS morethan £126 million a year according to research conductedby the London School of Hygiene and Tropical Medicineand the then Public Health Laboratory Service. 29 AlthoughUTIs can be relatively mild in nature, up to five per centdevelop into secondary bacteraemia which are often verypainful and can be life threatening. It is estimated that80 per cent of UTIs are associated with catheterisation.ActionAshford Hospital in Middlesex (part of Ashford andSt Peter's Hospital NHS Trust) participated in a qualityimprovement project aimed at reducing the incidence ofcatheter associated urinary tract infections (CAUTIs). Theaim was to reduce CAUTIs by at least 30 per cent throughthe use of silver/hydrogel coated catheters, as opposed tosilicone/hydrogel-coated catheters.The EPIC guidelines 40 noted that silver alloy coatedcatheters are associated with a lower incidence of bacteria,although they were not available in the UK at the time.They have been used extensively in the USA and Japan forover six years, but because of their lack of availability in theUK, silver/hydrogel catheters were used in this study.For a three month period in early 2001 a baseline CAUTIrate was determined. The silver/hydrogel coated catheterswere then introduced for a three month evaluation period.Two hundred and eighty-seven patients were catheterisedand evaluated, 144 in the initial baseline period and 143 inthe trial period.OutcomeAnalysis of the data collected showed that CAUTIs werereduced from 7.4 infections per 1000 catheter days duringthe baseline period to 2.9 infections per 1000 catheter daysin the trial period, achieving an over all reduction of60.6 per cent and exceeding the initial target of 30 per cent.An economic analysis showed that:■ with the cost of each UTI estimated at £1,327 by theLondon School of Hygiene and Tropical Medicine andthe Public Health Laboratory Service study, a saving of£42,464 a year would be made by using thesilver/hydrogel coated catheter to prevent a total of32 CAUTIs over a 12 month period;■■taking increased catheter costs into account, the netsaving in the hospital would be £38,000 a year;on the basis of Department of Health estimates thata hospital-acquired UTI prolongs a patient'shospitalisation by six days, the prevention of 32 UTIswould release 192 bed days a year.As a result of the evaluation, it was recommended that theTrust should use silver alloy-coated catheters. These haverecently been launched in the UK and have a greaterweight of clinical evidence backing their use.part four44


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 1Key developments and Departmentalinitiatives since the National Audit Officereport was published in February 2000(Further details on developments in surveillance can be found in Appendix 7)DateFeb 2000May 2000June 2000DetailsDepartmental guidance (HSC 2000/002) was issued as a programme of action to strengthen themanagement and control of hospital acquired infection.The Department adopted and published, through NHS Estates, "Standards for Environmental Cleanliness"which had been previously issued by The Infection Control Nurses Association and The Association ofDomestic Managers.The Government's new UK antimicrobial resistance strategy was launched at the NAO conference onthe management and control of hospital acquired infection - "The Way Ahead".The Department published "An Organisation with a Memory: report of an expert group on learningfrom adverse events in the NHS".July 2000September 2000October 2000The Government's NHS Plan included a £61 million campaign to clean up hospitals, based on theintroduction of national standards of cleanliness with performance monitored through PatientEnvironment Action Teams.A Healthcare Associated Infection Surveillance Steering Group (HAISSG) chaired by an NHS Executivewas set up to provide the Department with urgent recommendations on infection surveillance needs.The Government announced that all hospitals will be required to monitor levels of hospital acquiredinfections, and that these figures will be published.The Department published HSC 2000/032 which set out the requirements for the effectivedecontamination of medical devices.December 2000January 2001April 2001The NHS Implementation Programme was published. One of five core requirements was the need toput in place effective systems to prevent and control hospital acquired infection, and to reducemicrobial resistance.National evidence based "Guidelines for Preventing Healthcare Associated Infections"(EPIC)commissioned by the Department were published as a supplement to the Journal of Hospital Infection."National Standards of Cleanliness for the NHS" were published by NHS Estates.Departmental guidance (HSC 2001/010) "Implementing the NHS Plan - Modern Matrons: Strengtheningthe role of ward sisters and introducing senior sisters 21 " was published.Healthcare acquired bacteraemia surveillance statement was issued by the Department of Healthannouncing the mandatory reporting of MRSA bacteraemia rates.July 2001"Building a Safer NHS for Patients" was published, setting out the Government's plans for promotingpatient safety and for the implementation of An Organisation with a Memory."Government response to the House of Lords Select Committee on Science and Technology Report:Resistance to Antibiotics" was published.appendix one45


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTDateJanuary 2002March 2002August 2002December 2002May 2003June 2003DetailsThe Chief Medical Officer's report entitled "Getting Ahead of the Curve: A strategy for combatinginfectious diseases 9 " was published by the Department of Health.NHS Estates published National Standards of Cleanliness for the NHS.The National Patient Safety Agency initiated a Hand Hygiene Project "cleanyourhands", designed toimprove hand hygiene in NHS Trusts (see case study I).NHS Estates published "Infection Control in the Built Environment - guidance on infection control inrelation to design and planning".NHS Estates published a "Decontamination programme: strategy for modernising the provision ofdecontamination services".The Chief Medical Officer:■■reported the next tranche of surveillance, and that improvements in MRSA rates were to becomepart of the balanced score card that contribute towards the star ratings.announced the Hospital Pharmacy Initiative for promoting the prudent use of antibioticsin hospitals.The National Institute for Clinical Excellence published "Infection control: prevention of healthcareassociated infection in primary and community care" which had been developed by ThamesValley University.August 2003December 2003March 2004Revised Standards of Cleanliness were published by NHS Estates.The Chief Medical Officer's report entitled "Winning Way: Working together to reduce healthcareassociated in England" was published by the Department of Health.NHS Estates published "The NHS Healthcare Cleaning Manual".National Advisory CommitteesThe Specialist Advisory Committee on Antimicrobial Resistance established in July 2001.The Microbiology Advisory Committee - started as the microbiological advisory panel in 1984 and later became theMicrobiological Advisory Committee but no longer meets on a regular basis although it can be reconvened by e-mail ora meeting.The Advisory Committee on Dangerous Pathogens established in 1984.The Spongiform Encephalopathy Advisory Committee established in April 1990.The Healthcare Associated Infection Surveillance Steering Group (September 2000 - September 2002)appendix one46


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 2Comparison of the Committee of PublicAccounts Report recommendations and theGovernment's Treasury Minute Response,and developments as at February 2004Committee of Public Accounts Government's Treasury Minute Position as at end 2003/04recommendationsResponseiResearch indicates thatbetween 50 per cent and70 per cent of surgicalwound infections occurpost-discharge, but theseinfections are not monitored.We recommend thatpost-discharge infectionsare monitored in futurethrough the nationalsurveillance scheme.A UK-wide meeting of consultantmicrobiologists and others with a keyinterest in this area was held in Glasgowon 16 January 2001 to review progressand make recommendations. The NHSHealthcare Associated Surveillance Groupreferred to below would be taking thiswork forward.A study of post discharge surveillance ofpatients who had undergone a delivery byCaesarean Section was carried out by thePublic Health Laboratory Service.The study is continuing and beingextended to other units in the Region. Nofurther national work on post-dischargesurveillance has been undertaken.Only 21 per cent of infection controlteams reported that they carry out postdischargesurveillance, although moreclinicians do so as part of routineclinical follow-up in some specialties.(para 3.15)iiThe NHS Executive have nowtaken action to improvesurveillance, doubling theirinvestment in the NosocomialInfection NationalSurveillance Scheme (NINSS).We recognise that theExecutive are expanding theScheme, but we believe thatthey should go further andmake it mandatory.A new NHS Healthcare AssociatedInfection Surveillance Steering Group(HAISSG), was set up in September 2000to provide the Department with urgentrecommendations on infectionsurveillance, building on the limitedcoverage of NINSS to deliver mandatorynational surveillance reporting of hospitalacquired infection by all Acute Trusts from1 April 2001.NINSS was not made mandatory, and theDepartment adopted a new approach tosurveillance, commencing with themandatory laboratory based surveillanceof MRSA bacteraemia in April 2001.The HAISSG was disbanded inSeptember 2002. There has been limitedprogress in the implementation of otherstrands of surveillance. The mandatorysurveillance of glycopeptide resistantenterococci and serious untowardincidents commenced from September2003 and clostridium difficile from January2004. None of these are specialty specific.Mandatory reporting of orthopaedicsurgical site infection was also rolled outfrom April 2004. Some trusts havecontinued to use NINSS in the absenceof any other national specialty basedsurveillance system. (para 3.4 -3.14.)appendix two47


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCommittee of Public Accounts Government's Treasury Minute Position as at end 2003/04recommendationsResponseiiiThe NHS Executiveacknowledge that it should bepossible to reduce theincidence of hospitalacquired infection by15 per cent or more, avoidingcosts of some £150 millionand saving lives. Tangible,measurable progress is notexpected until 2003.The Implementation Programme for theNHS Plan made it clear that, as one of thecore requirements underpinning the NHStargets set out in the NHS Plan, allrelevant organisations must have effectivesystems in place to prevent and controlhospital acquired infection. TheDepartment was to consider how bestto strengthen current NHS performancemanagement arrangements forinfection control.Tangible progress is already beingdelivered in a number of areas forexample in increased senior managementcommitment and in the implementationof infection control programmes by trusts.The Department has issued a number ofinitiatives to improve the management andcontrol of hospital acquired infection asdetailed in Appendix 1. Most trusts haveimproved the systems and processes inplace for the management and control ofhospital acquired infection withaccountability arrangements leading to thetrust board. The majority of trusts do nothave the data necessary to demonstratechanges in rates, except for a few individualareas where reductions have beendemonstrated. The Government announcedthat infection control would be part of thebroader set of performance indicatorsmonitored by CHI and were included in theNHS star ratings from 2002/03. (para 3.20)ivKey to achieving Progress willbe the effective implementationof the new Controls AssuranceSystem, which builds on thestatutory duty of chiefexecutives for quality of care.This will raise the profile ofhospital acquired infection.As part of the controls Assurance processfor 1999-2000, NHS organisations wererequired to self assess against a number ofstandards, including one on infectioncontrol. The NHS Litigation Authority(NHSLA), issued a number of standardsfor assessing the effectiveness of riskmanagement in support of the ClinicalNegligence Scheme for Trusts (CNST).Revised NHS Standards for InfectionControl were issued in October 2002.Compliance with the standards isimproving which is indicative of thestrengthening of systems and processes attrust level to manage and control hospitalacquired infection. CNST have beeninspecting trusts against their standardssince 2001/02 and most trusts haveachieved Level 1 or above, indicating thatthey have basic risk management systemsin place. (para 2.4)vThe NHS Executive havelaunched initiatives to look atthe more prudent use ofantibiotics, and to monitor andcontrol prescribing includingthe new Government strategyto tackle antibiotic resistantinfections announced inJune 2000. We expect thiswork to lead to evidencebasedguidance on effectiveprescribing strategiesAn Interdepartmental Steering Group(IDSG) is overseeing and co-ordinatingwork on The UK Antimicrobial ResistanceStrategy and Action Plan.The National Prescribing Centre (NPC)has developed a tool kit providing clinicalaudit guidance on antimicrobialprescribing and monitoring and produceda change management resource pack inwhich the prudent prescribing ofantimicrobial agents is used as anillustrative example.The UK Antimicrobial Resistance Strategyand Action Plan was published inJune 2000, including action areas onsurveillance, prudent antimicrobial usein humans and infection control.The need for the prudent use of antibioticswas included in the Government strategiesGetting Ahead of the Curve and in WinningWays, published in December 2003.Most trusts were found to have antibioticpolicies in place, although not all coveredtheir prophylactic use. (para 4.31)appendix two48viHospital hygiene is crucial inpreventing hospital acquiredinfection, including basicpractice such as handwashing. We find itinexcusable that compliancewith guidance on handwashing is so poor and lookto the NHS Executive to auditprogress and report back to usby the end of 2001.The Controls Assurance Standard onInfection Control expects Trusts to havea policy on hand hygiene.New evidence based guidelines forthe prevention and control of hospitalacquired infection were published andalso include hand hygiene.£31 million was allocated directly toNHS Trusts to secure improvements inthe patient's environment with a further£30 million to be allocated next year.Hand hygiene initiatives were notedto be one of the three main changes toinfection control arrangements that trustshave initiated since 2000.£61 million was allocated to improve thepatient's environment alongside the launchof other initiatives as detailed in Appendix 1.However the level of cleanliness in clinicalareas remains a concern for clinicians,patients and as also highlighted in theCommission for Health Improvement'sreport Getting Better. (para 4.7- 4.19)


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTCommittee of Public Accounts Government's Treasury Minute Position as at end 2003/04recommendationsResponseviiThe increased priority andattention that is rightly nowbeing given to hospitalacquired infection has notbeen matched by resources.The scale of hospital acquiredinfection calls for sufficientfunding to ensure thathospitals can tackle theproblem effectively, and soreduce the impact on patientsand NHS costs.The Department welcomed theCommittee's acknowledgement of thehigh priority which it gave to combatinghospital acquired infection, and agreedthat this needed to be matched byappropriate funding locally. Over the nextfour years the NHS will receive its largestever level of sustained real terms growthin resources, and the Departmentexpected the Chief Executive of eachNHS Trust to judge how much shouldbe allocated to infection control.Funding to the NHS has increasedsignificantly since April 2003. PrimaryCare Trusts have been responsible forallocating these funds via thecommissioning of services from hospitals.Infection control is not being resourcedseparately but is incorporated within thesearrangements. Many trusts do not haveseparate budgets for infection control orservice level agreements to provideinfection control services. Although twothirdsof trusts have approved real termincreases in infection control staffingresources fewer than half have approvedchanges to the non-pay budget and24 per cent reported a decrease. (para 2.25)viiiThe NHS Executive recognisethat more effective bedmanagement can help reducehospital acquired infection.Greater use of smaller roomsand single bed rooms is nowpart of health serviceplanning, and the Executiveaccept that increasedinvestment in isolationfacilities is a priority. But highthroughput of patients is alsoa factor. Wider application ofbest practice will help AcuteTrusts manage beds better.Trusts also need to ensurethat infection control is anintegral part of their bedmanagement policiesThrough the National Booked AdmissionsProgramme, NHS Trusts are takingforward work on the relationship betweendemand and supply in order to schedulework more effectively. Central to this iseffective bed management.The NHS Plan provision for an additional2,100 general and acute beds by 2003-04will enable, among other things, theoccupancy rate to be reduced to82 per cent, significantly improvingbed availability in hospitals and themanagement of emergency and electiveworkloads. National Beds Inquiryplanning guidance to be issued soon willhelp Health Authorities to consider whereextra beds are required. NHS Estates is todevelop guidance on ways in which thebuilt environment can assist with thecontrol of infection.In 2001 NHS Estates published designand planning guidance on 'Infectioncontrol in the built environment' Thisdocument encourages collaborativeworking through all the stages of a capitalbuild project from initial concept throughto post-project evaluation and has specificrequirements to facilitate good infectioncontrol practice. This guidance wasexpanded and reissued in 2002.Bed management continues to be aproblem. Pressures from other governmenttargets are militating against good infectioncontrol practice and 71 per cent of trustsare operating at bed occupancy levels ofhigher than 82 per cent. Orthopaedic andvascular leads also reported average bedoccupancy levels of 89 per cent and91 per cent respectively in theirdirectorates. (para 2.34)ixThe Chief Medical Officeraccepts that in staffinginfection control teams, aratio of one nurse to 250 bedsis a good benchmark for NHSTrusts. But many Trusts havemuch larger numbers of bedsper nurse. While localvariations in circumstancesand practice may account forsome of these variations, weexpect the NHS Executive tocarry out further research, inconjunction with the InfectionControl Nurses Association,with the aim of developingstaffing guidelines for Trusts.It is for NHS Trusts and HealthAuthorities, who are accountable for thequality of services they provide, to decideon the number, grade and mix of staffthey require, to provide this serviceto patients.The Department will have discussionswith the Infection Control NursesAssociation and other professionalorganisations about the development ofan assessment tool for NHS Trusts to helpthem to reach decisions about staffinglevels and skill mix required within theirInfection Control Teams.Although staff resources have improved inmany trusts, the demands on their timehave also increased.In 2002 the Department of Health fundeda project to produce a staffing toolkit orformula to enable acute NHS Trusts inEngland to determine staffing levels forinfection control teams. This work hasbeen completed, but the report has yetto be published. (para 2.22-2.23)appendix two49


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 3Comparison of International Practicesin the Management and Control ofHospital-acquired Infectionsappendix three50The review focused on the occurrence, cost and strategicresponse to hospital-acquired infections in a range ofcomparable countries with western healthcare systems, matureinfection control structures and arrangements, and establishednetworks of infection control professionals. Countries that wereincluded in the review were: the USA, Australia, New Zealand,Belgium, Denmark, France, Germany, The Netherlands andSpain. Not surprisingly there are more similarities between thecountries selected for this review than there are differences. Ingeneral, the overall prevalence of HAI is similar and thestrategic responses are driven by corresponding imperatives. Ingeneral terms those countries reviewed faced similar challengesin reducing rates and the accompanying cost of HAI. There is acommon imperative to improve patient safety and minimise theinfection risks associated with modern healthcare.ExtentAll the countries reviewed have established HAI surveillanceprogrammes that are managed and conducted by eithergovernment agencies or University departments. The mostmature of these is the National Nosocomial InfectionsSurveillance (NNIS) System operated by the Centers forDisease Control and Prevention (CDC) in the USA which hasbeen influential in the development of the definitions and datacollection modules in surveillance systems in the othercountries included in the review (and the United Kingdom).Variations in protocols and numbers and frequency of hospitalparticipation between countries make direct comparisonunreliable. Table A shows the extent of hospital acquiredinfection in selected countries calculated as prevalence rates.Comparatively low rates of methicillin-resistant Staphylococcusaureus (MRSA) bacteraemia were found in countries such asDenmark and the Netherlands, attributed by them to the verystrict application of screening and isolation guidelines togetherwith stringent antibiotic prescribing policies. In theNetherlands, the past ten years has seen the 'search and destroy'strategy prevent MRSA infection from becoming endemic. InDenmark, the consistent and strict application of guidelines andthe development of systems to monitor resistance patterns leadto the early identification and management of local clusters ofMRSA infection. The economic costs of this strategy are unclear.The current trend in Europe through the DG SANCO fundedHELICS collaboration to share protocols and developstandardised surveillance protocols for targeted areas ofsurveillance (such as ICU) are likely to make futurecomparisons possible.Table A: Estimated prevalence of hospitalacquired infectionGermany 4%France 6-10%Spain 8%Denmark 8%England 9%USA 5-10%Australia 6%Norway 7%Netherlands 7%Source: Richard Wells Research Centre, Thames Valley University and otherexpert sourcesCostsUp to date comparable data concerning the economicimpact of HAI in the selected countries is lacking with somecountries referring to economic costs that were estimated inthe 1980s by extrapolating from the results of the SENIC studyconducted in the USA in 1985. Published literature in thefield concentrates on how economic analysis tools might beused to inform the issue of controlling HAI rather thanpresenting analyses of the economic impact. Where datadoes exist, it is generally based on the direct costs borne byhospital in the treatment of HAI and ignores the preventive,future and indirect costs (Table B). Additional costs to patientcare in the United States due to hospital acquired infectionswere estimated to be 4.5-5.7 billion US$ per year.One review of 55 economic papers published between1990 and 2000 identified the attributable costs of HAI and therelated costs of interventions. The majority of the papersretrieved in this review were from the USA and Europe andpresented a simple cost analysis that did not include acomparison group. The analysis concluded that the meanattributable costs of the infections were greater than the meancorresponding interventions.Bloodstream infections (BSI) and MRSA infections have thehighest attributable costs. A study conducted in Denmark,similar to that conducted by Plowman and Graves in the UK,suggested that costs were similar to those in the UK.


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTTable B: Estimated costings in selected countriesCountry USA Australia New Zealand Belgium NetherlandsCost 4.5-5.7 billion 180 million 137 million US $ 194 million Bf cost 2.8 million €US $ per year Australian $ per per year (estimated saving if guidelines (estimated 10additional costs year (data from from the costs on antibiotic year cost ofto patient care 1998 and is associated with HAI prophylaxis MRSA measuredtherefore likely to in 2 hospitals followed in 1 medical centre)be an underestimate) in AucklandSource: Richard Wells Research Centre, Thames Valley University.National Policy/StrategyAll the countries reviewed identified that a national strategyfor preventing HAI had been developed over the past twentyyears as a response to the threats of antimicrobial resistanceand increasing rates and costs of infection in healthcarefacilities. The development of more recent strategies in theUSA, Australia, New Zealand and France have beeninfluenced by patient safety and risk management agendasand are closely linked to accreditation of healthcare services.In other countries, strategic direction for preventing HAI isimplicitly contained in a range of linked activities includinglegislation, surveillance programmes, guideline developmentand funding streams for specific components of activity.The USA CDC Division of Healthcare Quality Promotion(DHPQ) campaign "Seven Healthcare Safety Challenges"launched in 2001 represents a significant governmentinitiative to set targets for reducing the risks of HAI over a fiveyear period. In May 2004, the Hong Kong Health Authoritydecided to adopt the Scottish standards as a framework forthe management and control of hospital acquired infection.The priorities within research are set at national level andstudies are conducted by specialist government fundedinstitutes or university research departments. In Europeresearch programmes are conducted by national networksand European collaborations and none of the countriessurveyed identified that there was a ring-fenced research fundfor HAI but indicated that funding came from generalhealthcare research funding. Current research initiatives arefocused on the establishing the epidemiology ofantimicrobial resistance in different settings but particularlyICU and developing standardised surveillance methods.Similar to the UK, most European research is conducted byuniversity research departments. The USA CDC DHPQ"Prevention Epicenters" represents a significant nationalgovernment initiative to coordinate relevant research fordeveloping the evidence base and assessing the cost ofinfection prevention and control.Quality StandardsThere is a growing trend towards placing surveillance dataand rates of nosocomial infection in the public domain.This trend is partly driven by the development and focus ongovernance issues in healthcare. Quality standards linked tohospital accreditation processes exist in the USA, Australia,New Zealand, Belgium, Denmark and France and includestandards relating to the management and control of HAI.The Netherlands is in the process of developing qualitystandards for HAI and the Spanish Ministry of Health uses aset of benchmarks based on EPINE surveillance data.GuidelinesThe development of National Guidelines features as a part ofeach of the selected countries strategy to reduce the incidenceof preventable HAI and to provide guidance for hospitalinfection control committees and healthcare professional. Allguidelines are linked to evidence from relevant literature butare predominantly developed by appropriate groups ofclinical experts on the basis of consensus.Roles and Responsibilities of SpecialistProfessionalsAll the selected countries (with the exception of Spain)identified that there were official profiles for the roles ofInfection Control Doctor (ICD) and Infection Control Nurse(ICN). These profiles are described in a range ofadministrative instruments including national/state law,accreditation criteria, national guidelines and standards.The role of ICD is undertaken by a range of medicalprofessionals and includes medical microbiologists, hospitalepidemiologists and infectious disease specialists. In somecountries profiles for the responsibilities of technicalprofessionals are also included. The ratio of infection controlprofessionals (ICPs) to hospital beds is also identified in somecountries, although these ratios are rarely met.Table C: Recommended ratio of infection control professionals to acute hospital bedsUSA Belgium France Germany NetherlandsICD 1:1000 1:800 1:450 1:1000ICN 1:250 2.5:1000 1:400 1:300 1:250appendix threeSource: Richard Wells Research Centre, Thames Valley University.51The full version of the international comparisons report can be found on our website at www.nao.org.uk.


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 4The Management and Control of HospitalAcquired Infection in Other UK countriesappendix fourScotlandBackground: The Scottish Executive Health Department(SEHD) set up a Working Group in November 2000 toproduce guidance to NHS Scotland with regard to assessingand managing risks related to Healthcare AssociatedInfection (HAI), decontamination and hospital cleanliness.The report produced by this group 'Managing the risk ofhealthcare associated infection in NHS Scotland' wasproduced in August 2001 and recommended that NHSScotland adopt a standard approach to HAI risk management.(http://www.show.scot.nhs.uk/sehd/mels/HDL2001_53Carey.pdf)Clinical Standards: The production of the above report set outdraft standards for NHS Scotland for infection control,decontamination of reusable medical devices and cleaningservices. The Clinical Standards Board for Scotland (CSBS),now known as NHS Quality Improvement Scotland (NHS QIS)further developed the HAI; Infection Control standards, anda methodology to evaluate and verify compliance.The standards were published in December 2001. Trusts andNHS Boards were then reviewed against these standardsduring summer 2002 and reports on these reviews and anational overview published in January 2003. In addition, HAI;Cleaning Services standards were published in June 2002.(http://www.clinicalstandards.org/pdf/finalstand/HAI_CLEANING.pdf)Watt Group Report: In May 2002 a group was formed toreview the circumstances surrounding the onset of theoutbreak of salmonella infection at the Victoria Infirmary,Glasgow in December 2001 and January 2002. The reportwas published October 2002.(http://www.scotland.gov.uk/library5/health/twgr-00.asp)The Scottish Ministerial HAI Task Force: In June 2002 aMinisterial Convention of HAI experts took place inrecognition of HAI being a high priority issue, both in termsof the safety and well-being of patients, and of theresources consumed by potentially avoidable infections.The recommendations from this Convention and fromthe Watt Group Report were used to inform theScottish Ministerial HAI Action Plan, Preventing infectionsacquired while receiving healthcare (October 2002).(http://www.scotland.gov.uk/library5/health/preventinfect.pdf). Theapproach included the formation of a multi-disciplinary HAITask Force, in January 2003, led by the Chief Medical Officer(CMO), which comprises members of the public and seniorexecutives from both NHS and non-NHS sectors and theSEHD. Their remit is to co-ordinate the development andimplementation of the Action Plan, monitor and to report onprogress to the Minister. Completion December 2005.Progress includes: Issuing guidance on The NHSScotlandCode of Practice for the Local Management of HAI andHygiene; The NHSScotland National Cleaning ServicesSpecification The Code of Practice - outlines specificguidance on a range of factors, from staff education tocompliance management, management of basic wardequipment, and guidance on the prevention and control ofinfection. (http://www.scotland.gov.uk/library5/health/lmhhai-00.asp)Information on how hospitals and other healthcare sitesshould be cleaned, including how frequently, is set out in theNational Cleaning Services Specification. In also highlightsstaff training and development as well as performancemanagement requirements.(http://www.scotland.gov.uk/library5/health/ncss-00.asp)Other documents issued include guidance on media handlingduring incidents and outbreaks, and a Best Practice Statementon Urinary Catheterisation. Documents being finalisedinclude national standards for infection control in adult carehomes, a framework for mandatory induction training on HAI,guidance on the management of HAI outbreaks (includingstaff screening), risk-based methodologies for prioritisingmeasures to reduce the risk of HAI and national guidance forprudent antimicrobial prescribing.HAI education: Both the Code of Practice and the CleaningServices Specification acknowledge the education of relevantstaff as essential in ensuring a safe healthcare environment forservice users, staff and visitors. Work is currently underwayto develop packages for regular ongoing training for allNHSScotland staff groups, including the mandatoryHAI induction training framework, an "on-call" trainingprogramme for public health and infection control teams anda training framework for those involved in media handling.HAI surveillance: in Scotland is progressed by the ScottishSurveillance of Healthcare Associated Infection Programmeteam, based at SCIEH. The Health Department Letter(HDL(2001)57) A Framework for National Surveillance ofHAI in Scotland requires operating divisions (formerly Trusts)to undertake mandatory specified HAI surveillanceinitiatives, namely:52


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT■Data on methicillin resistant Staphylococcus aureus(MRSA) bacteraemias to be made publicly availablefrom April 2002 and to be published quarterly. Trenddata are fed into the Performance AssessmentFramework and is used by SEHD to evaluate theperformance of individual operating divisions.■Voluntary components of the HAI surveillanceprogramme include: HAI outbreak/incident surveillance;Post discharge surgical site infection surveillance;Surveillance of HAI in intensive care units; Surveillanceof RSV infection in paediatric units; Surveillance ofcatheter-associated urinary tract infection.■Surveillance of surgical site infection (SSI) following twocategories of operative procedure, one of which shouldbe an orthopaedic procedure, selected from a list ofnine commonly performed surgical procedures, aswell as surveillance of SSI following neurosurgicalprocedures. All trusts were collecting in-patient data byMay 2003. The first national report of SSI surveillance inScotland was published in October 2003.Reviews of compliance with national standards for control ofHAI and for cleaning were published in January 2003 byNHS QIS and Audit Scotland respectively. Both reportsidentified significant progress in meeting standards but alsoareas where further improvements could be made. Each Trustreceived its own detailed evaluation, highlighting areas forfurther improvement. In summer 2003 NHS QIS the Ministerasked for a progress report. Update reviews commenced inOctober 2003 and the report will be published in 2004.WalesThe 2000 NAO report on infection control in hospitals inEngland formed a useful route to build on previous work inthis area in Wales. Professionals from Wales were fullmembers of the Department of Health's HealthcareAssociated Infection Strategy Steering Group and as a result,many developments have in the main been running parallelacross the UK.Surveillance and Outputs: Wales launched a mandatorybacteraemia reporting scheme for Staphylococcus aureusfrom April 2001. The Welsh scheme presents data on all fourmajor items collected (total blood culture, positive bloodcultures, MSSA and MRSA). All hospitals receive openfeedback (i.e. all named trust results) on the scheme.Each trust may publish their own data but not that of othertrusts without permission. Aggregated but anonymous resultsare published on the National Public Health Service web site(http://www.wales.nhs.uk/whaip).The Chief Medical Officer for Wales approved theestablishment, by the Welsh Committee for Control ofCommunicable Diseases, of the Welsh HealthcareAssociated Infection Subgroup. This group has worked withthe rest of the UK and in early 2003, further mandatoryschemes were introduced: hospital outbreak reporting fromApril 2003, surgical site surveillance in orthopaedics fromSeptember 2003 and locally based infection reductiontargets to be identified from January 2004.strategically placed across Wales, the communicable diseasesurveillance centre and health protection teams basedaround consultants in communicable disease control.This gives a central focus for national infection controlsystems and services, keying into all parts of the NHS.In November 2003, the draft healthcare associated infectionstrategy for hospitals was launched for professionalconsultation. The final version will be published mid 2004. Thishas a clear emphasis management accountabilities and onpersonal responsibility of all healthcare staff for healthcareassociated infection. A directorate based infection controlstructure is required, with directorates in trusts developinglocal infection control plans, with a prioritised diseasereduction target, as part of their response. The strategy is setwithin national standards and recommends improvements toinfrastructure and organisation of infection control. Specialistinfection and epidemiological control support will be providedby a dedicated project team based within the NPHS. Theactivities within the strategy have clear performance indicatorsbringing together NHS Wales performance managementstructures ensuring regular audit of processes and practice.Training of staff at all levels will be enhanced. Sharingoutputs and developments in infection reduction will besupported by further enhancements of the nationalsurveillance tools. A community based strategy is currentlybeing developed.DataStore is an information management tool created by theformer PHLS in Wales that captures all microbiologyinformation, both positives and negatives. The product isbeing rolled out across Wales so that country wide databecomes available. The system forms the backbone forenhanced surveillance, including antibiotic resistance.Structures and Services: The National Public Health Service(NPHS) was established in April 2003. This includes theInfection and Communicable Disease Service (ICDS), whichcomprises a network of public health laboratories,Finally, as a supplement to the wider management of HCAI,decontamination and sterilisation services have beenenhanced during the past 3 years. At the time of writing, 65%of hospital sterilisation and decontamination units haveachieved accreditation to the European medical devicedirective standard. Accredited sites may provide services tooutside organisation, including primary care. A primary carepilot has demonstrated the feasibility of provision to GP'sacross a wide rural area. Opportunities to develop this acrossWales will be sought as all units gain accreditation. Fullaccreditation across Wales is targeted for December 2004.appendix four53


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTNorthern IrelandAs with Wales, Northern Ireland had a representative on theHealthcare Associated Infection Strategy Steering Group andkept abreast of developments across the UK.The Hospital Acquired Infection Sub-Committee of theRegional Advisory Committee on Communicable DiseaseControl was set up in October 1999. Its key objectives are toadvise on:abcInfection control practices in hospitals includingroutine hygiene procedures such as hand washing;To promote optimum antimicrobial prescribing; andTo improve surveillance of hospital acquired infectionand resistant organisms and monitor antimicrobial use.All hospital trusts in Northern Ireland were surveyed in2001/2002 in relation to their management and control ofhospital acquired infection. The priorities identified includedincreasing the complement of infection control nurseswithin trusts, improving the computerisation of datacollection systems, and providing clericalofficer/surveillance officer support to trust hospitalmicrobiology departments. The complement of infectioncontrol nurses both at acute and community level iscurrently being looked at by a Sub-Committee of the CentralNurse Advisory Committee.Controls assurance standards for infection control for thehealth service in Northern Ireland were issued in April 2004.Northern Ireland Healthcare AssociatedInfection Surveillance Centre (HISC)DHSSPS has funded HISC since April 2001. The objectives ofHISC are to develop and improve surveillance methods byassisting hospitals to monitor healthcare acquired infection byfacilitating data collection, handling, analysis and feedback.HISC has developed a standardised model for core surgicalsite infections surveillance, procedure-specific modelsincluding post-discharge surveillance and tools for theinterrogation of databases that will enable timely andappropriate feedback. HISC has established a surveillanceprogramme in elective orthopaedics and vascular surgerythroughout Northern Ireland which has also being adapted foruse in Scotland and Wales. A pilot is currently underway toundertake post-discharge surveillance of caesarean section.Pan Celtic CollaborationA collaboration between the Northern Ireland HealthcareAssociated Infection Surveillance Centre (HISC), the ScottishSurveillance of Healthcare Associated Infection Programme(SSHAIP) and the Welsh Healthcare Associated InfectionProgramme (WHAIP) represents a major UK initiative toprovide support to orthopaedic clinical teams. A report waspublished in March 2004 combining data from 2001 to2003 and representing some 15,213 patient episodes, in thehope that it will be widely disseminated and used to developinfection control plans for orthopaedics in the threecountries involved. 25There has been a great deal of activity undertaken at trust,board and regional level to improve infection controlarrangements as part of the contingency planning for SARS.This has included a look at current provision of isolationfacilities. Specific SARS training material has beendeveloped for training staff in hospitals and the community.This covered generic elements of infection control.There have been a number of initiatives in relation tosurveillance of hospital-acquired infection:aSince 2002, the Northern Ireland Department ofHealth, Social Services and Public Safety (DHSSPS)has made the surveillance of MRSA bacteraemiasmandatory for all Trusts. Two regional reports onMRSA bacteraemias have been produced.appendix four54bcTrusts have been asked to undertake C.difficilesurveillance on a voluntary basis from summer of2004 with a view to making C.difficile surveillancemandatory from 1st January 2005.European Antimicrobial Resistance SurveillanceSystem (EARSS) - All laboratories here are submittingdata on S.aureus bacteraemias to EARSS.


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 5National Audit OfficeStudy MethodologyThe key features of our study methodology were that we:-■■■■Conducted a census in July/August 2003 of all176 acute NHS trusts in England. The census comprisedof four questionnaires to be completed by chiefexecutives, infection control teams, orthopaedic clinicalleads and vascular clinical leads. The census soughtinformation on changes to the management and controlof hospital acquired infection since the publication ofour original report in 2000, whether the Committeeof Public Accounts recommendations had beenimplemented, and whether there had been a discerniblechange in patient outcomes as a result of these changes.We commissioned Market & Opinion ResearchInternational Ltd. (MORI) to undertake the census onour behalf and to provide a summary report of thefindings. Response rates were as per the table below.Visited some acute trusts to identify examples ofgood practice.Organised seven one-day multidisciplinary workshopsto ascertain the views of clinicians and other healthcareprofessionals who have demonstrated an interest inpreventing and reducing healthcare associatedinfections.Examined key documents at the Department of Healthon surveillance and also discussion with the HealthProtection Agency.■Examined data held by other bodies that have aregulatory role on infection control including theCommission for Health Improvement and the NHSLitigation Authority and interviews with key members ofstaff at these bodies. We also interviewed staff at otherbodies that have a role in monitoring and supportinginfection control activity including the National PatientSafety Agency and The Medicines and HealthcareRelated Products Agency.■ Conducted a further electronic census in February 2004,which was sent to Association of MedicalMicrobiologists, Hospital Infection Society and Infexmembers, particularly to ascertain how trusts hadresponded to Winning Ways and the need to designate anew Director of Infection Prevention and Control.■Commissioned The Richard Wells Research Centre,Thames Valley University to undertake research oninternational comparisons on the management andcontrol of hospital acquired infection (Appendix 3).In addition we visited Hong Kong and Singapore tounderstand how SARS had impacted on their infectioncontrol arrangements - Hong Kong like New Zealandhave undertaken a similar audit to us based on ouroriginal questionnaire.NAO Survey of acute NHS Chief Executives Infection Control Orthopaedic VascularJuly-September 2003 Teams Directorates DirectoratesNumber of trusts 176 176 176 176Number stating survey not 0 0 13 38applicable to their trustTotal applicable trusts 176 176 162 138Responses received for in time 154 165 96 90for inclusion in analysisResponse rate for MORI analysis % 88 94 59 65Total responses including post- 165 174 111 98deadline returnsTotal response rate (all included in NAO 94 99 69 71open question analysis) %appendix five55


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT■■Interviewed key staff at a selection of strategic healthauthorities to understand their role in performancemonitoring with respect to hospital acquired infection.We also sought information from a sample of primarycare trusts on the commissioning of infection controlservices from acute NHS trusts via a combination oftelephone interviewing and an email survey.Commissioned CARA Research Ltd. to undertakeanalysis of the relationships between key performanceindicators and data held by the Department of HealthControls Assurance Team.■■Undertook an extensive literature review and attended anumber of sector conferences on infection control.Constituted an expert panel who provided advice andguidance throughout the study. A full list of its membersis shown below.Full details of our study methodology and detailed surveyanalyses are on our website www.nao.org.ukMembership of Expert Advisory Groupappendix five56Dr. Georgia DuckworthProfessor Brian DuerdenProfessor Gary FrenchMs. Carole FryDr. Helen GlenisterDr. Tony HowardDr. M.C. KelseyDr. Vicki KingDr. Deirdre LewisMrs. Ruth LockwoodMr. John F. NolanDr. William PascoeDr. Sally PearsonProfessor Robert PrattDr. Gina RadfordStephen RamsdenDr. G.L RidgwayProfessor Jennifer A. RobertsDr. Richard SlackDr Robert SpencerSharon WaightProfessor Mark H. WilcoxHead of Department of Healthcare Associated Infection and Antimicrobial Resistance inthe Communicable Disease Surveillance Centre, Health Protection AgencyNewly appointed Inspector of Microbiology for the Department of Health. Previously wasthe Director of Clinical Governance at the Health Protection AgencyProfessor of Microbiology, King's College London; Consultant Microbiologist & ChairmanInfection Control Committee, Guy's & St Thomas's Hospital Trust, LondonNursing Officer - Communicable Diseases, Department of HealthDirector of Safety Solutions, National Patient Safety AgencyDirector of the Infection and Communicable Disease Service, National Public HealthService for WalesConsultant Microbiologist and Infection Control Doctor, Whittington HospitalFormerly Head of the Blood and Healthcare Associated Infections Unit, CommunicableDiseases Branch, Department of HealthConsultant Epidemiologist, South West Communicable Disease Surveillance CentreSenior Nurse Infection Control, Swindon and Marlborough NHS TrustConsultant Orthopaedic Surgeon and Department Chairman at the Norfolk & NorwichUniversity Hospital NHS TrustHM Inspector of Health & Safety, Health Services Unit of the Health & Safety ExecutiveDirector of Clinical Strategy for Gloucestershire Hospitals NHS TrustProfessor of Nursing and Director of the Richard Wells Research Centre at Thames ValleyUniversity, London. President of the Infection Control Nurses AssociationRegional Director of Public Health, East of England Public Health GroupChief Executive, Luton & Dunstable Hospital NHS TrustConsultant Microbiologist, University College London Hospitals & Senior Medical Officer,Blood and Healthcare Associated Infections Unit, Department of HealthDirector of the Collaborative Centre for Economics of Infectious Disease, Department ofPublic Health and Policy, London School of Hygiene and Tropical MedicineConsultant/Senior Lecturer for Communicable Disease Control, University of Nottinghamand Health Protection Agency East Midlands (North)Chairman Hospital Infection Society/Consultant Medical Microbiologist Health ProtectionAgency, South West Regional Laboratory, BristolProject Manager- Older People Services NSF Reviews, Commission For Health ImprovementConsultant/Clinical Director of Microbiology, Director of Infection Prevention andControl, Leeds Teaching Hospitals NHS Trust & Professor of Medical Microbiology,University of Leeds


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 6Relationships between Department ofHealth key performance indicators onMRSA and Controls Assurance dataMethodologyWe commissioned CARA Research Ltd, an independentanalyst with experience of working with the Department ofHealth Controls Assurance Team, to analyse raw performancedata from the Department of Health, Health ProtectionAgency, Dr. Foster and the then Commission for HealthImprovement, with controls assurance data for 2002/2003obtained from the Department of Health Controls AssuranceTeam, using the analyst's own tailor-made software.The objectives of the study were to identify if there weresignificant relationships between levels of mortality, MRSAand other potentially interesting variables.MRSA bacteraemia rateMRSA bacteraemia2002-2003 improvement score iv1 Total % bed occupancy 2P2 PEAT score 1N3 Infection control standard 2N4 Star rating 3N5 Mortality index - fractured neck of femur 1P6 Overall numbers of controls assurance actions 2P7 Risk assurance 1N8 Staff sickness grade 2P9 Human resources risk-assurance level 1N10 Corporate governance standard 2NNumber coding indicates significance of relationship:3 = Higher weighting - more influence; 2 = Mid weighting; 1 = Lower weighting;P = Positive relationship between variables, i.e. as one increases, so does the other;N = Negative relationship between variables, i.e as one increases, the other decreasesSource: CARA Research Ltd/Department of Health Controls Assurance TeamFull report can be found on the NAO website at www.nao.org.uk.iv Based on the number of MRSA bacteraemia diagnoses in the nine months from April to December 2002 with the number in the same period during 2001.appendix six57


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTExplanatory notes of key relationships1 Lower rates of bed occupancy tend to be associatedwith lower rates of MRSA bacteraemia.2 As the MRSA bacteraemia improvement score improves,then the PEAT score tends to be lower (indicating thatbetter PEAT scores are not an indication of improvingMRSA bacteraemia rates).3 Trusts with higher scores in the infection control standardtended to have lower rates of MRSA bacteraemia.4 There is a tendency for the higher star-rated trusts tohave lower rates of MRSA bacteraemia.5 Trusts with higher MRSA bacteraemia rates tended tohave a higher mortality index for fractured neck of femur(but no relationship was found between the MRSAbacteraemia rates or improvement scores, and theoverall mortality rates).6 Higher rates of MRSA bacteraemia occur at lower levelsof risk-assurance and increasing levels of action in thetrusts (lower levels of risk assurance indicates lowerassurance and more risk in a trust, hence a highernumber of actions generated by trusts).7 There is a general positive relationship between theMRSA bacteraemia improvement score and the staffsickness grading.8 The average level of MRSA bacteraemia tends to reduceas the human resources risk-assurance score increases.9 Higher assurance levels in the clinical governancestandard are also associated with lower levels of MRSAbacteraemia.appendix six58


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTAppendix 7Chronology of developments inmandatory surveillance of hospitalacquired infectionsDevelopments in Surveillance1996 The Department of Health /Public Health Laboratory Service jointly funded (5 year) Nosocomial InfectionNational Surveillance Scheme (NINSS) was launched. Participation was voluntary and confidential.The aim was to help identification of and reductions in avoidable hospital acquired infections. There weretwo modules, hospital acquired bacteraemia and surgical site infections (covering twelve categoriesof surgical procedures).January 2000February 2000February 2000March 2000September 2000October 2000The Department commissioned a quinquennial review of the NINSS scheme (Cunningham report) whichrecommended that: the scheme needed to be re-packaged as a service provided for and owned by the NHS;existing management arrangements should be replaced by a broadly based steering group which shouldfocus on extending the surgical site infection and healthcare acquired bacteraemia modules to evenmore trusts.The National Audit Office report on The Management & Control of Hospital Acquired Infection concludedthat NINSS was starting to show the benefits of surveillance and recommended that the Department shouldbuild on the success of the scheme and encourage more trusts to participate.The Department issued HSC 2000-02 requiring all trusts to undertake surveillance.At the Committee of Public Accounts hearing in March 2000 there were concerns that the NHS did nothave a grip on the extent and costs of infection. The Committee therefore recommended that NINSS shouldbe made mandatory for all NHS trusts (report published in November 2000).A Healthcare Associated Infection Steering Group (HAISSG) chaired by an NHS Executive was set up toprovide the Department with urgent recommendations on infection surveillance needs at local, regionaland national level, building on and improving the limited coverage of NINSS. Sub-groups were formed forpost-discharge surveillance, orthopaedic surgical site infection surveillance and hospital acquired bacteraemia.The Minister of State for Health gave an undertaking that there would be compulsory surveillance ofhospital acquired infections in all trusts in England.appendix seven59


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTDevelopments in SurveillanceNovember 2000January 2001February 2002September 2002June 2003The HAISSG recommended that in order to meet the immediate national and regional surveillance needsthat they would use existing data to capture relevant data on MRSA.A healthcare acquired bacteraemia statement was issued by the Department of Health requiring themandatory reporting by trusts on MRSA bacteraemia rates from April 2001 and that data would bepublished from 2002.The first report on MRSA surveillance for April 2001 - September 2001 was published. These showed thatthe number of cases of MRSA bacteraemia ranged from 0 to 0.69 cases per 1000 bed days; single specialtyhospitals had lower rates than general acute and specialist treatment trusts; and rates between regionsvaried with London having the highest and the North West the lowest rates.The HAISSG was disbanded and a service level agreement between the Department of Health and theHealth Protection Agency was established to take forward the development of mandatory surveillance.The Chief Medical Officer announced that trusts should report to the Health Protection Agency anybloodstream infection caused by enterococci resistant to the glycopeptide group of antibiotics (GRE) andserious untoward incidents associated with hospital infections.It was also announced that improvements in MRSA rates were to be included as a performance indicatorto be included in the trusts' star ratings.September 2003December 2003January 2004April 2004Mandatory reporting of serious untoward incidents and GRE commenced.The Chief Medical Officer's report "Winning Ways" announced the expansion of the mandatorysurveillance system to include bloodstream infections, surgical site infections, Clostridium difficileassociated disease, serious incidents associated with infection and infections after discharge from hospital.In addition, a national audit of deaths is also to be established.Mandatory reporting of Clostridium difficile commenced.Mandatory reporting of orthopaedic surgical site infection rolled out.appendix seven60


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTBibliography1 Report by the Comptroller and Auditor General - HC 230 Session 1999-2000: The management and control ofhospital acquired infection in acute NHS trusts in England.2 Forty-second Report by the Committee of Public Accounts Session 1999-2000 - The management and control ofhospital acquired infection in Acute NHS Trust in England. House of Commons: The Stationary Office Limited, 2000.3 Department of Health (December 2003). Winning Ways: Working together to reduce Healthcare Associated Infectionin England: Report by the Chief Medical Officer.4 Department of Health (1999). HSC 1999/065: Clinical Governance: Quality in the new NHS5 Department of Health (1999). Controls Assurance Guidelines supplementing HSC 1999/123. London: Department ofHealth and Ministerial Press release 1999/0686 - New framework for managing hospital acquired infection: Infectioncontrol part of a new range of standards for the NHS.6 Department of Health (April 2001 and January 2002). Shifting the Balance of Power - "Securing Delivery" and"Next Steps."7 Department of Health (July 2003). Choice of hospitals guidance for PCTs, NHS trusts and SHAs on offering patientschoice of where they are treated.8 Department of Health. Payment by results.www.dh.gov.uk/policyandguidance/organisationpolicy/financeandplanning/nhsfinancialreforms9 European Antimicrobial Resistance Surveillance System data for 2002. Available at www.earss.rivm.nl10 Treasury Minute on the Thirty-eighth to Forty-second Reports from the Committee of Public Accounts Session1999-2000 - 42nd report - The management and control of hospital acquired infection.11 Department of Health (January 2002). Getting Ahead of the Curve: Action to strengthen the microbiology function inthe prevention and control of infectious diseases. London: Department of Health.12 Report by the Comptroller and Auditor General - HC 1005 Session 2002-2003 (September 2003): AchievingImprovements through Clinical Goverance: A progress report on implementation by NHS trusts.13 Co-ordination of reviews of risk management in England and Wales: Principles of agreement between revieworganisations, NHS Reviews coordination group, 2002. Available from www.chi.nhs.uk.14 Department of Health (December 2000). NHS Plan Implementation Programme.15 Department of Health: Chief Medical Officer's letters (June 2003) - PL CMO (2003)4: Surveillance of HealthcareAssociated Infections.16 Richard Wells Research Centre, Thames Valley University (September 2003). A Comparison of International Practicesin the Management and Control of Hospital-acquired Infections. www.nao.org.uk.17 Parnell, S; Fearon, A; Dell, A (August 2003) ASEPTIC: A Systems Evaluation Project for Infection Control Final Report.www.hpa.org.uk/infections/publications/pdf/aseptic_Report.pdf18 Commission for Health Improvement (May 2003). Getting Better? A report on the NHS.19 O'Boyle, C; Jackson, M; Henly, S.J. (October 2002). Staffing requirements for infection control programs in US healthcare facilities: Delphi project. American Journal of Infection Control Vol. 30(6) pp. 321 - 33320 Taylor, K; Plowman, R; Roberts, J.A. (2001) The Challenge of Hospital Acquired Infection. The National Audit Office.London: Stationary Office21 Department of Health (April 2001) - HSC 2001/010: Implementing the NHS Plan - Modern Matrons: Strengtheningthe role of ward sisters and introducing senior sisters.22 Poll of 100 modern matrons conducted at a Healthcare Events conference in September 2003.bibliography61


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT23 The House of Lords Select Committee on Science and Technology (March 2001). Resistance to Antibiotics.(HL Paper 56, 3rd report, Session 2000-01) London Stationary Office.24 The House of Lords Select Committee on Science and Technology (July 2003) Fighting Infection. (HL Paper 138,4th report, Session 2002-03) London Stationary Office.25 NHS Estates (April 2004) Ward housekeepers - www.nhsestates.gov.uk/patient_environment.26 Ayliffe G.A. et al (1998) Revised guidelines for the control of methicillin-resistant S. Aureus infection in hospitals.Journal of Hospital Infection. 39: 253-90.27 Khairulddin N et al (2004) Emergence of methicillin resistant Staphyloccus aureus (MRSA) bacteraemia amongchildren in England and Wales, 1990-2001. Archives of Disease in Childhood. 89: 378-379.28 Northern Ireland Healthcare-Associated Infection Surveillance Centre (HISC), Scottish Surveillance of HealthcareAssociated Infection Programme (SSHAIP), National Public Health Service for Wales (March 2004). Pan CelticCollaborative Surveillance Report.29 Plowman R, et al (1999) The socio-economic burden of hospital acquired infection. London: Public HealthLaboratory Service (now part of the Health Protection Agency).30 Crowcroft, N and Catchpole, M (2002) Mortality from methicillin resistant Staphylococcus aureus in England andWales: analysis of death certificates. British Medical Journal 325, 1390-1391.31 Griffiths, C et al (2004) Trends in MRSA in England and Wales: analysis of morbidity and mortality data for1993-2002. Office for National Statistics: Health Statistics Quarterly Spring 2004.32 Boyce, J.M; Pittet, D (2002) Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the HealthcareInfection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.33 Murphy, J. (2002) Literature review on relationship between cleaning and hospital acquired infections. CanadianUnion of Public Employees (CUPE). Available at www.cupe.ca.34 NHS Estates (April 2001). National Standards of Cleanliness for the NHS.35 NHS Estates (August 2003). Standards of Cleanliness in the NHS: A Framework in which to MeasurePerformance Outcomes.36 NHS Estates (March 2004). The NHS Healthcare Cleaning Manual.37 Department of Health (2003). National Survey of NHS Patients: Acute Inpatient Survey: National Overview 2001/02.38 Burstow P (2002) "Now Wash Your Hands!" An investigation into the delivery of infection control in the NHS. LiberalDemocrats publication.39 Burstow P (2004) "Now Wash Your Hands 2." An investigation into progress on Infection Control in the NHS. LiberalDemocrats publication.40 Pratt RJ et al (2001). The Epic Project: Developing national evidence-based guidelines for preventing healthcareassociated infections. Journal of Hospital Infection 2001: 47 (Supplement S3-S4).41 Society for Hospital Epidemiology of America workshop 2004.42 de Jonge E et al (2003), Effects of selective decontamination of digestive tract on mortality and acquisition of resistantbacteria in intensive care: a randomised controlled trial. Lancet. 2003;362:1011-6.43 French GL et al (2004). Tackling contamination of the hospital environment by methicillin-resistant Staphyloccusaureus (MRSA): A comparison between conventional terminal cleaning and hydrogen peroxide vapourdecontamination. Journal of Hospital Infection 57 (1) May 2004, pp.31-37.44 Brosnahan et al (2004) Types of urethral catheters for management of short-term voiding problems in hospitalisedadults (Cochrane Review): The Cochrane Library, Issue 2, 2004.bibliography45 Report by the Comptroller and Auditor General - HC 623 Session 2002-2003: A Safer Place to Work: Improving themanagement of health and safety risks to staff in NHS trusts.62


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTGlossaryAcute bedsAcute NHS TrustAgency NurseAntibioticAntibiotic policyAntimicrobial/AntibioticresistanceAntimicrobial agentAseptic techniqueAuditBacteraemiaBacterium (Bacteria)Catheter/cannulaClinical GovernanceClostridium difficileCommittee of Public AccountsIncludes beds on the following wards: Intensive care, terminally ill/palliative care,all surgical, medical and paediatric, acute maternity and acute elderly and youngphysically disabled.Hospitals, which are managed by their own Boards and which provide acute beds linkedto medical and surgical intervention.Temporary nursing staff booked by the NHS trust from a commercial employment agencyto provide holiday cover or to deal with temporary staff shortages.A substance that destroys or inhibits the growth of bacteria. Action may be selectiveagainst certain bacteria.Written guidance that recommends antibiotics and their dosage for treating andpreventing specific infections.Resistance to anti microbial agents that is either naturally occuring or develops in amicrorganism over time.Any compound that selectively destroys or inhibits the growth of micro-organisms.A precautionary method used in any procedure in which there is a possiblility ofintroducing pathogenic organisms into the patient's body. Achieved by ensuring that onlysterile equipment and fluids are used during specified clinical procedures.Organised review of staff of current practices and comparisons with pre-determinedstandards. Action is then taken to rectify any deficiencies that have been identified incurrent practices. The review is repeated to see if the pre determined standards arebeing met.Presence of bacteria in the bloodstream.A simple microscopic single-celled organism(s) that lacks a true nucleus.A tubular flexible instrument passed through body channels for withdrawal or introductionof fluids.A framework through which NHS organisations are accountable for continuouslyimproving the quality of their services and safeguarding high standards of care by creatingan environment in which excellence in clinical care will flourish.A toxin producing bacterium which can cause severe diarrhoea or enterocolitis. This mostcommonly occurs following a course of antibiotics which has disturbed the normalbacterial flora of the patient's gut.The senior Select Committee of the House of Commons. The main work of the Committeeis the examination of the Reports produced by the Comptroller and Auditor General(C&AG) on his value for money (VFM) studies of the economy, efficiency andeffectiveness with which Government Departments and other bodies have used theirresources to further their objectives. About 60 of these reports are adopted by theCommittee, either by taking oral evidence or, occasionally, by sending written questionsto the Government departments concerned. The Committee's objective is to draw lessonsfrom past successes and failures which can be applied to future activity by theDepartment examined or more generally.glossary63


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTglossary64Communicable diseaseComplianceConsultant in CommunicableDisease Control (CCDC)Controls AssuranceCriteriaDenominatorEndemicEnterococcusEpidemiologyEpidemiologistEuropean AntimicrobialResistance Surveillancesystem (EARSS)Healthcare AssociatedInfectionHospital acquired infectionHospital Infection ControlCommitteeHospital hygieneICU/ITUImmuneIncidenceInfectionInfection control doctorInfection control nurseA disease that can be transmitted from a person, animal or the environment to anothersusceptible individual.The degree to which patients follow the instructions for taking a course of treatment orhealthcare workers follow an infection control policy.A doctor, appointed by the Health Protection Agency, who has responsibility for thesurveillance, prevention and control of infections within a defined geographical area.A process designed to provide evidence that NHS bodies are doing their reasonable bestto manage themselves so as to meet their objectives and protect patients, staff, the publicand other stakeholders against risks of all kinds.A standard way by which you judge, decide about, or deal with something.The population considered to be at risk eg. the total number of people admitted to ahospital or receiving a particular anti microbial agent.A disease or infection constantly present in the community.A bacterium which normally colonises the human bowel and is associated with bladderand wound infections.The study of the occurrence, cause, control and prevention of disease in populations,as opposed to individuals.An expert in epidemiology.An international network of national surveillance systems, collecting comparable andvalidated antimicrobial resistance data for public health purposes.An infection acquired via the provision of healthcare in either a hospital orcommunity setting.An infection that was neither present nor incubating at the time of a patient's admissionwhich normally manifests itself more than forty eight hours after the patient's admissionto hospital.The main forum for routine consultation between the infection control team and the restof the NHS Trust. It is required to approve and lend support to the infection controlteams programme.The hospitals routine procedures on cleaning, housekeeping, disinfection, sterilization ofinstruments, equipment, production of sterile supplies, safe collection and disposal ofclinical waste, kitchen hygiene, control of insects, vermin, etc.Intensive Care Unit/Intensive Therapy Unit.Being resistant to a disease due to the formation of antibodies and/or the development ofimmunologically competent cells.The number of new events/episodes of a disease that occur in a population in a giventime period.Invasion and multiplication of harmful micro organisms in body tissues.Normally a consultant medical microbiologist, with knowledge of aspects of infectioncontrol, which should include epidemiology. The infection control doctor normallyprovides leadership to the infection control team and is responsible to the NHS TrustChief Executive for its work.A registered general nurse, normally with higher specialist training in infection control. Theinfection control nurse is usually the only full-time member of the infection control team.


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTInfection control teamInfectiousInspectionIntravascular (device)IsolationLink NursesMedical MicrobiologistMicrobiologyMicro- organismMorbidityMortalityMRSA (Methicillin ResistantStaphylococcus aureus)MSSA (Methicillin SensitiveStaphyloccus aureus)Multi resistanceNational Joint RegistryNormal floraNorovirusNosocomialOutbreakPrevalencePrimary Care TrustA team within an NHS Trust which has prime responsibility for, and reports to the ChiefExecutive on, all aspects of surveillance prevention and control of infection. The membersof the team include an infection control doctor and infection control nurse(s) and mayinclude surveillance nurses and clerical support staff.Caused by or capable of being communicated by infection.A visit carried out as part of a review, investigation or study to inspect premises ordocuments, or to require explanation.Catheter/cannula inserted into a vein or artery.To remove a patient from the general ward setting to a place where contact with otherpeople can be controlled.Ward-based nurses who receive regular and appropriate training in infection control,which they then apply in the ward setting. In some cases, they are also trained to collectsurveillance data for the infection control team.A doctor who studies the science of the isolation, identification and infectivity of microorganismsthat cause diseases in humans and applies this knowledge to treat, control andprevent infections.The science of the isolation, identification and mode of infectivity of micro organisms.Medical microbiology is concerned with those micro-organisms which cause diseasesin humans.An organism too small to be seen with the naked eye. The term includes bacteria, fungi,protozoa and viruses.The state of having a disease, or reduced state of health.DeathA strain of Staphylococcus aureus that is resistant to methicillin and other penicillin andcephalosporin antibiotics.A strain of Staphylococcus aureus that is sensitive to methicillin.A micro-organism that is resistant to two or more unrelated anti-microbial agents. Thesecan be MSSA or MRSA.A central database launched on 1 April 2003 which stores information on hip and kneereplacement procedures across England and Wales.The micro-organisms that normally live in or, on the body, and contribute to normalhealth. When antimicobial agents are used to treat infectious disease, changes affectingthe normal flora may reduce their ability to protect against infection.The Term used for a group of viruses including Norwalk-Like Virus (NLV) and small RoundStructured Virus (SRSV) that cause infections gastroenteritis.Hospital acquiredAn incident in which two or more people have the same infectious disease or similarsymptoms, and in which there is a time/place/person association. Also a situation wherethe observed number of cases unaccountably exceeds the expected number.The total number of cases of a specific disease in existence in a given population at acertain time.Receives budgets directly from the Department of Health and provide primary care(services provided by GPs and in the local community), as well as commissioning servicesfrom acute NHS trusts.glossary65


IMPROVING PATIENT CARE BY REDUCING THE RISK OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORTProphylaxisRegional EpidemiologistScreeningSelf-assessmentStandardStaphylococcusStrategic Health AuthoritiesSurveillanceVirusAny means taken to prevent infectious disease. For example, immunisation, or givingantibiotics when patients undergo surgery.A medically qualified consultant specialising in epidemiology and working with aregional unit of the Health Protection Agency Communicable DiseaseSurveillance Centre.Involves taking specimens from patients and staff which are then subject to microbiologytesting to determine whether that individual is colonised by specific micro-organisms ,e.g. MRSA.A method whereby individuals and organisations assess their own performance using aseries of questions or statements.A deserved and achievable level of performance against which actual performance canbe measured.A group of bacteria which cause a wide variety of infections especially of skin andwounds. More serious infections include bacteraemia and pneumonia as well as heartvalve, bone and joint infections.Twenty-eight SHAs are responsible for the performance of the local NHS and for settingstrategies within which the national framework set out by the Department of Health canbe achieved. SHAs have assumed many of the duties of the former 95 health authoritiesabolished in 2002.Systematic collection of data from the population at risk, identification of infectionsusing consistent definitions, analysis of these data and dissemination of the results tothose responsible for the care of the patients and to those responsible for implementationof prevention and central measures.A very small micro-organism of simple structure, only capable of surviving within aliving host cell.glossary66

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