COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
14 February 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Carál Ní Chuilín
Ms Sue Ramsey
Mr John Compton ) South Eastern Health and Social Care Trust
Mr Colm Donaghy ) Southern Health and Social Care Trust
Ms Norma Evans ) Northern Health and Social Care Trust
Dr Peter Flanagan ) Northern Health and Social Care Trust
Mr William McKee ) Belfast Health and Social Care Trust
Mrs Elaine Way ) Western Health and Social Care Trust
The Chairperson (Mrs I Robinson):
I welcome John Compton, chief executive of the South Eastern Health and Social Care Trust; Colm Donaghy, chief executive of the Southern Health and Social Care Trust; Norma Evans, chief executive of the Northern Health and Social Care Trust; William McKee, chief executive of the Belfast Health and Social Care Trust, and Elaine Way, chief executive of the Western Health and Social Care Trust. Each of you will have five minutes in which to make your presentation and then Committee members will pose questions.
Thank you for taking time to attend the meeting and make your presentations. As we all know, clostridium difficile is a burning issue for the public. We must be seen to be trying to allay the fears of the local community and of those families who have elderly folk in nursing homes or in residential homes where the bug seems to target — more obviously — elderly people with multiple health problems.
Mr William McKee (Belfast Health and Social Care Trust):
Clostridium difficile is an extremely important issue for us and for the wider public, and we welcome the interest that is being shown in this subject by the Health Committee. As chief executives, nothing is more important to us, our boards and our staff than the safety of our patients. Vigilance and action are everyone’s business. We each bring reports on clostridium difficile to our area, and those reports are in the public domain. We make regular reports to the boards as well as contributing to the surveillance that is undertaken centrally by various agencies and the Department.
Notwithstanding the current outbreak of clostridium difficile in the Northern Health and Social Care Trust, infection rates in our hospitals are low by international standards and by standards elsewhere in these islands. Therefore, although I must emphasise that there is no acceptable rate of clostridium difficile infections, we cannot prevent all cases happening. We can be vigilant; we can ensure that the number of cases is kept to a minimum, and that when an outbreak unfortunately occurs, we take resolute action to deal with it.
It is a rare but tragic fact that a very small number of cases of clostridium difficile infections result in death. Even so, that is to be regretted by everyone involved in patient care. We are committed to doing our very best to have no avoidable deaths in hospitals, either as a result of complications from clostridium difficile or from any other hospital infections.
I am glad that the Committee has the figures for the past five years from the relevant agency, but my figures show that there were 1,063 cases of clostridium difficile in Northern Ireland in 2006. In 63 cases in which a patient died, clostridium difficile was an underlying cause of death, while in 41 cases, it was the main cause of death. In other words, in about 3% of clostridium difficile cases, the infection has been registered as the main cause of death. That statistic is very much to be regretted, but it shows that in the context of an annual death rate in Northern Ireland of 15,000, such deaths are rare and tragic events.
At the moment, there is no outbreak in any of the other trusts in Northern Ireland. Across the trusts, the rates are very low and are generally falling — they are certainly not rising — with the exception of the current outbreak in the Northern Health and Social Care Trust. The fair way to assess our performance is to compare it with performance elsewhere. For example, in the Belfast Health and Social Care Trust area, the rate is less than one case per thousand bed days. At the moment, the average rate in England is above two cases per thousand bed days. So, overall, Northern Ireland is performing much better than England. I do not have the figures for Scotland and Wales with me, but I will provide the Committee with them in writing.
I really must stress to the Committee, and to everyone else, that hospitals in Northern Ireland are comparatively safe. We can never reduce the incidence of clostridium difficile to zero, but I assure the Committee that teams and individuals at ward level, institutional level and trust level are working very hard to keep the number of cases to a minimum. I pay tribute to the diligence and vigilance of staff in keeping the rates so comparatively low. Hospital infection rates across the developed world range from 5% to 10%. In Northern Ireland, it is in the order of about 5·1%. In other words, we compare well internationally. Surveillance work in Northern Ireland is recognised internationally as being world-class.
I would like to say something about this nasty little bug. About 3% of the adult population have it in their gut and experience no symptoms. For most people, it is simply one of the tens of billions of bacteria that exist in the bowels — which is where it lives mainly. As the population gets older, the percentage rises. Therefore, for people aged 65 and over, the figure rises to about 30%. For many people, particularly those who are gravely ill, we provide vital antibiotic intervention. However, as many of us have experienced, taking a broad spectrum antibiotic can sometimes cause diarrhoea.
I am not a doctor, and I have not been involved in microbiology for a long time, therefore I will use crude terminology: antibiotics kill the good bacteria, and bad bacteria overgrow and take a dominant position in the gut. Those bacteria do not do much harm; the danger lies in the toxins or poisons that they produce, which can overwhelm people who are already frail. That is the essential mechanism of the disease. Therefore, care must be taken with the drugs being prescribed to prevent diarrhoea, particularly antibiotics. People must be screened for susceptibility to clostridium difficile.
Forgive me for being so geeky, but the bacterium is named "difficile" because it is extremely difficult to grow in a laboratory. Therefore, instead of waiting to grow the culture, which would take too long, the laboratory sends the result of the test, stating which toxin is being produced. Specialist teams work every hour to identify patients on the wards who may be at risk or who have symptoms suggesting clostridium difficile. We look for evidence of the toxin and act on it.
A new nasty strain of clostridium difficile has emerged in the Northern Trust area. However, until samples are sent to Cardiff to be grown and ribotyped, we do not know whether patients have contracted the new virulent strain. Therefore, it is extremely tricky to deal with clostridium difficile, which is, to use the jargon, part of most older people’s gut flora.
It may be useful for each trust to submit written evidence of the best practices that are being implemented. However, the best evidence of best practice lies in the remarkably low rate of infection that exists. Again, I re-emphasise that there is no such thing as an acceptable rate of infection. Every avoidable death is to be deeply regretted, and we should redouble our efforts.
Ms Evans can speak for herself, but I am confident that the Northern Health and Social Care Trust took prompt action to deal with its outbreak. Another trust could have an outbreak at any time, because it is extremely difficult to prevent the spread of the infection. The key is whether we follow the external guidance and take internal action to control an outbreak, keeping the rate of infection low and, in many cases, at half the level in England.
Yesterday, we met the Minister to discuss a range of issues, and we gave him our personal assurance that we will meet the demanding target that has been set. Given that our rates of infection are already low, achieving a further reduction of 20% by April 2009 is an extremely challenging target. We welcome the challenge, and it is the sort of target that should be set. I am confident that, starting from a rate that is already low, we can achieve a further reduction of at least 20% by then.
Mr John Compton (South Eastern Health and Social Care Trust):
I want to reinforce what Mr McKee said about the overall trend in rates of infection, specifically in relation to the South Eastern Health and Social Care Trust. Our trust does not have, and, fortunately, has never had, an outbreak of clostridium difficile. The small number of patients annually who experience clostridium difficile is a matter of public record.
The Committee has the validated information to the end of September 2007, and there were 187 cases across all hospitals. There were 14 references to clostridium difficile over that period on the death certificates held by the General Registry Office. On six certificates clostridium difficile was identified as a primary cause of death and on eight it was recorded as a secondary cause of death.
Extensive infection control measures are in place throughout the organisation. All staff are alert to, and work energetically to avoid, clostridium difficile. As my colleague Mr McKee said, full avoidance is impossible, but we are keen to reduce the rate to the lowest possible level. The measures that we have in place are, I am sure, similar to those of my colleague. The hand-washing rule is audited monthly to provide the trust with the percentage of adherence.
We also use alcohol gel. We have established consultant-only antibiotic control. Antibiotics are a major contributing factor, so the senior doctor would be involved in order to ensure that prescription is properly handled. We have annual infection plans. Prevention and control of infection is monitored on a monthly basis by the trust board. Although our organisation is new, our board has met on five occasions already and the information from those meetings is a matter of public record.
Every area of the hospital has a direct link to our infection control and prevention teams. There is ongoing and extensive contact between them and the microbiology services. We report all information about infections to a number of external bodies.
We talk to all family members when clostridium difficile is present. It is good practice for a doctor or a consultant to discuss the nature of conditions with patients and their families. That is the case in the South Eastern Health and Social Care Trust. We have no desire to do anything other than be straightforward and matter-of-fact about the effects of a particular condition on an individual. We do that because we want to work in partnership with the family in managing the case. When a person acquires an infection we must take precautions around visiting and other issues that affect the family. It is in our shared interest to do that. We restrict visiting in the event of a significant outbreak. We also work closely with pharmacy and microbiology personnel to ensure that up-to-date information is freely available to staff.
I pay tribute to the staff; they have worked energetically. Quite properly, there has been a great deal of public interest in this matter, and I want to reassure the public that hospitals are safe for them and their loved ones to come for treatment and care. Although we can never be other than vigilant about these matters, I want to emphasise that we do not have an outbreak at present. Our incidence and prevalence rates are low, comparatively speaking — they can never be too low. We are entirely serious about how we handle this matter.
Mr Colm Donaghy (Southern Health and Social Care Trust):
I agree with everything that my colleagues have said. I will not repeat what they have said: the Committee has the Southern Health and Social Care Trust’s statistics in front of it. As regards clostridium difficile, the trend is downward and compares very favourably, as both my colleagues have said, with England, and globally.
I want to emphasise the prevention and detection aspects of care, and outline to the Committee how clostridium difficile is detected in our trust and in others. We have a laboratory service that operates seven days a week for 365 days a year. Samples are sent to the laboratory to be tested, and the wards receive the results on the same day. Robust advice is provided if clostridium difficile becomes an issue, but ward managers and staff are already well trained in dealing with it.
On the same day, a multi-disciplinary meeting will take place to examine all the laboratory results across the trust and in other trusts. If there is any indication from that meeting that further action is required, that action would be taken. I want to emphasise that to the Committee: we do not wait to see the statistics on a quarterly or annual basis to take action to combat clostridium difficile and other hospital-acquired infections. We have put detection and surveillance systems in place in order that we can take action very quickly.
I want to emphasise some of the points that John Compton made. We have a robust prevention policy, which takes account of all the aspects that John mentioned. Like my two colleagues, I pay tribute to the staff, who work in difficult and challenging circumstances and do their best to ensure that we give patients care of the highest quality.
Ms Norma Evans (Northern Health and Social Care Trust):
What has been said by William, John and Colm obviously applies in the Northern Health and Social Care Trust. I will refrain from speaking about general matters and confine my remarks to the outbreak, as our trust is the only one that is experiencing an outbreak.
The Committee has the figures before it. Until the end of the third quarter of last year the Northern Health and Social Services Board and the Northern Health and Social Care Trust area were showing the same steady, low level of infection as was apparent in the other trust areas.
The circumstances that led to identification of the outbreak were as follows. In July and August last year, microbiologists noticed that there was a change in the clinical presentation of two patients who had clostridium difficile-associated diarrhoea. As has been said already, one does not await the outcome of an analysis of samples; one immediately begins to treat the patients. The samples were sent to Wales for ribotyping; and they were confirmed as ribotype 027. That is a more virulent form of clostridium difficile, which causes a more prolonged bout of diarrhoea and leaves the patient more prone to relapse. The patient may have the clostridium difficile diarrhoea and may recover for a couple of weeks; but as many as 20% of patients suffer a relapse. Where a patient has been diagnosed with the ribotype 027 strain, particular difficulties are created with respect to prescription of antibiotics. As Mr McKee has said, 30% of older people have clostridium difficile in the bowel: if a patient has already suffered infection, extreme care must be exercised.
We treated the individual cases and looked after the patients until they had recovered. In late August and September, a cluster of clostridium difficile cases occurred; one in Whiteabbey Hospital and the other in the Antrim Area Hospital. Both were treated, and the majority of patients recovered. However, the statistics began to show a slight upward trend: the numbers of cases-per-month grew from mid-to-high teens to the early 20s; in October, 20 or 21 patients were identified with it. In November, the number of cases fell to 17; however, in December, they rose to 23, and by then, we realised that the upward trend was continuing and that the figures would not reduce. While we analysed the outbreaks, we followed best practice. Where single rooms were available, patients were isolated; where possible, they were cohorted in bays in wards. We strove to separate patients infected with clostridium difficile from other patients.
In early January, it was clear that the action we had taken systematically from September was not reducing the number of patients becoming infected. We decided to open an isolation ward. To begin with, this was a cohort ward; but we took advice from Professor Wilcox in Leeds, and Dr Smith in the communicable disease surveillance unit in Northern Ireland. They recommended that we remove all other patients from the ward. Therefore, we emptied a medical ward and devoted it exclusively to the treatment of patients who had clostridium difficile.
Clostridium difficile is a particularly difficult spore to eradicate; it does not respond to alcohol gel or to traditional cleaning agents. We re-emphasised to staff the need for hand-decontamination and hand-washing. Hand-washing was made mandatory for patients, staff and everyone entering and leaving the ward.
We introduced an intensive cleaning programme in all ward areas, and we changed the agents that we were using to ones that would kill the spores of clostridium difficile, which meant reverting to — as I understand it — more bleach-based chlorine-based agents, as opposed to the usual soap and water.
Since 1999, we have had strict antibiotic prescribing policies, which are being constantly updated, with further restrictions placed on them. Antibiotic prescribing in our trust, like in those of my colleagues, must be countersigned by a consultant, and that procedure must be reviewed every 72 hours. We know that, with regard to clostridium difficile, the shorter time a patient is on an antibiotic the better. We developed specific guidance for staff concerning visiting; we issued letters to visitors advising them that we had a problem with clostridium difficile and asked for their co-operation, which we have had in full as regards restricted visiting, hand-washing and ensuring that areas around beds and lockers are kept relatively clear to allow those areas to be cleaned thoroughly; and we did everything recommended as best practice for an escalation policy when there is a confirmed outbreak. We are continuing to do that, and we are continuing to nurse all patients with clostridium difficile in Antrim Area Hospital in the isolation ward.
We transfer patients from the outlying hospitals in Whiteabbey, Mid Ulster, Braid Valley and Moyle if there are no facilities for isolating them in those hospitals, providing that they are clinically or medically fit for transfer. Many patients are elderly and have other long-term conditions, which make them frail and vulnerable. In some cases, transfers have not been possible. We have been asked why we do not care for all those patients in Antrim Area Hospital, and that is the reason. Some of the patients are not fit to transfer.
Mrs Elaine Way (Western Health and Social Care Trust):
There has not been an outbreak of clostridium difficile in the western trust area. I assure the Committee that our trust takes infection prevention and control extremely seriously. As Mr McKee described earlier, vigilance and close monitoring of any infection increase, and the need to take corrective action, is on the agendas of senior directors in the trust. As he also said, the evidence of that can be seen in the relatively low rates of outbreak. Like the Belfast trust, our trust is sitting just below one case per 1,000 bed days. Figures from the General Registrar Office show that in 2006 clostridium difficile was mentioned on the death certificates in 10 cases in the western trust area, and in 2007 it was mentioned in four cases. I am not saying that with any sense of pride; nor am I ignoring the challenge ahead of us to ensure that we use the evidence-based standards for infection prevention and control. I met recently with the staff who have lead professional responsibility for infection prevention and control, and as other witnesses have described, they are using what are acknowledged to be the best international standards for infection prevention and control.
Some of our hospitals are quite old.
There are issues relating to the fabric of the building. For example, we are concerned about the patient-to-toilet ratio. A patient suffering from vomiting and diarrhoea could potentially be sharing a toilet with up to 12 other patients. We have to make sure that that patient makes the staff aware of that so that extra action can be taken to ensure that the toilet is properly cleaned.
If someone presents at any of our hospitals with signs of vomiting and diarrhoea, our primary focus is to try to admit them to a single room to keep them isolated, before we even try to ascertain whether they have clostridium difficile. Where a sample is taken and clostridium difficile is confirmed, there are detailed guidelines on every ward for how that should be managed. Our practice is that the infection prevention and control team nurses immediately go to that ward to help the staff to deal with it.
Since August 2007, we have been using the Saving Lives programme, which is a campaign by the Department of Health in England. It sets standards for infection prevention and control, which means that we audit all our infection rates and practices. Skilled nurses with enhanced training in audit assess the issues that have been mentioned by others, such as hand hygiene practice, isolation arrangements, use of personal protective equipment, antibiotic history and treatments, decontamination procedures for medical equipment and environmental cleanliness. Those audits have been ongoing since August 2007.
I mentioned the practical issue of the toilet-to-patient ratio. There are also issues about high occupancy levels, and that is particularly the case in Altnagelvin Hospital in the Western Health and Social Care Trust. One of the challenges for us is to try to reduce the occupancy level, so that more single rooms can be made available. I reassure members that if a patient presents with diarrhoea at the accident and emergency unit of Altnagelvin Hospital, they must not be admitted until we have an appropriate bed for them. At times, that has led to breaches of the 12-hour accident and emergency standard. However, our concern is to ensure that the strict infection control procedures are followed.
Some people have mentioned our staff. I wish to reiterate that the infection prevention and control staff are extremely skilled and committed. They pay tribute to the front-line staff — the ward managers, the nurses, the cleaners, and so on — who work hard to create the sort of record of evidence that William McKee referred to, and I want to acknowledge that.
Early in your life as a Committee, you wrote to the trust and said that you were concerned about healthcare-acquired infections and asked for our view on the matter. We responded on 19 September 2007 saying that there were issues and challenges for us. We are all encouraged by the Minister’s announcement that £9 million will be targeted at infection prevention and control. In the west, our priorities are to recruit further infection prevention control nurses, and also administrative staff to support them, because the data collection is important and we want to free up professional time. We want to underline again the importance of training for all staff, and we want protected time for training, particularly for front-line staff.
Finally, cleaning is very important. We have developed a case for more investment in rapid-access cleaning when there is diarrhoea and vomiting on a ward.
We can see the level of interest in the matter by the number of people here today. My office in Ards has been inundated with calls, and the media — particularly some of the radio shows — have been whipping up a frenzy.
Setting that aside, this is an important issue because we are dealing with the loved ones of people whose unfortunate deaths may have been accelerated by contributing factors. Therefore, it is important that your actions in developing and rolling out programmes indicate that everything possible is being done to alleviate the problem. Of course, we must also recognise how many tens of thousands of people go through hospitals without contracting any additional problems.
Why is the inquiry only considering the Northern Trust? Should it include all the trusts? Studying the list of hospitals, I am concerned by the fact that every trust has had deaths.
Famously, during a board meeting once, I rushed to answer a question and another director said that he would let me answer while he thought about what the answer should be. However, in this instance, I will rush in.
We would prefer to be judged on our performance, which is good. We are not complacent, and there is no acceptable level of infection in hospitals. However, our performance and the trends are good, and we can demonstrate that using a body of evidence. In order to put a little flesh on the bones of the outlines that we are giving, we should each submit a report to the Committee.
In 2006, the Healthcare Commission undertook a review of a much larger outbreak of clostridium difficile in Stoke Mandeville Hospital. That was an early example of the virulent 027 strain, and my staff have read and inwardly digested the report from cover to cover. Of course, we are also aware of the more recent case in Luton and Dunstable Hospital.
The other trusts do not have outbreaks; we do have cases, but, in international terms, at a low level. A review of what has happened in the Northern Trust will be read avidly by me and my board, not to mention the professional and clinical staff who are more directly charged with controlling hospital-acquired infections, and such a review will act as a learning vehicle for us all.
It is my understanding that the review will encompass the five trusts.
We thought that the Northern Trust would be the only trust to be investigated, which is why I asked whether that would be fair.
The review’s terms and conditions initially emphasise the Northern Trust; however, in the detail, they indicate that the review will involve other trusts, and we will contribute to it.
I have been listening intently to the morning radio programmes, and the other morning there were some anonymous comments from nursing staff about the use of bedpans by people with clostridium difficile and then by others within a ward system. Those comments came from nursing staff who did not wish to be named, although there is encouragement for whistle-blowing. Will you comment on that area of hygiene and tell us what is being done to ensure that bedpans used by patients with clostridium difficile are not given to other patients?
First, we encourage our staff to regard whistle-blowing as the last resort. We try to inculcate a culture of openness and fairness. All five of us feel under a lot of pressure to deliver demanding targets. Mrs Way provided an example of a situation where she would prefer to do the right thing instead of meeting a target. That is the case for all five of us — the targets are not meant to make us do the wrong thing. We work very hard to ensure that, in addition to delivering the set targets, we do the right thing. That means ensuring that there is a culture in our trusts, hospitals and wards where staff feel able to speak out about issues of concern to their line managers, and do not have to rely on whistle-blowing, which is the last resort. We work very hard to send that message to our managers, who pass it down the line.
In regard to ward hygiene, particularly with bedpans, we cannot comment on that specific example, because it was reported by telephone from an anonymous source. However, each of us would thoroughly investigate any specific examples that concerned our trusts. Each trust passed the audit arrangements for hospital cleanliness. Cleanliness is our highest priority, particularly in regard to the proper use of bedpans.
I thank the witnesses for their presentations and for letting the Committee know about the precautions that are being taken to combat clostridium difficile.
I am interested in the possible contribution of hospital beds to the spread of bugs such as clostridium difficile. Mrs Way spoke of a 12-hour accident and emergency standard, but I am not sure if that applies to hospital beds. What is the policy when a patient with an infection is moved from a bed? Is that bed reoccupied soon after, or is there an assessment of how long the bed must be left unoccupied to combat any potential infection? Do you agree that that is one way that an infection can spread? If so, what is each trust doing about that?
Each trust has standing policies about the stripping, cleaning and decontaminating of beds after use; those are part of a wide range of actions to control infection. The importance of those policies to overall hospital infection rates is more problematic; the GB Department of Health’s chief analyst published a very important report last December which analysed cleanliness scores for hospitals, and other measures, and then looked at their infection rates. The report found that there was not a good correlation between cleanliness scores and overall infection rates. In fact, the report concluded that the link between cleanliness as we understand it — cosmetic cleanliness, if you like — and infection rates was "contentious".
Do not get me wrong; hospital cleaning is central to what trusts do, because it gives confidence. However, I suspect — although it is only my opinion — that vigilance in preventing and identifying infections, scrupulous hand-washing and decontamination of items that are in direct contact with patients is of the highest importance. Although public perception is often focused on hospital cleaning, which, of course, is vitally important, hand-washing and other related activities are of core importance. As Ms Evans mentioned, clostridium difficile spores are so resistant that, when there is an outbreak, hands must be washed with soap and water and there must be a return to the use of old-fashioned disinfectants in order to ensure that spores are killed.
Trusts should be judged simply by their performance. Rates of infection are low compared with elsewhere on these islands. In most cases, they appear to be coming down. Trusts are committed to delivering the demanding target of a 20% reduction in infection rates by April 2009.
In any bed or room where a patient has had clostridium difficile — and a high percentage of patients with clostridium difficile are now in single rooms — not only is the bed linen stripped, et cetera, but the entire room is cleaned from top to bottom before anyone goes back into it. If a patient’s relative comes in to collect nightwear, hospital staff put it inside a bag that can be put straight into the washing machine without the person having to touch the clothing. The bag dissolves during the wash. Staff give visitors details on how they can avoid spreading the infection themselves. We are, therefore, taking every possible step to ensure that a patient’s bed and entire space are clean.
This is a massive public confidence issue. People want to feel safe and be assured that if they go into hospital for treatment, they will not pick up another condition while they are there.
Everyone is aware of the outbreak in the Northern Trust. It has been mentioned that there are cases in every trust area. Can you give the Committee up-to-date figures on the current level of cases in each trust area? Also, can you explain what defines an "outbreak"? Is it the number of cases overall, or the number during a certain period?
The Statistics and Research Agency report shows the number of deaths from clostridium difficile that have been recorded as such on death certificates. They occur primarily among the elderly, with 84% in the 75-plus category. Do infection-control procedures target that age group specifically — not just members of that age group who already infected, but anyone of that age group who is admitted to hospital?
With regard to how each trust deals with infection control, would there not be benefits from having a blanket approach across all trusts?
Essentially, five questions have been asked. I will try to work through them backwards. Clear regional and general guidance, advice and protocols are available to trusts. However, every hospital has highly experienced and trained clinical, medical and nursing staff, who know each individual patient’s circumstances. Therefore, trusts apply regional guidelines, but adapt them to different hospitals’ special circumstances. Part of the difficulty is that in saying our piece, each of us has given the impression that we are all doing things slightly differently. In fact, we are all doing the same things, because we are striving for best practice.
Regrettably, this infection targets elderly people, and most of our hospitals, save for maternity hospitals and children’s hospitals, serve that age group. Anything we do will specifically address the vulnerabilities and special circumstances of those elderly people.
What defines an "outbreak"? Well, a case is a case. As we explained, we normally rely on evidence of the toxin as proof that a patient has acquired a clostridium difficile infection. It can take several days to grow the culture in our own laboratories, and it takes the laboratory in Cardiff several weeks to find out whether it is this new virulent strain. A "cluster" is where we might have two or three cases, but, so far as we can tell, because we know the circumstances of the individual patient, it is just happenstance. An "outbreak" is where it becomes self-perpetuating, with clear evidence that it is being transmitted from a patient to a member of staff and on to a patient, or from a patient to a patient. An "outbreak" is what it says — an outbreak. A "cluster" is where there is probably no connection between individual cases. An individual case is an individual case.
To emphasise the point again, even with the very best practice that we can adopt, individual cases of clostridium difficile will always occur, because the bacterium is present in the gut, and because of the need to prescribe antibiotics. The key is to prevent those cases from becoming outbreaks.
What is the position today? We agonised over the answer to that, because we knew that the question would be asked. The only way I can get the answer to that is by diverting front-line staff from the vigilance that I seek from them so that they can provide me with updates. It changes hour by hour, never mind day by day. In recent weeks, some of us have been heavily criticised for giving unaudited and unagreed figures under pressure. We each have the figures, but we are reluctant to give them. There is a further complication: the numbers are so small that, if we are pressed about the detail of them, patients and relatives will be able to identify themselves from the conversation that we are having. We wondered whether we might not be able to give the figures — the most up-to-date figures that we have — separately to the Committee. Outside the Northern Trust, the figures are low and are within current trends. It is important that we give confidence to the Committee that when we say that there is no outbreak elsewhere, it is so. Perhaps we can provide that information and get an agreement, through the Committee Clerk, about whether it is the best information we have for yesterday. Even today, it is changing.
Public confidence is extremely important. I want to reassure the public and the Committee that we are doing everything that we can. I emphasise again that, on a daily basis, we have detection and surveillance in our hospitals in order to audit hospital-acquired infections and clostridium difficile. Michelle mentioned the need for consistency. Preventative measures across the trusts are consistent, and are being taken to prevent further clostridium difficile and hospital-acquired infections. Our performance, as measured against that in other jurisdictions, indicates that we are containing clostridium difficile as much as we can.
Ms Ní Chuilín:
When the Committee extended the invitation it was not trying to put staff under pressure, devalue them or not appreciate them. We do not want front-line staff to feel that this is a witch-hunt. However, there is a massive public-confidence issue, to the point where people who have waited for months, if not longer, for hospital appointments, are approaching elected representatives with the idea of putting their appointments off and not going into hospital. Those are sick people who have not been served well by the Health Service in the first place, because they have been kept waiting so long, but they cannot face the thought of going into hospital and acquiring a fatal infection, which is how clostridium difficile is portrayed.
I understand the need for patient confidentiality; no one on the Committee will disagree with that. However, it is not good enough that we are only being drip-fed with figures that we cannot collate. For example, apart from the Northern Trust, there seems to be an inability to provide figures for the number of people who have died or been infected by this bug. We hear that there have been 23 deaths, but we do not know the figures for January. There was a media report on 7 February that the Northern Health and Social Care Trust had confirmed that three more patients had died in recent days, bringing the number of deaths linked to clostridium difficile since last summer to 23, but the perception is that there are more.
I know that you are taking precautions, and we are not saying that you should ignore targets, but patient safety should come first. You will not find anyone who will disagree with that. However, we need to strike a balance, and I am not sure that we are. My concern is that older people who need to go into hospital are cancelling appointments that elected representatives have fought to get them. What assurance can we give the public that it is safe to go into hospital to receive the treatment that they have waited so long for? That is a burning question.
My colleague Michelle asked what the current statistics are. We have introduced people to a vocabulary, such as MRSA and clostridium difficile, that was not there a couple of years ago. It is no longer only the Health Committee and healthcare professionals who use those terms, but ordinary people in their kitchens.
We have a huge battle in front of us to convince people that hospitals are safe, and that they should have the operations that they need. How are we going to get a true account of the statistics? There appears to be a mismanagement of information.
I entirely agree that a huge aspect of this is public confidence. I can honestly say that, based on the audited and agreed public information, going into hospital in Northern Ireland is comparatively safe compared to other places. Going into hospital for treatment is not, by nature, risk-free, because of the treatments that we can now provide, and the frail condition of some of the patients that we treat. A fine balance has to be struck. Comparatively speaking, hospitals here are safer than those elsewhere when it comes to hospital-acquired infection, and we are committed to making them even safer. I cannot get that message across enough.
The matter of death certificates and death rates is really quite complicated. Doctors in hospitals fill in most of the death certificates, but not all of them, and they are subject to many other agencies. We provide detailed training for doctors in how to complete death certificates, and guidance has just been reissued as a result of the current situation. We will redouble our efforts to provide training so that recording of deaths is accurate. However, we are not responsible for all of them. Our emphasis has, rightly, been on prevention and detection; we have not been waiting for audited quarterly or annual reports on death certification processes. Each trust has, as much as possible, an up-to-date picture. However, the situation changes constantly.
I remind the Committee that some of us were criticised heavily in the media and elsewhere for giving information in good faith that was adjusted subsequently and served only to undermine people’s confidence. Therefore, if we give information, it is simply the best information that we can get by phoning our front-line staff. There are shortcomings in such a system in that the situation changes every day.
Each trust is happy to provide the best information available — with appropriate caveats — about the deaths that occurred in January and February 2008. Again, to use jargon; the data will be raw and will have to be treated with caution. As I said before, because further information became available, we were heavily criticised. Therefore, a balancing act is required.
I agree that it is important to restore people’s confidence. One key measure that each trust is taking is to harness the power of expert patients. As well as explaining what we are doing and what the issues are to the wider public, we need to work in partnership with patients — and their relatives — who may have had an illness and contracted clostridium difficile as a complication. Such people can help to quality-assure our processes and suggest how we could do better.
A central plank of Government policy has been to expand the use of patients who are experts as a result of their own experience, or that of a relative, in having contracted a hospital-acquired infection. We need to build on that expertise to do even better.
I am old enough to remember walking into hospitals and noticing the smell of disinfectant; I also remember how clean the surfaces were. By having to introduce bleach-based chemicals and disinfectants, are you indicating that we have been compounding the problem through the use of products that are less able to cleanse surfaces and, therefore, that are bad for general hygiene in hospitals?
Again, I am not an expert on such matters. It has been scientifically-based best practice to use detergent-based cleaning materials, as they achieve the best balance between efficacy and safety for staff, patients and users. On rare occasions, spores — of which clostridium difficile is an example — have been found to be resistant to detergent-based materials. However, in almost in every case, a proper mixture of detergent and water is as effective as bleach and water or chlorine-based cleaning disinfecting agents.
We are not using such materials to save money; we have simply been adopting best practice in cleaning technology. It is a complex issue. Clostridium difficile spores have been very resistant to ordinary cleaning.
The Belfast Health and Social Care Trust has been carrying out some experiments with cleaning practices. The Committee may recall that there was a cluster of infections in the neo-natal intensive care unit in the Royal Victoria Hospital. We were able to fill that unit with vaporised hydrogen peroxide — a very effective bactericide and sporicide — which completely decontaminated the ward, or side room. The vapour gets into every nook and cranny, down every crack in the wall, and kills every living thing in the room. The room is then safe to re-enter. Therefore, cutting-edge, world-leading innovation was being tested. It is a form of deep cleaning, which is the vogue in England. There has been evidence of its effectiveness, and I expect it to be more widely used. Therefore, we are trying to ensure that we use best practice in cleaning technology.
I mentioned cleaning agents, and I would like to clarify my point. We took advice from wherever we could get it, including from Professor Wilcox at the University of Leeds who is a recognised expert on clostridium difficile. He advised us that, because the spores of clostridium difficile have a hard outer skin, it is important to use the correct cleaning agents in order to be sure that the spore is killed and the surface cleaned. That is why we used an agent called Actichlor Plus. I mentioned bleach or chlorine earlier, but I should not have done so, because I am not a clinician. I was merely emphasising that a particular kind of cleaning agent is effective for clostridium difficile, and that is why we are now using it.
Most of us wonder why we did not hear about outbreaks, bugs and superbugs in days gone past, when the smell of disinfectant was in hospitals and there was in-house cleaning. Is there a link to how our hospitals are cleaned today, and are today’s treatments less effective?
No, that would be an oversimplification. I emphasise that I am not a clinician.
I accept that, Norma.
I am giving you the best information that is available to me. The single biggest change is the use of antibiotics, which kill the flora in the bowel and allow clostridium difficile to grow. My understanding is that three things must happen before a person gets clostridium difficile. First, the bug must be in the person’s bowel. We know that 30% of older people and 3% of the general population may have the bug. Secondly, the person must have taken an antibiotic or a proton pump inhibitor that will have the effect of killing the flora in the bowel. Thirdly, the person must have a reduced or compromised immune system so that if they get an infection, their body is so compromised that it cannot use its normal, natural responses to an infection.
If a person is very ill, frail or elderly, their immune system will be lowered. Therefore, they are at risk of clostridium difficile taking hold and becoming infected. It should be an assurance to a member of the public who is coming into hospital that all those conditions would have to be present.
Ms S Ramsey:
Thank you for your presentation, which has left me with a lot more questions than I thought that I would have. As previous speakers said, public confidence is at an all-time low. During the presentation, you said that you wanted to be straightforward with information. However, it has been accepted that at the early stage of the outbreak there was a lack of information in the public domain. We are continually being told that we are not doing too badly when compared with international standards. That is probably right, but 77 deaths is a high number, and we must take on board the fact that we are not talking about figures; they represent human beings and family members.
Like my colleagues, I am not being critical of front-line staff. I know that they are doing positive and proactive work. I am criticising the lack of resources that are available to them. As chief executives and senior managers, you must take that point on board and raise it with the Department internally. I have no doubt that the Health Committee will support you.
I have several questions. Is this the first time that you have come together as chief executives to discuss this outbreak? Do you come together to discuss major issues that take place in hospitals? I am glad that the Chief Medical Officer is in the public gallery, as another question strikes me: how many incidents, or deaths, need to happen before the Department or the Chief Medical Officer is informed?
How many patients currently have clostridium difficile and what is being done to reassure them? Ms Evans said it was possible that clostridium difficile was transferred to another person by staff or visitors in a number of cases — I would like some information about that. In addition, if 30% of older people have clostridium difficile, that poses another question. If we are aware that a percentage of people admitted to hospital have clostridium difficile, are they being screened on arrival? If every patient who has had diarrhoea is being examined for clostridium difficile, is that being done continuously — no matter who that person is?
Ms Evans referred to the intensive cleaning programme. How often is an intensive cleaning programme carried out? Are we waiting until there is a problem before carrying out that cleaning? Could the Committee have information about that? Does the strategy for infections cover all infections, including MRSA? My mother had MRSA and the family had to clean her room. I am not talking about 10 years ago; it happened only a few years ago.
Public confidence is the issue. As elected representatives, it is our job to tease out the issues, so that the Committee, through its roles and responsibilities, can give the public some confidence. The witnesses here today may not like to hear it, but the perception is, when one looks at the amount of work done recently with regard to BSE, animal health, and ports being closed, that that matter has been given more importance than this.
Confidence is the issue. However, I want to return to the question about information. No one on this side of the table is interested in anything other than being completely straightforward with the information. There is no desire not to give information. However, it is important that any information given out is accurate. There is nothing worse than giving out information and then having to change it, because that undermines an organisation straight away, even if it is trying to be helpful. That has certainly been our experience recently.
Information is published, and we contribute to the publication of that information through systems, which the Committee, and all of us, have access to. We may all agree that publication is not as timely as it should be, but that is under review. I am sure that the Chief Medical Officer will tell the Committee shortly that the timings will change. We will get more timely information all round. I emphasise that there is no desire not to be straightforward or open about information or its availability. It is not in anyone’s interest to do otherwise.
You asked whether we met as a group. The answer is yes; and I am the temporary chairperson of the group. We usually meet on the last Friday of the month, and we discuss a wide range of issues pertaining to all of the trusts. We have discussed how we deal with the infection and related matters in a normal, routine, businesslike manner.
In relation to transfers, the 30% referred to, and older people — when one knows something and one has a predisposing likelihood of something that can happen, one does pay attention to it. We all pay attention. We are trying to communicate to the Committee, and to the wider public, that we are aware of the risk factors as they pertain to older people, and we take considerable effort to try to avoid walking into a problem as opposed to preventing it. Frequently, a presumptive diagnosis is made, before it is confirmed by clinicians. We begin by treating the patient as though he or she had the infection, and we manage them accordingly.
We have a very straightforward deep-cleaning policy. If there are three cases in any area in a four-week period, a full environmental clean is carried out.
Ms S Ramsey:
If there are three cases of what?
If there are three cases in any one area in the South Eastern Health and Social Care Trust, we carry out a deep environmental clean. I am sure that the same thing happens elsewhere.
Ms S Ramsey:
Does that apply to any hospital-acquired infection?
I am sure that the same thing happens elsewhere, because we all operate to the same environmental cleanliness standards, and we have to make returns on environmental cleanliness. Recently inspections were carried out in all hospitals, and they were only given 24 hours’ notice. Therefore, if there were any problems, they could not be fixed within that time, especially given the size of the hospitals. The results of those inspections were very good — we have been told that verbally. However, the raw data will be published in due course. It will take a little time for the inspection teams to publish their findings, but that is the initial feedback to all the organisations. Obviously, there is no point in waiting for the publication of the findings to discover that there is a problem.
Today, we want to try and give confidence to people, because that is the issue. We want people to know that we are serious about tackling the problem and are not being complacent about it. We are doing everything we can to control difficult situations when they arise. However, we also want to ensure that people understand that it is comparatively safe to attend hospitals. No one can say that going into hospital is a risk-free experience, because, as my colleague indicated, some treatments carry inevitable risks. However, we encourage people who have appointments to attend hospital. They can ask questions and seek reassurance when they arrive at the hospital, rather than not attending at all. We really want to get that message across to the wider public today.
You rightly linked clostridium difficile, MRSA, and other bugs that can be acquired in hospital, because there is a long tail of rare but nasty bugs that are not as well known. All the evidence shows that if hospital-associated infections are tackled as vigorously as we are tackling them, there will be an improvement across the spectrum. Although I do not have the figures in front of me, I have been assured that there has also been an improvement in MRSA rates. We have a separate target to meet for MRSA rates.
Ms S Ramsey:
How many incidents, or deaths, take place before the Department or the Chief Medical Officer is informed?
There are reporting and surveillance mechanisms whereby we report to agencies that act on behalf of the Chief Medical Officer. The great thing about Northern Ireland is that we can also lift the telephone and talk to each other. I emphasise that we do not wait until we see the information on a death certificate before we take action. We are at the front end, trying to prevent infections. When infections are detected, we take prompt action.
We have gotten into trouble in the past through trying to reassure people by using unapproved death certification data before the relevant agencies have carried out their checks. We have up-to-date figures for January and February 2008 of the small number of incidences and deaths, but the figures have not been audited. We are happy to submit those figures separately. The numbers are so small that people may be able to identify themselves, particularly if we go into detail.
As Ms Evans said, people who acquire such infections are elderly, they have the bug in their gut already — but there are usually no symptoms with that — and they will have taken antibiotics and had their immune system compromised because of some other medication or illness. A small proportion of people get clostridium difficile, and an even smaller proportion of people die as a result. I cannot emphasise enough that our performance is not just OK — it is good compared to elsewhere. We are not complacent, and every avoidable death is to be regretted and requires a redoubling of effort.
There is great concern about whether clostridium difficile and MRSA have been recorded as contributory factors in the deaths of many elderly people in hospitals. There is a whole constituency that wonders whether there MRSA and clostridium difficile were contributory factors in the death of their mother, father or elderly frail grandparent. When the news emerged about the outbreak of all those superbugs, many in the community wondered whether those might have been a factor in their relatives’ deaths. I am not suggesting that hospitals were trying to hide outbreaks, but there are questions over how often deaths occurred before all the public interest in the matter. In other words, how often were those superbugs a contributory factor in people’s deaths but not recorded as such?
Because I have lost a loved one, I know that the relative is given a hard copy of the death certificate, which lists the primary cause of death and the associated causes of death. Thus, every family who has tragically lost a loved one will receive that certificate.
We provide training to all our doctors, particularly those involved in training, and I am sure that the Chief Medical Officer can detail the training that he advises us to provide. No doubt further guidance will be issued. The different Departments and agencies involved, including the Department of Health, Social Services and Public Safety and the Department of Finance and Personnel, have worked to improve death certification and the reporting of deaths. However, we have been doing our best.
If there are concerns, then those should be raised. If a person says that a doctor told them that their relative had a certain condition, but that condition is not listed on the death certificate, then the person should query that. We are as open as possible in that regard. The criticism has been made that we have been using information that has not been audited properly. Discussions with the relevant agencies have taken place on our behalf to see if more prompt, audited, information can be fed back to us as part of an effort to restore public confidence. However, I emphasise that we do not wait for deaths to occur before taking action. We act on risk factors and actual symptoms, and we are resolute in that.
There is a comparison to be drawn between this issue and the row over organ retention. As you know, Mr McKee, I was very involved in that matter at the time, and it caused people to lose a lot of confidence in hospitals. Indeed, the whole donor system was almost knocked out of kilter because there was no openness about organ retention, and so on. There are questions over the handling of that issue, too.
It used to be a fact of life that a doctor was like a god. People did not dare approach doctors or ask them questions — if they did, they would be given short shrift. I want to be encouraged that doctors no longer take that stance and that if families want to ask questions about what is wrong with their loved ones, or about complications, they will get the answers that they seek. Those loved ones are dearly held within the family unit, and if we put ourselves in their position, we would want to know everything that there is to know about how they died, and about any contributory factors. I hope that the clinicians who, for many years, were like little gods in their ivory towers do not feel that that they are still there now. Rather, I hope that they are open and transparent in their approach. We must encourage people to have faith that they will be told all the facts as and when they ask for them.
We can never say "never". Best practice shows that the doctor who has had most to do with the care of a particular patient should have a conversation with the family at every stage of treatment, whether it is because they suspect that the patient has a clostridium difficle infection, or is coming close to the end of life, or to talk about the underlying causes of a patient’s death. We try to encourage that. That is what happens. We inform families that they should expect that to happen.
So that is the standard? OK.
I would like to comment because, probably, the Northern Health and Social Care Trust was the trust about which the most questions were raised. Two sources of information are available. One source is the information that we take from the infection control teams, which we have already talked about. That is real-time information that we receive on a daily basis. We published our figures yesterday. Therefore, I know that yesterday we had 15 active cases of clostridium difficile and 13 patients who were recovering from that infection. We know that we had four deaths that were associated with clostridium difficile in the preceding week. We gather real-time information because we are in an outbreak situation.
A difficulty arose because we used infection-control information, in good faith, and reported 13 deaths that — we believed — we had had in the final two quarters of 2007. We analysed the preliminary figures that came from the Registrar-General’s Office that showed that there were 31 deaths in the Northern Health and Social Care Trust for the whole of the year, 20 of which occurred in the final two quarters. Therefore, there was a difference of seven deaths between those figures and the ones that we had declared, which again I emphasise, were taken in good faith from our infection-control team who were monitoring patients on a daily basis.
We have now got the names of all of the patients that the Registrar General’s Office identified as having died in hospitals in the Northern Health and Social Care Trust area. We are reviewing all of the files and cross-referencing them with those of the patients we declared through infection-control. It is a complex process. For example, after a person has recovered from clostridium difficile, for how long does one consider them to have recovered before one records on their death certificate that they had clostridium difficile? Should it be two weeks, a month, or a year? Those are the kinds of difficult decisions that clinicians have to consider when completing death certificates. We will know the answer when we complete the review of files.
Infection-control staff in my trust suggested that they had stopped tracking some patients because they no longer had the infection. If those patients died subsequently, the clinician may have said that although they had already recovered from the infection prior to their death, the infection had had a significant effect on their deterioration at some point during their illness. Therefore, clostridium difficile would be recorded on the death certificate even though we have stopped tracking them through our infection-control figures.
I do not know if that explanation helps the Committee to understand the discrepancy in the figures. I can assure you that, as far as the Northern Health and Social Care Trust is concerned, staff have been completely open and honest. We have provided accurate figures to the best of our ability. Unfortunately, that stance has rebounded on us because those figures were not validated, but we have tried to be open. We told people that we had an outbreak and we have provided the press with information on a weekly basis, as they have requested. I do not know whether my explanation is useful to Ms Ramsey.
Ms S Ramsey:
It is quite useful. It has been said that 30% of older people have that type of bug. Earlier, it was said that when people presented at accident and emergency with vomiting and diarrhoea, they were not put into a general ward. Surely it is common sense that if 30% of older people have the bug they should be screened for it?
One cannot screen for clostridium difficile. If someone presents with diarrhoea then a specimen can be tested and one can identify the infection. In the middle of the Northern Health and Social Care Trust’s clostridium difficile outbreak in December, we also had a norovirus outbreak. Therefore, a number of people had diarrhoea although it had nothing to do with clostridium difficile. It is important that one undertakes a microbiological examination of a specimen to be sure which bug one is dealing with, what ribotype it is, and whether it is clostridium difficile. Not all of the patients in the Northern Trust area have had ribotype 027. However, the largest proportion of them have.
Ms S Ramsey:
How do you explain the clusters? There have been no major outbreaks in other trust areas.
Frankly, the Northern Trust was simply unlucky. There is an element of chance.
Ms S Ramsey:
Part of the Committee’s job is to uncover that information.
Central to the issue is the fact that 30% of older people have clostridium difficile in their gut. All other matters being equal, they will not be aware of it and will not have symptoms. Three out of any 100 people who come through this room will have the bacterium and not be aware of it. It is difficult to obtain a specimen and to grow it in a lab. With the best will in the world, it takes several days to identify.
Trusts can, however, identify whether patients are at risk. For example, patients are transferred from regional hospitals to hospitals in central Belfast because of their acute condition. On balance, it is best to admit the patients, because they need particular clinical treatment. However, a risk analysis is carried out to determine whether the patient has come from a hospital where there have been cases or a cluster of clostridium difficile; has had diarrhoea recently; is on antibiotics; or has a compromised immune system. Then we take action based on that, just as infection control teams who work with front-line ward staff monitor diarrhoea and other symptoms and take action in advance of the result of the analysis. Because it is so difficult to grow the bug, the result simply states whether a particular toxin has been found that suggests that the bug is present. The point is that people who carry the bug do not know who they are.
I shall try to be as brief as possible. I have six questions, but yes or no answers may suffice. Do any of the trusts deal with clostridium difficile in the community, rather than just in hospital settings? Does any antibiotic work against the bug? Can trusts reassure the Committee that all patients who are infected with clostridium difficile are isolated?
It is positive that staff in Northern Trust hospitals, where there has been an outbreak of clostridium difficile, seek to ensure that infected patients are isolated and that their visitors are asked to wash their hands. However, should it not be the case that all trusts provide wash-hand basins outside every ward, with visiting restricted to once a day, and somebody standing at the door to ensure that visitors wash their hands? That may seem draconian, but I think that it would help a lot.
The Minister has suggested new staff uniforms. Have his proposals been implemented?
We all know of specific instances when a patient has had to be admitted to hospital from a community setting with symptoms of clostridium difficile infection. Because such a high proportion of older people have the infection, it is present in the community. The preconditions for catching the infection — having a compromised immune system, being on antibiotics — happen outside hospitals. If I were to sum up on the issue, I would say that this issue goes beyond hospital trusts.
I am not a qualified pharmacist or clinician. Therefore, I would need to take advice on how the infection is treated. As far as I know, one treats the symptoms. Ms Evans probably has more knowledge, because of her recent experience in the Northern Trust.
My understanding of the advice that is given is that certain antibiotics must be avoided. There is always a risk from the use of broad-spectrum antibiotics. Dr McBride, who is a clinician, will be speaking after us. My understanding is that there is always concern about the use of antibiotics to treat people who are immunocompromised.
Dr Peter Flanagan (Northern Health and Social Care Trust):
Two antibiotics — metronidazole and vancomycin — are specifically used to treat active clostridium difficile infections, and part of the approach is to ensure that such patients receive treatment as promptly as possible. It is slightly confusing because, on the one hand, we are saying that certain antibiotics can cause clostridium difficile and, on the other, specific antibiotics can be used to treat it.
Each trust is rolling out new, tougher visiting arrangements. Although we always seek to strike a balance between making our hospitals open and welcoming to relatives and loved ones and protecting the safety of those loved ones and others, nevertheless, we are all rolling out those new, stricter hospital-visiting arrangements.
The provision of wash-hand basins depends on how modern the particular hospitals that we have inherited are; some are well equipped and others are not. However, we make the best of what we have. Hand-sanitising solutions are universally available, either at the bottom of every bed or at the entrance to every bay or ward.
Do you believe that visitors should be made to wash their hands?
In the case of clostridium difficile, it is important that one washes one’s hands, because alcohol gel does not work. However, for other infections, we recommend that people use the alcohol gel that is provided and which is effective.
In addition, depending on the availability of single rooms and other methods to barrier-nurse, cohort or isolate patients, we take further actions to deal with clostridium difficile.
Uniforms are problematic. Huge investment would be required to provide facilities for all front-line staff to change from their uniforms into going-home clothes or from standard nurse’s uniforms into theatre scrubs. Much work has been undertaken by the Department to devise proposals; however, the cost would be great.
Once again, we must strike a balance. The Minister has made £9 million available in order to tackle hospital infections, and each trust wishes, for example, to beef up its cleaning-intervention teams in order to intensively clean particular at-risk areas. In addition, each trust would like to employ antibiotic-prescribing pharmacists to work alongside medical and nursing staff in order to improve their knowledge of, as Dr Flanagan said, whether or not to prescribe medicines depending on whether one is trying to avoid or control an infection. It is complicated, and therefore we will probably use the £9 million in various areas. The cost of dealing with the wider issue of nurses’ uniforms would be much bigger.
Obviously, there would be costs, and many hospitals would not have the space to isolate, or be suitable to provide, changing rooms. However, we must investigate that. Recently, I was in hospital, and I was amazed to find that one did not know who the doctors were unless they had stethoscopes around their necks. They dressed in their daywear and did not have coats. Considering that doctors are supposedly identified by their dress — in a white coat or whatever — I was amazed that they came in wearing their ordinary gear.
I agree with you. However, if I may say so, we are showing how old-fashioned we are. Regardless of what people wear, we expect each member of the clinical staff to clearly introduce and identify themselves when they meet a patient, and not rely on having a stethoscope around their neck. Often, white coats are considered to be more trouble than they are worth and can be a device for carrying infections. We encourage doctors to wear short-sleeved shirts and not to have long ties, such as the one that I am wearing. Now, it is difficult to persuade younger doctors to wear bow ties.
Those were the good old days.
In society, dress has generally become more informal. However, the current best-practice guidelines are to have short-sleeved shirts and not to have long ties.
I would like to pick up on the issue of isolation of patients by the trusts. We audited 48 patients who had acquired clostridium difficile since last August, and found that in four of those cases we had been unable to provide a single room. In those cases, we apply extra preventative measures and ways of looking after those patients as we try to get each of them into a single room.
My colleagues envy me because of the capital announcements. The west is doing very well in that we have two new-build hospitals, one in Enniskillen and one in Omagh. The Minister has said that those hospitals will comprise 100% single rooms. We would all agree that that is the way to go in preventing and controlling infection.
Many issues have been covered today. We have heard about the measurements that have been carried out against UK and international standards. There is no getting away from the fact that it is good to benchmark against something. However, we must be realistic today. The recent outbreak of clostridium difficile has caused a huge loss of public confidence and a mistrust of the Health Service, to the extent that elderly people are cancelling appointments. To stop that from happening, we must deal with that lack of confidence.
The infection prevention and control measures that have been taken have been described as "robust". Have those measures been applied in all trusts? That is important. We talk about hand-washing, in and out of the hospital, but the cleanliness of the hospitals and the wards is also a big issue. How often are wards cleaned? Constituents have told me that they have been in hospital for two or three days and not seen anyone cleaning the ward. That raises concerns for me, and I wonder how often wards are cleaned.
We have also talked about the importance of clean beds. I have been told by some folk that beds are now cleaned just with soap and water. I am not sure whether that is correct, but that is the message that I am getting from folk who have been in hospital or who work in hospitals.
Mrs Way talked about the high-occupancy beds in Altnagelvin Hospital. I am concerned about that, and about why it is happening. I could go into why that is happening in the west, but I am going to spare the Committee this afternoon. We know why that has happened in the west, but I want to know what the Western Health and Social Care Trust is doing to address that problem.
The private clinics are not affected by this infection at all. Why is that? Is there a message there? Is there something that we should be looking at? How can the infection be acquired in one area, while other areas are unaffected?
The issue of front-line nurses talking to their line managers was raised, and whether they could discuss concerns, difficulties, or things that could be changed. I welcome that, but many front-line nurses are afraid to speak out when they discover a problem or a difficulty because they are afraid of being reprimanded. I would like to see a situation brought about in which nurses have the confidence to speak out if they see something wrong or something that could be improved.
There were 77 deaths as a result of clostridium difficile infection in 2007. Did all those people go into hospital with the infection, or did some of them pick it up while in hospital? That breakdown may or may not be available, but I would like to know whether some people went into hospital without this infection and picked it up while they were there.
I suspect that some of those issues are specific to the Western Health and Social Care Trust. I would like to have the information relating to the patients who have said that they have been in our hospitals for days and that the wards have not been cleaned. It is my belief that every ward is cleaned daily. If people have different information, I will need to examine that.
I will pass that information to you.
Thank you. With regard to the high occupancy levels in Altnagelvin Hospital, we are working with Tribal, which is a consultancy that has done some work in England, to examine reducing the length of stay for medical admissions. That will require us to redesign things, to care for people differently and to move towards some out-of-hospital care. I am happy to meet you again and talk through that project.
My own belief about private clinics is that they deal with client work. They do not deal with the emergency admissions, such as cases of pneumonia, which come through the NHS doors. Therefore, we often deal with the most vulnerable patients. I cannot comment on the 77 deaths, because I do not have that information.
It is unfair to compare the work of health and social care trusts with smaller private hospitals, for a variety of reasons. We are subject to more public scrutiny than the private sector; therefore, the fairer comparison is with other public-sector health systems, or even privately-funded health systems, as opposed to small private hospitals. It would be better to compare us with England, Wales, Scotland, Ireland, or with the international comparisons that we have available.
With regard to those people whose underlying or associated cause of death was clostridium difficile, the difficulty is that 30% of older people have the bug in their gut without displaying any symptoms, so we do not know whether they have brought the bug into the hospital and well-intentioned actions around prescribing antibiotics allowed it to overgrow in the gut and contributed to their deaths, or whether the infection was transferred from one patient to another, or from one patient to another through a member of staff. We would not know whether they brought the bug into the hospital unless we went through a detailed analysis, because it is a hidden feature that three out of 10 older people have the bug without displaying any symptoms. We can identify some cases where we are pretty sure that the bug was caught in hospitals, but it is a small number, because 30% of people already have the bug.
The issue of confidence is central to this matter. The fact that we are here at the Committee is contributing to that confidence, because the purpose for us is to reassure people that no one is taking the matter lightly. We understand the issues around confidence. I hope that the willingness and openness that we are demonstrating today to provide whatever information we can is a sign that we believe that the issue of confidence is important, and we want to contribute to the restoration of that confidence.
We all follow standard cleanliness schedules across the Province. All of those schedules are audited. We relate in detail to our colleagues in the Department what we are doing on the cleanliness schedules, and a similar pattern of cleaning takes place in all our hospitals. It will vary slightly because of the age of buildings — newer buildings will have different patterns to older ones.
In the same way that you go to job interviews, we must go to the electorate. We get it in the neck if things do not run smoothly. With a newly devolved Administration, people want to see accountability and openness more than ever. It is very important to send out a message that there is openness and co-operation between elected representatives, who have been ignored in the past when trying to represent the rights of our constituents, and the public sector. Today can be a learning curve for all of us — we do not complain for the sake of it; we are trying to represent human beings who have a difficulty or a concern.
I was making the point that we are keen to hear those concerns.
With the new dispensation, it is good to have a rapport that helps politicians and the trusts know what the public think on various health issues.
Rev Dr Robert Coulter:
William, you have scared the life out of me.
I am nearly in the age bracket as well.
Rev Dr Coulter:
I am one of those older people you described, and I have just taken a double course of antibiotics. I will have to ask Dr Deeny here for a prescription.
I pay tribute to the Northern Trust for the way that it has responded to an extremely difficult situation. We congratulate Ms Evans and her team on the way that they handled the situation.
A number of my concerns have been addressed. Alex talked about staff hygiene, and we have heard nurses and medical personnel say that sometimes they have to change their uniforms in toilet cubicles. That is not good enough in this modern age. It will cost a lot of money to provide sanitised areas for staff to change their clothes because two, at the very least, would be needed in each hospital. One of the main concerns should be that staff areas are as sanitised as the ward areas. Is that too much to ask? The problem of staff wearing their uniforms to and from work is being addressed.
Another issue that has emerged from some of the media programmes is the amount of unchecked goods going into hospitals. I heard a delivery man say that he often walks into hospitals, delivers parcels to various wards and walks out without being checked. Would it not be better to have one centre that checks all incoming goods?
Alex also mentioned community health; I know the emphasis that the Northern Trust places on keeping older people in the community and the great work that it does in that regard. However, what happens when an older person is suddenly taken with diarrhoea? Are they expected to sit for 12 hours in an accident and emergency department? Having had diarrhoea, I would not like to sit for 12 hours in accident and emergency before receiving any treatment, or even attention.
What is happening in the outpatient areas? How clean are the vehicles that transfer people, including older people who have a 30% chance of having clostridium difficile, from their homes to hospital? There are many other issues, but that is enough for now.
I appreciate your comments in recognising the efforts that the staff and the trust have put in to trying to manage the outbreak. I did not refer earlier to staff, as my colleagues did. However, I must say that the staff in the Northern Trust — everyone from the trust board down to those at the front door of the hospitals — have been absolutely superb in their determination to address the situation. They are committed to ensuring that we get on top of the outbreak and that we manage and overcome it.
Mr McKee has said already that the issue of staff changing facilities is quite difficult, particularly in some of the older hospitals. We have good changing facilities — or better changing facilities — in the newer hospitals such as Antrim Area Hospital and the Causeway Hospital, whereas the facilities in some of the older hospitals, such as the Mid Ulster Hospital and Whiteabbey Hospital, are not as good. We have a very strict rule that staff should not wear their uniforms in public. If they do not have access to changing facilities before they go home, or when they are coming in to work, they should wear a coat over their uniform to cover it.
The majority of the patients in the current outbreak are in the Antrim Area Hospital and in an isolation ward, where all of the nursing staff change their uniforms every day. They have changing facilities and they have a clean uniform every day, and when they are going home they change into their day clothes.
With reference to the issue of people coming in from the community, as colleagues have already said, it is clear that clostridium difficile is in the community. In some cases, we are admitting patients with a confirmed diagnosis of clostridium difficile before they come to the hospital. It would be impossible for someone with diarrhoea to remain in an outpatients’ department for 12 hours without having facilities. I appreciate that it is an undignified situation. To the best of my knowledge, all of our accident and emergency departments have toilet facilities. Given that a lot of those people are older, many will use a commode or portable facility, which will be cleaned after each use.
In Antrim Area Hospital we have identified a separate area for the treatment of people who present with diarrhoea, because of the current problem. We try very hard to respect the dignity of people in that situation and respond to them appropriately. We will fast-track someone in that situation and try to get him or her into a bed and a more appropriate situation. I hope that no one with diarrhoea has had to sit for 12 hours in accident and emergency, and I hope that no one will say that their mother did. Nevertheless, that is our intention and aim.
Outpatient areas are cleaned in exactly the same way as all of the other areas of the hospital. In some ways, outpatient areas are easier to clean because that tends to be a nine-to-five or eight-to-six service. Those areas are empty of patients and staff for fairly lengthy periods, which facilitates cleaning — particularly of toilet areas. We clean all the toilets in the hospital every hour. We have put notices up in all the toilets asking people to advise a member of staff if they find a toilet that is unsatisfactory.
Vehicles are a major challenge for our colleagues in the Ambulance Service. I cannot speak for the Ambulance Service, because I do not know what its decontamination procedures are, although I know that it has procedures. Currently, the Ambulance Service is working closely with the Northern Trust. When we have to transfer patients with a clear diagnosis of clostridium difficile, the Ambulance Service provides a vehicle that is used for those patients only and is thoroughly cleaned before it goes back into the general fleet. I cannot speak about any other situation.
It was I who mentioned the target of 12 hours. Every patient who is delayed is treated with complete dignity. They are placed in discrete areas with access to a toilet. We would not want to admit a patient, who is known to have diarrhoea, into a six-bedded unit when a single room is not available. That patient is still counted as being there for more than 12 hours if he or she is not admitted to a bed. I assure you that patients are treated with dignity.
Ladies and gentlemen, you are more than welcome. I know all five of you now. I speak as a member of the Committee and also as a GP who has worked in the Health Service for years. I am glad that I have been called to speak near the end otherwise I could have had around 20 questions.
Hospital visitors have a responsibility for hygiene, as do health professionals. Mention has been made of staff moving backwards and forwards. Hygiene and cleanliness were mentioned, and that is where your role, as chief executives, comes into play. How often do you monitor the people who clean your hospitals?
I am the first to admit that doctors, including me, are often guilty of giving in to the public when they demand antibiotics for the second or third time. There is no doubt that we must be more firm.
The Chairperson, and others, referred to openness and transparency. I see the need for that through my role in public representation and through the job that I am involved in. For far too long, the public have felt that things are being done on an in-house basis, and the perception is that things are going wrong in hospitals and in the Health Service but are not getting into the public domain. I have heard those concerns since entering politics.
I commend Norma Evans and the Northern Health and Social Care Trust; you have led by example. Since coming into public representation, I have learned that the public want to hear the truth, warts and all, rather than having serious issues dealt with on an in-house basis. When issues leak, as they usually do, situations become far worse. It is nice to be open and upfront, and to identify a problem and deal with it.
I have been a GP for more than 20 years, and I recall working as a junior doctor in Newry when William McKee was there. Perhaps the problem is global, but the bottom line is that there are more people coming out of hospital with infections. They are frightened and they are getting sick. I will not blame or point the finger, but I will give two examples.
As you know, I work two days a week as a GP. In the last couple of months, a young lady, who was very ill after a Caesarean section because of a hospital-acquired infection, came into my office. I cannot remember that type of situation happening years ago. A mature lady, whom I have no reason to disbelieve, came to me about a similar issue in a hospital in the southern area — the area that Colm Donaghy is responsible for. Nurses and midwives at the hospital are run off their feet because of the large number of babies. Only a few weeks ago, that lady wiped a cot in the hospital’s post-natal ward and she could believe the amount of dirt that she found. The person who raised that issue was being honest, and I hear about similar sorts of issues.
As Mrs Way is aware, this is not a blame game. Elected representatives, health professionals and senior managers need to work together to address these issues.
The Chairperson made a point about whistle-blowing. Perhaps that is a term that people do not like to use as it is deemed to be like informing; perhaps a different term needs to be used. I have received two letters in the past year or 18 months about hygiene in the Erne Hospital. However, I could not do anything about it because the letters were anonymous.
People are frightened to raise issues in case they get punished. Staff members have approached me with problems, and I have asked them why they have not informed their line managers. They said that they were afraid of giving the hospital a bad name. They also believed that nothing would be done about the problem and that it would be hushed up. The public also perceive that there is no point in complaining as nothing will be done. What I am trying to say is that openness and transparency are required.
The five trusts are relatively new, and this is the time for a new beginning. A lot of the things I have been talking about may have happened in the past — and I am not pointing the finger at Mrs Way. I have worked in the Health Service for long enough to know that patients are the priority; that is paramount. As a health professional, I feel that if one of my colleagues is underperforming or putting a patient at risk, or if there are hygiene issues, then I am obligated to report it.
Political representatives, trusts, and, indeed, the Department and the Minister need to make a public statement soon to encourage health staff to come forward with issues without fear of punishment or recrimination. That is vitally important. For far too long, people have been frightened to raise issues in case they are blacklisted.
Several people have told me about awful situations in which relatives have to wash their loved ones in hospital beds or have to feed them because nurses are too busy. The understaffing of nurses has to be investigated.
The Minister has announced that spot checks are going to take place. I want to know what the witnesses think of that.
The Regulation and Quality Improvement Authority (RQIA) has been asked to conduct a review into the deaths that have been linked to clostridium difficile. I am delighted that Colm Donaghy and John Compton have said that that review is going to involve all of the trusts — that should be the case.
The RQIA gave evidence to the Committee on 11 October 2007. It has strong powers regarding nursing homes and so on. However, one of their representatives stated:
"Our powers in the statutory sector are more limited".
I want to know how much power the RQIA is going to have when conducting the review. The authority is a Government agency, which comes under the DHSSPS, and it concerns me that people may see its review as an in-house investigation.
Perhaps I have been prompted to speak; Dr Deeny said that I was staying quiet. I was staying quiet because I did not feel the need to intervene at any stage.
A specific issue was raised about births at Craigavon Area Hospital. It is a public fact that Craigavon Area Hospital currently provides a service to more mothers than it was doing over the past five years — births have increased exponentially. That does not mean that we are any less vigilant when it comes to detecting infection. In fact, our maternity and obstetrics services are as much a part of our detection process as any other part of the hospital. Therefore, owing to the detection, surveillance and audits that are in place, we would be aware if there were adverse impacts due to hospital-acquired infections. There are no adverse impacts.
Dr Denny spoke about cleaning, and a cot was mentioned. Perhaps he will make me aware of the specific incident. I assure the Committee that all wards are cleaned regularly — more than once a day. The work is monitored closely by trained hospital staff.
I also wanted to mention stewardship as regards the prescribing of antibiotics in relation to clostridium difficile. As Ms Evans said earlier, stewardship of narrow-spectrum antibiotics is part of our 10-point plan in Craigavon Area Hospital. There is a greater risk with broad-spectrum antibiotics as regards clostridium difficile. Therefore, antibiotic stewardship is applied where clostridium difficile has been caused by an antibiotic, and we take action very quickly. It is usually very effective.
Openness and transparency were mentioned, and Dr Deeny talked about what is truthful and what is hidden. We endeavour to be as truthful, open and transparent as we possibly can. If there is anything else that we can do to be more open, truthful and transparent, please tell us, and we will do it. We will be as open as we possibly can. My colleagues have already rehearsed the issues around information that is sometimes not validated. It is important not to mislead the public. We must be confident that the information that we give out builds public confidence.
I am not sure whether my colleagues have anything more to say about that.
I will go in to bat for a while. Dr Deeny was kind enough to remind me that nearly 30 years ago we were together in Daisy Hill Hospital. However, medicine has changed a great deal in the past 30 years, Kieran. You asked why, with all the good work that is going on, there is a new threat in the form of hospital-acquired infection. It is worth restating that infection rates here are lower than elsewhere, and but for the current outbreak of clostridium difficile in the northern trust area, we would be able to show very impressive figures.
We are not complacent; there is no acceptable level of hospital infections, but some of them are unavoidable. The trend is well researched, and it is well understood across the world that antimicrobial prescription and its use in agriculture and other areas has led to widespread resistance to these interventions. I had a difficult debate with a close family member who, quite rightly, demanded to know from me why a GP would not prescribe antibiotics for a cold. However, you will understand that there is a wider issue beyond hospitals, medicine and healthcare in general about the use of antibiotics.
Hospitals have changed. We do things that we would not have dreamed of doing 30 years ago. We treat very ill people with very risky interventions, and we are working at the cutting edge. For example, I have seen a doubling in the rate of Caesarean sections during my career. There are more Caesarean sections now, partly because of safe practice, and partly because of personal preference on the part of the mother.
The point is that the comparatively low level of hospital infections here is coming down. We will meet the tough ministerial target of a 20% reduction in clostridium difficile by April 2009 and a 10% reduction in the incidence of MRSA. In response to another question, I said that if we are doing the right thing, it will have an impact on the whole range of bugs that people are susceptible to in hospitals.
I did not complete my question to Mrs Way about whistle-blowing. I have received two anonymous letters about the Erne Hospital being dirty. I could not use them because people would have accused me of undermining the hospital. One letters was sent to me before she took up office. However, if those people had identified themselves, I could have contacted her. Why can people not go to someone they can trust, so that the situation can be dealt with? If not, they will come to people like me, although they are more than welcome to do so.
Your comments about whistle-blowing were very significant to me, Kieran.
When I was chief executive of Altnagelvin Hospitals Health and Social Services Trust, I spent five months out and about in preparation for the merger of the three trusts in the west. I received a number of anonymous letters from what I now describe as the southern sector of the trust. Since becoming chief executive of the Western Health and Social Care Trust, I have received a number of anonymous letters from the same sector of the trust. That says a lot about staff feeling unable to express their concerns openly to managers.
It is very early days in the new organisation — it is only the start of month 11 — but I am encouraged by the track record in two previous trusts, whereby staff have always felt enabled to say it as it is. For example, as some Members from the west will know, when we considered how to safely provide out-of-hours cover in the laboratories in Omagh and Enniskillen, a doctor went to the area to talk about the issue. He asked whether he could speak about this matter, and we told him to be open. I completely agree with others who have said that the new structure of five organisations presents a new opportunity to be absolutely open, particularly with public representatives. The point is well made that this is a completely different world in which there is the power to change things. We want to be open and work with you to create a better service for our patients.
Who should the public go to? It took the Western Health and Social Services Council to carry out an inspection of the Erne Hospital — having given the hospital an hour’s warning — to find out that the wards were dirty. However, I had been told in two letters that the wards were very dirty.
That inspection by the Western Health and Social Services Council was part of the Bugwatch survey, and the findings were presented to me by the council’s chief officer the day after it was completed. She has commended us on our approach — both on how we received the report and how we have developed an action plan. The point has been made today about the relationship between environmental cleanliness and the spread of infection, and I rest on what Mr McKee has said several times. If we look at the evidence, it is clear that infection rates and deaths in the Erne Hospital are among the lowest in the Province. Staff are working very hard to control infection. Since that survey was carried out, I have tried to address some of the environmental issues as well.
Good afternoon. You are all very welcome today. Obviously, everyone here wants the same outcome: we want to reduce the number of clostridium difficile cases and control the outbreak in the Northern Health and Social Care Trust area. Although we must keep this outbreak in perspective, it is undeniable that clostridium difficile can lead to a very nasty and undignified death, particularly for elderly patients. The experience is very traumatic for relatives, too. The spotlight is on this Committee meeting, and it is particularly on you as the senior personnel involved, because accountability stops with you.
We all agree that we must inspire public confidence, because that is a big problem at the moment. No one wants to hype up this issue and get it out of perspective, but there are concerns about it. Indeed, there have been concerns for quite a while about hospital-acquired infections such as MRSA and others. They have always been fairly high on the agenda, and the feeling has always been that we never quite got to the bottom of the problem. I welcome the fact that you said that the rates of MRSA have gone down.
We need a whole new regime and culture in our hospitals regarding cleanliness. We must demonstrate to the public that the culture has changed. It may be old-fashioned to say this, but I believe that people want to see us go back to basics. They want to see us go back to having respect for hospitals and for the fact that they are full of sick people who are vulnerable to infection. For some time, we have wanted to be all things to all people. Hospitals have become more like social centres: they are very open, and lots of pictures have been hung on the walls, and so on. That takes away from respect for the service being provided, and even respect for hospital personnel.
Visitors want to walk into a hospital and see clear signage on hand-washing and to know that nobody goes through the door of a treatment room without washing their hands first. I know that this matter is not all about hand-washing and cleanliness, and I have had discussions with consultants who have said that it is not. However, you have admitted today that hand-washing and the washing of hard surfaces are important.
Cleanliness is terribly important. Public confidence will not be restored unless cleanliness is improved. I want to be able to walk around hospitals and feel differently about them as soon as I open the door. Every day, we hear stories about the lack of cleanliness in hospitals. I do not blame hospital staff — everyone works hard. However, hospitals are so hi-tech nowadays that minor details, as they might have been considered, are being forgotten.
We do not want to return to the time of two patients to a bed and the ringing of bells. However, there certainly needs to be a return to those standards. When thorough cleaning and spot checks are carried out, they must be recorded. If there are door scores in restaurants, there must be door scores in hospitals. We must ensure that that level is maintained and that checks are carried out regularly. Public confidence cannot be restored until that happens.
As regards the culture of supplying information, to which Ms Ramsey and others referred, we live in a time when people are far better informed and when MRSA and clostridium difficile are household names. People turn on their computers and ‘Google’ terms in order to find out about them. Indeed, they often know more about them than the so-called experts. Therefore, there is an expectation that when information is released, it must be kept up to date.
There are concerns about the information’s accuracy. In order to pinpoint the focus and learn from what has happened, information must be accurate. However, it must also be fast, particularly with regard to the current outbreak. Although the information must be correct, people assume that with all of the information technology that is available — despite there being an issue in hospitals that it does not work as well as it should; a matter that has been discussed for years — there is no reason why it should not be easy to record and collate information quickly. People have that expectation.
Although you may not be able to provide details now, I am interested to obtain and examine the figures for all hospital-acquired infections — not to hype the situation in any way, but because it is important that we do not lose focus of the fact that clostridium difficile is still a problem. The public must be satisfied that cleanliness is being addressed. I understand that that is a simplistic view: lots of other factors must also be considered, such as antibiotic therapy, and so on.
It was asked why the outbreak was confined to the northern trust area. It is hard to believe that that was simply a matter of luck. I do not know whether it has anything to do bed closures in any of the other trusts’ hospitals. I do not expect an answer to this today. However, there must be more to it than simply luck. I do not understand that. You may have time to respond on that issue.
Is there any less control exercised over cleaning staff who are privately contracted? Is that an issue in hospitals in which cleaning is no longer carried out on an in-house basis?
I will run through the rest of my questions. If you do not have time to answer all of them, you can respond to them later.
Has a blanket approach been taken regarding the figures, or are hospitals being considered individually in order to determine whether different circumstances have contributed to the variation in the rates of clostridium difficile infection? For instance, some hospitals are in old buildings and some have few toilet facilities. Such matters must be taken into account. Is it possible to provide more toilet facilities in hospitals? Toilets are provided in the streets and when concerts take place. Toilet provision is important when people present with diarrhoea. I am not sure whether that is the first symptom or the only symptom of clostridium difficile infection.
While I am on the subject, I understand that examination of faeces is the only way to confirm that the infection is present, and that it cannot be done by blood test.
Antibiotics stewardship has been mentioned. That is a public-health issue and presents an opportunity to raise the matter of people’s saying, "doctor, doctor, give me a prescription" and to reiterate the sound reasons why that should not be done. Do hospital pharmacists have a role to play? I am not sure about their role. Dr Deeny mentioned the regulating body, the RQIA. Certainly, when the Committee talked to that organisation, it did not appear to have much control over hospitals. It is vitally important to know its role as regards acute hospitals.
Hospitals should provide much more education and information on how everyone must take responsibility for personal hygiene. It is important that people know that the hospitals do not have sole responsibility for preventing infection.
It is also important to provide information to the relatives of patients who are being discharged. Today, a patient spoke to me about MRSA, but it could equally have been about clostridium difficile. The patient, who had major surgery less than two weeks ago, was told that their father had MRSA. When the father returned home, the family was not told whether he still had MRSA. They did not know whether the infection was located in his wound or where the drip had been inserted. There is simply no co-ordination in the provision of information to relatives.
Mr McKee talked about an infection control co-ordinator. Every hospital must have someone who can provide information to relatives before a patient goes home, so that they are much better informed. People do not have enough knowledge about such conditions. My brother was already seriously ill when he contracted MRSA. It was regarded as a major problem that he had contracted MRSA on top of other conditions. I never got to the bottom of why, or how, my brother was infected. As he died very quickly, none of my family’s question was ever answered, and my brother was confused about his condition. Relatives, and particularly patients, are vulnerable and are not in a fit state to ask questions. It is important that relatives and visitors are much better informed.
Carmel has raised a raft of issues. Her comments are extremely wise, and I am sure that we all fully endorse what she said. I will try to rattle through the points that she raised.
I said that all trusts are in the process of rolling out a new, more stringent visitor policy. I am not sure that we will be ringing bells, Carmel, but we will certainly impose a strict limit on the number of people who can be at each bedside. You made a wise suggestion that the trusts need to devise a new compact with patients and the public about how we manage hospitals. We must acknowledge that involving patients and the wider public will lead to improvements. The trusts regard openness as the first step, and I hope that we are displaying that today.
Carmel is also correct in saying that there must be a return to old-fashioned values such as diligence and vigilance. The trusts rightly consider that their performance as regards cleaning is being extensively monitored internally and externally. The RQIA is only one example: trusts are required to monitor and audit their cleaning performance, in addition to the external monitoring that is carried out. It is reasonable to say that we, our managers and staff feel under the cosh in that regard.
I think that I am the only chief executive of a trust that has an outsourced cleaning team. I inherited the team from the Musgrave Park Hospital site, but I have given a clear undertaking that, as soon as that contract expires, there will be an in-house cleaning regime. The rates of infection are collated by trust, but are also broken down by hospital and by site.
Variations in infection rates relate primarily to the nature of the hospital. A hospital that, for various reasons, treats younger people tends to have a lower rate of infection than one that treats older people. Hospitals that treat people who are seriously ill — particularly those whose immune systems are compromised or who are receiving medication that, as a by-product, compromises their immune systems, as in the treatment of cancers — will have different rates of infection, because those are all risk factors. The figures are published on a hospital-by-hospital basis. The rate of infection is likely to have more to do with than the nature of the hospital and the type of patient that it treats than the number of toilets provided.
Pharmacists have a crucial role to play in the development of antimicrobial policy. As additional money has been made available, the trust is bidding for funding for specialist antimicrobial pharmacists to advise doctors on best practice and to monitor and audit its performance as part of the prescribing stewardship that others have mentioned.
I cannot comment on the RQIA. I can simply point to the fact that there was a much larger and more damaging outbreak in Stoke Mandeville Hospital in 2006. The equivalent body in England carried out the review that caused such a shake-up in England. We have learned from that, and I assure the Committee that we will also learn from the review of the outbreak in the northern trust area.
Ms Ní Chuilín:
My comments are not meant to be personal, but to describe the clustering and the outbreak in the Northern Trust as unfortunate is offensive. The Chairperson has pointed out that we are elected representatives. People have serious concerns about the situation. I appreciate the length of time that you have been here, but that comment does not reflect what is happening in that area. It is not good enough.
I am sorry if I have given that impression. I have tried to emphasise on the one hand that we are performing quite well but, on the other hand, that every avoidable death is tragic and we very much regret it, as do all the staff. I probably used the word "luck", and I meant it to mean that the Northern Trust was unlucky to get clostridium difficile. The fact that it has not spread elsewhere is down to the vigilance and diligence of staff. I am sorry if, in what has been a very long session, I used the word "unfortunate" when I could have used a stronger word. It is very much regretted by everyone. The openness and style of answering here reflects that, rather than one isolated word.
The Northern Trust has been open in expressing regret to the patients and the families about the situation. We have been treating the outbreak with the utmost seriousness since we were made aware of it.
I realise that we have been here since 1.30 pm and it is now 4.10 pm. Nevertheless, I welcome the fact that we have had a long discussion because of the nature and importance of the debate, and the expectations of the general public as to how the matter will roll out, and the answers we, as elected representatives, receive. We must also be realistic and recognise that the public have major concerns about the situation. The spectacle of older people not wishing to take up appointments to attend hospital when they are sick, because they are afraid of contracting one of the superbugs and having their life expectancy reduced, is understandable. We have an awful lot of work on our hands to try to bring back public confidence by rolling out the various programmes that are being enacted.
Thank you all for coming. The Chief Medical Officer will be speaking to the Committee next. Based on what we hear, we will decide whether to call for an independent, time-bound inquiry. Thank you for your time.