Healthcare Associated Infections: from hospitals to beyond an acute care setting and the future of regulation and assessment

Derek Butler, Chair, MRSA Action UK

 

Derek gave an insight into the Charity's work with the Improvement Foundation and how this has helped to identify the important part information sharing and care planning is in relation to safeguarding residents and staff in care homes from the risks of healthcare associated infections.

 

Some key lessons learned from the work with staff and residents:

-        Care Homes are people's homes and not institutions, as they are so often referred to

-         Residents need to be assured they have the same access to clean, safe care as patients in hospitals do

-         Staff need to be empowered to make changes and drive improvement

 

To deliver clean, safe care four key things spring immediately to mind

-         A clean environment

-         Attention to hand hygiene

-        Judicious antibiotic prescribing

-         Information and Communication

 

Communication is particularly key as it ensures the resident is well informed about what care they are receiving and why, it increases confidence that they will be receiving planned, safe quality care.

 

Staff in care homes involved in the Improvement Foundation programme came up with innovative ways to encourage good hand hygiene involving residents and visitors.

 

Hand hygiene encompasses a broad terminology and it's important that hand washing and drying is done effectively at the right time, removing any visible soiling and after cleaning or using the lavatory.  Hand gels are very convenient but should not be a substitute for washing hands.  Keeping skin moisturised, during breaks and at the end of the working shift helps reduce the potential for carriage of harmful bacteria, as dry skin can harbour germs that can be transmitted during resident / patient contact.

 

Good hand hygiene should be a process of excellence that is the cornerstone of good infection prevention and control, which is a recent quote from the National Patient Safety Agency Cleanyourhands campaign, another quote from the philosopher Aristotle could not be more apt "We are what we repeatedly do. Excellence, then, is not an act but a habit."

 

Visible aids remove any communication barriers; posters were popular with care home staff.  The pictorial care pathway for people who have been identified as MRSA positive was very popular with staff in the care homes, it was found to be a good tool to communicate.

 

Care Home staff in the Improvement Foundation Programme monitored the proportion of residents admitted and discharged from hospital who had a care plan which include their infection status, and also information on antibiotic prescribing.   Evidence showed improvement in communication between hospitals and care homes, and a reduction in high risk broad spectrum antibiotic prescribing.

 

The Charity's work is ongoing with the Department of Health and Health Protection Agency advising on data quality, for ease of use by patients in choosing their hospital and treatment. The work is also aimed at assisting health practitioners and regulators in the drive for improvement in the Acute and non-Acute setting, and making good use of data to bring about change and improvement.

 

MRSA Action UK has also contributed a patient-carer perspective to the review of progress in Tackling Healthcare Associated Infections in Hospitals to inform the National Audit Office findings, and welcome the launch of the progress report later this month. 

 

There were opportunities for questions following the presentations and Derek Butler and delegate Maria Cann took the opportunity to join the debate.

 

Following Professor Barry Cookson's presentation, Maria asked a question on hospital antibiotic prescribing and their usage data.  How do we think we can get them to improve that?

 

Barry outlined that there was a project already underway, establishing a database, the Department of Health Pharmacist is leading the project and already better data is coming through.  Barry agreed that it has been rather unfortunate that we lead Europe on the community side, we have probably got the best data in Europe on the community side, but we now need to match that with the hospital side, it's about a year and a half away.  There will be some data in some central hospitals before that, but it's a very complex thing to do with all the different information systems we have.

 

Following Professor Richard James' presentation Maria asked if there was more value in screening for more than one organism than just MRSA, such as MSSA or PVL.

 

Professor Richard James said provided you have the evidence base to include an organism in screening, yes.  Part of the problem at the moment is that much of the MRSA screening going on in our hospitals is still going to be culture based and slow and in many hospitals it is actually going to be on admission, not pre-admission, so most of the benefits of screening will be lost.  We need new technology to speed up the process, but also we need lower cost technology and also you don't just want one piece of information, is it MRSA, you would actually like several pieces of information, is there PVL, is it MSSA PVL, can you get some typing information to inform your control and infection measures as well, so I think all of those are feasible in the next few years if we do it right.

 

Professor Kathy Bamford outlined that they currently screen for both MRSA and MSSA in one particular patient group, and that's a patient group where intravascular lines are used very frequently and where infection is associated with carriage and that screening programme has been associated with a reduction in the carriage rate so that's been found to be effective.

 

Steps on the journey to reducing healthcare associated infections.....

What is the Department of Health doing to improve public confidence?

Janice Stevens, Associate Director, HCAI and Cleanliness Division, Department of Health

 

Janice thanked the organisers for being invited to speak on behalf of the Department of Health to share thoughts from the work that the Department have been doing over the last four years.

 

It was clear hearing from the previous speakers, there was some really fantastic and interesting information, but it was also a bit scary.  It is quite clear that infection generally, and healthcare infections specifically, is an area of real significant concern and it is going to need focus, attention, action for the foreseeable future, if not forever and the challenge for the Department of Health is to work out what is needed in terms of policy, and to keep doing, versus what organisations and healthcare settings need to do to improve practice locally.

 

Without doubt, healthcare environments are going to stay really busy.  We heard about occupancy but actually it is less about occupancy, it is more about our whole population.  What we are dealing with is people that are getting older, that have got chronic diseases that are going to need healthcare.  Diabetes, obesity and heart disease are more prevalent, more serious cancers are around and we have advances in technology and drugs, so hospitals and healthcare settings are just going to stay incredibly busy and the challenge then is how do you still manage the complexity of doing the daily work and still address the issues of preventing infection, and that is a challenge that we at the Department of Health have to make sure we are thinking about.  But also a big part of this is what do hospitals and health communities need to do to make sure people are doing the right things all of the time.  

 

Janice's presentation was followed by questions and comments from the floor.

 

Baroness Masham of Ilton asked what progress is being made in the hospitals in Leeds and Middlesbrough which came top in for infection in England and Leeds were fined 30 million pounds.

 

Janice Stevens: I am not sure that I can necessarily comment on specific numbers for individual trusts, my team are working with Leeds at the moment and there is an awful lot of work going on there, and my understanding is things have improved quite significantly.  We are certainly committed to supporting and helping any organisation that is still at the wrong end of the kerb in terms of getting them down to the right level.

 

Roger Goss: Co-Director Patient Concern asked in view of all the good things happening, how confident are you that we shan't have more Maidstone Hospital disasters?

 

Janice Stevens: I am probably significantly more confident than I was at the start of the programme.  I think what we have tried to show is you need to put a lot of things in place to make sure that everybody is doing the right things every time.  What we have now is the combination of regulation through the CQC, we have got a rigid performance management system.  We look at the performance of every hospital trust fortnightly to monthly. Trusts that are not performing as well we look at more frequently.  We are looking at performance all the time.  The combination of the performance management and the regulation, I think the other bit is that the PCTs and the SHAs are really on the case, they are really scrutinising their organisations, so I think there is enough in the system that should prevent that from happening again.

 

Derek Butler, MRSA Action UK said the Mid Staffordshire incident was basically down  to people not listening to patients and the relatives of those that were lost at that hospital.  For quite some time that group had been going on about the high risk mortality in the A&E.  Nobody was listening to them, there was information and communication there.  What guarantee have we got now that the CQC will listen to those families, patients and anybody else who may raise issues again about other hospitals so we avoid another Mid Staffs?

 

Janice Stevens: I am not sure that I can possibly answer that, but is my CQC colleague still here?  We do work closely with the CQC, on how we identify the risks, so there is a collaboration there that is helpful, the CQC were looking at the broader quality agenda.

 

Debbie Mead:  The answer is that I can't promise that there won't be another one because it's the reverse of what Janice was just saying.  What we have done so far and the journey that we have been on, on that long road is trying to line up the cheese without the holes matching and occasionally there is a slight shift somewhere or there is something that is not quite right and then all the holes line up and a disaster happens.  But we are doing everything that we can, in order to combat that and I think from what we have seen today everybody here is committed to it, so we are all doing the very best we can and hopefully it won't happen again, I can't promise that it won't.

 

Janice Stevens: I think there is a broader issue, Derek, around not just what the CQC are doing or what we are doing but I think around how Trusts and PCTs and SHAs are seeking views of their users and public and we know, we are as one on that kind of conversation, and I think the more that we can do or the more that people can do locally to make sure they are using surveys, using focus groups, using their governors, they are talking to their local action groups and really listening and using that information, then there is a kind of loop around how is that dealt with, then I think that is at the heart of how you ultimately avoid another Mid Staffs.  I think for me, that should be the system, so I do think there is a much greater message about everyone doing this locally as well.

 

Derek Butler: One of the things that came out of the Mid Staffs Report was the fact that you had staff there who were not qualified to do certain tasks.  You had receptionists doing medical assessments, now that was totally wrong and you have also got people who didn't know how to use that equipment.  The Care Quality Commission must ensure that those hospitals put the proper training in place so the staff are fully professional at what they do.

 

Janice Stevens: If you translate that back to the healthcare infections agenda that is something that we have pushed throughout the time of the programme and will continue to do.  I know you have heard me speak about it, which is its not just doing the training, because actually many organisations will do a fantastic amount of training, it's the follow up assessment of competence and ongoing checking that's really key and certainly we have seen organisations where they have done the training in aseptic technique and reassessed whole organisations, and that's the sort of level of detail you have to get down to if your organisation is struggling with any aspect of quality or safety, not just assuming competence but checking it, as well as providing the training and having a proper system for doing that.

The presentations are courtesy of Westminster Health Forum.  The dialogue from the question and answer sessions are taken from a combination of a transcript by Westminster Health Forum and MRSA Action UK, speakers have not had the opportunity for corrections, although we have made our best endeavour to reflect the discussion there may be errors that could alter the intended meaning of the reported content.

Keynote speakers' and other presentations:

 

Current trends in healthcare associated infections

Professor Barry Cookson, Director of the Laboratory of HealthCare Associated Infection,

Health Protection Agency

 

Healthcare associated infections and the Care Quality Commission

Debbie Mead, HCAI Assessments Manager, Care Quality Commission

 

Healthcare associated infections and improving public confidence - post deep clean

Professor Steve Green, Consultant Physician in Infectious Diseases and Tropical Medicine,

Sheffield Teaching Hospitals NHS Foundation Trust

 

Healthcare associated infections and public confidence

Rose Gallagher, Nurse Advisor, Infection Prevention and Control, Royal College of Nursing

 

Infections beyond an acute care setting

Trish Johnson, Programme Manager for Healthcare Associated Infections, Improvement Foundation

 

Healthcare associated infections - where next?

Professor Brian Duerden, Inspector of Microbiology and Infection Control, Department of Health

 

Healthcare associated infections beyond an acute care setting and the role of new technology

Professor Richard James, Director, Centre for Healthcare Associated Infections, University of Nottingham

 

How are healthcare infections recognised and treated away from an acute care environment?

Professor Kathy Bamford, Consultant Medical Microbiologist, Imperial College Healthcare NHS Trust