Preventing avoidable infection

Despite recent headline improvements, healthcare associated infections (HCAIs) remain an important problem for the NHS. Healthcare organisations in all settings must work together and share best practice if the NHS is to succeed in the prevention and control of HCAIs. This collaborative ethos is the basis of the newly formed South London Health Innovation and Education Cluster’s (HIEC) proposal to tackle HCAIs.
   
The South London Health Innovation and Education Cluster is a £1m-a-year government-funded network, comprising around 30 organisations, which has been established to improve patient care across the area.
   
The South London HIEC includes all of the region’s major health and education providers, and one of its goals is to enhance patient care through better infection prevention and control. The group is also focused on improving care in diabetes, mental health and stroke, by establishing excellent joint working across south London. By working closer together, these organisations can share knowledge and best practice, and develop new initiatives that bring real benefits to healthcare provision in south London and beyond.

INFECTION CONTROL CHALLENGES
Healthcare-associated infections (HCAIs) are infections that occur in healthcare settings. These may be transmitted to patients and healthcare workers as a result of healthcare procedures in hospital and other related settings. HCAIs may also result from infections of vulnerable patients by the bacteria they normally carry themselves. These infections have always existed, but have never been subjected to the scrutiny they receive today.
   
About one in eleven inpatients has an HCAI at any one time, which is equivalent to at least 100,000 infections a year. These potentially fatal infections often result in several additional days’ hospital admission and cost the NHS up to a billion pounds each year.

SUPERBUGS
Over recent years there has been a huge increase in press interest, public awareness and concern over HCAIs, in particular those caused by antibiotic-resistant superbugs such as Clostridium difficile and MRSA. There has been success in reducing the number of MRSA blood stream infections and C. difficile infections.         The number of MRSA bacteraemias fell by 75 per cent between 2003 and 2010, and the quarterly number of C. difficile infections has fallen by 54 per cent between 2007 and 2010.
   
However, as pointed out in a recent report by the national audit office, although up to nine per cent of patients in hospitals may have a healthcare-associated infection, MRSA and 
C. difficile only account for a very small proportion of these. It is also unclear to what extent these impressive reductions in C. difficile and MRSA infection rates are mirrored by falls in other HCAIs.

CARE QUALITY COMMISSION
There is increased regulation and oversight of the management and control of HCAIs. All acute NHS Trusts are now required to register with the new regulatory body responsible for ensuring hygiene standards in healthcare settings, the Care Quality Commission (CQC).

A 2009 study conducted by the CQC found that a quarter of UK health trusts failed to fully meet hospital infection standards. 21 NHS trusts, including one ambulance trust, have been given registration “with restriction”; if they do not improve to the required standard they could be forced to close their doors as, in effect, it becomes a criminal offence to offer healthcare without the approval of the CQC.
   
There are a number of high-profile initiatives to improve the prevention and control of HCAIs. These include the Department of Health’s HCAI Technology Innovation Programme, its Design Bugs Out project, and the Show Case Hospital programme.
   
Hospitals and community healthcare organisations continually face new and emerging infectious threats such as community MRSA, multi-resistant gram negative bacterial infections, and viral infections including pandemic influenza. The multi-resistant gram-negatives, particularly, are recognised to be a growing but largely unquantified burden in both the community and hospitals, threatening treatment of common community infections such as urinary tract infections as well as critically ill patients in hospitals. A dynamic, integrated and flexible approach is needed to improve the prevention and care of HCAIs, and to meet future challenges.

COLLABORATIVE WORKING
Infection prevention and control has traditionally been focused on acute hospitals, but many infectious diseases can spread in other care settings within the wider community as well.
   
There are few data available to estimate the amount of HCAI outside the acute hospital settings. There are indications, however, that there may be transmission of C. difficile, norovirus and MRSA in long term care facilities and care homes. There is also increasing recognition of the presence in the community of organisms usually associated with HCAI, such as MRSA, which is an increasing problem in the United States of America.
   
Consequently, avoidable spread of infection will not be achieved if healthcare organisations are working in isolation. The potential of an infection-reducing initiative in, for example, a hospital would always be limited by referred patients who may bring in infection from the community setting that referred them. Without improving communication between these settings and adopting a unified approach to infection prevention, successful initiatives in one healthcare setting will be limited by the actions of another.
   
The HIEC is broadening the perspective in south London to look at the prevention and control of HCAIs, not just in hospitals, but in care homes and primary medical care across the region. The complication of infection spread between healthcare environments aside, better collaboration between care settings can have a real impact on driving down infection in itself.

SHARING BEST PRACTICE
By sharing experiences – good or bad – knowledge and best practice efficiencies can be improved, and patient care can be improved because of this. Good projects can expand and spread through communities, whilst ineffective initiatives will not be repeated. Organisations will also benefit from a wider pool of resources and expertise that are needed to launch new care initiatives.
   
Before the HIEC was established in December 2009, individual member organisations had already implemented some of the most effective infection control programmes in the country. For example, St George’s Healthcare NHS Trust and Guy’s and St Thomas’ NHS Foundation Trust have achieved some of the greatest reductions in MRSA and C. difficile infection across England over the past few years.
   
The HIEC members are working to translate these successes with C. difficile and MRSA into driving down other HCAIs. By combining the experiences of the individual organisations, the group can share and roll out best practice in service delivery, training, and research and development that is unified across the south London community and its healthcare institutions. The HIEC will explore collaborative research opportunities for new infection control measures and diagnostic strategies.
   
Surveillance in hospital and other healthcare settings, early identification of infection, heightened infection control measures and the control of antimicrobials – those substances that kill or inhibit the growth of the microorganisms that cause infections – will embed a more proactive culture that sees emerging infections identified, tracked and addressed earlier.

RECORD SYSTEM
The HIEC is setting up a system to improve the care of bloodstream infections. Bloodstream infections are amongst the most severe HCAIs. Although important, MRSA is only a small cause of healthcare-associated bloodstream infections. There is currently a paper-based record system for microbiology specialists to help manage these infections. This system has been very effective until now for surveillance and management of these patients. The HIEC intends to innovate a new secure web-based record system to improve the security, patient safety and completeness of the existing system. The new system should also be able to greatly improve current surveillance of these important HCAIs.

EDUCATION
Educating healthcare professionals and sharing knowledge and best practice across organisations will play an important role in tackling HCAIs, particularly in areas such as south London where healthcare relies heavily on local delivery such as polyclinics.
   
HCAI education amongst healthcare staff is not a new concept and there is much experience of this teaching in the acute hospitals in the HIEC. The sharing of this best practice between acute trusts and other healthcare providers will be a natural part of the collaborative working at the centre of this HIEC.
   
But, because infections often spread between members of communities before they are brought into the healthcare environment, our education programmes would be wise to involve educating members of the local community as well as healthcare workers.
   
Already, HIEC members are involved in community programmes aimed at teaching young people in schools and other institutions about health and wellbeing. The HIEC will explore the possibility of expanding these to include the importance of infection control and antibiotic use. By using relevant and interesting methods of explaining these issues to young people, we hope their knowledge and understanding will help reduce the risk of HCAIs in the future.
   
Educating healthcare workers and members of the community, combined with collaborative working, are activities healthcare and education-related organisations have the ability to establish on a local level. They will complement existing government projects to tackle HCAIs, such as investment in new technologies. But by sharing and reporting on best practice and innovation, and conducting pilot projects, healthcare organisations can add to the evidence that can inform policy and practice across the NHS, ultimately helping to prevent avoidable infection and improve patient care.