Northern Health and Social Care Trust

Introduction

HCAI will occur, when a number of ill persons are cared for "under the one roof" for example in hospitals and nursing homes. While this can be reduced by hygienic practices and environmental cleanliness, it cannot be totally eliminated, particularly in the severely ill and those under going invasive procedures or aggressive modern therapy. Prior to 1994 the occurrence of bacteria resistant to a number of antibiotics was a rare event within the Northern Board Area.

Reasons for Increase in Healthcare Associated Infections

There are a number of factors which have contributed to the rise in HCAIs

(a) Environmental

It is vital that the highest possible levels of environmental cleanliness are maintained in all healthcare facilities. This can be particularly challenging in some of the older buildings currently being used to provide healthcare.

(b) Service Pressures

The increased number of admissions combined with the reduction in beds available resulted in 90-100% bed occupancy. This necessitated changes to increase efficiency in bed management and to overcome "trolley waits" and achieve performance related targets. It involved frequent patient transfers between hospitals and between wards within hospitals, often resulting in hurried cleaning of beds and patient care equipment between each patient’s use.

(c) Antibiotic Prescribing

HCAIs are related to the use of antibiotics and, in particular, inappropriate prescribing of antibiotics. The Northern Trust has had restrictive antimicrobial guidelines in place since 1999, however the present CDAD outbreak demonstrates that the causes of HCAI are multifactorial and all need to be applied concurrently to prevent the occurrence of HCAIs.

(d) Working Practices

There is the need for all staff to comply fully with infection control policies particularly with regard to hand washing, use of protective clothes and cleaning of equipment. To achieve this there is a basic requirement to have the proper skill mix in appropriate numbers to deliver a safe standard of care. Bed occupancy does not accurately reflect activity or through put; the level of activity is such that it is difficult to maintain hygienic practices. In addition, patients, visitors and the general public have also a part to play in preventing the spread of HCAIs.

(e) Demographic Changes

With an ageing population there is a greater number of older people in the community who are often frail and have multiple medical problems. Many of these individuals are at risk of contracting HCAIs. It is important to realise that approximately 75% of medical admission are aged 75 years or greater and require intensive nursing care.

Northern Trust Infection Control Plan

The Trust and legacy Trusts has had an Infection Control and Reduction plan in place for many years; detailing a three year strategy which is reviewed annually and monitored monthly.

Education and training for all staff which includes induction and mandatory training: Various approaches including the use of the Saving Lives programme and the production of a Trust training video have been used to overcome difficulties in releasing clinical staff to attend mandatory training. Service and Ward managers monitor staff attendance.

Trust infection control policies: include hand hygiene, standard precautions and additional precautions which require physical segregation in a single room or cohort bay as required. Patients with infective diarrhoea including CDAD are given priority for segregation The Trust proactively screens for the carriage of MRSA in high risk patients on admission and all patients in Intensive Care Unit (ICU) and the neonatal Unit at admission and on a weekly basis thereafter. The Trust has invested in real time PCR detection of MRSA with a 2 hour turn round time which is used for ICU patients. However to achieve its full potential all patients need to be screened and adequate isolation facilities are required to segregate positive patients.

Surveillance: From 1999 the Trust has monitored the infection control practices by auditing clinical practices, decontamination of equipment and environmental hygiene of each clinical area on an annual basis. The trust operates alert organism surveillance and has maintained a 24/7 microbiology service.

Environmental cleaning: Within the resources available, priority is given to clinical areas.

Public awareness including leaflets for patients and carers.

Antibiotic prescribing protocols.

Antimicrobial guidelines have been in place for primary care since 2003 and for secondary care since 1999 with shared guidelines for A&E and out of hours GP service (2002). Within the resources available An Infectious Disease Team (part time) has audited the use of antibiotics.

Research

The Trust has obtained resources through research grants to evaluate the effectiveness of MRSA decolonisation and the impact of infection control training; both these projects will be completed at the end of 2008. It has completed a time series analysis on the impact of antibiotic use on the emergence of MRSA