Reducing Healthcare Associated Infections - Community

Reducing Healthcare Associated Infections - Community

Final ED 10.04.08

The ‘How to Guide’ for

Reducing Healthcare Association Infections

(Community Guidance)

Main contacts for Reducing Healthcare Associated Infections

Campaign Director leading on the content area: Alan Willson

Faculty member for this content area: Eleri Davies

Point person for the content area: TBC

IA/Senior IA: Mike Davidge

Other (as determined by Director):

Reducing Healthcare Associated Infections (HCAI)

Getting Started Kit:

Reducing Healthcare Associated Infections

How-to Guide

Community Guidance

Main contacts for Improve Healthcare Associated Infections:

Campaign Director leading on the content area: Alan Willson

Faculty member for this content area: Eleri Davies

Point person for the content area: TBC

IA/Senior IA: Mike Davidge

Other (as determined by Director):

Reducing Healthcare Associated Infections

Goal:

Significantly reducing Healthcare Associated Infections by reliably implementing the seven components of care recommended in this Guide.

The Case for Reducing Healthcare Associated Infections

Health care-associated infections (HCAIs) remain a major cause of morbidity, mortality, and excess health care cost despite concerted infection control efforts over nearly a half-century. Recently, treatment of these infections has become more complex due to an alarming rise in antimicrobial resistance.

In 2006 a UK wide prevalence study1 of healthcare associated infections was conducted. In Wales the collection of data was compulsory and all adult in-patients in Wales were surveyed for HCAI between February and May 2006. Overall the prevalence of HCAI in Wales was 6.4% this compared with a rate of 8.2% in England and 5.4% in Northern Ireland. Scotland also conducted a prevalence study during 2006, but used a slightly different method, their rate was 9.5%2.

In Wales the most common HCAIs were Respiratory tract infections (Pneumonias and Lower respiratory tract infections combined) at 24%, surgical site infections (19%) and urinary tract infections (16%).

The prevalence of MRSA infections in Wales was <1%, i.e. of the 5734 patients surveyed in 2006 – 50 were found to have infections due to MRSA. Of the 364 patients who had HCAIs 14% of them had infections due to MRSA. The prevalence of C. difficile infections was 1%

As highlighted in the Wales Audit Office Report “Minimising Healthcare Associated Infections in NHS Trusts in Wales”3 HCAIs result in significant costs for the NHS in Wales. Based on a study sponsored by the Department of Health in England, an estimated cost of £3,154 per case has been attributed to HCAI, this translates into a total cost for the NHS in Wales of £50 mMillion.

The average cost of a C. difficile infection has been estimated to be £4,0005 and each healthcare related bacteraemia regardless of the causative organism has been estimated to cost £62096. Based on reported cases from 2006 C. difficile cases alone cost the NHS in Wales a total of £10.3million. Cases of MRSA bacteraemia reported in the year to March 2007 cost £1.9million3

The cost to patients in terms of morbidity and mortality is difficult to quantify. Data from death certificates7,8 suggests an average of 63 deaths per annum are due to MRSA in Wales and 78 deaths per annum due to C. difficile. It is likely however that this is an underestimate. An estimate based on American data9 suggests that as many as 321 deaths per annum may be directly attributable to HCAI in Wales with a further 963 deaths where HCAI might be a substantial contributor.

Concern about HCAI has resulted in the Welsh Assembly Government mandating the surveillance of certain diseases and infections related to surgical procedures. Currently the national mandatory HCAI surveillance scheme consists of the following programmes:

(All are supported centrally by the Welsh Healthcare Associated Infection Programme Team (WHAIP)

· Bacteraemia surveillance

o Staphylococcus aureus bacteraemia

o Top Ten bacteraemias

· Surgical Site Infection Surveillance

o Orthopaedic Primary hip and knee arthroplasties

o C-section surgery (Obstetrics)

o Vascular surgery under development 2008.

· ICU surveillance

o Central line infection surveillance

o Ventilator associated pneumonia surveillance under development 2008.

· Clostridium difficile infection surveillance (>65 years)

· Outbreak surveillance

Data from these surveillance schemes for Wales and for individual Trusts in Wales are available via the WHAIP website www.wales.nhs.uk/WHAIP

As shown above, to date much of the focus for reducing healthcare associated infection has been on hospital practice, but with early discharge from hospital post surgery and increasing use of care homes for the delivery of healthcare as well as more intense management of patients in the community there needs to be more awareness of the issue of HCAI in the community. Data from surveillance programmes for surgical site infection show that as many as 70% of the infections related to some types of surgery may present post-discharge10

In Wales the management and prevention of HCAI in the community is taken very seriously, in November 2007 a Community strategy for healthcare associated infections in Wales was launched and over the next two years it is hoped that the 1000 lives Lives campaign Campaign will be a major support for the implementation of the community strategy in Wales.

.

General Considerations for Reducing Healthcare Associated Infections.

Focused, committed leadership is a prerequisite to achieving breakthrough control of the growing burden of healthcare associated infection. Leadership commitment has the following major elements:

· Acknowledgment that the HCAI problem is serious, causes needless morbidity and mortality, and is associated with real costs that go to the bottom line of the healthcare service.

· Intolerance of the status quo, and a sense that major reductions in the rate of HCAI is possible with zero – tolerance for preventable infections.

· Empowerment of front-line multidisciplinary teams to get the job done, including provision of necessary supplies, personnel, and infection control, microbiological, and environmental services resources

· Accountability for reliable performance of basic infection control practices such as hand hygiene, once appropriate systems of care and supplies are in place

· Engagement of clinical staff

· Regular review of data and prompt removal of barriers to success

Further guidance on leadership and team working can be found in the “How to Guide” for the content area “Improving Leadership for Quality”.

It is imperative to involve a multidisciplinary team in any improvement process focused on infection reduction. Successful teams set clear aims for their work, establish baseline measurements of performance, regularly measure and study the results of their work, and test various process and systems changes over a variety of conditions in order to find the ones that lead to improvement in their particular setting. Active stakeholders (in addition to doctors and nurses) include personnel from Local Health Boards, Health Protection Teams, the microbiology laboratory, patients, and others depending on the nature of care being provided. The improvement effort will be enriched by including a patient on the team.

Reducing Healthcare Associated Infection: Seven Components of Care

In Wales the Strategy for Reducing Healthcare Associated Infections in the Community has been developed recently and published in November 2007. The strategy’s main principle is that healthcare associated infection is everyone’s business and that we should all as healthcare workers be trained to take action to reduce HCAI and have the appropriate specialist support in place to make the strategy work.

Within this new campaign to Save save 1000 lives in Wales, the healthcare associated infection content area aims to capture all the excellent work already being done in Wales to reduce HCAI and re-focus it within the campaignCampaign. The campaignCampaign embraces the strategies already in place in Wales to reduce HCAI and brings all the mandatory surveillance programmes and infection reduction targets into the campaignCampaign as information for action.

Initial efforts to reduce HCAI can be greatly facilitated by choosing a GP practice / Care Home where there is a vigorous clinical champion and opinion leader. This strategy allows a multidisciplinary team to focus its efforts in a well-defined geographical area and patient population, perform rapid-cycle tests of change, and act on real-time data. Reliable performance of all aspects of the HCAI reduction package (described below) is almost certainly easier to achieve initially in a relatively contained setting with receptive clinical leaders, and early success will demonstrate to institutional leadership that dramatic success is possible and the investment in needed resources can pay off.

For the Campaign, we recommend that organisations start with seven components of care:

1. Implementation of the recommendations of the HCAI strategy for Wales, Community (2007)

2. Standard precautions:

· Hand Hygiene

· use of PPE

· Sharps use and disposal

· Clinical Waste

· Decontamination of equipment

· Management of body fluid spillages

· Transmission isolation

· Linen management

3. Decontamination of the environment and equipment

4. Isolation precautions*

5. Antimicrobial Stewardship

6. Management of Invasive Devices

§ Management of Central Lines (care bundle)

§ Management of ventilated patients to prevent VAP (Ventilator bundle)*

§ Management of urinary catheters.

§ Management of peripheral lines

7. Prevention of Surgical site infections

*Less relevant for the community practice.

·

· Implementation of the Recommendations of the HCAI strategy in Wales (Community)

·

The strategic objectives of the community strategy take forward the work of the strategy for hospitals launched in 2004 into the community setting. The key aim is to ensure that all NHS and healthcare staff in Wales fully understand the impact of infections and have infection control practices at a high standard to enable them to discharge their personal responsibilities to patients, other staff, visitors and themselves. Linked with this key aim is the need to have information about HCAI and practices through surveillance and audit, adequately resourced specialist infection control staff to act as advisors and to support staff in understanding better what they can do to combat HCAI. Infection Reduction Targets are identified as an important process by which healthcare organisations across hospitals and the community can identify areas of concern with respect to HCAI and put in place a specific action plan for this area with the aim of reducing the HCAI identified.

» What changes can we make that will result in improvement?

The community strategy requires the embedding of infection reduction targets into practice. This is not yet established within the community, but this campaignCampaign provides an ideal opportunity for the principles of the campaignCampaign to be used in support of embedding infection reduction targets. LHBs and community healthcare organisations should consider the community strategy and implement its recommendations as soon as possible. The 1000 Lives campaign1000 Lives Campaign interventions and ethos should assist you with this.

To assist with understanding the impact of HCAI in your own clinical areas within the 1000 Lives campaign1000 Lives Campaign it is suggested that a monthly prevalence survey is conducted. In 2006 a UK wide survey was conducted which provides some baseline information for hospital practice. Such information is not yet available for the community, but this is an ideal opportunity to begin considering the impact of HCAI on community practice. A regular prevalence survey will allow healthcare organisations to identify what their key HCAI issues are. This can be used to identify an infection reduction target and / or areas requiring further ongoing surveillance or audit see the accompanying Reducing Healthcare associated infection “Drivers” document for further information.

Further support and advice with regard to the HCAI surveillance schemes and Infection Reduction Targets can also be obtained from the Welsh Healthcare Associated Infection Programme Team (WHAIP) www.wales.nhs.uk/WHAIP.

» Key Documents:

Healthcare Associated Infections A Community Strategy for Wales, Public Health Protection Division, Welsh Assembly Government November 2007.

http://wales.gov.uk/dphhp/publication/protection/communicable-disease/haistrategy/hia-strategy-e.pdf?lang=en

Healthcare Standards for Wales (WHC 2006 041)

http://www.wales.nhs.uk/sites3/home.cfm?OrgID=465

Outcome / Process Measures

· Monthly prevalence studies of HCAI

o Form for data collection available through the WHAIP team intranet website
http://howis.wales.nhs.uk/sites3/home.cfm?orgid=379&redirect=yes

o In the community consideration should be given to collecting data in a care home setting or community hospital or for one day a month for all patients attending a GP practice.

o Data to be reported monthly to campaignCampaign team as % HCAI

o Data to be analysed to identify main problem in the care home / community hospital or GP practice.

o Secondary outcome measures to be chosen based on the findings of the prevalence studies.

§

§ Standard Precautions

§

Standard precautions should be embedded in the daily practices of healthcare professionals throughout the healthcare service provided in the community.

Implementation of all the standards precautions is required to ensure safer patient care. Use of PPE and safe disposal of sharps also protects the staff member as well as the patient. The campaign Campaign is focussing on hand hygiene as a key measure in breaking the chain of cross infection and compliance with hand hygiene is one of the key process measures that the Ccampaign will be looking at, however this should not be taken to mean that the other standard precautions are less important.

If other areas of the application of standard precautions are an issue for your clinical area / healthcare organisation then other measures to consider are as follows:

· needlestick injury rates reflecting application of safe sharps handling – data available through occupational health / risk managers.

· Environmental audit results looking at cleanliness, storage and decontamination issues

· The clinical waste regulations have changed recently and implementation of the new guidance is challenging. – audits of compliance with new practices may be useful to assess progress.

Hand washing is recognised as one of the key measures in breaking the chain of cross-infection. Transient contamination of HCWs’ hands occurs while caring for colonised or infected patients, HCWs can contaminate their hands even while performing “low-risk” patient care activities such as taking a pulse or blood pressure, lifting a patient up in bed, or handling items in the patient’s vicinity.

Although wearing gloves when having direct contact with patients can reduce the risk of hand contamination, hands often are contaminated during glove removal. Therefore, cleaning hands before and after having contact with patients or their immediate environment is of paramount importance in reducing transmission of HCAI in health care facilities. Unfortunately, compliance with hand hygiene remains poor across the healthcare provision in Wales. It is doubtful whether such low rates of compliance are compatible with efforts to dramatically reduce the rate of HCAI in health care.

When hands are heavily contaminated or visibly soiled, handwashing with soap and water is critical. Also when managing patients with diarrhoea it is imperative that washing with soap and water is undertaken as alcohol gels have poor activity against C. difficile and norovirus. Sinks must be conveniently located near the point of care.