A Personal Experience

Derek Butler, Chair, MRSA Action UK

Derek thanked the steering group of the cleanyourhands campaign for the opportunity to represent the Charity, and to speak for the victims of healthcare infections.

Derek said that MRSA Action UK gave this campaign the full support that we believe it deserves in ensuring that hand hygiene is given the priority that it needs.

The Charity believes that the cleanyourhands campaign will have the biggest impact on reducing these infections in our hospitals. Derek outlined that he had been invited to give a personal perspective and therefore explained his involvement with this campaign and with the common goal of reducing infections.  It came not because he suffered from a healthcare infection himself, but because of the loss of his stepfather and dearest friend to MRSA.

John was a man who was not let down because of those that work in the system, but because the system itself is flawed. No matter how efficiently the hospital functions; how good the training, supervision, and procedures are; and how well the best, Doctor, Nurse, Cleaner or Manager perform his or her duties, people cannot perform better than the organisation supporting them.

John had a massive heart attack in September 2003 but he did not die because of the heart attack. He died profusely infected with MRSA at Christmas 2003.

Like John - Colin Law was taken from his family, Colin's family have been left devastated. Colin was admitted to a hospital for a routine set of tests for the suitability of having a liver transplant. He was expected to be in hospital for just 5 days, in fact he never left the hospital as he contracted MRSA whilst in the hospital. He never had surgery; the only procedure that Colin had was that he had an IV line inserted for the tests, 7 weeks later Colin died just one day before his 33^rd birthday.

The family have told us that they will never forget their shock and the pain of seeing Colin's face ... looking at each other he was sat up in his bed as they tried to hold back their tears whilst the Doctor told them that Colin was dying - that all of his organs were failing and he also had Pneumonia (no mention of MRSA)

Sir Liam was moved by your poem Mavis... "Dearest Colin, What you suffered you told but few, You didn't deserve what you went through, They never said you had M.R.S.A, Wish we knew then what we know today, Tired and weary ... You made no fuss, You tried so hard to stay with us, But God saw that the road was getting tough - The hills too steep to climb ..... He put his arms around you and whispered ... Colin - Peace be Thine. (You are only ever a whisper away Colin - Love you for always ) From your heartbroken family and your little dog Lady. x x x x x"

.... and by your tribute Linda "Loved by a love beyond all telling, And missed by a grief beyond all tears"

The pictures from the memorial event held in July says everything that we feel as victims of Healthcare Infections and the devastation they leave behind. "Loved by a love beyond all telling and missed by a grief beyond all tears". The events of a week ago at the Maidstone and Tunbridge Wells NHS Trust should be a salutary reminder of the price that many of us have paid in respect to Healthcare Infections when the system of Infection Prevention and Control fails.

The cleanyourhands campaign's aim should be to mitigate the risk from bacteria rather than fight it. The cleanyourhands campaign should be given the support of everyone from what ever background they are from. There are no borders either national or political with healthcare infections. There should be no pointing the finger of blame, there should be learning from the past, but not a living in the past.

Our Charity believes that healthcare infections should not be used as a football to be kicked around to suit any one personal agenda. There is not a single representative of the House of Commons who has not lost a constituent from a healthcare infection. There should be no squabbling by them, over how best to tackle these infections in our hospitals whilst people keep suffering and dying. As a Charity we would like to see the campaign for safer hospitals supported by all our elected representatives across the house.

Our Charity was born out of the suffering we feel everyday and we owe this to those that we have lost to and been harmed by healthcare infections. In their loss we can  ensure that today's and tomorrow's generations will not have to live with the legacy of Healthcare Infections. As parents we owe this to our children in that they inherit a world safer than the one passed on from our parents. For if we stand and do nothing, we will have discharged our responsibility to society, and to accept what some in authority think is inevitable would be a betrayal of those generations.  Derek ended with three thought provoking quotations from history.

"We are what we repeatedly do. Excellence, then, is not an act, but a habit."  Aristotle

"If there is a wrong, then it is incumbent on those that have the ability to correct that wrong, to have placed upon them the responsibility to correct that wrong".  Benjamin Franklin

And finally a thought from Florence Nightingale

"Let whoever is in charge keep this simple question in their head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?" Thank you.

Call to Action
Sir Liam Donaldson, Chief Medical Officer,
Department of Health, England

Sir Liam Donaldson thanked Derek and outlined the importance of patients being willing to stand up and tell us what is needed.  Sir Liam's speech was powerful and he had a very clear message that if someone does not want to comply with hand hygiene, then they should not be in the healthcare profession.

They should take the greatest inspiration from people who rise above tragedy and said we must be prepared to work with them.

He spoke of his annual report and how he wanted the hard hitting image of Ian Kelly portrayed. It took courage to speak out and to say what we needed to do to make the environment safer.

Ian went in for a minor operation caught MRSA and had his leg amputated.  Ian noted the lack of handwashing, buckets being used without changing water for cleaning, spreading infection around and was prepared to speak out.

We all knew the financial burden of healthcare infections, but the human cost was the biggest incentive to make sure we got this right.  The people who paid the heaviest price for healthcare infections were those like Ian and the families that Derek had just described.

Sir Liam was adamant in emphasising the need for the correct hand washing technique in the treatment of Clostridium difficile, it was important that any contamination was removed with soap and water.  The empowerment of patients and other tools to prompt and remind staff were important, but it was the responsibility of the healthcare workers to ensure they complied.  The key messages were

• Alcohol rub, makes it easier
• For C diff we have to wash with soap and water too
• Adding alcohol rub adds to the spectrum of action needed
• People who do not comply do not belong in the health service
• Strong leadership will tackle the full spectrum of hospital infections
• We had seen the financial arguments for improving, now the human cost was the prime motivating factor

Alcohol rub usage had increased in the 3 years since the Cleanyourhands campaign was launched from 13mls per patient per day to 30mls per patient per day, equating to 16 hand sanitising events up from 6 per patient, and the role of the patient challenging should be welcomed.  Initiatives like badges that say "ask me", posters "ask me" had proved successful in this campaign.

It was necessary to do extra to empower the patient in the patient care encounter.  It was planned to pilot the issue of alcohol gel to patients for a few months to see if this worked, it was necessary to strengthen the partnership between the patient and the carer to make it safer for the patient.

Clean, Safe Care
Christine Beasley, Chief Nursing Officer,
Department of Health, England

The campaign had been showing successes and there had been some really encouraging participation with school children being involved.

It was easy and natural to want one answer to the problems with healthcare infections.  Cleanyourhands had been critical and was a very significant in reducing healthcare infections.  This fitted in with a whole suite of things including patient involvement and improvement in technical areas. We needed to do all of it all of the time.  We saw the importance of line care from what had happened to Colin.  The use of antibiotics and initiating care was important.

The challenge was to do the basic things right all of the time.  We all know how difficult it is to change behaviour.  As Derek said we need systems to support that, cleanyourhands has helped.  We had to get the basics right, as what is the point of carrying out all the marvellous complex surgeries that save lives if we can't get things like line care right.

The Improvement Journey
Martin Fletcher, Chief Executive,
National Patient Safety Agency

Martin outlined that the cleanyourhands campaign was not just in the United Kingdom, but that this was a world wide initiative that had been signed up to by 69 countries all of who were equally determined to bring down the infection rates in their respective countries.

Martin showed how England and Wales were one of the first countries to have signed up to this initative and that we should be proud to be one of the leaders who are driving this campaign for safer standards and compliance on hand hygiene that will save so many lives. Maritn showed to the audience that 1.4 million people worldwide have a healthcare associated Infection at anyone time, and that in the United States 1 in 36 patients aquire an healthcare infection and that they have a minimum of 80,000 deaths annually.

Surveys and research had showed that staff wanted harder hitting campaign materials, something that stands out, and they wanted their own improvement goals.  The materials had been designed with this in mind and this had been done in response to encourage all staff to participate.

Martin thanked everyone for attending and launched the year 3 reveal.