1 The extent and impact of hospital
acquired infection
1. Hospital acquired infections are infections that
are neither present nor incubating when a patient enters hospital.
Their effects vary from discomfort for the patient to prolonged
or permanent disability and even death. Not all such infections
are preventable since the very old, the very young, those undergoing
invasive procedures and those with suppressed immune systems are
particularly susceptible (Figure 1).[2]
Figure 1:
The top five ways that hospital infections can be acquired and
their estimated prevalence levels
| Seven key points about hospital acquired infections
|
- There are at least 300,000 hospital acquired infections a year, with around 9% of patients at any one time having one;
- urinary tract infections are the most common type of hospital acquired infection and bloodstream infections have the highest associated mortality;
- the old and young and those with weakened immune systems due to illnesses are most at risk of catching one;
- the two strongest risk factors are the degree of underlying illness and the use of medical devices;
- there has been an increase in the number and frequency of infections resistant to common antibiotics for example the bacteria staphylococcus aureus is responsible for around half of all blood infections and in 2003 around 40% of these were resistant to the antibiotic methicillin (MRSA), compared with just over 2% in 1992.
- the cost to the NHS is around £1 billion a year as patients with one or more infections can incur costs that are on average 2.8 times greater than uninfected patients, mainly because such patients remain in hospital on average 11 extra days; and
- not all hospital acquired infection is preventable but the 2000 Report noted that infection control teams believed that they could be reduced by up to 15%, avoiding costs of some £150 million.
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Source: National Audit Office, Health Protection Agency and London
School of Hygiene and Tropical Medicine
2. Our predecessors reported on this subject in Session
1999-2000, concluding that the NHS did not have a grip on the
extent of hospital acquired infection and the costs involved.
Without such data it was difficult to see how the Department of
Health (the Department), health authorities and NHS trusts could
target activity and resources to best effect. The Committee emphasised
that a root and branch shift towards prevention was needed at
all levels of the NHS if hospital acquired infection was to be
kept under control and that this would require commitment from
everyone and a philosophy that prevention was everyone's business
not just the specialists'. Leadership and accountability, together
with education, training and effective performance monitoring
was also crucial to improving the management and control of infection.[3]
3. More than four years later, the Department still
does not have a grip on the extent of hospital acquired infection,
with the exception of the mandatory reporting of methicillin resistant
Staphylococcus aureus (MRSA) bloodstream infections
which was introduced in 2001-02. Indeed what evidence there is
suggests that things have got worse, particularly with reference
to MRSA. Between 2001-02 and 2003-04 there has been a 5% increase
in the number of Staphylococcus aureus bloodstream infections
(from 17.933 to 19,311) and the number that are methicillin resistant
have increased from 7,250 to 7,647.[4]
There is also no new information on the impact of hospital acquired
infection, either in terms of financial costs to the NHS, or the
human costs to patients and their families, particularly where
a patient dies as a result of contracting the infection.[5]
4. There has been only limited improvement in information
on the extent and impact of hospital acquired infection since
the figures used in the Comptroller and Auditor General's 2000
Report, particularly as these figures are based on research that
is now several years old. The Department acknowledged this concern,
but drew attention to the extensions to mandatory surveillance
which it introduced during 2004, with the first year's data available
in 2005. More recent initiatives are attempting to update the
national picture (Figure 2).[6]
5. In 2000 the Department told the then Committee
that it had 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 (NINSS). Whilst recognising the Department's
plans to expand the scheme, our predecessors recommended that
NINNS should be made mandatory.[7]
In the Treasury Minute response the Department accepted these
recommendations and indeed told the Committee that a new NHS Healthcare
Associated Infection Surveillance Group (HAISSG) had been set
up in September 2000 to provide the Department with urgent recommendations
on infection surveillance aimed at delivering mandatory reporting
of hospital acquired infection by all acute trusts from April
2001. HAISSG was also expected to take forward the work on post-discharge
surveillance.[8]
6. There has been little progress on many of these
actions. Instead of making NINSS mandatory the Department decided
to adopt a new national approach to surveillance starting with
the mandatory laboratory based reporting of MRSA bloodstream infections
in April 2001. Since then a limited number of other streams of
surveillance, mainly laboratory reporting, have been introduced,
but there has been no progress on mandatory surveillance of surgical
site infections (other than orthopaedics), on urinary tract infections
or on post-discharge surveillance (Figure 1).[9]
The HAISSG was disbanded in September 2002, and responsibility
for developing surveillance transferred to the Health Protection
Agency. The Department said that the Group was only meant to be
a short term arrangement to make recommendations which they have
since been implementing, and that they are now planning to put
together another group with a different area of expertise.[10]
Figure 2:
Data available on the extent and impact of hospital acquired infection,
and Departmental plans to improve this information
| Figure given to Committee
| Data source and explanation
| Proposals to improve the evidence base
|
| At any one time, 9% of hospital patients have an infection caught in hospital. This figure shows the prevalence of hospital acquired infection (Figure 1 also refers).
| Derived from the Second prevalence study by Emmerson et al, published in 1996(i), based on data from 157 hospitals studied over a 15 month period between May 1993 and July 1994 which provided a mean hospital acquired prevalence rate of 9% (range 2-29% depending on the type of infection).
| In December 2004 the Health Protection Agency, on behalf of the Department, asked the Hospital Infection Society to undertake a third prevalence study. The timeframe for the study has yet to be agreed.
|
| Over 300,000 in-patients acquire one or more infections each year in England. This figure shows the incidence of hospital acquired infection - the number of new cases that occur in a given time period.
| Derived from the Socio-economic burden study of hospital acquired infection (ii) . The report, which was published in 2000, indicated that in 1994-95 at least 321,000 patients acquired one or more hospital acquired infection. This figure is likely to be an underestimate as the study only covered 70% of adult non-day cases and excluded day cases, children, neonates and infections that presented post-discharge.
| Mandatory surveillance of MRSA introduced in April 2001. Glycopeptide resistant enterococci (September 2003); serious untoward incidents associated with infection (September 2003); Clostridium Difficile associated disease (January 2004) and Orthopaedic surgical site infection surveillance (April 2004) infection. Together this surveillance covers only 6-10% of hospital acquired infections.
|
| Around 5,000 deaths in the UK per year may be directly attributable to the presence of a hospital acquired infection, and in a further 15,000 deaths, hospital acquired infection may be a substantial contributor.
| The SENIC study (Haley et al, 1985)(iii) estimated that in the early 1980s hospital acquired infection was amongst the top ten causes of death in America. There are no equivalent data available in the United Kingdom, but in 1995, a crude comparison by a Department of Health and Public Health Laboratory Service Working Group arrived at the 5,000 and 15,000 estimates.
| A joint proposal from the Office of National Statistics and Health Protection Agency for a national audit of deaths from healthcare associated infections, was announced in the Chief Medical Officer's strategy Winning Ways in December 2003. An initial report concentrating on MRSA should be available by mid 2005 and a more detailed report, identifying avoidable factors and lessons learned by 2006.
|
| Hospital acquired infection in England may be costing the NHS as much as £1 billion per year.
| The £1 billion figure was derived from the Socio-economic burden study(ii). On average patients with a hospital acquired infection cost three times as much as an uninfected patients, equivalent to an additional £3,000 per case; their hospital stay that was 2.5 times that of an uninfected patient, equivalent to 11 extra days in hospital. The £1 billion figure is accepted as the most comprehensive estimate of costs currently available. However, the figure is likely to be an underestimate as it is based on only 70% of adult non-day cases.
| The National Audit Office Report (HC 876, Session 2003-04) identified that cost information has not improved nor are they aware of any plans to update this figure. They found that 11% of trusts had performed some type of economic evaluation, which demonstrated the significant burden of infection. Like a number of international studies they also found that the mean attributable costs of the infections were greater than corresponding interventions.
|
| Between 50 and 70% of surgical wound infections occur post-discharge
| Figure is derived from a review of international literature by Holtz et al, 1992 (iv).
| National Audit Office Report (HC 876, Session 2003-04) identified that there has been limited progress in improving this information.
|
Source: National Audit Office
(i) Emmerson A.M., Enstone J.E., Griffin M.,
Kelsey M.C., Smyth E.T.M. (1996), The second national prevalence
survey of infection in hospitals - overview of the results,
Journal of Hospital Infection 32: 175-190.
(ii) Plowman R, et al (2000), The socio-economic
burden of hospital acquired infection. London: Public Health
Laboratory Service.
(iii) Haley et al (1985), The efficacy of
infection surveillance and central programs in preventing nosocomial
infections in US Hospitals (SENIC), American Journal of Epidemiology
121: 182-205.
(iv) Holtz TH, Wenzel RP (1992) Post-discharge
surveillance for nosocominal wound infections: A brief commentary,
American Journal of Infection Control 20 (40) 206-213.
7. A major constraint to effective surveillance is
the infection control teams' lack of information technology (IT).
The Department expects that the IT support necessary to undertake
the new streams of surveillance will be built into the NHS National
Programme for IT, although in which phase of the project is not
clear.[11]
8. Similarly the introduction of electronic prescribing
through the NHS National Programme for IT is expected to improve
the collection of data on antibiotic prescribing. As 20-30% of
antibiotics are prescribed unnecessarily, leading to the growth
of antibiotic resistance, the collection of data is essential
so that improvements in prescribing, now being demonstrated in
primary care, can be achieved in the hospitals.[12]
9. Hospital acquired infections not only complicate
illness, cause anxiety and discomfort for patient but they can
lead to disability and even death. In 2000 our predecessors noted
that the estimate of 5,000 deaths could have been on the low side,
but the reality was that the Department did not know.[13]
There appears to have been no progress in improving information
on this issue except for a couple of research projects funded
by the Office for National Statistics and the Health Protection
Agency, which examined death certificates to identify those in
which MRSA was mentioned as a contributory factor. The results
suggested that the number of deaths which mentioned MRSA increased
from 51 in 1993 to 800 in 2002, a 15 fold increase. The research
also showed that there were 50 hospitals with 5 or more deaths
where MRSA was a contributory factor in 2002, and that hospitals
with less than 5 deaths could not be identified individually.[14]
10. We asked why, when present, MRSA and other hospital
acquired infections were not always included on a death certificate.
The Department explained that MRSA would be included only if the
certifying doctor considered it be the underlying cause of death,
and that many patients had other serious and potentially fatal
underlying medical conditions which were likely to be given as
the cause of death. It is a matter for individual professional
judgement whether the doctor lists MRSA infection as a contributory
cause. This situation is also complicated by the fact that the
International Classification of Diseases codes specify the clinical
types of infection such as septicaemia, abscess and pneumonia,
but there is no individual code for MRSA, or whether the infection
was hospital acquired. The Office for National Statistics has
worked with the World Health Organisation (WHO) to develop new
codes for antibiotic resistance. WHO has recommended that these
should be used internationally from 2006. The prospective introduction
of electronic certification will link it to information on patient
records and to the consent of the family member registering the
death.[15]
11. In recognition of the absence of information
on deaths, the Chief Medical Officer announced plans to establish
a national audit of deaths from healthcare associated infections
in his December 2003 report Winning Ways. More than nine
months later, however, the details of the timetable and methodology
had still not been announced. The Department told us that developing
the audit was now a priority, but was taking time because of the
need to consult with experts to devise methodologies, and ethical
considerations which needed to be taken into account before launching
the audit.[16]
2 42nd Report from the Committee of Public
Accounts, The management and control of hospital acquired infection
in Acute NHS Trusts in England (HC 306, Session 1999-2000)
paras 1-2; Ev 34 Back
3
42nd Report from the Committee of Public Accounts,
The management and control of hospital acquired infection in
Acute NHS Trusts in England (HC 306, Session 1999-2000) paras
1-3 Back
4
C&AG's Report, paras 3.7-3.8, 3.13; Qq 1-2, 44, 95; Ev 24,
26-30 Back
5
C&AG's Report, paras 15, 3.20-3.25 Back
6
ibid, para 3.3 and Figure 5; Qq 44, 173, 181; Ev 38 Back
7
42nd Report from the Committee of Public Accounts,
The management and control of hospital acquired infection in
Acute NHS Trusts in England (HC 306, Session 1999-2000) para
4(ii) Back
8
Treasury Minute on the 42nd Report from the Committee
of Public Accounts 1999-2000, Cm 5021 Back
9
C&AG's Report, paras 3.4-3.5 and Appendix 7; Ev 24, 38 Back
10
Qq 75, 116-121, 134 Back
11
C&AG's Report, paras 2.26-2.28; Qq 135-136 Back
12
Qq 14, 154-155 Back
13
42nd Report from the Committee of Public Accounts,
The management and control of hospital acquired infection in
Acute NHS Trusts in England (HC 306, Session 1999-2000), para
10 Back
14
C&AG's Report, paras 3.22-3.33; Ev 24-25 paras 8-9, 31-32,
37 Back
15
Qq 7, 44; Ev 35-36 Back
16
Qq 8-9, 55 ,78 Back
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