West Midlands Key Health Data 2007/08
CHAPTER SEVEN: HEALTHCARE ASSOCIATED INFECTIONS (HCAI)
Gaynor Evans and Yasmin Rehman
Main Body
7: Healthcare Associated Infections (HCAI)
7.1 Introduction
Healthcare associated infections are infections that are acquired in hospitals or as a result of healthcare interventions. The term is sometimes also used to describe an infection acquired by a healthcare worker in the course of his or her work. The issue is of equal importance for healthcare providers in the independent and voluntary sectors. The reduction, prevention and control of HCAI are a high priority for all NHS Trusts.(1) This profile has been enhanced by the Government’s determination to reduce the rates of MRSA bacteraemia and of Clostridium difficile (C. difficile)infections. The Healthcare Commission has published three documents relating to investigations into C. difficile outbreaks (Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust; University of Leicester NHS Trust and Maidstone and Tunbridge Wells NHS Trust)(2)
It is estimated that HCAI costs the health service around £1 billion per year with each episode costing between £4,000 and £10,000. Patients who get a HCAI are subjected to increased anxiety, pain, and suffering. Reducing HCAI improves the patient experience and clinical outcomes as well as the efficiency of health services, reducing the length of stay and lost bed days and reducing associated management costs.(3)
The Health Act 2006 establishes a code of practice for trusts helping them to plan and implement systems for the prevention and control of HCAI ensuring a safe and clean environment for their patients. It supports a number of published guidance documents published by the Department of Health on the prevention, management and control of HCAI such as The Health Act 2006 and Going further faster: Implementing the Saving Lives delivery programme 2007.
Recent focus on the prevention and control of HCAI has highlighted the need to tackle this agenda across the whole health economy with acute and primary care NHS trusts working in collaboration with local authority and private sector health providers.
In order to achieve this, surveillance of HCAI is changing subject to Department of Health requirements to more readily define HCAI acquired in wider community settings and identifying the impact on non-NHS healthcare providers. This evidence is supporting joint responsibility action plans for health care providers across defined population areas.
Reduction targets for trusts have been implemented by the Department of Health for both methicillin resistant Staphylococcus aureus (MRSA)bacteraemia and Clostridium difficile infection, both significant contributors to the burden of HCAI.
7.2 MRSA
Staphylococcus aureus is a bacterium that is commonly found on human skin and
mucosa (e.g. lining of nose). The bacterium usually lives harmlessly on the skin and in the nose of about one third of normal healthy people. This is called colonisation or carriage. S. aureus can cause actual infection and disease, particularly if there is an opportunity for the bacteria to enter the body – for example, via a cut or an abrasion.
Methicillin resistant S. aureus (MRSA) are varieties of S. aureus that have developed resistance to the antibiotic methicillin. Methicillin is an old antibiotic which is used as an indicator for flucloxacillin resistance, the antibiotic which is usually used to treat S. aureus infections. Methicillin resistance usually indicates resistance to other penicillin-related antibiotics too.(4)
7.3 Clostridium difficile
C. difficile infection ranges from mild to severe diarrhoea to, in rare cases, severe inflammation of the bowel which can result in a condition known as pseudomembranous colitis. The acquisition of C. difficile is associated with the use of broad spectrum antibiotics such as cephalosporins and quinalones.
People who are at increased risk of developing C. difficile infection are the elderly (specially those aged 65 years and above) and those individuals with serious underlying disease for example chronic renal impairment or respiratory illness and may require frequent antimicrobial treatment(5).
7.4 Surveillance
Interventions supporting the prevention and control of MRSA and C. difficile infection have been enhanced by the establishment of real-time web-based mandatory surveillance. This surveillance is being used as an epidemiological tool. It is also used to support performance management in acute trusts which are subject to targets set by the Department of Health. This use of surveillance data has not been tried anywhere else in the world.(3)
National surveillance of HCAI is collated by the Health Protection Agency on behalf of the Department of Health. Targeted mandatory surveillance of HCAI commenced in 2001 requiring laboratories to submit reports of MRSA bacteraemia. In October 2005 this system was enhanced to provide additional information with the introduction of the web-based system.
Figure 7.1: MRSA Bacteraemia cases in West Midlands 2001/2-2007/8
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Figure 7.1 demonstrates that there has been a significant decrease in the number of MRSA bacteraemia cases since 2004. The target reduction for MRSA bacteraemia is 50% (against the 2003/04 baseline) by 2008.
Figure 7.2: MRSA Bacteraemia rates by Trust Type
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Figure 7.2: effectively demonstrates overall downward trend in MRSA in all hospital categories
C. difficile data collection, voluntary since 1990 became mandatory in January 2004 for patients aged over 65 years. In April 2007 the scheme was extended to include data for patients aged over 2 years. It also enabled further information to be extracted to support the primary care trusts and strategic health authorities in reviewing improvement targets for acute trusts.
Figure 7.3: Clostridium difficile cases in West Midlands (by age) April 2007- March 2008
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Figure 7.4: Number of cases of C. difficile infection in the West Midlands by Trust type (April 2007- March 2008, provisional data)
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7.5 Surgical site infection
Surgical site infections (SSI) are significant, accounting for 22% of all HCAI(4, 6) .The SSI surveillance system was established in 1997. It became mandatory in 2004 for all trusts to undertake surveillance in at least one of four categories of orthopaedic surgery, for at least one three-month period each year. These are hip replacement, knee replacement, hip hemiarthroplasty and open reduction of long bone fractures.
Staphylococcus aureus is recognised as a major cause of SSI accounting for 45% of all SSI from 2004 to 2007. Of these 28% are MRSA infections(4) other significant infections have been attributed to Streptococcus, Enterococcus, Acinetobacter and Pseudomonas species.
In addition to the mandatory surveillance requirements, trusts may contribute voluntarily to surveillance of other categories of procedure in the same system. In practice most trusts now participate in several areas of the surveillance system continuously. These may include abdominal hysterectomy, vascular surgery, limb amputation, small bowel surgery and large bowel surgery.(3)
7.6 Health economy working
Embedding the responsibility for reducing HCAI within the culture of all healthcare providers and establishing responsibility for this function with Chief Executive Officers is essential to successful infection prevention and control programmes.
Strategies for combating the problems of HCAI are often simple and effective. Hand washing and cleaner environments as well as better management of antibiotic prescribing are all high on the list of control measures and yet failure to comply with these simple requirements continues to contribute to the burden of HCAI.
The Health Protection Agency, Primary Care Trusts, Local Authorities and acute trusts are continuing to work in partnership through local Health Economy fora to achieve compliance with these control measures and reduce the burden of HCAI within the region.
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References:
- Department of Health 2008. The Health Act 2006: Code of practice for the prevention and control of health care associated infections
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081927 - Healthcare Commission
http://www.healthcarecommission.org.uk/nationalfindings/healthcareassociatedinfection/outbreaksofclostridiumdifficile.cfm - Going further faster: Implementing the Saving Lives delivery programme
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4134547 - Health Protection Agency 2007. Surveillance of Healthcare Associated Infections Report 2007
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1196942166935?p=1158945066450 - Health Protection Agency. Topics A – Z. C difficile
http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1179744911867?p=1179744911867 - Monica Klevens R, Edwards JR et al, Estimating Health-care associated infections and deaths in US hospitals, Public Health Report, Vol 122, CDC, Mar-April 2007
For more information please contact Sarafina
Cotterill
© Public Health, Epidemiology and Biostatistics Unit, School of Health and Population Sciences, University of Birmingham