Chief medical officer names hand hygiene and organ donation as public health priorities
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39280.523657.4E (Published 19 July 2007) Cite this as: BMJ 2007;335:113All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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:
– set out a clear set of principles to guide reform;
– ensure a coherent approach to setting standards and managing the
delivery of training;
– provide robust and reliable information systems to support
the management of training;
– ensure a consistent and valid approach to assessment;
– place a strong emphasis on the quality assurance of training;
– introduce a sound process for the selection of trainees;" (3). It would
appear the author of this report and the chief architect of these reforms
has failed quite disastrously in his stated aims.
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
Michael R Whitehouse
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
Competing interests: No competing interests
Hand washing: Is it the only evidence to reduce hospital acquired infections?
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
Competing interests: No competing interests