Off the record – healthcare-acquired infections31 October 2014
Healthcare-acquired infections remain a significant worry, but are hospitals doing all they can to combat them? Barbara Harpham, national director at Heart Research UK and chair of the Medical Technology Group, discusses a recent report that suggests NHS trusts are in the dark over the full scale of the problem.
Most NHS Trusts are unaware of the full scale, cost and impact of healthcare-acquired infections (HAIs) such as sepsis and norovirus - that's according to a new report that explores the evidence for this and explains how the resulting issues could be remedied.
'Infection prevention and control - combating a problem that has not gone away', released by the Medical Technology Group (MTG), a coalition of patient groups, research charities and medical device manufacturers working to make medical technology available to everyone who needs it, shows that the incidence of HAIs has fallen in recent years but warns of the risk of this leading us to believe the problem has gone away. What is more, these infections are adding to the cost of patient care in the NHS while presenting a real threat to patients' lives; each infection extends hospital stay by an average of ten days and costs the NHS an extra £5,200.
According to the report, the vast majority of NHS Trusts are neglecting to track:
- the total number of extra nights each year that patients stay in hospital owing to an HAI
- the financial cost or operational impact of infections
- the total number of cases of sepsis, catheter-related urinary tract infections (CAUTIs), catheter-related blood infections (CRBIs), ventilator-associated pneumonia (VAP) and norovirus
- the total number of deaths from the above infections.
Not gone but still forgotten
Although meticillin-resistant Staphylococcus aureus (MRSA) and E coli rates have fallen dramatically in the past decade, there are two associated dangers: complacency about rates of other HAIs, to which the same attention is not being paid; and failure to apply the successes of the mandatory reporting initiative to these other infections.
HAIs remain a real problem. As UK Prime Minister David Cameron put it in July 2014: "Resistance to antibiotics is now a very real and worrying threat, as bacteria mutate to become immune to their effects. With 25,000 people a year already dying from infections resistant to antibiotic drugs in Europe alone, this is not some distant threat but something happening right now.
"If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work, and we are cast back into the dark ages of medicine where treatable infections and injuries will kill once again," Cameron said.
Dame Sally Davies, chief medical officer for England, agreed with the prime minister: "The soaring number of antibiotic-resistant infections poses such a great threat to society that, in 20 years' time, we could be taken back to a 19th-century environment where everyday infections kill us as a result of routine operations."
Research conducted in English hospitals found estimates of how much longer patients stay in hospital because of a surgical site infection (SSI) ranged from 3.3 days for an abdominal hysterectomy to 21.0 days for a limb amputation. Other studies found SSIs and HAIs extended hospital stays by 10.0 and 11.2 days respectively. One trust we contacted in the course of producing the report estimated that an SSI almost triples the length of stay for a patient in primary admission - from 11 days to 31 days.
HAIs also impose great costs on the NHS. The findings from one study showed an estimated cost for each SSI to vary from £959 for an abdominal hysterectomy to £6,103 for limb amputation, while another study found the median additional cost attributable to each SSI was £5,239.
Even as these avoidable costs are imposed on the NHS as a whole, there is evidence that trusts can actually benefit financially from reimbursements when they treat patients who acquire an infection in that trust's hospital, as they continue to receive money for the treatment of a patient with an SSI. The study's authors remarked that trusts could therefore be put in the "perverse position" of being financially worse off if they eliminate SSIs, although it must be noted that this benefit was only present in seven of 19 surgical categories, that elimination of all HAIs would still result in a saving and that the study was conducted in only one hospital.
Freedom of information and the cost of HAIs
The MTG's report began as an effort to demonstrate the scale of the problem by tracking the number of infections and deaths caused by infections other than MRSA, meticillin-sensitive Staphylococcus aureus, E coli and Clostridium difficile. However, as data from our Freedom of Information (FoI) requests came in, something more concerning was discovered: most trusts are failing even to measure the total number of cases of - and deaths from - sepsis, CAUTIs, CRBIs, VAP and norovirus.
Given the serious impact these conditions can have on patients and trusts alike, it's vital to track the number of cases and associated deaths. This is the beginning of the process of reducing the harm from these infections rather than the end.
Nonetheless, 58% of trusts that responded to the FoI request said they do not collate the number of cases of any of these infections, and a further 30% record some but not all of them; 76% fail to collate the number of deaths, with a further 18% recording some but not all. Only 12% of trusts recorded the total number of cases of all these infections, and only 6% recorded the total number of the associated deaths.
Similarly sparse reporting afflicts the measurement of the financial costs: of the 76 trusts that responded to an inquiry about whether they measure the financial cost or operational impact of infections, only nine (12.0%) confirmed that they did, while only one of 68 trusts (1.5%) measured the total number of extra nights each year that patients have to stay in hospital due to an HAI.
They have no idea either of the total number of extra nights each year that patients stay in hospital owing to an HAI or the total financial cost. This must change.
Flying the flag at half-staff
When looking in further detail at infection control staff numbers, further evidence emerges of significant disparities in staff cover from region to region.
As larger trusts can be expected to have a larger absolute number of infection control staff, as they have a larger total number of staff, a fairer measure is therefore to use the number of infection control staff for each bed within the trust.
Out of the 107 trusts that responded to a query about the number of staff on their infection prevention and control teams, the North-East and East Midlands are the two worst-performing regions, with London and the South-West performing best. London has one infection control member of staff for every 71 beds; the East Midlands has one for every 161 beds.
Another key measure of how seriously trusts are taking infection control is the number of infection prevention and control committee meetings the board attends. The 86 trusts that responded reported 1,983 occasions during 2008-13, which gives an encouraging figure of 5.76 per trust per annum.
However, the variation by trust was enormous. Torbay and Southern Devon Health and Care NHS Trust had board members attend 24 meetings a year in each of the five finanical years surveyed; by contrast, 15 trusts had no board members attend an infection prevention and control committee meeting for at least one of the financial years covered.
A similar scenario emerges when the amount invested is examined. The trusts that responded to our FoI requests indicated their budgets for infection prevention and control increased by an average of just 8% per annum in 2008-13. Seven trusts even received instructions to reduce expenditure on infection prevention and control in the past five years.
What can be done
All of this is very troubling in the context of increasing antimicrobial resistance, but what practical measures are there that the NHS trusts could implement to address these shortcomings? The MTG report offers some key recommendations:
- trusts must be required to record the total number of cases of and associated deaths from sepsis, CAUTIs, CRBIs, VAP and norovirus
- trusts must be required to record the total number of nights patients stay longer in hospital each month owing to an HAI
- device surveillance should be mandatory for all hospital wards
- the government should develop a strategy for using technology for infection prevention and control, and engage with industry on solutions to achieve this.
With so much variability by trust and region, there clearly needs to be a more effective national strategy to combat HAIs. There is also little evidence of a substantial investment in infection prevention and control.
With the evidence detailed in this report in mind, it is the MTG's contention that the NHS is too complacent on this issue and is moving far too slowly - with budgets only showing a minor average increase from an already low base, in spite of growing antimicrobial resistance and the increasing emergence of resistant strains.
Rather than continue to overspend on the overuse of antibiotics, there must be a real investment in preventing infections in the first place. Better measurement and prevention of HAIs is vital, and medical technology is key