Conclusions and recommendations
1. The Department hopes to reduce MRSA rates
by employing the same approach used in achieving targets for waiting
times in accident and emergency, cancer treatment, and surgery,
where the Department have driven through improvements using a
combination of financial incentives, close performance management
and support. The work
being undertaken by the Department and Health Protection Agency
to standardise data collection and ensure consistency of reporting
is crucial to the development of a robust comparable database
which will ensure consistency in recording and reporting. The
Department will also need to clarify from the outset what support
will be available to trusts, and whether and if so what incentives
will be available to help deliver improvements.
2. The Department's decision in 2001 to adopt
a more limited approach to mandatory national surveillance than
our predecessors had recommended means that they still lack a
grip on the extent and impact of hospital acquired infections
other than MRSA bacteraemia. This lack
of robust comparable data, meaningful to clinical staff is limiting
the NHS's ability to tackle the problem effectively. The Department
needs to work with the Health Protection Agency to expand national
mandatory surveillance, based on a robust risk assessment with
input from clinical staff. Its National Programme for IT needs
to include the hardware and software needed to support the collection
of national surveillance data, including effective links between
pathology, microbiology, prescribing and patient administration
systems.
3. The national prevalence figure which estimates
that at any one time 9% of patients have a hospital acquired infection
is at least 10 years old. In December
2004 the Department commissioned the Hospital Infection Society
to conduct a new prevalence survey to obtain up to date information.
The Department should agree a timetable for this work which will
produce results within the coming year.
4. The NHS do not know how many patients have
died as a result of a hospital acquired infection, and the much
quoted figure of 5000 deaths is based on 1980s American data.
Evidence from the reviews of death certificates which mention
MRSA as a contributory factor show a 15 fold increase since 1992.
The Department needs to expedite its proposal
for hospital acquired infections to be identified on death certificates,
and its proposed audit of deaths attributable to all the main
types of hospital acquired infection and report back to the Committee
by the end of 2006.
5. Compliance with good infection control
practice such as hand hygiene is still patchy. Most
NHS trusts have run hand hygiene initiatives in the last three
years, including making alcohol hand rub much more widely available.
Yet sustained compliance, among doctors in particular, is still
poor. The National Patient Safety Agency's (NPSA) cleanyourhands
campaign, which is being rolled out to the NHS from September
2004, is aimed at improving compliance. The Department needs to
work with the NPSA to develop a better understanding of the reasons
why compliance is not sustained and how it might best be tackled.
6. The Department has still not implemented
the National Audit Office's 2000 recommendation to publish a national
infection control manual, despite four years of research and consultation.
As a result there are still no consistent, evidence based, nationally
accessible infection control guidelines, nor an effective means
of disseminating examples of good practice. The Department, together
with the NHS University and the National Electronic Library for
Health, should establish a repository for national evidence based
guidelines and good practice examples on issues such as antibiotic
prescribing, screening of patients, isolation of infected patients,
aseptic techniques, uniforms, and bed management practices.
7. Each trust has now designated a new Director
of Infection Prevention and Control, but all are staff with existing
roles and responsibilities, predominantly infection control doctors.
Despite a small improvement in the ratio of infection control
nurses to beds there remains a mismatch between what is expected
of infection control teams and the resources available to them.
The Department, working with trusts and strategic health authorities,
should conduct a survey of the new Directors of Infection Prevention
and Control to determine whether they have the authority and resources
to fulfil their designated role, and whether there are any constraints
on implementation.
8. New initiatives such as the Secretary of
State's "Towards Cleaner hospitals and lower rates
of infection" programme, the new Matrons Charter
for cleaner hospitals and the model cleaning contract are welcome
developments in the fight to improve hospital hygiene.
NHS trusts' implementation of these initiatives should be evaluated
by an annual survey to see that they are actually improving cleanliness
on the wards. Trusts should also provide clear and accessible
guidance for patients on the standards of ward cleanliness that
they are entitled to expect, and obtain feedback from patients
on the standards achieved in practice. The Department should determine
whether hygiene assessments and cleaning methods used by the food
and hospitality industries could improve consistency and reduce
subjectivity of cleanliness assessments.
9. The design of hospitals can help minimise
hospital acquired infection, particularly by ensuring the provision
of sufficient single rooms with appropriate ventilation for use
as isolation facilities. Infection control
teams should be part of the planning team for refurbishments or
new buildings. Strategic health authorities should monitor whether
infection control requirements and guidance issued by NHS Estates
are being complied with, and whether contractors are being held
to account for any shortfalls.
10. There is evidence that wider factors such
as bed management policies and the need to meet waiting times
targets can compromise infection prevention and control.
Seven out of ten trusts are still operating with bed occupancy
levels higher than the 82% that the Department told our predecessors
it hoped to achieve by 2003-04. Trusts need to reduce bed occupancy
levels and to adopt more effective bed management practices which
avoid patients moving too frequently.
11. In 2001 the Department assured our predecessors
that the need for isolation facilities was being addressed, yet
only a quarter of the 56% of trusts that had undertaken a risk
assessment to determine the number and quality of isolation facilities
had obtained the required facilities.
Strategic health authorities should ensure that all NHS Trusts
have carried out a risk assessment of their isolation facilities,
in line with Health and Safety legislation, and work with them
to determine a timetable and resourcing strategy to address identified
shortfalls in requirements.
12. The Comptroller and Auditor General's
Report noted that 12% of infection control teams reported that
their recommendation to close a ward or hospital to admissions
for the purpose of infection control had been refused or discouraged
by their Chief Executive. NHS trusts should
inform their strategic health authorities when a recommendation
to close a ward is refused. Strategic health authorities should
ensure that these incidents are recorded and should work with
trusts to identify ways of minimising the impact of such closures.
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