(c) MRSA Action UK October 2009
Dr Ian Hossein facilitated the event where there was a strong focus on leadership. Karen Taylor, Director at the National Audit Office gave a keynote presentation on the effectiveness of the Department of Health's approach and progress made in the NHS on reducing healthcare associated infections. It was clear there was far more to be done to tackle the problem to deal with the 80% of infections that were not included in the Government's figures.
Not everything had been implemented that had been recommended in the reports of 2000 and 2004, although significant reductions were now evident in some healthcare trusts, the picture however is not the same across the board with only 25% of hospital trusts attaining 85% of the reduction, a point made in the debate, this 25% were seeing an overall reduction in other micro-organisms such as MSSA, a comment was made that the aggregate position of 190 Trusts is the number the PM would prefer to quote (not the true picture of 25% of Trusts making the 85% improvement).
Dr Ian Hossein, Consultant Microbiologist and Director of Infection Prevention and Control at North Middlesex University Hospital NHS Trust, discussed the importance of leadership in making the healthcare environment safer for patients.
It was clear that lessons needed to be learned from the reports of failure that cost patients' lives in Maidstone and Tunbridge Wells, Stoke Mandeville and Mid Staffs. Understanding of what needs to be done and a commitment and drive to make it happen was true leadership. Just do it (opposed to writing a business case). Do we need to say "we are a patient-centred NHS?" Clinical quality and patient safety were functions of command, control and creativity.
Rose Gallagher, Nurse Advisor Infection Prevention and Control at the Royal College of Nursing started her career in infection control surveillance at Royal United Hospital in Bath, said it was right to challenge avoidable infections, there were many challenges in healthcare but the ultimate challenge were the micro-organisms. The Royal College of Nursing was made up of three arms, the charitable arm, trade union arm and the professional arm that shaped policy, lobbied government and engaged with stakeholders. They were not a regulator and do not support nurses who don't want to do things that feel unpleasant but are legitimate. Education and competence were key; there had been a rise in mandatory training in infection prevention and control, the focus needed to be on putting this into practice and demonstrating competence.
It was recognised that there was a need to move away from the term "basics" in infection control, it's essential.
There was also recognition of the cross border movement of patients and staff; this was raised as a real concern at a recent meeting of the World Health Organisation in Prague.
Antibiotic resistance where there are countries that do not have the controls in place that we have here will present a global problem, we are running out of effective antibiotics with the changing epidemiology, and if we look at infection deaths from a European perspective these equate to an A320 plane crash every day. The Czech Republic only has one infection control nurse, so it's clear that more needs to be done in other countries. Work with a European network of infection prevention and control is underway to tackle the growing problem.
The debate that followed highlighted that getting some Trusts to invest in technology was proving difficult; a delegate asked how she could persuade them. The panel said that saving bed days should not be the focus, rather than saving patients from infection and worse outcomes, the patient experience should be driving that. Some good practice emerged from the debate, Great Ormond Street engage patients in auditing hand hygiene, including children and parents, where there are difficulties encountered, parent advocates will come to the Board and this had a significant impact.
Professor Hugh Pennington, Emeritus Professor of Bacteriology, University of Aberdeen, and President of MRSA Action UK spoke of lessons from history. Aberdeen University was founded in 1495, and the home of the discovery of Staphylococcus aureus in the 1880s. Hand washing and asepsis were known to be the best way to keep the bacteria at bay if surgery had to be carried out. Carbolic soap and 1 in 40 phenol spray was used and infection rates were very low, the carbolic soap however had toxic properties that were found to be harmful to surgeons, turning urine black so alternatives were needed. Ignaez Semmelweis instituted the use of strict hand washing policies in maternity clinics in Vienna in the 1880s and mortality rates reduced significantly; lime was used to help kill bacteria. Two clinics had vastly different mortality rates and using an early form of route cause analysis Semmelweis assessed that the clinic where midwives only dealt with births were less likely to experience child-birth fever, the other clinic housed staff that dealt with other procedures which included post mortem, the conclusion was that cross contamination of cadaverous bacteria was occurring through contact with the clinicians hands, the introduction of the strict hand washing policy worked.
The discovery of penicillin gave promise to clear infection once it occurred, but resistance then became a problem. More surgical and invasive procedures, over reliance on antibiotics and less assiduous attention to asepsis and hygiene, coupled with resistance adds to the spread of infectious pathogens. Interventions that had been introduced recently were beginning to have an impact on bringing down the numbers of bloodstream infections, and not before time, bloodstream infections are very avoidable with the correct ventilon care, and also not using invasive devices routinely.
Hugh spoke of his involvement in the E.coli Inquiries and the findings where children had been involved in the tragic consequences of cross infection from goats, cattle and sheep droppings. Consequences for under-5s can include kidney failure, the need for renal dialysis and death. In one Inquiry the efficacy of hand washing was borne out by evidence to show that Scouts who had been exposed to E.coli in this way were less likely to suffer from infection due to the assiduous attention to hand washing learnt through their programme of health awareness.
Wayne Spencer, Senior Technical Advisor for the National Decontamination Programme, Department of Health spoke of the importance of decontamination, he featured two cases that prompted some debate. Ownership, accountability and trust featured in the debate that followed. Case one, a sterilizer at Pittsburgh's Allegheny General Hospital was blamed for an outbreak of Pseudomonas that infected 16 patients and killed one. Eight other patients died of infection from another pathogen. The hospital claims the sterilizers were defective; the manufacturer maintained that the hospital disregarded proper sterilization procedures.
A Glasgow dentist who exposed patients to the risk of HIV by using dirty equipment was jailed for three years in 2001. He was sentenced to 21 months for culpably and recklessly exposing patients to the risk of infection by repeatedly using unsterilised equipment. Media reports said he may have exposed 4,500 patients to the risk of infection, including HIV. A delegate spoke of a similar incident in Southampton where she and her daughter had been recalled to be tested for hepatitis and HIV, this was last year.
Wayne also described the difficulties he had encountered in trying to get hospital trusts to work in partnership within strategic health authorities.
The panel debate was led by Dr Ian Hossein, Maria Cann joined the panel on behalf of MRSA Action UK.
Lack of trust and breaking down the barriers between Trusts were discussed, it was felt competition played a part, Trusts learning from one another, route cause analysis, the three reports on the C.diff outbreaks were mirror images of each other why didn't they learn from mistakes? Not wanting to "wash dirty laundry in public" and fear of litigation were seen as barriers. Bolton were willing to share Route Cause Analyses to help learning.
High bed occupancy rates were seen as barriers to infection prevention and control, budgets had always been a bug bearer in hospitals, Ogston was challenged on the cost of rags, it was clear resources must be put into infection prevention and control.
Cleaners on low pay, not being treated as part of the team, not trained sufficiently. It takes 45 minutes to clean a bed space; some hospitals were not given that time.
Patients with more complex needs, nurses being too busy to do the menial tasks as they were overwhelmed were seen as barriers. The introduction of a housekeeper role was suggested as a solution, leaving nurses to nurse. There was a need to challenge the concept of busy, the Productive Ward was now a renewed initiative called Releasing Time to Care.
One delegate said around 10-15% of delays were through access to social care, patients could develop pneumonia and infections whilst waiting to be discharged, however we would take the view that if attention was paid to assiduous hygiene and ensuring the patient receives physiotherapy and a high standard of care they should not end up with pneumonia and infection. A holistic approach was needed, MRSA Action UK were contacted regularly by people going into hospital with questions around decolonisation since the introduction of screening for MRSA, they needed to be referred for domiciliary care or help from the hospital to decolonise as they sometimes couldn't manage the regime prior to surgery. The other side of this was the lack of information being passed on through care plans where patients were discharged from hospital, more attention to social care was needed. The Charity was working with the Improvement Foundation on improving communication; inter-healthcare forms were being promoted to improve information sharing between care providers, the requirement to have infection prevention and control measures in place for registration with the Care Quality Commission would apply to Care Homes from the 1 April 2010. There was evidence that social care systems were failing patients, if reforms to provide a National Care Service were to bring about improvement then these issues would need to be addressed.
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