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The Sc ottish Parliament and Scottis h Parliament Infor mation C entre l ogos .
SPICe Briefing
Healthcare Associated Infections
16 November 2011
11/80
Sobia Raza
Healthcare associated infections (HAIs) are infections acquired in a hospital or other healthcare
settings. HAIs can arise as a result of a range of medical procedures and are caused by a
number of micro-organisms. This briefing outlines the prevalence and burden of HAIs, and
examines the trends in levels of key HAIs in Scotland over the past years. An overview of the
strategies in place for tackling these infections is provided. Finally research progress and
priorities in this area are explored.
CONTENTS
EXECUTIVE SUMMARY .............................................................................................................................................. 3
ACCRONYMS AND ABBREVIATIONS ...................................................................................................................... 4
INTRODUCTION .......................................................................................................................................................... 6
WHAT ARE HEALTHCARE ASSOCIATED INFECTIONS (HAIS) .......................................................................... 6
THE MOST COMMON HAIS AND CAUSATIVE MICRO-ORGANISMS ................................................................. 6
THE BURDEN OF HEALTHCARE ASSOCIATED INFECTIONS ............................................................................... 9
RISK AND INCONVENIENCE TO PATIENT ........................................................................................................... 9
BURDEN ON THE HEALTH SERVICE.................................................................................................................. 10
ECONOMIC BURDEN OF HAIS ............................................................................................................................ 11
TRENDS IN HEALTHCARE ASSOCIATED INFECTIONS ....................................................................................... 12
RATES OF INFECTION – SCOTTISH NHS BOARDS .......................................................................................... 12
STAPHYLOCOCCUS AUREUS BLOOD INFECTIONS .................................................................................... 12
CLOSTRIDIUM DIFFICILE INFECTIONS ......................................................................................................... 14
SURGICAL SITE INFECTIONS ......................................................................................................................... 15
HAI PREVELANCE – REST OF THE UK AND EUROPE ..................................................................................... 17
PREVENTION............................................................................................................................................................. 18
EFFECTIVENESS OF HAI PREVENTION MEASURES ....................................................................................... 19
BEHAVIOURAL FACTORS ............................................................................................................................... 19
ORGANISATIONAL FACTORS ......................................................................................................................... 20
CURRENT POLICY FOR TACKLING HEALTHCARE ASSOCIATED INFECTIONS .............................................. 22
GOVERNANCE – THE HEALTHCARE ASSOCIATED TASK FORCE ................................................................. 22
MAIN OUTCOMES OF THE HAI-TASK FORCES FIRST TWO WORK PROGRAMMES ............................... 22
THIRD PHASE OF THE HAI TASK FORCE’S WORK ...................................................................................... 25
OTHER DEVELOPMENTS – VALE OF LEVEN ................................................................................................ 27
CASE STUDY: DUTCH MRSA CONTROL STRATEGY ....................................................................................... 28
OTHER KEY ISSUES ................................................................................................................................................. 29
EMERGING HAI PATHOGENS ............................................................................................................................. 29
RESEARCH INITIATIVES AND PRIORITIES ........................................................................................................ 29
SOURCES .................................................................................................................................................................. 31
APPENDIX 1............................................................................................................................................................... 37
APPENDIX 2............................................................................................................................................................... 38
APPENDIX 3............................................................................................................................................................... 39
APPENDIX 4............................................................................................................................................................... 41
RELATED BRIEFINGS ................................................................................... ERROR! BOOKMARK NOT DEFINED.
2
EXECUTIVE SUMMARY
Healthcare associated infections (HAIs) are infections acquired by patients in a hospital or as a
result of healthcare intervention. In contrast, community acquired infection are those infections
contracted in the community, outside and prior to hospital admission. Surveys have revealed
9.5% of patients in Scotland have an infection that was not present or incubating at the time of
their acute hospital admission. Most HAIs are caused by bacteria. These bacteria are also found
in the general population and mostly exist harmlessly in the general environment. However in a
healthcare setting the chances of these micro-organisms causing an infection is increased
considerably. The major reasons for this are that hospital patients already have poor health or
an underlying condition and this can impair their natural immune defence. Furthermore,
healthcare treatments and procedures such as surgery can expose entry routes for the infection
causing micro-organisms (also known as pathogens).
The most common types of HAIs in Scotland are; lower respiratory tract infections (including
pneumonia), urinary tract infections and surgical site infections. These infections are commonly
related to healthcare procedures for example, use of mechanical ventilation, urinary
catheterisation and surgery. The most common types of HAI causing pathogens are the bacteria
Staphylococcus aureus (S. aureus), followed by Clostridium difficile (C. difficile) and a class of
bacteria known as Coliforms. Staphylococcus aureus can be further classified based on its
ability to be treated with the common antibiotic Methicillin. A strain of S. aureus that is resistant
to treatment with Methicillin is known as Methicillin Resistant Staphylococcus Aureus (or
MRSA). Data shows that C. difficile infections and bloodstream infections caused by MRSA
have been decreasing since surveillance began in Scotland. Conversely trends in deaths where
MRSA or C. difficile have been involved have generally been increasing at least up until the
year 2008. This anomaly may be explained by increased professional awareness of these
pathogens, resulting in better recording on death certificates.
Not all HAIs are preventable. Most estimates suggest around 20-30% of HAIs could be
prevented. The annual cost of HAIs to NHSScotland is estimated to be £183 million. It has
been suggested that cost savings of £36.6 million are possible if a 20% reduction in HAIs were
to be achieved. The single most cost effective intervention to prevent the transmission of HAIs
is good hand hygiene.
The Scottish Government‟s Healthcare Associated Infection (HAI) Task Force is responsible for
overseeing and co-ordinating the development and implementation of the national strategy on
HAIs. The Task Force has published three delivery plans for tackling HAIs to date. Key
strategies have included; HAI surveillance, development of educational programmes, hand
hygiene policy, and more recently an MRSA patient screening programme. Pre-emptive
screening for MRSA has been in place for many years in the Netherlands, a country with
relatively low rates of MRSA infection. Prudent use of antibiotics is also recognised as a crucial
factor in controlling HAIs. Increased exposure to antibiotics can allow HAI causing bacteria to
adapt and become resistant to treatment. Novel antibiotics to tackle HAIs are needed, however
the expense and risk involved in developing these is speculated to be a deterrent for
pharmaceutical companies to invest.
3
ACCRONYMS AND ABBREVIATIONS
BMA
British Medical Association
C. difficile
Clostridium difficile
CABG
Coronary Artery By-pass Grafting
CDI
C. difficile Infection
CDC
Centre for Disease Control
CNS
Coagulase-Negative Staphylococci
DoH
Department of Health
EARS-Net
European Antimicrobial Resistance Surveillance System
E.Coli
Escherichia coli
ECDC
European Centre for Disease Prevention and Control
GI
Gastrointestinal
GROS
General Register Office for Scotland
HAI /HCAI
Healthcare Associated Infection
HAI-SCRIBE Healthcare Associated Infection - System for Controlling Risk In the Built
Environment
HDL
Health Department Letter
HEI
Healthcare Environment Inspectorate
HFS
Health Facilities Scotland
HPA
Health Protection Agency
HPS
Health Protection Scotland
ICU
Intensive Care Unit
ISD
Information Services Division
NDM-1
New Delhi metallo-beta-lactamase-1
NHS
National Health Service
NHS NES
NHS Education for Scotland
NHS QIS
NHS Quality Improvement Scotland
4
PDS
Post Discharge Surveillance
PICT
Public Involvement and Communications Team
MRSA
Methicillin Resistant Staphylococcus Aureus
MSSA
Methicillin Sensitive Staphylococcus Aureus
S. aureus
Staphylococcus aureus
ScotMARAP Scottish Management of Antimicrobial Resistance Action Plan
SGHD
Scottish Government Health Directorates
SIRN
Scottish Infection Research Network
SPCC
Statistical Process Control Charts
SSI
Surgical Site Infection
SSHAIP
Scottish Surveillance of Healthcare Associated Infection Programme
VRSA
Vancomycin-Resistant Staphylococcus aureus
WHO
World Health Organisation
5
INTRODUCTION
WHAT ARE HEALTHCARE ASSOCIATED INFECTIONS (HAIs)
Healthcare Associated Infections (HAIs) are infections that develop as a direct result of any
healthcare intervention or contact in a healthcare or hospital setting. A “healthcare” setting is
inclusive of other medical locations in addition to hospitals, for example care homes, general
practice and dental surgeries.
“HAI” was originally used to abbreviate hospital acquired infection, which strictly speaking refers
to an infection that develops 48 hours or later after patient admission to a hospital. In
recognition of the increasingly complex procedures now undertaken outside hospitals, the term
“healthcare associated infection”, was coined1. The acronyms HCAI and HAI are used
interchangeably, to define healthcare associated infections. The term “nosocomial infection” is
synonymous with hospital acquired infection.
Community acquired infections are infections acquired by patients in a community setting,
outside and prior to their hospital or healthcare admission. The distinction between community
acquired and healthcare associated infections becomes significant where symptoms of an
infection present during the early stages of hospital admission (first 48 hours). In this scenario it
is generally considered that the infection was incubating prior to hospital admission and was
contracted in the community.
In 2006, a prevalence survey in England, Wales, Northern Ireland, and the Republic of Ireland
found 7.6% of patients have an infection that was not present or incubating at the time of their
acute hospital admission (those intended for short term medical care or surgical intervention)
(Smyth et al., 2006). Using the same HAI definitions as the four country study, Health Protection
Scotland (HPS) also performed a survey during 2005-2006. The national survey found the
prevalence of HAIs was 9.5% in acute hospitals and 7.3% in non-acute hospitals in Scotland
(Reilly et al., 2007).
THE MOST COMMON HAIS AND CAUSATIVE MICRO-ORGANISMS
A range of organisms are associated with the pathogenesis of HAIs. Although their existence is
prevalent in the general population and environment, the chances of these pathogens
manifesting into an infection is increased considerably in a hospital setting for several reasons;

Patients already have a medical condition or underlying illness and this can impair
their natural defence response against pathogens.

Patient wounds obtained through injury or surgery can provide a route of entry for
certain pathogens, as can the use of invasive medical devices (such as catheters,
drains and tubes).

Certain treatments can leave patients vulnerable to infections. Immunosuppressive
drugs, antimicrobial treatments and recurrent blood transfusions are all risk factors.

The nature of a hospital environment itself is a major contributory factor. Turnover of
patients and personnel, the concentration of people with poor health, and movement
1
This briefing will use the acronym “HAI” to refer to Healthcare Associated Infection, unless quoting sources that
use other abbreviations.
6
of medical staff from patient to patient all provide a fast means for spreading
pathogens.
The most common causative organisms identified in patients during the prevalence survey of
HAIs in acute hospitals in Scotland were the bacteria Staphylococcus aureus (S. aureus),
followed by Clostridium difficile (C. difficile) and a class of bacteria known as Coliforms
(Escherichia coli (E.coli) is the most well known member). Staphylococcus aureus can be
further classified as Methicillin Resistant Staphylococcus aureus (MRSA) or Methicillin Sensitive
Staphylococcus aureus (MSSA). MRSA is any strain of S. aureus that has developed resistance
to treatment with the antibiotic Methicillin. MSSA infection on the other hand can be treated with
Methicillin and has yet to become resistant to common antibiotic treatments. MRSA accounted
for 66% of all reported S. aureus infections in acute hospitals in Scotland (Reilly et al., 2007). A
full breakdown of the frequency at which different HAI causing pathogens were reported in
patients diagnosed with HAIs is shown in Table 1. The data (Table 1) is based on only those
infections where the type of pathogen was confirmed by laboratory analysis.
Table 1: Number and percentage of ten most frequently occurring organisms reported for
inpatients diagnosed with HAI in acute hospitals. Data extracted from the Health Protection
Scotland report on HAI prevalence.
Organism
Clostridium difficile
Staphylococcus aureus (MRSA) methicillin-resistant
Staphylococcus aureus (MSSA) methicillin-sensitive
Coliform (unspecified)
Escherichia coli
Coagulase-negative staphylococci (CNS)
Enterococcus spp.
Candida spp.
Enterococcus faecalis
All Other organisms*
Total
Type of
Pathogen
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Bacteria
Fungus
Bacteria
Reporting
Frequency
Number
%†
95
17.6
93
17.2
48
8.9
46
8.5
36
6.7
26
4.8
21
3.9
16
3.0
12
2.2
147
27.2
540
100.0
† The percentage reported is: (Count of Organisms reported / Count of all organisms reported) x 100
* The remaining organisms were grouped as „All Other organisms‟
Source: Reilly et al., 2007
The most common types of HAIs occurring in acute hospitals in Scotland were of the urinary
tract (17.9%), surgical sites (15.9%), gastro-intestinal (15.4%), followed by eye, ear, nose, throat
and mouth infections (12.5%) (Reilly et al., 2007). Lower respiratory tract infections (including
pneumonia) accounted for 20.0% of all HAIs. Pneumonia considered alone accounted for 8.8%
of all HAIs. Table 2 outlines the different types of HAIs, risk factors for contracting them and
their common causative micro-organisms.
7
Table 2: Overview of different healthcare associated infections. Infection percentages are
based on acute hospital inpatients in Scotland, extracted from the Health Protection Scotland
report on HAI prevalence, and presented as a percentage of all HAIs recorded.
Infection Type
and
(Percentage of
all HAIs)
Lower
Respiratory Tract
Infections
including
Pneumonia
(20.0%)
Urinary Tract
Infections
Description
Infections of the airways and the
lungs.
Pneumonia accounts for the
largest proportion of lower
respiratory tract infections in
Scotland (44.0%).
Urinary tract infections arise when
pathogens enter the urinary tract
and bladder.
(17.9%)
Surgical Site
Infections
(15.9%)
Gastrointestinal
(GI) Infections
(15.4%)
Ear, eye, nose,
throat, and
mouth infections
Wound infections occurring after
an invasive surgical procedure.
Examples include hip arthroplasty/
caesarean section, open heart
surgery.
Infections of the stomach, intestine
(digestive tract). An example of a
causative bacterium is C.difficile
which is released into the
environment as spores released
from faeces and can survive for
long periods outside the body.
Another causative pathogen
Norovirus, is also highly
contagious.
Infections of the oral cavity, upper
respiratory tract, eyes, (including
conjunctivitis).
Risk Factors and
Complications
Mechanical ventilation.
Contraction of pneumonia is the
most severe respiratory tract
infection, with fatality rate
approaching 40%.
Urine catheters.
Antibiotic resistance may develop in
patients with long term catheters
Duration of surgery, surgery
techniques, preparation, presence
of foreign material, and duration of
hospital stay.
Antibiotics use can disrupt the
balance of naturally occurring
bacteria in the gut, allowing the
usually modest number of C. difficile
to become over-populated.
The elderly (age 65+) are a high risk
group for C. difficile infection.
Risk factors are often site specific.
For example removal of tonsils is a
risk factor for healthcare associated
throat infections.
(12.5%)
Skin and soft
tissue Infections
Infections can be at the skin
surface or deeper and even
necrotizing (flesh eating).
Management of open wounds and
sores. Peripheral catheters.
Local infection can develop around
catheter entry site or / and
pathogens may enter the blood
stream and cause more serious
infection referred to as sepsis.
Other infection categories are;
Bone and joint, central nervous
systemic, cardiovascular system,
reproductive system, and systemic
infections.
Invasive devices, including
intravenous access devices.
Main Causative
Pathogen
Bacteria, including
Acinetobacter
species and
Staphylococcus
aureus (S. aureus).
Bacteria, in
particularly
Escherichia coli (E
coli).
S. aureus is the most
common.
Pseudomonas
aeruginosa.
Most healthcare
associated GI
infections are caused
by the bacterium
Clostridium difficile
(C. difficile).
Norovirus is also a
contagious virus
responsible for
stomach flu.
Range of pathogens,
although some are
specific to location.
Bacteria include:
MSSA, MRSA,
Pseudomanas,
Streptococcus and
E.coli. Virus:
Influenza. Fungus:
Candida.
S. aureus.
(11.0%)
Bloodstream
Infections
(4.4%)
Others
(3.2%)
E.coli, S. aureus,
including MRSA
Sources: Reilly et al., 2007; National Audit Office, 2009
8
THE BURDEN OF HEALTHCARE ASSOCIATED INFECTIONS
RISK AND INCONVENIENCE TO PATIENT
In terms of burden to patients who contract a HAI, the infection may:






complicate an existing medical condition
extend the duration of their stay in hospital
lead to physical and/or emotional stress
lead to a loss of earnings
reduce the chance of a successful recovery
and in the worst scenario, result in death
The General Register Office for Scotland (GROS) records and publishes data on deaths in
which C. difficile and MRSA have been involved (see Tables 3 and 4). Over the past decade or
so there has been a general upwards trend in the number of deaths where MRSA and C.difficile
have been mentioned, however the data for the last two years shows MRSA and
C. difficile related deaths have fallen. Figures should be interpreted with caution as changes in
the number of cases year on year may be influenced by increased professional awareness of
MRSA and C. difficile and subsequent recording on death certificates. This suggestion may well
be corroborated by the fact that surveillance data for these pathogens shows a downwards
tread in infection rates over the years.
Table 3 – MRSA related deaths in Scotland from 1996-2010. MRSA was: (a) recorded as the
underlying cause of death; (b) described as a contributory factor; and (c) mentioned as either
the underlying cause of death or a contributory factor.
Deaths where MRSA is mentioned as:
Year
(a) an underlying
cause
(b) a contributory
factor
6
28
13
56
14
64
22
72
35
74
36
100
46
109
39
130
42
148
38
174
51
162
56
174
48
166
24
137
25
93
Source: The General Register Office for Scotland(a)
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
(c) either the underlying
cause or a contributory
factor
34
69
78
94
109
136
155
169
190
212
213
230
214
161
118
9
Table 4 – C. difficile related deaths in Scotland from 2000-2010. C. difficile was: (a)
recorded as the underlying cause of death; (b) described as a contributory factor; and (c)
mentioned as either the underlying cause of death or a contributory factor.
Deaths where C. difficile is mentioned as:
Year
(a) an underlying
cause
(b) a contributory
factor
38
78
57
113
70
94
73
115
98
141
102
211
164
253
220
377
248
517
139
326
65
205
Source: The General Register Office for Scotland(b)
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
(c) either the underlying
cause or a contributory
factor
116
170
164
188
239
313
417
597
765
465
270
BURDEN ON THE HEALTH SERVICE
HAIs can have a significant negative impact on the health service. The repercussions include
the cost of diagnosis and treatment, increased length of stay of the patient and the
consequential strain on the availability of hospital beds, as well as increased staff workload.
Research commissioned by the Department of Health (England) into the socio-economic impact
of infections acquired in a hospital setting found costs incurred by the hospital were three times
more for infected patients than for uninfected (Plowman et al., 1999). In absolute terms this
represented an increase of £3154 per case, although the study was conducted in 1994-1995.
Nursing care accounted for the largest portion of the additional costs incurred, followed by
hospital overheads, capital changes and cost of management (a full breakdown is shown in
Figure 1).
The study also found infected patients were 7.1 times more likely to die in hospital than
uninfected patients and infected patients may spend on average an extra 11 days in hospital
(Plowman et al., 1999). However the more recent Scottish HAI prevalence report calculates the
average increased length of stay as 6.6 days (Reilly et al., 2007). The report also notes the
length of stay and cost associated with HAIs can vary depending on the hospital speciality the
patient is being treated in. Care of the elderly has the longest increase of additional acute
hospital stay (13.7 days) at a cost of £187 per added day and therefore an average total cost of
case treatment of £2562. Whereas obstetrics has the shortest increase in length of stay due to
patient HAI contraction (3.2 days) but the highest cost per added day at £596, resulting in a total
cost of £1907 per case.
There is also the danger of the HAI causing pathogens to develop resistance to common
antimicrobial treatments, especially where there is the need for regular use of antimicrobials as
the pressure on the pathogens can cause them to adapt. Consequently infections become more
difficult and costly to treat.
10
Figure 1: Breakdown of the additional costs incurred for treating patients who have
contracted a HAI during their hospital stay. Data extratced for Plowman et al., 1999.
ECONOMIC BURDEN OF HAIS
The Scottish prevalence survey report calculates the cost of HAIs to the NHS in Scotland at
£183 million per annum. In England the most commonly quoted estimate is at least £1 billion
annually (Plowman et al., 1999). However, these figures relate to health service costs only and
a 2006 review concluded that the costs of HAIs are underestimated and that MRSA alone
results in annual costs to the UK economy of between £3-11 billion (Gould, 2006). Wider
economic costs arise from lost productivity, litigation and the cost of social support.
The Scottish report also suggests NHS cost savings of £36.6 million are possible if a 20%
reduction in HAIs were to be achieved. The savings rise to £54.9 million or £73.2 million with
HAI reductions of 30% or 40% respectively. However, it is worth noting that it is generally
accepted that not all HAIs are preventable (see „Prevention‟). As a result, there may always be
an economic burden associated with HAIs. Even with a 30% reduction in HAIs (the higher end
of the estimated possible reduction), the remaining 70% would account to a cost of £128.1
million per annum (based on the most recent annual calculated cost of £183 million).
11
TRENDS IN HEALTHCARE ASSOCIATED INFECTIONS
RATES OF INFECTION – SCOTTISH NHS BOARDS
The predominant methods for HAI data collection are either incidence surveillance programmes
or prevalence surveys. The key distinction between these being:

Incidence surveillance is the ongoing systematic and regular collection of data on a
population over a period of time.

Prevalence surveys record numbers of specified events in a specific population at a point
in time or over a specified period of time.
In 2001 the Scottish Executive released a Health Department Letter HDL(2001)57, requiring the
mandatory implementation of incidence surveillance of both inpatient surgical site infections
(SSIs) and MRSA blood infections (bacteraemias). In 2006 the surveillance requirements were
revised to also include incidence of C. difficile infections, MSSA, and post discharge
surveillance following orthopaedic surgery and caesarean sections (HDL(2006)38). Voluntary
surveillance programmes were also introduced for catheter-associated urinary tract infections,
ventilator associated pneumonia and HAI outbreaks.
Surveillance data is reported by NHS Boards to the Scottish Surveillance of Healthcare
Associated Infection Programme (SSHAIP) a division of HPS. Key reports are then produced by
HPS and include; quarterly rates of all S. aureus bacteraemias; quarterly rates of C. difficile
infections and annual rates of SSIs.
The surveillance data is utilised for analysis and interpretation usually for the purpose of
planning, implementation, and evaluation of public health practice. Summarised in the
subsequent sections are incidence surveillance data collected over time for S. aureus blood
infections, C. difficile infections, and SSIs.
STAPHYLOCOCCUS AUREUS BLOOD INFECTIONS
In Scotland, all NHS boards report all isolates of MSSA or of MRSA from patient blood cultures
to HPS. These reports come from routine hospital laboratory data systems. The numbers and
rates of bactereamias are reported in quarterly publications and annual reports. Figures 2 and
3 show the trend in numbers and rates of MSSA and MRSA bactereamias over time.
Surveillance of MSSA commenced in 2005, and became mandatory in 2006 (HDL(2006)38).
In their most recent annual report, HPS calculated for the period of April 2005 to December
2009 a significant year on year reduction of 6.1% in S. aureus rates. During the same period
MRSA and MSSA bacteraemia rates reduced year on year by 14.5% and 1.7% respectively.
The data set of quarterly rates is appended (appendix 1).
12
Figure 2: Total quarterly numbers of Staphylococcus aureus bactereamias across
NHSScotland for the period January 2003 to June 2011
Source: HPS, 2011
Figure 3: Quarterly rates of Staphylococcus aureus bactereamias per 1000 occupied bed
days across NHSScotland for the period January 2003 to June 2011
Source: HPS, 2011
13
CLOSTRIDIUM DIFFICILE INFECTIONS
Surveillance and monitoring of C. difficile infection (CDI) began in 2005, with mandatory
surveillance being established in 2006 to monitor CDI in patients aged 65 and over. In April
2009 the surveillance programme was expanded to include the age group 15-64. Since the
predominant symptom of C. difficile infection (CDI) is diarrhoea, the surveillance programme
monitors the occurrence of CDI in all patients (aged 15 and over), with diarrhoea, and who have
been in contact with the healthcare system, including acute and non-acute hospitals and
primary care. According to HPS, compared to 2008, the number of CDI cases dropped by 43%
in 2009, in patients aged 65 years and older (HPS, 2010a). On average the age group 15-64
accounts for 26% of the total number of CDI cases, and the majority of these are concentrated
in the 40-64 year age group, reflecting the propensity for CDI to occur in older populations.
Figures 4 and 5 illustrate the trends in quarterly reported cases and rates of CDI in
NHSScotland. (Data set also available in appendix 2).
Figure 4: Total quarterly reported cases of Clostridium difficile infection across
NHSScotland for the period October 2006 and June 2011.
Source: HPS online appendix
14
Figure 5: Quarterly rates of Clostridium difficile infection per 1000 occupied bed days
across NHSScotland for the period October 2006 to June 2011
Source: HPS online appendix
SURGICAL SITE INFECTIONS
Recording of SSIs following hip arthroplasty and caesarean section procedures is mandatory for
NHS Boards where these procedures are performed. Each NHS Board is required to undertake
surveillance on at least two operation categories. If caesarean section or hip arthroplasty are not
carried out within an NHS Board then SSI surveillance is required for any of the following
procedures: abdominal hysterectomy, breast surgery, cardiac surgery, coronary artery by-pass
grafting (CABG), cranial surgery, knee arthroplasty, colorectal surgery, reduction of long bone
fracture, repair of neck of femur, and vascular surgery (HPS, 2010b).
Scotland was the first country in the world to introduce surveillance of patients after discharge
from hospital in 2006. This was done in recognition of a number of factors including; the differing
duration of post operative stay of patients for the same procedure in different hospitals, and
advances in surgery techniques over time which have been considered to reduce the length of
stay following surgery. Post discharge surveillance (PDS) is undertaken using prospective
readmission data and is mandatory for up to 30 days following a hip arthoplasty and for 10 days
following a caesarean section. From April to December 2009, over 80% of all caesarean section
SSIs were detected in the post discharge period (to day 10), underscoring the importance of
PDS (HPS, 2010a). The trends in rates of SSI following caesarean section and hip arthroplasty
procedures are shown in Figures 6 and 7 respectively. The data set of SSIs including actual
numbers of infections following caesarean section or hip arthroplasty procedures is also
available in appendix 3.
15
Figure 6: Quarterly rates of SSI following caesarean section procedures across
NHSScotland for the period April 2002 to June 2010. Rate is the number of reported
infections (over a quarter) as a proportion of the total number of caesarean section operative
procedures performed in that quarter. Rates are based on either inpatient surveillance only or
inpatient and PDS to 10 days post operatively since the introduction of PDS.
NHS Scotland: rate of SSI for caesarean section procedures
6.0%
Caesarean
section Inpatient
only
5.0%
SSI rate
4.0%
Caesarean
section Inpatient &
PDS
3.0%
2.0%
1.0%
0.0%
Quarter
Source: Obtained directly from HPS
Figure 7: Quarterly rates of SSI following hip arthroplasty procedures across
NHSScotland for the period April 2002 to June 2010. Rate is the number of reported
infections (over a quarter) as proportion of the total number of hip arthroplasty operative
procedures performed in that quarter. Rates are based on either inpatient surveillance only or
inpatient and readmission surveillance to 30 days post operatively since the introduction of
readmission surveillance.
NHS Scotland: rate of SSI for hip arthroplasty procedures
2.5%
Hip
arthroplasty Inpatient only
SSI rate
2.0%
Hip
arthroplasty Inpatient &
PDS
1.5%
1.0%
0.5%
0.0%
Quarter
Source: Obtained directly from HPS
16
HAI PREVELANCE – REST OF THE UK AND EUROPE
According to the World Health Organisation (WHO), in developed countries HAIs concern 5–
15% of hospitalised patients and can affect 9–37% of those admitted to intensive care units
(ICU) (WHO, 2009). In ICU settings, the use of invasive devices (e.g. catheters, mechanical
ventilation) poses one of the most important risk factors in patients who are already in a fragile
state of health. In developing countries reliable estimates of HAI burden are often difficult to
obtain, for reasons ranging from limited diagnostic facilities, paucity of laboratory data, and poor
medical record keeping (WHO, 2009).
In Europe, a number of countries have performed HAI prevalence surveys and on average the
HAI prevalence rate across industrialised Europe is considered to be ~7% (BMA, 2009). The
prevalence rates reported across Europe are shown in Figure 8 (and appendix 4), however
comparison of rates is somewhat confounded by differences in dates (year) and duration of
surveys, methodology, patient population sampling, and the selection of HAIs reported.
Figure 8: HAI prevalence across Europe. Prevalence data is based on reported prevalence
rates where information has been extracted from the major prevalence surveys across a
number of industrialised European countries (European Centre for Disease Prevention and
Control, 2008; BMA, 2009). However comparison of rates should be done with a degree of
caution since the prevalence surveys have been conducted at different times, may reflect
differences in data collection, and there will be variability in the duration, sample size and
methods of the survey.
17
The most recent prevalence survey performed in the UK countries and the Republic of Ireland,
was a four country wide survey of HAIs in acute hospitals in England, Wales, Northern Ireland,
and the Republic of Ireland (Smyth et al., 2006). A separate HAI prevalence survey was
performed in Scotland during 2005-2006 (Reilly et al., 2007). Table 5 shows the HAI prevalence
results and key details of the two surveys.
Table 5: Comparison of HAI prevalence across the UK and Republic of Ireland. Based on
HAI prevalence surveys conducted in acute hospitals the UK and Ireland (excluding Scotland)
(Smyth et al. 2006) and Scotland (Reilly et al., 2007). For consistency acute hospital information
is shown for Scotland, even if the survey also extended to non-acute facilities.
Country
UK and Ireland (exc. Scotland)
England
Wales
Northern Ireland
Republic of Ireland
Scotland
Number
of
hospitals
273
190
23
15
45
45
Number of
patients
75,763
58,795
5,825
3,625
7,518
11608
Infection
prevalence
rate
7.6%
8.2%
6.3%
5.5%
4.9%
9.5%
For reasons of consistency and rigour both surveys made use of strict definitions of „prevalent‟
infections known as the CDC (Centre for Disease Control) HAI case definitions. However,
comparison across countries should still be done with a degree of caution and consideration for
variability in factors including; differences in location, hospital size (an important factor known to
affect prevalence rates), hospital specialties, and population demographics.
PREVENTION
Not all HAIs are preventable. Although the preventable proportion of HAIs is unknown, various
estimates have been suggested. The more recent, relevant estimates include those from the
Hospital Infection Working Group of the Department of Health (DoH) in England who in 1995
suggested a 30% reduction in HAIs might be achievable (Department of Health, 1995). The
European Centre for Disease Prevention and Control (ECDC) in its First Report on
Communicable Diseases also noted that up to 30% of HAIs are preventable (ECDC, 2007). This
estimate is partly based on an evaluation of 30 relevant studies conducted in various patient
populations and healthcare settings, which suggests the potential to reduce HAI ranges from
10% to 70% depending on the setting, study design, baseline infection rates and type of
infection. On average the review estimates at least 20% of all HAIs to be preventable (Harbarth
et al., 2003).
The potential for preventing HAIs can be influenced by a variety of factors; ranging from patient
risk factors, treatment, and behavioural and organisational factors in the healthcare setting.
Patient risk factors include (but are not limited to); the patients age, underlying or chronic illness,
and malnutrition. The use of certain drugs (for example immunosuppressants) and the nature of
a medical procedure the patient is undergoing can also influence the chances of contracting a
treatment-associated infection. For example SSIs have been reported to have a reduction
potential of 24-34%. Whereas for catheter associated urinary tract infections the reduction
potential is estimated at 46-60% (Harbarth et al., 2003). This may imply that reducing the
chances of an infection during invasive surgical procedures is more difficult in comparison to
reducing infections during urinary catheterisation.
18
According to the HCAI research network, amongst the multiple causes of HAIs, the most
common causes arise from:
 contaminated hands of healthcare workers,
 contaminated medical devices, and
 failure to comply with local policies, procedures and guidelines.
Inadequate hand decontamination in particularly is recognised as a significant factor in
transmitting HAIs (WHO, 2009). A WHO review of best practise found that improved hand
hygiene can reduce the risk of transmission of pathogens and the incidence of HAIs (WHO,
2005). In addition to hand hygiene, the other most effective interventions leading to a reduction
of HAIs are reported to be surveillance, education and audit (Harbarth et al., 2003). Evidence
suggests that actively feeding back (surveillance) data to clinicians contributes to reductions in
rates of infection (Mangram et al., 1999). Education is another approach, for example training
for using indwelling devices (such as catheters) both correctly and aseptically has been reported
to decrease the incidence of associated HAIs by 30 - 35% (Conterno et al., 2007).
EFFECTIVENESS OF HAI PREVENTION MEASURES
In 2009 the British Medical Association (BMA) published a report on tackling HAIs through
effective policy action (BMA, 2009). The report which is intended for policy makers with strategic
or operational responsibility for public health in the UK, examines the evidence base for the
range of infection control policies and identify areas for action. The authors felt the strategies in
place to reduce the burden of HAIs, focused on identifying short-term solutions which have
failed to address the underlying problems that adversely impact on infection control.
The range of infection control policies in place generally focus on preventing the spread of
micro-organisms between patients and the transmission during invasive procedures and other
treatments. The policies relate to behavioural characteristics, organisational factors and wider
policy initiatives, such as surveillance and research priorities. The authors of the BMA report
also state that there has been a disproportionate focus on reducing MRSA and C. difficile
infection rates, rather than tackling the range of HAI causing micro-organisms. The BMA‟s
review of the effectiveness of key behavioural and organisational factors is discussed in more
detail below.
BEHAVIOURAL FACTORS
Amongst the infection control policies relating to behaviour, the BMA examines the role of
antimicrobial prescribing, hand hygiene, use of indwelling devices, and patients and visitors
(BMA, 2009). The report acknowledges complacency, poor prescribing practice and the misuse
of antimicrobials as major factors in the emergence of drug resistant infections. However the
authors still feel there is the need to further develop and implement strategies for promoting
optimal antimicrobial prescribing through local consultation. Furthermore optimal prescribing
policy should also be facilitated by close collaboration between clinical pharmacists, medical
microbiologists and infectious diseases physicians.
In concurrence with the WHO, the BMA also recognise good hand hygiene as a crucial factor in
preventing the transmission of infections. They note hand hygiene compliance requires
comprehensive training and commitment at the most senior levels through role modelling. To
improve compliance, the authors suggest that consideration should be given to the accessibility
19
and design of hand washing facilities, including the use of elbow operated or no touch activated
taps, as well as rewards for good practice and/or sanctions for unacceptable behaviour.
Indwelling devices can breach the body‟s natural defence and provide an entry route for
pathogens. The BMA review looked at the role of educational approaches and use of „care
bundles‟ for reducing device related infections. Recent years have seen the advent of „care
bundles,‟ an approach of combining a number of set practises (usually 3-5) to control a range of
HAIs. The notion behind these bundles is to provide a cohesive set of standard practises that
must be performed consistently in every case and thereby reduce the variability in care from
patient to patient. Health Protection Scotland‟s (HPS) Infection Control Team provides
descriptions of the care bundles in place for controlling HAIs. These range from infection
specific care bundles to the more generic hand hygiene standard procedures and monitoring
tools. Below (Table 6) is an example of a care bundle in place for controlling transmission of
C. difficile.
Table 6: Clostridium difficile Infection (CDI), cross-transmission minimisation bundle.
CDI transmission minimisation bundle, version 2 (24 August 2009), extracted from Health
Protection Scotland (2009a).
The Bundle
1. Isolating CDI patients in a single room with either en suite facilities, or an allocated
commode, until they are at least 48 hours symptom free.
2. Reviewing antibiotic regimens and stopping inappropriate antibiotics.
3. Checking all healthcare workers remove personal protective equipment (gloves
and aprons) after each CDI patient care activity.
4. Checking that the CDI patient’s immediate environment has been cleaned today
with chlorine based solution.
5. Ensuring healthcare workers perform hand hygiene with liquid soap and water
after leaving a CDI patient’s room.
A study published this year examined the effectiveness of care bundles to reduce mortality in
several diagnostic areas with high numbers of deaths in UK hospitals (Robb et al., 2010). The
authors concluded that implementing care bundles can lead to reductions in death rates in the
clinical diagnostic areas targeted and in the overall hospital mortality rate.
Finally, in terms of behavioural factors, the BMA state the role of patients and visitors has
received little attention and there is little formal policy in place that is supported by robust clinical
evidence.
ORGANISATIONAL FACTORS
The BMA assessed the role of key organisational, management and leadership factors that can
impact on infection control and HAI rates. The factors include; dress code, cleaning and
environmental hygiene, bed occupancy, screening and isolation, performance targets,
leadership, and workforce management. Some of these factors are discussed below in further
detail.
Dress Code
Although pathogens are frequently carried on clothes, the BMA cites studies where no
conclusive evidence linking contaminated uniforms and the spread of infection is found.
However the use of protective clothing (e.g. aprons and gloves) has been shown to significantly
reduce contamination with micro-organisms. Therefore they recommend that emphasis should
be placed on the use of appropriate protective clothing where healthcare staff are exposed to
20
pathogens. Furthermore, they recommend that the development of dress code policies should
be evidence based (BMA, 2009).
Cleaning and Environmental Hygiene
Regular cleaning is seen as an important component of effective infection control although there
is little direct evidence demonstrating that cleaning has an effect on HAI rates (BMA, 2009).
Attention in recent year has also focussed on the tendering of hospital cleaning contracts to the
private sector, the reduction in the number of cleaners and the rapid turnover of cleaning
personnel over time. During 2009 the Scottish Government announced the recruitment of 600
new hospital cleaning staff and no further privatisation of hospital cleaning across NHSScotland
(Scottish Government, 2009).
The BMA cites a 2007 review by Pratt et al which found that a hospital environment can become
contaminated with HAI causing pathogens and these have been recovered from a number of
hospital surfaces. However the review found no conclusive evidence that environmental
contamination is responsible for HAI transmission (Pratt et al., 2007). Improved cleaning
regimens are associated with the control of HAI outbreak, although given a number of
interventions are used to control outbreaks it is difficult to attribute any improvement to a single
factor such as cleaning. The BMA does acknowledge that risk of pathogen transmission via
contact with the environment is the greatest at „near-patient hand-touch‟ sites. These include
bed rails, bedside lockers, door handles and switches, and have generally not featured in
domestic cleaning specifications.
The effectiveness of hospital deep cleaning in reducing HAI rates has also been disputed (BMA,
2009). Although deep cleaning reduces the presence of pathogens it is not thought to
significantly impact on infection rates. Based on these multiple cleaning factors the BMA
suggest the following areas for action:




providing adequate resources for thorough everyday cleaning
cleaning of high-risk near-patient hand-touch sites
ward cleaners should be an integral part of the infection control team
deep cleaning regimens should consider the implication for resources and service
delivery
With respect to other organisational factors the BMA stress the need for reducing bed
occupancy rates since there is a significant positive correlation between bed occupancy levels
and MRSA rates (BMA, 2009). It is suggested this could be addressed through taking action on
the availability of beds, targets governing admissions, and bed management policies.
Management and leadership are key in developing an appropriate organisational culture for
tackling HAIs as is effective workforce management. A review of evidence shows the risk of
HAIs is greater during periods of understaffing and varies according to staff workload (BMA,
2009). Furthermore compliance with hand hygiene is also adversely affected by understaffing
and high workloads. The BMA therefore suggest effective work planning management is
required as well as training for all temporary and permanent staff.
Screening of patients to determine whether they are carriers of MRSA is now in place across
NHSScotland. Where patients test positive for the pathogen they will undergo decontamination
and potential isolation to prevent transmission to other patients as well as reducing the chances
of developing a HAI themselves. An MRSA screening policy has proven to be effective in the
Netherlands, a country with relatively low rates of HAIs. The BMA stress the need to assess the
21
evidence of effectiveness of screening patients as well as consideration for a number of
implications of a screening policy, in particularly:



the practical and cost implications in terms of the need to isolate and decontaminate all
those found to be positive
the requirement of adequate isolation facilities, staff education and training, as well as
procedures to manage screening, results, patient notification, isolation and follow-up
the impact on targets for admissions, bed occupancy and waiting times.
Finally consideration should also be given to the design of clinical areas in new healthcare
buildings, with a focus on single occupancy rooms as opposed to multi-bed wards (BMA, 2009).
CURRENT POLICY FOR TACKLING HEALTHCARE ASSOCIATED
INFECTIONS
GOVERNANCE – THE HEALTHCARE ASSOCIATED TASK FORCE
The Scottish Government‟s Healthcare Associated Infection (HAI) Task Force was formed in
January 2003 and is led by the Chief Nursing Officer. The Task Force which includes members
from the NHS, professional backgrounds as well as members of the public is responsible for
overseeing and co-ordinating the development and implementation of the national strategy on
HAIs. Specific objectives and strategy plans are set out in the Governments healthcare
associated work programmes, of which three have been published to date.
The most significant areas of work completed by the HAI taskforce during its first two work
programmes (over the period of 2003 – 2008) are summarised below. The third HAI task force
Delivery Plan for 2008 – 2011 was published in March 2007 with funding of £54 million. The
third phase of work encompasses a range of measures to tackle HAI including the roll out of a
national MRSA screening programme, a target to reduce C.difficile infections by 30% and a zero
tolerance approach to healthcare staff that do not follow hand hygiene rules.
MAIN OUTCOMES OF THE HAI-TASK FORCES FIRST TWO WORK PROGRAMMES
Implementation and Performance
The first phase of the work programme saw the publication of the NHSScotland Code of
Practice for the Management of HAI and Hygiene (Scottish Executive, 2004a). Arising from this
was the development and funding to support the role of Infection Control Managers and Nurse
Consultants in HAI. During the second phase of the work programme NHS Quality Improvement
Scotland (NHS QIS) was tasked with a review of its HAI standards. The final standards were
published in March 2008 (NHS QIS, 2008).
Antimicrobial Prescribing
Antibiotic resistance poses a threat and complication in controlling HAIs. The case for prudent
prescribing of antibiotics is recognised and guidelines to improve prescribing practices were
established; The Scottish Medicines Consortium drafted the Antimicrobial Prescribing Policy
and Practice in Scotland (Scottish Executive, 2005a), for the HAI Task Force. Further review of
the area led to the publication of a more detailed plan in February 2008; the Scottish
Management of Antimicrobial Resistance Action Plan (ScotMARAP) (Scottish Government
2008a). The document outlines a national programme for tackling antimicrobial resistance in
Scotland over the next five years.
22
Cleaning, Hygiene and the Environment
Ensuring micro-organisms are not allowed to accumulate in the healthcare environment through
regular cleaning is considered an important component of effective infection control. Initiatives
taken range from the training of domestic services staff on the contributions they can make in
minimising HAIs, guidelines for developing or renovating healthcare buildings, and minimum
standards for cleaning of NHSScotland buildings.
A National Education and Training Framework for Domestic Services (NHS Health Facilities
Scotland, 2007a), was developed in recognition that domestic staff at all levels have a
contribution to make (in terms of competence, capability, knowledge and behaviour) to the
provision of a quality service. Guidance was also created on reducing HAI in the built
environment. The HAI-SCRIBE (Healthcare Associated Infection - System for Controlling Risk In
the Built Environment) programme is aimed at all personnel who may be involved in providing
newly built, refurbished or extended healthcare establishments, with the purpose of minimising
the risk of HAIs through prior assessment and planning of new build and renovation projects
(NHS Health Facilities Scotland, 2007b). Guidance is also provided for the ongoing
maintenance of existing buildings in the Scottish Health Facilities Note 30: Infection Control in
the Built Environment (NHS Health Facilities Scotland, 2007c). Minimum standards for hospital
cleaning were set in the NHSScotland National Cleaning Services Specification (Scottish
Government, 2004b) followed by a framework for monitoring cleaning services across
NHSScotland (NHS Health Facilities Scotland(a)).
Public Involvement
In order to improve public engagement, the Task Force established the Public Involvement and
Communications Team (PICT) with membership drawn from the general public. PICT has
contributed to a number of areas of the task forces work programme including, the
NHSScotland Code of Practice for the Management of HAI and Hygiene and, the Public
Information Strategy.
Education and Training
Education and training are seen as priority areas in tackling HAIs and educational resources
have been developed by NHS Education for Scotland (NHS NES). A national framework for
mandatory induction training on HAI (NHS NES(a)) was introduced, as was a Cleanliness
Champions Programme (NHS NES(b)) to promote the prevention of infection amongst NHS
staff. The purpose of the programme was to equip staff with the appropriate skills and
knowledge required to prevent and reduce HAIs. The programme was developed for all
NHSScotland staff and is now also encouraged in undergraduate nursing and medical courses.
Hand Hygiene
Good hand hygiene is considered to be one of the most cost effective and important
interventions in preventing the transmission of HAI causing pathogens and consequently
infections. Measures taken during the task forces first two work programmes include;
educational resources developed by NHS NES (NHS NES(c)); provision of alcohol hand rubs
near every acute front line bed; and the launch of a national hand hygiene campaign entitled
“Germs – Wash Your Hands of Them” (HPS(a)). The hand hygiene campaign was aimed and
promoted at the general public; NHS Staff, patients and visitors, and nursery and primary school
children.
Surveillance and Prevalence Surveys
HPS were assigned with the task of conducting a national HAI prevalence study to provide
baseline information on the total prevalence of HAI in Scottish hospitals. The study reported on
23
the prevalence of HAIs in acute and non acute hospitals, the prevalence of different types of
HAIs, and the estimated costs to NHSScotland (Reilly et al., 2007).
National surveillance of HAIs is overseen by the SSHAIP division of HPS. During the first two
phases of the HAI task forces work programmes, mandatory surveillance of MRSA
bacteraemias continued, surveillance of certain SSI‟s became mandatory, as did surveillance of
CDI. Voluntary surveillance programmes were also developed. Incidence surveillance
programmes are discussed in the Rates of Infection across NHSScotland section of this
briefing.
A HAI outbreak is any increase in the incidence of an infection or presumed infection in people
associated with a healthcare setting. Outbreak surveillance is performed to:


identify potential outbreaks rapidly as they occur as a means of damage limitation
collect information on HAI outbreaks in order to identify any trends that may need
addressing
There are a number of toolkits (HPS(b)) in place to assist with prevention and control of
infection in the health setting. The toolkits are designed as part of a system to identify and
manage potential HAI outbreaks and include:



Hospital Outbreak Toolkit - a hospital outbreak management process
Local Surveillance Toolkit - data-driven local infection control system
Clostridium difficile infection (CDI) Toolkit – triggers and action warning limits for CDI in
wards and clinical setting.
Computerized Statistical Process Control Charts (SPCC) are used for the purpose of infection
surveillance at a ward and hospital level. SPCCs are the application of statistical theory to
Quality Control and in the context of HAI monitoring they allow the identification of potential
outbreaks. SPCCs show data chronologically and describes variation in infection levels as
natural (expected) or unnatural. Unnatural variation would indicate the number of HAIs identified
is outwith the expected range. When cases occur at a rate exceeding the normal number of
cases for the unit, ward or facility during a specified period of time, or when disease occurs at
increased severity, immediate actions and interventions are required.
NHS Boards are also required to complete a national reporting template to give the public
access to local hospital level data on infection rates. Infection data should be reported on a
monthly basis on NHS Board websites and discussed publically at bi-monthly Board meetings.
The Scottish Government website also has a portal through which the public can access the
information for each NHS board area. In England the UK coalition Government increased the
required frequency of reporting of MRSA bacteraemias and C. difficile infections to every week.
In 2010, Scottish Health Secretary Nicola Sturgeon commented on the infection reporting
frequency across NHSScotland:
S3W-34752 - Richard Simpson (Mid Scotland and Fife) (Lab) (Date Lodged
Wednesday, June 23, 2010): “To ask the Scottish Executive, in light of the UK
Government‟s decision to require the NHS in England to report rates of MRSA
bacteraemia and Clostridium difficile infections weekly, what steps it is taking to provide
the same level of information in Scotland.”
Answered by Nicola Sturgeon (Monday, July 05, 2010): “NHS boards in Scotland
already provide information on MRSA, Clostridium difficile, hand hygiene and
environmental cleaning compliance and the causes of adverse incidents. This is
24
published on NHS board websites and discussed publicly at bi-monthly NHS board
meetings.
A national HAI reporting template used to capture and report this data has recently been
revised and issued to NHS boards with a six month review date. This places a
requirement on boards to publish hospital level cases of Clostridium difficile, MSSA and
MRSA bacteraemia on a monthly basis. We will consider the merits of increasing the
frequency of reporting as part of our ongoing review process.”
Patient Safety and Research
Patient safety initiatives have included the introduction and development of HAI related care
bundles (HPS(c)) by the Infection Control Team at HPS. The Risk Management of HAI: A
Methodology for NHSScotland (Scottish Government, 2008b) was published as a guidance
document for assessing and controlling patient risks. The Scottish Patient Safety Programme
(NHS QIS(a)), co-ordinated by NHS QIS has the general objective of reducing adverse events
in Scotland‟s hospitals, and this includes reducing HAIs.
In recognition of the importance of high quality research in the subject, a Scottish Infection
Research Network (SIRN), based at the University of Glasgow was established with the aim of
improving the quality of research into HAIs.
THIRD PHASE OF THE HAI TASK FORCE’S WORK
The HAI Task Forces third delivery plan (Scottish Government, 2008c) which came into effect
on 1 April 2008, set out to improve or develop HAI strategy in the following areas (with
examples of planned actions):
(1) Patient safety, practice and culture
Example(s): Continued development and implementation of care bundles
(2) Education
Example(s): Further development of the national hand hygiene programme
Implementation of an Outbreak Management programme
(3) Surveillance, information and audit
Example(s): Repeated targeted prevalence survey
Surveillance of use of antimicrobial resistance drugs
(4) Guidance and standards
Example(s): Implementation of the MRSA control strategy
Full implementation of an MRSA screening programme following the pilot if
indicated
(5) Physical environment.
Example(s): Promote specification of new builds as fit for purpose for HAI prevention
The third work programme was set to run until March 2011, and some of the key strategies
completed or underway include the roll out of a national MRSA screening programme, targets to
reduce C. difficile by 30% (later increased to 50%) and a zero tolerance approach to healthcare
25
staff that do not follow hand hygiene rules. The zero tolerance policy launched in early 2009
(Scottish Government, 2009a) underscores the professional accountability of all NHS staff for
adherence to NHS Board policies and hand hygiene compliance. Staff are required to take
personal responsibility to remind colleagues, patients, and visitors of their responsibility to adopt
good hand hygiene practise at all times. NHS Boards are also responsible for ensuring
adequate facilities are available to enable staff to fully comply. HPS publish bi-monthly audit
reports on compliance with hand hygiene, amongst NHS staff, and present the information
according to national compliance, by the different NHS Boards, and by different staff groups.
The HPS Compliance with Hand Hygiene - Audit Report (HPS, 2011) reports national
compliance as 95% (for the period July – August 2011). During this period the most compliant
staff group were allied health professionals, with a 98% hand hygiene compliance rate. Medical
staff were the least compliant staff group with a compliance rate of around 88%. According to
the NHSScotland Chief Executive‟s Annual Report 2009/10 (Scottish Government, 2010) a 54%
reduction in C. difficile infections had already been achieved in NHSScotland against the
original set target of 30% by March 2011.
Following a trial MRSA screening programme (Scottish Government, 2008d) in three NHS
Boards, a national roll out (NHSScotland, 2009) of the scheme to be implemented by 31
January 2010 across NHSScotland was announced. Screening is undertaken for all patients
undergoing elective admission to acute hospitals (excluding paediatrics, obstetrics and
psychiatric admissions) and for all elective inpatient and emergency admissions as well as
hospital transfers into the specialties of nephrology, care of the elderly, dermatology and
vascular surgery. The screening process involves a swab being taken from patients nasal
cavities which is then tested for the presence of MRSA. HPS and NHSScotland have produced
a MRSA screening information leaflet for patients (HPS, 2009b).
A summary of some of the key HAI guidelines and policy now in place across NHSScotland are
provided in Table 7.
Table 7: A summary of some of the key guidelines and strategy in place for tackling HAIs
across NHSScotland
Intervention
Antimicrobi
al
Prescribing
Policy or Guidance




Hand
hygiene




Source
Antibiotic prescriptions should be compliant with a
hospitals local antimicrobial policy
and the rational for treatment should be recorded in
the clinical case notes (with the target of recording for
≥95% of cases)
Antibiotic prescribing training for foundation year
doctors
Surveillance of antimicrobial resistance (as part of the
European Antimicrobial Resistance Surveillance
System (EARS-Net)
NHSScotland, Hospitalbased empirical
prescribing. National
Report, May 2010
Zero tolerance policy towards healthcare workers
with poor hand hygiene compliance
Hand hygiene compliance audit
Hand hygiene care bundles
Hand hygiene procedure based on the WHO
recommendations of the five key moments for hand
hygiene:
o before patient contact
o before aseptic task
o after body fluid exposure risk
The Scottish
Government CEL 5
(2009)
NHS NES(d), antibiotic
prescribing.
Health Protection
Scotland(c), surveillance
systems.
Health Protection
Scotland(d), national
hand hygiene campaign
Health Protection
Scotland(e), Bundles
26
o after patient contact
o after contact with patient surroundings
Use of
indwelling
devices

Training available for healthcare workers: preventing
catheter related bloodstream infections.
Care bundle for central vascular catheter (CVC)
maintenance: to encourage appropriate use of CVCs,
including reviewing the need for a CVC.
Care bundle for preventing catheter associated
urinary tract infections (CAUTI): to encourage
appropriate use, hand hygiene and daily review of the
need for catheterisation.
NHS NES(e), Preventing
catheter related
bloodstream infections
Advice for patients and visitors from the chief medical
officer and chief nursing officer includes:
 To not visit patients if feeling unwell
 Practising hand hygiene
 Consulting hospital staff before bringing food
 Never touching dressing, drips, equipment
 Alerting charge nurse if concerned about hospital
cleanliness
Scottish Government Health Directorates (SGHD) have
introduced guidance for all NHS staff:
 avoid use of white coats, ties, and wristwatches when
providing patient care, as well as the wearing of pens
and scissors in outside pockets
 prohibiting staff from leaving work in their uniforms,
except where it is part of duties
Health Protection
Scotland and the
Scottish Government
(2009); Healthcare
associated infections,
information for the public

Scottish Executive, The
NHS Scotland National
Cleaning Services
Specification, (2005b)


Patients /
visitors
Dress code
Cleaning
Screening
The thoroughness of cleaning standards in NHS
Boards is monitored by Health Facilities Scotland
(HFS).
 HFS provides data on compliance with the
requirements set out in the NHSScotland National
Cleaning Services Specification.
 Announcement in 2009 of 600 new hospital cleaners
to be recruited and no further privatisation of hospital
cleaning.
Screening for MRSA presence in patients across all NHS
boards (for the chosen admissions and specialties).
Surveillance Mandatory surveillance of MSSA and MRSA blood
infections, C. difficile infections, SSIs following hip
arthroplasty and caesarean section procedures.
Health Protection
Scotland(e), Bundles
Health Protection
Scotland(f), Bundles
Scottish Government
Health Directorates (CEL
53) 2008(e) NHS
Scotland Dress Code.
Edinburgh:
Scottish Government
Health Directorates.
Scottish Government,
News release, 17 April
2009(b)
Health Protection
Scotland(g), MRSA
screening programme
Health Protection
Scotland(h), Scottish
Surveillance of
Healthcare Associated
Infection Programme
OTHER DEVELOPMENTS – VALE OF LEVEN
Following a significant outbreak of C. difficile in the Vale of Leven Hospital (Scottish
Government(a)) in early 2008, an independent review was commissioned (University of
Aberdeen, 2008). The review found the facilities at the Vale of Leven Hospital were inadequate
for effective patient isolation and infection control, and there were frequent patient transfers
27
between wards and other hospitals during period of the outbreak. Furthermore a number of key
facilities were found to be inadequate including:
 hand washing facilities
 single room accommodation
 sufficient toilets
 appropriate spacing between beds
 clinical and storage space to facilitate effective infection control practices
It was also noted that there was no active monitoring of the implementation of antibiotic policies
or feedback on usage to clinical staff. Following the publication of the independent review in
August 2008, the Scottish Government published a National Action Plan (Scottish Government,
2008f) to tackle C. difficile. This was in addition to and a supplement to the HAI Task Forces
Delivery Plan (Scottish Government (a & b)). Amongst some of the actions outlined in the
National Action Plan was the need for a clearer hand hygiene policy (indicating what agents to
use for hand hygiene and when they are indicated), the introduction of an interim NHS dress
code, and increased public engagement on HAIs. Currently a public inquiry (The Vale of Leven
Hospital Enquiry) is underway to examine the circumstances surrounding the 2008 outbreak of
Clostridium difficile in which 55 people developed C. difficile and 18 people died. Oral hearings
proceeded on Monday 7 June 2010. The enquiry is required to report its findings and
recommendations to the cabinet secretary for Health and Wellbeing by September 2012.
Healthcare Environment Inspectorate
The Healthcare Environment Inspectorate (HEI) was established by the Cabinet Secretary for
Health and Wellbeing following the 2008 Vale of Leven events. HEI‟s work feeds into the wider
work of NHS QIS to support improvement. Operating independently of both the Scottish
Government and NHS boards, HEI undertakes announced and unannounced inspections to
acute hospitals across Scotland. During the inspections HEI assess a number of factors that
contribute towards the quality of infection control, hygiene and cleanliness in hospitals. A recent
report sets out findings from the inspections over the past year (HEI, 2010). The report finds
most hospitals across NHSScotland are generally clean and improving. However it was also
noted that attention to detail could be improved in many areas, for example cleaning hard to
reach areas. The report also sets out other key recommendation and requirements to improve
standards. These include:



ensuring all staff are implementing standard infection control precautions
ensuring infection control managers have clear roles and responsibilities
the need to develop and implement a national specification for equipment cleaning
CASE STUDY: DUTCH MRSA CONTROL STRATEGY
The Netherlands has maintained low levels of MRSA infections over the past 30 years.
Following several outbreaks in the early 1980s a “search and destroy” strategy was deployed.
This approach includes systematically screening patients, and often staff, as well as isolating or
decolonising (decontaminating) those found to be infected. Other key elements of the strategy
include:
 pre-emptive isolation and screening of patients coming from foreign hospitals
 immediate isolation of every new case of MRSA
 screening of contact patients and care-givers and decontamination of carriers
 where more infections are observed, collective isolation of the entire ward and
discontinuation of further admissions is required
28
Similar strategies are also in place for other pathogens that are highly resistant to antimicrobial
treatment. Specific attention is given to high risk departments where patients are admitted from
foreign hospitals or Dutch hospitals with known problems with highly resistant pathogens.
Furthermore the general HAI strategy is also supported by restrictive antibiotic prescribing
policies (Marcel et al., 2008; Dekker et al., 2010).
OTHER KEY ISSUES
EMERGING HAI PATHOGENS
The most common HAI causing pathogens are outlined in Table 1. However over recent years
there has been increasing concern and media attention on other potentially difficult to treat
“hospital superbugs”. These include VRSA (vancomycin-resistant Staphylococcus aureus), a
strain of S. aureus that is resistant to the antibiotic vancomycin. Vancomycin has to date been
considered the most reliable therapeutic agent against infections caused by MRSA (Hiramatsu,
2001). During January 2010 HPS and Information Services Division (ISD) Scotland published a
report on antimicrobial resistance and use in humans (HPS, 2010d). The report found for the
observed period there were no MRSA resistant strains detected in Scotland. However 16.7%
resistance to vancomycin was observed amongst another type of bacteria (Enterococcus
faecium) isolated from blood infections. The report states this is of particular concern as these
resistance mechanisms can be transferred to other pathogens (including MRSA).
2010 witnessed considerable press coverage of NDM-1 (New Delhi metallo-beta-lactamase-1)
bacteria (BBC, 2010). NDM-1 is an enzyme found in some bacteria, and provides resistance to
treatment with a powerful class of antibiotics known as carbapenems (HPA, 2009a). There are
fears that the enzyme could transfer to resistant strains of bacteria, making them even more
difficult to treat. At least one case of NDM-1 case was reported in Scotland although this was
over a year ago (HPA, 2009b). NDM-1 bacteria are thought to be most prevalent in South East
Asia and a number of NDM-1 positives patients in the UK had travelled to India or Pakistan
within the past year (NHS UK news, 2010).
RESEARCH INITIATIVES AND PRIORITIES
Research into the mechanisms of antibiotic resistance is progressing although the scope for
developing new antibiotics is more challenging. Discovering new classes of antibiotics has
become increasingly difficult (Chopra et al., 2008). Moreover, there is some speculation of major
pharmaceutical companies reducing their investment and interests in the antibiotics market as
this is not necessarily as profitable as markets for treating chronic and lifestyle diseases (Norrby
et al., 2005). There is a considerable expense involved in establishing the safety and efficacy of
a new antibiotic with no guarantee of the drug being approved. If a new drug were to be
approved and manufactured, pharmaceutical companies may face long delays in recouping
costs since:


it would be expected that any new treatments would be used cautiously by clinicians
antibiotics are intended as short term medication.
Finally the inherent ability of pathogens to adapt and become resistant to antibiotics poses the
risk of the drug becoming ineffective before costs of developing it are recouped.
There are however other innovations into combating HAI pathogens. Recently researchers from
the University of Strathclyde developed a light based technology that can kill pathogens
including MRSA and C. difficile (University of Strathclyde news release, 2010).
29
Apart from research into therapeutics, there is also much to be understood about other HAI
preventative interventions. During 2009 the British Medical Association (BMA) published a
document examining the evidence base for the range of infection control policies (across the
UK) (BMA, 2009). HAI research priorities were one of the identified areas for action. The BMA
suggested further research is required into:




the effectiveness of educational and behavioural interventions in relation to compliance
with hand hygiene protocols, prescribing behaviour and the use of indwelling devices
the role of organisational factors such as bed occupancy, workforce management,
leadership, and resource allocation in relation to the implementation of infection control
policies
the effectiveness of current and emerging approaches to environmental decontamination,
including different cleaning regimens
the role and clinical effectiveness of different screening methods.
30
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36
APPENDIX 1
Table 8: Staphylococcus aureus bloodstream infections across NHSScotland: total
numbers and rates.
Number of bacteraemia
Quarter
MRSA MSSA
Jan 03 - Mar 03
255
Apr 03 - Jun 03
227
Jul 03 - Sep 03
176
Oct 03 - Dec 03
217
Jan 04 - Mar 04
267
Apr 04 - Jun 04
259
Jul 04 - Sep 04
201
Oct 04 - Dec 04
247
Jan 05 - Mar 05
253
Apr 05 - Jun 05
221
Jul 05 - Sep 05
247
Oct 05 - Dec 05
264
Jan 06 - Mar 06
274
Apr 06 - Jun 06
252
Jul 06 - Sep 06
212
Oct 06 - Dec 06
227
Jan 07 - Mar 07
249
Apr 07 - Jun 07
215
Jul 07 - Sep 07
210
Oct 07 - Dec 07
207
Jan 08 - Mar 08
198
Apr 08 - Jun 08
180
Jul 08 - Sep 08
150
Oct 08 - Dec 08
161
Jan 09 - Mar 09
170
Apr 09 - Jun 09
143
Jul 09 - Sep 09
101
Oct 09 - Dec 09
119
Jan 10 - Mar 10
117
Apr 10 - Jun 10
79
Jul 10-Sep 10
73
Oct 10-Dec10
82
Jan 11 – Mar 11
69
Apr 11 – Jun 11
52
Source: HPS, 2011
375
511
422
464
358
389
300
364
415
459
417
386
397
382
400
386
392
384
362
391
345
367
389
355
345
S.
aureus
596
758
686
738
610
601
527
613
630
669
624
584
577
532
561
556
535
485
481
508
424
440
471
424
397
Acute
occupied
bed days
Rate per 1000 acute
occupied bed days
MRSA MSSA
1394657
1360071
1347919
1366960
1395310
1325854
1324792
1340337
1382156
1327034
1325690
1342990
1390111
1362072
1329262
1339822
1378926
1344984
1308607
1321950
1382550
1335033
1299840
1334459
1353145
1319537
1290589
1314328
1339454
1299495
1264799
1281429
1301525
1284412
0.18
0.17
0.13
0.16
0.19
0.20
0.15
0.18
0.18
0.17
0.19
0.20
0.20
0.19
0.16
0.17
0.18
0.16
0.16
0.16
0.14
0.14
0.12
0.12
0.13
0.11
0.08
0.09
0.09
0.06
0.06
0.06
0.05
0.04
0.28
0.39
0.31
0.33
0.26
0.29
0.22
0.26
0.31
0.35
0.32
0.28
0.30
0.29
0.30
0.29
0.30
0.30
0.28
0.29
0.27
0.29
0.30
0.27
0.27
S.
aureus
0.45
0.57
0.51
0.53
0.45
0.45
0.39
0.45
0.47
0.51
0.47
0.42
0.43
0.41
0.42
0.41
0.41
0.38
0.37
0.38
0.33
0.35
0.37
0.33
0.31
37
APPENDIX 2
Table 9: Clostridium difficile infections across NHSScotland: total numbers and rates.
Clostridium difficile infections:
total numbers
Age 65 and
Quarter
above
Oct 06 - Dec 06
1213
Jan 07 - Mar 07
1775
Apr 07 - Jun 07
1588
Jul 07 - Sep 07
1459
Oct 07 - Dec 07
1608
Jan 08 - Mar 08
1861
Apr 08 - Jun 08
1729
Jul 08 - Sep 08
1435
Oct 08 - Dec 08
1300
Jan 09 - Mar 09
1157
Apr 09 - Jun 09
996
Jul 09 - Sep 09
808
Oct 09 - Dec 09
673
Jan 10 - Mar 10
640
Apr 10 - Jun 10
577
Jul 10 – Sep 10
575
Oct 10 – Dec 10
427
Jan 11 – Mar 11
355
Apr 11 – Jun 11
378
Source: HPS online appendix
Age 15-64
313
327
236
194
165
204
129
127
160
Clostridium difficile infections:
rates per 1000 occupied bed
days
Age 65 and
above
Age 15-64
0.96
1.47
1.47
1.16
1.26
1.41
1.33
1.15
1.02
0.88
0.77
0.79
0.66
0.86
0.51
0.61
0.49
0.50
0.46
0.42
0.47
0.52
0.34
0.34
0.28
0.34
0.31
0.43
38
APPENDIX 3
Table 10: Surgical site infection following caesarean section procedures across
NHSScotland. Total infection numbers and rates of infection as a proportion of total caesarean
section operative procedures. Infection numbers and rates are based on either inpatient
surveillance only or inpatient and post discharge surveillance (PDS) to 10 days post operatively
since the introduction of PDS.
Caesarean section
Inpatient
surveillance
Quarter
Apr 02 - Jun 02
Jul 02 - Sep 02
Oct 02 - Dec 02
Jan 03 - Mar 03
Apr 03 - Jun 03
Jul 03 - Sep 03
Oct 03 - Dec 03
Jan 04 - Mar 04
Apr 04 - Jun 04
Jul 04 - Sep 04
Oct 04 - Dec 04
Jan 05 - Mar 05
Apr 05 - Jun 05
Jul 05 - Sep 05
Oct 05 - Dec 05
Jan 06 - Mar 06
Apr 06 - Jun 06
Jul 06 - Sep 06
Oct 06 - Dec 06
Jan 07 - Mar 07
Apr 07 - Jun 07
Jul 07 - Sep 07
Oct 07 - Dec 07
Jan 08 - Mar 08
Apr 08 - Jun 08
Jul 08 - Sep 08
Oct 08 - Dec 08
Jan 09 - Mar 09
Apr 09 - Jun 09
Jul 09 - Sep 09
Oct 09 - Dec 09
Jan 10 - Mar 10
Apr 10 - Jun 10
Operations
24
229
571
546
637
685
614
774
774
765
824
1001
1223
1460
1283
1441
1563
1562
1586
2842
3269
3478
3559
3430
3354
3744
3507
3348
3659
3706
3784
3579
3799
Infections
1
8
12
10
10
14
12
14
10
19
14
20
17
18
16
23
29
31
21
37
27
23
21
21
16
15
16
11
14
20
16
8
14
Rate
4.2%
3.5%
2.1%
1.8%
1.6%
2.0%
2.0%
1.8%
1.3%
2.5%
1.7%
2.0%
1.4%
1.2%
1.2%
1.6%
1.9%
2.0%
1.3%
1.3%
0.8%
0.7%
0.6%
0.6%
0.5%
0.4%
0.5%
0.3%
0.4%
0.5%
0.4%
0.2%
0.4%
Inpatient and
post-discharge
surveillance to
day 10
Infections
Rate
148
133
135
100
113
94
109
100
100
91
89
92
77
119
5.2%
4.1%
3.9%
2.8%
3.3%
2.8%
2.9%
2.9%
3.0%
2.5%
2.4%
2.4%
2.2%
3.1%
Source: Obtained directly from HPS
39
Table 11: Surgical site infection following hip arthroplasty procedures across
NHSScotland. Total infection numbers and rates of infection as a proportion of total hip
arthroplasty operative procedures. Infection numbers and rates are based on either inpatient
surveillance only or inpatient and readmission surveillance to 30 days post operatively since the
introduction of readmission surveillance.
Hip arthroplasty
Inpatient
surveillance
Quarter
Apr 02 - Jun 02
Jul 02 - Sep 02
Oct 02 - Dec 02
Jan 03 - Mar 03
Apr 03 - Jun 03
Jul 03 - Sep 03
Oct 03 - Dec 03
Jan 04 - Mar 04
Apr 04 - Jun 04
Jul 04 - Sep 04
Oct 04 - Dec 04
Jan 05 - Mar 05
Apr 05 - Jun 05
Jul 05 - Sep 05
Oct 05 - Dec 05
Jan 06 - Mar 06
Apr 06 - Jun 06
Jul 06 - Sep 06
Oct 06 - Dec 06
Jan 07 - Mar 07
Apr 07 - Jun 07
Jul 07 - Sep 07
Oct 07 - Dec 07
Jan 08 - Mar 08
Apr 08 - Jun 08
Jul 08 - Sep 08
Oct 08 - Dec 08
Jan 09 - Mar 09
Apr 09 - Jun 09
Jul 09 - Sep 09
Oct 09 - Dec 09
Jan 10 - Mar 10
Apr 10 - Jun 10
Operations
214
324
507
508
729
1182
1087
1355
1313
1339
1474
1500
1629
1575
1498
1383
1441
1325
1191
1937
1962
2101
2141
2308
2303
2247
2336
2423
2374
2347
2357
2418
2113
Infections
3
4
6
8
18
25
19
25
18
22
23
18
13
23
26
13
14
14
17
16
22
16
17
15
21
22
13
14
28
9
24
15
10
Rate
1.4%
1.2%
1.2%
1.6%
2.5%
2.1%
1.7%
1.8%
1.4%
1.6%
1.6%
1.2%
0.8%
1.5%
1.7%
0.9%
1.0%
1.1%
1.4%
0.8%
1.1%
0.8%
0.8%
0.6%
0.9%
1.0%
0.6%
0.6%
1.2%
0.4%
1.0%
0.6%
0.5%
Inpatient and
readmission
surveillance to
day 30
Infections
Rate
24
34
20
20
26
34
32
25
20
38
24
33
27
19
1.2%
1.7%
1.0%
0.9%
1.1%
1.5%
1.4%
1.1%
0.8%
1.6%
1.0%
1.4%
1.1%
0.9%
Source: Obtained directly from HPS
40
APPENDIX 4
Table 12: Overview of recent prevalence surveys of HAI infections in industrialised
European countries
Year
Country
(study/ publication)
UK,
1996
Germany
1997
France
2001 (1996)
Switzerland
2002
Greece
2000
Slovenia
2001
Italy
2002
Portugal
2003
Denmark
2003
Latvia
2003
Finland
2005
Sweden
2004–2006
UK and Ireland
2006
France
2006
Norway
2002–2007
Scotland
2007
Spain
(1990) 2004–2007
Lithuania
2003, 2005, 2007
Netherlands
2007
Source: ECDC, 2008
Prevalence
%
9.00%
3.50%
6.60%
8.10%
9.30%
4.60%
7.50%
8.40%
8.70%
3.90%
8.50%
9.50%
7.60%
5.00%
6.80%
9.50%
6.80%
3.70%
6.90%
Hospitals
(N)
157
72
1,533
160
14
19
15
67
38
7
30
56
273
2,337
53
45
259
35
30
Patients
(N)
37,111
14,996
162,220
7,540
3,925
6,695
2,165
16,373
4,226
3,150
8,234
13,999
75,763
358,353
11,359
11,608
58,892
8,000
8,424
41
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