A new paradigm is needed for the control of MRSA, C difficile and other healthcare-associated infections, global experts agreed at the first International HCAI Technology Innovation Summit, London, UK
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The summit was held to celebrate the first anniversary of the HCAI Technology Innovation Programme, a joint initiative by the Department of Health and the NHS Purchasing Supply Agency.
As well as showcasing new technologies currently being piloted in the NHS, the summit looked at the international landscape of HCAI prevention, and enabled clinicians and policymakers from both sides of the Atlantic to share current practice successes and failures.
Speakers expressed widespread concern about prescribing antibiotics, and a consensus was reached at the end of the day that an “integrated approach” is needed to combat the rising tide of HCAIs.
Dennis Maki (professor of medicine, University of Wisconsin School of Public Health, and consultant to the Centers for Disease Control) told delegates: “HCAIs are still the greatest threat to hospital patients in the US, despite a multifaceted approach to infection and control over the past 35 years.”
He said 90% of nosocomial infections are preventable, but consistent compliance of infection control practices is difficult to achieve, especially when there are staff shortages. Studies repeatedly showed that hand hygiene compliance was “dismal”, despite evidence demonstrating the effectiveness of hand hygiene practices and the availability of guidance for healthcare professionals.
An “institutional approach” to infection control is needed, and technology, “a useful adjunct to good practice,” has a vital role to play. He cited a number of technologies with the potential to reduce rates of HCAIs, including a chlorhexidine-impregnated wipe used to administer total body washing to patients. This has been found to reduce the risk of central venous line-associated bloodstream infections by 60%.
Professor Maki said healthcare professionals must work smarter, rather than ever harder, and find new ways to assess the impact of their interventions.
Payment by performance in the USA
Pennsylvania, which pioneered reporting of hospital HCAIs in the USA in 2004 by making it mandatory, is now seeing a reduction of HCAI rates because of the growth in transparency related to patient safety generally, and HCAIs specifically, according to Patrick Brennan (CMO, University of Pennsylvania Health System, and professor of medicine and infectious disease). Disclosure of HCAI rates is now mandatory or under consideration in the vast majority of states, and there are also moves towards disease-specific reporting. “Rising healthcare costs are a big driver for change in HCAI prevention,” said Professor Brennan.
Currently, both federal and private funders are moving towards payment by performance and requiring reduction of HCAIs. Medicare – one of the two federal healthcare programmes providing healthcare for US citizens without health insurance – is destined to go bankrupt within seven years unless the system is reformed. Traditionally, healthcare funding in the USA has paid hospitals based on the complexity of care provided – effectively rewarding them for HCAIs. Now there is the prospect of a punitive system being introduced in which fines would be levied in some cases.
Studies in the Netherlands
Jan Kluytmans (VUmc Medical University, Amsterdam and Amphia Hospital, Breda, Laboratory for Microbiology and Infection Control, Netherlands) reported on the outcomes of a number of Dutch studies aimed at controlling resistance in hospitals. He said cross-infection is largely preventable but remains a challenge to most hospitals. Patient safety requires more than prevention of cross-infection, and an integrated approach was “mandatory” for a successful programme.
He said bacterial resistance adds significantly to the burden of disease, pointing out that while the number of deaths from nonresistant Staphylococcus aureus in the UK has remained relatively stable, there has been a huge rise in deaths from resistant forms.
Professor Kluytmans went on to say that levels of resistance directly correlate with levels of antibiotic use. Given this relationship between levels of antibiotic use and levels of resistance, it is a cause of concern that in a study of prescribing records, of 4,100 patients in the Netherlands in 2000, 23% received antibiotics. Of these, 40% of prescriptions were inappropriate either because the dose or drug was incorrect or because no antibiotics were indicated. Only 0.6% of patients did not receive antibiotics when they may have been indicated – of these, most either received them within a week, were discharged without needing them or were deliberately not treated because they were dying; in the remainder it was unclear from patient records whether antibiotics were indicated.
He also reported on a study examining the effectiveness of four interventions designed to improve the use of ciprofloxacin. The first was to move from intravenous to oral administration, and this alone resulted in a 70% reduction in use. After three further interventions (the introduction of a new formulary and staff education; laboratory reporting on use of ciprofloxacin; and active feedback on prescriptions) use had dropped by 85%. He said the rising trend in incidence of ciprofloxacin-resistant Escherichia coli in the hospital was reversed after the four interventions were introduced.
Professor Kluytmans also spoke about studies evaluating the effectiveness of reducing HCAIs by interventions such as decontaminating the digestive tracts of surgical patients expected to be admitted to intensive care after surgery. One study showed a 17% reduction in mortality and also reduced hospital stays. Another study showed rapid screening for S aureus in patients’ nasal mucosa on admission, followed by treatment of carriers, reduced postoperative infections from 7.7% in the untreated group to 3.4% in the experimental group and reduced average hospital stays.
However, he pointed out that community-acquired MRSA poses a threat to strategies to reduce staphylococcal infections. He called on healthcare providers to address this growing problem by focusing on risk groups such as surgical patients in their efforts to prevent the bacteria from infecting carriers or other patients.
HCAI in the UK
English Health Minister Ann Keen told the conference that tackling HCAIs, especially MRSA and C difficile is a key priority for the NHS. The target to halve MRSA bloodstream infections has been met and exceeded, and they are on course to maintain the reduction. This has been achieved through a raft of different measures, including extra funding and more support for hospitals that needed it.
Ms Keen, a former nurse, said in combatting HCAIs there were “few real substitutes for hand hygiene and aseptic techniques along with prudent antibiotic prescribing”.
However, she also emphasised the important role innovative use of technology can play, and reported on the success of the Department of Health’s HCAI Technology Innovation Programme. Launched in autumn 2007 to accelerate the development and adoption of new and novel technologies to help fight infection, it promotes collaboration between industry, the academic community and the health service. New products in the pipeline include a first-responder suit that will enable emergency professionals to work safely in hazardous areas such as chemical spills for up to two hours. Plans for the coming year include: rapid point-of-care testing for MRSA in under 30 minutes and introducing new methods and technologies to improve hand hygiene compliance.
“We all face largely the same challenges with infection control wherever we are in the world,” said Ms Keen, who hoped the summit would help develop international relationships to combat HCAIs.
The HCAI Technology Innovation Programme was launched in January 2008 in the Department of Health publication Clean, Safe Care – Reducing Infection and Saving Lives. Further information at www.clean-safe-care.nhs.uk