Coming clean on infection control

The Healthcare Commission last week published an analysis of its latest round of unannounced inspections on infection control procedures.

It revealed that only five of the trusts inspected – equivalent to 10% – were fully compliant with the government’s hygiene code, more than two years after it was brought into effect.

The hygiene code – The Health Act 2006: code of practice for the prevention and control of healthcare associated infection
– sets out 11 duties or standards that all NHS bodies must follow.

During each spot check, inspectors look at how a trust is doing against at least three of the duties, focusing mostly
on standards of management systems, cleanliness and decontamination and isolation facilities (see Box 1).

This year inspectors visited 51 acute trusts, comprising around 30% of such organisations in England, to provide a snapshot of how the NHS is progressing in infection control.

Perhaps unsurprisingly, that so many trusts had failed to meet all the standards attracted damning headlines in the national media. But this was a long way from the title of the Health Commission’s own press release, which read ‘Watchdog praises NHS progress on infection control’.

It said the overall picture was encouraging, with findings showing that only three trusts had committed serious breaches of the code that required the commission to issue them with improvement notices (see Box 2). The majority of other breaches ‘did not represent an immediate risk to the safety of patients’, the commission said.

The least well-observed standards related to cleanliness and the environment – 27 trusts were non-compliant through ‘failing to keep all areas of their premises clean and well maintained’. The inspectors found some areas were dusty, suggesting cleaning was not frequent or thorough enough, and other areas were cluttered, making cleaning difficult.

A further 31 trusts did not fully comply on cleanliness because they failed to publicly display cleaning rotas – overall, this
was the most common duty to be breached.

There was a strong correlation between these two failings, said the commission. Within the group that did not display rotas, two-thirds also did not have consistently suitable, clean and well-maintained premises.

However, such breaches do not necessarily affect patient care. ‘If you fail to do that, you are in breach of the hygiene code – but I don’t consider that to be a great risk to the public, although it is a really good thing to do,’ said Martin Kiernan, president of the Infection Prevention Society.

More serious perhaps was a continued failure of some trusts to comply with standards about handwashing and antibacterial handrubs – 11 out of 51 trusts did not comply. The same number of trusts were not compliant over decontamination of instruments and other equipment. Performance was stronger in relation to isolation facilities, with 42 trusts out of 48 meeting standards.

Anna Walker, the commission’s chief executive, said: ‘At nearly all trusts, we have found gaps that need closing. It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs that there may be a weakness in their systems.’

She added: ‘Where we have raised concerns, we have generally been encouraged by the positive and prompt response at those trusts.

‘Importantly, we have found few breaches requiring immediate action to protect the safety of patients and, where we have,
we have taken swift action.’

However, it could be argued that in some situations the commission acted too swiftly. For example, Ipswich Hospital NHS Trust in Suffolk was served with a notice because inspectors asked for the immediate removal of four desktop decontamination units used to sterilise surgical equipment. The trust had asked if it could keep two working for a couple of days to prevent operations being cancelled but was still served the notice.

The trust said it was confident that patients would not be put at risk and decided to put its needs first. The notice was withdrawn two weeks later once the trust had removed the units.

Ashford and St Peter’s Hospitals NHS Trust in Surrey was also served with an improvement notice, for a mattress decontamination facility. Dirty pressure mattresses were stored in the same room as clean ones, although the trust said they were not used for patients known to have healthcare-associated infections. The commission issued a notice in June and the breach was resolved within a month.

Linda Fairhead, consultant nurse for infection control at the trust, said the publicity attached to the improvement notice initially worried her.

‘I felt concerned because patients might have read the reports and thought it was every mattress in the trust, not just pressure mattresses. However patients have not been negative in their feedback,’ she told NT.

She added: ‘We have definitely moved on in the last year, which is why it is difficult when you get an improvement notice.’

The hygiene code appears to have produced some success stories, and MRSA rates are falling nationally.

One of the most notable successes is Kingston Hospitals NHS Trust in south-west London, which was rated third worst in the country for infection control when the commission began its ratings. Now it is one of the five trusts to have fully complied with all aspects of the hygiene code.

Helen Dirilen, the trust’s director of nursing and quality, and director of infection prevention and control, said the commission’s intervention had led to a culture change at the organisation which had caused a dramatic decrease in HCAI rates.

‘We have had real board-to-ward engagement, and it was seen as a top priority for the trust,’ she said. ‘Mainly through the hard work of nurses, we have turned it around.’

She added: ‘We have invested £1.4m in the last year in ward upgrades. We have also managed to get money from the London region to get equipment such as single-use commodes.’

Other initiatives included regular assessments of cannulas and having wards assess their own performance on infection control.

As a result, during the past six months, there has been just one MRSA bacteraemia, which was acquired outside the hospital, Ms Dirilen said. Yearly figures reported to the Health Protection Agency show the number of MRSA infections at the trust fell from 57 in 2005–2006 to 23 in 2007–2008.

Clostridium difficile cases have also dropped slightly – from 363 in 2005 to 333 in 2007 – but the trust is confident of greater progress this year. Between January and September, the trust reported 115 cases, compared with 312 over the same period in 2007.

Ms Dirilen said: ‘[The commission] certainly helped focus the attention. It has increased the amount of time we have had for infection control.’

Most nurses involved agree that the work must continue across the NHS, even though standards in hospitals are continuing to improve.

Any trust that does become complacent could fall foul of stricter regulations that come into force in April next year, when they will need to register with the Care Quality Commission which takes over the Healthcare Commission’s role.

Trusts risk receiving fines and having their registration suspended if they breach elements of the hygiene code.

For example, under proposals – outlined in a consultation on the Care Quality Commission’s enforcement policy, which is to close in January – a trust may

be issued with a fixed penalty notice if an inspection reveals that ‘a number of clinical areas are unclean’. Additionally, a
trust may have its registration suspended in the event of a large-scale outbreak of an infectious disease.

‘The challenge for trusts is to ensure they drive further sustained improvements by getting the right systems in place all of the time,’ said Ms Walker. ‘We make no apologies for demanding high standards.’

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