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 towards resistance.

Infection control in hospitals

  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"[45]; looking ahead, that Report said, "Antibiotic-resistant bacteria will almost certainly be an increasing problem [for hospital infection control] in the future".

Infection control teams

  4.3     According to the Cooke Report (ch. 2), every acute hospital should have an infection control team.[46] 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 Committee.

  4.4     A recognised qualification for infection control doctors has been established (DipHIC). As for nurses, the Infection Control Nurses Association (ICNA)[47] 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,[48] 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).

Contracting for infection control

  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 provisions—though 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).

Hygiene

  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).[49] 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).

Isolation

  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).[50] Where single rooms exist, they are sometimes carpeted—which 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).

Overcrowding and "hot-bedding"

  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[51], 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" (QQ 772-5).

Agency staff

  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).

Screening

  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.[52] Screening takes time and costs money[53]; 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).

Training

  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:

—  induction courses 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).

Infection control 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 control nurses".

  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 treatment

  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).

Surveillance

  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[54] 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.

Infection control in prisons

  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"[55]; 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[56]; 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.

A national MRSA strategy?

  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[57], and the United Kingdom had "excellent clinical guidelines"[58] 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.

46   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

47   The points made by the ICNA in relation to MRSA are supported by the evidence of the Royal College of Nursing (p 451). Back

48   250 is the maximum permitted by the US Joint Committee for Accreditation of Healthcare Organisations, which accredits hospitals to the satisfaction of insurers. Back

49   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

50   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

51   For example, at King's College Hospital, an 18-bed liver transplant ward saw 51 changes of bed occupant in four days. Back

52   Cp van Saene et al, p 559. Back

53   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

54   Hospital-acquired. Back

55   Cp Greenwood p 410. Back

56   A survey by the Hospital Infection Society in 1994 found 9 per cent prevalence (p 421). Back

57   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

58   Currently being revised. Back