Examination of Witnesses (Question 540-559)
DR ALISON
HOLMES, PROFESSOR
MATT GRIFFITHS
AND PROFESSOR
ANEEZ ESMAIL
5 FEBRUARY 2009
Q540 Dr Naysmith: We are coming on
to that.
Dr Holmes: That does not feature
highly enough, and that is not just for us now, that is for the
future, and that is slightly more difficult to report. It has
not got such snappy headlines, and conceptually it is little bit
more tricky. However, that is something I would just like to flag.
Q541 Dr Naysmith: We will be dealing
with that more in a minute or two; you are ahead of the game.
What I did want to ask you, and you have already talked about
it a little bit, is the framework for surveillance. How can we
get better information about the scale of the problem and how
much it costs the National Health Service? You have already made
reference to the need for a framework for surveillance, but what
does that actually mean in practice? Could we tease that out a
little bit? What do we have to do to get this better information?
Dr Holmes: Could I deal with the
question about cost and then a little bit more about getting good
data? I think we are struggling here. We really do need some very
good economic evaluations that are not just about bed days but
also the impact in primary care, and I think we really do have
to move towards thinking: this is `healthcare' acquired infection,
it is across a whole patient journey, and we should be working
very closely across primary and acute care. So economic evaluation
needs to consider not just what is happening in the hospital but
the impact on people's lives and in primary care. We also have
to use data that is useful, that actually comes from the UK and,
particularly, that is relevant to whether you are a large teaching
hospital or a smaller DGH. It would be useful to make economic
models based on English or UK data.
Q542 Dr Naysmith: You doubt the validity
of some of the information then?
Dr Holmes: I think a lot more
work could be done on getting economic evaluations. The other
thing we need to factor in—it is not just the impact on
the whole healthcare economy and within primary care as well—is
this issue about impact `in the future'. We are using antibiotics
and we are treating infections that might be causing us using
more antibiotics in the future. The economic evaluation in the
present is not really picking up some of the collateral damage
in terms of impact on antibiotic resistance around us and in the
future.
Q543 Dr Taylor: Good morning. You
are part of (do we call it) ARHAI?
Dr Holmes: Yes.
Q544 Dr Taylor: I am most impressed
with the evidence you have given us, and I am hoping that our
experts have read all the references because you have given us
an enormous pile of references. However, right at the beginning
you said that there was some good news. Does that mean you have
identified some solutions?
Dr Holmes: I think we have identified
models of working that are new and have been effective. I am being
very parochial here, but I think we have established ways of working
with a lot of clinical engagement, embedding it into the fabric
of how we run our organisations, and also a system that has demonstrated
some resilience. One thing I wanted to mention earlier is actually
we should maybe use infection as a marker of good management and
managing multiple complex systems. The way we manage our HR, the
way we manage change, the way we manage service reconfiguration—all
these things are a threat and they can reflect on infection outcomes;
so you could look at it as a marker of how well we can manage
complex organisations. Often when organisations go through massive
change that is when they have problems with c.diff. The Healthcare
Commission report in High Wycombe and the Healthcare Commission
report in Maidstone—reported these as organisations that
were going through much change at the same time, service reconfiguration
as well as other challenges, and I think if we really do embed
it in our organisations and use models which are sustainable—and
it is not all about enforcing, it is about developing good clinical
networks, shared sets of values—that actually is sustainable
through change. We published something about this, the Hammersmith
Organisational Model for Infection Prevention,[3]
which uses a whole raft of internal reinforcement measures which
has seemed to work and seemed to sustain us through massive changes
that we have gone through recently in West London in huge mergers.
Q545 Dr Taylor: As Director of Infection
Prevention and Control at Imperial College, you have close working
relationships with every clinician on every ward, do you?
Dr Holmes: Most clinicians on
most wards. I am a clinician myself, and actually it was very
important that the Director of Infection Prevention and Control
was seen to be somebody who saw patients. There is a huge amount
of clinical chauvinism out there and, actually, it is very important
for the person who is engaged in controlling antibiotics to be
giving recommendations and seeing patients. So that was important.
I hope in the future that will not be quite so important, but
it really is critically important if you are working with your
clinical colleagues and wanting to address issues around antibiotic
prescribing for instance.
Q546 Dr Taylor: Coming to the over
use of antibiotics, you say hospitals need to have a clear policy
on the prescribing of antibiotics. Do most hospitals have that
now, or ought we to be doing a survey or finding out how many
hospitals do have a proper policy?
Dr Holmes: There was a survey
that was done many years ago which showed significant gaps. That
has improved dramatically. The other thing that has improved dramatically
(and I would like to highlight this) is the role of the pharmacist.
The role of the pharmacist is absolutely critical. We need to
develop them more and they need to be a key member of clinical
teams, providing postgraduate education for them in this field.
They need to be colleagues working with us. Also, their role in
terms of developing, reviewing and revising policies is absolutely
key. Most hospitals would have an antibiotic policy, and that
is an important quality indicator as well as having a pharmacist
working in them.[4]
Q547 Dr Taylor: The other crucial thing,
you say, is if we were able to collect data on the type and number
of antibiotics prescribed and tie that in with the incidence of
c.diff, that would give us some really useful information?
Dr Holmes: Yes.
Q548 Dr Taylor: Can you expand on
that?
Dr Holmes: Certainly. I mentioned
collateral damage when I was talking about antibiotics. They can
cause side-effects, but the thing that I am particularly worried
about is the driving of antibiotic resistance and antibiotic resistant
infections and their relationship to c.diff—how they are
linked to c.diff. We absolutely need to understand our antibiotic
prescribing and our patterns of antibiotic prescribing to get
a handle on it and clearly establish the relationships with c.diff,
and not just c.diff but particular strain types of c.diff. That
level of understanding would really help us in targeting and choosing
what best antibiotic to use. Clearly, antibiotics are completely
valuable and we must use them immediately when we need them, but
we must use them incredibly carefully. We are running out of choices
here and they are driving the c.diff problem.
Q549 Dr Taylor: I do like your choice
of words: "Antimicrobial agents that induce CDI are believed
to perturb the normal gut bacteria." I think that is a lovely
way of putting it. You have mentioned other antibiotic resistant
infections. Are we talking E.coli?
Dr Holmes: We are talking about
a whole range, gram positives and gram negatives. MRSA is one,
glycopeptide-resistant enterococci is another gram positive.
Q550 Dr Taylor: Is there a simple
name for any of those that somebody like me might remember?
Dr Holmes: No. Multi-resistant
bacterial infections. You mention E.coli, which is a gram negative
enteric bacterium which lives in the gut. I think we really do
need to be mindful that this is a problem also in the community
with multi-resistant gram negative urinary tract infections, and
for those of us working in hospitals, particularly seeing patients
in intensive care units, we are facing enormous challenges trying
to treat highly resistant infections and also not wanting to drive
resistance any further, and the choices are narrowing because
of the organisms we are seeing.
Q551 Dr Taylor: One last one in this
group: bed occupancy rates. We are reassured by ministers that
there has been no correlation in the past two or three years between
bed occupancy rates and infection rates.
Dr Holmes: Yes.
Q552 Dr Taylor: I cannot believe
that, if you have got 90% or 92% occupation and you are rushing
people through, and you do not have time to change the beds and
clean things properly. Are there any facts that do show that high
occupancy rates do predispose to hospital acquired infection?
Dr Holmes: I think there have
been some more recent papers on this. I think the data was very
interesting that earlier on—2001-2003—there was a
clear correlation between bed occupancy and MRSA bacteraemia,
but that relationship appears to have gone. What they were looking
at was only MRSA bloodstream infections, which is the tip of the
iceberg in terms of MRSA infections, and it is multi-factorial.
One should never use bed occupancy for any complacency in terms
of best practice, and there is a huge amount of improvement that
can and has been done in spite of the bed occupancy. However,
I would just like to expand on a couple of points you made. Bed
occupancy is also really important in terms of staff/patient ratios:
there are huge amounts of data about if you get your ratios wrong
infection rates climb, particularly in high risk areas such as
neonatal intensive care units, or any intensive care or high dependency
unit; so staff ratios are incredibly important. The other issue
about bed occupancy: if you want to clean wards or decant wards
so you can do deep cleaning or a planned programme of maintenance,
or whatever, it is very hard if you have not got space, because
where can you put people to close a ward to clean? Also, for instance,
orthopaedic infection. It is critical if you come in for a hip
or a knee that you are either admitted to a ring-fenced area where
everybody is MRSA screened and MRSA free. So that is ring-fenced
just for you coming in for your hip or knee. That will mean that
you have got to run at whatever bed occupancy it is and keep beds
empty sometimes to do this. The other issue about bed occupancy
is that it is not just bed occupancy. We need to think about what
is our bed stock in terms of single rooms and isolation rooms
we can use. How often can we isolate a patient with diarrhoea
instead of closing all the beds around them? How often are we
working in wards that may be not the ideal type of estate to practice
21st century medicine and clinical and scientific aspiration?
So it is not just the issue about bed occupancy. Much can be done
even if you have got high bed occupancy. It is not the only factor,
but it certainly impinges on all those other issues.[5]
Q553 Dr Taylor: Just to be clear, MRSA
bacteraemia, you said, is the tip of the iceberg; the rest of
it are the wound infections.
Dr Holmes: The pneumonias, urinary
tract infections—absolutely.
Q554 Sandra Gidley: The buzz thing
in 2007 was big announcements that all hospitals would have to
have a deep clean. Locally there was a decision to do that even
before the edict came from on high. Did it actually make a difference
or was it just a gimmick?
Dr Holmes: I think it is very
important to have awareness about cleaning, and there was a response
also to the public's concern about cleaning, so the cleaning was
a good thing. However, I think a one-off clean is not enough;
we need a sustained programme of deep cleaning which needs to
have enough space that we can do it and also co-ordinate it with
any planned programme of maintenance so that you can do everything
at the same time and decant patients. I think a deep clean is
very important, but it is not a one-off, it should be a sustained
part of the organisation. There should be a rolling programme
of deep clean throughout all clinical areas, but you do need space
to be able to do that adequately.
Q555 Sandra Gidley: Certainly I know
that patient feedback was positive, because the place looked cleaner,
but is there any research to show whether it actually made a difference
to infection rates or not? That is what I am trying to establish.
Dr Holmes: I am unaware of any
clear research that has established that. I think it drove some
very important messages and I think it was useful. You pointed
out how it looked cleaner. The other issue is about de-cluttering,
which it helped with, but we do have a big issue with space.
Q556 Sandra Gidley: When they design
hospitals do they just not put enough cupboards in for everything,
because the amount of rubbish these days when you go round. They
are very messy, they do not look very clinical, and the staff
do not see it.
Dr Holmes: It is tricky to see
if there is a lot of kit everywhere, but I think the staff do
see it on the wards; I really think they do. There is an issue
about the fabric of many of our hospital buildings and, whilst
wanting to give patients space, sometimes it is compromising on
storage space. So the design of our buildings is absolutely critical
for patient experience, patient safety and for infection prevention.
Q557 Sandra Gidley: We have had a
lot of evidence that a lot of improvements can be made if you
change the culture: so how important are reporting and learning
for infection prevention and control?
Dr Holmes: Incredibly important.
I would suggest it is the continuous feedback of data, the continuous
surveillance and feedback of data, that is really important rather
than just the reporting of particular events. For quality improvement
within infection prevention and also for monitoring trends and
targeting activity, it is having good strong surveillance mechanisms
and also ones that are in real-time. Hearing about something six
months later is not good enough; we really need the fast turn-around
of surveillance data and information that is relevant to the people
that are receiving it so that they can make change.
Q558 Sandra Gidley: So data is available
from the National Reporting and Learning System. What I am not
sure about is how you use it. You can see whether something is
getting better or worse. It may be not quite so easy to link that
to a specific intervention that may have been made or an improvement;
so how is this wealth of information used in practice to change
things on the ground? I am not quite sure where the link comes
in?
Dr Holmes: I am talking about
several different surveillance schemes. There is the national
mandatory reporting of different infections, there is also a raft
of local ones and also a range of networks of reporting all around
quality improvement and also, locally, key performance indicators
that we have set around infection. In terms of the NRLS, there
has not been so much in my field, so I cannot answer that.
Q559 Sandra Gidley: Why has there
not been so much, and should there be more?
Dr Holmes: One thing that has
been extremely useful that has come from the NPSA has been their
Clean your Hands programme. That has been phenomenally useful
as a resource in terms of positive reinforcement, in terms of
providing masses of resources, in terms of awareness campaigns
and everything; that has been extraordinarily useful as a campaign.
3 Holmes A, Murray E, Dinneen M. `Creating a new
Culture'. Public Service Review, Issue 8, 2006 Back
4
Further information supplied by witness: H. J. Wickens and A.
Jacklin Impact of the Hospital Pharmacy Initiative for promoting
prudent use of antibiotics in hospitals in England Journal
of Antimicrobial Chemotherapy 2006 Dec;58(6):1230-7 (which suggested
that 92% of (responding) hospitals in England had some form of
empiric antibiotic guidance in place, and slightly fewer had an
antibiotic formulary); Back
5
Further information supplied by witness: Archie Clements, Kate
Halton, Nicholas Graves, Anthony Pettitt, Anthony Morton, David
Looke, Michael Whitby Overcrowding and understaffing in modern
health-care systems: key determinants in meticillin-resistant
Staphylococcus aureus transmission. Lancet Infect Dis 2008;
8: 427-34; Back
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