IMPROVING UNDERSTANDING OF THE EXTENT,
COST AND EFFECTS OF HOSPITAL ACQUIRED INFECTION
5. There is no requirement for NHS Trusts to publish
data on rates of hospital acquired infection and such data that
have been published are limited and not comparable. While most
Trusts undertake some surveillance there are wide variations in
the criteria used for defining infections, types of infection
monitored, methods used, and ways infection rates are measured.[4]
6. Various estimates of the size, cost and impact
of the problem were presented to the Committee. Figure 1 summarises
the key figures, their bases and their reliability. [5]
Though not necessarily consistent with each other,[6]
they suggested that:
- At any one time around 9 per cent of patients
had a hospital acquired infection;
- There are at least 100,000 hospital acquired
infections in England and Wales each year, and possibly many more;[7]
- Around 5,000 patients die each year in the United
Kingdom as a direct result of acquiring an infection;[8]
- These infections may be costing the NHS around
£1 billion a year;[9]
- While few Trusts monitor infections that develop
after a patient leaves hospital, several studies have indicated
that between 50 and 70 per cent of surgical wound infections occur
post-discharge.[10]
7. The NHS Executive acknowledged that hospital acquired
infection was a very serious issue but that the information available
was limited. The estimate that there were at least 100,000 cases
of hospital acquired infection a year made a number of assumptions,
excluded key areas such as teaching hospitals and intensive care
units, and did not include infections that present post discharge.
These could be significant and the 100,000 is likely to be an
underestimate.[11]
Research was continuing into post-discharge infection, and the
Executive hoped to have the results in the summer, and promised
to share it with us.[12]
8. The Executive did not have data on the incidence
of hospital acquired infection by NHS region or Trust, nor comparative
data between England, Northern Ireland, Scotland and Wales. In
particular, they could not identify the worst performing hospitals.[13]
They noted that hospital acquired infection was a world wide problem,
but here too the information was sketchy. Any international information
that was available was really just a composite of country-wide
studies and it was very difficult to make judgements about international
comparisons. But in the Executive's view, England was doing better
generally than most Scandinavian countries, did roughly as well
as the USA in relation to MRSA (methicillin resistant Staphylococcus
aureus), but did not do as well as some other European countries
such as France and the Netherlands. Overall, they saw England
as in the middle of the league rather than at the top.[14]
9. The estimate of £1 billion for the cost of
treating hospital acquired infection was based on a study that
was thought to be one of the most comprehensive undertaken in
the developed world. However, it was still shaky in some respects,
being based on one hospital, and then extrapolated across the
NHS. There were many variables, for example in terms of the pattern
of disease and in understanding the relationship between hospital
acquired infection and length of stay. Moreover, there was no
consistent basis for costing the work that went on in hospitals
in relation to the control of infection, and the NHS Executive
did not know in total how much the NHS spent on this issue.[15]
10. As regards the estimate of 5000 for the number
of deaths directly resulting from hospital acquired, the Executive
accepted that this could be on the low side, but the reality was
that they did not know. Getting accurate figures was difficult,
because in complex cases the causes of death were multiple. For
example, someone undergoing cancer treatment with their immune
system suppressed might be susceptible to secondary infection.[16]
11. We asked about the costs arising from clinical
negligence claims from hospital acquired infection. The Department
again told us that they did not know. Historically, information
on clinical negligence costs had not been collected consistently,
and although improvements had been made there was no centrally
held data on how many compensation claims the NHS has had where
hospital acquired infection was cited as a main or contributory
cause. It was unlikely that robust information could be obtained
even from a separate survey of NHS Trusts. Hospital acquired infection
was often a contributory, but not necessarily the primary, cause
of mortality and morbidity, so it was not uncommon for claims
to cite infection as only one of a number of factors that contributed
to the harm caused. That said, the NHS Litigation Authority was
aware that a small but growing number of clinical negligence claims
cited hospital acquired infection as a component of the circumstances
resulting in a claim being made. In the Executive's view, this
appeared to reflect the growing incidence of hospital acquired
infection in clinical settings generally.[17]
12. Overall, the NHS Executive shared our frustration
about the lack of authoritative information. The Chief Medical
Officer added that there had been a tendency in the Health Service
over the years not to invest as much money in information and
to regard money not directly spent on patient care as money wasted.
It was now obvious that the service had to spend money on information
if it was going to improve the quality of service.[18]
13. Since 1996, the Department and Public Health
Laboratory Service have been working together to develop a national
surveillance scheme, the Nosocomial (meaning hospital acquired)
Infection National Surveillance Scheme. The aim of the scheme
is to improve patient care by providing information to assist
NHS Trusts to reduce rates and risk of hospital acquired infection
and to provide national statistics on specific types of infection
for comparison with local results. Surveillance is an essential
component of the prevention and control of infection in hospitals.
The main objectives are the prevention and early detection of
outbreaks and the assessment of infection levels over time in
order to determine the need for, and measure the effect of, preventative
or control measures.[19]
14. The Comptroller and Auditor General reported
that there were some limitations in the way the scheme was operated,
including the fact that it comprised only self-selecting hospitals.
And while most infection control teams in hospitals carried out
some form of surveillance to detect infections, there were wide
variations in the methods used, types of infection monitored,
ways infection rates were measured and criteria used for evaluation.
Nevertheless, he concluded that the scheme's first year results
showed considerable scope for NHS Trusts to reduce rates through
better practice.[20]
15. The Department told us that they were doubling
their investment in surveillance to £1 million a year.
They were extending coverage to obtain data for more clinical
areas such as intensive care settings and on links between antimicrobial
resistance and prescribing. This work was being developed in a
systematic way with the commitment of everyone in the health service
and the Public Health Laboratory Service. The new system should
throw up data more systematically and in three to four years they
should have very good data. And as a result of this work, the
Executive's aim was to develop measures, targets and benchmarks
that will allow people to know whether their practice was getting
better.[21]
Conclusions
16. Research indicates that between 50 per cent and
70 per cent of surgical wound infections occur post-discharge,
but these infections are not monitored. The NHS Executive are
undertaking research into post-discharge infection, and we look
forward to seeing the outcome later this year. We recommend that
post-discharge infections are monitored in future through the
national surveillance scheme.
17. The NHS Executive have now taken action to improve
surveillance, including researching the links between antimicrobial
resistance and prescribing, measuring infections that occur after
patients have been discharged from hospital, and doubling their
investment in the Nosocomial Infection National Surveillance Scheme.
But by December 1999, only 139 self-selecting Acute NHS Trusts
in England were participating in the surveillance scheme. We recognise
that the Executive are expanding the Scheme, but we believe that
they should go further and make it mandatory.
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