Reducing HCAIs and Improving Patient Safety
22nd November 2012

Derek Butler and Maria Cann attended 'Reducing HCAIs and Improving Patient Safety' at the CBI Conference Centre, London. Dr Natasha Robinson, President, Patient Safety Section, Royal Society of Medicine was the chair of the conference; she is also an anaesthetist and said that one of biggest fears, apart from the effects of anaesthesia, is contracting a healthcare associated infection. Although it's good news that the data on published infections has reduced there is still a great deal to do.

Professor Anthony Kessel, Director of Public Health Strategy and Medical Director at the Health Protection Agency (HPA) drew on his own experiences over the last four years to talk about the role of the HPA in the surveillance, prevention and control of infectious disease and outbreaks.

Infections are important - they cause harm, kill people, cost a lot and create fear and adverse publicity. There has been a huge amount of policy interest over the last 10-12 years with National Audit Office reports, Chief Medical Officer reports, to include: Winning Ways, Saving Lives, the Health Act and the Code of Practice for the prevention and control of healthcare associated infections, and Safety First.

The HPA work closely with the Department of Health, and in terms of healthcare associated infections there have been three important Healthcare Commission reports that have impacted on the thinking on infection prevention and control: Stoke Mandeville, Maidstone and Tunbridge Wells and Mid Staffs.

Since 2003/04 there has been a declining trajectory in MRSA and Cdiff. Trends in reports of deaths are going in the right direction, since the Chief Medical Officer mandate to include contributory factors on death certificates.

The HPA oversees the mandatory reporting, and the decline is continuing. Surgical site infection surveillance started as a voluntary process, and many hospitals have taken part.

The HPA surgical site infection surveillance service includes four categories of mandatory orthopaedic surveillance (introduced in 2008) and 13 additional categories of voluntary surveillance (which preceded 2008).

There have been reductions in orthopaedic infections, but there are small increases in knee operation infections, this is being discussed with the Department of Health and the Royal College of Orthopaedic Surgeons.

The HPA were involved in the national point prevalence survey that took place in 2011. It was the first time that all UK and EU countries performed the point prevalence survey, this was the fourth survey, and all differed in their methodology, so they are not directly comparable. 8.2% of patients had a healthcare associated infection in 2006 in England.

The HPA developed the materials for the survey with the European Centre for Disease Control, so the analysis was performed in the same way for the first time. The survey also monitored antimicrobial use for the first time. The HPA undertook the data management, and provided an individualised report for all hospitals within four weeks, which was for use by the boards.

The survey showed that other infections are taking the place of MRSA and Clostridium difficile, including Enterobacteriaceae, Staphylococcus aureus, Pseudomonas and urinary tract infections.

Headline results showed that 6.4% of patients had a healthcare associated infection. Use of antimicrobials in patients was 34.7%. Specialist hospitals had higher rates of infection at 13.2%, Teaching hospitals 8%.

Antimicrobial use was 49% in specialist hospitals and independent hospitals 42.9%. There is surgical prophylaxis overuse. Meropenem, a last resort antibiotic, is the ninth highest in use, and this is not good stewardship. The ARHAI programme board are considering the findings. Infections in devices and surgical site infections are largely preventable so there is a big area of action.

Education and competencies are key, and there needs to be a shift in thinking, it should be about all infections, not just MRSA and Cdiff. Guidance on surgical prophylaxis is to be worked on. There is a need to start smart then focus. Use the data to inform action plans. Leadership stays important.

A framework agreement is being developed to support outbreaks in the community and hospital settings, residential homes and those kinds of settings.

The work of the HPA is not intended to interfere or supersede local infection prevention and control teams, if hospitals are struggling, or there is a rise in a trend in an organism, epidemiological experts at the HPA can help, and will work with the organisations.

There are whole scale changes to the NHS, there will be Commissioning Boards and groups, the HPA is to be incorporated into Public Health England and were reviewing all the mandatory surveillance. Antimicrobial resistance and stewardship is a priority, with more international work to be done as resistance knows no boundaries.

During the question and answer session an orthopaedic surgeon said that mandatory reporting keeps us on the right track, his Trust reported the data continuously, could this not be mandatory for all Trusts.

Derek said we were meeting the Department of Health today and there is a proposal to reduce some monitoring. 6.4% prevalence is far too high, and over a one in ten chance of getting an infection in a specialist hospital is not acceptable. Professor Kessel said that the current government is particularly attentive to every preventable healthcare associated infection it wasn't the intention to reduce the focus but to make more effective use of the data that we collect.

Improving care for older people

Margaret Dangoor introduced herself as a carer of a husband and mother aged 102, who both have dementia, she is a Life Fellow of the Royal Society of Medicine, and a former nurse. She set the scene with some facts and figures, her delivery was excellent and the audience were captivated by the thought provoking information, reminding us of why we are championing reducing infections and preventing harm.

Many older people enjoy high levels of independence; carers of older people are often older themselves and have their own health problems. The ageing population means that there are more people living with long term conditions. In 1948 nearly half the population died before 65. In 2012 life expectancy is 78 for men and 82 for women. There is now a 67% increase in acute admissions in over 75s. 65% of hospital admissions and 70% bed days are taken up by the over 65s. Around one in four adult beds are occupied by someone with dementia.

What do older people say would help them manage their care better in the community?
- Early information concerning support and signposting from their GPs
- Sharing of as much medical care information as possible with the patient and/or carer; an understanding of decisions made for ongoing treatment and care
- Intensive care in the community when appropriate to avoid admission into acute care (integrated care)
- Routine follow-up by GP of any emergency A&E attendances
- Clear information about what to do when needing urgent advice or in an emergency; particularly out of hours

Attendance at A&E results in 48% of older people being admitted to hospital. The main reasons for presenting included falls, most of the remainder were due to other conditions associated with heart disease, diabetes, and other long term conditions. They may have complex medical and social needs and be impeded by cognitive and sensory impairments.
They want to be seen promptly, treated with dignity and respect, and doctors have to be able to cope with linguistic needs, and individuals' culture, it was important to be kept informed of what's going on.

We shouldn't be working in silos, we need the personal approach, caring is a vocation.

Respect for the autonomy and dignity of the older person must underpin our approach and practice at all times. All older people have the right to a health and social care assessment. Psychiatric assessments were important.

If you are a carer ask about the Silver Book. A core focus of the Silver Book is the skills and competencies needed by healthcare staff to ensure they are better able to assess and manage frail older people. This includes appropriate communication skills - both with patients and other health and social care professionals; clinical reasoning and assessment skills in respect of complex co-morbidities, poly-pharmacy and altered physiological response to trauma and illness; and risk management skills surrounding discharge planning with knowledge of community services.

The Silver Book suggests that in acute medical units, greater use of geriatric liaison services should increase the proportion of older people able to be managed in community settings. It also encourages greater use of the voluntary sector.

Care when prescribing and administering medication was a crucial element of patient safety. Medication related problems cause 5,000 deaths per year in England and have an estimated cost of £750 million.

Published data suggests two thirds of patients in the UK do not receive information about the side effects of their drugs prior to leaving hospital. Up to 20% of hospital readmissions may be related to a medication related problem and poor communication between services is a recognised problem.

The North West London medicines management project aims to improve medication management at discharge from acute medical care through improved medication reconciliation in line with National Patient Safety Agency recommendations. This will be achieved by using increased pharmacy involvement combined with post-discharge telephone follow up from NHS Direct. A risk stratification tool to identify patients at risk of medication related problems is being developed.

A single multi-disciplinary medication reconciliation form has been introduced enabling doctors, nurses, pharmacists and therapists to document and communicate medication related matters clearly. It is envisaged that improving this process will empower patients to have greater involvement in their medicine management and improve safety.

Margaret's personal experience as a carer and healthcare professional gave great impetus to the good practice cited and what is desperately needed to improve the health and social care of the elderly.