Healthcare associated infections:
    Department of Health & Stakeholders national event
    30th July 2008 - Inmarsat, London

Janice Stevens, National Director of the Healthcare Associated Infection Programme welcomed everyone to the event.


The key question that was posed to the Stakeholders was "What can we do to increase patient and public confidence that activities aimed at reducing healthcare associated infections were working?"


Presentations were given by the Department of Health and Stakeholders outlining their work, concerns and the key messages on what was underway to address the issue of healthcare associated infections.


Janice opened her presentation looking at what had been done so far, with a view to moving forward and making further improvements.


MRSA bacteraemias were coming down at a great rate and this was impacting on other infections.  There had been some progress and improvement in C.diff results reflecting the hard slog that had been undertaken by hospital trusts.


The programme was now looking at advice for those affected by MRSA outside of hospital and the stakeholders had had an input into this process, developments included:

From Board to Ward

Ambulance guidance

Further faster II

Advice "outside hospital"

More Matrons

Deep Clean

New target for C.diff

Uniform advice, bare below elbows

Improvement Team support with 130 trusts, implementing the programme

 It was now possible to see and feel the difference, and there was acknowledgement that there was still a long way to go.  Some trusts were doing very well, some not so well, there was a focus to reduce infection nationally and address the variation, and a need to take a wider health economy view.  It was a long journey toward zero tolerance.  The 30% target reduction for C.diff was just a start.  There was a need to continue to improve cleanliness and address the implementation of MRSA screening and associated support.  The need to bring in new technologies to prevent and reduce infection was highlighted.  All of this was integral to high quality, safe, clean care.

Janice introduced Brian Duerden, Inspector of Microbiology and Infection Control who gave an overview of the current position on Healthcare Associated Infections


Brian outlined that it was not just MRSA and C.diff, there was consensus that we need to drive down all infections.  We need to be very clear about targets, we need to know what the irreducible figures are.  There was a small but welcome reduction in C.diff, but still too many.


The baseline for the reduction in the 30% figure was 2007/08.  However the fewer the better, we needed to go below that.


Responsibility for Healthcare Associated Infections was that of the Department of Health and NHS Clinicians. Safe patient care, diagnosis and treatment was the responsibility of the healthcare provider - The Board, Chief Executive and Director of Infection Prevention and Control were responsible for the corporate environment and making sure it happened.


The Government and Department of Health were responsible for setting standards, ensuring priorities and monitoring outcomes.  They were responsible for legislation and performance management.


The mindset needed changing from creating a system to deliver specialist clinical care and establish measure to prevent infection, to creating a safe environment for patients and making the first priority safe care.


How do we change bad habits?  There were still some there.  Good management is essential with an emphasis on infection prevention and control, enhanced surveillance of MRSA and C.difficile, protocols in clinical practice, hand hygiene and environmental cleaning, training and performance management [accountability].


      • July 2006 - Maidstone and Tunbridge Wells and brought about national recommendations.  C.diff regarded as a diagnosis in it's 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 and Health Protection Agency to agree clear and consistent arrangements for monitoring rates of Clostridium difficile infection
      • Boards to understand role and responsibility of Director of Infection Prevention and Control and receive regular information

 2008/11 contracting framework package reflected the clean, safe care programme:


MRSA continuation

      • If trust target achieved
      • At least maintain reduce further if possible
      • If not achieved, continue performance management
      • C.diff target based on SHA and PCT populations, not national - 200708 C.diff baseline for a 30% reduction.  Places with high rates need to come down more - they have the greatest opportunity for reduction [not a postcode lottery]

 MRSA target beyond 2008 - headline message was to continue to improve.  The mandatory surveillance system will continue

      • Web-based system
      • Chief Executive sign off
      • Quarterly publication
        Trajectory set for individual Trusts

 MRSA programme

      • Reduce incidence of MRSA infection [across healthcare community]
      • Principally healthcare associated infection
      • Bacteraemias
      • Sustain reductions at target level
      • Reduce further
      • Wound infections
      • Skin and soft tissue
      • ICU (ventilator) pneumonia

 Required outcomes

      • Reduce
      • Morbidity
      • Mortality
      • Length of stay
      • Long term disability
      • Reduce spend on healthcare infections and invest in positive healthcare

 Why are we screening?

Colonisation precedes infection - mostly

      • Risk of developing an infection
      • Possible source of transmission
      • Need to isolate-cohort
        Screening and decolonisation reduces the risk for the individual and reduces the bio-burden
      • 5 days body wash, nasal cream
      • 1 week 80-90% success
      • 3 months 60-70%
      • Carriage comes back

2009 all patients for elective surgery will be screened, 2011 all admissions to acute trusts, including emergencies, there was a need to consider mental health, dental and community hospitals, and what methods - which are the best, rapid, conventional


Contiuing investment aimed at clean, safe care delivery programme:

- 270 million pounds of investment by 2010-11

- Infection prevention and control nurses - 2 per trust

- Isolation nurses

- From Board to Ward

- Enhance Director of Infection Prevention and Control role

- C.diff guidance and care pathway

- Cleaning decontamination guidance - national standards for guidance

Dr Liz Jones gave a presentation on Cleanliness and Healthcare Associated Infections

Liz opened her presentation saying that good environments matter, it's everyone's business. A dirty front entrance may make a patient or visitor assume the operating theatres are dirty, a rude car park attendant, are nurses uncaring?


People see the building first.  What does your hospital say? "you are in safe hands"


Buildings make you do things, better design, clean, staff and patients behave differently - wash basins etc. In the NPSA survey 99% of patients state the believe a clean hospital is essential.


Cleanliness and tidiness - making an impression

Contracting should be based on quality as well as costs


The nurse in charge responsible for cleanliness throughout the shift - key message to staff now


The deep clean was a base for sustained improvement

Dismantle and clean beds

Replacement of carpets

Purchase of hydrogen peroxide foggers


Deep cleaning offers an opportunity to tackle potential reservoirs for infection that might be missed during routine cleaning - its not a one-off-never-to-be-repeated blitz with no attention to sustainability.  Needed to get that message across in the media.


Cleaning was simple in concept, but difficult to do - it was hard work

It needed to be done more often, and we needed to clean them better...........

We had asked for progress on what was being done to improve aseptic technique, a key factor in reducing risks of contracting infections, and one that we are constantly seeing poor practice, in the primary and acute settings. Michael Dickson, from the South of England Improvement Team gave a presentation on the work in Observations of care and aseptic technique


Improving practice for patients

Michael outlined the work of Chief Nurses in the Improvement Team who are leading on observations working across Strategic Health Authorities with the Department of Health.  The Observations are carried out in Acute Trusts, with Educational Providers, PCTs and the independent and voluntary sectors.


Aseptic technique an overview

      • Has to be done every single time
      • Hands, objects, sterile items
      • Protect "myself"

Aseptic means "without micro-organisms"


Aseptic technique refers to practices that help reduce the risk of post procedure infections in patients / clients by decreasing the likelihood that micro organisms will enter to body during clinical procedures.  Some of these practices are also designed to reduce staffs risk of exposure to potentially infectious blood and tissue during clinical procedures.


Aseptic techniques are those that do some or all of the following:

Remove or kill micro-organisms from hands and objects

Employ sterile instruments and other items

Reduce patients' risk of exposure to micro-organisms that cannot be removed


Why had things slipped on aseptic technique?

1970-1990s asepsis training less of a priority

Training has changed

Is training good enough?

Dressing packs

Dressings stay on for weeks on end, scope for patients to fiddle with dressings

Gloves, time, pressure


Observations of Care Team

Nine nurses - looking at high impact interventions and hand-hygiene

Education and training - increasing capacity

Benchmarking practices

Internal challenge - giving assurance that policies and procedures are followed


Empowering colleagues not to be scared of going up to doctor or nurse, asking do you know you've just breached our policy - why was it done that way?  Need to act immediately if not followed or opportunity is lost.


Audits do not need to take hours - can be built in

Rapid feedback at point of observation - immediate so people's practice start to change

Rotate teams out of comfort zone - fresh eye

Night shift, 4.00pm on a Friday  audits

Observation care work with Matrons

PCTS and SHAS, sharing information

Delivering training and not "assuming" competence, must use observation to be sure

Questions & Answer Session

Questions and answers attracted a good debate around accountability and responsibility, leadership and the need to drive improvement nationally.  Whilst some trusts had done excellent work there were others that had alarmingly high rates of infection.  Better recording of infections on patient records and death certificates would enhance surveillance, whilst there was a recognition that it may prove counter-productive to make every infection part of the recording system, there was a need to recognise the true scale of the problem.


Trusts not showing sufficient reductions in infections were being targeted by the improvement teams.


Making use of all the technology, better information for patients - removing the confusion over differing advice on C.diff - a worrying finding from Maidstone & Tunbridge Wells was that staff did not know that alcohol gel was not effective at removing C.diff spores - the message was confusing to both patients and staff.  Relatives were having to take soiled laundry home with no guidance on how to safely handle and wash the laundry.


Information was available on the Department of Health website, however it appeared that not everyone was aware of this, this had been prepared with the Stakeholders.


It was felt that there needed to be better publicity around the Deep Clean programme and the continuing work to drive hospital cleanliness standards upward.  The message needed to be conveyed in the media to improve public confidence.  There were concerns that many trusts had not followed the Health Protection Agency guidance, accountability was important, safety should come first the environment needed to by hygienically clean, not just visibly clean, assurance was needed that these poor practices would not be allowed to continue.


Presentations from MRSA Action UK, NCHI, Ashley Brooks & Max and the Governors of Sheffield Teaching Hospitals NHS Foundation Trusts followed, outlining the work of the organisations in the drive to bring improvement.


MRSA Action UK's presentation:

Sheffield Teaching Hospitals NHS Foundation Trust, An NHS Trust Perspective

Richard Chapman and Graham Thompson, Governors of The Trust

Richard and Graham gave an interesting overview of the hospital trust with 5 hospitals on 2 sites, 108 wards and 2,000 + beds.  They were to top performing trust in the country.


The MRSA cleaner hospitals hit squad visited in 2007 and a range of measures had been brought in to drive improvement even further:

- Full implementation of a Board Accreditation Scheme, with all 108 wards accreditied and  competition publishing results

- Cleaners were all in-house and part of the ward team

- Antibiotic prescribing, employ two full-time pharmacists to look at all hospital prescriptions, cephalosporins and quinolones use are severely restricted

- Junior doctors receive infection prevention and control sessions at induction including hand hygiene, how to take blood cultures and put in IV cannulae

There was also attention to the primary care setting with Primary Care and Community Trust microbiologists agreed and funded, job descriptions written. 

A Summit is being held in September, with the Trust, SHA, PCT, Community Trust and Health Protection Agency.  Screening, implementation for all elective surgery August.  The Trust was fully committed to a zero-tolerance approach to healthcare associated infections and continuous improvement.

Health Protection Agency Data
Andrew Pearson

Programme Manager

Responsible for all bacteraemias


US, biggest risk community bacteraemias coming into hospital

Need to be in hospital for 48 hours for it to be hospital acquired [could be acquired as A&E, Ambulance Trust patient]

MRSA and C.diff only a small proportion of healthcare associated infections

Neonatal units were showing increasing problems with coagulase staphylococci ? although not part of mandatory reporting


Need to crack all of these

The Health Protection Agency were leading the world in mandatory reporting and public reporting

London case mix different, more complex care - worst place to be?

Have had highest level of improvement

Biggest drops, large acute hospitals

Why are men worse than women at washing their hands?


Device usage high, lines


Renal Units

C.diff, seasonality, a third occur in the winter months, chronic use of antibiotics?

Mild winter, fewer people with pneumonia has contributed to reduction in use of antibiotics

Canada and US CDC shows epidemiology is changing

Community outbreaks, under 64's - 2 regions in the UK

New targets will address that

Future target setting will be clearer

Paul Cryer

Technological opportunities

HCAI Technology Innovation Programme

Purchasing and supply agency


Paul Cryer outlined the new programme aimed at getting innovations through the system and the Rapid Review Panel.  There were a range of technologies that had been assessed by the panel and were being trialled at showcase hospital trusts to include:

- Imperial College

- Calderdale and Huddersfield

- Southampton University Trust

- Co Durham and Darlington NHS FT

- Lewisham

- Central Manchester and Manchester Children's University Hospitals NHS Trust


There was Rapid Testing but it can takes 21 hours to get to lab, point of care MRSA testing in 30 minutes was being assessed - Cdiff point of care testing was not yet available

Surface coatings were always being assessed, 8 molicules high silicone coating

Side rooms, portable around the patient insitu, focussed on mrsa / cdiff, which need to be managed differently


Portable hand-wash station, new portable commode

Redesign in easy to clean materials

20,000 keyboards and mice, no keys, can drop in a bucket of water

They beep until you clean with alcohol

Phones that say "if you don't clean me soon I'm gonna shut down"


Paul gave an interesting and humerous insight into some of the innovations that were being tested, and we believe this programme is long overdue and welcome it's development, particularly in relation to the innovative ideas and solutions for screening and isolation and making it easier to keep the bacteria out of the environment.

Screening - The next policy challenge, how can we best support patients?
The work of the stakeholders concluded with looking at Screening for MRSA, there was a need to prepare for the full implementation programme and it was an opportunity to work together to look at what patients may require, communication was key.  Information would need to reassure patients and their families what was involved and its benefits, what happened if it was positive, what would it mean for them and their family.  Further work with the Stakeholders would take place to finalise the approach.


Janice thanked everyone for their continuing work and the push for improvements. 


MRSA Action UK's viewpoint
We felt that great strides were being made and many of the things we had called for were coming together in many hospital trusts.  The aim to seek out, isolate and destroy was now something that the Department of Health was committed to, new technologies were being fast-tracked to enable this to happen, there was commitment.

The Health Protection Agency data reporting is excellent and much improved with the ability to track outbreaks both in the community and in hospital.  We still feel however that the tracking of surgical site infections is important and should be a mandatory part of the reporting system.  The facilities are there and many trusts are using them on a voluntary basis.  Hospitals that are tracking the wound infection rates are showing diligence, there is a need to know those infections are coming down, and route cause analysis should be used for the purpose of managing wound infections, in the same way that it is used to reduce bacteraemias.


Board to ward was perhaps not working in all Trusts, there needed to be belief that it was possible to take a zero tolerance approach to healthcare infections - was there still lack of accountability?   What messages are the regulators sending out?


It can be done, for patients to feel confident accountability is key, they need to know that when Trust's are not putting safety first and foremost action will be taken.


The day of the Stakeholder Event this statement was made by Sandra Caldwell at the Health & Safety Executive:


"Firstly, I want to express my sympathy to anyone who lost their loved ones in these hospitals at the time of the outbreaks of C difficile infection within Maidstone and Tunbridge Wells Trust.

I also want to thank Kent Police for their co-operation and support throughout our joint review of the Healthcare Commission report. We have worked together throughout the review and are united on the conclusions.

The Healthcare Commission report alleged a series of failings by the Trust and individuals. We have reviewed the report through a series of interviews with the Healthcare Commission's lead investigator and all the experts who considered the information gathered by the Healthcare Commission in compiling their report.

We share the police's conclusion that, from the information available, we cannot establish with certainty a causal link between failings to manage infection and the death of any particular person.

From the interviews with the experts who advised the Healthcare Commission we also concluded that there was insufficient information to link the actions of any individual with the spread of infection or to show that any senior managers within the Trust was personally responsible for any direct failure that lead to infection.

The Trust has acknowledged that mistakes were made. There have been a series of changes in the management of the Trust and in the senior management team. The Healthcare Commission has reported improvements in the performance of the Trust in managing C. difficile infections.

We believe the priority now is to provide reassurance to the people of Kent that the infection risk at their hospitals is being properly managed. HSE therefore intend to audit the Trust during September. HSE's audit will focus on the Trust's overall management of health and safety as well as the current regimes for infection control. If we find any significant failures in the arrangements we will not hesitate to take enforcement action to address these. We are aware that the Healthcare Commission is about to undertake similar work at the Trust and we want to work with the Healthcare Commission to ensure our efforts are coordinated.

Thank you"

If you or someone you care about has been affected by a healthcare infection and you wish to discuss this with us, please contact us at