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.
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.
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.
Following National Audit Office reports 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.
The 2009 National Audit Office report on reducing HCAIs 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.
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
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.
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.
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.
The following documents provide further information on the referral, scope, and methodology used as the basis for this guide:
'Advice on the prevention and control of healthcare-associated infections: scope' – this sets out the referral and scope for the work
'Quality improvement guide – prevention and control of healthcare-associated infections: topic briefing paper'- this summarises the methods and process used to develop this guide and lists the source documents
 Department of Health (2008) Board to ward: How to embed a culture of HCAI prevention in acute trusts.
 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
 Department of Health (2006) The Health Act 2006: code of practice for the prevention and control of healthcare associated infections. London: Department of Health.
 National Audit Office (2009) Reducing healthcare associated infections in hospitals in England.