21 June 2016
Article by Hannah Roberts, National Assembly for Wales Research Service
The term Healthcare Associated Infections (HCAIs) includes Hospital Acquired Infections (infections that develop in a patient 48 hours or more post hospital admission) along with infections acquired directly as a result of care provided in the home, at the GP surgery or in a care home.
HCAIs are seen in about 4% of patients in acute and community hospitals in Wales according to the latest Point Prevalence Survey. They can prove fatal in the most severe cases and, as well as the impact they have on patients, they also result in an increased strain on healthcare resources: a Wales Audit Office report (PDF, 814KB) estimated the cost to the NHS in Wales in the region of £50m per year.
The vast majority of HCAIs are bacterial infections. Urinary tract infections (UTIs) and surgical site infections (SSIs) are the most common sorts, accounting for approximately 21% and 20% of the total respectively. Most UTIs are caused by the bacteria E. coli, whereas Staphylococcus aureus (S. aureus) is the most common cause of SSIs. While the ‘superbug’ Meticillin Resistant S. aureus (MRSA) has received substantial media attention, research shows it only accounts for the minority of S. aureus infections.
It has been reported that 15-30 per cent of HCAIs in Welsh hospitals are avoidable with the implementation of effective infection prevention and control measures.
Welsh Government strategy for dealing with HCAIs
The Welsh Government produced a general strategy for reducing healthcare associated infections (HCAIs) in 2004. UK-wide point prevalence surveys of HCAIs conducted in 2006 and 2011 showed that the prevalence in the acute sector in Wales decreased significantly from 6.4% to 4.4% over that time period.
In 2011 a framework of actions was produced which shifted the focus from control and reduction towards elimination. It also included recommendations on prudent use of antimicrobial medication (such as antibiotics), in response to increasing concern about levels of antimicrobial resistance in Wales.
The five core commitments of this framework were:
- To change the culture across all healthcare organisations to one in which no preventable HCAI is tolerated.
- To strengthen leadership at all levels to improve infection prevention and control (IPC) and antimicrobial stewardship.
- To improve the quality and safety of care by embedding core IPC practices and antimicrobial stewardship in every day activity.
- To measure success in eliminating preventable HCAIs.
- To build and maintain the confidence and understanding of citizens and through a culture of information sharing and transparency.
The Welsh Government followed this up in 2014 with a Code of Practice for the prevention and control of HCAIs, setting out the ‘minimum necessary infection prevention and control (IPC) arrangements for NHS healthcare providers in Wales’.
The first Welsh Government Delivery Plan specifically relating to antimicrobial resistance was published in March 2016. Theme 1 of this plan focuses on continuing to ensure that the Code of Practice for the prevention and control of HCAIs is implemented at that there is compliance to other relevant policies.
Programmes and Initiatives
Welsh Healthcare Associated Infection Programme
The Welsh Healthcare Associated Infection Programme (WHAIP), part of Public Health Wales, provides national leadership for the Welsh Government’s HCAI work. WHAIP has produced national infection control policies for Wales covering 10 key areas. It is the responsibility of individual Trusts/Health Boards to implement and manage HCAI control procedures.
1000 Lives Improvement
The 1000 Lives Improvement (or 1000 Lives Plus) campaign introduces new ways of working to reduce harm, waste and variation. Health Boards, Public Health Wales and various stakeholders are partners in the campaign which has been running since 2008. The healthcare associated infection elements within the campaign include:
- Standard infection control precautions
- Isolation precautions
- Use of antimicrobials
- Management of medical devices
Measures to deal with these elements are detailed in the How to Guide: Reducing HCAIs.
Reducing medical device-related infections
The insertion of medical devices is associated with an increased risk of HCAI; the most recent point prevalence survey found that around 50% of UTIs were catheter-related. The 1000 lives improvement How to Guide states that many hospitals have reduced or eliminated device-related infections through the implementation of care bundles; sets of evidence-based practices that when performed collectively have been proven to improve patient outcomes. Care bundles for urinary catheters and peripheral vascular cannulas (such as IV lines) are described in a second How to Guide.
The use of antimicrobial drugs, as well as contributing to the growth of antimicrobial resistance, is a risk factor for Clostridium difficile (C. difficile) associated diarrhoea. It has been estimated by the Welsh Antimicrobial Resistance Programme that 20-50% of antimicrobial prescription in healthcare settings is inappropriate and therefore results in unnecessary risk.
Health Boards have instituted policies to limit the use of certain broad spectrum antibiotics in order to reduce C. difficile infections. This seems to have had a noticeable effect; both the use of these drugs and the incidence of C. difficile has reduced significantly over the last 10 years.
The Welsh Antimicrobial Resistance Programme conduct annual point prevalence surveys of antimicrobial usage in secondary care. The 2014 survey highlights particular areas where prescribing is failing to conform to guidelines. For example only 48% of antimicrobial prescriptions had a stop/review date recorded in the notes, compared to a target of 95%.
Monitoring the situation
Seven mandatory surveillance schemes are in operation across Wales. These include incidence of S. aureus and C. difficile, blood stream infections, surgical site infections, hospital outbreaks and device-related infections. All Health Boards must report on these and the data is analysed and published by WHAIP. These seven schemes were most recently reviewed by WHAIP and the Welsh Government in 2014.
C.difficile and S. aureus (MRSA and MSSA) have received significant attention. Each Health Board is required to report incidence rates on a monthly basis. In April 2014, the Welsh Government introduced a target to reduce the rate of C. difficile and MRSA bloodstream infections over the next 18 months to 50% lower than the 2012/13 rate. Whilst the target was not achieved, the rates were reduced by 31% and 11% respectively. New reduction expectations have been agreed up to March 2017.
The next point prevalence survey of HCAIs and antimicrobial usage is due to take place later in 2016 as part of the EU-wide survey coordinated by the European Centre for Disease prevention and Control (ECDC). Comparison with the 2011 survey should provide a means of measuring the effectiveness of interventions and efforts to reduce HCAIs over the past 5 years.