11 Oct 2007 10:14 AM

Boards at all NHS trusts urged to provide strong leadership in infection control

The Healthcare Commission today (Thursday) published a report detailing significant failings in infection control at Maidstone and Tunbridge Wells NHS Trust.

The Commission conducted an investigation into the trust following a referral from the strategic health authority, which monitors the trust’s performance, after a major outbreak of Clostridium difficile (C. difficile), in 2006.

The investigation looked at the trust’s control of infection and the quality of care for patients with C. difficile between April 2004 and September 2006.

The Commission identified serious concerns about how patients with C. difficile were cared for, particularly during two outbreaks of the infection. It calls for changes to improve the care of patients and control of infection at the trust.

It issued recommendations for national action, sending a message to all NHS trusts that boards must provide strong leadership in preventing and managing infection. The Commission calls for C. difficile to be managed as a serious medical condition in its own right, not just a clinical complication.

The Commission worked with a team of experts, including experts in infection control, to examine more than 1,000 documents and interview nearly 200 current and former patients, relatives and members of staff. It also observed work on the wards and looked in detail at case notes of a sample of 50 patients.

Between April 2004 and September 2006, more than 1,170 patients were infected across the trust’s three hospitals. Based on a sample of patient records, the Commission estimates that about 90 of these patients definitely or probably died as a result of the infection. Sixty of those deaths occurred in two major outbreaks.

The first of the two outbreaks occurred between October and December 2005, affecting 150 patients. Despite the fact that the monthly number of new patients with C. difficile doubled, the trust failed to identify the outbreak at the time. A further 258 patients contracted C. difficile in a second outbreak from April to September 2006.

The Commission’s investigation found that the trust had not put in place appropriate measures to manage and prevent infection, despite having high rates of C. difficile over several years.

The trust had consistently been among the 25% of trusts with the highest rates of C. difficile since mandatory surveillance began in January 2004. However, the Commission found that the board was unaware of the high infection rates and did not spend enough time considering issues relating to infection control.

The board did not address problems that were consistently raised by patients and staff. These included the shortage of nurses, poor care for patients and poor processes for managing the movement of patients from one ward to another, all of which contributed to the risk of spreading the infection.

Evidence from patients, staff and the trust’s own records show that patients, including those with C. difficile, were often moved between several different wards, increasing the risk of spreading infection. In some instances this was due to concerns about meeting the government’s target for waiting times for treatment in A&E wards.

Other factors contributing to the outbreaks included old buildings, with few single rooms or side rooms to isolate patients. In the second outbreak, an isolation ward was not established until August, four months after it began.

The trust’s rates of bed occupancy were on a par with the national average for acute beds at 85%. But on medical wards, where patients were not receiving surgery, rates of bed occupancy averaged over 90% and in some cases were more than 100%, meaning that the trust had to open up special “escalation areas” to accommodate extra patients. This high turnover of patients limited the time available to clean beds between patients. Moreover, beds were placed too close together, making it difficult to clean between them.

The director of infection prevention and control had insufficient understanding of the role. Many of policies adopted for preventing and managing infection were out-of-date or not easily available to staff on the wards.

Only half the clinical staff attended mandatory updates on infection control and it was often difficult for people to attend training due to shortages of staff.

The shortage of nurses contributed to the spread of infection because nurses were often too rushed to clean their hands properly, empty and clean commodes, clean mattresses and equipment properly and wear aprons and gloves appropriately and consistently.

Patients and relatives told investigators about instances of poor nursing care. There was evidence of several occasions when nurses told patients to “go in their beds”, rather than assisting patients with diarrhoea to a commode or bathroom.

The Commission said the trust failed to protect the interests of patients by missing the first outbreak, being slow to react effectively to the second outbreak, and continuing to display poor infection control and hygiene during the course of the investigation.

The Commission’s report recommends that the board must review the leadership of the trust in light of these significant failings, to ensure that it can discharge its responsibilities to an acceptable standard.

Other recommendations relate to making the control of infection a priority; better management of risks relating to infection; improving the standard of care; and increasing levels of staff and training.

The Commission said that there were also national lessons to be learnt from the investigation. In particular, it said that C. difficile needs to be regarded as a serious condition, with patients receiving continuous care to manage the infection.

The Commission also recommends that the NHS and the Health Protection Agency agree clear and consistent arrangements for monitoring rates of C. difficile infection, using all relevant local and national information.

The Commission has visited and been in continuous contact with Maidstone and Tunbridge Wells NHS Trust throughout the investigation. The most recent visit was an inspection of compliance with the government’s hygiene code.

The trust has made a number of improvements. These include increasing space between beds; appointing a new director of infection prevention and control; implementing a new policy for prescribing antibiotics; and making a commitment to increase staff and training.

Most recent infection rates available from the Health Protection Agency show that rates of C. difficile more than halved at the trust for the period January to March 2007, compared to January to March 2006.

But the Commission stresses that more must be done and has insisted that the trust must develop an urgent action plan to address the recommendations. The Commission will work closely with NHS South East Coast strategic health authority to monitor the situation and ensure implementation of all recommendations. The Commission will inspect the trust annually in relation to infection control.

Anna Walker, the Commission’s chief executive, said: “What happened to the patients at this trust was a tragedy. This report fully exposes the reasons for that tragedy, so that the same mistakes are never made again.

"I urge all trusts to heed the lessons of this report so that they can look patients in the eye and say that everything possible is being done to protect people from infection. That is the least that patients can expect.

“There are clearly wider implications for the whole NHS. We published a report in the summer that showed that there are common features in trusts that are successfully reducing their rates of infection.

“Trust boards have a critical role to play with regards to leadership and creating a culture of safety. They must understand and monitor what is happening in their trust and ensure that quality of care and patients’ safety are their priorities.

“Infection control is complex. Cleanliness is an important part, but there are other relevant factors such as the appropriate use of antibiotics, availability of isolation facilities, regular training of staff, adequate levels of staff and high standards of nursing care.

“One thing this report really highlights again is the importance of leadership. Our inspections suggest infection control is not always prominent enough on the radar of some boards. Everybody - from managers to clinicians and cleaners - must understand their role. This will not happen effectively without commitment from the top.

"As the regulator, we will play our part by checking that standards are in place and reporting back publicly. We are inspecting two thirds of NHS acute trusts this year and, in line with the Government’s recent announcement, from next year will inspect all acute trusts every year on infection control.

"We are all consistently learning how to improve infection control. We will work with trusts, the Health Protection Agency and other experts to ensure that guidance on best practice is up to date and readily available to all healthcare organisations.”

Notes to editors


One of the aims of the investigation was to clarify how the trust had estimated the number of deaths from C. difficile since April 2004.

The Commission reviewed case notes from a sample of 50 of those patients who had died of various causes, but who also had C. difficile. The review assessed the quality of care that the patient received. It also assessed whether C. difficile contributed to or was the main cause of death.

The Commission extrapolated the findings from the 50 cases to all patients who died and had C. difficile between April 2004 and September 2006. The Commission found that:

· There were 1,176 cases of C. difficile. Of these, 738 were at Maidstone Hospital, 353 were at Kent and Sussex Hospital and 85 were at Pembury Hospital.

· There were 345 patients who died at the trust of various causes and who also had C. difficile.

· Projections from the sample group to all patients who died showed that for approximately 90 patients, C. difficile was “definitely” (21), or “probably” (69) the main cause of death.

· For the remaining 255 patients, projections show that C. difficile was “definitely” a contributing factor in 124 cases, “probably” a contributing factor in 55 cases, “possibly” a contributing factor in 62 cases and “unlikely” to be a contributing factor in 14 cases.

· Of the 90 deaths where C. difficile was “definitely” or “probably” the main cause, the Commission estimates that about 60 of those occurred during the outbreaks between October 2005 and September 2006.

Many of the 90 people may well have died of other causes if they had not acquired C. difficile. Some would have died of C. difficile infection even if they had the best care.

Information on the Healthcare Commission The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information contact Megan Tudehope on 0207 448 0868, or on
07779 990845 after hours.Alero Harrison
Media Relations Manager
Healthcare Commission
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