2 Achieving Reductions in MRSA bloodstream
and C. Difficile Infection
23. In 2004, the Department acknowledged that progress in implementing
many of the Committee's recommendations from 2000 within NHS trusts
had been 'patchy'. They told the Committee that they intended
to drive through improvements using the same approach to achieving
targets for waiting times: a combination of financial incentives,
performance management, and support.[36]
24. Since 2004, the Department has implemented
a combination of mandatory surveillance, targets, legislation,
inspection and support underpinned by performance management to
help achieve reductions in MRSA bloodstream infections and subsequently
C. difficile infection.[37] Strategic
health authorities have monitored weekly performance towards achievement
of these targets at hospital trust level reporting results to the
Department. The Department have operated national Improvement Teams
offering support and guidance to hospital trusts. 87% of trusts
which had been visited by these teams rated them as effective.[38]
25. The Department has also launched a number
of national initiatives aimed at reducing levels of healthcare
associated infection. These include the deep clean, expansion
of the modern matron initiative, the 'cleanYOURhands'
campaign and a Technology Programme which includes the Rapid Review
Panel. These are estimated to have cost around £120 million
since 2004. Due to the fact that there was a lack of baseline
information on what was happening before these initiatives were
implemented, and many of them were launched concurrently, it is
difficult to judge the impact of individual initiatives on reducing
infections.[39] The Deep Clean, however, has
been successful in improving the confidence of staff and patients
in hospitals.[40]
26. The National Patient Safety Agency's cleanYOURhands
campaign has delivered cost effective improvements in hand hygiene.
Independent evaluation of the campaign found that alcohol hand
rub was strongly associated with reductions in MRSA bloodstream
infections, and that combined use of alcohol hand rub and soap
procurement had risen within hospital trusts.[41]
This followed a recommendation by the Committee in 2004 that the
Department needed to develop a better understanding of the reasons
why compliance with hand hygiene has not been sustained. However,
initially the cleanYOURhands campaign was not
effective in reducing C. difficile as alcohol rub is not
successful in cleaning C. difficile spores from hands, and
new guidance on using soap and water needed to be issued in 2008.[42]
27. Screening of patients for MRSA colonisation is
being introduced in a staged process, with all elective patients
to be screened from April 2009 and all elective and emergency
by 2010-11. The Department estimates that the annual cost from
2010-11 will be £130 million per annum. The Department has
estimated that there will be savings made from reducing MRSA infections
when you take into account reduced cost of treatment and the wider
economic benefits to society. The Department's calculations are
based on reducing MRSA bloodstream infections from a baseline
of 7,000. However, when this screening programme was implemented
in 2009, the number of MRSA blood stream infections was already
less than 3,000. The Department's assumptions are also based on
reducing MRSA wound infections from a baseline of 30,000, but
there is no robust data on these infections.[43]
28. The Rapid Review Panel involves a methodology
for assessing the effectiveness of innovations. The Department
was not able to demonstrate the cost effectiveness of this programme.[44]
29. A final, national initiative, which has had an
impact, has been the introduction of modern matrons. The work
of these modern matrons is seen as contributing to improved cleanliness
and infection control practice. Modern matrons usually work over
two or three wards and are focused on quality of patient care.
Modern matrons are supported by ward sisters or charge nurses
who are responsible for the cleanliness of a ward.[45]
30. There has been a cultural shift in the way
hospital trusts are tackling healthcare associated infection and
the priority that trust boards give the issues, although this
is almost exclusively focused on MRSA bloodstream and C. difficile
infections.[46] Leadership from senior management
and systems of performance management have been key, and have led
to improvements in infection prevention and control across hospital
trusts.[47] However, the fact
that most hospital trusts do not report data on other healthcare
associated infections to the board means that the full picture is
unclear.[48]
31. The Department considered that what happened
at Maidstone and Tunbridge Wells and Stoke Mandeville exemplified
the critical importance of leadership. Whilst systems and processes
may have been in operation, without patient safety being seen
as a number one priority by leaders, required change is unlikely
to take place. The Department has made it clear that accountability
for improving patient safety and tackling healthcare associated
infections lies with the chief executive and trust board.[49]
32. Another initiative that has impacted at trust
level is the need for compliance with an improved regulatory framework.
From April 2009, the Care Quality Commission continues the Healthcare
Commission's work on healthcare associated infections, but with
tougher powers to inspect, investigate and intervene on cleanliness
and infections. The Department considers that this is one way
that trusts will sustain their focus on this high priority issue.[50]
33. Trusts have increased the amount they spend on
tackling healthcare associated infection and the staff resources
devoted to it. In 2007-08, hospital trusts spent approximately
£150 million on expenditure related to infection control.
Total expenditure on cleaning in hospital trusts increased from
£355 million in 2003-04 to £522 million.[51]
In addition to the £63 million the Department allocated for
the one-off deep clean in 2007-08.[52]
The Committee recommended in 2004 that the implementation of cleaning
initiatives should be evaluated by an annual cleaning survey.
Patient Environment Action Team inspections are now carried out
in every hospital and have shown improvements in standards.
34. The Department's estimate of the cost of
treating avoidable MRSA bloodstream infections is around £4,300.
This estimate is, however, based on a methodology and figures
from the 1990s.[53] Nevertheless, using this
estimate we estimate that the cost of treating patients with MRSA
bloodstream and C. difficile infection in 2007-08 was around
£150 million, but that this is £95 million less than it
would have cost if the NHS had not achieved its reductions in MRSA
and C. difficile. Indeed, since the implementation of the
MRSA target in 2004, there have been savings in treating MRSA bloodstream
infections against the baseline of around £45 million, and
savings as a result of the reduction in C. difficile since
2007 of around £96 million. This illustrates the cost benefits
of prevention and, if similar success could be achieved in reducing
the other 80% of healthcare associated infections, there should
be scope for further significant savings to be made.
36 C&AG's Report, para 3.1, Figure 3 Bac
37 Q 9 Back
38 C&AG's Report, para 3.5 Back
39 Qq 36-37; C&AG's Report, para 3.8, Figure
15 Back
40 Qq 58-59 Back
41 Q 15; The National Observational Study to Evaluate
the Cleanyourhands Campaign (2009) Back
42 Qq 5-8 Back
43 Q 38; Department of Health's Regulatory Impact
assessment of screening elective patients for MRSA Back
44 Qq 34-37; C&AG's Report, Figure 15 Back
45 Qq 56-57, 69 Back
46 Q 43 Back
47 Qq 14, 43 Back
48 Q 68; C&AG's Report, para 15 Back
49 Qq 14; C&AG's Report, Appendix 5 Back
50 Q 14; C&AG's Report, para 3.22 Back
51 Department of Health's Estates Return Information
Collection (2009) Back
52 Qq 58-59 Back
53 Q 13 Back
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