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Healthcare associated infection: what else can the NHS do?

The Healthcare Commission has published a national study into healthcare associated infection that outlines practical advice for trusts to consider in their attempts to reduce rates of infection. The report was prepared in response to a request from the chief medical officer for England who asked the Commission to examine the factors associated with reducing rates of infection

In May 2006, five months before the introduction of the government’s hygiene code, the Commission undertook a voluntary survey of acute NHS trusts to bring together information on how trusts were dealing with prevention and control of infection. The survey was completed by infection control teams and a range of managers at 155 out of 173 acute trusts in England.

The Commission conducted a detailed analysis to identify any significant relationships between information from the survey and data on rates of infection. The report identifies how different processes to prevent and control infection affect rates of infection.

The Commission says that in order to prevent and manage healthcare associated infection better, trusts must:

Develop a culture of safety

Safety should be paramount, from the ‘board to the ward’ and visible and strong leadership from the board and local staff is needed to tackle control of infection.

Trusts were likely to have lower rates of clostridium difficile associated disease if they had designated members of staff, working in a number of clinical areas to link management with staff at the frontline and ensure policies are put into practice on the wards. At the time of the survey, 86% of trusts had “link practitioners” in at least 50% of their clinical areas and 23% had them in all areas. The Commission also found that trusts with protected time for staff to concentrate on infection control had lower rates of healthcare-associated infection.

However, trusts did highlight some challenges in this area. Forty five per cent of trusts said that they had difficulties in reconciling the management of healthcare-associated infection with the target for treating patients in accident and emergency departments. Twenty nine per cent of trusts cited difficulties in reconciling control of infection and targets for waiting lists.

The Commission said that it recognised the importance of targets in meeting the needs of patients. Trusts should discuss any perceived conflicts with their strategic health authority. It said it was also willing to discuss these issues with trusts and convey results to the Department of Health.

Have good systems of corporate and clinical governance

Safety should not be “bolted on” to how an organisation is run. It is a fundamental part of all systems and a responsibility of all staff.

The hygiene code requires that trusts have a director of infection prevention and control who reports directly to the chief executive and is accountable to the board. 95% of trusts fulfilled this requirement.

Only 16% of trusts said that responsibility for compliance with policies and procedures on infection control was included in job descriptions for all staff working in clinical areas. In 17% of trusts, it was not included in any job descriptions. However it is now a requirement under the hygiene code. Trusts should have already reviewed job descriptions to ensure that they comply with the code.

Every trust surveyed had programmes for training nursing staff. However, only 11% had ongoing programmes to train medical staff or for non-clinical staff working in clinical areas. The Commission said that trusts should ensure that essential training takes place and that it is tailored to the experiences of the trust.

Review performance

Trusts must ensure policies and protocols are being put into practice.

Trusts that shared information about local rates of infection with the clinical teams were more likely to have lower rates of clostridium difficile associated disease. Most trusts (84%) said that clinical teams received this information, but the frequency of this varied.

The study found that 56% of trusts did not have a programme in place to check that policies to manage beds were being applied. Forty six per cent said that there was no programme to check that staff were adhering to policies for the cleaning of beds.

The study looked at what trusts did to hold individuals to account through appraisals and personal development plans. It found that 34% of trusts said that they did not include objectives for infection control in annual appraisals or personal development plans for medical staff and 12% said it was not included in the case of any staff working in clinical areas. Where trusts did have objectives for infection control for members of staff, they generally had lower rates of clostridium difficile associated disease and MRSA and such objectives are now a requirement under the hygiene code.

Manage risk

Trusts must have robust systems in place to identify and manage areas of risk to patients and to learn from incidents of infection.

Most trusts are making real changes as a result of internal audits or investigations. In the year preceding the survey, 89% had made changes to clinical protocols, 69% made changes to the prescribing of antibiotics and 70% made changes to the environment of care, including the arrangements for cleaning.

Boards need to consider regular analyses of information on infection control in a way that highlights the lessons that need to be learned.

The importance of high standards of cleaning is emphasised by the fact that trusts with better scores on cleanliness had lower rates of infection.

Thirty six per cent of trusts told the Commission that they had experienced difficulties reconciling the management of healthcare associated infection and cleanliness with the fulfilment of financial targets.

Almost half of trusts said that they report all incidents of healthcare associated infection to the National Patient Safety Agency, 6% said that they report “most” incidents, 26% report “some” and 19% do not report any.

Eighty eight per cent of trusts told the Commission that limited information technology infrastructure was restricting their ability to draw important lessons from incidents of infection.

Trusts that had a higher proportion of single rooms were more likely to be reducing their rates of MRSA in line with national targets. Those trusts that breached their guidance for the management of beds were more likely to have higher rates of MRSA. However, many trusts said that there were occasions when they breached their own policies due to lack of facilites for isolating patients.

Communicate with patients and the public

Trusts must provide information to reassure patients and the public who are concerned about catching a healthcare associated infection.

Trusts are required under the core standards set out by the government, and now the hygiene code, to provide information about healthcare associated infection in languages and forms relevant to their local population. However, 58% of trusts said that their information was not developed in a way that considered the needs of different ethnic groups and two thirds said they did not produce information that was tailored to the needs of those with a physical or mental impairment.

Further, 30% of trusts said that there was no protocol for discussing the risk of infection with patients or their relatives. Trusts should consider how they can ensure that patients are properly informed about the risks, not just at a particular hospital, but for particular procedures.

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