Prevention and control of healthcare-associated infections quality improvement guide

Introduction

Following a referral from the Department of Health, the National Institute for Health and Clinical Excellence (NICE), in partnership with the Health Protection Agency (HPA), have developed this quality improvement guide. The guide offers advice on management or organisational actions to prevent and control healthcare-associated infections (HCAIs) in secondary care settings.

The guide is aimed at board members working in (or with) secondary care. It may also be of use to senior managers, those working elsewhere in the NHS, as well as those working in local authorities and the wider public, private, voluntary and community sectors.

In producing this guide, NICE and the HPA have assumed that all secondary care settings are compliant with the current code of practice on preventing and controlling infections^[1].

The guide aims to help build on advice given in the code and elsewhere to improve the quality of care and practice in these areas over and above current standards. Taken together, the quality improvement statements contained in this guide describe excellence in care and practice to prevent and control HCAIs. Examples of evidence and other data to demonstrate progress against each statement are provided.

NICE and the HPA recognise that a range of factors associated with infection prevention and control have the potential to impact on health inequalities (for example, in relation to age, ethnicity, gender and disability). However, the relative impact of different factors will vary for different organisations. NICE and the HPA expect trusts and other secondary care organisations to consider local issues in relation to health inequalities when implementing this guide.

What is a healthcare-associated infection?

Healthcare-associated infections (HCAIs) can develop either as a direct result of healthcare interventions such as medical or surgical treatment, or from being in contact with a healthcare setting.

The term HCAI covers a wide range of infections. The most well known include those caused by meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus(MSSA), Clostridium difficile (C. difficile) and Escherichia coli (E. coli). HCAIs cover any infection contracted:

as a direct result of treatment in, or contact with, a health or social care setting
as a result of healthcare delivered in the community
outside a healthcare setting (for example, in the community) and brought in by patients, staff or visitors and transmitted to others (for example, norovirus).

HCAIs pose a serious risk to patients, staff and visitors. They can incur significant costs for the NHS and cause significant morbidity to those infected. As a result, infection prevention and control is a key priority for the NHS^[2].

What action has been taken?

Following National Audit Office reports^[3] highlighting concerns about HCAIs, the Department of Health introduced a range of policies and measures designed to reduce rates of infection.

For example, mandatory surveillance for meticillin-resistant Staphylococcus aureus (MRSA) was introduced in 2001. In 2004, a target was introduced to reduce MRSA bloodstream infections by 50% by 2008 in all NHS acute and foundation trusts. With the introduction of the Health Act in 2006, for the first time it became a legal requirement to have systems in place to minimise the risk of HCAIs^[4].

What action is needed now?

The 2009 National Audit Office report on reducing HCAIs^[5] identified four systemic issues that still needed to be tackled locally and nationally to reduce infection rates. It highlighted the need:

for a culture of continuous improvement
for a whole-system approach, with clear structures, roles and responsibilities
to ensure staff compliance with good infection control practice
to monitor and record hospital prescriptions and the use of antibiotics.

What is this guide for?

This guide will help secondary care and other healthcare organisations improve the quality of care and practice, reduce the risk of harm from HCAIs to patients, staff and visitors and reduce the costs associated with preventable infection. The 11 quality improvement statements provide clear markers of excellence in infection prevention and control at a management or organisational level. Each statement is supported by examples of the type of evidence that could be used to prove the organisation has achieved excellence, and examples of what this would mean in practice on a day-to-day basis.

The aim is to help boards:

assess current practice in relation to the prevention of HCAIs
identify areas for quality improvement
monitor progress
provide leadership and support to infection prevention and control teams and other staff working to implement the guide.

The guide may also help inform investment decisions.

It will also give patients and the public information about the quality of care they can expect, and how secondary care organisations can improve patient safety and outcomes by improving quality in key areas.

How should the guide be used?

This guide is not mandatory. Rather, each quality improvement statement describes a level of excellence that could be achieved to prevent and control infections. Key areas of practice that underpin infection prevention and control, such as hand hygiene, antimicrobial stewardship and environmental cleanliness are included as measures and examples, where appropriate.

Organisations wishing to use the guide for quality assessment and improvement may choose a selection of the most appropriate measures for their setting as potential evidence of achievement. In organisations where, for example, tertiary care services are provided alongside secondary care, senior management should consider the applicability of each statement to their setting.

The examples of measures that could be taken may not be appropriate in all cases - and secondary care organisations may identify and use alternate measures as evidence of achievement, as necessary.

Performance in each statement area will depend upon healthcare professionals and other trust staff who have HCAI prevention and control - and public health, generally - as part of their remit.

Much of the information required to support the measures is already available and a range of other guidance can be used alongside this guide to assess and improve quality in secondary care settings. Overlaps between the statements and certain aspects of the code of practice are highlighted. In addition, where data routinely collated may help trusts monitor progress in an area covered by one of the statements, this is also highlighted.

How was the guide developed?

This guide was developed as a pilot project, based on processes and methods used by NICE to develop other types of guidance. A topic expert group was set up and led by an independent chair. It consisted of practitioners from the NHS, local authorities and the voluntary sector, as well as academics and patient and public representatives. The group worked with NICE and the HPA to develop the guide.

The resulting quality improvement statements are based on recommendations from seven source guidance documents. They have been refined as a result of stakeholder consultation and committee discussion.

More information on how this guide was developed

Terms in bold are explained in the glossary.

Quality improvement statements

1. Trust boards demonstrate leadership in infection prevention and control to ensure a culture of continuous quality improvement and to minimise risk to patients.

2. Trusts use information from a range of sources to inform and drive continuous quality improvement to minimise risk from infection.

3. Trusts have a surveillance system in place to routinely gather data and to carry out mandatory monitoring of HCAIs and other infections of local relevance to inform the local response to HCAIs.

4. Trusts prioritise the need for a skilled, knowledgable and healthy workforce that delivers continuous quality improvement to minimise the risk from infections. This includes support staff, volunteers, agency/locum staff and those employed by contractors.

5. Trusts ensure standards of environmental cleanliness are maintained and improved beyond current national guidance.

6. Trusts work proactively in multi-agency collaborations with other local health and social care providers to reduce risk from infection.

7. Trusts ensure there is clear communication with all staff, patients and carers throughout the care pathway about HCAIs, infection risks and how to prevent HCAIs, to reduce harm from infection.

8. Trusts have a multi-agency patient admission, discharge and transfer policy which gives clear, relevant guidance to local health and social care providers on the critical steps to take to minimise harm from infection.

9.Trusts use input from local patient and public experience for continuous quality improvement to minimise harm from HCAIs.

10. Trusts consider infection prevention and control when procuring, commissioning, planning, designing and completing new and refurbished hospital services and facilities (and during subsequent routine maintenance).

11. Trusts regularly review evidence-based assessments of new technology and other innovations to minimise harm from HCAIs and antimicrobial resistance (AMR).

Key documents

NICE Pathways

This guidance has been incorporated into the following NICE Pathways, along with other related guidance and products.

Visit the NICE Pathway: prevention and control of healthcare associated infections

Consultation feedback

Consultation and on the HCAI quality improvement guide took place from 4 July 2011 to 9 August 2011. Stakeholders were emailed inviting individuals and organisations to comment. Additionally, a leaflet was distributed at the NHS Confederation Conference in July by staff on the NICE stand signposting the consultation. NICE also commissioned research company GHK Consulting to independently undertake field testing of the draft advice with professionals All eligible comments and the field testing report were reviewed by the Topic Expert Group and the standard was updated accordingly.

Evaluation

NICE and the HPA would like to evaluate stakeholder use of and views on this quality improvement guide during its first year of publication. We would be very grateful if you could complete this short survey for us.

NICE Shared Learning Database

NICE would like to hear about your local experiences of tackling healthcare associated infections within and across your organisation. Do you have any examples, tips or ideas that you could share with others? Are there any templates, or processes that you have set up that others may be able to adapt or learn from?

Further information on the NICE shared learning database

Endorsement

Many organisations share NICE's commitment to improve quality by making it clear what quality care is for patients and the public, health and social care professionals, commissioners and service providers.

So that this guide reaches the widest possible audience, some of the organisations who have been involved in the development process, and who endorse the healthcare associated infection quality improvement guide, have become partners in its publication.

If your organisation would like to endorse this guide please email nice@nice.org.uk.

This quality improvement guide is endorsed by the following organisations:

The Association for Clinical Biochemistry, Microbiology Group

British Infection Association

C-diff Support

Healthcare Infection Society

Infection Prevention Society

The Institute of Biomedical Science (IBMS)

The Kidney Alliance

MRSA Action UK

National Association of LINks Members

National Concern for Healthcare Infections

NHS Institute for Innovation and Improvement

Royal College of Pathologists

Royal College of Physicians

The Society for Acute Medicine

United Kingdom Clinical Pharmacy Association

References

1. Department of Health (2010) The Health and Social Care Act 2008: Code of practice for health and adult social care on the prevention and control of infections and related guidance.

2. Department of Health (2008) Board to ward: how to embed a culture of HCAI prevention in acute trusts.

3. National Audit Office (2000) The management and control of hospital acquired infection in acute NHS trusts in England. London: National Audit Office.

National Audit Office (2004) Improving patient care by reducing the risk of hospital acquired infection: a progress report. London: National Audit Office

4. Department of Health (2006) The Health Act 2006: code of practice for the prevention and control of healthcare associated infections. London: Department of Health.

5. National Audit Office (2009) Reducing healthcare associated infections in hospitals in England.

This page was last updated: 27 March 2012

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