Patient Safety - Health Committee Contents

Examination of Witnesses (Question 540-559)



  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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