Return of the One Hip Wonder!

After the encouraging progress since the 2nd stage operation I have suffered a set back and now once again no longer have a functioning hip joint!

By way of background here is an email I sent to the orthopaedic surgeon's secretary which explains all except what had had happened at the time. Read on to discover how I found out that the hip had dislocated (2 weeks ago!)  and how this might yet be sorted out.

Kathryn,

You very kindly helped me contact Mr yyyyyy in the past during the run up to my recent 2 stage hip revision this year following on going post operative sepsis, for which I am most grateful.

I hope that you will be able to bring the following account to Mr yyyyy's attention and let me know if he thinks I should see him in a clinic before my next appointment which is scheduled for 24th October at 9:15 a.m.

On the evening of 11th September while sitting down I experienced a sensation about half way up the outside of my right thigh which was akin to a spasm or twitch. On standing my balance seemed to be affected. I thought nothing more of it at the time but over subsequent days became increasingly aware that things seemed different from before.

I am convinced now that I have a leg leg differential (LLD) of about minus 2 cms in my right leg. I am using an improvised heel raise inside my right shoe to compensate. If I walk bare foot I need to raise my right heel and and walk on the ball of my right foot. If I place my right foot flat on the floor I dip in height and my left knee bends to accommodate the difference in height.

(On Monday 15th September I collected 5 left shoes which have had the previous raised soles removed. If I was still using the previously raised shoes the difference would be even more pronounced.)

Prior to the "twang" that occurred on Thursday 11th Sept I was walking with my right foot pointed out by about 30 degrees. I notice now that my right foot points to the front.

It appears to me that something has changed and I do not think that I am imagining the difference. I am in no pain other than that associated with the gradual return of sensation along and around the incision line from the last operation. Although reducing there is still some swelling above the back of my right knee which I am able to massage to remove the feeling of hardness which gravity alone seems to create.

I am due to see Dr Kkkkkk, Rheumatologist at Hallamshire on Wednesday 24th September at 10:30 and will share with her my current concerns. I wonder if it would be appropriate in the circumstances to request an X-ray of my right hip to allow comparison with the most recent one, in advance of my next appointment with you in about 4 weeks time. Alternatively would you want me to see you sooner than planned, if that can be arranged?

Having had experience of LLD before I am not concerned about the fact of it and know that if necessary I can manage with raised soles in my right shoes but I do wonder if the fact of a sudden difference is attributable to a tightening up of ligaments and / or muscle ( which might explain the change in angle that my right foot now points) or if it is caused by some movement in or around the prosthesis which might warrant a more conservative approach to rest and weight bearing?

I hope you do not mind me raising this with you. I am happy to wait until my next appointment with you but want to avoid exacerbating any possible cause in the interim if that can or should be avoided.

Thank you.

Regards

Although the note was printed out,  the pressure of work meant the surgeon had not got around to looking at it before my out patient appointment with the Rheumatologist. 

So yesterday morning I caught a bus to the local hospital and arrived in time for my 10:30 appointment at which I shared the above email with the Rheumatologist along with copies of the 2 recent X-rays (which you can see in an earlier posting) and she agreed that a new X-ray was called for. She indicated that an X-Ray review meeting would be held later in the week and she would let me know what it showed. A follow up appointment was made for 4 months and I was given the X-Ray request form, after which I could return home.

I was seen by the radiographer inside 5 minutes and the first clue that I had as to what was going on was when, after the initial X-ray of both hips, 2 more were taken of the head of femur and acetabulum of my right hip. Conspiratorial whispers between the 2 radiographers aroused my fears that the hip joint had dislocated. When they said they were arranging for a wheel chair, to take me to see the doctor again, it was pretty clear what had happened. They could not confirm that the hip had dislocated as this was "best left to the doctor to explain".

5 minutes later I was staring at a very clear picture which showed the round head of femur isolated from and outside of the cup. It had popped out and up. To my eye it was about one and a half inches above the centre line of the socket and about an inch to the outside. (no wonder my balance was affected!) 

In a way it was nice to know and to understand the cause of what I had been experiencing but also a surprise - as I had always imagined dislocation would have been associated with a sudden movement, possibly some noise but most definitely a  lot of pain. Needless to say the image was also quite a blow as I imagined that some degree of surgery would be needed to put this right.

The rheumatologist spoke to the orthopaedic surgeon from another room as her phone was not working so I had to rely on her report of the discussion. The surgeon had said I was to go to a ward at his hospital and they would "pop it back". It sounded like this would be a manipulation and not require surgery at all. The rheumatologist could not confirm this but did agree it was possible.

A taxi was booked to take me home to prepare to get into the other hospital. I had taken a bus to the rheumatology clinic but they were reluctant for me to return home by bus with a dislocated hip - not surprising I suppose. A taxi was arranged. I rang a neighbour who agreed to take me in, I gathered overnight stuff together in an bag and decided not to have any food or drink in case a general anaesthetic would be required. I then rang my wife to leave a message but as it happened she was just finishing a morning clinic and was due to do admin in the afternoon so instead she caught a bus home and I told the neighbour his help would not be required - this time.

When we arrived on the ward suggested by the surgeon we waited about 45 minutes for a bed and eventually a nurse arrived to say that she had tried to contact me by phone so had left a message to say to go to a different ward. She escorted me to that ward and as I was being directed to a bed in one of the bays I mentioned that I had previously tested positive for MRSA colonisation but had the required 2 clear swabs yet understood I should let them know nonetheless. They checked the notes and found that their records only showed the positive test on arrival for the 2nd stage operation, a couple of months before, and they had no knowledge of the clear swabs.  I was told that I would have to wait for a side room to become available. When one did I was just settled in when I was told that I would need to move back to a 6 bed bay as the room was now required for a trauma patient being transferred from another district.

A couple of hours later the surgeon and some of his team appeared and we discussed the plan to manipulate the joint back into place under anaesthetic first thing on the next morning's operating list. We discussed what would happen if this did not succeed and I was pleased to hear that it did not require major reconstruction and in particular that the acetabulum cup would not be touched at all - so weight bearing should not be an issue. A nurse had indicated that the normal practice is to relocate the joint under anaesthetic and then to try to dislocate it again! That way the doctors understand how it could have occurred and can either take some remedial action later or advise on positions and movements to avoid.

The surgeon explained that if manipulation did not work and they felt that popping the existing head of femur back in place would not be sufficient to stop it dislocating again they could always unscrew the current head of femur and screw in place a slightly larger one which of course should be more resistant to popping out. I expect that there must be some trade off between size of ball and weight or degree of movement that is possible but will explore that later if and when I have some direct experience.

Prior to travelling from home to the hospital I "googled" the words dislocation, hip and revision and found an article published in 2002  by the Mayo clinic where over 1200 of their patients, who had revisions, were followed up after dislocation. About 7% dislocated of which 12 had surgery straight away (of these about half remained stable after 2 years and half had become unstable). The remainder of the 112 or so who had dislocated were initially treated by manipulation and of these a percentage later required surgery some later required further manipulation to redress a subsequent dislocation. The summary of the article mentioned that in 2002 not enough was known about the reasons for dislocation other than the generalisation that patients with revisions had more scarring and greater stretching of ligaments etc and that as these settled down after surgery the movement of the soft tissue could cause the joint to dislocate.

In our discussion with the surgeon he confirmed that in my case it was probably scar tissue breaking down that may have caused the movement. I wanted to know for future reference if I could have done anything to avoid it happening or could watch for certain signs that it might happen again in the future and he confirmed I had probably not done anything to bring this about. In a way this was comforting as I would hate to think I had been at all reckless.

As it happens my wife, the surgeon and I were all thinking it was unlikely that manipulation 2 weeks after the event would work and if it did the joint would probably pop straight out again - but this was left unsaid at the time although as you will hear our unspoken doubts were in fact confirmed.

I was visited by the friendly anaesthetist who had been present at the first and second stage operations and he confirmed that I would escape need for the tubes and lines that had been necessary before - as this was to be a closed procedure. It will not be many patients, I suspect who can claim that an anaesthetist has provided by far the greater degree of "continuity of care" but we greeted each other like long lost friends!

Shortly after this I was moved to a side ward again. One nurse holding the case notes had clarified that I had previously tested positive for MRSA colonisation and said it was her "eagle eyed" companion who had "spotted" this. I remember seeing a red sticker on the front of the case notes with the word "infection record" on it and had assumed this is how the fact would be drawn to the attention of staff. I was however surprised that someone could be congratulated for spotting this.

I have previously commented on the NHS being like a relay team with the best individuals but little training in handing over the baton. Well here are 2 examples. The fact that I was cleared of any colonisation was not reported back to the people who had initiated treatment so they had to assume I was not clear "because their records did not show this and they could not take my word for it" - fair enough. But, to add insult to injury, the mechanism for drawing attention to the fact someone posed an increased risk was not sufficiently clear for it to register without someone being congratulated for spotting it!

I am not going to raise this with the infection control coordinators as they seem to have enough to be getting on with after my last reflections on the difference between rhetoric and reality of infection control but at some stage in the future I will try to take this issue forward.

Being admitted as an emergency I had to wait till 12:40 the next morning for the junior doctor to see me and take a history including signing me up for medication. I had written this down for the rheumatologist so had that note with me which I handed over to the junior doctor along with recent blood test results. This saved a lot of time so I was able to get off to sleep about 1:00 a.m.

However I must admit it took a little while to get off to sleep as I  reflected on what I had  observed with a 100 year old lady in a bed opposite me while I was in the 6 bed bay. 

She needed hip surgery (probably following a fall and a fracture) . She had been seen in the morning and seemed fit enough for surgery but later in the day she was developing fluid on her lungs. She was receiving oxygen through a mask and had apparently been catheterised. In addition she had a cannula in one arm, connected to a line (probably saline) but through which she could have injections administered. She was obviously confused and distressed. She called out for nursing staff who, as is often the case were busy passing through on one round or another and could not easily stop to provide the comforting words ( and touch)  that she needed. My wife at one time spent some time with her and afterwards I and a fellow male opposite her would try to call for a nurse or try from our beds to calm her down. When nothing happened she would look from one of us to the other silently mouthing words we could not hear and stretching her arms out as it pleading with us to do something to help her.

I overheard a discussion between 2 doctors after one failed to get her consent to have another cannula fitted prior to contrast medium being injected before going for a scan. They had ascertained that she knew where she was and why she was in and therefore she was fit to give consent which she was withholding so they had to respect her wishes.

For the best part of an hour  she continued calling out saying in a most plaintiff manner "please help me" and looking around for anyone to respond. She became increasingly desperate and tried pulling lines out and rolling back the bed covers which seemed to be uncomfortable. What really got to me was that she must have lost touch with where she was and why she was there because she resorted to saying "please help me - I'll tell you anything you want to know just help me - I'll give you names and addresses if you want , yes I can give you names and addresses!" I'm sure she must have thought she was being tortured!

She was calmed down when a senior nurse spent a few minutes with her talking calmly and stroking her hair but a few minutes later deprived of this degree of human comfort she was again distressed. Her escalating anxiety was only suppressed after she had a shot of morphine administered through the cannula in her arm. It was interesting in a way to her gradually quieten down and then fall asleep. She lay asleep and at peace but in what looked like a very uncomfortable position. She was in this condition when 2 visitors arrived and were informed of her "progress" they were told she had refused the further cannula and in answer to a question was told it probably would not affect the operation to fix her hip which would probably proceed.

I have no way of knowing what will happen to this lady but cannot help thinking that the chances of her having a successful outcome and walking again free of pain are very slim. She is now bed bound and not exercising, her lungs are filling with fluid, because she is not having a scan the doctors might not be able to ascertain the extent of the problem so she will remain at risk under anaesthetic. 

The experience confirmed me in my desire not to have my life end like that - if I can avoid it. Not that I expect to be around till I'm 100! Three score and ten remains a very optimistic score for me but I am convinced that the discussion of NHS priorities needs to move beyond the emotional "saving of lives" and be replaced with "deaths deferred". Perhaps once that happens less  attention will be given to the length of life and more to the quality of one's death. The World Health Organisation's mantra of "adding life to years as well as years to life" and the trade off between "cure and care" sum up this need for a more mature discussion of what the NHS is and should be about.

Returning now to the procedure itself. I was wheeled to theatre reception area around 8:40 a.m. I was transferred to a trolley and wheeled into the anaesthetic room about 9:00. I had a single cannula inserted into the back of my right hand through which I was injected with a sedative. I remember the senior registrar introduce himself again and ask for muscle relaxant ( The surgeon was in London and I knew the Senior Registrar would be in charge but that he could call on the asssitance of another consultant if necessary). I guess a little while later the sedation kicked in or was augmented so I was unaware of what happened until recovering outside of theatre. The friendly anaesthetist informed me that it had not been successful and I then overheard a discussion between him and the senior registrar to the effect that I would be on the list next week for "surgical reduction".

I was back on the ward by 10:30, had been in theatre about 40 minutes (it was thought I would only be there for about 15 minutes) and by 11:30 was ready for food and drink which duly arrived at lunch time.

I was discharged at 4:30 p.m after speaking to the senior registrar who confirmed that it was not successful and that I would be asked to come in next week for an open procedure. My wife and I fired many questions at the guy who was confident that next week he would only need to make a small incision and would pop the joint back in and as a result I would not need tubes and lines, should be able to weight bear straight away as they would not reconstruct the socket at all and I  would probably be discharged home after a few days.  If necessary he would fit a larger ball to the end of the femur but that would not require any further cutting of tissue.

He confirmed also that the manipulation relies on brute strenght and that he and 3 others tried, including the consultant from an adjacent theatre and despite being drenched in sweat they could not relocate the joint. When he phoned his boss in London and told him the news his response was " I didnot think it would" - so we all thought the same but didnot say it - it was worth a try but the best chance of success is straight after dislocation while tendons etc are still loose - not 2 weeks later and after driving 300 miles from Cornwall, followed by climbing stairs, driving around town, getting on and off buses and ( no small feat in itself) walking from the hospital bus stop to the rheumatology department (up a steep hill and some distance away)

I have one more observation to make to round off this tale of woe. On the way out of the hospital , getting into a lift,  I passed a gentleman also using 2 elbow crutches but with a metal cage running on the outside of his right leg. In the lift we compared notes and he said that he has already had 5 operations since May this year. He originally came in for a minor operation on his knee (probably keyhole removal of debris from a cartilege - or similar exploratory examination) but his knee became infected so he has had repeat visits to theatre to clean it out and repair the damage to his knee. He explained that he cannot bend his knee now without using spanners to adjust nuts on the bars that are screwed into his leg in at least 8 places. I noticed a spring running on the outside of his knee which probably keeps the required tension while he gradually "undoes" his knee to bend it when sitting down. 

Despite my own problems 2 things help me retain both a sense of proportion and optimism (most of the time) - the first is "this too will pass" (a much more succint expression of Kipling's If you can treat those imposters of success and failure as the same) and "however bad you might think things are - there's always someone worse off than you". I guess I did not expect the second of these to be so well demonstrated getting into a lift on my way back home while I wait for "only" my 4th operation of the year! 

As a result of this latest chapter in the saga, I can retrace my steps (or should that be hops) and  once again am able to live down to the claim of being a "one hip wonder".

Infection Control Reflections - An encouraging response

Some time ago I received the following encouraging response to my reflections on infection control practice in my local acute hospital:

Dear Mr xxxxxx

Following our previous e-mails I have some information to share with you.

I have had some dicsussions with the Lead Infection Control Nurse Specialist and we are looking into various ways we can improve the consistency of delivery of the topical treatments for MRSA. We feel that a multi-pronged approach is likely to be most effective and the ideas listed below are just for starters.

Topical treatment issues

• We are looking into producing posters for applying treatment which would include pictures along with relevant brief text. These could be presented to wards as posters for display but could also be produced as an information leaflet for patients that accompanies the topical treatments to the ward. We will discuss with Pharmacy re putting these posters/leafets in with the topical treatments which could help overcome the lack of information you experienced over the weekend and form part of the overall process improvement.
• We are investigating the possibility of a topical treatment pack which would include antiseptics, cotton buds, alcohol gel, wipes, information etc but we'd need to find out how we could make this work.
• We are looking into doing a series of roadshows to educate/re-educate staff on how topical treatments should be applied etc. We might borrow a resusci-Annie type model rather than use real flesh - unless we get volunteers!

Information
We are looking into the general MRSA information leaflet with a view to reworking it. One problem we have is that information leaflets have to be pitched at a certain level ( I think it is a reading age of 11) and if we add too much information we are asked to remove it as it is deemed to be too complicated. However, this is of course difficult given that this means that leaflets are often too bland etc for many people. We will see if we are allowed to produce a range of leaflets but there are all sorts of regulations etc that may prevent this.

Unanswered Questions
1) Our advice re shaving is to use disposable razors for the course of treatment, ideally using the Hibiscrub as the shaving foam. Any personal electric razor should also be thoroughly cleaned prior to re-use in case it's become contaminated.

2) The timing of MRSA screening is continually being reviewed and in fact we generally have a result on which we act within 18-24 hours. The Trust laboratories will shortly be processing and resulting MRSA screens seven days a week (currently 6 days a week) so any weekend delays should be a thing of the past. The issue of discharge screening is one on which there is no national agreement. One problem is that GPs have a variable response to being told a patient has MRSA. Many feel that they do not know what to do and therefore do not want to be repsonsible for informing patients of the results or for any follow up and mangement (I must stress some GPs are great but not all). We have addressed this issue with the PCT and we are currently appointing a PCT microbiologist and one of their roles will be to look into how to manage MRSA in the community and the education etc of community staff.

3) There is no correct dilution for Hibiscrub; it should be applied neat as you discovered.
4) We make widespread use of Infection Control policies and procedures in Sheffield Teaching Hospitals. For example, promotion of hand washing and audit of hand hygiene standards is a key feature of our Infection Control Accreditation Programme. Gloves and aprons are intended for routine use with non-infected patients when having contact with blood or body fluids such as dealing with commodes/bedpans, cleaning incontinent patients etc. Each of these is consistent with the approach of standard precautions, i.e. a set of precautions that should be applied at all times, with all patients, covering hand hygiene, use of protective equipment, disposal of waste, handling of laundry, dealing with blood spillage and covering of cuts/lesions. These are reflected in STH Infection Control Guidelines.

We agree that there is a tension between 'have to do' and 'should do' (point 7 of your reflections) but these targets have actually proved quite helpful to us in IPC to focus minds and resources. There are such a large number of issues which need to be addressed overall and there was a need to refine these to key ones at least to start with. Once these have been addressed other issues can be addressed over time. Please do not think that we will stop our efforts once the headline grabbing issues have been addressed, we have a long list of things we plan to do eventually. As you say these may vary locally but many effect the majority of areas. Also even when we do address something over time people forget etc and things need to be re-iterated time and again. As a Team we do try and help indivudal areas to address issues that are pertinent to them and this will increase once the big, healdine issues that effect all areas are sorted.

We would also like to support the senior managers in the Trust in respect of their efforts in respect of Infection Prevention and Control. They may not be perfect and perhaps come across as having the wrong focus and response when challenged but in our experience they are amongst the most supportive and receptive group of NHS managers and executives that we have come across. We will try subtly to suggest to them ways of reflecting this when they discuss/respond to infection issues publically etc.

Once again , thank you for sharing your experience and thoughts with use. The issues you have raised have been very useful and we will act on as many of them as we can. Things may takes several months to come to fruition but we do want to provide the best service we can although it is a long term project and will keep us busy for many years to come.

Kind regards, Christine

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