Healthcare Commission Report Highlights Substantial Progress On Infection Control At Stoke Mandeville Hospital, UK

Main Category: MRSA / Drug Resistance
Also Included In: Infectious Diseases / Bacteria / Viruses
Article Date: 19 Nov 2007 - 4:00 PDT

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The Healthcare Commission has found that staff at Stoke Mandeville Hospital have made substantial progress to prevent and manage healthcare-associated infections.

A year after an official investigation detailed serious failings at Buckinghamshire Hospitals NHS Trust, inspectors say that infection control is now a top priority and that the trust meets all 11 requirements of the Hygiene Code.

The follow-up report shows that significant changes have been made in working practices and that systems have been put in place to help protect patients, the public, and staff. These systems now need time to be fully implemented.

But there is still a need to make further progress in a number of areas including basic hand hygiene by some doctors, staffing levels, and some aspects of clinical management of patients with Clostridium difficile.

Following this latest report, the South Central Strategic Health Authority will continue to monitor the trust against the original recommendations, and the Healthcare Commission will meet with the trust in nine months time to ensure these have been completed.

Latest data published by the Health Protection Agency for Buckinghamshire Hospitals NHS Trust have shown that the C.difficile infection rate for the period January to December 2006 among patients aged 65 or over was 1.42 per 1000 bed days compared to the national rate of 2.38.

The original investigation by the Healthcare Commission followed two serious outbreaks of C.difficile at Stoke Mandeville Hospital between October 2003 and June 2005 in which 334 patients contracted the infection and at least 33 people died.

The subsequent report highlighted serious failings by senior managers who failed to follow advice on stopping the spread of infection from infection control staff, clinicians, nurses and the Health Protection Agency.

The investigation concluded that they had not implemented lessons from the first outbreak of the infection in 2003/2004. They mistakenly prioritised other objectives such as the achievement of government targets, the control of finances and the reconfiguration of services. Investigators found many factors that contributed to the outbreak at the trust, including poor layout of older wards, inadequate cleaning, a lack of hand washing facilities, and a lack of training in infection control.

As part of the follow-up to review progress at the trust, the Healthcare Commission made an unannounced visit to the Stoke Mandeville Hospital in May, checking nine wards. Over a further three days inspectors interviewed 30 members of staff at Stoke Mandeville and Wycombe Hospitals, including senior executives, infection control staff and clinicians at all levels of the organisation.

The Healthcare Commission team found that cleanliness of the wards had improved markedly, that training in infection control had being implemented for a majority of staff, and that the board and senior management were able to demonstrate that they take patient safety and the management of risk seriously.

Ian Biggs, head of the Healthcare Commission in the South West says the staff should be congratulated on their response to the report, and patients should be reassured.

"Our most important finding is that Stoke Mandeville Hospital is now a much safer place. I am glad to see that patient safety is now being given key priority.

"But the job isn't finished yet. We know that infection control is a very complex matter which can't be sorted out overnight. Buckinghamshire Hospitals NHS Trust has come a long way in a relatively short space of time and they recognise that there is still work to do.

"While we are satisfied that the trust has worked hard to address the main issues, we will be watching to ensure that our recommendations are fully addressed."

The latest report outlines progress made against the key recommendations in a number of areas:

Cleanliness: During the original investigation, patients and relatives had told the Commission about poor hygiene, including dirty wards, toilet areas and commodes.

- In 2007, the overall standard of cleanliness throughout the trust has improved markedly.
There was a positive approach to cleaning, and nursing and domestic staff were clear about their respective roles and responsibilities although audit results showed that there remain a few areas where cleanliness could improve further.

Ward layout: The primary factor that contributed to the outbreak of C.difficile was the failure to isolate infected patients. The nature of the hospital made control of the infection extremely difficult. There were few single rooms that could be used to isolate patients with infections.

- Since the investigation, a large proportion of the older wards at Stoke Mandeville which had been at the end of their functional life have been replaced and the new wards were found to be clean and well maintained. There are two older wards that remain, as well as the National Spinal Injuries Centre (NSIC) which still requires upgrading, and the trust needs to improve the provision of single sex accommodation across its hospitals.

Bed management: The movement of patients from ward to ward was a contributory factor. The investigation recommended that the criteria for transfer between wards should be reviewed to ensure that clinical advice was taken and to ensure that acutely ill patients were not placed on inappropriate wards without adequate support.

- Following the report, a new bed management policy was introduced within 60 days. Staff interviewed at all levels said that bed management has improved and they had moved away from crisis management. While there were fewer patients moved unnecessarily, and while the number of patients who were placed on inappropriate wards had also fallen, some major issues remain. In the first three months of the year, the hospital identified a large number of problem incidents involving transfers, admission or discharge of patients. The trust has acknowledged that inappropriate transfers can tend to go under-reported and the report says the trust should seek further improvements, including that clinicians are more closely involved in decisions to move patients.

Waste management: The investigation report listed issues with waste management including overflowing waste bins, hazardous waste left on wards and the entrance to utility rooms blocked by linen and waste bags.
- The latest report found that these issues, on the whole, are no longer evident. Staff commented that the portering services have improved significantly and that there is rarely a build-up of rubbish and waste.

Infection control: The original report called on the trust to improve infection control by making it part of the daily routine of all clinical staff, with added responsibilities written into the job descriptions of all relevant managers, not just the infection control team.

- The latest report says it is clear that the trust has made substantial progress in this area. Infection control has been given high priority by the trust and staff at all levels consider it in their daily practice. The trust has a large infection control team and a new Director of Infection Prevention and Control. The trust has clearly placed emphasis on hand hygiene, and inspectors noted that most staff followed good hand hygiene practices.

The exception to this was some doctors who showed a lack of awareness of infection control issues. Inspectors noticed medical staff on a number of occasions moving between wards and between patients without washing their hands, an observation echoed by the trust's own audit. The report notes: "The trust stated that they have taken these results very seriously. A letter has been sent to all doctors to highlight the results of the hand hygiene audit. The trust also stated that disciplinary action will (and has) been taken for staff who do not comply with the policy."

Standards of care: The original investigation found that in the clinical management of patients with C.difficile, greater attention must be given to ensuring that patients with diarrhoea do not become dehydrated and that better records should be kept of their intake and loss of fluid.

- While the trust has introduced new guidelines on patient care and records, the latest inspection shows continued poor practice in some areas. The trust's own audit found that in a significant proportion of cases, patients notes were not being properly completed. The report says that the trust must ensure improvements in record-keeping, particularly by senior medical staff. Overall, further work is required to meet this recommendation.

Staffing: Last year's investigation concluded that a shortage of nurses contributed to the spread of infection. Staff on the wards told investigators that they were too rushed to answer call bells or change soiled sheets. They did not take basic precautions such as washing their hands, using aprons and gloves consistently or even properly cleaning mattresses and equipment.

- Nurse staffing levels have remained a key challenge for the trust. The trust commissioned an independent nurse advisor to carry out a review of the staff levels in some clinical areas.

- The trust reports that the staff mix had changed from a 40:60 trained-to-untrained ratio to a 60:40 ratio, freeing up the senior staff to concentrate on risk assessments, audits, supervision and ward rounds. But the Healthcare Commission's own analysis of skill mix on a selection of wards does not support this. Current staffing levels reveal that wards are staffed with a high number of lower grade nursing staff and that the nursing skill mix on some wards is below national requirements.

- Staff interviewed at all levels of the organisation commented that while staffing levels had improved, there was still some way to go.

Training: The original report recommended that training in the control and prevention of infection should be mandatory for clinical staff.
Overall, the trust has made substantial progress in this area with a high proportion of staff attending the relevant training.

Progress made since July 2006 investigation report (pdf 176kb)

More information about Buckinghamshire Hospitals NHS Trust

Notes:

The Healthcare Commission carried out the investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital, part of Buckinghamshire Hospitals NHS Trust, from September 2005 to April 2006. The investigation was undertaken at the request of the Secretary of State for Health.

The Government's Hygiene Code, which came into force in October 2006, outlines 11 compulsory duties to prevent and manage healthcare-associated infections such as MRSA and Clostridium difficile. The code explains how organisations should work to ensure that patients are cared for in a clean and safe environment. It outlines trusts' duties to establish appropriate systems, assess and manage risks, implement clinical care protocols, ensure healthcare workers' access to occupational health services and provide induction and training.

About the Healthcare Commission

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

http://www.healthcarecommission.org.uk

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