Wednesday, January 02, 2008

Making a bad situation worse

It is not just Labour who want to install fines to enforce infection control, now the Tories want to start punishing NHS trusts for every case of hospital acquired infection. This kind of stupid idea could only have come from someone who has no understanding of the root causes of hospital acquired infections such as MRSA* and Clostridium difficile.

One rather misunderstood and worrying fact is that MRSA is now rather endemic in the community, outside of hospital, while many cases of Clostridium difficile also occur outside of hospital. That is not to say hospitals could not manage these problems better, of course they could, however would fining for failures really help improve the situation?

I would argue a very strong 'no'. Take Tunbridge Wells as a case in point, we can conduct a quick thought experiment here; here was a hospital in financial trouble with multiple management problems:
"Many of the buildings, especially at the Kent and Sussex Hospital, were old and in a poor state of repair ... indicated that shortages of nurses contributed to the spread of infection ... The trust’s bed occupancy rates were consistently over 90% in the medical wards ... By definition for these areas there were no funds for dedicated staff, and at least initially they were staffed almost entirely by bank or agency nurses, bringing little continuity of care. Many of these factors increased the risk of transmission of infection."

"The lack of organisational stability, with numerous structural changes over the last three to four years, and a high turnover of senior managers, meant that managers could not settle into roles and focus on the key issues. Many felt there was little delegation. The style of management was described as reactive, with frequent changes of direction."

"... were preoccupied with finances, and had a demanding agenda for reconfiguration and private finance initiative (PFI), all of which consumed much management time and effort."

The factors contributing to this disaster were complex and included outdated buildings and wards, government targets and the excessive movement of patients, the inadequate isolation of patients, high bed occupancy rates, shortages in nursing numbers and a lack of continuity of care, and managerial malaise due to frequent restructuring and a preoccupation with financial issues.

Virtually all of these factors have been contributed too and massively worsened by the government's incessant interference and meddling with the NHS. A chronic underinvestment has left buildings and infrastructure outdated and unable to cope with modern infection control needs. Top down targets have led to the excessive movement of patients and the catalysis of infection spread. Falling acute bed numbers over the last ten years have led to bed occupancy levels rising to too high a level on average, a known factor in increasing hospital acquired infection. Centrally imposed deficits gave led to the financial pressures that result in key front line staff being laid off, while wards are left dangerously short staffed. While endless political interference in the structure of the NHS has resulted in reorganisation after reorganisation, a situation where no one knows their role, and consequently a system of no responsibility and accountability.

The government has let hospital acquired infection multiply out of control in recent years because it has simply not addressed the root causes aggressively enough. These ideas of fining failing trusts are completely misconceived and would make a bad situation worse. In fact several causal factors are still being worsened by direct action from central government, so the idea of central government fining people for things that it is directly contributing towards is nothing short of idiotic, while the fines would only accentuate the problems by worsening the causative financial pressures on the trust concerned. We currently have a situation where there is no accountability or responsibility, and if there was I have a distinct feeling that several of the people being held to account for this mess would be of the political variety. The politicians should be fining themselves.

* It is worth pointing out that, although it is now used as a general catch-all term for hospital acquired infections, MRSA is a specific bacterium: methicillin-resistant Staphylococcus aureus (methicillin is an anti-biotic from the same family as penicillin).—DK


anthonynorth said...

Modern politics is in the game of punitive punishment for everything, rather than addressing the real problem. It's like a failed parent, which gives an indication of what they think of us 'children', the electorate.
Perhaps this is a political 'infection' in itself. But how to eradicate it?

JuliaM said...

Rather than fine them, how about sacking the ones found responsible for not implimenting the controls?


MRSA could be tackled more efficiently if the HS stopped hiring cleaners from private contract companies, who keep the bulk of the monies for administration, and then hire low skilled workers on low wages who are not motivated to keep a well paid position.
IF they did their own hiring , paid a better wage and provided mandatory training of infection control, the hospitals could eradicate MRSA and the like, for cheaper than what they are currently paying out now.

the a&e charge nurse said...

"Antibiotics are unique amongst pharmaceuticals in that they treat populations as well as individuals"
[Levy, 2002 - The antibiotic paradox - how the misuse of antibiotics destroy their curative powers].

It is well known that resistence in one group of bacteria can spread to different bacteria, these mutations can then can be carried to any part of the world [by the infected host] - this is exactly what has happened, and of course resistant bugs love to colonise environments where we find the most antibiotics........hospitals.

The burgeoning use of antibacterial cleaning problems in the home, and the blunderbuss approach in agriculture may have compounded medical failings when historical prescribing habits are analysed.

The battle against resistance will never be won while there are millions of punters committed to guzzling as many antibiotics as possible [or giving them to their children] - I do have a certain amount of sympathy for the relentless pressure put on doctors but even they are belatedly waking up to the nightmare scenario of mutant organisms resistant to all known treatment.

Be very afraid.

the a&e charge nurse said...

On a slightly different tack the DoH has an established and virtually failsafe mechanism to brow beat hospitals into submission.

If hospital A has MRSA rates of 10%, say, while hospital B's are 5% - the DoH simply points the finger at the "failing" hospital, rather like one of the alien clones in 'Invasion of the Bodysnatchers'.

Of course Joe Bloggs thinks a good dose of "competition" is just what the NHS needs, while fearful hospitals [who, by and large, are monitoring their own performance] develop a few special "strategies" to make the figures appear less alarming.

For example, some hospitals are more proactive when it comes to pre-emptive swabbing, and are thus more likley to identify colonised patients, [and indeed staff if they are swabbed too], but with no actual symptoms relating to the microbiology result - just the knowledge they have been colonised with MRSA and should therefore be placed in a sideroom, or cohort bay.

Incidentally, MRSA is endemic in nursing homes.

Other hospitals will not look so hard but reluctantly flag up a positive result once the patients condition is complicated by a HAI, such as MRSA.

Results are often spurious through poor technique, for example blood cultures are contaminated by the operators or patients skin flora.

I couldn't agree more, Dr De'ath linking punishment to arbitary standards will merely fuel the fiddling culture that most hospitals have resorted to in order to placate the DoH quislings - more importantly it will divert attention away from insane plans to reduce hospital beds even further [because everything in the community is rosey] while bed occupancy rates are running at well over 90%.

