Memorandum submitted by the National Audit
Office
IMPROVING PATIENT CARE BY REDUCING THE RISK
OF HOSPITAL ACQUIRED INFECTION: A PROGRESS REPORT (HC 876)
SUPPLEMENTARY INFORMATION
AND KEY
DEVELOPMENTS SINCE
PUBLICATION OF
THE NAO REPORT
New information from the Department of Health
1. On 12 July 2004, the Secretary of State
for Health announced new action plans for cleaner, safer hospitals.
On 14 July 2004, the publication date of the Comptroller and Auditor
General's report, the Department of Health also published MRSA
bloodstream infection rates for each acute NHS trust. The Comptroller
and Auditor General had included this data, both nationally and
by region, in his report. The National Audit Office were unaware
however, of the Department's intention to publish individual rates
by acute NHS trust, or the Secretary of State's intention to publish
new action plans. This memorandum now provides a summary of the
action plans and newly published trust MRSA data. We have also
used this opportunity to provide other information published since
the Comptroller and Auditor General's report. This information
does not affect the conclusions or recommendations made in the
report, but is included to assist the Committee's consideration
of this important subject.
Towards cleaner hospitals and lower rates of infection:
A summary of action, 12 July 2004
2. The Secretary of State for Health announced
new action to cut levels of hospital acquired infections like
MRSA and to improve general standards of hygiene. The Health Secretary
in acknowledging that cleanliness contributes to controlling infection
noted that preventing infections requires more than just cleanliness
and proposed a number of measures. Whilst some of these, such
as empowering modern matrons, asking staff to wash their hands
and cleanliness inspections have been trailed in previous departmental
guidance (Appendix 1 of our report). The main measures are listed
at Annex A.
MRSA bacteraemia (blood stream infection) rates
by individual named trust, 14 July 2004
3. In our report, we published MRSA bacteraemia
data obtained from the Health Protection Agency (HPA). This showed
that since the introduction of mandatory reporting in April 2001
the number of Staphylococcus aureus bloodstream infections
has continued to increase, from 17,933 (7,250 MRSA) in 2001-02
to 19,311 (7,647 MRSA) in 2003-04 (paragraph 3.7 and Figure 6,
p25). We also identified marked regional variations (paragraph
3.8 and Figure 7). The HPA were due to publish this information
in their weekly Communicable Disease Report (CDR 15 July 2004)
and agreed to share with us their findings so that our report
presented the most up to date picture available. At the time the
HPA was undertaking additional analysis and validation work to
identify performance at trust level.
4. On the same day as the publication of
our report, the Department of Health published individual trust
MRSA bacteraemia rates on their website, including a table of
trend data by trust for the first three years of mandatory reporting.
The data show that MRSA rates tend to be highest in specialist
trusts (with specialist services which receive patients referred
from other trusts for these services), and lowest in single specialty
trusts (for example trusts only undertaking orthopaedics or cancer).
Annex B lists the MRSA bacteraemia rates by trust for the last
three years, within each trust type, ranked by the MRSA rate in
2003-04.
5. In our report we noted that the mandatory
reporting of MRSA rates has had some benefits at trust level but
that there were some concerns about interpreting the data (paragraph
3.11-3.12). In publishing individual trust rates the Department
of Health noted that care needed to be taken in interpreting the
results as the MRSA bacteraemia infections reported by an acute
trust were not necessarily acquired there; some trusts had a more
complex case mix than others; bed occupancy figures used to derive
the MRSA bacteraemia rate are from a period before the MRSA data;
and the bed occupancy figures apply only to overnight admissions,
so MRSA bacteraemias in patients who are not admitted overnight
may make a trust's figures look falsely high.
New data on international comparisons, 12 July
2004
6. In our report, we presented a map (opposite
page 1) that showed data on the levels of MRSA bloodstream infections
as a proportion of all Staphylococcus aureus bloodstream
infections for various European countries. This data showed that
the United Kingdom has amongst the worst rates in Europe in 2002
(paragraph 10). On 12 July, the European Antimicrobial Resistance
Surveillance System (EARSS) updated their website with data for
2003. Annex C shows the figures for each country compared with
2002.
7. These data for 2003 showed that the United
Kingdom, whilst showing a slight improvement, still has amongst
the worst rates in Europe (42.9% of Staphylococcus aureus
is methicillin resistant compared with 43.8 in 2002). In comparison
Greece's rate has increased from 43.8% in 2002 to 51.4% in 2003
and Portugal and Romania are now showing higher rates than the
United Kingdom (45.5% and 45.9% respectively). Scandinavian countries
continue to have much lower rates, with the Netherlands, Denmark,
Sweden and Finland having rates of 0.9, 0.6, 0.9 and 1.4% respectively.
Over all, the rates have increased in 12 of the participating
countries, decreased in nine, and stayed the same in one.
Trust level analysis of mortality and MRSA, 22
July 2004
8. In paragraph 3.23 of our report, we noted
that the extent of deaths due to MRSA is not routinely identified
but that two research projects, funded by the Office for National
Statistics and the HPA, involving the manual examination of death
certificates, had shown that the number of deaths which mentioned
MRSA had increased 15 fold from 1993 to 2002. On 22 July, in response
to a Parliamentary Question raised by Andrew Mackinlay MP, the
National Statistician, Len Cook, provided information by individual
hospital on the number of deaths in 2002 where MRSA was a contributory
factor (Annex D). To minimise the risk of disclosure of confidential
information hospitals with less than five deaths were not listed.
9. The National Statistician noted that
it is not possible to put a firm figure on the number of people
who die from MRSA, because people are often very sick with a number
of other conditions, so the contribution of MRSA to the outcome
in any particular case is uncertain. We noted in our report that
there is currently no International Classification of Diseases
Code for MRSA (or indeed any other hospital acquired infection).
Internationally accepted guidance from the World Health Organisation
on the completion of death certificates requires that only those
conditions that contribute directly to death should be recorded.
Doctors are required to complete the medical certificate of cause
of Death (MCCD) to the best of their knowledge and belief. Since
publication of the report the Committee has received a number
of letters from members of the public who identify concerns that
the death certificate of a relative or friend, whom they believe
died as a result of contracting MRSA, does not mention MRSA, although
completion of certificates is a matter of clinical judgement.
The lack of data is the reason for the Department of Health's
commissioning of an audit of deaths.
New health and social care standards and planning
framework for 2005-06 to 2007-08, 21 July 2004
10. In our report we highlighted the important
role that Controls Assurance had played in raising the profile
of infection control at NHS trust level, and in ensuring that
it provided the necessary framework for trusts to monitor their
infection control arrangements (paragraph 2.3-2.4). On 21 July,
the Department announced that the existing NHS Controls Assurance
regime would be scrapped from 1 August 2004, to be replaced by
new slimmed down standards to reduce the burden on staff and to
strengthen risk management at a local level. This followed a consultation
on the new Health Care Standards launched by the Department in
February 2004. The new Standards for Better Health was
published as an Annex to the Department's National Standards,
Local Action: Health and Social Care Standards and Planning Framework
2005-06 to 2007-08. It forms a key part of the new performance
assessment regime by the Healthcare Commission of all health care
organisations. The Healthcare Commission is currently determining
the details of how this performance assessment will be conducted.
11. The document was also used to announce
that overall there would be fewer national targets, based on the
Department's Public Service Agreements (PSA), but with one target
on MRSA—which is not part of the PSA—Achieve year
on year reductions in MRSA levels, expanding to cover other health
care associated infections as data from other mandatory surveillance
becomes available.
12. Of the 24 Core standards, two are relevant
to hospital acquired infection:
C4 Health care organisations to keep patients,
staff and visitors safe by having systems to ensure that:
(a) the risk of health care acquired infection
to patients is reduced, with particular emphasis on high standards
of hygiene and cleanliness, achieving year on year reductions
in MRSA;
(b) all reusable medical devices are properly
decontaminated prior to use and that the risks associated with
decontamination facilities and processes are well managed;
(c) the prevention, segregation, handling,
transport and disposal of waste is properly managed so as to minimise
the risks to the health and safety of staff, patients, the public
and the safety of the environment.
C21 Health care services are provided in environments
which promote effective care and optimise health outcomes by being
well designed and well maintained with cleanliness levels in clinical
and non-clinical areas that meet the national specification for
clean NHS premises.
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