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Rapid Responses: Rapid Responses published:
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Responsibility for MTAS/MMC debacle
- Michael R Whitehouse (23 July 2007)
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Is the CMO on the right track?
- Nigel G B Richardson (23 July 2007)
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Hand washing is not enough
- Evan L Lloyd (23 July 2007)
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Hand washing: Is it the only evidence to reduce hospital acquired infections?
- Chelliah R Selvasekar (24 July 2007)
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Michael R Whitehouse, SpR Trauma and Orthopaedics Royal Surrey County Hospital, GU2 7XX
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Dear Editor In response to Professor Donaldson's statement regarding the recent problems with the junior doctor selection that "The responsibility for implementation was widely distributed, and it would be hard to find any single organisation or individual who could be said to be responsible."(1) I would like to submit a few comments. In the 2006 Annual Report of The Chief Medical Officer (2), Professor Donaldson expresses regret that the present crisis caused so much anxiety and distress for junior doctors. Although this expression of regret is welcome, the response is somewhat inadequate. As Professor Donaldson points out the last few months have been dominated by this crisis, yet the Chief Medical Officer has not felt the need to make a statement on the crisis initiated by himself until now. Your news article quotes Professor Donaldson effectively denying
responsibility for the crisis yet in his Annual Report he acknowledges
that he was the author of Unfinished Business which began the process of
reform. In this document Professor Donaldson states that "in a reform of
medical training it is important to:
In the subsequent publication Modernising Medical Careers from the four United Kingdom Health Ministers in development of the aims laid out in Unfinished Business, it clearly states that "the development of new training structures, programmes and the delivery of training itself must be effectively quality assured." (4). Again this has not been the case. Might I suggest that as the chief architect of this process of change that Professor Donaldson should either accept responsibility for the disastrous and widely predicted failings or at least be able to identify who is. An inability to identify who is responsible for the implementation of such a huge and important project would seem to confirm that the ideas were poorly thought out and implemented with little regard for the personal costs suffered by the junior doctors caught up in the process. Yours sincerely
1. Chief medical officer names hand hygiene and organ donation as public health priorities. BMJ 2007;335:113 (21 July) 2. Department of Health. 2006 Annual Report of The Chief Medical Officer. London: Department of Health; 2007. 3. Department of Health. Unfinished Business. London: Department of Health; 2002. 4. Department of Health. Modernising Medical Careers. London: Department of Health; 2003. Competing interests: None declared |
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Nigel G B Richardson, Consultant Surgeon Broomfield Hospital, Chelmsford CM1 7ET
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The CMO (Chief Medical Officer) this week states that hand washing is a major priority and quotes examples of poor practice by doctors and nurses (BMJ 21 July 2007, News page 113). Like so many before him, he makes no mention of overuse of NHS facilities as being a critical factor in the battle against hospital infections, because (presumably) it is so politically uncomfortable to do so. Of course handwashing could be improved - but so could ward occupancy rates approaching 100% in acute wards. I suspect we will never get significantly reduced rates of hospital acquired infection until we accept that wards must slow down their turnover, a solution which local managers cannot consider due to intolerable pressure "from above" to improve so-called efficiency. The CMO also states (bma news, 21 July 2007, page 1) that "there was broad agreement MMC itself had taken medical training in the right direction." While most would find it difficult to criticise the sentiments behind the changes involved in MMC, I know of not a single doctor outside the immediate group managing MMC, who ever thought it would work - and that was before we had even heard of MTAS! MMC ignores two important factors. Currently both junior and senior doctors make major contributions to the SERVICE element of the NHS. MMC assumes that an almost infinite amount of time will be available to train and be trained, but gives no suggestion as to how the service gap this will inevitably produce will be filled. As a worker on the front line, I do wonder if the CMO, and his advisors, really understand the implications of their comments, and more disturbingly, major changes which they are implementing in the NHS. Competing interests: None declared |
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Evan L Lloyd, Retired Consultant Anaesthetist 72 Belgrave Road, Edinburgh EH12 6NQ
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Hand washing is important but it must be done properly. If most people are observed washing their hands, they seem to rub their palms against each other before rinsing and drying. Experiments have shown that this technique leaves bacteria on the backs of the hands and between the fingers. Correctly they should ensure that they rub the soap over the back of the hands and between their fingers for several minutes before rinsing. This technique is also important if bactericidal/viricidal chemicals are used. Liquid alcohol based products are less efficient because the alcohol dries so quickly that effectively only the palms are coated. Foam or gel based products take longer to dry and people therefore tend to rub them between their fingers and over the backs of their hands, thus producing more effective protection. However there are other factors contributing to hospital acquired infections such as changes in hospital practice which were designed to ‘improve’ bed occupancy and officially to save money. In the past each surgical and medical team had a specific ward into which all their patients were admitted, and looked after by the one team. Surgical patients were admitted to the ward from which they went to the operating theatre. After surgery they returned to the same ward where they remained until they were ready to go home. Now a surgical patient is admitted into one ward, but may be moved to another before surgery. After surgery he often returns to a different ward, and may occasionally be moved again before discharge. Infectious bacteria are often carried by people, without causing any symptoms and, if even one of these patients is carrying a pathogenic bacterium, it can easily be spread round several wards. This risk is compounded by the fact that a medical or surgical team may have patients in several different wards. Therefore if a member of the team picks up the pathogen, it may be spread to still more wards. In the old system an outbreak of infection would be restricted to one ward, now it can easily spread rapidly round the whole hospital. A similar problem is the practice of “boarding” medical patients in surgical wards. When boarding of medical patients was done in an orthopaedic ward, where patients returned after having had joint replacements, the rate of infection in the surgical wounds, and in the joints, soared. This had disastrous effects on the patients who had their hospital stay prolonged and, sometimes had to have the artificial joints removed to control the infection. They then had to have further surgery to put new joints in again, though I believe sometimes, because the damage was so great, or the infection persistent, further artificial joints could not be inserted. All this also greatly increased costs for the orthopaedic department, and meant there were delays in admitting more patients thus increasing the waiting list times. This problem with infection was not stopped until the Orthopaedic Consultants refused to allow “boarding” of medical patients in that ward. This shows that trying to save money in the medical unit by having fewer beds in the medical units, actually cost the NHS far more, though probably this was not noticed because the costs were in the orthopaedic department. Finally, in the past, ward cleaners were part of the team in an individual ward. They therefore took pride in the cleanliness of “their ward”. The cleaners were also under the immediate control of the Ward Sister, and above her the Matron. The Ward Sisters ensured that the cleaners were taught simple facts of hygiene. In the ward the cleaners often used to provide additional information for the medical staff since they would chat to “their patients” and were often told things which the patients were too shy to mention to the doctors or thought were irrelevant. Unfortunately this function of the cleaners could not be factored in by accountants, and, to save money, ward cleaning was contracted out to private firms. The cleaners employed were often less well paid, had no personal feeling about any ward or its cleanliness, could not be ‘told’ what to do by the Ward Sister, and had no training in hygiene. For example a cleaner was observed using the same bucket, water, mop, sponge and gloves to clean the floor and working surfaces in the ward kitchen having just finished cleaning the ward toilet. The standard of ward cleanliness deteriorated. The introduction of Private Finance Initiative (PFI) has compounded the problem because Hospital Managers cannot even change the cleaning company if cleaning is not being carried out properly. The PFI company has become the private provider for cleaning in the hospital, and can be very inefficient. In the Edinburgh Royal Infirmary (ERI) the corridors became clogged up by a build up of bags of waste, including clinical waste (which includes dressings contaminated with blood and sepsis). It took a prolonged dispute between Lothian Health (LH) and the PFI contractors before the PFI organisers finally admitted that it was their responsibility. It is not surprising that the ERI was rated the second dirtiest hospital in Scotland. Infection comes with dirt, and people. It is ironic that, when Lothian Division of the BMA challenged LH about the possibility of infection derailing their plans for all patients to be discharged within three days, our fears were condescendingly dismissed by a bacteriologist who stated that, “because the ERI was ‘state of the art’, infection would not be a problem”. If Governments, Health Boards and Hospital Managers are to achieve any reduction in hospital acquired, and other, infections they will have to look at the whole picture. Competing interests: None declared |
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Chelliah R Selvasekar, Specialist Registrar in Colorectal Surgery Christie Hospital, Manchester. M20 4BX
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Dear sir, I read with interest the article by Day1 on the key need for hand washing to reduce the incidence of clostridium difficile in the annual report by the Chief Medical Officer (CMO) Sir L. Donaldson.1 Hand washing is practiced by most health professionals optimally and it is surprising to note in his report only 60% were practicing according to the reference from the world health organisation. There is good evidence that practicing hand washing and other decontamination techniques help to reduce the incidence of hospital acquired infections. There is even more literature to suggest that the incidence of these infection is high in patients who spend more time in the hospital due to inability to rehabilitate following acute admissions.2 I feel we need to have a discharge plan for patients admitted to secondary care soon after admission to reduce the incidence of these infections and save money for the NHS in the long-term. I believe we can reduce the incidence of c.difficile and MRSA in the hospitals if we can get patients discharged early from the secondary care following treatment for acute condition and feel strongly against the suggestion that we need more education to hand washing.1 If the hospital practice of hand hygiene is poor then we should be witnessing an increased incidence of hospital acquired infections among the health care professionals as they are exposed to the same environment and I am not aware of any data to suggest that this is true. So I suggest that in addition to emphasising the importance of hand washing if the CMO emphasises the urgent need for early discharge for patients admitted to the acute hospitals and urge the government to make provisions for early discharge and support enhanced recovery programmes3 which aims to reduce hospital stay following elective surgery rather than suggesting improvement in hand hygiene alone which to some extend from his report gives a bad impression about the practices by the health care professionals in the UK and suggest to Sir. L Donaldson that there is evidence of other practices which contribute to hospital acquired infections which need to change in the NHS. Conflict of interest: None References: 1. Day M. Hand hygiene is a key health issue, says CMO. BMJ 2007; 335:113. 2. Makris AT, Gelone S. Clostridium difficile in the Long-Term Care Setting. J Am Med Dir Assoc.2007; 8(5):90-9. 3. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr.2005; 24(3):466-77. Competing interests: None declared |
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