Taming the environment educational symposium

Martin Kiernan chaired the event and set the scene with where we had come from and the work that was ongoing in infection prevention and control.  The National Audit Office report in 2000 showed that there was more of a focus on the terminology "control" rather than "prevention", it was believed that between 5% to 20% of healthcare acquired infections were preventable, that meant we believed that between 80% to 90% were unpreventable. In 2006 there were over 55,000 cases of C.diff reported in the over 65s, which was a public scandal.

Annual infection rates for MRSA bacteraemia have reduced by 75% from their peak in 2003/04 - when 7,700 MRSA bacteraemias were reported - to 1,898 in 2009/10 [1]

A similar scale of reduction was achieved in respect of Clostridium difficile infections (CDI ): since their peak in 2006/07 when - although reporting was at the time limited to over-65 year-olds - there were 55,681 infections, which were reduced to 25,604 by 2009/10, when infections in all people over two years of age were included. Parallel reductions had been achieved in HCAI-related mortality: deaths in which MRSA had been reported to have been an underlying cause fell from a peak of 480 in 2006 to 133 in 2009, and deaths in which CDI was an underlying cause fell from a peak of 3875 in 2007 to 1510 in 2009 [2]

Now that cases are far fewer it is possible to carry out route cause analysis, involving all relevant clinicians, and it was possible to identify where we could have done more to prevent the infections.  There was still more to do with more challenges with NDM1, OXA48 and ESBLs.  It was clear there was still a lot to understand with regards to some of the more virulent bacteria in our healthcare facilities, both in and outside of the hospital environment.  Clostridium difficile remains a challenge and we still don't fully understand its epidemiology.

Martin moved to Derek Butler, MRSA Action UK, to talk about the people that the numbers represent.  In his introduction Martin spoke of the tenacity of the campaigning and the impact this was having, which was remarkable since Derek does this in a voluntary capacity and works in the nuclear industry, and was no doubt busy with events that had taken place in Japan.  Derek said it had indeed been busy and that when events happened in Japan, safety mechanisms were reviewed and shared amongst the 564 reactors worldwide, something that could be learned from in healthcare.  In his introduction to the charity and the people who had been affected Derek said the most important people in his presentation were the young people, as if we take our eye off the ball then we could be leaving the next generation with a future where antibiotics will be ineffective, setting healthcare back to the era before they existed.  If we have the ability to put things right then it is incumbent on us to do so.

The nine people and their families that featured in Derek's presentation were a stark reminder of why it was so important to do all we can to do things right and take a zero tolerance approach to avoidable harm and healthcare associated infections.  All of the families' experiences highlighted incidents that should not have happened, and there were two very recent incidents that prompted surprise from some delegates.  It was clear that there was still a lot to do to change hearts and minds in some cases.


Information and communication were so important, and in each case, the lack of it played a role in the harm.  Patients and families need to be told about the risks from healthcare associated infections, if a patient has an infection then discussing this with them and those who are close to them is important, and passing information on to all the people involved in the patients' care is vital to ensure previous infection status and treatments are communicated, antibiotics and potential resistance need to be recorded, without passing on information this is not possible.  We had reached a crossroads, if we take no action today we may be in a position where there is no cure tomorrow.  Derek's presentation can be read

Adam Fraise gave an interesting insight into the various disinfectants that are used in infection prevention and control and their limitations.  We know about antimicrobial resistance, but of particular interest was the evidence that had been presented on resistance to biocides used in fighting microbes that caused infections.  We knew that there was Mupirocin resistance, but there were cases of resistance to Chlorhexidine presented, although rare, in terms of the world of healthcare and infection prevention a worrying development.  

Delegates questioned efficacy of antibacterial wipes and the need for periodically testing for resistance in biocides.  There was no way of testing the efficacy of wipes, as disinfectants need to be tested for a period of time on their kill rate, wipes evaporate as you use them so this is not possible to determine.  In any use of disinfectants any organic material has to be removed before cleaning.  Wipes could be useful for this purpose, with commodes for example, but they should not be relied on for decontaminating endoscopes.

Tim Boswell gave very compelling evidence to suggest that both gram positive and gram negative bacteria can, on occasion be transmitted through environmental contamination.  Use of hydrogen peroxide vapour in bays produced good results, however there were occasions where spores were still found on curtains, so removing items where misting would not be effective was important.  The usage of the HPV technology in sluice rooms, toilets and, if you were decontaminating an area, the placement of equipment on the location was believed to be an innovative way of making the best use of the HPV technology.

Andrea Ladgerton, Infection Prevention & Control Team Leader at Arrowe Park Hospital gave a presentation outlining the problem they had with outbreaks of Clostridium difficile and how they had felt when they were highlighted as having the highest numbers of people affected in the North West, and at one point in the country.  They had taken action and at the time of the reports were beginning to see improvements.  There were problems with communication with the Hotel Services staff with outlining what type of cleaning was required, clearer specifications had resulted in improvements to the cleaning regime.  Mattresses were replaced which were identified as a reservoir for Clostridium difficile spores and antibiotic usage is monitored.  Changes and high impact interventions, including hydrogen peroxide vapour cleaning had resulted in significant improvements on the worst affected wards, and on Ward 21 they had gone for 308 days without a case of Clostridium difficile.  Maria Cann asked if they considered that their objective should be set lower for this year, as it currently stood at 122, and to go for that length of time without a case in that particular ward was a significant achievement, which from the patient perspective should be an aspiration for all wards.

There was some debate about the league table approach to publishing figures, and some hospitals varied in their policies on sending samples for testing, there was guidance but this was open to interpretation, and it was felt that this needed to be clearly set out by the Health Protection Agency, publishing the numbers of tests sent for analysis may reveal the extent of this problem.

Diane Wake, Executive Director of Nursing & Operations & Director of Infection Prevention & Control, Royal Liverpool Hospital spoke of the openness of their reporting and the practice of using information to monitor how they were improving, the use of route cause analysis, and the regular review of death certification with the registrar.  Maria Cann asked that if there were any discrepancies highlighted with the reporting on the death certificates was this raised with the certifying doctor, as we were still experiencing people coming to us to say that the pathogens were still not being recorded on death certificates if they had caused, or were contributory factors in deaths.  Diane confirmed that this would always be reviewed and rectified and taken up with the certifying doctor.  Martin added that sometimes very junior doctors are tasked with signing death certificates and that can be a reason for pathogens not being included.

The new Royal Liverpool Hospital was entirely single rooms and the interventions to reduce Clostridium difficile and other micro-organisms in the environment included the hydrogen peroxide vapour cleaning.  With other high impact interventions it is hoped that this will bring about a significantly safer patient experience.


1. MRSA bacteraemia and C. difficile mandatory reports 2009/10, HPR 4(28), 16 July 2010.

2. "Zero tolerance - the clinical challenges ahead", presentation by the Department of Health's inspector for microbiology and infection control, Dr Brian Duerden, at the national conference, "Reducing HCAIs 2010 - a transformation process: embedding the culture of patient safety", Wednesday, 8 September 2010, London, organised by GovToday


If you or someone you care about has been affected by a healthcare infection and you wish to discuss this with us, please contact us at info@mrsaactionuk.net