Care Quality Commission
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WATCHDOG HIGHLIGHTS BEST PRACTICE AND AREAS FOR ACTION IN NEW REPORT ON HEALTHCARE-ASSOCIATED INFECTION

The Healthcare Commission today 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 emphasises that while boards of trusts have to balance a range of priorities, the safety of patients is paramount.

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, 5 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 said that in order to prevent and manage healthcare-associated infection better, trusts must:

Develop a culture of safety … The Commission said that 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 (DIPC) who reports directly to the chief executive and is accountable to the board. Almost all trusts fulfilled this requirement (95%).

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 (48%) 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.

The report is part of the Commission’s focus on healthcare-associated infection. In June it began a programme of unannounced visits to 120 NHS Trusts. The Commission will have completed 15 visits by the end of this month. Reports on each visit will be published on the Commission’s website.

The Commission’s assessment managers have found many examples of good practice. Most trusts inspected so far are showing that the prevention and control of infection is a fundamental part of the organisation, from the board to the ward. Prevention and control of infection is included in business plans, procedures are in place to isolate patients, trusts are checking that staff have good hand-hygiene practices and the environment is clean. This is evidence of real progress since the survey in May last year.

The programme of inspections has also uncovered areas of concern. The Commission this month issued its first improvement notice, requiring a trust to rectify problems in the training of staff, lack of knowledge about procedures for isolation and poor hand-hygiene. If necessary, the Commission will again use its powers to issue an improvement notice and require immediate action by a trust.

Anna Walker, Chief Executive of the Healthcare Commission, said: "There is no universal ‘quick fix’ for reducing healthcare associated infection; it requires relentless attention to all aspects of recognised good practice, every moment, for every patient.

"The report that we have published today aims to provide advice on good practice, derived from our experience of trusts which are tackling infection control more effectively.

"Our analysis has shown that while safety is the responsibility of everyone, there must be a clear commitment from the trust’s board to infection control; staff designated to infection control with the time to commit to it; regular analysis of what is happening in the trust by board and staff; scrupulous attention to cleanliness; and policies on isolation, bed management and the prescribing of antibiotics.

"Trusts must also remember that amid the complexity and the array of competing priorities, the safety of patients is paramount.

"We’ve certainly seen progress since the survey was undertaken, with the implementation of the Hygiene Code that came into force on 1 October 2006 and a concerted drive by trusts to get the basics in place.

"The latest figures from the Health Protection Agency show that this is beginning to pay off, with the rates of MRSA down on last year and Clostridium difficile rising only marginally compared with the same time in the previous year.

"We cannot afford to loose momentum. Trusts should be asking themselves what more they can do to protect patients and the public from healthcare-associated infection. Trusts must ensure the basics are in place in order to take measures to control infection to the next level.

For a copy of the national visit the Healthcare Commission website at www.heatlhcarecommission.org.uk.

Notes to editors

· A 2006 study by the Hospital Infection Society to establish the

prevalence of healthcare-associated infection in inpatients found that 8.2% of patients in the wards of English hospitals surveyed were suffering from some kind of healthcare-associated infection.

· The National Audit office has estimated that healthcare-associated

infection could cost the NHS as much as £1billion each year.

Information on the Healthcare Commission The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW).

The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information contact Megan Tudehope on 0207 448 0868, or on 07779 990845 after hours.

 

 

 

 

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