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At the 70th AGM meeting of the League, Pam Padelopoulos introduced Paul Hately, Head of Nursing Pathologies and Patient Services. He looked at infection control in the past, the present and the future implications for nursing practice. Starting with the Black Death in 1348 there were regular epidemics and with the Great Plague in 1666 over a third of the world population had died. In 1817 Asiatic cholera was greatly feared, yet other familiar infectious diseases had caused a lot of deaths: typhoid, typhus, bacillary dysentery, and measles were still with us. Only smallpox had been eradicated, but with the threat of germ warfare two companies would restart making vaccines against it later this year. John Snow and the Broad Street well/pump story showed that good standards of hygiene could prevent infections. Polio was once endemic and is now controlled by vaccination. It is close to eradication: Africa, India, Algeria and Morocco still have cases, although administration of the vaccine is easy (on a sugar lump) and cheap. The Dutch outbreak in 1976 affected 100 people, with 80 paralysed, in a religious group that had refused vaccination. Two years later there were a further 6 related cases in Canada. Sometimes the source was not identified, as in Sweden in 1980s. Influenza could be virulent, such as the 1918 pandemic 'Spanish lady' that killed more people that World War One. In the UK in 1999/2000 there had been 20 000 flu-related deaths, mainly from secondary complications. Antibiotics and the rise of cross-infection Paul then turned to the development of the Infection Control service. He said Flemming's discovery of penicillin in 1928 had led, within ten years, to a commercially available antibiotic. In the 1950s cross-infection with new organisms and bacterial resistance was noted. Dr Brendan Moore of Exeter identified the need for a nurse to reduce cross-infections but the idea was opposed nationally by consultants. However in Torbay Hospital in 1959 there were problems with staphylococcal cross-infection that included nursing staff. The matron, Miss E Cotteral appointed the first infection control nurse (ICN). The Royal Devon and Exeter followed. Infection rates fell. The role for the Infection Control Officer (the doctor) to:
remains broadly the same today. By 1988 there were over 200 ICNs in England and Wales, rising to 650 across the UK by 2001. Nurses remain the only full-time members of the Infection Control Team, with doctors from a wide range of specialities each contributing a few hours. Barts and the Royal London Trust (BLT) has the largest team in the country, including 0.5 WtEq of a doctor, a head of nursing, 2 clinical nurse specialists and three 'G-grade posts (training). Most importantly it has a full-time Secretary and this probably equates to two more nursing posts as the clerical load is high and nurses are slower typists! In addition to the Trust, the Team covers three other hospitals in the East End and also provides services to primary care trusts. Key reports on infection control In the last two years there has been an increase in government interest in the incidence and cost of hospital-acquired infection.
The rate of 1 in 10 patients has hardly changed and nationally the cost, of treatment, extra days in hospital and from complications, must run into billions of pounds. BTL Trust meets over half the 1999 controls assurance standards but now has to work on an antibiotic policy. This requires 220 consultants to agree, yet there can be a variety of different prescribing regimes within one department and no difference in infection rates. It will be a major challenge for the Team. The Decontamination of Medical Devices guidance needs clarification between single-patient use and single-use. It says, "Never reuse medical devices designated for single use". Manufacturers are unclear – respiratory patients use nebulisers which state single-use on the packet and single-patient use in the accompanying literature. There is a major cost associated with single-use. According to the guidelines neurosurgical equipment should not be reused because of the small risk of cross-infection with new variant CJD arising from the prion associated with bovine spongiform encephalopathy (BSE). In theory anyone who has eaten beef in the last 25 years has risked prion exposure and therefore infection. Some of the specialist equipment used for brain surgery costs thousands of pounds, so following such guidance would drastically reduce the number of operations that could be afforded in any one year! The HSC 2000 number 32 'Timetable to Decontamination of Medical Devices' set targets. BLT has a good CSSD and only contracts out ethylene-oxide decontamination, but cannot comply fully because of the neurosurgical equipment issue. One weakness was that the Designated Accountable Officers were from Facilities Directorates and they did not understand all the clinical implications. The National Audit Office report on Hospital Acquired Infection highlighted the hidden costs of infection control, such as protective clothing (Executive Summary in pdf -200kb). If the BTL Trust implemented the recommendations in full it was estimated to cost an additional £20 million. The report did cover strengthening prevention and control of infection, also to secure appropriate healthcare services for patients with infections. At BTL Trust there were 12 beds at the RLH and 10 at Barts: more than any other London hospital. Developing national evidence-based guidelines was very expensive. The guidelines for preventing healthcare-associated infections project (EPIC) dealt with indwelling urethral catheters and central venous catheters and cost £2.8 million. The ICNA joined with the Association of Domestic Managers to agree standards for environmental cleanliness in hospitals (1999). This was the start of the 'Clean Hospitals ' campaign. In the BTL Trust the contract cleaning had not been of a high standard. This was set to change. Surveillance rates The number of patients treated in hospital continues to rise, as do the invasive procedures at a time when there are fewer effective antibiotics. At the moment the 100 000 infected patients a year (1 in 11 patients) is an underestimate of infection rates because some patients get 2 or 3 different organisms but are only counted once. Hospital acquired bacteraemias are associated with a small range of specialties: general medicine, general surgery, haematology, ICU, geriatics and nephrology. Half these infections are due to staphylococcus: aureus or epidemidis. Nationally 60 % are due to MRSA, but at BLT the level is only 6%. Surgical wound infections increase the length of stay and thus the waiting list. They increase antibiotic use and therefore the risk of antibiotic resistance. Nationally the levels are 47% staphylococcus – 81% aureus and 61% MRSA. At BLT the rate is just 4% with MRSA but even this level is expensive as the antibiotic, Vancomycin, is 7 times more expensive and requires IV equipment for its administration and careful monitoring of blood levels as it is nephrotoxic. How is BLT winning with MRSA? The national guidelines vary from the broad to the specific. The Trust uses a 'seek and destroy' approach. Every patient who has had a hospital admission in the last 12 months is screened. This has shown 87% of all MRSA found in the Trust is present on admission, 8% in referrals from other hospitals, and 5% is acquired from other sources including cross-infection and poor practice. Compliance with the decontamination regime can be a problem:. The main issues are:
There have been instances of the nasal cream administration being sign-for but the tube left unopened. Nurses can prescribe the MRSA decontamination protocol and this has improved compliance. Environmental audit data is available for 11 years at Barts and 8 years at RLH and the London Chest. The findings: dirty wards and poor management of clinical waste were confirmed by the recent Patient Environmental Audit Team (PEAT) visit. A Nursing and Facilities Partnership Board has been set up to plan the action but the recommendations are the same:
Action to claw-back money from the contract cleaning company for poor performance may now have an effect. Clinical governance also provides a level for change. Future issues The future is likely to see an increase in:
There is also a need to expand and develop the current work of the Control of Infection Team, particularly in studies and notification. The context within which the Team work will also have an impact. The East End has the highest level of tuberculosis in Western Europe. There are problems of compliance with the drug therapy and with drug resistance. Already four patients have had to have surgery as no drugs would work. Deprivation scores for the East End are low and are known to be associated with the incidence of infection. The future may see the resurgence of other known diseases. New organisms may arise, such as HIV/AIDS. Nebulised anti-viral therapies have been developed for some diseases. A lot of effort has gone into triple or quadruple therapies for HIV but for how long the effects will be sustained is unclear. The incubation for new variant CJD is thought to be over 20 years so an epidemic is possible in the future. The possibility of germ warfare is also there. Paul suggested we may be moving to a post-antibiotic era. Trimethoprim was the last new antibiotic in 1968, since then it has just been variations on existing ones. Vancomycin resistant strains are increasing. This powerful antibiotic has been fed to cattle as a 'growth promoter' so increasing the chance of resistance from gut flora. Food supplies often now come international sources so the resistance problem will increase. Paul suggested there were many challenges ahead, but the Trust was prepared to meet them. Notes prepared by Denise Barnet, any errors are hers, not Pauls! Page last revised by DEB on 14/6/01 |
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