CHAPTER 4 INFECTION CONTROL |
4.1 As resistance to
antimicrobials increases, so does the importance of infection
control. Preventing the spread of organisms which are resistant
and therefore hard to treat is obviously desirable. Less obvious,
but equally desirable, is control of infection by organisms which
are still susceptible; every infection not prevented requires
treatment, and every treatment adds to the selective pressure
4.2 In some respects,
hospitals achieve the level of infection control for which they
are willing or able to pay. Money can buy infection control in
various ways, some of which are considered in the next few paragraphs.
Standards of hospital infection control management in England
and Wales were recently defined by the "Cooke Report";
looking ahead, that Report said, "Antibiotic-resistant bacteria
will almost certainly be an increasing problem [for hospital infection
control] in the future".
4.3 According to the
Cooke Report (ch. 2), every acute hospital should have an
infection control team.
The team should consist of an infection control doctor (normally
a consultant medical microbiologist) and one or more infection
control nurses. Non-acute hospitals should be covered, under contract,
by a team from a neighbouring acute hospital. Every hospital should
also be covered by a multidisciplinary Hospital Infection Control
4.4 A recognised qualification
for infection control doctors has been established (DipHIC). As
for nurses, the Infection Control Nurses Association (ICNA)
told us, "The minimum recommended training requirement for
infection control nurses is a post-basic diploma-level course
in infection control and previous management experience...Most
NHS trusts comply with this; however some private hospitals do
not" (Q 201).
4.5 The AMM reckon
that each infection control nurse in the United Kingdom covers
400 acute beds (p 6). According to the ICNA (Q 201),
the figure is 700; they drew our attention to US research suggesting
that hospital-acquired infection could be reduced by 30 per
cent by reducing the number of beds per specialist nurse to 250,
though they admitted that this was not quite comparing like with
like. More nurses would mean a more "proactive" service,
and more surveillance. The Cooke Report offers different numbers
again (one nurse to 477 acute beds in 1993), but makes the same
point: an understaffed infection control team can do "little
more than respond to acute problems".
4.6 The ICNA claim
that an infection control team is much more effective when it
has resources, in terms of clerical staff and information technology.
"Not all infection control nurses have access to IT; there
is no doubt that this helps us in our work. None of us, or very
very few, have access to a full-time secretary or a data clerk"
(Q 201; on IT, cp Q 225; on support staff, cp Q 232).
4.7 According to the
ICNA (p 121), "The majority of infection control teams...do
not have formal contracting arrangements with their purchasers".
Where the contract does include the infection control team, it
is often incorporated into the contract for diagnostic microbiology;
according to the ICNA, "There can be virtually no resourcing
within the trust for infection control because it all goes on
diagnostic microbiology" (Q 232). However purchasers
are currently placing less emphasis on throughput (see paragraph 4.13
below), and more on clinical outcomes (Q 232); high standards
of infection control, of course, impede the former but improve
the latter. The NHS Priorities and Planning Guidance (PPG) for
1997-98 requires directors of public health to ensure that adequate
provision is made for infection control; "the easiest way
to do this is through formal contracting arrangements".
4.8 According to Dr
Mayon-White (Q 172), contracting for the infection control
team is less important than contracting for high standards of
infection control. The ICNA would like to see auditing against
minimum standards, such as those of the King's Fund Organisational
Audit, built into the contracting process (Q 232). According
to Dr Graham Winyard, Deputy Chief Medical Officer and Medical
Director of the NHS, the "key driver" of standards is
the desire for excellence, not contractual provisionsthough
a contract can provide an "entrée", e.g. a seat
for the Health Authority's Consultant in Communicable Disease
Control (CCDC) on the Infection Control Committee (Q 805).
4.9 Advances in basic
hygiene, both in hospitals and in the community, were reducing
mortality steadily long before the discovery of antibiotics; but
it is commonly believed that standards in this area are slipping,
perhaps partly through over-reliance on anti-infective drugs.
Poor hygiene has been definitely implicated in some outbreaks
of hospital infection, and the ICNA are especially concerned about
cleaning (QQ 201-9, p 124). A recent ICNA survey of
hygiene in United Kingdom hospitals revealed shortcomings which
the ICNA's Chairman found "quite surprising": e.g. cleaning
cloths and mops going unwashed from day to day. The position has
been complicated by the contracting-out of hospital cleaning services.
This means that cleaners are not responsible to the ward sister,
and instilling high standards and pride in the job is more difficult.
High cleaning standards and training requirements may be written
into the contract; but "because of cost this is often cut".
The ICNA observe that there is no United Kingdom standard for
hospital cleaning (p 130).
4.10 The ICNA say,
"adequate and appropriate handwashing is well recognised
as the single most important measure in infection control"
(p 124, Q 221).
The AMM are also concerned about handwashing; they blame high
patient turnover, and "poor provision of readily accessible
hand basins", for failures in this area (p 8).
4.11 Dr Mayon-White
blames falling standards of hygiene partly on penny-pinching by
contractors, and partly on the loss of experienced middle managers
from the NHS (Q 171). The AMM blame the pressure of high
bed occupancy (p 8; see below).
4.12 Isolation of patients
is an expensive but effective form of infection control. It can
take various forms: an isolation hospital, an isolation ward or
"cohort nursing" within a hospital, an isolation room
or side-room attached to a ward, or simply placing infected patients'
beds in a corner or at the end of a row. The ICNA told us, "Most
of us...have lost our isolation wards in the last five or six
years...because they were no longer cost-effective to run...and
now it is too late to get them back again" (Q 219; cp
Ulmanis p 528).
Where single rooms exist, they are sometimes carpetedwhich
is of no help in controlling dust-borne infections such as MRSA.
Cohort nursing involves dedicating a nursing team to the affected
patients; this "is becoming increasingly difficult in view
of the widespread reductions in permanently employed staff, significant
alterations to the nursing skill mix and an increased reliance
on agency staff" (p 124).
4.13 For some years,
the NHS has had a policy of maximum occupancy of beds. The ICNA
report that some doctors and managers consider standard infection
control measures to be "more disruptive than effective"
(p 123). Maximum occupancy militates against isolation, against
hygiene and cleaning, and against ward closure - "often the
most effective means of control" (ICNA p 124, cp AMM
p 8). It encourages hospitals to place beds too close together,
which has been known to increase the chances of infection since
the days of Florence Nightingale (QQ 39, 196). It also gives
rise to "hot-bedding", whereby patients move frequently
around the hospital as beds become free,
potentially spreading infections as they go (AMM p 8). The
shortage of beds is most acute in winter (Q 222).
4.14 While supporting
the principle of efficiency, the AMM commented, "We are beginning
to lose the flexibility to operate a workable infection control
policy" (Q 39). They admit, "Action on resistance now
is a difficult political matter since it requires diverting resources
from other priorities in the short term...for what is an uncertain
gain...in the future...More resources put into hospital cleaning
might result in longer waiting times for treatment" (p 12).
4.15 It is of course
inevitable that patients will be moved around within the hospital,
and being moved is often in the best interests of the patient.
The ICNA conceded, "That can be very effective bed management"
(Q 223). The Minister for Public Health conceded that "Faster
throughput increases risk"; but, she insisted, it is not
incompatible with good practice. The message that hospital-acquired
infection has an impact on both budgets and availability of beds
is getting through to hospital managers. However, she admitted
that "The level of control...is as good as the weakest link"
4.16 A concomitant
of general staff shortages and the pressure created by high bed
occupancy is the increasing use of agency nurses. Agency staff
are "sometimes poorly versed in infection control technique"
and may be unfamiliar with local procedures (AMM p 8); and,
in moving frequently from one place of work to another, they may
act as carriers of infection (Q 210).
4.17 The ICNA told
us that there has been a "significant rise" in screening
of patients for MRSA (p 125), but that some hospitals do
not currently screen at all (Q 222). However new guidelines
for MRSA, currently under discussion, will recommend more rigorous
screening for patients entering higher-risk units.
Screening takes time and costs money;
current techniques take 2-3 days. The ICNA say that a new molecular
test takes only one day, but costs £25 per test, which "may
prove prohibitive" (p 125).
4.18 According to the
ICNA, there is "no expert consensus" on screening hospital
staff for MRSA. However they have anecdotal evidence of staff
losing jobs, or being turned down for jobs, through screening
positive for MRSA, which, they observe, is not classified as an
industrial disease (p 125). They also have unpublished evidence
of the disruption and distress experienced by staff screened positive
for MRSA (p 127).
4.19 One of the roles
of the infection control team is training and education. The ICNA
perceive a cultural change in the United Kingdom at large, whereby
good basic hygiene is no longer habitual (Q 230). Education
for infection control can be delivered in various ways:
for new hospital staff, including medical staff (Q 230).
Domestic staff are in even greater need of induction, due to high
turnover and lack of basic knowledge (p 126);
in-service training: "The
release...of clinical [and ancillary] staff for training is very
difficult and we are getting fewer people attending educational
sessions" (Q 201);
education of patients
and the public (Q 227).
As already mentioned, it is especially
difficult to ensure training of agency nurses and contract cleaners.
Mrs Gill Stephens, Assistant Chief Nursing Officer, insisted,
"The policies are there"; but she admitted, "There
are areas where improvements can be made...certain recent research
has demonstrated that" (Q 773).
in the community
4.20 According to the
ICNA, "Very little has been done in the community in the
way of infection control" (Q 213). Some community NHS
Trusts have begun to set up infection control teams, and some
Consultants in Communicable Disease Control (CCDCs) at district
health authority level have begun to look at the public health
implications of community infection control. However most have
not; and there are no national guidelines analogous to the Cooke
Report for hospitals. This is of increasing importance as more
health services are delivered in non-hospital settings, e.g. GPs
performing minor surgery. The ICNA conclude, "Changes and
developments in health care organisation and delivery have established
the need for a dedicated `community' infection control nurse role...The
problems associated with the control and management of multi-resistant
organisms in the community setting make it imperative that community
infection control service requirements are examined and adequate
provisions are made to provide an effective service" (p 121;
cp AMM Q 22).
4.21 In the case of
certain organisms such as MRSA, it may be argued that community
infection control is not important because healthy people are
not at risk. The ICNA reply that the more healthy people are colonised,
the more MRSA will be carried back into hospitals to infect the
vulnerable; the AMM referred to this as the "revolving door".
4.22 The ICNA gave
us examples of best and worst practice (QQ 215-6). In one
health authority area, with "a CCDC with vision", the
infection control team have trained in MRSA control one senior
member of staff from each nursing home and residential home. As
a result, MRSA-positive patients do not block hospital beds while
awaiting discharge into a home prepared to have them; and general
standards of infection control in such homes have risen, so "We
do not get the big outbreaks now". In another area, there
is no community infection control nurse or public health nurse,
and infection control is not part of the community trust's contract.
In consequence, the infection control nurses in the local hospitals
receive requests for help with community infection control, which
they cannot give.
4.23 Dr Mayon-White
told us that, at least in Oxfordshire where he works as a CCDC,
the importance of community infection control in respect of MRSA
is now well understood. He cited two reasons for this (p 107).
The first was a major outbreak of MRSA around Kettering in 1991-92,
involving a new strain of MRSA (type 16) which did not depend
on the constant selective pressure of hospital antibiotics. The
strain established itself in the community, especially in community
hospitals and nursing homes, from which it was repeatedly reintroduced
into Kettering hospital, and into other hospitals in the region.
Control involved not only screening and isolation in the hospital,
but also the establishment of a community infection control nursing
service. The other cause was a sensational BBC television programme
(Panorama) in 1996, which dramatically raised public and
professional awareness of MRSA in the community: "A good
thing to have come out of this scare is that the role of the community
infection control team is well established in the 79 per
cent of health districts [in Oxfordshire] with community infection
4.24 For the NHS Executive,
Dr Winyard acknowledged that infection control in the community
is "an area of weakness" (Q 811). The Department
of Health has just reviewed the role of the CCDC, and the NHS
Executive is taking "active steps" to remedy certain
shortcomings which emerged in some areas, notably in "proactive
work" such as surveillance, policy development, research
and education (p 371, Q 801). Once the current review
of the Public Health (Control of Disease) Act 1984 is complete
(see below), the Chief Medical Officer agreed that it might be
helpful to produce a national standard for infection control management
in the community, along the lines of the Cooke Report for hospitals
(Q 817). The Department added, "Not every district currently
has community ICN cover, but the numbers are steadily increasing.
The salaries of these staff have now been excluded from the definition
of health authority costs which are subject to management cost
reductions in 1998/99; this should encourage more health authorities
to employ them" (p 372).
4.25 The approach of
nursing and residential homes to MRSA has been particularly problematical.
The level of training of staff is typically low; and, as noted
above, homes have tried to block admission of people carrying
MRSA. The ICNA see behind this a fear of litigation and high insurance
premiums (Q 231); they comment, "If nursing homes continue
to refuse MRSA, they are going to run out of patients!" The
Department of Health issued reassuring guidance to nursing and
residential homes in 1996. The ICNA recommend that all such homes
should be assessed for basic hygiene, and that staff should receive
training from community infection control teams; they admit that
this would be expensive (p 127).
Power to enforce
4.26 If someone at
large in the community carries an infection which threatens public
health, such as TB, and is unable or unwilling to submit voluntarily
to treatment, the public interest may demand that treatment be
enforced. The Public Health (Control of Disease) Act 1984, which
was largely a consolidation, gives power to a magistrate to order
medical examination (ss. 35-6), and removal to and detention
in hospital (ss. 37-8). Dr Mayon-White drew our attention
to several shortcomings of these provisions: they give no power
to enforce treatment; they place the initiative with local authorities,
which used to run infectious disease hospitals but no longer do
so; they assume that the best place for an infected person is
hospital; they are cumbersome; and they raise questions of ethics
and human rights. "They should be replaced by powers that
are more sensitive to human rights, recognise the benefits of
treatment, and are held by health authorities...Powers that enabled
supervised treatment and care at home would be more humane and
helpful..." (p 109, cp Q 185).
4.27 Like prudent use
of antimicrobials, infection control is supported by surveillance.
The PHLS told us, "The surveillance information is integral
to the advice we give to infection control teams [about MRSA]
on a regular basis" (p 43). We consider surveillance
in detail in chapter 5.
4.28 The Department
of Health and PHLS have set up the Nosocomial
Infection National Surveillance Scheme (NINSS), "to produce
consistent, anonymised data on hospital-acquired infection to
enable hospitals to compare their infection rates with others
and review the efficacy of their infection control practices"
(p 349, QQ 786-7). The Scheme so far covers bacteraemia
and surgical site infection, and involves 150 acute hospitals
in England; it is intended to bring in other infections and the
remaining acute hospitals, to extend it to long-stay hospitals,
and to set up a similar scheme in Scotland.
4.29 Infection control
in prisons in England and Wales is the responsibility of the Health
Care Service for Prisoners (formerly the Prison Medical Service),
which is part of the Prison Service, not the local health authority
or the NHS. The situation is similar in Scotland and Northern
Ireland. Dr Mayon-White finds this a problem. He calls, not
necessarily for a unified service, but for "a common standard,
preferably using common resources, so that it does not really
matter where the infection is, it is managed as a corporate effort"
(Q 152). A joint working group of the Home Office and the
Department of Health is in fact currently exploring options for
better integration of prison medical services with the NHS; it
is expected to report to Ministers later this year.
Costs and benefits
4.30 The Cooke Report
attempted to quantify the costs of hospital-acquired infections.
United Kingdom data are limited, but a study in 1988 found additional
costs to the hospital of between £400 and £3,200 per
patient. Most of the cost arose from extra days in hospital; Dr Mary
Cooke, Senior Medical Officer and principal author of the report,
pointed out to us (Q 774) that this not only increases cost
but also reduces patient through-put. There are also, of course,
costs to the patient and to the wider community.
4.31 Individual outbreaks
of hospital infection have been costed. The Cooke Report mentions
several, including the Kettering outbreak of MRSA mentioned above
which cost the hospital £400,000 (see Box 7). Outbreaks
may have consequences beyond the direct costs: e.g. staff absences,
adverse publicity, failure to meet targets due to ward closures,
increased stays and general disruption. The ICNA observe, "It
is difficult to justify the costs incurred from an intervention
where the successful outcome measure is an event not occurring";
they too cite direct costs of particular outbreaks of MRSA, including
one in Madrid which involved 900 patients and cost £700,000,
and they stress the wide range of headings under which costs,
tangible and intangible, can arise (p 122). Dr Davey
gives further examples (p 148).
4.32 Outbreaks may
lead to complaints and litigation. According to the ICNA (Q 212),
there has been a "tremendous increase" in complaints
arising from hospital-acquired infection, and managers are becoming
more aware of the implications for risk management.
4.33 Numbers can also
be put on the risk to patients and the public. About one in ten
patients in acute hospitals at any one time has an infection acquired
after admission, according to the Cooke Report;
according to the AMM, the average risk to an individual patient
is between 5 and 10 per cent (p 7). The risk varies
according to the situation: in an intensive care unit it may be
as high as one in two. Hospital-acquired infection in the United
Kingdom is significant as a primary or contributory cause of death
(Cooke Report 1.5).
4.34 Finally, the Cooke
Report offers some indications of what effective infection control
in hospitals can achieve. "We believe it is possible that
currently about 30 per cent of hospital acquired infection
could be prevented..." In the USA it has been calculated
that a mere 6 per cent reduction pays back the cost of a
three-person infection control team. A major study of 300 US hospitals
over five years in the 1970s found that, while infection in hospitals
with no control programmes rose by 18 per cent, rates in
hospitals with control programmes including surveillance and feedback
fell by 32 per cent.
COST OF MRSA OUTBREAK IN KETTERING 1991-92
Replacement of mattresses and pillows
|The figure does not include the costs associated with increased length of stay, additional prescribing costs, the cost arising from absence of infected staff on sick leave or the costs of litigation.
Source: Cooke Report
A national MRSA
4.35 MRSA poses one
of the biggest challenges to infection control. It is common,
it moves easily between hospital and community settings, and in
many United Kingdom hospitals it is now regarded as endemic. Professor Percival
put it at the top of his list of problem organisms in hospitals
(Q 103); and Dr Mayon-White put it top of the list of
community-acquired infections (Q 149A). MRSA is treatable;
but many consider that it is only a matter of time before untreatable
strains emerge. That time can probably be lengthened by keeping
MRSA in check. The Department of Health approved guidelines on
the control of MRSA in hospitals in 1990; the BSAC, ICNA and Hospital
Infection Society are currently revising them (pp 42, 349).
4.36 Dr Mayon-White
calls for a national MRSA strategy (p 108, Q 168). He
points out that MRSA is a marker of cross-infection generally.
Therefore a strategy to control MRSA would bear down on other
infections as well. He also observes that, whatever the cost of
such a strategy, it would be very small compared with the cost
of dealing with more outbreaks like the one in Kettering.
4.37 The Minister for
Public Health spoke confidently about MRSA (Q 753). Whereas
many countries now accepted MRSA as a fact of hospital life, this
need not be so here; rates of resistance were relatively low,
and the United Kingdom had "excellent clinical guidelines"
and surveillance which was "the best in the world".
She acknowledged, however, that a "much more proactive approach"
was called for, from Government and others, in order to avoid
passing a "legacy" of resistance to the next generation.
Hospital Infection Control-Guidance on the control of infection
in hospitals, prepared by the Hospital Infection Working Group
of the Department of Health and PHLS
(published with HSG(95)10, March 1995; see DH p 348). The
Department has recently commissioned detailed clinical guidelines
(QQ 755, 806-810). Back
For an account of the work of the infection control team at King's
College Hospital, see Appendix 5. The experience of King's
College Hospital is cited in several places in this Chapter by
way of example; this is simply because that is the hospital which
Sub-Committee I visited during their enquiry, and should
not be taken to imply any singular praise or blame. Back
The points made by the ICNA in relation to MRSA are supported
by the evidence of the Royal College of Nursing (p 451). Back
250 is the maximum permitted by the US Joint Committee for Accreditation
of Healthcare Organisations, which accredits hospitals to the
satisfaction of insurers. Back
The ICNA drew our attention to the particular problem of soap
(Q 221). Purchase of soap is usually the responsibility
of the cleaning contractor; some contractors buy cheap substandard
soap. With repeated use of such soap, nurses may acquire chronic
skin lesions on their hands, which render them vulnerable to chronic
colonisation with MRSA. This poses no special threat to their
own health; but of course it carries a risk to their patients,
and sometimes means that the staff concerned must spend long periods
off work. For a more sceptical treatment of hand-washing, see
van Saene et al, p 558. Back
Some dedicated isolation units still exist, mainly in major centres,
and act as a focus of high standards of cross-infection control.
Of the 1,000 beds at King's College Hospital, 63 are isolated;
this, we gathered, is not enough. Back
For example, at King's College Hospital, an 18-bed liver transplant
ward saw 51 changes of bed occupant in four days. Back
Cp van Saene et al, p 559. Back
For example, at King's College Hospital, 15,000 tests are carried
out each year, costing about £40,000 for consumables, £25,000
for staff and £55,000 in indirect costs. King's admits 42,000
patients per year; universal screening was once tried, but turned
out not to be cost-effective. Back
Cp Greenwood p 410. Back
A survey by the Hospital Infection Society in 1994 found 9 per
cent prevalence (p 421). Back
8 per cent in 1990-95, compared with 30 per cent in
France and 60 per cent in Japan-though differences in denominators
vitiate this comparison to some extent. Back
Currently being revised. Back