Memorandum by Dartex Coatings Ltd (PS
38)
PATIENT SAFETY
Dartex Coatings Ltd is a British company based
in Nottingham which supplies products to over 40 countries. Dartex
has 35 years of experience of premium transfer coated products
and has proven expertise in infection control issues and mattress
cover solutions. We are therefore acknowledged as the pioneer
and global market leader in patient support surfaces.
Dartex Coatings has joined forces with global
wound care leaders, Smith & Nephew to address the market need
for effective barriers to MRSA cross-infection. Together, we created
a product, Silver3, a mattress coating, which we
believe could be used as one of a series of effective measures
to combat the prevalence and spread of hospital acquired infections
in a clinical setting.
Tests have shown that Silver3 kills 99.9%
of MRSA within 24 hours and it maintains a high kill rate throughout
the warranted product life which may reduce the risk of exposing
bacteria to sub-lethal concentrations of silver. Silver3
does not release silver into the environment, but kills on contact,
not just MRSA but the whole plethora of pathogens and virii. Extensive
in vitro testing on "as made", after sterilisation,
abrasion, washing and ageing has provided the confidence for Dartex
to guarantee the efficacy of Silver3 mattress covers kill MRSA
for FOUR years.
EXECUTIVE SUMMARY
Healthcare-associated infections (HAIs) are
one of the most, if not the most prominent threat to patient safety.
This threat is recognised by the government in a plethora of publications
issued by the Department of Health. Yet, few other measures than
the tried and tested cleaning and hygiene initiatives are being
advocated by the government. Whereas cleanliness will always be
vital to combat HAIs, other methods and products exist that can
and will significantly reduce HAIs that are currently being overlooked
by the government. This continues to be the case even though it
is clear that HAIs are not only costly for Primary Care Trusts
to treat, but also place a financial burden on the British economy
as a whole.
Silver3 is a mattress coating which can
be used in healthcare settings that has been developed to kill
bacteria and has the potential to significantly reduce HAIs. Despite
Silver3's obvious benefits, purchasers are overlooking the infection
control element of the product due to the slight increase in price
its use contributes a £10 additional cost to mattress manufacturers
who reasonably want a margin and therefore up to £20 on mattress
selling prices. Static mattresses sell to NHS Trusts typically
between £160 and £220, with dynamic (therapy) mattresses
selling from £1,500 up to £4,000 and specialist ones
even more. On these latter types though the uplift should not
increase form the £20 indicated.
Dartex therefore urges the government to first
undertake more work to ascertain and calculate how the hospital
environment as well as products like Silver3 can contribute
to reducing HAIs and thereby also reduce costs for the NHS as
a whole. Second, the government must ensure that Trusts and hospitals
are encouraged to take a longer term holistic approach to procurement.
At the moment, procurement budgets are set with little regard
of the total NHS budget in mind which inhibits the take up of
innovative products such as Silver3, despite its potential
to bring significant cost savings to the NHS.
PATIENT SAFETY
1. Infection control is recognised as a
key component of patient safety as the NHS has a responsibility
to ensure that its patients remain safe while using its services.
2. HAIs are an avoidable risk to patients
safety to some extent, as system failures and human error- in
predominantly cleaning- is often the cause of an increased number
of HAIs. As such, HAIs are a major concern to patient's safety.
3. In particular, there is huge public concern
over MRSA and C difficile. The Office for National Statistics
published figures on the 28th August 2008 which showed that the
number of death certificates mentioning Meticillin-resistant Staphylococcus
aureus (MRSA) was 1,593 in 2007. This number also follows
a sustained increase from 51 to 1,652 deaths between 1993 and
2006. The same figures also show that the number of death certificates
mentioning Staphylococcus aureus, but not specifying meticillin
resistance, have also been relatively constant over the period
1993-2007 (http://www.statistics.gov.uk/cci/nugget.asp?id=1067).
4. As the above figures illustrate, HAIs
have sky-rocketed in the last decade and ensuring the safety of
everyone that comes into contact with the health services has
therefore rightly become one of the most important challenges
facing health care and the government today.
5. As it is widely acknowledged that infection
control is of vital significance to patient safety, the government
has put in place a range of policies designed to reduce HAIs in
NHS organisations in England. Both resources and attention have
been dedicated to improve hygiene in healthcare settings and to
eliminating the spread of antibiotic resistant organisms.
6. Numerous documents have been published
by the Department of Health in this area. For example, in 2004
they published a document entitled "Towards Cleaner Hospitals
and Lower Rates of Infection: A Summary of Action" and
this was subsequently followed by "Saving Lives: A Delivery
Programme to Reduce Healthcare Associated Infection Including
MRSA" in 2005, "Essential Steps to Safe, Clean
Care: Reducing Healthcare-Associated Infection", in 2006,
and "Saving Lives: Reducing Infection, Delivering Clean
and Safe Care" in 2007. Finally, the most recent publication
from 2008 on the issue is entitled "Clean, Safe Care:
Reducing Infections and Saving Lives.
7. In short, the Department of Health has
issued yearly guidance and policy documents. Yet, most of this
work focuses on reporting and monitoring the rates of HAIs. Various
action plans for cleaner hospitals have also been issued.
8. Despite all the government's work in
this area, figures from the European Antimicrobial Resistance
Surveillance System (EARSS) show that the United Kingdom still
has one of the highest recorded rates in Europe (EARSS 2007).
According to the EARSS report, the burden of MRSA is highest in
Portugal, Ireland, Italy and the United Kingdom. (www.rivm.nl/earss/Images/EARSS%202006%20Def_tcm61-44176.pdf)
9. As Britain has a very high level of HAIs
in comparison with other countries it is therefore clear that
the Department of Health's previous attempts to combat HAI's have
had little success. Whereas it is commendable that the issue is
high up on the government's agenda with many documents dedicated
to the issue, more is needed than merely publishing yearly policy
documents that focus on cleaning and monitoring.
10. Dartex would therefore like to urge
the government to look at what can be done to improve patient
safety further in the hospital environment. Dartex would also
like the government to encourage Primary Care Trusts and hospitals
to take into account the full long-term cost savings of being
able to reduce HAIs by using alternative infection control and
prevention methods.
11. First, whereas the government has launched
several initiatives such as the deep-clean campaign in hospital—little
has been done in the area of improving the hospital environment
through investment in new products and tools that combat HAIs.
As the hospital environment is an essential aspect of combating
HAIs and improving patient safety, more work must be done in addressing
this, and to go further than just looking at cleanliness and hygiene
as has traditionally been done.
12. For example, the Journal of Hospital
Infection published an article showing the results of a study,
in which it was made clear that Meticillin-resistant Staphylococcus
aureus (MRSA) and vancomycin-resistant enterococci (VRE) are capable
of surviving for days to weeks on environmental surfaces in healthcare
facilities. Environmental surfaces frequently touched by healthcare
workers are commonly contaminated in the rooms of patients colonized
or infected with MRSA or VRE. A number of studies have documented
that healthcare workers may contaminate their hands or gloves
by touching contaminated environmental surfaces, and that hands
or gloves become contaminated with numbers of organisms that are
likely to result in transmission to patients (John M. Boyce, Journal
of Hospital Infection, Volume 65, Supplement 2, 2007).
13. Whereas cleaning will always be essential
in the fight against HAIs, this will never be enough by itself
as it is virtually impossible to ensure that all areas in a hospital
are clean at all times.
14. Studies have been undertaken to that
effect, which show the hospital environment can become extensively
contaminated with MRSA that is not possible to eliminate by standard
cleaning methods (for an example, please see French G. L et al,
The Journal of Hospital Infection 2004, volume 57).
15. Routine cleaning of equipment items
and other surfaces does not always remove bacteria such as MRSA.
As a result, improved methods of ensuring that HAIs are tackled
are needed. Hospitals should be encouraged by the government to
invest in products, such as Silver3, that have the ability
to reduce the bioburden of bacteria at any given time to supplement
the cleaning and hygiene initiatives, which are naturally still
very important.
16. Please note Dartex has commissioned
a clinical study with TrusTech and the MRI, a Showcase hospital,
which should demonstrate that at all times Silver3 mattresses
are harbouring a significantly lower bioburden. Thus allowing
peer review to suggest that this is significant enough to lower
cross infection risk.
17. The second issue Dartex is concerned
about is that it seems as though the costs of procurement and
the costs of HAIs are seen in complete isolation. Little consideration
is given to products and tools that will result in a very small
increase of a Trust's procurement budget, but that will ultimately
significantly decrease the Trust's costs in treating patients
who have acquired a hospital infection.
18. It is clear that HAI's are very costly
to the NHS, Trusts and hospitals. A study funded by the Department
of Health estimated that HAIs cost the health sector in England
almost £1 billion a year, with patients remaining in hospital
an extra 3.6 million days. According to this analysis, a patient
who contracts a HAI stays in hospital on average 2.5 times longer
than a patient who does not, increasing their time in hospital
by 11 days. The cost of treating a patient with a HAI is 2.8 times
more than treating a patient without one, imposing an average
additional cost of £3,154. Patients with a healthcare-associated
infection identified in hospital and post-discharge also take
an average of 17 extra days to return to normal daily activities.
At the national level, this amounts to 8.7 million additional
days (Plowman et al 1999).
19. A more recent review of these figures
concludes that the costs of HAIs have been underestimated in this
study. MRSA alone is calculated to result in an annual loss to
the UK economy of £3-11 billion (Gould 2006).
20. Both of these studies show that controlling
HAIs is highly cost-effective. Yet, new technologies and products,
such as Silver3, that Dartex manufactures are not taken
up by the NHS. This is despite its clear ability to reduce the
number of HAIs and deliver cost saving benefits to Trusts and
hospitals.
21. The cost savings of a product such as
Silver3 can easily be calculated by using the two studies
mentioned above. Utilising the lower £3billion (Gould 2006)
figure and assuming the cost ratios to be the same as the (Plowman
et al) 1999 study, the mathematics would show that if a 473 bed
hospital paid an extra £20 for each of it's mattress covers
it would break even on cost if only one cross infection was prevented
in four years. It would also be able to treat another 2.5 patients
per HAI reduced.
22. Silver3 is a mattress coating
which has been developed to kill bacteria. This mattress coating
has been shown to maintain a high kill rate throughout the four
year warranted product life which may reduce the risk of exposing
bacteria to sub-lethal concentrations of silver. For example,
tests have shown that Silver3 kills 99.9% of MRSA within
24 hours. As high bed occupancy and patient to patient contact
in that way is one of the reasons of higher MRSA rates—Silver3
therefore has the potential to reduce HAIs.
23. Silver has a very long history of use
as an antimicrobial agent and unlike in the case of antibiotics,
resistance to silver has not appeared. Whereas antibiotics generally
have only one very specific mode of attack, silver attacks cells
in many ways. Silver will alter the structure of the cell wall,
damage the bacteria's DNA and interfere with vital cell processes.
It is thought that this complex attack makes developing resistance
to silver more difficult than developing resistance to an antibiotic,
as more than one mutation may be required. This is particularly
beneficial as the spread of many HAIs particularly C difficile
and MRSA, is associated with the (over)use of antibiotics.
24. Silver3 does not release silver
into the environment, but kills on contact. Because the silver
is not released, it may minimise the risk of exposing bacteria
to low silver concentrations in the care of the environment. Silver
ions are held in a soluble carrier on the surface of the material.
In the presence of moisture the carrier slowly dissolves and silver
is available to come into contact with any bacteria. Once bacteria
and silver interact the bacteria is killed off and more silver
moves to the surface of the material.
25. Silver3 is currently on the NHS
supply chain purchasing catalogue and can be purchased by Trusts.
However, due to the slight increase in price (around £20)
purchasers are overlooking the infection control element which
makes it a much more cost effective purchase over the longer-term.
26. In order for patient safety to be improved
and HAIs to be tackled, the government must put in place measures
to encourage Trusts to take a wider, more holistic approach to
their budget so that short-term increases in their expenditure
do not inhibit take up of products such as Silver3, as
this investment ultimately leads to a long-term overall saving
for the Trusts.
RECOMMENDATIONS
In summary our recommendations are:
— In addition to its work focusing
on hygiene and cleanliness, the government should undertake wider
work in the area of hospital environment to ascertain to what
degree and how other methods and products can reduce HAIs and
thereby increase patient safety.
— The government should also encourage
the procurement of products that can lead to long-term cost savings
for the NHS as a whole by ensuring that Trusts adopt a more holistic
approach to their total budget.
September 2008
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