ON HEALTHCARE ASSOCIATED INFECTIONS
ACHIEVING THE HEALTH ACT 2006
3RD OCTOBER 2007
Annette Jeanes, Director of Infection Prevention and Control, University College Hospital London, welcomed everyone to the first Masterclass on Healthcare Associated Infections.
This was an opportunity for everyone who had examples of excellence and good practice to share experiences and talk about what worked. The following are just a brief overview of some of the presentations given at the two day event, and the good practice should be applauded in terms of the Trusts that are starting to see real improvements and reductions in the number of MRSA cases. Of concern is the continuing rise is the number of patients who contract Clostridium diffiile.
Reducing Healthcare Associated Infection: The MRSA Improvement Team
Martin Kiernan, Nurse Consultant, Prevention and Control of Infection,
Martin Kiernan gave a presentation on the MRSA Inspection Programme and spoke of the work of the team that had involved visiting 61 trusts. Another £2 million was being made available to double the team, however this may prove difficult to sustain as the Improvement Team were made up of professionals who also had a "day job" within their own Trusts. There was now to be a focus on Clostridium difficile. From the work so far the ward visits had proved the most useful with real engagement at the front-line and at the top, however there were some bottlenecks in the middle. Overall the evidence suggests the Improvement Programme works. There was a good use of performance management data and a focus on data to drive improvement. Antibiotic prescribing, screening and decolonisation and a zero tolerance attitude was making a difference.
In terms of clinical practice the message was "do the right thing right every time"; high impact interventions were being implemented. Staff should be encouraged to ask questions if they weren't sure, sometimes it can be embarrassing to ask if they think they should know, but it was important to do absolutely everything.
What else was needed? Guidance on isolation and cohort nursing has been issued, there was to be a focus on wound management.
The Performance Improvement Network was convening quarterly in
Other good websites cited by Martin:
www.clean-safe-care.nhs.gov.uk www.neli.org.uk www.nric.org.uk
Healthcare Associated Infection the legal cost of getting it wrong
Simon Lindsay Partner, Bevan Brittan, 3rd October 2007
Simon Lindsay opened his presentation with some of the headlines that have appeared in the press raising the profile of MRSA, Myth, Reality, and Staphylococcus Aureus:
He outlined the reality of regulation:
The Effect of Litigation:
Taking statements, looking at infection control policies, staff suing employers as they haven't dealt with litigation properly all took a toll. With Payment by Results a hospital's tariff may reduce if fewer patients go through system.
Litigation: The Duty of Care
A duty to protect patients from acquiring infection measured by the standard of a responsible body of practitioners eg the Working Party Guidelines 1998/2006. If the standard of infection control achieved is inadequate and it caused or contributed to the acquisition of infection, the patient may be able to claim compensation.
There were three types of experts emerging:
Simon believed the Kitty Cope case was blown out of proportion, there was settlement, no open admission of liability, therefore the COSHH argument was still up for grabs.
MRSA Action UK would dispute the view on admission of liability, the settlement out of court was substantial as Mrs Cope needed considerable changes to adapt to the disability caused by the hospital's failure to implement their infection control policy. Providing a settlement is an admission of liability in that sense, although not in the legal sense of the word, and what hospital wants this kind of publicity?
Causation remains the strongest obstacle claimants have to cross, including:
Courts may deem it unacceptable for a patient to go into hospital and get an infection. C Section, may result in infection, that could be construed as injury.
Failure to inform 50%
Failure to operate proper prevention systems 20%
Failure to diagnose 10%
Failure to treat 5%
Failure to give correct antibiotics 3%
MRSA Action UK are aware that there is far more to this than meets the eye, the costs involved in taking each case through litigation can be in excess of £25,000, that is a conservative estimate. 177 claims were paid out between 1996 - 2003 where MRSA was involved in the litigation, there isn't any information other than this as it takes three years for the claims to go through litigation, more than £14m was paid out (completed claims only) where MRSA was involved. If these are just the successful claims then think of the costs involved in taking people through the system who have not been successful, the £25,000 stated was from a claimant who was not successful.
Common risks cited:
Isolation - space
Difficult to prove scientifically - hand hygiene - insufficient
Patient has to show identified breach at identified time
Health Act 2006 is not for use against individual patient
Failure does not have any criminal liability
Code of Practice for The Prevention and Control of Health Care Associated Infections
A court will look more favourably on a Trust that complies.
This case caused some excitement amongst the legal profession recently, where a judge ruled the COSHH regulations do not apply to patients treated in hospital, the problem was he didn't say why, so this is still up for grabs:
"It is clear from the whole structure of the regulations that patients in hospital are not to be included amongst the persons to be protected" Sir Douglas Brown - he didn't say why
Do patients fall within ambit of regulations?
Is the micro-organism a naturally occurring substance?
Is acquisition of the organism at the workplace sufficient?
Simon Lindsay believes the Health and Safety Executive position "does not include patient"
Derek Butler stated that it does as COSHH is augmented by the Health and Safety at Work Act, where patients and visitors are included. The Act came about through the innocent victims of the Aberfan disaster who were not employees of the Coal Board, and because of the Coal Board knowing the risks and their failure to act on them.
Cause or material contribution? Or material increase in risk
It cannot be said that the duty to take reasonable care in treating patients would be virtually drained of content unless the creation of a material risk of injury were accepted as sufficient to satisfy the causal requirements for liability. And the political and economic arguments involved in the massive increase in the liability of the NHS are far more complicated (Hoffman LJ)
H v an NHS Trust
Claimant broke her ankle on 26th December she underwent surgery on 27th and was discharged on 29th December 2002. She returned on 4th January 2003 with an infection and was found to have an MRSA positive surgical site infection. She underwent several procedures but after 18 months had an amputation.
2004 allegations were made. The Trust was able to demonstrate proactive infection control regime, good hygiene practices, audit trial, education and implementation of infection control policy. There was clear involvement of the infection control team and consultant at board level, and clear evidence of response and planning facilities. The claimant was unable to prove a specific link, the claim was withdrawn at mediation before trial. The Trust was able to show other contaminants - air, environment, or the patient may have brought it in.
Reducing Healthcare Associated Infections: Best Practice Considerations
Patients go into hospital to get better and contraction impairs healing, patient and public confidence, and frightens patients. Best practice is about going further to protect patients, so what else can the NHS do?
The National Study Report published in July 2007 analysed Healthcare Associated Infection outcomes at Trust level - covering Acute Trusts, mainly focusing on MRSA and Clostridium difficile.
The Study was drawn from detailed questionnaires completed by 90% of Acute Trusts; patient surveys, PEAT results, audit of single room provision (or surrogate) and other data. Statistical analysis exploring potential associations (regression, univariate and multivariate analysis) did not show any direct correlation to any specific process. Advice on analysis was sought from an expert reference group and advisors. To set the context the decree of route cause analysis on blood stream infections was filtering out in May.
What helps drive improvement? Why do some organisations struggle?
The study showed there was no
Main themes assessed:
Are we involving the patients?
Developing an organisational culture
Chief Executive walkabouts link to commitment to safety outcomes - leadership connecting with what happens on the ground, looking directly at systems.
Corporate and Clinical Governance
How are DIPCs reporting to Boards, did they have sufficient time? Just an additional duty thrown onto nurse or microbiologist. Chief Executives, have you assessed skills and qualifications of DIPCs.
Systems for reviewing performance
How do people know what their performance is,
There was a correlation between cleanliness and reducing Clostridium difficile
Integrated risk management
Dialogue with patients and the public
Current round of hygiene code inspections:
Paperwork is good, when you drill down, how genuine is board commitment, do people have performance targets in JDs - ie DIPC taking report to Board
Still finding that people are reporting data but not analysing and interrogating it
As outlined, complying with the Code of Practice needs relentless hard work - doing the right thing, for the patient, every time - reliably. Everything needs to be done in a highly reliably systematic way.
Network Dinner at the Houses of Parliament, Stranger's Dining Room
The network dinner provided a valuable opportunity to share concerns and listen to the views of microbiologists and experts in infection prevention and control. Opportunities to work together were forged and MRSA Action UK look forward to working collaboratively.
Derek and Maria at the entrance to The House of Commons, joined by Moya, pictures taken by Peter Mainprice of Index Communications
Moya Stevenson and Simon Lindsay, Bevan Brittan Solicitors, Sponsors of the Dinner at The House of Commons
MASTERCLASSES - Programme
Patient Empowerment and Involvement
Maria Cann, Secretary MRSA Action
Maria Cann gave a presentation on how patient empowerment can help Trusts meet the statutory duty to provide information on healthcare associated infections to patients and the public, and how involving the patient can help in the design of systems to prevent and control infections.
"Effective prevention and control of healthcare associated infections has to be embedded into everyday practice and applied consistently by everyone. It is particularly important to have a high awareness of the possibility of healthcare associated infections in both patient and health care workers..........." [Department of Health 2006]
As a Charity representing patients who have been adversely affected by healthcare infections, we present the case that patient participation in the shaping of the care they receive can significantly reduce the risks of contracting infections and help to contain the spread of infection.
For the purpose of this study the terminology patient also refers to carers.
The patient or carer's journey through the healthcare system and the problems and positive practices encountered can be used to identify risk and to improve the design of patient care. This session provided an opportunity for clinicians to see what effect not involving the patient and carer can have when the information about healthcare infections is not shared, and identified the benefits of involving the patient if an infection is diagnosed.
A Healthcare Infection, A Life Time Legacy
Derek Butler, Chair MRSA Action
Derek outlined the responsibility that Healthcare workers have to not only those they are treating in their care, but also the duty of care that they have to the family of those they are caring for.
Derek showed how his family discovered five months after the death of his stepfather, despite the fact that a meeting had taken place with the hospital, where they assured us that we had been informed of any changes in his condition and treatments, the family discovered that he was at the time of his death Profusely Infected with MRSA. Derek described how his family has been changed beyond all recognition and how the legacy of that Healthcare Infection will last a life time.
Other bereaved families and survivors, and effects on healthcare workers were included in the powerful presentation. Derek ends the presentation by saying "As a Charity we believe that to do nothing would be to discharge our responsibility to society, and to accept what some think is inevitable in our hospitals would be a betrayal"
Saving Lives: High Impact Interventions
Annette Bartley, Modernisation Manager, Conwy and Denbighshire NHS Trust
Health systems are not machines. They cannot be adjusted via manual controls or manipulated by a centralised bureaucracy. "A healthcare system is like a forest ecosystem that must evolve," says IHI faculty member Paul Pisek. "A better health care system cannot be centrally designed - it must evolve from within" Scientists call it a Complex Adaptive System. Healthcare is by definition a "complex" system because of the great number of interconnections between the part of the system - office practices, hospitals, laboratories, emergency departments, specialists, health plans, regulators. It is also considered an "adaptive" system because it is composed of people who have the ability to change their behaviour based upon experience. Annette gave a presentation on the implementation of Care Bundles at Conwy and Denbighshire Trust. Care is standardised and able to be tailored to individual patient requirements. There have been significant outcomes within ICU:
Ventilator days are less; ICU days are reduced; the drug bill is less; incidences of ventilator associated pneumonia are greatly reduced; tracheotomies are seldom done and central lines are removed earlier thus reducing the incidence of infection.
Work with the Infection Prevention and Control team has seen an 88% compliance with handwashing, which has been maintained year on year.
Annette demonstrated how staff were empowered and involved in developing the Care Bundles by taking a systemic approach to the design and implementation, testing and adapting in one unit, then to three, then five, progressing until the successful systems were fully implemented - using a Systems Thinking approach.
Reducing Antimicrobial Prescribing for MRSA / C.Diff
Gopal Rao, Consultant Microbiologist, University Hospital Lewisham NHS Trust
The association between antibiotic use and development of antibiotic resistant organisms and Clostricium difficile associated diarrhoea in hospitals is indisputable. Yet antibiotics remain as the most valuable weapons we have against bacterial infections and many of these infections are unavoidable. How then are we to continue treating patients with antibiotics but still avoid development of antibiotic resistant organisms and Clostricium difficile associated diarrhoea. Gopal demonstrates that it is possible to use antibiotics rationally without compromising patient care and at the same time achieve reduction in antibiotic resistant organisms and Clostricium difficile associated diarrhoea. Furthermore considerable savings can be made in expenditure on antibiotics and avoidance of costs incurred for treatment of antibiotic resistant organisms and Clostricium difficile associated diarrhoea.
Risk Assessment and Screening: Clostridium Difficile
Mike Wren, Professor of Clinical Microbiology UCH NHS Foundation Trust
Mike Wren gave a presentation to give an update on microbiology and emerging information about Clostridium difficile and risk. Mike had an interesting pronunciation of the bacterium in that the latter part of its name with his preferred pronunciation being de-fitch-illy. Clostridium difficile was an old organism originally isolated from neonates, therefore not thought to be a risk to under two-year-olds as this was normal flora for neonates, but it can cause problems in children under two. It is now found in animals, although a human pathogen it is being transmitted, and found in animals in sea and on land. It's found in clinical samples of Pseudomonas Colitis.
It can be life threatening, resulting in the need for surgery and is the primary cause of colitis in patients receiving antibiotics, spread primarily by hands of staff with high levels of colonisation, particularly in outbreaks. Metronidazole and Vancomycin is used to treat the infection and relapse is common. More work needs to be done to establish whether these occurrences are indeed relapse or reinfection, its not always clear, and practically impossible to rid the environment of the spores, therefore rapid recontamination occurs. ELISA test is not a stand alone test, other tests need to feature in making diagnosis.
Added problem that patients with severe colitis and Pseudomonas Colitis do not necessarily present with diarrhoea. The ELISA test is a poorly controlled test, with as many methods as there are laboratories.
In 1996 there were just 12 cases of Clostridium difficile, there were a staggering 60,000 cases and rising in 2006.
2-3% of population are Clostridium difficile positive, not all toxigenic. Antibiotic associated diarrhoea does produce the toxins
Patients with at least 2 hospital episodes have a recurrence rate of 50-65% (problem with relapse and reinfection, not known)
In a recent study of 69 asymptomatic patients
Spores in found in the Environment:
Further research to establish if the spores are found in the air with the discovery on the curtain rails.
There was concern expressed by Derek Butler, Chair of MRSA Action UK that Clostridium difficile spores were resistant to alcohol gel, the argument needs settling, more detailed studies were needed. Ethanol and industrial metholated spirits were used to isolate the spores for testing. Some testing carried out in-house had showed that contaminants on the hands were not killed by alcohol gel and that the gel actually "sealed" the contaminant to the skin. The jury was still out on this and until proven otherwise it should be taken that the gel is not effective and handwashing using the correct technique was the intervention necessary to prevent the spread of the spores from healthworker to patient.
Conclusion, there is a case for screening for Clostridium difficile and more investment in Ribotyping was needed. With the environment being so contaminated there was a need to think about the future for environmental cleaning. There were mixed opinions about the use of probiotics and the benefits of balancing the natural flora in the gut.
There did need to be procedures in place for patients presenting signs of Clostridium difficile, the use of algorithms developed locally were an effective way of putting the systems in place to design effective interventions. It was not clear why the epidemiology of Clostridium difficile was changing, 027 was the most common cause of disease presently, but 023 was rising. Some key challenges:
These presentations provided excellent evidence to argue the business case for implementing rapid screening and surveillance employing a "Search and Destroy" methodology, as created here in the UK and adopted by our Northern European peers.
The Case for Nasal Screening for Staphylococcus Aureus in Pre-surgical Patients
Peter Wilson, Consultant Medical Microbiologist, University College Hospitals NHS Foundation Trust
[Findings published in the British Journal of Surgery]
Surgical Site Surveillance - The Business Case
Peter Jenks, Director of Infection Control and Prevention, Plymouth Hospitals NHS Trust
The Business Case of MRSA PCR Testing in Critical Care
Richard Cunningham, Consultant Microbiologist, Plymouth Hospitals NHS Trust
*PCR is an acronym for the rapid polymerase chain reaction test (the 2 hour test)
The Case for Improved Environment
Liz Jones, Head of Patient Environment, Department of Health
Promoting an Infection Control Culture: Change Management
Annette Jeanes, Consultant Nurse Infection Control, Director of Infection Prevention and Control University College Hospitals NHS Foundation Trust
The event was sponsored by BD Diagnostics,
developers of the polymerase chain reaction (PCR) test.MRSA Action UK homepage