Health Business

The latest quarterly figures published by the Health Protection Agency (HPA, 2009a) showed yet another fall in the number of MRSA bacteraemias (bloodstream infections caused by meticillin-resistant Staphylococcus aureus bacteria) reported during a three-month period. The target set by the government to halve the number of these infections from the 2003-4 base line by last year was achieved, and new targets to reduce Clostridium difficile infections (CDI) have been set. Many NHS trusts are already reporting success in this area (HPA, 2009b).
    
Patients receiving healthcare are, however, still at risk of infection. The fact that 676 patients had an MRSA bacteraemia in the last three months of 2008 is a massive improvement on the 1,543 patients who suffered a similar infection in the corresponding period of 2006. But it is still likely that many of these infections could have been avoided.
    
Similarly, while there have been recent reductions in the number of reported cases of CDI – 7,061 in July-September 2008 compared with 10,884 in the same period of 2007 – many of these patients are frail and elderly, and their infection may well have serious consequences.
    
In addition, there are many healthcare-associated infections caused by organisms other than Clostridium difficile and MRSA, and the concern has been expressed that the efforts concentrated on these two organisms may not translate into reductions in overall infection rates.

Everyone’s business
The challenge for healthcare providers now is to ensure that recent improvements in infection prevention are sustained and extended. This has to be a responsibility accepted across the whole health economy: Infection prevention really is everyone’s business.
    
This has been summed up in the past in the phrase “board to ward”, but it could be argued that under current NHS management arrangements these responsibilities go beyond the organisations providing healthcare to the primary care trusts that are responsible for commissioning services.
    
Keeping patients and staff safe
The Health Act 2006 Code of Practice for the Prevention and Control of Healthcare Associated Infections (Department of Health (DH), 2008a) required NHS bodies commissioning healthcare from others to satisfy themselves that contractors had appropriate systems in place to keep patients and staff safe from healthcare-associated infections. While this has been superseded by the Health and Social Care Act 2008 (DH, 2008b), which only applies to providers of healthcare, commissioners should continue to require assurance that these systems are in place.
    
The Health and Social Care Act 2008 identifies some key elements of these systems, in particular good management and organisation, leadership, effective design and maintenance – both of the environment and medical devices – the application of evidence-based practice and education, training, information and communication.

Effective leadership
Leadership takes many forms throughout a healthcare organisation, and effective leadership at all levels is required for infection prevention to be firmly embedded. Clinical managers must lead by example by demonstrating good practice themselves and expecting it from their teams. In addition, senior executives and the Board must cultivate an organisational attitude that infection prevention is important to the organisation because it improves patient safety, and not just because of the need to hit the latest infection reduction target.
    
The executive and board should also ensure that there are clear systems of management and lines of accountability for infection prevention, not just through clinical services but also through estates and facilities services, to ensure that cleaning and maintenance programmes and new builds are designed with infection prevention in mind.
    
Effective design and maintenance requires a combination of talents, and is most likely to be achieved when there is effective collaboration between experts in the different fields who can learn from each other. Practitioners in infection prevention need a working knowledge of such varied estates issues as ventilation and flooring materials, as well as being familiar with the practicalities of facilities management in providing cost effective cleaning, laundry and catering services, while the experts in those fields need to know what is required, and what is less desirable, to promote infection prevention.
    
Effective collaboration of this nature can lead to infection risks being “designed out” of healthcare premises and services. Again, effective leadership is necessary to get the best out such collaborations. Very often this will come from the infection prevention practitioner as the individual with the widest range of clinical and other experience, but in practice the leadership abilities of this person are more important that their knowledge or profession in drawing out the best from all the individuals involved.

Education and training
In order to ensure that all the individuals from different professions have the skills and knowledge that they need to incorporate infection prevention into their practice, effective and appropriate education and training needs to be provided. The logistics of providing this for a large organisation can be a considerable challenge, and a number of different approaches have been utilised throughout healthcare, including face-to-face teaching, cascade training through link staff, online training packages and mandatory workbooks.
    
In practice it is unlikely that any single approach will be suitable for all staff groups, or even for providing all the required training and education for a single staff group, and a combination of approaches will be required.
    
Resources to aid education and training in infection prevention and control are available from a wide range of organisations from commercial providers to the Department of Health and professional organisations. One such is the Infection Prevention Society (IPS).
    
Incorporating the Infection Control Nurses Association, the IPS works together with healthcare colleagues, professional bodies, industry, government agencies and voluntary organisations to promote the prevention and control of infection, particularly in healthcare. In particular it aims to promote and provide training courses, accreditation schemes, educational materials, meetings and local and national conferences. Notable events in 2009 include a one-day conference in Birmingham 30 June and Infection Prevention 2009 21-23 September in Harrogate.
    
The first of these comprises programmes in education and professional development, community healthcare and, in partnership with the Association for Perioperative Practice (AfPP), the prevention of surgical site infections. The September Conference has a full programme of speakers and workshops over the three days as well the first full day’s programme organised by the recently-established IPS IV Forum, looking specifically at preventing infections associated with intravenous access. There will also be a series of free drop-in sessions on two of the days. Aimed primarily at workers in nursing and residential homes but open to all healthcare staff these sessions will focus on key issues in this sector such as the management of MRSA, Clostridium difficile infection and scabies.
    
More details of IPS events are available on the Society’s website at www.ips.uk.net.

Sharing knowledge
Membership of the Society is open to all those working in, or with an interest in, the prevention and control of infection. Local IPS meetings are normally free to members and usually include an educational session, while IPS-organised educational events are supported by industry colleagues to keep the cost as low as possible to ensure that they are accessible to the maximum number of people. The fee for the annual conference is also reduced for members. Members receive the Journal of Infection Prevention as a benefit of their membership.
    
The IPS produces quality improvement tools to help healthcare organisations monitor the quality of their service. These are currently being reviewed and the new versions, including tools for operating theatres, endoscopy suites, care homes and mental health and learning disability healthcare facilities – as well as general acute ward areas – will be a valuable aid for organisations aiming to maintain and improve the safety of their patients by protecting them from infection.
    
Many organisations have made a fantastic start by reducing MRSA and CDI. The focus on HCAI will continue over the next few years, with trusts working to reduce infections due to a range of micro-organisms. It is clear that industry and professional societies such as the IPS will need to continue to work closely in support of this agenda if real and sustained benefits to patient safety are to be realised in the long-term. It has definitely been a good start.

Paul Weaving is Editor of the Journal of Infection Prevention, and Lead Nurse, Infection Prevention and Control, at The Royal Marsden NHS Foundation Trust. E-mail This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Department of Health (2008a) The Health Act 2006: Code of practice for the prevention and control of healthcare-associated infections. Available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081927. Accessed 22.4.09
    
Department of Health (2008b) The Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. Available at www.mrsaactionuk.net/pdfs/Hygiene%20Code%20Revised%20January%202008.pdf
    
Health Protection Agency (2009a) Quarterly Results from the mandatory surveillance of MRSA bacteraemia. Available at www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1233906819629.
    
Health Protection Agency (2009b) Clostridium difficile infections continue to fall. Available at www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1239781746891?p=1231252394302.