COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Implementation of the Report of the Independent Review
of the Clostridium Difficile Outbreak in the Northern Trust
19 February 2009
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill
Ms Sue Ramsey
Witnesses:
Dr Lorraine Doherty )
Ms Elizabeth Mitchell ) Department of Health, Social Services and Public Saftey
Mr Robert Sowney )
The Chairperson (Mrs I Robinson):
The next item is a briefing from the Department on the implementation of the recommendations of the inquiry into the clostridium difficile outbreak in the Northern Health and Social Care Trust area. The Committee had received an update from the Minister but had requested more detail.
I welcome Elizabeth Mitchell, deputy chief medical officer, Lorraine Doherty, senior medical officer, and Robert Sowney from the Department’s service development unit.
Ms Elizabeth Mitchell (Department of Health, Social Services and Public Safety):
I thank the Committee for inviting us to provide an update. On 3 June 2008, the Minister made a statement to the Assembly about the Regulation and Quality Improvement Authority (RQIA) interim report on the review of the outbreak of clostridium difficile in the Northern Trust area.
On 14 October, he made a statement on the final report, and, as you know, he has accepted all of the review’s recommendations. The interim report had 36 recommendations, and there were a further 17 in the final report, making a total of 53. Of those, 30 recommendations are for the health and social care trusts, with 29 being for all five trusts and one being specifically for the Northern Trust. All trusts have been working with the service delivery unit and with support from the NHS cleaner hospitals team to ensure that those recommendations are being addressed. They are currently developing action plans, and my colleague Robert Sowney will be very pleased to give you an update on the progress of the trusts’ recommendations. The remaining 23 recommendations are for the Department or other regional organisations. Of those, eight have been completed and two are for the new Regional Agency for Public Health and Well-being, which comes into being on 1 April. Work is under way to address the other 13 recommendations.
I should like to highlight some of the key regional actions that we have taken to tackle healthcare-associated infections and to address the RQIA recommendations. I will start with the question of effective communication, which was of concern to the Committee when the Chief Nursing Officer, Martin Bradley, and I met the Committee last year. The Committee was concerned that there should be effective communication around patients with clostridium difficile when they are discharged from, or readmitted to, hospital, particularly if they are discharged into a nursing home or care home. A regional protocol has been developed by the Guidelines and Audit Implementation Network (GAIN), which in the past you may have known as the Clinical Resources Efficiency Support Team (CREST). That was put in place to ensure effective sharing of information between hospitals, GPs and care homes. In January, it was piloted in one trust, and this month it is being disseminated to all trusts for implementation.
Members will be aware that prudent antimicrobial prescribing is one of the five key control measures for clostridium difficile infection. Thus, it is no surprise that effective antimicrobial prescribing was one of the major themes of the RQIA review. I am pleased to report that in November, we published regional antimicrobial prescribing guidance for primary care. That guidance was developed by the newly established antimicrobial resistance action committee (ARAC), which is chaired by Dr Doherty. The guidance is aimed primarily at GPs and dentists. However, we have given it to all medical and dental students to enhance their knowledge in that area. Work is under way to develop equivalent guidance for the hospital sector.
As part of the package of measures to tackle healthcare-associated infections which the Minister announced in January 2008, five antimicrobial pharmacists have now been appointed, one in each trust. They will contribute to the management and monitoring of antimicrobial prescribing. ARAC is developing a full work programme, and Dr Doherty will be very happy to answer any questions that you may have on the whole area of antimicrobial prescribing.
In October 2008, a regional online infection control manual was launched. That is a very important initiative which will help to ensure consistent practice across all trusts and, indeed, across all professional disciplines. An editorial board has been established to make sure that that manual is kept up to date.
Hand hygiene is another vital element of the control measures for clostridium difficile. In June 2008, the Minister launched the Clean Your Hands programme for hospital settings; you may have seen the posters and other campaign materials for that during your visits to hospitals. Later this year, we will be extending that initiative to include a new phase for community and primary care settings. Dr Doherty will be very happy to give you more details on those initiatives, and on our relationship with the World Health Organization initiative on hand hygiene.
The RQIA review emphasised the need to avoid duplication of effort in the reporting of cases of clostridium difficile. A new web-based system for the collection of data on cases has been implemented, and will be used in the future for both performance management and surveillance purposes. The target date for discontinuing the current paper-based system is 30 September 2009.
That brings me on to the topic of surveillance and the RQIA team’s recommendation for a review of the level of staffing at the communicable disease surveillance centre. We have completed such a review and agreed to fund additional analytical and medical staff to support the healthcare-associated infections surveillance work. We are recruiting the new members of staff and hope that they will be in place from April.
Another area in which the RQIA review recommended development of regional guidance was on agreed terminology for outbreak management and case severity. The Department tasked the communicable disease surveillance centre with that project. The research into systems and processes has been completed, and the development of a web-based tool and guidance to support the implementation is under way. It is hoped that the system will be fully implemented in June 2009.
The recommended reviews of laboratory, IT and hospital surveillance systems has been completed. The digital information system laboratory system now has the facility to produce real-time clostridium difficile reports, which include patient demographic and ward details.
We have also been able to increase the number of clostridium difficile specimens that are typed: a Northern Ireland facility for clostridium difficile ribotyping based in the Belfast Link Laboratories has been established and has been running in parallel with the reference laboratory at Leeds General Infirmary. Last year, we aimed to have a sample of 400 specimens typed, but we are examining a business case to expand and enhance the facility so that we can ribotype all clostridium difficile specimens.
The RQIA team recommended the use of root cause analysis as an approach to the investigation of deaths and clusters or outbreaks of clostridium difficile in trusts. In December 2008, 200 staff from across the five trusts participated in training on root cause analysis. Trusts are now working with colleagues in the sustainable development unit and the NHS cleaner hospitals team to develop an agreed root cause analysis pathway.
The Department has completed a review of the reporting system for serious or adverse incidents. A new early-alert system will be implemented by 1 April, full operational responsibility for which will transfer to the Regional Agency for Public Health and Well-being in January 2010.
Enhanced environmental cleaning is also a key control measure for clostridium difficile. Approaches to cleaning, and the terminology used, vary between trusts — for example, “deep cleaning” means different things in different trusts. A regional baseline review of cleaning arrangements in all trusts against current standards and methodologies is under way. That will identify any gaps and make recommendations. A report on the findings of that review is expected by the end of June 2009.
Isolation of patients with clostridium difficile is another key control measure. Committee members will recall that last year the Minister announced that all newbuilds and major refurbishments will have 100% single rooms. In the interim, trusts have been asked to implement, where practical and affordable, measures to increase the level of single-room provision in existing accommodation. The RQIA team recommended that a regional risk assessment be carried out to identify areas of the hospital estate that have a high degree of risk with regard to the spread of infection. A risk assessment template has been issued so that the information can be pulled together in a standard format for the whole region, which will be used to inform the maintenance investment plans. The risk assessment should be completed by June 2009.
Some of the more complex RQIA recommendations relate to workforce issues and to training and development issues. A number of detailed workforce reviews will be carried out in 2009, including: a review of the medical workforce, which is due for completion in the spring; a review of technical and scientific staffing groups, which is scheduled for the autumn; and a review of the infection-control nursing workforce, to be completed by the end of the year. Once the trust action plans are finalised, the Department will commission a regional review of training and development needs. That review will take account of existing provision, such as the mandatory infection prevention and control training that is already taking place in trusts, the existing regional e-learning package, the online infection-control manual and the annual regional healthcare-associated infection surveillance training programme for trust staff.
I have not been able to cover everything in this brief overview. Much is going on locally to reduce clostridium difficile in particular and healthcare-associated infections in general. However, we recognise that there is still much to do and achieve. The Minister has made healthcare-associated infections one of his priorities for action, which is reflected in the new challenging target that he has set — an overall reduction of 35% on the 2007-08 rates of clostridium difficile and methicillin-resistant and methicillin-sensitive staphylococcus aureus infection by the end of March 2010.
The Chairperson:
Since the first outbreak, how many people have died from clostridium difficile or had that as a contributory cause of death on their death certificates?
When I attended hospital recently, I came across an innovative idea in waiting areas, which are used by a mix of people, some of whom may be very hygienic and others who may be less so. There were little hand-gel dispensers on the tables in the waiting areas, which I thought was a good location. There will always be vandalism, people taking them away, and so forth, but things can be fixed and larger containers could be used.
I also noticed that doctors still run around hospitals in their outdoor clothing, and, when shopping in my community, I still see hospital staff wearing their uniforms — even the green theatre gear. If people are to have confidence that everything is being done to tackle clostridium difficile, particularly by professionals, it does not look too good when the professionals do not play ball. The public have a role to play by ensuring that their hands are clean and using the gels and pumps provided when they go to visit sick relatives, but the lead must come from the top, and particularly from the consultants.
Is there any means by which hospitals can revert to a recognised uniform, as opposed to doctors wearing their ordinary, everyday clothes? Surely that would help the doctors’ budgets and prevent their clothes from becoming frayed, and so forth. Public confidence is extremely important, and people who attend my advice centre constantly ask how they can have faith that everything possible is being done when they see hospital staff doing their shopping in their uniforms.
Mr Robert Sowney (Department of Health, Social Services and Public Safety):
I absolutely agree with everything that you said about uniforms. I work in the service delivery unit, but my background is in nursing, and I am still a nurse, and that issue exercises me too. Leadership must be shown by medical and nursing staff and clinicians. One way to demonstrate such leadership would be by ensuring the eradication of the type of behaviour that you described. I also see nurses wearing their uniforms in supermarkets, and the difference is that I am sometimes in a position to challenge that behaviour, whereas members of the public are not.
The uniform issue is multifaceted. Hospitals must ensure the provision of facilities to enable nurses to change their clothing. Over the years, some changing facilities have disappeared. That is a key issue for future consideration. In the meantime, some hospitals and trusts have tried to develop locally by providing changing facilities within wards, and that helps. The underlying cause — not having changing facilities — has to be addressed, but, while we are waiting on that it is unacceptable for staff to wear uniforms in public areas. Even if we were to take the view that staff wearing their uniforms in public does not pose a risk, it does not create confidence. When members of the public see staff wearing theatre greens in the street it erodes their confidence, because they associate that uniform with theatre activity. That is totally unacceptable.
All of the trusts have policies around trying to eradicate that sort of behaviour, which is difficult. We must keep on challenging staff when we see that behaviour, and we must introduce measures that allow for disciplinary action, because it is a huge issue. Some staff, such as community nurses, may have to wear their uniforms in public, but we can ensure that they at least cover them with a long coat or something similar. Those kinds of things are helpful in instilling public confidence.
We must drive this issue. We must revisit how some of the changing areas disappeared and how we can get them back again. We should look at what can be done with the current facilities in relation to developing bespoke changing facilities. Let us get to grips with demonstrating true clinical leadership and leading from the front. We expect the public to wash their hands and so on, but we do not have reason or cause to complain if we do not set a good example. Leadership is key in all of this.
The Chairperson:
I am not deliberately targeting the staff as such, but I think that the public perception is that hospital cleanliness should start in-house. It is not coincidental that, since changing areas have disappeared, infection has come more and more to the fore. It will save money in the long run if we take a hold of the issues and do something about them rather than pen-pushing — and I am not referring to you. Let us put the talking and thinking into action. Everyone has a part to play — not just the consultants and junior doctors and so on, but right down the line of staff. Like the public, they have a responsibility to keep hygiene at the forefront of their minds.
Dr Lorraine Doherty (Department of Health, Social Services and Public Safety):
You asked about the visibility and size of the alcohol hand-gel containers. We should be aware that the trusts now have a regional hand-hygiene approach in place with the National Patient Safety Agency campaign, which includes signposting and posters for patients, staff and the public. The trusts should be commended for taking that on board.
The trusts struggle with the issue of where the alcohol hand gels should be placed. I hate to say this, but one of our trusts had problems with people coming in on Saturday nights and drinking the gel — it had to be replaced with foam. Trusts are very aware of the need to have those gels in places like A&E, and in waiting areas at the entrances of hospitals. I know that they are making concerted efforts, but they have a number of challenges to overcome in relation to making sure that those stay in place and are used appropriately.
The Chairperson:
I totally understand what you are saying. Given the nature of some of the folk who come to hospital on a Saturday night, one wonders how to protect the facilities. I thought that it was a very innovative idea to have the gels sitting around the tables, but that would not work at every location — they would have to be pinned down or nailed down.
What was the number of deaths from the first outbreak?
Ms Mitchell:
The outbreak started in June 2007. From then until the end of August 2008, clostridium difficile was mentioned on the death certificates of 53 people. However, the Committee will be aware that one of the issues that we think that the public inquiry should consider is the extent to which that diagnosis contributed to the deaths. That piece of work needs to be done in depth.
Mr Gardiner:
You may think that I am stupid, but I want clarification of what clostridium difficile is and how it affects patients. Is there a cure? If the patient is ever discharged from hospital, is the family informed and is there any follow-up treatment? Is information provided to families as to what to look out for?
Have members of the public any opportunity to be tested, by a GP or clinic, so that they can discover whether they are carriers of the infection? There could be carriers in this building and we would not know. We are always inclined to think that one picks up this infection in hospital, and clarification of that would benefit the public and all concerned.
Ms Mitchell:
Clostridium difficile infection is caused by a bacterium that causes spore formation. It is difficult to get rid of it from the environment; the spores can survive for a long time. It is often triggered by use of antibiotics, and that is why correct antibiotic prescribing is so important. The usual clinical features are diarrhoeal illness. Clostridium difficile is carried by a number of individuals at any one time, but, unless the patient has symptoms, there is no point in testing for it. There is no screening test as such. Only if people develop symptoms is there a test.
We would test anyone with a diarrhoeal illness, particularly if they are over 65. We see it in that age group especially: some 80% of cases occur in people of 65 years and over. We have produced a public information leaflet. I have only one copy with me, but I will leave it with you and send further copies. It provides information for the patient, relatives and carers and specifies who is to be contacted for further information.
Mr Gardiner:
Have those leaflets been put in doctors’ surgeries?
Ms Mitchell:
We may have shared it with —
Mr Gardiner:
It is no use if that is not done. The Department will not get the message across if you have only one leaflet. We do not know what the leaflet says, and the Department should be issuing them to surgeries.
Ms Mitchell:
I will double-check that. I think that they are in surgeries. They have been widely distributed in all the trusts; they all use the same leaflet. It gives patients, relatives and carers information about clostridium difficile. Specific antibiotics can be used to treat it.
Mr Gardiner:
Is there a cure?
Ms Mitchell:
Often people are ill with other underlying conditions, so some may not recover. However, the symptoms usually respond to the treatment. However, one can be reinfected or suffer a relapse. That is true with the more virulent type that we saw in the Northern Trust outbreak: patients infected with the 027 ribotype are particularly prone to relapse. Patients may present again with similar symptoms, either because they have been re-exposed and reinfected or because they have suffered a relapse, triggered perhaps by further antibiotics. That is why we have developed the GAIN guidance, which has just been circulated to trusts. Information will be shared with GPs and care homes to ensure that they know what to do if a patient suffers a relapse after discharge from hospital. It also advises on what information should be supplied to the hospital if the patient is readmitted.
Dr L Doherty:
The GAIN protocol, as Ms Mitchell has described it, is being widely disseminated this month to GPs, hospital trusts and care homes. When GPs send patients into hospital, it is important to ensure that the hospital knows whether the patient has diarrhoea or is on antibiotics. Similarly, when a patient is discharged from hospital, GPs need to know what the patient’s condition has been in hospital, whether they are still symptomatic and0020what antibiotics they have been treated with. The same is true of care homes. A high proportion of the elderly people admitted to hospitals come from care homes, so we have established clear communication protocols for care homes and hospitals to let each other know exactly what treatment patients are receiving.
That joins up the dots across the service, ensuring that everyone is kept in the loop about those patients, that there is no possibility of inappropriate use of antibiotics, and that appropriate infection-control measures are put in place for those patients.
Mrs O’Neill:
The RQIA report contained many powerful messages. It said that:
“The Independent Review Team found that the levels of nurse staffing across the hospitals in the southern sector of the Trust … are likely to have contributed to difficulties in maintaining good infection control standards at ward level and thus to the spread of the outbreak.”
That can be interpreted as a clear message that nursing staff levels were inadequate and that they contributed to the spread of infection. However, not one recommendation out of 53 relates to inadequate nursing staff. When that is considered in the context that 722 nursing staff will be lost, that will cement the problem further. No measures are in place. None of the recommendations is targeted towards tackling that problem. I am particularly concerned that although it has been highlighted as an area of concern, and 722 jobs are due to be lost, no recommendation deals with it. Can you comment on that?
Ms Mitchell:
Although no specific recommendation deals with that issue, the trust has considered it. I will ask Robert to comment further.
Mr Sowney:
You have raised a good point. Trusts and nursing directors, in particular, are keen to ensure that all wards have adequate nursing-staff levels. Just because the RQIA has not made a specific recommendation on the matter does not mean that it is not priority: it is an absolute priority for nursing directors. People need to be mindful that we and the cleaner hospitals team work with staff, directors and nursing directors in all of the trusts and hospital sites in order to ensure that the recommendations that have emerged from the RQIA review and, indeed, from lots of other reviews, are implemented in a timely way. We have held discussions. We have monitored infection-prevention control teams, for example. Some trusts’ levels of nursing staff are not robust enough. We have examined ways to enhance that, and enhancement has been the result.
Therefore, I accept your point about the recommendation. Although it may not reassure you, I stress that nursing-staff levels are a priority in our work with trusts. After the northern trust’s outbreak, the cleaner hospitals team undertook a review of all trusts. Unannounced RQIA inspections have been carried out. Indeed, one took place this morning in a trust hospital. Those reviews are ongoing. We have conversations with local directors and managers about how best to ensure that nursing-staff levels are not reduced to a state at which there are concerns — not only about that issue, but about lots of other clinical issues.
I do not believe that that issue can be separated from the wider reform and modernisation programme that we are driving through the service delivery unit and the Department of Health in order to ensure that the right patients are admitted to hospital and that if we can manage patients using alternative arrangements, we do so. In other words, we aim to drive down the number of inappropriate admissions to hospitals and thereby reduce bed-occupancy levels. We aim to reach a point at which hospital environments are not crowded. That is also a concern. If a ward is run at a 100% bed-occupancy rate, it does not matter how many staff are on the ward; they will be stretched to achieve appropriate and effective hand washing and cleaning of equipment. Those matters are also being tackled because they add to the staffing issue.
Mrs O’Neill:
I hear what you are saying. I welcome your commitment to tackle the issue. However, the fact is that you can have all the infection-control plans in place, but if nursing staff are already stretched — and will be stretched further in the future — with the best will in the world, it will be hard for them to keep up. You can provide wards with all of the antibacterial hand gel that you want, but if nurses have to run from pillar to post, it will be hard to manage infection.
Mr Sowney:
I understand that. You are absolutely right. I want to reassure the Committee that we do not consider that matter in isolation from all of the other things that we are trying to do. It is not simply a matter of numbers; it is about the crowded environments that we now have in hospitals. Much of that relates to poor systems and processes, which we must make more effective in order to get the right patients into acute beds; discharge patients in a timely manner; and reduce bed occupancy to a level at which care can be delivered safely and effectively.
We must ensure that staffing numbers do not fall to levels that would cause problems.
The Chairperson:
What penalties can be imposed on hospitals that do not perform to the protocols that you have set down in the guidelines for cleanliness? Who carries the can if things are not being done according to the guidelines?
Mr Sowney:
I will pick up on that. We must tie those objectives into reform as a whole and into the performance management arrangements that have been put in place through the service delivery unit, the Department and the trusts. We meet the trusts on a weekly basis at different levels: we meet the assistant directors — the operational managers who are responsible for delivering and driving change across the system — who ensure that things are as they should be; we meet the directors, who form the next line of accountability; and we meet once a month with the executive teams of each of the trusts, which are headed up by the lead executive directors. The chief executive may or may not attend those meetings, depending on availability, but does so quite often. That is how we hold trusts to account on their performance and their implementation of recommendations and actions.
Robust lines and measurements of accountability are now in place that did not exist in my many years as a Health Service nurse. You may call them sanctions; I prefer to think of them as incentives, but the strong conversations that we have across the table with the lead directors, using the targets that have been set for clostridium difficile, are a good mechanism. When it comes to other sanctions, I am not sure if you were thinking of something in particular —
The Chairperson:
Perhaps if there were a table that showed how hospitals perform every quarter, for example, so that people can see that hospitals are adhering to the strict guidelines. We are talking about life and death in some instances, particularly in the case of elderly frail people, who have multiple health problems. They are exposed and vulnerable to infection. There are tables that show how well schools are performing; I was thinking of something along those lines.
Mr Sowney:
That information is very powerful, and we do have it. We examine it weekly across all the trusts. As far as the usefulness of putting that information into the public domain is concerned, we encourage hospitals and trusts to publish their hand hygiene audits on notice boards in the wards, so that when members of the public come in, they can see the audit results and the standards that are applied. Openness and transparency are key elements in regaining the public confidence in the Health Service that we have lost as a result of the situation.
The Chairperson:
There is a long way to go. Progress is being made, step by step, but there are still folk whose first thought, if they get a hospital appointment for surgery, is whether the area around them is clean. We must take cognisance of that.
Mr Easton:
The Deputy Chairperson took my question. However, I wish to follow up on the situation with regard to nursing. On at least four separate pages, the RQIA report mentioned staffing levels, especially for nurses. The loss of 722 nursing posts on the back of this report makes efficiency savings look downright dangerous, especially when it comes to infections. That must be emphasised at the highest level in the Department.
The alcohol gel foam dispensers do not do anything to sort out clostridium difficile: I understand that the only effective measure is to wash with soap and water. Having been in the hospital quite a bit at Christmas visiting my mother-in-law, I noticed that a lot of people were ignoring the dispensers, and there appeared to be no hygiene. There does not seem to be an enforcement policy in place for the public. However, I enjoy using the dispensers as one gets a funny feeling when the foam is sprayed on the hands.
The Department should consider introducing wash-hand basins outside wards, and, during visiting hours, someone should be there to enforce that visitors wash their hands before visiting the wards. I know that that might be time consuming and costly, but I think that that is the only way to definitively tackle the issue.
Ms Mitchell:
I will respond on the nursing issue. Page 117 of the August report states that the northern trust took a decision in May 2008 to approve £1·9 million recurrent funding for nurse staffing. In a way, the trust had already addressed that issue, and that is why there was not a separate recommendation on the matter.
As regards the Chairperson’s comments on publication, it is extremely important that the Department puts information in the public domain. The Clostridium Difficile Surveillance Centre (CDSC) reports on surveillance of clostridium difficile infections by trusts are published quarterly. We mentioned already the RQIA unannounced inspections. A rolling programme of visits will take place during the year, and it is intended that the findings of those inspections will be published quarterly. That information will go into the public domain.
The whole issue of engagement with the public, finding out areas of concern, and trying to address those concerns is extremely important, and the Department must redouble its efforts on that.
I will ask Ms Doherty to address the issue of hand hygiene.
Ms L Doherty:
Mr Easton is right; alcohol hand gels are not effective against clostridium difficile. The Department has been trying to send out the clear message to health processionals, to staff in hospitals and primary care, and to patients that the only way to fight clostridium difficile is by washing hands with soap in warm running water. I take Mr Easton’s point about placing hand basins outside wards for visitors to use. Getting people to observe hand hygiene when they come into hospital is an issue. However, nurses and medical staff are busy and it is difficult to police. We need to do more exploratory work with the National Patient Safety Agency. It is not just an issue for hospitals here; it is an issue everywhere.
The Department’s Chief Nursing Officer has a particular interest in the issue, and he has been looking at how we develop better signage — something along the lines of telling people not to cross a line until they have washed their hands or used the alcohol hand gel. We need to be more blatant in our approach to the public, and what the public is expected to do before entering wards must be very visible.
Mr McCallister:
The public also has a responsibility. If a visitor going into a hospital sees someone in front of them not washing their hands, they should be challenged and say —
Mr Gallagher:
I am a member of the Health Committee — [Laughter.]
Mr McCallister:
I mean generally.
The Chairperson:
We all have a part to play. The life expectancy of frail patients could be cut short.
Dr Deeny:
Of course, I have a particular interest in the subject. I reiterate that public information is very important. I am interested in the major involvement of antibiotics. We know about that, as doctors, but the public are still not aware that that is the case. We are often asked about that in general practice, and we tell patients that we do not always prescribe them because very potent antibiotics that we should not be using are killing off all the good bacteria, allowing the bad bacteria to flourish. People find it hard to understand that there are such things as good bacteria. There is a lot of misunderstanding out there.
You have referred to healthcare acquired and hospital acquired infections. There is confusion there also. I am asked this often: people often hear of these infections happening in hospital, and ask why they are being told in the community that they should not be getting antibiotics. I tell them that the infections are due to close contact and overcrowding of hospitals.
Most practices are now sticking to the narrow-spectrum antibiotics, Lorraine will be glad to hear — erythromycin, flucloxacillin, amoxicillin; they very seldom prescribe anything other than those three. Most practices are doing that. By doing that, how can they contribute to the lessening of clostridium difficile? Secondly, how much does it contribute, because again people ask me why they do not hear about clostridium difficile in the community? It is down to overcrowded hospitals. That is an issue that the Department should look at again. We cannot have hospitals with 90%-plus occupancy: it is dangerous. That is why we have this problem.
On the information issue, I think that the public are learning, but we GPs are still being put under pressure to prescribe antibiotics. We are trying to tell patients that they do not need one, and there has been a recent advertisement, I think that the voice-over is done by Jim Neilly —
Ms L Doherty:
It has a boxing theme.
Dr Deeny:
Yes, it is a good advertisement. Rather than some of the tripe that we watch on television, it would be nice to have a programme telling people about an infection like this; how it is caused, and why GPs are told not to prescribe antibiotics, because people cannot see why they are being told they cannot have an antibiotic. The infection is not in the community, it is in hospitals. We know that visitors can bring the infection into hospitals, but we need something like that to explain the antibiotic involvement in the causation of clostridium difficile, how it gets into the community and into the hospital.
We have received your leaflets, but people often do not read leaflets. Maybe a television programme would be worthwhile. That advertisement of Jim Neilly’s is a good one. It rounds off by saying what antibiotics cannot do — they cannot beat the flu.
Ms L Doherty:
They do not work for colds and flu.
Dr Deeny:
Yes, that is it, and that is very good. People watch television a lot more than they read leaflets.
Ms L Doherty:
I can pick up on the communication issues and on the issues of clostridium difficile in the community. I will address the communication issue first.
We are very aware of the need to work with the public and ensure that they have access to information and educational materials to inform them, not just about clostridium difficile, but about antibiotic resistance, infection control and hand hygiene. We launched that television advertisement several years ago, and we updated it this year and re-launched it in January to coincide with the cold and flu season. That is when a lot of patients request antibiotics from their GPs. It has been very well received, and has been nominated for a healthcare communications award. The ceremony is next week, so we will see how it does. It has gone across very well with the public, and it was on the radio at the same time.
This is an issue that challenges everybody on what other resources we can use to educate patients. I take your point about having campaigns that involve television and radio, but we need to give more information about the pathogenesis of some of these diseases and what it means for people in the community. We need to be more innovative in our approach. We could certainly look at some online resources whereby people could access a five-minute clip to give more information on a particular condition.
We are very keen to explore the whole area of patient information. We will be looking at a new action plan for healthcare acquired infections, and that is one of the areas that we will be focusing our efforts on. On the issue of clostridium difficile in the community, I think that this is a message that we need to get across.
What we see from the surveillance data on clostridium difficile that is collated for us by the communicable disease surveillance centre (CDSC) is that over 30% of these infections are coming in from the community. The reason that they are not diagnosed in the community is because these patients are sick, they have got clostridium difficile-associated diarrhoea, and they end up in hospital, but anyone who is diagnosed within 48 hours of admission to hospital has acquired their infection in the community.
We perhaps need to highlight the fact that 30% of those infections come in to hospitals from the community. Again, the patient profile is the same; they are elderly, vulnerable patients with co-morbidities and co-existing medical conditions, and most of them have been treated with antibiotics. Perhaps that message should be reinforced to address the community’s perception of the infection.
Mrs McGill:
I intended to ask about staffing, but that issue was covered in the answers to the questions from the Deputy Chairperson and Alex Easton. However, I certainly want to support the comments about the difficulties that nurses face. Some time ago, the Committee visited the Erne Hospital. The recommendations were in place at the time. I happened to ask somebody who was looking after that. Somebody went away and had to get a nurse from somewhere, and she spoke to me. Truthfully, does that nurse have to do extra work on top of what she was originally doing in terms of her day-to-day work? Is that an extra duty?
Robert, the Chairperson asked you about getting information on clostridium difficile, and that is very important. It would be useful if the Committee could get that information. Is it quarterly or weekly that you get that information? Given that you get that information weekly, can you tell me which trust has the most recently recorded death or deaths from clostridium difficile? Perhaps you are not at liberty to say.
Finally, does each trust have a clinical champion? I noted somewhere in RQIA’s recommendation that there is an acceptance on the part of the review team that nothing will be achieved across Northern Ireland until there is an enhancement of relevant staffing levels. So, are the necessary staff in place?
Ms Mitchell:
I will ask Robert to respond to the question about the extra duties for nurses.
Mr Sowney:
I am not quite sure what the question was.
Mrs McGill:
Nurses are in place, and they were in place before the outbreak of clostridium difficile. The RQIA has made a number of recommendations. Do the nurses who are now charged with ensuring that the recommendations — or at least some of them — from RQIA are implemented within the hospital have extra duties, whatever they happen to be, associated with those recommendations? They clearly would be extra duties. How do nurses manage that? Are those extra duties with extra pay? I understood that nurses are already in place, but, because of the outbreak of infections, they have to carry out extra duties. The Deputy Chairperson and Alex Easton have said that nurses are already stretched. When I mentioned that issue on the visit to the Erne Hospital, I expected that the nurse was dedicated to doing that particular job. Obviously, the nurse was doing it, but along with an awful lot of other duties.
Mr Sowney:
I am not sure whether or not this will answer your question, but certainly through our work with trusts, we have identified gaps, and those gaps are being filled to ensure that the infection control teams of nurses are robust. The key aspect is that we are trying to drive forward a culture whereby clostridium difficile becomes everybody’s problem and concern, and so everybody becomes part of the solution.
In many respects, we have identified that infection control teams have had ownership of the issue for many years. We are trying to create a culture where everyone has ownership, so that it is not just the responsibility of the infection control team to identify problems managing outbreak, for example. It is everyone’s problem, and everyone is part of the solution. I am not sure whether that answers your question.
Mrs McGill:
It does not really answer my question. A similar response was given to the Deputy Chairperson. I simply want to know whether it will require extra work for nurses and the rest of the team, on top of all the other work that they have to do. Will extra staff be required?
Mr Sowney:
Infection control teams are generally made up of nurses. They do that work every day, and any gaps in the teams are being filled. Therefore, their roles are being enhanced.
Every day, nurses and clinical staff should be doing things like hand-washing, for example. That is all part and parcel of the things that they need to be doing. I am not really grasping the point that you are making. I am sorry.
Mr Gallagher:
Is there a specific person in each hospital who has responsibility for the initiative?
Mr Sowney:
Yes.
Mrs McGill:
I am not going to pursue my question on this occasion. I simply feel that nurses are already being stretched. The point has been made by the Deputy Chairperson, Michelle O’Neill, and by Alex Easton. If there is an issue with infection in hospitals, and there are recommendations to get rid of the infections and to prevent them, by definition and logic, someone somewhere has to do more work, or perhaps the work was not being done properly in the first place. That is really the point that I am trying to make. As a response to the recommendations from RQIA, they either have to do more work or they do not. However, I am not going to pursue the issue because it has already been aired.
Is there a specific named clinical champion in every trust? Will you address the other point about the recorded deaths from clostridium difficile in the Northern Trust?
Ms Mitchell:
I will pick up on the point about the champions first. There are infection prevention control leads in each trust, and they are clearly designated lead roles. We want to ensure that each clinical area and directorate will have someone who champions that, but, most importantly, we want to ensure that every member of staff regards it as their responsibility. It is important to try to get that recognised formally, so that all clinical staff understand that tackling infection is one of their key duties and responsibilities.
Mrs McGill:
Will the clinical champions be consultants?
Ms Mitchell:
It is important to have clinical champions from all the professional groups, including nurse directors and leaders, as well as consultants. However, we want to take forward and consider the whole role of how we get that engagement with clinicians. We want to continue trying to do further work in that area. One of the key issues is to identify the champions and also to identify how one encourages, fosters and develops them. That is very important as part of embedding the approach to HCAI interests.
There has been investment in the number of infection control nurses in trusts. In 2006, when the ‘Changing the Culture’ strategy was published, there were 33 infection control nurses full-time equivalents across Northern Ireland, and that has been increased to 40·7. That figure obviously includes one-part time nurse. Therefore, there has been an increase of more than seven infection control nurses in that two-year period.
Mrs McGill mentioned the publication of information. If the Committee wants to receive information more regularly, we will work with the secretariat to explore what information you require and when you want to receive it.
I cannot answer the question about the most recent death in the past week. We do not receive information about deaths weekly. It is sent to the registrar of deaths, and there can be a delay before the deaths are registered. We receive that information monthly, and the Northern Ireland Statistics and Research Agency publishes it quarterly.
Mr Gardiner:
Not all death certificates record the illness. People have died in Craigavon, and the illness has not always been recorded on the death certificate. I made that point when the Southern Trust attended the Committee.
The Chairperson:
That was the Committee’s main concern, Sam. We wanted it to be recorded on the death certificate in order that we know the extent of the difficulties of the infection.
Mrs McGill:
I might have misunderstood Robert. I thought that you received weekly up-to-date information on clostridium difficile. However, Elizabeth says that you receive that quarterly. I want to be aware of the latest situation in trusts instead of finding out through the media or newspapers.
Mr Sowney:
The information that we receive weekly relates to the number of patients with clostridium difficile.
Mrs McGill:
Do you have those figures?
Mr Sowney:
I do not have them with me, and I do not carry that information in my head. That weekly information is useful in our weekly discussions with trusts and ensures that we are reducing the number of patients who are affected by the infection.
Mrs McGill:
Has there been a recent clostridium difficile outbreak in any trust?
Mr Sowney:
No outbreak has been declared.
The Chairperson:
I suggest that, in order to reduce individual questions, information should be sent to the Committee Clerk regularly. He can include that information in members’ files so that we can monitor the situation. I thank Elizabeth, Lorraine and Robert for attending.