Select Committee on Health Written Evidence

Memorandum by the National Concern for Healthcare Infections (PS 08)



  1.  National Concern for Healthcare Infections (NCHI) was formed in January 2007 by a group of individuals that had all directly or indirectly been affected by Healthcare Associated Infections (HCAIs) and other patient safety Issues.

  2.  NCHI having identified the need to inform support and represent the interests and safety of all individuals affected by medical harm now works in collaboration with the Department of Health, other NHS bodies/agencies and leading academics to advance patient safety in its wider format. Although only formed in January 2007 individual members have been raising awareness of these concerns for many years. NCHI also works in close association, with the `Lee Spark' NF Foundation. Which was established in 2000 and is the only UK based registered charity, to provide support and assistance in respect of severe streptococcal and Necrotising Fasciitis Infections.

  3.  Patient Safety is a serious global public health issue. Estimates are that in developed countries as many as one in 10 patients is harmed whilst receiving hospital care and that 1.4 million people worldwide suffer from infections acquired in hospital at any given time. The National Patient Safety Agency received 796,142 reports of adverse patient safety events between April 2007 and March 2008; according to limited research there is a significant under reporting of the severity and prevalence of such events. The economic benefits of improving patient safety are compelling. Studies have shown that additional hospitalisation, litigation costs, infections acquired in hospitals, lost income, disability and medical expenses have cost some countries up to $29 billion a year.(Ref: WHO World Alliance for Patient Safety)

Q1.   what are the risks to patient safety and to what extent they are avoidable:

  4.  The application of medication, invasive surgery and drug therapy inevitably carry some degree of risk however simple the procedure may appear to be. These risks can be heightened by complacency in the application of what are considered routine techniques and are accentuated in surgical situations when unexpected and emergency situations arise and urgent decisions have to be made. Some of these risks can be reduced by education, including learning from previous experience and errors made, and team working which allows group expertise to be utilised for the benefit of patients.

  5.  The World Health Organisation recently released "Safer Surgery Saves Lives" which includes a checklist for surgical staff which can be used prior, during and after surgical procedures to ensure correct procedures are followed and all surgical implements are accounted for. Pilots of this guidance indicate that use of the checklist has been successful in reducing errors (including wrong site surgery) and improving patient safety. Unfortunately some surgical staff oppose the use of such a checklist as denigrating their professional expertise and have drawn comparison with motor mechanic worksheets

  6.  In a recent report Lord Darzi suggested that the introduction of monitoring equipment into surgical theatres could be useful in the assessment of practices, procedures and decisions. This appears to be an eminently sensible suggestion which could provide the ability to learn from experiences. Apparently the introduction of such equipment is not supported by surgeons who are suspicious of possible use in disciplinary hearings and/or litigation claims.

  7.  The European Union has policies relating to ability for cross-border movement of labour, including healthcare practitioners. There are, however, difficulties in ensuring that adequate qualification has been obtained and that translation between languages does not provide for different interpretations of practices and procedures which affect patient safety. The European Council is in the process of issuing recommendations relating to patient safety (November 2008) and these will need careful examination. Similarly the World Alliance for Patient Safety is developing a classification for patient safety incidents which will require consideration.

  8.  The public perception of patient safety in an acute environment mainly centres on the prevalence and contraction of healthcare associated infections. In England the prevalence rate is estimated to be 9.8% (Hospital Infection Society study) with a cost to the NHS of approx. £2 million per annum. There is great public concern surrounding the prevalence of healthcare associated infections with a basic belief that they should not be discharged from hospital in a worst condition than when they entered. In other words hospitals should do no harm.

  9.  Public perception, influenced by media hype and misinformation, tends to associate healthcare infections with MRSA and Clostridium Difficile and infections being confined to dirty hospitals. The reality of the situation is somewhat different:

    i.  There are over 1500 bacteria (or types of bacteria) which can infect the human body and the mandatory reporting system needs to be extended if these bacteria are to be controlled. For example in 2006 (the last year of voluntary surveillance figures published by HPA) E.Coli amounted to over 20000 cases; Staphylococcus Aureus other than MRSA 14886 cases and Klebsiella over 5000 people affected, and Streptococcal infections all of which (with the exception of E.Coli) are known to cause pneumonia. Many of these infections are also developing resistance to existing antibiotics and the threat to patient safety is very real and immanent. (These figures compare with approx. 4500 per annum for MRSA and cause the deaths of several thousand people). The Minister has been requested to review this situation but appear complacent despite the evidence presented.

    ii.  There were 690,013 live births recorded in 2007 of these approx. 22% (151,934) would have been by caesarean section. It should be noted that women involved in caesarean section are exposed to risk from unexpected reaction to anaesthetic and are more vulnerable to infection of the womb, urinary tract and/or surgical site infection. Mandatory surveillance needs to extend to this area and provision made for any expenditure incurred.

    iii.  Breast cancer and renal dialysis sufferers are also groups that require special mandatory surveillance in respect of contraction of infection. Treatment by injection and/or drip can expose the patient to risk of infection which is eventuated by the lowering of the body's immunity due to treatment.

    iv.  Latest mandatory surveillance reports from the Health Protection Agency indicate that approx. 25% of infections arise from areas other than the acute sector. Mandatory codes of practice for the prevention & control healthcare associated infections exist in the acute sector, however, there are no such regulations for social care. It therefore appears that elderly people (19% of the population is aged over 60 years) are being excluded from preventative measures and exposed to infection. In order to establish prevention methods the problems have to be addressed at source to prevent transmission to other patients in an acute environment.

    v.  Younger members of the community are not immune to the threat from MRSA with PVL (Community Acquired MRSA) which is rife in many areas of the USA and Canada. This infection has the capability to destroy the white blood cells causing a necrotising effect which if it reaches the lungs is fatal within 24 hours.

    vi.  Risks of infection cannot be eliminated but can be reduced to minimum levels if prevention measures are strictly adhered to. Hand hygiene being the most important measure. The World Alliance for Patient Safety indicates that there are five points where hands should be cleaned

    —  Before patient contact

    —  Before aseptic task

    —  After body fluid exposure risk

    —  After patient contact

    —  After contact with patient surroundings (C.diff spores can exist for many months)

    vii.  If these precautions are followed then the risk diminishes considerably. It also has to be emphasised that alcohol gels are ineffective if hands are soiled and against Clostridium Difficile spores. Only soap and water are effective where Clostridium Difficile is involved. Unfortunately patients and some healthcare professionals are unaware of these constraints and believe the gels are protection in all circumstances. Until this myth is exploded the number of infections will not substantially decrease.

    viii.  Prudent antibiotic prescribing which (if possible) avoids antibiotics which destroy the flora of the gut minimises the development of Clostridium Difficile both prior to entering hospital and whilst admitted. Recent international studies have revealed that quinolones, sulphomamides and parenteral amingoglycosides can contribute to the development of Clostridium Difficile in people who have natural carriage.

    ix.  Provision of isolation facilities in each hospital would represent an ideal position, however, age of buildings and design coupled with prohibitive cost probably restricts this option. It is, however, important that patients who have contracted Clostridium Difficile are not transferred between wards except in emergency situations.

  10.  International research has also identified a potential connection between antibiotics used in animal husbandry and Clostridium Difficile. Some strains of Clostridium Difficile (including the virulent strains) identified in species of animals which are connected to the food chain are very similar to those identified in humans, although a positive connection has not been established. This is an area which will require close scrutiny in the future.

  11.  Patients' experience both of adverse events and identification of avoidance of similar risks must be a determining factor in decisions on NHS policy. This would include decisions made by PCT's in relation to access to medication. The post code lottery of availability can cause people to adopt alternative methods of supply (eg internet) with sometimes tragic consequences for the patient and additional cost to the NHS

Q2.   What is the effectiveness of the following in ensuring patient safety—

  12.  Boards of Strategic Health Authorities whilst following the provisions of Safety First in establishing Patient Safety Action Teams (PSATs) have made little discernable progress in establishing local patient safety cultures.

  13.  Systems for accident reporting appear to have been revised and made more user friendly, however, there is no tangible evidence available to suggest these reports are followed up locally. Some NHS Trust Boards are receiving reports on progress in reducing healthcare infections and other adverse events but there is nothing to suggest that this is universal practice across the NHS

  14.  Safety First recommendations have in the main been initially implemented and are gradually being expanded upon. It has to be noted, however, that progress in the SHA's is extremely patchy. Decisions made at the National Patient Safety Forum although minuted and posted on the internet are slow to filter down to the PSAT's but this should improve with the development of the Patient Safety Campaign.

  15.  National targets, particularly those set out in the NHS Operating Framework are extremely relevant to patient safety. Achievement of the targets relating to healthcare infections will not only serve to protect patients but will also produce considerable savings to the NHS. And will far out weight expenditure incurred. Targets focus the attention but must not be used as an alternative or distraction from basic healthcare and patient safety.

  16.  The National Patient Safety Agency has conducted an effective "Cleanyourhands" campaign which has contributed to the reduction of healthcare infections and perhaps saved many patients' lives. This campaign, which is coterminous with the World Alliance for Patient Safety First Global Challenge initially, focuses on point of care in acute settings. This is planned to be extended to primary care but urgent consideration needs to be given to the social care sector. This latter area is a primary source of pressure sores many of which become infected and are referred to the acute sector. Additional expenditure to expand the "Cleanyourhands" campaign to the social sector would reduce some of the healthcare infections at source and would ultimately protect patients and provide further savings for the NHS.

  17.  Whilst NCHI applauds the sanctions in place at this moment in time with the Healthcare Commission's Inspection teams it is felt they do not go far enough—for instance if a Trust does not supply sufficient data to the HCC then the HCC comment is `insufficient evidence to decide upon compliance with this core standard'—that is not good enough the HCC are the regulators and as such should be given access to all areas they wish to inspect if there is a failure to do this then the recommendation should be failed to comply and appropriate improvement notice served'

Q3.   the Committee will also consider that the NHS should do next regarding patient safety specifically

  18.  The dissemination of information relating to best practice could be considered to be provided by NPSA & NICE together with reports and recommendations emanating from the Healthcare Commission. The adoption of best practice by NHS Trusts and healthcare practitioners is, however, probably the most difficult issue facing those seeking improvements in patient safety. Such adoption and improvements can only be achieved if Boards and Chief Executives accept that the patient is the most important ingredient of NHS services and display a commitment to patient safety. Various reports previously produced by the Healthcare Commission graphically demonstrate the failure of NHS Trusts to implement recommendations (Stoke Mandeville July 2006) and adverse impact on patient safety continue to escalate (Maidstone & Tunbridge Wells September 2007) Radical change is therefore required. It is to be hoped that the Health Act 2008 will provide the incentives for NHS Trusts to comply with patient safety requirements and that punitive measures will not have to be implemented.

  19.  There is a need to grasp and disseminate information regarding the introduction of new technologies and innovations which will improve patient safety. Electronic prescribing has been introduced in a small number of NHS Trusts. This involves the British National Formulary being matched with patients' records and prescriptions; this reduces the risk of selection of incorrect medication, controls dosage, concentration of dosage and the duration of therapy. Some companies have developed catheters and cannulas impregnated with antibacterial which deter bacteria from forming on the equipment and transmitting to patients. In the USA coloured wrist bands have been introduced to instantly identify differing potential individual patient safety issues (allergies, risk of fall etc). Some NHS Trusts have recognised that scratched and damaged commodes and toilet seats harbour bacteria which are resistant to recognised detergents and whilst there is initial cost in replacement the longer term reduction in healthcare associated infections have considerable financial advantage. Some healthcare providers have also recognised that the routine fitting of cannulas, some of which are never used, can have adverse effects upon patients; causing blood clots and being a source of transmitting infection.

  20.  There is a need to reassess the use and availability of patient records. Poor recording threatens patients' safety as does the inability to of different departments to access a patient's records. Patients that have undergone major surgery can for a number of reasons develop infections but there is a lack of openness by healthcare professionals to convey this vital information. The lack of availability of information relating to antimicrobial therapy can impede the commencement of chemotherapy and if treatment has commenced lead to its suspension. In either instance patients' safety is compromised and there can be a threat to life. Use of the coloured wrist bands mentioned above could be a solution to this problem.

  21.  Patients worldwide face the threat of bacterial, viral and fungal infection. Bacteria are becoming evermore resistant to contemporary antibiotics and urgent research is required to identify reasons for this resistance and to develop new antibiotics which have the capability to counter the ability of bacteria to mutate and form deadly toxins which threaten human life. Funding of such research requires urgent consideration.

  22.  The World Alliance for Patient Safety is in the process of developing a curricular guide for undergraduate medical students. This guide should have the capacity to embed patient safety at the core of future healthcare education. It will obviously take time to implement and in the interim period action needs to be taken to improve healthcare workers awareness and appreciation of patient safety.

  23.  Presentations by the Chief Medical Officer include graphic illustrations of the patient experience to demonstrate the impact of adverse events upon patients, their families and carers. Consideration should be given to adopting this approach in all NHS Trusts with perhaps Patient Champions appointed in accordance with Safety First being considered for this role.

  The critical point is that everyone is a potential patient of the NHS (including healthcare workers and their families) and therefore patient safety must be the first priority for everyone.

Graham Tanner (Chair)

Bev Hurst Secretary/Administrator

Acting for and on behalf of NCHI

September 2008

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Prepared 30 October 2008