Infection Control - Rhetoric & Reality

I reproduce below the content of an email I sent a few days ago to the Coordinator for Infection Control for our local acute hospitals Foundation Trust. The message compares the Trust's infection control policy with recent personal experience after being told I had tested positive for MRSA.

The content is fairly self explanatory and relates some of my previous experience and interest in this area. The term nosocomial infection basically means the entire range of hospital acquired infections and while incorporating the headline problems of MRSA and C. Difficile, includes all avoidable infections contracted while in hospital. A large proportion of the community have MRSA colonisation in the nose and/or groin areas. It does no harm provided they are not immuno supressed and avoid transferring the bugs to an open wound. If it then becomes established in the blood stream it is called a bacteremia. It is the level of bacteremia's that hospitals monitor to demonstrate the progress they are making in hitting government targets to reduce MRSA.

I remain concerned at the gap between rhetoric and reality and wish to assist local management to avoid becoming complacent and overly self congratulatory.

I have changed names to "protect the guilty" - otherwise the email is unedited. By the way the doctor charged with responsibility for co-ordination of infection control policy is known as the DIPC which is pronounced by those in the know as "dipsy" - what a great example of a self deprecating acronym!

Dr B.......,

BACKGROUND:

We met on a couple of occasions in the past when I was one of the original Patient Governors of the Foundation Trust.

I expressed a particular interest in nosocomial monitoring arrangements and we discussed how such a system might be designed once test results could be obtained on a more regular basis from existing laboratory systems. I had experience of designing a graphical module of an Executive Information System for 2 hospitals in Saudi Arabia which provided both comparative and chronological reports and offered to assist if that would be useful. You were at the time preparing a proposal to the Trust Board for the establishment of teams of ward based co-ordinators.

Adequate control of hospital acquired infections was the first of 4 reasons I put forward in my election statement for wanting to be a Patient Governor. At the first meeting with the Chief Nurse, after being elected, I asked whether any system existed to regularly monitor nosocomial infection rates with a view to the early identification of potential hot spots. I was told, erroneously as it turned out, that a system , along the lines that I had described setting up in Saudi Arabia, was then in existence. I was content with this response and concentrated instead on other matters that I had identified in my election statement.

Soon after election as a Governor I developed post operative infection in my right thigh which required an operation to clean out and resulted in an exacerbation of renal impairment requiring 2 weeks on dialysis and about 4 months recuperation at home to have the strength to get out and about outside of the house. 4 years on and after significant tissue and bone loss due to infection a 2 stage hip revision has been carried out. I was discharged from ........ ............. ward 2 days ago on Tuesday 22nd July.

Prior to admission I had been swabbed for MRSA colonisation in nose and groin on several occasions and had always been pleased when the results were "negative" (I have used quotes to signify that I understand that a negative result only means an undetectable level of MRSA)

In accordance with current policy I was swabbed for MRSA on admission for the 2nd stage operation on 16th July and again on return to the ward from POSU on Friday 18th July. I was notified that I had tested positive on Saturday morning 19th July and would be moved to a side ward once one became available. The nursing staff had I think previously determined that I had some insight into the implications of this and were in any event busy with other things so I had no further information or guidance about what actions I might need to take.

I want now to describe as factually as possible my experiences and leave you to compare how far this accords with current guidance. I would then like to reflect on this and identify a number of areas where I think current practice needs to be reinforced by further training; where current information for patients needs to be reviewed to improve the likelihood of success in treating colonisations and finally to seek clarification on a number of matters that I remain unclear about.

I am doing because I wish contribute in a constructive manner to something I have been concerned about for 20 years and in no way desire what I have to say to be treated as a complaint. Unfortunately complaint handling is so defensive within the Trust that it only serves to frustrate and deny opportunities for organisational learning - and that is the last thing I wish to see.

I do hope that you understand the background to my contacting you and will wish to continue to read what I have to say and recognise that I do this in a spirit of continuing process improvement rather than of criticism.

SPECIFIC EXPERIENCE

(1) On Saturday morning 19th July I was told - in a whisper so that other patients could not hear - that I had MRSA in my nose - not that I had tested positive for colonisation only. From previous knowledge I knew I did not necessarily have a bacteremia and that what I had could be treated. I indicated to the nurse concerned that I understood this could be treated and was told that was so and told that I would be moved to a side room once one became available.

(2) Shortly after this the physiotherapist and assistant came to help me get out of bed and bear weight for the first time post operatively. The central and arterial lines had been removed the day before in POSU and I had only just had the catheter and epidural removed. As a result although a cannula was still in place in my arm it was no longer attached to any line. I asked the Physio if she had been notified of my changed infectious status to which she sought clarification. I said I had tested positive for MRSA colonisation in the nose. She confirmed she had not been told, thanked me and disappeared along with her colleague to acquire protective apron and gloves. A zimmer frame was borrowed from another patient, my progress monitored and while I was transferring to a relocated and higher than average bedside chair, the zimmer frame handle was wiped before the zimmer frame was returned to the patient from whom it had been borrowed.

(3) I was removed to a side room later in the afternoon on Saturday 19th July. I still had received no further guidance about what I could and could not do. I was provided with a plastic wallet containing some wet wipes and told these were for my sole use and not to be used by any other patient.

(4) On Sunday 20th July in the morning after the drug round a nurse left a carton containing the nasal ointment and a 500 ml container of Hibiscrub and said she would return shortly to help me to wash. I understood from her that I had to apply the ointment 3 times a day to each nostril - no cotton buds were provided so I assumed I had to use a little finger instead. When the time came for a wash a bowl placed in a plastic bag was filled with hot water and a capful of Hibiscrub was poured into the bowl. I was told that I had to wash my face and upper body and wash my hair with this. I used my own flannel but on her return the nurse provided me with some disposable paper flannels and asked me to wet one to "wash" my hair with. I understood from her I would need to repeat the hair wash on day 4 of the treatment. The nurse used a flannel to wash my back and when I had finished drying myself with my own towel emptied the bowl and left. Later that day I repeated the use of the nasal ointment a further 2 times.

(5) On Monday 21st July I had read the patient information that came with the nasal ointment and noted that I should ensure I used hand gel or similar to wash the nozzle of the ointment tube to avoid recolonisation. The Control Of Infection Co-ordinator for the ward unit called by in the morning to introduce herself and to leave a newly printed patient information leaflet. From discussion with her I understood that I should not use my own flannel, should have a change of underwear and nightwear each day again to avoid recolonisation and should have been provided with some cotton buds to apply the nasal ointment. Shortly after this a different nurse appeared with an uncovered but filled bowl of hot water for me to wash with. She also poured a capful of hibiscrub into the bowl. This time I used the disposable flannels provided. I continued to apply the nasal ointment throughout the day. I read the patient information leaflet and realised that I should have been provided with a clean towel each day. I noted that the ward staff did dispose of the bedding in a plastic bag each day in accordance with the guidance in the patient information leaflet.

(6) On Tuesday 22nd July morning a Health Care Assistant came to help me wash. She filled a bowl covered in a plastic bag with hot water and asked me I if I had my own soap and flannel . I assumed from this that she did not fully comprehend that I had to wash using the hibiscrub and disposable flannels. I suggested to her that I would need a clean towel which she was happy to provide. I was discharged home around 2:00 p.m. and understood that I should continue the treatment until today 24th July and wait for 3 clear nasal swabs before being declared "free" of colonisation by MRSA.

(7) On Wednesday 23rd July my first morning wash at home meant that I read the instructions more carefully and realised that the HIbiscrub should be applied neat and not diluted and should be left for about 4 minutes to dry before being rinsed off with a disposable flannel before drying off with a towel used the one time only. I also "washed" my hair with an undiluted quantity of hibiscrub. In the absence of cotton buds I continued to apply the nasal ointment by finger and to clean the nozzle with gel that I had brought back with me from the hospital.

(8) The difference in the feel of using neat hibiscrub over the heavily diluted form favoured by the nurses on the ward persuaded me that I should continue to use neat Hibscrub for a further 4 days at least.

REFLECTIONS AND OBSERVATIONS

(1) There did not appear to be any system in place on the ward to help visiting staff (such as physiotherapists) being updated about the infectious state of newly diagnosed patients with MRSA colonisation.

(2) Insufficient support is available at weekends to appropriately "counsel" patients who are told for the first time that they have MRSA colonisation. I am relatively well informed but could not help but think to myself does this mean I might lose my life , or a limb or is it being over cautious. I was unclear also what I could and could not do to assist in the process. I do understand that the newly printed patient information leaflets will help answer some of these questions in future.

(3) The patient information leaflet is clear and well presented. However in common with much hospital literature for patients while it is strong on WHAT to do or not do it is weak on WHY and HOW. I think there needs to be a brief explanation about the risk of recolonisation before describing how this is best achieved. I think some diagrams would be helpful in this as they would underline the need to avoid recolonisation by appropriate sequencing of actions.

(4) Having experienced what it feels like to use neat Hibiscrub compared to the massively diluted form I do think this needs to be clarified and may indicate a need for retraining of ward based staff. Although I have attended operations as an observer on occasions I have never before used neat hibiscrub. After using it in the manner suggested in the guidance the nearest I can come to describing what it is like is the application of factor 30 sun block. It is heavy and sticky. It shows up white for a while on application before being absorbed. On rinsing with a wet disposable flannel it suds up such that repeated rinsing is required to remove it before towelling dry. When used as a neat hair wash the hibiscrub thickens the hair and ideally requires a shower head to be rinsed out properly prior to drying. I noticed that as it is Hibiscrub is a 4% solution. I have not tried to work out the effective strength of the active ingredient when a capful of hibiscrub is poured into a bowl of water but it must be approaching homeopathic levels. Although I keep an open mind on homeopathy I am not a believer and would prefer not to have to rely on faith or placebo effects when it comes to the adequate control of infection.

(5) An adequate supply of cotton buds should be dispensed to patients to use with the nasal ointment OR patients provided with a bottle of hand gel to rinse the nozzle after each application. Whichever approach is adopted this should be clear from diagrams included in the patient information leaflet and in future staff training/ guidance.

(6) The need for a daily change of towel on the ward should be adhered to and not left to chance reading by individual patients.

(7) There is no doubt that in the last 4 years the culture on the wards towards control of infection has improved considerably. I was impressed by the use of plastic bags around wash bowls and of course the repeated applications of hand gel, use of aprons and disposable gloves - so well done on that score. Unfortunately for the Trust's senior management this a no-win situation because people like me are forced to question why was this not done before? In my mind - and I have shared this with David Flint (Trust Chairman), Andrew Pound (Chief Executive) and Monitor (The Foundation Trust Regulator) in the past - the reason is that local management are denied the time and space to concentrate on other than what they HAVE to do - as defined centrally by targets - and are not free to do what they SHOULD do - even if they had the inclination - i.e. to focus on what is important locally to the people they should be serving.

(8) There remains a vast gap between rhetoric and the reality when it comes to adherence to guidelines and protocols. I concluded, when with a colleague I undertook a planned but unannounced visit to test compliance with Better Standards for Better Health, that the Trust is well able to produce the paper evidence that it has policies in place for all that is required of it even when experience as patients and as Governors suggested otherwise. I believe that what I have outlined in relation to control of infection applies to a similar extent with most other aspects of the insurance policies for senior management that pass as Trust Guidelines for their staff.

(9) Unless this gap between rhetoric and reality is reduced there will remain considerable scope for complacency and inappropriate self congratulation. This worries me because MRSA and C Diff are I believe the tip of the nosocomial infection iceberg. We should be as concerned about monitoring overall levels as we are with the headline figures. l know I am preaching to the converted but do so hope that you will be able to have continued success evangelising this cause within our locals hospitals. My own post operative infection 4 years ago ( caused to my mind by wound drainage pooling on bed sheets not being attended to quickly enough while staff and visitors alike were able to come and go without any of the current precautions) will not have figured on the radar of senior management at the time. I do hope that this sort of underlying infection issue does now - although I very much doubt it. As I said I have no wish to raise my experiences as a complaint nor do I see any merit in communicating with the Trust's senior management direct - they have made it clear that they are unresponsive to any comment that might be construed as being in any way critical or embarrassing for them personally - however if you wish to draw any aspect of my experience and reflections to their attention to assist you in avoiding further complacency please feel free to quote and extract at will.

UNANSWERED QUESTIONS

I still have some unanswered questions that might well be of value addressing if only to produce clearer patient information in future.

(1) When is the best if any time to shave during the 5 day treatment course. Bearing in mind that both safety and electric razors pass very near to the nose should shaving be done before using neat hibiscrub or after?. Should the razor be disposed of or if an electric razor is used should it be cleaned with hand gel / hibiscrub after use?

(2) If swabbing is done to detect MRSA colonisation on arrival on a ward and a positive result only happens if the level is detectable , given that there is a 48 hour deley before reporting results why is a swab not taken on discharge and a patient's GP advised if the result is positive?

(3) What evidence exists for the level of dilution of hibiscrub before its use becomes symbolic rather than effective?

(4) Why are the precautions, that I saw in place once someone is diagnosed as having MRSA colonisation, not applied to all patients at all times - after all a proportion may well have high but as yet undetectable levels and this gives the appearance of a approach to the control of infection that best resembles russian roulette.


I do hope you will feel able to acknowledge receipt of this email even if you are unable to answer specific points. If you follow up on any of the reflections and observations I would be delighted. If you wish to use my personal experience as evidence to support further resources and help avoid complacency on the part of senior management you would very much have my blessing - although I acknowledge how difficult this would be for you.

I continue to wish you good luck in your efforts to coordinate the control of hospital acquired infections.

My desire is that adequte control of hospital acquired infections should in future rely on good sense rather than good fortune.

Regards