Guide targets HCAI reduction through systemic improvement

The 2009 National Audit Office report on reducing HCAIs5 identified four systemic issues that still needed to be tackled locally and nationally to reduce infection rates. It highlighted the need for a culture of continuous improvement; for a whole-system approach, with clear structures, roles and responsibilities; to ensure staff compliance with good infection control practice, and to monitor and record hospital prescriptions and the use of antibiotics.

Produced in partnership with the Health Protection Agency (HPA) as part of a pilot project, the latest guide identifies the organisational characteristics, arrangements and practices that describe excellence in care and practice to prevent and control HCAIs. It was developed as a pilot project, based on processes and methods used by NICE to develop other types of guidance. A topic expert group led by an independent chair was set up. This consisted of practitioners from the NHS, local authorities and the voluntary sector, as well as academics and patient and public representatives.

The group then worked with NICE and the HPA to develop the guide, and its resulting quality improvement statements are based on recommendations from seven source guidance documents. These were then further refined through stakeholder consultation and committee discussion.

The guide is aimed at board members working in (or with) secondary care. It may also be of use to senior managers, those working elsewhere in the NHS, as well as those working in local authorities and the wider public, private, voluntary and community sectors.

What are HCAIs?
Healthcare-associated infections (HCAIs) can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting. The term covers a wide range of infections, the most well known being those caused by meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C.difficile) and Escherichia coli (E.coli).

HCAIs cover any infection contracted as a direct result of treatment in, or contact with, a health or social care setting as a result of healthcare delivered in the community outside a healthcare setting (for example, in the community) and brought in by patients, staff or visitors and transmitted to others (for example, norovirus).

HCAIs pose a serious risk to patients, staff and visitors. They can incur significant costs for the NHS and cause significant morbidity to those infected. As a result, infection prevention and control is a key priority for the NHS2. What action has been taken?

Following National Audit Office reports highlighting concerns about HCAIs, the Department of Health introduced a range of policies and measures designed to reduce rates of infection. For example, mandatory surveillance for meticillin-resistant Staphylococcus aureus (MRSA) was introduced in 2001. In 2004, a target was introduced to reduce MRSA bloodstream infections by 50 per cent by 2008 in all NHS acute and foundation trusts. With the introduction of the Health Act in 2006, for the first time it became a legal requirement to have systems in place to minimise the risk of HCAIs4.

HCAIs can cause significant morbidity to those affected and incur considerable costs for the NHS. In 2009/10 there were nearly 2000 reported incidences of methicillin-resistant staphylococcus aureus (MRSA) and over 25,000 reports of clostridium difficile infection (CDI) at a cost to the NHS of around £260 million. In addition, in 2009, 77 trusts reported 831 outbreaks of norovirus, the majority of which led to some form of ward closure.

A range of policies and measures introduced by the Department of Health have been successful in helping the NHS reduce rates of MRSA bloodstream infections and CDI, but HCAIs remain a significant financial burden for the NHS and as a result, infection prevention and control continues to be a key priority for the NHS.

NICE and the HPA recognise that a range of factors associated with infection prevention and control have the potential to impact on health inequalities (for example, in relation to age, ethnicity, gender and disability). However, the relative impact of different factors will vary for different organisations. NICE and the HPA expect trusts and other secondary care organisations to consider local issues in relation to health inequalities when implementing the guide.

The quality improvement guide is aimed at trust boards and senior management in secondary care settings including commissioners, auditors, managers and providers. The guide consists of eleven quality improvement statements describing a level of excellence in infection prevention and control at a management or organisational level. Evidence of achievement markers accompanying each statement allow trust boards to assess their compliance or progress towards each statement. In addition, the guide provides practical examples of the types of management and structural processes and associated interventions that need to be in place in order to reduce harm from infection.

The guide includes quality improvement documents for trusts that provide further information on referral, scope, and methodology in 11 key areas. Each statement is supported by examples of the type of evidence that could be used to prove the organisation has achieved excellence, and examples of what this would mean in practice on a day-to-day basis. The 11 areas are as follows:

Demonstrating leadership in infection prevention and control to ensure a culture of continuous quality improvement and to minimise risk to patients.

Using information from a range of sources to inform and drive continuous quality improvement to minimise risk from infection.

Having a surveillance system in place to routinely gather data and to carry out mandatory monitoring of HCAIs and other infections of local relevance to inform the local response to HCAIs.

Prioritising the need for a skilled, knowledgable and healthy workforce that delivers continuous quality improvement to minimise the risk from infections. This includes support staff, volunteers, agency/locum staff and those employed by contractors.

Ensuring standards of environmental cleanliness are maintained and improved beyond current national guidance.

Working proactively in multi-agency collaborations with other local health and social care providers to reduce risk from infection.

Ensuring there is clear communication with all staff, patients and carers throughout the care pathway about HCAIs, infection risks and how to prevent HCAIs, to reduce harm from infection.

Having a multi-agency patient admission, discharge and transfer policy which gives clear, relevant guidance to local health and social care providers on the critical steps to take to minimise harm from infection.

Using input from local patient and public experience for continuous quality improvement to minimise harm from HCAIs.

Considering infection prevention and control when procuring, commissioning, planning, designing and completing new and refurbished hospital services and facilities (and during subsequent routine maintenance).

Trusts regularly review evidence-based assessments of new technology and other innovations to minimise harm from HCAIs and antimicrobial resistance (AMR).

Professor Mike Kelly, director of the Centre for Public Health Excellence at NICE, said: “There have been major improvements within the NHS in infection control, particularly in relation to Clostridium difficile and MRSA bloodstream infections, in the last few years, but HCAIs are still a very real threat to patients, staff and visitors. Indeed, evidence suggests there is wide variability in Trusts’ success in reducing the impact of HCAIs.

Aspirational approach
Therefore, it is important that there is advice in place that can help trusts achieve excellence in management and organisational practices in order to prevent and control infections. Based on the best available evidence in this area, the guide illustrates how secondary care organisations can take a whole system approach in tackling the problem.

The guide is aspirational and aims to engage Trust boards and clinicians to improve the quality of care and practice in the area of infection prevention and control over and above current mandatory standards.”

Dr Bharat Patel, lead consultant medical microbiologist at the Health Protection Agency and member of the Topic Expert Group said: “This guide represents aspirational quality improvement statements in infection control and achieving these standards is something that all Trusts should aim for. It complements the existing guidelines on the prevention of healthcare associated infections and offers practical suggestions on how Trusts can best manage eleven key areas of quality improvement.

“The HPA has collaborated closely both with members of the expert group and colleagues from NICE on the production of these statements. We are confident that all Trusts will find them invaluable in planning and implementing their strategies to preventing healthcare associated infections.”

Professor Roger Finch, Consultant in Infectious Diseases, Nottingham University Hospitals Trust and Chair of the Topic Expert Group which developed the advice, said: “The control and prevention of healthcare associated infections is essential to ensuring patient safety. The nature of HCAI is complex and demands leadership and systems that are supportive and continuously refined. These quality improvement statements take an organisation-wide approach to support hospital Trusts achieve excellence and meet the high public expectations of healthcare delivery.”

Cheryl Etches, director of Nursing and Midwifery, Royal Wolverhampton Hospitals NHS Trust and member of the Topic Expert Group, said: “The NICE guide is a useful and important set of principles that are aimed at supporting Boards in delivering their infection prevention responsibilities. It should be used to offer assurance to Boards of their strategic direction on this subject and also to drive a culture of continuous quality improvement. Irrespective of where an organisation is on their HCAI improvement journey they can use the guide to agree their next steps to improvement.”

Paul Unsworth, area director London, NHS Institute for Innovation and Improvement and member of the Topic Expert Group, said: “I am delighted NICE has developed this guide. Healthcare associated infections are unacceptable, avoidable and can be significantly reduced as demonstrated by the recent reductions in MRSA bacteraemias and Clostridium difficile. If implemented, this quality improvement guide, to hospital clinicians, managers, patients, carers and commissioners of healthcare, will result in a better understanding of what infective organisms exist in hospitals and the community and will be a crucial step in taking the initiative to collectively reduce the spread of infections throughout hospital, community and social care.

Graham Tanner, chair, National Concern for Healthcare Infections and patient/lay member on the Topic Expert Group, said: “This quality improvement guide provides an opportunity to demonstrate that the NHS can deliver exemplary services for patients. The quality improvement statement relating to NHS Trusts working proactively with multi-agencies to reduce HCAIs within local health and social care organisations is of particular importance. This will support the development of integrated health and social care services, support development of patient centred care and potentially provide substantial cost savings to the NHS.”

How should the guide be used?
This guide is not mandatory. Rather, each quality improvement statement describes a level of excellence that could be achieved to prevent and control infections. Key areas of practice that underpin infection prevention and control, such as hand hygiene, antimicrobial stewardship and environmental cleanliness are included as measures and examples, where appropriate.

Organisations wishing to use the guide for quality assessment and improvement may choose a selection of the most appropriate measures for their setting as potential evidence of achievement. In organisations where, for example, tertiary care services are provided alongside secondary care, senior management should consider the applicability of each statement to their setting.

The examples of measures that could be taken may not be appropriate in all cases – and secondary care organisations may identify and use alternate measures as evidence of achievement, as necessary. Performance in each statement area will depend upon healthcare professionals and other trust staff who have HCAI prevention and control – and public health, generally – as part of their remit.

Much of the information required to support the measures is already available and a range of other guidance can be used alongside this guide to assess and improve quality in secondary care settings. Overlaps between the statements and certain aspects of the code of practice are highlighted. In addition, where data routinely collated may help trusts monitor progress in an area covered by one of the statements, this is also highlighted.

It’s hoped that the guide will help secondary care and other healthcare organisations improve the quality of care and practice, reduce the risk of harm from HCAIs to patients, staff and visitors and reduce the costs associated with preventable infection. The 11 quality improvement statements provide clear markers of excellence in infection prevention and control at a management or organisational level.

The aim of the guide is to help boards assess current practice in relation to the prevention of HCAIs, identify areas for quality improvement, monitor progress and provide leadership and support to infection prevention and control teams and other staff working to implement the guide. Its authors also believe it may have a role informing investment decisions.

Importantly, it will also give patients and the public information about the quality of care they can expect, and how secondary care organisations can improve patient safety and outcomes by improving quality in key areas.

Further information
www.nice.org.uk