House of Commons

 

Review of Healthcare Associated Infections:  Are we doing enough?

4-6pm on 1^st April 2009

Committee Room 8, House of Commons, Westminster

 

MRSA Action UK joined health campaigners in the House of Commons on 1 April 2009, the day the Care Quality Commission came into force.  The timing was apt, as a report will come from the meeting focusing on the Department of Health's Clean, Safe Care policy, the question being posed to campaigners taking part was "are we doing enough?"

 

 

Dr Brian Iddon, MP for Bolton South East introduced Ginny Edwards, of the Department of Health Cleaner Hospitals Programme.  Ginny outlined that the programme had been running from 2004, and the Department of Health had developed the programme to provide support and services to reduce healthcare associated infections.  Policy had been reviewed and the Code of Practice for the Prevention and Control of Healthcare Associated Infection had been developed and strengthened.  This was monitored by the Healthcare Commission, and with effect from today the Care Quality Commission, with the inception of the Health Act 2008.  Saving Lives had been developed along with Clean, Safe Care, the tools for improving clinical practice and care.  The Department of Health had worked with the National Patient Safety Agency on the Cleanyourhands Campaign and the Healthcare Associated Infections Technology Programme had been brought in to move high impact technologies into the arena quickly.

 

Ginny's team had worked on a programme of targeted support with 153/174 organisations to help drive the Cleaner Hospitals Programme forward.  They didn't just wish to take the programme forward with Trusts who had the highest rate of infection but they wished to work with better performing Trusts in order to share best practice.

 

There had been a 62% reduction in MRSA bacteraemias since 2004.  For the last two years the programme has also focused on Clostridium difficile, and by focusing on these two areas it was anticipated improved practice would bring reductions across all infections.  Ginny introduced Ruth Kennedy, Chief Executive from the Improvement Foundation.  Ruth outlined that the Improvement Foundation were formerly the NHS Primary Care Development Team, but were now an independent organisation taking a programme of work through engaging with Primary Care providers and focusing on Care Homes.  The programme Tackling Healthcare Associated Infections Outside of Hospital was designed for the whole healthcare community and began in the North East with 50 care homes.  Results were promising and the programme was scheduled for 400 care homes across the country.

 

Dr Brian Iddon said the Health and Social Care Act 2008 had come into force today with new regulatory powers on infection prevention and control.  MRSA Screening was now a requirement for all patients undergoing elective surgery.  These were both key events and we now needed to look at fresh ideas, for example on antibiotic prescribing.  Patient groups were at the forefront and there was a need to work in partnership to drive the agenda.

 

Professor Nick Bosanquet a former special advisor on public expenditure introduced colleagues from the Renal Service.  Dr Donal Donahue was the Tsar for kidney disease and spoke of this high risk group of patients who move in and out of the hospital setting, through the provision of kidney services at 52 hospitals and other satellite facilities they had developed a renal registry and had 25 years of experience in identifying risks and safety issues.  Other colleagues in kidney care spoke of the ability to drive through a strict framework.  With 300 plastic connections for a renal patient per annum, dialysis has to be patient centred, and the built environment was important.  Support for patients receiving care in the community, offering independence, was important, helping with self care.  Communication was important.  Patients are vulnerable but should not be afraid to challenge, it can be difficult when surgeons do not wash their hands, there needed to be a partnership between patients and surgeons, vascular care was important.  Being open and honest and explain if there are infections and what is going to be done.

 

Kidney patients carry an 800 fold risk of infection.  The use of venous catheters can be reduced and how they are looked after has been transformed.  Derby's renal unit had had no MRSA infections in their unit over two and a half years.

 

Dr Jorg Huber spoke of diabetes patients and the psychological aspects of the disease, there can be problems with depression and anxiety and lower motivation can bring about poor self-care which can affect hygiene behaviour.  Dr Reggie John and his colleague from Birmingham Heartlands spoke of the risks from ulcers.  5% of foot ulcers resulted in amputations.  Nerve damage and ischemia were common problems.  Good foot care was important in diabetic patients, education for patients to encourage good hygiene, washing twice a day, observing and getting prompt treatment if there were problems was important.  Good hand hygiene in the community needs to be emphasised.  Exposure to strong antibiotics such as Clindamycin to treat conditions in diabetic patients leaves them vulnerable to Clostridium difficile.

 

Ros Meek, Director of Muscular Skeletal Services, outlined that when she was receiving care recently she had to ask everyone to wash their hands, she felt vulnerable having to ask.  Staff should sit and observe for 15 minutes to see the number of opportunities to risk giving an infection through not washing their hands at the point of patient care.  Arthritis and muscular skeletal conditions affect a large proportion of the population and surgery for joint replacement presents a high risk of infection.  Inflammatory arthritis should be picked up and treated early.  The high turnover in beds and moving patients from ward to ward was high risk.  There should be more single beds for emergency admissions who may not have been screened as it was risky mixing patients who had been screened for elective surgery with those who had not.  Infection in newly replaced joints is disastrous, pre-operative checks should be carried out 10 days before surgery.

 

Ian Beaumont, Bowel Cancer UK said it was good prevention was overriding the acceptability that infection was inevitable.  Cancer patients were prone to healthcare associated infections, they were immune suppressed, often under-nourished with the added risks of lines and tubes.  There was increasing incidence of patients not being able to access treatment when they needed it due to the acquisition of healthcare infections and delays meant loss of life in some cases.  Hospitals could introduce nutritional screening, a partnership approach was needed.  Patients were being treated at home and this needed support.

 

Ruth Lilley from Marie Curie Cancer Care outlined that her organisation provided palliative care for people who required end of life care; they also provided palliative care for non-cancer patients.  They managed nine hospices and helped people in their own homes, often where there were no controls in place.  There was a responsibility to move between patients in a sensitive way.  They had contracts with PCTs and the pattern was changing with the need for a rapid response.

 

The care they gave was just a small step in the patient pathway, they helped with respite care too and were dealing with families at a difficult time, it may not always be appropriate to expect families to gown up.  Sensitivity was needed, but there was a need to ensure they were not endangering other patients.

 

Housekeeping teams were directly employed and there was something about the ownership that seemed to make a difference, they didn't have labs or access to the NHS IT system, they had approached NPSA to try to establish where the voluntary sector sits in infection prevention and control.  Care is one to one at a high level, they don't move the patient around, how you manage bedspaces makes a difference, there were not a lot of agency staff and they have good controls over admissions.

 

Professor Nick Bosanquet acknowledged the issues highlighted and said infection prevention and control was everyone's business, the transfusion service was treating people at home and an area that had taken this on board.  He had chaired the Cancer Reform Strategy and healthcare associated infections had not been raised then, it had a low profile with cancer compared to kidney disease who have pioneered metrics.  The risk factors were large in cancer, they needed to find out who is at risk, what are positive policies, it was a big agenda, they needed to start a much more active programme.

 

Dr David Jenkins, Infection Control Doctor at University Leicester Hospitals NHS Trust highlighted John Reid's target for reducing MRSA in 2004, he was an unsung hero.  MRSA and C.diff reporting, the Code of Practice for the Prevention and Control of Healthcare Associated Infections, Healthcare Commission Inspections and reports on Stoke Mandeville and Maidstone and Tunbridge Wells had brought about great focus on Healthcare Associated Infections.  Chief Executives should be really accountable, as Voltaire said 'but in this country it is a good thing to kill an admiral from time to time to encourage the others.'  It was great that the 50% target had been reached, however not all trusts had reached it, it was still high compared to Europe.  Leicester had attained a 90% reduction and now had zero MRSA bacteraemias.  Levels here were three times higher than the Dutch, who were now seeing an increase due to spread from pigs.  New strains of C.diff were difficult to get rid of, environmental and hand hygiene, deep cleaning and antibiotic prescribing had brought about an 80% reduction in Leicester, there were no winter peaks.  MRSA screens were around 5,000 a month at a cost of half a million pounds.

 

Actions and interventions such as barrier nursing and suppression therapy were necessary.  PCR testing would cost Leicester 1.5 million pounds as it was three times the cost, and this was just screening for MRSA, most organisms were not MRSA and C.diff.  A third of us carry MSSA, bacteraemias from MSSA had not reduced.  Organism specific screening has had a minimal impact on ESBL E.coli and Klebsiella, which have only one or two antibiotics left that can treat it.  USA300 CAMRSA is now in hospitals.  There is not enough surveillance and we needed to identify the bacteria quickly.  Education, audit and benchmarking was needed, financial inducements, possibly using payment by result.  Hand hygiene focus needed to continue and single rooms that do not have a detrimental impact on patient care would have an impact.

 

Martin Kiernan, President of the Infection Prevention Society (IPS) spoke of the success of the Dutch and how they adopted our Search and Destroy policy, but we hadn't followed their example and continued to use it.  John Reid was a hero, we all thought the target was unachievable, but we should celebrate, good things came out of it, infection is not inevitable, zero is not luck it's good practice.  The IPS was about providing education, it was not a campaigning organisation.  It was encouraging as now there were not just Infection Prevention doctors there were Infection Prevention Teams.  Surveillance was key to reducing infection.  If you can't measure then you can't improve.  There is no target or measure of surgical site infections or urinary catheter infections, yet they cause significant morbidity and mortality.  Pressure ulcers and pressure sores become colonised so there needed to be a huge focus on this area and a better approach.

 

Derek Butler, Chair of MRSA Action UK said he was heartened that patient groups and advocates were here to discuss infections, their prevention and the patient experience, and heartened by the work of the Clean, Safe Care team and how this work has been rolled out across the NHS.

 

In reviewing policy on Healthcare Associated Infections, Dr Iddon asked "Are we doing enough?"  Well, in the context of continually striving to improve patient care and patient safety, the answer to this question, is always going to be "no" as its like learning, you can never learn enough as you learn something new every day, you learn from history, but there is always new knowledge.  So we would prefer to answer this question in the context of "What more can we do?"

 

MRSA Action UK believe that when watershed events such as Maidstone & Tunbridge Wells happen we need to learn from those, and although this particular Trust has brought in measures to bring about improvements, we don't believe the same emphasis on learning from history came from that tragic event.

 

Conversely in Scotland there was all-party consensus on a fifteen point plan following the tragedy at the Vale of Leven hospital where many patients lost their lives.  We feel that when so many people have lost their lives in such a manner we owe it to their memory and their families to put very precise measures in place to stop these events ever happening again, and we are still seeing outbreaks of Clostridium difficile as the Health Protection Agency Statistics bear out.

 

Whilst we recognise that NHS Trusts will have local policies to respond to the needs of the community, there are instances where regulators will need to step in.

 

It is not acceptable that we have a Safe, Clean Care policy where Trust Boards can still choose to put barriers in the way by cutting staff and losing the focus on infection prevention and control.  We do not wish to name and shame here today, but we have and will continue to do so in the hope that regulators will take severe action when patient safety and care is compromised.

 

Trusts who have repeatedly said they have not met or only partially met the requirements in the Code of Practice for the Prevention and Control of Healthcare Associated Infections (The Health Act 2006) must be held to account.

 

Accountability is intrinsically linked to regulation.  We have this week visited an excellent hospital, it's clean, well-staffed, hand-hygiene is a top focus, there are good displays of posters encouraging the public to clean their hands and not to sit on the beds.  The elderly are helped, they are fed if they can't manage themselves.  99% of the staff comply with hand-hygiene and have a good knowledge and skill set in applying aseptic technique, invasive devices are monitored daily and recorded to say they have been checked.  Devices are used that reduce the risk of infection, alternative external non-invasive solutions to catheters for example.  We have witnessed this care and been recipients of this care first hand.

 

However, not all the doctors adhere to correct hand hygiene practices.  Everyone should be regularly observed and compliance with hand hygiene and aseptic and clinical procedures checked.  This can be built in by teams reviewing each other, and we feel it's an essential part of healthcare.  Most professionals would welcome this approach, those that don't, well these people would have to ask themselves if they are in the right profession.  If after being checked there is a continuance of poor practice then these people should not be entrusted with clinical care and be held to account, even if this means the sack.  I said this linked to regulation, and we believe the Care Quality Commission should check that these observations of clinical practice are happening, and their outcomes.  Where there are still fluctuations in MRSA bacteraemia figures then these are the areas to focus on.

 

On discharge from hospital, patients must have a care plan that includes information on infection status and treatment, so that people who continue to give care know what precautions to take and how to help the patient.

 

Finally, something that our Scottish Parliamentary colleagues have endorsed is the publication of hospital infection rates for individual hospitals, the public can't currently access this data, we would like to work with the Department of Health on helping put a strategy together on more accessible information for the public to help them make an informed choice about where to go for their care.

 

Nigel Edwards of the NHS Confederation said we needed to use route cause analysis, and look at the problem rather than exchange anecdotes.  Local leadership was needed.  There needed to be better incentives, middle management had to get involved, the built environment was important and more staff.  There also needed to be a willingness to be challenged from clinical managers and ward managers.  Mixing emergency and elective patients was high risk.  There needed to be full implementation of Clean, Safe Care; observation; washing hands; a focus on homecare workers; work with care homes and hospices and a need to deal with air borne infection.

 

Dr Brian Iddon closed the meeting with the offer for observers to write in as the debate from participants had taken up all of the time allotted and it was important that we all had an opportunity to contribute.

 

Further contribution from observers MRSA Action UK:

 

The timing of the debate is apt, with the introduction of the Care Quality Commission on the 1 April 2009.  We believe it's more a question of "what more can we do?" than "are we doing enough?"

 

Accountability and better regulation

 

MRSA Action UK believes the Care Quality Commission have an absolutely key role to play in helping organisations achieve the goal of "no avoidable infections"

 

Without effective regulation and stiff action where organisations are not putting safety as the number one priority we believe that this goal will fail to be reached by many and we could lose the great momentum we have gained in making hospitals a safer place to be.

 

Great strides have been made by many NHS Trusts, however there are still some that are not up to the job of shifting to a culture of "patient first".  We have this week seen the Dr Foster report 10 hospital trusts have higher mortality rates than Mid Staffordshire Hospital Trust, and last week figures from the Health Protection Agency showed that some hospitals were still experiencing fluctuating performance with MRSA bacteraemias, one Trust has a rising trend and has only partially met registration criteria set out by the Care Quality Commission. What then is the Care Quality Commission going to do about it?

 

Leeds Teaching Hospitals NHS Trust consistently say they do not meet the criteria set out in the Health Act 2006 - The Code of Practice for the Prevention and Control of Health Care Associated Infections. Yet despite Improvement Teams working with the Trust, it still isn't reducing it's MRSA bacteraemias, which we know have a high mortality rate and costs a great deal more to treat, with often a poor prognosis for those who do survive.

 

It's not a question of naming and shaming, it's more about the fact that 48 people had a bacteraemia in this Hospital Trust in the space of three months, and that was double the number of the previous quarter.  It's not luck when a hospital reports no bacteraemias; it's because of good practice.  This Trust clearly needs assistance.  If the management of the Trust cannot get the ethos right then there should be immediate intervention, bring in a management team that can turn the position around now.

 

One member of our charity whose family has been significantly affected by MRSA has reported that an NHS hospital gave absolutely exemplary care to her relative, there was a great focus on hand hygiene by everyone, posters and prominent gel stations, spotlessly clean wards, beds well spaced. Her relative she felt was in safe hands, invasive devices were checked daily and she saw these being inserted in A&E where everyone paid attention to aseptic procedures. She was however worried but felt unable to speak out when she went onto the ward. An unconscious patient in the bed opposite required IV lines, all the staff had so far followed assiduous hand hygiene, but the doctor treating this patient did not.

 

He was not bare below the elbows, he washed his hands at the sink and used the gloves designed for PPE (his protection), he did not use the surgical gloves that should be used for aseptic technique. Furthermore he did not follow the National Patient Safety Agency guidance on the five key moments of hand-hygiene, he handled curtains and other inanimate objects before inserting the IV line. He then handled key parts of equipment that go directly into the bloodstream.  The nurse working with him could have challenged this but didn't.

 

To the untrained eye this may seem a minor breach, but this patient could go on to develop a bacteraemia as a consequence.

 

This demonstrates that no matter how good the organisation and its staff, there should be observational checks carried out, teams can observe and check that everyone is carrying out aseptic procedures as part of their everyday role, whilst giving care.

 

The Care Quality Commission must have a role to play in monitoring this practice. Organisations must have these checks in place and demonstrate that they are confident all of their staff are equipped with the necessary competencies required to give clean, safe care. Health professionals expect to be reminded, but it should be their peers that do the checks and reminders, not an onus placed on the patient. Yes, if a patient is not unconscious and they don't mind asking, that's fine, but it's not right to expect it.

 

Beyond hospital wards

 

The wider issue of healthcare associated infections beyond hospital wards needs addressing.  The work of the Improvement Foundation is to be applauded, staff in care homes are being empowered to deal with healthcare infections, but there is still a lot to do with Acute Trusts making sure they pass information on to care homes and hospices with regard to a person's infection status.  This can be done discretely, as it is important to remember that people leave hospital and go back into their homes, whether this is in a care home or at home with relatives helping, they will have complex needs, they may have enteral feeding lines, catheters or other devices.  Attention to dealing with these safely must be adhered to; carers will need proper help and guidance, and a good understanding of infection prevention and control.  The Improvement Foundation are giving care home managers the tools to help them monitor people coming home from and going into hospital, everyone should have a care plan, and it should include details of the person's infection status.  These are key measures and will bring about better outcomes for patients if everyone understands good infection prevention and control.

 

Also beyond the ward of course is the operating theatre.  Patients that undergo lengthy surgery benefit from being warm, as a patient who is cold is at risk of the immune system not working efficiently and leaving the patient susceptible to a surgical site infection.  Use of patient warming is sporadic despite this intervention being recommended by NICE. 

 

Furthermore the method of patient warming is questionable, some techniques employ blowing warm air onto the patient, which is risky as airborne bacteria have the potential to get into patient wounds.  Warming blankets, warmed operating tables or other methods should be employed to ensure the patient is not put at risk from airborne bacteria. 

 

Screening staff

 

Linked to theatre practice is the need to consider screening for clinical staff, particularly where there are frequent occurrences of surgical site infections and bacteraemias that may have proved difficult to trace during route cause analysis, staff should be considered as a reservoir and if they are colonised then appropriate measures taken to suppress the bacteria and protect patients.

 

Better measurement and publication of information

 

Better measurement and publication of information on healthcare associated infections is essential.  If you don't measure how many surgical site infections and how many urinary catheter infections you have then how will you know when things are improving?  There is a mandatory reporting system for surgical site infections and we believe the quarterly reporting we have seen for bacteraemias should be extended to the collection of this data.  This should be collected each quarter for improvement to be measured and this data should be in the public domain.  The MRSA bacteraemia target focussed the mind, now its time to turn the focus on reducing mortality from surgical site wounds and mortality from infections in urinary catheters.

 

NHS Choices website only covers bacteraemias at a hospital trust level, not by individual hospital, the scorecard is still lacking fundamental information on infection rates.  Dr Foster Health provides much more comprehensive information and should link directly to the NHS Choices scorecard for each hospital, the data is freely available and should be made more accessible through NHS Choices. 

 

Hospitals should publish their infection rates at the door for people who do not have access to the Internet, and this information should be available on request.

 

The Department of Health will be embarking on a public information campaign which we welcome.  Furthermore, we would like to work with the Department of Health with this worthwhile campaign.  Our website has been designed in response to the questions we are frequently asked, including our tips for going into hospital, we are here as a resource to be used and hope the Department of Health will take advantage of our offer.