Reducing MRSA

MRSA and other healthcare associated infections like Clostridium difficile impact on every element of healthcare: they reduce the quality of care for patients, increase costs for providers and commissioners, reduce safety, hamper productivity and efficiency and damage the reputation of the NHS. Aside from the anxiety and distress caused to patients, these infections impact negatively across organisations too. If the impact on patients is not enough of a driver in itself then lets look at the business case as a means for improvement.
   
Going Further Faster (DH, May 2006) explains clearly to NHS leaders why reducing MRSA is so significant. Meeting the national target is paramount but it is about more than that if we want sustainable cultural change. This article explains just how healthcare organisations can make dramatic reductions to infections, why it is important and how to sustain momentum in delivery of clean and safe services.
   
Learning to date shows us that focusing our effort on big wins in specific areas, rather than doing everything we can across the board, will yield bigger gains. Maintaining high standards of infection prevention and control should be core business across healthcare, but ensuring reliability and reducing infections requires us to focus our energy where it matters most. I am often asked “But why is this important?”. The answer is simple - the NHS needs to provide care that is safe, of high quality, is efficient and has the confidence of the patients receiving it. Managers across the board including facilities, IT, HR as well as clinical and medical leaders must recognise that HCAIs severely hamper efficiency, flexibility and productivity.

What price for safety?
If we take a trust that has 40 MRSA bacteraemias in a year (below the average figure), based on £4,000 to £10,000 per infection to treat patients needing extra days in hospital, then this is a cost of between £160K to £400K per year just on MRSA bacteraemias. This takes no account of other HCAIs which could put this figure to between £1.6m and £4m. The financial and productivity argument for improvement alone means that reducing infections must be core business. If you add the harm and anxiety caused to patients then this has to be a top priority.
   
Guy’s and St Thomas’ Foundation Trust recently reduced their rates and state that savings associated with this were approximately 4,000 bed days, £1.4m in hospital costs, prevention of around 100 bacteraemias and 360 surgical site infections.   American studies have demonstrated that the cost of a ventilator associated pneumonia infection is around $12K per patient. These costs do not reflect the suffering to patients and families from healthcare associated infections. However, they go far in showing that the rewards for improved infection prevention and control speak for themselves.

Reliable care
In the new NHS landscape of Patient Choice, trusts will be judged by their ability to provide high quality care that is safe and reliable. Trusts that do not proactively reduce risk, improve cleanliness and reduce infection will not be the first choice for patients.
   
Under Payment by Results procedures will attract a defined tariff. If an infection occurs then the cost to the Trust will increase. If we take the above example of the costs of 40 MRSA bacteraemias then the impact on the balance sheet is significant.
   
Focusing energy where it matters most sits at the core of Going Further Faster. Providing high reliability to key clinical procedures by using the Saving Lives High Impact Interventions (www.dh.gov.uk/reducingmrsa ) allows trusts to monitor compliance and drive improvement. Trusts should risk assess their patient groups to identify which specialties require screening and/or decolonising before treatment.
   
Trusts like Leeds Teaching Hospitals NHS Trust have introduced protocols to screen or decolonise patient groups which present high risk as part of a package of measures to reduce infections. Trusts like Leeds, and Guy’s and St Thomas’ have seen significant reductions in these areas. Professor Brian Duerden, (Inspector of Microbiology, DH) is consulting on screening protocols now and CMO and I will be writing to the service with options and recommendations in the Autumn.

Engaging staff
Managing performance at every level underpins the strategy to sustain momentum and improvement and make infection prevention and control everyone’s business. Focusing on the key challenges within our delivery programmes will help the NHS to ensure their action plans incorporate national guidance and good practice, engage staff and make staff accountable for improvement. Individuals need to know the contribution they can make and how to make it - applying the principles of good infection prevention and control to everyday work. This must be reflected in personal development plans. Key steps to make this happen are: including infection control in job descriptions, ensuring all staff, including consultants, discuss infection control in appraisals and ensuring performance assessment includes HCAI performance. A good starting point for raising staff awareness is www.infectioncontrol.nhs.uk which is a free online and face to face tool for clinical and non-clinical staff about the principles of infection control.
   
At an organisational level clear accountability is fundamental - the Board and individual directorates require clear and comprehensive reports on HCAI including real time MRSA data. Typically focusing on priority or high risk areas through balanced scorecards will drive local improvement. As well as the scorecard within Saving Lives, trusts should consider using MSSA/MRSA numbers and rates, PEAT scores, other MES reported infections, compliance data for the high impact interventions, length of stay, lost bed days and antibiotic use and costs.
   
Individual actions of staff gather momentum to create change across an organisation and managers must create a culture where the trust is striving for “no avoidable infections”. We know not all infections are avoidable but a significant proportion of them are.

“No avoidable infections”
What would “no avoidable infections” look like as a culture? In my view its where infection control is owned by individual directorates, being supported by infection control teams. It is where all staff understand their role, responsibility and contribution and where there is high reliability to key clinical procedures. There is real clinical engagement embedded in HCAI and managers and professionals take a collaborative approach to improvement. Patients have confidence in the service provided, there are good news stories about the trust and ultimately patients choose that hospital rather than elsewhere.
   
Learning about the causes of infection will help us all to plan services that reduce infections happening in the future. Using the newly developed Root Cause Analysis Tool, developed by the NPSA, will ensure that MRSA bacteraemias are isolated as clinical incidents. Each bacteraemia should be investigated and measures enacted to ensure that another does not occur in the same way. The tool (www.npsa.nhs.uk ) focuses on learning, responding and reacting to causes of infections like MRSA bacteraemias and “designing them out” of the system locally.

Hitting the target
There is no doubt that meeting a trusts target and reducing MRSA bacteraemias by 60 per cent by March 2008 is going to challenge us all. It is not like other targets as it relies on significant behavioural change within acute trusts but also involves those actions taken by other staff across the NHS.
   
To ensure a whole system reduction of HCAIs I recently launched Essential Steps to Safe Clean Care. This is the delivery programme for care outside of the acute hospital. It uses the same tools, key challenges and balanced scorecards as the Saving Lives programme but applies to PCTs, Mental Health Trusts, GP surgeries, care homes, independent providers and residential homes. We urge these providers to sign up to this programme (www.dh.gov.uk/reducingmrsa ) and commit to a sustainable reducing of risk from HCAI. Reducing the risk of infection goes beyond the hospital - its needs to be part of the whole system. Whether we are motivated to reduce MRSA because of the suffering this causes or because of the money we save the outcome is the same: cleaner, safer more reliable care. This outcome is also central to the Health Act 2006. Within the Act, which received Royal Ascent in July, there is a dedicated Code of Practice for the reduction of HCAI. This gives us all a real opportunity to motivate our teams towards no avoidable infections. The Code is currently at draft stage but its intent is clear- safer, cleaner care for every patient. Services will be judged against this Code and their improvement history.
   
Implementing the action within Saving Lives, Essential Steps and those talked about in Going Further Faster will ensure the proactive reduction of risk from HCAI. I firmly believe that by embedding good infection prevention and control across every clinical setting we will make the NHS safer for patients, more productive and more reliable. The benefits are clear for all to see so let us aim for no avoidable infections and focus our energy where it matters.

For more information
Full details of all of the publications and tools is available at: www.dh.gov.uk/reducingmrsa  

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