1. A national perspective on progress Professor Brian Duerden Inspector of Microbiology and Infection Control, Department of Health, London

2. 2007 -The challenge of HCAI MRSA bacteraemia –2001/2 7291 (Q Av)1823 –2002/3 7426 (Q Av)1856 –2003/4 7700 (Q Av)1925 –2004/5 7212 (Q Av)1808 –2005/6 7097 (Q Av)1773 –2006/7 Q1 1741 Q2 1651 Q2 1651 Q3 1542 Q3 1542 Q4 1447 6381 6381 –2007/8 Q1 1303 C. difficile infection –2001 22008 –2002 28986 –2003 35537 –2004 43672 –2005 49850 (voluntary reporting, England, Wales, NI) –2004 44314 –2005 51767 –2006 55681 –2007 Q1 15639 – Q2 13660 +2890 (<65) (England, mandatory)

3. Responsibility for HCAI Clinicians –Safe patient care –Diagnosis –Treatment –Prevention –Control Board/CEx/DIPC –Corporate environment –Make it happen Government/DH –Set standards –Ensure priority –Monitor outcome –Legislation –Performance management

4. Reducing HCAI…. Change the mindset From: 1) create a system to deliver specialist clinical care 2) take measures to prevent infection To: 1) create a safe environment for patient care 2) deliver specialist clinical care within that environment

5. Getting Ahead of the Curve - 2002 Getting Ahead of the Curve - 2002 Priorities identified HCAI –bacteraemia (MRSA, GRE) –C. difficile associated diarrhoea –surgical site infection Tuberculosis Blood-borne & sexually transmitted viruses (and others!) Antimicrobial resistance

6. And then………. POLITICS (and the media hype)

7. HCAI 2003 - 04 Winning Ways - December 2003 –Strategy for HCAI NAO Report - July 2004 –Critical of slow progress Towards Cleaner Hospitals and Lower Rates of Infection - July 2004 –Action plan

8. MRSA Target ‘Halve MRSA infections by 2008’ –MRSA bacteraemia –Baseline 2003-04; Start date April 2005 –Monthly returns –3-monthly publication from Jan 2007 –Monthly submission and DH/SHA review Depends upon mandatory surveillance being accurate and timely – CEx sign-off

9. Monthly MRSA bacteraemia figures August 06 to July 07

10. MRSA reporting Timeliness –CEO lock down –Data entry in time –Use voluntary screen to record info to focus effort Extenuating circumstances –Duplicates –Repeats in untreatable patients –Responsible Trust (eg, renal satellite units)

11. What do the data tell us? Men >65 yrs are 43% of MRSA bacteraemias – (15% of all admissions nationally) 80% of MRSA bacteraemias are in emergency admissions – (37% of total admissions) 35% have been in hospital during the previous month Length of stay over 7 days increases risk 10% of MRSA bacteraemias come from nursing homes – 17% for pre-48 hour cases. 30% diagnosed in first 48hrs –but 65% of these patients have touched health care setting in recent past Risk factors –14% - chronic wounds –14% - central lines; 10% peripheral lines – 8% pneumonia

12. Healthcare Associated Infections MRSA - not the only one! Clostridium difficile Glycopeptide resistant enterococci ESBL-producing E. coli etc Acinetobacter baumannii Norovirus

13. C. difficile “new superbug” hits the national press Mon. June 6 th 2005. Jeremy Laurance – Health Editor, The Independent

14. C. difficile voluntary reporting 1991 – 2005: England, Wales and Northern Ireland

15. Mandatory surveillance 2004 - 7 January 2004 –All NHS Trusts in England –Report all cases of C. difficile disease Toxin +ve diarrhoea –Patients over 65 years (over 2 years from April 2007) Results –2004 : 44,314 –2005 : 51,767 –2006 : 55,681 –2007 : Q1 15639 – Q2 13660 + 2890 (<65y)

16. C. difficile deaths 1999-2005 199920012002200320042005 DC mentions 9751,2141,4281,7882,2473,807 UC5316917569581,2452,074 % as UC 545753555554 Office of National Statistics

17. Deaths in CDI HCC assessment –Definitely –Probably –Possibly –Unlikely –No What should we measure? Clinical experience –5-10% direct cause –5-10% probable contributory –30-day mortality 30% –60-day mortality 35-40%

18. C. difficile profile 2005-06 Public, media, politicians HCC/HPA Survey published Dec. 2005 –NHS Trusts not following guidance –Antibiotic policies; prevention; management; infection control; reporting Advisory letter from CMO/CNO Dec 2005 Saving Lives HII (care bundle) June 2006 HCC report on Stoke Mandeville July 2006 CMO/CNO/CPhO/CEx letter Dec 2006

19. CMO/CNO/CPhO/CEx guidance: Dec 2006 Antibiotic prescribing –Limit broad spectrum agents –Limit IV and oral courses Prompt diagnostic tests – Toxins A+B –isolates for typing if outbreak suspected Isolation/segregation/cohorting of cases Infection control – handwashing, gloves, gowns Decontamination/cleaning – increase –Chlorine-based disinfectant

20. C. difficile local targets Effective April 2007 PCT/Acute Trust agreement –Part of annual contracts Sliding scale of percentage reductions SHA monitoring

21. How do we change bad habits? Management –emphasis on infection control Enhanced surveillance (HPA) –MRSA & C. difficile Clinical practice protocols Cleanliness and hygiene –hand hygiene –environmental cleaning Training Targets and performance management

22. Management priority & responsibility HCAI –NOT just the Infection Control Team –Trust Board –Chief Executive –Clinical ownership –ALL STAFF DIPC is the focus –Responsibility –Authority – clinical and managerial –Resource allocation

23. WW Action area 6.Management and organisation Chief Executive’s responsibilities –Core part of Clinical Governance and Patient Safety programmes –Promote low levels of HCAI Ensure actions are taken –Aware of legal responsibilities to identify, assess and control risks of infection –Appoint Director of Infection Prevention and Control

24. DIPC role Senior management – Board/CEx report Professional credibility –Special expertise Reporting line for ICT Policy implementation Performance management Resource allocation A champion & a manager!!

25. Improved C. difficile surveillance Individual web entry; started April 1, 2007 All patients over 2 years Core data –Identifier; age; sex –Date of sample –Location of patient –Reporting laboratory –[from Jan. 08 – in/outpatient; admission date]

26. C. difficile voluntary page Risk factors –Health services contact –Antibiotic history –Specialty –Augmented care –Emergency or elective Suggest 2 – 4 weeks, 4 times a year? Local assessment; national pooling

27. Providing the tools Cleanyourhands campaign PEAT inspections for cleanliness Saving Lives & Essential Steps Root Cause Analysis tool – bacteraemia-specific version – Sept 2006 MRSA screening advice - October 2006 C. difficile guidance - December 2006 ……..and now……. ……..and now…….

28. …..legislation Health Act 2006 –Statutory Code of Practice –Compliance assessed by the Healthcare Commission Annual healthcheck 120 unannounced spot checks Improvement notices

29. ‘Saving lives’ toolkit Two components –Self assessment tool – now revised to reflect CoP core duties now revised to reflect CoP core duties –7 High Impact Interventions (Care Bundle approach) - plus guidance notes - plus guidance notes

30. High Impact Interventions (revised June 2007) High Impact Interventions (revised June 2007) 1. Central venous catheters 2. Peripheral line care 3. Dialysis catheters 4. Surgical site management 5. Urinary catheters 6. Ventilator management 7. Clostridium difficile

31. SL Guidance October 2006 –MRSA screening June 2007 –Blood Culture protocol –Antimicrobial prescribing framework September 2007 –Isolation and cohorting

32. Environmental hygiene Hospitals should be clean! Role of matrons & ward sisters Routine cleaning –Hand-contact areas Enhanced cleaning in infected areas –Use of disinfectants Deep cleaning after discharge of infected patient Cleaning of the bed and bed space Medical equipment

33. Training BMJ eLearning –C. difficile video CPD module DoctorsNet –CPD module Dialogue with –Undergraduate Deans –Tomorrow’s Doctors review group (GMC) –Royal Colleges –Postgraduate Deans

34. Target performance management DH Task Force –Reviews MRSA bacteraemia and C. difficle figures –Monitors programme activities –Identifies Trusts for SL reviews and visits SHA performance managers –Monthly review of Trust performance PCT commissioners – C. difficile

35. Improvement programme National Performance Improvement Network (PIN) –Meets 3 times a year Saving Lives self assessment reviews Improvement visits –DH team; 2-day interviews –Develop local action/recovery plan –Support implementation

36. Summer 2007 Saving Lives issue 2 (June) –C. difficile care bundle updated –Antimicrobial prescribing – best practice Improvement Team (formerly MRSA) –Double funding (and size!) –Extend remit to C. difficile DIPC – review SACAR report – J Antimicrob Chemother suppl Aug 2007 –Antimicrobial framework

37. Antibiotic policy - prevention Restrict use of broad spectrum agents Promote aminoglycosides (gentamicin etc) Reasons for prescribing recorded Stop dates – review by pharmacists Prophylaxis – single dose Audit, training and review Role of Antimicrobial Prescribing Team/Committee

38. Announcements Sept-Oct 2007 National CD target - 30% reduction by 2011 CMO PL on Death Certification Deep cleaning (PM) Matrons & Clinical Directors report to Boards quarterly Dress code – bare below the elbow MRSA screening – universal (asap) Isolation and cohorting guidance Regulator powers: fines and ward closures

39. Dress code (mainly for doctors) Bare Below the Elbow (BBE) –Short sleeves –No wrist watch –No wrist or hand jewellery (except plain wedding band) –Sleeves/cuffs and jewellery are impediments to hand hygiene and aseptic procedures No ties (except bow ties) – they are readily contaminated and not washed! No white coats! Scrubs where appropriate, eg, theatre, ICU/HDU, A&E

40. October 2007 HCC Report Maidstone & Tonbridge Wells –Major outbreak Oct 2005 – Sept 2006 –Not reported to HPU until April 2006 –Misleading public announcements in June –SHA initiated review in early July and immediately referred to HCC Findings –Very serious failures of management and clinical care

41. National recommendations C. difficile regarded as a diagnosis in own right Commissioners to ensure acute trusts have guidelines in place Education and training of junior doctors –Improve recording on Death Certificates Reinforce antibiotic stewardship messages NHS/HPA to agree clear and consistent arrangements for monitoring rates of CDI Boards to understand role and responsibility of DIPC and receive regular information

42. A wake-up call…….. We must no longer accept these infections as ‘normal’ Patients –Can be very ill –Can die –Stay in hospital longer –May need major surgery Significant NHS resources can be better used

43. Goal (Government/DH) - use Political imperative Measurement Target setting Professional support Performance management AND Legislation To change human behaviour (clinical & managerial) to Overcome the challenge of HCAI