1. HCAIs-Prevention & Control Nurses as Champions Karen Egan Associate Director of Infection Prevention & Control Mid Cheshire Hospitals NHS Trust, UK

2. Increasing Profile of Infection Prevention and Control Infection Control Hospital Acquired Infections Informal Systems Infection Prevention and Control Healthcare Associated Infections (HCAIs) Formal Systems/Services Integral Part of Governance

3. Increasing Profile of Infection Prevention and Control 5,000 deaths per year and 15,000 associated deaths per year Over one billion pounds pa for all HCAIs MRSA bacteraemia costing £4-10,000 per case Clostridium difficile; £4,000 Dept of Health targets, directives, guidance Change in delivery and monitoring of NHS healthcare in the UK

4. Current Climate Public Concern Media Politics Staff Concern Quality Issues Published data Commissioning Monitoring Patient Choice

5. Greater Emphasis on IP&C Winning Ways- 2003 NICE guidance- 2003 (primary care) Towards Cleaner Hospitals- 2004 National Audit Office Reports- 2004/04 NPSA Alert- 2004 (Cleanyourhands) Matrons Charter- 2004 MRSA targets- 2004 Healthcare Commission Standards- 2005 Saving Lives- 2005

6. Greater Emphasis on IP&C Going Further Faster- 2006 3 rd National Prevalence Study- 2006 (8.2% of hospitalised patients with an HCAI, previously 9.2%) Revised NHSLA Standards- 2006 Stoke Mandeville Report- 2006 ( 334 patients affected,38 deaths) Hygiene Code of Practice- 2006 Continuation of PEAT Assessments-2006-07 Kent & Tunbridge Wells Report- 2007 1,170 patients affected April 04-Sept 06 345 C.diff pos deaths; 90 def.or probably, 255 contributed

7. Greater Emphasis on IP&C C.difficile Targets (30%)- 2007/08-2011 Saving Lives &Code of Practice Tool- 07 DH guides for best practice; 1. Blood Cultures- Aug 07 2. Antibiotic Prescribing- Aug 07 3. Isolating Patients with HCAI- Sept 07 4. Chronic wound related BSIs- Nov 07 DH evidence base for uniforms and work wear- Sept 07 Deep clean, Matrons, Cleanliness & Reporting-07 Clean, Safe Care- Jan 07

8. Key Developments Code of Practice (OCT 06) Forms part of the Health Bill (Oct 06) Monitored by HC and results in Improvement Notices or Special Measures Three sections; 1) Management, Organisation and Environment 2) Clinical Care Protocols 3) Healthcare Workers All Healthcare providers by 2008

9. Key Developments MRSA Targets (Nov 2004) To reduce MRSA bacteraemia by 50% by 2008 Perform detailed surveillance and Root Cause Analysis on each case Reduction in the UK for the 3 rd year 2001/02 ( 7,291) 2002/03 (7,426) 2003/04 (7,700) 2004/05 (7,2330 2005/06 (7,096 2006/07 (6,378) Continuation of reduction target for further 3 years MRSA screening strategies; electives 2009, emergencies 2011

10. Key Developments Saving Lives Programme (05 onwards) Assessment of Infection Prevention & Control practice in clinical areas through the review of High Impact Interventions 1) Central Venous Catheters 2) Peripheral Lines 3) Renal Dialysis Care 4) Surgical Site Infection 5) Care of the Ventilated Patient 6) Urinary Catheters 7) Clostridium difficile

11. Key Developments Healthcare Commission Standards Annual review of corporate Infection Prevention & Control arrangements HC Report July 2007 1) An organisational culture 2) Management systems 3) Performance review systems 4) Integrated risk management 5) Dialogue with patients and the public www.healthcarecommission.org.uk www.clean-safe-care.nhs.uk www.nric.org.uk

12. Key Developments Clostridium difficile 2 significant reports with organisational recommendations HPA Care Bundle- Jan 07 Local targets with PCT- 07 National target (Public Service Agreement) NPSA; National Spec for Cleanliness (07) SLA for cleaning (07) www.patientexperience.nhsestates.gov.uk www.patientexperience.nhsestates.gov.uk Cleanyourhands (phase 3) Additional support (tariff uplift 2.3%) for IP&C Practitioners and Antibiotic Pharmacists

13. Strategic Aspects of IP&C Nurses as Champions Approach required from the whole health economy IP&C from Board to Ward LOCAL ACTION… Policies, Education, Audit, Accountability, Divisional Targets, Personal Objectives, Personal Development Plans, Management Plans, Patient Involvement Every clinical member of staff must practise effective Infection Prevention & Control…. AND….evidence must demonstrate this

14. Clinical Aspects of IP&C Nurses as Champions Implement National Directives (CYH, SL Programme, Code of Practice) Implement National Guidance (EPIC 2, MRSA Guidance & Screening Strategy) MRSA & Clostridium difficile targets/action RCA for MRSA bacteraemia and C.diff Environmental hygiene & measurement of Cleaning Standards Critical Care Bundles, Surviving Sepsis Campaign (17%bacteraemia in Critical Care)

15. Key Aspects of Patient Care Nurses as Champions Effective Infection Prevention & Control consists of many factors and not just one single action Many Healthcare workers are involved in patient care, patients are cared for in many different environments and they come into contact with a great deal of equipment Evidence must demonstrate that an organisation has an effective culture embedded, is aware of the potential risks to patients and puts measures in place to reduce risk and provide safe healthcare

16. How to Prioritise…..? Patients Staff Visitors Relatives

17. Environmental Factors…

18. Staphylococcal Abscess IM Premed Normal Staph aureus In the absence of a foreign body, Staph. aureus rarely causes infection deep IM bolus

19. Patient Bedside…

20. Staphylococcal Infection Pacing wire site Normal Staph aureus Presence of foreign body enhances the ability of the organism to become established

21. Invasive Devices…

22. The Role of Medical Devices 80% of UTI’s are due to indwelling catheters Over 60% of blood infections are introduced by feeding lines, catheters or similar devices Pneumonia occurs frequently in ventilated patients

23. PPE and Decontamination…

24. Hand Hygiene…

26. Infection Occurs When….. There is a source or reservoir of the bacteria, virus or other organism There is a means of transmission; equipment, hands, cough, sneeze There is a host; patient, visitor, staff There is an entry route; mouth, eyes, skin, lungs, innoculation

27. Basic Control Measures Aim to eliminate the source or reservoir Boost the host response to infection Break the chain of transmission

28. Overall responsibility lies with the Trust Board, but everyone involved in the patient journey has a responsibility to ensure safe, reliable healthcare Strategic/Clinical approaches required Many factors involved in HCAIs Interpreting how they were most likely transmitted (and responding) is key in relation to reducing rates of HCAIs Infection Prevention and Control is a given and not an option