Hospital Pharmacist Vol 7 No 7 p178-182
July 2000 Special Features

Antibiotic resistance

Hospital acquired infection - the current situation

By P. T. Mannion, FRCPath, MSc

In the first part of our special feature on antibiotic resistance, the author discusses the measures already in place to control hospital acquired infection and suggests ways in which they can be made more effective
The second part of the feature covers restrictive antibiotic policies

Hospital infection control has become very topical in recent months due to three separate initiatives. First, the National Audit Office (NAO) report on infection control¹ published earlier in the year. Second, the Controls Assurance Standards² which has a section on hospital infection control, the baseline assessment for which had to be completed by March 31. The third initiative is the Department of Health (DoH) guidance HSC 2000/002, "The management and control of hospital infection"³ which is complimentary to the ideals and objectives of the controls assurance framework.
So what is a hospital acquired infection, or HAI? A generally accepted definition is that it is an infection acquired four days or more after admission to hospital.⁴ This may be considered somewhat artificial but at least it provides a basis for comparison. It is said that at any time nine per cent of hospital inpatients have a hospital acquired infection.¹ Urinary tract infections and lower respiratory tract infections are the two commonest types of infection. This has obvious consequences in terms of increased mortality, morbidity, costs and length of stay.
A recently published study of HAI covered a 13-month period in one hospital in England.⁵ The project was funded by the Department of Health (DoH) and recruited 4,000 adult patients during the study period. Patients who experienced one or more HAIs incurred hospital costs that on average were 2.8 times greater than uninfected patients (an additional £2,917 per case) and they remained in hospital an average 2.5 times longer. Even after the adjustment for various factors (including age, diagnosis and the number of co-morbidities), patients with an HAI were 7.1 times more likely to die in hospital than uninfected patients. Extrapolation of these figures to the NHS in England produces an estimated cost of £986.36m annually for HAI (£930.62m while in hospital and £55.74m post-discharge). In terms of morbidity, patients who experience an HAI were estimated to need an additional 8.7m days nationally before they can resume normal daily activities.
There are clear guidelines for England and Wales as to how a typical hospital infection control service should be organised.⁶ The core of the service is the infection control team (ICT) comprising the trust infection control doctor (ICD) and one or more trust infection control nurses (ICNs). The ICD must have a sound knowledge of the management and control of infection in general as well as the specifics of hospital infection control. The ICD is normally a consultant medical microbiologist. Depending on the local circumstances, an infectious disease physician would also be a suitable choice. For the rest of this article I will assume the former model as it is the commoner of the two and one with which I am more familiar.
The ICD is generally an honorary title given to the individual acting on behalf of, and with, the authority of the chief executive of the trust (the latter is responsible for ensuring that there are effective arrangements for infection control). The title reflects the special interest and training of the ICD who would have obtained a CCST (certificate of completion of specialist training) in medical microbiology, usually after passing the relevant examination of the Royal College of Pathologists and becoming a member of the College (MRCPath). Nowadays, a more formal qualification in infection control can be sought.⁷
ICNs are specialist nurses who have to complete a one-year specialist training course before becoming independent practitioners. Traditionally, these have been diploma level courses although increasingly many ICNs continue their studies to BSc and ultimately MSc level (often in related subjects) while in post.
The ICDs and ICNs together perform the day-to-day duties of the ICT. The ICT cannot work in isolation and needs to be fully integrated into the trust with appropriate clerical, information technology (IT) and audit support from within the trust. Aside from responding to the day-to-day infection control problems of the trust, the ICT should ideally work to an annual programme developed by the trust infection control committee (ICC) of which the ICT is part. The ICT should produce regular updates or reports both to the ICC (which should meet at least twice a year) and to the trust management board or trust board on at least an annual basis. Guidance documents exist as to the composition of the ICC and the type of activities to be included in an annual programme.⁶ This has been reinforced by the controls assurance programme already referred to.
One could then ask that if hospitals have had ICTs and ICCs for many years (the first ICN was appointed in the UK in 1959), why do we still have problems with HAIs? It is certainly not due to a lack of effort on the part of ICTs/ICCs all over the country. Rather, it is related to the perception that infection control is a service provided for the trust when needed but not a primary responsibility of the clinical staff of the trusts. Most hospital clinical staff will be familiar with the ICT visiting the ward to advise on the care of individual patients with infections and will have been part of outbreak teams called upon to control a particular outbreak of infection (for example, Small round structured virus [SRSV]).
While clinical staff should be familiar with the infection control policies and guidance within their trust, as with any policy, they are only of benefit if they are clearly understood and regularly used. The NAO report and the other documents referred to at the start of this article are aiming towards changing the emphasis of the practice of infection control to one where clinicians confront the problems (for example, audit of wound infection rates, control of methicillin resistant Staphylococcus aureus, [MRSA]) while the ICT provided the specialist advice to guide them. It is a move that will place infection control within the clinical governance arena and not a stand-alone service provided for the trust. Infection control considerations need to be at the foundation of all activities within a trust.
Within hospitals, the health and safety officer and the ICT have been "risk managers" in their respective areas before this became a fashionable term. There is an overlap between the activities of the Health and Safety Committee (HSC) and the ICT/ICC, but there is also a difference in emphasis, with the ICT having a more clinical focus.
Generally, there is legislation on which all the Health and Safety Executive guidance is based and all organisations must comply with the current guidance. The guidance and policies that are available have been produced often by joint working groups (eg, "Revised guidelines for the control of methicillin resistant Staphylococcus aureus infection in hospitals"⁸) with representatives of the relevant societies and organisations such as the Public Health Laboratory Service (PHLS), Hospital Infection Society (HIS), Infection Control Nurses Association (ICNA) and the Association of Medical Microbiologists (AMM). It is interesting to note, however, that despite the problems caused by MRSA, no guidance on control and management within hospitals has ever been produced by the NHS.
Most of the DoH guidance relating to infection control is released by the NHS as health service circulars often in response to the findings of one of the national advisory groups. The recent circular "Variant Creutzfeldt-Jakob Disease (vCJD): minimising the risk of transmission"⁹ was released following the report of the Spongiform Encephalopathy Advisory Committee¹⁰ and is an example of such guidance. One of the biggest problems with this approach is that individual ICTs/ICCs then have to spend time developing local policies to implement such circulars and indeed one of the recommendations of the NAO report is that the DoH should consider producing a national infection control manual (with allowance for local "add-ons") as has been produced in Scotland.
Outside the trust, the local health authority (through its service agreements) will, in the future, monitor trusts to ensure that they meet the controls assurance standards on hospital acquired infection. Such external scrutiny has not been routine in the past. Approximately two years ago the DoH commissioned a group (EPIC) to produce a national infection control guidance. The first draft entitled "Draft evidence-based guidelines for preventing hospital acquired infections in England - indwelling urethral catheters" has recently been released on the internet for comment. This may well be the pattern for the future.
Unfortunately HAI will always occur but the aim of all hospitals should be to reduce this to the absolute minimum and the consensus from the NAO report is that a reduction of at least 15 per cent on current levels should be possible. So what are the problems with hospital infection control?

Resources

The Royal College of Pathologists recommends that the minimum input of an ICD should be three consultant sessions per 500 beds¹¹ but additional sessions would be required, subject to the specialities present in the trust (transplant unit, renal unit, burns unit, etc). The NAO reported that most trusts fulfilled this guideline (Figure 1). In contrast, the accepted ratio for ICNs (based on American studies from the 1970s) is one full time ICN for every 250 hospital beds and the NAO report identified a huge variation in the trusts in England (Figure 2).

Figure 1: The ratio of infection control doctors to number of beds in 218 NHS trusts © UK National Audit Office

Figure 2: The ratio of whole time equivalent infection control nurses to number of beds in NHS trusts Source for Figures 1 and 2: National Audit Office census, February 2000. © UK National Audit Office

Given the range of duties undertaken by the ICNs (including training, teaching and audit), either more time will need to be made available or clinical staff will have to take ownership of surveillance and audit to enable the ICN to have less of a hands-on role. Some trusts have link nurse schemes in place to try to act as a focus for infection control at ward level and although they can be successful at raising awareness, such schemes have encountered setbacks where there is a high staff turnover and where junior nurses take on the role but lack the authority to deal with more senior members of staff.
Another resource issue relates to how trusts fund the infection control service. Table 1 shows the breakdown of the budget elements that should be part of an infection control service. It can be seen that many trusts do not have all the elements formally budgeted for. Funding will obviously be found if infection-related problems occur but such an approach prevents a planned development of the infection control service to keep pace with the demands of the hospital.

Table 1: Items included in NHS trust infection control budgets
Budget elements recommended in DoH guidance*	Number of trusts with item in budget	% of trusts with item in budget**
Infection control doctor's time	17	20
Employment of infection control nurse(s)	76	89
Clerical and laboratory support staff costs	48	56
Microbiology tests and equipment specifically needed for infection control	18	21
Computer equipment for surveillance	25	29
Educational aids, videos, posters, etc	60	70
Training and education of infection control team members and provision of books, etc	63	74
Printing and dissemination of policies/manuals	45	53
Travel between institutions covered by infection control team	61	71
* The cost of managing outbreaks or other major infection incidents should be met from other sources such as contingency funds or insurance cover. If the infection control team provides infection control services outside the main hospital, these should be the subject of a clearly defined contract with associated funding (DoH 1995 guidance)
** There were 86 NHS trusts (40 per cent) with a separate budget for routine infection control
Source: National Audit Office census comparing actual contents against DoH 1995 guidance, February 2000. © UK National Audit Office

It is also relevant to note that the majority of infection control budgets have stayed the same between 1996 and 1999.¹ Another common complaint of ICTs is insufficient clerical and IT support. It is also worthy of note that only 40 per cent of ICDs have access to their NHS trust patient information systems.¹ This must become universal to ensure the "painless" collection of clinical data for HAI surveillance in the future.

Multi-resistant organisms

Surveillance

Training and education

This is a key function for ICTs. The majority of hospital staff with the exception of medical staff will receive an induction session that includes a basic awareness session of the principles of infection control. This obviously has to be tailored to the needs of staff attending the lecture. With medical staff, there is often a series of induction lectures when new house officers commence duties or change specialities, but unfortunately a consultant medical microbiologist or ICN has to compete for a 10 or 20 minute slot in an already crammed schedule. For senior medical staff, specialist registrars on regional rotations and locums there is often little or no opportunity to provide such induction sessions.
Updating and re-training nursing and medical staff once in post is a problem that, in my experience, has yet to be solved. The biggest problem is releasing staff to attend training sessions, When wards are busy or short-staffed it can be impossible for nursing staff to get away from the wards or have protected time. Medical staff have historically been able to take study leave; and continuous professional development (CPD) is an essential requirement for consultants both for re-accreditation and clinical governance. It would be of interest to find out from fellow consultants when they last attended an update session on infection control. It needs to become more of a core educational need for all medical staff, whether they are trained or in training.
An increased demand for training will have obvious consequences for manpower (increased ICN or ICD time will be required) but trusts are looking to utilise CD-ROM based self-teaching programmes which, if networked within a trust, can provide access at the workplace, particularly for staff who may have problems in attending daytime sessions, for example, night staff, agency staff, locum medical staff and members of professions allied to medicine.
The most important thing that all staff who care for patients must learn is to wash hands correctly. It sounds simplistic - everybody does it all the time. Interestingly, theatre scrub staff (medical and nursing) accept without question the need to be taught a surgical hand preparation but at the ward or clinic level health care staff do not clean their hands properly (Figure 4). Reinforcing the need for hand washing is part of the initial control measures in most hospital outbreaks but it is difficult to maintain the heightened awareness once an outbreak is over. Hand washing is critical to prevent the spread of infection and must follow every patient contact. It is of so much importance that the Handwashing Liaison Group produced an information leaflet for trust chief executives to suggest strategies to raise standards and improve awareness.¹⁴

Figure 4: Ineffective handwashing techniques result in some areas of the hands consistently being missed, facilitating cross infection by transient bacteria. Source: National Audit Office census, February, 2000. © UK National Audit Office

The safe use and disposal of "sharps" is also of critical importance. Sharps injuries can occur in many hospital settings. In operating theatres, the awareness about blood borne viruses (eg, human immunodeficiency virus and hepatitis C virus) has led to the introduction of many improved practices to prevent sharp instruments being passed from hand to hand and to avoid the use of sharps whenever possible. On the general wards and departments of any hospital, rigorous policies and procedures exist to ensure that all "sharps" are only disposed of in approved rigid containers (sharps' bins). Unfortunately, mistakes still occur and needles or other "sharps" can end up in the black domestic bin bags. The unfortunate consequence of such events can be a needle stick injury to innocent porters or domestic staff who have to handle such bags. All needle stick injuries must be taken seriously and any staff member must be offered appropriate post-exposure prophylaxis. Sharps injuries cause great concern to the injured party and it is the responsibility of all health care staff to ensure the safe disposal of any sharps they use in the care of patients.

Conclusion

The problems that ICTs face will always be challenging and will change due to the types of patients and the treatments being applied (for example, severely immunosuppressed patients). The current national focus on infection control will hopefully educate health care staff on their roles and responsibilities, because high standards of infection control mean high standards of patient care.
It is obvious that, at trust level, infection control has to take its place with all the other priorities. However, it cannot remain a Cinderella speciality and more resources may have to be committed to generate the long term improvements in standards we all hope to achieve. Infection control will become yet another tool by which health care standards are monitored and we must make the changes to ensure that HAI is reduced to the minimum to prevent the consequences for individual patients and to stop the wastage of valuable NHS resources. More awareness of such issues by patients and their relatives will also increase the pressure to raise standards further.

Dr Mannion is consultant medical microbiologist and hospital infection control doctor, based at the public health laboratory, Countess of Chester health park, Chester

References