Essay: To what extent have approaches to infection prevention and control in NHS Hospital been effective?

This essay will discuss the main issues connected to the spread of infections in the hospital environment and explore how effective the approaches to infection control measures in the NHS have been. This is an issue for the NHS as a whole, to prevent infections in the hospital environment and to find a solution to increase the trust and confidence of people. In addition, there is also growing media ( BBC News, 2014 and NHS Watch Dog, 2014) interest highlighting and exposing concerns due to the lack of effective infection control measures in NHS hospitals which put many patients’ lives and services at risk (Merrifield, 2015). Improving infection control measures can not only save peoples’ lives but also will reduce the financial burden on NHS. In my research I have looked at the various approaches used in controlling infections in the hospital environment: some of the NHS hospitals have been successful to control infections while others are still struggling due to many issues.
Research studies (Blackwell 201l, RCN 2000) show that there are some aspects which are linked together to cause an infection, known as ‘Chain of Infection’ (Figure 1). In order for HAI’s to occur there must be, a point of entry, a susceptible host, infectious agent, a source or reservoir of microorganism, a portal of exit and a mode of transmission. If one of these aspects is missing, then the result would be a break in the chain and the infection could be avoided. It is not possible to address all these aspects and their related issues within the scope of this essay. Therefore three main issues related to the control of hospital acquired infections (HAI’s) have been selected, for instance, the susceptible host, the means of transmission and the infectious agent. These issues will be examined and evaluated in this essay in as much as details as possible.
Figure 1: Chain of Infection
Source: http://www.instructor.mstc.edu (no date).
According to the medical experts (Custoids, 2015) Hospital Acquired Infections (HAI’s) are the infections which are not present at the point of admission, but get infected during a stay in hospital, that can be detected either during hospitalization or in the period after discharge from the hospital. Many microbes such as, bacteria, fungi, and viruses, are the main cause of various infectious diseases, for example, urinary tract (UTI’s), hospital acquired pneumonia, blood Septicemia, and skin infections (MRSA-methicillin-resistant staphylococcus aurous). The ‘Infection Prevention and Control’ involves the application of microbiology in clinical practice to fight against these microbes. The Department of Health (DoH, 2013) argues that about 40% percent of patients admitted in hospital may develop one of the HAI’s during their stay in hospital. Furthermore, the National Patient Safety S Agency (Parliament report, 2000 and NPSA, 2014) claims that there are 5000 deaths every year costing nearly 1 billion to NHS due to such infections.
The first issue to be considered is the susceptible host which appears in the chain of infection. One of the most difficult aspects to remove from the chain would be the susceptible host and the main reason being because most patients come into hospitals with an illness or injury. This status of their health makes them more vulnerable to infections. There are also high risk individuals, like premature babies (32 weeks or under), where their immune system not yet adequately developed to fight against infection or individuals suffering from Immunodeficiency virus (HIV) whose immune system might be declining. Furthermore, there are other category of patients, who can also be at risk of higher infections, for instance individuals with burns, after surgery, diabetes, and the patients undergoing immunosuppressive treatment like chemotherapy. However, there has been continues hospital efforts to protect such vulnerable patients through various strategies, such as assessing each patients at initial stage, recognizing their level of risk, and isolating them to protect and prevent from being contracted with HAI’s. In addition, this situation can be more improved with regular staff training to update their knowledge and produce a protective care plan. According to the UK Government report (2013, Figure 2) within last decade there has been about 30% decrease in cases of tuberculosis infections and this was possible by implementing effective strategies such as ‘BCG vaccination’ for all individuals and early intervention (screening) to diagnose and provide effective treatment.
Figure 2: Tuberculosis (TB) case reports, Wales 2004-2013.
Source: http://www.gov.uk (2014).
However, to in order to protect a vulnerable host effectively it is equally important to remove next aspect of the infection chain, ‘the means of transmission’ and many trusts are trying to avoid transmission by improving their standards of hygiene. There had been many precaution methods taken by hospitals to prevent and control infections, for instance, screening for MRSA, personal protection equipments (PPE), effective hand wash techniques. One of the areas which has been criticised in the media is hygiene practice in hospitals. The National Institute for Health and Care Excellence (NICE,2008), which is the main organization to sets up certain guidelines to improve health and social care practice in the UK, found that one in 16 individuals who had been treated by the NHS contracted with either MRSA or C diff. Therefore, in 2009, the DoH stated that, all elective patients being admitted to hospital should be screened for MRSA, including emergency patients. Since then many hospitals applied screening methods and reduced MRSA infections remarkably, for example at Papworth Hospital NHS Trust (2015) screening will take place at any point along the patient’s journey and it involves taking swabs from the nose, throat and groin or perineum. Any patient found to be ‘colonised’ with MRSA, is offered a simple washing treatment (Chlorohexidine disinfected solution) which can be used to remove the MRSA from the skin. The table 1 shows that Papworth hospital staff has managed to screen almost 100% services users for MRSA and C diff consistently since 2012. The number of C-diff cases reduced 50% compared to the cases in 2012, whereas MRSA bacteraemia cases has dropped to zero. This report reflects effective screening methods have helped to reduce HAI’s significantly and improved standards of hygiene at hospitals.
Table 1: MRSA bacteraemia and C.difficile infection rates:
(Source: Papworth NHS Trust website, 2015).
The NICE (no date) infection control guidelines argue that, in outbreak situations contaminated hands are often responsible for transmitting infections and the NHS Choices (2014) also highlighted the dangerous side-effects of not washing hands effectively by health professionals like spreading
C. diff. The nurses’ role involves direct patient care, mainly personal and intimate care activities, therefore the possibilities of contracting a patient with an avoidable infection is more than other staff members. This is because some of the infections may be caused by bacteria present on the hands of health care providers. The act of hand washing (Figure 3 and appendix 1) is not only easy but also works successfully against spreading infections between the service users and nurse. Normally, when people wash their there are more likely they miss bacteria in some areas (Figure 4). The effective hand wash techniques mainly involve eradicating these bacteria and avoid contamination. Basically, first, a person should wet his or her hands and apply antibacterial liquid soap, second, rinse hands under clean running water for at least 30 seconds, third dry hands with disposable hand towels or air dryer, finally apply alcohol based gel (Alcagel). This method kills almost 99% of bacteria (WHO, 2009 and NHS Choice, 2014).
Figure 3
Source: http://www.lboro.ac.uk (no date).
Figure 4: Areas leaving microbes on hand after normal wash.
Source: http://www.manchesterpct.nhs.uk (2005).
In 2008, Epsom and St. Heliers Hospitals have introduced an infection control campaign, ‘This is a clean hand zone’ to promote hand washing which has significantly decreased cases of MRSA bacteraemia and C. diff. In 2003-4, the Trust recorded 88 cases of MRSA bacteraemia. By 2012-13, that number significantly reduced to only 8. Similarly, cases of C-difficile were reduced from 268 in 2007-08 to 70 in 2012-13. This campaign (see appendix 2) was focused on the importance of maintaining good hand hygiene whilst in the hospital, encouraging all individuals ( patients and visitors) to ensure clean their hands or use disinfectant solution to rub before coming in and while leaving wards or clinical places. There are also instructions for patients, if they believe that staff members have not washed their hands, they can ask them to wash their hands without any hesitation and also if a staff member is not bare below the elbows, patients can express their concerns to the staff member regarding the possibilities of spreading infections. The ‘Bare below elbow policy’ was introduced to support effective hand washing, as wearing short sleeves is more convenient to wash hands with soap and water or use sanitiser gel effectively. This policy also banned wearing wrist watches, bracelets, and stone rings by the staff providing clinical care. This is because such items can contain bacteria and hard to get rid of them while washing hand. The Trust also invested in the total deep cleaning of the hospital ward areas, including improvement to walls and ceilings, equipment and ventilation filters. Implementing hand wash campaigns and deep clean methods had improved standards of hygiene of many hospital practices.
According to Health Protection Agency report (2004-2008), there has been an overall decrease of 5% MRSA and C-diff for 2007 other infections like MSSA (Methicillin Sensitive to Staphylococcus Aureus) bacteraemia account for 17.4% and the figures have continued to rise. That means bacteraemia is not only because of MRSA, but it can also be due to other bacteria such as MSSA, E Coli, Streptococcus, CNS, and Enterococcus (Chart 1). This indicates there are many other microbes which can be more potentially dangerous than MRSA and C. diff, which also need to be ruled out and find effective solution to reduce HAI’s.
Chart 1: Microbes accountable to cause bacteraemia (Hospital Protection Agency Report, 2004-08)
Source: infectionprotection.org.uk (2010).
The next issue is about to deal with infectious agent to remove from the chain of infection. This has been the biggest challenge so far, many microbes are becoming resistant to respond to their sensitive antibiotics. The UK Prime Minister (The Guardian, 2014) has recently expressed serious concerns about the outbreak of antibiotic resistant infections and said that the antibiotic- resistance superbugs are becoming potentially dangerous like olden days when there were no antibiotics to fight against infections and resulted to massive number of deaths. Similar concerns were expressed in an article of Nursing Times Journal (Staines, 2009) that the NHS hospitals are running out of choices to prevent or manage the infections due to the increasing number of drug-resistant bacterial strains like MRSA and C-diff. Some experts (BBC Health News, 2012) claim that there has been over prescription of antibiotics or patients may not be following the full course of antibiotics, which can create the circumstances where most of the strains (Sub-types) of microbes can become resistant to the antibiotics. In 2013, when medical experts highlighted the serious issues related to bacterial resistance, the UK government started a cross-government five year (2013 -18) antibacterial strategy. The fundamental goals of the first report from the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) are to develop surveillance systems, firstly, to measure both prescription of antibiotics and microbial resistance, secondly, to find out the impact of the antimicrobial prescribing on antimicrobial resistance and finally, to observe patient and public safety (Nursing Times, 2014). The outcome of this report was that there are a significant number of overused or incorrect prescriptions of antibiotics resulting in multiple-drug resistance to bacteria causing a threat to the world. As a result it has been suggested to health care professionals to cut down antibiotic prescription by recognising that many common infections, like symptoms associated with flu (coughs, colds) and stomach upsets, are more likely to be viral and will disappear after few days without any medication. It was also advised that a patient should take the full course of prescribed antibiotics to avoid further re-occurrence of infection or drug-resistant bacteria.
In a new effort, to tackle such drug resistant bacteria and detect the bacteria’s genetic variations,
‘Genome Project’ is in progress which involves technology known as ‘Whole Genome Sequencing’ (Figure 5) is in progress. Tang and Gardy (2014) writing in the journal Epidemiology that WGS is one of the most successful public health applications of sequencing pathogens, which not only detects and characterize outbreaks, but also informs outbreak management. Using genomics, infection control teams can now track, with extraordinarily high resolution, the transmission events within outbreaks, opening up possibilities for targeted interventions. These successes are positioning the emerging field of genomic epidemiology to replace traditional molecular epidemiology, and thereby increasing our ability to limit the spread of multidrug-resistant organisms. It has the additional benefits of being able to predict antimicrobial resistance phenotypes and identify virulence factors. In 2014, St. George’s Healthcare NHS Trust has been successful in becoming a pioneering Genomic Medicine centre, part of the ground-breaking 100,000 Genomes Projects all over the UK. Such research study has would be very useful to bring revolutionary change in health care system. It can not only help to predict and prevent disease but also allow new and more diagnostic methods. In addition, it will enable personalization of drugs and medication to specific genetic variants. Such a Genome project can predict the matching genes in a short period of time and can also find a sensitive drug to kill such microbes. Sample (2014) suggested that the rapid genetic sequencing of superbugs such as MRSA will allow health care professionals to use the most effective drugs from the initial stage of origin and trace the source of infection.
Furthermore, in research done on the case study of three babies (infected with MRSA) at Rosie Hospital in Cambridge (Gallagher, 2012), rapid genetic sequencing was used for the first time to track and halt an outbreak. Scientists at the newly formed Centre for Genomic Pathogen Surveillance at the Sanger Institute are developing systems to track outbreaks of all sorts in close to real-time. A real-time interpretation tool for hospital staff will help spot outbreaks much faster. Using the new system will surely save lives. The Cambridge outbreak did not kill anyone and deaths from MRSA continue to fall. This indicates the arrival of new technology ‘Rapid Genetic Sequencing’ can boost the power of infection control measures and save many lives effectively.
Figure 5: Whole Genome Sequencing
Source:knowgenetics.org (2012)
The figure 5, reflects the WGS technology, firstly detecting the various genomes (genetic material
of the genes) with similar characters, secondly sequencing in them in a row, so that it is easy to
predict what the next variation of a strain could be, such as GTTA followed by CAGT or CATA follows
CACG. Next, all these codes are placed in a sequence, hence the name ‘Whole Genome Sequencing.
Finally, a common sensitive drug can be predicated at the same time to destroy such microbe.
Therefore, this technology is also well known as real time sequencing technology
Analysis.
From the evaluation of the different challenges examined above it is clear that those difficulties with infection control measures are not going to be successfully addressed by actions at one level alone. Each challenge addressed in the essay to deal with the susceptible host, to improve stands of hygiene and the genome project faces its own area of particular difficulty, for example, even for the hospitals that are equipped with all of the necessary tools, it is still going to be a challenge to control infections which spread to the ‘susceptible host’ with low immunity levels, for example, in case of patient with AIDs (Acquired immunodeficiency virus illness) where their immunity level are deteriorating can be vulnerable to any microbes regardless of isolation, improved hand hygiene and all safety precautions. It would be almost impossible to tackle stop some infections like air born infections (tuberculosis or pneumonia) and protect them 100%. Furthermore, the back drop to all the efforts is (Merrifield, 2015) most of the time national health services are in crisis with lack of resources, such as shortage of staff or other essential needs (beds, isolation rooms) which may undermine success of infection control measures. Moreover,
continuous supplies of the adequate funds are needed for staff education and training, and further research in infection control methods.
A study (Tang and Gardy, 2014) shows that the percentage of hospitalised patients with the HAIs at any point of time is decreasing in the United Kingdom, from a high of 9.2% to 6.4% in 2011. But, unfortunately, hospitals are regularly seeing the introduction and onward transmission of HAIs in their settings due to factors, such as break downs in infection prevention and control practices, unrecognized transmission in the community, and importation of new strains of antimicrobial-resistant pathogens from endemic regions of the world, such as, Ebola virus). In addition, most studies claim that surveillance and screening, in combination with molecular genotyping, can indicate the presence of a nosocomial outbreak and conventional molecular epidemiology methods do not have sufficient resolution to reveal the origins and transmission dynamics of these outbreaks information, which is integral to implementing appropriate and effective infection control strategies. Over the past decades, a series of molecular epidemiology methods, including pulsed field gel electrophoresis and multi-locus sequencing typing, have been developed to estimate phylogenetic relationships between bacterial isolates, each one trying to improve upon the speed, accuracy, reproducibility, ease of use or discriminatory power of previous methods.
However, the introduction of next-generation genome sequencing technology offers the ultimate power at a relatively low cost. It has the additional benefits of being able to predict antimicrobial-resistance phenotypes and indentify virulence factors. The potential of this new ‘genomic’ epidemiology for the detection, characterization and management of infectious disease outbreaks can be tremendous.
In conclusion, in clinical environment, cross- contamination is more likely to occur and can be a problem
for any Trust, regardless of how many policies and procedures there are in place. It can be challenging
for any hospital to make sure that each and every person who walks into a hospital environment will
follow the preventative procedures to remove infection completely. Many studies comment that the infection is a common, but improving preventative measures can reduce the spread of contamination in hospitals. The services users, health care support workers, domestic and staff members all have different levels of knowledge (WHO, 2009). Therefore, It is essential to train and bring awareness among all individuals accessing hospitals or clinical environment regarding infections and its preventative measures.
The NHS management are approaching in various ways to tackle to break the chain of infection in various
ways. Firstly, as mentioned earlier, the susceptible host is screened for any illness to find state of vulnerability to infections and dealt accordingly by producing effective care plans, such as isolation or vaccination. Secondly, to remove means of transmission the standards are hygiene are improving by implementing effective hand wash techniques, deep cleaning methods of hospital or clinical environment.
Final issue of this essay is about infectious agents, are dealt with reduced prescription of unnecessary antibiotics and advising patients not to skip any dose of prescribed antibiotics, for example, anti-tubercular drugs. Moreover, if the latest technology ‘Genome Project’ is successful, then there would a revolutionary change in health sector to control any kinds of infections very effectively.