Reducing healthcare associated infections outside of hosptial programme

Wednesday 22nd April 2009

Forest Pines Hotel, Broughton, North Lincolnshire

 North Lincolnshire Primary Care Trust & 

 North East Lincolnshire Care Trust Plus 


Integrated Care Pathways

A Whole Healthcare Focus for Patients and Carers

Derek Butler & Maria Cann, MRSA Action UK


The final workshop for the North Lincs Teams held at Broughton comprised a number of interactive sessions at which MRSA Action UK presented case studies and the use of integrated care pathways, this also gave an opportunity to discuss patient empowerment and engagement during the interactive sessions. 


MRSA Action UK demonstrated how communication is key in working to reduce infections and save lives, and how care pathways can be used as an effective tool in communicating information that is required for patients' safety and ongoing care.  The session also considered NICE guidance on reducing surgical site infection, and featured the Lincolnshire Care Pathways Partnership Integrated Care Pathway, and pictorial guide for patients.  A form is also available for patients or residents who transfer between healthcare providers to pass on important information about their infection status and can be downloaded here.  It was confirmed by those taking part that the form was now being used more frequently, if the information was not being passed on then staff could feed this back to the Improvement Foundation or the Primary Care Trust.

Dr Bharat Patel

Practical Approaches to HCAI control


This interactive session provided an understanding of the management of residents with urinary catheters, PEG feeding, antibiotic prescribing and Clostridium difficile infections.


Using clinical scenarios and case studies, the session covered the concepts of good practice.


Basic information on the use of antimicrobial treatment regimes were provided for carers and prescribers.  Click here for the presentation

Dr David Lyon

The Improvement Foundation Programme

Beyond Workshop 3


Dr David Lyon outlined some of the great work that had been done in Care Homes in Lincolnshire, with improvements and raising awareness of what needs to be done to reduce the risks of the transmission of infections.  Two more examples of Plan, Do, Study, Act (PDSA) were given that had been developed by Care Home staff, which included working with residents.


PDSA - Ravendale Hall

PLAN - To encourage good hand hygiene by asking residents and staff to use hand gel before entering the dining room for lunch.  Hand sanitiser to be placed by the door to the dining room at lunchtime.  The Care Home Manager will observe the use of the hand gel and measure numbers.


DO - Hand sanitiser was placed in the hallway by the entrance to the dining room.  The Manager explained to staff why it was there and asked them to use the gel before entering the dining room.  Staff then explained to the residents why they were being asked to use the gel.  The Care Home Manager monitored the use of the hand gel with a tick list.


STUDY - On the first day 12/28 residents and all care home staff used the hand gel.  Not many residents without prompting from staff used the gel.  On the second day 26/31 residents and all care home staff used the gel.  The residents also appeared to 'queue' and observe one another cleaning their hands.


ACT - To continue observing residents and staff to ensure they continue to use the hand gel.  Delegate the checks to other members of the infection control team in particular two staff who have completed Essential Steps.  Monitor the use of hand gel at other mealtimes.


PDSA - Carisbrooke Manor

PLAN - Raise the awareness of good hand hygiene with residents by running a short training session delivered in house by the Training & Development Manager.  Measure its success and whether it should be added to the package of resident courses.


DO - A half-hour hand hygiene session was delivered to residents.  The Care Home Manager developed a short evaluation for the residents to complete and also asked the residents about their hand hygiene habits one week later.


STUDY - Residents were reluctant to use light box, therefore staff demonstrated results of effective hand washing using the light box.  Residents enjoyed the training and it provoked conversation.  All filled in the evaluation but not all remembered the training when asked at a later date.  Residents preferred yes/no responses to using smiley faces on the evaluation forms.


ACT - The Care Home Manager will amend the evaluation form from smiley faces to YES/NO responses for ease of use.  The general feedback from residents was very positive and this session will be added as part of a package of annual resident courses.




Dr Lyon said the learning would be applied to meet the government's objective of no avoidable infections.  It was everyone's responsibility.  The Improvement Foundation would continue to support the Care Homes with the programme with monthly process measures to be collected, and quarterly feedback using the assessment framework.  There were already significant measurable outcomes, with a reduction in the use of antibiotics over the winter period, and particularly a reduction in the use of cephlasporins, it was clear that work with Care Homes and GPs was having an impact.


The percentage of discharges from hospital to a Care Home accompanied by the discharge summary was rising - another significant contribution to the Government's commitment under the NHS Constitution, where everyone should be given a Care Plan.


The percentage of patients with the following information in their discharge documentation

January 2009

March 2009







Healthcare Associated Infection history including screening details




The Legal Cost of Getting Infection Prevention and Control Wrong

Sarah Rowland, Associate Solicitor at Irwin Mitchell spoke of the legal cost of getting infection prevention and control wrong and highlighted some key facts:


MRSA - The Facts

-          UK rates among the worst in Europe

-          Health Protection Agency data from 2006 to 2008

-          76% of cases of patients diagnosed with MRSA

-          bloodstream infection aged over 60on

-          Average age of patients with MRSA bloodstream infection was 69

-          51 deaths in 1993

-          1,593 in 2007

-          April 2007 to March 2008 - 4,448 reported cases of MRSA bacteraemia


It is believed deaths can be underreported mainly due to patients' other underlying illnesses that mean sometimes MRSA is not included on death certificates, when it may well have been a significant contributory factor or cause of death.


The proportion of MRSA cases detected within 2 days of hospital admission are estimated as:

-          67% of patients admitted from home

-          18% of patients admitted from nursing home

-          8% of patients admitted from another hospital

(Health Protection Agency Surveillance of Healthcare Associated Infections Report 2008)




Clostridium Difficile - The Facts

Since January 2004, mandatory surveillance for over 65 year old patients recorded incidence:

-          2004 - 44,314

-          2005 - 51,767

-          2006 - 55,681

-          2007 - 49,785

-          In 2007, 8,324 death certificates in England and Wales mentioned C.difficile

-          Rise of 28% from 2006

-          82% of infections in the over 65's

-          25% mortality rate in the over 65's


Cost of Healthcare Associated Infection

Treatment Cost

-          Estimated by National Audit Office to be 1bn pounds per annum

-          1 in 10 hospital patients is affected

-          Costs 3 times more to treat a patient with a HAI

Derek Butler said there was an additional cost to the welfare state of around 3 billlion pounds per annum


Litigation Cost

> 10 million pounds paid in damages since 2005


Human Cost

-          Pain and suffering

-          Ongoing disabilities

-          Ongoing treatment


Types of Legal Claim

Negligent acquisition

Must prove, on the balance of probabilities (i.e. 51% chance or more) any or all of the following:

-          That the HCAI was acquired in the hospital/residential home

-          The treatment given by the healthcare provider was substandard (negligent)

-          If the treatment had not been substandard, the patient would not have acquired the infection


Types of Legal Claim

Legal Considerations

-          Did the healthcare provider have proper policies in place to reduce the risk of infection?

-          Were infection control policies correctly implemented?

-          Is there evidence of a lack of hygiene?

-          Were infected patients properly isolated and barrier nursed?



-          Witness evidence from the patient and relatives

-          Nursing/medical records

-          Infection control policy documents

-          Minutes of infection control team meetings

-          Infection rates

-          Inspection reports

-          Expert evidence - nursing expert, microbiologist


COSHH Argument

-          Control of Substances Hazardous to Health 2002

-          Infection is a biological agent so there is a duty under the Regulations to reduce exposure to the lowest possible level

-          Failing to implement appropriate policies and procedures is a breach of the Regulations



Ndri v Moorfields Eye Hospital (2006) - Court held that COSHH Regulations were not intended to apply to patients and so the claim failed


Derek Butler said the COSHH regulations applied to anyone coming into the workplace, therefore this could be applied to patients, and MRSA was a man-made pathogen, so it was only a matter of time before this was proven.


Types of Legal Claim

Negligent treatment

Must prove, on the balance of probabilities (i.e. 51% chance or more) that

The healthcare provider treated the infection in a substandard way

The negligence caused injury and loss


Legal Considerations

Were signs of infection picked up quickly enough? e.g. stool samples taken

Were positive results acted upon?

Was appropriate medical treatment sought?

Were appropriate antibiotics given?



Kitty Cope v Bro Morgannwg NHS Trust (2005)

87 year old Claimant contracted an MRSA infection following a hip replacement operation

Prosthesis had to be removed, leading to significant disability

Hospital accepted that it did not comply with its own infection control policies

Settled out of Court


Baumber v United Lincolnshire Hospitals (2006)

72 year old lady underwent hip replacement surgery

Wound infected with MRSA

Infection did not respond to antibiotics

Entered bloodstream

Patient died of MRSA septicaemia 10 months later

Claim settled for 30,000 pounds


Brown v Southend General Hospital (2003)

69 year old man had successful hospital treatment for bowel cancer

While in hospital he developed pressure sores on his heel and sacrum

The sores became infected with MRSA

MRSA could not be controlled

Claimant underwent below knee amputation of the leg

Damages awarded of 100,000 pounds


C v Maidstone Hospitals NHS Trust (2008)

78 year old man developed clostridium difficile in hospital

Hospital admitted that it had failed to diagnose and properly treat the infection

The infection contributed to C's decline and his death

Damages awarded of 7,000 pounds


Ash v Chelsea & Westminster Hospital (2008)

Lesley Ash admitted to hospital with fractured ribs and punctured lung

Epidural given for pain relief

Developed MSSA at the epidural site

Noticed boil on her back before discharge

Mentioned to nurse but not examined

Creeping paralysis started - infected abscess

Emergency neurosurgery

Left with permanent nerve damage and mobility problems


Sarah's presentation can be downloaded here

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