Controlling MRSA in England: what we have done and what we think worked. Professor Barry Cookson

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1 Controlling MRSA in England: what we have done and what we think worked Professor Barry Cookson Depts. of Health Policy & Tropical & Infectious Disease, London School of Hygiene & Tropical Medicine. Dept Infectious Disease, Imperial College, University of London

2 PHLS Colindale Marples, 1985 Jevons, 1961 Cookson, Lancet 2011 Cookson!

3 Pathogenesis of Infections Seed Microbes e.g. MRSA Climate Environment e.g. healthcare delivery Soil Patients e.g. Elderly, Renal

4 number of reports methicillin resistance as a proportion of reports with methicillin susceptibility information *Source: voluntary laboratory reporting to CDSC MRSA as % of reports with methicillin susceptibility information Voluntary* S. aureus/mrsa bacteraemia reports (England & Wales, ) Late 1990s Media Patient Advocates Patient Safety NAO ,000 12,000 10,000 8,000 6,000 (ALL TRIGGERS) 4,000 2,000 0 Mandatory MRSAB Reporting 2001 Setting of Targets: 2004 Dr Read 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Staphylococcus aureus

5

6 NAO 2008 Report: MRSAB Trends % 4450 of Trusts Increased % 42% >80% Reductions 61%

7 Trigger Factors? April 2001 July 2003 July 2004 July 2004 Sept 2004 Oct 2004 June 2005 Oct 2005 Mandatory Acute Hospital MRSA bacteraemia surveillance: no 48h cut off: no transfer recording DIPC created Matrons Charter Target for reduction of MRSA bacteraemia: halved by cleanyourhands campaign Towards Cleaner Hospitals Saving Lives published: Seven Bundles followed Enhanced MRSA bacteraemia surveillance: CE Responsible

8 May 2006 Oct 2006 Oct May 2007 Trigger Factors? Going Further Faster published: CEs attended NPSA publish Root Cause Analysis tools for HCAI Code of Practice to prevent HCAI published as part of the Health Act : The STICK Improvement Teams: varied why went in and what done: The CARROT Healthcare Commission inspection programme: against Code 2008 The Deep Clean April 2009 MRSA Screening for elective surgery: many started earlier

9 NO Prospective studies to unravel individual effects: Sold as a Multi-Faceted Intervention Approach A joined up approach Legislation Code of Practice Health Care Inspection Service Re-design Saving Lives Organisational & behavioural change Best Practice e.g. Winning Ways Performance Management

10 Even More Apparent in Detail of Saving Lives High Impact Interventions Practices Protocols / Guidance Bed Management Cleaning Processes Admission & discharge Communications Ward Management Governance Hygiene / Aseptic Techniques Performance Staff Management Information An integrated approach Training / Induction Risk Management Roles & Responsibilities People Staffing Local Procurement Clinical Governance Leadership SAVING LIVES

11 Other Factors?

12 Number of Hospitals Hospitals affected each month by EMRSA-3, EMRSA-15, or EMRSA % of S. aureus BSIs due to E-15 and E-16 EMRSA -15 EMRSA Year CPHL-Laboratory of HCAI EMRSA (EARSS)

13 Decline of EMRSA-16 BSI in UK: Ellington et al, J Ant. Chemother 2010; 65: EARSS MRSAB : E15 (60%) E16 (35.4%) BSAC Surveillance scheme also explored Generalized linear regression model: during the reductions in English MRSA 2001; 2003; 2005 & 2007; 95% of MRSA BSI consistently same two strains (MLST and SCCmec) E16 declined further from 21.4% in 2001 to 9% in 2007 (P=0.05) EMRSA-15 rose accounting for 85% MRSA in Ciprofloxacin and erythromycin resistance common in E15 and E16. Conclusion: E-16 decline precedes the MRSAB decline from middle of the 2000s: no evidence E15 easier to control or less invasive

14 What do the data tell us?

15 MRSA Bacteraemia Rates in England April 2001 Mar 2005

16 MRSA Bacteraemia by Trust Category: Most General Medicine, Surgery, Elderly Care Wards ICU/High Dependency Wards 8% Dialysis Treatment

17 ! Gaming: are MRSAB data to be believed? Many checks eg HCC, CQC CE made responsible for locking the data down Death reporting (ONS) data also decreased Reductions in blood cultures taken?

18 Studies of MRSAB Reductions

19 MRSA bacteraemia (MRSAB) rate in specialist Trusts (April March 2003) Large variation within a country: opportunities from learning within the same healthcare system

20 Healthcare Commission Analysis of Healthcare Associated Infection 2006 Questionnaire survey 170 Acute English Trusts Organisational-wide analytical approach used later by Improvement Teams Surveys of Antimicrobial stewardship, staff and patient surveys Clinical Negligence Scheme for Trusts Patient Environment Action Team scores All data was analysed vs suite of outcome measures: Distance from DoH MRSA improvement target MRSA latest rate (Jan Mar 06) MRSA latest rate (48 hours post admission) MRSA trend ( ) Mears A et al, J Hosp Infection, 2009; 71:

21 Healthcare Commission Analysis of Healthcare Associated Infection 2006 Rates of MRSA bacteraemia (MRSAB) Lower if better hand hygiene parameters Higher if single rooms to isolate patients were less available Mears A et al, J Hosp Infection, 2009; 71:

22 Healthcare Commission Analysis Lower MRSAB and C difficile infection (CDI) rates: Better bed management parameters Inclusion of infection control in appraisal and personal development plans Higher rates: Protected time for infection control training for all healthcare workers May be an example of reactive practice NOTE: This study was Very Early in the implementation of Saving Lives and pre Improvement Team visits

23 The World s First National Hand Hygiene Improvement Campaign Rolled out to all 187 acute NHS hospitals Dec 2004 to June year campaign

24 Conclusions NOSEC Study Stone et al, BMJ in press Campaign associated with increased procurement of AHR and soap in each phase Strong independent associations with reductions in MRSA bacteraemia and C difficile infections (CDI) Higher procurement of soap and AHR Health Act DOH improvement visits Relative contributions unclear Other national interventions or hospital variations were not National infection control interventions, including a hand hygiene campaign, in context of a high profile political drive, can successfully reduce MRSA/CDI.

25 NAO Report 2008 Improvement Comments Trusts: 87% found Health Code helpful Leadership from CEs, Good Performance Management Stoke Mandeville/Maidstone Reports a wake-up call: Threat of CQC fines/shaming 61% included HCAI IPC in JDs Increase in ICT resourcing Quoted DH: Staff patient ratios/bed Occupancy no longer related to higher MRSABs

26 Prediction is very difficult, especially about the future Niels Bohr Danish physicist ( ) The future will be exactly like the past only far more expensive Jim Bishop, Author, 1959

27 Five decades of MRSA: controversy and uncertainty continues. Cookson, Lancet 2011; 378: It is vital that policy makers and governments realise that they must continue to spend money to save money.

28 Five decades of MRSA: controversy and uncertainty continues. Cookson, Lancet 2011; 378: MRSA and other hospital infection pathogens will continue to pose threats to patient safety in the foreseeable future. One thing is certain: the response to these challenges will determine the next decade of research and reaction to MRSA.

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