Select Committee on Health Appendices to the Minutes of Evidence

Attachment 4



  Patients admitted to hospital have always been at increased risk of acquiring new infections. This has been an inevitable consequence of housing a population of susceptible individuals in close proximity, the transmissibility of micro-organisms, and the result of medical and surgical interventions that impair the normal human barriers to infection. In the nineteenth century more than 50 per cent of patients undergoing surgery in major British hospitals died of a post operative infection. In the last hundred years improved hygiene (including aseptic practices and sterilisation techniques) and the introduction of antibiotics have improved matters dramatically; however, hospital acquired infection continues to provide a major burden of disease. It has been estimated that about nine per cent of inpatients in the UK have a hospital acquired infection (HAI) at any one time, equivalent to at least 100,000 infections a year. Based upon extrapolations from US data, around one per cent of all deaths in the UK have been attributable to hospital acquired infection (approximately 5,000) and around three per cent (15,000) where hospital acquired infection is a contributory factor. Associated costs are substantial. These relate to increased lengths of stay, treatment costs, and socio-economic losses, and probably amount to more than £1,000 million annually.

  A number of new challenges have contributed to the continued importance of HAIs. These include the increased use of intensive care and invasive procedures; more extensive use of indwelling devices and prostheses; greater and more aggressive use of immuno-suppressive drugs; improved survival of vulnerable patients; more intensive use of hospital facilities; and the emergence of highly antibiotic resistance and transmissible micro-organisms such as Methicillin Resistant Staphylococcus aureus (MRSA). Resistant infections are more difficult to treat resulting in increases in length and severity of illnesses, adverse reactions (due to the need to use less safe drugs), and costs.

  Evidence derived from the Nosocomial Infection National Surveillance Scheme (NINSS) operated by the PHLS on behalf of the NHS suggests that the incidence of HAIs may differ from hospital to hospital. The reasons for such variations are as yet unclear and probably multi-factorial. However, in some cases they are likely to represent different levels of infection control performance providing the population with a variable risk of HAI depending on where they live in the hospital they attend. It also suggests potential for improvement.


  HAIs cannot be prevented completely. The proportion that is avoidable is unclear. The Department of Health/PHLS Hospital Infection Working Group indicated that it might have been possible to achieve a 30 per cent reduction. On the basis of a census of infection control teams (ICTs) the recently published National Audit Office report suggested 15 per cent. This would represent a saving of at least 750 lives and £150 million annually.


  If current infection prevention and control arrangements (including measures to limit antibiotic resistance) are not developed and enhanced, it is likely that the health and financial burdens associated with HAIs will increase. This will result particularly from an inevitable rise in antibiotic resistance related problems and increasing numbers of vulnerable patients with chronic conditions, many of which result in decreased immunity, staying in hospital.


  The key individuals responsible for implementing and maintaining good practice in relation to the prevention and control of HAIs are the many health care staff whose work brings them into direct contact with patients or whose duties have a direct bearing on reducing risk (eg engineers, cleaners and staff involved in sterilising equipment and instruments). Hospital infection control teams comprising specialist medical and nursing staff play a vital role in: collection and analysis of data relating to the occurrence of HAIs; formulation of policies, and their development and dissemination; providing expert advice; undertaking education and training; monitoring and audit of hospital hygiene; and clinical audit. Ultimate managerial responsibility in hospital trusts lies with the chief executive. Primary care groups or trusts, health authorities, regional offices and central government discharge varying responsibilities at different levels. Local authorities have statutory duties in relation to communicable disease control within their boundaries. They usually take a direct involvement in outbreaks involving food or communicable diseases that have major implications for the community.

  The PHLS plays a major role in undertaking, supporting and guiding HAI prevention and control at local, regional and national levels. The functions can be summarised as follows:

    —  provision of diagnostic facilities for local hospitals complemented by specialist and reference microbiology at regional and national level;

    —  leadership of hospital infection control teams. Infection Control Nurses are also PHLS employees in some trusts;

    —  provision of expert advice locally, regionally and nationally;

    —  development, implementation and support of systems for routine and enhanced surveillance ("alert organism" eg MRSA, targeted clinical surveillance NINSS and outbreaks);

    —  identification and promulgation of good practice and effective quality and monitoring measures;

    —  contribution to risk identification, management and reduction;

    —  identification of effective interventions and facilitation of multi-centre intervention trials;

    —  contribution to training and education in areas relating to hospital infection control; and

    —  to inform and influence the formulation of health policy in this area.


  Although the situation is improving, there remains insufficient engagement of trust chief executives and other senior management staff in dealing with this important issue. This is reflected in the inadequate resources often made available to ICTs and their frequent lack of involvement in trust decisions relating to external contracts and estates issues. It also probably makes a major contribution to the most important problem, the variable commitment of clinical staff to adherence to infection control policies and best practice.

  The evidence base for infection control activities is also lacking. This deficiency includes: scientific data to guide practices and policies; surveillance and audit information to measure performance, and health economic analyses to assist decision making with regard to resource allocation.


  Clear direction and target setting in relation to performance standards and controls assurances from central government. This has been initiated.

  Engagement of chief executives in target setting for health improvement programmes relating to this area.

  Clear direction from chief executives to encourage involvement and ownership of hospital prevention and control by clinical staff.

  Ensure ICTs are provided with adequate resources. There is a common requirement for improved clerical and IT support.

  Provision of cost effective surveillance systems that offer tools that can give a comprehensive measure of performance that is comparable with other units and can identify areas that warrant intervention or further investigation. The development and adaptation of NINSS will be designed to do this. NINSS will also be an integral component of a broader surveillance strategy developed by the PHLS that incorporates laboratory ("Alert organism") and outbreak based systems.

  Agreement for a national surveillance strategy.

  Provision of audit tools to complement surveillance. These will be developed by the PHLS in partnership with others as a component of their surveillance strategy.

  Improved hospital information management systems to facilitate data collection.

  Full involvement of clinical teams in surveillance and audit programmes.

  Development of evidence based guidelines. The `EPIC' project will contribute substantially to this. It will also highlight many areas where further research and development are required.

  Investment in research and development. Information regarding effective interventions and improved surveillance methodology is particularly needed.

  Provision of improved support for surveillance, interventions, education and dissemination at regional level. The Regional Epidemiologists would be good focus for this activity.


  Hospital acquired infection is currently providing a substantial load of avoidable ill health, mortality and cost in the UK. Success in reducing this disease burden will depend critically on leadership and co-ordination across a wide range of agencies and individuals at all organisational levels dealing with health care provision. The breadth of the involvement of the PHLS in this area of activity, from provision of local hospital infection control services to national surveillance, places the PHLS in a unique position to guide and support the NHS in England and Wales to deal with this problem.

  Prepared by Drs Tony Howard and Noel Gill, Public Health Laboratory Services.

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Prepared 28 March 2001