Case Notes - Important BBC 4 Documentary reporting some success in Hospital Acquired Infections.

Case Notes is a BBC4 documentary programme presented by Dr Mark Porter who delves every week into what the medical profession does and doesn't know. This week he turned his attention to Hospital Acquired Infections. Like all Case Notes programmes it was informative, authoritative and is also available online as a repeat for 7 days, as a a full Transcript or as as Podcast.

This week the programme addressed what the Press like to call "Superbugs" -

"Hospital acquired infections - like ... MRSA and Clostridium difficile - are rarely out of the headlines these days. So how worried should we be? And what can you, and your hospital do, to reduce the risk? " the programme asked and provided an excellent and encouraging reponse.

Hospital Acquired Infections (HAI) were a problem first brought to a wider public attention when the Audit Commission led by the brilliant forensic mind of Sir John Bourn reported, not on the clinical problems but the costs of the lamentable record of people entering hospital for a cure and ending up with an infectious and sometimes fatal illness. In its original February 2000 report, the NAO noted that hospital-acquired infections (HAI) were (then) costing the NHS around £1 billion a year and resulting in at least 5,000 deaths - which broadly coincided with the experience in US hospitals.

A progress report issued 4 years later on Wednesday 14th July 2004 delivered the shocking news that the Department of Health’s mandatory MRSA reporting system had revealed an 8% increase in the number of Staphylococcus aureus bloodstream infections from 17,933 in 2001-02 to 19,311 in 2003-04. Of these, about 40% were MRSA, making the UK’s rate among the worst in Europe.

At the time Sir John Bourn said:

" .... I am concerned that, four years on from my original report, the NHS still does not have a proper grasp of the extent and cost of hospital-acquired infection in trusts.

"The war against hospital-acquired infection must be pursued on many different fronts: ranging from tackling the factors which inhibit good practice, including a more robust approach to antibiotic prescribing and hospital hygiene, though instituting a system of mandatory surveillance, to persuading all NHS staff to take responsibility for, and contribute towards, effective infection control."

It is unnerving that a well run, well funded, well staffed inner city hospitals of the University Hospitals of Leicester NHS Trust are still, 7 years on struggling manfully to control this problem.

In the programme Mark Porter talks to Dr David Jenkins ,the Director of Infection Prevention and Control, Andy Powell, Head of Facilities and Caroline Trevithick, Lead Infection Control Nurse about their plans.

Preventing entry of infected patients by swabbing for MRSA before admission, annual deep cleaning (see pic) to help keep the hospital environment clean and rigorous hand washing procedures to prevent cross contamination between health workers and patients, and visitors have all been introduced as well as isolation of infected patients. There has also been an intensive and combined programme with GP's and hospital clincians to control the use and types of antibiotics routinely used for routine treatment of infections.

University Hospitals of Leicester produce a very good well illustrated leaflet - Understanding and Preventing Infections - Answers to the most common questions patients ask about two of the most talked about ‘superbugs’, MRSA and Clostridium Difficile). Downloadable PDF (!) (1.46 MB)(also available in 6 languages in printed format)

Mark Porter asked Dr Jenkins how he saw the situation at Leicester in terms of battling C.difficile and MRSA?

JENKINS .."It's early days yet because we have had a problem with C.difficile in Leicester.... our numbers now are the lowest for many years, in fact lower than they were before this new strain (the 027 strain of C.difficile ) came along. Clearly this is something we do need to keep an eye and we're certainly not complacent about that."

".... the government set a target for halving MRSA bloodstream infections by the end of March. At the moment we're on track for 70% reduction, so over performing from that point of view."

Studies in the developed world have now clearly identified the costs and consequences, of MRSA. In the UK, the National Audit Office (NAO), an organisation with no direct health responsibilities it must be noted, are the people who have been instrumental in driving changes, essentially for economic, not clinical reasons. To the direct costs must be added the consequences of claims for damages - Lesley Ash (pic) the popular TV actres has just won a reported £5Mn. settlement for crippling MRSA infection.

Paradoxically, as a result of more rigorous definitions, improved reporting, and defined responsibilities for infection control in hospitals it is evident that the problem is larger and more pervasive in UK hospitals than initial studies had indicated.

For example it was only 3/4 years ago that the scale of the Clostridium difficile levels of infections and fatalaties became apparent , even to health workers at all levels and Infection Control staff - whose function has now become critical in managing clinical success in the way it is now calculated and reported.

The Press have been assiduous in promoting the happy story that anxious patients and relatives wringing their hands in grief have been replaced by nursing staffs educated in hand washing.

Probably if there was a Royal College of Hospital Cleaners, anxious to protect their members interests, such a simple solution identifying the prime cause of sloppy cleaning, might not be promoted with such zeal. Nor expensive and largely pointless "deep cleaning" ... whose presence and signage suggests more a desire to provide public re-assurance rather than any meaningful medical benefit.

The story from Leicester (Whose University is the leading and most progressive Department in treating patients rather than illness) is one of modest success, naturally no hospital would take part if they couldn't display such effort, energy, directed zeal and demonstrable results.

That's the Good News - but there is plenty of bad News.

There were different results from a BBC programme which focussed on just one hospital trust in early 2004.

BBC reporter Danielle Glevin went undercover in May 2004 in the Kent and Sussex Hospital to report a scandalous story .

In the resulting programme Hugh Pennington an eminent consultant microbiologist (He led a public inquiry into the 2005 E. coli outbreak in South Wales) said it was a dirty hospital.."the worst I've ever seen" . Rose Gibb the Chief Executive of the Maidstone and Tunbridge Wells NHS Trust responded "The hospital has cleaning problems".

There were subsequently two major outbreaks in their 3 hospitals of Clostridium difficile - 150 patients were affected between October and December 2005.

In a second outbreak from April to September 2006 285 patients were affected.

A report from health watchdog, the Healthcare Commission in October 2007 (3.5 years after the BBC programme) , concluded that infection by Clostridium difficile probably or definitely killed at least 90 patients and was a factor in the deaths of a further 241 in 3 Hospitals (Maidstone Hospital, Kent and Sussex Hospital, Pembury Hospital) run by the Maidstone and Tunbridge Wells NHS Hospital Trust . Kent Police and the Health and Safety Executive are now examining the report.

CEO Ms Rose Gibb ( a qualified nurse), resigned a day ahead of the publication of the report with an award of a years salary (£150,000), half of that has been paid despite the Health Minister Johnson's attempt to stop it and she is claiming for the balance of £75,000.

There are similiar problems reported recently in Suffolk Scotland and Northern Ireland
and Stoke Mandeville.

Stoke Mandeville Hospital was investigated by the HSE after a Healthcare Commission (HC) report claimed that there were “serious failings” in the hospital’s response to Clostridium difficle infection infecting 334 and killing 33 patients between October 2003 and June 2005. The HSE decided that they were unable to bring criminal proceedings against the trust due to a lack of “admissable evidence”.

...and Finally

Preliminary Health Protection Agency figures released this week show the most remarkable reduction in Hospital Acquired Infections (HAI) in England.

The latest Clostridum difficile figures, show that there was a 21% decrease to 10,734 cases in patients aged 65 years and over in England, for Q3 2007 (July – September) down from 13,699 in the previous Q2 2007(April – June) and 16% / 2,087 cases down on Q2 2006.

For patients 2 -62 , 2,496 cases were reported in the Q3 2007 (July – September) a 14% drop on the Q2 2007 (April – June).

The latest figures on MRSA bloodstream infections show that there were 1,072 cases reported in England during Q3 ( July/ September) 2007. This represents an 18% decrease on the previous quarter (April to June) when 1,304 reports were received. (HPA Press Release)

Whilst these dramatic reductions have raised a few eyebrows, indicating a massive level of success in 3 months not obtained in the previous 7 years, ther has been, at last some demonstrable success in the fight against HAI.... first raised as a problem 8 years ago by an Accountant.